A 21-year-old woman experienced anaphylaxis after receiving buccal misoprostol for labor induction at 41 weeks of gestation. She developed pruritus, flushing, urticaria, and laryngeal edema. Epinephrine and cesarean delivery were performed, allowing for safe delivery of the neonate with minimal maternal morbidity. This case report describes a rare occurrence of anaphylaxis induced by misoprostol during labor, highlighting the importance of prompt recognition and treatment of anaphylaxis when inducing labor to prevent maternal and neonatal complications.
Obstetric Anaesthesia and Analgesia: Some Notions Which Should be Addressed R...Aninda Pramanik
Obstetric anaesthesia and analgesia comes up with a lot of questions and doubts. However, this article tries to crack some negative stereotypes regarding this issue. Over here at www.hsbookstore.com, doctors are quite concerned regarding this issue.
Obstetric Anaesthesia and Analgesia: Some Notions Which Should be Addressed R...Aninda Pramanik
Obstetric anaesthesia and analgesia comes up with a lot of questions and doubts. However, this article tries to crack some negative stereotypes regarding this issue. Over here at www.hsbookstore.com, doctors are quite concerned regarding this issue.
Diagnostic approach and management of extrauterine pregnancyRustem Celami
An ectopic pregnancy is a pregnancy that develops outside a woman's uterus. This happens when the fertilized egg from the ovary does not reach or implant itself normally in the uterus. Instead, the egg develops somewhere else in the abdomen. The products of this conception are abnormal and cannot develop into fetuses. Urine pregnancy test is often done by women itself once amenorrhea is present about 2 weeks of expected menstrual period, however, pregnancy blood test such Beta – human Chorionic Gonadotropin (BhCG) and ultrasound examination are the best tool of diagnosis. The most common place that ectopic pregnancy occurs is in one of the fallopian tubes, a so-called tubal pregnancy. These are the tubes that transport the egg from the ovary to the uterus. Ectopic pregnancies also can be found on the outside of the uterus, on the ovaries, or attached to the bowel. Most serious complication of an ectopic pregnancy is intra-abdominal hemorrhage. In the case of a tubal pregnancy, for example, as the products of conception continue to grow in the fallopian tube, the tube expands and eventually ruptures. This can be very dangerous because a large artery runs on the outside of each Fallopian tube. If the artery ruptures, the woman can bleed severely. Ectopic pregnancy is usually found in the first 5-10 weeks of pregnancy and is the leading cause of pregnancy-related deaths in the first trimester of pregnancy in the USA. In Albania, we face difficulties not only in application of high technology of ultrasound machine in public health sector but unfortunately we are unable to perform BhCG in public health sector laboratories, such making not only challenge and even delay but an expensive process of diagnosis of this medical problem. In conclusion, since ectopic pregnancy is an abnormal pregnancy, and comes with high risk of serious complication, early diagnosis of pregnancy location and its management is crucial in preventing medical complication.
β –agonists use is decreasing worldwide due to safer alternative: Atosiban.
Atosiban: as effective as nifedipine with fewer cardiovascular side effects.
Introduction: Though there are many studies on the effects of anesthesia methods used for cesarean section on the newborn,
research on this topic still continues. In our prospective observational study, we investigated the effects of different anesthesia techniques used in routine cesarean deliveries on early neonatal outcomes in our hospital. This prospective, observational, randomized study included a total of 222 ASA II risk group pregnant women undergoing elective cesarean section at term (38-41 weeks’ gestation) without fetal distress. The women were randomized into three groups. In the general anesthesia with propofol group (Group P, n = 74), anesthesia was induced with 2 mg∙kg-1 propofol and 0.6-0.9 mg∙kg-1
rocuronium. In the general anesthesia with thiopental sodium group (Group T, n = 74), anesthesia was induced with 5 mg∙kg-1 thiopental sodium and 0.6-0.9 mg∙kg-1 rocuronium. Women in the spinal anesthesia group (Group SA, n = 74) were administered 0.5% (10 mg) hypertonic bupivacaine and 10 mcg fentanyl.
Diagnostic approach and management of extrauterine pregnancyRustem Celami
An ectopic pregnancy is a pregnancy that develops outside a woman's uterus. This happens when the fertilized egg from the ovary does not reach or implant itself normally in the uterus. Instead, the egg develops somewhere else in the abdomen. The products of this conception are abnormal and cannot develop into fetuses. Urine pregnancy test is often done by women itself once amenorrhea is present about 2 weeks of expected menstrual period, however, pregnancy blood test such Beta – human Chorionic Gonadotropin (BhCG) and ultrasound examination are the best tool of diagnosis. The most common place that ectopic pregnancy occurs is in one of the fallopian tubes, a so-called tubal pregnancy. These are the tubes that transport the egg from the ovary to the uterus. Ectopic pregnancies also can be found on the outside of the uterus, on the ovaries, or attached to the bowel. Most serious complication of an ectopic pregnancy is intra-abdominal hemorrhage. In the case of a tubal pregnancy, for example, as the products of conception continue to grow in the fallopian tube, the tube expands and eventually ruptures. This can be very dangerous because a large artery runs on the outside of each Fallopian tube. If the artery ruptures, the woman can bleed severely. Ectopic pregnancy is usually found in the first 5-10 weeks of pregnancy and is the leading cause of pregnancy-related deaths in the first trimester of pregnancy in the USA. In Albania, we face difficulties not only in application of high technology of ultrasound machine in public health sector but unfortunately we are unable to perform BhCG in public health sector laboratories, such making not only challenge and even delay but an expensive process of diagnosis of this medical problem. In conclusion, since ectopic pregnancy is an abnormal pregnancy, and comes with high risk of serious complication, early diagnosis of pregnancy location and its management is crucial in preventing medical complication.
β –agonists use is decreasing worldwide due to safer alternative: Atosiban.
Atosiban: as effective as nifedipine with fewer cardiovascular side effects.
Introduction: Though there are many studies on the effects of anesthesia methods used for cesarean section on the newborn,
research on this topic still continues. In our prospective observational study, we investigated the effects of different anesthesia techniques used in routine cesarean deliveries on early neonatal outcomes in our hospital. This prospective, observational, randomized study included a total of 222 ASA II risk group pregnant women undergoing elective cesarean section at term (38-41 weeks’ gestation) without fetal distress. The women were randomized into three groups. In the general anesthesia with propofol group (Group P, n = 74), anesthesia was induced with 2 mg∙kg-1 propofol and 0.6-0.9 mg∙kg-1
rocuronium. In the general anesthesia with thiopental sodium group (Group T, n = 74), anesthesia was induced with 5 mg∙kg-1 thiopental sodium and 0.6-0.9 mg∙kg-1 rocuronium. Women in the spinal anesthesia group (Group SA, n = 74) were administered 0.5% (10 mg) hypertonic bupivacaine and 10 mcg fentanyl.
Aim: To predict the probability of stone free status calculated by CROES nomogram and to test the accuracy of our fi tted regression model to predict outcomes of PCNL. Methods: From July 2018 to May 2019, data of 100 patients underwent PCNL procedure for renal stones at Urology department at Menoufi a University was collected and postoperative results were compared to the preoperative predicted stone free status. The CROES nomogram was applied to the data of all cases using its scale to calculate the total score and corresponding percent of stone free status after the procedure. We used binary logistic regression to test whether the six factors in the study can predict the PCNL outcome. We compared the calculated probabilities of stone free by our fitted regression model to the traditional method using the whole 6 parameters on the scale of nomogram.
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Except in association with molar or hydropic degeneration of the placenta, with or without a coexistent fetus, eclampsia before 20 weeks of gestation is rare and only few cases have been described. The case reported was that of a 24 year old primipara who had tonic-clonic seizures at 19 weeks gestation without prior Preeclampsia. She remained stable and was managed closely up to 36 weeks gestation. She had spontaneous vaginal delivery of a live baby at 38 weeks with good outcome. Atypical eclampsia may develop before 20 weeks of gestation and could pose serious management challenges. Such patients if carefully selected and closely monitored may have satisfactory outcome. This case deserves reporting because of its rare nature as several literature search did not reveal any reported case of eclampsia before 20 weeks that was successfully managed to term.
Van Wyke-Grumbach syndrome and pituitary hyperplasia in a six-year-old girlApollo Hospitals
Hypothyroidism is usually associated with delayed puberty and occasionally may present with isosexual precocious puberty. In girls, this may present with breast development, multicystic ovaries and vaginal bleeding. This entity characterized by ovarian hyper stimulation leading to early puberty secondary to hypothyroidism is known as Van Wyke Grumbach syndrome. In contrast to the early puberty caused by other causes, precocious puberty of hypothyroidism is characterized by short stature and delayed bone age. Awareness about this condition and the treatment of this condition with levothyroxine will lead to avoidance of surgery and unnecessary intervention. We present the case of a six-year-old girl who presented with precocious puberty and pituitary hyperplasia. This case highlights the need for the professionals to familiarize themselves about uncommon complications of untreated hypothyroidism.
Ectopic pregnancy refers to the pregnancy occurring outside the uterine cavity, predominantly i.e. 90% of them in the fallopian tube. Ectopic pregnancy affects 11 in 1000 pregnancies and is a significant cause of morbidity and at times mortality in the first trimester of pregnancy. In a 20-year longitudinal study on ectopic pregnancy in a defined
population of women aged 15e39 years the rate of ectopic pregnancy per 1000 diagnosed conceptions increased
from 5.8 during 1960e4 to 11.1 during 1975e9. The mean annual incidence of ectopic pregnancy per 1000 women
increased from 0.6 to 1.2 during the same period. The numbers of ectopic pregnancies per 1000 diagnosed
conceptions increased with increasing age of the women and were 4.1 in the teenage group, 6.9 in women aged
20e29 years, and 12.9 in women aged 30e39.
2. for inducing labor cause anaphylaxis.3
We report
a case of buccal misoprostol as a cause of anaphylaxis
during labor induction.
CASE
A 21-year-old primigravid woman was admitted for a post-
date induction of labor at 41 weeks of gestation. She
reported feeling painful contractions for “days” and re-
ported good fetal movement with no vaginal bleeding or
leakage of fluid. Her antenatal course was uncomplicated.
She had no previous obstetric, gynecologic, medical, or
surgical history. In addition, she was taking no medications
and denied any known drug or nondrug allergies. Her
social history was noncontributory. On admission, her
blood pressure was 103/56 mm Hg, pulse 80 beats
per minute, respirations 16 breaths per minute, and tem-
perature 98.1˚F. Fetal heart tracing was Category I with
a baseline heart rate of 130 beats per minute, moderate
variability, and accelerations. External tocometry indicated
she was contracting irregularly, every 2–6 minutes, and she
appeared comfortable.
Her cervix was 1 cm dilated, 50% effaced, and the fetal
vertex was at 23 station. Her Bishop score was 3. Induction
of labor was started with 25 micrograms buccal misoprostol
at 5:00 PM. At 5:22 PM, the patient reported pruritus and
flushing and was given 25 mg diphenhydramine by intra-
venous push. Uterine tachysystole was evident. As a result
of increasing urticaria, an additional 25 mg diphenhydra-
mine was given. Physical examination revealed facial flush-
ing and a normal lung examination without evidence of
oropharyngeal edema. She was mildly tachycardic at 110
beats per minute but normotensive. The urticaria rapidly
evolved. The fetal tracing remained Category I with a base-
line of 160 beats per minute. The patient then was given
0.3 mg 1:1,000 epinephrine intramuscularly for presumed
anaphylaxis. After administration of epinephrine, the
patient started to report lip tingling and became increas-
ingly tachycardic to 130 beats per minute but remained
normotensive. At 5:45 PM the fetal heart tracing began
showing variable decelerations and eventual deterioration
to fetal bradycardia of 70 beats per minute. There was con-
tinued tachysystole, but terbutaline was not given for fear of
worsening the maternal tachycardia. Magnesium sulfate
also was considered as treatment for the uterine tachysys-
tole, but fetal bradycardia and evolving maternal dyspnea
led to the decision for an emergent cesarean delivery,
which was performed under general endotracheal anesthe-
sia. Laryngeal edema was noted at laryngoscopy. Immedi-
ately before delivery, the fetal heart rate was 80 beats
per minute. Incision-to-delivery time was 8 minutes, and
the neonate had Apgar scores of 7 at 1 minute and 9 at
5 minutes and was taken to the term nursery. Arterial
cord blood gas showed a pH of 7.04 and base deficit of
7.7 mmol/L. The mother remained intubated overnight as
a result of her persistent laryngeal edema and was extu-
bated the next day. Serum tryptase level drawn 5 hours after
the event was 16 ng/mL (normal 2–10 ng/mL). The remain-
der of her postoperative course was uncomplicated and she
and the neonate were discharged home on postoperative
day 3.
COMMENT
The rates of allergic reactions and anaphylaxis to
misoprostol have not been quantified. We performed
an English language PubMed search using relevant key
words (“misoprostol,” “labor,” “allergy,” and “anaphy-
laxis”) from 1950 to 2013 and retrieved no results.
Using the additional search term “dermatoses,” we
Fig. 1. Algorithm to treat anaphylaxis in pregnancy. *These
medications may be used to treat mild to moderate allergic
reactions but should never replace epinephrine in the set-
ting of anaphylaxis.
Schoen. Anaphylaxis to Buccal Misoprostol. Obstet Gynecol 2014.
VOL. 124, NO. 2, PART 2, AUGUST 2014 Schoen et al Anaphylaxis to Buccal Misoprostol 467
3. found a case report that describes a lichenoid drug
eruption that occurred 2 months after 800 micrograms
misoprostol vaginally was used to induce a first-
trimester abortion.4
When we expanded our search
to include all languages, we found one case (in French)
of anaphylaxis and myocardial myocytic necrosis with
the concurrent use of diclofenac and misoprostol.5
To
our knowledge, even with the frequent use of miso-
prostol for second-trimester losses and third-trimester
induction of labor, there are no other reported cases
of acute anaphylaxis.
This case is consistent with a moderate-to-severe
(Class 3 on the Ring and Messmer Scale) IgE-
mediated hypersensitivity reaction characterized by
pruritus, flushing, urticaria, tachycardia, dyspnea, and
laryngeal edema.6
Tryptase is a protease found almost
exclusively in mast cells. An increase in serum levels
is highly sensitive for identifying mast cell activation.
Elevated tryptase levels can be used to confirm an
IgE-mediated allergic reaction compared with a non-
allergic anaphylactic event, which is not controlled by
immunologic mechanisms. The optimal time to draw
a serum tryptase level is 1–4 hours after the acute
event and compare it with a control specimen taken
at least 24 hours afterward. False-negative tryptase
levels have been reported, so skin testing should be
strongly encouraged if the clinical suspicion is high. In
this case, the increase in tryptase drawn 5 hours after
the event confirmed an IgE-mediated reaction. Usu-
ally tryptase levels will peak at 1 hour and decline
linearly with a half-life of 2 hours.6
The patient’s tryp-
tase level was just above the upper limit of normal;
however, the sample was drawn well after the ex-
pected peak. We can infer that at 1 hour, her tryptase
level would have been even higher, diagnosing this
reaction as a hypersensitivity reaction, although opti-
mally testing should have been initiated sooner.
Only three cases previously have reported ana-
phylaxis secondary to the use of a progesterone
induction agent during labor.3
These cases all were
associated with intracervical placement of dinopro-
stone gel and were followed by respiratory distress,
tetanic contractions, and fetal distress. Our literature
search recovered no reported cases of anaphylaxis
caused by misoprostol by any administration method
during labor induction. Oxytocin, another frequently
used induction agent, is rarely associated with allergic
reactions in women who have a latex allergy. This
may be secondary to the homology in the protein
sequence between oxytocin and the latex antigen, pa-
latin.7
Timely appropriate treatment of anaphylaxis is
critical to optimize maternal and perinatal outcomes
(Fig. 1). Hepner and colleagues2
reviewed a series of
anaphylaxis cases in pregnancy and found that neo-
natal deaths and neurologic morbidity (eg, seizure-like
activity, brain damage, hypoxic encephalopathy) may
be attributed to incorrect dosing or delayed adminis-
tration of epinephrine. Epinephrine is more effective
than other vasoconstrictors in increasing systemic vas-
cular resistance and improving cardiac output, utero-
placental perfusion, and ultimately fetal perfusion and
oxygenation.8
Treating physicians must also consider
immediate delivery (10–15 minutes) in these cases.
There were no cases in the series that had a poor neo-
natal outcome when cesarean delivery was performed
within this time frame. However, in 50% of the cases
with a poor neonatal outcome, the cesarean delivery
was delayed (time from anaphylactic event to delivery
30–120 minutes). Therefore, prompt correction of
maternal perfusion and immediate delivery remains
the most effective means of ensuring fetal perfusion
and a good pregnancy outcome.
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468 Schoen et al Anaphylaxis to Buccal Misoprostol OBSTETRICS & GYNECOLOGY