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Burn MS, Kwah JH, Son M. Diagnosis and clinical management of drug allergies in obstetrics and gynecology: an expert review. Am J Obstet Gynecol 2025; 232:243-261. [PMID: 39490659 DOI: 10.1016/j.ajog.2024.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 10/03/2024] [Accepted: 10/20/2024] [Indexed: 11/05/2024]
Abstract
Drug allergies, specifically antibiotic allergies, are frequently encountered in obstetrics and gynecology, with 10% of the US population reporting a penicillin allergy. This poses a particular challenge to the obstetrician-gynecologist, as beta-lactam antibiotics are indicated as first-line therapy for the treatment and prevention of most specialty-specific infections. Alternative antibiotic use in the setting of a reported allergy is not benign and has been associated with increased cesarean delivery, endometritis, wound complication, length of hospital stay in pregnant patients, Group B Streptococcus sepsis, neonatal length of stay, neonatal laboratory draw in neonates born to patients with allergies, and surgical site infection in gynecologic patients. Furthermore, alternative antibiotic use leads to increased antibiotic resistance, toxicity, and healthcare cost. In addition, the administration of antibiotics in a patient with a history of type I immediate hypersensitivity reaction poses a risk of anaphylaxis with repeat exposure. Fortunately, >90% of patients who report a penicillin allergy are not truly allergic and would tolerate penicillins if administered. This can be due to either mislabeling of the index reaction as an allergy (when it was due to a drug intolerance or a viral exanthem) or waning immunoglobulin E-mediated immunity over time. Given this, allergy evaluation is widely recommended, even in pregnancy. Allergy evaluation involves detailed patient history and allergy testing with skin testing and/or oral challenge, as appropriate. These tools have been found to be safe and effective in gravid and nongravid individuals and to result in increased use of first-line antibiotics when used appropriately. Furthermore, even in the setting of a true penicillin allergy, cross-reactivity with cephalosporins is extremely low and estimated at 2% to 3% among patients with a verified penicillin allergy and considerably lower than this among patients with an unverified penicillin allergy. Guidelines support the routine use of cephalosporins without testing or additional precautions in patients with an unverified nonanaphylactic penicillin allergy and the routine use of structurally dissimilar cephalosporins (specifically Ancef) even in patients with an anaphylactic penicillin allergy. In cases in which there is no appropriate alternative antibiotic than that for which the patient is allergic, such as syphilis in a pregnant patient with penicillin allergy, desensitization can be performed. This process involves temporary induction of drug tolerance through exposure to small amounts of the allergen until a therapeutic dose is achieved and has been safely performed in pregnancy. Desensitization requires expert supervision and is most often performed in the intensive care setting with a multidisciplinary team. The other 2 most common antibiotic allergies encountered in the field of obstetrics and gynecology are cephalosporin and metronidazole allergies. Cephalosporin allergies are managed similarly to penicillin allergies with readily available skin testing and oral challenge. Skin testing for metronidazole allergy lacks sensitivity and specificity, and thus, oral challenge or desensitization procedure is the preferred approach for low-risk and high-risk patients, respectively. When it comes to drug allergies, specifically antibiotic allergies, the role of the obstetrician-gynecologist is to identify patients with reported allergies and to refer patients to a specialist for further evaluation as soon as possible. Allergy evaluation using a detailed patient history and allergy testing (skin testing and/or oral challenge) when indicated has been shown to be safe and effective and is an important part of antibiotic stewardship.
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Affiliation(s)
- Martina S Burn
- Department of Obstetrics, Gynecology, and Women's Health, University of Minnesota, Minneapolis, MN
| | - Jason H Kwah
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Moeun Son
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
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2
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Cao Q, Zhou S, Chen H, Zhou R. Anesthetic anaphylactic shock in an emergency cesarean section: a case report. BMC Anesthesiol 2024; 24:468. [PMID: 39707181 DOI: 10.1186/s12871-024-02861-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 12/11/2024] [Indexed: 12/23/2024] Open
Abstract
BACKGROUND Neuraxial anesthesia is the gold standard for cesarean sections, but general anesthesia is sometimes necessary, especially in emergency cases. Anaphylactic shock due to succinylcholine, a commonly used neuromuscular blocking agent, is rare but life-threatening. CASE PRESENTATION A 42-year-old woman with severe preeclampsia and a history of intracranial vascular malformations underwent an emergency cesarean section. Induction with succinylcholine triggered an anaphylactic shock. Immediate intervention with epinephrine and corticosteroids stabilized the patient, allowing the safe delivery of a live infant. DISCUSSION AND CONCLUSION This case highlights the need for rapid identification and management of anaphylactic shock during emergency cesarean sections under general anesthesia, especially in high-risk patients with complex medical histories.
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Affiliation(s)
- Qi Cao
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, P. R. China
| | - Shengping Zhou
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, P. R. China
| | - Hongqin Chen
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, P. R. China
| | - Rong Zhou
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second University Hospital, Sichuan University, Chengdu, Sichuan, 610041, P. R. China.
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3
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Tufail T, Rasheed Y, Ain HBU, Arshad MU, Hussain M, Akhtar MN, Saewan SA. A review of current evidence on food allergies during pregnancy. Food Sci Nutr 2023; 11:4432-4443. [PMID: 37576037 PMCID: PMC10420761 DOI: 10.1002/fsn3.3451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 08/15/2023] Open
Abstract
Food allergy is the reaction of the immune system of the body that occurs after consuming specific foods. During specific physiological ages of pregnancy, women are more prone to different allergic reactions and mostly these reactions may prolong and have long-term effects. The hypersensitivity of different types of allergens is mainly linked with the adversity of reactions. The chances of suffering food allergies in women are greater than in men; women are usually more prone to get allergic to some foods during their specific physiological age of pregnancy. Food allergies are more common in pregnant women as every fifth pregnant woman is affected by some kind of allergy. The specific reasons and evidence of the causes of these food allergies during pregnancies have yet to be explored. A pregnant woman should take a balanced diet and avoid consuming known allergic foods to minimize the risk and complications. This review aimed to broaden the knowledge on food allergies during pregnancies, their onset in the babies, and to make it easy for pregnant women to cope with the complications caused by these food allergies. It also aimed to figure out the certain food that might be responsible for the onset of allergies in women during pregnancy and the effect of these allergies on their babies.
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Affiliation(s)
- Tabussam Tufail
- School of Food and Biological EngineeringJiangsu UniversityZhenjiangJiangsuChina
- University Institute of Diet and Nutritional SciencesThe University of LahoreLahorePakistan
| | - Yusra Rasheed
- University Institute of Diet and Nutritional SciencesThe University of LahoreLahorePakistan
| | - Huma Bader Ul Ain
- University Institute of Diet and Nutritional SciencesThe University of LahoreLahorePakistan
| | - Muhammad Umair Arshad
- Department of Food Science Government CollegeUniversity FaisalabadFaisalabadPakistan
| | - Muzzamal Hussain
- Department of Food Science Government CollegeUniversity FaisalabadFaisalabadPakistan
| | - Muhammad Nadeem Akhtar
- University Institute of Diet and Nutritional SciencesThe University of LahoreLahorePakistan
| | - Shamaail A. Saewan
- Department of Food Sciences, College of AgricultureUniversity of BasrahBasrahIraq
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4
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Ganguli MP, Sinha S, Dimov V, Eidelman F. Uterine Anaphylaxis Due to Subcutaneous Immunotherapy (SCIT) for Inhalant Allergens: A Case Series. Cureus 2023; 15:e42526. [PMID: 37637630 PMCID: PMC10457715 DOI: 10.7759/cureus.42526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Subcutaneous immunotherapy (SCIT), commonly known as "allergy shots," aims to achieve a clinical tolerance for allergens that cause symptoms of allergic rhinoconjunctivitis, allergic asthma, or insect sting allergies. Systemic reactions to SCIT are classified in severity from one organ system (grade 1) to anaphylaxis that potentially may have a fatal outcome (grade 5). Uterine cramps fall under grade 2, and they are rarely reported during SCIT. In this study, we report four cases of uterine anaphylaxis following SCIT for environmental allergens with symptoms such as severe lower abdominal cramping resembling menstrual cramps. Patients also experienced urticaria, angioedema, diffuse erythema, and flushing. None of the patients experienced uterine bleeding. To the best of our knowledge, this is the largest case series reporting this reaction to SCIT. We accompany this finding with a review of the literature on this rare but interesting topic.
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Affiliation(s)
| | - Shayan Sinha
- Internal Medicine, Cleveland Clinic Florida, Weston, USA
| | - Vesselin Dimov
- Allergy and Immunology, Cleveland Clinic Florida, Weston, USA
| | - Frank Eidelman
- Allergy and Immunology, Cleveland Clinic Florida, Weston, USA
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5
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Wolfson AR, Schatz MX. Management of the Pregnant Patient with Beta-Lactam Allergy. Curr Allergy Asthma Rep 2023; 23:189-194. [PMID: 36749447 DOI: 10.1007/s11882-023-01069-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW We review the literature and discuss the logistics of testing pregnant patients for penicillin allergy. RECENT FINDINGS As in the general population, pregnant patients commonly report a penicillin allergy, but most patients are able to tolerate penicillin. Avoidance of beta-lactams in pregnancy is associated with increased morbidity: longer hospitalizations, more frequent infections, and more complications. Penicillin allergy testing is safe in pregnant patients, and obstetricians are eager for allergists to offer this procedure to their patients. As allergists, we can improve our patients' health outcomes by offering penicillin allergy testing in our practices. The protocols for testing both with and without skin testing in pregnant patients have been studied, and future studies will continue to clarify the safety and efficacy of penicillin allergy delabeling in pregnant patients.
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Affiliation(s)
- Anna R Wolfson
- Harvard Medical School, Boston, MA, USA. .,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Michael X Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, CA, USA
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6
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Kuder MM, Baird R, Hopkins M, Lang DM. Anaphylaxis in Pregnancy. Immunol Allergy Clin North Am 2023; 43:103-116. [PMID: 36410997 DOI: 10.1016/j.iac.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anaphylaxis in pregnancy is a rare event, but has important implications for the pregnant patient and fetus. The epidemiology, pathophysiology, diagnosis, and treatment all carry important considerations unique to the pregnant patient. Common culprits of anaphylaxis are primarily medications, particularly antibiotics and anesthetic agents. Diagnosis can be difficult given the relative lack of cutaneous symptoms, and normal physiologic changes in pregnancy such as low blood pressure and tachycardia. Apart from patient positioning, treatment is similar to that of the general population, with a focus on prompt epinephrine administration.
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Affiliation(s)
- Margaret M Kuder
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation.
| | - Rachael Baird
- Women's Health Institute, Cleveland Clinic Foundation
| | - Maeve Hopkins
- Women's Health Institute, Cleveland Clinic Foundation
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation
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Drug desensitization during pregnancy: Improving patient safety through multidisciplinary collaborative approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:647-649.e2. [PMID: 36464158 DOI: 10.1016/j.jaip.2022.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/14/2022] [Accepted: 11/04/2022] [Indexed: 12/04/2022]
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Kumar R, Gaur S, Agarwal M, Menon B, Goel N, Mrigpuri P, Spalgais S, Priya A, Kumar K, Meena R, Sankararaman N, Verma A, Gupta V, Sonal, Prakash A, Safwan MA, Behera D, Singh A, Arora N, Prasad R, Padukudru M, Kant S, Janmeja A, Mohan A, Jain V, Nagendra Prasad K, Nagaraju K, Goyal M. Indian Guidelines for diagnosis of respiratory allergy. INDIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY 2023. [DOI: 10.4103/0972-6691.367373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Perelli F, Turrini I, Giorgi MG, Renda I, Vidiri A, Straface G, Scatena E, D’Indinosante M, Marchi L, Giusti M, Oliva A, Grassi S, De Luca C, Catania F, Vizzielli G, Restaino S, Gullo G, Eleftheriou G, Mattei A, Signore F, Lanzone A, Scambia G, Cavaliere AF. Contrast Agents during Pregnancy: Pros and Cons When Really Needed. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16699. [PMID: 36554582 PMCID: PMC9779218 DOI: 10.3390/ijerph192416699] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 05/13/2023]
Abstract
Many clinical conditions require radiological diagnostic exams based on the emission of different kinds of energy and the use of contrast agents, such as computerized tomography (CT), positron emission tomography (PET), magnetic resonance (MR), ultrasound (US), and X-ray imaging. Pregnant patients who should be submitted for diagnostic examinations with contrast agents represent a group of patients with whom it is necessary to consider both maternal and fetal effects. Radiological examinations use different types of contrast media, the most used and studied are represented by iodinate contrast agents, gadolinium, fluorodeoxyglucose, gastrographin, bariumsulfate, and nanobubbles used in contrast-enhanced ultrasound (CEUS). The present paper reports the available data about each contrast agent and its effect related to the mother and fetus. This review aims to clarify the clinical practices to follow in cases where a radiodiagnostic examination with a contrast medium is indicated to be performed on a pregnant patient.
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Affiliation(s)
- Federica Perelli
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Irene Turrini
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Maria Gabriella Giorgi
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Irene Renda
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, 50134 Florence, Italy
| | - Annalisa Vidiri
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
| | - Gianluca Straface
- Obstetrics and Gynecology Unit, Policlinico Abano Terme, 35031 Abano Terme, Italy
| | - Elisa Scatena
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Marco D’Indinosante
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Laura Marchi
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santo Stefano Hospital, 59100 Prato, Italy
| | - Marco Giusti
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Antonio Oliva
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Simone Grassi
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carmen De Luca
- Teratology Information Service, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Catania
- Department of Obstetrics and Gynecology, Ospedale “Santa Maria Alla Gruccia”, 52025 Montevarchi, Italy
| | - Giuseppe Vizzielli
- Department of Medicinal Area (DAME) Clinic of Obstetrics and Gynecology, Santa Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Stefano Restaino
- Department of Medicinal Area (DAME) Clinic of Obstetrics and Gynecology, Santa Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Giuseppe Gullo
- IVF Public Center, Azienda Ospedaliera Ospedali Riuniti (AOOR) Villa Sofia Cervello, University of Palermo, 90146 Palermo, Italy
| | - Georgios Eleftheriou
- Poison Control Center and Teratology Information Service, Hospital Papa Giovanni XIII, 24127 Bergamo, Italy
| | - Alberto Mattei
- Azienda USL Toscana Centro, Gynecology and Obstetric Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy
| | - Fabrizio Signore
- Obstetrics and Gynecology Unit, Santo Eugenio Hospital, 00144 Rome, Italy
- School of Medicine, Unicamillus University Rome, 00131 Rome, Italy
| | - Antonio Lanzone
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanni Scambia
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- School of Medicine, Catholic University of the Sacred Hearth, 00168 Rome, Italy
- Division of Gynecology and Obstetrics Fatebenefratelli Isola Tiberina, 00186 Rome, Italy
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10
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COMPAGNONE C, TROMBI G, RIDOLO E, RAFANO CARNÀ E, BIGNAMI EG. Local anesthetics allergy in pregnancy. Minerva Anestesiol 2022; 88:970-971. [DOI: 10.23736/s0375-9393.22.16540-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mitselou N, Stephansson O, Melén E, Ludvigsson JF. Exposure to Allergen-Specific Immunotherapy in Pregnancy and Risk of Congenital Malformations and Other Adverse Pregnancy Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1635-1641.e2. [PMID: 35487856 DOI: 10.1016/j.jaip.2022.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Owing to insufficient data, current guidelines recommend against initiating allergen-specific immunotherapy (AIT) during pregnancy but suggest that well-tolerated ongoing immunotherapy may be continued. OBJECTIVE To evaluate the safety of AIT in pregnancy, especially the risk for congenital malformations. METHODS This nationwide Swedish cohort study identified pregnancies exposed to AIT, both subcutaneous and sublingual, through the Swedish Medical Birth register and the Prescribed Drug Register between 2005 and 2014. Information on congenital malformations in offspring was retrieved from the National Patient Register. Using the personal identity number, we linked data between registers. Using logistic regression, we calculated odds ratios (ORs) with 95% CIs for congenital malformations and other adverse pregnancy outcomes after adjusting for potential confounders. RESULTS From 2005 to 2014, we identified 924,790 singleton pregnancies. Among these, 743 pregnancies had been exposed to AIT 3 months before conception up until gestational week 22. Allergen-specific immunotherapy in pregnancy was not linked to congenital malformations (OR = 0.90; 95% CI, 0.63-1.27) or other adverse pregnancy outcomes (preterm birth: OR = 0.98; 95% CI, 0.71-1.35; stillbirth: OR = 0.79; 95% CI, 0.26-2.47; or cesarean delivery: OR = 0.91; 95% CI, 0.76-1.09). Stratification by route of immunotherapy, subcutaneous or sublingual, resulted in similar ORs. Restricting the pregnancy cohort to women with asthma or pulmonary disease, nulliparous women, births in 2012 to 2014, or Swedish-born women yielded similar results. CONCLUSIONS This nationwide study found no evidence of congenital malformations or other adverse pregnancy outcomes in women treated with AIT in pregnancy.
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Affiliation(s)
- Niki Mitselou
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.
| | - Olof Stephansson
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Melén
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science and Education Södersjukhuset, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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12
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Ferrari J, Benvenuti P, Bono E, Fiorelli N, Elena C. Mastocytosis: Fertility and Pregnancy Management in a Rare Disease. Front Oncol 2022; 12:874178. [PMID: 35574357 PMCID: PMC9092525 DOI: 10.3389/fonc.2022.874178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Mastocytosis encompasses a subset of rare diseases, characterized by the presence and accumulation of abnormal neoplastic MC in various organ systems, including skin, bone marrow, spleen and gastrointestinal tract. Clinical manifestations are highly heterogeneous, as they result from both MC mediator release and MC organ infiltration. Both pregnancy, a lifetime dominated by huge physiological changes, and labor can provide triggers that could induce worsening of mastocytosis symptoms. On the other hand, mastocytosis has relevant implications in obstetric management and prenatal care during all the pregnancy. In this review article, current knowledge about the impact of mastocytosis on fertility and pregnancy outcome will be reviewed and discussed, with the aim to provide clinical practice guidance for the evaluation and management of pregnancy and delivery in patients with cutaneous and systemic mastocytosis.
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Affiliation(s)
| | - Pietro Benvenuti
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Elisa Bono
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Division of Hematology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) S. Matteo Hospital Foundation, Pavia, Italy
| | - Nicolas Fiorelli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Chiara Elena
- Division of Hematology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) S. Matteo Hospital Foundation, Pavia, Italy
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13
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Patel V, Gleeson PK, Delaney K, Ralston SJ, Feldman S, Fadugba O. Safety and outcomes of penicillin allergy evaluation in pregnant women. Ann Allergy Asthma Immunol 2022; 128:568-574. [PMID: 35123076 DOI: 10.1016/j.anai.2022.01.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/15/2022] [Accepted: 01/20/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Penicillin allergy in pregnancy is associated with increased morbidity and the use of less effective antibiotics. Penicillin allergy evaluation in pregnancy is now recommended as per obstetrical guidelines but remains infrequent. OBJECTIVE We studied pregnant women who underwent penicillin allergy evaluation in an allergy clinic to assess the effectiveness and safety of penicillin skin testing (PST) and incremental drug challenge (IDC) in pregnancy. METHODS Index drug reactions, PST, and IDC results were reviewed. Antibiotic use, pregnancy outcomes, and pregnancy complications were compared with a control cohort of pregnant women with penicillin allergy who did not undergo allergy evaluation before delivery. RESULTS Penicillin allergy was evaluated in 136 women. Culprit drugs included penicillin (37%), amoxicillin (30%), and unknown (20%). Index reactions occurred greater than 5 years ago in 91%, and these reactions were cutaneous or unknown in 92%. Of the 133 patients who underwent skin testing, 131 (99%) had negative or equivocal results and proceeded to incremental challenge. All 131 women passed penicillin IDC. Of the 69 women who ultimately used intrapartum beta-lactam antibiotics, all but 1 patient tolerated them. Women who underwent penicillin allergy evaluation did not have an increased risk of cesarean delivery or other pregnancy complications when compared with women without penicillin allergy evaluation. CONCLUSION PST and IDC can be safely conducted in pregnant women. When evaluated as low risk, most women tolerate IDC and can receive penicillin intrapartum without adverse reactions or negative pregnancy outcomes.
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Affiliation(s)
- Vima Patel
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Allergy and Asthma Specialists, LLC, Bluebell, Pennsylvania
| | - Patrick K Gleeson
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn Delaney
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Ralston
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Howard University, Cambridge, Massachusetts
| | - Scott Feldman
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Olajumoke Fadugba
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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14
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Zhang J, Yu C, Liu H, Zhu Q. Sudden respiratory and circulatory collapse after cesarean section: Amniotic fluid embolism or other reasons? - a case report. BMC Pregnancy Childbirth 2022; 22:369. [PMID: 35484512 PMCID: PMC9052550 DOI: 10.1186/s12884-022-04701-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 04/22/2022] [Indexed: 11/23/2022] Open
Abstract
Background For a healthy parturient, a cardiopulmonary collapse that suddenly occurs shortly after an uneventful caesarean section is a relatively rare event and presents a significant challenge for the anesthesia provider. Case presentation Amniotic fluid embolism (AFE) is characterized by acute and rapid collapse and is well known to the obstetric team. Our patient experienced sudden cardiovascular collapse, severe respiratory difficulty and hypoxia, in the absence of other explanations for these findings at the time, and thus AFE was immediately become the focus of the consideration. However, there is no quick, standard laboratory test for AFE, therefore the diagnosis is one of exclusion based on presenting symptoms and clinical course. After given symptomatic treatment, the patient made an uneventful initial recovery in a short period and developed a rash. We recognized that the postpartum shock was associated with delayed anaphylaxis of antibiotics. Conclusions These observations have implications for understanding whenever administering drugs in surgery, which may affect the anesthesiologist’s judgment regarding the complications of anesthesia. Even though serious complications of common perioperative drugs may rarely occur, anesthesia providers should be aware of the consideration. Early recognition and effective treatment are more important than prompt diagnosis.
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Affiliation(s)
- Jinxi Zhang
- Department of Anesthesiology, West China Second University Hospital; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
| | - Chao Yu
- Department of Anesthesiology, West China Second University Hospital; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
| | - Hui Liu
- Department of Anesthesiology, West China Second University Hospital; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China
| | - Qing Zhu
- Department of Anesthesiology, West China Second University Hospital; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), Sichuan University, Chengdu, China.
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15
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Munasinghe BM, Perera RN, Kumara SKWR. Two lives at stake: Obstetric anaphylactic shock resulting in acute respiratory distress syndrome - A case report. SAGE Open Med Case Rep 2022; 10:2050313X221084843. [PMID: 35320983 PMCID: PMC8935580 DOI: 10.1177/2050313x221084843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/14/2022] [Indexed: 12/23/2022] Open
Abstract
Maternal anaphylaxis is rare albeit life-threatening critical incident dreaded by many due to negative effects on not only the mother but the foetus as well. Antibiotics and anaesthetic agents still contribute to majority of the episodes. Consequences of anaphylaxis such as placental insufficiency and subsequent foetal neurocognitive deficits are devastating outcomes. Acute respiratory distress syndrome following anaphylaxis is even rarer among the normal population. The management of maternal anaphylaxis does not differ from routine recommendations even though close monitoring and preparedness for early delivery should be embedded in the protocols. This is a rare case report of a primi mother who developed anaphylactic shock following intravenous penicillin in the background of negative allergic history, resultant foetal distress requiring emergency lower segment caesarian section and delayed onset acute respiratory distress syndrome which was later attributed to anaphylaxis. Pertinent identification and management which included a multidisciplinary team culminated in favourable outcomes.
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Affiliation(s)
| | - RN Perera
- District General Hospital Mannar, Mannar, Sri Lanka
| | - SKWR Kumara
- District General Hospital Mannar, Mannar, Sri Lanka
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16
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Pfaller B, Bendien S, Ditisheim A, Eiwegger T. Management of allergic diseases in pregnancy. Allergy 2022; 77:798-811. [PMID: 34427919 DOI: 10.1111/all.15063] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/21/2021] [Indexed: 12/19/2022]
Abstract
Allergic diseases like asthma, allergic rhinitis, food allergy, hymenoptera allergy, or atopic dermatitis are highly prevalent in women of childbearing age and may affect up to 30% of this age group. This review focuses on the management of allergic diseases during pregnancy. Furthermore, we discuss the challenges of counseling women with allergic diseases in the reproductive age, including considerations relevant to the ongoing SARS-CoV-2 pandemic. To create the optimal milieu for the unborn child, a multitude of immunological changes occur during pregnancy which may favor type 2 responses and aggravate disease phenotypes. In co-occurrence with suboptimal preconception disease control, this elevated Th2 responses may aggravate allergic disease manifestations during pregnancy and pose a risk for mother and child. Due to limitations in conducting clinical trials in pregnant women, safety data on anti-allergic drugs during pregnancy are limited. The lack of information and concerns among pregnant patients demands counseling on the benefits of anti-allergic drugs and the potential and known risks. This includes information on the risk for mother and child of disease aggravation in the absence of treatment. By doing so, informed decisions and shared decision-making can take place.
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Affiliation(s)
- Birgit Pfaller
- Karl Landsteiner University of Health Sciences Krems Austria
- Department of Internal Medicine 1 University Hospital St. PöltenKarl Landsteiner Institute for Nephrology St. Pölten St. Pölten Austria
| | - Sarah Bendien
- Department of Respiratory Medicine Haga Teaching Hospital The Hague The Netherlands
| | - Agnès Ditisheim
- Center for Maternal‐Fetal Medicine La Tour Hospital Meyrin Switzerland
- Faculty of Medicine University of Geneva Geneva Switzerland
| | - Thomas Eiwegger
- Karl Landsteiner University of Health Sciences Krems Austria
- Translational Medicine Program Research InstituteThe Hospital for Sick Children Toronto Canada
- Department of Immunology University of Toronto Toronto ON Canada
- Department of Pediatric and Adolescent Medicine University Hospital St. Pölten St. Pölten Austria
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17
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MRI in Pregnancy and Precision Medicine: A Review from Literature. J Pers Med 2021; 12:jpm12010009. [PMID: 35055324 PMCID: PMC8778056 DOI: 10.3390/jpm12010009] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/11/2021] [Accepted: 12/15/2021] [Indexed: 12/29/2022] Open
Abstract
Magnetic resonance imaging (MRI) offers excellent spatial and contrast resolution for evaluating a wide variety of pathologies, without exposing patients to ionizing radiations. Additionally, MRI offers reproducible diagnostic imaging results that are not operator-dependent, a major advantage over ultrasound. MRI is commonly used in pregnant women to evaluate, most frequently, acute abdominal and pelvic pain or placental abnormalities, as well as neurological or fetal abnormalities, infections, or neoplasms. However, to date, our knowledge about MRI safety during pregnancy, especially about the administration of gadolinium-based contrast agents, which are able to cross the placental barrier, is still limited, raising concerns about possible negative effects on both the mother and the health of the fetus. Contrast agents that are unable to cross the placenta in a way that is safe for the fetus are desirable. In recent years, some preclinical studies, carried out in rodent models, have evaluated the role of long circulating liposomal nanoparticle-based blood-pool gadolinium contrast agents that do not penetrate the placental barrier due to their size and therefore do not expose the fetus to the contrast agent during pregnancy, preserving it from any hypothetical risks. Hence, we performed a literature review focusing on contrast and non-contrast MRI use during pregnancy.
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18
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Gregory A, Mackey C. Drastic Decontamination in a Patient With Anaphylaxis. J Emerg Med 2021; 61:e113-e115. [PMID: 34479752 DOI: 10.1016/j.jemermed.2021.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/01/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Allergic reactions are common symptoms in the emergency department (ED), with anaphylaxis comprising 1-3% of ED visits. Anaphylaxis is a clinical diagnosis. Treatment of anaphylaxis starts with airway, oxygenation, and decontamination, followed by medication administration. CASE REPORT We describe a patient who presented to the ED with anaphylaxis complicated by a persistent exposure to the allergen with need for emergent decontamination. Why Should an Emergency Physician be Aware of This? Knowing the treatment of anaphylaxis is critical to prevent morbidity and mortality. This case is a reminder to always remove the offending agent and nuances involved with treating critically ill pregnant patients.
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Affiliation(s)
- Alexandria Gregory
- Department of Emergency Medicine, University of Massachusetts Meical School, Worcester, Massachusetts
| | - Cassandra Mackey
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.
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19
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State-of-the-Art on Biomarkers for Anaphylaxis in Obstetrics. Life (Basel) 2021; 11:life11090870. [PMID: 34575019 PMCID: PMC8467046 DOI: 10.3390/life11090870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 12/25/2022] Open
Abstract
Anaphylaxis is an unpredictable systemic hypersensitivity reaction and constitutes a high risk of maternal and fetal morbidity and mortality when occurring during pregnancy. Currently, the acute management of anaphylaxis is based on clinical parameters. A total serum tryptase is only used to support an accurate diagnosis. There is a need to detect other biomarkers to further assess high-risk patients in obstetrics. Our objective is to present biomarkers in this complex interdisciplinary approach beyond obstetrician and anaesthetic management. Candidate biomarkers derive either from mediators involved in immunopathogenesis or upcoming molecules from systems biology and proteomics. Serum tryptase is determined by singleplex immunoassay method and is important in the evaluation of anaphylactic mast cell degranulation but also in the assessment of other risk factors for anaphylaxis such as systemic mastocytosis. Another category of biomarkers investigates the IgE-mediated sensitization to triggers potentially involved in the etiology of anaphylaxis in pregnant women, using singleplex or multiplex immunoassays. These in vitro tests with natural extracts from foods, venoms, latex or drugs, as well as with molecular allergen components, are useful because in vivo allergy tests cannot be performed on pregnant women in such a major medical emergency due to their additional potential risk of anaphylaxis.
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20
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Abstract
Die Allergenimmuntherapie (AIT) ist – neben der oft nicht suffizient durchzuführenden Allergenmeidung – die einzige kausale Therapie Ig(Immunglobulin)E-vermittelter Allergien gegen Aeroallergene und Hymenopterengifte. Sie kann je nach Allergen als subkutane Injektion (subkutane Immuntherapie [SCIT]) oder über eine sublinguale Applikation (sublinguale Immuntherapie [SLIT]) erfolgen, kürzlich wurde zudem auch ein Verfahren zur oralen Immuntherapie zur Behandlung der Nahrungsmittelallergie zugelassen. Neben der korrekten Indikationsstellung (positive Anamnese und Diagnostik einer IgE-vermittelten Allergie, Allergenkarenz nicht ausreichend möglich) sind mögliche Kontraindikationen und Risikofaktoren zu beachten. Zudem kann es unter einer AIT zu – potenziell auch lebensgefährlichen – Nebenwirkungen kommen. Im Folgenden sollen häufig gestellte Fragen und Fakten zur Entscheidungsfindung für die Durchführung und zum Risikomanagement der AIT beleuchtet und unter Berücksichtigung der aktuellen Datenlage diskutiert werden.
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21
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Carra S, Schatz M, Mertes PM, Torres MJ, Fuchs F, Senna G, Castells MC, Demoly P, Tanno LK. ANAPHYLAXIS AND PREGNANCY: A SYSTEMATIC REVIEW AND CALL FOR PUBLIC HEALTH ACTIONS. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4270-4278. [PMID: 34365055 DOI: 10.1016/j.jaip.2021.07.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although rare, anaphylaxis during pregnancy implies a risk to both mothers and newborns. OBJECTIVE This systematic review is intended to identify key issues in the diagnosis and management of this condition in order to support prevention strategies and decrease the risk of death related to anaphylaxis during pregnancy. METHODS We searched MEDLINE, Cochrane, Lilacs, Scielo and Science Direct databases for manuscripts concerning terms "anaphylaxis during pregnancy" without language restrictions. We screened studies, extracted data, and assessed risk of bias independently in duplicate. RESULTS We selected 12 articles. Frequency of anaphylaxis during pregnancy is estimated between 1.5 to 3.8 per 100 000 maternities. Only one study provided anaphylaxis mortality data in pregnant women, and the rate of anaphylaxis-related maternal mortality is estimated at 0.05 per 100 000 live births. No standard definition of anaphylaxis severity has been utilized. Forty-nine percent to 74% of anaphylaxis cases were described during caesarean sections. Beta-lactam antibiotics (58%), latex (25%) and anaesthetic agents (17%) were the main culprits. In 17% of papers, causative agents were proven by allergy testing. Seventy two percent of articles proposed the same management and treatment for a clinical episode of anaphylaxis during pregnancy as in non-pregnant patients, and, use of epinephrine in the patient's care during anaphylaxis in pregnancy. CONCLUSION Few studies address anaphylaxis during pregnancy, and the majority have been produced by non-allergy specialists. Collaboration between different specialists involved in the care of pregnant women should be established in order to support preventive strategies and reduce avoidable deaths.
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Affiliation(s)
- Sophie Carra
- Department of Allergy, University Hospital of Montpellier, Montpellier, France
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente, San Diego, California, USA
| | - Paul-Michel Mertes
- Department of Anaesthesia and Critical Care, Strasbourg University Hospital, EA 3072, FMTS Strasbourg, France 1 Place de l'Hôpital - BP 426 67091 STRASBOURG CEDEX
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Florence Fuchs
- Departement of gynecology and obstetric, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; Inserm, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, 94807 Villejuif, France
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Mariana C Castells
- Brigham and Women's Hospital, Boston (M.C.C.); and the Department of Medicine, Vanderbilt University Medical Center, Nashville (E.J.P.), USA
| | - Pascal Demoly
- Department of Allergy, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Luciana Kase Tanno
- Department of Allergy, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; WHO Collaborating Centre on Scientific Classification Support, Montpellier, France; Hospital Sírio-Libanês.
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22
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Hatoum S, Farhat T. Acute heart failure during delivery: Is it the pregnancy or the allergen? Eur J Obstet Gynecol Reprod Biol 2021; 264:380-381. [PMID: 34274132 DOI: 10.1016/j.ejogrb.2021.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
- S Hatoum
- American University of Beirut Medical Centre, Beirut, Lebanon.
| | - T Farhat
- Faculty of Medicine, Beirut Arab University, Beirut, Lebanon
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23
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Pramanick A, Kanneganti A, Wong JLJ, Li SW, Dimri PS, Mahyuddin AP, Kumar S, Illanes SE, Chan JKY, Su LL, Biswas A, Tambyah PA, Huang RY, Mattar CNZ, Choolani M. A reasoned approach towards administering COVID-19 vaccines to pregnant women. Prenat Diagn 2021; 41:1018-1035. [PMID: 34191294 PMCID: PMC8362094 DOI: 10.1002/pd.5985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/20/2021] [Accepted: 05/28/2021] [Indexed: 12/24/2022]
Abstract
There are over 50 SARS-CoV-2 candidate vaccines undergoing Phase II and III clinical trials. Several vaccines have been approved by regulatory authorities and rolled out for use in different countries. Due to concerns of potential teratogenicity or adverse effect on maternal physiology, pregnancy has been a specific exclusion criterion for most vaccine trials with only two trials not excluding pregnant women. Thus, other than limited animal studies, gradually emerging development and reproductive toxicity data, and observational data from vaccine registries, there is a paucity of reliable information to guide recommendations for the safe vaccination of pregnant women. Pregnancy is a risk factor for severe COVID-19, especially in women with comorbidities, resulting in increased rates of preterm birth and maternal morbidity. We discuss the major SARS-CoV-2 vaccines, their mechanisms of action, efficacy, safety profile and possible benefits to the maternal-fetal dyad to create a rational approach towards maternal vaccination while anticipating and mitigating vaccine-related complications. Pregnant women with high exposure risks or co-morbidities predisposing to severe COVID-19 infection should be prioritised for vaccination. Those with risk factors for adverse effects should be counselled accordingly. It is essential to support patient autonomy by shared decision-making involving a risk-benefit discussion with the pregnant woman.
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Affiliation(s)
- Angsumita Pramanick
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Abhiram Kanneganti
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
| | - Jing Lin Jeslyn Wong
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Sarah Weiling Li
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Pooja Sharma Dimri
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
| | - Aniza Puteri Mahyuddin
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Sailesh Kumar
- Mater Research Institute‐University of QueenslandSouth BrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandHerstonQueenslandAustralia
| | | | - Jerry Kok Yen Chan
- Department of Reproductive MedicineKK Women's and Children's HospitalSingapore
- Academic Clinical Program in Obstetrics and GynaecologyDuke‐NUS Medical SchoolSingapore
| | - Lin Lin Su
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Arijit Biswas
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Paul Anantharajah Tambyah
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Ruby Yun‐Ju Huang
- School of MedicineCollege of Medicine, National Taiwan UniversityTaipeiTaiwan
| | - Citra Nurfarah Zaini Mattar
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
| | - Mahesh Choolani
- Department of Obstetrics and GynaecologyNational University Hospital SingaporeSingapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingapore
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24
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Vitte J, Sabato V, Tacquard C, Garvey LH, Michel M, Mertes PM, Ebo DG, Schwartz LB, Castells MC. Use and Interpretation of Acute and Baseline Tryptase in Perioperative Hypersensitivity and Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2994-3005. [PMID: 33746087 DOI: 10.1016/j.jaip.2021.03.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
Paired acute and baseline serum or plasma tryptase sampling and determination have recently been included as a mechanistic approach in the diagnostic and management guidelines of perioperative immediate hypersensitivity and anaphylaxis. The timing of this paired sampling is clearly defined in international consensus statements, with the optimal window for acute tryptase sampling between 30 minutes and 2 hours after the initiation of symptoms, whereas baseline tryptase should be measured in a sample collected before the event (preop) or at least 24 hours after all signs and symptoms have resolved. A transient elevation of the acute tryptase level greater than [2 + (1.2 × baseline tryptase level)] supports the involvement and activation of mast cells. Here, we provide the clinical, pathophysiological, and technical rationale for the procedure and interpretation of paired acute and baseline tryptase. Clinical examples, up-to-date knowledge of hereditary α-tryptasemia as a frequent cause of baseline tryptase of 7 μg/L and higher, mastocytosis, other clonal myeloid disorders, cardiovascular or renal failure, and technical improvements resulting in continued lowering of the 95th percentile value are discussed. Clues for improved management of perioperative immediate hypersensitivity and anaphylaxis include (1) sustained dissemination and implementation of updated guidelines; (2) preoperative sample storage for deferred analysis; (3) referral for thorough allergy investigation, screening for mast cell-related disorders, and recommendations for future anesthetic procedures; and (4) sustained collaboration between anesthesiologists, immunologists, and allergists.
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Affiliation(s)
- Joana Vitte
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; IDESP, INSERM UMR UA11, University of Montpellier, Montpellier, France
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Charles Tacquard
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Paul-Michel Mertes
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy & Immunology, Virginia Commonwealth University, Richmond, Va
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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25
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Heller A, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Leitlinie zu Akuttherapie und Management der Anaphylaxie - Update 2021. ALLERGO JOURNAL 2021; 30:20-49. [PMID: 33612982 PMCID: PMC7878028 DOI: 10.1007/s15007-020-4750-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Johannes Ring
- Haut- und Laserzentrum an der Oper, Perusastraße 5, 80333 München, Germany
| | - Kirsten Beyer
- Klinik für Pädiatrie - Pneumologie und Immunologie, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie, Biedersteiner Str. 29, 80802 München, Germany
| | - Andreas Bircher
- Universitätskliniken Basel, Petersgraben 4, 4031 Basel, Schweiz
| | - Matthias Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und, ALB FILS Kliniken Göppingen,, Göppingen, Germany
| | - Axel Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Isidor Huttegger
- Klinik für Pädiatrie, Universitätsklinikum Salzburg, Salzburg, Österreich
| | - Thilo Jakob
- Klinik für Dermatologie, Venerologie und Allergologie, Gaffkystraße 14, 35392 Gießen, Germany
| | - Ludger Klimek
- Zentrum f. Rhinologie und Allergologie, An den Quellen 10, 65183 Wiesbaden, Germany
| | | | - Claudia Kugler
- TU München, Biedersteiner Straße 29, 80802 München, Germany
| | - Lars Lange
- Klinik für Pädiatrie - Pneumologie und Immunologie, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Oliver Pfaar
- Sektion für Rhinologie und Allergologie, Baldingerstraße, 35043 Marburg, Germany
| | - Ernst Rietschel
- Pädiatrische Pneumologie u. Allergologie, Klinikum der Univ. Köln, Kerpener Str. 62, 50924 Köln, Germany
| | - Franziska Rueff
- Dermatologische Klinik u. Poliklinik der LMU, Frauenlobstr. 9-11, 80337 München, Germany
| | - Sabine Schnadt
- Deutscher Allergie- und Asthmabund (DAAB), An der Eickesmühle 15 - 19, 41238 Mönchengladbach, Germany
| | - Roland Seifert
- Institut für Pharmakologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Britta Stöcker
- Kinderpneumologie u. Allergologie, Robert-Koch-Str. 1, 53115 Bonn, China
| | - Regina Treudler
- Universitätsklinikum Leipzig, Philipp-Rosenthal-Str. 23, 4103 Leipzig, Germany
| | | | - Thomas Werfel
- Klinik für Dermatologie, Allergologie und Venerologie, Carl-Neuberg-Str. 1, 30449 Hannover, Germany
| | - Margitta Worm
- Allergie-Centrum-Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Helmut Sitter
- Klinik für Dermatologie und Allergologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Knut Brockow
- Klinik f. Dermatologie und Allergologie am Biederstein, Biedersteiner Str. 29, 80802 München, Germany
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Fuchs T, Heller A, Hoffmann F, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE). ALLERGO JOURNAL INTERNATIONAL 2021; 30:1-25. [PMID: 33527068 PMCID: PMC7841027 DOI: 10.1007/s40629-020-00158-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Johannes Ring
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Kirsten Beyer
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité—University Hospital Berlin, Berlin, Germany
| | - Tilo Biedermann
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Andreas Bircher
- Department of Dermatology, University Hospital of Basel, Basel, Switzerland
| | - Matthias Fischer
- Clinic for Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, ALB FILS Hospitals Göppingen, Göppingen, Germany
| | - Thomas Fuchs
- Department of Dermatology, University Hospital Göttingen, Göttingen, Germany
| | - Axel Heller
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Florian Hoffmann
- Dr. von Hauner Children’s Hospital, Ludwig Maximilians University, Munich, Germany
| | - Isidor Huttegger
- Department of Pediatrics, University Hospital Salzburg, Salzburg, Austria
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Medical Center Gießen (UKGM), Justus-Liebig-University Gießen, Gießen, Germany
| | - Ludger Klimek
- Center of Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias V. Kopp
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Kugler
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | | | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Ernst Rietschel
- Department of Pediatrics, University Hospital Cologne, Cologne, Germany
| | - Franziska Rueff
- Department of Dermatology and Allergology, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Sabine Schnadt
- German Allergy and Asthma Association, Mönchengladbach, Germany
| | - Roland Seifert
- Institute of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Britta Stöcker
- Medical practice for pediatrics and youth medicine, Poppelsdorfer Allee, Bonn, Germany
| | - Regina Treudler
- Department of Dermatology, Venereology, and Allergology, Leipzig Interdisciplinary Allergy Center, University Hospital Leipzig, Leipzig, Germany
| | - Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Thomas Werfel
- Immunodermatology and Experimental Allergology Unit, Department of Dermatology, Allergology, and Venereology, Medical University Hannover, Hannover, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité—University Hospital Berlin, Berlin, Germany
| | - Helmut Sitter
- Institute for Surgical Research, Philipps-University Marburg, Marburg, Germany
| | - Knut Brockow
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
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Penicillin Allergy Assessment in Pregnancy: Safety and Impact on Antibiotic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1338-1346. [PMID: 33212237 DOI: 10.1016/j.jaip.2020.10.063] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Penicillin and other beta-lactam antibiotics are recommended for group B Streptococcus and cesarean section prophylaxis, but approximately 10% of pregnant patients report a penicillin allergy. OBJECTIVE To assess the safety and impact of penicillin allergy evaluation in pregnant patients. METHODS In this retrospective study of obstetrician-ordered Allergy/Immunology (AI) electronic consultations (e-consults) from September 20, 2017 through December 31, 2019, we reviewed the electronic health record for e-consult recommendation; patient demographic, obstetric, and allergy histories; and peripartum antibiotic utilization with indication. For patients whose electronic consultation recommended an in-person AI evaluation, testing outcomes were determined, and multivariable logistic regression models were used to compare antibiotic use between patients who did and did not receive an in-person AI evaluation. RESULTS Of 389 obstetrician-ordered e-consults, 363 (93%) recommended an in-person AI evaluation; of these, 222 (61%) patients received an in-person AI evaluation. Of 220 (99%) patients skin tested, 209 (95%) had their penicillin allergy label safely removed. Compared with patients who did not receive an in-person AI evaluation despite it being recommended (n = 141), patients with in-person AI evaluation (n = 222) had reduced peripartum vancomycin (adjusted odds ratio [aOR], 0.07; 95% CI, 0.01-0.33), clindamycin (aOR, 0.17; 95% CI, 0.08-0.34), and gentamicin (aOR, 0.39; 95% CI, 0.19-0.78) use and increased penicillin (aOR, 18.0; 95% CI, 6.30-51.2) use. The fully AI evaluated patients had increased first-line antibiotic prophylaxis for group B Streptococcus (aOR, 26.9; 95% CI, 6.32-114) and cesarean section (aOR, 1.94; 95% CI, 1.06-3.52). CONCLUSIONS In a sample of 220 pregnant patients with penicillin allergy histories and in-person AI evaluation, penicillin allergy testing was safe and associated with significantly reduced broad-spectrum antibiotic use and increased first-line beta-lactam antibiotic use.
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D'Astous-Gauthier K, Graham F, Paradis L, Des Roches A, Bégin P. Beta-2 Agonists May be Superior to Epinephrine to Relieve Severe Anaphylactic Uterine Contractions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1232-1241. [PMID: 33181341 DOI: 10.1016/j.jaip.2020.10.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Uterine contractions are recognized as a potential manifestation of anaphylaxis, but literature on their proper management is limited. It is widely recognized that anaphylactic reactions can cause uterine contractions, but little is known about their optimal management. OBJECTIVE Review potential treatments for painful uterine contractions associated with anaphylaxis or mast cell activation. METHODS This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. PubMed, Embase, and Cochrane were searched in English, French, and Spanish for reports of uterine anaphylaxis published up until July 2020. The search strategy used a combination of Boolean operators and included the following Medical Subject Heading terms and keywords: hypersensitivity; anaphylaxis; mastocytosis; uterus; uterine contraction; pelvic pain; labor, obstetric; labor, premature; and endometriosis. RESULTS This systematic review identified 19 studies reporting on 31 cases of painful uterine contractions occurring during anaphylaxis or other events associated with mast cell activation. Nine patients were pregnant. We present 2 additional cases in nonpregnant women, one associated with an oral food challenge and the other associated with oral food desensitization. The most frequent triggers were subcutaneous immunotherapy (14 cases), food (6 cases), and drugs (4 cases). Uterine cramps were associated with systemic symptoms in 24 cases and lasted on average for 2.4 hours. Pretreatment with antihistamines and montelukast generally failed to prevent recurrence, but nonsteroidal anti-inflammatory drugs were used successfully in some reports. Response to intramuscular epinephrine was inconsistent. Data from ex vivo models indicate that epinephrine may paradoxically contribute to uterine contractions through alpha-receptor activity. A small number of cases showed good response to beta-2 agonists. CONCLUSIONS There is a lack of quality data on painful uterine contractions occurring in the context of anaphylactic reactions and on their optimal management. In the absence of counterindication, use of a beta-2 agonist and premedication with nonsteroidal anti-inflammatory drugs could be the preferred options.
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Affiliation(s)
- Katherine D'Astous-Gauthier
- Division of Allergy, Department of Medicine, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| | - Francois Graham
- Division of Allergy, Department of Medicine, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada; Division of Allergy, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Montreal, QC, Canada
| | - Louis Paradis
- Division of Allergy, Department of Medicine, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada; Division of Allergy, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Montreal, QC, Canada
| | - Anne Des Roches
- Division of Allergy, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Montreal, QC, Canada
| | - Philippe Bégin
- Division of Allergy, Department of Medicine, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada; Division of Allergy, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Montreal, QC, Canada.
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Furness A, Kalicinsky C, Rosenfield L, Barber C, Poliquin V. Penicillin Skin Testing, Challenge, and Desensitization in Pregnancy: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1254-1261.e3. [PMID: 32005632 DOI: 10.1016/j.jogc.2019.11.067] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study sought to evaluate available evidence of the safety of penicillin skin testing (PST), challenge, and desensitization in pregnancy, with efforts to improve perinatal care for patients with a penicillin allergy history and mitigate the negative sequelae of unverified penicillin allergy labels. METHODS A systematic review of studies was conducted using Cochrane Library, Medline, EMBASE, and International Pharmaceutical Abstracts. Included were peer-reviewed studies without date restrictions, published in English or French, relating to PST, challenge, or desensitization in pregnancy. Editorials, opinion pieces, and letters were excluded. Review authors independently screened citations and full-text articles, extracted data, and conducted quality assessment. Given the heterogeneity of study designs, a narrative synthesis was conducted. RESULTS The search identified 1195 references, of which 18 studies met inclusion criteria. In total there were 231 patients with varying histories of penicillin allergy, the majority requiring treatment for syphilis or group B streptococcal (GBS) disease during pregnancy. Of the 203 participants who underwent PST, 83.7% had negative test results. Allergy-related reactions were rare in PST (1.5%) and challenge (0%), and although these reactions were more common in desensitization (19.7%), most were benign. Among the 231 cases, only one adverse pregnancy outcome was reported (0.4%). CONCLUSION This review demonstrates that the known prevalence of true penicillin allergy extends to pregnant women. PST and desensitization can be safely applied during pregnancy and are tools that should be used more frequently. Further data on the safety of challenge during pregnancy are recommended.
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Affiliation(s)
- Allison Furness
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB.
| | - Chrystyna Kalicinsky
- Section of Allergy and Clinical Immunology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB
| | - Lana Rosenfield
- Section of Allergy and Clinical Immunology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB
| | - Colin Barber
- Section of Allergy and Clinical Immunology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB
| | - Vanessa Poliquin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB
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Abstract
MRI is a powerful diagnostic tool with excellent soft tissue contrast that uses nonionizing radiation. These advantages make MRI an appealing modality for imaging the pregnant patient; however, specific risks inherent to the magnetic resonance environment must be considered. MRI may be performed without and/or with intravenous contrast, which adds further fetal considerations. The risks of MRI with and without intravenous contrast are reviewed as they pertain to the pregnant or lactating patient and to the fetus and nursing infant. Relevant issues for gadolinium-based contrast agents and ultrasmall paramagnetic iron oxide particles are reviewed.
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Affiliation(s)
- Jason T Little
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Candice A Bookwalter
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Spindola MAC, Solé D, Aun MV, Azi LMTDA, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MÂ, Watanabe AS, Curi EF, Sano F. [Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part I: post-crisis guidelines and treatment]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2020; 70:534-548. [PMID: 33077175 PMCID: PMC9373446 DOI: 10.1016/j.bjan.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/17/2020] [Accepted: 06/20/2020] [Indexed: 11/20/2022]
Abstract
Experts from the Brazilian Association of Allergy and Immunology (ASBAI) and the Brazilian Society of Anesthesiology (SBA) interested in the issue of perioperative anaphylaxis, and aiming to strengthen the collaboration between the two societies, combined efforts to study the topic and to prepare a joint document to guide specialists in both areas. The purpose of the present series of two articles was to report the most recent evidence based on the collaborative assessment between both societies. This first article will consider the updated definitions, treatment and guidelines after a perioperative crisis. The following article will discuss the major etiologic agents, how to proceed with the investigation, and the appropriate tests.
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Affiliation(s)
- Maria Anita Costa Spindola
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Dirceu Solé
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, Brazil; Faculdade Israelita de Ciências da Saúde Albert Eisntein, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital Universitário, São Paulo, SP, Brazil
| | - Liana Maria Tôrres de Araújo Azi
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brazil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brazil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | | | - Alex Eustáquio Lacerda
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Luciana Cavalcanti Lima
- Associação Brasileira de Alergia e Imunologia, Brazil; Instituto Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil
| | - Edelton Flávio Morato
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Rogean Rodrigues Nunes
- Sociedade Brasileira de Anestesiologia, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Maria Ângela Tardelli
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | - Flávio Sano
- Associação Brasileira de Alergia e Imunologia, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brazil
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Spindola MAC, Solé D, Aun MV, Azi LMTDA, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MÂ, Watanabe AS, Curi EF, Sano F. Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) – Part I: post-crisis guidelines and treatment. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33077175 PMCID: PMC9373446 DOI: 10.1016/j.bjane.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Maria Anita Costa Spindola
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Dirceu Solé
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, Brazil; Faculdade Israelita de Ciências da Saúde Albert Eisntein, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital Universitário, São Paulo, SP, Brazil
| | - Liana Maria Tôrres de Araújo Azi
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brazil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brazil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | | | - Alex Eustáquio Lacerda
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Luciana Cavalcanti Lima
- Associação Brasileira de Alergia e Imunologia, Brazil; Instituto Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil
| | - Edelton Flávio Morato
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Rogean Rodrigues Nunes
- Sociedade Brasileira de Anestesiologia, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Maria Ângela Tardelli
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | - Flávio Sano
- Associação Brasileira de Alergia e Imunologia, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brazil
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Abstract
To use medications appropriately, patients need to be treated based on their clinical conditions, in doses that are based on their individual requirements, for an adequate amount of time, and at the lowest expense. The perinatal period is characterized by an excessive use of antibiotics. This antibiotic abuse can lead to antibiotic resistance, microbiome alterations, and dysbiosis, which have been associated with serious complications such as infections, abnormal brain development, allergies, autoimmune disorders, obesity, and an increase in mortality as well as an increase in health care expenditures. The need to optimize antibiotic utilization in perinatal medicine has never been more urgent; there is not much more time to wait.
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Affiliation(s)
- Augusto Sola
- Ibero American Society of Neonatology (SIBEN), Wellington, FL
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34
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Abstract
PURPOSE OF REVIEW Is sexual dimorphism also true in anaphylaxis as described in other allergic diseases? Possible gender differences in the epidemiology, triggers, severity, outcomes of anaphylaxis as well as in the pathogenesis of the disease are discussed. RECENT FINDINGS Hormonal status and the X-chromosome-coded factors deeply involved in the regulation of T-cell and B-cell responses may influence the gender difference noticed in allergic diseases, such as asthma and rhinitis. Little is known if sex is also relevant for anaphylaxis, although the description of catamenial anaphylaxis is intriguing. However, epidemiologic bias, lack of reliable animal models for the human disease, differences into diagnostic codes and not harmonized clinical grading unfortunately represent hurdles to obtain meaningful information on this topic. SUMMARY The female sex predisposes to a dysregulation of the immune response as suggested by the increased prevalence of autoimmunity and atopy. In anaphylaxis, pathomechanisms are not fully disclosed, triggers are numerous and IgE-dependent mast cell degranulation only represents a part of the story. Improvement into the definition of the disease including a more careful coding system and better investigations about triggers seem the only way to allow a more precise assessment of the possible different risk for women to develop anaphylaxis.
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Hantoushzadeh S, Anvari Aliabad R, Norooznezhad AH. Antibiotics, Inflammation, and Preterm Labor: A Missed Conclusion. J Inflamm Res 2020; 13:245-254. [PMID: 32547156 PMCID: PMC7261809 DOI: 10.2147/jir.s248382] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/14/2020] [Indexed: 12/30/2022] Open
Abstract
Regarding the risk of antibiotic therapy during pregnancy, any medication given to the mother should be according to the indications due to the risk of possible side effects. Antibiotics are one of the most important groups of these medications to be considered. Along with direct antibiotic-induced side effects, indirect pathways also affect the fetus through the maternal changes. According to the data, different cytokines including interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α) are involved in both term and preterm parturition. These cytokines could trigger expression of different substances such as prostaglandins (PGs), their receptors, and PGs synthetizing molecules with already proven roles in parturition. Moreover, IL-1, IL-6, and TNF-α knocked-out mice have delayed parturition and lower levels of PGs compared to the wild types. The earlier-mentioned cytokines are able to induce matrix metalloproteinases and are also involved in parturition. Certain antibiotics have been shown capable of inducing inflammation cascade directly. Both in-vivo and in-vitro studies in human have also demonstrated this inflammation as elevated levels of inflammatory cytokines especially IL-1, IL-6, and TNF-α. This increase has been observed both in the presence and the absence of lipopolysaccharide (LPS). Moreover, antibiotics can induce endotoxemia in healthy cases which finally leads to the pro-inflammatory cytokine release. Regarding the role of mentioned pro-inflammatory cytokines in both term and preterm parturition, it seems that non-indicated use of antibiotics during pregnancy may increase the risk of preterm labor.
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Affiliation(s)
- Sedigheh Hantoushzadeh
- Maternal, Fetal and Neonatal Research Center, Vali-Asr Hospital, Imam Khomeini Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
| | - Roghayeh Anvari Aliabad
- Department of Gynecology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Amir Hossein Norooznezhad
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Reazaul Karim H, Poonuraparampil J, Garhwal A, Babu M. The conundrum of perioperative management for emergency cesarean section in a patient with anaphylactic shock. BALI JOURNAL OF ANESTHESIOLOGY 2020; 4:74. [DOI: 10.4103/bjoa.bjoa_87_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Abrupt deterioration in the mother's condition may occur postpartum as a result of a broad array of conditions, many of them rare. Maternal survival depends on aggressive resuscitation, rapid precise diagnosis and the institution of disease-targeted therapy. Additionally there may be implications for any future pregnancy. A case of sudden maternal collapse postpartum is presented, the differential diagnosis is discussed, and the management plan and outcome for a subsequent pregnancy reviewed.
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Affiliation(s)
- Adam Morton
- Mater Health and University of Queensland, Brisbane, Australia
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Novel Epigenetic Biomarkers in Pregnancy-Related Disorders and Cancers. Cells 2019; 8:cells8111459. [PMID: 31752198 PMCID: PMC6912400 DOI: 10.3390/cells8111459] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/08/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
As the majority of cancers and gestational diseases are prognostically stage- and grade-dependent, the ultimate goal of ongoing studies in precision medicine is to provide early and timely diagnosis of such disorders. These studies have enabled the development of various new diagnostic biomarkers, such as free circulating nucleic acids, and detection of their epigenetic changes. Recently, extracellular vesicles including exosomes, microvesicles, oncosomes, and apoptotic bodies have been recognized as powerful diagnostic tools. Extracellular vesicles carry specific proteins, lipids, DNAs, mRNAs, and miRNAs of the cells that produced them, thus reflecting the function of these cells. It is believed that exosomes, in particular, may be the optimal biomarkers of pathological pregnancies and cancers, especially those that are frequently diagnosed at an advanced stage, such as ovarian cancer. In the present review, we survey and critically appraise novel epigenetic biomarkers related to free circulating nucleic acids and extracellular vesicles, focusing especially on their status in trophoblasts (pregnancy) and neoplastic cells (cancers).
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McCall SJ, Kurinczuk JJ, Knight M. Anaphylaxis in Pregnancy in the United States: Risk Factors and Temporal Trends Using National Routinely Collected Data. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:2606-2612.e3. [PMID: 31102701 PMCID: PMC6848914 DOI: 10.1016/j.jaip.2019.04.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/10/2019] [Accepted: 04/19/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Anaphylaxis in pregnancy is an understudied, rare, and severe complication of pregnancy. OBJECTIVE To describe the incidence and temporal trends, and to identify potential risk factors for anaphylaxis-related hospitalizations while pregnant in the United States. METHODS All hospitalizations while pregnant and any anaphylactic reactions were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes from the National Inpatient Sample, United States, over the period 2004 to 2014. Annual incidence rates of anaphylaxis during pregnancy were calculated. Logistic regression models assessed risk factors for anaphylaxis during pregnancy, presented as odds ratios (ORs) and 95% CIs. RESULTS During the period 2004 to 2014, the incidence of anaphylaxis during pregnancy was 3.8 (95% CI, 3.4-4.2) per 100,000 hospitalizations while pregnant. The incidence did not statistically differ during the period 2004 to 2014. After adjustment, there were 3 factors that increased the odds of anaphylaxis during pregnancy: cesarean delivery (adjusted OR [aOR], 4.19; 95% CI, 3.28-5.35) compared with noncesarean delivery; history of an allergic reaction (aOR, 4.05; 95% CI, 2.64-6.23) compared with no history; and a black race (aOR, 1.57; 95% CI, 1.15-2.15) and other race (aOR, 1.69; 95% CI, 1.08-2.63) compared with white race. CONCLUSIONS Despite increased rates of cesarean delivery in the United States and consequent drug administration, there was no evidence of an increasing trend in anaphylaxis. Cesarean delivery and history of an allergic reaction allow the identification of women at risk of anaphylaxis. Not all women had clear risk factors, and preparations should always be in place to ensure timely management if this uncommon event occurs.
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Affiliation(s)
- Stephen J McCall
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Headington, Oxford, United Kingdom.
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Headington, Oxford, United Kingdom
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Headington, Oxford, United Kingdom
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Affiliation(s)
- Johannes Ring
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland.
| | - Andreas Weins
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland
| | - Martine Grosber
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland
| | - Knut Brockow
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland
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Anaphylaxis-related mortality in the obstetrical setting: analysis of the French National Confidential Enquiry into Maternal Deaths from 2001 to 2012. Br J Anaesth 2019; 123:e151-e153. [DOI: 10.1016/j.bja.2018.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/27/2018] [Accepted: 12/19/2018] [Indexed: 11/19/2022] Open
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Abstract
RATIONALE Anaphylaxis is a very rare event in pregnancy, triggering maternal hypotension leading to intrapartum hypoxic-ischemic encephalopathy in infant. Furthermore, cesarean sections are performed at a high rate in anaphylactic pregnant women. PATIENT CONCERNS A 34-year-old pregnant woman presented with maternal anaphylaxis following prophylactic antibiotic injection for cesarean section. Within a few minutes after initiation of intradermal skin test with cefotetan, the pregnant woman developed generalized itchy rash, chest tightness, and dyspnea. DIAGNOSES Several minutes after the injection of antibiotics, a diffuse urticarial rash was detected over her face and trunk followed by complaints of chest tightness and dyspnea. She was diagnosed with hypotension and hypoxia. Further, fetal heart tones showed bradycardia. A presumptive diagnosis of anaphylactic reaction induced by cefotetan was made for surgical prophylaxis. INTERVENTIONS The patient was managed for anaphylaxis, via administration of epinephrine, glucocorticoid, and antihistamine. Emergency cesarean section performed under general anesthesia resulted in a favorable perinatal outcome for the fetus. OUTCOMES Maternal and fetal outcomes were good after prompt treatment for anaphylaxis and emergency cesarean section. LESSONS This is the first reported case of anaphylaxis following cefotetan administration in pregnancy. Cefotetan, a second-generation cephalosporin, is a commonly prescribed antibiotic used to treat a wide range of bacterial infections. The case demonstrated life-threatening anaphylactic reaction during pregnancy. Even a skin test using antibiotics alone triggered anaphylaxis.
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Affiliation(s)
| | - Aeli Ryu
- Departments of Obstetrics and Gynaecology
| | - Jiwon Min
- Departments of Obstetrics and Gynaecology
| | - Nan Seol Kim
- Anesthesiology and Pain Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Ring J, Klimek L, Worm M. Adrenaline in the Acute Treatment of Anaphylaxis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:528-534. [PMID: 30149833 PMCID: PMC6131363 DOI: 10.3238/arztebl.2018.0528] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 05/03/2018] [Accepted: 05/03/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anaphylaxis is the most serious manifestation of an immediate allergic reaction and the most common emergency event in allergology. Adrenaline (epi- nephrine) is the mainstay of acute pharmacotherapy for this complication. Although epinephrine has been in use for more than a century, physicians and patients are often unsure and inadequately informed about its proper administration and dosing in everyday situations. METHODS This review is based on pertinent publications from the period 1 January 2012 to 30 September 2017 that were retrieved, on the basis of the existing guide- lines of 2007 and 2014, by a PubMed search employing the keywords "anaphylaxis treatment," "allergic shock," "adrenaline," and "epinephrine," as well as on further ar- ticles from the literature. RESULTS Adrenaline/epinephrine administration often eliminates all manifestations of anaphylaxis. The method of choice for administering it (except in intensive-care medicine) is by intramuscular injection with an autoinjector; this is mainly done to treat reactions of intermediate severity. The injection is given in the lateral portion of the thigh and can be repeated every 10-15 minutes until there is a response. The dose to be administered is 300-600 µg for an adult or 10 µg/kg for a child. The risk of a serious cardiac adverse effect is lower than with intravenous administration. There have not been any randomized controlled trials on the clinical efficacy of ephi- nephrine in emergency situations. The use of an autoinjector should be specially practiced in advance. CONCLUSION The immediate treatment of patients with anaphylaxis is held to be ad- equate, yet major deficiencies remain in their further diagnostic evaluation, in the prescribing of emergency medications, and in patient education. Further research is needed on cardiovascular involvement in anaphylaxis and on potential new thera- peutic approaches.
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Affiliation(s)
- Johannes Ring
- Department of Dermatology and Allergology, Technical University Munich
| | | | - Margitta Worm
- Department of Dermatology, Venerology and Allergology, Charité—Universitätsmedizin Berlin
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McCall SJ, Bunch KJ, Brocklehurst P, D'Arcy R, Hinshaw K, Kurinczuk JJ, Lucas DN, Stenson B, Tuffnell DJ, Knight M. The incidence, characteristics, management and outcomes of anaphylaxis in pregnancy: a population-based descriptive study. BJOG 2018; 125:965-971. [PMID: 29193647 PMCID: PMC6033185 DOI: 10.1111/1471-0528.15041] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to estimate the incidence of anaphylaxis in pregnancy and describe the management and outcomes in the UK. DESIGN A population-based descriptive study using the UK Obstetric Surveillance System (UKOSS). SETTING All consultant-led maternity units in the UK. POPULATION All pregnant women who had anaphylaxis between 1 October 2012 and 30 September 2015. Anaphylaxis was defined as a severe, life-threatening generalised or systemic hypersensitivity reaction. METHODS Prospective case notification using UKOSS. MAIN OUTCOME MEASURES Maternal mortality, severe maternal morbidity, neonatal mortality and severe neonatal morbidity. RESULTS There were 37 confirmed cases of anaphylaxis in pregnancy, giving an estimated incidence of 1.6 (95% CI: 1.1-2.2) per 100 000 maternities. Four cases of anaphylaxis were in women with known penicillin allergies: two received co-amoxiclav and two cephalosporins. Twelve women had anaphylaxis following prophylactic use of antibiotics at the time of a caesarean delivery. Prophylactic use of antibiotics for Group B streptococcal infection accounted for anaphylaxis in one woman. Two women died (5%), 14 (38%) women were admitted to intensive care and seven women (19%) had one or more additional severe maternal morbidities, which included three haemorrhagic events, two cardiac arrests, one thrombotic event and one pneumonia. No infants died; however, in those infants whose mother had anaphylaxis before delivery (n = 18) there were seven (41%) neonatal intensive care unit admissions, three preterm births and one baby was cooled for neonatal encephalopathy. CONCLUSIONS Anaphylaxis is a rare severe complication of pregnancy and frequently the result of a reaction to antibiotic administration. This study highlights the seriousness of the outcomes of this condition for the mother. The low incidence is reassuring given the large proportion of the pregnant population that receive prophylactic antibiotics during delivery. TWEETABLE ABSTRACT Anaphylaxis is a rare severe complication of pregnancy and frequently the result of a reaction to antibiotic administration.
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Affiliation(s)
- SJ McCall
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology Unit (NPEU)Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - KJ Bunch
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology Unit (NPEU)Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - P Brocklehurst
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology Unit (NPEU)Nuffield Department of Population HealthUniversity of OxfordOxfordUK
- Birmingham Clinical Trials UnitUniversity of BirminghamBirminghamUK
| | - R D'Arcy
- Nuffield Department of Obstetrics and GynaecologyJohn Radcliffe HospitalUniversity of OxfordOxfordUK
| | - K Hinshaw
- Department of Obstetrics and GynaecologySunderland Royal HospitalSunderlandUK
| | - JJ Kurinczuk
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology Unit (NPEU)Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - DN Lucas
- Department of AnaestheticsNorthwick Park HospitalLondonUK
| | - B Stenson
- Neonatal UnitRoyal Infirmary of EdinburghEdinburghUK
| | - DJ Tuffnell
- Teaching Hospitals Foundation NHS TrustBradfordUK
| | - M Knight
- Policy Research Unit in Maternal Health and CareNational Perinatal Epidemiology Unit (NPEU)Nuffield Department of Population HealthUniversity of OxfordOxfordUK
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Management of Mastocytosis in Pregnancy: A Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1217-1223. [DOI: 10.1016/j.jaip.2017.05.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/09/2017] [Accepted: 05/24/2017] [Indexed: 01/08/2023]
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Hermans MAW, Arends NJT, Gerth van Wijk R, van Hagen PM, Kluin-Nelemans HC, Oude Elberink HNG, Pasmans SGMA, van Daele PLA. Management around invasive procedures in mastocytosis: An update. Ann Allergy Asthma Immunol 2017; 119:304-309. [PMID: 28866309 DOI: 10.1016/j.anai.2017.07.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/07/2017] [Accepted: 07/19/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Mastocytosis is a chronic hematologic disorder that is characterized by the accumulation of aberrant mast cells and typically involves the skin and/or bone marrow. Patients with mastocytosis are at increased risk of anaphylaxis. Based on theoretical assumptions, medical procedures requiring general anesthesia or radiocontrast media are deemed hazardous for patients with mastocytosis. The objective of this article is to provide a comprehensive overview of the actual risk of iatrogenic anaphylaxis and provide recommendations for daily practice. DATA SOURCES Various scientific search engines were used (eg, PubMed and Medline). STUDY SELECTIONS Because of the paucity of high-level studies on this topic, all available evidence was considered, including case reports. RESULTS Reliable data on the incidence of iatrogenic anaphylaxis in mastocytosis are lacking. However, although the incidence as reported in (retrospective) cohort studies is higher than in the general population, it is still lower than commonly anticipated, with an incidence of 5.4% in 1 study. Adequate premedication and avoidance of certain physical stimuli can further decrease this risk by 10-fold. The role of drugs as elicitors of anaphylaxis is perhaps overestimated, and physical stimuli are at least as important in inducing release of mast cell mediators. CONCLUSION This article provides practical recommendations for the management of invasive procedures in patients with mastocytosis based on current knowledge of this topic.
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Affiliation(s)
- Maud A W Hermans
- Department of Internal Medicine, Section of Allergy, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Section of Clinical Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Nicolette J T Arends
- Department of Pediatrics, Sophia Children's Hospital and Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roy Gerth van Wijk
- Department of Internal Medicine, Section of Allergy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - P Martin van Hagen
- Department of Internal Medicine, Section of Clinical Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hanneke C Kluin-Nelemans
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hanneke N G Oude Elberink
- Department of Internal Medicine, Section of Allergy, University Medical Center Groningen, Groningen, The Netherlands
| | - Suzanne G M A Pasmans
- Department of Dermatology, Sophia Children's Hospital and Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Paul L A van Daele
- Department of Internal Medicine, Section of Allergy, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Section of Clinical Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Wu SS, Abraham T, Michaud C, Peppers B, Ward A, Buchner SE, Teba CV, Tcheurekdjian H, Hostoffer R, Jhaveri D. Fetal response to intramuscular epinephrine for anaphylaxis during maternal penicillin desensitization for secondary syphilis. J Matern Fetal Neonatal Med 2017; 31:2223-2225. [PMID: 28562129 DOI: 10.1080/14767058.2017.1336221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Penicillin desensitization is indicated in pregnant patients with severe allergies to penicillin with syphilis. The immediate effects of intramuscular epinephrine on the fetus during desensitization remain unreported. We describe a pregnant patient with secondary syphilis and penicillin allergy who developed anaphylaxis during penicillin desensitization. Anaphylaxis resolved after administration of intramuscular epinephrine. Throughout the procedure, continuous electronic fetal monitoring showed a stable fetus without a decrease in variability, tachycardia, decelerations, or signs of fetal distress. This case showed that intramuscular epinephrine is effective in treatment of anaphylaxis in a pregnant patient with little to no immediate effects on the fetus.
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Affiliation(s)
- Shan Shan Wu
- a Internal Medicine Residency Program , University Hospitals Regional Hospitals , Richmond Heights , OH , USA
| | - Tina Abraham
- b Allergy/Immunology Fellowship Program , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Chelsea Michaud
- b Allergy/Immunology Fellowship Program , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Brian Peppers
- b Allergy/Immunology Fellowship Program , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Andrea Ward
- c Obstetrics and Gynecology Residency Program , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Stacey Ehrenberg Buchner
- d Department of Obstetrics and Gynecology , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Catalina V Teba
- e Department of Medicine, Division of Pulmonary/Critical Care , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | | | - Robert Hostoffer
- f Allergy/Immunology Associates, Inc. , Mayfield Heights , OH , USA
| | - Devi Jhaveri
- f Allergy/Immunology Associates, Inc. , Mayfield Heights , OH , USA
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Umgang mit absoluten und relativen Kontraindikationen bei der spezifischen Immuntherapie mit Hymenopterengiften. ALLERGO JOURNAL 2017. [DOI: 10.1007/s15007-017-1367-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sridharan K, Sivaramakrishnan G. Sublingual immunotherapy in patients with latex allergy: systematic review and meta-analysis of randomized controlled trials. J DERMATOL TREAT 2017; 28:600-605. [PMID: 28320227 DOI: 10.1080/09546634.2017.1303567] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Latex allergy (LA) is a commonly observed entity for which sublingual immunotherapy (SLIT) has been shown to be effective in many small randomized clinical trials. The present study was conducted with an aim of systematically reviewing the existing literature on the efficacy and safety of SLIT in patients with LA and to apply the principles of meta-analysis. A search for randomized controlled trials with appropriate search strategy in PubMed and CENTRAL was conducted. Studies with documented clinical history of LA and SLIT administered in any dose, duration and regimen compared with placebo were included. Outcome measures were symptom scores, glove provocation test score, serum IgE levels, induration following latex skin prick test, medication scores and adverse effects. Random effects model was used when moderate to severe heterogeneity was observed and fixed effects model when there was mild heterogeneity. Forest plots for standardized mean difference (95% confidence interval) for all the continuous outcome measures were created. A total of 152 records were identified from the electronic databases and four studies were finally included in the meta-analysis. A statistically significant reduction for induration following glove provocation test (pooled results from two studies) was observed in the SLIT group with SMD of -0.9 [-1.71, -0.08]. No significant differences were observed in any other outcome measures between the interventions. We did not identify significant reduction in most of the outcome measures with SLIT in patients with LA except for glove provocation test score wherein only two studies were included. Large and more randomized controlled trials are required to ascertain and confirm the utility of SLIT in such patients.
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Affiliation(s)
- Kannan Sridharan
- a Pharmacology, Department of Health Sciences , Fiji National University , Suva , Fiji
| | - Gowri Sivaramakrishnan
- b Prosthodontics, Department of Oral Health, College of Medicine, Nursing and Health Sciences , Fiji National University , Suva , Fiji
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