A parturient with a 14-year history of
autoimmune progesterone dermatitis presented in labour at 36 weeks' gestation. She had suffered recurrent episodes of
angioedema over a long period and had been scheduled for elective caesarean
hysterectomy and bilateral
oophorectomy at 37 weeks' gestation. In most cases surgical
oophorectomy provides prolonged relief from the recurrent
angioedema and dermatological manifestations that are typical of
autoimmune progesterone dermatitis. Spinal anaesthesia was chosen in order to avoid airway manipulation,
a factor frequently implicated in the development of
angioedema. Delivery was uneventful and the obstetricians proceeded to
hysterectomy and
oophorectomy. Forty minutes after delivery the patient experienced an attack of
angioedema, she was markedly hypotensive and was given fluids,
ephedrine and
phenylephrine with good effect. As she remained normotensive, she was given intramuscular rather than intravenous
epinephrine to provide a slower release. She recovered well and stabilised without the need for intubation or ventilation. This case reinforces the rationale for regional anaesthesia in these patients and demonstrates how intramuscular
epinephrine contributed towards a positive outcome.