LATEX sensitivity in the surgical population has been well-described, including anaphylactic reactions from contact with latex products in the operating suite. 1–4The use of powdered latex examination gloves is associated with increased levels of latex particles in the air. 5,6Exposure to airborne latex antigen can trigger allergic reactions in sensitized individuals. 5,7,8We describe a case of a parturient with known latex sensitivity who had an anaphylactic reaction in the obstetric triage room after unintentional exposure to airborne latex particles. This reaction precipitated fetal distress and the potential need for emergency cesarean delivery.
A 32-yr-old gravida 1 para 0 patient at 32 weeks’ gestational age presented to the triage room of the obstetric unit for evaluation of possible preterm labor. At the time of her arrival, the obstetric nurse approached the patient while wearing a pair of powdered latex examination gloves (Perry X-AM®; Ansell Healthcare Products, Inc., Massillon, OH). Questioning of the patient before physical contact revealed a history of latex allergy. She reported contact dermatitis to latex in the past and had undergone skin-prick testing to latex antigen, the results of which she reported as positive. She had not had a previous life-threatening reaction to latex. In her prenatal visits, she had been treated with latex-safe precautions. The obstetric staff member removed the gloves in the immediate vicinity of the patient at that time. No contact with the patient was made, nor were medications administered. Within several minutes, the patient began to complain of tightness in her chest and dyspnea. As additional staff were summoned, the dyspnea progressed, and audible wheezing was appreciated. A generalized urticarial rash was noted over her face and trunk. Vital signs were obtained, and oxygen delivery via face mask, left uterine displacement, and insertion of an intravenous cannula were accomplished. Initial blood pressure was 80/40 mmHg, pulse was 98 beats/min, and respiratory rate was 24 breaths/min. Fetal heart rate was externally assessed by Doppler ultrasonography and showed fetal bradycardia in the range of 80–90 beats/min.
The obstetrician in attendance instituted initial treatment, which consisted of a rapid 500-ml bolus of lactated Ringer’s solution, 50 mg diphenhydramine, and 100 mg hydrocortisone acetate intravenously as the obstetric anesthesia team was summoned to the triage room. At the time of our arrival, the patient was hypotensive, with cuff blood pressure of 78/40 mmHg and persistent fetal bradycardia. Given the patient’s history of previous latex allergy, the presumptive diagnosis of anaphylactic reaction caused by accidental exposure to latex antigen was made. Ephedrine, 10 mg intravenously, was administered for treatment of maternal hypotension because of its immediate availability. Because of prolonged fetal bradycardia (approximately 80 beats/min), the patient was immediately transferred to the operating suite for emergent operative delivery of the fetus. Because the operative suite had not been prepared as a latex-safe environment, the patient underwent preoxygenation in the operating room via the latex-free anesthesia ventilator bellows. Reexamination of the patient at this time (approximately 10 min after initial symptoms) revealed a blood pressure of 110/55 mmHg, a heart rate of 100 beats/min, and a respiratory rate of 20 breaths/min. Symptomatically, the dyspnea was less pronounced, and reexamination showed the fetal heart rate to be 100 beats/min and increasing. The patient was observed in the operating room for an additional 15–20 min, during which time her vital signs and symptoms of dyspnea and urticaria resolved. She was transferred to a patient room that had been ventilated and prepared as latex-safe, and was subsequently discharged from the hospital later that day. The patient returned several times in the ensuing weeks for obstetric examination without further difficulties. Strict latex-safe precautions were followed for her subsequent care. She subsequently had a spontaneous vaginal delivery, with delivery of a normal term fetus. The patient declined further laboratory investigation of her latex sensitivity because of her previous positive allergy testing.
Latex use is ubiquitous in the medical field. The incidence of potentially life-threatening allergic reaction to latex has been increasing since the late 1980s. 9Healthcare providers at all levels are aware of the need for exposure avoidance in the care of the latex-allergic patient. Nevertheless, with mandatory implementation of universal precautions for bodily fluid avoidance, latex is still commonly found throughout the hospital environment.
Airborne exposure to latex can lead to systemic reactions in sensitized individuals, including bronchospasm, angioedema, and hypotension. The use of latex examination gloves, in particular powdered gloves, is associated with a measurable increase in airborne latex particles. 10Anaphylaxis after airborne exposure has been previously reported during inhalational latex challenge testing. 11
Systemic anaphylaxis is a potentially life-threatening condition. Symptoms may include flushing, urticaria, bronchospasm, hypotension, and seizures. 12In the obstetric population, hypotension with anaphylaxis has been associated with poor fetal outcomes, despite maternal recovery. 12,13
The management of anaphylaxis in pregnancy consists of maternal resuscitation and close monitoring of the fetal status, with preparation for immediate delivery of the fetus if compromised. Treatment of the parturient depends on the severity of the reaction and consists of fluid resuscitation and administration of supplemental oxygen, epinephrine, H1 and H2 blockers, and corticosteroids. 12Support of maternal circulation is mandatory to prevent uteroplacental insufficiency. Epinephrine is the first-line drug in the treatment of anaphylaxis, and its use in this patient was contemplated. In this case, ephedrine was readily available and was used primarily for immediate treatment of maternal hypotension. The use of epinephrine in the obstetric population has raised concerns of decreasing uteroplacental perfusion and worsening of fetal distress 14; however, maternal hypotension in anaphylaxis must be aggressively treated with fluid resuscitation and pressors, including epinephrine for severe reactions. 15
We present a case in which exposure to airborne latex particles triggered an anaphylactic reaction in a primigravida, with resulting fetal distress. The severity of the reaction nearly led to an emergency cesarean delivery in a preterm pregnancy. Our treatment of this patient consisted of support of maternal circulation with intravenous fluids, vasopressors, and oxygen. Preparations for emergent delivery of the fetus with latex-safe precautions were made as ongoing treatment of anaphylaxis was undertaken. The quick resolution of her symptoms after removal of the latex source obviated the need for more aggressive pharmacologic intervention and cesarean delivery. External fetal heart monitoring was instituted to guide the obstetric management of this emergency.
The high risk of anaphylactic reaction to mother and fetus leads us to suggest that a latex-safe environment, particularly in areas where an obstetric patient is initially examined, be provided to avoid unanticipated exposure to latex allergens in the latex-sensitive patient. In addition, medications and equipment to quickly treat allergic reactions in these patients should be readily available.