A Caesarean section under spinal anaesthesia for a patient with pustular psoriasis

Abstract

Pustular psoriasis is a rare but potentially severe form of the common skin condition psoriasis. The extensive skin involvement is often considered to be at least a relative contraindication to neuraxial blockade in these patients. We present the case of a patient who was able to have spinal anaesthesia for Caesarean section after having targeted steroid therapy for the skin over her lumbar spine. Case report The 37-year-old multiparous patient, a life-long sufferer from generalised pustular psoriasis, was referred to the Obstetric Anaesthetic clinic at 18 weeks into her third gestation. In her two previous pregnancies she had emergency Caesarean sections for obstetric indications; both were performed under general anaesthetics and were followed by long and complicated postoperative hospital stays. She had been booked for an elective Caesarean section at 37 weeks' gestation and requested spinal anaesthesia. On discussion with the dermatologist, a plan was formulated for her to be admitted 1 week before the procedure for targeted therapy for the skin over her lumbar spine and surgical scar. She suffered several flare-ups of her psoriasis during the pregnancy but these were successfully treated. The targeted therapy comprised daily applications of mometasone cream under dressings with hydrocortisone cream added on the last day. On pre-operative anaesthetic review the skin lesions in the treated area had lessened in severity and she was deemed suitable for spinal anaesthesia. On the next day she underwent the Caesarean section under spinal anaesthesia and gave birth to a healthy male infant weighing 2.53 kg. Her postoperative course was uneventful and she was discharged home after four days. Discussion Pustular psoriasis is a remitting and relapsing disease which features crops of pustules erupting through areas of reddened skin - the pustules are, however, not infectious per se. Systemic manifestations may also occur and can be severe. An especially aggressive form of the disease, impetigo herpetiformis, can emerge de novo in pregnancy. While many patients with this condition would be given general anaesthesia for Caesarean sections, this is not without risk. Aside from the overall risks of general anaesthesia in obstetric patients, pustular psoriasis is associated with airway and facial oedema which may make tracheal intubation more difficult. As such the possibility of avoiding these airway issues by use of spinal anaesthesia is of potentially great benefit. The involvement of a multi-disciplinary team in the management of this patient was crucial in enabling the successful outcome.