Caesarean delivery in a pregnant woman with epidermolysis bullosa: anaesthetic challenges

Dystrophic Epidermolysis Bullosa (DEB): How Can Pregnancy Alter the Course of This Rare Disease? An Updated Literature Review on Obstetrical Management with an Additional Italian Experience

Epidermolysis Bullosa (EB) is an extremely rare and disabling inherited genetic skin disease with a predisposition to develop bullous lesions on the skin and inner mucous membranes, occurring after mild friction or trauma, or even spontaneously. Within the spectrum of EB forms, dystrophic EB (DEB) represents the most intriguing and challenging in terms of clinical management, especially with regard to pregnancy, due to the highly disabling and life-threatening phenotype. Disappointingly, in the literature little focus has been directed towards pregnancy and childbirth in DEB patients, resulting in a lack of sound evidence and guidance for patients themselves and clinicians. The current study aims to contribute to the DEB literature with an updated summary of the existing evidence regarding the obstetrical and anesthesiological management of this rare disease. Furthermore, this literature review sought to answer the question of whether, and if so, in which way, the pregnancy condition may alter the course of the underlying dermatologic skin disease. Having all this information is indispensable when counseling a patient with DEB who desires a child or is expecting one. Finally, we reported own experience with a pregnant woman with a recessive DEB whom we recently managed, with a favorable outcome.

Recommendations on pregnancy, childbirth and aftercare in epidermolysis bullosa: a consensus-based guideline

Linked Comment:A.W. Lucky and E. Pope. Br J Dermatol 2022; 186:602–603.

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Anesthetic Management of Adults With Epidermolysis Bullosa

Epidermolysis bullosa (EB) is a group of rare, inherited diseases characterized by skin fragility and multiorgan system involvement that presents many anesthetic challenges. Although the literature regarding anesthetic management focuses primarily on the pediatric population, as life expectancy improves, adult patients with EB are more frequently undergoing anesthesia in nonpediatric hospital settings. Safe anesthetic management of adult patients with EB requires familiarity with the complex and heterogeneous nature of this disease, especially with regard to complications that may worsen during adulthood. General, neuraxial, and regional anesthetics have all been used safely in patients with EB. A thorough preoperative evaluation is essential. Preoperative testing should be guided by EB subtype, clinical manifestations, and extracutaneous complications. Advanced planning and multidisciplinary coordination are necessary with regard to timing and operative plan. Meticulous preparation of the operating room and education of all perioperative staff members is critical. Intraoperatively, utmost care must be taken to avoid all adhesives, shear forces, and friction to the skin and mucosa. Special precautions must be taken with patient positioning, and standard anesthesia monitors must be modified. Airway management is often difficult, and progressive airway deterioration can occur in adults with EB over time. A smooth induction, emergence, and postoperative course are necessary to minimize blister formation from excess patient movement. With careful planning, preparation, and precautions, adult patients with EB can safely undergo anesthesia.

Management of epidermolysis bullosa simplex in pregnancy: A case report

Epidermolysis bullosa (EB) encompasses a group of diseases characterized by extreme fragility of skin and mucous membranes, resulting in blister formation following minimal injury. There are 4 types of EB, with epidermolysis bullosa simplex (EBS) being the most common. We report our experience with the care of a parturient woman diagnosed with EBS. There is little literature on pregnancy in women with this condition. Special precautions are necessary during diagnostic and therapeutic interventions to avoid bullae formation or exacerbation of existing lesions. Frictional or shearing forces are typically more damaging than compressive forces. Multidisciplinary planning was done for our patient to ensure uneventful labor and delivery. Elective induction of labor was started at 40 weeks of gestation. She eventually underwent a cesarean delivery after failed trial of labor. We present this case to highlight the obstetric and anesthetic implications of caring for a parturient with EBS.

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Blister formation occurs following minimal injury in epidermolysis bullosa.

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Frictional or shearing forces rather than direct pressure predispose to bullae.

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Use of adhesive materials should be avoided during patient care.

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Vaginal delivery without instrumentation is preferred for pregnant women with epidermolysis bullosa.

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If cesarean delivery is necessary, neuraxial anesthesia is preferred to general anesthesia.

Anesthetic management with subcostal transversus abdominis plane block in recessive dystrophic epidermolysis bullosa for peritoneal dialysis catheter replacement: a case report

Background

Recessive dystrophic epidermolysis bullosa (RDEB) is a rare, hereditary mucocutaneous disorder that can involve renal insufficiency. If a vascular access for hemodialysis is unavailable, peritoneal dialysis can be utilized. This report describes an anesthetic management with ultrasound-guided transversus abdominis plane block (TAPB) in a patient with RDEB for peritoneal dialysis catheter replacement.

Case presentation

A 49-year-old woman with RDEB needed to undergo peritoneal dialysis catheter replacement. As general, neuraxial and local infiltration anesthesia can lead to serious complications; we planned anesthetic management with subcostal TAPB as the primary analgesia modality. In the operating theater, surgery was initiated after performing left-sided subcostal TAPB. The patient complained of moderate pain at some points during surgery, and the pain was controlled with intravenous or local anesthetics without serious complications.

Conclusions

In summary, subcostal TAPB could be a useful option for peritoneal dialysis catheter surgery in patients with RDEB.