Discussion
A revised definition for anaphylaxis is “a rapid onset serious systemic
hypersensitivity reaction that has potential to cause death. It is
characterized by compromise in breathing that is potentially life
threatening and/or circulatory collapse, and may occur in the absence of
typical skin features or circulatory shock” (8). Our patient
developed sudden onset respiratory depression immediately following
administration of IV tramadol which is consistent with the world allergy
organization’s (WAO) amended diagnostic criteria for anaphylaxis
(8).
The prevalence of anaphylaxis in pregnancy was 2.7 cases per 1,00,000
deliveries (95% confidence interval, 1.7-4.2 cases per 1,00,000
deliveries). β-lactams antibiotics were responsible for anaphylaxis in
11out of 19 patients (3). Tramadol is commonly used as labor analgesics
at Jigme Dorji Wangchuck National Referral Hospital, Bhutan. This is the
first anaphylaxis during intrapartum period due to tramadol in this
hospital. Whereas, the reported trigger for anaphylaxis during pregnancy
was β-lactam antibiotics (3).
Ideally, perimortem caesarean section should be performed within 5
minutes of maternal cardiac arrest(9). However, in a systematic review
on management of cardiac arrest in pregnancy, perimortem caesarean
section within recommended 4-5 mins of cardiac arrest was performed in 8
out of 38 cases. Perimortem caesarean section in 30-38 weeks pregnancy
done after recommended 5 minutes has shown successful maternal and
neonatal outcomes (9). In our case, emergency caesarean section was done
87 minutes after maternal respiratory arrest and endotracheal intubation
with live baby with APGAR score of 8/10 and 10/10 at one and five
minutes of birth respectively. The successful neonatal outcome can be
attributed to abrupt and successful intubation and maintenance of oxygen
saturation. Her cardiac function was stable and she was kept in left
lateral tilt of 150 from the horizontal as per the
International Liaison Committee on Resuscitation (ILCOR) consensus on
science and treatment recommendations of 2005 (10) and the 2005 European
Resuscitation Council Guidelines (11).
The 57 minutes delay between onset of respiratory arrest and caesarean
section was because of delay in GeneXpert report. As Bhutan was in
second nationwide lockdown due to surge in community spread of
SARS-COVID 19, emergency patients need COVID-19 GeneXpert report
negative to shift from ER to operation room (OR) and there is no
emergency OR available in ER.
The sensitivity of Xpert Xpress SARS-CoV-2 assays (GeneXpert) was 100%
and the specificity was 80% for the diagnosis of COVID-19 in low middle
income countries (LMICs) (12).
Healthy mother and newborn was discharged home on third postoperative
day which corresponds with the length of hospital stay in other studies
(3).