D1.289 - Severe allergy to albumin after cesarean section

The patient is a woman, healthy with no regular medication. Low total serum-IgE. No allergies. Sometimes urticaria caused by heat.

13.7.2021 emergency caesarean section at pregnancy week 32+3. The caesarean section was done in epidural/spinal anesthesia. After the birth of the baby, the patient’s blood pressure collapsed, and she was resuscitated and followed-up at the intensive care unit.

10:46: patient received Lidocaine, Bupivacaine, Fentanyl, Labetalol, and Morphine

At 11.00 and after the birth of the baby patient received Tranexamic acid, Oxytocin, Plasmalyte and albumin infusions.

At 11.12. after the birth of the baby, patient had abundant bleeding from the placenta 1800 ml.

11.30: Blood pressure collapsed; RR 40/30, patient got pulseless and was resuscitated for 10 minutes. Poor response to fenylefrine, efedrin and fluid correction, got adrenaline in total 3 mg. No skin reaction or obstruction was reported.  

A couple of hours after the resuscitation during uterine scraping she received Tranexamic acid, Oxytocin, Lidocaine, Morphine, Fentanyl and Plasmalyte without problems.

Later during hospitalization, she received Plasmalyte infusion, Oxytocin, Labetalol and Morphine without problems.

4 hours after the resuscitation serum tryptase was 22,5, next day only 2,8, which rose the suspicion of an allergic reaction.

Allergy testing: Skin testing was done, but patient had dermografism (negative control NaCl 3-5 mm), which made test interpretation impossible.

- Basofil activation testing was planned, but the positive stimulation control was not reacting to IgE-mediated activation.

- Serum specific IgE (immunospot) towards lidocaine, fentanyl and human serum albumin (control) were negative.  

-Patient did not have a c-KIT-mutation

Provocations: Provocations were planned with an anesthesiologist at the recovery ward. Day 1 local anesthetics were tested. Both bupivacaine 2 ml and lidocaine 3 ml S.C. were negative.

Day 2 oxytocin 9 mg and tranexamic acid 1100 mg provocations were negative. After albumin 200 g/l 10 ml infusion the patient got redness of the skin on the chest, pruritus of the palms and a feeling of swelling of the lips. Infusion was stopped and the mild symptoms disappeared. Albumin infusion was continued, but after 60 ml patient developed widespread urticaria of the skin and feeling of swelling of the tongue, but no hypotension nor obstruction.