Warming part of CAD pain management during C-section
Corticosteroid, anesthesia given to manage birth, case report says
Warming and an extra dose of corticosteroid medication were part of multiple strategies doctors used to allow for a safe Cesarean section (c-section), without complications, in a pregnant woman with cold agglutinin disease (CAD), according to a case report.
The woman was kept warm right during her hospital stay, and received an extra dose of a corticosteroid during the c-section to suppress the immune system. Anesthetics were administered directly into the spinal canal right before the procedure, and between the muscles of the abdominal wall afterwards to manage post-surgery pain.
“CAD presents unique challenges in the peripartum period, necessitating prompt recognition and management,” the researchers wrote, adding that “tailoring management strategies can minimize side effects and optimize outcomes.” The peripartum period is the time shortly before, during, and immediately after giving birth.
The case study, “Anesthesia Management of Cold Agglutinin Disease in a Pregnant Patient: A Case Report,” was published in Clinical Case Reports.
CAD is an autoimmune disease marked by self-reactive antibodies, called cold agglutinins, that bind to red blood cells at temperatures below normal, making them clump together and be marked for destruction (hemolysis). This results in low counts of red blood cells (anemia), fatigue, and other signs and symptoms.
Risks for pregnant CAD patients
Pregnant women are at risk of hypothermia, an abnormally low body temperature, during delivery due to blood vessel widening, administration of anesthetics and other medications, and blood loss with rapid replacement of body fluids. This can boost hemolysis in CAD patients, worsening symptoms.
“Cold temperatures can trigger the activation of cold-reactive antibodies, leading to red blood cells agglutination (clumping together),” and “preventing hypothermia reduces the likelihood of cold-induced hemolysis,” the researchers wrote.
Reports of CAD in pregnancy are rare, and little is known about the management and outcomes of delivery, and particularly of c-section, in pregnant women with CAD.
The team of researchers at Cleveland Clinic described the case of a 37-year-old woman, pregnant with her second child, who was admitted for a planned c-section.
She had a history of anemia linked to CAD, and needed a blood transfusion of 20 units during her pregnancy. To keep CAD under control, she had also started treatment with oral prednisone, a corticosteroid that suppresses immune activity. The dose was gradually reduced from 40 mg to 10 mg daily, without any signs of disease worsening.
While rituximab and Enjaymo (sutimlimab-jome) — the only approved CAD therapy — were also considered, hematologists, or blood disease specialists, preferred to delay such treatments until after delivery due to “the lack of data during pregnancy with these medications,” the researchers wrote.
“Anesthesiology was consulted for pre-assessment before her Cesarean section,” they wrote.
Pain management during, after C-section
To prevent cold-induced hemolysis during the c-section, doctors kept the woman warm during her hospital stay with a forced warm-air blanket, and administered warmed fluids when necessary.
As the woman had been on long-term prednisone, doctors decided to administer an extra, or stress, dose of methylprednisolone (125 mg), another corticosteroid, directly into her bloodstream during the c-section.
“Additionally, the decision was to perform spinal anesthesia, complemented by a TAP [transabdominal plane] block for postoperative pain management,” the researchers wrote. A TAP block refers to the injection of a local anesthetic between the muscles of the abdominal wall.
In the operating room, and immediately before the c-section, the woman received the anesthetics bupivacaine and fentanyl into the spinal canal at the lumbar level. Her vital signs remained stable, and she delivered a healthy baby. After delivery, a TAP block was performed on both sides of the abdomen to relieve pain.
Her levels of hemoglobin, the protein in red blood cells that transport oxygen, dropped after the procedure, and she received two additional units of red blood cells with a blood warmer. Her hemoglobin levels increased.
The woman “met appropriate postpartum milestones and was discharged home in stable condition,” the team wrote, adding that “hematology recommended continuing prednisone postpartum and reassessing the need for alternative therapies such as rituximab or [Enjaymo].”
“The patient’s peripartum course was successfully managed through a multidisciplinary approach involving obstetrics, anesthesiology, and hematology teams,” which “facilitated effective pain management while considering the patient’s underlying condition,” the researchers concluded.
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