Fetal risks with dextrans during delivery

Epidural analgesia for caesarean section is increasingly used and is gradually replacing general anaesthesia. Hypotension is one of the main risks: preloading of the maternal circulation is used to prevent maternal hypotension and its consequences. For this, various colloid and crystalloid solutions are used. We report a case of maternal anaphylactoid reaction with apparent death in a neonate after dextran administration to the mother. After 100ml of a dextran 40 solution administered intravenously, immediately before an epidural blockade, the mother fainted and developed urticaria and mild respiratory disturbances, without hypotension. At that point dextran infusion was stopped. An apparently dead neonate was rapidly delivered. Immediate and vigorous cardiopulmonary resuscitation was successful. Clonismus appeared 12h later, followed by 3 general epileptic fits treated by phenytoin infusion and subsequently oral phenobarbital. No aetiology was found. After 2 months of treatment, barbiturates were stopped following clinical and electroencephalogram (EEG) improvement. Several similar cases of neonatal disorders resulting from preventive dextran administration during delivery were studied in a national pharmacovigilance survey in France. There were 32 cases reported with moderate maternal anaphylactoid reaction associated with severe acute fetal distress; it is probably advisable to take a cautious approach and avoid preventive fluid preload by dextran administration. Gelatins or crystalloid solutions should be preferred, with intravenous vasopressive amine administered promptly and repeated if necessary should significant maternal hypotension occur during epidural anaesthesia.