Labor epidural/ringworm

[B-Bone]

---

Members do not see this ad.

Here's a little scenario from my call today:

Called to place labor epidural on thin healthy 20-something lady, no concerning history. Talking about risk/benefits while I sit her up to prep. Feeling interspaces, I note some roundish patches of scaly, peeling skin in upper back and right over her lumbar spine. Very subtle, especially because there's a tattoo there as well. Ask her about it; she states she always has it and her husband rubs "lotion" on it sometimes. The "lotion" is called clotrimazole, and it was prescribed for "fungus". Anyway, long story short it is ringworm. I told her no epidural. Did not want to cause fungal meningitis/death/etc. Would anybody place a labor epidural through a patch of ringworm? what if the patch is 6 inches away from your puncture site? two inches? how about a spinal for c-section? what if she has a terrible airway? what's the risk of neuraxial fungal infection with epidural/spinal? is it negligible, or is the potential outcome so bad you can't risk it? Anyway, just food for thought.

 

[WholeLottaGame7]

Here's a little scenario from my call today:

Called to place labor epidural on thin healthy 20-something lady, no concerning history. Talking about risk/benefits while I sit her up to prep. Feeling interspaces, I note some roundish patches of scaly, peeling skin in upper back and right over her lumbar spine. Very subtle, especially because there's a tattoo there as well. Ask her about it; she states she always has it and her husband rubs "lotion" on it sometimes. The "lotion" is called clotrimazole, and it was prescribed for "fungus". Anyway, long story short it is ringworm. I told her no epidural. Did not want to cause fungal meningitis/death/etc. Would anybody place a labor epidural through a patch of ringworm? what if the patch is 6 inches away from your puncture site? two inches? how about a spinal for c-section? what if she has a terrible airway? what's the risk of neuraxial fungal infection with epidural/spinal? is it negligible, or is the potential outcome so bad you can't risk it? Anyway, just food for thought.

I definitely wouldn't stick a needle through it. Somehow I doubt we can "know the risk" of neuraxial fungal infection, since I doubt there's a study out there where half the people had needles intentionally stuck through ringworm into the neuraxial space to determine the incidence of fungal infection.

As far as distance, good question. I think if it's far enough to stay out from underneath the dressing, I'd consider it.

 

[Mman]

Here's a little scenario from my call today:

Called to place labor epidural on thin healthy 20-something lady, no concerning history. Talking about risk/benefits while I sit her up to prep. Feeling interspaces, I note some roundish patches of scaly, peeling skin in upper back and right over her lumbar spine. Very subtle, especially because there's a tattoo there as well. Ask her about it; she states she always has it and her husband rubs "lotion" on it sometimes. The "lotion" is called clotrimazole, and it was prescribed for "fungus". Anyway, long story short it is ringworm. I told her no epidural. Did not want to cause fungal meningitis/death/etc. Would anybody place a labor epidural through a patch of ringworm? what if the patch is 6 inches away from your puncture site? two inches? how about a spinal for c-section? what if she has a terrible airway? what's the risk of neuraxial fungal infection with epidural/spinal? is it negligible, or is the potential outcome so bad you can't risk it? Anyway, just food for thought.

Good question. I'd probably put an epidural or spinal at least a good 2 inches from any site of local infection.

 

[BobBarker]

Great questions. Certainly wouldn't place an epidural catheter through the ringworm. 2" clear probably would do it. Spinal for c section, yes if there is any room clear at all in all situations, through the worm if difficult airway suspected.

 

[cchoukal]

Great questions. Certainly wouldn't place an epidural catheter through the ringworm. 2" clear probably would do it. Spinal for c section, yes if there is any room clear at all in all situations, through the worm if difficult airway suspected.

You'd put a needle into the csf thru a ringworm infection for a suspected difficult airway before you'd do an awake fiber?

 

[BobBarker]

You'd put a needle into the csf thru a ringworm infection for a suspected difficult airway before you'd do an awake fiber?

You are correct, I'd do an awake fiber first. Wasn't thinking thouroughly. You could probably use the proper baricity and positioning with a spinal that you could definitely find a clear spot.

 

[leaverus]

how did you guys choose your distances "clear of the dressing," "two inches," etc.? seems pretty arbitrary. it's a fungus so i'm not sure the clear delineation on the skin rules out further microscopic spread but i don't know - is it true histologically? if i had to take a stand, no spinal nor epidural. with a bad airway, inform the OB and perform elective c-section under GA.

 

[Orin]

n = 1 but if you want a reason to be a cowboy
http://www.ncbi.nlm.nih.gov/pubmed/21680133

Abstract: Epidural analgesia is usually contraindicated in case of infection at the site of needle insertion. Tinea versicolor is a benign superficial cutaneous fungal infection caused by the proliferation of a skin commensal yeast of low pathogenicity. We report the case of a pregnant woman with a tinea versicolor in the lumbar region, who benefited from a labor epidural analgesia, realised with reinforced antiseptic measures. No neurological or infectious complication occurred.

Can't read French so couldn't tell you what "reinforced antiseptic measures" are...

Also can't find any well described cases of trichophyton or microsporum meningitis/encephalitis.

Still, I don't have the stones for that.

 

[pjl]

Stat derm consult.

 

[Mman]

how did you guys choose your distances "clear of the dressing," "two inches," etc.? seems pretty arbitrary. it's a fungus so i'm not sure the clear delineation on the skin rules out further microscopic spread but i don't know - is it true histologically? if i had to take a stand, no spinal nor epidural. with a bad airway, inform the OB and perform elective c-section under GA.

Would you do an epidural if they had athlete's foot? I mean anything is an arbitrary cutoff. What if they had ringworm on their abdomen? On their upper back? Gotta pick somewhere as a cutoff.

 

[pgg]

I wouldn't place a labor epidural.

What good could possibly come of it? It's an elective procedure. She can get IV drugs, maybe even pudendal blocks from her motivated and caring obstetrician. She gets a great story she can rub in her wimpy epidural-getting friends faces, too.

If it comes to section, it's not quite elective any more and the risk/benefit calculus shifts a bit. I might consider a spinal, though not through an obvious lesion. I guess my unscientific distance cutoff would be the window through the drape. I wouldn't shy away from GA.