Background

Behçet’s disease (BD) is a chronic vasculitis that affects mostly young adults. It is

characterized by recurrent oral ulcers, genital ulcers, and uveitis. Although the most

common manifestations are skin and eye lesions almost every organ can be involved.

BD is also associated with a higher risk of thromboembolic events 1 .

Case report

A 28 year old woman with BD (G1, P0, 38 weeks), was proposed for a cesarean

section due to fetal breech presentation. She had no history of past surgeries or

experience with anesthesia. Her pregnancy was uneventful.

The patient had recurrent oral and genital ulcers and relapsing nodules resembling

erythema nodosum in her lower extremities. She had no skin lesions on her chest,

trunk or back and no other manifestations of the disease. She wasn’t under any

treatment, except for topical mometasone. Mouth opening demonstrated a Mallampati

class II airway and numerous ulcers. The preoperative laboratory values were normal.

The patient underwent a successful single puncture spinal anesthesia with bupivacaine

0.5% (11.5mg) and morphine (100µg).

After surgery she was under a prophylactic dose of low molecular weight heparin

(LMWH) for one week.

Discussion

The main concerns in this case are: the difficult airway risk due to scarring from

recurrent ulceration, the inflammatory responses to skin prick and the higher risk of

thromboembolic events.

Although regional anesthesia is less ideal because it involves skin puncture, the airway

risk is far more severe with the possibility of a difficult intubation and the worsening of

pre-existing oral lesions 2 .

The choice between combined spinal/epidural and spinal anesthesia relied on the fact

that spinal alone was less invasive. There would be also a higher risk of inflammatory

local skin response if an epidural catheter had been placed and used for postoperative

analgesia.

A prophylactic dose of LMWH was considered essential to prevent thromboembolic

events since pregnancy and BD increase the risk of thromboembolism.

References

1 Gupta, Anurag et al. Repeated Surgeries in a Patient with Behçet’s Disease, What

Changes to Expect? Anesthesia, Essays and Researches 7.2 (2013): 279–281.

2 Bhalerao, PM et al. A Case of Behcet’s Disease Posted for Surgery: Anaesthetic

Implications. Indian Journal of Anaesthesia 59.8 (2015): 517–519.

Learning Points

Anesthetic management of any patient should take into consideration underlying

diseases, adapting to their own challenges.

Anaesthetic management of Cesarean section on Behçet´s disease - a case report