Atopy, the use of condoms, and a history of cesarean delivery: Potential predisposing factors for latex sensitization in pregnant women

Atopy, the use of condoms, and a history of cesarean delivery: Potential predisposing factors for latex sensitization in pregnant women

Atopy, the use of condoms, and a history of cesarean delivery: Potential predisposing factors for latex sensitization in pregnant women Frank Chih-Kan...

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Atopy, the use of condoms, and a history of cesarean delivery: Potential predisposing factors for latex sensitization in pregnant women Frank Chih-Kang Chen,a Donata von Dehn,a Ulrich Büscher, MD,a Joachim W. Dudenhausen, MD,a and Bodo Niggemann, MDb Berlin, Germany OBJECTIVE: Our purpose was to assess the prevalence of latex sensitization among women admitted for delivery and the relevant risk factors. STUDY DESIGN: In a prospective study 333 consecutive patients admitted for delivery were screened for specific immunoglobulin E antibodies to latex and for atopic status. A questionnaire was filled in and included questions about the obstetric and surgical history, known contact with latex, and previous use of condoms. RESULTS: Nine of 333 (2.7%) women showed latex-specific immunoglobulin E. All 9 women had atopy (100% vs 26.2% in the latex-negative group; P < .00001). Of 8 patients with specific immunoglobulin E who gave details about the use of condoms, 6 had had frequent contact with latex condoms (75% vs 51%). Previous cesarean delivery was more frequent in latex-sensitized patients (33% vs 8.4%; P < .05), whereas previous pregnancies, previous deliveries, and total number of operations had no influence. CONCLUSION: Given a prevalence of 2.7% of latex sensitization, all obstetric patients should be questioned about known immediate allergic reaction to latex, a predisposition to atopy, previous intra-abdominal operations, and the regular use of condoms in the past. Patients with atopy and additive risk factors should be treated in a latex-free environment. (Am J Obstet Gynecol 1999;181:1461-4.)

Key words: Allergy, atopy, cesarean delivery, condoms, latex, obstetrics, risk factor

The first reports of immediate immunoglobulin (Ig) E–mediated type I reactions to latex products appeared in the German literature in 1927.1 More than 50 years later, Nutter2 reported the first English language case of a type I reaction to natural rubber. The first intraoperative anaphylactic reactions to latex were described in 1984 and occurred during a cesarean delivery and after a sterilization procedure.3 Both patients were nurses. The number of individual persons with sensitization or allergic reactions to latex has increased over the past 2 decades. This may be the result of heightened clinical awareness, to the efforts undertaken to prevent the spread of human immunodeficiency virus (ie, gloves), or to changes in rubber manufacturing. The published cases of acute allergic reactions were most frequently associated with exposure to latex gloves, although other latex products in health care units and common house-

From the Department of Obstetricsa and the Department of Pediatrics,b Charité, Campus Virchow-Klinikum, Humboldt University. Received for publication December 31, 1998; revised May 10, 1999; accepted July 15, 1999. Reprint requests: Bodo Niggemann, MD, Department of Pediatric Pneumology and Immunology, Children’s Hospital Charité, Humboldt University, Augustenburger Platz 1, 13353 Berlin, Germany. Copyright © 1999 by Mosby, Inc. 0002-9378/99 $8.00 + 0 6/1/101538

hold items (balloons, condoms) have also been reported to induce type I reactions. The highest prevalence of latex sensitization (55%) has been found among patients with spina bifida.4 Other populations at increased risk include patients with a history of latex-induced immediate reaction during or after invasive procedures, patients with a predisposition to atopy, and patients with occupational exposure to natural rubber latex, such as health care workers and workers in the rubber industry. The prevalence of positive skin prick test results found among selected groups of health professionals ranges from 2.9% to 17%.5-7 The presence of latex-specific IgE may precede the development of a positive skin prick test result and clinical symptoms. In a recent study 12 of 48 children (25%) found to have positive results for latex-specific IgE showed clinical symptoms in a provocation test.8 Little is known about specific risk factors in women. Therefore the aim of this prospective study was to evaluate the risk factors for sensitization and allergy to latex in women at delivery. Material and methods A total of 333 pregnant women who were admitted for delivery were included in this prospective study. Ages ranged from 17 to 44 years (median, 28 years). A question1461

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Table I. Condom use and latex sensitization (difference not statistically significant) Latex-positive

Σ

6 (8%) (75% of total) 2 (3%) (25% of total) 8

80

160

Latex-negative

Latex-positive

Σ

26 (90%) (8% of total) 285 (98%) (92% of total) 311

3 (10%) (33% of total) 6 (2%) (67% of total) 9

Latex-negative Condom user Condom nonuser Σ

74 (92%) (49% of total) 78 (97%) (51% of total) 152

80

Table II. History of cesarean delivery and latex sensitization (P < .05)

History of cesarean delivery No history of cesarean delivery Σ

naire was filled in by the women within 24 hours after delivery. This included questions about known history of atopy, the obstetric and surgical history, previous contact with latex in the daily environment, and previous use of condoms. The latter questions were not answered by all women. In 13 patients the obstetric history remained unclear. Venous blood was collected from the antecubital vein of all patients within 24 hours after admittance. The study protocol was approved by the local ethics committee. Total IgE and specific IgE to latex were determined from sera by a solid-phase immunoassay (Pharmacia CAP-system; Pharmacia Upjohn, Uppsala, Sweden).9 To establish atopic status, inhalant (SX1) and nutritional (fx5) allergens were investigated by screening tests in which the same automated IgE assay was used.10 SX1 contains the allergens timothy, birch, mugwort, house-dust mite, cat, dog, and Cladosporium herbarum. Fx5 contains milk, egg, fish, soy, wheat, and peanut. None of these allergens is known to cross react with latex. Atopy was defined as showing positive results in either SX1 or fx5 or both (>0.35 kU/L). For statistical analysis we used the Mann-Whitney U test for continuous variables, the χ2 test for discrete variables, and Fisher’s exact test. Significance was established at P < .05. Results Total IgE and specific IgE to latex were determined from sera of all 333 pregnant women within 24 hours after admittance for delivery. Nine of 333 (2.7%) were found to have positive results for latex-specific IgE. Among the women willing to answer questions about the use of condoms, 6 of 8 who tested positive for latex stated that they had used condoms regularly before pregnancy (75%) whereas only 78 of 152 in the latex-negative group made this statement (51%) (Table I). Because of the small number of cases, this difference was not significant.

29 291 320

A history of cesarean delivery was significantly more frequent in the latex-positive group (33%) than in the latex-negative group (8.4%; P < .05) (Table II). Neither the number of pregnancies or deliveries nor the number of anesthesia procedures or operations in the history had a significant influence on latex sensitization. All 9 women who tested positive for latex sensitization were atopic in terms of being positive in either SX1 or fx5 or both (>0.35 kU/L), whereas only 85 of 324 (26.2%) in the latex-negative group were atopic. This difference was highly significant (P < .00001) (Table III). Comment Prevalence of latex sensitization in the general population can be estimated at between 6% and 7%, as has been shown by 2 studies on 1000 volunteer blood donors11 and 996 ambulatory surgical patients.12 In a prospective birth cohort study, 5% (20/398) of all children showed specific serum IgE to latex at the age of 5 years.13 When we take into consideration a lower prevalence (4.2%) in women,11 our results are in the range of previous studies. Numerous studies have proved the clinical relevance of latex sensitivity. The first reports of intraoperative anaphylactic reactions to latex in 1984 occurred during intra-abdominal gynecologic procedures. One patient reacted to the surgeon’s rubber gloves during a cesarean delivery, and anaphylaxis developed in the other immediately after a sterilization procedure.3 Anaphylactic reactions were also observed after vaginal examination,14-16 during registration of a cardiotocograph caused by its tape,17 after vaginal delivery,18 after cesarean section,6, 15, 19, 20 during suturing of an episiotomy,6, 21 and during gynecologic surgery.20 In our study all 9 patients with positive specific IgE to latex were atopic. In contrast, only 26.2% (85/324) in the latex-negative group were atopic. This difference was statistically significant. The prevalence of atopy in all patients tested for atopy was 37.9%. Among the atopic pa-

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Table III. Atopy and latex sensitization (P < .00001) Latex-negative Atopic Nonatopic Σ

85 (90%) (36% of total) 154 (100%) (64% of total) 239

tients the prevalence of latex sensitization was 9.6%. A history of atopic disease, including food allergy, has been shown to increase the risk of development of latex sensitization. In other studies 67% to 84.6% of latex-sensitized persons were found to be atopic5, 22 when tested by skin prick, and almost 100% were atopic when sensitization was defined as positive for specific IgE.8, 13 In atopic children 60 of 306 (19.6%) were latex-sensitized, compared with 1 of 303 (0.3%) nonatopic children.8 In conclusion, without atopic predisposition the risk of becoming sensitized to latex seems to be negligible. A history of cesarean delivery was significantly more frequent in the latex-positive group (33%) than in the latex-negative group (8.4%; P < .05), whereas neither the number of previous deliveries nor the number of operations had a significant influence on latex sensitization. From these results it appears that not the number of surgical procedures itself but the type of operation has to be regarded as a risk factor. Cesarean delivery, the most frequent operation in an obstetrics clinic, involves extensive contact of surgeon’s gloves with highly absorptive membranes. This could be one reason why we identified a history of cesarean delivery as a risk factor for latex sensitization. On the other hand, the number of operations, in general, was not higher in the patients positive for specific IgE. Our findings are consistent with a recent study of Lebenbom-Mansour et al12 demonstrating no significant relationship between the number of previous operations and the presence of latex sensitization. Skin is the most frequent site of contact with latex products, but most cases of anaphylactic reactions to latex follow exposure of absorptive membranes. A high absorption capacity for the allergen may be the factor that determines the extent of sensitization. Latex reactivity can be suspected to be the result of cumulative exposure via skin, mucous and absorptive membrane, or inhalation. With repeated exposure, allergy to latex can worsen or become life-threatening. Contact of products containing latex with mucous membranes or blood circulation during surgical procedures may permit the rapid introduction of sufficient amounts of antigen to mast cells and circulating basophils and result in massive histamine release. Several reports highlight the hazards of latex exposure for patients with previously mild cutaneous and respiratory reactions, who experience more severe reactions with mucosal or parenteral exposure.6, 16

Latex-positive 9 (10%) (100% of total) 0 (0%) (0% of total) 9

Σ 94 154 248

An operation method with minimum contact to absorptive membranes might limit the risk of sensitization. Among the patients who gave details about previous use of condoms, 6 out of 8 who were sensitized to latex stated that they had had contact with condoms regularly before pregnancy. Up to now, only a few cases have been published in which allergic reactions were associated with latex condoms. Taylor et al23 reported the case of a life-threatening anaphylactic reaction in a woman. In a study of Turjanmaa and Reunala,24 29 of 46 patients with latex-glove contact urticaria had a history of condom use, and 7 of them reported allergic symptoms during sexual intercourse. Levy et al25 also found a majority of 84% (79/94) among patients with latex allergy who reported symptoms from contact with condoms. But patients do not always report allergic reactions experienced after the use of condoms for various reasons. Some may feel ashamed; others do not relate their symptoms to the use of condoms. We are aware of the problem of underreporting. Having regard to all points, the use of condoms in history as a risk factor for latex sensitization may be underestimated and should be investigated more thoroughly. Atopic patients should be made aware of the risk they are taking by using latex condoms. Our data indicate that women, regardless of risk group status, should be questioned in the routine obstetric record about atopic diseases, use of condoms, and clinical symptoms after contact with latex products or fruits with potential cross-reactivity to latex (ie, banana, avocado, kiwi). Special care should be taken in atopic patients, particularly if other risk factors are known (occupation, history of cesarean delivery, condom use). REFERENCES

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