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C1-ESTERASE INHIBITOR DEFICIENCY/C1-INHIBITOR DEFICIENCY

C1-esterase inhibitor controls a protein called C1, which is part of the complement system. See Complement system. A C1-esterase inhibitor deficiency can result in an acquired recurrent angioedema without urticaria. It can be caused by B cell lymphoproliferative disorders. This condition can be treated with icatibant. See Angioedema.

CAESAREAN SECTION (CS)

Classification codes for CS urgency

  1. Code critical/Class 1—delivery in under 15 min e.g. cord prolapse.

  2. Class 2—within 1 h e.g. failed instrumental delivery.

  3. Class 3—required within hours e.g. failure of labour to progress.

  4. Class 4—CS can be arranged at a time to suit patient and staff.

Code critical CS pre-anaesthetic fetal/maternal resuscitation

  1. Resuscitate the mother adequately if required.

  2. Position the mother full left lateral.

  3. Increase IV fluids if already in progress.

  4. Turn off oxytocin infusion.

  5. Continue fetal CTG monitoring. See Intrauterine fetal resuscitation (IUFR).

Preoperative assessment/preparation for elective/semi-elective CS

In addition to routine history, examination and preparation (e.g. fasting), the following are important considerations.

  1. Carefully assess the airway, as there is an increased incidence of difficult airway in the pregnant patient. See Difficult airway management.

  2. Consider acid aspiration prophylaxis with sodium citrate 0.3 M 30 mL, especially if GA likely.

  3. A group and hold is not needed in an uncomplicated pregnancy. A FBC and group and hold should be performed for all non-elective CS, and any pregnancy with complications or increased risk e.g. previous PPH, multiple pregnancy.

  4. Calf compressors and compression stockings are not necessary unless thromboprophylaxis is contraindicated or a patient is at an especially high risk for DVT/PE.

  5. Diabetes in pregnancy is very common. See Diabetes mellitus (DM).

  6. Neuraxial anaesthesia is preferred for safety and the parental birthing experience.

Subarachnoid block (SAB)

For insertion technique, see Subarachnoid block (SAB). Load the patient with 1 L IV fluid while preparing and administering the block.

  1. Consider 4 mg ondansetron IV prior to SAB. This may reduce the incidence of maternal hypotension and nausea with SAB.1

  2. Give prophylactic antibiotics e.g. cefazolin 2 g (unless cephalosporin or penicillin allergy).

  3. Use a 27 G Sprotte spinal needle. Suggested drugs for SAB are heavy bupivacaine 0.5% 2.2–2.4 mL, fentanyl 20–25 mcg and preservative-free morphine 100 mcg.

  4. Immediately after SAB injection, commence an IV infusion of metaraminol (10 mg in 20 mL N/S) or phenylephrine (2 mg in 20 mL N/S), run at 10–15 mL/h titrated to blood pressure readings.

  5. Place the patient supine with left lateral tilt 15°. Recent studies suggest left lateral tilt is possibly unnecessary.2

  6. A block to T4 is ideal for CS.

  7. Treat hypotension (SBP < 100 mmHg) promptly with boluses of metaraminol (0.5–1 mg), phenylephrine (100 mcg) ...

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