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23 - Immunology, including testing and management of allergy during pregnancy
- from Section 4 - Medical conditions in pregnancy
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- By Gareth Kitchen, Specialty Trainee in Anaesthesis, North Western Deanery, Manchester, UK, Tomaz Garcez, Central Manchester University Hospitals, Nigel J. N. Harper, Central Manchester University
- Edited by Kirsty MacLennan, Kate O'Brien, W. Ross Macnab
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- Book:
- Core Topics in Obstetric Anaesthesia
- Published online:
- 05 December 2015
- Print publication:
- 26 October 2015, pp 176-184
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Summary
Introduction
This chapter focuses on allergic diseases and their relevance to obstetric anaesthesia, with practical advice on management. Ideally, parturients with suspected allergic disease should be assessed prior to pregnancy, in order to identify relevant allergens and to confirm a management plan. Parturients with a history suggestive of adverse drug reaction require further investigation to identify the cause or to exclude allergy. A previous perioperative or peripartum adverse event necessitates review of those anaesthetic and medical records. If a patient has experienced a serious adverse reaction, their notes should be clearly marked with drug allergy information and a hazard-warning bracelet advised.
Pregnancy presents other immunological challenges to the mother and semiallograft fetus. For the pregnancy to succeed, local and systemic immunological changes are required, including reduction in cytotoxic adaptive immunity and enhancement of regulation. The systemic impact of the immunological changes is not clear, but there is an increased risk of atopic and autoimmune dermatoses in pregnancy. There is no clear evidence to suggest that general atopic diseases are affected.
Autoimmune diseases can have a significant impact on pregnancy, particularly when autoantibodies directed against phospholipids, SS-A or SS-B are present. Antiphospholipid syndrome is associated with increased risk of pregnancy morbidity and loss. The presence of antibodies directed against SS-A and/or SS-B is associated with neonatal lupus and congenital heart block. The effect of pregnancy on the course of autoimmune diseases is more variable, with both improvement and deterioration reported without consistency.
Immunodeficiency syndromes may also present challenges in pregnancy. Patients with antibody deficiency syndromes will have increased requirements of immunoglobulin replacement in the third trimester of pregnancy due to active transplacental transfer of immunoglobulin G. Patients with hereditary angioedema (HAE) may improve, remain stable or deteriorate during pregnancy and should receive prophylactic treatment before any instrumental delivery or surgical procedure. Increased vigilance through pregnancy and during delivery is therefore advised for most patients with pre-existent immunologically mediated diseases.
Allergens relevant to anaesthesia
A perioperative allergic reaction is often attributed to drugs, chlorhexidine or latex exposure.
Taking a clinical history for drug allergy
Type I hypersensitivity (IgE-mediated) is often considered to be true allergy. See Table 23.1.
Many patients report allergy to medications: 10% of hospital inpatients self-report penicillin allergy; 90% of patients self-reporting penicillin allergy are able to tolerate penicillin on challenge without adverse reaction (see Box 23.1 and Figure 23.1).
Costing day case anesthesia: obtaining accurate patient-based costs for adults and children
- Rachel A. Elliott, Linda M. Davies, Katherine Payne, Julia K. Moore, Nigel J. N. Harper
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- Journal:
- International Journal of Technology Assessment in Health Care / Volume 20 / Issue 4 / November 2004
- Published online by Cambridge University Press:
- 01 November 2004, pp. 552-561
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Objectives: This study proposes the method requirements for a valid costing study in anesthesia to allow differences to be identified between treatments and uses these method requirements to design and conduct a robust costing study.
Methods: A prospective, patient-based costing study was carried out in adult and pediatric day surgery in the United Kingdom. The perspective was that of the National Health Service and the patient. Data were collected for each patient until 7 days after hospital discharge.
Results: Data were collected for 1,063 adults and 322 children undergoing day surgery between October 1999 and January 2001. Statistically significant differences were found only between variable costs, which accounted for 11.4 percent and 9.0 percent of adult and pediatric costs, respectively. There were no differences in length of stay, fixed costs, or semi-fixed costs. Differences were not found in total costs in adults but were found in children. By day 7, postdischarge primary and secondary care costs were not different between groups in either study. No differences were found in costs to patients or parents.
Conclusions: The use of prospective, patient-based cost data enabled the detection of differences in variable costs between difference anesthetic regimens in day surgery. The stochastic nature of the data provided a measure of variability around mean cost estimates. Practice patterns in the study reflected normal practice in the United Kingdom so the costing data have direct clinical relevance. The use of different anesthetic agents only affected variable costs and had no effect on larger cost drivers such as length of stay or staff input.