به نام خد ا

روش های زایمان و ختم حاملگی در بیماران روماتیسمی

SYSTEMIC LUPUS ERYTHEMATOSUS

Labor and Delivery a continuation of her antenatal Care Exacerbations of SLE can occur during labor and may require the acute administration of steroids Stress doses of glucocorticoids should be given during labor or at the time of cesarean delivery to all patiens who have been treated with chronic steroids

endogenous adrenal insufficiency in these patients Intravenous hydrocortisone, given in three doses of 100 mg every 8 hours is an acceptable regimen

Complications such as preeclampsia and IUGR should be dealt with based on obstetric concerns; their management is not specifically altered by the presence of SLE

Neonatology support may be needed at delivery for problems associated with congenital complete heart block and other manifestations of neonatal lupus.

ANTI PHOSPHOLIPID SYNDROME labor and Delivery should be managed in the same way as in any patient who is considered at high risk for preeclampsia and uteroplacental insuffciency

continuous electronic fetal monitoring throughout labor, given the increased risk of nonreassuring fetal heart rate tracings noted in women with APS. APS probably involves the need to alter anticoagulation regimens in a way that minimizes the risk of bleeding at the time of delivery without placing the patient at a prohibitively high risk of thromboembolism.

treatment approaches vary and there is no evidence that one method is better than another. Patients receiving prophylactic anticoagulation with heparin can be instructed to with hold their injections at the onset of labor.

injections can be discontinued 12 hours before a planned induction. The most common practice in women with APS on full-dose anticoagulation (unfractionated heparin or LMWH) Is to hold the last injection 24 hours prior to a planned induction of labor or cesarean delivery.

extremely high risk for thromboembolism, including those with an event within 2 weeks of delivery intravenous heparin can be started in labor and discontinued 2 to 4 hours prior to anticipated delivery. Intravenous heparin can be resumed 4 to 6 hours after vaginal delivery and 12 hours after cesarean

Spontaneous labor is problematic for women who are fully anticoagulated, particularly those receiving LMWH preparations. Anti-factor Xa levels might be helpful but have been found to underestimate the risk of bleeding in some patients.

Protamine sulfate may be necessary in the event of surgical intervention. For those on adjusted dose unfractionated heparin, careful monitoring of the aPTT (or heparin level) is required. If the aPTT is prolonged near delivery protamine sulfate may be necessary to reduce the risk of bleeding

Many anesthesiologists are particularly concerned that anticoagulation in any form increases the risk of spinal hematoma formation in women receiving regional anesthesia in labor or for cesarean delivery

The American Society of Regional Anesthesia (ASRA) recommends that neuraxial blocked should be with held until 24 hours after the last injection in women on full anticoagulation with LMWH.

The same recommendation has been made for women receiving adjusted-dose anticoagxlation with unfractionated heparin For women receiving low-dose thromboprophylaxis (low-dose twice-daily unfractionated heparin or once-daily LMWH), ASRA has recommended that needle placement be delayed until 10 to 12 hours after the last dose.

RHEUMATOID ARTHRITIS Iabor and Delivery Because RA has little, if any, adverse effect on pregnancy outcome, there are no special prenatal obstetric concerns. In a rare case, severe deforming RA can pose a problem to the mechanics of vaginal delivery; such cases are obvious and require individualized care

SYSTEMIC SCLEROSIS Labor and Delivery In patient with mild to moderated disease,few additional precautions are needed during the labor and deliverv process A gain, signs of preeclampsia should be thought, since this complication may be more likely with scleroderma

Wound healing may be a problem in patients with advanced disease or those on steroids operative interventions require meticulous attentlon to this tissue In patients with significant pulmonary cardiac, or renal impairment, intensive care management may be needed

MYASTHENIA GRAVIS Labor and Delivery The management of labor and delivery in patients with MG requires limitation of emotional and physical stress and the appropriate use of parenteral anticholinesterase drugs.

Neostigmine can be given subcutaneously,in tramuscularly, or intravenously. As a rough guide, 60 mg oral pyridostigmine is equivalent to 0.5 mg IV neostigmine and 1.5 mg subcutaneous neostigmine

The usual dose of parenteral neostigmine is 0.5 to 2.5 mg. Maximal effects on skeletal muscle may occur 2 to 30 minutes after intramuscular injection; the effects last for about 2.5 hours.

Pyridostigmine can be give intramuscularly or very slowly intravenously. The usual dose is 2 mg (approximately l/30 of the usual oral dose) every 2 to 3 hours. The course of the first stage of labor in patients with MG is not altered because MG does not affect smooth muscle

The second stage of labor could be affected by the weakened material expulsive efforts, although the average duration of labor in MG patients is normal.

It is important to recognize that certain medications that may be used in the management of obstetric concerns are contraindicated in patients with MG.

Magnesium sulfate is absolutely contraindicated because it further interferes with the neuromuscular blockade of MG. Preterm labor can probably be treated with beta-sy mpathomimetics,but the associated hypokalemia should be carefully avoided. A small number of patients with MG have an associated cardiomyopathy, which could increase the risks of betasympathomimetics.

Because the patient with MG is particularly sensitive to neuromuscular drugs, analgesic and anesthetic considerations are important before the onset of labor

All patients with MG should be seen in consultation with an anesthesiologist early in the course of pregnancy. Epidural anesthesiais probably best becausei t limits the need for analgesia, may help prevent anxiety and fatigue, and is excellent for forceps procedure

Amide-type local anesthesia agents are used.some authors recommend general endotracheal anesthesia for cesarean section in patients with respiratory involvement

Myasthenic crises requiring ventilatory support may be precipitated by the stress of labor and delivery an inadvertent change in medication, or surgery.

Rarely, cholinergic crises may result from overdosage with anticholinesterase drugs. These patients have prominent muscarinic symptoms in addition to respiratory weaknes

In all patients with MG, labor and delivery management should include the immediate availability of personnel and equipment for ventilatory support and airway maintenance