Obstetrical & gynecological survey
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Obstet Gynecol Surv · Dec 2003
ReviewLabor analgesia for the parturient with an uncommon disorder: a common dilemma in the delivery suite.
There appears to be an absence of uniform guidelines for management of labor analgesia in pregnant patients with uncommon medical conditions such as Marfan's syndrome, Ehlers-Danlos syndrome, achondroplastic dwarfism, previous back surgery, and kyphoscoliosis. A Medline search for articles highlighting considerations for obstetric anesthesia in parturients with these disorders was performed. Because of the multiorgan involvement and varied presentations of these disorders, no uniform or routine obstetric anesthetic recommendations can be made. In the absence of uniform obstetric anesthesia guidelines for pregnant patients with Marfan's syndrome, Ehlers-Danlos syndrome, achondroplastic dwarfism, previous back surgery, and kyphoscoliosis, the decision whether to administer regional anesthesia (epidural labor analgesia) should be based on an individual risk-to-benefit ratio on a case-by-case basis.
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Many clinicians in the United States routinely screen all pregnant women in their practices for gestational diabetes. Recently, the US Preventive Services Task Force re-emphasized that such screening is not supported by rigorous scientific evidence. Recommendations for diagnosis and management are based on an even scantier scientific foundation. Although this review questions several aspects of current dogma, it, too, is based on the frequently flawed existing data. It is surprising how, in spite of an abundance of published information on the subject, we continue to be ignorant of the real benefits of the widespread practice of screening and treating for gestational diabetes. The authors hope that the results of a randomized clinical trial, now in progress, will help to resolve some of the controversies surrounding gestational diabetes. ⋯ After completion of this article, the reader should be able to describe the controversy surrounding the significance of gestational diabetes, to break down the data regarding the efficacy of screening for gestational diabetes, and to outline potential treatment options for gestational diabetes.
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Pregnancies in spinal cord-injured patients present unique clinical challenges to obstetric providers. Spinal cord injury (SCI) alters the function of multiple organ systems, and chronic medical conditions are extremely common in this patient population. Autonomic dysreflexia (ADR) is a potentially life-threatening complication of SCI, usually involving patients with spinal cord lesions at or above the T6 level. ⋯ A multidisciplinary team in a unit capable of invasive hemodynamic monitoring should deliver these patients. Epidural anesthesia should be administered early in labor to prevent ADR. If proper precautions are taken, most patients with SCI will have successful vaginal deliveries at term.
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Obstet Gynecol Surv · Sep 2003
ReviewLabor analgesia for the drug abusing parturient: is there cause for concern?
Drug abuse has crossed geographic, economic and social borders, and it remains one of the major problems facing our society today. The prevalence of recreational drug abuse among young adults (including women) has increased markedly over the past two decades. Nearly 90% of drug abusing women are of childbearing age. Consequently, it is not surprising to find pregnant women with a history of drug addiction. Obstetricians and obstetric anesthesiologists become involved in the care of drug abusing patients either in emergency situations, such as placental abruption, uterine rupture or fetal distress, or in more controlled situations, such as request for labor analgesia. The diverse clinical manifestations of maternal substance abuse may result in life-threatening complications and significantly impact the peripartum care of these patients. ⋯ After completion of this article, the reader will be able to list the most commonly abused substances during pregnancy, to describe the various effects of particular substances on pregnancy including the mechanism of desired effect for various substances, and to outline the obstetric anesthesia recommendations for the various substances abused during pregnancy.