Friday, April 20, 2012

Pregnancy and Dysautonomia: Introduction

What do we really know about Pregnancy and Dysautonomia?

Very little research has been done in this subject, and it is a multidimentional scenario. First, the diagnosis of dysautonomia has to be made, and many patients are undiagnosed for a time period before a diagnosis is made. Therefore, there are pregnancies with undetected dysautonomia that will not be captured. Perhaps these undiagnosed cases account for a variety of complications of pregnancy. Once the diagnosis of dysautonomia has been made, the patient should be at an advantage.

Dysautonomia can be broken down into its different forms such that POTS occurs more often in younger women of child-bearing age. MSA may occur in women past child-bearing age, so pregnancy may not be possible. Lastly, social isolation and bed-ridden status may be implicated as further confounding variables that change the likelihood of pregnancy.  Further research is needed.

With any pregnancy, it is important to avoid medications and seek excellent medical care throughout the pregnancy. The management of dysautonomia in the general internal medicine or family practice specialties can be challenging for both the patient and the physician. Many have experienced that finding a good internal medicine, family practitioner, or cardiologist to manage and treat dysautonomia in the nonpregnant state challenges the medical system. Emergency Room treatment of patients with dysautonomia continues to vary,  but perhaps fluid resuscitation with 5% Dextrose and 0.9% Saline is perhaps most commonly used. With pregnancy and dysautonomia, great care must be taken in the selection of a Ob/Gyn and an Anesthesiologist that understand the disease and are willing to implement a Plan.

A woman with dysautonomia should be considered a High Risk Pregnancy and the recommendation is that a course of labor should be avoided, and an Elective Caesarian Section be performed. In the USA, Elective C-Sections are not as popular as in Brazil, where 80% of the women received a C-Section electively. Women with dysautonomia should feel comfortable with the idea of getting a C-Section.

During Elective C-Section, the goal is to avoid hypotension, minimize blood loss, and keep up with volume replacement. The Obstetrician and the Anesthesiologist will be well-versed at intraoperative blood loss. The usual decision will consider the need for anesthesia, and the type of anesthesia to be given. The major choices include epidural, spinal, or general anesthesia; this will be discussed in a follow-up article. Epidural anesthesia may provide the smoothest management of vital signs.

The peripheral vasodilation of both dysautonomia and pregnancy will usually require intraoperative blood pressure support through pharmacreutical drugs. For dysautonomia, the drug of choice is phenylephrine, also known as neosynephrine.

Usually, the treatment of intraoperative hypotension includes the consideration of two common intravenous drugs, ephedrine or phenylephrine. The Anesthesiologist knows that ephedrine will usually increase both blood pressure and heart rate. In contrast, phenylephrine will usually increase blood pressure and stabilize or decrease the heart rate. Thus, it is the heart rate that requires special attention with dysautonomia, so that undue stress on the heart is not placed by causing tachycardia.

So enjoy the prospect of being pregnant. Many of the physiologic changes of pregnancy, such as peripheral vasodilation, are characteristics of dysautonomia any way.  The awareness of dysautonomia is on the rise, and continues to increase as we discuss the topic. Talk to your Obstetrician and talk to your Anesthesiologist. Both will be concerned and both will desire to make this time a smooth transition for you and your new little one.

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