I have a 25 year old primigravida patient. She is a known case of motor neurone disease for the last 5 years. She is unable to move all her limbs and she is on ambulatory ventlator before her pregnancy. She is also a known case of DM on insulin. Now she reached 20 weeks of gestaion and attending our clinic regularly. My question: What is the best time to deliver her? What is the best mode of delivery for her?
Two years ago we had a patient with LAS and repeated delievery. She had vaginal spontaneous delievery after PPROM at about 34 weeks. I guess we have no evidential basement for the management of such patients.
Thanks Dr Lakhno for your reply. I want to clarify was your patient on ventilator? How did you manade your patient in her antenatal period.
I know of one patient in a a coma with CPAP for respiratory support. Because the patient could not push due to her coma, we performed an elective caesarean sections at 38 weeks to avoid her going into labour. Up till then routine antenatal care was provided. She was managed with Clexane, TED stockings and controlled nutrition to manage risks of DVT and pregnancy nutrition.
My key message would be that the patient will eventually go into labour regardless, so you either have to perform caesarean section or else plan on monitored labor and lift out forceps (given you have no maternal effort). As our patient was in a high dependency unit, we could not effectively and safely manage a labour in that setting and hence made the decision for elective caesarean section.
Because your patient also has diabetes on insulin she will additionally require antenatal, intrapartum and postnatal management as per your diabetes protocol with blood sugar monitoring, controlled nutrition and ultrasound for growth and timing of delivery adjusted according to fetal parameters. This means delivery may need to be brought forward depending upon fetal well being. Delivery should be covered with an insulin dextrose infusion to control sugars.
Regards
Hi . My patient with ALS had PROM and preterm labour at 35 weeks of gestation. She had emergency LSCS as advised by her neurosurgeon, Her post operative period was uneventful. She delivered a femal baby weighing 2,2 KG . The required to be on ventilator for few days and dischaged home after 1 week.