Anaesthesiological aspects of pregnancy in patients with rheumatic diseases

The anaesthesiologist facing a pregnant woman with rheumatic disease is caught between a rock (the problems of general anaesthesia, i.e., the difficult airway and/or the cardiopulmonary dysfunctions that can worsen the response to general anaesthetics or to mechanical ventilation) and a hard place (the problems of loco-regional anaesthesia, i.e., intrinsic or iatrogenic haemostatic dysfunctions, potentially causing spinal haematoma, the most threatening complication). However, the term lupus anticoagulant is a misnomer and in the absence of an underlying coagulation deficit or anticoagulant therapy, the anaesthesiologist can usually guarantee epidural analgesia for vaginal delivery to parturients affected by rheumatic diseases (so contributing to the decrease of the caesarean section rate) and, in case of a caesarean section for medical or obstetrical indications, often he can perform a loco-regional anaesthesia, which determines a substantially lower maternal mortality rate. It is very important to adopt a multidisciplinary approach comprising an antepartum team evaluation (to be performed at 36th gestational week) of the basal condition of the parturient: together, the obstetrician, the rheumatologist and the anaesthesiologist should define the type of delivery. We will also try to define the haemostatic safety criteria to be fulfilled for administration of an epidural analgesia to a parturient affected by rheumatic disease.