Addison's Disease requires c/s? Need help for friend!

[kaydee]

Not sure if this is the best forum for this request, but here goes!

A good friend is 7+ month pg. She also has Addison's disease (an autoimmune-type condition). Her OB and her endocrinologist both are urging her to have a planned c-section. From what I understand, this is b/c she will need IV steroids during labor/delivery, and they want to limit the amount of time that the baby is exposed to the steroids. The docs have said she can try vag. delivery, but are clearly steering her away from this and towards the c/s.

Does anyone here have some info that might be helpful as my friend tries to decide what to do? Do you know of a woman who has Addison's and who faced a similar choice?

TIA!

[Lula's Mom]

Just did some cursory checking about Addison's and pregnancy, but it sounds like Addison's patients are normally on a regular, daily dose of hydrocortisone, right? When they have to undergo surgery, labor, or some other stress event, they are given a large IV dose, which is then tapered off over the course of days back to the maintenance or replacement dose.

In pregnancy, the usual steroid replacement doses should be maintained. Occasionally, dose adjustments may need to be made depending on the patient's well being and the presence or absence of symptoms of adrenal insufficiency.

Pregnancy increases the production of cortisol-binding globulins (CBGs) and, therefore, cortisol binding. Free cortisol is proportionately increased so no dose adjustments should be needed.

In labor and delivery, vaginal or caesarean, parenteral stress-dose steroid coverage should be used as at other times of major stress. Stress-dose steroids also may be needed during the stress related to hyperemesis gravidarum.

The preferred mode of steroid administration is by continuous IV infusion and then rapid dose-tapering to the usual maintenance doses when the clinical situation allows.

What's interesting is that they're not apparently concerned about the hydrocortisone given on a daily basis, and it's even deemed safe for a pregnant woman (and her fetus) to take the 'stress dose' when she experiences hyperemesis gravidarum. So why not in labor? Which, unlike hyperemesis, is a one-time event. I don't know, I think I need to look up the effects of hydrocortisone exposure in a baby.

Another article, which says "The delivery can be by the vaginal route, unless there are obstetric contra-indications": http://www.ncbi.nlm.nih.gov/entrez/q...&dopt=Abstract

[ldsapmom]

My best friend has lupus, and I am not sure if these two autoimmune disorders are related or not, but what perked my ears (eyes, lol) was the steroid use.

My best friend does have c-sections because she had a placenta accreta with her first, and she opted to have repeat sections with baby 2 and baby 3. They do give her a steriod in her IV before the section to prevent a flare-up after birth.

She was on prednisone for years, but they weaned her off after her second baby was born. Her doc told her (rheumatologist, not OB) that during pregnancy often moms with lupus feel better and do not need to take steroids because your body produces more at that time.

I agree with the last poster -- if she has been receiving steroids throughout pregnancy, certainly a dose before vaginal delivery should be fine, right? But I really don't know anything about the disease. Good luck finding answers.

[kaydee]

Thanks for the feedback--I'll share these perspectives with my friend. If it is the same sort of steroids she has been receiving throughout her pg., it does seem strange that they would be used as a reason for not allowing vag. delivery.

I welcome more input from others, as well!

[georgia]

I would recommend her firmly requesting the research/protocol that definitively shows surgery is necessary. Would the outcomes be better with major surgery? Is the risk from the drugs involved with it less harmful than the steroids?

Hunches or opinions not based on evidence don't count in evidence-based medicine.....I honestly doubt they can provide the proof, but maybe they can---which would definitely be reassuring to say the least!

It seems like this might be another case of sacrificing normal birth at the altar of ignorance, but I'm not a dr.... She should at least be fully informed of her options and the complete rationale behind them. Just because this is how we've always done it......Please let us know what she learns! Best wishes to her!