Pharmacologic therapy of asthma during pregnancy

Asthma is a common, potentially serious medical complication during pregnancy. Optimal clinical and pharmacologic management is necessary to mitigate maternal and fetal complications. Mild asthma may be managed in most cases with inhaled beta 2-mimetics. Anti-inflammatory therapy is recommended for the treatment of moderate and severe asthma. Based on limited human experience, beclomethasone is currently the recommended inhaled corticosteroid during pregnancy. However, other inhaled corticosteroids may have advantages compared to beclomethasone because of reduced systemic absorption, which may adversely affect intrauterine growth. Based upon theoretic considerations, theophylline is now considered a secondary therapy, but data demonstrating the superiority of inhaled corticosteroids versus theophylline during pregnancy are lacking.     

Outpatient termination of pregnancy

Termination of pregnancy was performed under local anaesthesia as an outpatient procedure on 251 patients. The gestational ages ranged from 5 to 12 weeks. Either the portable Karman curette equipment or the syringe kits were used. The incidence of complications was low. Only 6 per cent of patients would have preferred general anaesthesia. The optimal gestational age at which to terminate pregnancies appeared to be between 6 and 10 weeks. Ninety-one per cent of patients used effective contraception after the termination.     

Outpatient management

The successful management of outpatients with COPD requires a multifaceted approach that includes prophylactic, palliative, and life-extending therapies. All patients should undergo smoking cessation, avoid potentially harmful environments, and receive influenza and pneumococcal vaccines at recommended intervals. Although medical therapy may yield only marginal benefits in patients with minimal airway responsiveness, even small improvements may translate into significant functional benefits and will be greatly appreciated. Therefore, every effort should be expended to optimize the patient's medical regimen and to ascertain that methods of delivery (such as use of spacers) are as recommended. Physical therapy measures may be useful in patients with copious sputum production, and pursed-lip and diaphragmatic breathing exercises may reduce dyspnea and lend a sense of control to patients with severe flow limitation. Oxygen therapy is the only modality demonstrated to improve survival in patients with severe COPD and may give symptomatic relief to some patients. Its use, however, is restricted to patients meeting guidelines for hypoxemia, and although dyspneic patients not meeting these guidelines may desire oxygen, insurers will decline coverage for them. Newer modalities, such as noninvasive ventilation, may improve gas exchange and quality of life in some patients with hypercapnia and nocturnal oxygen desaturations, but subgroups of COPD patients who benefit have not been well-defined, and pending further investigation, guidelines for use should be considered tentative. Patients should be encouraged to enter a comprehensive rehabilitation program, but if one is unavailable or the patient declines, a rehabilitation approach should be applied. Practitioners should attempt to educate patients at each visit, offering advice not only on medications, but also on regular exercise, good nutrition, and ways of coping psychologically with chronic illness. By taking such a comprehensive and caring approach, and being available to assist with problems and crises, the practitioner can help to enhance the quality and length of the COPD patient's life.     

Ectopic pregnancy loss during fertility management

Using qualitative techniques, data were obtained from seven women who experienced an ectopic pregnancy loss while undergoing fertility management. Ectopic pregnancy is a risk factor associated with fertility management, but unlike early miscarriage in fertility management, an ectopic pregnancy has additional potential negative sequelae for the women, including risk for severe hemorrhage and death and threat to future fertility. The purpose of this study was to describe women's experiences of loss following diagnosis and treatment of an ectopic pregnancy while undergoing fertility management. A thematic analysis of the data derived from semistructured interviews was conducted. Themes emerging from the women's discussion of their pregnancy loss and fertility plans included physical pain and shutdown, emotional protection, grief, and pressure, endpoints, and decision making. For women continuing fertility management, both the life-threatening risks of future ectopics and time allowances for grieving were minimized.     

Outpatient management of deep vein thrombosis

OBJECTIVE: To assess whether patients with deep vein thrombosis (DVT) could be satisfactorily treated on an outpatient basis with low molecular weight (LMW) heparin and warfarin. DESIGN: A 22 month prospective study of adults attending St Peter's Hospital accident and emergency department with DVT. RESULTS: 1093 patients were referred and assessed; 160 were venogram positive, of which 159 patients between the ages of 22 and 89 years of age have now been treated with LMW heparin as outpatients. Direct liaison with community nurses has minimised the impact on general practitioner workload. CONCLUSIONS: 1272 bed days were saved during this period (an estimated 320,000 pounds). The outpatient treatment of thromboembolism has been shown to be effective and safe.     

Nutritional management of the female with phenylketonuria during pregnancy

This paper discusses a rational approach to appropriate nutritional management of the pregnant woman with phenylketonuria (PKU). Special food items, including new formulas and low-phenylalanine products, as well as allowable nutral foods are described. Particular emphasis is placed on the nutritional adequacy of this PKU diet during pregnancy. Such a diet should be palatable and tolerated well and should also take into consideration important economic, cultural, and psychological aspects. Clinics caring for PKU individuals should be so prepared because many otheir females are approaching childbearing age.     

Pharmacological management of asthma

Asthma management is changing, and there are many potential new drugs undergoing early and late phase trials. Nonetheless, it is unlikely that any dramatic alterations in therapy will occur within the next 3 years. The asthma treatment paradigm has altered over the past 10 or so years, with the emphasis on symptom relief from short acting beta agonists giving way to preventive treatment of underlying airway inflammation with inhaled corticosteroids. More recently, long acting beta agonists have been demonstrated to reduce the need for increasing doses of inhaled steroids in patients with poorly controlled asthma. This article reviews these trends.     

Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines

OBJECTIVE: Given concerns about use of psychotropic medication during pregnancy, the authors reviewed the literature regarding the effects of prenatal exposure to psychotropic medications on fetal outcome. METHOD: A MEDLINE search of all articles written in English from 1966 to 1995 was performed to review information on the effects of psychotropic drug use during pregnancy on fetal outcome. Where sufficient data were available and when methodologically appropriate, meta-analyses were performed to assess risk of fetal exposure by psychotropic medication class. RESULTS: Three primary effects are associated with medication use during pregnancy: 1) teratogenicity, 2) perinatal syndromes (neonatal toxicity), and 3) postnatal behavioral sequelae. For many drug classes there are substantial data regarding risk for teratogenicity. Tricyclic antidepressants do not seem to confer increased risk for organ dysgenesis. The available data indicate that first-trimester exposure to low-potency phenothiazines, lithium, certain anticonvulsants, and benzodiazepines may increase the relative risk for congenital anomalies. However, the absolute risk of congenital malformations following prenatal exposure to most psychotropics is low. CONCLUSION: Exposure to certain psychotropic drugs in utero may increase the risk for some specific congenital anomalies, but the rate of occurrence of these anomalies even with the increased risk remains low. Use of psychotropic medications during pregnancy is appropriate in many clinical situations and should include thoughtful weighing of risk of prenatal exposure versus risk of relapse following drug discontinuation. The authors present disorder-based guidelines for psychotropic drug use during pregnancy and for psychiatrically ill women who wish to conceive.     

Review article: The management of inflammatory bowel disease during pregnancy

The management of inflammatory bowel disease during pregnancy is a particular challenge because adequate disease control before and during gestation is essential for both maternal and foetal health. As a practical problem this situation arises frequently, because a quarter of patients conceive after the diagnosis of their disease. Many of the clinical, biochemical, radiological and endoscopic investigations that are used to monitor and assess disease activity are difficult to use and interpret during pregnancy. Furthermore, patients and clinicians often have concerns about the safety of medical and surgical treatments for the foetus. This review is designed for the practising clinician, to guide the management of patients with inflammatory bowel disease before and during pregnancy. The literature is at times conflicting and data on some issues are scanty, therefore recommendations are based on the balance of evidence including, if necessary, extrapolation from other conditions.     

Outpatient management without antibiotics of fever in selected infants

BACKGROUND: In many academic centers it is standard practice to hospitalize all febrile infants younger than two months of age, whereas in community settings such infants are often cared for as outpatients. METHODS: We conducted a controlled study of 747 consecutive infants 29 through 56 days of age who had temperatures of at least 38.2 degrees C. After a complete history taking, physical examination, and sepsis workup, the 460 infants with laboratory or clinical findings suggestive of serious bacterial illness were hospitalized and treated with antibiotics. The screening criteria for serious bacterial illness included a white-cell count of at least 15,000 per cubic millimeter, a spun urine specimen that had 10 or more white cells per high-power field or that was positive on bright-field microscopy, cerebrospinal fluid with a white-cell count of 8 or more per cubic millimeter or a positive Gram's stain, or a chest film showing an infiltrate. The 287 infants who had unremarkable examinations and normal laboratory results were assigned to either inpatient observation without antibiotics (n = 148) or outpatient care without antibiotics but with reexaminations after 24 and 48 hours (n = 139). RESULTS: Serious bacterial illness was diagnosed in 65 infants (8.7 percent). Of these 65 infants, 64 were identified by our screening criteria for inpatient care and antibiotic treatment (sensitivity = 98 percent; 95 percent confidence interval, 92 to 100). Of the 287 infants assigned to observation and no antibiotics, 286 (99.7 percent) did not have serious bacterial illness. Only two infants assigned to outpatient observation were subsequently admitted to the hospital; neither was found to have a serious illness. Outpatient care without antibiotics of the febrile infants at low risk for serious illness resulted in a savings of about $3,100 per patient. CONCLUSIONS: With the use of strict screening criteria, a substantial number of febrile one-to-two-month-old infants can be cared for safely as outpatients and without antibiotics.     

Outpatient management program of patients with chronic heart failure

Hospitalization of patients with heart failure is often caused by poor adherence to drug therapy, by suboptimal utilization of ACE inhibitors and beta-blockers, and by the lack of systematic monitoring of patients after discharge. The aim of the study is to verify the impact of an outpatient management program on the hospitalization rate and functional status of patients with chronic heart failure. Over a five-year period, 435 patients entered our outpatient management program, which includes adjustment in medical therapy, patient education and visits timed according to the patient's status. Fifty-six percent of the patients were in New York Heart functional class I-II; 74% were male; mean age was 62 +/- 11 years. Heart failure was due to coronary heart disease in 42%, dilated cardiomyopathy in 35%, hypertensive heart disease in 13%, other etiologies in 10%. The following changes in medical therapy were made compared to the period before referral: ACE inhibitors in 88% of the patients vs 70% (p < 0.05), mean dose of enalapril and captopril respectively 18 +/- 6 mg vs 11 +/- 4 mg (p < 0.05) and 89 +/- 28 mg vs 61 +/- 34 mg (p < 0.05); digoxin in 71 vs 70% (NS); furosemide in 90 vs 87%; beta-blockers in 16 vs 6% (p < 0.05); amiodarone in 24 vs 16% (p < 0.05); oral anticoagulants in 22 vs 12% (p < 0.05); calcium channel blockers in 10 vs 16% (p < 0.05). During the follow-up period (35 +/- 11 months), there were 111 hospital admissions compared to 518 during the year before recruitment (p < 0.05). Seventy-two patients died (65 for cardiac causes) and four patients underwent cardiac transplantation. Functional status improved (301 patients in I-II functional class and 56 in III-IV after referral compared to 225 and 132 before referral, respectively). Our results were obtained through adjustment in pharmacological therapy, intensive patient education and therapeutic continuity made possible by our outpatient heart-failure clinic organization. It is likely that the increase in costs due to therapeutic adjustment and to the increase in the number of visits is counterbalanced by the reduced rate of hospital admissions.     

Acute management of severe childhood asthma

Severe childhood asthma is a serious, life-threatening disease that presents a challenge for patients, families, and caregivers. Despite evolving medical and pharmacologic therapies, the incidence and severity of asthma are increasing. Vasoactive substances are released in response to environmental and intrinsic triggers and result in bronchospasm, bronchial mucosal edema, and mucus plugging of the airways. Early recognition of symptoms and prompt, aggressive treatment, including oxygen, beta agonists, corticosteroids, and anticholinergic agents, are essential in halting the progression of asthma symptoms. In the most severe cases, intubation, mechanical ventilation, and treatment with anesthetic agents may be needed to avoid significant morbidity and mortality. This article reviews epidemiology, pathophysiology, and acute care of the child experiencing an acute asthma exacerbation.     

Percutaneous umbilical blood sampling in the management of immune thrombocytopenic purpura during pregnancy

Severe neonatal thrombocytopenia occurs in about 15% of deliveries from women with immune thrombocytopenic purpura (ITP). Conflicting data exist about the real usefulness of percutaneous umbilical blood sampling (PUBS) in evaluating the fetal platelet count. We report successful experience, using PUBS, in the management of 12 pregnant women with ITP.     

Diagnosis and management of steroid-resistant asthma

The term "steroid-resistant (SR) asthma" has been used to describe a group of asthmatics who demonstrate persistent airway obstruction and inflammation despite treatment with high doses of systemic glucocorticoids. There are at least two forms of SR asthma, that is, primary and acquired types. Type I SR asthma is acquired and is associated with abnormally reduced glucocorticoid receptor (GR) ligand and DNA binding affinity. Type II SR asthma is due to a primary GR binding abnormality. An important distinction between these two types of SR asthma is that the GR defect in Type I, but not Type II, SR asthma is reversible in culture and is sustained by incubation with combination IL-2 and IL-4. The treatment of these patients requires a systematic approach to rule out confounding factors, including triggers of immune activation, optimizing steroid therapy, and use of alternative strategies to inhibit airway inflammation.