Radiation therapy during pregnancy

A case of recovered memory of childhood trauma is reported with documented sexual trauma in early childhood, chronicled evidence of the absence of memory for traumatic experience over a period of time, and substantial evidence of 'spontaneous' recovery of memory. This account contains the first available prospective report of memory loss in a case in which there is both documented evidence of trauma and evidence of recovery of memory. The case emerged as part of a broadband, large-scale study of children followed closely from birth to adulthood which was not focused on memory for trauma. Prospective data gathered in a neutral research context, corroborated and supplemented by retrospective information, circumvent many limitations of previous retrospective accounts of recovered memories.     

Antifungal therapy during pregnancy

Careful consideration of the benefit to the mother and the risk to the fetus is required when prescribing antifungal therapy in pregnancy. Imidazoles are considered safe as topical therapy for fungal skin infections during pregnancy. Nystatin is minimally absorbed and is effective for vaginal therapy. Although vaginal use of the imidazoles is probably safe during the later stages of pregnancy, their systemic absorption is higher than when applied to the skin. The systemic antifungal drug with which there has been the most experience in pregnancy is amphotericin B. There have been no reports of teratogenesis attributed to this agent. There is evidence to suggest that fluconazole exhibits dose-dependent teratogenic effects; however, it appears to be safe at lower doses (150 mg/day). Ketoconazole, flucytosine, and griseofulvin have been shown to be teratogenic and/or embryotoxic in animals. Iodides have been associated with congenital goiter and should not be used during pregnancy.     

Low-dose oral vitamin K reliably reverses over-anticoagulation due to warfarin

BACKGROUND: Patients receiving long-term warfarin frequently develop asymptomatic excessive prolongation of their international normalized ratio (INR) results. The most appropriate management strategy in these patients is unknown. This prospective cohort study was designed to address whether 1 mg of oral vitamin K effectively reduces the INR value of such patients. METHODS: A prospective cohort study was performed in two tertiary care teaching hospitals, in which 62 patients receiving warfarin who had INR values between 4.5 and 10.0 received 1 mg of oral vitamin K. All patients had daily INR values and clinical assessments performed. RESULTS: The mean INR value at presentation was 5.79 (95% confidence interval (CI) 5.48 to 6.09, range 4.5 to 9.5). Sixteen hours after receiving the 1 mg of oral vitamin K, the mean INR was 2.86 (95% CI 2.50 to 3.23). On the second and third days after vitamin K, the mean INR values were 2.20 (1.93 to 2.47) and 2.14 (1.85 to 2.44), respectively. No adverse events or bleeding complications were observed. In three patients (6%) the INR value rose between the time of vitamin K administration and the next INR determination; two patients received a further 2 mg dose of subcutaneous vitamin K. CONCLUSIONS: In patients receiving warfarin who have asymptomatic excessive prolongations in their INR results, 1 mg of oral vitamin K reliably reduces the INR to the therapeutic range within 24 h. This therapy is more convenient, less expensive, and might be safer than parenteral vitamin K. Thus, it should be considered in all non-bleeding patients receiving warfarin, who present with INR results of 4.5 to 9.5.     

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.     

Fetal growth in the baboon during the second half of pregnancy

PURPOSE: The purpose of this study was to determine the prevalence of feeding tube placement errors in children. DESIGN AND METHODS: The hospital records of 201 children having both an enteral tube and at least one radiograph showing tube placement were retrospectively reviewed. Chart review was also used to determine the risk factors associated with these errors. Tube placement error was defined as tube tip or orifices in the esophagus or intestine (if the tube was supposed to be in the stomach) or tip or orifices in the esophagus or stomach (if the tube was supposed to be in the intestine.) RESULTS: On the first day, a radiograph documenting tube placement showed that 32 of the 201 children (15.9%) had tube placement errors. Overall, 53 tube placement errors were evident during the 385 observation days on which radiographs were obtained (13.8%). Of the 201 children, 42 (20.9%) had experienced tube placement errors at some time during the period reviewed. Over all radiograph days, activity level was independently related to radiographic tube placement (p = < 0.02), with more errors among active children. Also, classification regression tree analysis showed that age, level of consciousness (alert or comatose versus semicomatose), abdominal distention, vomiting, and orogastric tubes were associated with more tube placement errors. NURSING IMPLICATIONS: Nurses need to be especially careful in assessing tube placement if the pediatric client has one or more of the identified risk factors. Health care providers need to carefully weigh the benefits and risks of feeding by nasal or oral enteral tubes versus the benefits and risks of feeding by endoscopically or surgically placed enteral tubes.     

Massive ascites due to abdominal pregnancy

We describe a case of an abdominal pregnancy which presented in the first trimester with rapid accumulation of blood stained ascites. The ascites resolved completely following surgical removal of a gestational sac from the peritoneal cavity. The pathophysiology of ascites in this case may be similar to that in cases of ascites in other non-malignant gynaecological conditions.     

Anticoagulant therapy of thromboembolic disease during pregnancy

There is growing interest in low molecular weight heparin for the management of thromboembolic disease in pregnancy. Greater understanding of the risk of thromboembolic disease versus the risk of various management practices is urgently needed to reduce maternal mortality and embryopathy in the fetus.     

Fetal branch pulmonary arterial vascular impedance during the second half of pregnancy

OBJECTIVE: Our purpose was to establish normal physiologic parameters in the fetal proximal and distal branch pulmonary arterial vascular impedance during the second half of pregnancy and to analyze relationships between proximal and distal pulmonary arterial blood velocity waveforms. STUDY DESIGN: In this cross-sectional study 100 uncomplicated singleton pregnancies were studied by pulsed color Doppler techniques between 18 and 41 weeks of gestation (median 30 weeks). Both right and left proximal (immediately after the bifurcation of the main pulmonary artery) and distal (beyond the first bifurcation of the branch pulmonary artery) pulmonary artery blood velocity waveforms were recorded and pulsatility index values were calculated. Peak systolic velocities and time-to-peak-velocity intervals were measured. Time-to-peak-velocity intervals were also analyzed at the level of aortic and pulmonary valves and at the ductus arteriosus. Right and left pulmonary artery diameters and right lung length were measured. RESULTS: In both right and left proximal and distal pulmonary arteries pulsatility index values decreased (p < 0.0001) and the peak systolic velocities (p < 0.003) and time-to-peak-velocity intervals (p < 0.0001) increased during the second half of pregnancy. In the proximal pulmonary arteries the pulsatility index values decreased linearly until 34 to 35 weeks of gestation and in the distal pulmonary arteries until 31 weeks of gestation. Thereafter they remained unchanged. In pulmonary arteries time-to-peak-velocity intervals were shorter (p < 0.01) than at the pulmonary valve level. There were no significant differences between the right or left pulmonary arteries in the pulsatility index values, peak systolic velocities, time-to-peak-velocity intervals, or pulmonary artery diameters. In the proximal pulmonary arteries the pulsatility index values (p < 0.02) and peak systolic velocities (p < 0.0001) were higher and time-to-peak-velocity intervals (p < 0.0001) were longer than in the distal pulmonary arteries. There was a 2.5-fold increase in pulmonary artery diameters and right lung length. CONCLUSIONS: Fetal branch pulmonary arterial vascular impedance decreases significantly during the second half of pregnancy. The linear decrease in vascular impedance during the second trimester and in the beginning of the third trimester may be related to the growth of the lung and the increase in the number of resistance vessels. During the latter part of the third trimester pulmonary vascular impedance does not decrease further.     

Fetal transfusion therapy

Rapid advances are occurring in the diagnosis and treatment of the fetus with a red blood cell or platelet cytopenia. Noninvasive methods of monitoring the alloimmunized pregnancy, invasive methods such as amniocentesis and cordocentesis, and intrauterine transfusion therapy of both red cells and platelets, are being further refined to allow the prompt recognition and treatment of fetal cytopenias. Specialized centers have now accrued a large experience in the management of the fetus severely affected by alloimmunization. Advances in ultrasound, blood banking techniques, and genetic engineering technology have spurred the most recent advances. The indications for diagnosis, timing and frequency of invasive procedures for treatment, and technical considerations regarding preparation of blood products and volume of transfusion, are outlined in this review. Polymerase chain reaction (PCR) determination of fetal Rh(D) genotype by chorionic villus sampling or amniocentesis in the first or second trimesters is a recent clinically useful advance. The advent of hematopoietic stem cell transplantation and the potential for gene therapy are exciting advances in the treatment and prevention of hematopoietic diseases, including, but not limited, to the fetal cytopenias.     

Fetal drug therapy

As prenatal diagnosis has become more sophisticated, avenues for a variety of intrauterine therapies have been opened. Considerable experience has been gained with surgical and pharmacologic approaches. This article provides a review of intrauterine drug therapy aimed at preventing fetal and neonatal disease and treating existing fetal conditions. The future awaits the exciting applications of intrauterine hematopoietic transplants and genetic therapy.     

Acute urinary retention due to ectopic pregnancy

Two cases of ectopic pregnancy are presented in which acute urinary retention was a salient clinical feature. The emergency physician must consider ectopic pregnancy in the differential diagnosis in any woman of child-bearing age with abdominal, pelvic, or urinary complaints.