Abdominal pain during pregnancy

In evaluating the pregnant patient with abdominal pain, the physician is presented with a wide range of diagnostic possibilities, including disorders that can occur in nonpregnant individuals and disorders that are unique to pregnancy. The development of modern laboratory testing methods and diagnostic imaging techniques has led to a decline in the morbidity and mortality from many of these disorders. With an understanding of the physiologic changes occurring during pregnancy, a careful history and physical examination, and judicious use of laboratory tests and imaging studies, the physician should be able to determine the cause of the patient's pain in the great majority of cases and, in the words of Babler, avoid "the mortality of delay."     

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.     

Prolonged pregnancy. Review of the literature

There have been various estimations of the frequency of postdate pregnancies. On the average, 10% of all pregnancies exceed 42 weeks amenorrhoea with a range from 4 to 14% according to the authors. Rates vary with use of ultrasound examinations early, avoiding false dating and induced labour. A pregnancy becomes a pregnancy at risk at the end of the 41st week of amenorrhoea. Fetal maturity may be affected by a disease process or due to individual or ethnic variations. The potential danger of prolonged pregnancy is inhalation of meconium prepartum. Expulsion of meconium is both a frequent consequence of fetal distress and the result of increased intestinal reactivity. There does not appear to be agreement on the degree of risk of sudden death at the end of pregnancy, although the risk does appear to exist. Surveillance should include recording fetal heart rate under basal conditions and an assessment of the amniotic fluid volume with ultrasounds. The Doppler technique is currently under study. When the status of the cervix is favourable, labour may be induced by rupturing the membranes of with a perfusion of Syntocinon. When the status of the cervix is unfavourable, prostaglandin E2 is applied intravaginally or intracervically with a gel. Therapeutic trial published to date do not demonstrate any advantage over cesarean section or fetal morbidity. The safety of the procedure has not been proven. Randomized trials comparing systematic induction of labour with a wait-and-see attitude have not given a definitive answer. Only two trial have shown a significant advantage of systematic induction of labour. The others have shown that the rate of cesarean section and neonatal morbidity are comparable in the two groups.     

Review article: current treatment and optimal patient management in pancreatic cancer

Pancreatic cancer is the tenth most prevalent malignancy and the fifth most common cause of cancer death in the developed world. Less than 10% of patients survive for more than 1 year following diagnosis and the 5-year survival rate (0.4%) is the lowest of any cancer. The poor prognosis associated with this diagnosis led in the past to therapeutic nihilism on the part of clinicians who were all too aware of the limitations of their available therapeutic strategies. Breaking this therapeutic impasse requires a significant expansion in the knowledge of clinicians concerning the pathogenesis and behaviour of pancreatic cancer. Recent advances in the scientific understanding of the aetiology of pancreatic cancer has facilitated progress towards the development of promising and innovative approaches to the early detection and diagnosis of pancreatic cancer. While acknowledging that pancreatic cancer will continue to present significant challenges to both scientists and clinicians in the foreseeable future, it is becoming increasingly clear that recent advances in our scientific knowledge base holds the potential to significantly improve prognosis for patients. The challenge facing both scientists and clinicians is how best to translate such promising scientific advances into survival and quality of life benefits to patients.     

Review of Developing management ability.

Reviews the book "Developing management ability" by Earl G. Planty and J. Thomas Freeston (1954). This book is made up of six hundred questions that vary in scope with answers varying in length from a single sentence to several pages. According to the reviewer, to the person who is looking for answers to many of the questions that arise concerning management development without getting into the theoretical implications or research background, this book can be recommended highly. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conservative management of extra-uterine pregnancy

Expectant management was studied in 35 patients representing 4.9% of all ectopic pregnancies during an 8 year period. Laparoscopy was performed in a first period to define the inclusion criteria: hematosalpinx < or = 2 cm and hemoperitoneum < or = 50 ml. In a second period, inclusion criteria used a predictive pretherapeutic score < or = 11 with a sonographic visualization of the ectopic pregnancy. This score involved six criteria graded on a scale from 1 to 3: gestational age, hCG and P level, existence of abdominal pain, size of hemoperitoneum and diameter of hematosalpinx assessed sonographically. The patients were on out-patients basis. Success rate was 85.7% (30/35 patients). When the pretherapeutic score was < or = 11 and the initial hCG level < 1,000 mUl/ml the success rate increased to 96%. Thirteen patients (87%) had patent tubes evaluated by hysterosalpingography on the side of the ectopic pregnancy. Twelve patients delivered one miscarriage occurred and none ectopic pregnancy was observed. Expectant management is a useful form of treatment for ectopic pregnancy in selected cases.     

Active management of prolonged pregnancy

OBJECTIVES: We assessed perinatal morbidity and mortality of prolonged pregnancies (> or = 294 days) compared with those of term gestations. We also evaluated the impact of induction of labor compared with spontaneous onset of labor. STUDY DESIGN: This observational study included consecutive cases treated at Chicago Lying-In Hospital from July 1980 to December 1984. Complications, presence of meconium, indications for cesarean section, mode of delivery, perinatal morbidity (and mortality), meconium aspiration, and duration of labor were compared with those in the total hospital population, in infants weighing > or = 2500 gm, and within prolonged gestation groups; spontaneous onset and induced ("active management") labors were also compared. The chi 2 analysis was used. RESULTS: Of 12,930 deliveries there were 707 prolonged gestations (5.5%) and 10,698 with infants > or = 2500 gm. Among the prolonged gestations 67% were in multiparous women and 33% in primiparous women. Labor started spontaneously in 62%, and 38% underwent induction; the overall cesarean section rate was 17% with similar indications in both spontaneous onset and induction groups. Meconium was present in 34%; it was present in 23% of inductions, which is fewer (p < 0.01) than among those with spontaneous onset of labor (40%). Also there were fewer depressed neonates at 5 minutes (p = 0.03) among inductions. Meconium aspiration was seen in 24, with nine deaths. The perinatal mortality was 14 per 1000 (corrected 12.7/1000), significantly more than in the general population. Among those with spontaneous onset of labor it was 20.5 per 1000; there were no deaths among inductions. Postpartum maternal morbidity was 16% among cesarean sections and 4% among vaginal deliveries. CONCLUSIONS: Prolonged gestation has a high perinatal morbidity and mortality rate. All perinatal deaths were observed among patients whose labor started spontaneously. "Active management" (induction at 42 weeks) did increase the primary cesarean section rate compared with that of the general obstetric population; it did not do so among prolonged gestations and prevented perinatal deaths in this group. From this experience an active approach seems justified.     

Small cell anaplastic carcinoma of lung. Reappraisal of current management

The relative roles of radiotherapy, intensive chemotherapy, and a combination of both were evaluated by an analysis of 157 of 188 patients who were registered at Tumor Registry and the Department of Radiation Medicine at Massachusetts General Hospital with a diagnosis of small cell anaplastic carcinoma of the lung between 1968 and 1974. Stage of the tumor was the single most important prognostic factor. Bone marrow involvement was found in 29% of patients studied. For extensive tumor, better survival was obtained by a combination of intensive chemotherapy and radiotherapy than with radiotherapy alone. However, no improvement of survival was noted with combination of concomitant or sequential intensive COPP or COP chemotherapy and radiotherapy over that obtained with radiotherapy followed by subsequent chemotherapy for progressive disease in patients with localized tumor. For localized tumor, primary radiotherapy should be given with an intention of local control or cure. Conclusions regarding the proper timing of chemotherapy and radiotherapy in apparently localized small cell anaplastic carcinoma require further prospective evaluation.     

Review of Clinical management of memory problems.

Reviews the book, Clinical management of memory problems by Barbara A. Wilson and Nick Moffat (1984). This short and serviceable volume amalgamates a series of papers presented at the University of Nottingham, England, in 1982. Its editors have brought together contributors from both academic and clinical settings in an attempt to bridge current theoretical models of human memory with practical approaches to memory assessment and its remediation. This book offers sound guidelines for anyone working with clients who present with memory deficits secondary to cortical dysfunction. Its brevity, easy reading style, and practical approach make it a useful reference for students and clinicians alike. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conservative surgical management of tubal pregnancy

In an attempt to maintain optimal fertility in the patient treated for midtubal pregnancy, an investigation of conservative surgical procedure was made. The technic developed utilizes tubal excision, reanastomosis, and a single hydrotubation with Dextran. Tubal patency was maintained without the use of stents that may damage the fimbria. The procedure is compared to other conservative technics and its advantages discused. Thus far 2 patients have undergone this excision and reanastomosis, and both patients successfully established intrauterine gestations within 2 months of returning to normal active coital frequency. Both were in the midtrimester of pregnancy at the time of this report.     

Laparoscopic management of rudimentary horn pregnancy

A unicornuate uterus with rudimentary horn is a rare Müllerian abnormality. This uterine anomaly may cause many gynaecological and obstetric complications, including infertility, recurrent abortions, preterm deliveries and rupture of the uterus, especially when the pregnancy implants in the rudimentary horn. To date, laparotomy has been the treatment of choice when resection of a rudimentary horn was indicated. We report on the case of a woman who benefited from laparoscopic surgery of a rudimentary horn pregnancy. Laparoscopy, in these exceptional cases, is the most accurate diagnostic tool that carries significant advantages in effective surgical management, thereby avoiding laparotomy.     

Laparoscopic management of an intramural pregnancy

Adult cat fleas, Ctenocephalides felis (Bouché), survive and reproduce when fed human blood through an artificial membrane system. When a dog hair substrate was included in cages with the fleas, mean adult mortality was 2.4 after 12 d of bloodfeeding. Egg production began after 3 d and was continuous for 12 d, ranging from 3 to 4 eggs per female per day. In cages without hair, mean adult mortality was 61.2% after 12 d of bloodfeeding. Egg production began after 2 d, reached a maximum of two eggs per female per day after 7 d, and decreased thereafter. No significant differences in egg hatch were seen in treatment groups sampled from 5 to 7 d after the onset of bloodfeeding. After 7 d, however, egg hatch for fleas maintained in cages without hair was significantly lower than in cages where fleas were maintained on dog hair. Adult emergence from these larvae did not differ significantly between the two groups. Egg hatch and adult emergence in both groups of fleas fed on human blood did not differ significantly from egg hatch and adult emergence in fleas fed on colony cats.     

Outpatient management of asthma during pregnancy

CS-834 is a prodrug of the carbapenem R-95867, developed by Sankyo Co., Ltd., Tokyo, Japan. To investigate the possibility that CS-834 may be the first carbapenem usable in an oral dosage form, its in vitro antibacterial activity (as R-95867) and in vivo antibacterial activity were compared with those of cefpodoxime proxetil, cefditoren pivoxil, cefdinir, ofloxacin, imipenem, and amoxicillin. R-95867 had high levels of activity against methicillin-susceptible staphylococci and streptococci, including penicillin-resistant Streptococcus pneumoniae, as well as Neisseria gonorrhoeae, Moraxella catarrhalis, the members of the family Enterobacteriaceae (with the exception of Serratia marcescens), Haemophilus influenzae, and Bordetella pertussis; for all these strains, the MICs at which 90% of tested strains are inhibited (MIC90s) were 1.0 microg/ml or less. Against methicillin-resistant staphylococci, enterococci, Serratia marcescens, Burkholderia cepacia, Stenotrophomonas maltophilia, and Acinetobacter calcoaceticus, R-95867 showed activity comparable to or slightly less than that of imipenem, with MIC90s ranging from 2 to >128 microg/ml. The in vivo efficacy of oral CS-834 against experimental mouse septicemia caused by gram-positive and gram-negative bacteria was better than that of comparative drugs. In murine respiratory infection models, the efficacy of CS-834 reflected not only its potent in vitro activity but also the high levels present in the lungs.     

The management of diabetes in pregnancy

The aim of the diabetes specialist is to provide a service to the pregnant diabetic woman so that she will present to her obstetrician with such well-controlled plasma glucose levels that her pregnancy will proceed without any diabetes-related problem, and she will be delivered of a normal baby, of normal size, at the normal full-term gestation, by the normal route. There are some problems in achieving this aim. The exact definition of hyperglycaemia in pregnancy is still a matter of dispute. Screening methods to identify the problem differ widely. Many centres have developed joint diabetes/antenatal clinics, but there are practical problems with such an approach. Pre-pregnancy counselling, and discussion of contraceptive measures is an important task for the diabetologist and requires up-to-date knowledge. Control of plasma glucose requires alteration of insulin doses as pregnancy proceeds. Mothers with retinal, renal or cardiac problems will need special care. The medical problems which develop, and the management of blood glucose during labour and delivery, mean that the diabetes team must be very adjacent to the obstetric service, and a centralised approach offers many advantages. The postpartum state, and the long-term outcome for both mother and baby, remain both an interest and a responsibility for the obstetric physician.     

Common dermatophyte infections. A simple diagnostic test and current management

Tinea pedis, onychomycosis, tinea cruris, and tinea capitis are among the most common dermatophyte infections and are seen in all socioeconomic groups. Successful treatment of these conditions depends first on accurate diagnosis, which is often quickly accomplished with a KOH examination. Culture may be needed in some cases, but results may not be available for 2 weeks or more. Immunocompromised patients are particularly susceptible to dermatophyte infection, and any deviations in presentation or failure to respond to treatment should prompt investigation for an underlying problem.     

Management of cerebral aneurysms. How can current management be improved?

Rupture of cerebral aneurysms is a complex and devastating pathophysiologic event. The successful management of aneurysm rupture requires a dedicated multidisciplinary team. This article reviews pathophysiology; clinical grading that can be used to predict outcome and guide therapy; factors that may affect outcome such as rebleeding, poor clinical grade, intracerebral hemorrhage, intraventricular hemorrhage, and acute hydrocephalus; preoperative care and assessment; pharmacological therapy; anesthetic, surgical, and endovascular considerations; and postoperative care following aneurysm rupture.     

Preoperative pregnancy testing: a survey of current practice

STUDY OBJECTIVE: To examine contemporary practices and opinions regarding preoperative testing requirements, with special emphasis on perioperative pregnancy recognition and consequences thereof. DESIGN AND SETTING: Anonymous questionnaire survey distributed to 300 (almost exclusively American) physicians attending the 1996 Society of Obstetric Anesthesia and Perinatology meeting. MEASUREMENTS AND MAIN RESULTS: Responses from 169 anesthesiologists indicated that approximately one-third mandated pregnancy testing via departmental policy. More anesthesiologists (p = 0.02) mandated routine pregnancy testing of all elective (30%) versus all emergency (17%) surgical patients. Sixty-six percent versus 20% percent, respectively, would require rather than simply offer pregnancy testing when history indicated possible pregnancy; 20% and 15%, respectively, of those surveyed indicated elective surgery would be canceled by the anesthesiologist if the patient were pregnant or refused testing (p = NS). Although 98% of respondents recognized a legal requirement to report child abuse, and 82% believed pregnancy in a juvenile (i.e., the child's age is under local legal defined age for consent to sex) by definition constituted child abuse, fewer than 4% would report this information to the police, even if the impregnating male were known to be an adult. CONCLUSIONS: The desire to identify pregnancy using patient history was most prevalent among anesthesiologists, with less than one third using mandatory, departmentally imposed screening programs. Positive test results in minors are shared primarily with surgeons and patients, occasionally with parents and social services, but rarely with police, although a positive test almost universally signified child abuse, and mandatory reporting laws were acknowledged by anesthesiologists surveyed.