Protective sensation of the plantar aspect of the foot

For decades pregnancy has been regarded as an unfavourable prognostic factor in women with malignant melanoma and for many patients termination of pregnancy was recommended. Likewise, it was suspected that pregnancy during the first few years after diagnosis of the tumor would impair the prognosis and, therefore, a contraindication was established. An analysis of the data of the Central Malignant Melanoma Registry of the German Dermatological Society revealed that 1% of female melanoma patients were pregnant and 40.5% were found to be in premenopausal status. In several recent studies survival rates of melanoma patients who were pregnant and those who became pregnant after diagnosis were compared to the rates in women without pregnancies. No significant differences were found. In addition, the use of oral contraceptives and menopausal estrogens, which were formerly thought to be related to an elevated risk of developing melanoma, was shown not to affect the risk and natural course of malignant melanoma. In conclusion, the recent results of extensive investigations no longer substantiate recommendations for abortion in pregnant melanoma patients. The use of oral contraceptives and menopausal estrogens is likewise no longer contraindicated in melanoma patients. A waiting period before having children may be recommended in the first 2-3 years after diagnosis, as this is the period with the highest probability of relapse, and one can be more certain that the course will be favourable.     

An update on clonality, cytokines, and viral etiology in Langerhans cell histiocytosis

The incidence of malignant melanoma is rising, and this may be the most frequently encountered malignancy during pregnancy. Because effective treatment of advanced or metastatic disease remains elusive, the key to adequate therapy is surveillance for early disease with prompt diagnostic work-up and treatment. Review of the most prominent reports in the literature fails to yield a consensus on whether pregnancy contributes to a worse prognosis. It seems clear that after controlling for all known prognostic variables, prognosis is unchanged; however, groups of patients diagnosed during pregnancy may have a disproportionately high incidence of high-risk primary lesion sites and increased tumor thickness. Surgical treatment during pregnancy should be prompt, with appropriate avoidance of general anesthesia during the first trimester. There is as yet insufficient evidence to warrant the use of adjuvant chemotherapy or biologic therapy during pregnancy.     

Melanoma in pregnancy

The incidence of pregnancy complicated by melanoma of the skin, calculated from data of the Netherlands Cancer Registry, is 1 per 10,000 pregnancies. The prognosis of a melanoma is not affected by prior or subsequent pregnancy. A melanoma diagnosed during pregnancy does appear to have a more unfavourable prognosis, due not to a less favourable clinical course, but to a delay in diagnosing melanoma during pregnancy and (or) a less favourable site. When a pregnancy is complicated by malignancy, in case of a melanoma there is a higher risk of placental metastasis compared with other malignancies. In nearly 50% of the cases reported in literature of placental metastasis there was foetal involvement.     

Moyamoya disease and pregnancy: case report and review of the literature

OBJECTIVE AND IMPORTANCE: Many female patients with moyamoya disease are of childbearing years, including those who were diagnosed before entering their childbearing years. However, there have been no extensive reviews of the management of pregnancy and delivery in association with moyamoya disease. The purpose of this report is to describe the case of a patient with moyamoya disease complicated by pregnancy and to review the literature on other such cases. CLINICAL PRESENTATION AND INTERVENTION: We report a 23-year-old primipara with moyamoya disease who delivered uneventfully by cesarean section under spinal anesthesia at 38 weeks of gestation. In the literature, 30 cases were reported of patients who had been diagnosed with moyamoya disease before pregnancy and delivery, and 23 patients who were symptomatic and were diagnosed for the first time with moyamoya disease in association with pregnancy. CONCLUSION: There is no evidence that pregnancy increases the risk of cerebrovascular accident or that bypass surgery decreases its risk. Poor prognosis of the patient or the newborn is mostly caused by cerebral hemorrhage and not by cerebral ischemia. It is important to control blood pressure and especially to avoid toxemia during pregnancy. Either cesarean section or vaginal delivery can be accomplished safely. Any anesthetic method can be used, provided special attention is given to avoiding hypocapnia, hypotension, and hypertension. Oral contraceptives should be avoided.     

Scleroderma and pregnancy

Pregnancy in systemic sclerosis may be uneventful, with both good maternal and fetal outcomes. Because scleroderma is a multisystem disease and complications do occur, however, careful antenatal evaluations, discussion of potential problems, and participation in a high-risk obstetric monitoring program is very important to optimize the best outcome. Because women with diffuse scleroderma are at greater risk for developing serious cardiopulmonary and renal problems early in the disease, they should be encouraged to delay pregnancy until the disease stabilizes. All patients who become pregnant during this high-risk time should be monitored extremely carefully. Although there are some suggestions that there are increases in infertility and miscarriages before disease onset, recent studies show that these issues probably do not have major impact for women with established scleroderma who plan to become pregnant. The high risk of premature and small infants may be minimized with specialized obstetric and neonatal care, however. Renal crisis in scleroderma is the only truly unique aspect of these pregnant, which, unlike blood pressure elevation in nonscleroderma pregnancies, must be treated aggressively with ACE inhibitors. Other pregnancy problems may not be unique to scleroderma, but because it is a chronic illness, any complication carries higher risks for both mother and child. Careful planning, close monitoring, and aggressive management should allow women with scleroderma to have a high likelihood of a successful pregnancy.     

Thyroid autoimmunity in pregnant women at risk for GDM

Presence of antithyroid autoantibodies (ThyAb) during pregnancy is strictly related to the risk of developing post partum thyroiditis (PPT) and this risk is increased in IDDM pregnant women. Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance of variable severity that begins, or is first diagnosed, during pregnancy. GDM is considered a risk factor for both type 1 and type 2 diabetes and various non-organ specific autoantibodies have been found to be associated with GDM, although there is little information on the association of GDM with thyroid autoimmunity. In this study oral glucose tolerance and prevalence of ThyAb were evaluated in a group of 41 pregnant women at increased risk of developing GDM and in a healthy control group. Our results showed that 22% of GDM risk group had impaired glucose gestational tolerance (IGGT) or GDM at the time of oral glucose tolerance test (OGTT). Moreover, ThyAb prevalence found in the women at increased risk of GDM (14.6%) was similar to that observed in healthy pregnant controls (12.5%). Nevertheless ThyAb frequency was higher in those GDM risk women with family history of diabetes (30.7%).     

Cryptococcal pneumonia complicating pregnancy

In the present report we describe 4 previously healthy women who developed cryptococcal pneumonia during pregnancy, and 1 pregnant woman with cryptococcal meningitis. These cases illustrate a previously uncharacterized spectrum of cryptococcal disease. We also discuss 24 patients previously reported who had cryptococcal meningitis during pregnancy. Finally, we review the available data for each therapeutic option and present an algorithm for management based on appraisals of disease severity and risk to the unborn fetus. This report emphasizes the need for heightened awareness of cryptococcosis in the differential diagnosis of pneumonia, chest pain, and hypoxemia in the pregnant patient, but at present, there are insufficient epidemiologic data to determine whether incidences of pulmonary or disseminated cryptococcosis actually increase during pregnancy. The risk of congenital cryptococcosis to the unborn fetus is low, and the most likely mechanism whereby neonates acquire invasive fungal pulmonary infection is through aspiration. While it is unclear whether there is any real increased risk of spontaneous abortion or premature labor, the data indicate that overall fetal outcome depends on effective treatment of maternal infection. For patients with dense air-space consolidation, progressive pulmonary disease, or dissemination, antifungal therapy is necessary. Optimal treatment is determined by the acuity and severity of the clinical presentation. Amphotericin B (approximately 1 g) with or without flucytosine represents the choice for initial treatment of the more acutely ill patient with disseminated or progressive pulmonary cryptococcosis who requires hospitalization (whether during or after pregnancy). Oral fluconazole appears to be safe and effective alternative therapy after delivery for the less severely ill patient who can be managed on an outpatient basis. While the use of fluconazole during pregnancy generally appears safe in terms of fetal outcome (49, 58), the class C status and single report of fetal malformation (62) preclude confident recommendation for its use during pregnancy. The risks and benefits of this effective and generally less toxic drug should be discussed with the parents and weighed against the use of amphotericin B. For pregnant women with limited pulmonary cryptococcosis (segmental or nodular infiltrates) and no evidence of dissemination, we recommend close follow-up without antifungal therapy similar to the recommendation for normal hosts with minimal disease. However, it is important to note that there is no extensive experience upon which to base this recommendation for pregnant individuals (45, 55, 103, 108). It is prudent to use frequent physical examinations (for example, every 1-2 months), combined with chest roentgenograms and serum cryptococcal antigens to monitor progression and/or development of disease in both the mother and child for approximately 6 months postpartum. In conclusion, cryptococcosis during pregnancy presents a special challenge to the clinician. A balanced therapeutic approach holds great promise for successful maternal and fetal outcomes.     

Symptom-related self-care of Mexican Americans with type 2 diabetes: preliminary findings of the Starr County Diabetes Education Study

OBJECTIVES: Late age at first birth and nulliparity are established risk factors for breast cancer, yet the extent to which fertility problems contribute to these associations remains largely unexplored. Here, we examine self-reported fertility problems as a risk factor for breast cancer in young women. METHODS: We used a population-based case-control study of 2,173 cases and 1,990 controls aged 20 to 54 years in the United States. Structured in-person interviews were used to elicit detailed information on established and potential breast cancer risk factors. Information was collected on pregnancy details, including difficulties becoming pregnant or maintaining a pregnancy. RESULTS: Self-reported difficulty in becoming pregnant or maintaining a pregnancy was reported by 450 cases and 377 controls. Overall, there was little association between these fertility problems and risk of breast cancer (odds ratio [OR] = 1.05). Parity was associated with a decreased risk of breast cancer in women both with (OR = 0.71) and without (OR = 0.79) fertility problems. There was little evidence of an increased risk of breast cancer with later age at first full-term birth among women without fertility problems (ORage 35+ :age <20 = 1.13, 95 percent confidence interval [CI] = 0.7-1.9), but a relatively strong association among women with fertility problems (ORage 35+ :age <20 = 2.96, CI = 1.3-7.0). Among women with a first full-term birth at age 35 or older, fertility problems were associated with a twofold risk of breast cancer. Analyses of duration of unprotected sexual intercourse prior to first pregnancy as an alternative estimate of infertility produced similar results. CONCLUSIONS: Our study suggests that the association between late age at first birth and breast cancer is stronger among women with self-reported fertility problems than among women with no fertility problems.     

Use of enzyme replacement therapy for Gaucher disease during pregnancy

OBJECTIVE: To date there has been little published experience with enzyme replacement therapy in pregnant women with symptomatic type I Gaucher disease. STUDY DESIGN: We describe six patients, including three with repeated early pregnancy loss, five of whom successfully carried pregnancies to term; the last pregnancy was terminated because of pulmonary hypertension. RESULTS: All pregnancies were uneventful and five resulted in healthy newborns. CONCLUSION: We concluded that in patients with Gaucher disease of childbearing age,for whom obstetric complications are an important symptom of the disease, pregnancy is not contraindicated (unless there is evidence or suspicion of pulmonary hypertension) and treatment should not be interrupted because the clinical improvement engendered by enzyme replacement therapy is conducive to fewer complications during pregnancy and delivery and post partum.     

Incidence of diabetes mellitus in women following impaired glucose tolerance in pregnancy is lower than following impaired glucose tolerance in the non-pregnant state

Impaired glucose tolerance (IGT), which is asymptomatic and requires a glucose tolerance test for detection, is a well-known risk factor for diabetes mellitus. Outside the research setting it is rarely identified in people who lack specific risk factors for diabetes except during pregnancy, at which time screening with an oral glucose challenge is a routine procedure. A 75-g oral glucose tolerance test was performed during the latter part of pregnancy or during a routine epidemiology survey in 15-39-year-old Pima Indian women with no history of abnormal glucose tolerance. Those with IGT by World Health Organization criteria were included in this study. Diabetes incidence in women was compared between those whose IGT was first detected during pregnancy and those who were not pregnant when IGT was first recognized. Seventeen of 73 pregnant women and 114 of 244 non-pregnant women developed diabetes within 10 years. When controlled for plasma glucose concentration, age, body mass index, parity and duration of follow-up, those who were not pregnant were at higher risk of developing diabetes than those who were pregnant (hazard rate ratio = 1.71, 95% confidence interval = 1.01-2.91). Previous studies had reported that women with IGT during pregnancy are at higher risk of diabetes than women with normal glucose tolerance. This study suggests that women with IGT during pregnancy are at lower risk than non-pregnant women with a similar plasma glucose concentration who, in the clinical setting, are likely to remain unrecognized.     

Hemoglobin A1c in diabetes related to pregnancy induced hypertension

OBJECTIVE: To test the hypothesis that the poor control of diabetes during pregnancy is correlated with a high rate of pregnancy induced hypertension (PIH). METHODS: A retrospective analysis on 146 pregnant women with diabetes mellitus of White's class B to RF (gestational diabetes was excluded) diagnosed before pregnancy was carried out in Yale-New Haven hospital, U.S.A. RESULTS: 36.3% of the diabetic women developed PIH. Hemoglobin A1c (HbA1c) levels were higher than normal in 63.7% (93 cases) of the patients during their initial prenatal visits. In the group with HbA1c score > or = 6 and White's Class D-RF, more cases developed PIH than that in groups with HbA1c score < 6 and White's Class B and C (P < 0.01, P < 0.05). CONCLUSION: Diabetic women with high HbA1c score or advanced White's Class during pregnancy were at increased risk for PIH. Good control of blood glucose level throughout pregnancy may reduce the risk of PIH in diabetic women.     

Listeriosis during pregnancy

Listeriosis is an uncommon infection that has a unique predilection for pregnant women and may result in pregnancy loss. Contaminated food is the usual source of infection, and increased federal surveillance of foodstuffs is the most effective strategy for prevention of disease. Although dramatic epidemics have received the most publicity, more cases of perinatal listeriosis are isolated. If Listeria chorioamnionitis is diagnosed preterm, in contrast to other types of chorioamnionitis, in utero therapy with high-dose penicillin or trimethoprim-sulfamethoxazole is possible, and preterm delivery may be avoided. The clinical characteristics of neonatal listeriosis are similar to neonatal Group B Streptococcus sepsis, with early and late onset forms of disease. The epidemiology, diagnosis, and management of Listeria infection in pregnancy are reviewed.     

Malignant lymphoma: implications during the reproductive years and pregnancy

The malignant lymphomas are reviewed, and involvement of urogenital-ridge derivatives, including the reproductive organs, is summarized. Implications of therapy for pelvic lymphoma are discussed. It is shown by a retrospective analysis that Hodgkin's disease has little effect on fertility, the course of gestation, delivery or fetal wastage and that maternal death is not increased. No adverse effect of pregnancy on the symptoms or longevity of women with Hodgkin's disease can be demonstrated. Women diagnosed in pregnancy as having lymphoma should undergo therapeutic abortion so that proper staging and therapy may be given. Pregnancies over 32 to 34 weeks should be induced. Women previously treated for lymphoma may become infertile as a result of therapy. Those not infertile after therapy should avoid pregnancies since there is a potential risk of malformations and malignancies in the offspring.     

Methodological difficulties in assessing contributions by community-based organizations to improving child health

The seroprevalence of toxoplasmosis was assessed between 1995 and 1997 on 767 pregnant women on the occasion of their medical check-ups for pregnancy in the preventive health centre of Franceville, province of the Haut-Ogooué, Gabon. Among the women under investigation, 71.2% were found to be IgG seropositive, including 2.6% IgM seropositive. When compared to similar studies conducted for the last 20 years in the same region, these results give evidence of an increase of the seroprevalence to toxoplasmosis among pregnant women, contributing to a decreased risk of contracting the disease during pregnancy.     

Prevalence of heart disease diagnosed de novo in pregnancy in a West London population

OBJECTIVES: To determine the prevalence of heart disease diagnosed de novo in pregnancy in a West London population and to re-examine the current role of routine cardiovascular examination in antenatal care in the UK. DESIGN: Retrospective study. SETTING: Obstetric medical clinics at Queen Charlotte's and Chelsea Hospital, University College Hospital and Northwick Park Hospital. POPULATION: Three hundred and twenty women referred for cardiac evaluation during pregnancy. RESULTS: The majority of the 139 women referred specifically for evaluation of murmurs during pregnancy were found to have physiological murmurs (97%). Only four women (3%) were found to have significant cardiac lesions de novo in their pregnancy. Three of these four women were immigrants who had no previous history of heart disease. The only woman from the UK was already known to have a murmur from childhood. CONCLUSIONS: Our study shows that heart disease diagnosed de novo in pregnancy in a West London population is an uncommon problem with low prevalence. It also appears to be a problem seen mainly in the immigrant population. The results emphasise the importance of taking a thorough medical history in all pregnant women. However, our results if they are confirmed, would suggest that only immigrants and those with significant symptoms or a known history of heart murmur or heart disease need undergo cardiovascular examination during pregnancy. These findings need to be confirmed in a larger group in other parts of the UK before further recommendations on selective cardiovascular examination can be made. This will have significant implications for midwifery-led care.     

Social influences on drinking during pregnancy.

The influence of social networks on the drinking practices of pregnant women was examined. Pregnant women (n?=?153) were classified according lo whether they were heavy or light drinkers just before pregnancy and whether they reduced their alcohol risk status after pregnancy recognition. Failure to reduce alcohol risk status following pregnancy recognition among initially heavy drinkers was associated with reporting drinking as a social activity and difficulty in resisting social pressure to drink. There was also evidence that failure to reduce drinking was associated with greater approval for drinking during pregnancy and more frequent serving of alcohol among the social network. Findings suggest that interventions designed to reduce drinking among pregnant women help them to find alternative social activities and to develop strategies for resisting pressure to drink (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Continuation of pregnancy in infaust fetal prognosis

In three pregnant women, lethal anomalies of the fetus were diagnosed ultrasonographically in the second trimester. These women decided to continue their pregnancies for different reasons. One woman strongly regretted her decision to abort a previous pregnancy. The second hoped that the doctors were mistaken on the prognosis. The third woman was afraid of medical interventions. In case of lethal anomalies of the fetus, doctors should advise their patients to consider both options: termination as well as continuation of their pregnancy. Irrespective of the women's choice, doctors ought to be committed to support the pregnant women in such a troublesome situation.     

Periodic health examination, 1996 update: 2. Screening for chlamydial infections. Canadian Task Force on the Periodic Health Examination

OBJECTIVE: To update the 1984 recommendations of the Canadian Task Force on the Periodic Health Examination on the routine screening of asymptomatic patients for infection with Chlamydia trachomatis. OPTIONS: Screening, with the use of culture or nonculture tests, of the general population, of certain high-risk groups or of all pregnant women; or no routine screening. OUTCOMES: Rates of asymptomatic and symptomatic chlamydial infection, perinatal complications, longterm complications of infection (i.e., pelvic inflammatory disease, infertility and ectopic pregnancy), coinfection with other sexually transmitted diseases, disease spread, hospital care, complications of therapy and costs of infection and of screening. EVIDENCE: Search of MEDLINE for articles published between Jan. 1, 1983, and Dec. 31, 1995, with the use of the major MeSH heading "chlamydial infections," references from recent review articles and recommendation by other organizations. VALUES: The evidence-based methods of the Canadian Task Force on the Periodic Health Examination were used. Advice from reviewers and experts and recommendations of other organizations were taken into consideration. Prevention of symptomatic disease and decreased overall costs were given high values. BENEFITS, HARMS AND COSTS: The greatest potential benefits of screening asymptomatic patients for chlamydial infections are the prevention of complications, especially infertility and perinatal complications, and the prevention of disease spread. There is no evidence that screening of the general population for chlamydial infections leads to a reduction in complications, and screening may increase costs. However, there is evidence that annual screening of selected high-risk groups and of pregnant women during the first trimester is beneficial in preventing symptoms and reducing the overall cost resulting from infection. RECOMMENDATIONS: There is fair evidence to support screening and treatment of pregnant women during the first trimester (grade B recommendation) as well as annual screening and treatment of high-risk groups (sexually active women less than 25 years of age, men or women with new or multiple sexual partners during the preceding year, women who use nonbarrier contraceptive methods and women who have symptoms of chlamydial infection: cervical friability, mucopurulent cervical discharge or intermenstrual bleeding; grade B recommendation). There is fair evidence to exclude routine screening of the general population (grade D recommendation). VALIDATION: These recommendations are similar to those of the US Preventive Services Task Force and the US Centers for Disease Control and Prevention, Atlanta. SPONSOR: These guidelines were developed and endorsed by the Canadian Task Force on the Periodic Health Examination, which is funded by Health Canada and the National Health Canada and the National Health Research and Development Program. The principal author (H.D.D.) was supported in part by the Ontario Ministry of Health and the Canadian Infectious Diseases Society Lilly Fellowship.     

Valvular heart disease in pregnancy. A contemporary perspective

Valvular heart disease may have a significant impact on the course and outcome of pregnancy with implications for fetal as well as maternal health. Optimally, serious symptomatic valvular heart disease should be detected and treated before pregnancy. Whether a pregnant woman is known to have valvular heart disease or is diagnosed during pregnancy, it is imperative that she is managed by an experienced multidisciplinary team. Although medical therapy may alleviate symptoms of heart failure in some patients, definitive intervention either with percutaneous balloon valvuloplasty or with surgical valve replacement may be necessary.     

Incidence and thickness of primary tumours and survival of patients with cutaneous malignant melanoma in relation to socioeconomic status

OBJECTIVE: To study incidence of and survival from cutaneous malignant melanoma in relation to socioeconomic status. DESIGN: Application of Carstairs deprivation score to all malignant melanoma patients diagnosed in a geographically defined area over a 15 year period. SETTING: West of Scotland (area population 2,716,900). SUBJECTS: 3142 patients first diagnosed with malignant melanoma in the period 1979-93. INTERVENTIONS: Surgical excision of primary malignant melanoma with additional treatment as appropriate and follow up until December 1994. MAIN OUTCOME MEASURES: Malignant melanoma incidence, primary tumour thickness and five year survival by socioeconomic status. RESULTS: From 1979 to 1993, the age standardised incidence rate for cutaneous malignant melanoma was 9.1/100,000 for the most affluent men and 2.4/100,000 for the least affluent men and 16.1/100,000 and 5.0/100,000 respectively for most and least affluent women (P < 0.001 for trend in both). The incidence increased steadily over time in both sexes in all socioeconomic groups. Good prognosis tumours ( < 1.5 mm thick) were most common in the most affluent men and women, and over the study period the proportion of such tumours increased most in the intermediate affluence group (both sexes) and in the least affluent women. Five year disease free survival from melanoma for the sexes combined was 81% for most affluent, 77% for intermediate, and 73% for least affluent groups. Even after adjustment for known prognostic factors of tumour thickness, ulceration, age, and body site of primary melanoma, the more affluent the group, the better the survival. CONCLUSION: Although the incidence of cutaneous malignant melanoma is higher among more affluent people, the prognosis is better in this group than for less affluent individuals. Early diagnosis campaigns should be targeted particularly to less affluent men and primary prevention campaigns should emphasise the greater risk in more affluent women.