Obstetric Medicine current issue

The growing importance of medical problems in pregnancy

Rosene-Montella, K., Lowe, S., Nelson-Piercy, C. — Thu, 04 Mar 2010 09:26:02 PST

Behcet's syndrome in pregnancy

Martineau, M., Haskard, D. O, Nelson-Piercy, C. — Thu, 04 Mar 2010 09:26:02 PST

Behçet's syndrome (BS), a systemic inflammatory disease characterized by oral and genital ulceration, eye inflammation and arthritis, usually presents in the third and fourth decades of life, but is rare in pregnancy. BS is not usually associated with a detrimental effect on pregnancy outcome. In most women BS is reported to improve in pregnancy, although it may not always follow a similar course in successive pregnancies and it is not possible to predict the course of BS in a particular pregnancy. Many of the drug therapies used to treat BS are safe to use in pregnancy and in the breastfeeding mother. These include corticosteroids, azathioprine, calcineurin inhibitors and probably colchicine. Experience with use of biologics in pregnancy is increasing. Drugs used in the management of BS that should be avoided in women planning a pregnancy include methotrexate, mycophenolate mofetil, thalidomide, cyclophosphamide and chlorambucil.

Maternal cardiac arrhythmias during pregnancy and lactation

Cordina, R., McGuire, M. A — Thu, 04 Mar 2010 09:26:03 PST

Arrhythmias occurring during pregnancy can cause significant symptoms and even death in mother and fetus. The management of these arrhythmias is complicated by the need to avoid harm to the fetus and neonate. It is useful to classify patients with arrhythmias into those with and without structural heart disease. Those with a primary electrical problem, but an otherwise normal heart, often tolerate rapid heart rates without compromise whereas patients with problems such as rheumatic heart disease, congenital heart disease or cardiomyopathy may quickly decompensate during an arrhythmia.

Iron deficiency in pregnancy

McMahon, L. P — Thu, 04 Mar 2010 09:26:03 PST

Iron deficiency (ID) and related anaemia (IDA) during pregnancy are highly prevalent worldwide in both developed and developing nations although the causes are often different. At conception, many women lack sufficient iron stores to meet the increased requirements of pregnancy, which are calculated at approximately 1200 mg. Appraisal of iron status in pregnant women is problematic, however the most reliable available diagnostic test is a serum ferritin < 20 µg/L. ID is often associated with other nutritional disorders, and there is frequently a secondary cause or association. A greater oral intake is usually insufficient to meet the increased demands of pregnancy, however regular oral supplements (given either daily or intermittently) can often meet maternal needs and avoid associated neonatal complications of IDA. Over-treatment with iron should be avoided, but intravenous administration is useful when deficiency is discovered late, is severe, or if the woman is intolerant of oral formulations. This paper reviews the current literature, and addresses differences in the prevalence and causes of ID betwen developed and developing nations. It examines gestational iron requirements, distinguishes between ID and IDA, and highlights difficulties in diagnostic testing. Finally, it appraises the evidence for and against different treatment regimens, ranging from food fortification to intravenous iron infusions, according to availability and to need.

Pruritus in pregnancy: a study of anatomical distribution and prevalence in relation to the development of obstetric cholestasis

Thu, 04 Mar 2010 09:26:03 PST

The main objective of this study was to determine the prevalence and anatomical distribution of pruritus in 6532 pregnant women from a UK antenatal population. Pregnant women attending and completing antenatal care at two general hospitals over a 12-month period were recruited and contacted on three occasions by post. Medical advice and a questionnaire detailing the nature and severity of their pruritus were included. Pruritus in pregnancy, as reported by questionnaire, affected approximately 23% of pregnancies (n = 1521/6532 women) and 1.6% (n = 25) of these women developed obstetric cholestasis (OC). Overall, 0.66% of the antenatal population (43/6532) had a clinical diagnosis of OC (95% CI: 0.48–0.89%). Itching unrelated to OC was most commonly reported to be worst on the abdomen (31%, 616/2014). Women with OC reported pruritus to be most severe on the palms and soles in 16% (4/25) and ‘all over’ in 24% (6/25) compared with 5% (54/1120) (P < 0.05) and 4% (42/1120, P < 0.0001) of those without OC. In conclusion, pruritus affected approximately one in four women and OC one in 135 women during the study period. Women whose pruritus is ‘all over’ or most severe on the ‘palms or soles’ may be at greater risk of the disease.

Twin gestation with complete hydatidiform mole and a coexisting live fetus: case report and brief review of literature

Makary, R., Mohammadi, A., Rosa, M., Shuja, S. — Thu, 04 Mar 2010 09:26:03 PST

Complete hydatidiform (also referred to as hydatiform) mole with coexisting live fetus is an exceedingly rare event. The fetus usually has a normal karyotype, and approximately 25–40% chance of survival, if pregnancy is allowed to continue until reasonable fetal lung maturity is achieved. However, risk of maternal complications including preeclampsia and subsequent trophoblastic disease are significant. We report a case of a 19-year-old primigravida, at 25 weeks gestation with a complete hydatidiform mole and a coexisting live fetus. She developed severe preeclampsia with uncontrolled hypertension, and pregnancy was terminated by caesarean section, after a short course of dexamethasone to accelerate fetal lung maturity. A morphologically normal live female fetus and placenta were delivered without complications, along with a separate mass of complete mole. The postpartum course was complicated by uterine choriocarcinoma with metastases to lung and left kidney, which responded to chemotherapy. Our case is a rare example of a twin gestation composed of a complete hydatidiform mole with a coexisting live fetus, and illustrates the associated spectrum of maternal complications that mandate close pre- and post-natal surveillance.

Three case reports of maternal primary hyperparathyroidism in each trimester and a review of optimal management in pregnancy

Hui, E., Osakwe, O., Teoh, T. G., Tolley, N., Robinson, S. — Thu, 04 Mar 2010 09:26:03 PST

Primary hyperparathyroidism (PHPT) during pregnancy is associated with significant maternal and fetal risks. Prompt diagnosis and effective management during pregnancy can improve both maternal and fetal outcomes. However, there is no consensus with regard to conservative versus surgical management especially in the first and third trimester. We report three cases of PHPT associated with pregnancy that underwent parathyroidectomy each in a different trimester. Cases 1 and 2 were found to have hypercalcaemia and elevated parathyroid hormone levels in the second and first trimesters, respectively. Case 3 was known to have PHPT prenatally but previously declined parathyroidectomy. All three cases underwent parathyroidectomies during pregnancy without significant postoperative complications and all achieved favourable maternal and neonatal outcomes. Maternal hyperparathyroidism represents a preventable cause of maternal morbidity, with fetal morbidity and mortality. The benefits of parathyroidectomy with normalization of serum calcium in the mothers outweigh the risks of hypercalcaemia and suppression of the fetal parathyroid, especially where maternal vitamin D concentration is low.

Dialysis for severe hyponatraemia in preeclampsia

Hennessy, A., Hill, I. — Thu, 04 Mar 2010 09:26:03 PST

Severe hyponatraemia is a rare complication of preeclampsia. In the case presented, the rapid recovery of liver function test abnormalities and thrombocytopenia were accompanied by acute renal failure, relative oliguria and progressive hyponatraemia contributing to confusion and ileus. Dialysis was instigated and the patient promptly recovered. Renal function recovered fully.

Use of therapeutic dose low molecular weight heparin during pregnancy in women with mechanical heart valves

McLintock, C. — Thu, 04 Mar 2010 09:26:03 PST

Textbook of Periconceptional Medicine

Rajasingam, D. — Thu, 04 Mar 2010 09:26:03 PST

The Auckland City Hospital's experience with novel H1N1 influenza in pregnant women

Soh, M. C., Wilkinson, L. — Thu, 04 Mar 2010 09:26:03 PST