A case of delayed onset of threatened premature labor in association with electroconvulsive therapy in the third trimester of pregnancy.

Electroconvulsive therapy (ECT) is recommended by the American Psychiatric Association Task Force on ECT as a safe and effective treatment of depression throughout pregnancy. We report here administration of ECT in the third trimester of pregnancy in a 33-year-old patient with severe bipolar depression. The patient had a good antidepressant response to ECT. She experienced, however, delayed onset premature uterine contractions at home after her sixth session of ECT (10 hours post-ECT administration). After receiving tocolytics, the patient's contractions did not progress to premature labor. In consultation with the obstetrics team, it was decided to terminate the ECT course earlier than planned. The patient is delivered of a healthy female newborn infant spontaneously at 37 weeks' gestational age. Four months after delivery, the baby's development is progressing normally. This case illustrates that premature contractions in association with ECT during the third trimester of pregnancy may be delayed in onset. Patients and treatment team need to be aware of this possibility, particularly when ECT is conducted on an outpatient basis.

Neonatal outcomes with the use of lamotrigine for bipolar disorder in pregnancy and breastfeeding: a case series and review of the literature.

The treatment of bipolar disorder in pregnant women and the postpartum period is a complex clinical issue requiring careful consideration of the risks involved in using psychotropic medications versus the benefits of successfully managing this chronic illness. We present three cases of women exposed to lamotrigine during pregnancy and breastfeeding, with follow up of their infants until 15-18 months of development.

Branched stent-grafts: will these become the new standard?

During the past 15 years, endovascular methods of repair have assumed an ever more prominent role in the management of aortic aneurysms because they do not require direct exposure of the aneurysm and do not interrupt flow through the aneurysm. However, one cannot use endovascular techniques to exclude aneurysms that have branches to vital organs without first providing those branches with an alternative source of blood flow. One approach involves conventional surgical bypass to effectively "debranch" the affected segment. This approach has gained popularity because the endovascular part of the procedure is relatively simple and the surgical part does not necessarily require exposure of the aneurysm itself. The other approach involves endovascular bypass to the branches of the aorta through branches of the stent-graft. The relative merits of the two approaches depend largely on the morbidity of surgical debranching, which varies from segment to segment depending on the surgical accessibility of the branch arteries and the consequences of downstream ischemia. The authors generally favor the use of branched stent-grafts in the thoracoabdominal aorta and a combined approach in the aortic arch.

Subclinical embolization after carotid artery stenting: new lesions on diffusion-weighted magnetic resonance imaging occur postprocedure.

OBJECTIVES: The reported rate of subclinical brain injury after carotid artery stenting (CAS) seen on diffusion-weighted magnetic resonance imaging (DWI) varies from 10% to >40%. Data from transcranial Doppler after CAS indicate that embolization may continue for several days, suggesting that that at least some lesions seen on DWI occur postprocedure. Because DWI lesions appear or=60 microm. RESULTS: There were two periprocedural strokes and one transient ischemic attack (TIA), but no strokes or TIAs occurred during follow-up. In the 23 patients imaged 1 hour postprocedure, new lesions were found in two (9%), and 18 (78%) had new lesions at 48 hours (P < .001). For the entire study group, the incidence of new lesions at 48 hours was 67% (36/54). The median number of DWI lesions was four (range, 1 to 17). Every protection device examined had atherosclerotic debris, with a mean of 135 +/- 73 fragments (range, 18 to 310) sized >60 microm and a mean of eight fragments (range, 2 to 21) sized >500 microm. Findings on postprocedure DWI did not correlate with the degree of stenosis, size of angioplasty balloon, or number of inflations, nor with the number or size of fragments retrieved from the protection device. CONCLUSIONS: CAS can be performed with a very low incidence of clinically evident neurologic events; however, it is associated with embolization during and after the procedure. Protection devices effectively prevent clinical and subclinical events during the procedure. Significant embolization continues for at least 48 hours postprocedure, causing lesions on DWI when there is no mechanism for cerebral protection. These data correlate with transcranial Doppler reports of continued embolization after CAS and indicate that DWI should be done as late as possible to accurately assess the rate of subclinical brain injury with CAS procedures.