Bilateral renal artery stenosis due to fibromuscular dysplasia presenting as superimposed pre-eclampsia.

Renal vascular hypertension is a diagnosis that needs to be entertained in the setting of refractory, otherwise unexplained hypertension in pregnancy. Conclusive diagnosis of the condition is made by the use of angiography, which confers only a low, safe dose of radiation to the fetus, especially after the first trimester. Percutaneous angioplasty is effective in treating this condition and is best performed postnatally to avoid fetal exposure to ionising radiation. While it could be managed pharmacologically, more refractory cases in pregnancy may be offered interventional treatment.

Tranexamic acid therapy for heavy menstrual bleeding.

INTRODUCTION: Heavy menstrual bleeding (HMB, also known as menorrhagia) is an important health problem that interferes with women's quality of life. It is one of the most common reasons why women are seen by their family doctors in primary care and is a condition frequently treated by surgery. AREAS COVERED: This review covers the pharmacology of tranexamic acid in brief and concentrates on its use in the treatment of HMB. Papers published in the English language between January 1985 and November 2010 were reviewed using Medline, Embase, Cinahl and the Cochrane Database of Systematic Reviews. Search terms were 'heavy menstrual bleeding', 'tranexamic acid' and 'menorrhagia'. EXPERT OPINION: Tranexamic acid, a competitive inhibitor of plasminogen activation, has been used to treat HMB for well over four decades. Although several treatment options are available for HMB, tranexamic acid is particularly useful in women who either desire immediate pregnancy or for whom hormonal treatment is inappropriate. Tranexamic acid is a well-tolerated, cost-effective drug that reduces menstrual blood loss in the range of 34-59%. It improves the health-related quality of life in women in HMB.

Wernicke's encephalopathy: a preventable cause of maternal death.

Wernicke's encephalopathy is a rare cause of maternal death. It is a difficult diagnosis to make but prevention and treatment is straightforward. Severe thiamine deficiency causes Wernicke-Korsakoff syndrome. Correct diagnosis and treatment with thiamine will decrease the case fatality rate.

Flexible mifepristone and misoprostol administration interval for first-trimester medical termination.

BACKGROUND: The administration interval between mifepristone and misoprostol is usually about 36-48 h, which might affect a woman's choice of method of termination. Unwanted outcomes such as uterine bleeding, painful cramps and psychosocial issues which may occur during this long interval can be altered by a shorter administration interval. A shorter interval will be cost-effective as it saves both women's and clinician's time and other resources. If the waiting time interval between therapeutic interventions could be reduced without compromising efficacy, it will potentially improve compliance, patient acceptability and quality of care. STUDY DESIGN: A systematic review of randomized controlled trials published from 1999 to 2008 was conducted to assess the evidence for a shorter mifepristone and misoprostol administration interval at first trimester medical termination. Searching strategy included MEDLINE, EMBASE, CLINAHL and Cochrane Library. The primary outcome measure was complete abortion without the need for a surgical procedure. RESULTS: Five randomized controlled trials (RCT) compared the efficacy of mifepristone and misoprostol administration intervals between 0 and 72 h in 5139 participants. The complete abortion rates varied between 90% and 98%. Although the meta-analysis of pooled data of all RCTs shows no statistically significant difference in efficacy between the shorter and longer dosing intervals, there is a trend toward slightly lower success rates with administration intervals earlier than 8 h. CONCLUSIONS: Overall efficacy of complete abortion is not statistically different between the longer and shorter administration intervals. This might encourage the clinician to adopt a 'flexible policy' with fully informed consent and consideration of all circumstances.

Implementation of guidelines on oxytocin use at caesarean section: a survey of practice in Great Britain and Ireland.

OBJECTIVE: Caesarean section is one of the most commonly performed major operations on women worldwide. Operative morbidity includes haemorrhage, anaemia, blood transfusion and in severe cases, maternal death. Various clinical guidelines address oxytocin use at the time of caesarean section. We previously reported wide variation in practice amongst clinicians in the United Kingdom in the use of oxytocin at caesarean section. The aim of this current study was to determine whether the variation in approach is universal across the individual countries of Great Britain and Ireland and whether this reflects differences in interpretation and implementation of clinical practice guidelines. STUDY DESIGN: We conducted a survey of practice in the five individual countries of Great Britain and Ireland. A postal questionnaire was sent to all lead consultant obstetricians and anaesthetists with responsibility for the labour ward. We explored the use of oxytocin bolus and infusion, the measurement of blood loss at caesarean section and the rates of major haemorrhage. Existing clinical guidelines from the National Institute for Clinical Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG) and ALSO (Advanced Life Support in Obstetrics) were used to benchmark reported practice against recommended practice for the management of blood loss at caesarean section. RESULTS: The response rate was 82% (391 respondents). Use of a 5 IU oxytocin bolus was reported by 346 respondents (85-95% for individual countries). In some countries, up to 14% used a 10 IU oxytocin bolus despite recommendations against this. Routine use of an oxytocin infusion varied greatly between countries (11% lowest-55% highest). Marked variations in choice of oxytocin regimens were noted with inconsistencies in the country-specific recommendations, e.g. NICE (which covers England and Wales) recommends a 30 IU oxytocin infusion over 4h, but only 122 clinicians (40%) used this. CONCLUSIONS: Clinicians' approach to the use of oxytocin at the time of caesarean delivery varies between countries. Even in countries with on-site visits to ensure guideline implementation (e.g. Clinical Negligence Scheme for Trusts in England), deviations from guideline recommendations exist. These variations may reflect a lack of robust evidence and the need for future research in this area.

Diabetes and the menopause.

Diabetes mellitus is the commonest chronic disease in post-menopausal women and is a predisposing factor for cardiovascular disease, which is the leading cause of death in this cohort in Western societies. Diabetes and the menopause are two independent risk factors for development of cardiovascular disease. Risk factor modification in terms of diabetes appears straightforward; however, correction of oestrogen deficiency which hallmarks the menopause appears complex. Our aim is to discuss this question based on the evidence available. Co-morbid diseases are common in post-menopausal diabetics. Hence, it not easy to either conduct or establish clear causal relationships in randomised controlled trials. Consequently, making decisions about treatment becomes difficult. However, it is important adopt strategies to help post-menopausal diabetic women alleviate their menopausal symptoms and to minimise the adverse consequences of their condition. We conclude that the low-risk diabetic post-menopausal women should be offered appropriate hormone replacement therapy, whereas non-oestrogen-based treatments should be the treatment of choice for high-risk women.

Use of oxytocin to prevent haemorrhage at caesarean section--a survey of practice in the United Kingdom.

OBJECTIVE: To establish the views and current practice of obstetricians and anaesthetists with regard to the use of oxytocin to prevent haemorrhage at caesarean section. STUDY DESIGN: A national survey of all lead consultant obstetricians and anaesthetists for the labour ward in the United Kingdom. A postal questionnaire was sent to all clinicians with one subsequent reminder to non-responders. The use of oxytocin bolus and infusion, perceived side effects of intravenous oxytocin, estimated blood loss at caesarean section, and willingness to participate in a future clinical trial were explored. RESULTS: The response rate was 84% (365 respondents). A slow bolus of 5 IU oxytocin was the preferred approach of obstetricians and anaesthetists (153, 86% and 171, 92%, respectively). Oxytocin infusions were used routinely by 72 clinicians (20%) with selective use for particular clinical circumstances by 289 (80%). Most clinicians used either 30 IU (158, 43%) or 40 IU (192, 53%) infusions over 4h, with a total of 38 different regimens. The perceived risk of side effects with an oxytocin infusion was low. Estimated "average" blood loss varied (150-1,500 ml) with 56 clinicians (17%) and 93 (28%) reporting a >20% risk of postpartum haemorrhage for elective and emergency caesarean sections, respectively. CONCLUSION: There is wide variation in the use of oxytocin at caesarean section reflecting limited research in this area. Excess haemorrhage is considered to occur frequently and the perceived risk of oxytocin bolus and infusion is low. Further research is required addressing the optimal use of oxytocic agents at caesarean section.