Extending the window for thrombolysis for treatment of acute ischaemic stroke during pregnancy: a review.

Historically, safety of intravenous recombinant tissue plasminogen activator (IV rt-PA) for the treatment of acute ischaemic stroke (AIS) is limited to use within 4.5 hours from symptom onset. Recent studies suggest the treatment window may be extended when patients have salvageable brain tissue on advanced neuroimaging. This paper describes a novel use of IV rt-PA for treatment of AIS in a pregnant patient within an extended-time window (>4.5 hours, and <9 hours) based on advanced neuroimaging with a favourable outcome. TWEETABLE ABSTRACT: Novel use of IV rt-PA for treatment of AIS in pregnancy within an extended-time window based on advanced imaging with a favourable outcome.

Addison's disease in pregnancy: Case report, management, and review of the literature.

BACKGROUND: Addison's disease is an uncommon condition encountered during pregnancy; however, pregnant patients with Addison's disease are at higher risk for multiple pregnancy related complications. Treatment during pregnancy involves steroid replacement therapy. CASE REPORT: A 34-year-old previously healthy G2P1001 presented with lethargy, skin hyperpigmentation, polyuria, and salt craving. Laboratory evaluation showed hyperkalemia, hyponatremia, elevated ACTH, and low cortisol. The patient terminated the pregnancy due to her symptoms. She was then placed on a regimen of hydrocortisone and fludrocortisone, leading to symptom resolution. On second presentation as a G5P1031, her Addison's disease was managed with hydrocortisone and fludrocortisone. When Addison's symptoms recurred, ACTH levels were checked to determine if her current medications could be optimized. She ultimately delivered a healthy male infant vaginally. For her third presentation as a G6P2032, her pregnancy was managed in a similar manner to the previous pregnancy. CONCLUSION: There is currently minimal cohesive literature on the management of Addison's disease during pregnancy. Patients can be managed successfully by monitoring for recurrence of Addison's symptoms and adjusting medication dosing as needed.

Moyamoya disease in pregnancy: management after intracranial bypass grafting.

Moyamoya disease (MD) is a chronic, progressive cerebrovascular disease distinguished by bilateral stenosis or occlusion of the arteries around the circle of Willis with resulting prominent arterial collateral circulation. We describe a pregnant woman in whom this diagnosis was confirmed by cerebral angiogram and treated with bilateral superficial temporal artery-middle cerebral artery (STA-MCA) bypass grafting prior to conception. The patient was managed with strict blood pressure monitoring and low-dose aspirin antepartum, intrapartum, and postpartum. The patient presented in spontaneous labor at term and underwent a spontaneous vaginal delivery without complications.

Maternal obesity, associated complications and risk of prematurity.

OBJECTIVE: We aimed at (a) examining the rates of obesity over a 12-year period; (b) studying the effect of obesity and morbid obesity on gestational age and birth weight and (c) determining the influence of race on the association between maternal obesity and the gestational age of a newborn. STUDY DESIGN: We conducted a retrospective analysis using data from the perinatal data set of mothers delivering at the George Washington University between 1992 and 2003. We stratified mother/infant pairs (n=14 183) into three groups on the basis of maternal prepregnancy body mass index (BMI): not obese (BMI<30), obese (BMI 30 to 39) and morbidly obese (BMI> or =40). We identified all spontaneous and induced preterm deliveries in each group. Bivariate and multivariate analyses were conducted to control for significant differences between groups. RESULT: We identified obesity in 1707 (12%) and morbid obesity in 415 (3%) of the mothers. Obesity and morbid obesity increased over time during the study period. In crude analysis, mothers with obesity and morbid obesity were more likely to deliver prematurely (16.7 and 20.3%, respectively) when compared with nonobese women (14.5%), and were also more likely to have other complications including smoking, anemia, hypertension, diabetes and cesarean delivery. When controlling for these complications in a logistic regression model, obesity and morbid obesity were not associated with prematurity. CONCLUSION: There is no direct link between obesity and prematurity. Prematurity is more likely caused by medical complications that frequently occur in obese women. Further studies are needed on this growing population to test whether providing adequate prenatal care can control the associated medical conditions and subsequently ameliorate the rate of prematurity.

Care of HIV-infected pregnant women in maternal-fetal medicine programs.

OBJECTIVE: To survey the evolution over the past decade of attitudes and practices of obstetricians in maternal-fetal medicine fellowship programs regarding the management of human immunodeficiency virus (HIV)-infected pregnant women. METHODS: Directors of all 65 approved maternal-fetal medicine training programs were sent questionnaires, responses to which were to reflect the consensus among members of their faculties. Programs were stratified based upon the number of HIV-infected pregnant patients cared for in the previous year. RESULTS: Responses reflect experience with over 1000 infected pregnant women per year, nearly one-quarter with advanced disease. Combination antiretroviral therapy was prescribed by all respondents, universally in the 2nd and 3rd trimesters. A three-drug regimen (often containing a protease inhibitor) was used more often by those who treated at least 20 HIV-infected pregnant patients per year than by those programs seeing a lower number of patients (80 vs 59%). Despite the known and unknown risks of the use of antiretrovirals during pregnancy, only half of all responding programs report adverse events to the Antiretroviral Pregnancy Registry; reporting was more common among the institutions seeing a higher number of patients (61 vs 45%). Seventy-eight percent of higher volume programs enroll their patients in clinical studies, usually multicenter, versus 35% of lower volume programs. CONCLUSIONS: Care for HIV+ pregnant women has dramatically changed over the past decade. Antiretroviral therapy is now universally prescribed by physicians involved in maternal-fetal medicine training programs. Given limited experience with these agents in the setting of pregnancy, it is essential for maternal-fetal medicine practitioners to actively report on adverse events and participate in clinical trials.

Management and therapy of human immunodeficiency virus-infected pregnancies in maternal-fetal medicine fellowship training programs.

OBJECTIVE: To determine attitudes and practices of obstetricians in maternal-fetal medicine fellowship programs regarding the management of human immunodeficiency virus (HIV) infection and the use of zidovudine during pregnancy. METHODS: We sent a questionnaire to the directors of all 78 approved maternal-fetal medicine fellowship programs. The responses, reflecting the consensus of the staffs of each program, were obtained and tabulated. RESULTS: Although their programs annually provide care for more than 2100 pregnant women infected with HIV, less than 25% of all maternal-fetal medicine fellowship directors reported that their patients participate in multicenter studies of HIV infection complicating pregnancy. Nearly two-thirds of the infected women are excluded from such multicenter studies. More than 70% of all program directors believe that zidovudine should be offered to symptomatic pregnant women infected with HIV; one-half question whether zidovudine poses short-term fetal risks. Nevertheless, nearly half of all HIV-infected pregnant women they manage are excluded from trials of zidovudine therapy during pregnancy. CONCLUSIONS: Many HIV-infected pregnant women who receive care in clinics of maternal-fetal medicine fellowship programs are excluded from multicenter studies. Consideration should be given to creating a national registry for this important, currently unreported, clinical resource.

Identification of cell types in rat hippocampal slices maintained in organotypic cultures.

We have cultured transverse slices of the hippocampal formation from neonatal rats and have identified the cell types which appear in the outgrowth with cell type specific markers. Tetanus toxin and anti-tetanus toxoid, as well as antisera to neurofilaments and 14-3-2 protein, were used to identify neurons. Astrocytes were identified with antisera to glial fibrillary acidic protein and were the predominant non-neural cell type. Fibroblastic cells were labeled with antisera to fibronectin and to myosin and oligodendroglia were identified with antisera to galactocerebroside. The hippocampal neurons could be classified as 1 or the 3 types present in vivo (pyramidal cells, granule cells, or GABAergic interneurons) on the basis of their size, shape, location, or reaction with antisera to glutamic acid decarboxylase. Outgrowth of glial cells and neurites occurred within hours of explantation. Within a few days granule cell neurons migrated onto the glial cell layer from the explant. Their movement is probably related to their migration during in vivo development of the granule cell layer. Synapse formation was observed by electron microscopic analysis beginning about 3-5 days in vitro and areas of neuropil containing many synapses were observed after 3-4 weeks. This culture system should be useful for further studies on the cellular processes which occur during hippocampal development and plasticity.