Management of Nephrotic Syndrome in the Pregnant Patient.

Objective: To present a case series of pregnant women with nephrotic syndrome, describe maternal and fetal outcomes, and propose treatment strategies. Study Design: A retrospective cohort case review of 11 pregnant women with nephrotic syndrome was performed over 2 years. Treatment regimens and trends were recorded. Linear regression was used for continuous outcomes, and logistic regression for categorical outcomes (p<0.05). Results: On first admission, 3 of 11 patients had a serum creatinine >1.4 mg/dL; all 11 exhibited an antepartum increase in creatinine. Two required antepartum dialysis, and 3 were dialyzed postpartum. Initial mean 24-hour urine protein was 10,522 mg (2,160-36,603) and increased to 26,220 mg (4,650-49,980). Pregravid weight increased from a mean 95 kg (BMI 33.8) to 112 kg (BMI 39.9) at time of delivery. Mean antepartum and postpartum diuresis was 33.2 L (±25.8) and 5.2 L (±8.2), respectively. Mean serum albumin levels were 2 g/dL. Ten patients received intravenous diuretics and 9 received intravenous albumin. Mean gestational age at delivery was 34w 3d (30.4-38.4). Conclusion: Pregnant women with nephrotic syndrome can be managed successfully by a collaborative team of obstetricians and nephrologists with careful diuresis, repletion of albumin, and administration of anticoagulants, when necessary, to deliver a healthy, probably preterm, neonate.

Association of group B streptococcus colonization with early term births.

OBJECTIVE: The objective of this study was to reproduce and validate the association of group B streptococcus (GBS) colonization resulting in early-term birth (370/7-386/7 weeks' gestation) and lower birth weight, reported in African-American and Caucasian populations, in a Hispanic cohort. METHODS: GBS status of women 18-40 years of age with uncomplicated pregnancies who experienced spontaneous labor and vaginal delivery between 370/7 and 420/7 weeks' gestation over 5 years were identified. Bivariate analysis was conducted on stratified data (GBS+ vs. GBS-) to assess relationship to early versus late-term delivery. Chi-square, Fisher's exact, and Student's t-tests were used for analysis. RESULTS: Our cohort was 86% Hispanic, with a GBS+ rate of 10%. No difference for mean gestational age at delivery for GBS+ (275.9 days±6.8) vs. GBS- (275.6 days±6.9) was seen (P-value=0.61). Birth weight for GBS+ and GBS- groups were similar (3388.5 g±388.6 vs. 3395.1 g±401.7, P-value=0.86). CONCLUSIONS: In specific evaluation of Hispanic women experiencing spontaneous, term, vaginal delivery, GBS colonization does not result in early-term delivery. This is not consistent with prior data in the African-American and Caucasian population suggesting racial disparity in outcomes related to GBS colonization.

Extended cycle combined oral contraceptives and prophylactic frovatriptan during the hormone-free interval in women with menstrual-related migraines.

BACKGROUND: Migraine headaches are a significant problem for American women with many of them suffering from headaches around the time of their menstrual cycle. Women taking oral contraceptives in the standard 21/7 cycle regimen often suffer from headaches around the time of the hormone free intervals (HFIs) as well. Extended oral contraceptive regimens have been shown to decrease the frequency, but not eliminate these headaches. This study is a double-blind, randomized, placebo-controlled pilot study of participants with menstrual-related migraines (MRMs) who were initiated on extended combined oral contraceptives and given frovatriptan prophylactically during HFIs. METHODS: Participants having spontaneous menstrual cycles or taking daily combined oral contraceptives in a 21/7 regimen with MRMs were placed on a contraceptive containing levonorgestrel and ethinyl estradiol. Analyses compared headache scores during pre-study baseline cycles to those in a 168-day extended regimen with placebo versus frovatriptan treatments during HFIs. RESULTS: Daily headache scores decreased (p=0.034) from 1.29 ± 0.10 during pre-study cycles to 1.10 ± 0.14 during extended combined oral contraceptive use. Frovatriptan blocked the increase in headache score over the placebo during HFIs. However, following the withdrawal of frovatriptan, headache scores increased (p>0.01) despite resuming combined oral contraceptive use. CONCLUSIONS: Extended combined oral contraceptive regimen reduces MRM severity. Frovatriptan prevents headaches during HFIs, but is associated with new headache symptoms when withdrawn.

The role of NADPH oxidase in a mouse model of fetal alcohol syndrome.

OBJECTIVE: Fetal alcohol syndrome (FAS) is the most common cause of nongenetic mental retardation. Oxidative stress is one of the purported mechanisms. Nicotinamide adenine dinucleotide phosphate oxidase (NOX) is an enzyme involved in the production of reactive oxygen species. Our objective was to evaluate NOX in the fetal brain of a well-validated mouse model of FAS. STUDY DESIGN: Timed, pregnant C57BL/6J mice were injected intraperitoneally with 0.03 mL/g of either 25% ethyl alcohol or saline. Fetal brain, liver, and placenta were harvested on gestational day 18. The unit of analysis was the litter; tissue from 6-8 litters in the alcohol and control group was isolated. Evaluation of messenger ribonucleic acid (mRNA) expression of NOX subunits (DUOX1, DUOX2, NOX1, NOX2, NOX3, NOX4, NOXA1, NOXO1, RAC1, p22phox, and p67phox) was performed using quantitative real-time polymerase chain reaction; alcohol vs placebo groups were compared using a Student t test or a Mann-Whitney test (P < .05). RESULTS: Alcohol exposed fetal brains showed significant up-regulation in subunits DUOX2 (1.61 ± 0.28 vs 0.84 ± 0.09; P = .03), NOXA1 (1.75 ± 0.27 vs 1.09 ± 0.06; P = .04), and NOXO1 (1.59 ± 0.10 vs 1.28 ± 0.05; P = .02). Differences in mRNA expression in the placenta were not significant; p67phox was significantly up-regulated in alcohol-exposed livers. CONCLUSION: Various NOX subunits are up-regulated in fetal brains exposed to alcohol. This effect was not observed in the fetal liver or placenta. Given the available evidence, the NOX system may be involved in the causation of FAS through the generation of reactive oxygen species and may be a potential target for preventative treatment in FAS.

A true cornual (interstitial) pregnancy resulting in a viable fetus.

BACKGROUND: Interstitial ectopic pregnancies are known for their dangerous implantation location and high risk of rupture. CASE: We report an interstitial pregnancy that was not ruptured at the time of cesarean delivery. Hysterectomy was not necessary and a viable fetus was delivered with a neonatal intensive care unit stay compatible to any neonate of his gestational age. CONCLUSION: In very rare circumstances, interstitial pregnancies can result in a viable fetus, and careful inspection of second-trimester ultrasonogram can lead to proper management of complicated ectopic pregnancies.

A new method for creating the bladder flap.

BACKGROUND: Bladder flaps are commonly created during routine cesarean deliveries and often require multiple steps that increase operating time and expose the surgeon to inadvertent injury. OBJECTIVE: We report a simple method of creating a bladder flap that eliminates the need for multiple instrument handoffs and repositioning. CONCLUSION: The simplicity of this method allows the surgeon decreased operative entry time while decreasing exposure to injuries from multiple instrument handoffs during bladder flap development.

Umbilical artery aneurysm.

BACKGROUND: Umbilical artery aneurysm is a rare condition associated with increased risk for aneuploidy and fetal demise. CASE: We report a case of umbilical artery aneurysm discovered at 27 weeks of gestation in one fetus of a dichorionic, diamniotic twin pregnancy. The patient was hospitalized to monitor for expansion of the aneurysm. Corticosteroids were administered, and, after genetic amniocentesis revealed a normal karyotype, cesarean delivery was performed at 28 2/7 weeks of gestation. Pathologic examination confirmed an umbilical artery aneurysm in the cord of the affected fetus. CONCLUSION: Given the high incidence of aneuploidy associated with umbilical artery aneurysm, it is important to consider karyotype analysis of the affected fetus. If a normal karyotype is identified, early delivery may be warranted to decrease the risk of fetal demise.