Ursodeoxycholic acid for the treatment of intrahepatic cholestasis of pregnancy.

OBJECTIVE: To report our experience in managing intrahepatic cholestasis of pregnancy with ursodeoxycholic acid. METHODS: All cases of intrahepatic cholestasis of pregnancy that were diagnosed at Bridgeport Hospital from January 1997 to August 1999 were identified. Information was abstracted on demographics, medical and obstetric history, symptoms, laboratory data, therapy and pregnancy outcome. Statistical analysis was primarily descriptive; continuous variables were analyzed with t tests. RESULTS: A total of 20 cases of intrahepatic cholestasis of pregnancy were identified (0.32% of live births). All patients presented with pruritus. The mean gestational age at onset of symptoms was 31.1 weeks (range 13-38.4, median 32.4). Bile acids were measured in 18 cases and were elevated in all. The mean gestational age at delivery was 36.4 weeks (32.3-39.9). Eight patients were treated with ursodeoxycholic acid (600-1200 mg). All eight patients experienced subjective improvement in pruritus after initiation of treatment with ursodeoxycholic acid. Ursodeoxycholic acid was associated with a decrease in bile acids in most patients (p = 0.16) and with a significant decrease in serum transaminases (p = 0.03). CONCLUSIONS: Ursodeoxycholic acid is an effective therapy for relief of pruritus and improvement of the liver dysfunction that occurs with intrahepatic cholestasis of pregnancy.

Indicated preterm birth: a possible contribution to group B streptococcal sepsis prophylaxis protocol failures. A case report.

BACKGROUND: Despite the acceptance of protocols for the prevention of group B streptococcal (GBS) sepsis for the newborn, protocol violations, with subsequent failure to initiate intrapartum antibiotic therapy, occur at many institutions. The causes for GBS prophylaxis protocol violations are not well understood. CASES: We report two cases of indicated preterm birth in which appropriate antibiotic prophylaxis for GBS sepsis was not initiated. CONCLUSION: In the setting of indicated preterm birth, GBS prophylaxis may be overlooked. We suspect that the attention given to the medical or fetal complications of indicated preterm birth may contribute to the omission of GBS sepsis prophylaxis in these situations.

Prospective evaluation of bone density in pregnant women receiving the low molecular weight heparin enoxaparin sodium.

OBJECTIVE: To evaluate changes in bone density in women receiving enoxaparin sodium during pregnancy. METHODS: Bone density in the proximal femur was serially measured in 16 women receiving enoxaparin sodium (40 mg daily) during pregnancy. Baseline measurements were taken within 2 weeks of starting therapy and then at 6-8 weeks postpartum and 6 months postpartum. RESULTS: Patients received enoxaparin sodium for a mean duration of 25 weeks (range, 19-32 weeks). There was no significant change in mean bone density measurement from baseline measurements to the conclusion of therapy at 6 weeks postpartum and no patient experienced a decrease in bone mass of >10% at 6 weeks postpartum. By 6 months postpartum, there was a significant mean decrease in bone density (P = 0.02) and two of the 14 patients evaluated (14%) experienced an overall bone loss of >10%. CONCLUSION: The prolonged used of enoxaparin sodium may not cause significant bone loss during pregnancy.

Evaluation and management of infertility in women: the internists' role.

Interventions for infertility have greatly increased in number and sophistication. Women with multiple medical problems and women near or beyond menopause are now able to conceive. The internist will be called on to assess the risk that infertility interventions pose and to counsel patients accordingly. Knowledge of the medical illnesses associated with infertility, the types of infertility treatments available, and the medical complications of these interventions are required to properly assess this risk. Medical complications of infertility interventions can be direct effects of related drugs and technologies and indirect consequences of the induced pregnancy, multiple gestation, or associated medical conditions. This article reviews the definitions and scope of infertility, the interventions used for treatment of infertility, the medical complications of these interventions, the potential risks of fertility treatment in women unable to conceive spontaneously, and important issues for preconception counseling.

Successful pregnancy after suspected anaphylactoid syndrome of pregnancy (amniotic fluid embolus). A case report.

BACKGROUND: Limited information is available on the recurrence risk of anaphylactoid syndrome of pregnancy. CASE: A successful pregnancy followed suspected anaphylactoid syndrome of pregnancy. CONCLUSION: A review of the literature revealed five cases of successful subsequent pregnancies following anaphylactoid syndrome of pregnancy. No instances of recurrent anaphylactoid syndrome of pregnancy have been reported.

Pregnancy outcome after successful external cephalic version.

OBJECTIVE: Recent studies have suggested that the rate of cesarean delivery in patients who have undergone a successful external cephalic version is higher than expected. This study compares the incidence of cesarean delivery in patients who underwent successful external cephalic version and patients with primary cephalic presentations. STUDY DESIGN: We identified and reviewed the charts of 92 patients who underwent a successful external cephalic version. We identified a control population of 184 patients from the delivery room logs. We collected outcome data and information on additional risk factors that may affect cesarean delivery rates. RESULTS: There were no significant differences between study and control populations. There was no significant difference in the cesarean delivery rate between study patients (22.8%) and control patients (23.4%). CONCLUSIONS: We could not demonstrate a significant increase in the cesarean delivery rate for women who underwent successful external cephalic version in comparison with patients in labor with primary cephalic presentations.

Changes in the pharmacokinetics of the low-molecular-weight heparin enoxaparin sodium during pregnancy.

OBJECTIVE: We sought to evaluate the pharmacokinetics of subcutaneously administered enoxaparin sodium during and after pregnancy. STUDY DESIGN: Daily subcutaneous injections of enoxaparin sodium (40 mg) were administered to 13 pregnant women. On 3 separate occasions, once early in pregnancy (12-15 weeks), once late in pregnancy (30-33 weeks), and once in the nonpregnant state (6-8 weeks post partum), serial blood samples were collected, and plasma was analyzed for antifactor Xa activity. Analysis of variance was used for statistical analysis. P <.05 was significant. RESULTS: The time to maximum concentration and the mean residence time in pregnancy compared with the postpartum state were not significantly different. During early and late pregnancy, maximum concentration and the last measurable anti-factor Xa activity level were lower than in the nonpregnant state (P <.05). The area under the plasma activity-versus-time curve was significantly lower in pregnancy than in the postpartum state (P <.05). CONCLUSION: The pharmacokinetics of enoxaparin sodium are significantly different during pregnancy than in the same women when nonpregnant. The observed difference is likely because of increased renal clearance of enoxaparin during pregnancy. This finding has significant implications for appropriate dosing of enoxaparin in pregnancy.

The association of increased fetal nuchal translucency and spinal muscular atrophy type I.

We report a fetus with spinal muscular atrophy type I, who presented with an increased nuchal translucency at 13 weeks' gestation. A review of the literature reveals additional cases of spinal muscular atrophy type I associated with increased nuchal translucency and suggests increased nuchal translucency may be an early finding in this disorder.

Factors influencing preconception control of glycemia in diabetic women.

BACKGROUND: Although periconceptional glycemic control directly impacts perinatal outcome for pregestational diabetic women, these women still frequently enter pregnancy with suboptimal control of glycemia. OBJECTIVES: To determine how frequently diabetic women enter pregnancy with suboptimal glycemic control and to identify factors associated with not achieving optimal periconceptual control of glycemia. PATIENTS AND METHODS: Pregestational diabetic women (n = 55) who attended the Maternal Fetal Medicine Faculty Practice or the Resident Medical Complications Obstetric Clinic, Magee Women's Hospital, Pittsburgh, Pa, were administered a brief questionnaire pertaining to periconceptional education and control of glycemia. Levels of periconceptional hemoglobin A1c, were measured in all patients. RESULTS: Sixty-one percent of pregestational diabetic women presented for prenatal care with suboptimal control of their blood glucose levels (hemoglobin A1c measurement, >0.08). Of the 55 diabetic women who participated in the questionnaire, 47 (86%) were under the care of a physician for their diabetes, 45 (82%) monitored their glucose level at least 3 times per day, 34 (60%) stated that they had been advised to plan a pregnancy, and 29 (53%) stated that they had planned their pregnancies. Women who had not been advised to achieve target hemoglobin A1c levels were more likely to enter pregnancy with suboptimal control of their blood glucose levels (P = .02). Women who experienced prior complications with pregnancy were significantly more likely to enter pregnancy with suboptimal control of their blood glucose levels (P = .02). CONCLUSIONS: Diabetic women frequently enter pregnancy with suboptimal control of glycemia. Women not advised to achieve target glucose or hemoglobin A1c levels were more likely to enter pregnancy with suboptimal control of glycemia.

Pregnancy after liver transplantation.

This article reviews the reported experience with pregnancy after liver transplantation and describes obstetric risks and medical issues that the maternal fetal medicine specialist has a reference for managing these pregnancies and for providing appropriate preconception counseling. Women who undergo liver transplantations have a higher risk of preeclampsia, worsening hypertension, preterm premature rupture of membranes, anemia, small for gestational age, preterm delivery, and cesarean section than the normal obstetric population. Women with preconceptional renal dysfunction appear to be at greatest risk for pregnancy complications. Women who conceived within 6 months of transplant had a high risk of rejection. Reproductive-aged recipients of liver allograft should receive contraception and preconception counseling. In an appropriately timed and planned pregnancy, women who undergo liver transplantations can have successful pregnancies with little risk to their allograft function.

Association of pregnancy complications and choice of immunosuppressant in liver transplant patients.

BACKGROUND: The purpose of this study was to identify factors associated with antenatal complications for an ongoing series of pregnant women who have undergone orthotopic liver transplantation. METHODS: We reviewed Magee-Womens Hospital records from 14 pregnancies in 13 women in whom a liver had been transplanted before pregnancy. We collected and analyzed data regarding the primary liver disease, allograft status, liver function at conception and during pregnancy, immunosuppressive medications, associated medical conditions, time from transplant to conception, cytomegalovirus serostatus, and maternal and fetal outcome. RESULTS: Seven patients had evidence of renal dysfunction (creatinine, 1.3-2.0 mg/dl), five of whom also were hypertensive at their first prenatal visit. The complications of preeclampsia, worsening hypertension, and small for gestational age occurred only in women with renal dysfunction at conception. Renal dysfunction was more often associated with cyclosporine than tacrolimus use. CONCLUSIONS: Renal dysfunction is the primary determinant of adverse pregnancy outcome in liver transplant recipients. Immunosuppression with cyclosporine during pregnancy was more often associated with antenatal complications than with the use of tacrolimus.

Felodipine use in pregnancy. Report of three cases.

BACKGROUND: Calcium channel blockers are effective agents for the management of chronic hypertension and are being used with increasing frequency. If their safety and efficacy during pregnancy can be documented, women can be counseled to continue their antihypertensive agent during pregnancy. To our knowledge, the use of felodipine, a calcium channel blocker of the dihydropyridine group, during pregnancy has not been described. CASES: We report three cases of felodipine use in pregnancy by women with chronic hypertension. CONCLUSION: In women with severe hypertension (diastolic blood pressure > 100 mm Hg) who require pharmacologic treatment of it during pregnancy, felodipine appears to be an acceptable option.

Successful pregnancy after bilateral hypogastric artery ligation. A case report.

BACKGROUND: Selective embolization of the hypogastric arteries is an effective, nonsurgical alternative for the management of obstetric and gynecologic hemorrhage. Successful pregnancy following bilateral hypogastric artery occlusion has been reported, but experience is extremely limited. CASE: We report a case of successful pregnancy in a patient previously treated with bilateral hypogastric artery embolization. Although a diminution of fetal growth toward term was observed, the fetus tolerated labor and subsequently thrived, without sequelae. CONCLUSION: This case supports the possibility of normal labor for women who conceive after bilateral hypogastric artery embolization.

Peak expiratory flow rate in normal pregnancy.

OBJECTIVE: To determine whether peak expiratory flow rate changes with pregnancy and advancing gestation. METHODS: We measured the peak expiratory flow rate in 57 women during each trimester of pregnancy and postpartum. During four visits, all subjects exhaled forcefully three times into a peak flow meter. For each visit, the best of three attempts defined their peak expiratory flow rate. Using accepted standard nomograms, we normalized peak expiratory flow rate with respect to height and age. Using analysis of variance, we compared the mean normalized peak expiratory flow rates in each of the trimesters and postpartum. RESULTS: The subjects' peak expiratory flow rates did not change significantly during the three trimesters and postpartum (P = .317). The mean peak expiratory flow rates for the three trimesters and postpartum were 434 +/- 18, 452 +/- 16, 444 +/- 15, and 450 +/- 16 (values in liters per minute +/- 95% confidence intervals [CIs]). The mean normalized peak expiratory flow rates for the three trimesters and postpartum were 0.92 +/- 0.036, 0.95 +/- 0.032, 0.94 +/- 0.030, and 0.95 +/- 0.031 (values +/- 95% CI). CONCLUSIONS: This study demonstrates that peak expiratory flow rate does not change with pregnancy and advancing gestation. Therefore, testing peak expiratory flow rate in pregnancy is valid, and physicians can use peak expiratory flow rate accurately and reliably in the management of pregnant women with asthma.

Management of thromboembolic disease associated with pregnancy.

Our objective was to identify practice patterns of members of the Society of Perinatal Obstetricians with regard to the management of thromboembolic disease in pregnant women. We sent survey-questionnaires to members of the Society of Perinatal Obstetricians and requested information on antepartum and postpartum management of four clinical case scenarios. We also requested information on the evaluation of hypercoagulability and on the dosing and monitoring of heparin during pregnancy. We received 515 responses after a single mailing (47%). Most respondents utilize some form of anticoagulation in pregnant women with a history of thromboembolic disease, although there was variation in the duration and intensity of anticoagulation. Nearly all respondents (96%) use full anticoagulation with heparin for pregnant women with prosthetic heart valves. Most respondents evaluate pregnant women for hypercoagulable disorders who present with a thromboembolism or have a history of thromboembolic disease. There is considerable variation with respect to the dosing and monitoring of heparin therapy during pregnancy. Although most SPO members recommend anticoagulation in pregnant women with a history of venous thromboembolism, there is marked variation in the intensity, duration, and monitoring of heparin therapy in pregnant patients. Randomized prospective studies are needed to establish accurate recurrence risks and to evaluate the efficacy of anticoagulation in pregnant women with a history of venous thromboembolism.

Hepatic transplantation during pregnancy and the puerperium.

Liver transplantation is the treatment of choice for many patients with acute and chronic hepatic failure. Although uncommon, hepatic failure may occur during pregnancy or after delivery, and liver transplantation may be life-saving. We report a case of a liver transplant performed during pregnancy in a patient with decompensated cirrhosis from chronic autoimmune hepatitis. A patient with chronic autoimmune hepatitis developed decompensated cirrhosis at approximately 18 weeks' gestation. Despite attempts at medical stabilization, her condition worsened, and an orthotopic liver transplant was performed at 23 weeks. The procedure was complicated by transient hypotension, and fetal death was diagnosed postoperatively. Her postoperative course was complicated by hypotension, infection, oliguric renal failure, anemia, thrombocytopenia, and rejection. She spontaneously labored on the 6th postoperative day and delivered without difficulty a 560-g stillborn male. The patient recovered and was discharged 31 days after surgery on prednisone, tacrolimus, mycostatin, erythropoietin, and iron. Liver transplantation may be a valuable therapeutic option for treatment of pregnant or puerperal women with hepatic failure.

Hemorrhagic complication of anticoagulation during pregnancy in a woman with lupus anticoagulant.

BACKGROUND: Lupus anticoagulant is an acquired antiphospholipid antibody that can increase greatly the risk of thromboembolism during pregnancy. Because a baseline elevated activated partial thromboplastin time (PTT) is associated frequently with this antibody, monitoring anticoagulant effect with activated PTT can be unreliable. CASE: A pregnant woman with lupus anticoagulant being treated with adjusted dose heparin experienced concurrent severe thrombotic and hemorrhagic complications. CONCLUSION: This case illustrates the pitfall of activated PTT monitoring when administering anticoagulation therapy to a patient with a baseline elevated activated PTT. We propose that heparin levels be used to monitor anticoagulation in these patients.