1/67. Cushing's syndrome in pregnancy treated by ketoconazole: case report and review of the literature.We report on a 30-year-old female with a pituitary-dependent Cushing's disease, who refused transsphenoidal surgery and was treated with ketoconazole and cabergoline. After approximately 3 years of therapy, the patient herself decided, without the knowledge of her treating physician, to interrupt contraception. As the patient became pregnant she ceased the intake of all medication (between the third and seventh week), but resumed it soon after pregnancy was diagnosed because of relapsing clinical signs. pregnancy and vaginal delivery at 37 weeks gestation passed uneventfully. The newborn male infant did not demonstrate any congenital malformations and was normally sexually developed. With reference to this case, we discuss the difficulties in the medical treatment of Cushing's syndrome during pregnancy. Whereas outside pregnancy only efficacy and side-effects are taken into account, teratogenicity is an important question in these patients. Experience with different drugs is listed. This is only the second time that ketoconazole has been used during pregnancy for the treatment of Cushing's syndrome. We argue that ketoconazole may be safe as well as effective in pregnancy and, furthermore, without any consequences for the child.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/67. Multiple pregnancy with adnexal torsion after in vitro fertilization: case report.Assisted reproductive techniques (art) are widely accepted procedures for infertile couples. Rare complications, like heterotopic pregnancy, bilateral tubal pregnancy, and adnexal torsion during pregnancy, have been diagnosed with increasing frequency after art. We present a case of an early triplet pregnancy complicated with adnexal torsion. The patient was pregnant through in vitro fertilization. Early ultrasound examination revealed a triplet pregnancy within the uterine cavity. At 7 weeks' gestational age, an acute onset of lower abdominal pain, progressive abdominal distension, and massive internal bleeding prompted emergency laparotomy. The right ovary was enlarged, twisted, necrotic and hemorrhagic. Attempts to preserve the ovary failed because of the friable nature of the affected ovary, and an oophorectomy had to be performed. Although the removed ovary contained a corpus luteum, the pregnancy continued smoothly after only short luteal support. A precise pre-surgery diagnosis in our case was difficult based on the patient's initial clinical presentation. However, with high clinical suspicion in addition to color Doppler ultrasound, the physician should be able to make an early decision for an exploratory laparotomy or laparoscopy, gaining the benefit of more conservative treatment.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/67. The effect of pregnancy in Parkinson's disease.pregnancy in patients with Parkinson's disease (PD) is a rare occurrence. Previous reports based on retrospective analysis suggest that pregnancy may have a deleterious effect on PD. We describe the effects of pregnancy on the symptomatology of a 33-year-old woman with PD using quantitative neurologic and quality-of-life scales prepartum, intrapartum, and postpartum. During her pregnancy, she was only treated with carbidopa/levodopa. The pregnancy resulted in a normal full-term vaginal delivery of a healthy infant. Significant worsening of this patient's motor symptoms occurred during pregnancy without return to baseline at 15 months postpartum. pregnancy may exacerbate PD and may have a long-term negative impact on the course of the illness. This report may assist physicians in the counseling of patients with young-onset PD who wish to consider pregnancy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/67. risk-benefit decision making for treatment of depression during pregnancy.OBJECTIVE: The Committee on research on Psychiatric Treatments of the American Psychiatric association identified treatment of major depression during pregnancy as a priority area for improvement in clinical management. The goal of this article was to assist physicians in optimizing treatment plans for childbearing women. METHOD: The authors' work group developed a decision-making model designed to structure the information delivered to pregnant women in the context of the risk-benefit discussion. Perspectives of forensic and decision-making experts were incorporated. RESULTS: The model directs the psychiatrist to structure the problem through diagnostic formulation and identification of treatment options for depression. Reproductive toxicity in five domains (intrauterine fetal death, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity) is reviewed for the potential somatic treatments. The illness (depression) also is characterized by symptoms of somatic dysregulation that compromise health during pregnancy. The patient actively participates and provides her evaluation of the acceptability of the various treatments and outcomes. Her capacity to participate in this process provides evidence of competence to consent. Included in the decision-making process are the patient's significant others and obstetrical physician. The process is ongoing, with the need for incorporation of additional data as the pregnancy and treatment response progress. CONCLUSIONS: The conceptual model provides structure to a process that is frequently stressful for both patients and psychiatrists. By applying the model, clinicians will ensure that critical aspects of the risk-benefit discussion are included in their care of pregnant women.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
5/67. Maternal persistent vegetative state with successful fetal outcome.A woman suffered from massive blunt injuries in a motor vehicle accident at a presumed 4 weeks' gestation, but she successfully carried the fetus for an additional 29 weeks. Premature labor began at 33 weeks' gestation and a live 1,890 g male was delivered. His development was normal for the 12-months postnatal follow-up period. The patient remained in a persistent vegetative state. Only 12 cases of severely brain-injured pregnant patients who delivered babies have been reported in English literature. Such patients need special maternal and fetal monitoring. As shown in our patient, successful fetal outcome could be obtained in a mother who suffered from hypovolemic shock and diffuse axonal injury, was treated with numerous medications from 4 weeks' gestation, and survived premature labor at 33 weeks' gestation in a persistent vegetative state. This report represents the longest interval from maternal vegetative state to obstetric delivery. From our case, it would seem that no clear limit exists that restricts the physician's ability to support a severely injured pregnant patient.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/67. Acute paraparesis due to terbutaline sulfate.A woman who was 30 weeks pregnant was given terbutaline sulfate to prevent premature labor contractions. Within several days, she had an acute paraparesis with myalgias and was unable to walk. Full neurologic investigation failed to show any obvious cause. terbutaline therapy was discontinued, and in 48 hours she became asymptomatic. terbutaline sulfate (Brethine) is a beta-adrenergic agonist that works on smooth muscle. Various theories about its effect on skeletal muscle have been published. The importance of this case report is to make physicians aware of the rare muscular side effects of terbutaline, and careful observation may obviate extensive and invasive testing.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/67. Perioperative medical management of antiphospholipid syndrome: hospital for special surgery experience, review of literature, and recommendations.patients with antiphospholipid syndrome (APS), who are predisposed to vascular thrombotic events, are at additional risk for thrombosis when they undergo surgery. Serious perioperative complications (recurrent thrombosis, catastrophic exacerbation, or bleeding) occur despite prophylaxis. We describe our perioperative experience with APS patients who underwent a variety of surgeries, review the literature, and discuss strategies that may guide other physicians in their perioperative evaluation and management of patients with APS. Recommendations: perioperative strategies should be clearly identified before surgical procedure; pharmacological and physical antithrombosis interventions vigorously employed; periods without anticoagulation kept to a minimum; and any deviation from a normal course should be considered a potential disease related event.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/67. cystic fibrosis and hemolytic uremic syndrome coexisting during pregnancy.BACKGROUND: As more women with cystic fibrosis are living into their reproductive years, this disease can complicate pregnancy and coexist with other entities. We report a case of cystic fibrosis with hemolytic uremic syndrome. CASE: An 18-year-old primigravida with cystic fibrosis was admitted at term with pulmonary symptoms, hypertension, and thrombocytopenia. She was delivered with the admitting diagnosis of severe preeclampsia. Postpartum, thrombocytopenia, and microangiopathic hemolytic anemia worsened. She developed renal failure and acute respiratory distress syndrome, requiring plasmapheresis, mechanical ventilation, and hemodialysis. Renal biopsy was consistent with the diagnosis of hemolytic uremic syndrome. CONCLUSION: cystic fibrosis, a disease once managed predominantly by pediatric subspecialists, will be seen increasingly by physicians caring for adults, including obstetrician-gynecologists. We may also expect to see it coexisting with other disorders. The management of such patients may prove challenging.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/67. The course of pregnancy in a patient with nail-patella syndrome.INTRODUCTION: The nail-patella syndrome is a rare autosomal dominant condition with high penetrance. pregnancy in such a patient is rare and we believe this to be the first report of a live birth occurring in a patient with nail-patella syndrome. CLINICAL PICTURE: A 25-year-old patient presented in her first pregnancy with nephrotic syndrome associated with characteristic bone abnormalities and nail dysplasia and was later diagnosed to have nail-patella syndrome. In her second pregnancy, the course of her pregnancy was complicated by further deterioration of renal function with superimposed pre-eclampsia resulting in early delivery at 28 weeks. CONCLUSION: Such pregnancies should be regarded as high risk and managed jointly with the renal physician in a tertiary care centre to ensure an optimal outcome to the mother and baby.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/67. pruritus of pregnancy and jaundice induced by oral contraceptives.This article presents a young girl who developed jaundice while on oral contraceptives. A most significant feature in this particular patient's history was the severe pruritus she developed during a previous gestation. This combination of events should alert physicians to the possible diagnosis. Oral contraceptives should be prescribed to such a patient with great caution.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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