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1/1230. safety of antiarrhythmics during pregnancy: case report and review of the literature.

    A young woman is reported with intractable sustained ventricular tachycardia thought to originate in the right ventricle, which was treated successfully with encainide after failure to respond to beta-blockers and several class IA antiarrhythmic agents. She became pregnant twice while on encainide and gave birth to two healthy children. This is the first report of pregnancy during treatment with encainide. A literature review showed no other reported case of encainide taken during pregnancy, but several reports of the safe use of flecainide, a similar class IC drug, during pregnancy. Other antiarrhythmics are also reviewed. ( info)

2/1230. pulmonary embolism during labor and the effect on the fetus monitored with oxycardiotocography.

    We report on a rare case of pulmonary embolism which we observed in the second stage of labor. For fetal surveillance we used oxycardiotocography (OCTG), an experimental system which combines internal CTG and pulse oximetry which enabled us to observe hemodynamic reactions of the unborn child and the effect on maternal-fetal gas exchange. It was possible to record marked fetal bradycardia simultaneously with decrease in oxygen saturation in the fetal arterial system during the acute event. ( info)

3/1230. Epidural analgesia for labour and delivery in a parturient with congenital hypertrophic obstructive cardiomyopathy.

    We report a parturient delivering vaginally at term with symptomatic congenital hypertrophic obstructive cardiomyopathy. Epidural analgesia was used during labour and delivery and is likely to have made a useful contribution to the successful outcome. Although controversial, reported use of epidural analgesia during labour for hypertrophic obstructive cardiomyopathy parturients has been generally positive. A multi-disciplinary team approach, early anaesthetic assessment and a carefully managed epidural catheter inserted in early labour can optimize analgesia and minimize the stresses of labour and vaginal delivery provided the risks of reduced preload and afterload are minimized. ( info)

4/1230. Anaesthesia for caesarean section in a patient with an intracranial arteriovenous malformation.

    Intracranial haemorrhage from an arteriovenous malformation (AVM) during pregnancy is rare but may result in significant maternal and fetal morbidity and mortality. In the untreated patient with an AVM, the best mode of delivery remains debatable with most obstetricians preferring a caesarean section in order to avoid Valsalva manoeuvres associated with vaginal delivery. We describe the administration of epidural anaesthesia for such a parturient undergoing Caesarean section and the anaesthetic implications. ( info)

5/1230. Catheter-directed thrombolysis for thromboembolic disease during pregnancy: a viable option.

    Anticoagulation with intravenous heparin has been the standard treatment for the management of gestational thromboembolic complications. Catheter-directed thrombolysis is an encouraging approach for the treatment of thromboembolic disease and has not been previously reported during pregnancy. One gravid woman with pulmonary embolism, critically ill, and hemodynamically compromised, and two gravid women with iliofemoral venous thrombosis, who failed to respond to standard treatment with intravenous heparin, were treated with catheter-directed urokinase. All three patients experienced rapid resolution of symptoms and successful pregnancy outcomes. In our three patients, catheter-directed thrombolysis for thromboembolic disease during pregnancy allowed rapid resolution of hemodynamic abnormalities and/or resolution of thrombus. Catheter-directed thrombolysis offered a reasonably safe alternative to prolonged medical management in these young, otherwise healthy, patients. Long-term, it may prevent the postphlebitic syndrome. ( info)

6/1230. Crack-cocaine-associated aortic dissection in early pregnancy--a case report.

    Even though uncommon in pregnancy, aortic dissection is a potentially catastrophic vascular complication, occurring mainly in the late stages of pregnancy. Vascular events, including aortic dissection are recognized complications of crack-cocaine use. The authors report a case of aortic dissection in early pregnancy related to crack-cocaine use. They believe that the combined effects of pregnancy and crack cocaine on the vasculature create the requisite milieu potentiating such catastrophic events as aortic dissection. This paper reviews the possible underlying pathophysiologic mechanisms and the available diagnostic, therapeutic, and management options. ( info)

7/1230. Anticoagulant-induced skin necrosis in a patient with hereditary deficiency of protein s.

    skin necrosis is a rare but debilitating complication of treatment with vitamin k antagonist anticoagulants such as warfarin. A clinically similar syndrome has been reported less frequently with heparin therapy. We recently managed a thirty-year-old female patient who developed skin necrosis on her left lower extremity while on warfarin for postpartum DVT. The lesions started to develop 48 hr after stopping heparin therapy. Discontinuation of warfarin and reinstitution of heparin was complicated by a rapid decrease in platelet count consistent with heparin-induced thrombocytopenia (HIT) and its associated risk of platelet activation and thrombosis. The diagnosis was supported by the identification of antibodies against heparin/platelet factor 4 complexes in the patient's serum. The platelet count recovered and the patient improved after switching to therapy with the heparinoid danaparoid. Evaluation for a hypercoagulable state revealed a partial deficiency of protein s, a condition that previously was identified in two of her family members. It is not clear if this patient suffered from warfarin-induced skin necrosis, a manifestation of heparin-mediated platelet activation, or a complex condition in which both drugs contributed. HIT may affect 1-3% of patients who receive unfractionated heparin, and this case raises the possibility that heparin may contribute to, or cause, some episodes of skin necrosis attributed to warfarin. Because many patients who develop warfarin-induced skin necrosis have been treated initially with heparin, it would seem prudent to consider HIT in these situations. ( info)

8/1230. Focal aneurysmal dilatation of subchorionic vessels simulating chorioangioma.

    Subchorionic vascular aneurysms of the placenta are rare lesions and may present confusion with chorioangioma or focal mesenchymal dysplasia on sonography. To our knowledge, the findings of placental aneurysms have not been reported in the ultrasound literature. We present a case with detailed sonographic evaluation, including spectral and color Doppler and pathological analysis, that was mistaken for chorioangioma prenatally. knowledge of this benign entity may allow the sonologist to recommend conservative management in similar cases. ( info)

9/1230. Severe cardiac dysrhythmia in patients using bromocriptine postpartum.

    Used worldwide since 1980 for the prevention of breast engorgement in the puerperium, in 1994 bromocriptine mesylate was withdrawn from the American market as an agent suitable for ablactation. The relevant recommendation of the food and Drug Administration rested on case reports that described severe vasospastic reactions among users of the drug. Some patients so affected suffered stroke, intracranial bleeding, cerebral edema, convulsions, myocardial infarction, and puerperal psychosis. More recently, it has been suggested that the side effects of the drug may also include circulatory collapse secondary to cardiac dysrhythmia. This report describes two additional cases in this category. The antepartum clinical evaluation of these women suggested that they were predisposed to arrhythmias. ( info)

10/1230. Implantation of permanent dual chamber pacemaker in a pregnant woman by transesophageal echocardiographic guidance.

    A 37-year-old woman complained of fatigue and dizziness because of intermittent sinus arrest and asystole up to 5.2 seconds. She was 3 months into her pregnancy and a dual chamber permanent pacemaker was implanted by transesophageal echocardiographic guidance. ( info)
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