Karen Rosene-Montella

Pulmonary embolism in pregnancy

Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world. Mortality from PE in pregnancy might be related to challenges in targeting the right population for prevention, ensuring that diagnosis is suspected and adequately investigated, and initiating timely and best possible treatment of this disease. Pregnancy is an example of Virchows triad: hypercoagulability, venous stasis, and vascular damage; together these factors lead to an increased incidence of venous thromboembolism. This disorder is often suspected in pregnant women because some of the physiological changes of pregnancy mimic its signs and symptoms. Despite concerns for fetal teratogenicity and oncogenicity associated with diagnostic testing, and potential adverse effects of pharmacological treatment, an accurate diagnosis of PE and a timely therapeutic intervention are crucial. Appropriate prophylaxis should be weighed against the risk of complications and offered according to risk stratification.

Alveolar-arterial oxygen gradient in acute pulmonary embolism in pregnancy

OBJECTIVE Our goal was to determine the prevalence of normal alveolar-arterial gradients in pregnant patients with documented pulmonary embolism. STUDY DESIGN A retrospective chart review was performed on all pregnant women with pulmonary embolism at two large obstetric centers between 1990 and 1995. Alveolar-arterial gradients were calculated from room air arterial blood gas values and compared with values from patients who had been established as normal. RESULTS Ten of 17 patients with pulmonary embolism identified had alveolar-arterial gradients that were normal. CONCLUSIONS In our study 58% of pregnant women with documented pulmonary embolism had a normal alveolar-arterial gradient. This markedly differs from the published data in nonpregnant patients, in which the incidence of normal alveolar-arterial gradients in pulmonary embolism has ranged from 1.9% to 20%. This suggests that the alveolar-arterial gradient should not be used to determine the likelihood of pulmonary embolism in pregnant women because this could lead to the withholding of appropriate treatment for this life-threatening condition.

The incidence of deep vein thrombosis in women undergoing cesarean delivery

INTRODUCTION Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States. Cesarean delivery is a known risk factor. This study was to determine the incidence of deep vein thrombosis (DVT) post cesarean delivery. MATERIALS AND METHODS This was a prospective cohort study where two patients having undergone cesarean delivery each day were randomly selected. A lower extremity compression ultrasound was performed prior to hospital discharge. If no DVT was detected, participants were asked to return for a second ultrasound two weeks postpartum. Participants were also telephone-interviewed at three months for reported VTE. RESULTS Of the 194 patients who consented to study participation, only one participant developed DVT after cesarean delivery, giving an overall incidence of 0.5% (95% CI, 0.1 to 2.8%). There were no DVT identified on the second ultrasound nor VTE reported 3 months postpartum. CONCLUSIONS We found the DVT rate after cesarean delivery to be 0.5%.

Evaluation and Management of Infertility in Women: The Internists' Role

Medical and surgical services for infertility increased dramatically in number and sophistication during the last quarter of the 20th century (1). Social and scientific trends (such as delayed childbearing), increases in sexually transmitted diseases that can cause fallopian tube dysfunction, new drugs and techniques for treating infertile women and men, and an expanding cohort of physicians specializing in reproductive assistance have been the driving forces behind this remarkable extension of reproductive opportunities (2, 3). Internists and family physicians may be faced with questions and decisions about infertility evaluation and pregnancy management in older patients, patients with serious medical illness, and patients with heritable conditions that affect reproduction (4, 5). Definitions and Scope There is no standard definition of normal fertility. Biologically, inability to procreate can be classified as infertility (the inability of a couple to conceive) or infecundity (the inability of a couple to produce a live birth) (6). The word barren conveys the trying, potent emotional toll that failure to produce children exerts on a couple (7). The importance of male infertility should not be minimized; in fact, a male factor may be present in up to 40% of cases. This paper, however, focuses on the medical import of infertility treatments among women. During their reproductive lives, 10% to 15% of couples are unable to achieve conception and deliver a living child after 1 year of unprotected coitus (2, 6). The proportion of women unable to bear children increases with age. Among the Hutterite Brethren of North America, contraception is discouraged and there is no incentive to limit family size. Although the fecundity of Hutterite women is legendary, Teitze (8) found that 11% bore no children after 34 years of age, 33% bore no children after 40 years of age, and 87% of women were infertile by the time they reached 45 years of age. Approximately one third of women who defer pregnancy until their mid- to late 30s and half of women who defer pregnancy until after 40 years of age will be unable to conceive (9-11). Advancing maternal age is associated with a higher risk for maternal illness, which may in turn be associated with infertility or increased obstetric risk. Prevention of Infertility The primary prevention of infertility should be a goal of all physicians caring for young women. Prevention should be aimed at lowering risk for sexually transmitted diseases by recommending use of condoms and limitation of number of sexual partners. It is imperative that sexually transmitted diseases and postpartum endometritis be promptly diagnosed and treated to avoid pelvic inflammatory disease and tubal dysfunction. Screening for sexually transmitted diseases in asymptomatic women may be indicated in certain high-risk groups, including patients with HIV infection; patients with previous pelvic inflammatory disease, preterm labor, or ectopic pregnancy; and patients with abnormal Papanicolaou smears. Progressive dysmenorrhea and pelvic pain should be aggressively evaluated to exclude endometriosis so that intervention can occur before fertility is affected. Patients should be reminded that fertility rates decrease after 35 years of age and that they should modify their lifestyle to maximize chances of conception. Women should decrease smoking or recreational drug use and reduce vigorous exercise, especially when menses are abnormal. Men should minimize occupational exposures, avoid use of hot tubs and anabolic steroids, and avoid wearing tight briefs. Treatment of Infertility Once infertility is diagnosed, patients are likely to ask their internists for referral to an infertility specialist or for information on the medical risks associated with various infertility interventions. Primary approaches include 1) ovulation induction with the antiestrogen clomiphene citrate for women with ovulatory dysfunction; 2) radiographic, endoscopic, or surgical procedures to alleviate tubal obstruction; 3) medical or surgical ablation of endometriosis; 4) artificial or intrauterine insemination with donor or partner sperm for male factor infertility; and 5) hormonal support of an inadequate luteal phase (defined as a lag of more than 2 days in histologic development of the endometrium compared with the day of the cycle) with clomiphene or progesterone derivatives. If the cause of infertility is unexplained or if conventional therapy is ineffective, controlled ovarian stimulation and assisted reproductive techniques may be used. Ovulation Induction After other reversible causes of anovulation have been excluded, clomiphene citrate is the first-line drug for induction of ovulation. It is a nonsteroidal medication that binds to the estrogen receptor and can initiate ovulation in women who still have some endogenous estrogen. It could be thought of as one of the first of the selective estrogen receptor modulators, similar to raloxifene. Approximately 80% of women will ovulate and 40% will conceive with clomiphene treatment alone. Multiple pregnancy rates are approximately 5%, most of which are twin gestations (12). Controlled ovarian stimulation, or superovulation, is a method of ovulation induction resulting from administration of exogenous human gonadotropins (luteinizing hormone and follicle-stimulating hormone). The goal of superovulation is the recruitment of multiple ovarian follicles. The ovarian response to stimulation is monitored with sonographic imaging of ovarian follicles and assessment of serum estradiol concentrations. Human chorionic gonadotropin is then used to stimulate the final maturation or ovulation of the follicles. Controlled ovarian stimulation may be used for patients who do not respond to clomiphene citrate, but it is primarily used to treat unexplained infertility in conjunction with in vitro fertilization or other assisted reproductive techniques. The main risks of superovulation include multifetal pregnancies and the ovarian hyperstimulation syndrome. Assisted Reproduction Assisted reproductive technology involves the retrieval, manipulation, and replacement of oocytes or sperm to achieve fertilization and conception. In vitro fertilization was first introduced in the early 1980s for treatment of infertility secondary to tubal disease (13). It remains the most common assisted reproductive technique and is used for tubal disease as well as for other indications, such as unexplained infertility and endometriosis. Some of the other assisted reproductive techniques used for unexplained infertility are defined in Table 1. The basic protocol for performing in vitro fertilization includes controlled ovarian stimulation, ultrasound-guided transvaginal aspiration of oocytes, insemination and fertilization of oocytes in vitro, and transfer of the resultant embryos to the maternal uterus. Progesterone supplementation is commonly used during the first trimester if a successful pregnancy occurs. Table 1. Assisted Reproductive Technology Assisted reproductive techniques have revolutionized the treatment of infertility. Women previously unable to become pregnant because of medical disorders or premature ovarian failure are now able to bear children. Pregnancies are possible in postmenopausal women and have even been reported in women in their sixth and seventh decades of life (14, 15). Application of assisted reproductive technologies has raised troubling ethical dilemmas in some cases (16), and the economic considerations are enormous (17, 18). Effect of Advanced Maternal Age on Infertility Interventions Women seeking infertility treatment are often older than 35 years of age. This increases the likelihood of coexistent medical problems, such as hypertension and diabetes, and the likelihood that the woman will require pharmacologic therapy for underlying medical disorders, some of which may have adverse effects in pregnancy. Maternal disease, drugs, and the potential for chromosomal anomalies with advanced maternal age must be considered before initiating treatment and when determining maternal and fetal risk. Studies of conception and gestation in achieved pregnancies indicate that age has a greater effect on the gamete than on the capacity of a healthy uterus to support pregnancy (9-11). Women 50 years of age or older routinely have successful pregnancies with donated, fertilized oocytes (9, 11). In contrast, among women with pregnancies resulting from ovulation induction, the incidence of spontaneous abortion increases dramatically after 30 years of age, an epidemiologic pattern similar to that of unassisted conceptions in women in their 30s and 40s. The effect of aging on tubal function is unexplored, although the time between fertilization and implantation is an important determinant of the risk for spontaneous abortion (19). Medical Conditions Associated with Infertility The many causes of infertility include tubal or pelvic pathologic conditions, hypothalamicpituitary disorders, ovulatory dysfunction, and unexplained infertility. It is best to consider and review associated medical conditions according to the cause of the infertility. Tubal or Pelvic Pathologic Conditions Disorders that interfere with normal endometrial function include the Asherman syndrome, uterine scarring and synechiae from previous dilation and curettage, and endometriosis. Tubal infertility is caused by ascending pelvic infections (for example, Chlamydia trachomatis), adhesions from previous pelvic surgery, and pelvic inflammation (for example, inflammatory bowel disease and endometriosis). Sexually transmitted diseases tend to occur together and in women with more sexual partners. Women with tubal infertility should be screened for multiple sexually transmitted diseases, particularly HIV infection, syphilis, and viral hepatitis. Pelvic tuberculosis has also been associated with endometrial impairment and tubal infertility. In one retrospectiv

Early onset preeclampsia and second trimester serum markers.

To examine serum markers measured in the second trimester to identify women who subsequently develop preeclampsia.

The pregnant heart: cardiac emergencies during pregnancy.

BACKGROUND Cardiovascular emergencies in pregnant patients are often considered a rare event; however, heart disease as a cause of maternal mortality is steadily increasing. DISCUSSION In this article, we review 3 common cardiovascular emergencies and the important subtle differences in their treatment in the pregnant patient: peripartum/postpartum cardiomyopathy, acute myocardial infarction, and cardiac resuscitation. CONCLUSION Managing these conditions in the emergency department setting requires a high index of suspicion, knowledge of anatomical and physiologic changes associated with pregnancy, and updated management strategies related to optimizing maternal and fetal health.

Medical problems during pregnancy

Dramatic physiologic changes are part of normal human pregnancy. The physiologic alterations of pregnancy have the potential to affect chronic diseases, to unmask subclinical conditions, or to alter the presentation and course of newly acquired illnesses. An update in selected topics of obstetric medicine follows, focusing on clinical entities in which there have been significant advances in diagnosis or management. Additionally, reviews of selected medical disorders, such as HIV infection and asthma, that are rising in incidence in women of reproductive age are included.

Teaching internal medicine residents about medical problems in pregnancy.

When they became aware that many of their internal medicine residents were not being routinely exposed to a representative range of medical illnesses in pregnancy, the authors set out to develop and implement a brief practical curriculum on the medical problems of pregnancy. They began with a retrospective chart review of 562 consultations with pregnant women and used their findings to develop nine 15-minute lectures that covered a majority of the concepts essential to the care of the medically compromised pregnant woman. Topics included hypertension in pregnancy, the febrile pregnant woman, and renal disease in pregnancy. The authors also created a learner handout, a teaching script, teaching cases, and a bibliography for each lecture. Residents have responded well to the curriculum, and their mean pre- and posttext scores have shown that the lectures improved their knowledge of obstetric medicine. This brief-lecture format may be adapted to other special topics in residency training and readily integrated into already-crowded training schedules.

Special Hematologic Issues in the Pregnant Patient

Evaluation and treatment of hematologic disorders in pregnancy requires an understanding of normal physiologic changes during pregnancy. Hematologic disorders may be caused by preexisting conditions, normal physiologic changes, or can be acquired. A multidisciplinary approach is often necessary for monitoring and treatment of both the mother and the fetus. In general, outcomes are good for both the mother and the fetus.

The growing importance of medical problems in pregnancy.

Internal medicine and its subspecialties will become an even more integral part of the care of pregnant patients as the obstetric population ages and has an increase in comorbid conditions, such as diabetes, heart disease, hypertension and obesity. In the United States, there are 62 million women of childbearing age, most of whom will have given birth by the age of 44, translating to 4 million births annually. Over 25% of these women will enter pregnancy with a chronic medical condition, and nearly half will be overweight or obese, further increasing risk. The metabolic syndrome has been associated with hypertension, preeclampsia and increased risk for thromboembolic disease. A recent review of maternal morbidity during obstetric hospitalizations in the US has shown a 26% increase in overall medical complications, and an even higher rate for pulmonary embolism, respiratory and renal failure. Complications rise with increase in age and with caesarean delivery, and this was especially true for pulmonary embolism and acute respiratory distress syndrome, but all of the increase cannot be accounted for by age or mode of delivery. There is little doubt that internal medicine will need to step up and fill the void that exists in treating this complex patient group. Obstetric medicine specialists must act as mediators between women with complex medical illnesses and their obstetrical care team.