Raymond Powrie

HERBAL AND ALTERNATIVE MEDICINE USE DURING PREGNANCY: A CROSS-SECTIONAL SURVEY

Background: The use of herbal and alternative medical therapies has been increasing rapidly across the United States over the past 10 years. Women of reproductive age often are users of herbs. The use of herbal and alternative medical therapies among pregnant women is important but poorly studied to date. Objective: To determine the frequency of use of herbal and alternative medicine by women during pregnancy. Methods: Two hundred fifty pregnant women attending antepartum visits were prospectively enrolled in a cross-sectional survey about use of herbal and alternative medical therapies. Results: Two hundred forty-two women completed surveys (97%). Of the respondents, 9.1% reported use of herbal supplements during the current pregnancy, 7.5% using these agents at least weekly. The most commonly used herbs during pregnancy were garlic, aloe, chamomile, peppermint, ginger, echinacea, pumpkin seeds, and ginseng. Herb use during pregnancy was strongly associated with prior use of herbal supplements (25.6% versus 1.2%, P <0.001). There were trends toward greater use among white women (11.4% versus 6.1% in other racial groups) and in women with at least college-level education (10.1% versus 7.6% for high school or less). No association was found between herb use during pregnancy and age or income level. Alternative medical therapies were used by 13.3% of pregnant women. The therapies included aromatherapy, meditation/relaxation, chiropractic, yoga, acupressure, therapeutic touch, homeopathy, acupuncture, and reflexotherapy. Conclusion: Herbal and alternative medicine use is common among pregnant women. Pregnant women should be asked about their use of these therapies. Further research is needed to clarify the safety and effectiveness of these therapies during pregnancy.

Intrahepatic cholestasis of pregnancy is associated with an increased risk of gestational diabetes

OBJECTIVE To evaluate the association between intrahepatic cholestasis of pregnancy (ICP) and gestational diabetes mellitus (GDM). STUDY DESIGN A retrospective case-control study of pregnancy outcomes in 57,724 women managed at a university teaching hospital in Rhode Island, USA, in whom universal screening for GDM had been performed and who were assessed for the incidence of ICP. Pregnancies complicated by ICP or GDM between February 2005 and June 2011 were identified from the electronic patient records using appropriate ICD codes. A total of 125 cases were required to detect a difference in the incidence of GDM in ICP at 5% significance with 80% power. Demographic and clinical outcome data (including maternal age, ethnic group, BMI, and infant weight and gender) were also collected. RESULTS Of the 57,724 pregnancies, 143 were complicated by ICP (0.25%) and 4880 by GDM (8.5%). Nineteen ICP cases had GDM. The incidence of GDM in ICP was 13.6% (19/140, OR 1.68 CI 1.04-2.72). Where gestational ages were available (n=105), of those screened for GDM prior to developing ICP, 13.4% (11/82, OR 1.64 CI 0.88-3.06) had a confirmed diagnosis, rising to 30% (7/23, OR 4.69 CI 1.98-11.1) in cases that were screened following the onset of cholestasis. Simple linear regression analysis of adjusted birth weight centiles in ICP revealed a significant linear trend of increasing centiles with gestational age (p=0.005). CONCLUSIONS These data support the hypothesis that the incidence of GDM is higher in women predisposed to developing ICP. It is likely that this susceptibility increases further following the onset of cholestasis.

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%.

The Metabolic Profile of Intrahepatic Cholestasis of Pregnancy Is Associated With Impaired Glucose Tolerance, Dyslipidemia, and Increased Fetal Growth

OBJECTIVE Quantification of changes in glucose and lipid concentrations in women with intrahepatic cholestasis of pregnancy (ICP) and uncomplicated pregnancy and study of their influence on fetal growth. RESEARCH DESIGN AND METHODS A prospective study comparing metabolic outcomes in cholestastic and uncomplicated singleton pregnancies was undertaken at two university hospitals in the U.K. and U.S. from 2011–2014. A total of 26 women with ICP and 27 control pregnancies with no prior history of gestational diabetes mellitus were recruited from outpatient antenatal services and followed until delivery. Alterations in glucose, incretins, cholesterol, and triglycerides were studied using a continuous glucose monitoring (CGM) system and/or a standard glucose tolerance test (GTT) in conjunction with GLP-1 and a fasting lipid profile. Fetal growth was quantified using adjusted birth centiles. RESULTS Maternal blood glucose concentrations were significantly increased in ICP during ambulatory CGM (P < 0.005) and following a GTT (P < 0.005). ICP is characterized by increased fasting triglycerides (P < 0.005) and reduced HDL cholesterol (P < 0.005), similar to changes observed in metabolic syndrome. The offspring of mothers with ICP had significantly larger customized birth weight centiles, adjusted for ethnicity, sex, and gestational age (P < 0.005). CONCLUSIONS ICP is associated with impaired glucose tolerance, dyslipidemia, and increased fetal growth. These findings may have implications regarding the future health of affected offspring.

Anticoagulants and pregnancy : When are they safe?

Prescribing anticoagulants to pregnant women can be difficult and stressful. Fortunately, low-molecular-weight heparins (LMWHs) and unfractionated heparin are quite safe and efficacious when properly selected, dosed, and monitored. Maternal and fetal concerns must be considered at all times, with a careful assessment of the risks and benefits of anticoagulant therapy in each patient. Further research should help to clarify who should receive thromboprophylaxis, how to prevent adverse pregnancy outcomes in women with various thrombophilias, and how best to treat pregnant women who have a prosthetic heart valve. Thrombotic risk is higher in pregnancy, and some women need anticoagulant therapy. Unfractionated heparin and low-molecular-weight heparins are effective and safe, with caveats.

Managing Asthma in Expectant Mothers

Pregnancy does not appear to have a consistent effect on the frequency or severity of asthma. The most common cause of worsening asthma in pregnancy is likely to be noncompliance with medication. Emphasizing to the patient in advance that fetal well-being is dependent on maternal well-being may help prevent this.In general, well controlled asthma is not associated with a higher risk of adverse pregnancy outcomes. Essential to successful asthma management is patient education that helps to ensure effective medication use, avoidance of triggers, and prompt treatment. This education should include measurement of peak expiratory flow rate and a written asthma action plan. Most of the medications that are used to control asthma in the general population can be safely used in pregnant women. Inhaled β-adrenoceptor agonists (β-agonists), cromolyn sodium (sodium cromoglycate), and inhaled and systemic corticosteroids all appear to be very well tolerated by the fetus. Budesonide and beclomethasone should be considered as the preferred inhaled corticosteroids for the treatment of asthma in pregnancy. Use of the leukotriene receptor antagonists zafirlukast and montelukast in pregnancy is probably safe but should be limited to special circumstances, where they are viewed essential for asthma control. Zileuton should not be used in pregnancy.Acute asthma exacerbations in pregnant women should be treated in a similar manner to that in non-pregnant patients. Maternal blood glucose levels should be monitored periodically in pregnant women receiving systemic corticosteroids because of the deleterious effects of hyperglycemia upon embryos and fetuses. During pregnancy, maternal arterial oxygen saturations should be kept above 95% if possible for fetal well-being. Ambulatory oxygenation should be checked prior to discharge to ensure that women do not desaturate with their daily activities.Acute exacerbations of asthma during labor and delivery are rare. Dinoprost, ergometrine, and other ergot derivatives can cause severe bronchospasm, especially when used in combination with general anesthesia, and should be avoided in asthmatic patients. Pregnant women who have been treated with corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. Most asthma medications, including oral prednisone, are considered compatible with breast-feeding.

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.

Prevalence of syncope and recurrent presyncope during pregnancy

Abstract Background: Syncope is a condition that can lead to serious injury, and recurrent episodes of syncope or presyncope can be disabling. Syncope is thought to occur fairly commonly during normal pregnancy, but to date almost no data have been published regarding syncope and presyncope during pregnancy. Objective: To determine the prevalence of syncope and recurrent presyncope during pregnancy. Methods: One hundred ninety randomly selected postpartum women were prospectively enrolled in a cross-sectional survey. They were asked about episodes of syncope and presyncope during their pregnancy, associated symptoms, pregnancy complications, and underlying medical conditions. Results: One hundred seventy-four women completed surveys (92%). Of the respondents, 4.6% experienced syncope during pregnancy, 28.2% reported at least one episode of presyncope, and 10.3% reported recurrent presyncopal episodes sufficient to cause a change in activity or lifestyle. The most frequent symptoms reported were diaphoresis (53%), dyspnea (53%), palpitations (42%), nausea (32%), and visual disturbance (32%). Syncope or recurrent presyncope was associated with history of migraine headaches (28.9% versus 9.6%, P = 0.02), with trends to increased prevalence with low salt intake (17.0% versus 10.0%, P = 0.13), and with higher anxiety levels ( P = 0.29). No association was found with age, race, marital status, hemoglobin levels, blood pressures, occurrence of pregnancy complications, or presence of other underlying medical conditions. Conclusion: Syncope and recurrent presyncope are common during pregnancy. Further research is needed to clarify the etiology and potential treatment for these troubling symptoms.

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.