Thyrotoxicosis in Pregnancy Presenting as Pancytopenia

EDITORIAL COMMENT: In spite of its rarity we accepted this case report for presentation to remind readers of the dire complications that can occur in a woman with thyrotoxicosis that has escaped recognition. It is a reminder that thyroid function should be tested in patients who present with severe medical emergencies of uncertain aetiology.
Summary: Delay in diagnosis of thyroid disease can result in morbidity and mortality. Thyroid disorders are not uncommon in the reproductive age group and therefore in pregnancy; recognition of both the common and the more unusual manifestations will optimize outcome.     

Diabetes in pregnancy

Diabetes is probably the most frequent pathological condition that influences the outcome of pregnancy. 0.2–0.3% of women of reproductive age are known to have diabetes prior to conception and a further significant proportion of pregnancies in otherwise normal women may be complicated by gestational diabetes. Diabetic pregnancy is a high risk state for both the woman and fetus. The usual complications of pregnancy such as infection, hydramnios, pre-eclampsia and placental insufficiency may occur more frequently and the diabetic state predisposes additional complications. These include: the development of progression of specific diabetic complications; particularly retinopathy; miscarriage; stillbirth; intrauterine death; congenital malformation and macrosomia in the fetus; increased perinatal mortality rate and neonatal morbidity. Without appropriate care of established diabetes during pregnancy, perinatal mortality may exceed 10% and the rate of major congenital malformations is at least 2–3 times higher than in non-diabetic pregnancies. Increased fetal growth in the last trimester of pregnancy is the main risk in gestational diabetes and early recognition through screening is important. Most of these complications can be reduced to the level of the non-diabetic pregnant population by expert medical care and the achievement of nearly normal glucose levels in the pregnant woman.     

Treatment of thrombotic microangiopathy in pregnancy with plasma exchange: a report of two cases.

Thrombotic microangiopathy is a rare disease that can be induced and precipitated by pregnancy, and is associated with high maternal and fetal morbidity and mortality. It results from abnormal intravascular platelet aggregation that leads to transient ischemia in various organs, including the central nervous system, kidneys and placenta. Plasma exchange is the most widely accepted method of treatment for this condition. Delayed diagnosis is the main reason for morbidity and mortality, and results from difficulty in differentiating thrombotic microangiopathy from other obstetric emergencies. We report two cases of thrombotic microangiopathy that occurred antepartum and postpartum, respectively. The first patient was a 33-year-old woman who had two previous episodes of intrauterine fetal death in the 13th and 28th weeks of gestation, respectively. She received early plasma exchange at the 23rd week of gestation during this pregnancy and the fetus was delivered uneventfully. The second patient was a 28-year-old woman with progressive thrombocytopenia, anemia and deterioration of renal and liver function postpartum. She received early plasma exchange and it markedly improved her thrombocytopenia without sequelae. In conclusion, early diagnosis and early initiation of plasmapheresis may improve both maternal and fetal prognosis in thrombotic microangiopathy.     

剖宫产术成功用于抢救复合伤濒死孕妇及其胎儿一例

妊娠晚期孕妇突发复合外伤，生命垂危濒临死亡，此种为少见突发事件。本文介绍1例患者收治情况，在对孕妇及其胎儿伤情判断的基础上，着重从患者病情的角度探讨如何对孕妇及胎儿进行抢救，从而更有效地为今后类似病例提供救治参考。通过本例病例发现，对生命垂危的产妇进行积极有效的心肺复苏后，产妇仍无有效的自主循环时应考虑实施围死亡期剖宫产（PMCS），取出胎儿后再对孕妇和胎儿进一步抢救，对孕妇和胎儿均有益。     

Reproduction in the older gravida. A literature review.

Infertility, spontaneous abortions and trisomic anomalies increase with maternal age, as do ectopic pregnancy, low birth weight, macrosomia, abruptio placentae and labor dysfunction. However, those phenomena are multifactorial in origin and cannot be ascribed solely to advancing age. Older pregnant women are also at increased risk for diabetes and hypertension. Whereas the older gravida is at increased risk for maternal mortality and morbidity and for fetal and infant mortality, those problems are explainable in large part by coexisting medical complications. The healthy older pregnant woman who receives appropriate prepregnancy counseling and up-to-date perinatal care can achieve results comparable to those achieved by younger ones.     

A comparison of complications of pregnancy and delivery in morbidly obese and non-obese women.

Morbid obesity in pregnancy is a growing problem and is having an impact on morbidity, mortality as well as significantly increasing antenatal and intra-partum costs of pregnancy care. The incidence of morbid obesity in pregnancy in our unit was 7.5% during the study period and this was associated with statistically significant increased maternal and perinatal morbidity. It also led to increased costs because of multidisciplinary management of the pregnancies, increased investigations and hospital stay when compared with normal weight pregnant women. Looking after morbidly obese pregnant women is an expensive undertaking, as the cost of the care of one morbidly obese pregnant woman and her baby is several times that of the normal weight woman. Health planners need to factor in these costs which are set to escalate given the predicted increase in the obese population in the UK.     

Respiratory disease in pregnancy

Respiratory diseases are an important cause of morbidity and mortality in pregnant women. Chronic lung diseases, such as asthma and cystic fibrosis, may present unique management problems in pregnancy, and other lung diseases, such as pneumonia and tuberculosis, can target pregnant women just as they target non-pregnant women. Other disease such as pulmonary embolism may be made more likely owing to the pregnant state. In this review we will cover the important lung diseases that are likely to be encountered in pregnancy and highlight any modifications in conventional management which are necessary.     

Consideraciones sobre el parto en una paciente con miocardiopatía hipertrófica y desfibrilador automático implantable

Hypertrophic cardiomyopathy is inherited as an autosomal dominant trait and can be diagnosed during pregnancy. Cardiomyopathy is the leading cause of nonobstetric maternal morbidity and mortality. We present the case of a 26-year-old pregnant woman with hypertrophic cardiomyopathy and an automatic implantable cardioverter defibrillator and we discuss the most important therapeutic considerations in the management of these patients before and during delivery and in the immediate postpartum period.     

Pregnancy-specific liver diseases

Liver disease presenting in pregnancy may be due to a pregnancy-specific liver disorder, due to previously unrecognised pre-existing liver disease, or de novo liver disorders coincidentally presenting in a pregnant woman. The pregnancy-specific liver diseases can span from mild disease with limited impact on maternal and foetal health to severe disorders that can result in significant morbidity and mortality for mother and foetus. Swift identification of these disorders is essential to allow timely and appropriate management via a multi-disciplinary approach. The pregnancy-specific conditions, including their presentation, investigations, and management are reviewed in this chapter in detail.     

Severe acute asthma

Asthma is common among women of reproductive age and affects between 4% and 8% of pregnant women. Pregnancy outcomes are correlated to the degree of asthma severity and control. Approximately one-third of pregnant women with asthma remain stable, a third will have improvement of their asthma, and a third will have worsening of the disease. Pregnant women with severe asthma are at markedly increased risk of maternal and perinatal morbidity and mortality, preeclampsia, low-birth weight infants, and preterm delivery. A severe asthma exacerbation in a pregnant woman may be clinically daunting, however immediate intervention with appropriate supplemental oxygenation, medical therapy, and intubation if necessary can be life-saving. A focus on maternal well-being and pulmonary function in a pregnant asthmatic is essential to ensure optimal outcomes for both mother and her fetus. This article will provide an overview of asthma management, particularly in the acute care setting.     

Perforated colon volvulus coiling around the uterus in a pregnant woman with a history of severe constipation

A case of intestinal volvulus in both the sigmoid colon and cecum in a pregnant woman suffering from severe constipation is reported herein. The fetus was dead and the mother developed acute shock. The twisted sigmoid colon coiled twice around the uterus and was perforated. The mother died 10 h after the onset of severe abdominal pain. Volvulus should be considered when examining severe abdominal pain in a pregnant woman with a history of severe constipation. Early suspicion together with prompt intervention will minimize maternal and fetal morbidity and mortality of this rare complication of pregnancy.     

Nocardial tubo-ovarian abscess in a pregnant woman: a rare case report

Nocardiosis is a rare disease associated with significant morbidity and mortality in immunocompromised patients. We report on a 32-year-old pregnant woman with nocardiosis, which may be the third reported case in which no risk factor for the infection (other than the pregnancy itself) could be found. Pregnancy was complicated by the formation of a tubo-ovarian nocardia abscess, resulting in abortion. Lapartomy with trimethopprim-sulfamethoxazole led to complete cure of the patient at the end of the fifth month. This case emphasizes the difficulty in the diagnosis and treatment of a nocardial infection during pregnancy.     

Congenital disorders of glycosylation type Ia as a cause of mirror syndrome.

Mirror syndrome (that is fetal hydrops with subsequent edema in the pregnant woman) is a rare condition. Early diagnosis is warranted, as maternal and fetal morbidity and mortality is increased if not diagnosed and treated properly. In most cases, the underlying cause remains unclear. We report a woman who has had two pregnancies complicated by mirror syndrome. Congenital disorder of glycosylation type Ia (CDG-Ia) was identified as the underlying fetal disease in both cases.     

Perinatal depression

Despite the fact that childbirth is often a time of joy for a family, the occurrence of perinatal depression is very common. It is essential for the depressed patient to be identified and treated during the pregnancy or postpartum because the failure to treat can have significant morbidity and even mortality for the woman and the child. Despite various concerns several antidepressant medications are generally safe and, after a careful risk/benefit analysis and informed consent, indicated for the severely depressed pregnant or lactating patient.     

Menstrual therapies in commonwealth Asian law

This review of the application of abortion laws confines itself to the 900 million people--20% of the world's population--who live under the commonlaw tradition of the British Commonwealth. One of the historic ties to the British Commonwealth is the commonlaw tradition, which is reflected in reference to common leading cases and approaches taken to case precedents. There are 2 Commonwealth legal traditions concerning penal legislation, and they differ on an issue of major significance regarding abortion. Under English law, acting with the intention to procure an abortion whether a woman is pregnant or not is a crime. In Asian Commonwealth jurisdictions, and Pakistan, menstrual therapies are not as restricted as they may be in England. Menstrual therapy, a generic term, describes medical and surgical procedures performed on the uterus for diagnostic and therapeutic indications. This includes menstrual aspiration and the use of drugs as well as the more traditional dilatation and curettage. Diagnostic biopsy of the uterine lining may be indicated upon a variety of clinical grounds, including apparent infertility, dysfunctional bleeding, and suspected uterine cancer. Treatment of incomplete abortion is a common medical procedure and involves the operator in no liability under abortion laws. Uterine evacuation initiated for purposes of abortion in a woman known to be pregnant must conform to the abortion law of the jurisdiction, but some procedures will be undertaken before pregnancy can be diagnosed by the routinely available methods. A woman may occupy 1 of 3 positions: 1) she may clearly be pregnant; 2) it may be unclear whether she is pregnant or not; and 3) she may clearly not be pregnant. English abortion law applies to the first 2 positions but the Penal Code abortion provisions applies only to the 1st position. Thus, performing menstrual therapy in a woman in position 2 may be illegal abortion under English law (unless pregnancy would endanger her life or health) but not under the Penal Codes of the Commonwealth Asian jurisdictions. Menstrual therapy undertaken as a means of abortion in a case of proven pregnancy must conform to local abortion law, but menstrual therapy undertaken for another purpose need not conform to such a law. Without clear and compelling evidence of pregnancy in the individual case, the physician may proceed on the presumption that the woman is not pregnant. Any mistake of fact made in good faith constitutes a good legal defense.     

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.     

Indications for caesarean section

Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.     

Abruptio placentae and fetal death following a Malayan pit viper bite

Reports of venomous snakebites during pregnancy are uncommon. Little is known about maternal and fetal outcome following the venomous snakebite of a pregnant woman, and there is no consensus for proper management. In southern Thailand, Malayan pit viper (Calloselasma rhodostoma) bites are quite common, and we have some experience with bites of pregnant women. With these victims, the toxicity is most severely expressed in a bleeding disorder that is a significant cause of both morbidity and mortality in both the gravid woman and the fetus. Herein, because there are few such published reports, we report the case of a 43-year-old woman, gravida 5 para 4, 32 weeks pregnant who was bitten by a Malayan pit viper and, as a result, developed abruptio placentae, coagulopathy, and death of fetus in utero. She otherwise responded well to antivenom and blood components. A hysterotomy was performed and the postoperative course was unremarkable.     

Fatal influenza A pneumonia in pregnancy

Today, influenza A infections are an uncommon cause of maternal morbidity and mortality. This is a report of a 20-year-old pregnant woman who died from pneumonia caused by influenza A/Philippines/1982. The decreased immune system and respiratory functions of pregnancy make pregnant women especially susceptible to having a complicated influenza infection, though such infections probably do not directly threaten the fetus. The use of influenza immunizations and antiviral medication during pregnancy is discussed.     

Thromboembolism and thrombophilia in pregnancy

Venous thromboembolism (VTE) is one of the leading causes of maternal mortality worldwide and is also the cause of significant maternal morbidity. This article discusses the risk factors for VTE in pregnancy, the management of the pregnant woman at risk both antenatally and postpartum and the acute management of VTE when it occurs during pregnancy.The thrombophilias, both heritable and acquired are becoming increasingly recognised as a cause of morbidity and mortality both within and outside pregnancy. There has been recent increased interest in the thrombophilias and their link with recurrent miscarriage, pre-eclampsia, abruption and intrauterine growth restriction. The relationship between the thrombophilias and adverse pregnancy outcome is addressed in detail with reference to the current literature available on this evolving subject.