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In a review of almost 63,000 pregnancies, Sciscione and coworkers found that pulmonary edema occurred most often during the antepartum period (47%); 39% occurred in the postpartum period and the remaining 14% occurred in the intrapartum period. These increases in blood pressure can result in cerebral, retinal, or subarachnoid hemorrhage as well as increased operative blood loss. There have been numerous comparisons of methadone and buprenorphine for the treatment of opioid dependence in pregnant women. When 2-hour postmeal glucose measures averaged 120 mg/dL or less, approximately 20% of infants were macrosomic, but when 2-hour postprandial glucose measures averaged up to 160 mg/dL, the rate of macrosomia reached 35%. Treatment of a symptomatic pneumothorax requires evacuation of air from the pleural space by aspiration through a small-bore plastic catheter or placement of a chest tube. The role of prophylactic administration of bronchodilators to reduce the incidence of perioperative bronchospasm has not been clearly established. During the last trimester, a series of physiologic events leads to changes in the hormonal milieu of the fetus and the mother to facilitate neonatal transition. This rhythm is incompatible with life because there is no associated stroke volume or cardiac output. Several studies have called into question the use of cultures to identify the microbes of community-acquired pneumonia. Ghasemi A, Gorouhi F, Rashighi-Firoozabadi M, et al: Striae gravidarum: associated factors, J Eur Acad Dermatol Venereol 21:743, 2007. Arguments against more extensive respiratory quinolone use are based on concerns about the potential for developing resistance, the variable incidence of Legionella, and cost. With chronic hypoxemia, there is also an increase in red blood cell mass to improve the oxygencarrying capacity of the blood. For example, reported adherence rates were approximately 50% in one study of asthmatic adults; decreased adherence was associated with an increased frequency of asthma exacerbations in this study. Angiotensin-converting enzyme activity is increased in patients with sarcoidosis, presumably due to production of this enzyme by cells within the granuloma. Antiretroviral Pregnancy Registry identified comparable overall birth defect prevalences for lamivudine and tenofovir (2. The initial 1985 report184 described 23 67 Substance Abuse in Pregnancy 1143 cocaine-exposed infants who demonstrated depression of interactive behavior and poor organizational response to environmental stimuli on the Brazelton Neonatal Behavioral Assessment Scale. Embolectomy is rarely feasible for atheromatous embolism, because the atheromatous material usually fragments into very small pieces. In contrast, women who are in opioid-agonist treatment with methadone or buprenorphine should be encouraged to breastfeed, because methadone and buprenorphine concentrations in breast milk are low. There is clinical evidence that neonates may exhibit similar symptoms after withdrawal from antenatal nicotine exposure. The outcome of severe thyroid hormone deficiency in utero was fetal distress, permanent auditory deficit, brain atrophy, and severely impaired neuromotor development despite adequate neonatal treatment. It has been related to an expanded trinucleotide repeat in a gene localized to 19cenq13. In patients who are candidates for percutaneous embolectomy, conventional pulmonary angiography can be performed to confirm the diagnosis of pulmonary embolism immediately before the embolectomy procedure. Aneurysms affecting the ascending aorta are primarily the result of lesions that cause degeneration of the aortic media, a pathologic process termed cystic medial necrosis. Treatment of orthostatic hypotension is symptomatic and includes use of elastic stockings, consumption of a highsodium diet to expand intravascular fluid volume, and administration of vasoconstricting 1-adrenergic agonists such as midodrine or 2-adrenergic antagonists such as yohimbine. Only 13% occur in the antepartum period, and of these, 3% are related to an induced or spontaneous abortion. Patients often have minimal pain postoperatively, which responds well to opioids and nonsteroidal antiinflammatory drugs.

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Pulmonary artery occlusion pressures below 15 mm Hg may reflect inadequate intravascular fluid volume. This overexpression was reproduced in normal colonic cells treated with progesterone. This operation has been replaced by the arterial switch operation in which the pulmonary artery and ascending aorta are transected above the semilunar valves and reanastomosed with the right and left ventricles; the coronary arteries are then reimplanted so that the aorta is connected to the left ventricle and the pulmonary artery is connected to the right ventricle. Intravenous administration of sodium bicarbonate may be needed to treat extreme acid-base abnormalities. A history of myomectomy after laparotomy carries an increased risk for uterine rupture (about 1. The principles of drug management of a seizure disorder in the pregnant woman are the same as in the nonpregnant woman. Fetal mortality correlated with the estimated percentage of placental detachment, the location (retroplacental), and size (>60 mL) of hemorrhage. However, side effects, including peripheral vasodilation and negative inotropy, can contribute to an undesirable degree of hypotension. Sinus tachycardia in patients with ischemic heart disease, diastolic dysfunction, or congestive heart failure can lead to significant clinical deterioration because of the increased oxygen demand, increased wall stress, and inability to increase myocardial perfusion in many of these patients. However, as pericardial pressure increases, the right atrial pressure increases in parallel, so that the right atrial pressure becomes an accurate reflection of the intrapericardial pressure. This may include in-line stabilization during laryngoscopy with either a standard laryngoscope or videolaryngoscope or awake fiberoptic intubation. Because the syndrome is distinctly uncommon, with other conditions associated with shock and vascular collapse, it is assumed that the hyperplastic gland in pregnancy is more vulnerable to an inadequate blood supply. Because it avoids instrumentation of the airway and tracheal intubation, regional anesthesia is an attractive option when the operative site is suitable for this. Their risk may be as high as 28% for respiratory failure, 12% for cardiac dysrhythmias, 11% for congestive heart failure, and 7% for overall perioperative mortality for noncardiac surgery. Currently used prostacyclins include epoprostenol (Flolan), treprostinil (Remodulin), and iloprost (Ventavis). The investigators concluded that the presentation varied greatly, ranging from clinically and radiologically silent cases to neonates with severe skeletal disease and bone demineralization. Hepatitis A is a self-limited disease without the chronic process that complicates other viral hepatitis infections, and recovery follows typically within 4 to 6 weeks. Administration of nimodipine, a calcium channel blocker, has been shown to improve outcome when initiated on the first day and continued for 21 days after subarachnoid hemorrhage, which presumably reflects a protective effect from the consequences of vasospasm. Elective endotracheal intubation may be required to protect the airway (particularly before transfer and surgical procedures, including delivery) before the development of overt cerebral edema. Medical management of patients with mitral stenosis involves activity restriction, treatment of dysrhythmias, -blockers to control heart rate, and judicious diuretic use. Chemotherapy in the first trimester has been associated with fetal malformations, an increased risk of spontaneous abortion, and stillbirth. The cause of this new deficit may be either a mass effect from an expanding aneurysm that compresses normal neurologic structures or small emboli to the distal cerebral circulation from a thrombus contained within the aneurysm. Malnutrition can increase the risk of prolonged postoperative air leaks in patients after lung surgery. In patients with large macroadenomas with suprasellar extension, the risk of tumor expansion is significant when using dopamine agonists to establish pregnancy. Among infants exposed to phenytoin in utero, 11% have enough clinical features to be classified as having this syndrome, and almost three times as many may show lesser degrees of impairment of performance or morphogenesis. Pulmonary edema reflects acute left ventricular failure resulting from dramatically increased afterload. Prematurity and intrauterine growth restriction are the greatest risks to the infant. Twentyfour-hour urine collection has been traditionally used for determination of the degree of proteinuria, but a protein-to-creatinine ratio in spot urine specimens has been shown to strongly correlate with 24-hour urine protein excretion in pregnancy. These infants are characterized by severe mental retardation with a neurologic picture that includes deaf-mutism, squint, and pyramidal and extrapyramidal syndromes. Some patients are helped by injection of steroids into the carpal tunnel and others by treatment with diuretics. A nondepolarizing neuromuscular blocking drug that does not release histamine is best. Although neurofibromas are histologically benign, functional compromise and cosmetic disfigurement may result from their presence.

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All pregnant women who report methamphetamine use should be encouraged to seek treatment. Decreased diastolic time (myocardial perfusion time), diastolic aortic pressure, and effective stroke volume reduce myocardial O2 supply. It can be treated with anticholinesterase drugs and usually subsides within 6 weeks of delivery, but it may result in death caused by aspiration or respiratory failure. Blood eosinophil counts often parallel the degree of airway inflammation, and airway hyperreactivity provides an indirect assessment of the current status of the disease. There is evidence that obstructive sleep apnea leads to sustained hypertension independent of known confounding factors such as obesity. Currently, this procedure is reserved for treatment of terminal right-sided heart failure and as a bridge to cardiac transplantation. The diagnosis ultimately requires specific serologic markers for acute and chronic infection (Table 63-5 and Box 63-2; see Table 63-4). It was suggested that suppression of physiologic lactotroph hyperplasia by bromocriptine might permit noninvasive management of the pituitary adenoma in pregnancy. In summary, given that the risks for obstetric complications, including prematurity and placental abnormalities, may be higher than expected for the general population, uterine artery embolization for myomas seems most appropriate for patients with symptomatic myomas who have completed childbearing. This results in overdistention of the cerebral blood vessels, and as a result, fluid may be forced across the blood vessel walls into the brain tissue, producing cerebral edema. During most of gestation, most cortisol in the fetal circulation is supplied by the mother through transplacental passage, although fetal cortisol concentrations are lower than maternal because of placental cortisol metabolism. Magnetic Resonance Imaging Magnetic resonance imaging can be safely used during pregnancy to evaluate adnexal masses even without the use of gadolinium-based contrast. The disease usually improves during pregnancy or with oral contraceptive therapy, probably because of an estrogen effect. However, the remaining infants did well and were discharged with apparently normal pulmonary function. Intravascular fluid volume should be maintained at normal levels, since these patients are preload dependent. These findings do not contradict the possibility that suboptimal control of asthma during pregnancy is associated with increased risk to the mother or baby. Monthly follow-up visits during pregnancy usually permit satisfactory supervision of the patient. In patients with a large pneumothorax, the findings on physical examination of the affected side may include decreased chest wall movement, hyperresonance to percussion, and decreased or absent breath sounds. If transcutaneous pacing is needed, the chest and back electrodes should be placed over areas of lower skeletal muscle mass, and low-density constant-current impulses should be delivered. Drugs administered intravenously are distributed with minimal dilution to organs such as the heart and brain. Serum amylase concentrations greater than three times normal suggest pancreatitis. The second letter indicates the antitachycardia pacing chamber (O, none; A, atrium; V, ventricle; D, dual). Several studies have demonstrated an additional advantage to maternal immunization with the pneumococcal vaccine: a significant transplacental transmission of vaccine-specific antibodies in infants, measured at birth and at 2 months. Prenatal diagnosis offers an opportunity to plan for delivery room management and provide anticipatory guidance. The need for appropriate vitamin supplementation in this population must be recognized. O2 consumption Pneumonia in Pregnancy Pneumonia is fortunately a rare complication of pregnancy, occurring in 1 of 118 to 2288 deliveries. Psychiatric illness can lead to poor self-care, partial or total disability that can impair the care of others, and, in the worst scenario, suicide or homicide as a result of psychotic thoughts. In normal pregnancy, the ability of the insulin receptor to transduce an intracellular signal is diminished.

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Because of the lack of safety data and a potential risk of anaphylaxis, treatment with omalizumab should not be initiated during pregnancy. Disease of a cardiac valve rarely occurs without an accompanying murmur, reflecting turbulent blood flow across the valve. Corticosteroids and azathioprine are probably safer than cyclophosphamide and mycophenolate, which should be avoided unless absolutely necessary. Conservative treatments include topical astringents such as potassium permanganate or tannic acid, or antiperspirants. Definitive management is deferred to the intrapartum (with cesarean hysterectomy) or the postpartum period. After implantation of the valve, echocardiography is used to assess prosthesis position; to determine the degree of aortic regurgitation, if any; and to detect the presence of perivalvular leaks, aortic dissection, mitral regurgitation, left ventricular dysfunction, or new regional wall motion abnormalities. Disturbances of speech, sensation, or vision may also occur, and patients may have mild pyrexia. The relationship between variations in systemic arterial pressure that occur with a positive-pressure breath is based on combining the Starling principle. Several drugs are efficacious in converting atrial fibrillation to sinus rhythm, including amiodarone, propafenone, ibutilide, and sotalol. In others, treatment can be delayed until after delivery or until a gestational age at which delivery will not produce significant morbidity. Denervation of the heart is another consideration in patients undergoing heart-lung transplantation. It is also a risk if excision of a tumor that has invaded temporal bone results in exposure of veins that cannot collapse because of bony attachments. Although -adrenergic antagonists are a mainstay for patients who have experienced myocardial infarction, their use solely as an antihypertensive agent has fallen out of favor. Concentrations of 4-androstenedione, testosterone, and 17-hydroxyprogesterone are used to monitor adequacy of suppression. When air enters the right atrium and ventricle, there is interference with right-sided cardiac output and blood flow into the pulmonary artery. Assessment for the presence of myocardial ischemia, previous myocardial infarction, valvular dysfunction, and heart failure is important in performing risk stratification and in planning maneuvers for risk reduction. The mortality rate of asymptomatic patients with normal left ventricular size and function is less than 0. Metoclopramide is an effective migraine abortive that is probably safe in pregnancy. Echocardiography at this time may be particularly helpful in determining the adequacy of volume replacement and cardiac function. Both syndromes occur most frequently in the third trimester or in the immediate postpartum period and can include hypertension and proteinuria as part of the presenting syndrome. The most frequent organisms include groups A, B, and G streptococci, Escherichia coli, Streptococcus oralis, Staphylococcus aureus, and Citrobacter and Fusobacterium species. Closed pelvic fracture is not a contraindication to vaginal delivery if the birth canal is not compromised. Occasionally, larger doses may be needed to treat cardiac arrest resulting from -blocker or calcium channel blocker overdose. In that context, hepatomegaly should be considered a potential pathologic finding, signifying the need to determine whether underlying liver disease exists. When quadriplegic patients are placed in the upright position, the weight of the abdominal contents pulls on the diaphragm, and the absence of abdominal muscle tone results in less efficient function of the diaphragm. An increased rate of cesarean delivery before labor is the obstetric complication most frequently observed for women with leiomyomas. Degenerative changes can also occur and may be related to ischemia, which is thought to occur when the growth of the myoma, stimulated by the hormonal changes of pregnancy, outpaces its blood supply. This disease occurs most commonly in primigravidas, with symptoms tending to occur in the early part of pregnancy and remitting after delivery. An accompanying commentary stated that a sodium level of 140 mEq/L should be considered hypernatremia in most pregnant women, and early recognition and treatment were advised.

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TraumaticParaplegia When spinal cord injury resulting in paraplegia occurs during the course of an established pregnancy, it may be followed by spontaneous abortion or stillbirth. Meperidine is the drug of choice for analgesia; unlike morphine, it does not constrict the sphincter of Oddi. It includes administration of diuretics to treat pulmonary and systemic congestion. The best strategy for most diabetic women on dialysis who desire pregnancy is to undergo kidney transplantation. The degree of pulmonary hypoplasia in congenital diaphragmatic hernia is directly related to the extent of herniation. The risk of reexpansion pulmonary edema after relief of a pneumothorax or pleural effusion is related to the amount of air or liquid that was present in the pleural space (>1 L increases the risk), the duration of collapse (>24 hours increases the risk), and the rapidity of reexpansion. Histamine and bradykinin released during surgical manipulation can cause profound hypotension. Transtrophoblastic calcium transfer also depends on an increase in calcium-binding protein, which reaches maximal concentrations in the third trimester when fetal growth is most rapid. The primary antibody response to infection mediated by the infant is production of immunoglobulin M (IgM). Secondary factors such as hypovolemia, opioid administration, sedation, hypercarbia, concurrent medical illnesses, and long-term use of medications that slow the heart rate can contribute to the development of bradycardia. During temporary clamping of the feeding vessel, systemic blood pressure should be maintained toward the higher end of the normal blood pressure range to encourage collateral circulation. Those with asthma that is not well controlled should be considered to be at risk for pregnancy complications and may benefit from increased fetal surveillance. In practice, this medication has not been particularly effective, largely due to noncompliance, as suggested by a study of U. Surgical treatment may also be necessary in a patient with clinical or electrophysiologic evidence of increasing nerve dysfunction despite conservative measures, but it can usually be avoided during the pregnancy. There are substantial data about the use of older, typical antipsychotic agents in pregnancy, and clinicians may elect to rely on these agents. The incidence of complications related to pacemaker insertion is approximately 5%. Does consumption of four drinks in 1 week pose the same risk as consuming four drinks in one sitting On the street, it is known as pot, reefer, Mary Jane, hash, weed, hemp, blunt, and many other nicknames. Although benign intracranial hypertension is self-limiting, remission may not occur until well after delivery. Transthoracic and transesophageal echocardiography has facilitated early, accurate diagnosis of congenital heart disease, assessment of the intraoperative and postoperative course, and evaluation of the ventricular function response to anesthetics in these patients. Eliciting the oculovestibular reflex will result in tonic conjugate eye movements toward the side of cold water irrigation of the external auditory canal. The relationship between insulin sensitivity and insulin response has been characterized as a hyperbolic curve or, when multiplied, as the disposition index. With these points in mind, inquiries by a pregnant woman with multiple sclerosis who is worried that her child may later become affected should be met with firm reassurance. Low-Glycemic Foods Manipulation of the type of carbohydrate in the diet can provide additional benefits in glycemic control. Low-dose sevoflurane may be desirable because of its relatively minimal impairment of cerebral autoregulation, although low-dose isoflurane is also a good choice. This finding suggests that cases that are undiagnosed by standard test can be identified with the assay. Palliative treatment of symptoms with steroids, single-agent treatment with vinblastine, and delayed therapy until the second trimester are preferable options. Prophylactic tocolytics at the time of surgery in the second trimester do not decrease the risk of preterm labor or preterm delivery, but they may be beneficial in the third trimester. Young individuals with massive hypertrophy, even if they have few or no symptoms, deserve consideration for an intervention to prevent sudden death. An endotracheal tube bypasses most of the natural airway humidification system, so humidification of inspired gases and use of low gas flows are needed to keep airway secretions moist.

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As expected, the likelihood of abruption, uterine rupture, maternal death, and adverse neonatal outcomes, including fetal and neonatal death, was significantly higher for the group that delivered during the trauma admission. Cockroaches can be controlled by poison baits or bait traps and eliminating exposed food or garbage. It can occur as part of the normal physiologic response to stimuli such as fear or pain or as a pharmacologic response to medications or substances such as atropine or caffeine. Postmarketing data about prenatal exposure to risperidone showed a rate of malformations that was consistent with the rate (3. The pathophysiology of the pain associated with trigeminal neuralgia is uncertain. In patients with active disease at the time of delivery, separation of the mother and newborn should be accomplished to prevent infection of the newborn. Considerable variability exists in the severity of the disease, and the classic presentation of hemoglobinuria is seen in only 25% of patients. The mechanism (or mechanisms) responsible for the compromised renal function in preeclampsia may be related to renal vasoconstriction and to the glomerular endotheliosis noted on renal biopsies. In this situation, not only is the anterior spinal artery blood flow reduced directly, but the potential for collateral blood flow to the spinal cord is also reduced because aortic pressure distal to the cross-clamp is very low. The anesthesiologist must be aware of the potential for altered hemodynamics, especially with cervical and high thoracic cord lesions. Clostridium tetani infection by means of tetanus spores may follow injury, surgical procedures, childbirth, abortion, and injections. The striae become involved in 67% of women, suggesting that abdominal distention may contribute to the inflammation occurring with this rash. Hemodynamic stability, optimal surgical conditions, and rapid emergence from anesthesia at the end of surgery are appropriate goals when selecting anesthetic maintenance medications. Ricci E, Parazzini F, Motta A, et al: Pregnancy outcome after cabergoline treatment in early weeks of gestation, Reprod Toxicol 16:791, 2002. The rate of infection in lung transplant recipients is several times higher than that in recipients of other transplanted organs and is most likely related to exposure of the allograft to the external environment. Although spontaneous remission may occur, treatment of severe cases requires whole-lung lavage to remove alveolar material and improve macrophage function. In contrast to the mechanical disorders of the thoracic cage, in which an effective cough is typically preserved, the expiratory muscle weakness characteristic of neuromuscular disorders prevents generation of sufficient expiratory airflow velocity to provide a forceful cough. As a result of depression and/ or pain, these patients are often treated with antidepressants and analgesics, including opioids, that require attention when anesthetic management is planned. Ehlers-Danlos syndrome represents a group of connective tissue disorders associated with skin fragility, easy bruisability, and osteoarthritis. Little may be found on physical examination, but in severe cases cutaneous sensation is disturbed in the affected area. A large series of 66 patients with placenta accreta found that 95% required red blood cell transfusion and 39% required massive transfusion, including 10% who required more than 20 units of packed red blood cells. It may be tempting to terminate a pregnancy because of the severity of myasthenic symptoms-death has been reported in pregnancy complicated by myasthenia gravis-and because of the difficulties in their treatment, but termination does not necessarily lead to clinical benefit. Those at high risk include individuals with sickle cell disease with autosplenectomy, patients who have had a surgical splenectomy, and individuals who are immunosuppressed. Patients with stage B heart failure have structural heart disease but no symptoms of heart failure. Adjuvant chemotherapy is recommended for all premenopausal patients with node-positive breast cancer or with tumors greater than 1 to 2 cm in diameter that are poorly differentiated. Fifty-eight women received their first dose of varicella vaccine during the first or second trimester.

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In patients with previously recognized adrenal disorders, replacement hormone therapy is continued throughout gestation, and the patient is monitored. This is also useful in the event a cesarean delivery is indicated, because general anesthesia and its possible effects on pulmonary function can be avoided. Induction and maintenance of anesthesia with ketamine or a benzodiazepine in combination with nitrous oxide is often used. Although some studies report an incidence similar to that with open aortic surgery, others showed a lower rate with endovascular repair. The laboratory evaluation and diagnostic studies used in the workup of pulmonary hypertension of any cause are listed in Table 5-11. Therefore they have become an attractive therapeutic option for an increasing number of patients with heart failure. Most affected infants are 6 to 9 days old when admitted and have a typical history of continuous crying for up to 48 hours, followed by cessation of sucking and then of crying, accompanied by convulsions and often by fever. Administrative error is the culprit in most of these events, underscoring the need for accurate accounting of transfused units, particularly in an emergent situation. Additional therapeutic options for melasma persisting after pregnancy include daily topical retinoic acid (tretinoin [RetinA, Avita]), salicylic acid (SalAc cleanser), or azelaic acid (Azelex, Finacea). Pressure transducers can be placed under aseptic conditions into the subdural space (known as a subdural bolt), brain parenchyma, or ventricle. Also, the failure to find more adverse outcomes among women with severe asthma may be a function of the relatively small numbers and the resulting lack of statistical power. Premature ventricular beats may reflect the electrical instability of the ventricle due to surgical ventriculotomy. Infants with tracheoesophageal fistula with esophageal atresia often have difficulty feeding due to tracheomalacia, recurrent esophageal stricture, and gastroesophageal reflux, which are known associates of this disorder. A focused mechanical injury during this small window of time could stretch cardiac fibers and cause an unsynchronized impulse, a mechanical R-on-T phenomenon. History and Physical Examination Questions designed to define exercise tolerance are necessary to evaluate cardiac reserve in the presence of valvular heart disease and to provide a functional classification according to the criteria established by the New York Heart Association (Table 2-1). The action potential developed in a contractile cardiac cell differs from that occurring in an automatic cardiac cell in that phase 4 is not characterized by spontaneous depolarization. Methadone maintenance programs are not widely available, and transportation issues and the need for daily compliance are often obstacles to participation. Most of the 133 women who were hospitalized with pneumonia in this study did not receive a chest radiograph for confirmation of the diagnosis. It is usually attributed to decreased oxygen delivery to the optic disk in association with hypotension and/or anemia. The pathophysiology of fat embolism syndrome relates to obstruction of blood vessels by fat particles and the deleterious effects of free fatty acids released from the fat particles as a result of lipase activity. In the presence of acute respiratory failure, Paco2 can be increased, unchanged, or decreased depending on the relationship of alveolar ventilation to metabolic production of carbon dioxide. Initial management of patients with acute head injury includes immobilization of the cervical spine, establishment of a patent airway, protection of the lungs from aspiration of gastric contents, and maintenance of brain perfusion by treatment of hypotension. The mechanism for this effect is most likely increases in muscle afferent activity, a process somewhat independent of visible muscle fasciculations. In many such instances, the neuropathy follows clinical or subclinical infection with Campylobacter jejuni. The origin of syncope in patients with aortic stenosis is controversial but may reflect an exercise-induced decrease in systemic vascular resistance that remains uncompensated because cardiac output is limited by the stenotic valve. Vesicles occur in a minority of cases and can cause confusion with pemphigoid gestationis, but the results of direct immunofluorescence of skin biopsy specimens are usually negative. Sentinel lymph node biopsy is not recommended for pregnant women with early-stage breast cancer.

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The effect of pregnancy on pulmonary mechanics has been compared with the effect of a pneumoperitoneum. This includes any necessary surgical approach, appropriate replacement of blood products, and correction of severe acidosis, hypothermia, and hypocalcemia. Physiologic Changes of the Respiratory System Because there is no increase in respiratory rate, the increase in maternal minute ventilation results from an increase in tidal volume. In such cases, it is often possible to obtain a history of hydramnios or reduced fetal movements during the latter part of the pregnancy. Maximizing the success of defibrillation involves decreasing thoracic impedance, positioning the electrodes properly, and selecting proper electrode size. In a German study of marijuana use the prevalence was 90% for comorbid alcohol use, 68% for nicotine, 12% for cocaine, 9% for stimulants, 6% for hallucinogens, 3% for opioids, and 1% for sedatives. Of note, apical cardiac function may be preserved, a phenomenon attributed to the paucity of sympathetic innervation at the cardiac apex. In that scenario, continuing efforts to wean the vasopressor are recommended while simultaneous volume replacement continues. A diagnosis of Takayasu arteritis requires a biopsy, angiogram, or magnetic resonance or positron emission image that documents involvement of the aorta or its great branches. A large sonographic series of almost 15,000 women found significantly higher rates of placenta previa among patients with myomas (3. Right ventricular function should be carefully assessed by clinical examination and echocardiography in patients with advanced pulmonary disease. The maternal response (or lack thereof) to resuscitative efforts dictates whether perimortem cesarean section is necessary. Fibrinogen levels decrease in the setting of hemorrhage as a result of consumption. Nitrous oxide has limited application in these patients, because it is important to administer oxygen at high inspired concentrations. Tocolysis should be undertaken with caution because the side effects of the medications. It seems reasonable to adhere to the concept that hypertensive patients should be made normotensive before elective surgery. Stress ulcer prophylaxis should be administered as well, with a proton pump inhibitor (rather than an H2 blocker) in patients with bleeding risk factors (coagulopathy, mechanical ventilation for >48 hours, and possibly hypotension). Ribault V, Castanet M, Bertrand A-M, et al: Experience with intraamniotic thyroxine treatment in nonimmune fetal goitrous hypothyroidism in 12 cases, J Clin Endocrinol Metab 94:3731, 2009. However, distal embolization may still occur to any downstream vascular bed, including to the bowel or kidneys. When located in the myometrium, they should be differentiated from focal myometrial contractions, which tend to disappear during the examination or on follow-up scans. The initial management of any comatose patient involves establishing a patent airway and ensuring the adequacy of oxygenation, ventilation, and circulation. High gas flows allow for a shorter inspiratory time and a longer time for exhalation. Other risk factors for rupture include hypertension, cigarette smoking, cocaine abuse, female sex, and use of oral contraceptives. As a result of these data, new guidelines have been issued for the treatment of hypertension in octogenarians. Appropriate monitoring to detect venous air is indicated when venous air embolism is considered a risk. Continuous infusion of propofol is uniquely attractive for this purpose, because the brief context-sensitive half-life of this drug is not influenced by the duration of the infusion, and rapid awakening is predictable.