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Some cases are probably caused by viral infection or an inflammatory reaction involving the facial nerve near the stylomastoid foramen or in the bony facial canal. At moderate doses (5 to 7 mcg/kg/min), effects predominate, producing increased heart rate, contractility, and cardiac output with a decrease in systemic vascular resistance. The disorder is classically associated with unpredictable exacerbations during which neurologic deficits develop, followed by remissions during which symptoms and signs may partially or completely resolve. At 70 Anesthesia Considerations for Complicated Pregnancies 1177 least one should be included as part of a rapid-sequence induction, and they should be immediately available to treat hypertension if it occurs. Gestational age at term had the strongest correlation with birth weight and lean body mass. Factors that negatively affect surfactant synthesis include maternal diabetes, perinatal asphyxia, cesarean section without labor, and genetic factors. Pregnancy was well tolerated in 5 of 10 women, two of whom went on to have subsequent pregnancies that were similarly well tolerated. Breathing is best managed by mechanical ventilation, since abdominal and intercostal muscle weakness or paralysis is exacerbated by general anesthesia and increases the likelihood of respiratory failure with ensuing hypoxemia and hypercapnia. Only four case reports of the use of trastuzumab in pregnancy have been published. Because they are functionless, these pituitary tumors are relatively asymptomatic in their early stages and tend to be larger at the time of diagnosis. Compression resulting from this pressure can be manifested as inspiratory stridor, difficulty mobilizing secretions, and dysphagia. Hypotension should be treated aggressively with -agonists such as phenylephrine that do not cause tachycardia and therefore maintain diastolic filling time. After delivery, parenteral glucocorticoids should be continued in smaller dosages for a few days along with intravenous fluids. Abdominal ultrasonography is a very sensitive test for the detection of abdominal aortic aneurysms. Although alphathalassemia-1 minor does not present a hazard to the adult, there are serious genetic implications when a mating of two individuals with the trait occurs. The clinical features of congenital neurosyphilis, which may become apparent after the first few weeks of life or may be delayed for several years, are essentially the same as those of 65 Neurologic Disorders 1113 neurosyphilis in adults. Chest Radiography Chest radiography (posteroanterior and lateral views) may detect the presence of pulmonary disease, cardiomegaly, pulmonary venous congestion, and interstitial or alveolar pulmonary edema. The anesthesiologist must be aware of the potential for altered hemodynamics, especially with cervical and high thoracic cord lesions. In a series of 95 pregnancies in 78 women with cirrhosis, 10 stillbirths were observed, and no significant change in liver function occurred in two thirds of the women. Allergic women should at least keep furry pets out of the bedroom; ideal animal dander control involves removing the pet from the home. Caturegli P, Newschaffer C, Olivi A, et al: Autoimmune hypophysitis, Endocr Rev 26:599, 2005. When used with psychosocial support, naltrexone can effect a significant decrease in relapse. Patients who discontinue hydroxychloroquine for pregnancy often have recurrence of rash. They found that five women tolerated pregnancy without difficulty but that three had irreversible deterioration in their clinical status. Instrumentation of the nares should be avoided because of the high incidence of chronic sinusitis in these patients. The committee also does not recommend administering antibiotics solely to prevent infective endocarditis in patients undergoing genitourinary or gastrointestinal tract operations. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. Two general pathophysiologic mechanisms contribute to pulmonary hypoplasia: extrinsic compression and neuromuscular dysfunction. In most cases, the principal concern is potential transmission of the virus to contacts and the fetus during pregnancy and delivery. An embolus resulting from rheumatic or ischemic heart disease, subacute bacterial endocarditis, or a cardiac myxoma may occur. The latter is rare, occurs in children born of healthy mothers, and is usually permanent.

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This cardiac defect is often detected during a routine physical examination, at which time the characteristic continuous systolic and diastolic murmur is best heard at the left infraclavicular area or left upper sternal border. If aortic and/or mitral regurgitation accompany mitral stenosis, there is often evidence of left ventricular dysfunction. Despite the adverse outcomes associated with exposure, only about 41% and 20% of obstetric providers effectively screen patients for use of alcohol and illicit drugs, respectively. The absolute risk reduction in stroke is small (approximately 1% per year for the first few years) but is higher with longer-term followup. Differential diagnosis of restrictive cardiomyopathy and constrictive pericarditis. It has been suggested that the hyperventilation of pregnancy results primarily from progesterone acting as a respiratory stimulant. The most severe and life-threatening disorders occur early in the biosynthetic cascade and are usually fatal or incompatible with successful reproduction. It may relate to genetic factors, seizures arising during pregnancy, or the metabolic and toxic consequences of seizures or anticonvulsant drugs. A sudden decrease in end-tidal Paco2 may reflect increased alveolar dead space and/or diminished cardiac output resulting from air embolism. If that is the case, then establishment of intravenous access may prove challenging in an extremity with a significant tremor. Spinal or epidural anesthesia can be considered, although the risk of hypotension demands diligence and caution. She should receive all needed diagnostic tests to optimize her management, with shielding for the fetus when possible. These parameters can be measured directly by obtaining a blood sample from the distal port of the pulmonary artery catheter. Phoojaroenchanachai M, Sriussadaporn S, Peerapatdir T, et al: Effect of maternal hyperthyroidism during late pregnancy on the risk of neonatal low birth weight, Clin Endocrinol 54:365, 2001. This hemodynamic change reflects selective impairment of diastolic filling of the left ventricle. Renal insufficiency in pregnancy is often associated with systemic lupus, diabetes, preeclampsia, or sepsis. Pulmonary hypertension and cor pulmonale develop as progressive pulmonary fibrosis results in the loss of pulmonary vasculature. Monitoring consists of at least intravascular blood pressure and urine output monitoring. The recommendations regarding which antibiotic to use for endocarditis prophylaxis are not dissimilar from previous recommendations. This abundance may explain the low T3 and high reverse T3 concentrations characteristic of fetal thyroid hormone metabolism. Hyperlucency due to arterial vascular deficiency in the lung periphery and hyperinflation (flattening of the diaphragm with loss of its normal domed appearance and a very vertical cardiac silhouette) suggest the diagnosis of emphysema. Therefore, a diastolic heart murmur is due to stenosis of the mitral or tricuspid valves or incompetence of the aortic or pulmonic valves. In addition to placental calcium transfer, an expanding extracellular volume and increased urinary calcium losses place further stress on maternal calcium homeostasis. Ferrous sulfate, aluminum hydroxide, and sucralfate may inhibit thyroid hormone absorption substantially-an important interaction in pregnant women who are taking iron and thyroid hormones. Laboratory evaluation of women with subcapsular hematoma or rupture reveals thrombocytopenia, hypofibrinogenemia, or prolonged prothrombin and partial thromboplastin times. The time to onset of pulmonary edema after relief of airway obstruction ranges from a few minutes to as long as 2 to 3 hours. Caron P, Broussaud S, Bertherat J, et al: Acromegaly and pregnancy: a retrospective multicenter study of 59 pregnancies in 46 women, J Clin Endocrinol Metab 95:4680, 2010.

Diseases

• Coloboma of macula type B brachydactyly
• Urioste Martinez Frias syndrome
• Cutaneous T-cell lymphoma
• Diabetic nephropathy
• Lymphatic filariasis
• Launois Bensaude adenolipomatosis
• Hemeralopia, congenital essential
• Neuropathy, hereditary sensory, type II

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Detection of misuse largely depends on accurate self-report from the patient and biologic testing. Early case reports described complications, including gastrointestinal bleeding,198 intrauterine growth restriction,199 and fetal anomalies. Studies demonstrate an association between late preterm delivery and long-term neurodevelopmental problems, including learning disabilities and attention deficit disorders. Clinical Presentation and Diagnosis the most common clinical presentation of breast cancer in pregnant and nonpregnant women is a painless lump in the breast. In infants (and children) with decreased pulmonary blood flow, the physical examination reveals central cyanosis, clubbing (in older children), tachypnea or hyperpnea, normal pulses, a prominent a wave in the jugular venous pulse (if there is interatrial obstruction), no hepatic enlargement, and no clinical signs of congestive heart failure. The increased blood flow and near systemic pressure to the pulmonary vasculature can lead to irreversible vascular changes and elevated pulmonary vascular resistance. Lymphatic drainage disrupted by transection of the trachea and bronchi may be reestablished during the first few weeks postoperatively. There is an inverse relationship between dietary potassium and calcium intake and blood pressure in the general population. Patients not responding optimally to treatment should be stepped up to more intensive medical therapy. Maintenance of anesthesia with nitrous oxide plus opioids or with opioids alone in high doses is recommended for patients with marked left ventricular dysfunction. Pregnancy is associated with a fourfold increase in the risk of thromboembolism and is a major contributor to maternal mortality. Newer agents may increase the risk for insulin resistance and weight gain in pregnancy. Multiparity is a risk factor; one study found that gallstones occurred in 7% of nulliparous women, with the rate rising to 19% of women with two or more pregnancies. In patients with large macroadenomas with suprasellar extension, the risk of tumor expansion is significant when using dopamine agonists to establish pregnancy. The patient can be instructed to increase her dose by two extra doses per week and be checked a few weeks later. Patients who meet these criteria do not require routine imaging studies to rule out occult cervical spine injury. Since there is so much variability in patient anatomy, it is difficult to find a single graft that will be adequate to cover an aneurysm. Transesophageal echocardiography can also be useful for procedures in the sitting position to identify intravenous air and help assess cardiac function. Many retinal artery occlusions are due to emboli during open heart surgery, and these resolve promptly. Of 140 macroadenomas previously treated by surgery or radiation, 7 (5%) had symptomatic enlargement, and none required surgery. Displacement can be accomplished manually, by moving the patient to a lateral position, or by placing a wedge under the hip. Echocardiography confirms the presence, severity, and often the cause of the mitral regurgitation. Bundle Branch Blocks Conduction disturbances at various levels of the His-Purkinje system are called bundle branch blocks or intraventricular conduction defects. Potential long-term side effects include visual disturbances, thyroid dysfunction, pulmonary toxicity, and skin discoloration. Increasing the ambient temperature of the operating room and maintaining normothermia are basic considerations. Temporizing measures likely to help maintain stroke volume until definitive treatment of cardiac tamponade can be instituted include expanding intravascular volume, administering catecholamines to increase myocardial contractility, and correcting metabolic acidosis. The germinal matrix is composed of thin-walled blood vessels that lack supportive tissue. Increased dosage requirements may plateau by the 20th week,146 but the need for increased dosage may occur as late as the third trimester in about one third of patients. Bicuspid aortic valve is the most common congenital anomaly resulting in aortic dilation/dissection. Caron P, Gerbeau C, Pradayrol L, et al: Successful pregnancy in an infertile woman with a thyrotropin-secreting macroadenoma treated with somatostatin analog (octreotide), J Clin Endocrinol Metab 81:1164, 1996. These vessels arising from the carotid arteries comprise the anterior circulation and ultimately supply the frontal, parietal, and lateral temporal lobes; the basal ganglia; and most of the internal capsule.

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In contrast, symptomatic patients have a mortality rate greater than 10% per year. Heroin use in particular is strongly associated with the behaviors of a male partner. The goal of treatment in hypertensive emergencies is to decrease the diastolic blood pressure promptly but gradually. They found that the cesarean rate was significantly higher among the falsepositive macrosomics than among the true negatives (42. Glucocorticoids are excreted in breast milk and have the potential to cause growth restriction in the neonate. When uterine atony occurs, the obstetric provider should mobilize other members of the labor and delivery teams, including anesthesiologists. However, despite these many disturbances, 57 Renal Disorders 959 successful conception and delivery have been described in patients on chronic hemodialysis or on peritoneal dialysis. End-organ damage (angina pectoris, left ventricular hypertrophy, congestive heart failure, cerebrovascular disease, stroke, peripheral vascular disease, renal insufficiency) should be evaluated preoperatively. This group therefore concluded that pregnancy had no adverse effect on graft function. Truncus arteriosus results in unrestrictive left-to-right shunting of blood and pulmonary overcirculation. In addition to maternal protection, prospective studies have demonstrated higher cord blood levels of antibody to influenza in infants born to mothers immunized during pregnancy. Typical infusion rates are 5% dextrose in lactated Ringer solution at a rate of 100 mL/hr and lispro or aspart insulin at 0. Bone loss because of reduced formation or increased resorption may occur in estrogen-deficiency states, glucocorticoid-excess syndromes, thyrotoxicosis, and other circumstances. Weight loss is caused by a combination of factors, including an increase in the metabolic rate, anorexia, nausea, decreased intestinal absorption of food because of splanchnic venous congestion, and the presence of high levels of circulating cytokines. Alternatively, cesarean delivery followed immediately by radical hysterectomy and lymphadenectomy is often recommended for reproductiveage women with early cervical cancer to preserve ovarian and vaginal function compared with radiation therapy. Sciatic or common peroneal nerve palsies are easy to confuse with a plexus palsy because their constituent fibers are susceptible to compressive injury in the sacral plexus during labor. Advantages of low-molecular-weight heparin over unfractionated heparin include a longer half-life, a more predictable dose response without the need for serial assessment of activated partial thromboplastin time, and a lower risk of bleeding complications. Methotrexate is associated with fetal malformations and fetal demise, and it should not be used during pregnancy, and ideally for not at least 3 months before conception. The initial priority is recognition of smoke inhalation injury, carbon monoxide poisoning, and airway management. Recognizing these risks, many experts have recommended early delivery (at 37 to 38 weeks) to optimize fetal outcome. Laboratory testing should be performed to eliminate other causes of cardiac dilation such as hyperthyroidism. Coagulopathy occurs in head injury patients and may be enhanced by hypothermia and the need for massive blood transfusion. Management of anesthesia in patients with syringomyelia or syringobulbia should consider the neurologic deficits associated with this disease. It accounts for 25% to 50% of clinic referrals to gastroenterologists and approximately 10% of referrals to primary care physicians. Incidence of these complications is inversely related to decreasing birth weight and gestation. The terms lobular capillary hemangioma, pregnancy tumor, and granuloma gravidarum are other synonyms for pyogenic granuloma. Symptoms can include modest weight gain, decrease in exercise capacity, lethargy, and intolerance to cold.

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The occurrence of congenital defects varies with timing of the maternal infection. Between 1983 and 2004, the rate of preterm birth increased in the United States by 30%, from 9. Bronchodilator therapy does not influence inflammatory changes in the airways and could mask underlying inflammation by relieving symptoms and allowing continued exposure to allergens. The history and physical findings guide the manner in which these patients are evaluated further. Adverse outcomes for women with hyperemesis and low maternal weight gain compared with those for patients without hyperemesis include higher rates of small-for-gestational-age fetuses, low birth weight, prematurity, and 5-minute Apgar scores less than 7. The required ventilatory support can precipitate additional lung injury, and efforts have been made to devise ventilatory strategies that maintain adequate gas exchange while minimizing secondary lung injury. A review of the largest series reveals that three types of benign ovarian pathology account for most ovarian masses in pregnancy: corpus luteum cysts, mature teratomas, and cystadenomas (Table 69-2). National Center for Health Statistics: National hospital discharge survey: annual summary 1990, Vital Health Stat 13:1, 1992. In view of the current trend toward earlier surgical intervention in patients with subarachnoid hemorrhage due to rupture of an intracranial aneurysm, it is likely that many patients will have brain edema. Patients who receive early treatment to restore cerebral perfusion have better outcomes. The results of pulmonary function tests and arterial blood gas analysis can be useful for predicting pulmonary function following lung resection, but they do not reliably predict the likelihood of postoperative pulmonary complications after nonthoracic surgery. However, if return of spontaneous circulation does not occur, attention must then be directed to evacuation of the uterus by cesarean section. If possible, this should be done before induction of anesthesia to help ensure a hemodynamically stable induction sequence. For some patients, exercise-induced asthma can be avoided with inhalation of albuterol 10 to 30 minutes before exercise. Therefore, during cross-clamping of the thoracic aorta, proximal aortic pressures should be maintained as high as the heart can safely withstand unless other modalities (such as temporary shunts or hypothermia) are implemented. Percutaneous transluminal angioplasty of iliac arteries has a high initial success rate that is further improved by selective stent placement. Decreased diastolic time and coronary perfusion pressure decrease myocardial O2 supply. Intravenous transfusions may be hazardous, because any increase in right atrial pressure is transmitted directly to the pulmonary veins, which can lead the common presentation of newborns with hypoplastic left heart syndrome at birth is cardiovascular collapse and shock. For patients with established dystonia, genetic counseling may be prudent if the disorder has a hereditary basis, and the need to continue on pharmacologic treatment should be evaluated before planned pregnancy. The deficiency can be partial-affecting trophic hormones in various degrees-or it can be complete, resulting in panhypopituitarism. Triggering by Afterdepolarizations Afterdepolarizations are oscillations in membrane potential that occur during or after repolarization. Angiography of the aorta may be required for patients undergoing elective surgery on the thoracic aorta so that the complete extent of the dissection and the location of all compromised aortic branches can be defined. In the nonobstetric population, gram-positive organisms represent most of those isolated in septic patients, followed closely by gramnegative bacteria. Pericardiocentesis performed under local anesthesia is often preferred for the initial management of hypotensive patients with cardiac tamponade. Optimal removal of airway secretions is facilitated by adequate hydration and humidification of inspired gases. In this population, the risk of developing an adverse fetal outcome (preterm delivery, neonatal or fetal death, low birth weight) has been shown to be at least two times higher than in normal healthy pregnant women. Seizures and opisthotonos have been observed in rare cases after propofol anesthesia, which suggests caution when administering this drug to patients with known seizure disorders.

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Nonsyndromic familial aortic dissection and aneurysm is found in approximately 20% of patients referred for repair of thoracic aneurysm or dissection. Prenatal diagnosis and treatment of 21-hydroxylase deficiency is possible and effective. Simple seizures involve no loss of consciousness, whereas altered levels of consciousness are seen in complex seizures. In pregnant women with a cervical biopsy suggesting microinvasive cervical cancer, a cervical cone biopsy must be performed to definitively establish the diagnosis. Such patients may benefit from the addition of an angiotensin receptor blocker to their medical therapy. Possible causes of peripartum cardiomyopathy include viral myocarditis, an abnormal immune response to pregnancy, and maladaptive responses to the hemodynamic stresses of pregnancy. As with all neuromuscular syndromes, central nervous system depressant drugs should be avoided or administered in minimal dosages when necessary. Another compelling reason to continue antihypertensive therapy throughout the perioperative period is to avoid the risk of rebound hypertension should certain drugs, especially -adrenergic antagonists and clonidine, be abruptly discontinued. At the initial visit, trough values of total and free concentrations of each drug should be measured. Breastfeeding has been discouraged because of the potential hazard of corticosteroids passing into the maternal milk, but some investigators disagree. Therefore, in addition to adequate depth of anesthesia, skeletal muscle paralysis is typically maintained during intracranial surgery. Preventive Services Task Force could not substantiate the safety or efficacy of pharmacotherapy during pregnancy. The effect of pregnancy on diabetes insipidus has been reviewed by Durr and Lindheimer. A multidisciplinary team approach consisting of maternal-fetal medicine and liver specialists is recommended to guide therapy. Bifurcated grafts are under development that will be used in the near future to achieve aneurysm exclusion with preservation of flow to important vessels such as the celiac and renal arteries when the aneurysms involves their origins. Use of noninvasive ventilation as a bridge to discontinuation of mechanical ventilation may occasionally be considered. Transesophageal echocardiography may provide higherresolution images, especially of a prosthetic valve in the mitral position. The peak prevalence of disease occurs in the reproductive age group, and for females, heterosexual contact represents the most common method of infection. Clinical experience suggests that succinylcholine is usually a safe drug to use in patients with artificial cardiac pacemakers and that, if myopotential inhibition does occur, it is generally transient. However, these patients should be monitored for worsening bradycardia or hemodynamic deterioration. These guidelines are based on the best available evidence regarding this medical problem. There is little agreement about whether beta cell dysfunction is an independent event or coincident with declining insulin sensitivity and whether the abnormalities are causally linked. Functional tumors are usually smaller (<1 cm in diameter) at the time of diagnosis; hence, they are often called microadenomas. Other rare diagnoses are pulmonary hypertension, meconium aspiration, and polycythemia. Decreased venous return can result from excess blood loss, hypotension, and sympathetic blockade from regional anesthesia and from vena caval occlusion in the supine position. Slowly titrated local anesthetics combined with epidural opioids may avoid the abrupt decline in systemic vascular resistance and provide adequate analgesia depending upon the surgical procedure. The neck and axillae can become hyperpigmented, but if those areas become velvety or papillomatous, the physician should consider acanthosis nigricans associated with diabetes mellitus and other endocrinopathies. In one large series of 5352 injured pregnant women, minor trauma during the first or second trimester was found to be independently associated with fetal demise, with an adjusted odds ratio of 1. In the presence of a patent foramen ovale or atrial septal defect, paradoxical embolization may occur and interatrial rightto-left shunting of blood may cause severe hypoxemia. However, Buchanan proposed that insulin resistance causes beta cell dysfunction in susceptible individuals.

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The most common 66 Management of Depression and Psychoses in Pregnancy and in the Puerperium 1129 anomalies are cardiac, for which the incidence is 1. The eruption was called toxemic rash of pregnancy32 and lateonset prurigo of pregnancy in the older literature. Mechanisms proposed to explain the cellular injury include tissue ischemia, cytopathic injury, and an altered rate of apoptosis (programmed cell death). This may manifest as unexplained abrupt changes in heart rate and blood pressure with or without overt clonic movement, depending on the degree of muscle paralysis. Near-miss morbidity, defined as end-organ injury associated with length of stay greater than the 99th percentile or discharge to a second medical facility, was reviewed from 2003 through 2006 in the Nationwide Inpatient Sample to determine what maternal characteristics predict which parturients are at risk. This issue is important for women with relative iodine deficiency, because T3 is preferentially synthesized. However, intramyometrial injection of vasopressin has been used to significantly decrease blood loss during hysterectomy, presumably through the same mechanism. Delivery by cesarean section through a burned abdomen 71 Intensive Care Considerations for the Critically Ill Parturient 1209 and vaginal delivery through a burned perineum have been reported. A reduction in fraction of capillary volume and increased thickness of the villous membrane have been demonstrated and contribute to impaired gas exchange. Other factors may be associated with the anatomic anomalies and may have the potential to affect pregnancy outcomes. Theophylline is an alternative treatment for mild persistent asthma and an adjunctive treatment for the management of moderate and severe persistent asthma during pregnancy. The principal causes of unclamping hypotension are (1) central hypovolemia caused by pooling of blood in reperfused tissues, (2) hypoxia-mediated vasodilation causing an increase in vascular capacitance in the tissues below the level of aortic clamping, and (3) accumulation of vasoactive and myocardial-depressant metabolites in these tissues. Whole blood has not been separated into the various components and therefore offers an advantage because it contains clotting factors and platelets in addition to red blood cells. Although menstrual migraine should be treated with the same approach as nonmenstrual migraine, the predictable timing of the headaches allows other strategies, such as a short course of twicedaily triptans or transdermal estradiol perimenstrually. However, if there is evidence of fetal compromise or profound maternal compromise and impending demise, delivery should be accomplished. An ultrasound study should be performed early in the emergency room to determine gestational age and fetal viability, and fetal monitoring should be continued if the fetus is living and of a viable gestational age. Transesophageal echocardiography is an excellent technique for monitoring left ventricular function and adequacy of intravascular volume replacement, but it requires specific equipment and specially trained personnel, and it may not be universally available. Often, these deficits will disappear and neurologic function will return to its baseline state with time. The term "metabolic inflammation" is applied to situations of lowgrade chronic inflammation observed in several metabolic disorders such as obesity and diabetes. The incidence of complications related to pacemaker insertion is approximately 5%. In a large, prospective study of pregnant women, those Asthma in Pregnancy Asthma may be the most common potentially serious medical condition to complicate pregnancy. Localized tetanus is more benign and is characterized by persistent rigidity of muscles close to the site of inoculation with the organism. The vertebral arteries each give rise to a posterior-inferior cerebellar artery before converging at the level of the pons to form the basilar artery. This prompts diffusion out of the neuron and into the synapse, where postsynaptic receptors are activated. The topic of pituitary tumors in pregnancy has been reviewed by Molitch5 and Gillam and colleagues. Tocolytics should not be used prophylactically but should be considered when signs of preterm labor are present in coordination with obstetric consultation (level I, grade A). After the patient is euthyroid (reflected by monthly free T4 and free T3 values), the dose of antithyroid drugs should be tapered. Echocardiography, although definitive for diagnosing pericardial effusion, cannot always confirm the presence of cardiac tamponade. The single most important factor determining survival after cardiac arrest due to ventricular fibrillation is the time between arrest and the first defibrillation attempt.

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This can increase the incidence of spotting after collection, but it appears to have no effect on the risk for serious adverse outcomes related to the pregnancy. When the diagnosis is made after 20 weeks of pregnancy, surgery may be delayed until the fetal prognosis has improved. Women should also be instructed to avoid and control other asthma triggers, as described earlier. Anticoagulation may be needed in patients with atrial fibrillation and/or low cardiac output. The use of a combined insulin and glucose infusion during labor maintains the maternal plasma glucose level in a narrow range (80 to 110 mg/dL) and reduces the incidence of neonatal hypoglycemia. Iodide is actively trapped by the thyroid and is the ratelimiting step in hormone biosynthesis. The atria are enlarged because of the high atrial pressures, but the ventricles are normal in size. In some instances of the familial disease, the lower cranial nerves were involved, and isolated mononeuropathies of the other extremities were present. Likewise, cardiac dysrhythmias or increases in heart rate that become hemodynamically significant should be rapidly corrected. Adequate analgesia and anesthesia during labor and delivery also reduce excessive cardiac demands associated with pain and anxiety. If the skin is extremely dry and scaly, greasy ointments may be more effective than creams. However, epidural anesthesia may be less effective than spinal anesthesia in preventing autonomic hyperreflexia because of its relative sparing of the sacral segments and lesser block density. When general anesthesia is selected, induction of anesthesia is most often accomplished with an intravenous induction drug. Although most patients find it necessary to organize their mealtimes and physical activity around their insulin regimen, changes in the timing of insulin injections and the types of insulin used are frequently necessary to match lifestyle and occupational needs and to optimize glycemic control. Decerebrate responses consist of extension of the elbow, internal rotation of the forearm, and leg extension and imply more severe brain dysfunction. Pregnancy has a variable effect on the muscle weakness, but a high perinatal mortality rate has been reported. Patients undergoing lower abdominal aortic repair still must be followed closely with particular attention to the development or worsening of renal dysfunction, even if it is transitory because of intravenous dye administration. Iodides Iodides decrease circulating T4 and T3 levels by up to 50% within 10 days by acutely inhibiting the release of stored hormone. Patients who have asthma that is well controlled and who are not receiving controller medications can be classified as having intermittent rather than persistent asthma. Dopamine then binds dopamine receptors, stimulates the postsynaptic cell, and creates a positive emotional response. Stimulation of the various nuclei within the basal ganglia via an implanted deep brain stimulating device can relieve or help to control tremor. The previous (1990) guidelines were focused on prevention of the small or growthrestricted fetus. Historically, early pregnancy termination has been recommended to avoid complications. This includes any necessary surgical approach, appropriate replacement of blood products, and correction of severe acidosis, hypothermia, and hypocalcemia. Induction of anesthesia with an intravenous drug is acceptable, but the importance of avoiding sudden decreases in systemic vascular resistance and increases in heart rate and contractility must be kept in mind. Adaptations in normal pregnancy and alterations that occur in women with preexisting or newonset kidney disease during pregnancy are the subject of Chapter 7. Postimmunization testing is important for high-risk groups likely to have carriers within a household. The atypical antidepressant bupropion in a sustained-release formulation can also aid in smoking cessation. There is little evidence that the liver undergoes any major histologic changes during pregnancy.

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It is not unusual for patients with traumatic brain injury who initially are in stable condition and awake or in light coma to deteriorate suddenly. There is a high rate of concordance among twins and an increased risk in individuals who have a first-degree relative with the disease. Wheezing in association with pulmonary edema has been characterized as "cardiac asthma. It is the leading cause of disability and the third leading cause of death in the United States. Whether these criteria are sufficient to determine a separate disease is questionable. As a measure of in utero hyperinsulinemia, they obtained cord-blood serum C-peptide measurements at delivery and reported the frequency when greater than the 90th percentile. In preparation for surgery, the seizure focus is first located by imaging and functional studies. Associated pulmonary dysfunction may be limited to arterial hypoxemia, which is always present, or it may progress from tachypnea to acute respiratory distress syndrome. However, the subset of patients at high risk of sudden death (family history of sudden death or history of malignant ventricular dysrhythmias) have a mortality rate of 5% per year. Current recommendations have resulted in a more restrictive use of such prophylaxis. Arterial oxygen desaturation is present even when the patient breathes 100% oxygen (Pao2 is usually <50 mm Hg), indicating central cyanosis. The diagnosis of polyarteritis nodosa depends on histologic evidence of vasculitis on biopsy specimens and demonstration of characteristic aneurysms on arteriography. Increasing numbers of triplet repeat expansions govern clinical expression of disease; prenatal detection of the disorder is possible. In extreme cases, temporary occlusion of one pulmonary artery serves to decrease the Pao2. Despite the suppressant effect of many antihypertensive drugs on the autonomic nervous system, extensive clinical experience has confirmed that the response to sympathomimetic drugs is both appropriate and predictable. Yes, with increased risk for preterm premature rupture of membranes at higher dosages Safe in Breastfeeding Yes, but breastfeeding is not encouraged if receiving >60 mg prednisolone daily Yes Azathioprine Mycophenolate mofetil Yes Tacrolimus Yes Slightly increased risk for congenital malformations, specifically ventricular and atrial septal defects208 Hypoplastic nails, shortened fifth fingers, diaphragmatic hernia, microtia (ear deformity), micrognathia, cleft lip and palate, and congenital heart defects214 No Fetal growth restriction, and dosage-related myelosuppression in the neonate208 Yes Yes No. The anesthesiologist should be aware of the dose, route, and major side effects of the oxytocic drugs that can be used (Table 70-5). A meta-analysis confirmed the increased risk of miscarriage in euthyroid women with thyroid autoimmunity with a pooled relative risk of 2. Isolated mitral regurgitation can be associated with ischemic heart disease or result from papillary muscle dysfunction, mitral annular dilation, or rupture of chordae tendineae. In addition, the use of halothane, isoflurane, and sevoflurane, with a fractional concentration of inspired oxygen of 1. Rubella virus can be isolated most consistently from throat or nasal swabs by inoculation of the appropriate cell culture. The success of this strategy prompted the publication of guidelines for intrapartum antibiotic prophylaxis by the Centers for Disease Control and Prevention. When deterioration does occur, it often begins at about the 6th or 7th month of pregnancy. Plasma creatine kinase concentrations are normal, which distinguishes this disease from chronic polymyositis. A total of 67 instances of myomas removed at laparotomy and six removed laparoscopically have been reported in the literature (and have been summarized41,42). Several studies have attempted to identify prognostic factors that increase the risk for deterioration of renal function in women with overt diabetic nephropathy. Volatile anesthetics can diminish cardiac contractility and result in exaggerated hypotension, because absent carotid sinus activity will impair the usual compensatory responses to a decreased cardiac output such as vasoconstriction or tachycardia. It also appears that the risk of antibiotic-associated adverse events exceeds the benefits of endocarditis prophylaxis overall and that the common use of antibiotic prophylaxis promotes the emergence of antibioticresistant organisms.

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In some patients, symptoms, especially pain, are precipitated or aggravated by exercise and relieved by rest, whereas symptoms in other patients may relate to specific postures, such as sitting or bending forward. Herniation of the cerebellar tonsils can occur in the setting of elevated infratentorial pressure, which leads to extension of these cerebellar structures through the foramen magnum. In a review of 38 patients delivered in the perimortem period by cesarean section, the causes included trauma, cardiac abnormalities, embolism, magnesium overdose, sepsis, intracranial hemorrhage, anesthetic complications, eclampsia, and uterine rupture. The best way to ventilate patients with acute respiratory failure and restrictive lung disease has not been determined. There are differences in both myocardial architecture and function in systolic and diastolic heart failure, but clinical signs and symptoms cannot reliably differentiate between these two entities. Laparotomy in the third trimester was associated with a 50% risk for preterm delivery. When hemodynamic compromise (hypotension) resulting from increased intrapericardial pressure is present before surgery, management of anesthesia is as described for cardiac tamponade. Cardiac dysrhythmias range from acute sinus arrhythmia to ventricular premature beats or ventricular tachycardia. It has even been suggested that the hormonal stimulation of pregnancy may potentiate growth of this congenital tumor. Decisions about timing and mode of delivery should be made in a setting that involves a multidisciplinary team of nurses, maternal-fetal medicine specialists or obstetricians, anesthesiologists, and cardiologists. If intubation is planned, an anesthesiologist familiar with temporomandibular arthritis and rheumatoid cervical spine disease should be available. This secondary confirmatory process prevents inappropriate shocks in response to self-terminating events or spurious signals. Empiric administration of high-dose corticosteroids does not improve survival among unselected septic patients and may worsen outcomes due to secondary infection. Regular counseling of women with epilepsy is necessary during the reproductive years, because unplanned pregnancy may occur. Other than the inherited tendency to develop rheumatic illness, there are no other known risks to children of mothers with other rheumatic disease. Of note, apical cardiac function may be preserved, a phenomenon attributed to the paucity of sympathetic innervation at the cardiac apex. Embolectomy is rarely feasible for atheromatous embolism, because the atheromatous material usually fragments into very small pieces. Conversely, patients taking theophylline may require higher dosages of adenosine to produce a therapeutic effect because of competition with adenosine for receptor sites. Three (8%) were positive for papillary thyroid cancer, and nine (23%) were suspicious for papillary cancer or a follicular (Hurthle cell) neoplasm. Hypotension, tachycardia, cardiac dysrhythmias, and cyanosis are late signs of venous air embolism. Systemic embolization is also common as a result of the formation of mural thrombi in dilated and hypokinetic cardiac chambers. At delivery, the neonate may be asymptomatic or may display profound effects of blood loss, including high-output heart failure or hypovolemic shock. Delivery of the placenta usually produces prompt improvement, although in a few cases, when the disease is severe and advancing rapidly, symptoms may persist and even progress for several days to weeks after delivery. Maternal vitamin B12 deficiency during pregnancy and the puerperium may lead to a similar deficiency in the fetus and neonate. The highest-risk lesions are mitral and aortic stenosis, right-to-left intracardiac shunting, primary pulmonary hypertension or Eisenmenger syndrome,25 Marfan syndrome, and peripartum myocardial infarction. The abnormal viscoelastic properties of the sputum in patients with cystic fibrosis lead to sputum retention resulting in airway obstruction. There is no evidence that prophylactic antibiotics decrease the incidence of pulmonary infection or alter outcome. Although some studies report an incidence similar to that with open aortic surgery, others showed a lower rate with endovascular repair. With cardiac tamponade, the pressures within the cardiac chambers will eventually equilibrate. Laparoscopic appendectomy was first performed in 1980, and it spawned controversy about its use in pregnancy that continues to the present.