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Peripheral edema and congestive hepatomegaly are the most prominent clinical manifestations. Similarly, in a series of 131 tumors, ultrasonography accurately identified 95% of dermoid cysts, 80% of endometriomas, and 71% of simple cysts during pregnancy, and, more importantly, it correctly suspected the only case of malignancy. The pregnant patient should be admitted to the hospital and a thorough investigation undertaken to determine the cause. In the resting state, the inside of a cardiac cell is negative relative to the outside. Diuretics must be administered very carefully, because diuretic-induced metabolic alkalosis, which encourages carbon dioxide retention, may aggravate ventilatory insufficiency by depressing the effectiveness of carbon dioxide as a stimulus to breathing. Continuous positive airway pressure is reserved for the prevention of postoperative pulmonary complications in patients who are not able to perform deep-breathing exercises or incentive spirometry. Short-term therapeutic goals in patients with heart failure include relieving symptoms of circulatory congestion, increasing tissue perfusion, and improving quality of life. Patients already diagnosed with this disease should undergo an updated cardiac evaluation before elective surgery. In some cases, there may be progressive disease with multisystem organ failure and possibly maternal death. Chest radiography is acceptable during pregnancy with appropriate abdominal and pelvic shielding. It is best for patients with acetaminophen overdose or hepatitis A and less favorable for other causes. This, in turn, requires aggressive therapy, including hypertension, hypervolemia, passive hemodilution, or invasive radiographic interventions. Typical infusion rates are 5% dextrose in lactated Ringer solution at a rate of 100 mL/hr and lispro or aspart insulin at 0. Truncus arteriosus results in unrestrictive left-to-right shunting of blood and pulmonary overcirculation. Because a subdural hematoma is usually caused by venous bleeding, normocapnia is desirable following evacuation of the hematoma to allow for a larger brain volume, which may help to tamponade any sites of venous bleeding. Fluid overload during the perioperative period may contribute to the development or worsening of heart failure. Patients with atrial flutter lasting longer than 48 hours should receive anticoagulant therapy and should be evaluated by transesophageal echocardiography for the presence of an atrial thrombus before any attempt at cardioversion is made. Anticoagulation is required in patients with mitral stenosis and atrial fibrillation, because the risk of embolic stroke in such patients is about 7% to 15% per year. The course of illness can vary: some women become depressed in pregnancy and continue to be symptomatic into the postpartum period. Estrogen reduces sebaceous gland size and activity, but this is probably a function of negative feedback on androgen production by the ovary. The atypical antidepressant bupropion in a sustained-release formulation can also aid in smoking cessation. The treatment and anesthetic implications are similar to those for chronic heart failure. Preload may not increase if the aorta is clamped distal to the celiac artery because the blood volume from the distal venous vasculature may be redistributed into the splanchnic circulation. Serosanguineous (exudative) fluid is typically seen when the pericardial disease is due to cancer, tuberculosis, or radiation exposure. The miscarriage rate in an update was not significantly different in treated or untreated women. Neoadjuvant chemotherapy can be considered before definitive surgery for women who present with locally advanced-stage disease. 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. Do not intervene to deliver immediately unless abruption or cord prolapse has occurred. Treatment with -adrenergic antagonists should be continued until the induction of anesthesia in patients receiving these drugs for prophylaxis against hypercyanotic attacks.

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It is commonly recommended that women who are currently taking systemic corticosteroids or who have received several short courses of systemic corticosteroids during pregnancy receive intravenous corticosteroids. Those who have smoked more than 60 pack-years have double the risk of any pulmonary complication and triple the risk of pneumonia compared with those who have smoked less than 60 pack-years. The headache in such patients is often an intermittent, dull, nonthrobbing ache that is exacerbated by exercise and may be associated with nausea or vomiting, but these features do not in themselves permit any reliable distinction from migraine. Because of the poorly defined risks of increased obstetric complications among pregnant epileptic women, close supervision of these patients by the obstetrician is mandatory, and delivery in a hospital is advised. Therefore, this test has a low predictive value for the diagnosis of heart failure. For some patients, it may be prudent to postpone until after the birth attempts to reduce therapy that is effectively controlling the asthma. Other causes of mitral regurgitation include endocarditis, mitral valve prolapse, trauma, congenital heart disease (such as an endocardial cushion defect), left ventricular hypertrophy, cardiomyopathy, myxomatous degeneration, systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, and carcinoid syndrome. Loughead and colleagues180 reviewed 16 cases of congenital hyperparathyroidism resulting from maternal hypocalcemia; bone features of hyperparathyroidism were documented in 13 cases. However, only a minority of patients with severe preeclampsia require supportive hemodialysis for the management of acute renal failure. The fistula may close spontaneously, but if it remains patent, embolization of the feeding vessels may help to relieve intolerable symptoms or failing vision. Oxytocin then induces contraction of the myoepithelial cells and mammary duct smooth muscle, resulting in milk ejection. Unfortunately, many of the medications used to treat bipolar disorder, including selected anticonvulsants such as valproate and carbamazepine, have teratogenic effects (described previously and in Chapter 31). Ketamine, because of its ability to stimulate the sympathetic nervous system and enhance left ventricular emptying, may cause an increase in prolapse and regurgitation. This type of transmission does not fit with an autosomal dominant pattern of inheritance. The early use of acyclovir was associated with an improved hospital course after the fifth day and a lower mean temperature, lower respiratory rate, and improved oxygenation. However, in patients who have relatively low intravascular volume, an increase in these parameters is observed, indicating fluid responsiveness. If intercostal muscle function is impaired, patients may be at high risk of postoperative hypoventilation and may have an impaired cough and a corresponding accumulation of secretions. Other physical findings include wheezing, fever, rales, a pleural rub, a loud pulmonic component of the second heart sound, a right ventricular lift, and bulging neck veins. Certain drugs such as cimetidine can also cause an increase in the plasma concentration of lidocaine. The resources available to address substance abuse, especially while pregnant, are often minimal, and many practitioners are reluctant to screen for a problem they cannot satisfactorily treat. Repair or replacement of the tricuspid valve in conjunction with closure of the interatrial communication is recommended for older patients who have severe symptoms despite medical therapy. Acute intermittent porphyria, inherited as an autosomal recessive trait, is characterized by increased production and urinary excretion of porphobilinogen and -aminolevulinic acid. Although there is impaired diastolic function and reduced ventricular compliance, systolic function is usually normal. Strokes and transient ischemic attacks caused by carotid stenosis occur as a result of atheroembolic phenomena or hemodynamically significant pressure drops across the stenosis in the absence of sufficient collateral cerebral blood flow. It has been suggested that the hyperventilation of pregnancy results primarily from progesterone acting as a respiratory stimulant. In blacks, the most common two-gene deletion state consists of one gene missing on each chromosome (trans). Tremors are characterized as rhythmic, alternating flexion and extension of the thumbs and other digits (pill-rolling tremor). In addition, direct mechanical airway stimulation by endotracheal intubation, parasympathetic nervous system activation, and/ or release of neurotransmitters of pain such as substance P and neurokinins may play a role. In patients in whom subarachnoid hemorrhage complicates otherwise normal pregnancies, the underlying source is less often an aneurysm than in nonpregnant patients with subarachnoid hemorrhage. The onset of these symptoms has been shown to correlate with an average time to death of 5, 3, and 2 years, respectively.

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The possibility of spinal cord hemangioblastomas may limit the use of spinal anesthesia, although epidural anesthesia has been described for cesarean section. Shimizu H: Prenatal diagnosis of epidermolysis bullosa, Prenat Diagn 26:1260, 2006. Pulsus paradoxus is a regular feature of cardiac tamponade but is often absent in constrictive pericarditis. Bone loss because of reduced formation or increased resorption may occur in estrogen-deficiency states, glucocorticoid-excess syndromes, thyrotoxicosis, and other circumstances. Surgical or radiation treatment of low-grade gliomas usually results in symptom-free long-term survival. Although there are no screening scales for schizophrenia in pregnant or postpartum women, the development of delusions or hallucinations should trigger a psychiatric evaluation. Plasma concentrations of testosterone and estradiol are decreased because of diminished binding activity, but their unbound fractions are increased. Thymectomy often leads to a remission of symptoms, and myasthenia gravis may be associated with thymoma. These guidelines are based on the best available evidence regarding this medical problem. Patients not responding optimally to treatment should be stepped up to more intensive medical therapy. The majority of the mortality and morbidity in these patients can be attributed to chronic difficulties, namely, cardiovascular causes such as chronic heart failure. Type A includes all cases in which the ascending aorta is involved by the dissection, with or without involvement of the arch or descending aorta. Continued activity of the ventricles is due to impulses from an ectopic pacemaker distal to the site of the conduction block. When myocardial ischemia that occurs intraoperatively does not respond to intravenous administration of phenylephrine or fluids, or the use of positive end-expiratory pressure, consideration may be given to temporary banding of the pulmonary artery to increase systemic and coronary blood flow. The prevalence of sinus node dysfunction may be as high as 1 in 600 patients older than 65 years of age. Placement of an intraarterial catheter to continuously monitor systemic blood pressure is recommended during treatment with potent vasoactive drugs. Blood products may be preferable, especially when anemia or coagulopathy require treatment. During periods of cellular hypoxia or anoxia, as occur with stroke, glucose is metabolized to lactic acid, which results in tissue acidosis and increased tissue injury. The inflow cannula is percutaneously placed in the femoral vein, advanced to the right atrium, and then positioned transseptally into the left atrium. At least three early-morning sputum samples should be examined for the presence of acid-fast bacilli. The incidence of dysrhythmias may be increased by metabolic or respiratory alkalosis. However, both have been associated with worse neonatal outcomes when administered repeatedly in large doses. In the event that cardiac pacing is delayed or pacing capabilities are limited, an epinephrine or dopamine infusion may be titrated to response while cardiac pacing is awaited. In women with biopsyproven dysplasia identified during pregnancy who have no evidence of invasion by colposcopy, management may consist of serial colposcopy examinations with intermittent cervical cytology and expectant management of the pregnancy. Intravascular fluid volume should be maintained at normal levels, since these patients are preload dependent. This form of heart disease continues to be an important cause of perioperative morbidity and mortality. Myomas are often classified on the basis of their location in relationship to the uterine cavity.

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However, caution must be used when administering -blockers to patients with reactive airway disease, diabetic patients with frequent hypoglycemic episodes, and patients with bradydysrhythmias or heart block. The most widely available screening test for celiac disease is the antiendomysial IgA test. It occurs against a background of low initial maternal intrathyroid iodine stores, the increased need for iodine after pregnancy occurs, and an insufficiency of iodine intake throughout the gestation. The surgeon must be familiar with pelvic vascular anatomy to avoid ureteral injury or inadvertent ligation of the common or exterior iliac artery, which will obstruct blood flow to the lower extremity. Patients with ascending aortic aneurysms associated with dilation of the aortic valve annulus may have signs of aortic regurgitation and congestive heart failure. Screening for microalbuminuria can be performed by three methods: measurement of the albumin-tocreatinine ratio in a random spot collection; 24-hour urine collection with serum creatinine, allowing the simultaneous measurement of creatinine clearance; and timed (4-hour or overnight) collection. It is usually caused by dysfunction of regions of the brain that are responsible for maintaining consciousness, such as the pontine reticular activating system, midbrain, or cerebral hemispheres. The common alternative diagnosis is dyspnea of pregnancy, which is not associated with cough, wheezing, chest tightness, or airway obstruction. Moreover, a case-control study of myomas larger than 5 cm detected prospectively at routine sonographic screening found no significant association between myomas and abruption. Gastrointestinal perfusion may be compromised during periods of hypotension from any type of shock, leading to a compromise in intestinal mucosal integrity and subsequent translocation of vasoactive substances and gut bacteria. Low-dosage computer tomography has high sensitivity and specificity with relatively low risk for fetal harm, but it should be considered only if other measures are inconclusive. Difficulty in diagnosing causative factors and reversing this phenomenon explains the high mortality rates for patients with shock. If the results indicate overt diabetes, treatment should be as for preexisting diabetes. The prognosis of the limb is determined by the extent of arterial disease, the severity of limb ischemia, and the feasibility and rapidity of restoring arterial circulation. 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. Although vasopressin is widely used in treating septic shock and results in higher systemic pressures than when it is not used, the outcome data supporting its use are controversial, with most efficacy demonstrated in less severe cases. Mechanical valves are composed primarily of metal or carbon alloys and are classified according to their structure, such as caged-ball, single tilting-disk, or bileaflet tilting-disk valves. Prenatal diagnosis is confirmed by measuring 11-deoxycortisol concentrations in amniotic fluid. Pregnancy should be delayed for at least 1 year after transplantation because pregnancies occurring within that period have an increased incidence of prematurity, low birth weight, and acute cellular rejection compared with those occurring later than 1 year. Few pregnant patients with gastrointestinal disorders need gastrointestinal endoscopy, but if they do, the main risks are related to the endoscopy itself. Management of anesthesia in patients with syringomyelia or syringobulbia should consider the neurologic deficits associated with this disease. MovementDisorders When dystonia develops during pregnancy, it usually manifests acutely as a consequence of treatment with antiemetic dopamine antagonists. Cyclophosphamide therapy has been tried because of the autoimmune nature of the disease. During the monitoring period, anesthesia should be managed with agents such as narcotics, nitrous oxide, droperidol, diphenhydramine, and possibly dexmedetomidine. Arrows indicate initiation of a spontaneous breath by the patient, who triggers the ventilator to deliver a mechanically assisted breath. The highest maternal mortality rates occur in states with higher percentages of births for African-American women. Hyperventilation is spontaneous and may be so severe that the Paco2 is decreased to less than 20 mm Hg. Hypovolemia may be present since these patients avoid oral intake and its associated pharyngeal stimulation in an attempt to avoid triggering the pain attacks. Buckshee K, Chadha S: Post-tonsillitic erythema nodosum in pregnancy, Int J Gynaecol Obstet 55:293, 1996.

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Succinylcholine should be used with caution in patients with preexisting neurologic deficits resulting from the risk of hyperkalemia. Death typically occurs by the third decade of life and is usually the result of myocardial hemochromatosis. Most recommendations regarding dietary therapy are based on common sense and experience. If the desired effect of reduced symptomatology with carotid massage is obtained, then the nerve can be ablated with alcohol. Pregnancy may be followed by the development of choriocarcinoma, which commonly metastasizes to the brain (see Chapter 56). Numerous pregnancies resulted from restoring normal gonadal function in these women, and in the 1980s, information about these pregnancies was consolidated. Broad and notched P waves (P mitrale) suggest the presence of left atrial enlargement typical of mitral valve disease. These infants typically require supplemental tube feedings by nasogastric, nasojejunal, or gastrostomy feeding tube. Because of the need for many tertiary care services, maternal morbidity is reduced when delivery occurs in a hospital with blood bank capabilities, anesthesiology services available regardless of time or day, and ready access to surgical specialists. Occasionally, refusal by an infant to nurse from a lactating breast may signify an occult carcinoma; this has been described as the milk rejection sign. Perinatal complications such as preterm birth have been found among women who were treated with antipsychotic agents, particularly older, highpotency agents. A small number of patients have persistent skeletal muscle weakness and are susceptible to recurring episodes of respiratory failure in association with pulmonary infection. In the presence of an acceptable ventricular rate and an adequate cardiac output, no treatment is needed. Amiodarone is metabolized in the liver and slows the metabolism and increases the blood levels of other drugs metabolized by the liver, such as warfarin, digoxin, diltiazem, quinidine, procainamide, disopyramide, mexiletine, and propafenone. Therefore, these patients are preload dependent and require adequate intravascular volume. The sympathomimetic effects of nicotine on the heart are transient, lasting only 20 to 30 minutes. Mannisto T, Vaarasmaki M, Pouta A, et al: Perinatal outcome of children born to mothers with thyroid dysfunction or antibodies: a prospective population-based cohort study, J Clin Endocrinol Metab 94:772, 2009. Anticholinergic drugs should be immediately available to treat these vagally mediated responses. However, the increased cardiac wall tension produced by an enlarged ventricular radius is associated with increased myocardial oxygen requirements and decreased pumping efficiency. Grimes and Brooks61 reviewed the pregnancies of their patients with Sheehan syndrome. Bleeding originates in the subependymal germinal matrix but may rupture through the ependyma into the ventricular system. For patients with preeclampsia, many anesthesiologists are comfortable placing neuraxial blocks with platelet counts as low as 75,000/mm3, provided the count is stable and not falling and that there are no signs of clinical bleeding at venipuncture sites, gums, or other locations. Tadalafil (Adcirca), a long-acting phosphodiesterase 5 inhibitor, is similarly well tolerated. Cross-clamping of the thoracic aorta just distal to the left subclavian artery is associated with severe decreases (approximately 90%) in spinal cord blood flow and renal blood flow, glomerular filtration rate, and urinary output. Prenatal diagnosis and treatment of pulmonary hypoplasia are discussed in Chapter 35. This passage of air from the right to left circulation is known as paradoxical air embolism. Digoxin has a low therapeutic/toxic ratio (therapeutic index), especially in the presence of hypokalemia. The serum levels of other proteins, such as ceruloplasmin and transferrin, also increase with gestation. The increased blood flow and near systemic pressure to the pulmonary vasculature can lead to irreversible vascular changes and elevated pulmonary vascular resistance.

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Cardiac catheterization and selective angiocardiography are the most definitive diagnostic procedures available for use in patients with congenital heart disease. Levels of nonspecific antibacterial proteins such as lysozyme and lactoferrin are low. All other agents are category C drugs, and unless the potential risks and benefits of oral antidiabetic agents in the preconception period have been carefully weighed, they usually should be discontinued in pregnancy. Parallel with the development of the prolactin assay and improved radiologic techniques for diagnosing these tumors came the development and refinement of transsphenoidal microsurgical techniques and a powerful new drug, bromocriptine mesylate, which can suppress elevated prolactin concentrations to normal levels. A threshold value of 135 mg/dL or 140 mg/dL can be used at the discretion of the provider. However, depression of intercostal muscle function may have special implications in these patients. Fasting and premeal plasma glucose levels were usually lower than 80 mg/dL and often lower than 70 mg/dL. Patients with mediastinal adenopathy often notice increasing shortness of breath or cough, symptoms common in normal pregnancies, which may delay diagnosis in pregnant women. The major disadvantage of drug discontinuation is a potential loss of blood pressure control. Stimulation of the various nuclei within the basal ganglia via an implanted deep brain stimulating device can relieve or help to control tremor. Thrombolytic therapy may be considered to hasten dissolution of pulmonary emboli, especially if there is hemodynamic instability or severe hypoxemia. A digoxin-specific antibody is available for treatment of severe digitalis toxicity. In all pregnant women, the continuing fetal consumption of glucose from the maternal bloodstream results in a steady downward drift in maternal glucose levels unless feeding occurs. Other laboratory abnormalities can include elevated levels of creatine phosphokinase, cholesterol, and carotene and liver function abnormalities. Hemothorax can result from trauma to the great vessels or other vascular structures. Nitrous oxide can evoke some pulmonary vasoconstriction and increase pulmonary vascular resistance if pulmonary hypertension is present. The suppressibility of cortisol was shown to be 40% after 1 mg of dexamethasone in second- and third-trimester normal pregnancies, compared with 80% in nongravid controls; loss of suppression increased with increasing gestation. Tumors with symptoms consistently related to pregnancy are usually located so that only slight enlargement leads to significant involvement of important neural structures. Schlumberger M, deVathaire F, Ceccarelli C, et al: Exposure to radioactive iodine 131I for scintigraphy or therapy does not preclude pregnancy in thyroid cancer patients, J Nucl Med 37:606, 1996. In addition, urinary losses of electrolytes, particularly potassium, may occur, and thus careful monitoring and replacement are required. A preprandial glucose level of 130 mg/dL would require 1 U lispro more than the prescribed dose for that meal. Cyclosporine (or tacrolimus, although data for it are more limited) and steroids, with or without azathioprine, form the basis of immunosuppression during pregnancy. Furthermore, there were no differences in need for insulin therapy or in birth weight between the intervention and control groups. Permissive hypercapnia is not recommended in patients with increased intracranial pressure, cardiac dysrhythmias, or pulmonary hypertension. The decision should be based on the stability of the fracture and presence of pelvic deformities. Pregnancy should not alter any necessary evaluations or treatments for the mother. Although the 2% to 10% incidence of asymptomatic bacteriuria in pregnant women-defined as significant growth of a urinary bacterial isolate in the absence of symptoms-is the same as in sexually active nonpregnant women,1 this condition more often results in ascending pyelonephritis in pregnancy. The course may be subacute, with relapses followed by remissions, or the course may be chronic and progressive. Consisting of two lobes and connected by the isthmus, it weighs approximately 20 to 25 g. Although some clinicians often remove them in the second trimester because of the risk for complications, even large and complex masses may be followed expectantly if they appear to be benign.

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Kato T, Seki K, Matsui, et al: Monomeric calcitonin in pregnant women and in cord blood, Obstet Gynecol 92:241, 1998. Measurements of lung function can be very helpful in assessing the severity of status asthmaticus and the response to treatment. Sivojelezova A, Shuhaiber S, Sarkissian L, et al: Citalopram use in pregnancy: prospective comparative evaluation of pregnancy and fetal outcome, Am J Obstet Gynecol 193:2004, 2005. The alternative thionamide can be used, although cross-sensitivity occurs in 50% of patients. Hypotonic and glucose-containing solutions should be avoided, since the former can exacerbate cerebral edema and the latter can worsen the outcome of neurologic ischemia. Treatment is not very effective, but bilateral anterior rhizotomy at C1 and C3, with a sectioning of the spinal accessory nerve, may be attempted. Numerous case reports illustrating the influence of pregnancy on these lesions have been published. Before widespread use of the rubella vaccine, rubella was an epidemic disease, with most infections occurring in children. The phosphodiesterase inhibitors amrinone and milrinone increase myocardial contractility and are excellent pulmonary artery vasodilators. This hypotension has been responsive to fluid infusion and administration of sympathomimetic drugs. Eliciting the oculovestibular reflex will result in tonic conjugate eye movements toward the side of cold water irrigation of the external auditory canal. The innervation of the lung, the lymphatic drainage of the lung, and the bronchial circulation are disrupted when the donor pneumonectomy is performed. Immunosuppressive therapy, such as cyclosporin and tacrolimus, that is commonly used in liver transplant recipients does not appear to be teratogenic, and breastfeeding is advocated. The possibility of a familial incidence of multiple sclerosis is widely recognized, but this pattern is uncommon and tends to involve siblings rather than different generations. Infants of diabetic mothers also appear to have disorders of catecholamine and glucagon metabolism and have diminished capability to mount normal compensatory responses to hypoglycemia. Surgery in patients with asymptomatic aortic regurgitation may not require invasive monitoring. When flow rates during inspiration are added to these curves, flow-volume loops are obtained. Azathioprine does not appear in breast milk,217 but cyclosporine and tacrolimus do. The changing and unpredictable neurologic presentation of patients with multiple sclerosis during the perioperative period must be appreciated when regional anesthetic techniques are selected. The unbound fraction also increases and is reflected by an increase in the urinary free cortisol level. The most plausible explanation for this effect is a drug-induced decrease in systemic vascular resistance and afterload, and increased venous capacitance. One third of myomas larger than 5 cm grow during pregnancy, but less than 10% of myomas smaller than 5 cm grow. Hydroxyethyl starch (hetastarch) is a synthetic molecule available in a 6% solution in normal saline (Hespan) or lactated electrolyte solution (Hextend). Postural drainage is useful to assist in expectoration of secretions that pool distal to the diseased airways. Regular counseling of women with epilepsy is necessary during the reproductive years, because unplanned pregnancy may occur. There are also changes in synapses and in the activity of several major neurotransmitters, especially involving acetylcholine and central nervous system nicotinic receptors. In others, treatment can be delayed until after delivery or until a gestational age at which delivery will not produce significant morbidity. Pneumonia in pregnancy has several causes, including mumps, infectious mononucleosis, swine influenza, influenza A, varicella, coccidioidomycosis, and other fungi. Although balloon dilation is a therapeutic alternative, the procedure is associated with a higher incidence of subsequent aortic aneurysm and recurrent coarctation than is surgical resection. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. However, data from other series support the conclusion that delivery does not uniformly result in significant maternal improvement.

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Cardiac tamponade may present whenever pericardial fluid accumulates under pressure. In women with microalbuminuria that precedes the pregnancy, urinary protein excretion may increase 10-fold, with 20% to 30% of patients developing nephrotic-range proteinuria (>3. Local measures, including skin protectants and topical anesthetics, can improve symptoms. If the findings of such investigations are unremarkable, discuss the controversial issue of anticonvulsant drug treatment with the patient but generally recommend that treatment be withheld unless a future attack occurs. For women with advanced cervical cancer who present in the second half of pregnancy, delay of therapy for fetal maturity carries a small but unquantifiable risk of adverse cancer outcome. Hypotension resulting from carotid sinus hypersensitivity is usually treated with vasopressors such as phenylephrine. For diabetic women with cardiac involvement, pregnancy outcome is dismal, with a maternal mortality rate of 50% or higher and perinatal loss rates approaching 30%. Currently in the United States 150,000 patients are listed as candidates for cardiac transplantation, but only 2000 hearts are available per year. Treatment of a flail chest includes positive pressure ventilation until a definitive stabilization procedure can be carried out or the rib fractures are stabilized. In one study, psoriasis remained unchanged during pregnancy in 43% of patients, improved in 41%, and worsened in 14%. Preeclampsia Preeclampsia occurs two to four times as frequently in women with pregestational diabetes as in those without diabetes. In preeclamptic patients, the pressure can decrease to 18 mm Hg by term and drop further to 14 mm Hg after delivery. Cardiopulmonary bypass may be needed if cardiac or respiratory instability develops during the procedure. Treatment is symptomatic, and mild cases usually respond to adequate skin lubrication and topical antipruritics. In addition to the impedance caused by the chest wall (the skin and fat overlying the bone), the electrical current encounters some increase in impedance from air spaces within the lung tissue in the current path. All patients experiencing fever or unexpected sore throat on therapy should discontinue the drug and have white blood cell count monitoring. The most commonly used drugs for this purpose are -blockers, calcium channel blockers, and digoxin. The V1 receptors are also found in the myometrium, kidneys, bladder, adipocytes, hepatocytes, platelets, and spleen. As with immune responses, it may take 6 weeks or longer for hepatic enzyme activity to return to normal following cessation of smoking. 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 hypothyroid phase can be marked by fatigue, hair loss, depression, impairment of concentration, and dry skin. Most patients eventually make a good recovery, but it may take many months, and some patients have persistent disability. This has been attributed to its high maternal protein binding, its rapid clearance rate, and the role of placental efflux transporters such as the breast cancer resistance protein. Current flows from the negative pole (active lead) to stimulate the heart, then returns to the positive pole (the casing of the pulse generator). Among 312 pregnancies, there was no increase in the number of birth defects and no consistent pattern of congenital abnormalities. The prognostic significance of ventricular ectopy depends on the presence and severity of co-existing structural heart disease. Monitoring in patients with essential hypertension is influenced by the complexity of the surgery. Concentrations of 4-androstenedione, testosterone, and 17-hydroxyprogesterone are used to monitor adequacy of suppression.