ITEMS IN AFP WITH MESH TERM:
ABSTRACT: In patients without established cardiac disease, the occurrence of premature ventricular complexes without sustained ventricular tachycardia is more an annoyance than a medical risk, and treatment is not required. In contrast, patients with established heart disease and premature ventricular complexes have a higher likelihood of developing ventricular tachycardia or fibrillation. These patients should be treated with a beta blocker or class I antiarrhythmic drug. Treatment of arrhythmias in pregnant women is rarely needed. When treatment is required, amiodarone should be avoided, and beta blockers should be used with caution, because these agents have been associated with fetal growth retardation. The most important rhythm abnormality in athletes is ventricular tachycardia associated with hypertrophic cardiomyopathy. If the presence of the disease is confirmed by echocardiography, beta-blocker therapy is necessary, and these patients should be limited to participation in nonstrenuous sports. Acute arrhythmias in children with Wolff-Parkinson-White syndrome can be treated with adenosine. Radiofrequency ablation of the accessory pathway can provide long-term control.
ABSTRACT: Genitourinary tract infections are one cause of preterm delivery. Prematurity is one of the leading causes of perinatal mortality in the United States. Uterine contractions may be induced by cytokines and prostaglandins, which are released by microorganisms. Asymptomatic bacteriuria, gonococcal cervicitis and bacterial vaginosis are strongly associated with preterm delivery. The role of Chlamydia trachomatis, Trichomonas vaginalis and Ureaplasma urealyticum is less clear. By adopting a rational approach to the diagnosis and treatment of genitourinary infections, family physicians can substantially decrease a patient's risk of preterm delivery.
Initial Management of Breastfeeding - Article
ABSTRACT: Breast milk is widely accepted as the ideal source of nutrition for infants. In order to ensure success in breastfeeding, it is important that it be initiated as early as possible during the neonatal period. This is facilitated by skin-to-skin contact between the mother and infant immediately following birth. When possible, the infant should be allowed to root and latch on spontaneously within the first hour of life. Many common nursery routines such as weighing the infant, administration of vitamin K and application of ocular antibiotics can be safely delayed until after the initial breastfeeding. Postpartum care practices that improve breastfeeding rates include rooming-in, anticipatory guidance about breastfeeding problems and the avoidance of formula supplementation and pacifiers.
Counseling Issues in Tubal Sterilization - Article
ABSTRACT: Female sterilization is the number one contraceptive choice among women in the United States. Counseling issues include ensuring that the woman understands the permanence of the procedure and knowing the factors that correlate with future regret. The clinician should be aware of the cumulative failure rate of the procedure, which is reported to be about 1.85 percent during a 10-year period. Complications of tubal sterilization include problems with anesthesia, hemorrhage, organ damage, and mortality. Some women who undergo tubal ligation may experience increased sexual satisfaction. While the procedure is commonly performed postpartum, it can be done readily, without relation to recent pregnancy, by laparoscopy or, when available, by minilaparotomy. Surgery should be timed immediately postpartum, or coincide with the first half of the woman's menstrual cycle or during a time period when the woman is using a reliable form of contraception.
Neonatal Herpes Simplex Virus Infections - Article
ABSTRACT: Neonatal herpes simplex virus infections can result in serious morbidity and mortality. Many of the infections result from asymptomatic cervical shedding of virus after a primary episode of genital HSV in the third trimester. Antibodies to HSV-2 have been detected in approximately 20 percent of pregnant women, but only 5 percent report a history of symptomatic infection. All primary episodes of HSV and secondary episodes near term or at the time of delivery should be treated with antiviral therapy. If active HSV infection is present at the time of delivery, cesarean section should be performed. Symptomatic and asymptomatic primary genital HSV infections are associated with preterm labor and low-birth-weight infants. The diagnosis of neonatal HSV can be difficult, but it should be suspected in any newborn with irritability, lethargy, fever or poor feeding at one week of age. Diagnosis is made by culturing the blood, cerebrospinal fluid, urine and fluid from eyes, nose and mucous membranes. All newborns suspected to have or who are diagnosed with HSV infection should be treated with parenteral acyclovir.
Epilepsy in Women - Article
ABSTRACT: Epilepsy in women raises special reproductive and general health concerns. Seizure frequency and severity may change at puberty, over the menstrual cycle, with pregnancy, and at menopause. Estrogen is known to increase the risk of seizures, while progesterone has an inhibitory effect. Many antiepileptic drugs induce liver enzymes and decrease oral contraceptive efficacy. Women with epilepsy also have lower fertility rates and are more likely to have anovulatory menstrual cycles, polycystic ovaries, and sexual dysfunction. Irregular menstrual cycles, hirsutism, acne, and obesity should prompt an evaluation for reproductive dysfunction. Children who are born to women with epilepsy are at greater risk of birth defects, in part related to maternal use of antiepileptic drugs. This risk is reduced by using a single antiepileptic drug at the lowest effective dose and by providing preconceptional folic acid supplementation. Breastfeeding is generally thought to be safe for women using antiepileptic medications.
ABSTRACT: Vaginal birth after cesarean section is common in this country. Physicians providing obstetric care should be aware of the potential complications. Uterine rupture occurs in approximately one of every 67 to 500 women (with one prior low-transverse incision) undergoing a trial of labor for vaginal birth after cesarean section. Rupture poses serious risks to mother and infant. There are no reliable predictors or unequivocal clinical manifestations of rupture, so physicians must maintain a high index of suspicion for possible rupture, especially in the presence of fetal bradycardia or other evidence of fetal distress. Management is surgery for prompt delivery of the infant and control of maternal hemorrhage. Newborns often require admission to an intensive care nursery. Prevention of poor outcomes depends on thorough anticipation and preparation. The physicians and the delivery institution should be prepared to provide emergency surgical and neonatal care in the event of uterine rupture.
ABSTRACT: The management of infants whose mothers are infected with the human immunodeficiency virus (HIV) involves minimizing the risk of vertical transmission of HIV, recognizing neonatal HIV infection early, preventing opportunistic infections, and addressing psychosocial issues. Maternal antiretroviral drug therapy during pregnancy and labor, followed by six weeks of neonatal zidovudine therapy, can significantly decrease the risk of vertical transmission. Additional antiretroviral drugs may be needed in some high-risk newborns. Elective cesarean section also may prevent vertical transmission of HIV. Virologic tests allow early diagnosis of HIV infection, facilitating the timely initiation of aggressive treatment and the prevention of opportunistic infections. Even when tests are negative, infants must be closely monitored until age 18 months to completely rule out HIV infection. Prophylaxis for Pneumocystis carinii pneumonia should be initiated when HIV-exposed infants are six weeks old and should be continued for at least four months, regardless of negative virologic tests, because P. carinii pneumonia is often the initial presentation of HIV infection in infants. Laboratory monitoring, screening for perinatal infections, appropriate social support, and other modifications of standard infant care are also necessary.
ABSTRACT: The National High Blood Pressure Education Program's Working Group on High Blood Pressure in Pregnancy recently issued a report implicating hypertension as a complication in 6 to 8 percent of pregnancies. Hypertension in pregnancy is related to one of four conditions: (1) chronic hypertension that predates pregnancy; (2) preeclampsia-eclampsia, a serious, systemic syndrome of elevated blood pressure, proteinuria and other findings; (3) chronic hypertension with superimposed preeclampsia; and (4) gestational hypertension, or nonproteinuric hypertension of pregnancy. Edema is no longer a criterion for preeclampsia, and the definition of blood pressure elevation is 140/90 mm Hg or higher. Patients with gestational hypertension have previously unrecognized chronic hypertension, emerging preeclampsia or transient hypertension of pregnancy, an obstetrically benign condition. Because distinguishing among these conditions can be done only in retrospect, clinical management of gestational hypertension consists of repeated evaluations to look for signs of emerging preeclampsia. Women with chronic hypertension should be followed for evidence of fetal growth restriction or superimposed preeclampsia. Management options for chronic hypertension in most women include discontinuing antihypertensive medications during pregnancy, switching to methyldopa or continuing previous antihypertensive therapy.
ABSTRACT: Traditionally, psychiatric medications were withheld during pregnancy because of fear of teratogenic and other effects. The emergence of evidence of the safety of most commonly used psychiatric medications, the availability of this information in the form of online databases, and the documentation of the adverse effects of untreated maternal mental illness have all increased the comfort of physicians and patients with respect to the use of psychiatric medications during pregnancy. The tricyclic antidepressants and fluoxetine (Prozac) appear to be free of teratogenic effects, and emerging data support similar safety profiles for the other selective serotonin reuptake inhibitors. The mood stabilizers appear to be teratogenic. With the exception of the known risk for depression to worsen in the postpartum period, there is little consistent evidence of the effects of pregnancy on the natural history of mental illness. Decisions regarding the use of psychiatric medications should be individualized, and the most important factor is usually the patient's level of functioning in the past when she was not taking medications.