Plasmapheresis during pregnancy

Q: A 32-year-old female, first-time, 26 weeks pregnant, with a known history of Myasthenia Gravis (MG), presented with severe myasthenia crisis requiring intubation. Plasmapheresis should not be performed during pregnancy.

 

A) True

B) False

Answer: B

Two major rescue therapies for myasthenic crisis are:

• Plasmapheresis 
• High-dose intravenous immune globulin

They are both safe in pregnancy.

#Ob-gyn

#neurology

References:

1. Varner M. Myasthenia gravis and pregnancy. Clin Obstet Gynecol 2013; 56:372.

2. Sanders DB, Wolfe GI, Benatar M, et al. International consensus guidance for management of myasthenia gravis: Executive summary. Neurology 2016; 87:419.

3. Watson WJ, Katz VL, Bowes WA Jr. Plasmapheresis during pregnancy. Obstet Gynecol 1990; 76:451.

catamenial epilepsy

Q: Catamenial epilepsy occurs more frequently in which phase of the menstrual cycle?

A) early 

B) mid

C) late

Answer: C

Catamenial epilepsy can best be predicted by keeping a seizure diary. In a regular menstrual cycle, estrogen levels peak during mid-cycle (without conception) and drop just before the onset of menses. During this period, most seizure clusters are reported. Although a periovulatory seizure may occur. 

Standard treatment of seizures should be sufficient.

Use of Clobazam during the vulnerable phase of the menstrual cycle has shown some promise. 20 to 30 mg of Clobazam per day for 10 days during the high-risk phase of the menstrual cycle has been found to be effective. Intermittent lorazepam may also be used in the vulnerable period.

Some experts recommend the use of an adjunctive continuous estrogen-progestin contraceptive as hormonal prophylaxis for catamenial epilepsy, though evidence is weak for such practice. Other recommended treatments, but with very limited data, are acetazolamide, gonadotropin analogs, and neurosteroids (ganaxolone).

#neurology

#ob-gyn

References:

1. Herzog AG, Fowler KM, Sperling MR, et al. Variation of seizure frequency with ovulatory status of menstrual cycles. Epilepsia 2011; 52:1843.

2. Maguire MJ, Nevitt SJ. Treatments for seizures in catamenial (menstrual-related) epilepsy. Cochrane Database Syst Rev 2021; 9:CD013225.

3. Herzog AG, Fowler KM, Smithson SD, et al. Progesterone vs placebo therapy for women with epilepsy: A randomized clinical trial. Neurology 2012; 78:1959.

4. Feely M, Calvert R, Gibson J. Clobazam in catamenial epilepsy. A model for evaluating anticonvulsants. Lancet 1982; 2:71.

5. Ansell B, Clarke E. Acetazolamide in Treatment of Epilepsy. Br Med J 1956; 1:650.

6. Reddy DS. Neurosteroid replacement therapy for catamenial epilepsy, postpartum depression and neuroendocrine disorders in women. J Neuroendocrinol 2022; 34:e13028.

Parovirus 19 fetal severe anemia

Q: A 24-year-old female with 22 weeks of pregnancy is admitted to the ICU with severe symptoms of Parvovirus 19, confirmed with a high IgM titer but a negative IgG titer. There is a severe fetal anemia, and thrombocytopenia is suspected. How should the blood transfusion be given? -select one

A) Slow Intravenous 

B) Intrauterine

C) Plasmapheresis

Answer: B

Usually, a fetus can handle mild to moderate anemia without any major intervention. Severe fetal anemia can lead to hydrops fetalis. Noninvasive methods to detect fetal anemia are:

• Doppler middle cerebral artery (MCA) peak systolic velocity (PSV), and 
• ductus venosus velocity  

Invasively, cord blood sampling can be performed via percutaneous umbilical venous sampling, but is reserved for suspected severe cases requiring intervention.

Interesting, blood transfusions in such situations are given directly via intrauterine. Intrauterine transfusion is possible only after 18 weeks of pregnancy due to the small vessel size prior to it.

The authors of this question highly encouraged students to review reference #4 below.

#Ob-gyn

References:

1. Fairley CK, Smoleniec JS, Caul OE, Miller E. Observational study of effect of intrauterine transfusions on outcome of fetal hydrops after parvovirus B19 infection. Lancet 1995; 346:1335.

2. Rodis JF, Borgida AF, Wilson M, et al. Management of parvovirus infection in pregnancy and outcomes of hydrops: a survey of members of the Society of Perinatal Obstetricians. Am J Obstet Gynecol 1998; 179:985.

3. von Kaisenberg CS, Jonat W. Fetal parvovirus B19 infection. Ultrasound Obstet Gynecol 2001; 18:280.

4. Devlieger R, Vergote S, Van den Eede E, Haenen K, Lewi L. Intrauterine transfusion: Best practices, techniques, and evolving trends. Best Pract Res Clin Obstet Gynaecol. 2026 Feb;104:102686. doi: 10.1016/j.bpobgyn.2025.102686. Epub 2025 Nov 20. PMID: 41289715.

HEV in pregnancy

Q: Hepatitis E virus (HEV) infection is most life-threatening in pregnancy when it occurs in? - select one

A) First trimester

B) Second trimester

C) Third trimester

Answer: C

HEV infection in pregnancy is unusually associated with high mortality up to 25 percent. Pregnant patients are more prone to developing acute hepatic failure if they contract HEV. Liver failure is more common during the third trimester of pregnancy. Fortunately, in endemic areas, if a female child is exposed to HEV early in life, it reduces the risk of acute liver failure in pregnancy if re-infected later in life.

In endemic countries, poor nutritional status and lack of access to medical care also play a part in this high mortality.

#hepatology

#Ob-gyn

#ID

References:

1. Khuroo MS, Teli MR, Skidmore S, et al. Incidence and severity of viral hepatitis in pregnancy. Am J Med 1981; 70:252.

2. Patra S, Kumar A, Trivedi SS, et al. Maternal and fetal outcomes in pregnant women with acute hepatitis E virus infection. Ann Intern Med 2007; 147:28.

3. Navaneethan U, Al Mohajer M, Shata MT. Hepatitis E and pregnancy: understanding the pathogenesis. Liver Int 2008; 28:1190.

Thyroid and Recurrent Pregnancy loss connection

Case: 36 years old woman is admitted to the ICU for severe depression and suicidal ideation since she had three consecutive losses of pregnancy. All lab work appears relatively stable except for mild thyroid-stimulating hormone (TSH) elevation of 5.2 mIU/L.   

Discussion: Interestingly, thyroid health is highly related to pregnancy health. Even in mild and clinically asymptomatic hypothyroidism, the incidence of spontaneous miscarriage is high. 

Also, in euthyroid females with thyroid peroxidase (TPO) antibodie,s the risk can be doubled to tripled. 

Fortunately, with thyroid treatment, the risk can be minimized.

#ob-gyn

#endo

#psychiatry

References:

1. Negro R, Schwartz A, Gismondi R, et al. Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 in the first trimester of pregnancy. J Clin Endocrinol Metab 2010; 95:E44.

2. Chen L, Hu R. Thyroid autoimmunity and miscarriage: a meta-analysis. Clin Endocrinol (Oxf) 2011; 74:513.

3. Thangaratinam S, Tan A, Knox E, et al. Association between thyroid autoantibodies and miscarriage and preterm birth: meta-analysis of evidence. BMJ 2011; 342:d2616.

4. Bliddal S, Feldt-Rasmussen U, Rasmussen ÅK, et al. Thyroid Peroxidase Antibodies and Prospective Live Birth Rate: A Cohort Study of Women with Recurrent Pregnancy Loss. Thyroid 2019; 29:1465.

Ectopic pregnancy - medical Rx

Q: A female, 21 years old presented to ER with suspicion of ectopic pregnancy. Ob-Gyn service is considering surgical vs medical approach after the 'expectant management' is ruled out. Which is the drug of choice for medical management of an ectopic pregnancy?

Answer: Methotraxate (MTX)

ΜTX is a folic acid antagonist. It is clinically used in other medical conditions as well, such as neoplasia, severe psoriasis, and rheumatoid arthritis (RA). It inhibits deoxynucleic acid (DNA) synthesis and cell reproduction, primarily in actively proliferating cells such as malignant cells, trophoblast cells which are rapidly proliferating fetal cells (cytotrophoblast and syncytiotrophoblast). One of the advantages of MTX is its rapid renal clearance. 

Paradoxically, to its mechanism of action, reduced folates (leucovorin, also called folinic acid, N5-formyl-tetrahydrofolate, citrovorum factor) are given in combination with МΤX. This bypasses the metabolic block induced by МΤX and rescues normal cells from toxicity.

ΜТX is usually given intramuscularly (IM) but can be given intravenously, orally, and in some cases directly into the ectopic рrеgոanϲy sac either transvaginally or transabdominal through a laparoscope which is the preferred method mostly implied.

A pharmacy service should be consulted for dosage.

#ob-gyn

References:

1. Bleyer WA. The clinical pharmacology of methotrexate: new applications of an old drug. Cancer 1978; 41:36.

2. Hajenius PJ, Mol F, Mol BW, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007; :CD000324.

3. Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing "single dose" and "multidose" regimens. Obstet Gynecol 2003; 101:778.

PPCM

Q: The most commonly used definition of Peripartum Cardiomyopathy (PPCM) requires the development of heart failure (HF) towards the end of pregnancy or within _________ month(s) following delivery. (select one)

A) One

B) Two 

C) Three

D) Four

E) Five 

Answer: E

The definition developed by the 2010 European Society of Cardiology (ESC) Working Group on Peripartum Cardiology is widely used. It has been included in the 2018 ESC guidelines on managing cardiovascular diseases during pregnancy and in the position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy (PPCM). It requires all three conditions:

- Development of HF in the last month of pregnancy (or toward the end of pregnancy) or within five months following delivery.

- Absence of another identifiable cause for the HF.

- Left ventricular (LV) systolic dysfunction with LV ejection fraction (LVEF) of less than 45 percent, with or without LV dilation.

#cardiology

#ob-gyn

References:

1. Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010; 12:767.

2. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Kardiol Pol 2019; 77:245.

3. Bauersachs J, König T, van der Meer P, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail 2019; 21:827.

PREGNANCY-ASSOCIATED RISK MARKERS for ASCVD

Q: All of the following are the PREGNANCY-ASSOCIATED RISK MARKERS for atherosclerotic cardiovascular disease (ASCVD) in the future EXCEPT? (select one)

A) Hypertensive disorders of pregnancy 

B) Gestational diabetes

C) Preterm delivery 

D) Placental abruption

E) Lactation

Answer: E

Although emerging data shows that males and females carry almost the same burden of risks for ASCVD, females have some particular risk markers for ASCD, including.

• preeclampsia 
• gestational hypertension
• gestational diabetes 
• preterm delivery 
• delivery of infants with fetal growth restriction
• placental abruption
• spontaneous pregnancy loss
• stillbirth

These associations may be due to either the risk of developing a chronic state after pregnancy is over, such as HTN and DM or to procoagulant and proinflammatory states associated with some of these conditions.

Lactation is found to have a protective effect.

#cardiology

#obgyn

References:

1. Parikh NI, Gonzalez JM, Anderson CAM, et al. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e902.

2. Crump C, Sundquist J, McLaughlin MA, et al. Adverse pregnancy outcomes and long term risk of ischemic heart disease in mothers: national cohort and co-sibling study. BMJ 2023; 380:e072112.

3. Nguyen B, Jin K, Ding D. Breastfeeding and maternal cardiovascular risk factors and outcomes: A systematic review. PLoS One 2017; 12:e0187923.

D&C risks

Q: 26 years old patient has been taken to Obstetrics-OR for Dilatation and Curettage (D&C) for termination of molar pregnancy. The ICU team has been called due to perforation of uterus during the procedure. Pregnant uterus tends to have a higher rate of perforation?

A) True

B) False

Answer: A

Uterine perforation is the common immediate complication of D&C. As expected, it is high when emergent D&C is required such as in postpartum hemorrhage particularly in case of a molar pregnancy because uterus is more friable in molar pregnancy. 

In contrast to diagnostic D&C, pregnant uterus tends to perforate more as the uterine wall is soft and bulkier. The risk of perforation rises higher in proportion to advancement of pregnancy. 

Management is either observation or surgical, depending on the level of perforation, risk of surgical procedure, and level of available institutional support/backup.

#Ob-gyn

#surgical-critical-care

References:

1. Ben-Baruch G, Menczer J, Shalev J, et al. Uterine perforation during curettage: perforation rates and postperforation management. Isr J Med Sci 1980; 16:821.

2. Hefler L, Lemach A, Seebacher V, et al. The intraoperative complication rate of nonobstetric dilation and curettage. Obstet Gynecol 2009; 113:1268.

3. Kaali SG, Szigetvari IA, Bartfai GS. The frequency and management of uterine perforations during first-trimester abortions. Am J Obstet Gynecol 1989; 161:406.

TOA in older patients

 Q: 64 years old postmenopausal woman presented with abdominal pain and sepsis-like picture. CT scan of abdomen raises high suspicion of Tubo-Ovarian abscess (TOA). What is the biggest concern? 

 Answer: Malignancy

Age plays an important role in the causality of TOA. Premenopausal patients develop TOA mostly due to Pelvic Inflammatory Disease (PID). TOA in postmenopausal women raises a strong suspicion of underlying malignancy. These patients should be strongly considered for full staging procedure besides treatment of TOA with antibiotics and/or drainage of the abscess.

If surgery is performed it requires an experienced surgeon who can explore the abdomen and pelvis fully to evaluate for metastatic disease and staging for cancer.

#surgical-critical-care

#ob-gyn

Reference:

Protopapas AG, Diakomanolis ES, Milingos SD, et al. Tubo-ovarian abscesses in postmenopausal women: gynecological malignancy until proven otherwise? Eur J Obstet Gynecol Reprod Biol 2004; 114:203.

AUB and SIS

 Q: 48 years old female is admitted to ICU with severe abnormal uterine bleeding (AUB). Ob-Gyn service is called while ICU service worked on hemodynamic stabilization. At the bedside service requests for sterile saline. What is the purpose of sterile saline in Ob-Gyn examination and in AUB?

Answer: Instilling sterile saline directly into the uterine cavity via the cervix during ultrasound of the uterus enhances endometrial visualization. It helps in delineate different endometrial pathologies like polyps, hyperplasia, cancer, leiomyomas, or adhesions. A recent version of Saline Infusion Sonography (SIS) is to replace saline with hydroxyethylcellulose gel, which provides a relatively more stable filling of the uterine cavity and does not require continuous installation. In severe AUB a balloon tamponade can be used with saline infusion to control heavy bleeding. 

Although SIS is a very safe procedure in experienced hands there is always a concern about disseminating infection and carcinoma. SIS may give rise to false diagnoses due to blood clots, debris, mucus plugs, and other artifacts.

#Ob-Gyn

References:

1. American College of Obstetricians and Gynecologists. ACOG Technology Assessment in Obstetrics and Gynecology No. 5: sonohysterography. Obstet Gynecol 2008; 112:1467. 

2. Guideline developed in collaboration with the American College of Radiology, American College of Obstetricians and Gynecologists, Society of Radiologists in Ultrasound. AIUM Practice Guideline for the Performance of Sonohysterography. J Ultrasound Med 2015; 34:1.

3. Chawla I, Tripathi S, Vohra P, Singh P. To Evaluate the Accuracy of Saline Infusion Sonohysterography (SIS) for Evaluation of Uterine Cavity Abnormalities in Patients with Abnormal Uterine Bleeding. J Obstet Gynaecol India. 2014;64(3):197-201. doi:10.1007/s13224-013-0501-4 

4. Alcázar JL, Errasti T, Zornoza A. Saline infusion sonohysterography in endometrial cancer: assessment of malignant cells dissemination risk. Acta Obstet Gynecol Scand 2000; 79:321.

Remdesivir in pregnancy

 Q: During COVID-19 treatment Remdesivir should be avoided in pregnancy? 

A) True 

B) False

Answer: B

Management in pregnancy is not much different than in any other patient with COVID-19, though extra caution is needed. So far experience in COVID-19 and with previous viruses in the past such as the Middle East respiratory syndrome (MERS), Ebola, and Marburg virus, remdesivir is found to be safe at any stage of pregnancy.

COVID-19 literature continues to evolve fast. Readers are advised to consult updated guidelines before making any clinical decision.

#ob-gyn

#COVID

#pharmacology

References:

1. Igbinosa I, Miller S, Bianco K, et al. Use of remdesivir for pregnant patients with severe novel coronavirus disease 2019. Am J Obstet Gynecol. 2020;223(5):768-770. doi:10.1016/j.ajog.2020.08.001 

2.  Sheahan TP, Sims AC, Graham RL, et al. Broad-spectrum antiviral GS-5734 inhibits both epidemic and zoonotic coronaviruses. Sci Transl Med 2017; 9. 

3. Mulangu S, Dodd LE, Davey RT Jr, et al. A Randomized, Controlled Trial of Ebola Virus Disease Therapeutics. N Engl J Med 2019; 381:2293. 

4. Burwick RM, Yawetz S, Stephenson KE, et al. Compassionate Use of Remdesivir in Pregnant Women with Severe Covid-19. Clin Infect Dis 2020.

PPH

 Q: 32 years old female is admitted to ICU from Labor and Delivery (L & D). Which of the following is a higher risk factor for postpartum hemorrhage (PPH)? (select one)

 A) Retained placenta/membranes 

 B) Eclampsia 

 Answer: A

In terms of Odd Ratio (OR) retained placenta/membranes is the highest risk factors for PPH. 

Evaluating 666 PPH from 154,000 deliveries retained placenta/membranes has an OR of 3.5 whereas preeclampsia/eclampsia/HELLP syndrome has an OR of 1.7 for PPH. Other high risk factors were failure to progress during the second stage of labor (OR 3.4), morbidly adherent placenta (OR 3.3), lacerations (OR 2.4), instrumental delivery (OR 2.3), large for gestational age newborn (OR 1.9), induction of labor (OR 1.4), and prolonged first or second stage of labor (OR 1.4). 1 

There are many other risk factors for PPH which includes placenta accreta or previa, placental abruption, intrauterine fetal demise, previous history, family history, obesity, high parity, Asian or Hispanic race, multiple gestation, polyhydramnios, macrosomia, chorioamnionitis, uterine inversion, leiomyoma, Couvelaire uterus, inherited bleeding diathesis, uterine relaxants, and use of SSRIs by a patient.

#ob-Gyn

References:

1. Sheiner E, Sarid L, Levy A, et al. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med 2005; 18:149. 

2. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010; 110:1368. 

3. Kramer MS, Berg C, Abenhaim H, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013; 209:449.e1. 

4. Sharp GC, Saunders PT, Greene SA, et al. Intergenerational transmission of postpartum hemorrhage risk: analysis of 2 Scottish birth cohorts. Am J Obstet Gynecol 2014; 211:51.e1. 

5. Bruning AH, Heller HM, Kieviet N, et al. Antidepressants during pregnancy and postpartum hemorrhage: a systematic review. Eur J Obstet Gynecol Reprod Biol 2015; 189:38. 

6. Skalkidou A, Sundström-Poromaa I, Wikman A, et al. SSRI use during pregnancy and risk for postpartum haemorrhage: a national register-based cohort study in Sweden. BJOG 2020; 127:1366.

gallstone related acute cholecystitis in pregnancy

 Q: 24 years old female in 22 weeks of pregnancy is admitted to ICU with concern for sepsis secondary to gallstone related acute cholecystitis. Which of the following antibiotics should be avoided? (select one)

A) Metronidazole 

B) Aztreonam 

C) Ceftriaxone 

D) Clindamycin 

E) Meropenem 

Answer: E  (Meropenem)

Management of gallstone-related complications is usually supportive in pregnancy and not much different than the general population including surgery if required. Like all other antibiotics, two classes of antibiotics should be avoided in pregnancy i.e., fluoroquinolones and carbapenems due to the risk of fetal toxicity. 

Monotherapy is usually enough with ampicillin-sulbactam, piperacillin-tazobactam, or ticarcillin-clavulanate. Another acceptable regimen is a combination of third-generation cephalosporin (ceftriaxone) and metronidazole. Clindamycin can be used in penicillin allergy. Aztreonam is also described as safe in pregnancy.

#ID

#Ob-Gyn

#hepatology

References:

1. Chloptsios C, Karanasiou V, Ilias G, Kavouras N, Stamatiou K, Lebren F. Cholecystitis during pregnancy. A case report and brief review of the literature. Clin Exp Obstet Gynecol. 2007;34(4):250-1. PMID: 18225691. 

2. Tseng JY, Yang MJ, Yang CC, Chao KC, Li HY. Acute Cholecystitis During Pregnancy: What is the Best Approach? Taiwan J Obstet Gynecol. 2009 Sep;48(3):305-7. doi: 10.1016/S1028-4559(09)60311-9. PMID: 19797027. 

3. İlhan M, İlhan G, Gök AFK, Günay K, Ertekin C. The course and outcomes of complicated gallstone disease in pregnancy: Experience of a tertiary center. Turk J Obstet Gynecol. 2016;13(4):178-182. doi:10.4274/tjod.65475

4. Bookstaver PB, Bland CM, Griffin B, Stover KR, Eiland LS, McLaughlin M. A Review of Antibiotic Use in Pregnancy. Pharmacotherapy. 2015 Nov;35(11):1052-62. doi: 10.1002/phar.1649. PMID: 26598097.

PV and pregnancy

 Q: 32 year old female with a past medical history of Polycythemia Vera (PV) is admitted to ICU after a complication in her first pregnancy with abruptio placentae. You should inform the patient that pregnancy is highly contraindicated in PV? (select one)

A) True

B) False

Answer: B

Despite an increased risk of complications in pregnancy such as miscarriages, abruptio placentae, pre-eclampsia, and intrauterine growth retardation, pregnancy is not a contraindication in patients with PV. A low dose aspirin decreases the rate of pregnancy loss. Patients should be closely monitored throughout the pregnancy. The European LeukemiaNet recommends the target hematocrit either less than 45% or the normal midgestation hematocrit range, whichever is lower. If cytoreduction is needed Interferon alfa is the preferred agent in pregnant women with PV.

#Ob-gyn

#hematology-oncology

References:

1. Barbui T, Barosi G, Birgegard G, et al. Philadelphia-negative classical myeloproliferative neoplasms: critical concepts and management recommendations from European LeukemiaNet. J Clin Oncol 2011; 29:761. 

2. Aggarwal N, Chopra S, Suri V, et al. Polycythemia vera and pregnancy: experience of four pregnancies in a single patient. Arch Gynecol Obstet 2011; 283:393. 

3. Maze D, Kazi S, Gupta V, et al. Association of Treatments for Myeloproliferative Neoplasms During Pregnancy With Birth Rates and Maternal Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e1912666.

AUB and NSAIDS

Q; 32 year old female is admitted to ICU due to hypovolemic shock after having a severe uterine bleed. OB-Gyn service has been called to assist in management. Besides other standard treatment Nonsteroidal anti-inflammatory drug (NSAIDs) has been prescribed as an adjuvant treatment. How the NSAIDS directly help in abnormal uterine bleed (AUB)?

Answer:  NSAIDs decrease the volume of menstrual blood by causing a decline in the rate of prostaglandin synthesis in the endometrium, leading to vasoconstriction and consequently reduced bleeding. Mostly prescribed NSAIDs are Mefenamic acid, Naproxen, and Ibuprofen.

#OB-GYN


References:

1. Rees MC, DiMarzo V, Tippins JR, et al. Leukotriene release by endometrium and myometrium throughout the menstrual cycle in dysmenorrhoea and menorrhagia. J Endocrinol 1987; 113:291. 

2. Smith SK, Abel MH, Kelly RW, Baird DT. Prostaglandin synthesis in the endometrium of women with ovular dysfunctional uterine bleeding. Br J Obstet Gynaecol 1981; 88:434.

'maternal cause-specific' mortality in cardiac arrest

Q: Which of the following is found to be the leading 'maternal cause-specific' mortality in cardiac arrest in the United States?

A) Postpartum hemorrhage
B) Antepartum hemorrhage
C) Amniotic fluid embolism
D) Sepsis
E) Anesthesia complications


Answer: A

The Nationwide Inpatient Sample (NIS) over fifteen years from 1998 to 2011 from 4843 patients looked for 'maternal cause-specific' mortalities in cardiac arrest. Although there was a long list of causes but almost 28% of women die due to postpartum hemorrhage followed by about 17% due to antepartum hemorrhage. Other three leading causes were heart failure, amniotic fluid embolism, and sepsis.

Causes also include anesthesia complications, aspiration pneumonitis, venous thromboembolism, eclampsia, magnesium toxicity, status asthmaticus, aortic dissection, and others.

#ob-GYN


Reference: 

Mhyre JM, Tsen LC, Einav S, et al. Cardiac Arrest during Hospitalization for Delivery in the United States, 1998-2011. Anesthesiology 2014; 120:810

coccidioidomycosis meningitis. in pregnancy

Q: 32 year old female with 12 weeks of pregnancy is admitted to ICU with coccidioidomycosis meningitis. CSF pressure reported normal on Lumbar Puncture (LP). What would be the first line of therapy? 

A) fluconazole 
B) Itraconazole 
C) Intrathecal amphotericin B 
D) echinocandins
E) Repeated LP


Answer: C

Azoles may have teratogenic effects on fetal bone formation. They are contraindicated in the first trimester of pregnancy. In such scenarios, intrathecal amphotericin B deoxycholate is the recommended therapy. Experts recommend avoiding azoles throughout the pregnancy.

Fluconazole and Itraconazole are azoles (choices A & B).

Interestingly, despite being very potent antifungals, echinocandins have no role in coccidioidal meningitis (choice D).


Repeated LPs are recommended for symptomatic relief only if CSF pressure is high (choice E).


#infectious-diseases
#ob-gyn
#neurology


References:

1. Bercovitch RS, Catanzaro A, Schwartz BS, et al. Coccidioidomycosis during pregnancy: a review and recommendations for management. Clin Infect Dis 2011; 53:363. 

2. Mølgaard-Nielsen D, Svanström H, Melbye M, et al. Association between use of oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth. JAMA 2016; 315:58.

3. Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis 2016; 63:e112.

Hyperemesis Gravidarum

Q: 28 years old female with 12 weeks of pregnancy is admitted to ICU with hypotension and severe hypovolemia secondary to hyperemesis gravidarum. Which of the following is considered as the first line of treatment in hyperemesis gravidarum? 

A) metoclopramide
B) prochlorperazine
C) promethazine
D) droperidol
E) dexamethasone 


Answer: C

Experts have tried to find the best approach for a wide range of nausea stimulators depending on neurotransmitters. Unfortunately, so far no specific neurotransmitter can be identified for pregnancy-related severe nausea. But promethazine is found to be most effective and considered as the first line of treatment in hyperemesis gravidarum. Serotonin antagonists and corticosteroids are considered as second-line agents. Interestingly, the use of ginger and vitamin B6 is also found to be effective.

#gastroenterology
#Ob-gyn


Reference:

Flake ZA, Scalley RD, Bailey AG. Practical selection of antiemetics. Am Fam Physician 2004; 69:1169.

anticoagulation in pregnancy

Q: 28 year old female with 20 weeks pregnancy is admitted to ICU with pulmonary embolism. Patient developed Heparin Induced Thrombocytopenia (HIT) with heparin infusion and was switched to bivalirudin. Patient can be transitioned to which of the following with relative safety?

A) Subcutaneous (SQ) full dose enoxaparin
B) Warfarin
C) Dabigatran 
D) Apixaban 
E) Subcutaneous (SQ) fondaparinux


Answer: E

Objective of the above question is to highlight the point that fast getting popular direct oral anticoagulants (DOACs) i.e. dabigatran, apixaban, edoxaban, or rivaroxaban are not safe in pregnancy or breastfeeding.  (Choices C and D)

Warfarin is well known to be avoided in pregnancy. (Choice B)

Once the suspicion or diagnosis of HIT is made, any kind of heparin should be avoided like enoxaprin. (Choice A)

Fondaparinux is a synthesized version of the active pentasaccharide subunit of heparin, with the property of no interaction with platelet factor 4, and can be used safely in pregnancy and HIT. (Choice E)


#pharmacology
#hematology
#Ob-Gyn


References: 

1. Wijesiriwardana A, Lees DA, Lush C. Fondaparinux as anticoagulant in a pregnant woman with heparin allergy. Blood Coagul Fibrinolysis 2006; 17:147–149. 

2.  Lameijer H, Aalberts JJJ, van Veldhuisen DJ, Meijer K, Pieper PG. Efficacy and safety of direct oral anticoagulants during pregnancy; a systematic literature review. Thromb Res. 2018 Sep;169:123-127.