Site promoting training/education in Obstetric Medicine http://www.obstetricmedic.org.uk Current recommendations are that patients delay pregnancy for 2 years following treatment for breast cancer. This allows a time period in the event of early recurrence and for completion of adjuvant therapy. Data from this study shows that patients with localised disease who have completed treatment need only wait 6 months. http://www.bmj.com/cgi/content/abstract/334/7586/194 10 breastfeeding women on azathioprine supplied 31 samples of breastmilk. Azathioprine levels were undetectable in most samples and extremely low in two. It would seem that azathioprine is safe during lactation. http://www.blackwell-synergy.com/doi/abs/10.1111/j.1471-0528.2006.01232.x Glargine (Lantus®) is a relatively new insulin. This pilot study compares glargine with normal, intermediate acting insulin. There were no differences between the two in terms of neonatal outcome (macrosomia & neonatal morbidity ). http://www.blackwell-synergy.com/doi/abs/10.1111/j.1471-0528.2006.01216.x An excellent guideline/review of haemoglobinopathies in pregnancy. http://www.obstetricmedic.org.uk/journalwatch.html Should we screen for toxoplasmosis? if so, how (since Toxoplasmosis in pregnancy is usually asymptomatic)? Does treatment reduce mother-to-child transmission? Mother-to-child transmission is more likely if seroconversion occurs at advanced gestational age. Conversely, clinical manifestations (neuro/eye) become less likely as gestational age increases. Treatment within 3 weeks of seroconversion may reduce mother-to-child transmission, however, the evidence to support this is weak. Furthermore, there is no evidence that treatment reduces the incidence of clinical manifestations. The researchers conclude that a proper RCT is required. http://www.obstetricmedic.org.uk/journalwatch.html Three review articles of interest: Lyme disease, Ehlers-Danlos and Fertility options for Women with Malignacies. http://www.obgynsurvey.com/pt/re/obgynsurv/abstract.00006254-200701000-00022.htm;jsessionid=FDnQ2WL65vq4pQYJLdYdPLtv2qpnl5fnpg2vpmw5KyLZqndR8lMM!2082300909!-949856145!8091!-1 Starbucks can breathe a huge sigh of relief...it's official - coffee is safe! E http://www.bmj.com/cgi/content/short/bmj.39062.520648.BEv1 A review article, suitable for both obstetric and medical registrars, on imaging for pulmonary embolism in pregnancy. Includes radiation statistics for perfusion scan vs CTPA and discusses risks/benefit for mother and fetus. http://www.bmj.com/cgi/content/short/334/7590/418 A pre-pregnancy counseling information leaflet for patients with chronic hypertension. Discusses the effect of long-term hypertension on pregnancy including issues surrounding medication and signs/symptoms of pre-eclampsia. The terminology and knowledge assumed is reasonably advanced making the leaflet more suitable for a well educated patient group. http://circ.ahajournals.org/cgi/reprint/115/7/e188 Have you ever wondered why PCR has not replaced 24 hour collections? This article reviews current thinking on proteinuria summarising normal pregnancy physiology, the pathophysiology of proteinuria in the context of pre-eclampsia and the benefits and problems associated with current methods for detecting proteinuria. A good summary, except for the use of non-SI units which is very un-Euro-friendly! http://www.obgynsurvey.com/pt/re/obgynsurv/abstract.00006254-200702000-00024.htm Gestational diabetes (GDM) is an extremely confusing and controversial topic. Not only are there different diagnostic criteria around the world, but also diverse opinion as to how GDM should be managed varying from no intervention to tight diabetic control and early delivery. This paper discusses the complications of GDM on both mother and fetus and whether treatment improves outcome. The Australian ACHOIS trial (NEJM 2005; 352:2477-2486) which showed an improved perinatal outcome with intervention is heavily criticised. The paper concludes that, given the lack of good evidence, it is difficult to make clear recommendations regarding GDM. Results from the on-going Hyperglycemia and Adverse Pregnancy Outcome (HAPO) trial are eagerly awaited. http://www.obgynsurvey.com/pt/re/obgynsurv/abstract.00006254-200702000-00025.htm Whilst it is well established that folic acid reduces the incidence of neural tube defects, less is known about its effect on facial cleft abnormalities. This well designed study from Norway shows that preconception supplementation of folic acid reduces the prevalence of cleft lip by 40%. Confounding and recall bias complicate almost all such case-control studies – however, the authors have tried hard to eliminate these biases. It is interesting that, although cleft lip defects are reduced, folic acid supplementation has no impact on cleft palate, suggesting an alternative contributing pathological mechanism. In summary, this paper contributes to the wealth of evidence that at least 400mcg of folic acid is beneficial pre-conceptionally and during early pregnancy. The editorial BMJ 2007;334:433-434 discusses the wider issues surrounding the controversy over whether we should be fortifying our foodstuffs with folic acid http://www.bmj.com/cgi/content/abstract/334/7591/464 Heparin induced thrombocytopenia (HIT) and osteoperosis are currently risks which patients on long-term heparin should be counselled for. Although the incidence of these complications has declined due to the widespread use of low-molecular weight heparin, occasionally HIT still occurs. This is a useful review article about drug induced thrombocytopenia, primarily describing the background pathophysiology, which is differs according to the drug. Perhaps the most important fact is that HIT is associated with a high rate of thrombosis (despite a reduction in platelets) and that warfarin makes this worse. Unfortunately, the article does not reveal how to manage this catch-22 situation… http://content.nejm.org/cgi/content/extract/356/9/891 How long should we treat patients with first-onset DVT/PE and no underlying cause such as thrombophilia or malignancy? This randomised control trial showed no difference in terms of major adverse outcome or recurrence of thrombosis between patients anticoagulated for 3 or 6 months. The only difference being an increased risk of haemorrhage in the group anticoagulated for longer. http://www.bmj.com/cgi/content/short/bmj.39098.583356.55v1 Hepatitis E has many similarities to Hepatitis A. Both are transmitted via the faecal-oral route and in the majority of cases cause a self-limiting illness. Fulminating hepatitis will occur in a minority with a case fatality rate between 0.1-4%. What is perhaps less well known is that if hepaitis E is contracted during pregnancy then the fatality rate is much higher – approaching 25%. Phase III trials of a new Hepatitis E vaccine look promising and potentially women of child-bearing age who live or plan to visit an endemic area may benefit the most from vaccination in the future. http://content.nejm.org/cgi/content/extract/356/9/949 Asthma is common and unsurprisingly, not necessarily well managed during pregnancy. Both patients and doctors are understandably worried about the effect of asthma medications on the fetus. This is a useful summary of the effects and consequences of asthma and its pharmacological treatment during pregnancy. http://www.obstetricmedic.org.uk/journalwatch.html An excellent review article on Type 1 diabetes systematically covering pre-conception, the effects of pregnancy on diabetes and diabetes on pregnancy, labour and delivery and drug management. A clear and concise summary. Highly recommended reading for anyone looking after diabetic patients through pregnancy. http://www.bmj.com/cgi/content/extract/334/7596/742 Women do not fair well when it comes to viral infections acquired during pregnancy (see March review on Hepatitis E above). This article discusses the risks associated with influenza along with more exotic species such as severe acute respiratory syndrome (SARS) and ‘bird flu’ (avian flu H5N1). It is interesting reading from an education point-of-view and summarises the effects of these viral infections that have been subject to extensive media coverage in recent years. Fortunately, the numbers of pregnant patients exposed to SARS/avian flu remains small which makes it difficult to draw any meaningful conclusions regarding pregnancy outcome and management from the case reports in this review. http://www.co-obgyn.com/pt/re/coobgyn/abstract.00001703-200704000-00005.htm;jsessionid=G0TJ2BLwQlNZDvGKNP3DhfTyXh5HGYJ1ns8zz6F3JCGY1GbW3fvN!-1465501618!-949856144!8091!-1 The prevalence of congenital and acquired valvular heart disease is increasing. Advances in cardiac surgery mean that more women are surviving to childbearing age. Valvular heart disease comprises of a largely heterogeneous population. Some valve lesions are more serious than others and may present a particular challenge during pregnancy. The issue of anticoagulation for patients with valve replacement is also complex with a number of factors to consider. This is a useful review article covering haemodynamic changes during pregnancy, pre-pregnancy assessment, management during antenatal, intrapartum and post partum periods and a summary of the problems associated with specific valve lesions. Anticoagulation options are summarised. Suitable for obstetricians, cardiologists and general physicians interested in cardiac disease in pregnancy. http://heart.bmj.com/cgi/content/abstract/93/5/552 Transmission of HIV rates vary from less than 2% in the developed world to greater than 30% in the developing world. Interventions that have led to a reduction in transmission are: antiretroviral therapy, elective caesarean section and exclusive formula feeding of the neonate. These may be easy to achieve in developed countries, but are difficult to provide in resource-poor healthcare settings. Review includes a brief case study and some discussion regarding the use of anti-retroviral drugs during pregnancy. Summary boxes contain British HIV association guidelines. http://www.bmj.com/cgi/content/extract/334/7600/950 Rates of depression are higher during pregnancy than at any other time during a woman's life. Depression is associated with poor obstetric outcome - although this may be due to confounding factors such as lower socioeconomic class, poor diet, smoking, etc. This review summarises some of the current thinking on depression - exploring hypotheses linking changes in the hypothalamic-pituitary axis and physiological changes occuring in pregnancy. Further discussion of the safety of anti-depressants in pregnancy is needed. http://www.bmj.com/cgi/content/extract/334/7601/1003 Myocardial infarction is relatively rare in pregnancy, but is associated with significant maternal mortality. Whilst atherosclerosis is the commonest cause in the general population, consideration should be made to rarer causes such as coronary artery dissection, coronary thrombosis without atheroma and congenital abnormalities of the coronary arteries in pregnancy. This case report highlights the need for urgent coronary angiography for all pregnant women presenting with myocardial infarction as a diagnosis is essential in determining further management. http://ats.ctsnetjournals.org/cgi/content/abstract/83/5/1879 A large retrospective study to identify the effects of hypothyroidism in early pregnancy in terms of obstetric and perinatal outcome. The study shows no excessive adverse pregnancy outcomes in women with isolated hypothyroidism (ie. low T4, raised TSH). Women with subclinical hypothyroidism (defined by the paper as normal T4, TSH raised ?3.0) however, had increased rates of the following: placental abruption, prematurity, gestational diabetes, Apgar =3, NICU admission and neonatal RDS. There are problems with this study. It doesn't reveal many of the women were treated, specifically the women with subclinical hypothyroidism. Does treating subclinical hypothyroidism improve outcome? In addition, although there would appear to be no immediate problems in the neonates born to women with isolated hypothyroidism - other studies have shown that long-term measures of IQ and neurodevelopment are impaired in this group. A good paper to discuss in journal club. http://www.greenjournal.org/cgi/content/abstract/109/5/1129 The development and use of antidepressant drugs has increased rapidly over the last five years. Two articles this month examine the increased prevalence of antidepressant use in pregnancy. There have been recent concerns over the possible teratogenic effects of antidepressants - in particular SSRIs - in terms of cardiac anomaly and pulmonary hypertension. The first study (BJOG) is from Montreal, Canada the other (AJOG) is from Nashville, Tennessee. Both studies looked at pharmacy data to determine whether women were using antidepressants. It was assumed that if women were filling prescriptions then they were taking the drug (this is potentially problematic). Most presciptions were for SSRIs and almost half stopped taking the medication once pregnant. http://www.blackwell-synergy.com/doi/full/10.1111/j.1471-0528.2007.01387.x Whether to treat mild hypertension in pregnancy is controversial. Whilst earlier studies have shown that treatment reduces the risk of developing severe maternal hypertension, the benefits (if any) to the fetus are less clear. Some feel that mild elevation in blood pressure during pregnancy is a response to increased requirements of the fetoplacental unit. Homeostatic interference with anti-hypertensive drugs is therefore potentially detrimental to the fetus. This is a pilot study for a larger multi-centre randomised control trial, Control of Hypertension in Pregnany Study (CHIPS), which aims to answer this important question. http://www.blackwell-synergy.com/doi/abs/10.1111/j.1471-0528.2007.01315.x A series of three cases designed to test your medical and differential diagnostic skills. Answers are provided separately. Useful for teaching Obstetric Medicine/tutorial discussion. http://www.greenjournal.org/content/vol109/issue6/#STUMP_THE_PROFESSORS An interesting case report of a late termination of pregnancy at 35 weeks complicated by amniotic fluid embolism. The case highlights the need for early transfer to a high level of ITU where extracorporeal life support was required. Steroids were also useful in dampening an acute inflammatory response. The patient survived. http://www.thelancet.com/journals/lancet/article/PIIS0140673607608575 A useful review article - part of the Pregnancy Plus series published in the BMJ. Covers the consequences of psoriasis on pregnancy and treatment safety. http://www.obstetricmedic.org.uk/journalwatch.html Review article on the pro's and con's of training in maternal medicine from both an obstetric and physician pathway http://careerfocus.bmj.com/cgi/content/full/324/7333/S41a Career article relating to the history of Obstetrics & the increasing need for Obstetric physicians. http://www.rcpe.ac.uk/publications/articles/June_06/Hadden_obstetric.pdf Review article on training in Maternal Medicine http://www.ingentaconnect.com/content/rcop/cm/2002/00000002/00000002/art00012