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The analgesia effects of pethidine become apparent after 10-15 minutes (not 30) and it is 40-60% protein bound. Intravenous pethidine administered via a patient-controlled analgesia (PCA) pump provides better analgesia compared with nurse-controlled analgesia (NCA), but almost double the amount of drug is used.
Pethidine causes foetal side effects which include loss of beat-to-beat variability, depression of the Apgar scores (not elevation) and respiratory depression.

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The addition of opioids to local anaesthetics solutions used in regional anaesthesia is associated with delayed respiratory depression, and this is more likely to occur with hydrophilic opioids than with lipophilic opioids. The risk of aspiration of gastric contents is reduced under regional anaesthesia but it can still occur, especially with a high block or total spinal. The incidence of a venous air embolism (VAE) during lower segment Caesarean Section (LSCS) under regional is about 25% (using doppler ultrasound and echocardiography). Thrombus and amniotic fluid emboli have also been reported.
The incidence of electrocardiograph (ECG) ischaemic changes demonstrated in ASA 1 females undergoing LSCS is about 35%. This is believed to be due to increase in myocardial work and oxygen demand that occurs secondary to the hypotension induced by the sympathetic blockade.
A postural headache usually suggests that there is a cerebrospinal fluid lead close to the level of insertion of the regional block. This may be an indication for an epidural blood patch in order to seal the puncture.

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While no single diagnostic imaging procedure would result in a radiation dose that would threaten the well-being of a developing embryo or fetus, and fetal risk is considered negligible at 5 rad or less, certain imaging procedures do carry a higher radiation dose than others.
Fluoroscopic barium enema …………… .3.986 rad
Intravenous pyelogram. ……………….. .1.395 rad
Lumbrosacral spine films ……………… .0.359 rad
V/Q lung scan ………………… …0.215 rad
Chest film, two views ……………… 0.00007 rad

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During routine prenatal care, if a fetal ultrasound shows Intra-uterine Growth Retardation (IUGR) it is important to investigate further. In Symmetrical IUGR there is inadequate growth of the head, body and extremities. The growth problem is the result of a decrease in the rate of cell reproduction, resulting in fewer cells. This usually has its onset prior to 32 weeks of pregnancy and has a 25% risk for chromosomal abnormalities (Down syndrome, trisomy 13, trisomy 18) which should definitely be investigated.
Asymmetrical IUGR usually occurs early in the third trimester and implies a fetus who is undernourished and is directing most of its energy to maintaining growth of vital organs, such as the brain and heart, at the expense of the liver, muscle and fat. This type of growth restriction is usually the result of placental insufficiency.

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In a woman with Rh incompatibility, there is a substance in her baby red blood cells that in not in her blood cells. This substance ie called the Rho (D) factor. People who have the Rho (D) factor are Rh positive. People who do not have it are Rh negative. While pregnant or during delivering, some of the baby´s red blood cells may come in contact with the mother´s blood. The mother´s body may then make antibodies to the Rho (D) factor. This reaction is called- sensitization. The antibodies may cross the placenta and destroy the red blood cells in the baby or any Rh-positive babies you have later. This destruction of red blood cells is called hemolytic disease. Rh incompatibility happens only if you are Rh negative and your baby is Rh positive. RhoGAM contains antibodies to the Rho (D) factor. The antibodies in the shot will destroy any red blood cells from the baby that are the mother´s blood. Then the mother will not make its own antibodies to the Rho (D) factor. A shot at 28 weeks and after delivery, sensitization will be prevented and Rh incompatibility should not be a problem during the next pregnancy.
If a woman has a threatened miscarriage but does not actually miscarry, she will need a RhoGAM shot.

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There are two parts to this question. The first is realizing that the child´s illness is the classic description of Fifth disease or erythema infectiosum. It is caused by parvovirus B19, which is spread from human to human. Animals do not carry this particular parvovirus. The disease is contagious prior to the onset of the rash. The initial symptoms, during the period of contagion, are nonspecific constitutional symptoms such as fever, myalgia, lethargy, coryza, pharyngitis, and abdominal pain. When the typical “slapped cheek” rash begins, the child is no longer contagious. The rash begins with the erythematous cheeks and then the upper part of the body becomes red and then reticulated, i.e., the typical lacy appearance of the rash develops. This fades but can come and go for the next three weeks. Parvovirus is a cause of aplastic anemia. It may be responsible for aplastic crises in patients with sickle cell anemia. In addition, exposure of a pregnant woman in the first trimester may result in a fetus with aplastic anemia, which results on non immune hydrops fetalis. Because the virus infects immature erythrocytes, causing severe anemia, the fetus dies of cardiac failure. Cutaneous scarring occurs in an infant with congenital varicella syndrome (exposure to varicella during pregnancy). The other major feature is limb defects. Congenital heart defects may occur due to many different reasons. It is, however, associated with the congenital rubella syndrome, where one sees a patent ductus arteriosus and pulmonary artery stenosis most commonly. Hemolytic anemias are usually not associated with prenatal exposure to an infectious agent. They may be produced due to isoimmunization (Rh disease) red cell membrane detects (spherocytosis), red cell enzyme detects (pyruvate kinase deficiency), as well as many other etiologies. Hydrocephalus also has diverse etiologies. There is an association with prenatal exposure to mumps and the fetal development of aqueductal stenosis resulting in obstructive hydrocephalus.

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A patient who is HIV EIA positive must always have the result confirmed by a confirmatory assay (e.g. HIV Western blot). The HIV Western blot is considered positive when the patient demonstrates the presence of antibody to at least two of three important HIV antigens which are gp 41 and p24.
If no reaction is observed, then the patient is considered negative, but any reaction that not consistent with a positive is reported indeterminate. Therefore; this patient is considered indeterminate. The physician can wait 6 months and retest by Western blot; if the results are identical, then the patient is reported as negative, or the patient can be rested by another confirmatory test such as the PCR assay. A negative PCR in this situation would classify this patient as negative; however it would be wise to retest the patient in 3 to 6 months she had risk factors. Approximately 30% of the babies from untreated and 8% from treated HIV-positive mothers will be infected. One cannot conclude from the available data that both she and her baby are infected.
It is possible that this patient had a false positive HIV EIA assay but with the present data it is impossible to know if the patient is in the early stages of seroconversion or if the result is a false positive. Rapid plasma reagin (RPR) is a test for syphilis (and not a very specific one). It is not a test for HIV.
Because this patient´s Western blot was indeterminate a confirmatory test (e.g., Western or POR) must be performed to determine whether she is truly positive for the HIV virus.

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This patient has syphilis. Syphilis is a disease caused by Treponema pallidum, a spirochete. A painless ulcer, called a chancre, typically found on the vagina or cervix, characterizes primary syphilis. If primary syphilis is untreated it can progress to secondary syphilis, which is characterized by “moth-eaten” alopecia, a maculopapular skin rash involving the palms and soles, and white patches on the tongue. Gumma formation, cardiac lesions, and central nervous system abnormalities characterize tertiary syphilis. Syphilis in pregnancy is associated with increased rates of preterm delivery, intrauterine growth retardation, and fetal demise. However, the most devastating complication of syphilis in pregnancy is congenital infection. Congenital infection of the fetus can lead to severe fetal morbidity and mortality. The key to preventing congenital infection of the fetus is adequate treatment of the mother. Therefore, every woman should be tested for syphilis during routine prenatal care.

The RPR test andVENEREAL Disease Research Laboratory (VDRL) are screening tests for syphilis and are not entirely specific for Treponema pallidum infection. Certain other conditions, such as autoimmune syndromes and pregnancy itself, can give a falsely positive RPR test. Therefore, the RPR test should be followed up with a test that is specific for syphilis, such as the MHA-TP test.

When both of these tests are positive and there is no history of syphilis infection and treatment, then the patient should be treated with intramuscular penicillin. Erythromycin (choice A) is recommended by some as the first-line treatment for chlamydia in pregnancy (others recommend azithromycin). Erythromycin is not the drug of choice for syphilis in pregnancy. Levofloxacin (choice B) and the other fluoroquinolones are considered contraindicated in pregnancy because of an association with musculoskeletal congenital anomalies. Metronidazole (choice C) is used during pregnancy for the treatment of bacterial vaginosis and trichomoniasis. It is not used for treatment of syphilis. Tetracycline (choice E) is contraindicated during pregnancy because of effects on fetal bones and teeth.If a pregnant mother is identified as being infected with syphilis, treatment can effectively prevent congenital syphilis from developing in the unborn child, especially if she is treated before the sixteenth week of pregnancy.

The child is at greatest risk of contracting syphilis when the mother is in the early stages of infection, but the disease can be passed at any point during pregnancy, even during delivery (if the child had not already contracted it). A woman in the secondary stage of syphilis decreases her child´s risk of developing congenital syphilis by 98% if she receives treatment before the last month of pregnancy. An afflicted child can be treated using antibiotics much like an adult; however, any developmental symptoms are likely to be permanent (choice F).

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Women that acquire rubella during pregnancy are at risk of developing fetal infection and congenital rubella syndrome. If the mother is infected during the first trimester the malformation rate in the fetus is approximately 50%. These malformations include microcephaly, mental retardation, cataracts, deafness, and congenital heart disease although all organs may be affected.

Therefore, all women need to be vaccinated with the rubella vaccine-most often given as part of the MMR series of vaccines. However, because the MMR vaccine is a live-virus vaccine, there is a concern that administration of the vaccine within 3 months of conception, or during the pregnancy, could result in birth defects or illness. Yet, this concern is more theoretical than real as studies performed on women given the rubella vaccine shortly before becoming pregnant or during pregnancy have failed to show any increase in the risk of malformations compared to the general background risk in the population. The current US immunization policy is that the risk of vaccine-associated defects is virtually negligible and should not be a reason in itself to consider termination. To state that there is no vaccine risk and termination is completely inappropriate (choice A) is incorrect.

Although the risk of the MMR vaccine appears more theoretical than real, one cannot state that there is no risk. To state that the vaccine risk is moderate and termination should be considered (choice C) or that the vaccine risk is high and termination should be strongly considered (choice D) is incorrect. As stated above, the risk of the MMR vaccine-associated defects is so small as to be considered negligible. To state that the vaccine risk is high and termination is mandated (choice E) is absolutely incorrect. First, the vaccine risk is not high. Second, even if the fetus were found to have severe defects, it is the patient´s choice whether or not to keep the pregnancy.

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Ninety percent of early and immediate postpartum hemorrhage is due to failure of the uterus to contract satisfactorily (uterine atony). Other less frequent causes are lacerations of the cervix, vagina, or perineum; hematomas, usually located near lacerations or episiotomy repairs; and uterine rupture, either spontaneous or iatrogenic. All of these occur in the immediate postpartum period. Delayed hemorrhage, occurring beyond the first 24 hours after delivery, is usually caused by retained placental fragments. Interestingly, placenta accreta is among the most common causes of postpartum hemorrhage necessitating hysterectomy.

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Following insertion of either device, a follow-up appointment should be planned after the next menses to address any concerns or adverse effects, ensure the absence of infection, and check the presence of the strings.
The most common adverse effects of IUDs are cramping, abnormal uterine bleeding, and expulsion. Adverse effects related specifically to the hormone releasing IUD include amenorrhea, acne, depression, weight gain, decreased libido, and headache.
If the IUD threads are ever not present, a pregnancy test should be performed. When the results are negative, a cytobrush can be inserted gently into the cervical canal to locate the threads. If this method is unsuccessful, radiography or ultrasonography may be used to locate the IUD.
When the results of the pregnancy test are positive, an ectopic implantation must be ruled out. If the strings are visible and the pregnancy is early, the IUD can be removed but with a risk of pregnancy loss. If the strings are not visible, ultrasonography should be performed to identify the IUD for removal.

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Accutane or Isotretinoin is a powerful drug used to combat the most serious and complicated cases of acne. One of the most serious complications of accutane is its effect on pregnant women and their unborn fetuses. Accutane is so dangerous to babies in the womb that no amount of accutane should be taken by a pregnant woman. Some of the most common birth defects caused by accutane include: Heart Defects, Mental Retardation, Microcephaly (unusually small head), hydrocephaly enlarged fluid filled spaces located in the brain), and deformities of the face and ears.

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Hyperbilirubinemia can occur in up to 60% of term newborns during the first week of life. Early guidelines on management of elevated bilirubin were based on studies of bilirubin toxicity in infants who had hemolytic disease. Current recommendations now support the use of less intensive therapy in term newborns with jaundice who are otherwise healthy. Phototherapy should be initiated when the bilirubin level is above 15 mg/dL for infants at age 29-48 hours old, at 18 mg/dL for infants 49-72, and at 20 mg/dL in infants older than 72 hours. Generally, this problem is not considered pathologic unless it presents during the first hours after birth and the total serum bilirubin rises by more than 5mg dL/day or is higher than 17 mg/dL, or if the infant has signs or symptoms suggestive of a serious underlying illness such as sepsis. Fortunately, very few term newborns with jaundice have serious underlying pathology.
Physiologic jaundice follows a pattern, with the bilirubin level peaking on the third or fourth day of life and then declining over the first week after birth. Infants with multiple risk factors may develop an exaggerated form of physiologic jaundice, with the total bilirubin level rising as high as 17 mg/dL. Breastfed infants are at an increased risk for exaggerated physiologic jaundice because of relative caloric, deprivation in the first few days of life. Compared with formula-fed infants, those who are breastfed are six times more likely to experience moderate jaundice, with the bilirubin rising above 12 mg/dL. For breastfed newborns who have an early onset of hyperbilirubinemia, the frequency of feeding should be increased to more than 10 times per day. If the newborn has a decrease in weight gain, delayed stooling, and continued poor intake, then formula supplementation may be necessary. Breastfeeding should be continued to maintain breast milk production. Supplemental water or dextrose and water should not be given, as thin can decrease breast milk production and may place the infant at risk for iatrogenic hyponatremia.

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When a gravid woman goes into labor her baby can be in a variety of positions. See picture:

Of these the most appropriate for delivery is the vertex face position. Occasionally we see one of the other presentations. A footling presentation is seen here:

This is a presentation with the feet entering the birth canal ahead of any other part of the body. This may occur with two feet (double footling) or a single foot (single footling). Most often one leg is extended while the other is flexed at the knee. It is usually safer to deliver this kind of baby by a Cesarean section early in labor or before labor begins. If a footling breech is delivered vaginally, there is a risk that the head may not easily pass through the birth canal.

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Disseminated intravascular coagulation (DIC) is characterized by consumption of both platelets and clotting factors. The best tests to order are platelet count (which will be markedly decreased), serum fibrinogen level (which will be low), and fibrin degradation products (which will be high). Prothrombin time (PT) measures factors I (fibrinogen), II, V, VII, and X. Partial thromboplastin time (PTT) measures prekallikrein, high molecular-weight kininogen, and factors I, II, V, VIII. IX. X and XI. Both PT and PTT are relatively nonspecific. Thrombin time (TT) is a more specific measure of fibrinogen and would potentially be a useful test in this setting. However, specific measurement of factor VIII, kininogen, or prekallikrein levels would not be rational in evaluating DIC.

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This patient has a deep venous thrombosis (DVT) in her right lower extremity. Pregnancy is a risk factor for the development of DVTs because of alterations in coagulation factors, venous stasis, and, often, decreased physical activity. It is essential that DVT during pregnancy be treated so that the thrombus does not proliferate or embolize and so that new thrombi do not form. Coumadin is contraindicated during the first trimester because of the risk of birth defects in fetuses exposed to this drug.

Coumadin embryopathy is a syndrome consisting of nasal hypoplasia and stippled vertebral and femoral epiphyses. Second- and third-trimester exposure to Coumadin can lead to hydrocephaly, microcephaly, ophthalmologic abnormalities, fetal growth retardation, and developmental delay. Low-molecular-weight heparin has been shown to be an excellent anticoagulant because it has a longer half-life and a more predictable dose-response relationship compared with unfractionated heparin, which allows once- or twice-daily dosing without the need for frequent laboratory monitoring of the prothrombin time and activated partial thromboplastin time.

Low-molecular-weight heparin is also less likely to cause thrombocytopenia and hemorrhagic complications than unfractionated heparin. Low-molecular-weight heparin does not have a shorter half-life (choice A) than unfractionated heparin. In fact, low-molecular-weight heparin has a longer half-life, and it is this quality that allows for once- or twice-daily dosing. Lowmolecular- weight heparin is not cheaper (choice B) than unfractionated heparin. Lowmolecular- weight heparin itself is more expensive, but there is a cost advantage in that less frequent laboratory monitoring is needed. Neither low-molecular-weight heparin nor unfractionated heparin is likely to cause birth defects (choice C). Neither crosses the placenta (choice E) and neither is associated with teratogenesis.

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Pregnancy brings about numerous, normal physiologic changes in the pregnant woman. Some of the most obvious changes are those found in the cardiovascular system. For example, cardiac output rises markedly in pregnancy with increases up to 50% over nonpregnant levels.

Cardiac murmurs are common in pregnancy with as many as 90% of all pregnant women having some degree of a systolic murmur. Diastolic murmurs are different, however. The finding of a diastolic murmur in a pregnant woman must be thoroughly evaluated as this type of murmur is often related to important cardiac disease. For example, mitral stenosis, the most common rheumatic valvular lesion in pregnancy, is characterized by a rumbling diastolic murmur. Therefore, patients with diastolic murmurs should have an echocardiograph and possible referral to a cardiologist for further evaluation.

An enlarged uterus (choice B) is a normal finding in a pregnant woman. It is important to examine the uterus for size at the first prenatal visit to ensure that the size correlates to the patient´s dating by last menstrual period. If there is a discrepancy, then the patient should be sent for an ultrasound to obtain correct dating, which is essential for the management of the pregnancy. Fatigue (choice C) and nausea and vomiting (choice D) are very common findings in the first trimester of pregnancy.

While fatigue can sometimes be a symptom of structural heart disease, it is not nearly as concerning as the diastolic murmur in this patient. Nausea and vomiting is present in anywhere from 50 to 90% of all pregnant women. As noted above, a systolic murmur (choice E) is a very common finding during pregnancy. Up to 90% of all pregnant women will have such a murmur during pregnancy. As long as the murmur is systolic, no louder than III/VI and there is no other symptomatology, the murmur can be considered to be benign.

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Entonox is a gaseous mixture of nitrous oxide and oxygen and has been has been used since the 1960´s. It is twice as effective as pethidine at providing labour analgesia, but inhalation should begin as soon as the uterine contraction is felt, became it takes forty five seconds before the maximum analgesic effect is achieved.
Low dose isoflurane and sevoflurane have been given in addition to entonox which has demonstrated an increased analgesic efficacy over entonox alone. Combining the analgesic effects of entonox with other analgesics agents provides superior analgesia to using entonox alone.

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The normal physiological changes in pregnancy are as follows:
Cardiac output rises 30 to 50 percent above baseline. It peaks by the end of the second trimester; after which it reaches a plateau until delivery. The change in cardiac output is mediated by 1) increased preload due to the rise in blood volume, 2) reduced afterload due to a fall in systemic vascular resistance, 3) a rise in the maternal heart rate by 10 to 15 beats per minute. Stroke volume increases during the first and second trimesters, but declines in the third trimester due to caval compression by the gravid uterus. The direct effect of pregnancy on cardiac contractility is controversial. Blood pressure typically falls, usually reaching a nadir of 10 mm Hg below A baseline by the end of the second trimester. The decline in blood pressure is mediated by a-fall in systemic vascular resistance induced by hormonal changes and by the addition of a low-resistance circuit through the uteroplacental bed.

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Vaginal birth after cesarean (VBAC) is done but only if conditions are favorable. Absolute contraindication to VBAC includes prior classical (vertical) uterine incision.
The most serious risk of a VBAC is that the previous C-section scar could come open. This can be very serious for both the mother and the baby. The risk that a scar will tear open is very low during VBAC when you have just one low horizontal cesarean scar and your labor is not started with medicine.

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The size and nutrient transfer capacity of the placenta play central roles in determining the prenatal growth trajectory of the fetus. Abnormalities in placental structure and function are central to many cases of IUGR.
Placental insufficiency results in fetal hypoxia and hypoglycemia during late gestation.

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This patient has had a complication of delivery, i.e., a fourth-degree laceration. This means that there has been a traumatic rupture of the perineal body down through the external rectal sphincter to include the rectal mucosa. Careful repair of this injury must be undertaken lest there be continuing dysfunction, e.g., rectal incontinence, rectovaginal fistula, or dyspareunia. Postpartum surveillance includes routine assessment of breasts, extremities, abdomen, and perineum. In this case, particular attention must be paid to the condition of the perineum to be certain of healing, and the absence of infection or hematoma formation. Because perineal healing is an evolutionary process, the decision about hospital discharge cannot be made in advance. Her ability to ambulate and void well suggests a successful and uncomplicated repair.
The patient´s concern about bowel function should be addressed. Strategies to improve postpartum bowel function include initiating a low-residue diet, and prescribing a short course of stool softeners and a mild laxative on the first postpartum night. She should be reassured that normal bowel function can be anticipated. The status of her success at breastfeeding tomorrow is not known; however, customarily there are support sources available, which can be recommended. The nursery can also be alerted to provide extra instruction to and observation of the patient while breastfeeding. Given appropriate reassurance and counseling, the patient´s outlook may be changed by tomorrow.

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Disseminated intravascular coagulation (DIC) involves abnormal, excessive generation of thrombin and fibrin in the circulating blood. During the process, increased platelet aggregation and coagulation factor consumption occur. DIC that evolves slowly (over weeks or months) causes primarily venous thrombotic and embolic manifestations; DIC that evolves rapidly (over hours or days) causes primarily bleeding. DIC occurs in the following clinical circumstances: Complications of obstetrics-eg, abruptio placentae (most common), saline-induced therapeutic abortion, retained dead fetus or products of conception, or amniotic fluid embolism. Placental tissue with tissue factor activity enters or is exposed to the maternal circulation. Infection, particularly with gram-negative organisms. Gram-negative endotoxin, causes generation of tissue factor activity in phagocytic, endothelial, and tissue cells. Malignancy, particularly mucin-secreting adenocarcinomas of the_ pancreas and prostate and acute promyelocytic leukemia, in which tumor cells expose or release tissue factor activity.

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The first stage of labour is from the commencement of rhythmic, regular contractions until full cervical dilatation. The second stage is from full cervical dilatation until delivery of the foetus. The third stage begins after the delivery the foetus until delivery of the placenta, thus the placenta (not the foetus) is delivered during the third stage. Braxton-Hicks contractions may occur from 20 weeks and they do not necessarily signify the onset of labour.
Syntocin may be used to augment contractions in the first stage, or contract uterus in the third stage. Foetal heart rate may be monitored using a cardiotocograph, and heart rate of 120-160 per minute is normal, as are accelerations after a uterine contraction.

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Under such unusual circumstances, when a second twin is breech or a breech vaginal birth is progressing quickly, a cesarean is neither recommended nor possible.
There are several different types of vaginal breech deliveries: The delivery can occur without help from a health professional (spontaneous breech birth). During a spontaneous breech birth, the fetus comes out of the vagina without problems. The health professional just supports the fetus´s body as it emerges from the birth canal.
A health professional may need to help deliver the upper part of the fetus´s body (partial breech extraction). During a partial breech extraction, a health professional pulls gently downward on the fetus and rotates its body as needed to deliver the shoulders, arms, and head. Occasionally, a health professional may need to help the fetus during the entire delivery (total breech extraction). This is usually done only when the fetus is having problems and needs to be delivered as quickly as possible.
During a partial or total breech extraction, the health professional may need to reach into the birth canal in order to move part of the fetus into a better position for delivery. If the health professional is having difficulty delivering the fetus´s head, forceps may be used to guide the head through the birth canal. Forceps may also be used to speed delivery if the fetus is in danger.

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A deep vein thrombosis (DVT) is a blood clot that forms in a deep vein. Veins are blood vessels that take blood towards the heart. Deep veins in the leg run through the muscles of the calf and thighs. The most common sites for a DVT during pregnancy and after birth are in a vein in the leg (especially the “calf or thigh) or in the pelvis (lower part of abdomen).
Treatment is with an injection of heparin. This medication is said to ´thin the blood´ (an anti-coagulant). There are different types of heparin. The type that is commonly chosen in pregnancy is low molecular weight heparin (LMWH). Heparin is safe to give during pregnancy because it does not cross the placenta.

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The following table explains the different types of abortions that may occur during a pregnancy:

The above patient most likely has had a complete abortion.

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Controlled trials have shown that delaying the first breastfeeding session until more than 2 hours after delivery, test weighing to determine the, amount of milk ingested, and provision of formula samples to nursing mothers all substantially decreases the proportion of women successfully nursing by the first postpartum visit. Test weighing has also been shown to be inaccurate and unreliable. Ointment containing vitamins A and D was worse than nothing in clinical trials: the main effective preventive and remedial measure for sore nipples is correct positioning of the baby´s mouth on the breast. New mothers should be taught the breastfeeding basics, including the fact that milk supply adjusts to the infant´s demands, i.e., the frequency, vigor, and duration of suckling.

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A recent Canadian research study about the treatment of asymptomatic bacterial vaginosis in pregnancy, asked the question:
“Vaginal swabs done at routine antenatal visits frequently come back positive for Gardnerella vaginalis, but most of the women have no symptoms of bacterial vaginosis (BV). Is there any benefit to treating these women?
Their study concluded: Treating pregnant women with clinically asymptomatic BV does not reduce rates of preterm delivery or decrease numbers of low- birth-weight babies. Results of subgroup analysis also suggest there is no benefit in treating high-risk pregnant women with asymptomatic BV. Although common practice would be to treat these high-risk women, this practice is not supported by-results reported in the study.

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Preeclampsia is pregnancy-induced hypertension plus proteinuria. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Preeclampsia and eclampsia develop between 20 weeks gestation and the end of the 1st week postpartum. Preeclampsia may be asymptomatic or may cause edema or excessive weight gain. Other signs may include increased reflex reactivity, indicating neuromuscular irritability, which can progress to seizures (eclampsia). Preeclampsia is diagnosed when pregnant women have new-onset hypertension (BP ≥ 140/90 mm Hg) plus unexplained proteinuria of ≥ 1+ on dipstick.
Definitive treatment is delivery. Patients with severe preeclampsia or with eclampsia are often admitted to the ICU. As part of stabilization, these patients are given IV fluids to increase urine output and IV Mg sulfate to stop or prevent seizures.

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The decision of whether to have a termination of pregnancy is a deeply personal one. This patient has just been notified that she is pregnant with a 10-week fetus. She is unsure whether she wants to keep her pregnancy or terminate it. In this setting, the most appropriate next step is to counsel the patient regarding her options or refer the patient for counseling. In a balanced way, the patient should be fully informed of all of her options including raising the child herself, placing the child up for adoption, and abortion. To notify the patient´s parents (choice B) is not appropriate. Such an act would violate the patient´s confidentiality. A 34-year-old woman is an adult and issues of parental notification do not apply. To notify the patient´s partner (choice C) is not appropriate.

This notification would also violate confidentiality. To schedule a termination of pregnancy (choice D) would not be appropriate. This patient has just informed the physician that she is unsure what she wants to do. To just go ahead and schedule the termination without proper counseling of the patient would not be a balanced or proper approach for the patient. To tell the patient that she is likely to have a miscarriage (choice E) is inappropriate. This patient may have a miscarriage, as might any patient with a first trimester pregnancy. However, once an intrauterine pregnancy with fetal cardiac activity is identified, the risk of miscarriage is approximately 10%. Therefore, she is most likely not to have a miscarriage.

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Mitral valve prolapse affects approximately 5% of women of childbearing age. Consequently, the issue of mitral valve prolapse and the need for antibiotics comes up quite often in obstetrics, particularly with delivery (either vaginal delivery or cesarean delivery). Bacterial endocarditis is a life-threatening infection that can develop in patients with structural cardiac disease who are exposed to bacteremia.

The risk for any given procedure depends upon the nature of the procedure itself and on the nature of the cardiac lesion. Periodically, the American Heart Association publishes guidelines for the prevention of bacterial endocarditis. According to the American Heart Association guidelines, antibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery. The possible exception to this is for patients with “high risk” cardiac conditions, which includes women with a history of endocarditis or who have prosthetic heart valves, complex cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts. Mitral valve prolapse, if associated with mitral regurgitation (demonstrated by Doppler or a murmur), is considered a moderate risk condition and, therefore, antibiotic prophylaxis is not necessary. This patient, therefore, does not require antibiotics prior to, during, or after her cesarean delivery. To administer intravenous antibiotics 30 minutes prior to the procedure (choice A), immediately after the procedure (choice B), 24 hours after the procedure (choice C), or to administer oral antibiotics 6 hours after the procedure (choice D) would all be unnecessary. As explained above, the reason for administering antibiotics to women with structural cardiac disease is to prevent bacterial endocarditis. Bacterial endocarditis is a potentially fatal condition.

However, there are different degrees of structural cardiac disease. Mitral valve prolapse with regurgitation is considered to be a moderate risk condition. The American Heart Association does not recommend endocarditis prophylaxis for women with moderate risk conditions undergoing vaginal or cesarean delivery.

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