Obstetrical Management of an Extremely Overweight Pregnant Woman (184 kg bw) with Special Attention on Thromboprophylaxis

The 27-year-old pregnant woman has been overweight since her childhood. Endocrinological assessments did not confirm hormonal disease. Her pregnancy was without complication. A signs of intrauterine distress were observed and elective caesarean section was performed under heparin protection because of anatomy unsuitable for delivery per vias naturals. The mother’s bodyweight was 184 kg. By monitoring the change in fX activity LMWH treatment (Enoxaparin) initiated with a dose of 120 mg twice daily and then the dose was gradually elevated to 200 mg twice daily thereby achieving the lower range of the desired therapeutic effect. Apart from mild disorder of wound healing, the recovery was free of complication. The patient suffered from thrombophilia (extremely overweight, pregnant, thrombophlebitis under the knee, surgery, and postoperative immobilization). In case of quite extreme bodyweight there is no dosage recommendation or clinical practice for LMWH. Because of the extreme overweight and the therapeutic dose titration test of heparin, monitoring of fX activity by measurement of inhibition, dosage of heparin other than the recommended (abdominal wall instead of upper arm SC), and the very fluctuating heparin dosage which is well correlating with clinical practice, it is reasonably expected that this case will take interest.

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Giant fibroepithelial vulvar polyp in a pregnant woman

BMJ Case Reports ◽

10.1136/bcr-2020-236106 ◽

2021 ◽

Vol 14 (1) ◽

pp. e236106

Author(s):

Carolina Smet ◽

Tatiana Gigante Gomes ◽

Lurdes Silva ◽

Júlio Matias

Keyword(s):

Pregnant Woman ◽

Elective Caesarean Section ◽

Reproductive Age ◽

Benign Lesions ◽

Third Trimester ◽

Women Of Reproductive Age ◽

Spontaneous Bleeding ◽

The Third ◽

Fibroepithelial Polyps ◽

The Right

Fibroepithelial polyps are benign lesions that may appear in the vulvovaginal region. They usually occur in women of reproductive age and tend to grow up to 5 cm, but there are some rare cases in which they grow up to 20 cm. We report a case of a 22-year-old woman in the third trimester of her first pregnancy with spontaneous bleeding from a pedunculated mass measuring 15 cm in the widest diameter on the right side of the vulva. Features of this case are discussed as well as its implications, especially regarding the decision of labour. Due to the big size of the mass and its propensity to bleed, we decided to perform an elective caesarean section as well as its excision.

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Antibacterial therapy during pregnancy and breastfeeding

Vrač skoroj pomoŝi (Emergency Doctor) ◽

10.33920/med-02-2107-01 ◽

2021 ◽

pp. 6-20

Author(s):

A.G. Zamalutdinova ◽

L.Yu. Kulagina ◽

\A.Z. Nigmedzyanova ◽

E.V. Kanner ◽

M.L. Maksimov

Keyword(s):

Body Weight ◽

Clinical Practice ◽

Pregnant Woman ◽

Lower Limit ◽

Antibacterial Therapy ◽

Mechanism Of Action ◽

Therapeutic Efficacy ◽

Clinical Microbiology ◽

The Body ◽

Medicinal Products

The use of drugs during pregnancy and breastfeeding remains one of the least studied, but important issues in pharmacology today. When choosing medicinal products during pregnancy, one of the crucial principles is to ensure the safety of the embryo and fetus. Among the generally accepted rules aimed at eliminating fetal risk, a decrease in the dosage of the drug to the lower limit of the therapeutic range is usually named. However, one should take into account the changes that occur in the body of a pregnant woman: the body weight and the volume of circulating blood rise, the excretion of drugs is accelerated (the clearance increases), which, on the contrary, requires an increase in the dosages of individual drugs to maintain therapeutic efficacy. Antibacterial drugs (ABD) are the most difficult group of drugs to use, since they require taking into account not only the mechanism of action of drugs, but also the basics of clinical microbiology. ABD occupy a special place in clinical practice, as they are one of the most frequently prescribed classes of drugs.

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Postoperative use of slow-release opioids: The impact of the Australian and New Zealand College of Anaesthetists/Faculty of Pain Medicine position statement on clinical practice

Anaesthesia and Intensive Care ◽

10.1177/0310057x20956664 ◽

2020 ◽

Vol 48 (6) ◽

pp. 444-453

Author(s):

Adeline CH Tan ◽

Bernadette A Bugeja ◽

David A Begley ◽

Jennifer A Stevens ◽

Kok-Eng Khor ◽

...

Keyword(s):

Clinical Practice ◽

New Zealand ◽

Odds Ratio ◽

Slow Release ◽

Immediate Release ◽

Prescribing Patterns ◽

Dose Titration ◽

Pain Medicine ◽

Zealand College ◽

The Impact

Dose titration with immediate-release opioids is currently recommended for acute pain. The Australian and New Zealand College of Anaesthetists and the Faculty of Pain Medicine released a statement in March 2018 supporting their use in the treatment of opioid-naïve patients; however, the impact of this statement on clinical practice is currently unknown. This retrospective cohort study was conducted to compare opioid prescribing patterns before and after the release of the recommendations. Data were collected on 184 patients (2017, n = 78; 2018, n = 106) admitted to the Prince of Wales Hospital in November 2017 and 2018, which consisted of demographic data, opioid prescriptions and discharge opioid information. The main outcome is the number of prescriptions of slow-release opioids in 2017 versus 2018 after the recommendations were published. Confounding factors were accounted for using logistic and multiple regression as appropriate. There was a 29% decrease in slow-release opioid prescriptions during hospitalisation ( n = 31, 40% versus n = 12, 11%; P < 0.001) and 17% decrease at discharge ( n = 20, 26% versus n = 9, 9%; P = 0.02) post-publication. After adjusting for confounders, the odds of slow-release opioids being prescribed postoperatively and at discharge reduced by 86% and 88%, respectively (postoperative period: odds ratio 0.14, P < 0.05; discharge: odds ratio 0.12, P < 0.05). In addition, orthopaedic patients were more likely to receive slow-release opioids, consistent with existing literature. As the use of slow-release opioids has been associated with increased harm and protracted opioid use compared to immediate-release opioids, it is hoped that wider dissemination of these recommendations and a change in prescribing practice can be a step towards overcoming the opioid crisis.

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Pyelonephritis of Pregnant Women: Clinical Case

Herald Urology ◽

10.21886/2308-6424-2020-8-1-55-58 ◽

2020 ◽

Vol 8 (1) ◽

pp. 55-58 ◽

Cited By ~ 1

Author(s):

S. V. Shkodkin ◽

Yu. B. Idashkin

Keyword(s):

Clinical Practice ◽

Pregnant Woman ◽

Urinary Tract ◽

Pregnant Women ◽

Clinical Case ◽

Upper Urinary Tract ◽

Negative Side ◽

Urinary Drainage ◽

Clinical Observations ◽

Inflammatory Changes

Pyelonephritis during pregnancy is a threat to the fetus and the pregnant woman. There are no studies showing the benefits of drainage management for pregnant women with pyelonephritis. Despite this, the drainage of the upper urinary tract is a tradition of a fairly large number of clinics. Guidelines for the duration of drainage in this category of patients are also not defined. Frequently, drainage is removed after delivery. And this is the «standard» in clinical practice. The negative side of this approach is persistent drainage infection, obstruction, and the need for frequent drainage changes. The article presents the clinical observations of patients with early removal of urinary drainage, which made it possible to stop bacteriuria and inflammatory changes in the urine.

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Placental pathology in a pregnant woman with severe COVID-19 and successful ECMO treatment: a case report

BMC Pregnancy and Childbirth ◽

10.1186/s12884-021-04228-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Anna Rosner-Tenerowicz ◽

Tomasz Fuchs ◽

Aleksandra Zimmer-Stelmach ◽

Michał Pomorski ◽

Martyna Trzeszcz ◽

...

Keyword(s):

Pregnant Woman ◽

Pregnant Women ◽

Elective Caesarean Section ◽

Good Condition ◽

Intrauterine Infection ◽

Coagulation System ◽

Multidrug Therapy ◽

Plasma Therapy ◽

Severe Condition ◽

Ecmo Treatment

Abstract Background Infection with SARS-CoV-2 during pregnancy can lead to a severe condition in the patient, which is challenging for obstetricians and anaesthesiologists. Upon severe COVID-19 and a lack of improvement after multidrug therapy and mechanical ventilation, extracorporeal membrane oxygenation (ECMO) is introduced as the last option. Such treatment is critical in women with very preterm pregnancy when each additional day of the intrauterine stay is vital for the survival of the newborn. Case presentation We report a case of a 38-year-old woman at 27 weeks of gestation treated with multidrug therapy and ECMO. The woman was admitted to the intensive care unit (ICU) with increasing fever, cough and dyspnoea. The course of the pregnancy was uncomplicated. She was otherwise healthy. At admission, she presented with severe dyspnoea, with oxygen saturation (SpO2) of 95% on passive oxygenation, heart rate of 145/min, and blood pressure of 145/90. After confirmation of SARS-CoV-2 infection, she received steroids, remdesivir and convalescent plasma therapy. The foetus was in good condition. No signs of an intrauterine infection were visible. Due to tachypnea of 40/min and SpO2 of 90%, the woman was intubated and mechanically ventilated. Due to circulatory failure, the prothrombotic activity of the coagulation system, further saturation worsening, and poor control of sedation, she was qualified for veno-venous ECMO. An elective caesarean section was performed at 29 weeks on ECMO treatment in the ICU. A preterm female newborn was delivered with an Apgar score of 7 and a birth weight of 1440 g. The newborn had no laboratory or clinical evidence of COVID-19. The placenta showed the following pathological changes: large subchorionic haematoma, maternal vascular malperfusion, marginal cord insertion, and chorangioma. Conclusions This case presents the successful use of ECMO in a pregnant woman with acute respiratory distress syndrome in the course of severe COVID-19. Further research is required to explain the aetiology of placental disorders (e.g., maternal vascular malperfusion lesions or thrombotic influence of COVID-19). ECMO treatment in pregnant women remains challenging; thus, it should be used with caution. Long-term assessment may help to evaluate the safety of the ECMO procedure in pregnant women.

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Anticholinergic therapy of an overactive bladder: clinical practice aspects

Russian Medical Inquiry ◽

10.32364/2587-6821-2021-5-5-273-279 ◽

2021 ◽

Vol 5 (5) ◽

pp. 273-279

Author(s):

I.V. Kuzmin ◽

◽

S.V. Kuzmina ◽

◽

Keyword(s):

Decision Making ◽

Clinical Practice ◽

Overactive Bladder ◽

Anticholinergic Drug ◽

Multiple Criteria Decision Making ◽

Multiple Criteria ◽

Vulnerable Groups ◽

Dose Titration ◽

Clinical Aspects ◽

Anticholinergic Therapy

The review presents data on the epidemiology, clinical course and modern methods to the treatment of overactive bladder. It also describes the pharmacological bases of anticholinergic drug use, which are first-line in the treatment of this disease. The pharmacological and clinical aspects of the new M-holinoblocker, fesoterodine, are considered. The drug belongs to the competitive blockers of M2-and M3-cholinergic receptors. The conducted studies have shown the high clinical efficacy of fesoterodine. Due to the low lipophilicity and large molecular weight, the drug’s ability to penetrate the blood-brain barrier is minimal, which causes a low frequency of adverse events from the central nervous system. The pharmacokinetic and pharmacodynamic properties of fesoterodine allow it to be prescribed to "vulnerable" groups of patients — the elderly, patients with CNS diseases and cognitive disorders. According to the FORTA system, fesoterodine is the only antimuscarinic drug classified in category B. The results of a multiple-criteria decision-making showed a favorable benefit-risk profile of fesoterodine, prescribed according to a flexible dosage regimen of 4 mg and 8 mg. Important benefits of fesoterodine are the convenience of intake, the possibility of dose titration, as well as the ratio of treatment costs and its efficacy. The practical issues of using fesoterodine in various clinical cases are considered. KEYWORDS: overactive bladder, anticholinergic therapy, fesoterodine, multiple-criteria decision-making, FORTA classification. FOR CITATION: Kuzmin I.V., Kuzmina S.V. Anticholinergic therapy of an overactive bladder: clinical practice aspects. Russian Medical Inquiry. 2021;5(5):273–279 (in Russ.). DOI: 10.32364/2587-6821-2021-5-5-273-279.

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ESE audit on management of Adult Growth Hormone Deficiency in clinical practice

Acta Endocrinologica ◽

10.1530/eje-20-1180 ◽

2020 ◽

Author(s):

Luciana Maria Martel-Duguech ◽

Jens Otto L. Jorgensen ◽

Marta Korbonits ◽

Gudmundur Johannsson ◽

Susan M Webb ◽

...

Keyword(s):

Clinical Practice ◽

Educational Status ◽

Normal Serum ◽

European Countries ◽

Hormone Deficiency ◽

Dose Titration ◽

Childhood Onset ◽

Adult Growth ◽

Igf I ◽

Healthcare Administrators

Guidelines recommend adults with pituitary disease in whom GH therapy is contemplated, to be tested for GH deficiency (AGHD); however, clinical practice is not uniform. Aims: 1) To record current practice of AGHD management throughout Europe and benchmark it against guidelines; 2) To evaluate educational status of healthcare professionals about AGHD. Design: On-line survey in endocrine centres throughout Europe. Patients and Methods: Endocrinologists voluntarily completed an electronic questionnaire regarding AGHD patients diagnosed or treated in 2017-2018. Results: Twenty-eight centres from 17 European countries participated, including 2139 AGHD patients, 28% of childhood-onset GHD. Aetiology was most frequently non-functioning pituitary adenoma (26%), craniopharyngioma (13%) and genetic/congenital mid-line malformations (13%). Diagnosis of GHD was confirmed by a stimulation test in 52% (GHRH+arginine, 45%; insulin-tolerance, 42%, glucagon, 6%; GHRH alone and clonidine tests, 7%); in the remaining, ≥3 pituitary deficiencies and low serum IGF-I were diagnostic. Initial GH dose was lower in older patients, but only women <26 years were prescribed a higher dose than men; dose titration was based on normal serum IGF-I, tolerance and side-effects. In one country, AGHD treatment was not approved. Full public reimbursement was not available in four countries and only in childhood-onset GHD in another. AGHD awareness was low among non-endocrine professionals and healthcare administrators. Postgraduate AGHD curriculum training deserves being improved. Conclusion: Despite guideline recommendations, GH replacement in AGHD is still not available or reimbursed in all European countries. Knowledge among professionals and health administrators needs improvement to optimize care of adults with GHD.

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The use of beta-blockers in patients with chronic obstructive pulmonary disease and chronic heart failure in real clinical practice

South Russian Journal of Therapeutic Practice ◽

10.21886/2712-8156-2021-2-1-70-75 ◽

2021 ◽

Vol 2 (1) ◽

pp. 70-75

Author(s):

N. A. Karoli ◽

A. V. Borodkin ◽

A. P. Rebrov

Keyword(s):

Heart Failure ◽

Chronic Obstructive Pulmonary Disease ◽

Clinical Practice ◽

Chronic Heart Failure ◽

Pulmonary Disease ◽

Beta Blockers ◽

Dose Titration ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

Real Clinical Practice

Objective: to reveal the features of the use of beta-blockers (BB) in patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) in real clinical practice.Materials and methods: the study included 90 patients with COPD and CHF, and 41 patients with CHF of ischemic genesis without COPD.Results: patients with COPD and CHF were significantly less likely to receive beta-blockers (BB) compared with patients with CHF. Of the BB patients with COPD and CHF were primarily prescribed bisoprolol, its average dose was 4.45 ± 1.74 mg per day. Patients with COPD and CHF of ischemic genesis of BB were prescribed significantly more often, and diuretics were significantly less likely than patients with COPD and CHF without myocardial infarction. Patients with COPD and CHF with ejection fraction of the left ventricle (LVEF) more than 40% were less likely to take BB than patients with COPD and CHF with reduced EF (less than 40%), and also less frequently, than patients with CHF without COPD with LVEF more than 40%.Conclusion: BB, as first-line drugs in the treatment of CHF, was prescribed on an outpatient basis only to half of patients with COPD and CHF, which does not comply with current guidelines for the management of patients with comorbid conditions. In the vast majority of cases, highly selective BB were prescribed. It should be noted low doses of BB, the absence of dose titration, which does not correspond to modern recommendations for the treatment of chronic heart failure.

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Anticoagulants

Fibrinolytic and Antithrombotic Therapy ◽

10.1093/oso/9780195155648.003.0036 ◽

2006 ◽

Author(s):

Richard C. Becker ◽

Frederick A. Spencer

Keyword(s):

Clinical Practice ◽

Prothrombin Time ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Plasma Concentrations ◽

Therapeutic Index ◽

Dose Titration ◽

Direct Thrombin Inhibitors ◽

Factor V ◽

High Concentrations

Because of the narrow therapeutic index of warfarin and unfractionated heparin (UFH), monitoring their anticoagulant effects is required. On the other hand, lowmolecular- weight heparin (LMWH) and fibrinolytic agents need to be monitored only under certain circumstances. Although newer anticoagulants will not require routine monitoring for dose titration, a means to determine their systemic effects and individual (patient-specific) response to administration will likely have roles in clinical practice. The prothrombin time is used to monitor vitamin K antagonist therapy. This test is sensitive to the plasma concentrations (activity) of clotting factors II (prothrombin), V, VII, and X. Vitamin K antagonists affect the vitamin K–dependent factors II, VII, IX, and X, as well as proteins C, S, and Z. Thus, the prothrombin time does not reflect the effect of vitamin K antagonists on some factors (IX and proteins C, S, and Z) and is sensitive to others (factor V) (not directly influenced by treatment). The prothrombin time is not an ideal test for monitoring vitamin K antagonists; however, its simplicity and widespread availability have established its place in clinical practice. By convention, prothrombin times are now reported as international normalized ratios (INRs). This is the ratio of the patient’s prothrombin time to a control prothrombin time, raised to a power—the international sensitivity index (ISI). The latter reflects the calibration of the thromboplastin used for the prothrombin time testing to an internationally agreed upon standard. In many laboratories the reagent currently used is a recombinant thromboplastin, which has an ISI of 1.0 There are several cautions related to interpreting the results of prothrombin time tests that are worth monitoring. Since the test is sensitive to the level of factor V in the plasma, improper sample storage or delayed testing may cause loss of factor V (activity) and yield prothrombin time values above the expected range. High concentrations of heparin may also prolong the prothrombin time; this usually occurs when the sample is obtained within a few minutes of administering a bolus dose. Direct thrombin inhibitors, such as hirudin, bivalirudin, argatroban, and ximelagatran, may also prolong the prothrombin time to a variable degree.

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