Unique Case of Spontaneous Left Main Coronary Dissection in Second Trimester of Pregnancy Successfully Treated with Percutaneous Coronary Intervention: A Happy Ending

Among pregnant women, SCAD is the most frequent etiology of non-atherosclerotic acute coronary syndrome. SCAD related to pregnancy is more frequent within the first month (especially first week) of puerperium or last trimester, or is otherwise anecdotal. The concomitance of SCAD and pregnancy poses many issues regarding diagnosis and treatment in respect to maternal and fetal safety and requires tailored intervention with close interaction between clinical cardiologists, interventional cardiologists, cardiothoracic surgeons, and obstetricians. We report the case of a patient, pregnant in the second trimester with a life-threatening SCAD, successfully treated with percutaneous coronary intervention with excellent outcome for mother and baby.

Lupus Eritematosus Sistemik (LES) pada Kehamilan

Systemic lupus erythematosus (SLE) is a multi-organ autoimmune disease that can affect women of childbearing age. Pregnancy causes alterations of the immune and neuroendocrine systems. Moreover, SLE in pregnancy is associated with prematurity and preeclampsia. Confirmation of the SLE diagnosis based on anamnesis, physical examination, and laboratory results is essential to differ the similar symptoms of normal pregnancy from pregnancy with SLE, such as preeclampsia, to lupus nephritis due to differences in treatment. The management of SLE in pregnancy has begun to be well understood; therefore, immunosuppressive drugs can be administered according to the indications and fetal safety. It is essential to educate women with SLE to not get pregnant before the 6-months remission period and explain the relative contraindications to pregnancy.Keywords: systemic lupus erythematosus; pregnancy; immunosuppressive Abstrak: Lupus eritematosus sistemik (LES) merupakan suatu penyakit autoimun multi-organ yang dapat menyerang wanita usia reproduktif. Kehamilan menyebabkan perubahan pada sistem imun dan neuroendokrin. LES pada wanita hamil dihubungkan dengan kejadian kelahiran prematuritas dan preeklamsia. Penentuan diagnosis berdasarkan anamnesis, pemeriksaan fisik, dan pemeriksaan penunjang penting untuk membedakan gejala-gejala yang mirip pada kehamilan normal dengan kehamilan yang disertai LES seperti preeklamsia dengan lupus nefritis karena tatalaksana yang diberikan berbeda. Tatalaksana LES pada kehamilan telah mulai dipahami sehingga pemberian obat-obatan imunosupresif dapat diberikan sesuai dengan indikasi dan keamanan pada janin. Penting untuk mengedukasi wanita dengan LES untuk tidak hamil sebelum melewati masa remisi enam bulan dan menjelaskan kontraindikasi relatif pada kehamilan.Kata kunci: lupus eritematous sistemik; kehamilan; imunosupresif

Antibiotic Prescriptions among China Ambulatory Care Visits of Pregnant Women: A Nationwide Cross-Sectional Study

Background: Antibiotic use in pregnant women at the national level has rarely been reported in China. Objectives: We aimed to investigate antibiotic prescriptions during pregnancy in ambulatory care settings in China. Methods: Data of 4,574,961 ambulatory care visits of pregnant women from October 2014 to April 2018 were analyzed. Percentages of Antibiotic prescriptions by different subgroups and various diagnosis categories and proportions of inappropriate antibiotic prescriptions for different subgroups were estimated. Food and Drug Administration (FDA) pregnancy categories were used to describe the antibiotic prescription patterns. The 95% confidence intervals (CIs) were estimated using the Clopper––Pearson method or Goodman method. Results: Among the 4,574,961 outpatient visits during pregnancy, 2.0% (92,514 visits; 95% CI, 2.0–2.0%) were prescribed at least one antibiotic. The percentage of antibiotic prescriptions for pregnant women aged >40 years was 4.9% (95% CI, 4.7–5.0%), whereas that for pregnant women aged 26–30 years was 1.5% (95% CI, 1.4–1.5%). In addition, percentages of antibiotic prescriptions varied among different trimesters of pregnancy, which were 5.4% (95% CI, 5.3–5.4%) for the visits in the first trimester of pregnancy and 0.5% (95% CI, 0.4–0.5%) in the third trimester of pregnancy. Furthermore, the percentages of antibiotic prescriptions substantially varied among different diagnosis categories and nearly three-quarters of antibiotic prescriptions had no clear indications and thus might be inappropriate. In total, 130,308 individual antibiotics were prescribed; among these, 60.4% (95% CI, 60.0–60.8%) belonged to FDA category B, 2.7% (95% CI, 2.1–3.5%) were classified as FDA category D and 16.8% (95% CI, 16.2–17.4%) were not assigned any FDA pregnancy category. Conclusions: Antibiotic prescriptions in ambulatory care during pregnancy were not highly prevalent in mainland China. However, a substantial proportion of antibiotics might have been prescribed without adequate indications. Antibiotics whose fetal safety has not been sufficiently illustrated were widely used in pregnant women.

Canadian Association of Radiologists Recommendations for the Safe Use of MRI During Pregnancy

The use of magnetic resonance imaging (MRI) during pregnancy is associated with concerns among patients and health professionals with regards to fetal safety. In this work, the Canadian Association of Radiologists (CAR) Working Group on MRI in Pregnancy presents recommendations for the use of MRI in pregnancy, derived from literature review as well as expert panel opinions and discussions. The working group, which consists of academic subspecialty radiologists and obstetrician-gynaecologists, aimed to provide updated, evidence-based recommendations addressing safety domains related to energy deposition, acoustic noise, and gadolinium-based contrast agent use based on magnetic field strength (1.5T and 3T) and trimester scanned, in addition to the effects of sedative use and occupational exposure.

A Case of De Novo Antiglomerular Basement Membrane Disease Presenting during Pregnancy

Background. Acute kidney injury (AKI) requiring dialysis during pregnancy is uncommon. We present a case of a young female diagnosed with antiglomerular basement membrane (anti-GBM) disease during pregnancy. Case Presentation. A 23-year-old woman approximately 15 weeks pregnant experienced weakness, nausea, vomiting, and anorexia for one week and anuria for 48 hours. No known drug allergies and no significant social or family history for kidney or genitourinary disease were reported. Laboratory analysis revealed anemia, life-threatening hyperkalemia, AKI, and elevated antiglomerular basement membrane (GBM) antibodies. Renal biopsy revealed 100% cellular crescents, confirming the diagnosis. The patient was treated using plasmapheresis and methylprednisolone followed by oral steroids, azathioprine, and tacrolimus. At 24 weeks and 4 days of gestation, the patient had hypoxic respiratory failure as well as preterm premature rupture of membranes. Due to the development of infection and lack of renal recovery, immunosuppression was discontinued. At 28 weeks and 0 days of gestation, the patient developed uncontrollable hypertension requiring emergent delivery. Postpartum, her hypertension improved without signs of preeclampsia though still requires dialysis. Discussion. Pregnancy presents a unique challenge for providers treating patients with anti-GBM disease. Fetal safety should be considered and risks thoroughly discussed with the patient when choosing an immunosuppressive regimen for this condition.

The prediction and assessment of the intrauterine fetal with umbilical cord around neck well-being by daily fetal movement counting chart (DFMC)

Background Currently, FM is a sole subjective index which depends on self-assessment of pregnant women, and it can objectively reflect the well being of intrauterine fetus. It has been the focus of obstetricians' research and attention how to quantify fetal movement (FM) and change it into a relatively objective evaluation index. We sought to predict and evaluate the well being of intrauterine fetal with umbilical cord around the neck (UCAN) by performance of daily fetal movement counting chart (DFMC). Methods To retrospectively select 100-case pregnant women who met the enrolled requirements, and whether the fetal was intrauterine safety or not was predicted by analysis of the DFMC before delivery. According to the different perinatal outcomes after delivery, 100-cases pregnant women were divided into intrauterine safety (IUS) group (44 cases) and intrauterine unsafe (IUNS) group (56 cases). And the independent risk factors of fetal intrauterine safety, including maternal age, gestational week, umbilical artery systolic blood flow to diastolic blood flow ratio (S/D), amniotic fluid index (AFI), modified Fischer score of non stress test (NST), DFMC and mode of delivery were analyzed by multi-factors Binary Logistic Regression. Results Only FM and mode of delivery were independent risk factors affecting fetal safety intrauterine (all p value < 0.05). There was no remarkable difference between DFMC prediction and clinical retrospective evaluation of fetal safety in natural delivery and forceps delivery (all P value > 0.05), except in cesarean section (p < 0.05). The sensitivity, specificity and Yuden index of DFMC for predicting the intrauterine safety in natural vaginal delivery were 86.5%, 90.0% and 0.77 respectively, and in cesarean section were 66.7%, 94.6% and 0.61, respectively. Abnormal DFMC may account for the highest proportion of emergency cesarean section (87.5%, 35/40). Conclusions DFMC can effectively predict and evaluate the well being of intrauterine fetus with UCAN. At the same time, it can also provide limited clinical proofs for pregnant women with UCAN to choose model of delivery.