PREGNANCY JOURNAL PDF
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The unpublished literature includes registered studies, unpublished theses or research, and meeting reports. Whilst there is no language restriction, the focus to date has been on the European family of languages and predominantly English.
Entries are categorized according to reference type, content and topic. The reference types include journal article, report, thesis, book or book chapter, conference proceeding abstract , registered study, and other e.
Categories are not mutually exclusive such that single entries can contribute to multiple categories. Items which are both available in English and another language are categorized as English.
A Review of Antibiotic Use in Pregnancy
Entries obtained from clinical trial registries are removed from the library once publications of data from the registered studies are entered in the database, to avoid double entries of included studies.
A similar procedure is maintained for conference proceedings abstracts. In the postpartum period there is a high risk of a bipolar episode and hospitalization for psychiatric morbidity Munk-Olsen et al. A perinatal history of affective psychosis or depression is the most important risk factor, as reported in a recent cohort study investigating risk factors for postpartum recurrence in bipolar disorder Di Florio et al. Unfortunately, this study did not investigate the effect of medication use during pregnancy on the risk of recurrence.
Of these 60 patients with prophylactic medication during pregnancy, the majority used lithium Bergink et al.
Hence, lithium prophylaxis during pregnancy in women with bipolar disorder might be important not only to maintain mood stability during pregnancy, but also for postpartum relapse prevention.
Interestingly, a recent population based cohort study reported that lamotrigine during pregnancy was not inferior to lithium in the prevention of severe postpartum episodes Wesseloo et al. However, the authors point out the likely influence of confounding by indication since lamotrigine was primarily prescribed to women with a vulnerability for depressive episodes, while lithium was primarily prescribed to women with a history of manic episodes.
Physiological changes in pregnancy
Therefore, this finding requires replication in studies that can account for diagnosis, variant and severity of illness. Dosing and monitoring of blood levels during pregnancy and around delivery Lithium has a narrow therapeutic range of 0.
Excretion of lithium is almost exclusively renal, hence blood plasma levels mainly depend on intravascular volume and glomerular filtration rate GRF Oruch et al.
As pregnancy progresses total body water, plasma volume and GFR are increased Pariente et al. Clinical studies have shown lithium blood levels to decrease significantly during pregnancy Wesseloo et al. Creatinine blood levels showed a similar longitudinal pattern, showing that indeed changes in lithium blood level reflect changes in renal physiology.
Management of Severe Epistaxis during Pregnancy: A Case Report and Review of the Literature
In summary, first and second trimester are characterised by a significant decrease of lithium blood levels with a risk of subtherapeutic levels. In third trimester and the postpartum, lithium levels gradually return to their preconception level which implicates that in this period clinicians need to be aware of the risk of lithium intoxication.
Close monitoring and dose adjustment is needed with conditions such as hyperemesis gravidarum, pre-eclampsia, impaired renal function, concomitant medication or acute blood loss occur, as these conditions increased the risk of toxicity Handler ; Blake et al. There is a minimal fall at term.
An increase in stroke volume is possible due to the early increase in ventricular wall muscle mass and end-diastolic volume but not end-diastolic pressure seen in pregnancy. The heart is physiologically dilated and myocardial contractility is increased. Although stroke volume declines towards term, the increase in maternal heart rate 10—20 bpm is maintained, thus preserving the increased cardiac output. Blood pressure decreases in the first and second trimesters but increases to non-pregnant levels in the third trimester There is a profound effect of maternal position towards term upon the haemodynamic profile of both the mother and foetus.
In the supine position, pressure of the gravid uterus on the inferior vena cava IVC causes a reduction in venous return to the heart and a consequent fall in stroke volume and cardiac output.
Pregnancy & Child Birth
Pregnant women should therefore be nursed in the left or right lateral position wherever possible. If the woman has to be kept on her back, the pelvis should be rotated so that the uterus drops to the side and off the IVC, and cardiac output and uteroplacental blood flow are optimised.
Reduced cardiac output is associated with a reduction in uterine blood flow and therefore in placental perfusion, which could compromise the foetus. Although both blood volume and stroke volume increase in pregnancy, pulmonary capillary wedge pressure and central venous pressure do not increase significantly.
Pulmonary vascular resistance PVR , like systemic vascular resistance SVR , decreases significantly in normal pregnancy.
Pulmonary oedema will be precipitated if there is either an increase in cardiac pre-load such as infusion of fluids or increased pulmonary capillary permeability such as in pre-eclampsia or both.
Cardiac output is increased between contractions but more so during contractions. Following delivery there is an immediate rise in cardiac output due to relief of the inferior vena cava obstruction and contraction of the uterus, which empties blood into the systemic circulation.
Transfer of fluid from the extravascular space increases venous return and stroke volume further.
Those women with cardiovascular compromise are therefore most at risk of pulmorary oedema during the second stage of labour and the immediate postpartum period. Cardiac output has nearly returned to normal pre-pregnancy values two weeks after delivery, although some pathological changes e.
The above physiological changes lead to changes on cardiovascular examination that may be misinterpreted as pathological by those unfamiliar with pregnancy. The murmur may be loud and audible all over the precordium, with the first heart sound loud and possibly sometimes a third heart sound. There may be ectopic beats and peripheral oedema.
Normal findings on ECG in pregnancy that may partly relate to changes in the position of the heart include: atrial and ventricular ectopics Q wave small and inverted T wave in lead III ST-segment depression and T-wave inversion in the inferior and lateral leads left-axis shift of QRS.
Adaptive changes in renal vasculature The primary adaptive mechanism in pregnancy is a marked fall in systemic vascular resistance SVR occurring by week six of gestation. The fall in SVR is combined with increased renal blood flow and this is in contrast to other states of arterial under-filling, such as cirrhosis, sepsis or arterio-venous fistulas.
Serum concentrations of relaxin, already elevated in the luteal phase of the menstrual cycle, rise after conception to a peak at the end of the first trimester and fall to an intermediate value throughout the second and third trimester.
Relaxin stimulates the formation of endothelin, which in turn mediates vasodilation of renal arteries via nitric oxide NO synthesis.Valsalva maneuvers could also aggravate the bleeding during labor, increasing the risk of fetal hypoxia. The exact underlying mechanism is not clear but pregnancy-associated hormones such as human chorionic gonadotropin hCG , oestrogen and progesterone could to be involved in the aetiology.
However the peak demand for calcium is only in the third trimester.
The levels of hCG peak at the end of the first trimester when the trophoblast is most actively producing hCG, correlating with the nausea symptoms. Plasma volume increases progressively throughout normal pregnancy.
This increased risk is present from the first trimester and for at least 12 weeks following delivery. In normal pregnancies the total protein concentration in urine does not increase above the upper normal limit.