Patients with a first episode of idiopathic venous thromboembolism should be treated with anticoagulant agents for longer than three months.

Conventional-intensity warfarin therapy is more effective than low-intensity warfarin therapy for the long-term prevention of recurrent venous thromboembolism. The low-intensity warfarin regimen does not reduce the risk of clinically important bleeding.

Although maternal mortality has declined steadily over the past 2 decades, the proportion of heart disease among all causes of mortality has remained unchanged. Reported rates of heart disease in pregnancy range from 0.9% to 3.7%. The authors retrospectively studied 207 pregnancies encountered in the years 1994 to 2000 at a tertiary care center. These women had cardiac disease and delivered at or after 28 weeks gestation. Those whose cardiac status was becoming worse or who were already in New York Heart Association (NYHA) class III/IV were hospitalized. Heparin treatment was stopped when labor began. Labor was induced only for obstetric reasons, using oxytocin cautiously. All women were kept propped up and given oxygen intermittently, and the second stage of labor was shortened if indicated by using outlet forceps or vacuum extraction. A majority of these women were multigravidas and ranged in age from 18 to 35 years. Rheumatic heart disease was present in 88% of pregnancies, most often in the form of isolated mitral stenosis. Another 24 women had congenital heart disease. Pregnancies occurred an average of 6.6 years after the diagnosis of heart disease, but in 13% of cases, it was diagnosed during the index pregnancy. One in 5 women were in NYHA class III/IV at the first antenatal visit. New-onset cardiac complications occurred in 30% of pregnancies. Women in NYHA classes I/II had fewer complications, and their infants were heavier at birth than those in the class III/IV group. The hospitalization rate before 37 weeks gestation was 55%, and the mean hospital stay was 2 weeks. All but 20% of women delivered vaginally. The cesarean section rate was 46% in women with the most advanced cardiac disease. Fetal complications occurred in 20% of pregnancies but there were no infant deaths. Cardiac interventions were necessary before pregnancy in 61% of women with rheumatic heart disease. Both maternal and fetal outcomes were better in women with prosthetic valves, a large majority of whom remained in NYHA class I/II. Ten women had interventions while pregnant; one of them developed congestive heart failure during labor. None of 41 newborn infants whose mothers had received anticoagulants had congenital malformations. These results emphasize the need for prepregnancy counseling of women with heart disease to ensure close surveillance during pregnancy. Early diagnosis is important, as is the surgical correction of cardiac lesions when indicated. OBSTETRICSVolume 59, Number 2 OBSTETRICAL AND GYNECOLOGICAL SURVEY ABSTRACT Even women with uncomplicated pregnancies frequently have nausea and vomiting and, when this is severe or longlasting, drug treatment is often indicated. Meclozine is an antihistamine that has been widely used in Sweden to treat nausea and vomiting in pregnancy (NVP), but other countries warn against its use. Studies in rats have suggested a teratogenic risk, although available epidemiologic studies are limited. This prospective study examined outcomes of delivery in 16,536 women who reported having used m...

We sought to determine whether thrombophilic defects increase recurrent venous thromboembolism (VTE) during warfarin therapy. Six hundred sixty-one patients with unprovoked VTE who were randomized to extended low-intensity (international normalized ratio

Duration of anticoagulant therapy for venous thromboembolism provoked by a transient risk factor should not be reduced from 3 months to 1 month as this is likely to increase recurrent venous thromboembolism without achieving a clinically important decrease in bleeding.

The vasoconstrictor effect, the binding, and the response of inositol phosphates to endothelin-1 (ET-1) were investigated in blood vessels of deoxycorticosterone acetate (DOCA) -salt hypertensive rats within 2 weeks of development of hypertension and in uninephrectomized control rats. In DOCA-salt and uninephrectomized rats, plasma levels of endothelin were similar (1.2±0.1 fmol/ml). Thoracic aorta and mesenteric artery rings devoid of endothelium presented significantly decreased responses to increasing concentrations of ET-1. Binding of ET-1 to mesenteric artery membranes was significantly lower in DOCA-salt rats (106±22 fmol/mg protein) than in uninephrectomized rats (172 ±19 fmol/mg protein, p< 0.05), whereas affinity was similar. Phosphoinositide metabolism was examined in aorta and mesenteric arteries after incubation with The endothelium synthesizes and releases paracrine hormones that regulate the contraction and physiology of vascular smooth muscle cells. 4 In addition to the well-described vasorelaxant factors (i.e., endo-

The transient increase in norepinephrine levels observed with NPA and the sustained increases in norepinephrine levels observed after chronic treatment with amlodipine suggest that sympathetic activation occurs with those two drugs. The lack of increase in norepinephrine levels after administration of NGITS suggests that this formulation does not activate the sympathetic system. The lowering of epinephrine levels after administrations of NGITS and amlodipine suggests that inhibition of release of epinephrine by the adrenal medulla occurs with longer-acting dihydropyridine formulations.

The effects of beta-blockade on muscle utilization of glycogen and triglycerides, as well as potassium metabolism, were studied in eight healthy male subjects performing long-duration exercise to exhaustion. Subjects were studied after treatment with either placebo (PLAC), beta 1-selective (atenolol, 100 mg/day, AT), or nonselective beta-blockade (nadolol, 80 mg/day, NAD) each for 1 wk according to a randomized, double-blind, cross-over design. NAD and AT caused identical decreases in exercise heart rates, but endurance (71 +/- 8 min with PLAC) decreased significantly more with NAD (-33 +/- 4%) than with AT (-14 +/- 6%). Muscle glycogen breakdown, taking exercise time into account, was unaffected by treatment. In contrast, muscle triglyceride utilization was completely blocked by NAD whereas it was unchanged with AT as compared to PLAC. Adipose tissue lipolysis was inhibited to a similar extent by the two beta-blockers. Serum potassium increased to higher levels at exhaustion and muscle potassium decreased to lower levels with NAD than with AT or PLAC. These results suggest that decreased utilization of muscle triglycerides combined with lack of an enhanced glycogenolysis to compensate as well as alterations in potassium metabolism contribute to the decreased exercise capacity with nonselective beta-blockade compared with beta 1-selective blockade.