Post-laparoscopic pain is multi-factorial and many modes of perioperative analgesia have been proposed. We present the case of a patient who experienced severe abdominal pain following gynaecologic laparoscopy. Repeat laparoscopy revealed small bowel hypermotiliy which was successfully treated with intravenous (i.v.) hyoscine butylbromide. Neostigmine, a widely used muscle relaxant reversal agent, is known to increase small bowel motility. Intravenous hyoscine butylbromide is a rapid treatment of neostigmine-induced small bowel hypermotility post-laparoscopy.
BackgroundWomen with RA have increased risk of complications including preeclampsia, low birth weight babies and Caesarean sections compared with unaffected women.1 Higher levels of disease activity have a negative influence on birth weight.2 More women are being treated with biologic agents, and there is growing evidence for their safe use in pregnancy.3
ObjectivesTo assess disease activity during pregnancy, and to review foetal and maternal outcomes.MethodsRetrospective review of case notes.ResultsBetween 2002 and 2013, 17 women with RA treated with biologic agents attended the combined clinic. 13 were treated with Etanercept, 2 Adalimumab, 1 Tocilizumab and 1 Rituximab. 13 were in combination with disease modifying anti-rheumatic agents (DMARDs). There were 17 pregnancies. 2 women stopped their biologic prior to conception; 14 stopped on confirmation of pregnancy. 12 women had active disease during pregnancy. All had some form of steroid treatment, 3 had a DMARD introduced, and 1 restarted Etanercept at 20 weeks.There were 14 live births and 2 first trimester miscarriages. There was 1 elective Caesarean section, 7 spontaneous deliveries, and 5 inductions, 3 of which proceeded to Caesarean. Data is missing for 2 women. 10 babies were born at term, 3 were pre-term and data is missing for 2. 2 babies weighed less than 2500 g and 2 more than 4500 g. Data is missing for 3 babies. The low birth weight babies were also pre-term, had cardiac abnormalities and required admission to the neonatal unit. Both mothers had stopped Etanercept at confirmation of pregnancy. Both flared during pregnancy.6 women developed complications: hypertension, diabetes, proteinuria, cervical incompetence, and hypothyroidism. 4 of these had active disease during their pregnancies. 2 babies had intrauterine growth restriction, 2 cardiac abnormalities and 1 macrosomia. All had mothers who flared during pregnancy.ConclusionsOur group of patients is small, but the outcomes are comparable to those of women with RA. There is no discernible increase in adverse events due to biologic use. In 2014 product recommendations were to stop biologics prior to conception.4 Since 2016 the British Society for Rheumatology has advised that Etanercept and Adalimumab are compatible with use in the first and second trimesters. Tocilizumab and Rituximab should still be stopped prior to conception.3 Local practice has changed to reflect this guidance, and the next step in this project is to review the data from more recent pregnancies to determine whether more prolonged use of biologics improves disease control and in turn foetal and maternal outcomes.References[1] Lin H, et al. Increased risk of adverse pregnancy outcomes in women with rheumatoid arthritis. Annals of the Rheumatic Diseases2010;69(4):715–7.[2] de Man Y, et al. Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight. Arthritis & Rheumatism60:3196–3206.[3] Flint J, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding—Part I. Rhe...
Introduction
Chronic renal impairment is associated with adverse obstetric outcomes including pre-eclampsia, prematurity and intra-uterine growth restriction. Pregnancy can accelerate decline in renal function: degree of deterioration is dependent on pre-pregnancy renal function, underlying diagnosis and association with chronic hypertension and proteinuria.
Methods
This retrospective longitudinal cohort study investigated obstetric outcomes and pregnancy-related changes in renal function in patients attending a tertiary renal antenatal clinic over a 5 year period. Details of renal function pre-pregnancy, during each trimester and postpregnancy were collected via the Proton renal database. Obstetric outcome data was collected via Protos Maternity System and included gestation at delivery and customised birthweight centiles.
Results
75 patients with a wide range of renal diagnoses were included in the study, including four renal transplant patients. Mean delivery gestation was 36+6 weeks. Mean birthweight was 2727 g: mean customised birthweight centile was 32. There were 73 livebirths and 2 terminations of pregnancy with no stillbirths or neonatal deaths. Mean pre-pregnancy creatinine was 93 µmol/l and eGFR 63. Mean postpregnancy creatinine was 131 µmol/l and eGFR 55. 14% patients had a significant decline in postpregnancy renal function. All patients with a booking creatinine >100 µmol/l delivered infants with a birthweight centile of <30. The four renal transplant patients demonstrated no significant difference between pre- and postpregnancy renal function.
Conclusion
This study demonstrates favourable pregnancy outcomes in patients with chronic renal disease. Higher creatinine levels at booking correlated with lower birthweight. Most patients in this cohort avoided a significant decline in postpregnancy renal function.
Introduction
Fetal macrosomia is increasing in prevalence and is associated with increased maternal and neonatal morbidity. Challenges include varying definitions, difficulties in accurate antenatal diagnosis and lack of consensus on ideal management in non-diabetic patients. We examined the management of large-for-gestational-age (LGA) pregnancies in our unit and compared obstetric outcomes of infants weighing 4250–4500 g and >4500 g respectively.
Methods
We conducted a cross-sectional survey investigating detection and management of LGA pregnancies. We compared obstetric outcomes of 100 babies weighing >4500 g (mean weight 4720 g, SD 198.5) and 4250–4500 g (mean weight 4347 g, SD 75.3). Data was collected via retrospective case note review. Comparison was made between ultrasound estimated-fetal-weight (EFW) and actual birthweight.
Results
The two groups were matched for maternal age, BMI and parity. There was no statistically significant difference between rate of LSCS, instrumental delivery or shoulder dystocia in the two groups (p=0.837,0.944). In the >4500 g group, 41% were LGA antenatally, 81% were managed expectantly and 77% delivered vaginally with a major complication rate of 2.6%. Ultrasound correctly predicted macrosomia in 6/16 cases (sensitivity 63%, specificity 40%) Abdominal circumference measurement alone and EFW estimation were equivalent in accuracy.
Conclusion
Management of LGA pregnancy is often influenced by concerns about increased obstetric intervention and complication rates. However, we found no difference between vaginal delivery and shoulder dystocia rates in 4250–4500 g and >4500 g infants, supporting the available literature in advocating spontaneous vaginal delivery in LGA pregnancies. Comparison of EFW with actual birthweight highlights the poor sensitivity and specificity of ultrasound to correctly predict LGA pregnancy.
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