LINEBURG


<< . .

 71
( 87)



. . >>

deoxycholic acid. Gut 1995; 37: 580“4. anesthetic risk. Int. J. Pediatr. Otorhinolaryngol. 1995; 33: 75“80.
34. Kowdley, K. V. Lipids and lipid-activated vitamins in chronic cholestatic 62. Kabra, N. S., Nanavati, R. N. & Srinivasan, G. Neonatal methemoglobinemia
diseases. Clin. Liver Dis. 1998; 2: 373“89. due to transplacental transfer of dapsone. Indian Pediatr. 1998; 35: 553“5.
35. Yarnell, R. W. & D™Alton, M. E. Epidural hematoma complicating cholestasis 63. Golusin, Z., Poljacki, M., Preveden, R. et al. What do we know today about
of pregnancy. Curr. Opin. Obstet. Gynecol. 1996; 8: 239“42. diaminodiphenylsulfone? Med. Pregl. 2000; 53: 369“72.
36. Schumann, R. & Hudcova, J. Cholestasis of pregnancy, pruritus and 5- 64. Schmutz, J. L. Specific dermatoses of pregnancy. Presse Med. 2003; 32:
hydroxytryptamine 3 receptor antagonists. Acta Obstet. Gynecol. Scand. 1813“17.
2004; 83: 861“2. 65. Erbagci, Z. & Erkilic, S. A case of recurrent impetigo herpetiformis with a
37. Milton, J. L. The Pathology and Treatment of Diseases of the Skin. London: positive family history. Int. J. Clin. Pract. 2000; 54: 619“20.
Robert Hardwick, 1872, p. 201. 66. Stewart, A. F., Battaglini-Sabetta, J. & Millstone, L. Hypocalcemia-induced
38. Amato, L., Coronella, G., Berti, S. et al. Successful treatment with doxycy- pustular psoriasis of von Zumbusch. New experience with an old syndrome.
cline and nicotinamide of two cases of persistent pemphigoid gestationis. Ann. Intern. Med. 1984; 100: 677“80.
J. Dermatolog. Treat. 2002; 13: 143“6. 67. Gollnick, H. P. Oral retinoids “ efficacy and toxicity in psoriasis.
39. Hacker-Foegen, M. K., Zillikens, D., Giudice, G. J. & Lin, M. S. T cell receptor Br. J. Dermatol. 1996; 135: 6“17.
gene usage of BP180-specific T lymphocytes from patients with bullous 68. Roizen, M. F. Diseases of the endocrine system. In Katz, J., Benumof, J. L. &
pemphigoid and pemphigoid gestationis. Clin. Immunol. 2004; 113: Kadis, L. B. (eds.), Anesthesia and Uncommon Diseases, 3rd edn.
179“86. Philadelphia: W.B. Saunders, 1990, p. 254.
40. Borthwick, G. M., Holmes, R. C. & Stirrat, G. M. Abnormal expression of 69. Yeowell, H. N. & Pinnell, S. R. The Ehlers-Danlos syndromes. Semin.
class II MHC antigens in placentae from patients with pemphigoid gesta- Dermatol. 1993; 12: 229“40.
tionis: analysis of class II MHC subregion product expression. Placenta 70. Kuczkowski, K. M. & Benumof, J. L. Cesarean section and Ehlers-Danlos
1988; 9: 81“94. syndrome: choice of anesthesia. Int. J. Obstet. Anesth. 2002; 11: 222“4.
41. Shornick, J. K. Herpes gestationis. Dermatol. Clin. 1993; 11: 527“33. 71. Goldstein, M. & Miller, R. Anesthesia for cesarean delivery in a patient with
42. Shornick, J. K., Meek, T. J., Nesbitt, L. T., Jr. & Gilliam, J. N. Herpes gestatio- Ehlers-Danlos syndrome type II. Reg. Anesth. 1997; 22: 280“3.
nis in blacks. Arch. Dermatol. 1984; 120: 511“13. 72. De Vos, M., Nuytinck, L., Verellen, C. & De Paepe, A. Preterm premature
43. Shornick, J. K., Stastny, P. & Gilliam, J. N. Paternal histocompatibility (HLA) rupture of membranes in a patient with the hypermobility type of the
antigens and maternal anti-HLA antibodies in herpes gestationis. J. Invest. Ehlers-Danlos syndrome. A case report. Fetal Diagn. Ther. 1999; 14: 244“7.
Dermatol. 1983; 81: 407“9. 73. Klipple, G. L. & Riordan, K. K. Rare inflammatory and hereditary connective
44. Shornick, J. K. & Black, M. M. Secondary autoimmune diseases in herpes tissue diseases. Rheum. Dis. Clin. North Am. 1989; 15: 383“98.
gestationis (pemphigoid gestationis). J. Am. Acad. Dermatol. 1992; 26: 74. Lurie, S., Manor, M. & Hagay, Z. J. The threat of type IV Ehlers-Danlos
563“6. syndrome on maternal well-being during pregnancy: early delivery may
45. Kromminga, A., Sitaru, C., Meyer, J. et al. Cicatricial pemphigoid differs make the difference. J. Obstet. Gynaecol. 1998; 18: 245“8.
from bullous pemphigoid and pemphigoid gestationis regarding the fine 75. Dolan, P., Sisko, F. & Riley, E. Anesthetic considerations for Ehlers-Danlos
specificity of autoantibodies to the BP180 NC16 A domain. J. Dermatol. Sci. syndrome. Anesthesiology 1980; 52: 266“9.
2002; 28: 68“75. 76. Anstey, A., Mayne, K., Winter, M. et al. Platelet and coagulation studies in
46. Zillikens, D. BP180 as the common autoantigen in blistering diseases with Ehlers-Danlos syndrome. Br. J. Dermatol. 1991; 125: 155“63.
different clinical phenotypes. Keio J. Med. 2002; 51: 21“8. 77. Safdar, Z., O™Sullivan, M. & Shapiro, J. M. Emergent bullectomy for acute
47. Wilson, B. D., Beutner, E. H., Kumar, V. et al. Linear IgA bullous dermatosis. respiratory failure in Ehlers-Danlos syndrome. J. Intensive Care Med. 2004;
An immunologically defined disease. Int. J. Dermatol. 1985; 24: 569“74. 19: 349“51.
48. Carrozzo, M., Broccoletti, R., Carbone, M. et al. Pemphigoid of the mucous 78. Halko, G. J., Cobb, R. & Abeles, M. Patients with type IV Ehlers-
membranes. The clinical, histopathological and immunological aspects Danlos syndrome may be predisposed to atlantoaxial subluxation.
and current therapeutic concepts. Minerva Stomatol. 1996; 45: 455“63. J. Rheumatol. 1995; 22: 2152“5.
49. Harris-Stith, R., Erickson, Q. L., Elston, D. M. & David-Bajar, K. Bullous erup- 79. Dill-Russell, P. & Jones, L. S. Anaesthesia for caesarean section in a patient
tion: a manifestation of lupus erythematosus. Cutis 2003; 72: 31“7. with Ehlers-Danlos syndrome and mitral valve prolapse. Int. J. Obstet.
50. Buscher, U., Wessel, J., Anton-Lamprecht, I. & Dudenhausen, J. W. Anesth. 2001; 10: 192“7.
Pregnancy and delivery in a patient with mutilating dystrophic epidermo- 80. Campbell, N. & Rosaeg, O. P. Anesthetic management of a parturient with
lysis bullosa (Hallopeau-Siemens type). Obstet. Gynecol. 1997; 89: 817“20. Ehlers Danlos syndrome type IV. Can. J. Anaesth. 2002; 49: 493“6.
51. Loret de Mola, J. R., Muise, K. L. & Duchon, M. A. Porphyria cutanea tarda 81. Brighouse, D. & Guard, B. Anaesthesia for caesarean section in a patient
and pregnancy. Obstet. Gynecol. Surv. 1996; 51: 493“7. with Ehlers-Danlos syndrome type IV. Br. J. Anaesth. 1992; 69: 517“19.




360
Chapter 19


82. Abouleish, E. Obstetric anaesthesia and Ehlers-Danlos syndrome. Br. J. 108. Uhoda, I., Pierard-Franchimont, C., Arrese, J. E. et al. How to investigate. A
Anaesth. 1980; 52: 1283“6. darkened skin lesion during pregnancy. A difficult task for the clinician.
83. Smith, F. The molecular genetics of keratin disorders. Am. J. Clin. Rev. Med. Liege 2003; 58: 766“9.
Dermatol. 2003; 4: 347“64. 109. O™Meara, A. T., Cress, R., Xing, G. et al. Malignant melanoma in pregnancy. A
84. Pfendner, E. G., Nakano, A., Pulkkinen, L. et al. Prenatal diagnosis for population-based evaluation. Cancer 2005; 103: 1217“26.
epidermolysis bullosa: a study of 144 consecutive pregnancies at risk. 110. Lens, M. B., Rosdahl, I., Ahlbom, A. et al. Effect of pregnancy on survival in
Prenat. Diagn. 2003; 23: 447“56. women with cutaneous malignant melanoma. J. Clin. Oncol. 2004; 22:
85. Eady, R. A. Epidermolysis bullosa: scientific advances and therapeutic 4369“75.
challenges. J. Dermatol. 2001; 28: 638“40. 111. Naldi, L., Lorenzo Imberti, G., Parazzini, F. et al. Pigmentary traits, mod-
86. Benavente, M. A. & Sanchez-Guijo, J. J. Combined anaesthesia in a young alities of sun reaction, history of sunburns, and melanocytic nevi as risk
patient with dystrophic epidermolysis bullosa. Paediatr. Anaesth. 2003; 13: factors for cutaneous malignant melanoma in the Italian population:
274. results of a collaborative case-control study. Cancer 2000; 88: 2703“10.
87. Herod, J., Denyer, J., Goldman, A. & Howard, R. Epidermolysis bullosa in 112. Alexander, A., Samlowski, W. E., Grossman, D. et al. Metastatic melanoma
children: pathophysiology, anaesthesia and pain management. Paediatr. in pregnancy: risk of transplacental metastases in the infant. J. Clin. Oncol.
Anaesth. 2002; 12: 388“97. 2003; 21: 2179“86.
88. Diwan, R., Vas, L., Shah, T. et al. Continuous axillary block for upper limb 113. Heesen, M. & Rossaint, R. Anaesthesiological considerations in patients with
surgery in a patient with epidermolysis bullosa simplex. Paediatr. Anaesth. Sneddon™s syndrome. Paediatr. Anaesth. 2000; 10: 678“80.
2001; 11: 603“6. 114. Toubi, E., Krause, I., Fraser, A. et al. Livedo reticularis is a marker for
89. Iohom, G. & Lyons, B. Anaesthesia for children with epidermolysis bullosa: predicting multi-system thrombosis in antiphospholipid syndrome. Clin.
a review of 20 years™ experience. Eur. J. Anaesthesiol. 2001; 18: 745“54. Exp. Rheumatol. 2005; 23: 499“504.
90. Scherhag, A. & Dick, W. Special aspects of anesthesia in patients with 115. Frances, C., Papo, T., Wechsler, B. et al. Sneedon syndrome with or without
epidermolysis bullosa based on a case example. Anaesthesiol. Reanim. antiphosholipid antibodies. A comparative study in 46 patients. Medicine
1998; 23: 129“33. 1999; 78: 209“19.
91. Lin, A. N., Lateef, F., Kelly, R. et al. Anesthetic management in epidermo- 116. www.nfinc.org. Site accessed July 31, 2005.
lysis bullosa: review of 129 anesthetic episodes in 32 patients. J. Am. Acad. 117. The Elephant Man™s Bones Reveal Mystery. http://rarediseases.about.
Dermatol. 1994; 30: 412“16. com/cs/proteussyndrome/a/031301.htm. Accessed July 31, 2005.
92. Spielman, F. J. & Mann, E. S. Subarachnoid and epidural anaesthesia for 118. Spits, C., De Rycke, M., Van Ranst, N. et al. Preimplantation genetic
patients with epidermolysis bullosa. Can. Anaesth. Soc. J. 1984; 31: 549“51. diagnosis for neurofibromatosis type 1. Mol. Hum. Reprod. 2005; 11:
93. Boughton, R., Crawford, M. R. & Vonwiller, J. B. Epidermolysis bullosa “ a 381“7. Epub 2005 Apr 15.
review of 15 years™ experience, including experience with combined gen- 119. Agarwal, U., Dahiya, P. & Sangwan, K. Recent onset neurofibromatosis
eral and regional anaesthetic techniques. Anaesth. Intensive Care 1988; 16: complicating eclampsia with maternal death: a case report. Arch. Gynecol.
260“4. Obstet. 2003; 268: 241“2.
94. Ohara, T., Fujimoto, K., Okutsu, Y. et al. Intraoperative indirect monitoring 120. Posma, E., Aalbers, R., Kurniawan, Y. S. et al. Neurofibromatosis type I and
of electrocardiogram. Masui 1999; 48: 1347“53. pregnancy: a fatal attraction? Development of malignant schwannoma
95. Farthing, B., Bagan, J. V. & Scully, C. Mucosal disease series. Number IV. during pregnancy in a patient with neurofibromatosis type I. B.J.O.G.
Erythema multiforme. Oral. Dis. 2005; 11: 261“7. 2003; 110: 530“2.
96. Bastuji-Garin, S., Rzany, B., Stern, R. S. et al. Clinical classification of cases 121. Kusaba, T., Oguni, A., Narumiya, H. et al. Intravascular ultrasound imaging of
of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema the renal artery in patients with renovascular hypertension caused by neu-
multiforme. Arch. Dermatol. 1993; 129: 92“6. rofibromatosis 1. Nippon Jinzo Gakkai Shi 2003; 45: 32“6.
97. Sehgal, V. N. & Srivastava, G. Toxic epidermal necrolysis (TEN) Lyell™s 122. Tidwell, C. & Copas, P. Brachial artery rupture complicating a pregnancy
syndrome. J. Dermatolog. Treat. 2005; 16: 278“86. with neurofibromatosis: a case report. Am. J. Obstet. Gynecol. 1998; 179:
98. Roujeau, J. C. Stevens-Johnson syndrome and toxic epidermal necrolysis 832“4.
are severity variants of the same disease which differs from erythema 123. Serleth, H. J., Cogbill, T. H. & Gundersen, S. B., 3rd. Ruptured pancreatico-
multiforme. J. Dermatol. 1997; 24: 726“9. duodenal artery aneurysms and pheochromocytoma in a pregnant patient
99. Nekhlyudov, L., Gradzka, M., Conti-Kelly, A. M. & Greco T. P. Erythema with neurofibromatosis. Surgery 1998; 124: 100“2.
nodosum associated with antiphospholipid antibodies: a report of three 124. Segal, D., Holcberg, G., Sapir, O. et al. Neurofibromatosis in pregnancy.
cases. Lupus 2000; 9: 641“5. Maternal and perinatal outcome. Eur. J. Obstet. Gynecol. Reprod. Biol.
100. Mert, A., Ozaras, R., Tabak, F. et al. Erythema nodosum: an experience of 1999; 84: 59“61.
10 years. Scand. J. Infect. Dis. 2004; 36: 424“7. 125. Tubbs, R. S., Rutledge, S. L., Kosentka, A. et al. Chiari I malformation and
101. Tay, Y. K. Erythema nodosum in Singapore. Clin. Exp. Dermatol. 2000; 25: neurofibromatosis type 1. Pediatr Neurol. 2004; 30: 278“80.
377“80. 126. Dounas, M., Mercier, F. J., Lhuissier, C. & Benhamou, D. Epidural analge-
102. Requena, L. & Requena, C. Erythema nodosum. Dermatol. Online J. sia for labour in a parturient with neurofibromatosis. Can. J. Anaesth. 1995;
2002; 8: 4. 42: 420“2.
103. Ytting, H., Vind, I., Bang, D. & Munkholm, P. Sweet™s syndrome “ an 127. Esler, M. D., Durbridge, J. & Kirby, S. Epidural haematoma after dural
extraintestinal manifestation in inflammatory bowel disease. Digestion puncture in a parturient with neurofibromatosis. Br. J. Anaesth. 2001; 87:
2005; 72: 195“200. 932“4.
104. Cohen, P. R. Pregnancy-associated Sweet™s syndrome: world literature 128. Choudhary, S., MacKinnon, C. A., Morrissey, G. P. & Tan, S. T. A case of
review. Obstet. Gynecol. Surv. 1993; 48: 584“7. giant nasal pyogenic granuloma gravidarum. J. Craniofac. Surg. 2005; 16:
105. Silverman, M. A., Datner, E. M. & Jolly, B. T. A case presentation of Sweet™s 319“21.
syndrome and discussion of life-threatening dermatoses. Am. J. Emerg. 129. Yuan, K., Wing, L. Y. & Lin, M. T. Pathogenetic roles of angiogenic factors in
Med. 1996; 14: 165“9. pyogenic granulomas in pregnancy are modulated by female sex hor-
106. Matoses, M. S., Alcala, E. & Laguarda, M. Subarachnoid anesthesia for mones. J. Periodontol. 2002; 73: 701“8.
cesarean section of a patient with Sweet™s syndrome related to pregnancy. 130. Choudhary, S., MacKinnon, C. A., Morrissey, G. P. & Tan, S. T. A case of
Rev. Esp. Anestesiol. Reanim. 2004; 51: 111“12. giant nasal pyogenic granuloma gravidarum. J. Craniofac. Surg. 2005; 16:
107. Smith, L. H., Danielsen, B., Allen, M. E. & Cress, R. Cancer associated with 319“21.
obstetric delivery: results of linkage with the California cancer registry. 131. Wang, P. H., Chao, H. T., Lee, W. L. et al. Severe bleeding from a pregnancy
Am. J. Obstet. Gynecol. 2003; 189: 1128“35. tumor. A case report. J. Reprod. Med. 1997; 42: 359“62.




361
5 Other disorders


132. Hayakawa, H., Tara, M., Niina, K. & Osame, M. A clinical study of adult 152. Owen, J. & Hauth, J. C. Polyarteritis nodosa in pregnancy: a case report and
human parvovirus B19 infection. Intern. Med. 2002; 41: 295“9. brief literature review. Am. J. Obstet. Gynecol. 1989; 160: 606“7.
133. Seve, P., Ferry, T., Charhon, A. et al. Systemic manifestations of Parvovirus 153. Reed, N. R. & Smith, M. T. Periarteritis nodosa in pregnancy: report of a
B19 infections. Rev. Med. Interne. 2004; 25: 740“51. case and review of the literature. Obstet. Gynecol. 1980; 55: 381“4.
134. Severin, M. C., Levy, Y. & Shoenfeld, Y. Systemic lupus erythematosus and 154. Burkett, G. & Richards, R. Periarteritis nodosa and pregnancy Obstet.
parvovirus B-19: casual coincidence or causative culprit? Clin. Rev. Allergy Gynecol. 1982; 59: 252“4.
Immunol. 2003; 25: 41“8. 155. Rabhi, M., Tiev, K. P., Genereau, T. & Cabane, J. Scleroderma and preg-
135. Meyer, O. Parvovirus B19 and autoimmune diseases. Joint Bone Spine nancy. Ann. Med. Interne. 2002; 153: 193“200.
2003; 70: 6“11. 156. Benson, E. M. Immunologic manipulation for the threatened fetus.
136. Schwarz, T. F. & Roggendorf, M. Parvovirus infections in dermatology. Thromb. Res. 2004; 114: 427“34.
Z. Hautkr. 1989; 64: 272“3. 157. Berger, J. R. & Koralnick, I. J. Progressive multifocal leukoencephalopathy and
137. Hornsleth, A. & Carlsen, K. M. Parvovirus B19 infections. The cause of fifth natalizumab “ unforeseen consequences. N. Engl. J. Med. 2005; 353: 414“16.
disease-erythema infectiosum “ can also cause aplastic crises, fetal 158. Van Assche, G., Van Ranst, M., Sciot, R. et al. Progressive multifocal
damage and polyarthritis. Ugeskr. Laeger. 1990; 152: 1354“7. leukoencephalopathy after natalizumab therapy for Crohn™s disease. N.
138. Miller, E., Fairley, C. K., Cohen, B. J. & Seng, C. Immediate and long term Engl. J. Med. 2005; 353: 362“8.
outcome of human parvovirus B19 infection in pregnancy. Br. J. Obstet. 159. Kleinschmidt-DeMasters, B. K. & Tyler, K. L. Progressive multifocal leu-
Gynaecol. 1998; 105: 174“8. koencephalopathy complicating treatment with natalizumab and inter-
139. Harger, J. H., Ernest, J. M., Thurnau, G. R. et al. National Institute of Child feron beta-1a for multiple sclerosis. N. Engl. J. Med. 2005; 353: 369“74.
Health and Human Development, Network of Maternal-Fetal Medicine 160. Langer-Gould, A., Atlas, S. W., Green, A. J. et al. Progressive multifocal
Units. Risk factors and outcome of varicella-zoster virus pneumonia in leukoencephalopathy in a patient treated with natalizumab. N. Engl. J.
pregnant women. J. Infect. Dis. 2002; 185: 422“7. Med. 2005; 353: 375“81.
140. Brown, N. W., Parsons, A. P. & Kam, P. C. Anaesthetic considerations in a 161. Gompels, M. M., Lock, R. J., Abinun, M. et al. C1 inhibitor deficiency:
parturient with varicella presenting for Caesarean section. Anaesthesia consensus document. Clin. Exp. Immunol. 2005; 139: 379“94.
2003; 58: 1092“5. 162. Griffiths, R. J. & O™Sullivan, G. C1-esterase inhibitor deficiency and elective
141. Gei, A. F., Pacheco, L. D., Vanhook, J. W. & Hankins, G. D. The use of a caesarean section. Int. J. Obstet. Anesth. 2005; 14: 263“4.
continuous infusion of epinephrine for anaphylactic shock during labor. 163. Oskay, T., Kutluay, L., Kaptanoglu, A. & Karabacak, O. Autoimmune pro-
Obstet. Gynecol. 2003; 102: 1332“5. gesterone dermatitis. Eur. J. Dermatol. 2002; 12: 589“91.
142. Steere, A. C. Lyme disease. N. Engl. J. Med. 2001; 345: 115“25. 164. Snyder, J. L. & Krishnaswamy, G. Autoimmune progesterone dermatitis
143. Luman, E. T., Barker, L. E., Shaw, K. M. et al. Timeliness of childhood and its manifestation as anaphylaxis: a case report and literature review.
vaccinations in the United States: days undervaccinated and number of Ann. Allergy Asthma Immunol. 2003; 90: 469“77.
vaccines delayed. J.A.M.A. 2005; 293: 1204“11. 165. O™Rourke, J., Khawaja, N., Loughrey, J. & McKenna, P. Autoimmune pro-
144. Mastaglia, F. L. & Phillips, B. A. Idiopathic inflammatory myopathies: epi- gesterone dermatitis in a parturient for emergency caesarean section. Int.
demiology, classification, and diagnostic criteria. Rheum. Dis. Clin. North J. Obstet. Anesth. 2004; 13: 275“8.
Am. 2002; 28: 723“41. 166. Villeneuve, V., Kaufman, I., Weeks, S. & Deschamps, A. Anesthetic man-
145. Eymard, B. Polymyositis, dermatomyositis and inclusion body myositis, agement of a labouring parturient with urticaria pigmentosa. Can. J.
nosological aspects. Presse Med. 2003; 32: 1656“67. Anesth. 2006; 53: 380“4.
146. Sarkar, K., Weinberg, C. R., Oddis, C. V. et al. Seasonal influence on the 167. Castells, M. C. Mastocytosis: classification, diagnosis, and clinical presen-
onset of idiopathic inflammatory myopathies in serologically defined tation. Allergy Asthma Proc. 2004; 25: 33“6.
groups. Arthritis Rheum. 2005; 52: 2433“8. 168. Worobec, A. S., Akin, C., Scott, L. M. & Metcalfe, D. D. Mastocytosis com-
147. Amato, A. A. & Shebert, R. T. Inclusion body myositis in twins. Neurology plicating pregnancy. Obstet. Gynecol. 2000; 95: 391“5.
1998; 51: 598“600. 169. Garcia Collada, J. C., Pereda Marin, R. M., Miralles Serrano, E. & Pacheco
148. Silva, C. A., Sultan, S. M. & Isenberg, D. A. Pregnancy outcome in adult- Lopez, J. F. Epidural analgesia for labor in a patient with systemic mas-
onset idiopathic inflammatory myopathy. Rheumatology 2003; 42: tocytosis. Rev. Esp. Anestesiol. Reanim. 2000; 47: 326“7.
1168“72. 170. Donahue, J. G., Lupton, J. B., & Golichowski, A. M. Cutaneous
149. Gutierrez, G., Dagnino, R. & Mintz, G. Polymyositis/dermatomyositis and mastocytosis complicating pregnancy. Obstet. Gynecol. 1995; 85: 813“15.
pregnancy. Arthritis Rheum. 1984; 27: 291“4. 171. Vaughan, S. T. & Jones, G. N. Systemic mastocytosis presenting as pro-
150. Stoelting, R. K. & Dierdorf, S. F. Skin and musculoskeletal diseases. found cardiovascular collapse during anaesthesia. Anaesthesia 1998; 53:
In Stoelting, R. K. & Dierdorf, S. F. (eds.), Anesthesia and Coexisting 804“7.
Disease, 4th edn. Philadelphia: Churchill Livingstone, 2002; p. 514. 172. Auvray, L., Letourneau, B. & Freysz, M. Mastocytosis: general anesthesia
151. Shieh, S., Fang, Y. V., Becker, J. L. et al. Pemphigus, pregnancy, and plas- with remifentanil and sevoflurane. Ann. Fr. Anesth. Reanim. 2001; 20:
mapheresis. Cutis. 2004; 73: 327“9. 635“8.




362
PSYCHIATRIC DISORDERS IN PREGNANCY
20
Timothy J. G. Pavy




Introduction The aim of this chapter is to consider the anesthetic implica-
tions of conditions that arise de novo, as well as existing illnesses
The peak incidence of affective disorders in women occurs at 23 to
that may or may not be affected by the pregnant state.
44 years of age, which coincides with the prime child bearing
years. Pregnancy and childbirth represent major life stresses, as
well as a time of fundamental psychological and social change.
Schizophrenia
The experience of childbirth constitutes a major mental health
hazard for women, with an estimated fivefold increase in the The characteristic features of schizophrenia are delusions, hallu-
appearance of mental illness in the year following childbirth.1 cinations (auditory), disorganized speech (frequent derailment or
Women who are pregnant, or have recently given birth, may incoherence), grossly disorganized or catatonic behavior, and
experience relapses of earlier mental disease or develop a new negative symptoms (flat affect, alogia, or avolition). Two or
disorder. Women with psychiatric disorders become pregnant more of these features are required to make a diagnosis of schizo-
and their psychiatric condition can present management pro- phrenia and each must be present for a significant time during a
one-month period (or less if successfully treated).4
blems at different stages of pregnancy. Less commonly, previously
Schizophrenia affects 1% of the general population,5 and
well women may develop a major psychiatric disturbance during
or after pregnancy, which may or may not herald a chronic con- although it is often more florid in the reproductive years there is
dition. Many of these individuals take medications that have the a paucity of data concerning its incidence in pregnancy. The
potential to interact with anesthetic agents and other drugs. These condition was formerly further subdivided into the principal sub-
women require considerable tact and skill on the part of their types of paranoid, disorganized, and catatonic, although the clin-
attendants. ical relevance of that classification is now minimal.
The first three years of a consultation-liaison psychiatry service A significant disturbance of one or more ˜˜major areas of func-
to an obstetric inpatient unit in an Australian hospital had a tioning™™ occurs, such that self-care and interpersonal relation-
referral rate of 1.2% of obstetric admissions, totalling 90 consulta- ships are impaired. The disturbance has particular implications
tions over three years.2 The commonest DSM-III-R psychiatric for the newborn child, whose safety is of concern if the schizo-
diagnoses were personality disorders (19%), mood disorders phrenia is not properly managed.
(17%), schizophrenic disorders (15%), and adjustment disorders. Maintenance therapy consists of major tranquillizers, in either
Reasons for referral included coping problems, depression, anxi- oral or injectable form. Haloperidol and the phenothiazines have
ety or fear, and a history of major psychiatric illness. been the most studied drugs of this class during pregnancy. The
Obstetric anesthesiologists may have their management skills oral formulations include haloperidol, chlorpromazine, and
tested with women who have personality disorders. These thioridazine, whereas depot-injectable preparations include flu-
patients may be rude or complain excessively. The category of phenazine and flupenthixol.
dramatic personality disorders includes histrionic, borderline, All major tranquillizers have the potential to produce extra-
narcissistic, and antisocial. Affected women may also display pyramidal side effects, hence the common practice of coadminis-
poor impulse control, requiring a degree of firm professionalism. tration of atropine-like antiparkinsonian agents such as benztropine
However, these women are not commonly on medication for and benzhexol. If these agents are discontinued during the first
trimester, the balance of risks and benefits needs to be considered.1
their dysfunctional personality and interactions with anesthetic
agents per se are less likely. Case reports of limb reduction in babies born to women taking
haloperidol have been published,6 but the few large prospective
Women with a history of major psychiatric illness need coun-
seling before becoming pregnant as they are at greater risk for studies conducted have not found any teratogenic action related
postpartum psychoses, increasing the risk of harm to mother and to major tranquillizers. Chlorpromazine may be an exception,
child. It is important that the question of medication be dis- although the evidence implicating phenothiazines is based on
their use in treating hyperemesis gravidarum7 and not psychoses.
cussed. This is a contentious area that many clinicians find diffi-
cult to approach. The various risks are to the fetus, the pregnant Although there is little hard evidence to associate psychotropic
woman (due to altered physiology), the future behavioural tera- drugs with teratogenesis, there is an almost universal reluctance
togenesis in the newborn (effects on brain morphogenesis may to continue necessary medication during pregnancy. This reluct-
not appear for years), and to the mother and fetus from inade- ance is despite the fact that clinical deterioration may occur as a
quately managed disease.3 result. As pointed out by Kuller and coworkers,8 continuation of


Obstetric Anesthesia and Uncommon Disorders, eds. David R. Gambling, M. Joanne Douglas and Robert S. F. McKay. Published by Cambridge University Press.
# Cambridge University Press 2008.
5 Other disorders


a difficult area for obstetric anesthesiologists, becomes even more
Table 20.1 Guidelines for antipsychotics in pregnancy complicated in this clinical setting.
Consideration may be required for abandonment of regional
1. Avoidance during weeks four to ten postconception
techniques if operative delivery is necessary, on the grounds that
2. Discontinue two weeks predelivery
a violent awake patient presents a threat to the safe conduct of
3. Use potent agents
cesarean section (C/S) anesthesia. The principal tenet for inter-
4. Discontinue if neuroleptic malignant syndrome develops
action with these patients is that the attending clinician should be
5. Resume immediately postpartum
˜˜the ambassador of reality,™™ and the anesthesiologist needs to be
6. Avoid antiparkinsonian drugs
particularly sensitive to the dynamics of the situation. Emotional
support and a quiet environment are important, and the need for
medication throughout pregnancy is probably the wisest choice
urgent psychiatric consultation is self-evident.
in someone with a history of instability without medication, even
though exposure to the lowest dose is the preferred approach in
Neuroleptic malignant syndrome
the first trimester. Furthermore, patients with severe schizophre-
nia who are difficult to manage should be actively discouraged
This rare but sometimes fatal condition is similar to malignant
from conceiving until their illness is better controlled.
hyperthermia (MH), and may involve common pathways. It
When it is feasible to withdraw therapy, Miller9 has provided
occurs typically early in treatment and is characterized by fever,
specific guidelines, which are outlined in Table 20.1. Anti-
muscular rigidity, autonomic dysfunction, leukocytosis, and
psychotics should be avoided, if possible, during the period of
impaired level of consciousness. Therapy includes resuscitation
highest risk (four to ten weeks post conception) and discontinued,
with intravenous (i.v.) fluids, aggressive cooling, and administra-
if possible, two weeks before delivery to minimize withdrawal
tion of dantrolene following guidelines for management of MH.
effects in the neonate. Resumption of antipsychotic medication
An initial dose of 2.5 mg/kg can be repeated every 15 minutes
should begin immediately postpartum. Potent agents should be
until improvement or a total of 10 mg/kg has been administered.
given to minimize sedation, orthostasis, gastrointestinal slowing,
Bromocriptine has also been described in its management.9
and tachycardia. Therapy is discontinued if the neuroleptic malig-
nant syndrome develops (see later). Routine antiparkinsonian
Electroconvulsive therapy
agents are avoided.
Although this highly effective therapy is used most commonly in
the management of major depressive illness,11 it is sometimes
Anesthetic implications
indicated in the acutely psychotic schizophrenic pregnant patient
when urgent control is required. Varan and coworkers12 reported
The archetypal phenothiazine is chlorpromazine, which was
its use in the emergency management of a pregnant woman at 18
given the trade name Largactil because of its ˜˜large actions.™™
to 20 weeks™ gestation who had homicidal impulses and tried to
The ability to exert an effect at many different receptors is a
strangle a nurse. The patient responded well to modified electro-
feature of most of the major tranquillizers. They are lipophilic
convulsive therapy (ECT) and low-dose chlorpromazine. She
amines whose action is on neuronal membranes. Binding sites
received a total of 12 courses of ECT with a conventional general
include presynaptic and postsynaptic receptors, as well as reup-
anesthetic of 0.6 mg atropine, 80 mg methohexital, 40 mg succi-
take sites for a host of neurotransmitters, including norepineph-
nylcholine, and assisted ventilation with 100% oxygen. Fetal heart
rine, dopamine, histamine, and acetylcholine.
rate (FHR) monitoring revealed a short-duration bradycardia
It is the action of antipsychotics on the a-1 adrenergic receptor
coinciding with the tonic phase of the seizure. External uterine
that has the greatest significance for anesthesiologists, because the
monitoring indicated no abnormal activity.
reduction in peripheral vascular resistance can lead to orthostatic
DeBattista and coworkers13 have reported a short but marked
hypotension. In the anesthetized patient, hypotension, heat loss,
FHR deceleration to 60 beats per minute (bpm) for three to five
and inadequate compensation for blood loss are complicating fac-
seconds some ten seconds after ECT was administered to a
tors. The quinidine-like effects of these drugs can produce changes
depressed 41-year-old primigravid woman. These authors specu-
on the electrocardiogram, including increases in PR, QRS, and QT
intervals. Preexisting heart block may be exacerbated.10 late that activation of the sympathetic nervous system by the
seizure may have played a role by reducing uterine blood flow.
Schizophrenic women are at increased risk of peripartum psy-
Unlike grand mal seizures, when hypoxia is common, anesthe-
choses, with considerable potential for self-harm, as well as harm
tized patients receiving ECT are well oxygenated. The clinical
to the neonates, if the mothers are delusional. Women with poorly
significance of decelerations is uncertain but probably of no
controlled disease may be uncooperative and hostile when
great moment, in view of their very short duration.
attempts are made to provide analgesia for labor pain. Paranoid
patients, in particular, may suspect that the anesthesiologist means
to harm them. It is useful to obtain a brief psychiatric history and
Manic depressive illness
ascertain whether medication has been taken as prescribed. Non-
This general term embraces a number of disturbances of affect
compliance, perhaps as part of perinatal deterioration, may pre-
(mood), including unipolar depression, unipolar mania, bipolar
sage a difficult interaction. Informed consent, which is traditionally



364
Chapter 20


vomiting, prolonged sick leave during pregnancy, and increased
Table 20.2 Features of depression numbers of visits to the obstetrician.17 There is also a significant
increase in planned C/S and epidural analgesia in labor.
1. Depressed mood most of the day, nearly every day
Untreated depression in pregnancy carries substantial perina-
2. Markedly diminished interest or pleasure in all, or almost all,
tal risks.18 These include direct risks to the fetus and infant, as
activities most of the day
well as risks secondary to the unhealthy maternal behaviors seen
3. Significant weight loss
in depressed women. Untreated maternal depression can result
4. Insomnia or hypersomnia
in a catastrophic outcome. Too many studies focus on the poten-
5. Psychomotor agitation or retardation
tial but unproven risks of psychotropic medication (see later).18
6. Fatigue or loss of energy
Women suffering from gestational depression, with its attendant
7. Feelings of worthlessness or excessive or inappropriate guilt
biological dysregulation, may refuse treatment because of
(which may be delusional)
unfounded fears about teratogenesis. This is regrettable and has
8. Diminished ability to think or concentrate
important implications for the mental health of the woman and
the care of her child. One study showed that 75% of women who
disorder, and hypomania. An estimated 10% of pregnant women stopped taking antidepressants soon after conception had
develop a serious depression,14 for which therapy may be insti- relapses, often in the first trimester, with symptoms severe
enough to require retreatment.19 However, although continuing
tuted. Depression includes some or all of the symptoms listed in
Table 20.2. antidepressants throughout pregnancy reduces relapses, it does
Maternal depression has been associated with a number of not eliminate them. Pregnant women are twice as likely to have a
relapse if they do not take their medication.20
factors that predict poor neonatal outcome. Depressed women
often have poor appetite and so may have low weight gain in
pregnancy and are more likely to use tobacco, alcohol, or illicit
Lithium
drugs. All of these factors increase the risk of preterm birth, small
head circumference, and low Apgar scores. Mood modulation in women with a bipolar disorder is achieved
A systematic review15 aimed at estimating the prevalence of commonly with lithium, but great concern has been expressed
depression in pregnancy by trimester, as detected by validated about the use of this drug in pregnancy. Avoidance of lithium in

<< . .

 71
( 87)



. . >>

Copyright Design by: Sunlight webdesign