Acute Myocardial Infarction in Pregnancy.

Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction has been rising over the past 2 decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of acute myocardial infarction in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to acute myocardial infarction in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex condition. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with acute myocardial infarction in pregnancy.

Airway clearance by exercising in mild cystic fibrosis (ACE-CF): A feasibility study.

BACKGROUND: People with cystic fibrosis (CF) are encouraged to perform airway clearance techniques on a daily basis. Whilst several short-term studies support a potential role for exercise as an airway clearance technique, to date no medium to longer term studies have investigated the use of exercise as a stand-alone airway clearance technique. OBJECTIVE: To determine the feasibility of a protocol investigating the use of exercise as a stand-alone form of airway clearance in adults with CF. METHODS: Adults with CF and a FEV1 ≥ 70% predicted were eligible. After a four week wash-in period of daily positive expiratory pressure (PEP) and exercise, adherent participants were randomised to either daily PEP plus exercise or exercise-only for three months. Pre-specified thresholds for feasibility for the primary outcomes were rates of recruitment ≥30%, randomisation ≥80% and completion ≥80%. Secondary outcomes included respiratory function tests, respiratory exacerbation rate and health-related quality of life. RESULTS: Of the 57 eligible patients identified, 17 were recruited (30%). After the wash-in period, 13 of the 17 participants (76%) were randomised and all 13 (100%) completed the final assessment. The median (IQR) change in FEV1 (L) over the intervention period was 0.00 (-0.08 - 0.15) L for the PEP plus exercise group and -0.03 (-0.19 - 0.13) L for the exercise-only group. CONCLUSION: The study achieved its a priori target feasibility rates for recruitment and completion but failed to meet the randomisation target rate. Changes in lung function and quality of life were similar between groups. Further refinement of the protocol may be required prior to expansion to a multi-centred trial.

Marijuana and Breastfeeding: Applicability of the Current Literature to Clinical Practice.

With recent legalization of marijuana in numerous U.S. states, the risk of marijuana exposure via breast milk is a rising concern. This review analyzes the available human and animal literature regarding maternal use of marijuana during lactation. The findings can be categorized into four areas of analysis: effects of marijuana on the mother, transfer into milk, transfer to the offspring, and effects on the offspring. Human and animal data have reported decreased prolactin levels as well as potential maternal psychological changes. Animal and human studies have reported transfer into milk; levels were detected in animal offspring, and metabolites were excreted by both human and animal offspring. Further, animal data have predominately displayed motor, neurobehavioral, and developmental effects, whereas human data suggested possible psychomotor outcomes; however, some studies reported no effect. Despite these results, many human studies were marred by limitations, including small sample sizes and confounding variables. Also, the applicability of animal data to the human population is questionable and the true risk of adverse effects is not entirely known. There are large gaps in the literature that need to be addressed; in particular, studies need to focus on evaluating the short- and long-term consequences of maternal marijuana use for the infant and the potential for different risks based on the frequency of maternal use. Until further evidence becomes available, practitioners need to weigh the benefits of breastfeeding for mother and child, with the potential influence of marijuana on infant development when determining the infant's most suitable form of nutrition.

A retrospective cohort study of hospital versus home care for pregnant women with preterm prelabor rupture of membranes.

OBJECTIVE: To compare maternal and neonatal outcomes between in-hospital management and prepartum care at home (PCAH) among women with preterm prelabor rupture of membranes (PPROM) before 34 weeks of pregnancy. METHODS: In a retrospective study, data were analyzed from women who experienced PPROM between 23 and 34 weeks of pregnancy, and received care from two hospitals in British Columbia, Canada, between April 2007 and March 2012. Women were included if they had been stable in hospital for at least 72 hours and met eligibility criteria for PCAH. Management of PPROM differs at the centers: at one, women are monitored in hospital, whereas PCAH is used at the other. Outcomes were compared between management strategies. Logistic regression was used to assess severe maternal morbidity and neonatal morbidity/mortality after adjustment for pregnancy length at PPROM. RESULTS: Among 176 included women, 87 received PCAH and 89 were managed in hospital. There was no difference in severe maternal morbidity (adjusted odds ratio [aOR] 0.64, 95% confidence interval [CI] 0.35-1.17) or neonatal morbidity/mortality (aOR 0.63, 95% CI 0.31-1.30). Latency increased and length of stay decreased with PCAH (P<0.001 for both). CONCLUSION: Maternal and newborn outcomes were similar between women who received PCAH and those who were managed in hospital. The reduced resource use in PCAH might lead to cost savings without compromising outcomes.

The psychometric properties of the Leicester Cough Questionnaire and Respiratory Symptoms in CF tool in cystic fibrosis: A preliminary study.

BACKGROUND: There are few tools to quantify the impact of cough in cystic fibrosis (CF). The psychometric properties of the Leicester Cough Questionnaire (LCQ) and Respiratory Symptoms in CF (ReS-CF) tool were investigated in adults with CF. METHODS: Validity and reliability were assessed in clinically stable participants who completed the questionnaires twice, along with the Cystic Fibrosis Questionnaire - Revised (CFQ-R). Responsiveness was assessed by change in questionnaires following treatment for an acute respiratory exacerbation. RESULTS: Correlations between the LCQ and CFQ-R respiratory domain were moderate (n=59, rs=0.78, p<0.001). Correlations between ReS-CF and CFQ-R respiratory domain were fair (rs=-0.50, p<0.001). The LCQ total score was repeatable (ICC 0.92, 95%CI 0.87-0.96, n=50). In those reporting improvement in symptoms following treatment (n=36), LCQ total score had a mean change of 4.6 (SD 3.7) and effect size of 1.2. CONCLUSIONS: The LCQ and ReS-CF appear to be valid, reliable and responsive in CF. TRIAL REGISTRATION: www.anzctr.org.au: ACTRN12615000262505.

The Management of Nausea and Vomiting of Pregnancy.

OBJECTIVES: To review the evidence-based management of nausea and vomiting of pregnancy and hyperemesis gravidarum. EVIDENCE: MEDLINE and Cochrane database searches were performed using the medical subject headings of treatment, nausea, vomiting, pregnancy, and hyperemesis gravidarum. The quality of evidence reported in these guidelines has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventative Health Care. BENEFITS: Nausea and vomiting of pregnancy has a profound effect on women's health and quality of life during pregnancy as well as a financial impact on the health care system, and its early recognition and management is recommended. COST: Costs, including hospitalizations, additional office visits, and time lost from work, may be reduced if nausea and vomiting in pregnancy is treated early.

Drug-induced fulminant hepatic failure in pregnancy.

Liver disease in pregnancy can be classified as predating, co-incidental or unique to pregnancy. Medications are often overlooked as a significant cause of liver disease. We present the case of a 39-year-old patient who presented at 20 weeks with jaundice, elevated liver enzymes, and abnormal liver function progressing eventually to fulminant hepatic failure. The patient was on methyldopa and labetalol from 12 weeks' gestational age. Liver biopsy was consistent with drug-induced liver injury. Both methyldopa and labetalol have been associated with hepatotoxicity including liver failure. This case highlights the importance of including medications as a cause of liver failure in pregnant patients.

Maternal medication, drug use, and breastfeeding.

This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in breastfeeding women. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, the article reviews common medical conditions (eg, depression, hypertension, infections) in breastfeeding women and their appropriate treatment.

Comparison of pharmacist knowledge, perceptions and training opportunities regarding maternal-fetal medicine in Canada, Qatar and Uganda.

BACKGROUND: Although pharmacists have great potential to modify and optimize drug therapy in pregnancy and lactation, current literature demonstrates that they do not routinely provide this care and often feel ill equipped to do so. The objective of this study was to determine pharmacists' knowledge and perceptions of maternal-fetal medicine in Canada, Uganda and Qatar. Secondary objectives were to determine factors associated with pharmacists' knowledge and to characterize training opportunities and resources available to practising pharmacists. METHODS: A cross-sectional survey using online software (SurveyMonkey) was sent to the e-mails of potential research participants. Practising pharmacists and resident pharmacists in British Columbia, Canada; the country of Qatar; and the country of Uganda were eligible for inclusion. The survey was designed to assess knowledge and perceptions, and to create a baseline inventory of current practice and information resources used in practice. RESULTS: The mean knowledge assessment scores of pharmacists in Canada, Qatar and Uganda were 62.9%, 53.3%, and 57.7%, respectively (p < 0.05). Pharmacists in British Columbia scored higher on knowledge assessment than pharmacists in Qatar (p < 0.05), but other country comparisons were not significant. No predefined factors (gender, years of experience, practice area or parental status) were found to be significant in determining the knowledge score. More than two-thirds of pharmacists expressed interest in participating in continuing education opportunities in maternal-fetal medicine. CONCLUSION: Pharmacists have differing levels of knowledge in the area of maternal-fetal medicine. Continuing education and degree curricula should be reviewed and developed to fill the knowledge gaps of student pharmacists and practising pharmacists in maternal-fetal medicine.

Transfer of linezolid into breast milk.

Linezolid, a broad-spectrum antibiotic used primarily for treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, is the first oxazolidinone approved for clinical use. This is a case report of a 30-year-old woman who was exclusively breastfeeding her infant prior to taking linezolid 600 mg orally every 12 hours to treat a MRSA mastitis. Breast milk samples were obtained over a 12-hour dosing interval on day 1 (after a single dose of therapy) and again on day 14 (at steady state). The relative infant dose at steady state was found to be 15.61% on day 14 of therapy. Using the average concentration at steady state, the estimated infant dose would have been 1.84 mg/kg/day, which is well below the recommended dose given to neonates requiring linezolid drug therapy. The infant did not breastfeed during maternal treatment with linezolid.

Pharmacists and maternal-fetal medicine: development of a tool to characterize knowledge and current clinical practice.

OBJECTIVE: To develop a knowledge assessment tool to assess baseline knowledge and current practice regarding maternal-fetal medicine. METHODS: A literature search was complemented with categorization of questions under five predefined domains related to maternal-fetal medicine. The final questionnaire was sent for expert review, cultural adaptation, and piloting, with feedback incorporated accordingly. RESULTS: A questionnaire was developed consisting of questions pertaining to demographics, knowledge, and current practice. CONCLUSIONS: This tool is of interest to researchers, educators, and clinicians aiming to assess baseline knowledge, current curricula (both entry-to-practice and graduate) and continuing education opportunities for practicing pharmacists.

Physical activity levels of patients with cystic fibrosis hospitalised with an acute respiratory exacerbation.

BACKGROUND: The physical activity levels of adult patients with cystic fibrosis hospitalised for an acute respiratory exacerbation is unknown. METHODS: A prospective observational study was undertaken. Physical activity levels were measured for a 24-h period using an activity monitor (SenseWear(®) Pro 3) during hospitalisation for an acute respiratory exacerbation and one month post-discharge. Measures of exercise tolerance and muscle strength were also recorded. RESULTS: Twenty-four patients completed the study. Most outcomes significantly increased from hospitalisation to one month post-discharge. Time spent doing physical activity (≥3 METs) increased from a mean ± SD of 95 ± 58 to 209 ± 111 min. CONCLUSIONS: Hospitalisation for an acute respiratory exacerbation was associated with less time spent performing physical activity compared to one month post-discharge. Physical activity levels were higher than anticipated, even during hospitalisation, suggesting an increased metabolic rate may have contributed to the physical activity levels documented. Activity level definitions for moderate intensity exercise that are based on higher MET levels seemed more appropriate in this patient setting. CLINICAL TRIAL REGISTRY: Australian New Zealand Clinical Trials Registry Number: ACTRN12610000595011.

Maternal medication, drug use, and breastfeeding.

This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in women who are breastfeeding. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, common medical conditions and suitable treatments of depression, hypertension, infections and so forth for women who are breastfeeding are also reviewed.