A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups.

To analyze the risks versus benefits of flexible sigmoidoscopy and colonoscopy to the pregnant female and fetus, we conducted a multiyear, retrospective study at 10 hospitals of 46 patients undergoing 48 sigmoidoscopies and 8 patients undergoing 8 colonoscopies during pregnancy. Sigmoidoscopy controls included two study control groups and the average American pregnancy outcomes. Sigmoidoscopy indications included hematochezia in 28, diarrhea in 10, abdominal pain in 4, and other in 3. Thirteen patients were in the first trimester of pregnancy, 18 were in the second trimester, and 15 were in the third trimester. Twenty-seven patients had a lesion diagnosed by sigmoidoscopy, including reactivated or newly diagnosed inflammatory bowel disease, bleeding internal hemorrhoids, and other colitidies. Twenty-two of 29 patients with rectal bleeding had a significant lesion identified by sigmoidoscopy. Sigmoidoscopy was significantly more frequently diagnostic for hematochezia than for other indications (p < 0.03, chi2). No endoscopic complications occurred to the pregnant patients. Excluding 4 voluntary abortions and 1 unknown pregnancy outcome, 38 (93%) of 41 pregnant females delivered healthy babies (study control rate = 93%; NS, Fisher's exact test). Mean live-born infant Apgar scores were 8.2+/-1.5 (SD) at 1 min and 9.0+/-0.2 at 5 min (control mean Apgar scores: 8.1+/-1.7 at 1 min and 8.8+/-1.0 at 5 min; NS, Student's t test). Three high-risk pregnancies ended with fetal demise at 8, 9, or 12 weeks after sigmoidoscopy, from causes unrelated to sigmoidoscopy. No fetal cardiac abnormalities were detected by fetal cardiac monitoring during two sigmoidoscopies. Eight pregnant females underwent colonoscopy, without complications. Pregnancy outcomes included six healthy babies delivered at full term, one voluntary abortion, and one fetal demise in a high-risk pregnancy 4 months after colonoscopy from causes unrelated to colonoscopy. This study suggests that sigmoidoscopy does not induce labor or result in congenital malformations, that sigmoidoscopy is not contraindicated during pregnancy, and that sigmoidoscopy may be beneficial in pregnant patients with significant lower gastrointestinal bleeding. Colonoscopy during pregnancy should be considered for life-threatening lower gastrointestinal bleeding or when the only alternative is surgery.

A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups.

OBJECTIVES: To analyze risks versus benefits of esophagogastroduodenoscopy (EGD) during pregnancy to the fetus and pregnant female. METHODS: Retrospective study of 83 consecutive pregnant patients who underwent EGD admitted to eight university teaching hospitals during a study period of up to 14 yr, with follow-up of fetal outcome. Controls included: 48 pregnant females matched for EGD indications who did not undergo EGD (pregnant controls), 83 nonpregnant females undergoing EGD matched for age and EGD indication (EGD controls), and national pregnancy outcome rates (national controls). RESULTS: EGD indications included acute GI bleeding in 37, vomiting and abdominal pain in 17, vomiting in 14, abdominal pain in 11, and other in four. The mean week of gestation was 19.8 +/ 8.9 EGD was diagnostic in 65 patients. The diagnostic yield of EGD was 95% for acute GI bleeding and ranged from 50 to 82% for the other indications (significantly different rates, odds ratio = 9.3, p < 0.001, odds ratio confidence interval = 2.22-45.5). Esophagitis was found in 62+ of patients with a diagnostic EGD. No significant endoscopic complications occurred. EGD did not induce labor. Excluding six voluntary abortions and three unknown pregnancy outcomes, 70 (95%) of 74 patients delivered healthy babies (pregnant control rate = 94%, national control rate = 98.4%, all not significant, Fisher's exact test). Moreover, the four poor outcomes (three stillbirths and one involuntary abortion) occurred in high risk pregnancies and were unrelated to EGD temporally or etiologically. No other infant had a congenital malformation noted in the neonatal nursery. Nine (12.7%) of the live born infants had a low birth weight (pregnant control rate = 8.5%, national control rate = 7.0%, all not significant, kappa 2). Mean Apgar scores of live born infants were 7.7 +/ 1.6 at 1 min and 9.0 +/ 0.6 at 5 min (pregnant control scores = 7.6 +/ 2.0 at 1 min and 8.5 +/ 1.1 at 5 min; national control mean scores = 8.0 +/ 1.4 at 1 min and 9.0 +/ 0.9 at 5 min; all not significant, Student's t test). In three cases with fetal cardiac monitoring, EGD did not induce abnormal fetal heart rates (preendoscopy rate = 143.3 +/ 5.8 beats/min, postendoscopy rate = 148.0 +/ 10.6 beats/min). CONCLUSIONS: In this study, EGD did not induce labor or result in congenital malformations. EGD is not contraindicated during pregnancy. EGD is beneficial in pregnant patients with upper GI bleeding.

Low-dose prazosin in patients with muscle cramps during hemodialysis.

Sympathetic nervous system response to volume stress is more marked in patients with frequent hemodialysis-associated skeletal muscle cramps than in most patients who cramp infrequently. Accordingly, we conducted a double-blind, randomized, and balanced trial in which five patients with frequent hemodialysis-associated cramps were given either placebo or a prazosin dose (ranging from 0.25 to 1.0 mg) at the start of 16 dialysis sessions. These low doses of prazosin appeared to reduce cramp frequency in four of the five patients, and patient-stratified multiple logistic regression analysis indicated an aggregate 58% reduction in cramp frequency (p = 0.030). On the other hand, prazosin therapy was associated with an increased incidence of hypotension that required therapeutic intervention both during (p = 0.033) and after (p = 0.010) hemodialysis. Our findings support the hypothesis that sympathetic activation plays a pathogenetic role in hemodialysis-associated skeletal muscle cramps and suggest that pharmacologic attenuation of this response may be of therapeutic benefit.

Renal cell carcinoma presenting as polymyalgia rheumatica. Resolution after nephrectomy.

Renal cell carcinoma can present as a variety of paraneoplastic, nonmetastatic conditions, including vasculitis. We describe a patient who presented with the polymyalgia rheumatica syndrome but did not respond to a trial of prednisone. An asymptomatic, nonmetastatic renal cell carcinoma was found during this patient's evaluation. Nephrectomy led to resolution of the systemic complaints. Malignancy, in this case, renal cell carcinoma, can present as polymyalgia rheumatica and resolve after surgical removal of the underlying tumor.