Not Pre-Eclampsia

Abstract

A woman aged 71 had suffered from chronic sinusitis and recurrent nasal polyps for many years. She had been treated with various intranasal corticosteroids including betamethasone nasal drops, beclomethasone nasal spray, mometasone nasal spray and¯uticasone nasal spray. No other topical or systemic corticosteroid treatment had been prescribed. At presentation she reported having been unwell and tired for about twelve months; at this time she had been using betamethasone 0.1% drops for eight months, 1±2 drops in each nostril once daily. Clinically she was not cushingoid. A short tetracosactrin (Synacthen) test was arranged, and she was asked to stop the steroid drops a few days beforehand. After stopping treatment she became unwell and experienced weakness, fatigue, nausea and headache, and was almost unable to get out of bed. The short Synacthen test (250 mg tetracosactrin intramuscularly) showed severe adrenal impairment. The basal cortisol was only 10 nmol/L, rising to 312 nmol/L after 30 minutes. After completing the test she was restarted on the betamethasone drops and felt much better.Over the next two months she was weaned off the betamethasone drops and a repeat short Synacthen test four months later showed a much improved response with basal plasma cortisol 180 nmol/L, rising to 593 nmol/L at 30 minutes. She felt very well, with only minor return of nasal symptoms. COMMENTThis case illustrates the ability of intranasal corticosteroid treatment to cause symptomatic adrenal suppression without cushingoid features. There may be a tendency for patients inadvertently to administer too many drops. In a study by Gallagher and Mackay, doctors were shown how to administer drops correctly but even in this group over a 14-day period overuse was the rule 8 . Excess steroid nasal drops probably trickle down the nasopharynx and are swallowed. The patient is thus effectively on systemic as well as local steroids.Drops do seem more likely than sprays to result in systemic steroid absorption 2±7 . Thus Synacthen tests have given normal results in patients on beclomethasone spray 10 but subnormal results after 6 weeks of betamethasone drops 11 . Long-term use of nasal steroid drops is probably inadvisable. With nasal steroid sprays more accurate doses can be delivered. By far the commonest cause of hypertension in pregnancy is pre-eclampsia, but other causes must not be forgotten. REFERENCES CASE HISTORYOn the second day after a normal delivery a woman aged 16 was referred because of uncontrolled hypertension. 2 years previously she had been found hypertensive when taking the combined oral contraceptive pill. Six months after stopping the pill she had been treated for missed abortion, at which time her blood pressure was 160/95 mmHg. There was no family history of hypertension or congenital heart disease.In the last trimester of her second pregnancy, blood 351

Management of Severe Coarctation of the Aorta During Pregnancy

“…For aortic procedures, high estrogen levels can impact aortic remodeling, predisposing the aorta to dissection and rupture ( 3 , 6 ). However, if residual arch gradient is low, outcomes of further pregnancies are favorable, with rates of preeclampsia similar to those of the general population ( 4 ).…”

“…When invasive intervention for COA is indicated, treatment options include balloon angioplasty alone, transcatheter stent implantation, and surgical coarctectomy ( 4 ). To the best of the present authors’ knowledge, only one other transcatheter stent has been successfully placed during pregnancy for treatment of COA ( 3 ).…”

“…Maternal complications include cerebral infarction, aortic dissection, aortic rupture, congestive heart failure, hypertensive crisis, and infective endocarditis. Fetal complications include growth retardation and premature birth with increased risk for placental ischemia or abruption ( 3 , 4 ).

Learning Objectives

To understand the risks of unrepaired COA to the mother and to the fetus.

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“…When medical management with typical antihypertensive drugs fails to decrease the coarctation gradient, invasive intervention may be indicated ( 4 ). Management of COA is dependent upon the patient’s age, size (weight, length, and width of the coarctation), and coarctation characteristics.…”