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Cardiac dysrhythmias and low cardiac output may require treatment during the postoperative period. The parents of an affected child have at least one haplotype for the defect, giving each subsequent offspring a 25% chance of having the condition and a 50% chance of being a carrier. Therefore, in addition to adequate depth of anesthesia, skeletal muscle paralysis is typically maintained during intracranial surgery. At delivery, stress corticosteroid doses (usually 100 mg of hydrocortisone every 8 hours from the onset of labor until 24 hours after delivery) are administered to patients currently or recently taking corticosteroids. It is an inodilator, increasing myocardial contractile strength and promoting dilation of systemic, pulmonary, and coronary arteries. The other component of asthma treatment is the use of "reliever" or rescue agents for acute bronchospasm. This system can generate cardiac outputs similar to those produced by the Impella system. Treatment of the hydatidiform mole or choriocarcinoma restores thyroid function to normal. There have been few case reports, and some of the reported cases of papular dermatitis have been questionable because of the lack of appropriate laboratory studies to exclude the other pregnancy rashes discussed in this chapter. Abnormal function of these enzymes can lead to maternal virilization and virilization of the female fetus, together with low estriol secretion in pregnancy. In contrast, the Endocrine Society recommends treatment of subclinical hypothyroidism regardless of the antibody status, although the evidence was only fair to poor for those who were antibody negative. Bloody pleural effusion is common in patients with malignant disease, trauma, or pulmonary infarction. Nausea, vomiting, reduced gastric motility, or use of antacids may also lead to reduced absorption of anticonvulsant drugs. As the cardiac output becomes fixed and eventually falls, patients may have episodes of syncope or nearsyncope. In addition to ductal patency, infant survival depends on a balance between systemic vascular resistance and pulmonary vascular resistance, because both circulations are supplied from a single ventricle in a parallel fashion. In the lean pregnant woman with normal glucose tolerance, there is a significant 30% increase in basal hepatic glucose production by the third trimester of pregnancy. Vasodilation and hypotension may be further aggravated by the transient increase in carbon dioxide release and oxygen consumption in these tissues following unclamping. A review of 89 cases of eclampsia found that 33% of seizures occurred after delivery and that 79% of those manifested more than 48 hours after the birth. Symptomatic benefit follows bed rest and sedation, and there is no indication for termination of pregnancy. Nevertheless, the risks of surgical closure are significant and include intracranial hemorrhage, infections, and recurrent laryngeal nerve paralysis, especially in infants born at less than 28 weeks of gestation. Amiloride is used to treat hyperaldosteronism in men, because spironolactone may cause gynecomastia. Serosanguineous (exudative) fluid is typically seen when the pericardial disease is due to cancer, tuberculosis, or radiation exposure. Patients should be instructed on proper dosages and administration of their asthma medications. If the foramen ovale is patent, right-to-left intracardiac shunting of blood may occur, causing cyanosis and clubbing. Although spontaneous remission may occur, treatment of severe cases requires whole-lung lavage to remove alveolar material and improve macrophage function. American College of Obstetricians and Gynecologists: Management of abnormal cervical cytology and histology: practice bulletin no. Anesthesiologists who practice pain medicine also have the opportunity to encourage smoking cessation in their patients. Patients who undergo mechanical ventilation for treatment of acute respiratory failure are at risk of neuromuscular weakness that persists long after the cause of the respiratory failure has resolved.

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When moderate liver congestion is present, liver enzyme levels may be mildly elevated, and when liver engorgement is severe, the prothrombin time may be prolonged. These and other reports of small series with a variety of treatment strategies suggest that a moderate delay of definitive therapy does not incur excessive risk. The onset and severity of symptoms produced by this abnormality depend on the amount of pulmonary blood flow routed through the right side of the heart. They can include substernal burning, epigastric discomfort, dyspepsia, mild dysphagia, and regurgitation. Fast losers had high serum levels of osteocalcin (a marker of bone formation), and it was suggested that this could be used as a marker of the change. Stillbirths are most likely associated with death due to placental abruption, and undelivered pregnancies occur most often with lacerations or uterine ruptures. In patients with severe mitral regurgitation, vasodilators such as nitroprusside or nitroglycerin may be carefully titrated to maximize forward left ventricular flow and decrease left ventricular end-diastolic volume and left atrial pressure. For hyperparathyroidism presenting during pregnancy, standard practice favors surgical treatment. If the patient experiences rapid tumor growth of 50% or more or has evidence of lymph node metastases or extracapsular invasion, surgery should be considered in the second trimester. Although the traditional admonition is to treat venous air embolism by placing the patient in the lateral position with the right chest uppermost, this is rarely possible or safe during intracranial surgery. The vasoconstrictive properties of cocaine can have a wide range of fetal effects. They may be dull or throbbing; are commonly accompanied by nausea, vomiting, and photophobia; and are often associated with blurring of vision, lightheadedness, and scalp tenderness. The selection of drugs for induction and maintenance of anesthesia is not influenced by this disease. Whereas most of the immune changes in pregnancy return to normal by 12 months after delivery, there is a marked increase after most pregnancies in many different types of autoantibody secretion and an exacerbation of autoimmune disease. Disturbances of speech, sensation, or vision may also occur, and patients may have mild pyrexia. These results suggest that women with well-managed, stable beta-thalassemia can do very well during pregnancy. The decision about the mode of delivery is often complex because the mother is likely to have a coagulopathy. These mothers were also found to abuse other substances and have higher rates of domestic violence and adoption. Symptoms resulting from thoracic aneurysm typically reflect impingement of the aneurysm on adjacent structures. Echocardiography is used to assess right atrial dilation, the distortion of the tricuspid valve leaflets, and the severity of the tricuspid regurgitation or stenosis. Nesiritide given intravenously has been studied extensively in large clinical trials. Harris B, Fung H, Johns S, et al: Transient postpartum thyroid dysfunction and postnatal depression, J Affect Disord 17:243, 1989. In addition to the impedance caused by the chest wall (the skin and fat overlying the bone), the electrical current encounters some increase in impedance from air spaces within the lung tissue in the current path. This high rate was probably an overestimate resulting from ascertainment bias, because the risk for Ebstein anomaly among lithium users in subsequent prospective studies ranged from 2 per 1000 (0. Minor transfusion reactions are relatively common occurrences and are not caused by hemolysis. Until additional information is available, admission for all pregnant women with pneumonia is still recommended. Septate uterus has been associated with the poorest reproductive outcome, mainly because of an association with a high rate of spontaneous abortion. About 215,000 people younger than 20 years of age had diabetes (type 1 or type 2) in 2010. The major therapeutic modalities during pregnancy are iron therapy, transfusions, corticosteroids, and androgen treatment (if the fetus is male). Similarly, no agreement was reached regarding universal screening in the Endocrine Society guidelines, with unanimous agreement on targeted screening.

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Theophylline is indicated only for chronic therapy and is not effective for the treatment of acute exacerbations during pregnancy. In advanced stages of heart failure, there are high circulating levels of aldosterone. In one report, three of four deaths during pregnancy occurred in gravidas colonized with B. Maternal hirsutism or virilization has been documented in approximately 30% of reported cases. Lumley J, Chamberlain C, Dowswell T, et al: Interventions for promoting smoking cessation 73. The link between subclinical hypothyroidism and such outcomes is less evident (discussed later). Cunningham and McCubbin113 identified delays in diagnosis of 18% and 75% in the second and third trimester, respectively, which corresponded to the higher rates of 62 Gastrointestinal Disease in Pregnancy 1065 complications, including perforation and peritonitis, found in other series. In the critically ill population, hyperglycemia is a common phenomenon attributable to insulin resistance and escalations in glucagon, cortisol, and catecholamine levels, which promote glycogenolysis and gluconeogenesis. Epidemiologic and other studies suggest a triggering role for enteroviruses, whereas other microorganisms might provide protection. Typical devices that provide positive pressure ventilation include volume-cycled and pressurecycled ventilators. The most significant of these cardiovascular conditions and valvular disorders are discussed here. Patients with more severe disease may have disseminated intravascular coagulation. Although vasopressin is widely used in treating septic shock and results in higher systemic pressures than when it is not used, the outcome data supporting its use are controversial, with most efficacy demonstrated in less severe cases. It has been suggested that the hyperventilation of pregnancy results primarily from progesterone acting as a respiratory stimulant. Concentrations of 4-androstenedione, testosterone, and 17-hydroxyprogesterone are used to monitor adequacy of suppression. Measurement of gastric fluid pH is useful since it reflects the pH of the aspirated fluid. Clinically, the uterus is larger than expected because of the molar pregnancy or the resultant ovarian thecal lutein cysts. In this situation, not only is the anterior spinal artery blood flow reduced directly, but the potential for collateral blood flow to the spinal cord is also reduced because aortic pressure distal to the cross-clamp is very low. A typical regimen is to add 1 to 2 U lispro for every 50 mg/dL that the glucose level is out of target range. Moreover, the effect of pregnancy may vary on different occasions, so that the outcome in individual cases cannot be predicted on this basis. Echocardiography will demonstrate significant diastolic dysfunction and normal systolic function. Shalev E, Goldstein D, Zuckerman H: Compulsive water drinking in pregnancy, Int J Gynaecol Obstet 18:465, 1980. Women who smoke during pregnancy have higher risks of deep venous thrombosis, stroke, pulmonary embolus, myocardial infarction, and pulmonary complications such as influenza, pneumonia, and bronchitis. Aspirin is most commonly prescribed, although ketorolac has also been used successfully. As early as 1923, research by Moulton101 described variability in weight among different mammalian species that was attributed to the amount of adipose tissue or fat mass rather than lean body mass. However, various disease processes, including tumors and congenital and degenerative diseases of the spinal cord and vertebral column, can also cause cord injury. Establishment of physiologic acid-base values, normalization of serum electrolyte concentrations, and stabilization of autonomic nervous system activity are important and maximize the possibility of reestablishing normal sinus rhythm. Carbohydrate intolerance occurs in up to 50% and overt diabetes in up to 20% of acromegalic women, and the insulin resistance of pregnancy is additive. The use of nitrous oxide is controversial if there is any potential for venous air embolism. Fortunately, this is a rare occurrence, but it may lead to a fatal outcome for the mother or fetus.

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The advantage of primary surgical management includes the ability to preserve ovarian function and to avoid the potential negative impact on sexual function imparted by radiation therapy. They then reviewed the literature and reported neonatal outcomes at various time intervals after delivery. The choice of pharmacologic agent depends on the co-existing medical conditions of the patient. The disorder results from overactivity of sudomotor nerve fibers innervating eccrine sweat glands. Herniation of the cerebellar tonsils can occur in the setting of elevated infratentorial pressure, which leads to extension of these cerebellar structures through the foramen magnum. Breathing at rapid rates and with low tidal volumes usually signifies an inability to tolerate extubation. Hallmarks of decreased cardiac reserve and low cardiac output include fatigue and weakness at rest or with minimal exertion. The workup should include a physical examination, arterial blood gas determinations, a chest radiograph, sputum Gram stain and culture, and blood cultures. Renal replacement therapy is sometimes required in patients with severe sepsis, and similar survival rates have been shown with both intermittent and continuous techniques. They are more effective than leukotriene receptor antagonists or theophylline as add-on therapy to inhaled corticosteroids. Mariotti S, Chiovato L, Vitti P, et al: Recent advances in the understanding of humoral and cellular mechanisms implicated in thyroid autoimmune disorders, Clin Immunol Immunopathol 50:573, 1989. Loss of atrial contraction, as during junctional rhythm or atrial fibrillation, may produce a dramatic decrease in stroke volume and blood pressure. However, the remaining infants did well and were discharged with apparently normal pulmonary function. Characteristically isoproterenol administration causes the systolic blood pressure to increase and the diastolic blood pressure to decrease. Pulsus paradoxus is a regular feature of cardiac tamponade but is often absent in constrictive pericarditis. Postoperative hypertension should be treated either by eliminating the specific cause if identified or by initiating antihypertensive therapy. Decisions about timing and mode of delivery should be made in a setting that involves a multidisciplinary team of nurses, maternal-fetal medicine specialists or obstetricians, anesthesiologists, and cardiologists. Signs of syringomyelia are present in approximately 50% of patients with this disorder. Liver biopsy remains safe in expert hands if coagulation parameters are within normal limits. Symptoms of aqueductal stenosis are the same as those seen with other forms of intracranial hypertension. Combined oral contraceptives may increase the metabolism of lamotrigine, causing lower lamotrigine blood levels, and may increase seizure frequency in patients on this medication. Electrocorticography, as mentioned earlier, involves placement of electrodes either as a grid directly on the brain surface or deeper within the brain. These hemodynamic changes are collectively known as spinal shock and typically last 1 to 3 weeks. Adrenal Glands the adrenal cortex plays an important and essential metabolic role in humans. Osman H, Rubeiz N, Tamim H, et al: Risk factors for the development of striae gravidarum, Am J Obstet Gynecol 196:62, 2007. Sudden increases in intraabdominal pressure from coughing or emesis should be avoided, and palpation of the liver should be kept to a minimum. This vasodilatory effect does increase coronary blood flow, but the increased oxygen demand resulting from a higher heart rate outweighs the potential benefit of any increase in myocardial blood flow. For example, brain growth and development proceeds rapidly during the third trimester and continues for the first several years of life. Maternal complications include hyperemesis, renal calculi (36%), pancreatitis (13%), hypertension (10%), bone disease (19%), hypercalcemic crises (8%), and psychiatric problems. There was a surprisingly long interval between the obstetric event and diagnosis (>10 years) for more than half of the patients. Involvement of the pharyngeal muscles makes these patients susceptible to pulmonary aspiration.

Diseases

• Congenital short bowel
• Anophthalmia plus syndrome
• Allanson Pantzar McLeod syndrome
• Emphysema-penoscrotal web-deafness-mental retardation
• Blaichman syndrome
• Galactorrhea hyperprolactinemia

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Management of migraine consists of the avoidance of precipitating factors coupled with prophylactic or abortive drug treatment, if necessary. Infection usually results from a lack of hygiene during delivery, with consequent contamination of the umbilical cord. Biologic testing for cocaine measures its metabolite benzoylecgonine, which is present in urine for 2 to 4 days after exposure. Patients with asthma that is not well controlled should generally be stepped up one step, and those whose asthma is very poorly controlled should be stepped up two steps. The insertion of an intraarterial catheter is useful for continuous monitoring of blood pressure and blood sampling as needed. Chorea developing for the first time during pregnancy must not automatically be regarded as a variant of Sydenham chorea, because it may arise for other reasons. These compelling indications were identified based on the results of several outcome studies. Because most procedures are done with the patient in the left lateral position, this is usually not an issue. The mechanism (or mechanisms) responsible for the compromised renal function in preeclampsia may be related to renal vasoconstriction and to the glomerular endotheliosis noted on renal biopsies. Amenorrhea and infertility are common in affected women and represent the classic phenotype of disease. Duplex ultrasonography can identify areas of plaque formation and calcification as well as blood flow abnormalities caused by arterial stenoses. Some patients are helped by injection of steroids into the carpal tunnel and others by treatment with diuretics. Unless the patient is having a primary or staged cardiac repair, there are no evidence-based recommendations to guide the anesthetic management of the adult congenital heart disease patient undergoing surgery. Magnetic Resonance Imaging Magnetic resonance imaging can be safely used during pregnancy to evaluate adnexal masses even without the use of gadolinium-based contrast. The significant decreases in insulin sensitivity in late gestation affect the metabolism of glucose, lipids, and amino acids. However, a high sensory level of anesthesia with its associated sympathetic denervation can unmask unsuspected hypovolemia. Churg-Strauss Syndrome Churg-Strauss syndrome is a vasculitis of small and mediumsized vessels. Although Pap smears and routine screening are readily available in most developed countries, most women diagnosed with cervical cancer have not had appropriate screening. Common causes of atraumatic and traumatic pericardial effusion are listed in Table 7-1. The human fetus at term has the greatest percentage of body fat (approximately 10% to 12%) when compared with other mammals. Diagnosis Constrictive pericarditis is difficult to diagnose, and its signs and symptoms are therefore often erroneously attributed to liver disease or idiopathic pericardial effusion. Stasis of blood in the distended left atrium predisposes patients with mitral stenosis to a higher risk of systemic thromboembolism. There is no cutaneous sensory loss because the trigeminal nerve, not the facial nerve, supplies sensory innervation to the face. Furthermore, the combination of arterial hypoxemia and hypercarbia exert synergistic effects. Concern has been raised regarding unaffected fetuses of mothers with thyroid hormone resistance.

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Magnetic resonance imaging can be used if prosthetic valve regurgitation or a paravalvular leak is suspected but not adequately visualized by echocardiography. In most studies, total immunoglobulin G and autoantibody levels rise above pre-pregnancy levels during the first 6 months after delivery, suggesting continuing nonspecific immune stimulation. If a lethal condition or high risk of death in the delivery room is anticipated, the neonatologist can assist with the formulation of a birth plan and develop parameters for delivery room intervention. Combinations of opioids, benzodiazepines, and nitrous oxide with or without low doses of volatile anesthetics are appropriate for maintenance of anesthesia. Cocuroccia B, Gisondi P, Gubinelli E, et al: Autoimmune progesterone dermatitis, Gynecol Endocrinol 22:54, 2006. Three of the gravidas had severe disease characterized by a vital capacity of no more than 1. The suppressibility of cortisol was shown to be 40% after 1 mg of dexamethasone in second- and third-trimester normal pregnancies, compared with 80% in nongravid controls; loss of suppression increased with increasing gestation. Umbilical cord sampling can be considered if there is doubt about fetal thyroid disease. Angina pectoris associated with coronarysubclavian steal syndrome requires surgical bypass grafting. However, the risks of fetal macrosomia, birth injury, and fetal death increase as the due date approaches. The disease usually improves during pregnancy or with oral contraceptive therapy, probably because of an estrogen effect. Calcium channel blockers have negative inotropic properties and should be avoided in patients with left ventricular dysfunction. The measurement of the echo-free space between the heart and pericardium allows easy assessment of effusion size and may also provide information about the cause of the effusion. The first encompasses events that occur during or before labor, also known as sentinel lesions, which can cause fetal hypoxia. The basal and bolus insulin doses required after delivery are typically 30% to 50% of the preprandial doses required during pregnancy just before delivery. Therefore, this disease process produces both upper and lower motor neuron degeneration. If needed, a free T4 index using the product of total T4 and T3 resin uptake should be used. Exposure to six different classes of drugs during pregnancy is then reviewed: tobacco, alcohol, marijuana, opioids, stimulants, and benzodiazepines. When the diagnosis is based on symptoms in the neonatal period, the reported incidence is 1 case in 4000 live births. If the atrial fibrillation is hemodynamically significant, the treatment is cardioversion. Bearing these changes in mind, urinary free-cortisol excretion of more than three times the upper limit of normal in the second or third trimesters may suggest Cushing syndrome. Moen V, Dahlgren N, Irestedt L: Severe neurological complications after central neuraxial blockades in Sweden 1990-1999, Anesthesiology 101:950, 2004. A retrospective review of 78 pregnancies in 76 patients showed that nonoperative management of symptomatic cholelithiasis. Medical management only improves symptoms; it does not affect the progression of the disease. Chest radiographs may demonstrate an abnormal separation between the esophagus and the trachea. Noncardiac causes of acute arterial occlusion include atheroemboli from an upstream artery, plaque rupture, and hypercoagulability derangements. Patients with decreased pulmonary blood flow and arterial hypoxemia should be managed in the same way as patients with tetralogy of Fallot. However, patient movement during the procedure poses the risk of aneurysm rupture or coil dislodgment resulting in coil embolization. Women with cervical cancer who have delivered vaginally with episiotomy and later develop a lesion in the episiotomy should undergo biopsy to rule out recurrence at this site. Radiofrequency Catheter Ablation In radiofrequency catheter ablation, an intracardiac electrode catheter inserted percutaneously under local anesthesia through a large vein (femoral, subclavian, internal jugular, or cephalic) is used to produce small, well-demarcated areas of thermal injury that destroy the myocardial tissue responsible for initiation or maintenance of dysrhythmias. Iodide is actively trapped by the thyroid and is the ratelimiting step in hormone biosynthesis.

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It typically accompanies pulmonary hypoplasia, in which diminished surface area for gas exchange and inadequate pulmonary blood flow lead to hypoxia and remodeling of the resistance pulmonary arterioles. The anesthesia considerations for parturients abusing amphetamines or cocaine are primarily the control of hemodynamics. Patients with acute liver failure should be considered for transfer to a tertiary care center with transplantation facilities. Therefore, this test has a low predictive value for the diagnosis of heart failure. MultipleSclerosis Multiple sclerosis is a disorder in which plaques of demyelination develop at different times and in different sites throughout the central nervous system. Other sports in which similar injuries have been reported are hockey and lacrosse. Thrombocytopenia, if a new occurrence during pregnancy, usually remits after delivery. The clinical presentation of acute pulmonary thromboembolism ranges from shock or sustained hypotension to mild dyspnea. Regional anesthesia is acceptable for suitable operations in heart failure patients. High levels of serum progesterone block aldosterone action, preventing kaliuresis. Temporizing measures likely to help maintain stroke volume until definitive treatment of cardiac tamponade is undertaken include expanding intravascular volume, administering catecholamines to increase myocardial contractility, and correcting metabolic acidosis. However, compared with control women, the 21 women with tubercular involvement of other extrapulmonary sites had higher rates of antenatal hospitalization (24% versus 2%; P <. Signs and symptoms of congenital heart disease in infants and children often include dyspnea, slow physical development, and the presence of a cardiac murmur (Table 3-2). If substantial growth or lymph node metastases are shown, second-trimester surgery is recommended. Tachydysrhythmias can result from three mechanisms: (1) increased automaticity in normal conduction tissue or in an ectopic focus, (2) reentry of electrical potentials through abnormal pathways, and (3) triggering of abnormal cardiac potentials due to afterdepolarizations. A pediatric cardiologist should evaluate a child with a loud systolic murmur and wide splitting of the second heart sound. Loss of consciousness and seizures may also occur, and cardiac dysrhythmias are often present. The onset of symptoms sometimes follows abortion or occurs in the postpartum period, possibly because of rupture of the thin-walled dural arteries during the straining of labor or because of the circulatory changes that occur in pregnancy. Hypovolemia caused by diabetes insipidus, third space losses, or drugs can contribute to hypotension. Mechanisms proposed to explain the cellular injury include tissue ischemia, cytopathic injury, and an altered rate of apoptosis (programmed cell death). Patients with refractory symptoms may require band ligation, injection, sclerotherapy, or coagulation. After surgical exposure, the distal normal trachea is opened and a sterile cuffed tube is inserted and attached to the anesthetic circuit. Nocturnal ventilation with noninvasive techniques such as nasal intermittent positive pressure or external negative pressure ventilation may be useful. This enzyme mediates formation of phosphatidylinositol anchors for various transmembrane proteins, including inhibitors of the complement proteins. A depressive episode requires at least five symptoms, including either low mood or diminished pleasure, lasting for 2 weeks. Hypothalamic and pituitary disorders were discussed previously and have been reviewed by Lindsay and colleagues. Severe hemolytic anemia is uncommon, and its presence usually indicates valvular dysfunction or endocarditis. Therefore, sonographic monitoring of fetal growth seems indicated, particularly with multiple myomas or those larger than 5 cm in diameter. A glucose-containing intravenous line should be established promptly on arrival at the hospital, with short-acting insulin given as intravenous boluses on a sliding scale as needed every 1 to 4 hours to maintain the maternal plasma glucose level in the range of 80 to 160 mg/dL. Patients with co-existing cerebrovascular disease may be more vulnerable to the development of new central nervous system complications.

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In the 25- to 32-week period, a reactive nonstress test is defined as two accelerations of at least 10 beats/min during a 20-minute interval. These laboratory tests should be repeated at regular intervals until the situation has resolved. Primary Adrenocortical Insufficiency: Addison Disease Atrophy of the adrenals on an autoimmune basis is the most common cause of adrenal failure, accounting for 83% of cases. The process depends on crucial physiologic mechanisms, including production of functional surfactant, dilatation of high-resistance pulmonary arterioles, bulk transfer of fluid from airspaces, and physiologic closure of the ductus arteriosus and foramen ovale. Respiratory diseases can be divided into the following groups for discussion of their influence on anesthetic management: acute upper respiratory tract infection, asthma, chronic obstructive pulmonary disease, acute respiratory failure, restrictive lung disease, pulmonary embolism, and lung transplantation. Avoid massive crystalloid resuscitation to prevent increases in hydrostatic pressure and decreases in colloid oncotic pressure that can dislodge clots at the sites of endothelial injury and cause fluid leak from the intravascular compartment. If aqueductal stenosis is present, the third, but not fourth, ventricle is enlarged. Low-dose methotrexate is relatively nontoxic and inhibits both cellmediated and humoral immunity due to its antiinflammatory effects. Developmental delay and behavioral problems are observed, and associated factors such as poverty, lack of prenatal care, and low socioeconomic status also contribute. Small doses of vasopressor medications that have less impact on pulmonary vascular resistance. Close fetal surveillance is essential because the fetus might have been suffering from uteroplacental insufficiency during gestation and is more prone to develop evidence of compromise during labor. When a pregnant patient is in shock or suffering severe respiratory failure, her blood pressure should be measured using an indwelling arterial catheter. Chemical peels with trichloroacetic acid, phenol, glycolic acid, Jessner solution. Effects of anesthetic agents and physiologic changes on intraoperative motor evoked potentials. Dural arteriovenous fistulas commonly present with pulsatile tinnitus or headache. In the fetus, the ductus arteriosus permits pulmonary arterial blood to bypass the deflated lungs and enter the descending aorta for oxygenation in the placenta. Endemic cretinism constitutes only the extreme expression of the spectrum of physical and intellectual abnormalities. Therapeutic options include observation, radiotherapy, chemotherapy, and termination of pregnancy. In the absence of normal ciliary function, placement of organs to the left or the right is random. Perhaps most importantly, there were no differences in preeclampsia-related complications. Currently, treatment may involve a combination of surgical resection, highly focused (Gamma Knife) irradiation, and/or angiographically guided embolization. All long-term pulmonary vasodilator therapy must be continued throughout the perioperative period. Surgical treatment is aimed at preventing further hemorrhages, but induction of hypotension during the course of the intracranial surgery should be avoided unless it is essential, because it may be followed by premature labor or fetal death; hypothermia is well tolerated. The syndrome can be prevented or treated by spinal or epidural anesthesia extending to the level of the 10th thoracic segment, and early consultation with an anesthesiologist may therefore be helpful. Spontaneous occurrence is less frequent than with anterior ischemic optic neuropathy. There should be a thorough search for the underlying cause, with particular attention paid to the possibility of a treatable infection such as sepsis or pneumonia. Antibiotic coverage (a cephalosporin plus gentamicin, or vancomycin plus gentamicin) may be indicated in women who have artificial joint replacements and are undergoing vaginal delivery. Infratentorial tumors have more unusual patient positioning requirements and may be performed with the patient in the lateral, prone, or sitting position.