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In particular, many of the newest antihypertensives and antiarrhythmics have been sparsely studied in pregnant women, and are thus commonly avoided. Patients who would benefit from surgical repair of a lesion as in mitral or aortic stenosis should undergo surgical repair a year or more before becoming pregnant. It is important that patients and their families are aware of the risks of disabling morbidity and mortality if they decide to continue the pregnancy. Management and early intervention during labor and delivery can help reduce risk for cardiac patients. Early epidural analgesia to control pain can minimize the cardiac stress of labor and delivery. Likewise, an assisted vaginal delivery (using forceps or vacuum) can diminish the potential detrimental cardiac effect of Valsalva while pushing. In addition, careful fluid monitoring should be maintained, possibly with a central venous pressure monitor and arterial line. After delivery, massive fluid shifts make the immediate postpartum period a particularly dangerous transition for women with congenital heart disease. First, postpartum women have increased venous return because they no longer have an enlarged uterus compressing the vena cava. Second, the uterus clamps down after placental expulsion and demands less circulation, leading to an effective autotransfusion of its blood supply (approximately 500 cc). Patients with aortic stenosis and aortic insufficiency require a decreased afterload to maintain cardiac output, and thus initially may have diminished symptoms in response to the decreased systemic vascular resistance seen in pregnancy. Patients with pulmonary stenosis who elect to continue their pregnancy may actually undergo valvuloplasty during the pregnancy if they have severe disease. During pregnancy, the hyperdynamic state can increase the risk of aortic dissection and/or rupture, particularly in those patients with an aortic root diameter greater than 4 cm. In order to decrease some of the pressure on the aorta, patients are advised to maintain a sedentary lifestyle and are often placed on beta-blockers to decrease cardiac output. Small case series show that, if optimally managed, these patients do relatively well in pregnancy. Throughout pregnancy and during labor and delivery, it is important to minimize increased demand on the heart. Some of these patients likely have a baseline mild cardiomyopathy, whereas others have a postinfectious dilated cardiomyopathy. Patients present with classic signs and symptoms of heart failure and on echocardiogram have a dilated heart with an ejection fraction far below normal in the 20% to 40% range. In Eisenmenger syndrome, an initial left-to-right shunt overfills the right heart.
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Evaluation of fine needle aspiration biopsy in the preoperative selection of cold thyroid nodules. Gender, clinical findings, and serum thyrotropin measurements in the prediction of thyroid neoplasia in 1005 patients presenting with thyroid enlargement and investigated by fine needle aspiration cytology. Diagnostic accuracy of conventional vs sonography-guided fine-needle aspiration biopsy of thyroid nodules. Effect of early referral to an endocrinologist on efficiency and cost of evaluation and development of treatment plan in patients with thyroid nodules. Joint publication, British Thyroid Association and Royal College of Physicians 2002. Treatment guidelines for patients with thyroid nodules and well differentiated thyroid cancer. Administration of a single low dose of recombinant human thyrotropin significantly enhances radioidine uptake in nontoxic nodular goitre. Is percutaneous ethanol injection a useful alternative for the treatment of the cold benign thyroid nodules Ultrasound guided percutaneous ethanol injection in the treatment of cystic thyroid nodules. This chapter primarily relies on observational studies and the peer-reviewed literature relating to anatomy and physiology and is therefore level 4 evidence. The principal role of the surgeon in parathyroid surgery is to be able to localize and distinguish diseased from normal parathyroid glands. At present, there are several noninvasive imaging techniques available for aiding the localization of parathyroid tissue. However, the precise application of knowledge of the anatomy and embryology of the parathyroid glands is essential to plan an operative strategy and to achieve successful therapy in those patients with parathyroid disease. A thorough understanding of the physiology and regulation of calcium metabolism is important to the clinician. A duct-like connection exists between the third pharyngeal pouch and the pharyngeal wall which is soon lost, although the connection between the parathyroid and thymic rudiments persists for longer. The ventral aspect of the pouch and the remnants of the fifth pharyngeal pouch form the ultimobranchial bodies, which form C (parafollicular) cells. The ultimobranchial bodies appear to be analogues of parathyroid tissue and play a role in calcium metabolism with their embryological origin supporting this. The caudal migration of the superior parathyroid gland is less in comparison to the migration of the inferior parathyroid gland which is associated with the descent of the thymus gland, thus explaining their paradoxical positioning. This is the reason for the increased proportion of anomalies of position of the inferior parathyroid gland. There is some controversy regarding the embryological origin of the parathyroid glands from the ectodermal (epipharyngeal) placode.
