- Email: [email protected]
Clinical experience with phenytoin prophylaxis in severe preeclampsia
ABSTRACTS
quinolone, theophylline
Effect of quinolone antimicrobials on theophylline p h a r m a c o k i n e t i c s Prince RA, Casabar E, Adair CG, et al J Clin Pharmacol 29:650-654 Jul 1989
This controlled, blinded study looked at the effect of quinolone antimicrobials on theophylline pharmacokinetics. Subjects were given nalidixic acid, ciprofloxacin, norfloxacin, or placebo for seven days. Drugs were given in usual therapeutic doses. Five mg/kg IV theophylline was infused on the seventh day, and levels were checked 15 times over the next 16 hours. Eight subjects underwent each of the four treatments with a seven-day washout period between treatments. Theophylline clearance rates were similar after treatment with anlicixic acid and placebo. Clearance was decreased 0% to 31% after treatment with nalicixic acid and 0% to 41% after ciprofloxacin treatment. The same subject had no change in clearance of theophylline after either quinolone. It was concluded that treatment with quinolone antimicrobials in patients taking theophylline m a y cause clinically significant decreases in theophylline clearance and that more frequent monitoring of theophylline level is recommended in these patients. Laurie Vande Krol, MD
phenytoin, preeclampsia
Clinical e x p e r i e n c e with phenytoin prophylaxis in severe p r e e c l a m p s i a Ryan G, Lange IR, Naugler MA Am J Qbstet Gynecol 16:1297-1304 Nov 1989
In this uncontrolled, prospective, nonblinded study, 104 patients with eclampsia, preeclampsia, or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) were treated prophylactically for seizures with phenytoin instead of magnesium sulfate (MgSO4). Serial levels of free phenytoin and albumin were measured from maternal, neonatal, and cord blood. The initial group consisted of patients who were given a 1-g bolus that resulted in inconsistent serum levels due to varying patient weights. Following this, 18 mg/kg in a single dose was administered, but three of eight patients in this group developed transient choreoathetosis. Later, one group received 18 mg/kg in two doses of 9 mg/kg, and a fourth group of patients was administered 15 mg/kg dose in a 10-mg/kg bo-
192/347
lus followed in two hours by a 5-mg/kg bolus. The latter dosage regimen resulted in therapeutic drug levels in 94% of patients and caused the lowest rate of side effects. There was only one transient hypotensive episode. Hypertension was controlled with hydralazine. Only one of the 104 patients had a seizure, and in her case, the loading dose of phenytoin had been erroneously low at 6.6 mg/kg. Maintenance doses were given orally or IV and continued for three to five days. There were no changes in fetal heart rates with infusion, and there were no neonatal side effects attributable to phenytoin. It was concluded that phenytoin is a safe, logical anticonvulsant alternative to MgSO 4 in preeclamptic patients. Advantages of phenytoin are that it provides a central rather than a peripheral mechanism of action, is free of toxolytic activity in patients who often require induction of labor, and can be used to provide antiseizure prophylaxis in the immediate postpartum period. Laurie Vande Krol, MD
appendicitis, pregnancy
Diagnosis of a c u t e appendicitis in pregnancy Richards C, Daya S Can J Surg 32:358-360 Sep 1989
In this retrospective case controlled study, 28 pregnant w o m e n with a clinical diagnosis of appendicitis were compared with nonpregnant women matched for age in an effort to compare historical, clinical, and laboratory data in the two groups. The results showed that there was lit-tle difference in the clinical presentation of t h e two groups, in which both groups went on to have 82% histologically proven appendicitis. In both groups, more than two thirds had nausea, abdominal guarding, rebound tenderness, a p o s i t i v e R o v s i n g ' s sign ( t e n d e r n e s s over McBurney's point). Anorexia and diarrhea were seen infrequently in both groups. The two groups also had statistically similar temperatures and leukocyte counts. Both groups had identical false-positive rates (ie, histologically normal appendix). Two of the four true-positive, thirdtrimester patients had perforated appendices. It was concluded that the diagnosis of appendicitis is no more difficult in the pregnant than in the n o n p r e g n a n t state. [Editor's note: Even though the likelihood of making the diagnosis is not changed by concomitant pregnancy, the diagnosis of appendicitis continues to be one of the most difficult problems in medicine. Unfortunately, this is contrary to the generally held impression by members of the lay community and the attorneys who represent them.] Andrew Ziller, MD
Annals of EmergencyMedicine
19:3 March 1990
quinolone, theophylline
Effect of quinolone antimicrobials on theophylline p h a r m a c o k i n e t i c s Prince RA, Casabar E, Adair CG, et al J Clin Pharmacol 29:650-654 Jul 1989
This controlled, blinded study looked at the effect of quinolone antimicrobials on theophylline pharmacokinetics. Subjects were given nalidixic acid, ciprofloxacin, norfloxacin, or placebo for seven days. Drugs were given in usual therapeutic doses. Five mg/kg IV theophylline was infused on the seventh day, and levels were checked 15 times over the next 16 hours. Eight subjects underwent each of the four treatments with a seven-day washout period between treatments. Theophylline clearance rates were similar after treatment with anlicixic acid and placebo. Clearance was decreased 0% to 31% after treatment with nalicixic acid and 0% to 41% after ciprofloxacin treatment. The same subject had no change in clearance of theophylline after either quinolone. It was concluded that treatment with quinolone antimicrobials in patients taking theophylline m a y cause clinically significant decreases in theophylline clearance and that more frequent monitoring of theophylline level is recommended in these patients. Laurie Vande Krol, MD
phenytoin, preeclampsia
Clinical e x p e r i e n c e with phenytoin prophylaxis in severe p r e e c l a m p s i a Ryan G, Lange IR, Naugler MA Am J Qbstet Gynecol 16:1297-1304 Nov 1989
In this uncontrolled, prospective, nonblinded study, 104 patients with eclampsia, preeclampsia, or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) were treated prophylactically for seizures with phenytoin instead of magnesium sulfate (MgSO4). Serial levels of free phenytoin and albumin were measured from maternal, neonatal, and cord blood. The initial group consisted of patients who were given a 1-g bolus that resulted in inconsistent serum levels due to varying patient weights. Following this, 18 mg/kg in a single dose was administered, but three of eight patients in this group developed transient choreoathetosis. Later, one group received 18 mg/kg in two doses of 9 mg/kg, and a fourth group of patients was administered 15 mg/kg dose in a 10-mg/kg bo-
192/347
lus followed in two hours by a 5-mg/kg bolus. The latter dosage regimen resulted in therapeutic drug levels in 94% of patients and caused the lowest rate of side effects. There was only one transient hypotensive episode. Hypertension was controlled with hydralazine. Only one of the 104 patients had a seizure, and in her case, the loading dose of phenytoin had been erroneously low at 6.6 mg/kg. Maintenance doses were given orally or IV and continued for three to five days. There were no changes in fetal heart rates with infusion, and there were no neonatal side effects attributable to phenytoin. It was concluded that phenytoin is a safe, logical anticonvulsant alternative to MgSO 4 in preeclamptic patients. Advantages of phenytoin are that it provides a central rather than a peripheral mechanism of action, is free of toxolytic activity in patients who often require induction of labor, and can be used to provide antiseizure prophylaxis in the immediate postpartum period. Laurie Vande Krol, MD
appendicitis, pregnancy
Diagnosis of a c u t e appendicitis in pregnancy Richards C, Daya S Can J Surg 32:358-360 Sep 1989
In this retrospective case controlled study, 28 pregnant w o m e n with a clinical diagnosis of appendicitis were compared with nonpregnant women matched for age in an effort to compare historical, clinical, and laboratory data in the two groups. The results showed that there was lit-tle difference in the clinical presentation of t h e two groups, in which both groups went on to have 82% histologically proven appendicitis. In both groups, more than two thirds had nausea, abdominal guarding, rebound tenderness, a p o s i t i v e R o v s i n g ' s sign ( t e n d e r n e s s over McBurney's point). Anorexia and diarrhea were seen infrequently in both groups. The two groups also had statistically similar temperatures and leukocyte counts. Both groups had identical false-positive rates (ie, histologically normal appendix). Two of the four true-positive, thirdtrimester patients had perforated appendices. It was concluded that the diagnosis of appendicitis is no more difficult in the pregnant than in the n o n p r e g n a n t state. [Editor's note: Even though the likelihood of making the diagnosis is not changed by concomitant pregnancy, the diagnosis of appendicitis continues to be one of the most difficult problems in medicine. Unfortunately, this is contrary to the generally held impression by members of the lay community and the attorneys who represent them.] Andrew Ziller, MD
Annals of EmergencyMedicine
19:3 March 1990