In a recent study, neither ibuprofen nor naproxen increased the risk of spontaneous abortion when used in the first six weeks of pregnancy. 38 A Swedish study of nonsteroidal anti-inflammatory drug (NSAID) use in early pregnancy did not demonstrate an increased risk of congenital anomalies overall; however, naproxen was associated with orofacial clefts, and all NSAIDs were associated with structural cardiac defects. 39 More recent data show a potential association between NSAID use and dextro-transposition of the great arteries, particularly in the first trimester. 29 NSAIDs are not recommended in the third trimester because of the risk of premature closure of the ductus arteriosus and subsequent primary pulmonary hypertension in the newborn. Because indomethacin (Indocin) is known to cause oligohydramnios and delay delivery, OTC NSAIDs are assumed to have the same risk. Although NSAID use is generally not recommended during pregnancy, women may ingest these medications inadvertently in many OTC combinations. Prolonged use of NSAIDs, including aspirin, should occur only for specific medical indications during pregnancy. Table 4 summarizes the safety of analgesics and antipyretics in pregnancy. 10 – 16
Once the diseased venous segments are crossed, I then perform rapid-lysis PMT for acute DVT. If the DVT is chronic, I first perform serial venoplasty of each involved segment up to the expected size of the corresponding normal patent vein. This initial dilatation is dependent on the access site and size of my sheath. Once the venoplasty is completed, I prefer to stent any chronic central occlusion to the level of the inguinal ligament and reevaluate for flow and residual thrombus. After balloon dilatation with or without stenting, I subsequently place the Ekos thrombolytic system for overnight infusion, typically at mg/h with pneumatic compression boots placed immediately. After overnight Ekos thrombolysis, venography and further intervention with additional venoplasty and possibly stenting if needed is performed the next day. The goal is to create inline flow from the calf to the thigh and the thigh into the pelvis and IVC. If, after all attempts at gaining flow from the femoral vein into CFV and iliac veins are unsuccessful, then I will stent across the inguinal ligament only to the level of the lesser trochanter—but again, only if needed.
Thyroid hormone therapy in persons with undiagnosed Addison disease may precipitate an adrenal crisis because the thyroid hormone increases the hepatic clearance of cortisol. In addition, patients with a new diagnosis can have a reversible increase in thyroid-stimulating hormone levels because glucocorticoids inhibit secretion. 25 , 26 Glucocorticoid replacement can result in the normalization of thyroid-stimulating hormone levels less than 30 mIU per L. In individuals with type 1 diabetes mellitus, unexplained hypoglycemia and decreasing insulin requirements may be the initial signs of Addison disease. 27