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Clinical Scenario: Patients who experience prolonged concussion symptoms can be diagnosed with postconcussion syndrome (PCS) when those symptoms persist longer than 4 weeks. Aerobic exercise protocols have been shown to be effective in improving physical and mental aspects of health. Emerging research suggests that aerobic exercise may be useful as a treatment for PCS, where exercise allows patients to feel less isolated and more active during the recovery process. Clinical Question: Is aerobic exercise more beneficial in reducing symptoms than current standard care in patients with prolonged symptoms or PCS lasting longer than 4 weeks? Summary of Key Findings: After a thorough literature search, 4 studies relevant to the clinical question were selected. Of the 4 studies, 1 study was a randomized control trial and 3 studies were case series. All 4 studies investigated aerobic exercise protocol as treatment for PCS. Three studies demonstrated a greater rate of symptom improvement from baseline assessment to follow-up after a controlled subsymptomatic aerobic exercise program. One study showed a decrease in symptoms in the aerobic exercise group compared with the full-body stretching group. Clinical Bottom Line: There is moderate evidence to support subsymptomatic aerobic exercise as a treatment of PCS; therefore, it should be considered as a clinical option for reducing PCS and prolonged concussion symptoms. A previously validated protocol, such as the Buffalo Concussion Treadmill test, Balke protocol, or rating of perceived exertion, as mentioned in this critically appraised topic, should be used to measure baseline values and treatment progression. Strength of Recommendation: Level C evidence exists that the aerobic exercise protocol is more effective than the current standard of care in treating PCS.

Clinical Scenario: Shoulder range of motion (ROM) in throwing athletes relies on a balance of mobility and stability to maintain proper function and health that, if disrupted, can lead to shoulder injury. There have been several studies that address the relationship between ROM deficits and overhead injuries; however, it may be unclear to clinicians which interventions are most effective for increasing ROM in the glenohumeral joints of overhead athletes., Clinical Question: In overhead athletes who have deficient shoulder ROM, is instrument-assisted soft tissue mobilization (IASTM) more effective at acutely increasing ROM over the course of a patient's treatment when compared with self-stretching? Summary of Key Findings: A thorough literature review yielded 3 studies relevant to the clinical question, and all 3 studies were included. Two articles found a significant increase in acute ROM when compared with a self-stretch measure. All 3 articles showed increases in internal rotation and horizontal adduction, and 1 study reported an increase in total arc of shoulder ROM. Clinical Bottom Line: There is moderate evidence to support the use of IASTM to acutely increase ROM in the glenohumeral joint of overhead athletes. Clinicians should be aware of the variability with recommended treatment times; however, positive results have been seen with treatments lasting 5 to 6 minutes per treatment region. There is no consensus for treatment intensity, and certain IASTM tools require certification. Strength of Recommendation: Grade B evidence exists that IASTM is more effective at increasing shoulder ROM (ie, internal rotation, horizontal adduction, external rotation, total arc of motion) in overhead athletes than self-stretching measures.

Rationale: The incidence of pulmonary arterial hypertension is greater in women, suggesting estrogens may play a role in the disease pathogenesis. Experimentally, in males, exogenously administered estrogen can protect against pulmonary hypertension (PH). However, in models that display female susceptibility, estrogens may play a causative role., Objectives: To clarify the influence of endogenous estrogen and sex in PH and assess the therapeutic potential of a clinically available aromatase inhibitor., Methods: We interrogated the effect of reduced endogenous estrogen in males and females using the aromatase inhibitor, anastrozole, in two models of PH: the hypoxic mouse and Sugen 5416/hypoxic rat. We also determined the effects of sex on pulmonary expression of aromatase in these models and in lungs from patients with pulmonary arterial hypertension., Measurements and Main Results: Anastrozole attenuated PH in both models studied, but only in females. To verify this effect was caused by reduced estrogenic activity we confirmed that in hypoxic mice inhibition of estrogen receptor α also has a therapeutic effect specifically in females. Female rodent lung displays increased aromatase and decreased bone morphogenetic protein receptor 2 and Id1 expression compared with male. Anastrozole treatment reversed the impaired bone morphogenetic protein receptor 2 pathway in females. Increased aromatase expression was also detected in female human pulmonary artery smooth muscle cells compared with male., Conclusions: The unique phenotype of female pulmonary arteries facilitates the therapeutic effects of anastrozole in experimental PH confirming a role for endogenous estrogen in the disease pathogenesis in females and suggests aromatase inhibitors may have therapeutic potential.

As we uncover the complex pathophysiology underlying idiopathic and familial pulmonary arterial hypertension, multiple disease associated pathways, cell types and processes reveal links to elements of the serotonin system. Beyond the original 'serotonin hypothesis' observed with anorexigens, and the latterly demonstrated association with vascular tone and pulmonary artery smooth muscle cell proliferation, recent studies suggest links to BMPR2, PDGF and RhoK pathways, as well as an impact upon more complex lesion formation and pathologic bone marrow progenitor mobilization. Clinical experience with antagonists targeting the various elements of the serotonin pathway has been unsatisfactory, yet perhaps this is less than surprising given our expanding knowledge around serotonin production and signaling biology, which indicate opportunities for novel therapeutic options., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Rationale: Whether idiopathic, familial, or secondary to another disease, pulmonary arterial hypertension (PAH) is characterized by increased vascular tone, neointimal hyperplasia, medial hypertrophy, and adventitial fibrosis. Imatinib, a potent receptor tyrosine kinase inhibitor, reverses pulmonary remodeling in animal models of PAH and improves hemodynamics and exercise capacity in selected patients with PAH., Objectives: Here we use both imatinib and knockout animals to determine the relationship between platelet-derived growth factor receptor (PDGFR) and serotonin signaling and investigate the PAH pathologies each mediates., Methods: We investigated the effects of imatinib (100 mg/kg) on hemodynamics, vascular remodeling, and downstream molecular signatures in the chronic hypoxia/SU5416 murine model of PAH., Measurements and Main Results: Treatment with imatinib reduced all measures of PAH pathology observed in hypoxia/SU5416 mice. In addition, 5-hydroxytryptamine (5-HT) and tryptophan hydroxylase 1 (Tph1) expression were reduced compared with the normoxia/SU5416 control group. Imatinib attenuated hypoxia-induced increases in Tph1 expression in pulmonary endothelial cells in vitro via inhibition of the PDGFR-β pathway. To better understand the consequences of this novel mode of action for imatinib, we examined the development of PAH after hypoxic/SU5416 exposure in Tph1-deficient mice (Tph1(-/-)). The extensive changes in pulmonary vascular remodeling and hemodynamics in response to hypoxia/SU5416 were attenuated in Tph1(-/-) mice and further decreased after imatinib treatment. However, imatinib did not significantly further impact collagen deposition and collagen 3a1 expression in hypoxic Tph1(-/-) mice. Post hoc subgroup analysis suggests that patients with PAH with greater hemodynamic impairment showed significantly reduced 5-HT plasma levels after imatinib treatment compared with placebo., Conclusions: We report a novel mode of action for imatinib, demonstrating TPH1 down-regulation via inhibition of PDGFR-β signaling. Our data reveal interplay between PDGF and 5-HT pathways within PAH, demonstrating TPH1-dependent imatinib efficacy in collagen-mediated mechanisms of fibrosis.

Knockout mice lacking the adenosine A(2A) receptor are less sensitive to nociceptive stimuli, and this may be due to the presence of pronociceptive A(2A) receptors on sensory nerves. In support of this hypothesis, we have recently shown that in A(2A) receptor knockout mice there are marked reductions in the changes of two markers of spinal cord neuronal activity, [(3)H]MK801 binding to NMDA receptors and uptake of [(14)C]-2-deoxyglucose, in response to formalin injection. We now report that following a more prolonged inflammatory stimulus, consisting of intraplantar injections of PGE(2) and paw pressure, there was in contrast an increase in [(3)H]MK801 binding and [(14)C]-2-deoxyglucose uptake in the spinal cords of the A(2A) receptor knockout mice which was much greater than in the wild-type mice. This increase suggests that when there is a pronounced inflammatory component to the stimulus, loss of inhibitory A(2A) receptors on inflammatory cells outweighs the loss of pronociceptive A(2A) receptors on peripheral nerves so that overall there is an increase in nociceptive signalling. This implies that although A(2A) antagonists have antinociceptive effects they may have only limited use as analgesics in chronic inflammatory pain., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Mice lacking the adenosine A(2A) receptor are less sensitive to nociceptive stimuli, and A(2A) receptor antagonists have antinociceptive effects. We have previously shown a marked reduction in the behavioural responses to formalin injection in A(2A) receptor knockout mice. This may be due to the presence of pronociceptive A(2A) receptors on sensory nerves, and if so spinal cords from A(2A) receptor knockout mice may have altered neurochemical responses to a nociceptive stimulus. We tested this hypothesis by studying two parameters known to change with spinal cord activity, NMDA glutamate receptor binding and [(14)C]-2-deoxyglucose uptake, following intraplantar formalin injection in wild-type and A(2A) receptor knockout mice. In naïve untreated A(2A) knockout mice [(14)C]-2-deoxyglucose uptake in all regions of the spinal cord was significantly lower compared to the wild-type, similar to the reduced NMDA receptor binding that we have previously observed. Following formalin treatment, there was an decrease in [(3)H]-MK801 binding to NMDA receptors and an increase in [(14)C]-2-deoxyglucose uptake in the spinal cords of wild-type mice, and these changes were significantly reduced in the A(2A) knockout mice. In addition to altered behavioural responses, there are therefore corresponding reductions in spinal cord neurochemical changes induced by formalin in mice lacking adenosine A(2A) receptors. These observations support the hypothesis that activation of A(2A) receptors enhances nociceptive input into the spinal cord and suggests a possible role for A(2A) antagonists as analgesics., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: The cheek-to-cheek diameter (CCD) has been shown to be an indicator of subcutaneous tissue mass in the fetus. However, the correlation between CCD and the abdominal circumference (AC) has not been investigated yet. The objective of the present study was to demonstrate whether a correlation exists between fetal CCD, AC, estimated fetal weight (EFW), and the 1 h, 50 g, glucose challenge test (GCT) levels in patients with and without gestational diabetes mellitus., Methods: A prospective, institutional review board approved study was performed. The CCD was obtained as part of the ultrasound for obstetric interval growth scans and biophysical profiles. Exams were performed during the third trimester. The CCD was obtained on a coronal view of the fetal face, at the level of the nostrils and lips. Patients were enrolled between November 2005 and May 2006. Pearson correlation coefficient and linear regression modeling were used as appropriate., Results: Eighty-three patients were enrolled, 29 (33%) of them were diabetic. The mean gestational age is 34.8 +/- 3 weeks and the mean maternal age is 29.9 +/- 5.1. A significant linear association was found between CCD and EFW (Pearson coefficient of correlation being 0.51, P = 0.01). The Pearson correlation coefficient of the relationship between the CCD and AC was 0.47 (P = 0.01). Using a linear regression model, controlling for gestational age at performance of the ultrasound, the association between CCD and EFW remained significant (P = 0.021). There were no significant differences between diabetic and non-diabetic patients regarding the CCD (6.2 +/- 0.9 vs. 6.3 +/- 0.9 respectively, P = 0.669) or the EFW (2,527.9 +/- 705 vs. 2,645 +/- 760 g). While AC was significantly correlated with the GCT levels (Pearson coefficient of correlation = 0.46, P = 0.024), no such correlation was demonstrated for CCD (Pearson correlation coefficient = 0.23, P = 0.160)., Conclusions: The cheek-to-cheek diameter is significantly correlated to the abdominal circumference and the estimated fetal weight. However, the abdominal circumference has a tighter correlation with the glucose challenge test.

Adenosine is a neuromodulator with complex effects on pain pathways. Mice lacking the adenosine A2A receptor are hypoalgesic, and have altered analgesic responses to receptor-selective opioid agonists. These and other findings suggest a role for the adenosine A2A receptor in sensitizing afferent fibres projecting to the spinal cord. To test this hypothesis formalin (20 microl, 5%) was injected into the paw and nociceptive responses were measured in wildtype and adenosine A2A receptor knockout mice. There was a significant reduction in nociception associated with sensory nerve activation in the knockout mice as measured by time spent biting/licking the formalin-injected paw and number of flinches seen during the first phase, but only the number of flinches was reduced during the second inflammatory phase. In addition, the selective adenosine A2A antagonist SCH58261 (3 and 10 mg/kg) also antagonised both phases of the formalin test. We also labelled NMDA glutamate and NK1 receptors in spinal cord sections as an indirect measure of nociceptive transmission from peripheral sites to the spinal cord. [3H]-Substance P binding to NK1 receptors was unaltered but there was a substantial reduction in binding of [3H]-MK801 to NMDA glutamate receptors in all regions of the spinal cord from knockout mice. The decrease in NMDA glutamate receptor binding may reflect reduced peripheral sensory input to the spinal cord during development and could relate to the hypoalgesia in this genotype. These results support a key role for the adenosine A2A receptor in peripheral nociceptive pathways.

Purpose: As a form of energy, diagnostic ultrasound has bioeffects on living tissues. The thermal index (TI), TIS (TI for soft tissue), TIB (TI for bone), TIC (TI for cranial bone) expresses the potential for rise in temperature at the ultrasound beam's focal point. The mechanical index (MI) indicates the potential for the ultrasound beam to induce inertial cavitation in tissues. The goal of this study was to characterize the acoustic output of clinical ultrasound instruments, as expressed by TI and MI, during routine first-trimester sonographic examinations., Methods: A prospective observational study was conducted. First-trimester patients were randomly selected from those scheduled for viability scans. An obstetrician collected data. Sonographers were blinded to the data being sought, which included gestational age, duration of the examination, and every variation in the MI and TI during each sonographic examination., Results: A total of 52 first-trimester examinations were evaluated. The mean gestational age was 8.9 +/- 1.9 weeks. The mean duration of the sonographic examinations was 8.1+/- 1.4 minutes. During the examinations, there were 178 MI variations (mean +/- SD, 0.9 +/- 0.3) and 167 TI variations (mean +/- SD, 0.2 +/- 0.1)., Conclusion: First-trimester sonographic examinations are associated with a negligible rise in TI.

Objective: Three-dimensional (3D) ultrasound is gaining popularity in prenatal diagnosis. While there are no studies regarding the safety of 3D ultrasound, it is now widely performed in non-medical facilities, for non-diagnostic purposes. The present study was aimed at comparing the acoustic output, as expressed by thermal index (TI) and mechanical index (MI), of conventional two-dimensional (2D) and 3D/4D ultrasound during pregnancy., Methods: A prospective, observational study was conducted, using three different commercially available machines (iU22, Philips Medical Systems; Prosound Alfa-10, Aloka; and Voluson 730 Expert, General Electric). Patients undergoing additional 3D/4D ultrasound examinations were recruited from those scheduled for fetal anatomy and follow-up exams. Fetuses with anomalies were excluded from the analysis. Data were collected regarding duration of the exam, and each MI and TI during 2D and 3D/4D ultrasound exams., Results: A total of 40 ultrasound examinations were evaluated. Mean gestational age was 31.1 +/- 5.8 weeks, and mean duration of the exam was 20.1 +/- 9.9 min. Mean TIs during the 3D (0.27 +/- 0.1) and 4D examinations (0.24 +/- 0.1) were comparable with the TI during B-mode scanning (0.28 +/- 0.1, P = 0.343). The MIs during the 3D volume acquisitions were significantly lower than those in the 2D B-mode ultrasound studies (0.89 +/- 0.2 vs. 1.12 +/- 0.1, P = 0.018). The 3D volume acquisitions added 2.0 +/- 1.8 min of actual ultrasound scanning time (i.e. not including data processing and manipulation, or 3D displays, which are all post-processing steps). The 4D added 2.2 +/- 1.2 min., Conclusions: Acoustic exposure levels during 3D/4D ultrasound examination, as expressed by TI, are comparable with those of 2D B-mode ultrasound. However, it is very difficult to evaluate the additional scanning time needed to choose an adequate scanning plane and to acquire a diagnostic 3D volume.

Objective: The present study was aimed at evaluating acoustic outputs during clinical ultrasound examinations, as expressed by the thermal index (TI) and the mechanical index (MI), during the second half of pregnancy and comparing acoustic outputs between B-mode and Doppler examinations., Methods: Patients with suspected fetal growth problems undergoing Doppler studies of the fetal circulation in addition to B-mode sonography were selected. Examinations took place between 21 and 40 weeks' gestation. An obstetrician collected data prospectively. Sonographers were unaware of the data being sought. The analysis of variance test was applied for differences in continuous variables., Results: A total of 63 examinations were evaluated. The mean gestational age +/- SD was 31.6 +/- 5.1 weeks. The mean duration of the total examinations was 17.6 +/- 8.6 minutes, whereas the Doppler studies lasted 0.9 +/- 0.8 minutes. The TI was significantly higher in the pulsed wave Doppler studies (mean, 1.5 +/- 0.5; range, 0.9-2.8) and color flow imaging studies (mean, 0.8 +/- 0.1; range, 0.6-1.2) compared with B-mode sonography (mean, 0.3 +/- 0.1; range, 0.1-0.7; P < .01). During the examination, 190 B-mode MI variations were recorded (mean, 1.1 +/- 0.1), which were comparable with those of the 31 color flow Doppler studies (mean, 1.0 +/- 0.1; P = .09) but higher than the 190 pulsed wave Doppler MI variations (mean 0.9 +/- 0.2; P < .001)., Conclusions: Increased acoustic output levels, as expressed by TI levels, are reached during obstetric Doppler studies. In particular, TI levels may reach 1.5 and higher. Doppler procedures should be performed with caution and be as brief as possible during obstetric sonography.

Very recently it was shown that the molecular three-body distorted wave (M3DW) approach gives good agreement with the shape of the experimental data for electron-impact ionization of H(2) in a coplanar symmetric geometry, providing the incident electrons have an energy of 35 eV or greater. One of the weaknesses of these studies was that only the shape of the cross section could be compared to experiment, since there was no absolute or relative normalization of the data. Here we report a joint experimental/theoretical study of electron-impact ionization of H(2) in a coplanar asymmetric geometry where the energy of the incident electron was fixed, and different pairs of final state electron energies were used. In this case, the experimental data can be normalized such that only one renormalization factor is required. It is shown that the M3DW is pretty good in agreement with experiment. However, a better treatment of polarization and exchange between the continuum and bound state electrons is required before quantitative agreement between experiment and theory is achieved.

This paper reports the success of outreach efforts to immunize adults at high risk of acquiring hepatitis B virus (HBV) infection. Local health department testers recruited clients when they sought anonymous HIV testing. Interested clients were serologically tested for HBV infection. Susceptibles were offered a free hepatitis B vaccine. Of 189 clients who were tested, 161 (86%) were susceptible to HBV infection and 140 (74%) were men who have sex with men (MSM). Of the susceptibles, 82 (51%) started the hepatitis B vaccine series. Sixty-five (80%) received three doses of hepatitis B vaccine and an additional 10 (12%) received two doses. Completing the hepatitis B vaccine series was associated with being a MSM (odds ratio [OR] 8.8, confidence interval [CI] 1.5-56.0) and with not being an injection drug user (IDU) (OR 0.2, CI 0.02-1.0). One way to provide hepatitis B vaccine to MSM is to attach an immunization program to a successful anonymous HIV testing program. The feasibility of implementing such programs would increase if public vaccine policymakers made more federally purchased hepatitis B vaccine available for adults.

Objective: Intrauterine growth restriction in an ovine model occurs after exposure to environmental heat stress for 80 days beginning at 35 days' gestation. Our objective was to determine whether intrauterine growth restriction is reversible on removal of the heat stress after only 55 days of exposure; that is, does a brief exposure at a critical point of development suffice?, Study Design: Five pregnant ewes were exposed to heat stress beginning at 35 days' gestation and were removed after 55 days of exposure. Five ewes in a control group were studied as contemporaneous controls and added to data from 37 ewes in a control group previously studied. Serial fetal biometric ultrasonographic measurements (biparietal diameter, abdominal circumference, femur length, and tibia length) were obtained beginning at 50 days' gestation. Growth curves were calculated for each parameter, and comparisons were made between fetuses in the group exposed to heat stress for 55 days and 42 fetuses in the control group and 4 fetuses from a previous study that were exposed to heat for 80 days. Regression lines, 95% confidence intervals, and slopes were determined for each study group., Results: Both the 55-day and the 80-day heat exposure groups showed a significant reduction in fetal and placental weights compared with the control group. Animals in the 80-day group had significantly lower fetal and placental weights than the animals in the 55-day group (P <.05). Indexes of somatic growth (abdominal circumference, femur length, and tibia length) for the control group were significantly greater than those of either the 55-day group or the 80-day group (P <.001). Asymmetric growth restriction was evident in both heat groups by a biparietal diameter/abdominal circumference ratio that was significantly higher than in the control group (P <.004 for the 55-day group and P <.001 for the 80-day group). The slopes for somatic parameters (abdominal circumference, femur length, and tibia length) versus time became significantly different between the control and 55-day groups at 77, 101, and 80 days' gestation, respectively. The 55-day group had abdominal circumference and femur length measurements that were significantly greater than those in the 80-day group., Conclusion: The fetuses in the 55-day and 80-day groups reflect a pattern of asymmetric intrauterine growth restriction. Our findings suggest that the initial insult affecting fetal and placental growth occurs early in gestation, but removal of fetuses after only 55 days of exposure significantly reduces the degree of fetal growth restriction compared with that found in those fetuses exposed for 80 days.

Objective: The aim of the study was to compare the diagnostic utility of the Gram stain, the amniotic fluid glucose level, and the ratio of amniotic fluid glucose level to serum glucose level in detecting intra-amniotic infection., Study Design: We conducted a prospective study of 127 patients with preterm labor and 26 patients with preterm premature rupture of the membranes (153 total). All patients underwent amniocentesis to diagnose intra-amniotic infection. The diagnostic criterion for intra-amniotic infection was a positive amniotic fluid culture result., Results: The Gram stain is 80% sensitive and 91% specific when a positive is considered the presence of white blood cells or bacteria. Amniotic fluid glucose level and the ratio of amniotic fluid glucose level to serum glucose level are significantly lower when amniotic fluid culture results are positive, but as diagnostic tests they are inferior to the Gram stain. Logistic regression models that combine predictors yield superior accuracy with respect to individual tests. The most accurate combination was amniotic fluid glucose level and Gram stain with white blood cells or bacteria. Although the number of patients with preterm premature rupture of the membranes was small in this study (n = 26), analysis of our data suggests that the diagnostic performance levels of these tests were similar when used in patients with preterm labor and intact membranes and in patients with premature rupture of the membranes., Conclusions: The amniotic fluid glucose level and the ratio of amniotic fluid to serum glucose level have equivalent diagnostic utility and are inferior to the Gram stain. The combination of Gram stain with amniotic fluid glucose level is superior to any individual test.

Objective: With an ovine model in which growth restriction was induced by exposure to heat stress, our aims were as follows: (1) to describe the normal gestational age-related changes in Doppler velocimetry in the ovine fetal aorta and umbilical artery and (2) to compare Doppler velocimetry between heat-stressed and non-heat-stressed fetuses., Study Design: Five ewes were exposed to heat stress for 55 days beginning at 35 days' gestation. Five ewes were not exposed and served as controls. Aortic and umbilical artery pulsed Doppler velocimetry was obtained, including the systolic/diastolic ratio, pulsatility index, and resistance index. Data were obtained between 50 and 120 days' gestation. Linear regression analysis was used to analyze gestational age-related changes in velocimetry. Comparison of mean index values between heat-stressed and non-heat-stressed fetuses were made with analysis of variance., Results: Heat-stressed fetuses demonstrated significantly higher systolic/diastolic ratios and pulsatility index values for both umbilical artery (p < 0.025; p < 0.033) and aorta (p < 0.017; p < 0.022) compared with controls. The umbilical artery and aortic resistance index values were not different between groups (p < 0.079; p < 0.28). The slopes for each of the Doppler index values were negative in both normal and heat-stressed fetuses. Umbilical artery and aortic end-diastolic flows remained absent through the first 70 days of gestation in both groups., Conclusion: Doppler velocimetry index values decrease with increasing gestational age, reflecting decreased placental bed vascular resistance. The higher Doppler index values seen in the heat-stressed group are consistent with increased placental vascular resistance. The normal absence of diastolic flow until 70 days' gestation is similar to the pattern described in humans.

Pregnancies in women on dialysis and in women who have had renal transplant are no longer uncommon. Optimal obstetric outcomes require a multidisciplinary team approach, patient counseling, and clinicians who are knowledgeable and experienced in taking care of these patients. Counseling should begin before pregnancy, and all reproductive age women on dialysis and who have undergone renal transplant should receive family planning counseling. Preconceptional counseling should be provided to those patients who desire pregnancy. If the patient presents in early pregnancy, she should be informed about the maternal and fetal risks associated with her pregnancy. Prenatal care must include intensive surveillance for hypertension, preeclampsia, preterm labor, intrauterine growth restriction, anemia, infection, and renal allograft rejection. Aggressive treatment of complications is mandatory. There are limitations to our current knowledge about pregnancies in these patients. It is important for clinicians who provide care for these patients to be aware of these limitations when making obstetric management decisions. Cesarean section should be reserved for usual obstetric indications. Breast-feeding is not advised in patients taking cyclosporin or azathioprine. Transplant patients have unique gynecologic needs, so they should be encouraged to pursue follow-up gynecologic care after the pregnancy.