Pregnancy, labour and delivery in a Jehovah's Witness with esophageal varices and thrombocytopenia.

PURPOSE: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10-61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness. CLINICAL FEATURES: A 25-yr-old Jehovah's Witness parturient with portal hypertension and esophageal varices secondary to cryptogenic cirrhosis was referred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000 x microl(-1). Her esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesarean section which could result in massive hemorrhage, to elective induction of labour with an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery. CONCLUSION: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.

General stress transcription factor sigmaB and its role in acid tolerance and virulence of Listeria monocytogenes.

The gene encoding the general stress transcription factor sigmaB in the gram-positive bacterium Listeria monocytogenes was isolated with degenerate PCR primers followed by inverse PCR amplification. Evidence for gene identification includes the following: (i) phylogenetic analyses of reported amino acid sequences for sigmaB and the closely related sigmaF proteins grouped L. monocytogenes sigmaB in the same cluster with the sigmaB proteins from Bacillus subtilis and Staphylococcus aureus, (ii) the gene order in the 2, 668-bp portion of the L. monocytogenes sigB operon is rsbU-rsbV-rsbW-sigB-rsbX and is therefore identical to the order of the last five genes of the B. subtilis sigB operon, and (iii) an L. monocytogenes sigmaB mutant had reduced resistance to acid stress in comparison with its isogenic parent strain. The sigB mutant was further characterized in mouse models of listeriosis by determining recovery rates of the wild-type and mutant strains from livers and spleens following intragastric or intraperitoneal infection. Our results suggest that sigmaB-directed genes do not appear to be essential for the spread of L. monocytogenes to mouse liver or spleen at 2 and 4 days following intragastric or intraperitoneal infection.

Demodex sinocricetuli: new species of hair follicle mite (Acari:Demodecidae) from the Chinese form of the striped hamster, Cricetulus barabensis (Rodentia:Muridae).

Demodex sinocricetuli sp. nov. is described in all its life stages from the Chinese form of the striped hamster, Cricetulus barabensis. A large sample size of > 11,500 mites (96% adults and only 4% ova and immatures) was surveyed. The cause of the apparent reproductive stasis is not known. Limited data sets from other demodecid species reveal populations that are 42-82% adult.

Role of needle gauge and tip configuration in the production of lumbar puncture headache.

BACKGROUND AND OBJECTIVES: Postdural puncture headache (PDPH) is a morbidity that occurs frequently after lumbar puncture. The purpose of this study was to evaluate the role of needle diameter and tip configuration in causing PDPH. The incidence of PDPH was evaluated in parturients because this group of patients is at high risk for developing PDPH and because they often undergo lumbar puncture for spinal anesthesia. METHODS: The incidence of PDPH after spinal anesthesia with 26- and 27-gauge Quincke and 25-gauge Whitacre needles was studied in a series of 4,125 parturients undergoing spinal anesthesia over a 4-year period. Data were also collected on the incidence of PDPH with 17-gauge Huber-tipped Weiss needles in 21,578 parturients receiving lumbar epidural analgesia and/or anesthesia over the same interval. Additionally, the need to treat PDPH with epidural blood patch in all of these patients was studied. RESULTS: The incidence of PDPH was 5.2% with 26-gauge Quincke needles (1987-1989), 2.7% with 27-gauge Quincke needles (1989-1990), and 1.2% with 25-gauge Whitacre needles (1990-1991). During the same periods, the incidence of PDPH with 17-gauge Weiss needles averaged 1.1%, 1.7% and 1.2%, respectively. As compared with the 26-gauge Quincke needle, there was a lower incidence of PDPH with the 27-gauge Quincke (P < .006) and 25-gauge Whitacre spinal needles (P < .001). The incidence of PDPH with the 25-gauge Whitacre needle was less than that with the 27-gauge Quincke needle (P < .05), and it was similar to the overall rate of headache, which occurs occasionally from accidental dural puncture during the performance of lumbar epidural analgesia/anesthesia for labor and cesarean delivery (P = .974). The need for treating PDPH with epidural blood patching was greatest with the 17-gauge Weiss epidural needle (75.3% of cases), but was similar with the various spinal needles (13-39%). However, because the Whitacre needle produced the fewest PDPHs, it was associated with the lowest absolute requirement for epidural blood patching. CONCLUSIONS: The morbidity associated with lumbar puncture can be decreased by selecting the proper needle gauge and tip configuration. Use of the smallest gauge needle and one that has a noncutting Whitacre tip produces the lowest incidence of PDPH in parturients, a group of patients at increased risk for developing PDPH.

Evaluation of detomidine anesthetic combinations in the rabbit.

Detomidine, a potent alpha 2-adrenergic receptor agonist, was chosen for study alone and in combination with ketamine with or without diazepam. Four regimens were evaluated: detomidine (150 micrograms/kg of body weight) alone (D); ketamine (35 mg/kg) and detomidine (150 micrograms/kg) (KD); ketamine (35 mg/kg) and high-dose detomidine (300 micrograms/kg) (KDh); and ketamine (35 mg/kg), diazepam (1 mg/kg), and detomidine (150 micrograms/kg) (KDD). The same six rabbits were anesthetized with each combination at weekly intervals. Atropine (0.04 mg/kg) was administered as a preanesthetic 5 min prior to test substance administration. All agents were administered IM, except for diazepam, which was administered IV. Heart and respiratory rates, mean arterial blood pressure, and arterial blood gas tensions were measured. Pedal, palpebral, and righting reflexes also were evaluated. Cardiopulmonary depression, as indicated by decrease in heart and respiratory rates, blood pH, PO2, and increase in PCO2, was observed in all groups. With the exception of heart rate, detomidine used alone caused the least depression of these parameters. Reflexes were consistently lost only after KDh and KDD administrations. The pedal reflex, used as an index of anesthetic depth, was lost in response to KDh and KDD for 56.7 +/- 11.6 and 43.8 +/- 7.4 min, respectively (mean +/- SEM). Three of the six rabbits were anorectic after KDh administration. Necropsy and histologic evaluation revealed myocardial necrosis and fibrosis in five animals. Due to the inconsistent reflex loss in response to KD and D and inappetance associated with KDh, these combinations were not considered safe or reliable.(ABSTRACT TRUNCATED AT 250 WORDS)

Demodex cricetuli: new species of hair follicle mite (Acari: Demodecidae) from the Armenian hamster, Cricetulus migratorius (Rodentia: Cricetidae).

Demodex cricetuli sp. nov. is described, in all life stages, from the Armenian hamster, Cricetulus migratorius. This demodecid inhabits the hair follicles of all body regions of the host. Heavy infestations are associated with dermatitis and alopecia. Demodex cricetuli is most similar to D. aurati, from the Golden hamster, but adults differ in podosomal length, shape of the opisthosomal terminus, genital opening and opisthosomal organ of the male, and overall length-to-width ratios.

Prolactin-secreting pituitary adenomas with mammary dysplasia in New Zealand white rabbits.

Nine aged (mean age = 3.2 years) nulliparous New Zealand white rabbit does were found to have markedly enlarged teats. The teats were frequently engorged with fluid but were not hot and did not cause signs of pain. The number of affected teats per animal ranged from 1 to 8 (mean = 4). The teats and associated glandular tissue were typically discolored grey, blue, or greenish black (n = 6). Prolactin concentrations were evaluated by radioimmunoassay. Serum prolactin concentrations ranged from 22.4 ng/ml to 2.21 micrograms/ml (mean = 397.3 ng/ml), which was 10- to 1000-fold greater than normal values in nonpregnant rabbits. Conventional radiography of the skull of six rabbits did not reveal pituitary enlargement. Necropsy revealed an enlarged pituitary gland and sella turcica in six of nine does. The diaphragma sellae had ruptured in two rabbits. All nine rabbits had pituitary acidophil adenomas. The neoplastic portions of the pituitaries were diffusely immunoreactive when stained immunohistochemically for prolactin. In contrast, only small clusters of five to seven cells stained positively in normal pituitaries selected as controls. Histologic examination of the mammary glands revealed numerous large dilated cystic spaces containing proteinaceous fluid. Many cysts had numerous papillary epithelial infoldings. The cystic dilations extended into and included the teat canal producing the gross appearance. Prolactin-secreting acidophil adenomas have not been previously reported in the rabbit, and the association with mammary dysplasia is unique.

An evaluation of three neuroleptanalgesic combinations in rabbits.

In this study, novel combinations of analgesics and neuroleptics were used in the rabbit in an attempt to produce a surgical level of anesthesia. A commercially available mixture of fentanyl (0.06 mg/kg) and droperidol (3.0 mg/kg; F/D) was evaluated alone and in combination with either the benzodiazepine derivative, diazepam (2 mg/kg) or the alpha-2 adrenoceptor agonist, detomidine (20 micrograms/kg). Rabbits were anesthetized on consecutive weeks with one of the three regimens. Heart rate, respiratory rate, blood pressure, and arterial blood gases (pH, PCO2, PO2) were measured throughout each trial. The times of loss and return of palpebral, righting, and pedal reflexes were recorded. The addition of diazepam to the F/D combination caused marked prolongation of the duration of reflex loss for all reflexes. If the duration of reflex loss for F/D is considered to be 100%, then F/D plus diazepam (F/D/diazepam) prolonged the duration of reflex loss to 547% and 204% for righting and pedal reflex, respectively. The combination of F/D/diazepam produced significantly different results from those for either of the other combinations for righting reflex and palpebral reflex. The results for F/D/diazepam were also markedly different from F/D for pedal reflex, but were not significantly different from those for F/D/detomidine. Prolongation of the duration of reflex loss was more moderate with the addition of detomidine (148% and 174% for righting and pedal reflexes, respectively). Reflexes persisted in some rabbits for each anesthetic regimen. Palpebral reflex was preserved in one of the rabbits given F/D/diazepam, four of five rabbits given F/D, and in two rabbits given F/D/detomidine.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of epinephrine on the anesthetic and hemodynamic properties of ropivacaine and bupivacaine after epidural administration in the dog.

Ropivacaine is a new local anesthetic that is chemically related to mepivacaine and bupivacaine. Previous laboratory studies have demonstrated that ropivacaine possesses an anesthetic profile similar to that of bupivacaine and has less arrhythmogenic potential. The current study was initiated to compare the hemodynamic and anesthetic effects of epidurally administered 0.75% bupivacaine and 1% ropivacaine, with and without epinephrine (1:200,000), in the dog. Two groups of six dogs were randomly assigned to the ropivacaine or bupivacaine treatment groups. Administration of 0.75% bupivacaine and 1% ropivacaine with and without epinephrine was randomized. Volumes of 3 ml of each solution were injected in a blinded manner via an indwelling lumbar epidural catheter with 48 hours between injections. No statistically significant difference existed between the four treatment groups with regard to onset and duration of sensory or motor block. Hemodynamic changes were, for the most part, not different between drugs. Significant decreases were seen in mean arterial blood pressure and cardiac output in all test groups. No difference in the degree of cardiovascular depression was observed. The addition of epinephrine did not alter onset or duration of sensory or motor block in this animal model. Epinephrine reduced the average anesthetic blood concentration observed in both treatment groups at the various time intervals, but not the time to achieve the mean maximum blood level. No residual adverse effects were observed in any animal.

Sensory analgesia for vaginal deliveries: a preliminary report of continuous spinal anesthesia with a 32-gauge catheter.

Our initial experience in providing pain relief during labor and delivery for 20 parturients using a 32-gauge continuous spinal microcatheter using 1% lidocaine is described. The technique significantly reduced the pain of labor, which was assessed as severe by 18 of the patients, and provided adequate perineal anesthesia for vaginal delivery with 18 patients indicating pain during delivery to be minimal. The major advantage of continuous spinal anesthesia is the ability to rapidly establish sensory anesthesia with the flexibility to reinject additional local anesthetic should a complete sensory or sensory and motor block be required for forceps or cesarean delivery. Technical difficulty was the main disadvantage with the use of the 32-gauge microcatheter. An inability to thread the catheter (two patients) through the 26-gauge spinal needle or kinking of the catheter (two patients) making injection impossible, and unintentional catheter removal (one patient) resulted in a 25% failure rate with this technique.

Spinal opioids in the management of obstetric pain.

Spinal opioids have become increasingly popular agents for providing analgesia during labor, augmenting anesthesia during cesarean section, and providing pain relief after operative delivery. The development of spinal opioids in the management of obstetric pain is reviewed.

Plasma and cerebrospinal fluid progesterone concentrations in pregnant and nonpregnant women.

Pregnancy is associated with a wider dermatomal spread of local anesthetics after epidural and spinal anesthesia. This phenomenon also exists in the immediate postpartum period. The mechanism of this observation is unresolved. However, an increase in progesterone concentration in pregnancy has been implicated as one of the factors. Although plasma progesterone concentrations in humans have been well-documented, the cerebrospinal fluid (CSF) progesterone levels, which may also be important in this regard, have not been determined. Therefore, this study was undertaken to measure plasma and CSF progesterone in the nonpregnant, term parturient and in the immediate postpartum patient and also to determine the relationship between the CSF progesterone concentration and the intrathecal spread of lidocaine used for spinal anesthesia. The plasma progesterone concentrations in 12 nonpregnant, 21 term and eight postpartum patients were 2.3 +/- 61 (SEM) ng/ml, 122 +/- 8 ng/ml and 16 +/- 2.2 ng/ml, respectively. The CSF progesterone concentrations in term parturients (3 +/- 0.28 (SEM) ng/ml) and postpartum patients (1.03 +/- 0.16 ng/ml) were eight and three times greater than that of nonpregnant women (0.39 +/- 0.01 ng/ml). Significantly less lidocaine was needed (P less than 0.05) for comparable segmental levels of spinal anesthesia in term and postpartum patients than in nonpregnant individuals. These data suggest that high CSF, plasma progesterone concentrations, or both may augment the anesthetic spread of lidocaine.

Dietary ascorbic acid and muscle carnitine (beta-OH-gamma-(trimethylamino) butyric acid) in guinea-pigs.

Tissue ascorbic acid (AA) contents of approximately 12 and 100% saturation respectively were produced in two groups of guinea-pigs. The 'low-AA' group had a significantly lower muscle carnitine concentrations than the 'high-AA' group. There was no concomitant emergence of the symptoms customarily regarded as characteristic of hypovitaminosis C. It is concluded that muscle carnitine (beta-OH-gamma-(trimethyl-amino)butyric acid) is a highly-sensitive indicator of tissue AA contents; this could account for the lassitude and fatique reported to precede the emergence of frank scurvy in man.