The pathophysiology of pre-eclampsia: current clinical concepts.

Despite decades of intense research on the problem, pre-eclampsia remains one of the great mysteries of medical science. This paper is an overview of the existing knowledge on the disease that unifies the essential and validated findings of past and current scientific investigation. A key focus has been an attempt to distinguish foundationally pathogenic mechanisms from multiple epiphenomena that continue to be elucidated. The hypothesis was developed after taking into consideration the various known risk factors for pre-eclampsia, epidemiologic trends, and the most available research to date regarding the pathogenesis of the disease. In summary, it may be stated that pre-eclampsia is a systemic disease of maternal endothelial cell dysfunction, resulting from a deficient endovascular invasion of fetal extravillous cytotrophoblasts into the maternal spiral arterioles--a process facilitated by cytokine and angiogenic factor producing uterine/decidual CD56bright Natural Killer (NK) cells and impeded by the more cytotoxic peripheral CD56dim NK cells of the innate immune system. Therefore, the disease process appears to be fundamentally one of a unique variant of immune maladaptation at the level of the maternal-fetal interface in the setting of more or less susceptible persons caused by a mixture of both insufficient maternal tolerance induction to the paternal antigens and unfavourable combinations of genetically determined maternal leukocyte receptors and fetal antigens.

Pharmacokinetics of theophylline in hepatic disease.

The disposition of theophylline was examined in eight male cirrhotic (six proven by biopsy) patients without heart failure. An oral dose of 100 mg of theophylline per square meter of surface area was administered, and samples of serum and saliva were collected from 0 to 60 hours and were assayed by high-pressure liquid chromatographic techniques. Controls were 57 young normal subjects and 25 age-matched patients. The body clearance of theophylline in cirrhotic patients was low, averaging 18.8 +/- 11.3 ml/kg/hr (+/- SD) vs 53.7 +/- 19.3 and 63.0 +/- 28.5 ml/kg/hr in the control patients and the normal subjects, respectively. The half-life of theophylline in cirrhotic patients was prolonged wiht a mean of 28.8 +/- 14.3 hours compared to 6.0 +/- 2.1 hours in normal subjects. Patients with cirrhosis proven by biopsy had significantly lower values for body clearance and longer half-lives than subjects without biopsies. The values for body clearance correlated well with the serum level of bilirubin (r = -0.81) and the serum level of bile acids (r = -0.81). The slow and variable metabolism in cirrhotic patients necessitates a reduction in the maintenance dosage of aminophylline to 0.20 to 0.45 mg/kg/hr and monitoring of the serum level during therapy.

Active giant cell arteritis with cerebral involvement. Findings following four years of corticosteroid therapy.

A patient had continued active giant cell arteritis proved on biopsy four years after the initial diagnosis of temporal arteritis. The patient had had erythrocyte sedimentation rates within the normal range and had been receiving corticosteroids without interruption for four years. Central nervous system symptoms occurred three and four years after the initial diagnosis.

Southeast Asian folklore about pregnancy and parturition.

Southeast Asian refugees immigrating to the United States bring many traditional beliefs about pregnancy and childbearing to their new home. Harmony with nature, dualistic concepts of disease, and pathogenetic metaphor are important ingredients of indigenous health practices. Pregnant and postpartum women must be protected against "wind," lost of "heat," and poisons. Because these notions and the behaviors used to carry them out may seem bizarre to unsuspecting Western-trained health care personnel, it is important for Westerners to understand the basis for these beliefs.

Dilatation and nontraumatic rupture of the urinary tract during pregnancy: a review.

Rupture of the urinary tract during pregnancy is uncommonly reported. Nevertheless, pregnancy-induced changes in the urinary tract predispose to tears and leaks in the renal parenchyma or collecting system. Pyelonephritis, painful overdistension, and rupture are consequences of the effects of pregnancy on the urinary tract. Thirteen cases of urinary tract rupture from the literature and one from the authors' experience illustrate the clinical manifestations of this serious complication of pregnancy.

Intestinal parasites and pregnancy.

Intestinal parasites and pregnancy commonly coexist. Environmental, nutritional, and immunologic factors influence the clinical manifestations and determine the need for treatment of intestinal parasitism during pregnancy. No serious medical or obstetric problems attributable to intestinal parasites developed among 147 parasitized pregnant refugees living and delivering in a refugee camp in Southeast Thailand. These patients received adequate nutrition, careful prenatal monitoring, and no antiparasitic drug therapy. During pregnancy chemotherapy for intestinal parasites should not be used unless required for appropriate clinical and public health reasons.

Histiocytosis X and pregnancy.

BACKGROUND: Histiocytosis X, a clinically heterogeneous infiltrating disorder, is rarely associated with pregnancy. Diabetes insipidus is a common manifestation of histiocytosis X. CASE: A 27-year-old pregnant woman was diagnosed with histiocytosis X by biopsy. At 31 weeks' gestation, she developed diabetes insipidus and required treatment with intranasal 8-D-arginine vasopressin. A hypothalamic mass was noted on magnetic resonance imaging. She delivered a 363-g male at term by cesarean. Two months postpartum, after a motor vehicle accident, she developed a T6 sensory and motor deficit. An intramedullary spinal cord mass was diagnosed and surgically removed. She was treated postoperatively with radiation therapy to the spine and hypothalamus. Despite systemic chemotherapy, the disease progressed, and the patient died 18 months after delivery. CONCLUSION: Pregnancy in patients suffering from histiocytosis X is rare. When pregnancy and histiocytosis X do coincide, diabetes insipidus may appear or worsen. Treatment with intranasal 8-D-arginine vasopressin does not pose risks for the fetus or for premature labor.

Erythrocyte filterability in normal and high-risk pregnancy.

Erythrocyte filterability was studied longitudinally in normal pregnancy and in certain categories of high-risk pregnancy. Study subjects included ten normal controls, 12 insulin-dependent diabetics, eight gestational diabetics, and five essential hypertensives. Our results indicate that erythrocyte filterability remains relatively stable over the course of normal gestation. We noted no differences between controls and essential hypertensives or gestational diabetics, although a favorable effect of insulin therapy was suggested in gestational diabetics. Erythrocyte filterability and mean arterial blood pressure were not related. Insulin-dependent diabetics demonstrated a significantly elevated and widely varying erythrocyte filterability, and individual patient trends correlated well with outcome. Fibrinogen levels in diabetics rose precipitously and were significantly higher than normal throughout gestation. Fibrinogen levels paralleled changes in erythrocyte filterability, with the two parameters positively correlated. Mean glucose control had no influence on filterability. We conclude that in the diabetic pregnancy, varying erythrocyte filterability is related to altered fibrinogen metabolism and may contribute to perinatal morbidity.

Total parenteral nutrition during pregnancy.

Parenteral hyperalimentation or total parenteral nutrition has become an established therapy for patients with a wide variety of conditions that preclude oral feeding. Because pregnancy is an infrequent event in poorly nourished women with acute or chronic illness, total parenteral nutrition has not been widely used for pregnant patients. Some obstetricians believe that total parenteral nutrition entails risks in excess of its potential benefit to pregnancy and demands skills and knowledge that are either not available or are in limited supply. Sufficient favorable clinical experience has accumulated over the past 15 years so that total parenteral nutrition can be recommended in the management of malnutrition during pregnancy. The purpose of this report is to review the authors' experience and the literature about total parenteral nutrition during pregnancy.

Prolonged use of a diaphragm and toxic shock syndrome.

PIP: A case report is presented that involves the extended use of a contraceptive diaphragm and illustrates the problems in promptly establishing a clinical diagnosis of staphylococcal toxin syndrome. A 27-year old woman, 2 months postpartum, was admitted to the hospital after 24 hours of fever, shaking, chills, sweats, nausea and vomiting, and diminished urine output. She had been unable to remove a new coil spring diaphragm, used for the 1st time since parturition, for 3-1/2 days before admission. On the day of admission the diaphragm was removed with some difficulty. A purulent, foul-smelling vaginal discharge at the time the diaphragm was extracted was noted. She was lactating and had had no menses since conception. Her past medical history was unremarkable except for mitral valve prolapse. Evaluation at the time of admission was remarkable for a pulse rate of 120 beats/minute and orthostatic lightheadness. The blood pressure was 110/70 mm Hg when the patient was supine and fell less than 15 mm Hg systolic when she was seated. The white blood cell count was 17,000 with 63% segmented and 33% juvenile polymorphonuclear leukocytes. The sedimentation rate was 45 mm/hour. Multiple cultures of vagina, throat, urine, and blood were obtained. Vigorous intravenous fluid and electrolyte therapy was administered, and the patient was initially begun on ampicillin and tobramycin. Shortly after the appearance of the rash, staphylococcal toxic shock syndrome (TSS) was suspected, and the ampicillin was changed to oxacillin. The rash and strawberry tongue faded within 24 hours, and she became normotensive and afebrile by the 2nd hospital day. She was changed to oral dicloxacillin as the only antibiotic on the 4th hospital day, after the culture results were confirmed. At the time of discharge on the 6th hospital day, desquamation of the skin on the palms and soles had started and continued for another 7-10 days. A 10 day course of dicloxacillin was completed. Follow-up vaginal, cervical, and pharyngeal cultures 3 and 5 months later contained no S. aureus. The patient had resumed menstruation but was not using tampons or a diaphragm. Increased vigilance for the potential dangers of using vaginal occulusive devices when the lower genital tract is colonized by S. aureus is necessary.^ieng

Parasites and pregnancy: the problems of malaria and toxoplasmosis.

Infections caused by parasites are common and not limited to the developing world. The spectrum of interactions between pregnancy and parasite infection ranges from minor discomfort to fetal death and are well illustrated by the problems of toxoplasmosis and malaria.

Sir Richard Francis Burton: explorer, anthropologist, irregular physician.

Travellers to remote areas seem to have a magical aura. Indigenous folk often seek them out asking for medical treatment. It does not matter whether or not the traveller is in fact a doctor. Non-medical travellers have rendered good care, and by so doing ensured the success of their expedition. Nevertheless, there are reservations about 'playing doctor' and many travellers shun the role. Others, however, have purposefully impersonated doctors and capitalized on their medical fraud.