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Pressure ulcer prevention and maternity services are areas of health care that are rarely linked. However, anecdotal evidence appears to support the view that increasing numbers of women develop pressure damage during childbirth (Malone, 2000; Newton and Butcher, 2000). This is becoming an area of concern for clinicians and risk managers (Butcher, 1999).
Pregnancy is an unusual event in patients with chronic renal failure undergoing dialysis. The outcome in these cases is usually poor. We report a pregnancy complicated by severe renal insufficiency that was managed successfully by continuous ambulatory peritoneal dialysis. Dialysis was initiated at 24 weeks' gestation. At 34 weeks, premature labor associated with peritonitis resulted in the spontaneous delivery of a healthy male infant weighing 2400 g. The use of continuous ambulatory peritoneal dialysis during pregnancy offers theoretical advantages compared with hemodialysis. Our case, added to the available limited experience with this new modality, suggests that it may be an appropriate approach in women developing renal disease for the first time during pregnancy.
BACKGROUND: This study investigated postpartum metabolic abnormality in women with previous gestational diabetes mellitus (GDM) and predictive factors for postpartum glucose intolerance. METHODS: From March 2001 to February 2003, 127 prior-GDM women underwent a 75g oral glucose tolerance test (OGTT) and metabolic assessment at least six weeks after delivery. To identify the predictors, clinical variables obtained at the time of GDM were compared. RESULTS: The cumulative incidence rates of diabetes mellitus (DM) and abnormal glucose tolerance (AGT) i.e. impaired fasting glucose or impaired glucose tolerance, in women with previous GDM were 13.4% and 29.1%, respectively. Postpartum body mass index (BMI), total cholesterol, HDL cholesterol, triglycerides, blood pressure, waist-to-hip ratio and fasting C-peptide were not significantly different among DM, AGT and normal glucose tolerance (NGT) women. However, the C-peptide/glucose score was lower in DM than in AGT and NGT women (p < 0.01). DM or AGT women had higher prepregnancy BMI and fasting glucose level for 100g OGTT than NGT women (p < 0.05) at the time of GDM. The fasting glucose value was an independent risk factor. The cutoff point of three abnormal values in 100g OGTT provided 86% sensitivity and 43% specificity for the prediction of postpartum DM or AGT. CONCLUSIONS: High prepregnancy BMI and increased glycemic deterioration at the time of GDM are found in women developing postpartum DM and AGT. The fasting glucose value for 100g OGTT is an independent risk factor and more than three abnormal glucose values offers good diagnostic efficacy in predicting postpartum glucose intolerance.
A 44-year-old women developed marked myopathy one year earlier, when she was treated with intravenous prednisolone for acute severe exacerbation of ulcerative colitis. When she was admitted to our hospital for another severe exacerbation, intravenous cyclosporine A was administered as monotherapy because she could not tolerate corticosteroid. The treatment was successful and she obtained complete remission. Cyclosporine A monotherapy is considered to be a valuable alternative to proctocolectomy for severe ulcerative colitis patients who cannot tolerate corticosteroid.
Two pregnant women developed overt polyuria (up to 11 l/day) and polydipsia during their second and third trimesters of pregnancy. In one patient hydronephrosis was present. Both patients suffered from mild gestational diabetes mellitus. Plasma sodium was 145 and 162 mmol/l. Polyuria and urinary hypo-osmolality responded well to desmopressin acetate. After delivery, polyuria and polydipsia disappeared in one patient and significantly improved in the other. Infusion of hypertonic saline one and two weeks respectively after delivery led to plasma hyper-osmolality (294 mosmol/kg and 305 mosmol/kg) without detectable stimulation of arginine vasopressin (AVP). Anterior pituitary function was normal. No stimulation of AVP occurred following insulin-induced hypoglycemia. AVP plasma disappearance after i.v. pulse injection of 1 microgram AVP as well as AVP plasma concentration after continuous infusion of 10 ng AVP/min was studied two weeks after delivery in one patient. The results suggested markedly elevated degradation of AVP compared to control subjects, probably due to an increased vasopressin activity. Eight months after delivery, hypertonic saline infusion in one patient led to a plasma-osmolality of 312 mosmol/kg without stimulation of AVP. In the second patient, AVP was not detectable (less than 0.2 pg/ml) six months after delivery when plasma osmolality was 290 mosmol/kg. Our studies demonstrate that a subclinical compensated diabetes insipidus was preexistent in both patients. Exacerbation occurred due to an increased AVP-clearance and presumably due to the hemodynamic and hormonal alterations during pregnancy, including a mild gestational diabetes mellitus.
The long term complications of renal transplantation were assessed in 36 patients who had lived for 10 or more years with a functioning renal transplant. Thirty-three patients were alive with a mean plasma creatinine of 0.13 mmol/L (SD 0.07). A 62 year old women died from a myocardial infarction 11 years after transplantation and two women developed chronic rejection and returned to dialysis after 17 years. Nineteen patients have required antihypertensive therapy, five have suffered ischaemic heart disease and two a cerebrovascular event. Malignancy has developed in 13 patients, with four having two or more organs involved. Skin cancers (9 squamous cell, 4 basal cell) were present in all 13 patients and recurred in six. The other malignancies included carcinoma of cervix (2), cervix and bladder (1) and thyroid (1). Three patients have required parathyroidectomy for autonomous hyperparathyroidism, two splenectomy for hypersplenism, and one bilateral hip replacement for avascular necrosis of the femoral heads. The development of hypertension, vascular disease and malignancy are the most important long term complications after renal transplantation. Strategies must be formulated to reduce the morbidity and mortality from these causes.
The widespread use of exercise testing for the detection of myocardial ischemia in patients suspected of having coronary artery disease led to the detection of ischemic changes in many subjects who subsequently were found to have angiographically normal epicardial vessels--the false positive response. Such a result is usually interpreted as indicating that the subject's chest pain is of noncardiac origin. For the past several years, we have studied the mechanism of pain resembling angina that occurs in patients with normal epicardial coronary arteries demonstrated by angiography; we believe these studies have shed some light on this problem. Patients with angiographically normal coronary arteries who present because of a history of angina-like pain and/or ischemic changes detected during exercise electrocardiogram testing were evaluated by measuring great cardiac vein flow (under baseline conditions and after cardiac pacing, with and without intravenous administration of ergonovine) and by radionuclide angiography before and during exercise. We found that a substantial number of these subjects showed inadequate coronary vasodilator reserve and had exercise-induced left ventricular dysfunction suggestive of myocardial ischemia. We concluded from our results that there is a distinct clinical syndrome of myocardial ischemia caused by abnormal resistance responses of the prearteriolar coronary microvasculature. We now refer to this syndrome as microvascular angina. In a series of 115 patients with documented microvascular angina, we also found that only 10% had ischemic ST changes with exercise testing (2% of the men and 17% of the women developed ischemic ST segment changes).(ABSTRACT TRUNCATED AT 250 WORDS)
Atrial natriuretic factor (ANF) may play a role in the regulation of the changes of blood volume and vascular reactivity during pregnancy and when pregnancy is complicated by hypertension. Reports of plasma ANF levels during pregnancy are conflicting. We have prospectively studied plasma ANF levels during pregnancy in 25 women, and compared these with 20 age-matched non-pregnant women. Five women developed hypertension during pregnancy and a further five who remained normotensive had insulin-dependent diabetes mellitus. Plasma ANF was 6.8 +/- 1.2 (mean +/- SEM) and 6.3 +/- 0.9 pmol/l during weeks 8-15 and 24-31 of normal pregnancy (n = 15; vs non-pregnant levels (4.0 +/- 0.6 pmol/l) P less than 0.05, n = 20). Levels were 4.3 +/- 0.8 and 3.9 +/- 0.4 pmol/l during weeks 16-23 and 32-39. In the diabetic patients and in the group who developed hypertension levels were at no time different from the uncomplicated pregnancy group. Serum aldosterone increased as pregnancy progressed, but plasma renin activity remained unchanged. As plasma ANF was not different between those who did, and those who did not develop hypertension, early measurement of it will not predict who will and who will not develop hypertension during pregnancy.
A review of eclampsia in Kelantan was undertaken from 1983-1988. There were 146 documented cases in the state (66 per 100,000 deliveries). Eight maternal deaths occurred. Sixty seven (45.9%) were primigravida. Six of the 79 multiparous women developed eclampsia for the first time following remarriages to new partners. The multisystem dysfunction resulting from eclampsia resulted in varied maternal complications. Fatal cerebral haemorrhage (3 cases), acute pulmonary oedema (8 cases), acute renal failure (6 cases), HELLP Syndrome (8 cases) and acute abruptio placentae were the commoner complications. The average number of convulsions per patient was 1.3. The mean gestation of mothers who delivered prematurely (28.2%) was 34.6 weeks and that for those at term (71.8%) was 39.1 weeks. The caesarean section rate was 42.5%. The perinatal mortality rate was 185.9 per 1000. The implications of this high maternal and fetal mortality and morbidity are discussed in the light of the health delivery system and patient education. A team approach to medical management of eclampsia with the need for intensive care monitoring is suggested.
A glucose metabolism impairment occurs in about 2-3% of all pregnancies. Two different groups of women are involved: diabetic women who become pregnant and healthy women developing gestational diabetes or glucose intolerance during pregnancy. Due to therapeutic improvements and new techniques of fetal monitoring, maternal and perinatal mortality now approaches that of normal pregnancies. On the contrary, congenital anomalies are still four times more frequent. A good control of the mother metabolism is necessary to reduce complications in fetal development, especially during the first six weeks, a crucial period for the early cell division. Fetal monitoring is very important not only to control the normality of the growth and the well-being of the fetus, but also for early identification of possible anomalies.
The present report describes an unusual association between postpartum renal failure and systemic lupus erythematosus. Two healty young women developed progressive renal failure several weeks after delivery accompanied by the presence in their serum of strongly reactive anti-nuclear antibodies and positive anti-DNA antibodies. In both cases kidney biopsy disclosed light and electron microscopy pictures typical of idiopathic postpartum renal failure, with multiple intravascular thrombi and no evidence of active lupus nephritis. Intrarenal microthrombi formation may represent a form of exacerbation of systemic lupus erythematosus after delivery. The early recognition of this syndrome may have therapeutic implications.
Fifty-three patients were treated in the gynaecological unit of the Mater Hospital for ovarian cancer between 1980-86. The demographic features of the patients reviewed were similar to those of the Southern Tumour Registry (1981-85), and in the absence of a national tumour registry are presumed to be representative of the country as a whole. Data from the STR indicates that the annual incidence of ovarian cancer is 20/100,000; extrapolating from these figures to the national would suggest that approximately 280 women develop ovarian cancer each year. The majority of Mater patients (72%) had either stage I or stage II ovarian cancer which is at variance with other studies and may reflect an under-staging at initial laparotomy. Their survival rates were better than those of the STR, probably because they had presented earlier and had a lower portion of undifferented tumours. Ovarian cancer is the main cause of death from genital cancer in Ireland. While the stage of disease at diagnosis is critical to survival, chemotherapy did not influence survival.
One hundred and sixteen patients with cervical intraepithelial neoplasia were treated by CO2 laser excisional conization, from 1985 to 1987. All operations in this series were performed in the outpatient unit. 1) In this series, 83.6% (97 out of 116) were patients with CIN and 44.0% (51 out of 116) were patients under the age 39 who can be pregnant. 2) There was no remaining in the 16 materials out of 44 obtained by hysterectomy due to cervical dysplasia and carcinoma in situ (CIS). 3) In our series, 10.3% (6 out of 58) of the women with dysplasia or CIS (surgical margin negative) required two treatments respectively to eradicate their disease from 9 months to 16 months after laser conization. 4) None of 72 women developed postoperative cervical stenosis and cervical infection. 5) Much of the epithelial cover, although originating from columnar cells, became squamous epithelium by 28 days. 6) There were 5 pregnancies in 72 patients, from 5 months to 13 after laser conization. From our studies, a CO2 laser conization for treating CIN preserved the architecture of the cervix, permitting adequate colposcopic and cytological follow-up, and preserved cervical function, so that fertility is not affected and so that there is no interference with pregnancy.
Twenty-five women, 23-41 year old, suffering from premestrual cyclical mastodynia linked or otherwise to benign breast disease (BBD), with moderate or severe pain at least seven days before each menstrual period, were treated with daily beta-carotene (BC) supplementation associated with intermittent administration of retinol (all-trans-retinol 300,000 IU per day). In this therapy retinol was given for 7 days immediately before each menstrual period. After 6 months' treatment, the results revealed marked reduction in breast pain, and sometime recovery, in 23-41 year old women with no toxic side effects. But no such advantages in 5 women with non-cyclical mastodynia treated as above were found. Above this age range, the advantages appear to be absent. All the women developed a healthy look because of a slight tanning of the skin due to beta-carotene supplementation. These data demonstrated a therapeutic synergism between BC and retinol.
The escalation of airline travel compounded by federal deregulation, fostering crowded airports, delayed flights, and inconvenient gate scheduling, has forced the frequent flyer to run from one gate to another, carrying heavy under-the-seat bags. Eleven busy executive, nine men and two women, developed cervical radicular pain complaints associated with weakness and painful dysesthesias in the involved extremity. Four had right C6 root symptoms and seven had left C7 complaints. All had evidence, by x-ray, of cervical degenerative disc disease and three had abnormal electromyograms. Treatment, consisting of intermittent cervical traction after moist heat, as well as a modification of their travel habits including the use of a folding wheeled cart, in every instance resolved these complaints.
The epidemiology of rheumatoid arthritis is poorly defined. We know neither how long rheumatoid arthritis has been a major disease, nor whether its incidence is decreasing. If it is decreasing, is this because of the contraceptive pill or some other variable? We do know that the disease occurs worldwide and that there may be increased prevalence among urban living individuals, compared to their rural counterparts. To some extent the disease 'runs in families', but heritibility is low. Concordance among monozygotic twins is only 32 per cent. Women develop the disease more frequently than men. The prognosis for black males is said to be better than for white females. Whether seronegative 'rheumatoid arthritis' should be considered part of the same disease process is unknown. An agreed definition for rheumatoid arthritis is essential before meaningful genetic and immunogenetic data can be developed. However, it is unclear whether the term rheumatoid arthritis should only be given to those individuals with seropositive erosive disease or whether we should include a self-limiting process of poorly characterized change that is sometimes seen, for example, in the first degree relatives of index cases with disease. The ARA criteria for rheumatoid arthritis are unhelpful since 'possible' and 'probable' rheumatoid arthritis patients almost certainly do not have rheumatoid disease. Moreover, the majority of patients with 'definite' rheumatoid arthritis are seronegative. These subjects may be differentiated from seropositive patients on epidemiological, familial, clinical, immunogenetic, and perhaps radiological grounds. The consensus view is that the DR4 allotype occurs more frequently in severe seropositive disease than in severe seronegative 'rheumatoid arthritis'.(ABSTRACT TRUNCATED AT 250 WORDS)
Doxorubicin and its epimerized analog epirubicin were tested at a dose of 75 mg/m2 given iv every 3 weeks to 42 patients with advanced breast cancer, 23 of whom were in relapse from prior cyclophosphamide, methotrexate, and 5-FU (CMF) chemotherapy. The median cumulative dose was 540 mg/m2 (range, 225-650) for doxorubicin and 565 mg/m2 (range, 150-600) for epirubicin. Complete plus partial response was documented in 11 of 21 patients (52%) following doxorubicin and in 13 of 21 patients (62%) following epirubicin. The median observation period was 22 months (range, 14-30); the median duration of response and the median survival were superimposable. Doxorubicin and epirubicin exhibited a superior response rate in previously untreated patients [six of eight (75%) vs eight of 11 (73%)] compared to those previously given CMF with or without endocrine therapy [five of 13 (38%) vs five of ten (50%)]. Vomiting, mucositis, and leukopenia were documented less frequently following administration of epirubicin as compared to doxorubicin. Regarding cardiac evaluation, no significant differences were evident between the two drugs. However, a significant fall in the left ventricular ejection fraction was documented in women who received doxorubicin following a cumulative dose greater than 550 mg/m2. Following completion of doxorubicin therapy at cumulative doses of 580 and 562 mg/m2, two women developed left ventricular failure at 6 and 14 months, respectively. Epirubicin appears to be an effective drug for the treatment of breast cancer and, given at equal doses, is less toxic than doxorubicin.
Analysis of mortality and incidence rates over a 30-year period discloses differing trends in the risk of cervical cancer in older and younger women. Age-specific rates have been declining in older women, but there has been a marked rise in incidence among women under 40. Birth-cohort analyses show declining risks in successive cohorts of women born from late in the last century until the 1930's, except that risks were slightly elevated in the generation who were young adults during the Second World War. The risk of cervical cancer has increased very rapidly in cohorts born since the 1930s. A mathematical model suggests that women born around 1957 may have over three times the risk experienced by women born around 1932. The numbers of New Zealand women developing, and dying from, cervical cancer will increase strikingly over the next few decades unless effective control measures are introduced.