Serological Assessment of Rubella During Pregnancy

In 45 patients with rubella-like illnesses during pregnancy serological tests showed that the clinical diagnosis had been accurate in only 20. Since only 16 of these patients had presented for laboratory investigations within a week of the onset of symptoms, the value of haemagglutination-inhibition tests was considerably reduced; the diagnosis in these cases was confirmed by complement-fixation and rubella-specific IgM tests.Of 172 patients exposed to a rubella-like illness, only 17 were seronegative; 105 sought advice within two weeks of exposure, and therefore the haemagglutination-inhibition antibody tests were useful in determining immunity. Since the clinical diagnosis of rubella was proved incorrect in a number of cases, these pregnancies were saved. Hence both doctors and patients should report both exposure to and rubella-like illnesses as early as possible, so that laboratory investigations may be carried out without delay.     

Recovery after subarachnoid haemorrhage.

OBJECTIVE--To determine the implications of subarachnoid haemorrhage for quality of life and aftercare. DESIGN--Prospective follow up study of patients surviving subarachnoid haemorrhage over one year (at discharge, three months, and one year) by examination of cognitive functions (a test battery) and changes in everyday life (semistructured interview). SETTING--Regional neurosurgical unit at a tertiary referral centre. PATIENTS--100 Patients with subarachnoid haemorrhage; 17 were lost during the study because of ineligibility (further surgery, previous head injury, relevant psychiatric history, and cultural differences), loss of contact, and non-compliance; a further 13 patients who developed a neurological deficit were considered separately. MAIN OUTCOME MEASURE--Performance on cognitive test battery and reported changes in quality of life. RESULTS--At discharge patients with and without neurological deficit scored below established norms with most tests, but by three months the difference had resolved in patients without deficit. Reduced quality of life attributable to subarachnoid haemorrhage at one year mainly included less energy (seven patients), adverse emotional changes (five), early retirement, affected social life, and domestic tension (three each). None reported reduced capacity for work. CONCLUSIONS--Patients surviving subarachnoid haemorrhage without neurological symptoms have a good prognosis and should be encouraged to return to a normal lifestyle within about three months.     

Fibrin Degradation Products in Normal and Abnormal Pregnancy and Parturition

The levels of fibrin, fibrinogen degradation products (F.D.P.) in the serum were investigated in normal pregnancy and parturition, after caesarean section, and in patients with abruptio placentae, eclampsia, intrauterine death, and post-partum haemorrhage. No significant change occurred during normal pregnancy, but a highly significant increase was found during labour and again during the first week after normal delivery. After caesarean section the levels of F.D.P. were increased two to four hours after operation, and substantially higher levels were found three to eight days after operation than after normal delivery. High levels of F.D.P. were associated with abruptio placentae and eclampsia, and increased levels after intrauterine death and post-partum haemorrhage.An excess of F.D.P. with diminished or normal systemic fibrinolytic activity suggests that local intravascular fibrin deposition and fibrinolysis occur in normal parturition and in these complications of pregnancy. The very high levels of F.D.P. found in abruptio placentae will be important in the pathogenesis of the defective haemostasis that may accompany this complication.     

A case of Cushing's syndrome in pregnancy

Cushing's syndrome (also known as hypercortisolemia) is rare in pregnant women due to the menstrual disturbances and infertility in women with hypercortisolism. A diagnosis of pathological hypercortisolism in pregnant women is often difficult as some symptoms of the disease may be associated with a complicated pregnancy. Hypercortisolemia leads to serious complications for mother and foetus, and is associated with premature labour and high foetal mortality. Hormonal and radiological diagnostics in pregnancy are limited. The results of hormonal measurements and dynamic tests are difficult to interpret due to the physiological changes in the hypothalamo-pituitaryadrenal axis connected with pregnancy. The optimal time and method of treatment should be chosen cautiously case by case because of the possibility of maternal and foetal complications. In this paper, we present a case of Cushing's syndrome secondary to adrenal adenoma in which the diagnosis was made in the 22(nd) week of pregnancy. Due to the advanced gestational status and mild symptoms of hypercortisolism, only symptomatic treatment was introduced. The patient was under continuous obstetric and endocrinological care. At 35 weeks of gestation, the pregnancy was terminated by emergency caesarean section because of premature detachment of the placenta. A male infant weighing 2,450 g was delivered; neither adrenal insufficiency in the child nor hypercortisolemia complications in the mother were observed.     

Role of liver scanning in the preoperative evaluation of patients with cancer

Liver scan characteristics and liver function tests of 72 patients with proved hepatic malignancy (54 metastatic, 18 primary) were evaluated. Well-defined focal defects were observed in 83% of patients with metastatic and 77% of patients with primary liver carcinoma. In 10% of the patients with metastatic liver disease the distribution of radioactivity was normal. Four or more biochemical liver function tests were normal in 33% of metastatic and 29% of primary liver cancer patients. Hepatic enlargement was present in the scan in 94% of the patients with liver metastases; however, data obtained from 104 necropsies of patients with hepatic metastases showed that only 46% had hepatomegaly. We recommend, therefore, that a liver scan should be performed before major tumour surgery in every patient with known malignancy regardless of normal liver size or normal liver function tests.     

Positive Smear in Pregnancy

Of 8,500 consecutive cervical cytology tests in the antenatal period a positive or suspect result was found in about 1%. For the patients with a positive smear, examination under anaesthesia and small four-quadrant cervical biopsies are proposed as an alternative to antenatal conization, with its risk of subsequent haemorrhage or abortion.A waiting policy is safe and permits normal delivery in hospital. Clinical and cytological follow-up is a vital part of conization-excision therapy. For the suspect smear (dyskaryosis) follow-up tests may revert to normal, but others may become positive and demand biopsy.     

Role of [131I]metaiodobenzylguanidine therapy in carcinoids.

From cumulative reported data the sensitivity of [131I]metaiodobenzylguanidine (131I-MIBG) scintigraphy of carcinoids appears to be greater than 60%; at our Institute 131I-MIBG scintigrams were positive in 51 of 70 patients with metastatic carcinoid. Twenty patients with symptomatic, metastatic disease have received 7.4 GBq doses of 131I-MIBG for palliation. Most of these patients had multiple large metastases showing no response to other therapies. No objective response (greater than 50% tumor volume reduction) was ever observed; however, 13 patients were relieved of symptoms, such as flushes, diarrhea, anorexia and pain. Palliation in some of these patients was meaningful and long lasting. Possible explanations for a palliative effect in the absence of objective remission are discussed. Treatment with escalating doses of stable MIBG (up to 80 mg) in 9 patients does not support the hypothesis that the palliation is due to a purely pharmacological effect. Palliation might be explained by the observation that carcinoid liver metastases may present both as hot and cold lesions; 131I-MIBG therapy will thus target exclusively at metabolically active metastases, which are responsible for the patient's symptoms.     

Evaluation of the beta-Neocept test for early pregnancy.

We tested the validity of the beta-Neocept test for early pregnancy against that of the plasma human chorionic gonadotropin beta-subunit radioimmunoassay (beta-HCG RIA). The beta-Neocept test had a sensitivity of 88%, a specificity of 93%, a positive predictive value of 95%, a negative predictive value of 84% and an accuracy of 90%. In view of these performance characteristics, its low cost and its ease of use, the beta-Neocept test could be used as the initial pregnancy test when there is a high probability of pregnancy, as there was in this study population, which consisted of 111 women attending endocrine infertility clinics. The more expensive beta-HCG RIA could be reserved for special indications and for patients in whom the results of the urinary hemagglutination inhibition tests are inconsistent with the clinical signs and symptoms.     

Pregnancy in women with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is increasingly being diagnosed in pregnant women. Women with HCM generally tolerate pregnancy well. The risk is however higher in women who are symptomatic before pregnancy or in those with severe left ventricular outflow tract obstruction. The incidence of arrhythmias does not appear to be increased during pregnancy and maternal mortality is low. Prior to conception, women with HCM should have a risk assessment as well as genetic counselling. During pregnancy beta-blockers should be continued and the judicious use of diuretics may be required to treat symptoms of dyspnoea. A vaginal delivery with regional anaesthesia is usually appropriate. Women should be managed by a specialist multidisciplinary team.     

Consequences of fetomaternal haemorrhage after intrauterine transfusion.

Fetomaternal haemorrhage was studied after 68 consecutive fetal intravascular transfusions performed in 20 patients with Rh isoimmunisation. alpha Fetoprotein concentration was assayed in maternal blood taken before, and immediately after each transfusion and three and 24 hours later. An increase of 50% or more in the concentration in any of the samples after transfusion was considered to indicate fetomaternal haemorrhage. Fetal alpha fetoprotein concentration in blood sampled before transfusion was also assayed and the amount of fetomaternal haemorrhage calculated. Fetomaternal haemorrhage occurred in 21 of 32 patients with an anterior placenta and in six of 36 with a posterior or fundal placenta. The mean estimated volume of haemorrhage was 2.4 ml, which was on average equal to 3.1% of the total fetoplacental blood volume. When the volume of fetomaternal haemorrhage at the first transfusion was greater than 1 ml there was a greater increase in maternal Rh (D) antibody titres and a greater fall in fetal packed cell volume. Sampling of fetal blood should not be routinely done early in patients with Rh isoimmunisation, and intrauterine transfusion should be delayed as long as possible. Sampling sites other than the placental cord insertion reduces the risk of fetomaternal haemorrhage.     

A more specific ELISA assay for the detection of antiphospholipid antibodies

The anticardiolipin ELISA assay was devised just over 10 years ago to detect patients with the APS, a disorder of recurrentthrombosis and/or pregnancy Though a series of workshops, the ELISA technique for detection of anticardiolipin antibodies has been standardized and units of measurement established.Manipulation of phospholipid antigens has enable a more specific detection of APS sera without loss of sensitivity. Inclusion of an in-house positive control in addition to calibrators may enable greater reproducibility of the anticardiolipin test. Since the lupus anticoagulant test alone may be positive, physicians should order both tests in patients suspected of having the APS. These patients need to be diagnosed since prophylactic tre prevent recurrent thrombosis and pregnancy losses.     

Haematemesis: a new syndrome?

Three patients presented with symptoms suggesting a Mallory-Weiss tear. Endoscopy showed a localized, clearly demarcated area of bright red mucosa near the gastro-oesophageal junction; this was thought to have arisen by retrograde intussusception of the stomach during vomiting or retching and may have caused the haemorrhage.     

Feto-maternal haemorrhage in therapeutic abortion

The incidence of feto-maternal haemorrhage in induced abortion has been studied with the Kleihauer technique. All four methods of termination used were shown to result in such haemorrhages. The incidence below 12 weeks'' gestation, however, was very small and there seems to be no reason for offering routine rhesus-immunoglobulin to these women. When it is essential to terminate a pregnancy of 12 weeks'' size or more in a rhesus-negative woman immunoglobulin should be given.     

Gastrointestinal manifestations of diabetic ketoacidosis

The evaluation of gastrointestinal symptoms in patients with diabetic acidosis frequently challenges the physician's clinical acumen. Faced with a seriously ill patient, he must judge whether the abdominal pain, nausea, or vomiting are a consequence of the metabolic decompensation, and hence likely to resolve with correction of the ketoacidosis, or if these symptoms signal a serious underlying intra-abdominal process (e.g., cholecystitis, appendicitis, etc.) which may have precipitated the development of ketoacidosis. The pathogenesis of the reversible gastrointestinal symptoms which frequently accompany diabetic acidosis has not been rigorously defined and may be multifactorial, involving metabolic, humoral, and neural processes. Careful attention to the medical history and abdominal examination greatly facilitates distinguishing patients with intra-abdominal pathology from those with reversible symptoms secondary to ketoacidosis. Similarly, the judicious use of laboratory tests (electrocardiography, blood counts, urinalysis, serum enzyme profile, and abdominal roentgenograms) materially aids in differential diagnosis. Finally, clinical suspicion of an acute abdominal process should prompt early surgical consultation and, if required, surgical intervention as the acidosis is being brought under control.     

Relative contribution of humoral and metastatic factors to the pathogenesis of hypercalcaemia in malignancy.

Some relations between metastatic bone disease and calcium homoeostasis were determined in a consecutive series of 81 patients with solid malignant tumours attending for radionuclide bone scans. Biochemical evaluation showed that bone resorption from metastatic disease was generally not enough to account for hypercalcaemia. While skeletal metastases were present in about half of the patients who developed hypercalcaemia, biochemical indices of bone resorption in these subjects were greatly increased and disproportionate to the extent of metastatic disease detected by the bone scans. Furthermore, a reduced renal phosphate threshold and increased tubular calcium reabsorption were generally observed in hypercalcaemic patients when compared with their normocalcaemic counterparts. These findings suggest that in most cases malignancy associated hypercalcaemia may be caused by the release of a humoral factor by tumour tissue which exhibits "parathyroid-hormone-like" activity with regard to bone resorption, renal phosphate threshold, and renal calcium handling. It may be postulated that this putative humoral mediator predisposes to hypercalcaemia both by stimulating generalised osteolysis and in most cases also by impairing the renal excretion of the resultant increase in filtered calcium load. While hypercalcaemia may arise as a result of metastatic bone disease alone, these data indicate that this may be the exception rather than the rule. Hence the term "metastatic hypercalcaemia" should probably be reserved for patients with extensive skeletal tumour disease in whom biochemical evaluation fails to yield evidence of an underlying humorally mediated cause.     

Postpartum thyroiditis: current views on unappreciated disease

Postpartum thyroiditis is a form of autoimmune thyroiditis developing during the first 12 months postpartum as a consequence of the immunologic flare following the immune suppression of pregnancy. This disease, found in 5-10% of women in a general population and even more frequently in patients suffering from other autoimmune disorders, may re-occur in about 70% of women after a subsequent pregnancy. Postpartum thyroiditis is strongly associated with antithyroid peroxidase antibodies. Patients may present with symptoms of either thyrotoxicosis or hypothyroidism which may be transient or, in some (20-30%) cases of hypothyroidism, permanent in nature. A thyrotoxic phase of postpartum thyroiditis is usually brief and often unnoticed before a more long-lasting hypothyroid phase occurs. The diagnosis of postpartum thyroiditis is based on the observation of abnormal thyroid function tests in a postpartum antithyroid peroxidase- positive woman. In this paper, we discuss the etiopathogenesis, clinical picture, diagnosis, prognosis and treatment of postpartum thyroiditis and provide the reader with some practical guidance concerning dealing with a patient suffering from this disorder.     

Occult pulmonary haemorrhage in leukaemia.

Through gleeding into the lung parenchyma is responsible for morbidity and mortality in patients with leukaemia pulmonary haemorrhage is seldom diagnosed during life. We diagnosed occult pulmonary haemorrhage in five leukaemic patients with unexplained infiltrates on chest roetgenograms by examining alveolar macrophages retrieved by bronchopulmonary lavage. Macrophage haemosiderin content was greatly increased in the patients with pulmonary haemorrhage as compared to normal and thrombocytopenic control subjects. Haemoglobin and intact erythrocytes in alveolar macrophages were taken as evidence of recent haemorrhage. Intrapulmonary bleeding may occur often in patients with leukaemia, and bronchopulmonary lavage offers a safe approach to diagnosis and allows for concomitant identification of pulmonary infection.     

Carcinoembryonic Antigen in Patients With Breast or Colon Cancer

The rationale and results of clinical use of carcinoembryonic antigen (CEA) tests in patients with carcinoma of the breast and colon deserve review. Plasma CEA levels have been found to correlate with the extent of tumor invasion and site of metastatic spread, and CEA titers have diagnostic and prognostic value. Although postresectional serial CEA testing is not as useful in cases of breast carcinoma, in cases of carcinoma of the colon it may indicate recurrence or progression of the lesion. However, there are limitations and CEA results should be interpreted in conjunction with other clinical information.     

Clinical importance of acquired cystic disease of the kidney in patients undergoing dialysis.

From 1976 to 1982 five patients undergoing haemodialysis at Oxford Renal Unit suffered serious complications from acquired cystic disease of the kidney and two died as a direct result. Clinical features seen were pain, haematuria, palpable renal enlargement, massive haemorrhage, resolution of anaemia, and metastatic malignancy. The clinical histories emphasise the features of a disease that is likely to assume increasing importance in patients undergoing haemodialysis.     

Postural shock in pregnancy

Signs and symptoms of shock may be produced in some patients in late pregnancy by putting them in the dorsal recumbent posture. Change from this position will relieve the condition. The features of the supine hypotensive syndrome can be duplicated by applying pressure to the abdomen with the patient in a lateral position. The postural variations of venous pressure, blood pressure, and pulse appear to be due to obstruction of venous return from the lower portion of the body caused by the large uterus of late pregnancy compressing the vena cava. When shock is observed in a woman in late pregnancy, she should be turned to a lateral position before more active measures of treatment are begun.