ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsThe diagnosis of pulmonary thromboembolism is a controversial subject. The present article outlines a practical guide for the use of ventilation-perfusion scintigraphy in patients with suspected pulmonary embolism.Fatal pulmonary embolism commonly is unrecognized before death, particularly in elderly patients and in those with congestive heart failure or pneumonia. The symptoms, physical signs, routine laboratory findings, and standard roentgenographic studies of the chest frequently are inconclusive. Dyspnea, pleuritic chest pain, and apprehension are the most common presenting symptoms, but the classic triad of pleuritic chest pain, dyspnea, and hemoptysis occurs in less than 20 per cent of affected individuals. Findings on physical examination which suggest deep venous thrombosis are present in one-third of the patients with pulmonary thromboembolism.Because of the limitations of clinical evaluation, laboratory studies, and roentgenographic studies of the chest in the evaluation of patients suspected of having this disease, the need exists for a method that provides greater sensitivity and specificity. Pulmonary ventilation-perfusion scintigraphy fulfills this role adequately. Perfusion imaging involves the intravenous injection of radiolabeled particles ranging from 10 to 60 μm in diameter. These particles are trapped in the capillaries and precapillary arterioles of the lung. The particles are distributed to the lungs in proportion to the regional pulmonary blood flow. The examination is relatively safe, although the total number of radiolabeled particles injected should be reduced in patients with severe lung disease. An adequate perfusion lung scan should consist of at least six views: anterior, posterior, left and right laterals, and left and right posterior obliques.Pulmonary embolism causes mechanical obstruction of the pulmonary artery, which results in one or more perfusion defects on the scintigrams, but is not the only cause of such defects. Other pathophysiological disturbances may lead to focal defects in pulmonary perfusion. The addition of ventilation scintigraphy to the standard pulmonary perfusion study improves specificity in the diagnosis. Combined ventilation-perfusion scintigraphy has a positive predictive value of nearly 90 per cent, as opposed to only 60 per cent for perfusion scintigraphy alone.The scintigraphic diagnosis of pulmonary embolism is based on the following: multiple regions of abnormal perfusion are present, corresponding to bronchopulmonary segments; ventilation studies are normal (ventilation-perfusion mismatch); and abnormal densities on roentgenograms of the chest are absent. Angiographically demonstrable embolization is common in patients with mismatched perfusion defects. Conversely, the condition is infrequent in patients with matching ventilation and perfusion abnormalities.Scintigrams are classified as normal or as indicating a low, intermediate, or high probability of embolus. A normal perfusion scan virtually excludes an embolus.The accurate method for the diagnosis of pulmonary embolus is pulmonary angiography. An intraluminal filling defect or an abrupt vascular “cut-off” in a large pulmonary artery is required for a specific diagnosis.When performed by experienced physicians, pulmonary angiography is an invasive, albeit relatively safe procedure, with a morbidity of approximately 1 per cent and a mortality of less than 0.3 per cent. The following general guidelines have proved useful in determining when to apply the procedure. Pulmonary angiography is not performed following a normal scan. In the case of high-probability scintigrams, angiography is reserved for those patients in whom anticoagulants are contraindicated. Most patients with low probability scans need not undergo pulmonary angiography, and they do not receive anticoagulants. Patients with intermediate probability scans are more likely to have angiography performed if the clinical setting is appropriate.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsSome investigators think that placental size is just a manifestation of fetal growth and has no independent clinical significance. There are, however, cases in which abnormal-sized placentas are the result of clinically important disorders. The present study attempted to identify the factors that affect placental growth. The information thus obtained was used to determine if relative placental underweight and overweight have independent correlations with perinatal health and childhood growth and development.The data for the study came from the Collaborative Perinatal Study (CPS) of the National Institute of Neurological and Communicative Disorders and Stroke. The CPS followed the course of more than 55,000 pregnancies in 12 medical school-affiliated hospitals in different regions of the United States between 1959 and 1966 by recording (prospectively) events of gestation, labor, and the neonatal period. Placental weight and other data were available from 38,351 single-born children (20,724 white and 17,627 black), 65 per cent of whom were available for follow-up at 7 years of age. This made it possible to determine if abnormal placental size has any long-term correlation with the growth and development of children.All but two of the 10 factors that had significant positive or negative correlations with birth weights had similar correlations with placental weights (Table 1). The two exceptions were cigarette smoking and short maternal stature, neither of which affected placental weight significantly.A placental growth table and percentile growth charts were constructed, taking into consideration the factors that had the greatest influence on placental weights, i.e., maternal pregravid body weight, race, pregnancy weight gain, and gestational blood pressure (Table 2, Figs. 1 and 2). Baseline placental weights in Table 2 are for normotensive women who weighed 48 to 66 kg before pregnancy and gained 6 to 14 kg during pregnancy. Adjustments in placental weights for gravidas in different body-weight and weight-gain categories are found in Table 2. After these adjustments are made, the weight percentile for any placenta can be determined from the curves in Figures 1 or 2.Relatively low placental weight was associated with higher-than-expected hemoglobin values in newborns. Relative placental underweight was associated also with small body size at 7 years of age, independent of the factors that have the greatest effect on placental growth. The latter correlation was present in blacks but not in whites.Neonatal manifestations of acute or subacute antenatal hypoxia, including death and neurological abnormalities, were most frequent when placentas were relatively overweight. These effects were greatest before 35 weeks of gestation and decreased progressively toward term. Some of the neurological abnormalities present in newborns with overweight placentas persisted into later childhood. At 7 years of age, 5.6 per cent of the children whose placentas had been overweight demonstrated neurological abnormalities, compared with 4.2 per cent of the children whose placentas had been of normal weight (P <0.001). Relative placental underweight was not followed by long-term neurological abnormalities.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsA relationship between pregnancy outcome and working conditions for women has been reported frequently. In France, changes in such conditions, if indicated, are required by law. The present study shows how the outcome of pregnancy was related to working conditions in France in 1981, when a nationwide survey of births was carried out.The study was confined to 2387 employees who had worked during the first trimester of pregnancy and after. Two indicators of outcome of pregnancy were selected: preterm delivery occurring before 37 completed weeks of amenorrhea and birth weight below 2500 gm.Among employees who worked beyond the first trimester, 39 per cent belonged to the group of manual occupations: production workers (21 per cent), service workers (12 per cent), and shop assistants (6 per cent). The second group included professional workers (7 per cent), managerial workers and teachers (19 per cent), and clerical workers (35 per cent).Preterm delivery was significantly more frequent among production, shop, and service workers (7 per cent, as compared to 4 per cent among professional, administrative, or clerical staff; P < 0.01).Assembly line workers had preterm delivery more frequently than other women, this relationship being significant among manual workers only. All women who combined three or four of the strenuous working conditions (standing positions, heavy load carrying, assembly line work, and physically demanding work) had a significantly higher preterm delivery rate (8 per cent) than women who had none of these conditions (4 per cent) or one or two of them (5 per cent).For the four strenuous working conditions listed above, the proportion of women who did not work at all during the third trimester was higher when the work was strenuous. Reasons for the absences were varied, but apart from the legal prenatal leave, sick leaves were the most frequent. They were commoner and longer when the work was physically tiring.Women whose employers refused to modify their working conditions had a high rate of sick leave, and they were more likely to stop working after the second trimester than other women. The same trend was observed in the women who thought a modification of their working conditions impossible. Women who considered these changes unnecessary had shorter periods of sick leave. Women who benefitted from a change had a high rate of sick leave, although they were unlikely to stop working during the third trimester. These figures were the same, whatever the working conditions happened to be.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsSevere aplastic anemia can be treated successfully with bone marrow transplantation. Cyclophosphamide, commonly used for conditioning of the patient before transplantation, causes reversible sterility. Late teratogenicity for offspring is a potential risk. The present authors report the pregnancy and delivery of a 23-year-old woman who had a successful allograft for severe aplastic anemia.The patient was admitted, 12 months after delivery of a healthy baby, with phlegmonous angina in December 1981. Her blood counts were: hemoglobin, 6.4 gm/dl; leukocytes, 1.24 × 109per liter; and platelets, 17 × 109per liter. The bone marrow was hypocellular. The patient complained of dyspnea and easy bruising. On admission, physical findings were normal except for bleeding manifestations. Liver and spleen were normal. The diagnosis of severe aplastic anemia was established, and the patient was transfused with red blood cells and platelets.Four months after diagnosis, the patient was prepared with 4 × 50 mg/kg body weight cyclophosphamide (days −5 to −2) and received 3.8 × 108nucleated bone marrow cells from her HLA-identical, MLC-nonreactive, ABO major mismatched 24-year-old sister. The red blood cells were removed from the bone marrow graft by centrifugation. Methotrexate was used to prevent graft-versus-host disease (GVH-D), and unirradiated donor buffy coat cells were given on 4 consecutive days postgraft for rejection prophylaxis. The early posttransplantation period was uncomplicated. Granulocytes exceeded 1 × 109per liter on day 46; platelets were administered up to day 18. There was no acute GVH-D, and the patient was discharged on day 39. Normal leukocyte and platelet counts were reached on day 131, but reticulocytosis was delayed until day 330, unless a 2-fold plasmapheresis was performed.A mild graft-host reaction on skin and mucous membranes appeared on day 140 and disappeared without treatment around day 500. After 200 days of cyclophos-phamide-induced secondary amenorrhea, the patient developed regular menses again.About 570 days after bone marrow transplantation, the patient became pregnant and refused an elective abortion. Except for mumps in the 14th week, pregnancy was uneventful. The blood counts remained in the normal range. On day 857 after bone marrow transplantation, the patient was delivered by cesarean section, because of vaginal fibrosis (a residue of chronic graft-host reaction of the mucous membranes), of a normally developed female infant, weighing 3450 gm.Soon after delivery, the newborn developed central cyanosis and tachypnea. Breathing 100 per cent oxygen ameliorated the cyanosis slightly. The condition was diagnosed as persistent fetal circulation syndrome with reactive vasoconstriction of the lung vessels and right-to-left shunting over a patent ductus arteriosus Botalli. After surgical closure of the patent ductus arteriosus Botalli 3 weeks postpartum, the baby recovered quickly. One year after birth, both infant and mother have normal blood counts and Karnovsky scores of 100 per cent.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsThe Obstetrical Services of the University of California advocate vaginal birth for term infants in the breech position under selected circumstances. Since 1980, external version has been attempted at 37 to 39 weeks of gestation in an increasing number of cases. If the version was unsuccessful, a trial of labor was considered. It is the present authors' hypothesis that the attempt at external version for the term infant in the breech position, followed by a trial of labor for selected patients, is preferable to a policy of routine cesarean section. They believe that their program can be carried out without an increase in fetal morbidity or mortality, and since it will reduce the incidence of cesarean section, at lower cost.To evaluate their hypothesis, the authors reviewed all cases of term infants in breech presentations from 1976 through 1984. Three groups were compared with respect to demographic factors, maternal and fetal outcome, and charges: 1) patients delivered by cesarean section without labor; 2) patients allowed a trial of labor but subsequently delivered by cesarean section; and 3) patients with trial of labor and subsequent vaginal delivery. There were 716 cases of singleton breech presentation occurring at 37 or more weeks of gestational age.Of the 716 breech presentations, only 433 (61 per cent) were identified before the onset of labor. Of these, 171 (44 per cent) underwent an attempt at external version. Eighty-three versions (48 per cent) were successful and 88 (52 per cent) were unsuccessful. Seventy-four (89 per cent) of the 83 women with successful versions had vaginal deliveries, whereas nine women (11 per cent) were delivered by cesarean section for either fetal distress or abnormal labor.Of the 623 patients in whom version was unsuccessful (or was not tried) 379 (61 per cent) were delivered by cesarean section without labor. Two hundred and forty-four women (39 per cent) underwent trial of labor. Sixty-nine of these (28 per cent) ultimately were delivered by cesarean section. The indications for surgery were: abnormal labor in 44 patients (64 per cent), fetal distress in 14 (20 per cent), and cord prolapse in 11 (16 per cent). The remaining 175 women (72 per cent) were delivered vagi-nally. X-ray pelvimetry was performed on 119 of the 244 patients (49 per cent) who were permitted a trial of labor. Of the 623 babies who remained breech, 20 per cent were footling, 72 per cent were frank, and 8 per cent were complete.Data for the 625 patients and their babies were stratified into the three groups outlined above. Antepartum, intrapartum, and postpartum maternal variables and neonatal outcome variables (such as Apgar scores, cord blood gases, birth trauma, admission to intensive care, and perinatal death) were compared among the three study groups.There were no differences among the groups in age, parity, gravidity, height, race, or type of breech. When group 1 was compared with groups 2 and 3 (the vaginal trial groups), the pelvic measurements were found to be significantly smaller in group 1. The estimated fetal weight was significantly greater in group 1. These factors influenced the decision to proceed with cesarean section without labor in women with small pelvic measurements or those thought to be carrying large infants.There were significant differences among the three groups with respect to actual birth weight. The mean weight of babies in group 2 (the failed vaginal trial group) was significantly greater than those in the other groups. There were also differences among the groups with respect to both 1− and 5-minute Apgar scores. In each instance, the group 2 babies fell between those in groups 1 and 3. These findings were placed in clinical perspective by examination of blood gas values of the cord. Although the pH and base excess were significantly higher in the infants delivered by cesarean section without labor, the differences had little clinical significance. The fact that there were no significant differences between group 2 and group 3 suggests that labor rather than the route of delivery has some effect on the blood gas values of the umbilical cord. With respect to birth trauma, there was significantly more of it in infants delivered vaginally than in those delivered by cesarean section. Most of the difference was accounted for by an increased frequency of “bruising” in group 3 infants. There were no significant differences in the incidence of admission to intensive care or of perinatal mortality among the three groups. There were five neonatal deaths: four in group 1 and one in group 2. The cause of death in each case was a congenital anomaly, none of which had been diagnosed before delivery.The estimated maternal blood loss was significantly greater in group 1 than in either of the other two groups, but there was no difference in either the frequency of transfusion or the hematocrit value among the groups. The incidence of endometritis was significantly greater in both groups delivered by cesarean section than in the vaginal delivery group.The length of hospital stay for both mother and newborn was significantly longer when cesarean section was performed. The lengthened stay had a significant effect on hospital charges. It is clear that attempted external version is cost effective, with an advantage of almost $1600 per birth (as of 1985) over a population in which no version is attempted.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsBabesiosis is an intraerythrocyte parasitic infection, only recently described in infants. The course of the illness varies from mild, self-limited disease to more severe involvement with fever, hemolysis, and thrombocytopenia. Severely affected patients have required exchange transfusions or antimicrobial therapy or both. The present authors describe the clinical manifestations of babesiosis in an infant who apparently acquired the disease via perinatal transmission from her mother.The 4200-gm infant was born after a full-term pregnancy by elective cesarean section because of transverse lie. Her mother was bitten by a tick 1 week before delivery but remained asymptomatic. The infant continued in good health for a time. She was checked frequently for ticks, but no bites were noted.At 1 month of age, the infant became pale and irritable. One day later, she became febrile and was admitted to a local hospital with presumed sepsis. She was subsequently transferred to North Shore University Hospital because of increasing pallor. There is no family history of hemolytic anemia or hemoglobinopathies.Physical examination on admission revealed an alert but pale infant with a rectal temperature of 38.7°C, blood pressure of 98/62 mm Hg, pulse of 200 beats per minute, respiratory rate of 60 breaths per minutes, and weight of 4.8 kg. The liver and spleen were palpable 3 cm below the respective costal margins. There were no hemorrhagic lesions or tick bites.The initial laboratory findings included hemoglobin, 9.3 gm/dl, and leukocyte count, 6500 mm3. The differential count showed 10 per cent segmented neutrophils, 8 per cent immature neutrophils, 60 per cent lymphocytes, 11 per cent atypical lymphocytes, and 11 per cent monocytes. The platelet count was 38,000/mm3, and the reticulocyte count was 3.6 per cent. The total bilirubin concentration was 4.2 mg/dl, with a direct fraction of 0.6 creatinine kinase 282 units/liter (normal, 0–170 units/liter); lactic de-hydrogenase, 894 units/liter (normal, less than 600 units/ liter); alkaline phosphate, 468 units/liter (normal, 109–265 units/liter); serum glutamic oxaloacetic transaminase, 90 units/liter (normal, 14–70 units/liter); and serum glutamic pyruvic transaminase, 90 units/liter (normal 0–54 units/liter). Blood, urine, and cerebrospinal fluid cultures were negative, and stool was guaiac negative.Babesia microti organisms were found in 5 per cent of the erythrocytes on the initial Wright stain of the peripheral smear. The mother's peripheral blood smears at the time of delivery, and 30 and 32 days later, revealed no parasites. Serological studies in both mother and infant showed evidence of babesiosis.After blood, urine, and cerebrospinal fluid cultures were obtained, therapy was begun with ampicillin and pentamicin. Clindamycin phosphate (40 mg/kg/day intravenously in four divided doses) and quinine sulfate (25 mg/kg/day orally in three divided doses) were added after discovery of parasitized red blood cells. Ampicillin and gentamicin were discontinued on the third hospital day. On the fourth hospital day, the hematocrit dropped to 18 per cent, and packed red blood cells were administered. By the fifth hospital day, the platelet count was 102,000/mm3, hepa-tosplenomegaly had been resolved, and the parasitemia was less than 1 per cent. The infant was discharged the next day, to complete a 10-day course of orally administered clindamycin and quinine. She continues to do well 6 months later.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID