Outcome of pregnancy in an Oxford-Cardiff cohort of women with previous bacteriuria.

To investigate the influence of asymptomatic bacteriuria in childhood on subsequent pregnancy, we reviewed the outcome of 139 pregnancies in 88 women who were first identified during a programme of screening schoolgirls for asymptomatic bacteriuria carried out between 1970-1972. Data were analysed for the following groups: 50 pregnancies in 28 women with known renal scars (group 1); 16 pregnancies in 14 women with normal kidneys and reflux (group 2); 73 pregnancies in 46 women with normal urinary tracts (group 3); 139 healthy controls. Women in group 1 had a 3.3-fold increased relative risk of hypertension (p < 0.01) and a 7.6-fold increased risk of pre-eclampsia (p < 0.05) compared to controls, and a higher rate of obstetric interventions, including emergency caesarean section. Women in groups 2 and 3 appeared to carry a slightly increased risk of hypertension during the last trimester (RR = 1.8) but there were no significant differences in this or the incidence of pre-eclampsia or mode of delivery. Bacteriuria was more prevalent in all index groups compared to controls (37 per cent vs. 8 per cent, p < 0.01) and included four cases of acute pyelonephritis in in the study group. Fetal outcome was satisfactory in all cases. These results suggest that women with renal scars are at risk of hypertension and pre-eclampsia during pregnancy but that modern obstetric care minimizes these risks.     

Asymptomatic Thrombocytopenia Developing During Pregnancy (Gestational Thrombocytopenia) - A Clinical Study

During pregnancy some women develop unexplained thrombocytopenia(gestational thrombocytopenia). Previous studies have detectedabnormal platelet antibodies, suggesting an autoimmune aetiology.To determine whether gestational thrombocytopenia is associatedwith increased maternal bleeding or adversely addressed affectsthe fetus, 31 pregnant women with asymptomatic thrombocytopeniawere compared with 12 women with thrombocytopenia associatedwith pre-eclampsia and 34 normal pregnant controls. There wasno increase in maternal bleeding in those with asymptomaticthrombocytopenia compared with the normal controls, but pre-eclampticwomen experienced more bleeding (mean difference 181 ml, 95per cent confidence limits 50-312 ml, p < 0.01). There wasno difference in the mean weights of the babies or placenta,nor in the APGAR scores between infants born to controls andthose with asymptomatic thrombocytopenia. Cord blood plateletlevels were measured in 26 women with asymptomatic thrombocytopeniaand were normal in 25 and mildly reduced in one. Thus measuresused for the treatment and delivery of pregnancies complicatedby autoimmune thrombocytopenia are not indicated in gestationalthrombocytopenia. Pregnant women should not be considered thrombocytopeniaunless the platelet count has fallen below 120 x 10⁹/l.     

A Comparative Study of the Relative Effects of Anticonvulsant Drugs and Dietary Folate on the Red Cell Folate Status of Patients with Epilepsy

In a survey of the red cell folate status of 200 patients withepilepsy, compared to 72 controls, we found that median redcell folate levels were reduced significantly in patients treatedwith phenytoin (p<0.01) or carbamazepine (p<0.001) alone.Patients taking more than one drug had reduced levels also (p<0.001),but in patients treated with sodium valproate alone there wasno significant decrease in red cell folate levels compared tocontrols. Twenty-two per cent of patients in the group takingmore than one drug had reduced levels of red cell folate comparedwith 17 per cent of those taking carbamazepine alone, 13 percent of those taking phenytoin only, and 9 per cent of thosetaking sodium valproate only. Dietary folate intake was significantlyreduced in all the patient groups compared with controls (p<0.001for the carbamazepine and phenytoin groups, p<0.01 for thepolypharmacy and sodium valproate groups); a significant correlation,between red cell folate levels and dietary folate was not established. Significant negative relationships were established betweencarbamazepine dose (r=0.35, p<0.01) or serum level (r=-0.27,p<0.05) and red cell folate level in patients on one drugonly. The correlation between dose or serum level-of phenytoinand red cell folate level was also negative but did not reachsignificance. Our findings show that all anticonvulsant drugs interfere withfolate metabolism. While the effect is greatest with drugs whichinduce microsomal liver enzymes, low levels of folate also occurredin patients taking the non-enzyme inducer sodium valproate.Although a significant relationship between diet and red cellfolate was not established, dietary folate could be a furthercontributory factor.     

A Study to Assess the Efficacy of Chemoprophylaxis in the Prevention of Endoscopy-related Bacteraemia in Patients Aged 60 and Over

Five hundred and fifteen patients aged 60 and over (mean age74.7; 278 men and 237 women) underwent routine endoscopic procedures(gastroscopy, bronchoscopy and cystoscopy). Alternate patientswere given antibiotics before the procedure, as currently recommended,and blood was taken for culture from all patients within fiveminutes of completion of the procedure. Of 74 patients who underwent bronchoscopy, only one culture,from one of 37 controls was positive. Of 262 who underwent gastroscopy,cultures were negative in the 130 who received antibiotics butpositive in 13 of the 132 controls (9.8 per cent p<0.001).Cystoscopy was performed in 179; one culture was positive inthe 88 given antibiotics (1.1 per cent) compared to 25 in the91 controls (27.5 per cent; p<0.001). Bacteraemia rates appear to be low following bronchoscopy (<5per cent) but higher with gastroscopy (10 per cent) and cystoscopy(28 per cent). Chemoprophylaxis was effective in reducing theserates in this patient group.     

Asymptomatic thrombocytopenia developing during pregnancy (gestational thrombocytopenia)--a clinical study.

During pregnancy some women develop unexplained thrombocytopenia (gestational thrombocytopenia). Previous studies have detected abnormal platelet antibodies, suggesting an autoimmune aetiology. To determine whether gestational thrombocytopenia is associated with increased maternal bleeding or adversely affects the fetus, 31 pregnant women with asymptomatic thrombocytopenia were compared with 12 women with thrombocytopenia associated with pre-eclampsia and 34 normal pregnant controls. There was no increase in maternal bleeding in those with asymptomatic thrombocytopenia compared with the normal controls, but pre-eclamptic women experienced more bleeding (mean difference 181 ml, 95 per cent confidence limits 50-312 ml, p < 0.01). There was no difference in the mean weights of the babies or placenta, nor in the APGAR scores between infants born to controls and those with asymptomatic thrombocytopenia. Cord blood platelet levels were measured in 26 women with asymptomatic thrombocytopenia and were normal in 25 and mildly reduced in one. Thus measures used for the treatment and delivery of pregnancies complicated by autoimmune thrombocytopenia are not indicated in gestational thrombocytopenia. Pregnant women should not be considered thrombocytopenic unless the platelet count has fallen below 120 x 10(9)/l.     

Obstetric and neonatal outcome following chronic hypertension in pregnancy among different ethnic groups

We retrospectively studied pre-eclampsia rate and obstetric outcome in a cohort of 436 pregnancies amongst 318 women of different ethnic backgrounds attending an antenatal hypertension clinic from 1980-1997, identifying 152 women (213 pregnancies) with chronic essential hypertension. The ethnic breakdown was: White, 64 (30.0%) pregnancies in 48 (31.5%) women; Black/Afro-Caribbean, 79 (37.1%) pregnancies in 56 (36.8%) women; and Indo-Asians, 70 (32.3%) pregnancies in 48 (31.6%) women. The prevalences of pre-eclampsia in White, Black and Indo-Asian women were 17.2%, 12.7% and 18.6%, respectively (p = 0.58). Pregnancies of Indo-Asian women were of shorter gestation, and babies in this group also had lower birth weight and ponderal index compared to those of White and Black women (all p < 0.05). The proportions of overall perinatal mortality were 1.6% for Whites (1/64), 3.8% for Blacks (3/79) and 10.0% for Indo-Asians (7/70), suggesting increased risk in the Indo-Asian group. Indo-Asian women with chronic essential hypertension need careful antenatal care and observation during pregnancy.     

Peri-partum Cardiac Failure

The syndrome of peri-partum cardiac failure (PPCF) has beenstudied in 224 women seen in three years in Zaria, in northernNigeria. A very high proportion were rural Hausa patients. Therewas a seasonal peak in July, and the incidence was about oneper cent of deliveries. The risk increased with both age andparity. Symptoms began most commonly in the second week after delivery,and admission was commonest in the fourth. Typical signs ofcardiac failure were found, and pulsus alternans, atrio-ventricularvalvular incompetence, transient systemic hypertension and splenomegalywere common. The chest radiograph showed marked cardiomegaly,and extrasystoles and inverted T waves were often present inthe electrocardiogram (ECG). Hypoalbuminaemia was common. Digoxinand diuretics were rapidly effective, causing a mean, weightloss of 29 per cent in 15 days, resolution of hypertension,and a fall in the cardio-thoracic ratio (CTR) from 61 to 53per cent. During the first year after diagnosis, the CTR became normalin 82 per cent of patients, and the ECG in 60 per cent. PPCFrecurred, again with the same seasonal variation, after 19 percent of subsequent pregnancies. During follow up for two tofive years, 22 per cent of the women became hypertensive, and11 per cent died. The prognosis was worst in those with an arrhythmia,hypertension, sustained cardiomegaly or aged 30 or more. Asymtomatic post-partum hypertension (PPHT) was found in 61per cent of normal Hausa women, with a seasonal peak in May,especially in those with hypertension during pregnancy or labour,and twin pregnancies. Peri-partum cardiac failure may be due to the combined pressureload of PPHT, the volume load from eating the customary sodium-richkanwa, and the cardiovascular demands of heat, both climaticand traditionally self-imposed.     

Androgenic Status and Sexual Function in Males with Rheumatoid Arthritis and Ankylosing Spondylitis

The pituitary-testicular axis was investigated in 31 males withrheumatoid arthritis (age range 19–60 years, median 55years) and 33 males with ankylosing spondylitis (age range 22–55years, median 37 years) and compared with a control group of95 normal male volunteers. Using analysis of covariance, patientswith rheumatoid arthritis showed significantly lower serum testosterone(p<0.05) and derived free testosterone (p<0.01) concentrationsand significantly higher serum LH and FSH concentrations (p<0.05)compared with controls. All patients had normal serum prolactinand cortisol concentrations. Serum testosterone correlated withESR, haemoglobln concentrations and rheumatoid factor titres(r<–0.448, p<0.02; r=0.440, p<0.02; r<–0.360,p<0.05 respectively) in the rheumatoid patients. Althoughthere was a significant negative correlation between ESR andhaemoglobin concentrations (p<0.005) in the patients withankylosing spondylitis, neither variable correlated with serumtestosterone concentrations. There was no association betweentesticular dysfunction and the presence of extraarticular featuresof rheumatoid arthritis. Ten patients (33 per cent) with rheumatoidarthritis and four (13 per cent) with ankylosing spondylitisadmitted to periods of impotence while 15 (50 per cent) of theformer and 12 (39 per cent) of the latter had periods of decreasedlibido. There was no evidence for increased rates of infertilityin either group.     

Abnormalities of Glucose Tolerance Following Gestational Diabetes

Glucose tolerance and insulin secretion were studied in 56 women6–12 years following a pregnancy complicated by gestationaldiabetes, and in 23 matched controls. At recall 14 women wereknown to have diabetes and five were again pregnant with recurrentgestational diabetes. The early development of diabetes wasassociated with a fasting plasma glucose >6 mmol/l duringpregnancy and with a high plasma glucose response to oral glucosewhich persisted after delivery. Obesity was predictive of non-insulin-dependentdiabetes whereas those that later required insulin were notobese. At recall, seven of the remaining 37 women were foundto have unrecognized diabetes, 13 had impaired glucose tolerance(IGT) and 17 were normal by WHO criteria using a 75 g oral glucosetolerance test. In these 37 women, fasting plasma glucose andthe glucose response to oral glucose in pregnancy were not predictiveof subsequent diabetes or impaired glucose tolerance. Obesityin pregnancy and subsequent weight gain were associated withnon-insulin-dependent diabetes and impaired glucose toleranceat recall. Insulin deficiency was observed during the oral glucosetolerance test in the diabeties (the mean±SEM ratio insulinarea: glucose area 4.1±1.3 diabetics, 10.7±1.8controls, p<0.05), whereas in the group with impaired glucosetolerance insulin levels were high and in proportion to theirhyperglycaemia (insulin area: glucose area 10.9±1.4 1GT,9.4±1.4 controls). Women with normal glucose toleranceand previous gestational diabetes had significantly lower insulinresponses than their controls, despite mild hyperglycaemia (insulinarea: glucose area 4.0±0.7 normal glucose tolerance,7.6±1.1 controls, p<0.02). Abnormalities of glucosetolerance and insulin secretion are present following a gestationaldiabetic pregnancy. Gestational diabetes identifies women atrisk for developing diabetes and impaired glucose tolerance,both of which are risk factors for premature vascular disease.     

Primary glomerulonephritis and pregnancy

Three hundred and ninety-five pregnancies undertaken by 238 women with primary glomerulonephritis between 1962 and 1987 were analysed to record fetal and maternal outcome and identify risk factors for a poor outcome. Of 398 fetuses, 26 per cent were lost (including therapeutic abortions), 24 per cent surviving infants were premature (less than or equal to 36 weeks gestation) and 51 per cent were term. Excluding therapeutic abortions, 20 per cent of fetuses were lost, 15 per cent after 20 weeks gestation. Fifteen per cent of 237 fetuses whose birth weight was recorded were small for gestational age: Deterioration in maternal renal function was seen in 15 per cent of pregnancies and in 5 per cent of women failed to resolve post partum. Only four women had impaired renal function recorded in the first-trimester and two of these were known to have renal impairment before pregnancy. Hypertension was recorded in 52 per cent of pregnancies, developed early (less than or equal to 32 weeks gestation) in 26 per cent and was severe in 18 per cent. Treated hypertension pre-dated 12 per cent of pregnancies and in 7 per cent (included in the overall incidence of hypertension) exacerbation occurred during pregnancy despite continued antihypertensive medication. Forty-four women (18 per cent) who developed de novo hypertension in pregnancy had permanent hypertension postpartum. Increased proteinuria was recorded in 59 per cent of pregnancies and was irreversible in 15 per cent of women. Comparison of pregnancies which occurred before or after renal biopsy revealed a significantly higher fetal loss rate after 20 weeks gestation in those pregnancies undertaken before the diagnosis of renal disease, and a significantly higher incidence of hypertension and increased proteinuria. Impaired renal function, early or severe hypertension or nephrotic range proteinuria was significantly associated with increased fetal loss, prematurity and fewer full-term infants. There was no significant difference in fetal outcome or maternal complications in pregnancy in patients with treated hypertension before pregnancy and those who were normotensive in the first-trimester. The highest incidence of fetal and maternal complications occurred in patients with primary focal and segmental hyalinosis and sclerosis and the lowest in non-IgA diffuse mesangial proliferative glomerulonephritis. The presence of severe vessel lesions on renal biopsy was associated with a significantly higher total fetal loss and fetal loss after 20 weeks gestation.     

Chronic hypertension in pregnancy.

Pregnancies in women with chronic hypertension are at increased risk of superimposed pre-eclampsia, abruptio placentae, fetal growth retardation and prematurity. The frequencies of these complications are increased in those women who have high-risk chronic hypertension, ie severe hypertension or pre-existing cardiovascular or renal diseases, as well as in those with target organ damage. Such women should receive antihypertensive therapy and close management to improve maternal and fetal outcome. In women with low-risk chronic hypertension, antihypertensive treatments do not improve pregnancy outcome. Prophylactic low-dose acetylsalicylic acid treatment does not reduce the frequency of superimposed pre-eclampsia nor does it improve perinatal outcome in these pregnancies.     

Chronic hypertension in pregnancy

Pregnancies in women with chronic hypertension are at increased risk of superimposed pre-eclampsia, abruptio placentae, fetal growth retardation and prematurity. The frequencies of these complications are increased in those women who have high-risk chronic hypertension, ie severe hypertension or pre-existing cardiovascular or renal diseases, as well as in those with target organ damage. Such women should receive antihypertensive therapy and close management to improve maternal and fetal outcome. In women with low-risk chronic hypertension, antihypertensive treatments do not improve pregnancy outcome. Prophylactic low-dose acetylsalicylic acid treatment does not reduce the frequency of superimposed pre-eclampsia nor does it improve perinatal outcome in these pregnancies.     

The prevalence of pre-eclampsia and obstetric outcome in pregnancies of normotensive and hypertensive women attending a hospital specialist clinic

To study the prevalence of pre-eclampsia (PE) and other obstetric outcomes (growth restriction and fetal mortality) in pregnancies of normotensive and hypertensive women attending an antenatal hypertension clinic, we studied a cohort of 372 pregnancies from 267 women. The prevalence of PE in the groups of pregnancies of normotensive and chronic hypertensive women was 11.9% (19/159 cases) and 16.0% (34/213 cases) respectively (chi 2 = 1.2, p = 0.27). There were no significant differences in respect of ethnicity, being primi- or multigravida and smoking status or age. Treatment with antihypertensive drugs during pregnancy did not decrease the prevalence of PE. In pregnancies with hypertensive complications (with or without PE) there was a trend towards higher rates of pre-term delivery (< 37 weeks), caesarean section, small for gestational age babies, stillbirth and lower baby birth weight and ponderal index values. Pregnancies in women with uncomplicated hypertension had an increased risk for emergency caesarean section, pre-term delivery (< 37 weeks), birth weight < 2500 g and stillbirth (relative risks [with confidence intervals] 2.5 [1.9-3.2], 2.3 [1.8-2.9], 3.1 [2.5-3.7] and 5.5 [2.6-11.9] respectively) compared with the general hospital obstetric population. After classification according to the type of hypertensive syndrome, a progressively higher risk for fetal growth restriction and adverse perinatal outcome was shown in the hypertensive and pre-eclamptic groups. In chronic hypertension, this was irrespective of superimposed pre-eclampsia or antihypertensive therapy. The high prevalence of PE in chronic hypertensive women (16.0%) was not statistically significant to that of normotensive women (11.9%), reflecting the referral selection of 'high risk' normotensive women to our clinic.     

Clinico-pathological Correlations and Long-term Follow-up of 253 United Kingdom Patients with IgA Nephropathy. A report from the MRC Glomerulonephritis Registry

The Medical Research Council's Glomerulonephritis Registry wasused to study clinicopathological correlations and renal survivalin patients with IgA nephropathy reported between 1978 and 1985.IgA nephropathy was the histological diagnosis in 9.3 per centof all renal biopsies reported to the registry during this period,and in 18.1 per cent of those with a primary glomerulonephritis.The 10-year cumulative renal survival rate accounting for censoreddata (Kaplan-Meier) was 83.3 per cent. Univariate analysis ofsurvival curves (log-rank test) found the following parametersto be significantly correlated with poor renal survival: serumcreatinine >120 µmol/l (p<0.001), hypertension(p<0.001), serum albumin <40 g/l (p<0.005), proteinuria>1 g (p<0.025), age >30 years (p<0.025), and focalmesangial proliferation (p<0.05). There was no significantdifference in renal survival between males and females. Multivariateanalysis (Cox's proportional hazards model) revealed that onlya serum creatinine of > 120 µmol/l and a serum albuminof <40 g/l were independently predictive of outcome. These findings indicate marked similarities between the UK experienceof IgA nephropathy and the published European experience. IgAnephropathy is not a benign condition in the UK and patientswith impaired renal function and/or those with a reduced serumalbumin are significiantly more likely to progress to end-stagerenal failure within 10 years.     

Prevalence of Persistent Cough During Long-term Enalapril Treatment: Controlled Study Versus Nifedipine

The prevalence and severity of cough during long-term enalapriltreatment were examined by comparing a cohort of 136 hypertensivepatients who started treatment with enalapril with consecutiveage and sex-matched patients who commenced nifedipine therapyduring the same period. Cough and other symptoms were assessedby a questionnaire designed to avoid bias towards reportingcough. After a mean of 27 months' treatment patients on enalaprilhad an excess of persistent cough (16 per cent, 95 per centCI 7–25, p < 0.01), voice change (14 per cent, 95 percent CI 2–27, p < 0.05) and sore throat (10 per cent,95 per cent CI –0.1 to 20.3 per cent, p < 0.01) whencompared to nifedipine-treated patients. The cough was usuallydry, moderate or severe, paroxysmal, and troublesome at night.Cough tended to be more common in women (23 per cent vs. 7.2per cent), non-smokers, and at higher doses of enalapril, butwas not related to age, duration of treatment, or chronic respiratorydisease. Dry cough commonly persists as a troublesome side-effectduring long-term enalapril treatment, and is often associatedwith voice change and sore throat.     

Prolactin Dynamics and Tumour Size in the Prediction of Surgical Outcome for Prolactinoma

Each of 62 females were studied for a period of between twoand 72 months ( mean 36 months) following the removal of a prolactinomaby transsphenoidal pituitary surgery. Our aims were to definethe relationships between pre- and post-operative features,the operative findings and the functional outcome. Pre-operativeserum prolactin (PRL) concentrations correlated with tumourdiameter (r = 0.55, p < 0.001). Following surgery two groupsof patients were identified: Group 1, 46 spontaneously and regularlymenstruating patients and Group 2, 16 patients with persistentamenorrhoea. The patients in Group 1 had significantly lowerpre-operative and postoperative serum (PRL) concentrations (p< 0.02 and p < 0.001 respectively) and significantly greaterPRL responses to thyrotrophin releasing hormone (TRH) and metoclopramidestimulation after surgery (p < 0.001). There was not a significantdifference in tumour size between the groups. Forty-four (96per cent) of the patients in Group 1 had normal post-operativeserum PRL concentrations within one week of surgery. By comparison(p < 0.001) only 42 and 20 per cent respectively of Group1 patients who were tested had normal TRH and metoclopramideevoked PRL secretion following surgery. Return of regular menstruationwas associated with cessation of galactorrhoea in 44 patients(96 per cent) and ovulation occurred in 37 of 38 menstruatingpatients for whom data are available. All patients with normalTRH and metoclopramide stimulation tests menstruated spontaneously.Nevertheless most patients who menstruated did so in spite ofretaining suppressed PRL responses. Of 46 patients followedto date whose serum PRL was normal one week after surgery, sevenlater were found to have an elevation of serum PRL outside thenormal range but in only two has this been persistent. We suggestthat a single measurement of serum PRL one week following transsphenoidalpituitary surgery for prolactinoma provides a good basis fordeciding about the future management of patients who desiremenstruation and pregnancy.     

Maternal plasma folate and vitamin B12 are independent risk factors for neural tube defects

Blood was taken at the first antenatal clinic from 56049 pregnantwomen. Neural tube defect (NTD) pregnancies (81) were comparedto controls (247) for plasma vitamin B₁₂ (B₁₂) (ng/l), plasmafolate (µg/1), and red cell folate (RCF) (µg/l).Median values were significantly different and were, respectively,243 and 296 (p = 0.001); 3.47 and 4.59 (p = 0.002); and 269and 338 (p < 0.001). There was a significant correlationbetween plasma B₁₂ and RCF in cases (r = 0.31, p = 0.004) butnot in controls (r = 0.02, p = 0.725). In cases only, multipleregression showed that both plasma B₁₂ and plasma folate influencedthe maternal RCF (multiple r = 0.68, p < 0.001). Plasma folateand plasma B₁₂ were independent risk factors for NTDs, suggestingthat the enzyme methionine synthase is involved directly orindirectly in the aetiology. The levels of folate and B₁₂ whereincreased risk occurred were not those usually associated withdeficiency, calling for a re-evaluation of their recommendeddaily allowances. Whether the aetiology is purely nutritionalor a metabolic defect, this study suggests that considerationshould be given to including B₁₂ as well as folic acid in anyprogramme of supplementation or food fortification to preventNTDs.     

Maternal plasma folate and vitamin B12 are independent risk factors for neural tube defects

Blood was taken at the first antenatal clinic from 56049 pregnantwomen. Neural tube defect (NTD) pregnancies (81) were comparedto controls (247) for plasma vitamin B₁₂ (B₁₂) (ng/l), plasmafolate (µg/1), and red cell folate (RCF) (µg/l).Median values were significantly different and were, respectively,243 and 296 (p = 0.001); 3.47 and 4.59 (p = 0.002); and 269and 338 (p < 0.001). There was a significant correlationbetween plasma B₁₂ and RCF in cases (r = 0.31, p = 0.004) butnot in controls (r = 0.02, p = 0.725). In cases only, multipleregression showed that both plasma B₁₂ and plasma folate influencedthe maternal RCF (multiple r = 0.68, p < 0.001). Plasma folateand plasma B₁₂ were independent risk factors for NTDs, suggestingthat the enzyme methionine synthase is involved directly orindirectly in the aetiology. The levels of folate and B₁₂ whereincreased risk occurred were not those usually associated withdeficiency, calling for a re-evaluation of their recommendeddaily allowances. Whether the aetiology is purely nutritionalor a metabolic defect, this study suggests that considerationshould be given to including B₁₂ as well as folic acid in anyprogramme of supplementation or food fortification to preventNTDs.     

Haemostatic Changes in the Loin Pain and Haematuria Syndrome: Secondary to Renal Vasospasm?

Twenty-five patients (seven male, 18 female) were diagnosedas having the loin pain and haematuria syndrome. Presentingsymptoms were either loin pain alone or pain associated withmacroscopic or microscopic haematuria, and were longstanding,having been present for mean of 9.3 years in males, and 10 yearsin females. Ten patients described symptoms of passing gravelor renal stones but these were only demonstrated radiologicallyin two patients. Investigation of all patients showed anatomicallynormal renal tracts, normal renal function, and no significantproteinuria. Phase-contrast microscopy during episodes of haematuriarevealed dysmorphic red cells in all 10 patients studied. Renalbiopsies were performed in 20 patients and showed no glomerularpathology, but arteriolar and arterial hyalinosis was seen in13 of 20 (65 per cent), fibro-elastosis in larger vessels ineight of 20 (40 per cent) and red blood cells in tubules in13 of 20 (65 per cent) patients. The histological appearancein vessels was similar to that seen in cyclosporin A nephrotoxicityand would be consistent with the hypothesis that regional vasospasmoccurs in the cortical circulation. Haematological studies in22 patients, when compared with age and sex matched controls,showed the presence of circulating platelet aggregates, elevationof plasma ß-thromboglobulin (p < 0.001), and increasedplatelet aggregation in response to serotonin and ADP (p <0.05 and p < 0.03, respectively). Plasma concentrations ofD dimer (p < 0.02) and C-reactive protein (p < 0.03) werealso significantly elevated in the patient group. There wasno deterioration of renal function during a mean observationperiod of 3.7 years and no patients developed proteinuria. Treatmentwas largely supportive; seven patients with intractable loinpain underwent surgical denervation with the relief of painin four.     

Transvaginal color and pulsed Doppler study of uterine blood flow in the first and early second trimesters of pregnancy: normal versus abnormal.

Transvaginal color Doppler ultrasonography was used to study 131 normal early pregnancies, 30 molar pregnancies, 20 threatened abortions, two blighted ova, and five pregnancies with intramural myoma. Four separate parts of the maternal circulation were studied: uterine, arcuate, radial, and spiral arteries. There was statistical difference in the RI and PI among uterine, arcuate, radial, and spiral arteries (P < 0.001) in all observed groups of patients except those with intramural myoma. When the same part of the maternal circulation was compared among different groups of patients, the following results reached statistical significance: uterine artery in normal and molar pregnancy (P < 0.001); arcuate artery in normal and molar pregnancy (P < 0.001); radial artery in normal and molar pregnancy (P < 0.001) and in normal pregnancy and threatened abortion (P < 0.01); spiral artery in normal and molar pregnancy (P < 0.001), in normal pregnancy and threatened abortion (P < 0.01), and in molar pregnancy and threatened abortion (P < 0.01). The standard values of blood flow are different in normal and in some cases of abnormal early pregnancy (molar pregnancy, threatened abortion).