Pregnancy outcome following recurrent spontaneous abortions

OBJECTIVE: The purpose of the present study was to examine the association between spontaneous consecutive recurrent abortions and pregnancy complications such as hypertensive disorders, abruptio placenta, intrauterine growth restriction and cesarean section (CS) in the subsequent pregnancy. METHODS: A population-based study comparing all singleton pregnancies in women with and without two or more consecutive recurrent abortions was conducted. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 154,294 singleton deliveries occurred, with 4.9% in patients with history of recurrent consecutive abortions. Using a multivariate analysis, with backward elimination, the following complications were significantly associated with recurrent abortions-advanced maternal age, cervical incompetence, previous CS, diabetes mellitus, hypertensive disorders, placenta previa and abruptio placenta, mal-presentations and PROM. A higher rate of CS was found among patients with previous spontaneous consecutive recurrent abortions (15.9% versus 10.9%; OR = 1.6; 95% CI, 1.5-1.7; P < 0.001). Another multivariate analysis was performed, with CS as the outcome variable, controlling for confounders such as placenta previa, abruptio placenta, diabetes mellitus, hypertensive disorders, previous CS, mal-presentations, fertility treatments and PROM. A history of recurrent abortion was found as an independent risk factor for CS (OR = 1.2; 95% CI, 1.1-1.3; P < 0.001). About 58 cases of inherited thrombophilia were found between the years 2000-2002. These cases were significantly more common in the recurrent abortion as compared to the comparison group (1.2% versus 0.1%; OR = 11.1; 95% CI, 6.5-18.9; P < 0.001). CONCLUSION: A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions. Careful surveillance is required in pregnancies following recurrent abortions, for early detection of possible complications.     

Erythropoietin concentration among patients with and without preeclampsia

Purpose: Controversy exists in the literature regarding the association between erythropoietin levels and preeclampsia. This study was aimed to compare serum erythropoietin concentrations among patients with and without preeclampsia. Material and methods: A prospective study was designed and two groups were defined: 22 patients with preeclampsia (study group) and 19 normotensive patients (control group). Preeclampsia was defined as blood pressure higher than 140 mmHg systolic or 90 mmHg diastolic and proteinuria >300/24 h or dipstick >1. Women in the control group were matched for gestational age. Blood was collected in tubes containing EDTA, and centrifuged in 4°C within 30 min of collection. Serum erythropoietin level was determined by ELISA (R&D Systems, Inc. Minneapolis, USA). Statistical analysis was performed using the SPSS package. Results: Erythropoietin concentration was higher among patients with preeclampsia, but did not reach significance (24.8±8.9 mU/ml vs. 19.9±9.9 mU/ml; P-0.19). Also, hemoglobin and hematocrit levels were similar in both groups (12.0±4.2 g/dl vs. 11.6±3.9 g/dl; P-0.16 and 36.5±10.8% vs. 35.3±11.4%; P-0.13, respectively). Conclusions: A nonsignificant trend towards higher maternal serum levels of erythropoietin was demonstrated among patients with preeclampsia. Further prospective studies are needed to investigate the association between preeclampsia and erythropoietin.     

Pneumothorax in pulmonary eosinophilic granuloma

The cases are described of two patients with pulmonary eosinophilic granuloma who presented with spontaneous pneumothorax. Prolonged air leak and recurrence of the pneumothorax after initial re-expansion of the lung occurred in both patients. In one of the patients the pneumothorax was simultaneously bilateral and almost complete.

Thoracotomy, with aggressive and total pleurodesis, is recommended in the management of these patients to prevent recurrence and complications. Lung biopsy should be performed in all patients undergoing thoracotomy for recurrent pneumothorax.

     

Predicting individual phenytoin dosage

Most previously suggested methods for predicting phenytoin dosage from steady-state drug levels (Cpss)measured in the clinical setting fail to fully exploit all relevant (population) information. A Bayesian prediction method, applicable to any drug, is available. It appropriately combines all types of information. In this paper, we compare the Bayesian method as applied to phenytoin to two other prediction methods (and a baseline, nonfeedback one). Actual doses are compared to predictions in 49 patients. Each method is optimized, as far as possible, for the test data. The comparison favors the Bayesian method. Since each of the other prediction methods for phenytoin can be shown to be a theoretically suboptimal special case of the Bayesian one, the superiority of the latter may be a general phenomenon. Because the pharmacokinetic model linking steady-state phenytoin levels and dosage is so simple, a good approximation of the general Bayesian method can be implemented as a graphical device, or as a program for a programmable calculator. We present and describe both of these approximations.Work supported in part by USDHEW Grants GM 00001, GM 16496, and GM 26676, and by the Swiss National Research Foundation.     

Gas in the Portal Vein: A Report of Two Cases

Gas in the portal venous system was detected on plain roentgenograms of the abdomen in two women aged 61 and 72 years, respectively. Both patients had intestinal necrosis, due in one instance to a small bowel volvulus around a mesenteric band, and in the second instance to occlusion of the celiac axis, superior and inferior mesenteric arteries. In the first patient, the portal venous gas was detected before surgery, and in the second case the gas was observed at laparotomy and was visualized on radiographs of the abdomen taken shortly after death. Both patients died. Portal venous gas can be distinguished radiologically from air in the bile ducts by its characteristic slender branching gas pattern in the periphery of the liver substance. The presence of portal gas in the adult indicates intestinal necrosis in the majority of cases and should lead to early operative intervention.     

Fine-needle aspiration cytology in the management of breast disease

The results of a series of fine needle aspiration biopsies of breast lumps were reviewed to evaluate the accuracy of this diagnostic method and its place in the clinical management of breast lesions. A high level of diagnostic accuracy was achieved. There were no false positive diagnoses of malignancy and fewer than 3% of diagnoses were falsely negative. Eighty per cent of carcinomas could be confidently diagnosed by means of cytological investigation. The patient with a benign cytological diagnosis can either be reassured, or her surgical management planned as a day case. For the patient with a cytological diagnosis of malignancy, discussion of the nature of her surgery and subsequent care is possible before operation. In selected cases of carcinoma, mastectomy can be performed without frozen-section confirmation. Diagnostic accuracy is dependent upon experience, especially in aspiration technique, and optimum results are obtained if the pathologist/cytologist also performs the procedure.     

Nephrolithiasis during pregnancy: characteristics, complications, and pregnancy outcome

Purpose  

To evaluate obstetric complications and birth outcome in pregnant women with nephrolithiasis.     

Liver graft failure and hyperbilirubinemia in liver transplantation recipients after Clostridium difficile infection

Introduction

Liver transplant recipients are at high risk for Clostridium difficile infection. We have recently encountered multiple cases of CDI in our liver transplant recipients and for some of them it led to severe hyperbilirubinemia, liver failure, and even death. Our goals are to report our experience and analyze the factors that contributed to unfavorable outcomes.

Material and Methods

All liver transplant recipients diagnosed with CDI between December 1, 2007, and January 30, 2009, were included and retrospectively reviewed.

Results

Twenty-four patients were identified, 14 men and 10 women. Fourteen patients experienced hyperbilirubinemia after the infection and 7 progressed to liver failure. Pre-CDI biopsy-proven liver abnormality, use of extended-criteria donors (ECDs) and a donor risk index (DRI) greater than 1.9 were associated with a higher risk of graft failure (P < .05). Hepatitis C, inpatient versus outpatient diagnosis, and a donor age greater than 50 years were not associated with a higher risk of graft failure. Use of ECDs and timing of the infection at more than 1 month but less than 1.5 years posttransplant were also associated with higher chances of sustained hyperbilirubinemia (P < .05).

Conclusion

CDI in liver transplant patients can be very serious and may lead to sustained hyperbilirubinemia or graft failure. Marginal grafts are more susceptible to decompensate after such an infection than standard criteria grafts; moreover, already abnormal grafts do not tolerate this infection well and decompensate to complete failure in 85% of the cases.