Endogenous hypertriglyceridemia intensifies the course of cerulein-induced pancreatitis in rat: relation with changes in the VLDL composition.

AIMS: To study if the course of cerulein-induced pancreatitis in rats changes in a state of triglyceride-rich lipoprotein metabolism alteration. METHODS: Two groups of rats received control diet during a 90-day period (A) and sucrose-rich diet to induce endogenous hypertriglyceridemia (B). Subgroups A2 and B2 received i.p. 45 microg cerulein/kg body weight (to induce acute pancreatitis). Histological examination of pancreas tissue, serum pancreatic lipase, lipoprotein profile and VLDL chemical composition were assessed. Then, pancreatic lipase hydrolytic activity on VLDL-triglycerides was evaluated in vitro. RESULTS: Cellular vacuolization was observed in all of the cerulein-injected rats, but only in subgroup B2 fat necrosis was present. Serum triglycerides were higher in subgroup B1 than in subgroup A1 (mean +/- SEM, mg/dl 123,77 +/- 25.7 vs. 65.8 +/- 7, p < 0.01). Triglycerides from rats fed with sucrose-rich diet, decreased after cerulein-induced pancreatitis (80.38 +/- 11.3 vs. 123,77 +/- 25.7, p < 0.02). Moreover, the endogenous hypertriglyceridemic rats showed an increment of VLDL triglyceride content, which decreased when rats were injected with cerulein. A negative correlation was found between VLDL-triglyceride content and serum pancreatic lipase activity (r = 0.58, p < 0.02). The in vitro assay showed a decrease in VLDL-triglyceride content post incubation with pancreatic lipase enriched serum (mean +/- SD: 59.2 +/- 27.7%, p < 0.01). CONCLUSIONS: The endogenous hypertriglyceridemia intensifies the course of cerulein-induced pancreatitis and it could be related to the decrease in VLDL-triglycerides as a consequence of pancreatic lipase hydrolytic activity.

HELLP syndrome and cholecystitis: case report and review of the literature.

A case of the HELLP syndrome is reported that was initially diagnosed as cholecystitis. Much overlap exists between the two diagnoses, and the emergency physician must be aware of the important differences between them. Because the HELLP syndrome and preeclampsia may occur in both the second and third trimesters, they represent serious diagnoses that must be considered when evaluating a pregnant patient with right upper quadrant abdominal pain.

Maternal characteristics and risk of severe neonatal thrombocytopenia and intracranial hemorrhage in pregnancies complicated by autoimmune thrombocytopenia.

OBJECTIVE: The antenatal and intrapartum management of women with autoimmune thrombocytopenia is controversial. The current approach emphasizes an effort to identify maternal characteristics predictive of severe neonatal thrombocytopenia or to measure fetal platelet counts and perform cesarean section in patients considered to be at risk for neonatal intracranial hemorrhage. In the current study we review our experience with maternal autoimmune thrombocytopenia and neonatal outcome. STUDY DESIGN: Fifty-five pregnancies with autoimmune thrombocytopenia over a 10-year period in three major medical centers in San Diego, California, were evaluated. Maternal characteristics and neonatal outcomes were assessed and compared with those in other recent reports. Data were submitted to Fisher's exact (two-tailed), chi2, and Student t tests, with linear regression performed to analyze the association between variables. RESULTS: Maternal characteristics including platelet count, presence of antiplatelet antibody, antecedent history of autoimmune thrombocytopenia, and corticosteroid therapy were not predictive of severe neonatal thrombocytopenia. Maternal history of splenectomy was significantly correlated with fetal platelet counts <50 x 10(9)/L (odds ratio 5.63; 95% confidence interval 2.2 to 14.3). There were four neonates with severe neonatal thrombocytopenia (8%), and one who was delivered by cesarean section had intracranial hemorrhage. CONCLUSIONS: These findings, combined with others in the literature, confirm that severe neonatal thrombocytopenia is an infrequent complication of maternal autoimmune thrombocytopenia and is not reliably predicted by maternal characteristics. Intracranial hemorrhage is also a rare event and is not related to mode of delivery. Cesarean section should be reserved for obstetric indications only.

[Cerulein-induced acute pancreatitis enhanced by chronic hyperlipidic diet in the rat]. / La dieta hiperlipídica crónica intensifica la pancreatitis aguda inducida por ceruleina en la rata.

The object of the present work was to study the relationship between acute pancreatitis (PA) and hyperlipidic diets. PA was induced by Caerulein (CE) by a single intraperitoneal doses (50 mcg/kg), after feeding the rats during 6 weeks with an hyperlipidic diet (45%). Rats with a normolipidic diet (lipids 5%) were used as control. The increase of serum lipase was similar in both groups treated with CE (control and with hyperlipidic diet). There were increase of interstitial edema, cariorrexis and a specially marked increase in the level of vacuolization of acinar cells with respect to the control group. It was concluded that chronic hyperlipidic diet increases histopathologic lesions in PA induced by CE in rats.

Reactivation of coccidioidomycosis in pregnancy.

A woman presented in the third trimester with a recurrence of coccidioidomycosis. She had been treated 5 years earlier for coccidioidal meningitis. We induced delivery, and both mother and infant had favorable outcomes. We believe that this case represents a reactivation of the previously treated disease.

Angiographic embolization in the management of hemorrhagic complications of pregnancy.

Obstetric hemorrhage continues to be a major cause of maternal mortality and morbidity. Recent developments in percutaneous angiographic embolization techniques have afforded the ability to control persistent bleeding from pelvic vessels while avoiding the morbidity of surgical exploration. We report the use of angiographic embolization in 10 cases of pregnancy-related hemorrhage, including persistent postcesarean bleeding (three cases), vaginal wall hematomas (four cases), cervical ectopic pregnancies (two cases), and postpartum bleeding as a secondary complication of uterine myomas (one case). The embolization procedures were successful in all cases. Nine of 10 patients experienced postprocedural fever with eight cases resolving with antibiotic therapy alone and one patient requiring vaginal drainage of the hematoma-abscess. The mean length of time for the procedure was 167 minutes (range 70 to 270). The average length of hospitalization was 8 days (range 2 to 13). These data indicate that angiographic embolization is effective in treating hemorrhagic complications of pregnancy in hemodynamically stable patients and is preferable to surgery in selected cases.

Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants: a preliminary procedural report.

Partially edentulous patients with alveolar defects contraindicating implant placement were treated with bone grafts obtained from the mandibular symphysis. Complications encountered were minor and uneventful. Evaluation 4 months after surgery revealed minimal graft resorption, thus implant placement was possible in all potential sites. Advantages of the symphysis graft include easy access, availability of greater quantities of bone over other intraoral donor sites, low morbidity, no hospitalization, minimal discomfort, no alteration in ambulation, and no cutaneous scar. Compared with other bone regenerative methods for implant placement, a superior quality of bone was found and a shorter healing period is required. Results of this preliminary clinical investigation demonstrate that chin grafts offer a viable alternative for reconstruction of alveolar defects prior to dental implant placement.

Post-operative maxillary cyst associated with a maxillary sinus elevation procedure: a case report.

Proper diagnosis, treatment planning, and surgical manipulation of the posterior maxilla require a thorough knowledge of the anatomy, physiology, and pathology associated with the maxillary sinus. This case report of a post-operative maxillary cyst diagnosed following routine post-operative examination of a sinus elevation procedure illustrates the need for a meticulous surgical technique, proper management of complications, and routine, long-term follow-up. With the increased utilization of sinus elevation techniques, reports of this destructive lesion may become more common.

A reappraisal of the need for autologous blood donation in the obstetric patient.

There has been recent interest in autologous blood donation in obstetric patients, but little attention has been paid to whether such programs are needed or whether the patients that will require transfusion can be accurately predicted. At the University of California San Diego Medical Center from July 1 to Dec. 31, 1988, there were 2265 deliveries; 13 women (0.57%) received blood transfusions. Traditionally accepted risk factors were identified in 251 patients, with only four (1.6%) requiring transfusion. Among the 150 patients delivered by repeat cesarean section, only one (0.7%) required blood. one of 27 (3.7%) multiple gestations, two of eight (25%) patients with placenta previa, and none of the 66 grandmultiparous women had transfusions. These data suggest that autologous blood donation may not be beneficial or cost effective when the low frequency of blood transfusions in this high-risk obstetric population and the difficulty in accurately predicting those likely to require transfusions are considered.

The association of maternal floor infarction of the placenta with adverse perinatal outcome.

Maternal floor infarction of the placenta is a relatively rare disorder that on gross examination is characterized by a thickened gray-yellow maternal floor of the placenta with histologic evidence of massive fibrin deposition involving the decidua basalis and the contiguous villi. This lesion has been associated with fetal death, preterm delivery, and intrauterine growth retardation and is thought to be recurrent. Sixty cases of maternal floor infarction were identified in 48 women. Fetal death occurred in 24 of the 60 cases (40%). Preterm birth occurred in 21 of 36 (58.3%) live-born infants, and 19 of the 35 (54.2%) live-born infants for whom a birth weight was known had evidence of intrauterine growth retardation. Among the 41 multiparous patients in our series there were five documented recurrences (12.2%). Review of the past reproductive history of these 48 patients (196 pregnancies) demonstrated a significant incidence of fetal death (24.1%), intrauterine growth retardation (31.3%), and preterm death (35.4%). The association of fetal death and maternal floor infarction emphasizes the importance of a placental examination with all cases of fetal death and infants with intrauterine growth retardation. Given the risk of recurrence, the identification of maternal floor infarction should alert the clinician to the potential for growth retardation, preterm birth, and fetal death in subsequent pregnancies.

Lack of specific placental abnormality associated with cocaine use.

Detailed gross and histologic examinations were performed on 13 placentas from pregnancies complicated by maternal cocaine use. There were no characteristic changes in placental morphologic features that would explain the increased morbidity associated with cocaine use. It is likely that cocaine exerts its deleterious effects through acute or chronic pathophysiologic changes rather than alterations in placental architecture.

Antenatal origin of neurologic damage in newborn infants. II. Multiple gestations.

Necrosis of the cerebral white matter may be identified in living infants with echoencephalography. Echoencephalographic studies were performed in 89 twins and 12 triplets at less than 36 weeks of gestation to determine the incidence and complications associated with antenatal necrosis of the cerebral white matter. Antenatal necrosis of the cerebral white matter was identified when brain atrophy or cavities in the white matter were present by day 3 of life. Fourteen infants (13.8%) were considered to have antenatal necrosis of the cerebral white matter. The incidence of antenatal necrosis of the cerebral white matter was higher in monochorionic than in dichorionic infants (30% vs 3.3%; p less than 0.001). Univariate analysis showed that antenatal necrosis of the cerebral white matter was significantly associated with polyhydramnios, intrauterine fetal death of the cotwin, hydrops, multiple placental vascular connections, and placental artery-to-artery, vein-to-vein, and artery-to-vein anastomosis. Logistic regression analysis showed that antenatal necrosis of the cerebral white matter was predicted by the presence of either artery-to-artery or vein-to-vein anastomosis and by intrauterine fetal death of a cotwin. Vein-to-vein anastomosis had the strongest association, because 89% of seven infants with vein-to-vein anastomosis demonstrated antenatal necrosis of the cerebral white matter (p = 0.003). Monochorionic multiple gestations frequently are complicated by antenatal necrosis of the cerebral white matter. Multiple vascular connections with vein-to-vein anastomosis appear as the most important associated factor for antenatal necrosis of the cerebral white matter in this population.

The "elderly primigravida" in 1990.

PIP: This editorial addresses the issues raised by Berkowitz and her coworkers, who studied the pregnancy outcome of 3917 primiparous women (women who are 30 years or older and pregnant for the 1st time). The study found that this population had a slight increased risk of delivering low birth weight infants, and no increased risk in having a small for gestational age infant, an infant with low Apgar scores, or one which died in the perinatal period. Also, the study population presented with a higher rate of antepartum complications, and a substantial increased likely hood of a cesarian section for women who are older that 35 years. The author argues that the data presents encouraging news to women in their 30's and are contemplating their 1st pregnancy. Although other studies have shown that older women are more likely to deliver infants with chromosomal abnormalities, it should be noted that advances in genetic diagnosis provide women with accurate information to permit them to make necessary decisions. However, Berkowitz's findings should be interpreted with the limitation of the characteristics of the studied population, who were private patients, predominantly white, married, college educated and non-smoking.^ieng

Angiographic embolization of intractable puerperal hematomas.

Puerperal hematomas may not respond to conventional therapy, including vaginal packing, drainage, and hypogastric artery ligation. Two cases are presented in which selective angiographic arterial embolization was used to manage this potentially lethal complication.

Successful pregnancy after cardiac transplantation.

A case report of a successful pregnancy after cardiac allotransplantation is presented. The patient underwent transplantation for an inoperable cardiac tumor 5 years before conception. Cardiac function before and during all stages of pregnancy was normal. Maintenance immunosuppressive therapy consisting of prednisone and azathioprine was continued through gestation. The pregnancy was complicated by a primary herpes virus infection requiring parenteral acyclovir treatment and a single episode of preterm labor that was successfully treated. The infant was born at term, weighed 3278 gm, and has developed normally during the first 3 years of life. The patient died 5 months after delivery as a result of an acute immunologic rejection 5 months post partum caused by self-initiated discontinuation of immunosuppressive therapy. Preconceptional counseling and pregnancy care guidelines are discussed.

Antenatal origin of neurologic damage in newborn infants. I. Preterm infants.

Currently, the diagnosis of white matter necrosis may be performed with echoencephalography when cysts are observed in the white matter adjacent to the lateral ventricles. One hundred twenty-seven infants with a gestational age less than 36 weeks (mean [+/- SE] gestational age = 31 +/- 3.2 weeks) were studied in the neonatal period with echoencephalography to determine the incidence of white matter necrosis and the perinatal variables associated with this complication. Twenty-three infants (18.3%) had white matter necrosis. Thirteen (10.3%) had cysts by day 3 (11 on day 1), indicating that the onset of white matter necrosis occurred antenatally. The incidence of antenatal white matter necrosis was inversely related to birth weight and was more frequent in infants weighing less than 1000 gm (19%). Stepwise logistic regression analysis of 31 antenatal variables showed that placental vascular anastomoses in multiple pregnancies, funisitis, and purulent amniotic fluid were the only complications associated with antenatal white matter necrosis. Follow-up neurologic evaluations were abnormal in four of six patients with antenatal white matter necrosis. The findings in this study focus attention on prenatal, rather than intrapartum and postnatal, factors as causative agents of neurologic morbidity and emphasize the importance of early and sequential evaluation of neonatal brain structures.

Hemodynamic effects of intravenous cocaine on the pregnant ewe and fetus.

Cocaine is a potent vasoconstrictive agent that is currently the subject of widespread drug abuse. Because little is known of the physiologic responses to cocaine in pregnancy, the effects of intravenous cocaine on uterine blood flow and other maternal and fetal cardiovascular parameters were studied. Eight ewes in late pregnancy were equipped with electromagnetic flow probes around both uterine arteries and catheters were placed in the maternal and fetal inferior vena cavae and aortas. Bolus intravenous infusion of 0.5 and 1.0 mg/kg of maternal body weight achieved peak plasma cocaine levels similar to those observed in human subjects after abuse of the drug (mean level = 229 to 400 ng/ml, n = 8). After bolus infusion of 0.5 or 1.0 mg/kg of cocaine, mean maternal arterial pressure increased 32% and 37%, respectively (p less than 0.005). Fetal blood pressure rose 12.6% after a dosage of 0.5 mg/kg of cocaine. These cocaine infusions significantly decreased uterine blood flow by 36% and 42% for a duration of 15 minutes (p less than 0.005). Analysis of maternal catecholamine responses demonstrated a significant (210%) rise in plasma norepinephrine levels after cocaine infusion. These studies demonstrate that cocaine, when administered in doses that produce plasma levels observed in humans, significantly decreases uterine blood flow for a duration of greater than or equal to 15 minutes while inducing a hypertensive response in the pregnant ewe and fetus.

The perinatal and economic impact of prenatal care in a low-socioeconomic population.

Reductions in publicly funded prenatal care programs in 1981 to 1984 resulted in an increase in unregistered patient deliveries from 7.8% to 14.9% of births at University of California San Diego Medical Center. To assess the economic and perinatal impact of the increasing number of deliveries of women without prenatal care, 100 consecutive patients with fewer than three prenatal visits were studied. Each "no care" patient was matched by age, parity, and week of delivery with a control patient who received care in a state-funded perinatal project (Comprehensive Perinatal Program). Maternal antenatal risk factors were equally distributed between the two groups when maternal age, parity, history of substance abuse, prior preterm delivery, hypertension, and abortion were compared. Maternal obstetric outcomes were similar, including cesarean section rate and incidence of postpartum fever and hemorrhage. However, neonates delivered of women receiving no care experienced significantly greater morbidity than the neonates of women in the Comprehensive Perinatal Program, including an increased incidence of premature rupture of the membranes and preterm delivery (13% versus 2%, p less than 0.05), low birth weight (21% versus 6% less than 2500 gm, p less than 0.002), and intensive care unit admissions (24% versus 10%, p less than 0.005). When the total inpatient hospital charges were tabulated for each mother-baby pair, the cost of perinatal care for the group receiving no care ($5168 per pair) was significantly higher than the cost for patients in the Comprehensive Perinatal Program ($2974 per pair, p less than 0.001) including an antenatal charge of $600 in the Comprehensive Perinatal Program. The excess cost for delivery of 400 women receiving no care per year in the study hospital was $877,600. These results suggest that extension of prenatal care programs to medically indigent women is likely to result in a net reduction in perinatal morbidity and health care expenditures.