Obstetric infections

Maternal infections are unique because of their implications for the outcome of pregnancy. Bacterial infections that can be favorably influenced by prompt diagnosis and preventive management include urinary tract infections and chorioamnionitis. However, viral infections such as genital herpes and cytomegalovirus, and the parasitic disease toxoplasmosis, require specialized forms of testing and a complicated management plan. Altered physiological and immunological states during pregnancy are important in understanding the pathophysiology of maternal infections.     

Obstetric cholestasis

The field of orthopaedic surgery has changed rapidly in the last ten years, increasing the demand for a readily available supply of allograft. Historically, bone was first grafted in 1668. The first clinical allograft was performed in 1820 by Phillips von Walter who reconstructed part of a skull. Clinical use of allograft has developed steadily during this century, making it now an essential requirement in orthopaedic surgery. Nationally, there is a shortage of available allograft for orthopaedic procedures. Allograft bone can be used in spinal fusion, filling of bone cysts, non-union of fractures and, most commonly, in revision joint replacements. In the last twenty years joint replacement surgery has become common practice and the number of patients requiring revision joint surgery has also increased. This expansion will continue owing to the growing demands made on our health service by our increasingly elderly population. We can expect an increase in demand for allograft.     

Obstetric risk assessment

Obstetric risk assessment is an important component of comprehensive obstetric care. It is a tool used to evaluate the medical, psychosocial, familial, and environmental factors that increase the chance of an adverse outcome. Such outcomes may involve the mother, the infant, or both. Risk assessment collects and organizes data obtained from a pertinent history, physical examination, and laboratory assessment into an accurate and easily retrievable medical record. It can be used to adapt diagnostic or therapeutic management plans, arrange consultation or shared care with another specialist, or tailor anticipatory guidance and patient and family education.     

Obstetric deaths in Lusaka

A detailed study of the obstetric services in Lusaka is presented. The maternal and perinatal mortality rates for 1976 were estimated at 1.7 and 55.1 per 1000 live births respectively. The persistent increase in mortality suggests a fall of accepted standards of maternity care. The causes of deaths are discussed. Avoidable factors were identified in 79.6% of the maternal deaths and 49.1% of the stillbirths. Recommendations are made for a more integrated type of maternity service, provisions of maternity centres, education programmes for the public and a more thorough perinatal care. Only a concerted effort of this nature will eventually result in a satisfactory progress in the obstetric services and a reduction of obstetric deaths and morbidity.     

Pulmonary defence mechanisms

Renal involvement occurs in the majority of patients with systemic lupus erythematosus. Contemporary therapeutic regimens for immunosuppression and for the treatment of hypertension, hyperlipidemia, infections, and seizures have likely contributed to improvements in the prognosis of these patients over the last four decades. Corticosteroids usually ameliorate the manifestations of lupus nephritis but achieve less complete and sustained remissions than do cytotoxic drugs. Among the cytotoxic drugs, pulse cyclophosphamide has one of the best profiles of efficacy and toxicity. Because each episode of exacerbation of lupus nephritis results in cumulative scarring, atrophy and fibrosis, we recommend continued maintenance treatment for 1 year beyond the point of complete remission of proliferative lupus nephritis. Studies are in progress to determine whether innovative treatment strategies will enhance efficacy and minimize toxicity associated with cytotoxic drug therapies. Lupus membranous nephropathy poses a lower risk of renal failure, but persistent nephrotic syndrome confers risks of cardiovascular events; this form of lupus nephritis is usually treated with less intensive regimens of corticosteroids, cytotoxic drugs, or cyclosporine. The prognosis and overall success of treatment for lupus nephritis seem to vary widely among geographically and racially diverse populations. The causes for the apparently worse prognosis and poorer responses to treatment of lupus nephritis in Black patients are currently unexplained and require further study. Until such data are available, caution is clearly warranted in extrapolating evidence, particularly about prognosis and effects of treatment, among different populations of patients with lupus nephritis.     

Obstetric and gynecologic emergencies

This article reviews the pearls and pitfalls of obstetric and gynecologic emergencies occurring in women presenting to the emergency department. Some pitfalls include failure to screen for ectopic pregnancy, tachycardia as an unreliable indicator of a ruptured ectopic pregnancy, and the use of serum hCG as a testing procedure during pregnancy. Updates include serologic markers of ectopic pregnancy, ultrasonography in the emergency department, methotrexate treatment of ectopic pregnancy, traumatic placental separation, and fetomaternal hemorrhage.     

Evaluation of elite British cyclists: the role of the squad medical

Haptoglobin (Hp), a hemoglobin-binding protein, is known as an acute phase protein increasing in blood during inflammation in most mammals. On the basis of our previous studies on purification and characterization of bear Hp (Comp. Biochem. Physiol. 110B, 785-789, 1995), in this study, we developed an immunoassay method to measure serum Hp level in bear, and measured the concentration of Hp in blood samples collected from 84 reared and 25 wild brown bears in Hokkaido, Japan. The mean serum Hp concentration was 0.94 +/- 0.25 mg/ml in wild bears, which is nearly equal to those reported in other species. In reared bears, the Hp concentration was apparently higher (3.82 +/- 0.29 mg/ml), although total protein and albumin concentrations were nearly equal in the two groups. A significant seasonal variation of serum Hp, low in spring and high in autumn and winter, was found in reared bears. Possible factors participating in the seasonal variation were discussed with special references to hibernation.     

Obstetric Doppler--justified i high-risk pregnancies

Doppler ultrasound is a well established technique for evaluating impedance to blood flow. A review of current literature in the field yields convincing support for the use of obstetric Doppler ultrasonography in the management of high-risk pregnancies. By measuring the pulsatility index of Doppler blood flow velocity waveforms in the umbilical and uterine arteries, it is possible to obtain accurate information on the placental circulation. Meta-analysis of 12 randomised studies showed perinatal mortality to have been significantly reduced as a result of Doppler measurements of umbilical artery blood flow in high-risk pregnancies. However, every technique has its limitations, and it should be borne in mind that even if fetal hypoxia is often revealed by an abnormal Doppler ultrasound result before the cardiotocography pattern becomes abnormal, it is nonetheless a late sign. It is concluded in the article that Doppler ultrasonography needs to be combined with other methods, such as the measurement of biochemical markers, to ensure satisfactory fetal monitoring.     

Obstetric outcome of teenage pregnancies

A retrospective cohort study was performed in a tertiary centre to determine if teenage nulliparas (aged alpha19 years, study group) had higher incidences of instrumental and Caesarean deliveries compared with nulliparas aged 20-34 years (control group) selected from the first women in the birth registry who delivered after each study case and satisfying the criteria for controls. The hospital records of the study and control cases were retrieved for review. Comparison was made in the maternal demographics, major antenatal complications, outcome of labour, mode of delivery, and perinatal outcome. In the study group, maternal height was similar but the body mass index was lower. Although the mean birthweight was lower and the incidences of preterm labour and small-for-gestational-age infants higher, there were also increased incidences of large-for-gestational-age and macrosomic infants. While there was no difference in the types of labour, there were fewer Caesarean and instrumental deliveries, a finding that persisted even after excluding the preterm deliveries. Lastly, teenage mothers aged <17 years had similar outcomes to those aged 17-19 years. These results indicated that teenage mothers had better obstetric outcomes, despite the higher incidence of preterm labour, and that young adolescents (<17 years) performed as well as their older peers.     

In defence of humanitarianism

Muscular changes in male forest machine operators with work-related neck and shoulder myalgia were studied. Enzyme cyto- and immunohistochemical analysis was carried on muscle biopsies obtained from ten myalgic subjects (M), nine non-myalgic selected in the same work place (NM) and six healthy young men (C). The M group displayed a significant increase in type IIA fibres in comparison to the C group. This hypertrophy was accompanied by a parallel increase in the capillary bed. Both the M and NM groups exhibited an increase in fibres with a disorganised mitochondrial pattern. Interestingly, fibres lacking cytochrome c oxidase occurred in the M group (0.9%) but also in the NM group (0.5%), suggesting a mitochondrial defect. Central nuclei (5.2%) and developmental myosin (3%) were also more frequent in the M group. These changes are probably related to injury-regeneration cycles. These data support the association between the work conditions and muscle changes in work-related trapezius myalgia.     

Obstetric complications of antiphospholipid antibodies

Upper-eyelid retraction is a common sign of thyroid-associated eye disease (TAED), and these patients are highly bothered by the appearance of their eyes. In this study, botulinum toxin A (BTA) was injected into the levator palpebrae superioris muscle in 8 eyes of 4 patients in an attempt to control the abnormal elevation of the upper eyelid. BTA provided control of the upper-eyelid retraction, and the cosmetically acceptable effect lasted for 3-4 months. It was concluded that BTA is an effective method of treatment in this condition. Since it has a temporary effect, it can safely be used to provide relief of symptoms related to upper-eyelid retraction during unstabilized periods of TAED, which may last as long as several years in some patients.