Pharmacology of the endocrine pancreas, adrenal cortex, and female reproductive organ

It is estimated that there are up to 14 to 15 million diabetics in the United States and that many are unaware of their condition. Millions of women will become pregnant each year, although many will take oral contraceptives to prevent pregnancy. Thousands of patients are prescribed chronic doses of glucocorticoid medications every year. Many of these patients can be expected to seek some degree of dental care. The dentist must have a basic understanding of the physiologic changes associated with each of these endocrinological conditions to provide safe and appropriate dental care.     

Liver disease in pregnancy

The liver is one of the many organs affected by the physiologic and hormonal changes that occur during pregnancy. Hepatic disorders diagnosed before pregnancy may be unaffected or exacerbated by the pregnant state. Liver disorders that are specific to pregnancy, including hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, preeclampsia/ eclampsia, HELLP, and hepatic rupture, may have a profound impact on the morbidity and mortality rates of mother and fetus. Although an unequivocal diagnosis is often difficult to make, it should be attempted in a timely manner so that optimal treatment can be determined. After the diagnosis is made, maximizing the health of the mother and fetus determines future management.     

Caring for the older patient, Part IV: The value of nuclear medicine in meeting the needs of an aging society

This is the last article of a four-part series on gerontology and its applications to the care of elderly patients in nuclear medicine. This article reviews selected nuclear medicine procedures that are more commonly performed on older patients. On completion of this article, the reader should be able to: (a) identify nuclear medicine procedures commonly performed on older patients; (b) give examples of how normal age-related anatomic and physiologic changes may affect various nuclear medicine procedures and findings; and (c) identify new or developing nuclear medicine techniques that may have future applications in the elderly population.     

Spontaneous recovery of impaired memory span: does comprehension recover?

Low back pain is common during pregnancy and is of moderate or severe intensity in about one fourth of all pregnancies. The etiology is multifactorial but in most cases is related to the physical and physiologic changes brought about by pregnancy. For most women, the pain resolves spontaneously, although they remain at higher risk for increased LBP in future pregnancies and for the development of symptomatic disc disease in later life. Many of the common treatments for LBP are contraindicated or must be modified in this setting. Neurologically symptomatic herniated discs are rare during pregnancy, yet, when indicated, pregnant women can safely undergo surgery.     

Exercise during pregnancy

Exercise has become a vital part of many women's lives. However, theoretic concerns have been raised about the safety of some forms of exercise during pregnancy. Because of the physiologic changes associated with pregnancy, as well as the hemodynamic response to exercise, some precautions should be observed. The physician should screen for any contraindications to exercise and encourage patients to avoid overly vigorous activity, especially in the third trimester, when most pregnant women have a decreased tolerance for weight-bearing exercise. Adequate hydration and appropriate ventilation are important in preventing the possible teratogenic effects of overheating. Pregnant women should avoid exercise that involves the risk of abdominal trauma, falls or excessive joint stress, as in contact sports and vigorous racquet sports. In the absence of any obstetric or medical complications, most women can maintain a regular exercise regimen during pregnancy. Some studies have found a greater sense of well-being, shorter labor and fewer obstetric interventions in physically well-conditioned women as compared with other women.     

Diagnosis and management of the adnexal mass

Adnexal masses are frequently found in both symptomatic and asymptomatic women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses, but the possibility of ectopic pregnancy must always be considered. Other masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses and benign neoplasms. Malignant neoplasms are uncommon in younger women but become more frequent with increasing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms must be considered, along with leiomyomas, ovarian fibromas and other lesions such as diverticular abscesses. Information from the history, physical examination, ultrasound evaluation and selected laboratory tests will enable the physician to find the most likely cause of an adnexal mass. Measurement of serum CA-125 is a useful test for ovarian malignancy in postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts less than 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts less than 3 cm in diameter may also be followed, provided the serum CA-125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy.     

Evidence for reduced Th1 function in normal pregnancy: a hypothesis for the remission of rheumatoid arthritis

OBJECTIVE: The mechanisms underlying the pregnancy induced remission of rheumatoid arthritis (RA) remain unclear. We assessed the hypothesis that it reflects systemic physiologic changes in immune response during gestation. METHODS: We used in vitro whole blood culture systems stimulated with either lipopolysaccharide or phytohemagglutinin to assess cytokine secretion of cells from healthy pregnant and control donors. RESULTS: Interleukin 2 (IL-2) production was decreased during pregnancy, more so in the 3rd trimester, and soluble tumor necrosis factor (TNF) receptor p55 and p75 was increased, again most significantly in the 3rd trimester. TNF-alpha and IL-1 beta were unchanged. CONCLUSION: These findings are consistent with the hypothesized downregulation of Th1 responses during pregnancy. Further studies to assess the relationship with fetal/maternal HLA class II disparity, and eventually the presence or absence of remission in actual patients with RA, are required.     

Pregnancy in women with spinal cord injuries

Most women with spinal cord injuries (SCI) resume normal reproductive function, can have sexual relationships, and become pregnant. Pregnancy is not contraindicated in women with SCI, but pregnant women with acute or chronic SCI pose unique challenges for perinatal health care providers. The normal physiologic changes of pregnancy may predispose women with SCI to potentially life-threatening complications, including autonomic hyperreflexia, pyelonephritis, respiratory insufficiency, thrombophlebitis, and unattended delivery of the infant. This article reviews the effect of SCI on female reproduction, pregnancy, and labor, and summarizes the treatment of the pregnant woman with a spinal cord injury.     

Wantedness of pregnancy and prenatal health behaviors

This study examined the relationships between wantedness of pregnancy and the initiation of prenatal care as well as smoking and drinking alcohol during pregnancy. Three hundred and eighty post-partum women were interviewed in a randomly selected sample of Chicago area hospitals. Approximately half of the women said that they had wanted their recently completed pregnancy. Unadjusted analyses revealed that women who wanted their pregnancies were more likely to begin prenatal care in the first trimester and were less likely to smoke while there was no relationship between wantedness and alcohol use during pregnancy. After adjustment for sociodemographic variables, women who wanted their pregnancies were less likely to have smoked cigarettes or drunk alcohol during pregnancy, but were not more likely to have initiated prenatal care in the first trimester. These results suggest that positive health behaviors during pregnancy are influenced by wantedness of pregnancy as well as sociodemographic characteristics. Therefore, efforts to reduce unwanted pregnancies are an important strategy to improve the health of women and children.     

The critical control of progesterone levels and pregnancy by antiprogesterone

Circulating plasma progesterone (P) has been quantitatively controlled in the rat "model" through highly specific binding by treatment with anti-P (A-P). Knowing the constant, which characterizes the binding of P to A-P in plasma, sequential assays of circulating A-P and A-P bound total P (Pt) revealed the levels of the biologically active unbound P (Pu). The studies showed that at different stages of gestation the mechanisms through which A-P reduces Pu and terminates pregnancy are the same. However, the doses of AP which effectively reduce Pu and also the critical levels of Pu at which pregnancy terminates are different. The moderate and transient physiologic P-withdrawal (Pw) at midterm permits the continuation of normal gestation, but pregnancy is terminated by a drastic and sustained reduction in Pu. In contrast, when Pu is only slightly and briefly reduced below physiologic levels, pregnancy continues and only retarded conceptus growth signals that Pw occurred. Apparently Pw has to be controlled and measured with "razor's-edge" precision to fully expose and define the regulatory significance of this steroid in the maintenance and termination of pregnancy. Short of this precision, the key regulator of the pregnant uterus will remain buried, as it has been during 40 years, in controversial findings.     

Pregnancy complicated by diabetes mellitus, superimposed preeclampsia, and adult respiratory distress syndrome: a case study

Pregnancy complicated by insulin-dependent diabetes mellitus carries severe physiologic risks for both the mother and the fetus. This article presents a case study to illustrate disease progression through multiple systems and psychosocial complications associated with diabetes mellitus in pregnancy. The case study also illustrates the role of nursing interventions, the use of technology, and interdisciplinary collaboration in caring for the patient and her family.     

Management of upper and lower urinary tract infections in pregnant women

Nurse practitioners often manage pregnant women for many health problems. Early recognition, treatment, or timely referral of any infectious process, especially urinary tract infections, is crucial to an optimal pregnancy outcome. Knowledge of urinary tract anatomic and physiologic changes in pregnancy and bacterial features necessary for infection to occur expands understanding the foundation of urinary tract infection prevention and treatment. This article discusses urinary tract infections, specifically focusing on clinical features, diagnosis, and treatment measures among pregnant women.     

Colposcopy in pregnancy

The management of the abnormal smear in pregnancy remains a challenge to the modern colposcopist. Colposcopy in pregnancy is difficult. Anatomic variants can mimic disease. Significant cytologic overall detection of low-grade squamous intraepithelial lesions demands an increased understanding of physiologic variants in pregnancy. Possible recent increases in cervical cancer incidence in younger women requires comprehensive knowledge of warning signs of early invasion. Modern management approaches must temper the need for accurate exclusion of cancer with the risk of overly aggressive interference in patients without disease or with very minor atypia.     

Dilatation of the urinary tract during pregnancy: proposal of a curve of maximal caliceal diameter by gestational age

OBJECTIVE: Dilatation of the urinary tract is common during pregnancy, but the limits between physiologic and pathologic dilatation are unknown. Our purpose was to establish the pattern of physiologic urinary tract dilatation during pregnancy. STUDY DESIGN: This was a cross-sectional study. The maximal caliceal diameter was measured by ultrasonography at different weeks' gestational age in 1506 pregnant and 181 postpartum women. A curve with the 90th, 75th, and 50th percentiles was drawn for each kidney. RESULTS: Fifty-three (6%) pregnant and postpartum women had some degree of dilatation. The right kidney was more frequently and severely affected, as were nulliparous women. The 90th percentile of maximal caliceal diameter of the right kidney increased about 0.5 mm/wk up to 24 to 26 weeks, about 0.3 mm/wk up to 31 to 32 weeks, and remained stable until term. The left maximal caliceal diameter attained 8 mm around week 20 to 24 and remained stable until term. Only 6% had dilatation in the postpartum period. CONCLUSION: A normal curve of dilatation of the urinary tract is proposed.     

Trade-off between segregational stability and metabolic burden: a mathematical model of plasmid ColE1 replication control

Gastrointestinal surgical problems often mimic symptoms and signs of nonsurgical conditions that occur during pregnancy. This mimicry presents a particular challenge to diagnosis because avoiding a delay in treatment is critical to successful management. Some of these conditions, such as acute appendicitis and biliary colic, are common in younger women; however, the anatomic and physiologic changes of pregnancy can alter their usual manner of presentation. Many elective and urgent operations can be performed during pregnancy with minimal risk to the mother and fetus. The mother's condition should always take priority because her proper treatment usually benefits the fetus as well.     

Diagnosis of Cushing's disease in pregnancy

The Cushing syndrome during pregnancy is very infrequent, being even more so that of hypophysary etiology despite corticotropic adenomas being more prevalent in fertile-aged women. Its diagnosis is difficult since it may be confused with the physiologic alterations of the cortisol and the ACTH which occur during pregnancy. The treatment is controversial. In the cases reported to date, pregnancy represented a worsening of the picture. The case of a patient diagnosed with Cushing disease during the first trimester of pregnancy is presented. The hypercorticism improved clinically and biochemically during the pregnancy with no maternofetal complications observed. The disease activity continued following delivery.     

Regulation of progesterone biosynthesis in the human placenta by estradiol 17 beta and progesterone

The information available concerning the effects of chemotherapy administered during pregnancy is limited and consists of case reports and small series. A registry has been established at the National Cancer Institute, but there are currently only several hundred cases of neonates exposed to chemotherapy registered. All clinicians who care for women receiving chemotherapy during pregnancy should report those experiences to the National Cancer Institute to increase the data base. When chemotherapy is used during the embryogenesis period in the first trimester there is an increased rate of spontaneous abortion and major birth defects. The most toxic chemotherapeutic agents administered during pregnancy are methotrexate and aminopterin and should be avoided when possible, particularly during the first trimester. Pregnancy-related physiologic changes should be kept in mind when dosing and administering cytotoxic chemotherapy. The risk of fetal malformation when chemotherapy is administered during the second and third trimesters is probably not greater than background rate, but there may be a greater risk of stillbirth, fetal growth restriction, premature birth, and maternal and fetal myelosuppression. Breastfeeding should be avoided in women receiving chemotherapy.     

Antioxidants, prostaglandins and prematurity

Preterm labor could have very bad consequences for the new-born. Every method which maintain pregnancy till term deserves to be analyzed. Such an analysis could throw a light on the process of parturition and open therapeutic possibilities against prematurity. Once a food-stuff antioxidant, Diphenyl-p-Phenylene-Diamine (DPPD) given to pregnant rats, delays or prevents parturition. We confirm the results of Oser. The daily dose of 20 mg from the 17th day of pregnancy upsets parturition. If injected from the 14th day, the parturition never occurs on time. Under the same circumstances (from the 14th day) the daily dose of 40 mg, more effective than 20 or 30 mg prolongs the pregnancy duration, causes fetal resorptions and often prevents birth of living fetuses. 200 micrograms of prostaglandin F2 alpha given on the 21st day almost totally cancel the very toxic action of 40 mg of DPPD which has been injected daily from the 14th day. When an antioxidant lengthens the pregnancy duration of rats, prostaglandin F2 alpha reestablish parturition. Thus the parturition delaying action of an antioxidant may be stymied by prostaglandin F2 alpha. This delaying action might be due to an inhibition of the synthesis of prostaglandin. If applied against the threat of preterm birth, it will be necessary to test the innocuity, at the doses used, of the selected antioxidant and the absence of side effects for the mother and fetus.     

Hypertensive and normal pregnancy: a longitudinal study of blood pressure, distensibility of dorsal hand veins and the ratio of the stable metabolites of thromboxane A2 and prostacyclin in plasma

OBJECTIVE: By combining serial measurements of the circulating concentrations of thromboxane A2 and prostacyclin with measurements of venous distensibility (taken during the pregnancies of both normal women and those with pregnancy induced hypertension or pre-eclampsia), to test the following hypotheses: 1. that changes in the venous plasma ratio of thromboxane (TXB2) and 6-keto-PGF1 alpha would correlate with changes in the blood pressure of women developing and recovering from pregnancy induced hypertension or pre-eclampsia and 2. that changes in venous distensibility would correlate with changes in arterial blood pressure in pregnancy induced hypertension or pre-eclampsia. DESIGN: Prospective, longitudinal cohort study. SETTING: John Hunter Hospital clinic, Newcastle, Australia. SUBJECTS: One hundred and sixty primiparous women, recruited when presenting for their first routine antenatal visit, were investigated at, or close to, 19, 28 and 37 weeks of gestation; a subgroup was also studied in the postnatal period. The measurements of the patients who developed pregnancy induced hypertension or pre-eclampsia were compared with those of controls selected from the cohort. MAIN OUTCOME MEASURES: Serial measurements of the circulating concentrations of the stable metabolites of thromboxane A2 and prostacyclin (TXB2 and 6-keto-PGF1 alpha, respectively), venous distensibility and immediate (no rest) and resting (for at least 30 min) blood pressures. RESULTS: There was no significant difference between the subject and control groups at any time during or after the pregnancy in the concentrations of prostaglandin metabolites, their ratio or venous distensibility. In contrast, there was a significant difference between the groups at 19 weeks for immediate and resting readings of diastolic pressure (6 mmHg (95% CI 1.5 to 10.5) and 4 mmHg (95% CI 0.1 to 7.9), respectively). These differences increased through the pregnancy but mean postnatal readings for the groups were almost identical suggesting that the subjects were not intrinsically hypertensive compared with controls. Blood pressures for the subject group, both immediate and resting, were significantly different from the 19 week readings at 28 weeks (diastolic) and at 37 weeks (systolic and diastolic). The only significant change from first readings among controls was in postnatal systolic pressure which was significantly higher than 19 week values, probably reflecting the vasodilatation, with accompanying hypotension, of early, normal pregnancy. This difference was not observed in those who subsequently developed pregnancy induced hypertension or pre-eclampsia. CONCLUSIONS: Our study was unable to demonstrate differences in circulating metabolites or venous distensibility between normotensive women and those with pregnancy induced hypertension or pre-eclampsia. If pregnancy induced hypertension or pre-eclampsia in humans represents not so much the presence of abnormal constrictor influences as a process initiated by failure of normal vasodilatation in early pregnancy, studies carried out later may detect mainly adaptive and secondary changes.     

Progress in the development of a transcutaneously powered axial flow blood pump ventricular assist system

Development of the Jarvik 2000 intraventricular assist system for long-term support is ongoing. The system integrates the Jarvik 2000 axial flow blood pump with a microprocessor based automatic motor controller to provide response to physiologic demands. Nine devices have been evaluated in vivo (six completed, three ongoing) with durations in excess of 26 weeks. Instrumented experiments include implanted transit-time ultrasonic flow probes and dual micromanometer LV/AoP catheters. Treadmill exercise and heart pacing studies are performed to evaluate control system response to increased heart rates. Pharmacologically induced cardiac dysfunction studies are performed in awake and anesthetized calves to demonstrate control response to simulated heart failure conditions. No deleterious effects or events were encountered during any physiologic studies. No hematologic, renal, hepatic, or pulmonary complications have been encountered in any study. Plasma free hemoglobin levels of 7.0 +/- 5.1 mg/dl demonstrate no device related hemolysis throughout the duration of all studies. Pathologic analysis at explant showed no evidence of thromboembolic events. All pump surfaces were free of thrombus except for a minimal ring of fibrin, (approximately 1 mm) on the inflow bearing. Future developments for permanent implantation will include implanted physiologic control systems, implanted batteries, and transcutaneous energy and data transmission systems.