[Interventional radiology and the medical applications of information systems: what consequences for the radiology department?]

The French health care system reform has introduced some changes in the distribution of hospital budgets according to the distribution of admitted patients in diagnosis related groups (DRGs). This new model of budget allocation does not take into account the more technical nature of some medical procedures and services and does not promote the implementation of new technologies. Using four simulated clinical cases, we studied the length of stay in different DRGs and the number of associated points (points d'indice synthétique d'activité, ISA). The addition of the interventional radiologic procedures did not modify the DRG (which remained unchanged from the initial DRG). In order to achieve recognition of the specific nature of interventional radiology procedures, a database should be created and an economical evaluation conducted.

The impact of pregnancy and puerperium on panic disorder: a review

There is little known about the effect of pregnancy and the puerperium on the risk for, and course of anxiety disorders. Initial case reports concerning the relationship between panic disorder (PD) and pregnancy/puerperium suggested that pregnancy protected against PD, while the postpartum period seemed to increase the risk for onset or exacerbation of PD. Later studies have offered a more mixed picture. A computerized search identified eight relevant studies in this area. All were non-controlled and all but one retrospective. Out of the total 215 pregnancies that were described in these studies, 89 (41%) were associated with improvement of PD symptoms during the pregnancy, while 38% of the described pregnancies exhibited onset or exacerbation of PD in the postpartum period. No definite conclusions regarding the effect of pregnancy and puerperium on PD can be drawn from these reviewed studies.

[Peripartum cardiomyopathy. Clinical case series]

We report a retrospective analysis of four cases of peripartum cardiomyopathy admitted, within a 10-year period, to the maternity hospital of Sousse. The age of the patients was over 30 years, two had gemellary pregnancies and two suffered toxaemia. Congestive cardiac failure, mainly of the left ventricle, with acute pulmonary oedema, was the main symptom. Chest X-ray showed a cardiothoracic index above 0.58 and echocardiography a left ventricular telediastolic diameter above 5.7 cm and a shortening ratio of 25% or less. Endomyocardial biopsy for ascertaining the diagnosis was not available. Treatment included bed rest, water and salt restriction, digitalis, a diuretic and an anticoagulant in case antepartum cardiomyopathy, a converting enzyme inhibitor and a diuretic in case of postpartum cardiomyopathy. Three patients recovered totally and in one echocardiography showed a persisting impaired left ventricular function. Five neonates had a favourable outcome and one foetus died in utero. Main problems raised by peripartum cardiomyopathy are discussed.

[Ozone hemotherapy and endogenous intoxication in gestoses]

The paper is concerned with the study of chief markers of endogenous intoxication such as bodily content of medium-weight molecules (MWM) in patients with grave forms of gestoses, as well as with quest for ways of initiating a correcting therapy. Results of complex studies permitted coming to the conclusion that endogenous intoxication in different forms of gestoses runs its course through stages. This validates not only MWM levels but peculiarities of their distribution in erythrocytes, blood plasma and urine of patients as well. In particular, a change in the urine MWM level depends on the functional state of the Kidneys. Decline in bodily content of the studied toxic substrates owing to inclusion of ozone hemotherapy in conventional intensive therapy of gestoses makes for an appreciable lessening of the degree of catabolic disturbances.

Puerperal ovarian vein thrombosis with extension into the inferior vena cava

The incidence of puerperal ovarian vein thrombosis is estimated to range between 1 in 600 and 1 in 2000 deliveries. The cardinal signs of puerperal ovarian vein thrombosis include fever, leukocytosis, and right lower quadrant abdominal pain, most often in a recently delivered female patient. These patients are classically described as failing to improve with intravenous antibiotic therapy alone; resolution of symptoms and presumptive diagnosis is made on defervescence with the addition of intravenous heparin therapy. Objective diagnostic modalities include venography, ultrasound, laparoscopy, and MRI, although CT remains the gold standard for the identification of this under-diagnosed entity. We present a case report of a 20-year-old female treated at our facility for puerperal ovarian vein thrombosis. She was transferred to our vascular surgery service after developing the classic signs of puerperal ovarian vein thrombosis and undergoing CT demonstrating ovarian vein thrombosis with extension of free-floating thrombus into her inferior vena cava (IVC). This degree of thrombosis was particularly concerning when one considers the 3 to 33 per cent rate of pulmonary embolism reported in patients with puerperal ovarian vein thrombosis. Treatment modalities for such extensive degrees of thrombosis are described in the literature and range from hysterectomy and thrombectomy to ligation of the IVC. In our case, we prophylactically placed a suprarenal IVC Greenfield filter to protect against pulmonary embolism and proceeded with the standard regimen of anticoagulation and antibiotics. This treatment approach has been reported only twice previously in the literature, to our knowledge.

Splenic rupture in a patient with acute myeloid leukemia undergoing peripheral blood stem cell transplantation

Splenic rupture is a rare but well-recognized complication of hematological malignancies. Here, we present the case of a 22-year-old woman with the diagnosis of acute myeloid leukemia who was undergoing peripheral blood stem cell transplantation. On day + 10 she developed a hypovolemic shock due to rupture of her spleen and went to emergency laparotomy. This is the first report of splenic rupture during peripheral blood stem cell transplantation.

Stroke complicating pregnancy and the puerperium

BACKGROUND

The role of nonobstetric factors, such as stroke, in maternal mortality has become of increasing importance because maternal deaths resulting directly from obstetric causes are decreasing. Strokes contribute to high mortality and morbidity, and are severe complications during pregnancy and puerperium. The objective of this study was to investigate the maternal outcome of patients with complications of stroke during pregnancy and puerperium. The causes, incidence and essential management of stroke are also reviewed.

METHODS

During the 10-year period from January, 1986, to January, 1996, women who suffered from stroke during pregnancy, or up to six weeks postpartum, and were discharged from our hospital were identified. Stroke was defined as the abrupt onset of a focal neurologic syndrome that consisted of hemorrhagic and ischemic central nervous system events. All were assessed using computerized tomography or magnetic resonance imaging. Neurologists reviewed each case from the medical records.

RESULTS

Thirteen women who had had a stroke during pregnancy or puerperium were identified. Nine of these women had intracerebral hemorrhage and four had ischemic strokes. During this 10-year period, approximately 85,321 women gave birth at the Mackay Memorial Hospital, and the incidence of stroke was approximately 1 in 6,500 pregnancies. Among the nine cases of hemorrhagic strokes, three women had preeclampsia and one had gestational diabetes mellitus. Mortality from strokes was 38%, and 63% of survivors had residual neurologic deficits; 46% of the strokes occurred during the puerperium.

CONCLUSIONS

Stroke during pregnancy and puerperium causes high mortality and morbidity. Early diagnosis and adequate treatment cannot be overemphasized, as prompt and proper management is beneficial for outcome. The same meticulous care provided during the antepartum and intrapartum periods should be continued into the puerperium.

Breast cancer during pregnancy and lactation

Three cases of breast cancer during pregnancy and lactation which were referred to the Obstetrics and Gynecology Department of loannina University Hospital during the period 1990-1997 are presented. Diagnosis and management of these cases are discussed and a strength protocol is suggested to identify new cases of breast cancer during pregnancy and lactation.

A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence

A randomized controlled trial was carried out to evaluate the extent to which a program of reinforced pelvic floor muscle exercises (PFME) reduces urinary incontinence 1 year after delivery. Two hundred and thirty women who were incontinent 3 months postpartum were randomized to either a control group doing standard postnatal pelvic floor muscle exercises (n = 117) or to an intervention group (n = 113) who saw a physiotherapist for instruction at approximately 3, 4, 6 and 9 months postpartum. Results collected 12 months after delivery included prevalence and frequency of incontinence and PFME, sexual satisfaction, perineometry measurements and pad tests. Twenty-six (22%) of the control group and 59 (52%) of the intervention group withdrew before the final assessment. The prevalence of incontinence was significantly less in the intervention group than in the control group (50% versus 76%, P=0.0003), and this group also did significantly more PFME. There were no significant differences between the groups as regards sexual satisfaction, perineometry measurements or pad test results.

Recurrent intracranial hemorrhage due to postpartum cerebral angiopathy: implications for management

BACKGROUND

Postpartum cerebral angiopathy as a cause of hemorrhagic stroke in young women is not well recognized. It is unknown whether this disorder represents a true inflammatory vasculitis or transient vasoconstriction related to the hormonal events of pregnancy and the postpartum period.

CASE DESCRIPTION

A 39-year-old woman presented with postpartum intracranial hemorrhage and, 32 months later, with subarachnoid hemorrhage, following normal pregnancies. Cerebral angiography obtained after each stroke demonstrated diffuse irregularity of branches of the middle cerebral arteries consistent with a diffuse vasospastic process or classic vasculitis. Neurological deficits resolved and results of a transcranial Doppler study normalized after a short course of high-dose corticosteroids following the second stroke.

CONCLUSIONS

Postpartum cerebral angiopathy should be considered in the differential diagnosis of recurrent intracranial hemorrhagic stroke in young women. Recognition of this condition may preclude treatment with potentially toxic therapies for vasculitis and will have important implications for counseling women on subsequent pregnancies.

[Early discharge after delivery, a safe and cost-effective form of care]

Early discharge after delivery, followed by home care, has been offered to maternity patients at Motala General Hospital since 1983. The results have been analysed retrospectively with regard to home care quality, morbidity, mortality, and cost-effectiveness. During the period, 1983-95, about 10,000 children were born at Motala General Hospital. Morbidity and mortality data have been elicited from the patients' records and from Statistics Sweden, the national bureau of statistics. The frequency of early discharge increased from about 20 per cent in 1984 to 66 per cent (79% of normal deliveries) in 1995. Hyperbilirubinaemia and nutritional problems were the predominant forms of morbidity among newborns in the early discharge subgroup, and mortality was zero. The numbers of nurses, assistant nurses and midwives were reduced by 50 per cent during the period, partly due to the early discharge programme, but also due to economies in Swedish health care expenditure. Provided a stable and well organised system is established, with home visits by a midwife and examination by a paediatrician 5-7 days after delivery, and alertness to the possibility of jaundice and nutritional problems is maintained, early discharge is a safe procedure.

Medical conditions of the puerperium

The puerperium is a time of continued, dramatic pregnancy-associated adaptation. Although much less common than in the early part of the century, maternal death can still occur from common postpartum problems such as infection, hemorrhage, and disease. This article reviews the physiologic and emotional changes as well as the clinical management of common problems in the puerperium.

Postpartum hemolytic uremic syndrome with a more severe liver involvement

A 22-year-old woman presented with postpartum hemolytic uremic syndrome with a more severe hepatic involvement. The patient was dialysed and successfully treated with plasma infusion and intravenous immunoglobulin. Two months following discharge her creatinine clearance was 105 ml/min/1.73 m2, 99mTc DTPA scan and brain CT were normal. Here child is also alive and healthy.

Socio-cultural factors in maternal morbidity and mortality: a study of a semi-urban community in southern Nigeria

STUDY OBJECTIVE

To understand community based or socio-cultural factors that determine maternal morbidity and mortality in a semi-urban setting.

DESIGN

The study is an exploratory multidisciplinary operations research and the instruments were focus groups and interviews.

SETTING

Ekpoma, a semi-urban community with a population of 70,000 in central part of Edo state in southern Nigeria.

PARTICIPANTS

Thirteen groups of women, two groups of men, and two groups of traditional birth attendants.

RESULTS

There is a fairly good knowledge of haemorrhage but this is circumscibed by attitudes, practices, and situations that keep women away from or delay the decision to seek modern obstetric care.

CONCLUSIONS

For a fuller understanding of maternal morbidity and mortality, it is important to consider factors outside the hospital and formal medical practice. Furthermore, a change of existing knowledge, attitudes, practices, and situations can be enhanced through modelling on them.

Postpartum mood disorders: diagnosis and treatment guidelines

Mood disturbance occurs commonly during the postpartum period. The symptoms may be transient and relatively mild (as in postpartum blues) or may be associated with significant impairment of functioning (as in postpartum depression and puerperal psychosis). Despite the prevalence of postpartum mood disorders, depressive symptoms that emerge during the puerperium are often overlooked. Puerperal affective illness places the mother at risk for the development of recurrent depression and has also been associated with significant long-term effects on child development and behavior. Therefore, the prompt recognition and efficacious treatment of puerperal mood disorders are essential in order to avoid adverse outcomes for both mother and infant. This article discusses the evaluation of postpartum mood disturbance and offers guidelines for the treatment of affective illness during the puerperium.

Postpartum psychiatric illness: the role of the pediatrician

PPD occurs in 10% to 20% of postpartum women. Maternal depression can affect a child's development significantly. Pediatricians can screen for maternal psychiatric illness with little effort; of all the health care professionals, they may be in the best position to do so. Pediatricians can help affected mothers obtain appropriate treatment and help mobilize social resources. This simple process can minimize morbidity to pediatric patients.