Antibiotic prophylaxis against infective endocarditis after normal delivery--is it necessary?

During the years 1959 to 1978 inclusive 2165 women with rheumatic or congenital heart disease had vaginal deliveries at three large Dublin maternity hospitals. There were two (0.09%) cases of puerperal infective endocarditis, neither of which was unequivocally related to preceding childbirth during this period. Routine peripartum antibiotic prophylaxis was not given to either. A questionnaire of the practice of 19 obstetricians in Ireland showed that 12 (63%) gave antibiotics routinely during labour and after delivery in cardiac patients, five (26%) did not, and two (11%) used them occasionally. Peripheral vein blood was drawn serially from 0 to 30 minutes after vaginal delivery to determine the incidence of asymptomatic puerperal bacteraemia. A total of 299 cultures was obtained from 83 normal women and single blood cultures were positive in three women (3.6% of patients, 1.0% of cultures). A review of the published reports showed that well-documented cases of infective endocarditis and of asymptomatic puerperal bacteraemia after normal vaginal delivery are uncommon. There is evidence that antibiotic prophylaxis may increase the risk of developing antibiotic-resistant endocarditis. Recommended prophylactic regimens carry a considerable risk of drug toxicity. These facts, coupled with a lack of direct evidence in support of the efficacy of antibiotic prophylaxis, suggest that routine peripartum antibiotic prophylaxis is not indicated.

Hazards of oral anticoagulants during pregnancy

Prenatal exposure to oral anticoagulants during pregnancy may result in defective fetal development or life-threatening hemorrhage. Fetal exposure during the first eight weeks of pregnancy may cause abnormal development of the facial structures, hypoplastic digits, strippled epiphyses, and mental retardation. Midtrimester exposure may result in optic atrophy, faulty brain growth, and developmental retardation. Third-trimester exposure may produce fetal anticoagulation, predisposing the infant to life-threatening hemorrhage in the perinatal period. Anticoagulation with heparin sodium does not provide a clearly safe alternative, since this therapy has been associated with excessive fetal loss.

The effect of maternal cardiac disease and digotoxin administration on labour, fetal weight and maturity at birth

One hundred and twenty-two patients with cardiac disease were compared with 250 controls with respect to the duration of pregnancy and labour, birth weight percentile and Apgar score. The babies of the patients with cardiac disease were light-for-dates (18% below the 10th percentile); the mothers, if multiparous, delivered at an earlier gestational age. The patients with cardiac disease did not have shorter labours than the control group. Digoxin administration and the severity of heart disease had no significant effect on these variables.

Evaluating patients' warfarin requirements

Seventy consecutive patients receiving warfarin as an anticoagulant were evaluated for the relationship between the response to the loading dose of warfarin and the response to the maintenance dose. No patients were excluded because of complicating diseases or the concurrent use of other drugs. There was a moderate correlation (r = 0.54, p less than 0.01) between response to the loading dose and response to the maintenance dose. Thus, a relatively weak response to a loading dose of warfarin can be used to predict a need for a relatively large maintenance dose in unselected patients requiring anticoagulant therapy. Age seems to be a relatively weak determinant of warfarin sensitivity. Other factors such as the genetic control mechanism, concurrent drug therapy, and complicating diseases apparently are more important determinants.

[Rheumatic fever: present status (author's transl)]

In general, there is a falling incidence of rheumatic fever in the Federal Republic of Germany. Data from 1949 to 1977 at the University Children's Clinic Mainz indicate that in the last few years rheumatic carditis and arthritis occurred with the same severity and frequency in relation to the total number of cases as 20--25 years ago. Merely the number of recurrences has been significantly lowered since the introduction of penicillin prophylaxis. The reduction in recurrences is the main reason why acquired heart disease has become less common.

Research related to medical treatment of cardiovascular disease

Medical treatment of heart disease has improved significantly in the past 30 years. The spectacular change in the natural history of rheumatic heart disease is apparent from a 1948 article that reported that 42% of children with rheumatic heart disease died of rheumatic infection or bacterial endocarditis. Antibiotics and cardiac surgery have improved the outcome from rheumatic heart disease. Cardiopulmonary resuscitation has had a major impact on the treatment of myocardial infarction and on the management of sudden death. The fundamental principle underlying the discovery of cardiopulmonary resuscitation is reviewed, and recent developments emphasizing the importance of intrathoracic pressure in the hemodynamics of cardiopulmonary resuscitation are highlighted. The important new drugs of the last 30 years include the oral diuretics, the antihypertensives and the antiarrhythmic agents. The development of the beta-blocking agents is cited as an example of the translation of basic physiological research to medical care. Finally, the role of epidemiologic techniques in the design of clinical trials to evaluate medical therapy and hence improve medical management is discussed.

[Acute rheumatic carditis. Follow-up (author's transl)]

Thirteen cases with a first attack of acute theumatic carditis are presented, analyzing the clinical picture and long-term follow-up. Although the clinical acute attack was quite benign, incidence and importance of residual heart disease has not changed.

[Course of the rheumatic process in mitral heart defects after primary and repeated courses of treatment with titrated gamma-globulin]

Titrated gamma-globulin, which the authors used in the preoperative management of patients with acquired valvular disease and minimum rheumatism activity, contained high titers of antibodies against the antigens of streptococcus (streptokinase, streptohyaluronidase, streptolysin 0) and Coxsackie A13, A18, and B3 viruses. Its use in combination with antirheumatic agents did not cause any complications and made it possible to reduce the activity of the process in most cases with grade I and after repeated courses also in grade II activity of rheumatism. Treatment with titrated gamma-globulin stimulates the organism's defence forces (factors of nonspecific immunity: complement, lysozyme, interferon) and leads to diminution of the isolation of cardiotropic viruses from blood and bioptic material of the atria of patients.

Introduction of antifolics in psoriasis. A twenty-five year retrospect of antineoplastic agents in nonmalignant disease

Presented herein is a review of the beneficial use of the folic acid antagonist, aminopterin, in the treatment of psoriasis and other dermatologic disorders.

[Use of the aldosterone antagonist, canrenoate potassium for treating chronic circulatory insufficiency]

The results of studying the clinical effect of the diuretic soldacton and its effect on a number of indices of water-electrolyte metabolism are discussed. The drug was used in 16 patients with IIB--III stage of circulatory insufficiency. It was found that soldacton possesses a moderate diuretic and natriuretic effect and produces a potassium-preserving effect. The drug is effective in various initial concentrations of plasma aldosterone which does not change significantly under its effect. Soldacton promotes improvement of tolerance to cardiac glycosides and diminishes the risk of the development of digitalis intoxication.