The prevalence of intrahepatic cholestasis of pregnancy in a primarily Latina Los Angeles population

OBJECTIVE

To establish the prevalence of intrahepatic cholestasis of pregnancy (ICP) in a primarily Latina population in the United States.

STUDY DESIGN

Over a period of 16 months, a convenience sample of subjects admitted to labor and delivery in the third trimester was enrolled. Each subject completed a questionnaire rating their severity of pruritus on a numeric scale of 1 to 10. Serum was analyzed via radioimmunoassay for total bile acid concentration. ICP was defined as pruritus score >4 and a total serum bile acid concentration of >or=20 micromol/l. Ethnicity was determined from hospital record demographic data.

RESULTS

All invited participants enrolled in the study. Three hundred and forty subjects were enrolled. Three hundred and sixteen subjects (93%) were identified as Latina. The serum bile acid concentration range for the entire study population was 1 to 580 micromol/l with a mean of 10.4+/-34.9 micromol/l. Twenty-four (7.1%) subjects had a serum bile acid concentration >or=20 micromol/l. A pruritus score >4 was found in 19.7% (67/340). Of the 24 subjects with a bile acid concentration >or=20 micromol/l, 19 also had a pruritus score >4. Thus, the prevalence of ICP in this population was 5.6% (19/340). In subjects with ICP, the mean serum bile acid concentration was 89.5+/-124.0 micromol/l. When controlling for confounders, women with ICP were associated with higher rates of chorioamnionitis (P=0.043) and their fetuses had higher rates of thick meconium (P=0.053).

CONCLUSIONS

The overall prevalence of ICP in this population was 5.6%, 10 to 100 times higher than previously reported data from the United States. Larger studies of perinatal morbidity examining the diagnostic criteria of cholestasis need to be conducted.

Genital herpes during pregnancy: inability to distinguish primary and recurrent infections clinically

OBJECTIVE

To determine if the signs and symptoms of genital herpes in pregnancy accurately identify primary genital herpes infections using serologic testing for final classification.

METHODS

Twenty-three women with clinical signs and symptoms suggestive of primary genital herpes infections in the second and third trimesters of pregnancy were subsequently cultured and tested serologically (for herpes simplex virus type 1 and herpes simplex virus type 2 antibodies) and classified as having true primary (no herpes simplex virus type 1 or type 2 antibodies), nonprimary (heterologous herpes simplex virus antibodies present), or recurrent (homologous antibodies present) infections.

RESULTS

Only one of 23 women with clinical illnesses consistent with primary genital herpes virus simplex infections had serologically-verified primary infection. This primary infection was caused by herpes simplex virus type 1. Three women had nonprimary type 2 infections, and 19 women had recurrent infections. Among culture-proven recurrent infections, 12 were caused by herpes simplex virus type 2 and three by herpes simplex virus type 1. Only one infant was born preterm, and no clinically significant perinatal morbidity was observed.

CONCLUSION

Correct classification of gestational genital herpes infections can be accomplished only when clinical evaluation is correlated with viral isolation and serologic testing using a type-specific assay. Severe first episodes of genital herpes infections among women in the second and third trimesters of pregnancy are not usually primary infections and are not commonly associated with perinatal morbidity.

Arthroscopic staple capsulorrhaphy for anterior shoulder instability

We reviewed the results of the arthroscopic staple capsulorrhaphy on 47 patients with a followup of 4 years. Thirty-four of the 47 shoulders had a history of traumatic dislocation, while the remaining 13 had a history of subluxation. The recurrence rate was 25%, with 8 shoulders developing recurrent frank dislocation and 4 developing subluxation. Only 21 of the 47 patients were able to resume normal sporting activities after surgical repair. We had no cases of staple loosening within the joint, but we did have 3 patients whose staples were removed because of persistent pain in the shoulder.

Central hemodynamic alterations in amniotic fluid embolism

Amniotic fluid embolism is an uncommon but devastating obstetric emergency. We report hemodynamic data derived from pulmonary artery catheterization in four previously unpublished cases of amniotic fluid embolism syndrome. These findings confirm a recently published reinterpretation of the central hemodynamics of this condition.

Medial osteochondritis of the talus in children: review and new surgical management

Review of the management of medial osteochondritis of the talus in the young patient has revealed the poor results of casting and the equivocal results of past surgical options. A new surgical technique of bone grafting is described. The results in six patients treated with bone grafting are compared with the results in 10 patients treated by excision. Because of the more favorable results following bone grafting, we recommend it as primary treatment of this condition in children and adolescents.

Clinical utility of the nonstress test in the conservative management of women with preterm spontaneous premature rupture of the membranes

Preterm spontaneous premature rupture of the membranes (SPROM) is responsible for significant perinatal morbidity and mortality, largely related to prematurity. Consequently, conservative management is frequently elected. These pregnancies, however, are still at risk. Antepartum fetal heart rate testing has been of demonstrable value in other high-risk pregnancies and should offer a method of assessing risk in SPROM. Therefore, a retrospective analysis of patients with SPROM who underwent antepartum fetal heart rate testing was undertaken to evaluate its clinical utility in identifying the fetus at risk. Forty-eight patients underwent 154 nonstress tests in the study population. Indications for delivery included fetal pulmonary maturity, amnionitis and persistent variable decelerations with the failure of amniotic fluid to reaccumulate. Variable decelerations were present in 32% of all tests. Fetal heart rate abnormalities severe enough to warrant delivery were noted in 10 of 48 patients (21%). No intrauterine deaths occurred. Our data suggest that once conservative management is elected in preterm patients with SPROM, the nonstress test may identify fetuses at risk of repeated umbilical cord compression and may allow continuous monitoring or delivery.

Peripartum colloid osmotic pressures: correlation with serum proteins

Colloid osmotic pressure is a principal regulator of capillary fluid exchange. Alterations in colloid osmotic pressure in preeclamptic patients, as well as significant peripartum changes in colloid osmotic pressure in normotensive patients, are reported. In a study of 72 normotensive and preeclamptic patients, peripartum colloid osmotic pressure, serum albumin, and total serum protein were compared. Both groups exhibited significantly lower colloid osmotic pressure in the postpartum period than that measured antepartum. The mean antepartum colloid osmotic pressure in preeclamptic patients was significantly lower than in normotensive subjects. Regression equations were calculated [colloid osmotic pressure = 5.21 (total serum protein) -11.4 (r2 = 0.851)] and [colloid osmotic pressure = 8.1 (serum albumin) -8.2 (r2 = 0.891)]. Within the physiologic ranges most commonly reported for normotensive and preeclamptic patients, the use of these equations allowed calculation of colloid osmotic pressure to within 10% of measured values in 75 and 80% of the cases, respectively. Where direct measurement of colloid osmotic pressure is not readily available, calculated values may be helpful in patient management.

Missing hospital records: a confounding variable in retrospective studies

In retrospective chart reviews there are often a certain number of missing hospital records. To elucidate this variable we compared the outcomes of very low birth weight breech infants with respect to the method of collecting data. A prospective sampling, during the hospital stay, of data was performed in 1979 to 1980 and in 1983 to 1984, and the frequencies of very low birth weight were 1.89 and 1.90, respectively, per 1000 live births. For 1981 to 1982 a retrospective record search was performed with the use of the ordinary medical record search system at this institution. For this period 39 of 52 (75%) hospital records were recovered, giving an apparent frequency of 1.32/1000 live births, which differed significantly from either period studied prospectively. An analysis of demographic data of the three groups revealed that the mean gestational age and the mean birth weights were higher in the period studied retrospectively compared with both periods studied prospectively and that the neonatal mortality rates were higher in the periods studied prospectively (74.1% and 57.1%, respectively) than in the period studied retrospectively (28.2%). It is concluded that the more complicated a clinical case is, the more likely the record will not be found for retrospective chart review. This problem should be kept in mind, and it ought to be a requirement that the number of missing charts be stated in retrospective observational studies.

Squamous cells in the maternal pulmonary circulation

Identification of squamous cells in the maternal pulmonary arterial circulation, either at autopsy or in blood aspirated from a pulmonary artery catheter, is currently regarded as pathognomonic for amniotic fluid embolism. Sixteen pregnant women underwent pulmonary arterial catheterization for a variety of medical indications. Examination of the buffy coat fraction of the distal lumen aspirate resulted in the identification of squamous cells in all cases. Squamous cells were similarly identified in control specimens from 17 nonpregnant patients; however, the difference in cell count between the pregnant and nonpregnant patients was significant. Such cells presumably reflect, in part, bloodstream contamination from sites of venous access. Reliable differentiation of adult from fetal squamous cells is not possible; however, the significant increase in cell count documented in pregnant patients suggests a possible fetal origin for some squamous cells detected during pregnancy. The detection of squamous cells in the pulmonary arterial circulation of pregnant women is not pathognomonic for amniotic fluid embolism. In a critically ill obstetric patient, such a finding should not deter the clinician from a thorough search for other causes of hemodynamic instability.

Clinical chorioamnionitis--analysis of the incubation period in patients with preterm premature rupture of membranes

Rankit analysis of the incubation periods in 37 patients with preterm premature rupture of membranes and chorioamnionitis was done. The analysis revealed the existence of three distinctive groups: short (6.4 +/- 2.9 hours), medium (40 +/- 24.5), and long (210 +/- 75 hours) incubation period. It is postulated that in the short incubation period group the preterm premature rupture of membranes is a result, rather than the cause, of the infection.

Labor and delivery in the presence of mitral stenosis: central hemodynamic observations

During a 1-year period, eight patients with New York Heart Association Class III or IV mitral stenosis were studied throughout the peripartum period with a pulmonary artery catheter. All patients were delivered vaginally. Intrapartum management was based upon cautious diuresis for preload optimization and heart rate control with propranolol. A mean increase in pulmonary capillary wedge pressure of 10 mm Hg was observed in the immediate postpartum period. Only two patients demonstrated a significant increase in cardiac output during this same time period. Central venous pressure correlated poorly with pulmonary capillary wedge pressure in seven of eight patients. Neonatal outcome was uniformly excellent. With the management approach described, no patient exhibited deterioration of cardiopulmonary status during the peripartum period.

A teaching catalogue of physical findings developed on the geriatric ward of an acute-care teaching hospital

A catalogue of physical findings from patients on a geriatric ward run by a Family Practice Centre was developed for the use of both medical educators and students. The collection and organization of the data is described, as well as the ethical problems involved. Advantages to both teachers and students are discussed with respect to the teaching of physical diagnosis. An added benefit of producing and using a catalogue of this nature could be the changing of negative attitudes towards the geriatric patient.