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The hypertensive disorders of pregnancy are a frequent cause of neonatal morbidity and mortality. 259 newborns of hypertensive women were study to establish the relationship between some maternal findings and the subsequent neonatal complications. The severity, early onset of hypertension, proteinuria and the gestation of 32 week or less, are related with special risk of small-for-date, anoxia, seizures and neutropenia. Preeclampsia was related with foetus more compromised. Also hyperuricemia, thrombocytopenia and cesarean section were light predictors of neonatal trouble. These findings can orientate the neonatologist to select the newborns prone to complications, watching them closely to start the treatment, if necessary, as soon as possible.
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PMID:[Prediction of complications in children of hypertensive mothers]. 176 48

An analysis of 4 cases of the thrombotic thrombocytopenia in children of 4 to 10 years of age is performed. The disease was characterized by fever, purpura, headache and abdominal pains, arterial hypertension, microangiopathic haemolytic anemia, thrombocytopenia, increase of blood urea and serum creatinine, micro-haematuria and proteinuria. The duration of the disease was from 4 days to 7 months. Anuria, gangrene of the ears, scrotum, penis and soft tissues of legs and feet were registered in a 5-year-old patient with a fulminant disease. The cause of death of other patients was heart failure with acute lung oedema, brain haemorrhages and haemorrhagic pancreonecrosis. The diagnosis of the thrombotic thrombocytopenia was confirmed by the finding in the autopsy material of thrombotic microangiopathy of small arteries, veins, arterioles, venules and capillaries in kidneys and other organs and tissues. Kidney damage in fulminant disease is complicated by segmentary cortical necrosis, in a more prolonged disease--by glomerulosclerosis or mesangio-capillary glomerulonephritis.
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PMID:[Thrombotic thrombocytopenic purpura in children]. 180 69

Fourteen of 3,754 U.S. Marines who participated in a joint United States-Republic of Korea training exercise during the autumn of 1986 developed hemorrhagic fever with renal syndrome (HFRS). Clinical and laboratory findings among cases included fever, headache, fatigue, gastrointestinal dysfunction, thrombocytopenia, and proteinuria. Ten individuals were hospitalized; 2 died. No subclinical infections were identified through a post-deployment screen of sera obtained from 2,053 exercise participants. Analysis of questionnaires identified no environmental, occupational, or temporal factors as risks for developing disease. However, 13 of the 14 cases occurred among individuals housed at 1 of the 2 base camps used during the exercise. This outbreak represents the largest cluster of HFRS cases among U.S. personnel in the Republic of Korea since the Korean conflict.
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PMID:Outbreak of hemorrhagic fever with renal syndrome among U.S. Marines in Korea. 197 3

Women on regular dialysis are usually infertile, but contraception should not be neglected. Pregnancy is invariably complicated and poses excessive risks, with an uncertain and low chance of success. Even when therapeutic abortion is excluded, the live birth outcome at best is 19%. Renal transplantation usually reverses abnormal reproductive function and comprehensive pre-pregnancy counseling is essential, with discussion of all implications, including the harsh realities of long-term maternal survival. In this survey of 2,309 pregnancies in 1,594 women, therapeutic abortion was undertaken in 27% of conceptions and the spontaneous abortion rate was 13%. Of the conceptions that continued beyond the first trimester, 92% ended successfully. In most, renal function was augmented in pregnancy, with transient deterioration in late pregnancy (with or without proteinuria). Permanent renal impairment occurred in 15% of pregnancies. There was a 30% chance of developing hypertension, preeclampsia or both. Preterm delivery occurred in 50%, and intrauterine growth retardation in 25% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produced dystocia and was not injured during vaginal delivery. Cesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leukopenia, thrombocytopenia, adrenocortical insufficiency, and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. For the future more work is needed to improve pre-pregnancy assessment criteria, to understand the mechanisms of gestational renal dysfunction and proteinuria, to assess the side effects and implications of immunosuppression in pregnancy, and to elucidate the remote effects of pregnancy on both renal prognosis and the offspring.
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PMID:Dialysis, transplantation, and pregnancy. 195 48

A questionnaire survey of current practice at a small cross-section of obstetric units, covering 22% of all United Kingdom deliveries, revealed a marked lack of standard practice regarding requests for coagulation screens on pre-eclamptic patients who require epidural procedures. A retrospective audit was therefore carried out on 434 coagulation screens requested for pre-eclamptic patients in whom epidural analgesia might have been considered. Borderline abnormalities of coagulation were found in only 10 patients (2%). Platelet counts of less than 150 x 10(9)/litre were present in 28% of cases. 'Significant' thrombocytopenia (less than 100 x 10(9)/litre) and all coagulation abnormalities were only encountered in severe pre-eclampsia (diastolic blood pressure of greater than 110 mmHg and proteinuria of + + or greater). Furthermore, coagulation abnormality was always associated with a reduced platelet count (mean, 97 x 10(9)/litre). This study would therefore support anaesthetic practice which restricted any requests for coagulation testing to severe pre-eclamptic patients only. For these patients first line testing could be limited to a platelet count.
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PMID:Coagulation screening before epidural analgesia in pre-eclampsia. 186 17

On the basis of a review of the literature and five case histories, the pathophysiological and clinical features in pregnant women with haemolysis, elevated liver enzymes and thrombocytopenia which together constitute the HELLP syndrome (haemolysis, elevated liver enzymes and low platelet count) are illustrated. This syndrome describes a complicated obstetric course with greatly increased neonatal and maternal morbidities. Hypertension/proteinuria are common but are not obligatory. The condition should be suspected in pregnant women with pain under the right rib margin and unexplained jaundice. The diagnosis is verified by the blood picture, liver enzyme count and a blood smear. Women with verified HELLP syndrome and gestational age greater than 34 weeks should be delivered immediately. Women with the same syndrome and gestational age less than 32 weeks should be delivered if the condition cannot be rapidly controlled. In exceptional cases cesarean section may be necessary. On the basis of the coagulation status, the defective plasma components may be supplied (e.g. fresh frozen plasma and antithrombin-III). Plasmapheresis and specific pharmacological intervention must be considered as experimental at present, although these present promising therapeutic possibilities.
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PMID:[Hemolysis, elevated liver enzymes and thrombocytopenia: the HELLP syndrome--a manifestation of severe pre-eclampsia]. 204 40

Thrombotic thrombocytopenic purpura (TTP) is a syndrome that occurs mainly in adults with multiorgan microvascular thrombosis consisting of thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal involvement, and fever. The female to male ratio is 3:2, and peak incidence occurs in the 3rd decade of life. Clinical signs are the consequence of hyaline thrombosis and occlusion of capillaries and arterioles. Renal ailment manifests itself in hematuria and proteinuria with azotemia and even overt renal failure. In severe disease, azotemia is typical of hemolytic uremic syndrome (HUS). TTP was first described in 1925 by Moschcowitz. The clinical picture of TTP consists of a prodromal phase, a viruslike disease occurring in up to 40% of patients. 60% have neurologic disturbances, 90% have purpura initially, and fever occurs in all. Anemia is often severe with hemoglobin values of 7-9 gm/dl, renal involvement in 90%, and renal failure in 40-80% of patients. Clinical variants include the acute and fulminant variety mortality, the chronic form, and the relapsing form. Predisposing factors and triggering agents are autosomal recessive inherited traits in acute idiopathic TTP, systemic diseases, tumor antigens, pregnancy and puerperium, viruses (endotoxins for HUS), and possibly oral contraceptives and hypertension. Therapy includes corticosteroids (prednisone 100-400 mg/day); heparin for postpartum HUS; and antiplatelet agents (Dextran 70, aspirin, and dipyridamole in high doses). The infusion of PGI2 is controversial; splenectomy is also questionable; and vincristine, azathioprine, and cyclophosphamide have unproven efficacy. Fresh-frozen plasma exchange is the method of choice as it produces survival in 90%. Others are iv immunoglobulins, vitamin E, and dialysis and renal transplant. Platelet transfusions are contraindicated because of sudden death and decreased survival.
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PMID:Thrombotic thrombocytopenic purpura and related disorders. 210 74

One hundred and forty patients with classic or definite rheumatoid polyarthritis were treated with N2 mercapto-propionly-glycine: thiopronine (Acadione) at an average dose of 1 g per day over a mean duration of 11.7 months + 10.7 months. The retrospective study of these cases, followed between 1980 and 1988 by the same medical team, permits to evaluate the long-term tolerance of the product. Adverse reaction, always subsiding were observed in 55 p. cent of the patients, requiring discontinuation of the treatment in 40 p. cent of the cases. These side effects occur in 3/4 of the cases, during the first 6 months of the treatment. The intolerance mainly affect skin and mucosae: 46 cases (32.8 p. cent) resulting in 32 instances (22.8 p. cent) discontinuation of the treatment because of stomatitis, pruritus, various types of erythema, pemphigus (1 case). Fourteen patients presented a renal failure (10 p. cent) requiring in 8 instances (5.7 p. cent) discontinuation of the thiopronine because of nephrotic syndrome (3 case) and proteinuria (5 cases). Haematological disorders were observed in 13 instances (9.2 p. cent), justifying, in 10 instances (7.1 p. cent) discontinuation of the treatment because of thrombopenia or leucothrombopenia. The other side effects observed are the following: digestive disorders 15 cases (10.7 p. cent) requiring discontinuation of the treatment in 3 instances (2.1 p. cent), agueusia in 6 instances (4.2 p. cent) requiring discontinuation of the treatment in one case; miscellaneous disorders 13.5 p. cent for which the responsibility of thiopronine is not precisely established (especially hepatic cholostasis, muscle disorders), requiring discontinuation the the treatment in 1.4 p. cent of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Long-term tolerability of tiopronin (Acadione) in the treatment of rheumatoid arthritis. Apropos of 140 personal cases]. 213 12

Although many reports have been made on the effectiveness of plasma exchange (PE) in active systemic lupus erythematosus (SLE), but there are no clear-cut criteria of indication for lupus nephritis (LN). In order to determine the criteria for indication of LN, 35 patients with LN treated by PE were studied with respect to renal function (F), proteinuria (P), immunological activity (A) and renal histology. The patients were divided into 4 groups according to the severity of renal function: F1 (stable chronic renal failure (CRF) or stable renal function n = 13), F2 (relapse type n = 9), F3 (rapidly progressive LN; creatinine clearance (Ccr) less than 40 ml/min n = 7) and F4 (acute renal failure; Ccr less than 10 ml/min n = 6). Proteinuria was also studied in 4 groups: P1 & P2 (without nephrotic syndrome (NS], P3 (acute type NS n = 15), and P4 (chronic type NS n = 7). These patients were divided into 3 groups to study immunological activity: A1 (chronic stage n = 6), A2 (relapse stage n = 12) and A3 (active stage n = 17). Comparison was made in each parameter. Renal histological classification according to WHO criteria of LN, activity score (AS) and chronicity score (CS) were evaluated and compared. As a result, the following indication was obtained. 1) ABSOLUTE INDICATION: 1. Rapidly progressive LN with high immunological activity; elevated serum creatinine (SCr) greater than 1.0 mg/dl/month or decreased Ccr from normal renal function to less than 40 ml/min within 1-2 months after onset. 2. Acute type NS within 1 year after onset. 3. histological AS greater than 20. 2) RELATIVE INDICATION: 1. Relapse LN with moderate immunological activity, decreased Ccr from normal function to 40-50 ml/min within 3-6 months, the rise in SCr of greater than 1.0 mg/dl/month. 2. Proteinuria is 1.0-3.5 g/day within 1 year after onset. 3. Such complication as CNS, serositis, thrombocytopenia and leukopenia, steroid resistance and/or severe side effects of steroid. 3) NO INDICATION: 1. CRF or stable renal function (Ccr greater than 50 ml/min). 2. Chronic type NS over 1 years with past history of NS and/or edema. 3. Low immunological activity and mild renal histology.
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PMID:[The criteria for indication of plasma exchange on lupus nephritis]. 221 18

The question of whether the HELLP syndrome exists as a distinct entity or is part of a spectrum of pregnancy complications, which have in common hemolysis, elevated liver enzymes, and thrombocytopenia, has long been a source of speculation and debate among obstetricians and internists. A review of the literature indicates a definite need for a uniform definition, diagnosis, and management of this syndrome. Patients manifesting this syndrome usually are seen before term (less than 36 weeks' gestation) complaining of malaise (90%), epigastric or right upper-quadrant pain (90%), and nausea or vomiting (50%), and some will have nonspecific viral-syndrome-like symptoms. Hypertension and proteinuria may be absent or slight. Thus some of these patients may have a variety of signs and symptoms, none of which are diagnostic of classic preeclampsia. In consideration of the high maternal and perinatal mortality and morbidity reported with the presence of this syndrome, I recommend that all pregnant women having any of these symptoms should have a complete blood cell count with platelet and liver enzyme determinations irrespective of maternal blood pressure.
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PMID:The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing? 240 34


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