Recurrent versus first cervical artery dissection - a retrospective study of clinical and vascular characteristics

BACKGROUND AND PURPOSE

Most recurrent cervical artery dissection (CeAD) events occur shortly after the acute first CeAD. This study compared the characteristics of recurrent and first CeAD events and searched for associations between subsequent events of an individual person.

METHODS

Cervical artery dissection patients with a new CeAD event occurring during a 3-6 month follow-up were retrospectively selected in seven specialized stroke centers. Clinical and vascular characteristics of the initial and the recurrent CeADs were compared.

RESULTS

The study sample included 76 patients. Recurrent CeADs were occlusive in one (1.3%) patient, caused cerebral ischaemia in 13 (17.1%) and were asymptomatic in 39 (51.3%) patients, compared to 29 (38.2%) occlusive, 42 (55.3%) ischaemic and no asymptomatic first CeAD events. In 52 (68.4%) patients, recurrent dissections affected both internal carotid arteries or both vertebral arteries, whilst 24 (31.6%) patients had subsequent dissections in both types of artery. Twelve (28.6%) of 42 patients with an ischaemic first dissection had ischaemic symptoms due to the recurrent CeADs, too. However, only one (1.3%) of 34 patients with a non-ischaemic first CeAD suffered ischaemia upon recurrence.

CONCLUSION

Recurrent CeAD typically affects the same site of artery. It causes ischaemic events less often than the first CeAD. The risk that patients who presented with solely non-ischaemic symptoms of a first CeAD will have ischaemic symptoms in the case of a recurrent CeAD seems very small.

Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study

BACKGROUND AND PURPOSE

Risk factors for IS in young adults differ between genders and evolve with age, but data on the age- and gender-specific differences by stroke etiology are scare. These features were compared based on individual patient data from 15 European stroke centers.

METHODS

Stroke etiology was reported in detail for 3331 patients aged 15-49 years with first-ever IS according to Trial of Org in Acute Stroke Treatment (TOAST) criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-vessel occlusion (SVO), other determined etiology, or undetermined etiology. CE was categorized into low- and high-risk sources. Other determined group was divided into dissection and other non-dissection causes. Comparisons were done using logistic regression, adjusting for age, gender, and center heterogeneity.

RESULTS

Etiology remained undetermined in 39.6%. Other determined etiology was found in 21.6%, CE in 17.3%, SVO in 12.2%, and LAA in 9.3%. Other determined etiology was more common in females and younger patients, with cervical artery dissection being the single most common etiology (12.8%). CE was more common in younger patients. Within CE, the most frequent high-risk sources were atrial fibrillation/flutter (15.1%) and cardiomyopathy (11.5%). LAA, high-risk sources of CE, and SVO were more common in males. LAA and SVO showed an increasing frequency with age. No significant etiologic distribution differences were found amongst southern, central, or northern Europe.

CONCLUSIONS

The etiology of IS in young adults has clear gender-specific patterns that change with age. A notable portion of these patients remains without an evident stroke mechanism according to TOAST criteria.

Neurostimulation for Parkinson's disease with early motor complications

BACKGROUND

Subthalamic stimulation reduces motor disability and improves quality of life in patients with advanced Parkinson's disease who have severe levodopa-induced motor complications. We hypothesized that neurostimulation would be beneficial at an earlier stage of Parkinson's disease.

METHODS

In this 2-year trial, we randomly assigned 251 patients with Parkinson's disease and early motor complications (mean age, 52 years; mean duration of disease, 7.5 years) to undergo neurostimulation plus medical therapy or medical therapy alone. The primary end point was quality of life, as assessed with the use of the Parkinson's Disease Questionnaire (PDQ-39) summary index (with scores ranging from 0 to 100 and higher scores indicating worse function). Major secondary outcomes included parkinsonian motor disability, activities of daily living, levodopa-induced motor complications (as assessed with the use of the Unified Parkinson's Disease Rating Scale, parts III, II, and IV, respectively), and time with good mobility and no dyskinesia.

RESULTS

For the primary outcome of quality of life, the mean score for the neurostimulation group improved by 7.8 points, and that for the medical-therapy group worsened by 0.2 points (between-group difference in mean change from baseline to 2 years, 8.0 points; P=0.002). Neurostimulation was superior to medical therapy with respect to motor disability (P<0.001), activities of daily living (P<0.001), levodopa-induced motor complications (P<0.001), and time with good mobility and no dyskinesia (P=0.01). Serious adverse events occurred in 54.8% of the patients in the neurostimulation group and in 44.1% of those in the medical-therapy group. Serious adverse events related to surgical implantation or the neurostimulation device occurred in 17.7% of patients. An expert panel confirmed that medical therapy was consistent with practice guidelines for 96.8% of the patients in the neurostimulation group and for 94.5% of those in the medical-therapy group.

CONCLUSIONS

Subthalamic stimulation was superior to medical therapy in patients with Parkinson's disease and early motor complications. (Funded by the German Ministry of Research and others; EARLYSTIM ClinicalTrials.gov number, NCT00354133.).

Migraine in cervical artery dissection and ischemic stroke patients

OBJECTIVE

Several small to medium-sized studies indicated a link between cervical artery dissection (CeAD) and migraine. Migrainous CeAD patients were suggested to have different clinical characteristics compared to nonmigraine CeAD patients. We tested these hypotheses in the large Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) population.

METHODS

A total of 968 CeAD patients and 653 patients with an ischemic stroke of a cause other than CeAD (non-CeAD IS) were recruited. CeAD patients with stroke (CeAD(stroke), n = 635) were compared with non-CeAD IS patients regarding migraine, clinical characteristics, and outcome. CeAD patients with and without migraine were compared in terms of clinical characteristics and outcome.

RESULTS

Migraine was more common among CeAD(stroke) patients compared to non-CeAD IS patients (35.7 vs 27.4%, p = 0.003). The difference was mainly due to migraine without aura (20.2 vs 11.2%, p < 0.001). There were no differences in prevalence of strokes, arterial distribution, or other clinical or prognostic features between migrainous and nonmigrainous CeAD patients.

CONCLUSION

Migraine without aura is more common among CeAD(stroke) patients compared to non-CeAD IS patients. The mechanisms and possible causative link remain to be proved. Although CeAD is often complicated by stroke, our data do not support increased risk of stroke in migrainous CeAD patients.

CADISP-Genetics: An International Project Searching for Genetic Risk Factors of Cervical Artery Dissections

Background

Cervical artery dissection (CAD) is a frequent cause of ischemic stroke, and occasionally death, in young adults. Several lines of evidence suggest a genetic predisposition to CAD. However, previous genetic studies have been inconclusive mainly due to insufficient numbers of patients. Our hypothesis is that CAD is a multifactorial disease caused by yet largely unidentified genetic variants and environmental factors, which may interact. Our aim is to identify genetic variants associated with an increased risk of CAD and possibly gene-environment interactions.

Methods

We organized a multinational European network, Cervical Artery Dissection and Ischemic Stroke Patients (CADISP), which aims at increasing our knowledge of the pathophysiological mechanisms of this disease in a large group of patients. Within this network, we are aiming to perform a de novo genetic association analysis using both a genome-wide and a candidate gene approach. For this purpose, DNA from approximately 1100 patients with CAD, and 2000 healthy controls is being collected. In addition, detailed clinical, laboratory, diagnostic, therapeutic, and outcome data are being collected from all participants applying predefined criteria and definitions in a standardized way. We are expecting to reach the above numbers of subjects by early 2009. Conclusions We present the strategy of a collaborative project searching for the genetic risk factors of CAD. The CADISP network will provide detailed and novel data on environmental risk factors and genetic susceptibility to CAD.

Factor XII C46T gene polymorphism and the risk of cerebral venous thrombosis

BACKGROUND

The TT genotype of a functional factor XII (FXII) C46T gene polymorphism was shown to be a risk factor for peripheral venous thrombosis. We tested whether this genetic variant also increases the risk for cerebral venous thrombosis (CVT).

METHODS

We performed a case-control study including 78 consecutive patients with proven CVT and 201 healthy population controls from South Germany. The FXII C46T genotype was assessed using a PCR technique.

RESULTS

The TT genotype of the FXII C46T polymorphism was more common in patients (16.7%) than in controls (5.5%). A strong association of the TT genotype with CVT was found, which was independent of covariables (adjusted odds ratio 4.57; 95% CI 1.55 to 13.41; p = 0.006).

CONCLUSION

The TT genotype of the functional factor XII C46T gene polymorphism may be a new independent risk factor for cerebral venous thrombosis (CVT). Our finding warrants confirmation in an independent study before this genetic variant should be added to the panel of established risk factors for CVT.

No association of the -105 promoter polymorphism of the selenoprotein S encoding gene SEPS1 with cerebrovascular disease

A common pro-inflammatory promoter variant of the selenoprotein S encoding gene (SEPS1) was studied in young stroke patients from Italy and Germany and in healthy control subjects. The -105A-allele was found in 56 of 205 (27.3%) patients with ischemic stroke IS because of a spontaneous cervical artery dissection (CAD), and in 69 of 295 (23.4%) patients <50 years with IS of non-CAD origin. The SEPS -105A promoter variant was detected in 87 of 393 healthy control subjects (22.1%) and in 11 of 55 CAD patients without IS (20%). The non-significant differences of SEPS1 allele frequencies between disease groups and healthy controls suggest that the SEPS1 -105A allele is not a major-risk factor for stroke.

MTHFR 677TT genotype increases the risk for cervical artery dissections

The methylene tetrahydrofolate reductase (MTHFR) C677T polymorphism was studied in 174 German patients with cervical artery dissection (CAD). The results were compared with published data on 927 healthy German controls. In the series of patients, the frequency of T alleles and of TT carriers was slightly higher (13.8%) than among the healthy controls (10.6%). In patients with multiple dissections (n = 50), the proportion of TT carriers (18%) was found to be even higher and correlated with the number of events. The MTHFR C677T polymorphism was suggested to modify the risk for CAD.

MTHFR 677TT genotype increases the risk for cervical artery dissections

The methylene tetrahydrofolate reductase (MTHFR) C677T polymorphism was studied in 174 German patients with cervical artery dissection (CAD). The results were compared with published data on 927 healthy German controls. In the series of patients, the frequency of T alleles and of TT carriers was slightly higher (13.8%) than among the healthy controls (10.6%). In patients with multiple dissections (n = 50), the proportion of TT carriers (18%) was found to be even higher and correlated with the number of events. The MTHFR C677T polymorphism was suggested to modify the risk for CAD.

Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome

OBJECTIVE

A significant number of patients with obsessive-compulsive disorder (OCD) fail to benefit sufficiently from treatments. This study aimed to evaluate whether certain OCD symptom dimensions were associated with cognitive-behavioral therapy (CBT) outcome.

METHOD

Symptoms of 104 CBT-treated in-patients with OCD were assessed with the clinician-rated Yale-Brown Obsessive-Compulsive Scale symptom checklist. Logistic regression analyses examined outcome predictors.

RESULTS

The most frequent OCD symptoms were aggressive and contamination obsessions, and compulsive checking and cleaning. Patients with hoarding symptoms at baseline (n = 19) were significantly less likely to become treatment responders as compared to patients without these symptoms. Patients with sexual and religious obsessions tended to respond less frequently, although this failed to reach statistical significance (P = 0.07). Regression analyses revealed that higher scores on the hoarding dimension were predictive of non-response, even after controlling for possible confounding variables.

CONCLUSION

Our results strongly indicate that in-patients with obsessive-compulsive hoarding respond poorly to CBT.

Impact of comorbid depressive symptoms on neuropsychological performance in obsessive-compulsive disorder

There is indirect evidence from previous research that several executive disturbances in obsessive-compulsive disorder (OCD) are mediated by comorbid depressive symptoms. For the present study, the authors investigated whether OCD patients with elevated Hamilton Rating Scale for Depression (HRSD) scores would exhibit deficits in tasks sensitive to the medial and dorsolateral frontal cortex as well as other executive tasks. The 36 OCD patients were split along the median according to their HRSD scores and compared with matched control subjects. Patients with high HRSD scores performed significantly worse than control subjects and patients with low HRSD scores on the Wisconsin Card Sorting Test, the Trail-Making Test (TMT, Part B), and the TMT difference score. Moreover, patients with high HRSD scores exhibited deficits on a (creative) verbal fluency task. It is suggested that comorbid depressive symptoms may have artificially inflated some executive deficit scores in previous studies.

Impact of comorbid depressive symptoms on neuropsychological performance in obsessive-compulsive disorder

There is indirect evidence from previous research that several executive disturbances in obsessive-compulsive disorder (OCD) are mediated by comorbid depressive symptoms. For the present study, the authors investigated whether OCD patients with elevated Hamilton Rating Scale for Depression (HRSD) scores would exhibit deficits in tasks sensitive to the medial and dorsolateral frontal cortex as well as other executive tasks. The 36 OCD patients were split along the median according to their HRSD scores and compared with matched control subjects. Patients with high HRSD scores performed significantly worse than control subjects and patients with low HRSD scores on the Wisconsin Card Sorting Test, the Trail-Making Test (TMT, Part B), and the TMT difference score. Moreover, patients with high HRSD scores exhibited deficits on a (creative) verbal fluency task. It is suggested that comorbid depressive symptoms may have artificially inflated some executive deficit scores in previous studies.

Enhanced semantic priming in thought-disordered schizophrenic patients using a word pronunciation task

Previous research on semantic priming in schizophrenia has produced contradictory findings. For the present study, it was intended to resolve some of the ambiguities in the literature. Using a semantic priming task with word pronunciation, evidence is provided that thought-disordered schizophrenic (TD) patients exhibit significantly increased semantic priming as compared to healthy and psychiatric controls. Results suggest that enhanced semantic priming is not confined to tasks that require lexical decision. Moreover, results indicate that TD schizophrenic patients suffer from a decay of hierarchical thinking, i.e. TD schizophrenics reveal a tendency to process the less meaningful rather than the dominant aspects of external information. Priming effects for the inferior meaning of homograph words (for example, 'dance' is an inferior, and 'game' is a superior associate of the word 'ball') were significantly greater compared to healthy controls and non-TD schizophrenics. Results were not moderated by sociodemographic background variables, psychomotor slowing and psychopathological symptoms other than thought disorder.

'Hyper-priming' in thought-disordered schizophrenic patients

BACKGROUND

A number of studies have suggested that indirect semantic priming is enhanced in thought-disordered schizophrenics. However, research on direct semantic priming has produced conflicting results. The aim of the present study was to resolve some of the ambiguities of previous findings.

METHODS

For the present study, 44 schizophrenic patients were split according to the presence of associative loosening into a positive thought-disordered (TD) and non-positive thought-disordered (NTD) group. Thirty healthy subjects and 36 psychiatric patients served as controls.

RESULTS

Schizophrenics displayed increased indirect semantic priming compared with psychiatric controls. When subtyping the sample, TD-patients exhibited significantly enhanced indirect semantic priming compared with healthy and psychiatric controls as well as NTD-patients. Overall slowing was found to be independent of priming effects. Medication, age and chronicity of the schizophrenic illness did not modulate priming.

CONCLUSIONS

In line with Spitzer and Maher it is inferred that disinhibited semantic networks underlie formal thought disorder in schizophrenia. For future research, it would be appropriate to: employ indirect semantic priming rather than direct semantic priming conditions; and, pay more attention to potential moderators of the priming effect, most importantly, the prime display duration and the length of the stimulus onset asynchrony.

Electrocardiographic remodeling in patients paced for heart failure

Congestive heart failure due to advanced coronary artery disease or dilated cardiomyopathy is often associated with intraventricular conduction delays. Electrical resynchronization is an evolving method to improve clinical and functional status. To evaluate whether pacing-induced changes in the electrocardiogram are related to hemodynamic changes, we analyzed electrocardiograms of patients enrolled in the Pacing Therapies in Congestive Heart Failure trial. The study population consisted of 42 patients, New York Heart Association functional class III-IV with a baseline QRS complex of 175 +/- 32 msec and a PR interval of 196 +/- 33 msec. The mean left ventricular ejection fraction was 0.23. Using high-resolution computer scans, we measured QRS duration of intrinsic and paced electrocardiographs at different times during the study. Results of the electrocardiographic measurements were correlated with functional results. During the crossover period, 34 episodes of biventricular pacing, 27 episodes of left ventricular pacing, and 5 episodes of right ventricular pacing occurred, each at an individual optimized atrioventricular (AV) delay. The only significant difference was that right ventricular pacing increased the QRS width by 40 msec as compared with baseline or biventricular pacing. Functional benefit, as indicated by relative increase of peak oxygen uptake (VO2) compared with baseline, was significantly correlated with shortening of paced QRS width (correlation coefficient, r = 0.55; p <0.05). After 12-month follow-up of 28 patients, we saw a slight, nonsignificant decrease of intrinsic QRS width. With regard to the underlying disease, intrinsic QRS width at baseline and at 12 months was also not significantly different between patients with coronary artery disease and dilated cardiomyopathy. This study found that right ventricular pacing causes an increase in QRS duration in patients with left bundle-branch block, whereas in left ventricular and biventricular pacing, QRS width remains unchanged. Shortening of QRS width is correlated with a pronounced relative increase of peak VO2, and thus may become a noninvasive marker of clinical efficacy. There is no evidence of remodeling of the intrinsic electrocardiogram after 12 months of pacing.

Potential benefit of biventricular pacing in patients with congestive heart failure and ventricular tachyarrhythmia

Treatment of congestive heart failure (CHF) aims for symptomatic relief and reduction of mortality both from sudden death and pump failure. The implantable cardioverter defibrillator (ICD) is highly effective in the prevention of sudden death, but no mortality benefit in advanced CHF has yet been shown. Biventricular pacing may lead to functional improvement in selected patients with CHF. Thus, a biventricular pacemaker with defibrillation capabilities may be ideal for patients with advanced CHF. We retrospectively analyzed the data from 384 patients (age 59 +/- 12 years, 322 male and 62 female) with regard to New York Heart Association (NYHA) CHF class, mean QRS duration, mean PR interval, presence of a QRS > 120 msec and incidence of atrial fibrillation at the time of ICD implantation. Based on eligibility criteria from studies in biventricular pacing, we analyzed how many patients may benefit from biventricular pacing. Patients with CHF were older (NYHA class III: 60.9 +/- 9.7, class II: 61.3 +/- 10 versus class I: 50.8 +/- 13.6 years, p < 0.001 each) and mean QRS duration was longer with advanced CHF (NYHA class III 127.8 +/- 30 msec; class II 119.4 +/- 27.7 msec; class 0-1: 103.9 +/- 17.7 msec, p < 0.001, analysis of variance) as was the mean PR interval (NYHA class III 189.9 +/- 33.5 msec; class II 176.1 +/- 29.3 msec; class 0-1 162.7 +/- 45.9 msec, p < 0.001, analysis of variance). The incidence of atrial fibrillation was higher in class III (25.5%) compared with class 0-1 (16.9%) and class II patients (14.1%, p = 0.043, chi-square test). A total of 28 patients (7.3%) fulfilled eligibility criteria for biventricular pacing if NYHA class III patients were considered candidates and 48 (12.5%) if patients with NYHA II CHF and ejection fraction < or = 30% were included. Thus, biventricular pacing may offer a promising therapeutic approach for a significant proportion of patients with CHF at risk for ventricular tachyarrhythmia.

Antibodies to beta2 glycoprotein I are associated with in vitro fertilization implantation failure as well as recurrent miscarriage: results of a prevalence study

OBJECTIVE

To investigate whether antiphospholipid and related autoantibodies are associated with IVF implantation failure as well as with recurrent spontaneous miscarriage.

DESIGN

Prevalence study.

SETTING

University teaching hospital and associated IVF unit.

PATIENT(S)

Patients with at least three consecutive first-trimester miscarriages (n = 97), patients undergoing IVF who had at least 10 embryos transferred without any resulting clinical pregnancy (n = 105), fertile women (n = 106), and patients newly referred for IVF treatment (n = 52).

INTERVENTION(S)

Antibodies tested included lupus anticoagulant; immunoglobulin (Ig) G and IgM isotypes of each of anticardiolipin antibody, antiphosphatidylserine, antiphosphatidylethanolamine, and antiphosphatidylinositol; beta2 glycoprotein I antibodies; and antinuclear antibodies. Statistical analysis included chi2 and Fisher's exact tests for differences between groups, and multiple linear regression analysis and Spearman's nonparametric tests for relations between results.

MAIN OUTCOME MEASURE(S)

Seropositivity for autoantibodies tested.

RESULT(S)

Overall, 84 (23%) of the 360 samples tested positive for at least one autoantibody. Beta2 glycoprotein I IgM antibody and antinuclear antibody were significantly associated with both IVF implantation failure and recurrent miscarriage.

CONCLUSION(S)

Autoantibodies, particularly beta2 glycoprotein I antibodies and antinuclear antibodies, are associated with IVF implantation failure as well as with recurrent spontaneous abortion, although the mechanism is still unclear. The high seroprevalence of antibodies to beta2 glycoprotein I suggests that it may have an important role in autoimmune reproductive failure that needs to be explored further.

The Royal Women's Hospital Family Birth Centre: the first 10 years reviewed

In reviewing the first 10 years experience of the Royal Women's Hospital Family Birth Centre (FBC), we examined the outcomes of pregnancy and labour in a group of women who requested alternative birthing care and who were identified antenatally as being a 'low-risk' population. This study is a retrospective analysis of 5,365 women booked with the birth centre between 1980 and 1989. Over 16% of women developed antenatal complications precluding further care there, while a further 16% developed complications in labour requiring transfer out to conventional labour wards. Thus 67% of those originally booked delivered in the FBC. The instrumental delivery rate was 11%, and the Caesarean section rate was 4%. Of the women who delivered in the FBC, 3.1% had a postpartum haemorrhage and 1.8% required manual removal of placenta. Approximately 4% of babies born in the FBC required some resuscitation, and 0.8% needed admission to the neonatal nursery. Two perinatal deaths occurred in women admitted in labour to the FBC with a live baby, whilst 2 other women presented in labour with a fetal death in utero (perinatal mortality 0.89 per 1,000).

Predictors of pregnancy success in repeated miscarriage

Factors that may have a bearing on subsequent pregnancy success or failure in patients with recurrent abortion were examined in 165 women with a history of three or more consecutive miscarriages in the first trimester. The overall success rate was 67.9%. Factors that were found to correlate significantly with success rate were length of abortion history, total number of abortions, interval from last miscarriage to present pregnancy, and whether there was any degree of subfertility. Logistic regression analysis showed that the abortion x years index and maternal age accounted for all the variation observed in our data. Where all other known causes of abortions are excluded, recurrent aborters can be subdivided into two populations--namely, those with a relatively good prognosis characterized by a short abortion history and absence of subfertility problems, compared to those with a poor prognosis namely those with a long abortion history or presence of subfertility problems. These data clearly demonstrate major differences in success rates in women depending on the number of abortions and the length of abortion history (abortion x year index), particularly in women over the age of 30 years.

Treatment of recurrent aborters by immunization with paternal cells--controlled trial

A paired sequential trial was undertaken to establish whether paternal mononuclear cells improved the prognosis in couples with recurrent abortions. For this purpose, 10(7)-10(8) cells obtained from the blood of partners were injected intravenously, subcutaneously, and intra-dermally into women who had had three or more consecutive miscarriages with the same partner. Control women were given normal saline, injected in the same manner. The result of the sequential analysis showed that there was no significant beneficial effect of the cells compared to control. The overall success rate was 70% (32/46 couples). The success rate in patients given cells was 62% (13/21), while in those given saline it was 76% (19/25). While the overall success rate in this study compares with a number of other studies, we find an equally high success rate with non-immunized patients. We conclude that the value of immunization for the prevention of recurrent miscarriage has not been established.

Postabortal pelvic sepsis in association with Chlamydia trachomatis

Cervical swabs for Chlamydia trachomatis culture were taken from 527 women presenting for elective termination of pregnancy. Twenty-six patients (4.9%) harboured C. trachomatis; 21 (81%) of these were less than 25-years-old and 21 (81%) were nulliparas. Postoperative pelvic sepsis developed in 11.5% of chlamydia-positive women, in contrast to 3.6% of chlamydia-negative women. Consequently it is suggested that all patients, especially those younger than 25 years, presenting for termination of pregnancy or in whom an intrauterine device is to be inserted should be screened and have treatment commenced for C. trachomatis prior to the operative procedure.

Primary glomerulonephritis and pregnancy

Three hundred and ninety-five pregnancies undertaken by 238 women with primary glomerulonephritis between 1962 and 1987 were analysed to record fetal and maternal outcome and identify risk factors for a poor outcome. Of 398 fetuses, 26 per cent were lost (including therapeutic abortions), 24 per cent surviving infants were premature (less than or equal to 36 weeks gestation) and 51 per cent were term. Excluding therapeutic abortions, 20 per cent of fetuses were lost, 15 per cent after 20 weeks gestation. Fifteen per cent of 237 fetuses whose birth weight was recorded were small for gestational age: Deterioration in maternal renal function was seen in 15 per cent of pregnancies and in 5 per cent of women failed to resolve post partum. Only four women had impaired renal function recorded in the first-trimester and two of these were known to have renal impairment before pregnancy. Hypertension was recorded in 52 per cent of pregnancies, developed early (less than or equal to 32 weeks gestation) in 26 per cent and was severe in 18 per cent. Treated hypertension pre-dated 12 per cent of pregnancies and in 7 per cent (included in the overall incidence of hypertension) exacerbation occurred during pregnancy despite continued antihypertensive medication. Forty-four women (18 per cent) who developed de novo hypertension in pregnancy had permanent hypertension postpartum. Increased proteinuria was recorded in 59 per cent of pregnancies and was irreversible in 15 per cent of women. Comparison of pregnancies which occurred before or after renal biopsy revealed a significantly higher fetal loss rate after 20 weeks gestation in those pregnancies undertaken before the diagnosis of renal disease, and a significantly higher incidence of hypertension and increased proteinuria. Impaired renal function, early or severe hypertension or nephrotic range proteinuria was significantly associated with increased fetal loss, prematurity and fewer full-term infants. There was no significant difference in fetal outcome or maternal complications in pregnancy in patients with treated hypertension before pregnancy and those who were normotensive in the first-trimester. The highest incidence of fetal and maternal complications occurred in patients with primary focal and segmental hyalinosis and sclerosis and the lowest in non-IgA diffuse mesangial proliferative glomerulonephritis. The presence of severe vessel lesions on renal biopsy was associated with a significantly higher total fetal loss and fetal loss after 20 weeks gestation.

Lupus anticoagulant associated with renal thrombotic microangiopathy and pregnancy-related renal failure

The clinical features in 12 women with a circulating coagulation inhibitor (lupus 'anticoagulant') were studied and correlated with findings in 22 renal biopsies in these patients. Four of 12 women had serological evidence of systemic lupus. Only two of 23 pregnancies in these women were successful. Lesions in all biopsies were remarkably similar. Seven biopsies taken during or soon after pregnancy showed acute fibrinoid lesions. 'Acute' lesions consisted of fibrin thrombi in glomeruli arterioles and arteries and double contours in glomerular capillary walls. Biopsies carried out remote from pregnancy in these seven patients showed persisting double contours in glomeruli together with narrowing of arteries due to recanalizing thrombi and cellular intimal proliferation. All other biopsies showed similar lesions. The lesions were essentially the same as those of thrombotic microangiopathy and those described previously in post-partum renal failure. Renal function was severely impaired in four patients and showed moderate impairment in two patients at the time that acute thrombotic lesions were demonstrated in glomeruli. Renal function in two patients improved during plasma exchange therapy. Because all biopsies showed either acute, healing or healed, thrombotic lesions, it is proposed that these lesions are characteristic of the renal findings in patients with a lupus 'anticoagulant'. In all but two cases the acute lesions were seen during or soon after pregnancy.

Histocompatibility antigens and habitual abortion

Eighty-five couples with habitual abortion were studied: 43 were primary aborters (i.e., had no advanced pregnancy beyond 20 weeks gestation), and 42 were secondary aborters. The only significant finding in primary female aborters was a reduction in the incidence of B35. In contrast, in secondary female aborters there was a reduction in the incidence of DR3 and A1/B8/DR3 and an increase in the degree of homozygosity of HLA B. In the male partners of primary aborters, there was a reduced incidence of DR3 and A1/B8/DR3. In addition, in male partners of both primary and secondary aborters, there was increased HLA-B homozygosity and increased frequency of DR4-5 phenotype. Increased sharing of HLA antigens between partners was not found to be significantly different from the control population. These findings emphasize that primary and secondary female aborters form distinct populations, which could explain differences in immunological responses to various antigens, including fetal-related antigens. The closely related findings in female secondary aborters and male partners of primary aborters are intriguing but cannot be explained. Whether or not these genetic markers bear any relationship to reproductive success remains to be determined.

The management of severe preeclampsia with intravenous magnesium sulphate, hydralazine and central venous catheterization

A prospective study of patients with severe preeclampsia managed by magnesium sulphate infusion for eclampsia prophylaxis, hydralazine infusion for vasodilatation and central venous catheterization for fluid monitoring is reported. In this preliminary report of 46 patients, there was no episode of eclampsia following treatment, no maternal death, and hypertension was well controlled in all patients. Of the 51 babies born, there were 7 stillbirths, and 4 neonatal deaths; 6 of the 7 stillbirths were less than 30 weeks' gestation, and 23 of the 46 patients were delivered by Caesarean section.

Immunogenetic studies in habitual abortion

Recent evidence suggests that immunological factors could play a role in the aetiology of habitual abortion. In this study, 71 couples with habitual abortion (i.e. more than 3 successive abortions) were investigated. Sharing of HLA-A, B, DR between partners was not found to be significantly increased. Anti-HLA antibodies in women against their partners' lymphocytes were found in 18.3%. After immunization with 10(7)-10(8) lymphocytes obtained from husband or unrelated donor, there was a seroconversion rate of 61% in those without antibodies initially. This was not dependent on the number of cells injected, source of cells, degree of sharing of HLA antigens or whether the couple were primary aborters (i.e. having had no advanced pregnancy), or secondary aborters. Seven pregnancies have resulted following the immunization procedure so far, 5 occurring in cross-match positive patients and 2 in cross-match negative. Growth retarded infants resulted from the pregnancy of 1 primary aborter and 2 secondary aborters.