106
Communications
in brief
prolonged apnea as one might expect under these conditions. Baraka and associates’ repor’& prolonged ;IprlC” of 2.1 and 6 hours, respectiveI\. in a inother and her nexvborn infant. both h~JmcyygcJ& for the atypical enzyme. following 100 nig of intravenous succinylcholine. In our case the mother received at least fiwn rimes thal close and was apncic foi- X hours. \c-t the neonate shmed no ill eftec-ts f’roni rhc drug. It ‘k gelierally believed that the f’et~~s is prolectrtl from lhc bticcinylcholine in the mother’s circulation by the placental hai-rier. Howzver, DralAo\a, GUI ;~ntl Van Ikr Kle)n’ ixzprtecl that in near-tewi ,2lrrcactr m~tlutftr inotlheys I hc placental transfer of suc~inylcholine bxs rapid aAd. at the time of the peak maternal plasma concentratioii of I pg/nil, llie t‘ctal plasm;i ~onceiit~~a~ion ws 0.6 pginil. On lhe basis of that stud!, one can tafculate lhar the Ilconate in the case reported by Bar;ika ;~nd ;iSSo<eS’ was esposed 10 approxirnatel~ 3 rng of succim lcholiiw and exhibited prolonged apnm. whertx~ in OIII- c‘asc the infant must have been exposed (0 appi-oxiniatvI\ 12 mg of succinvlcholine but was apwic tor (~11~ 3 mintltt’s. This dk’erse finding apparenrl\ cil11 tJc eiplainrd OII the hasis of the diffkenws in the inf’alirs’ en/vmatit W~~Ot,‘fJ~S. III ~;lr~lk;l’S GISC, ttlt, itlfilllr \\‘;lS i101110/\~.Y I gous f’or the ;ttlpical cholinrsrerasc antI coultl not IWZtillXJliLc the drug. ~vherc;lS our int;int \\;is hetel-cmgo115 illld conId rnetaholim the 5ilccin\le holiile as ‘il crossed
the
IJlz
ental
Ixlrriei-.
~1bus, although succinylcholine nCght CYOX~Ihe iJ1;1ccnlal barrier in significant aniount~, it is thr f’cbtal VII/vmc sylenn that determine5 whether or not sriccin!,lc-holinc p~~otiuc-es p~x~longetl apnt‘;~ in Ilie ~IC‘Mhorn iiifkit. REFERENCES 1. Hxaka, .%.. Haroun. S., Bassilc. hi.. CI .tl.: Kespor~se 01 the newborn 10 ruccinylcholine injection in homozygotic at) pical mothers. Anesthesiology 43: 1 Ii. lCVi.5. 2. Lhhkma, J,, CI.LII, J, R.. and Van Der Kleyn. L-‘..: t’latental lransfrr of ‘JC labelled succinylcholinc in near-term .Ifutrcco wuictftcl monkeys. Br. ,I. Anaesthc. 45: 10X7. 1!173.
Combined pregnancy and ruptured corpus luteum cyst
Communications
pregnanq makes the case not only more unique, perhaps the first of its kind to be reported.
hut
REFERENCES
Hcllunan, 1.. >I.. and Pritchard, J, A.: Williams’ Obstetrics, ed. 11. Net< \‘ork, 1971 1 Appleton-f:enrurli-(:rofts. 2. Schonberg, 1.. A.: Ectopic pregnancy and fil-st trimester abortion. Ohstet. Cynecol. 49: 73s. 1977. I.
Gouty nephropathy and pregnancy
Trio
primary gout in women in their years is unusual. The Framingham Heart Epidemiology Study reported a 0.4% incidence
OCCLIRRENCEO~
reproductive
Disease of’affected women in the group studied over a 14 year period, with 44 years of age as the average age of onset. Of the 2344 female patients in the study, only one ’ Thus, the occurrence of developed gout): nephritis.
primary complicating
gout
and pregnancy
subsequent is rarely
gout);
nephrop;lth!
encountered.
This report deals with the outcome and management of a pregnant patient with primary gout and gout) nephropathy. The patient. a 30-)ear-old white woman, gravida 2, para 1, with one living c.hild, was referred to our Maternal-Fetal Medicine Service at 30 weeks and ?I days’ gestation for management of her chronic renal disease. Her past obstetric history revealed that in 1968 she had a normal, spontaneous, term deliver! 01 ,m int’&nt that weighed 2,52:3 grams. In December. 1972. the patient experienced a painful swelling of her right great toe. The symptoms lasted 2 or 3 days and I hen resolved, only to recur two more times over the next 1 ?‘G months. She experienced 110 further problems until Februar), 1974, when she was admitted to the hospital with a swelling of the right knee of 2 days’ duration. Birefringent crystals were noted on examination of joint aspiration fluid and confirmed the suspected diagnosis of gouty arthr-apathy. At that time a ml. and serum uric acid of serum creatinine of 9. 4 mg/lOO I I .2 mgi IO0 ml. were recorded. The creatinine clearance was $0 to 33 ml./minute on several evaluations and the blood urea II itrogcn rangecl fr-om 30 to 40 mgi 100 ml. The blood pres‘I‘he opiniona and assertions contained herein are the private ones of. the authors and are not to be construed as official or reflecting the viewr of the Navy Department or the naval service at large. Rept-int requests: R. C. Cefalo, M.D., Department of Obstetl-its and Gynecology. National Naval Medical Center, Bethesda. Maryland 20014.
in brief
107
sure was normal. There was no hisror! of urinary tract infections, kidney disease, blood disorders, or unusual drug ingestion, Family history for gout and renal disease was negative. The patient was treated initially with colchicine and phenylburazone, with rapid recovery. Since 1974 she has been maintained only on allopurinol, 300 mgida). and has remained symptom free. In 1977, while on allopurinol. she conceived her present pregnancy. At 14 weeks’ gestation she was admitted for baseline evaluation of her renal status. The creatinine clearance was 37 ml/minute and the blood urea nitl-ogen \vas 3.3 mgi 100 ml. During this admission allopurinol was discontinued for several days: however, due to the immediate and marked increase in her serum uric acid level the medication was restarted. A prompt decrease in the uric acid level followed. The patient remained asymptomatic and serial kidney function tests remained unchanged. Evaluation during the present admission at 30 weeks and 3 days revealed a weight gain of 26 pounds over bet- usual idea1 weight. Her blood pressure was 126178 tot-r. McDonald’s measurement revealed the uterine fundus to be 28 cm. Fetal heart tones weI-e normal. The hemoglobin was 9.3 mgi 100 ml., the hematocrit was 27.9 vol.%, and the serum creatinine was 2 mgi 100 ml. A 23 hour collection of urine t-evealed the creatinine clearance to be 32 ml./ minute. Uric acid and protein excretion were 78.9 and 26.6 mgiliter. respectively. The patient was maintained on modified bed rest, ferrous sulfate, allopurinol. prenatal vitamins, and a regular diet (sodium content 3 to 4 &day). Serial B-scans showed appropriate fetal gro\\th as judged by the increase in biparietal diameter. Nonstress tests were performed week]! and revealed good fetal heart acceleration with fetal movement. At 35 weeks and 3 days the patient experienced spontaneous rupture of the membranes. After placement of the internal fetal monitor scalp electrode, oxytocin induction of labor was started. After- 4 hours of labor ;I 2.ilO gram temale infant with an Apgar score of 7/X was delivered vaginally. The neonate was appropriate for gestational age hy \veigbt and phvsical examination. The 500 mg placenta \\a5 normal. Six-week postpartum evaluation revealed the patient’s renal function and blond pressure to he unchanged from pretouception levels. The infant has gained weight ,q~propria~el? (k5,i02 qams at 10 l\,reks). The clinical course of symptomaticgout in pregnancr is usuallp one of improvement. with a high rate of’ recurrence immediately postpartumz Tltis is consistent tvith the increased incident oc gout in the postmenopausal patient and during menses, which has been associated \\ith a decrcasett estrogen level.’ In addition to the decreasing hormones. the process of
reabsorption of hy-pertrophied and exc.essive protein catabolism
tissues, tissue trauma. are associated with in-
creased uric acid levels in the postpartum period. which ma) lead to recurrence of gout.’ Extensive renal disease (secondary to gout) has been reported. The diagnosis of nephropathy secondary to gout in this patient was based on her history, physical findings, evidence of‘ gout) arthropathy, response to therapy. and disturbance of renal function, without
Communications
in brief
prolonged apnea as one might expect under these conditions. Baraka and associates’ repor’& prolonged ;IprlC” of 2.1 and 6 hours, respectiveI\. in a inother and her nexvborn infant. both h~JmcyygcJ& for the atypical enzyme. following 100 nig of intravenous succinylcholine. In our case the mother received at least fiwn rimes thal close and was apncic foi- X hours. \c-t the neonate shmed no ill eftec-ts f’roni rhc drug. It ‘k gelierally believed that the f’et~~s is prolectrtl from lhc bticcinylcholine in the mother’s circulation by the placental hai-rier. Howzver, DralAo\a, GUI ;~ntl Van Ikr Kle)n’ ixzprtecl that in near-tewi ,2lrrcactr m~tlutftr inotlheys I hc placental transfer of suc~inylcholine bxs rapid aAd. at the time of the peak maternal plasma concentratioii of I pg/nil, llie t‘ctal plasm;i ~onceiit~~a~ion ws 0.6 pginil. On lhe basis of that stud!, one can tafculate lhar the Ilconate in the case reported by Bar;ika ;~nd ;iSSo<eS’ was esposed 10 approxirnatel~ 3 rng of succim lcholiiw and exhibited prolonged apnm. whertx~ in OIII- c‘asc the infant must have been exposed (0 appi-oxiniatvI\ 12 mg of succinvlcholine but was apwic tor (~11~ 3 mintltt’s. This dk’erse finding apparenrl\ cil11 tJc eiplainrd OII the hasis of the diffkenws in the inf’alirs’ en/vmatit W~~Ot,‘fJ~S. III ~;lr~lk;l’S GISC, ttlt, itlfilllr \\‘;lS i101110/\~.Y I gous f’or the ;ttlpical cholinrsrerasc antI coultl not IWZtillXJliLc the drug. ~vherc;lS our int;int \\;is hetel-cmgo115 illld conId rnetaholim the 5ilccin\le holiile as ‘il crossed
the
IJlz
ental
Ixlrriei-.
~1bus, although succinylcholine nCght CYOX~Ihe iJ1;1ccnlal barrier in significant aniount~, it is thr f’cbtal VII/vmc sylenn that determine5 whether or not sriccin!,lc-holinc p~~otiuc-es p~x~longetl apnt‘;~ in Ilie ~IC‘Mhorn iiifkit. REFERENCES 1. Hxaka, .%.. Haroun. S., Bassilc. hi.. CI .tl.: Kespor~se 01 the newborn 10 ruccinylcholine injection in homozygotic at) pical mothers. Anesthesiology 43: 1 Ii. lCVi.5. 2. Lhhkma, J,, CI.LII, J, R.. and Van Der Kleyn. L-‘..: t’latental lransfrr of ‘JC labelled succinylcholinc in near-term .Ifutrcco wuictftcl monkeys. Br. ,I. Anaesthc. 45: 10X7. 1!173.
Combined pregnancy and ruptured corpus luteum cyst
Communications
pregnanq makes the case not only more unique, perhaps the first of its kind to be reported.
hut
REFERENCES
Hcllunan, 1.. >I.. and Pritchard, J, A.: Williams’ Obstetrics, ed. 11. Net< \‘ork, 1971 1 Appleton-f:enrurli-(:rofts. 2. Schonberg, 1.. A.: Ectopic pregnancy and fil-st trimester abortion. Ohstet. Cynecol. 49: 73s. 1977. I.
Gouty nephropathy and pregnancy
Trio
primary gout in women in their years is unusual. The Framingham Heart Epidemiology Study reported a 0.4% incidence
OCCLIRRENCEO~
reproductive
Disease of’affected women in the group studied over a 14 year period, with 44 years of age as the average age of onset. Of the 2344 female patients in the study, only one ’ Thus, the occurrence of developed gout): nephritis.
primary complicating
gout
and pregnancy
subsequent is rarely
gout);
nephrop;lth!
encountered.
This report deals with the outcome and management of a pregnant patient with primary gout and gout) nephropathy. The patient. a 30-)ear-old white woman, gravida 2, para 1, with one living c.hild, was referred to our Maternal-Fetal Medicine Service at 30 weeks and ?I days’ gestation for management of her chronic renal disease. Her past obstetric history revealed that in 1968 she had a normal, spontaneous, term deliver! 01 ,m int’&nt that weighed 2,52:3 grams. In December. 1972. the patient experienced a painful swelling of her right great toe. The symptoms lasted 2 or 3 days and I hen resolved, only to recur two more times over the next 1 ?‘G months. She experienced 110 further problems until Februar), 1974, when she was admitted to the hospital with a swelling of the right knee of 2 days’ duration. Birefringent crystals were noted on examination of joint aspiration fluid and confirmed the suspected diagnosis of gouty arthr-apathy. At that time a ml. and serum uric acid of serum creatinine of 9. 4 mg/lOO I I .2 mgi IO0 ml. were recorded. The creatinine clearance was $0 to 33 ml./minute on several evaluations and the blood urea II itrogcn rangecl fr-om 30 to 40 mgi 100 ml. The blood pres‘I‘he opiniona and assertions contained herein are the private ones of. the authors and are not to be construed as official or reflecting the viewr of the Navy Department or the naval service at large. Rept-int requests: R. C. Cefalo, M.D., Department of Obstetl-its and Gynecology. National Naval Medical Center, Bethesda. Maryland 20014.
in brief
107
sure was normal. There was no hisror! of urinary tract infections, kidney disease, blood disorders, or unusual drug ingestion, Family history for gout and renal disease was negative. The patient was treated initially with colchicine and phenylburazone, with rapid recovery. Since 1974 she has been maintained only on allopurinol, 300 mgida). and has remained symptom free. In 1977, while on allopurinol. she conceived her present pregnancy. At 14 weeks’ gestation she was admitted for baseline evaluation of her renal status. The creatinine clearance was 37 ml/minute and the blood urea nitl-ogen \vas 3.3 mgi 100 ml. During this admission allopurinol was discontinued for several days: however, due to the immediate and marked increase in her serum uric acid level the medication was restarted. A prompt decrease in the uric acid level followed. The patient remained asymptomatic and serial kidney function tests remained unchanged. Evaluation during the present admission at 30 weeks and 3 days revealed a weight gain of 26 pounds over bet- usual idea1 weight. Her blood pressure was 126178 tot-r. McDonald’s measurement revealed the uterine fundus to be 28 cm. Fetal heart tones weI-e normal. The hemoglobin was 9.3 mgi 100 ml., the hematocrit was 27.9 vol.%, and the serum creatinine was 2 mgi 100 ml. A 23 hour collection of urine t-evealed the creatinine clearance to be 32 ml./ minute. Uric acid and protein excretion were 78.9 and 26.6 mgiliter. respectively. The patient was maintained on modified bed rest, ferrous sulfate, allopurinol. prenatal vitamins, and a regular diet (sodium content 3 to 4 &day). Serial B-scans showed appropriate fetal gro\\th as judged by the increase in biparietal diameter. Nonstress tests were performed week]! and revealed good fetal heart acceleration with fetal movement. At 35 weeks and 3 days the patient experienced spontaneous rupture of the membranes. After placement of the internal fetal monitor scalp electrode, oxytocin induction of labor was started. After- 4 hours of labor ;I 2.ilO gram temale infant with an Apgar score of 7/X was delivered vaginally. The neonate was appropriate for gestational age hy \veigbt and phvsical examination. The 500 mg placenta \\a5 normal. Six-week postpartum evaluation revealed the patient’s renal function and blond pressure to he unchanged from pretouception levels. The infant has gained weight ,q~propria~el? (k5,i02 qams at 10 l\,reks). The clinical course of symptomaticgout in pregnancr is usuallp one of improvement. with a high rate of’ recurrence immediately postpartumz Tltis is consistent tvith the increased incident oc gout in the postmenopausal patient and during menses, which has been associated \\ith a decrcasett estrogen level.’ In addition to the decreasing hormones. the process of
reabsorption of hy-pertrophied and exc.essive protein catabolism
tissues, tissue trauma. are associated with in-
creased uric acid levels in the postpartum period. which ma) lead to recurrence of gout.’ Extensive renal disease (secondary to gout) has been reported. The diagnosis of nephropathy secondary to gout in this patient was based on her history, physical findings, evidence of‘ gout) arthropathy, response to therapy. and disturbance of renal function, without
