Lowell E. Davis

Right ventricular function in chronically anemic fetal lambs

OBJECTIVE Our purpose was to determine whether the increase in extravascular fluid in chronic fetal anemia occurs either because of heart failure or despite successful cardiac adaptation. STUDY DESIGN Right ventricular function curves were obtained in five ovine fetuses at the start, midpoint, and end of 5 to 8 days of anemia induced by isovolemic daily hemorrhage. Least-squares fit of the ascending and plateau lines of stroke volume versus right atrial pressure were used to establish breakpoints (intersection of the ascending and plateau lines), which were compared by analysis of variance for repeated measures. Myocardial blood flow was measured by microspheres. RESULTS Carotid arterial oxygen content was reduced from 7.0 +/- 0.3 to 2.1 +/- 0.1 ml/dl and the hematocrit from 29% +/- 1.8% to 13% +/- 0.6%. Breakpoint analysis of function curves showed that although right atrial pressure remained unchanged (3.4 +/- 0.7 and 3.6 +/- 0.6 mm Hg) stroke volume increased from 1.03 +/- 0.14 to 1.62 +/- 0.25 ml/kg. Both right and left ventricular coronary blood flow were increased, 1351 +/- 313 and 1166 +/- 264 ml/min per 100 gm. Excess fluid was present in abdomen and chest of most animals at autopsy. CONCLUSION Tissue edema during severe anemia occurs despite normal right atrial pressure, increased stroke volume, and markedly increased coronary blood flow, markers of successful cardiac adaptation.

Changes in left thoracic duct lymph flow during progressive anemia in the ovine fetus

OBJECTIVE The purpose of this study was to evaluate the extent to which increased lymph flow can return fluid and protein to the circulation in the chronically anemic fetus. STUDY DESIGN Thoracic duct lymph flow rate over a range of outflow pressures was measured in 8 near-term fetal sheep 4 to 5 days after surgery and daily thereafter for 5 days. After each days study 60 to 150 ml of blood was withdrawn at a rate of 1 ml per minute. Regression analysis was used to establish the lymph flow function curve. Lymph and plasma protein concentrations and lymph flow rate were compared by analysis of variance for repeated measures. RESULTS As the hematocrit was reduced from 34.6% +/- 1.3% (mean +/- SE) to 14.4% +/- 1.0%, thoracic duct lymph flow increased from 0.12 +/- 0.01 to 0.28 +/- 0.02 ml/min/kg. Plasma total protein concentration did not change, lymph protein concentration fell (2.6 +/- 0.1 to 2.4 +/- 0.1 gm/dl), and the difference between plasma and lymph protein concentrations increased (1.04 +/- 0.05 to 1.34 +/- 0.10 gm/dl). Protein returned to the circulation increased from 11.5 +/- 0.3 to 23.7 +/- 1.5 mg per minute. Central venous pressure did not change and remained less than the breakpoint pressure. Although the plateau lymph flow rate increased, neither the breakpoint or stopflow pressures of the lymph flow function curve were altered. CONCLUSIONS Fetal lymph flow and thereby capillary filtration increased progressively as anemia became more severe. The increase in lymph flow did not appear to be limited by outflow pressure. By returning protein to the circulation, an increase in thoracic duct lymph flow helped to limit expansion of extravascular fluid volume during chronic fetal anemia.

Thyrotoxicosis complicating pregnancy

During the 12-year period from 1974 through 1985, nearly 120,000 women were delivered of infants at Parkland Hospital, and pregnancy was complicated by overt thyrotoxicosis in 60 of them (1:2000). Initial treatment was based on clinical assessment, and propylthiouracil was usually given in doses of 300 to 800 mg daily. In compliant women seen by midpregnancy, euthyroidism was achieved by a mean of 8 weeks; however, the daily dose was decreased to less than or equal to 150 mg by delivery in only 10%. Metabolic status at delivery correlated directly with pregnancy outcome, and women treated earlier in pregnancy were more likely to be euthyroid at delivery and to have good outcomes. Diagnosis of thyrotoxicosis antecedent to pregnancy was associated with earlier treatment, and 80% of 28 such women were euthyroid by delivery. Conversely, 32 women with a first diagnosis during pregnancy had the preponderance of morbidity, including five of six stillbirths and six of seven cases of heart failure. This group was characterized by a relative delay in gestational age at diagnosis. Preterm delivery, perinatal mortality, and maternal heart failure were more common in women who remained thyrotoxic despite treatment and in those who were never treated. Although we infrequently achieved maintenance doses recommended by most, because there were minimal adverse effects from therapy described here and because uncontrolled thyrotoxicosis caused significant maternal and perinatal morbidity, aggressive medical therapy seems appropriate, especially when pregnancy is advanced.

Rabbit Plasma Fibronectin Levels Associated with Staphylococcus aureus Enterotoxin B: An Acute-Phase Reaction

Variation in fibronectin (Fn) levels and white blood cell counts (WBC) following staphylococcal enterotoxin B (SEB) or SEB + cryoprecipitate containing Fn challenge was studied in New Zealand white rabbits. Increased plasma Fn levels were observed 2 h after the intravenous injection of SEB and peaked at 48-72 h (from a mean level 194.6 +/- 4.5 micrograms/ml prechallenge Fn level to a 72-hour postchallenge mean level of 407.9 +/- 25.4 micrograms/ml). Fn levels then decreased over the succeeding 5 days to approximately prechallenge levels. The total WBC count decreased by 88% within 2 h after the SEB injection. A slow increase in circulatory WBC was observed over the next 24 h. SEB caused an increase in plasma Fn levels and decreased WBC counts with lymphopenia that was followed by a normal lymphocyte count within 5 days. These data suggest that an acute-phase reaction was induced by interleukin-1. Fn prophylaxis provided no change in clinical signs when given at the time of SEB injection.