- Preeclampsia is a disorder occurring between the twentieth week of pregnancy and the first week postpartum characterized by hypertension, proteinuria, and edema. Eclampsia is diagnosed when a woman with preeclampsia develops convulsions or becomes comatose in the absence of any other underlying neurologic disorder.

Causes and Incidence The cause of preeclampsia and eclampsia is unknown. Preeclampsia occurs in 5% of pregnant women. Primigravidas and women with preexisting cardiovascular conditions, diabetes mellitus, or renal disease are at greatest risk. About 1 in 200 of those individuals diagnosed with preeclampsia develops eclampsia.

Disease Process An increased sensitivity to angiotensin II develops, followed by vasospasms, which cause increased resistance to vascular flow and increased aterial pressure, with accompanying hemoconcentration.

Symptoms The primary signs of preeclampsia are a blood pressure of 140/90, or an increase of 15 mm Hg diastolic or 30 mm Hg systolic over the woman’s baseline pressure; and proteinuria and nondependent edema of the hands and face. These signs may be accompanied by a sudden weight gain. Seizure activity or coma (or both) in a woman with preeclampsia is indicative of eclampsia.

Potential Complications A major complication of preeclampsia is abruptio placentae. Untreated preeclampsia leads to eclampsia, and untreated eclampsia is generally fatal.

Diagnostic Tests Evaluation is based on the presenting symptoms.

Treatments

Surgery
Delivery for women with severe or unresponsive preeclampsia–vaginal delivery if cervix is ripe, cesarean section if vaginal delivery is unlikely

Drugs
Severe preeclampsia: IV magnesium sulfate to reduce blood pressure, addition of hydralazine if no response occurs; calcium gluconate as an antidote for excess magnesium sulfate; diuretics are contraindicated because they reduce uteroplacental perfusion.

General
Mild preeclampsia: Bed rest, positioned on the left side to increase urinary output and lessen intravascular dehydration and hemoconcentration; increased fluid intake and normal salt intake; close monitoring of blood pressure, daily or every other day.

Severe preeclampsia and eclampsia: immediate hospitalization, IV with balanced salt solution and administration of drugs in preparation for delivery; vital signs and fetal heart tone every 15 minutes; intake and output measurements hourly; monitoring for signs of abruptio placentae, seizure, decrease in consciousness, HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count).

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- Adenocarcinomas account for most prostate cancers. The rest are transitional cell, squamous cell, endometrioid, or sarcomatous cancers. (Also see Cancer.)

Causes and Incidence The cause is unknown but appears to be related to endogenous hormones. Prostate cancer is the most commonly diagnosed cancer in men in the United States, with more than 165,000 cases reported annually. It is the third leading cause of cancer deaths in men and strikes those over age 50 most frequently (more than 85% are over age 65). The incidence and mortality rate are higher in black men.

Disease Process Adenocarcinomas usually begin in the lower posterior prostate and grow slowly to encompass the entire gland. The tumor spreads directly to the bladder and levator ani muscles and, via the lymphatic system, throughout the pelvis. Metastasis occurs through the bloodstream to the bones, liver, lungs, and kidneys.

Symptoms Early signs mimic benign prostatic hypertrophy; they include difficulty initiating and stopping the urinary stream, frequency and pain on urination, and a weak urinary stream.

Potential Complications The prognosis is good with tumors that have not metastasized (more than 70%), and even with metastasized disease, treatment may achieve long-term palliation. Complications of advanced disease include thrombosis, pulmonary emboli, retrograde ejaculation, and impotence.

Diagnostic Tests Palpable nodules on digital rectal examination and an elevated prostate-specific antigen offer suspicions of tumor. A needle biopsy is the definitive follow-up.

Treatments

Surgery
Prostatectomy for localized tumor; transurethral resection when the bladder is involved; bilateral orchiectomy for metastatic disease.

Drugs
Hormone therapy for palliation.

General
Radiation as a primary treatment alternative to surgery and for palliation; counseling for changes in sexual functioning.

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• Medical Information

– A recurrent chronic disease of the skin characterized by dry, scaly plaques and papules of varying size.

Causes and Incidence The cause is unknown but is thought to be related to genetic and environmental factors that trigger an overproduction of epidermal cells. The onset typically occurs between 10 and 40 years of age, and the disorder affects 2% to 4% of the U.S. population. Whites are at greater risk than blacks, as are those with a family history of psoriasis.

Disease Process Three main pathologic components are at work in psoriasis, to varying degrees. An increased miotic rate causes rapid epidermal cell turnover and shortened transit time of the cell from the basal layer to the epidermis. Faulty keratinization of the horny layer causes easy desquamation and diminishes protection for underlying tissue. Dilation of dermal vessels and intermittent discharge of leukocytes into the dermis cause hot, red skin.

Symptoms The onset is gradual, and the disorder is characterized by chronic exacerbation and remission. The scalp, elbows, knees, back, and buttocks are the most common sites. The nails, eyebrows, axillae, and anal and genital regions may also be affected. The lesions are well-defined, dry, nonpruritic papules or plaques overlaid with shiny silver scales, and they heal without scarring. The skin may be reddened and hot to touch. Affected nails are pitted, discolored, thickened, and crumbly.

Potential Complications Common complications include psoriatic arthritis and exfoliative psoriatic dermatitis, which can lead to crippling and general debility.

Diagnostic Tests The diagnosis is based on examination of characteristic lesions.

Treatments

Surgery
None.

Drugs
Topical corticosteroids, keratolytics used in lotion, cream, ointment, or shampoo form to treat lesions; antineoplastic agents for severe recalcitrant disease.

General
Shortwave or longwave ultraviolet light therapy; lubricants to soften skin; exposure to sunlight but avoiding sunburn; stress reduction programs; prevention of mechanical injury to skin; instruction that lesions are not communicable; counseling if body image is affected and to adapt to chronic nature of disease.

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– Sudden blockage of a pulmonary artery by foreign matter, which impedes the blood flow to the lung tissue.

Causes and Incidence The most common cause is a thrombus, which typically forms in the leg or pelvic vein but may be seen in other locations. Other causes include fat, amniotic fluid, air, and gas. Common risk factors are thrombophlebitis, major surgery, pregnancy and childbirth, fractures, myocardial infarction, congestive heart failure, venous insufficiency, polycythemia vera, prolonged immobility, and chronic illness. It is estimated that up to 5% of hospital deaths are attributable to pulmonary emboli.

Disease Process Emboli in whatever form travel through the bloodstream and lodge in one or more pulmonary arteries. The area of the lung supplied by the affected artery becomes underperfused but is still ventilated. This results in physiologic dead space or wasted ventilation and contributes to hyperventilation. Histamine release from the embolus produces reflex bronchoconstriction, leading to further hyperventilation. Depletion of alveolar surfactant results in diminished lung volume and compliance. If the clot is large enough and interferes greatly with pulmonary perfusion, it may result in pulmonary hypertension.

Symptoms The manifestations of a pulmonary embolus (PE) are nonspecific and vary in degree and intensity, depending on the size of the embolus, the extent of occlusion, the amount of collateral circulation, and preexisting cardiopulmonary function. Small emboli may be asymptomatic. The chief manifestation is breathlessness. Other symptoms include anxiety, restlessness, tachypnea, sweating, cough, hemoptysis, chest pain, fever, and rales. Cyanosis may be present with a massive embolus.

Potential Complications Cardiac arrhythmias, cor pulmonale, atelectasis, shock, hepatic congestion, and necrosis are complications. Pulmonary infarction is an uncommon complication of PE that results in hemorrhagic consolidation and tissue necrosis distal to the occlusion. Death following a PE usually occurs within 1 to 2 hours of the initial event. Those with underlying cardiovascular or pulmonary disease and those with a large embolus are at greater risk of dying. Untreated individuals risk recurrent emboli and about a 50% chance of death.

Diagnostic Tests The diagnosis is suggested by the presenting clinical picture and confirmed by the following procedures.

Pulmonary angiogram
Visualization of intraarterial filling defects

Lung perfusion scan
To detect perfusion defects

Ventilation scan
To detect altered ventilation patterns

Blood gases
Arterial hypoxemia (decreased PaO2 and PaCO2)

Electrocardiography
To rule out myocardial infarction; PE is characterized by tall, peaked P waves, depressed ST segments, T-wave inversions, and supraventricular tachyarrhythmias

Chest x-ray
Unilateral elevation of the diaphragm, enlarged pulmonary artery, and pleural effusion 2 hours or longer after the event

Treatments

Surgery
Embolectomy for large emboli unresponsive to treatment; umbrella filter in inferior vena cava to trap multiple emboli before they reach the lung; interruption of blood flow through the inferior vena cava by ligation for multiple emboli.

Drugs
Anticoagulants to halt clot propagation (heparin is used in the acute phase and is replaced by coumadin, which may be administered for 6 months to life; medications should overlap for 5 to 7 days to achieve effective blood levels of coumadin); fibrinolytic enzymes may be used in place of anticoagulants for clot lysis, particularly of large clots; analgesics for pain; vasopressors, dopamine to treat hypotension.

General
Oxygen therapy; bed rest in acute phase, followed by progressive mobilization; hemodynamic and cardiac monitoring; facilitation of breathing; intake and output measurements to monitor renal function; observation for bleeding as a side effect of anticoagulants, and safety measures to prevent bleeding; information about long-term anticoagulant therapy; antiembolism hose and instruction in preventing pooled blood in the lower extremities.

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- An acute or chronic infection and inflammation of the kidney or renal pelvis. (Also see Urinary Tract Infection.)

Causes and Incidence Acute pyelonephritis is caused by a bacterial invasion that moves from the urethra to the bladder to the ureters to the kidney. The infecting bacteria are commonly normal intestinal and fecal flora that grow readily in urine. Individuals with a condition that interferes with the dynamics of normal urine flow are at greater risk. This includes those with underlying obstructions (strictures, calculi, tumors, prostatic hypertrophy), neurogenic bladder, vesicourethral reflux, diabetes, or renal disease; those who are sexually active or pregnant; and those undergoing medical or surgical procedures such as catheterization or cystoscopy. Women are more susceptible than men because of the anatomic construction of the female urinary system. The annual incidence of pyelonephritis in the United States is 16 in 100,000; the annual nosocomial incidence rises to 73 in 100,000. Chronic pyelonephritis most typically occurs as a result of repeated acute episodes but may also be caused by metastatic disease.

Disease Process Bacteria ascend the urinary tract and colonize one or both kidneys. The kidney enlarges as the inflammatory process is activated, and parenchymal tissue is destroyed. Chronic inflammatory cells appear within a few days, and medullary abscesses and papillary tissue necrosis occur. Patchy spots of infection develop and spread to the pelvic and calyceal epithelia and the cortex. If the process becomes chronic, atrophy, calyceal deformity, and parenchymal scarring occur.

Symptoms The onset is fairly rapid and is characterized by dull, constant flank pain, chills, and fever. Concomitant signs of a lower urinary tract infection (e.g., urinary frequency, dysuria) occur in about one third of individuals.

Potential Complications The most common complication of acute disease is septic shock or chronic pyelonephritis (or both). With chronic disease there is a 2% to 3% chance of developing end-stage renal failure.

Diagnostic Tests Presenting clinical symptoms are confirmed by urinalysis, which reveals antibody-coated bacteria, bacteriuria, WBC casts, and pyuria; a complete blood count shows an increase in WBCs. Renal function studies may assist in the diagnosis of chronic disease.

Treatments

Surgery
Correction of underlying obstructions.

Drugs
Oral or parenteral antiinfective drugs to combat infection; continuous suppression antiinfective therapy may be used to treat recurrent or chronic infection; antipyretics for fever.

General
Increased fluid intake; urine cultures to track effectiveness of antiinfective drugs; instruction in preventing infection (cleansing perineum, proper wiping technique, adequate fluid intake, cleansing after sexual activity).

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