Severe preeclampsia and antioxidant nutrients

Volume 173, Number Am J Obstet Gynecol

Letters

2

tice often encompass elements of both primary and specialty care. However, as time spent in primary care increases, then time spent in specialty care decreases with a further erosion of income. A second factor, not recognized in the above-described financial equation, is the personal satisfaction of the health care team leader. Most obstetricians and gynecologists enter the specialty because of the balance between primary and specialty medicine with time spent in specialty practice largely in the operating suite or delivery room. As primary or ambulatory practice time increases and specialty medicine time decreases, this will result in decreased operating room and delivery room time, both of which bring personal satisfaction to the obstetrician-gynecologist. I noted the growth of the medical school and hospital department structure as a secondary effect of the shift from primary medicine to specialty medicine. With changing technology and reimbursement mechanisms, the paradigm shift will be away from departments to “functional units,” whose final designation has not yet emerged from the depths of managed care. The growth of the functional unit may well see the demise of the department structure in hospitals and medical schools. The realignment of medical cardiology with invasive cardiology, cardiac surgery, and their supporting disciplines is a natural development. The gynecologic urologist and surgical urologist could combine. Maternalfetal medicine and neonatology could combine in a mother-child diad. The gynecologic oncologist would combine with medical and surgical oncology and therapeutic radiology. General obstetrics and gynecology would be grouped with family medicine, general internal medicine, and general pediatrics into a primary care functional unit, and there would be no reason to have the traditional department structure. The paradigm shift would be complete, and business principles and principals would reign supreme. The paradigm shift to managed and primary care is not always easy to understand and certainly not always accepted by physicians trained in the traditional department and practicing in the traditional office setting. As the cost of providing care at the hospital and physician end of the health care ladder continues under attack and as we, as obstetricians and gynecologists, face the professional task of redirecting our practices to encompass more primary or generalist care, it is extremely important that we do understand the imposed need for this most recent paradigm shift. This explanation of the changes in medical care finances and practice should aid the practicing obstetrician-gynecologist in his or her ability to accept and adapt to the new world of obstetrics and gynecology and managed care. Donald Department of Obstetrics Augusta, GA 30912

and Gynecology,

Medical

M.

Sherline,

The views expressed aw those of the author and do not reject o&al views of the Medical College of Georgia. h/8/655

77

MD

College of Georgia, the

Severe preeclampsia

673

and antioxidant nutrients

To the Editors: We read with interest the article by Mikhail et al. (Mikhail MS, Anyaegbunam A, Garfinkel D, Palan PR, Basu J, Romney SL. Preeclampsia and antioxidant nutrients: Decreased plasma levels of reduced ascorbic acid, or-tocopherol, and beta-carotene in women with preeclampsia. AM J OBSTET GYNECOL 1994; 17 1: 150-7). Their findings offer new possible strategies in preventing preeclampsia. We know that plasma a-tocopherol increases during pregnancy.’ Therefore a case-control study seems to be a better way to investigate the behavior of antioxidant nutrients in preeclampsia. We would like to report our unpublished preliminary data on plasma a-tocopherol and beta-carotene in 11 severely preeclamptic patients defined according to The American College of Obstetricians and Gynecologists. Plasma levels of these two vitamins were measured by high-pressure liquid chromatography at the diagnosis of severe preeclampsia (range 25 to 39 weeks) and were compared with 11 pregnant controls matched for age, gestational age, and parity. We didn’t find any difference between the two groups (beta-carotene: 0.387 ? 0.1 vs 0.315 * 0.14 mg/L; cx-tocopherol: 17.43 ? 5.78 vs 20.22 + 3.97 mg/L). Then we considered the seven severely preeclamptic patients in which an intrauterine growth retardation was detected and found significantly reduced plasma levels of a-tocopherol in comparison with the matched controls (13.65 ? 1.85 vs 19.83 2 3.42 mg/L, p < 0.002). Our data suggest that this is the degree of placental injury to determine a reduction of antioxidant nutrients rather than the severity of maternal disease (i.e., hypertension, proteinuria, coagulopathy). L.

Valsecchi,

MD,

A. Fausto,

MD,

and

V. Grazioli,

MD

VI Department of Obstetrics and Gynecology, University of Milan, Istituto Scientz$co San Raffaele, Via Olgettina n 60, Milan, Italy REFERENCE

1. Wang Y, Walsh SW, Guo Y, Zhang J. Maternal levels of prostacyclin, thromboxane, vitamin E, and lipid peroxide throughout normal pregnancy. AM J OBSTET GYNECOL. 1991; 165:1690-4. 6/8/66209

Reply To the Editors: The unpublished data of Valsecchi et al. support previous reports of decreased plasma antioxidant levels in women with preeclampsia. Their observation that plasma ol-tocopherol levels are decreased in preeclamptic women with intrauterine growth retardation is interesting and requires further investigation. We agree with their suggestion that free radical-induced placental injury may be of particular significance. We recently presented preliminary data’ demonstrating that placental concentrations of lipid-soluble antioxidants are significantly decreased in women with severe preeclampsia. We speculate that, in the presence of decreased placental antioxidant levels, excess free radi-