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PubMed1996

[Liver rupture in pregnancy: a life-threatening complication of the HELLP syndrome].

A 31-year-old primigravida with pre-existent hypertension was admitted at 28.5 weeks gestation with foetal growth retardation. On the third day after admission she developed a 'haemolysis, elevated liver enzymes and low platelets' (HELLP) syndrome with severe pain in the epigastrium. Intrauterine death had occurred and abruptio placentae was suspected. Induction of labour was started with intravenous prostaglandins. The next day the haemoglobin concentration had decreased despite transfusions of red blood cell concentrates. At ultrasound examination, free fluid was detected in the abdomen and at explorative laparotomy a subcapsular liver haematoma appeared to have ruptured. An intrahepatic haematoma does not require operative treatment, unless it has ruptured. Packing of the ruptured liver with gauze and later removal of the gauze is preferable to lobectomy.

Adult↗
PubMed1996

Feto-maternal outcome in pre-eclampsia/eclampsia with and without multisystem organ failure managed by strict input/output fluid regimen.

To determine whether peripartum homeostasis can be maintained without invasive vascular monitoring, comparison of biological parameters in severe preeclampsia (PE)/eclampsia(E) with and without multisystem organ failure (MSOF) was done. Twenty six cases of severe PE/E with (n = 13) and without (n = 13) MSOF were managed with a strict input/output fluid regimen. Day one pre- and day one postdelivery haematology and blood chemistry were performed. MSOF was characterised by self-limiting hepato-renal failure and thrombocytopenia. Foetal demise was higher with MSOF (53.8%) than without (38.5%), but not significantly (chi-square = 0.62). Abruptio placentae was significantly more prevalent without (30.8%) than with MSOF (7.7%; chi-square = 5.54). Eclamptic seizures occurred at the same rate (46.2 and 30.8%; chi-square = 0.65) with both conditions. There was no maternal death. Without invasive vascular monitoring peripartum homeostasis can be achieved in severe PE/E with or without MSOF through a strict input/output regimen using Ringer's lactate.

Adolescent↗
PubMed1996

Gestational diabetes mellitus--screening in a developing country.

All gravid women attending the antenatal clinic of the department of Gynaecology Unit-II, Civil Hospital Karachi and unbooked cases presenting in labour from October, 1986 to December, 1993, were included in the study. On the basis of risk factors for diabetes mellitus (DM), they were divided into 3 groups. Women in Group-I had family history of DM, bad obstetric history, congenitally malformed babies, polyhydramnios, obesity and macrosomia. Group-II included women with pregnancy induced hypertension (PIH) abruptio placentae, age > 30 years and multiple pregnancy. Group-III comprised of the pregnant women with no risk factors for DM. Screening of 4497 subjects from the antenatal clinic was performed and DM was diagnosed in 211 (12%) in Group-I, 11 (3%) in Group-II and 13 (0.6%) in Group III. Chi-square analysis demonstrated that frequency of DM was significantly higher (P < 0.001) in Group I and Group II as compared to Group III. Non-booked admissions numbered 7600, of these, DM was detected in 166 (20%) belonging to Groups-I and II, whereas, 38 (0.6%) were from Group-III. Screening was done by the O'Sullivan criteria. It was concluded that all pregnant women should be screened for DM. However, if financial constraints prevail, then women with high risk factors only should be subjected to screening.

Adult↗
PubMed1996

[Disseminated intravascular coagulations].

Disseminated intravascular coagulation (DIC) syndromes can be defined as the formation of fibrin deposits within the microcirculation, occurring in definite clinical situations. Their biological counterpart is a consumption coagulopathy. The clinical profiles of DIC have been well known for decades, are multiform and range from latency to overwhelming haemorrhagic diatheses, including also characteristic but rare situations, such as purpura fulminans, acral cyanosis and pictures resembling thrombotic thrombocytopenic purpura or haemolytic-uraemic syndrome. Biological tests of DIC show a consumption coagulopathy, displayed on the standard haemostasis sheet; along with signs of paracoagulation and/or of secondary fibrinolysis (FDP). New tests have recently been introduced: D-dimers are specific and sensible; Antithrombin-III, protein C and alpha 2-antiplasmin also can sometimes be useful. The knowledge of the pathophysiology of DIC has made advances with passing years. Fibrin deposits may be non-occlusive, and indeed they are swiftly removed by a secondary fibrinolysis. Except in very rare situations, such as those leading to a cortical renal necrosis, and perhaps in some ARDS, there is little evidence relating DIC to organ failure syndromes. Moreover, there is no clear relationship between the severity of the consumption coagulopathy and the prognosis. For instance, the mortality is much lower in abruptio placentae, where the coagulopathy is very severe, than in septic shock, where it is usually moderate. In septic shock, the disorders of haemostasis were related initially to a platelet activation, then to an activation of the contact system (releasing kinins and triggering complement cascade), and nowadays to the activation of the extrinsic coagulation system. The treatment of DIC is mainly the treatment of its cause. Indications for heparin therapy should be strictly limited to a few exceptional circumstances. When haemorrhagic diathesis threatens, FPC and/or platelet transfusion may be indicated. Aprotinin can be useful in rare cases of overwhelming secondary fibrinolysis. Trials with antithrombin-III or C1-esterase inhibitors are in progress.

Blood Coagulation↗
PubMedDate not supplied

Clinical aspects of DIC--disseminated intravascular coagulation.

1.286 patients were diagnosed as DIC, among 123.231 patients who were admitted in the 285 departments of the university hospitals in Japan, in 1992. The incidence of DIC was high in acute promyelocytic leukemia, fulminant hepatitis, abruptio placentae, acute respiratory distress syndrome, and sepsis. In cases of DIC, bleeding tendency due to consumption coagulopathy is most important, but organ dysfunction due to circulatory disturbances by development of multiple thrombi is also noteworthy. As a whole, DIC may be divided in two types. The first type is cases of DIC with severe bleeding symptoms. However, except cerebral hemorrhage, organ dysfunction is rare in these cases. These cases may be called as "fibrinolysis-dominant DIC", because hemostatic thrombi as well as thrombi which cause organ dysfunction by circulatory disturbances are rapidly removed by abnormally enhanced fibrinolysis. The second type involves cases of DIC with severe organ dysfunction. Bleeding symptoms in these cases are usually not severe. These cases may be called as "coagulation-dominant DIC". The most typical causative disease of the fibrinolysis-dominant DIC is acute promyelocytic leukemia. The most typical causative disease of the coagulation-dominant DIC is sepsis. The presence of causative disease of DIC, elevation of FDP, and depletion of platelet count are most important to diagnose DIC. In the treatment of DIC, removal of cause of DIC, administration of heparin to protect further development of multiple thrombi, and replacement of platelets in cases of acute leukemia are most important.

Antithrombins↗
PubMed1977

Disseminated intravascular coagulation in pregnancy.

The DIC syndrome is the most common cause of an abnormal hemorrhage tendency during pregnancy and the puerperium and reflects systemic activation of the coagulation cascade by circulating thromboplastic material, with secondary activation of the fibrinolytic system. Its presence in a pregnant patient almost invariably is evidence of an underlying obstetric disorder such as abruptio placentae, eclampsia, retention of a dead fetus, amniotic fluid embolism, placental retention or bacterial sepsis. Diagnosis of the DIC syndrome rests on the demonstration of reduced levels of fibrinogen and platelets, prolongation of the thrombin, prothrombin and partial thromboplastin times, and the presence of fibrin/fibrinogen degradation products (FDP) in the serum. Therapy consists of prompt removal of the source of procoagulant material, replacement of depleted clotting factors and, in some cases, anti-coagulation with heparin.

Blood Coagulation Tests↗
PubMed1997

Bimanual uterine compression as a major technique in controlling severe postpartum hemorrhage from uterine atony.

A 27-year old woman, primigravida, 33 weeks' gestation, presented with complaints of labor pain and absent fetal movement. A dead fetus in utero, abruptio placentae, and labor pain were diagnosed. Severe postpartum hemorrhage from uterine atony and disseminated intravascular cogulopathy was noted after spontaneous delivery of the baby and placenta. Bimanual uterine compression for 40 minutes was performed as a major procedure accompanied by uterotonic drugs, correction of hypovolemic shock and coagulopathy by crytalloid, blood, fresh frozen plasma. The patient had no complications when seen at 6 weeks' postpartum follow-up.

Adult↗
PubMed1997

Pregnancy outcome and neurodevelopment of children exposed in utero to psychoactive drugs: the Motherisk experience.

This paper presents an overview of the Motherisk Program data on pregnancy outcome and neurodevelopment of children exposed in utero to selected psychoactive drugs. First, the use of cocaine during pregnancy has been associated with increased risk of spontaneous abortions, abruptio placenta, premature labor, and stillbirth. Twenty-three adopted children exposed in utero to cocaine demonstrated an 8-fold increase in risk for microcephaly compared with controls. Global intelligence quotients (IQ) did not differ between the 2 groups, but the cocaine-exposed children achieved significantly lower scores on the Reynell language test. Second, the long-term neurobehavioral effects of fetal alcohol syndrome (FAS) were studied in 384 children to show that alcohol-induced brain insults, which consist of attention and memory deficits together, and poor adaptability and organization are not attenuated with age. Third, the rates of major malformations in children exposed in utero to fluoxetine, tricyclic antidepressants, and nonteratogenic drugs did not differ or exceed the expected rates in the general population. A 2nd phase of this study established the safety of antidepressants during pregnancy by demonstrating that the mean IQ and language scores are comparable in the 3 groups. A level 2 ultrasonography is recommended in cases of in utero exposure to lithium and carbamazepine because of an increased risk of cardiac malformations and spina bifida, respectively.

Developmental Disabilities↗
PubMed1997

HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) pathophysiology and anesthetic considerations.

HELLP syndrome in the parturient (hemolysis, elevated liver enzymes, and low platelet count) is associated with poor maternal and fetal outcomes. Maternal mortality has been estimated to be as high as 24%. Patients with HELLP syndrome are also at greater risk of pulmonary edema, adult respiratory distress syndrome, abruptio placentae, disseminated intravascular coagulation, ruptured liver hematomas, and acute renal failure. Perinatal mortality is equally high, ranging from 79 to 367 per 1,000 live births, and neonatal complications correlate with the severity of maternal disease. Many clinicians view HELLP syndrome as an entity of preeclampsia, and because of varied symptomatology, the initial diagnosis may be obscured. Prodromal signs include: (1) weakness and fatigue, (2) nausea and vomiting, (3) right upper quadrant and/or epigastric pain, (4) headache, (5) changes in vision, (6) increased tendency to bleed from minor trauma, (7) jaundice, (8) diarrhea, and (9) shoulder or neck pain. Before delivery, aggressive obstetric management is directed toward stabilization of the affected organ systems, if possible, and timely interruption of the pregnancy in the early phase of the accelerated disease progression. Definitive therapy is delivery. Parturients with HELLP syndrome are often critically ill; their infants are frequently premature and their conditions are compromised. Management criteria should include a multidisciplinary approach in a tertiary care center. Obstetric anesthesia personnel should perform a thorough preanesthetic evaluation and be familiar with the pathophysiologic changes of this syndrome. Determining the anesthetic of choice depends on the patient's condition, fetal well-being, and the urgency of the situation. In the presence of severe coagulopathy, regional anesthesia is contraindicated.

Adult↗
PubMed1997

Ruptured bacterial intracranial aneurysm in pregnancy. A case report.

BACKGROUND: Rupture of a documented infectious cerebral aneurysm is a rare complication of infectious endocarditis, with a high morbidity and mortality rate. The only previously reported case was associated with maternal and neonatal mortality. No known report exists of a ruptured bacterial intracranial aneurysm complicating an ongoing pregnancy with maternal or fetal survival. CASE: A 38-year-old, white woman, gravida 9, para 4, at 18 weeks' gestation, developed infectious endocarditis with peripheral and cerebral emboli secondary to intravenous drug abuse, causing renal failure and cortical strokes. She required hemodialysis and also suffered a subarachnoid hemorrhage due to rupture of cerebral bacterial aneurysms. A team approach to her care was necessary. At 28 weeks' gestation she delivered by cesarean section for abruptio placentae. Both the mother and neonate recovered. CONCLUSION: Rupture of mycotic aneurysms can be catastrophic and is often managed surgically. The patient described here was severely affected, and though indicated, surgical intervention was not possible. An aggressive team approach provided a good maternal and fetal outcome.

Adult↗
PubMed1997

Vascular abnormalities of the uterus, concerning a case of diffuse cavernous angiomatosis of the uterus.

A case of diffuse cavernous angiomatosis of the uterus after delivery is reported. Owing to suspicion of abruptio placentae, cesarean section was performed. In the course of this section, several hematomas were noted in the myometrium, making total hysterectomy necessary. In view of this case, etiopathogenesis, causes and dynamics of clinical manifestation, possible complications, differential diagnosis and opportunities for the clinical diagnosis of uterine vascular abnormalities are discussed.

Adult↗
PubMedDate not supplied

Selective second-trimester termination of an abnormal fetus in twin pregnancies.

The probability of detecting a chromosomal or structural abnormality in one fetus of a dizygotic twin gestation is about twice that of the risk for a singleton. During the period January 1992 to October 1994 we performed selective termination of the abnormal fetus in 14 bichorionic twin gestations. Indications for selective termination were 10 structural abnormalities and 4 chromosomal abnormalities. The procedure was done at 14, 16, and between 20 and 25 weeks in 1, 2, and 11 cases, respectively. We had no pregnancy losses before 24 weeks' gestation. The mean gestational age at delivery was 34.2 +/- 3.9 (SD) weeks. In one case, severe abruptio placentae occurred and the neonate died. Thirteen neonates are alive and well. In five cases in which the procedure was done after 21 weeks' gestation, no decrease in the amount of amniotic fluid in the sac of the terminated fetus was observed. Our experience supports the general conclusion that selective termination for bichorionic abnormal twins is safe and effective.

Chromosome Aberrations↗
PubMed1996

Medical and life-style risk factors affecting fetal mortality, 1989-90.

OBJECTIVES: This report presents fetal mortality data by medical and life-style risk factors of the mother and the fetus. METHODS: Deaths and fetal mortality rates are presented in this descriptive report. Data sources used are vital statistics data for fetal deaths and live births. RESULTS: The data that became available with the revision of the U.S. Standard Report of Fetal Death in 1989 expanded the medical and health data available on mothers and fetuses. Reporting of medical conditions is probably incomplete for fetal deaths as well as for live births. Therefore, caution should be exercised in using this data. Reported occurrences of medical and life-style risk factors of mother and fetus for fetal deaths and live births and fetal mortality rates are presented. Maternal medical conditions most often associated with having a fetal death were problems with amniotic fluid levels and blood disorders. Fetal mortality was 35 percent greater when tobacco was used during pregnancy and 77 percent higher when alcohol was consumed during pregnancy. The complication of labor most often associated with fetal mortality was abruptio placenta. Although a very small proportion of all deliveries have specific congenital anomalies reported, fetal mortality was close to 50 percent for anencephalus, about 25 percent for renal agenesis, and slightly more than 20 percent for hydrocephalus.

Adult↗
PubMedDate not supplied

Rupture of uterus in a primigravida prior to onset of labor.

Spontaneous rupture of the uterus in a primigravida is very rare. Furthermore, uterine rupture in a primigravida prior to the onset of active labor is extremely uncommon, with very few reported cases. We present a case of antepartum uterine rupture in a 20-year-old primigravida in whom the clinical features resembled those of abruptio placentae.

Adult↗
PubMed1998

Ultrasonically dense amniotic fluid in early pregnancy in asymptomatic women without vaginal bleeding. A report of two cases.

BACKGROUND: During the second trimester of pregnancy, the presence of free-floating particles in the amniotic fluid on ultrasonography has been associated with aggregates of cells or fetal blood and with unexplained elevation of maternal serum alpha-fetoprotein and the later development of abruptio placentae and fetal distress. During the third trimester, particulate amniotic fluid is thought to represent meconium or vernix. CASES: An unusual, ultrasonically dense appearance of the amniotic fluid was noted prior to 18 weeks of pregnancy in two asymptomatic women who carried exencephalic fetuses. In both cases, prenatal evaluation of the amniotic fluid suggested that the free-floating particles were due to the presence of blood. CONCLUSION: A detailed ultrasonographic evaluation should be undertaken should dense amniotic fluid be detected early in pregnancy because this sign may help in the early diagnosis of fetuses with congenital malformations likely to bleed.

Adult↗
PubMed1976

[Intensive care in obstetrics and gynecology. Indications for transfer to the intensive care unit].

Between the years of 1969 and 1974, 68 patients were transferred from our Department of Obstetrics and Gynecology to the Intensive Care Unit. This figure represents 0,5% of all operative cases. 50% were high risk patients, previously under the care of our physicians. 11,8% occurred because of problems arising from latent diseases not previously diagnosed. The main reasons for transfer were septic shock, coagulopathy arising from abruptio placenta, placenta praevia, embolism and pneumonia. Interdepartmental cooperation is indispensable for correct diagnosis and a timely transfer.

Acid-Base Imbalance↗