MATERNAL MORTALITY IN BRITISH COLUMBIA: A STUDY OF 145 DEATHS FROM 1955 TO 1962.
(25/254)
Between 1955 and 1962, 145 maternal deaths were reported in the Province of British Columbia. One hundred of them were due to obstetrical causes. Of these deaths, hemorrhage was by far the commonest cause (40 cases), followed in frequency by vascular accidents (23 cases), infections (17 cases), toxemia (10 cases), anesthetic deaths (five cases), and other causes (five cases). Significant avoidable factors were noted in 80%. Indirect obstetrical deaths accounted for 29 cases, or 20% of all maternal mortalities. The most frequently encountered causes of indirect obstetrical deaths were cardiac (nine cases) and vascular accidents (six cases). Avoidable factors were considered to be present in 19 of the 29, an incidence of 65%.When all deaths were considered together, 72% were felt to have significant avoidable factors when judged against an academic standard. It was also apparent that some 40% to 50% of deaths were intimately involved with social factors. (+info)
Thrombelastography. Present and future perspectives in clinical practice.
(26/254)
RESULTS: Thrombelastography (TEG) is a method for evaluating the viscoelastic properties of the blood clot, from its formation to its lysis. All major surgeries may be associated with massive blood loss, with blood component transfusion therapy often becoming mandatory. The clinician's goal is thus to optimize and possibly minimize blood components usage. To this end, TEG allows for a qualitative and dynamic analysis of the specific blood clotting process, from clot formation through its lysis, highlighting alterations at every single step in the cascade. With TEG is thus possible to know if bleeding is due to a failure to provide adequate surgical hemostasis, if there is platelet dysfunction, or to detect anomalies in coagulation proteases or their inhibitors, or if the blood loss is associated to early, excessive fibrinolysis. The theoretical advantages of TEG are the ease of performing the test, the fast sample reading times (now 30 minutes) and the informative (+info)
Use of a condom to control massive postpartum hemorrhage.
(27/254)
OBJECTIVES: To evaluate the efficacy of a condom as a tamponade for intrauterine pressure to stop massive postpartum hemorrhage (PPH). DESIGN AND SETTING: This prospective study was done in the Obstetrics and Gynecology Department of Dhaka Medical College and Hospital, Bangladesh, between July 2001 and December 2002. PATIENTS: During the study period, 152 cases of PPH were identified; 109 were managed medically; 20 were managed using the B-Lynch procedure, and 23 were managed using the condom catheter. Patients were selected for intervention with the condom catheter when PPH that occurred as a result of atonicity or morbid adhesion (accreta) could not be controlled by uterotonics or a surgical procedure. In patients who were in shock due to massive hemorrhage, a condom catheter was introduced immediately without prior medical management. INTERVENTION: With aseptic precautions, a sterile rubber catheter fitted with a condom was introduced into the uterus. The condom was inflated with 250-500 mL normal saline, according to need. The condom catheter was kept for 24-48 hours, depending upon the initial intensity of blood loss, and gradually deflated when bleeding ceased. MAIN OUTCOME MEASURES: (1) Ability of condom catheter to stop bleeding; (2) time required to stop bleeding after the tamponade was applied; (3) subsequent morbidity in terms of severe infection, despite use of prophylactic antibiotics. RESULTS: In all 23 cases in which the condom catheter was used, bleeding stopped within 15 minutes. No patient needed further intervention. No patient went into irreversible shock. There was no intrauterine infection as documented by clinical signs and symptoms and culture and sensitivity of high vaginal swab. CONCLUSION: The hydrostatic condom catheter can control PPH quickly and effectively. It is simple to use, inexpensive, and safe. In developing countries where PPH remains a primary cause of maternal mortality, any healthcare provider involved in delivery may use this procedure for controlling massive PPH to save the lives of patients. (+info)
High incidence of myocardial ischemia during postpartum hemorrhage.
(28/254)
BACKGROUND: Postpartum hemorrhage remains a major cause of global maternal morbidity and mortality, even in developed countries, despite the use of intensive care units. This study sought to (1) assess whether myocardial ischemia could be associated with and even aggravate hemorrhagic shock in young parturients admitted for postpartum hemorrhage, and (2) identify the independent risk factors for myocardial ischemia. METHODS: On their referral to the intensive care unit, a multidisciplinary team managed parturients with severe postpartum hemorrhage. Ventilation, transfusion, catecholamines, surgery, or angiography with uterine embolization were provided as clinically indicated. Plasma cardiac troponin I levels were used as a surrogate marker of acute myocardial injury and electrocardiograms of myocardial ischemia. RESULTS: A total of 55 parturients were referred with severe postpartum hemorrhage, all in hemorrhagic shock. Twenty-eight parturients (51%) had elevated serum levels of cardiac troponin I (9.4 microg/l [3.7-26.6 microg/l]), which were associated with electrocardiographic signs of ischemia and deteriorated myocardial contractility and correlated with the severity of hemorrhagic shock. Indeed, multivariate analysis identified low systolic and diastolic arterial blood pressure (< 88 and < 50 mmHg, respectively) and increased heart rate (> 115 beats/min) as independent predictors of myocardial injury. In addition, all patients who were given catecholamines also had elevated cardiac troponin I levels. CONCLUSIONS: These results suggest that treatment of postpartum hemorrhage-induced hemorrhagic shock should be coupled with concomitant prevention of myocardial ischemia, even in young parturients. (+info)
Menses, fertility and pregnancy after arterial embolization for the control of postpartum haemorrhage.
(29/254)
BACKGROUND: The long-term effects of uterine artery embolization for the control of postpartum haemorrhage on menses, fertility and future pregnancy evolution have not been assessed. METHODS: Between November 1993 and July 1999, 31 women with obstetric haemorrhage underwent arterial embolization. Four patients underwent a hysterectomy. Gynaecological information on 25 of the 27 patients who did not undergo hysterectomy was obtained by interview. RESULTS: All women had a return of normal menses. Nine of the 25 patients desired subsequent pregnancy and five patients became pregnant with normal delay of conception. Moreover, two other patients who did not plan another pregnancy became pregnant. A total of 10 pregnancies was studied, four ended during the first trimester. For the six others, the maternal evolution of the pregnancy was uneventful until term. No case of pre-eclampsia was observed. The ultrasonographic examinations revealed normal fetal growth and umbilical and uterine Doppler studies showed no anomaly. No repetition of obstetric haemorrhage was observed. All full-term, newborns were healthy, weighing from 3220 to 4100 g. CONCLUSION: Our results suggest that women who undergo arterial embolization for obstetric haemorrhage should expect to have a return of normal menses with preservation of future fertility and successful uneventful pregnancies. (+info)
High-intensity focused ultrasound in the treatment of postpartum hemorrhage: an animal model.
(30/254)
OBJECTIVE: To investigate the use of high-intensity focused ultrasound (HIFUS) to reduce uterine artery blood flow in ewes in the postpartum period. METHODS: HIFUS was applied to the uterine arteries of seven ewes in the postpartum period. Arterial flow velocities were measured before and after the procedure at the site of HIFUS application (target), as well as 3 cm upstream and 3 cm downstream from the target. The uterine arteries were then removed for macroscopic and histological examination. RESULTS: Maximum flow velocities in the target area increased after the procedure by 350% and those upstream from the target decreased by 65%. Macroscopically, the vessel diameter was shown to have reduced at the site of HIFUS application. Microscopically, both the endothelium and media showed thermal lesions. Tissues surrounding the arteries were macroscopically and microscopically normal. CONCLUSION: Exposure of uterine arteries to HIFUS reduces the vessel diameter and thus induces a dramatic increase in the maximum flow velocities within the target area. HIFUS may have a role in the treatment of postpartum hemorrhage. (+info)
Rapid decrease in high titer of factor VIII inhibitors upon immunosuppressive treatment in severe postpartum acquired hemophilia A.
(31/254)
A 25-year-old woman was diagnosed with acquired hemophilia caused by factor VIII (FVIII) inhibitors two months after normal delivery of her first child. She presented with severe spontaneous bleeding in the right forearm and distal part of the right leg. After venipuncture for diagnostic purposes, severe hematoma developed, affecting the whole left arm and shoulder. The diagnosis of acquired hemophilia was confirmed by the presence of FVIII inhibitors (Bethesda units=76), low activity of factor VIII (5%), and prolonged activated partial thromboplastin time (APTT=89 s). The treatment with fresh frozen plasma, cryoprecipitate, red blood cells concentrate, methylprednisolone (3 mg/kg/day for 8 days, then 1 mg/kg/day), and cyclophosphamide (150 mg/day for 5 days, then 100 mg/day) was followed by the regression of hematomas and normalization of APTT and FVIII activity. The titer of FVIII inhibitors rapidly decreased and total disappearance of antibodies was achieved after 15 days. To the best of our knowledge, this is the shortest time to the disappearance of inhibitors to FVIII in postpartum acquired hemophilia ever reported. Transient reappearance of inhibitors occurred 10 months later and also promptly reacted to the same therapy. In the follow-up period of 4 years, the patient had two more pregnancies with no clinical and laboratory signs of illness recurrence. This case indicates important role of immunosuppressive therapy, which can rapidly induce a remission of this rare condition and be life-saving if introduced early in the course of illness and in doses higher than usually recommended. (+info)
Role of tissue factor in hemostasis, thrombosis, and vascular development.
(32/254)
Tissue factor (TF) is best known as the primary cellular initiator of blood coagulation. After vessel injury, the TF:FVIIa complex activates the coagulation protease cascade, which leads to fibrin deposition and activation of platelets. TF deficiency causes embryonic lethality in the mouse and there have been no reports of TF deficiency in humans. These results indicate that TF is essential for life, most likely because of its central role in hemostasis. In addition, aberrant TF expression within the vasculature initiates life-threatening thrombosis in various diseases, such as sepsis, atherosclerosis, and cancer. Finally, recent studies have revealed a nonhemostatic role of TF in the generation of coagulation proteases and subsequent activation of protease activated receptors (PARs) on vascular cells. This TF-dependent signaling contributes to a variety of biological processes, including inflammation, angiogenesis, metastasis, and cell migration. This review focuses on the roles of TF in hemostasis, thrombosis, and vascular development. (+info)