1/237. Successful treatment of severe myocardial failure after postpartum haemorrhage with the use of an intra-aortic balloon pump. We report a 29-year-old primigravid who developed cardiac failure following postpartum haemorrhage unresponsive to volume resuscitation and therapy with catecholamines and phosphodiesterase-inhibitors. Transoesophageal echocardiography (TEE) demonstrated left atrial and ventricular dilatation and global left ventricular hypokinesis. No elevation of serum MB-isoenzyme fraction was detected and other organ functions remained stable. Although emergency cardiac transplantation was considered in the presented patient, the institution of intra-aortic counterpulsation was decided on as a first treatment option. Intra-aortic balloon counter-pulsation rapidly improved cardiac function and led to weaning from pharmacological cardiac support within a few days. Mechanical circulatory assist devices can be life-saving in postpartum-haemorrhage-associated cardiac failure. ( info) |
| PURPOSE: disseminated intravascular coagulation (DIC) is a well-known complication of an amniotic fluid embolus. However, clinical experience has shown that, in some patients, clinical hemorrhage may be the initial presentation. Mortality in this subset of patients is high. This report describes a patient with a suspected amniotic fluid embolus who survived and in whom the initial presentation was post partum hemorrhage. CLINICAL FEATURES: During the post delivery repair of a fourth degree perineal tear a 29 yr old prima gravida was noted to have excessive vaginal bleeding despite a well contracted uterus. Laboratory investigations revealed a decrease in hemoglobin from 126 g x l(-1) to 86 g x l(-1) and a severe disseminated intravascular coagulopathy (PT 27.5 sec, APPT 149 sec, direct fibrinogen < 0.6 g x l(-1), FDP > 640 g x l(-1)). Treatment included massive blood component therapy and, eventually, total abdominal hysterectomy. The patient subsequently recovered without sequelae. In the absence of any other explanation, the coagulopathy was considered to be secondary to amniotic fluid embolus. CONCLUSION: amniotic fluid embolus remains an important cause of maternal mortality. Clinical reports, reviews of the literature, and the development of the national registry have all contributed to our understanding of this syndrome. Contrary to earlier beliefs, not all patients present with sudden cardiorespiratory collapse. As the present case illustrates, a less common presentation is the development of an isolated DIC in the peripartum period without antecedent hemodynamic or respiratory instability. Therefore, anesthesiologists must maintain a high index of suspicion for the disorder in order to facilitate early recognition and treatment. ( info) |
3/237. Management of labor in Eisenmenger syndrome with inhaled nitric oxide. Administration of nitric oxide by means of inhalation during the labor of a woman with Eisenmenger's syndrome caused by an atrial septal defect resulted in improved oxygenation and initial pulmonary arterial pressure. She gave birth to a live infant at 34 weeks' gestation but died of worsening pulmonary hypertension and heart failure 21 days post partum. ( info) |
4/237. Hyperbaric oxygen therapy in the management of severe acute anaemia in a Jehovah's witness. A case is described in which a Jehovah's Witness patient who refused blood transfusion suffered massive antepartum haemorrhage, her haemoglobin falling as low as 2.0 g.dl(-1). She was treated on an intensive care unit with intermittent positive pressure ventilation and general supportive measures, pulsed hyperbaric oxygen therapy and recombinant human erythropoietin. ( info) |
5/237. Treatment of severe postpartum hemorrhage by rectally administered gemeprost pessaries. OBJECTIVE: To assess the efficacy of rectally administered gemeprost pessaries in the treatment of severe postpartum hemorrhage. DESIGN: Retrospective analysis of a twelve month period in which all patients having postpartum hemorrhage treated with rectal gemeprost were analyzed. SETTING: Royal Darwin Hospital, northern territory, australia. population: Fourteen women with established postpartum hemorrhage not responding to oxytocine and ergometrine regimens, or not responsive to oxytocine and having contraindications to ergometrine. MAIN OUTCOME MEASURES: Per vaginum bleeding with continued postpartum hemorrhage; adverse patient reactions to gemeprost; need for operative intervention. RESULTS: All patients who were treated with rectally administered gemeprost pessaries had cessation of bleeding per vaginum. There were no adverse side effects noted from the medication and no patient required surgical treatment. CONCLUSIONS: Rectally administered gemeprost administered pessaries appear to be safe and effective method of treating severe postpartum hemorrhage in those patients in whom the standard oxytocic regimens fail. This form of treatment may avoid the need for parenteral prostaglandins or surgical intervention. ( info) |
| factor vii deficiency is a rare hereditary coagulation disorder with an incidence estimated at 1 in 500,000 individuals. In this report, we describe the 13th case in pregnancy. The diagnosis of severe factor vii deficiency (factor VII level <5%) was established at 10 weeks' gestation after initial laboratory testing showed a markedly prolonged prothrombin time and a normal activated partial thromboplastin time. There was a history of two preterm deliveries, but there was no evidence of previous bleeding manifestations. Antenatal progress of the index pregnancy was unremarkable. Prophylactic treatment with fresh frozen plasma was started at the onset of labor and the patient had a vaginal delivery of a live girl at 36 weeks' gestation. There was no postpartum hemorrhage and mother and newborn were discharged in good condition. The patient's postpartum level of factor VII remained undetectable. Two aspects are outlined: the absence of any significant increase in factor VII clotting activity during this pregnancy and the need to give replacement therapy at labor in patients with severe factor VII deficiency to decrease the risk of postpartum hemorrhage. ( info) |
7/237. Precipitate delivery and postpartum hemorrhage after term induction with 200 micrograms misoprostol. misoprostol has been widely applied in early pregnancy termination and term pregnancy induction. However, the upper dosage limit of misoprostol through vaginal route has not been firmly established. Most popular dosages of vaginal misoprostol recommended are 25, 50 or 100 micrograms. There are no reports on the dangers of high-dosage misoprostol 200 micrograms as used in term labor induction. We present a primiparaous woman who was administered 200 micrograms misoprostol vaginally for term labor induction. The following precipitate delivery resulted in multiple lacerations of the isthmus, cervix and vagina, postpartum hemorrhage and disseminated intravascular coagulopathy. Inevitably, a hysterectomy was performed. A postsurgical check of the uterus confirmed lacerations of the isthmus and internal cervix. This rare complication suggests the possible dangers of vaginal misoprostol doses as high as 200 micrograms for term induction of labor at term. ( info) |
8/237. A hypothesis to explain the occurence of inner myometrial laceration causing massive postpartum hemorrhage. BACKGROUND: Inner myometrial lacerations were found in three patients who developed uncontrollable postpartum massive bleeding despite the usual treatment for uterine atony. Because all the patients suffered from hemorrhage shock and their medical status deteriorated, their uteri were surgically removed to stop bleeding. After removal, one of them died. postpartum hemorrhage was caused by inner myometrial laceration. We hypothesized a cause of inner myometrial laceration, using the three resected uteri, an assumed model of the uterine body, and 34 women. methods: The subjects were 37 women, of whom three were patients with inner myometrial laceration, 23 were women without inner myometrial laceration who underwent cesarean section, and 11 were women in the first stage of labor. The three resected uteri were examined both macroscopically and microscopically. We measured the thickness of the wall of the uterine muscle at the widest point of the uterine corpus and the thickness of the myometrial wall at a transverse section of the uterine cervix, as well as the radius of the inner lumen at the widest point of the uterus in 23 women during cesarean section. We also measured the thickness of the myometrial wall at the widest point of the uterine corpus in 11 women at the end of the first stage of labor during ultrasonic examination. The data were then used to estimate the stress on the uterine muscle. RESULTS: The stress on the uterine cervix was stronger than that on the uterine corpus during labor. When the stress on the uterine muscle is stronger than a specific value, inner myometrial lacerations develop on the right and/or left side of the uterine cervix. These lacerations may involve large vessels. CONCLUSIONS: We have discovered another cause of postpartum hemorrhage which we have named inner myometrial laceration. These lacerations appeared to result from a strong stress on the uterine cervix caused by an abnormal rise in intrauterine pressure during labor. ( info) |
| The perinatal mortality, maternal mortality, infant mortality rates, and the complications of delivery at the Provincial Hospital of Quang Ngai, South vietnam are described. The perinatal mortality is the only valid statistic available as the infant usually leaves the hospital within three days of delivery. knowledge pertaining to the 4th to 28th day after birth is scanty and there is insufficient knowledge about the first year of life. infant mortality is estimated at 277 per 1,000 live births. The perinatal mortality 64.6 per 1,000 live births, and maternal mortality, 106 per 10,000 live births are extremely high in contrast to Western countries. The high perinatal mortality is attributable to deaths during birth, the neonatal and immediate postnatal period. The high maternal mortality is primarily due to caesarean section, anemia, uterine rupture, toxemia, post-partum hemorrhage and puerperal infection. ( info) |
| BACKGROUND: postpartum hemorrhage is a major contributor to maternal morbidity and mortality. Numerous medical and surgical therapies have been used, but none has been uniformly successful. CASE: Two women with postpartum hemorrhage due to uterine atony after cesarean for twins are presented. Neither responded to medical management. In the first subject, O'Leary uterine artery ligation and utero-ovarian branch ligations were done without benefit. The B-Lynch suture immediately sustained correction of hemorrhage in both subjects. magnetic resonance imaging and hysterosalpingogram after the first case showed no uterine defects. CONCLUSION: The B-Lynch suture might be a valuable addition to the surgical treatment of postpartum hemorrhage due to uterine atony. ( info) |