Biomedical subjects

K G Perry

Publications and source records attributed to K G Perry.

At least 55 records · Page 3Linked to original sources

PubMed1995

Risk of preterm delivery from preterm labor in high-risk patients.

This study aimed to determine the incidence of preterm labor and birth (< 37 weeks' gestation) in patients at high risk for early delivery. In this retrospective, descriptive study, 17,186 women with high-risk factors for early delivery were studied over a five-year period (1986-1990). Study groups included women with prior preterm delivery, multifetal gestations, uterine abnormalities and cervical factors. The rate of preterm labor for all patients averaged 40% (range, 30-46%). The rate of preterm delivery in the four groups ranged from 14% to 30% and averaged 19.7%. In those who experienced preterm delivery, only 32% of cases were due to preterm labor with advanced cervical dilatation, failed tocolysis or preterm premature rupture of membranes. The majority of early deliveries were due to medical or obstetric disorders as well as to patient/physician factors. The incidence of preterm labor remains significant when women have high-risk factors for preterm delivery. However, the incidence of preterm delivery, particularly that due to avoidable factors, such as failed tocolysis and preterm rupture of the membranes, is considerably lower than that quoted in the literature.

Adult↗

PubMed1995

Management of diabetic ketoacidosis in the obstetric patient.

Because of the normal metabolic changes found in pregnancy, diabetics are at increased risk to develop ketoacidosis. Even though the incidence of DKA during pregnancy has declined in recent years, prompt recognition of the presenting signs and symptoms followed by appropriate treatment of the associated metabolic disturbances can be lifesaving to the mother and her unborn child. Therapy is directed toward aggressive fluid resuscitation, avoidance of hypokalemia, and reversal of the hyperglycemia and ketoacidosis. When the clinician is confronted with DKA in the obstetric patient, aggressive therapeutic measures should maximize maternal and fetal outcome.

Diabetic Ketoacidosis↗

PubMed1994

Plasma exchange for preeclampsia: II. Unsuccessful antepartum utilization for severe preeclampsia with or without HELLP syndrome.

OBJECTIVE: To explore the efficacy of plasmapheresis/plasma exchange as the primary therapy to arrest and reverse the progression of severe preeclampsia with or without HELLP syndrome in order to postpone delivery and improve perinatal outcome in very preterm pregnancies. STUDY DESIGN: In this case series of patients managed over a 4-year period from 1984 to 1987, seven gravidas with severe preterm preeclampsia underwent 1-2 plasmaphereses/plasma exchange procedures using the IBM 2997 Cell Separator with continuous electronic fetal heart rate monitoring (n = 7 patients) and central cardiovascular monitoring (n = 3 patients). RESULTS: The seven patients (one with HELLP syndrome, six without HELLP) presented between 24 and 30 weeks gestation and, despite plasmapheresis/plasma exchange, the severity of each study subject's preeclampsia persisted without clinically significant improvement. Maternal-fetal deterioration required cesarean delivery in all cases within 48 (in four patients within < 36) hours of therapy. No clinically significant adverse effect of plasma exchange therapy was recorded during cardiovascular and laboratory monitoring; two fetuses developed repetitive late decelerations during exchange despite adequate maternal fluid preload. The only patient with HELLP syndrome developed eclampsia as her third plasma exchange within 25 hours was being initiated. Significant problems with fluid retention and displacement (variable amounts of pulmonary edema, pleural effusions, large volume ascites) were encountered in all patients. Four neonates died (24-27 weeks/438-820 g) and three survived intact (740, 950, and 1,280 g). One mother (case 5) developed end-stage renal disease 21 months postpartum. CONCLUSIONS: The application of plasmapheresis/plasma exchange therapy as described in order to prolong very preterm pregnancies in the undelivered patient with severe preeclampsia/eclampsia with or without HELLP syndrome did not produced encouraging results. Patients in general were exposed to additional medical and surgical risk without a corresponding improvement in perinatal outcome.

Adolescent↗

PubMed1994

Plasma exchange for preeclampsia: III. Immediate peripartal utilization for selected patients with HELLP syndrome.

OBJECTIVE: To explore the potential efficacy of plasma exchange as an ancillary interventive therapeutic tool immediately before or after delivery in the patient with severe preeclampsia/eclampsia and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. STUDY DESIGN: Two gravidas with complicated severe preeclampsia/eclampsia/HELLP syndrome were treated emergently in the immediate peripartal period with single-volume plasma exchange and fresh frozen plasma fluid replacement using the IBM 2997 Cell Separator. RESULTS: Despite multiple platelet unit infusions, one primigravida in active labor at 5 cm cervical dilation and 39 weeks' gestation remained at a platelet count of 14,000/microL and began to ooze from her guns. A second primigravida remained obtunded, oliguric, and thrombocytopenic with epistaxis and hematuria following cesarean delivery and platelet transfusions. A single expedited 3-liter plasma exchange procedure reversed the rapidly deteriorating clinical situation for each patient and accelerated recovery from HELLP syndrome. Both patients and progeny suffered no permanent sequelae. CONCLUSION: Based on our experience, we believe that the therapeutic modality of plasma exchange with fresh frozen plasma can be employed effectively for the pregnant patient with severe atypical HELLP syndrome that progressively worsens during labor or the early puerperium despite the use of conventional transfusion therapy.

Adolescent↗

PubMed1994

Postpartum corticosteroids: accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP).

OBJECTIVE: Because most morbidity and mortality associated with atypical preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets is a postpartum phenomenon, we undertook this investigation to evaluate the use of high-dose corticosteroids to minimize maternal morbidity and accelerate postpartum recovery in patients with this form of severe preeclampsia. STUDY DESIGN: Into this prospective, randomized study 40 parturients with the syndrome were recruited. The syndrome was defined by a clinical presentation consistent with a diagnosis of severe preeclampsia or eclampsia in addition to laboratory evidence of hemolysis, hepatic dysfunction, and thrombocytopenia. Immediately post partum 20 parturients assigned to the treatment group received four doses of intravenous dexamethasone at 12-hour intervals (10 mg, 10 mg, 5 mg, 5 mg) over 36 hours. Patients assigned to the control group received no corticosteroids. All study subjects were intensively monitored by mean arterial pressure and urinary output every 2 hours, hematocrit and platelet count every 6 hours and lactic dehydrogenase, aspartate aminotransferase, and alanine aminotransferase every 12 hours for the first 48 hours post partum. RESULTS: The steroid-treated group with the syndrome of hemolysis, elevated liver enzymes, and low platelets had significant changes over time in mean arterial pressure, urinary output, platelet count, lactic dehydrogenase and aspartate aminotransferase versus the control group with the syndrome. Relative to the control group, the mean arterial pressure became significantly decreased at 22 hours in the steroid-treated group (p < 0.03), urinary output increased significantly by 16 hours (p < 0.02), the platelet count increased significantly by 24 hours (p < 0.05), and both lactic dehydrogenase and aspartate aminotransferase decreased significantly by 36 hours (p < 0.04 and p < 0.05, respectively). CONCLUSIONS: In association with high-dose corticosteroid administration, parturients with the syndrome of hemolysis, elevated liver enzymes, and low platelets recovered from the disease process more rapidly than did control subjects, as measured by urinary output, mean arterial pressure, platelet count, lactic dehydrogenase, and aspartate aminotransferase. In this disease process, which has significant associated morbidity and mortality, especially in patients with advanced cases, high-dose corticosteroid therapy appears to significantly hasten recovery and lessen the severity of the disease post partum. We postulate that use of this therapeutic approach in properly selected patients could result in lessened overall maternal morbidity and mortality, shorter patient stays in recovery and intensive-care areas, and shorter overall hospitalization with reduced medical care costs.

Adolescent↗

PubMed1994

The intrapartum platelet count in patients with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome: is it predictive of later hemorrhagic complications?

OBJECTIVE: We wished to determine in patients with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) whether (1) there is an intrapartum threshold platelet count that is predictive of immediate or delayed hemorrhagic complications and (2) whether prophylactic platelet transfusion at delivery prevents these outcomes. STUDY DESIGN: In this retrospective, descriptive study, the peripartal courses of 132 patients with class 1 (< or = 50,000/microliters platelet nadir) and 160 patients with class 2 (> 50,000 but < or = 100,000/microliters platelet nadir) HELLP syndrome were reviewed with special attention to laboratory data, evidence of hemorrhage, and details of platelet transfusion therapy. RESULTS: A higher incidence of postpartum hemorrhagic complications (p < 0.001) occurred in class 1 versus class 2 HELLP pregnancies. The tendency to have postpartum incisional bleeding after abdominal or vaginal delivery was related to the degree of thrombocytopenia (p = 0.006). The antepartum threshold platelet count most predictive of subsequent postpartum hemorrhagic complications was < or = 40,000/microliters. The prophylactic administration of platelets does not appear to have either significantly decreased the incidence of postpartum hemorrhagic complications or significantly hastened normalization of the postpartum platelet count. CONCLUSIONS: Although bleeding in the gravid patient is related to more factors than platelet count alone, patients with HELLP syndrome in whom an intrapartum platelet count above 40,000/microliters maintained are unlikely to have clinically significant postpartum bleeding. Patients with intrapartum platelet counts < or = 40,000/microliters, however, are at significant risk for postpartum bleeding, but prophylactic platelet transfusion at delivery does not ensure a significantly lower incidence of postpartum hemorrhagic complications.

Adolescent↗

PubMed1994

The recurrence risk of the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) in subsequent gestations.

OBJECTIVE: Although it is an important clinical issue, accurate prediction of recurrence risk for the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) has been problematic because of limited patient experience. This study was undertaken to determine the likelihood that this form of severe preeclampsia-eclampsia or any other hypertensive disorder would occur in a subsequent pregnancy. STUDY DESIGN: An extensive retrospective analysis of medical records and patient follow-up regarding subsequent pregnancy outcome were undertaken for the 481 patients with HELLP syndrome managed at this tertiary medical center between Jan. 1, 1980, and Oct. 30, 1991. The Mississippi three-class system was used to define severity of disease on the basis of the lowest observed perinatal platelet count (class 1 < or = 50,000/microliters, class 2 > 50,000/microliters to < or = 100,000/microliters, and class 3 > 100,000/microliters to < or = 150,000/microliters). RESULTS: Subsequent gestations (n = 195) occurred in 122 of 481 patients. Evaluable data were available for analysis in 161 of 195 possible pregnancies. Seventy-eight (48%) pregnancies were complicated by some type of hypertensive disorder, 44 (27%) of which had class 1, 2, or 3 HELLP syndrome. Non-HELLP preeclampsia-eclampsia was detected in 25 subsequent gestations (15%). Thus the total frequency of preeclampsia was 69 in 161 (43%). If the data for class 3 HELLP are completely excluded from the analysis, 81 subsequent evaluable and viable gestations were identified, 19 pregnancies with preeclampsia-eclampsia (23%) and 15 patients with HELLP syndrome (19%), for a total recurrence rate of 42%. Subsequent HELLP gestations were frequently delivered abdominally (64%) on average 2 weeks later than the index pregnancy (32.6 +/- 5.0 weeks versus 34.7 +/- 5.3 weeks). Delivery at < 32 weeks conferred a high risk (61%) for a similar preterm delivery in a subsequent gestation. CONCLUSION: The risk of recurrence of the HELLP syndrome in our population is 19% to 27%. When data from all pregnancies with all forms of preeclampsia are considered, the risk of recurrence for any type of preeclampsia-eclampsia is 42% to 43%. A previous preterm delivery is a very high risk factor for recurrence of prematurity with preeclampsia-eclampsia.

Adolescent↗

PubMed1994

Assessment of fetal well-being using the nonstress test in the home setting.

OBJECTIVE: To determine the feasibility of performing nonstress tests (NSTs) in the home setting instead of the health clinic environment. METHODS: In this prospective study, ten women were tested using a Sonicaid TEAM portable monitor and a Hewlett-Packard device in the health clinic. The women were then instructed on use of the Sonicaid device and were tested once a week in the home as well as in the high-risk clinic. All tests were reviewed independently by two of the authors to assess agreement in interpreting the NST. In the health clinic setting, a nonreactive NST was followed by a nipple stimulation contraction stress test (CST); in the home, a nonreactive NST was followed by maternal voice acoustic stimulation. RESULTS: There was 100% correlation during the concurrent study. Two blinded authors agreed on all tests. During the second phase, eight of the ten subjects had NSTs that were consistently reactive in both the home and office settings. In one woman, a nonreactive NST in the clinic was followed by a negative CST. In the remaining patient, a reactive NST in the health clinic was followed 3 days later by a nonreactive NST in the home, which persisted in the provider's office. CONCLUSION: Nonstress testing in the home appears to be an accurate method of antenatal fetal health assessment that adds convenience and potential cost savings.

Feasibility Studies↗

PubMed1994

Factors relevant to mode of preterm delivery with syndrome of HELLP (hemolysis, elevated liver enzymes, and low platelets).

OBJECTIVE: Our purpose was to investigate factors relevant to mode of delivery for patients with preterm (< 34 weeks) gestation complicated by the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). STUDY DESIGN: The pregnancies of 189 patients with HELLP syndrome and delivery < 34 weeks' gestation between January 1980 and October 1991 were studied retrospectively. Only patients with class 1 (platelet nadir < or = 50,000 per microliter, n = 83) and class 2 (platelet nadir > 50,000 to < or = 100,000 per microliter, n = 106) HELLP syndrome were included. Maternal and perinatal factors relevant to type of delivery were reviewed. RESULTS: The incidence of cesarean delivery for all patients was 76.2% (primary rate 72.4%). Abdominal delivery occurred equally between class 1 (78.3%) and class 2 (74.5%) patients. Cesarean section was the mode of delivery for 87% of pregnancies at < 30 weeks' gestation in contrast to 68% of pregnancies at > or = 30 weeks but < 34 weeks' gestation (odds ratio 3.2, 95% confidence interval 1.4 to 7.5, p < 0.005). Indications for cesarean section included deteriorating maternal condition alone (50%), deteriorating maternal and fetal condition (27%), nonvertex fetal presentation (11.5%), and failure to progress (11%). Induction of labor was significantly more successful during the > or = 30 but < 34 weeks' pregnancy interval (47.5%) than in pregnancies at < 30 weeks (15.2%) (odds ratio 0.2, 95% confidence interval 0.1 to 0.55, p < 0.001). A trial of labor was successful in 22% of patients with an initial modified Bishop score < or = 2 versus 45% with an initial Bishop > 2 (odds ratio 0.5, 95% confidence interval 0.2 to 1.3, p = 0.16). CONCLUSION: Parturients with class 1 and 2 HELLP syndrome at < 34 weeks' gestation are at high risk for cesarean delivery. At a gestational age < 30 weeks, the likelihood of successful labor induction with vaginal delivery is remote, especially in association with an unfavorable cervix or the absence of labor.

Adult↗

PubMed1993

The interrelationship of eclampsia, HELLP syndrome, and prematurity: cofactors for significant maternal and perinatal risk.

OBJECTIVE: To determine if there are differences between mothers and fetuses in eclamptic pregnancies with or without concurrent HELLP syndrome. DESIGN: Retrospective review. SETTING: A single tertiary perinatal centre, the University of Mississippi Medical Center. SUBJECTS: All eclamptic pregnancies treated during a 141 month period from 1980 until the end of 1991. METHODS: Pregnancies were grouped according to the presence or absence of HELLP syndrome subclassified as class 1 = platelet nadir < or = 50,000/microliters, class 2 = platelet nadir > 50,000 to < or = 100,000/microliters, and class 3 = platelet nadir > 100,000 to < or = 150,000/microliters. RESULTS: Among 49,782 live births, there were 117 women with eclampsia prior to delivery (incidence 1:425), 62 of which had HELLP syndrome. The group with HELLP syndrome were delivered significantly earlier (32.1 vs 36.4 weeks), and had lower birthweights (1821 vs 2550 grams) and higher perinatal mortality (113 vs 18:100). They were also transfused more frequently (65% vs 35%), and suffered greater overall serious maternal morbidity and mortality. CONCLUSION: Eclampsia is more likely to be associated with the HELLP syndrome at early gestations. Although eclamptic patients are already at risk, the presence of HELLP syndrome accentuates the risk for adverse maternal-perinatal outcome.

Adolescent↗

PubMed1993

The University of Mississippi Medical Center's Antenatal Diagnostic Unit: on the cutting edge of tomorrow.

Prenatal diagnosis is a rapidly expanding field in the specialty of obstetrics. Modern providers of perinatal care must understand the fundamentals of inherited disease and keep abreast of advances in antenatal diagnosis. Pivotal in providing appropriate evaluation in this area is a referral center that is capable of affording the necessary evaluation, documentation and consultation. Although pregnancy termination is an option for some couples, many will use the information provided to prepare emotionally and financially for the birth of a child with special problems and needs. Some diagnoses will change obstetric management during the remainder of pregnancy or will lead to a recommendation for delivery at a tertiary medical facility. Other women with medical conditions warrant preconception counseling regarding pregnancy management and likelihood of a successful outcome. Patients with genetic disorders within their families may desire carrier detection through DNA analysis. Finally, women on medications at or near the time of conception frequently have concerns regarding potential teratogenesis. The ADU represents a commitment by both the Department of Obstetrics and Gynecology and the University of Mississippi Medical Center to furnish these services to providers and patients of the State of Mississippi.

Academic Medical Centers↗

PubMed1993

Immediate postpartum curettage: accelerated recovery from severe preeclampsia.

OBJECTIVE: To investigate the ability of immediate postpartum curettage to accelerate maternal recovery from severe preeclampsia. METHODS: Thirty-two parturients with severe preeclampsia were randomly assigned to either undergo ultrasound-directed curettage following delivery or to have no curettage. RESULTS: Subjects who underwent immediate postpartum curettage had a significantly decreased mean arterial pressure at each 2-hour point for the first 24 hours compared with those who were not curetted (P < .0002). The mean urine output after uterine curettage was significantly greater during each 4-hour interval of the first 24 hours postpartum compared with controls (P < .0002). The platelet count increased in the curettage group from 12 to 24 hours following curettage, whereas controls exhibited a decrease in the platelet count from 12 to 24 hours (P < .0003). CONCLUSION: Immediate puerperal uterine curettage of the parturient with severe preeclampsia appears to accelerate disease recovery with no apparent adverse sequelae.

Adolescent↗

PubMed1992

Vaginal birth after cesarean delivery: are there useful and valid predictors of success or failure?

OBJECTIVE: Before parturition are there useful and valid predictors of successful or unsuccessful vaginal birth after previous cesarean birth that could be used to enhance the obstetric care of a patient and her pregnancy? STUDY DESIGN: The clinical course and outcome of all patients who attempted vaginal birth after cesarean delivery at one level III center during 1989 were evaluated to identify factors prognostic of a successful or unsuccessful patient group; use of this information in stepwise logistic regression and cluster analysis was disappointing. RESULTS: No single criterion or optimal clusters of factors were found and no equation achieved greater than 75% predictability of outcome with acceptable sensitivity and specificity. CONCLUSIONS: Before parturition prediction of outcome of vaginal birth after cesarean delivery is tenuous regardless of past obstetric history or recent clinical parameters. Thus it seems appropriate to encourage a trial of labor in almost all patients with a prior low-segment uterine incision (transverse or vertical) unless there is a strong physician or patient-derived contraindication to such an undertaking.

Body Weight↗

PubMed1992

Oral magnesium and the prevention of preterm labor in a high-risk group of patients.

OBJECTIVE: The null hypothesis of this study is that treatment with oral magnesium gluconate 1 gm four times daily will not decrease the rate of preterm labor and delivery in a high-risk group of pregnant women. STUDY DESIGN: Fifty-four women at risk for preterm delivery were selected randomly to receive magnesium gluconate 1 gm orally four times daily or placebo. These women were monitored prospectively for signs and symptoms of preterm labor. A subgroup of 31 women also received a home uterine activity monitor. The serum magnesium level was measured initially and again 2 weeks after study enrollment. The data were analyzed with Fisher's exact test and analysis of variance. RESULTS: Preterm labor developed in 15 women in the placebo group and in 16 women in the magnesium group. There were no differences in birth weight or gestational age at delivery. The mean increase in serum magnesium level while the patients were taking magnesium gluconate was 0.10 mg/dl (p = not significant). Five women did not have an increase in serum magnesium level and preterm labor developed in all of them. CONCLUSION: Magnesium gluconate in a dose of 1 gm four times daily is not effective for preventing preterm delivery in a high-risk group of patients.

Administration, Oral↗

PubMed1992

Adjunctive antibiotic treatment of women with preterm rupture of membranes or preterm labor.

Subclinical infection is associated with preterm rupture of the membranes (PROM) and preterm labor (PTL) in many cases. It was hypothesized that antibiotic treatment might delay delivery and/or decrease infectious morbidity in those with PROM or PTL. Patients from 19 to 34 weeks with PROM and no labor or PTL with intact membranes (but not both) were separately randomized to receive ampicillin versus placebo in addition to usual therapy. There were 36 women with PTL (21 ampicillin/15 placebo) and 84 with preterm PROM (41 ampicillin/43 placebo). Demographically, the treatment and placebo groups were similar. Outcome variables analyzed included delivery delay after treatment, maternal chorioamnionitis/endometritis, Apgar score, neonatal infection, or respiratory distress, and hospital stay. There were no significant differences between the ampicillin and placebo groups in those with PTL or preterm PROM as it concerned outcome parameters. Adjunctive ampicillin used for treatment of idiopathic PTL or preterm PROM was not beneficial in this study.

Adult↗

PubMed1992

Hematologic disorders in pregnancy.

Hematologic disorders in pregnancy are relatively common and encompass a wide spectrum of clinical conditions. The treatment and obstetric management of the majority of these diseases are well established, although controversy exists in areas such as sickle cell disease and ITP. Once the diagnosis of a specific disorder is confirmed, therapy is directed toward improved perinatal outcome. Recent advances in prenatal diagnostic techniques make in utero diagnosis feasible for most of the inherited disorders and aid in genetic counseling.

Anemia↗

PubMed1992

Ascites: a portent of cardiopulmonary complications in the preeclamptic patient with the syndrome of hemolysis, elevated liver enzymes, and low platelets.

OBJECTIVE: Maternal ascites is frequently found at cesarean delivery in patients with severe preeclampsia or eclampsia expressed as hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). We attempted to determine whether large-volume maternal ascites present at cesarean delivery in HELLP syndrome patients is correlated with disease severity or with any specific form of increased maternal morbidity. METHODS: For this retrospective case series, we reviewed the medical records of 190 patients and noted the presence or absence of large-volume maternal ascites, peripartum complications, laboratory data, and specific operative techniques. RESULTS: The incidence of large-volume ascites in patients with HELLP syndrome who underwent abdominal delivery was approximately 10% in classes 1, 2, and 3. Compared with HELLP syndrome patients without ascites, those with HELLP-associated ascites at surgery had a significant sixfold increase in the incidence of congestive heart failure and a ninefold increase in the incidence of adult respiratory distress syndrome, both of which usually became clinically apparent within 24 hours postpartum. Those HELLP syndrome patients without ascites at surgery developed congestive heart failure or adult respiratory distress syndrome infrequently, and more than 24 hours postoperatively. CONCLUSION: Cautious fluid administration and observation for cardiopulmonary deterioration are crucial in management of the critically ill, high-risk group of HELLP syndrome patients with large-volume ascites.

Adult↗

PubMed1992

Abnormal hemostasis and coagulopathy in preeclampsia and eclampsia.

Preeclampsia and eclampsia appear to be a state of increased coagulopathy as evidenced by an increase in fibrin formation, activation of the fibrinolytic system, platelet activation and a decrease in platelet count. Routine tests used to assess decompensated disseminated intravascular coagulopathy are of limited value in the preeclamptic and eclamptic population. More sophisticated tests such as determinations of antithrombin III, thrombin-antithrombin III complex, D-dimer, factor VIII antigen/activity ratio, and beta-thromboglobulin, however, show a compensated coagulopathy in the preeclamptic patient. These hemostatic changes, probably the result of endothelial damage, are implicated in the pathogenesis of this disease. A better understanding about the abnormalities of hemostasis and coagulation in the preeclamptic and eclamptic patient may allow the clinician to provide improved management and possibly peripartum therapy.

Blood Coagulation Disorders↗