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PubMed1999

[Neurologic diseases and pregnancy].

Neurological diseases during and following pregnancy represent a small subgroup of all neurological diseases. They can be divided into three groups. 1) Diseases which existed already before pregnancy or which appear just by chance during this phase like migraine, multiple sclerosis, myasthenia gravis, epilepsy, brain tumors or Guillain-Barre syndrome. 2) Diseases that can appear without pregnancy but which display a higher incidence in connection with pregnancy. Cerebral ischemia, intracerebral hemorrhage, subarachnoidal hemorrhage, intracranial venous thrombosis and compression neuropathies belong to this group. 3) Preeclampsia/eclampsia, HELLP syndrome, amniotic fluid embolism and pituitary apoplexy are diseases with neurological symptoms which occur only with pregnancy. The pregnancy itself can imply some restrictions or even a contraindication concerning diagnosis and therapy of these diseases. The decision in favour or against diagnostic or therapeutic approaches is determined by possible effects on the fetus and by potential danger resulting from not recognizing or not treating such a disease.

Diagnosis, Differential↗

PubMed2005

Emergency obstetric hysterectomy in Kuwait: a clinico pathological analysis.

The major objective of this study is to analyze the histological findings in emergency obstetric hysterectomy specimens and correlate them with the clinical diagnosis, epidemiological factors and number of tissue blocks examined. The records of all peripartum hysterectomy specimens examined between 1995 and 2001 in the Department of Pathology, Al-Sabah Hospital Kuwait were analyzed. A minimum of ten blocks from the cervix or lower uterine segment was arbitrarily regarded as adequate. Fifty-eight patients had peripartum hysterectomies (incidence of 0.07% of all deliveries) out of which 65% were aged between 30 and 40 years. The number of hysterectomy increased with parity up to five and then declined. The number of blocks examined varied from 2 to 53. Satisfactory pathology was found in 40 and absent in 18 cases. There were 33 adherent placentas. Amniotic fluid embolism (AFE) was found in seven patients. Adequate tissue blocks (>or=10) were significantly associated with positive pathological findings. P value <0.05.

Adult↗

PubMed2000

Disseminated intravascular coagulopathy in pregnancy: thorough comprehension of etiology and management reduces obstetricians' stress.

In pregnancy and puerperium disseminated intravascular coagulopathy may accompany abruptio placenta, intrauterine fetal demise with retained dead fetus, amniotic fluid embolism, endotoxin sepsis, preecalampsia with HELLP and massive transfusion. Clinical signs and symptoms of DIC can include oozing from venipuncture sites and/or mucous membranes, red cell lysis from activation of the complement system, hemorrhage from coagulopathy and possible uterine atony, hypotension from hemorrhage and/or bradykinin release, and oliguria from end-organ insult and hypovolemia/hypotension. Treatment of DIC consists of replacement of volume, blood products, and coagulation components and cardiovascular and respiratory support with elimination of underlying triggering mechanism.

Disseminated Intravascular Coagulation↗

PubMed1994

Laminaria versus Dilapan osmotic cervical dilators for outpatient dilation and evacuation abortion: randomized cohort comparison of 1001 patients.

OBJECTIVE: Our purpose was to compare the clinical experience in using Dilapan osmotic dilator and Laminaria japonicum as overnight osmotic cervical dilators in second-trimester dilation and evacuation abortion with respect to measurable outcome variables, including complication rates. STUDY DESIGN: A cohort comparison was performed of 1001 patients receiving alternate preoperative treatment with either osmotic dilator after initial randomization until this number had been reached in the series. RESULTS: Few significant differences were found in the two cohorts with respect to blood loss, procedure times, and overall complication rates. However, patients receiving the Dilapan dilator were at least twice as likely to experience problems in cervical dilation or problems resulting from poor dilation or disintegration of the device than were patients receiving Laminaria japonicum. Although more patients receiving laminaria experienced amniotic fluid embolism or disseminated intravascular coagulation syndrome, these problems could not be attributed to the type of osmotic dilator used. CONCLUSION: Both osmotic dilators are acceptable for use in overnight dilation in this procedure, but the Dilapan dilator is more likely to disintegrate, retract, or present minor problems associated with poor dilation.

Abortifacient Agents↗

PubMed1975

Distinction between fibrinogen and fibrin degradation products in plasma.

Polyacrylamide (PA) gel electrophoresis in sodium dodecyl sulphate (SDS) has been shown to distinguish between the major components in the plasmin induced lysates of purified crosslinked fibrin and fibrinogen. The D dimer fragment from crosslinked fibrin separated on SDS-PA gels from the fibrinogen fragments X, Y, Dg and E. Follwing immuno-absorption of plasmin induced lysates of plasma clots, plasma fibrinogen, and mixtures of both, the major fragments of fibrinogen and fibrin were capable of being discriminated by SDS-PA gel electrophoresis. The presence of D dimer in patient plasma suggested the efficacy of heparin in the management of haemorrhage associated with amniotic fluid embolism.

Electrophoresis, Polyacrylamide Gel↗

PubMed1996

Training in the management of critical problems: teacher's view.

Teaching in critical obstetric problems should have special interest during residency and thereafter. Obstetric emergencies are relatively rare but may occur at any time. The obstetrician at that moment enters a special area requiring a multidisciplinary approach. From experiences in recent years and study of the literature the following recommendations can be summarized; (1) the need to understand (patho)physiologic changes in pregnancy, (2) cultivation of an anticipative attitude towards conditions with elevated risks, (3) adequate knowledge of diagnostic procedures, (4) the discipline to make a differential diagnosis, (5) experience with monitoring of (fetal and) maternal condition, (6) availability of management protocols for emergencies such as shock, eclampsia, uterine rupture, amniotic fluid embolism, thrombo-embolism, sepsis and diabetic ketoacidosis, (7) awareness of pitfalls with inspection of lesions and assessment of blood loss, (8) awareness that caesarean section without prior stabilization can be a life threatening procedure, (9) practice in life-saving measures such as uterine compression, packing, ligation of vessels, postpartum hysterectomy, (10) teaching of postoperative care, (11) insight into the cascade of events finally leading to multi-organ failure. Obstetric emergencies require a disciplined approach, in which teamwork is the cornerstone.

Emergency Medicine↗

PubMed2004

Unselected low-risk pregnancies and the effect of continuous intrapartum fetal heart rate monitoring on umbilical blood gases and cerebral palsy.

OBJECTIVE: Our purpose was to evaluate the clinical validity of electronic fetal heart rate monitoring to detect fetal acidemia and to evaluate the prevalence of cerebral palsy in unselected low-risk pregnancies. STUDY DESIGN: We selected two secondary and two tertiary level institutions in which 10,030 infants were born. Among them, 5546 of the pregnancies were low-risk pregnancies by antepartum evaluation. The fetal heart rate patterns were interpreted according to the guidelines of the National Institute of Child Health and Human Development. The correlations between the fetal heart rate pattern and umbilical blood gases and the fetal heart rate pattern and cerebral palsy were studied. Spastic cerebral palsy was diagnosed at > or =1 year by pediatric neurologists. Statistics included unpaired t test, contingency table with chi(2) and Fisher tests, and one-way analysis of variance with Bonferroni/Dunn test. RESULTS: On the basis of the severity of decelerations, frequency of decelerations, and decreased variability, umbilical pH, and Po(2) level were decreased accordingly, and incidence of pH<7.1 was increased. Sensitivity and false-positive rate of nonreassuring fetal heart rate patterns for fetal acidemia were 63% and 89%. There were nine cerebral palsy cases: six of the cases were preexisting asphyxia before monitoring was initiated, two of the cases were cytomegaloviral infections, and one of the cases was a maternal amniotic fluid embolism. CONCLUSION: In low-risk pregnancies, intrapartum fetal heart rate monitoring was useful to detect fetal acidemia. Cerebral palsy caused by intrapartum asphyxia was restricted to unavoidable accidents under continuous fetal heart rate monitoring.

Acids↗

PubMed2005

Perimortem cesarean delivery: were our assumptions correct?

OBJECTIVE: The recommendation to perform a perimortem cesarean delivery within 4 minutes of maternal cardiac arrest was introduced in 1986. This recommendation was based on the assumptions that cardiopulmonary resuscitation is ineffective in the third trimester because of aortocaval compression, and that fetal and perhaps maternal outcomes would be optimized by timely delivery. Our objective was to review the outcomes of perimortem cesarean deliveries to attempt to validate those assumptions. STUDY DESIGN: Ovid MEDLINE searches using maternal mortality, cardiopulmonary resuscitation, perimortem cesarean delivery, heart attack, and cardiac arrest from 1985 until 2004. Citations from bibliographies of identified publications were perused and cross-referenced for other potential articles. Case reports were included for analysis when mothers had complete cardiopulmonary arrest, and cardiopulmonary resuscitation had been initiated before cesarean delivery. RESULTS: There were 38 cases of perimortem cesarean delivery identified; 34 infants survived (3 sets of twins, 1 set of triplets); 4 other infants survived initially, but died several days after the deliveries from complications of prematurity and anoxia. Of the 34 infants (25-42 weeks' gestation), time of delivery after maternal cardiac arrest was available for 25. Eleven infants were delivered within 5 minutes, 4 were delivered from 6 to 10 minutes, 2 were delivered from 11 to 15 minutes, and 7 were delivered more than 15 minutes. Of 20 perimortem cesarean deliveries with potentially resuscitatable causes, 13 mothers were resuscitated and discharged from the hospital in good condition. One other mother was successfully resuscitated after the delivery, but died within 24 hours from complications related to her amniotic fluid embolism. In 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery. We wish to emphasize the large selection bias in this data. CONCLUSION: Published reports from 20 years support, but fall far from proving, that perimortem cesarean delivery within 4 minutes of maternal cardiac arrest improves maternal and neonatal outcomes.

Cardiopulmonary Resuscitation↗

PubMed1983

Rupture of the uterus with DIC.

Rupture of the uterus is an uncommon obstetric emergency that usually occurs after 36 weeks gestation in a woman with a previous cesarean section. Complete rupture of the uterus with extrusion of the fetus into the peritoneal cavity is associated with high fetal mortality and with hypovolemic shock in the mother. Incomplete ruptures are less catastrophic and are often found incidentally at routine elective cesarean section. Management of uterine rupture consists of prompt recognition, rapid replacement of maternal blood volume, and early laparotomy and hysterectomy or, in selected cases, uterine repair. Disseminated intravascular coagulation has been reported in association with such obstetrical emergencies as abruptio placentae, intrauterine fetal demise, septic abortion, and amniotic fluid embolism. We report a case in which there was clinical and laboratory evidence of DIC in a patient with uterine rupture. The patient was successfully managed with prompt hysterectomy and replacement of coagulation factors.

Adult↗

PubMed2001

Monitoring for suspected pulmonary embolism.

It is fortunate that serious embolic phenomena are uncommon because, with the exception of neurosurgery in the sitting position and cardiac surgery, thoracic echocardiography and the precordial Doppler device, the most sensitive indicators of embolism, are seldom used. Vigilance is required of the anesthesiologist to recognize the rapid fall in end-tidal PCO2, the usual first indicator of a clinically significant PE. Any sudden deterioration in the patient's vital signs should include embolism in the differential diagnosis, particularly during procedures that carry a high risk of the complication.

Embolism, Air↗

PubMed1998

Severe mitral stenosis in a parturient with congestive cardiac failure and hypoglycaemia.

We report a case of maternal mortality in a 34-year-old multipara who presented at the 35th week of gestation with severe hypoglycaemia. She had no history of diabetes mellitus. This episode was a prelude to catastrophic and refractory congestive cardiac failure due to previously undiagnosed severe mitral stenosis. The rapid cardiovascular deterioration initially appeared to be consistent with amniotic fluid embolism. She also developed deranged liver function with disseminated intravascular coagulation, which mimicked acute fatty liver of pregnancy. The problems of diagnosis and management are discussed. Unfortunately the patient died before mitral valvular commissurotomy could be effected.

Journal Article↗

PubMed2001

The tissue factor pathway in disseminated intravascular coagulation.

In most instances, tissue factor (TF) exposed to the circulation is the sole culprit underlying the initiation of disseminated intravascular coagulation (DIC), although notable exceptions because of a more direct activation of the coagulation system, by snake venoms, for example, do occur. Peripheral monocytes and subendothelial structures are the potential sources of such TF; in the former, TF emerges on the cell surface on synthesis induction and in the latter it becomes available subsequent to permeability changes or damage to the endothelium. Subendothelial TF is constitutively present in fibroblasts, pericytes, and macrophages and at a higher than normal level in tumor-associated macrophages. This scenario of coagulation activation probably describes the principal events underlying emerging acute DIC states under pathophysiological conditions such as abruptio placentae, septic abortion, amniotic fluid embolization, and pregnancy toxemia. Under disease conditions associated with DIC, the continuous exposure to excess TF typically exhausts the available tissue factor pathway inhibitor (TFPI), leading to rampant thrombin generation, persistent feedback activation of factor XI (FXI) by the generated thrombin, and hence virtually uncheckable ongoing fibrin generation (DIC). Recently, it was shown that patients subject to meningococcal sepsis had comparatively large amounts of mainly monocyte-derived circulating TF-containing microparticles. Because phosphatidylserine (PS) is exposed on such particles, in addition to TF, they probably contribute crucially to DIC during meningococcal sepsis. Although endothelial cells (EC) have been shown to express large amounts of TF in vitro, this observation hardly relates to the situation in vivo, where, in contrast, synthesis and exposure of EC TF is very limited and not likely to be of any significance in emerging and ongoing DIC.

Animals↗

PubMed2004

[Fatal amnioinfusion with previous choriocarcinoma in a parturient woman].

The case of 36-year-old tercipare is described who developed choriocharcinoma in a previous pregnancy. During the first term labour the patient developed cardiac arrest, so reanimation and sectio cesarea was performed. A male new-born was delivered in good condition, but even after intensive therapy and reanimation occurred death of parturient woman with picture of disseminate intravascular coagulopathia (DIK). On autopsy and on histology there was no sign of malignant disease, so it was not possible to connect previous choricarcinoma with amniotic fluid embolism. Maybe was place of choriocarcinoma "locus minoris resistentiae" which later resulted with failure in placentation what was hard to prove. On autopsy we found embolia of lung with a microthrombosis of terminal circulation with punctiformis bleeding in mucous, what stands for DIK.

Adult↗

PubMed1998

Hypercoagulability and DIC in high-risk infants.

Asphyxiated newborns have evidence of disseminated intravascular coagulation (DIC). Several hemostatic parameters were assayed in venous umbilical cord blood of 93 infants, 58 of which suffered from asphyxia due to abruptio placentae, breech delivery, preeclampsia, dead twin, and amniotic fluid embolism. Levels of factor XIII were markedly lower in the high-risk infants; the lowest values coincided with lowest Apgar scores. Plasma levels of thrombin-antithrombin (TAT) complexes, D-dimer, fibrin(ogen) degradation products (FDP), and soluble fibrin monomer complexes (SFMC) were markedly higher in the asphyxiated newborns with good correlations to DIC scores. DIC scores for infants were explained. A significant negative correlation was found between plasma levels of SFMC and Apgar scores. Also primary hemostasis measurements by a Thrombostat 4000 revealed defects in the asphyxiated infants. The data strongly suggest the presence of DIC in the high-risk group of infants.

Antithrombin III↗

PubMed1993

Fatal Clostridium perfringens and Escherichia coli sepsis following urea-instillation abortion.

Intraamniotic instillation of urea is a common mode of legal second-trimester pregnancy termination. Associated mortality rarely occurs and is most commonly due to amniotic fluid embolism, pulmonary thromboembolism, infection, hemorrhage, and disseminated intravascular coagulation (DIC). We present the case of an 18-year-old gravida 2, para 1 white woman at 18 weeks' gestation who underwent intraamniotic instillation of hyperosmolar urea and intracervical insertion of laminaria tents; 19 h later, she became unresponsive, academic, and went into shock. Coagulation studies were diagnostic of DIC. Bacilli were seen on peripheral blood smear. Autopsy showed marked subcutaneous emphysema of the anterior abdominal wall, necrosis and emphysema of the uterus, diffuse pulmonary alveolar damage, and renal cortical necrosis. Antemortem blood cultures grew Clostridium perfringens and Escherichia coli. Postmortem culture of the uterus grew E. coli. The source of infection was most likely the introduction of vaginal organisms via laminaria insertion. This is apparently the first reported case of death caused by Clostridium perfringens and E. coli sepsis following urea instillation.

Abortion, Induced↗

PubMed1972

Air embolism.

Explore the source record for details and available documents.

Carbon Dioxide↗

PubMed1993

Amnioinfusion: a review.

Amnioinfusion is a commonly practiced technique used for intrapartum improvement of the fetal condition. Room temperature normal saline (0.9 per cent) infused through an intrauterine pressure catheter has been used to alleviate variable decelerations, dilute thick meconium, and improve the intrauterine environment. Randomized studies comparing amnioinfusion to no therapy have shown that amnioinfusion is associated with lower cesarean delivery rates, decreased numbers of operative deliveries, and improved umbilical artery and venous blood gas values. Amnioinfusion also has been suggested as means to instill antibiotics into an infected uterine cavity, or the uterine cavity of a woman with preterm premature rupture of the membranes. Transabdominal amnioinfusion may be used to improved prenatal ultrasound evaluation in pregnancies associated with oligohydramnios. Complications of amnioinfusion include umbilical cord prolapse, uterine overdistention, fetal bradycardia, and one report of possible amniotic fluid embolism. Overall, amnioinfusion seems to be a safe and effective technique to improve the intrauterine milieu.

Amnion↗

PubMed2006

Use of a fascial prosthesis for management of abdominal compartment syndrome secondary to obstetric hemorrhage.

BACKGROUND: Massive obstetric hemorrhage can be catastrophic, with considerable maternal morbidity and mortality. CASE: A 41-year-old term gravida experienced massive postpartum hemorrhage attributed to an amniotic fluid embolism with rapid development of disseminated intravascular coagulation and resultant abdominal compartment syndrome. In this critically ill patient, a fascial prosthesis used for abdominal wall closure was placed to expedite multiple abdominal explorations and packing. Additionally, this device facilitated fascial closure once the abdominal compartment syndrome was resolved. CONCLUSION: Abdominal compartment syndrome resulting from overwhelming obstetric hemorrhage may necessitate emergent decompressive laparotomy to alleviate increased intra-abdominal pressure and end-organ dysfunction. The fascial prosthesis allows a staged abdominal wall closure to be performed once the abdominal compartment syndrome is resolved.

Abdomen↗