Cases reported "Postpartum Hemorrhage"

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1/9. Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII.

    BACKGROUND: postpartum hemorrhage is one of the most common causes of maternal mortality and morbidity worldwide. The aims of treatment are to maintain the circulation and to stop the bleeding. The latter is achieved by either medical or surgical management. In intractable bleeding, emergency hysterectomy is usually required. CASE: A 30-year-old nullipara presented with major postpartum hemorrhage due to uterine atony and vaginal lacerations. The patient developed hemorrhagic shock, resulting in prolonged prothrombin time, prolonged activated partial thromboplastin time, and low levels of factor viii and fibrinogen. Treatments with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, packing of the pelvis, and blood transfusion failed to control diffuse pelvic and vaginal bleeding. Recombinant activated factor viia (60-microg/kg intravenous bolus injection) was given as a final attempt to control the bleeding. The bleeding was successfully controlled within 10 minutes after administration. No side effects were noted. CONCLUSION: Recombinant factor VIIa may be an alternative hemostatic agent in a patient with life-threatening postpartum hemorrhage unresponsive to conventional therapy.
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2/9. Intravenous nitro-glycerine versus general anaesthesia for placental extraction--a sequential comparison.

    BACKGROUND: Postpartum haemorrhage due to retained placenta is one of the commonest life-threatening conditions during the third stage of labour. Uterine relaxation is usually required to facilitate placental removal. 'Full-stomach' obstetric patients (which includes those who delivered within 48 h), parturients with a history of antepartum or recurrent postpartum hemorrhage, grand multiparity, twin pregnancy, and those with cardiac abnormalities may benefit from an alternative to volatile-based general anaesthesia for uterine relaxation to avoid complications associated with the technique (e.g. aspiration pneumonitis and cardiovascular compromise). CASE REPORT: A 34-year-old gravida 4, para 3 parturient with rheumatic valvular heart disease presented with retained placenta and postpartum haemorrhage on two consecutive deliveries and had the placenta removed manually by the same surgeon under two different anaesthetic techniques. On the first occasion, general anaesthesia was administered whereas only i.v. fentanyl and nitro-glycerine were used on the second occasion. The postoperative course was uneventful on both occasions. CONCLUSIONS: The use of nitro-glycerine was found to be efficacious for manual removal of placenta with minimal haemodynamic perturbations, avoiding the use (and associated risks) of general anaesthesia for uterine relaxation. The ability of nitro-glycerine to reduce spontaneous uterine activity, induce uterine relaxation, coupled with its short duration of action and high efficacy, may render it a safe alternative to general anaesthesia for facilitating intrauterine manoeuvres. Nitro-glycerine may be useful especially in patients with associated co-morbid chronic cardiac conditions, e.g. rheumatic heart disease, which is characterised by impaired haemodynamics and cardiac reserves.
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3/9. Hemostatic cervical suturing technique for management of uncontrollable postpartum haemorrhage originating from the cervical canal.

    OBJECTIVE: To evaluate the efficacy and safety of a novel cervical suturing technique for management of uncontrollable postpartum haemorrhage originating from the cervical canal. STUDY DESIGN: Cervical suturing was performed on three women to control intractable postpartum haemorrhage originating from the cervical canal and not responding to classic management. Haemostatic cervical suturing by using no. 1 chromic catgut is a new surgical technique which approximates anterior and posterior cervical lips. It controls cervical haemorrhage by attachment and compression of the haemorrhage site of the cervical lips and lower uterine segment. RESULTS: The procedure was effective in all cases and hysterectomy was not needed in any case. No complication occurred and the survival rate was 100%. The procedure required no special expertise or extraordinary equipment. CONCLUSION: Cervical suturing technique for management of postpartum haemorrhage originating from the cervical canal is an easy, safe and highly effective conservative surgical technique that may be alternative to hysterectomy.
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4/9. Uterovaginal packing with rolled gauze in postpartum hemorrhage.

    Management options for postpartum hemorrhage (PPH) include oxytocics, prostaglandins, genital tract exploration, ligation or angiographic embolization of uterine/internal iliac arteries, and hysterectomy. After excluding uterine rupture, genital tract lacerations, and retained placental tissue, efforts are directed toward contracting the uterus by bimanual compression and oxytocics. If these are not successful, one must resort to surgical techniques. At this stage, an alternative option to remember is uterovaginal packing. Easy and quick to perform, it may be used to control bleeding by tamponade effect and stabilize the patient until a surgical procedure is arranged. Uterovaginal packing may sometimes obviate the need for surgery altogether. Two cases, a primary and a secondary PPH, managed recently with uterovaginal packing are reported. Despite concerns about concealed hemorrhage or the development of infection with this intervention, none of these problems were encountered, and uterine packing was successful even in the case of secondary PPH with documented infection.
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5/9. Modified B-Lynch technique for the control of massive postpartum hemorrhage. An alternative to hysterectomy.

    The B-Lynch, brace suture technique is a life saving procedure. It is a simple and safe procedure, which has the advantage of preserving the uterus and thus fertility. The efficacy of the procedure can be assessed immediately and complete hemostasis is obtained in most cases. The special advantage of the B-Lynch technique is that it is an alternative to major surgical procedures such as hysterectomy and internal iliac artery ligation. A modified technique of the B-Lynch embracing suture has been performed in the case reported without any apparent complications.
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6/9. extracorporeal membrane oxygenation therapy for circulatory arrest due to postpartum hemorrhage.

    BACKGROUND: Cardiac arrest after postpartum hemorrhage may not respond to advanced life support. Various resuscitation methods have been proposed, including sternotomy and direct cardiac massage. extracorporeal membrane oxygenation (ECMO) might be an alternative. CASE: We report the case of a woman who suffered atonic uterine hemorrhage perioperatively after cesarean delivery of twins. During initial conservative treatment using prostaglandin analog (sulprostone), cardiac decompensation developed and was followed by cardiopulmonary arrest. Circulatory failure remained unresponsive after 2 hours of resuscitation, when ECMO was initiated. The ensuing recovery was favorable. CONCLUSION: Aggressive mechanical circulatory support, such as ECMO, should be considered in a case of potentially reversible cardiocirculatory failure in a young obstetric patient.
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7/9. Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization.

    A case of severe postpartum hemorrhage is reported. Three separate surgical procedures failed to reveal the source of bleeding, and standard surgical techniques, including bilateral ligation of the hypogastric arteries, were unsuccessful in producing hemostasis. However, angiography successfully identified the specific bleeding vessel, and transcatheter embolization with Gelfoam fragments quickly and effectively stopped the hemorrhage. The authors consider angiographic embolization to be an effective alternative approach to the control of pelvic hemorrhage and recommend that the technique be considered prior to surgical intervention.
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8/9. Vaginal ligature of uterine arteries during postpartum hemorrhage.

    Immediate postpartum hemorrhage due to uterine inertia is usually treated by injection of oxytocics. In some situations, bleeding continues and distends the uterine cavity, in turn disturbing the hemostasis that accompanies uterine retraction. Uterine bleeding must be rapidly reduced while the coagulation defect is corrected. The authors propose the vaginal ligature of uterine arteries, which can be performed in the delivery room, as an alternative to hysterectomy.
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9/9. Successful pregnancy after bilateral hypogastric artery ligation. A case report.

    BACKGROUND: Selective embolization of the hypogastric arteries is an effective, nonsurgical alternative for the management of obstetric and gynecologic hemorrhage. Successful pregnancy following bilateral hypogastric artery occlusion has been reported, but experience is extremely limited. CASE: We report a case of successful pregnancy in a patient previously treated with bilateral hypogastric artery embolization. Although a diminution of fetal growth toward term was observed, the fetus tolerated labor and subsequently thrived, without sequelae. CONCLUSION: This case supports the possibility of normal labor for women who conceive after bilateral hypogastric artery embolization.
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