Cases reported "Postpartum Hemorrhage"

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1/73. 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.
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2/73. 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.
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3/73. Bilateral renal cortical necrosis: a report of 2 cases.

    Two cases of renal cortical necrosis, one of which occurred after an obstetric complication (abruptio placentae) and the other after postpartum haemorrhage, are described. The diagnosis was made by percutaneous renal biopsy, intravenous pyelography and selective nephro-angiography. Immunofluorescence studies of the kidney showed no abnormality in one patient, but showed the presence of IgM in the glomerular basement membrane in the second patient. hypotension was not observed when anuria occurred. Both patients survived. The importance of prolonged haemodialysis is stressed, since one patient was oliguric for 57 days and required intermittent haemodialysis for 5 months, while the second patient was oliguric for 17 days, required haemodialysis for 5 months and now has established hypertension.
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4/73. Ambulance transport of obstetric emergencies.

    Ninety-eight patient records from obstetric flying squad calls were reviewed. The reasons for call-out and the effect of transport on maternal and foetal cardiovascular parameters were analysed. The main reason for calling the flying squad is now antepartum haemorrhage. Transporting the patient to hospital has little effect on the cardiovascular state.
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5/73. Management in intractable obstetric haemorrhage: an audit study on 61 cases.

    OBJECTIVE: To refine the indications of bilateral hypogastric artery ligation (BHAL) and angiographic selective embolisation (ASE) in intractable obstetric haemorrhage. DESIGN: an audit study. SETTING: Tertiary care university hospital. population AND methods: Retrospective analysis of 61 cases of obstetric intractable post partum haemorrhage (PPH) initially managed either by hysterectomy or a conservative approach in a tertiary referral centre between 1983 and 1998. Procedures were reviewed as a primary (P) or secondary (S) attempt to arrest the haemorrhagic process. RESULTS: Ten hysterectomies (5 P, 5 S), 49 BHAL (48 P, 1 S) and 9 ASE (8 P, 1S) were successfully performed in arresting the haemorrhagic process. There were 7 maternal deaths, 5 following hysterectomy and 2 following a conservative approach. Atony of the uterus was the main cause of haemorrhage (n=21) and genital tract laceration was associated with the worst prognosis. time-elapse between delivery and surgery appears to be the main prognostic factor. Nine patients became pregnant 1 to 4 years later following a conservative approach. CONCLUSIONS: ASE seems to be indicated in haemodynamically stable patients with birth canal trauma or uterine atony and clotting anomalies. BHAL is indicated when haemorrhage occurs after a cesarean section or when the patient is haemodynamically unstable. BHAL should be taught to Junior doctors in an attempt to decrease the number of patients transferred in tertiary referral centers for intractable PPH. This might also decrease the number of hysterectomies in intractable PPH.
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6/73. Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy.

    Postpartum haemorrhage remains a significant complication of childbirth in the UK and worldwide. The most common cause of postpartum haemorrhage is uterine atony, but placent accreta is becoming more frequent. In these situations tamponade may be required. The successful use of the inflated stomach balloon (300ml) of a Sengstaken-Blakemore tube has been reported previously. We describe an innovative method of 'tamponade' which is simple and effective, using the Rusch urological hydrostatic balloon catheter. In two cases of failed medical therapy for PPH, where the catheter has been tried, further surgical interventions have been avoided.
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7/73. Postpartum acquired haemophilia: clinical recognition and management.

    Postpartum acquired haemophilia is a rare but serious complication of an otherwise normal pregnancy. patients usually present with postpartum haemorrhage (PPH) or uncontrolled bleeding following surgical interventions, which fail to respond to conservative treatment. A high index of clinical suspicion along with early laboratory diagnosis and prompt institution of appropriate therapy is essential for the management of acute bleeding episodes. Our patient, a 32-year-old female, presented with severe PPH and shock. She had undergone dilation and curettage three times, with subsequent total abdominal hysterectomy and internal iliac artery ligation, before she was diagnosed with acquired haemophilia (factor viii autoantibodies) and an inhibitor level of 8 Bethesda units (BU). The patient underwent an abdominal laparotomy for removal of the abdominal packing used in the previous operation, and blood and blood clots, and was given FEIBA(R) therapy. The patient responded to these measure and the factor viii inhibitor level decreased to 2 BU at the time of discharge 10 weeks later.
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8/73. False aneurysm of the uterine pedicle: an uncommon cause of post-partum haemorrhage after caesarean section treated with selective arterial embolization.

    We report three cases of post-partum haemorrhage following caesarean delivery attributed to a false aneurysm of the uterine pedicle and treated with artery embolization. These lesion were probably post-traumatic in origin related to hysterotomy. Angiographic study of the anterior division of hypogastric arteries confirmed the diagnosis and embolization of the false aneurysm was successful in controlling the haemorrhage.
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9/73. Hypovolaemic shock.

    Measured blood loss up to 1000 ml is well tolerated by healthy pregnant women. This is partly due to physiological increases in plasma volume and red cell mass during pregnancy. Nevertheless, hypovolaemic shock is a major cause of maternal mortality. Management requires teamwork, co-ordination, speed and adequate facilities to be life-saving. The first priority is rapid fluid replacement. Evidence from randomized trials has established that crystalloids are the fluids of choice over colloids and particularly albumen, which was associated with increased mortality. Rapid access to blood or blood products for transfusion is necessary, as well as laboratory back-up. Further management includes accurate assessment of the site of bleeding; control of the bleeding; diagnosis and management of the underlying condition; supportive therapy; and monitoring of the clinical, haematological and biochemical response to treatment. Bedside diagnostic ultrasound has several applications in the evaluation of obstetric hypovolaemic shock.
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10/73. Acquired factor viii inhibitors as a cause of primary post-partum haemorrhage.

    Acquired haemophilia was diagnosed following detailed investigation of a post-partum haemorrhage unresponsive to standard management. Circulating factor viii inhibitors and low factor viii levels were detected and intravenous DDAVP treatment lead to a resolution of symptoms. This case highlights the importance of haematological investigations in persisting post-partum haemorrhage.
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