Cases reported "Uterine Hemorrhage"

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1/19. Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience.

    OBJECTIVE: Obstetric hemorrhage is a significant cause of maternal morbidity and death. postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years. STUDY DESIGN: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included cervical pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2). RESULTS: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days. CONCLUSIONS: uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary.
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2/19. Transient myocardial ischemia may occur following subendometrial vasopressin infiltration.

    A case of transient myocardial ischemia following subendometrial vasopressin infiltration in intractable intra-operative postpartum bleeding due to placenta accreta is described. In our experience, the rate of this side effect is one in 14 patients (rate of 7.1%). We believe that the benefits of the treatment outweigh the risks, since the uterus was saved in all 14 patients. Nevertheless, this case emphasises that extreme precaution is needed with subendometrial vasopressin infiltration. It should be emphasised that the needle must not be within a blood vessel because intravascular injection of vasopressin solution can precipitate acute arterial hypertension, bradycardia and even death. We suggest that local vasopressin infiltration into the placental site is indicated in cases of intractable bleeding at cesarean section after other conventional obstetric and pharmacological maneuvers have failed.
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keywords = death
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3/19. Chorioepithelioma presenting as a bleeding gingival mass.

    A case is reported in which a very malignant neoplasm appeared clinically to be a pregnancy tumor or a hemangioma. There was, of course, no question as to the cause of death in this particular case. It was of interest because of the rarity of the tumor, the metastasis to the oral cavity, and the fact that the final diagnosis was established from pathologic examination. The case demonstrates, with emphasis, the great importance of biopsy and routine pathologic examination of all tissue for accurate and correct diagnosis, regardless of its clinical appearance.
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keywords = death
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4/19. Survey of amniocentesis for fetal sex determination in hemophilia carriers.

    A study was designed to determine whether there is an increased risk of complications when amniocentesis for fetal sex determination is performed on hemophilia carriers. questionnaires were sent to 112 medical centers providing this service in the united states, and to 19 outside the united states. Responses were received from 76% of the centers in the united states. Data on 11,819 taps were obtained. Only 75 taps (0.64%) were performed for the indication of hemophilia. The frequency of fetal deaths in the general sample (1.84%) was not significantly different from that in the subsample of hemophilia carriers (1.33%). The results of this survey correspond very closely to data from a National Registry on amniocentesis for various indicaions in such variables as the number of taps needed for diagnosis, color of the fluid obtained, and number of dry taps. Carrier women who had bleeding problems during the monitored pregnancy are described. The problems might have been related to the amniocentesis in three women. It is calculated that only 2-4% of hemophilia carrier women who might have amniocentesis are utilizing the service.
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5/19. Placenta percreta with bladder invasion as a cause of life threatening hemorrhage.

    PURPOSE: Abnormal placental penetration through the myometrium with bladder invasion is a rare obstetric complication with potential for massive blood loss. Urologists are usually consulted after a life threatening emergency has already arisen. Their familiarity with this condition is crucial for effective management. We describe 2 cases of placenta percreta with bladder invasion to highlight the catastrophic nature of this clinical entity, and review the literature on current diagnostic and management strategies. MATERIALS AND methods: Between 1986 and 1998, 250 cases of adherent placenta (0.9%) were identified in 25,254 births at our institution, including 2 (0.008%) of placenta percreta with bladder invasion. We treated these 2 multiparous women who were 33 and 30 years old, respectively. Each had undergone 2 previous cesarean sections. RESULTS: Presenting symptoms were severe hematuria in 1 patient and prepartum hemorrhage with shock in the other. Ultrasound showed complete placenta previa in each with evidence of bladder invasion in 1 patient. hysterectomy, bladder wall resection and repair, and bilateral internal iliac artery ligation were required to control massive intraoperative hemorrhage. The patients received 22 and 15 units of packed red blood cells, respectively. fetal death occurred in each case. convalescence was complicated by disseminated intravascular coagulation in patient 1 but subsequent recovery was uneventful. CONCLUSIONS: A high index of suspicion for placenta percreta with bladder invasion is required when evaluating pregnant women with a history of cesarean delivery and placenta previa who present with hematuria and lower urinary tract symptoms. ultrasonography and magnetic resonance imaging may assist in establishing the diagnosis preoperatively. With proper planning and a multidisciplinary approach fetal and maternal morbidity and mortality may be decreased.
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ranking = 1
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6/19. Complications of third-trimester amniocentesis using continuous ultrasound guidance.

    OBJECTIVE: The objective of the study was to estimate the risks of third-trimester amniocentesis with continuous ultrasound guidance. methods: Cohort study. We reviewed the medical records of women who had an amniocentesis with continuous ultrasound guidance after 30 weeks' gestation at a single institution from January 1991 through December 1994. For procedures performed from January 1991 to February 1994, we obtained information from a chart review. From March 1994 to December 1994, we collected data prospectively. The primary outcome was whether or not there were any complications within 48 hours of the procedure. We also sought to determine any risk factors associated with complications. RESULTS: Complete records and data were available for 562 amniocenteses during the study period. The mean gestational age at the time of amniocentesis was 34.9 weeks. Of the 562 procedures, five (0.8%) were unsuccessful and 50 (9%) required more than one needle stick. The complication rate was 0.7% (95% confidence level (CI) = 0.02%, 1.9%). These included spontaneous labor in a preterm gestation (1), premature rupture of the membranes (1), placental abruption (1), and fetal-maternal hemorrhage (1). No patient required an emergency cesarean delivery and none suffered a perinatal death (95% CI 0, 0.8%). Complications were not associated with the number of needle sticks, the presence of bloody amniotic fluid, or the level of operator experience. CONCLUSIONS: Third-trimester amniocentesis performed with continuous ultrasound guidance has a high success rate and low risk for complications.
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7/19. Ovarian cancer: a case study.

    Ovarian cancer is the leading cause of death from gynecologic malignancies in the united states, accounting for approximately 15,000 deaths each year. patients commonly present to their primary care providers with vague abdominal symptoms. health care providers need to become more aware of the importance of pursuing seemingly vague symptoms. A discerning knowledge of the risk factors and symptoms of this disease enables the clinician to institute appropriate assessment strategies, intervention, and referral, resulting in reduced mortality rates. This case report of a white woman aged in her 60s diagnosed with ovarian cancer stresses the need for early screening and detection, disease education, and prompt referral and management to displace the fear associated with the diagnosis and improve survival.
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ranking = 2
keywords = death
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8/19. Maternal deaths from anaesthesia. An extract from Why mothers die 1997-1999, the Confidential Enquiries into Maternal Deaths in the United Kingdom.

    This article is reprinted from Why mothers Die 1997-1999, the fifth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.
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keywords = death
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9/19. life-threatening bleeding, pregnancy and lupus anticoagulant: success after steroid and anticoagulant therapy.

    PROBLEM: The clinical manifestations associated with the presence of the lupus anticoagulant (LAC) are usually thrombotic and/or obstetric complications, specially miscarriages and/or repeated fetal deaths. The bleeding episodes in patients with LAC with no other coagulation disorders are exceptional, especially during pregnancy, intra- and postpartum. METHOD OF STUDY: Here we present two cases of patients with classification criteria of primary antiphospholipid antibody syndrome, a history of recurrent complicated pregnancies and massive bleeding during abortion and postpartum. We studied anticardiolipin (IgG/IgM), beta2glicoprotein-1 (IgG) and antimitochondrial (type 5) antibodies, LAC, rapid plasma reagin, coagulation test, clotting factors and, placental vascular flow from the second trimester of their last pregnancies. RESULTS: LAC was repeatedly detected in both cases. The prothrombin time and clotting factors including factors II and XIII were normal. Intrauterine growth restriction was also observed in both patients. pre-eclampsia was detected in patient 2. We tried enoxaparin (60-80 mg/day) and prednisone (1 mg/kg/day) therapy and no maternal, hemorrhagic or thrombotic episodes were observed. CONCLUSIONS: Exceptionally, LAC may be associated with recurrent, life-threatening bleeding, even in patients with no prothrombin deficiency. The close follow-up and early anticoagulant and steroid therapy seems to be able to control thrombotic and hemorrhagic complications during the pregnancy and postpartum.
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ranking = 1
keywords = death
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10/19. Perivascular epithelioid cell (PEC) tumors of the uterus: a clinicopathologic study of two cases with aggressive features.

    We report the clinicopathologic, immunohistochemical and ultrastructural features of two unusual tumors of the uterus composed of spindle and epithelioid cells strongly positive for HMB45. The two patients of 56 and 48 years of age had, respectively, hemoperitoneum and abnormal uterine bleeding. Morphologically, both tumors showed atypia and extensive necrosis. The neoplastic cells express immunohistochemically both melanogenesis (HMB45) and smooth muscle markers (actin). Ultrastructural analysis showed the presence of intracytoplasmic membrane-bound granules. We viewed these neoplasms as perivascular epithelioid cell (PEC) tumors with aggressive features. Follow-up has shown the death of one patient whereas the other is alive without disease 36 months after the surgery. The two patients were evaluated for signs of tuberous sclerosis complex, and findings were negative.
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