[Massive haemolysis: a rare manifestation of sepsis due to Clostridium perfringens]. / Massale hemolyse, een zeldzaam verschijnsel bij sepsis door Clostridium perfringens.

A 59-year-old man was admitted to the hospital to be operated on for carcinoma of the pancreas. During the operation, it turned out that resection ofthe tumour was not possible. Therefore, a double bypass was created for palliation: hepaticojejunostomy and duodenojejunostomy. The postoperative course was complicated by a fulminant sepsis accompanied by massive intravascular haemolysis. This is a rare and often fatal complication of a Clostridium perfringens sepsis. The patient was given antibiotics and multiple blood transfusions, but his haemoglobin remained low and despite the administration of large amounts of fluid, high doses ofinotropic agents and corticosteroids, it was not possible to achieve an adequate circulation. The patient died within 40 hours after admission to Intensive Care. Severe intravascular haemolysis with spherocytes in the blood smear must be interpreted as an important indication of a C. perfringens-sepsis.

Lumbar epidural catheter insertion: the midline vs. the paramedian approach.

BACKGROUND AND OBJECTIVE: The purpose of this study was to compare the characteristics of epidural catheter insertion via the midline or the paramedian approach with regard to ease of catheter insertion, incidence of paraesthesias and efficacy of epidural block. In addition to the type of approach, the prognostic value of Patients characteristics variables with regard to the incidence of paraesthesias was assessed. METHODS: Thirty patients scheduled for surgery under epidural anaesthesia were randomly assigned to one of two groups of 15 patients each. Epidural anaesthesia was performed via a midline or paramedian approach using loss of resistance to saline. Variables measured were: time needed to identify the epidural space, time needed for and ease of epidural catheter insertion and the incidence of paraesthesias. After completion of these observations, epidural anaesthesia was established with 150 mg ropivacaine 1%. Efficacy of the epidural block was assessed by the need for intraoperative analgesics and by the patient on a three-point scale (good/fair/poor). RESULTS: Quality of sensory blockade was adequate in both groups. Catheter insertion was significantly faster using the paramedian approach. The difference between the two approaches with regard to the incidence of paraesthesias was not significant, however, there was a trend towards more paraesthesias in the midline group. In the multivariate analysis, type of approach was an independent significant predictor of paraesthesias and we found a trend towards a higher incidence of paraesthesias in female patients. CONCLUSIONS: Catheter insertion was faster in the paramedian group and we found a trend towards a higher incidence of paraesthesias with the midline approach.

Low-molecular-weight heparin combined with aspirin in pregnant women with thrombophilia and a history of preeclampsia or fetal growth restriction: a preliminary study.

OBJECTIVE: To assess the prevalence of haemostatic abnormalities in patients with an obstetric history of preeclampsia and/or fetal growth restriction and documented thrombophilia, and to evaluate the effects of low-molecular-weight heparin (LMWH) and aspirin on pregnancy outcome. METHOD: A total of 276 patients with a history of preeclampsia and/or fetal growth restriction were tested for the presence of coagulation abnormalities and anticardiolipin antibodies (ACA). Ninety patients with preeclampsia and 15 patients with isolated fetal growth restriction had haemostatic abnormalities. Twenty-six patients with coagulation abnormalities: protein S-deficiency, activated protein C (APC) resistance and/or > or =15 ACA GPL and/or MPL had a subsequent pregnancy and were treated with aspirin in combination with LMWH. Their pregnancy outcome was compared with all patients having a subsequent pregnancy from the same cohort without abnormalities, or <15 ACA GPL and/or MPL who received aspirin (n=19). RESULTS: In subsequent pregnancies birth weight of babies born to patients with an unequivocal coagulation abnormality (i.e., protein S-deficiency, APC resistance, or ACA titres > or =15 GPL and/or MPL), were higher than in the group with no disorders or <15 ACA GPL and/or MPL (P=0.019). CONCLUSIONS: In this preliminary study, LMWH appears to have a favourable effect on the pregnancy outcome of women with a history of preeclampsia and/or fetal growth restriction and documented thrombophilia. Randomised trials are required.

Effects of folic acid and vitamin B6 supplementation on women with hyperhomocysteinemia and a history of preeclampsia or fetal growth restriction.

OBJECTIVE: Our purpose was to assess the incidence of hyperhomocysteinemia in patients with a history of preeclampsia or fetal growth restriction, to evaluate the effects of vitamin supplementation on the methionine loading test, and to study the course of subsequent pregnancies in women with hyperhomocysteinemia and a history of preeclampsia or fetal growth restriction. STUDY DESIGN: A total of 207 consecutive patients with a history of preeclampsia or fetal growth restriction was tested for hyperhomocysteinemia. Thirty-seven were found to be positive and were treated with folic acid and vitamin B6, and 27 had a second methionine loading test after vitamin supplementation. Fourteen patients became pregnant again while receiving vitamins and aspirin. RESULTS: All patients who underwent a methionine loading test after vitamin supplementation had a completely normalized methionine loading test. Of the 14 pregnancies in women receiving vitamins and aspirin, 7 were complicated by preeclampsia. Birth weights were 2867 +/- 648 g compared with 1088 +/- 570 g in the previous pregnancies. CONCLUSIONS: Vitamin B6 and folic acid correct the methionine loading test in patients with hyperhomocysteinemia. Perinatal outcome in patients with a history of preeclampsia or fetal growth restriction and hyperhomocysteinemia appears to be favorable.