RESUMO
BACKGROUND: Surgical packing should not be seen as a 'bail out' for the less skilled obstetrician who is unable to control obstetric haemorrhage using conventional techniques. Rather, this should be considered in cases of coagulopathy or where haemorrhage persists from raw surfaces, venous plexuses and inaccessible areas. MATERIALS AND METHODS: Data from seven women who underwent abdomino-pelvic packing for intractable postpartum bleeding were collected. The primary outcome was success of intra-abdominal packing and secondary outcomes included estimated blood loss, units transfused, length of stay and postoperative complications. RESULTS: All seven women (median age 39 years, interquartile range (IQR) 3.25) had caesarean section deliveries with median estimated blood loss of 5521.4 mL (IQR 4475) and median of 6.9 (IQR 4.75) units transfused. Abdomino-pelvic packing was successful in all cases including in three women who had continued bleeding after peripartum hysterectomy. In the remaining four, bleeding stopped with packing, enabling the uterus to be conserved. The median number of packs inserted was 6.1 (IQR 4.2) and median shock index at time of decision to pack was 0.98 (IQR 0.13). The median pack dwell time was 30.8 h (IQR 24), while median length of stay following removal was 48 h (IQR 2.14). CONCLUSION: Intractable bleeding in these seven cases was successfully controlled by abdomino-pelvic packing, allowing supportive correction of hypothermia, tissue acidosis, coagulopathy and hypovolemia. The technique of packing is an essential skill in managing massive obstetric haemorrhage, in addition to uterine balloon tamponade, compression sutures and peripartum hysterectomy.
Assuntos
Técnicas Hemostáticas , Hemorragia Pós-Parto/terapia , Tampões Cirúrgicos , Adulto , Cesárea , Feminino , Humanos , Histerectomia , Pessoa de Meia-Idade , Gravidez , Estudos RetrospectivosAssuntos
Anticoncepção/métodos , Anomalias dos Vasos Coronários/epidemiologia , Complicações Cardiovasculares na Gravidez/fisiopatologia , Doenças Vasculares/congênito , Adulto , Clomifeno/efeitos adversos , Anticoncepcionais Orais/efeitos adversos , Anomalias dos Vasos Coronários/fisiopatologia , Anomalias dos Vasos Coronários/prevenção & controle , Terapia de Reposição de Estrogênios/efeitos adversos , Estrogênios/fisiologia , Feminino , Humanos , Levanogestrel , Gravidez , Complicações Cardiovasculares na Gravidez/epidemiologia , Complicações Cardiovasculares na Gravidez/prevenção & controle , Progesterona/fisiologia , Doenças Vasculares/epidemiologia , Doenças Vasculares/fisiopatologia , Doenças Vasculares/prevenção & controleRESUMO
OBJECTIVE: How do numbers of oocytes retrieved per In vitro fertilisation (IVF) cycle impact on the live birth rate (LBR) and multiple gestation pregnancy (MGP) rates? DESIGN: Retrospective observational longitudinal study. SETTING: UK IVF clinics. POPULATION: Non-donor IVF patients. MAIN OUTCOME MEASURES: LBR per IVF cycle and MGP levels against number of oocytes retrieved into subgroups: 0, 1-5, 6-15, 16-25, 26-49 oocytes and 50+ oocytes. Relative risk (RR) and 95% CIs were calculated for each group against the intermediate responder with '6-15 oocytes collected'. RESULTS: From 172 341 attempted fresh oocyte retrieval cycles, the oocyte retrieved was: 0 in 10 148 (5.9%) cycles from 9439 patients; 1-5 oocytes in 42 574 cycles (24.7%); 6-15 oocytes in 91 797 cycles (53.3%); 16-25 oocytes in 23 794 cycles (13.8%); 26-49 oocytes in 3970 cycles (2.3%); ≥50 oocytes in 58 cycles (0.033%). The LBRs for the 1-5, 6-15, 16-25 and 26-49 subgroups of oocytes retrieved were 17.2%, 32.4%, 35.3% and 18.7%, respectively. The RR (95% CI) of live birth in comparison to the intermediate group (6-15) for 1-5, 16-25 and 26-49 groups was 0.53 (0.52 to 0.54), 1.09 (1.07 to 1.11) and 0.58 (0.54 to 0.62), respectively. The corresponding MGP rates and RR were 9.2%, 11.0%, 11.4% and 11.3%, respectively and 0.83 (0.77 to 0.90), 1.04 (0.97 to 1.11) and 1.03 (0.84 to 1.26), respectively. CONCLUSION: There was only limited benefit in LBR beyond the 6-15 oocyte group going to the 16-25 oocytes group, after which there was significant decline in LBR. The MGP risk was lower in 1-5 group.
Assuntos
Fertilização in vitro , Indução da Ovulação , Gravidez , Feminino , Humanos , Estudos Retrospectivos , Estudos Longitudinais , Oócitos , Nascido Vivo , Coeficiente de Natalidade , Recuperação de Oócitos , Reino Unido , Taxa de GravidezAssuntos
Transfusão Feto-Fetal/diagnóstico por imagem , Placenta/fisiologia , Policitemia/diagnóstico , Gravidez de Gêmeos , Adulto , Evolução Fatal , Feminino , Transfusão Feto-Fetal/patologia , Transfusão Feto-Fetal/fisiopatologia , Humanos , Artéria Cerebral Média/embriologia , Artéria Cerebral Média/patologia , Placenta/patologia , Gravidez , Ultrassonografia Doppler em Cores , Ultrassonografia Pré-NatalRESUMO
OBJECTIVE: Patients who decline blood products because of their religious beliefs pose a unique challenge in the context of obstetric haemorrhage. Four large series assessing maternal outcomes in Jehovah's Witnesses from USA, UK, Netherlands and Japan estimate that maternal mortality is increased by between 44 and 160-fold. A review of maternal deaths from obstetric haemorrhage was undertaken in mothers who decline blood transfusion, using UK Confidential Enquiries into Maternal Deaths reports (1967-2019) in order to identify common trends and lessons learnt. DESIGN: Retrospective review using 18 triennial Confidential Enquiries in Maternal Deaths reports between 1967 and 2019. RESULTS: Fifteen maternal deaths from haemorrhage were reported in patients who declined blood products for religious beliefs in the 52 years reviewed. Common themes noted included delay in senior escalation, hesitation to perform life-saving hysterectomy and loss of situational awareness. Placental abruptions (3/15) and curettage for secondary postpartum haemorrhage (2/15) especially warrant senior input and cooperation with Jehovah's Witness Hospital Liaison Committees is recommended. CONCLUSIONS: Guidelines from the UK's Royal College of Obstetricians and Gynaecologists and Royal College of Surgeons highlight the need for collaborative, Montgomery-competent discussions during the antenatal period, as well as the engagement of local Jehovah's Witness Hospital Liaison committees. Consultant-led care, antenatal optimisation of haemoglobin and techniques to mitigate blood loss at delivery are paramount. We advocate using a lower threshold for hysterectomy than was used in the cases analysed, for example when the haemoglobin level drops below 8-9 g/l in the context of ongoing bleeding. As patients increasingly begin to decline blood products for non-religious reasons, the lessons learnt in the management of Jehovah's Witnesses are becoming ever more relevant.
Assuntos
Testemunhas de Jeová , Hemorragia Pós-Parto , Feminino , Humanos , Mortalidade Materna , Placenta , Hemorragia Pós-Parto/terapia , Gravidez , Reino UnidoRESUMO
Introduction: The immunogenicity of BCG vaccination in infants differs between populations. We hypothesized that prenatal exposure to mycobacterial antigens might explain the differences in immune responses to BCG seen in other studies of infants in Africa and the United Kingdom (UK) and we explored this in birth cohorts in Uganda and the UK. Materials and Methods: Blood samples were obtained from BCG-immunized infants of mothers with (n = 110) and without (n = 121) latent Mycobacterium tuberculosis infection (LTBI) in Uganda and BCG-immunized infants of mothers without LTBI (n = 25) in the UK at 10 and 52 weeks after birth. Cytokine and chemokine responses to PPD were measured to assess responses to BCG immunization, and to ESAT6/CFP10 to assess exposure to or infection with M. tuberculosis or non-tuberculous mycobacteria (NTM) in 6-day whole blood culture supernatants by a 17-plex Luminex assay. Median responses were compared between Ugandan infants (together, and separated by maternal LTBI status) and UK infants. Results: The IFN-γ response to BCG vaccination was similar between Ugandan and UK infants at 10 and 52 weeks. At week 52, TNF production was marginally higher in Ugandan infants, but after adjusting for multiple comparisons this difference was not significant. At weeks 10 and 52, stimulation of blood with ESAT6/CFP10 produced significantly higher IFN-γ, TNF, IL-12p40, IL-1α, IL-1ß, IL-1Ra, IP-10, MIP-1α, MIP-1ß, and GM-CSF in Ugandan compared to UK infants. Stimulation of blood with ESAT6/CFP10 produced significantly higher amounts of IL-8 (p = 0.0001), IL-10 (p = 0.0022), and IL-13 (p = 0.0020) in the UK than in Ugandan infants of mothers without LTBI at week 10, but not at week 52. Conclusions: Immune responses to mycobacterial antigens following BCG immunization are similar for PPD, but differ for ESAT6/CFP10, between infants in Uganda and the UK. Neither maternal LTBI nor infant exposure to or infection with mycobacteria impacts the response to BCG. The observed global differences in immune response to BCG immunization are likely to be due to other causes.
Assuntos
Anticorpos Antibacterianos/sangue , Antígenos de Bactérias/imunologia , Vacina BCG/imunologia , Proteínas de Bactérias/imunologia , Mycobacterium tuberculosis/imunologia , Fragmentos de Peptídeos/imunologia , Tuberculina/imunologia , Feminino , Humanos , Lactente , Interferon gama/sangue , Tuberculose Latente/imunologia , Mycobacterium tuberculosis/metabolismo , Gravidez , Efeitos Tardios da Exposição Pré-Natal/imunologia , Fator de Necrose Tumoral alfa/sangue , Uganda , Reino UnidoRESUMO
This review highlights the rising prevalence of HIV in pregnancy both in the developed and developing world. It focuses on the challenges of diagnosis and management of Pneumocystis (carinii) jiroveci pneumonia in an HIV-positive pregnant woman. Public health efforts need to continue addressing testing at the earliest opportunity, the psychosocial issues which impact negatively on the care of HIV-positive individuals and ways to reduce stigmatisation associated with this viral illness.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/microbiologia , Infecções por HIV/complicações , Pneumonia por Pneumocystis/microbiologia , Complicações Infecciosas na Gravidez/microbiologia , Infecções Oportunistas Relacionadas com a AIDS/complicações , Adulto , Evolução Fatal , Feminino , Infecções por HIV/microbiologia , Infecções por HIV/psicologia , Humanos , Pneumocystis carinii/isolamento & purificação , GravidezAssuntos
Doença de Crohn/complicações , Complicações na Gravidez/etiologia , Gravidez não Planejada , Adulto , Anticoncepcionais Orais Hormonais/farmacocinética , Doença de Crohn/metabolismo , Feminino , Seguimentos , Humanos , Recém-Nascido , Síndromes de Malabsorção/etiologia , Síndromes de Malabsorção/metabolismo , Gravidez , Complicações na Gravidez/metabolismo , Resultado da GravidezAssuntos
Anticoncepcionais Femininos/efeitos adversos , Comunicação Interdisciplinar , Erros de Medicação , Acetato de Medroxiprogesterona/efeitos adversos , Oligomenorreia/diagnóstico , Adulto , Ética Clínica , Feminino , Humanos , Programas Nacionais de Saúde , Oligomenorreia/fisiopatologia , Insuficiência Ovariana Primária/diagnóstico , Reino UnidoAssuntos
Antirretrovirais/uso terapêutico , Anticoncepcionais Femininos , Desogestrel , Infecções por HIV/tratamento farmacológico , Adulto , Anticoncepcionais Femininos/normas , Desogestrel/normas , Interações Medicamentosas , Feminino , Humanos , Relações Médico-Paciente , Autorrevelação , Falha de Tratamento , Revelação da VerdadeAssuntos
Síndrome de Gitelman/sangue , Potássio/sangue , Complicações na Gravidez/sangue , Evolução Fatal , Feminino , Morte Fetal , Síndrome de Gitelman/terapia , Humanos , Hipopotassemia/sangue , Hipopotassemia/terapia , Masculino , Oligo-Hidrâmnio , Gravidez , Complicações na Gravidez/terapia , Resultado da Gravidez , Natimorto , Desequilíbrio Hidroeletrolítico/sangue , Desequilíbrio Hidroeletrolítico/terapia , Adulto JovemRESUMO
We present a case of a 30-year-old mother of four who was incidentally diagnosed with cervical intraepithelial neoplasia (CIN) III following surgical termination of pregnancy. Five years previously a routine smear test had shown mild dyskaryosis but was never repeated. She was referred to colposcopy and, underwent loop excision of the transformation zone (LLETZ) and subsequently vaginal hysterectomy. Without this incidental finding she would have undoubtedly developed cervical cancer. We discuss the deficiencies in current cervical cancer prevention strategies and termination of pregnancy services. We emphasise the importance of ensuring that patients with dyskaryosis are not lost to follow-up and we consider whether there should be clearer guidance on the value of histological examination of products of conception following termination of pregnancy.
RESUMO
A 69-year-old woman presented to the emergency department (ED) with a swollen left thigh and leg. D-dimer test was positive, a radiology department ultrasound showed no direct evidence of a deep venous thrombosis but a lack of respiratory modulation was seen. ED ultrasound showed large groin lymph nodes and this, together with low haemoglobin, prompted a CT scan which led to the diagnosis of metastatic carcinoma.
Assuntos
Veia Ilíaca , Trombose Venosa/diagnóstico por imagem , Idoso , Diagnóstico Diferencial , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Humanos , Tomografia Computadorizada por Raios X , Ultrassonografia , Trombose Venosa/sangueRESUMO
A 87-year-old man presented to the emergency department (ED) with right-sided abdominal and thigh pain which had been present for the last 3 days and was getting worse. He had been diagnosed with a deep venous thrombosis of the left common femoral and superficial veins 10 days previously and had been discharged on a loading dose of warfarin and low-molecular weight heparin (dalteparin) injections. Despite his international normalised ratio being only 2.4, an ED ultrasound showed an unusual mass in the right iliac fossa, partly cystic and partly solid. A CT scan was performed which showed the lesion was a haematoma in the right iliopsoas muscle mass.
Assuntos
Anticoagulantes/efeitos adversos , Artéria Femoral/patologia , Hemorragia/diagnóstico , Músculos Psoas/patologia , Trombose Venosa/complicações , Varfarina/efeitos adversos , Idoso de 80 Anos ou mais , Quimioterapia Combinada , Artéria Femoral/diagnóstico por imagem , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Coeficiente Internacional Normatizado , Masculino , Músculos Psoas/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ultrassonografia , Trombose Venosa/tratamento farmacológicoRESUMO
An intramural ectopic is a rare type of ectopic pregnancy in which the gestational sac is implanted within the myometrium, separate from the endometrial cavity and Fallopian tubes. There are only 53 cases in the published literature. We report a case of intramural ectopic pregnancy treated surgically and review the published data on this rare type of ectopic pregnancy, with respect to aetiology, diagnosis and management.