[Severe pregnancy hemostasis disorders: diagnosis and therapeutic procedures]. / Schwere geburtshilfliche Hämostasedefekte: Diagnostik und therapeutisches Vorgehen.

We evaluated 21 pregnant patients with severe disorders of haemostasis by retrospective chart analyses, 15 patients were treated with intravenous heparin (10.000 to 20.000 I.U.) during and after surgery. Eighteen of 21 patients developed renal failure and 8 died. Postoperative bleeding complications making laparotomies mandatory occurred in 10 patients. These bleeding complications are seen in relation to the heparin treatment instituted immediately after surgery. We do not favor the administration of heparin during the immediate obstetrical postoperative period, the more as Antithrombin III-concentrate is now available. Surgical intervention in order to achieve haemostasis is of paramount therapeutic importance. Drainage of infections remains furthermore the most important task in those obstetrical emergency cases where infections play a predominant role. To maintain or to re-establish the normovolemic perfusion ameliorates the rheological conditions which should monitored with care.

Morphology of Fallopian tubes removed from a patient after failure of clip sterilization.

A bilateral salpingectomy was performed at the time of vaginal hysterectomy in a pregnant patient sterilized 20 months earlier by application of Bleier clips to the fallopian tubes. Clip application to the left tube had been incomplete. Undisturbed tissue (left tube) and clipped tissue (right tube) were examined and compared by light and scanning electron microscopy. The segment of tube fully grasped by the clip had a completely detached lining epithelium with coarse and flattened mucosa, a loose stroma, and disorganized muscular bundles. The left tubal mucosa was normal, whereas the right tube was stenosed at the site of clip placement, with rigid walls and a 0.175 mm luminal diameter. With progressively greater stenosis toward the clip site, mucosal destruction increased. Polypoidal mucosal folds were seen, as well as fibrous adhesions between mucosal folds. These observations indicate that tissue damage is extensive enough after clip application to require excision of the damaged segment of tube and microsurgical re-anastomosis for reversal of sterilization.

PIP: A 37-year-old woman had a bilateral salpingectomy performed at the time of vaginal hysterectomy although she had been sterilized 20 months before via application of Bleier clips to the fallopian tubes. The woman presented pregnant. Using both a scanning electron and a light microscope, undisturbed tissue (left tube where clip application had been incomplete) and clipped tissue were examined. The right tube (clipped) showed completely detached lining epithelium with coarse and flattened mucosa, loose stroms, and disorganized muscular bundles in the segment where the clip had been attached. The left tubal mucosa, where the clip had failed to attach, was perfectly normal, whereas the right tube was stenosed at the site of clip placement. The tissue destruction seen after clip sterilization is so extensive that excision of damaged segment followed by microsurgical reanastomosis seems the only procedure to reverse sterilization of this type.