Postpartum haemorrhage.

Postpartum haemorrhage remains an important cause of maternal death in the developed and especially in the developing world. An appreciation of the physiological changes of pregnancy that predispose to rapid development of severe haemorrhage and DIC help maintain a level of vigilance. Although routine antenatal assessment can identify women with factors associated with an increased risk of severe postpartum haemorrhage, a significant proportion of women will develop intrapartum complications that cause severe haemorrhage. Prompt recognition and treatment of women with severe ongoing blood loss is essential to prevent morbidity and mortality. In addition to surgical correction of bleeding, replacement of plasma components to reverse coagulopathy and red cells to maintain tissues oxygenation are the basic aims of management. The haemostatic agent, recombinant Factor VIIa is a potentially useful addition to management of massive, life-threatening obstetric haemorrhage but its safety and efficacy remains untested in clinical trials.

[Postpartum hemorrhage: frequency, consequences in terms of health status, and risk factors before delivery]. / Hémorragies du post-partum: fréquence, conséquences en termes de santé et facteurs de risque avant l'accouchement.

In the developing countries, postpartum hemorrhage is the leading cause of maternal death and affects approximately 1% of pregnant women. In developed countries like ours, maternal mortality is one hundred fold lower but remains the cause of maternal death for about 10 women per 100,000 births. In the last decade, French confidential inquiries show that the number of maternal deaths by postpartum hemorrhage are probably the double of the number in nearby countries, whereas hemorrhage should no longer be the leading cause of maternal death in our countries. Postpartum hemorrhage is defined as the loss of 500 ml or more blood in the 24 hours following delivery (5% of deliveries), but maternal tolerance is really threatened starting from 1,000 ml (1% of the women approximately). "Life-threatening" situations concern approximately one patient in one thousand so that obstetricians are rarely faced with this situation. For maternal morbidity or mortality, the risk factors of postpartum hemorrhage are nearly the same: maternal age, multiple pregnancies, uterine scars, abruptio placentae, cesarean section, poor social condition and absence of prenatal care constitute the main risk factors of postpartum hemorrhage. Maternal age must be kept in mind because it is the most related to mortality by hemorrhage, even if prevention is difficult. However, progress in delivery care which are applied to all the patients could make it possible to limit the harmful effects of this risk factor. A recent study showed that organizational factors also part of the factors of risk of maternal morbidity/mortality and could be studied for intervention.

Recombinant factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy.

This case report illustrates the successful use of activated recombinant factor VIIa in the management of severe postpartum hemorrhage secondary to amniotic fluid embolism.

Report of the use of hyperbaric oxygen therapy (HBO2) in an unusual case of secondary infertility.

We report the use of hyperbaric oxygen therapy (HBO2) in the treatment of an unusual case of secondary infertility. The patient had failed to conceive after a 1-year period of in-vitro fertilization, during which oral sildenafil had also been administered. However she became pregnant after an IVF cycle and the use of adjunctive HBO2 and sildenafil, which was administered intravaginally on this occasion. There is currently very little evidence to support the use of HBO2 in this context. The possible mechanisms of action of HBO2 in this case are discussed.

[Sheehan's syndrome: an erratic diagnosis in the early postpartum]. / Le syndrome de Sheehan: un diagnostic difficile en post-partum immédiat.

Post-partum pituitary necrosis (Sheehan's syndrome) is a rare complication of the post-partum haemorrhage. The diagnosis can be erratic and often delayed. We report the case of a patient who had headaches and meningitis signs few hours after a post-partum haemorrhage. Magnetic Resonance Imaging (MRI) performed at day 2 showed a specific hypophysitis. The onset of asthenia, loss of weight, polyuro-polydipsy, persistent amenorrhoea and absence of lactation led to hormonal investigation. This permitted to diagnose global antehypopituitarism associated with diabetes insipidus. Progressive pituitary atrophy due to necrosis was found using MRI follow-up over 1 year. Our report summarises pathophysiological features of Sheehan's syndrome and early clinical and biological signs are discussed. MRI of the sellar region may be useful to early suspect the diagnosis.

High incidence of myocardial ischemia during postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage remains a major cause of global maternal morbidity and mortality, even in developed countries, despite the use of intensive care units. This study sought to (1) assess whether myocardial ischemia could be associated with and even aggravate hemorrhagic shock in young parturients admitted for postpartum hemorrhage, and (2) identify the independent risk factors for myocardial ischemia. METHODS: On their referral to the intensive care unit, a multidisciplinary team managed parturients with severe postpartum hemorrhage. Ventilation, transfusion, catecholamines, surgery, or angiography with uterine embolization were provided as clinically indicated. Plasma cardiac troponin I levels were used as a surrogate marker of acute myocardial injury and electrocardiograms of myocardial ischemia. RESULTS: A total of 55 parturients were referred with severe postpartum hemorrhage, all in hemorrhagic shock. Twenty-eight parturients (51%) had elevated serum levels of cardiac troponin I (9.4 microg/l [3.7-26.6 microg/l]), which were associated with electrocardiographic signs of ischemia and deteriorated myocardial contractility and correlated with the severity of hemorrhagic shock. Indeed, multivariate analysis identified low systolic and diastolic arterial blood pressure (< 88 and < 50 mmHg, respectively) and increased heart rate (> 115 beats/min) as independent predictors of myocardial injury. In addition, all patients who were given catecholamines also had elevated cardiac troponin I levels. CONCLUSIONS: These results suggest that treatment of postpartum hemorrhage-induced hemorrhagic shock should be coupled with concomitant prevention of myocardial ischemia, even in young parturients.

Alternativa quirúrgica en la hemorragia grave del puerperio / Surgical alternative int he serius hemorrhage of puerperium

Se presenta caso clínico de una paciente de 32 años de edad, primípara, puérpera de cesárea, con diagnóstico de inercia uterina refractaria a tratamiento médico, se comenta manejo y técnica quirúrgica conservadora.

Obstetric and gynecologic complications in women with Marfan syndrome.

OBJECTIVE: To analyze the maternal and fetal outcomes of pregnancy and gynecologic problems in women with Marfan syndrome. STUDY DESIGN: The outcomes of 14 pregnancies in 4 women with Marfan syndrome were prospectively observed between January 1988 and December 2000. The cardiovascular and obstetric complications were analyzed. During pregnancy all the patients were carefully monitored with serial echocardiography and close attention to symptoms. RESULTS: Of the 14 pregnancies, 5 (35.7%) ended in abortion, and 3 of them occurred in the early second trimester due to cervical incompetence. Premature onset of labor occurred in 2 pregnancies at 31 and 34 weeks. Postpartum hemorrhage complicated 3 deliveries, and inversion of the uterus occurred in 1 patient. Significant cardiovascular complications occurred in 2 patients, who required surgical correction of the aortic aneurysm and replacement of the aortic valve. In one patient the operation was performed within hours of vaginal delivery, and the other patient underwent surgery 8 weeks postpartum. No maternal death occurred in the study. One infant in the series was diagnosed as having Marfan syndrome. A premature infant delivered at 31 weeks died on the second day of life. CONCLUSION: Women with Marfan syndrome are at high risk of aortic dissection in pregnancy even in the absence of preconceptional aortic root dilatation. Obstetric complications in patients with this condition have been underreported in the past. Women with aortic root dilatation of < 40 mm usually tolerate pregnancy well, with good maternal and fetal outcomes. Women with Marfan syndrome should be counseled regarding the risk of pregnancy to both mother and fetus. Patients who have cardiac decompensation or aortic dilatation > 40 mm are advised to avoid pregnancy.

[Irreversible coma following hypoglycemia in Sheehan syndrome with adrenocortical insufficiency]. / Irreversibel coma na hypoglykemie bij het syndroom van Sheehan met bijnierschorsinsufficiëntie.

A 24-year-old woman of Somali origin delivered at term after an uncomplicated pregnancy. Post-partum haemorrhage resulted in hypovolaemic shock which was treated by hysterectomy. Five days later she became comatose due to unrecognised hypoglycaemia which caused severe irreversible brain damage and status epilepticus. Treatment in the intensive care unit with artificial respiration, prednisolone, desmopressin, inotropic support, barbiturates and an anaesthetic under EEG guidance was unsuccessful. The patient died 28 days post-partum. The hypoglycaemia was due to a combination of (a) inadequate glucose intake and (b) lack of counter-regulatory mechanisms due to a deficiency of steroids and growth hormone as a result of loss of pituitary function (Sheehan syndrome) together with adrenocortical insufficiency. The combination of Sheehan syndrome and primary adrenocortical insufficiency has not been described previously in the literature.

Clinical report of 28 patients with Sheehan's syndrome.

The aim of the present study was to determine the clinical and hormonal characteristics with Sheehan's syndrome in 28 cases that we had diagnosed and followed in the last 20 years. Twenty-eight patients with Sheehan's syndrome, diagnosed and followed at our University Endocrinology Clinic in the last 20 years were reported in the study. Medical history, physical examination, routine laboratory examinations, pituitary hormone analysis, CT and/or MRI scan of the sella of the patients were reviewed. All patients had a history of massive hemorrhage at delivery and physical signs of Sheehan's syndrome. Twenty-six of them lacked postpartum milk production, followed by failure of resumption of menses. There were 9 subjects with disturbances in consciousness associated with hyponatremia on admittance. All 28 patients had secondary hypothyroidism, adrenal cortex failure, hypogonadotrophic hypogonadism and growth hormone deficiency. Diabetes insipidus has not been found in any patient. Empty sellae were revealed in 8 patients by CT and/or MRI scan. Sheehan's syndrome is still encountered in clinical practice occasionally. If not diagnosed early, it could cause increased morbidity and mortality. The most important clues for diagnosis of Sheehan's syndrome are lack of lactation and failure of menstrual resumption after a delivery complicated with severe hemorrhage.

Sheehan syndrome: a splinter of the mind.

A 40-year-old woman presented with headache and diplopia after hypotension from postpartum hemorrhage. A noncontrasted cranial magnetic resonance imaging (MRI) showed an enlarged pituitary with a rim of slight increased signal. A repeat gadolinium-enhanced cranial MRI showed peripheral enhancement of the pituitary gland surrounding an isointense central area consistent with infarction of the pituitary and the clinical diagnosis of Sheehan syndrome. The patient was treated with intravenous hydrocortisone. Immediately after treatment, her symptoms remitted and the examination normalized. One month later, a gadolinium-enhanced cranial MRI was normal. The characteristic appearance of the post-gadolinium enhanced cranial MRI helped confirm the diagnosis of Sheehan syndrome and facilitate early treatment with corticosteroids.

Successful rescuing a pregnant woman with severe hepatitis E infection and postpartum massive hemorrhage.

AIM: To sum up the experience of the successful therapy for the severe hepatitis of pregnant woman with postpartum massive hemorrhage. METHODS: The advanced therapeutic methods including the bilateral uterine artery embolism, hemodialysis and artificial liver support therapy were performed with comprehensive medical treatments and the course of the successful rescuing the patient was analyzed. RESULTS: Through the hospitalization of about two mouths the patient and her neonatus had gotten the best of care in our department and pediatric department separately. Both of them were discharged in good condition. CONCLUSION: The key points for a successful therapy of the pregnant woman with severe hepatitis are termination of the pregnancy and the control of their various complications. It was suggested that the proper combination of these measures of modern therapy would race against time for renewing of hepatic and renal functions.

Sheehan's syndrome.

Sheehan's syndrome occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. It may be rarely seen without massive bleeding or after normal delivery. Improvement in obstetric care and availability of rapid blood transfusion coincided with a remarkable reduction in the frequency of Sheehan's syndrome particularly in western society. But it has recently been reported more often from well-developed countries. It is one of the most common causes of hypopituitarism in underdeveloped or developing countries. Enlargement of pituitary gland, small sella size, disseminated intravascular coagulation and autoimmunity have been suggested to play a role in the pathogenesis of Sheehan's syndrome in women who suffer from severe postpartum hemorrhage. The patients may seek medical advice because of various presentations ranging from non-specific symptoms to coma and the clinical manifestation may change from one patient to another. Failure of postpartum lactation and failure to resume menses after delivery are the most common presenting symptoms. Although a small percentage of patients with Sheehan's syndrome may cause abrupt onset severe hypopituitarism immediately after delivery, most patients have a mild disease and go undiagnosed and untreated for a long time. It may result in partial or panhypopituitarism and GH is one of the hormones lost earliest. The great majority of the patients has empty sella on CT or MRI. Lymphocytic hypophysitis should be kept in mind in differential diagnosis. In this review, the old and recent data regarding Sheehan's syndrome are presented.

[Chest pain and sulprostone during postpartum hemorrhage]. / Angor et sulprostone au cours d'une hémorragie de la délivrance.

A case of chest pain in a 31-year-old woman after vaginal delivery with epidural analgesia during sulprostone administration is described. Chest pain occurred shortly after sulprostone was started and disappeared when sulprostone was stopped. Ischaemia related data were negative. Angiographically coronary arteries were normal. Coronary artery spasm aetiology was retained. Sulprostone pharmacology is summarized. Coronary artery effects are compared with literature reports. Recommendations before sulprostone use are underlined.

Postpartum hemorrhage complicated with irreversible renal failure and central diabetes insipidus.

Sheehan's syndrome is a rare complication of pregnancy with multiple hormone deficiency. The exact pathogenetic mechanism is not well understood, because such endocrine abnormalities are not obvious in most women with severe hemorrhage. Central diabetes insipidus with fluid and sodium disturbances occurred in about 5% of the patients. [1,2] There are very few existing literature discussing concomitant Sheehan's syndrome and acute renal failure. The following case reports a patient showing Sheehan's syndrome, irreversible acute renal failure and central diabetes insipidus concurrently.