Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries.

Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient's median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Septic miscarriage with toxic shock syndrome and disseminated intravascular coagulation (DIC): The role of surgery, recombinant activated factor VII and intravenous immunoglobulin (IVIG).

Severe sepsis with multi-organ failure is associated with a high mortality rate. This case report highlights the challenges and modalities available in the management of a lady with refractory shock and disseminated intravascular coagulation (DIC) due to toxic shock syndrome (TSS) from genital tract sepsis. Early surgical intervention to remove the source of infection, the use of recombinant activated factor VII to treat intractable disseminated intravascular coagulation and intravenous immunoglobulin to neutralise the circulating exotoxins, have been employed and shown to drastically improve outcomes.

Trombosis de la vena ovárica: Factores de riesgo, diagnóstico y tratamiento / Ovarian vein thrombosis: risk factors, diagnosis and treatment

La trombosis de la vena ovárica es una complicación muy poco frecuente (0.002-0.05%), que se observa en mujeres que presentan un incremento en los factores de coagulación. La principal situación en la que es posible detectar esta complicación es el embarazo, aunque no es la única. Se describe el caso de una mujer de 31 años de edad, gestante de 16 semanas, que presenta un aborto espontáneo séptico complicado con una trombosis de la vena ovárica. Se aprovecha el caso clínico para revisar en la literatura los factores de riesgo, el diagnóstico y el tratamiento de esta inusual patología.

Ovarian vein thrombosis is an uncommon complication (0.002-0.05%) related to hypercoagulated status of women. The most frequent condition associated to ovarian vein thrombosis is pregnancy, but there are other possible causes. We present a case of a 31 year old pregnant woman at 16th week of gestation who had spontaneuos septic abortion complicated with an ovarian vein thrombosis. A discussion of risk factors, diagnostic and treatment options of ovarian vein thrombosis are presented.

A review of septic induced abortion cases in one year at Khyber Teaching Hospital, Peshawar.

BACKGROUND: Working in a tertiary level hospital we get complicated cases as a result of termination or attempts at termination of unwanted pregnancies. Most of the patients that we get are complicated and need expensive treatments including surgery. This study was conducted to assess the out come of septic induced abortion cases in a year. METHODS: It was conducted at the Department of Obstetrics and Gynaecology, unit B, Khyber Teaching Hospital, Peshawar, from 1.7.01 to 30.6.02. The data of a total of 28 patients admitted as emergency cases with septic induced abortion in above period were collected. History, management given, post operative care, complications and associated morbidity and mortality were taken into account and result compiled. RESULTS: 78.5% patients with unsafe abortions were multi gravida. Termination was attempted at home or other small centers. 57%, had history of surgical interference, 28.5% had used a mechanical device. 78.5% patients needed evacuation and curettage, 42% had laparotomy for visceral injuries. 15% patients had a subtotal hysterectomy. 57% patients had associated complications. 7.5% patients who came with septicemic shock died. CONCLUSION: Septic induced abortion is an important contributor to maternal morbidity and mortality, increasing the burden on not only the patients but health workers and their resources. However, it is preventable, and we suggest commitment to health education, family planning promotion and bringing down the rates of unsafe abortions as solutions to the problems.

Embarazo séptico cervical: informe de un caso / Septic cervical pregnancy: report of a case

Se comunica el caso de un embarazo cervical en una paciente de 40 años de edad que se manifestó como aborto séptico y que ameritó histerectomía total con salpingooforectomía unilateral, sin complicaciones en el postoperatorio. El caso se diagnostíco clínicamente y por ultrasonografía. En los últimos doce años se estableció el Hospital General de Acapulco, Guerrero, se atendieron 30,000 partos y se han encontrado únicamente cuatro casos bien documentados de embarazo cervical. En la literatura mundial únicamente se han encontrado dos casos como el que aquí presentamos

[Current concepts in the pathogenesis and treatment of abortion and septic shock. II. The physiopathological bases and outlook in the management of septic shock]. / Conceptos actuales en la patogénesis y tratamiento del aborto y el choque séptico. Parte II. Bases fisiopatológicas y perspectivas en el manejo del choque séptico.

The septic shock has a low frequency in the gynecologic-obstetric patients, nevertheless several obstetric conditions like: septic abortion, chorioamnionitis or puerperal infections can be complicated with this syndrome. The infections cause near 20% of the maternal deaths. Because the high morbidity and mortality of the patients with septic shock is necessary to have an actual knowledge of its pathogenesis and treatment. Any person can be infected but only few of them will develop a septic shock, the response of the host to the microorganisms is the critical point for the develop of this syndrome. Many studies had showed the importance of the bacterial endotoxin and the tumoral necrosis factor as mediators of septic shock. The treatment include: control of the infectious process, restoration of tissue perfusion pressure, restoration of blood volume, use of inotropic agents and general support measures. The role of monoclonal antibodies against endotoxin in the management of Gram-negative sepsis is still ignored, but there are several studies that support its use.

[Current concepts in the pathogenesis and treatment of abortion and septic shock I. The epidemiology, pathogenesis and management of septic abortion]. / Conceptos actuales en la patogénesis y tratamiento del aborto y el choque séptico. Parte I. Epidemiología, patogénesis y manejo del aborto séptico.

In view of the illegal status induced abortion, it is difficult to determine the degree to which it is practiced. In our country there are a great inconsistency in the statistics on the number of abortions and the number of maternal deaths due to this cause. The principal complication of the illegal induced abortion is the septic abortion, with an uncontrolled bacterial infection and systemic complications that dominate the clinical picture. The mortality of the septic abortion is elevated, in the majority of cases due to septic shock. The treatment consist on antimicrobial agents and early surgery. A reduction on the number of illegal abortions will decrease significantly the number of septic abortion's cases.

A rabbit model for bacteria-induced preterm pregnancy loss.

Bacterial infection has been implicated in premature labor in humans. To elucidate mechanisms and potential intervention strategies, we sought to develop a model of infection-induced pregnancy loss in rabbits. On day 21 (70% of gestation), each uterine horn was inoculated hysteroscopically with 0.2 ml containing saline solution of 10(6) cfu Escherichia coli or Bacteroides bivius or Fusobacterium necrophorum. Fetal viability was assessed. Animals were sacrificed at various times or as delivery occurred. Serum progesterone and amniotic fluid prostaglandins were measured. Cultures and histologic sections were prepared. Compared with the saline solution group, E coli and F. necrophorum-inoculated rabbits were significantly more likely to deliver (16 of 16 and six of seven with mean times of 31.9 +/- 10.7 and 28.3 +/- 11.5 hours, respectively for E. coli and F. necrophorum). Positive amniotic fluid cultures for the E. coli group were found in 11 of 12 (92%) and for the F. necrophorum group in three of three cases (100%). Histologic inflammation was seen heavily in both the E. coli and F. necrophorum groups, whereas it was absent in the saline solution group. Inoculation with B. bivius led to a much lower pregnancy loss rate (eight of 32) and less histologic inflammation despite positive uterine cultures in most animals. This model may provide an opportunity to determine mechanisms of clinical or subclinical intraamniotic infection and to test intervention strategies.

Spontaneous abortion.

As a result of improved investigation and treatment techniques, understanding of all aspects of spontaneous abortion has improved. The term "threatened abortion" is often a misnomer, for the fate of the pregnancy is decided when bleeding occurs. A dilated cervix indicates that abortion is inevitable. If the cervix is not dilated, pelvic ultrasonography will usually show the following: a live fetus, an anembryonic pregnancy, incomplete abortion or missed abortion. If fetal heart movement is seen, no further treatment is needed and the prognosis is excellent (98% fetal survival). In other cases, the uterus must be evacuated, with a Karman catheter if the uterus is small, with a suction curette if the uterus is large. Forceful dilation of the cervix is avoided through the use of Laminaria.

Chlamydia and incidental carcinoid tumor in spontaneous abortion.

Maternal Chlamydia trachomatis infections have been associated with premature rupture of the membranes, preterm labor, premature birth, and fetal wastage. Women with acute infection may be at particular risk. We report the case of an unexplained second trimester spontaneous abortion with serologic evidence of recent infection with C. trachomatis. Serum IgG antibody titer ultimately exceeded 1:10,240. This patient also had an incidental finding of appendiceal carcinoid tumor. While treatment of asymptomatic chlamydial infections in early pregnancy is controversial, we suggest that delaying treatment may result in fetal loss.

Human parvovirus infection in pregnancy and hydrops fetalis.

Human parvovirus is the causative agent of erythema infectiosum, a mild epidemic illness. In a recent outbreak in northeast Scotland, six women had serologic evidence of having contracted human parvovirus infection during pregnancy. Two of the women had midtrimester abortions, and both abortuses were grossly hydropic with anemia. They had similar microscopical histopathological features--a pronounced leukoerythroblastic reaction, hepatitis, excessive iron pigment in the liver, and eosinophilic changes in the hematopoietic cell nuclei. Dot hybridization with radiolabeled human parvovirus DNA probes revealed viral DNA in several tissues from both fetuses, indicating that they had been infected by the virus in utero. The remaining four women had uncomplicated pregnancies and delivered apparently healthy babies, none of whom had human parvovirus-specific IgM antibody at delivery. We conclude that this common virus may pose a serious risk to the fetus after maternal infection.

Pestivirus fetopathogenicity in cattle: changing sequelae with fetal maturation.

The events which followed the introduction of a heifer into a dairy herd were consistent with the animal being persistently infected with bovine diarrhoea-mucosal disease virus. Obvious damage was limited to the progeny of cows which were in the first 168 days of gestation at that time. Only fetuses up to 81 days of gestation at the putative time of introduction of infection became persistently infected in calfhood and, although they exhibited body tremor, two such calves necropsied at three months of age lacked macroscopic or microscopic lesions in the central nervous system. In contrast calves which had been more advanced in gestation, at 146 and 153 days at the time of infection, had eliminated the infection and had lesions of cerebellar dysplasia and multifocal retinal atrophy.

Conservative vs. surgical management of septic abortion with renal failure.

The role of surgery in the management of postabortum renal failure complicated with extensive uterine sepsis, perforation or peritonitis is controversial. This study compares the course and final outcome of 14 patients (66.6%) conservatively managed with appropriate antibiotics, fluid or blood replacement and dialysis, with seven patients (33.3%) for whom hysterectomy or laparotomy was undertaken in addition. Whereas all 14 patients treated conservatively died as the result of uncontrolled septicemia, three of the seven surgical patients recovered completely. Extensive necrosis with perforation of the uterine wall was confirmed either at laparotomy or at autopsy in all 21 women. To reduce mortality, the authors recommend early surgical intervention for patients suffering from postabortum renal failure complicated with uterine sepsis or perforation.

Bowel injury in septic abortion: the need for more aggressive management.

An analysis of bowel injury in cases of septic abortion treated over a six-year period at the University of Nigeria Teaching Hospital at Enugu is presented. Seventy-three percent (11/15) of the patients who underwent laparotomy had concomitant injury to the bowels. Overall, 16.4% of the 67 patients with septic abortion had intestinal injuries (this does not include the patients who died as a result of fulminating peritonitis before surgery could be performed). The survival of those patients with intestinal injuries was very much dependent on the operative procedures adopted. When a dysfunctioning colostomy was raised, the mortality was nil. In patients who had simple closure of the perforation and in those who had primary resection and anastomosis, mortality was 66.6%. The importance of performing laparotomy much sooner than usual is discussed.

Salmonella septic abortion.

Two cases of salmonella septic abortion are reported as unusual focal manifestations of salmonellosis. The possible route of infection and the guidelines for its management are discussed.

Epidemiology of listeriosis in Sweden 1958--1974.

In 1958--1974 altogether 110 cases of listeriosis were diagnosed in Sweden by culture. 64 cases were seen in children and adults. Of these, 52 had manifestations of meningoencephalitis and 10 of septicemia. Another 46 cases were seen in pregnant women and/or their neonates. Pregnancy ended in abortions in 8 cases and in stillborns in 3. Out of 37 neonates born alive, 22 had "early disease", mostly granulomatosis infantiseptica, and 8 had "late disease" with meningoencephalitis. The reported frequency of listeriosis in humans showed no correlation with that in animals. With the exception of pregnant women the incidence and mortality showed no difference with sex. Serotypes 1 and 4b prevailed and were equally common. The serotype did not vary with the clinical diagnosis or the outcome. There was no seasonal variation. Cases of all serotypes were uniformly distributed over the country in proportion to the density of its population. Occupational contact with animals was less common. Only in a few cases was there reason to suspect infection from animals. Co-existing disorders predisposed for the disease and often determined its outcome. Neonates with early onset of disease were infected by their mothers, while neonates with late onset of disease were infected from other and often nosocomial sources.