Abordaje integral de la Interrupción Voluntaria del Embarazo: (segunda entrega) / Comprehensive approach to the voluntary interruption of pregnancy: (second issue)

La legalización de la interrupción voluntaria del embarazo ha transformado la práctica médica con respecto a la atención de las pacientes que desean interrumpir la gestación hasta la semana 14 en Argentina. En la primera entrega, el equipo PROFAM compartió su punto de vista a través de una adaptación de su material educativo destinado, sobre todo, a aclarar los aspectos legales que hacen a la práctica cotidiana. En esta entrega se desarrolla en detalle el procedimiento para realizar un aborto farmacológico con misoprostol y mifepristona, así como las generalidades del aspirado manual endouterino. (AU)

The legalization of voluntary termination of pregnancy has transformed medical practice regarding the care of patients who wish to terminate a pregnancy up to 14 weeks in Argentina. In the first issue, the PROFAM team shared its point of view through an adaptation of its educational material aimed, above all, at clarifying the legal aspects of daily practice. In this issue, the procedure to perform a pharmacological abortion with misoprostol and mifepristone is developed in detail, as well as the generalities of manual uterine aspiration technique. (AU)

Coagulopatía asociada a síndrome de malabsorción por enfermedad celíaca / Coagulopathy associated with celiac disease malabsorption syndrome

This article describes a 19-y-old patient with abdominal pain and signs of malnutrition. She had been treated previously with an antibiotic for chronic diarrhea. Laboratory analyses showed the presence mild hypoalbuminemia, and considerably prolonged prothrombin time. Tests revealed that hemostasis improved after the patient received fresh frozen plasma and vitamin k. A coagulation profile showed a decrease in clotting factors V, VII, IX, and fibrinogen. Positive serology (immunoglobulin A antitissue transglutaminase and immunoglobulin A antiendomysial antibodies) and small bowel mucosal histopathology confirmed the presence of celiac disease (CD). The girl recovered completely after she was put on a gluten-free diet. Vitamin K­deficiency is a rare complication that occurs in celiac disease manifestations. In addition to antibiotic therapy, treatment with other drugs that influence vitamin K resorption and metabolism may increase the risk of bleeding in patients with CD with hypoprothrombinemia.

Trastornos hereditarios de la coagulación en adolescentes con sangrado menstrual excesivo, ¿debemos evaluar la vía fibrinolítica? / Inherited bleeding disorders in adolescents with excessive menstrual bleeding: should we evaluate the fibrinolytic pathway?

Resumen: Introducción: El Sangrado Menstrual Excesivo (SME) es un problema frecuente en la adolescencia. La prevalencia de trastornos hereditarios de la coagulación (THC) como causa del SME no está bien establecida y la participación de defectos de la vía fibrinolítica ha sido poco explorada. Objetivo: Determinar la prevalencia de THC y defectos de la fibrinólisis en adolescentes con SME. Pacientes y Método: Se incluyeron 93 adolescentes, edad 11 a 18 años. Los antecedentes personales y familiares de sangra do se obtuvieron con un cuestionario estandarizado. Se controló exámenes: tiempo de protrom- bina (TP), tiempo de tromboplastina parcial activada (TTPa), estudio del factor Von Willebrand, recuento y función plaquetaria. Los pacientes que no fueron diagnosticados como THC, se evaluaron adicionalmente con el tiempo de lisis del coágulo. Resultados: 41 pacientes (44%) fueron diagnos ticados como THC: Enfermedad de Von Willebrand n = 28, defectos de la función plaquetaria n = 8, hemofilia leve n = 5. Se confirmó disminución del tiempo de lisis del coágulo en 31 pacientes. El 54% de pacientes diagnosticado como THC, tuvo SME como la primera manifestación hemorrágica. Conclusión: Estos resultados apoyan la necesidad de evaluación de la coagulación, incluyendo la vía fibrinolítica, en el estudio de adolescentes con SME.

Abstract: Introduction: Heavy Menstrual Bleeding (EMB) is a frequent problem in adolescence. The prevalence of inherited bleeding disorders (IBD) as a cause of EMB is not well established and the involvement of fibri nolytic pathway defects has been poorly explored. Objective: To determine the prevalence of IBD and fibrinolysis defects in adolescents with EMBs. Patients and Method: 93 adolescents (11 to 18 years old) were included. Personal and family history of bleeding were obtained through a standard ized questionnaire. The following lab tests were performed: prothrombin time (PT), activated partial thromboplastin time (aPTT), von Willebrand factor quantification, and platelet count and function. Those patients who were not diagnosed with IBD were further evaluated with clot lysis time assay. Results: 41 patients (44%) were diagnosed as IBD (Von Willebrand disease n = 28, platelet func tion defects n=8, mild hemophilia n = 5. Decreased clot lysis time was found in 31 patients. 54% of patients diagnosed with IBD had EMB as the first hemorrhagic manifestation. Conclusion: These results support the need to evaluate the coagulation process, including the fibrinolytic pathway in the study of adolescents with EMB.

Coma mixedematoso e trombo de veia cava superior. Relato de caso e revisão da literatura / Myxedema coma and superior vena cava thrombus: case report and literature review

O coma mixedematoso é uma emergência endocrinológica rara e consiste na máxima expressão do hipotireoidismo, com alta mortalidade por suas complicações hemodinâmicas e ventilatórias, podendo ser agravadas por distúrbios da coagulação. Relatamos o caso de uma paciente diagnosticada com coma mixedematoso e trombo de veia cava superior. Buscamos salientar os distúrbios de coagulação frequentes no hipotireoidismo grave, que contribuem para o aumento da mortalidade deste grupo de pacientes. O diagnóstico e o tratamento precoce do coma mixedematoso, aliados à instituição imediata da terapia para o fenômeno trombótico encontrado, permitiram a evolução favorável do quadro. O relato, juntamente da bibliografia pesquisada, orientou o raciocínio sobre a relação dos distúrbios de coagulação, que ocorrem no hipotireoidismo descompensado. Apesar de poucos relatos, estes distúrbios podem ser frequentes e devem ser pesquisados, pois contribuem com o aumento da mortalidade.(AU)

Myxedema coma is a rare endocrinological emergency, consisting of the highest expression of hypothyroidism with high mortality due to hemodynamic and ventilatory complications, which may be aggravated by coagulation disorders. We report the case of a patient diagnosed with myxedema coma and superior vena cava thrombus. We sought to emphasize the frequent coagulation disorders in severe hypothyroidism, which contribute to increased mortality in this group of patients. The diagnosis and early treatment of myxedema coma, together with the immediate institution of therapy for the thrombotic phenomenon found, allowed the favorable evolution of the condition. The report, together with the literature, has guided the rationale for the influence of coagulation disorders that occur in decompensated hypothyroidism. Despite the few number of reports, these disorders can be frequent and should be investigated because they contribute to the increase in mortality.(AU)

Coagulopatía Aguda Traumática y hemorragia masiva: una relación que debemos conocer / Acute traumatic coagulopathy and massive hemorrhage: a relationship that we should know

Los traumatismos y accidentes ocupan una proporción relevante de las causas de muerte para el grupo de edad que abarca desde la primera infancia hasta la cuarta década de la vida. En los últimos diez años la mortalidad mundial por traumatismos se incrementó en el 20 por ciento. En esos casos se estima que las hemorragias aportan entre el 30 y 70 por ciento de la mortalidad. Además, la hemorragia masiva es conocida por ser una de las principales causas de muerte intraoperatoria en pacientes sin traumatismos, sobre todo en aquellos sometidos a intervenciones que implican lesiones tisulares importantes. En alrededor de un tercio o más de esos pacientes se desarrolla una coagulopatía aguda asociada al trauma o coagulopatía aguda traumática, que obedece a mecanismos fisiopatogénicos complejos, superpuestos y dependientes en gran medida de la naturaleza del evento que originó la pérdida sanguínea. Esta coagulopatía se define básicamente como una reducción funcional de la fortaleza del coágulo con cambios mínimos en los tiempos de coagulación. Su aparición incrementa el riesgo de sangrado masivo, la utilización de mayores volúmenes de componentes sanguíneos e implica una mayor probabilidad de fallecer por hemorragia. Su identificación temprana mediante técnicas de evaluación hemostáticas como el TP/INR, y pruebas viscoelásticas (tromboelastometría rotacional y tromboelastografía), modifica los riesgos y aporta un blanco terapéutico factible que constituye la base de las nuevas estrategias transfusionales en el enfrentamiento a los sangrados masivos(AU)

Accidents and different kind of injuries account for a relevant proportion of death causes from childhood to the fourth decade of life. Death from injury has increased by 20 percent over the last decade. Hemorrhages are estimated to cause between 30 to 70 percent of those deaths. Massive bleeding is also known for being one of the main causes of death during surgery in cases with extensive tissue damage from not traumatic origin. In around one third or more of such patients an acute traumatic coagulopathy or trauma associated coagulopathy is developed. This phenomenon obeys to complex, overlapping mechanisms which would be in its major part dependent on the event that caused the blood lost. This kind of coagulopathy can be defined as a functional reduction in clot strength with only minimal changes in clotting times. Its presence increases the risk of a massive bleeding, the use of larger volumes of blood components and the likelihood of dying by the hemorrhage. The early identification of acute traumatic coagulopathy through hemostatic tests such as TP/INR and viscoelastic assays as thrombelastography or rotational thrombelastometry modifies those risks since it brings a feasible therapeutic target to aim at, becoming the cornerstone for the newer transfusional strategies while facing massive bleedings(AU)

Factores asociados a coagulopatías adquiridas en una unidad de cuidados intensivos / Factors Associated with Acquired Coagulopathies in an Intensive Care Unit

Introducción: en los pacientes críticos existe un desequilibrio entre las actividades procoagulantes y las anticoagulantes, por ello las alteraciones de la coagulación o coagulopatías son una complicación frecuente que se asocia con una elevada morbilidad y mortalidad. Objetivos: identificar factores de riesgo asociados con coagulopatías adquiridas en pacientes ingresados y analizar la relación entre coagulopatía y mortalidad. Métodos: se realizó un estudio longitudinal prospectivo, donde se revisaron complementarios e historias clínicas de 29 pacientes ingresados en la unidad de cuidados intensivos del hospital Hermanos Ameijeiras, desde abril hasta junio de 2011. Se identificaron factores de riesgo asociados a las coagulopatías y se analizó su relación con la mortalidad. Resultados: se identificó la presencia de coagulopatías al ingreso en 58,62 por ciento, entre las 48-72 h 44,82 por ciento y en la última evaluación 51,73 por ciento. Predominó la coagulopatía por deficiencia de factores dependientes de vitamina K. Dentro de la unidad, el uso de hemocomponentes y la administración de aminoglucósidos resultaron estadísticamente significativos. Fallecieron 21 de los pacientes y en 13 de ellos se detectó la presencia de coagulopatía representando 44,8 por ciento. Conclusiones: se detectó que es dos veces más probable que a la persona que le administren hemocomponentes desarrolle algún tipo de coagulopatía y 5 veces más probable si se le administran aminoglucósidos. No se encontró relación significativa entre la presencia de coagulopatía y mortalidad, ni relación significativa entre la presencia de sangramiento y mortalidad(AU)

Introduction: There is an imbalance between procoagulant activities and anticoagulants in critical patients, so coagulation disorders or coagulopathies are a frequent complication associated with high morbidity and mortality. Objectives: To identify risk factors associated with acquired coagulopathies in hospitalized patients and to analyze the relationship between coagulopathy and mortality. Methods: A prospective longitudinal study was carried out. Complementary and clinical histories of 29 patients were reviewed. These patients had been admitted to the intensive care unit at Hermanos Ameijeiras hospital from April to June 2011. Risk factors associated with coagulopathies were identified. Mortality relationship was analyzed. Results: The presence of coagulopathies on admission was identified in 58.62 percent, 44.82 percent in 48-72 h and 51.73 percent in last assessment. Coagulopathy was predominant due to deficiency of vitamin K dependent factors. The use of blood components and the administration of aminoglycosides were statistically significant in the unit. Twenty one (21) patients died and thirteen (13) coagulopathy was detected, (44.8 percent). Conclusions: It was detected that it is twice as likely that the person receiving hemocomponents will develop some type of coagulopathy and five times more likely if they are administered aminoglycosides. No significant relationship was found between the presence of coagulopathy and mortality, nor significant relationship between the presence of bleeding and mortality(AU)

Reanimación con fluidos y hemoderivados en trauma / Resuscitation with fluids and blood products in trauma

The leading cause of preventable death in trauma is uncontrolled bleeding. Some of these deaths may be secondary to the Acute Coagulopathy of Trauma, which is present in 30% of patients on admission to hospital. In recent years, Damage Control Resuscitation has been developed, which aims to give a hemostatic resuscitation and avoid deaths caused by bleeding. This strategy considers control of bleeding with damage control surgery or interventional procedures, early transfusion of all blood products, permissive hypotension and limited use of crystalloids. Several studies have reported that early transfusion of all blood products, with a ratio close to 1:1, may be associated with lower mortality and less requirements of total transfusions in trauma patients at risk of massive bleeding and massive transfusion. These findings must be corroborated in randomized controlled trials, along with determining the optimum ratio between blood products. In stable patients, a restrictive transfusion strategy is safe and appropriate.

Right-to-left shunt and the hypercoagulable state: does paradoxical embolism play a role in patients with antiphospholipid syndrome and stroke? / Shunt direita-esquerda e hipercoagulabilidade: embolia paradoxal pode ser responsável pelo AVC na síndrome antifosfolipídica?

OBJECTIVE: Patent foramen ovale is associated with paradoxical embolism (PE) and stroke. Hypercoagulable states, such as antiphospholipid syndrome (APS), can exacerbate PE by increasing clot formation. The aim of this study was to verify whether patients with APS and stroke present a right-to-left shunt (RLS) with greater frequency than patients with APS but without stroke. METHODS: Fifty-three patients with APS were tested for RLS using contrast-enhanced transcranial Doppler (cTCD): 23 patients had a history of stroke (Stroke Group) and 30 had no history of stroke (No-stroke Group). RESULTS: cTCD was positive in 15 patients (65%) from the Stroke Group and in 16 patients (53%) in the No-stroke Group (p=0.56). The proportion of patients with a small RLS (<10 high-intensity transient sign or HITS) and a large RLS (>10 HITS) was similar between the groups without significant difference. CONCLUSIONS: Our data do not support the theory that paradoxical embolism may play an important role in stroke in APS patients.

OBJETIVO: O forame oval patente está associado com embolia paradoxal e acidente vascular cerebral isquêmico (AVCi). Estados de hipercoagulabilidade, como a síndrome antifosfolipídica (SAF), podem facilitar esse processo, aumentando a formação de coágulos. O objetivo deste estudo foi verificar se pacientes com SAF e AVCi apresentam maior frequência de shunt direita-esquerda (SDE), comparados a pacientes com SAF sem AVCi. MÉTODOS: Cinquenta e três pacientes com SAF foram testados para SDE usando Doppler transcraniano contrastado (DTCc): 23 com AVCi (Grupo AVC) e 30 sem história de AVCi (Grupo Controle). RESULTADOS: DTCc foi positivo em 15 pacientes (65%) do Grupo AVC e em 16 pacientes (53%) no Grupo Controle (p=0,56). A proporção de pacientes com pequeno SDE (<10 HITS) e grande SDE (>10 HITS) foi semelhante nos dois grupos. Não houve diferença significativa entre os grupos. CONCLUSÕES: Nossos dados não sugerem que embolia paradoxal seja causa importante de AVCi em pacientes com SAF.

Ureteroscopy in patients with coagulopathies is associated with lower stone-free rate and increased risk of clinically significant hematuria

PURPOSE: Patients with coagulopathy are at increased risk of peri-operative hemorrhage. The aim of the present study was to compare ureteroscopy (URS) in these high risk patients to those with normal bleeding profile. MATERIALS AND METHODS: Twelve patients with coagulopathies (Group I) undergoing 17 URS were included in the study [3 for biopsy of ureteral lesions and 9 for Holmium Laser Lithotripsy (HLL)]. A patient had Child B (MELD 11) cirrhosis, 6 patients were on warfarin, 3 patients on ASA, 1 patient on ASA and clopidogrel, and the last patient was on heparin. URS in Group I was performed without correction of coagulopathy. Group II consisted of 32 patients with normal bleeding profile who underwent 34 URS concurrently. RESULTS: Group I included 4 ureteral biopsies in 3 patients with suspicious ureteral lesions and 13 URS for HLL in 9 patients with nephrolithiasis. There were no significant differences between the two groups in terms of patient age, sex, percent of renal stones, median operative and fluoroscopy times. When compared with Group II, Group I had significantly larger median stone size (9.2 vs. 14.0 mm, p = 0.01) and significantly lower stone-free rate after first URS (94.1% vs. 69.2%, p = 0.04). However, after second URS, stone-free rates were comparable in both groups (92.3% vs. 100%, p = 0.9). Two (16.7%) patients with coagulopathy were readmitted due to gross hematuria. There were no post-operative complications in Group II. CONCLUSIONS: Although URS in selected patients with coagulopathies is safe, it is associated with significantly lower stone-free rates and higher readmissions due to gross hematuria.

Coagulopathy as a Prognostic Factor of Acute Lung Injury in Children

The coagulation cascade and inflammatory process are known to be associated with the pathophysiology of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). We retrospectively investigated laboratory values indicating coagulopathy obtained within 24 hr from diagnosis of ALI/ARDS in 79 children who received mechanical ventilation between 2008 and 2009 and their final outcomes. Prothrombin time (PT) (P = 0.001) and activated partial thromboplastin time PTT (APTT) (P = 0.001) were more prolonged in non-survivors than survivors (mean; 1.57 vs 1.33; 63 vs 57). In multivariate analysis with stratification by oxygenation-index ( or = 14.5), prolonged PT (> or = 1.46 international normalized ratio, [INR]) (hazard ratio; 2.043, 1.027-4.064) was associated with lower non-pulmonary-organ-failure-free survival rate (FFS), and prolonged APTT (> or = 50 seconds) (2.062, 1.031-4.121; 2.422, 1.227-4.781) was associated with lower overall survival rate (OS) and lower FFS. In stratification by ventilation-index ( or = 40), prolonged PT (2.232, 1.095-4.540; 2.177, 1.092-4.342) and prolonged APTT (2.574, 1.230-5.386; 3.089, 1.500-6.360) were associated with lower OS and lower FFS. Prolonged PT and APTT are associated with mortality in mechanically ventilated children with ALI/ARDS. We suggest PT and APTT as prognostic factors of ALI/ARDS in children.

Craniectomía descompresiva en paciente pediátrico con trauma craneoencefálico grave y alteraciones de la coagulación asociadas: reporte de 1 caso / Descompresive craniectomy in pediatric patient with a seriously cranio-encephalic trauma and associated alterations of the coagulation: a case report

Introducción: Según algunos autores el 75 por ciento de todas las hospitalizaciones por traumatismos en los niños se deben a un traumatismo craneoencefálico, el 70 por ciento de las muertes ocurren en las primeras 48 horas, con una mortalidad que fluctúa entre el 20 y 35 por ciento. La asociación de trastornos de la coagulación con el traumatismo craneoencefálico grave, ha sido descrita desde la década de los años 60 del pasado siglo, pero son escasos los informes en la literatura sobre esta asociación, aunque en general se reconoce el mal pronóstico de los pacientes que la presentan. Caso: Se describe un paciente pediátrico que sufrió un TCE grave al que se asocian trastornos severos de la coagulación, con fenómenos hemorrágicos intracraneales e hipertensión intracraneal incontrolable, tratado con medidas terapéuticas de emergencia y craniectomía descompresiva bifrontal para el control de la hipertensión intracraneal. Conclusiones: Se realiza una reintervención; los resultados son satisfactorios.

Introduction: Head injury is present in 75 percent of all children admitted at the emergency rooms by a traumatic event and mortality have been reported about 20-35 percent. Since 60´s decade the association between severe head injury and coagulopathy was described but there are a low number of reports about it in the scientific literature. Case: We are reporting a paediatric patient who suffered from severe head injury with coagulopathy associated as fundamental cause of severe intracranial hemorrhage with refractory intracranial hypertension. Emergent medical therapy was used to treat the coagulopathy and bifrontal decompressive craniectomy as surgical treatment for intracranial hypertension.

Analysis of death caused by postpartum hemorrhage / 法医学杂志

OBJECTIVE@#To analyze the pathological characteristics and the death reasons due to postpartum hemorrhage, and to help to deal with the obstetrical medical tangles.@*METHODS@#Thirty-two cases of death caused by postpartum hemorrhage encountered in our department since 1995 had been collected and retrospectively analyzed.@*RESULTS@#Death caused by postpartum hemorrhage could be divided into single factor and multi-factor, with 81.25% due to single factor, 12.50% multi-factor, and 6.25% unknown reason. The single factors included uterine atony, retained placenta, placenta increta, laceration of the lower genital tract, and coagulation defects. The multi-factor included a combination of two or more factors mentioned above.@*CONCLUSION@#The causes of death due to postpartum hemorrhage should be analyzed according to the clinical characteristics of the postpartum hemorrhage and the autopsy examination.

Cerebral venous thrombosis in Saudi Arabia. Clinical variables, response to treatment, and outcome

To investigate cerebral venous thrombosis [CVT] clinical presentations, risk factors, and response to treatment in Saudi Arabia. Retrospective analysis of the King Fahad Medical City, Riyadh, acute stroke database from April 2005 through February 2008 revealed 22 patients with CVT. Hypercoagulable work-up and neuroimaging were performed. Sixteen patients were female [72.7%], and the median age was 35 years. Clinical presentations included: headache [77.3%], seizures [54.5%], focal neurological signs [54.5%], and decreased level of consciousness [50%]. Over two-thirds [n=11; 69%] of female patients had a history of oral contraceptive use, which was the most common risk factor. Protein S deficiency [n=3], antiphospholipid antibody syndrome secondary to systemic lupus erythematosus [SLE] [n=1], rhinocerebral mucormycosis [n=1], leukemia [n=1], non-Hodgkin's lymphoma [n=1], sepsis [n=1], and unknown [n=6] were causes. Affected areas included superior sagittal [n=13], transverse [n=16], sigmoid [n=14], straight [n=6] and cavernous sinus [n=1]; internal cerebral vein [n=2]; vein of Galen [n=3]; cortical veins [n=10]; and internal jugular vein [n=12]. Two patients had quadriparesis, and 2 patients died. The remainder [n=18, 81.8%] improved. Bilateral hemorrhagic presentation or venous infarction, deep venous system thrombosis, and underlying malignancy had less favorable results. Presentations in our series were similar to those in other reports, although altered consciousness and seizures were more common, Cortical vein involvement was also higher than commonly reported. Oral contraceptive use was a primary risk factor in female patients. Outcomes were favorable in 81.8% of patients

Uneventful epidural analgesia in a patient with severe thrombocytopenia

Epidural analgesia is the most effective method for analgesia in labor. It has, however, contraindications and carries many serious side effects. Though coagulopathy is an absolute contraindication for epidural and axial blocks, yet there are no absolute limits for platelet counts that stand in the way of providing epidural analgesia. In a patient who is writhing in pain due to severe uterine contractions, and in whom there exists a recent normal platelet screening and no history of bleeding disorders, it is internationally acceptable between anesthetists to provide epidural analgesia without waiting for a new platelet screening

Prognostic indicators in patients with primary intraventricular haemorrhage

Primary intraventricular haemorrhage [PIVH] is a rare clinical entity. We sought to evaluate risk factors, clinical and radiological features, and outcome of patients with PIVH. Cases of PIVH were identified from cohort of patients with non traumatic intracerebral haemorrhage [ICH] by reviewing the radiological data. Their charts were reviewed and demographic, clinical, radiological and laboratory data was recorded and analyzed. Chi square and t test were used to determine predictors of poor outcome. Fifteen of 677 [2%] patients with ICH had PIVH. Nine [60%] were men. Median age was 56 years. Predisposing factors included hypertension in twelve [80%], coagulopathy in five [33%] and vascular malformations in two [13%] patients. Eleven [73%] patients developed hydrocephalus. Two patients died. Univariate analysis identified diabetes mellitus, blood in all ventricles and coagulopathy as predictors of death during initial hospital stay and hydrocephalus as predictor of poor outcome [death and disability combined] [p<0.05]. Hypertension is most common associated risk factor for primary intraventricular haemorrhage followed by coagulopathy. Hydrocephalus is a common complication, associated with poor outcome. Diabetes mellitus, coagulopathy and panventricular blood predict early mortality

Ischemic stroke in children: a study of the associated alterations

Acidente vascular cerebral Isquêmico (AVCI) na infância é relativamente raro, de conhecimento ainda obscuro, e com etiologia multifatorial. Pode causar grave impacto na criança e ser a primeira manifestação de doença sistêmica. O subdiagnóstico ainda é comum e são praticamente inexistentes as pesquisas sobre o assunto no nosso meio. Desordens protrombóticas têm sido descritas como importantes fatores causais do evento isquêmico na infância. Foram estudados 46 pacientes de zero a 18 anos, com diagnóstico de AVCI, no período de março/2002 a setembro/2003. Exames laboratoriais, incluindo proteínas de coagulação e ecocardiograma foram realizados. AVCI neonatal ocorreu em 35% dos casos. Crise focal e hemiparesia foram os sintomas iniciais mais freqüentes; 40% dos casos apresentaram patologia prévia. Anormalidades nas proteínas S e C ocorreram em 22% e 17% da amostra. Alterações associadas, principalmente as que geram um estado hipercoagulável, indicam que mais de um fator de risco pode causar essa doença na infância.

An abnormal systemic and regional hypercoagulable state in patients with mitral stenosis.

Mitral stenosis still remains a major problem in Southeast Asia including Thailand. It contributes to the morbidity and mortality related to thromboembolism which was associated with the left atrial thrombus. However, the pathogenesis of left atrial thrombus in these patients is not completely understood. Therefore, the objective of this study was to investigate the coagulation and platelet activity including the function of the endocardium in the left atrium and peripheral circulation in patients with mitral stenosis who were free of left atrial thrombus and to compare those hematologic markers activity in the peripheral venous blood between the patients with mitral stenosis and the control. Thirty-six patients with moderate to severe mitral stenosis were included in the study. Most of the patients were in functional class II and 50 per cent had atrial fibrillation. Blood was obtained from the femoral vein, femoral artery, pulmonary artery and left atrium of these patients before heparin was administered to determine the value of various hematologic markers. In the control group, blood for determining the hematologic markers was collected only from the antecubital vein. The results of this study demonstrated that the levels of prothrombin activation fragment 1+2 (F1+2), thrombin-antithrombin III complex (TAT) and Beta-thromboglobulin (beta-TG) in the left atrium of the patients with mitral stenosis were significantly higher than those in the femoral vein and femoral artery, whereas the level of thrombomodulin was significantly lower in the left atrium compared with the femoral artery and vein. When comparing with the control group, the levels of TAT, plasminogen activator inhibitors-1 (PAI-1) from the peripheral vein were significantly higher and the level of thrombomodulin was also significantly lower in the patients with mitral stenosis. In conclusion, the present study demonstrated an abnormal hypercoagulable state of the left atrium and systemic circulation related to the abnormalities of coagulation, platelets and the endocardium which may cause the formation of left atrial thrombus in patients with mitral stenosis.

Trombofilia-estado actual / Trombofilia-current state

Introducción: Los estados de trombofilia son una tendencia especial a producir trombosis venosa, que se presentan habitualmente en personas jóvenes y a menudo son recurrentes. Sus consecuencias más trascendentes son el Tromboembolismo Pulmonar y el Síndrome Post-trombótico. Objetivos: Teniendo en cuenta las patologías de la coagulación que pueden producir estados de trombofilia en pacientes jóvenes, se evaluó la prevalencía de estos procesos en pacientes con síndrome post-trombótico severo. Lugar de aplicación: Departamento de Flebología y Linfología del Hospital Nacional de Clínicas, Córdoba. Materiales y métodos: Durante el periodo marzo de 2001 a marzo de 2002 concurrieron a la consulta flebológica 635 pacientes, de los cuales seis de ellos, 3 hombres y 3 mujeres menores de 45 años, presentaban severos trastornos del retorno venoso compatibles con cuadros postrombóticos. La edad promedio de 39 años (r: 29-45); Estos pacientes fueron estudiados mediante clínica de rutina, ecodoppler color venoso y análisis específicos de laboratorio como la Resistencia a la Proteína C activada, Proteína C, Proteína S, Anticuerpos antifosfolípidos, Antitrombina III, homocisteinemia. Resultados: Se obtuvieron valores anómalos en el perfil biológico del laboratorio en 3 pacientes; la correlación clínica y del laboratorio fue la siguiente: positivo para proteína C y Proteína S; Positivo para Anticuerpos Antifosfolípidos; y positivo para Hiperhomocisteinemia. Conclusiones: Deben preconizarse los estudios de laboratorio necesarios para descartar estados trombofilicos en pacientes menores de 45 años que presenten un primer episodio de trombosis o bien cualquier paciente que haya presentado trombosis recurrentes. Es importante resaltar que la detección temprana de estas patologías y la oportuna derivación al hematólogo, permiten establecer un tratamiento preventivo y así evitar episodios trombóticos con sus respectivas complicaciones.