Non-Cardiogenic Pulmonary Edema Due to Administration of Atosiban.

We report the case of a pregnant woman, treated with atosiban for premature labor, who developed non-cardiogenic pulmonary edema. She corresponded initially to oxygen supplementation and furosemide administration to induce diuresis but the onset of preterm contractions combined with aggravation of respiratory failure led the patient to a cesarean section, and subsequently to the intensive care unit where she remained intubated for 24 hours. In this case report, we emphasize the importance of distinguishing between two types of pulmonary edema: cardiogenic and non-cardiogenic. The instant separation between these two categories, most of the time with transthoracic echocardiography while the patient is on early support of ventilation, increases the optimum outcome for the patient.

Systemic Thrombolysis for Treatment of Acute Life-threatening Pulmonary Embolism During Cesarean Section Followed by Post-partum Rescue Hysterectomy: A Case Report and Review of the Literature.

BACKGROUND/AIM: Acute pulmonary embolism during cesarean section is extremely rare and only a limited number of cases have been reported in literature. The aim of this study was to report a case of acute high risk pulmonary embolism during elective cesarean section treated with systemic thrombolysis and discuss the multidisciplinary management in both early recognition and prompt treatment. CASE REPORT: A 39-year-old, G5P2, ASA II parturient presented for repeat cesarean section under general anesthesia. A sudden drop in end-tidal CO2 after placenta delivery combined with significant hemodynamic instability after an uneventful intraoperative course was strongly indicative of pulmonary embolism. Urgent transthoracic ultrasound revealed a sizable thrombus in the inferior vena cava and the right atrium. Thrombolysis was carried out intraoperatively using recombinant tissue plasminogen activator, which was administered under continuous US monitoring until thrombus resolution. This resulted in significant bleeding that was treated in a stepwise manner beginning with implementation of massive transfusion protocol, Bakri balloon placement, and rescue hysterectomy several hours after the event. Follow-up was uneventful and she was discharged on the 12th postoperative day. CONCLUSION: Though pregnancy is one of the major risk factors of the development of venous thromboembolism, acute intraoperative pulmonary embolism is extremely rare. Specific guidelines for the management of such cases are difficult to issue due to the paucity of relevant data. Thus, an individualized approach by a multidisciplinary team for diagnosis and intervention is mandated.

Inguinal endometriosis: A systematic review.

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.

Follicle inhibition at the primordial stage without increasing apoptosis, with a combination of everolimus, verapamil.

The aim of the present study was to test whether inhibition of ovarian primordial follicles and subsequent activation can be achieved by transient mTOR inhibition. In this preclinical investigation, forty-five female immature Wistar rats were randomized in 5 groups. The control group received subcutaneous saline injections. The other groups received Everolimus, Everolimus plus Verapamil, Everolimus plus Fisetin, and Fisetin alone. Primary and secondary outcomes were measured in the left ovary after a treatment period of 8 weeks. Ten days later, animals received 35 IU FSH for 4 days and 35 IU of hCG on the 5th day. The same parameters were examined in the right ovary. AMH, estradiol, and progesterone levels were assessed at the end of both interventions. Significantly, more primordial and less atretic follicles were observed in the Everolimus plus Verapamil group. AMH and progesterone levels were substantially lower in the Everolimus group. Interestingly, after ovarian stimulation higher levels of AMH and progesterone were observed in the Everolimus plus Verapamil group. Immunoblot analysis of ovarian extracts revealed that the administration of Everolimus led to a significant reduction in the mTORC1-mediated phosphorylation of the 70-kDa ribosomal protein S6 kinase 1. This decrease was reversed in the presence of FSH after stopping drug administration. The expression of the anti-apoptotic molecule Bcl2 as well as of LC3-II and ATG12 was increased after removal of the Everolimus plus Verapamil combination, indicating reduced apoptosis and increased autophagy, whereas the levels of the proliferation marker PCNA in the granulosa cells were elevated, consistent with initiation of follicular growth.Thus, the combination of Everolimus plus Verapamil is capable of increasing the number of competent primordial follicles while reducing atresia.

The combination of Everolimus with Verapamil reduces ovarian weight and vascular permeability on ovarian hyperstimulation syndrome: a preclinical experimental randomized controlled study.

The efficacy of pathways inhibition and the combined effect of Everolimus (mTOR inhibitor) and Verapamil (CYP3A inhibitor) in ovarian hyperstimulation syndrome (OHSS) need to be tested. Therefore, the impact of a leucotriene receptor antagonist, an anticoagulant, a GnRH antagonist as well as Everolimus plus Verapamil (at various doses and days of administration) on an OHSS rat model was tested. Sixty three female Wistar rats were randomly divided into seven groups. The control group received saline, while the OHSS group received rec-FSH for four consecutive days. The other five groups received rec-FSH for four days and Montelukast daily, Heparin daily, GnRH antagonist daily, Everolimus plus Verapamil in the last two days (half days group) and Everolimus plus Verapamil (half dose group) daily, respectively. All groups received also hCG at the fifth day. Significantly reduced ovarian weight was observed in the Everolimus plus Verapamil groups (half days and half-dose groups) and the Montelukast group compared to the OHSS group (p = 0.001 and p = 0.001, respectively). The vascular permeability was significantly reduced in the Everolimus plus Verapamil group (half dose group) and the GnRH antagonist group compared to the OHSS group (p < 0.001 and p = 0.011, respectively). However, estradiol and progesterone levels did not differ significantly between the groups. Studying the inhibition of different pathways, we concluded that the co-administration of Everolimus and Verapamil (at half dose) is beneficial for reducing ovarian weight and vascular permeability in an OHSS animal model.