[Acute intermittent porphyria in the puerperium].

INTRODUCTION: Acute intermittent porphyria emerges as a result of partial defect of porphobilinogen deaminase and is manifested by repeated episodes of somatic, psychiatric and neurological disorders. The disease is conducted via the autosomal-dominant gene of variable penetration, so most of the carriers never experience seizures. Timely making of diagnosis, screening of blood relatives of the patient and education of patients on avoidance of provoking factors are the key to adequate treatment. CASE OUTLINE: A 23-year-old patient having born the third child was hospitalized due to pains in the abdomen and convulsive seizures nine days after the vaginal delivery. At admittance, she suffered a generalized convulsive seizure of clonic-tonic type. The patient immediately underwent a complete clinical, laboratory, bacteriological and ultrasound examination. Bearing in mind the fact that the patient had several convulsive seizures even after the given neurological therapy, haem-arginate was introduced into therapy during four days. The administration of haem-arginate led to the normalization of blood pressure, pulse and bowel function. The administration of haem-arginate led to the normalization of blood pressure, pulse and bowel function. The patient was treated by a team of doctors, in the intensive care ward, with the use of medicaments, which are allowed in the case of acute porphyria. Sixteen days after the admittance, with clean neurological status and gynaecological and ultra-sound findings, she was released for ambulatory treatment. CONCLUSION: The presented case exhibits the gravity of making a diagnosis of acute intermittent porphyria in puerperium and the necessity of multi-disciplinary approach in treating this disease. Acute intermittent porphyria should be considered in cases of ambiguous abdominal pain, as well as in patients having abdominal pains followed by neuro-psychiatric disorders.

[Spontaneous intra-abdominal bleeding in twin pregnancy--case report].

INTRODUCTION: Spontaneous rupture of utero-ovarian vessels is a rare cause of haemoperitoneum in pregnancy, leading to significant maternal and foetal morbidity and mortality. Aetiopathogenesis of this condition is still unclear. Establishing clinical diagnosis of this condition is difficult, but very important. Clinical symptoms are nonspecific, and the diagnosis is usually made at laparotomy. CASE OUTLINE: We report a case of spontaneous haematoperitoneum in the third trimester of twin pregnancy. Differential diagnosis included uterine rupture and placental abruption. Due to the deteriorated condition of the patient, it was decided to perform laparotomy which established the diagnosis of ruptured venous varices on the posterior uterine wall. Delivery was performed by caesarean section. The postoperative period was uneventful. CONCLUSION: The clinical presentation of spontaneous rupture of utero-ovarian blood vessels is not specific and clinical examination and ultrasonographic scanning may be insufficient for diagnosis. Once the diagnosis of spontaneous haematoperitoneum in pregnancy is established, emergency laparotomy is indicated. Following caesarean delivery, it is necessary to establish surgical haemostasis. There are some authors who suggest leaving the pregnancy intact in cases when the foetus is not viable, although one must have in mind the possibility of recurrent bleeding. The safety of this procedure requires further investigation. It is necessary to have in mind the possibility of blood vessel rupture in all cases of abdominal pain and hypotension of unknown origin during pregnancy.

[Myocardial dysfunction in septic shock--a case report].

INTRODUCTION: Sepsis is characterized by generalized inflammatory response induced by infection. The incidence of myocardial dysfunction in sepsis is unknown as well as its impact on survival, independently other organ system dysfunction. CASE REPORT: A female patient, age 36, with clinical signs of septic shock was admitted to the Intensive Care Unit. After initial therapy of septic shock, patient was still haemodynamically unstable. Transthoracic echocardiography showed left ventricular dysfunction (EF = 20%), with mitral regurgitation 2-3+, tricuspid regurgitation 3+, and estimated systolic right ventricular pressure of 53 mm Hg. Inotropic drug, dobutamine, was initiated, which led to significant improvement of hemodynamic parameters. Eight days after the initiation of therapy the clinical improvement was observed and the control transthoracic echocardiography was performed. It showed the improvement in left ventricular size and function, with EF of 57%, and reduced mitral regurgitation to 2+, and tricuspid regurgitation to 1+. DISCUSSION: A hyperdynamic state is typically present in sepsis. Myocardial dysfunction in sepsis is characterized by decreased ejection fraction, ventricular dilatation and impaired contractile response to volume loading. Cardiac output can be measured using pulmonary artery catheter, transthoracic and transoesophageal echocardiography, or by pulse contour analysis. In this patient, myocardial dysfunction was detected by echocardiography, which helped in clinical decision making to administer inotropic agent. The recovery of myocardial function was also confirmed by echocardiography. CONCLUSION: Echocardiography can be used in septic patient for diagnosis of myocardial dysfunction, decision making, follow-up of the response to inotropic therapy, and detection of the complete recovery of cardiac function.

[Our experince with the use of recombinant activated factor VII in postpartum haemorrhage].

INTRODUCTION: Massive obstetric bleeding is the most common cause of maternal mortality and morbidity. The first step in treatment of these patients is establishing the adequate circulatory volume. The primary goal of therapy is to identify and remove the cause of bleeding, with appropriate symptomatic and substitution therapy. Human recombinant activated factor VII (rFVIIa) is officially registered for the treatment of patients suffering from haemophilia with inhibitors. Its use has also proved successful in other congenital and acquired coagulopathies and in patients with acute non-haemophilic bleeding. A special significance is given to the application of rFVIIa in cases of obstetric haemorrhage, in order to avoid postpartum hysterectomy and occurrence of complications of haemorrhagic shock in obstetrics. OBJECTIVE: The aim of this study is to show our experience and results of the use of rFVIIa in the treatment of patients with massive postpartum bleeding. METHOD: The retrospective study encompassed six patients with primary postpartum haemorrhage treated with rFVIIa at our institution in the period from 2005 to 2007. RESULTS: The treated patients were divided into two groups. In the first group, there were three patients who underwent hysterectomy and who received rFVIIa over 24 hours after delivery. The second group consisted of three patients who received rFVIIa in the first 24 hours after delivery, before we decided to perform hysterectomy. The application of rFVIIa led to successful cessation of bleeding in all patients. Relevant side effects were not registered. CONCLUSION: The administration of rFVIIa in obstetrics should be considered for each patient before decision to apply hysterectomy, and it should certainly be applied in patients who want to preserve the uterus and fertile capability. According to our experience, in cases of postpartum hemorrhagia rFVIIa is to be administered in intravenous bolus doses of at least 90 mcg/kg, at least 6 hours after the onset of bleeding. rFVIIa is not an alternative to adequate surgical haemostasis; therefore, it needs to be administered after its detailed revision.

[Central venous catheter-related infections: risk factors and effects of glycopeptide antibiotics].

INTRODUCTION: Central venous catheters (CVC) are used in the treatment of critically ill patients. Indications for placement of CVCs include hemodynamic monitoring, administration of intravenous fluids, medications and total parenteral nutrition. MATERIAL AND METHODS: We investigated risk factors and effects of glycopeptide antibiotics on the development of central venous catheter-related injections in 300 patients treated in intensive care units. A semiquntitative culture technique was used. The investigation included: age, diagnosis on admission, catheter insertion site, catheter duration, the first or next catheter and using of glycopeptide drugs. RESULTS: 91 catheters (30.3%) were colonised, catheter-related infection was found in 50 catheters (16.7%). Infections were more frequent in catheters inserted through the internal jugular vein than in subclavian venous catheters, they were also more frequent if duration of catheterization was longer than seven days, but less frequent in patients who received glycopeptide antibiotics. The isolated microorganism was Staphylococcus aureus. Discussion According to the literature, a number of catheter-related risk factors for infections include: insertion site, type of catheter, the number of manipulations, inadequat asepsis, lumen number, type of antiseptic. The relative importance of one risk factor over another is difficult to assess, given that studies have no priority report. CONCLUSION: The duration of catheterization and the insertion site were the most frequent risk factors for infection. The use of glycopeptide antibiotics during catheterization has protective effects.

[Labor pain--physiologal basis and regulatory mechanisms].

Clinically, labor (visceral) pain is extremely prevalent in general population, yet its mechanisms have been poorly understood. With development of new electrophysiological techniques and molecular biology technologies, our understanding of physiological bases of labor pain has been markedly improved; in that way possibilities for therapeutic modulation of labor pain are expanded. The aim of this study was to describe the new insight into this topic. In this paper, the theory was exposed that the reason for labor pain had been found in sensitization at the levels of the uterus, dorsal root neurones and phychologic factors. Peripheral sensitization occurs due to cervical inflammatory reaction, associated with cervical ripening and remodeling. Chemical inflammatory mediators (notably prostaglandins, cytokines, granulocytes, enzymes such as metalloproteinases, integrines) activate nociceptive nerve fibers. Nociceptive threshold is reduced (resulting in primary hyperalgesia) and because of that there occurs the total number of action potentials generated and propagated by nociceptive peripheral nerves (visceral hypersensitivity). Central sensitization arises due to phosphorylation of N-methyl-D-aspartate (NMDA) receptors of dorsal root neurones. Numerous receptors, ion channels and signaling molecules, which, together with opioid peptides participate in spinal pain control, represent, at the level of central sensitization, possible therapeutic goals for labor pain modulation. Some of them are: DREAM which constitututively suppresses transcription of mRNA for opioid peptides, oncostatin M, COX-2 inhibitors, cFOS protein, tachykinins, gamma-butyric acid agonist, L-type Ca++ channels. Fear, as one of the most frequent phychologic factors, does (not) provide good control in transmision of pain sensitization by descendent nerve fibers. Some of the candidates for objective pain marker are also described. This article outlines the factors that, based on the contemporary viewpoint, could reduce transmission of pain signals, and thus broaden therapeutic possibilities for modulation of labor pain.

[Nosocomial infections in the intensive care unit of a gynecology clinic].

INTRODUCTION: Nosocomial infections are caused by microorganisms, and they develop 48 hours or more after admission to a hospital. It is considered that these infections are neither manifested nor present during the incubation period at the time of admission. MATERIAL AND METHODS: The objective of our study was to identify the most frequent microorganisms causing nosocomial infections in the Intensive Care Unit of the Institute of Gynecology and Obstetrics. The study included 33 patients, mean age 43.5 +/- 5 years, who were critical cases treated in Intensive Care Unit of the Institute of Gynecology and Obstetrics, Clinical Center of Serbia, in the period 2001 - 2003. All patients were surgically treated, intubated and assisted by mechanical ventilation. RESULTS: The most common causative agents isolated from the endotracheal tube were Staphylococcus aureus, Staphylococcus coagulasa negative and Pseudomonas spp., whereas Escherichia colli and Enterococcus were isolated from the wounds. These are highly resistant strains to antimicrobial agents. DISCUSSION: Two big groups of microorganisms were isolated as causative organisms of nosocomial infections. The first group causes blood stream infections, such as Staphilococcus aureus and coagulasa negative, and the second group causes respiratory infections like Pseudomonas aeruginosa, Klebsiella Enterobacter and Acinetobacter. The mortality and morbidity are very high, up to 40 - 80%. CONCLUSION: We can conclude that invasive diagnostic procedures are causing a high percentage of nosocomial infections. It is of utmost importance to prevent these infections by early use of antibiotics and infection control which depends on the hospital or clinic.

[Plasma levels of cortisol and opioid peptide beta-endorphin during spontaneous vaginal delivery].

INTRODUCTION: Labor pain is very frequent in clinical practice, but the underlying mechanisms as well as numerous neuroendocrine responses activated by such pain have not been fully explained yet. OBJECTIVE: The objective of the study was to determine the influence of labor pain on plasma levels of cortisol and opioid peptide beta-endorphin. METHOD: Cortisol and beta-endorphin levels were measured in blood plasma of: health, non-pregnant women (group 1, n=8), health pregnant women (group 2, n=8) and in parturitions, through fourth ages (group 3, n=8). Plasma level ofcortisol was measured by radioimmunoassay, and beta-endorphin by enzyme immunoassay. Data were expressed as mean +/- standard error of mean and were analyzed by Student's t test and Mann Whitney test. RESULTS: Plasma level of cortisol in group 2 was significantly increased compared to the group 1. During labor progression, plasma level of cortisol was rising till the third labor age. Plasma level of cortisol in fourth labor age was not significantly different from the age one and group 1. Plasma level of beta-endorphin was (ng/L): in group 1: 64 +/- 20, group 2: 70 +/- 22, group 3: the first labor age: 75 +/- 15, the second labor age: 193 +/- 54, the third labor age: 346 +/- 97 and the fourth labor age: 114 +/- 31. CONCLUSION: These results indicate that both beta-endorphin and cortisol are involved in regulation and modulation of labor pain and stress.

[The assessment of severity of lung injury in sepsis]. / Procena tezine ostecenja pluca u sepsi.

Adult respiratory distress syndrome (ARDS) is an acute and severe pulmonary dysfunction. It is clinically characterized by dyspnea and tachypnea, progressive hypoxemia (within 12-48 hours), reduction of pulmonary compliance and diffuse bilateral infiltrates seen on pulmonary radiogram. Etiological factors giving rise to development of the syndrome are numerous. The acute lung injury (ALI) is defined as the inflammation syndrome and increased permeability, which is associated with radiological and physiological disorders. Lung injury score (LIS), which is composed of four components, is used for making a distinction between two separate but rather similar syndromes. The study was aimed at the assessment of the severity of the lung injury in patients who had suffered from sepsis of the gynecological origin and its influence on the outcome of the disease. The total of 43 female patients was analyzed. Twenty patients (46.51%) were diagnosed as having ARDS based on the lung injury score, while 23 patients (53.48%) were diagnosed with acute lung injury. In our series, lung injury score ranged from 0.7 to 3.3 in ARDS patients, and lethal outcome ensued in 11 (55%) cases in this group. As for the patients with the acute lung injury, the score values ranged from 0.3 to 1.3 and only one patient from this group died (4.34%). The obtained results indicate that high values of the lung injury score are suggestive of the severe respiratory dysfunction as well as that lethal outcome is dependent on LIS value.