Are the Wells Score and the Revised Geneva Score valuable for the diagnosis of pulmonary embolism in pregnancy?

OBJECTIVES: To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. STUDY DESIGN: All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS: A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54-0.79) and Revised Geneva Scores (0.64, 95% CI 0.52-0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. CONCLUSION(S): The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.

Spontaneous subserosal venous rupture overlying a uterine leiomyoma in a young woman.

Uterine leiomyomas are very common tumors found in women. Rupture of veins on the surface of uterine leiomyoma is an unusual source of hemoperitoneum. It is an extremely uncommon gynaecological cause of hemoperitoneum. It is a life threatening emergency. We report a case of massive intraperitoneal hemorrhage due to rupture of vessels on the surface of subserous leiomyoma. A differential diagnosis of rupture of leiomyoma'ssurface vessel should be considered, while dealing with a case of hemoperitoneum with pelvic mass.

[Early postpartum discharge: outcomes and risk factors of readmission]. / Sortie précoce en post-partum: résultats et facteurs de risque de ré hospitalization.

The objective of this study is to evaluate the practice of early postpartum discharge by analyzing maternal readmission rates and identifying readmission risk factors. This is a prospective and analytical study of 1206 patients discharged from hospital on postpartum day 1. For each patient we collected the epidemiological data, the course of pregnancy and childbirth. We identified the causes of readmission and their evolution. Cesarean delivery rate was 42%. Maternal readmission rate was 0.99%. The average length of stay in hospital after readmission was 26 hours. Intestinal transit disorders were the most frequent reason for consultation (50% of cases) followed by fever (25% of cases). The readmission risk factors identified in our study were: cesarean section (p = 0.004), emergency cesarean section (p = 0.016) anemia (P < 0.001) and thrombopenia (p = 0.003). Early postpartum discharge seems a safe option for the mother and their newborn children subject to the ability to clearly communicate health information to the patient and to the compliance with selection criteria.

Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting.

OBJECTIVES: To study the safety and effectiveness of pelvic packing in the control of post emergency peripartum hysterectomy (EPH) bleeding in a postpartum hemorrhage (PPH) setting. STUDY DESIGN: From 39 patients with a severe PPH leading to an EPH (January 2010-December 2013), we identified a group of 17 patients requiring a pelvic packing (packing group) and a second group of 22 patients not requiring a pelvic packing (non-packing group). For each group, transfusion requirements were recorded from time of PPH diagnosis to end of the surgical procedure (P1: Period 1) and from that point to the end management in the SICU (P2: Period 2). Laboratory values, transfusion requirements and complications were compared between the 2 groups. Statistical comparisons were performed using Mann-Whitney test, Fisher's exact test and chi-square test. A p-value <0.05 was considered statistically significant. RESULTS: Pelvic packing was successful in the control of bleeding in all the cases. During the second laparotomy for pack removal, none of the patients developed complications such as bowel injuries or necrosis. The 2 groups were similar in term of laboratory values at the end of the surgical procedure and 24h after the end of the surgical procedure. The number of PRBC units required in P1 was higher in the packing group compared to the non-packing group (16.6±5.3 vs 14±5; p=0.04), however the decrease in the amount of PRBCs transfused between P1 and P2 was higher in the packing group (13.3) compared to the non-packing group (9.1) (p<0.01). The incidence of febrile morbidity was higher in the packing group compared to the non-packing group (53% vs 9%; p=0.04); but no significant difference was shown in term of generalized sepsis, as well as renal failure, ARDS, deep vein thrombosis, pulmonary embolism and MOF. CONCLUSION: The pelvic packing is a valuable method with a high success rate in the control of hemorrhage after an EPH in PPH setting with a low rate of complications. It is quite simple and quick to perform, and therefore should be kept in mind by all obstetricians as a lifesaving technique.

[Which surgical strategy to adopt for the management of postpartum haemorrhage and how to improve the effects of hypogastric arteries ligation?] / Quelle stratégie chirurgicale adopter devant une hémorragie du post-partum et comment améliorer les résultats de la ligature des artères hypogastriques?

The objective were to identify the success factors of bilateral hypogastric arteries ligation and to assess its role in surgical treatment of postpartum hemorrhages. We conducted a retrospective study of all the cases of postpartum hemorrhage requiring surgical treatment between January 2008 and December 2011. The study included 88 patients (0,47% of all births). Uterine atony was the most common etiology (64,8 % of patients). Bilateral ligation of the hypogastric arteries was performed in 81.8% of patients. When surgery was the first choice treatment, its success rate was 66%. This rate was variable depending on the etiology of hemorrhage, the presence or the absence of hemostasis disorders and the time between diagnosis and surgical treatment. In case of uterine atony, the association with a second conservative technique, when the first was inadequate, helped stop the bleeding in 98% of cases. Ligation of hypogastric arteries is an effective surgical technique for the treatment of postpartum hemorrhage. Its success rate has increased thanks to early implementation and to the association with other conservative techniques.