Laparoscopic splenectomy for the treatment of refractory immune thrombocytopenia in pregnancy.

BACKGROUND: Immune thrombocytopenic purpura (ITP) is a condition with potential hazard during pregnancy for both mother and fetus if platelet concentrations fall below a critical level. This report describes the use of laparoscopic splenectomy following unsuccessful medical management. CASE: A 35-year-old primigravid woman with systemic lupus erythematosis (SLE) developed ITP several years before becoming pregnant. She was treated early in pregnancy with high-dose oral prednisone and weekly intravenous immunoglobulin (IVIG) alternating with anti-D immune globulin, but laparoscopic splenectomy was indicated at 20 weeks' gestation because of thrombocytopenia. Following surgery, she continued prednisone and intermittent IVIG therapy until spontaneous delivery at 34 weeks' gestation. A small accessory spleen was identified postpartum by nuclear medicine scan. Satisfactory platelet concentrations were maintained postpartum using danazol and prednisone. CONCLUSION: Laparoscopic splenectomy is a therapeutic option for women with ITP during pregnancy that fails to respond to medical management.

Surgical site infection following elective Caesarian section: a case-control study of postdischarge surveillance.

OBJECTIVES: To ascertain the incidence of postoperative surgical site infection (SSI) following elective Caesarean section (CS) and to compare demographic characteristics and antibiotic administration between infected cases and noninfected control subjects. METHODS: We conducted a retrospective case-control study of patients undergoing elective CS between 1996 and 2002 at a tertiary centre. Infection-control personnel attempted to contact by telephone all women who had had Caesarean sections, 1 month after their surgery. The women they reached were asked to complete a questionnaire based on CDC-validated criteria for infection to determine whether SSI had occurred. Control subjects without SSI were matched on the basis of having had an elective CS and by date of surgery. We then reviewed the hospital records of both groups. RESULTS: Over the study period, 1250 elective Caesarean sections were performed and 124 infected cases were identified, giving an overall SSI incidence of 9.9%. Of the 342 women reviewed (124 cases, 218 control subjects), 23% received prophylactic intraoperative antibiotics. Cases and control subjects differed significantly in terms of estimated blood loss, with fewer control subjects having excessive blood loss (P = 0.04). Among those women receiving postoperative antibiotics, case subjects received a significantly higher number of doses than did control subjects (P = 0.003). The groups did not differ significantly in terms of overall antibiotic administration or other demographic variables. CONCLUSIONS: The incidence of SSI following elective CS according to postdischarge surveillance was 9.9%, which is higher than expected for a low-risk procedure. Because follow-up was not possible for all cases, this incidence may be an underestimate. Underuse of antimicrobial prophylaxis may also be a contributing factor, because prophylactic antibiotics were administered in less than 25% of cases.