RESUMO
Hemorrhages are the first cause of perinatal deaths in French women. Thirteen percent of these deaths are not linked to obstetrical problems but rather to hemoperitoneum. These incidents are under-diagnosed and as a result, treatment is delayed and fetal and maternal mortality increases. We report three cases of patients, all White female in their last trimester of a non-problematic pregnancy presenting with hemoperitoneum and resulting in different outcomes. The analysis of published materials and of our cases leads us to infer that a diagnosis of hemoperitoneum must be considered in pregnant women when abdominal pain, symptoms of shock and a decrease in hemoglobin are associated. An immediate response and intensive care followed by hemostatic surgery give these patients the best chance to survive.
Assuntos
Hemoperitônio/complicações , Hemoperitônio/diagnóstico , Complicações Cardiovasculares na Gravidez/diagnóstico , Dor Abdominal/etiologia , Adulto , Evolução Fatal , Feminino , Hemoglobinas/metabolismo , Hemoperitônio/terapia , Humanos , Período Periparto , Gravidez , Complicações Cardiovasculares na Gravidez/terapia , Choque/etiologiaRESUMO
OBJECTIVES: To describe management and screening for high-risk patients concerning post-partum hemorrhage (PPH) and antenatal management for severe anemia, thrombopenia, bleeding disorders and anticoagulant therapy. METHODS: Bibliographic search restricted to French and English languages using Medline database and recommendations of medical societies. RESULTS: The appropriate place for delivery should be chosen after multidisciplinary concertation based on level of risk (especially past-history of severe PPH and bleeding disorder) and easy access to blood products (Professional Consensus). Prevention for severe anemia is mainly based on oral iron supplementation (grade B). Explorations are required in case of thrombopenia<100Giga/L (grade C). Patients with bleeding disorder require the assistance of a physician skilled in hemostasis for perinatal management (grade C). Preventive anticoagulant therapy has no impact on PPH risk and perimedullar analgesia is usually authorized 12hours after last injection (grade C). Curative anticoagulant therapy slightly increases PPH risk and perimedullar analgesia is authorized only after 24hours since last injection (Professional Consensus). CONCLUSION: Prenatal identification of high-risk patients concerning PPH implies multidisciplinary concertation to determine the most appropriate birthplace where technical and human resources are available.
Assuntos
Complicações do Trabalho de Parto/terapia , Doenças Placentárias/terapia , Hemorragia Pós-Parto/prevenção & controle , Feminino , Humanos , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/prevenção & controle , Doenças Placentárias/diagnóstico , Hemorragia Pós-Parto/diagnóstico , GravidezRESUMO
OBJECTIVE: To describe the knowledge of paediatricians regarding the practice of antimicrobial prophylaxis for caesarean section in reference to the Consensus Conference of the French Society of Anesthesia and Intensive Care (SFAR) and assess the feasibility of a change in attitude (injection of the antibiotic prior to incision) among paediatricians Perinatal Health Network of Auvergne (RSPA) working in maternity. STUDY DESIGN: Cross sectional study by survey. METHODS: First questionnaire was sent to 46 RSPA paediatricians working in maternity. Almost one-third of paediatricians who returned the questionnaire said they were not concerned. A second questionnaire was developed with two paediatricians of the CHU and sent to the same 46 paediatricians. The statistical part involved percentages. RESULTS: Response rates were respectively 61% and 67%. For the first questionnaire, only 25% of the paediatricians knew the antibiotic and the time for injection. For the second questionnaire, 87% were in favour of an administration before incision and 42% thought it will not affect the care of the newborn. For 35% of respondents, it could lead to a change in the duration of antibiotic therapy in cases of perinatal infection and for 13% only a delay in the implementation of antibiotic therapy in children. CONCLUSION: The RSPA paediatricians did not know the practices of antibiotic prophylaxis for caesarean section. However, they did not appear opposed to an administration before cord clamping as it would not delay the implementation of any antibiotics in the newborn.
Assuntos
Antibioticoprofilaxia/métodos , Cesárea/métodos , Adulto , Estudos Transversais , Feminino , França , Pesquisas sobre Atenção à Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Recém-Nascido , Masculino , Pediatria , Assistência Perinatal , Médicos , Gravidez , Inquéritos e QuestionáriosRESUMO
We studied the potentiation of analgesia for labour by the addition of clonidine to epidural low-concentration levobupivacaine with sufentanil in a randomised, double-blinded study. We enrolled primiparous women who were in spontaneous labour. The study solutions, made of 100 ml levobupivacaine 0.0625% plus sufentanil 0.45 µg.ml(-1) and either 150 µg clonidine or no clonidine, were used for induction of analgesia, and for its maintenance with self-administered boluses and a continuous background infusion. The need for additional epidural boluses during labour was lower and analgesia and maternal satisfaction were better in the clonidine (n = 57) than in the control group (n = 58). Blood pressure was lower and the rate of instrumental delivery higher in the clonidine group. Clonidine (1.36 µg.ml(-1)) added to the epidural solution of low-concentration levobupivacaine improves the quality of analgesia. The relevance of the haemodynamic effects should be explored in larger validation studies.
Assuntos
Analgesia Epidural , Analgesia Obstétrica , Analgesia Controlada pelo Paciente , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Clonidina/administração & dosagem , Sufentanil/administração & dosagem , Adulto , Bupivacaína/administração & dosagem , Bupivacaína/análogos & derivados , Método Duplo-Cego , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Levobupivacaína , GravidezRESUMO
OBJECTIVES: Our objective was to report perinatal outcome during the first three years of an emerging centre for laser photocoagulation in twin-twin transfusion syndrome (TTTS) and to compare with outcome observed earlier in the same centre when management consisted in recurrent amniodrainage. PATIENTS AND METHODS: We conducted a single centre retrospective study. We compared perinatal outcome of 19 consecutive cases of mid trimester TTTS managed by amniodrainage over a 10-year period with 49 cases of TTTS managed by laser photocoagulation over a 3-year period. RESULTS: Laser photocoagulation increased survival rate at birth (P=0.02) and at postnatal day 28 (P=0.01). Neurologic and cardiologic complications did not differ significantly (P=0.5 and P=0.3 respectively). We observed a significant increase in survival of the donor after laser coagulation at birth (P=0.04). DISCUSSION AND CONCLUSION: Our study demonstrated better outcome after laser photocoagulation. Early results of an emerging centre appeared comparable to those of more experienced centres.
Assuntos
Transfusão Feto-Fetal/cirurgia , Fetoscopia , Terapia a Laser/métodos , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
OBJECTIVE: To assess the management of post-partum haemorrhage (PPH) in delivery rooms by the anaesthetists of the Auvergne region. STUDY DESIGN: Cross sectional study. METHODS: An anonymous postal survey was sent to all the anaesthetists working in a public or private hospital with a maternity unit. RESULTS: The response rate was about 70 %. Eight percent of the respondents never practiced in obstetrics; others all declared to have managed PPH at least once. Only 66 % declared to know the right definition of PPH, 98 % declared to have guidelines in the delivery room, 87 % to use graduate blood receipt pockets, 85 % to work under midwives-directed delivery at expulsion, 88 % to have a HemoCue™ system. More than 80 % declared to use first oxytocin and to switch for prostaglandins in case of failure, to put two venous catheters and a urinary catheter, to administer broad-spectrum prophylactic antibiotic and to draw a blood sample for early biology. Packed red cells, platelets and fresh frozen plasma were accessible in less than 30 minutes for 98 %. Transfusion guidelines were applied. Only 27 % could have arterial radiologic embolisation on site. The knowledge about PPH and its consensual care tended to be poorer in practitioners from the university hospital, and younger under 40 also. CONCLUSION: This survey, with a good response rate, showed a practice generally fitting to the guidelines, although with some failures depending on the practioner's age and type of hospital.
Assuntos
Salas de Parto , Hemorragia Pós-Parto/terapia , Antibacterianos/uso terapêutico , Transfusão de Sangue , Competência Clínica , Estudos Transversais , Embolização Terapêutica , Feminino , França , Guias como Assunto , Pesquisas sobre Atenção à Saúde , Humanos , Recém-Nascido , Ocitócicos/uso terapêutico , Ocitocina/uso terapêutico , Gravidez , Prostaglandinas/uso terapêutico , Inquéritos e Questionários , Cateterismo UrinárioRESUMO
OBJECTIVE: To describe perioperative management and perinatal outcome for patients undergoing laparoscopy during pregnancy. PATIENTS AND METHODS: We conducted a retrospective study of all cases of laparoscopy during pregnancy performed in our university hospital over a period of six years (from February 2000 to February 2006). RESULTS: We observed 34 cases managed from five to 30 weeks of gestation (11 cases of adnexal torsion, ten adnexal masses, eight appendicitis, one cholecystitis, one sigmoid volvulus, one pelvic peritonitis, two heterotopic pregnancies). Open laparoscopy was used in 12 cases. Conversion was required in two cases mainly due to adherences (one borderline lesion at 16 weeks and one tubal cyst torsion at 24 weeks). No maternal complication was observed. One miscarriage occurred at Day 1 (peritonitis, five weeks of gestation) and one patient opted for abortion. No threatened preterm labour occurred after the perioperative course and no neonate required admission in neonatology unit. DISCUSSION AND CONCLUSION: This study illustrates safety and efficacy of laparoscopy in management of surgical diseases in the gravid patient. Emergent indications are the most common, highlighting the need for all physicians to know specific recommendations related to laparoscopy during pregnancy.
Assuntos
Laparoscopia/métodos , Complicações na Gravidez/cirurgia , Resultado da Gravidez , Doenças dos Anexos/cirurgia , Adulto , Apendicite/cirurgia , Feminino , Cálculos Biliares/cirurgia , Humanos , Laparoscopia/efeitos adversos , Assistência Perinatal , Assistência Perioperatória , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Estudos Retrospectivos , Anormalidade Torcional/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
Pelvic pain during pregnancy and postpartum period is common. Pubic separation is a physiologic phenomenon caused by pregnancy and delivery. It's an aetiology of pregnancy and postpartum pain requiring a specialized management in case of severe pain. We report the case of a 34-year-old multiparous woman suffering from severe pubic symphysis pain after twin delivery by vaginal approach, with extraction support, under epidural analgesia. Pubic symphysis separation was diagnosed according both to the clinical symptoms and to the radiology. A local anesthetic infiltration was performed twice to substantially relieve the patient.
Assuntos
Extração Obstétrica , Dor Pélvica/etiologia , Gravidez Múltipla , Sínfise Pubiana/fisiopatologia , Adulto , Analgesia Epidural , Analgesia Obstétrica , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/administração & dosagem , Feminino , Humanos , Lidocaína/administração & dosagem , Bloqueio Nervoso , Dor Pélvica/tratamento farmacológico , Gravidez , Sínfise Pubiana/diagnóstico por imagem , Radiografia , GêmeosRESUMO
BACKGROUND AND OBJECTIVE: Combined spinal-epidural is an alternative technique to epidural analgesia for labour, but its benefits are not clearly identified. METHODS: A prospective, blinded, randomized study was undertaken involving 113 women attending a university hospital obstetric department. Analgesia was initiated with intrathecal bupivacaine 0.25% 1 mL + sufentanil 5 microg in the combined spinal-epidural group (n = 54), and with bupivacaine 0.125% + epinephrine 2.5 microg mL(-1) + sufentanil 7.5 microg in the epidural group (n = 59). In both cases this was followed by patient-controlled epidural analgesia with bupivacaine 0.125% (+ sufentanil 0.25 microg mL(-1)). Duration of labour, quality of analgesia and side-effects were compared between groups. RESULTS: In the combined spinal-epidural group, the onset of analgesia was faster (5 vs. 15 min, P < 0.001), the consumption of bupivacaine was lower (7.5 vs. 11.3 mg h(-1), P = 0.003) and there was less unilateral analgesia (14.8% vs. 40.7%, P = 0.002) than in the epidural group. The characteristics of labour were similar in both groups. However, in the combined spinal-epidural group, there was a higher incidence of posterior presentation (25.9% vs. 10%, P = 0.03), pruritus (P < 0.001), hypotension (P = 0.002), somnolence (P = 0.01), nausea (P = 0.02) and one case of meningitis. CONCLUSIONS: The combined spinal-epidural technique provided more effective analgesia during labour than epidural analgesia alone but offered no other advantage. It induced more adverse effects and this should be considered before routinely using the combined spinal-epidural technique.
Assuntos
Analgesia Obstétrica/métodos , Analgesia Controlada pelo Paciente , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/uso terapêutico , Bupivacaína/uso terapêutico , Trabalho de Parto , Sufentanil/uso terapêutico , Adulto , Analgesia Epidural , Analgésicos Opioides/efeitos adversos , Raquianestesia , Anestésicos Locais/efeitos adversos , Bupivacaína/efeitos adversos , Feminino , Humanos , Hipotensão/induzido quimicamente , Apresentação no Trabalho de Parto , Náusea/induzido quimicamente , Medição da Dor , Gravidez , Estudos Prospectivos , Prurido/induzido quimicamente , Método Simples-Cego , Fases do Sono/efeitos dos fármacos , Sufentanil/efeitos adversos , Fatores de TempoRESUMO
Thirteen episodes of fever in bone marrow transplantation recipients (23 months to 11 years old children) were treated by ceftazidime (100-200 mg/kg/j) and netilmicin (7 mg/kg/j). Vancomycin was added at the 24th hour in 10 cases of persistent fever. 6 presumed agents of infection were isolated before antibiotic treatment: blood cultures (streptococci 2, staphylococcus 1, proteus 1), fecal sample (E. coli 1), urine (E. coli 1). Modifications of aerobic fecal flora were studied under this treatment. E. coli, staphylococci and enterococci were the mainly strains isolated. There were no third generation cephalosporins resistant Gram-negative bacteria. High level resistance to aminoglycosides was observed in enterococcal strains, isolated during and after treatment. Ceftazidime-netilmicin (+/- vancomycin) was an effective and safe combination for the management of febrile neutropenic episodes.
Assuntos
Infecções Bacterianas/tratamento farmacológico , Transplante de Medula Óssea , Ceftazidima/administração & dosagem , Netilmicina/administração & dosagem , Complicações Pós-Operatórias/tratamento farmacológico , Sepse/tratamento farmacológico , Bactérias/efeitos dos fármacos , Ceftazidima/farmacologia , Criança , Pré-Escolar , Avaliação de Medicamentos , Quimioterapia Combinada , Feminino , Humanos , Masculino , Testes de Sensibilidade Microbiana , Netilmicina/farmacologia , Fatores de Tempo , Vancomicina/administração & dosagem , Vancomicina/farmacologiaAssuntos
Fosfolipídeos/fisiologia , Cuidado Pré-Natal , Surfactantes Pulmonares/fisiologia , Síndrome do Desconforto Respiratório do Recém-Nascido/fisiopatologia , Desenvolvimento Embrionário e Fetal , Feminino , Humanos , Recém-Nascido , Pulmão/crescimento & desenvolvimento , Gravidez , ViscosidadeRESUMO
The authors report a case of Schwartz-Jampel syndrome (osteo-chondro muscular dystrophy with myotonia). The diagnosis was made when the child was 3 1/2 year old. Then, there were no clinical symptoms; however, the electromyographic and histologic patterns of the disease were found. Two years later, the clinical status provided confirmation of the diagnosis. The discussion focuses on the difficulty of the diagnosis and the relevance of electrophysiological studies and muscular biopsy in order to distinguish this disease from others with similar clinical pattern (as Freeman-Sheldon, or Marden Walker syndromes).
Assuntos
Músculos/patologia , Osteocondrodisplasias/diagnóstico , Pré-Escolar , Eletromiografia , Humanos , Masculino , Osteocondrodisplasias/patologia , Osteocondrodisplasias/fisiopatologiaRESUMO
The authors report 5 cases of congenital hydrocephalus due to isolated stenosis of the aqueduct of Sylvius. In the first three cases (2 brothers and 1 sister) ventriculograms showed apparent obstruction of the aqueduct. A valve shunting was necessary at 1 month of age in cases 1 and 2, at 3 years of age in case 3. In cases 4 and 5 (1 brother and 1 sister) ultrasonic prenatal diagnosis showed ventriculomegaly and pregnancies were interrupted respectively at 31 and 28 weeks of gestational age. The pedigree of the families suggests that the inheritance of this abnormality is autosomal recessive. Such an inheritance is very unusual and confirms the difficulty of genetic counseling facing the first occurrence of hydrocephalus with stenosis of the aqueduct of Sylvius in a family. The prenatal diagnosis is based on fetal ultrasonic examination and may be obtained late in the pregnancy leading to therapeutic and ethical tricky decisions.
Assuntos
Aqueduto do Mesencéfalo , Genes Recessivos , Hidrocefalia/genética , Aborto Terapêutico , Adolescente , Ventriculografia Cerebral , Criança , Feminino , Humanos , Hidrocefalia/diagnóstico por imagem , Hidrocefalia/etiologia , Masculino , Linhagem , Gravidez , Diagnóstico Pré-NatalRESUMO
The authors report a case of homocystinuria diagnosed in a 2 year-old boy presenting with psychomotor retardation and with widespread cerebral vascular thromboses, unusually severe at that age. The disease was of the pyridoxin-resistant type, for which use of remethylation activators led to a good biological result.
Assuntos
Cistinúria/complicações , Embolia e Trombose Intracraniana/etiologia , Piridoxina/uso terapêutico , Pré-Escolar , Cistinúria/tratamento farmacológico , Resistência a Medicamentos , Humanos , Masculino , Transtornos Psicomotores/etiologiaRESUMO
The authors report two cases of HUS that presented as colitis due to E. Coli. They emphasize the interest--from an epidemiological point of view--of looking for E. Coli in stools of children with HUS and serotyping them.