Choc hémorragique péri-opératoire au Centre Hospitalier Universitaire Androva, Mahajanga, Madagascar

Introduction : Le choc hypovolémique est une défaillance circulatoire aiguë et critique, mettant rapidement en jeu le pronostic vital. L'objectif de l'étude était de déterminer les aspects épidémio-cliniques et la prise en charge du choc hémorragique periopéraoire au centre hospitalier de Mahajanga. Méthodes : Il s'agit d'une étude rétrospective, descriptive, observationnelle et monocentrique réalisée dans le service de Réanimation Chirurgicale du CHU PZaGa de Mahajanga, sur une période de 52 mois. Les données socio-démographiques, les paramètres cliniques périopératoires, la prise en charge médico-chirurgicale, l'évolution et les retentissements organiques de l'état de choc hémorragique ont été les paramètres étudiés. Résultats : Nous avons collecté 6896 dossiers des patients, dont 70 cas de choc hémorragique ont été recensés (1,02%) pour tout type de chirurgie ; 62 dossiers ont été retenus dans l'étude. La majorité des cas était du genre féminin (87,10%). Les pathologies gynéco-obstétricales étaient la principale source de l'état de choc de (77,4%), dont 59,4% d'hémorragie du post-partum. L'insuffisance rénale aiguë était la principale atteinte viscérale (61%, n=38) suivie de 10% (n=6) des cas des troubles neurologiques. Tous les patients ont bénéficié d'une oxygénothérapie, et d'un remplissage vasculaire par des cristalloïdes et 3,2% ont eu des colloïdes. Les substances vasoactives utilisées étaient l'éphédrine 41,9%, suivie de l'adrénaline 27,4% et de la noradrénaline 17,7%. Vingt-sept virgule quarante pourcent de nos patients étaient décédés, et la cause la plus incriminée était la coagulopathie par défibrination. Conclusion: Les hémorragies obstétricales constituent la première cause de choc hémorragique ; le taux de mortalité reste encore élevé.

Tendance de la mortalité maternelle au Centre Hospitalo-Universitaire de Constantine entre 2012 et 2017 / Trend in maternal mortality at Constantine University Hospital between 2012 and 2017

Contexte et objectifs. Les données sur la tendance de la mortalité maternelle sont fragmentaires en Afrique Subsaharienne. La présente étude avait pour objectif de faire une analyse triennale de l'évolution du taux de mortalité maternelle et identifier les causes de décès. Méthodes : Il s'agissait d'une étude observationnelle documentaire, sur la mortalité maternelle enregistrée ; au Centre hospitalo universitaire de Constantine, entre le 1er Janvier 2012 et le 31 Décembre 2017. Résultats. Soixante-dix décès maternels ont été déplorés. Le taux de mortalité maternelle est de 101,3 décès pour 100 000 naissances vivantes. Les hémorragies obstétricales et les complications hypertensives de la grossesse sont les premières causes de mortalité. L'analyse des données triennales met en évidence une baisse importante de la mortalité par hémorragie et par complications de l'anesthésie. Conclusion. Cette étude a permis de dresser un profil des causes de la mortalité maternelle dont les niveaux restent inquiétants et requièrent une action globale.

Bleeding and thrombosis outcomes in hospitalised COVID-19 patients on low-molecular-weight heparin and antiplatelet therapy

Background. An increased incidence of thromboembolic events in hospitalised COVID­19 patients has been demonstrated despite the use of low-molecular-weight heparin (LMWH). Antiplatelet therapy prior to admission and early in the disease course has been hypothesised to be protective against thrombosis.Objectives. To describe the bleeding and thrombosis outcomes in hospitalised patients with confirmed COVID­19 receiving LMWH, with and without concomitant antiplatelet therapy. Secondary objectives were to explore predictors of bleeding and thrombosis outcomes, and dosing practices of antiplatelet therapy and LMWH.Methods. We conducted a descriptive, cross-sectional study of bleeding and thrombosis outcomes at Tygerberg Academic Hospital, Cape Town, South Africa, during the first COVID­19 wave, in 808 hospitalised patients with confirmed COVID­19 receiving LMWH with and without concomitant antiplatelet therapy. Multivariate logistic regression analysis was performed if predictors were deemed statistically and clinically significant.Results. Patients receiving both LMWH and antiplatelet therapy had similar bleeding outcomes compared with patients only receiving LMWH (odds ratio (OR) 1.5; 95% confidence interval (CI) 0.6 - 4.0). Patients receiving both LMWH and antiplatelet therapy had increased odds of developing thrombosis compared with patients only receiving LMWH (OR 4.8; 95% CI 2.1 - 10.7).Conclusion. The bleeding risk in COVID­19 patients receiving both LMWH and antiplatelet therapy was not significantly increased. A potentially higher risk of thrombosis in patients receiving LMWH and antiplatelet therapy was observed. However, this could reflect confounding by indication. Randomised studies are required to further evaluate the use of antiplatelet therapy to treat hospitalised patients with COVID­19.

Home therapy for inherited bleeding disorders in south Africa: results of a modified delphi consensus process

Background. Optimal care of patients with inherited bleeding disorders requires that bleeding episodes are treated early, or still better prevented, through extension of patient care beyond hospital-based treatment to home-based therapy. In South Africa (SA), adoption of home therapy is variable, in part owing to lack of consensus among healthcare providers on what constitutes home therapy, which patients should be candidates for it, how it should be monitored, and what the barriers to home therapy are.Objectives. To conduct a modified Delphi process in order to establish consensus on home therapy among haemophilia healthcare providers in SA.Methods. Treaters experienced in haemophilia care were invited to participate in a consensus-seeking process conducted in three rounds. In round 1, provisional statements around home therapy were formulated as questions and collated in a structured list. In rounds 2 and 3, evolving versions of the questionnaire were administered to participants. Consensus was defined as ≥70% agreement among the participants.Results. The panel composition included an equal number of physicians and non-physicians. The participation rate was 100% through all three consensus rounds. The group reached consensus for 92% of the statements. Consensus of 100% was reached on starting home therapy in paediatric patients, requiring all patients on home therapy to sign informed consent and indemnity, and providing round-the-clock support for patients on home therapy.Conclusions. The home therapy consensus statements in this report have the potential to translate to policy on home therapy and to guide the initiation, practice and evaluation of home therapy programmes in SA

Clinical presentation and management outcome of emergency adolescent gynecological disorders at federal teaching hospital, abakaliki, Nigeria

Background: Gynecological emergencies which affect the adolescents may pose a serious challenge to both the patient and the gynecologist. Objectives: The objective of this study is to determine the clinical presentations and management outcomes of emergency adolescent gynecological disorders at Federal Teaching Hospital, Abakaliki. Materials and Methods: This is a retrospective review of all cases of adolescent gynecological emergencies managed at Federal Teaching Hospital Abakaliki between January 1, 2012, and December 31, 2014. Data obtained from their case notes were analyzed using the IBM statistics version 20 (IBM Corp., Armonk, NY, USA). Data were presented using percentages and pie chart. Results: The prevalence of adolescent gynecological emergency disorders was 5.1%. The majority (82%) of the patients belong to the age bracket 15­19 with a mean age of 16.7 (2.4) years. About 90% of the patients were nulliparous. Unmarried patients comprised 80% of the study group. Vaginal bleeding was the most common clinical presentation (86%). The two most common diagnoses were abortion (60%) and sexual assault (26%). Only 10% of sexually active adolescent were using any form of contraception. Care received includes manual vaccum aspiration, laparotomy, and antibiotics. Blood transfusion was given in 18% of the cases. No death was recorded in all the cases. Conclusion: Abortive conditions and sexual assault were the most common clinical diagnosis among adolescents in the study. The percentage of adolescent assaulted in our study is unacceptable and should be prevented and efforts should be made to reduce the high unmet need for contraception seen in the study

A National Survey of Oxytocin Use during Caesarean Section in Zimbabwe

Background: Post-partum haemorrhage is the leading cause of mortality for labouring women in Zimbabwe. Current literature supports the use of low dose oxytocin to prevent bleeding during Caesarean section. Internationally; clinical practice has been slow to change and the use of potentially harmful; higher than recommended dose is common.Objective: To describe the current clinical practice in Zimbabwe.Design: A self-administered questionnaire survey. Descriptive statistics were used to report the study results.Setting: In 2013 a national survey was conducted on the use of oxytocin by different types of clinicians; who provide either anaesthesia or surgery for Caesarean section.Results: Of a total of 221 (61%) questionnaires returned; 170 (80%) were completed fully. Only 23% of respondents would give an intravenous dose of 5.0 IU or less of oxytocin for elective Caesarean section. The majority of clinicians (77%) would administer more than 5.0 IU of oxytocin at elective. A significant number of nurse anaesthetists 16/59 (27%); and a non-negligible number of specialist anaesthetists 3/48 (6%) would even give 20 IU of oxytocin in elective cases rising to 30% and 13% respectively for emergency cases. In case of persistent bleeding due to uterine atony; oxytocin was more likely to be repeated (45%); rather than using misoprostol (25%) or ergometrine (19%). Conclusion: Most clinicians in Zimbabwe use oxytocin doses well above current internationally recommended. This illustrates the urgent need for updated national guidelines for the prevention of post-partum haemorrhage during Caesarean section

Incidence and Clinical Features of Bleeding Peptic Ulcers in Acute Upper Gastrointestinal Bleeding: -Experience of Moroccan University Hospital Unit

Introduction: Peptic ulcer disease (PUD) has been recognized as the leading cause of acute upper gastrointestinal bleeding (AUGIB). This study aims to report general features of bleeding peptic ulcers in patients who benefit of urgent endoscopy in our department after an acute upper gastrointestinal hemorrhage. Results: A total of 1809 patients were explored for acute upper gastrointestinal bleeding in our unit since 2003 to 2008. Gastroduodenal peptic ulcers were the most frequent diagnosed etiology. They present 38% of all reported causes of bleeding (n=527) (table I). 25% were located at duodenal mucosa (n= 347) and 13% were gastric ulcers (n=180). No esophageal ulcers were reported. Incidence of both duodenal and gastric ulcers decreases during the last years. Conclusion: In our department; incidence of bleeding peptic ulcer disease is decreasing but they continue to be the first cause of AUGIB

Peri-mortem laparotomy in a patient with a ruptured intra-abdominal pregnancy

Introduction :Intra-abdominal pregnancies can present at an advanced stage of pregnancy and can have the potential for life-threatening rupture and haemorrhage. The purpose of this case report was to discuss the early recognition and prompt management options of a patient with a life threatening ruptured intra-abdominal pregnancy.Case report:We report what we believe to be the first case of a patient who presented with an intra-abdominal pregnancy who underwent a peri-mortem laparotomy in the Emergency Centre following a cardiac arrest; and who exhibited a return to spontaneous circulation (ROSC).Conclusion: Peri-mortem laparotomy/thoracotomy coupled with high quality CPR and resuscitation may be lifesaving in a patient with a life threatening ruptured intra-abdominal pregnancy

Accuracy in Diagnosis of Postpartum Haemorrhage Using Visual Estimation of Blood Loss versus Change in Haematocrit in a Tertiary Teaching Hospital in Tanzania

Abstract:Postpartum haemorrhage is the leading cause of maternal death in the developing country and yet is poorly diagnosed due to inaccurate measurement of blood loss following delivery. A study was carried out at Muhimbili National Hospital (MNH) Tanzania between October 2005 and January 2006 to determine the accuracy of visual estimation of blood loss (VEBL) in comparison to laboratory measurement of blood loss in diagnosis of primary postpartum haemorrhage (PPH). A total of 426 pregnant women who were in active phase of labour were recruited and their venous blood was drawn for estimation of haematocrit before delivery and 12 hours thereafter. Active management of third stage of labour was conducted by giving 10IU of oxytocin (intramuscularly or intravenously) and this was followed by visual estimation of blood loss. The proportion of patients who developed PPH was then determined by both methods. The mean duration of third stage of labour was 8.3 minutes and mean blood loss was 164.9ml. The prevalence of PPH was 8.9 and 16.2 by VEBL and changes in haematocrit; respectively. Change in haematocrit in diagnosis of PPH was found to be more accurate; specific with high positive predictive values compared to VEBL. The need for additional uterotonics was 5.8 and the commonest labour complications associated with PPH were second degree tear; retained placenta and EUA for continued bleeding. In conclusion; VEBL using calibrated vessel will increase accuracy where conventional method using non calibrated method is used for diagnosis of PPH. Service providers working in labour wards need to be trained on how to estimate blood loss using simulated methods so as to increase their long term memory and accuracy in diagnosis of post-partum haemorrhage; hence provision of immediate intervention

Pregnancy Epulis Associated With Life Threatening Haemorrhage in a Nigerian Woman

Pregnancy tumour is a clinical term used to identify a pyogenic granuloma that occurs in pregnant women. Pregnancy tumour is not uncommon; but severe bleeding associated with the lesion necessitating blood transfusion is rare. We report a rare case of mandibular gingival pregnancy tumour with a life-threatening haemorrhage in a 25-year-old Nigerian woman. The patient had lost an estimated 2 litres of blood before presentation. Her packed cell volume was 8at presentation. The patient was managed by infusion of fluid; transfusion of 4 units of blood and ligation of the facial artery; and excision of the lesion. Following an uneventful healing; she was discharged 10 days later with a PCV of 40.5. Following subsequent review there was a recurrence 2 months later that regress after 1 month. She was subsequently lost to further follow up

Forme hemorragique grave de la fievre de la vallee du Rift observee chez un jeune Malgache

La fievre de la vallee du Rift (FVR) est une zoonose virale qui touche principalement les animaux mais elle peut contaminer l'homme. La forme hemorragique constitue une complication grave et mortelle de la FVR; elle ne s'observe que dans 1des cas mais gravement mortelle dans 50des cas. Notre etude rapporte un cas grave de forme hemorragique de FVR qui est observe dans le service de reanimation du CHU Antananarivo (Hopital Joseph Raseta Befelatanana) chez un eleveur de 22 ans. La maladie se manifeste par un syndrome infectieux et une apparition precoce (des le 2e jour) des complications hemorragiques. Ce sont des hemorragies diffuses (hematemese; gingivorragie; petechies; hematurie; hemorragie au point de ponction veineuse..). Cette complication hemorragique a entraine le deces de ce patient des le 4e jour du debut de symptome malgre la reanimation. Le bilan biologique a montre des alterations de la fonction hepatique et des troubles de la coagulation. Des defaillances multi viscerales ont ete egalement observees

Risk factors for Placenta Praevia Presenting with severe Vaginal Bleeding in Mulago Hospital; Kampala; Uganda

Objective: To determine the risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital; Kampala; Uganda. Design: A case control study. Set- ting: Mulago hospital labour suite Participants: Between 15th November 2001 and 30th November 2002 we identified and recruited thirty six parturients with placenta previa who developed severe bleeding and 180 women with normal delivery. The risk factors were studied. Variables of interest: Socio demographic characteristics; social and family history; gynaecological operations; blood transfusion; medical conditions; past and present obstetric performance and HIV status. Results: Significant predictors for severe bleeding in parturients with placenta praevia were: previous history of evacuation of the uterus or dilation and curettage (O.R. 3.6; CI: 1.1-12.5); delivery by caesa- rean section in previous pregnancy (O.R. 19.9; CI: 6.4-61.7); residing more than ten kilometres from Mulago hospital (O.R. 2.4; CI: 1.0-5.7) and recurrent vaginal bleeding during the current pregnancy (O.R. 7.3; CI 2.4-63.7). Conclusion: Severe bleeding in placenta praevia is associated with high maternal morbidity and mortality. The determi- nants of severe bleeding in placenta praevia can be used in the antenatal period to identify mothers at risk. These; with prompt interventions to deliver the women can be used to reduce the maternal morbidity associated with this condition

Haemorheological changes in African breast cancer patients

Several Studies have indicated the existence of thrombo-embolic complications in cancer patients and that this could be associated with changes in heamorheological para- meters. Packed cell volume (PCV); heamoglobin (Hb); relative plasma viscosity (RPV) and plasma Fibrinogen concentration (PFC) were measured in 50 healthy control women; 50 age-matched women with breast cancer; and 10 women with histophathologically proven benign breast tumour. There were significant differences between the controls and breast cancer patients in all the parameters measured (p0.05). However; patients with cancer have significantly higher RPV and PFC (P0.001) respectively than controls. There was significant mean difference between pre and post mastectomy in fibrinogen concentration (p0.05) and this was observed over the 5-week study period. Since increased fibrinogen may give rise to increase fibrin formation which has been asserted as an independent cardiovascular risk factor for thromb-oembolic complications; African patients with breast cancer may well be predisposed to thrombotic complications during illness. The rheological assessment may offer valuable benefit for the management and early diagnosis of breast cancer in African women

The Effect of Cold and Haemorrhagic Stress on Reticulocytes in Male Albino Wistar Rats

Background: In this study; the effect of cold and haemorrhagic stressors in male albino Wistar rats will be investigated. Methods: Cold stress was induced by placing the animals in thermostatic chamber containing ice cold water (0-10oC) and well aerated. Rats were allowed to stay for 5; 10; 15 and 20 minutes before they were bled from the tail vein at 2; 4; 6; 8 and 24 hours for reticulocyte counts. For the haemorrhagic stress; 30of blood was withdrawn from the vein after which reticulocytes were counted at 2; 4; 6; 8 and 24 hours. Results: Cold and haemorrhagic stress caused increased reticulocyte counts in male albino Wistar rats. The controls were not subjected to any condition. In cold stress; the maximum percentage reticulocyte count was (at zero hour) 6.21 + 0.21while the control was 1.02 + 0.12. In the case of the haemorrhagic stressor; the percentage reticulocyte was seen to peak at the 6th hour (6.19 + 0.12) and subsequently decrease to 2.59 + 0.02. The probable causes of this rise in reticulocytes are discussed. Conclusion: In cold and haemorrhagic stress; reticulocyte count peaked at 2 and 6 hours respectively; depicting when maximum erythropoietic activity was reached in blood forming organs

Fluctuating pulse deficits associated with intimal arterial injury following gunshot wounds of the extremity - a sign not to be missed

Gunshot wounds may result in intimal arterial injury without breach of the arterial wall integrity. Haemorrhage; haematoma and a pulse deficit are therefore not always found. We report on two cases of lower extremity gunshot wounds with temporal variations in the clinical and radiological assessment of the pedal pulses. In both cases surgical exploration revealed intact arterial vessel walls but significant intimal injury with overlying thrombus. We propose that the pulse deficits were due to distal thromboembolism. Subsequent clot lysis led to a return of the original pulse deficit. Variation in the distal pulses in patients with gunshot wounds of the extremities should alert one of the possibility of an intimal arterial injury; imaging of the vessels is therefore advised

Aspects epidemiologiques et endoscopiques des rectorragies : a propos de 139 cas chez le noir africain

BUT:repertorier les differents aspects des lesions observees en. coloscopie totale au COUTS des rectorragies. A. MATERIEL ET METHODES : Etude retrospective de 139 comptes rendus de malades ayant subi une coloscopie totale pour rectorragie; colliges entre Avril 1992 et Janvier 2003 dans l'unite d'endoscopie digestive du service d'Hepato-Gastroenterologie du CHU de Cocody (Abidjan). Les parametres etudies etaient : lige ; le sexe ; la profession; la qualite de la preparation colique ; le siege et l'aspect des lesions. RESULTATS : -II existait une predominance masculine (87 hommes et 52 femmes) avec un sex-ratio de 1;7 ; -La preparation colique a ete jugee bonne dans 9l;pour cent des cas; -La coloscopie totale etait normale chez 19 patients; -Les 120 malades restants ont presente au moins une lesion; -La repartition des lesions etait la suivante: hemorroides (50;8pour cent); anorectocolite (45pour cent); polype (9;2pour cent); cancer (8;3pour cent); diverticule (8;3pour cent); varice (4;2pour cent); angiodysplasie (1;7pour cent); fissure (1;7pour cent); condylome (0;8pour cent) ; -La topographie ano-rectale predominait avant l'age de 45 ans (p 0;05). Cette etude montre la prevalence endoscopique elevee des rectorragies ainsi que leurs origines multiples et diversifiees. D'ou la necessite d'effectuer devant toute rectorragie une investigation endoscopique poussee; afin de ne pas attribuer a tort ces rectorragies aux hemorroides qui sont un diagnostic d'elimination

Near-mis par hemorragie ou morbidite maternelle grave par hemorragie : a propos de 298 cas colliges au CHU de Cocody

"Notre travail est une etude prospective descriptive transversale sur une periode de 12 mois allant du premier janvier 2004 au 31 decembre 2004. Il a porte sur 298 ""NEAR-MISS"" par hemorragie recues en salle d'accouchement et aux urgences gynecologiques. L'objectif de notre etude etait de determiner les facteurs contrariant la prise en charge des ""NEAR-MISS""; en vue de corriger les deficiences. Sur les 298 ""NEAR-MISS"" 78;5pour cent etaient des patientes evacuees. Leur prise en charge a necessite une laparotomie pour 60;1pour cent d'entre elles et une transfusion sanguine pour 72;5pour cent. La prise en charge a ete contrariee par certains facteurs : *Le personnel medical par son manque de collaboration: 1;7pour cent ; *Les infrastructures et equipements a savoir : l'absence de banque de sang au sein du CHUC: 93;9pour cent; l'indisponibilite du bloc operatoire:10;4pour cent et le manque de materiel medical a la pharmacie du CHU : 18;5pour cent ; *Les conditions financieres : 45;3pour cent. Au terme de notre etude; nous avons fait des suggestions pour ameliorer la prise en charge des ""NEAR-Miss"": *Necessite d'avoir un medecin anesthesiste reanimateur affecte au service de gynecologie-obstetrique ; *""NEAR-Miss"" ; *Necessite d'avoir une banque de sang au sein du CHUC ; *Ouverture d'un deuxieme bloc operatoire d'urgence pour le service de gynecologie-obstetrique ; *Organiser des rencontres periodiques avec le personnel medical des structures evacuatrices ; *Necessite d'un meilleur approvisionnement de la pharmacie du CHUC."

Cystique hemorragique anti-inflammatoire non steroidien : a propos d'un cas survenu au CHU de Bordeaux

Les cystites sont en general d'origine infectieuse. Il arrive cependant que la persistance; des signes cliniques (pollakiurie; mictions imperieuses; brulures mictionnelles; douleurs hypogastriques et parfois hematurie) contraste avec des examens cytobacteriologiques des urines montrant une leucocyturie (et parfois une hematurie) avec absence de germes. Une cause medicamenteuse est alors a envisager; entre autres. Les principaux medicaments incrimines sont certains anti-inflammatoires non steroidiens (AINS); et certains cytotoxiques. Parmi les complications vesicales imputables aux medicaments; la cystite hemorragique est particulierement grave. La meconnaissance du diagnostic du fait de la rarete de cette affection (en France; 48 cas signales depuis 1986); nous a conduit a nous interesser a un cas de cystite hemorragique survenu en 1996 au CHU de Bordeaux. Il s'agit d'une dame qui a beneficie de plusieurs traitements anti-inflammatoire dans le cadre d'une polyarthrite rhumatoide connue depuis 1975. En 1996; on decouvre chez elle l'existence d'une cystite hemorragique. Les moyens therapeutiques entrepris pour faire face aux saignements intravesicaux se sont averes inefficaces. Face a la deterioration de l'etat hemodynamique de notre patiente; l'equipe soignante a finalement opte pour une prise en charge radicale (la cystectomie d'hemostase). Cependant; il est important de souligner qu'en cas de diagnostic precoce; un arret des medicaments en cause permet le plus souvent une disparition des symptomes