Hematoma subcapsular hepático en síndrome de HELLP: reporte de dos casos / Hepatic subcapsular hematoma in HELLP syndrome. Report of 2 cases

Resumen OBJETIVO Reportar el tratamiento clínico-quirúrgico y en la unidad de cuidados intensivos obstétricos de dos pacientes con síndrome de HELLP y hematoma subcapsular hepático. CASO CLINICO A Paciente de 29 años en curso de las 36.1 semanas de embarazo, con ausencia de movimientos fetales, choque hipovolémico, desprendimiento prematuro de placenta normoinserta y óbito. Hemoperitoneo de 2000 mL y hematoma subcapsular del lóbulo hepático izquierdo. Se le colocó un empaquetamiento Miculicz durante 48 horas. Permaneció en la unidad de cuidados intensivos durante nueve días. Reporte de tomografía axial computada de hematoma subcapsular hepático. CASO CLINICO B Paciente de 15 años, con embarazo de 38.6 semanas, dolor epigástrico y lumbar, bradicardia fetal y síndrome de HELLP. Hemoperitoneo de 300 cc, feto de 2400 g, Apgar 1-5, desprendimiento de placenta del 100%, hematoma hepático subcapsular contenido por el ligamento triangular sin necesidad de empaquetamiento. Atención en la unidad de cuidados intensivos obstétricos durante tres días. Reporte de tomografía axial computada de hematoma hepático subcapsular. CONCLUSIÓN El síndrome de HELLP puede originar complicaciones hepáticas graves, como: rotura hepática o hematoma subcapsular roto o no roto. La mortalidad es de 18 a 86% en caso de rotura del hematoma. Las pacientes deben tratarse en hospitales de tercer nivel. La intervención temprana, la atención multidisciplinaria, el soporte hemodinámico y el seguimiento con estudios de imagen son decisivos para reducir su elevada morbilidad y mortalidad.

Abstract OBJECTIVE Report clinical-surgical management and in the Obstetric Intensive Care Unit of the HELLP Syndrome and hepatic subcapsular hematoma of two clinical cases. CLINICAL CASE A 29 years of age, 36.1 weeks of gestation, absence of fetal movements, hypovolemic shock, premature detachment of normoinserta placenta, stillbirth. Hemoperitoneum finding of 2000 mL and subcapsular hematoma of the left hepatic lobe; Miculicz packaging is placed for 48 hours. Management in the Obstetric Intensive Care Unit for 9 days. Computed Axial Tomography reports hepatic subcapsular hematoma. CLINICAL CASE B 15 years of age, 38.6 weeks of gestation, pain in the hypogastrium and lumbar region, fetal bradycardia and HELLP syndrome; hemoperitoneum finding of 300 cc, product of 2,400 gr, Apgar 1-5, placental abruption of 100%, hepatic subcapsular hematoma contained by triangular ligament without the need for packaging. Management in the Obstetric Intensive Care Unit for 3 days. Computed Axial Tomography reports hepatic subcapsular hematoma. CONCLUSION The HELLP syndrome can present serious hepatic complications such as ruptured hepatic or subcapsular hematoma. Mortality is 18 to 86% in case of hematoma rupture. They require management in highly complex centers. Early intervention, multidisciplinary management, hemodynamic support and follow-up with imaging studies are essential to reduce their high morbidity and mortality.

Fetal isolated congenital heart block associated with maternal anti-SSA/SSB antibodies.

Isolated Congenital Heart Block (CHB) affects 1:15000-20000 live births. 30-50% of fetuses with CHB will have a structural anomaly. Congenital heart block detected in utero is strongly associated with maternal antibodies to SSA (Ro) and SSB (La). Their pathogenic role in the development of CHB has been established in several studies. The mothers of affected infants frequently had autoimmune disease (systemic lupus erythematosus, Sjögren's syndrome) or were entirely asymptomatic. We report a case of fetal isolated congenital heart block in an asymptomatic mother with anti-SSA/SSB antibodies.

Intrauterine fetal bradycardia after accidental administration of the anesthetic agent in the subdural space during epidural labor analgesia: A case report / 대한마취과학회지

Subdural injection of epidural anesthesia is rare and is usually undiagnosed during epidural anesthesia causing severely delayed maternal hypotension, hypoxia, and fetal distress. A 38-year-old primiparous woman was administered epidural labor analgesia at 40(+6) weeks' gestation, and developed progressive maternal respiratory depression, bradycardia, and hypotension after accidental subdural administration of the anesthetic agent. Furthermore, fetal distress occurred soon after administration. The patient was managed with oxygen, position changes, fluid resuscitation, and ephedrine. Intrauterine fetal resuscitation was successfully performed with atropine before cesarean section, and a healthy baby was delivered. Although subdural injection is uncommon, this case emphasizes the importance of anesthesiologists monitoring patients for a sufficient period after epidural labor analgesia, and being prepared to perform maternal or fetal resuscitation.

Is Transient Bradycardia Following Cordocentesis Associated with Adverse Pregnancy Outcome? / 대한산부인과학회잡지

OBJECTIVE: To evaluate the association between transient bradycardia following cordocentesis and adverse pregnancy outcome. METHODS: 117 cordocentesis was performed at Samsung Cheil hospital and women's healthcare center, between January 1, 2000, and December 31, 2002. Clinically significant bradycardia was defined as a drop in the heart rate to less than 120 bpm. The adverse outcome included major anomaly, chromosomal abnormality, intrauterine growth restriction, preterm birth, and intrauterine fetal death. RESULTS: Bradycardia following cordocentesis was observed in 13 cases (11.1 per cent). The fetal heart rate before (149.2 +/- 0.7 bpm) and after (144.7 +/- 2.8 bpm) cordocenteis was significantly different. The adverse outcome rate was 50.0 per cent (6/12) in cases with bradycardia and 27.7 per cent (26/94) in those without bradycardia (RR=2.6, P=NS). CONCLUSION: Our result is that the association between transient bradycardia following cordocentesis and adverse pregnancy isn't statistically significant, even though adverse outcome is more frequent in pateints with bradycaredia. Therefore, patient with bradycardia following cordocentesis need periodic fetal surveillance.

Is Transient Bradycardia Following Cordocentesis Associated with Adverse Pregnancy Outcome? / 대한산부인과학회잡지

OBJECTIVE: To evaluate the association between transient bradycardia following cordocentesis and adverse pregnancy outcome. METHODS: 117 cordocentesis was performed at Samsung Cheil hospital and women's healthcare center, between January 1, 2000, and December 31, 2002. Clinically significant bradycardia was defined as a drop in the heart rate to less than 120 bpm. The adverse outcome included major anomaly, chromosomal abnormality, intrauterine growth restriction, preterm birth, and intrauterine fetal death. RESULTS: Bradycardia following cordocentesis was observed in 13 cases (11.1 per cent). The fetal heart rate before (149.2 +/- 0.7 bpm) and after (144.7 +/- 2.8 bpm) cordocenteis was significantly different. The adverse outcome rate was 50.0 per cent (6/12) in cases with bradycardia and 27.7 per cent (26/94) in those without bradycardia (RR=2.6, P=NS). CONCLUSION: Our result is that the association between transient bradycardia following cordocentesis and adverse pregnancy isn't statistically significant, even though adverse outcome is more frequent in pateints with bradycaredia. Therefore, patient with bradycardia following cordocentesis need periodic fetal surveillance.

Predictable ultrasonographic findings of early abortion

Early fetal growth delay and early oligohydramnios have been suspected as signs of embryonal jeopardy. However, little information is available for the prediction of early abortion. Sonographic examination of 111 early pregnancies between the sixth and ninth gestational week with regular, 28 day menstrual cycles was performed to investigate predictable sonographic findings of early abortion. Sonographic measurements of the gestational sac (G-SAC), crown-rump length (CRL) and fetal heart rate (FHR) were performed using a linear array real time transducer with Doppler. All measurements of 17 early abortions were compared to those of 94 normal pregnancies to investigate the objective rules for the screening of early abortion. Most of the early aborted pregnancies were classified correctly by discriminant analysis with G-SAC and CRL (G-SAC = 0.5222 CRL + 14.6673 = 0.5 CRL + 15, sensitivity 76.5% specificity 96.8%). With the addition of FHR, 94.1% of early abortions could be predicted. In conclusion, sonographic findings of early intrauterine growth retardation, early oligohydromnios and bradycardia can be predictable signs for the poor prognosis of early pregnancies.