Embarazo a término posterior a ruptura hepática secundaria a síndrome de HELLP / Term pregnancy after hepatic rupture secondary to HELLP syndrome

Resumen ANTECEDENTES: La ruptura hepática es una complicación inusual, pero potencialmente mortal, que sucede en 1 de cada 100,000 a 250,000 embarazos. La mortalidad materna se ha reportado en 86% de los casos. En las pacientes con síndrome de HELLP debe considerarse que la manifestación de un hematoma hepático puede culminar en ruptura hepática y muerte. CASO CLINICO: Paciente de 46 años de edad, con antecedente de embarazo gemelar doble, bicorial, biamniótico de 36.5 semanas y preeclampsia severa, posterior a ruptura hepática por síndrome de HELLP y muerte de ambos fetos. El último embarazo evolucionó sin problemas y finalizó en cesárea en la semana 37, sin complicaciones materno-fetales, por lo que fue dada de alta del hospital al tercer día y posteriormente evolucionó sin incidentes. CONCLUSIONES: La atención médica multidisciplinaria y la infraestructura hospitalaria permitieron que la paciente no perdiera la vida debido a la ruptura hepática y hemorragia grave. La hipertensión durante el embarazo es una de las principales causas de muerte materna en todo el mundo; por tanto, es importante concientizar a las pacientes para que acudan a control prenatal regularmente y orientarlas acerca de la hipertensión y sus complicaciones. Los ginecoobstetras deben considerar que la ruptura hepática es una complicación muy grave, con consecuencias fatales para la madre y el feto.

Abstract BACKGROUND: Hepatic rupture is a potentially fatal rare complication, which is diagnosed in 1 of each 100,000 to 250 000 pregnancies. Maternal mortality has been reported in up to 86% of the patients. In cases where there has been a diagnosis of HELLP syndrome, the presence of a hepatic hematoma has to be suspected since it could lead to a hepatic rupture and eventually death. CLINICAL CASE: 46 year old female in late stage of pregnancy, following a hepatic rupture caused by HELLP syndrome and fetal demise of both fetuses in previous twin pregnancy. Her last pregnancy being of normal evolution, having been submitted to cesarean section without complications on her 37th week of gestation, and discharged on her third post-operative day showing a good evolution. CONCLUSION: The multidisciplinary medical attention given to the patient, as well as the hospital infrastructure, allowed the patient to be kept in good health despite the hepatic rupture and hemorrhage presented. It is important to remember that one of the leading causes of maternal death around the world is hypertension during pregnancy. Therefore, patients have to be made conscious of the significance and importance of attending prenatal care on a regular basis and be given information on hypertension and its complications. Additionally, it is important that obstetricians keep in mind that although this is a rare complication, it can lead to a fatal outcome when presented.

Stoppa-type laparoscopic repair of complex groin defects.

With the laparoscopic approach, bilateral and complex groin defects can be corrected simultaneously by applying a preperitoneal mesh that covers the entire posterior wall of the groin, using a technique similar to the one described by Stoppa. We present our series of hernias repaired by the transabdominal preperitoneal laparoscopic approach with the Stoppa-type technique. The report consists of 78 cases of bilateral defects, of which 60% were indirect bilateral hernias, 23% direct bilateral, and 17% combined defects; 28.5% were recurrent hernias. Only minor complications were observed (hematomas and urinary retention) in some patients, but all resolved spontaneously. Three recurrences (0.7%) have been seen to this date. This method is recommended as the method of choice for complex groin defects.

Gallbladder rupture during laparoscopic cholecystectomy: does it have an effect on postoperative morbidity?

Gallbladder rupture during laparoscopic cholecystectomy is a common event that may lead to increased postoperative morbidity. To evaluate this event, we reviewed 300 cases of laparoscopic cholecystectomy. Duration of surgery and hospitalization, postoperative symptoms, wound infection, and late complications were analyzed by comparing two groups of patients, one without gallbladder rupture (A) and one with rupture (B). Gallbladder rupture was found in 40 cases (13.9%). Duration of surgery averaged 81 min for group A and 96.5 min for group B. Postoperative symptoms in the first 24 hours were present in approximately 10% of patients in both groups. Within the first 24 hours, 92.3% of patients in group A were discharged compared with 85% in group B. One patient (0.4%) in group A developed wound infection compared with 2 patients (5%) in group B (p = 0.05). To date, no patients have developed late abdominal complications associated with the procedure. Although this was a retrospective and uncontrolled study, gallbladder rupture during laparoscopic cholecystectomy was found to be associated with increased wound infections. No other significant effects on postoperative morbidity were detected.

Laparoscopic repair of pleural laceration produced during truncal vagotomy: case report.

A partial pneumothorax developed in a patient undergoing laparoscopic truncal vagotomy when a small pleural laceration was accidentally produced. Changes in oxygen saturation and PETCO2 were immediately detected by the anesthesiologist and measures were taken to maintain the patient's ventilatory stability. The pleural laceration was repaired laparoscopically, and the pneumothorax was corrected by ventilatory manipulation, avoiding the placement of a chest tube. The procedure was completed uneventfully. Literature about the causes of pneumothorax during laparoscopic procedures as well as preventive and therapy viewed.

Quantitation of dolastatin-10 using HPLC/electrospray ionization mass spectrometry: application in a phase I clinical trial.

A highly sensitive and specific assay for the quantitation of the anticancer agent dolastatin-10 (DOL-10) in human plasma is described. The method was based on the use of electrospray ionization-high-performance liquid chromatography/mass spectrometry (ESP-LC/MS). The analytical procedure involved extraction of plasma samples containing DOL-10 and the internal standard (DOL-15) with n-butyl chloride, which was then evaporated under nitrogen. The residue was dissolved in 50 microl mobile phase and 10 microl was subjected to ESP-LC/MS analysis using a C18 microbore column. A linear gradient using water/acetonitrile was used to keep the retention times of the analytes of interest under 5 min. The method exhibited a linear range from 0.005 to 50 ng/ml with a lower limit of quantitation (LLQ) at 0.005 ng/ml. Absolute recoveries of extracted samples in the 85-90% range were obtained. The method's accuracy (< or =5% relative error) and precision (< or =10% CV) were well within industry standards. The analytical procedure was applied to extract DOL-10 metabolites from samples obtained following incubation of the drug with an activated S9 rat liver preparation. Two metabolic products were detected and were tentatively identified as a N-demethyl-DOL-10 and hydroxy-DOL-10. Structural assignments were made based on the fragmentation patterns obtained using the electrospray source to produce collision-induced dissociation (CID). The method was also applied to the measurement of DOL-10 in the plasma of patients treated with this drug. Preliminary investigation of the pharmacokinetics suggested that drug distribution and elimination may be best described by a three-compartment model with t1/2alpha = 0.087 h, t1/2beta = 0.69 h and t1/2gamma = 8.0 h. Plasma clearance was 3.7 l/h per m2.

The efficacy of laparoscopic surgery in the diagnosis and treatment of peritonitis. Experience with 107 cases in Mexico City.

BACKGROUND: Peritonitis continues to be an important cause of morbidity and mortality and often an etiologic diagnosis is unclear. To evaluate the efficacy and safety of laparoscopy the authors analyzed their 5-year experience with this modality of treatment. METHODS: A review was made of 107 consecutive nonselected laparoscopic procedures performed between October 1990 and November 1995. The diagnosis was established by clinical, laboratory, and imaging findings and confirmed by laparoscopy and/or laparotomy. RESULTS: An etiologic diagnosis was unclear in 35% of the cases and was established in all by laparoscopy; 94 patients (87.9%) were successfully treated by laparoscopy while 13 (12.1%) required conversion. Mortality was 4.6%; 14% had postoperative complications and 7.4% had reoperations. CONCLUSIONS: Laparoscopic surgery is safe and very efficient in the diagnosis and treatment of patients with peritonitis. In most instances a definitive treatment can be carried out without conversion and has the additional and well-known advantages of minimally invasive surgery.

Use of subdiaphragmatic bupivacaine instillation to control postoperative pain after laparoscopic surgery.

Although postoperative pain has been reduced significantly since the advent of laparoscopic surgery, many patients still complain of moderate abdominal and shoulder pain during the first 48 to 72 h after surgery. In this study, the effect of subdiaphragmatic instillation of bupivacaine after laparoscopic cholecystectomy was investigated. The evaluation of postoperative pain was done according to a numerical verbal scale and the dose of analgesia required. The results showed a considerable reduction of postoperative pain during the first 48 h after surgery in patients who received bupivacaine instillation. Although the literature shows certain controversy as to the effects of similar methods, our study concludes that instillation of a long-acting anesthetic, such as bupivacaine, into the subdiaphragmatic space after laparoscopic procedures is effective in postoperative pain reduction.

In vitro and in vivo murine metabolism of spirogermanium.

We report the identification of spirogermanium (SG) metabolites derived from incubation of the drug with a mouse liver microsomal preparation as well as those obtained from the urine of mice injected with the drug. GC/MS data using electron impact and chemical ionization indicate that the major metabolic products appearing in the urine of mice are hydroxylated metabolites resulting from oxidation of the ethyl substituents on germanium. Thermospray (TSP) LC/MS data suggest that these hydroxy metabolites are further oxidized to an acid and a deethylated metabolite that has undergone hydroxylation of the germanium atom. In a separate experiment, human urine from a subject undergoing therapy with SG was subjected to TSP-LC/MS analysis. The SG metabolite pattern observed in the urine from human was similar to that observed in the mouse urine. These results suggest that the metabolic fate of SG in human is qualitatively similar to that found in the mouse.

A new quantitative thermospray LC-MS method for nicotine and its metabolites in biological fluids.

A rapid thermospray liquid chromatography-mass spectrometry (TSP LC-MS) method is described for the simultaneous determination of nicotine and 17 of its metabolites. Chemical ionization of nicotine and its metabolites separated by reversed-phase HPLC is achieved by postcolumn addition of ammonium acetate buffer with the filament of the ion source turned off. Quantification is accomplished by selectively monitoring the unique protonated molecular ion of each metabolite. Trideuterated cotinine serves as an internal standard. Linear responses for cotinine, demethylcotinine, and trans-3'-hydroxycotinine were observed over a concentration range of 20-8000 ng/mL, and 80-8000 ng/ml for nicotine and nicotine-1'-N-oxide. Of the 17 metabolites examined, only nicotine, cotinine, demethylcotinine, and trans-3'-hydroxycotinine were detected in smokers' urine.

Determination of nicarbazin in chicken tissues by liquid chromatography and confirmation of identity by thermospray liquid chromatography/mass spectrometry.

A liquid chromatographic method is described for the quantitative measurement of nicarbazin in chicken liver, fat, muscle, and skin tissues. The 4,4'-dinitrocarbanilide (DNC) portion of nicarbazin is extracted from tissues with ethyl acetate. After filtration and evaporation, the extract is purified by liquid-liquid partitioning with acetonitrile-hexane and alumina cartridge chromatography. DNC is separated and measured by reverse-phase liquid chromatography (RP-LC) with an octadecylsilyl (ODS) column and a UV detector set at 340 nm. The overall average recovery of DNC added to tissues was 83.4 +/- 3.1%. The lowest level validated in tissues by this procedure was 0.10 ppm. The limit of detection was estimated to be 0.020 ppm. This method provides a sensitive, selective, rapid, and reproducible alternative to existing purification, separation, and detection techniques, such as differential pulse polarography and colorimetry, for determination of nicarbazin in chicken tissues. Identity of DNC is confirmed by subjecting the purified extracts to thermospray-LC/mass spectrometric analysis using negative-ion detection and selected ion monitoring. Three structural-indicating ions at m/z 302, 272, and 164 are monitored in the thermospray-mass spectrum which are characteristic of the DNC molecule.

Thermospray collisionally induced dissociation with single and multiple mass analyzers.

A thermospray discharge ionization source has been used to obtain a collisionally induced dissociation (CID) spectrum of nabilone (MW 372) using a single stage quadrupole mass spectrometer. The resulting CID-mass spectrometry (MS) data show only a few structural features. Since most of the important fragments are above mass 200, it is difficult to assign structural identities to the primary daughter fragments or the nabilone molecule. Further information was obtained by using the thermospray discharge ionization source with a triple stage quadrupole mass spectrometer. Selected primary daughter ions were subjected to a second stage of CID fragmentation. Many of the resulting granddaughter ions are now in the mass range of 50-150 daltons and confident structure assignments can be made. The CID-MS-CID-MS data on nabilone showed the following features: a C9 aliphatic chain with a branch giving a C6 chain; losses of masses 58, 86, and 100 suggesting a ketonic structure that can break with up to 6 aliphatic carbons; losses of masses 60, 61, and 102 suggesting an ether or alcoholic oxygen; presence of one aromatic ring with one or two phenolic oxygens; low mass fragments of masses 55, 69, and 83 indicative of rings or unsaturation. It is audacious to suggest that the information given here is sufficient to write the full structure of nabilone. Nevertheless, the granddaughter fragment information permits a reasonable reconstruction of possible structures that could not be made with the first-order collisional fragmentation.

Method of analysis of the new cardiotonic agent, MDL 19,205, in plasma and urine and its application in a dog pharmacokinetic study.

A high-performance liquid chromatographic method has been developed for the analysis of plasma and urine concentrations of a new cardiotonic agent, MDL 19,205 (I). This procedure was utilized to study the pharmacokinetics of I in beagle dogs. The results of the dog study show that the compound is completely and rapidly absorbed. Plasma concentrations fell in a monoexponential manner with a half-life of about 1.3 h which was unaffected by dose in the range 3-30 mg/kg. Urinary excretion of unchanged I accounts for about one-half of the dose and is essentially complete in 24-48 h.

Pharmacokinetics and biotransformation studies of terfenadine in man.

Comparison of plasma level data obtained from a dose-response study to that of a 14C material balance study indicates that 99.48% of the alpha-[4-(1,1-dimethylethyl)phenyl] 4-(hydroxydiphenylmethyl)-1-piperidinebutanol (terfenadine, RMI 9918, Triludan, Teldane, resp.) related material absorbed undergoes biotransformation. From the balance study it has been determined that fecal excretion accounts for ca. 60% of the dose administered. Thin-layer chromatographic analysis of urine and feces revealed the presence of two major metabolic products. These compounds have been isolated and their structures determined by GC-MS. One of the metabolic products, a carboxylic acid analog of terfenadine has been shown to have antihistaminic activity and may play a role in the activity of the parent drug in vivo.

Pharmacokinetic linearity of desipramine hydrochloride.

The pharmacokinetic linearity of two single oral doses of desipramine hydrochloride was examined in a parallel study involving 30 subjects. Fourteen subjects received 75 mg (3 x 25 mg) of desipramine hydrochloride, and 16 subjects received 150 mg (1 x 150 mg). An open one-compartment model with a lag time to the start of absorption was used to examine the pharmacokinetic linearity. The results of the study suggest that the kinetics are linear in the dose range studied.

Identification of basic metabolites of 4-[4-(p-chlo- robenzoyl)piperidino]-4'-fluorobutyrophenone, an experimental neuroleptic agent.

Two metabolites of 4-[4-(p-(chlorobenzoyl)piperidino]-4'-fluorobutyrophenone (RMI 9901) as well as unchanged drug, have been identified in the urine of rats following oral administration of the drug. Analysis of basic urine extracts by combined gas chromatography-mass spectrometry was employed for metabolite identification. N-dealkylation appears to be a major metabolic pathway and results in formation of 4-(p-chlorobenzoyl)piperidine (I). Subsequent oxidation of this metabolite results in the formation of 4-(p-chlorobenzoyl)-2-piperidone (II), and represents rather unusual metabolic pathway for compounds of this chemical class.

3-Hydroxymethyl-s-triazolo[3,4-a]phthalazine, a novel urinary hydralazine metabolite in man.

The elucidation of the structure of a new major metabolic product of hydralazine, 3-hydroxymethyl-s-triazolo[3,4-a]-phthalazine, is described. The structures of several other previously described metabolites of the drug, phthalazone, s-triazolo[3,4-a]phthalazine, and 3-methyl-s-triazolo[3,4-a]phthalazine, are confirmed. A metabolic pathway of hydralazine is also proposed.