ABSTRACT
Amniotic fluid embolism (AFE) is a rare, but often catastrophic, complication of pregnancy and associated with severe coagulopathy. We present an algorithm-based approach in managing coagulopathy and hemorrhage in a fatal case of histopathologically proven AFE. Thrombelastometry was used for rapid evaluation of the coagulation status. Stop of extensive hyperfibrinolysis with tranexamic acid, stabilization of initial clot formation with high-dose fibrinogen and platelet transfusions, and use of prothrombin complex concentrate together with a 1: 1 transfusion regimen of red packed cells and fresh frozen plasma was successful to control diffuse bleeding and restore clot firmness after hysterectomy. Stable clotting situation was maintained despite further clinical deterioration and development of multiple organ failure in this patient.
Subject(s)
Algorithms , Case Management , Embolism, Amniotic Fluid/therapy , Acidosis/etiology , Adult , Blood Coagulation Factors/therapeutic use , Blood Component Transfusion , Cardiovascular Agents/therapeutic use , Catastrophic Illness , Combined Modality Therapy , Diagnosis, Differential , Drug Therapy, Combination , Embolism, Amniotic Fluid/blood , Embolism, Amniotic Fluid/diagnosis , Embolism, Amniotic Fluid/drug therapy , Embolism, Amniotic Fluid/surgery , Fatal Outcome , Female , Fibrinogen/therapeutic use , Humans , Hypotension/etiology , Hysterectomy , Infant, Newborn , Male , Multiple Organ Failure/etiology , Placenta, Retained/diagnosis , Postpartum Hemorrhage/drug therapy , Postpartum Hemorrhage/etiology , Postpartum Hemorrhage/surgery , Pregnancy , Sperm Injections, Intracytoplasmic , Thrombelastography , Tranexamic Acid/therapeutic useABSTRACT
OBJECTIVE: To analyze nm23-H1 protein immunohistologically in squamous cell carcinoma of the vulva. STUDY DESIGN: In 68 carcinomas, tumor type, grade, inflammation and vascular space involvement were determined. Formalin-fixed, paraffin-embedded tissue was stained for nm23-H1. Staining pattern, intensity and percentage of stained tumor cells were evaluated. Staining results were analyzed statistically univariately by the chi2 test, Kaplan-Meier survival analysis with log-rank test and receiver operator characteristic curves and multivariately by proportional hazard analysis. RESULTS: Of the tumors, 9% were negative for nm23-H1. Positive tumors showed 4 staining patterns. Tumors with inhomogeneous expression of nm23-H1 tended to have shorter disease-free and overall survival. Carcinomas with nm23-H1 staining in <50% of the tumor cells more frequently developed nonlocal tumor recurrences (p= 0.018) and showed shorter disease-free survival (p = 0.017). Tumors with high nm23-H1 expression were associated with patients younger than 60 years (p = 0.02). CONCLUSION: Immunohistologic staining for nm23-H1 protein shows different staining patterns and percentages of stained cells in squamous cell carcinoma of the vulva. Tumors with inhomogeneous and low nm23-H1 expression are associated with a worse prognosis.
