PP068. Catastrophic antiphospholipid-syndrome (CAPS) - A severe pregnancy complication.

INTRODUCTION: Antiphospholipid syndrome (APS), is an autoimmune, hypercoagulable state caused by antibodies against cell-membrane phospholipids provoking arterial and venous thromboses as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, or severe preeclampsia. The syndrome occurs due to the autoimmune production of antibodies against phospholipid (aPL), a cell membrane substance. In particular, the disease is characterised by antibodies against cardiolipin (anti-cardiolipin antibodies) and ß2 glycoprotein I. In rare cases, APS can lead to rapid organ failure due to generalised thrombosis. This life-threatening complication is termed "catastrophic antiphospholipid syndrome" (CAPS) and is associated with a high maternal mortality. OBJECTIVES: To describe the characteristics of patients who developed catastrophic APS triggered during pregnancy and to possibly identify potential risk factors for the development of this complication. METHODS: Patients charts of women with autoimmune disorders (such as APS or systemic lupus erythematodes) observed and treated at the University of Graz and The University of Jena between 2007 and 2012 were evaluated. RESULTS: Four cases of CAPS were identified. In all women CAPS occurred as a severe early onset complication (<34 weeks of gestation) and all women had to be delivered by caesarean section between 27 and 32 weeks. With an "individualized" treatment including plasmapheresis, pregnancy can be prolonged for a short period to at least achieve lung maturation by steroids. Several specific features could be found: HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome-like symptoms, eclampsia-like symptoms (headache, amaurosis), abdominal pain resistent to conventional analgesic therapy, and intrauterine growth restriction. Histologic examination after delivery revealed placental infarctions. CONCLUSION: It is important to consider the possibility of the development of catastrophic APS in those patients with signs of HELLP syndrome and multiorgan failure during pregnancy or puerperium, especially in those patients with previous history of abortions and/or thrombosis. In specialised centers prolongation of pregnancy with an individualized treatment including plasmapheresis may be an option.

Haemodynamic effects of carbetocin and oxytocin given as intravenous bolus on women undergoing caesarean delivery: a randomised trial.

OBJECTIVE: This study compares the maternal heart rate effects of carbetocin and oxytocin during elective caesarean delivery. DESIGN: Double blind randomised single centre study (1:1). SETTING: University hospital providing intrapartum care. POPULATION: Fifty-six women undergoing elective caesarean section after spinal anaesthesia. METHODS: Haemodynamic parameters were measured non-invasively using the Task Force(®) Monitor 3040i system. Measurements were taken for 500 seconds upon administration of a slow intravenous bolus of the clinically recommended doses of 100 µg of carbetocin or 5 IU of oxytocin to prevent postpartum haemorrhage (PPH). MAIN OUTCOME MEASURE: Effect on maternal heart rate (HR). RESULTS: Statistically indistinguishable haemodynamic effects were seen for both drugs, with a maximal effect at about 30-40 seconds: HR increased 17.98 ± 2.53 bpm for oxytocin and 14.20 ± 2.45 bpm for carbetocin. Systolic blood pressure (sBP) decreased (-26.80 ± 2.82 mmHg for oxytocin versus -22.98 ± 2.75 mmHg for carbetocin). Following the maximal effect, women treated with carbetocin recovered slowly to baseline values asymptotically (HR and BP), whereas women treated with oxytocin displayed a slight rebound bradycardia at 200 seconds (-6.8 ± 1.92 bpm). Patients under both treatments showed a similar profile of side effects without any indication of unexpected adverse effects. CONCLUSION: Both oxytocins have comparable haemodynamic effects and are uterotonic drugs with an acceptable safety profile for prophylactic use. Minimal differences in the recovery phase beyond 70 seconds are in keeping with the fact that carbetocin has an extended half-life compared with oxytocin.

[Preemptive randomized, double-blind study with lornoxicam in gynecological surgery]. / Lornoxicam bei gynäkologischen Eingriffen. Eine präemptive randomisierte, doppelblinde Studie.

AIM: Lornoxicam is a non opioid analgesic belonging to the oxicam group. The aim of this study was to determine whether lornoxicam has a preemptive analgesic effect. METHODS: This study was carried out in a randomized, double-blind fashion with 66 patients divided into three groups undergoing gynecological operations. Group I was administered 8 mg of lornoxicam i.v. preoperatively followed by an 8-mg bolus every 8 h for a total dose of 24 mg in the first 24 h. Group II was administered 8 mg of lornoxicam i.v. bolus before the end of the operation followed by 8 mg every 8 h for a total dose of 24 mg in the first 24 h. Group III was administered placebo before and after the operation and for the first 24 h. The effectiveness was assessed postoperatively using the visual analogue scale (at rest, on exertion) and by calculating the total analgesic consumption of morphine hydrochloride in the first 24 h following operation. Vital signs and side effects were documented. RESULTS: Groups I and II demonstrated significantly reduced pain scores compared to group III at various points in time. Group I also demonstrated a weakly significant reduction in analgesic consumption of morphine hydrochloride postoperatively compared to groups II and III. CONCLUSION: Lornoxicam administered preemptively appears to improve the quality of postoperative analgesia and lead to reduced consumption of opioid analgesics postoperatively in patients undergoing gynecological operations.

Percutaneous venoarterial extracorporeal membrane oxygenation for emergency mechanical circulatory support.

In this retrospective study we report our initial experience with percutaneous venoarterial extracorporeal membrane oxygenation in the emergency treatment of intractable cardiogenic shock or pulseless electrical activity. Between January 1994 and July 1995, percutaneous venoarterial extracorporeal membrane oxygenation was attempted in seven patients (pulseless electrical activity, five patients; cardiogenic shock, two patients). In two of the seven patients, efforts at arterial cannulation resulted in cannula perforation at the level of the iliac artery. In the remaining five patients, percutaneous venoarterial extracorporeal membrane oxygenation could be established and was maintained for 3-84 h. Major bleeding remained a common complication during extracorporeal membrane oxygenation despite the use of heparin-coated bypass circuits and was responsible for death during extracorporeal membrane oxygenation in one patient. The remaining four patients could be weaned from mechanical circulatory support within 24 h, two after surgical interventions (resection of right atrial tumor, heart transplantation), one after thrombolytic therapy. In one patient, cardiac function recovered spontaneously after 6 h on venoarterial extracorporeal membrane oxygenation. Three patients were discharged from hospital, two of them made a full recovery, one sustained severe hypoxic brain injury. A few patients with intractable cardiogenic shock or pulseless electrical activity can be resuscitated with the help of emergency percutaneous venoarterial extracorporeal membrane oxygenation. Emergency venoarterial extracorporeal membrane oxygenation is associated with a high rate of complications and its use should therefore be limited to selected patients with a rapidly correctable underlying cardiopulmonary pathology (anatomic, metabolic or hypothermic) who do not respond to conventional advanced cardiac life support.