Conservative management of abnormally invasive placenta complicated by local hyperfibrinolysis and beginning disseminated intravascular coagulation.

INTRODUCTION: Abnormally invasive placenta (AIP) is often associated with high maternal morbidity. In surgical treatment, caesarean hysterectomy or partial uterine resection may lead to high perioperative maternal blood loss. A conservative treatment by leaving the placenta in utero after caesarean delivery of the baby is an option to preserve fertility and to reduce peripartum hysterectomy-related morbidity. Nevertheless, due to increased placental coagulation activity as well as consumption of clotting factors, a disseminated intravascular coagulation (DIC)-like state with secondary late postpartum bleeding can occur. PURPOSE: Systematic review after the presentation of a case of conservative management of placenta percreta with secondary partial uterine wall resection due to vaginal bleeding, complicated by local hyperfibrinolysis and consecutive systemic decrease in fibrinogen levels. METHODS: Systematic PubMed database search was done until August 2019 without any restriction of publication date or journal RESULTS: Among 58 publications, a total of 11 reported on DIC-like symptoms in the conservative management of AIP, in the median on day 59 postpartum. In most cases, emergency hysterectomy was performed, which led to an almost immediate normalization of coagulation status but was accompanied with high maternal blood loss. In two cases, fertility-preserving conservative management could be continued after successful medical therapy. CONCLUSION: Based on these results, we suggest routinely monitoring of the coagulation parameters next to signs of infection in the postpartum check-ups during conservative management of AIP. Postpartum tranexamic acid oral dosage should be discussed when fibrinogen levels are decreasing and D-Dimers are increasing.

Measurement of fetal head descent using the 'angle of progression' on transperineal ultrasound imaging is reliable regardless of fetal head station or ultrasound expertise.

OBJECTIVES: To assess whether ultrasound experience or fetal head station affects the reliability of measurement of fetal head descent using the angle of progression on intrapartum ultrasound images obtained by a single experienced operator, and to determine reliability of measurements when images were acquired by different operators with variable ultrasound experience. METHODS: One experienced obstetrician performed 44 transperineal ultrasound examinations of women at term and in prolonged second stage of labor with the fetus in the occipitoanterior position. Three midwives without ultrasound experience, three obstetricians with < 5 years' experience and three obstetricians with > 10 years' experience measured fetal head descent based on the angle of progression in the images obtained. The angle of progression was measured by two obstetricians in independent ultrasound examinations of 24 laboring women at term with the fetus in the cephalic position to allow assessment of the reliability of image acquisition. Intraclass correlation coefficients (ICCs) with 95% confidence interval (CI) were used to evaluate interobserver reliability and Bland-Altman analysis was used to assess interobserver agreement. RESULTS: In total, 444 measurements were performed and compared. Interobserver reliability with respect to offline image analysis was substantial (overall ICC, 0.72; 95% CI, 0.63-0.81). ICCs were 0.82 (95% CI, 0.70-0.89), 0.81 (95% CI, 0.71-0.88) and 0.61 (95% CI, 0.43-074) for observers with > 10 years', < 5 years' and no ultrasound experience, respectively. There were no significant differences between ICCs among observer groups according to ultrasound experience. Fetal head station did not affect reliability. Bland-Altman analysis indicated reasonable agreement between measurements obtained by two different operators with > 10 years' and < 5 years' ultrasound experience (bias, -1.09 degrees ; 95% limits of agreement, -8.76 to 6.58). The reliability of measurement of the angle of progression following separate image acquisition by two experienced operators was similar to the reliability of offline image analysis (ICC, 0.86; 95% CI, 0.70-0.93). CONCLUSIONS: Measurement of the angle of progression on transperineal ultrasound imaging is reliable regardless of fetal head station or the clinician's level of ultrasound experience.

[Effectiveness and safety of atosiban vs. pulsatile administration of fenoterol in the treatment of preterm labour]. / Wirksamkeit und Sicherheit von Atosiban vs. pulsatiler Applikation von Fenoterol bei der Behandlung vorzeitiger Wehen.

BACKGROUND: The aim of this study was to compare the efficacy and side effects of atosiban with those of fenoterol (pulsatile administration) for acute tocolysis. METHODS: A prospective, open-label, randomised controlled trial was performed. Patients in preterm labour at 24+0 to 33+6 weeks of gestation were randomised to receive atosiban (A) or fenoterol (F) pulsatile administration. Primary outcome was the arrest of preterm labour. RESULTS: The proportion of woman remaining undelivered at 48 hours (86.3% atosiban group and 79.6% fenoterol group) and at 7 days (78.4% vs. 66.7%) was comparable. The incidence of maternal cardiovascular side effects was lower in the atosiban group (4% vs. 78%, p=0.0). Tocolysis was terminated as a result of maternal adverse effects in the fenoterol group (9%). Fetal tachycardia was lower in the atosiban group (2% vs. 22%). The mean duration of tocolytic administration was lower in the atosiban group (19 h vs. 24.5 h, p<0.05). DISCUSSION: The adverse effects in the pulsatile administration of fenoterol for short duration were only dependent on the initial dosage for the arrest of preterm labour. Neonatal outcome were similar between the treatment groups and were rather related to the gestational age not to the tocolytic agent. CONCLUSIONS: Atosiban was comparable in clinical effectiveness and was associated with fewer maternal and fetal adverse effects, so that fenoterol cannot be recommended. Completion of tocolytic therapy 12 hours after arrest of preterm labour is effective and associated with a short mean duration.

Further evaluation of transurethral laser ablation of the prostate in patients treated with anticoagulant therapy.

Transurethral Nd:YAG laser ablation of the prostate gland was used to treat benign prostatic hyperplasia (BPH) in 20 patients on Warfarin anticoagulant therapy, and in two patients with abnormal coagulation parameters secondary to haematologic disorders. Preliminary results for the first 10 of these patients has been reported previously. The mean pre-operative international normalized ratio (INR) was 2.6 (range 1.19 to 5.25) and the mean prostate volume was 56 cc (13.6-112 cc). All patients had significant subjective and objective indicators of prostatic obstruction and six patients were in urinary retention. Postoperative improvement in symptom score, maximum flow rate and post-void residual was noted in 82% of patients at 3 months, 89% at 6 months and 75% at 1 year. Two patients have required revision laser or transurethral resection of the prostate (TURP) for persistent obstruction, while one patient required revision TURP for intractable haematuria. Three patients developed haematuria requiring transfusion while four patients had mild haematuria requiring no intervention. Laser ablation of the prostate can be used successfully and safely to treat prostatic obstruction in patients with abnormal coagulation parameters, or in those who are fully anticoagulated. Anticoagulation can be maintained during surgery in this group unlike TURP where pre-operative reversal is necessary with reinstitution of therapy several days postoperatively. Other authors report at least a 50% blood transfusion rate in this group. Laser prostatectomy appears the more appealing surgical option in these patients.

On-orbit performance of the Hubble Space Telescope optical control system.

On-orbit data are used to examine the performance of the Hubble Space Telescope optical control system. The precision, relative accuracy, and absolute accuracy of the off-axis Wavefront-Sensor measurements are evaluated and compared with design requirements. The internal stability of the sensors is better than 0.006 microm rms over five years, including launch. Random errors are estimated to be within 0.01 microm rms. Systematic errors are present in the estimates of focus, spherical, and coma aberrations, but none has been identified for astigmatism. Primary-mirror spherical aberration is believed to be the probable cause of all subspecification performances.

Hubble Space Telescope fine-guidance-sensor transfer function and its impact on telescope alignment and guidance.

We describe the use of Hubble Space Telescope Fine Guidance Sensor transfer scans to characterize telescope alignment. To accomplish this we developed a software system to extract the aberration content from the observed transfer scans. The transfer scans show large aberration levels that do not originate in the telescope. The appearance of significant coma in the transfer scans has been identified as resulting from the shearing of spherical aberration caused by a beam misalignment within the Fine Guidance Sensors themselves.

Regioselective O-demethylation of scoparone: differentiation between rat liver cytochrome P-450 isozymes.

The ratios of the scoparone O-demethylation products scopoletin to isoscopoletin were determined for reconstituted complexes of NADPH-P-450 reductase and each of four P-450 isozymes in a 2:1 molar ratio with a 1:1 mixture of [7-O-methyl-14C]- and [6-O-methyl-14C]-scoparone as substrate. The two phenobarbital inducible forms P-450PB-B and P-450PB-D have a 1:0.8 +/- 0.05 scopoletin to isoscopoletin ratio, and the two beta-naphthoflavone inducible forms P-450 beta NF-B and P-450 beta NF/ISF-G have ratios of 1:4.4 +/- 0.1 and 1:3.8 +/- 0.1, respectively. The scoparone-O-demethylation activities of the reconstituted preformed complexes of the four P-450 isozymes are given.

[Eye changes following bone marrow transplantation]. / Augenveränderungen nach Knochenmark-Transplantation.

Blood diseases such as acute leukemia can now be cured by bone marrow transplants. Complications such as a chronic host-versus-graft reaction lead to typical conjunctival changes, as described for Sjögren's syndrome and ocular pemphigoid. A patient with typical eye complications is described and the probable immunological course discussed.