Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries.

Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient's median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Septic miscarriage with toxic shock syndrome and disseminated intravascular coagulation (DIC): The role of surgery, recombinant activated factor VII and intravenous immunoglobulin (IVIG).

Severe sepsis with multi-organ failure is associated with a high mortality rate. This case report highlights the challenges and modalities available in the management of a lady with refractory shock and disseminated intravascular coagulation (DIC) due to toxic shock syndrome (TSS) from genital tract sepsis. Early surgical intervention to remove the source of infection, the use of recombinant activated factor VII to treat intractable disseminated intravascular coagulation and intravenous immunoglobulin to neutralise the circulating exotoxins, have been employed and shown to drastically improve outcomes.

Incidence and determinants of severe maternal morbidity: a transversal study in a referral hospital in Teresina, Piaui, Brazil.

BACKGROUND: Maternal near miss (MNM) investigation is a useful tool for monitoring standards for obstetric care. This study evaluated the prevalence and the determinants of severe maternal morbidity (SMM) and MNM in a tertiary referral hospital in Teresina, Piauí, Brazil. METHODS: A transversal and prospective study was conducted between September 2012 and February 2013. The cases were included according to criteria established by the WHO. Odds ratio, their respective confidence intervals, and multivariate analyses were examined. RESULTS: Five thousand eight hundred forty one live births, 343 women with SMM, 56 cases of MNM, and 10 maternal deaths were investigated. The rate for severe maternal outcomes was 11.2 cases per 1000 live births, the rate of MNM was 9.6 cases/1000 live births, and the rate for mortality was 171.2 cases/100,000 live births. Management criteria were most frequently observed among MNM/death cases. Hypertensive diseases (86.1%) and hemorrhagic complications (10.0%) were the main determinants of MNM, but infectious abortion was the most common isolated cause of maternal death. There was a correlation between MNM/death and hospitalized more than 5 days (p = 0.023) and between termination of pregnancy by cesarean (p = 0.002) and APGAR < 7 in the 1(st) minute (p = 0.015). CONCLUSIONS: SMM and MNM were quite prevalent in the population studied. Women whose condition progressed to MNM/death had a higher association with terminating pregnancy by cesarean, longer hospitalization times, and worse perinatal results. The results from the study can be useful to improve the quality of obstetric care and consequently diminish maternal mortality in the region.

Septic abortion with placenta accreta in pregnancy after endometrial ablation.

BACKGROUND: Pregnancy after endometrial ablation is a rare event, occurring in approximately 0.7% of cases. When it occurs, serious complications may be anticipated for both mother and fetus, including abnormal placentation. Termination of pregnancy in these cases is a challenging issue, made more so by the lack of availability of these services. CASE: We report a case of pregnancy after endometrial ablation complicated by placenta accreta. Initiation of a second-trimester termination procedure with lethal fetal injection resulted in subsequent septic abortion necessitating abdominal hysterectomy. CONCLUSION: Pregnancy after endometrial ablation is a rare and potentially morbid event. Patients should be counseled about the necessity of contraception at the time of endometrial ablation. Termination should be approached with caution and requires the availability of skilled providers.

Insights into potential pathogenesis mechanisms associated with Campylobacter jejuni-induced abortion in ewes.

BACKGROUND: Campylobacter jejuni is commonly found in the gastrointestinal tract of many food-animals including sheep without causing visible clinical symptoms of disease. However, C. jejuni has been implicated in ovine abortion cases worldwide. Specifically, in the USA, the C. jejuni sheep abortion (SA) clone has been increasingly associated with sheep abortion. In vivo studies in sheep (the natural host) are needed to better characterize the virulence potential and pathogenesis of this clone. RESULTS: Pregnant ewes intravenously (IV) or orally inoculated with ovine or bovine abortion-associated C. jejuni SA clones exhibited partial or complete uterine prolapse with retained placenta, and abortion or stillbirth, whereas delivery of healthy lambs occurred in pregnant ewes inoculated with C. jejuni 81-176 or in the uninfected group. In sheep inoculated with the SA clone, histopathological lesions including suppurative necrotizing placentitis and/or endometritis coincided with: 1) increased apoptotic death of trophoblasts, 2) increased expression of the host genes (e.g. genes encoding interleukin IL-6 and IL-15) related to cellular necrosis and pro-inflammatory responses in uterus, and 3) decreased expression of the genes encoding GATA binding protein 6, chordin, and insulin-like 3 (INSL3) that account for embryonic development in uterus. Immunohistochemistry revealed localization of bacterial antigens in trophoblasts lining the chorioallantoic membrane of ewes inoculated with the C. jejuni SA clone. CONCLUSIONS: The results showed that C. jejuni SA clones are capable of causing abortion or stillbirth in experimentally infected sheep. Furthermore, down- or up-regulation of specific genes in the uterus of infected pregnant ewes might implicate host genes in facilitating the disease progression. Since the C. jejuni SA strains share genotypic similarities with clones that have been isolated from human clinical cases of gastroenteritis, these strains might represent a potential public health risk.

Bubaline herpesvirus 1 associated with abortion in a Mediterranean water buffalo.

During routine analysis of water buffalo foetuses, one sample was positive for herpesvirus and negative to all the other abortive agents investigated. Sequencing of the herpesvirus glycoprotein E gene identified the virus as bubaline herpesvirus 1, showing few differences with the published sequences. This represents the first finding of bubaline herpesvirus in a water buffalo foetus associated with abortion.

Acute kidney injury requiring hemodialysis in the tropics.

The morbidity and mortality from acute kidney injury (AKI) have remained relatively high over the last six decades. The triad of infections, nephrotoxins and obstetric complications are still major causes of acute kidney injury in the tropics. This retrospective study is a five-year audit of acute renal failure (ARF) (or stage 3 AKI) in patients requiring hemodialysis at the renal unit of the Department of Medicine of the Ladoke Akintola University of Technology (LAUTECH) Teaching Hospital, Osogbo, Nigeria. A total of 80 patients with AKI were treated over a five-year period at our center, of which 45 (56.2%) were in ARF, i.e. stage 3 AKI requiring hemodialysis. There were 24 males and 21 females. The most common cause of ARF among the patients was sepsis syndrome 16 (35.5%), while pregnancy-related cases accounted for 15 (33.3%) and nephrotoxins for 6 (13.3%). Five (33%) of the 15 pregnancy-related patients survived, and all were cases of septic abortion. Of the other 10 patients that did not survive, three (30%) had post-partum hemorrhage and seven (70%) post-partum eclampsia. In all, the mortality rate among our AKI presenting for hemodialysis at our center over a given year period was 28.8%. Majority of these were eclampsia related. The causes of ARF still remain the same in the tropics, eclampsia portends poor prognosis. Concerted efforts should be made at limiting this trend by active preventive services and early recognition of high-risk obstetrics cases.

Clostridium septicum infection in a young pregnant patient.

This report describes a young pregnant woman who presented to a rural emergency department with vaginal bleeding at 7 weeks of gestation. Initially, the patient was stable; however, within 8 h the patient deteriorated into fulminant septic shock. She required aggressive resuscitation and surgical management of a septic abortion. The patient's condition improved rapidly following surgical evacuation of the uterus with dilatation and curettage. She has had no long-term sequelae. Blood and tissue cultures returned positive for Clostridium septicum. To the best of our knowledge, this is the only reported case of survival from C septicum infection in a pregnant woman and highlights the importance of improved awareness and management of such infections by the medical community so that future cases can achieve similarly successful outcomes.

Expression of toll-like receptors 2 and 4 in subplacental trophoblasts from guinea pigs (Cavia porcellus) following infection with Campylobacter jejuni.

Toll-like receptors 2 and 4 (TLR2 and TLR4) are well-characterized cell surface receptors that recognize specific pathogen-associated molecular patterns and play an important role in pathogen recognition and activation of the innate immune system. Variable expression of TLR2 and TLR4 has been described in trophoblasts from normal and diseased placentas; yet, there are limited data regarding trophoblast TLR expression in response to specific placental pathogens, and TLR expression in the guinea pig placenta has not been described. The guinea pig is an effective model for Campylobacter-induced abortion of small ruminants, and the authors have shown by immunohistochemistry that C jejuni localizes within syncytiotrophoblasts of the guinea pig subplacenta. The present study was designed to determine if the expression of either TLR2 or TLR4 would be affected in subplacental trophoblasts following infection with C jejuni. Immunohistochemistry for TLR2 and TLR4 was performed on placenta from guinea pigs that aborted following inoculation with C jejuni and from sham-inoculated controls. Quantitative assessment of TLR expression was performed, and mean immunoreactivity for TLR2 was significantly higher in subplacental trophoblasts from animals that aborted compared with uninfected controls (P = .0283), whereas TLR4 expression was not statistically different (P = .5909). These results suggest that abortion in guinea pigs following infection with C jejuni is associated with increased TLR2 expression in subplacental trophoblasts and may reveal a possible role for TLR2 in the pathogenesis of Campylobacter-induced abortion.

[Ovarian vein thrombosis. Risk factors, diagnosis and treatment]. / Trombosis de la vena ovárica. Factores de riesgo, diagnóstico y tratamiento.

Ovarian vein thrombosis is an uncommon complication (0.002-0.05%) related to hypercoagulated status of women. The most frequent condition associated to ovarian vein thrombosis is pregnancy, but there are other possible causes. We present a case of a 31 year old pregnant woman at 16th week of gestation who had spontaneuos septic abortion complicated with an ovarian vein thrombosis. A discussion of risk factors, diagnostic and treatment options of ovarian vein thrombosis are presented.

Trombosis de la vena ovárica: Factores de riesgo, diagnóstico y tratamiento / Ovarian vein thrombosis: risk factors, diagnosis and treatment

La trombosis de la vena ovárica es una complicación muy poco frecuente (0.002-0.05%), que se observa en mujeres que presentan un incremento en los factores de coagulación. La principal situación en la que es posible detectar esta complicación es el embarazo, aunque no es la única. Se describe el caso de una mujer de 31 años de edad, gestante de 16 semanas, que presenta un aborto espontáneo séptico complicado con una trombosis de la vena ovárica. Se aprovecha el caso clínico para revisar en la literatura los factores de riesgo, el diagnóstico y el tratamiento de esta inusual patología.

Ovarian vein thrombosis is an uncommon complication (0.002-0.05%) related to hypercoagulated status of women. The most frequent condition associated to ovarian vein thrombosis is pregnancy, but there are other possible causes. We present a case of a 31 year old pregnant woman at 16th week of gestation who had spontaneuos septic abortion complicated with an ovarian vein thrombosis. A discussion of risk factors, diagnostic and treatment options of ovarian vein thrombosis are presented.

[Abortion due to non-capsulated Haemophilus influenzae]. / Abort på grund af nonkapsulaer Haemophilus influenzae.

The case reported involves a 31-year-old gravida III para II at 20 + 2 weeks estimated gestational age. The patient presented with fever, malaise and a shortened cervix uteri. Cultures from blood and cervix uteri grew non-typeable Haemophilus influenzae and intravenous cefuroxim 1,5 g x 3 was initiated. Later the same day the patient spontaneously aborted a dead foetus. We discuss the case, the laboratory requirements for detection of H. influenzae and the importance of paying attention to febrilia in pregnancy.

Prevalence of induced abortion and associated complications in women attending hospitals in Isfahan.

A high proportion of maternal deaths are caused by abortion, especially induced abortion. This cross-sectional study determined the prevalence of illegally-induced abortion prior to admittance and its associated risk factors in 8 maternity hospitals in Isfahan, Islamic Republic of Iran, during 2003-04. In confidential interviews with 417 women who attended the hospitals with abortion, 50 (12.0%) reported that it was illegally induced. These abortions had a significant correlation with fever, septic shock and septic abortion. Of all pregnancies, 35.0% were unwanted, and 27.1% of these were illegally-terminated by induced abortions. Unwanted pregnancy was one of the most important risk factors for induced abortion (OR = 8.84, 95% CI: 4.36-17.92).

Maternal morbidity following routine second trimester genetic amniocentesis.

Two cases of septic complications of routine second trimester amniocentesis are presented. The first case is a 37-year-old gravida suffering from ulcerative colitis who was admitted for amniocentesis in the 18th week of her third pregnancy. An uncomplicated transabdominal amniocentesis was performed using a sterile technique and ultrasound guidance. Twenty-eight hours later the patient had a septic abortion and sepsis. The second case is a 34-year-old gravida in the 24th week of her pregnancy who was admitted with amnionitis 10 h after an uncomplicated amniocentesis, and subsequently had a septic abortion. A high index of suspicion and rapid intervention were crucial in both cases.

Septic abortion: a review of social and demographic characteristics.

Septic abortion is a significant health problem with short- and long-term complications that affect the quality of life of those fortunate enough to avoid mortality. Both spontaneous and induced abortion can result in septic complications, with the latter disproportionately higher. Its incidence is high in environments with restrictive abortion laws, as clandestine procedures by non-doctors in unhygienic settings are prevalent. This study shows that it is still more common among teenagers and mainly performed by health professionals, which means that health care interventions should be re-evaluated and appropriately directed to preserve the reproductive health status of this vulnerable population.

Factors influencing post abortion outcomes among high-risk patients in Zimbabwe.

Post abortion complications remain one of the major causes of mortality among women of child bearing age in Zimbabwe. Based on this problem, factors associated with mortalities due to abortion were investigated with the aim of improving post abortion outcomes for Zimbabwe's women, and possibly also for women of other African countries. Cases and controls were selected from 4895 post abortion records to conduct a retrospective case-control study. Significant risk factors identified for reducing mortalities due to post abortion complications included the administration of oxytocic drugs and evacuation of the uterus whilst anaemia and sepsis apparently reduced these women's chances of survival. Women who died (cases) from post abortion complications apparently received better reported quantitative care than controls. Recommendations based on this research report include improved education of health care workers and enhanced in-service training, regular audits of patients' records and changed policies for managing these conditions more effectively in Zimbabwe.

A review of septic induced abortion cases in one year at Khyber Teaching Hospital, Peshawar.

BACKGROUND: Working in a tertiary level hospital we get complicated cases as a result of termination or attempts at termination of unwanted pregnancies. Most of the patients that we get are complicated and need expensive treatments including surgery. This study was conducted to assess the out come of septic induced abortion cases in a year. METHODS: It was conducted at the Department of Obstetrics and Gynaecology, unit B, Khyber Teaching Hospital, Peshawar, from 1.7.01 to 30.6.02. The data of a total of 28 patients admitted as emergency cases with septic induced abortion in above period were collected. History, management given, post operative care, complications and associated morbidity and mortality were taken into account and result compiled. RESULTS: 78.5% patients with unsafe abortions were multi gravida. Termination was attempted at home or other small centers. 57%, had history of surgical interference, 28.5% had used a mechanical device. 78.5% patients needed evacuation and curettage, 42% had laparotomy for visceral injuries. 15% patients had a subtotal hysterectomy. 57% patients had associated complications. 7.5% patients who came with septicemic shock died. CONCLUSION: Septic induced abortion is an important contributor to maternal morbidity and mortality, increasing the burden on not only the patients but health workers and their resources. However, it is preventable, and we suggest commitment to health education, family planning promotion and bringing down the rates of unsafe abortions as solutions to the problems.

Viable intrauterine pregnancy with acute salpingitis progressing to septic abortion. A case report.

BACKGROUND: A viable intrauterine pregnancy with salpingitis has been reported rarely. CASE: A 27-year-old woman at 10 weeks' gestation developed abdominal pain, fever, leukocytosis, peritoneal signs, closed cervix and a viable pregnancy. Progression from acute salpingitis to septic abortion was documented. CONCLUSION: Acute salpingitis in the presence of a viable pregnancy warrants aggressive intervention.