Urinary tract infection associated with bacteremia caused by vancomycin-resistant enterococcus following continent urinary diversion.

Key Clinical Message: Even in a country where vancomycin-resistant enterococcus is rare, multidrug-resistant organism precautions are necessary when admitting patients with a history of medical exposure in other countries. On admission, screening is necessary and if infection is confirmed, a multidisciplinary approach involving different specialists is required. Abstract: The patient was a 49-year-old Japanese female living in the United States. Total pelvic exenteration for cervical carcinoma, Miami pouch formation, and ileostomy had been performed in the United States. She returned to Japan to undergo postoperative adjuvant chemotherapy. Fever and abdominal pain occurred 42 days after surgery. She consulted the fever outpatient clinic, and a diagnosis of urinary retention-associated acute renal failure and pyelonephritis was made. We detected vancomycin-resistant enterococcus on urine/blood culture 5 days after admission. Infection control measures were implemented, and the ward was closed for 3 days. We administered linezolid, which was effective for pyelonephritis and bacteremia.

Usefulness of shock indicators for determining the need for blood transfusion after massive obstetric hemorrhage.

AIM: Massive obstetric hemorrhage (MOH) requires prompt transfusion of red blood cells and coagulation factors. Because MOH has a diverse pathogenesis, the shock index (SI) alone may be insufficient for determining blood transfusion. Here, we retrospectively analyzed patients with MOH to determine usefulness of the indicators of shock including the SI in evaluating the need for blood transfusion. METHODS: We reviewed records of 80 emergency referral patients who had received blood transfusions at our department between 1 January 2009 and 31 July 2011. The shock indicators for blood transfusion are estimated blood loss, fibrinogen level, hemoglobin concentration, the Japan Society of Obstetrics and Gynecology disseminated intravascular coagulation (JSOG DIC) score and the SI. The strength of the correlation of each shock indicator with the transfusion volume was ranked using Spearman's rank correlation coefficient-ρ and multivariate analysis. RESULTS: Although the SI showed significant positive correlation with blood transfusion volume for red blood cell concentrate (RCC) and fresh frozen plasma (FFP) in patients with dilutional coagulopathy, a stronger correlation was seen with the fibrinogen level and JSOG DIC score. In patients with consumptive coagulopathy, the strongest correlation was seen between RCC transfusion volume and fibrinogen level, and between FFP transfusion volume and JSOG DIC score followed by fibrinogen level. In multivariate analysis, only fibrinogen level was significantly associated with both RCC and FFP massive transfusion. CONCLUSION: Because MOH has a diverse pathogenesis, various indicators should be evaluated. Among shock indicators, fibrinogen level was the best indicator of the need for blood transfusion following MOH.

Post-partum recovery course in patients with gestational hypertension and pre-eclampsia.

AIM: We examined the post-partum recovery course in patients with pre-eclampsia (PE) and gestational hypertension (GH) and evaluated the associated factors. METHODS: In a retrospective review of 145 patients with GH or PE who gave birth between 1 January 2008 and 30 October 2011 at our institution, there were 125 PE and 20 GH cases. Data collected included the gestational age at initial examination and delivery, delivery mode, time for normalization of blood pressure (BP), and time until resolution of proteinuria in PE patients. Comparisons were made between singleton and multiple pregnancies, onset (early, <32 weeks; late, ≥ 32 weeks) and fetal growth restriction in singleton pregnancies. RESULTS: The mean interval for normalization of BP was 41.8 ± 29.4 days (median, 31.5). The mean interval for resolution of proteinuria was 30.0 ± 39.6 days (median, 27.0). Ninety percent of patients required 77 and 60 days to recover from hypertension and proteinuria, respectively. The time for BP normalization was longer in the early-onset group. The time for resolution of proteinuria was not affected by any factor examined. CONCLUSION: A post-partum observation period of 12 weeks is acceptable for differentiating PE and GH from chronic hypertension or renal disease. GH severity did not affect the recovery period, but proteinuria severity did. Onset time was a factor influencing the recovery from PE and GH.

Placental transfer of intravenous nicardipine and disposition into breast milk during the control of hypertension in women with pre-eclampsia.

OBJECTIVE: To assess nicardipine safety for fetuses and neonates. METHODS: Nicardipine was measured in maternal plasma (MP), umbilical cord arterial (UaP) and venous (UvP) plasma and breast milk (BrM) of 18 women with severe preeclampsia. RESULTS: Nicardipine was infused for a mean 11.9 ± 10.5 days before and 4.6 ± 1.6 days after delivery. Nicardipine dose and MP concentration were linearly correlated, as were MP with UaP, UvP, and BrM concentrations. The BrM/MP ratio was 0.06 to 0.30. The mean relative infant dose was 0.082%. CONCLUSION: Nicardipine is safe for fetuses and neonates due to its low levels of placental transfer and disposition in BrM.

Recombinant tissue plasminogen activator for massive pulmonary thromboembolism.

Pulmonary thromboembolism (PTE) can result in significant adverse maternal and fetal outcomes. Monteplase-a recombinant tissue plasminogen activator-is considered effective for the treatment of PTE; however, only a few reports have described cases wherein surgical procedures were performed following treatment with monteplase. Here, we present a patient diagnosed with a massive PTE at 28 weeks of gestation leading to maternal cardiac arrest and intrauterine fetal death. The patient was treated with percutaneous cardiopulmonary support and monteplase. Thrombolysis was achieved 30 min after its administration. The patient went into spontaneous labour and delivered a stillborn vaginally. Using gauze tamponade and uterotonic agents, haemostasis was achieved after 4 h, and bleeding completely ceased after 7 h. Thus, we suggest that a thrombolytic agent can be administered in critical cases, even if delivery is expected shortly.

Neonatal outcome in infants of chronically hypertensive mothers.

AIM: We investigated the neonatal outcome in chronically hypertensive patients with controlled hypertension, uncontrollable hypertension, or superimposed pre-eclampsia. MATERIAL AND METHODS: The study included 120 patients who had chronic hypertension and were divided into three groups for which the perinatal and neonatal outcomes were retrospectively compared: pre-eclampsia superimposed on chronic hypertension (SP: n = 28), chronic hypertension with severe hypertension uncontrolled in spite of intravenous or multiple oral antihypertensive medications in the latter half of pregnancy (uCH: n = 44), and chronic hypertension with controlled to mild hypertension with or without medication (cCH: n = 48). RESULTS: Preterm birth rate incidence was significantly higher in the SP and uCH groups than in the cCH group (P < 0.05 for both). The incidence rates of low birthweight, very low birthweight, and extremely low birthweight for the groups were as follows: SP > uCH > cCH. Admission to the neonatal intensive care unit was significantly higher in the uCH and SP groups than in the cCH group (P < 0.05 for both). CONCLUSION: Like superimposed pre-eclampsia, uncontrolled chronic severe hypertension during late pregnancy results in a poorer neonatal outcome than controlled chronic mild hypertension. We conclude that absolute blood pressure can be used as a predictor of clinical outcome in pregnant chronic hypertension patients.

Pregnancy complicated by focal nodular hyperplasia: a case report of one woman over two consecutive courses of pregnancy.

KEY CLINICAL MESSAGE: We encountered a woman with a preexisting large focal nodular hyperplasia (FNH) of the liver, persisting during two separate pregnancies. FNH size was not affected by either pregnancy. Her elevated serum γ-glutamyltransferase and alkaline phosphatase levels before pregnancy were reduced during both pregnancies, but returned to prepregnancy levels after delivery.

A retrospective analysis of transfusion management for obstetric hemorrhage in a Japanese obstetric center.

Background. Since cryoprecipitate, fibrinogen concentrate, or recombinant activated factor VII is not approved by public medical insurance in Japan, we retrospectively assessed blood product usage in patients with obstetric hemorrhage at our tertiary obstetric center. Material and Methods. 220 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in our institution during a 5-year period were reviewed for the types and volumes of blood products transfused. Results. There was a significant positive correlation (P< 0.001) between the volume of RCC (red blood cell concentrate) transfused and that of FFP (fresh frozen plasma), irrespective of underlying obstetric disorders. The median of FFP to RCC ratio in each patient was 1.3-1.4, when 6 or more units of RCC were transfused. Conclusions. In transfusion for massive obstetric hemorrhage in terms of appropriate supplementation of coagulation factors, the transfusion of RCC : FFP = 1 : 1.3-1.4 may be desirable.