The effect of assisted reproductive technology on postpartum bleeding: hormonal cycle frozen embryo transfer might increase blood loss.

BACKGROUND: Among assisted reproductive technologies, frozen thawed embryo transfer (FET) is associated with increased blood loss at delivery. Anesthesiologists need to be aware of new factors that affect postpartum blood loss. This study investigated whether FET cycles with or without hormonal support affect the amount of postpartum bleeding. METHODS: We conducted a retrospective cohort study of patients admitted for delivery at a single university hospital between January 2015 and December 2018. Patients were divided into no-assisted reproductive technology (No-ART), hormonal cycle FET (HC-FET) and natural cycle FET (NC-FET) group. The primary outcome was the amount of blood loss after delivery (median [interquartile range]), which was compared among the three groups. Multiple regression analysis was performed to investigate the factors affecting blood loss. RESULTS: Between 2015 and 2018, 3187 women delivered neonates. In vaginal delivery, postpartum blood loss in the HC-FET group (1060 [830] g) was significantly greater than in the NC-FET group (650 [485] g, P = 0.001) and in the No-ART group (590 [420] g P < 0.001). Multiple linear regression analysis showed that HC-FET (P < 0.001) was one of the independent factors for the amount of bleeding. In cesarean delivery, the HC-FET group had more blood loss than the No-ART group (910 [676] g vs. 784 [524] g, P = 0.039). However, HC-FET was not an independent factor for postpartum blood loss. CONCLUSIONS: The HC-FET group had more blood loss than the No-ART group for both vaginal and cesarean deliveries. Furthermore, HC-FET was an independent factor that increased postpartum blood loss in vaginal deliveries.

[Post-brain angiographic asymptomatic pulmonary embolism diagnosed before general anesthesia].

A 58-year-old man was scheduled for resection of a brain tumor. He had undergone brain angiography two days before the operation. His right femoral artery punctured for the insertion of a catheter, had been compressed with a sponge for six hours after the brain angiography. He had gone without food for 13 hours and drink for 11 hours before entering the operating room. He was given 2.5 mg of midazolam im as premedication. Though we found his SpO2 value decreased to 88-90%, he did not complain of any clinical symptoms. Arterial blood gas (ABG) analysis showed PaO2 of 60 mmHg with room air. We asked him to take deep breaths for five minutes, but his ABG analysis continued to show hypoxia. Therefore, his scheduled operation was canceled in order to investigate the cause of hypoxia. As chest enhanced computed tomography revealed thrombosis of 3 cm in length in the A 3 artery of his right lung, we diagnosed pulmonary embolism and treated it with continuous intravenous injection of heparin. Pulmonary thromboembolism in this case might have been due to femoral vein compression, vein congestion during extended periods of bed rest after the brain angiography, deep leg vein thrombosis produced by femoral artery injury, and dehydration before the operation. Care has to be taken for the onset of pulmonary embolism after angiography through the femoral artery. Measurement of SpO2 is useful for the early diagnosis of asymptomatic pulmonary embolism.

[Tension pneumothorax associated with re-intubation through percutaneous tracheostoma site].

Percutaneous tracheostomy (PT) has become popular recently, but occasionally cannula exchange can be difficult and hazardous. A 55-year-old woman with pontine hemorrhage was admitted to our ICU after oral intubation. On the 3 rd day, PT was performed with no complication to prepare for prolonged airway management. On the 14 th day, surgical removal of the pontine hematoma was scheduled. Since our neurosurgeon requested a prone position with maximal neck anteflexion, she was re-intubated orally and the tracheostomy cannula was removed during the operation. At the end of the operation, the tracheostoma had already been narrowed and re-insertion of a narrower tracheostomy cannula was unsuccessful even with bronchoscopic guidance. Following several attempts, her Spo2 gradually decreased and her blood pressure dropped. A chest X-ray showed right pneumothorax and a chest drainage tube was inserted. Posterior tracheal wall injury was suspected, though the exact injury site was not identified bronchoscopically. She was treated conservatively because no air leak was observed after advancing the oral tube. Three weeks later, surgical tracheostomy was performed without major abnormal findings. A small tracheostoma characteristic of PT might be associated with an increased risk of delayed airway complication. Cannula exchange should be performed more carefully after PT compared with surgical tracheostomy.