Sofiene Ben Marzouk

Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting

OBJECTIVES To study the safety and effectiveness of pelvic packing in the control of post emergency peripartum hysterectomy (EPH) bleeding in a postpartum hemorrhage (PPH) setting. STUDY DESIGN From 39 patients with a severe PPH leading to an EPH (January 2010-December 2013), we identified a group of 17 patients requiring a pelvic packing (packing group) and a second group of 22 patients not requiring a pelvic packing (non-packing group). For each group, transfusion requirements were recorded from time of PPH diagnosis to end of the surgical procedure (P1: Period 1) and from that point to the end management in the SICU (P2: Period 2). Laboratory values, transfusion requirements and complications were compared between the 2 groups. Statistical comparisons were performed using Mann-Whitney test, Fishers exact test and chi-square test. A p-value <0.05 was considered statistically significant. RESULTS Pelvic packing was successful in the control of bleeding in all the cases. During the second laparotomy for pack removal, none of the patients developed complications such as bowel injuries or necrosis. The 2 groups were similar in term of laboratory values at the end of the surgical procedure and 24h after the end of the surgical procedure. The number of PRBC units required in P1 was higher in the packing group compared to the non-packing group (16.6±5.3 vs 14±5; p=0.04), however the decrease in the amount of PRBCs transfused between P1 and P2 was higher in the packing group (13.3) compared to the non-packing group (9.1) (p<0.01). The incidence of febrile morbidity was higher in the packing group compared to the non-packing group (53% vs 9%; p=0.04); but no significant difference was shown in term of generalized sepsis, as well as renal failure, ARDS, deep vein thrombosis, pulmonary embolism and MOF. CONCLUSION The pelvic packing is a valuable method with a high success rate in the control of hemorrhage after an EPH in PPH setting with a low rate of complications. It is quite simple and quick to perform, and therefore should be kept in mind by all obstetricians as a lifesaving technique.

Are the Wells Score and the Revised Geneva Score valuable for the diagnosis of pulmonary embolism in pregnancy

OBJECTIVES To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. STUDY DESIGN All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54-0.79) and Revised Geneva Scores (0.64, 95% CI 0.52-0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. CONCLUSION(S) The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.

Spontaneous subserosal venous rupture overlying a uterine leiomyoma in a young woman

Uterine leiomyomas are very common tumors found in women. Rupture of veins on the surface of uterine leiomyoma is an unusual source of hemoperitoneum. It is an extremely uncommon gynaecological cause of hemoperitoneum. It is a life threatening emergency. We report a case of massive intraperitoneal hemorrhage due to rupture of vessels on the surface of subserous leiomyoma. A differential diagnosis of rupture of leiomyoma’ssurface vessel should be considered, while dealing with a case of hemoperitoneum with pelvic mass.

Evaluation of the simplified acute physiology score (SAPS-OB) in critically ill obstetric patients

Different predictive scoring systems have been developed to assist physicians in decision making by estimating the mortality rate and the illnesses severity and identify the patients which require ...

Ultrasound-guided bilateral transversus abdominis plane block versus spinal morphine for pain relief after caesarean section

Background: Ultrasound-guided transversus abdominis plane block is an effective method for pain relief after cesarean delivery. The gold standard to treat pain after cesarean delivery is spinal morphine administration; at the same time TAP is considered as an effective method to treat this pain. In this study, we compared efficiency and side effects of these techniques in patients undergoing elective cesarean delivery. Methods: 104 women undergoing elective cesarean delivery under spinal anesthesia were randomized to receive either TAP block with Bupivacaïne 0.25% (BUPICAÏNE, UNIMED, TUNISIA) or spinal morphine. All patients received a standard postoperative analgesia with Paracetamol intravenously. Rescue analgesia using Nefopam and morphine intravenously was given when necessary. Patients were assessed at 2, 4, 6, 12 and 24 hours after cesarean delivery. Visual analog scale (VAS) pain scores at rest and during the palpation of the uterine globe were recorded. Analgesic consumption, time to first analgesic request, heart rate, systolic and diastolic blood pressure were noted. Patients rated the severity of opoid side effects and their satisfaction with the protocol of analgesia. Results: Pain scores at rest and during the palpation of the uterine globe during the first 24 postoperative hours were similar in both groups. The number of patients who received additional analgesia was similar in both groups. The intestinal transit recovery was earlier in the TAP block group with a statistically significant difference (p < 10-3). Maternal satisfaction was similar in both groups. Conclusion: TAP block and intrathecal morphine were of similar efficiency for pain relief after cesarean section. The incidence of side effects was comparable in both groups. Correspondence to: Sofiene Ben Marzouk, Anesthesiologist, University Hospital Assistant, Center Of Maternity And Neonatology , La Rabta, Tunis, Tunisia, Tel: 0021699941968; E-mail: bmarzouksofiene@live.fr