Clinical case of thrombotic microangiopathy in obstetric practice.

Author(s):  
В.В. Черепанова ◽  
П.С. Зубеев ◽  
А.В. Баландина ◽  
К.В. Мокров ◽  
С.В. Одинцова ◽  
...  

Тромботическая микроангиопатия (ТМА) – клинико-морфологический синдром, в основе которого лежит повреждение эндотелия сосудов микроциркуляторного русла, вызванное разными причинами, но проявляющееся сходной клинической симптоматикой и гистологическими признаками. Одним из важнейших триггеров возникновения ТМА является беременность. Во время беременности возможно развитие вторичной ТМА – при тяжелой преэклампсии и HELLP-синдроме или после тяжелой кровопотери, осложнившейся синдромом диссеминированного внутрисосудистого свертывания крови (ДВС-синдромом). Первый клинический пример иллюстрирует роль в индукции атипичного гемолитико-уремического синдрома (аГУС) многочисленных акушерских осложнений и ДВС-синдрома, возникшего в результате своевременно некомпенсированной кровопотери. Их можно рассматривать как дополнительные комплемент-активирующие состояния. Представленное наблюдение иллюстрирует классическое течение вторичного аГУС с характерными признаками ТМА. Прекращение трансфузий свежезамороженной плазмы (СЗП) и начало таргетной комплемент-блокирующей терапии (экулизумаб) привело к значительному улучшению состояния и обратному развитию ТМА. Во втором наблюдении клинико-лабораторные признаки указывали на наличие вторичной ТМА, вызванной преэклампсией, HELLP-синдромом при отсутствии острого повреждения почек. Назначенная базовая терапия преэклампсии, а также введение СЗП и антикоагулянта позволили прервать внутрисосудистый гемолиз. Thrombotic microangiopathy (TMA) is a clinical morphological syndrome developing as a result of microvascular endothelium damage caused by various reasons but manifesting similar clinical symptoms and histological signs. Pregnancy is one of the most critical TMA triggers. Pregnancy may be accompanied with secondary TMA development in case of severe preeclampsia and HELLP-syndrome or after massive blood loss complicated with disseminated intravascular coagulation (DIC). The first clinical case demonstrates the role of multiple obstetric complications and DIC emerged as a result of failure to timely compensate blood loss in atypical haemolytic-uremic syndrome (aHUS) induction. They may be viewed as additional complement-activating conditions. The described observation illustrates classic progress of secondary aHUS with typical TMA signs. Stopping of fresh frozen plasma (FFP) transfusions and beginning of a target complement blocking therapy (eculizumab) led to significant improvement of condition and TMA involution. In the second observation clinical laboratory signs indicated secondary TMA caused by preeclampsia and HELLP-syndrome without acute renal injury. Prescribed basic therapy of preeclampsia, as well as administration of FFP and anticoagulant, allowed to interrupt intravascular hemolysis.

Author(s):  
Anne Craig ◽  
Anthea Hatfield

Part one of this chapter tells you about the physiology of blood and oxygen supply, about anaemia and tissue hypoxia, and the physiology of coagulation. Drugs that interfere with clotting are discussed. Bleeding, coagulation, and platelet disorders are covered as well as disseminated intravascular coagulation. Part two is concerned with bleeding in the recovery room: how to cope with rapid blood loss, managing ongoing blood loss, and how to use clotting profiles to guide treatment. There is also a section covering blood transfusion, blood groups and typing. Massive blood transfusion is clearly described, there are guidelines about when to use fresh frozen plasma, when to use platelets, and when to use cryoprecipitate. The final section of the chapter is about problems with blood transfusions.


2021 ◽  
Author(s):  
João Vitor Ribeiro dos Santos ◽  
Mariana Spitz ◽  
Ana Carolina Andorinho

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a hematological disease resulting from the ADAMTS 13 plasmatic protein deficit. It can be congenital or sporadic, and is usually autoimmune. Pathological platelet adhesion occurs, leading to microthrombi in capillary and arterial circulation, microangiopathic anemia and ischemia. The clinical picture includes thrombocytopenia, renal dysfunction, fluctuating neurological symptoms, microangiopathic hemolytic anemia, and fever. Methods: Case report of a 51-year-old male hypertensive patient, diagnosed with idiopathic thrombocytopenic purpura (ITP) 10 years ago and submitted to splenectomy 5 years ago, who developed acute cholecystitis. He underwent urgent colecistectomy, and on the fourth postoperative day presented sudden space and time disorientation, transcortical motor aphasia and right faciobrachial paresis, with ipsilateral Babinski and Hoffman signs. Results: Brain CT showed left frontoparietal hypodensity. During hospitalization, there was worsening of renal function, increased LDH, and thrombocytopenia. Hematoscopy identified signs of intravascular hemolysis (erythrocyte fragmentation, reticulocytosis, helmet erythrocytes). Direct Coombs was negative. There was no history of heparin use. TTP was diagnosed, and fresh frozen plasma and prednisone 1mg/kg were prescribed. There was resolution of thrombotic microangiopathy, with subsequent increase of platelet levels, decreased LDH and improved hematoscopy. Conclusions: This case illustrates a rare cause of stroke and an unusual association of two hematological conditions: ITP and TTP. The treatment of TTP consists of replacement of deficient ADAMTS13 protein through plasmapheresis or fresh frozen plasma. The use of immunosuppressants is also associated, initially with glucocorticoids, followed by rituximab or splenectomy in order to prevent recurrences.


2012 ◽  
Vol 93 (2) ◽  
pp. 390-394
Author(s):  
G R Khalikova ◽  
I S Malkov ◽  
V V Fattakhov ◽  
M N Nasrullaev

Aim. To improve the treatment outcomes of patients with acute bleedings from the upper gastrointestinal tract by improving methods of endoscopic hemostasis and prediction of disease recurrence. Methods. The results of treatment of 776 patients with bleedings from the upper gastrointestinal tract have been analyzed. Methods of conservative therapy, endoscopic hemostasis and surgical treatment were used in combination with infusion therapy. Results. Established was the necessity of a differentiated method of endoscopic hemostasis, depending on the localization of the bleeding source, its intensity and effectiveness during ongoing bleedings. Infusion therapy should be initiated from the moment of verification of the diagnosis of acute bleeding from the upper gastrointestinal tract, regardless of the degree of blood loss, and already in the hospital’s emergency department. In cases of mild bleedings the infusion volume is 800-1000 ml: 80% crystalloids + 20% of colloids. The volume of infusion in moderate blood loss is 1500-2300 ml: 60% crystalloids + 20 colloids % + 20% fresh frozen plasma. The volume of infusion in severe blood loss is 2700 ml and more: 20% of crystalloids + 30% colloids + 30% fresh frozen plasma + 20% erythrocyte mass. Replacement therapy requires careful monitoring of the hemodynamic parameters and infusion load due to the unpredictability of body reactions to blood loss and its replacement. In the absence of an effect of conservative treatment within 6-24 hours an emergency operation is indicated with the choice of an optimal method based on an assessment of the physiological status on a POSSUM scale of assessment. Conclusion. Implementation of substitution therapy, which correlates to the degree of blood loss, critically important in order to eliminate ischemia of the wall of the gastrointestinal tract and prevent recurrence of bleeding; the usage of new approaches to the prediction of recurrent bleedings and improvement of methods of endoscopic haemostasis reduces the frequency of their occurrence, duration of in-hospital stay of patients and postoperative mortality.


Author(s):  
Anthea Hatfield

Part one of this chapter tells you about the physiology of blood and oxygen supply, about anaemia and tissue hypoxia, and the physiology of coagulation. Drugs that interfere with clotting are discussed. Bleeding, coagulation, and platelet disorders are covered as well as disseminated intravascular coagulation. Part two is concerned with bleeding in the recovery room: how to cope with rapid blood loss, managing ongoing blood loss, and how to use clotting profiles to guide treatment. There is also a section covering blood transfusion, blood groups and typing. Massive blood transfusion is clearly described, there are guidelines about when to use fresh frozen plasma, when to use platelets, and when to use cryoprecipitate. The final section of the chapter is about problems with blood transfusions.


1997 ◽  
Vol 87 (2) ◽  
pp. 260-267 ◽  
Author(s):  
Mary C. Theroux ◽  
David H. Corddry ◽  
Amy E. Tietz ◽  
Freeman Miller ◽  
Joseph D. Peoples ◽  
...  

Background Studies examining the use of desmopressin acetate (DDAVP) have shown variable results in DDAVP's efficacy for reducing blood loss. Studies of adults having cardiac surgery and of children having spinal fusion have suggested that patients with complicated medical histories and complex surgical procedures may benefit from use of DDAVP. Therefore, this study was designed to examine the homeostatic effects of DDAVP in children with severe cerebral palsy undergoing spinal fusion. Methods A randomized, double-blinded, and placebo-controlled trial of DDAVP was designed to enroll 40 patients. However, termination of the study was advised by the Institutional Review Board after 21 patients were enrolled. All patients had spastic quadriplegic-type cerebral palsy and were randomly assigned to one of two groups. The DDAVP group received 0.3 microg/kg DDAVP in 100 ml normal saline, and the placebo group received normal saline alone. All patients were anesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl. Factor VIIIC and von Willebrand's factor (vWF) concentrations were measured in blood drawn before DDAVP infusion and 1 h after infusion. Blood pressure was maintained at a systolic pressure of less than 100 mmHg. Use of crystalloids, packed erythrocytes, platelets, and fresh frozen plasma were based on criteria established by protocol. Estimated blood loss was assessed by weighing sponges and measuring suctioned blood from canisters. Results Estimated blood loss (intraoperative and postoperative) and amount of packed erythrocytes transfused were similar for the DDAVP and placebo groups. Concentrations of both factor VIIIC and vWF were significantly greater after DDAVP infusion when compared with concentrations after placebo infusion. Conclusions In the children who had complex spinal fusion, there was no difference in estimated blood loss between those who received DDAVP and those who received a placebo. Administration of DDAVP significantly increased factor VIIIC and vWF levels.


1993 ◽  
Vol 21 (2) ◽  
pp. 156-162 ◽  
Author(s):  
M. D. Nicholls ◽  
G. Whyte

Hypothetical clinical cases were used to investigate transfusion-related decision-making. Three red cell, three fresh frozen plasma (FFP) and three albumin transfusion decision cases were administered by questionnaire to 228 medical staff. The transfusion decision triggers were identified and comparisons made between resident and specialist groups and between Melbourne and Sydney participants. Factors important in red cell transfusion decisions included haemoglobin, symptoms of anaemia, presence of co-morbidities or surgery, gender, period of hospitalisation and the degree of documented blood loss. FFP administration was influenced by an abnormal coagulation test, the presence of co-morbidities and by the number of red cell units transfused. The administration of albumin, concentrated or 5% SPPS, was influenced by the period of hospitalisation and clinical circumstances such as a falling urine output postoperatively, and by the presence of hypotensive complications. Different transfusion responses were noted: resident staff transfused red cells and FFP earlier than specialists; Sydney specialists were more conservative of red cell transfusion; Melbourne specialists more conservative of FFP administration and surgeons were four times more likely to transfuse patients than physicians or anesthetists at certain haemoglobin values.


2003 ◽  
Vol 75 (5) ◽  
pp. 1506-1512 ◽  
Author(s):  
William C Oliver ◽  
Froukje M Beynen ◽  
Gregory A Nuttall ◽  
Darrell R Schroeder ◽  
Mark H Ereth ◽  
...  

1994 ◽  
Vol 22 (6) ◽  
pp. 666-671 ◽  
Author(s):  
P. L. Mcnicol ◽  
G. Liu ◽  
I. D. Harley ◽  
P. R. Mccall ◽  
G. M. Przybylowski ◽  
...  

The blood loss data and transfusion requirements including blood bank, salvaged washed red cells, fresh frozen plasma and cryoprecipitate were analysed for the first 75 cases of liver transplantation performed at the Austin Hospital between June 1988 and October 1992. The mean blood loss was 8.8 litres (standard deviation 14.1) with a median value of 4.0 litres. Blood product use expressed as mean number of units (SD) was bank red blood cells 7.1 (12.7), washed red blood cells 3.9 (5.9), fresh frozen plasma 7.1 (9.1), platelets 5.1 (7.4), and cryoprecipitate 1.7 (5.1). These results demonstrate that liver transplantation can be performed without imposing excessive demands on blood transfusion services. Management should include surgical techniques to minimize bleeding and use of autologous transfusion. Use of component therapy (FFP, platelets and cryoprecipitate) should not be empirical. It should be selective on the basis of clinical bleeding assessment and guided by results of the laboratory coagulation profile and changes in thrombelastographic (TEG) parameters.


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