Oxford-AstraZeneca Coronavirus Disease-2019 Vaccine-Induced Immune Thrombocytopenia on Day Two

Introduction. Vaccines have been one of the most impactful human discoveries that have significantly changed life expectancy. Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by platelet damage, life-threatening thrombocytopenia, and haemorrhage when the platelet count reaches below 20 × 109/mcL. Its pathogenesis involves viral mimicry or T-cell-induced immune destruction in antibody-negative cases. The clinical manifestations of thrombocytopenia vary according to the severity (level of platelets) and range from being asymptomatic to severe haemorrhage. ITP is treated with immunosuppression. Case Presentation. A 26-year-old Iraqi male laboratory analyst with an unremarkable medical history presented with severe thrombocytopenia 2 days after receiving the Oxford-AstraZeneca coronavirus disease-2019 vaccine. The patient was asymptomatic with unremarkable examination findings. However, his low platelet count was discovered accidentally, and the patient did not exhibit the resistance pattern of ITP and recovered successfully with regular immunosuppressant treatment. Conclusion. Patients with a history of thrombocytopenia can develop vaccine-induced thrombocytopenia earlier than the expected onset. Close monitoring, through regular complete blood counts, is highly recommended for patients with previous thrombocytopenia because the immune modulation process of the vaccine can worsen preexisting thrombocytopenia.

Acute and severe haemorrhage following pentosan polysulfate injection in a Cornish Rex

Case summary A 14-year-old male castrated Cornish Rex cat was referred for lethargy progressing rapidly to collapse in the hours following a subcutaneous injection of a product containing 100 mg/ml pentosan polysulfate sodium and 168 mg/ml glucosamine. Physical examination revealed the cat to be in hypotensive shock with swelling and interstitial oedema around the cranial thorax and caudal cervical regions without cutaneous haemorrhage. Initial diagnostics revealed a severe anaemia (packed cell volume 11%) which later deteriorated further, necessitating a blood transfusion and aggressive fluid therapy. Post-transfusion, the patient remained dyspnoeic and subsequent diagnostics found evidence of pre-existing cardiomyopathy and congestive heart failure. The cat was euthanased 24 h following presentation due to increasing dyspnoea. Post-mortem findings were of severe subcutaneous and intermuscular haemorrhage over the neck and thorax, among other changes. There were no detectable levels of coumarin anticoagulants in the liver. Relevance and novel information This is the first reported case of acute subcutaneous and intermuscular haemorrhage of this severity suspected to be related to the off-label use of an injectable product containing pentosan polysulfate in a cat. Given the popularity of its use for feline arthritis, there is a need for large-scale clinical trials to evaluate the safety and efficacy of products containing pentosan polysulfate for cats, and any side effects to be reported.

Resusitasi Pengendalian Kerusakan Di Unit Perawatan Intensif

Abstrak Resusitasi dengan pengendalian kerusakanmenggambarkan suatu pendekatan ke perawatan awal pada pasien dengan cedera berat. Tujuan pendekatan ini untuk menjaga pasien tetap stabil dengan menghindari intervensi dan kondisi yang berisiko kepada keadaan perburukan dengan mengendalikan trias kematian, yaitu hipotermia, koagulopati, dan asidosis. Merupakan hal yang penting bahwa konsep dan kepraktisan pendekatan ini dipahami oleh semua yang terlibat dalam manajemen awal pasien trauma. Pendekatan ini dimulai dengan pemberian produk darah sejak awal, penghentian perdarahan dan pengembalian volume darah yang bertujuan untuk mengembalikan stabilitas fisiologis dengan cepat. Resusitasi dengan pengendalian kerusakan memilikibeberapa tambahan pendekatan dari bidang farmakologis dan laboratorium untuk meningkatkan perawatan pasien yang mengalami perdarahan. Pendekatan ini termasuk trombelastografi sebagai ukuran rinci kaskade pembekuan, asam traneksamat sebagai antifibrinolitik. Kata kunci : hipotermia, koagulopati, asidosis, perdarahan masif Damage Control Resuscitation in Intensive Care Unit Abstract Damage control resuscitation (DCR) describes an approach to the early care of very seriously injured patients. The aim is to keep the patient alive whilst avoiding interventions and situations that risk worsening their situation by driving the lethal triad of hypothermia, coagulopathy and acidosis.It is critical that the concepts and practicalities of this approach are understood by all those involved in the early management of trauma patients. Damage control resuscitation forms part of an overall approach to patient care rather than a specific intervention and has evolved from damage control surgery. It is characterised by early blood product administration, haemorrhage arrest and restoration of blood volume aiming to rapidly restore physiologic stability. The infusion of large volumes of crystalloid is no longer appropriate, instead the aim is to replace lost blood and avoid dilution and coagulopathy. In specific situations, permissive hypotension may also be of benefit, particularly in patients with severe haemorrhage from an arterial source. Damage control resuscitation has been augmented by both pharmacologic and laboratory adjuncts to improve the care of the hemorrhaging patient. These include thrombelastography as a detailed measure of the clotting cascade, tranexamic acid as an antifibrinolytic. Keywords: hypothermia, coagulopathy, acidosis, massive bleeding

Adenomyosis a Rare Contributor to Severe Primary Post-Partum Haemorrhage

Adenomyosis is a challenging clinical condition for women of reproductive age with both proven and speculated, major gynaecologic and obstetric consequences. We present the case of a woman who had adenomyosis of the uterus, a successful in-vitro fertilized (IVF) conceived twin pregnancy, and severe primary postpartum haemorrhage (PPH) during caesarean section. The 38-year-old, gravida 2, para 0+1, with a 6-year history of prior infertility, had severe primary postpartum haemorrhage at caesarean delivery of a live set of twins at estimated gestational age of 35weeks. Conservative treatment included uterine compression and massage, blood transfusion, administration of intravenous carbetocin and application of multiple figure of eight haemostatic sutures at the placenta bed. Intra-operative finding on gross inspection of the uterus was in keeping with focal adenomyosis in the region of the placenta bed. Biopsy of the involved myometrial wall was avoided due to risk of provoking further severe haemorrhage. Her prior medical record revealed pelvic endometriosis at diagnostic laparoscopy prior to conception while being evaluated for infertility. Women with prior infertility and/or endometriosis, due to very probable co-existing adenomyosis, are at high risk of life-threatening, severe post-partum haemorrhage at delivery.

GULFA MARMA IN RELATION TO THE MODERN HUMAN ANATOMY

Marma is originated from the Sanskrit root word etymologically, ‘Mr’- Marne and the term ‘Sthana’ signi-fies the location. This jointly signifies the vitality of Marma in the human body. Any kind of injury to these parts of body may cause sensory or functional deformity or severe haemorrhage or even collapse and death instantaneously or lately. The Marma have been included as one of the important chapters in Sharir Sthana of Sushruta Samhita. In which Marma are categorized according to fatality, dimensions, integrity etc. Marma has a common factor as being a seat of Prana or seat of life in Ayurveda literature. Marma therapy focuses on stimulation of these points for activation of Prana factor in management of related dis-orders. But only described as danger spots of body Marma points have gained a lot of therapeutic im-portance nowadays. Considering present modern anatomy Marma being a physical entity also should be explored parallelly as it still lacks the adequate and comprehensive western science description. The meas-urements are given in Anguli Pramana of the person himself. Sushruta has described the anatomical classi-fication of Marma which makes it a little easier to explore them. This will lead to a proper understanding, for better learning and practice of Marma. Gulfa Marma is explored anatomically and in similarity to struc-ture and various other characteristics with modern anatomy.

Partial Molar Caesarean Scar Pregnancy- A Case Report

Caesarean Scar Pregnancy (CSP) is a rare entity. Gestational Trophoblastic Disease (GTD) in a CSP is exceedingly rare. This can lead to complications like rupture uterus, severe haemorrhage, hypovolemia which may require hysterectomy, endanger a woman’s life, her future fertility and death. As no therapeutic protocols have been established about this rare condition, it is difficult to diagnose and manage. The case report describes a patient, 26-year-old gravida 2 para 1, was diagnosed with a CSP with partial mole. She was treated with systemic Methotrexate (MTX) followed by surgery-wedge resection of ectopic mass and repair of uterus. Patient remained on β-hCG follow-up with us. The management of CSP requires high clinical suspicion and immediate action with combination of various treatment modalities. Primary caesarean section rate must be reduced by performing caesareans only for justified reasons, so as to decrease the incidence of scar pregnancies.

A Case of Ruptured Rudimentary Horn of Uterus during Pregnancy

Pregnancy in a rudimentary horn of an unicornuate uterus is a rare and life threatening situation for mother and fetus. Usually pregnancy continues upto approximately 18-20 weeks of gestational age. Then it usually ruptures and severe haemorrhage ensues. Emergency laparotomy is the treatment of choice. Here we report a case of 36 years woman with secondary subfertility who has history of taking ovulation inducing drug. She presented with 20 weeks amenorrhoea with severe abdominal pain and hypovolemic shock. Urgent laparotomy was done and the diagnosis was confirmed. Bangladesh J Obstet Gynaecol, 2017; Vol. 32(2) : 121-123

Obstetrics

This chapter covers emergency management for obstetric crises including maternal collapse, severe haemorrhage, amniotic fluid embolus, pre-eclampsia and eclampsia, total spinal, accidental dural puncture, cord prolapse, failed intubation, ruptured ectopic, retained placenta, and placenta praevia. The authors give guidance on how to perform intrauterine resuscitation and conduct anaesthesia for a category I Caesarean section. In addition, the definitions, presentation, management strategies, investigations, risk factors, exclusions and causes, and any special considerations for each potential obstetric-related situation are given. Lists of up-to-date online resources and further reading are also provided here, offering invaluable know-how to encourage the reader to broaden their knowledge.

Tranexamic acid and international ambulance services

Introduction: Severe haemorrhage may lead to pathologic release of fibrinolytic enzymes, which break down blood clots. Tranexamic acid (TXA) is a drug that inhibits the fibrinolysis of blood clots. Aim: The purpose of this review is to explore current literature regarding prehospital TXA administration for patients suffering severe haemorrhage following trauma, and to discuss whether this drug should be more widely used across modern international ambulance services. Methods: Literature searches of EBSCO Host, ProQuest and PubMed databases were conducted in August, 2019. Results: TXA administration within 3 hours following injury is associated with improved outcomes for severe haemorrhage patients. However, there are reservations that the success of TXA in developing countries and military settings may not be directly transferrable to the modern civilian healthcare systems. Discussion: The benefits of prehospital TXA administration appear compelling. Further studies will help guide wider international implementation of this drug in paramedic practice.