A Rare Cause of Hemoperitoneum in Pregnancy

Spontaneous hemoperitoneum in pregnancy is a rare complication resulting in high maternal and fetal morbidity and mortality. The authors describe the case of a pregnant woman presenting at 32 weeks of gestation with abdominal pain and free abdominal fluid on ultrasound. Laparotomy revealed a hemoperitoneum resulting from a suspected ruptured varices on the uterine posterior surface. A live newborn was delivered by cesarean-section, and hemorrhage was controlled with sutures and compression. Clinicians should be aware of this diagnosis when a pregnant woman presents with abdominal pain, anemia or hypovolemic shock. Early intervention will avoid poor outcomes for both the mother and the fetus.

Informational Value of Proadrenomedullin Blood Levels in Patients with Septic Shock, Once Measured Upon Admission to ICU

The objective: to assess the information value of proadrenomedullin (PAM), once measured upon admission to ICU in predicting mortality and differential diagnosis of septic and hypovolemic shock.Subjects and Methods. A prospective cohort retrospective study was carried out. 134 patients in a state of shock were included in the study. Of these, 125 patients had septic shock; 9 ‒ hypovolemic one. The diagnosis of septic shock was established according to the Sepsis-3 criteria. To compare hypovolemic and septic shock, blood levels of proadrenomedullin (PAM), procalcitonin (PCT) and lactate were tested in 9 patients with obvious hypovolemic shock. Samples (venous blood) were collected within 24 hours from the moment the vasopressors began to be used in ICU or by the ambulance team (EMS).Results. The ROC analysis showed comparable predictive value with APACHE II, SOFA and lactate scales in patients with septic shock with cut-off > 4.23 nmol/L. The range of PAM values in patients with septic shock was Me 4.56 (2.9‒6.7) in patients with hypovolemic shock – Me 0.6 (0.1‒1.4).Conclusion. Proadrenomedullin can be used for differential diagnosis of septic shock and hypovolemic shock. Blood levels greater than 2.9 nmol/L are of absolute value for the diagnosis of septic shock. Procalcitonin is inferior to PAM within the range of 1.0–6.45 ng/ml. PAM unlike SCT is a statistically significant predictor of global outcome in septic shock along with lactate and scales. But such scales as SOFA and ARACНE-II are more laborious in comparison with testing proadrenomedullin blood level.

INTERPRETATION OF INJURIES AND ASSESSMENT OF CAUSES OF DEATH IN WILD MAMMALS RECEIVED AT CETAS / IBAMA IN RIO BRANCO, ACRE, BRAZIL:

The necropsy of wild animals is necessary to raise the awareness of the competent public organizations and the population about the risks of zoonosis. Given the scarcity of information the aim of this article was to survey of the main injuries and causes of deaths of wild mammals kept in captivity was made, through the post mortem diagnosis and who passed through Wild Animal Screening Center (Centro de Triagem de Animais Silvestres - CETAS) of Rio Branco - Acre, Brazil, from September 2012 to September 2015. After death, the animals were kept refrigerated or frozen until the time of necropsy, using the standard technique for small mammals. Fragments of organs and tissues were collected, and the material was processed for histopathology using formalin fixation (10%), paraffin impregnation, hematoxylin and eosin staining, in 4 µm thick sections. 42 animals were submitted to necropsy, 27 males (64.3%) and 15 females (35.7%), of which 21 were adults (50%), 15 were puppies (35.7%) and six were young (14.3%). The main cause of death was hypovolemic shock (11.6%), followed by starvation (9.3%). There were also many deaths from undetermined causes (11.6%). A greater occurrence of deaths was registered in the Guariba monkey (Alouatta senicullus). The identification of necropsy findings and the interpretation of macroscopic lesions showed that cardiovascular lesion was the most common deaths. There does not seem to be an influence between the dry and rainy periods on the number of deaths of these animals.

Shock Index In Obstetric Hemorrhage As An Applicable Method To Anticipate Adverse Outcome

Background: To establish the ability of shock index and the different vital signs to predict the adverse maternal outcomes in the cases of obstetric hemorrhage . Methods: This prospective - retrospective study comprised patients with primary PPH or hemorrhage due to obstetric cause who were referred to zagazig University hospital Egypt , from January 2018, to December 2019 Data of vital signs of them ; systolic and diastolic blood pressure, pulse rate, pulse pressure, mean arterial pressure and shock index (heart rate divided by systolic blood pressure) at time of arrival were investigated . Adverse outcome like ,death , admission to the intensive care unit , massive transfusion and invasive procedures were revised and analyzed. AUROC (area under the receiver operating characteristic curve ) was used for shock index in comparison to each vital sign for predicting the adverse maternal outcomes. Sensitivity, specificity, and negative and positive predictive values were assessed to detect the best predictor.Results: The mean age of participants years (SD)was 29.2 ( ±7.3) of admission and 44% had altered. The most Common cause of hemorrhage was Iatrogenic ; either misuse of uterotonic or traumatic 30.2% The mean value of HR 108.1±26.6 , SBP 101± 28.7 mmHg , DBP 58.9±21.3 mmHg , SI 1.153±0.541 and mean blood loss 1922 (0.862) .For death, SI and SBP had the highest AUC value at 0.88 (0.81–0.95) with P=0.213). For ICU blood transfusion ≥ 5iu , admission and invasive surgical interventions, SI had the uppermost AUROC value at 0.76, 0.78 and 0.61. Sensitivity for all adverse outcomes of SI ≥ 0.7,is h from 99 to 90.0 . For death prediction SI≥ 0.7 had very low specificity ;0.6{0.2-1.3}and of SI ≥ 0.9 ;6.4{2.8-7.1}Conclusion: Shock index is a strapping applicable predictor of adverse outcomes. for patients who suffering from hypovolemic shock due to obstetric hemorrhage,

Food Restriction Augmented Alpha1 Adrenergic Mediated Contraction in Mesenteric Arteries

Food restriction (FR) enhances the sensitivity to cardiopulmonary reflexes and alpha1 adrenoreceptors in the female, despite hypotension. The effect of male FR on cardiopulmonary and systemic vascular function is not well understood. This study examines the effects of FR on cardiopulmonary, isolated mesenteric arterial function and potential underlying mechanisms. We hypothesized that FR decreased eNOS activity in mesenteric arteries. Male Sprague Dawley (SD) rats were randomly divided into three groups: (1) control (n=30), (2) 20 percent of food reduction (FR20, n=30), and (3) 40 percent of food reduction (FR40, n=30) for five weeks. Non-invasive blood pressure was measured twice a week. Pulmonary arterial pressure (PAP) was measured using isolated/perfused lungs in rats. The isolated vascular reactivity was assessed in double-wire myograph. After five weeks, food restricted rats exhibited a lower mean arterial pressure and heart rate, however, only FR40 groups exhibited statistically significant differences. The basal tone of PAP and various vasoconstrictors did not show significant differences in pulmonary circulation between each group. We observed that food restriction were enhanced the sensitivity (EC50) in response to α1-adrenoreceptors (phenylephrine, PhE)-induced vasoconstriction, but not to serotonin, U46619, and high K+ in the mesenteric arteries. FR reduced endothelium-dependent relaxation via decreased function of endothelial nitric oxide synthase (eNOS)-nitric oxide (NO) pathway in the mesenteric arteries. PhE-mediated vasoconstriction in mesenteric arteries was eliminated in the presence of eNOS inhibitor (L-NAME). In addition, incubation with NOX2/4 inhibitors (apocynin, GKT137831, VAS2870) and reactive oxygen species (ROS) scavenger inhibitor (Tiron) were eliminated the differences of PhE-mediated vasoconstriction but not to cyclooxygenase inhibitor (indomethacin) in the mesenteric artery. Augmentation of alpha1 adrenergic mediated contraction via inhibition of eNOS-NO pathway by increased activation of ROS through NOX2/4 in response to FR. Reduced eNOS-NO signaling might be a pathophysiological counterbalance to prevent hypovolemic shock in response to FR.

The role of procalcitonin and lactate at single determination in the intensive care unit in the diagnosis and prognosis of hypovolemic and distributive (septic) shock

Introduction. The greatest difficulties arise in the differential diagnosis of hypovolemic or distributive (septic) shock. The aim of this study was to critically analyze the information value of the blood plasma content of lactate and procalcitonin (PCT) in patients with septic and hypovolemic shock.Materials and methods. The diagnosis of «Sepsis» and «Septic shock» in the study was established according to the criteria of «Sepsis-3». 143 IRCs were filled, 34 of them with septic shock, 44 IRCs with hypovolemic, 65 IRCs with sepsis and organ dysfunction (OD).Results. When determining the content of PCT in the blood plasma in patients with septic and hypovolemic shock, we found a statistically significant difference. The level of PKT in infectious shock —33.3 (95% CI 7.9 — 58.0) ng / ml was higher than hypovolemic-0.9 (95% CI 0.43 — 6.45) ng/ml on average more than 30 times. In contrast to PCT, the content of lactate in the blood plasma did not carry a differential diagnostic value. Once measured at admission to the ICU, the level of PCT has no informational significance and does not indicate a likely outcome of the disease, complicated by the development of septic and hemorrhagic shock. Together with the low predictive ability of the nature of shock, lactate was highly informative in relation to the outcome of the disease, complicated by the development of shock syndrome.Discussion. In our analysis, it is obvious that there were observations when the PCT level during hypovolemia was noticeably higher than normal, reaching a maximum of 6.4 ng / ml. Apparently, there was a combination of factors with an obvious activation of a trigger that affects its libration or the presence of endotoxinemia in hypovolemic shock in these specific patients. The informational value of PCT is not absolute and, according to meta-analyzes, is about 80%.Conclusion. The blood content of procalcitonin in shock of an infectious nature was more than 30 times higher than the hypovolemic level on average. The informational value of procalcitonin in terms of predicting the course of the disease in septic and hypovolemic shock is absent. In the absence of predicting the nature of the shock, lactate is informative about the outcome of the shock. The possibility of increasing the blood lactate content in severe hemorrhagic shock with renal damage was noted.

Congenital Renal Arteriovenous Malformation: Diagnostic Clues and Methods

Background and objectives: Renal arteriovenous malformation (AVM) is a rare disease and is difficult to be diagnosed by conventional methods because of its rarity. In this study, we investigated the diagnostic clues, and made an algorithm for the better diagnosis of renal AVM. Materials and Methods: We reviewed 13 patients who were diagnosed with AVM by using renal angiography from 1986 to 2020 at our institutes. We evaluated clinical features, diagnostic tools, treatment modalities, and outcomes after the treatment of patients. Results: All patients were female, and the mean age was 36.9 years (range 19 to 54 years). Twelve (92.3%) patients complained of gross hematuria. Four (30.8%) patients showed symptoms in relation with pregnancy and delivery. Angiographic findings demonstrated cirsoid type in 10 patients and aneurysmal type in 3 patients. Among the 11 patients who underwent computed tomography, AVMs were detected in 3 (27.3%) patients. Renal duplex Doppler was performed in 6 patients, and all of these patients were diagnosed with AVM, demonstrating a vascular turbulence or blood-rich area. Twelve patients were initially treated with transarterial embolization. Nephrectomy was performed in two patients due to persistent bleeding with hypovolemic shock. Conclusions: We should consider possible AVMs in patients who were not detected by conventional work up for hematuria, especially in mid-aged, pregnant, or recently delivered women. Renal duplex Doppler might be the optimal diagnostic modality in these patients. Our diagnostic algorithm could be aid to diagnosis and treatment for renal AVM patients.

Pancreatic pseudoaneurysm and its conundrum

Rupture of visceral artery pseudoaneurysm can lead to hypovolemic shock in a patient with pancreatitis. With the advent of minimally invasive treatment techniques most of these can be managed by minimally invasive route and have excellent prognosis when timely intervention is initiated. Herewith, we reported a case of ruptured pseudoaneurysm of superior pancreaticoduodenal artery in a patient with pancreatitis who presented with haematemesis. The patient was successfully managed with coil embolization. A brief case report with review of literature is presented here.

Nephrogenic Diabetes Insipidus with New-Onset Diabetic Ketoacidosis in a Child- Challenges in Fluid and Electrolyte Management

BackgroundIntensive care management of diabetic ketoacidosis (DKA) is targeted to reverse ketoacidosis, replace the fluid deficit, and correct electrolyte imbalances. Adequate restoration of circulation and treatment of shock is key. Pediatric treatment guidelines of DKA have become standard but complexities arise in children with co-morbidities. Congenital nephrogenic diabetes insipidus (NDI) is a rare hereditary disorder characterized by impaired renal concentrating ability and treatment is challenging. NDI and DKA together have only been previously reported in one patient.Case Diagnosis/TreatmentWe present the case of a 12-year-old male with NDI and new onset DKA with hyperosmolality. He presented in hypovolemic shock with altered mental status. Rehydration was challenging and isotonic fluid resuscitation resulted in increased urine output and worsening hyperosmolar state. Use of hypotonic fluid and insulin infusion led to lowering of serum osmolality faster than desired and increased the risk for cerebral edema. Despite the rapid decline in serum osmolality his mental status improved so we allowed him to drink free water mixed with potassium phosphorous every hour to match his urinary output (1:1 replacement) and continued 0.45% sodium chloride based on his fluid deficit and replacement rate with improvement in his clinical status.ConclusionsThis case illustrates the challenges of managing hypovolemic shock, hyperosmolality, and extreme electrolyte derangements driven by NDI and DKA.

Uterine Artery Laceration after Vacuum Delivery

Post-partum hemorrhage is one of the leading causes of maternal mortality and it’s etiology needs to be identified in order for adequate treatment to be provided. We report a case of a post-partum hemorrhage in a multiparous woman treated with selective coil packing embolization after identification of laceration of the right uterine artery’s ascending branch. The patient was admitted to an intensive care unit in hemorrhagic hypovolemic shock and disseminated intravascular coagulation and underwent total hysterectomy due to infectious complications.