Bleeding

Perioperative Steroids Do Not Increase Serious Bleeding After Tonsillectomy .

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Children undergoing tonsillectomy who receive perioperative corticosteroid therapy — as recommended by current guidelines to reduce postoperative nausea and vomiting — do not face increased risk for postoperative bleeding, according to a JAMA study.

In response to a study suggesting such steroid use increases hemorrhage after tonsillectomy, researchers randomized some 300 children to perioperative intravenous dexamethasone or placebo. During the 14 days after tonsillectomy, rates of bleeding that required hospitalization or surgical repair (so-called level II or III bleeds) did not differ between the groups.

Level I bleeds — defined as any reported bleeding event, regardless of clinical evidence — were more common with dexamethasone than with placebo (11 vs. 7 events). However, the authors point out that such events tended to be “nondescript and self-limited.” Level II and III bleeds, they say, “are a more reliable indicator for complications.”

Source: JAMA

Ovarian ectopic pregnancy.

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Summary

The authors report the rare case of a 25-year-old female who suffered from an ovarian ectopic pregnancy. She presented at 10 weeks gestation with a 1-day history of vaginal bleeding and lower abdominal discomfort. β-human chorionic gonadotropin concentration was 8538 IU/ml. Ultrasound showed a right adnexal mass 4.0 × 3.8 × 5.5 cm with a 16 mm cystic area suggesting right ovarian ectopic pregnancy. Diagnostic laparoscopy confirmed a ruptured right ovarian ectopic pregnancy with haemoperitoneum. This was excised laparoscopically. She made a good postoperative recovery and was discharged on the second postoperative day. Histology confirmed a ruptured ovarian ectopic pregnancy. Ovarian ectopic pregnancy is a rare condition. There are two features that make this an unusual case; the relatively late gestation at which she presented and her mild presenting features. Unlike tubal ectopic pregnancies, which usually present at earlier gestations, this patient presented relatively late. She also presented with mild symptoms and signs.

Background

Ovarian pregnancy is a rare condition and high index of suspicion is needed. Ovarian pregnancy comprises 0.15% of all pregnancies and 1–3% of ectopic gestations.1

Clinical diagnosis can be difficult and challenging. If an ovarian pregnancy ruptures, mortality is quite high.

In this case of right ovarian pregnancy, the clinical findings were mild and not characteristic of an ectopic pregnancy. She attended accident and emergency earlier on in the day and was discharged. This case illustrates how an ovarian pregnancy can be easily missed and the patient can even be discharged.

Case presentation

A 25-year-old female at 10 weeks gestation (spontaneous conception) in her fourth pregnancy presented to accident and emergency department with vaginal bleeding and lower abdominal discomfort. There was no history of dizzy spells or faintness. There was no history of vomiting, bladder or bowel problems. She had used Implanon as her contraception and had come off just a month prior to her last menstrual period. She had irregular periods while on Implanon. She had two previous uneventful pregnancies and vaginal deliveries at term and one previous termination of pregnancy.

There was no significant medical history. There was no history of pelvic infection or any gynaecological procedures apart from surgical termination of pregnancy which was done in 2004 after which she had spontaneous conception and vaginal delivery at term in 2006.

There was no significant family history.

On examination, her observations were all within normal limits. Her abdomen was soft and she had some mild tenderness in her right loin, right iliac fossa and suprapubic areas. On speculum examination, the cervical os was closed and only minimal bleed was noted. On vaginal examination, she had no cervical excitation and no adnexal tenderness. She was explained although ectopic pregnancy is always a possibility but in her case in absence of tenderness threatened spontaneous abortion was most likely diagnosis. She was discharged from accident and emergency with appointment of Early Pregnancy Assessment Unit in 1 week’s time for ultrasound scan of pelvis. But this patient presented again in few days to accident and emergency with increasing discomfort in right loin area. She was admitted to the gynaecology ward and had ultrasound scan next day which clearly suggested right ovarian ectopic pregnancy.

Investigations

Serum β-human chorionic gonadotropin (β-HCG) concentration was 8538 IU/l. Haemoglobin was 11.3 g/dl on admission, then 9.9 g/dl postoperatively. Microbiology swabs were negative for Chlamydia, Gonorrhoea and Candida. Urine dipstick was negative for nitrites and leucocytes.

Transvaginal ultrasound scan suggested a normal uterus, endometrial thickness of 7 mm, normal left ovary and adnexa. Adjacent to right ovary there was a 4.0 × 3.8 × 5.5 cm mass with 16 mm cystic area within it consistent with ectopic pregnancy. Laparoscopic findings showing ruptured ectopic pregnancy.

Differential diagnosis

Treatment

The patient underwent a diagnostic and therapeutic laparoscopy and the right ovarian ectopic pregnancy was resected laparoscopically with conservation of more than two-thirds of her right ovary

Outcome and follow-up

She had an uneventful procedure. Despite the ectopic pregnancy being adherent to right ovary still her right ovary was conserved. She had good postoperative recovery and was discharged home on the second postoperative day.

Discussion

We conducted a Medline search for reports of ovarian ectopic pregnancy and found approximately 100 cases; however, many of them being related to fertility treatment, intrauterine devices or tubal ligation.

The incidence of ectopic pregnancies is 1%.2 Among these ectopic pregnancies, ovarian pregnancy is quite rare, constituting 1–3% of all ectopic pregnancies.3 It is the most important cause of maternal death in the first trimester accounting for approximately 10% of deaths related to pregnancy.4

The aetiology of ovarian pregnancy remains unclear, it occurs as a result of a fertilised ovum getting implanted on the ovarian tissue. Although several factors, such as pelvic inflammatory disease and previous gynaecological surgery, are closely linked to tubal pregnancies but do not seem to be related to ovarian pregnancies.5 6 Ovarian ectopic pregnancies have been mostly associated with high parity, younger age and people receiving in-vitro fertilisation treatment.7 9 It has been found that intrauterine device use and ovulation induction are the most common risk factors for ovarian ectopic pregnancy.8 10 11

The clinical findings of ectopic pregnancy include secondary amenorrhoea, abdominal pain and vaginal haemorrhage, with a clinical picture of varying acuteness.12 It has been reported that the presentation of ovarian ectopic pregnancies can be delayed.5 13

This case meets all the diagnostic criteria as described by Spiegelberg:

  1. An intact fallopian tube on the affected side
  2. A gestational sac must occupy the normal position of the ovary
  3. The ovary and gestational sac must be connected by the utero-ovarian ligament to the uterus
  4. Histological confirmation of ovarian tissue in the gestational sac wall.10

Investigation is mainly with transvaginal ultrasound scan which can detect ovarian ectopic pregnancy. However, ultrasound scan may not be able to diagnose all cases of ovarian pregnancy due to anatomical location.

Laparoscopy is the gold standard for both investigation and therapeutic intervention.1 It is the treatment of choice for haemodynamically stable patients.1 The aim should be to conserve the ovary on which the ectopic pregnancy is attached to by doing an ovarian cystectomy or wedge resection.12 Patients who are haemodynamically unstable would need an urgent laparotomy.12 Methotrexate is a good alternative to laparoscopic management in unruptured ovarian ectopic pregnancy; however, it’s toxicity has to be taken into account.14

Learning points

  • ▶ Ovarian ectopic pregnancy can present with mild pain and tenderness and very subtle clinical findings and can therefore be easily missed and even discharged, posing a big diagnostic challenge.
  • ▶ One should have a high index of suspicion of ovarian ectopic pregnancies even when the patient has no risk factors.
  • ▶ Ovarian ectopic pregnancy can have a delayed presentation compared to tubal ectopic pregnancies.
  • ▶ In the case of an ovarian ectopic pregnancy, the ovary can be conserved in many cases.

References

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    1. Tinelli A,
    2. Hudelist G,
    3. Malvasi A,
    4. et al

. Laparoscopic management of ovarian pregnancy. JSLS 2008;:169–72.

[Medline]

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Royal College of Obstetrics and Gynaecologists. The Management of Tubal Pregnancies. Guideline 21. London: RCOG, 2004.

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    1. Adeniran A,
    2. Stanek J

. Ovarian pregnancy. Arch Pathol Lab Med 2003;:1635–6.

[Medline]

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Ectopic Pregnancy – United States, 1990-1992. MMWR Morb Mortal Wkly Rep 1995;:44–6.

[Medline]

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    1. Vasilev SA,
    2. Sauer MV

. Diagnosis and modern surgical management of ovarian pregnancy. Surg Gynecol Obstet 1990;:395–8.

[Medline][Web of Science]

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    1. Ercal T,
    2. Cinar O,
    3. Mumcu A,
    4. et al

. Ovarian pregnancy; relationship to an intrauterine device. Aust N Z J Obstet Gynaecol 1997;:362–4.

[CrossRef][Medline]

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    1. Hallatt JG

. Primary ovarian pregnancy: a report of twenty-five cases. Am J Obstet Gynecol 1982;:55–60.

[Medline][Web of Science]

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    1. Raziel A,
    2. Schachter M,
    3. Mordechai E,
    4. et al

. Ovarian pregnancy-a 12-year experience of 19 cases in one institution. Eur J Obstet Gynecol Reprod Biol 2004;:92–6.

[CrossRef][Medline]

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    1. Fernandez H,
    2. Coste J,
    3. Job-Spira N

. Controlled ovarian hyperstimulation as a risk factor for ectopic pregnancy. Obstet Gynecol 1991;:656–9.

[Medline][Web of Science]

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    1. Spiegelberg H

. Zot casuistic der ovarial schwangetsshaft. Archives Gynaecology 1878;:73–7.

Search Google Scholar

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    1. Plotti F,
    2. Di Giovanni A,
    3. Oliva C,
    4. et al

. Bilateral ovarian pregnancy after intrauterine insemination and controlled ovarian stimulation. Fertil Steril 2008;:2015.e3–5.

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    1. Stucki D,
    2. Buss J

. The ectopic pregnancy, a diagnostic and therapeutic challenge. J Med Life 2008;:40–8.

[Medline]

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    1. Gaudoin MR,
    2. Coulter KL,
    3. Robins AM,
    4. et al

. Is the incidence of ovarian ectopic pregnancy increasing? Eur J Obstet Gynecol Reprod Biol 1996;:141–3.

[CrossRef][Medline]

  1. ↵
    1. Habbu J,
    2. Read MD

. Ovarian pregnancy successfully treated with methotrexate. J Obstet Gynaecol 2006;:587–8.

[CrossRef][Medline]

Source: BMJ.

Placenta accreta associated with submucosal fibroid polyp.

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  1. Papa Dasari

+ Author Affiliations

1.      JIPMER, Puducherry, India
  1. Correspondence to Papa Dasari, dasaripapa@gmail.com

Summary

A 35-year-old para 1, whose child birth was 5 years ago, was on barrier contraception and safe period. She was diagnosed to have a small submucosal posterior wall fibroid when she planned for her second child now. She conceived spontaneously during the next cycle after consultation. Her first trimester ultrasonography revealed placental implantation on the fibroid. She developed severe pre-eclampsia at 32 weeks of pregnancy and suffered from uncontrolled hypertension. and pulmonary oedema. Pregnancy was terminated at 33+4 weeks by elective lower segment caesarean section (LSCS) because of severe pre-eclampsia, pulmonary oedema and unfavourable cervix. At LSCS, placenta was found to be adherent to the pedunculated fibroid polyp which was removed by clamping, cutting and ligating the pedicle. Histopathological examination revealed placenta accreta and hyaline change of leiomyomatous polyp. Fetus was preterm, weighed 2.1 kg and survived.

Background

Complications are greater in cases of submucosal pedunculated intrauterine fibroid polyps associated with pregnancy. Adherent placenta is to be expected in cases of submucosal fibroid of uterus when placenta is seen anterior to it on ultrasonogram. Posterior wall fibroids may not be visualised in advanced pregnancy.

It is easy to remove the fibroid polyp at lower segment caesarean section (LSCS) and prevent the complications of postpartum haemorrhage and inversion which may result in case of vaginal birth.

Case presentation

A 35-year-old para 1 whose child birth was 5 years ago consulted for planning for second pregnancy. The couple were using male condom and safe period for contraception till she came for consultation. She gave history of menorrhagia (which did not make her anaemic) for the past 6 months . She was found to have a posterior wall fibroid of 3×2 cm size which appeared as submucosal in location on transvaginal ultrasound. She was advised to take folic acid tablet and was asked to return after 3 months if conception does not occur.

She conceived the following month after consultation. Her first trimester ultrasound showed posterior implantation with a single live fetus. The placenta was implanted posteriorly overlying the fibroid but there was an anechoic space between the placenta and the fibroid which was visualised up to second trimester (18 weeks scan) of pregnancy (figure 1). At 32 weeks, she developed severe pre-eclampsia and was hospitalised for the same at 32+3 days as her blood pressure (BP) was not controlled with tablet, –methyl Dopa given 500 mg 8 hourly on outpatient basis. She had severe pedal oedema extending up to knee joints. It was planned to manage her conservatively till 34 weeks of pregnancy and inj. Dexamethasone 6 mg was given intramuscularly 12 hourly for two doses for fetal lung maturity. She was also started on antioxidants, viz, vitamin A, vitamin C and vitamin E, along with sedatives. Five days after admission, that is, at 33+1 day she developed cough and difficulty in breathing. Respiratory system examination revealed fine crepitations. BP was within 150/100 mm of Hg. She was given injection Morphine and tab. Lasix 40 mg 8 hourly with which she had partial relief from dyspnoea. After 2 days the BP was on the rise >160/100 mm Hg and her output started decreasing and a decision to terminate pregnancy was taken. She was decided for elective LSCS in view of pulmonary oedema and unfavourable cervix at 33+4 weeks of gestation. On the operation table, her BP was 170/105 mm of Hg and there were bilateral crepitations. Oxygen saturation was 89%, hence LSCS was done under general anaesthesia with careful fluid administration, and injection magnesium sulphate was started prophylactically soon after the surgery. At surgery, the lower segment was not well formed and the fetal head was high floating and hence delivered with the help of forceps. The liquor was meconium stained and the placenta could not be removed by controlled cord traction though signs of placental separation were present. On intrauterine examination, the placenta was found to be adherent to the posterior wall and hence it was attempted to remove manually. When it was being removed, the upper part of the placenta was found to be attached to the posterior uterine wall by a pedunculated firm structure which was clamped cut and ligated with No-1 vicryl. After removal it was recognised to be the fibroid polyp of 3×4 cm on which the placenta was implanted. Placenta along with polyp was sent for histopathological examination. Uterine incision was closed in two layers with No-1 vicryl, and tubectomy was performed as per the patient’s wish. Fetus was preterm, alive with an Apgar of 6/10 at 1 min and 8/10 at 5 min and weighed 2.1 kg.

She was monitored in RICU (respiratory intensive care unit) and was on continuous oxygen by mask. She developed hypertensive crisis which was controlled by inj. Labetalol for 24 h. Magnesium sulphate was discontinued after 24 h. She was shifted out of RICU after 36 h when she maintained Sp O2 of 96% with room air. She was started on tab. Amlodepine 5 mg twice daily after the Physician’s opinion. She was discharged on the 8th postoperative day along with the baby and advised to continue the antihypertensives for 2 weeks.

Investigations

Her complete haemogram performed after admission at 33 weeks of gestation was normal except for low platelet counts of 156 000/mm3. Renal function, liver function tests and glucose tolerance test were normal. Fundus examination showed grade I hypertensive changes. Ultrasonography (USG) at 32+4 weeks showed biometry corresponding to 31 weeks with estimated fetal weight of 1.8 kg. Placenta was posterior and the fibroid could not be visualised properly at this time. Amniotic fluid index was 16 cm.

The histopathological examination of placenta with polyp was reported as leiomyomatous polyp with hyaline change and placenta accreta

Treatment

  • ▶ Injection Dexamethasone for fetal lung maturity.
  • ▶ Antihypertensives for pre-eclampsia.
  • ▶ Prophylactic magnesium sulphate for imminent eclampsia.
  • ▶ Inj. Morphine and Lasix for pulmonary oedema.
  • ▶ LSCS polypectomy with bilateral tubectomy.

Outcome and follow-up

Normal at 6weeks.

Discussion

Fibroids are diagnosed in 4–5% of women undergoing prenatal ultrasound. Submucosal fibroids are the least common type of uterine fibroids (5%) and the pedunculated type account for only 2.5%.1 Uterine fibroid polyps (pedunculated submucous fibroids) can interfere with implantation causing infertility or they can cause miscarriage or preterm labour. The outcome of a pregnancy in a case of submucosal posterior wall fibroid is reported here.

The symptoms of submucous fibroids include abnormal uterine bleeding (most often menorrhagia, less commonly metrorrhagia), pain lower abdomen, dysmenorrhoea and increased vaginal discharge. Rarely they prolapse out of cervix into the vagina and occasionally cause inversion of uterus. This case was, however, asymptomatic except for mild menorrhagia (which did not make her anaemic). Hysteroscopic myomectomy is feasible and effective for submucous fibroids and it should be considered in women with intracavitary submucous fibroids suffering from infertility, pregnancy loss and abnormal uterine bleeding.2 But hysteroscopic myomectomy is associated with significant complications like bleeding, perforation, burns, electrolyte imbalance, possibility of hysterectomy and even death. Data describing the fertility and pregnancy outcomes following hysteroscopic myomectomy is limited.3 A pregnancy rate of 60% was reported in patients with infertility after hysteroscopic myomectomy.4 In this case, hysteroscopic resection was not considered as she was asymptomatic. A prospective study which assessed the positional affect of fibroids on pregnancy rates revealed 43.3% pregnancy rate in patients with submucosal fibroids who underwent myomectomy compared to 27.2% in those who did not undergo surgery.5 The affect of submucosal fibroids may not be purely positional as it was found that polyps and leiomyomas produce excess glycodelin, a glycoprotein, in the uterus which impairs fertilisation and implantation.6

Pregnancy has a variable and unpredictable effect on myoma growth, majority do not increase and in those that grow, the greatest growth usually occurs before 10 weeks of gestation.7 The pregnancy outcome differs from those who do not have fibroid only in the rate of caesarean section, which was significantly higher in those with fibroid uterus.8 Although most pregnancies are unaffected by fibroids, large submucosal and retroplacental fibroids seem to impart greater risk for complications including degeneration, abruptio placentae, preterm labour and delivery.9 This case did not suffer from abruptio placentae despite pre-eclampsia, and the fibroid polyp underwent degeneration without significant growth. However, adherent placenta was the result because of its implantation on the fibroid polyp. Submucosal fibroids have long been recognised as one of the causes for placenta accreta as mentioned by Fox.10 Both hyaline degeneration and placenta accreta were evident in this case.

The sonographic appearance of myomas is generally characteristic but as they can undergo various kinds of degeneration, the sonographic appearance can vary mimicking other cystic conditions. MRI is more accurate and specific in diagnosing the various changes that occur in a fibroid.11 The fibroid could not be visualised during the later half of pregnancy by USG in this case because of its posterior location and it’s small size and most probably because of hyaline degenerative change reported on histopathological examination. MRI would have been useful in delineating the fibroid in such a situation.

The pedicle could be easily felt on the posterior wall of the uppersegment and clamped and ligated at LSCS in this case. If she had a vaginal delivery, retained placenta with primary postpartum haemorrhage (PPH) would have been the result as there is partial adherence of placenta, that is, on the polyp, and attempts at manual removal would not be successful because of pedunculated polyp and she would have required a laparotomy for the same. A case of pedunculated submucosal myoma that prolapsed during 26 weeks of pregnancy causing preterm labour was reported to be successfully managed by vaginal myomectomy.12 Postnatal complications of pedunculated uterine polyp include PPH, infection, necrosis, prolapse of the polyp and inversion of uterus if the polyp is large. A case of pedunculated submucosal fibroid of lower segment causing PPH is recently reported13 and two cases of infection and necrosis and prolapse were reported in older literature.14

This case illustrates the outcome of pregnancy when the placenta is implanted on the submucosal pedunculated fibroid polyp. Placenta accreta and hyaline change of the fibroid polyp were the outcome. Postpartum haemorrhage and inversion of uterus were prevented in this case because of recognition and prompt action in removing the adherent placenta along with fibroid polyp at LSCS.

Learning points

  • ▶ Placenta can get implanted on the pedunculated submucosal fibroid and can become morbidly adherent.
  • ▶ Fibroid polyp can undergo degenerative change during pregnancy.
  • ▶ Posterior submucous fibroids may not be visualised during late pregnancy.
  • ▶ Pedunculated submucosal fibroids can safely be removed at caesarean section.
  • Competing interests None.
  • Patient consent Obtained.

Footnotes

References

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. Submucosal uterine leiomyomas: diagnosis of prolapse into the cervix and vagina based on MR imaging. AJR Am J Roentgenol 1992;:555–8.

[Abstract/FREE Full text]

  1. ↵
    1. Lefebvre G,
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    3. Allaire C,
    4. et al

. The management of uterine leiomyomas. SOGC clinical practice guidelines. No. 128. J Obstet Gynaecol Can 2003;:396–405.

[Medline]

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    1. Goldenberg M,
    2. Sivan E,
    3. Sharabi Z,
    4. et al

. Outcome of hysteroscopic resection of submucous myomas for infertility. Fertil Steril 1995;:714–16.

[Medline][Web of Science]

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    1. Ubaldi F,
    2. Tournaye H,
    3. Camus M,
    4. et al

. Fertility after hysteroscopic myomectomy. Hum Reprod Update 1995;:81–90.

[Abstract/FREE Full text]

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    1. Casini ML,
    2. Rossi F,
    3. Agostini R,
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. Effects of the position of fibroids on fertility. Gynecol Endocrinol 2006;:106–9.

[CrossRef][Medline][Web of Science]

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    2. Ramachandran S,
    3. Shanti A,
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. Glycodelin levels in uterine flushings and in plasma of patients with leiomyomas and polyps: implications for implantation. Hum Reprod 2002;:2742–7.

[Abstract/FREE Full text]

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    3. Mancuso S

. Longitudinal evaluation of myoma growth during pregnancy. A sonographic study. J Ultrasound Med 1992;:511–15.

[Abstract]

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    1. Qidwai GI,
    2. Caughey AB,
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. Obstetric outcomes in women with sonographically identified uterine leiomyomata. Obstet Gynecol 2006;:376–82.

[Medline][Web of Science]

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. Obstetric complications of fibroids. Obstet Gynecol Clin North Am 2006;:153–69.

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. Placenta accreta- review. Obstet Gynecol Survey 1972;:475.

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[FREE Full text]

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Source: BMJ

 

Volumetric analysis of subarachnoid hemorrhage: assessment of the reliability of two computerized methods and their comparison with other radiographic scales.

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Object

There were two main purposes to this study: first, to assess the feasibility and reliability of 2 quantitative methods to assess bleeding volume in patients who suffered spontaneous subarachnoid hemorrhage (SAH), and second, to compare these methods to other qualitative and semiquantitative scales in terms of reliability and accuracy in predicting delayed cerebral ischemia (DCI) and outcome.

Methods

A prospective series of 150 patients consecutively admitted to the Hospital 12 de Octubre over a 4-year period were included in the study. All of these patients had a diagnosis of SAH, and diagnostic CT was able to be performed in the first 24 hours after the onset of the symptoms. All CT scans were evaluated by 2 independent observers in a blinded fashion, using 2 different quantitative methods to estimate the aneurysmal bleeding volume: region of interest (ROI) volume and the Cavalieri method. The images were also graded using the Fisher scale, modified Fisher scale, Claasen scale, and the semiquantitative Hijdra scale. Weighted κ coefficients were calculated for assessing the interobserver reliability of qualitative scales and the Hijdra scores. For assessing the intermethod and interrater reliability of volumetric measurements, intraclass correlation coefficients (ICCs) were used as well as the methodology proposed by Bland and Altman. Finally, weighted κ coefficients were calculated for the different quartiles of the volumetric measurements to make comparison with qualitative scales easier. Patients surviving more than 48 hours were included in the analysis of DCI predisposing factors and analyzed using the chi-square or the Mann-Whitney U-tests. Logistic regression analysis was used for predicting DCI and outcome in the different quartiles of bleeding volume to obtain adjusted ORs. The diagnostic accuracy of each scale was obtained by calculating the area under the receiver operating characteristic curve (AUC).

Results

Qualitative scores showed a moderate interobserver reproducibility (weighted κ indexes were always < 0.65), whereas the semiquantitative and quantitative scores had a very strong interobserver reproducibility. Reliability was very high for all quantitative measures as expressed by the ICCs for intermethod and interobserver agreement. Poor outcome and DCI occurred in 49% and 31% of patients, respectively. Larger bleeding volumes were related to a poorer outcome and a higher risk of developing DCI, and the proportion of patients suffering DCI or a poor outcome increased with each quartile, maintaining this relationship after adjusting for the main clinical factors related to outcome. Quantitative analysis of total bleeding volume achieved the highest AUC, and had a greater discriminative ability than the qualitative scales for predicting the development of DCI and outcome.

Conclusions

The use of quantitative measures may reduce interobserver variability in comparison with categorical scales. These measures are feasible using dedicated software and show a better prognostic capability in relation to outcome and DCI than conventional categorical scales.

Source: Journal of neurosurgery.

 

 

Resuming Warfarin After a GI Bleed: Benefits Appear to Outweigh the Risks .

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Many patients who’ve had a warfarin-associated gastrointestinal bleed can safely resume warfarin therapy soon after the bleeding event, according to an industry-funded, retrospective study in the Archives of Internal Medicine.

Researchers identified some 440 adults who experienced a GI bleed while taking warfarin; nearly 60% either stayed on warfarin continuously or resumed treatment within about a week (median time to retreatment, 4 days). Compared with patients who did not restart warfarin, those who continued or resumed treatment had a significantly lower 90-day incidence of thrombosis (0.4% vs. 5.5%) and death (6% vs. 20%). The most common causes of death were cancer, infection, and cardiac disease.

Patients who continued or restarted warfarin did have more recurrent GI bleeds (10% vs. 6%), but this difference did not achieve statistical significance. None of the recurrent bleeds were fatal.

Archives commentators conclude: “We believe that most patients with warfarin-associated GI bleeding and indications for continued long-term antithrombotic therapy should resume anticoagulation within the first week following the hemorrhage.”

Source: Archives of Internal Medicine

Warfarin plus Aspirin After Aortic Valve Prosthesis Placement?

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An observational study suggests that the combination reduces mortality, at the cost of increased bleeding, when used in the 3 months after surgery.

Patients receiving an aortic bioprosthesis have a low overall risk for thromboembolism, but controversy surrounds whether they benefit from anticoagulation in the first months after surgery. To address this issue, researchers used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to compare the effectiveness of the early use of aspirin alone, aspirin plus warfarin, and warfarin alone.

The sample included 25,656 patients aged 65 (median age, 77; 39% women) who received an isolated aortic valve prosthesis at 797 hospitals from 2004 through 2006. At 3 months, the mortality rate was 3.0% in the aspirin-only group, 3.1% in the aspirin-plus-warfarin group, and 4.0% in the warfarin-only group. In the multivariable analysis, the addition of warfarin to aspirin was associated with a 20% relative reduction in risk for death (0.6% absolute risk reduction). Mortality with warfarin alone was no different than with aspirin alone. The addition of warfarin to aspirin was associated with 48% relative reduction in the risk for embolic events (0.4% absolute risk reduction). Again, warfarin alone was not associated with a reduction. Bleeding was more common in patients treated with warfarin plus aspirin than in those treated with aspirin only or warfarin only (2.8% vs. 1.0% and 1.4%, respectively).

Comment: Absolute risks for death and embolic events are low in the 3 months after the placement of an aortic valve bioprosthesis, but the addition of warfarin to aspirin provided additional risk reduction in this observational study, at the cost of more bleeding. The authors recommend warfarin plus aspirin for those at low risk for bleeding, and I agree — we ought to be personalizing treatment based on the bleeding risk.

Source: Journal Watch Cardiology

Therapeutic vs. Prophylactic Platelet Transfusions

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Prophylactic platelet transfusions might not be needed for thrombocytopenic patients undergoing stem-cell transplantation, but are indicated for those receiving chemotherapy for acute myeloid leukemia.

Current practice is to give platelet transfusions to patients with hematologic malignancies when platelet counts decline to 10,000/µL. However, fewer platelet transfusions might be required if they were limited to thrombocytopenic patients with clinically important bleeding (WHO grade 2), regardless of the platelet count.

To determine the feasibility and safety of this approach, German investigators conducted a prospective, open-label, multicenter study involving 391 patients receiving chemotherapy for acute myeloid leukemia (AML) or undergoing stem-cell transplantation (SCT) for hematological cancers. Patients were randomized to receive platelet infusions when their morning platelet counts were 10,000/µL (prophylactic group) or only when they experienced grade 2 or higher bleeding (therapeutic group). Patients were assessed twice daily and all new bleeding, headaches, or other cerebral symptoms were investigated. Results were as follows:

  • The therapeutic group required fewer transfusions than the prophylactic group (mean, 1.63 vs. 2.44; P<0.0001), but experienced a higher rate of bleeding (42% vs. 19%; P<0.0001), including more grade 4 bleeding (5% vs. 1%; P=0.02).
  • AML patients experienced more bleeding than SCT patients (37% vs. 18%; P<0.0001); only AML patients experienced grade 4 bleeding, including two episodes of fatal cerebral hemorrhages in the therapeutic group.
  • The therapeutic and prophylactic groups experienced similar overall survival, number of red blood cell transfusions, duration of thrombocytopenia, and number of days in the hospital.

Comment: The indications for platelet transfusions require continued review, and pegging their use to a specific platelet count might not always be appropriate (JW Oncol Hematol Feb 17 2010). As this study shows, thrombocytopenic SCT patients infrequently experienced major hemorrhages, so therapeutic platelet transfusion might be more appropriate for this population. In contrast, predicting bleeding does not seem possible in thrombocytopenic AML patients, even with careful monitoring. So platelet transfusions only for bleeding might be more appropriate for these patients.

Source: Journal Watch Oncology and Hematology

HAS-BLED for Assessing Bleeding Risk with Anticoagulation: Best of the Mediocre.

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Notwithstanding a lackluster performance, HAS-BLED beat two other scoring systems in a comparative analysis of trial data.

Bleeding continues to be the Achilles heel of systemic anticoagulation, whether the agent used is warfarin or any of the new anticoagulants entering the market. Predictive models for bleeding include the following:

ATRIA (anticoagulation and risk factors in atrial fibrillation)

Investigators for the AMADEUS trial comparing warfarin with idraparinux (JW Gen Med Feb 26 2008) retrospectively applied all three scoring systems to the 2293 patients randomized to the warfarin arm. Although none of the three demonstrated more than modest efficacy in predicting any clinically relevant bleeding (c-index range, 0.50–0.60), HAS-BLED — the simplest to use — outperformed the others, especially with regard to intracranial hemorrhage (c-index, 0.75).

Comment: Although their predictive value is limited, these scoring systems quantify bleeding risk and thus are better than qualitative clinical judgment alone. The simple HAS-BLED model performed better than the others and is a reasonable tool to assess bleeding risk in clinical practice, at least for now.

Source: Journal Watch Cardiology