Cerebro-meningeal hemorrhage secondary to ruptured vascular malformation during pregnancy and post-partum

Thirty two new cases of vascular malformations discovered during pregnancy were reviewed in a multicentric retrospective study and compared to the literature. The authors studied both the influence of pregnancy and post-partum on cerebral vascular malformations and the corresponding neurosurgical and obstetrical management. The relative frequencies of arteriovenous malformations (AVMs) and arterial aneurysms (AAs) is the same for pregnant and non-pregnant women. Pregnancy does not increase the risk of first bleeding of vascular malformations but the risk of re-bleeding is increased for AVMs. The bleeding of a vascular malformation is more strongly correlated to age than to parity. The mean maternal age at the time of rupture is greater for AAs than for AVMs, as it is in the general population. The bleeding of a vascular malformations occurs more frequently during the second and third trimesters of pregnancy than in the first one and in the post-partum. Labor and delivery are not great-risk-periods. Management of vascular malformation in pregnant woman is proposed as follow : --a ruptured AA or AVM is managed as it is in non-pregnant woman, whatever the gestational age; no fetal extraction needs to be performed except ed if the rupture occurs at the very end of the pregnancy;--an non-ruptured AVM discovered during pregnancy is treated after delivery; an non-ruptured AVM that never bled before pregnancy is managed in the same way that an non-ruptured AA.     

Protein C deficiency and cerebral venous thrombosis in pregnancy

A fatal case of cerebral venous thrombosis associated with protein C deficiency is reported. It occurred at six months of gestation in a 25 year old patient during her first pregnancy. She had generalized seizures. Computed axial tomography displayed cerebral haemorrhagic infarction, and the carotid angiograms signs of superior longitudinal sinus thrombosis. Before the patient's death on the seventh day after admission, protein C deficiency was discovered. The occurrence of thrombosis of the superior longitudinal sinus during pregnancy, as well as that of protein C deficiency in atypical cases of thromboembolic disease, are discussed.     

Bone remodeling during pregnancy and post-partum assessed by metal lead levels and isotopic concentrations

Bone remodeling is normally evaluated using bone turnover markers/indices as indicators of bone resorption and formation. However, during pregnancy and post-partum, there have been inconsistent results between and within biomarkers for bone formation and resorption. These differences may relate to pregnancy-related changes in metabolism and/or hemodilution altering measured marker levels. An alternative approach to evaluating bone remodeling is to use the metal lead (Pb) concentrations and Pb isotopic compositions in blood. These measurements can also provide information on the amount of Pb that is mobilized from the maternal skeleton. Despite some similarities with accepted bone turnover markers, the Pb data demonstrate increased bone resorption throughout pregnancy that further continues post-partum independent of length of breast-feeding, dietary intake and resumption of menses. Furthermore the isotopic measurements are not affected by hemodilution. These data confirm calcium balance studies that indicate increased bone resorption throughout pregnancy and lactation. They also indicate potentially major public health implications of the transfer of maternal Pb burden to the fetus and new born.     

Vascular access thrombosis prophylaxis

Vascular access thrombosis in the hemodialysis patient leads to significant cost and morbidity. Fistula patency supersedes graft patency, therefore obtaining a mature functioning fistula in patients approaching end-stage renal disease (ESRD) by early patient education and referral needs to be practiced. Current methods to maintain vascular access patency rely on early detection and radiologic or surgical prevention of thrombosis. Study of thrombosis biology has elucidated other potential targets for the prophylaxis of vascular access thrombosis. The goal of this review is to examine the current available methods for vascular access thrombosis prophylaxis.     

Vascular malformations and pregnancy

Between January 1975 and June 1989, 240 patients with cerebral vascular malformations were treated at Henry Ford Hospital. In 16 of the patients, the treatment was influenced by pregnancy. Eleven of the patients presented with hemorrhage, four with seizures, and one with hydrocephalus. There were no maternal or fetal deaths in the patients presenting with seizure or hydrocephalus. There were two maternal deaths and one fetal death among the cases presenting with hemorrhage. In the patients with seizure or hydrocephalus, the pregnancy was brought to term and obstetric indications used to determine the time and method of delivery. Hydrocephalus was treated by shunting, and seizures with medication. Antiepileptic drug levels fluctuate in pregnancy and hence were closely monitored to ensure therapeutic levels. Vascular malformations are the most common cause of subarachnoid hemorrhage in pregnancy. The risk of rebleed in the same pregnancy is about 27%. If an arteriovenous malformation ruptures during pregnancy and the patient's condition deteriorates, appropriate emergency surgery should be done. In stable patients, our policy has been to bring the pregnancy to term and then electively perform a craniotomy to excise the arteriovenous malformation.     

Combination HIV prevention during pregnancy and the post-partum period in Malawi and Zambia: a mathematical modelling analysis

Introduction

Despite widespread success in reducing vertical HIV transmission, most antenatal care (ANC) programmes in eastern and southern Africa have not emphasized primary prevention of maternal HIV acquisition during pregnancy and lactation/breastfeeding. We hypothesized that combination HIV prevention interventions initiated alongside ANC could substantially reduce maternal HIV incidence.

Methods

We constructed a multi-state model describing male-to-female HIV transmission in steady heterosexual partnerships during pregnancy and lactation/breastfeeding, with initial conditions based on population distribution estimates for Malawi and Zambia in 2020. We modelled individual and joint increases in three HIV prevention strategies at or soon after ANC initiation: (1) HIV testing of male partners, resulting in HIV diagnosis and less condomless sex among those with previously undiagnosed HIV; (2) initiation (or re-initiation) of suppressive antiretroviral therapy (ART) for male partners with diagnosed but unsuppressed HIV; and (3) adherent pre-exposure prophylaxis (PrEP) for HIV-negative female ANC patients with HIV-diagnosed or unknown-status male partners. We estimated the percentage of within-couple, male-to-female HIV transmissions that could be averted during pregnancy and lactation/breastfeeding with these strategies, relative to base-case conditions in which 45% of undiagnosed male partners become newly HIV diagnosed via testing, 75% of male partners with diagnosed but unsuppressed HIV initiate/re-initiate ART and 0% of female ANC patients start PrEP.

Results

Increasing uptake of any single strategy by 20 percentage points above base-case levels averted 10%−11% of maternal HIV acquisitions during pregnancy and lactation/breastfeeding in the model. Joint uptake increases of 20 percentage points in two interventions averted an estimated 19%−23% of transmissions, and with a 20-percentage-point increase in uptake of all three interventions, 29% were averted. Strategies achieving 95% male testing, 90% male ART initiation/re-initiation and 40% female PrEP use reduced incident infections by 45%.

Conclusions

Combination HIV prevention strategies provided alongside ANC and sustained through the post-partum period could substantially reduce maternal HIV incidence during pregnancy and lactation/breastfeeding in eastern and southern Africa.     

Vascular plasminogen activator and deep vein thrombosis

In attempts to determine the aetiology of deep vein thrombosis (DVT) it has been established that some patients with a history of lower limb DVT have a low level of vascular plasminogen activator (VPA) in their superficial hand veins and this combined with a poor VPA release is thought to predispose to thrombosis (1). Hand veins rarely develop thrombosis and so the level of VPA has been measured quantitatively in the more commonly at risk veins of the lower limb. In 6 limbs operated on for varicose veins, paired samples of vein from the groin and from the calf were examined. The median activity score for the groin veins (8138 cpm/micrograms) was significantly higher than the activity in the calf veins (2353 cm/micrograms)(P = 0.01). In 9 limbs amputated for critical ischaemia, paired samples of calf long saphenous vein and soleal vein were examined. The VPA in the former was 1675 cpm/micrograms compared with 6796 cpm/micrograms in the soleal veins. This difference is significant at the 1 per cent level. A correlation has been shown between the VPA content of these two sets of veins (R = 0.87). The low level of VPA in the superficial calf veins may be an aetiological factor in superficial thrombophlebitis, but the commonest site for DVT, the soleal veins of the calf, have a high level of VPA.     

Does caesarean section negatively influence the post-partum prognosis of low back pain and pelvic pain during pregnancy?

Low back and pelvic pain (LBPP) is prevalent during pregnancy and also post-partum. The aetiology is poorly understood. The aim of this study was to investigate possible associations between epidural or spinal anaesthesia and caesarean section (CS) with persistent LBPP half a year after pregnancy. In a previous questionnaire study (n=891) altogether 639 (72%) women had reported LBPP during pregnancy. We sent these respondents a second questionnaire at approximately 6 months post-delivery. The response rate was 72.6% (n=464). The respondents were divided into three groups reporting ‘no pain’, ‘recurrent pain’ and ‘continuous pain’ in relation to LBPP 6 months after delivery. Pearson’s chi-square test was used to test the difference between groups and logistic regression analysis was performed. Forty percent of the respondents had received epidural anaesthesia (EDA) or spinal anaesthesia during delivery and 18.5% of women had been delivered by CS. Epidural or spinal anaesthesia was not associated with persistent LBPP. There was no significant difference in CS rates between different sub-groups. The risk of persistent LBPP was increased three- to fourfold in women delivered by elective CS compared with women delivered by emergency CS. Epidural or spinal anaesthesia was not associated with risk of persistent LBPP. Elective CS was associated with an increased risk of persistent LBPP. However, the results must be interpreted with caution because of a relatively small study sample.     

Morphometric analysis of pre-eclampsia in women biopsied in pregnancy and post-partum

The importance of endothelial cell swelling and subepithelial deposits in producing capillary wall thickening in women with pre-eclampsia is controversial. In this study renal biopsy tissue from 16 women with a diagnosis of pre-eclampsia was analyzed morphometrically. Women biopsied during pregnancy (N = 6) showed substantial, electron-dense subendothelial deposits in capillary loops, but these were rare or absent in women (N = 10) biopsied post-partum (P less than 0.01). Endothelial cell swelling was present in both groups of patients to an equal degree. Mesangial cell interposition occurred but was not the dominant feature, and was similar in both pregnancy and post-partum biopsies. The median percentage per patient occupied by basement membrane was similar for both groups. Subendothelial deposits appear to resolve early in the post-partum period.     

围产期并发下肢深静脉血栓的治疗

对32例围产期并发下肢深静脉血栓患者进行治疗分析，病程在1周内者行腔内手术治疗，即滤器置入加取栓管取血栓，尽可能取出新鲜血栓，同时预防肺栓塞。病程>1周者行非手术治疗，即抗凝加溶栓药物；通过足背静脉注射尿激酶，以提高局部药物浓度。二者均取得良好效果。     

A successfully operated case of prosthetic valve thrombosis during planned pregnancy.

The patient was a 29-year-old woman who, when she was an 8-year-old, had undergone atrial septal defect (ASD) closure and mitral valve replacement (MVR) using a Bj?rk-Shiley valve (25 mm) for Lutembacher syndrome. Because of a planned pregnancy, warfarin had been replaced by heparin. During the 7th week of pregnancy, she was admitted to our hospital because of dyspnea. She was diagnosed with acute heart failure due to prosthetic valve thrombosis. Following termination of pregnancy, the mitral valve was replaced with an ATS valve (25 mm). She was discharged 10 days after surgery without complications.     

Dural sinus and cerebral venous thrombosis

Eighty patients with 'primary' dural sinus and cerebral venous thrombosis were seen over a period of 16 years. There was an equal distribution amongst the sexes and the largest number of patients presented in the third decade. The commonest predisposing factors were puerperium, pregnancy, synthetic steroid contraceptives and anaemia. Seventy patients presented in an acute fashion with headache, focal or generalized seizures and focal neurological deficits. Ten patients presented in a subacute to chronic manner, with features to suggest an intracerebral space-occupying lesion. The investigation of choice was angiography. Thirty-five patients were treated conservatively with anticonvulsants, low molecular weight dextran and anti-oedema measures. Anti-coagulants were not used for fear of haemorrhage in the associated red infarcts. Antibiotics were not needed as infection played no part in the pathogenesis. Thirty-four patients needed an operation which took the form of a decompressive craniotomy and dural closure with the aid of a pericranial graft. The conservatively treated group appeared to fare better only because it included patients with a milder ictus. Forty patients improved, three remained unchanged and 37 expired. Autopsy in the 35 of the 37 patients showed cortical vein and sinus thrombosis and oedema with a haemorrhagic infarct. Long term follow-up showed good recovery of neurological function, but epilepsy was a troublesome sequel and needs regular anti-epileptic drug treatment.     

Deep venous thrombosis during pregnancy and after delivery: indications for and results of thrombectomy

PURPOSE: Pregnancy and the puerperium are time periods of an increased risk for venous thromboembolism. An ideal treatment should lead to complete restoration of the venous lumen, elimination of the embolic source, and prevention of severe postphlebitic syndrome. Anticoagulation therapy with heparin or thrombectomy are treatment options. In the current literature, these options are discussed controversially. METHODS: From January 1982 to December 2001, 97 women underwent (93% transfemoral) thrombectomy and construction of an arteriovenous fistula (AVF) for deep venous thrombosis related to pregnancy. The clinical and coagulation parameters were evaluated. The AVF was ligated 3 to 6 months later. Follow-up with duplex ultrasound scan, photoplethysmography, and strain-gauge plethysmography was completed in 87 women. RESULTS: Surgery was performed without any maternal death or pulmonary embolization. A cesarean section was carried out during the same anesthesia in 11 cases. Thrombectomy was completed with construction of a temporary AVF in 90 patients (92.8%). One fetal death occurred in the recovery room for unknown reasons. In the early postoperative course, 16 patients (16.5%) underwent redo surgery for rethrombosis with or without the occlusion of the fistula. In 14 of these patients, the venous system remained patent thereafter. Fetal or neonatal death occurred in five cases 2 to 10 weeks after surgery, mainly because of abruption of the placenta probably from anticoagulation. Among 247 preoperatively occluded anatomic regions, 221 could be restored, and the secondary patency rate amounted to 89.5%. After a mean follow-up period of 6 years, 49 patients (56.3%) were seen without a postphlebitic syndrome, and only three patients (3.5%) had had a leg ulcer develop. CONCLUSION: In experienced hands, venous thrombectomy is a safe method to prevent pulmonary embolism and postphlebitic syndrome in women during pregnancy and the puerperium. The frequency of a severe postphlebitic syndrome after our surgical approach is lower than the rates published for anticoagulation treatment alone.     

Imaging of cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is a potentially life-threatening emergency. The wide ranging of clinical symptoms makes the use of imaging in “slices” even more important for diagnosis. Both CT and MRI are used to diagnose the occlusion of a venous sinus, but MRI is superior to CT for detecting a clot in the cortical or deep veins. CT can show the hyperintense clot spontaneously and CT angiography the intraluminal defect. MRI also detects this thrombus, whose signal varies over time: in the acute phase, it is hypointense in T2*, whilst T1 and T2 can appear falsely reassuring; in the subacute phase, it is hyperintense on all sequences (T1, T2, FLAIR, T2*, diffusion). MRI easily shows the ischemic damage, even hemorrhagic, in the cerebral parenchyma in cases of CVT. Finally, imaging may reveal pathology at the origin of the CVT, such as a fracture of the skull, infection, tumor, dural fistula, or intracranial hypotension.