Foie et prééclampsie

HELLP syndrome complicates PE in 5 to 20 % of cases.     

Prévention de la prééclampsie

Aspirin has shown efficacy in preventing PE with a 10 % incidence reduction.     

Déficits rares de la coagulation et gestes invasifs

Rare inherited bleeding disorders include fibrinogen disorders, and deficiencies of factors II (prothrombin), V, VII, X, XI, XIII, and combined V + VIII, and combined vitamin K-dependent factors, with general population prevalence rates between 1/500,000 and 1/2,000,000. These inherited disorders, transmitted as autosomal recessive traits, are characterized by a heterogeneous clinical presentation (asymptomatic, mild, moderate or severe bleeding tendency); this variability is more important for deficiencies with factor levels ranging from 5 to 50%. Individual bleeding risk assessment before an invasive procedure or during peri-partum period remains difficult, although an essential step to decide whether a substitution with clotting factor is necessary or not. Because there is a poor correlation between factor activity levels and the severity of bleeding symptoms, factor correction before an invasive procedure should not be based on factor level only, but physicians must also take into account the patient phenotype as well as the haemorrhagic risk of the procedure.     

Dissection artérielle carotidienne bilatérale dans un contexte de prééclampsie sévère : une cause inhabituelle de céphalées du post-partum

A 30-year-old woman with severe preeclampsia presented at 27 weeks of amenorrhea with left headache, neck pain, blurred vision and numbness of left hemiface that resolved spontaneously within 2 hours. A week later, hypertension remained poorly controlled despite combination of nicardipine and labetalol intravenous therapy; an urgent caesarean section was eventually performed due to onset of HELLP syndrome. At day 5 postpartum, the patient had a Horner syndrome with right ipsilateral disabling tinnitus. A CT-angiography of supra-aortic trunks was performed urgently; it showed a bilateral carotid arterial dissection without stroke, which was subsequently confirmed by MRI angiography. The patient was transferred in neurovascular intensive care unit. Anticoagulant therapy was implemented to prevent cerebral and retinal ischemic lesions. Symptoms resolved quickly and the patient was discharged at day 7 postpartum. MR-angiography performed 4 months later showed a full resolution of the bilateral carotid dissection. Anticoagulant therapy was therefore discontinued.     

Principes généraux de la prise en charge hospitalière de la prééclampsie

The management of the PE patient requires admission in order to perform a meticulous assessment of the mothers’ and fetal state, distinguishing between the severe and the mild forms.     

Prise en charge pré- et interhospitalière des formes graves de prééclampsie

Prior to transport, agreement must be reached among all the senior medical staff members involved in the transfer. Tight clinical surveillance is necessary during the transport.     

Rein et prééclampsie

During normal pregnancy, renal blood flow and GFR increase gradually until they reach a peak of about 150% of their normal values by the end of the 1^st trimester.     

Manifestations hémodynamiques et respiratoires de la prééclampsie

The hemodynamic and cardiovascular changes seen during PE vary according to the natural history of the disease, its severity and eventual therapeutic measures taken.     

Placenta de la prééclampsie : lésions anatomiques et corrélations anatomocliniques

The histopathological examination of the placenta is part of the investigational workout since it is a convenient method of examining the central organ involved in the disease process.     

Chirurgie arthroscopique de l’épaule et complications ischémiques cérébrales

The authors report three cases in which cerebral ischemia occurred during arthroscopic shoulder surgery performed in beach chair position under general anaesthesia and interscalene plexus block. Several similar cases have been published in the literature. This rare but extremely severe complication is related to the decrease in cerebral perfusion pressure (CPP). Monitoring of CPP in the beach chair position using the measurement of arterial pressure and taking into account the hydrostatic gradient is essential. Prevention includes correction of preoperative hypovolaemia, treatment of postural arterial hypotension, adequate installation of the patient's head, aggressive treatment of perioperative arterial hypotension (whatever the cause) and avoidance of deliberate perioperative arterial hypotension. Routine use of non-invasive monitoring of cerebral oxygenation has been advocated to avoid this accident but its usefulness has to be confirmed by clinical studies.     

Évaluation de l’utilisation du sulfate de magnésium dans la prévention secondaire de l’éclampsie : étude rétrospective sur 39 cas

Introduction

The use of magnesium sulfate (MgSO₄) has been advocated since 2000 in France in the management of eclampsia. The aim of this study was to determine the frequency of use of this treatment for eclampsia in a French department.

Patients and methods

All patients obstetrical patients admitted to Critical Care Units of Seine-Maritime for eclampsia over a period of 7 years (2002–2008) were included. Obstetric data, the treatment used for eclampsia and pre-eclampsia and maternofetal complications were collected. The primary outcome parameter was the use of MgSO₄ in the secondary prevention of eclampsia.

Results

Thirty-nine patients were included. Nineteen patients (48%) had eclampsia in prepartum, three (8%) in per-partum and 17 (44%) in post-partum periods. The use of MgSO₄ in the secondary prevention of eclampsia was observed in 92% of cases (36/39). Primary prevention was seen in 8% of cases. The duration of treatment was 2 days (1–7 days). The maternal and perinatal mortality was respectively 2.5 and 11%.

Conclusion

In this study, the use of MgSO₄ in the secondary prevention is frequent. This result emphasizes the importance of the recommendations of learned societies in the homogenization of the management of rare but serious conditions such as eclampsia.     

Hémostase et prééclampsie

Clotting disorders are associated with the severe, early and complicated forms of PE. Compensated hypercoagulability states associated with a thrombocytopenia (PLT < 150k/mm³) affect 25 to 50% of severe PE patients. Laboratory markers of platelet and endothelial activation are the early increase of fibronectin levels, the worsening of the thrombocytopenia and the raised platelet turnover. The excessive thrombin formation is physiologically compensated by a rise in thrombin-antithrombin (TAT) complex levels, which is the most specific marker of a PE pregnancy, and a decrease in anti-thrombin (AT) activity. The placenta induced depression of the fibrinolysis appears to contribute towards the hypercoagulable state. The etiological importance of the erythrocyte and leucocyte activation with regards to the abnormal clotting activation is highlighted in the setting of maternal systematic inflammatory disease. The state of compensated coagulopathy found in the PE patient can suffer a pro-coagulatory imbalance because of a quantitative, or a qualitative failure (i.e. thrombophilia) of the physiological coagulation inhibitors, or a combination of both. This disseminated intravascular coagulation, qualified as chronic, is associated with clinically evident signs of fœto-placental unit impairment (i.e. IUGR, foetal death) with or without systemic repercussions in the mother (i.e. renal failure, HELLP syndrome, eclampsia). This set of haemostatic disturbances found in the PE patient is a dynamic phenomenon, which can evolve by the hour therefore requires frequent laboratory investigations. Delivery remains the only curative treatment for these haemostatic disturbances. A better understanding of the aetiology of DIC in PE, an early detection method and a specific identification of the at-risk patients could allow prophylactic and curative treatment.     

Épidémiologie

In France, the incidence of PE is estimated to range between 1 and 3% in the nuliparous and between 0.5 and 1.5% in the multiparous women. Factors associated with the development of PE are ofvarious types. Studies conducted on families affected by PE suggest the existence of a genetic component to the disease, even though the association between PE and certain genes, allotypes and polymorphisms are still under scrutiny. The hypotheses suggesting an immunological mechanism is supported by several arguments. Indeed, being nuliparous, changing partner, insemination with donor semen are factors associated with the development of PE whereas pre-exposition to the father's sperm bears protection.     

Impact d’une démarche d’évaluation des pratiques professionnelles sur l’utilisation du monitorage de la curarisation et l’antagonisation des curares

Introduction

As part of a quality assurance in the anaesthesia department, this study was designed to enhance the rate of neuromuscular blockade monitoring for patients receiving muscle relaxant during anaesthesia.

Methods

After approval of our local ethical committee, we assessed 200 computerized anaesthesia records in which neuromuscular relaxants were used. The following data were collected: demographic characteristics, durations of anaesthesia and surgery, use of neuromuscular monitoring, reversal agents and the quality of neuromuscular monitoring. The results were discussed with all anaesthesia providers of the department and an internal guideline was elaborated with the endpoint that all patients having muscle relaxants should have quantitative neuromuscular monitoring. Six months later, another assessment of 200 consecutive records collected the same data to check the efficiency of the elaborated guideline.

Results

The monitoring rate was of 67% at the first assessment and increased to 94% (p < 0.05). The reversal rate was at 48% in the first assessment and was stable at the second assessment (50%). The rate of patients not monitored and not reversed decreased from 5 to 2% (p < 0.05).

Discussion

This study shows that as part of a quality assurance program systematic quantitative monitoring of neuromuscular blockade can be significantly increased.     

Monitorage continu et automatisé de la précharge dépendance en anesthésie et en réanimation : intérêts et limites

Objectives

To describe preload dependence monitoring tools currently available as well as their limits and potential applications in the anaesthesiology setting.

Data source

References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: fluid responsiveness, cardiopulmonary interactions, preload dependence, hypovolemia, cardiac output.

Data synthesis

When measured in optimal conditions, dynamic parameters are the best predictors of fluid responsiveness as compared to static indicators in patients under general anaesthesia and mechanical ventilation. These dynamic parameters rely on cardiopulmonary interactions and allow evaluating preload dependence and the ability of the heart to transform an increase in preload into an increase in cardiac output. Recently, it is possible to monitor these dynamic parameters either invasively (from the arterial pressure waveform) or noninvasively (from the plethysmographic waveform). These tools have intrinsic limitations. However, they have potential to be used for fluid optimization during anaesthesia.     

Décision médicale chez la personne très âgée : à propos d’un cas d’application de la loi Leonetti en médecine d’urgence

Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in accordance with the spirit of the law.