Pulmonary embolism associated with transfusion after severe post-partum haemorrhage: is less more?

Spontaneous uterine rupture complicated by bilateral pulmonary emboli: A case report

Spontaneous uterine rupture in unscarred uteri complicated by pulmonary emboli is a rare event with major maternal morbidity and mortality. This is a case of a 32-year-old woman, G1P0, at term, with no pertinent past medical/surgical history, who underwent an emergency cesarean delivery for failed induction of labor complicated by uterine rupture. Post-operatively, the patient was tachycardic and hypoxic. CT arteriogram revealed massive bilateral pulmonary emboli, and she was transferred for specialist care. An emergency pulmonary embolectomy and implantation of an extracorporeal right ventricular assist device were performed. Once the patient was clinically stable, an evaluation for thrombophilias and collagen disorders was done, and was positive for a variant of unknown significance in the ELN gene (c.205G > C). This case report highlights a potential connection between uterine ruptures, hemorrhage, and multiple, large pulmonary emboli. The authors propose a multidisciplinary discussion and evaluation to identify risk factors and biologic causes for these rare but life-threatening complications.

Hormones and thrombosis: the dark side of the moon

BACKGROUND

The main drawback of oral contraceptives (OC) and hormone replacement therapy (HRT) is an increased risk of venous and, to a lesser extent, arterial thrombosis.

MATERIALS AND METHODS

This narrative, case-based review describes the effect of available estrogens and progestogens on the hemostatic system and their potential impact on the risk of thrombosis. Clinical cases are used to illustrate different options for prescribing OC and HRT in the real-word. The aim is to offer discussion topics that could be helpful to guide the choice of different hormonal treatments over a woman's lifetime and in the presence of risk factors.

RESULTS

We describe physio-pathological changes occurring during the administration of hormonal therapies. Furthermore, we analyze the risk of venous and arterial thrombosis associated with different products, routes of administration and additional risk factors. New hormonal preparations, such as estradiol combined with dienogest, as well as non-oral hormonal therapies, are suggested to decrease thrombotic risk significantly.

DISCUSSION

The availability of many products and different routes of administration allow most women to safely use contraception, as well as HRT. We encourage careful counselling instead of inflexible or fearful behavior, as expanding options and choices will allow women to make the best decisions for their health.

Mortality and clinical outcome of Italian patients undergoing orthopaedic surgery: effect of peri-operative blood transfusion

BACKGROUND

Blood transfusion is a relevant issue for elderly and frail patients, as they are often anaemic and have chronic diseases. Transfusion of red blood cells (RBC) can potentially affect morbidity and mortality of elderly patients undergoing major orthopaedic surgery.

MATERIALS AND METHODS

We carried out a retrospective analysis of 2,593 patients undergoing major orthopaedic surgery between 2013 and 2017 in a single research institution in the Region of Apulia. The aims of the study were: 1) to describe the characteristics of transfused patients according to a restrictive or liberal strategy of transfusion and haemoglobin (Hb) triggers and targets; 2) to investigate the effect of RBC transfusion on mortality and complications.

RESULTS

Older, women and patients with American Society of Anesthesiologists (ASA) score 3-4 were more often transfused. Those with lower admission Hb level had a higher risk of being transfused. Hb triggers were associated with the patients' age. A restrictive transfusion strategy was significantly more frequent in patients undergoing primary knee replacement and in those with higher estimated blood loss. We did not observe any significant difference of complications in patients transfused with a liberal vs restrictive strategy. Logistic regression correcting for potential confounders revealed that sex (males more than females), duration of stay in hospital, hip fracture and Charlson score >4 were good predictors of complications and/or mortality. Mortality was significantly higher in males and in older patients with ASA score 3-4.

DISCUSSION

In this large cohort of Italian patients undergoing major orthopaedic surgery males were significantly more exposed than women to complications and in-hospital mortality. Furthermore, those undergoing urgent surgery because of hip fracture had a 3-fold higher chance of complications. Charlson score >4 and ASA 3-4 are good predictors of complications and mortality, respectively.