Fahmy's four quadrant sutures: a new technique for control of blood loss during cesarean delivery for placenta previa

Background: The objective of this study is to assess the efficacy and safety of Fahmy's four quadrant suture technique (FFQS) in controlling blood loss during cesarean delivery for placenta previa (PP).Methods: The study was carried out in a tertiary University Hospital between January 2017 to December 2017 involved 12 women with heavy bleeding occurred after removal of the placenta from the lower section during cesarean delivery for PP. The FFQS technique consisted of two sutures to ligate the uterine branches on both sides and two sutures on the anterior and posterior wall of the lower uterine segment. Details regarding the management and maternal outcomes were recorded.Results: The mean age of the study participants was 29.58±5.29 years and the mean parity was 2.25±1.14. The mean gestational age at termination of pregnancy was 36.91±1.38 weeks.  The mean duration of the whole surgery was 78.75±43.28 minutes, while the mean duration of FFQS technique was only 10±2.09 minutes. The technique was exclusively effective in 8 out of 12 cases (66.67%) while 2 cases needed bilateral internal iliac artery ligation and 2 cases needed hysterectomy. The mean amount of blood loss in all cases was 2433.33±833.76 ml. the mean amount of transfused packed RBCs was 3.92±1.68 units and fresh frozen plasma (FFP) was 3.42±1.44 units. All cases had uneventful postoperative course and no mortality cases in present series.Conclusions: The new technique; FFQS represents a rapid, effective, and inexpensive opportunity for women with bleeding from the lower segment of uterus due to PP. This simple procedure should be attempted before other complex measures to achieve good hemostasis

Mechanical Thrombectomy for Acute Ischemic Stroke in Metastatic Cancer Patients: A Nationwide Cross-Sectional Analysis

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke. Patients with active malignancy have an increased risk of stroke but were excluded from MT trials. METHODS: We searched the National Readmission Database for LVO patients treated with MT between 2016-2018 and compared the characteristics and outcomes of cancer-free patients to those with metastatic cancer (MC). Primary outcomes were all-cause in-hospital mortality and favorable outcome, defined as a routine discharge to home (regardless of whether home services were provided or not). Multivariate regression was used to adjust for confounders. RESULTS: Of 40,537 LVO patients treated with MT, 933 (2.3%) had MC diagnosis. Compared to cancer-free patients, MC patients were similar in age and stroke severity but had greater overall disease severity. Hospital complications that occurred more frequently in MC included pneumonia, sepsis, acute coronary syndrome, deep vein thrombosis, and pulmonary embolism (P\u3c0.001). Patients with MC had similar rates of intracerebral hemorrhage (20% vs. 21%) but were less likely to receive tissue plasminogen activator (13% vs. 23%, P\u3c0.001). In unadjusted analysis, MC patients as compared to cancer-free patients had a higher in-hospital mortality rate and were less likely to be discharged to home (36% vs. 42%, P=0.014). On multivariate regression adjusting for confounders, mortality was the only outcome that was significantly higher in the MC group than in the cancerfree group (P\u3c0.001). CONCLUSION: LVO patients with MC have higher mortality and more infectious and thrombotic complications than cancer-free patients. MT nonetheless can result in survival with good outcome in slightly over one-third of patients

Short-term Outcomes of Hypertensive Crises in Patients with Orthostatic Hypotension

INTRODUCTION: Supine hypertension-orthostatic hypotension disease (SH-OH) poses a management challenge to clinicians. Data on short term outcomes of patients with OH who are hospitalized with hypertensive (HTN) crises is lacking METHODS: The Nationwide Readmission Database 2016-2019 was queried for all hospitalizations of HTN crises. Hospitalizations were stratified according to whether OH was present or not. We employed propensity score to match hospitalizations for patients with OH to those without, at 1:1 ratio. Outcomes evaluated were 30-days readmission with HTN crises or falls, as well as hospital outcomes of in-hospital mortality, acute kidney injury (AKI), acute congestive heart failure (CHF), acute coronary syndrome (ACS), type 2 myocardial infarction (T2MI), aortic dissection, stroke, length of stay (LOS), discharge to nursing home and hospitalization costs. RESULTS: We included a total of 9,451 hospitalization (4,735 in the OH group vs 4,716 in the control group). OH group was more likely to be readmitted with falls (Odds ratio [OR]:3.27, p\u3c0.01) but not with HTN crises(p=0.05). Both groups had similar likelihood of developing AKI (p=0.08), stroke/TIA (p=0.52), and aortic dissection(p=0.66). Alternatively, OH group were less likely to develop acute HF (OR:0.54, p\u3c0.01) or ACS (OR:0.39, p\u3c0.01) in the setting of HTN crises than non-OH group. OH group were more likely to have longer LOS and have higher hospitalization costs. CONCLUSION: Patients with OH who are admitted with HTN crises tend to have similar or lower HTN-related complications to non-OH group while having higher likelihood of readmission with falls, LOS and hospitalization costs. Further studies are needed to confirm such findings

An advanced second trimester tubal pregnancy: Case report

Background: Lack of early ultrasound examination and proper antenatal care in rural areas explain why most ectopic pregnancies are presented to our center only after they become disturbed. However, this is almost always restricted to the first trimester. Case: A middle aged woman presented with acute abdomen and hemodynamic instability was admitted at our emergency department. History revealed an unexpected definite period of amenorrhea of 18 weeks and 2 days duration and pregnancy test was found positive. Ultrasound examination showed hemoperitoneum and a right large adnexal swelling with a viable fetus inside and as such immediate exploration was decided. Laparotomy revealed profound intra-abdominal and pelvic blood collection and an advanced right tubal pregnancy with intact gestational sac. Right salpingectomy was done and the patient had a smooth postoperative course until being discharged. Conclusion: According to this case, tubal pregnancy should always be considered even in the second trimester if the clinical presentation is relevant, and ultrasound examination is mandatory to identify pregnancy location