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Within 4 hours of admission, patient haemoglobin had dropped from The otolaryngologist did not consider a posterior nasal packing because the endoscopy showed an anterior bleeding site.
A new endoscopy to locate the exact site of bleeding for direct cauterization was not indicated in acute setting due to vascular congestion and mucosal oedema. Patient clotting studies were within the normal range.
A blood transfusion was required, using two packed red blood cells PRBCs. The patient also started antibiotic therapy with IV Cephazolin 2 g every 8 hours.
Physiological changes in pregnancy
Cardiotocography CTG , biophysical profile, and fetal Doppler demonstrated fetal well-being. During her second day of admission, repeated blood tests showed that her haemoglobin remained persistently low at 7. The patient became tachycardic rate bpm , tachypnoeic 22 breaths per minute , and asthenic. After accurate counselling with the patient and considering the failure of conservative treatment, we thereby decided for a surgical management of pregnancy.
The patient delivered a healthy baby girl weighing 3. The execution of caesarean section was followed by an immediate resolution of the nasal bleeding.
We discharged the patient from the hospital with nasal packing, in order to ensure the formation of an adequate clot. Five days later, the otolaryngologist performed an endoscopy to locate the exact site of bleeding for direct cauterization. The patient experienced no other episodes of epistaxis. Discussion Epistaxis in pregnancy is common but the vast majority of cases do not require medical attention.
The prevalence of epistaxis in pregnant women is more than three times that in nonpregnant ones [ 1 ]. Several conditions predispose to epistaxis during pregnancy. In particular, the elevated oestrogen levels increase the vascularity of the nasal mucosa [ 10 ], which may potentiate and prolong the bleeding.
The Malaria in Pregnancy Library: a bibliometric review
Progesterone causes an increase in blood volume, which may exacerbate both vascular congestion and hence bleeding, and may mask blood loss in the event of severe epistaxis, due to apparently effective cardiovascular compensation [ 11 ]. Placental growth hormone has systemic effects, including vasodilation [ 11 ]. Indirect hormonal effects include vascular inflammatory and immunological changes that may predispose to nasal hypersensitivity and hence to problems such as nasal granuloma gravidarum [ 11 ].
In general, delivery or fetal death causes immediate cessation of the nasal bleeding, because some of the underlying factors, such as congestion and hyperemia, disappear. Few cases of severe epistaxis during pregnancy were described in literature [ 2 — 8 , 12 ] Table 1. We excluded cases of epistaxis associated with nasal lesions, like granuloma gravidarum [ 9 ] and nasal polyp [ 13 ], or clotting disorders [ 14 ].
Table 1: Cases of severe epistaxis during pregnancy not associated with nasal lesion or clotting disorders. Treatment of severe epistaxis must always consider conservative measures first-line, like IV tranexamic acid administration, anterior packing and bipolar cautery.
If conservative treatment fails, two radical treatments have to be considered: the one is surgical, in the form of vessel ligation, and the other is obstetrical and is termination of the pregnancy. In our case, the patient clinical worsening and the failure of conservative treatment imposed an emergency caesarean section.
The cervix was unfavorable for easy induction and a long induction of labor was considered contraindicated for this patient. Valsalva maneuvers could also aggravate the bleeding during labor, increasing the risk of fetal hypoxia.
The decision to deliver was also influenced by the gestational age; in fact in the case of a preterm pregnancy, when maternal and fetal conditions are good, a conservative management is preferred, in order to avoid the possible risks associated with preterm birth.
Fetal anemia is a well-known cause of antenatal fetal distress. The case report by Braithwaite JM et al. Severe epistaxis is potentially life-threatening to both mother and fetus.
This case highlights the importance of early recourse to ear, nose, and throat ENT referral, when epistaxis is unresponsive to simple measures. Moreover, pregnancy is associated with significant anatomic and physiologic remodeling of the cardiovascular system.
Termination of pregnancy resolves hypervolemia and hormonal changes; in fact in all the cases reported in Table 1 , we can observe a nasal bleeding resolution after delivery. Conflicts of Interest The authors declare that they have no conflicts of interest.
References M. Dugan-Kim, S. Connell, C. Stika, C. Wong, and D. Green, R. Green, and R. El Goulli and M. View at Google Scholar D. Altogether, guidelines give inconsistent and highly variable information regarding the safety of lithium use during pregnancy.
To guide clinicians in their decision making we provide a narrative review of the literature on efficacy of lithium use in the perinatal period and the risks for mother and child.
Lithium during pregnancy Efficacy To date the literature on the impact of pregnancy on the course of bipolar disorders is inconsistent. Previous studies suggested that women with bipolar disorder may have a lower risk of relapse during pregnancy, when compared to the period before or after Grof et al.
Pregnancy & Child Birth
Viguera et al. In the postpartum period there is a high risk of a bipolar episode and hospitalization for psychiatric morbidity Munk-Olsen et al. A perinatal history of affective psychosis or depression is the most important risk factor, as reported in a recent cohort study investigating risk factors for postpartum recurrence in bipolar disorder Di Florio et al.
Unfortunately, this study did not investigate the effect of medication use during pregnancy on the risk of recurrence.
Of these 60 patients with prophylactic medication during pregnancy, the majority used lithium Bergink et al. Hence, lithium prophylaxis during pregnancy in women with bipolar disorder might be important not only to maintain mood stability during pregnancy, but also for postpartum relapse prevention.
Interestingly, a recent population based cohort study reported that lamotrigine during pregnancy was not inferior to lithium in the prevention of severe postpartum episodes Wesseloo et al. However, the authors point out the likely influence of confounding by indication since lamotrigine was primarily prescribed to women with a vulnerability for depressive episodes, while lithium was primarily prescribed to women with a history of manic episodes. Therefore, this finding requires replication in studies that can account for diagnosis, variant and severity of illness.
Dosing and monitoring of blood levels during pregnancy and around delivery Lithium has a narrow therapeutic range of 0.
Excretion of lithium is almost exclusively renal, hence blood plasma levels mainly depend on intravascular volume and glomerular filtration rate GRF Oruch et al. As pregnancy progresses total body water, plasma volume and GFR are increased Pariente et al.
Clinical studies have shown lithium blood levels to decrease significantly during pregnancy Wesseloo et al. Creatinine blood levels showed a similar longitudinal pattern, showing that indeed changes in lithium blood level reflect changes in renal physiology.
In summary, first and second trimester are characterised by a significant decrease of lithium blood levels with a risk of subtherapeutic levels. In third trimester and the postpartum, lithium levels gradually return to their preconception level which implicates that in this period clinicians need to be aware of the risk of lithium intoxication.
Close monitoring and dose adjustment is needed with conditions such as hyperemesis gravidarum, pre-eclampsia, impaired renal function, concomitant medication or acute blood loss occur, as these conditions increased the risk of toxicity Handler ; Blake et al.
Furthermore, as lithium levels in the fetus equal those in the mother, changes in dosing may impact fetal health and increase the risk of complications Newport et al. A multiple day dosing regime has been proposed to minimise fetal risk by minimising peak lithium levels Horton et al.
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However, multiple day dosing has been associated with an increased risk of renal side effects and as a consequence possible non-adherence Singh et al.However, there is currently no evidence that suggests this strategy decreases the risk of perinatal and infant complications and this strategy has to be weighed against the risk of maternal relapse during a high-risk period. The posterior pituitary produces oxytocin and arginine vasopressin AVP.
Abstract Background. Gynecol Endocrinol. Locktich G. Five days later, the otolaryngologist performed an endoscopy to locate the exact site of bleeding for direct cauterization. Mitchell-Innes, and J.