Tehran University Medical Journal

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It this prospective cross sectional study out-patient endometrial biopsy by PIPELLE was compared with diagnostic curretage (D&C) in patients suffering of Abnormal Uterine bleeding (AUB). Diagnostic accuracy, sufficient tissue sampling, intensity of pain and effective factors in biopsy results were the evaluated parameters in this study. In 70 patients with complaint of AUB (20 of them were post-menoupsal age admitted in hospital for D&C) endometrial biopsy was conducted by PIPELLE before operation and the results were compared. 96% of total patients (67) and 91% of patients with post menopause age had tolerance of undergoing out-patient PIPELLE biopsy of endometrium. 79% of these individuals complained of mild pain and 21% of moderate pain. Endometrium biopsy by PIPELLE in 77% of patients had similar accurate diagnostic results as compared to D&C. PIPELLE in 34% of patients (24) could not be conducted with the same accuracy of D&C patients, although in 14 (20%) of them, notissue samples could be collected by D&C. In none of these methods endometrial hyperplasia or endometrial cancer were detected. This study showed that in 77% of the total patients, the extra cost and general anesthetical risk of D&C could have been eliminated, by utilization of out-patient biopsy with PIPELLE

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Breakthrough bleeding (BTB) is the cause of 50% of discontinuations of use by long-acting progestogen-only contraceptive users. BTB appears to be associated with capillaries of abnormal morphology and fragility. Disturbances in vessels integrity, intercellular junctions or alteration of the basement membrane (BM) composition has been proposed to contribute toward the fragility of these capillaries. In a clinical trial study, 34 healthy fertile volunteers were studied before and during use of levonorgestrel releasing subdermal contraceptive implant Norplant. Three endometrial biopsies were taken from each volunteer, one before insertion and 2 at different time intervals after exposure to Norplant. Then 3 major components of BM of endometrial vessels Collagen IV (CIV), laminin and heparan sulphate proteglycan (HSPG) were immunostained and studied. The density of immunostained vessels by each antibody were measured and compared with density of vessels stained by CD34. Double immunostain of CD34 and laminin was also used for demonstration of vessels without BM. Significant decrease in vascular density showing BM components were shown in the study. The density of laminin, CIV, and HSPG-positive vessels were decreased from 176±8, 166±6.6 and 61±6 vessels/mm² (Mean±SEM) in the endometrium of Norplant acceptors before use control samples to 156±6, 144±6.2 and 33±2.9 in the endometrium of Norplant acceptors after 2 to 13 weeks Norplant exposure, respectively (P<0.05). This was occurring at the same time as the overall density of small vessels in Norplant exposed endometrium was showing increase. Significant decrease was also demonstrated over 13 to 42 weeks of use in the densities of laminin and HSPG-positive vessels compared with control (P<0.05), although decrease in the density of CIV positive vessels was not significant. Percentages of vessels showing BM was also calculated in the study. Significant decrease in the percentage of vessels showing BM were demonstrated after 2 to 13 weeks of Norplant use. The percentages of CD34 positive vessels showing laminin, CIV and HSPG-positive BM in control samples were 97±3%, 88±32% and 31±2% (Mean±SEM) which significantly decreased to 79±3%, 75±4% and 20±2% in Norplant users, respectively (P<0.05). Decrease in the percentage of vessels showing BM was thought to be due to disturbances in the integrity of BM in endometrial vessels of women using Norplant, which could be a cause for the fragility of the vessels. The decrease could also be due to decrease in the density of arteriols and increase in the density of venules and appearance of solid cords of endothelial cells. Double immunostaining of the endometrial vessels with anti-CD34 and anti-laminin clearly demonstrated loss of BM or weak staining of BM in the endometrial vessels of Norplant users. Clarification of the local mechanisms which leads to capillary fragility and abnormal endometrial bleeding may lead to the development of better treatments or prevention and ultimately improve the acceptability of these contraceptives.

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This study was conducted to evaluate effect of clonidine as a premedication on endoscopic sinus surgery bleeding.
Methods and Materials: during a randomized double blind clinical trial we compared two groups of patients who scheduled for endoscopic sinus surgery for polypectomy and etmoidectomy. 216 patients randomly assigned in two groups.In first group 2 hours befor surgery a 0.2mg tablet of clonidine orally adminestered to patients and in second group a 100 mg tablet of vit Bj(with same size and color- as
placebo)was adminestered to patients. The amount of bleeding measured in two groups.
Results: mean bleeding volume in clonidine group was 113+76 ml and in control group was 211 + 113 ml. There was a significant statistical difference between two groups (pO.0001).
Conclusion: Clonidine as premedication can reduce bleeding of endoscopic sinus surgery significantly.

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The aim of this study was to compare the effects of intraoperative autotransfusion and tranexamic acid on post-operative bleeding and need for allogeneic transfusion.
Materials and Methods: In a prospective, randomized study, 200 patients undergoing CABG allocated into two groups:
□ AT group = 100 patients received 1-2 units (300-450cc) autologous blood after termination of CPB D TX group = 100 patients received tranexamic acid, 15mg/kg before the injection of heparin and 15mg/kg after protamin injection Postoperative bleeding, transfusions, complications, ICU stay and hospital stay were recorded.
Results: The postoperative bleeding was lower in TX group (600 ml) than in AT group (1100 ml) (P <0.001). The rates of transfused patients in AT and TX groups were 72% and 65%. Patients in the AT group received more whole blood (2.82 units per patient vs. 1.93 units in TX group) (P<0.01). The numbers of FFP units administered per patient in AT and TX groups were 3.08 and 2.38 (P <0.01). In TX group, ICU stays and hospital stays were 0.8, 5.4 days (vs. 1.2s, 6.7days in AT group). In AT group, there were 2 transient renal dysfunctions and two re-operations. There was no difference between all groups regarding to neurological dysfunction and coagulopathy. There is no hospital mortality in all groups.
Conclusion: Tranexamic acid in comparison with intra-operative autotransfusion effectively reduces postoperative complications and allogeneic transfusions in CABG. In addition this technique due to shorter ICU and hospital stay is cost- effective.

 

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Background: Perioperative administration of tranexamic acid (TA), decreases bleeding and the need for transfusion after cardiac procedures. Hence, the results may vary in different clinical settings and the most appropriate timing to get the best results is unclear. The primary objectives of the present study were to determine the efficacy of TA in decreasing chest tube drainage, the need for perioperative allogeneic transfusions and the best timing for TA administration following primary, elective, coronary artery bypass grafting (CABG) in patients with a low baseline risk of postoperative bleeding.

Methods: In this double-blind, prospective, placebo-controlled clinical trial in Seiedoshohada Hospital during 2011-2012, we evaluated 150 patients scheduled for elective, primary coronary revascularization. They were randomly divided into three groups. Group B received tranexamic 10 mg/kg prior to, Group A received tranexamic acid 10 mg/kg after cardiopulmonary bypass and group C received an equivalent volume of saline solution. Blood requirement and postoperative chest tube drainage were recorded.

Results: The placebo group (group C) had a greater postoperative blood loss 12 h after surgery (501±288 vs. 395±184 in group B and 353±181 mL in group A, P=0.004). The placebo group also had greater postoperative total blood loss (800±347 vs. 614±276 in group B and 577±228 mL in group A, P=0.001). There was a significant increase in allogeneic blood requirement in the placebo group (P=0.001).

Conclusion: For elective, first time coronary artery bypass surgery, a single dose of tranexamic acid before or after cardiopulmonary bypass is equally effective.

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Background: The most common symptom of patients with gestational trophoblastic neoplasia is abnormal vaginal bleeding. Despite repeated visits of patients with postpartum choriocarcinoma and abnormal postpartum hemorrhage, delayed diagnosis leads to advanced disease with widespread metastasis. Therefore, occurrence of choriocarcinoma with variable patterns in different diagnosis of late onset postpartum hemorrhage should be considered. Early diagnosis of choriocarcinoma after term pregnancy is important that resulted in decrease of maternal morbidity. Therefor late onset postpartum hemorrhage should have an awareness. The aim of this study was to report a case of choriocarcinoma after caesarian section. Case Presentation: A 33-years-old woman one month after antecedent caesarian section in her second pregnancy admitted with abnormal vaginal bleeding. Based on raised titer concentration of β-hCG was 187000 u, with clinical suspicious of choriocarcinoma she was referred to oncology department of Ghaem Hospital, Mashhad University of Medical Sciences, Iran, in 2016. Vaginal exam revealed an enlarged uterus about 10 weeks of pregnancy. Transvaginal sonography showed an intracavitary heterogeneous mass with irregular surface in fundus without myometrium invasion. Extra pelvic metastasis excluded via vaginal exam, pulmonary X-ray and, ultrasonography and computed tomography scan. Due to early stage of gestational trophoblastic neoplasia and diagnosis of this condition, single agent chemotherapy (methotrexate) was recommended, but because of unresponsive disease, subsequently, she was treated with combination chemotherapy (etoposide, methotrexate, and actinomycin, followed by cyclophosphamide and vincristine) that led to remarkable response. After three courses of therapy, normal level of β-hCG was observed and now the patient is free of disease and under-serial follow-up visit for choriocarcinoma. Conclusion: Diagnosis of choriocarcinoma should be considered in any postpartum woman with abnormal vaginal bleeding.

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Background: Control of bleeding during dacryocystorhinostomy (DCR) surgery is of particular importance and controlling the body's hemodynamic responses to stress effectively reduces the amount of bleeding during surgery and improves the surgical area. Therefore, in this study, we aimed to investigate the effect of two-drug combinations Labetalol-Hydralazine and Labetalol-Trinitroglycerin on hemodynamic factors during dacryocystorhinostomy surgery.
Methods: The present study is a double-blind randomized clinical trial that was performed on 71 patients who were candidates for dacryocystorhinostomy (DCR) surgery. Patients enrolled in the study using computerized randomization software (Random allocation software).they were divided into two groups. The study was conducted from September 2016 to September 2017 in Isfahan. The amount of bleeding, the cardiovascular response of patients during and after surgery, the degree of satisfaction of the surgeon and the patient, the severity of pain, and the occurrence of nausea and vomiting were assessed, collected and analyzed.
Results: Between the two groups in terms of demographic characteristics there was no significant difference. There was no significant difference between the two groups in terms of mean arterial blood pressure (MAP), heart rate (HR) during surgery and the time of staying in the recovery room (P>0.05). There was no significant difference between the two groups in terms of bleeding volume, surgeon and patient satisfaction (P=0.73), frequency of vomiting, length of stay in recovery (P=0.57), the severity of nausea (P=0.38), pain (P=0.33) and rebleeding in recovery (P=0/75).

Conclusion: The results of the present study show that the use of labetalol with hydralazine in comparison with labetalol with trinitroglycerin has similar results in terms of hemodynamic factors as well as bleeding volume and surgeon and patient satisfaction criteria. Therefore, both of these compounds can be used to reduce bleeding and control vital signs during and after dacryocystorhinostomy surgery.

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