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Our experience with intraoperative cell salvage during cesarean delivery in women with uterine myomas--four case reports/ Nasa iskustva sa intraoperativnim spasavanjem krvi tokom carskog reza kod Pacijentkinja sa miomima uterusa--prikaz cetiri slucaja.

Introduction

Myomas are the most common benign tumor of the genital organs of women of childbearing age. Cesarean section (CS) is more common in women with myomas than in those without them, their incidence being up to 49.1% [1]. The incidence of cesarean section is increased by 26% for every 10 mm increase in the diameter of myoma in the group of women with myomas of 50 mm or more [2]. In some cases, myomectomy during CS is inevitable, which further increases the risk of hemorrhage [1]. Peripartum hemorrhage occurs in 2.5% of women with uterine myomas [3]. Massive obstetric hemorrhage, defined as blood loss greater than 1.5 liter, a reduction in hemoglobin levels greater than 40 g/l, the need for transfusion of more than 4 units of packed red blood cells (RBC) or the occurrence of coagulopathy is the most common cause of maternal mortality and morbidity [4, 5].

The idea of autologous transfusion in cases of obstetric hemorrhage dates back to the nineteenth century, when James Blundell documented the first application of autologous blood in the treatment of postpartum hemorrhage in 1818. The first prototype of cell saver was constructed by Taswell and Wilson, and was used in the Mayo Clinic in 1968 [6, 7].

Intraoperative blood salvage was developed in the 1970s and has been applied in orthopedic, cardiovascular and neurosurgery ever since [8]. The theoretical risks of the amniotic fluid embolism and Rh alloimmunization of the mother slowed down the application of this method in obstetrics [3, 9]. The first case of cell salvage in obstetrics was published in 1988 and a large number of studies on its use in obstetrics were published during the last decade [10, 11], which resulted from the technological progress in this field and the introduction of leukocyte depletion filter, which was applied in obstetric indications for the first time in 1999, as well as from better understanding of the pathophysiology of amniotic fluid embolism, the risks of administration of allogeneic blood, and increasing complexity of obstetric pathology [5, 11].

The process of intraoperative blood salvage consists of three phases: blood collection (aspiration of blood from the surgical field), blood processing (centrifugation and washing with heparinized saline solution) and reinfusion. The aspiration of blood from the operative field is performed by a dual lumen anticoagulation suction tube. The aspirate passes through the filter and is collected in the reservoir. From the reservoir, blood is pumped into the centrifugation bowl, where it undergoes centrifugation and washing. Following these processes, the supernatant is separated in the waste bag and the washed red cells are collected in the transfer bag. The erythrocytes obtained in this way can be re-infused immediately or within next 6 hours [9, 10].

The aim of this study was to present our experiences and results of applying intraoperative blood salvage during CS in patients with uterine myoma. "Dideco Electa Essential Concept" Cell Saver has been used at the Department for Gynecology and Obstetrics, Clinical Center of Serbia since 2009 and is handled by specially trained personnel (Figure 1).

Material and Methods

1. This retrospective study included patients with intraoperatively confirmed presence of uterine myoma who were hospitalized and delivered by CS at our Department from January 2010 to December 2011.

2. The sources of data were: the operating protocols from the operating room, patients' files, data protocols and histopathology findings of myomas. The criterion for inclusion in the study was the presence of myomas confirmed by visual inspection of the uterus during CS and the application of intraoperative cell salvage device, i.e. cell saver, during CS.

3. The indications for CS were defined on the basis of the primary indication for operation. The duration of operation was assessed on the basis of anesthetic list in the patient's file in minutes from the skin incision to the skin closure. Experience of the surgeon was evaluated on the basis of his years of practice in gynecology and obstetrics.

4. The type, localization and number of myomas was determined based on the operative notes in the patient's file. The size of myoma was defined by the diameter of the largest myoma according to the measurements made by the pathologist on the enucleated myoma, ultrasound measurement before surgery or evaluation given by the surgeon in the operative note. In cases of multiple fibroids, the diameter of the largest fibroid was taken into account. Intraoperative hemorrhage was assessed on the basis of the findings from the operative notes.

5. The hemogram parameters before and after surgery were defined by the values of red blood cells, hemoglobin and hematocrit before operation and on the first postoperative day. Blood transfusion during and after operation was defined as heterologous transfusion and/or autologous trans fusion when the cell saver was applied for intraoperative blood salvage.

6. Febrile morbidity was defined as measured body temperature [greater than or equal to] 38[degrees]C in two consecutive measurements [greater than or equal to] 6 hours, with the exception of postoperative day zero [3, 9]. Positive culture of the lochia, wound infections, and urinary tract infection after operation were determined according to the microbiological findings of wound swabs, urine and lochia samples. The existence of a hematoma in the uterus and abdominal wall hematoma after operation was determined by visualizing the hematoma during the postoperative ultrasound examination. Uterine subinvolution was defined as the need for providing therapy with uterotonics after the third postoperative day. Postoperative anemia was defined as hemoglobin values at discharge [less than or equal to] 100 g/l [1].

7. The duration of treatment in the intensive care unit and the total duration of postoperative hospitalization were defined by the number of days of treatment in the intensive care unit, or the number of postoperative days from the operation to the discharge from hospital, while the day of operation was taken as day zero.

Results

The patients are presented as the patient number (No) 1, number 2, number 3 and number 4. None of the patients had any comorbidity such as diabetes and pregnancy induced hypertension. Fetus was in cephalic presentation in all four patients. Table 1 shows the characteristics of patients.

The patients No 1, 2 and 4 were 30-39 years old, while the patient No 3 was 46 years old, and her pregnancy was achieved by in vitro fertilization with an oocyte donation. All patients were delivered by CS in term pregnancy. The patient No 4 was tertipara who had two previous CS and myomectomy before the index pregnancy. The other three patients were nulliparous, without previous surgery on the uterus. The patient No 2 was delivered by emergency CS, while others were delivered by elective CS. Myomectomy was not performed in two women: the patient No 1 had an intramural myoma on the posterior wall of the uterus with a diameter of 150 mm and the patient No 2 who had a pedunculated anterior wall myoma 110 mm in diameter. The operation in both patients lasted 65 minutes. Cesarean myomectomy was performed in two women with multiple fibroids, the largest ones being on the anterior uterine wall of the uterus, measuring 45 mm in diameter in one woman and 90 mm in diameter in another. Additional incision on the uterus was therefore required in both cases. Operations on the patient No 3 and No 4 took 105 minutes and 90 minutes, respectively. Microbiological analysis of intraoperative swab of the uterus in the patient No 3 showed the presence of Escherichia coli, while in other three patients the finding was sterile. Body weight of all four infants was below 4000 grams. The length of work experience of the surgeon who operated the patient No 1 and No 4 was 27 years and of the surgeon who operated the patient No 2 and No 3 was 19 years. Intraoperative hemorrhage was present in all patients, all patients were given oxytocin intravenously in doses of 10 to 20 IU, and the patient No 2 was given prostaglandin F2[alpha] during operation. No injury of the fetus, digestive and urinary organs occurred during operation.

None of the patients had wound infection and/or dehiscence, urinary tract infection, postoperative hemorrhage, hematoma in the uterus and/or in the abdominal wall and bacteremia, nor was it necessary to enlarge the scope of surgery and perform relaparotomy. Data on the postoperative course and reported complications are shown in Table 2.

The patients who did not undergo cesarean myomectomy postoperatively were not treated in the intensive care unit; they did not require postoperative transfusion and were discharged on the fourth postoperative day. The patient No 1 had uterine subinvolution. Antibiotic treatment was corrected postoperatively according to the antibiogram in the patient No 2 because of Escherichia coli found in the uterine microbiological swab. The postoperative course of the patient No 3 was complicated by intestinal sub-occlusion; she was, therefore, treated in the obstetric intensive care unit for 7 days and her postoperative hospital treatment lasted 11 days in total. The patient No 4 was treated for one day in the intensive care unit. This patient was febrile postoperatively (two days after the application of allogeneic RBC transfusion), and her postoperative hospital treatment lasted 11 days in total. Administration of allogeneic blood was avoided in three patients. All the women studied, except for the patient No 4, who had received RBC after operation, had hemoglobin levels below 100 g/l at discharge.

Hemogram values before and after operation, as well as the volume of intraoperatively salvaged and transfused blood are shown in Table 3.

All hemogram parameters were reduced postoperatively in all patients, and the volume of autologous blood transfused was 400-700 ml. The mean preoperative and postoperative hemoglobin and erythrocyte values were 103.80 g/l and 4.00 x [10.sup.9], and 94.38 g/l and 3.37 x [10.sup.9], respectively. There was no statistically significant difference between these values (for hemoglobin levels p = 0.059; for erythrocyte p = 0.132; in both cases, p > 0.05). The lowest postoperative hemogram values were recorded in the patient No 4, and the decrease in hemoglobin levels in this patient was the highest (15.71 g/l), although she received the greatest amount of salvaged blood intraoperatively.

Discussion

The decision regarding transfusion in young women is complex and should depend on the cause of anemia, its extent and possible chronicity, compensatory abilities of the patient, cardiopulmonary condition and the risk of further blood loss. Potential risks of blood transfusion must be balanced in relation to the expected benefits of its use. Although most of the existing recommendations for administration of blood transfusions are defined on the basis of hemoglobin and hematocrit values, the approach should be individualized, and clinical assessment should be based on the general condition of the patient [12]. However, the decision about transfusion is based on laboratory values of hemoglobin and hematocrit in most cases [13].

The therapeutic goal of transfusion is to improve tissue oxygenation in accordance with the needs of the recipient. Bearing in mind the risks of allogeneic blood use, modern medicine provides three ways to avoid its administration: preoperative autologous donation, acute normovolemic hemodilution and intraoperative blood salvage [5, 12]. Despite many advantages of preoperative autologous donation, it is not the method of choice in obstetric practice for the following reasons: in most cases, the extent of obstetric hemorrhage significantly exceeds the amount of blood that can be taken preoperatively; it can not be used in emergency situations, which are relatively common in obstetrics and it is unacceptable in certain populations for religious reasons [13]. The application of this method in obstetrics is recommended only in exceptional cases such as rare blood groups and the presence of irregular antibodies in pregnant women with a high risk of peripartum hemorrhage, multiple pregnancies, repeat CS (three or more), CS in second stage of labor, low preoperative hemoglobin values, uterine myoma and thrombocytopenia [12, 13]. The relative contraindications for intraoperative blood salvage are the contaminated and septic operative fields, suspected malignancy, P thalassemia, sickle cell anemia and the presence of infectious diseases that are transmitted through the blood [13]. According to the recommendations of the British Committee for Standards in Hematology, the application of the cell saver is indicated in operations with the clear operating field and the expected blood loss of more than 20% of blood volume, in operations that are associated with allogeneic transfusions in more than 10% of cases or where the average number of transfused blood units is greater than one [14]. The recommendation of the American College of Obstetricians and Gynecologists is that intraoperative blood salvage should be used in all patients when profuse bleeding is expected [15]. The Association of Anesthetists of Great Britain and Ireland recommends intraoperative blood salvage during CS in women with large and/or multiple uterine fibroids [12, 13].

The patients presented in this study had other risk factors for perioperative hemorrhage, besides myoma, and the consequent need for blood transfusions, such as age and myomectomy during CS in the patient No 3 and No 4, Escherichia coli detected in the uterus in the patient No 2 and prolonged surgery in the patient No 3. Namely, the patient No 4 had had three surgical procedures on the uterus (myomectomy and two CSs) before the index operation as well as the lowest preoperative and postoperative values of hemogram. Thus, despite intraoperative blood salvage, she received a single unit of RBC postoperatively. In the files of this patient neither were the indications for postoperative transfusion precisely defined, nor was the existence of possible clinical symptoms of anemia recorded. This is the only patient who had hemoglobin levels higher than 100 g/l at discharge, and we can not exclude the possibility that she would have recovered successfully without that single unit of RBC she had received. The justification of this transfusion cannot be ascertained, which is not a rare event in obstetric patients. The other three patients had hemoglobin levels below 100 g/l at discharge, but none of them had the value less than 90 g/l.

Uterine subinvolution in the patient No 1 was due to the presence of fibroids. Apart from anemia at discharge, the patient No 2 had no other postoperative complications reported. Intestinal sub-occlusion recorded in the patient No 3 cannot be correlated with intraoperative blood salvage. Fever observed in the patient No 4 could be a consequence of allogeneic transfusion as well as of myomectomy. The fact that fever developed in this patient after she had received the allogeneic transfusion suggests that it could not have been caused by the intraoperative blood retransfusion. Intraoperative blood salvage does not completely exclude the need for the administration of allogeneic blood in cases of profuse intraoperative bleeding.

The efficacy of intraoperative blood salvage defined as the percentage of patients who completely avoided the use of allogeneic blood ranges from 6 to 97.1% in the literature [15]. In our study, the use of allogeneic blood was avoided in three cases. Most authors agree that the use of intraoperative blood salvage reduces the need for allogeneic blood transfusions [16]. Prolonged hospitalization in the patient No 3 and No 4 was not the result of the use of cell salvage.

Complications caused by the use of intraoperative blood salvage described in the literature were not reported in any of the studied patients [12, 13, 16, 17].

Cell savers are unable to distinguish maternal from fetal red blood cells; therefore, Rh alloimmunization of the mother is a real risk of the application of this procedure. Aspiration of fetal red blood cells and their retransfusion in the maternal circulation increases the risk of maternal Rhesus alloimmunization in cases of incompatibility between the mother and the fetus. This can be prevented by the anti-D immunoglobulin. The required dose is calculated by determining the volume of fetal red blood cells transfused to the mother, using the Kleihauer-Betke test [16, 17]. All the women in our study had the positive Rhesus factor. Clinically relevant antibodies can be generated to other erythrocyte antigens as well, which can lead to a hemolytic disease in the newborn, but the risk of such alloimmunization is considered to be similar to the one during vaginal delivery [15, 16]. Adverse events observed after intraoperative blood salvage are: hypotension, disseminated intravascular coagulation, heparin toxicity, adult acute respiratory distress syndrome, hypocalcaemia, hypomagnesaemia and hypoproteinemia [12, 13, 17]. The only fatal outcome after the application of the salvaged blood in obstetrics is the case report published in 2000 by Oei et al, who concluded that the cause of death was amniotic fluid embolism [18]. The cited authors presented a patient with significant obstetric comorbidity, who, due to her religious believes, refused the transfusion of allogeneic blood. She was delivered by an emergency CS due to preeclampsia and HELLP (Hemolysis, EL: elevated liver enzymes, LP: a low platelet count) syndrome, with consequent anemia (the hemoglobin level before surgery was 71 g/l and the platelet count was 48 * 109/l) and coagulopathy. The cell saver without leukocyte filter was used during the operation, and a cardiac arrest occurred immediately after the retransfusion of the salvaged blood. The authors of papers published later expressed their disagreement with the presented conclusion, thus it has not been generally accepted in the literature published afterwards that this death could be attributed to the intraoperative blood salvage [4, 9, 10].

So far, only one randomized study on elective application of intraoperative blood salvage during CS has been published, which showed a significant reduction in number of patients who required transfusions in the study group [16, 17]. Multicentre cohort study published by Rebarber et al. has not proved the existence of differences between the groups in terms of infectious complications, the incidence of disseminated intravascular coag ulopathy and duration of postoperative hospitalization [19]. In this study, none of the patients developed amniotic fluid embolism or adult acute respiratory distress syndrome.

The application of cell saver reduces the need for allogeneic blood transfusions, thereby avoiding the risk of infection and post transfusion reactions. Most authors agree that the benefits to be gained by the application of cell saver in obstetrics exceed the potential risks [9-11].

Conclusion

Obstetric hemorrhage, which is often associated with operative delivery, is the major cause of maternal morbidity and mortality both in developing and in developed countries. One of the risk factors for peripartum hemorrhage is the myoma, whose incidence in pregnancy is increasing. The leading cause of morbidity after cesarean section in women with myoma is perioperative hemorrhage, which is manifested through the number and scope of perioperative transfusion. Thus, intraoperative blood salvage represents a significant opportunity for a reduction of morbidity in this population.

Intraoperative blood salvage should be considered in patients with uterine myomas, and certainly in those in whom myomectomy during cesarean section is planned, particularly in cases when massive intraoperative hemorrhage is expected.

In the absence of large randomized prospective studies which would confirm the safety of the broad application of intraoperative blood salvage in obstetrics, it is necessary to collect all the data about experiences of its use thoroughly. Although the number of women in our study was relatively small, none of them received a transfusion of allogeneic blood intraoperatively. Recommendations for the use of cell saver during myomectomy have already been given in the publications of authors who have investigated its application during the classical abdominal myomectomy. The use of intraoperative blood salvage in obstetrics could lead to a significant reduction of maternal morbidity and mortality in the future.

Abbreviations

CS    --cesarean section

No    --number

RBC   --red blood cells


DOI: 10.2298/MPNS1404111S

Rad je primljen 25. VII 2013.

Recenziran 13. XII 2013.

Prihvacen za stampu 29. I 2014.

BIBLID.0025-8105:(2014):LXVII:3-4:111-117.

References

[1.] Sparic R. Miomektomija tokom carskog reza-intraoperativne i neposredne postoperativne komplikacije (magistarski rad). Beograd: Medicinski fakultet Univerzitet u Beogradu; 2013.

[2.] Vergani P, Locatelli A, Ghidini A, Andreani M, Sala F, Pezzulo JC. Large uterine leiomyomata and risk of cesarean delivery. Obstet Gynecol 2007; 109(2):410-4.

[3.] Machado LS, Gowri V, Al-Riyami N, Al-Kharusi L. Caesarean Myomectomy: Feasibility and safety. Sultan Qaboos Univ Med J 2012; 12(2):190-6.

[4.] Liumbruno GM, Liumbruno C, Rafanelli D. Autologous blood in obstetrics: where are we going now? Blood Transfus 2012; 10:125-47.

[5.] King M, Wrench I, Galimberti A, Spray R. Introduction of cell salvage to a large obstetric unit: the first six months. Int J Obstet Anesth 2009; 18:111-7.

[6.] Tevet A, Grisary-Granovsky S, Samueloff A, Ioscovich A. Peripartum use of cell salvage: a university practice audit and literature review. Arch Gynecol Obstet 2012; 285(2):281-4.

[7.] Sparic R, Dokic M, Argirovic R, Kadija S, Bogdanovic Z, Milenkovic V. Incidence of postpartum post-cesarean hysterectomy at the Institute for Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade. Srp Arh Celok Lek 2007; 135(3-4):160-2.

[8.] McDonnell NJ, Kennedy D, Long LJ, Gallagher-Swans MC, Paech MJ. The development and implantation of an obstetrics cell salvage device. Anaesth Intens Care 2010; 38:492-9.

[9.] Lougage S, Van de Velde M. Cell salvage in obstetric anesthesia. Acta Anaesth Belg 2010; 61:13-24.

[10.] Allam J, Cox M, Yentis SM. Cell salvage in obstetrics. J Obstet Anesth 2008; 17:37-45.

[11.] Geoghegan J, Daniels B, Moore PAS, Thompson PJ, Khan KS, Gulmezoglu AM. Cell salvage at caesarean section: need for an evidence-based approach. BJOG 2009; 116:743-7.

[12.] Pallasmaa N, Ekblad U, Aitokallio-Tallberg A, Uotila Rudaskoski T, Ulander VM, et al. Cesarean delivery in Finland: maternal complications and obstetric risk factors. Acta Obstet Gynecol Scand 2010; 89(7):896-902.

[13.] Fong J, Gurewitsch ED, Kang HJ, Kump L, Mack PF. analysis of transfusion practice and the role of intraoperative red blood cell salvage during cesarean delivery. Anesth Analg 2007; 104:666-72.

[14.] Murphy MF, Wallington TB, Kesley P, Boulton F, Bruce M, Cohen H, et al. British Committee for standards in haematology, blood transfusion task force. Guidelines for clinical use of red cell transfusions. Br J Haematol 2001; 113(1):24-31.

[15.] Yamada T, Yamashita Y, Terai Y, Ueki M. Intraoperative blood salvage in abdominal uterine myomectomy. Int J Gynecol Obstet 1997; 56:141-5.

[16.] Rainaldi MP, Tazzari PL, Scagliarini G, Borghi B, Conte R. Blood salvage during caesarean section. Br J Anaesth 1998; 80:195-8.

[17.] Ozumba BC, Ezegwui HU. Blood transfusion and caesarean section in a developing country. J Obstet Gynaecol 2006; 26(8):746-8.

[18.] Oei SG, Wingen CBM, Kerkkamp HEM. Cell salvage: how safe in obstetrics? Int J Obstet Anesth 2000; 9:143.

[19.] Rebarber A, Lonser R, Jackson S, Copel JA, Sipes S. The safety of intraoperative autologous blood collection and the autotransfusion during cesarean section. Am J Obstet Gynecol 1998; 179:715-20.

Radmila SPARIC (1), Biljana LAZOVIC (2), Nenad SULOVIC (3,4) and Snezana BUZADZIC (1)

Clinical Center of Serbia, Belgrade, Department of Gynecology and Obstetrics (1)

Clinical Hospital Center Zemun, Department of Internal Medicine, Belgrade (2)

Clinical Hospital Center Pristina, Gracanica, Department of Gynecology and Obstetrics (3)

University in Pri stina, Faculty of Medicine, Kosovska Mitrovica (4)

Corresponding Author: Dr Radmila Sparic, Klinika za ginekologiju i akuserstvo, 11000 Beograd, Visegradska 26, E-mail: radmila@rcub.bg.ac.rs

Table 1. Patient characteristics

Tabela 1. Karakteristike pacijentkinja

Characteristics//Karakteristike            1

Age/Godine starosti                        33
Parity/Porodaj po redu                     1
Gestational week/Nedelja gestacije         40
Previous myomectomy                        No
Prethodna miomektomija                     Ne
Indications for cesarean section     Myoma previum
Indikacije za carski rez              Miom previja
Type of cesarean section                Elective
Vrsta carskog reza                     Elektivan
No of laparotomy/Laparotomija              1
  po redu
Type of myoma                          Intramural
Tip mioma                             Intramuralni
Localization of myoma                Posterior wall
Lokalizacija mioma                     Zadnji zid
Size of myoma/Dimenzije mioma (mm)        150
Number of myoma/Broj mioma                 1
Myomectomy/Miomektomija                  No/Ne
Number of incisions on uterus              1
Broj incizija na uterusu
Duration of surgery (min)                  65
  Trajanje operacije (min)
Bacteriological smear of uterus         Sterile
Mikrobioloski bris uterusa              Sterilan
Neonatal weight (gr)                     3 350
Telesna masa novorodenceta (gr)
Years of specialist service                27
  of the surgeon
Godine specijalisti?kog
  staza operatora

Characteristics//Karakteristike              2

Age/Godine starosti                          30
Parity/Porodaj po redu                       1
Gestational week/Nedelja gestacije           39
Previous myomectomy                          No
Prethodna miomektomija                       Ne
Indications for cesarean section     Fetal indications
Indikacije za carski rez             Fetalne indikacije
Type of cesarean section                 Emergency
Vrsta carskog reza                         Hitan
No of laparotomy/Laparotomija                1
  po redu
Type of myoma                           Pedunclated
Tip mioma                               Na peteljci
Localization of myoma                  Anterior wall
Lokalizacija mioma                      Prednji zid
Size of myoma/Dimenzije mioma (mm)          110
Number of myoma/Broj mioma                   1
Myomectomy/Miomektomija                    No/Ne
Number of incisions on uterus                1
Broj incizija na uterusu
Duration of surgery (min)                    65
  Trajanje operacije (min)
Bacteriological smear of uterus       Escherichia coli
Mikrobioloski bris uterusa
Neonatal weight (gr)                       3 600
Telesna masa novorodenceta (gr)
Years of specialist service                  19
  of the surgeon
Godine specijalistickog
  staza operatora

Characteristics//Karakteristike              3

Age/Godine starosti                          46
Parity/Porodaj po redu                       1
Gestational week/Nedelja gestacije           38
Previous myomectomy                          No
Prethodna miomektomija                       Ne
Indications for cesarean section     Fetal indications
Indikacije za carski rez             Fetalne indikacije
Type of cesarean section                  Elective
Vrsta carskog reza                       Elektivan
No of laparotomy/Laparotomija                1
  po redu
Type of myoma                             Multiple
Tip mioma                                 Multipli
Localization of myoma                  Anterior wall
Lokalizacija mioma                      Prednji zid
Size of myoma/Dimenzije mioma (mm)           45
Number of myoma/Broj mioma                   2
Myomectomy/Miomektomija                    Yes/Da
Number of incisions on uterus                2
Broj incizija na uterusu
Duration of surgery (min)                   105
  Trajanje operacije (min)
Bacteriological smear of uterus           Sterile
Mikrobioloski bris uterusa                Sterilan
Neonatal weight (gr)                       3 200
Telesna masa novorodenceta (gr)
Years of specialist service                  19
  of the surgeon
Godine specijalistickog
  staza operatora

Characteristics//Karakteristike                  4

Age/Godine starosti                             39
Parity/Porodaj po redu                           3
Gestational week/Nedelja gestacije              39
Previous myomectomy                             Yes
Prethodna miomektomija                          Da
Indications for cesarean section     Previous cesarean section
Indikacije za carski rez               Prethodni carski rez
Type of cesarean section                     Elective
Vrsta carskog reza                           Elektivan
No of laparotomy/Laparotomija                    4
  po redu
Type of myoma                                Multiple
Tip mioma                                    Multipli
Localization of myoma                      Anterior wall
Lokalizacija mioma                          Prednji zid
Size of myoma/Dimenzije mioma (mm)              90
Number of myoma/Broj mioma                       2
Myomectomy/Miomektomija                       Yes/Da
Number of incisions on uterus                    2
Broj incizija na uterusu
Duration of surgery (min)                       60
  Trajanje operacije (min)
Bacteriological smear of uterus               Sterile
Mikrobioloski bris uterusa                   Sterilan
Neonatal weight (gr)                           3 150
Telesna masa novoroden?eta (gr)
Years of specialist service                     27
  of the surgeon
Godine specijalistickog
  staza operatora

Table 2. Complications registered in studied patients

Tabela 2. Registrovane komplikacije kod ispitivanih pacijentkinja

Complication/Komplikacija               1   2   3     4

Number of days of intensive care unit   0   0   7     1
  treatment/Broj dana lecenja u
  jedinici intenzivne nege
Number of postoperative days in         4   4   11   11
  hospital/Broj dana
  postoperativnog bolnickog lecenja
Postoperative transfusion (ml)/         0   0   0    260
  Postoperativna transfuzija (ml)
Febrile morbidity after operation/      -   -   -     +
  Febrilno stanje posle operacije
Hemoglobin < 100 g/l at discharge/      +   +   +     -
  Hemoglobin < 100 g/l pri otpustu
Uterine sub-involution/                 +   -   -     -
  Subinvolucja uterusa
Intestinal sub-occlusion/               -   -   +     -
  Crevna subokluzija

Table 3. Hematological results and volumes of intraoperatively
salvaged blood in studied patients

Tabela 3. Nalazi hemograma i zapremine intraoperativno spasene krvi
kod ispitivanih pacijentkinja

Hematological results and volumes of       1      2      3       4
intraoperatively salvaged blood in
studied patients/Nalazi hemograma i
zapremine intraoperativno spasene krvi

Hemoglobin before operation               104    110    105    96.21
(g/l)/Hemoglobin pre operacije (g/l)

Hemoglobin after operation                101     96    100    80.5
(g/l)/Hemoglobin posle operacije (g/l)

Erytrocites before operation              3.99   3.71   3.91   4.39
(x [10.sup.9])/Eritrociti pre
operacije (x [10.sup.9])

Erythrocytes after operation              3.55   3.31   3.76   2.86
(x [10.sup.9])/Eritrociti posle
operacije (x [10.sup.9])

Hematocrite before operation              32.9   34.0   31.6   34.0
(%)/Hematokrit pre operacije (%)

Hematocrite after operation               30.0   29.2   30.7   29.2
(%)/Hematokrit posle operacije (%)

Volume of intraoperatively salvaged and   670    400    450     700
transfused blood (ml) Zapremina
intraoperativno spasene i transfuzijom
date krvi (ml)
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Title Annotation:Case report/Prikaz slucaja
Author:Sparic, Radmila; Lazovic, Biljana; Sulovic, Nenad; Buzadzic, Snezana
Publication:Medicinski Pregled
Article Type:Case study
Date:Mar 1, 2014
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