Parathyroid adenoma in pregnancy: A case report and systematic review of the literature

OBJECTIVE

Primary hyperparathyroidism is a common disorder of the parathyroid glands. Parathyroid adenoma (PA) in pregnancy is a relatively rare disease, whose diagnosis and treatment is a challenging task. The aim of the present study is to present a new case of parathyroid adenoma during pregnancy and to give a detailed account of all reported cases of parathyroid adenoma during pregnancy in the literature.

STUDY DESIGN

A bibliographic research was performed, and characteristics of parathyroid adenomas in pregnancy such as age, gestational week at diagnosis, ionized calcium levels, genetic testing result, symptomatology, radiological method of localization, treatment method, gestational week at operation, and maternal/fetal complications were recorded.

RESULTS

A 34-year-old woman at her 25 weeks' gestation was diagnosed with parathyroid adenoma and was referred to our Surgical Department due to contraindication for conservative treatment. A parathyroidectomy was performed, and the maternal and fetal postoperative period was uneventful. Two hundred eleven cases of parathyroid adenoma in pregnancy were recorded in the literature, and statistical analysis was performed. The median gestational week at diagnosis was 21 ± 9.61 weeks. The mean level of ionized calcium was 2.69 mmol/l [SD = 0.75 (2.55-2.84 95% CI)]. Most cases were familiar (72.4%), while surgery was the preferred treatment option (67.3%). The majority of cases were asymptomatic (21.7%), and the main radiological method applied for localization was ultrasound (63.4%).

CONCLUSION

Parathyroid adenoma in pregnancy is a rare condition. The early diagnosis is of great importance as surgical treatment at the second trimester of pregnancy outweighs the maternal and fetal risks.

Occlusion of the right coronary artery after blunt thoracic trauma with fatal outcome: A case report and review of the literature

BACKGROUND

Although damage of the heart vessels is a possible complication of blunt thoracic trauma, occlusion of the right coronary artery is rare and demands high level of suspicion by the emergency physicians.

OBJECTIVE

Our objective is to present a case of fatal acute occlusion of the right coronary artery after blunt thoracic trauma due to vehicle accident and conduct a brief review of the current literature.

CASE REPORT

A 58-year-old sustained chest trauma after a vehicle accident, complicated by acute occlusion of the right coronary artery. Despite invasive intervention the patient deteriorated and died due to multi-organ failure.

CONCLUSION

Acute occlusion of the right coronary artery is a rare complication of blunt chest trauma. Early diagnosis and intervention, collaboration between different specialties and proper hospitalization are vital for the outcome of the patient.

Preoperative withdrawal of antiplatelet treatment in lower limb vascular patients prior to surgical management under epidural or spinal anaesthesia: an evidence based approach and systematic review

Antiplatelet drugs given to high risk patients for secondary prevention of cardiovascular disease are frequently withdrawn prior to surgical or diagnostic procedures to reduce bleeding complications. This is also the case for many patients undergoing lower limb vascular surgery via spinal or epidural anaesthesia. The aim of this study is to corroborate the clinician's decision for discontinuing or continuing the anti-platelet treatment in these patients perioperatively. We screened MEDLINE and Scopus (January 1980 - July 2007) with additional manual cross-referencing for clinical studies, surveys on the opinions of doctors and guidelines according to Evidence Based Medicine rules. One randomized controlled trial, 2 meta-analyses, 1 prospective and 4 retrospective studies as well as 6 esteemed medical societies'" guidelines all conclude that there is no justification for the discontinuation of aspirin and NSAIDs prior to neuraxial anesthesia. However, for other antiplatelet drugs like ticlopidine, clopidogrel, abciximab, eptifabatide and tirofiban not enough data exist to support their continuation through the procedure. Therefore, their preoperative withdrawal is suggested 8 hours to 14 days prior, accordingly. The existing evidence does not justify the discontinuation of aspirin and NSAIDs before the intended procedure. Anesthesiologists and surgeons should be aware of the cardiovascular risks of withdrawal versus the non - evidence based benefit in hemorrhage complications.

The role of endothelium and endogenous vasoactive substances in sepsis

Sepsis and septic shock are great challenges for the doctors who treat critically ill patients. A big part of the scientific community is performing researches about the pathophysiology and treatment of this clinical problem. The endothelium has a very significant role in the alterations that sepsis causes especially to the circulatory system. The disorders of the normal function of the endothelium include derangement of the vascular tone, increase of endothelium permeability, activation of the endothelial cells, production of various regulators and disorders of coagulation. Nitric oxide is the modulator that mediates the action of most vasodilators. The overproduction of nitric oxide during sepsis is possibly the most important cause of the vasopressor-resistant hypotension which characterizes septic shock. The levels of natriuretic peptides are also increased. These peptides act through several ways on the circulatory system both peripherally and directly on the myocardium. Endothelin, vasopressin, adrenomedullin and prostacyclin are vasoactive substances that have their own role in the regulation of the circulatory system during sepsis.

Awareness during anesthesia: how sure can we be that the patient is sleeping indeed?

Awareness during surgery is a very serious problem for the anesthetist and the patient as well. Such incidents are the cause for 2% of the legal claims against anesthetists while patients with intraoperative awareness experience describe it as the worst thing they have ever suffered from. Pain, anxiety and inability to react due to muscle paralysis often lead to the situation called posttraumatic stress disorder which demands psychiatric support. The fact that there are patients who report intraoperative experience, even several days after surgery, raises questions about the way the anesthetic drugs interfere with the mechanisms of memory and consciousness while, in bibliography, there are studies proving that even deeply anesthetized patients can be influenced by auditory stimuli without being able to recall them. Intraoperative monitoring of the anesthesia depth is important for the prevention of this problem. From all the available devices only the Bispectral Index Monitoring (BIS) has been proven to be effective for this purpose but the high cost per person and the low specificity in preventing awareness episodes do not allow its everyday use. The surgeon and especially the anesthesiologist must be aware of the risk factors, the prevention measures and the actions that must be taken after an awareness incident in order to minimize the unfortunate complications for both the patient and the doctors.