Good Neu ro log i cal Out come Af ter Hypoxic-ischemic Coma Caused by Se vere Postpartum Hem or rhage: Three Case Re ports and Lit er a ture Review

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1 Good Neu ro log i cal Out come Af ter Hypoxic-ischemic Coma Caused by Se vere Postpartum Hem or rhage: Three Case Re ports and Lit er a ture Review K. Vrotniakaitë* R. Jacevièiûtë* V. Rudaitis** D. Jatuþis*** *Vilnius University, Faculty of Medicine **Vilnius University, Faculty of Medicine; Vilnius University Hospital Santariðkiø Klinikos, De part ment of Gy ne col ogy, Cen ter of Woman s Pa thol ogy and Phys i ol ogy ***Vilnius Uni ver sity, Faculty of Medicine; Vilnius University Hospital Santariðkiø Klinikos, Cen ter of Neu rol ogy Summary. Postpartum hem or rhage is a life threat en ing con di tion, which may cause a va ri - ety of dis or ders that may also be as so ci ated with long-last ing hypoxia. Due to prog ress in re - sus ci ta tion, the com pli ca tions of hypoxic ischemic encephalopathy are found to be var i ous not only in post car diac at tack set ting, but also in any cause of bleed ing. Our ob jec tives were to pres ent three case re ports of neu ro log i cal out come af ter se vere postpartum hem or rhage and an a lyze the literature in this field including prognostication. The details of hemorrhage were col lected ret ro spec tively from the med i cal re cords. Af ter mean fol low-up time of 35 months the women were in vited to neu ro log i cal ex am i na tion, neuropsychological as sess - ment (Addenbrooke s Cognitive Examination Revised adapted to Lithuanian speaking pop u la tion ACE-R LT ), depression and anxiety evaluation (Hospital Anxiety and Depres - sion Scale HADS). All three women were se verely bleed ing af ter la bor with signs of dis - sem i nated intravascular coagulation and syndrome of multiple organ dysfunction. Two of them ex pe ri enced asystole of 5 and 4 min utes, and the third had he mo glo bin value of 15 g/l. Im pair ment of con scious ness due to se vere brain hypoperfusion evolved to hypoxicischemic coma in all three cases. Dur ing crit i cal acute pe riod and sub se quently the neu ro log - i cal eval u a tions were recorded, showing a variety of neurological disorders delirium, extra - pontine myelinolysis, sei zures, re vers ible pos te rior leukoencephalopathy syn drome and other dis abil i ties, such as ataxia, hypertonus of the limbs and im paired psychosocial abil i ties. In gen eral, long-term neu ro log i cal out come of these pa tients was found to be very good. It shows good po ten tial adap tive pos si bil i ties and re cov ery of the brain af ter postpartum bleed - ing. At fol low-up cog ni tive ex am i na tion one woman reached max i mal ACE-R LT score, oth - ers showed the re sults above 89. All three women have re turned to work and were able to drive a car. How ever, at fol low-up they had com plained of mem ory and at ten tion dis tur - bances, and two of them had sig nif i cantly el e vated de pres sion or anx i ety score on HADS. In the ab sence of spe cific prog nos tic mea sures for postpartum hem or rhage, we ap plied ret ro - spec tively the prognostication scores originally dedicated for predicting neurological out - come af ter car diac arrest. The results allowed fairly reliably predict good neurological prog - no sis in pa tients af ter se vere postpartum bleed ing as well. These cases em pha size the im por - tance of co op er a tion and multidisciplinary ap proach to the pa tient and show prom is ing long-term re sults in this field of medical emergency. Keywords: postpartum hem or rhage, hypoxic-ischemic coma, brain in jury, neu ro log i cal out come. Neurologijos seminarai 2013; 17(57): IN TRO DUC TION Ac cord ing to the World Health Or ga ni za tion, postpartum hem or rhage (PPH) is re spon si ble for around 25% of ma - ter nal mor tal ity world wide, and is also one of the lead ing causes of ma ter nal death in de vel oped coun tries [1]. The Adresas: Dalius Jatuþis Cen ter of Neu rol ogy Vilnius Uni ver sity Hos pi tal Santariðkiø Klinikos Santariðkiø str. 2, Vilnius 08661, Lith u a nia Phone/fax: dalius.jatuzis@santa.lt eti ol ogy of PPH is di vided into four main po ten tial causes, de fined as four T Tonus, Tis sue, Trauma and Throm - bo sis, the first of which uter ine atony plays the most im - por tant role. All these con di tions have their own pre dis - pos ing fac tors, how ever, a large num ber of women ex pe ri - enc ing PPH have no risk fac tors at all [2]. Clas si cally, PPH is de fined as a blood loss of more than 500 ml fol low ing a vag i nal de liv ery or more than 1000 ml fol low ing ce sar ean de liv ery [3]. In ad di tion to death, se ri ous mor bid ity may fol low PPH, which could cause long term re sid ual ef fects [4]. The usual sequelae in clude adult re spi ra tory dis tress syn drome, coagulopathy, postpartum pi tu itary ne cro sis, chronic ane mia, and fer til ity loss due to hys ter ec tomy or fi - bro sis and ad he sions in the cav ity of the uterus. PPH dis - 203

2 K. Vrotniakaitë, R. Jacevièiûtë, V. Rudaitis, D. Jatuþis rupts the sys temic cir cu la tion, cause ce re bral hypoperfu - sion and even elec tro lyte disbalance, which may lead to os - motic myelinolysis. How ever, there are only few re ports in lit er a ture con cern ing neu ro logic con se quences and out - comes af ter PPH [5], con trary to a num ber of de scrip tions of neurological outcome after cardiac arrest. Therefore prog nos tic fac tors of neu ro log i cal out come con cern ing woman af ter PPH are nei ther gen er ally ana lysed nor de - scribed. In this re port we would like to pres ent three cases of a good neu ro log i cal out come in women, which were in deep coma af ter se vere PPH in in ten sive care unit (ICU) of Vil nius Uni ver sity Hos pi tal Santariðkiø Klinikos (VUHSK). De tails and cir cum stances of bleed ing, gen eral and neu ro log i cal con di tion af ter PPH were eval u ated ret ro - spec tively from the med i cal re cords. Long-term neu ro log i - cal and cog ni tive out come was as sessed dur ing fol low-up visit of the pa tients at the VUHSK Cen ter of Neu rol ogy; the pa tients were con tacted and in vited by phone call. In or der to eval u ate the cog ni tive out come Addenbrooke s Cog ni tive Ex am i na tion Re vised re cently adapted to Lith - u a nian speak ing pop u la tion (ACE-R LT ) was per formed (max. score 100; ori en ta tion-at ten tion 18, mem ory 26, ver bal flu ency 14, lan guage 26, and visuo spatial abil ity 16) [6]. The scores of Hos pi tal Anx i ety and De - pres sion Scale (HADS) were counted for as sess ment of de - press ive ness (HADS-D) and anx i ety (HADS-A) (min 0, max 21 on each subscale). Cur rent sub jec tive com plaints of the pa tients were re corded (on 0 10 point grad ing scale, where 0 shows the worst, and 10 the best abil ity). CASE PRE SEN TA TIONS First case A 33-year-old woman was re ferred to ICU of VUHSK with se vere hem or rhagic shock, dis sem i nated intravascu - lar co ag u la tion (DIC) syn drome and mul ti ple or gan dys - func tion syn drome (MODS). These com pli ca tions oc - curred be cause of bleed ing af ter a first planned la bor due to uter ine atony, which re sulted in pri mary PPH lead ing to hys ter ec tomy in a pri vate ma ter nity hos pi tal. Dur ing hys - ter ec tomy a 5 min asystole oc curred, con se quently re sus ci - ta tion and defibrillation were per formed. The pa tient was trans ferred to the VUHSK in crit i cally se vere con di tion. She had clin i cal signs of shock, ar te rial blood pres sure (ABP) was im mea sur able, heart beat rate (HR) 130 b/min, Hb level 65 g/l, APPT s, lac tates 11.9 mmol/l, blood glu cose 3.7 mmol/l. 2 relaparotomies due to un con trolled bleed ing were per formed in VUHSK, which re sulted in li ga tion of both in ter nal iliac ar ter ies. Dur ing first two days in VUHSK the pa tient re ceived mas - sive trans fu sions of blood prod ucts (RBC, PLT, fresh frozen plasma), adren a line for hemodynamical sup port, and an ti bi ot ics for in fec tion pro phy laxis. Hemodialysis was ini ti ated due to acute re nal fail ure. Even tu ally hemodynamics and gen eral con di tion was sta bi lized, how - ever it re mained very se vere for a few weeks. Neu ro log i cal con di tion af ter PPH. The woman was ad mit ted to ICU in deep est ce re bral coma (Glas gow Coma Score (GCS) 3). Within two weeks af ter ad mis sion GCS im proved to 11 with a max i mal mo tor (M) and eye (E) re - sponse, but the state of con scious ness re mained fluc tu at - ing. The pa tient de vel oped py ram i dal hypertonia of the limbs and un der went an ep i sode of clonus in the right limbs. 4 weeks af ter ad mis sion she grad u ally be came con - scious and started to talk in short sen tences. The pa tient could move her legs and feet (mus cle strength 2 points), how ever, marked py ram i dal hypertonia did not im prove. One week later she de vel oped a head ache, am ne sia and hor ror dreams evolv ing to ep i sodes of de lir ium which re - curred one week. Re peated neuroimaging tests (2 CT scans and 2 MRIs) were per formed dur ing the first months. They ini tially showed 5 mm subdural hematoma in the left oc - cip i tal area and dif fuse ce re bral edema, and af ter 1.5 months bi lat eral hyperintensive sig nals in basal gan - glia and subcortical dif fuse le sions in both oc cip i tal and left frontoparietal ar eas. Later the pa tient was re ferred to rehabilitation department with remaining complaints of memory and difficulties to concentrate, inability to walk long dis tances, tired ness, limb weak ness, and spasticity. In one month her Barthel in dex (BI) in creased from 75 to 90, func tional in de pend ence mea sure (FIM) score from 91 to 100, and Mini Men tal State Ex am i na tion (MMSE) re - mained max i mal (30 points). Af ter over all 3.5 months treatment in different VUHSK departments and rehabilita - tion she was dis charged home. Neu ro log i cal out come at fol low-up. The woman started to drive a car 7 months af ter the event. 1.5 years af ter the in ci dent, she re turned to the pre vi ous work. Dur ing the fol low-up visit (31 months af ter the event) we ob served sig nif i cant im prove ment. The long- term neu ro log i cal con - se quences in cluded only mild slow ness of move ments of right limbs, mild weak ness of prox i mal leg mus cles, and in - creased stretch re flexes with out clonus (3+) in legs. The pa - tient com plained of lim ited body flex i bil ity and sub jec - tively rated her mem ory and con cen tra tion/at ten tion abil i - ties 9 and 8 points out of 10, re spec tively. Cog ni tive ex am i - na tion re vealed very good cog ni tive func tions the pa tient scored 97 points out of 100 in ACE-R LT (1 miss ing point in visuospatial abil ity, and 2 miss ing points in ver bal flu - ency). On the other hand, HADS showed sig nif i cantly in - creased level of de press ive ness (HADS-D: 14 points), con - trary to bor der line level of anx i ety (HADS-A: 7 points). Sec ond case A 32-year-old woman started bleed ing due to cer vi cal and per i neal rup ture and uter ine hypotony af ter child birth of macrosomic new born (4050 g). Laparotomy was per - formed, re sult ing in hys ter ec tomy and li ga tion of both in - ternal iliac arteries. During the procedure, an episode of 4 min asystole oc curred, re sus ci ta tion and defibrillation were per formed, and the pa tient was trans ferred to ICU of VUHSK with sus pi cion of DIC syn drome. On ad mis sion she was al ready intubated and ven ti lated, Hb 68 g/l, 204

3 Good Neu ro log i cal Out come Af ter Hypoxic-ischemic Coma Caused by Se vere Postpartum Hem or rhage: Three Case Re ports and Lit er a ture Re view ABP 70/40 mmhg (main tained with adren a line), APTT 183 s., lac tates 3,3 mmol/l, blood glu cose 13,7 mmol/l. Due to con tin ued bleed ing a sec ond laparatomy was per - formed. Af ter two days her ABP was >180 mmhg, and so - dium nitropruside was ad min is tered to treat hy per ten sion, re sult ing in ABP re duc tion to 150/80 mmhg. Mas sive blood trans fu sions (RBC, PLT, FFP, prothrombine com - plex) were given dur ing and af ter bleed ing. Neu ro log i cal con di tion af ter PPH. The pa tient was ad mit ted to the ICU with a GCS 6 (M 2, ver bal (V) 2, E 2). On the next day GCS was 8 (M 4, V 1, E 3), her stretch re - flexes were nor mal (2+), Babinski sign was pos i tive in both sides. On the fourth day of ad mis sion the pa tient was extubated. She was able to com mu ni cate, how ever, re - mained dis ori ented. On the fifth day an hour long ep i sode of head ache oc curred, with sub se quent pro longed loss of vi sion. Mo tor im pair ment in cluded com plete pa ral y sis of left arm and pa re sis of right arm and left leg. MRI was per - formed and showed hyperintensive sig nals (T2) in basal gan glia, hip po cam pus, fron tal cor tex and pa ri etal lobe bi - lat er ally and right in su lar area. These clin i cal and im ag ing find ings were in ter preted as hypoxic-ischemic; how ever, re vers ible pos te rior leukoencephalopathy syn drome was also con sid ered (Fig. 1). Within the next five days the vi - sion re cov ered, and the pa tient started to move her limbs, how ever, dis ori en ta tion per sisted. Af ter 19 days in hos pi tal the pa tient was sent to re ha bil i ta tion with com plaints of weak ness of arms; she was not able to per form fin - ger-to-nose and heel-to-shin tests. Neu ro log i cal out come at fol low-up. The pa tient ar - rived for a fol low-up 38 months af ter PPH. Dur ing this pe - riod she had one ep i sode of clonic sei zures. The pa tient re - turned to her pre vi ous work and re sumed driv ing 2 months af ter the event. At fol low-up she ad mit ted writ ing dif fi cul - ties and as sessed her mem ory and at ten tion of 6 and 8 points, re spec tively. On neu ro log i cal ex am i na tion, slow - ness and in creased stretch re flexes (3+) in the left arm were found. HADS scores for de press ive ness and anx i ety were 5 (HADS-D) and 8 (HADS-A). No cog ni tive def i cit was found (ACE-R LT score 100 points). Fig. 1. Hyperintensive sig nals (MRI T2) in basal gan glia and hippocampus bilaterally, and right insular area Third case A 27-year-old woman was ad mit ted to the ICU of VUSKH with PPH due to cer vi cal rup ture and atony of the uterus af - ter her first la bor. Laparotomic hys ter ec tomy with li ga tion of both in ter nal iliac ar ter ies was per formed. Dur ing op er a - tion her Hb level de creased to 15 g/l, she re ceived mas sive blood trans fu sions (RBC, FFP), and was intubated. On ad - mis sion she was un con scious; ABP 112/20 mmhg (main - tained with adren a line), Hb 90 g/l, APTT 150 s., blood glu cose 10.3 mmol/l, lac tates 8 mmol/l. As bleed ing con tin ued, on the same day re vi sion relaparo to my was per - formed, which re sulted in pa tient s sta bi li za tion and extubation in 2 days. Next day MODS with sep sis were di - ag nosed. The pa tient was treated with an ti bi ot ics, hemo dia - lysis, blood transfusions, and anticoagulants. Several years af ter this event von Willebrand dis ease was di ag nosed. Fig. 2. Extrapontine demyelination in cor pus cal lo sum, limbic lobes of parahippocampal gyrus and hip po cam pus (MRI T2 dark fluid) Neu ro log i cal con di tion af ter PPH. The pa tient was ad mit ted to the ICU with GCS 5. On the next day she had al ready re gained con scious ness, how ever, head ache, sleep i ness and fluc tu at ing signs of dis ori en ta tion in time and place ap peared. Stretch re flexes were nor mal (2+) and 205

4 K. Vrotniakaitë, R. Jacevièiûtë, V. Rudaitis, D. Jatuþis sym met ri cal, Kernig sign was slightly pos i tive. Af ter one week her neu ro log i cal sta tus ap par ently wors ened the pa - tient be came very slug gish, was able to say only her name and could not re spond to any com mands. Ini tial CT scan showed hypodense le sion in brain stem, and sub se quent MRI re vealed signs of sym met ric extrapontine demyeli na - tion in cor pus cal lo sum, limbic lobes of parahippocampal gyrus and hip po cam pus (Fig. 2). The pa tient im proved in one week, how ever, sleep i ness, am ne sia, dis ori en ta tion in time and place, im paired at ten tion con cen tra tion, slow ness of move ments re mained, and ataxia (ab nor mal fin ger- tonose test) ap peared. Af ter 2 weeks (1 month af ter ad mis - sion) she was trans ferred to re ha bil i ta tion with BI of 80, MMSE 24, poor short-term and long-term mem ory, at - ten tion def i cit, and slight dis ori en ta tion in time and place. She had hypoesthesia in right leg (electroneurography showed right peroneal nerve dam age), could not ac cu - rately per form heel-to-shin test on the left side, and had a positive Romberg sign. Af ter 3 weeks her BI was 95, MMSE 29, at ten tion and ori en ta tion im proved, nev er the - less, tired ness per sisted and she needed as sis tance for bath - ing. Af ter 1.8 months treat ment the pa tient was sent to out-pa tient de part ment for fur ther as sis tance. Neu ro log i cal out come at fol low-up. The pa tient re - sumed driv ing 6 months af ter the event and re turned to her work af ter 1.5 years. Dur ing the fol low-up visit (36 months af ter PPH) she as sessed her own mem ory and at ten tion of 5 and 4 points, re spec tively. The patient com plained of mood fluc tu a tions and tired ness. Neu ro log i cal ex am i na - tion re vealed slow move ments and nor mal mus cle tone in both arms. No tremor was pres ent. HADS-D and HADS-A scores were 13 and 14, re spec tively. Cog ni tive as sess ment: ACE-R LT 89 points (missed 1 point in ori en ta tion and at - ten tion, 4 points in mem ory, 2 points in lan guage flu ency, and 4 points in visuospatial abil ity). DIS CUS SION GEN ERAL. Hypoxic-ischemic brain in jury is of ten caused by car diac ar rest. Less com mon causes in clude re - spi ra tory ar rest, se vere hypotension/shock, near-drown ing and chem i cal gas in tox i ca tion [7]. In gen eral, pa tients with brief ep i sodes of sys temic hypoxia usu ally dem on strate clin i cal fea tures of re vers ible met a bolic encephalo - pathy few hours of coma, short-last ing mo tor, sen sory, intellectual deficits, transient confusion or amnesia. How - ever, if sys temic an oxia-ischemia is more se vere, struc - tural dam age to spe cific brain ar eas may oc cur. The most vulnerable areas include cerebral cortex, cerebellum, hip - po cam pus, the basal gan glia, and spi nal cord [8], prob a bly be cause these re gions are the most met a bol i cally ac tive [9] and wa ter shed ter ri to ries of the brain [10]. Hem or rhagic shock is un com mon cause of neu ro log i cal im pair ment, as the clas sic neuroendocrine re sponse to hem or rhage at - tempts to main tain per fu sion to the heart and brain via cen - tral in tense vasoconstriction [11]. In ad di tion, if se vere hem or rhage oc curs in a hos pi tal, all the con di tions for pro - vid ing ad e quate fluid ther apy and packed RBC for main - tain ing nor mal or gan and cel lu lar per fu sion are ac ces si ble, there fore the prob a bil ity of anoxic brain dam age is not high. Nev er the less, these cases of PPH pres ent the rel e - vance and haz ards of this ill ness, which re quires the cli ni - cians to be vig i lant in daily prac tice. PROG NO SIS. In lit er a ture, prog nos tic fac tors of neu - ro log i cal out come and re cov ery of con scious ness af ter hypoxic-ischemic coma are widely de scribed in car diac ar - rest set ting. Dif fer ent prog nos tic scales and ta bles are re - ported, which are mostly based on anamnesis, clin i cal and lab o ra tory find ings. GCS score alone or its sep a rate el e - ments con nected to time are one of the most fre quently used cri te ria [12, 13]. Nor mally, the pupillary light re flex is an early in di ca tor, while oculocephalic re sponse is a later prog nos tic fac tor, which is eval u ated in two weeks [14]. Other clin i cal ob ser va tions such as brainstem re flexes, func tion of cra nial nerves, in clud ing cor neal and oculo - vestibular re flexes, re spi ra tory pat tern and data such as du - ra tion of CPR, du ra tion of an oxia, and blood glu cose lev els on ad mis sion are also im por tant [15]. These clin i cal find - ings re tain the best prog nos tic value ap proved by new est stud ies [16]. Two clin i cal cri te ria ab sence of mo tor re - sponse and pupillary or cor neal re flexes on day three have been found to be al most 100% spe cific for poor prog - no sis [17]. Myoclonic sta tus epilepticus is also usu ally as - so ci ated with poor out come but it should not be con fused with multifocal myoclonus or gen er al ized tonic-clonic sei - zures, which are not re li ably use ful for prog nos ti ca tion [18]. Fur ther test ing is only an cil lary and is used when comor bid con di tions are pres ent. The value of N20 com po - nent in somatosensory evoked po ten tials as well as EEG as sess ment are still ques tion able due to high interobserver vari abil ity [19]. Two main bio chem i cal mark ers neu - ron- spe cific enolase and the glial S-100 pro tein are as so - ci ated with poor out come and may help in a clin i cal trial set ting [20]. Now a days, due to ad vanced meth ods of re sus - ci ta tion, eval u a tion of hypoxic-ischemic out comes fo cuses on neuropsychological pat tern, where the GCS is less im - por tant for pre dic tion of good cog ni tive func tions. C. P. Kaplan et al. found that re cov ery of re call mem ory dur ing the first month af ter anoxic event may pre dict good cog ni tive func tions [21]. More over, quan ti ta tive MRI 6 months af ter anoxic brain dam age shows prom is ing re - sults in pre dic tion of cog ni tive out come af ter this type of in jury [22, 23]. Data re gard ing pa tients with PPH who are ad mit ted to ICU are scant, and ar ti cles usu ally an a lyze gen eral ob stet - ric pop u la tion, so it may mis rep re sent the data con cern ing PPH. Lit er a ture pres ents some risk fac tors of bad out come and ad verse ma ter nal mor bid ity af ter PPH, in clud ing late on set of DIC, blood trans fu sions, car diac dis ease, other co-morbidities, etc. However, these studies are superficial and lack re ports of pa tient out comes sub se quent to ICU ad - mis sion [4, 24]. Fur ther more, no prog nos tic fac tors have been re ported an a lyz ing pa tients neu ro log i cal out comes af ter se vere brain dam age due to hypovolemia caused by 206

5 Good Neu ro log i cal Out come Af ter Hypoxic-ischemic Coma Caused by Se vere Postpartum Hem or rhage: Three Case Re ports and Lit er a ture Re view PPH. We pre sumed that this out come could be re flected by the same prog nos tic fac tors, used for prog no sis af ter car - diac at tack, which through hypovolemia shows the sim i lar pathogenetic pat tern as PPH. Ac cord ing to sev eral scales of worse or better prog no sis, our ob served three women had only a few fac tors of worse prog no sis, de spite the fact that the gen eral and neu ro log i cal con di tion of the pa tients was crit i cally se vere af ter PPH [25, 26]. Ac tu ally, A. Peskine et al. in di cated that this type of in jury pres ents no cor re la tion be tween acute stage data, ex cept the length of stay in the ICU, and the out come [27]. OUT COME. Im prove ment in re sus ci ta tion and life sup port ing tech niques re sulted in a greater num ber of pa - tients with vari able de gree of hypoxic-ischemic brain in - jury de ter min ing higher mor bid ity. Pos si ble neu ro log i cal out comes of anoxic-ischemic brain dam age may vary rang ing from brain death to rel a tively mi nor re sid ual ef - fects, but gen er ally the prog no sis is in ter me di ate, com - pared to other causes of nontraumatic coma. This type of coma also pres ents a sig nif i cantly in creased fre quency of per ma nent veg e ta tive state as any other type of non-trau - matic coma [28]. How ever, even if the im pact of sys temic hypoxia on the brain func tions is not se vere and neu ro log i - cal func tions are not im paired dra mat i cally, only a few pa - tients avoid neu ro log i cal dys func tion. If the struc tural dam age of brain tis sue is pres ent, full re cov ery is un likely. R. O. Hopkins et al. are one of the few who have re ported a case of three in di vid u als with sus tained se vere an oxia and chronic sequelae in a num ber of cog ni tive func tions, where one of the pa tients re turned to pre-in jury lev els of func tion - ing [22]. Pa tients who sur vive coma make most of their im - prove ment dur ing the first month. The lon ger the coma lasts, the less are the chances of re gain ing in de pend ent func tions [28]. Out come of anoxic brain in jury is of ten characterized by amnesic syndrome: severely impaired long term re call, in tact short-term mem ory, proactive in - ter fer ence, and more or less de pressed rec og ni tion of vi - sual and ver bal ma te rial [29, 30]. Am ne sia in this case is most likely caused by bi lat eral hip po cam pus in jury due to its high met a bolic ac tiv ity [9]. In mild cases of hypoxia, recollection (but not familiarity) is usually impaired, how - ever, both types of rec og ni tion mem ory also can be af - fected [31]. In ad di tion, al most all pa tients af ter anoxic brain in jury pres ent some sort of at ten tion and self-reg u la - tion impairment (deficits in sustained attention and effort) [32]. Postanoxic ax ial mo tor dis tur bances (due to basal gan glia in jury), extrapyramidal syn drome, dysarthria, dyspraxia, and agnosia are also men tioned in the lit er a ture [27, 33 36]. Generaly, a wide spread cog ni tive def i cit, be - hav ioural fron tal lobe and dysexecutive syn drome may ap - pear af ter this type of in jury, caus ing dif fer ent lev els of in - abil ity and pat terns of im pair ments [10, 27, 36]. Obstetric patients are generally different from general pop u la tion and of ten have pe cu liar out comes af ter ad mis - sion in ICU. Preg nant women are usu ally young and in good health, and pos sess lower mor tal ity rate ac cord ing to dif fer ent scales and scores ap plied in ICU [37]. Ac cord ing to maternal morbidity outcome indicator (MMOI), PPH is the main fac tor pre dis pos ing ma ter nal mor bid ity (28 56%) [38]. In lit er a ture, how ever, the out come and mor bid ity usu ally rep re sent a snap shot in time of the ICU ad mis sion with vir tu ally no data on late-on set out comes and postpartum fol low-up [39]. Our find ings are con sis tent with ear lier ob ser va tions of cog ni tive and psychosocial im pair ment of the pa tients af ter hypoxic-ischemic brain in - jury. Though the pa tients re sumed a nor mal life with al - most no patho log i cal neu ro log i cal find ings af ter the event, they were found to have sub jec tive com plaints and def i cits of mem ory and at ten tion, which nev er the less af fect the work and fam ily re la tion ships. More over, two pa tients showed sig nif i cant signs of de pres sion (2) or anx i ety (1), and this cor re lated with de creased ACE-R LT re sults. In con clu sion, al though eval u at ing the prog no sis of such pa tients may be chal leng ing, our small ob ser va tion shows that ba sic prog nos ti ca tion may be based on the other hypoxic-ischemic pat terns. When talk ing about more spe - cific and pre cise neuropsychological eval u a tion, there is no con sen sus, which could help out line more ac cu rate prog no sis. Pre dic tion of neu ro log i cal out come is even more con fus ing due to het er o ge ne ity of PPH. As a young part of the pop u la tion, women af ter child birth are im por - tant not only to rel a tives and their de scen dants, but also to the so ci ety due to so cio eco nomic fac tors. Ac cord ing to our ob ser va tions, most PPH pa tients made no ta ble im prove - ment over an ex tended pe riod of time. 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7 Good Neu ro log i cal Out come Af ter Hypoxic-ischemic Coma Caused by Se vere Postpartum Hem or rhage: Three Case Re ports and Lit er a ture Re view ku rios ga li tu rë ti di de lës reikð mës ne tik mo ti nos, bet ir jos vai ko, ðeimos gy ve ni mui, ga li ma so cio lo gi në ir eko no mi në þa la ir vals - tybei. Dël pa ge rë ju sios pra di nio ir spe cia lio jo gai vi ni mo kokybës svar biau sio mis ir ak tu a liau sio mis tam pa neu ro lo gi nës komplika - ci jos, su si ju sios su hi pok si ja hi pok si në ið emi në ko ma ir hipok - si nis sme ge nø pa þei di mas. Ðia me straips ny je ap ta ria me 3 mo te rø neu ro lo gi nes ið ei tis po sun kaus po gim dy mi nio nu krau javimo ir jo su kel to gal vos sme ge nø pa þei di mo. Dis ku si jo se pa tei kiama li - te ra tû ros, su si ju sios su ðia pro ble ma, ap þval ga. Duo me nys apie bu vu sá nu krau ja vi mà, gim dy viø ben drà jà ir neu ro lo gi næ bûklæ, gal vos sme ge nø vaiz di niø ty ri mø ra di nius po jo bu vo renkami ret ros pek ty viai ið Vil niaus uni ver si te to li go ni nës (VUL) San ta - rið kiø kli ni kø li gos is to ri jø. Da bar ti nei bûk lei, sub jek ty viai savi - jau tai ir ga li moms ato kioms pa sek mëms áver tin ti (pra ëjus vi du ti - nið kai 35 mën. po ávy kio) mo te rys bu vo te le fo nu pa kviestos at - vyk ti á VUL San ta rið kiø kli ni kø neu ro lo gi jos cen trà. Da bartiniai nu si skun di mai, neu ro lo gi në ir kog ni ty vi në bûk lë, dep resijos ir neri mo ly gis bu vo ver ti na mi ak ty viai klau siant, ob jek tyviai ti - riant, nau do jant Adenb ru ko kog ni ty vi nio ty ri mo tai sy tos metodi - kos adap ta ci jà lie tu við kai kal ban tiems gy ven to jams (ACE-R LT ), Li go ni nës ne ri mo ir dep re si jos ska læ (HADS). Vi sos trys moterys ûmi niu pe ri odu po nu krau ja vi mo bu vo kri tið kai sun kios bûklës, su dau gi nio or ga nø ne pa kan ka mu mo ir di se mi nuo tos in travasku - li nës ko a gu lia ci jos sin dro mø po þy miais. Dviem ið jø ap ra ðy ti ati - tin ka mai 4 ir 5 mi nu èiø truk mës asis to li jos epi zo dai, tre èios gim - dyvës hemoglobino kiekis kraujyje po nukraujavimo tebuvo 15 g/l. Jø neurologinë bûklë tiek kritiniu ûminiu, tiek sveikimo periodu buvo itin sunki pasireiðkë hipoksinë iðeminë koma, de - ly ras, eks tra pon ti në mie li no li zë, trau ku liai, gráþ ta ma sis uþ pa ka - linës leukoencefalopatijos sindromas, koordinacijos sutrikimai, galûniø raumenø hipertonija, sutriko psichosocialiniai gebëji - mai. Moterø atoki neurologinë bûklë buvo stebëtinai gera. Tai ro - do geras potencialias galvos smegenø funkcijø atsistatymo po po gim dy mi nio nu krau ja vi mo ga li my bes. Vie nos mo ters ACE-R LT ro dik lis sie kë mak si mu mà, ki tø vir ði jo 89 ba lus ið 100. Vi sos grá þo á dar bà, vai ruo ja au to mo bi lá, ta èiau tu ri sub jek ty viø nu si skun di mø ávai raus laips nio at min ties ir dë me sio su tri ki mais. Dviem moterims buvo nustatytas reikðmingai padidëjæs depre - siðkumo, vienai jø taip pat ir nerimastingumo lygis. Kadangi specialiø metodø, pritaikytø iðeitims po pogimdyminio nukrauja - vimo prognozuoti, neradome, retrospektyviai taikëme literatûro - je plaèiai apþvelgtus prognostinius veiksnius, naudojamus neu - ro lo gi nëms ið ei tims po ðir dies su sto ji mo nu ma ty ti. Jø re zul ta tai, mû sø at ve jais, ga na pa ti ki mai ati ti ko ste bi mas ge ras neu ro lo gi - nes iðeitis po iðeminës hipoksinës komos dël pogimdyminio nu - kraujavimo. Apraðyti atvejai pabrëþia bendradarbiavimo ir ligo - niø interdisciplininës prieþiûros svarbà bei galimus gerus atokius re zul ta tus. Raktaþodþiai: pogimdyvinis nukraujavimas, hipoksinë-ið - eminë koma, smegenø paþeidimas, neurologinë iðeitis. 209