IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
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IntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
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Designed to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
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After a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
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Our innovative Book Series format brings you:
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Topic Focused Publications - Each topic showcases high impact subject areas
\n\t
Renowned Editorial Expertise - Series Editors, Topic Editors, and a team of international Board Members that permanently support each Book Series
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Fast Publishing - quick turnaround which is unique for book publishing
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The benefit of ISSN and ISBN for increased citation and indexing possibilities
\n
\n\n\n\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\n
IntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
We invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
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Note: Edited in October 2021
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\r\n\tPsychometrics generally refers to a specialized field of psychology concerning the techniques of assessment, measurement, and their respective theories. Psychometrics include objective measurement of cognitive functions (intelligence, memory, attention, reaction times, etc.), characteristics of personality (e.g. hypochondria, hysteria, paranoia, social introversion, psychotic traits), emotions (happiness, sadness, anger, fear, disgust, surprise), behavior, and socio-educational qualities. Their constructs are also applied to emotional and mental disorders (especially anxiety and depression). Psychometric measures are inferred through mathematical models based on observation and statistical analysis conducted on a sample of subjects in comparison with the general population that leads to the planning of mental tests, scales, and open or close-ended questionnaires. Psychometricians usually possess specific qualifications such as those of psychologists and other operators with experience and training in psychometrics and with knowledge in measurements theories.
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\r\n\tThis book aims to provide an update on theoretical approaches, instruments, and procedures of modern psychometrics. Authors are encouraged to include examples of psychometric assessments in human experimental models and possible clinical applications in human disorders.
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In 2003, he obtained a Ph.D. in Neuroscience with a thesis about the behavioural and cognitive profile of frontotemporal dementia. Dr. Misciagna has worked in various neurology departments, Alzheimer’s clinics, neuropsychiatric clinics, and neuro-rehabilitative departments. 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1. Introduction
Anemia, the meaning of which in Greek is “without blood,” is a relatively common sign and symptom of various medical conditions. Anemia is defined as a significant decrease in the count of total erythrocyte [red blood cell (RBC)] mass, although this definition is rarely used in clinical settings. According to the World Health Organization, anemia is a condition in which the number of red blood cells (RBCs, and consequently their oxygen-carrying capacity) is insufficient to meet the body’s physiologic needs [1, 2]. The individual variation such as a person’s age, gender, residential elevation above sea level (altitude), and different stages of pregnancy changes the specific physiologic requirements of the body. Anemia is not a disease, but is instead the sign of an underlying basic pathological process. Nonetheless, the sign may function as a compass in the search for the cause, as well as function as a road marker in the investigation of underlying pathological process [3]. Hence, the diagnosis according to the symptoms obtained by history and physical examination of patients with anemia should be supported by laboratory parameters related to the underlying pathological cause. The first step in the diagnosis of anemia is detection with predictive, accurate tests so that important clues to underlying disease are not missed and patients are not subjected to unnecessary tests for and treatment of nonexistent anemia. Instead, clinicians rely on several other measures to identify the degree and the cause of anemia in a given patient.
The purpose of this chapter is to discuss the clinical approaches with which a practicing physician is able to evaluate a patient with underlying anemia.
2. Classification of anemia
Based on determination of the red blood cell mass, anemia can be classified as either relative or absolute. Relative anemia is characterized by a normal total red blood cell mass in an increased plasma volume, resulting in a dilution anemia, a disturbance in plasma volume regulation. However, dilution anemia is of clinical and differential diagnostic importance for the hematologist [4]. Classification of the absolute anemias with decreased red blood cell mass is difficult because the classification has to consider kinetic, morphologic, and pathophysiologic interacting criteria. Anemia of acute hemorrhage is not a diagnostic problem and is usually a genitourinary or gastrointestinal event, not a hematologic consideration.
Initially, anemias should be classified into two groups as diminished production and increased destruction of RBCs. The number of reticulocytes is a remarkable parameter in the materialization of this classification. Then, diagnostic analysis is able to be based upon both morphologic and pathophysiological hallmarks.
Anemias can morphologically be classified into three subgroups as macrocytic, normocytic, and microcytic hypochromic anemias. This classification is based on mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC) of complete blood count (CBC) and aids the physician to the diagnosis and monitoring of anemias that can be easily cured, such as deficiency of vitamin B12, folic acid, and iron.
Pathophysiologic classification is best suited for relating disease processes to potential treatment (Figure 1). In addition, anemia resulting from vitamin- or iron-deficiency states occurs in a significant proportion of patients with normal red blood cell indices.
Figure 1.
Classification of anemia according to pathophysiologic characteristics (figure has been modified from Ref. [4]).
Each step indicated in Figure 1 can be disrupted and cause anemia. Identifying the affected step is important for therapeutic intervention and specific treatment. The limitation of pathophysiologic classification is that pathogenesis involves several steps in most anemias. Therefore, the provided chapter is a guideline for the practical understanding of the processes underlying the production and destruction of RBCs. Despite all these morphological classification is more useful in terms of convenience and clinical usage. Hence, morphological classification serves to support the diagnosis and indirectly treatment in connection with the laboratory and clinic. The major limitation of such a classification is that it tells nothing about the etiology or reason for the anemia [5].
3. Laboratory evaluation
A comprehensive laboratory evaluation is required for definitive diagnosis and treatment for any anemia, although the anamnesis (history of patient) and physical examination of the patient may indicate the presence of anemia and propose its cause. As appropriate to this aim, the various tests for the diagnosis of anemia are done with routine hematological tests such as CBC and reticulocyte counts as well as studies of iron status that serve as a leaping point to the diagnosis (Figure 2). When the diagnosis of specific anemic conditions is confirmed, a large number of other specific tests are used [6]. Laboratory tests used in the diagnosis of anemia are roughly summarized in Figure 2. The laboratory investigation of anemias involves the quantitative and semiquantitative measurements of RBCs and supplementary testing of blood and body fluids. The laboratory results obtained from these parameters are important arguments in the diagnosis, treatment, and monitoring of the anemias.
Figure 2.
Laboratory tests used in anemia diagnosis (figure has been modified from Ref. [4]).
3.1. Complete blood count
Prior to the development of modern hematology blood analyzers, blood counts included hemoglobin (Hb) concentration, white blood cell (WBC) count, and manual platelet count. The other parameters like mean corpuscular volume (MCV) had to be mathematically calculated by using the measured parameters such as Hb, RBC count, and hematocrit (Hct). Modern analyzers provide CBC indices by using various physical and chemical methods such as electronic impedance, laser light scattering, light absorption, and staining properties [7].
How will CBC parameters such as Hb concentration, Hct, RBC count, MCV, MCHC, WBC count, platelet count, and other parameters related to formed elements of blood measured by modern blood analyzers help the diagnosis or management of the patient? CBC identifies several different parameters and can provide a great deal of information. Hematologic and biochemical variations of red blood cells determine whether the patient is anemic or not. If anemia is present, MCV is likely to provide clues about the cause of anemia. While an infection can lead to increased WBC, lymphocytosis can be seen in viral infections (but not always so). Abnormal size or number of platelets may be either due to the direct effect of any underlying blood disease or may simply be the reflection of the presence of some other underlying pathologies. Because of all these, CBC parameters obtained as a result of clinical evaluation should be reassessed more carefully and curiously [7]. Therefore, the fundamental parameters of CBC such as Hb concentration, RBC, Hct, MCV, mean corpuscular hemoglobin (MCH), MCHC, and red blood cell distribution width (RDW) which plays an important role in the diagnosis, treatment, and monitoring of the anemic patient will be explained below.
3.2. Hemoglobin concentration
Determination of Hb is a part of CBC. Hemoglobin is intensely colored, and this property has been used in methods for estimating its concentration in the blood. Erythrocytes contain a mixture of hemoglobin, oxyhemoglobin, carboxyhemoglobin, methemoglobin, and minor amounts of other forms of hemoglobin [4].
Monitoring the response to treatment of anemia and to evaluate polycythemia, Hb concentration is used to screen for diseases associated with anemia and to determine the severity of anemia [6]. Finding an increased Hb concentration requires a systematic clinical approach for differential diagnosis and further investigation. The conditions such as polycythemia vera, congestive heart failure, chronic obstructive pulmonary disease, etc., can cause Hb levels to rise.
Decreased Hb levels are found in anemia. Hb must be evaluated along with the RBC and Hct. In iron deficiency, hemoglobinopathies, pernicious anemia, liver disease, hypothyroidism, hemorrhage (chronic or acute), hemolytic anemia (caused by transfusions, reactions to chemical or drugs, infectious and physical agents), and various systemic diseases (e.g., Hodgkin’s disease, leukemia, etc.), decrease in Hb levels can be observed.
Variations in Hb levels occur after hemorrhages, transfusions, and burns (Hb and Hct are both high during and immediately after hemorrhage). Hb and Hct supply valuable information in an emergency situation [8].
Excessive fluid intake, pregnancy, and drugs, etc., which cause increase in plasma volume and decrease the Hb values, are interfering factors. Drugs such as methyldopa and extreme physical exercise can give rise to increased Hb levels. In addition, people living in high altitudes have increased Hb concentration, Hct, and RBC count [8].
3.3. Red blood cell count
The quantification of the percentage of microcytic and hypochromic RBCs has proved its clinical usefulness in the differential diagnosis of microcytic anemia [9]. RBC count has been recognized as the most efficient single classical measurement in the differential diagnosis of microcytic anemia [10]. Iron-deficient erythropoiesis is characterized by the production of RBC with a decrease in Hb content, so a high percentage of hypochromic cells are present.
In β-thalassemia cases, increased RBC count is a characteristic as a result of chronic increase in erythropoiesis. Therefore, MCV and MCH are lower in beta thalassemia than in iron deficiency anemia [11].
3.4. Hematocrit
The word hematocrit, also called packed cell volume (PCV), means “to separate blood,” which underscores the mechanism of the test, because the plasma and blood cells are separated by centrifugation [6].
Decreased Hct values are an indicator of anemia, in which there is a reduction in the Hct. An Hct ≤30% means that the patient is severely anemic. Decreased values also occur in leukemias, lymphomas, Hodgkin’s disease, adrenal insufficiency, chronic diseases, acute and chronic blood loss, and hemolytic reactions (transfusions, chemical, drug reactions, etc.).
Increased Hct values are observed in erythrocytosis, polycythemia vera, and shock (when hemoconcentration rise) [4].
Interfering factors such as pregnancy, age, sex, and dehydration have different effects in Hct. People living in high altitudes have increased Hct values and RBC count. Hct decreases in the physiologic hydremia of pregnancy. Hct varies with age and gender. Hct levels are lower in men and women older than 60 years of age. Severe dehydration from any cause falsely increases the Hct value [8, 12].
4. Red blood cell indices
The size and hemoglobin content of erythrocytes (red blood cell indices), based on population averages, have traditionally been used to assist in the differential diagnosis of anemia [13]. Some red blood cell parameters (for instance, RBC count, Hb concentration, MCV, RDW) are directly measured, while the others (e.g., Hct, MCV, MCHC) are derived from these primary measurements [14]. These measurements are provided by any of the common automated instruments. Instruments vary somewhat in their technologies. The most commonly used method is either a combination of a highly focused light source, an electric field, and a laser-based flow cytometry or a radiofrequency wave to discriminate between cells. Automated instruments are not only fast but extremely accurate. The coefficient of variation (measurement error) of an automated counter is usually less than 2%, and each of the major measurements, including the hemoglobin level, red blood cell count, and mean corpuscular volume, can be standardized independently with commercial red blood cell and hemoglobin standards [4, 6, 12].
4.1. Mean corpuscular volume (MCV)
MCV has been used to guide the diagnosis of anemia in patients, for example, testing patients with microcytic anemia for iron deficiency or thalassemia and those with macrocytic anemia for deficiency of folate or vitamin B12 [4, 15].
The reference value of MCV ± 2 SD is 90 ± 9 fL and generally coincides with the peak of the Gaussian distribution of RBC size. Although MCV is both accurate and highly reproducible, errors may be introduced by RBC agglutination, distortions in cell shape, the presence of very high numbers of WBCs, and sudden osmotic swelling [8]. MCV results are the basis of the classification system used to evaluate an anemia (Table 1, Figure 3).
Microcytic anemias (MCV 50–79 fL)
• Disorders of iron metabolism
Iron deficiency anemia, anemia of chronic disease, congenital hypochromic-microcytic anemia with iron overload
Classification and possible diagnosis of anemia according to MCV in clinical use [8].
Figure 3.
Flowchart to follow in the diagnosis of anemia according to MCV [4].
Increased reticulocytes and marked leukocytosis can also increase MCV [8]. The mixed population of microcytes and macrocytes results in normal MCV values and is an interfering factor in evaluating MCV.
4.2. Mean corpuscular hemoglobin (MCH)
MCH, the amount of hemoglobin per red blood cell, increases or decreases in parallel with MCV and generally provides similar diagnostic information. Because this parameter is affected by both hypochromia and microcytosis, it is least sensitive as MCV in detecting iron deficiency states [16].
The reference value of MCH is 32 ± 2 pg. This is an excellent measure of the amount of hemoglobin in individual red blood cell. Patients with iron deficiency or thalassemia who are unable to synthesize normal amounts of hemoglobin show significant reductions in the MCH [8, 17].
An increase of MCH is associated with macrocytic anemia; a decrease of MCH is associated with microcytic anemia.
Hyperlipidemia is one of the interfering factors of MCH because it falsely increases MCH values. WBC counts >50,000/mm3 also falsely provide increased level for MCV as well as for Hb. In addition, high heparin concentrations also falsely elevate MCH value [8].
4.3. Mean corpuscular hemoglobin concentration (MCHC)
MCHC is not used frequently for diagnostic purpose, but is primarily useful for quality control purposes, such as detecting sample turbidity. Because MCHCs are average quantities in the blood with mixed-cell populations, it is difficult for these red blood cell indices to detect abnormalities in the blood [4].
The reference value of MCHC is 33 ± 3 g/dL. The principal purpose of MCHC is to detect patients with hereditary spherocytosis who has very small, dense spherocytes in the circulation. These spherocytes represent cells that have lost considerable intracellular fluid because of a membrane defect. In situations such as sideroblastic anemia, recently transfused patients, patients with severe pernicious anemia with red blood cell fragmentation, and in conditions where both folate and iron deficiency are present, both large and small red blood cells are observed, which compromise the value of MCV. When present in significant numbers, they will cause MCHC to increase to levels in excess of 36 g/dL [4, 6, 15].
Decreased MCHC indicates that packed RBCs (a unit volume) contain less Hb than normal. MCHC is decreased in hypochromic anemia (MCHC < 30 g/dL) observed in iron deficiency, microcytic anemias, chronic blood loss anemia, and some thalassemias.
Increased MCHC levels (RBCs cannot accommodate more than 37 g/dL Hb) occur in spherocytosis, in newborns and infants.
Because of falsely elevating MCHC, lipemia, cold agglutinins or rouleaux, and high heparin concentrations may be among the interfering factors. MCHC cannot be greater than 37 g/dL because the RBC cannot accommodate more than 37 g/dL Hb [8].
4.4. Red blood cell distribution width (RDW)
RDW is an estimate of the variance in the volume within the population of red blood cells [4]. RDW, provided by automated counters, is an index of the distribution of RBC volumes. RDW is derived from pulse height analysis and can be expressed as an SD (fL) or as a coefficient of variation (%) of the red cell volume. Automated counters use two methods to calculate RDW [6]. The first is referred to as RDW-CV. RDW-CV is the ratio of the width of the red blood cell distribution curve at 1 SD divided by MCV (normal RDW-CV = 13 ± 1%) (Figure 4). Since it is a ratio, changes in either the width of the curve or MCV will influence the result. In microcytosis, any changes in the RDW-CV simply reduce the denominator of the ratio. Conversely, in macrocytosis the change in the width of the curve will minimize the change in RDW-CV. A second method of measuring the RDW is RDW-SD and is independent of MCV. RDW-SD is measured by calculating the width at the 20% height level of the red blood cell size distribution histogram (normal RDW-SD = 42 ± 5 fL) [6, 8, 15].
Figure 4.
Red blood cell distribution width. Automated counters provide measurements of the width of the red blood cell distribution curve. RDW-CV is calculated from the width of the histogram at 1 SD from the mean divided by MCV [6].
Both measurements of RDW are essentially mathematical statement of anisocytosis. Increases in the RDW suggest the presence of a mixed population of cells. Double populations, whether microcytic cells mixed with normal cells or macrocytic cells mixed with normal cells, will widen the curve and increase the RDW. The RDW-SD is more sensitive to the appearance of minor populations of macrocytes or microcytes since it is measured lower on the red blood cell volume-distribution curve (Figure 4) [4, 8].
The RDW can be used to distinguish thalassemia (normal RDW) from iron deficiency anemia (high RDW). Also, it can be used to distinguish chronic disease anemia (normal RDW) from early iron deficiency anemia (elevated RDW). RDW increases in iron deficiency anemia, vitamin B12 or folate deficiency (pernicious anemia), abnormal Hb (S, S-C, or H), S-β thalassemia, immune hemolytic anemia, marked reticulocytosis, and posthemorrhagic anemia.
The RDW may be an alternate marker for systemic inflammation and/or oxidative stress; however, the predictive value of RDW is independent of other inflammatory markers. This suggests that this biomarker also follows other nonempirical processes [8, 17]. The determination of the physiological and biological mechanisms that associate RDW to adverse clinical results is important in using these prognostic biomarkers to therapeutic decisions [18].
4.5. Stained peripheral blood smear
Peripheral blood smears can provide important additional information about RBC morphology in anemia and are easily prepared manually using glass slides. The hematology laboratory usually examines a peripheral blood smear if the patient’s indices are abnormal (unless there has been no major change from previous CBCs). If an underlying blood disorder is suspected, a film should be requested. Automated instruments ensure accurate RBC counts and indices and WBC counts and differentials in both healthy and diseased individuals [8, 19].
The peripheral blood smear complements the automated countermeasurements of MCV and MCH. Visible changes in cell diameter, shape, and hemoglobin content can be used to distinguish both microcytic and macrocytic cells from normocytic/normochromic RBCs (Table 2) [6].
The patterns of some abnormal RBCs
Comment
Macrocyte
Larger than normal (>8.5 μm diameter)
Microcyte
Smaller than normal (<7 μm diameter)
Hypochromic
Less hemoglobin in the cell. Enlarged area of central pallor
Spherocyte
Loss of central pallor, stains more densely, often microcytic. Hereditary spherocytosis and certain acquired hemolytic anemias
Target cell
Hypochromic with central “target” of hemoglobin. Liver disease, thalassemia, Hb D, and postsplenectomy
Leptocyte
Hypochromic cell with a normal diameter and decreased MCV. Thalassemia
Elliptocyte
Oval to cigar shaped. Hereditary elliptocytosis, certain anemias (particularly vitamin B12 and folate deficiency)
Stomatocyte
Slit-like area of central pallor in erythrocyte. Liver disease, acute alcoholism, malignancies, hereditary stomatocytosis, and artifact
Acanthocyte
Five to ten spicules of various lengths and at irregular intervals on surface of RBCs
Echinocyte
Evenly distributed spicules on surface of RBCs, usually 10–30. Uremia, peptic ulcer, gastric carcinoma, pyruvate kinase deficiency, and preparative artifact
Sickle cell
Elongated cell with pointed ends. Hb S and certain types of Hb C
Table 2.
Various forms and interpretations of RBCs observed in the peripheral blood smear examination [31].
In clinical cases, the variation such as staining, color, shape, and inclusion bodies in the blood smear of RBCs is not only an indication of RBC abnormalities but also a diagnosis of diseases.
4.6. Reticulocyte count
Reticulocyte count is an essential component of CBC and has a substantial role in initially classifying any anemia. Reticulocytes are newly formed red blood cells with residual strands of nuclear material called “reticulin” that remain following extrusion of the nucleus from bone marrow normoblasts [20]. The reticulocyte is a young red blood cell containing residual ribosomal RNA that can be stained with a supravital dye such as acridine orange or new methylene blue [4]. The reticulocyte count can be used in differentiation of the patients with a functionally normal marrow response to anemia/hypoxia and those with a failed marrow response. Whenever the reticulocyte production index (RPI) increases to levels greater than three times normal in response to an anemia (hematocrit <30%), it can be assumed that the patient has normal renal function with an appropriate erythropoietin response and a normal erythroid marrow with an adequate supply of key nutrients (iron, folic acid, and vitamin B12) [6, 15].
Reticulocytosis, increased RBC production, occurs when the bone marrow is replaced, is lost, or has prematurely destroyed cells. Identifying reticulocytosis is important for the recognition of other clinic conditions such as hidden chronic hemorrhage or unrecognized hemolysis (e.g., thalassemia, sickle cell anemia). Reticulocyte levels increase in hemolytic anemia, immune hemolytic anemia, primary RBC membrane problems, hemoglobinopathy, RBC enzyme deficits, and malaria.
Increased reticulocyte count after hemorrhage (3–4 days) or after treatment of anemias can be used as an index for an effective treatment. In iron deficiency anemia, reticulocytes may increase to more than 20% after sufficient doses of iron. A proportional increase in reticulocytes can also be seen when pernicious anemia is treated by transfusion or vitamin B12 therapy.
If there is not enough erythrocyte production in the bone marrow, the reticulocyte count decreases in untreated iron deficiency anemia and aplastic anemia, untreated pernicious anemia, anemia of chronic disease, radiation therapy, endocrine problems, tumor in the marrow (bone marrow failure), myelodysplastic syndromes, and alcoholism.
Interfering factors: Reticulocytes are normally increased in infants and during pregnancy. Recently transfused patients have a lower count because of the dilution effect. The presence of Howell-Jolly bodies falsely elevates reticulocyte count when automated methods are used.
Some other laboratory tests are useful to define the physiologic defects responsible for anemia. Indirect serum bilirubin and lactic dehydrogenase (LDH) levels increase in patients with increased hemolysis and in ineffective erythropoiesis. Indirect bilirubin levels correlate with RBC turnover rate. Serum LDH is exceedingly responsive to increased rates of RBC destruction (because of the excess levels of LDH 1 in RBCs) [8, 21].
Reticulocyte hemoglobin content (CHr or Ret-He) measurement demonstrates Hb synthesis in marrow precursors. Ret-He also reflects the early stages of iron deficiency. Ret-He is defined as an auxiliary parameter in the differential diagnosis of anemias.
5. Additional new red blood cell and reticulocyte indices
Current high-end automated cell counters measure unique properties of mature red blood cells and reticulocytes on a cell-by-cell basis, not just as population averages. This results a plethora of new indices that are in many cases specific to an instrument manufacturer, presenting diagnostic opportunities but also a confusing nomenclature and a potential lack of comparability. Some examples of parameters that have been studied include hypochromic erythrocytes (HypoHe%), percentage microcytic red blood cells (MicroR%), reticulocyte hemoglobin equivalent (Ret-He), reticulocyte hemoglobin content (CHr), red blood cell size factor (RSf), low hemoglobin density (LHD%), and fragmented red blood cells (FRCs) [22–24].
Ret-He demonstrates the real-time information on the synthesis of young RBCs in the bone marrow. Other available parameters are the percentage of RBCs with Hb content equivalent ≤17 pg (HypoHe%) and the percentage of RBCs with a volume of <60 fL (MicroR%), which reflects the subpopulation of mature RBCs exhibiting evidence of insufficient iron content [6, 8].
Estimates of reticulocyte-specific hemoglobin content (which are comparable) by light-scatter measurements of reticulocytes are closely related to adequacy of iron availability to erythroid precursors during the preceding 24–48 hours and have been described as diagnostically useful in detecting functional iron deficiency [8, 22].
The CHr may be a better predictor of depleted marrow iron stores than traditional serum iron parameters in nonmacrocytic patients and is a more sensitive predictor of iron deficiency than hemoglobin for screening infants and adolescents for iron deficiency [25, 26].
Schistocytes or FRC is also used as new red blood cell indices. Nevertheless only a few studies have been published on this parameter, but concerns have been expressed for false positivity in the presence of hypochromic samples. Schistocytes are elevated in thrombotic microangiopathies [1].
5.1. Marrow examination
Bone marrow examination has a special place in the cause of anemia since it is the organ of blood production [20]. The marrow examination is of greatest value in patients who fail to show an appropriate increase in the reticulocyte production index in response to anemia. A sample of the marrow can easily be obtained by needle aspirate or biopsy to evaluate overall cellularity, the ratio of erythroid to granulocytic precursors (E/G ratio), and cellular morphology. In these patients defects in erythroid precursor proliferation or maturation play a major role. Examination of any marrow aspirate should include a careful assessment for evidence of a red blood cell maturation abnormality, especially changes in cell size, nuclear morphology, and hemoglobin production. A number of anemias are characterized by distinct abnormalities in the maturation sequence and the morphology at each stage of maturation [6]. The assessment of the bone marrow is the gold standard in iron deficiency. The presence of the mineral in reticuloendothelial cells is the key to the diagnosis [20].
5.2. Tests of iron
Iron supply tests (serum iron level, transferrin iron-binding capacity, and serum ferritin level) play an important role in the initial differential diagnosis of an anemia. They are essential components to the marrow iron stain whenever a marrow aspirate is performed [8, 22, 25].
Serum iron levels. This is serum iron (SI) measurement which reflects an amount of iron bound to transferrin. The reference range of SI level is 50–150 μg/dL for an individual. The proliferative capacity of the erythroid marrow and its ability to synthesize hemoglobin are assessed by serum iron level [6].
Total iron-binding capacity (TIBC). The amount of iron which is bound to transferrin is called TIBC. Actually, it is equivalent to measuring the level of transferrin. The reference value of TIBC is 300–360 μg/dL. TIBC increases in excess of 360 μg/dL in patients with severe iron deficiency.
Serum ferritin level. Ferritin is a spherical protein and is used clinically to evaluate total body storage iron (body iron stores). A normal adult male has a serum ferritin level of between 50 and 150 μg/L, reflecting iron stores of 600–1000 mg. Serum ferritin levels decrease when the iron stores are depleted. Levels below 10–15 μg/L indicate iron deficiency due to exhaustion of iron store [6].
5.3. Other measurements
For the diagnosis of specific hematopoietic disorders, there are some other laboratory tests. Table 3 demonstrates some of the special assays for such disorders [1, 4].
Hypoproliferative anemias
Maturation disorders
Hemolytic anemias
*Cytometric assay of CD59/CD55 levels (paroxymal nocturnal hemoglobinuria) *Chromosomal analysis (leukemias) *Marrow aspirate/biopsy special stains • Trichrom stain, silver stain for reticulin (myelofibrosis)
Specific hematopoietic disorders and the associated laboratory tests [6].
The flowchart that follows is intended as a first approach for the diagnosis of anemia and is a supplement to this chapter to demonstrate how the steps might be placed in a logical order (Figure 3).
5.4. Evaluation and investigation of the patient with anemia according to laboratory parameters
A CBC and differential and reticulocyte counts together with stained peripheral blood smear examination should be the starting point of investigations. These confirm the clinical suspicion of anemia and direct further investigation [5].
The points to be followed in Figure 5 (A–F) may help to begin anemia investigation:
A. Check RBC status of the patient.
Figure 5.
Flowchart as a first approach to diagnose anemia. In anemic patients, approaches should follow according to MCV and RDW because of their comprehensibility and simplicity [27].
The RBC performs some functions such as transportation of O2 and CO2. An increase in RBC is referred as polycythemia. Patient may have α- or β-thalassemia. Confirm abnormal hemoglobins with electrophoresis, Hb A2 value in β-thalassemia will be >3.5%, check if there are target cells, etc. A decrease in RBC accounts for less hemoglobin. If RBC count is low, patient iron status should be checked (iron, TIBC, Sat%, ferritin, etc.).
B. If red blood cell morphology demonstrates schistocytes.
Red blood cell fragmentation can be investigated. Fragmented red blood cells (FRCs) and hemolysis occur when RBCs get stressed through partial vascular occlusions or over abnormal vascular surfaces. “Split” RBCs, or schistocytes, are considered on peripheral blood smears under these conditions; significant quantities of lactate dehydrogenase are released into the blood from injured RBCs [4].
The ethnicity of the patient is important for this situation.
Check the patient for sickle cell disease (SCD). If the patient is normal for SCD, investigate iron deficiency anemia.
C. Screen for uncorrected reticulocyte count.
Reticulocyte count and indices: Reticulocytes are stained by supravital staining. Typical normal range is 0.5–1.5%. The count depends on total RBC count [12]. For both the pathophysiological classification of anemia and to monitor marrow response after therapeutic interventions, reticulocyte count is clinically important [11, 19].
Reticulocyte count was used in the clinical and laboratory practice for a long time due to three main factors: technical limitations in the detection of cell, the imprecision of manual microscopic method, and high coefficient of variations in counts [28, 29]. The index is the corrected value in relation to total red blood cell mass and Hb%. Increased count indicates increased red blood cell turnover. Reticulocyte count can be used as a measure of red blood cell production by correcting red blood cell count for both changes in hematocrit. The result of correction reflects the effect of erythropoietin on reticulocyte release from the marrow [6].
Obtain single correction reticulocyte count (reticulocyte index) (S):
S=Reticulocytecount×PatientHct/0.45E1
Double-corrected reticulocyte count or reticulocyte production index (RPI) is calculated by dividing the single correction reticulocyte count by the maturation index.
In situations where the reticulocyte count is elevated, other possibilities should be investigated, for example, serum haptoglobin and hemopexin, which are degraded hemoglobin-bound complexes, are impaired and can’t be monitored in acute intravascular hemolysis. Unconjugated bilirubin in serum and urobilinogen in urine should be also measured. Unconjugated hyperbilirubinemia in the absence of urobilirubinogen in urine is a marker of hemolysis [12].
If reticulocyte production index (RPI) is ≥3, peripheral blood smear should be examined for abnormal morphology, and the values of bilirubin, LDH, serum-free Hb, urine Hb, urine hemosiderin, and haptoglobin should be evaluated.
If Haptoglobin is >40 mg/dL, the patient probably has/had an acute hemorrhage or is responding to hematinic. Patient should be evaluated for external or internal bleeding.
If Haptoglobin is <30 mg/dL, probably the patient has hemolytic anemia. Bilirubin is usually between 1.0 and 5.0 mg/dL. Mostly indirect bilirubin is present.
Screen for uncorrected reticulocyte count if the patient has any morphological abnormalities screen for uncorrected reticulocyte count.
Often, the etiology of a patient’s anemia can be determined if the shape or size of RBCs is altered or if they include inclusion bodies (Table 2). Plasmodium falciparum malaria is suggested by the presence of more than one ring form in an RBC, and the infection produces pan-hemolysis of RBCs of all ages [30].
D. If normocytic, heterogeneous anemia is present.
The levels of ferritin and RBC folate/vitamin B12 should be examined to confirm/exclude the possible early diagnosis of iron deficiency anemia, sideroblastic or megaloblastic anemia, mixed deficiency, and myeloproliferative disorder. Serum transferrin receptor, homocysteine, and methylmalonic acid levels can be also considered.
E. Check pyruvate kinase and glucose-6-phosphate dehydrogenase (G6PD) enzyme.
In severe hemolytic anemia, spherocytosis and RBC fragmentation may be seen in the stained film. Although drug-induced hemolysis may indicate “bite cells” in the blood of patients with G6PD deficiency, this may not always be associated with G6PD deficiency because such cells are generally not found in patients with acute hemolytic conditions of chronic G6PD variants or patients with chronic hemolytic G6PD deficiency [4]. Repeat the history and physical examination for splenomegaly.
F. If macrocytic, heterogeneous anemia is present.
The pattern of folate or vitamin B12 of the patient should be checked. The homocysteine, methylmalonic acid, LDH, and indirect bilirubin values can be investigated. It is necessary to evaluate the intrinsic factor and parietal cell antibody to confirm or exclude pernicious anemia.
The proper use and interpretation of laboratory tests are important in the diagnosis and treatment of anemia. Whether the patient is anemic can be determined by using Hb, Hct, or RBC count and the reference intervals for age and sex or the patient’s previous values [31]. Routine examination of the blood includes CBC and examination of a stained peripheral blood smear. The values could be normal in mild anemia with RBC count in normal range [32].
6. Conclusion
There is no single optimal marker or test combination in the differential diagnosis of anemias [33]. The knowledge and experience of the physician who demands appropriate hematological and biochemical tests related to preliminary diagnosis have the important role in the diagnosis of anemias. It is recommended to use algorithms as a tool in determination of anemias in order to reduce the laboratory tests and accurately diagnose the underlying cause(s) in patients.
For the past decade, remarkable progress has been made in the procedures and algorithms in the differential diagnosis of anemias. CBC is the main procedure for investigating anemia. The percentage of microcytic RBCs is considered in the first step. In the second step, MCV, RDW, and RBC count should be examined. It is advocated that innovative algorithms, including parameters reflecting hemoglobinization of RBCs and reticulocytes, are integrated to improve the differentiation between anemias. Subsequently, new algorithms, including conventional as well as innovative hematological parameters, were assessed for subgroups with microcytic erythropoiesis. Nowadays automated reticulocyte counts provide new parameters to evaluate marrow activity [29]. It is therefore important to establish accurate and reliable criteria for both identifying the specific causes of anemia and evaluating the impact of intervention strategies. These should be followed by laboratory tests that are mandatory and simple to perform.
7. Key points of this chapter
CBC is the most sensitive measure in the routine use to obtain the information about the presence and severity of anemia.
For the evaluation of anemia, there are some essential basic laboratory tests such as CBC, reticulocyte count, blood smear morphology changes, iron balance studies, and bone marrow morphology reports.
Severity of the hematocrit/hemoglobin changes in MCV, RDW, and blood smear morphology are the first parameters to evaluate anemia. These help to define the anemia as normocytic, microcytic, or macrocytic.
Reticulocyte index defines the adequacy of the erythropoietin and red blood cell production response.
Bone marrow examination can also provide information about proliferative response and whether there is any defect in precursor maturation.
Iron studies should also be included in the investigation of anemia.
In conclusion, identification of the cause of anemia by the clinician with the support of laboratory data is an important step to diagnose, treat, and monitor the underlying pathological process.
\n',keywords:"anemia, complete blood count, red blood cell indices, reticulocyte",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/56750.pdf",chapterXML:"https://mts.intechopen.com/source/xml/56750.xml",downloadPdfUrl:"/chapter/pdf-download/56750",previewPdfUrl:"/chapter/pdf-preview/56750",totalDownloads:6113,totalViews:4552,totalCrossrefCites:2,totalDimensionsCites:4,totalAltmetricsMentions:0,impactScore:3,impactScorePercentile:85,impactScoreQuartile:4,hasAltmetrics:0,dateSubmitted:"December 19th 2016",dateReviewed:"July 11th 2017",datePrePublished:"December 20th 2017",datePublished:"February 7th 2018",dateFinished:"August 18th 2017",readingETA:"0",abstract:"Anemia is a major cause of morbidity and mortality worldwide and can be defined as a decreased quantity of circulating red blood cells (RBCs). The epidemiological studies suggested that one-third of the world’s population is affected with anemia. Anemia is not a disease, but it is instead the sign of an underlying basic pathological process. However, the sign may function as a compass in the search for the cause. Therefore, the prediagnosis revealed by thorough investigation of this sign should be supported by laboratory parameters according to the underlying pathological process. We expect that this review will provide guidance to clinicians with findings and laboratory tests that can be followed from the initial stage in the anemia search.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/56750",risUrl:"/chapter/ris/56750",book:{id:"5942",slug:"current-topics-in-anemia"},signatures:"Ebru Dündar Yenilmez and Abdullah Tuli",authors:[{id:"183998",title:"Ph.D.",name:"Ebru",middleName:null,surname:"Dündar Yenilmez",fullName:"Ebru Dündar Yenilmez",slug:"ebru-dundar-yenilmez",email:"edundar@cu.edu.tr",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Cukurova University",institutionURL:null,country:{name:"Turkey"}}},{id:"209103",title:"Prof.",name:"Abdullah",middleName:null,surname:"Tuli",fullName:"Abdullah Tuli",slug:"abdullah-tuli",email:"tuliabd@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Classification of anemia",level:"1"},{id:"sec_3",title:"3. Laboratory evaluation",level:"1"},{id:"sec_3_2",title:"3.1. Complete blood count",level:"2"},{id:"sec_4_2",title:"3.2. Hemoglobin concentration",level:"2"},{id:"sec_5_2",title:"3.3. Red blood cell count",level:"2"},{id:"sec_6_2",title:"3.4. Hematocrit",level:"2"},{id:"sec_8",title:"4. Red blood cell indices",level:"1"},{id:"sec_8_2",title:"4.1. Mean corpuscular volume (MCV)",level:"2"},{id:"sec_9_2",title:"4.2. Mean corpuscular hemoglobin (MCH)",level:"2"},{id:"sec_10_2",title:"4.3. Mean corpuscular hemoglobin concentration (MCHC)",level:"2"},{id:"sec_11_2",title:"4.4. Red blood cell distribution width (RDW)",level:"2"},{id:"sec_12_2",title:"4.5. Stained peripheral blood smear",level:"2"},{id:"sec_13_2",title:"4.6. Reticulocyte count",level:"2"},{id:"sec_15",title:"5. Additional new red blood cell and reticulocyte indices",level:"1"},{id:"sec_15_2",title:"5.1. Marrow examination",level:"2"},{id:"sec_16_2",title:"5.2. Tests of iron",level:"2"},{id:"sec_17_2",title:"5.3. Other measurements",level:"2"},{id:"sec_18_2",title:"5.4. Evaluation and investigation of the patient with anemia according to laboratory parameters",level:"2"},{id:"sec_20",title:"6. Conclusion",level:"1"},{id:"sec_21",title:"7. Key points of this chapter",level:"1"}],chapterReferences:[{id:"B1",body:'Brugnara C, Mohandas N. Red cell indices in classification and treatment of anemias: From M.M. Wintrobes’s original 1934 classification to the third millennium. Current Opinion of Hematology. 2013;20(3):222-230'},{id:"B2",body:'WHO Scientific Group. Nutritional anemias. In: WHO Meeting; 13-17 March 1967; Geneva. Switzerland: WHO; 1968. pp. 1-28'},{id:"B3",body:'Bridges KP, Howard A. Principles of anemia evaluation. In: Bridges KP, Howard A, editors. Anemias and Other Cell Disorders. 1st ed. USA: The McGraw-Hill; 2008. pp. 4-18. DOI: 10.1036/0071419403'},{id:"B4",body:'Narla M. The erythrocyte. In: Kenneth K, Marshall A, Lichtman JT, Marcel L, Oliver W, Caligiuri MA, editors. Williams Hematology. 9th ed. USA: McGraw-Hill Education; 2016. pp. 461-915. DOI: 978-0-07-183301-1'},{id:"B5",body:'Alli N, Vaughan J, Patel M. Anaemia: Approach to diagnosis. South African Medical Journal. 2016;107(1):23-27. DOI: 10.7196/SAMJ.2017.v107i1.12148'},{id:"B6",body:'Hillman R, Ault K, Leporrier M. Red blood cell disorders. In: Hillman R, editor. Hematology in Clinical Practice. 5th ed. USA: McGraw-Hill Education; 2010. pp. 10-26. DOI: 978001766531'},{id:"B7",body:'Provan D, Singer CRJ, Baglin T, Inderjeet D. Oxford Handbook of Clinical Haematology. UK: Oxford University Press; 2009. DOI: 019922739X'},{id:"B8",body:'Fischbach FT, Dunning MB. A Manual of Laboratory and Diagnostic Tests. 8th ed. China: Wolters KluwerHealth/Lippincott W&W; 2009. 1064 p. DOI: 978-0-7817-7194-8'},{id:"B9",body:'Urrechaga E. Discriminant value of microcytic/hypochromic ratio in the differential diagnosis of microcytic anemia. Clinical Chemistry and Laboratory Medicine. 2008;46(12):1752-1758'},{id:"B10",body:'Urrechaga E. Red blood cell microcytosis and hypochromia in the differential diagnosis of iron deficiency and β‐thalassaemia trait. International Journal of Laboratory Hematology. 2009;31(5):528-534'},{id:"B11",body:'Urrechaga E, Borque L, Escanero JF. Erythrocyte and reticulocyte parameters in iron deficiency and thalassemia. Journal of Clinical Laboratory Analysis. 2011;25(3):223-228. DOI: 10.1002/jcla.20462'},{id:"B12",body:'Mukherjee N. A Clinical Approach. In: Anemia. India: CME; 2004. pp. 358-363'},{id:"B13",body:'Wintrobe M. Anemia: Classification and treatment on the basis of differences in the average volume and hemoglobin content of red corpuscles. Archives of Internal Medicine. 1934;54(2):256-280'},{id:"B14",body:'Ryan DH. Clinical evaluation of the patient. In: Kaushansky K, editor. Williams Hematology. 9th ed. USA: McGraw-Hill Education; 2016. pp. 11-26. DOI: 978-0-07-183301-1'},{id:"B15",body:'Coyer SM. Anemia: Diagnosis and management. Journal of Pediatric Health Care. 2005;19(6):380-385'},{id:"B16",body:'Jolobe OM. Mean corpuscular haemoglobin, referenced and resurrected. Journal of Clinical Pathology. 2011;64(9):833-834'},{id:"B17",body:'Wang F, Pan W, Pan S, Ge J, Wang S, Chen M. Red cell distribution width as a novel predictor of mortality in ICU patients. Annals of Medicine. 2011;43(1):40-46'},{id:"B18",body:'Patel A, Brett SJ. Identifying future risk from routine tests? Cricical Care Medicine. 2014;42(4):999-1000'},{id:"B19",body:'Buttarello M. Laboratory diagnosis of anemia: Are the old and new red cell parameters useful in classification and treatment, how? International Journal of Laboratory Hematology. 2016;38(S1):123-132'},{id:"B20",body:'Bridges KP, Howard A. Principles of anemia evaluation. In: Bridges KP, Howard A, editors. Anemias and Other Red Cell Disorders. 1st ed. United States of America: The McGraw-Hill Companies, Inc.; 2008. p. 374. DOI: 10.1036/0071419403'},{id:"B21",body:'Buttarello M, Plebani M. Automated blood cell counts: State of art. American Journal of Clinical Pathology. 2008;130(1):104-116'},{id:"B22",body:'Prchal JT. Clinical manifestations and classification of erythrocyte disorders. In: Kaushansky K, editor. Wiliams Hematology. 9th ed. United States: McGraw-Hill Education; 2016. pp. 503-511. DOI: 978-0-07-183301-1'},{id:"B23",body:'Torino ABB, Gilberti MFP, de Costa E, de Lima GAF, Grotto HZW. Evaluation of red cell and reticulocyte parameters as indicative of iron deficiency in patients with anemia of chronic disease. Revista Brasileira de Hematologia e Hemoterapia. 2014;36(6):424-429'},{id:"B24",body:'Chabot-Richards D, Zhang Q-Y, George TI. Automated hematology. In: Rifai N, Horvath AR, Wittwer CT, editors. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 6th ed. St. Louis, Missouri, USA: Elsevier; 2017. p. e1734. DOI: 978032335921'},{id:"B25",body:'Mast AE, Blinder MA, Lu Q, Flax S, Dietzen DJ. Clinical utility of the reticulocyte hemoglobin content in the diagnosis of iron deficiency. Blood. 2002;99(4):1489-1491'},{id:"B26",body:'Ullrich C, Wu A, Armsby C, Rieber S, Wingerter S, Brugnara C, et al. Screening healthy infants for iron deficiency using reticulocyte hemoglobin content. Jama. 2005;294(8):924-930'},{id:"B27",body:'DeMott WR, Skikne BS. Hematology. In: Jacobs DS, Oxley DK, editors. Laboratory Test Handbook. 5th ed. USA: Lexi Comp Inc.; 2001. pp. 391-399'},{id:"B28",body:'Grotto HZW. Platelet and reticulocyte new parameters: Why and how to use them?. Revista Brasileira de Hematologia e Hemoterapia. 2016;38(4):283-284'},{id:"B29",body:'Cortellazzi LC, Teixeira SM, Borba R, Gervásio S, Cintra CS, Grotto HZ. Reticulocyte parameters in hemoglobinopathies and iron deficiency anemia. Revista Brasileira de Hematologia e Hemoterapia. 2003;25(2):97-102'},{id:"B30",body:'Medscape. Anemia Workup [Internet]. 2016 [Updated: September 24, 2016]. Available from: http://emedicine.medscape.com/article/198475-workup#showall [Accessed: April 15, 2017]'},{id:"B31",body:'McPherson RA, Pincus MR, Henry JB. Henry’s Clinical Diagnosis and Management by Laboratory Methods. 22nd ed. China: Elsevier; 2011. 1513 p'},{id:"B32",body:'Baker RD, Greer FR. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126(5):1040-1050'},{id:"B33",body:'Schoorl M, Linssen J, Villanueva MM, NoGuera JA, Martinez PH, et al. Efficacy of advanced discriminating algorithms for screening on iron-deficiency anemia and beta-thalassemia trait: A multicenter evaluation. American Journal of Clinical Pathology. 2012;138(2):300-304'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Ebru Dündar Yenilmez",address:"edundar@cu.edu.tr",affiliation:'
Department of Medical Biochemistry, Faculty of Medicine, Çukurova University, Adana, Turkey
Department of Medical Biochemistry, Faculty of Medicine, Çukurova University, Adana, Turkey
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1. Introduction
Considered the second most commonly performed operation after cesarean section worldwide, hysterectomy may be classified as abdominal (laparotomy, laparoscopy, or robotic assistance) and vaginal (via an incision through the superior part of the vagina).
The most common indications for hysterectomy are benign conditions such as uterine fibroids, endometriosis, genital prolapse, pelvic pain, heavy menstrual bleeding, but the technique is also used for gynecological malignancy (usually ovarian, uterine, or cervical) and risk-reducing surgery (in cases of BRCA 1 or 2 mutations or Lynch syndrome) [1, 2, 3, 4].
Actually, there are three types of hysterectomy—total hysterectomy (the uterus and cervix are removed), subtotal or partial hysterectomy (the uterus is removed, but the cervix is left in place), and total hysterectomy with bilateral salpingo-oophorectomy (uterus, fallopian tubes, ovaries, and cervix are removed) [1, 2, 3, 4]. The term radical hysterectomy (removal of the uterus, cervix, parametrium, vaginal cuff, and fallopian tubes) is used to describe a wide range of procedures universally applicable to cervical cancer. However, the degree of radicality clearly depends on preoperative estimation of tumor location, surgical margins and the risk of occult lymphatic spread. Moreover, the ovaries may or may not be removed according to the patient age [1, 2, 3, 4]. In addition, supracervical hysterectomy is sometimes preferred to diminish the intraoperative complications and surgical times, as well as to limit the possibility of lower urinary tract issues and maintain normal sexual function [1, 2, 3, 4].
The best route for hysterectomy is multifactorial, depending not only on the surgeon’s skills and patient safety (minimally invasive procedures as vaginal, laparoscopic, laparoscopic-assisted, and robotic-assisted hysterectomies) but also on economic reasons [1, 2, 3, 4].
Hemorrhage after hysterectomy is recognized as an occasional life-threatening complication in modern gynecological surgery, assuming appropriate medical and surgical management [2, 3, 4, 5, 6, 7, 8, 9].
Classified as “reactionary” (postoperative bleeding within the first 24 hours following surgery) and secondary (bleeding occurring in the interval 3–22 days after surgery), unexpected hemorrhage may arise regardless of the route or subtype of hysterectomy [5, 6, 9]. Early recognition and prompt intervention (reoperation or arterial embolization) to arrest bleeding are essential strategies for the suitable outcome of the patient [2, 3, 4, 5, 6, 7, 8, 9, 10].
While the role of risk factors for “reactionary” hemorrhage is emerging and critical for a correct assessment of the patient, operative laparoscopy is still ideal to treat hemorrhage after vaginal hysterectomy, laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparotomy being necessary only in selected cases [2, 3, 4, 6, 9].
Secondary hemorrhage presents with varying degrees of severity and tends to be more common after laparoscopic hysterectomy, especially total laparoscopic hysterectomy than after the other hysterectomy approaches [5, 9]. Factors potentially responsible are vaginal vault infection, vault hematoma, a poor surgical technique including excessive thermal injury by electrocoagulation, and early resumption of physical activity, large uterus size, excessive use of an energy source for the uterine artery, and culdotomy [2, 3, 4, 5, 7, 9, 10].
Ultimately, the management of secondary hemorrhage is challenging and involves diverse approaches based on the exact cause of bleeding, comprising vaginal packing with or without vault suturing, laparoscopic coagulation of the uterine artery if the source of bleeding could not be identified vaginally or arterial embolization [6, 9, 10].
Because of elective gynecologic surgery, we encourage selective patients to donate their own blood before surgery [6, 11]. Several definitions are actually used:
autologous blood transfusion, when is done with the patient’s own blood; blood is stored and can be transfused during surgery;
homologous transfusion or transfusion from another woman;
parachute pack or umbrella pack is a useful tool for pelvic bleeding after pelvic exenteration;
peanut dissector; this tool is indicated for blunt pressure dissection of small places;
total blood volume; estimated blood volume of total body weight is 8% or 4.5–5.0 liters in the average women. When intraoperative blood loss exceeds 15% of the blood volume, blood transfusion must be taken into consideration in combating hypovolemic shock. About 15% of an adult blood volume can be calculated by amplification a patient’s weight in kg 10 times. The usual method of performing abdominal hysterectomy involved the use of clamps or forceps on vessels.
The present chapter will give an overview on different aspects of bleeding after hysterectomy such as incidence rate, risk factors, mechanisms, and management techniques aiming to expand our knowledge and skills in recognizing and treating this unexpected potentially serious complication. Furthermore, we intend to offer a guide toward standardizing treatment practice across bleeding issues following hysterectomy considering clear recommendations and algorithms.
2. Postoperative bleeding: Current trends/concepts
Postoperative hemorrhage represents a significant potential complication of contemporary gynecological surgery. Despite normal hemostasis, appropriate/suitable surgical technique and close monitoring, postoperative bleeding may occur, leading to the different clinical and operative scenarios and challenging even the most experienced operative team [2, 3, 4, 9, 11, 12].
2.1 Subtypes, incidence rate, location, predisposing factors, and complications
2.1.1 Postoperative bleeding subtypes
Based on their timing to surgery, two main subtypes of postoperative hemorrhage are actually recognized [5, 6, 7, 8, 9]:
subtype 1, early or reactionary postoperative gynecological hemorrhage where bleeding happens within the first 24 hours following surgery, commonly within the first 4–6 hours postoperative; early bleeding in modern gynecological surgery is reported irrespective of the route of intervention [6, 9];
subtype 2, delayed or secondary postoperative bleeding that develops in the interval 3–22 days after the surgery [5, 9]; secondary hemorrhage is rare and may arise more often after total laparoscopic hysterectomy than after other hysterectomy approaches [5].
2.1.2 Incidence rate of postoperative bleeding
Although the incidence of postoperative hemorrhage basically varies according to surgery, the difference between abdominal, laparoscopic, and vaginal hysterectomy remains statistically insignificant [5, 6, 7]. Indeed, some authors postulate that postoperative bleeding occurs more frequently after abdominal and laparoscopic than after vaginal hysterectomy, but overall, the incidence of hemorrhagic events after a hysterectomy varies from 0.2 to 3.1%, irrespective of surgical route [5, 6, 7, 8, 10, 13, 14].
On the other hand, the true frequency of delayed bleeding complications is still unknown, although the consequences can be particularly significant in women undergoing outpatient surgery [5, 6, 7, 8, 10, 13, 14]. Paul et al. reported an overall cumulative incidence of secondary hemorrhage after a total laparoscopic hysterectomy of 1.3% [5]. Although secondary hemorrhage is rare, it is more often reported after total laparoscopic hysterectomy than after other hysterectomy approaches [5, 6, 7, 8, 10, 13, 14].
Table 1 summarizes data on the incidence of postoperative hemorrhage reported by several authors.
Hemorrhage is responsible for about half of the postoperative complications following gynecological surgery, ranging from persistent venous oozing to massive blood loss from injury to retroperitoneal vessels [5, 6, 7, 12, 13].
Main bleeding sites comprise the anterior abdominal wall (both the suprapubic and the umbilical incision), the vaginal cuff (after laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy), and intraabdominal bleeding. Abdominal wall vessel injury occurs with increasing frequency, as the practice of laparoscopic surgery becomes wider and trocars become sharper [2, 3, 4, 7, 9].
The source of bleeding in secondary hemorrhage can be the uterine vessels or descending cervical/vaginal vessels; occasionally, uterine artery pseudoaneurysm can cause delayed heavy vaginal bleeding after laparoscopic hysterectomy [2, 3, 4, 7, 9]; additionally, the technique of vaginal vault closure may also contribute to the occurrence of secondary hemorrhage [5, 9].
Postoperative pelvic hematoma emerging after gynecological surgery may generate serious morbidity and impaired quality of life if large, infected, or incompletely resolved hematoma or hematoma with residual fibrosis and persistent pain [2, 3, 4, 9]. It usually develops above the vaginal vault, along the pelvic side-wall, retroperitoneal, in the paravesical space, in the abdominal wall as well as in the ischiorectal fossa and vulva [9]. According to its location, postsurgical hematoma may be recognized at routine abdominal and/or pelvic examinations in women with outstanding postoperative discomfort and unexpected anemia, but a definitive diagnosis can only be made by ultrasound or CT scan [5]. A simple or CT/ultrasound-guided or through abdominal incision drainage is commonly required to address the pelvic hematoma issue [2, 3, 4, 9].
Postoperative hemorrhage can result from failure to control vascular injury during surgery. Accurate clamp placement, gentle handling of tissues, and the accuracy of dissection are all important and contribute to maximum efficiency with minimum blood loss and minimum tissue damage when abdominal hysterectomy is performed [9].
The electrosurgical instrument can be used for a precise incision of the abdominal wall with minimal tissue injury. By holding the electrode close to the tissue or touching the metal clamp and pressing the coagulation button, superficial coagulation can be achieved [2, 3, 4, 9].
2.1.4 Predisposing factors
Intra- and post-operative bleeding generally develops in younger women or those with a more vascular pelvis who underwent a hysterectomy, especially laparoscopic hysterectomy in the presence of fibroids [6, 16].
Possible rationales for secondary hemorrhage comprise a bleeding vessel missed at the end of the procedure, effects of pneumoperitoneum, Trendelenburg position, low intraoperative pressure, wearing off the effect of vasopressin, subacute infection, postoperative analgesia, as well as bleeding disorders [2, 3, 4, 5, 7, 9].
Other potential factors accounting for delayed postsurgical bleeding are vaginal vault infection, vault hematoma, poor surgical technique with excessive thermal injury by electrocoagulation, and early resumption of physical activity [5, 7, 9]. A large-sized uterus, high vascularity, large-sized vessels, excessive use of an energy source for the uterine artery, and culdotomy also play a role in this hemorrhagic event [5, 7, 9].
2.1.5 Complications of bleeding
Most of the complications during or after hysterectomy are preventable or treatable. Other complications may exist as medical conditions before hysterectomy but are worsened during surgery, especially if not managed as part of holistic woman’s care.
Complications after surgery include [2, 3, 4, 9, 12]:
hemorrhage; occurs more often after laparoscopic hysterectomy as compared to vaginal surgery;
infections; occur more often after vaginal hysterectomy than keyhole surgery;
damage to internal organs such as bowel or urinary tract; the injury may occur to the ureter, bladder, or rectum and complications include incontinence, the urgency of urination, and infections;
vaginal cuff dehiscence; is more commonly reported in laparoscopic hysterectomy as compared to laparoscopic assisted procedures or vaginal hysterectomy;
anesthetic complications; smoking, obesity, and heart/lung infections are the most common causes of anesthetic complications;
ovarian failure; interruption to ovarian blood supply following removal of the uterus may precipitate the symptoms of menopause and lead to osteoporosis and ischemic heart disease;
low libido; the removal of the uterus may lead to less sexual enjoyment due to the loss of uterine contractions;
venous thromboembolism; prophylactic anticoagulants are associated with a lowering of the risk for such events;
depression; most of the women complain of feeling depressed because they have lost an important part of them.
In Romania, the mortality rate following a hysterectomy is very low.
Contemporary management of surgical interventions includes postoperative bleeding and the possibility of blood transfusion with risks of HIV transmission (in 1.9 million cases), the transmission of hepatitis B (one in every 180.000 cases), or a febrile reaction to transfusion (1% cases) [2]. Most experts recommend acute normovolemic hemodilution and cell salvage in women undergoing hysterectomy section who will not accept blood products.
Hypovolemic shock can occur after major bleeding as a direct result of uncontrolled hemorrhage. Depending on the total blood volume lost, hypovolemic shock may be divided into four classes: I (< 75 mL or 15%), II (750–1500 mL, or 15–30%), III (1500–2000 mL or 30–40%) and IV (>2000 mL or > 40%) [6].
The clinical manifestations of class I hypovolemia are not measurable and compensatory mechanisms restore plasma volume within a day. In class II hypovolemia, tachycardia is the most frequent clinical finding as a result of inadequate circulatory volume. The distinction between class I and II hypovolemic shock is made by recording blood pressure and pulse in the standing, sitting, or reclining position. Postural hypotension is observed as result of cardiac failure. Compensatory mechanisms begin to fail with the class III hypovolemic shock. This results in an increase in the arterial and venous oxygen difference with classic signs including worked tachycardia, tachypnea, oliguria, and cold skin. With the class IV hypovolemic shock, a patient’s survival depends on rapid transfusion of blood and immediate surgical intervention before cardiovascular collapse and death or organ system failure.
After initial resuscitative measures are instituted, it is highly recommended for patients to be carried out in a critical care unit. Use of sympathomimetic agents after sufficient hydration and vasodilator is normally preferred in the management of patients with hemorrhagic shock who have arterial pressure higher than 70 mm Hg.
Once restoration of the intravascular volume has been completed, it is important to reassess the patient’s response to blood transfusion when managing women with severe blood loss, especially in those patients who have pulmonary edema, myocardial infarction, or congestive heart failure [12].
Transfusion for patients with hemoglobin of 8–10 mg/dL is no longer recommended.
When major surgery is anticipated and transfusion is massive, platelets in addition to packed cell transfusion are required. It is recommended that cryoprecipitate be reserved for patients with deficiencies in von Willebrand factor, factor VIII, and fibrinogen factor XIII.
2.2 Management of postoperative hemorrhage
Recognized as an uncommon complication of hysterectomy, postoperative hemorrhage represents a true challenge in routine practice [8]; irrespective of the procedure, a close follow-up of the patient in a high-dependency unit is indicated in order to exclude recurrence of bleeding [6, 7].
The key to successful management is timely intervention meaning prompt diagnosis, urgent resuscitation if necessary and rapid decision for either arterial embolization or reoperation according to the severity of bleeding and the hemodynamic stability of the patient. Both techniques are highly effective to control bleeding; nevertheless, if the patient is hemodynamically unstable or of the interval since surgery is under 24 hours suggesting rapid hemorrhage, the emergency return to the operating theater to arrest the bleeding is preferred [6, 7, 9].
Current options for managing hemorrhage include [6, 7, 9]:
every patient should be carefully monitored postoperatively for signs of bleeding (hypotension, tachycardia, tachypnea, abdominal distension);
ultrasound can confirm intraperitoneal bleeding; more ways to determine intraabdominal hemorrhage include abdominal and pelvic CT scan; a routine coagulation profile should be done immediately for the patient with a rapid pulse, low blood pressure, and/or low urine output. The surgeon must take charge of the problem and execute the technical steps necessary to treat hemorrhagic shock in the operating room. Intraperitoneal bleeding can be hidden by incisional pain and analgesic medications. Despite adequate dissection, a small vessel may bleed or the suture may cut through tissue. Skeletonized vessels and small sutures should be used for significantly reducing the incidence of postoperative hemorrhage. Venous bleeding can be more life-threatening than arterial hemorrhage which can be clearly seen and controlled with fast small sutures or clamps.
the presence of unexpected drop in hematocrit or hemoglobin postoperatively.
A simplified algorithm to describe steps after gynecological surgery and potential post-surgery bleeding is provided in Figure 1.
Figure 1.
A simplified algorithm of post-surgery bleeding approach.
A closer look at the holistic management of postoperative blood should also underpin the following [9]:
to assess blood value and coagulation mechanisms;
to identify changes in the coagulation components, and to initiate replacement therapy in order to achieve adequate hemostasis. In assessing the patient’s coagulation status, it is very important to avoid such a situation known as the trauma triad of death consisting of—hypothermia, metabolic acidosis, and coagulopathy. In some patients with benign disease, blood transfusion is rarely indicated. Experience has shown that blood transfusion may be significant in women with malignant disease;
to establish the therapeutic strategy by measuring the level of prothrombin time < 14 sec, activated partial thromboplastin time (aptt) < 40 sec, fibrinogen >100 mg/dL, platelets >80 × 103 mL.
2.2.1 Reoperation
In hemodynamically unstable women (rapid pulse, falling blood pressure, with or without renal impairment) or if the bleeding occurs shortly in post-surgery (the so-called reactionary hemorrhage), it is desirable to return to the operating room [5, 6, 7, 8, 9].
A preoperative abdominal and pelvic ultrasound or CT scan is routinely required to visualize the source of bleeding as being intra- or retro-peritoneal, as well as adequate local examination without or under anesthesia. Moreover, the operative procedure should be mentally revised to identify any potential bleeding issue [9].
Surgical revision for postoperative bleeding may be performed transvaginally, laparoscopically, or both [5, 6, 7, 8, 9, 13, 14].
Postoperative hemorrhage from the vaginal vault recurrently originates from the vaginal artery in the lateral vaginal fornix or from one of its branches, since the lateral vaginal angle which includes the vaginal artery may not be accurately protected or turn into disligated [9, 13, 14]. Excessive vaginal bleeding needs to be objectively measured; since the vagina is a distensible organ, clots obstructing the vaginal introitus may lead to a large amount of blood accumulating and distending the vagina, subsequently covering the true significance of hemorrhage [9, 13, 14]. Vaginal bleeding can be controlled by clamping and ligating the bleeding point as well as by delayed-absorbable transfixion suturing of the vaginal mucosa and paravaginal tissue [9, 13, 14]. If such techniques are not enough or bleeding vessels have retracted, other tactics should be intended [8].
When no noticeable vaginal source, bleeding after abdominal or vaginal hysterectomy is traditionally treated by laparotomy or laparoscopy [7, 9]. While laparotomy is recommended in cases of intraperitoneal bleeding or unsuccessful conservative transvaginal treatment, operative laparoscopy is clearly indicated if the source of bleeding cannot be identified by the means of vaginal examination and/or if an intraabdominal bleeding source is suspected [7, 9, 13].
2.2.2 Laparotomy
Post-surgery bleeding requires laparotomy in two situations.
Firstly, if the surgical hemostasis cannot be achieved transvaginally, laparotomy may be necessary [9].
Secondly, if the patient underwent an abdominal hysterectomy, the incision should be reopened, succeeding the following steps (i) clots and blood evacuation from the abdomen and pelvic area; (ii) searching of the potential bleeding sites, commencing with the most expected places; (iii) ligating, suturing, or clipping of the identified bleeding sites; (iv) verifying the ureteral integrity as high risk of ureteral damage during reoperation; and (v) closing second time after a completely dry abdomen and pelvis [9].
2.2.3 Laparoscopy
The laparoscopic approach to postoperative bleeding following laparoscopic hysterectomy, vaginal hysterectomy, or laparoscopic-assisted vaginal hysterectomy is an attractive alternative to the abdominal surgical approach in the majority of patients [6, 7, 9, 13]. The procedure can be used to adequately evaluate the pelvis and the abdominal wall, which is occasionally the source of hemorrhage after laparoscopic hysterectomy. Moreover, whether the bleeding is from the abdominal wall, the surgical pedicles, or the vaginal cuff, it can be managed laparoscopically [8, 9]. Evidently, hemostasis can be more easily obtained in laparoscopic surgery because of magnification, close inspection, routine use of suction irrigation, and bipolar coagulation [7, 9]. Besides, bipolar coagulation, a Foley catheter introduced in the port-site bleeding, or a collagen-fibrin agent can be used to achieve local hemostasis during laparoscopy [7, 9].
Following laparoscopic irrigation/suction using Ringer’s solution to clear the operative field, a combination of laparoscopic suturing using absorbable suture material and laparoscopic bipolar coagulation is commonly recommended [6, 8, 9]. Also, electrosurgery is effective in controlling bleeding during laparoscopic surgery. Furthermore, different forms of fibrin adhesive are tested in gynecologic open surgery in order to stop oozing hemorrhages after primary hemostatic treatment with a high efficacy rate (98%) [6]. Holub and Kliment reported successful treatment of hemorrhage from damaged tissue near important pelvic structures using the laparoscope to apply collagen fleece combined with fibrin glue [7, 17].
To avoid further risk of injury to the abdominal wall and to improve the recovery time from surgery, single incision laparoscopic surgery is a viable option for the management of hemorrhage, particularly for those patients whose original surgery was accomplished via single incision laparoscopic surgery. Curlin et al. reported a case where single incision laparoscopy was used to manage postoperative hemorrhage after total laparoscopic hysterectomy with right salpingectomy and left salpingo-oophorectomy [8].
2.3 Arterial embolization
Conversely, if the patient is reasonably stable and there is not abrupt early bleeding (based on the volume of blood in the abdomen or retroperitoneal space as estimated by ultrasound and the time from surgery), it seems realistic to try to identify the bleeding artery and embolize it by transcatheter interventional radiological techniques [2, 3, 4, 9, 10].
Arterial embolization remains an important minimally invasive option for the management of delayed postoperative hemorrhage [2, 3, 4, 8, 9, 18]. Transcatheter arterial embolization has been shown to be an effective tool for the management of postoperative hemorrhage after gynecologic laparoscopy, but also after abdominal and vaginal hysterectomy [8, 9]. Selective angiographic arterial embolization is a quite simple and safe procedure with a clinical success rate up to 90% in routine practice and usually a low complication rate less than 10%, including a mild postembolization syndrome with pain, fever, high leucocyte count related to vascular thrombosis and tissue necrosis [8, 9]. Bladder necrosis, vesicovaginal fistula, neuropathies as well as renal toxicity are uncommon, isolated side effects [9].
Arterial embolization technique comprises the following main steps—(i) identification of the site of bleeding by angiofluoroscopy if more than 2–3 mL/min bleeding rate; (ii) percutaneous catheterization of the femoral artery or, uncommonly, brachial artery under local anesthesia with retrograde direct access to the hypogastric artery; (iii) canulation of the hypogastric artery or specific collateral vessel if appropriate; (iv) injection of the embolization material under angiographic observation (metal coins, autologous clot, small pieces of gelfoam, small silastic spheres, subcutaneous tissue, or other hemostatic materials; (v) repeat angiography to demonstrate the occlusion of the bleeding vessel; (vi) remove of the catheter followed by careful monitoring for further bleeding [8, 9, 10].
Although second surgery is often the initial choice for postoperative hemorrhage, for a patient who is hemodynamically stable but is experiencing postoperative hemorrhage, transcatheter arterial embolization is a welcome alternative to a second surgery [8, 9]. However, if rapid access to interventional radiology is not available or if transcatheter arterial embolization is unsuccessful, laparoscopy can still be considered [8, 9]. Besides, a potential advantage of surgical management of postoperative hemorrhage over transcatheter arterial embolization is the ability to evacuate the hemoperitoneum, which may decrease postoperative pain, the risk of infection, and the risk of ileus [8, 9].
3. Recommendations for managing postoperative bleeding in gynecological surgery
It is typical to expect some bleeding after hysterectomy in the 6–8 weeks following the procedure; the discharge may be red, brown, or pink. Bleeding should steadily decrease in the days and weeks following the surgery and should never be excessive at any point of recovery [18]. The exception is menstruation in women who have undergone a subtotal hysterectomy [18, 19]. In case of bleeding after hysterectomy, it is more likely to be of some pathologic cause instead of menstruation which needs to be ruled out [19].
However, a sudden and significant increase in bleeding during recovery should be considered abnormal. Points of concern comprise but are not limited to—bright red vaginal bleeding (indicating active bleed), temperature over 100.4°F, severe nausea or vomiting, increasing pelvic pain, a local complication such as redness, swelling, or drainage at the incision site as well as difficulty in urinating or pain with urination suggesting either an infection or a neurogenic bladder [18].
Delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy usually requires emergent reoperation. Several studies have described continued cyclical bleeding from the cervical stump after supracervical hysterectomy in 0–25% of cases [20].
Effective interventions addressing hemorrhage after hysterectomy are needed to reduce women’s mortality worldwide.
3.1 Recommendations
Counseling
Prior to hysterectomy, these women should be offered specific counseling and have a prospective plan for the management of their disease, developed by gynecologists of how their condition and hysterectomy interact. Prehysterectomy counseling services starting for all women planning this surgical intervention are a key part of hospital services and should be an integral part of the local health services network. They could be provided by general practitioners or specialist clinicians or surgeons, all of whom should be suitably trained or may require different management or specialized services before hysterectomy. There are special circumstances as congenital or acquired coagulation disorders that should be considered to evaluate by a thorough history and lab tests.
Professional interpretation services for women who do not speak English.
It is not clear how much the specific medical terminology is conveyed to the patient. Healthcare providers have to invest in technology, security, specialists, and translators to ensure healthcare becomes world-class. Medical tourism is growing each year. Romania provides the highest quality healthcare at the lowest price. Also, the cost of hysterectomy in Romania is lower than the same treatment in UK or UE. In developed countries as the USA, UE countries or Canada patients have to wait a long time for major surgeries. The cost involved in treating a patient depends upon factors like—type of hysterectomy needed, hospital and physician selected for it, and duration of staying.
Communication and referrals among professionals.
Good communication among professionals is essential. Referral between specialties involved should be rapid. They can use a variety of communication methods including—mobile phone, email, fax, Whatsapp, Instagram, Tik Tok, Facebook, etc. In many cases, junior trainees in the front line did not have proper support and need to have clear guidelines about when to seek senior help.
Women with serious medical conditions
They require immediate and appropriate multidisciplinary specialist care; women will require referral to tertiary or specialist medical centers for their preexisting medical or mental conditions before hysterectomy. Conditions that require prehysterectomy counseling and advice include—epilepsy, diabetes, asthma, congenital or known acquired cardiac disease, autoimmune disorders, renal and liver disease, obesity (BMI > 30), severe mental illness, or psychiatric conditions that require a change of medication, HIV infection. Women with potential serious underlying preexisting medical on mental health conditions should be immediately referred to appropriate specialist centers of expertise as soon as their symptoms develop.
Clinical training
All clinical staff must undertake regular training for the identification and management of serious disease conditions or potential emergencies or signs and symptoms of potentially life-threatening conditions, circulatory failure, severe hypertension or major hemorrhage, pyrexia >38°C, tachycardia >100 bpm, breathlessness. The local clinicians may be excellent at the management of severely ill women but must also accept written, documented, and audited courses. There should be a well-trained team of doctors for recording and charting investigations performed, obtaining quick results, ensuring that abnormal results are followed up promptly and have resulted in a better outcome.
Identifying and managing very sick women with critical illness before, during or after hysterectomy
In very acute situations, a team approach can be very healthful. The management of patients with an acute severe illness with circulatory failure, arterial hypertension, and major hemorrhage requires a team approach and help from the anesthetic and critical care services. There are some healthcare professionals who failed to manage crisis situations outside their immediate area of expertise; therefore, it is crucial to recognize their limitations and to know when and whom to call for another opinion once the patient was admitted to the hospital.
Coagulation factors, hematocrit, serum calcium, glucose, and electrolytes could be assessed every 120 minutes or after 10 U of transfusion; these lab tests are very helpful for the diagnosis of postoperative bleeding.
RCOG guidelines of the responsibilities of the consultant on call should be followed.
Bilateral hypogastric artery ligation can reduce blood loss to a minimum during hysterectomy [9].
Hypotensive anesthesia is also a safe and effective technique in reducing the circulation to the operative field [9].
Serious incident and women death reporting
Health professionals, senior or junior, must recognize an act on the signs and symptoms of potentially life-threatening conditions.
The evaluation of such a report must include clinicians from relevant disciplines (including anesthetics) who were not involved with the deaths. This report is recommended to be a requirement in the future.
The identification and act on women’s death should be reviewed as a serious incident and disseminated to all health professionals, junior or senior. Women’s deaths are generally underreported because of incorrect classification of cause.
Fatal hemorrhage can result from laceration of the external iliac vein or the hypogastric vein where they join together which are at risk of injury when the surgeon dissects between the distal common iliac artery, the psoas muscle, and the area of lumbosacral nerve trunks [9]. These vessels cannot be clamped and ligated with clips or sutures [9].
Dissection around the aorta and vena cava done with inadequate exposure performed in order to remove lymph nodes around them can result in serious hemorrhage. Bleeding usually can be avoided by placing a finger over the laceration and a vascular needle is used to close the laceration from side to side. The same technique may be used for common and external iliac veins [9].
Also, bleeding can occur by dissecting pararectal space and presacral space as well as obturator fossa [9].
Pathology
Patient death autopsy must be improved and require more expertise.
In Romania, the number of women death after hysterectomy (death rate) is very small and many of the autopsies reviewed were considered adequate. When an autopsy is needed, the body can be taken to another area for more expert examination. Despite evaluation by many examiners in the different specialties, the final diagnosis could not be resolved because of inadequate clinical data, poor autopsy quality, or the unmanageable nature of some death.
4. Conclusion
The lack of routine observation in the postoperative period or a failure to appreciate blood loss or recognition of abnormal vital signs such as oxygen saturation and respiratory rate can lead to death after hysterectomy. The patient should be evaluated before hysterectomy for risk factors and the medical conditions of the women should be diagnosed by a careful history and lab tests in order to decrease the possibility of hemorrhage.
The risks of blood transfusion, the transmission of HIV or hepatitis B should be discussed before surgical procedure.
The peace of surgical intervention should be governed by good exposure of the tissue, accuracy of dissection, and clamping or suturing the vessels in a precise manner. The skills and experiences of the surgeon without wasting time with unnecessary hesitation or indecision will reduce the risk of uncontrolled hemorrhage after a hysterectomy.
The surgeon should control the life-threatening hemorrhage by judgment, knowledge, and technical skills. The patient’s medical history for vital signs, blood loss volume, and levels of coagulation factors will determine how quickly blood transfusion is initiated. Careful postoperative clinical evaluation of the patient by the surgeon and surgical team with abdominal or pelvic ultrasound or CT scanning will help to prevent or minimize significant blood loss after hysterectomy and localize the site of bleeding.
Acknowledgments
No funding was received for this chapter.
\n',keywords:"post-surgery bleeding, hysterectomy, reactionary hemorrhage, secondary post-hysterectomy hemorrhage, management",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/79921.pdf",chapterXML:"https://mts.intechopen.com/source/xml/79921.xml",downloadPdfUrl:"/chapter/pdf-download/79921",previewPdfUrl:"/chapter/pdf-preview/79921",totalDownloads:192,totalViews:0,totalCrossrefCites:0,dateSubmitted:"October 16th 2021",dateReviewed:"October 25th 2021",datePrePublished:"January 5th 2022",datePublished:null,dateFinished:"January 5th 2022",readingETA:"0",abstract:"Bleeding after gynecological surgery remains an infrequent life-threatening complication, demanding appropriate medical and surgical management. Classified as early/“reactionary” and delayed/secondary, unexpected postoperative hemorrhage may arise regardless of the route or subtype of hysterectomy. Timely recognition and prompt intervention to arrest bleeding are essential strategies for the suitable outcome of the patient. The present chapter presents an overview on different aspects of bleeding after hysterectomy such as incidence rate, risk factors, mechanisms, and management techniques aiming to expand knowledge and skills in recognizing and treating this unpredicted potentially serious problem. Furthermore, we intend to offer a guide toward standardizing treatment practice across bleeding issues following hysterectomy considering clear recommendations and algorithms.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/79921",risUrl:"/chapter/ris/79921",signatures:"Eugen Ancuța, Radu Zamfir, Gabriel Martinescu, Eduard Crauciuc, Dumitru Sofroni, Larisa Sofroni, Lilian Guțu, Codrina Ancuța and Dragoș Valentin Crauciuc",book:{id:"11040",type:"book",title:"Hysterectomy - Past, Present and Future",subtitle:null,fullTitle:"Hysterectomy - Past, Present and Future",slug:null,publishedDate:null,bookSignature:"Prof. Zouhair Amarin",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-80355-061-9",printIsbn:"978-1-80355-060-2",pdfIsbn:"978-1-80355-062-6",isAvailableForWebshopOrdering:!0,editors:[{id:"101551",title:"Prof.",name:"Zouhair",middleName:null,surname:"Amarin",slug:"zouhair-amarin",fullName:"Zouhair Amarin"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Postoperative bleeding: Current trends/concepts",level:"1"},{id:"sec_2_2",title:"2.1 Subtypes, incidence rate, location, predisposing factors, and complications",level:"2"},{id:"sec_2_3",title:"2.1.1 Postoperative bleeding subtypes",level:"3"},{id:"sec_3_3",title:"Table 1.",level:"3"},{id:"sec_4_3",title:"2.1.3 Location and source of bleeding",level:"3"},{id:"sec_5_3",title:"2.1.4 Predisposing factors",level:"3"},{id:"sec_6_3",title:"2.1.5 Complications of bleeding",level:"3"},{id:"sec_8_2",title:"2.2 Management of postoperative hemorrhage",level:"2"},{id:"sec_8_3",title:"2.2.1 Reoperation",level:"3"},{id:"sec_9_3",title:"2.2.2 Laparotomy",level:"3"},{id:"sec_10_3",title:"2.2.3 Laparoscopy",level:"3"},{id:"sec_12_2",title:"2.3 Arterial embolization",level:"2"},{id:"sec_14",title:"3. Recommendations for managing postoperative bleeding in gynecological surgery",level:"1"},{id:"sec_14_2",title:"3.1 Recommendations",level:"2"},{id:"sec_16",title:"4. Conclusion",level:"1"},{id:"sec_17",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'Dawood AS, Elbohoty SB, Abbas AM, Elgergawy AE. Colpotomizer-assisted total abdominal hysterectomy (CATAH Technique): A new technique for uterine removal in benign pathologies. Gynecology and Minimally Invasive Therapy. 2021;10(2):109-113'},{id:"B2",body:'Jones HW III, Hysterectomy A. In: Rock J, Jones H III, editors. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 727-744'},{id:"B3",body:'Kovac RS. Vaginal Hysterectomy. In: Rock J, Jones H III, editors. TeLinde’s operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 744-763'},{id:"B4",body:'Howarsd F. Laparoscopic Hysterectomy. In: Rock J, Jones H III, editors. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 763-776'},{id:"B5",body:'Paul PG, Prathap T, Kaur H, et al. Secondary hemorrhage after total laparoscopic hysterectomy. JSLS. 2014;18(3):e2014.00139. DOI: 10.4293/JSLS.2014.00139'},{id:"B6",body:'Erian M, Mc Laren G, Khalil A. Reactionary hemorrhage in gynecological surgery. JSLS. 2008;12(1):81-84'},{id:"B7",body:'Holub Z, Jabor A. Laparoscopic management of bleeding after laparoscopic or vaginal hysterectomy. JSLS. 2004;8(3):235-238'},{id:"B8",body:'Curlin H, Scheib S. Single incision laparoscopy for the management of postoperative hemorrhage. JSLS. 2012;16(3):478-480'},{id:"B9",body:'Jones HW III, Rock WA Jr. Control of pelvic hemorrhage. In: Rock J, Jones H III, editors. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer Health; 2008. pp. 371-394'},{id:"B10",body:'Takeda A, Koyama K, Mori M, Sakai K, Mitsui T, Nakamura H. Diagnostic computed tomographic angiography and therapeutic emergency transcatheter arterial embolization for management of postoperative hemorrhage after gynecologic laparoscopic surgery. Journal of Minimally Invasive Gynecology. 2008;15:332-341'},{id:"B11",body:'Katz VL. Preoperative counseling and management – patient evaluation, informed consent, infection prophylaxis, avoidance of complications. In: Katz V, Lentz G, Lobo R, Gershenson D, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby Elsevier; 2007'},{id:"B12",body:'Katz VL. Postoperative counseling and management – fever, respiratory, cardiovascular, thromboembolic, urinary tract, gastrointestinal, wound, operative site, neurologic injury, psychological sequelae. In: Katz V, Lentz G, Lobo R, Gershenson D, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby Elsevier; 2007'},{id:"B13",body:'Wilke I, Merker A, Schneider A. Laparoscopic treatment of hemorrhage after vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH). Surgical Endoscopy. 2001;15(10):1144-1146'},{id:"B14",body:'Yamashita Y, Harada M, Yamamoto H, et al. Transcatheter arterial embolization of obstetric and gynaecologic bleeding: Efficacy and clinical outcome. The British Journal of Radiology. 1994;67:530-534'},{id:"B15",body:'Makinen J, Johansson J, Tomas C, et al. Morbidity of 11 110 hysterectomies by type of approach. Human Reproduction. 2001;16:1473-1478'},{id:"B16",body:'McPherson K, Metcalfe MA, Herbert A, et al. Severe complications of hysterectomy: The VALUE study. BJOG: An International Journal of Obstetrics and Gynaecology. 2004;111(7):688-694'},{id:"B17",body:'Holub Z, Kliment L. The effectiveness of collagen fleece combined with a fibrin glue in hemostasis during laparoscopic surgery. Journal of Gynecologic Surgery. 1999;15:185-191'},{id:"B18",body:'Whitlock J. Bleeding after a hysterectomy. Available from: https://www.verywellhealth.com/bleeding-after-a-hysterectomy-3156906 [Accessed: October 15, 2021]'},{id:"B19",body:'Lyngdoh BT, Kriplani A, Garg P, et al. Post-hysterectomy menstruation: A rare phenomenon. Archives of Gynecology and Obstetrics. 2010;281:307-309. DOI: 10.1007/s00404-009-1173-2'},{id:"B20",body:'Holloran-Schwartz MB, Potter SJ, Kao MS. Massive delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy. Case report. Case Reports in Obstetrics and Gynecology. 2012;2012:871041. DOI: 10.1155/2012/871041'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Eugen Ancuța",address:"eugen01ro@yahoo.com",affiliation:'
Research Department, “Elena Doamna” Obstetrics and Gynecology Clinical Hospital, Romania
University of Medicine and Pharmacy “Grigore T. Popa”, Romania
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Shohel"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"1286",title:"Biomechanics",slug:"biomechanics",parent:{id:"255",title:"Kinematics",slug:"kinematics"},numberOfBooks:1,numberOfSeries:0,numberOfAuthorsAndEditors:32,numberOfWosCitations:4,numberOfCrossrefCitations:19,numberOfDimensionsCitations:23,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicId:"1286",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"6135",title:"Kinematics",subtitle:null,isOpenForSubmission:!1,hash:"64adad9c40c91ce89d9056f769b6cf52",slug:"kinematics",bookSignature:"Efren Gorrostieta Hurtado",coverURL:"https://cdn.intechopen.com/books/images_new/6135.jpg",editedByType:"Edited by",editors:[{id:"38850",title:"Dr.",name:"Efren",middleName:null,surname:"Gorrostieta Hurtado",slug:"efren-gorrostieta-hurtado",fullName:"Efren Gorrostieta Hurtado"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:1,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"57610",doi:"10.5772/intechopen.71417",title:"Forward and Inverse Kinematics Using Pseudoinverse and Transposition Method for Robotic Arm DOBOT",slug:"forward-and-inverse-kinematics-using-pseudoinverse-and-transposition-method-for-robotic-arm-dobot",totalDownloads:2250,totalCrossrefCites:7,totalDimensionsCites:8,abstract:"Kinematic structure of the DOBOT manipulator is presented in this chapter. Joint coordinates and end-effector coordinates of the manipulator are functions of independent coordinates, i.e., joint parameters. This chapter explained forward kinematics task and issue of inverse kinematics task on the structure of the DOBOT manipulator. Linearization of forward kinematic equations is made with usage of Taylor Series for multiple variables. The inversion of Jacobian matrix was used for numerical solution of the inverse kinematics task. The chapter contains analytical equations, which are solution of inverse kinematics task. It should be noted that the analytical solution exists only for simple kinematic structures, for example DOBOT manipulator structure. Subsequently, simulation of the inverse kinematics of the above-mentioned kinematic structure was performed in the Matlab Simulink environment using the SimMechanics toolbox.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Ondrej Hock and Jozef Šedo",authors:[{id:"208453",title:"Dr.Ing.",name:"Ondrej",middleName:null,surname:"Hock",slug:"ondrej-hock",fullName:"Ondrej Hock"},{id:"209566",title:"Dr.Ing.",name:"Jozef",middleName:null,surname:"Šedo",slug:"jozef-sedo",fullName:"Jozef Šedo"}]},{id:"57605",doi:"10.5772/intechopen.71409",title:"Optimization Approach for Inverse Kinematic Solution",slug:"optimization-approach-for-inverse-kinematic-solution",totalDownloads:1672,totalCrossrefCites:4,totalDimensionsCites:4,abstract:"Inverse kinematics of serial or parallel manipulators can be computed from given Cartesian position and orientation of end effector and reverse of this would yield forward kinematics. Which is nothing but finding out end effector coordinates and angles from given joint angles. Forward kinematics of serial manipulators gives exact solution while inverse kinematics yields number of solutions. The complexity of inverse kinematic solution arises with the increment of degrees of freedom. Therefore it would be desired to adopt optimization techniques. Although the optimization techniques gives number of solution for inverse kinematics problem but it converses the best solution for the minimum function value. The selection of suitable optimization method will provides the global optimization solution, therefore, in this paper proposes quaternion derivation for 5R manipulator inverse kinematic solution which is later compared with teachers learner based optimization (TLBO) and genetic algorithm (GA) for the optimum convergence rate of inverse kinematic solution. An investigation has been made on the accuracies of adopted techniques and total computational time for inverse kinematic evaluations. It is found that TLBO is performing better as compared GA on the basis of fitness function and quaternion algebra gives better computational cost.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Panchanand Jha and Bibhuti Bhusan Biswal",authors:[{id:"209316",title:"Dr.",name:"Panchanand",middleName:null,surname:"Jha",slug:"panchanand-jha",fullName:"Panchanand Jha"},{id:"209681",title:"Dr.",name:"Bibhuti Bhusan",middleName:null,surname:"Biswal",slug:"bibhuti-bhusan-biswal",fullName:"Bibhuti Bhusan Biswal"}]},{id:"57452",doi:"10.5772/intechopen.71406",title:"Kinematic Performance Measures and Optimization of Parallel Kinematics Manipulators: A Brief Review",slug:"kinematic-performance-measures-and-optimization-of-parallel-kinematics-manipulators-a-brief-review",totalDownloads:1604,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"This chapter covers a number of kinematic performance indices that are instrumental in designing parallel kinematics manipulators. These indices can be used selectively based on manipulator requirements and functionality. This would provide the very practical tool for designers to approach their needs in a very comprehensive fashion. Nevertheless, most applications require a more composite set of requirements that makes optimizing performance more challenging. The later part of this chapter will discuss single-objective and multi-objectives optimization that could handle certain performance indices or a combination of them. A brief description of most common techniques in the literature will be provided.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Abdur Rosyid, Bashar El-Khasawneh and Anas Alazzam",authors:[{id:"209597",title:"Dr.",name:"Bashar",middleName:null,surname:"El-Khasawneh",slug:"bashar-el-khasawneh",fullName:"Bashar El-Khasawneh"},{id:"217882",title:"Mr.",name:"Abdur",middleName:null,surname:"Rosyid",slug:"abdur-rosyid",fullName:"Abdur Rosyid"},{id:"217884",title:"Dr.",name:"Anas",middleName:null,surname:"Alazzam",slug:"anas-alazzam",fullName:"Anas Alazzam"}]},{id:"57479",doi:"10.5772/intechopen.71444",title:"A New Methodology for Kinematic Parameter Identification in Laser Trackers",slug:"a-new-methodology-for-kinematic-parameter-identification-in-laser-trackers",totalDownloads:1239,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"In recent years, there has been an increasing interest in measurement systems such as laser trackers (LT) for the verification of large-scale parts in the aeronautic, spatial or naval sectors because of their advantages in terms of portability, flexibility, high speed in data acquisition, accuracy, and reliability. These systems present systematic errors caused by geometrical misalignments, environmental conditions, mechanical wear and tear and other unpredictable variables. Different standards such as the ASME B89.4.19 and the VDI 2617-10 suggest tests to calculate the geometric errors of the LT. In this work, we present an alternative calibration method based on a new errors model. The LT can be considered as an open kinematic chain, so it is possible to shape a kinematic model of the LT. Once the kinematic model has been set, the error model is defined. The model has been validated with synthetic data. Then, experimental tests based on the measurement of a mesh of reflectors placed at suitable places for different locations of the LT have been performed to ensure the reliability of the method proposed. A sensitivity analysis shows the best experimental setup to perform a calibration test. The calibration results have been validated with nominal data.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Ana Cristina Majarena, Javier Conte, Jorge Santolaria and Raquel\nAcero",authors:[{id:"5350",title:"Dr.",name:"Jorge",middleName:null,surname:"Santolaria",slug:"jorge-santolaria",fullName:"Jorge Santolaria"},{id:"153147",title:"Dr.",name:"Ana Cristina",middleName:null,surname:"Majarena Bello",slug:"ana-cristina-majarena-bello",fullName:"Ana Cristina Majarena Bello"},{id:"209623",title:"Mr.",name:"Javier",middleName:null,surname:"Conte",slug:"javier-conte",fullName:"Javier Conte"},{id:"209624",title:"Dr.",name:"Raquel",middleName:null,surname:"Acero",slug:"raquel-acero",fullName:"Raquel Acero"}]},{id:"57491",doi:"10.5772/intechopen.71407",title:"How to Expand the Workspace of Parallel Robots",slug:"how-to-expand-the-workspace-of-parallel-robots",totalDownloads:1384,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"In this chapter, methods for expanding the workspace of parallel robots are introduced. Firstly, methods for expanding the translational workspace of the parallel robot are discussed. The parallel robot has multiple solutions of the inverse and forward displacement analysis. By changing its configurations from one solution to another, the parallel robot can expand its translational workspace. However, conventional nonredundant parallel robot encounters singularity during the mode change. Singularity-free mode changes of the parallel robot by redundant actuation are introduced. Next, methods for expanding the rotational workspace of the parallel robot are shown. In order to achieve the large rotation, some mechanical gimmicks by gears, pulleys, and helical joints have been embedded in the moving part. A novel differential screw-nut mechanism for expanding the rotational workspace of the parallel robot is introduced.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Takashi Harada",authors:[{id:"57026",title:"Dr.",name:"Takashi",middleName:null,surname:"Harada",slug:"takashi-harada",fullName:"Takashi Harada"}]}],mostDownloadedChaptersLast30Days:[{id:"57435",title:"Kinematic Model for Project Scheduling with Constrained Resources Under Uncertainties",slug:"kinematic-model-for-project-scheduling-with-constrained-resources-under-uncertainties",totalDownloads:1172,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Project management practitioners and researchers recognize that the project scheduling efforts are made based on information with many uncertainties and in an environment with constrained resources. This chapter presents the kinematic model named as Coupled Estimate Technique for project scheduling with constrained resources under uncertainties. The Coupled Estimate Technique provides tools of analytical analysis, given that the modelled duration depends on the planned duration and on the resource variability (aleatory uncertainty), as well as the modelled resource depends on the planned resource and on the duration variability (aleatory uncertainty), and also provides tools of graphical analysis, given that the durations and resources of activities, work packages or phases of the project are represented in the bidimensional graphics. In developing the mathematical formulation of the Coupled Estimate Technique, the project precedence diagram was considered as a kinematic chain of robotic manipulators, which may be in chain configuration open (serial), closed (parallel) and/or hybrid. This chapter describes the resource-constrained project scheduling problem (RCPSP) under uncertainties, identifies the limitations and opportunities in the previous work on planning under uncertainties and presents the fundamentals and method of the kinematic model for project scheduling with constrained resources under uncertainties along with a short example of implementation.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Giuliani Paulineli Garbi and Francisco José Grandinetti",authors:[{id:"208870",title:"Dr.",name:"Giuliani",middleName:null,surname:"Garbi",slug:"giuliani-garbi",fullName:"Giuliani Garbi"},{id:"221823",title:"Dr.",name:"Francisco José",middleName:null,surname:"Grandinett",slug:"francisco-jose-grandinett",fullName:"Francisco José Grandinett"}]},{id:"57578",title:"Kinematic and Biodynamic Model of the Long Jump Technique",slug:"kinematic-and-biodynamic-model-of-the-long-jump-technique",totalDownloads:1948,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"The main aim of the study was to determine the kinematic model for long jump and define the kinematic and dynamic parameters of an elite long jumper’s technique. The theoretical model was based on real data where the jumper was defined with a joint mass point. In view of certain previous similar studies, our study identified kinematic and dynamic parameters directly without using the inverse mechanics method. The analysis was made on two jumps of the top level athlete G.C., who won the bronze medallion in long jump at the World Championships in Seville. The kinematic parameters of the take-off, flight and landing were measured with a 3-D video ARIEL system (Ariel Dynamics Inc., USA). The dynamic characteristics of take-off in the X, Y and Z axes were registered with a force-platform (KISTLER-9287), which was installed immediately prior the take-off board. The take-off efficiency was defined best by the following parameters: horizontal velocity, VXTO—8.10 m s−1; vertical velocity, VYTO—3.90 m s−1; angle of projection, PATO—24.1°; duration of compression phase, TDMKF—84 ms, duration of lift phase, MKFTO—43 ms and maximal force in Y-vertical axis, FYMAX—5132 N. An important factor of a rational technique of long jump is also the landing, which is defined by the landing distance and fall-back distance. The efficiency of the landing depended on the landing distance L3—0.63 m and fall-back distance LFB, which amounted to 0.15 m.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Milan Čoh, Milan Žvan and Otmar Kugovnik",authors:[{id:"208530",title:"Ph.D.",name:"Milan",middleName:null,surname:"Čoh",slug:"milan-coh",fullName:"Milan Čoh"}]},{id:"57610",title:"Forward and Inverse Kinematics Using Pseudoinverse and Transposition Method for Robotic Arm DOBOT",slug:"forward-and-inverse-kinematics-using-pseudoinverse-and-transposition-method-for-robotic-arm-dobot",totalDownloads:2250,totalCrossrefCites:7,totalDimensionsCites:8,abstract:"Kinematic structure of the DOBOT manipulator is presented in this chapter. Joint coordinates and end-effector coordinates of the manipulator are functions of independent coordinates, i.e., joint parameters. This chapter explained forward kinematics task and issue of inverse kinematics task on the structure of the DOBOT manipulator. Linearization of forward kinematic equations is made with usage of Taylor Series for multiple variables. The inversion of Jacobian matrix was used for numerical solution of the inverse kinematics task. The chapter contains analytical equations, which are solution of inverse kinematics task. It should be noted that the analytical solution exists only for simple kinematic structures, for example DOBOT manipulator structure. Subsequently, simulation of the inverse kinematics of the above-mentioned kinematic structure was performed in the Matlab Simulink environment using the SimMechanics toolbox.",book:{id:"6135",slug:"kinematics",title:"Kinematics",fullTitle:"Kinematics"},signatures:"Ondrej Hock and Jozef Šedo",authors:[{id:"208453",title:"Dr.Ing.",name:"Ondrej",middleName:null,surname:"Hock",slug:"ondrej-hock",fullName:"Ondrej Hock"},{id:"209566",title:"Dr.Ing.",name:"Jozef",middleName:null,surname:"Šedo",slug:"jozef-sedo",fullName:"Jozef Šedo"}]},{id:"57605",title:"Optimization Approach for Inverse Kinematic Solution",slug:"optimization-approach-for-inverse-kinematic-solution",totalDownloads:1672,totalCrossrefCites:4,totalDimensionsCites:4,abstract:"Inverse kinematics of serial or parallel manipulators can be computed from given Cartesian position and orientation of end effector and reverse of this would yield forward kinematics. Which is nothing but finding out end effector coordinates and angles from given joint angles. Forward kinematics of serial manipulators gives exact solution while inverse kinematics yields number of solutions. The complexity of inverse kinematic solution arises with the increment of degrees of freedom. Therefore it would be desired to adopt optimization techniques. Although the optimization techniques gives number of solution for inverse kinematics problem but it converses the best solution for the minimum function value. The selection of suitable optimization method will provides the global optimization solution, therefore, in this paper proposes quaternion derivation for 5R manipulator inverse kinematic solution which is later compared with teachers learner based optimization (TLBO) and genetic algorithm (GA) for the optimum convergence rate of inverse kinematic solution. An investigation has been made on the accuracies of adopted techniques and total computational time for inverse kinematic evaluations. 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The optimization of these parameters is aimed at improving the quality and flatness of the machined surfaces. The uniformity of tool wear was assumed as main optimization criterion. Lapping plate wear model was created and in detail was analyzed. A Matlab program was designed to simulate the abrasive particles trajectories and to count their distribution. 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In Southeast Asia, for example, Talaromyces marneffei is an important pathogenic thermally dimorphic fungus that causes systemic mycosis. Widespread fungal infections with complicated and variable clinical manifestations, such as Candida auris infection resistant to several antifungal medicines, Covid-19 associated with Trichoderma, and terbinafine resistant dermatophytosis in India, are among the most serious disorders. \r\nInappropriate local or systemic use of glucocorticoids, as well as their immunosuppressive effects, may lead to changes in fungal infection spectrum and clinical characteristics. Hematogenous candidiasis is a worrisome issue that affects people all over the world, particularly ICU patients. CARD9 deficiency and fungal infection have been major issues in recent years. Invasive aspergillosis is associated with a significant death rate. Special attention should be given to endemic fungal infections, identification of important clinical fungal infections advanced in yeasts, filamentous fungal infections, skin mycobiome and fungal genomes, and immunity to fungal infections.\r\nIn addition, endemic fungal diseases or uncommon fungal infections caused by Mucor irregularis, dermatophytosis, Malassezia, cryptococcosis, chromoblastomycosis, coccidiosis, blastomycosis, histoplasmosis, sporotrichosis, and other fungi, should be monitored. \r\nThis topic includes the research progress on the etiology and pathogenesis of fungal infections, new methods of isolation and identification, rapid detection, drug sensitivity testing, new antifungal drugs, schemes and case series reports. It will provide significant opportunities and support for scientists, clinical doctors, mycologists, antifungal drug researchers, public health practitioners, and epidemiologists from all over the world to share new research, ideas and solutions to promote the development and progress of medical mycology.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",keywords:"Emerging Fungal Pathogens, Invasive Infections, Epidemiology, Cell Membrane, Fungal Virulence, Diagnosis, Treatment"},{id:"5",title:"Parasitic Infectious Diseases",scope:"Parasitic diseases have evolved alongside their human hosts. In many cases, these diseases have adapted so well that they have developed efficient resilience methods in the human host and can live in the host for years. Others, particularly some blood parasites, can cause very acute diseases and are responsible for millions of deaths yearly. Many parasitic diseases are classified as neglected tropical diseases because they have received minimal funding over recent years and, in many cases, are under-reported despite the critical role they play in morbidity and mortality among human and animal hosts. The current topic, Parasitic Infectious Diseases, in the Infectious Diseases Series aims to publish studies on the systematics, epidemiology, molecular biology, genomics, pathogenesis, genetics, and clinical significance of parasitic diseases from blood borne to intestinal parasites as well as zoonotic parasites. We hope to cover all aspects of parasitic diseases to provide current and relevant research data on these very important diseases. In the current atmosphere of the Coronavirus pandemic, communities around the world, particularly those in different underdeveloped areas, are faced with the growing challenges of the high burden of parasitic diseases. At the same time, they are faced with the Covid-19 pandemic leading to what some authors have called potential syndemics that might worsen the outcome of such infections. Therefore, it is important to conduct studies that examine parasitic infections in the context of the coronavirus pandemic for the benefit of all communities to help foster more informed decisions for the betterment of human and animal health.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",keywords:"Blood Borne Parasites, Intestinal Parasites, Protozoa, Helminths, Arthropods, Water Born Parasites, Epidemiology, Molecular Biology, Systematics, Genomics, Proteomics, Ecology"},{id:"6",title:"Viral Infectious Diseases",scope:"The Viral Infectious Diseases Book Series aims to provide a comprehensive overview of recent research trends and discoveries in various viral infectious diseases emerging around the globe. The emergence of any viral disease is hard to anticipate, which often contributes to death. A viral disease can be defined as an infectious disease that has recently appeared within a population or exists in nature with the rapid expansion of incident or geographic range. This series will focus on various crucial factors related to emerging viral infectious diseases, including epidemiology, pathogenesis, host immune response, clinical manifestations, diagnosis, treatment, and clinical recommendations for managing viral infectious diseases, highlighting the recent issues with future directions for effective therapeutic strategies.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/6.jpg",keywords:"Novel Viruses, Virus Transmission, Virus Evolution, Molecular Virology, Control and Prevention, Virus-host Interaction"}],annualVolumeBook:{},thematicCollection:[],selectedSeries:null,selectedSubseries:null},seriesLanding:{item:null},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/347194",hash:"",query:{},params:{id:"347194"},fullPath:"/profiles/347194",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()