Contexto de las hemorragias, en el puerperio inmediato / Context of hemorrhages, in the immediate puerperium

La hemorragia postparto es una de las complicaciones obstétricas más temidas por los obstetras a nivel mundial, pudiendo causar la muerte de las puérperas. El objetivo de este estudio fue determinar las causas de las hemorragias y las patologías asociadas a estas en las pacientes atendidas en el Hospital Gineco-Obstétrico Enrique C. Sotomayor de Guayaquil, Ecuador en el periodo 2016­2018 y que estaban en su puerperio inmediato. Las mujeres atendidas en ese periodo en dicha institución fueron 528, de las cuales 160 presentaron hemorragias en el puerperio inmediato. Las hemorragias por desgarro del suelo pélvico representaron un 48,75% y se asociaron en un 35% a hematomas en las paredes del suelo, las causadas por retención de restos placentarios, constituyeron un 26,25% y el 20% presentó acretismo placentario y finalmente las ocasionadas por atonía uterina fueron de un 25%, correspondiendo un 25% a coagulopatías. Se concluyó que las hemorragias postparto por desgarro del suelo pélvico son la causa con mayor porcentaje en contraposición con otros estudios que indican que la atonía uterina es la causa más frecuente de hemorragias postparto inmediato(AU)

Postpartum hemorrhage is one of the obstetric complications most feared by obstetricians worldwide, and may cause the death of puerperal women. The objective of this study was to determine the causes of hemorrhages and the pathologies associated with these in the patients treated at the Enrique C. Sotomayor Obstetric Hospital of Guayaquil, Ecuador in the period 2016 - 2018 and that were in their immediate puerperium. The women who attended in that period were 528 women, 160 of them presented hemorrhages in the immediate puerperium. Hemorrhages by pelvic floor tearing represented 48.75% and 35% were associated to bruises in the floor walls, those caused by retention of placental remains constituted 26.25% and 20% presented accretism and finally those caused by uterine atony were 25% while 25% corresponded to coagulopathies. We concluded that the postpartum hemorrhages by tearing of the pelvic floor are the cause with the highest percentage; in contrast to other studies, which indicate that uterine aton is the most frequent cause of immediate postpartum hemorrhage(AU)

Perineal trauma in a low-risk maternity with high prevalence of upright position during the second stage of labor / Trauma perineal em uma maternidade de baixo risco com alta prevalência de parto vertical durante o período expulsivo

Abstract Objective Perineal trauma is a negative outcome during labor, and until now it is unclear if the maternal position during the second stage of labormay influence the risk of acquiring severe perineal trauma. We have aimed to determine the prevalence of perineal trauma and its risk factors in a low-risk maternity with a high incidence of upright position during the second stage of labor. Methods A retrospective cohort study of 264 singleton pregnancies during labor was performed at a low-risk pregnancymaternity during a 6-month period. Perineal trauma was classified according to the Royal College of Obstetricians and Gynecologists (RCOG), and perineal integrity was divided into three categories: no tears; first/ second-degree tears + episiotomy; and third and fourth-degree tears. A multinomial analysis was performed to search for associated factors of perineal trauma. Results From a total of 264 women, there were 2 cases (0.75%) of severe perineal trauma, which occurred in nulliparous women younger than 25 years old. Approximately 46% (121) of the women had no tears, and 7.95% (21) performed mediolateral episiotomies. Perineal trauma was not associated with maternal position (p = 0.285), health professional (obstetricians or midwives; p = 0.231), newborns with 4 kilos or more (p = 0.672), and labor analgesia (p = 0.319). The multinomial analysis showed that white and nulliparous presented, respectively, 3.90 and 2.90 times more risk of presenting perineal tears. Conclusion The incidence of severe perineal trauma was low. The prevalence of upright position during the second stage of labor was 42%. White and nulliparous women were more prone to develop perineal tears.

Resumo Objetivo O trauma perineal é um desfecho negativo durante o parto, e é incerto, até omomento, se a posiçãomaternal durante o período expulsivo pode influenciar o risco de evoluir com trauma perineal severo. Nós objetivamos determinar a prevalência de trauma perineal e seus fatores de risco em uma maternidade de baixo risco com alta prevalência de posição vertical durante o período expulsivo. Métodos Um estudo de coorte retrospectivo de 264 gestações únicas durante o trabalho de parto foi realizado durante 6 meses consecutivos. O trauma perineal foi classificado de acordo com o Royal College of Obstetricianns and Gynecologists (RCOG). A integridade perineal foi dividida em três categorias: períneo íntegro; trauma perineal leve (primeiro e segundo graus + episiotomia); e trauma perineal severo (terceiro e quarto graus). Uma análise multinomial foi realizada para buscar variáveis associadas ao trauma perineal. Resultados De um total de 264 mulheres, houve 2 casos (0,75%)de trauma perineal severo m nulíparas com menos de 25 anos. Aproximadamente 46% (121) das mulheres não tiveram trauma perineal e 7,95% (21) realizaram episiotomias mediolaterais. Não houve correlação do trauma perineal com a posição de parto (p = 0,285), tipo de profissional que realizou o parto (p = 0,231), recém-nascidos com 4.000 gramas ou mais (p = 0,672), e presença de analgesia de parto (p = 0,319). Uma análise multinomial evidenciou que mulheres brancas e nulíparas apresentaram, respectivamente, um risco 3,90 e 2,90 vezes maior de apresentar trauma perineal. Conclusão A incidência de trauma perineal severo foi baixa. A prevalência de parto vertical durante o período expulsivo foi de 42%. Mulheres brancas e nulíparas foram mais suscetíveis a apresentar trauma perineal.

Impact of female genital mutilation on second stage of labour in primigravida at Omdurman Maternity Hospital, Sudan 2010

To find out the impact of female genital mutilation [FGM] on the second stage of labour at Omdurman Maternity Hospital [OMH]. A descriptive cross-sectional study, for primigravidae delivered vaginally in 2010. After an informed consent circumcised women, were included as study group and uncircumcised ladies as control group. Data was collected by trained registrars using a structured questionnaire to collect frequency of postpartum haemorrhage [PPH], perineal tear, birth asphyxia, neonatal death and hospital stay. A total of 1961 primigravidae, delivered in 2010 at OMH, 629[32.1%] were circumcised and 1332[67.9%] were uncircumcised. There was no significant difference in the mode of delivery and episiotomy. FGM places women at a greater risk during childbirth, endangering their health and their babies compared to uncircumcised.

Factors related to obstetric third and fourth degree perineal lacerations in a jamaican cohort / Factores relacionados con las laceraciones perineales obstétricas de tercer y cuarto grado en una cohorte de Jamaica

OBJECTIVES: The aim of this study was to identify significant and modifiable risk factors associated with obstetric third and fourth degree perineal lacerations and to produce recommendations that may reduce their morbidity and prevalence. METHODS: This is a retrospective case control study performed between March 2004 and March 2008. All patients diagnosed with third and fourth degree perineal lacerations were identified (cases) along with randomly assigned controls who delivered during the same time period. Nineteen cases and 38 controls were identified giving a total of 57 patients. Each patient's hospital record was collected and the data extracted. RESULTS: When analysed for weight greater than or equal to 3.5 kg versus birthweight of less than 3.5 kg, the difference between cases and controls was found to be statistically significant, with a p value of 0.012. Of the cases, 21% had an operative delivery (forceps or vacuum) whereas only 2.6% of the controls had an operative delivery. This was found to be statistically significant (p = 0.011). CONCLUSIONS: This study has shown that the two main factors related to the obstetric third and fourth degree perineal lacerations were babies weighing more than 3.5 kg and the use of forceps or vacuum to assist with deliveries. These high risk patients should be attended to by the most senior staff that is available.

OBJETIVOS: El objetivo de este estudio fue identificar factores de riesgo modificables y significativos asociados con las laceraciones perineales obstétricas de 3er y 4to grado, y producir recomendaciones que puedan reducir su morbilidad y prevalencia. MÉTODOS: Se trata de un estudio de caso control retrospectivo realizado entre marzo de 2004 y marzo de 2008. Todas las pacientes diagnosticadas con laceraciones perineales de 3er y 4to grado fueron identificadas (casos) con controles asignados de manera aleatoria, que tuvieron el parto en el mismo período de tiempo. Diecinueve casos y 38 controles fueron identificados, para un total de 57 pacientes. Se recogieron y se extrajeron los datos de las historias clínicas de cada paciente. RESULTADOS: Al analizárseles en términos de peso superior o igual a 3.5 kg frente a un peso al nacer por debajo de 3.5 kg, la diferencia entre los controles y los casos resultó ser estadísticamente significativa, con un valor p de 0.012. De los casos, el 21% tuvo un parto operativo (fórceps o vacío), mientras que sólo el 2.6% de los controles tuvo un parto operativo. Esto resultó ser estadísticamente significativo (p = 0.011). CONCLUSIONES: Este estudio ha demostrado que los dos factores principales relacionados con las laceraciones perineales obstétricos de 3er y 4to grado, eran bebés con un peso de más de 3.5 kg y el uso de fórceps o vacío en la asistencia a los partos. Estos pacientes de alto riesgo deben ser atendidos por el personal disponible de mayor experiencia.

Impacto materno del manejo activo del alumbramiento / Maternal impact of the active management of accouchement

Según la Organización Mundial de la Salud ocurren 529 000 muertes por año debido a complicaciones del embarazo y el parto. La hemorragia posparto es la causa más frecuente y la responsable de la cuarta parte de las muertes maternas que ocurren. El manejo activo del tercer periodo del parto, implementado en nuestro país en 2005, es una de las intervenciones efectivas para prevenir y disminuir la hemorragia posparto. OBJETIVO: Evaluar el impacto de la introducción del manejo activo del alumbramiento sobre la ocurrencia de hemorragia posparto y complicaciones graves maternas en el año 2005 en el Hospital Docente Ginecoobstétrico "Eusebio Hernández". MÉTODOS: Se realizó un estudio observacional, comparativo, longitudinal, retrospectivo y homodémico, en el cual se estudiaron las historias clínicas de 804 pacientes que tuvieron un parto transpelviano en el año 2003 donde se manejó el tercer periodo del parto de manera expectante y 820 historias clínicas de pacientes que tuvieron un parto transpelviano en el año 2005 y el alumbramiento se manejó de manera activa. RESULTADOS: El manejo activo del alumbramiento estuvo asociado con disminución de: la hemorragia posparto (riesgo relativo (RR): 0.52; intervalo de confianza (IC del 95 por ciento): 0,44 a 0,61); del hematocrito (RR: 0,56; IC del 95 por ciento: 0,48 a 0,65); del uso de transfusiones (RR: 0,27; IC del 95 por ciento: 0,10 a 0,73). No hubo diferencia significativa entre los dos grupos respecto al uso de uterotónicos adicionales (RR: 0,86; IC del 95 por ciento: 0,59 a 1,24) y no se presentaron complicaciones graves maternas. CONCLUSIËN: El empleo sistemático del manejo activo del tercer periodo del parto es mejor opción que la conducta expectante en cuanto a la pérdida de sangre y otras complicaciones maternas

According to World Health Organization (WHO) about 500 000 women die annually across the world from causes related to pregnancy and childbirth. Haemorrhage is the main cause of maternal death. It has been estimated that at least 25 percent of these deaths are due to haemorrhage - the majority due to postpartum haemorrhage. One intervention that has been promoted as effective to prevent the post partum haemorrhage is the active management of the third stage of labour, this intervention started in our country in 2005. OBJECTIVES: To evaluate the impact of the introduction of the active management of the third stage of labour over occurred of the post partum haemorrhage and serius maternal complications in 2005 in "Eusebio Hernandez" hospital. METHODS: Observational, comparative and retrospective study of 804 clinical reports from women with vaginal delivery and expectant management of the third stage of labour in 2003 and 820 women with vaginal delivery and active management of the third stage of labour in 2005. RESULTS: Active management was associated with the reduction of: post partum haemorrhage (relative risk 0.52, 95 percent confidence interval 0.44 to 0.61) and blood transfusion (RR: 0.27; CI 95 percent: 0.10 to 0.73), the increase of hematocrit reduction (RR: 0.56; CI 95 percent: 0.48 to 0.65) and absence of adverse maternal outcomes. CONCLUSIONS: Routine active management is superior to expectant management in terms of blood loss, post partum haemorrhage and maternal outcomes

[Obstetric Vesicovaginal fistulas, about 131 cases]

Vesicovaginal fistulas are the most frequent type of urogenital fistulas. Obstetrical cause remains the dominant etiology. They still represent a public health problem. to study epidemiological aspects of obstetric vesico-vaginal fistulas and their management. a retrospective multicentric study among 19 hospital departments from February 1982 to January 2007. 131 VVF [92% of urogenital fistulas]. The vaginal route for surgical repair was used in 2/3 cases. The mean diameter of the fistula was 11.35mm. In 122 cases [86.5%], the fistula was unique. IVU findings were normal in 83% cases. All patients had normal renal function apart one who had acute renal failure. 177 interventions were performed [1.37 intervention per patient]. Our findings suggest a regression in obstetrical VVF. However many efforts on institutional, socioeconomic and obstetrical levels have to be done in order to eradicate this pathology that is of major handicap for women regarding socioeconomic, functi6nal and psychological effects

Associação entre via de parto e complicações maternas em hospital público da Grande São Paulo, Brasil / Association between mode of delivery and maternal complications in a public hospital in Greater Metropolitan São Paulo, Brazil

O estudo objetivou avaliar associação entre via de parto e complicações maternas. Realizou-se coorte retrospectiva com partos ocorridos durante o ano de 2003, em um hospital público. As complicações avaliadas foram: infecção, hemorragia, histerectomia, rotura uterina, lesão de órgão contíguo, trombose venosa profunda e embolia pulmonar. Utilizou-se a odds ratio (OR) e os testes de qui-quadrado de Pearson e de Fisher, além da regressão logística. Estabeleceu-se o nível de 0,05 como significante. Foram encontradas 15 complicações. Tomando-se o parto vaginal como referência, encontrou-se associação entre cesárea e as complicações tomadas em conjunto. Analisando-se variáveis confundidoras, encontrou-se associação das complicações com hipertensão, soropositividade para HIV, placenta prévia e descolamento prematuro de placenta. Após controle para estas quatro variáveis, manteve-se a associação entre cesárea e complicações (OR = 9,7; p = 0,04). Encontrou-se também associação entre complicações e cesárea eletiva comparada ao parto vaginal (OR = 4,7; p = 0,02), e maior proporção de complicações, no limite da significância estatística, nas cesáreas eletivas comparadas à "tentativa de parto vaginal" (OR = 3; p = 0,058). Conclui-se que a cesárea associa-se a complicações maternas, mesmo após a realização de vários ajustes.

The purpose of this study was to assess the relationship between mode of delivery and maternal complications, based on a retrospective cohort of all births at a public hospital in 2003. Complications included: infection, hemorrhage, hysterectomy, uterine rupture, lesions in adjacent organs, deep venous thrombosis, and pulmonary embolism. The analysis used odds ratio (OR), chi-squared test, and Fisher's exact test, besides logistic regression. Fifteen complications were identified. Taking vaginal delivery as the reference, an association was found between cesarean section and overall complications. Analysis of confounding showed an association between hypertension, HIV, placenta previa, and abruptio placentae. After controlling for these variables, an association remained between overall complications and cesarean section (OR = 9.7; p = 0.04). Another analysis comparing elective cesareans and vaginal deliveries also showed an increased risk for cesarean (OR = 4.7; p = 0.02). Finally, comparing elective cesareans with trial of labor, we found an increased proportion of complications in elective cesareans, with borderline significance (OR = 3; p = 0.058). We concluded that cesarean section is associated with maternal morbidity, even after controlling for confounders.

Sobrepeso y obesidad pregestacional como factor de riesgo de cesárea y complicaciones perinatales / Maternal pre-pregnancy overweight and obesity as a risk factors for cesarean delivery and other obstetrical complications

Objetivo: Comprobar si el sobrepeso y la obesidad materna son factores de riesgo de complicaciones pe-rinatales. Método: Estudio transversal de 1.223 gestantes nulíparas atendidas en el Hospital La Paz entre agosto 2007 y abril 2008. Las gestantes se dividieron en tres grupos según el índice de masa corporal (IMC) al inicio del embarazo: 482 con peso normal (IMC: 18,5-24,9 Kg/m²); 419 con sobrepeso (IMC: 25-29,9Kg/m²) y 322 con obesidad (IMC: >30Kg/m²). Se estudiaron las complicaciones obstétricas, semanas de gestación en el momento del parto, tipo de parto y peso fetal. Resultados: El riesgo de cesßrea en las gestantes con sobrepeso fue casi el doble que el de las gestantes de peso normal (OR: 1,9; IC95 por ciento 1,4-2,5) Las gestantes obesas sufrieron el triple de cesáreas que las de peso normal (OR: 3,1; IC95 por ciento 2,8-4,3). El número de inducciones del parto fue mayor en las gestantes con sobrepeso (OR: 1,7; IC95 por ciento 1,4-1,9) y el doble en las obesas (OR: 2,0; IC95 por ciento 1,8-2,9) con respecto a las de peso normal. El riesgo de macrosomía fetal (>4.000 gramos) fue mayor en las gestantes con sobrepeso (OR: 1,5; IC95 por ciento 1,4-2,2) y en las obesas (OR: 1,9; IC95 por ciento 1,3-2,8) que en las de peso normal. En el análisis de regresión logística multivariante (ajusfando por edad, diabetes e hipertensión gestacionales) persistió la asociación entre sobrepeso y cesárea (OR: 2,1; IC95 por ciento 1,7-2,7) y entre obesidad y cesárea (OR: 3,0; IC95 por ciento 2,6-3,8). Conclusiones: El sobrepeso y la obesidad materna al inicio del embarazo están asociados con un aumento del número de cesáreas y de inducciones del parto. Este riesgo es mayor a medida que aumenta el IMC materno.

Objective: The objective of this study is to determine if the maternal prepregnancy overweight and obesity are related to risk of cesarean delivery and other obstetrical complications. Methods: Transversal study of 1223 nulliparous women that delivered in our maternity between August 2007 and April 2008. Women were categorized by the body mass index (BMI): 482 normal weight (BMI: 18.5-24.9 Kg/m²), 419 overweight (BMI: 25-29.9 Kg/m²) and 322 obesity (BMI: >30 Kg/m²). Obstetrical complications, labor and its complications, and neonatal weight were studied. Results: Women who were overweight was nearly twice as likely to deliver by cesarean section as women with normal weight (OR: 1.8; 95 percent CI 1.4-2.9). Obese women experienced a three-fold increase in risk of cesarean section in comparison to normal weight women (OR: 3.02; 95 percent CI 2.6-4.5). Number of labor inductions was higher in overweight and obese group (OR: 1.6; 95 percent CI 1.3-1.9) and (OR: 2.1; 95 percent CI 1.7-2.9) respectively in comparison to control group. The highest risk of fetal macrosomia (weight >4000 g) was in the overweight (OR: 1.5; 95 percent CI 1.4-2.2) and obese women (OR: 1.9; 95 percent CI 1.3-2.8) compared with the normal weight women. In multivariate logistic regression analysis, the association persisted between obesity and cesarean delivery (OR 3.0; 95 percentCI 2.6-3.8) and among overweight and cesarean section (OR 2.1; 95 percentCI 1.7-2.7) after adjusting for variables such as age, diabetes and hypertension. Conclusions: Overweight or obesity prior to pregnancy are associated with an increased risk of cesarean delivery and labor inductions. This risk increases as the BMI increases.

Fetomaternal outcome of cases referred to Nishtar Hospital, Multan

To determine feto-maternal outcome and to identify factors associated with adverse obstetric outcome. This descriptive case series study was conducted in the Department of Obstetrics and Gynecology Unit lit. Nishtar Hospital, Multan. During the period from 18[th] July 2007 to 17[th] January 2008. One hundred patients who were admitted through emergency after a trial of labour by traditional birth attendants [TBAs], lady health visitors [LHVs] or doctors at home or private clinics were managed and followed in the department of gynecology and obstetrics Unit-II. Mean age of the patients was 27.28 +/- 5.13 years. Fever was the most common complication found in 69[69%] patients. Antepartum hemorrhage occurred in 22 [22%] cases. Postpartum hemorrhage complicated 46 [46%] pregnancies leading, to shock in 51 [51%] patients. Oligohydramnios was observed in 35 [35%] patients and uterine rupture in 5[5%] cases. There were 3 [3%] maternal deaths. Low Apgar score was observed in 36 [36%] patients. Meconium staining was common in 34 [34%] cases and 34 [34%] patients needed for hospitalization. Fetal growth restriction was found in 23 [23%] patients. There were 23 [23%] fetal deaths. Postpartum hemorrhage led to maternal and fetal complications in majority of the patients which was not handled

Rupture of the pregnant uterus--a 20 year review.

Nepal is a land-locked developing country located in between China and India with a population of 2.34 millions. The male: female ratio being 49:51 and very high maternal mortality. (539/100,000 live birth-1996) The geography of the country makes the situation very much divergent and difficult to cater the health services, especially operative procedures in remote places. THE AIMS OF THE STUDY ARE:- 1. To find out the incidence of R.U, distance from where the patients came, age, parity antenatal attendance, type of rupture, type of intervention and foetal outcome. 2. To suggest the concerned authorities to focus their attention to strengthen and expand comprehensive emergency obstetric care service (CEOCS) in remote areas of the country. Material and method: This is a retrospective study of rupture of pregnant uterus (RU) after 28 weeks of pregnancy for the period of 20 years from 1985 to 2005 A.D. (2042-2061 BS) admitted in the very busy tertiary centre for women (Maternity Hospital, Thapathali, Kathmandu.) with approximately 16000 deliveries and 11% Caesarean section rate per year. Available charts from hospital records of cases of R.U. admitted for the period of 20 years were analysed. During the period, 251 cases of R.U. were admitted. RESULT: There were 272245 live births, 25819 Caesarean section, 270 maternal deaths and 11197 perinatal foetal deaths, during the study period. Incidence of rupture of pregnant uterus was (0.09%) 1:1100 live-birth. There were 60% spontaneous, 29% scar rupture and 11% traumatic rupture. Maximum cases were brought from distance of more than 70 kilometres away, between 25-29 years of age, (mean age 28.7), of third and fourth gravida at 36-40 weeks of gestational period with 68% without antenatal attendance. Seventy percent (70%) had complete rupture. Sixty percent (60%) were managed with suture repair with bilateral tubal ligation, 24% had only repair and 15% had hysterectomy. The case mortality of R.U. (n=20) was 7.9%. Two percent (n=5) cases died before intervention due to arrival in moribund condition. Seventy five percent (75%) cases had stillborn babies. Conclusion More cases of RU are coming to the hospital due to better communication and awareness of the people outside the capital, and case- mortality is reduced compared to previous years.

Obstructed labour; how can we help?

Obstructed Labour. To determine the frequency, risk factors, complications and maternal and foetal out come of obstructed labour. A tertiary care teaching Hospital. A retrospective study conducted at the department of Obstetric and Gynecology Unit II Sandeman Provincial Hospital Quetta. The Patients were selected on a random basis as they were admitted through emergency. 98 cases of obstructed labour were managed during the study period. All were non booked, illiterate majority belonged to poor socio-economical class, and came from far flung areas of Balochistan and Afghanistan. The most vulnerable group was grand multipara in third decade of life. The leading cause of obstruction was cephalopelvic disproportion. There was one rare case of Locked Twin and one very rare case of 6.0 x 4.5 cm vesical stone as cause of obstruction. 74 cases[74.5%] were managed by caesarean section. Out of 14 cases of Ruptured uterus 10[10.2%] were subjected to caesarean hysterectomy and the rest four were managed by repair with or without ligation in groups of two. Urinary fistula was found in 10 cases out of which two were ureteric fistulae and eight were vesico-vaginal. The over all perinatal mortality rate was 87%, with 100% in referred cases. The maternal mortality rate was < 1.0/ thousand in the referred cases. No maternal death occurred in cases who developed obstruction in the hospital

Analgesia and the Outcome of Labor

Analgesia y trabajo de parto. El bloqueo epidural es actualmente el único medio efectivo y más seguro disponible para analgesia en el trabajo de parto. Muchos investigadores se han preguntado: la analgesia epidural, ¿ prolonga el trabajo de parto ? Esta suposición data desde los años 50s. El trabajo de parto prolongado se asocia con mujeres que han recibido analgesia epidural cuando se comparan con aquellas que no recibieron analgesia epidural, sin embargo, aunque la analgesia epidural puede correlacionarse con trabajo de parto anormal y cesárea, esta asociación no es causada por la analgesia epidural propiamente dicha. La presente revisión discute la evidencia publicada en la literatura y el impacto del manejo obstétrico sobre el riesgo de operación cesárea asociada con analgesia epidural

Sudden maternal deaths from amniotic fluid embolism.

Sudden maternal death from amniotic fluid embolism is a rare but serious complication which usually occurs during late pregnancy, often during labour or shortly after, with more than 80% mortality. Such a death causes immense stress to both the relatives and the attending doctors as it is sudden and unexpected. Three such deaths are discussed here. Traditionally, it was believed that this complication usually occurred in prolonged and difficult labour, but there is evidence contrary to this, and it is not possible to predict when and where this fatal complication will occur. Current views and various pathophysiologic mechanisms leading to the fatal outcome are also discussed.

Ruptura uterina en el Instituto Nacional de Perinatología / Uterine rupture at the Instituto Nacional de Perinatologia

La ruptura uterina es una complicación grave que se asocia con un incremento en la morbilidad y mortalidad materno fetal. Es un evento raro, pero potencialmente catastrófico y se asocia principalmente al antecedente de cicatriz uterina previa, de acuerdo a esto se realizó una investigación retrospectiva de enero de 1989 a diciembre de 1994. En el Instituto Nacional de Perinatología, en este lapso se encontraron 21 casos de 35080 nacimientos, simples que se encuentra una incidencia global de uno en 1670 nacimientos de los 21 casos sólo una no presentaba el antecedente de cicatriz uterina previa, el promedio de edad fue de 28.3 años y el de gestaciones fue de 2.5. El diagnóstico se realizó en siete casos durante el trabajo de parto (33 por ciento), cuatro en el transquirúrgico (19 por ciento) y 10 en el postparto inmediato. La resolución del embarazo en nueve casos fue con parto instrumentado (42.8 por ciento), diez vía abdominal (47.6 por ciento) y sólo dos casos mediante eutocia (9.5 por ciento) la duración del trabajo de parto fue de un promedio de cuatro horas. El tratamiento en el 100 por ciento de los casos fue quirúrgico realizándose histerectomía total abdominal en 52 por ciento y reparación de la ruptura en 48 por ciento restante; no se informa ningún caso de mortalidad materna en ningún caso se realizó inducción del trabajo de parto, pero en 10 se utilizo oxitocina para la conducción del mismo. Esta revisión coincide con la literatura mundial en el aspecto de que la ruptura uterina se incrementa en pacientes multigestas con uso de oxitócicos y antecedente de cicatriz uterina previa

La violencia doméstica durante el embarazo y su relación con el peso al nacer / Domestic violence during pregnancy and its relation to birth weight

Objetivo. Determinar la prevalencia de la violencia doméstica durante el embarazo así como su asociación con el peso del producto al nacer y con las complicaciones en el parto y posparto inmediato. Material y métodos. Se exploró sobre violencia doméstica (física, emocional y sexual) a un total de 100 usuarias del servicio de ginecobstetricia del Hospital Civil de Cuernavaca, Morelos, utilizando para ello un cuestionario de preguntas cerradas, aplicado por personal especializado. Se usó un modelo de regresión lineal múltiple para ajustar las diferencias de medias en el peso del producto al nacer, por edad y paridad. Para el caso de la complicaciones se utilizó un modelo de regresión logística. Resultados. Las mujeres maltratadas (MM) víctimas de violencia durante el embarazo tiene tres veces más complicaciones durante el parto y posparto inmediato que las mujeres no maltratadas (MNM) (IC 95 por ciento 1.3-7.9). La diferencia en el peso del producto al nacer entre los dos grupos fue de 560 g (p<0.01 ajustado por edad y paridad), con desventaja para las MM. Las mujeres violentadas tuvieron cuatro veces más riesgo de tener productos de bajo peso en comparación con la MNM (IC 95 por ciento 1.3-12.3). Conclusiones. Se propone profundizar la investigación sobre el tema y estudiar otros grupos poblacionales, asimismo sensibilizar al personal de salud sobre la violencia hacia las mujeres como riesgo reproductivo

Objective. To determine the prevalence of domestic violence during pregnancy and its impact on birth weight and the immediate post-partum period. Material and methods. We conducted a survey of 110 pregnant women who delivered at the Hospital Civil in Cuernavaca, Morelos. The questionnaire was applied by specialized personal. We used multiple linear regression to adjust for differences between birth weight means and multiple logistic regression for complications. Results. In our study, women who suffered violence during pregnancy had three times more complications during delivery (CI 95% 1.3-7.9). The difference in birth weight of newborns of these women was 560 g less (p< 0.01 adjusted by age and parity) in comparison with women who did not undergo violence during pregnancy. Women who suffered violence during pregnancy had a four times greater risk for having low birth weight babies (CI 95% 1.3-12.3) than the non-battered women. Conclusions. We propose more research be done on this topic, including studies of other population groups. Also, health personnel should be educated that violence towards women could constitute a reproductive risk.

Macrosomía y óbito. Relación con diabetes materna / Macrosomia and abitus. relationship with maternal diabetes

Se revisó la incidencia de macrosomía y óbitos, y su relación con diabetes mellitus (DM) materna durante un semestre en el Hospital de Ginecoobstetricia "Dr. I. Morones", IMSS, tomando los criterios de >4,000 g y >4,500g, así como la vía de terminación del embarazo y la asociación con diabetes mellitus (DM) materna. Hubo un total de 15,217 recién nacidos (RN) vivos, de los cuales 872,(5.73 por ciento), tuvieron un peso >4,000 g, encontrándose 42 madres con DM, 4.2 por ciento del total. Tomando como cifra de corte 4,500 g, hubo 105 RN, 0.69 por ciento del total, y ocho madres cursaron con Dm, 7.6 por ciento. Quinientos un embarazos se resolvieron por cesárea y 337 por parto. Con relación a los óbitos, fueron 151, es decir, 9.9 por 1,000 nacimientos, de los cuales hubo 8 cuyo peso fue >4,000 g, en dos de ellos la madre padecía DM. Se concluye que si se aplica el criterio de 4,000 g para macrosomía, la incidencia en nuestra población es menor que la informada en países europeos, y aunque la DM materna se asocia con una alta incidencia de macrosomía, no representa un segmento causal importante en la población general del hospital, ya que la DM como causa de macrosomía ocurrió en menos de 5 por ciento de las madres

randomized comparative study on the effect of the use of vacuum extraction with metal or silastic cups versus outlet forceps delivery in the second stage management of nulliparas on maternal and neonatal complications

A prospective study was designed to determine the effectiveness and safety of different outlet instrumental deliveries. One hundred and fifty two nulliparas women for whom instrumental delivery was decided and had the criteria for low forceps delivery, were randomized to low forceps, vacuum extraction with the conventional metal cup or the silastic rubber cup. Forceps delivery had the lowest significant failure rate [9.8%] compared to metal cup and silc-cup deliveries [17% and 18.5%]. However, there was a significant greater incidence of maternal soft tissue injuries in the forceps group [45%] compared to 16.7% in the silc-cup and 23.4% of the metal vacuum extractors. Neonatal scalp injuries were significantly higher in the forceps group [47%] compared to silc-cup group [20.4%], while the difference was not significant as regards the metal cup group [40%]. There was a significant increase in neonatal morbidity for the metal cup group compared with silc-cup delivery, specially scalp trauma and cephalohematomata. There were no significant differences in the Apgar score, neonatal jaundice, retinal hemorrhages, intracranial hemorrhage and umbilical artery, pH between the metal cup, the silc- cup, the vacuum extractors and forceps groups. Based on these findings, the vacuum extractor is effective instrument outlet delivery with less maternal morbidity compared to forceps delivery. The silicon cup is preferred to metal cup due to less neonatal morbidity. Although the forceps is the most effective instruments, but due to the associated maternal morbidity, its use is limited to selected cases as preterm and uncooperative parturients