Attempted vaginal birth after cesarean: assessment of morbidity and predictors of success / Parto tras cesárea anterior: análisis de la morbimortalidad materno-fetal

Objective: Determining the appropriate approach for delivery after previous cesarean is a very controversial issue. Our objective was to establish whether pregnant women with a previous cesarean have an increased maternal and fetal morbidity and mortality after attempting vaginal delivery as well as to determine which factors may influence the achievement of a vaginal birth after cesarean. Materials and methods: A retrospective observational cohort study including 390 patients (196 cesarean group and 194 nulliparous group) was carried out. We compared neonatal and maternal outcomes between groups. Afterward, a multivariate logistic regression was applied for our second objective. Results: There were higher rates of uterine rupture (2% vs. 0%, p: 0.045) and puerperal hemorrhage (9.7% vs. 3.1%, p: 0.008) in the cesarean group and lower vaginal delivery rate (58.2% vs. 77.8%, p < 0.0005). We found that the induced onset of labor (OR = 2.9) and new born weight (OR = 1.0001) were associated with an increased risk of cesarean section. Conclusions: Our findings stress the need for further investigations in this field, which might provide a basis for a better management of patients with a previous cesarean.

Objetivo: Determinar el abordaje adecuado del tipo de parto tras una cesárea previa es un tema muy controvertido. Nuestro objetivo fue establecer si las gestantes con cesárea previa presentan mayor morbimortalidad materna y fetal tras intentar parto vaginal, así como determinar qué factores pueden influir en conseguir un parto vaginal posterior a la cesárea. Material y métodos: Estudio observacional de cohortes retrospectivo incluyendo 390 pacientes (196 con cesárea previa, 194 nulíparas). Comparamos los datos sobre los resultados neonatales y maternos. Posteriormente se aplicó un modelo de regresión logística multivariante. Resultados: Hubo mayores tasas de ruptura uterina (2% vs. 0%; p = 0.045) y hemorragia puerperal (9.7% vs. 3.1%, p: 0.008) en el grupo de cesárea anterior, así como una tasa de parto vaginal mas baja (58.2% vs. 77.8%, p < 0.0005). La inducción del parto (OR = 2,9) y el peso del recién nacido (OR = 1.0001) se asociaron a un mayor riesgo de cesárea. Conclusión: La probabilidad de parto vaginal en estas pacientes disminuye cuanto mayor sea el peso del recién nacido y con partos inducidos.

Risk factors for postpartum hemorrhage and its severe forms with blood loss evaluated objectively - a prospective cohort study / Fatores de risco para hemorragia pós-parto e suas formas graves com perda sanguínea avaliada objetivamente - Um estudo de coorte prospectivo

Abstract Objective To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively. Methods This is a complementary analysis of a prospective cohort study that included pregnant women delivering vaginally. The total blood loss was obtained through the sum of the volume collected from the drape with the weight of gauzes, compresses and pads used by women within 2 hours. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. The risk factors for postpartum bleeding were evaluated using linear and logistic regression. Results We included 270 women. Themean blood loss at 120 minutes was 427.49 mL (±335.57 mL). Thirty-one percent (84 women) bled > 500mL and 8.2% (22 women) bled > 1,000 mL within 2 hours. Episiotomy, longer second stage of labor and forceps delivery were related to blood loss > 500mL within 2 hours, in the univariate analysis. In the multivariate analysis, only forceps remained associated with bleeding > 500 mL within 2 hours (odds ratio [OR] = 9.5 [2.85-31.53]). Previous anemia and episiotomy were also related to blood loss > 1,000mL. Conclusion Prolonged second stage of labor, forceps and episiotomy are related to increased incidence of PPH, and should be used as an alert for the delivery assistants for early recognition and prompt treatment for PPH.

Resumo Objetivo Identificar os fatores de risco para hemorragia pós-parto e hemorragia pósparto grave com o sangramento pós-parto avaliado objetivamente. Métodos Trata-se de uma análise complementar de umestudo de coorte prospectivo que incluiu somente mulheres que evoluíram para parto vaginal. O total de perda sanguínea foi avaliado objetivamente durante 24 horas pós-parto através da soma da quantidade de sangue mensurada através de um coletor de sangue pós-parto somado ao peso de compressas, gases e absorventes utilizados no período pós-parto. Análises exploratórias dos dados foram realizadas através do cálculo de médias, desvio-padrão (DP), frequência, porcentagem e percentis. Os fatores de risco foram avaliados através de regressão linear e logística. Resultados Foram incluídas 270 mulheres. A média de perda sanguínea pós-parto após 120 minutos foi de 427.49 mL (±335.57 mL). Trinta e umpor cento (84 mulheres) sangraram> 500mL e 8,2% (22 mulheres) sangraram > 1.000mL em 2 horas. Episiotomia, segundo período do parto prolongado e uso de fórceps estiveram associados a perda sanguínea > 500mL em 2 horas. Na análise multivariada, somente fórceps manteve-se entre os fatores de risco para sangramentos superiores a 500mL em 2 horas (odds ratio [OR] = 9.5 [2.85-31.53]). Anemia prévia e episiotomia estiveram associadas com perda sanguínea > 1.000 mL. Conclusão Segundo período do parto prolongado, fórceps e episiotomia estão associados a aumento da incidência de hemorragia pós-parto e devem ser usados como um alerta para os profissionais de saúde para o reconhecimento precoce e tratamento imediato da patologia.

Perfil das pacientes com diagnóstico de hemorragia puerperal em uma maternidade filantrópica do município de São Paulo / Profile of patients diagnosed with puerperal hemorrhage in a philanthropic maternity hospital in São Paulo

Objetivo: A hemorragia puerperal (HPP) é um problema de saúde pública. A finalidade deste estudo foi estereotipar as pacientes diagnosticadas com HPP e saber seu desfecho ante a aplicação do protocolo da instituição. Foram avaliadas características anteparto e intraparto para encontrar perfil materno propenso ao desenvolvimento da HPP. Métodos: O método escolhido foi coorte com análise de prontuários no Hospital Filantrópico Beneficência Portuguesa, envolvendo 197 mulheres com diagnóstico de HPP, com administração de ácido tranexâmico de forma precoce, juntamente com ocitocina. O perfil predominante foi de idade materna não avançada, não brancas, multíparas, parto vaginal sem preparo de colo, ausência de síndrome hipertensiva e com idade gestacional de 39 semanas. A principal causa foi atonia uterina, seguida das lacerações de trajeto. Resultados: Além do ácido tranexâmico em conjunto com a ocitocina, a droga mais usada foi a metilergometrina; 71 (36%) mulheres precisaram de procedimentos, sendo o principal a sutura de trajeto e 45 (22,8%) precisaram de hemoderivados. Conclusão: A terapia farmacológica foi eficaz, com menor necessidade procedimentos e ausência de mortalidade.(AU)

Objective: Postpartum hemorrhage (PPH) is a public health problem. The purpose of this study is to stereotype patients diagnosed with PPH as well as know their outcome according to the institution's protocol. Antepartum and intrapartum characteristics were evaluated to find a maternal profile prone to the development of PPH. Methods: The method chosen was the cohort analysis of medical records at the Hospital Filantrópico Beneficência Portuguesa, involving 197 women diagnosed with PPH, with administration of tranexamic acid early, associated with oxytocin. As results, the predominant profile was non-advanced maternal age, non-white, non-primigravida, vaginal delivery without prior cervical ripening, without hypertensive syndrome and gestational age of 39 weeks. Results: The main cause was uterine atony, followed by trauma. In addition to tranexamic acid and oxytocin, the most used drug was methylergometrine; 71 (36%) women needed procedures, the main one was the path suture and 45 (22,8%) needed blood products. Conclusion: Pharmacological therapy was effective, with less need for procedures and no mortality.(AU)

La hemorragia posparto / Postpartum hemorrhage

Introducción: La hemorragia posparto es una de las principales causas de mortalidad materna. Objetivo: Caracterizar la hemorragia posparto. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo en el servicio de Anestesiología y Reanimación del Hospital Dr. Agostinho Neto entre los años 2015-2017. El universo se constituyó por 65 pacientes. Se estudiaron las siguientes variables: edad biológica, edad gestacional, tipo de hemorragia, cantidad estimada del sangrado, etiología, variables de laboratorio clínico y hemodinámicas, reanimación con fluidos y hemoderivados, complicaciones. Se emplearon métodos empíricos (análisis documental, instrumentos para la recolección de la información), teóricos (procedimientos de análisis, síntesis, inducción, deducción) y matemático-estadístico (porcentaje, media, la desviación típica e intervalos de confianza). Resultados: La edad media de las pacientes fue de 24,2 ± 6,2 años; la edad gestacional fue de 34,2 ± 6,2 años; 73,8 por ciento terminó el embarazo por vía vaginal e intervalo entre el parto, el inicio de la hemorragia posparto fue de 2,46 h ± 53 min. La atonía uterina (61,5 por ciento) fue la causa más común de la hemorragia. El shock fue la complicación más común (100 por ciento), lo que condicionó el uso de altos volúmenes de fluidos y hemoderivados para su reanimación. La histerectomía y ligadura arterias hipogástricas fue la técnica quirúrgica más utilizada (52,3 por ciento). Conclusiones: La hemorragia posparto fue una causa importante de morbilidad y mortalidad en el mencionado servicio de salud(AU)

Introduction: Postpartum hemorrhage is one of the main causes of maternal mortality. Objective: To characterize postpartum hemorrhage. Methods: A descriptive, longitudinal and prospective study was carried out in the Anesthesiology and Resuscitation service of Dr. Agostinho Neto Hospital, between 2015 and 2017. The study population was made up by 65 patients. The following variables were studied: biological age, gestational age, type of hemorrhage, estimated amount of bleeding, etiology, hemodynamic and clinical laboratory variables, fluid resuscitation and blood products replacement, complications. We used empirical methods (document analysis, instruments for the collection of information), theoretical methods (analysis, synthesis, induction, deduction), and mathematical-statistical methods (percentage, mean, standard deviation and confidence intervals). Results: The average age of the patients was 24.2±6.2 years; the gestational age was 34.2±6.2 years; 73.8 percent completed the pregnancy by natural delivery, while the interval between delivery and the onset of postpartum hemorrhage was 2.46h±53 min. Uterine atony (61.5 percent) was the most common cause of hemorrhage. Shock was the most common complication (100 percent), which conditioned the use of high volumes of replacement fluids and blood products. Hysterectomy and ligation of hypogastric arteries was the most used surgical technique (52.3 percent). Conclusions: During the study period, postpartum hemorrhage was an important cause of morbidity and mortality in the Anesthesiology and Resuscitation service of Dr. Agostinho Neto Hospital(AU)

Factores de riesgo de hemorragia primaria posparto / Postpartum primary haemorrhage's risk factors

Introducción: La hemorragia primaria posparto es la principal causa de muerte materna en el Perú y se ha relacionado directamente con el parto domiciliario, por lo que podría reflejar la oportunidad y calidad de los servicios de salud cuando ocurre en un parto institucionalizado. Objetivo: Identificar los factores de riesgo de hemorragia primaria posparto producidos por desgarro del tracto genital. Métodos: Se realizó un estudio analítico de casos y controles en el Hospital Augusto Hernández Mendoza- EsSalud. La muestra estuvo conformada por 30 casos (con hemorragia primaria posparto por desgarro del tracto genital) y 120 controles (sin hemorragia primaria posparto). Se usaron las pruebas T de Student y U de Mann -Withney para comparar las variables numéricas y la prueba de Chi cuadrado para determinar la asociación entre las variables. La fuerza de asociación se determinó calculando Odds Ratio crudo y ajustado con sus intervalos de confianza (IC) al 95 por ciento mediante regresión logística binaria con prueba de bondad de ajuste de Hosmer-Lemeshow. Resultados: El valor promedio de hemoglobina fue 8,85 ± 0,39 mg por ciento en los casos y 11,90 ± 0,13 mg por ciento en los controles (p = 0,000). En el análisis multivariado los predictores de riesgo fueron: Nulípara (ORa = 11,49; IC95 por ciento = 3,11-42,42), soltera (Ora = 8,81; IC95 por ciento = 1,83-42,41), < 8 controles pre-natales (Ora = 7,95; IC95 por ciento = 2,60-24,31), y peso al nacer del recién nacido ≥ 3500 gramos (Ora = 7,34; IC95 por ciento = 2,15-25,06). Conclusiones: El riesgo de hemorragia primaria posparto por desgarro del tracto genital fue mayor en solteras, nulíparas, con menos de ocho controles prenatales y recién nacidos con peso mayor de 3500 gramos(AU)

Introduction: Postpartum primary hemorrhage is the leading cause of maternal death in Peru, and it has been directly related to home birth, so it could reflect the opportunity and quality of health services when it occurs during a hospital's birth. Objective: To identify the risk factors for postpartum primary hemorrhage caused by tearing of the genital tract. Methods: An analytical study of cases and controls was carried out at Augusto Hernández Mendoza Hospital - EsSalud. The sample was composed by 30 cases (with postpartum primary hemorrhage by tearing of the genital tract) and 120 controls (without postpartum primary hemorrhage). T´s Student and U´s Mann-Whitney tests were used to compare the numerical variables, and the Chi square test to determine the association between the variables. Association´s strength was determined by calculating crude Odds Ratio and it was adjusted with its confidence intervals (CI) to 95 percent by binary logistic regression with the Hosmer-Leme show goodness-of-fit test. Results: The average haemoglobin value was 8.85 ± 0.39 mg percent in the cases and 11.90 ± 0.13 mg percent in the controls (P = 0.000). In the multivariate analysis, the risk predictors were: Nulliparae (ORa = 11.49; IC95 percent = 3,11-42,42), single (Ora = 8.81; IC95 percent = 1,83-42,41), < 8 Pre-natal controls (Ora = 7.95; IC95 percent = 2,60-24,31), and newborn birth weight ? 3500 grams (Ora = 7.34; IC95 percent = 2,15-25,06). Conclusions: The risk of primary post-partum hemorrhage by tearing of the genital tract was greater in single, nulliparae women, with less than eight prenatal controls and newborns weighing more than 3500 grams(AU)

Cost-effectiveness of carbetocin versus oxytocin for prevention of postpartum hemorrhage resulting from uterine atony in women at high-risk for bleeding in Colombia / Rendimento da carbetocina versus oxitocina para a prevenção da hemorragia pós-parto resultante da atonia uterina em mulheres com alto risco de sangramento na Colômbia

Abstract Objective To assess the cost-effectiveness of carbetocin versus oxytocin for prevention of postpartum hemorrhage (PPH) due to uterine atony after vaginal delivery/ cesarean section in women with risk factors for bleeding. Methods A decision treewas developed for vaginal delivery andanother one for cesarean, in which a sequential analysis of the results was obtained with the use of carbetocin and oxytocin for prevention of PPH and related consequences. A third-party payer perspective was used; only directmedical costs were considered. Incremental costs and effectiveness in terms of quality-adjusted life years (QALYs) were evaluated for a one-year timehorizon. The costs were expressed in 2016 Colombian pesos (1 USD = 3,051 Col$). Results In the vaginal delivery model, the average cost of care for a patient receiving prophylaxis with uterotonic agents was Col$ 347,750 with carbetocin and Col$ 262,491 with oxytocin,while theQALYs were 0.9980 and 0.9979, respectively. The incremental costeffectiveness ratio is above the cost-effectiveness threshold adopted by Colombia. In the model developed for cesarean section, the average cost of a patient receiving prophylaxis with uterotonics was Col$ 461,750 with carbetocin, and Col$ 481,866 with oxytocin, and the QALYs were 0.9959 and 0.9926, respectively. Carbetocin has lower cost and is more effective, with a saving of Col$ 94,887 per avoided hemorrhagic event. Conclusion In case of elective cesarean delivery, carbetocin is a dominant alternative in the prevention of PPH compared with oxytocin; however, it presents higher costs than oxytocin, with similar effectiveness, in cases of vaginal delivery.

Resumo Objetivo Avaliar a relação custo-eficácia da carbetocina versus oxitocina para prevenção de hemorragia pós-parto (HPP) vaginal e cesariana devido à atonia uterina em mulheres com fatores de risco para desenvolver sangramento. Métodos Foram desenvolvidos protocolos de manejo para parto vaginal e outra para parto por cesárea e analisados resultados obtidos com carbetocina e oxitocina na prevenção de HPP, assim como, consequências relacionadas à ocorrência do evento hemorrágico. A perspectiva utilizada foi a do terceiro pagador, portanto, apenas os custos médicos diretos foram levados em consideração. Os custos incrementais e a eficácia em termos de anos de vida ajustados pela qualidade (QALY) foram avaliados para um horizonte de tempo de um ano. Os custos foram expressos em pesos colombianos de 2016 (1 USD = 3.051 Col$). Resultados No modelo de parto vaginal, o customédio de cuidados para um paciente que recebeu profilaxia com agentes uterotônicos foi de Col$ 347.750 com carbetocina e Col$ 262.491 com oxitocina, enquanto os QALYs foram 0,9980 e 0,9979, respectivamente. O índice incremental de custo-efetividade está acima do limite de custoefetividade adotado pela Colômbia. No modelo desenvolvido para parto por cesárea, o custo médio do paciente que recebeu profilaxia com terapia uterotônica foi de Col$ 461.750 com carbetocina e Col$ 481.866 com oxitocina e os QALYs foram 0,9959 e 0,9926, respectivamente. A carbetocina foi a alternativa com menor custo e maior efetividade com uma economia de $94.887 por evento hemorrágico evitado. Conclusão A carbetocina no parto eletivo por cesárea é uma alternativa dominante na prevenção da PPH em relação à oxitocina; porém representa custos mais altos com uma eficácia similar à da oxitocina no caso de parto vaginal.

Cero muertes maternas comunitarias por hemorragia postparto: urge intervenir / Zero community maternal deaths by postpartum hemorrhage: a need for urgent intervention

La hemorragia vaginal post parto continúa siendo una de las primeras causas de muerte materna en países con desarrollo social y económico pobre o detenido. Existen a la fecha intervenciones de éxito que son utilizadas a nivel hospitalario y comunitario en países con altas tasas de parto en el hogar . Propósito: Sugerir intervenciones que mejoren la salud materna de la población indígena, rural y pobre del país. Material y método: Se realizó un análisis secundario de bases de datos sobre vigilancia de muerte materna . Se revisó la base de datos del Sistema Gerencial de Salud (SIGSA y SIGSA2) sobre muertes en mujeres de edad fértil y muertes maternas de 17 municipios y 19 distritos del departamento de Alta Verapaz y 32 municipios de del departamento de Huehuetenango, previamente analizados por los comités de mortalidad materna. ..AU

Ingresos a Unidad de Cuidados Intensivos de mujeres durante el embarazo y periodo puerperal / Admission of women to an intensive care unit during pregnancy or the postpartum period

Introducción: las complicaciones del embarazo y parto constituyen las principales causas de muerte entre las mujeres en edad reproductiva. Las embarazadas o puérperas que ingresan a Unidad de Cuidados Intensivos (UCI) son en su mayoría casos agudos críticos con riesgo de muerte, que necesitan tratamiento especializa do y complejo. Constituyen un grupo significativo de la práctica obstétrica. Objetivo: determinar las características clínicas y demográficas de las pacientes gestantes o puérperas que ingresaron a UCI del Hospital Nacional de Itauguá durante 5 años (2011-2015) Materiales y métodos: diseño observacional descriptivo de corte trasverso. Fueron incluidas gestantes y puérperas que requirieron ingreso a UCI por complicaciones obstétricas y no obstétricas, descompensación materna, con y sin morbilidad previa. Resultados: necesitaron ingreso a UCI 135 pacientes (0,48%). La edad media fue 27 ± 6,7 años. La muestra estuvo conformada por 21 gestantes (15,5%), 85 puérperas (63%), 27 mujeres con post aborto (20%) y 2 con embarazo ectópico (1,5 %). La complicación obstétrica más frecuente que motivó el ingreso a UCI fue la sepsis y entre las no obstétricas la cardiopatía descompensada. El tiempo medio de internación en la UCI fue 6,47 ± 8,5 días y 50 pacientes (37,03%) necesitaron asistencia respiratoria mecánica. Hubo 19 óbitos (14%) Conclusiones: el ingreso a UCI se observó en 0,48%. La mortalidad en UCI fue 14%.

Introduction: complications of pregnancy and childbirth are the main causes of death among women of childbearing age. Pregnant women or postpartum women entering the Intensive Care Unit (ICU) are mostly acute cases with a high risk of death, which require specialized and complex treatment. They constitute a significant group of obstetric practice. Objective: to determine the clinical and demographic characteristics of the pregnant or puerperal patients who entered the ICU of the National Hospital of Itauguá for 5 years (2011-2015) Materials and methods: descriptive observational cross-sectional design. Pregnant women and postpartum women who required admission to the ICU due to obstetric and non-obstetric complications, maternal decompensation, with and without prior morbidity were included. Results: 135 patients required admission to the ICU. The mean age was 27 ± 6.7 years. The sample consisted of 21 pregnant women (15.5%), 85 postpartum women (63%), 27 women with post abortion (20%) and 2 with ectopic pregnancy (1.5%). The most frequent obstetric complication that led to ICU admission was sepsis and non-obstetric heart disease was decompensated. The mean ICU admission time was 6.47 ± 8.5 days and 50 patients (37.03%) required mechanical ventilation. There were 19 deaths (14%) Conclusions: ICU admission was observed at 0.48%. Mortality in ICU was 14%.

Impacto de la hemorragia obstétrica mayor en la morbilidad materna extremadamente grave / Impact of major obstetric hemorrhage in extremely severe maternal morbidity

Introducción: la hemorragia es la complicación más significativa durante el embarazo, fundamentalmente del tercer y cuarto periodo del parto. Objetivos: caracterizar a las gestantes con hemorragia obstétrica mayor como causa de morbilidad materna extremadamente grave. Métodos: se realizó un estudio de desarrollo, transversal, observacional en el Hospital Ginecobstétrico Docente Mariana Grajales de Villa Clara desde enero de 2012 hasta diciembre de 2014. La población está constituida por 46 mujeres que tuvieron una hemorragia obstétrica mayor. Los datos se obtuvieron de la revisión documental del registro de partos e historias clínicas. Para el análisis estadístico se utilizó la prueba de chi cuadrado para identificar la relación entre variables. Se aplicó la prueba no paramétrica del Test de la mediana para buscar diferencias en los grupos según la causa de hemorragia. Resultados: predominan las pacientes que ya han tenido un parto o más con 78,3 por ciento y la atonía uterina como causa fundamental de hemorragia con 45,7 por ciento. Ocurrió la hemorragia después del parto en 71,7 por ciento. Conclusiones: la hemorragia obstétrica mayor se presenta con más frecuencia en las edades entre 20 y 35 años, y de ellas, las que han tenido un parto o más en su historia obstétrica. La atonía uterina sigue siendo la primera causa de hemorragia obstétrica mayor, y el puerperio el momento más crítico para la morbilidad materna extremadamente grave por hemorragia(AU)

Introduction: Hemorrhage is the most significant complication during pregnancy, mainly in the third and fourth stage of labor. Objectives: To characterize the pregnant women with major obstetric hemorrhage as a cause of extremely severe maternal morbidity. Methods: Observational, cross-sectional and developing study performed in ¨Mariana Grajales¨ teaching gynecobstetric hospital in Villa Clara from January 2012 to December 2014. The study population was made up of 46 women who had major obstetric hemorrhage. Data were taken from review of documents from the delivery register and medical histories. For the statistical analysis, Chi square test was used to identify association among variables. The non-parametric test of the median´s test was applied to find differences among the groups by cause of hemorrhage. Results: Predominance of patients with one or more deliveries with 78.3 percent and uterus atony as an essential cause of hemorrhage with 45.7 percent of cases. Postpartum hemorrhage occurred in 71.7 percent of the group. Conclusions: Major obstetric hemorrhage occurs more frequently at ages of 20 to 35 years and in women with one or more deliveries in their obstetric history. Uterus atony remains the first cause of major obstetric hemorrhage and the puerperium is the most critical time for extremely severe maternal morbidity from hemorrhage(AU)

Pattern of Obstetrical Emergencies and Fetal Outcomes in a Tertiary Care Center.

Introduction: Th ere is increasing awareness and facilities provided by various government and non government organizations regarding antenatal care and safe delivery practices but it is still a public health concern due to high maternal and perinatal mortality. Th e aims of present study is to assess the availability of manpower which provided services to the mothers in the peripheries, role of demographic characteristics, educational status, common pregnancy complications and there maternal and fetal outcome along with the hospital stay. Material and Methods: It was a retrospective study carried out in the Teerthanker Mahaveer Medical College. All the patients who were admitted through casualty were analysed with respect to Age, parity, Socioeconomic status, antenatal check-up, reason for referral from periphery, maternal and fetal condition at the time of admission, mode of delivery, maternal and fetal outcome along with NICU admission & hospital stay. Result: It has been observed that most of the patients with poor obstetrical outcome are multiparous or grand multiparous with low socio economic status not receiving any antenatal care. Th e common obstetrical emergencies came out were PIH (18%), obstructed labor (10.3%) followed by APH (8.2%), fetal mal-presentation (7.5%) and anemia (7.2%). Conclusion: Illiteracy and ignorance of female regarding healthcare requirements came out to be a major contributor of poor pregnancy outcome. Early diagnosis and management of high risk pregnancies is one of the measures which can reduce poor pregnancy outcomes. It is to be emphasized that majority of the maternal death from pregnancy are preventable by sample priority intervention. Co-ordination between healthcare providers at gross root level to tertiary care centre is the need of time. Health care providers at PHC and CHC levels should have adequate knowledge of antenatal requirements and importance of immunization. Th ere must be referral of high risk cases for their early and timely management. Th ere must be adequate transport facility and systematic referral system as well as provision of immediate management of referred cases at tertiary care centre. So it is high time for urgent strategic planning and investment for upgrading eff ective obstetric and neonatal care.

Associação entre síndromes hipertensivas e hemorragia pós-parto / Asociación entre las síndromes hipertensivas y hemorragia posparto / Association between hypertensive disorders and postpartum hemorrhage

RESUMO Objetivo Investigar a associação entre síndromes hipertensivas e hemorragia pós-parto (HPP) através da mensuração do nível de hemoglobina (Hb) e hematócrito (Ht) em mulheres atendidas em um hospital universitário do interior paulista. Métodos Estudo epidemiológico, seccional, realizado com 100 primíparas, no período entre agosto e dezembro de 2012. Realizaram-se dosagens de hemoglobina e hematócrito na admissão da parturiente e 48 horas pós-parto. Consideraram-se como HPP valores ≥ queda de 10% do valor do hematócrito da admissão. A HPP foi considerada variável dependente, e as variáveis independentes consideradas foram as socioeconômicas, patológicas, assistência pré-natal, admissão, parto e assistência. Utilizaram-se análises estatísticas uni e bivariadas, com nível de significância de 5%. Resultados As síndromes hipertensivas foram as doenças mais frequentes; houve presença de correlação positiva entre a queda nos níveis de Ht e Hb e não se identificou uma associação entre síndromes hipertensivas e HPP. Conclusões Primíparas portadoras de síndromes hipertensivas não apresentaram maior probabilidade de HPP.

RESUMEN Objetivos Investigar la asociación entre síndromes hipertensivas y hemorragia posparto (HHP), midiendo el nivel de hemoglobina y hematocrito entre mujeres que acuden a un hospital universitario de una provincia en el interior de São Paulo. Métodos Estudio epidemiologico, seccional o en corte, realizado con 100 primiparas, en el período comprendido entre agosto y diciembre de 2012. Fue realizado dosis de hemoglobina y hematocrito, en la admisión y 48 horas después del parto. Consideró como (HPP) valores / la caída del 10% del valor de lo hematocrito de la admisión. (HPP) fue considerada variable dependiente y socioeconómicas, patológicas, asistencia prenatal, admisión, parto y evolución y asistencia, independientes. Se utilizaron estadísticas univariadas y bivariadas, con nivel de significación del 5%. Resultados Síndromes hipertensivas fueron la enfermedad más frecuente; hubo presencia de correlación positiva entre la caída en los niveles del Ht y Hb y no encontraron una asociación entre las síndromes hipertensivas y HPP. Conclusiones primíparas con síndromes hipertensivas no fueron más propensas a PPH.

ABSTRACT Objective To investigate the association between hypertensive disorders and postpartum hemorrhage (PPH), by measuring the hemoglobin (Hb) and hematocrits (Ht) levels among women attending a university hospital in the Sao Paulo countryside. Method Epidemiological, cross-sectional study, conducted with 100 primiparous, in the period between August and December 2012. Hemoglobin and hematocrit dosages were tested upon admission of the mother and 48 hours after delivery. Values ≥ 10% drop in the hematocrit numbers when compared to those shown in admission, were considered as HPP. HPP was considered the dependent variable and the independent variables were socioeconomic, pathological, prenatal care, admission, delivery and assistance. Univariate and bivariate statistics were used, with 5% significance level. Results The hypertensive disorders were the most commonly occurring disorders; there was the presence of positive correlation between the fall in Ht and Hb levels and there was no association found between hypertensive disorders and HPP. Conclusions Primiparous not suffering from hypertensive disorders were more likely to present PPH.

Grandmultiparas; frequency of hypertension placental abruption and postpartum haemorrhage in

Intrapartum complications that are classically associated with grandmultiparas include fetal malpresentation, dysfunctional labour, chronic hypertension, abruptio placentae, postpartum haemorrhage and macrosomic babies. Excellent maternal and fetal outcome is possible in grandmultiparas with improvement in health care system and free provision of health facilities to all pregnant women. The objective of the study was: to find the frequency of hypertension, placental abruption and primary postpartum hemorrhage in grandmultiparas. It was a prospective study with descriptive pattern. Gynaecology and Obstetric unit-I of Allied Hospital, Punjab Medical College Faisalabad. January to June 2006. Eighty patients were included in the study. Eighty grandmultiparas were randomly selected for the study. Detailed evaluation of all patients was done by thorough history, examination and investigation. Patients were analyzed for complications during pregnancy, labour and delivery, especially hypertension, placental abruption and primary post partum haemorrhage. Hypertensive disorders found to be in 32 [33.8%], placental abruption in 7[8.8%] and postpartum hemorrhage in 19[23.8%] of grandmultiparas. It was concluded from the result of my study that grandmultiparity is still a major obstetric hazard in developing countries like Pakistan with higher incidence of complications. Safe maternal and perinatal outcome is possible in grandmultiparas with improvement in health care system and free provision of health care facilities to all pregnant women

Uso de suturas uterinas compressivas na hemorragia pós-parto / Use of uterine compression sutures in postpartum hemorrhage

A hemorragia pós-parto é uma complicação presente em mais de 18% dos nascimentos e é responsável por cerca de 25 a 30% das mortes maternas no mundo. Nas últimas décadas, várias técnicas conservadoras visando o controle hemorrágico no período pós-parto têm sido relatadas, com destaque para as ligaduras vasculares, suturas uterinas compressivas, embolização arterial, balões intrauterinos e a interrupção do ato operatório com laparostomia, empacotamento pélvico e posterior abordagem cirúrgica. O presente artigo apresenta uma revisão das suturas uterinas compressivas, com destaque para a cronologia de criação das técnicas de execução, e as publicações em periódicos. São descritas as suturas de Schnarwyler, B-Lynch, Cho, Hayman, Bhal, Pereira, Ouabha, Hackethal, Meydanli, Marasinghe-Condous, Matsubara-Yano, Zheng e a técnica de Halder. Foram detalhadas também as indicações, as técnicas associadas e as complicações.(AU)

Postpartum hemorrhage is present in over 18% of births and accounts for 25 to 30% of maternal deaths worldwide. In the last decades, several conservative techniques direct at controlling hemorrhage in the postpartum period have been reported, principally vascular ligatures, uterine compression sutures, arterial embolization, intrauterine balloons and surgery interruption with laparostomy, pelvic packing and subsequent surgical intervention. This article presents a review of uterine compression sutures, especially the chronology of creation of the execution techniques and publications in journals. Schnarwyler, B-Lynch, Cho, Hayman, Bhal, Pereira, Ouabha, Hackethal, Meydanli, Marasinghe-Condous, Matsubara-Yano, Zheng and Halder sutures were reviewed. Indications, associated techniques and complications were also detailed.(AU)

Uso de balões intrauterinos em pacientes com hemorragia pós-parto / Use of intrauterine balloons in patients with postpartum haemorrhage

A hemorragia pós-parto é uma complicação presente em mais de 18% dos nascimentos e responsável por cerca de 25 a 30% das mortes maternas no mundo. No Brasil, apesar da ampliação do acesso aos serviços de saúde e da melhoria em praticamente todos os indicadores de saúde materna, esta etiologia continua se apresentando entre os três principais grupos de causas de morte no ciclo grávido-puerperal. Nas últimas décadas, várias técnicas conservadoras visando o controle hemorrágico no período pós-parto têm sido relatadas, com destaque para as técnicas de desvascularização uterina, suturas compressivas, embolização arterial, balões intrauterinos e a interrupção do ato operatório com laparostomia, empacotamento pélvico e posterior reabordagem cirúrgica. O presente artigo apresenta uma revisão do uso de balões intrauterinos no controle hemorrágico com destaque para os tipos, aplicabilidades e cronologia de invenção e publicações. Foram avaliados os balões de Sengstaken-Blakemore, os artesanais, as sondas de Foley, balão de Rusch, de Bakri e o BT-cath. Detalhou-se também o teste do tamponamento e a técnica do "sanduíche uterino".(AU)

Postpartum hemorrhage is present in over 18% of births and accounts for 25-30% of maternal deaths worldwide. In Brazil, despite the expansion of access to health care and the improvement of virtually all maternal health indicators, such etiology is still present among the three main causes of death during pregnancy and childbirth. In the last decades, several conservative techniques direct at controlling hemorrhage in the postpartum period have been reported, principally techniques of uterine devascularization, compression sutures, arterial embolization, intrauterine balloons and surgery interruption with laparostomy, pelvic packing and subsequent surgical intervention. This article presents a review of the use of intrauterine balloons in controlling hemorrhage especially types, applicability and chronology of invention and publications. Sengstaken-Blakemore balloons, the artisanal, Foley probes, Rusch balloon, Bakri and BT-cath were reviewed. The tamponade test and the "uterine sandwich" technique were also detailed.(AU)

Reduction of maternal mortality due to preeclampsia in Colombia - an interrupted time-series analysis / Reducción de la mortalidad materna por preeclampsia en Colombia - un análisis de series de tiempo interrumpido

Abstract Introduction. Preeclampsia is the most important cause of maternal mortality in developing countries. A comprehensive prenatal care program including bio-psychosocial components was developed and introduced at a national level in Colombia. We report on the trends in maternal mortality rates and their related causes before and after implementation of this program. Methods: General and specific maternal mortality rates were monitored for nine years (1998-2006). An interrupted time-series analysis was performed with monthly data on cases of maternal mortality that compared trends and changes in national mortality rates and the impact of these changes attributable to the introduction of a bio-psychosocial model. Multivariate analyses were performed to evaluate correlations between the interventions. Results: Five years after (2002-2006) its introduction the general maternal mortality rate was significantly reduced to 23% (OR= 0.77, CI 95% 0.71-0.82).The implementation of BPSM also reduced the incidence of preeclampsia in 22% (OR= 0.78, CI 95% 0.67-0.88), as also the labor complications by hemorrhage in 25% (OR= 0.75, CI 95% 0.59-0.90) associated with the implementation of red code. The other causes of maternal mortality did not reveal significant changes. Biomedical, nutritional, psychosocial assessments, and other individual interventions in prenatal care were not correlated to maternal mortality (p= 0.112); however, together as a model we observed a significant association (p= 0.042). Conclusions: General maternal mortality was reduced after the implementation of a comprehensive national prenatal care program. Is important the evaluation of this program in others populations.

Resumen Introducción. La preeclampsia es la causa más importante de mortalidad materna en los países en desarrollo. Se desarrolló e introdujo en Colombia y a nivel nacional un programa de cuidado prenatal que incluyó componentes bio-psicosociales. Se muestran las tendencias de las tasas de mortalidad materna y las causas relacionadas antes y después de la implementación del programa. Métodos: Las tasas de mortalidad general y específica fueron monitoreadas durante 9 años (1998-2006). Un análisis de series de tiempo ininterrumpido se realizó con datos mensuales de casos de mortalidad materna y se compararon las tendencias de cambio en las tasas de mortalidad nacional y el impacto de los cambios atribuibles a la introducción del modelo. Se hizo un análisis multivariado para evaluar la asociación entre las intervenciones. Resultados: Cinco años después de la introducción del programa (2002-2006) la tasa de mortalidad maternal se redujo significativamente en 23% (OR= 0.77, CI 95% 0.710.82). La implementación del MBPS redujo la incidencia de la preeclampsia en 22% (OR= 0.78, CI 95% 0.67-0.88 , igual la mortalidad materna por complicación del parto por hemorragias en 25% (OR= 0.75, CI 95% 0.59-0.90). Otras causas de mortalidad materna no mostraron cambios significativos. No se correlacionó la mortalidad materna con intervenciones de cuidado prenatal individuales como las biomédicas, nutricionales y psicosociales (p= 0.112), sin embargo, ellas en conjunto como un modelo (biopsicosocial) si observaron una asociación significativa (p= 0.042). Conclusiones: La mortalidad maternal general se redujo después de la implementación de un programa nacional de cuidado prenatal. Es importante evaluar este programa en otras poblaciones.

Hepatitis C in haemorrhagic obstetrical emergencies

To determine the maternal health and fetal outcome in hepatitis C with obstetrical haemorrhagic emergencies. An observational study. Department of Obstetrics and Gynaecology Unit-I, Liaquat University of Medical and Health Sciences Hospital, Hyderabad, Sindh, from January 2009 to December 2010. All the women admitted during the study period with different obstetrical haemorrhagic emergencies were included. On virology screening, hepatitis C screening was done on all. The women with non-haemorrhagic obstetrical emergencies were excluded. Studied variables included demographic characteristics, the nature of obstetrical emergency, haemorrhagic conditions and maternal and fetal morbidity and mortality. The data was analyzed on SPSS version 20. More frequent obstetrical haemorrhagic emergencies were observed with hepatitis C positive in comparison with hepatitis C negative cases including post-partum haemorrhage in 292 [80.88%] and ante-partum haemorrhage in 69 [19.11%] cases. Associated morbidities seen were disseminated intravascular coagulation in 43 [11.91%] and shock in 29 [8.03%] cases with hepatitis C positive. Fetal still birth rate was 37 [10.24%] in hepatitis C positive cases. Frequency of maternal morbidity and mortality and perinatal mortality was high in obstetrical haemorrhagic emergencies with hepatitis C positive cases

L'hemorragie grave du post partum; epidemiologie et prise en charge a l'Hopital

Introduction : L'hemorragie grave du post partum est une urgence obstetricale imprevisible mettant en jeu le pronostic vital et fonctionnel. Elle reste la principale cause de mortalite maternelle dans notre pays et ailleurs Buts : Rapporter l'experience de la maternite universitaire de Nabeul dans la prise en charge de l'hemorragie grave du post partum. Patientes et methodes : etude retrospective; descriptive; couvrant la periode de 2009 a 2011; et portant sur 92 dossiers des patientes ayant presente une hemorragie grave du post partum.. Resultats : Pres d'une patiente sur deux (46;8) avait moins de 30 ans. La frequence de l'hemorragie grave du post partum a ete de 6;03 pour mille accouchements. Les paucipares ont represente la majorite dans cet echantillon (69;6).La pre-eclampsie (21;7); l'hematome retro placentaire (14;1); et la macrosomie fotale (5;4); ont ete les principales associations morbides La cesarienne a ete le principal mode de delivrance dans ce groupe (68;5). Le diagnostic a ete souvent etabli en postpartum immediat (2h) avec une estimation moyenne du saignement de 1278ml. Le taux moyen d?hemoglobine au moment du diagnostic etait de 7;75 g/dl. Des troubles graves de l?hemostase avec CIVD ont ete retrouves chez 5 patientes (5;43). Les etiologies etaient dominees par l'inertie uterine (92;39 ); les lesions genitales basses (12.88) et la rupture uterine (3.68). Le Sulprostone a ete utilise chez 86 patientes (93;5). Trente sujets (32;6) ont necessite un recours a la chirurgie reparatrice; contre 62 (83;3) qui ont beneficie d'un traitement conservateur. Dans 5 cas; une hysterectomie d'hemostase a ete indiquee. Aucun deces maternel n'a ete rapporte. Conclusion : L'hemorragie grave du post-partum est une complication presente dans notre milieu ; elle concerne surtout la jeune parturiente et justifie des mesures preventives adequates ciblees sur les principales causes et les complications observees

Les hemorragies de la delivrance : a propos de 134 cas referees a la maternite du CHU de Treichville

Objectifs : Determiner la frequence des patientes referees pour hemorragie du post partum immediat (HPPI); decrire les caracteristiques socio-demographiques des patientes et identifier les dysfonctionnements pouvant aggraver le pronostic maternel. Population et methode : Etude descriptive et retrospective menee de janvier 2005 a juin 200 incluant toutes les patientes referees a la maternite du CHU de Treichville pour HPPI. Resultats : 134 patientes ont ete referees pour HPPI soit une incidence de 1;27. L'age moyen des patientes etait de 28;5 ans. La parite moyenne etait de 3;5. La majorite des patientes etaient sans activite remuneratrices et sans niveau d'instruction. La decision de transfert etait decidee dans 85;82 des cas par la sage femme. Le transfert avait ete assure par de vehicules non medicalises (86;58). La duree moyenne d'evacuation etait de 62;7min. A l'admission; 47;76 etaient en etat de choc hypovolemique avec dans 16;42 une coagulation intravasculaire disseminee. Trente et six patientes sont decedees soit un taux de letalite de 26;90. Les principales causes de deces etaient la coagulopathie (55;6) et le choc hypovolemique (36;1). Conclusion : Le taux de letalite par hemorragie de la delivrance chez les patientes referees est eleve. Sa reduction passe par l'amelioration des dysfonctionnements identifies dans l'itineraire therapeutique des patientes

Trastornos de la hemostasia durante la gestación / Hemostasia disorders during pregnancy

Se realizó una revisión de la literatura en relación con los trastornos hemorrágicos durante la gestación y se mencionan los cambios hematológicos fisiológicos que ocurren durante el embarazo y el puerperio. La conocida teoría de la coagulación como un proceso en cascada no tiene vigencia en la actualidad, sino que esta ha dado paso a la moderna teoría celular de la coagulación. Se describen también los criterios diagnóstico y terapéutico en las hemorragias obstétricas por incoagulabilidad sanguínea (HOICS). Al analizar el cuadro clínico y los resultados de laboratorio, se puede realizar un diagnóstico seguro de la HOICS que se presenta. La disminución de las plaquetas en sangre, constituye con frecuencia en los casos de HOICS la alteración inicial, el factor V de la coagulación siempre está disminuido, mientras que el factor VIII de la coagulación, generalmente se encuentra elevado. El uso de heparina de alto y bajo peso molecular, y de factores de la coagulación para el tratamiento de las HOICS ha sido controvertido. Se ha recomendado en estos casos la administración de sangre fresca, plasma fresco, plasma homólogo, crioprecipitados y concentrado de plaquetas. Actualmente, se vienen remplazando estas conductas terapéuticas por el uso del FVIIa recombinante, el cual puede asociarse con el misoprostol. La evacuación de la cavidad uterina tan pronto como sea posible constituye una medida necesaria en algunas pacientes

A literature review was performed in relation to hemorrhagic disorders during pregnancy signaling the physiologic and hematologic changes occurring at pregnancy and the puerperium. The well-known theory of coagulation as a cascade process has not validity at present time, but that this one gave way to the modern cellular theory of coagulation. The diagnostic and therapeutical in blood incoagulability obstetrics hemorrhages (BIOH). Analyzing the clinical picture and the lab results, it is possible to make an accurate diagnosis of present BIOHs. The blood platelet decrease, frequently in BIOH cases is the first alteration, the V coagulation factor, in general is always decreased, whereas the VIII coagulation factor is in general increased. The high and low weight heparin use and of coagulation factors for treatment of BIOHs has been controversial. In such cases it is recommended the administration of fresh blood, fresh plasma, the homologous plasma cryoprecipitates and platelet concentrates. Nowadays these therapeutical behaviors have been replaced by the use of recombinant FVIIa, which may be associated with the Misoprostol. The uterine cavity evacuation as soon as possible is a needed measure in some patients.