Analysis of the efficacy of prophylactic tranexamic acid in preventing postpartum bleeding: systematic review with meta-analysis of randomized clinical trials

Abstract Background Postpartum Hemorrhage (PPH) is one of the main causes of maternal mortality, mainly in the poorest regions of the world, drawing attention to the need for strategies for preventing it. This study aims to evaluate the efficacy of prophylactic administration of Tranexamic Acid (TXA) in decreasing blood loss in pregnant women in delivery, preventing PPH. Methods Systematic review of randomized clinical trials. We searched for publications in PubMed, EMBASE and Cochrane Library databases, with the uniterms "postpartum, puerperal hemorrhage" and "tranexamic acid", published between January of 2004 and January of 2020. The eligibility criteria were trials published in English with pregnant women assessed during and after vaginal or cesarean delivery about the effect of prophylactic use of TXA on bleeding volume. The random-effects model was applied with the DerSimonian-Laird test and the Mean Difference (MD) was calculated for continuous variables together with each 95% CI. This systematic review was previously registered in the PROSPERO platform under the registration n° CRD42020187393. Results Of the 630 results, 16 trials were selected, including one with two different doses, performing a total of 6731 patients. The intervention group received a TXA dose that varied between 10 mg.kg−1 and 1g (no weight calculation). The TXA use was considered a protective factor for bleeding (MD: -131.07; 95% CI: -170.00 to -92.78; p= 0.000) and hemoglobin variation (MD: -0.417; 95% CI: -0.633 to -0.202; p= 0.000). In the subgroup analysis related to the cesarean pathway, the effect of TXA was even greater. Conclusion The prophylactic use of tranexamic acid is effective in reducing the post-partum bleeding volume. PROSPERO registration ID CRD42020187393.

Investigación de incidencia y complicaciones de histerectomía de emergencia en periparto / Investigation of Incidence and Complications of Emergency peripartum hysterectomy

Introducción: La histerectomía periparto de emergencia es una cirugía de alto riesgo, que se realiza mayoritariamente después de un parto vaginal o cesárea. Dada la importancia de las complicaciones y la mortalidad de las embarazadas para el sistema de salud, el presente estudio tuvo como objetivo investigar la incidencia y las complicaciones de la histerectomía periparto de emergencia en los hospitales generales y docentes de la Universidad de Ciencias Médicas de Zahedan. Materiales y Métodos: En este estudio descriptivo-analítico transversal, luego de obtener la aprobación del Comité de Ética, se investigó la historia clínica de las pacientes con histerectomía periparto de emergencia ingresadas en el hospital Ali ibn Abitaleb de Zahedan para la interrupción del embarazo durante 2017-2018. fueron estudiados. Después de evaluar las características demográficas, incluida la edad, la educación y la ocupación, se investigaron las causas y las complicaciones de la histerectomía de emergencia. Finalmente, los datos fueron analizados por el software SPSS.Resultados: De 2438 casos, se investigaron 50 casos de histerectomía. La edad media de las madres y el número medio de embarazos fue de 31,06 ± 5,21 y 5,72 ± 2,31, respectivamente. En este estudio, se registraron 35 cesáreas (70%) y 15 partos vaginales normales (30%), y solo el 2% condujo a una histerectomía de emergencia. Las causas más comunes de histerectomía de emergencia incluyeron placenta accreta (28%), atonía uterina (24%) y rotura uterina (20%). Las complicaciones también incluyeron fiebre (24%), coagulopatía (14%) e infección de la herida (12%). Conclusión: la placenta accreta y la atonía uterina son las causas más importantes de histerectomía. Las complicaciones más comunes de la histerectomía de emergencia son fiebre, coagulopatía e infecciones de heridas. Una disminución en el parto por cesárea electiva y un mayor fomento del parto vaginal natural podrían reducir significativamente la incidencia de histerectomía periparto y la mortalidad materna

Introduction: The emergency peripartum hysterectomy is a high-risk surgery, which is mostly performed after vaginal delivery or Caesarean section. Given the importance of complications and mortality of pregnant mothers for the health system, the present study aimed to investigate the incidence and complications of emergency peripartum hysterectomy in general and teaching hospitals of Zahedan University of Medical Sciences. Materials and Methods: In this cross-sectional descriptive-analytic study, after obtaining the Ethics Committee approval, the medical record of patients with emergency peripartum hysterectomy admitted to Ali ibn Abitaleb hospital of Zahedan for pregnancy termination during 2017-2018 were investigated. were studied. After evaluating demographic characteristics, including age, education, and occupation, causes, and complications of emergency hysterectomy were investigated. Finally, data were analyzed by SPSS software. Results: Out of 2438 cases, 50 cases of hysterectomy were investigated. The mean age of mothers and the average number of pregnancies was 31.06±5.21 and 5.72±2.31, respectively. In this study, 35 caesarean sections (70%) and 15 normal vaginal delivery (30%) were recorded, with only 2% leading to emergency hysterectomy. The most common causes of emergency hysterectomy included placenta accreta (28%), uterine atony (24%), and uterine rupture (20%). The complications also included fever (24%), coagulopathy (14%), and wound infection (12%). Conclusion: Placenta accreta and uterine atony are the most important causes of hysterectomy. The most common complications of emergency hysterectomy are fever, coagulopathy, and wound infections. A decrease in elective caesarean delivery and further encouraging to natural vaginal delivery could significantly reduce the incidence of peripartum hysterectomy and maternal mortality

Guía de práctica clínica para el uso de uterotónicos en la prevención de la hemorragia posparto / Clinical practice guide for the use of uterotonics in postpartum hemorrhage prevention

Objetivo: Proveer recomendaciones para mejorar la calidad del cuidado y desenlaces para mujeres que reciben atención del parto, en relación a la prevención de la hemorragia posparto (HPP) por atonía uterina en El Salvador. Métodos: La presente guía fue desarrollada siguiendo los lineamientos del Manual para la elaboración de guías de la Organización Mundial de la Salud1. De forma general, se creó un grupo para la elaboración con enfoque multidisciplinario compuesto por expertos sobre el tema, epidemiólogos, metodólogos y pacientes. Con base en la evidencia proveniente de la guía para el uso de uterotónicos para la prevención de hemorragia posparto, se desarrolló una adaptación para el contexto del sistema de salud de El Salvador2. Se realizó inclusión de evidencia local y la contextualización de sus recomendaciones. Las recomendaciones fueron graduadas en un panel de expertos conformado por profesionales en estadística, enfermería, materno infantil, médicos generales y especialistas en ginecología y obstetricia, perinatología, anestesiología, medicina familiar, economía de la salud, epidemiología, además se incluyó la participación de pacientes siguiendo el enfoque GRADE. Adicionalmente, la guía fue evaluada por pares temáticos y metodológicos. Todos los participantes del panel y del grupo desarrollador firmaron un formato de conflicto de intereses que analizaron los coordinadores de la guía.

Tecnologias de cuidado para prevenção e controle da hemorragia no terceiro estágio do parto: revisão sistemática / Care technologies to prevent and control hemorrhage in the third stage of labor: a systematic review / Tecnologías de cuidado para prevención y control de la hemorragia en la tercera etapa del parto: revisión sistemática

Objetivo identificar evidências acerca das contribuições das tecnologias de cuidado usadas para prevenção e controle da hemorragia no terceiro estágio do parto. Método revisão sistemática com busca em bases de dados. Dois investigadores selecionaram os textos de forma independente na primeira etapa e, na segunda, em reunião de conciliação. Para avaliação da concordância, aplicou-se o coeficiente Kappa; para avaliação do risco de viés e classificação dos níveis de evidência, adotou-se o Grading of Recommendations, Assessment, Development and Evaluation. Resultados incluíram-se 42 artigos; desses, 34 classificados como tecnologias de produto, sendo a maioria produtos farmacológicos; dois referentes ao uso do saco plástico transparente para a coleta de sangue e contribuição do intervalo de nascimento e dos cuidados pré-natais. Os oito artigos classificados como tecnologias de processo se referiam a manejo ativo do terceiro estágio do parto, tração controlada de cordão, massagem uterina e intervenções educacionais. Conclusão as tecnologias de produto e de processo apresentaram evidência alta e moderada confirmada em 61,90% dos artigos. Os níveis de evidência demonstram contribuições das tecnologias para prevenção e controle da hemorragia. Na prática clínica, o enfermeiro deve oferecer cuidados à mulher fundamentados em evidências científicas e construir protocolos sobre as ações de cuidado da enfermagem.

Objective to identify evidence concerning the contribution of health technologies used to prevent and control hemorrhaging in the third stage of labor. Method systematic review with database searches. First, two researchers independently selected the papers and, at a second point in time, held a reconciliation meeting. The Kappa coefficient was used to assess agreement, while the Grading of Recommendations, Assessment, Development and Evaluation was adopted to assess risk of bias and classify level of evidence. Results in this review, 42 papers were included, 34 of which addressed product technologies, most referred to pharmacological products, while two papers addressed the use of blood transparent plastic bags collector and the contribution of birth spacing and prenatal care. The eight papers addressing process technologies included the active management of the third stage of labor, controlled cord traction, uterine massage, and educational interventions. Conclusion product and process technologies presented high and moderate evidence confirmed in 61.90% of the papers. The levels of evidence confirm the contribution of technologies to prevent and control hemorrhaging. Clinical nurses should provide scientific-based care and develop protocols addressing nursing care actions.

Objetivo identificar las evidencias acerca de las contribuciones de las tecnologías de cuidado usadas para la prevención y el control de la hemorragia en la tercera etapa del parto. Método revisión sistemática con búsqueda en bases de datos. Dos investigadores seleccionaron los textos, de forma independiente, en la primera etapa; y, en la segunda en reunión de conciliación. Para evaluación de la concordancia fue aplicado el coeficiente Kappa; para evaluación del riesgo de sesgo y clasificación de los niveles de evidencia, se adoptó el Grading of Recommendations, Assessment, Development and Evaluation. Resultados fueron incluidos 42 artículos; de estos, 34 fueron clasificados como: tecnologías de producto (siendo la mayoría productos farmacológicos), dos referentes a la contribución del saco plástico transparente recolector de sangre y del intervalo de nacimiento y de los cuidados prenatales. Los ocho artículos clasificados como tecnologías de proceso se referían al manejo activo de la tercera etapa del parto, a la tracción controlada del cordón, al masaje uterino y a intervenciones educacionales. Conclusión las tecnologías de producto y de proceso presentaron evidencia alta y moderada, lo que fue confirmado en 61,90% de los artículos. Los niveles de evidencia demuestran las contribuciones de las tecnologías para la prevención y el control de la hemorragia. En la práctica clínica, el enfermero debe ofrecer cuidados a la mujer fundamentados en evidencias científicas y construir protocolos sobre las acciones de cuidado de la enfermería.

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

El Balón de Bakri como herramienta en el manejo de la hemorragia post parto / THE BAKRI´S BALLOON AS AN IMPORTANT TOOL FOR THE MANAGEMENT OF POST PARTUM HEMORRHAGE

Introducción La hemorragia post parto es una de las complicaciones más graves del puerperio y una de las principales causas de mortalidad materna a nivel mundial. Dentro del esquema del manejo de la misma se encuentra el uso del balón de Bakri para evitar la histerectomía post parto. Objetivo: presentar la experiencia en la utilización del Balón de Bakri en un trabajo colaborativo entre los Servicios de Obstetricia del Hospital Nacional Posadas y de la Madre y el Niño de Formosa Capital entre enero de 2015 a junio de 2016. Método: Estudio transversal y descriptivo que incluyó a 25 pacientes con hemorragia post parto sin respuesta al tratamiento con Ocitócicos y que requirieron colocación del Balón de Bakri. Resultados: El balón de Bakri fue aplicado a 25 mujeres con hemorragia refractaria. La mediana de insuflación del Balón de Bakri fue de 300 (240/ 600 mL). La hemostasia se consiguió en 23 (92 %) de estas mujeres. Dos mujeres debieron ser histerectomizadas por continuar sangrando luego de la colocación del balón. Conclusión: El balón de Bakri es una herramienta eficaz para el manejo de la hemorragia post parto refractaria a carbetocina, evitando la histerectomía en el 92% de los casos.

Postpartum hemorrhage is one of the most serious complications of puerperium and one of the leading causes of maternal mortality worldwide. Within the framework of the management of it is the use of Bakri balloon to prevent puerperal hysterectomy. The aim of this study is to present the experience in the use of Bakri balloon in a collaborative work between the Obstetrics Departments of the Posadas National Hospital and the Madre y el Niño Hospital of Formosa Capital, Argentina, from January 2015 to June 2016. Methods: Cross-sectional descriptive study that included 25 patients with postpartum bleeding with uterine atony refractory to treatment with uterotonics and required Bakri balloon placement. Results: The Bakri ballon was applied to 25 women with refractory bleeding Oxytocics after vaginal delivery. The median Bakri balloon inflation was 300 (240/600 mL). Hemostasis was achieved in 23 (92%) of these women. Two women (8%) had to be undergone hysterectomy for bleeding continue after placement of the ball. Conclusion: The Bakri balloon is an effective tool for the management of post partum hemorrhage refractory to Carbetocin avoiding hysterectomy in 92% of cases.

Histerectomía obstétrica en el Hospital General Dr. Aurelio Valdivieso, Oaxaca, México / Obstetric hysterectomy in a secondary hospital

Objetivo: Determinar la incidencia, principales indicaciones y complicaciones de la histerectomía obstétrica (HO) en un hospital de segundo nivel de atención a cuatro años de implementar el programa de prevención y manejo de la hemorragia obstétrica. Método: Estudio de tipo descriptivo de revisión de expedientes clínicos, de tipo transversal, analítico y retrospectivo. Resultados: Se hallaron 51 expedientes de pacientes a quiénes se realizó HO de enero de 2012 a noviembre de 2015. La prevalencia fue de 17,1/10.000 nacimientos, la incidencia por año fue de 1,7 (2012), 1,7 (2013), 1,4 (2014) y 1,9 (2015) por cada mil nacimientos respectivamente. La prevalencia de HO post-cesárea fue de 25,6/10.000 y en el post-parto de 10,6/10.000. Las variables que alcanzaron significancia entre cirugía programada y de emergencia fue pérdida sanguínea y necesidad de transfusiones sanguíneas. El procedimiento se asocia a anemia en el puerperio 7 veces más y las principales indicaciones para realizar el procedimiento fueron alteración de la adherencia placentaria e hipotonía. Conclusiones: El diagnóstico prenatal de anomalías en la adherencia placentaria, la mejor utilización de hemoderivados y la técnica quirúrgica ha eliminado la mortalidad materna por hemorragia obstétrica masiva en los últimos cuatro años en el Hospital General Dr. Aurelio Valdivieso.

Objective: To determine the incidence, main indications and complications of obstetric hysterectomy in a secondary hospital care to four years to implement the program of prevention and management of obstetric hemorrhage. Methods: Descriptive study of review of clinical records, transversal, analytical and retrospective. Results: 51 cases of patients who obstetric hysterectomy (OH) was held between January 2012 to November 2015. The prevalence was 17.1/10,000. The incidence per year was 1.7 (2012), 1.7 (2013), 1.4 (2014) and 1.9 (2015) per 1000 births, respectively. The prevalence of post-cesarean OH was 25.6/10,000 while postpartum OH was 10.6/10,000. The variables that reached significance between scheduled and emergency surgery was blood loss and need for blood transfusions. The procedure is associated with anemia in the postpartum period 7 times and the main indications for the procedure were alteration abnormal placental adhesion and uterine atony. Conclusions: The prenatal diagnosis of abnormal placental adhesion, better use of blood products and surgical technique has eliminated maternal mortality by massive obstetric hemorrhage in the last four years in the General Hospital Dr. Aurelio Valdivieso.

Hemorragia pós-parto / Postpartum hemorrhage

Hemorragia pós-parto (HPP) é a principal causa de morte materna em países em desenvolvimento. Neste artigo, revisaremos os principais conceitos sobre o tema, especialmente aqueles referentes à prevenção e tratamento.

Postpartum hemorrhage is the leading cause of maternal mortality in developing countries. The aim of this article is to review the main aspects of this subject, focusing on prevention and treatment

Efficacy of rectal misoprostol for prevention of postpartum hemorrhage

Postpartum hemorrhage is an important cause of maternal morbidity and mortality after delivery. Active management of postpartum hemorrhage by an uterotonic drug decreases the rate of postpartum hemorrhage. The aim of this study is to evaluate the efficacy of rectal misoprostol for prevention of postpartum hemorrhage. This double blind randomized clinical trial was performed on full term pregnant women candidate for vaginal delivery, referred to Zahedan Imam Ali Hospital during 2008-2009. They were randomly divided into two groups of rectal misoprostol and oxytocin. The women in misoprostol group received 400 micro g rectal misoprostol after delivery and the women in oxytocin group received 3 IU oxytocin in 1 L ringer serum, intravenously. Rate of bleeding, need to any surgery interventions, rate of transfusion and changes in hemoglobin and hematocrite were compared between two groups. A total of 400 patients [200 cases in misoprostol group and 200 in oxytocin group] entered to the study. Rate of bleeding > 500 cc was significantly higher in oxytocin group than misoprostol group [33% vs. 19%] [p = 0.005]. Also, need to excessive oxytocin for management of postpartum hemorrhage was significantly lower in misoprostol group than oxytocin group [18% vs. 30%] [p = 0.003]. Decrease in hematocrite was significantly more observed in oxytocin group than misoprostol group [mean decrease of hematocrite was 1.3 +/- 1.6 in misoprostol group and 1.6 +/- 2.2 in oxytocin group]. Two groups were similar in terms of side-effects. Rectal misoprostol as an uterotonic drug can decrease postpartum hemorrhage and also can prevent from decrease of hemoglobin as compared to oxytocin

[ effect of tranexamic acid on pregnancy outcome and vaginal post-parturition hemodynamics]

Tranexamic acid, as an anti-fibrinolytic agent, has been shown to reduce bleeding, but its use has been limited in the scope of vaginal delivery. The purpose of this study was to examine the effect of tranexamic acid on pregnancy outcome and vaginal post-parturition hemodynamics. In a randomized, double-blind clinical trial, 200 primgravida pregnants were divided into the two groups [case and control]. The case group received IV tranexamic acid immediately post-parturition and the control group IV glucose 5%. Hemoglobin [Hb] on admission and 24 hours post-parturition were measured and Hb level drop more than 10% was considered as postpartum hemorrhage. The Hb status was evaluated through measuring blood pressure and heart rate. The pregnancy outcome measures [e.g. changes in Hb level, need for the additional uterotonic drugs, blood transfusion and surgery] were evaluated. There was a significant difference between the two groups in Hb level drop within the first 24 hours post-parturition. Moreover, no severe bleeding, blood transfusion and misoprostol administration were reported in the case group, but 4 cases in the control group. Tranexamic acid administration can effectively reduce post-partum bleeding and therefore prevent a further decrease in maternal Hb levels

Prevenção e manejo da hemorragia pós-parto / Prevention and management of postpartum haemorrhage

Introdução: As síndromes hemorrágicas estão entre as principais causas obstétricas diretas de mortes maternas. Segundo dados da Organização Mundial de Saúde estima-se uma morte a cada quatro minutos. A hemorragia pós-parto reflete diretamente a qualidade da assistência, sendo uma das causas potencialmente prevenível e tratável. O desenvolvimento de manejos clínicos para seu controle torna-se de extrema importância na redução da mortalidade materna. Objetivo: Definir a melhor estratégia para a prevenção e o tratamento da hemorragia pós-parto, enfatizando o manejo ativo no terceiro estágio do trabalho de parto. Métodos: Foi realizada uma revisão de literatura no banco de dados Medline/PubMed, LILACS/SciELO, Cochrane Library e no site do Royal College of Obstetricians and Gynaecologists em busca das melhores evidências clínicas disponíveis, considerando-se o grau de recomendação. Resultados: Verificou-se que o manejo ativo da terceira fase do trabalho de parto é de fundamental importância para a prevenção da hemorragia pós-parto. O uso de uterotônicos, sendo a ocitocina o fármaco de primeira linha para este fim, a tração controlada de cordão umbilical com massagem uterina são a base deste tratamento. O tratamento cirúrgico também pode ser necessário e deve ter uma indicação precisa e de acordo com a experiência do cirurgião. Conclusão: Uma boa assistência a gestantes durante o trabalho de parto, principalmente uma conduta ativa no terceiro estágio, interfere de forma positiva para a prevenção de hemorragias maternas graves, contribuindo para o controle e diminuição da mortalidade materna.(AU)

Introduction: The haemorrhagic syndromes are the main causes of direct obstetric maternal deaths. According to data from the World Health Organization estimated one death every four minutes. Postpartum haemorrhage directly reflects the quality of care, being a potentially preventable and treatable causes. The development of clinical managements to their control it becomes of extremely important for reduction maternal mortality. Objective: The aim of this work was to search in literature the most important strategy to prevent and the treat the postpartum haemorrhage, emphaesing the active management in the third stage of labour. Methods: A revision of literature in the Medline/ PubMed, LILACS/ SciELO, Cochrane Library and in the site of the Royal College of Obstetricians and Gynaecologists data base was carried through, in search of the best clinical evidences available, take into account also the degree of recommendation. Results: It was founded that the active management of third stage of labour is fundamental for prevention of postpartum hemorrhage. The oxytocin was first line drug for this effect, the control umbilical lace traction with uterine massage is the base of this treatment. The surgery can be necessary and must have a straight indication and the experience of surgeon has a lot of importance. Conclusion: A good care for pregnant women during the labour, mainly in the active third stage of labour interferes in a positive way to prevent severe mothers' haemorrhages, and contributes to the reduction of maternal mortality.(AU)

Hemorragia severa post-parto en la región centroamericana: manejo de la hemorragia severa post-parto por atonia uterina en los hospitales formadores de ginecólogos y obstetras en la región centroamericana de marzo 2011 a febrero de 2012 / Severe postpartum hemorrhage in Central America: management of severe postpartum hemorrhage by uterine atony in hospitals forming gynecologists and obstetricians in Central America from March 2011 to February 2012

Los avances en el manejo de enfermedades del embarazo y la reducción de la mortalidad materna han sido puntos clave de conferencias internacionales desde finales de los años ochenta y de la Cumbre del Milenio del año 2000. Las estadísticas nacionales de MM a lo largo del tiempo son cruciales para orientar la planificación de programas de salud sexual y reproductiva, y guiar las labores de promoción y la investigaciòn a nivel internacional...

[Comparing intravenous oxytocin Vs. rectal misoprostol for third-stage management after second-trimester medically induced abortion]

Induction of medical abortion during the second trimester of pregnancy is considered under certain medical conditions. Abortion in the second trimester of pregnancy could be accompanied by several side effects including hemorrhage and placenta retention. Several types of medications including oxytocin, ergots, and prostaglandins are used to control and optimize the third stage of labor and condition of delivery. The aim of this study was to compare the efficacy of intravenous oxytocin versus rectal misoprostol for the management of the third stage of labor during pregnancy termination. In this randomized clinical trial, 80 pregnant women between 14 to 24 weeks of gestational age were randomly assigned into two intervention groups. Twenty units of intravenous oxytocin was used as the standard regimen and it was compared with 400 microg of rectal misoprostol to manage the third stage of labor. In this study, the frequency of placenta retention was significantly [P=0.034] lower in the misoprostol group [n=3, 7.5%] compared with oxytocin group [n=10, 25%]. The average duration of placenta delivery was significantly lower in the misoprostol group [7.95 min Vs. 19.22 min, respectively; P=0.015]. Decreases in hemoglobin concentration was not significantly different between the two groups. Generally, management of the third stage of labor in second-trimester abortions could reach a better outcome, regarding lower risks of placenta retention and duration of delivery, if rectal misoprostol is administered instead of intravenous oxytocin

audit of primary postpartum hemorrhage

The purpose of this study is to determine the causes of PPH, its risk factors, and treatment measures adopted. This prospective study was carried out in. the Department of obstetrics and gynaecology, Peoples Medical Collage Hospital Nawabshah from January 2009 to December 2009. Treatment measures including medical, surgical and blood transfusion were evaluated. A total of 165 cases of primary PPH were managed in one year. Uterine atony was identified major cause 128 [77.5%], traumatic causes of genital tract were 37 [22.4%], socioeconomic status was poor in 110 [66%] and lower middle class in 41 [24%]. Most of the patients 86 [52.1%] were delivered by traditional birth attendant, lady health visitors 36 [21.8%] and qualified medical doctors 29 [17.5%]. Blood pressure was unrecordable in 43 [26.0%], systolic B.P was below 80 mm in 55 [33.3%], systolic B.P above 100 mm in 67 [40.6%], hemoglobin [Hb%] level were b/w 8-10 gm% in 89 [53.93%], and less than 8 gm% in 76 [46.06%]. Blood transfusion was done in all cases. Uterine massage was done in 45 [27.27%]. Minor surgical procedures were performed in 57 [34.5], manual removal of placenta in 8 [4.8%], compression suture were applied in 2 [1.2%], hysterectomy in 20 [12.12%], and repair of uterus in 5 [3%]. Out of 62 cases who developed complications, 35 [21.21%] developed anemia, acute renal failure in 10 [6.06%], and disseminated intravascular coagulation in 3 [1.81%], maternal deaths due to irreversible shock and renal failure were in 10 [6.06%]. Maternal mortality during year 2009 due to PPH was 10 [29.41%]. PPH is a preventable problem. Maternal mortality and morbidity resulting from it can be reduced by identifying the risk factors, early referral, proper assessment and treatment of the cause. Conservative procedures should be considered prior to undertaken hysterectomy, and hysterectomy should be performed as the last option

Prophylactic Hypogastric Artery Ballooning in a Patient with Complete Placenta Previa and Increta

Abnormal attachment of the placenta (Placenta accreta, increta, and percreta) is an uncommon but potentially lethal cause of maternal mortality from massive postpartum hemorrhage. A 33-yr-old woman, who had been diagnosed with a placenta previa, was referred at 30 weeks gestation. On ultrasound, a complete type of placenta previa and multiple intraplacental lacunae, suggestive of placenta accreta, were noted. For further evaluation of the placenta, pelvis MRI was performed and revealed findings suspicious of a placenta increta. An elective cesarean delivery and subsequent hysterectomy were planned for the patient at 38 weeks gestation. On the day of delivery, endovascular catheters for balloon occlusion were placed within the hypogastric arteries, prior to the cesarean section. In the operating room, immediately after the delivery of the baby, bilateral hypogastric arteries were occluded by inflation of the balloons in the catheters previously placed within. With the placenta retained within the uterus, a total hysterectomy was performed in the usual fashion. The occluding balloons were deflated after closure of the vaginal cuff with hemostasis. The patient had stable vital signs and normal laboratory findings during the recovery period; she was discharged six days after delivery without complications. The final pathology confirmed a placenta increta.

Hemorragia Pós-parto / Postpartum hemorrhage

A hemorragia pós-parto (HPP) constitui a complicação obstétrica com maior índice de mortalidade materna em todo o mundo. Até 90% desses óbitos podem ser evitados com cuidado médico adequado. Este trabalho objetiva a atualização da classificação e diagnóstico da HPP com o intuito de tornar o conhecimento adequado quanto às medidas preventivas e a instituição da terapêutica em tempo hábil e de forma eficaz.

The postpartum hemorrhage (PPH) is the obstetric complication with the largest maternal mortality rate all over the world. Motivated by the estimate that up to 90% of those deaths could be avoided by appropriate medical care, this work aims at supplying the professionals in charge of the attendance of the delivering women general knowledge on how to proceed before HPP situation, reducing the maternal morbimortality. It is a bibliographical revision accomplished by scientific articles obtained through searches in portals recognized in the academic-scientific group that approaches some of the definitions of PPH accepted currently, its classification and diagnosis. The knowledge of the risk factors makes possible to the assistance team to take preventive measures and to be prepared to institute the therapeutic measures, in case it is necessary, in skilled time and in an effective way. It is hoped that the correct intervention in the cases leads to a reduction of the maternal morbimortality due to that condition, something not just desirable, but feasible.