Especificidades técnicas no tamponamento uterino com balões e algumas dificuldades técnicas / Technical specificities in uterine tamponade with balloons and some technical difficulties

A mortalidade materna é inaceitavelmente alta. A hemorragia pós-parto encontra- se na primeira posição no mundo, tendo como principal causa específica a atonia uterina. Eventualmente, as medidas iniciais e a terapia farmacológica não são efetivas no controle do sangramento, impondo a necessidade de tratamentos invasivos, cirúrgicos ou não. Entre esses, o tamponamento uterino com balão requer recursos locais mínimos e não exige treinamento extensivo ou equipamento muito complexo. Entretanto, algumas dificuldades podem ocorrer durante a inserção, infusão ou manutenção do balão na cavidade uterina, com especificidades relacionadas à via de parto. Após o parto vaginal, a dificuldade mais prevalente é o prolapso vaginal do balão. Na cesárea, as principais dificuldades são a inserção e o posicionamento do balão na cavidade uterina, principalmente nas cesáreas eletivas. Este artigo revisa e ilustra as principais dificuldades e especificidades relacionadas ao tamponamento uterino com balões.

Maternal mortality is unacceptably high. Postpartum hemorrhage is ranked first in the world, with the main specific cause being uterine atony. Eventually, initial measures and pharmacological therapy are not effective in controlling bleeding, imposing the need for invasive treatments, surgical or not. Among these, uterine balloon tamponade requires minimal local resources and does not require extensive training or very complex equipment. However, some difficulties may occur during insertion, infusion, or maintenance of the balloon in the uterine cavity, with specificities related to the mode of delivery. After vaginal delivery, the most prevalent difficulty is vaginal balloon prolapse. In cesarean section, the main difficulty is the insertion and positioning of the balloon in the uterine cavity, especially in elective cesarean sections. This article reviews and illustrates the main difficulties and specificities related to uterine balloon tamponade.

Condições potencialmente ameaçadoras à vida no ciclo gravídico-puerperal / Condiciones potencialmente amenazantes para la vida en el ciclo gravídico puerperal / Potentially life-threatening conditions determinants in pregnancy-puerperal cycle

ABSTRACT Objetivo: Descrever as principais condições potencialmente ameaçadoras à vida de mulheres durante o ciclo gravídico e puerperal e variáveis relacionadas a esses agravos. Método: Estudo do tipo documental, descritivo e quantitativo, realizado com prontuários de gestantes, parturientes e puérperas internadas em hospital de média complexidade, que apresentaram Condições Potencialmente Ameaçadoras à Vida (CPAV). Foram excluídos os de acesso impossibilitado por estarem sob judice. A amostra foi temporal e a análise univariada. Resultados: Inclui-se 181 prontuários. A maioria das condições ocorreu em mulheres de 16 a 34 anos de idade (61,3%), união estável (60,8%), pardas (31,5%), sem renda ocupacional (29,2%), multíparas (28,87%), com complicações no primeiro trimestre gestacional (32,6%). Verificaram-se a realização de um número insuficiente de consultas (13,8%), dados referentes ao pré-natal ignorados (68%). As principais CPAV foram as síndromes hemorrágicas (28,2%), hipertensivas (25,4%) e infecção (13,3%). Como desfecho, foram observados prevalência de aborto não especificado (22,1%), morte perinatal por doença infecciosa e parasitária da mãe (2,2%). Conclusão: As principais CPAV foram as síndromes hemorrágicas, hipertensivas e infecções. Como desfecho, foram observados alta hospitalar, aborto, referenciamento à UTI, morte perinatal e morte materna.

RESUMEN Objetivo: describir las principales condiciones potencialmente amenazantes para la vida de las mujeres durante el ciclo gravídico y puerperal, además de las variables relacionadas con estos agravios. Método: estudio del tipo documental, descriptivo y cuantitativo, realizado con registros médicos de gestantes, parturientes y puérperas internadas en hospital de mediana complejidad, que presentaron Condiciones Potencialmente Amenazantes a la Vida (CPAV). Se excluyeron los de acceso imposibilitado por estar bajo juicio. La muestra fue temporal y el análisis univariado. Resultados: se incluyen 181 registros médicos. La mayoría de las condiciones ocurrió en mujeres de 16 a 34 años de edad (61,3%), unión estable (60,8%), pardas (31,5%), sin ingreso ocupacional (29,2%), multíparas (28,87%), con complicaciones en el primer trimestre gestacional (32,6%). Se constató un número insuficiente de consultas (13,8 %), datos relativos al prenatal ignorados (68 %). Las principales CPAV fueron los trastornos hemorrágicos (28,2%), hipertensivos (25,4%) e infecciosos (13,3%). Como resultado, se observaron: prevalencia de aborto no especificado (22,1%), muerte perinatal por enfermedad infecciosa y parasitaria de la madre (2,2%). Conclusión: las principales CPAV fueron los trastornos hemorrágicos, hipertensivos e infecciones. Como resultado, se observó alta hospitalaria, aborto, referencia a la UCI, muerte perinatal y muerte materna.

ABSTRACT Objective: To describe the main conditions potentially threatening the lives of women during the pregnancy and puerperal cycle and variables related to these diseases. Method: Documentary, descriptive and quantitative study, conducted with medical records of pregnant women, women giving birth and puerperal women hospitalized in a hospital of medium complexity, who presented Potentially Life Threatening Conditions (PLTC). Those with access unable to be sob judice were excluded. The sample was temporal and the analysis was univariate. Results: This includes 181 medical records. Most conditions occurred in women aged 16 to 34 years (61.3%), stable union (60.8%), brown (31.5%), without occupational income (29.2%), multiparous (28.87%), with complications in the first gestational trimester (32.6%). There was an insufficient number of consultations (13.8%), data regarding prenatal care ignored (68%). The main CPAV were hemorrhagic syndromes (28.2%), hypertensive (25.4%) and infection (13.3%). As an outcome, we observed a prevalence of unspecified miscarriage (22.1%), perinatal death from infectious and parasitic disease of the mother (2.2%). Conclusion: The main CPAV were hemorrhagic, hypertensive and infections syndromes. As an outcome, hospital discharge, miscarriage, ICU referral, perinatal death and maternal death were observed.

Ligaduras vasculares no tratamento cirúrgico da hemorragia pós-parto / Vascular ligations in the surgical treatment of postpartum hemorrhage

Hemorragia pós-parto é a maior causa de histerectomia periparto. Esta revisão descreve e ilustra as técnicas de ligaduras vasculares utilizadas no tratamento cirúrgico da hemorragia pós-parto. São apresentados os detalhes técnicos da ligadura das artérias uterinas, da ligadura das conexões útero-ovarianas, da ligadura tríplice de Tsirulnikov, das ligaduras sequenciais de AbdRabbo e de Morel e da ligadura das artérias ilíacas internas. Também são revistos os fatores que dificultam o sucesso dessas técnicas. As ligaduras vasculares são estratégias eficientes para o controle hemorrágico durante cesarianas e devem integrar o conjunto de técnicas que preservam o útero no tratamento da hemorragia pós-parto.(AU)

Postpartum hemorrhage is the major cause of peripartum hysterectomy. This review describes and illustrates the techniques of vascular ligations used in the surgical treatment of postpartum hemorrhage. The technical details of the uterine arteries ligation, of the ligation of the utero-ovarian connections, of the Tsirulnikov triple ligation, of the AbdRabbo and Morel sequential ligations and of the internal iliac arteries ligation are presented. The factors that hinder the success of these techniques also are reviewed. Vascular ligations are efficient strategies for hemorrhagic control during cesarean sections and should integrate the set of techniques that preserve the uterus in the treatment of postpartum hemorrhage.(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)

Embolização de artéria uterina para hemorragia pós-parto: uma revisão de literatura / Uterine artery embolization for postpartum hemorrhage: a review of the literature

A hemorragia pós-parto é uma emergência obstétrica que acomete grande parcela de puérperas e leva à extensa quantidade de óbitos por ano. Entre as suas principais causas estão a atonia uterina e o acretismo placentário. Atualmente, as técnicas mais utilizadas para a resolução do sangramento se apresentam por muitas vezes ineficazes e/ou levam à infertilidade feminina. O presente estudo trata-se de uma revisão da literatura em modelo PRISMA, no qual foram selecionados 35 artigos dos últimos 12 anos, nas bases de dados do UpToDate, SciELO, PubMed, Plos ONE, Lilacs e Datasus, no qual serão apresentadas evidências de que, nas mãos de um profissional treinado, a embolização de artéria uterina se mostra como uma excelente alternativa no tratamento da hemorragia obstétrica, apresentando-se como terapêutica minimamente invasiva, com altas taxas de sucesso, baixo número de complicações e que preserva a função reprodutiva da mulher.(AU)

The post-partum hemorrhage is an obstetric emergency that affects a big percentage of women who have recently given birth and leads to a big amount of deaths per year. Its main causes are uterine atony and placentary accretism. Currently the main techniques for its resolution are the utilization of uterotonics and aggressive surgical approaches to the pelvic structure, which are commonly inefficient or bring long term injuries to the fertility. This study is a literature review structure on PRISMA model, where was selected 35 articles of the last 12 years, in these databases: UpToDate, SciELO, PubMed, Plos ONE, Lilacs and Datasus, in which will be presented evidences of, in expert professional hands, uterine artery embolization being an excellent alternative in the treatment of obstetric hemorrhage, presenting itself a minimally invasive technique, with high rates of success, low numbers of complications and the capacity of preserving the patient reproductive system.(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.

Maternal complications and cesarean section without indication: systematic review and meta-analysis / Complicações maternas e cesárea sem indicação: revisão sistemática e meta-análise

ABSTRACT OBJECTIVE The objective of this study was to determine the risks of severe acute maternal complications associated with cesarean section without medical indication. METHODS A systematic review was carried out with meta-analysis. The literature search was performed systematically, in multiple stages, in the PubMed, Lilacs, and Web of Science databases using the following descriptors: (postpartum period) and (cesarean section or natural childbirth) and ((morbidity or mortality) or (postpartum hemorrhage) or (puerperal infection) or (surgical infection) or (puerperal disorders)). The protocol of the study was registered at PROSPERO as CRD42016032933. A total of 1,328 articles were found; after selection, eight publications that met the study objective and inclusion criteria were selected, with information on 1,051,543 individuals. RESULTS The results obtained in the meta-analyses indicate that women with cesarean section have a higher chance of maternal death (OR = 3.10, 95%CI 1.92-5.00) and postpartum infection (OR = 2.83, 95%CI, 1.585.06), but they have a lower chance of hemorrhage (OR = 0.52, 95%CI 0.48-0.57). For the blood transfusion outcome, the group effect was not associated with the type of delivery (95%CI 0.88-2.81). CONCLUSIONS The quality of evidence was considered low for hemorrhage and blood transfusion and moderate for postpartum infection and maternal death. Thus, cesarean sections should be performed with caution and safety, especially when its benefits outweigh the risks of a surgical procedure.

RESUMO OBJETIVO Determinar os riscos de complicações maternas agudas graves associadas ao parto cesárea sem indicação médica. MÉTODOS Foi conduzida uma revisão sistemática com meta-análise. A busca na literatura ocorreu de forma sistemática, em múltiplas etapas, nas bases de dados PubMed, Lilacs e Web of Science, utilizando os descritores: (postpartum period) and (cesarean section or natural childbirth) and ((morbidity or mortality) or (postpartum hemorrhage) or (puerperal infection) or (surgical infection) or (puerperal disorders)). O protocolo de estudo foi registrado na PROSPERO sob o número CRD42016032933. Foram encontrados 1.328 artigos, permanecendo, após seleção, oito publicações que atendiam ao objetivo do estudo e critérios de inclusão, com informações de 1.051.543 indivíduos. RESULTADOS Os resultados obtidos nas meta-análises indicam que mulheres de parto cesárea tem maior chance de morte materna (OR = 3,10; IC95% 1,92-5,00) e infecção pós-parto (OR = 2,83; IC95% 1,58-5,06), mas possuem menor chance de hemorragia (OR = 0,52; IC95% 0,48-0,57). Para o desfecho transfusão de sangue, o efeito agrupado não foi associado à via de parto (IC95% 0,88-2,81). CONCLUSÕES A qualidade da evidência foi considerada baixa para os desfechos hemorragia e transfusão de sangue e moderada para infecção pós-parto e morte materna. Assim, as cesáreas devem ser realizadas com prudência e segurança, principalmente quando seus benefícios superam os riscos de um procedimento cirúrgico.

Morbilidad Materna Extremadamente Grave en el Hospital Ginecobstétrico de Guanabacoa. La Habana, Cuba (2008-2012) / Extremely severe maternal morbidity at the Obstetrics and Gynecology Hospital in Guanabacoa, Havana, Cuba (2008-2012)

Introducción: la morbilidad materna extremadamente grave es un indicador íntimamente asociado a la muerte materna y refleja la calidad de los cuidados obstétricos. Objetivo: analizar la morbilidad materna extrema. Métodos: se realizó un estudio descriptivo de corte transversal y retrospectivo en el Hospital Docente Ginecoobstétrico de Guanabacoa desde enero de 2008 hasta diciembre de 2012. La muestra la integraron 65 pacientes. Resultados: se encontró como riesgos relevantes las edades extremas de la vida (75,4 por ciento). Prevalecieron la hipertensión arterial (49,2 por ciento), la diabetes mellitus (32,3 por ciento) y el asma bronquial (24,6 por cientot). El 61 por ciento de las complicaciones ocurrieron en el puerperio con la atonía uterina (64 por ciento) como principal causa de hemorragia. Conclusión: la morbilidad materna extrema es una complicación que puede presentarse en el embarazo, parto y puerperio que pone en peligro la salud reproductiva y la vida de la madre(AU)

Introduction: extremely severe maternal morbidity is an indicator closely related to maternal death which reflects the quality of obstetric care. Objective: analyze extreme maternal morbidity Methods: a descriptive cross-sectional retrospective study was conducted at the Obstetrics and Gynecology University Hospital in Guanabacoa from January 2008 to December 2012. The study sample was composed of 65 patients. Results: extreme age was found to be a relevant risk factor (75,4 percent). There was a predominance of arterial hypertension (49,2 percent), diabetes mellitus (32,3 percent) and bronchial asthma (24,6 percent). On the other hand, 61 percent of the complications occurred during puerperium, with uterine atony (64 percent) as the main cause of hemorrhage. Conclusion: extreme maternal morbidity is a complication of the pregnancy, delivery or puerperium which affects reproductive health and may threaten the life of women(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)

Caracterización de la morbilidad materna extremadamente grave en la provincia de Camagüey (2009) / Characterization of extremely severe maternal morbidity in Camaguey province (2009)

Introducción: a través del control y análisis de la morbilidad materna extremadamente grave se adopta una forma acertada y precisa para evaluar el nivel de salud. Se considera un indicador muy asociado a la muerte materna: constituye una alternativa válida como indicador de la calidad de los cuidados maternos. Objetivo: caracterizar la morbilidad materna extremadamente grave en Camagüey. Métodos: se realizó un estudio descriptivo transversal, desde enero hasta diciembre del año 2009, con un universo de 72 pacientes que fueron diagnosticadas como morbilidad materna extremadamente grave en los hospitales maternos de Camagüey y la Unidad de Cuidados Intensivos del Hospital Provincial, según criterios de clasificación. La información se obtuvo mediante la historia clínica de cada gestante durante su atención prenatal y hospitalaria. Resultados: el grupo etario que prevaleció fue el de más de 35 años con 26,3 por ciento. Se identificaron 72 pacientes (93,0 por ciento); como morbilidad materna extremadamente grave, de ellas, el 65,3 por ciento llegaron al parto 34,7 por ciento no lo lograron por diferentes causas (embarazos ectópicos, abortos diferidos y angina de Ludwing). Se identificaron como riesgos que se destacan la malnutrición (38,8 por ciento), la edad extrema (35,1 por ciento), la hipertensión arterial(31,4 por ciento), la anemia (25,9 por ciento), la infección vaginal (22,2 por ciento) y la preeclampsia (16,6 por ciento). Conclusiones: el diagnóstico de esta entidad se realizó fundamentalmente durante el parto, y la hemorragia obstétrica es la principal causa de morbilidad(AU)

Introduction: through the control and analysis of extremely severe maternal morbidity, it is possible to evaluate the health status in an accurate and precise way. This indicator, closely associated to maternal death, is a valid alternative as a maternal care quality indicator. Objective: to characterize extremely severe maternal morbidity in Camaguey province. Methods: a cross-sectional descriptive study was conducted from January through December 2009 in a universe of 72 patients, who were diagnosed as extremely severe maternal morbidity in the maternal hospitals of Camaguey and in the intensive care unit of the provincial hospital, according to the classification criteria. Data were collected from the medical history of each pregnant woman during her prenatal and hospital care. Results: the prevailing age group was over 35 years accounting for 26.3 percent. Seventy two patients were classified as extremely severe maternal morbidity cases; 65.3 percent of them did give birth but 34.7 percent did not because of several causes (ectopic pregnancies, delayed abortions and Ludwig angina). The identified risks were malnutrition (38.8 percent), extreme age (35.1 percent), blood hypertension (31.4 percent), anemia (25.9 percent), vaginal infection (22.2 percent) and preeclampsia (16.6 percent). Conclusions: the condition was mostly diagnosed during delivery, being the obstetric hemorrhage the main cause of morbidity(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...

Applying the new concept of maternal near-miss in an intensive care unit

OBJECTIVES: The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria. METHODS: In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate's correction or Fisher's exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals. RESULTS: Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially lifethreatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths). CONCLUSIONS: Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.

Algunos factores asociados a la morbilidad obstétrica extremadamente grave / Some features associated with the critically severe obstetric mortality

Se realizó un estudio descriptivo longitudinal y prospectivo en el Hospital Universitario Ginecoobstétrico "Mariana Grajales" de Santa Clara de enero de 2007 a diciembre de 2008, con el objetivo de describir los principales factores relacionados con la morbilidad obstétrica grave. Para la recogida de la información se confeccionó un formulario con las variables de interés a través de la revisión de historias clínicas individuales, de entrevistas a las pacientes y de datos ofrecidos por el departamento de estadísticas del hospital. Se constató que en el periodo del estudio 93 pacientes presentaron morbilidad obstétrica grave. Las principales causas estuvieron relacionadas con la hemorragia con 39,8 % y la preeclampsia 37,6%; la sepsis solo apareció relacionada en un 4,3 %; el parto distócico por cesárea fue un evento obstétrico relacionado directamente con la morbilidad grave y la realización de histerectomías obstétricas. Existe una relación directa entre los resultados maternos y los resultados perinatales en este grupo de pacientes. Se utilizaron los servicios de Terapia intensiva en los casos de extrema gravedad y ocurrieron 4 muertes maternas en estos dos años, se dejaron de vivir un total de 169 años por causas asociadas a la maternidad, y como promedio de años de vida potencialmente perdidos, cada mujer dejó de vivir 42,25 años por dichas causas

A prospective, longitudinal and descriptive study was conducted in "Mariana Grajales" Gynecology-Obstetrics University Hospital from January, 2007 to December, 2008 to describe the major factors related to asevere4 obstetric mortality. For information collection a form was designed including the interesting variables by individual medical records review, by interviews with patients and of data offered by hospital statistic department. We verified that during the study period 93 patients had a severe obstetric mortality. Major causes were related to hemorrhage (39,8 percent) and pre-eclampsia (37,6 percent); sepsis only was related to these causes in the 4,3 percent; dystocia cesarean section labor was a obstetric event related directly to the severe mortality and carrying out of obstetric hysterectomies. There is a direct link among maternal findings and the perinatal ones in this group of patients. Intensive Care Unit services were used in cases critically severe with 4 maternal deaths during these two years with a total of 169 years lost by causes associated with motherhood, and as average of potentially lost life years, each woman lost 42,45 years of life due such causes

Maternal morta1ity 2007-2008; [confidential inquiries of Ghulam Mohammad Mahar medical college hospital, Sukkur]

To analyse the maternal mortality with its causes and possible contributing risk factors at Ghulam Mohammad Mahar Medical College Hospital, Sukkur. This study was carried out at Gynae / Obs Unit-1 of Ghulam Mohammad Mahar Medical College Hospital, Sukkur from Jan-2007 to Dec-2008. Descriptive case series study. This study was conducted by analysing the death records of all maternal deaths who died over a period of two [02] years from Jan 2007 to Dec 2008. The demographic record included age, parity, booking status and education. The cause of death and possible contributing factors were evaluated. 48 mothers died during this period making Maternal Mortality Ratio [MMR] of 1578/100,000 live births. Direct causes contributed to 79% [38] of maternal deaths while 21% [10] were due to indirect causes. The major causes of deaths were eclampsia 27% [13], haemorrhage 33% [11], Sepsis 21% [10], Obstructed labour 8% [4]. Among indirect causes, hepatic encethalopathy, anemia and renal failure were observed. Eclampsia, haemorrhage and Sepsis are still the major killers. Factors which need urgent improvement include education, antenatal booking, early diagnosis and referrals to tertiary care centers

Management of obstetric hemorrhage

Major obstetric hemorrhage is an extremely challenging obstetric emergency associated with significant morbidity and mortality. Pharmacological treatment of uterine atony has not altered much in recent years apart from the increasing use of misoprostol, although controversy surrounds its advantages over other uterotonics. Placenta accreta is becoming more common, a sequel to the rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine compression sutures, intrauterine tamponade balloons and cell salvage have been introduced in the last decade

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