Traumatic injuries to the pregnant patient: a critical literature review.

INTRODUCTION: Trauma during pregnancy is the leading non-obstetrical cause of maternal death and a significant public health burden. This study reviews the most common causes of trauma during pregnancy, morbidity, and mortality, and the impact upon perinatal outcomes associated with trauma, providing a management approach to pregnant trauma patients. MATERIALS AND METHODS: A systematic review of the current literature from January 2006 to July 2016 was performed. RESULTS: Fifty-one articles were identified, including a total of 95,949 patients. Motor vehicle crash was the most frequent cause of blunt trauma, followed by falls, assault both domestic and interpersonal violence, and penetrating injuries (gunshot and stab wounds). CONCLUSIONS: Trauma in pregnant women is associated with high rates of adverse maternal and neonatal outcomes. Knowledge of the mechanism of injury is important to identify the potential injuries and the complexity of the management of these patients. As in all traumatic events, prevention is of paramount importance.

Skin infection caused by Scedosporium apiospermum in immunocompromised patients. Report of two cases.

Scedosporium apiospermum is a filamentous fungus that can cause cutaneous or extracutaneous disease. A large number of cases have been published over the last decades, mainly in patients immunocompromised as a result of their disease or treatment. These kinds of infections can progress rapidly and become disseminated, leading to very serious or even fatal complications. We report two new cases of skin infection by Scedosporium apiospermum from our hospital.

[Differences in the degree of control of arterial hypertension according to the measurement procedure of blood pressure in patients ≥ 65 years. FAPRES study]. / Diferencias en el grado de control de la hipertensión arterial según procedimiento de medida de la presión arterial en pacientes de edad ≥ 65 años. Estudio FAPRES.

BACKGROUND AND OBJECTIVES: Control of arterial blood pressure (BP) in hypertensive patients differs based on the evaluation procedure. This fact can be enhanced in subjects over 65 years of age. We have studied the degree of BP control with determinations in the office or ambulatory blood pressure monitoring (ABPM). METHODS: A multicenter, cross-sectional study was conducted in primary care (PC) and hypertension units in the Valencian Community. The first three hypertensive patients ≥ 65 years who attended the consultation on the first day of visits of the week of each investigator were included in the study. Cardiovascular risk factors, target organ damage and associated cardiovascular disease were recorded. Good clinical control values were defined as < 140/90 in the office and < 130/80 by ABPM for 24-hour according to 2007 ESH/ESC guidelines. RESULTS: A total of 1,028 hypertensive patients were included, 52.7% of whom were women, with a mean age of 72.6 years. Mean clinical BP was 146.7/81.1 mmHg and 24-hour ABPM 128.5/70.8 mmHg. Ninety-two percent of the patients were treated with antihypertensive drugs (35.6% monotherapy and 56.4% with combinations of two or more drugs). Good clinical control was found in 35.3% of cases (CI 95%: 32.4-38.2) and 50.9% (CI 95%: 47.8-54.0) (P < .001) had good control of 24-hour BP in ABPM. Male gender, personal background of heart disease and stroke were associated with good control of hypertension (P < .01) in 24-hour ABPM. CONCLUSIONS: In hypertensive patients over 65 years, and compared to the clinical determination of BP, the evaluation of ABMP showed a better proportion of controlled subjects. These findings support a wider use of ABPM to evaluate the control of BP in this population.

Diferencias en el grado de control de la hipertensión arterial según procedimiento de medida de la presión arterial en pacientes de edad >= 65 años. Estudio FAPRES / Differences in the degree of control of arterial hypertension according to the measurement procedure of blood pressure in patients >= 65 years. FAPRES study

Antecedentes y objetivos. El control de la presión arterial (PA) en pacientes hipertensos difiere en función del procedimiento de valoración. Este hecho puede estar acentuado en los mayores de 65 años. Hemos examinado el grado de control de la PA con determinaciones en consulta y monitorización ambulatoria de la PA (MAPA). Metodología. Estudio transversal multicéntrico realizado en Atención Primaria y unidades de HTA de la Comunidad Valenciana. Se incluyeron los tres primeros pacientes hipertensos ≥ 65 años que acudieron a consulta el primer día de visita de la semana de cada investigador. Se registraron factores de riesgo cardiovascular, lesión de órgano diana y enfermedad cardiovascular. Se definió buen control clínico. Valores < 140/90 mmHg y buen control ambulatorio valores por MAPA en 24 horas < 130/80 mmHg. Resultados. Se incluyó a 1.028 pacientes, edad media 72,8 años (52,7% de mujeres). La PA clínica media fue de 146,7/81,1 mmHg y con MAPA de 24 horas 128,5/70,8 mmHg. El 92% de los pacientes estaba tratado con antihipertensivos (35,6% monoterapia y 56,4% con combinaciones de dos o más fármacos). El 35,3% (IC95%,32,4-38,2) presentó buen control clínico y un 50,9% (IC95%: 47,8-54,0). Buen control con MAPA (p < 0,001). El género masculino y los antecedentes personales de cardiopatía e ictus fueron los factores significativamente asociados al buen control de la PA (p < 0,01) con MAPA. Conclusiones. En los pacientes hipertensos mayores de 65 años y en comparación con las determinaciones clínicas de PA, la valoración con MAPA muestra una mayor proporción de sujetos controlados. Estos hallazgos sustentan un uso más amplio de la MAPA para valorar el control de la PA en esta población(AU)

Background and objectives. Control of arterial blood pressure (BP) in hypertensive patients differs based on the evaluation procedure. This fact can be enhanced in subjects over 65 years of age. We have studied the degree of BP control with determinations in the office or ambulatory blood pressure monitoring (ABPM). Methods. A multicenter, cross-sectional study was conducted in primary care (PC) and hypertension units in the Valencian Community. The first three hypertensive patients ≥ 65 years who attended the consultation on the first day of visits of the week of each investigator were included in the study. Cardiovascular risk factors, target organ damage and associated cardiovascular disease were recorded. Good clinical control values were defined as < 140/90 in the office and < 130/80 by ABPM for 24-hour according to 2007 ESH/ESC guidelines. Results. A total of 1,028 hypertensive patients were included, 52.7% of whom were women, with a mean age of 72.6 years. Mean clinical BP was 146.7/81.1 mmHg and 24-hour ABPM 128.5/70.8 mmHg. Ninety-two percent of the patients were treated with antihypertensive drugs (35.6% monotherapy and 56.4% with combinations of two or more drugs). Good clinical control was found in 35.3% of cases (CI 95%: 32.4-38.2) and 50.9% (CI 95%: 47.8-54.0) (P < .001) had good control of 24-hour BP in ABPM. Male gender, personal background of heart disease and stroke were associated with good control of hypertension (P < .01) in 24-hour ABPM. Conclusions. In hypertensive patients over 65 years, and compared to the clinical determination of BP, the evaluation of ABMP showed a better proportion of controlled subjects. These findings support a wider use of ABPM to evaluate the control of BP in this population(AU)

Clustering of target organ damage increases mortality after acute coronary syndromes in patients with arterial hypertension.

The impact of target organ damage (TOD) clustering in hypertensive patients with established cardiovascular disease has not been clearly defined. Multicentre, observational and prospective study of 1054 consecutive patients with acute coronary syndromes (ACSs). The objective was describing the impact of TOD on first-year mortality. Ankle-brachial index (ABI), left ventricular hypertrophy and renal dysfunction were assessed during hospital stay. Hypertensive patients accounted for 80% of the cohort and had slightly higher mean age, higher prevalence of risk factors, previous cardiovascular disease and TOD. During follow-up, mean time 387.9 (7.2) days and median 382 (364.0-430.0) days, mortality rate tended to be higher in hypertensive patients (6.1 versus 3.5%; P=0.16). Cox regression survival analysis identified pathological ABI as the only TOD independently associated with mortality. When assessed globally, the presence of at least one TOD predicted mortality only in patients with hypertension and differences in mortality rate appeared very early in the follow-up. A linear increase in mortality rate was observed with the clustering of TOD: 2.0%, if no TOD was present, 7.6% in one TOD, 11.1% in two TODs and 20.0%, if three TODs were present. An increased risk in the combined end point of ischaemic events was observed in hypertensive patients without TOD (odds ratio (OR): 3.18; 95% confidence interval (CI): 1.31-7.70; P=0.01) and was still higher in patients with hypertension and TOD (OR: 4.61; 95% CI: 1.90-11.80; P<0.01). TOD predicts mortality and ischaemic events of hypertensive patients after ACS.

Laboratory alteration of gypsiferous materials below a landfill.

Some urban solid waste landfill sites in Spain are located on geological substrates of gypsiferous lithology. Although this type of substrate is assumed to be of low permeability, it can develop secondary pores by dissolution and, under favourable environmental conditions, form a karstic system that may pose serious geotechnical problems in the medium and long term. The purpose of this work was to study alterations caused by selective tests in various sections of a gypsum lithological column obtained from the Colmenar de Oreja landfill site (Spain). The tests were used to assess the influence of individual environmental factors and involved the addition of milli-RO water, solutions containing a 1%, 5% or 10% concentration of landfill leachate, and 2, 5, 10 and 15mgl(-1) solutions of NaCl in successive immersion-drying cycles at -15, 20 or 60 degrees C. Differences in alterability between the six studied segments of the lithological column were found to be due to differences in lutite content, specific crystal habit and type of cement. Segments with specular gypsum were the strongest in the tests, while the segment with the highest amount of detrital materials was the most responsive to temperature and moisture changes. The treatments that produce greater alterations are those that contain only milli-RO water.

¿Es realmente necesaria y útil la oxigenoterapia suplementaria en lacesárea programada bajo anestesia subaracnoidea? / Is oxygen therapy truly useful and necessary during elective cesarean section under spinal anesthesia?

OBJETIVOS: Analizar el bienestar maternofetal enfunción de la administración o no de oxígeno suplementario.MATERIAL Y MÉTODOS: Estudio prospectivo y aleatorizadode gestantes a término con embarazo controlado,ASA I, sin patologías maternofetales, programadas paracesárea bajo anestesia subaracnoidea, divididas en 2grupos cuya única diferencia metodológica fue la respiraciónde aire ambiente (grupo AA) o la administraciónde oxígeno con mascarilla facial (FiO2 40%) (grupo MF).Valoramos el bienestar neonatal postparto inmediatocon la gasometría del cordón umbilical y el test deApgar.RESULTADOS: Se incluyeron 130 gestantes. Ambos gruposresultaron homogéneos, sin diferencias demográficas,hemodinámicas, en el tiempo incisión uterinaextracciónfetal, peso de los recién nacidos, presencia deanomalías del cordón umbilical, tipo de reanimación delrecién nacido o Apgar al 1º y 5º min. La saturación periféricade oxígeno materna fue mayor (p < 0,001) a partirde los 10 min en el grupo MF. Observamos diferenciasestadísticamente significativas en la sangre arterialumbilical en la pCO2 (51,14 vs 54,33 mm Hg) (p=0,016),bicarbonato (22,19 vs 23,23 mEq.L-1) (p=0,012) y lactato(1,85 vs 1,64 mmol.L-1) (p=0,038) y en la pO2 venosa(25,53 vs 28,13 mm Hg) (p=0,033) en los grupos AA vsMF respectivamente.CONCLUSIONES: En la cesárea bajo anestesia subaracnoideade pacientes sanas, la administración de oxígenosuplementario no se acompaña de diferencias en el estadode bienestar final neonatal (AU)

OBJECTIVE: To analyze maternal and fetal well-beingwith and without the application of oxygen therapy.MATERIAL AND METHODS: Randomized trial of full-termparturients who had received prenatal care duringpregnancy. The women were healthy and classified as ASA1.They were scheduled for delivery by cesarean sectionunder spinal anesthesia and randomized to 2 groups tobreathe room air or air providing an inspired oxygenfraction of 40% through a face mask. We assessed thewell-being of the neonate immediately after birth with theApgar test and by measuring umbilical cord blood gases.RESULTS: One hundred thirty women were enrolled.Both groups were similar, with no differences indemographic or hemodynamic variables, time fromuterine incision to fetal extraction, neonatal birth weight,presence of umbilical cord abnormalities, type ofresuscitation required by the neonate, or Apgar score inthe first or fifth minute. Oxygen saturation in maternalblood by pulse oximetry was higher after 10 minutes inthe group of women who received supplemental oxygenthrough face masks. We also observed significantdifferences in umbilical cord arterial blood between theroom air and supplemental oxygen groups, respectively,as follows: PaCO2, 51.14 mm Hg vs 54.33 mm Hg(P=.016); bicarbonate, 22.19 mEq·L-1 vs 23.23 mEq·L-1(P=.012); lactate, 1.85 mmol·L-1 vs 1.64 mmol·L-1 (P=.038).The PO2 in venous blood also differed significantly: 25.53mm Hg vs 28.13 mm Hg, respectively (P=0.33).CONCLUSIONS: Breathing supplemental oxygen or notduring elective cesarean delivery of healthy parturientsunder spinal anesthesia does not have a significant effecton neonatal well-being (AU)

[Underestimation of renal risk in cardiology clinics. RICAR study]. / Infravaloración del riesgo renal en consultas de cardiología. Estudio RICAR.

AIMS: The aim of this study was to assess the rate of patients attended in cardiology outpatient clinics in whom microalbumine or glomerular filtration rate had been determined, at least once, in the previous 12 months. METHODS: It was an observational, transversal, multicentric study. 1224 patients were included from 124 centers in Spain. Epidemiological, anthropometric, analytic and electrocardiographic data were recruited. Glomerular filtration rate was calculated thereafter by means of the simplified equation of the MDRD. Results. Microalbumine was determined in 34% of the patients, of those 49% had positive microalbumine. Microalbumine rates were higher in patients with diabetes, heart failure, atrial fibrillation, peripheral artery disease or serum creatinine levels > 1.3 mg/dl. However, only young patients, diabetics and those with left ventricular hypertrophy had this exam performed more often. The glomerular filtration rate was determined in 11% of the patients. 30% of the population had moderate or severe renal dysfunction (filtration rate < 60 ml/min) and only 21% of the population hat normal renal function (filtration rate > 90 ml/min). Glomerular filtration rate was assessed more frequently in patients with serum creatinine > 1.3 mg/dl and those with history of heart failure. CONCLUSIONS: The prevalence of renal dysfunction in hypertensive patients attended in Cardiology clinics is high. However, the methods recommended for early detection of renal dysfunction are scarcely used by cardiologists. These figures do not improve significantly in high risk patients.

[Continuous subarachnoid analgesia and anesthesia for labor and cesarean section in a patient who had previously undergone surgery for ependymoma]. / Analgoanestesia subaracnoidea continua para trabajo de parto y cesárea en paciente intervenida de ependimoma.

We report the case of a 38-year-old primipara who had undergone surgery 2 years earlier for an intradural ependymoma at L2-L3 and who was currently asymptomatic. A combined epidural-subarachnoid block was performed for analgesia during labor but this technique was only effective for the first 2 hours. When analgesia via epidural cannula was no longer adequate, it was decided to perform a continuous subarachnoid block. Later, the fetus's head was seen to be too large to fit through the pelvis; for cesarean section, the mother was administered fractionated doses of local anesthetic via the subarachnoid cannula until analgesia reached T4. The patient did not develop postdural puncture headache. Continuous subarachnoid anesthesia may be considered the technique of choice where the patient has a history of spinal surgery.

Analgoanestesia subaracnoidea continua para trabajo de partoy cesárea en paciente intervenida de ependimoma / Continuous subarachnoid analgesia and anesthesia for labor and cesarean section in a patient who had previously undergone surgery for ependymoma

Presentamos el caso de una primigesta de 38 años deedad, entre cuyos antecedentes personales destacabahaber sido intervenida dos años antes de ependimomaintradural a nivel de L2-L3 y en la actualidad se encontrabaasintomática.Se realizó un bloqueo combinado epidural –subaracnoideopara analgesia de parto, que sólo fue eficazdurante las dos primeras horas ya que transcurrido estetiempo, la analgesia por catéter epidural no resultó adecuada,por lo que se optó por realizar un bloqueo subaracnoideocontinuo. Posteriormente fue necesario realizaruna cesárea por una desproporción pélvico– cefálicaadministrándose dosis fraccionadas de anestésico localpor el catéter subaracnoideo hasta alcanzar un nivelanalgésico en las metámeras correspondientes a T4. Lapaciente no refirió cefalea postpunción dural. La anestesiasubaracnoidea continua para cesárea puede ser consideradauna técnica de elección cuando existe el antecedentede una cirugía de raquis (AU)

We report the case of a 38-year-old primipara whohad undergone surgery 2 years earlier for an intraduralependymoma at L2-L3 and who was currentlyasymptomatic. A combined epidural-subarachnoid blockwas performed for analgesia during labor but thistechnique was only effective for the first 2 hours. Whenanalgesia via epidural cannula was no longer adequate,it was decided to perform a continuous subarachnoidblock. Later, the fetus’s head was seen to be too large tofit through the pelvis; for cesarean section, the motherwas administered fractionated doses of local anestheticvia the subarachnoid cannula until analgesia reachedT4. The patient did not develop postdural punctureheadache. Continuous subarachnoid anesthesia may beconsidered the technique of choice where the patient hasa history of spinal surgery (AU)

[Remifentanil bolus for cesarean section in high-risk patients: study of 12 cases]. / Uso del remifentanilo en bolus en la cesárea de la paciente de alto riesgo: estudio sobre 12 casos.

OBJECTIVES: To evaluate the utility and safety of remifentanil for hemodynamic control during cesarean section in high-risk patients ineligible for spinal anesthesia. METHODS: One minute before induction we injected a bolus of 1 microg x kg(-1) of remifentanil, followed by propofol (2.5 mg x kg(-1)), succinylcholine (1 mg x kg(-1)), cisatracurium, sevoflurane in oxygen and nitrous oxide, and fentanyl (5 microg x kg(-1)) after clamping the umbilical cord. We recorded maternal hemodynamic variables, pulse oximetry, capnography, bispectral index, and presence of muscular rigidity. In the neonate we assessed fetal wellbeing, weight, and requirement for naloxone. Hemodynamic stability was defined as no more than 15% variation in arterial pressure with respect to baseline. RESULTS: Twelve patients undergoing surgery because of placenta abruptio, subarachnoid hemorrhage, HELLP syndrome, or preeclampsia were enrolled. Hemodynamic variables were consistently stable during surgery in all patients. No cases of neonatal rigidity were noted and there was no need for naloxone. The mean Apgar score was 6.42 (1.5) at 1 minute and 8.42 (0.9) at 5 minutes. CONCLUSION: Bolus injection of 1 microg x kg(-1) of remifentanil may be useful for maintaining maternal hemodynamic stability in high-risk obstetric cases. Given the risk of neonatal depression, this resource should be used selectively and the means for neonatal resuscitation should be available.

Prevalence and prognostic influence of peripheral arterial disease in patients >or=40 years old admitted into hospital following an acute coronary event.

OBJECTIVE: A significant proportion of patients with ischemic heart disease have associated peripheral arterial disease (PAD), but many are asymptomatic and this condition remains underdiagnosed. We aimed to study the prevalence of PAD in patients with an acute coronary syndrome (ACS) and to evaluate its influence in hospital clinical outcomes. METHODS: The PAMISCA register is a prospective, multicenter study involving patients >or=40 years old with ACS admitted to selected Spanish hospitals. All patients had their ankle-brachial index (ABI) measured between days 3 and 7 after the ischemic event. RESULTS: 1410 ACS patients (71.4% male) were included. PAD determined by ABI was documented in 561 patients (39.8%). Factors independently related to PAD were age (OR: 1.04; 95% CI: 1.03-1.06; p<0.001), smoking (OR: 1.88; 95% CI: 1.41-2.49; p<0.0001), diabetes (OR: 1.30; 95% CI: 1.02-1.65; p<0.05), previous cardiac disease (OR: 1.54; 95% CI: 1.22-1.95; p<0.001) and previous cerebrovascular disease (OR: 1.90; 95% CI: 1.28-2.80; p<0.001). Following the ACS, an ABIor=40 years presenting with ACS is high and it is associated with increased cardiovascular risk.

[Experience with uterine artery embolization in the treatment of massive postpartum hemorrhage]. / Experiencia con la embolización arterial en el tratamiento de la hemorragia masiva obstétrica.

OBJECTIVE: To analyze our experience with uterine artery embolization in the management of massive hemorrhage in obstetric patients. PATIENTS AND METHODS: This observational, retrospective study analyzed all deliveries requiring a blood transfusion that were performed in the maternity unit of Hospital Universitario La Paz between January 1, 2000 and December 31, 2005. RESULTS: A total of 57,835 deliveries were performed with an incidence of postpartum hemorrhage of 0.7% (406 episodes). Uterine artery embolization was performed on 51 patients and 45 patients underwent obstetric hysterectomy. Both procedures were performed on 11 patients. Ten of the patients who underwent obstetric hysterectomy subsequently required uterine artery embolization, whereas only 1 patient required an obstetric hysterectomy following embolization because the hemorrhage was not resolved. The mean consumption of blood products for patients who underwent obstetric hysterectomy was twice that for patients who underwent uterine artery embolization. There were no complications secondary to embolization. CONCLUSIONS: Uterine artery embolization is a safe and effective procedure for managing massive postpartum hemorrhage.

Uso del remifentanilo en bolus en la cesárea de la paciente de altoriesgo: Estudio sobre 12 casos / Remifentanil bolus for cesarean section in high-risk patients: study of 12 cases

OBJETIVOS: Evaluar la utilidad y seguridad del remifentanilopara el control hemodinámico en cesáreas de pacientes de alto riesgo no susceptibles de anestesia espinal.MÉTODOS: Un minuto antes de la inducción administramos un bolo de 1 μg kg-1 de remifentanilo, después,propofol (2,5 mg kg-1), succinilcolina (1 mg kg-1), cisatracurio, sevoflurano-O2 - N2O y 5 μg kg-1 de fentanilo trasla ligadura del cordón. Registramos los valores hemodinámicos maternos, pulsioximetría, capnografía, índicebiespectral, presencia de rigidez muscular. En el neonatovaloramos el bienestar fetal, peso y necesidad de naloxona.Consideramos estabilidad hemodinámica cuando la presión arterial no variaba más del 15% respecto al basal.RESULTADOS: Incluimos 12 pacientes con indicación quirúrgica por abruptio placentae, hemorragia subaracnoidea,síndrome HELLP y preeclampsia. Observamos resultados concordantes con estabilidad hemodinámicaen todas las pacientes durante la cirugía. Ningún neonato presentó rigidez ni necesitó naloxona. El test de Apgaral minuto fue 6,42±1,5 y 8,42±0,9 a los 5 min.CONCLUSIÓN: El remifentanilo en bolo de 1 μg kg-1 puede ser útil en el control hemodinámico materno de lapaciente obstétrica de alto riesgo. Ante el riesgo de depresión neonatal, es conveniente seleccionar los casosdonde se utilice, y disponer de medios de reanimación neonatal (AU)

OBJECTIVES: To evaluate the utility and safety of remifentanil for hemodynamic control during cesarean section in high-risk patients ineligible for spinal anesthesia.METHODS: One minute before induction we injected a bolus of 1 μg·kg-1 of remifentanil, followed by propofol(2.5 mg·kg-1), succinylcholine (1 mg·kg-1), cisatracurium, sevoflurane in oxygen and nitrous oxide, and fentanyl (5μg·kg-1) after clamping the umbilical cord. We recorded maternal hemodynamic variables, pulse oximetry,capnography, bispectral index, and presence of muscular rigidity. In the neonate we assessed fetal wellbeing,weight, and requirement for naloxone.Hemodynamic stability was defined as no more than 15% variation in arterial pressure with respect tobaseline.RESULTS: Twelve patients undergoing surgery because of placenta abruptio, subarachnoid hemorrhage, HELLPsyndrome, or preeclampsia were enrolled. Hemodynamic variables were consistently stable during surgery in allpatients. No cases of neonatal rigidity were noted and there was no need for naloxone. The mean Apgar scorewas 6.42 (1.5) at 1 minute and 8.42 (0.9) at 5 minutes.CONCLUSION: Bolus injection of 1 μg·kg-1 of remifentanil may be useful for maintaining maternal hemodynamicstability in high-risk obstetric cases. Given the risk of neonatal depression, this resource should be usedselectively and the means for neonatal resuscitation should be available (AU)

Experiencia con la embolización arterial en el tratamiento de la hemorragia masiva obstétrica / Experience with uterine artery embolization in the treatment of massive postpartum hemorrhage

OBJETIVO: Analizar la experiencia de la embolizaciónarterial en el manejo de la hemorragia masiva en lapaciente obstétrica.PACIENTES Y MÉTODOS: Estudio retrospectivo y observacional en el que se analizaron todos los partos, que requirieron transfusión sanguínea, realizados en lamaternidad del Hospital Universitario La Paz durante elperiodo comprendido entre el 1 enero del 2000 y el 31 dediciembre del 2005.RESULTADOS: Se realizaron 57.835 partos, siendo laincidencia de hemorragia obstétrica del 0,7% (406 episodios). A 51 pacientes se les realizó una embolización arterial y a 45 se les practicó una histerectomía obstétrica. En 11 pacientes se realizaron ambos procedimientos. Diez de las pacientes a las que se les realizó una histerectomía obstétrica precisaron posteriormente una embolización arterial, mientras que sólo una paciente embolizada precisó en último término una histerectomía obstétrica por no resolverse el cuadro hemorrágico. La media de consumo de hemoderivados fue del doble en la histerectomía obstétrica respecto a las pacientes embolizadas. No se evidenciaron complicaciones secundarias a la embolización arterial.CONCLUSIONES: La embolización arterial es un procedimiento seguro y eficaz para el manejo de la hemorragia masiva obstétrica

OBJECTIVE: To analyze our experience with uterineartery embolization in the management of massivehemorrhage in obstetric patients.PATIENTS AND METHODS: This observational, retrospectivestudy analyzed all deliveries requiring a bloodtransfusion that were performed in the maternity unit ofHospital Universitario La Paz between January 1, 2000and December 31, 2005.RESULTS: A total of 57 835 deliveries were performedwith an incidence of postpartum hemorrhage of 0.7% (406episodes). Uterine artery embolization was performed on 51 patients and 45 patients underwent obstetric hysterectomy. Both procedures were performed on 11 patients. Ten of the patients who underwent obstetric hysterectomy subsequently required uterine artery embolization, whereas only 1 patient required an obstetric hysterectomy following embolization because the hemorrhage was not resolved. The mean consumption of blood products for patients who underwent obstetric hysterectomy was twice that for patients who underwent uterine artery embolization. There were no complications secondary to embolization.CONCLUSIONS: Uterine artery embolization is a safeand effective procedure for managing massive postpartumhemorrhage

[Is oxygen therapy truly useful and necessary during elective cesarean section under spinal anesthesia?]. / Es realmente necesaria y útil la oxigenoterapia suplementaria en la cesárea programada bajo anestesia subaracnoidea?

OBJECTIVE: To analyze maternal and fetal well-being with and without the application of oxygen therapy. MATERIAL AND METHODS: Randomized trial of full-term parturients who had received prenatal care during pregnancy. The women were healthy and classified as ASA 1. They were scheduled for delivery by cesarean section under spinal anesthesia and randomized to 2 groups to breathe room air or air providing an inspired oxygen fraction of 40% through a face mask. We assessed the well-being of the neonate immediately after birth with the Apgar test and by measuring umbilical cord blood gases. RESULTS: One hundred thirty women were enrolled. Both groups were similar, with no differences in demographic or hemodynamic variables, time from uterine incision to fetal extraction, neonatal birth weight, presence of umbilical cord abnormalities, type of resuscitation required by the neonate, or Apgar score in the first or fifth minute. Oxygen saturation in maternal blood by pulse oximetry was higher after 10 minutes in the group of women who received supplemental oxygen through face masks. We also observed significant differences in umbilical cord arterial blood between the room air and supplemental oxygen groups, respectively, as follows: PaCO2, 51.14 mm Hg vs 54.33 mm Hg (P=.016); bicarbonate, 22.19 mEq L(-1) vs 23.23 mEq L(-1) (P=.012); lactate, 1.85 mmol L(-1) vs 1.64 mmol L(-1) (P=.038). The PO2 in venous blood also differed significantly: 25.53 mm Hg vs 28.13 mm Hg, respectively (P=033). CONCLUSIONS: Breathing supplemental oxygen or not during elective cesarean delivery of healthy parturients under spinal anesthesia does not have a significant effect on neonatal well-being.

[Emergency cesarean in a patient with Coffin-Siris syndrome]. / Cesárea urgente en una paciente con síndrome de Coffin-Siris.

Coffin-Siris syndrome is a rare genetic disease characterized by coarse facial features, sparse scalp hair, hirsutism, hypoplasia of the distal phalanges, hypoplastic nail in the fifth digit, and mental retardation and delayed growth evident in both weight and height. Most cases are sporadic, but the possibility of recessive or dominant autosomal inheritance has been suggested. Facial abnormalities that make intubation difficult and mental retardation that interferes with cooperation are aspects of this disease that can affect the choice of type of anesthesia. We report the case of a parturient with Coffin-Siris syndrome who refused epidural analgesia for labor pain and for whom the obstetrician later decided that an emergency cesarean was necessary due to fetal distress.

Cesárea en una gestante con crisis aguda de paludismo / Cesarean section in a woman with acute blood-stage malaria

La infección por malaria durante el embarazo es unimportante problema de salud en la mayoría de lasregiones tropicales del mundo. Sin embargo, tambiénimporta en los países occidentales, ya que cada vez haymás mujeres infectadas que emigran desde zonas endémicas,pudiendo quedar gestantes. La infección durantela gestación puede tener importantes repercusiones tantopara la madre como para el feto. El diagnóstico debeser precoz y el manejo multidisciplinario.Presentamos el caso clínico de una embarazada quellegó a nuestro país desde Guinea y que en la semana 32debutó con una crisis aguda y muy grave de malariaque requirió el ingreso en la Unidad de Reanimación

Malaria infection during pregnancy is a serious healthproblem in most of the world’s tropical regions. Thedisease has also been imported into Western countries,however, as an increasing number of infected women, whomay become pregnant, emigrate from areas where malariais endemic. Infection during pregnancy can have seriousrepercussions for both mother and fetus. Early diagnosisand multidisciplinary management are essential.We report the case of a woman from Guinea whodebuted with severe, acute blood-stage malaria in the 32nd week of pregnancy and was admitted to the recovery care unit

Cesárea urgente en una paciente con síndrome de Coffin-Siris / Emergency cesarean in a patient with Coffin-Siris syndrome

El síndrome de Coffin–Siris es una enfermedad genéticamuy poco frecuente, caracterizada por rasgos facialesprimitivos, pelo ralo con hirsutismo corporal, acortamiento de las falanges distales, hipoplasia ungueal del quinto dedo y retraso del desarrollo mental y pondoestatural. La mayoría de los casos son esporádicos, pero se ha planteado una posible herencia autosómica recesiva o dominante. La elección del tipo de anestesia en estos pacientes viene determinada por las malformaciones faciales que pueden condicionar una intubación difícil y por el retraso mental que los hace ser pacientes poco colaboradores.Presentamos el caso de una gestante diagnosticada desíndrome de Coffin–Siris que rechazó la analgesia epidural para control del dolor de trabajo de parto y posteriormente el ginecólogo indicó una cesárea urgentepor riesgo de pérdida de bienestar fetal

Coffin-Siris syndrome is a rare genetic diseasecharacterized by coarse facial features, sparse scalp hair, hirsutism, hypoplasia of the distal phalanges, hypoplastic nail in the fifth digit, and mental retardation and delayed growth evident in both weight and height. Most cases are sporadic, but the possibility of recessive or dominant autosomal inheritance has been suggested. Facial abnormalities that make intubation difficult and mental retardation that interferes with cooperation are aspects of this disease that can affect the choice of type of anesthesia.We report the case of a parturient with Coffin-Sirissyndrome who refused epidural analgesia for labor painand for whom the obstetrician later decided that anemergency cesarean was necessary due to fetal distress

[Cesarean section in a woman with acute blood-stage malaria]. / Cesárea en una gestante con crisis aguda de paludismo.

Malaria infection during pregnancy is a serious health problem in most of the world's tropical regions. The disease has also been imported into Western countries, however, as an increasing number of infected women, who may become pregnant, emigrate from areas where malaria is endemic. Infection during pregnancy can have serious repercussions for both mother and fetus. Early diagnosis and multidisciplinary management are essential. We report the case of a woman from Guinea who debuted with severe, acute blood-stage malaria in the 32nd week of pregnancy and was admitted to the recovery care unit.