Risk Profiling In Vitro Fertilization Pregnancies that Develop Placenta Accreta Spectrum.

OBJECTIVE: The objective of this study is to assess whether, among a cohort of placenta accreta spectrum (PAS) patients, antenatal suspicion of PAS was less likely in in vitro fertilization (IVF) compared with non-IVF patients. In addition, we aimed to assess whether IVF patients exhibited similar risk factors for PAS compared with non-IVF patients. STUDY DESIGN: This is an international multicenter retrospective study of patients with pathologically confirmed PAS (accreta, increta, percreta) between 1998 and 2021. PAS patients were identified through a central international PAS database. Antenatal and pathological criteria are specific to each institution. Pregnancies that resulted from IVF were compared with non-IVF pregnancies. Comparisons were made using a chi-square or Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. RESULTS: Of the 692 pregnancies included, 44 were in the IVF group and 648 were in the non-IVF group. The IVF group was less likely to have had a prior cesarean delivery (70.5 vs. 91%, p < 0.01) but a similar prevalence of placenta previa (63.6 vs. 68.1%, p = 0.12) compared with the non-IVF group. The IVF group was also less likely to have either a prior cesarean delivery or placenta previa than the non-IVF group (79.5 vs. 95.4%, p < 0.01). Antenatal detection of PAS was less common in the IVF group compared with the non-IVF group (40.9 vs. 60.5%, p < 0.01, respectively), even when adjusted for maternal age, prior cesarean delivery, prior uterine surgery, placenta previa and site (risk ratio: 0.70, 95% confidence interval: 0.62-0.81). The IVF group had less severe pathological disease compared with the non-IVF group (p = 0.02). CONCLUSION: Pregnant people with PAS who underwent IVF are less likely to have an antenatal suspicion compared with non-IVF patients. This finding may be explained by the lower incidence of prior cesarean deliveries and/or placenta previa as well as less severe forms of PAS. KEY POINTS: · IVF group is less likely to have antenatal PAS suspicion.. · IVF group is less likely to have had prior cesarean delivery.. · Risk profile for PAS differs in IVF pregnancies..

Impact of nonpneumatic antishock garment in the management of patients with hypoperfusion due to massive postpartum hemorrhage.

Objective: The objective of this article was to compare hemodynamic and perfusion parameters as well as the clinical outcomes in critically ill patients with postpartum hemorrhage (PPH) who received treatment with a nonpneumatic antishock garment (NASG) as part of an intervention package, with a group of patients in similar conditions who did not receive an NASG.Methods: This observational study analyzed a historic cohort of 154 patients with PPH, secondary hypovolemic shock and signs of hypoperfusion who were admitted to this institution from 2012 to 2015. Group 1 (n= 77) was managed with NASG and Group 2 (n = 77) received interventions other than NASG. Hypoperfusion markers and maternal outcomes were compared in both groups.Results: Of 154 patients included in the analysis, 36.4% required a total abdominal hysterectomy (TAH) to achieve hemorrhage control, 98.2% of whom belonged to Group 2 and 1.8% to Group 1 (p = .001). The use of blood products was more common in Group 2 (p < .001), as was the administration of vasoactive agents. The mean number of days of hospitalization at the Obstetric High Dependency Unit (OHDU) was significantly lower in Group 1 and reached a statistically significant p value. Only two cases of maternal death occurred in Group 2.Discussion: The use of NASG in the management of PPH is a cost-effective strategy for patients with severe shock and signs of hypoperfusion and is optimal in a limited-resource scenario. In this study, the use of NASG was related to better outcomes in a statistically significant manner with better results regarding maternal outcomes such as uterine preservation and decreased transfusion requirements and hospital days.Conclusions: NASG, associated with the use of uterotonic agents and other strategies for PPH control, is a safe tool that helps reduce morbimortality in critically ill patients with PPH.

Placenta accreta: importance of a multidisciplinary approach in the Colombian hospital setting.

Introduction: The management of patients with placenta accreta (PA) poses a challenge to health services. Although it may lead to devastating complications, its low incidence limits the development of expertize in all obstetric centers. We evaluated the results obtained from a multidisciplinary approach in patients with PA in a Latin American hospital.Methods: The study included patients with prenatal suspicion or intraoperative diagnosis of PA, before and after initiating a set of interdisciplinary and institutional interventions, with the aim of achieving better outcomes.Results: From December 2011 to December 2017, 62 patients with prenatally or intraoperatively suspected PA underwent surgery. The first 30 women (Group A), admitted until April 2016 and before any changes in the management protocol, had a longer hospital stay and surgery time, higher newborn hospitalization, and greater use of general anesthesia, compared to the 20 patients from Group B, who were admitted during the last 20 months of the observation period. A total of 12 women with late and intraoperative diagnosis, under no institutional protocol, showed greater blood loss and more frequent red blood cell transfusions.Conclusions: The expertize of the multidisciplinary team responsible for managing women with PA is associated with better clinical outcomes.

Experience of a Colombian center in the endovascular management of lifethreatening postpartum hemorrhage / Experiencia de un centro colombiano en el tratamiento endovascular de la hemorragia posparto que amenaza la vida

Introduction: Postpartum hemorrhage is a world-leading cause of morbidity and mortality. Lacerations are the second most frequent cause. Early management with appropriate treatment is essential to obtain adequate outcomes; the endovascular occlusion of pelvic vessels is among the management options. Objective: To describe the management experience with the arterial embolization of pelvic vessels. Materials and methods: We conducted a retrospective case series study based on the institutional registry of Fundación Valle del Lili (Cali, Colombia), which included patients with postpartum hemorrhage admitted between January 1st, 2011 and October 31st, 2016. Results: Out of 430 patients diagnosed with PPH, 11 were subject to embolization of pelvic vessels. Within our group, 10 patients had a vaginal delivery with severe vaginal lacerations; most of them (9 cases, 82%) were referred from other lower-complexity institutions after 20.5 hours. Occlusion was more frequent in the superior vaginal and the internal pudendal arteries. No patients showed complications associated with the procedure and only 2 showed recurrent bleeding while 3 required a hysterectomy, but no deaths occurred. Conclusion: Percutaneous management is a safe and effective third-line method for difficult-management bleedings control in patients with postpartum hemorrhage after a severe perineal tear. These results are similar to case reports published in the worldwide literature available to date.

Introducción. La hemorragia posparto es la primera causa de morbimortalidad materna en el mundo y las laceraciones son la segunda causa en frecuencia. Su tratamiento temprano y apropiado es clave para obtener buenos resultados, y la oclusión endovascular de los vasos pélvicos se cuenta entre las opciones terapéuticas. Objetivo. Describir la experiencia del tratamiento con la 'embolización' (sic) arterial de los vasos pélvicos. Materiales y métodos. Se trató de un estudio retrospectivo del tipo de serie de casos basado en el registro institucional de la Fundación Valle del Lili, Cali, Colombia, en el que se incluyeron las pacientes con hemorragia posparto atendidas entre el 1º de enero del 2011 y el 31 de octubre del 2016. Resultados. De las 430 pacientes con diagnóstico de hemorragia posparto, 11 fueron sometidas a la 'embolización' de los vasos pélvicos. De este grupo, 10 pacientes tuvieron parto vaginal con laceraciones vaginales complejas, y la mayoría (9 casos, 82 %) fue remitida por otras instituciones de menor complejidad después de 20,5 horas. Las arterias ocluidas frecuentemente fueron la vaginal superior y la pudenda interna. Ninguna paciente presentó complicaciones asociadas al procedimiento y solo dos presentaron sangrado recurrente. Tres pacientes requirieron histerectomía y ninguna murió. Conclusión. El manejo percutáneo es un método de tercera línea, seguro y efectivo para el control de los sangrados de difícil manejo en las pacientes con hemorragia pospartopor desgarros perineales complejos. Estos resultados son similares a los reportados en la literatura científica mundial disponible hasta la fecha.

Use of Negative Pressure Wound Therapy in Surgical Site Infection During Pregnancy: A Case Study.

BACKGROUND: Surgical site infections (SSIs) are a known cause of morbidity and mortality; however, evidence related to management of SSIs during pregnancy is sparse. CASE: A 26-year-old female patient with an adnexal cystic lesion underwent laparotomy at 19 weeks of pregnancy. She experienced a late SSI 10 days after initial surgery, necessitating surgical debridement. She was treated with multiple surgical interventions for wound irrigations and wound closure assisted by a negative pressure wound therapy. CONCLUSION: Negative pressure wound therapy was used for treatment of an SSI during pregnancy without causing premature delivery or requiring a cesearan section.

Experiencia de un centro colombiano en el tratamiento endovascular de la hemorragia posparto que amenaza la vida / Experience of a Colombian center in the endovascular management of life-threatening postpartum hemorrhage

Resumen Introducción. La hemorragia posparto es la primera causa de morbimortalidad materna en el mundo y las laceraciones son la segunda causa en frecuencia. Su tratamiento temprano y apropiado es clave para obtener buenos resultados, y la oclusión endovascular de los vasos pélvicos se cuenta entre las opciones terapéuticas. Objetivo. Describir la experiencia del tratamiento con la 'embolización' (sic) arterial de los vasos pélvicos. Materiales y métodos. Se trató de un estudio retrospectivo del tipo de serie de casos basado en el registro institucional de la Fundación Valle del Lili, Cali, Colombia, en el que se incluyeron las pacientes con hemorragia posparto atendidas entre el 1º de enero del 2011 y el 31 de octubre del 2016. Resultados. De las 430 pacientes con diagnóstico de hemorragia posparto, 11 fueron sometidas a la 'embolización' de los vasos pélvicos. De este grupo, 10 pacientes tuvieron parto vaginal con laceraciones vaginales complejas, y la mayoría (9 casos, 82 %) fue remitida por otras instituciones de menor complejidad después de 20,5 horas. Las arterias ocluidas frecuentemente fueron la vaginal superior y la pudenda interna. Ninguna paciente presentó complicaciones asociadas al procedimiento y solo dos presentaron sangrado recurrente. Tres pacientes requirieron histerectomía y ninguna murió. Conclusión. El manejo percutáneo es un método de tercera línea, seguro y efectivo para el control de los sangrados de difícil manejo en las pacientes con hemorragia posparto por desgarros perineales complejos. Estos resultados son similares a los reportados en la literatura científica mundial disponible hasta la fecha.

Abstract Introduction: Postpartum hemorrhage is a world-leading cause of morbidity and mortality. Lacerations are the second most frequent cause. Early management with appropriate treatment is essential to obtain adequate outcomes; the endovascular occlusion of pelvic vessels is among the management options. Objective: To describe the management experience with the arterial embolization of pelvic vessels. Materials and methods: We conducted a retrospective case series study based on the institutional registry of Fundación Valle del Lili (Cali, Colombia), which included patients with postpartum hemorrhage admitted between January 1st, 2011 and October 31st, 2016. Results: Out of 430 patients diagnosed with PPH, 11 were subject to embolization of pelvic vessels. Within our group, 10 patients had a vaginal delivery with severe vaginal lacerations; most of them (9 cases, 82%) were referred from other lower-complexity institutions after 20.5 hours. Occlusion was more frequent in the superior vaginal and the internal pudendal arteries. No patients showed complications associated with the procedure and only 2 showed recurrent bleeding while 3 required a hysterectomy, but no deaths occurred. Conclusion: Percutaneous management is a safe and effective third-line method for difficult-management bleedings control in patients with postpartum hemorrhage after a severe perineal tear. These results are similar to case reports published in the worldwide literature available to date.

Paraganglioma in pregnancy: interdisciplinary management during pregnancy.

Paragangliomas are tumors that originate from the extra-adrenal neural crest, the incidence of which during pregnancy is not more than two to eight cases per million people per year and are known to be highly morbid. The purpose of this report is to describe the experience and results obtained during management of a primigravida diagnosed with paraganglioma on week 21.2 and received both medical and surgical management with good maternal and perinatal outcomes. This case report evidences the importance of practicing interdisciplinary management of patients with clinical suspicion of paragangliomas or pheochromocytomas during pregnancy at high-complexity centers even in a medium-income country.

Resuscitative endovascular balloon occlusion of the aorta deployed by acute care surgeons in patients with morbidly adherent placenta: a feasible solution for two lives in peril.

Morbidly adherent placenta (MAP), which includes accreta, increta, and percreta, is a condition characterized by the invasion of the uterine wall by placental tissue. The condition is associated with higher odds of massive post-partum hemorrhage. Several interventions have been developed to improve hemorrhage-related outcomes in these patients; however, there is no evidence to prefer any intervention over another. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular intervention that may be useful and effective to reduce hemorrhage and transfusions in MAP patients. The objective of this narrative review is to summarize the evidence for REBOA in patients with MAP. We posit that acute care surgeons can perform REBOA for patients with MAP.

Encefalopatía de Wernicke secundario a hiperémesis gravídica: la importancia del diagnóstico temprano / Wernicke encephalopathy secondary to hyperemesis gravidarum: importance of early diagnosis

RESUMEN Introducción: La hiperémesis gravídica (HG) es una condición frecuente en el embarazo, que puede resultar en complicaciones potencialmente letales como la encefalopatía de Wernicke (EW), síndrome que al ser reconocido y tratado tardíamente puede traducirse en una alta morbi-mortalidad materna y fetal. Objetivo: Describir el primer caso de EW secundario a HG en Colombia y realizar una revisión de la literatura publicada sobre su diagnóstico y tratamiento. Materiales y métodos: Se describe un caso de EW secundario a HG en el que se brindó un manejo interdisciplinario. Se realizó una revisión de la literatura con los términos "encefalopatía de Wernicke", "hiperémesis gravídica" y "embarazo" incluyendo reportes de casos, series de casos, artículos de revisión, investigaciones originales o cartas al editor en inglés, español y francés, en donde se analizaron el método y tiempo del diagnóstico, pauta de tratamiento y estado funcional final. Resultados: Se incluyeron 69 publicaciones y se identificaron 89 casos. En 23 de ellos se presentó pérdida gestacional, sólo en el 12,4% de los casos se reportó el nivel de tiamina, de los cuales en el 90% se encontraba disminuido y de los casos en donde se reportó estado funcional final en el 5,9% la gestante falleció. Conclusión: La EW secundaria a HG es una complicación potencialmente letal. Debe sospecharse ante cualquier alteración neurológica e historia de emesis persistente. El diagnóstico y tratamiento oportuno interdisciplinario son fundamentales para disminuir el riesgo de secuelas que limitan la capacidad funcional con alto impacto en la calidad de vida.

ABSTRACT Introduction: Hyperemesis gravidarum (HG) is a frequent condition in pregnancy, which can result in potentially lethal complications such as Wernicke encephalopathy (WE), a syndrome that can be translated into a high maternal and fetal morbidity and mortality if it is recognized and treated late. Objective: To describe the first case of WE due to HG in Colombia and to review the published literature about its diagnosis and treatment. Materials and methods: We describe a case of WE due to HG with an interdisciplinary approach. A review of the literature was performed with the terms "Wernicke's encephalopathy", "hyperemesis gravidarum" and "pregnancy" including case reports, case series, review articles, original investigations or letters to the editor in English, Spanish and French, where the method and time of the diagnosis, treatment regimen and sequelae were analyzed. Results: Sixty-nine publications were included and 89 cases were identified. In 23 of them had a gestational loss, only in 12.4% of the cases the thiamine level was reported, in which 90% was diminished and in the cases where the final functional status was reported in 5.9% of the pregnant woman died. Conclusion: WE due to HG is a potentially lethal complication. In any neurological disturbance and history of persistent emesis it should be suspected. Timely interdisciplinary diagnosis and treatment are essential to reduce the risk of sequelae that limit functional capacity with a high impact on quality of life.

Enfermedad de Gaucher, diagnostico en el embarazo, reporte de caso y consideraciones de su tratamiento en Colombia / Gaucher disease, diagnosis in pregnancy, report case study and considerations of its treatment in Colombia

RESUMEN Introducción y Objetivo: La enfermedad de Gaucher es una condición autosómica recesiva de baja prevalencia, de difícil diagnóstico y manejo, especialmente en embarazo. Reportamos una gestante con enfermedad de Gaucher manejada desde la semana 15,3 hasta el término del embarazo con Taliglucerasa en la Unidad de Alta Complejidad Obstétrica, en la Fundación Valle del Lili en Cali, Colombia. Métodos: Reporte de caso de gestante con diagnóstico de enfermedad de Gaucher diagnosticada durante el embarazo, con exacerbación de síntomas, quien presento severa pancitopenia y esplenomegalia. Resultados: El manejo medico interdiscilplinario permitió el control del severo deterioro clínico de la paciente durante el parto, presentó hemorragia postparto con choque hipovolémico, con adecuada respuesta al manejo médico. La madre y el neonato fueron dados de alta sin otras complicaciones asociadas. Conclusión: El manejo interdisciplinario es indispensable en gestantes con esta entidad para lograr buenos resultados maternos y perinatales.

ABSTRACT Introduction and Objective: Gaucher disease is a low prevalence autosomal recessive condition, difficult to diagnose and manage especially during pregnancy. We reported a pregnant woman with Gaucher disease managed with Taliglucerase in a critical care obstetric unit from week 15.3 until the end of her pregnancy, at the Fundación Valle del Lili, Cali, Colombia. Methods: A case report of a pregnant woman diagnosed during her pregnancy with Gaucher disease, who presented severe pancytopenia and splenomegaly. Results: The interdisciplinary medical management allowed the control of the severe clinical deterioration of the patient. During the delivery, she presented postpartum hemorrhage with hypovolemic shock, which resolved with medical management. The mother and the newborn were discharged without other associated complications. Conclusion: Interdisciplinary management is essential for handling a critically ill obstetric patient with Gaucher disease, and to achieve good maternal and perinatal outcomes.

Prophylactic use of resuscitative endovascular balloon occlusion of the aorta in women with abnormal placentation: A systematic review, meta-analysis, and case series.

BACKGROUND: We describe intraoperative and postdischarge outcomes of a case series after the prophylactic use of resuscitative endovascular balloon occlusion of the aorta (REBOA) during elective cesarean delivery in pregnant women with morbidly adherent placenta (MAP). We furthermore performed a systematic review and meta-analysis to investigate the safety and effectiveness of the use of REBOA during elective cesarean delivery in pregnant women with MAP. METHODS: Descriptive case series of REBOA (December 2015 to June 2017) used during elective cesarean delivery in pregnant women with MAP. The systematic review was conducted following PRISMA guidelines. We included studies involving pregnant women with a diagnosis of MAP who underwent an elective cesarean delivery with prophylactic REBOA placement. A meta-analysis was performed to assess the overall amount of transfusions and intraoperative hemorrhage of REBOA compared to NO-REBOA cases. RESULTS: A total of 12 patients with MAP underwent elective cesarean delivery with REBOA deployment. The median (interquartile range) of packed red blood cells transfused during the first 24 hours following surgery was two units (0-3.5). The median (interquartile range) of intraoperative blood loss was 1,500 mL (900-2,750). At 28 days, all patients were alive, and no adverse outcomes were observed. Four articles were included in the systematic review and meta-analysis. These articles included a total of 441 patients. Quantitative synthesis (meta-analysis) found that the use of REBOA as prophylaxis for the prevention of major hemorrhage was associated with a lower amount of intraoperative hemorrhage (in milliliters) (weighted mean difference, -1,384.66; 95% confidence interval, -2,141.74 to -627.58) and lower requirements of blood products transfusions (in units) (weighted mean difference, -2.42; 95% confidence interval, -3.90 to -0.94). CONCLUSION: We provide clinical data supporting the use of REBOA in the management of pregnant women with MAP undergoing elective cesarean delivery. Our findings demonstrate the feasibility of REBOA as a prophylactic intervention to improve outcomes in women at risk of catastrophic postpartum hemorrhage. LEVEL OF EVIDENCE: Therapeutic study, level V; Systematic Review, level IV.

Model of obstetric attention based on critical care in Latin America.

PURPOSE: Report the results obtained following the implementation of an OCC (Obstetric Critical Care) model. MATERIALS AND METHODS: This is an observational prospective study in obstetric population with high complexity illness attended in a safety and quality model of attention in a specific unit supporting the concept of obstetric critical care. Records were used as the primary source for collecting information, using the standards of the Center for Clinical Research. RESULTS: In a 5-year period, 10,956 patients were admitted. About 51% had diseases that were not exclusive to pregnancy, 91% were admitted while pregnant and, from all births, 46% were by vaginal delivery. 1685 (19%) patients met the criteria for Near Miss Maternal Mortality (NMMM). Forty-three patients died, which represented a mortality rate of 0.49% of the total of hospitalized patients. CONCLUSIONS: The implementation of an OOC model, security models, and an institutional support system improve the quality of care in the obstetric services of reference hospitals in developing countries.

Pregnant Women Hospitalized with Chikungunya Virus Infection, Colombia, 2015.

In 2015 in Colombia, 60 pregnant women were hospitalized with chikungunya virus infections confirmed by reverse transcription PCR. Nine of these women required admission to the intensive care unit because of sepsis with hypoperfusion and organ dysfunction; these women met the criteria for severe acute maternal morbidity. No deaths occurred. Fifteen women delivered during acute infection; some received tocolytics to delay delivery until after the febrile episode and prevent possible vertical transmission. As recommended by a pediatric neonatologist, 12 neonates were hospitalized to rule out vertical transmission; no clinical findings suggestive of neonatal chikungunya virus infection were observed. With 36 women (60%), follow-up was performed 1 year after acute viremia; 13 patients had arthralgia in >2 joints (a relapse of infection). Despite disease severity, pregnant women with chikungunya should be treated in high-complexity obstetric units to rule out adverse outcomes. These women should also be followed up to treat potential relapses.

Experience in the use of non-pneumatic anti-shock garment (NASG) in the management of postpartum haemorrhage with hypovolemic shock in the Fundación Valle Del Lili, Cali, Colombia.

BACKGROUND: The aim of this case series is to describe the experience of using the non-pneumatic anti-shock garment (NASG) in the management of severe Postpartum hemorrhage (PPH) and shock, and the value of implementing this concept in high-complexity obstetric hospitals. METHODS: Descriptive case series of 77 women that received NASG in the management of PPH with severe hypovolemic shock from June 2014 to December 2015. Vital signs, shock index (SI), the lactic acid value and the base deficit were compared before and after NASG application. RESULTS: Fifty-six (77%) women had an SI > 1.1 at the time shock management was initiated; 96% had uterine atony. All women received standard does of uterotonics. The average time between the birth and NASG applications was 20 min. Forty-eight percent of women recovered haemodynamic variables in the first hour and 100% within the first 6 h; 100% had a SI < 1.0 in the first hour. The NASG was not removed until definitive control of bleeding was achieved, with an average time of use of 24 h. There were no mortalities. CONCLUSIONS: In this case series of women in severe shock, the NASG was an effective management device for the control of severe hypovolemic shock. It should be considered a first-line option for shock management.