Gerenciamento clínico da hemorragia pós-parto pelo enfermeiro obstetra: um protocolo de revisão de escopo / Clinical management of postpartum hemorrhage by obstetric nurses: a scoping review protocol

OBJETIVO: Mapear as evidências científicas sobre as ações dos enfermeiros obstétricos no gerenciamento clínico da hemorragia pós-parto. MÉTODO: Trata-se de uma revisão de escopo elaborada segundo as recomendações do JBI Institute Manual do Revisor para Scoping Review. As buscas serão realizadas nas bases de dados eletrônicas CINAHL, Cochrane Library, EMBASE, Literatura Latino-americana e do Caribe em Ciências da Saúde, MEDLINE/PubMed, SciELO, ScienceDirect, SCOPUS, Web of Science e na literatura cinzenta. Os estudos que serão incluídos precisarão responder ao objetivo desta pesquisa e estar nos idiomas Português, Espanhol ou Inglês. Além disso, é necessário ter disponibilidade dos estudos na íntegra através de acesso remoto pelo acesso da CAFe. Os estudos que não serão incluídos serão os em formato de editorial e carta ao editor. Haverá a seleção por meio da leitura do título e resumo dos materiais encontrados nas buscas, sendo assim avaliados de maneira independente por dois revisores e nos casos de divergências por um terceiro avaliador. Os dados coletados estarão organizados e relacionados segundo a análise descritiva. Os resultados poderão estar dispostos em tabelas ou quadros, e serão discutidos com suporte de literatura acerca da temática, retratando a quinta etapa do método escolhido.

OBJECTIVE: To map the scientific evidence regarding the actions of obstetric nurses in the clinical management of postpartum hemorrhage. METHOD: This scoping review was developed according to the JBI Institute Reviewer's Manual for Scoping Reviews. The electronic databases CINAHL, Cochrane Library, EMBASE, Latin American and Caribbean Health Sciences Literature, MEDLINE/PubMed, SciELO, ScienceDirect, SCOPUS, Web of Science, and gray literature were searched. Included studies must address the research objective in Portuguese, Spanish, or English. In addition, full remote access to the studies via CAFe is required. Studies in editorial or letter format will be excluded. Selection will be based on the title and abstract of the materials found in the searches, independently assessed by two reviewers, with disagreements resolved by a third reviewer. Collected data will be organized and related through descriptive analysis. Results may be presented in tables or figures and discussed with support from literature, reflecting the fifth step of the selected methodology.

Prevención de hemorragia posparto durante la cesárea mediante ligadura de las arterias uterinas en pacientes con factores de riesgo / Uterine artery ligation for prevention of postpartum hemorrhage in patients with risk factors for cesarean section

Resumen OBJETIVO: Evaluar la utilidad preventiva de la hemorragia posparto mediante la ligadura bilateral de las arterias uterinas en pacientes con factores de riesgo. MATERIALES Y MÉTODOS: Estudio prospectivo, experimental, aleatorizado no probabilístico, por conveniencia, de casos y controles, longitudinal, comparativo al que se incluyeron pacientes con factores de riesgo de hemorragia posparto que finalizaron el embarazo mediante cesárea de urgencia. Se integraron dos grupos: experimental, en quienes se aplicó la técnica de ligadura bilateral de arterias uterinas y el grupo control: solo con cesárea. Antes y después del procedimiento quirúrgico se estimaron la pérdida de sangre, los parámetros de hemoglobina y hematocrito y se compararon con el grupo de control. RESULTADOS: Se estudiaron 91 pacientes: 45 en el grupo experimental y 46 de solo cesárea. Se observaron diferencias significativas en la pérdida de sangre del grupo experimental (345.56 ± 64.69 mL) en comparación con el grupo control (426.06 ± 125.49 mL; p = 0.000247), en los parámetros de hemoglobina (grupo experimental: 11:13 ± 1.62 g/dL; grupo control: 10.49 ± 1.32 g/dL, p = 0.037) y hematocrito (grupo experimental: 33.86%; grupo control: 31.87%; p = 0.017). CONCLUSIÓN: La ligadura bilateral de las arterias uterinas a pacientes con factores de riesgo de hemorragia poscesárea es una medida preventiva eficaz que ayuda a disminuir la pérdida sanguínea. Al complementarla con los uterotónicos reduce el volumen de sangrado.

Abstract OBJECTIVE: Evaluation of the benefits and harms of bilateral uterine artery ligation for prevention of postpartum hemorrhage in patients with risk factors. MATERIALS AND METHODS: Prospective, experimental, randomized, case-control, longitudinal, comparative study conducted during 2022, which included patients with risk factors for postpartum hemorrhage who terminated pregnancy by emergency cesarean section. Two groups were included: the experimental group, in which the technique of bilateral uterine artery ligation was applied, and the control group, in which only cesarean section was performed. Before and after the surgical procedure, blood loss, hemoglobin and hematocrit parameters were estimated and compared with the control group. RESULTS: Ninety-one patients were studied: 45 in the experimental group and 46 in the cesarean only group. Significant differences were observed in blood loss in the experimental group (345.56 ± 64.69 mL) compared to the control group (426.06 ± 125.49 mL; p = 0.000247), in hemoglobin (experimental group: 11:13 ± 1.62 g/dL; control group: 10.49 ± 1.32 g/dL, p = 0.037) and hematocrit (experimental group: 33.86%; control group: 31.87%; p = 0.017). CONCLUSION: Bilateral uterine artery ligation in patients with risk factors for post-cesarean hemorrhage is an effective preventive measure that helps to reduce blood loss. When combined with uterotonics, it reduces the volume of bleeding.

Bundle para quantificação de perda sanguínea pós-parto vaginal / Bundle para la cuantificación de pérdida sanguínea posparto vaginal / Bundle for quantifying vaginal blood loss after childbirth

Resumo Objetivo Construir e validar o conteúdo de um bundle para quantificação da perda sanguínea pós-parto vaginal. Métodos Estudo metodológico desenvolvido de fevereiro a agosto de 2022, em três etapas: levantamento bibliográfico, construção do instrumento e validação de conteúdo por 14 experts. O instrumento para validação foi composto por 11 itens selecionados a partir de revisão sistemática. Para cada item do bundle aplicou-se escala Likert e para verificar a concordância entre experts, calculou-se o Índice de Concordância. Consideraram-se válidos os itens com concordância acima de 80%. A validação de conteúdo foi realizada em uma única rodada de avaliação. Resultados A versão final do bundle foi composta por nove itens. Os cuidados propostos estão relacionados à quantificação direta do sangramento pós-parto e seu registro, observação da puérpera, a utilização de protocolos institucionais em casos de hemorragia pós-parto, assim como a capacitação da equipe. Conclusão O estudo permitiu construir e validar bundle para quantificação da perda sanguínea pós-parto vaginal, com vistas à melhora do diagnóstico de hemorragia pós-parto.

Resumen Objetivo Elaborar y validar el contenido de un bundle para la cuantificación de pérdida sanguínea posparto vaginal. Métodos Estudio metodológico, llevado a cabo de febrero a agosto de 2022, en tres etapas: análisis bibliográfico, construcción del instrumento y validación de contenido por 14 expertos. El instrumento para validación consistió en 11 ítems seleccionados a partir de revisión sistemática. Se aplicó la escala Likert para cada ítem del bundle; y para verificar la concordancia entre expertos, se calculó el Índice de Concordancia. Se consideraron válidos los ítems con concordancia superior a 80 %. La validación de contenido se realizó en una única ronda de evaluación. Resultados La versión final del bundle consistió en nueve ítems. Los cuidados propuestos están relacionados con la cuantificación directa del sangrado posparto y su registro, la observación de la puérpera, la utilización de protocolos institucionales en casos de hemorragia posparto, así como también la capacitación del equipo. Conclusión El estudio permitió elaborar y validar un bundle para la cuantificación de pérdida sanguínea posparto vaginal, con el fin de mejorar el diagnóstico de hemorragia posparto.

Abstract Objective To construct and validate the content of a bundle to quantify vaginal blood loss after childbirth. Methods This is a methodological study developed from February to August 2022, divided into bibliographic survey, instrument construction and content validity, by 14 experts. The instrument for validity consisted of 11 items selected from a systematic review. For each item in the bundle, a Likert scale was applied, and to check agreement among experts, the Concordance Index was calculated. Items with agreement above 80% were considered valid. Content validity was carried out in a single round of assessment. Results The final version of the bundle consisted of nine items. The proposed care is related to direct quantification of postpartum bleeding and its recording, observation of postpartum women, use of institutional protocols in cases of postpartum hemorrhage as well as team training. Conclusion The study allowed constructing and validating a bundle for quantifying vaginal blood loss after childbirth, with a view to improving postpartum hemorrhage diagnosis.

Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation.

BACKGROUND AND AIMS: Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation. MATERIAL AND METHODS: Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete. RESULTS: Mean blood loss during cesarean section after REBOA (3507.5 mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was <2 days. CONCLUSION: The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.

Factores de riesgo relacionados con las complicaciones de la hemorragia obstétrica

Introducción: La hemorragia obstétrica es considerada una causa mayor de mortalidad materna. El reconocimiento de las mujeres con riesgo de desarrollar complicaciones durante la hemorragia obstétrica, es la primera acción para promover un tratamiento optimizado y evitar la muerte. Objetivo: Identificar los factores de riesgo de complicaciones en pacientes con hemorragia obstétrica. Métodos: Estudio observacional, analítico de casos y controles, con 12 casos (con complicaciones) y 24 controles (sin complicaciones). Se aplicó las medidas resúmenes para cada tipo de variables y la determinación de los factores de riesgos mediante la aplicación del odds ratio (OR), se utilizó el paquete estadístico SPSS versión 26.0, con un intervalo de confianza (IC) del 95 %. Resultados: La combinación del choque hipovolémico, más la insuficiencia renal aguda, fue la complicación más frecuente para un 13,8 %. Predominó la atonía uterina para un 50,0 % como causa de hemorragia. Las variables predictivas de complicaciones fueron: el valor de creatinina ≥ 113 µmol/L (OR= 19,08; IC: 2,75-138,36), índice internacional normalizado ≥ 2 (OR= 4,66; IC: 1,46-14,90), hematocrito < 0,23 (OR= 4,00; IC: 1,76-9,08) y hemoglobina < 70 g/L (OR= 2,22; IC: 1,25-3,95). Conclusiones: La creatinina ≥ 113 µmol/L, índice internacional normalizado ≥ 2, hematocrito < 0,23 y hemoglobina < 70 g/L son los principales factores de riesgo identificados para el desarrollo de complicaciones durante la hemorragia obstétrica.

Introduction: Obstetric hemorrhage is considered a major cause of maternal mortality. Recognition of women at risk of developing complications during obstetric hemorrhage is the first action to promote optimized treatment and avoid death. Objective: Identify risk factors for complications in patients with obstetric hemorrhage. Methods: Observational, analytical case-control study, with 12 cases (with complications) and 24 controls (without complications). The summary measures were applied for each type of variables and the determination of the risk factors by applying the odds ratio (OR), the SPSS statistical package version 26.0 was used, with a confidence interval (CI) of 95%. Results: The combination of hypovolemic shock, plus acute renal failure, was the most frequent complication for 13.8%. Uterine atony predominated for 50.0% as the cause of hemorrhage. The predictive variables of complications were: creatinine value ≥ 113 µmol/L (OR= 19.08; CI: 2.75-138.36), international normalized ratio ≥ 2 (OR= 4.66; CI: 1. 46-14.90), hematocrit < 0.23 (OR= 4.00; CI: 1.76-9.08) and hemoglobin < 70 g/L (OR= 2.22; CI: 1.25-3.95). Conclusions: Creatinine ≥ 113 µmol/L, international normalized ratio ≥ 2, hematocrit < 0.23 and hemoglobin < 70 g/L are the main risk factors identified for the development of complications during obstetric hemorrhage.

Utilidad de la oclusión aórtica con balón REBOA para el control de las hemorragias puerperales en pacientes con anomalías de la implantación placentaria / Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation

Antecedentes y objetivo: Las anomalías en la implantación placentaria, que conforman el espectro de la placenta acreta, son causa de alta morbimortalidad maternal por la hemorragia masiva que se produce en estas pacientes durante el parto. La colocación previa de balones de oclusión aórticos ayuda a controlar el sangrado, disminuyéndolo y facilitando la intervención quirúrgica. Existe un nuevo balón de oclusión aórtico denominado REBOA que minimiza los riesgos y las complicaciones asociadas a la colocación de los balones aórticos tradicionales además de lograr el control de las hemorragias. El objetivo del presente estudio es evaluar la utilidad, la eficacia y la seguridad del balón REBOA en las hemorragias puerperales por anomalías en la implantación placentaria. Material y métodos: Desde noviembre del 2019 hasta noviembre del 2021 se han colocado, por parte de radiología intervencionista, 6 balones REBOA en 6 mujeres que iban a ser tratadas mediante cesárea programada de acretismo placentario. Resultado: En el estudio realizado, las pérdidas de volumen sanguíneo durante la cesárea tras la colocación del balón REBOA son similares a las reportadas en la literatura con otros balones aórticos, con una media de 3.507,5ml. La media de requerimientos transfusionales fue de 3,5 concentrados de hematíes. El uso del balón REBOA proporcionó al equipo quirúrgico unas condiciones adecuadas para realizar la cirugía. No hubo complicaciones derivadas de su colocación y la estancia media en UCI de las pacientes fue inferior a 2 días. Conclusión: El balón REBOA, gracias a sus características técnicas, se plantea como una nueva alternativa segura y útil para el control de las hemorragias masivas en las pacientes con acretismo placentario.(AU)

Background and aims: Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation. Material and methods: Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete. Results Mean blood loss during cesarean section after REBOA (3507.5mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was < 2 days. Conclusion The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.(AU)

[Prenatal diagnosis of placenta acretta by ultrasound and its histopathological association]. / Diagnóstico prenatal de acretismo placentario por ultrasonido y su asociación histopatológica.

Background: Anomalous adhesions of the placenta, known as placenta accreta and its variants, are the cause of obstetric hemorrhages that put the pregnant woman at risk. Accretism is strongly associated with a history of uterine surgery (cesarean section, myomectomy, curettage), as well as ultrasonographic signs, such as the presence and size of placental lacunae, loss of the placenta/bladder interface, location on the anterior face of the placenta, and presence of Doppler flow; these markers can be assessed by prenatal ultrasound. Objective: To analyze the association of prenatal diagnosis of placenta accreta by ultrasound with the histopathological result using the Tovbin index. Material and methods: Observational, cross-sectional and analytical study. 63 patients who had placenta accreta data by ultrasound measured with the Tovbin index and by means of the histopathological result obtained from the platform of the Mexican Institute for Social Security (IMSS) were included. The association between the two studies with the presence of placenta accreta was analyzed. Results: 63 patients were analyzed; the Tovbin index was positive in 89% of the patients with a diagnosis of placenta accreta confirmed by histopathology. Both the Tovbin index and the histopathology report showed a statistically significant association with a p value of 0.04 for the diagnosis of placenta accreta. Conclusion: The Tovbin index as an ultrasonographic prenatal diagnosis of placenta accreta has a statistically significant association with histopathology diagnosis.

Introducción: las adherencias anómalas de la placenta, conocidas como acretismo, y sus variantes son causa de hemorragias obstétricas que ponen en riesgo a la gestante. El acretismo se asocia firmemente con antecedentes de cirugías uterinas (cesárea, miomectomía, legrados), así como con signos ultrasonográficos como presencia y tamaño de lagunas placentarias, pérdida de la interfaz placenta/vejiga, localización en cara anterior de la placenta y presencia de flujo Doppler; estos marcadores pueden ser valorados mediante ecografía prenatal. Objetivo: analizar la asociación de diagnóstico prenatal de acretismo placentario por ultrasonido con el resultado histopatológico utilizando el Índice de Tovbin. Material y métodos: estudio observacional, transversal y analítico. Se incluyeron 63 pacientes que tenían datos de acretismo placentario por ultrasonido medido con el Índice de Tovbin y mediante el resultado histopatológico obtenido de la plataforma del Instituto Mexicano del Seguro Social. Se analizó la asociación de ambos estudios con la presencia de acretismo placentario. Resultados: se analizaron 63 pacientes; el Índice de Tovbin fue positivo en un 89% de las pacientes con diagnóstico de acretismo placentario confirmado por histopatología. Tanto el Índice de Tovbin como el reporte de histopatología mostraron una asociación estadísticamente significativa con un valor de p de 0.04 para el diagnóstico de acretismo placentario. Conclusión: el Índice de Tovbin como diagnóstico prenatal ultrasonográfico de acretismo placentario tiene asociación estadísticamente significativa con el diagnóstico de histopatología.

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.

Manejo de la hemorragia posparto en una paciente con útero bicorne con la sutura B-Lynch. Reporte de caso y revisión de la literatura / Management of postpartum hemorrhage in a patient with bicornuate uterus using the B-Lynch suture. Case report and review of the literature

Objetivos: Describir un caso de manejo con sutura de B-Lynch en una mujer con útero bicorne que presenta hemorragia posparto (HPP), y realizar una revisión de la literatura acerca de las estrategias de control quirúrgico de la HPP en pacientes con malformaciones müllerianas, los resultados maternos en términos de control de la hemorragia, así como las complicaciones tempranas y tardías. Materiales y métodos: Se reporta el caso de una paciente con útero bicorne, atendida en un hopsital de referencia regional, que, posterior a parto por cesárea, presenta hemorragia posparto, la cual es controlada con éxito empleando la sutura de B-Lynch. Se realizó una búsqueda en las siguientes bases de datos: PubMed, Embase, Medline, Google Scholar y LILACS. Se emplearon los términos MeSh: "Uterine Atony", "Postpartum Hemorrhage", "Immediate Postpartum Hemorrhage", "Bicornuate Uterus", "Mullerian Anomalies", "Mullerian Ducts Abnormalities", "Uterine Compression Suture". Se incluyeron reportes y series de casos que hubieran incluido pacientes con malformaciones müllerianas con HPP que no respondieran al manejo farmacológico inicial, con uso de procedimientos quirúrgicos conservadores para el control de la hemorragia. Se hace análisis narrativo de los hallazgos respecto a las características de los estudios, técnicas utilizadas y complicaciones. Resultados: Se seleccionaron 5 estudios, 4 de tipo reporte de caso y 1 serie de casos, que corresponden a 12 mujeres con malformación uterina que desarrollaron HPP, en las cuales se empleó manejo quirúrgico (suturas de compresión uterina), y con dispositivo (tipo balón intrauterino) para el control de la hemorragia, logrando controlar el sangrado en 11 casos, solo una (8,3 %) requirió histerectomía. No se reportan complicaciones a largo plazo. Conclusiones: El manejo de la HPP en mujeres con malformaciones uterinas müllerianas cuenta con una literatura limitada a reportes de casos, con uso tanto de suturas compresivas como dispositivos médicos tipo balones intrauterinos. La sutura compresiva tipo B-Lynch parece ser una buena alternativa en el control de la HPP en estas mujeres con el fin de preservar la fertilidad, con baja tasa de complicaciones. Se requiere continuar documentando este tipo de casos con el fin de consolidar evidencia de la utilidad de esta técnica en el control del sangrado uterino posparto en esta población.

Objectives: To describe the use of the B-Lynch suture in a case of postpartum hemorrhage of a woman with bicornuate uterus, and to carry out a review of the literature on PPH control strategies in patients with müllerian anomalies, maternal outcomes in terms of hemorrhage control, as well as early and late complications. Material and methods: Case report of a patient with bicornuate uterus who presented to a regional referral hospital with postpartum hemorrhage following a cesarean section, which was successfully controlled using the B-Lynch suture. A search was conducted in the PubMed, Embase, Medline, Google Scholar and LILACS databases. The MeSh terms used were: "Uterine Atony," "Postpartum Hemorrhage," "Immediate Postpartum Hemorrhage," "Bicornuate Uterus," "Müllerian Anomalies," "Müllerian Duct Abnormalities". Case reports and case series of patients with müllerian malformations and PPH not responding to initial pharmacological management in whom conservative surgical procedures were used to control bleeding were included. A narrative analysis of the findings was carried out based on study characteristics, techniques used and complications. Results: Five studies were selected, 4 case reports and 1 case series which included 12 women with uterine malformations who developed PPH and in whom surgical management (uterine compression sutures) or devices (intrauterine balloon) were used for hemorrhage control. Bleeding was successfully controlled in 11 cases, with hysterectomy required only in one case (8.3 %). No long-term complications were reported. Conclusions: The literature on PPH management in women with müllerian uterine malformations is limited to case reports in which either compression sutures or medical devices such as intrauterine balloons were used. The B-Lynch-type compression suture appears to be a good option for controlling PPH in these women in order to preserve fertility, with a low rate of complications. Further documentation of these types of cases is needed in order to build the evidence regarding the usefulness of this technique for controlling postpartum uterine bleeding in this population.

Resultados de la estrategia de código rojo en la atención a pacientes con hemorragia posparto / Results of the red code strategy in the care of patients with postpartum hemorrhage

Introducción: La estrategia de código rojo permite la atención inmediata, sistematizada y coordinada de la hemorragia posparto. Es un esquema de trabajo organizado que contribuye a un tratamiento oportuno y pertinente de la hemorragia obstétrica. Con esta herramienta, el equipo asistencial puede seguir los pasos indicados sin desviarse del objetivo, trabajar de manera ordenada y aplicarlo en cada situación específica, para disminuir la morbilidad y mortalidad materna. Objetivo: Caracterizar los resultados de la estrategia de código rojo en la atención a pacientes con hemorragia posparto en Villa Clara. Métodos: Se realizó un estudio de desarrollo, observacional, de corte transversal y retrospectivo de las pacientes con hemorragia posparto en Villa Clara, durante el período de enero 2018 a junio de 2021. La muestra no probabilística quedó conformada por 127 pacientes. Se utilizaron medidas de resumen para la descripción de las variables. En las cuantitativas se emplearon medidas de tendencia central y de dispersión (media y desviación estándar), para las variables cualitativas se mostraron frecuencias absolutas y relativas. Para establecer las relaciones entre variables se aplicó la prueba de independencia basada en la distribución Ji cuadrado. Resultados: En la evaluación del cumplimiento del protocolo de código rojo resultaron incorrectos algunos parámetros como: el diagnóstico de las etapas del choque y el tiempo de accionar. Conclusiones: Cada institución debe contar con protocolos y guías de atención de pacientes obstétricas con bases científicas que se correspondan a las posibilidades de cada país; estos protocolos deben facilitar y perfeccionar las acciones del médico.

Introduction: the red code strategy allows immediate, systematized and coordinated care of postpartum hemorrhage. It is an organized work scheme that contributes to timely and relevant treatment of obstetric hemorrhage. The healthcare team can follow with this tool the indicated steps without deviating from the objective, work in an orderly manner and apply it in each specific situation to reduce maternal morbidity and mortality. Objective: to characterize the results of the red code strategy in the care of patients with postpartum hemorrhage in Villa Clara. Methods: a retrospective, cross-sectional, observational and developmental study was carried out in patients with postpartum hemorrhage in Villa Clara from January 2018 to June 2021. The non-probabilistic sample consisted of 127 patients. Summary measures were used to describe the variables. Measures of central tendency and dispersion (mean and standard deviation) were used in the quantitative variables as well as absolute and relative frequencies were shown for the qualitative ones. The independence test based on the Chi-square distribution was applied to establish the relationships between variables. Results: some parameters were incorrect in the evaluation of compliance with the red code protocol such as the diagnosis of the stages of shock and the time to act. Conclusions: each institution must have protocols and guidelines for the care of obstetric patients with scientific bases that correspond to the possibilities of each country; these protocols should facilitate and improve the doctor's actions.

Influencia de la obesidad, los factores sociodemográficos y las características del parto en la aparición de la hemorragia posparto / Influence of obesity, sociodemograpgical factors and characteristitcs of delivery on the development of post-partum hemorrhage

Objetivo: analizar la asociación de las características sociodemográficas, la obesidad pregestacional, la ganancia ponderal excesiva durante la gestación y las características del parto, con el riesgo de sufrir una hemorragia posparto (HPP).Método: estudio descriptivo, transversal, retrospectivo realizado con mujeres cuyos partos acontecieron en el año 2018 en un hospital de segundo nivel. Se incluyeron mujeres gestantes con parto único, con un recién nacido vivo, a término, con parto vaginal y con un completo control gestacional en el hospital. Se recogió información de la historia clínica acerca de la edad y el origen de la mujer, el índice de masa corporal pregestacional, la ganancia ponderal durante la gestación y diferentes variables relacionadas con el parto. La variable resultado fue la HPP (> 500mL).Resultados: se incluyeron N= 831 mujeres. La edad media fue de 31,8 años (DE:5,38), el 62,7% era española; el 64,6%, multípara; el 41,7% presentaba sobrepeso/obesidad pregestacional; el 26,2%, una ganancia ponderal excesiva durante la gestación; el 89,3% tuvo un parto eutócico y el 70,4% de los alumbramientos fue dirigido. Veinte mujeres presentaron HPP (2,4%). No se halló asociación con ninguna característica de las estudiadas a excepción del tipo de alumbramiento (p= 0,039). Las pacientes con alumbramiento no-espontáneo presentaron mayor riesgo de sufrir HPP: 5,39 veces más (1,13-25,75; p= 0,022) cuando el alumbramiento era dirigido y 5,29 (1,3-21,69; p= 0,013) cuando era manual.Conclusiones: ni los factores sociodemográficos ni las características antropométricas pre y posgestacionales influyen en la aparición de HPP. Un alumbramiento no-espontáneo aumenta el riesgo de HPP hasta cinco veces más. Estos datos deben ser interpretados con cautela.(AU)

Objective: to analyse the association of sociodemographic characteristics, pre-pregnancy obesity, excessive weight gain during pregnancy and characteristics of delivery with the risk of suffering a post-partum haemorrhage (PPH).Method: a retrospective, cross-sectional, descriptive study conducted with women who gave birth during 2018 in a second level hospital. The study included pregnant women with single birth of a live newborn at term, with vaginal delivery and complete pregnancy monitoring at hospital. The following information was collected from the clinical record: age and origin of the mother, pre-pregnancy body mass index, weight gain during pregnancy, and different variables associated with delivery. The outcome variable was PPH (> 500mL).Results: the study included N= 831 women; their mean age was 31.8 years (SD:5.38), 62.7% were Spanish; 64.6% were multiparous; 41.7% presented pre-pregnancy overweight / obesity; 26.2% had an excessive weight gain during pregnancy; 89,3% had natural deliveries and 70,4% of deliveries were directed. Twenty women presented PPH (2.4%). No association was found with any of the characteristics studied, except for type of delivery (p= 0.039). Patients with non-spontaneous delivery presented higher risk of suffering PPH; 5.39 times more (1.13-25.75; p= 0.022) when delivery was directed and 5.29 (1.3-21.69; p= 0.013) when it was manual.Conclusions: neither sociodemographic factors nor pre and post-pregnancy anthropometric characteristics have influence on the development of PPH. Non-spontaneous delivery increases the risk of PPH up to five times more. These data must be interpreted cautiously.(AU)

Manejo de la hemorragia posparto por parte de las matronas en centros sanitarios del estado de Ekiti: estudio cualitativo exploratorio / Management of postpartum hemorrhage by midwives in healthcare facilities in Ekiti state: An exploratory qualitative study

Objetivos: La mortalidad materna continúa planteando un desafío crítico en la práctica obstétrica, siendo la hemorragia posparto (HPP) una de las principales causas. El objetivo de este estudio fue explorar las experiencias vividas de matronas en relación con el manejo de la HPP. Métodos: El estudio empleó un enfoque fenomenológico cualitativo. Los participantes fueron seleccionados utilizando la técnica de muestreo intencional, reclutándose un total de 15 participantes para el estudio. La recopilación de datos se realizó utilizando una entrevista guiada semiestructurada para entrevistas en profundidad. Las entrevistas fueron grabadas en audio, y el análisis de datos se realizó mediante análisis temático. Resultados: Dos temas emergieron del análisis: 1) prácticas de manejo adoptadas contra la HPP y 2) protocolo hospitalario para el manejo de la HPP. Las principales prácticas de manejo adoptadas por las matronas fueron el uso de uterotónicos, especialmente la oxitocina junto con otras prácticas de manejo como el uso de prendas antichoque, estimulación de las contracciones por frotamiento del útero, evaluación de la causa del sangrado y sutura de laceraciones. También se dedujo que los diferentes centros sanitarios tienen su propia política para el manejo de la HPP. Las barreras que afectan el manejo efectivo de la HPP incluyen la falta de personal, la falta de disponibilidad de instalaciones y equipos adecuados, las restricciones de las enfermeras/parteras en el manejo de la HPP, la política hospitalaria desfavorable y la falta de comunicación entre el equipo de atención sanitaria. Conclusión: Las experiencias de los participantes sugieren que están algo satisfechos con el manejo de la HPP en sus centros. Sin embargo, deben abordarse las barreras como la falta de personal, la falta de disponibilidad de equipos, la mala comunicación entre los equipos...(AU)

Objectives: Maternal mortality continues to pose a critical challenge in obstetric practice, with postpartum haemorrhage as one of the major causes. This study aimed to explore the lived experiences of midwives regarding the management of postpartum hemorrhage (PPH). Methods: The study employed a qualitative phenomenological approach. Participants were selected using purposive sampling technique, and 15 participants were recruited for the study. Data collection was done using a semi-structured interview guide for in-depth interviews. The interviews were audio-recorded, and data analysis was done using thematic analysis. Results: Two themes emerged from the analysis, including 1) management practices adopted against PPH and 2) hospital protocol for the management of PPH. The major management practices adopted by the midwives were using uterotonics, especially oxytocin, and other management practices such as anti-shock garments, stimulation of contractions by rubbing the uterus, and assessment of the cause of bleeding and suturing of lacerations. It was also deduced that different healthcare facilities had policies for managing postpartum hemorrhage. Barriers affecting the effective management of PPH were understaffing, unavailability of suitable facilities and equipment, restrictions on nurses/midwives in managing PPH, unfavourable hospital policy and lack of communication among the healthcare team. Conclusion: The participants’ experiences suggest they are somewhat satisfied with PPH management in their facilities. However, barriers such as understaffing, unavailability of equipment, poor communication among healthcare teams and restrictions on nurses in PPH management should be addressed to improve midwives’ experiences in PPH management.(AU)

Complicaciones hemorrágicas y trombóticas del embarazo: diagnóstico, prevención y tratamiento

Las hemorragias y la enfermedad tromboembólica venosa (ETEV) figuran entre las cinco causas más frecuentes de morbilidad y mortalidad materna en el mundo. Revisamos la evaluación y el manejo actualizado de las causas obstétricas de la hemorragia posparto (HPP), así como el diagnóstico y manejo de condiciones hematológicas que pueden causar o agravar la HPP, por ejemplo: coagulación intravascular diseminada, enfermedad de von Willebrand, trombocitopenia autoinmune y las microangiopatías trombóticas. Revisamos el rol del síndrome antifosfolípido y las trombofilias hereditarias como factores predisponentes a pérdidas fetales recurrentes y la ETEV en el embarazo y las recomendaciones actuales para la prevención de ambas complicaciones. Asimismo, repasamos el abordaje diagnóstico y líneas de manejo de la ETEV. Un objetivo adicional fue enfatizar la importancia del trabajo colaborativo multidisciplinario para lograr el manejo exitoso de las gestantes con las complicaciones obstétricas y hematológicas descritas.

Bleeding and venous thromboembolism (VTE) are among the five most common causes of morbidity and mortality in pregnant women worldwide. This review describes the current evaluation and management of the obstetric causes of postpartum hemorrhage (PPH), as well as the diagnosis and management of hematologic conditions which can cause or worsen PPH, such as disseminated intravascular coagulation, von Willebrand disease, autoimmune thrombocytopenia and the thrombotic microangiopathies. It also describes the role of the antiphospholipid syndrome and inherited thrombophilia as predisposing factors for recurrent pregnancy loses and VTE, and the current recommendations for the prevention of both complications. As well, the current diagnostic approach and management of ETEV are described. An additional objective of this Review is to emphasize the importance of a collaborative multidisciplinary approach for the successful management of the obstetric and hematologic complications herein described.

Desenlaces maternos según el tipo de placenta previa en un hospital de alta complejidad en Cali, Colombia. Estudio de cohorte retrospectivo / Maternal outcomes according to the type of placenta previa in a high complexity hospital in Cali, Colombia. Retrospective cohort study

Objetivos: Describir la frecuencia de complicaciones maternas en mujeres gestantes con placenta previa (PP) mayor o menor y evaluar una posible asociación entre tipo de PP y la presencia de hemorragia materna severa y otros resultados maternos asociados. Materiales y métodos: Cohorte retrospectiva, descriptiva. Se incluyeron gestantes con 20 semanas o más de embarazo, con diagnóstico confirmado de placenta previa, quienes fueron atendidas en un hospital de alto nivel de complejidad localizado en Cali (Colombia), entre enero de 2011 y diciembre de 2020. Se excluyeron las gestantes con diagnóstico de placenta previa y acretismo placentario concomitante. Las variables recolectadas fueron: edad materna, índice de masa corporal, tabaquismo, obesidad, paridad, presencia de sangrado, hemorragia posparto, manejo de la hemorragia posparto, transfusión y admisión a UCI de la gestante. Se realizó análisis descriptivo. El protocolo fue aprobado por el comité de ética de la Fundación Valle de Lili. Resultados: 146 pacientes cumplieron con los criterios de inclusión. La población estuvo constituida por mujeres con una mediana de edad de 32 años, sin antecedente quirúrgico, con diagnóstico prenatal de placenta previa a la semana 22. En el 70,5 % de los casos se trató de pacientes con placenta previa mayor. Las complicaciones más frecuentes fueron hemorragia posparto (37,9 % vs. 16,3 % para pacientes con placenta previa mayor y menor, respectivamente), requerimiento de transfusión (23,3 y 9,3 %, respectivamente) y el ingreso materno a la UCI (40,8 % vs. 18,6 %, respectivamente). No se registraron muertes maternas. Conclusiones: Las mujeres con placenta previa experimentan una frecuencia elevada de complicaciones; probablemente, dicha frecuencia es más alta cuando se documenta placenta previa mayor. Se requieren más estudios que comparen la frecuencia de complicaciones maternas según el tipo de placenta previa.

Objectives: To describe the frequency of maternal complications in pregnant women with major or minor placenta previa (PP), and to assess a potential association between PP type and the presence of severe maternal bleeding and other associated outcomes. Material and methods: Retrospective descriptive cohort. The study included pregnant women with 20 weeks of gestation or more and a confirmed diagnosis of placenta previa who were seen in a high complexity hospital in Cali (Colombia), between January 2011 and December 2020. Women with a diagnosis of placenta previa and concomitant placenta accreta were excluded. The collected variables were maternal age, body mass index, smoking, obesity, parity, presence of bleeding, postpartum hemorrhage, management of postpartum hemorrhage, transfusion, and maternal ICU admission. A descriptive analysis was performed. The protocol was approved by the ethics committee of Fundaciónn Valle de Lili. Results: A total of 146 patients met the inclusion criteria. The population consisted of women with a mean age of 32 years, with no history of prior surgery, with a prenatal diagnosis of placente previa at week 22; 70% were major placenta previa cases. The most frequent complications were postpartum hemorrhage (37.9 % vs. 16.3 % for patients with major and minor placenta previa, respectively), transfusion requirement (23.3 and 9.3 %, respectively), and maternal ICU admission (40.8 % vs. 18.6 %, respectively). There were no cases of maternal death. Conclusions: There is a high frequency of complications in women with placenta previa, and it is probably higher in cases of major placenta previa. Further studies are needed to compare the frequency of maternal complications according to the type of placenta previa.

Codetecção de dengue e chikungunya durante a gestação: relato de caso / Dengue and chikungunya codetection during pregnancy: case report

Introdução: A tripla circulação de arboviroses no cenário nacional, traz uma constante preocupação para a saúde pública. Relato de caso: Gestante, 38 anos, primigesta, apresenta infecção aguda com quadro de febre, artralgia e mialgia, alteração de níveis pressóricos, elevação de enzimas hepáticas, plaquetopenia e elevação de LDH que gerou quadro grave, resultando em parto de emergência e hemorragia pós-parto maciça. Após suspeição e realização de exames sorológicos, foi constatado codetecção por dengue e chikungunya. Considerações finais: A codetecção de dengue aguda e chikungunya gerou quadro de pré-eclâmpsia e hemorragia pós-parto. Após conduta oportuna, gestante e RN seguiram bem e em alta. Tal situação serve de alerta para vigilância epidemiológica.

Introduction: The triple circulation of arboviruses on the national scene is a constant concern for public health. Case report: Pregnant woman, 3 years old, primigravidae, presented with an acute infection with fever, arthralgia and myalgia, changes in blood pressure levels, elevated liver enzymes, thrombocytopenia and elevated LDH levels, which generated a severe condition, resulting in emergency delivery and hemorrhage. massive postpartum. After suspicion and serological tests, co-detection by dengue and chikungunya was confirmed. Final considerations: The co-detection of acute dengue and chikungunya generated preeclampsia and postpartum hemorrhage. After timely conduct, the pregnant woman and the NB continued well and were discharged. This situation serves as a warning for epidemiological surveillance.

Management of postpartum hemorrhage by midwives in selected healthcare facilities in Ekiti State: An exploratory qualitative study.

OBJECTIVES: Maternal mortality continues to pose a critical challenge in obstetric practice, with postpartum haemorrhage as one of the major causes. This study aimed to explore the lived experiences of midwives regarding the management of postpartum haemorrhage (PPH). METHODS: The study employed a qualitative phenomenological approach. Participants were selected using purposive sampling technique, and 15 participants were recruited for the study. Data collection was done using a semi-structured interview guide for in-depth interviews. The interviews were audio-recorded, and data analysis was done using thematic analysis. RESULTS: Two themes emerged from the analysis, including 1) management practices adopted against PPH and 2) hospital protocol for the management of PPH. The major management practices adopted by the midwives were using uterotonics, especially oxytocin, and other management practices such as anti-shock garments, stimulation of contractions by rubbing the uterus, and assessment of the cause of bleeding and suturing of lacerations. It was also deduced that different healthcare facilities had policies for managing postpartum haemorrhage. Barriers affecting the effective management of PPH were understaffing, unavailability of suitable facilities and equipment, restrictions on nurses/midwives in managing PPH, unfavourable hospital policy and lack of communication among the healthcare team. CONCLUSION: The participants' experiences suggest they are somewhat satisfied with PPH management in their facilities. However, barriers such as understaffing, unavailability of equipment, poor communication among healthcare teams and restrictions on nurses in PPH management should be addressed to improve midwives' experiences in PPH management.

Fetal Macrosomia and Postpartum Hemorrhage in Latin American and Caribbean Region: Systematic Review and Meta-analysis / Macrossomia fetal e hemorragia pós-parto na região da América Latina e Caribe: Revisão sistemática e metanálise

Abstract Objective To determine the association between fetal macrosomia (FM) and postpartum hemorrhage (PPH) in Latin American and Caribbean (LAC) women. Data Sources Studies evaluating the association between FM and PPH (≥ 500 ml) and severe PPH (≥ 1,000 ml) until November 4, 2021, indexed in CINHAL, Scopus, Embase, Cochrane Library, MEDLINE, LILACS, and SciELO. Selection of Studies Inclusion criteria were cohort and case-control studies that provided the number of PPH and FM cases. Exclusion criteria were studies lacking information about the number of cases, with a population of women who were not from LAC; published in a language other than English, Spanish, or Portuguese, and with a different design. Data Collection Data extraction was performed independently by two authors, and discrepancies were resolved with a third author. Data regarding FM and PPH cases were retrieved. Data Synthesis Of the 1,044 articles evaluated, 5 studies were included, from 6 different countries: Argentina and Uruguay (multi-country), West Indies, Antigua and Barbuda, French Guyana, and Suriname. The pooled odds ratio (OR) for FM and PPH in the meta-analysis (five studies) was 2.10 (95% confidence interval [CI]: 1.79-2.47; I2: 0%), with estimates within this 95% CI in the sensitivity analysis. The combined OR for severe PPH (3 studies) was 1.61 (95% CI: 0.40-6.48; I2: 91.89%), showing high heterogeneity. Conclusion There was a positive association between FM and PPH in the LAC, increasing the risk of the presence of this event 2-fold. The high heterogeneity of the studies that measured severe PPH does not allow drawing conclusions about the estimates obtained.

Resumo Objetivo Determinar a associação entre macrossomia fetal (FM) e hemorragia pós-parto (HPP) em mulheres da América Latina e Caribe (ALC). Fontes de dados Estudos avaliando a associação entre FM e HPP (≥ 500 ml) e HPP grave (≥ 1.000 ml) até 4 de novembro de 2021, indexados no CINHAL, Scopus, Embase, Biblioteca Cochrane, MEDLINE, LILACS e SciELO. Seleção de estudos Os critérios de inclusão foram estudos de corte e caso-controle que forneceram o número de casos de HPP e FM. Os critérios de exclusão foram estudos sem informação sobre o número de casos, com uma população de mulheres que não eram da ALC; publicado em um idioma diferente do inglês, espanhol ou português e com um design diferente. Coleta de dados A extração de dados foi realizada independentemente por dois autores, as discrepâncias foram resolvidas com um terceiro autor. Os dados relativos aos casos de FM e HPP foram recuperados. Síntese dos dados Dos 1.044 artigos avaliados, foram incluídos 5 estudos, de 6 países diferentes: Argentina e Uruguai (multipaíses), Índias Ocidentais, Antígua e Barbuda, Guiana Francesa e Suriname. O odds ratio agrupado (OR) para FM e HPP na meta-análise (cinco estudos) foi de 2,10 (intervalo de confiança de 95% [IC]: 1,79-2,47; I2: 0%), com estimativas dentro deste IC de 95% no análise sensitiva. O OR combinado para HPP grave (3 estudos) foi de 1,61 (95% CI: 0.40-6.48; I2: 91.89%), mostrando alta heterogeneidade. Conclusão Houve associação positiva entre FM e HPP na ALC, aumentando em 2 vezes o risco da presença desse evento. A alta heterogeneidade dos estudos que mediram a HPP grave não permite tirar conclusões sobre as estimativas obtidas.

Diferencias en la gravedad del choque hemorrágico en mujeres con placenta previa y acretismo placentario antes y durante la pandemia de COVID-19 / Differences in the degree of hemorrhagic shock in women with placental insertion anomalies before and during the COVID-19 pandemic / Diferenças na gravidade do choque hemorrágico em mulheres com placenta previa e acretismo placentário antes e durante a pandemia de COVID-19

Resumen: Introducción: estudios previos han mostrado una mayor incidencia de todas las causas de hemorragia postparto durante la pandemia de COVID-19. El acretismo placentario es una causa frecuente de hemorragia postparto. Objetivo: determinar las diferencias en la severidad del choque hemorrágico y la cantidad de sangrado en mujeres con diagnóstico del espectro placenta previa-acretismo, antes de la pandemia y durante la pandemia por COVID-19. Material y métodos: en un estudio con cohortes comparativas de mujeres con placenta previa-acretismo, atendidas en el Instituto Nacional de Perinatología, durante el periodo de enero de 2017 a diciembre de 2019, grupo I (prepandemia), y de enero de 2020 a marzo de 2022, grupo II (pandemia), se comparó entre los grupos la cantidad de hemorragia y la clase del choque hemorrágico de acuerdo a ATLS. Resultados: se estudió a 277 mujeres, 211 fueron del grupo I (pre-COVID-19) y 66 del grupo II (COVID-19), se observó una mayor cantidad de sangrado durante la pandemia de COVID versus la fase pre-COVID (2,150.56 ± 1,910.08 mL versus 1,246.34 ± 1,494.1 mL) p = 0.001, existieron diferencias en las proporciones de la gravedad del choque hemorrágico en la fase de pandemia para las clases III y IV. Conclusión: se encontró un incremento en la cantidad de sangrado y gravedad del choque durante la pandemia de COVID-19.

Abstract: Introduction: previous studies have shown an increased incidence of all-cause postpartum hemorrhage during the COVID-19 pandemic. Placental accreta is a frequent cause of hemorrhagic shock. Objective: determine the severity of shock and the amount of bleeding during the COVID-19 pandemic in women diagnosed with placenta previa and placental accreta. Material and methods: in a comparative cohort study of women with placenta previa and accreta treated at the National Institute of Perinatology during the period from January 2017 to December 2019 group I (pre-pandemic) and from January 2020 to March 2022 group II (pandemic) the amount of hemorrhage and the class of hemorrhagic shock according to ATLS were compared between the groups. Results: 277 women were studied, 211 were from group I (pre COVID-19) and 66 from group II (COVID-19). A greater amount of bleeding was observed during the COVID pandemic versus the pre COVID phase (2,150.56 ± 1,910.08 mL vs 1,246.34 ± 1,494.1 mL) p = 0.001, there were differences in the proportions of severity of hemorrhagic shock in the pandemic phase for classes III and IV. Conclusion: an increase in the amount of bleeding and severity of shock was found during the COVID-19 pandemic.

Resumo: Introdução: estudos anteriores mostraram uma maior incidência de hemorragia pós-parto de todas as causas durante a pandemia de COVID-19. O acretismo placentário é uma causa frequente de hemorragia pós-parto. Objetivo: determinar as diferenças na gravidade do choque hemorrágico e na quantidade de sangramento em mulheres diagnosticadas com o espectro de placenta prévia-acretismo antes da pandemia e durante a pandemia de COVID-19. Material e métodos: em um estudo de coorte comparativo de mulheres com placenta prévia e acreta tratadas no Instituto Nacional de Perinatologia durante o período de janeiro de 2017 a dezembro de 2019, grupo I (pré-pandemia) e de janeiro de 2020 a março de 2022, grupo I II (pandemia) a quantidade de sangramento e a classe de choque hemorrágico de acordo com o ATLS foram comparadas entre os grupos. Resultados: foram estudadas 277 mulheres, 211 eram do grupo I (pré-COVID-19) e 66 do grupo II (COVID-19). Observou-se uma maior quantidade de sangramento durante a pandemia de COVID versus a fase pré-COVID (2,150.56 ± 1,910.08 mL vs 1,246.34 ± 1,494.1 ml) p = 0.001, houve diferenças nas proporções da gravidade do choque hemorrágico na fase pandêmica para as classes III e IV. Conclusão: um aumento na quantidade de sangramento e gravidade do choque foi encontrado durante a pandemia de COVID-19.

Prevalence of risk factors for primary postpartum hemorrhage in a university hospital / Prevalencia de factores de riesgo de hemorragia posparto primaria en un hospital universitario / Prevalência dos fatores de risco para hemorragia pós-parto primária em um hospital universitário

ABSTRACT Objectives: to identify the risk factors associated with primary postpartum hemorrhage in a university hospital. Methods: a cross-sectional study was conducted with 277 postpartum women who received care during childbirth or cesarean section between June and August 2020. Data were collected using a pre-structured questionnaire administered 24 hours after delivery. Poisson Regression was employed to analyze the factors associated with postpartum hemorrhage. Results: postpartum hemorrhage was observed in 30% of the study sample. Shock Index and uterine distension were found to be statistically associated with postpartum hemorrhage. Postpartum women with a Shock Index ≥ 0.9 had a 61% higher prevalence of postpartum hemorrhage (PR=1.61, 95% CI: 1.07 - 2.43), while those with uterine distension had a 134% higher prevalence (PR=2.34, 95% CI: 1.63 - 3.36). Conclusions: recognizing these factors contributes to improvements in clinical practice, as they enable the prediction of their occurrence and call for appropriate management, thereby preventing unfavorable outcomes.

RESUMEN Objetivos: identificar los factores de riesgo asociados con la hemorragia posparto primaria en un hospital universitario. Métodos: se realizó un estudio transversal con 277 mujeres posparto que recibieron atención durante el parto o la cesárea entre junio y agosto de 2020. Los datos se recopilaron mediante un cuestionario preestructurado administrado 24 horas después del parto. Se empleó una Regresión de Poisson para analizar los factores asociados con la hemorragia posparto. Resultados: se observó hemorragia posparto en el 30% de la muestra del estudio. El índice de choque y la distensión uterina se encontraron estadísticamente asociados con la hemorragia posparto. Las mujeres posparto con un índice de choque ≥ 0,9 tenían una prevalencia de hemorragia posparto un 61% mayor (PR=1,61, IC del 95%: 1,07 - 2,43), mientras que aquellas con distensión uterina tenían una prevalencia un 134% mayor (PR=2,34, IC del 95%: 1,63 - 3,36). Conclusiones: reconocer estos factores contribuye a mejoras en la práctica clínica, ya que permiten predecir su ocurrencia y requieren una gestión adecuada, previniendo así resultados desfavorables.

RESUMO Objetivos: identificar os fatores de risco associados à hemorragia pós-parto primária em um hospital universitário. Métodos: estudo transversal realizado com 277 puérperas que receberam assistência durante o parto ou cesárea no período de junho a agosto de 2020. Os dados foram coletados por meio de um questionário previamente estruturado, aplicado após 24 horas do nascimento. Para a análise dos fatores associados à hemorragia pós-parto, utilizou-se a Regressão de Poisson. Resultados: a hemorragia pós-parto foi observada em 30% da amostra do estudo. O Índice de Choque e a distensão uterina foram estatisticamente associados à hemorragia pós-parto. Puérperas com Índice de Choque ≥ 0,9 apresentam uma prevalência 61% maior de hemorragia pós-parto (RP=1,61; IC 95%: 1,07 - 2,43) e com distensão uterina 134% (RP=2,34; IC 95%: 1,63 - 3,36). Conclusões: o reconhecimento desses fatores subsidia melhorias na prática clínica, visto que possibilitam a previsão de sua ocorrência e alertam para o manejo adequado, prevenindo desfechos indesejáveis.

Quantification of blood loss for the diagnosis of postpartum hemorrhage: a systematic review and meta-analysis / Cuantificación de la pérdida de sangre para el diagnóstico de hemorragia posparto: revisión sistemática y metanálisis / Quantificação da perda sanguínea para o diagnóstico de hemorragia pós-parto: revisão sistemática e metanálise

ABSTRACT Objective: to compare the effectiveness of different diagnostic methods to estimate postpartum blood volume loss. Methods: a systematic review of effectiveness according to PRISMA and JBI Protocol. Searches in PubMed/MEDLINE, LILACS, Scopus, Embase, Web of Science and CINAHL, with descriptor "Postpartum Hemorrhage" associated with keyword "Quantification of Blood Loss". Tabulated extracted data, presented in metasynthesis and meta-analysis was applied to quantitative data. To assess risk of bias, JBI Appraisal Tools were applied. Results: fourteen studies were included, published between 2006 and 2021. Quantification of loss by any method was superior to visual estimation and is highly recommended, however the studies' high heterogeneity did not allow estimating this association. Conclusion: the studies' high heterogeneity, with a probable margin of error given the uncontrolled factors, indicates the need for further studies, however quantification proved to be effective in relation to visual estimate. PROSPERO registration CRD 42021234486.

RESUMEN Objetivo: comparar la efectividad de diferentes métodos diagnósticos para estimar la pérdida de volumen sanguíneo posparto. Métodos: revisión sistemática de efectividad según PRISMA y Protocolo JBI. Búsquedas en bases de datos: PubMed/MEDLINE, LILACS, Scopus, Embase, Web of Science y CINAHL, con el descriptor "Postpartum Hemorrhage" asociado a la palabra clave "Quantification of Blood Loss". Los datos extraídos tabulados fueron presentados en metasíntesis y metanálisis se aplicaron a los datos cuantitativos. Para evaluar el riesgo de sesgo, se aplicaron las herramientas de evaluación de JBI. Resultados: se incluyeron 14 estudios, publicados entre 2006 y 2021. La cuantificación de pérdida por cualquier método fue superior a la estimación visual y es muy recomendable, sin embargo, la alta heterogeneidad de los estudios no permitió estimar esta asociación. Conclusión: la alta heterogeneidad de los estudios, con probable margen de error dado el descontrol de los factores, indica la necesidad de más estudios, sin embargo la cuantificación demostró ser efectiva en relación a la estimación visual. Registro PRÓSPERO CRD 42021234486.

RESUMO Objetivo: comparar a efetividade de diferentes métodos diagnósticos para estimar a perda volêmica sanguínea pós-parto. Métodos: revisão sistemática de efetividade, de acordo com protocolo PRISMA e JBI. Buscas nas bases PubMed/MEDLINE, LILACS, Scopus, Embase, Web of Science e CINAHL, com o descritor "Postpartum Hemorrhage" associado à palavra-chave "Quantification of Blood Loss". Dados extraídos tabulados, apresentados em metassíntese, e aplicou-se metanálise para dados quantitativos. Para avaliar o risco de viés, aplicou-se o JBI Appraisal Tools. Resultados: incluídos 14 estudos, publicados entre 2006 e 2021. A quantificação da perda por qualquer método apresentou superioridade em relação à estimativa visual, sendo altamente recomendada, porém a alta heterogeneidade dos estudos não permitiu estimar essa associação. Conclusão: a alta heterogeneidade dos estudos, com provável margem de erro dado aos fatores não controlados, indica a necessidade de realização de novos estudos, contudo a quantificação se mostrou efetiva em relação à estimativa visual. Registro PROSPERO CRD 42021234486.