A Narrative Review on the Pathophysiology of Preeclampsia.

Preeclampsia (PE) is a multifactorial pregnancy disorder characterized by hypertension and proteinuria, posing significant risks to both maternal and fetal health. Despite extensive research, its complex pathophysiology remains incompletely understood. This narrative review aims to elucidate the intricate mechanisms contributing to PE, focusing on abnormal placentation, maternal systemic response, oxidative stress, inflammation, and genetic and epigenetic factors. This review synthesizes findings from recent studies, clinical trials, and meta-analyses, highlighting key molecular and cellular pathways involved in PE. The review integrates data on oxidative stress biomarkers, angiogenic factors, immune interactions, and mitochondrial dysfunction. PE is initiated by poor placentation due to inadequate trophoblast invasion and improper spiral artery remodeling, leading to placental hypoxia. This triggers the release of anti-angiogenic factors such as soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng), causing widespread endothelial dysfunction and systemic inflammation. Oxidative stress, mitochondrial abnormalities, and immune dysregulation further exacerbate the condition. Genetic and epigenetic modifications, including polymorphisms in the Fms-like tyrosine kinase 1 (FLT1) gene and altered microRNA (miRNA) expression, play critical roles. Emerging therapeutic strategies targeting oxidative stress, inflammation, angiogenesis, and specific molecular pathways like the heme oxygenase-1/carbon monoxide (HO-1/CO) and cystathionine gamma-lyase/hydrogen sulfide (CSE/H2S) pathways show promise in mitigating preeclampsia's effects. PE is a complex disorder with multifactorial origins involving abnormal placentation, endothelial dysfunction, systemic inflammation, and oxidative stress. Despite advances in understanding its pathophysiology, effective prevention and treatment strategies remain limited. Continued research is essential to develop targeted therapies that can improve outcomes for both mothers and their babies.

Peripartum Hysterectomy: Is There Any Difference Between Emergency and Planned Surgeries? / Histerectomia periparto: Existe alguma diferença entre as cirurgias de emergência e planejada?

Abstract Objective To compare the outcomes of emergency and planned peripartum hysterectomies. Methods The present retrospective cross-sectional study was conducted in two hospitals. Maternal and neonatal outcomes were compared according to emergency and planned peripartum hysterectomies. Results A total of 34,020 deliveries were evaluated retrospectively, and 66 cases of peripartum hysterectomy were analyzed. Of these, 31 were cases of planned surgery, and 35 were cases of emergency surgery. The patients who underwent planned peripartum hysterectomy had a lower rate of blood transfusion (83.9% versus 100%; p=0.014), and higher postoperative hemoglobin levels (9.9±1.3 versus 8.3±1.3; p<0.001) compared with the emergency hysterectomy group. The birth weight was lower, although the appearance, pulse, grimace, activity, and respiration (Apgar) scores were higher in the planned surgery group compared with the emergency cases. Conclusion Planned peripartum hysterectomy with an experienced team results in less need for transfusion and improved neonatal outcomes compared with emergency peripartum hysterectomy.

Resumo Objetivo Comparar os resultados das histerectomias periparto de emergência e planejada. Métodos Este estudo transversal retrospectivo foi realizado em dois hospitais. Os resultados maternos e neonatais foram comparados de acordo com as histerectomias periparto de emergência e planejada. Resultados Um total de 34.020 partos foram avaliados retrospectivamente, e 66 casos de histerectomia periparto foram analisados. Destes, 31 eram casos de cirurgias planejadas, e 35, cirurgias de emergência. As pacientes que foram submetidas à histerectomia periparto planejada tiveram uma taxa menor de transfusão de sangue (83,9% versus 100%; p=0,014), e níveis mais elevados de hemoglobina pós-operatória (9,9±1,3 versus 8,3±1,3; p<0,001) em comparação com o grupo de histerectomia de emergência. O peso ao nascer foi menor, embora as pontuações na escala de aparência, frequência cardíaca, irritabilidade reflexa, tônus muscular, e respiração (appearance, pulse, grimace, activity, and respiration, Apgar, em inglês) fossem maiores no grupo da cirurgia planejada em comparação com os casos de emergência. Conclusão A histerectomia periparto planejada com uma equipe experiente resulta em menos necessidade de transfusão e melhora os resultados neonatais em relação à histerectomia periparto de emergência.

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.

Expanding the field of acute care surgery: a systematic review of the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in cases of morbidly adherent placenta.

PURPOSE: Prophylactic placement of endovascular balloon occlusion catheters has grown to be part of the surgical plans to control intraoperative hemorrhage in cases of abnormal placentation. We performed a systematic literature review to investigate the safety and effectiveness of the use of REBOA during cesarean delivery in pregnant woman with morbidly adherent placenta. METHODS: A systematic review was performed. Relevant case reports and nonrandomized studies were identified by the literature search in MEDLINE. We included studies involving pregnant woman with diagnosis of abnormal placentation who underwent cesarean delivery with REBOA placed for hemorrhage control. MINORS' criteria were used to evaluate the risk of bias of included studies. A formal meta-analysis was not performed. RESULTS: Eight studies were included in cumulative results. These studies included a total of 392 patients. Overall, REBOA was deployed in 336 patients. Six studies reported the use of REBOA as an adjunct for prophylactic hemorrhage control in pregnant woman with diagnosis of morbidly adherent placenta undergoing elective cesarean delivery. In two studies, REBOA was deployed in patients already in established hemorrhagic shock at the moment of cesarean delivery. REBOA was deployed primarily by interventional radiologists; however, one study reported a surgeon as the REBOA provider. The results from our qualitative synthesis indicate that the use of REBOA during cesarean delivery resulted in less blood loss with a low rate complications occurrence. CONCLUSION: REBOA is a feasible, safe, and effective means of prophylactic and remedial hemorrhage control in pregnant women with abnormal placentation undergoing cesarean delivery.