Uterine tamponade in postpartum hemorrhage with handmade balloons: Comparison of manufacturing, infusion, and total times.

OBJECTIVE: To compare the manufacturing, infusion, and total times of handmade balloons for uterine tamponade using the El Hennawy and Alves techniques, given the failure of initial measures and uterotonic therapy to control postpartum hemorrhage. METHODS: An open clinical trial (clinical article) was conducted among 30 physicians, residents, and assistants in an Obstetrics Department. Each participant manufactured and infused one of two different balloons compared in the study, in a randomly predefined sequence. The manufacturing and infusion times were timed by the researchers and their medians were compared using the t test or Mann-Whitney U test. RESULTS: The manufacturing time of the El Hennawy balloon was 72 s lower in relation to the Alves balloon (P < 0.010). Regarding the infusion time, the Alves balloon was filled faster than the El Hennawy balloon (P < 0.010). The total time (manufacturing and infusion) of Alves balloon was also lower than the El Hennawy device (P < 0.010). CONCLUSIONS: Although the El Hennawy balloon was manufactured more quickly, the total time of manufacturing and infusing the Alves balloon was much faster, which makes it the most suitable device to be used in critical situations of postpartum hemorrhage.

Manejo quirúrgico conservador de la hemorragia posparto mediante sutura compresiva uterina (Técnica de Hayman). Reporte de caso / Conservative surgical management of postpartum hemorrhage by uterine compressive suture (Hayman technique). Case report

La hemorragia posparto es una de las complicaciones más frecuentes en obstetricia, siendo la segunda causa de mortalidad materna a nivel mundial. La atonía uterina es su principal causa. Instaurada la hemorragia, el tiempo y el manejo de la misma dependerá de la experticia del obstetra. Inicialmente el tratamiento se enfoca en el uso de fármacos uterotónicos, pero al no existir una respuesta adecuada se puede optar por un manejo quirúrgico conservador. Las suturas compresivas uterinas son consideradas una buena opción de tratamiento. Una técnica quirúrgica efectiva y sencilla es la descrita por Hayman, una herramienta valiosa para el control de la hemorragia posparto. Se presenta el caso de una paciente de 17 años, con embarazo de 37 semanas y diagnóstico de preeclampsia grave, quien presenta desprendimiento prematuro de placenta y atonía uterina posterior, a quien se le realizó sutura compresiva uterina por técnica de Hayman, con evolución satisfactoria(AU)

Postpartum hemorrhage is one of the most frequent complications in obstetrics, being the second cause of maternal mortality worldwide. Uterine atony is its main cause. Once the hemorrhage is established, the time and management of it will depend on the expertise of the obstetrician. Initially, treatment focuses on the use of uterotonic drugs, but in the absence of an adequate response, conservative surgical management may be chosen. Compressive uterine sutures are considered a good treatment option. An effective and simple surgical technique is described by Hayman, a valuable tool for the control of postpartum hemorrhage. We present the case of a 17-year-old patient, 37 weeks pregnant and diagnosed with severe preeclampsia, who presents placental abruption and posterior uterine atony, who underwent uterine compressive suture by Hayman technique, with satisfactory evolution(AU)

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.

Clinical Experience Over 15 Years with the B-Lynch Compression Suture Technique in the Management of Postpartum Hemorrhage / Experiência clínica ao longo de 15 anos com a técnica de sutura compressiva de B-Lynch no manejo da hemorragia pós-parto

Abstract Objective To describe the clinical experience with the B-Lynch technique in the management of postpartum hemorrhage as well as the factors related to the indication of the technique and to present the success rates of the application of the B-Lynch technique. Methods Observational, retrospective, cross-sectional, and analytical study. Patient data was obtained through the study of medical records. The study population comprised of patients who underwent hemostatic suture using the B-Lynch technique, including 104 patients within the period from January 1, 2005, to December 31, 2019. Results Of the total of 104 patients, 82.7% did not present any complications. Blood transfusion and intensive care unit admission were the most prevalent complications, with 13.5% and 15.4%, respectively. Only 1% of the patients had puerperal and surgical site infections. The factors most related to the application of the technique were the presence of previous cesarean section (30.8%), use of oxytocin (16.3%), and pre-eclampsia (11.6%). Puerperal hysterectomy was performed in 4.8% of the patients due to failure of the method. Conclusion The clinical experience with the B-Lynch technique was satisfactory since it presented few complications, with excellent results in hemorrhagic control. Previous cesarean section, the use of oxytocin, and preeclampsia stood out as factors related to the indication of the application of the technique, and the success rate in controlling postpartum hemorrhage was 95.2%.

Resumo Objetivo Descrever a experiência clínica com a técnica de B-Lynch no manejo da hemorragia pós-parto e os fatores relacionados à indicação da técnica bem como apresentar as taxas de sucesso da aplicação da técnica de B-lynch. Métodos Estudo observacional, retrospectivo, de corte transversal e analítico. Os dados foram obtidos por estudo de prontuário. A população do estudo foi constituída de pacientes submetidas à sutura hemostática com a técnica de B-Lynch, sendo incluídas 104 pacientes dentro do período de 01 de janeiro de 2005 a 31 de dezembro de 2019. Resultados Do total de 104 pacientes, 82,7% não apresentaram qualquer complicação. A transfusão de sangue e a internação na UTI foram as complicações mais prevalentes, com 13,5% e 15,4%, respectivamente. Apenas 1% teve infecção puerperal e do sítio cirúrgico. Os fatores mais relacionados com a aplicação da técnica foram a presença de cesárea anterior (30,8%), uso de ocitocina (16,3%) e pré-eclâmpsia (11,6%). A histerectomia puerperal foi realizada em 4,8% das pacientes por falha do método. Conclusão A experiência clínica com a técnica de B-Lynch foi satisfatória, pois apresentou poucas complicações, com excelentes resultados no controle hemorrágico. A cesárea anterior, o uso de ocitocina e a pré-eclâmpsia se destacaram como fatores relacionados à indicação da aplicação da técnica. A taxa de sucesso avaliada foi de 95,2%.

Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review.

OBJECTIVES: To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols. SEARCH STRATEGY: PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021. STUDY SELECTION: Randomised and non-randomised comparative studies. OUTCOMES: Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy. RESULTS: All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon. CONCLUSIONS: The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting. TWEETABLE ABSTRACT: Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

INVESTIGACIÓN DE LA INCIDENCIA Y COMPLICACIONES DEL PERIPARTO DE EMERGENCIA HISTERECTOMÍA / 9 INVESTIGATION OF INCIDENCE AND COMPLICATIONS OF EMERGENCY PERIPARTUM HYSTERECTOMY

Introduction: The emergency peripartum hysterectomy is a high-risk surgery, which is mostly performed after vaginal delivery or Cesarean section. Given the importance of complications and mortality of pregnant mothers for the health system, the present study aimed to investigate the incidence and complications of emergency peripartum hysterectomy in general and teaching hospitals of Zahedan University of Medical Sciences. Materials and Methods: In this cross-sectional descriptive-analytic study, after obtaining the Ethics Committee approval, the medical record of patients with emergency peripartum hysterectomy admitted to Ali ibn Abitaleb hospital of Zahedan for pregnancy termination during 2017-2018 were investigated. were studied. After evaluating demographic characteristics, including age, education, and occupation, causes, and complications of emergency hysterectomy were investigated. Finally, data were analyzed by SPSS software. Results: Out of 2438 cases, 50 cases of hysterectomy were investigated. The mean age of mothers and the average number of pregnancies was 31.06±5.21 and 5.72±2.31, respectively. In this study, 35 cesarean sections (70%) and 15 normal vaginal delivery (30%) were recorded, with only 2% leading to emergency hysterectomy. The most common causes of emergency hysterectomy included placenta accreta (28%), uterine atony (24%), and uterine rupture (20%). The complications also included fever (24%), coagulopathy (14%), and wound infection (12%). Conclusion: Placenta accreta and uterine atony are the most important causes of hysterectomy. The most common complications of emergency hysterectomy are fever, coagulopathy, and wound infections. A decrease in elective caesarean delivery and further encouraging to natural vaginal delivery could significantly reduce the incidence of peripartum hysterectomy and maternal mortality.

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.

Morbilidad y mortalidad asociadas con protocolos de transfusión masiva en hemorragia obstétrica severa / Morbidity and mortality associated with mass transfusion protocols in severe obstetric hemorrhage

Resumen OBJETIVO: Determinar la morbilidad y mortalidad debidas a la aplicación de protocolos de transfusión masiva en pacientes con hemorragia obstétrica atendidas en cuidados intensivos. MATERIALES Y MÉTODOS: Estudio de una cohorte retrospectiva de pacientes con hemorragia obstétrica severa atendidas en la unidad de cuidados intensivos obstétricos del Hospital Materno Infantil del Instituto de Seguridad Social del Estado de México y Municipios, entre septiembre de 2014 y mayo de 2019. Se compararon tres protocolos de transfusión masiva en los que se aplicaron los derivados de la sangre en relación con la proporción de concentrado eritrocitario, de plaquetas y plasma con las siguientes proporciones: 2:1:1, 1:1:1 y liberal. Para analizar la posible asociación de las complicaciones con la elección de los diferentes protocolos de transfusión masiva, se utilizó un análisis mediante prueba ANOVA y χ2 en el programa SPSS versión 21; se consideró significativo el valor de p < 0.05. RESULTADOS: Se analizaron 75 pacientes con edad promedio de 32.8 años; 63 eran multigestas. La causa principal de la hemorragia obstétrica fue la atonía uterina. 51 de 75 de los protocolos de transfusión masiva fueron liberales, 11 de ellos con una relación 2:1:1 y 4 de 51 de 1:1:1. Las complicaciones fueron: síndrome de insuficiencia respiratoria aguda, lesión renal aguda, lesión renal aguda originada por la transfusión, infecciones y reintervención quirúrgica. Se encontró asociación positiva con: los días de estancia en cuidados intensivos (p = 0.031), reintervención quirúrgica (p = 0.006) y síndrome de insuficiencia respiratoria aguda (p = 0.044) y los protocolos de transfusión masiva liberal respecto de los protocolos con relación 1:1:1. Solo una paciente falleció y ello se asoció con el protocolo de transfusión masiva liberal. CONCLUSIONES: La aplicación de protocolos de transfusión masiva 1:1:1 y 2:1:1 en pacientes con hemorragia obstétrica severa disminuye el riesgo de complicaciones. La mortalidad materna debido a la aplicación del protocolo de transfusión masiva liberal fue de solo un caso en 51 pacientes.

Abstract OBJECTIVE: To determine the morbidity and mortality due to the application of massive transfusion protocols in patients with obstetric hemorrhage treated in intensive care. MATERIALS AND METHODS: study of a retrospective cohort of patients with severe obstetric hemorrhage treated in the obstetric intensive care unit of the maternal and child hospital of the social Security Institute of the State of Mexico and municipalities, between september 2014 and may 2019. three massive transfusion protocols were compared in which blood derivatives were applied in relation to the ratio of erythrocyte concentrate, platelets and plasma with the following ratios: 2:1:1, 1:1:1 and liberal. to analyze the possible association of complications with the choice of the different mass transfusion protocols, an anova and χ2 test was used in the spss version 21 program; the value of p < 0.05 was considered significant. RESULTS: Seventy-five patients with a mean age of 32.8 years were analyzed; 63 were multigrafted. The main cause of obstetric bleeding was uterine atony. 51 of 75 of the mass transfusion protocols were liberal, 11 of them with a 2:1:1 ratio and 4 of 51 of 1:1:1. The complications were: acute respiratory failure syndrome, acute renal injury, acute renal injury originated by transfusion, infections and surgical reintervention. Positive association was found with: days of stay in intensive care (p = 0.031), surgical reintervention (p = 0.006) and acute respiratory failure syndrome (p = 0.044) and liberal mass transfusion protocols with respect to 1:1:1 ratio protocols. Only one patient died and this was associated with the liberal mass transfusion protocols. CONCLUSIONS: The application of 1:1:1 and 2:1:1 mass transfusion protocols in patients with severe obstetric hemorrhage decreases the risk of complications. Maternal mortality due to the application of liberal mass transfusion protocols was only one case in 51 patients.

Ovario supernumerario en una paciente embarazada. Reporte de un caso y revisión bibliográfica / Supernumerary ovary in a pregnant patient. Case report and literature review

Resumen: ANTECEDENTES: El ovario supernumerario es una alteración rara, cuya incidencia es inespecífica. Es una anomalía que suele diagnosticarse de manera fortuita en procedimientos quirúrgicos. CASO CLÍNICO: Paciente de 39 años, con embarazo de término y trabajo de parto en fase latente con ruptura de membranas. El embarazo concluyó mediante cesárea, sin complicaciones, con el nacimiento de una niña. En el área de recuperación, la paciente tuvo atonía uterina y mala reacción al tratamiento farmacológico, por lo que se realizó histerectomía obstétrica, con hallazgo transoperatorio de un ovario supernumerario, con ligamentos de fijación propios y características de un ovario con desarrollo normal. No se efectuó ningún procedimiento quirúrgico. La evolución de la paciente fue favorable. CONCLUSIÓN: El ovario supernumerario es una alteración poco frecuente, de la que existe escasa bibliografía. Hasta la fecha no se ha establecido ningún tratamiento específico para esta anomalía, por lo que se requiere un consenso de estudio al respecto.

Abstract: BACKGROUND: The supernumerary ovary is a rare entity with a non-specific incidence it is an unusual anomaly presented in gynecology that is a mostly incidental finding in surgical procedures. CLINICALCASE: 39-year-old patient with term pregnancy and latent labor with rupture of membranes, to which the induction-conduction of labor was performed, obtaining live vaginal newborn live without complications, in the area of recovery, presented drug-resistant uterine atony, so obstetric hysterectomy was performed, with a transoperative finding of a supernumerary ovary which has its own fixation ligaments, with the characteristics of being an ovarian with normal development, without performing any surgical procedure in said ovary, with favorable evolution for the patient. CONCLUSION: The ovary supernumerary is a little frequent alteration, of which exists scarce bibliography. To date it has not established any specific treatment for this anomaly, by what requires a consensus of study in this regard.

La hemorragia posparto / Postpartum hemorrhage

Introducción: La hemorragia posparto es una de las principales causas de mortalidad materna. Objetivo: Caracterizar la hemorragia posparto. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo en el servicio de Anestesiología y Reanimación del Hospital Dr. Agostinho Neto entre los años 2015-2017. El universo se constituyó por 65 pacientes. Se estudiaron las siguientes variables: edad biológica, edad gestacional, tipo de hemorragia, cantidad estimada del sangrado, etiología, variables de laboratorio clínico y hemodinámicas, reanimación con fluidos y hemoderivados, complicaciones. Se emplearon métodos empíricos (análisis documental, instrumentos para la recolección de la información), teóricos (procedimientos de análisis, síntesis, inducción, deducción) y matemático-estadístico (porcentaje, media, la desviación típica e intervalos de confianza). Resultados: La edad media de las pacientes fue de 24,2 ± 6,2 años; la edad gestacional fue de 34,2 ± 6,2 años; 73,8 por ciento terminó el embarazo por vía vaginal e intervalo entre el parto, el inicio de la hemorragia posparto fue de 2,46 h ± 53 min. La atonía uterina (61,5 por ciento) fue la causa más común de la hemorragia. El shock fue la complicación más común (100 por ciento), lo que condicionó el uso de altos volúmenes de fluidos y hemoderivados para su reanimación. La histerectomía y ligadura arterias hipogástricas fue la técnica quirúrgica más utilizada (52,3 por ciento). Conclusiones: La hemorragia posparto fue una causa importante de morbilidad y mortalidad en el mencionado servicio de salud(AU)

Introduction: Postpartum hemorrhage is one of the main causes of maternal mortality. Objective: To characterize postpartum hemorrhage. Methods: A descriptive, longitudinal and prospective study was carried out in the Anesthesiology and Resuscitation service of Dr. Agostinho Neto Hospital, between 2015 and 2017. The study population was made up by 65 patients. The following variables were studied: biological age, gestational age, type of hemorrhage, estimated amount of bleeding, etiology, hemodynamic and clinical laboratory variables, fluid resuscitation and blood products replacement, complications. We used empirical methods (document analysis, instruments for the collection of information), theoretical methods (analysis, synthesis, induction, deduction), and mathematical-statistical methods (percentage, mean, standard deviation and confidence intervals). Results: The average age of the patients was 24.2±6.2 years; the gestational age was 34.2±6.2 years; 73.8 percent completed the pregnancy by natural delivery, while the interval between delivery and the onset of postpartum hemorrhage was 2.46h±53 min. Uterine atony (61.5 percent) was the most common cause of hemorrhage. Shock was the most common complication (100 percent), which conditioned the use of high volumes of replacement fluids and blood products. Hysterectomy and ligation of hypogastric arteries was the most used surgical technique (52.3 percent). Conclusions: During the study period, postpartum hemorrhage was an important cause of morbidity and mortality in the Anesthesiology and Resuscitation service of Dr. Agostinho Neto Hospital(AU)

Modified pereira suture as an effective option to treat postpartum hemorrhage due to uterine atony / Sutura de Pereira modificada como uma opção eficaz para tratar a hemorragia causada por atonia uterina

Abstract Nowadays, postpartum hemorrhage is the major cause of maternal mortality and morbidity worldwide. Uterine atony is its main cause; thus, prophylactic measures, as well as medical and surgical fast approaches, have been developed to manage it. The uterine compression sutures are a possible treatment that preserves the uterus and, consequently, the fertility potential. Bearing that in mind, we report two cases of postpartum hemorrhage after caesarean section, successfully treated with a new modification of Pereira suture - longitudinal and transverse uterine sutures were applied after no response was registered to the first-line therapies. Both women recovered, and the postpartum evaluation revealed a normal uterus with an adequate blood supply, suggesting potential fertility, as described in the literature regarding this kind of therapeutic approach.

Resumo Atualmente, a hemorragia pós-parto é a maior causa de morbimortalidadematerna em todo o mundo. Sua principal causa é a atonia uterina, pelo que têm sido instituídas e desenvolvidas medidas profiláticas, bem como tratamentos médicos e cirúrgicos para esta complicação. As suturas uterinas de compressão representam uma possibilidade terapêutica que permite a preservação do útero e, por conseguinte, do potencial fértil. Tendo isso por base, apresentamos dois casos de hemorragia pós-parto após cesariana, que foram tratados com sucesso com uma nova modificação da sutura de Pereira - suturas uterinas longitudinais e transversais foram efetuadas após falha das terapias de primeira linha. Ambas as pacientes se recuperaram, e na reavaliação pós-parto objetivou-se um útero normal com manutenção de uma irrigação adequada, sugerindo a preservação do seu potencial fértil, tal como vem sendo descrito na literatura em relação a este tipo de procedimento.

Hematoma retroperitoneal espontáneo concurrente con una atonía uterina poscesárea / Concurrent Spontaneous Retroperitoneal Hematoma with Uterine Atony Post Cesarean

El hematoma retroperitoneal espontáneo durante el embarazo es una complicación infrecuente definido como el sangrado en el espacio retroperitoneal que ocurre sin historia de trauma reciente, tratamiento anticoagulante o enfermedad vascular. El objetivo del trabajo es presentar un caso grave poco usual en que el hematoma retroperitoneal coexistió en una paciente con atonía uterina. Se presenta una gestante de 21 años y 39 semanas que acudió al Cuerpo de Guardia del Hospital Ginecobstétrico de Guanabacoa en noviembre 2016 por presentar dolor abdominal. Se ingresa en Cuidados perinatales. Los exámenes complementarios, físico y la cardiotocografía fueron normales. Cuatro horas después aqueja dolor lumbar y se detectó dolor a la palpación en región intercostal posterior derecha sin otro hallazgo ni alteraciones hemodinámicas. No hay dinámica uterina y frecuencia fetal 140 latidos/minuto. Dos horas después, presentó un cuadro que el familiar informa como una "convulsión", no observada por personal médico o de enfermería. No hay toma de conciencia y los signos vitales normales, se comprueba una bradicardia fetal que motiva la indicación de cesárea de urgencia. La hemoglobina descendió a 70 g/L. Se repone volumen y se extrae un neonato con Apgar 1-3. Se produce atonía uterina que no cedió al tratamiento medicamentoso y/o masaje. Se realiza técnica de B- Lynch para la hemostasia que se logra. Se comprueba hematoma retroperitoneal no activo desde borde superior hepático hasta flanco derecho. Se estabiliza hemodinámicamente. El neonato fallece a las 72 horas. El diagnóstico y tratamiento precoz del hematoma retroperitoneal contribuye a disminuir la morbilidad y mortalidad materna.

Spontaneous retroperitoneal hematoma during pregnancy is an uncommon complication defined as bleeding in the retroperitoneal space that occurs without a history of recent trauma, anticoagulant treatment or vascular disease. The objective of this study is to present an unusual case in which the retroperitoneal hematoma coexisted in a patient with uterine atony. A 21 year old pregnant woman of 39 weeks who went to the Emergency Room at Guanabacoa Gynecobstetric Hospital in November 2016, due to abdominal pain. The patient is admitted to perinatal care. Complementary studies and physical examination were normal, including cardiotocography. Four hours later, she suffered back pain, which was detected on palpation in the right posterior intercostal region without any other finding or hemodynamic changes. There were no uterine dynamics and fetal frequency was 140 beats / minute. Two hours later, this patient presented a "seizure," according to her family member that was not observed by medical or nursing staff. There was no loss of consciousness and her vital signs were normal. A fetal bradycardia is verified that motivates the indication of emergency caesarean section. Hemoglobin decreased to 70 g / L. Volume was replaced and an Apgar 1-3 neonate was extracted. There was uterine atony that did not yield to drug treatment and massage. The B-Lynch technique was performed for the hemostasis that was achieved. A non-active retroperitoneal hematoma was found from the superior border of the liver to the right flank. The patient was hemodynamically stabilized. The neonate died at 72 hours. The diagnosis and early treatment of retroperitoneal hematoma help to reduce maternal morbidity and mortality.

Sutura de B-Lynch en hemorragia postparto por inercia uterina: experiencia Hospital Dr. Luis Tisné Brousse 2013-2016 / B-Lynch suture in postpartum hemorrhage due to uterine inertia: Hospital Experience Dr. Luis Tisné Brousse 2013-2016

INTRODUCCIÓN Y OBJETIVOS: La Hemorragia Postparto (HPP) es uno de los grandes desafíos para el equipo multidisciplinario y sigue siendo una de las principales causas de muerte materna en el mundo, pese a los adelantos en su manejo. Se define como la hemorragia que produce compromise hemodinámico de la paciente e involucra entre el 1 al 5% de todos los partos. Dentro de las técnicas quirúrgicas conservadoras, existen las suturas compresivas, tales como la sutura de B-Lynch. Nuestro objetivo es determinar la efectividad de la sutura de B-Lynch como manejo quirúrgico conservador de hemorragia postparto por inercia uterina, a través de la necesidad de reintervención o de recurrir a la histerectomía obstétrica como manejo quirúrgico final. MÉTODOS: Estudio retrospectivo observacional, a través de revisión de fichas clínicas de pacientes sometidas a técnica B-Lynch entre enero de 2013 y diciembre de 2016, en el Servicio de Ginecología y Obstetricia del Hospital Dr. Luis Tisné Brousse. RESULTADOS: En 48 pacientes, la efectividad de la sutura de B-Lynch como técnica única o asociada a ligadura arterias uterinas o hipogástricas fue de 91,7%. Requirieron reintervención 8,3%, no se reportaron muertes fetales ni maternas y se obtuvo sólo un recién nacido con Apgar inferior a 7 a los 5 minutos. CONCLUSIONES: La sutura de B-Lynch es una técnica segura, de rápido acceso y con Buenos resultados, por lo que recomendamos su uso en la HPP por inercia uterina que no responde a manejo médico y con deseos de preservación uterina.

INTRODUCTION AND OBJECTIVES: Postpartum haemorrhage (HPP) is one of the major challenges for the multidisciplinary team and remains one of the leading causes of maternal death in the world despite advances in its management. It is defined as hemorrhage that produces hemodynamic compromise of the patient and involves between 1 and 5% of all deliveries. Within conservative surgical techniques, there are compressive sutures, such as the B-Lynch suture. Our goal is to determine the effectiveness of B-Lynch suture as a conservative surgical management of postpartum hemorrhage by uterine inertia, through the need for reoperation or to resort to obstetric hysterectomy as final surgical management. METHODS: Retrospective observational study, through review of clinical files of patients submitted to B-Lynch technique between January 2013 and December 2016, at the Gynecology and Obstetrics Service of the Dr. Luis Tisné Brousse Hospital. RESULTS: In 48 patients, the effectiveness of the B-Lynch suture as a single technique or associated with ligature uterine or hypogastric arteries was 91.7%. 8.3% were reoperated, fetal or maternal deaths were not reported, and only one Apgar score was less than 7 at 5 minutes. CONCLUSIONS: The B-Lynch suture is a safe technique, of fast access and good results, so we recommend its use in PPH by uterine inertia that does not respond to medical management and with desires of uterine preservation.

Frecuencia y factores asociados a la histerectomía obstétrica en un hospital de segundo nivel en México / Frequency and factors associated with obstetric hysterectomy in a second level hospital in México

INTRODUCCION La histerectomía obstétrica es procedimiento de urgencia para resolver una situación grave, su incidencia es de 5 a 15 por cada 1000 eventos obstétricos OBJETIVO GENERAL Determinar la frecuencia y factores asociados a la histerectomía obstétrica en un hospital de segundo nivel en México. METODOLOGIA Estudio descriptivo, transversal y retrospectivo en el periodo de Enero de 2014 a Diciembre del 2016, se incluyeron todos los casos de histerectomía posterior a un evento obstétrico, se estudiaron: edad, paridad, vía de interrupción del embarazo, antecedente de cesárea previa, indicaciones y complicaciones de la histerectomía, ingreso al servicio de terapia intensiva y mortalidad, el análisis se realizó con estadística descriptiva. RESULTADOS Durante el periodo de estudio, se atendieron 37 308 eventos obstétricos, efectuándose histerectomía obstétrica a 153 pacientes que representan el 0.57%, es decir, una HO por cada 243 embarazos. La edad promedio de quienes se les efectuó la histerectomía fue de 34 años de edad, siendo más frecuente en el grupo de mayores de 35 años, que habían tenido dos o tres embarazos previos. El antecedente de cesárea previa fue del 69.2%. La vía de interrupción del embarazo actual fue de cesárea en el 72.1%. La principal indicación fue la atonía uterina en 51 casos (33.3%). La complicación más frecuente fue la anemia aguda en el 83%. Hubo 1 muerte materna (0.6%). CONCLUSIONES La Histerectomía obstétrica es una cirugía de urgencia, por lo que se deben de identificar durante el control prenatal los factores asociados a las principales indicaciones de esta complicación.

INTRODUCTION Obstetric Hysterectomy (OH) is an emergency procedure to solve a life threatening condition, and its incidence is 5 to 15 per 1000 obstetric events. GENERAL OBJETIVE To determine the frequency and factors related with obstetric hysterectomy at a secondary hospital in Mexico. METHODOLOGY Descriptive, cross-sectional and retrospective study from January 2014 to December 2016 including all hysterectomy cases due to an obstetric event. Factors such as Age, number of deliveries, abortions, and previous cesarean sections, admission to the Intensive care unit, surgical indications, complications and mortality because of hysterectomy were analyzed thru descriptive statistics. RESULTS 37 308 obstetric events were registered and 153 were treated with Obstetric Hysterectomy representing 0.57% of the total, meaning one OH per every 243 pregnancies. The average age of those who had a hysterectomy was 28.5 years, and the procedure had its peak at the group of age older than 35 years who had had two or more pregnancies. The history of previous cesarean section was 39.2%. In 72.1% the pregnancy was terminated with a cesarean section. The main indication for hysterectomy was Uterine Atony in 33.3% (51 cases). The most frequent complication was acute anemia in 83%. There was a maternal death (0.6%). CONCLUSIONS Obstetric Hysterectomy is an emergency surgery, there are related factors that must be identified during the prenatal control to avoid this complication.

Uso de carbetocina frente al uso de oxitocina en pacientes intervenidas por cesárea con alto riesgo de atonía uterina / Use of Carbetocin versus Oxytocin in Cesareans with High Risk of Uterine Atony

Introducción: la utilización adecuada de medicamentos uterotónicos es fundamental en el manejo de la hemorragia obstétrica. Objetivo: describir los efectos de la carbetocina y su comparación con la oxitocina como primera elección para prevenir la hemorragia obstétrica en pacientes cesareadas con riesgo de atonía uterina. Métodos: se realizó un estudio prospectivo, comparativo y transversal, en el 2016, donde se incluyeron 165 pacientes embarazadas que ingresaron para interrupción del embarazo por cesárea, las cuales tenían factores de riesgo de atonía uterina. Se formaron dos grupos: el A, con 110 pacientes que recibieron oxitocina a dosis de 10 U por vía intravenosa, y el B, con 55 pacientes a las que se les administraron 100 mg de carbetocina después del nacimiento. Resultados: ambos grupos resultaron similares en la edad. En el grupo A, el promedio de edad fue de 27,5 años, y en el B, de 28,1 años. Se encontró una adecuada contractilidad en 83 pacientes del grupo A (75,45 por ciento) y en 53 del grupo B (96,36 por ciento). El grupo que recibió carbetocina requirió menor cantidad de maniobras o medicamentos adicionales. El sangrado transoperatorio fue, en promedio, de 845 ± 124,8 mL, para el grupo A, y de 709 ± 275,21 mL para el grupo B, en 21 pacientes del grupo A fue mayor de 1 000 mL y en 12 del grupo B. Conclusiones: las pacientes que recibieron carbetocina tuvieron resultados mejores en la contractilidad uterina. La necesidad de maniobras y medicamentos adicionales así como en la magnitud del sangrado y por tanto menor cantidad de transfusiones de hemoderivados(AU)

Introduction: the proper use of uterotonic drugs is fundamental in the management of obstetric hemorrhage. Objective: describe the effects of carbetocin and its comparison with oxytocin as the first choice to prevent obstetric hemorrhage in patients who are at risk for uterine atony. Methods: aprospective, comparative and cross-sectional study was conducted in 2016, which included 165 pregnant patients admitted for cesarean section, who had risk factors for uterine atony. Two groups were formed: A, with 110 patients receiving oxytocin at a dose of 10 U intravenously, and B, with 55 patients given 100 mcg of carbetocin after birth. Results: both groups were similar in age. In group A, the mean age was 27.5 years, and in B, 28.1 years. Adequate contractility was found in 83 patients in group A (75.45 percent) and 53 patients in group B (96.36 percent). The group receiving carbetocin required fewer maneuvers or additional medications. The intraoperative bleeding was, on average, 845 ± 124.8 mL in group A and 709 ± 275.21 mL in group B. It was more than 1,000 mL in 21 patients in group A and 12 patients in group B. Conclusions: patients who received carbetocin had better results in uterine contractility. The need for maneuvers and additional drugs was lesser as well as the magnitude of bleeding and therefore less transfusions of blood products(AU)

Sutura compresiva invaginante para control de la hemorragia obstétrica / Invaginant compression suture for the management of obstetric hemorrhage

Resumen OBJETIVO: determinar el efecto de la aplicación de la sutura compresiva invaginante para control de la hemorragia obstétrica secundaria a atonía uterina. MATERIALES Y MÉTODOS: estudio retrospectivo, transversal y descriptivo. Expedientes clínicos de pacientes del Hospital de Ginecología y Obstetricia de Ciudad Cuauhtémoc atendidas entre enero 2015 a marzo 2016 a quienes se aplicó la sutura compresiva invaginante como primer procedimiento quirúrgico en hemorragia obstétrica secundaria a atonía, sin respuesta al tratamiento farmacológico. Para el análisis estadístico se utilizaron medidas de tendencia central y el programa SPSS versión 16.0. RESULTADOS: se identificaron 9 pacientes con edad promedio de 25.1 años (límites 14 y 40), edad gestacional de 37.2 semanas (límites 32 y 40). El sangrado promedio fue de 2033 mL (límites 1800 y 2500 mL). El tiempo promedio de la intervención quirúrgica fue de 49 minutos y el tiempo de colocación de la sutura de 1.8 minutos. La sutura compresiva invaginante fue efectiva como único procedimiento en 8 casos (89%). En un caso se requirieron otros procedimientos (B-Lynch, ligadura de arterias hipogástricas, histerectomía obstétrica). No se identificaron complicaciones a corto plazo asociadas con el procedimiento, ni hubo muertes maternas. CONCLUSIONES: la sutura compresiva invaginante fue efectiva, como primer procedimiento quirúrgico, para controlar la hemorragia obstétrica y sin complicaciones a corto plazo. La cantidad de casos es limitada por lo que no puede descartarse la posibilidad de complicaciones a largo plazo y la necesidad de más estudios.

Abstract OBJECTIVE: To determine the effect of the implementation of the invaginant compression suture in the management of obstetric hemorrhage due to uterine atony. MATERIALS AND METHODS: Observational, descriptive, transversal, retrospective study. Medical records from the Obstetrics & Gynecology Hospital of the city of Cuauhtémoc in Mexico in which the invaginant compression suture was used as a first option in the surgical management of an obstetric hemorrhage due to uterine atony unresponsive to pharmacological treatment, from January 2015 to March 2016. Measures of central tendency were performed for the statistical analysis using the software SPSS, version 16.0. RESULTS: nine patients were identified during the study. The mean age was 25.1 years (14-40y), the mean gestational age was 37.2 weeks (32-40w). The mean of the estimated bleeding was 2033 ml (1800-2500ml). The duration of the surgical procedure was 49 minutes, duration of the suture placement 1.8 minutes (1-3). The invaginant compression suture was effective as the only option in 8 cases (89%). In one case other procedures were required (B-Lynch suture, hypogastric arteries ligation, hysterectomy). There were no complications associated or maternal deaths reported. CONCLUSIONS: The invaginant compression suture was effective as a first surgical option in the management of obstetric hemorrhage in these patients, without short-term complications. There was a limited number of patients and long-term complications can not be ruled out. More studies to evaluate this parameter are required.

Histerectomía obstétrica en el Hospital General Dr. Aurelio Valdivieso, Oaxaca, México / Obstetric hysterectomy in a secondary hospital

Objetivo: Determinar la incidencia, principales indicaciones y complicaciones de la histerectomía obstétrica (HO) en un hospital de segundo nivel de atención a cuatro años de implementar el programa de prevención y manejo de la hemorragia obstétrica. Método: Estudio de tipo descriptivo de revisión de expedientes clínicos, de tipo transversal, analítico y retrospectivo. Resultados: Se hallaron 51 expedientes de pacientes a quiénes se realizó HO de enero de 2012 a noviembre de 2015. La prevalencia fue de 17,1/10.000 nacimientos, la incidencia por año fue de 1,7 (2012), 1,7 (2013), 1,4 (2014) y 1,9 (2015) por cada mil nacimientos respectivamente. La prevalencia de HO post-cesárea fue de 25,6/10.000 y en el post-parto de 10,6/10.000. Las variables que alcanzaron significancia entre cirugía programada y de emergencia fue pérdida sanguínea y necesidad de transfusiones sanguíneas. El procedimiento se asocia a anemia en el puerperio 7 veces más y las principales indicaciones para realizar el procedimiento fueron alteración de la adherencia placentaria e hipotonía. Conclusiones: El diagnóstico prenatal de anomalías en la adherencia placentaria, la mejor utilización de hemoderivados y la técnica quirúrgica ha eliminado la mortalidad materna por hemorragia obstétrica masiva en los últimos cuatro años en el Hospital General Dr. Aurelio Valdivieso.

Objective: To determine the incidence, main indications and complications of obstetric hysterectomy in a secondary hospital care to four years to implement the program of prevention and management of obstetric hemorrhage. Methods: Descriptive study of review of clinical records, transversal, analytical and retrospective. Results: 51 cases of patients who obstetric hysterectomy (OH) was held between January 2012 to November 2015. The prevalence was 17.1/10,000. The incidence per year was 1.7 (2012), 1.7 (2013), 1.4 (2014) and 1.9 (2015) per 1000 births, respectively. The prevalence of post-cesarean OH was 25.6/10,000 while postpartum OH was 10.6/10,000. The variables that reached significance between scheduled and emergency surgery was blood loss and need for blood transfusions. The procedure is associated with anemia in the postpartum period 7 times and the main indications for the procedure were alteration abnormal placental adhesion and uterine atony. Conclusions: The prenatal diagnosis of abnormal placental adhesion, better use of blood products and surgical technique has eliminated maternal mortality by massive obstetric hemorrhage in the last four years in the General Hospital Dr. Aurelio Valdivieso.