Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America.

OBJECTIVE: To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country. METHODS: Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period. RESULTS: We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00). CONCLUSION: The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.

Neuroleptic malignant syndrome in pregnancy: case report and literature review.

BACKGROUND: Neuroleptic malignant syndrome (NMS) is a serious complication associated with the use of drugs that affect dopaminergic system neurotransmission. The occurrence of NMS during pregnancy or gestation is considered a life-threatening obstetric emergency. CASE: We are reporting the first case in Latin America of NMS in one pregnant women with acute psychotic episode. One day after starting with antipsychotic therapy, she developed a fever higher than 39.0 °C with tachycardia, tachypnea, generalized muscle rigidity and somnolence, with creatine kinase (CPK) levels evidencing a result of 2800 U/L. She was treated successfully with levetiracetam, biperiden and quetiapine. DISCUSSION: A search in PubMed, Embase and Ovid from 1988 to 2016 resulted in seven cases reported in either pregnant or puerperal women. In general, NMS resolves within 3-14 days; most NMS cases reported during pregnancy have involved the use of haloperidol (5 case reports) which is concordant with this report. The obstetric results were good in cases reported, only two women showed signs, among them: hyperemesis gravidarum and preterm delivery. Most of the pregnant women who had NMS presented other associated comorbidities, being mostly of infectious origin. In other investigations, it has been affirmed that NMS can become lethal in adults; however, in our search for pregnant women with this disease, no associated mortality was found. CONCLUSIONS: NMS is seen infrequently during pregnancy. The clinical diagnosis requires high suspicion by the examiner. It is important that obstetricians timely recognize the condition.

Hepatic rupture associated with preeclampsia, report of three cases and literature review.

BACKGROUND: Hepatic rupture is a complication during pregnancy that, although rare, accounts for high morbidity and mortality rates. It is mainly associated with severe preeclampsia and HELLP syndrome. Incidence is estimated to be at one per 67,000 births or one per 2000 patients with preeclampsia/eclampsia/HELLP, mainly in multiparous women; women in their 40s; after 32 weeks of gestation; and during the first 15 h postpartum. CASES: This article exposes the institutional experience at Fundación Valle del Lili in Cali, Colombia, in managing and treating hepatic rupture associated with severe preeclampsia and HELLP syndrome in three patients in the 30th, the 26th, and the 27th week of gestation, not resulting in maternal death. DISCUSSION: A search in Pubmed, Embase, and Ovid from 2000 to 2017 resulted in 35 cases reported in either pregnant or puerperal women. Hepatic rupture is a rare complication in pregnancy associated with preeclampsia and HELLP syndrome. Its pathophysiology is attributed to the presence of vasospasm due to an increase in concentration and sensitivity to circulating vasopressors during pregnancy. There is no standard management, but surgery reduces mortality significantly. It includes endovascular management, partial hepatectomy, or transplant (only one patient required a liver transplant in our search). The most used techniques have been ligation of the hepatic artery, embolization of the hepatic artery, and examination, packing, and drainage of hepatic lesion for bleeding control (27 cases were treated with laparotomy with evacuation of hematoma and hemostasis and four cases were treated with embolization of the hepatic artery). Hepatic artery occlusion both by surgery ligation and by embolization through interventional radiology has reported successful and failing results during pregnancy Conclusion: Management of pathologies as hepatic rupture associated with severe preeclampsia and HELLP syndrome has to be clearly protocolized for prompt diagnosis and early management. Furthermore, it has to be carried out through multidisciplinary teams in high-complexity obstetrics scenarios.

Trombosis de vena cava inferior en embarazo a término: reporte de caso y revisión de la literatura / Inferior vena cava thrombosis in term pregnancy: Case report and review of the literature

RESUMEN Objetivo: Realizar una revisión de la literatura publicada sobre el tratamiento de la trombosis de vena cava inferior en las gestantes. Materiales y métodos: Se describe un caso de trombosis de vena cava inferior en embarazo a término que consultó a una institución privada de cuarto nivel de complejidad, centro de referencia. Se manejó inicialmente con heparina de bajo peso molecular, suspendida 24 horas antes del parto. Se obtuvo un buen resultado perinatal, aunque presentó hemorragia postparto y hematoma perineal. Posteriormente se hizo manejo endovascular para trombolisis e intento de trombectomía. Se realizó una revisión de la literatura con los términos "vena cava inferior", "filtros de vena cava", "trombosis" y "embarazo". Se incluyeron reportes de caso y series de casos en inglés y español. Se seleccionaron todos los casos que describieran el tratamiento utilizado en mujeres con trombosis de vena cava inferior, diagnosticadas durante el embarazo o el puerperio. Resultados: Se incluyeron 17 publicaciones que cumplieron con los criterios de búsqueda. Se identificaron 41 casos; 35 pacientes fueron diagnosticadas con trombosis de vena cava inferior durante el embarazo y 6 durante el puerperio. El 100 % de las pacientes fueron anticoaguladas con heparina de bajo peso molecular o heparina no fraccionada, 34 gestantes requirieron filtro de vena cava inferior para manejo periparto y solo una gestante terminó en trombectomía. Conclusión: La trombosis de vena cava inferior en el periparto es un reto desde el punto de vista terapéutico, se debe equilibrar el riesgo de TEP y hemorragia masiva. Es fundamental tener una adecuada coordinación entre los diferentes servicios implicados garantizando máxima seguridad para evitar complicaciones.

ABSTRACT Objective: To conduct a review of the published literature on the treatment of inferior vena cava thrombosis in pregnancy. Materials and methods: Case description of inferior vena cava thrombosis in a woman with term pregnancy coming to a private level IV referral centre. It was initially managed with low-molecular weight heparin, which was discontinued 24 hours before delivery. Although the perinatal outcome was good, the patient developed postpartum bleeding and perineal haematoma. Endovascular treatment for thrombolysis and attempted thrombectomy was performed later. A review of the literature was conducted using the terms "inferior vena cava", "vena cava filters", "thrombosis" and "pregnancy". Case reports and case series in English and Spanish were included. All the cases describing the treatment used in women with vena cava thrombosis diagnosed during pregnancy or the postpartum period were selected. Results: Overall, 17 publications that met the search criteria were included, and 41 cases were identified: 35 patients were diagnosed with inferior vena cava thrombosis during pregnancy and 6 were identified during the postpartum period. Low molecular weight heparin or unfractionated heparin was used for anticoagulation in 100 % of the patients; 34 pregnant women required inferior vena cava filter for peripartum management, and only one patient needed thrombectomy. Conclusion: Peripartum inferior vena cava thrombosis is challenging from the therapeutic point of view. There is a need to balance the risk of pulmonary thromboembolism and massive bleeding. Adequate coordination between the different services involved is mandatory in order to ensure maximum safety and avoid complications.

Oclusión temporal de la aorta abdominal mediante el uso de balón intraarterial en acretismo placentario: reporte de un caso / Temporal occlusion of the abdominal aorta using an intra-arterial balloon in the placental accreta: a case report

RESUMEN El acretismo placentario es una enfermedad caracterizada por una inserción anómala de la placenta en la pared uterina. La oclusión infra renal de la aorta abdominal es un procedimiento innovador usado para disminuir el flujo vascular a la pelvis y lograr un mejor control del sangrado. Nosotros reportamos el caso de una gestante de 33 años con embarazo de 25 semanas y diagnóstico de placenta percreta, se aplicó el protocolo institucional que incluye: colocación de catéteres ureterales, inserción de balón intra aórtico (BIA) y finalización del embarazo por cesárea (urología, cirugía de trauma y cuidado critico obstétrico). El binomio madre hijo no presentó complicaciones, el sangrado visual estimado fue de 800 cc y la evolución posquirúrgica fue satisfactoria (sin signos de hipoperfusión o hiperlactatemia); no se reportó mortalidad materno-perinatal. Nuestra experiencia abre la posibilidad a los países de medianos y bajos ingresos a la innovación en la aplicación de estrategias para disminuir la pérdida de sangre intraoperatoria y la necesidad de transfusión; el uso del BIA es una estrategia segura para el control vascular en pacientes con percretismo placentario.

ABSTRACT Placenta accreta is characterized by anomalous placental insertion onto the uterine wall. Infra-renal aortic occlusion is an innovative procedure that reduces blood flow to the pelvis, which helps to achieve a better bleeding control. This case report is about a 33-year-old pregnant woman at 25 weeks, diagnosed with placenta percreta. We used our institutional protocol which includes: insertion of two urethral catherters, insertion of intraaortic balloon and pregnancy termination via cesarean section. Neither the mother or the newborn suffered any complications, the estimated visual bleeding was 800 cc. Postoperative evolution was satisfactory (without signs of hypoperfusion or hyperlactatemia) and there was not any reports of materno-perinatal mortality. This experience allows low and middle income countries the possibility to innovate regarding strategies to decrease intraoperative blood loss and transfusion requirements; intraaortic balloon insertion is a safe strategy to achieve bleeding control in patients with placenta percreta.

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

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