Hallazgos ecocardiográficos en el embarazo y posparto tardío en mujeres mexicanas sanas / Echocardiographical findings in pregnancy and late postpartum of healthy mexicans women´s

Resumen: OBJETIVO: Evaluar y comparar la adaptación cardiovascular materna mediante variables antropométricas y parámetros hemodinámicos con ecocardiografía Doppler en mujeres mexicanas sanas, con embarazo único. MATERIALES Y MÉTODOS: Estudio prospectivo, observacional, longitudinal, efectuado de enero de 2014 a enero de 2017 en mujeres que cursaban el segundo y tercer trimestres del embarazo. A los 6 meses posparto se practicaron ecosonogramas obstétricos y registros ecocardiográficos Doppler a todas las pacientes del estudio. Cada paciente fue su propio control. Se aplicó el análisis estadístico con SPSS Windows v17, ANOVA para comparar los 3 grupos, con valor significativo de p < 0.05, y correlación no paramétrica de Pearson. RESULTADOS: Se estudiaron 30 embarazadas con edad promedio de 22.5 ± 3.1 años. Las semanas de embarazo se corroboraron con ultrasonido obstétrico. En el ecocardiograma transtorácico se observaron cambios significativos entre el segundo trimestre y los 6 meses posparto: el ventrículo izquierdo en diástole (cm), 4.5 ± 2.5 vs 4.2 ± 3.3, p < 0.01. El volumen diastólico final del ventrículo izquierdo (mL) fue de 93 ± 14.8 vs 78 ± 17.8 (p < 0.05), el volumen latido (mL): 99.5 ± 15.7 vs 86 ± 11.8 (p < 0.01). Las resistencias vasculares sistémicas (dinas/seg/cm-5), 870 ± 108 vs 1262 ± 176 (p < 0.01). Del segundo al tercer trimestres y posnatal hubo incrementos en la aurícula izquierda (cm): 3.1 ± 4.6, 3.3 ± 4.4, 2.9 ± 4.3 (p < 0.001), gasto cardiaco (L/m): 6.8 ± 0.4, 7.0 ± 0.4, 4.7 ± 0.4 (p < 0.001). CONCLUSIONES: El embarazo es un estado de sobrecarga transitoria de volumen con importantes efectos orgánicos y funcionales, sobre todo en el segundo trimestre.

Abstract: OBJECTIVE: The aim of this prospective, observational and longitudinal study, was to evaluate and to compare the maternal adaptation through changes on anthropometric and Doppler echocardiographic parameters in Mexican normal pregnancy with single product. MATERIALS AND METHODS: Prospective, observational, longitudinal study, from January 2014 to January 2017. Obstetric ecosonograms and echocardiographic Doppler studies were performed on 2nd and 3rd trimester and six months postpartum. Each patient was her own control. The data were analyzed using SPSS Windows 17, ANOVA for compared the 3 groups with P value < 0.05 was considered significant, as well as a non-parametric correlation of Pearson. RESULTS: There were thirty pregnant with a mean age 22.5 ± 3.1 years-old, between 2nd and 3rd trimester, with obstetrics ultrasound were corroborated gestational age. With transthoracic echocardiography, we found significant changes between 2nd trimester and 6 month post-partum, among the main, the left ventricle (LV) in diastole (cm), 4.5 ± 2.5 versus 4.2 ± 2.3 (p < 0.01), end diastolic left ventricle volume (mL) 93 ± 14.8, vs 78 ± 17.8 (p < 0.05). Stroke volume (mL) 99.5 ± 15.7 vs 86 ± 11.8 (p < 0.01). Systemic vascular resistance (dyne/sec/cm5 ) 870 ± 108 vs 1,262 ± 176 (p < 0.001). From, 2nd and 3rd trimester and postpartum, left atrial diameter (cm), 3.1 ± 4.4, 3.3 ± 4.4, 2.9 ± 4.3 (p < 0.001). Cardiac output (L/m), 6.8 ± 0.4, 7.0 ± 0.4, 4.7 ± 0.4 (p < 0.001). CONCLUSION: Pregnancy is a transitory overload condition with important organic and functional effects mainly in the second trimester.

[Using polypropylene mesh in surgery for stress urinary incontinence]. / Uso de malla de polipropileno en cirugías para incontinencia urinaria de esfuerzo.

BACKGROUND: Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine while making an effort, such as coughing, sneezing or during activity. Since SUI generates high costs and affects the quality of life, it is important to make a proper diagnosis and, consequently, manage SUI efficiently. The objective was to know whether it is appropriate to use polypropylene mesh for SUI. METHODS: A historical cohort was conducted by reviewing records of patients with SUI treated with polypropylene mesh during 2013 with a follow-up of 12 months. RESULTS: Urinary continence was achieved in 98% of patients at one year. The complication rate was 2%. Only 12% of patients had normal weight. The most commonly used surgery was the placement of tension-free transobturator tape. CONCLUSION: The healing average reported worldwide is 90%, while the average for complications is 10%. In this study we achieved similar results. Using polypropylene mesh for surgical correction of SUI is a safe and effective alternative; however, studies with larger populations and more extensive monitoring to clarify this situation are required.

Introducción: la incontinencia urinaria de esfuerzo (IUE) se define como la pérdida involuntaria de orina con esfuerzos como toser, estornudar o realizar actividad física. Dado que la IUE genera costos elevados y afecta la calidad de vida, es importante el diagnóstico y el manejo adecuados. El objetivo fue conocer si es adecuado el uso de malla de polipropileno para la IUE. Métodos: se hizo un estudio de cohorte histórica que incluyó a pacientes con incontinencia urinaria de esfuerzo en los que se utilizó malla de polipropileno durante 2013 con un seguimiento a 12 meses. Resultados: se logró una corrección de la IUE en el 98% de las pacientes al año de seguimiento. La tasa de complicaciones fue del 2%. Solo el 12% de las pacientes tenía un peso normal. La cirugía más utilizada fue la colocación de cinta libre de tensión transobturadora. Conclusión: la curación que se reporta a nivel mundial en promedio es del 90%, mientras que para las complicaciones el promedio es del 10%. En este estudio tenemos resultados similares. Utilizar malla de polipropileno para la corrección quirúrgica de la IUE es una alternativa segura y eficaz; sin embargo, se requieren estudios con mayores poblaciones y un seguimiento más extenso para aclarar esta situación.

[Carbetocin and oxytocin: Prevention of postpartum hemorrhage in patients with risk factors for uterine atony]. / Carbetocina y oxitocina: prevención de hemorragia posparto en pacientes con factores de riesgo para atonía uterina.

BACKGROUND: In Mexico, during 2010, obstetric hemorrhage was second (19.6%) as a direct cause of maternal death. The aim of this paper is to evaluate the effect of oxytocin and carbetocin, in preventing postpartum hemorrhage in patients with risk factors for uterine atony. METHODS: Study type clinical trial, patients experiencing at least one of the risk factors for uterine atony included. Randomly, they were divided into two groups: one was given Oxytocin and other received Carbetocin. The following variables were determined: risk factors for uterine atony, hemoglobin and hematocrit, vital signs, trans-surgical bleeding, whether or not presented uterine atony, uresis, need for additional tonics uterus and need for blood transfusion. RESULTS: A total of 120 patients were studied in 6 months were excluded 3, 60 were treated with Carbetocin, and 57 with Oxytocin. It was determined that there is a greater number of events of uterine atony (p = 0.007, with RR 11.06) and therefore greater need for additional tonic uterus (p = 0.027, with RR 5.44) in the group of Oxytocin. There was no statistically significant difference in the other variables. CONCLUSIONS: Carbetocin is recommended as prophylaxis of obstetric hemorrhage in patients with risk factors for uterine atony.

Introducción: en México, en 2010, la hemorragia obstétrica ocupó el segundo lugar (19.6%) como causa directa de muerte materna. El objetivo de este trabajo es evaluar el efecto de la oxitocina y la carbetocina, en la prevención de hemorragia posparto en pacientes con factores de riesgo para atonía uterina. Métodos: estudio tipo ensayo clínico, se incluyeron a pacientes que presentaron al menos uno de los factores de riesgo para atonía uterina. De manera aleatoria, se dividieron en dos grupos: a uno se le administró oxitocina y el otro recibió carbetocina. Se determinaron las siguientes variables: factores de riesgo para atonía uterina, hemoglobina y hematocrito, signos vitales, sangrado transquirúrgico, si presentó o no atonía uterina, uresis, necesidad de uterotónicos adicionales y necesidad de transfusión de hemoderivados. Resultados: se estudiaron un total de120 pacientes en 6 meses, se excluyeron 3, de las cuales 60 fueron tratadas con carbetocina y 57 con oxitocina. Se determinó que existe un mayor número de eventos de atonía uterina (p = 0.007, con RR de 11.06) y, por ende, mayor necesidad de uterotónico adicional (p = 0.027, con RR de 5.44), en el grupo de la oxitocina. No hubo diferencia estadísticamente significativa en el resto de las variables. Conclusiones: Se recomienda carbetocina como profilaxis de hemorragia obstétrica en pacientes con factores de riesgo para atonía uterina.

[Klippel-Trenaunay syndrome and pregnancy. Case report]. / Síndrome de Klippel-Trenaunay y embarazo. Comunicación de un caso.

The Klippel-Trenaunay syndrome is a rare congenital disorder consisting of: cutaneous vascular nevi, varicose veins or venous malformations and hypertrophy of soft tissue and bone, affecting one or more limbs. The morbidity of the disease is associated with vascular anomalies. Pregnancy is discouraged because this rare disease puts a pregnant woman in an increased obstetric risk, due to pregnancy can exacerbate complications. The pregnancy has been reported rarely in patients with Klippel-Trenaunay syndrome, although the incidence is unknown. Until 2006 there have been only 17 reported cases of pregnancy in patients with Klippel-Trenaunay syndrome in the literature in English. We report the case of the second pregnancy of 22 years old woman with this disease.

[Pregnancy and tetralogy of Fallot with and without surgical correction]. / Embarazo y tetralogía de Fallot con y sin corrección quirúrgica.

BACKGROUND: Tetralogy of Fallot is the most common cyanotic congenital cardiac lesions. Although pregnancy in patients with corrected tetralogy of Fallot usually have a satisfactory outcome, there may have maternal cardiovascular complications. OBJECTIVE: To report our experience in monitoring and treatment of 16 pregnancies in 14 women with tetralogy of Fallot. PATIENTS AND METHOD: Prospective study performed in 16 pregnancies of 14 patients with tetralogy of Fallot, who attended the services of Cardiology and High Risk Pregnancy in the Hospital de Gineco-Obstetricia of the Centro Médico de Occidente (Mexico), from January 1997 to January 2010. Nine women had total surgical correction and five hadn't. All patients obtained complete study protocol and tests of fetal wellbeing. RESULTS: Hemoglobin and hematocrit were significantly higher in the group without surgical correction; this group also had lower oxygen saturation and right ventricular enlargement. Of the 16 pregnancies, five were resolved vaginally, the other by cesarean section. The cyanotic mothers had premature termination of pregnancy, lower birth weight and Apgar slightly deteriorated. There were no maternal or neonatal deaths, neither cardiac malformation in newborns. CONCLUSIONS: There are more risks for the binomial in patients with uncorrected tetralogy of Fallot and in those operated with significant residual lesions. A greater anatomical impact was significantly correlated with major hemoglobin and minor oxygen saturation, which are the most important risk factors for adverse fetal outcomes.

[Ballantyne syndrome or mirror syndrome]. / Síndrome de ballantyne o sindrome en espejo.

Ballantyne syndrome or mirror syndrome is a triad consisting of the presence of fetal hydrops, generalized edema placentomegaly mother. May be related to any cause of fetal hydrops. The fetal prognosis is poor in untreated cases, the mother has reference to be the cause or the termination of pregnancy. Present the case of a 26-year-old who developed mirror syndrome secondary to non-immune fetal hydrops of unknown origin, accompanied by preeclampsia.

[Modification to surgical technique of cesarean hysterectomy]. / Modificación a la técnica quirúrgica de cesárea-histerectomía.

BACKGROUND: Bleeding is a significant cause of maternal mortality in the world. Obstetric hysterectomy increases maternal morbidity and mortality. OBJECTIVES: To describe a modified technique of cesarean-hysterectomy to limit bleeding during surgery in cases of placenta accreta and placenta previa, which consist of hypogastric artery ligation before the removal of the uterus. Another objective of this study is to compare maternal outcomes of patients undergoing this technique with the usual technique. PATIENTS AND METHOD: Comparative, longitudinal, closed stydy. We analyzed the records of 86 patients undergoing cesarean-hysterectomy surgery, from July 1, 2008 to July 31, 2009, were programmed 29 patients with the modified technique and 57 with the usual. The main outcomes analyzed were: estimated bleeding during surgery, number of packed red blood cells and plasma units transfused and hospital stay in intensive care. RESULTS: Bleeding during surgery, blood transfusion and admission to intensive care demand, and hospital stay were significantly lower in patients with the modified technique. Also there were fewer trans and postoperative complications in this group. CONCLUSIONS: The results of this study show that the modified technique of cesarean-hysterectomy derives significant reduction of maternal morbidity, less massive transfusions demand to manage intensive care units.

[Cardiovascular risk factors in climacteric]. / Factores de riesgo cardiovascular en el climaterio.

BACKGROUND: Ischemic heart disease is the second leading killer of women in Mexico, regardless of age group. The incidence of cardiovascular events increases after menopause, and depend on the prevalence and accumulation of risk factors. OBJECTIVE: To determine the prevalence of cardiovascular risk factors in a population of Mexican women who receive care in a menopause clinic. METHODS: Cross-sectional study included 308 women. Sociodemographic characteristics were collected, and background somatometric-family inherited cardiovascular risk factors, biochemical variables: blood glucose and lipid profile. Women were classified into two groups: pre-and postmenopause, the latter being subdivided according to time since menopause: less than three years and more than three years. RESULTS: Two hundred six (66.7%) women had inherited a positive family history. We identified 123 (39.9%) in premenopausal, mean age 46.4 +/- 3.2 years and 185 (60.1%) postmenopausal with a mean age of 50.5 +/- 3.2. We found no differences in blood pressure and blood glucose somatometric features. The levels of total cholesterol (TC) and cholesterol of low density lipoprotein (LDL-C) were significantly higher in the group of postmenopausal women. It was noted that total cholesterol and triglycerides increased with age regardless of hormonal status. Hypercholesterolemia was detected in 41.5% of premenopausal patients and in 51.4% of postmenopausal women. More than half of the population studied had three or more cardiovascular risk factors. CONCLUSIONS: There is a high prevalence of cardiovascular risk factors in Mexican women present from pre-menopause. The major modifiable: sedentary lifestyle, dyslipidaemia and overweight.

[Chronic high blood pressure in 110 pregnant women]. / Hipertensión arterial crónica en 110 mujeres embarazadas.

BACKGROUND: Hypertension is associated with increased maternal and fetal mortality and morbidity. While there is consensus that severe hypertension should be treated, antihypertensive treatment for mild chronic hypertension during pregnancy remains controversial. OBJECTIVE: To evaluate clinical course, and maternal and perinatal outcomes of pregnant women with mild chronic hypertension without other disease, under strict control of maternal hypertension (target dBP of 85-89 mmHg). PATIENTS AND METHODS: We conducted a prospective cohort study of 110 pregnant women with mild chronic hypertension without other disease; clinical course was classified in three groups: stable condition, exacerbation of hypertension and superimposed preeclampsia. We compare maternal and perinatal outcomes; statistical comparisons were performed by ANOVA test. Relative risk (RR) was calculated for adverse perinatal outcomes. RESULTS: Atotal of 110 women were included, mean maternal age was 33 +/- 5.8 years. There were 78 (71%) women with stable condition, 26 (24%) with exacerbation of hypertension and 6 (5%) with superimposed preeclampsia (PE). Women with superimposed PE and exacerbation of hypertension delivered earlier and had more small for gestational age (SGA) babies than women with stable condition and exacerbation. Delivery route was vaginal in 45 patients (40%) while 65 patients (60%) underwent cesarean section in order to avoid fetal distress. CONCLUSIONS: Results demonstrated that fetuses in the stable condition group (strict control) did not have worst outcomes than those in the other groups. This cohort study shows efficacy and safety of treating mild chronic hypertension during pregnancy.

[Twin pregnancy with partial hydatidiform mole and alive fetus: case report]. / Embarazo gemelar con mola hidatidiforme parcial y feto vivo coexistente: comunicación de un caso.

We report a case of a pregnant patient with a twin of 29 gestational weeks, and partial hydatidiform mole with coexistent living fetus. She was admitted at gyneco-obstetric urgencies due to a mild preeclampsia that evolves to severe. She has a complicated vaginal delivery with obstetric bleeding and there was practiced a total abdominal hysterectomy. Newborn dies 30 days later due to secondary complications (extreme prematurity). Patient evolution was satisfactory and she is currently under follow-up therapy to gestational trophoblastic disease without clinical or biochemical evidence of persistence or recurrence.

[Pregnancy in patients with single ventricle, corrected and uncorrected]. / Embarazo en pacientes con ventrículo único, con y sin corrección quirúrgica.

We describe two cases of pregnancy in women with congenital heart disease, single ventricle. The first one underwent Fontan surgery at the age of 5 years due to a single ventricle of the left ventricular morphology. The second one, had uncorrected single ventricle. There were no maternal complications. Both deliveries were by cesarean section. Infants were premature, being delivered at 33 and 27 weeks, and weighing 1,250 and 625 g, respectively.

[Placenta percreta with bladder invasion. Case report]. / Placenta percreta con invasión a la vejiga. Reporte de un caso.

We report a case of a 30-year-old woman, who had two previous caesarean sections, attended for the first time at 18 weeks of gestation. Pelvic ultrasonography and color Doppler imaging showed a placenta percreta invading the urinary bladder. A caesarean section was carried out at 27th week of gestation for preterm premature rupture of membranes. Placental tissue was firmly attached to the anterior surface of the bladder. A cesarean hysterectomy was performed with bilateral anterior internal iliac artery ligation before hysterectomy was finished. The bladder was repaired, leaving a suprapubic catheter.

[Analysis of maternal mortality during three periods at Hospital de Ginecología y Obstetricia del Centro Médico Nacional de Occidente]. / Análisis de la mortalidad materna, en tres periodos, en el Hospital de Ginecología y Obstetricia del Centro Médico Nacional de Occidente.

BACKGROUND: Most of deceases due to pregnancy, delivery, puerperium and them attention are avoidable with current medicine resources. OBJECTIVE: To analyze some basic elements of epidemiologic behavior of a hospital environment maternal mortality in a third level hospital during a period of 21 years. MATERIAL AND METHODS: Analytical cross-sectional study, 222 maternal deaths registered at Hospital de Ginecologia y Obstetricia, Centro Medico Nacional de Occidente del Instituto Mexicano del Seguro Social, were included, during the period 1985-2005. Deaths were analyzed in three periods of 7 years each one. The analysis of results was made based on descriptive statistic. chi2 was used for comparison between periods. RESULTS: Maternal death ratio was 73 per 100,000 live births during the 21 years. Maternal mortality was lower in the group of women under 20 years and increase agreed maternal age. Frequency of direct obstetric deaths decreased when comparing the 3 periods. The main causes of maternal death were preeclampsia/eclampsia and obstetric hemorrhage, which were responsible for almost 50% of maternal deaths. There was no significant difference to anticipation by comparing periods, between 28 and 37% of deaths were foreseen. 98% of deaths occurred at Intensive Care Units. CONCLUSIONS: Direct and indirect maternal deaths show very similar values in the third period, which translates in an improvement in anticipation. It must be reinforce the simple and opportune information to the patient with regard to warning signs and the permanent medical training must be a priority at the 3 medical levels.

[Prescription and drug expenditure in gynecology and obstetrics in Northwest medical units from IMSS]. / Análisis de la prescripción y gasto de medicamentos en gineco-obstetricia en unidades médicas del noroccidente del IMSS.

BACKGROUND: Drug prescription is the most frequent medical intervention in Gynecology and Obstetrics; however, studies of prescription profile are limited. In this study, we analyzed differences of expense by drug prescription for gynecologic and obstetrics health problems. PATIENTS AND METHOD: It was performed a cross sectional study for one year analysis in each medical area that shape IMSS western district. We calculated spending and consumption coefficients for each drug and therapeutic groups. User coefficients were ordered to compare consumption differences. Besides the statistical ratio of consumption between drugs groups, we described the differences found and analyzed the prescription profile among medical regions. RESULTS: Data related to the expenses in each one of the regions show important differences in each one of the drugs and therapeutic groups. The most common expense for drugs is related to the treatment of osteoporosis, menopause and fertility problems. We also found differences in prescription drug preferences in each therapeutic subgroup. DISCUSSION: Drug prescription studies are useful as a basis for further specific studies in each pharmacologic subgroup. There are few studies that analyze the drug prescription profile on Gynecology and Obstetrics. In this study it is possible to suppose that medical prescription was not based on known medical evidences; therefore, we must reconsider the need of a permanent actualization and systematic medical evaluation.

[Pulmonary thromboembolism in obstetrics]. / Tromboembolia pulmonar en obstetricia.

BACKGROUND: Pulmonary embolism is a serious and sometimes mortal complication of pregnant and puerperal women. Pulmonary embolism diagnosis can be difficult. In Mexico, it causes between 2.5 and 16% of maternal mortality. OBJECTIVES: To estimate the incidence of pulmonary embolism, to identify most frequently risk factors that contribute to the presence of pulmonary embolism as an obstetrical complication and to determine clinical characteristics and specific diagnostic tests in hospitalized patients at the Hospital de Ginecoobstetricia, Centro Medico Nacional de Occidente, Instituto Mexicano del Seguro Social. MATERIAL AND METHODS: We conducted a cross-sectional study from January 1st 1997 to December 31st, 2002. We identified 30 patients with pulmonary embolism confirmed by ventilation-perfusion scan. RESULTS: Incidence of 4.7 cases per 10,000 pregnancies was found. Most frequently, risk factors were varicose veins in lower extremities (0.045), previous thromboembolic event (0.030) and pre-eclampsia/eclampsia (0.05). Cesarean section was present in 85% of the cases with pulmonary embolism during puerperium. The most common clinical findings were: dyspnea (100%), chest pain (63%), tachycardia (93%) and tachypnea (93%). Sinus tachycardia (93%) and S1 Q3 T3 were the electrocardiogram findings most commonly observed. 83% of the patients showed abnormalities in chest radiography. 100% presented altered blood values. Mortality rate was of 6.6%. CONCLUSION: Diagnosis of pulmonary embolism should be based on risk factors and clinical findings. Basic laboratory and scan are essential. Early diagnosis and treatment significantly reduce mortality rates.

[Medically indicated preterm birth. Maternal and fetal consequences]. / Nacimiento pretérmino por indicación médica. Consecuencias maternas y fetales.

One of the principal challenges of obstetrics is to reduce the percentage of perinatal mortality. Preterm birth is considered the main cause of neonatal morbidity and mortality. Preterm birth by medical indication, is a condition rarely documented in medical literature, but it requires analysis to determine the effect in perinatal health. In a third care hospital setting, a prospective study was performed on 154 pregnant women that delivered preterm babies between 25 and 36 weeks of gestation. The Relative Risk (RR) was obtained to compare the association between the medical indication of the preterm birth, the use of fetal pulmonary maturants, type of delivery, the health status of the newborn at birth and hospital discharge. The main causes of preterm birth by medical indication were: premature rupture of membranes, preeclampsia, intrauterine growth retardation and fetal distress. Neonatal mortality was 13%. The rate of cesarean section was higher than expected. Despite the various types of delivery, there were no significant differences between mortality, length of hospital stay or hospital complications. The probability of death to preterm born was explained to gestational age and was not modified for medical decision to interrupt pregnancy.

Mortalidad materna en el Hospital de Gineco-Obstetricia del Centro Médico Nacional de Occidente. Revisión de 12 años / Maternal mortality at the Gynec Obst Hospital, western National Medical Center. 12 years review

El objetivo de este trabajo es presentar el análisis de las características encontradas en los casos de muerte materna (MM) ocurridos en el Hospital de Gineco-Obstetricia (HGO) y en el Hospital de Especialidades (HE) del Centro Médico Nacional de Occidente (CMNO) durante 12 años, para así tener un panorama más amplio y encaminar esfuerzos con el fin de reducir la mortalidad materna. Se revisaron los expedientes e informes del comité de muerte materna de 151 mujeres que ingresaron y fallecieron en el HGO y HE-CMNO del Instituto Mexicano del Seguro Social en la ciudad de Guadalajara, Jalisco, México, del 1o. de enero de 1985 al 31 de diciembre de 1996. Durante el periodo revisado la tasa de muerte materna fue de 64 x 100,000 nacimientos vivos. La causa más frecuente de mortalidad materna correspondió a toxemia gravídica, seguida por hemorragia obstétrica, embolia pulmonar obstétrica, infección y complicaciones anestésicas, con tasas x 100,000 nacidos vivos de 16, 15, 10, 8 y 4 respectivamente. El 73 por ciento fueron muertes previsibles y 23 por ciento no previsibles. A su ingreso al HGO 37 por ciento se dictaminaron como muertes evitables, 66 por ciento de las muertes fueron por causa obstétrica directa, 34 por ciento por causa indirecta. En 54 por ciento de los casos la resolución de la gestación fue por operación cesárea. La responsabilidad profesional existió en el 72 por ciento y la hospitalaria en el 23 por ciento. Se analizan los factores relacionados y proponen estrategias para disminuir la muerte materna