Especificidades técnicas no tamponamento uterino com balões e algumas dificuldades técnicas / Technical specificities in uterine tamponade with balloons and some technical difficulties

A mortalidade materna é inaceitavelmente alta. A hemorragia pós-parto encontra- se na primeira posição no mundo, tendo como principal causa específica a atonia uterina. Eventualmente, as medidas iniciais e a terapia farmacológica não são efetivas no controle do sangramento, impondo a necessidade de tratamentos invasivos, cirúrgicos ou não. Entre esses, o tamponamento uterino com balão requer recursos locais mínimos e não exige treinamento extensivo ou equipamento muito complexo. Entretanto, algumas dificuldades podem ocorrer durante a inserção, infusão ou manutenção do balão na cavidade uterina, com especificidades relacionadas à via de parto. Após o parto vaginal, a dificuldade mais prevalente é o prolapso vaginal do balão. Na cesárea, as principais dificuldades são a inserção e o posicionamento do balão na cavidade uterina, principalmente nas cesáreas eletivas. Este artigo revisa e ilustra as principais dificuldades e especificidades relacionadas ao tamponamento uterino com balões.

Maternal mortality is unacceptably high. Postpartum hemorrhage is ranked first in the world, with the main specific cause being uterine atony. Eventually, initial measures and pharmacological therapy are not effective in controlling bleeding, imposing the need for invasive treatments, surgical or not. Among these, uterine balloon tamponade requires minimal local resources and does not require extensive training or very complex equipment. However, some difficulties may occur during insertion, infusion, or maintenance of the balloon in the uterine cavity, with specificities related to the mode of delivery. After vaginal delivery, the most prevalent difficulty is vaginal balloon prolapse. In cesarean section, the main difficulty is the insertion and positioning of the balloon in the uterine cavity, especially in elective cesarean sections. This article reviews and illustrates the main difficulties and specificities related to uterine balloon tamponade.

Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery.

BACKGROUND: Prophylactic use of tranexamic acid at the time of cesarean delivery has been shown to decrease the calculated blood loss, but the effect on the need for blood transfusions is unclear. METHODS: We randomly assigned patients undergoing cesarean delivery at 31 U.S. hospitals to receive either tranexamic acid or placebo after umbilical-cord clamping. The primary outcome was a composite of maternal death or blood transfusion by hospital discharge or 7 days post partum, whichever came first. Key secondary outcomes were estimated intraoperative blood loss of more than 1 liter (prespecified as a major secondary outcome), interventions for bleeding and related complications, the preoperative-to-postoperative change in the hemoglobin level, and postpartum infectious complications. Adverse events were assessed. RESULTS: A total of 11,000 participants underwent randomization (5529 to the tranexamic acid group and 5471 to the placebo group); scheduled cesarean delivery accounted for 50.1% and 49.2% of the deliveries in the respective groups. A primary-outcome event occurred in 201 of 5525 participants (3.6%) in the tranexamic acid group and in 233 of 5470 (4.3%) in the placebo group (adjusted relative risk, 0.89; 95.26% confidence interval [CI], 0.74 to 1.07; P = 0.19). Estimated intraoperative blood loss of more than 1 liter occurred in 7.3% of the participants in the tranexamic acid group and in 8.0% of those in the placebo group (relative risk, 0.91; 95% CI, 0.79 to 1.05). Interventions for bleeding complications occurred in 16.1% of the participants in the tranexamic acid group and in 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82 to 0.97); the change in the hemoglobin level was -1.8 g per deciliter and -1.9 g per deciliter, respectively (mean difference, -0.1 g per deciliter; 95% CI, -0.2 to -0.1); and postpartum infectious complications occurred in 3.2% and 2.5% of the participants, respectively (relative risk, 1.28; 95% CI, 1.02 to 1.61). The frequencies of thromboembolic events and other adverse events were similar in the two groups. CONCLUSIONS: Prophylactic use of tranexamic acid during cesarean delivery did not lead to a significantly lower risk of a composite outcome of maternal death or blood transfusion than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT03364491.).

Association Between Surgeon Gender and Maternal Morbidity After Cesarean Delivery.

Importance: The stereotype that men perform surgery better than women is ancient. Surgeons have long been mainly men, but in recent decades an inversion has begun; the number of women surgeons is increasing, especially in obstetrics and gynecology. Studies outside obstetrics suggest that postoperative morbidity and mortality may be lower after surgery by women. Objective: To evaluate the association between surgeons' gender and the risks of maternal morbidity and postpartum hemorrhage (PPH) after cesarean deliveries. Design, Setting, and Participants: This prospective cohort study was based on data from the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, a multicenter, randomized, placebo-controlled trial that took place from March 2018 through January 2020 (23 months). It aimed to investigate whether the administration of tranexamic acid plus a prophylactic uterotonic agent decreased PPH incidence after cesarean delivery compared with a uterotonic agent alone. Women having a cesarean delivery before or during labor at or after 34 weeks' gestation were recruited from 27 French maternity hospitals. Exposures: Self-reported gender (man or woman), assessed by a questionnaire immediately after delivery. Main Outcomes and Measures: The primary end point was the incidence of a composite maternal morbidity variable, and the secondary end point was the incidence of PPH (the primary outcome of the TRAAP2 trial), defined by a calculated estimated blood loss exceeding 1000 mL or transfusion by day 2. Results: Among 4244 women included, men surgeons performed 943 cesarean deliveries (22.2%) and women surgeons performed 3301 (77.8%). The rate of attending obstetricians was higher among men (441 of 929 [47.5%]) than women (687 of 3239 [21.2%]). The risk of maternal morbidity did not differ for men and women surgeons: 119 of 837 (14.2%) vs 476 of 2928 (16.3%) (adjusted risk ratio, 0.92 [95% CI, 0.77-1.13]). Interaction between surgeon gender and level of experience on the risk of maternal morbidity was not statistically significant. Similarly, the groups did not differ for PPH risk (adjusted risk ratio, 0.98 [95% CI, 0.85-1.13]). Conclusions and Relevance: Risks of postoperative maternal morbidity and of PPH exceeding 1000 mL or requiring transfusion by day 2 did not differ by the surgeon's gender.

Condições potencialmente ameaçadoras à vida no ciclo gravídico-puerperal / Condiciones potencialmente amenazantes para la vida en el ciclo gravídico puerperal / Potentially life-threatening conditions determinants in pregnancy-puerperal cycle

ABSTRACT Objetivo: Descrever as principais condições potencialmente ameaçadoras à vida de mulheres durante o ciclo gravídico e puerperal e variáveis relacionadas a esses agravos. Método: Estudo do tipo documental, descritivo e quantitativo, realizado com prontuários de gestantes, parturientes e puérperas internadas em hospital de média complexidade, que apresentaram Condições Potencialmente Ameaçadoras à Vida (CPAV). Foram excluídos os de acesso impossibilitado por estarem sob judice. A amostra foi temporal e a análise univariada. Resultados: Inclui-se 181 prontuários. A maioria das condições ocorreu em mulheres de 16 a 34 anos de idade (61,3%), união estável (60,8%), pardas (31,5%), sem renda ocupacional (29,2%), multíparas (28,87%), com complicações no primeiro trimestre gestacional (32,6%). Verificaram-se a realização de um número insuficiente de consultas (13,8%), dados referentes ao pré-natal ignorados (68%). As principais CPAV foram as síndromes hemorrágicas (28,2%), hipertensivas (25,4%) e infecção (13,3%). Como desfecho, foram observados prevalência de aborto não especificado (22,1%), morte perinatal por doença infecciosa e parasitária da mãe (2,2%). Conclusão: As principais CPAV foram as síndromes hemorrágicas, hipertensivas e infecções. Como desfecho, foram observados alta hospitalar, aborto, referenciamento à UTI, morte perinatal e morte materna.

RESUMEN Objetivo: describir las principales condiciones potencialmente amenazantes para la vida de las mujeres durante el ciclo gravídico y puerperal, además de las variables relacionadas con estos agravios. Método: estudio del tipo documental, descriptivo y cuantitativo, realizado con registros médicos de gestantes, parturientes y puérperas internadas en hospital de mediana complejidad, que presentaron Condiciones Potencialmente Amenazantes a la Vida (CPAV). Se excluyeron los de acceso imposibilitado por estar bajo juicio. La muestra fue temporal y el análisis univariado. Resultados: se incluyen 181 registros médicos. La mayoría de las condiciones ocurrió en mujeres de 16 a 34 años de edad (61,3%), unión estable (60,8%), pardas (31,5%), sin ingreso ocupacional (29,2%), multíparas (28,87%), con complicaciones en el primer trimestre gestacional (32,6%). Se constató un número insuficiente de consultas (13,8 %), datos relativos al prenatal ignorados (68 %). Las principales CPAV fueron los trastornos hemorrágicos (28,2%), hipertensivos (25,4%) e infecciosos (13,3%). Como resultado, se observaron: prevalencia de aborto no especificado (22,1%), muerte perinatal por enfermedad infecciosa y parasitaria de la madre (2,2%). Conclusión: las principales CPAV fueron los trastornos hemorrágicos, hipertensivos e infecciones. Como resultado, se observó alta hospitalaria, aborto, referencia a la UCI, muerte perinatal y muerte materna.

ABSTRACT Objective: To describe the main conditions potentially threatening the lives of women during the pregnancy and puerperal cycle and variables related to these diseases. Method: Documentary, descriptive and quantitative study, conducted with medical records of pregnant women, women giving birth and puerperal women hospitalized in a hospital of medium complexity, who presented Potentially Life Threatening Conditions (PLTC). Those with access unable to be sob judice were excluded. The sample was temporal and the analysis was univariate. Results: This includes 181 medical records. Most conditions occurred in women aged 16 to 34 years (61.3%), stable union (60.8%), brown (31.5%), without occupational income (29.2%), multiparous (28.87%), with complications in the first gestational trimester (32.6%). There was an insufficient number of consultations (13.8%), data regarding prenatal care ignored (68%). The main CPAV were hemorrhagic syndromes (28.2%), hypertensive (25.4%) and infection (13.3%). As an outcome, we observed a prevalence of unspecified miscarriage (22.1%), perinatal death from infectious and parasitic disease of the mother (2.2%). Conclusion: The main CPAV were hemorrhagic, hypertensive and infections syndromes. As an outcome, hospital discharge, miscarriage, ICU referral, perinatal death and maternal death were observed.

Healthcare providers experiences of using uterine balloon tamponade (UBT) devices for the treatment of post-partum haemorrhage: A meta-synthesis of qualitative studies.

BACKGROUND: Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and severe morbidity globally. When PPH cannot be controlled using standard medical treatments, uterine balloon tamponade (UBT) may be used to arrest bleeding. While UBT is used by healthcare providers in hospital settings internationally, their views and experiences have not been systematically explored. The aim of this review is to identify, appraise and synthesize available evidence about the views and experiences of healthcare providers using UBT to treat PPH. METHODS: Using a pre-determined search strategy, we searched MEDLINE, CINAHL, PsycINFO, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-2019, reporting qualitative data on the views and experiences of health professionals using UBT to treat PPH. Author findings were extracted and synthesised using techniques derived from thematic synthesis and confidence in the findings was assessed using GRADE-CERQual. RESULTS: Out of 89 studies we identified 5 that met our inclusion criteria. The studies were conducted in five low- and middle-income countries (LMICs) in Africa and reported on the use of simple UBT devices for the treatment of PPH. A variety of cadres (including midwives, medical officers and clinical officers) had experience with using UBTs and found them to be effective, convenient, easy to assemble and relatively inexpensive. Providers also suggested regular, hands-on training was necessary to maintain skills and highlighted the importance of community engagement in successful implementation. CONCLUSIONS: Providers felt that administration of a simple UBT device offered a practical and cost-effective approach to the treatment of uncontrolled PPH, especially in contexts where uterotonics were ineffective or unavailable or where access to surgery was not possible. The findings are limited by the relatively small number of studies contributing to the review and further research in other contexts is required to address wider acceptability and feasibility issues.

Liver failure in pregnancy: a review of 25 cases.

We retrospectively reviewed the medical records from 25 pregnant women with liver failure from May 2009 to July 2019. Data describing clinical symptoms and manifestations, routine blood analyses, coagulation, and liver and kidney function were extracted. Swansea criteria were assessed to identify variables with prognostic significance for maternal mortality. The results showed that acute fatty liver was the primary cause of liver failure and 8 (88.89%) patients died within 7 days. Swansea diagnostic criteria for assessing the severity of liver failure were consistent with Chinese guidelines and were more systematic and convenient. The incidence of postpartum haemorrhage was 76%, and the velocity of bleeding was approximately 600 mL per hour. Increased Swansea score, hepatic encephalopathy and decreased PWR were important prognostic indicators for mortality. Recovery during the 7 days postpartum period was an important determinant of maternal outcomes.Impact statementWhat is already known on this subject? Liver failure in pregnant women is a rare but potentially devastating disease with a high rate of short-term morbidity and mortality. There are limited reports about clinical predictors of maternal-foetal outcomes and the dilemmas faced in the term of delivery.What the results of this study add? The incidence of postpartum haemorrhage was 76% in pregnant women with liver failure, but the velocity of bleeding was approximately 600 mL per hour. Our study revealed the Swansea score and the ratio of hepatic encephalopathy were significantly higher and platelet-to-white blood cell ratio (PWR) was lower in women who died compared to those who survived. During treatment period, 8 (88.89%) patients died within 7 days.What the implications are of these findings for clinical practice and/or further research? Swansea score, hepatic encephalopathy and PWR were important prognostic indicators for mortality in pregnant women with liver failure. Recovery during the 7 days postpartum period was an important determinant of maternal outcomes. Our findings may prompt researchers to conduct a large multicentre study to evaluate the prognostic indicators for mortality in pregnant women with liver failure.

Ligaduras vasculares no tratamento cirúrgico da hemorragia pós-parto / Vascular ligations in the surgical treatment of postpartum hemorrhage

Hemorragia pós-parto é a maior causa de histerectomia periparto. Esta revisão descreve e ilustra as técnicas de ligaduras vasculares utilizadas no tratamento cirúrgico da hemorragia pós-parto. São apresentados os detalhes técnicos da ligadura das artérias uterinas, da ligadura das conexões útero-ovarianas, da ligadura tríplice de Tsirulnikov, das ligaduras sequenciais de AbdRabbo e de Morel e da ligadura das artérias ilíacas internas. Também são revistos os fatores que dificultam o sucesso dessas técnicas. As ligaduras vasculares são estratégias eficientes para o controle hemorrágico durante cesarianas e devem integrar o conjunto de técnicas que preservam o útero no tratamento da hemorragia pós-parto.(AU)

Postpartum hemorrhage is the major cause of peripartum hysterectomy. This review describes and illustrates the techniques of vascular ligations used in the surgical treatment of postpartum hemorrhage. The technical details of the uterine arteries ligation, of the ligation of the utero-ovarian connections, of the Tsirulnikov triple ligation, of the AbdRabbo and Morel sequential ligations and of the internal iliac arteries ligation are presented. The factors that hinder the success of these techniques also are reviewed. Vascular ligations are efficient strategies for hemorrhagic control during cesarean sections and should integrate the set of techniques that preserve the uterus in the treatment of postpartum hemorrhage.(AU)

Mortality Synopsis Among Women of Reproductive Age Group in Nigeria: A Hospital-Based Study.

PURPOSE: Identification of health problems of women of reproductive age, using a reliable mortality data, is essential in evading preventable female deaths. This study aimed at investigating mortality profile of women of reproductive age group in Nigeria. MATERIALS AND METHODS: This is a descriptive, retrospective study involving women of reproductive age group of 15-49 years that died at DELSUTH from 1st January 2016 to 31st December 2018. The age, date of death and cause of death were retrieved from the hospital records and subsequently analyzed using SPSS version 21. RESULTS: One hundred and eighty-seven eligible deaths were encountered in this study, constituting 17.5% of all deaths in the hospital. Twenty four (12.8%) cases were of maternal etiology while 163 (87.2%) were of non-maternal causes. Non-communicable disease, communicable disease and external injuries accounted for 100 (53.5%), 44 (23.5%) and 19 (10.2%) deaths among the non-maternal causes. The mean age and the peak age group are 34.4 years and the 4th decade respectively. The leading specified non-maternal causes of death (in descending order) are AIDS/TB, cerebrovascular accidents (CVA), breast cancer, road traffic accident (RTA), diabetes, perioperative death and sepsis while the leading maternal causes of death are abortion, postpartum hemorrhage, eclampsia and puerperal sepsis. CONCLUSION: Most deaths affecting WRAG are preventable, with non-maternal causes in excess of maternal causes. There is need for holistic life-long interventional policies and strategies that will address the health need of these women, using evidence-based research findings.

[Maternal deaths in Sweden: Diagnostics and clinical management could be improved]. / Mödradöd i Sverige: Vården hade många gånger kunnat vara bättre - Lärdomar från 11 års extern kollegial granskning.

MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions.  MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny.  A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.

Scaling up interventions: findings and lessons learned from an external evaluation of Niger's National Initiative to reduce postpartum hemorrhage.

BACKGROUND: Niger has one of the highest maternal mortality ratios in Sub Saharan Africa, of which postpartum hemorrhage is the leading cause. In 2014, Health and Development International and the Ministry of Health of Niger launched an initiative to introduce and scale-up three PPH interventions in health facilities nationwide: misoprostol, uterine balloon tamponade, and the non-pneumatic anti-shock garment. METHODS: A two-phase mixed-methods evaluation was conducted to assess implementation of the initiative. Health facility assessments, provider interviews, and household surveys were conducted in May 2016 and November 2017. RESULTS: All evaluation facilities received misoprostol prevention doses. However, shortages in misoprostol treatment doses, UBT kits, and NASG stock were documented. Health provider training increased while knowledge of each PPH intervention varied. Near-universal uterotonic coverage for PPH prevention and treatment was achieved and sustained throughout the evaluation period. Use of UBT and NASG to manage PPH was rare and differed by health facility type. Among community deliveries, fewer than 22% of women received misoprostol at antenatal care for self-administered prophylaxis. Among those who did, almost all reported taking the drugs for PPH prevention in each phase. CONCLUSIONS: This study is the first external evaluation of a comprehensive PPH program taking misoprostol, UBT, and NASG to national scale in a low resource setting. Although gaps in service delivery were identified, results demonstrate the complexities of training, managing stock, and implementing system-wide interventions to reach women in varying contexts. The experience provides important lessons for other countries as they develop and expand evidence-based programs for PPH care.

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)

Patient blood management in obstetrics - Review.

Patient blood management (PBM) aims to reduce red blood cell transfusion, minimize preoperative anemia, reduce intraoperative blood loss as well as optimize hemostasis, and individually manage postoperative anemia. Benefits include improved clinical outcome with a reduction in patient morbidity and mortality, but also lower hospital costs and shorter hospital length of stay. To date, it has been successfully implemented in several medical specialties, such as cardiac, trauma and orthopedic surgery. In obstetrics, postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality. PBM has the potential to improve outcome of mother and child. However, pregnancy and childbirth pose a special challenge to PBM, and several adaptations compared to PBM in elective surgery are necessary. To date, awareness of the clinical advantages of PBM among obstetricians and midwifes regarding PBM and its concept in PPH is limited. In the following review, we therefore aim to present the current status quo in PBM in obstetrics and its challenges in the clinical routine.

Comparison of outcome between intrauterine balloon tamponade and uterine artery embolization in the management of persistent postpartum hemorrhage: A propensity score-matched cohort study.

INTRODUCTION: The aim of this study was to compare the outcomes of women who were initially managed by intrauterine balloon tamponade or uterine artery embolization because of persistent postpartum hemorrhage demanding an immediate intervention to control bleeding. MATERIAL AND METHODS: Propensity score-matched cohort study including women who had intrauterine balloon tamponade or uterine artery embolization as initial management strategy to control persistent postpartum hemorrhage, that is, refractory to first-line therapy combined with at least one uterotonic agent. The primary outcome measure was a composite of peripartum hysterectomy and/or maternal mortality. Secondary outcomes measures were total volume of blood loss and total number of packed red blood cells transfused. RESULTS: Our 1:1 propensity score-matched cohort comprised of 50 women who had intrauterine balloon tamponade and 50 women who underwent uterine artery embolization at a blood loss between 1000 and 7000 mL. There was no statistically significant difference in the hysterectomy risk between the two groups (n = 6 in each group, odds ratio [OR] 1.00, 95% confidence interval [CI] .30-3.34), in total volume of blood loss (median 4500 mL, interquartile range [IQR] 3600-5400) for balloon vs 4000 mL (IQR 3250-5000) for embolization, P = 0.382) or in total units of packed red blood cells transfused (median 7 (IQR 5-10) for balloon vs 6 [IQR 4-9] for embolization, P = 0.319). Fifteen women (30%) who were initially managed by an intrauterine balloon still underwent uterine artery embolization, of whom one had an embolization-related thrombo-embolic event. Maternal mortality occurred in neither of the intervention groups. CONCLUSIONS: No difference in the risk of peripartum hysterectomy and/or maternal death was observed between women who had intrauterine balloon tamponade and women who underwent uterine artery embolization as an initial management for persistent postpartum hemorrhage. Although this study was underpowered to demonstrate equivalence, our study design provides a framework for future research in which intrauterine balloon tamponade may prove to be a suitable intervention of first choice in the management of persistent postpartum hemorrhage.

Embolização de artéria uterina para hemorragia pós-parto: uma revisão de literatura / Uterine artery embolization for postpartum hemorrhage: a review of the literature

A hemorragia pós-parto é uma emergência obstétrica que acomete grande parcela de puérperas e leva à extensa quantidade de óbitos por ano. Entre as suas principais causas estão a atonia uterina e o acretismo placentário. Atualmente, as técnicas mais utilizadas para a resolução do sangramento se apresentam por muitas vezes ineficazes e/ou levam à infertilidade feminina. O presente estudo trata-se de uma revisão da literatura em modelo PRISMA, no qual foram selecionados 35 artigos dos últimos 12 anos, nas bases de dados do UpToDate, SciELO, PubMed, Plos ONE, Lilacs e Datasus, no qual serão apresentadas evidências de que, nas mãos de um profissional treinado, a embolização de artéria uterina se mostra como uma excelente alternativa no tratamento da hemorragia obstétrica, apresentando-se como terapêutica minimamente invasiva, com altas taxas de sucesso, baixo número de complicações e que preserva a função reprodutiva da mulher.(AU)

The post-partum hemorrhage is an obstetric emergency that affects a big percentage of women who have recently given birth and leads to a big amount of deaths per year. Its main causes are uterine atony and placentary accretism. Currently the main techniques for its resolution are the utilization of uterotonics and aggressive surgical approaches to the pelvic structure, which are commonly inefficient or bring long term injuries to the fertility. This study is a literature review structure on PRISMA model, where was selected 35 articles of the last 12 years, in these databases: UpToDate, SciELO, PubMed, Plos ONE, Lilacs and Datasus, in which will be presented evidences of, in expert professional hands, uterine artery embolization being an excellent alternative in the treatment of obstetric hemorrhage, presenting itself a minimally invasive technique, with high rates of success, low numbers of complications and the capacity of preserving the patient reproductive system.(AU)

Factores de riesgo de hemorragia primaria posparto / Postpartum primary haemorrhage's risk factors

Introducción: La hemorragia primaria posparto es la principal causa de muerte materna en el Perú y se ha relacionado directamente con el parto domiciliario, por lo que podría reflejar la oportunidad y calidad de los servicios de salud cuando ocurre en un parto institucionalizado. Objetivo: Identificar los factores de riesgo de hemorragia primaria posparto producidos por desgarro del tracto genital. Métodos: Se realizó un estudio analítico de casos y controles en el Hospital Augusto Hernández Mendoza- EsSalud. La muestra estuvo conformada por 30 casos (con hemorragia primaria posparto por desgarro del tracto genital) y 120 controles (sin hemorragia primaria posparto). Se usaron las pruebas T de Student y U de Mann -Withney para comparar las variables numéricas y la prueba de Chi cuadrado para determinar la asociación entre las variables. La fuerza de asociación se determinó calculando Odds Ratio crudo y ajustado con sus intervalos de confianza (IC) al 95 por ciento mediante regresión logística binaria con prueba de bondad de ajuste de Hosmer-Lemeshow. Resultados: El valor promedio de hemoglobina fue 8,85 ± 0,39 mg por ciento en los casos y 11,90 ± 0,13 mg por ciento en los controles (p = 0,000). En el análisis multivariado los predictores de riesgo fueron: Nulípara (ORa = 11,49; IC95 por ciento = 3,11-42,42), soltera (Ora = 8,81; IC95 por ciento = 1,83-42,41), < 8 controles pre-natales (Ora = 7,95; IC95 por ciento = 2,60-24,31), y peso al nacer del recién nacido ≥ 3500 gramos (Ora = 7,34; IC95 por ciento = 2,15-25,06). Conclusiones: El riesgo de hemorragia primaria posparto por desgarro del tracto genital fue mayor en solteras, nulíparas, con menos de ocho controles prenatales y recién nacidos con peso mayor de 3500 gramos(AU)

Introduction: Postpartum primary hemorrhage is the leading cause of maternal death in Peru, and it has been directly related to home birth, so it could reflect the opportunity and quality of health services when it occurs during a hospital's birth. Objective: To identify the risk factors for postpartum primary hemorrhage caused by tearing of the genital tract. Methods: An analytical study of cases and controls was carried out at Augusto Hernández Mendoza Hospital - EsSalud. The sample was composed by 30 cases (with postpartum primary hemorrhage by tearing of the genital tract) and 120 controls (without postpartum primary hemorrhage). T´s Student and U´s Mann-Whitney tests were used to compare the numerical variables, and the Chi square test to determine the association between the variables. Association´s strength was determined by calculating crude Odds Ratio and it was adjusted with its confidence intervals (CI) to 95 percent by binary logistic regression with the Hosmer-Leme show goodness-of-fit test. Results: The average haemoglobin value was 8.85 ± 0.39 mg percent in the cases and 11.90 ± 0.13 mg percent in the controls (P = 0.000). In the multivariate analysis, the risk predictors were: Nulliparae (ORa = 11.49; IC95 percent = 3,11-42,42), single (Ora = 8.81; IC95 percent = 1,83-42,41), < 8 Pre-natal controls (Ora = 7.95; IC95 percent = 2,60-24,31), and newborn birth weight ? 3500 grams (Ora = 7.34; IC95 percent = 2,15-25,06). Conclusions: The risk of primary post-partum hemorrhage by tearing of the genital tract was greater in single, nulliparae women, with less than eight prenatal controls and newborns weighing more than 3500 grams(AU)

Antifibrinolytic drugs for treating primary postpartum haemorrhage.

BACKGROUND: Postpartum haemorrhage (PPH) - heaving bleeding within the first 24 hours after giving birth - is one of the main causes of death of women after childbirth. Antifibrinolytics, primarily tranexamic acid (TXA), have been shown to reduce bleeding in surgery and safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events.An earlier Cochrane review on treatments for primary PPH covered all the various available treatments - that review has now been split by types of treatment. This new review concentrates only on the use of antifibrinolytic drugs for treating primary PPH. OBJECTIVES: To determine the effectiveness and safety of antifibrinolytic drugs for treating primary PPH. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (28 May 2017) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs), including cluster-randomised trials of antifibrinolytic drugs (aprotinin, TXA, epsilon-aminocaproic acid (EACA) and aminomethylbenzoic acid, administered by whatever route) for primary PPH in women.Participants in the trials were women after birth following a pregnancy of at least 24 weeks' gestation with a diagnosis of PPH, regardless of mode of birth (vaginal or caesarean section) or other aspects of third stage management.We have not included quasi-randomised trials, or cross-over studies. Studies reported as abstracts have not been included if there was insufficient information to allow assessment of risk of bias.In this review we only identified studies looking at TXA. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each study using an agreed form. We entered data into Review Manager software and checked for accuracy.For key review outcomes, we rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach. MAIN RESULTS: Three trials (20,412 women) met our inclusion criteria. Two trials (20,212 women) compared intravenous (IV) TXA with placebo or standard care and were conducted in acute hospital settings (labour ward, emergency department) (in high-, middle- and low-income countries).One other trial (involving 200 women) was conducted in Iran and compared IV TXA with rectal misoprostol, but did not report on any of this review's primary or GRADE outcomes. There were no trials that assessed EACA, aprotinin or aminomethylbenzoic acid.Standard care plus IV TXA for the treatment of primary PPH compared with placebo or standard care aloneTwo trials (20,212 women) assessed the effect of TXA for the treatment of primary PPH compared with placebo or standard care alone. The larger of these (The WOMAN trial) contributed over 99% of the data and was assessed as being at low risk of bias. The quality of the evidence varied for different outcomes, Overall, evidence was mainly graded as moderate to high quality.The data show that IV TXA reduces the risk of maternal death due to bleeding (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.00; two trials, 20,172 women; quality of evidence: moderate). The quality of evidence was rated as moderate due to imprecision of effect estimate. The effect was more evident in women given treatment between one and three hours after giving birth with no apparent reduction when given after three hours (< one hour = RR 0.80, 95% CI 0.55 to 1.16; one to three hours = RR 0.60, 95% CI 0.41 to 0.88; > three hours = RR 1.07, 95% 0.76 to 1.51; test for subgroup differences: Chi² = 4.90, df = 2 (P = 0.09), I² = 59.2%). There was no heterogeneity in the effect by mode of birth (test for subgroup differences: Chi² = 0.01, df = 1 (P = 0.91), I² = 0%). There were fewer deaths from all causes in women receiving TXA, although the 95% CI for the effect estimate crosses the line of no effect (RR 0.88, 95% CI 0.74 to 1.05; two trials, 20,172 women, quality of evidence: moderate). Results from one trial with 151 women suggest that blood loss of ≥ 500 mL after randomisation may be reduced (RR 0.50, 95% CI 0.27 to 0.93; one trial, 151 women; quality of evidence: low). TXA did not reduce the risk of serious maternal morbidity (RR 0.99, 95% CI 0.83 to 1.19; one trial, 20,015 women; quality of evidence: high), hysterectomy to control bleeding (RR 0.95, 95% CI 0.81 to 1.12; one trial, 20,017 women; quality of evidence: high) receipt of blood transfusion (any) (RR 1.00, 95% CI 0.97 to 1.03; two trials, 20,167 women; quality of evidence: moderate) or maternal vascular occlusive events (any), although results were imprecise for this latter outcome (RR 0.88, 95% CI 0.54 to 1.43; one trial, 20,018 women; quality of evidence: moderate). There was an increase in the use of brace sutures in the TXA group (RR 1.19, 95% CI 1.01, 1.41) and a reduction in the need for laparotomy for bleeding (RR 0.64, 95% CI 0.49, 0.85). AUTHORS' CONCLUSIONS: TXA when administered intravenously reduces mortality due to bleeding in women with primary PPH, irrespective of mode of birth, and without increasing the risk of thromboembolic events. Taken together with the reliable evidence of the effect of TXA in trauma patients, the evidence suggests that TXA is effective if given as early as possible.Facilities for IV administration may not be available in non-hospital settings therefore, alternative routes to IV administration need to be investigated.

Postpartum Hemorrhage.

Interventional radiologists are often called for emergent control of abnormal uterine bleeding. Bleeding, even heavy bleeding as a result of uterine fibroids is not a common emergent procedure; instead, pregnancy and pregnancy related conditions, trauma and malignancy associated with bleeding can be the source of many interventional radiology on call events or procedures. Postpartum hemorrhage (PPH) is the most common cause, and is defined as blood loss of 500mL after vaginal delivery or 1000mL after cesarean section. Several authors have suggested a simpler definition of any amount of blood loss that creates hemodynamic instability in the mother. Regardless, PPH can be a life-threatening emergency and is a leading cause of maternal mortality requiring prompt action. Primary PPH is bleeding within the first 24 hour of delivery and secondary PPH is hemorrhage that occurs more than 24 hour after delivery. In addition to death, other serious morbidity resulting from postpartum bleeding includes shock, adult respiratory distress syndrome, coagulopathy, and loss of fertility due to hysterectomy. Transcatheter uterine artery embolization was first introduced as a treatment for PPH in 1979. It is a nonsurgical, minimally invasive, extremely safe and effective treatment for controlling excessive bleeding of the female reproductive track usually after conservative measures have failed, yet somewhat underused. Referring providers have limited awareness of the procedure. In hospitals where interventional radiologists have the experience and technical expertise to perform pelvic arteriography and embolization, this therapeutic option can play a pivotal role in the management of emergent obstetric hemorrhage.

Uterine balloon tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage: a randomised controlled trial in Benin and Mali.

OBJECTIVE: To assess the effectiveness of low-cost uterine tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage (PPH) in low-resource settings. DESIGN: Randomised controlled trial. SETTING: Seven healthcare facilities in Cotonou, Benin and Bamako, Mali. POPULATION: Women delivering vaginally who had clinically diagnosed PPH that was suspected to be due to uterine atony, who were unresponsive to oxytocin and who needed additional uterotonics. METHODS: Women were randomly assigned to receive uterine balloon tamponade with a condom-catheter device or no tamponade; both groups were also given intrarectal or sublingual misoprostol. MAIN OUTCOME MEASURE: Proportion of women with invasive surgery or who died before hospital discharge. RESULTS: The proportion of primary composite outcome did not differ significantly between the tamponade arm (16%; 9/57) and the standard second line treatment arm (7%; 4/59): relative risk 2.33 (95% CI 0.76 to 7.14, p=0.238). A significantly increased proportion of women with tamponade and misoprostol versus misoprostol alone had total blood loss more than 1000 mL: relative risk 1.52 (95% CI 1.15 to 2.00, p=0.01). Case fatality rate was higher in the tamponade group (10%; 6/57) than in the control group (2%; 1/59) (p=0.059). TRIAL REGISTRATION NUMBER: ISRCT Registry Number 01202389; Post-results.

Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review.

Essentials The evidence on how to manage life-threatening pregnancy-related pulmonary embolism (PE) is scarce. We systematically reviewed all available cases of (sub)massive PE until December 2016. Thrombolysis in such severe PE was associated with a high maternal survival (94%). The major bleeding risk was much greater in the postpartum (58%) than antepartum period (18%). SUMMARY: Background Massive pulmonary embolism (PE) during pregnancy or the postpartum period is a rare but dramatic event. Our aim was to systematically review the evidence to guide its management. Methods We searched Pubmed, Embase, conference proceedings and the RIETE registry for published cases of severe (submassive/massive) PE treated with thrombolysis, percutaneous or surgical thrombectomy and/or extracorporeal membrane oxygenation (ECMO), occurring during pregnancy or within 6 weeks of delivery. Main outcomes were maternal survival and major bleeding, premature delivery, and fetal survival and bleeding. Results We found 127 cases of severe PE (at least 83% massive; 23% with cardiac arrest) treated with at least one modality. Among 83 women with thrombolysis, survival was 94% (95% CI, 86-98). The risk of major bleeding was 17.5% during pregnancy and 58.3% in the postpartum period, mainly because of severe postpartum hemorrhages. Fetal deaths possibly related to PE or its treatment occurred in 12.0% of cases treated during pregnancy. Among 36 women with surgical thrombectomy, maternal survival and risk of major bleeding were 86.1% (95% CI, 71-95) and 20.0%, with fetal deaths possibly related to surgery in 20.0%. About half of severe postpartum PEs occurred within 24 h of delivery. Conclusions Published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest a high maternal and fetal survival (94% and 88%). In the postpartum period, given the high risk of major bleeding with thrombolysis, other therapeutic options (catheter [or surgical] thrombectomy, ECMO) may be considered if available.