Management of obstetric hemorrhage; an observational study highlighting the efficacy of uterine artery ligation

Background: Obstetrical hemorrhage is leading cause of maternal mortality. UAE is termed safe and effective method for resolving hemorrhage. objective of this study was to determine efficacy of uterine artery ligation in management of obstetrical hemorrhage.Methods: This cross sectional observational using non-probability convenient sampling technique was carried out for six months. After ethical approval, females between 18 to 35 years diagnosed with obstetrical hemorrhage, uterine atony refractory to medical treatment, having active bleeding from placental side or having normal coagulation profile were while females with post-partum hemorrhage because of retained products of conception, due to genital tract trauma or with disseminated intravascular coagulation were excluded. Analysis of data was done using SPSS version 23.0. Quantitative variables were reported as mean and standard deviation and for qualitative variables, frequency and percentages. Chi-square test was applied keeping p-value of <0.05 as statistically significant.Results: From 109 females with mean age 47±5.25 years. In comparison of parity distribution, 62 (56.88%) were multiparous and 47 (43.12%) were primiparous. Type of bleeding observed was antepartum 36(33.03%), peripartum 39 (35.78%) and postpartum in 34 (31.19%). Efficacy of uterine artery ligation in management of obstetric hemorrhage was observed to be 35 (32.11%). The efficacy of uterine artery ligation in management of obstetric hemorrhage in three categories of age groups reported significant association (p=0.0005) and type of bleeding (p=0.025).Conclusions: Efficacy of UAE in different types of obstetrical hemorrhage reported in our study was lower than expected in about one-third of females.

A study of the efficacy and safety of the balloon tamponade in the management of atonic post-partum hemorrhage

Background: The most common cause of post-partum hemorrhage (PPH) is uterine atony. Treatment for atony follows a well-defined stepwise approach, including drugs and mechanical interventions followed by surgery as a last resort. Early use of intrauterine balloon tamponade is a way of limiting ongoing uterine blood loss while initiating other measures and can be readily implemented by providers with minimal training.Methods: This prospective interventional study was conducted in 112 consecutive patients attended department of obstetrics and gynecology, Gandhi Medical College and Associated Sultania Zanana Hospital, Bhopal, Madhya Pradesh, India, in one year of study period.Results: In this study most of the patients had gestational age >37 weeks [83 (74.1%)]. Most of the patients in the study had vaginal delivery [64 (57.1%)]. In 84 (75%) patients Bakri balloon was used followed by Burke balloon in 17 (15.2%) patients, condom catheter in 7 (6.2%) patients and CG balloon in 4 (3.6%) patients. Different types of balloons were used according to availability of balloon at the time of management. Most of the patients [71 (63.3%)] had trans-vaginal route of balloon placement and 41 (36.7%) patients underwent trans-abdominal balloon placement. Most of the patients 69 (61.65%), responded to tamponing within 20 minutes of balloon placement while 9 patients had negative tamponade and continued to bleed. Bakri balloon tamponade was most commonly used in 84 (75.0%) patients. CG balloon and condom catheter were used only in 4 (3.6%) and 7 (6.3%) patients respectively. Tamponading was effective and successful in 103 (92%) patients.Conclusions: PPH is still a leading but preventable cause of maternal morbidity and mortality. In the majority of cases, relatively simple methods are used to avert a disaster, although these are not always employed. Uterine tamponade using intrauterine balloons appears to be an effective tool in the management of PPH.

Study of cases of post-partum hemorrhage after spontaneous vaginal delivery in labour room of obstetrics and gynecology department of tertiary care center, Ranchi, Jharkhand, India

Background: Postpartum haemorrhage is one of the common causes of maternal death worldwide. Whenever the amount of blood loss from or into genital tract is 500 ml or more after delivery of baby or any amount of bleeding that makes patients haemodynamically unstable is post-partum haemorrhage.Methods: In this study amount of blood loss after spontaneous vaginal delivery was measured in 100 cases by calibrated blood drape. Patients having high risk criteria for PPH were excluded.Results: In this study 55% patients were from 20-30 years age group. 82% cases were nontribal. 94% belonged to lower middle class. 67% patients were primigravida. 89% patients had atonic PPH and 11% had traumatic PPH. 85% patients had mild PPH. 60% of atonic PPH was managed by oxytocin only. 10% required oxytocin + Methergin, 6% required oxytocin + Methergin + Misoprostol. 6% required Oxytocin + Methergin + Misoprostol + Carboprost. In this study surgical intervention was required in 18% cases. Blood transfusion was required in 74% cases. 75% cases were from non-tribal ethnicity.Conclusions: PPH is a life-threatening condition. If it can be diagnosed early and managed properly then many maternal lives can be saved. In this study there was no maternal death.

Factors associated with increased blood loss during delivery

Background: The present study was done to assess the blood loss during delivery even after active management of third stage of labor with oxytocin and the maternal outcomes of PPH.Methods: We studied 100 pregnant women were either in spontaneous labor or admitted for induction of labor, underwent vaginal delivery or caesarean section in our institute. Active management of third stage of labor in all 100 cases included 10 IU intramuscular oxytocin or 10 to 20 IU intravenous in 500 ml of Ringer’s Lactate. Blood loss in all cases was noted.Results: Of the included cases, 27 had to be given extra-uterotonics for atonic uterus, of which 12 parturient still had PPH. Atonic uterus was the cause of PPH in 11 of the 12 cases, while one case was of atonic uterus plus trauma. Half of all PPH cases responded to medical management alone, five cases had to undergo tamponade/stepwise devascularization and one case had to undergo obstetric hysterectomy. Blood loss was significantly higher in women aged more than 35 years, primigravida, not in labor, oligohydramnios or post-datism, elective LSCS, scarred uterus in and had more than 1 high risk factor. Among various high-risk conditions, significantly higher blood loss was observed in patients with chronic hypertension, gestational hypertension, pre-gestational diabetes mellitus, multipara with prior PPH, placenta previa, preeclampsia and sickle cell trait.Conclusions: Fifteen women avoided PPH by using a reliable method of blood loss measurement and initiating interventions early. Organized PPH management protocol morbidity and mortality of the mother and neonate can be prevented.

Intramuscular oxytocin 10 units versus intravenous methylergometrine 0.2 mg in active management of third stage of labour for prevention of postpartum haemorrhage: a comparative study

Background: To compare the effectiveness of 10 IU of oxytocin IM with 0.2 mg methyl ergometrine IV in the prevention of post-partum hemorrhage when used as a part of active management of third stage of labour. This study aims to compare their influence on duration of the third stage of labour, the amount of blood loss during the third stage of labour and the immediate post-partum period and side effects of the drugs if any.Methods: The study was conducted in a tertiary care teaching hospital. 200 women, who underwent normal delivery with or without episiotomy, were enrolled and were randomly distributed into two groups. 100 women received 10 IU of intramuscular Oxytocin and 100 women received intravenous 0.2 mg of methyl ergometrine. Women of both the groups were given the medication after delivery of anterior shoulder of the baby. Comparison done between percentages fall in Hb from before delivery to 24 hours after delivery, need for additional uterotonic agents, need for blood transfusion, duration of third stage of labour and any side effects including retained placenta and need for manual removal of placenta.Results: Intravenous methylergometrine was observed to be equally effective as intramuscular oxytocin in prevention of post-partum hemorrhage. There was no difference in the duration of third stage of labour, amount of blood loss, need for additional uterotonic agents, and need for blood transfusion in both the groups. There was no significant side effect in both the groups.Conclusions: Intramuscular oxytocin is as efficacious as Intravenous methylergometrine in the prevention of postpartum hemorrhage with no side effects.

A near miss case of placenta percreta in a patient with post myomectomy scar

The term placenta accreta or placenta accrete syndrome is used to describe a spectrum of an abnormal placental implantation and firm adherence which are classified according to the depth of invasion into the uterus. A 28-year-old elderly primigravida presented AIIMS OPD to for the 1st time at 13+2 weeks of gestation with brownish discharge per vaginum. Ultrasonography done showed 12 weeks single intrauterine pregnancy with subchorionic haemorrhage of 3.7×2.52 cm with placenta being fundoanterior. She underwent myomectomy 2 years back and during her antenatal care in 3rd trimester growth scan at 30+2 weeks of gestation placenta was fundoanterior with loss of retroplacental hypoechoic in the upper margin of placenta at the myomectomy scar site with small extra uterine collection seen measuring 7.6×2.3 cm and hence possibility of placenta accreta was suggestive by the above findings confirmed by MRI. Emergency cesarean section done at 36+6 weeks of gestation for leaking per vaginum. Manual removal of placenta was tried but it failed and soon atonic PPH developed. Seeing no response with uterotonics internal iliac artery ligation was also attempted but failed. Immediate decision for hysterectomy was taken as a life-saving method. On adhesiolysis in the fundal region placental tissue perforating uterine serosa was visible on the surface of uterus, hence diagnosis of placenta percreta was confirmed which was further confirmed on histopathological report. Currently hysterectomy or local resection is preferred over conservative management with methotrexate.

Role of Placental Cord Drainage in the Management of Third Stage of Labor after Normal Delivery

Background: Globally and especially in the under developing nations Postpartum Hemorrhage (PPH) is the most common cause of maternal mortality. All women who deliver are at risk of complications of third stage of labor. Multiple researches have been done to compare active vs expectant management of third stage of labor. Placental Cord Drainage (PCD), one of the active method for control of third stage of labor, incudes opening of clamp from mother’s side of umbilical cord thereby allowing the blood from placenta to flow freely immediately after clamping and cutting of the umbilical cord. Aim: Thus, the following study was conducted to assess the effect of PCD via umbilical cord in decreasing the time period of third stage of labor and incidence of PPH. Materials and Methods: This hospital based comparative study was conducted in the department of Obstetrics and Gynecology, National Institute of Medical Sciences & Research, Jaipur. A total of 300 consecutive patients with term pregnancy (>37 weeks) fulfilling the inclusion criteria were taken after informed consent. These were divided into two groups of 150 cases each, study group (PCD group) and control group. The various parameters like blood loss, need for transfusion, duration of third stage of labor, manual removal of placenta, hospital stay, secondary PPH (after 24 hours and before 6 weeks) were noted for every female. Statistical analysis was done using t-test for quantitative data, nonparametric data was analyzed by Mann Whitney test and categorical data was analyzed using chisquare test. The significance threshold of p-value was set at <0.05. All analysis was carried out by using SPSS software version 21. Results: Average blood loss was significantly less in subjects of drainage group as compared to control group (273.8 ml vs 391.2 ml; p<0.05). Also, average duration of third stage of labor was significantly less in drainage group (4.1 vs 7.7 mins; p<0.05). No difference was observed between two groups based on placenta weight (p-0.121). Conclusion: In the present study, PCD had a beneficial effect on the duration of third stage of labor and on postpartum blood loss. Thus, use of PCD is recommended in active management of labor by trained professionals

A randomized controlled trial of sublingual Misoprostol - 600µg versus intravenous Oxytocin - 10IU in prevention of post partum hemorrhage during cesarean section

Background: Mortality related to pregnancy and childbirth causes half a million women around the world to die annually. About 35% of these deaths are from postpartum hemorrhage (PPH). Prevention of PPH has been advised by the WHO by the use of Oxytocin 10 IU IM or IV and Misoprostol 600 µg in low resource settings in vaginal delivery. However there have been only a few reports on the use of Misoprostol during cesarean section. The best route and dose of Misoprostol is still being debated.Methods: One hundred women with term singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive either Misoprostol 600µg sublingually or intravenous oxytocin 10 IU soon after delivery of the baby. Estimated blood loss and comparative change in preoperative hemoglobin to post operative hemoglobin levels and side effects were evaluated.Results: Blood loss was found to be more in Misoprostol than Oxytocin. Eight patients of the Misoprostol group required additional oxytocics. Oxytocin group did not receive any additional drugs. No surgical intervention was made in either of the groups.  The most common side effect with Misoprostol was shivering (46%) and in Oxytocin group fever (4%).Conclusions: Sublingual Misoprostol of 600µg works to prevent postpartum bleeding. In our study Oxytocin was more effective than Misoprostol in preventing PPH during cesarean section. Late onset of action of Misoprostol in comparison to Oxytocin may render suturing of the uterus difficult due to pooling of blood. In settings in which use of Oxytocin is not feasible, Misoprostol might be a suitable alternative for post-partum hemorrhage.

Histopathological examination of emergency obstetric hysterectomy specimens

Background: Obstetric hysterectomy is done as a lifesaving procedure in very trying circumstances of life threatening severe hemorrhage. The study was undertaken with the aim to evaluate the relative frequency of hysterectomy done for obstetric indication among the hysterectomy specimens and also to assess the histopathological findings in the hysterectomy specimens.Methods: The study was conducted at a tertiary care center over a period of two and half years. Consecutive specimens of hysterectomy done for obstetrical indication were included. Gross and microscopic findings noted and data analysed. The study was approved by the Institute Ethical Committee.Results: Of the total hysterectomy specimens received obstetrical hysterectomy comprised only 1.3%(12/915) of all the hysterectomies. Patient’s age ranged from 20-36 years; mean 28.6 years. Parity ranged from 1 to 5; mean 2. More multiparous women 91.7%(11/12) had hysterectomies as compared to primiparous 8.3%(1/12) cases                         (p value <0.0001). All patients had single pregnancy. All (100%) patients underwent surgery through abdominal route with subtotal hysterectomy with preservation of the bilateral adnexae undertaken in most (11/12; 91.7% cases). About 5(41.6%) cases hysterectomies were performed after previous caesarean section and had abnormal placentation. Histopathological examination revealed adherent placenta in 33.4%(4/12), endometritis in 25%(3/12), rupture in 25%(3/12) and histologically unremarkable in 16.6%(2/12) cases.Conclusions: Obstetric hysterectomy is an emergency lifesaving procedure done in situations of uncontrolled post-partum hemorrhage. In recent years with more number of caesarean sections the incidence of abnormal placentation has drastically increased, thus making adherent placenta as the most common histopathological finding.

Causes and management of post-partum hemorrhage at tertiary care center, Rajasthan, India

Background: PPH is responsible for 25% of all maternal deaths. In India, PPH incidence in India is 2%-4% following vaginal delivery and 6% following cesarean section. PPH as the important cause of 19.9% of maternal mortality in India. The objectives of the study were to study the incidence, risk factors, cause, morbidity and mortality pattern and management of PPH.Methods: This is a cross-sectional study conducted among 102 pregnant women selected by convenient sampling and admitted in labour room during the study period who will be deliver by vaginally or by caesarean section. The patient having PPH were divided into two groups: Group I: Patients having primary atonic PPH, Group II: Patients having traumatic PPH.Results: Mean age of participants was 33.6 and 32.9 years, 59.3 and 51.2 have ‘0’ parity, mean BMI 22.8 and 23.9 kg/m2, 34.6% and 17.1 babies were delivered by LSCS, 11.7% and 12.2% have history of PPH in the group of atonic and traumatic respectively. In the group of atonic PPH cases, 77.2%, 15.4%, 4.3% and 3.1% cases managed by the method of ‘Uterotonics +<2 blood transfusions’, ‘Uterotonics + >2blood transfusions’, ‘Perineal Tear Repair’ and ‘Surgical Intervention’ respectively. All the traumatic PPH cases (100.0%) were managed by ‘surgical intervention’.Conclusions: A multi-disciplinary approach include medical, mechanical, surgical and radiological is required in severe haemorrhage. Availability of blood and blood products is very crucial. Prediction and assessment of blood loss and timely identification of uterine atony are remaining the cornerstone for prompt and effective management of PPH.

Indications and foeto-maternal outcome of emergency cesarean sections in rural Mewar region

Background: In the 21st century caesarean section is the most common operation in modern obstetrics but its indications have been changed in elective and emergency cases. The aim of the present study was to find out the incidence, indication of caesarean, foeto-maternal outcome in patients who came in emergency from rural areas.Methods: This retrospective study was conducted at Pannadhai Mahila Hospital, R. N. T. Medical College, Udaipur from September 2017 to February 2018. All the women who were unbooked, belonged to rural Mewar region and underwent emergency caesarean section.Results: Total no. of deliveries conducted were 1560 in the emergency labour room out of which 462 were emergency caesarean sections. The mean age of the participants was 27 years. Foetal distress was the most common indication (17.75%) followed by prolonged labour/ failed induction 14.5%. Post-partum haemorrhage and adhesions were the commonly encountered complications.Conclusions: LSCS due to maternal and foetal indications is inevitable. Timely performed LSCS decreases the morbidity and mortality. The government of India has also taken initiative in making caesarean deliveries more acceptable, affordable to patients belonging to rural areas. The government is also enhancing primary and community health centers.

Efficacy of internal iliac artery ligation for control of post-partum haemorrhage

Background: Pelvic hemorrhage is associated with a great degree of morbidity and mortality and has to be controlled immediately. Ligation of the internal iliac arteries is a method to achieve the goal. We conducted this study to assess the outcome, effectiveness and complications of internal iliac artery ligation (IIAL) in controlling postpartum haemorrhage.Methods: This study was a retrospective study conducted in a rural tertiary referral centre from April 2015 to March 2018. IIAL was performed in women with PPH either at caesarean section or at laparotomy performed at a variable time after vaginal or caesarean delivery.Results: Over the study period of 3 years, 29 cases of IIAL were performed. The most common indication for IIAL was atonic PPH. Uterine salvagability was 62% in this study.Conclusions: All obstetric surgeons should be fully aware of the indications, timing and technical aspects of IIAL. Bilateral internal iliac artery ligation remains a safe, fast, effective and life saving salvage procedure which should be encouraged and used routinely by obstetricians when faced with cases of severe obstetric hemorrhage, especially in young women of low parity.

Use of non-pneumatic anti shock garment in hemorrhagic shock

Background: Non-pneumatic anti-shock garment (NASG) is a first-aid device that reverses hypovolemic shock and decreases obstetric haemorrhage. It consists of articulated neoprene segments that close tightly with Velcro, shunting blood from the lower body to the core organs, elevating blood pressure and increasing preload and cardiac output. The use of an NASG can stabilize a patient while awaiting transport, during transport, or during delays in receiving care at referral facilities.Methods: A prospective observational study of use of non-pneumatic anti shock garment (NASG) in cases with obstetric hemorrhagic shock was carried out at a tertiary referral center. As soon as severe shock was recognized in the hospital, the anti-shock garment was placed. Data on various parameters related to use of NASG was collected and interpreted to draw conclusions.Results: NASG was used in 25 cases of hemorrhagic shock during one-year period. Post-partum hemorrhage (36%) was the commonest indication for NASG use, followed by ruptured tubal ectopic pregnancy (28%). It was observed that 68% and 32 % of women had shock index of 1-1.5 and above 1.5 respectively at the time of application of NASG. The shock index rapidly improved to 0.5-0.9 in 92% and 1-1.5 in 8 percent of cases respectively after the application of NASG. The NASG was mainly used in labour room (40%) and emergency department (36%).  NASG was applied by nurses and doctors together in 64% of cases. NASG was kept for a period 24 hours in 92% cases. The survival rate was 96% following use of NASG.Conclusions: NASG is a temporizing alternative measure in hemorrhagic shock management that shows a trend to reduce hemorrhage related deaths and severe morbidities. NASG should be made available at all health facilities that deal with high risk pregnancies and deliveries.

Hemostatic function change during pregnancy of women with placental abruption and its application for predicting postpartum hemorrhage / 临床检验杂志

Objective@#To investigate whether the changes of hemostatic system in pregnant women with placental abruption are different from the pattern of the pregnant women without complications, and the tests of hemostatic function before labor are helpful for prediction and estimation of postpartum hemorrhage. @*Methods@#The pregnant women diagnosed with placental abruption who delivered at Peking University Third Hospital from December 1st, 2013 to December 1st, 2018 were enrolled. The normal pregnant women with matched age and gestational weeks and the women complicated with gestational diabetes mellitus (GDM) were also involved in our study as controls. Their medical records, pregnancy outcomes and all the results of hemostatic tests were completely collected and analysed. @*Results@#A total of 152 pregnant women with placental abruption, 268 normal pregnant women and 101 pregnant women with gestational diabetes mellitus were included. The hemostatic system in uncomplicated women and the women with GDM shared a similar course of changes, during which time PT, APTT and TT dropped, while Fib (fibrinogen), FDP and DD grew with increasing gestational weeks. However, in the women with placental abruption, Fib(g/L) presented downward trend in the second trimester and were significantly lower than the uncomplicated women at the same pregnancy period (4.11±0.17 vs 4.35±0.07, P=0.011). The Fib（g/L） levels in the women at delivery with placental abruption, whether complicated with GDM or not, showed significant difference between the women with and without postpartum hemorrhage (3.41±1.29 vs 4.30±0.94, P=0.001). According to the receiver operating charctistic curve, the area under the curve of Fib was 0.703 (95% confidence interval: 0.596-0.810) with cutoff value of 4.00 g/L and negative predictive value of 0.883. @*Conclusions@#The fibrinogen level in pregnant women with placental abruption did not increase with gestational weeks as it was in uncomplicated women and the women with GDM. Fib level at the time of delivery may contribute to predict the occurrence of postpartum hemorrhage in the women with placental abruption.

Postpartum hemorrhage and pregnancy induced hypertension during emergency lower segment cesarean section: dexmedetomidine to our rescue / Hemorragia pós-parto e hipertensão induzida pela gravidez durante cesariana de emergência em segmento uterino inferior: dexmedetomidina para nosso resgate

Abstract Dexmedetomidine is a highly selective α-2 agonist which has recently revolutionized our anesthesia and intensive care practice. An obstetric patient presented for emergency cesarean delivery under general anesthesia, with pre-eclampsia and postpartum hemorrhage. In carefully selected cases with refractory hypertension and postpartum hemorrhage, dexmedetomidine can be used for improving overall patient outcome. It was beneficial in controlling both the blood pressure and uterine bleeding during cesarean section in our patient.

Resumo Dexmedetomidina é um α2-agonista altamente seletivo que recentemente revolucionou a nossa prática de anestesia e tratamento intensivo. Uma paciente obstétrica foi admitida para cesariana de emergência sob anestesia geral, com pré-eclâmpsia e hemorragia pós-parto. Em casos cuidadosamente selecionados com hipertensão refratária e hemorragia pós-parto, dexmedetomidina pode ser usada para melhorar o resultado geral da paciente. O fármaco foi benéfico no controle tanto da pressão arterial quanto do sangramento uterino durante cesariana em nossa paciente.

Vigilancia de morbilidad materna extrema en una institución de referencia en Cali, Colombia, 2013-2014 / Surveillance of near miss maternal morbidity in a referral institution in Cali, Colombia, 2013-2014

Objetivo: describir la razón de prevalencia de la morbilidad materna extrema (MME) y las características de la población en la que se presentó. Materiales y métodos: estudio de corte transversal basado en la vigilancia epidemiológica durante los años 2013 y 2014; se incluyeron las pacientes gestantes atendidas en una institución de referencia ubicada en suroccidente del departamento de Valle, Colombia. Se utilizaron los criterios para vigilancia de morbilidad materna extrema según definición del protocolo de vigilancia del Instituto Nacional de Salud de Colombia. Se midieron las características sociodemográficas; los criterios de inclusión de MME: disfunción orgánica, manejo o causa específica, el número de criterios de severidad y la estancia. En el análisis se emplearon medidas de tendencia central y dispersión para las variables continuas, y frecuencias absolutas, proporciones para las variables categóricas. Se calculó la razón de prevalencia de MME y la razón caso criterio. Resultados: de 3985 partos se identificaron 219 casos de MME (55 x 1000 nacidos vivos), el 89 % de las pacientes fueron remitidas de otra institución y un 21,0 % no vivían en la ciudad de Cali. El prome- dio de edad fue de 26 años, el 64,0 % pertenecían al régimen subsidiado de salud. No hubo casos de mortalidad materna durante el periodo de estudio. El 18,0 % de las pacientes presentaron más de 3 criterios de severidad. La categoría de morbilidad más frecuente fueron los trastornos hipertensivos del embarazo en el 74,4 % de los casos. Conclusión: la MME en la Clínica Rafael Uribe de Cali, con el instrumento del INS de Colombia, muestra una razón de prevalencia 55 x 1000 nacidos vivos.

Objective: To describe the prevalence ratio of 'near-miss' maternal morbidity and the characteristics of the population in which EMM occurred. Materials and methods: Cross-sectional study based on epidemiological surveillance conducted during 2013 and 2014 with pregnant women seen at a referral institution in the southwestern region of the Department of Valle, Colombia. Criteria based on the definition of near miss maternal mor- bidity set forth in the Colombian National Health Institute surveillance protocol were used. Social and demographic characteristics were measured and the inclusion criteria for EMM were based on organ dysfunction; management and specific cause were described together with the number of se- verity criteria and length of stay. For the analysis, measures of central tendency and spread were used for continuous variables, and absolute frequency and proportions were used for categorical variables. The prevalence ratio for EMM and the case/criterion ratio were estimated. Results: Out of 3985 births, 219 cases of EMM were identified (55 x 1000 live births), 89 % of the patients were referred from a different institution and 21.0 % did not live in the city of Cali. The mean age was 26 years, and 64.0 % of the patients belonged to the subsidized health regime. Eighteen per cent of the patients had more than 3 severity criteria. The most frequent morbidity category was Pregnancy Induced Hypertension (74.4%). There were no cases of maternal death. Conclusion: The prevalence rate for EMM at Clínica Rafael Uribe in Cali measured with the Colombian National Health Institute tool was 55 x 1000 live births.

Clinical, hormonal and radiological features of partial Sheehan's syndrome: an Indian experience

ABSTRACT Objective The objective of this study was to describe clinical presentation, hormonal profile and imaging characteristics of 21 patients with partial Sheehan’s syndrome. Subjects and methods This prospective study was carried out over a period of six years (2008-2013). The evaluation of patients included clinical assessment, hormone estimations and contrast enhanced magnetic resonance imaging of pituitary. Results We documented preservation of gonadotroph, corticotroph and lactotroph function in 71.4, 61.9, and 9.5% of patients respectively. Conclusion To conclude some of the pituitary functions can be preserved in Sheehan’s syndrome and this has important implications from the treatment and long term morbidity point of view.

Feasibility and safety of preoperative autologous blood donation for pregnant patients / 医学研究生学报

Objective Preoperative autologous blood donation ( PABD) may reduce the need for allogeneic blood , but it may also cause a short massive blood loss in pregnant women , and its fetal and maternal safety has to be adequately assessed .This study was to evaluate the feasibility and safety of PABD for pregnant women and their fetuses . Methods A prospective observational study was conducted among the women who met the inclusion criteria and gave birth in Nanjing Drum Tower Hospital between January and December 2013 .According to the clinical validation of risk stratification criteria for peripartum hemorrhage of California 2013 , the ca-ses were classified into a low-, a medium-, and a high-risk group.Data on blood donation procedures , obstetric outcomes, and blood transfusions were collected after delivery for analysis . Results Totally, 92 pregnant women accomplished 115 blood donations .The median volumes of the donated blood were 300, 300, and 400 mL in the low-, medium-, and high-risk groups, respectively ( P>0.001).There were no significant changes in HR , SBP and SpO2 during the blood donation procedures (P>0.05) except for the fall of diastolic blood pressure by an average of 3.4 mmHg (P0.05), which were similar to those in the cases who donated twice , with no significant differences before and after the donation (P>0.05). Homologous blood transfusion was performed for 5 cases (17.9%) in the high-risk group, with the volume of blood loss >2000 mL in all the cases.All the newborns survived without asphyxia and there was no perinatal death . Conclusion PABD can provide timely autologous whole blood donation for pregnant women .Under strict management , PABD is feasible and safe for pregnant patients who are at a high risk for massive blood loss during delivery or have a rare type of blood no readily available .

Cómo describen el cuidado de enfermería las mujeres que presentaron hemorragia postparto / How Women who Had Postpartum Hemorrhage (PPH) Describe the Nursing Care / Como as mulheres que apresentam hemorragia pós-parto descrevem o cuidado de enfermagem

La hemorragia postparto ocupa los primeros lugares de morbilidad y mortalidad obstétrica en el mundo. El personal de enfermería, profesional y auxiliar, es el encargado de brindar a la mujer y a su hijo un cuidado de calidad durante el trabajo de parto, parto y postparto, ya sea normal o complicado. Es fundamental que el personal de enfermería tenga claro los cuidados que las mujeres esperan recibir desde una mirada de cuidado humanizado. Objetivo: describir cómo las mujeres, que presentaron hemorragia postparto, perciben el cuidado prestado por el personal de enfermería durante el trabajo de parto, parto y postparto. Método: es una investigación cualitativa de tipo fenomenológico interpretativo, basada en la teoría de Heidegger. Resultados: la población estuvo compuesta por mujeres que tuvieron hemorragia postparto inmediata. Luego de las entrevistas, ellas identificaron tres temas: el cuidado como un todo, la otra cara de la enfermera: acciones de no cuidado, y el proceder de las pacientes que condicionan el comportamiento de las enfermeras. Para este artículo se abordó el tema del "cuidado como un todo", en donde las mujeres reconocen el cuidado ofrecido por las enfermeras y auxiliares durante el trabajo de parto, parto y postparto, cuando estas, por ejemplo, están pendientes del bienestar físico y emocional de la madre y del bebé o apoyan a la mujer en su rol maternal. El personal de enfermería también es visto como amigos y como los responsables del personal médico. Conclusión: la investigación mostró que las mujeres receptoras del cuidado de enfermería percibieron la importancia del mismo, a través de los comportamientos y acciones de las enfermeras y auxiliares durante el trabajo de parto, parto y postparto. Sus narraciones expresan agrado cuando el personal de enfermería ofreció comodidad y bienestar a ella, su bebé y su familia, desde lo físico y lo emocional. También se identificó la reciprocidad que hay entre el comportamiento de las mujeres y el personal de enfermería cuando se ofrece un cuidado humanizado.

Post-partum hemorrhage is the worldwide leading cause of obstetric morbidity and death. Both professional nurses and attendants are responsible for providing nursing care to mother and child during the labor, delivery and post-partum stages. It is essential for the nursing staff to have a clear understanding of the care women expect from a more humane perspective. Objective: Describe how women who had postpartum hemorrhage, perceive the care provided by the nursing staff during labor, delivery and postpartum. Method: This is a qualitative case-based and interpreted study based on Heidegger's philosophy. Results: The women were interviewed upon their release after experiencing immediate post-partum hemorrhage; during the interviews, they identified three main issues: comprehensive nursing care; the other side of the nursing staff: actions leading to lack of care and patient behaviors that condition nursing staff behavior. This article deals with comprehensive care, where women acknowledge the care provided by nurses and nursing attendants during the labor, delivery and post-partum stages such as: caring for the physical and emotional well being of both mother and child; supporting women in their role as mothers; finally, the role of nurses as friends and as professionals responsible for the medical staff. Conclusion: The study revealed how women receiving this type of nursing care were able to perceive its importance through the nursing staff's behavior and actions during the labor, delivery and post-partum stages. Their testimonies evidenced pleasure whenever the nursing staff had provided emotional and physical comfort and well being to them, their child and their families. The study also revealed the reciprocity between women's behavior and that of the nursing staff whenever humane care is provided.

A hemorragia pós-parto ocupa os primeiros lugares de morbidade e mortalidade obstétrica no âmbito mundial. O pessoal de enfermagem - profissional e auxiliar - é o encarregado de dar à mulher e ao seu filho cuidados com qualidade durante o processo de trabalho de parto, parto e pós-parto. É fundamental que o pessoal de enfermagem tenha claros os cuidados que as mulheres esperam receber do ponto de vista do cuidado humanizado. Objetivo: a abordagem deste tema surge como produto da pesquisa sobre o significado que as mulheres que tiveram hemorragia pós-parto dão aos cuidados recebidos pelo pessoal de enfermagem durante o trabalho de parto, parto e pós-parto. Método: esta é uma pesquisa qualitativa de tipo fenomenológico interpretativo, baseada na filosofia de Heidegger. Resultados: as mulheres foram entrevistadas depois da alta pela complicação por causa da hemorragia pós-parto imediata, e nestes encontros elas identificaram três temas: o cuidado como um todo, o outro lado da enfermagem e o comportamento dos pacientes que determina a conduta das enfermeiras. Para este artigo, abordou-se o tema do cuidado como um todo, no qual as mulheres reconhecem a atenção oferecida pelas enfermeiras e auxiliares durante o processo de trabalho de parto, parto e pós-parto em momentos como: estar ciente do bem-estar físico e emocional da mãe e do bebê; apoiar a mulher em seu papel maternal; a enfermeira como amiga e as enfermeiras como responsáveis do pessoal médico. Conclusão: a pesquisa mostrou que as mulheres que recebem cuidados de enfermagem perceberam a importância deles nos comportamentos e nas ações deste pessoal durante o trabalho de parto, parto e pós-parto. Seus relatos expressam satisfação quando o pessoal de enfermagem ofereceram comodidade e bem-estar a ela, a seu bebê e a sua família, tanto física quanto emocionalmente. Igualmente, identifica-se a reciprocidade que há entre o comportamento das mulheres e o pessoal de enfermagem quando se oferece um cuidado humanizado.

Uterine Arteriovenous Malformation

Uterine arteriovenous malformation (AVM) is a rare condition, with fewer than 100 cases reported in the literature. Despite it being rare, it is a potentially life-threatening condition. This case report describes a 33-year-old woman who presented with secondary post-partum hemorrhage. Transabdominal ultrasound (US) of the pelvis showed increased vascularity with multidirectional flow of the uterus and a prominent vessel, located on the left lateral wall. She also had retained product of conception, which complicated the diagnosis. A uterine artery angiogram confirmed an AVM in the fundal region with an early draining vein. Embolisation of the AVM was performed successfully.