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1.
J Plast Reconstr Aesthet Surg ; 85: 98-103, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37478653

RESUMEN

COVID-19 has emerged as a global pandemic leading to an increase in hospitalization and intensive care unit (ICU) admissions worldwide. Due to severe acute respiratory distress syndrome (ARDS), many patients require prone positioning, which is associated with increased pressure ulcer/injury (PU/PI) incidence. COVID-19 pathophysiology may favor the occurrence of PU/PI due to hypoxemia, inflammatory status, and vasculopathy. This study aimed to compare the incidence of PU/PI in ICU patients before and during the COVID-19 pandemic. A retrospective cohort study was conducted at a university hospital in Brazil. Data from the medical charts of every adult patient admitted to ICU from March to July 2019 and the same period in 2020 were collected. The group from 2019 included 408 patients admitted due to multiple causes, and the group from 2020 included 229 patients admitted due to COVID-19 infection. The incidence of PU/PI was significantly higher in patients admitted in 2020 compared to 2019 (62,5 vs. 33,8%, respectively). Also, PU/PI location and severity have been different between groups, with the patients with COVID-19 (2020 group) more exposed to stage 3, 4, and non-stageable lesions, as well as more PU/PI on face skin and other less common locations. In conclusion, the COVID-19 pandemic has highlighted a higher PU/PI incidence. ICU patients were older during the pandemic, had higher body mass index and comorbidities, and needed more invasive medical devices and pronation. The occurrence of PU/PI was also associated with prolonged hospitalization and mortality.


Asunto(s)
COVID-19 , Lesiones por Aplastamiento , Úlcera por Presión , Adulto , Humanos , Úlcera por Presión/epidemiología , Úlcera por Presión/etiología , Pandemias , COVID-19/epidemiología , Estudios Retrospectivos , Estudios de Cohortes , Unidades de Cuidados Intensivos
2.
Ann Surg ; 277(2): 198-205, 2023 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-35081576

RESUMEN

OBJECTIVE: The aim of this study was to compare clinical and biomechanical features of scars resulting from the treatment of burn contractures using different acellular dermal matrices (ADM). SUMMARY BACKGROUND DATA: Extensive burns often lead to severe sequelae, such as skin contractures, that can be treated using ADM to improve the quality of these scars. METHODS: A prospective, randomized and controlled clinical trial was performed including patients with burn contractures at least 1-year post-burn, treated using split-thickness skin graft (STSG). These patients were randomized into 4 groups: control (received only STSG without ADM), Integra (ADM + STSG), Matriderm (ADM + STSG), and Pelnac (ADM + STSG). Exclusion criteria were loss of follow-up and graft integration failure. The evaluation was performed using the Vancouver Scar Scale (VSS), the durom-eter, and the cutometer in areas of normal skin, hypertrophic scar, and surgical scar, at least 1 year after the surgery. RESULTS: In the VSS, durometer, and cutometer evaluation, there was no difference in the comparison of surgical scars among groups. Analyzing each group, with an intraindividual evaluation comparing areas of normal skin with surgical scars, the results suggested a possibility of a surgical scar hardness closer to normal skin for Integra and Matriderm groups measured with the durometer. In the cutometer evaluation, surgical scars were not comparable to areas of normal skin. CONCLUSIONS: This study suggests that there is no difference in the quality of scar assessed through the analysis of clinical and biomechanical features comparing acellular dermal matrices (Integra, Matriderm, and Pelnac) and only split-thickness skin graft without a dermal matrix.


Asunto(s)
Dermis Acelular , Cicatriz Hipertrófica , Contractura , Humanos , Estudios Prospectivos , Contractura/etiología , Contractura/cirugía , Progresión de la Enfermedad
4.
J Card Surg ; 37(8): 2315-2316, 2022 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-35471579

RESUMEN

Deep sternal wound infection and dehiscence has been classified as complex wound, and its treatment is a challenge for the surgeon. There are many flap choices for its treatment, each one having advantages and drawbacks. The article by Wang et al. evidenced that the unilateral pectoralis major muscle flap is a simple and effective option for wound closure resulting from sternotomy dehiscence in infants and children. The report discussed herein highlights that the unilateral pectoralis major muscle flap has been a good and feasible option for the reconstruction of the sternal wound in adults, as previously described by our group and other authors. This technique presents low morbidity and acceptable esthetic and functional results, providing stability to the sternal region.


Asunto(s)
Músculos Pectorales , Esternón , Adulto , Niño , Humanos , Lactante , Músculos Pectorales/trasplante , Estudios Retrospectivos , Esternotomía , Esternón/cirugía , Colgajos Quirúrgicos , Dehiscencia de la Herida Operatoria/cirugía , Infección de la Herida Quirúrgica/cirugía , Resultado del Tratamiento
5.
Wound Repair Regen ; 30(2): 222-231, 2022 03.
Artículo en Inglés | MEDLINE | ID: mdl-35141977

RESUMEN

Burn injuries commonly result in serious sequelae (such as skin contractures) in surviving patients, for which no single optimal solution is known. The goal of this study was to compare the late contraction of autologous skin grafts with or without dermal matrices used in the treatment of patients with burn contractures. This parallel design prospective, randomised and controlled clinical trial included patients with burn contracture treated using autologous skin grafts and dermal matrix. Patients were randomly assigned to one of the four groups: Integra® matrix (n = 10), Pelnac® matrix (n = 10), Matriderm® matrix (n = 9) or a Control Group (n = 10, without dermal matrix, only skin graft). The boundaries of skin defect were marked and transferred to a flat sterile surface for area measurement. The current area of the skin grafts was measured during surgery and compared with those obtained at 1, 3, 6 and 12 months postoperatively. Twelve months after surgery, the Control Group presented lower rates of skin graft contraction than Integra® (p < 0.01), Matriderm® (p = 0.01) and Pelnac® (p < 0.01) groups. Pelnac® resulted in larger skin graft contraction than Matriderm® (p < 0.01) and Integra® (p = 0.02), while differences between Integra® and Matriderm® were not significant (p = 0.16). The comparison between intraoperative and 12 months after surgery showed that the worst mean rates of skin graft contraction were from the Pelnac® (51.79%) and Matriderm® (59.17%). In patients with burn contractures, the use of these three dermal matrices did not reduce or avoid the occurrence of late contraction of the skin graft, so their use for this purpose should be carefully evaluated.


Asunto(s)
Quemaduras , Contractura , Piel Artificial , Quemaduras/complicaciones , Quemaduras/cirugía , Contractura/cirugía , Humanos , Estudios Prospectivos , Trasplante de Piel/métodos , Cicatrización de Heridas
6.
Indian J Dermatol Venereol Leprol ; 88(4): 464-477, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-34672479

RESUMEN

Leprosy is a chronic disease with clinical presentations according to the immunologic spectrum. Lepromatous form is the most advanced, with the highest transmissibility and risk of causing disabilities. Lucio's phenomenon is a rare manifestation among lepromatous patients with a rapid and severe evolution and high mortality. It is difficult to differentiate from ulcerative/necrotic erythema nodosum leprosum and has no consensus on how it should be treated. This article is a qualitative review of the literature after the introduction of multidrug therapy, aiming to bring consensus related to the clinical, laboratory and histopathological diagnostic criteria of the disease and its management.


Asunto(s)
Eritema Nudoso , Lepra Lepromatosa , Lepra Multibacilar , Lepra , Quimioterapia Combinada , Eritema Nudoso/diagnóstico , Eritema Nudoso/terapia , Humanos , Leprostáticos/uso terapéutico , Lepra/diagnóstico , Lepra/tratamiento farmacológico , Lepra Lepromatosa/diagnóstico , Lepra Lepromatosa/tratamiento farmacológico , Lepra Lepromatosa/patología , Lepra Multibacilar/tratamiento farmacológico
9.
Wound Repair Regen ; 29(3): 486-494, 2021 05.
Artículo en Inglés | MEDLINE | ID: mdl-33772964

RESUMEN

Pyoderma gangrenosum (PG) is a rare painful ulcerative neutrophilic inflammatory skin disease, necessitating a high level of diagnostic suspicion associated with appropriate treatment to avoid progression. Negative pressure wound therapy (NPWT) has been efficiently used in the treatment of different types of wounds. However, the role of NPWT in the management of PG is still controversial, due to the risk of the pathergy phenomenon. In this article, we conducted a systematic review (according to the PRISMA guidelines) on the use of NPWT in the treatment of PG, and we report our personal experience with two patients treated with this device. The result of the review showed that articles on the topic are, in their entirety, of low levels of evidence, such as case series, case reports, and reviews. Improvement in wound healing with the use of NPWT was observed in 85.1% of the patients studied. Besides, a significant association between improvement in wound healing with NPWT and immunosuppressive therapy was observed. Regarding the cases reported here, both showed good outcomes with the use of NPWT and skin graft during the treatment of PG injuries. Due to the rarity of PG, there is a scarcity of studies with robust evidence for standardization and comparison between treatments, which consequently makes it difficult to select therapeutic options. However, based on this systematic review and reported cases, we consider NPWT a safe option for adjuvant treatment of wounds caused by PG if combined with systemic immunosuppression, which plays a key role in greater chances of successful treatment. This approach should be recommended, whenever possible, associated with skin grafting to accelerate wound closure. The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: a systematic review and personal experience.


Asunto(s)
Terapia de Presión Negativa para Heridas , Piodermia Gangrenosa , Humanos , Piodermia Gangrenosa/terapia , Piel , Trasplante de Piel , Cicatrización de Heridas
11.
Int Wound J ; 16(2): 559-563, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30379394

RESUMEN

Scalping is considered a complex wound with difficult treatment, requiring early surgical intervention, reconstructive plastic surgery, and a multidisciplinary team. The reconstruction of the scalp frequently requires a combination of therapies, including temporary coverage, such as negative pressure wound therapy (NPWT). Complications of NPWT, such as bleeding, infection, and pain, have been described. However, there is no report of acute otitis externa (AOE) because of NPWT. In this article, we present an unprecedented clinical case - a female patient who developed AOE after scalping treatment with NPWT applied over the head and ear canal. We consider that it may be a result of the direct physical action of subatmospheric pressure, the presence of dressing covering the external meatus, and alteration of the bacterial population.


Asunto(s)
Antiinflamatorios/uso terapéutico , Conducto Auditivo Externo/cirugía , Terapia de Presión Negativa para Heridas/efectos adversos , Otitis Externa/tratamiento farmacológico , Otitis Externa/etiología , Procedimientos de Cirugía Plástica/efectos adversos , Dermatosis del Cuero Cabelludo/cirugía , Adulto , Femenino , Humanos , Resultado del Tratamiento
12.
J Burn Care Res ; 39(6): 1037-1042, 2018 10 23.
Artículo en Inglés | MEDLINE | ID: mdl-29931152

RESUMEN

Some groups have avoided early microsurgical flaps in electrical burns under the pretext of injury to the microvasculature, which could increase vascular thrombosis. However, this option frequently results in amputation of the extremity. This study aims to evaluate the early application of microsurgical flaps for the treatment of electrical burns of extremities. A case series was retrospectively evaluated including patients with electrical trauma in extremities undergoing early microsurgical reconstruction. Data were obtained from medical charts, including age, trauma location, flap type and microvascular anastomosis, the need for other procedures, postoperative complications, the length of hospital stay after the flap surgery, and patient outcomes. Five microsurgical flaps were performed in less than 30 days to trauma, one anterolateral thigh flap to cover skin failure in upper limb, and four radial forearm flaps to cover failure in feet. The patient ages had a mean of 25.8 years (from 12 to 42 years). The microsurgical procedure occurred from 21 to 27 days after the burn, with a mean of 24.2 days. Hospital discharge had a mean of 26.6 days (from 19 to 35 days after the surgery). Only one patient required reintervention for re-anastomosis. All patients had a good flap viability, avoiding amputation of the affected extremity and with a proper preservation of function. The early application of microsurgical flaps for patients with electrical burns of extremities may provide adequate, sturdy, and stable skin coverage, contributing to the treatment of noble structures exposed and avoiding amputation of the extremities.


Asunto(s)
Quemaduras por Electricidad/cirugía , Extremidades/lesiones , Extremidades/cirugía , Microcirugia , Colgajos Quirúrgicos , Adolescente , Adulto , Niño , Femenino , Humanos , Masculino
13.
Int Wound J ; 15(1): 174-177, 2018 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-29171159

RESUMEN

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21-year-old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.


Asunto(s)
Angina de Ludwig/complicaciones , Mediastinitis/etiología , Mediastinitis/cirugía , Músculos Pectorales/trasplante , Esternotomía/efectos adversos , Dehiscencia de la Herida Operatoria/cirugía , Adulto , Humanos , Masculino , Complicaciones Posoperatorias , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos/trasplante , Resultado del Tratamiento , Adulto Joven
14.
Dis Colon Rectum ; 60(9): 945-953, 2017 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-28796733

RESUMEN

BACKGROUND: There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. OBJECTIVE: The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. DESIGN: This was a prospective case series. SETTINGS: This flap could represent a step forward over other perineal flap approaches or primary closure. PATIENTS: A total of 73 consecutive patients with anorectal tumors were included. INTERVENTIONS: The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. MAIN OUTCOME MEASURES: Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien-Dindo grades) were measured. RESULTS: The means of the perineal defect, hospital stay, and healing time were 51.62 cm, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien-Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. LIMITATIONS: As a nonrandomized study, our results have to be interpreted with caution. CONCLUSIONS: Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.


Asunto(s)
Neoplasias del Ano , Carcinoma de Células Escamosas , Colectomía/métodos , Colgajo Perforante , Perineo , Procedimientos de Cirugía Plástica , Complicaciones Posoperatorias , Neoplasias del Recto , Abdomen/patología , Abdomen/cirugía , Neoplasias del Ano/patología , Neoplasias del Ano/cirugía , Arterias/cirugía , Brasil , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Perineo/irrigación sanguínea , Perineo/patología , Perineo/cirugía , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/métodos , Neoplasias del Recto/patología , Neoplasias del Recto/cirugía
15.
Microsurgery ; 35(7): 546-52, 2015 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-26367370

RESUMEN

OBJECTIVE: The purpose of this study is to evaluate the results of reconstruction and rehabilitation of patients with plantar defects by using a chimerical flap of muscle and skin from anterolateral thigh. METHODS: Twenty-five patients with plantar defects were reconstructed with a chimerical anterolateral thigh (ALT) flap, composed by a vastus lateralis muscle segment and a thinned skin island. Neurorrhaphy between lateral femoral cutaneous nerve and calcaneal nerve was performed in 7 patients. Evaluation of flap contour and stability and patient ambulation was performed 6 and 12 months after surgery. Evaluation of cutaneous sensiblity of ALT flap and contralateral thigh was performed 12 months after surgery using Pressure Specified Sensory Device™ (PSSD™). RESULTS: Flap viability was complete in 23 patients and 2 patients had complications with partial flap loss of its cutaneous component. Six months postoperatively, flap contour, and stability was considered good in 19 and 21 patients respectively, and all 25 patients presented good ambulation. Twelve months postoperatively, all 25 patients presented good flap contour and stability, as well as good ambulation. All 7 flaps undergoing to reinnervation partially recovered cutaneous sensibility in comparison to donor site (contralateral thigh). Cutaneous tactile thresholds (g/mm(2) ) of static one-point test and moving one-point test from the ALT flap and the contralateral thigh presented statistically significant differences, for both comparisons (P = 0.009, P = 0.002). CONCLUSION: This flap is suitable for reconstruction of plantar defects, with good flap contour and stability, proper patient ambulation and low complication rates.


Asunto(s)
Traumatismos de los Pies/cirugía , Pie/cirugía , Colgajos Tisulares Libres/trasplante , Melanoma/cirugía , Procedimientos de Cirugía Plástica/métodos , Neoplasias Cutáneas/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Muslo , Resultado del Tratamiento
16.
Microsurgery ; 35(5): 387-92, 2015 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-25417603

RESUMEN

OBJECTIVE: This study aims to compare the major anatomical aspects among anterolateral thigh, parascapular and lateral arm flaps. METHODS: Sixty flaps were dissected in 20 human cadavers, comparing their vascular pedicle length, flap thickness and arterial/venous pedicle diameters. RESULTS: The vascular pedicle length (from the origin of the vascular pedicle to its entry into the skin flap) of anterolateral thigh flap (13.43 ± 3.92 cm, lateral circumflex femoral artery) was longer than parascapular (9.07 ± 1.20 cm, circumflex scapular artery) and lateral arm flap (8.90 ± 1.65 cm, posterior collateral radial artery) (P < 0.001). The thickness of lateral arm flap (6.32 ± 2.33 mm) was lesser than parascapular (8.59 ± 2.93 mm) and anterolateral thigh flap (9.30 ± 3.54 mm) (P < 0.001). The arterial/venous pedicle diameters of lateral arm flap (2.37 ± 0.69 mm / 2.61 ± 0.74 mm) were lesser than parascapular (3.46 ± 0.80 mm / 4.07 ± 0.87 mm) and anterolateral thigh flap (3.26 ± 0.74 mm / 3.87 ± 0.70 mm) (P < 0.001). CONCLUSIONS: The vascular pedicle length of anterolateral thigh flap was the longest and that lateral arm flap presented a pedicle with the smallest arterial and venous diameters, in addition to being the thinnest flap.


Asunto(s)
Brazo/irrigación sanguínea , Escápula/irrigación sanguínea , Colgajos Quirúrgicos/irrigación sanguínea , Muslo/irrigación sanguínea , Adolescente , Adulto , Anciano , Arterias/anatomía & histología , Humanos , Masculino , Persona de Mediana Edad , Venas/anatomía & histología , Adulto Joven
17.
Obes Surg ; 20(4): 480-6, 2010 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-19937152

RESUMEN

BACKGROUND: Collapsed skin folds after bariatric weight loss are often managed by plastic procedures, but changes in dermal composition and architecture have rarely been documented. Given the potential consequences on surgical outcome, a prospective histochemical study was designed. The hypothesis was that a deranged dermal fiber pattern would accompany major changes in adipose tissue. METHODS: Female surgical candidates undergoing postbariatric abdominoplasty (n=40) and never obese women submitted to control procedures (n=40) were submitted to double abdominal biopsy, respectively in the epigastrium and hypogastrium. Histomorphometric assessment of collagen and elastic fibers was executed by the Image Analyzer System (Kontron Electronic 300, Zeiss, Germany). RESULTS: Depletion of collagen, but not of elastic fibers, in cases with massive weight loss was confirmed. Changes were somewhat more severe in epigastrium (P=0.001) than hypogastrium (P=0.007). Correlation with age did not occur. CONCLUSIONS: (1) Patients displayed lax, soft skin lacking sufficient collagen fiber network. (2) Elastic fiber content was not damaged, and was even moderately increased in epigastrium; (3) Preoperative obesity negatively correlated with hypogastric collagen concentration; (4) Future studies should pinpoint the roles of obesity, and especially of massive weight loss, on dermal architecture and response to surgery.


Asunto(s)
Pared Abdominal/patología , Colágeno/análisis , Tejido Elástico/metabolismo , Obesidad Mórbida/fisiopatología , Obesidad Mórbida/cirugía , Piel/fisiopatología , Adulto , Femenino , Derivación Gástrica , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Piel/química , Pérdida de Peso
20.
Rev Saude Publica ; 38(3): 379-84, 2004 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-15243667

RESUMEN

OBJECTIVE: To determine changes in the incidence of vaginal deliveries, cesarean sections, and forceps deliveries and their potential association with fetal, early neonatal, and perinatal mortality rates over time. METHODS: A retrospective study was carried out and the occurrence of deliveries supervised by university services between January 1991 and December 2000 was determined. Data regarding fetal, early neonatal, and perinatal deaths were assessed using obstetric and pediatric records and autopsy reports. RESULTS: Of a total of 33,360 deliveries, the incidence of vaginal deliveries, cesarean sections, and forceps deliveries was relatively steady (around 60, 30, and 10%, respectively) while, at the same time, there was a marked reduction in fetal mortality (from 33.3 to 13.0 per thousand), early neonatal mortality (from 30.6 to 9.0 per thousand), and perinatal mortality (from 56.4 to 19.3 per thousand). CONCLUSIONS: The marked reduction in perinatal mortality rates seen during the study period without an increase in cesarean sections indicates that the decrease in perinatal mortality was not impacted by cesarean section rates. The plausible hypothesis seems to be that the reduction in perinatal mortality of deliveries performed under the supervision of university services was more likely to be associated with better neonatal care rather than the mode of delivery.


Asunto(s)
Parto Obstétrico/tendencias , Mortalidad Infantil , Cesárea/estadística & datos numéricos , Cesárea/tendencias , Femenino , Mortalidad Fetal , Humanos , Recién Nacido , Parto Normal/estadística & datos numéricos , Parto Normal/tendencias , Embarazo , Estudios Retrospectivos , Instrumentos Quirúrgicos/estadística & datos numéricos , Instrumentos Quirúrgicos/tendencias
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