Descripción de los factores contribuyentes a las muertes secundarias a trastornos hipertensivos asociados al embarazo en Antioquia, Colombia (2012-2020) / Description of the contributing factors to deaths secondary to hypertensive disorders associated with pregnancy in Antioquia, Colombia (2012-2020)

Resumen OBJETIVO: Describir las características de la población afectada y los retrasos que contribuyeron a la mortalidad materna, secundaria a los trastornos hipertensivos del embarazo. MATERIALES Y MÉTODOS: Estudio descriptivo y retrospectivo efectuado con base en la vigilancia epidemiológica de casos centinela de muertes maternas tempranas de mujeres residentes en Antioquia, Colombia, durante el embarazo, el parto y los 42 días siguientes a éste ocurridas en el periodo 2012-2020. Se creó una base de datos en Microsoft Access 2007 (Microsoft, Redmond, WA, USA) y los datos se analizaron en Microsoft Excel y SPSS versión 22. RESULTADOS: Se registraron 266 muertes maternas, de las que 38 fueron secundarias a trastornos hipertensivos del embarazo. La eclampsia fue causa de 15 fallecimientos; 12 por síndrome HELLP, 9 por hemorragia intracerebral y 2 por desprendimiento prematuro de placenta y coagulación intravascular diseminada. En 13 de los 38 casos no hubo una pauta adecuada del sulfato de magnesio, 19 no recibieron tratamiento antihipertensivo, que estaba indicado y 17 no tuvieron un control antihipertensivo adecuado. CONCLUSIÓN: La atención prenatal es una oportunidad decisiva para la detección, prevención y estratificación del riesgo. Todos los centros de atención obstétrica deben estar preparados para gestionar urgencias asociadas con los trastornos hipertensivos del embarazo. Los desenlaces mejoran con la aplicación de protocolos de emergencia estandarizados, organizados y la participación de equipos multidisciplinarios que garanticen una atención de calidad y un efecto positivo en la morbilidad y mortalidad materna susceptible de prevención.

Abstract OBJECTIVE: To describe the characteristics of the affected population and the delays that contributed to maternal mortality secondary to hypertensive disorders of pregnancy. MATERIALS AND METHODS: Descriptive and retrospective study based on the epidemiologic surveillance of sentinel cases of early maternal deaths of women residing in Antioquia, Colombia, during pregnancy, delivery and the 42 days after delivery occurring in the period 2012-2020. A database was created in Microsoft Access 2007 (Microsoft, Redmond, WA, USA), and data were analyzed in Microsoft Excel and SPSS version 22. RESULTS: There were 266 maternal deaths, of which 38 were secondary to hypertensive disorders of pregnancy. Eclampsia was the cause of 15 deaths; 12 due to HELLP syndrome, 9 due to intracerebral hemorrhage, and 2 due to placental abruption and disseminated intravascular coagulation. In 13 of the 38 cases, there was no adequate magnesium sulfate regimen, 19 did not receive indicated antihypertensive treatment, and 17 did not have adequate antihypertensive control. CONCLUSION: Antenatal care is a critical opportunity for detection, prevention, and risk stratification. All obstetric care centers should be prepared to manage emergencies associated with hypertensive disorders of pregnancy. Outcomes improve with the use of standardized, organized emergency protocols and the participation of multidisciplinary teams that ensure quality care and a positive impact on preventable maternal morbidity and mortality.

Amniocele associated with placental abruption: a case report.

Amniocele is a rare condition involving herniation of the amniotic sac through a uterine breach. Our case is of a 29-year-old pregnant woman at 31 weeks of pregnancy who presented to the maternity triage of the Mirebalais Teaching Hospital for abdominal pain and the passage of blood through the vagina. After an ultrasonographic evaluation, the diagnosis of amniocele was made. In practice, for a third-trimester, nonlaboring pregnant woman with this symptomatology, the most common diagnoses that come to mind are placenta previa and placental abruption. This case highlights that a diagnosis of silent uterine rupture should also be kept in mind knowing that a uterine rupture is a life-threatening event for both the mother and the fetus, therefore, early diagnosis is very important to improve the maternal-fetal prognosis.

Medical treatment in pregnant women with subclinical hypothyroidism: systematic review and meta-analysis / Tratamiento médico en gestantes con hipotiroidismo subclínico: revisión sistemática y meta-análisis

Abstract Objectives: to determine the effectiveness of medical therapy in reducing complications associated with subclinical hypothyroidism during pregnancy. Methods: in 2021, a systematic review of available cohort studies was carried out in three databases, with no publication date limit. Study selection and data extraction were performed in duplicate. Random-effects meta-analysis was performed, and odds ratios were calculated, with the corresponding 95% confidence intervals. Cohort risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). The certainty of the evidence was assessed using the GRADE methodology. Results: five studies were included for qualitative and quantitative synthesis. A statistically significant relationship was found between medical treatment in pregnant women with subclinical hypothyroidism with respect to spontaneous abortion (p=0.03; OR=0.77; CI95%=0.61-0.97), and no statistically significant relationship was found for delivery preterm (p=0.46; OR=1.11; CI95%=0.85-1.44), nor for abrupt placentae (p=0.56; OR=1.60; CI95%=0.33-7.66). Three studies were at moderate risk of bias, and two were at low risk of bias. In all the results the certainty was very low. Conclusions: medical treatment of subclinical hypothyroidism during pregnancy can have a beneficial effect in reducing cases of spontaneous abortion.

Resumo Objetivos: determinar la efectividad de la terapia médica para disminuir las complicaciones asociadas al hipotiroidismo subclínico durante la gestación. Métodos: en el 2021 se realizó una revisión sistemática de estudios de cohortes disponibles en tres bases de datos, sin límite de fecha de publicación. La selección de estudios y extracción de datos se realizaron por duplicado. Se realizó metaanálisis de efectos aleatorios y se calcularon los Odds ratio, con los correspondientes intervalos de confanza al 95%. El riesgo de sesgo de las cohortes se evaluó mediante la escala de Newcastle-Ottawa (NOS). La certeza de la evidencia se evaluó con la metodología GRADE. Resultados: cinco estudios fueron incluidos para síntesis cualitativa y cuantitativa. Se encontró una relación estadísticamente significativa del tratamiento médico en gestantes con hipotiroidismo subclínico con respecto al aborto espontáneo (p=0,03; OR=0,77; IC95%=0,61-0.97), no se encontró relación estadísticamente significativa para parto pre término (p=0.46; OR=1,11; IC95%=0.85-1.44), ni para abrupto placentae (p=0.56; OR=1,60; IC95%=0.33-7.66). Tres estudios tenían riesgo moderado de sesgo, y dos tenían riesgo de sesgo bajo. En todos los resultados la certeza fue muy baja. Conclusiones: el tratamiento médico del hipotiroidismo subclínico durante la gestación puede tener un efecto beneficioso para reducir los casos de aborto espontaneo.

Uterine Fibroids and Pregnancy: How Do They Affect Each Other?

The present narrative review is aimed to rekindle discussion regarding whether and how uterine leiomyoma and pregnancy may impact each other. Although fibroids are hormone-dependent lesions, their growth during pregnancy seems to have a nonlinear trend. Besides placental estrogens and progesterone, an array of endocrine and paracrine factors affect fibroid blood supply, growth rate, and risk of degeneration along the gestational and puerperal periods. According to current evidence, the presence of leiomyomas might increase the risk of some adverse pregnancy outcomes. Although a causative relation between fibroids and spontaneous abortion is questionable, the presence of multiple submucosal lesions in certain populations, such as infertile women, may increase the risk of pregnancy loss. Slightly increased risks of placenta previa, placental abruption and fetal malpresentation may occur, mainly due to the mechanical influence of multiple and large fibroids. Cesarean section and preterm birth rates are also probably increased in the presence of fibroids. The risk associations are based on meta-analyses of cohort studies (level of evidence 2a), retrospective cohort studies (2b), case-control (3a), and cross-sectional studies (3b), but with a predominantly low risk of bias. For evaluating the growth pattern of leiomyomas and their real influence on obstetric outcomes, future studies should enroll women with fibroids diagnosed prior to pregnancy and follow them prospectively throughout the gestation and puerperium.

Morbilidad y mortalidad a largo plazo en mujeres con antecedente de desprendimiento prematuro de placenta normoinserta / Long-term morbidity and mortality in women with a history of premature placental abruption normoinserta

Resumen OBJETIVOS: Analizar las consecuencias a largo plazo del desprendimiento prematuro de placenta normoinserta, principalmente la incidencia de enfermedad cardiovascular y secundariamente otras causas de morbilidad y mortalidad (diabetes, neoplasias o trastornos psiquiátricos). MATERIALES Y MÉTODOS: Estudio de casos y controles, con recolección retrospectiva de datos de pacientes embarazadas que acudieron al Complexo Hospitalario Universitario de Ourense entre 1996 y 2008. El criterio de inclusión en el grupo casos fue el antecedente de desprendimiento prematuro de placenta normoinserta. El grupo control lo integraron pacientes con parto anterior y posterior al grupo de casos y que no habían sufrido desprendimiento de placenta. Las historias clínicas se analizaron mediante la recolección de datos de la "gestación índice" y se realizó el seguimiento a largo plazo para establecer el diagnóstico de hipertensión arterial, diabetes mellitus, enfermedad cardiovascular, neoplasias o alteraciones psiquiátricas. Para el análisis estadístico se requirió el programa SPSS15.0. Se consideró estadísticamente significativo el valor de p < 0.05. RESULTADOS: Se estudiaron 198 mujeres: 66 en el grupo de casos y 132 en el grupo control. Durante el seguimiento (15.8 ± 3.58 años), la incidencia de diabetes mellitus y dislipidemia fue mayor en el grupo de casos, pero sin significación estadística. No se encontraron diferencias en la incidencia de hipertensión arterial, síndrome metabólico, enfermedad cardiovascular ni trastorno ansioso-depresivo. En el grupo de casos se encontró una alta tasa de enfermedad neoplásica. CONCLUSIONES: No existe relación entre desprendimiento prematuro de placenta y enfermedad cardiovascular. Se carece de una explicación que justifique la alta tasa de patología tumoral en este grupo de pacientes.

Abstract OBJECTIVE: To analyze if women with a history of premature placental abruption have a long-term increase in morbidity and mortality. MATERIALS AND METHODS: Case-control study with retrospective data collection of pregnant women from the Hospital University Complex of Ourense between 1996 and 2008. The criteria for inclusion in the case group were the history of placental abruption. The control group was constituted by the women with previous and subsequent delivery to the case group and who had not presented placental abruption. The clinical histories were analyzed with data collection of the index pregnancy and a long-term follow-up was carried out to detect the subsequent diagnosis of arterial hypertension, diabetes mellitus, cardiovascular disease, as well as neoplastic and psychiatric pathology. The statistical study was carried out using the SPSS15.0 computer program. Values of p < 0,05 were considered significant results. RESULTS: A total of 198 women were studied, of which 66 belong to the case group and 132 to the control group. In the follow-up period (15,8±3,58 years) the incidence of diabetes mellitus and dyslipidemia was higher in the case group, but without statistical significance. No differences were found in the incidence of hypertension, metabolic syndrome, cardiovascular disease or anxiety-depressive illness. In the case group, a high rate of oncological pathology was found. CONCLUSIONS: We found no relationship between the history of placental abruption and cardiovascular disease. We lack an explanation that justifies the high rate of tumor pathology in this group of women.

Genetic variations and risk of placental abruption: A genome-wide association study and meta-analysis of genome-wide association studies.

INTRODUCTION: Accumulating epidemiological evidence points to strong genetic susceptibility to placental abruption (PA). However, characterization of genes associated with PA remains incomplete. We conducted a genome-wide association study (GWAS) of PA and a meta-analysis of GWAS. METHODS: Participants of the Placental Abruption Genetic Epidemiology (PAGE) study, a population based case-control study of PA conducted in Lima, Peru, were genotyped using the Illumina HumanCore-24 BeadChip platform. Genotypes were imputed using the 1000 genomes reference panel, and >4.9 million SNPs that passed quality control were analyzed. We performed a GWAS in PAGE participants (507 PA cases and 1090 controls) and a GWAS meta-analysis in 2512 participants (959 PA cases and 1553 controls) that included PAGE and the previously reported Peruvian Abruptio Placentae Epidemiology (PAPE) study. We fitted population stratification-adjusted logistic regression models and fixed-effects meta-analyses using inverse-variance weighting. RESULTS: Independent loci (linkage-disequilibrium<0.80) suggestively associated with PA (P-value<5e-5) included rs4148646 and rs2074311 in ABCC8, rs7249210, rs7250184, rs7249100 and rs10401828 in ZNF28, rs11133659 in CTNND2, and rs2074314 and rs35271178 near KCNJ11 in the PAGE GWAS. Similarly, independent loci suggestively associated with PA in the GWAS meta-analysis included rs76258369 near IRX1, and rs7094759 and rs12264492 in ADAM12. Functional analyses of these genes showed trophoblast-like cell interaction, as well as networks involved in endocrine system disorders, cardiovascular diseases, and cellular function. CONCLUSIONS: We identified several genetic loci and related functions that may play a role in PA risk. Understanding genetic factors underlying pathophysiological mechanisms of PA may facilitate prevention and early diagnostic efforts.

Comparison of stillbirth rates by cause among Haitians and non-Haitians in Canada.

OBJECTIVE: To compare rates of stillbirth among Haitians and non-Haitians in Canada. METHODS: A retrospective cohort study was performed using data on all stillborn and live-born singletons weighing at least 500 g in the province of Quebec, Canada, from 1981 to 2010. Stillbirth rates were computed, and hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for Haitians relative to non-Haitians. The main outcome measure was stillbirth by cause of death. RESULTS: Data for 9657 stillbirths (124 Haitian) and 2 414 751 live births (17 165 Haitian) were included. Stillbirth rates were higher for Haitians than non-Haitians (7.17 [95% CI 5.91-8.43] vs 3.96 [95% CI 3.88-4.04] per 1000 births), particularly for cord prolapse (adjusted HR 1.87, 95% CI 1.10-3.18) and placental abruption (adjusted HR 2.84, 95% CI 1.95-4.15). Haitians had higher risks of stillbirth due to cord prolapse and abruption at every week of pregnancy. Risks were not elevated for stillbirth due to congenital anomaly, a cause less responsive to urgent intervention. CONCLUSION: Stillbirth rates among Haitians are disproportionately high in Canada, particularly fetal death due to cord prolapse and placental abruption. The potential to reduce stillbirth rates through optimal emergency care in vulnerable minorities requires further investigation.

[Placental abruption: Background and revisited pronostic factors about a series of 171 cases]. / Hématome rétroplacentaire : terrain et facteurs pronostiques revisités à propos d'une série de 171 cas en Guyane francaise.

OBJECTIVE: To describe the epidemiological, clinical and prognostic factors of placental abruption and fetal death in utero and to investigate possible risk factors for their occurrence. PATIENTS AND METHODS: Observational retrospective study including the women having presented a placental abruption between January 2001 and January 2012, in a IIB maternity. Women's sociodemographic characteristics, clinical symptoms and the method used to detect placental abruption were collected. Patient data of those whose pregnancy resulted in fetal death were compared to those with more favorable outcomes. RESULTS: There were 171 cases of placental abruption among 21,913 patients having delivered, which represents a 0.78% incidence. Diagnosis was rarely based on clinical data (30%). The rate of fetal death in utero represented 25% of the pregnancy's outcomes. A history of fetal death in utero increased the risk of placental abruption (P<0.001). This complication was more frequent for patients who did not have pregnancy monitoring (P=0.054) and before 37 weeks of amenorrhoea (P=0.005). CONCLUSION: Placental abruption is an important cause of perinatal mortality and maternal morbidity. Among the observed risk factors, only regular pregnancy monitoring can be an easy way to prevent these complications.

Urgencias en obstetricia / Emergencies in obstetrics

Tradicionalmente, el embarazo es considerado un evento fisiológico. Sin embargo, cerca de un 20 por ciento de las embarazadas desarrolla patologías obstétricas que se asocian a mortalidad materna y perinatal. A nivel mundial, cada año medio millón de mujeres fallece durante el embarazo y parto debido a estas complicaciones. Desafortunadamente, un número significativo de las urgencias obstétricas ocurre en pacientes sin factores de riesgo, por lo que la prevención, identificación precoz e intervención a tiempo de estos eventos juegan un rol fundamental para contrarrestar un resultado perinatal adverso. En el presente capítulo hemos seleccionado las emergencias que concentran la mayor morbimortalidad de nuestra especialidad. Si bien algunas han quedado fuera, creemos que los temas aquí presentados representan las urgencias obstétricas más importantes que enfrentamos a diario, para las cuales debemos estar preparados con el fin de realizar un manejo óptimo del embarazo y parto para la obtención de un resultado perinatal favorable.

Traditionally, pregnancy is considered a physiologic condition. However, close to 20 percent of pregnant women develop obstetrical diseases that are associated to maternal and perinatal mortality. World wide, every year half a million of women die during pregnancy, labor and delivery due to these complications. Unfortunately, a significant number of obstetrical emergencies occur among patients without risk factors, so that prevention, early identification and timely intervention play a key role to overcome an adverse pregnancy outcome. In the present chapter, we have selected the emergencies that concentrate most of the morbidity and mortality of our field. Although some have not been included, we believe that the obstetrical emergencies presented here in represent the most important ones that we face daily, and for which we should be prepared in order to execute the best possible obstetrical care either during pregnancy or at the time of delivery to obtain a favourable perinatal outcome.

Óbito fetal no descolamento prematuro da placenta: comparação entre dois períodos / Fetal death in placental abruption: comparison of two different time periods

OBJETIVOS: Comparar a incidência de descolamento prematuro da placenta (DPP), de óbito fetal e o perfil dos fatores maternos associados ao óbito fetal em casos acometidos por DPP em dois períodos, num mesmo serviço médico terciário. MÉTODOS: Avaliação retrospectiva dos casos de DPP ocorridos entre 1º de janeiro de 1994 a 31 de dezembro de 1997 (período 94-97) e 1º de abril de 2001 a 31 de março de 2005 (período 01-05), em gestações únicas com peso do recém-nascido superior a 500g e idade gestacional acima da 20ª semana. Foram analisados os fatores: idade materna, cor, antecedentes obstétricos, ocorrência de hipertensão arterial ou ruptura prematura de membranas ovulares, presença de sangramento genital, hemoâmnio, características do tônus uterino, ocorrência de CIVD, insuficiência renal, anemia puerperal, bem como a idade gestacional e peso do RN no parto. RESULTADOS: No período 94-97, foram realizados 7.692 partos e o DPP ocorreu em 0,78 por cento (60 casos), e no período 01-05 foram 8.644 partos com 0,59 por cento (51 casos) de DPP, sem diferença significativa. No período 94-97, a proporção de casos sem sangramento genital foi significativamente maior no grupo que evoluiu com óbito fetal quando comparado aos casos cujo feto nasceu vivo (57,9 por cento vs 22,0 por cento; p=0,01). No período 01-05, a proporção de casos com hipertonia uterina foi significativamente maior no grupo que evoluiu com óbito fetal quando comparado aos casos com recém-nascido nativivo (66,7 por cento vs 29,3 por cento; p=0,04). As complicações maternas no pós-parto foram mais freqüentes nos casos de óbito fetal, em ambos os períodos 94-97 e 01-05 (31,6 por cento vs 4,9 por cento, p=0,009, e, 50,0 por cento vs 5,1 por cento, p=0,001, respectivamente). CONCLUSÃO: O DPP permanece grave problema obstétrico com conseqüências potencialmente fatais, principalmente nos casos com maior área de descolamento da placenta. Maior gravidade do quadro clínico materno é observada...

OBJECTIVE: To compare the incidence of placental abruption (PA), fetal death and the profile of maternal factors associated with fetal death in pregnancies affected by placental abruption during two different time periods in the same hospital. METHODS: retrospective study between January 1, 1994 and December 31, 1997 and April 1, 2001 and March 31, 2005, including singleton pregnancies with a birth weight higher than 500g and gestational age of more than 20 weeks. Factors analyzed were maternal age, race, obstetric history, presence of arterial hypertension or premature rupture of membranes, presence of genital bleeding, presence of amniotic fluid contaminated with blood, characteristics of uterine tonus, occurrence of renal insufficiency, postpartum coagulopathy, puerperal anemia, gestational age and weight at birth. RESULTS: there were7692 births in the 1994-1997 period, placental abruption incidence of 0.78 percent (60 cases); 8644 births occurred in the 2001-2005 period, placental abruption incidence of 0.59 percent (51 cases), with no statistical difference. During the 1994-1997 period, proportion of cases without genital bleeding was significantly higher in the group whose fetuses died compared to cases of live born fetuses (57.9 percent vs 22.0 percent; p=0.01). During the 2001-2005 period, proportion of cases with uterine hypertonia was significantly higher in the group whose fetuses died compared to cases of live born fetuses (66.7 percent vs 29.3 percent; p=0.04). Postpartum maternal complications were more frequent in cases of fetal death during both periods (31.6 percent vs 4.9 percent; p=0.009; and 50 percent vs 5.1 percent; p=0.001, respectively). CONCLUSION: Placental abruption continues to be a serious obstetric problem, with fatal consequences, especially when the placental abruption area is large. Maternal clinical symptoms are more severe in cases of fetal death.