Hemofilia adquirida A en embarazo. Caso clínico de medicina crítica en obstetricia por morbilidad extrema y su abordaje transdisciplinario perioperatorio / Acquired hemophilia A in pregnancy. Clinical case of critical medicine in obstetrics due to extreme morbidity and its perioperative transdisciplinary approach

Resumen: La identificación de múltiples factores de riesgo que predisponen a la hemorragia durante el evento obstétrico, como la hemofilia adquirida que es un trastorno que se desarrolla por la generación de autoanticuerpos inhibidores de factores de la coagulación, la interpretación objetiva de las pruebas de laboratorio rutinarias, el desarrollo de un pensamiento sistematizado en la integración diagnóstico-terapéutica por parte del personal de salud, y la disposición de los recursos farmacológicos hospitalarios, es lo que determina frecuentemente el pronóstico en pacientes obstétricas con morbilidad extrema que requieren atención multidisciplinaria en las diferentes unidades hospitalarias del sector salud de nuestro país. El objetivo es presentar un caso clínico de morbilidad extrema por hemofilia adquirida, su presentación clínica, evolución y desenlace fatal. Se presenta un caso referido de otra unidad del Sector Salud ISEM (Instituto de Salud del Estado de México), atendido en la Unidad de Cuidados Intensivos Obstétricos del Hospital «Mónica Pretelini Sáenz¼, resaltando la importancia en la integración diagnóstico-terapéutica y la interacción multifactorial de variables relacionadas con su desenlace fatal. Conclusiones: Desconocimiento de la patología, retraso en el diagnóstico, múltiples procedimientos condicionantes de hemorragia iatrógena y la limitación en recursos terapéuticos son factores que contribuyen a un desenlace fatal.

Abstract: The identification of multiple risk factors that predispose to bleeding during the obstetric event, such as acquired hemophilia, which is a disorder that develops due to the generation of autoantibodies that inhibit coagulation factors, the objective interpretation of routine laboratory tests , the development of systematized thinking in diagnostic-therapeutic integration by health personnel, and the provision of hospital pharmacological resources, is what frequently determines the prognosis in obstetric patients with extreme morbidity who require multidisciplinary care in the different hospital units of the health sector of our country. The objective is to present a clinical case of extreme morbidity due to acquired hemophilia, its clinical presentation, evolution and fatal outcome. A case referred from another unit of the ISEM (Instituto de Salud del Estado de México) Health Sector, treated at the Obstetric Intensive Care Unit of the «Mónica Pretelini Sáenz¼ Hospital, is presented, highlighting the importance of diagnostic-therapeutic integration, and the multifactorial interaction of variables related to its fatal outcome. Conclusions: Ignorance of the pathology, delay in diagnosis, multiple conditioning procedures of iatrogenic hemorrhage and the limitation in therapeutic resources are factors that contribute to a fatal outcome.

Sclerotherapy with 6% polidocanol solution in patients with placenta accreta.

OBJECTIVE: Placenta accreta is one of the main obstetrical complications worldwide. The aim of this study was to report the experience of managing placenta accreta with a 6% polidocanol solution sclerotherapy. MATERIALS AND METHODS: We selected patients between 37 weeks of gestation and 38 weeks of gestation, diagnosed with placenta accreta, treated at the Maternal Perinatal Hospital "Monica Pretelini Sáenz", Toluca, Mexico, during the period from November 2013 to August 2014. The surgical technique has two steps: (1) fundic-arciform caesarean section followed by a 6% polidocanol sclerosing solution through a 6Fr neonatal feeding tube upon its reaching the placental bed; (2) total abdominal hysterectomy with internal hypogastric artery ligation. RESULTS: Data were collected from 11 patients with a mean age of 33.9 years (range, 26-42 years) and 2.8±0.6 days of hospitalization in the obstetrical intensive care unit. The majority of patients were classified as having pregnancies at an advanced age. All women were multigravidas. Bleeding volume exhibited a range between 2.5 L and 3 L without any case of neonatal death but one mother died because of coagulopathy. CONCLUSION: We conclude that the technique that we are reporting is feasible for implementation in obstetric hospitals, with technical and economic feasibility.

Experience of the MALA bag in the open abdomen management in an obstetrical intensive care unit.

INTRODUCTION: Current indications for open abdomen management are damage control surgery, severe intra-abdominal sepsis, abdominal compartment syndrome, abdominal wall closure under tension and mass loss of the abdominal wall. OBJECTIVE: To describe the experience in open abdomen management using the MALA (mayor absorción de líquido abdominal [greater absorption of abdominal liquid]) bag at the Maternal-Perinatal Hospital Mónica Pretelini Saénz, Health Institute of the State of Mexico. MATERIAL AND METHODS: This was a bidirectional, descriptive and observational study. All patients with the diagnosis of open abdomen managed with the MALA bag admitted to the Obstetric Intensive Care Unit from February 2009 to June 2012 were included. RESULTS: From 25 cases identified in the period of the study, seven were eliminated for incomplete files, remaining 18 cases for the analysis. The mean age was 31.5 years. 78% of the patients were multigravidas, 50% of them with a history of 2 or more deliveries, 83% had a previous cesarean section and 78% were hysterectomized. Evisceration was present in one patient. The main indication for surgical management was damage control. One patient died and a second was transferred to another institution, the rest were discharged by clinical improvement. 12 patients (67%) spent less than 14 days in the Obstetric Intensive Care Unit, only one patient required more than 30 days in the unit. DISCUSSION: Half the women who required this surgical alternative, were above 30 years of age. Stressing is the fact that from the 18 admitted patients, 14 (78%) had undergone obstetric hysterectomy, with the etiology of uterine atony in most cases. Damage control surgery seems to be the most elective surgical option to use MALA bag followed by ACS and abdominal sepsis. CONCLUSION: The MALA bag can offer an economic and effective surgical option for the open abdomen management as well as a drainage technique.

Introdução: As indicações atuais para a gestão de abdómen aberto são a cirurgia de controlo de danos, a abordagem de sepsis intraabdominal grave, a síndrome de compartimento abdominal, o encerramento da parede abdominal sob tensão e a perda de massa da parede abdominal.Objetivo: Descrever a experiência em gestão e cirurgias de abdómen aberto usando a bolsa MALA (Maior Absorção de Líquido Abdominal).Material e Métodos: Estudo descritivo, incluindo todos os doentes com o diagnóstico de abdómen aberto gerido com a bolsa MALA internados na Unidade de Cuidados Intensivos Obstétricos de Fevereiro de 2009 a Junho de 2012.Resultados: Dos 25 casos identificados no período do estudo, sete foram eliminados por arquivos incompletos, permanecendo 18 casos para a análise. A média de idade foi de 31,5 anos. Setenta e oito por cento dos doentes eram multíparas, 50% com uma história de dois ou mais partos, 83% com uma cesariana anterior e 78% histerectomizadas, por atonia uterina, na maioria dos casos. A principal indicação para tratamento cirúrgico foi o controlo de danos. Uma doente morreu e uma segunda foi transferida para outra instituição, tendo as demais tido melhoria clínica. Doze doentes (67%) permaneceram menos de 14 dias na Unidade de Cuidados Intensivos Obstétricos e apenas uma precisou de mais de 30 dias na unidade.Conclusão: A bolsa MALA pode oferecer uma opção económica e eficaz para a gestão cirúrgica abdominal aberta, bem como umatécnica de drenagem.