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1.
BMJ Open ; 11(5): e041566, 2021 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-33952535

RESUMO

OBJECTIVE: To investigate the long-term risk of developing hypertension and cardiovascular disease (CVD) among those women who suffered a postpartum haemorrhage (PPH) compared with those women who did not. DESIGN: Population-based longitudinal open cohort study. SETTING: English primary care (The Health Improvement Network (THIN)) and secondary care (Hospital Episode Statistics (HES)) databases. POPULATION: Women exposed to PPH during the study period matched for age and date of delivery, and unexposed. METHODS: We conducted an open cohort study using linked primary care THIN and HES Databases, from 1 January 1997 to 31 January 2018. A total of 42 327 women were included: 14 109 of them exposed to PPH during the study period and 28 218 matched for age and date of delivery, and unexposed to PPH. HRs for cardiovascular outcomes among women who had and did not have PPH were estimated after controlling for covariates using multivariate Cox regression models. OUTCOME MEASURES: Risk of hypertensive disease, ischaemic heart disease, heart failure, stroke or transient ischaemic attack. RESULTS: During a median follow-up of over 4 years, there was no significant difference in the risk of hypertensive disease after adjustment for covariates (adjusted HR (aHR): 1.03 (95% CI: 0.87 to 1.22); p=0.71). We also did not observe a statistically significant difference in the risk of composite CVD (ischaemic heart disease, heart failure, stroke or transient ischaemic attack) between the exposed and the unexposed cohort (aHR: 0.86 (95% CI: 0.52 to 1.43; p=0.57). CONCLUSION: Over a median follow-up of 4 years, we did not observe an association between PPH and hypertension or CVD.


Assuntos
Doenças Cardiovasculares , Hipertensão , Hemorragia Pós-Parto , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Estudos de Coortes , Feminino , Humanos , Hipertensão/epidemiologia , Estudos Longitudinais , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/etiologia , Gravidez , Fatores de Risco , Atenção Secundária à Saúde
2.
BMC Res Notes ; 14(1): 167, 2021 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-33947454

RESUMO

OBJECTIVE: Hospital data are a useful resource for studying pregnancy complications, including bleeding-related conditions, however, the reliability of these data is unclear. This study aims to examine reliability of reporting of bleeding-related conditions, including anaemia, obstetric haemorrhage and blood disorders, and procedures, such as blood transfusion and hysterectomy, in coded hospital records compared with obstetric data from two large tertiary hospitals in New South Wales. RESULTS: There were 36,051 births between 2011 and 2015 included in the analysis. Anaemia and blood disorders were poorly reported in the hospital data, with sensitivity ranging from 2.5% to 24.8% (positive predictive value (PPV) 12.0-82.6%). Reporting of postpartum haemorrhage, transfusion and hysterectomy showed high sensitivity (82.8-96.0%, PPV 78.0-89.6%) while moderate consistency with the obstetric data was observed for other types of obstetric haemorrhage (sensitivity: 41.9-65.1%, PPV: 50.0-56.8%) and placental complications (sensitivity: 68.2-81.3%, PPV: 20.3-72.3%). Our findings suggest that hospital data may be a reliable source of information on postpartum haemorrhage, transfusion and hysterectomy. However, they highlight the need for caution for studies of anaemia and blood disorders, given high rates of uncoded and 'false' cases, and suggest that other sources of data should be sought where possible.


Assuntos
Anemia , Hemorragia Pós-Parto , Anemia/diagnóstico , Anemia/epidemiologia , Austrália , Feminino , Hospitais , Humanos , New South Wales/epidemiologia , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/epidemiologia , Gravidez , Reprodutibilidade dos Testes
3.
J Int Med Res ; 49(5): 3000605211010730, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33947256

RESUMO

Compression sutures are primarily used to treat atonic postpartum hemorrhage. We herein describe three cases of selective arterial ligation combined with B-Lynch or modified B-Lynch suture for the treatment of intractable postpartum hemorrhage unresponsive to available conservative interventions. Three pregnant women underwent a cesarean section for a macrosomic fetus, fetal distress, and oligohydramnios, respectively. All three women developed intractable postpartum hemorrhage due to uterine atony with no chance of embolization therapy. B-Lynch or modified B-Lynch suture and additional selective arterial ligation were performed using braided absorbable suture. The first woman developed postoperative hematometra and infection without response to drainage and antibiotic therapy. Although laparoscopic exploration was performed to loosen the suture line and drain the hematometra and pyometra, the necrosis and infection could not be controlled. Subtotal hysterectomy was therefore conducted, and the necrotic uterine adnexa was removed. The other two women developed subinvolution of the uterus resulting in prolonged menstruation and amenorrhea, although the uterus was preserved and the bleeding was controlled. Modified B-Lynch suture combined with vascular ligation is an invaluable technique for women with severe intractable postpartum hemorrhage. However, it can lead to serious complications such as uterine necrosis, infection, and subinvolution.


Assuntos
Cesárea , Hemorragia Pós-Parto , Cesárea/efeitos adversos , Feminino , Humanos , Ligadura/efeitos adversos , Necrose , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/cirurgia , Gravidez , Estudos Retrospectivos , Técnicas de Sutura , Suturas/efeitos adversos , Útero/diagnóstico por imagem , Útero/cirurgia
4.
Am J Case Rep ; 22: e930908, 2021 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-33951030

RESUMO

BACKGROUND Sheehan syndrome (pituitary necrosis after postpartum hemorrhage) can present in various ways, depending on the hormones that are deficient. There may be a long delay to diagnosis of over a decade because symptoms are often vague and pituitary dysfunction progresses gradually. We describe a case of a patient with acute presentation of Sheehan syndrome 7 years after the obstetric event and with no clear precipitating event. CASE REPORT A 46-year-old woman with a history of hyperlipidemia and transaminitis came to the clinic for evaluation of hypotension and syncope. She had a history of longstanding anhedonia, fatigue, and postpartum hemorrhage 7 years previously and had undergone medical evaluations with her primary doctor with no cause found. Laboratory results showed anemia, central hypothyroidism, and adrenal insufficiency. A diagnosis of Sheehan syndrome was made. CONCLUSIONS Sheehan syndrome is a rare condition of progressive pituitary dysfunction, which can present with nonspecific symptoms and a myriad of laboratory abnormalities until an adrenal crisis is triggered years after the precipitating event. Screening patients for hypopituitarism by free thyroxine levels and adrenocorticotropic hormone (ACTH) stimulation testing is vital for determining whether hypopituitarism is the cause in the appropriate clinical scenario. Use of thyroid-stimulating hormone levels and morning cortisol testing alone will miss this diagnosis, and free thyroxine levels and ACTH stimulation testing are vital.


Assuntos
Insuficiência Adrenal , Hiperlipidemias , Hipopituitarismo , Hemorragia Pós-Parto , Feminino , Humanos , Hipopituitarismo/diagnóstico , Hipopituitarismo/etiologia , Pessoa de Meia-Idade , Período Pós-Parto , Gravidez
5.
Curr Opin Anaesthesiol ; 34(3): 260-268, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-33935172

RESUMO

PURPOSE OF REVIEW: The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. RECENT FINDINGS: Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. SUMMARY: Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.


Assuntos
Anestésicos , Placenta Acreta , Hemorragia Pós-Parto , Cesárea , Feminino , Humanos , Histerectomia/efeitos adversos , Recém-Nascido , Placenta Acreta/diagnóstico , Placenta Acreta/epidemiologia , Placenta Acreta/cirurgia , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/prevenção & controle , Gravidez
7.
Artigo em Inglês | MEDLINE | ID: mdl-33925427

RESUMO

Postpartum hemorrhage (PPH) is a common complication of pregnancy and a global public health concern. Even though PPH risk factors were extensively studied and reported in literature, almost all studies were conducted in non-Asian countries or tertiary care centers. Our study aimed to explore relevant risk factors for PPH among pregnant women who underwent transvaginal delivery at a Thai-Myanmar border community hospital in Northern Thailand. An exploratory nested case-control study was conducted to explore risk factors for PPH. Women who delivered transvaginal births at Maesai hospital from 2014 to 2018 were included. Two PPH definitions were used, which were ≥ 500 mL and 1000 mL of estimated blood loss within 24 h after delivery. Multivariable conditional logistic regression was used to identify significant risk factors for PPH and severe PPH. Of 4774 women with vaginal births, there were 265 (5.55%) PPH cases. Eight factors were identified as independent predictors for PPH and severe PPH: elderly pregnancy, minority groups, nulliparous, previous PPH history, BMI ≥ 35 kg/m2, requiring manual removal of placenta, labor augmentation, and fetal weight > 4000 gm. Apart from clinical factors, particular attention should be given to pregnant women who were minority groups as PPH risk significantly increased in this population.


Assuntos
Hemorragia Pós-Parto , Idoso , Estudos de Casos e Controles , Feminino , Hospitais Comunitários , Humanos , Mianmar/epidemiologia , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/etiologia , Gravidez , Fatores de Risco , Tailândia/epidemiologia
8.
BMC Pregnancy Childbirth ; 21(1): 317, 2021 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-33882864

RESUMO

BACKGROUND: Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds. METHODS: This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities. RESULTS: Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39-2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39-0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy). CONCLUSIONS: Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings. TRIAL REGISTRATION: This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016).


Assuntos
Procedimentos Clínicos/organização & administração , Serviços de Saúde Materna , Sistemas de Registro de Ordens Médicas/estatística & dados numéricos , Hemorragia Pós-Parto , Encaminhamento e Consulta/estatística & dados numéricos , Adulto , Países em Desenvolvimento , Diagnóstico Precoce , Feminino , Humanos , Serviços de Saúde Materna/normas , Serviços de Saúde Materna/estatística & dados numéricos , Mortalidade Materna , Avaliação de Processos e Resultados em Cuidados de Saúde , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/mortalidade , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Sinais Vitais
9.
BMC Pregnancy Childbirth ; 21(1): 320, 2021 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-33888075

RESUMO

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other low-income countries observe low provider adherence to recommended practices for PPH prevention and treatment. Our study addresses gaps in the literature by applying a behavioral science lens to identify barriers inhibiting facility-based providers' consistent following of PPH best practices in Madagascar. METHODS: In June 2019, we undertook a cross-sectional qualitative research study in peri-urban and rural areas of the Vatovavy-Fitovinany region of Madagascar. We conducted 47 in-depth interviews in 19 facilities and five communities, with facility-based healthcare providers, postpartum women, medical supervisors, community health volunteers, and traditional birth attendants, and conducted thematic analysis of the transcripts. RESULTS: We identified seven key behavioral insights representing a range of factors that may contribute to delays in appropriate PPH management in these settings. Findings suggest providers' perceived low risk of PPH may influence their compliance with best practices, subconsciously or explicitly, and lead them to undervalue the importance of PPH prevention and monitoring measures. Providers lack clear feedback on specific components of their performance, which ultimately inhibits continuous improvement of compliance with best practices. Providers demonstrate great resourcefulness while operating in a challenging context with limited equipment, supplies, and support; however, overcoming these challenges remains their foremost concern. This response to chronic scarcity is cognitively taxing and may ultimately affect clinical decision-making. CONCLUSIONS: Our study reveals how perception of low risk of PPH, limited feedback on compliance with best practices and consequences of current practices, and a context of scarcity may negatively affect provider decision-making and clinical practices. Behaviorally informed interventions, designed for specific contexts that care providers operate in, can help improve quality of care and health outcomes for women in labor and childbirth.


Assuntos
Procedimentos Clínicos/normas , Serviços de Saúde Materna , Hemorragia Pós-Parto , Gestão de Riscos , Adulto , Atitude do Pessoal de Saúde , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Madagáscar/epidemiologia , Serviços de Saúde Materna/normas , Serviços de Saúde Materna/estatística & dados numéricos , Mortalidade Materna , Tocologia , Preferência do Paciente , Hemorragia Pós-Parto/mortalidade , Hemorragia Pós-Parto/prevenção & controle , Hemorragia Pós-Parto/terapia , Gravidez , Pesquisa Qualitativa , Gestão de Riscos/métodos , Gestão de Riscos/estatística & dados numéricos , Percepção Social , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos
10.
BMC Pregnancy Childbirth ; 21(1): 323, 2021 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-33892626

RESUMO

BACKGROUND: Emergency Obstetric Hysterectomy (EOH) is removal of the uterus due to life threatening conditions within the puerperium. This life saving intervention is associated with life threatening complications. In our setting, little is known on EOH. OBJECTIVES: To determine the prevalence, indications and outcomes of emergency obstetric hysterectomy while comparing both postpartum hysterectomy and caesarean hysterectomy. METHODS: A 5-year hospital-based retrospective cohort study involving medical records of patients who underwent emergency obstetric hysterectomies between 1st January 2015 and 31st December 2019, was carried out at the Bafoussam Regional Hospital (BRH) from 1st February 2020 to 30th April 2020. Cases were classified as caesarean hysterectomy (CH) or postpartum hysterectomy (PH). Epidemiological data, indications, and complications of EOH were collected and analyzed in EPI-INFO 7.2.2.1. The chi-squared test was used to compare the two groups, and bivariate analysis was used to identify indicators of adverse outcomes of EOH. Statistical significance was set at p < 0.05. RESULTS: There were 30 cases of emergency obstetric hysterectomy (24 caesarean hysterectomies and 6 postpartum hysterectomies), giving a prevalence rate of 3.75 per 1000 deliveries. The most common indication for CH, was intractable postpartum haemorrhage and uterine rupture (33.33% each), while abnormal placentation (50%) was commonly indicated for PH. Anaemia (both groups) (p = 0.013) and sepsis (PH group only, 33.33%) (p = 0.03) were the most statistically significant complications of EOH respectively. Absence of blood transfusion prior to surgery (p = 0.013) and prolonged surgery lasting 2 or more hours (p = 0.04), were significantly associated with a negative clinical outcome. CONCLUSION: The prevalence of EOH is high. There were no differences in the sociodemographic profile, risk factors and indications of both groups. PH group was more likely to develop sepsis as complication. Lack of blood transfusion prior to surgery and prolonged surgeries were significantly associated to complication. Meticulous care and timely recognition of negative prognostic factors of delivery as well as those of EOH will help improve maternal outcomes of pregnancy.


Assuntos
Cesárea , Parto Obstétrico , Serviços Médicos de Emergência , Histerectomia , Complicações do Trabalho de Parto/epidemiologia , Hemorragia Pós-Parto , Adulto , Camarões/epidemiologia , Cesárea/métodos , Cesárea/estatística & dados numéricos , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Histerectomia/métodos , Histerectomia/estatística & dados numéricos , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/cirurgia , Gravidez , Resultado da Gravidez/epidemiologia , Prevalência , Estudos Retrospectivos , Fatores de Risco
11.
BMC Pregnancy Childbirth ; 21(1): 332, 2021 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-33902475

RESUMO

BACKGROUND: Although maternal deaths are rare in developed regions, the morbidity associated with severe postpartum hemorrhage (SPPH) remains a major problem. To determine the prevalence and risk factors of SPPH, we analyzed data of women who gave birth in Guangzhou Medical Centre for Critical Pregnant Women, which received a large quantity of critically ill obstetric patients who were transferred from other hospitals in Southern China. METHODS: In this study, we conducted a retrospective case-control study to determine the prevalence and risk factors for SPPH among a cohort of women who gave birth after 28 weeks of gestation between January 2015 and August 2019. SPPH was defined as an estimated blood loss ≥1000 mL and total blood transfusion≥4 units. Logistic regression analysis was used to identify independent risk factors for SPPH. RESULTS: SPPH was observed in 532 mothers (1.56%) among the total population of 34,178 mothers. Placenta-related problems (55.83%) were the major identified causes of SPPH, while uterine atony without associated retention of placental tissues accounted for 38.91%. The risk factors for SPPH were maternal age < 18 years (adjusted OR [aOR] = 11.52, 95% CI: 1.51-87.62), previous cesarean section (aOR = 2.57, 95% CI: 1.90-3.47), history of postpartum hemorrhage (aOR = 4.94, 95% CI: 2.63-9.29), conception through in vitro fertilization (aOR = 1.78, 95% CI: 1.31-2.43), pre-delivery anemia (aOR = 2.37, 95% CI: 1.88-3.00), stillbirth (aOR = 2.61, 95% CI: 1.02-6.69), prolonged labor (aOR = 5.24, 95% CI: 3.10-8.86), placenta previa (aOR = 9.75, 95% CI: 7.45-12.75), placenta abruption (aOR = 3.85, 95% CI: 1.91-7.76), placenta accrete spectrum (aOR = 8.00, 95% CI: 6.20-10.33), and macrosomia (aOR = 2.30, 95% CI: 1.38-3.83). CONCLUSION: Maternal age < 18 years, previous cesarean section, history of PPH, conception through IVF, pre-delivery anemia, stillbirth, prolonged labor, placenta previa, placental abruption, PAS, and macrosomia were risk factors for SPPH. Extra vigilance during the antenatal and peripartum periods is needed to identify women who have risk factors and enable early intervention to prevent SPPH.


Assuntos
Cesárea/efeitos adversos , Complicações do Trabalho de Parto/epidemiologia , Assistência Perinatal , Hemorragia Pós-Parto , Complicações na Gravidez , China/epidemiologia , Estado Terminal/epidemiologia , Feminino , Idade Gestacional , Necessidades e Demandas de Serviços de Saúde , Humanos , Idade Materna , Assistência Perinatal/métodos , Assistência Perinatal/normas , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/epidemiologia , Prevalência , Medição de Risco/métodos , Fatores de Risco , Índice de Gravidade de Doença
12.
BMJ Open ; 11(4): e044310, 2021 04 19.
Artigo em Inglês | MEDLINE | ID: mdl-33875443

RESUMO

INTRODUCTION: Postpartum haemorrhage (PPH) is an obstetric emergency requiring prompt and accurate response. PPH emergency kits containing equipment and medications can facilitate this kind of intervention, but their design and contents vary, potentially introducing risk of confusion or delay. Designs may be suboptimal, and relying on localised kit contents may result in supply chain costs, increased waste and missed opportunities for economies of scale. This study aims to characterise contextual influences on current practice in relation to PPH kits and to describe the range of kits currently employed in UK maternity units. METHODS AND ANALYSIS: This mixed-methods study comprises two phases. The first will use field observations and semistructured interviews to research PPH kits in a small number (3-5) of maternity units that will be selected to represent diversity. Analysis will be conducted both using an established human factors and ergonomics framework and using the constant comparative method for qualitative data analysis. The second phase will use a research and development platform (Thiscovery) to conduct a crowdsourced photography-based audit of PPH kits currently in use in the UK. Participants will tag images to indicate which objects have been photographed. Quantitative analysis will report the frequency of inclusion of each item in kits and the content differences between kit and unit types. All maternity units in the UK will be invited to take part, with additional targeted recruitment strategies used, if necessary, to ensure that the final sample includes different maternity unit types, sizes and PPH kit types. Study results will inform future work to develop consensus on effective PPH kit designs. ETHICS AND DISSEMINATION: Approval has been received from the UK Health Research Authority (project ID 274147). Study results will be reported through the research institute's website, presented at conferences and published in peer-reviewed journals.


Assuntos
Hemorragia Pós-Parto , Feminino , Humanos , Hemorragia Pós-Parto/terapia , Gravidez , Projetos de Pesquisa
13.
BMC Pregnancy Childbirth ; 21(1): 280, 2021 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-33832453

RESUMO

BACKGROUND: We aimed to describe the characteristics and outcomes in pregnant women with liver cirrhosis, and identify the predictors of adverse events of mother and fetus. METHODS: Retrospectively collected mothers with liver cirrhosis in our center from 6/2010 to 6/2019. Women without liver cirrhosis were selected as a control in a 1:2 ratio. The primary assessment was the frequency of maternal and fetal adverse events. The secondary assessment was the adverse events in patients continuing pregnancy or not and the factors to predict the severe adverse events. RESULTS: Of 126 pregnancies enrolled, 29 pregnancies were terminated for worrying disease progression and 97 pregnancies continued. One hundred ninety-four pregnancies without liver cirrhosis were selected as control. At baseline, patients with liver cirrhosis have a lower level of platelet, hemoglobin, prothrombin activity, and a higher level of ALT, total Bilirubin, creatinine. Compared to control, patients with liver cirrhosis had a higher frequency of adverse events, including bleeding gums (7.2%vs. 1.0%), TBA elevation (18.6%vs.3.1%), infection (10.3%vs.0.5%), cesarean section (73.6%vs.49.5%), postpartum hemorrhage (13.8% vs 2.1%), blood transfusion (28.9% vs 2.1%), new ascites or aggravating ascites (6.2% vs.0%), MODS (7.2% vs.0.5%) and intensive care unit admissions (24.1% vs 1.1%). The incidence of severe maternal adverse events was also higher (32.0% vs 1.5%). Women who chose to terminated the pregnancy had less severe adverse events (3.4% vs.32.0%). A higher frequency of fetal/infants' complications was observed in liver cirrhosis population than control, including newborn asphyxia (10.2% vs1.1%), low birth weight infant (13.6% vs. 2.6%). In patients who progressed into the third trimester, multivariable regression analysis demonstrated that severe adverse events were associated with a higher CTP score (OR 2.128, 95% CI [1.002, 4.521], p = 0.049). Wilson's disease related liver cirrhosis has a better prognosis (OR = 0.009, 95% CI [0, 0.763], p = 0.038). CONCLUSIONS: The incidence of the adverse events was significantly increased in pregnancies complicated by cirrhosis. The predictor of severe adverse events is higher CTP score. Wilson's disease induced liver cirrhosis have a better prognosis. Timely termination of pregnancy during the first trimester may avoid the incidence of severe adverse events.


Assuntos
Asfixia Neonatal/epidemiologia , Cesárea/estatística & dados numéricos , Cirrose Hepática/complicações , Hemorragia Pós-Parto/epidemiologia , Complicações na Gravidez , Adulto , Asfixia Neonatal/etiologia , Estudos de Casos e Controles , Feminino , Humanos , Incidência , Recém-Nascido de Baixo Peso , Recém-Nascido , Hemorragia Pós-Parto/etiologia , Gravidez , Resultado da Gravidez , Prognóstico
14.
Eur J Obstet Gynecol Reprod Biol ; 260: 208-211, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33839646

RESUMO

OBJECTIVE: Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide. Uterine atony is the most common cause of bleeding accounting for ∼80 % of cases of postpartum hemorrhage. To reduce maternal morbidity and mortality due to bleeding caused by uterine atony even under limited resources, a simple and effective procedure that can be easily applied by all obstetricians and junior physicians is required. The aim of this study was to evaluate the efficacy of novel three vertical compression sutures for severe postpartum hemorrhage. DESIGN: Two vertical sutures are transfixed, one on each side of the lower uterine segment, from anterior to posterior over the bladder reflection avoiding the endometrial cavity, and tied over the fundus. The lateral sutures should be placed approximately 2 cm from the lateral edge of the lower uterus and approximately 4 cm from the cornual border, because the uterus widens upward from below. The third vertical suture is placed in the midline at the same level as the two vertical sutures, passing the endometrial cavity from anterior to posterior, and is tied in the middle of the fundus, where the three sutures are positioned side-by-side. RESULTS: We report 25 cases of postpartum hemorrhage secondary to life-threatening severe uterine atony treated with this novel approach of using three vertical compression sutures. Success was achieved in 24/25 (96 %) of cases treated with three vertical sutures, without requiring hysterectomy except one. CONCLUSIONS: To reduce maternal morbidity and mortality, three vertical compression sutures as a novel technique, can be attempted before applying other more complex interventions. It does not require any extra skill or training, and is an ideal option as its simplicity allows it to be performed by all obstetricians, including junior obstetric staff.


Assuntos
Hemorragia Pós-Parto , Inércia Uterina , Feminino , Humanos , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/cirurgia , Período Pós-Parto , Gravidez , Técnicas de Sutura , Suturas , Inércia Uterina/cirurgia , Útero/cirurgia
15.
N Engl J Med ; 384(17): 1623-1634, 2021 04 29.
Artigo em Inglês | MEDLINE | ID: mdl-33913639

RESUMO

BACKGROUND: Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive. METHODS: In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion. RESULTS: Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P = 0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P = 0.08). CONCLUSIONS: Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes. (Funded by the French Ministry of Health; TRAAP2 ClinicalTrials.gov number, NCT03431805.).


Assuntos
Antifibrinolíticos/uso terapêutico , Cesárea/efeitos adversos , Hemorragia Pós-Parto/prevenção & controle , Ácido Tranexâmico/uso terapêutico , Administração Intravenosa , Adulto , Antifibrinolíticos/efeitos adversos , Transfusão de Sangue/estatística & dados numéricos , Método Duplo-Cego , Feminino , Humanos , Gravidez , Embolia Pulmonar/etiologia , Ácido Tranexâmico/efeitos adversos , Trombose Venosa/etiologia
17.
Artigo em Inglês | MEDLINE | ID: mdl-33824063

RESUMO

The incidence of placenta accrete spectrum (PAS) disorders is increasing worldwide. Pregnancies complicated by PAS are at a high risk of intrapartum surgical complications, mainly due to severe maternal hemorrhage, potentially leading to death, thus highlighting the need for a tailored an appropriate surgical management for these women. Despite its clinical relevance, there are still unanswered questions regarding the surgical management of women with PAS. Hysterectomy has been considered as the gold standard for the surgical treatment of these women. However, the surgical approach has not yet been standardized, and several conservative surgical procedures such as the Triple P Procedure are also being performed for PAS. Interventional radiology techniques have been demonstrated to reduce the risk of severe blood loss in women with postpartum hemorrhage, but their role in the management of women with PAS has not yet been fully defined. The aim of this chapter is to provide an up-to-date insight on the radical surgical approach to adopt during cesarean delivery in pregnancies complicated by PAS disorders.


Assuntos
Placenta Acreta , Hemorragia Pós-Parto , Cesárea , Feminino , Humanos , Histerectomia/efeitos adversos , Incidência , Gravidez
18.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 33(3): 305-310, 2021 Mar.
Artigo em Chinês | MEDLINE | ID: mdl-33834971

RESUMO

OBJECTIVE: To observe the effect of fluid therapy on volume and coagulation function in patients with severe postpartum hemorrhage during cesarean section of placenta accreta under the guidance of inferior vena cava diameter (IVCD) and inferior vena cava collapse index (IVC-CI). METHODS: A prospective randomized controlled study was conducted in 60 pregnant women with severe postpartum hemorrhage (blood loss ≥ 1 000 mL) who were hospitalized for delivery or referred for delivery in the Peking University Third Hospital from December 2018 to July 2019. The patients were divided into routine fluid replacement group and goal-oriented fluid resuscitation group (goal-oriented fluid replacement therapy was given) according to the different ways of fluid replacement. The hemodynamics, blood gas analysis, coagulation function, total fluid replacement, urine volume, prognosis, intraoperative vasoactive drugs utilization rate and postoperative adverse events were recorded before skin incision, after the fetus delivered, postpartum hemorrhage and at the end of operation, and the differences of these indices between the two groups were compared. RESULTS: (1) Hemodynamics: the heart rate (HR) of the two groups were reached the peak during postpartum hemorrhage, but there was no significant difference in HR at each time point between the two groups. The mean arterial pressure (MAP) was decreased at first and then increased in both groups, and reached the trough at postpartum hemorrhage, but the MAP in the goal-oriented fluid resuscitation group was significantly higher than that in the routine fluid replacement group [mmHg (1 mmHg = 0.133 kPa): 75.6±10.7 vs. 69.2±8.9, P < 0.05]. In the goal-oriented fluid resuscitation group, the central venous pressure (CVP) was increased slightly after the fetus delivered and then stabilized, while in the routine fluid replacement group, the CVP was increased at first and then decreased, and reached the peak in postpartum hemorrhage. During postpartum hemorrhage, CVP in the goal-oriented fluid resuscitation group was significantly lower than that in the routine fluid replacement group [cmH2O (1 cmH2O = 0.098 kPa): 9.5±3.9 vs. 11.4±3.4, P < 0.05]. (2) Arterial blood gas: partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) in arterial blood at the end of operation in both groups were higher than those in postpartum hemorrhage. There was no significant difference in PaO2 at the end of operation between the goal-oriented fluid resuscitation group and routine fluid replacement group (mmHg: 189.3±100.5 vs. 240.2±126.3, P > 0.05). The PaCO2 in the goal-oriented fluid resuscitation group was significantly lower than that in the routine fluid replacement group (mmHg: 34.6±4.6 vs. 36.8±4.1, P < 0.05). The lactic acid (Lac) at the end of operation of the goal-oriented fluid resuscitation group was significantly lower than that of the routine fluid replacement group (mmol/L: 2.2±0.6 vs. 2.6±1.1, P < 0.05). (3) Liquid intake and output volume: the total infusion volume, crystal fluid infusion volume and suspended red blood cell infusion volume in the goal-oriented fluid resuscitation group were significantly less than those in the routine fluid replacement group [total infusion volume (mL): 3 385.9±1 144.1 vs. 4 448.3±1 194.4, crystal infusion volume (mL): 2 635.6±789.7 vs. 3 160.0±860.3, suspended red blood cell input volume (mL): 695.6±366.2 vs. 911.1±284.7, all P < 0.05], and the utilization rate of vasoactive drugs in the goal-oriented fluid resuscitation group was decreased significantly during operation [13.3% (4/30) vs. 60.0% (18/30), P < 0.05]. The amount of bleeding in the goal-oriented fluid resuscitation group was also significantly less than that in the routine fluid replacement group (mL: 1 451.7±373.8 vs. 1 725.9±372.8, P < 0.05), but there was no significant difference in urine volume between the goal-oriented fluid resuscitation group and the routine fluid replacement group (mL: 369.0±262.7 vs. 485.0±286.8, P > 0.05). (4) Coagulation function: at the end of operation, the prothrombin time (PT) in the goal-oriented fluid resuscitation group was significantly shorter than that in the routine fluid replacement group (s: 10.9±0.6 vs. 11.2±0.6), and the fibrinogen (Fib) in the goal-oriented fluid resuscitation group was significantly higher than that in the routine fluid replacement group (g/L: 3.7±0.5 vs. 2.9±0.8), and the differences were statistically significant (both P < 0.05). (5) Prognostic index: compared with the routine fluid replacement group, the proportion of patients transferred to intensive care unit (ICU) at the end of operation in the goal-oriented fluid resuscitation group was significantly lower [16.7% (5/30) vs. 66.7% (20/30), P < 0.05], and ICU length-of-stay was significantly shorter [hours: 0 (0, 24) vs. 24 (0, 24), P < 0.05], but there was no significant difference in the incidence of disseminated intravascular coagulation (DIC), acute renal injury (AKI) or hysterectomy between the goal-oriented fluid resuscitation group and the routine fluid replacement group [the incidence of DIC: 0% (0/30) vs. 6.7% (2/30), the incidence of AKI: 0% (0/30) vs. 3.3% (1/30), the hysterectomy rate: 10.0% (3/30) vs. 26.7% (8/30), all P > 0.05]. CONCLUSIONS: Fluid resuscitation guided by IVC-CI can effectively reduce the volume of blood and fluid transfusion and blood loss in patients with severe postpartum hemorrhage and improve their blood coagulation function.


Assuntos
Hemorragia Pós-Parto , Cesárea/efeitos adversos , Feminino , Hidratação , Objetivos , Humanos , Hemorragia Pós-Parto/terapia , Gravidez , Estudos Prospectivos
19.
Medicina (Kaunas) ; 57(3)2021 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-33807607

RESUMO

Background and Objectives: COVID-19, a disease caused by SARS-CoV-2, is a public health emergency. Data on the effect of the virus on pregnancy are limited. Materials and Methods: We carried out a retrospective descriptive study, in order to evaluate the obstetric results on pregnant women in which SARS-CoV-2 was detected through RT-PCR of the nasopharyngeal swab, at admission to the maternity hospital. Results: From 16 March to 31 July 2020, 12 SARS-CoV-2 positive pregnant women have been hospitalized. Eleven were hospitalized for initiation or induction of labor, corresponding to 0.64% of deliveries in the maternity hospital. One pregnant woman was hospitalized for threatened abortion, culminating in a stillbirth at 20 weeks of gestation. Regarding the severity of the disease, nine women were asymptomatic and three had mild illness (two had associated cough and one headache). Three had relevant environmental exposure and a history of contact with infected persons. None had severe or critical illness due to SARS-CoV-2. There were no maternal deaths. The following gestational complications were observed: one stillbirth, one preterm labor, one preterm prelabor rupture of membranes, and one fetal growth restriction. Four deliveries were eutocic, two vacuum-assisted deliveries and five were cesarean sections. The indications for cesarean section were obstetric. Conclusions: SARS-CoV-2 infection was found in a minority of hospitalized pregnant women in this sample. Most are asymptomatic or have mild illness, from gestational complications to highlight stillbirth and preterm birth. There were no cases of vertical transmission by coronavirus.


Assuntos
/epidemiologia , Complicações Infecciosas na Gravidez/epidemiologia , Adulto , Cesárea , Tosse/fisiopatologia , Feminino , Retardo do Crescimento Fetal/epidemiologia , Ruptura Prematura de Membranas Fetais/epidemiologia , Cefaleia/fisiopatologia , Hospitalização , Maternidades , Humanos , Trabalho de Parto Induzido , Trabalho de Parto Prematuro/epidemiologia , Portugal/epidemiologia , Hemorragia Pós-Parto/epidemiologia , Gravidez , Resultado da Gravidez , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Natimorto/epidemiologia , Vácuo-Extração
20.
Am J Obstet Gynecol ; 224(5): 512.e1-512.e6, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33689752

RESUMO

BACKGROUND: In the United States, Black women are 3 to 4 times more likely to die from childbirth and have a 2-fold greater risk of maternal morbidity than their White counterparts. This disparity is theorized to be related to differences in access to healthcare or socioeconomic status. Military service members and their dependents are a diverse community and have equal access to healthcare and similar socioeconomic statuses. OBJECTIVE: This study hypothesized that universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of race or ethnic background. STUDY DESIGN: A retrospective cohort study included data from the inaugural National Perinatal Information Center special report comparing indicators of severe maternal morbidity by race. National Perinatal Information Center data from participating military treatment facilities in the Department of Defense performing more than 1000 deliveries annually from April 1, 2018, to March 31, 2019, were included. Using this convenience data set, Chi-square analyses comparing the percentages of cesarean deliveries, adult intensive care unit admissions, and severe maternal morbidity between Black and White patients were performed. RESULTS: Black women were more likely to deliver via cesarean delivery (31.68% vs 23.58%; P<.0001; odds ratio, 1.5; 95% confidence interval, 1.38-1.63), be admitted to an adult intensive care unit (0.49% vs 0.18%; P=.0026; odds ratio, 2.78; 95% confidence interval, 1.46-5.27), and experience overall severe maternal morbidity (2.66% vs 1.66%; P=.0001; odds ratio, 1.67; 95% confidence interval, 1.3-2.15) even when excluding blood transfusion (0.64% vs 0.32%; P=.0139; odds ratio, 1.99; 95% confidence interval, 1.17-3.36) than their White counterparts. There were no substantial differences between races in overall severe maternal morbidity associated with postpartum hemorrhage even when excluding blood transfusion in this subset. CONCLUSION: Equal access to healthcare and similar socioeconomic statuses in the military healthcare system do not explain the healthcare disparities seen regarding maternal morbidity encountered by Black women having children in the United States. This study identifies healthcare disparities in severe maternal morbidity among active duty service members and their families. Further studies to assess causes such as systemic racism (including implicit and explicit medical biases) and physiological factors are warranted.


Assuntos
Afro-Americanos/estatística & dados numéricos , Cesárea/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Serviços de Saúde Militar/estatística & dados numéricos , Militares/estatística & dados numéricos , Complicações na Gravidez/epidemiologia , Transfusão de Sangue/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde , Humanos , Unidades de Terapia Intensiva , Admissão do Paciente/estatística & dados numéricos , Hemorragia Pós-Parto/epidemiologia , Gravidez , Estudos Retrospectivos , Estados Unidos/epidemiologia
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