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1.
BMC Res Notes ; 12(1): 618, 2019 Sep 23.
Artigo em Inglês | MEDLINE | ID: mdl-31547856

RESUMO

OBJECTIVE: Since data related to postpartum hemorrhage in Ethiopia is scarce, this study was aimed to assess the magnitude and associated factors of postpartum hemorrhage among mothers who delivered in Debre Tabor general hospital. RESULTS: In this study, one hundred forty-four mothers' charts were reviewed which made the response rate 100%. This study revealed that the magnitude of postpartum hemorrhage was 7.6% (CI 6.2, 9.8). Chi-square test revealed that there was an association between postpartum hemorrhage and gravidity, parity, having antenatal care visit, and the previous history postpartum hemorrhage. This finding confirmed that uterine atony, retained placenta, and genital tract trauma were the most common leading cause of postpartum hemorrhage.


Assuntos
Hospitais Gerais , Placenta Retida/fisiopatologia , Hemorragia Pós-Parto/diagnóstico , Inércia Uterina/fisiopatologia , Adolescente , Adulto , Estudos Transversais , Parto Obstétrico , Etiópia/epidemiologia , Feminino , Genitália Feminina/lesões , Número de Gestações/fisiologia , Humanos , Visita a Consultório Médico/estatística & dados numéricos , Paridade/fisiologia , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/fisiopatologia , Gravidez , Fatores de Risco
2.
Saudi J Kidney Dis Transpl ; 30(4): 919-923, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31464250

RESUMO

Renal cortical necrosis (RCN) is characterized by patchy or diffuse destruction of all the elements of renal cortex resulting from significantly diminished renal arterial perfusion due to vascular spasm and microvascular injury. It is a rare cause of acute kidney injury (AKI) in developed countries with frequency of 1.9%-2% of all patients of AKI. In contrast, the incidence of RCN is higher in developing countries ranging from 6%-7%. Obstetric complication is the main cause of RCN, earlier it was about 20%-30% which has been declining to 5% in the Indian subcontinent during the past two decades. The aim of this study is to review five consecutive cases of RCN diagnosed within very short span of time. Histopathologically, diagnosed five cases of RCN during one-month span in September 2016 at Armed Forces Institute of Pathology, Dhaka were included in this study. All the cases were referred cases from a tertiary level obstetric center of Dhaka city; the mean age was 24.2 ± 3.4 years. All the cases had the history of postpartum hemorrhage followed by septicemia. They all presented with acute renal failure dependent on hemodialysis for >21 days. On histological examination, three (60%) had patchy RCN and two (40%) had diffuse RCN. Two (40%) showed coagulative necrosis of all the glomeruli, two (40%) showed coagulative necrosis of >50% of glomeruli, and in one (20%) case necrosis of about 25% of glomeruli. One of the glomeruli showed global sclerotic change of most of the glomeruli. In all the cases, interstitium showed moderate focal lymphocytic infiltration and mild edema. Among all, one (20%) was found with immunoglobulin A nephropathy as an associated diagnosis. RCN is still encountered as an obstetric complication in our setting and this type of grave consequences should be prevented by better monitoring of pregnancies.


Assuntos
Lesão Renal Aguda/etiologia , Necrose do Córtex Renal/etiologia , Córtex Renal/patologia , Hemorragia Pós-Parto/etiologia , Sepse/etiologia , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/terapia , Adulto , Feminino , Humanos , Necrose do Córtex Renal/patologia , Hemorragia Pós-Parto/diagnóstico , Gravidez , Diálise Renal , Fatores de Risco , Sepse/diagnóstico , Adulto Jovem
3.
PLoS One ; 14(7): e0216654, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31276503

RESUMO

BACKGROUND: In the state of Bihar, India a multi-faceted quality improvement nurse-mentoring program was implemented to improve provider skills in normal and complicated deliveries. The objective of this analysis was to examine changes in diagnosis and management of postpartum hemorrhage (PPH) of the mother and intrapartum asphyxia of the infant in primary care facilities in Bihar, during the program. METHODS: During the program, mentor pairs visited each facility for one week, covering four facilities over a four-week period and returned for subsequent week-long visits once every month for seven to nine consecutive months. Between- and within-facility comparisons were made using a quasi-experimental and a longitudinal design over time, respectively, to measure change due to the intervention. The proportions of PPH and intrapartum asphyxia among all births as well as the proportions of PPH and intrapartum asphyxia cases that were effectively managed were examined. Zero-inflated negative binomial models and marginal structural methodology were used to assess change in diagnosis and management of complications after accounting for clustering of deliveries within facilities as well as time varying confounding. RESULTS: This analysis included 55,938 deliveries from 320 facilities. About 2% of all deliveries, were complicated with PPH and 3% with intrapartum asphyxia. Between-facility comparisons across phases demonstrated diagnosis was always higher in the final week of intervention (PPH: 2.5-5.4%, intrapartum asphyxia: 4.2-5.6%) relative to the first week (PPH: 1.2-2.1%, intrapartum asphyxia: 0.7-3.3%). Within-facility comparisons showed PPH diagnosis increased from week 1 through 5 (from 1.6% to 4.4%), after which it decreased through week 7 (3.1%). A similar trend was observed for intrapartum asphyxia. For both outcomes, the proportion of diagnosed cases where selected evidence-based practices were used for management either remained stable or increased over time. CONCLUSIONS: The nurse-mentoring program appears to have built providers' capacity to identify PPH and intrapartum asphyxia cases but diagnosis levels are still not on par with levels observed in Southeast Asia and globally.


Assuntos
Asfixia Neonatal/diagnóstico , Asfixia Neonatal/terapia , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/terapia , Asfixia Neonatal/epidemiologia , Gerenciamento Clínico , Educação , Educação Continuada em Enfermagem , Feminino , Humanos , Índia/epidemiologia , Recém-Nascido , Tutoria , Hemorragia Pós-Parto/epidemiologia , Gravidez , Melhoria de Qualidade
4.
Am J Obstet Gynecol ; 221(3): 267.e1-267.e6, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31229429

RESUMO

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal mortality in developing countries and the primary cause of one-quarter of all maternal deaths globally. Inaccuracy in estimating blood loss obscures the diagnosis of postpartum hemorrhage and its management. OBJECTIVE: Our objective was to compare assessment of blood loss using the quantitative Triton system (Gauss Surgical, Inc, Los Altos, CA) with other measures of blood loss in women undergoing cesarean delivery. STUDY DESIGN: Women scheduled for cesarean deliveries at our facility were included. Intraoperative blood loss was measured using the Triton, which was masked to the clinical team, as well as estimated by the surgeon (subjective estimated blood loss). The relation between the 2 methods (Triton and subjective estimated blood loss) and postoperative hemoglobin as well as delta hemoglobin (postoperative minus preoperative hemoglobin) was determined using the Spearman correlation. Triton measurement and subjective estimated blood loss were compared between women with delta hemoglobin in the upper quartile (cases) vs all other quartiles (control). Prediction of delta hemoglobin in the upper quartile also was evaluated for each method, and the area under the receiver operating characteristic curves was compared. RESULTS: The trial enrolled 242 patients. The mean blood loss estimated by the Triton device was significantly lower than that estimated by clinical judgment (415.3±260.6 vs 799.6±215.6 mL, P<.01). The Triton estimate correlated best with delta hemoglobin. Seventy patients had delta hemoglobin in the upper quartile (delta hemoglobin ≥2). There was a significant difference in the Triton blood loss measurement between cases and controls but no difference with subjective estimated blood loss. Triton, but not subjective estimated blood loss, was predictive of delta hemoglobin ≥2 g/dL (Triton: area under the receiver operating characteristic curve, 0.66; 95% confidence interval, 0.58-0.74; P<.01 vs subjective estimated blood loss: area under the receiver operating characteristic curve, 0.53; 95% confidence interval, 0.45-0.61; P=.45). CONCLUSIONS: The Triton system provides a better estimate of blood loss than the visual estimate. Clinical trials to evaluate its benefit are warranted.


Assuntos
Perda Sanguínea Cirúrgica/estatística & dados numéricos , Cesárea , Hemorragia Pós-Parto/diagnóstico , Adulto , Feminino , Seguimentos , Humanos , Gravidez , Estudos Prospectivos , Curva ROC
5.
PLoS One ; 14(6): e0217907, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31185036

RESUMO

OBJECTIVE: To determine Shock Index (SI) reference values in the first two hours of the postpartum period after objectively measuring postpartum bleeding. MATERIALS AND METHODS: A complementary analysis using data from a prospective cohort study at Women's Hospital of the University of Campinas, Brazil, between 1 February 2015 and 31 March 2016. It included women giving birth vaginally unless they had one of these conditions: gestational age below 34 weeks, hypertension, hypo- or hyperthyroidism without treatment, any cardiac disease, infections with fever or sepsis, history of coagulopathy or delivery by C-section. Blood loss was measured by adding the blood volume collected in the drape placed under the women's buttocks and the weight of gauzes and compresses used (excluding the dry weight). Vital signs were measured every 5-15 min after delivery. Exploratory data analysis was performed to assess the mean, standard deviation, median, and percentiles (5th, 10th, 25th, 50th, 75th, 90th, 95th). To identify variation among the periods after delivery, the mean SI and heart rate (HR) values observed for the following intervals were used in the analysis: 0-20 min, 21-40 min, 41-60 min, 61-90 min and 91-120 min. RESULTS: One hundred eighty-six women were included. The mean age ± SD was 24.9 ± 6.1 years and the mean gestational age at birth was 39.2 ± 1.8 weeks. At the puerperal period, the mean SI values ranged from 0.68 ± 0.14 to 0.74 ± 0.15. The percentile distribution ranged from 0.46 (5th percentile) to 1.05 (95th percentile). The mean HR values ranged from 80.8 ± 12.7 bpm to 92.3 ± 14.4 bpm. The percentile distribution ranged from 62.0 bpm (5th percentile) to 117 bpm (95th percentile). CONCLUSION: Reference ranges were established for SI and HR values which showed small variations throughout the postpartum period.


Assuntos
Idade Gestacional , Parto , Hemorragia Pós-Parto , Período Pós-Parto , Choque , Adulto , Brasil , Feminino , Humanos , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/fisiopatologia , Gravidez , Estudos Prospectivos , Choque/diagnóstico , Choque/fisiopatologia
6.
Artigo em Inglês | MEDLINE | ID: mdl-31155462

RESUMO

Interventions for prevention and treatment of postpartum haemorrhage have been the subject of numerous clinical trials. However, there is substantial heterogeneity in the outcomes reported by trialists, making the evidence difficult to interpret and compare across studies. Recommendations for clinical practice can be robust only if they are based on good-quality evidence, where therapeutic options are compared using indicators that are standardised, important and meaningful measures of wellbeing. The aim of this chapter is to discuss the challenges in selecting outcome measures for postpartum haemorrhage trials, to describe the current state of outcomes reporting in this area and to make recommendations for clinical trials evaluating interventions for prevention and treatment of postpartum haemorrhage, based on the recently developed Core Outcome Sets.


Assuntos
Hemorragia Pós-Parto , Ensaios Clínicos como Assunto , Feminino , Humanos , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Índice de Gravidade de Doença
7.
Artigo em Inglês | MEDLINE | ID: mdl-31235396

RESUMO

Postpartum haemorrhage is a major global cause of mortality and morbidity amongst childbearing women. Failure or delay in recognising the severity of bleeding is an important contributory factor in these outcomes. Earlier recognition of haemorrhage would facilitate earlier intervention and treatment, helping resolve the causes of bleeding sooner, and thereby improving outcomes for women. Ways to achieve earlier recognition have traditionally focussed on the clinical skill of assessing the volume of blood loss. However, despite extensive research, the optimum method of assessing blood loss and achieving earlier diagnosis remains unclear. Examination of the psychological literature suggests that clinical decision-making is more complex and highlights some of the reasons why traditional approaches have had a limited effect. Using psychological theories of decision-making to inform solutions may lead to more successful strategies to address the issues than the current focus on volume assessment of blood loss.


Assuntos
Hemorragia Pós-Parto , Feminino , Humanos , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/terapia , Gravidez
8.
Curr Opin Anaesthesiol ; 32(3): 278-284, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31045634

RESUMO

PURPOSE OF REVIEW: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the United States, and worldwide. Recognition of PPH is challenging, but once hemorrhage is recognized, management needs to focus on achieving adequate uterine tone and maintaining maternal hemodynamic stability. There have been several advances in the management of postpartum hemorrhage, many of which can be implemented at the labor and delivery unit level. RECENT FINDINGS: There have been many advances in the understanding of at-risk parturients, and the use of hemorrhage protocols and safety bundles have been shown to improve patient outcomes. There are many new advances in transfusion management (e.g. fibrinogen concentrate, prothrombin complex concentrate, tranexamic acid) that can compliment traditional component therapy. Consideration should be given to transferring women at high risk for complications (e.g. invasive placentation) to a higher level facility for delivery. SUMMARY: Although postpartum hemorrhage itself may not be preventable, early identification of blood loss, and mobilization of resources may prevent adverse outcomes. Multidisciplinary planning at the system level, ensuring that hemorrhage protocols exist, as well as for management of high-risk patients is important for improving patient outcomes.


Assuntos
Transfusão de Sangue/métodos , Planejamento de Assistência ao Paciente/organização & administração , Hemorragia Pós-Parto/diagnóstico , Gravidez de Alto Risco , Feminino , Humanos , Mortalidade , Equipe de Assistência ao Paciente/organização & administração , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/terapia , Gravidez
9.
J Obstet Gynaecol ; 39(6): 757-762, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31020886

RESUMO

Postpartum haemorrhage (PPH) is a potentially life-threatening condition. Women undergoing caesarean section (CS) are at particular risk, and improvements in the management of PPH during CS are required. We investigated the use of a tissue hardness metre to quantify uterine contractions during CS with a view to its application for obstetric bleeding management. Fifty pregnant women at term who underwent elective CS were recruited. Using a tissue hardness metre, we measured uterine hardness twice during CS: after placental removal and before peritoneum closure. Each measurement was conducted at two standardised points: fundus and corpus uteri. Concurrently, obstetricians subjectively graded uterine contractions as weak, medium, or strong. The hardness metre accurately quantified the degree of uterine contraction assessed by the obstetricians, and could be an effective clinical tool for early recognition of intra-operative massive bleeding. IMPACT STATEMENT What is already known on this subject? Maintaining adequate uterine contraction leads to prevention of excessive blood loss, which decreases the incidence and severity of PPH. However, the assessment of uterine contraction is currently judged by obstetricians, who manually and subjectively evaluate uterine contraction according to uterine hardness. Therefore, uterine atony remains a clinical diagnosis without a universal definition. What do the results of this study add? The present study investigated the use of a tissue hardness metre to quantify uterine contractions during CS with a view to its application for obstetric bleeding management. The hardness metre was able to quantify the degree of uterine contraction perceived by obstetricians. Quantifying uterine hardness during CS correlates with the amount of intra-operative bleeding and is useful for early recognition of massive haemorrhage. What are the implications of these findings for clinical practice and/or further research? To improve the management of atonic PPH and avoid serious complications, the tissue hardness metre should be considered as a potential clinical tool during CS.


Assuntos
Fenômenos Biomecânicos/fisiologia , Cesárea , Estudos de Viabilidade , Hemorragia Pós-Parto/terapia , Contração Uterina/fisiologia , Útero/fisiopatologia , Adulto , Feminino , Testes de Dureza/instrumentação , Humanos , Pessoa de Meia-Idade , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/fisiopatologia , Gravidez
10.
Emerg Med Clin North Am ; 37(2): 287-300, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30940373

RESUMO

This article covers a high-risk time in a woman's life, the period just after delivery of her baby. There are large variations in complication rates across various groups in the United States. Many women seek care in the emergency department for routine and more serious postpartum pathologies. Emergency physicians should be well versed in common and life-threatening complications of delivery. The specific pathologies discussed in this article include lactation in the emergency department, postpartum hemorrhage, amniotic fluid embolism, endometritis, and mastitis.


Assuntos
Transtornos Puerperais/diagnóstico , Embolia Amniótica/diagnóstico , Embolia Amniótica/terapia , Serviço Hospitalar de Emergência , Endometrite/diagnóstico , Endometrite/terapia , Feminino , Humanos , Transtornos da Lactação/diagnóstico , Transtornos da Lactação/terapia , Mastite/diagnóstico , Mastite/terapia , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/terapia , Gravidez , Transtornos Puerperais/terapia
11.
Gynecol Obstet Fertil Senol ; 47(5): 465-470, 2019 05.
Artigo em Francês | MEDLINE | ID: mdl-30872188

RESUMO

OBJECTIVE: The aim of the study was to assess the impact of the introduction of training workshops on the quality of prevention and management of Post-Partum Hemorrhage (PPH) in a type III university center. METHODS: A clinical audit was carried out in our type III university center before and after the introduction of training workshops on the prevention and management of PPH, in two periods between January 1st to December 31st 2011 and March 1st and August 1st, 2015. Training workshops were according to the recommendations for clinical practice of the National College of Gynecologists-Obstetricians French published in 2014, and included a theoretical portion and a simulation of low fidelity manikin. Data on the management of patients presenting with PPH after vaginal birth of a singleton were retrospectively collected consecutively from medical records. Data were collected using a standardized analytical grid. Between the two data collections, some improvement actions were implemented. RESULTS: After implementation of training workshops, the proportion of patients with active management of the third stage of labor (prophylactic uterotonic after delivery) has significantly improved (72% before, vs. 92% after, P=0.001); time to PPH diagnosis has been significantly higher notified (40% before, vs. 94% after, P<0.001), as well as the quantification of bleeding at diagnosis (46% before, vs. 72% after, P<0.003) and total bleeding (68% before, vs. 92%, P<0.001). PPH-specific monitoring sheet was found to be used significantly more frequently (3 before, vs. 30 after, P=0.00015). Additionally, the Physician Anesthesiologist has been contacted significantly more often (34% before, vs. 53% after, P=0.002). CONCLUSION: Our study highlights a significant improvement in professional practices between 2011 and 2015 on PPH prevention and management in our type III university center.


Assuntos
Obstetrícia/educação , Hemorragia Pós-Parto/terapia , Adulto , Auditoria Clínica , Feminino , Hospitais Universitários , Humanos , Trabalho de Parto , Massagem , Obstetrícia/métodos , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Estudos Retrospectivos , Útero
13.
Taiwan J Obstet Gynecol ; 58(2): 223-226, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30910143

RESUMO

OBJECTIVE: This study aimed to explore the clinical characteristics and outcomes of placental abruption. MATERIALS AND METHODS: A total of 62 placental abruption cases were collected from the Second Hospital of Jilin University between January 2007 and December 2012. A retrospective study was conducted to explore the risk factors for placental abruption, clinical characteristics, and maternal and fetal outcomes. RESULTS: Risk factors for placental abruption mainly include preeclampsia (39%) and premature rupture of membrane (10%). Abdominal pain (68%) and bleeding (35%) comprise the classical symptoms of placental abruption but the clinical picture varies from asymptomatic, in which the diagnosis is made by inspection of the placenta at delivery, to massive abruption leading to fetal death and severe maternal morbidity. Emergency cesarean section was performed in 45 cases (73%) of placental abruption. Sixty-two placental abruption cases were divided into 2 groups according to whether uteroplacental apoplexy occurred. The incidence of preeclampsia and the duration (time between on-set of clinical symptom and placenta delivery) in the observational group were significantly higher than that of the control group, showing statistical significance (P < 0.01). CONCLUSION: The diagnosis of placental abruption should consider risk factors, symptoms, physical signs, dynamic ultrasound monitoring, and cardiac care. Early diagnosis and treatment can improve maternal and infant prognosis.


Assuntos
Descolamento Prematuro da Placenta/fisiopatologia , Hemorragia Pós-Parto/prevenção & controle , Resultado da Gravidez/epidemiologia , Descolamento Prematuro da Placenta/diagnóstico , Descolamento Prematuro da Placenta/etiologia , Adulto , Estudos de Casos e Controles , Cesárea , Diagnóstico Precoce , Feminino , Ruptura Prematura de Membranas Fetais/diagnóstico , Ruptura Prematura de Membranas Fetais/epidemiologia , Humanos , Incidência , Morte Materna/prevenção & controle , Poli-Hidrâmnios/diagnóstico , Poli-Hidrâmnios/epidemiologia , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/etiologia , Pré-Eclâmpsia/diagnóstico , Pré-Eclâmpsia/epidemiologia , Gravidez , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
14.
Scand J Clin Lab Invest ; 79(1-2): 32-38, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30727759

RESUMO

Haemostatic treatment in women experiencing postpartum haemorrhage is increasingly based on point-of-care devices such as ROTEM® thromboelastometry. Recently, a fully automated successor of the ROTEM® Delta device, the ROTEM® Sigma was introduced. To determine whether these devices provide similar results, we compared ROTEM® parameters using the ROTEM® Delta and Sigma devices in women experiencing postpartum haemorrhage. Prospective observational cohort study of 23 women experiencing postpartum haemorrhage. ROTEM® INTEM, EXTEM, FIBTEM and APTEM measurements handled by the ROTEM® Delta and Sigma devices were compared. ROTEM® FIBTEM values were also related to Clauss fibrinogen values. A correlation of Spearman's r (rs) varying between 0.76 and 0.95 was displayed between clot firmness measured in millimeters at 5 (A5), 10 (A10) and 20 (A20) minutes after start of clot formation measured by EXTEM, INTEM and APTEM assays executed on both devices; A5, A10 and A20 of FIBTEM correlated less well (rS between 0.71 and 0.74), especially after five and ten minutes. Correlation between both devices regarding clotting time (CT) was poor. The observed correlation between levels of Clauss fibrinogen and FIBTEM A5 was rs = 0.70, (95% confidence interval (CI): 0.38 to 0.87) for Delta and rs = 0.85, (CI 0.65 to 0.94) for Sigma. A5, A10 and A20 measured in EXTEM, INTEM and APTEM obtained from ROTEM® Delta and Sigma devices were similar. EXTEM, FIBTEM and APTEM CT values from both devices showed no correlation. Substantial variation was found between FIBTEM assays of the devices. Consequently, results of FIBTEM assays should always be interpreted in the context of device-specific reference values. Correlation with Clauss fibrinogen was better in the ROTEM® Sigma device.


Assuntos
Coagulação Sanguínea , Fibrinogênio/metabolismo , Hemorragia Pós-Parto/diagnóstico , Tromboelastografia/instrumentação , Adulto , Feminino , Humanos , Sistemas Automatizados de Assistência Junto ao Leito , Hemorragia Pós-Parto/sangue , Gravidez , Estudos Prospectivos , Tromboelastografia/métodos , Tromboelastografia/normas
15.
Am J Obstet Gynecol ; 220(4): 297-307, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30682365

RESUMO

Compared with adults who are admitted to general medical-surgical wards, women who are admitted to labor and delivery services are at much lower risk of experiencing unexpected critical illness. Nonetheless, critical illness and other complications that put either the mother or fetus at risk do occur. One potential approach to prevention is to use automated early warning systems, such as those used for nonpregnant adults. Predictive models that use data extracted in real time from electronic records constitute the cornerstone of such systems. This article addresses several issues that are involved in the development of such predictive models: specification of temporal characteristics, choice of denominator, selection of outcomes for model calibration, potential uses of existing adult severity of illness scores, approaches to data processing, statistical considerations, validation, and options for instantiation. These have not been addressed explicitly in the obstetrics literature, which has focused on the use of manually assigned scores. In addition, this article provides some results from work in progress to develop 2 obstetric predictive models with the use of data from 262,071 women who were admitted to a labor and delivery service at 15 Kaiser Permanente Northern California hospitals between 2010 and 2017.


Assuntos
Diagnóstico Precoce , Processamento Eletrônico de Dados/métodos , Registros Eletrônicos de Saúde , Complicações do Trabalho de Parto/epidemiologia , Transtornos Puerperais/epidemiologia , Automação , Cardiotocografia , Estado Terminal , Eclampsia/diagnóstico , Eclampsia/epidemiologia , Eclampsia/prevenção & controle , Embolia/diagnóstico , Embolia/epidemiologia , Embolia/prevenção & controle , Feminino , Morte Fetal , Humanos , Hipóxia-Isquemia Encefálica/diagnóstico , Hipóxia-Isquemia Encefálica/epidemiologia , Hipóxia-Isquemia Encefálica/prevenção & controle , Morte Materna , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/prevenção & controle , Obstetrícia , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/prevenção & controle , Pré-Eclâmpsia/diagnóstico , Pré-Eclâmpsia/epidemiologia , Pré-Eclâmpsia/prevenção & controle , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/prevenção & controle , Transtornos Puerperais/diagnóstico , Transtornos Puerperais/prevenção & controle , Medição de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Hemorragia Uterina/diagnóstico , Hemorragia Uterina/epidemiologia , Hemorragia Uterina/prevenção & controle , Ruptura Uterina/diagnóstico , Ruptura Uterina/epidemiologia , Ruptura Uterina/prevenção & controle
16.
J Matern Fetal Neonatal Med ; 32(19): 3251-3254, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29621917

RESUMO

Purpose: To assess whether the ultrasonographic measurement of the inferior vena cava (IVC) diameter in postpartum women is a useful parameter in evaluating the actual blood loss during delivery due to massive postpartum hemorrhage. Materials and methods: In postpartum women with blood loss ≥500 g, abdominal ultrasonography was performed 1 hour after delivery. The IVC diameter was measured during inspiration (IVCi) and expiration (IVCe). The maternal heart rate, blood pressure, and shock index (heart rate/systolic blood pressure) were also measured. The predictive value of these parameters for severe anemia (hemoglobin <7.0 g/dL) a day after delivery was evaluated via receiver operating characteristic (ROC) analyses. Results: Seven patients with severe anemia and 77 controls were included in the analysis. The area under the curve (AUC) for IVCi (0.905) and IVCe (0.926) was higher than that for the shock index (0.890), heart rate (0.874), or systolic blood pressure (0.752). Among the examined parameters, the best sensitivity was achieved by IVCe and systolic blood pressure (71.4%). Conclusions: The ultrasonographic measurement of the IVC diameter was found to be the most useful parameter in evaluating the actual maternal blood loss after delivery.


Assuntos
Hemorragia Pós-Parto/diagnóstico , Veia Cava Inferior/anatomia & histologia , Veia Cava Inferior/diagnóstico por imagem , Abdome/diagnóstico por imagem , Adolescente , Adulto , Anemia/complicações , Anemia/diagnóstico , Pressão Sanguínea , Estudos de Casos e Controles , Feminino , Humanos , Pessoa de Meia-Idade , Período Pós-Parto/fisiologia , Valor Preditivo dos Testes , Gravidez , Prognóstico , Índice de Gravidade de Doença , Ultrassonografia , Adulto Jovem
17.
Anesth Analg ; 128(3): 414-423, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-29944523

RESUMO

BACKGROUND: Rotational thromboelastometry (ROTEM) can provide clinical information in 10-20 minutes for guiding administration of fibrinogen, platelets, and fresh frozen plasma products. While ROTEM testing is well established for cardiac and other surgeries, it is less characterized for use in postpartum hemorrhage (PPH) patients. We wanted to determine if the earlier-measured ROTEM parameters (α-angle and amplitude at 10 minutes [A10]) could replace the later parameters (amplitude at 20 minutes and maximum amplitude [maximum clot firmness {MCF}]) in all patient groups studied. We also correlated the A10 and α-angle of the EXTEM and FIBTEM tests to the fibrinogen levels and platelet counts in these patients. METHODS: We retrospectively analyzed 100 sets of EXTEM and FIBTEM results ordered on patients undergoing operations for PPH, patients in intensive care units (ICU), and those undergoing cardiothoracic surgery (cardiothoracic operating room [C/T OR]). We determined if the correlations among the various parameters were similar among the PPH, ICU, and C/T OR patients. RESULTS: As expected, the EXTEM A10 (A10EX) and FIBTEM A10 (A10FIB) correlated highly to the EXTEM MCF and FIBTEM MCF in all patient groups. The A10EX parameter correlated significantly to both fibrinogen and platelet levels, and the A10FIB correlated to the fibrinogen levels. The difference between the A10EX and the A10FIB (PLTEM) is related to platelet activity, and we found that the PLTEM and platelet count correlated highly for all 100 PPH patients (r = 0.80), C/T OR patients (r = 0.70), and ICU patients (r = 0.66), despite 4 high platelet counts with relatively low PLTEM values in the ICU group. The earlier-reported parameter EXTEM α angle (α-EX) is an excellent indicator of the A10EX, with an α-EX ≥65° (ie, normal) giving a >96% probability that the A10EX was ≥44 mm, and an α-EX value below 65 mm giving an 86% probability that the A10EX was <44 mm. CONCLUSIONS: The correlations among the ROTEM parameters for the PPH comparisons were equivalent to the C/T OR patients studied, and the A10EX and A10FIB could replace the MCF results in all patient groups. Also, the α-EX was an early indicator of the A10EX and had good correlations to the A10FIB and the fibrinogen in all patient groups. Finally, in a separate group of 62 comparisons, the FIBTEM α angle showed promise as an early indicator of the A10FIB and the fibrinogen levels.


Assuntos
Coagulação Sanguínea/fisiologia , Cuidados Críticos/métodos , Fibrinogênio/metabolismo , Ativação Plaquetária/fisiologia , Hemorragia Pós-Parto/sangue , Tromboelastografia/métodos , Feminino , Humanos , Cuidados Pós-Operatórios/métodos , Hemorragia Pós-Parto/diagnóstico , Distribuição Aleatória , Estudos Retrospectivos
18.
J Perinat Med ; 47(2): 195-199, 2019 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-30285948

RESUMO

Background Hemorrhage is a critical contributor to maternal morbidity but estimation of blood loss at delivery is frequently inaccurate. Due to this inaccuracy we sought to examine blood transfusion as a surrogate marker for morbidity in a large non-population based consecutive cohort. Methods A retrospective analysis of prospectively gathered data was carried out at two university institutions serving a heterogeneous urban obstetric population from January to December 2016. Data were analyzed to determine whether individual characteristics were associated with perinatal transfusion. Hematological indices and requirement for other blood products were also characterized. Results A total of 16,581 deliveries were recorded during the study and 1.7% (289/16,581) of the cohort required red cell transfusion. Those who received transfusion were more likely to be nulliparous, and to deliver <37 weeks' or >42 weeks' gestation. They were also more likely to have a macrosomic infant (birthweight >4 kg) and to have had a multiple pregnancy. Characteristics not associated with risk of transfusion included obesity [18% (52/289) vs. 15% (2445/16,292); P=0.18], and maternal age ≥35 years [28% (82/289) vs. 33% (5537/16,292); P=0.05]. Additional blood products were necessary in a small number of patients who received red cells. Conclusion The rate of transfusion in a contemporary Irish cohort has risen compared with previous data. Several variables associated with transfusion are consistent with older studies but importantly; maternal obesity and advanced maternal age are not associated with transfusion. These data may encourage the investment of resources in a population previously considered low-risk and, following future studies, to improve strategies aimed at limiting blood transfusion.


Assuntos
Cesárea , Hemorragia Pós-Parto , Adulto , Cesárea/métodos , Cesárea/estatística & dados numéricos , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Testes Hematológicos/métodos , Humanos , Irlanda/epidemiologia , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/terapia , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/terapia , Gravidez , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
19.
J Matern Fetal Neonatal Med ; 32(8): 1238-1244, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29113517

RESUMO

OBJECTIVE: To determine whether shock index (SI) is superior to traditional vital signs in predicting postpartum hemorrhage and need for intervention. METHODS: Retrospective case-control study in an academic tertiary-care county hospital. Forty-one consecutive postpartum hemorrhage (PPH) cases and 41 controls were frequency-matched by mode of delivery and maternal weight. We measured four criteria: heart rate, systolic blood pressure (SBP), SI (HR/SBP), and delta-SI (peak SI - baseline SI). Using received operating characteristic curves, we compared the discrimination performance of each criterion to predict PPH, transfusion, and surgical intervention, and identified thresholds with the strongest classification. RESULTS: SI ≤1.1 can be normal in peripartum. Peak SI and delta-SI were generally superior to heart rate (HR) and SBP in predicting PPH, transfusion, and surgical intervention. SI ≥1.143 and SI ≥1.412 were strong initial and "critical" thresholds. Delta-SI was the strongest classifier overall; both SI and delta-SI remain sensitive and specific when adjusted for potential confounders. CONCLUSIONS: SI and delta-SI appear to be superior to HR and SBP in predicting PPH and need for intervention. Utility of delta-SI should be prospectively explored.


Assuntos
Hemorragia Pós-Parto/diagnóstico , Índice de Gravidade de Doença , Choque/diagnóstico , Adulto , Pressão Sanguínea , Estudos de Casos e Controles , Feminino , Frequência Cardíaca , Humanos , Hemorragia Pós-Parto/fisiopatologia , Gravidez , Curva ROC , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto Jovem
20.
Semin Perinatol ; 43(1): 22-26, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30503399

RESUMO

Obstetrical hemorrhage is the most common cause of maternal mortality worldwide. Together with adequate surgical control and judicious transfusion of blood products, the use of pharmacological agents (e.g., tranexamic acid) and clotting factor concentrates (e.g., fibrinogen concentrates and prothrombin complex concentrates) results in improved hemostasis and decreased bleeding-associated mortality. Guidance in the administration of these agents with the use of viscoelastic testing will likely become standard of care in the near future.


Assuntos
Antifibrinolíticos/uso terapêutico , Fatores de Coagulação Sanguínea/uso terapêutico , Hemostáticos/uso terapêutico , Obstetrícia , Hemorragia Pós-Parto/terapia , Ácido Tranexâmico/uso terapêutico , Testes de Coagulação Sanguínea , Transfusão de Sangue/estatística & dados numéricos , Feminino , Humanos , Mortalidade Materna , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/prevenção & controle , Guias de Prática Clínica como Assunto , Gravidez
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