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1.
Medicine (Baltimore) ; 98(50): e18378, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31852150

RESUMO

INTRODUCTION: The Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder. The obstetric course of women with KTS varies. Complications include bleeding, disseminated intravascular coagulation (DIC), thromboembolic events, etc. PATIENT CONCERNS:: Here, we report a case of late puerperal hemorrhage of a Chinese puerpera with KTS. The repeating severe hemorrhage, the DIC, and the Kasabach-Merrit syndrome made the treatment more difficult. DIAGNOSIS: KTS is a mixed malformation with a vascular component that is characterized by abnormal development of veins, capillaries, and lymphatics. Our patient was first diagnosed with KTS at the last trimester of pregnancy. INTERVENTIONS: Massive infusion of blood products, two laparotomies, as well as bilateral internal iliac artery embolization was carried out. OUTCOMES: Although the patient survived from the life-threatening hemorrhage, she lost her uterus forever. CONCLUSION: An interdisciplinary cooperation of obstetrician, anesthesiologist, vascular surgeon, and intensive care physician is highly recommended. Prophylactic anticoagulation is generally advised in the gestational and postpartum period.


Assuntos
Síndrome de Klippel-Trenaunay-Weber/complicações , Hemorragia Pós-Parto/terapia , Adulto , Transfusão de Sangue , Feminino , Humanos , Histerectomia , Síndrome de Klippel-Trenaunay-Weber/fisiopatologia , Hemorragia Pós-Parto/etiologia , Gravidez
2.
Vox Sang ; 114(8): 861-868, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31587289

RESUMO

BACKGROUND: Blood transfusion is suggested to be immunosuppressive in surgical patients. However, the immunomodulatory effect of blood transfusion in obstetric patients with massive haemorrhage remains unknown. METHODS: Three hundred and fifty-five patients at active labour in the obstetric department were enrolled, and clinical characteristics were extracted from electrical medical records, inpatient notes, anaesthesia notes and discharge summaries. The transfused blood products included RBC, FFP and PLTs. RT-PCR was used to quantify gene expression in the blood samples, and the Spearman rank correlation coefficient was used to test correlation. RESULTS: Among the 355 patients, 138 received a diagnosis of obstetric haemorrhage and were treated with blood transfusion. The risk factors for blood transfusion included maternal age, gestational age, preterm labour and instrumental delivery. The infants delivered by the transfusion group had significantly lower birthweight and 1- and 5-min Apgar scores. Most importantly, blood transfusion is associated with a broad suppression of Th cells and an increased IL-10 response. CONCLUSIONS: Our results show that blood transfusion is associated with immunomodulation in obstetric haemorrhage patients, suggesting more stringent criteria for blood transfusion should be taken into account in the obstetric haemorrhage patients.


Assuntos
Imunomodulação , Hemorragia Pós-Parto/terapia , Reação Transfusional/imunologia , Adulto , Transfusão de Sangue/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Gravidez , Reação Transfusional/epidemiologia
4.
J Med Eng Technol ; 43(4): 248-254, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31478761

RESUMO

Postpartum haemorrhage (PPH), the leading cause of maternal mortality, is particularly problematic in low resource settings where access to safe blood supplies and definitive medical treatment is limited. We describe the continued development of an autotransfusion device designed to treat PPH by collection, filtration and infusion of maternal blood. Previous study has demonstrated that the device effectively moves blood through a filtration apparatus and removes up to 97% of aerobic bacteria but had poor anaerobic bacteria reduction. In this study, we investigate the filtration efficacy of the device using configurations comprised of three different leukocyte depletion filter designs: the Pall Leukoguard RS leukocyte reduction filter (PLRF), the Haemonetics BPF4™ (BPF4) leukocyte reduction filter, and the Haemonetics SCRC Leukotrap® (SCRC) filter. All configurations performed well with reductions ranging from 49 to 98%. Configurations containing 2 Haemonetics SCRC Leukotrap®filters (configuration 5 and 6) consistently reduced anaerobic bacteria by at least 73%. These results indicate that utilising a combination of SCRC and PLRF filters confers a high level of microbial filtration with improved removal of anaerobic organisms.


Assuntos
Transfusão de Sangue Autóloga/instrumentação , Filtração/instrumentação , Bactérias Anaeróbias , Feminino , Humanos , Leucócitos , Hemorragia Pós-Parto/terapia , Gravidez
5.
BJOG ; 126(13): 1577-1586, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31483935

RESUMO

OBJECTIVE: To estimate incidence, trends over time, and risk factors for massive blood transfusions in obstetric patients. A secondary aim was to evaluate transfusion ratios in relation to massive transfusion. DESIGN: Population-based cohort. SETTING: Five hospitals, in the Stockholm County, Sweden, from 1990 to 2011. POPULATION: All women that gave birth in Stockholm county, Sweden, and who received blood transfusions postpartum between 1990 and 2011. METHODS: Data on pregnancies and deliveries from the Swedish National Medical Birth Registry was cross-linked to the Stockholm transfusion database. Massive blood transfusion was defined as the transfusion of ≥10 units of red blood cells from partus through the next day. MAIN OUTCOME MEASURES: Main primary outcome was massive blood transfusion postpartum. RESULTS: Our cohort comprised 517 874 deliveries. Massive blood transfusion occurred in 277 women, for an incidence of 5.3 per 10 000 deliveries, and increased by 30% (P < 0.001) between the first and the second half of the study period. Major risk factors apparent before delivery were abnormal placentation (odds ratio [OR] 41; 95% CI 29.3-58.1), pre-eclampsia/placental abruption (OR 4; 95% CI 2.8-5.6), and previous caesarean delivery (OR 4; 95% CI 3.1-6.0). Risk factors at time of delivery were uterine rupture, atonic uterus, and caesarean delivery (OR 38, 17, and 3, respectively). CONCLUSION: We found an increasing trend in the postpartum rate of massive transfusion. Women with abnormal placentation were found to have the highest increased risk. Improved antenatal awareness of these women at risk might improve management and reduce the rate of massive transfusion. TWEETABLE ABSTRACT: Risk of massive blood transfusion in obstetric patients increases with placental complications and prior caesarean section.


Assuntos
Transfusão de Sangue , Cesárea/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Hemorragia Pós-Parto/epidemiologia , Descolamento Prematuro da Placenta/epidemiologia , Adulto , Transfusão de Sangue/estatística & dados numéricos , Cesárea/efeitos adversos , Parto Obstétrico/efeitos adversos , Feminino , Inquéritos Epidemiológicos , Humanos , Histerectomia/estatística & dados numéricos , Incidência , Placenta Acreta/epidemiologia , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/terapia , Gravidez , Fatores de Risco , Suécia/epidemiologia , Inércia Uterina/epidemiologia , Inércia Uterina/terapia
6.
BJOG ; 126(13): 1612-1621, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31410966

RESUMO

OBJECTIVE: To assess the effectiveness of introducing condom-catheter uterine balloon tamponade (UBT) for postpartum haemorrhage (PPH) management in low- and middle-income settings. DESIGN: Stepped wedge, cluster-randomised trial. SETTING: Eighteen secondary-level hospitals in Uganda, Egypt and Senegal. POPULATION: Women with vaginal delivery from October 2016 to March 2018. METHODS: Use of condom-catheter UBT for PPH management was introduced using a half-day training and provision of pre-packaged UBT kits. Hospitals were randomised to when UBT was introduced. The incident rate (IR) of study outcomes was compared in the control (i.e. before UBT) and intervention (i.e. after UBT) periods. Mixed effects regression models accounted for clustering (random effect) and time period (fixed effect). MAIN OUTCOME MEASURES: Combined IR of PPH-related invasive surgery and/or maternal death. RESULTS: There were 28 183 and 31 928 deliveries in the control and intervention periods, respectively. UBT was used for 9/1357 and 55/1037 women diagnosed with PPH in control and intervention periods, respectively. PPH-related surgery or maternal death occurred in 19 women in the control period (IR = 6.7/10 000 deliveries) and 37 in the intervention period (IR = 11.6/10 000 deliveries). The adjusted IR ratio was 4.08 (95% confidence interval 1.07-15.58). Secondary outcomes, including rates of transfer and blood transfusion, were similar in the trial periods. CONCLUSIONS: Introduction of condom-catheter UBT in these settings did not improve maternal outcomes and was associated with an increase in the combined incidence of PPH-related surgery and maternal death. The lack of demonstrated benefit of UBT introduction with respect to severe outcomes warrants reflection on its role. TWEETABLE ABSTRACT: Stepped wedge trial shows UBT introduction does not reduce the combined incidence of PPH-related surgery or death.


Assuntos
Mortalidade Materna/tendências , Hemorragia Pós-Parto/terapia , Tamponamento com Balão Uterino/instrumentação , Adulto , Análise por Conglomerados , Preservativos , Egito , Feminino , Recursos em Saúde , Humanos , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Senegal , Uganda
7.
Eur J Obstet Gynecol Reprod Biol ; 241: 66-70, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31446249

RESUMO

In this study, we present a noninvasive procedure of bilateral cervix apex clamping (BCAC) procedure to control refractory postpartum hemorrhage (PPH) in vaginal delivery as a new second line therapy for refractory PPH. The procedure clamps the anterior and posterior walls of the cervical apex using toothless ovum forceps to arrest bleedingafter the failure of the first line therapy for PPH. 44 women were performed BCAC to control persistent bleeding in 13,359 vaginal deliveries from 1 January 2016 to 31 May 2018. In all of the BCAC, it can reduce bleeding significantly. The bleeding speed after BCAC was far less than that before it (2.64 ± 4.99 ml/min vs 20.23 ± 9.40 ml/min P < 0.001). The blood loss after BCAC was less than that before it (146.57 ± 170.83 vs 797.84 ± 200.73 ml P < 0.001). 41 (93.2%) BCACsucceeded and 3(6.8%) failed turned to intrauterine balloon tamponade, 2 succeeded and 1 failed turned to hysterectomy. In the successful group the bleeding speed after the BCAC was 1.38 ± 0.99 ml/min less than that 19.84 ± 6.27 ml/min in the failure group. (p < 0.001). The blood loss in the success group is also less than that in the failure ones after BCAC (107.29 ± 78.36mL vs 683.33 ± 202.07 ml P < 0.001) Even in the failure group, the bleeding speed also reduced after BCAC compared with that before BCAC (19.84 ± 6.27 vs 29.17 ± 7.12 ml/min p = 0.02). But the blood loss had no statistical difference (683.33 ± 202.07 vs 950 ± 132.29 ml p = 0.27) In all of the 13,359 vaginal deliveries, the incidence of PPH was 1.21% while the severe PPH was only 0.27%. The BCAC may reduce the incidence of severe PPH (0.27%) and also can reduce the necessity of IUBT (3/13,359 0.22‰), uterine artery embolization (UAE) (0/13,359) and even the exploratory laparotomy hysterectomy (1/13,359). Because it is effective, convenient, cheap and noninvasive, so we think it can be used as a new second line noninvasive treatment for PPH.


Assuntos
Procedimentos Cirúrgicos Obstétricos/métodos , Hemorragia Pós-Parto/terapia , Adulto , Colo do Útero , Constrição , Feminino , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Procedimentos Cirúrgicos Obstétricos/estatística & dados numéricos , Gravidez , Estudos Retrospectivos , Adulto Jovem
9.
Eur J Obstet Gynecol Reprod Biol ; 240: 151-155, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31284089

RESUMO

BACKGROUND: Postpartum hemorrhage (PPH) is a major cause of maternal death worldwide. Management of PPH includes the administration of uterotonics, and intrauterine packing techniques. OBJECTIVE: In this study the effectiveness and safety of chitosan covered gauze versus a balloon tamponade for managing severe PPH should be assessed. STUDY DESIGN: This retrospective cohort study was conducted at the Department of Obstetrics, Charité, university hospital Berlin, between October 2016 and June 2018. Women with PPH were treated according to management guidelines. When bleeding persisted, we applied additional uterine packing with either chitosan covered gauze or a balloon tamponade. The primary outcome was uterine bleeding termination without additional surgical interventions. Secondary outcomes included the amount of blood loss, the amount of blood transfusions and maternal complications. RESULTS: Among the 78 patients included in this study, 47 (60.3%) received chitosan covered gauze tamponade and 31 (39.7%) received a balloon tamponade. The major reason for PPH was atonic bleeding, no statistically significant group differences were observed. With respect to the outcomes monitored, the groups were not significantly different in postpartum vital signs, hemoglobin levels, blood loss, admission to intensive care unit, or inflammation parameters. However, three patients in balloon tamponade group required a hysterectomy. No hysterectomy was required in gauze group. CONCLUSION: Chitosan covered gauze is an excellent option for treating PPH, it appeared to be at least equivalent to the balloon tamponade, in our experience particularly suitable for atony or placenta bed bleeding after spontaneous delivery or during cesarean sections, in cases of lower uterine segment atony, placenta previa bed bleeding, and/or coagulopathy.


Assuntos
Quitosana , Hemorragia Pós-Parto/terapia , Tamponamento com Balão Uterino/métodos , Adulto , Bandagens , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
10.
Transfus Apher Sci ; 58(4): 412-415, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31285133

RESUMO

Patient blood management (PBM) aims to reduce red blood cell transfusion, minimize preoperative anemia, reduce intraoperative blood loss as well as optimize hemostasis, and individually manage postoperative anemia. Benefits include improved clinical outcome with a reduction in patient morbidity and mortality, but also lower hospital costs and shorter hospital length of stay. To date, it has been successfully implemented in several medical specialties, such as cardiac, trauma and orthopedic surgery. In obstetrics, postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality. PBM has the potential to improve outcome of mother and child. However, pregnancy and childbirth pose a special challenge to PBM, and several adaptations compared to PBM in elective surgery are necessary. To date, awareness of the clinical advantages of PBM among obstetricians and midwifes regarding PBM and its concept in PPH is limited. In the following review, we therefore aim to present the current status quo in PBM in obstetrics and its challenges in the clinical routine.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Parto Obstétrico , Procedimentos Cirúrgicos Eletivos , Hemostasia , Hemorragia Pós-Parto/terapia , Perda Sanguínea Cirúrgica/mortalidade , Feminino , Humanos , Mortalidade Materna , Hemorragia Pós-Parto/mortalidade
11.
Best Pract Res Clin Obstet Gynaecol ; 61: 130-142, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31285175

RESUMO

Postpartum haemorrhage contributes to 25% of maternal deaths worldwide, rising to 40% in sub-Saharan Africa. Treatment of postpartum haemorrhage-particularly for women with anaemia -requires timely, quality blood transfusions. There are a number of barriers to the provision of transfusion services, especially in low- and middle-income settings where the need is the greatest. These include unavailability of blood, unsafe blood, poor uptake of labour and delivery care, difficulties getting blood to transfusing facilities and poor documentation of patient information. Examples of innovative and practical solutions to overcome these barriers are highlighted.


Assuntos
Anemia , Transfusão de Sangue , Hemorragia Pós-Parto , África ao Sul do Saara , Anemia/etiologia , Feminino , Humanos , Hemorragia Pós-Parto/terapia , Gravidez
12.
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
13.
Rev Bras Enferm ; 72(3): 624-631, 2019 Jun 27.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31269125

RESUMO

OBJECTIVE: To construct and validate a clinical simulation setting for postpartum haemorrhage. METHOD: Quantitative research of methodological development, carried out from May to July of 2016 with 22 expert judges and 30 students. Analysis was performed from descriptive statistics, Binomial Test and Content Validity Index (CVI), considering CVI ≥ 80%. RESULTS: Setting construction was based on learning objectives, fidelity, evaluation tool, pre-setting activities and debriefing. Agreement, regarding its validity, was satisfactory in the 23 items analyzed. Items evaluated by judges had CVI> 0.90; in the evaluation by students, CVI was > 0.95. CONCLUSION: It was considered validated and suitable for training and use by nursing students. Other studies should be carried out in order to test its effectiveness in the construction of theoretical and practical knowledge of both nursing students and nurses during Permanent Education.


Assuntos
Hemorragia Pós-Parto/terapia , Treinamento por Simulação/normas , Adulto , Competência Clínica/normas , Feminino , Humanos , Pessoa de Meia-Idade , Simulação de Paciente , Gravidez , Treinamento por Simulação/métodos , Treinamento por Simulação/estatística & dados numéricos , Estudantes de Enfermagem/estatística & dados numéricos , Inquéritos e Questionários
14.
Int J Gynaecol Obstet ; 146(3): 339-343, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31206652

RESUMO

OBJECTIVE: To identify an inexpensive catheter suitable for uterine suction tamponade (UST) for postpartum hemorrhage and assess its functionality. METHODS: Randomized, single-center, double-blind feasibility study in East London, South Africa, among 45 women undergoing cesarean delivery between October and November 2018. A search of medical supply websites for catheters with predefined characteristics (inexpensive, flexible, wide-bore, circumferentially-arranged side apertures, rounded tip) identified the FG36 Levin stomach tube. During cesarean, the tube was placed in the uterus and connected transvaginally to a suction unit. Participants were randomized via a computer-generated random sequence to early (after uterine closure; n=24) or delayed (after skin closure; n=21) UST. RESULTS: The tube functioned well with respect to stability in the uterus and aspirating blood from the uterine cavity without blockage. Blood loss was similar between the groups (mean difference, 7.3 mL; 95% confidence interval, -61 to 75; P=0.433), as were secondary outcomes. There were no complications. Absolute effectiveness was not tested because there was no non-suction group. CONCLUSION: The FG36 Levin tube was found to be a suitable device for "suction-tube uterine tamponade". There was no difference in functionality between early and late UST. Future trials should assess the effectiveness of this approach for postpartum hemorrhage. CLINICAL TRIAL REGISTRATION: Registered in the Pan African Clinical Trial Registry as PACTR201809584199573.


Assuntos
Cesárea/efeitos adversos , Hemorragia Pós-Parto/terapia , Tamponamento com Balão Uterino/métodos , Adulto , Método Duplo-Cego , Estudos de Viabilidade , Feminino , Humanos , Hemorragia Pós-Parto/etiologia , Gravidez , Distribuição Aleatória , África do Sul , Sucção , Adulto Jovem
15.
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
16.
Prog. obstet. ginecol. (Ed. impr.) ; 62(3): 216-220, mayo-jun. 2019. tab
Artigo em Inglês | IBECS | ID: ibc-185001

RESUMO

Care process re-engineering combining patient in situ simulation with a systems-based approach has proven useful for improving the quality of care of patients with postpartum hemorrhage. However, new processes are not always transferred to clinical practice. We studied the degree of implementation of a new process and the reasons for introducing it. Professionals managing postpartum hemorrhages between January 15 and April 4, 2018 were interviewed and completed anonymous questionnaires. An ethnographic analysis of the workplace was also carried out. There was bleeding in 1.26% of deliveries, and the massive hemorrhage protocol was activated in 0.47%. The data collected were categorized according to a sociotechnical health system-based approach, including human, social and organizational factors, as well as clinical, technical, and architectural aspects. All participants interviewed found the new process and the flowchart useful for the management of hemorrhage. Only 12.5% of the incidents detected were clinical, and the rest were related to the system. Modifications introduced after the analysis included placing all drugs and instructions for the hemorrhage kit in a single location and signaling this in the flowchart, moving the flowchart to a more accessible location, and removing the old process protocol and disseminating the current one among new staff. The redesign of the postpartum hemorrhage care process combining in situ simulation with a sociotechnical health system-based approach is viable and well accepted by clinicians


La reingeniería de procesos asistenciales combinando la simulación clínica con un enfoque al sistema de trabajo se ha mostrado como un método útil para mejorar la calidad de la atención a la hemorragia posparto. Sin embargo, en ocasiones los nuevos procesos diseñados no se llevan a la práctica clínica. Se estudió el grado de implantación de un nuevo proceso y las causas que lo condicionaron. Se realizaron entrevistas individuales y cuestionarios anónimos a quienes asistieron las hemorragias postparto ocurridas entre el 15 enero y el 4 abril, 2018, y un análisis etnográfico del lugar de trabajo. Hubo sangrado en 1,26% de los partos y se activó el protocolo de hemorragia masiva en 0,47% de ellos. Los datos recogidos se categorizaron según el enfoque del diseño de sistemas socio-técnicos, incluyendo factores humanos, sociales y organizacionales, así como aspectos clínicos, técnicos y arquitectónicos. Todos los entrevistados encontraron útil el nuevo proceso, así como el flujograma para guiar el manejo de la hemorragia. El 12,5% de las incidencias detectadas fueron clínicas y el resto del sistema. Tras el análisis se introdujeron modificaciones incluyendo la colocación de todos los fármacos e instrucciones del kit de hemorragia en una única localización indicándolo en el flujograma, cambiar de ubicación el mapa del proceso, retirar el antiguo proceso y difundir el actual entre el nuevo personal. El rediseño del proceso de atención a la hemorragia masiva postparto combinando la simulación con un enfoque al sistema sanitario socio-técnico es viable y aceptado por los profesionales


Assuntos
Humanos , Feminino , Hemorragia Pós-Parto/terapia , Melhoria de Qualidade/organização & administração , Eficiência Organizacional/tendências , Avaliação de Processos e Resultados (Cuidados de Saúde)/métodos , Algoritmos , Unidades Hospitalares/organização & administração , Protocolos Clínicos
17.
Best Pract Res Clin Obstet Gynaecol ; 61: 143-155, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31103529

RESUMO

Mortality from postpartum haemorrhage (PPH) is higher in low resource settings due to increased incidence, higher case fatality rates and poor general health of the population. The challenges of managing PPH with limited resources are presented. Feasible interventions for preventing and treating PPH for home births are described. Given that maternity care is organised around levels of care in low resource settings, guidance is provided for what measures can be performed to manage PPH at different levels of care (clinic, community health centre, district hospital, regional and central hospital); and by which cadre (midwife, clinical officer, general doctor, specialist). Effective management of PPH requires on-going training and emergency drills. Reducing mortality from PPH is not possible without available urgent transport from home to facility and between levels of care. In addition, the essential building blocks of the health system must be functional to enable effective management of PPH.


Assuntos
Recursos em Saúde , Parto Domiciliar , Tocologia , Hemorragia Pós-Parto , Feminino , Humanos , Incidência , Hemorragia Pós-Parto/prevenção & controle , Hemorragia Pós-Parto/terapia , Gravidez
18.
Int J Gynaecol Obstet ; 146(2): 231-237, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31081140

RESUMO

OBJECTIVE: To examine the association between the use of invasive treatments for postpartum hemorrhage and the risk of sepsis and severe sepsis. METHODS: Secondary data analysis of the WOMAN randomized controlled trial, including 20 060 women with postpartum hemorrhage in 21 countries. Logistic regression with random effects was used. RESULTS: The cumulative incidence was 1.8% for sepsis and 0.5% for severe sepsis. All-cause mortality was 40.4% in women with severe sepsis versus 2.2% for women without. After adjusting for bleeding severity and other confounders, intrauterine tamponade, hysterectomy, and laparotomy increased the risk of sepsis (aOR 1.77 [95% CI 1.21-2.59], P=0.004; aOR 1.97 [95% CI 1.49-2.65], P<0.001; and aOR 6.63 [95% CI 4.29-10.24], P<0.001, respectively) and severe sepsis (aOR 2.60 [95% CI 1.47-4.59], P=0.002; aOR 1.97 [95% CI 0.83-2.46], P=0.033; and aOR 5.35 [95% CI 2.61-10.98], P<0.001, respectively). CONCLUSION: In this secondary data analysis, certain invasive treatments for postpartum hemorrhage appear to increase the risk of sepsis. Further research is needed to confirm this finding and investigate the role of prophylactic antibiotics during these procedures. The harms and benefits of such interventions must be carefully weighed, both in treatment guidelines and during individual patient management. TRIAL REGISTRATION: ISRCTN76912190.


Assuntos
Hemorragia Pós-Parto/terapia , Sepse/mortalidade , Adulto , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Histerectomia/efeitos adversos , Incidência , Laparotomia/efeitos adversos , Modelos Logísticos , Hemorragia Pós-Parto/epidemiologia , Gravidez , Medição de Risco , Fatores de Risco , Sepse/etiologia , Embolização da Artéria Uterina/efeitos adversos , Adulto Jovem
19.
Br J Radiol ; 92(1099): 20180896, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31045432

RESUMO

OBJECTIVE: To assess the safety and efficacy of transcatheter arterial embolization (TAE) of the inferior mesenteric artery (IMA) for the management of post-partum hemorrhage (PPH). METHODS: A retrospective analysis was performed regarding eight patients (mean age, 34.4 y; age range, 31 - 40 y) who underwent TAE of the IMA for PPH between March 2001 and September 2018. Obstetric records, including maternal characteristics, clinical manifestations, complications, and clinical outcomes, as well as TAE details were obtained. RESULTS: All eight patients had primary PPH and the vaginal delivery mode. CT scans of two patients showed active bleeding from the lower uterus or hematoma and with the origin of contrast extravasation abutting the adjacent rectum. In seven patients, an aortogram or IMA arteriogram following persistent vaginal bleeding after sufficient embolization of the bleeding focus from the bilateral iliac arteries, found the bleeding focus of the IMA, while in one patient, the IMA bleeding focus was found at the second session 4 h after the first session. TAE of the IMA was technically successful in all eight patients and cessation of bleeding without repeated TAE or additional hemostatic surgery was achieved in all patients after TAE of the IMA. There were neither procedure-related complications nor bowel ischemia during follow-up. CONCLUSION: TAE of the IMA for PPH was safe and effective with successful hemostasis. Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries. ADVANCES IN KNOWLEDGE: Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.


Assuntos
Embolização Terapêutica/métodos , Artéria Ilíaca/diagnóstico por imagem , Artéria Mesentérica Inferior/diagnóstico por imagem , Artéria Mesentérica Inferior/fisiopatologia , Hemorragia Pós-Parto/terapia , Adulto , Angiografia por Tomografia Computadorizada/métodos , Feminino , Humanos , Artéria Ilíaca/fisiopatologia , Hemorragia Pós-Parto/diagnóstico por imagem , Estudos Retrospectivos , Resultado do Tratamento
20.
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
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