Obstetric pulmonary embolism and long-term cardiovascular symptoms: a cross-sectional study in Western Mexico.

OBJECTIVES: Pulmonary embolism (PE) is an important cause of maternal mortality. There are several guidelines for its diagnosis and management, but there is little information regarding follow-up and frequency of long-term complications. The aim of the study was to determine the frequency of long-term cardiovascular symptoms in patients who had obstetric PE. METHODS: Cross-sectional study including patients who had PE during pregnancy or the puerperium. A telephone interview was conducted at least one year after PE, to determine the frequency of cardiovascular symptoms, general health, and COVID-19 infection, considering the study was conducted during the 2020 pandemic. RESULTS: In five years (2015-2019) there were eleven patients with PE, two died during the acute phase, and the rest (nine) were alive and able to answer our interview. Cardiovascular symptoms were common (6, 67 %), the most frequent were fatigue, edema, and mild dyspnea. Four patients (44 %) had slight limitation of physical activity and one (11 %) had PE recurrence. Of the six symptomatic patients four had obesity and one was overweight. CONCLUSIONS: There is a high frequency of long-term cardiovascular symptoms in patients who had PE during pregnancy or the puerperium. Stronger evidence is needed to design a long-term care pathway after obstetric PE.

Factores asociados con mortalidad en la cirugía de control de daños en hemorragia obstétrica grave / Factors associated with mortality in damage control surgery in severe obstetric hemorrhage

OBJETIVO: Identificar los factores de riesgo relacionados con mortalidad en la cirugía de control de daños en pacientes con hemorragia obstétrica grave. MATERIALES Y MÉTODOS: Estudio descriptivo, retrospectivo y observacional efectuado en el Hospital Civil de Guadalajara Dr. Juan I. Menchaca. Se revisaron los expedientes de pacientes atendidas entre enero de 2016 y diciembre de 2019. Criterio de inclusión: pacientes con cirugía de control de daños por hemorragia obstétrica grave. Criterio de exclusión: pacientes sin histerectomía. Se obtuvieron las características clínicas y quirúrgicas y su desenlace mortal. Se utilizó estadística descriptiva e inferencial paramétrica. RESULTADOS: Se incluyeron 45 pacientes. La media de edad fue de 30 años (DE ± 6.7). El motivo más frecuente de la hemorragia fue la atonía uterina (15 de 45 pacientes). La media de sangrado fue de 3983 mL (DE ± 1695), la media de compresas 5.3 (DE ± 1.6). La mitad de la muestra tuvo complicaciones (22 de 45). Las pacientes con ruptura uterina y tromboembolismo tuvieron 9.7 veces más probabilidades de morir respecto al resto (p = 0.043). Se encontró asociación entre sepsis y muerte (p = 0.002). El sangrado (p = 0.034), los días de estancia intrahospitalaria (p = 0.022) y las cirugías (p = 0.028) se asociaron con mortalidad. CONCLUSIONES: Las cirugías, el sangrado, los días de estancia intrahospitalaria, la ruptura uterina, la sepsis y tromboembolia pulmonar se asociaron con incremento significativo de la mortalidad. (AU)

OBJECTIVE: To identify the risk factors related to mortality in damage control surgery in patients with severe obstetric hemorrhage. MATERIALS AND METHODS: Descriptive, retrospective, observational study at the Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Mexico. The records for the period between January 2016 and December 2019 were reviewed. Patients with damage control surgery for severe obstetric hemorrhage were included. Non-hysterectomized patients were excluded. The clinical and surgical characteristics and Its fatal outcome was considered descriptive and inferential parametric statistics. RESULTS: 45 patients were included. The mean age was 30 years (SD ± 6.7). The most frequent reason for bleeding was uterine atony (15/45). The mean of bleeding was 3983 (SD ± 1695) mL, the mean of compresses was 5.3 compresses (SD ± 1.6). Half of the complicated sample (22/45). Patients who had uterine rupture and thromboembolism were 9.7 times more likely to die than the rest (p = 0.043). In addition, an association was found between patients who had sepsis and died (p = 0.002). Bleeding (p = 0.034), days of hospital stay (p = 0.022), and number of surgeries (p = 0.028) were associated with mortality. CONCLUSIONS: The number of surgeries, bleeding, the days of hospital stay, uterine rupture, as well as the patients who suffer the following complications; sepsis, pulmonary thromboembolism, were associated with a significant increase in mortality.(AU)

Concentraciones de 25-hidroxivitamina D en embarazadas con y sin diabetes gestacional / Levels of 25-hydroxyvitamin D in pregnant womens with and without gestational diabetes mellitus

Resumen Objetivo: Comparar las concentraciones de 25-hidroxivitamina D (25[OH]D) en pacientes con y sin diabetes gestacional. Materiales y métodos: Estudio observacional, transversal y analítico consistente en la toma de muestras sanguíneas para determinar y comparar las concentraciones de 25-hidroxivitamina D. El tamaño de la muestra se determinó previamente con base en una prevalencia de 35% para la deficiencia de vitamina D, un error alfa de 0.05 y un error beta de 0.80. Resultados: Se reclutaron 784 embarazadas, 394 con diabetes gestacional y 390 sin este padecimiento. En este último grupo 51% (n = 199) tuvieron concentraciones suficientes, 33% (n = 129) concentraciones insuficientes y 16% (n = 62) concentraciones deficientes. En el grupo de mujeres con diabetes gestacional, 12% (n = 47) tuvieron concentraciones suficientes, 67% (n = 264) concentraciones insuficientes y 21% (n = 83) concentraciones deficientes. Los resultados obtenidos muestran que 88.9% (n = 350) de las mujeres con diabetes gestacional tenían concentraciones inferiores a 30 ng/mL vs 48.5% (n = 189) del grupo sin diabetes gestacional (p < 0.00001; RM: 7.69; IC95%: 5.3-11). Conclusiones: Las concentraciones inferiores a 30 ng/mL de vitamina D total son más frecuentes en pacientes con diabetes gestacional.

Abstract Objective: To compare the levels of vitamin (25[OH]D) between patients with or without gestational diabetes. Materials and methods: Analytical cross-sectional study that consisted in taking blood samples to determine and compare the concentrations of (25[OH]D) vitamin D. The sample size was previously determined considering a prevalence of 35% for vitamin D deficiency, an alpha error of 0.05 and a beta error of 0.80 for which 784 pregnant women were recruited, 394 patients with gestational diabetes and 390 without gestational diabetes. Results: In the group of patients without gestational diabetes, 51% (n = 199) had sufficient levels, 33% (n = 129) insufficient levels and 16% (n = 62) deficient levels. In the group of patients with gestational diabetes, 12% (n = 47) had sufficient levels, 67% (n = 264) insufficient levels and 21% (n = 83) deficient levels. The results obtained show that 88.9% (n = 350) of women with gestational diabetes present with levels lower than 30 ng/mL vs 48.5% (n = 189) of the group without gestational diabetes [p <0.00001 OR 7.69 (IC95%: 5.3 - 11)]. Conclusions: Levels below 30 ng/mL of total vitamin D are more frequent in patients with gestational diabetes.

Indicaciones del factor VII recombinante activado en hemorragia obstétrica grave / Use of recombinant activated Factor VII in severe obstetric hemorrhage

Resumen OBJETIVO: Describir la situación final de salud de las pacientes con hemorragia obstétrica grave (≥ 1000 mL) en quienes se indicó factor VII recombinante activado como parte del tratamiento e identificar las complicaciones atribuibles a este medicamento. MATERIALES Y MÉTODOS: Estudio retrospectivo, transversal y descriptivo efectuado en pacientes con hemorragia obstétrica grave atendidas en el Hospital Civil de Guadalajara Dr. Juan I Menchaca entre 2001 y 2017 y tratadas con factor VII recombinante activado. Se identificaron los antecedentes de importancia y se calculó la dosis promedio y cantidad de dosis de factor VII recombinante activado; se valoró la respuesta hemostática y se determinó si la diferencia en cantidad de sangrado, administración de hemoderivados y parámetros hematológicos antes y después de utilizar factor VII recombinante activado fue significativa. RESULTADOS: Se identificaron 10 pacientes en quienes se aplicó factor VII recombinante activado. La causa de hemorragia obstétrica grave fue atonía uterina en seis casos. La dosis promedio de factor VII recombinante activado fue de 91 mcg/kg. En 8 pacientes se administró una dosis y 2 dosis en 2 pacientes. En todas las pacientes se logró la hemostasia; el sangrado disminuyó significativamente posterior a la administración del factor VII recombinante activado (5075 vs 928 mL; p = 0.000) lo mismo que la cantidad de concentrados eritrocitarios trasfundidos (7 vs 3; p = 0.006). Una paciente no requirió histerectomía, otra tuvo tromboembolia pulmonar, que se trató sin problemas y ninguna paciente falleció. CONCLUSIÓN: El factor VII recombinante activado como hemostático en hemorragia obstétrica grave mostró resultados favorables y evitó la histerectomía en una paciente. Requiere vigilancia estrecha de las complicaciones trombóticas.

Abstract OBJECTIVE: To describe outcome of patients with severe obstetric hemorrhage (≥ 1000 mL) treated with rFVIIa as part of the management and to detect complications related to its use. MATERIALS AND METHODS: Retrospective, cross-sectional and descriptive study carried out in patients with severe obstetric hemorrhage treated at the Hospital Civil de Guadalajara Dr. Juan I Menchaca between 2001 and 2017 and treated with activated recombinant factor VII. We identified relevant antecedents, average dose and number of doses of rFVIIa, and hemostatic response. We determined if quantity of bleeding, administration of blood products and hematological parameters before and after using rFVIIa was significantly different. RESULTS: We identified ten patients with rFVIIa administration. The cause of severe obstetric hemorrhage was uterine atony in six cases. The average dose of rFVIIa was 91 mcg/kg; one dose was administered in eight patients and two doses in two patients. Hemostasis was achieved in all patients, bleeding decreased significantly after administration of rFVIIa (5075 mL vs 928 mL, p = 0.000) and the number of erythrocyte concentrates required 7vs 3, p = 0.006). One patient did not require a hysterectomy after rFVIIa administration; one patient presented pulmonary thromboembolism and recovered without complications, no patient died. CONCLUSION: rFVIIa administration as a hemostatic in severe obstetric hemorrhage had favorable results, preventing hysterectomy in one patient. Follow-up requires close monitoring of thrombosis.