Morbilidad extrema (near-miss) en obstetricia. Revisión de la literatura

Abstract

RESUMEN. Objetivo:Presentar la evidencia científica más reciente referente a la definición, diagnóstico y consecuencias de morbilidad extrema en obstetricia (MEO). Metodología de búsqueda: Búsqueda en PubMed, The Cochrane Library, OVID, Science Direct, Google Académico, Artemisa, LILACS e Imbiomed de artículos publicados en inglés y español entre los años 2005 a 2018 con las siguientes palabras clave: severe maternal morbidity, near miss morbidity, severe acute maternal morbidity, obstetric near miss and maternal near miss. Se excluyeron estudios cualitativos. Resultados: La MEO (o near miss) se refiere a cualquier complicación aguda que puede presentarse en el embarazo, labor o hasta seis semanas después de haber concluido el embarazo, estas complicaciones ponen en riesgo la vida de la madre, pero no resulta en su muerte. Los indicadores de MEO fueron desarrollados con base a la incidencia y presencia de trastornos hemorrágicos, hipertensivos y otras alteraciones sistémicas y condiciones maternas graves que pueden tener un impacto en la salud de la madre. En la actualidad, se sugiere que el estudio de los indicadores de MEO son de más utilidad que los de muerte materna. Conclusiones: El ejercicio de la práctica médica con base en la mejor evidencia científica, el estudio y la mejora de la calidad de la práctica clínica, de la planificación familiar, la asesoría prenatal y los programas hospitalarios son estrategias que permitirán ayudar a disminuir los casos de MEO. ABSTRACT. Objective: To provide the most recent scientific evidence about definitions, diagnosis and consequences of severe maternal morbidity (SMM). Research methodology:We searched databases in PubMed, The Cochrane Library, OVID, Science Direct, Google Scholar, Artemisa, LILACS and Imbiomed from 2005 to 2018 with the following keywords: severe maternal morbidity, near miss morbidity, severe acute maternal morbidity, obstetric near miss and maternal near miss. The search was restricted to articles written in the English and Spanish language and published from 2005 to 2018. Qualitative studies were excluded. Results: SMM or maternal near miss event refers to any acute obstetric complication that immediately threatens a woman's survival but does not result in her death either by chance or because of hospital care she receives during pregnancy, labor or within six weeks of termination of pregnancy. The indicators for SMM were developed and based on the incidence and presence of hemorrhagic disorders, hypertensive disorders, other systemic disorders and severe maternal conditions which could have an impact on maternal health. Nowadays it is suggested that the study of indicators for SMM is a more useful indicator of obstetric care than mortality. Conclusions: Use of best evidence-based practices, studying and improving the effectiveness and quality of clinical practice, family planning, prenatal check-up, and hospital obstetric care programs are strategies that could help to reduce cases of SMM.

Use of Renal Replacement Therapy in Pregnant Women with Acute Kidney Injury or Chronic Kidney Disease: A Systematic Review

“…There is limited standardized data on the time of initiation, duration of therapy, or choice of modality in Pr-AKI; therefore, dialysis prescription needs to be individualized. 12,18,50 The method depends on the hemodynamic state and treatment availability since any dialysis modality can be used during pregnancy. Though there are no randomized trials that show benefits for a specific modality, intermittent HD is the most used technique; however, continuous RRT is necessary for the hemodynamically unstable patient.…”

“…[6][7][8] Of particular concern, the renal failure incidence in pregnant women can reach, depending on the etiology, up to 24%. 9 Pregnancy-related acute kidney injury (Pr-AKI) defines AKI during pregnancy, childbirth, or the puerperium; 10,11 its incidence has decreased dramatically in recent decades, reaching 1.6 to 6.3 per 10,000 pregnancies 10,12,13 . However, it remains high in developing countries, estimated between 4% and 26% of pregnancies.…”

“…[15][16][17][18] As in non-pregnant patients, the causes of AKI are divided into: prerenal, renal, and postrenal. 12,13,19 According to Vijayan et al, pregnancyrelated causes of AKI are preeclampsia, acute fatty liver of pregnancy (AFLP), HELLP syndrome, and thrombotic microangiopathies such as Thrombotic Thrombocytopenic Purpura (TTP) and atypical Hemolytic Uremic Syndrome (HUS). 20 Prerenal causes are usually due to hemodynamic alterations such as massive bleeding, miscarriage, amniotic fluid embolism, adrenocortical insufficiency, chorioamnionitis, hyperemesis gravidarum, pyelonephritis and puerperal sepsis, [12][13][14]16,19,21 Pr-AKI complications include low birth weight, miscarriage, premature delivery and stillbirth.…”

“…13,20 The Pr-AKI post-renal causes include hydronephrosis due to uterine compression, injury to the ureters or the bladder during cesarean section, ureteral obstruction by stones or tumor, mechanical changes induced by multiple gestations, polyhydramnios or fibroids, and bladder outlet obstruction. 12,14,16,20 There is a changing pattern of the Pr-AKI etiology, with a decrease in early pregnancy causes like miscarriage and puerperal sepsis and an increase in causes in late pregnancy due to hypertensive disorders and thrombotic microangiopathies. This change is partially thanks to advances in obstetric care and new maternal risk factors.…”

Hemofilia adquirida A en embarazo. Caso clínico de medicina crítica en obstetricia por morbilidad extrema y su abordaje transdisciplinario perioperatorio

“…Se reporta una incidencia de 1.3 a 1.5 casos por millón de personas por año, es de presentación bimodal correspondiendo el primer pico a mujeres en edad fértil y el segundo a adultos de la tercera edad con predominio en sexo masculino. En 1964, se descubrió que la fracción crioprecipitada del plasma contiene grandes cantidades de factor VIII y desde la década de 1970 se producen concentrados liofilizados de estos factores (1)(2)(3) .…”