Portal de Boas Práticas em Saúde da Mulher, da Criança e do Adolescente

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Effect of early tranexamic acid administration on mortality, hysterectomy …

WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 May 27;389(10084):2105-2116. doi: 10.1016/S0140-6736(17)30638-4. Epub 2017 Apr 26. PubMed PMID: 28456509; PubMed Central PMCID: PMC5446563. Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and …

Jauniaux E, Bhide A, Kennedy A, Woodward P, Hubinont C, Collins S; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and screening. Int J Gynaecol Obstet. 2018 Mar;140(3):274-280. doi:10.1002/ijgo.12408. PubMed PMID: 29405319. Recent population studies have shown that placenta accreta spectrum (PAS) disorders remain undiagnosed before delivery in half1,2 to two-thirds of cases. In a series from specialist diagnostic units in the USA, around one-third of cases of PAS disorders were not diagnosed during pregnancy. Maternal mortality and morbidity are reduced when women with PAS disorders, particularly the invasive forms—placenta increta or percreta—deliver in a center of excellence by a multidisciplinary care team with experience in managing the surgical risks and perioperative challenges presented by these disorders.5–8 Transfer to a center of excellence, however, relies on both recognition of the women at risk of PAS disorders and on accurate prenatal diagnosis. Current prenatal diagnosis rests on subjective interpretation of "typical" sonographic findings or signs with two-dimensional (2D) grey-scale and color Doppler imaging. Many signs have been reported in the literature with varying descriptions as to their sensitivity and specificity. The published literature is difficult to interpret because of several problems in the definition, terminology, and diagnosis of this disorder.10 To improve consistency and allow appropriate comparison of different imaging markers, panels of experts have published consensus statements that aim to standardize the descriptions and minimum requirements for an ultrasound scan to diagnose PAS disorders.PAS disorders are a growing obstetric issue and with the continuous increase in cesarean deliveries more studies are being published yearly. The definitive diagnosis, however, can only be made clinically at delivery and should be confirmed by histopathology wherever possible. This chapter reviews the various prenatal diagnostic techniques described in the international literature for the diagnosis of PAS disorders. As abnormal placentation is a spectrum disorder including both abnormal adherence (placenta creta) and abnormal invasion (placenta increta and placenta percreta), the term PAS disorders is used here as the overarching descriptor of the whole condition

Strategy for Zero Maternal Deaths by Hemorrhage in Brazil: A Multidisciplinary …

Osanan GC, Padilla H, Reis MI, Tavares AB. Strategy for Zero Maternal Deaths by Hemorrhage in Brazil: A Multidisciplinary Initiative to Combat Maternal Morbimortality. Rev Bras Ginecol Obstet. 2018 Mar;40(3):103-105. doi: 10.1055/s-0038-1639587. Epub 2018 Apr 2. PubMed PMID: 29609191.Obstetric hemorrhage is one of the leading causes of preventable maternal deaths in the world. There are 14 million cases of postpartum hemorrhage and 140 thousand related deaths annually worldwide. There is also a large contingent of womenwho survive a postpartum hemorrhage event with related reproductive and emotional consequences. Postpartum hemorrhage stands out as the second major cause of maternal deaths in Brazil. However, it continues to be a leading cause of numerous preventable maternal deaths in manyareas of the country, especially the countryside and the Amazon region, where there is a low density of health care facilities, fewer health care professionals, and an inefficient logistic network for quickly obtaining blood supply. Maternal mortality is an indicator of a population’s living conditions and health care, and it also reflects the human development of a country. Almost all maternal deaths occur in developing countries. Low instruction levels, inadequate nutrition conditions, insufficient social support, and lack of access to health care are strongly associated with maternal deaths. In addition, maternal mortality is an indicator of inequity between the richest and the poorest, and it also reveals gender inequalities with in a society. Given this scenario,the acceleration of maternal mortality reduction was established as one of the priority global targets in the United Nation’s Sustainable Development Goals. The reduction in maternal morbidity and mortality has been widely sought,but despite ongoing efforts,the current results are still disappointing.

OPAS Recomendações assistenciais para hemorragia obstétrica

Organização Pan-Americana da Saúde. Recomendações assistenciais para prevenção, diagnóstico e tratamento da hemorragia obstétrica. Brasília: OPAS; 2018A Razão de Morte Materna – RMM global diminuiu cerca de 44% nos últimos 25 anos: saindo de uma RMM de 385 por 100 000 nascidos vivos em 1990 a uma RMM de 216 por 100.000 nascidos vivos em 2015. O Brasil não cumpriu o compromisso de chegar em 2015 com no máximo 35 óbitos maternos a cada 100 mil nascidos vivos. A mortalidade materna é um indicador das condições de vida e assistência em saúde de uma população e a quase totalidade das mortes, são evitáveis e ocorrem em países em desenvolvimento. A mortalidade materna ainda evidencia as desigualdades de gênero, tanto no acesso à educação, à nutrição, como no acesso à saúde e seu caráter prevenível, considerando a importância de se estabelecer ações intersetoriais que garantam a qualidade do acesso à saúde a toda população. A OPAS/OMS em sua representação no Brasil, em conjunto com o Ministério da Saúde apresentam a Estratégia Zero Morte Materna por Hemorragia – 0MMxH como esforço coletivo de gestores e profissionais de saúde para acelerar a redução da morbimortalidade grave no Brasil. A Estratégia 0MMxH é uma iniciativa do Centro Latino-Americano para Perinatologia, Saúde das Mulheres e Reprodutiva (CLAP/SMR) dedicada à prevenção da mortalidade materna por hemorragia pós evento obstétrico. A Estratégia também opera no sentido de dar maior poder de decisão às mulheres, para que seus direitos e suas preferências sejam respeitados. Um dos eixos principais desta Estratégia é fortalecer as capacidades dos profissionais da área da saúde em habilidades para controle das emergências obstétricas hemorrágicas. Complicações graves obstétricas requerem a atenção de profissionais da área da saúde bem treinados e para atingir esse objetivo, apoiamos o fortalecimento dos serviços de saúde, a eliminação das barreiras ao acesso e a garantia de disponibilidade de medicamentos essenciais e sangue seguro para transfusões. Neste sentido, espera-se que os profissionais treinados sejam mobilizados e treinem outros em seus municípios ou em seu estado. Queremos que o conhecimento e as técnicas que previnem mortes maternas difundam-se por todo o país.

WHO recommendations on antenatal care for a positive pregnancy experience

WHO. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization, 2016. ISBN 978 92 4 154991 2 Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for important healthcare functions, including health promotion, screening and diagnosis, and disease prevention. It has been established that, by implementing timely and appropriate evidence-based practices, ANC can save lives. Endorsed, by the UN Secretary-General, this is a comprehensive WHO guideline on routine ANC for pregnant women and adolescent girls. It aims to complement existing WHO guidelines on the management of specific pregnancy-related complications. The guidance aims to capture the complex nature of the issues surrounding ANC health care practices and delivery, and to prioritize person-centred health and well-being, not only the prevention of death and morbidity, in accordance with a human rights-based approach.

Pushing/bearing down methods for the second stage of labour

Lemos A, Amorim MM, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2015 Oct 9;(10):CD009124. doi: 10.1002/14651858.CD009124.pub2. Review. Update in: Cochrane Database Syst Rev. 2017 Mar 26;3:CD009124. PubMed PMID: 26451755. Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterus contraction. Currently, there is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on mother and fetus.This review is based on a total of 20 included studies that were of a mixed methodological quality.Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and double the risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no difference in the caesarean and instrumental deliveries, perineal laceration and episiotomy, and in the other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing. Futhermore, the adverse effects on maternal pelvic floor is still unclear.Therefore, there is insufficient evidence to justify routine use of any specific timing of pushing since the maternal and neonatal benefits and adverse effects of delayed and immediate pushing are not well established.For the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style or recommendation as part of routine clinical practice. Women should be encouraged to bear down based on their preferences and comfort.In the absence of strong evidence supporting a specific method or timing of pushing, patient preference and clinical situations should guide decisions.Further properly well-designed randomised controlled trials are required to add evidence-based information to the current knowledge. These trials should address clinically important maternal and neonatal outcomes and will provide more complete data to be incorporated into a future update of this review.

Position in the second stage of labour for women with epidural anaesthesia

Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD008070. doi: 10.1002/14651858.CD008070.pub2. Review. Update in: Cochrane Database Syst Rev. 2017 Feb 24;2:CD008070. PubMed PMID: 23440824. Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects.There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour. Future research should involve large trials of positions that women can maintain and predefined endpoints. One large trial is ongoing.

Selective versus routine use of episiotomy for vaginal birth

1: Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017 Feb 8;2:CD000081. doi: 10.1002/14651858.CD000081.pub3. Review. PubMed PMID: 28176333; PubMed Central PMCID: PMC5449575. To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births. In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby.The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.

Position in the second stage of labour for women without epidural anaesthesia

Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2012 May 16;(5):CD002006. doi: 10.1002/14651858.CD002006.pub3. Review. Update in: Cochrane Database Syst Rev. 2017 May 25;5:CD002006. PubMed PMID: 22592681. For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down have advantages for women delivering their babies. The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.

Diretriz Nacional de Assistência ao Parto Normal: Relatório de Recomendação

Brasil. Ministério da Saúde. Diretriz Nacional de Assistência ao Parto Normal: relatório de recomendação/ Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Gestão e Incorporação de Tecnologias em Saúde. – Brasília: Ministério da Saúde, 2016. 381 p. O nascimento no ambiente hospitalar se caracteriza pela adoção de várias tecnologias e procedimentos com o objetivo de torná-lo mais seguro para a mulher e seu filho ou filha. Se por um lado, o avanço da obstetrícia moderna contribuiu com a melhoria dos indicadores de morbidade e mortalidade materna e perinatais, por outro permitiu a concretização de um modelo que considera a gravidez, o parto e o nascimento como doenças e não como expressões de saúde, expondo as mulheres e recém-nascidos a altas taxas de intervenções, que deveriam ser utilizadas de forma parcimoniosa e apenas em situações de necessidade e não como rotina. Esse excesso de intervenções deixou de considerar os aspectos emocionais, humanos e culturais envolvidos no processo, esquecendo que a assistência ao nascimento se reveste de um caráter particular que vai além do processo de adoecer e morrer. Quando as mulheres procuram ajuda, além da preocupação sobre a sua saúde e a do seu filho ou filha, estão também em busca de uma compreensão mais ampla e abrangente da sua situação, pois para elas e suas famílias o momento da gravidez e do parto, em particular, é único na vida e carregado de fortes emoções. A experiência vivida por eles neste momento pode deixar marcas indeléveis, positivas ou negativas, para o resto das suas vidas. O escopo da Diretriz e as perguntas a serem respondidas foram definidas com a participação de um grupo ampliado de interessados (grupo consultivo), entre eles, sociedades e associações médicas, de enfermagem e das mulheres, agências reguladoras, pesquisadores, profissionais e conselhos de profissionais de saúde, além de áreas técnicas do Ministério da Saúde - da Mulher e da Criança - e a CONITEC. O documento resultante do consenso obtido pelo grupo ampliado, foi apresentado à CONITEC na 42 ª Reunião da CONITEC, realizada nos dias 02 e 03 de dezembro de 2015, onde os membros da CONITEC apreciaram a proposta da Diretriz do Parto Normal que será disponibilizada em consulta pública com recomendação preliminar favorável.

Perineal techniques during the second stage of labour for reducing perineal trauma

Aasheim V, Nilsen ABV, Reinar LM, Lukasse M.Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub3.Most vaginal births are associated with tr auma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including per ineal massage, warm or cold compresses, and perineal management techniques h ave been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques. Most studies did not report data on our secondary outcomes. We downgraded evidence for r isk of bias, inconsistency, and imprecision for all comparisons.

Principais Questões sobre DIU de cobre nas maternidades

O DIU é um método contraceptivo conhecido pelas mulheres, mas pouco utilizado. A oferta de DIU de cobre nas maternidades visa reduzir a gravidez não planejada e melhorar o acesso a esse método contraceptivo.