{"id":64294,"date":"2021-10-13T11:21:17","date_gmt":"2021-10-13T09:21:17","guid":{"rendered":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/?p=64294"},"modified":"2021-10-13T10:24:40","modified_gmt":"2021-10-13T08:24:40","slug":"hemorragia-postparto-tardia-a-proposito-de-un-caso-clinico","status":"publish","type":"post","link":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/hemorragia-postparto-tardia-a-proposito-de-un-caso-clinico\/","title":{"rendered":"Hemorragia postparto tard\u00eda. A prop\u00f3sito de un caso cl\u00ednico"},"content":{"rendered":"

Hemorragia postparto tard\u00eda. A prop\u00f3sito de un caso cl\u00ednico<\/strong><\/p>\n

Autora principal: Isabel Guerrero Guzm\u00e1n<\/p>\n

XVI; n\u00ba 19; 928<\/p>\n

Late postpartum hemorrhage. About a clinical case<\/strong><\/p>\n

Fecha de recepci\u00f3n: 12\/09\/2021<\/p>\n

Fecha de aceptaci\u00f3n: 11\/10\/2021<\/p>\n

Incluido en Revista Electr\u00f3nica de PortalesMedicos.com Volumen XVI. N\u00famero 19 \u2013\u00a0 Primera quincena de Octubre de 2021 – P\u00e1gina inicial: Vol. XVI; n\u00ba 19; 928<\/p>\n

AUTORES: <\/strong><\/p>\n

ISABEL GUERRERO GUZM\u00c1N. CARMEN CORRALES LOBATO.<\/p>\n

RESUMEN:<\/strong><\/p>\n

Mujer prim\u00edpara que acude a consulta de matrona de atenci\u00f3n primaria por sangrado vaginal durante sesenta d\u00edas tras ces\u00e1rea por embarazo gemelar bicorial-biamni\u00f3tico.<\/p>\n

Tras valoraci\u00f3n de constantes vitales y exploraci\u00f3n abdominal, recomiendo a la paciente acudir a urgencias del hospital para una valoraci\u00f3n m\u00e1s exhaustiva por parte de ginecolog\u00eda.<\/p>\n

Tras valoraci\u00f3n ginecol\u00f3gica y ecograf\u00eda vaginal visualizan retenci\u00f3n de co\u00e1gulos que necesita legrado evacuador.<\/p>\n

Se explica a la paciente los riesgos y beneficios, aceptando y firmando consentimiento.<\/p>\n

Tras el legrado evacuador la paciente sufre un shock hemorr\u00e1gico necesitando ingreso en Unidad de cuidados intensivos.<\/p>\n

PALABRAS CLAVE:<\/p>\n

Ces\u00e1rea, hemorragia, postparto, legrado. Shock hemorr\u00e1gico.<\/p>\n

ABSTRACT:<\/strong><\/p>\n

Primiparous woman who attended a primary care midwife for vaginal bleeding for sixty days after cesarean section for bicorial-biamniotic twin pregnancy.<\/p>\n

After evaluation of vital signs and abdominal examination, I recommend that the patient go to the hospital emergency room for a more exhaustive evaluation by the gynecologist.<\/p>\n

After gynecological evaluation and vaginal ultrasound, they visualized retention of clots that requires evacuator curettage.<\/p>\n

The risks and benefits are explained to the patient, accepting and signing consent.<\/p>\n

After the evacuator curettage, the patient suffered a hemorrhagic shock requiring admission to the intensive care unit.<\/p>\n

KEYWORDS:<\/p>\n

Caesarean section, hemorrhage, postpartum, curettage. Hemorrhagic shock.<\/p>\n

DESCRIPCI\u00d3N DEL CASO<\/p>\n

Mujer de 29 a\u00f1os que acude a urgencias por sangrado despu\u00e9s de ces\u00e1rea por no progresi\u00f3n de parto, en gestaci\u00f3n bicorial biamni\u00f3tica. En estudio ecogr\u00e1fico se aprecia imagen en fondo uterino sugestiva de co\u00e1gulo y BetaHCG de 80.2mUI\/ml.\u00a0 Se oferta legrado puerperal, que la paciente comprende y acepta, firmando consentimiento informado.<\/p>\n

En postoperatorio inmediato, encontr\u00e1ndose en servicio de reanimaci\u00f3n, la paciente presenta cuadro de taquicardia e hipotensi\u00f3n, acompa\u00f1ado de sangrado vaginal abundante.<\/p>\n

CASE DESCRIPTION<\/p>\n

29-year-old woman who came to the emergency room due to bleeding after cesarean section due to non-progression of labor, in bichorionic biamniotic pregnancy. An ultrasound study shows a fundus image suggestive of a clot and BetaHCG of 80.2mIU \/ ml. Puerperal curettage is offered, which the patient understands and accepts, signing informed consent.<\/p>\n

In the immediate postoperative period, while in the resuscitation service, the patient presented with tachycardia and hypotension, accompanied by abundant vaginal bleeding.<\/p>\n

ANAMNESIS Y EXPLORACI\u00d3N:<\/p>\n

Antecedentes familiares: sin inter\u00e9s.<\/p>\n

Antecedentes personales: Hipotiroidismo pregestacional en tratamiento con eutirox 50mg\/24h.<\/p>\n

No alergias medicamentosas conocidas.<\/p>\n

No refiere enfermedades m\u00e9dicas de inter\u00e9s.<\/p>\n

No h\u00e1bitos t\u00f3xicos.<\/p>\n

Grupo y RH: A POSITIVO.<\/p>\n

Tratamiento actual: Yodo para la lactancia materna y eutirox 50.<\/p>\n

Constantes: TA 120\/60. FC: 100LPM. Peso: 53kg. Talla: 158. IMC: 19.<\/p>\n

Antecedentes Gineco-obst\u00e9tricos:<\/p>\n

Formula obst\u00e9trica: G1C1.<\/p>\n

Menarquia: 13 a\u00f1os. FM 4\/28.<\/p>\n

exploraci\u00f3n:<\/p>\n

Ecograf\u00eda vaginal: Engrosamiento endometrial con imagen compatible con co\u00e1gulo, se realiza aspiraci\u00f3n de 200cc de sangre y se repite ecograf\u00eda persistiendo engrosamiento endometrial por lo que se programa legrado.<\/p>\n

ANAMNESIS AND EXPLORATION:<\/p>\n

Family history: uninteresting.<\/p>\n

Personal history: Pregestational hypothyroidism in treatment with euthyrox 50mg \/ 24h.<\/p>\n

No known drug allergies.<\/p>\n

It does not refer to medical illnesses of interest.<\/p>\n

No toxic habits.<\/p>\n

Group and HR: A POSITIVE.<\/p>\n

Current treatment: Iodine for breastfeeding and euthyrox 50.<\/p>\n

Constants: TA 120\/60. FC: 100LPM. Weight: 53kg. Size: 158. BMI: 19.<\/p>\n

Gyneco-obstetric history:<\/p>\n

Obstetric formula: G1C1.<\/p>\n

Menarche: 13 years. FM 4\/28.<\/p>\n

exploration:<\/p>\n

Vaginal ultrasound: endometrial thickening with an image compatible with a clot, an aspiration of 200cc of blood is performed and an ultrasound is repeated, persisting endometrial thickening, so curettage is programmed.<\/p>\n

EVOLUCI\u00d3N Y PRUEBAS COMPLEMENTARIAS:<\/p>\n

Se realiza legrado puerperal sin incidencias durante la intervenci\u00f3n.<\/p>\n

En el postoperatorio inmediato, encontr\u00e1ndose en el servicio de reanimaci\u00f3n, la paciente presenta un cuadro de hipotensi\u00f3n y taquicardia, acompa\u00f1ado de sangrado vaginal abundante. Se administra cuatro comprimidos de misoprostol 200 microgramos v\u00eda rectal, con adecuada respuesta remitiendo sangrado vaginal y constantes mantenidas.<\/p>\n

A las dos horas, comienzan de nuevo con sangrado vaginal abundante, hipotensi\u00f3n, taquicardia de 160lpm y mal estado general de la paciente, precisa de reanimaci\u00f3n con 2000ml de cristaloides. Realizan ecograf\u00eda abdominal, no visualiz\u00e1ndose liquido libre en pelvis ni en gotieras parietoc\u00f3licas.\u00a0 Abundantes co\u00e1gulos en \u00fatero y vagina. Se decide realizaci\u00f3n de legrado hemost\u00e1tico bajo visualizaci\u00f3n ecogr\u00e1fica. Se administra 20 UI de oxitocina, carboprost Intramuscular en dosis \u00fanica y colocaci\u00f3n de sonda Foley intrauterina como m\u00e9todo hemost\u00e1tico, consigui\u00e9ndose correcta hemostasia. Taponamiento vaginal que se mantiene 48 horas tras la intervenci\u00f3n y sondaje vesical permanente.<\/p>\n

Se canaliza v\u00eda central, se saca anal\u00edtica y pruebas cruzadas urgente.<\/p>\n

La paciente entra en situaci\u00f3n de shock hemorr\u00e1gico en quir\u00f3fano y precisa de activaci\u00f3n del protocolo de transfusi\u00f3n masiva y poli transfusi\u00f3n (cuatro concentrados de hemat\u00edes, 800 cc de plasma, un pool de plaquetas, 2 gramos de fibrin\u00f3geno y 1 gr de anchafibr\u00edn). Ingresa en UCI por cuadro hemorr\u00e1gico.<\/p>\n

Durante su estancia en UCI:<\/p>\n

Control anal\u00edtico con un descenso de plaquetas de 100000 a 70000. Caogulaci\u00f3n en rango.<\/p>\n

Gasometr\u00eda con Hb de 6,8, necesitando una nueva transfusi\u00f3n con 2 concentrados de hemat\u00edes y Hierro intravenoso.<\/p>\n

Se cursa Biopsia al servicio de anatomia patol\u00f3gica: Descripci\u00f3n macrosc\u00f3pica: fragmentos de tejido fibronecr\u00f3ticos parduzcos, que agrupados ocupan un volumen aproximado de 20 cc. Resultados de la biopsia: restos deciduo-coriales.<\/p>\n

La paciente evoluciona de forma favorable, retir\u00e1ndose sonda Foley intrauterina a las 48 horas. Tras tres d\u00edas de ingreso en UCI con evoluci\u00f3n favorable sin sangrado activo, pasa a sala de maternidad.<\/p>\n

EVOLUTION AND COMPLEMENTARY TESTS:<\/p>\n

Puerperal curettage was performed without incident during the intervention.<\/p>\n

In the immediate postoperative period, while in the resuscitation service, the patient presented a picture of hypotension and tachycardia, accompanied by abundant vaginal bleeding. Four 200 microgram misoprostol tablets were administered rectally, with an adequate response, remitting vaginal bleeding and constant sustained bleeding.<\/p>\n

Two hours later, they began again with abundant vaginal bleeding, hypotension, a tachycardia of 160 bpm and a poor general condition of the patient, requiring resuscitation with 2000 ml of crystalloids. They performed abdominal ultrasound, not visualizing free fluid in the pelvis or in parietocolic drops. Abundant clots in the uterus and vagina. It was decided to perform a hemostatic curettage under ultrasound visualization. 20 IU of oxytocin, intramuscular carboprost in a single dose and placement of an intrauterine Foley catheter are administered as a hemostatic method, achieving correct hemostasis. Vaginal tamponade that is maintained 48 hours after the intervention and permanent bladder catheterization.<\/p>\n

The central line is channeled, analytical and urgent crossmatches are taken out.<\/p>\n

Biopsy is taken at the pathological anatomy service: Macroscopic description: brownish fibronecrotic tissue fragments, which when grouped occupy an approximate volume of 20 cc. Biopsy results: deciduous-chorionic remains.<\/p>\n

The patient enters a situation of hemorrhagic shock in the operating room and requires activation of the massive transfusion and poly-transfusion protocol (four packed red blood cells, 800 cc of plasma, a pool of platelets, 2 grams of fibrinogen and 1 gram of broad fibrin). She is admitted to the ICU due to hemorrhagic symptoms.<\/p>\n

During your stay in ICU:<\/p>\n

Analytical control with a decrease in platelets from 100,000 to 70000. Caogulation in range.<\/p>\n

Blood gas with Hb of 6.8, requiring a new transfusion with 2 packed red blood cells and intravenous iron.<\/p>\n

The patient progressed favorably, withdrawing intrauterine Foley catheter 48 hours later. After three days of admission to the ICU with a favorable evolution without active bleeding, she went to the maternity ward.<\/p>\n

DISCUSI\u00d3N.<\/p>\n

El sangrado puerperal es una de las principales causas de morbimortalidad en la mujer.<\/p>\n

A d\u00eda de hoy hay pocos estudios sobre la hemorragia postparto tard\u00eda o secundaria, quiz\u00e1s por su baja asociaci\u00f3n con la mortalidad materna, pero s\u00ed tiene una alta morbilidad ya que puede tener grandes complicaciones y requerir hospitalizaci\u00f3n materna.<\/p>\n

La hemorragia postparto tard\u00eda o secundaria se define, seg\u00fan la SEGO, como el sangrado uterino excesivo que ocurre entre las 24 horas y las 12 semanas posteriores al parto.<\/p>\n

Las causas son multifactoriales. Es muy importante realizar un diagn\u00f3stico r\u00e1pido y conocer su causa para poder tratarla lo antes posible.<\/p>\n

Seg\u00fan la biograf\u00eda consultada las causas m\u00e1s comunes que pueden favorecer la Hemorragia postparto tard\u00eda son: la endometritis y la producida por retenci\u00f3n de restos placentarios, siendo a veces dif\u00edcil de diferenciar ya que en muchas ocasiones ambas causas van unidas.<\/p>\n

En el caso descrito anteriormente la causa de la hemorragia fue retenci\u00f3n de restos placentarios. Existen diferentes tratamientos para tratar la retenci\u00f3n placentaria, en este caso El legrado uterino es la t\u00e9cnica quir\u00fargica m\u00e1s utilizada. El misoprostol es dentro del tratamiento m\u00e9dico el f\u00e1rmaco m\u00e1s utilizado para favorecer la expulsi\u00f3n de los restos placentarios. Actualmente hay estudios que recomiendo la resecci\u00f3n de restos placentarios con resectoscopio ya que es una t\u00e9cnica que tiene menos complicaciones que el legrado tradicional.<\/p>\n

Es conveniente administrar antibioterapia de amplio espectro antes de la realizaci\u00f3n del legrado evacuador.<\/p>\n

Es muy frecuente las complicaciones tras legrados puerperales, entre ellas: evacuaci\u00f3n incompleta que requiere nuevos tratamientos quir\u00fargicos yvque incrementan la probabilidad de complicaciones, tal y como vemos en el caso anteriormente descrito.<\/p>\n

Los factores que pueden provocar la hemorragia postparto tard\u00eda son los mismas que provocan la hemorragia puerperal precoz, aunque se diferencian en la frecuencia de estos. (TABLA I)<\/p>\n

Como matronas debemos de tener en cuenta todas las complicaciones que puede haber en el postparto y hacer un buen seguimiento durante el puerperio desde las consultas de atenci\u00f3n primaria.<\/p>\n

DISCUSSION.<\/p>\n

Puerperal bleeding is one of the main causes of morbidity and mortality in women.<\/p>\n

To date, there are few studies on late or secondary postpartum hemorrhage, perhaps due to its low association with maternal mortality, but it does have a high morbidity since it can have major complications and require maternal hospitalization.<\/p>\n

\n

Late or secondary postpartum hemorrhage is defined, according to SEGO, as excessive uterine bleeding that occurs between 24 hours and 12 weeks after delivery.<\/p>\n

The causes are multifactorial. It is very important to make a quick diagnosis and know its cause so that it can be treated as soon as possible.<\/p>\n

According to the biography consulted, the most common causes that can favor late postpartum hemorrhage are: endometritis and that produced by retention of placental remains, being sometimes difficult to differentiate since both causes are often linked.<\/p>\n

In the case described above, the cause of the hemorrhage was retention of placental remains. There are different treatments to treat placental retention, in this case Uterine curettage is the most widely used surgical technique. Misoprostol is the most widely used drug in medical treatment to promote the expulsion of placental remains. Currently there are studies that recommend the resection of placental remains with a resectoscope since it is a technique that has fewer complications than traditional curettage.<\/p>\n

It is advisable to administer broad-spectrum antibiotic therapy before performing the evacuator curettage.<\/p>\n

Complications after puerperal curettage are very common, including incomplete evacuation that requires new surgical treatments and that increase the probability of complications, as we see in the case described above.<\/p>\n

The factors that can cause late postpartum hemorrhage are the same as those that cause early postpartum hemorrhage, although they differ in their frequency. (TABLE I)<\/p>\n

As midwives we must take into account all the complications that may occur in the postpartum period and do a good follow-up during the puerperium from the primary care consultations.<\/p>\n

ANEXO:<\/p>\n

TABLA I. ENTIDADES DESCRITAS COMO ETIOLOGIA DE LA HEMORRAGIA POSTPARTO TARD\u00cdA.<\/p>\n\n\n\n
\u2013\u00a0 Retenci\u00f3n de restos placentarios (RPOC)<\/p>\n

\u2013\u00a0 Subinvoluci\u00f3n del lecho placentario<\/p>\n

\u2013\u00a0 Lesiones del canal del parto<\/p>\n

\u2013\u00a0 Anormalidades de la placentaci\u00f3n<\/p>\n

\u2013\u00a0 Miomas uterinos submucosos<\/p>\n

\u2013\u00a0 Endometritis<\/p>\n

\u2013\u00a0 Inversi\u00f3n uterina subaguda y cr\u00f3nica<\/p>\n

\u2013\u00a0 Alteraciones de la coagulaci\u00f3n<\/p>\n

\u2013\u00a0 Coriocarcinoma<\/p>\n

\u2013\u00a0 Alteraciones vasculares:<\/p>\n

\u2022\u00a0 Seudoaneurisma de la arteria uterina<\/p>\n

\u2022\u00a0 Malformaci\u00f3n arteriovenosa uterina<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

BIBLIOGRAFIA<\/strong><\/p>\n

    \n
  1. Alvarez Silvares E, Canedo Carballeira EM, Due\u00f1as Carazo MB, Aguiar Couto R, \u00c1lvarez Men\u00e9ndez L, Mart\u00ednez Mart\u00ednez O et al. Encuesta Perinatal de la Sociedad Gallega de Obstetricia y Ginecolog\u00eda 2010-2011. Prog Obstet Ginecol 2014;57(3):109-6.<\/li>\n<\/ol>\n
      \n
    1. Organizaci\u00f3n Mundial de la Salud (OMS). Concentraciones de hemoglobina para diagnosticar la anemia y evaluar su gravedad. Ginebra, Organizaci\u00f3nMundial de la Salud, 2011. (Citada 31\/07\/2014). Disponible en: http:\/\/www.who.int\/vmnis\/indicators\/haemoglobin_es.pdf.<\/li>\n
    2. Belfort MA. Overview of postpartum hemorrhage. En: UpToDate, Barbieri RL, Lockwood CJ, editors, UpToDate, Waltham MA [consultado 27 Ene 2015). Disponible en: http:\/\/www.uptodate.com<\/li>\n
    3. Protocolo SEGO. Hemorragia postparto precoz (actualizado en 2006). Disponible en http:\/\/www.sego.es\/.<\/li>\n
    4. Mousa HA, Alfirevic Z. Treatments for primary postpartum haemorrhage. Cochrane Database of Systematic Rewiews. 2007.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

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