Balones para uso en Hemorragia Post Parto

salud y guia de HPP

2. BALONES PARA EL MANEJO NO QUIRÚRGICO
DE LA HEMORRAGIA POSTPARTO

3. Objetivos
•Descripción de balones
•Indicaciones para su uso
•Aplicación y retiro de balones
•Evidencia para su utilización en HPP

4. ConsensusStatement
NationalPartnershipforMaternalSafety
ConsensusBundleonObstetricHemorrhage
ElliottK.Main,MD,DenaGoffman,MD,BarbaraM.Scavone,MD,LisaKaneLow,PhD,CNM,
DebraBingham,DrPH,RN,PatriciaL.Fontaine,MD,MS,JedB.Gorlin,MD,DavidC.Lagrew,MD,
andBarbaraS.Levy,MD
Hemorrhageisthemostfrequentcauseofseveremater-
nalmorbidityandpreventablematernalmortalityand
thereforeisanidealtopicfortheinitialnationalmaternity
patientsafetybundle.Thesesafetybundlesoutlinecritical
clinicalpracticesthatshouldbeimplementedinevery
maternityunit.Theyaredevelopedbymultidisciplinary
workgroupsoftheNationalPartnershipforMaternal
SafetyundertheguidanceoftheCouncilonPatientSafety
inWomen’sHealthCare.Thesafetybundleisorganized
intofourdomains:Readiness,RecognitionandPrevention,
Response,andReportingandSystemLearning.Although
thebundlecomponentsmaybeadaptedtomeetthere-
sourcesavailableinindividualfacilities,standardization
withinaninstitutionisstronglyencouraged.References
containsampleresourcesand“PotentialBestPractices”
toassistwithimplementation.
(ObstetGynecol2015;126:155–62)
DOI:10.1097/AOG.0000000000000869
O
bstetrichemorrhageisthemostcommonseri-
ouscomplicationofchildbirthandisthemost
preventablecauseofmaternalmortality.
1,2
Further-
more,recentdatasuggestthatratesofobstetric
hemorrhageareincreasingindevelopedcountries,
includingtheUnitedStates,
3
andthatratesof
hemorrhage-associatedseverematernalmorbidity
exceedthemorbiditiesassociatedwithotherobstetric
andmedicalconditions.
4,5
Standardized,comprehensive,multidisciplinary
programshavedemonstratedsignificantreductionsin
morbidity.
6,7
Therefore,aworkgroupofthePartner-
shipforMaternalSafety,withintheCouncilonPatient
SafetyinWomen’sHealthCareandrepresentingall
majorwomen’shealthcareprofessionalorganizations,
hasdevelopedanobstetrichemorrhagesafetybundle.
8
Thegoalofthepartnershipistheadoptionofthesafety
bundlebyeverybirthingfacilityintheUnitedStates.A
patientsafetybundleisasetofstraightforward,
evidence-basedrecommendationsforpracticeandcare
processesknowntoimproveoutcomes.
9
Suchabundle
isnotanewguideline,butratherrepresentsaselection
ofexistingguidelinesandrecommendationsinaform
thataidsimplementationandconsistencyofpractice.
Theconsensusbundleonobstetrichemorrhageisorga-
nizedintofouractiondomains:Readiness,Recognition
andPrevention,Response,andReportingandSystems
Learning.Thereare13keyelementswithinthesefour
actiondomains(Box1).Itisanticipatedthatfew,ifany,
hospitalswillhave100%oftheseelementsinplaceat
thestartofthisqualityimprovementprocess,andthis
documentshouldserveasachecklistfromwhichto
work.Low-resourcehospitalsshouldbeabletoaccom-
plishmostoftheserecommendations,but,ifsomeare
FromtheCaliforniaMaternalQualityCareCollaborative,Stanford,California;
theAmericanCollegeofObstetriciansandGynecologists,DistrictII,NewYork,
NewYork;theSocietyforObstetricAnesthesiaandPerinatology,Milwaukee,
Wisconsin;theAmericanCollegeofNurse-Midwives,SilverSpring,andthe
AmericanAssociationofBloodBanks,Bethesda,Maryland;theAssociationof
Women’sHealth,ObstetricandNeonatalNurses,andtheAmericanCongressof
ObstetriciansandGynecologists,Washington,DC;andtheAmericanAcademy
ofFamilyPhysicians,Leawood,Kansas.
BarbaraS.Levy,MD,isanemployeeoftheAmericanCongressofObstetricians
andGynecologists(ACOG).Allopinionsexpressedinthisarticlearetheauthors’
anddonotnecessarilyreflectthepoliciesandviewsofACOG.Anyremuneration
thattheauthorsreceivefromACOGisunrelatedtothecontentofthisarticle.
ThisarticleisbeingpublishedconcurrentlyintheJuly/August2015issue(Vol.44,
No.4)ofJournalofObstetric,Gynecologic,&NeonatalNursing,theJuly/
August2015issue(Vol.60,No.4)ofJournalofMidwifery&Women’s
Health,andtheJuly2015issue(Vol.121,No.1)ofAnesthesia&Analgesia.
Correspondingauthor:ElliottK.Main,MD,CaliforniaMaternalQualityCare
Collaborative,StanfordUniversity—MedicalSchoolOfficeBuilding,X2C22,
Stanford,CA94305;e-mail:[email protected].
FinancialDisclosure
Dr.GorlinisemployedbyInnovativeBloodResourcesandistheAmerican
AssociationofBloodBanks(AABB)LiaisontotheAmericanCollegeof
ObstetriciansandtheGynecologists,theAssociationofWomen’sHealth,Obstet-
ric,andNeonatalNurses(AWHONN),andtheCaliforniaMaternalQuality
CareCollaborative(CMQCCL).Theotherauthorsdidnotreportanypotential
conflictsofinterest.
©2015byTheAmericanCollegeofObstetriciansandGynecologists.Published
byWoltersKluwerHealth,Inc.Allrightsreserved.
ISSN:0029-7844/ 15
VOL.126,NO.1,JULY2015 OBSTETRICS&GYNECOLOGY155
CopyrightªbyTheAmericanCollegeofObstetricians
andGynecologists.PublishedbyWoltersKluwerHealth,Inc.
Unauthorizedreproductionofthisarticleisprohibited. Preparación
Cada unidad
Reconocimiento
y prevención
Cada paciente
Respuesta
Cada caso HPP
Reporte y
aprendizaje
Cada unidad
13 elementos claves de calidad y
seguridad
MainEK et al. ObstetGynecol2015 Jul;126(1):155-62.

5. P
Preparación
R
Respuesta
R
Reconocimiento
R
Reporte
•CarroyKitdeHPP
•Equipoderespuestarápidacon
sistemadealertatemprano
•Educaciónenprotocolosbasado
ensimulacióncondebriefing
•Protocolosdemanejodela
hemorragia obstétrica
estandarizadosyunificados,
deacuerdoaestadiosclínicos
yconlistasdechequeoConsensusStatement
NationalPartnershipforMaternalSafety
ConsensusBundleonObstetricHemorrhage
ElliottK.Main,MD,DenaGoffman,MD,BarbaraM.Scavone,MD,LisaKaneLow,PhD,CNM,
DebraBingham,DrPH,RN,PatriciaL.Fontaine,MD,MS,JedB.Gorlin,MD,DavidC.Lagrew,MD,
andBarbaraS.Levy,MD
Hemorrhageisthemostfrequentcauseofseveremater-
nalmorbidityandpreventablematernalmortalityand
thereforeisanidealtopicfortheinitialnationalmaternity
patientsafetybundle.Thesesafetybundlesoutlinecritical
clinicalpracticesthatshouldbeimplementedinevery
maternityunit.Theyaredevelopedbymultidisciplinary
workgroupsoftheNationalPartnershipforMaternal
SafetyundertheguidanceoftheCouncilonPatientSafety
inWomen’sHealthCare.Thesafetybundleisorganized
intofourdomains:Readiness,RecognitionandPrevention,
Response,andReportingandSystemLearning.Although
thebundlecomponentsmaybeadaptedtomeetthere-
sourcesavailableinindividualfacilities,standardization
withinaninstitutionisstronglyencouraged.References
containsampleresourcesand“PotentialBestPractices”
toassistwithimplementation.
(ObstetGynecol2015;126:155–62)
DOI:10.1097/AOG.0000000000000869
O
bstetrichemorrhageisthemostcommonseri-
ouscomplicationofchildbirthandisthemost
preventablecauseofmaternalmortality.
1,2
Further-
more,recentdatasuggestthatratesofobstetric
hemorrhageareincreasingindevelopedcountries,
includingtheUnitedStates,
3
andthatratesof
hemorrhage-associatedseverematernalmorbidity
exceedthemorbiditiesassociatedwithotherobstetric
andmedicalconditions.
4,5
Standardized,comprehensive,multidisciplinary
programshavedemonstratedsignificantreductionsin
morbidity.
6,7
Therefore,aworkgroupofthePartner-
shipforMaternalSafety,withintheCouncilonPatient
SafetyinWomen’sHealthCareandrepresentingall
majorwomen’shealthcareprofessionalorganizations,
hasdevelopedanobstetrichemorrhagesafetybundle.
8
Thegoalofthepartnershipistheadoptionofthesafety
bundlebyeverybirthingfacilityintheUnitedStates.A
patientsafetybundleisasetofstraightforward,
evidence-basedrecommendationsforpracticeandcare
processesknowntoimproveoutcomes.
9
Suchabundle
isnotanewguideline,butratherrepresentsaselection
ofexistingguidelinesandrecommendationsinaform
thataidsimplementationandconsistencyofpractice.
Theconsensusbundleonobstetrichemorrhageisorga-
nizedintofouractiondomains:Readiness,Recognition
andPrevention,Response,andReportingandSystems
Learning.Thereare13keyelementswithinthesefour
actiondomains(Box1).Itisanticipatedthatfew,ifany,
hospitalswillhave100%oftheseelementsinplaceat
thestartofthisqualityimprovementprocess,andthis
documentshouldserveasachecklistfromwhichto
work.Low-resourcehospitalsshouldbeabletoaccom-
plishmostoftheserecommendations,but,ifsomeare
FromtheCaliforniaMaternalQualityCareCollaborative,Stanford,California;
theAmericanCollegeofObstetriciansandGynecologists,DistrictII,NewYork,
NewYork;theSocietyforObstetricAnesthesiaandPerinatology,Milwaukee,
Wisconsin;theAmericanCollegeofNurse-Midwives,SilverSpring,andthe
AmericanAssociationofBloodBanks,Bethesda,Maryland;theAssociationof
Women’sHealth,ObstetricandNeonatalNurses,andtheAmericanCongressof
ObstetriciansandGynecologists,Washington,DC;andtheAmericanAcademy
ofFamilyPhysicians,Leawood,Kansas.
BarbaraS.Levy,MD,isanemployeeoftheAmericanCongressofObstetricians
andGynecologists(ACOG).Allopinionsexpressedinthisarticlearetheauthors’
anddonotnecessarilyreflectthepoliciesandviewsofACOG.Anyremuneration
thattheauthorsreceivefromACOGisunrelatedtothecontentofthisarticle.
ThisarticleisbeingpublishedconcurrentlyintheJuly/August2015issue(Vol.44,
No.4)ofJournalofObstetric,Gynecologic,&NeonatalNursing,theJuly/
August2015issue(Vol.60,No.4)ofJournalofMidwifery&Women’s
Health,andtheJuly2015issue(Vol.121,No.1)ofAnesthesia&Analgesia.
Correspondingauthor:ElliottK.Main,MD,CaliforniaMaternalQualityCare
Collaborative,StanfordUniversity—MedicalSchoolOfficeBuilding,X2C22,
Stanford,CA94305;e-mail:[email protected].
FinancialDisclosure
Dr.GorlinisemployedbyInnovativeBloodResourcesandistheAmerican
AssociationofBloodBanks(AABB)LiaisontotheAmericanCollegeof
ObstetriciansandtheGynecologists,theAssociationofWomen’sHealth,Obstet-
ric,andNeonatalNurses(AWHONN),andtheCaliforniaMaternalQuality
CareCollaborative(CMQCCL).Theotherauthorsdidnotreportanypotential
conflictsofinterest.
©2015byTheAmericanCollegeofObstetriciansandGynecologists.Published
byWoltersKluwerHealth,Inc.Allrightsreserved.
ISSN:0029-7844/ 15
VOL.126,NO.1,JULY2015 OBSTETRICS&GYNECOLOGY155
CopyrightªbyTheAmericanCollegeofObstetricians
andGynecologists.PublishedbyWoltersKluwerHealth,Inc.
Unauthorizedreproductionofthisarticleisprohibited.
MainEK et al. ObstetGynecol2015 Jul;126(1):155-62.

6. UNIDAD DE ALTA COMPLEJIDAD OBSTÉTRICA

JULIO / 2017 – V1. WC 854_H91

LISTA DE CHEQUEO HEMORRAGIA OBSTÉTRICA

Reconocimiento: Llamar por ayuda – Activar código rojo obstétrico.

DESIGNAR:
Líder Registro/lista de chequeo


ANUNCIAR:
Sangrado acumulado: Signos vitales:

Frecuencia cardiaca: Tensión arterial sistólica: Tiempo en minutos del sangrado:


Etapa 1:
Sangrado entre 500 a 1000 cc - Índice de choque de 0.9 - Tiempo de sangrado menor a 10 minutos

Pasos iniciales:
- Aplicar ABCD de reanimación.
- Asegurar dos accesos venoso 16G o 18G.
- Dar bolos de cristaloides 500 cc y evaluar
respuesta.
- Dar masaje uterino bimanual.
- Medir signos vitales cada 5 minutos.
- Insertar sonda urinaria.
- Tomar paraclínicos.

Medicamentos:
- Iniciar uterotónicos dosis de protocolo.

Banco de Sangre:
- Tomar hemoclasificación y pruebas cruzadas de
2 UGRE.

Acción:
- Determinar la etiología y tratar.

Oxitocina: 40 unidades en 500 de solución a 60 cc por
hora por bomba de infusión.

Metilergonovina: 0.2 miligramos IM cada 20 minutos las
dos primeras dosis y luego cada 4 horas hasta 5 dosis si
no hay hipertensión.

Misoprostol: 800 microgramos sublingual.

Ácido tranexámico: 1 gramo.


Tono: atonía uterina.
Trauma: cervical, vaginal o uterino.
Tejido: retención placentaria.
Trombina: coagulopatías o deficiencias.

Etapa 2:
Sangrado entre 1000 a 1500 cc - Índice de choque entre 0.9 y 1.3 - Tiempo de sangrado menor a 20 minutos


Pasos iniciales:
- Aplicar traje antichoque no neumático.
- Colocar el balón intrauterino (Bakri).
- Definir cirugía conservadora hemostática – B-Lynch.
- Solicitar gases arteriales, ácido láctico y fibrinógeno.
- Preparar quirófanos.
- Movilizar ayuda adicional.

Medicamentos:
- Continuar uterotónicos de etapa 1.
- Definir segunda dosis de ácido tranexámico.

Banco de Sangre:
- Obtener 2 UGRE (NO ESPERAR resultados de laboratorio, transfundir por clínica).
- Calentar 2 unidades de PFC.

Acción:
- Escalar rápidamente terapia con metas de hemostasia.

UNIDAD DE ALTA COMPLEJIDAD OBSTÉTRICA

JULIO / 2017 – V1. WC 854_H91


Etapa 3:
Sangrado mayor a 1500 cc - Índice de choque mayor a 1.3 - Tiempo de sangrado mayor a 20 minutos


Pasos iniciales:
- Aplicar traje antichoque no neumático.
- Dar bolos de cristaloides 500 cc y evaluar respuesta.
- Anunciar al equipo estado clínico: signos vitales, sagrado acumulado, etiología.
- Llevar a quirófanos.
- Preparar al equipo para histerectomía de emergencia.
- Pensar en cirugía de control de daños.
- Movilizar ayuda adicional.
- Desarrollar y anunciar plan.

Medicamentos:
- Continuar uterotónicos de etapa 1 y 2.

Banco de Sangre:
- Iniciar protocolo de transfusión masiva.
- Si hay coagulopatía clínica: administrar crioprecipitado o consultar para agentes adicionales.

Acción:
- Lograr hemostasia, intervención basada en etiología.


Etapa 4:
Colapso cardiovascular con choque hipovolémico profundo y coagulopatía

Pasos iniciales:

- Aplicar traje antichoque no neumático.
- Dar bolos de cristaloides 500 cc y evaluar
respuesta.
- Realizar cirugía de control de daños.
- Movilizar ayuda adicional – cirugía general si hay
disponibilidad.
- Manejo en Unidad de Cuidado Intensivo.

Medicamentos:
- Reanimación hemostática avanzada.

Banco de Sangre:
- Transfusión masiva agresiva simultánea.

Acción:
- Lograr hemostasia, intervención basada en
etiología.

Manejo post-hemorragia:

- Determinar disposición de la paciente.

- Hacer debriefing con el equipo.

- Hacer debriefing con la paciente.

- Hacer debriefing con la familia.

- Documentar intervenciones.




Listas de chequeo
Balones

8. Enfoque de las 4 t’s:
Tono Trauma Tejido Trombina
Indicaciones de los balones de taponamiento uterino
Deteneroreducirhemorragiasposterioresalpartoantefracasofarmacológico

9. Efectomecánicoque invierte el gradiente de presión desde el interior al
exterior de la pared uterina al superar la presión arterial sistémica
Efecto directo dela presión hidrostática del balón sobre las arterias
uterinas

10. La presión intraluminal del balón no debe superar la presión
sistolica de la paciente durante el manejo con el máximo
volumen de insuflación
Georgiou C. BJOG. 2010 Feb;117(3):295-303.
doi: 10.1111/j.1471-0528.2009.02436.x

11. Anthony K et al. Am J Perinatol Rep 2017;7:e86–e92
El balón ideal debe ser de facil y rápido proceso de inflado, con
la adecuada presión intraluminal de llenado y sin ruptura con el
promedio de volumen al que se somete

12. El mecanismo del control del
sangrado puede involucrar ademas
interacciones entre las interfaces
del endometrio y el balón,
alteraciones de patrones de flujo
del miometrio uterino, actividad
celular de la compresión
miometrial y el efecto oclusivo de
la compresión de las estructuras
vasculares secundaria a la
atenuación de la pared uterina

13. Al menos 315 artículos publicados
En los estudios observacionales (98% de los
estudios), la tasa de éxito para el control de
la hemorragia cuando se utiliza como
estrategia de segunda línea, esta reportada
entre el 75 al 96%
La tasa de éxito para evitar una histerectomía
esta entre el 80 al 90%

14. Suarez S et al Am J Obstet Gynecol.2020 Jan 6. pii: S0002-9378(19)32751-6
•UBTtieneunaaltatasadeéxitopara
tratarlaHPPgraveyparecesersegura.La
evidenciasobrelaeficaciayefectividad
deUBTdeestudiosaleatoriosyno
aleatoriosescontradictoria,conestudios
experimentalesquesugierenquenohay
ningúnefectobeneficiosoencontraste
conlosestudiosobservacionales.

15. La tasa de éxito global UBT agrupada
fue del 85,9% (IC 95%, 83,9-87,9).
Las tasas de éxito más altas
correspondieron a atonía uterina
(87.1%) y placenta previa (86.8%)
La tasa de éxito UBT fue menor en
partos por cesárea (81.7%) que en
partos vaginales (87.0%).
Suarez S et al Am J Obstet Gynecol.2020 Jan 6. pii: S0002-9378(19)32751-6

16. Un metanálisis de dos ensayos aleatorios que
compararon UBT versus no-UBT en HPP debido a
atonía uterina después del parto vaginal no
mostró diferencias significativas en el riesgo de
intervenciones quirúrgicas o muerte materna (RR
0,59; IC del 95%: 0,02-16,69)
Un metaanálisis de dos estudios antes y después
no aleatorizados mostró que la introducción de
UBT en los protocolos para el tratamiento de la
HPP grave disminuyó significativamente el uso de
embolización arterial
(RR 0,29; IC del 95%: 0,14-0,63).

17. Darwish AM et al. J Matern Fetal Neonatal Med. 2018 Mar;31(6):747-753.
doi: 10.1080/14767058.2017.1297407.

18. RISK
Etapa I Etapa II Etapa III
Menora 0.9Menora 0.9 0.9 a 1.6 Mayor a 1.7 Colapso
Etapa IVNormal
Burke TF et al. Int J Gynaecol Obstet. 2017 Oct;139(1):34-38.
doi: 10.1002/ijgo.12251.
•303 pacientes con HPP incontrolable en Sierra Leona, Kenya, Senegal y Tanzania
•57% de las pacientes en estadios avanzados de choque hipovolemico

19. Tasa de sobrevida:
•Choque hipovolemico Estadio III: 97%
•Choque hipovolemico Estadio IV: 86%
Burke TF et al. Int J Gynaecol Obstet. 2017 Oct;139(1):34-38.

20. 9 hospitales sin balón
10 hospitales con balón OriginalResearch
IntrauterineBalloonTamponadeforSevere
PostpartumHemorrhage
MathildeRevert,MSc,PatrickRozenberg,MD,JonathanCottenet,MSc,andCatherineQuantin,MD,PhD
OBJECTIVE:Tocomparetheratesofinvasiveprocedures
(surgicalorvascular)forhemorrhagecontrolbetween
aperinatalnetworkthatroutinelyusedintrauterine
balloontamponadeandanotherperinatalnetworkthat
didnotinpostpartumhemorrhagemanagement.
METHODS:Thispopulation-basedretrospectivecohort
studyincludedallwomen(72,529)deliveringbetween
2011and2012inthe19maternityunitsintwoFrench
perinatalnetworks:apilot(inwhichballoontamponade
wasused)andacontrolnetwork.Outcomeswere
assessedbasedondischargeabstractdatafromthe
nationalFrenchmedicalinformationsystem.General
andobstetriccharacteristicswereincludedintwosep-
aratemultivariatelogisticmodelsaccordingtothemode
ofdelivery(vaginalandcesarean)toestimatethe
independentassociationofthenetworkwithinvasive
procedures.
RESULTS:Invasiveprocedures(pelvicvesselligation,
arterialembolization,hysterectomy)wereusedin298
womenandin4.1per1,000deliveries(95%CI3.7–4.6).
Theproportionofwomenwithatleastoneinvasivepro-
cedurewassignificantlylowerinthepilotnetwork(3.0/
1,000vs5.1/1,000,P,.01).Amongwomenwhodelivered
vaginally,theuseofarterialembolizationwasalsosignif-
icantlylowerinthepilotthanthecontrolnetwork
(0.2/1,000vs3.7/1,000,P,.01)asitwasforthosewho
deliveredbycesarean(1.3/1,000vs5.7/1,000,P,.01).
Aftercontrollingforpotentialconfoundingfactors,the
riskofaninvasiveprocedureamongwomenwhodeliv-
eredvaginallyremainedsignificantlylowerinthepilot
network(adjustedoddsratio[OR]0.14,95%CI0.08–
0.27),butnotforwomenwhodeliveredbycesarean
(adjustedOR1.19,95%CI0.87–1.61).
CONCLUSION: Theuseofintrauterineballoontampo-
nadeinroutineclinicalpracticewasassociatedwith
asignificantlyloweruseofinvasiveproceduresfor
hemorrhagecontrolamongwomenundergoingvaginal
delivery.
(ObstetGynecol2018;0:1–7)
DOI:10.1097/AOG.0000000000002405
S
everepostpartumhemorrhageoccursin1–2%of
deliveriesinhigh-incomecountriesanditsfre-
quencyisincreasing.
1,2
Postpartumhemorrhageis
amongthemostcommoncausesofpregnancy-
relateddeathworldwide,
3
notablyintheUnited
States
4
andEurope.
5
Itremainstheleadingcauseof
maternalmortalityinFrance,whereitisresponsible
for18%ofmaternaldeaths;moreover,90%ofthese
deathsfrompostpartumhemorrhageareconsidered
avoidable.
6
Theinitialtreatmentofseverepostpartum
hemorrhageinvolvesuterinemassageanduterotonic
drugs.Whenthesefirst-linetreatmentsfail,second-
linetherapies,includinginvasiveproceduressuchas
arterialembolization,uterinecompressionsutures,
pelvicvesselligation,andhysterectomy,canbeused
individuallyorincombination.
7–10
Intrauterineballoontamponadehasemergedas
awidelyrecommendedtechniquetoavoidinvasive
procedures.
11,12
Thisnoninvasiveprocedureiseffec-
tiveforthemanagementofpostpartumhemorrhage
withasuccessratefrom83%to86%accordingtotwo
recentpublications.
13,14
Onlytwobefore-and-after
studiesinvestigatedchangesininvasiveprocedure
FromtheEA7285,VersaillesSaintQuentinUniversity,Versailles,the
DepartmentofObstetricsandGynecology,Poissy-SaintGermainHospital,
Poissy,andBiostatisticsandBioinformatics(DIM),UniversityHospital,Dijon,
BourgogneFranche-ComtéUniversity,Inserm,CIC1432,andDijonUniversity
Hospital,ClinicalInvestigationCenter,ClinicalEpidemiology/ClinicalTrials
Unit,Dijon,andBiostatistics,Biomathematics,Pharmacoepidemiologyand
InfectiousDiseases(B2PHI),INSERM,UVSQ,InstitutPasteur,Université
Paris-Saclay,Paris,France.
SupportedbyaresearchgrantfromtheDépartementdelaRechercheCliniqueet
duDéveloppement,AssistancePublique–HôpitauxdeParis.
Eachauthorhasindicatedthatheorshehasmetthejournal’srequirementsfor
authorship.
Correspondingauthor:CatherineQuantin,MD,PhD,CHUdeDijon—Service
deBiostatistiqueetd’InformatiqueMédicale—BP77908,21079DijonCEDEX,
France;email:[email protected].
FinancialDisclosure
Theauthorsdidnotreportanypotentialconflictsofinterest.
©2017byTheAmericanCollegeofObstetriciansandGynecologists.Published
byWoltersKluwerHealth,Inc.Allrightsreserved.
ISSN:0029-7844/ 18
CopyrightÓbyTheAmericanCollegeofObstetricians
andGynecologists.PublishedbyWoltersKluwerHealth,Inc.
Unauthorizedreproductionofthisarticleisprohibited.
VOL.0,NO.0,MONTH2018 OBSTETRICS&GYNECOLOGY1
Revert M et al. Obstet Gynecol 2018;0:1–7
Pacientes sometidas al menos a un procedimiento: 4.1/1,000; 95% CI 3.7–4.6

21. network,whichroutinelyusedintrauterineballoon
tamponade,thaninthecontrolnetwork.Afteradjust-
mentforthewomen’sgeneralandobstetriccharacter-
isticsandfororganizationalfactors,thepilotnetwork
wassignificantlyassociatedwithalowerriskofinva-
siveproceduresamongwomenundergoingvaginal
deliverybutnotthoseundergoingcesareandelivery.
Inasensitivityanalysisrestrictedtohemorrhagesre-
sultingfromatony,wefoundsimilarresults.
PublicationoftheFrenchguidelinesforpost-
partumhemorrhagemanagementin2004ledtoan
increaseinembolizationratesinanattempttoreduce
maternalmortalitybyobstetrichemorrhage,which
wasespeciallyhigh:1.6per100,000livebirthsin
2007–2009.
25
Theresultsofcohortstudiesinthegen-
eralpopulationshowmorefrequentrecourseto
second-linetreatmentsinFrancethaninotherindus-
trializedcountries.
26,27
Thisfindingsuggestsaflawin
themanagementofpostpartumhemorrhagebefore
anyinvasivetreatments.
28,29
Inabefore-and-afterstudyconductedinasingle
Frenchmaternityunit,Laasetal
13
showedthatinclud-
ingintrauterineballoontamponadeinaprotocolfor
themanagementofseverepostpartumhemorrhage
resultedinasignificantdecreaseintheembolization
rateaftervaginaldelivery.Morerecently,usingasim-
ilardesign,Gauchotteetal
15
confirmedthatintrauter-
ineballoontamponadesignificantlyreducedtheneed
forinterventionalradiologyorsurgeryforpostpartum
hemorrhage.Ourresultsfromalargepopulation-
basedcohortstudywithacontrolgroupreinforce
theconclusionsofthesetwostudiesforvaginal
Table2.RatesofInvasiveProceduresintheTwoPerinatalNetworks
PilotNetwork ControlNetwork P*
Totalcohort 35,133 37,396
Embolization 17(0.5[0.3–0.7]) 153(4.1[3.5–4.7]) ,.01
Arterialligation 78(2.2[1.7–2.7]) 25(0.7[0.4–1.0]) ,.01
Hysterectomy 18(0.5[0.3–0.7]) 20(0.5[0.3–0.7]) .89
Womenwithatleast1surgicalprocedure 93(2.6[2.1–3.1]) 41(1.1[0.8–1.4]) ,.01
Womenwithatleast1invasiveprocedure 107(3.0[2.4–3.6]) 191(5.1[4.4–5.8]) ,.01
Vaginaldeliveries 26,299 29,024
Embolization 5(0.2[0.03–0.4]) 106(3.7[3.0–4.4]) ,.01
Womenwithatleast1surgicalprocedure 6(0.2[0.03–0.4]) 7(0.2[0.04–0.4]) .68
Womenwithatleast1invasiveprocedure 11(0.4[0.2–0.6]) 112(3.9[3.2–4.6]) ,.01
Cesareandeliveries 8,653 8,286
Embolization 11(1.3[0.5–2.1]) 47(5.7[4.1–7.3]) ,.01
Womenwithatleast1surgicalprocedure 87(10.1[8.0–12.2]) 34(4.1[2.7–5.5]) ,.01
Womenwithatleast1invasiveprocedure 95(11.0[8.8–13.2]) 79(9.5[7.4–11.6]) .35
Dataaren(per1,000[95%CI])unlessotherwisespecified.
*Pearsonx
2
oraFisherexacttest.
Table3.MultivariateRegression—FactorsAssociatedWithInvasiveProceduresbyModeofDeliveryinthe
PerinatalNetworks*
Variable
VaginalDeliveries CesareanDeliveries
AdjustedOR 95%CI P AdjustedOR 95%CI P
Pilotvscontrolnetwork 0.14
†
0.08–0.27 ,.01 1.19
‡
0.87–1.61 .27
Maternalage(pery) 1.00 0.97–1.03 .93 1.06 1.03–1.09 ,.01
Obesity 1.51 0.70–3.26 .30 1.78 1.03–3.09 .04
Levelofcare ,.01 ,.01
Level2vs1 1.07 0.47–2.41 .88 2.11 1.21–3.68 ,.01
Level3vs1 5.22 2.53–10.78 ,.01 2.70 1.54–4.75 ,.01
Gestationalage(perwk) 1.06 0.96–1.17 .26 0.92 0.88–0.96 ,.01
Priorcesareandelivery 1.44 0.66–3.10 .35 1.58 1.07–2.33 .02
OR,oddsratio.
*Onlythosevariablesthatweresignificantinatleastoneofthetwofinalmodelswereincluded.
†
CrudeOR0.11(0.06–0.19),P,.01.
‡
CrudeOR1.14(0.85–1.54),P5.39.
CopyrightÓbyTheAmericanCollegeofObstetricians
andGynecologists.PublishedbyWoltersKluwerHealth,Inc.
Unauthorizedreproductionofthisarticleisprohibited.
VOL.0,NO.0,MONTH2018 RevertetalBalloonTamponadeforPostpartumHemorrhage5 Revert M et al. Obstet Gynecol 2018;0:1–7

22. Matsubara S et al. BJOG 2017 Oct;124(11):1792-1793

23. •LospredictoresdefallaconelusodelBalónson:
•Víadelnacimiento:menosefectividadencesárea
•Tiempoymagnituddelsangrado
•Presenciadecoagulopatia
•Sielsangradonodisminuyeenlosprimeros15minutosdecolocadoelbalón,la
probabilidaddefallaenelmanejoesmuyalta
Matsubara S et al. BJOG 2017 Oct;124(11):1792-1793

24. Factores pronostico de éxito
Perdida menor a 1400 cc al momento de la colocación del balón
Drenaje menor a 50 cc durante los primeros 30 minutos de colocado el balón
Kong CW, To WW. Int J Gynaecol Obstet. 2018 Jul;142(1):48-53.
doi: 10.1002/ijgo.12498. 48|
wileyonlinelibrary.com/journal/ijgo Int J Gynecol Obstet 2018; 142: 48–53
| | |
CLINICAL ARTICLE
Obstetrics
|
*
-
P
P
-
|
1
2
-
-
8
10
-
13
311 casos de HPP, 81 con Balón

25. Test de taponamiento
•Siexisteunsangradomayora50ccpor
horalaprobabilidaddeexistodisminuye
•Untestdetaponamientoendondeno
hayefectividaddelBakry,indicala
necesidad probablemente de
histerectomia.

26. Dahlke JD et al. Am J Obstet Gynecol 2015;213:76.e1-10.

27. Mavrides E et al. BJOG 2016; DOI: .10.1111/ 1471-0528.14178.
Georgiou C et al. BJOG 2009;116:748–57.
Ikechebelu JI et al. J Obstet Gynaecol 2005;25:70–2.
Bakri YN et al. Int J Gynaecol Obstet 2001;74:139–42.
Chan C et al. Int J Gynaecol Obstet 1997;58:251–2.
Condous et al. Obstet Gynecol 2003;101: 767–72.
Akhter S e al. MedGenMed 2003;5:38.
Keriakos R et al. Obstet Gynaecol 2006;26:335–8.
Lennox C et al. 10th Annual Report. Edinburgh: Healthcare Improvement Scotland; 2014.
Frenzel D et al. BJOG 2005;112:676–7.
Tindell K et al. , BJOG 2013;120:5–14.

28. •Eltaponamientouterinoconvariostiposdebaloneshasidoreportadocon
unatasadeéxitodel90%
•2014ScottishConfidentialAuditofSevereMaternalMorbidityidentifico83
casosdepacientesconsangradomayora2500ccenmanejoconbalones
hidrostaticoscontasadeéxitodel91%
•Debeutilizarseelconceptodeltestdetaponamientouterino
Mavrides E et al. BJOG 2016; DOI: .10.1111/ 1471-0528.14178.

29. Uso de balones
hidrostáticos

30. Usar cuando los uterotonicos y el
masaje uterino han fallado en el
control del sangrado
Cada hospital debe adoptar una
aproximación de manejo y entrenar
a su personal para la
implementación
“
Committee on Practice Bulletins
-
Obstetrics. Obstet Gynecol. 2017 Oct;130(4):e168
-
e186.
doi: 10.1097/AOG.0000000000002351. e168 VOL. 130, NO. 4, OCTOBER 2017 OBSTETRICS & GYNECOLOGY
Postpartum Hemorrhage
Maternal hemorrhage, defined as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accom-
panied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of
maternal mortality worldwide (1). Additional important secondary sequelae from hemorrhage exist and include adult
respiratory distress syndrome, shock, disseminated intravascular coagulation, acute renal failure, loss of fertility, and
pituitary necrosis (Sheehan syndrome).
Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in the United States
closely followed by disseminated intravascular coagulation (2). In the United States, the rate of postpartum hemor-
rhage increased 26% between 1994 and 2006 primarily because of increased rates of atony (3). In contrast, maternal
mortality from postpartum obstetric hemorrhage has decreased since the late 1980s and accounted for slightly more
than 10% of maternal mortalities (approximately 1.7 deaths per 100,000 live births) in 2009 (2, 4). This observed
decrease in mortality is associated with increasing rates of transfusion and peripartum hysterectomy (2–4).
The purpose of this Practice Bulletin is to discuss the risk factors for postpartum hemorrhage as well as its evalu-
ation, prevention, and management. In addition, this document will encourage obstetrician–gynecologists and other
obstetric care providers to play key roles in implementing standardized bundles of care (eg, policies, guidelines, and
algorithms) for the management of postpartum hemorrhage.
NUMBER 183, OCTOBER 2017 (Replaces Practice Bulletin Number 76, October 2006)
ACOG PRACTICE BULLETIN
Clinical Management Guidelines for Obstetrician–Gynecologists
Background
The American College of Obstetricians and Gynecolo-
gists’ (ACOG) reVITALize program defines postpartum
hemorrhage as cumulative blood loss greater than or
equal to 1,000 mL or blood loss accompanied by signs
or symptoms of hypovolemia within 24 hours after the
birth process (includes intrapartum loss) regardless of
route of delivery (5). This is in contrast to the more
traditional definitions of postpartum hemorrhage as an
estimated blood loss in excess of 500 mL after a vaginal
birth or a loss of greater than 1,000 mL after a cesarean
birth (6). This new classification is likely to reduce the
number of individuals labeled with postpartum hemor-
rhage. However, despite this new characterization, a
blood loss greater than 500 mL in a vaginal delivery
should be considered abnormal and should serve as an
indication for the health care provider to investigate the
increased blood deficit. Although visually estimated
blood loss is considered inaccurate, use of an educa-
tional process, with limited instruction on estimating
blood loss, has been shown to improve the accuracy of
such estimates (7). Historically, a decrease in hematocrit
of 10% had been proposed as an alternative marker to
define postpartum hemorrhage; however, determinations
of hemoglobin or hematocrit concentrations are often
delayed, may not reflect current hematologic status, and
are not clinically useful in the setting of acute postpartum
hemorrhage (8).
In postpartum women, it is important to recognize
that the signs or symptoms of considerable blood loss
(eg, tachycardia and hypotension) often do not present or
do not present until blood loss is substantial (9). There-
fore, in a patient with tachycardia and hypotension, the
obstetrician–gynecologist or other obstetric care provider
should be concerned that considerable blood loss, usually
Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the American College of Obstetricians and Gynecologists’
Committee on Practice Bulletins–Obstetrics in collaboration with Laurence E. Shields, MD; Dena Goffman, MD; and Aaron B. Caughey, MD, PhD.
CopyrightªbyTheAmericanCollegeofObstetricians
andGynecologists.PublishedbyWoltersKluwerHealth,Inc.
Unauthorizedreproductionofthisarticleisprohibited.

31. e174 Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY
ending with extension of the gauze through the cervi-
cal os. To avoid leaving gauze in the uterus at time of
removal, it can be carefully counted and tied together.
Similarly, multiple large Foley catheters (which were
common before the development of commercial intra-
uterine tamponade devices) can still be used, but the
challenge is placing multiple devices and keeping
Tamponade Techniques
When uterotonics and bimanual uterine massage fail to
sustain uterine contractions and satisfactorily control
hemorrhage, the use of compression (including manual
compression), intrauterine tamponade or packing can be
effective in decreasing hemorrhage secondary to uterine
atony (Table 4). Although the evidence that compares
these approaches is poor or absent, it is important for
institutions to adopt an approach and train personnel
in this approach. For example, the California Maternal
Quality Care Collaborative recommends the use of an
intrauterine balloon for tamponade after uterotonics
have failed.
Evidence for the benefits of use of intrauterine bal-
loon tamponade is limited; however, in one study, 86%
of women who had balloon tamponade did not require
further procedures or surgeries (12, 51). Similarly, a
summary of studies showed that 75% of patients did
not need further treatment after intrauterine balloon
tamponade (12). In some refractory cases, intrauterine
tamponade and uterine compression sutures (described
later) may be used together (52).
If a balloon tamponade system is not available, the
uterus may be packed with gauze. This requires careful
layering of the material back and forth from one uterine
cornu to the other repeatedly using a sponge stick, and
Table 3. Acut e M edical M anagement of Post part um Hemorrhage
Drug* Dose and Rout e Frequency Cont raindicat ions Adverse Effect s
Oxytocin IV: 10–40 units per 500–1,000 mL Continuous Rare, hypersensitivity to Usually none.
as continuous infusion medication Nausea, vomiting,
or hyponatremia with
IM : 10 units prolonged dosing.
Hypotension can result
from IV push, which is not
recommended.
M ethylergonovine IM : 0.2 mg Every 2–4 h Hypertension, preeclampsia, Nausea, vomiting, severe
cardiovascular disease, hypertension particularly
hypersensitivity to drug when given IV, which is
not recommended
15-methyl PGF
2 IM : 0.25 mg Every 15–90 min, Asthma. Relative Nausea, vomiting,
Intramyometrial: 0.25 mg eight doses contraindication for diarrhea, fever (transient),
maximum hypertension, active hepatic, headache, chills,
pulmonary, or cardiac disease shivering hypertension,
bronchospasm
M isoprostol 600–1,000 micrograms oral, One time Rare, hypersensitivity to Nausea, vomiting, diarrhea
sublingual, or rectal medication or to prostaglandins shivering, fever (transient),
headache
Abbreviations: IV, intravenously; IM , intramuscularly; PG, prostaglandin.
*All agents can cause nausea and vomiting.
M odified from Lyndon A, Lagrew D, Shields L, M ain E, Cape V, editors. Improving health care response to obstetric hemorrhage version 2.0. A California quality improve-
ment toolkit. Stamford (CA): California M aternal Quality Care Collaborative; Sacramento (CA): California Department of Public Health; 2015.
Table 4. Tamponade Techniques for Post part um Hemorrhage
Technique Comment
Commercially available intrauterine
balloon tamponade devices
- Bakri Balloon
- ebb uterine tamponade system
Foley catheter Insert one or more 60 mL bulbs
and fill with 60 mL of saline.
Uterine packing 4-inch gauze, can be soaked
with 5,000 units of thrombin in
5 mL of saline then insert from
one cornua to the other with
ring forceps.
Inserted transcervically or
through cesarean incision; has
an exit port for blood drainage
Inflated with 300–500 mL of
saline
Double Balloon: maximum rec-
ommended fill volumes are 750
mL for the uterine balloon and
300 mL for the vaginal balloon.
CopyrightªbyTheAmericanCollegeofObstetricians
andGynecologists.PublishedbyWoltersKluwerHealth,Inc.
Unauthorizedreproductionofthisarticleisprohibited. Committee on Practice Bulletins-Obstetrics. Obstet Gynecol. 2017 Oct;130(4):e168-e186.
doi: 10.1097/AOG.0000000000002351.

32. Recomendaciones de la
OMS para la prevención
y el tratamiento de
la hemorragia posparto
Para obtener más información, comuníquese con:
Departamento de Salud Reproductiva e Investigaciones Conexas
Correo electrónico: [email protected]
www.who.int/ reproductivehealth
Salud Materna, Neonatal, Infantil y Adolescente
Correo electrónico: [email protected]
www.who.int/ maternal_child_adolescent
Organización Mundial de la Salud
Avenue Appia 20, CH-1211 Ginebra 27
Suiza
ISBN 978 92 4 354850 0 ISBN 978 92 4 354850 0, 2014

33. WHO recommendation on
Uterine balloon tamponade
for the treatment of
postpartum haemorrhage Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
Serecomiendaeltaponamientouterinocon
balónparaeltratamientodelahemorragia
pospartodebidaaatoníauterinadespuésdel
partovaginalenmujeresquenorespondenal
tratamientoestándardeprimeralínea,siempre
quesecumplanlassiguientescondiciones:
•El recurso inmediato a la intervención quirúrgica y el
acceso a productos sanguíneos es posible si es necesario.

34. •Sedisponedeunprotocolodetratamientodeprimeralíneaparala
hemorragiapospartoprimaria(queincluyeelusodeuterotónicos,ácido
tranexámico,líquidosintravenosos)yseimplementadeformarutinaria.
•Sepuedendescartarrazonablementeotrascausasdehemorragiaposparto
(tejidoplacentarioretenido,traumatismo).
•Elprocedimientolorealizapersonaldesaludcapacitadoycon
entrenamientoenelmanejodelaHPP,incluidoelusodetaponamiento
uterinoconbalón.
•Lacondiciónmaternapuedesermonitoreadaregularmentey
adecuadamenteparaunaprontaidentificacióndecualquiersignode
deterioro.WHO recommendation on
Uterine balloon tamponade
for the treatment of
postpartum haemorrhage

35. Los procedimientos como colocación de balón de Bakrio
cirugía de B-lynchtienen ratas de éxito comparables y son
dependientes de las experiencia de los obstetras para
seleccionar el procedimiento apropiado en cada paciente
Matsubara S. Arch Gynecol Obstet 2016 May;293(5):1147-8

36. •Eltaponamientoreducesignificativamentelanecesidadderadiologíaintervencionista
ocirugíaparaeltratamientodelahemorragiaposparto.
Gauchotte E et al. Acta Obstet Gynecol Scand. 2017;96(7):877-882.
doi:10.1111/aogs.13130
Eltaponamientoconbalónintrauterinopuedeserunaintervenciónadecuadadeprimeraelecciónenel
tratamientodelahemorragiapospartopersistente
Deffieux X et al. .PLoS One. 2017;12(6):e0177092. Published 2017 Jun 1.
doi:10.1371/journal.pone.0177092

37. Ensayo clinico controlado en 7 hospitales en Benin y Mali
Dumont A et al. BMJ Open 2017;7:e016590. doi:10.1136/ bmjopen-2017-016590

38. Problemasasociadosal estudio
Severos problemas metodológicos y
adherencia al protocolo
Tiempo de entrenamiento para la
colocación de los balones.
Manejo médico sub optimo y retrasos
en la colocación del balón: La mitad
de las pacientes recibieron el balón
despues de 30 minutos de manejo
Dumont A et al. BMJ Open 2017;7:e016590. doi:10.1136/ bmjopen-2017-016590

39. •Ensayoclínicoaleatorizadoporetapas
•Mediodíadeentrenamientoen9institucionesdeUganda,EgiptoySenegal
•UsodeUBTen9pacientesde1357delgrupocontrolyen55de1037del
grupodelaintervención:alamitaddelaspacientesdelgrupode
intervenciónnoselescolocoelbalóndetaponamientouterino.
Anger HA et al. BJOG. 2019 Dec;126(13):1612-1621.
doi: 10.1111/1471-0528.15903.

40. Anger HA et al. BJOG. 2019 Dec;126(13):1612-1621.
doi: 10.1111/1471-0528.15903.

41. To ensure that efforts lead to tangible reductions in
maternal mortality and morbidity, future approaches
should prioritise the strengthening of health systems,
including addressing personnel shortages and unreliable
blood supply
Anger HA et al. BJOG. 2019 Dec;126(13):1612-1621.
doi: 10.1111/1471-0528.15903.

43. •CUSUM(Cumulativesumcontrol
chart)esunatécnicadeanalisis
secuencaldesarolladaporUniversity
ofCambridge.
•Monitoriadedeteccióndecambio
Chang R, Mc Lean I. BMC Medical Research Methodology 2006, 6:8
doi:10.1186/1471-2288-6-8

44. Taponamiento uterino Suturas compresivasDevascularización uterina
Ligaduras A. HipogastricasHisterectomia
Lumbreras
-
Marquez MI et al
J Matern Fetal Neonatal Med. 2019;1
-
7.
doi:10.1080/14767058.2019.1685974

45. 106 pacientes
Tasa de éxito: 94%
IC 95% 88–98%
3 minutos
Transfusión en 35
pacientes
Fácil uso
D'Alton ME et al. Obstet Gynecol. 2020 Nov;136(5):882-891.
doi: 10.1097/AOG.0000000000004138.

46. El uso del balón de Bakri combinado con taponamiento vaginal y compresión
abdominal es más efectivo en el tratamiento de la HPP en comparación con
balón de Bakri solo.
Guo Y et al. J Obstet Gynaecol Can. 2018;40(5):561-565.
doi:10.1016/j.jogc.2017.08.035

47. Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=ijmf20
The Journal of Maternal-Fetal & Neonatal Medicine
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: https://www.tandfonline.com/loi/ijmf20
Impact of nonpneumatic antishock garment in the
management of patients with hypoperfusion due
to massive postpartum hemorrhage
Maria Fernanda Escobar, Paula Andrea Fernández Pérez, Javier Andrés
Carvajal, Juan Manuel Burgos, Adriana Messa, Maria Paula Echavarria,
Albaro Nieto, Daniela Montes, Suellen Miller & David Felipe Hurtado
To cite this article: Maria Fernanda Escobar, Paula Andrea Fernández Pérez, Javier Andrés
Carvajal, Juan Manuel Burgos, Adriana Messa, Maria Paula Echavarria, Albaro Nieto, Daniela
Montes, Suellen Miller & David Felipe Hurtado (2019): Impact of nonpneumatic antishock garment
in the management of patients with hypoperfusion due to massive postpartum hemorrhage, The
Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2019.1568982
To link to this article: https://doi.org/10.1080/14767058.2019.1568982
Accepted author version posted online: 11
Jan 2019.
Published online: 22 Jan 2019.
Submit your article to this journal
Article views: 84
View Crossmark data Escobar MF et al.J Matern Fetal Neonatal Med 2019 Jan 22:1-5.

48. Int J Gynecol Obstet 2019; 1–6 |1
| |
DOI: 10.1002/ijgo.12872
CLINICAL ARTICLE
Obstetrics
Experience of combined use of a Bakri uterine balloon and a
non-­pneumatic­anti-­shock­garment­in­a­university­hospital­
in Colombia
María F. Escobar
1,2,
* | Juan­P.­Suso
2
| María­A.­Hincapié
2
| María­P.­Echavarría
1,2
|
Paula­Fernández
3
| Javier­Carvajal
1,2
1
2

3
*Correspondence
Abstract
Objective
Methods
-
Results
P
P
P
Conclusions
KEYWORDS
1 | INTRODUCTION
-
the Caribbean.
1
2
1
3–12

- Escobar MF et al. Int J Gynecol Obstet 2019 May 27. doi: 10.1002/ijgo.

49. Gracias por el compromiso!