ISSN Version Online: 2308-0531 Rev. Fac. Med. Hum. 2019;19(2):82-88. (April 2019) DOI 10.25176/RFMH.v19.n2.2072 Facultad de Medicina Humana URP ORIGINAL ARTICLE MATERNAL-FETAL CLINICAL EPIDEMIOLOGIC INDICATORS OF UTERINE ATONY IN PRIMARY CESAREAN POSTPARTUM A IN A PRIVATE CLINIC DURING AUGUST 2017 - AUGUST 2018 MATERNAL-FETAL CLINICAL EPIDEMIOLOGIC INDICATORS OF UTERINE ATONY IN PRIMARY CESAREAN POSTPARTUM A IN A PRIVATE CLINIC DURING AUGUST 2017 - AUGUST 2018 María Y. Ponce de León-Galarza1

ABSTRACT Objective: To determine the association between maternal-fetal epidemiologic indicators and the presence of uterine atony in a primary cesarean postpartum at the Good Hope clinic during the period of August 2017 - August 2018. Methods: An observational, analytical, retrospective and quantitative study, type of cases and controls was carried out. The dependent variable was the atony of the uterus, and the independent variables were maternal age, multiple gestations, polyhydramnios, pregnancy, parity, maternal anemia, concomitant diseases, fetal weight, fetal presentation, and cesarean section indicators. The population consisted of 106 cases and 212 controls (ratio 2:1). For the inferential statistics, a bivariate analysis was used to find the Odds Ratio, 95% confidence intervals. The p-value <0.05 were considered statistically significant. Results: From the 318 patients in the study, the mean age was 30.87 ± 0.298 years. Associated variables to uterine atony in the bivariate analysis were age over 30 years, multiple gestation, polyhydramnios, low birth weight, and macrosomia. In multivariate analysis were polyhydramnios (OR:5,973, 95% CI: 2,443-14,603) and macrosomia (ORa : 6.280, 95% CI: 2,307-17,095). Conclusion: There ORIGINAL ARTICLE ORIGINAL was an association of uterine atony with polyhydramnios indicators and fetal macrosomia. Key words: Uterine Inertia, Uterine Hemorrhage, Polyhydramnios, Fetal Macrosomia. (source: MeSH NLM) RESUMEN Objetivo: Determinar la asociación entre indicadores clínico – epidemiológicos materno - fetales y la presencia de atonía uterina en puérperas post cesárea primaria en la clínica privada durante el período de Agosto 2017 – Agosto 2018. Métodos: Se realizó un estudio observacional, analítico, retrospectivo y cuantitativo, tipo casos y controles. La variable dependiente fue la atonía uterina, y las variables independientes fueron edad materna, gestación múltiple, polihidramnios, gestación, paridad, anemia materna, enfermedades concomitantes, peso fetal, presentación fetal e indicación de cesárea. La población estuvo conformada por 106 casos y 212 controles (ratio 2:1). Para la estadística inferencial se utilizó el análisis bivariado para hallar los Odds Ratio, intervalos de confianza al 95%. Se consideró a los valores p<0,05 como estadísticamente significativos. Resultados: De los 318 pacientes del estudio, la media de la edad fue de 30,87 ± 0,298 años, de los controles fue de 28 ± 0,423 años mientras que de los casos 33 ± 0,168 años. Las variables asociadas en el análisis bivariado a atonía uterina fueron la edad mayor de 30 años, gestación múltiple, polihidramnios, bajo peso al nacer y macrosomía. Mientras que en análisis multivariado fueron polihidramnios (OR: 5,973 IC95%: 2,443-14,603) y macrosomía (OR: 6,280 IC95%: 2,307-17,095). Conclusión: Se concluye que, se encontró asociación de atonía uterina con los indicadores de polihidramnios y macrosomía fetal Palabras clave: Inercia uterina; Hemorragia uterina; Polihidramnios, Macrosomía fetal. (fuente: DeCS BIREME)

1 Good Hope Clinic, Lima-Peru. a Medical internship. Quote as: María Y. Ponce de León-Galarza. Maternal-fetal clinical epidemiologic indicators of uterine atony in primary cesarean postpartum a in a private clinic during august 2017 - august 2018. [Original Article].2019;19(2):82-88. (April 2019). DOI 10.25176/RFMH.v19.n2.2072

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Pág. 82 ORIGINAL ARTICLE Rev. Fac. Med. Hum. 2019;19(2):82-88. Suriname, Paraguay, and Venezuela rates ofmaternal mortality, Guyana, Bolivia, after 2015,PeruIn amongthecountries with ranked sixth maternal deaths, ofwhichmost occurAmerica. inSouth the continent, year In America. theyare every 34 000 the figures continue to beoneofthehighestLatin was 111.92 whichhasdecreased inthelastdecade, but ratiothe average 2002-2011 during maternal mortality ofHealthPeru, of Epidemiology(DGE)theMinistry thedocument presentedIn by theGeneralDirectorate of response from theHealthSystem. social inequality, ofgenderandevident lack inequality international politics1 placeoccupying inapproaches a priority national and about 529,000 maternal deaths occur when year, According to the World HealthOrganization (WHO), each day ofthe year1 24hours or approximatelyevery 1maternal death for year. meansthat there are It approximately 380deaths represents 130,000to 140,000maternal deaths every of 1000mlblood)affects1.6million women and countries. theworld, In severe PPH(definedasloss inhigh-income one ofthemaincausesmorbidity the countries oflow andmiddleincome (LMIC). This is in andmortality causeofmaternal morbidity primary (PPH),whichisthe hemorrhage been thepostpartum threat to thesafety ofwomen agehas ofchildbearing From thebeginning ofthe20thcentury, thegreatest INTRODUCTION determinants ofuterine atony inourpopulation, to themain to know and eclampsia)9,itisnecessary the hypertensive (preeclampsia diseasesofpregnancy diverse, one of the main causes is uterine atony, and continue. are hemorrhage The causesofpostpartum andrural between urban indigenousareasdisparities is stillthecauseof40%maternal deaths, andthe although Peru has made impressive progress, HPP increased insome high-income countries has thissame period, maternal20152. During mortality of75%for ofthemillenniumreduction objectives 4 andtheachievingits 67 deaths per100000live births inPeru hasdecreasedmaternal mortality by 66%to to note that inthelast decade, isimportant the It . . It also serves, as a reflection of of asareflection alsoserves, . It 12 . 5,6 . However, Maternal-fetal clinical epidemiologic indicators of uterine atony in primary cesarean postpartum adjusted ORs. Finally, to multivariate get analysis was performed a significance p(<0.05) through theChi test -square. with their respective 95% confidence and intervals The bivariate analysisRatio, was usedtoOdd findthe into adatabase inSPSSversion 23. program and CIE10. The data were collected entered recorded in medical records through theQuick View Documentation was usedasatechnique data collection, incomplete data material and/or fetal. with andto thosewithmedicalhistory uterine surgery of previouspatients cesarean with a history or any other intheintraoperativedescribed report. We excluded those and 212controls, women diagnosed withuterine atony, We ratio of1:2,with106cases worked withacase-control from August of2017to August 2018. Hope, oftheclinicGood in thegynecology department Cesarean patients section withprimary 318 postpartum casesand controls.type The population consisted of analytical,Observational, retrospective and quantitative METHODS diseases. Table 1 patients, 60.7%,hadnopresence ofconcomitant frequent was uterine myomatosis with7.9%.Most pregnancy,diseases during itwas found that themost acute fetal distressregards with7.9%.In to concomitant with33.3%andsuffering Cephalopelvic disproportion 0.168 years. The mainindication for cesarean was whereas, oftheexperimental cases, itwas of33± ± 0.298years, for thecontrols itwas 28±0.423years and medicalreports. The average total agewas 30.87 Information was from collected 318clinicalhistories RESULTS 2017 -August 2018. private clinicofLima-Peru ofAugust theperiod during ina cesareanuterine atony postpartum inprimary EPIDEMIOLOGIC INDICATORS andthepresence of association between MATERNAL-FETAL CLINICAL ofthepresentobjective studywas to determine the all theprotocols required to prevent it. The primary timelywhenthisispresentedbe ableto act and apply Pág. 83 ORIGINAL ARTICLE Rev. Fac. Med. Hum. 2019;19(2) Pág. 84 statistically significant (p=0.017). atony hadmultiplepregnancies, thisrelationship is women whohaduterine 4.72% (5)ofthepostpartum regardsIn to multiplegestations, itwas found that Table 1. No Yes Cephalic presentation No Yes Anemia No Yes Gestation Multiple Younger than30years old Older than30years old Age Yes Fetal macrosomia No Yes weightLow birth No Yes Concomitant disease Primipara Multipara Parity No No Yes Polyhydramnios Bivariate associated analysis ofthefactors withuterine atony. :82-88. YES 101 33 73 88 18 91 40 66 15 99 63 43 97 87 19 5 7 9 UTERINE ATONY 161 188 206 113 209 130 183 204 211 NO 51 24 99 82 29 1 6 3 8 multiple gestations, table2. uterine women atony without thanpostpartum multiple pregnancies have 10.45timesofhaving Likewise, women itwas found with that postpartum TOTAL 165 234 276 297 153 125 308 193 280 291 312 84 42 21 10 38 27 6 10,45 (1,20-90,58) 4,92 (1,25-19,45) 5,57 (2,35-13,20) 5,66(2,13-15,05) 1,60 (0,83-3,10) 0,70 (0,42-1,17) 1,88 (1,17-3,03) 0,58 (0,26-1,28) 1,08 (0,67-1,74) OR (IC95%) Ponce de León-Galarza Met al P-VALUE 0,164 0,180 0,009 0,001 0,018 0,017 0,203 0,808 0,001 ORIGINAL ARTICLE Rev. Fac. Med. Hum. 2019;19(2):82-88. uterine atony weight; had children with low birth women whopresented6.6% (7)ofthepostpartum weight. theanalysis,with lowIn birth itwas found that total numberofpuerperal women (318)hadchildren regards weight,In to only3.14%(10)ofthe low birth womenfound that that 17.92%(19)ofthepostpartum Furthermore, concerning polyhydramnios, it was Graph 2. Graph 1. Table 2. GESTATION MULTIPLE TOTAL The relationship between multiplegestations andthepresence ofuterine atony. Yes No Relationship between polyhydramnios andthepresence ofuterine atony. The relationship between macrosomia andthepresence of uterine atony. % % % % % 5% % % % 9% % % % % % % 5% % % % 9% % 101 (95.28%) 5 (4.72%) YES 106 9% % 55% 5% Macrosoa etal Si UTERINE ATONY 9 Si Polihidranios Si 9 5 211 (99.53%) Si 1 (0.47%) 212 NO Atona uterina Atona uterina Maternal-fetal clinical epidemiologic indicators of uterine atony in primary cesarean postpartum relationship isstatistically significant (p=0.001),figure 1. had uterine atony presented polyhydramnios; this had uterine atony hadchildren withfetal macrosomia. found that 14.15%(15)ofthepuerperal women who Finally, intheanalysis between macrosomia, itwas this relationship isstatistically significant (p=0.018). Polihidranios No 312 (98.12%) Macrosoa etal No 6 (1.88%) TOTAL 318 9% % 9% % No No OR (IC95%) (1,20-90,58) 10,45 P-VALUE 0,017 Pág. 85 ORIGINAL ARTICLE Rev. Fac. Med. Hum. 2019;19(2) conducted in Peru,conducted at Almenara theGuillermo Irigoyen adjusted OR of3.2) cesarean for (withan factor risk intrapartum section (withanadjusted ORof8),aswellhemorrhage asa multiple pregnancies were for factor arisk postpartum al. intheUnited States in2017,shealsofound that A.et by studyconducted Butwick A case-control its statistical significance inthemultivariate analysis. however,atony; thisrelationship didnotmaintain relationship withmultiple gestation anduterine Likewise, there was astatistically significant Pág. 86 hemorrhage postpartum while thoseolderthan35years hadnomore of risk hemorrhage, 19 years ofpostpartum hadahigherrisk States where itwas found that women between 15and other studies. The studyofCavazos etal. intheUnited statistical power. This result issimilarto thosefound in time ofmultivariate analysis, probably dueto alackof However, this relationship was notmaintained at the for factor is a risk uterine with atony; an OR of 1.88. present study, it was found that age over 30 years andisavoidable. the causes ofmaternal In mortality health problems; uterine atony isoneoftheleading LMaternal deathpublic isoneofthemostcritical DISCUSSION Table 3. with respect towith respect uterine atony years there was nostatistically significant difference between 19and25years, whileinwomen over 35 had thehighestprevalence ofuterine atony inwomen in Peru, found that inapopulation of Villa ElSalvador with an OR of 3.6416. Finally, a study also conducted among others, having anagegreater than30years Peru, found for that factors therisk uterine atony were, Augusto M.etal. at theAlmenara HospitalinLima, who underwent cesareanwho underwent section an adjusted ORof1.59for uterine atony inpatients was publishedin2014,where multiplegestations had A.etal.Butwick intheUnited conducted States that Macrosomia weightLow birth Polyhydramnios pregnancy Multiple Age over 30years Multivariate associated analysis ofthefactors withuterine atony. 14 :82-88. . Asimilarresult was found by 23 . Also, anotherstudyby 15 . OR ADJUSTED 20 . Also, anotherstudy 6,280 3,911 5,973 6,522 1,672 LOWER LIMIT 2,307 2,443 this variable no data aboutanadjusted ORinthisstudyconcerning is anORlower thanthat found inourstudy. There is gestations had an OR of 2.15 for uterine atony, which ofLima,Peru;Hospital inthecity found that multiple adequate weight an adjusted OR of 8.72 compared to those with an al. found inIndia that withlow newborns weights had multivariate statistics. by Astudyconducted Nairet however, this relationship was not maintained inthe weight was associated withuterine atony inthisstudy; regardsIn to weight, itwas found that low birth polyhydramnios anduterine atony andhemorrhage Wetta etal. found that there isarelationship between intheUnitedanother studyconducted States by hemorrhage was performed, ofonly2.7%. was performed, hemorrhage low prevalencea studywithvery ofpostpartum the presence ofpolyhydramnios, probably because and hemorrhage an association between postpartum intheSultanate ofOmandidnotfind One performed not many studiesthat have explored thisrelationship. that canbefatal. hemorrhage postpartum There are uterine bleedingcannotbecontrolled causinga creating theatony oftheuterus. meansthat the It that alters contraction thecorrect ofitsmusclefibers, polyhydramnios condition causesauterine distention with theconsequent stoppage ofbleeding. The contraction ofthesefibersthat causetheirocclusion myometrium have asamechanismofhemostasisthe veins that travel between themusclecells ofthe and may that theuterine arteries bedueto thefact analysis withanadjusted ORof5.97. This difference of 5.57;significance that remained inthemultivariate was found inthebivariate analysis, withacrudeOR regardsIn to polyhydramnios, a significant association reported by etal. Said reported inastudy Tanzania, where was related to uterine atony. This agrees withthat Regarding weight, itwas found that macrosomia ,876 ,679 ,996 95 %IC 16 . 17 UPPER LIMIT . 17,465 62,629 17,095 14,603 2,806 Ponce de León-Galarza Met al P-VALUE 22 ,074 ,104 ,052 ,000 ,000 However, 24 . ORIGINAL ARTICLE Rev. Fac. Med. Hum. 2019;19(2):82-88. haemorrhage: a nationwide cohort studyintheNetherlands. a nationwide PLoShaemorrhage: cohort increases ofpostpartum therisk Pre-eclampsia KWM. J, Bloemenkamp 9. 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