Sedación con dexmedetomidina/Dexmedetomidine for sedation

Dosis óptima de dexmedetomidina para sedación durante raquianestesia   Optimal dose of dexmedetomidine for sedation during spinal anesthesia. Ok HG, Baek SH, Baik SW, Kim HK, Shin SW, Kim KH. Department of Anesthesia and Pain Medicine, Pusan National University College of Medicine, Yangsan, Korea. Korean J Anesthesiol. 2013 May;64(5):426-31. doi: 10.4097/kjae.2013.64.5.426. Epub 2013  Abstract BACKGROUND:Sedation in spinal anesthesia can reduce patient's anxiety and discomfort. Dexmedetomidine has a sedative, hypnotic, analgesic, and minimal respiratory depression effect. However, use of the dexmedetomidine is associated with prolonged recovery. This study was designed to investigate the optimal dose of intravenous dexmedetomidine for proper sedation with minimal recovery time in spinal anesthesia. METHODS: One hundred twenty eight patients, aged 20-70 years (58.8 ± 0.7), were recruited. After performing the spinal anesthesia with hyperbaric bupivacaine (13 mg), a loading dose of dexmedetomidine (1 µg/kg) was administered for 10 min, followed by the maintenance infusion of the following: Group A (n = 33; normal saline), Group B (n = 35; dexmedetomidine 0.2 µg/kg/hr), and Group C (n = 39; dexmedetomidine 0.4 µg/kg/hr). Heart rate, blood pressure, and the bispectral index score (BIS) were recorded during the operation. In the recovery room, modified aldrete score (MAS) was measured. RESULTS: There were no significant differences in mean blood pressure and heart rate among the three groups. BIS was not significantly different among the three groups from baseline to 60 min after the infusion of dexmedetomidine. BIS were significantly increased in Group A after 70 and 80 min, and Group A and B after 90, 100, 110 min of dexmedetomidine infusion (P < 0.05). MAS was higher in Group A as compared to Group B and C, within 30 min after admission in the recovery room (P < 0.05). CONCLUSIONS: The loading dose (1 µg/kg/10 min) of dexmedetomidine was sufficient for surgery of less than 60 min. Dexmedetomidine infusion followed by maintenance dose (0.2 µg/kg/hr) was sufficient for surgery within 90 min. KEYWORDS: Dexmedetomidine, Sedation, Spinal anesthesia  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668104/pdf/kjae-64-426.pdf Dexmedetomidina para sedación de pacientes de cirugía electiva bajo anestesia raquídea       Dexmedetomidine for sedation of patients undergoing elective surgery under regional anesthesia. Song J, Kim WM, Lee SH, Yoon MH. Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Gwangju, Korea. Korean J Anesthesiol. 2013 Sep;65(3):203-8. doi: 10.4097/kjae.2013.65.3.203. Epub 2013 Sep 25. Abstract BACKGROUND:Dexmedetomidine may be useful as a sedative agent. However, it has been reported that dexmedetomidine decreases systemic blood pressure, heart rate, and cardiac output in a dose-dependent manner. The purpose of this study was to determine the appropriate dose of intravenously administered dexmedetomidine for sedation. METHODS: Forty-five American Society of Anesthesiologists physical status I-II patients under spinal anesthesia received dexmedetomidine 1 µg/kg intravenously as a loading dose. The patients were randomly allocated to one of three groups for maintenance dose: Group A (0.25 µg/kg/hr), Group B (0.50 µg/kg/hr), and Group C (0.75 µg/kg/hr). The hemodynamic variables and the Ramsay Sedation Scale (RSS) score were recorded for all patients. The numbers of patients who developed hypotension, bradycardia, or inadequate sedation necessitating further drug treatment were also recorded. RESULTS: Systolic blood pressure, heart rate, and SpO2 were decreased, and RSS score was increased significantly at both 20 min and 40 min after injection of dexmedetomidine in the three study groups compared to baseline, without significant differences between the groups. The prevalence of hypotension, but not that of bradycardia or adjunctive midazolam administration, exhibited a positive correlation with the dose of dexmedetomidine. CONCLUSIONS: Intravenous injection of dexmedetomidine 1 µg/kg followed by continuous administration at infusion rates of 0.25, 0.50, or 0.75 µg/kg/hr produced adequate levels of sedation. However, there was a tendency for the incidence of hypotension to increase as the dose increased. To minimize the risk of hemodynamic instability, a dose of 0.25 µg/kg/hr may be the most appropriate for continuous administration of dexmedetomidine. KEYWORDS: Continuous dose, Dexmedetomidine, Regional anesthesia, Sedation http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3790030/pdf/kjae-65-203.pdf Atentamente Anestesiología y Medicina del Dolor www.anestesia-dolor.org

Cuidado prehospitalario del trauma

Fase de implementación de un sistema multicéntrico prehospitalario de apoyo a paramédicos: posibilidades y viabilidad


Implementation phase of a multicentre prehospital telemedicine system to support paramedics: feasibility and possible limitations.
Bergrath S, Czaplik M, Rossaint R, Hirsch F, Beckers SK, Valentin B, Wielpütz D, Schneiders MT, Brokmann JC.
Department of Anaesthesiology, University Hospital Aachen, Aachen, Germany. sbergrath@ukaachen.de
Scand J Trauma Resusc Emerg Med. 2013 Jul 11;21:54. doi: 10.1186/1757-7241-21-54.
Abstract
BACKGROUND: Legal regulations often limit the medical care that paramedics can provide. Telemedical solutions could overcome these limitations by remotely providing expert support. Therefore, a mobile telemedicine system to support paramedics was developed. During the implementation phase of this system in four German emergency medical services (EMS), the feasibility and possible limitations of this system were evaluated. METHODS:After obtaining ethical approval and providing a structured training program for all medical professionals, the system was implemented on three paramedic-staffed ambulances on August 1st, 2012. Two more ambulances were included subsequently during this month. The paramedics could initiate a consultation with EMS physicians at a teleconsultation centre. Telemedical functionalities included audio communication, real-time vital data transmission, 12-lead electrocardiogram, picture transmission on demand, and video streaming from a camera embedded into the ceiling of each ambulance. After each consultation, telephone-based debriefings were conducted. Data were retrieved from the documentation protocols of the teleconsultation centre and the EMS. RESULTS: During a one month period, teleconsultations were conducted during 35 (11.8%) of 296 emergency missions with a mean duration of 24.9 min (SD 12.5). Trauma, acute coronary syndromes, and circulatory emergencies represented 20 (57%) of the consultation cases. Diagnostic support was provided in 34 (97%) cases, and the administration of 50 individual medications, including opioids, was delegated by the teleconsultation centre to the paramedics in 21 (60%) missions (range: 1-7 per mission). No medical complications or negative interpersonal effects were reported. All applications functioned as expected except in one case in which the connection failed due to the lack of a viable mobile network. CONCLUSION: The feasibility of the telemedical approach was demonstrated. Teleconsultation enabled early initiation of treatments by paramedics operating under the real-time medical direction. Teleconsultation can be used to provide advanced care until the patient is under a physician's care; moreover, it can be used to support the paramedics who work alone to provide treatment in non-life-threatening cases. Non-availability of mobile networks may be a relevant limitation. A larger prospective controlled trial is needed to evaluate the rate of complications and outcome effects.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599067/pdf/1757-7241-21-9.pdf





La adherencia a las guías y protocolos en el ámbito de la atención pre-hospitalaria y de emergencia: una revisión sistemática.

Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review.
Ebben RH, Vloet LC, Verhofstad MH, Meijer S, Mintjes-de Groot JA, van Achterberg T.
Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, Nijmegen 6525 EJ, The Netherlands. Remco.Ebben@han.nl
Scand J Trauma Resusc Emerg Med. 2013 Feb 19;21:9. doi: 10.1186/1757-7241-21-9.
Abstract
A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals' adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals' adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710491/pdf/1757-7241-21-54.pdf

Vía aérea prehospitalaria/Prehospital airway

Uso del tubo laríngeo en para cardiaco fuera del hospital por paramédicos noruegos  Laryngeal tube use in out-of-hospital cardiac arrest by paramedics in Norway. Sunde GA, Brattebø G, Odegården T, Kjernlie DF, Rødne E, Heltne JK. Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. geir.arne.sunde@helse-bergen.no Scand J Trauma Resusc Emerg Med. 2012 Dec 18;20:84. doi: 10.1186/1757-7241-20-84. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547736/pdf/1757-7241-20-84.pdf Determinación prehospitalaria de la colocación del tubo traqueal en daño grave de cabeza   Prehospital determination of tracheal tube placement in severe head injury. Grmec S, Mally S. Source Emergency Medical Service, Prehospital Unit, Maribor, Slovenia. Emerg Med J. 2004 Jul;21(4):518-20. Abstract OBJECTIVES: The aim of this prospective study in the prehospital setting was to compare three different methods for immediate confirmation of tubeplacement into the trachea in patients with severe head injury: auscultation, capnometry, and capnography. METHODS: All adult patients (>18 years) with severe head injury, maxillofacial injury with need of protection of airway, or polytrauma were intubated by an emergency physician in the field. Tube position was initially evaluated by auscultation. Then, capnometry and capnography was performed (infrared method). Emergency physicians evaluated capnogram and partial pressure of end tidal carbon dioxide (EtCO(2)) in millimetres of mercury.Determination of final tube placement was performed by a second direct visualisation with laryngoscope. Data are mean (SD) and percentages. RESULTS: There were 81 patients enrolled in this study (58 with severe head injury, 6 with maxillofacial trauma, and 17 politraumatised patients). At the first attempt eight patients were intubated into the oesophagus. Afterwards endotracheal intubation was undertaken in all without complications. The initial capnometry (sensitivity 100%, specificity 100%), capnometry after sixth breath (sensitivity 100%, specificity 100%), and capnography after sixth breath (sensitivity 100%, specificity 100%) were significantly better indicators for tracheal tube placement than auscultation (sensitivity 94%, specificity 66%, p<0.01). CONCLUSION: Auscultation alone is not a reliable method to confirm endotracheal tube placement in severely traumatised patients in the prehospitalsetting. It is necessary to combine auscultation with other methods like capnometry or capnography. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726371/pdf/v021p00518.pdf   Manejo de vía aérea en trauma maxilofacial. Estudio retrospectivo de 177 casos   Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases. Raval CB, Rashiduddin M. Department of Anesthesia, Al-Nahdha Hospital, Muscat, Oman. Saudi J Anaesth. 2011 Jan;5(1):9-14. doi: 10.4103/1658-354X.76476. Abstract BACKGROUND: Airway management in maxillofacial injuries presents with a unique set of problems. Compromised airway is still a challenge to the anesthesiologist in spite of all modalities available. Maxillofacial injuries are the result of high-velocity trauma arising from road traffic accidents, sport injuries, falls and gunshot wounds. Any flaw in airway management may lead to grave morbidity and mortality in prehospital or hospital settings and as well as for reconstruction of fractures subsequently. METHODS: One hundred and seventy-seven patients of maxillofacial injuries, operated over a period of one and half years during July 2008 to December 2009 in Al-Nahdha hospital were reviewed. All patients were reviewed in depth with age related type of injury, etiology and techniques of difficult airway management. RESULTS: The major etiology of injuries were road traffic accidents (67%) followed by sport (15%) and fall (15%). Majority of patients were young in the age group of 11-30 years (71 %). Fracture mandible (53%) was the most common injury, followed by fracture maxilla (21%), fracture zygoma (19%) and pan-facial fractures (6%). Maxillofacial injuries compromise mask ventilation and difficult airway due to facial fractures, tissue edema and deranged anatomy. Shared airway with the surgeon needs special attention due to restrictions imposed during surgery. Several methods available for securing the airway, both decision-making and performance, are important in such circumstances. Airway secured by nasal intubation with direct visualization of vocal cords was the most common (57%), followed by oral intubation (17%). Other methods like tracheostomy and blind nasal intubation was avoided by fiberoptic bronchoscopic nasal intubation in 26% of patients. CONCLUSION:The results of this study indicated that surgically securing the airway by tracheostomy should be revised compared to other available methods. In the era of rigid fixation of fractures and the possibility of leaving the patient without wiring an open mouth and alternative techniques like fiberoptic bronchoscopic intubation, it is unnecessary to carry out tracheostomy for securing the airway as frequently as in the past. KEYWORDS: Difficult airway, fiberoptic bronchoscopic intubation, maxillofacial injuries, tracheostomy http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101764/ Atentamente Anestesiología y Medicina del Dolor www.anestesia-dolor.org

ebooks. Alerta

La Ovejita Ebooks, una empresa global que lleva a cabo su ... El Correo de Béjar
"Dado que nosotros estamos en contra de pagar por publicar, cuando creamos La Ovejita Ebooks en abril de 2011, que incorpora ebooksa su catálogo gratis ...
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El Correo de Béjar

Las bibliotecas de Sant Josep Inauguran web y sevicio de e-books Diario de Ibiza
diariodeibiza.es | ibiza Coincidiendo este jueeves con la celebración del Día de las Bibliotecas la Biblioteca de Sant Josep y la Biblioteca Vicente Serra Orvay ...
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Los hombres españoles prefieren ebooks Mirada 21
Los hombres españoles prefieren ebooks. A las mujeres les gusta más oler y sentir los libros, mientras que los jóvenes prefieren el formato digital.
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Mirada 21

David Beckham protagonizará primeros libros digitales en Facebook Perú.com
El ex futbolista inglés ha sorprendido a muchos con esta noticia, podremos conocerlo ahora en su faceta de escritor desde eBooks en Facebook. Inglaterra.
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(1) “Si tienes un Kindle compras hasta cuatro veces más libros” Media-Tics
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El Congreso del Libro electrónico trabaja ya en su segunda edición ABC.es
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Más del 80% de españoles lee en formato digital Europa Press
Es multiplataforma y lee alrededor de 10 ebooks al año, a lo que le dedica una ... Mientras tanto, el 48 por ciento no compra ebooks en la red, pero sí los lee.
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Europa Press

LA E-VOLUCIÓN DE LA LECTURA El Periódico de Aragón
Aunque solo el 26% de los libros que se editan en España son en formato electrónico, los ebooks ganan adeptos y suponen la entrada de la tecnología digital ...
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Apuestan por el libro impreso El Universal
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El Universal

La situación del ebook: Un gran transatlántico varado eldiario.es
A esta cifra se suma el hecho de que el 50% de usuarios compra en tiendas online, el 72% se descarga ebooks habitualmente en la red. En definitiva, un lector ...
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Blogs 1 resultado nuevo para E-Books

Amazon lanzó un programa de descargas de e-books con ... Daniel Barbosa
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EE.UU. aprueba el uso de e-books y tabletas durante el despegue y ... Finanzas.com
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Finanzas.com

Libros para entender la realidad latinoamericana InfoBAE.com
Conozca los mejores eBooks sobre el tema. E-mail; Imprimir. Crédito: Violencia, desigualdad, crisis e inestabilidad son términos sumamente familiares para ...
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BajaLibros.com apuesta a la cultura y educación en Estados Unidos ... Que Pasa Bulletin
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Netflix, Spotify, Gaikai, Oyster Books y otras tarifas planas digitales ... Softonic ES
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PDFfetch, buscador de archivos en PDF, libros digitales y otras ... eju.tv
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EE.UU. aprueba el uso de e−books y tabletas durante el despegue ... EntornoInteligente
ABC de España 2 / Las autoridades estadounidenses han aprobado el uso de aparatos electrónicos como tabletas durante todas las fases del vuelo en aviones ...
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Blogs 2 resultados nuevos para E-Books

PDFfetch, un potente buscador de documentos y ebooks en formato ... Juan Luis Bermúdez
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Trombofilias y embarazo

Plaquetas en el embarazo  Platelets in pregnancy. Juan P, Stefano G, Antonella S, Albana C. Poliambulatorio di Ceprano, Ospedale SS Trinita di Sora, Ultrasound in Obstetrics and Gynecology Divisions; (FR), Italy. J Prenat Med. 2011 Oct;5(4):90-2. Abstract As stated in this review, platelets functions and their important role in coagulabity in pregnancy must be well understood, not only in thrombosis related complications in pregnancy (i.e., hypertension, diabetes, thrombophilia).Clinical findings suggest that a periodical monitoring of haematological markers such as MPV and coagulation markers may be associated to Doppler velocimetry, keeping in mind also that the incidence of complications is increased in women who have heritable platelet function disorders. KEYWORDS: coagulation, high risk pregnancies, platelets   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399052/pdf/prenatal-5-90-92.pdf   Trombofilias y daño renal durante el embarazo Thrombophilia and damage of kidney during pregnancy. Giovanni L, Maria LG, Mauro R, Carlotta M, Federica R, Fabrizio P, Sheba J, Giuseppe DP, Alessandro B, Elio C, Herbert V. Department of Obstetrics and Gynaecology, Fatebenefratelli Isola TiberinaHospital, Rome. J Prenat Med. 2011 Oct;5(4):78-82. Abstract ABSTRACT OBJECTIVES:It's known that heritable thrombophilias are a risk factor for the development of obstetrics complications associated to inadequate uterine-placental circulation, as pre-eclampsia/eclampsia, HELLP syndrome, placental abruption and intrauterine growth restriction (IUGR), however it was never investigated the role that they could have in the renal failure associated to such conditions. The purpose of this study is to evaluate ifthrombophilia itself that predispose to a possible renal damage or if its occurrence determines a more severe involvement of the kidneys in the course of these obstetric pathologies. METHODS: In the study were enrolled 301 pregnant women, who carried a thrombophilic state, 125 of whom (B group) has had an obstetric complication. In all the women the renal function was assessed taking into consideration proteinuria, creatininaemia and hypalbuminaemia. RESULTS:Of the three parameters which have been considered as evidence of a severe renal involvement the hypalbuminaemia appears statistically significant compared to the controls. Even creatinaemia is significantly increased in pregnant women with an Anthithrombin deficiency, and increased levels are detected in women with Factor V Leiden. CONCLUSIONS: In obstetric complications associated to thrombophilic state could be a more severe involvement of the kidney. KEYWORDS: heritable thrombophilias, obstetric complications, renal damage in pregnancy http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399050/pdf/prenatal-5-78-82.pdf     Síndrome antifosfolípido durante el embarazo: estado del arte  Antiphospholipid Syndrome during pregnancy: the state of the art. Di Prima FA, Valenti O, Hyseni E, Giorgio E, Faraci M, Renda E, De Domenico R, Monte S. Policlinico Hospital, Department of Obstetrics and Gynecology, University of Catania, Italy. J Prenat Med. 2011 Apr;5(2):41-53. Abstract Obstetric complications are the hallmark of antiphospholipid syndrome. Recurrent miscarriage, early delivery, oligohydramnios, prematurity, intrauterine growth restriction, fetal distress, fetal or neonatal thrombosis, pre-eclampsia/eclampsia, HELLP syndrome, arterial or venous thrombosis and placental insufficiency are the most severe APS-related complication for pregnant women. Antiphospholipid antibodies promote activation of endothelial cells, monocytes and platelets, causing an overproduction of tissue factor and thromboxane A2. Complement activation might have a central pathogenetic role. These factors, associated with the typical changes in the hemostatic system during normal pregnancy, result in a hypercoagulable state. This is responsible of thrombosis that is presumed to provoke many of the pregnancy complications associated with APS. Obstetric care is based on combined medical-obstetric high-risk management and treatment with the association between aspirin and heparin. This review aims to deter- mine the current state of the art of APS by investigating the knowledge achievements of recent years, to provide the most appropriate diagnostic and therapeutic management for pregnant women suffering from this syndrome. KEYWORDS:Antiphospholipid, Hypercoagula- bility, Thrombophilia, Thromboprophylaxis. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279165/pdf/prenatal-05-0041.pdf Atentamente Dr. Benito Cortes-Blanco Anestesiología y Medicina del Dolor www.anestesia-dolor.org

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Actualmente, en España esta distinción tan solo la tienen el área de Biblioteca y Archivo de la Universidad de Cádiz, pionera en 2011, y la Biblioteca de la ...
El Baluarte de Cádiz - Periódico digital

Actividades Semana de la Ciencia 2013 en la Biblioteca de Derecho Biblioteca de Derecho
Las actividades de la Semana de la Ciencia 2013 de la Biblioteca de Derecho giran en torno al tema "El derecho al agua". Contamos con una exposición ...
CanalBiblos: blog de la Biblioteca y Archivo de la UAM

Celebrando el día de la biblioteca | Biblioteca Municipal de Aguilar ... quiquebr
El pasado 24 de octubre celebrábamos el día de la BIBLIOTECA compartiendo palabras y sonrisas con ROBERTO MEZQUITA. Nos lo pasamos genial, los ...
Biblioteca Municipal de Aguilar de Campoo

Biblioteca Nro 16 Paraje El Saltito - 25 de Mayo | "Un sueño" para ... patricia liliana Ocampo
La biblioteca se instalo en el salón de usos múltiples del paraje, ya que la escuela tiene terreno pero no edificio y los 70 alumnos que concurren a clase ...
"Un sueño" para Misiones

La gestión de la información y el conocimiento como clave de éxito del activismo social

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La gestión de la información y el conocimiento como clave de éxito del activismo social

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Dos décadas de gestión del conocimiento Hace aproximadamente dos décadas que la gestión de la información y del conocimiento forma parte de nuestro “argot” habitual. Todos sabemos qué son, para qué...

Grupo formado por profesionales y académicos provenientes del mundo de la Información y Gestión documental. Los artículos publicados por los miembros del grupo se encuentran disponibles en nuestra sede web: http://www.thinkepi.net

Ortopedia. Alerta

El Complejo Asistencial de Ávila organiza un curso de “Ortopedia y ...Tribuna Ávila
El Complejo Asistencial de Ávila, dependiente de la Junta de Castilla y León, celebra hoy viernes 8 de noviembre la segunda edición del curso “Ortopedia y ...
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Caderas y rodillas nuevas con la operación “Walk”Crítica
El doctor Carlos Martínez, jefe de Ortopedia del HST, indicó que los pacientes pasan por una evaluación a fin de cerciorarse de que están aptos para ...
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Trombofilia y embarazo/Pregnancy and thrombophilia

Tromboembolismo venoso, trombofilia, terapia antotrombótica y embarazo   VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO; American College of Chest Physicians. Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada. batesm@mcmaster.ca Chest. 2012 Feb;141(2 Suppl):e691S-736S. doi: 10.1378/chest.11-2300. Abstract BACKGROUND: The use of anticoagulant therapy during pregnancy is challenging because of the potential for both fetal and maternal complications. This guideline focuses on the management of VTE and thrombophilia as well as the use of antithrombotic agents during pregnancy. METHODS:The methods of this guideline follow the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS:We recommend low-molecular-weight heparin for the prevention and treatment of VTE in pregnant women instead of unfractionated heparin (Grade 1B). For pregnant women with acute VTE, we suggest that anticoagulants be continued for at least 6 weeks postpartum (for a minimum duration of therapy of 3 months) compared with shorter durations of treatment (Grade 2C). For women who fulfill the laboratory criteria for antiphospholipid antibody (APLA) syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic or intermediate-dose unfractionated heparin or prophylactic low-molecular-weight heparin combined with low-dose aspirin (75-100 mg/d) over no treatment (Grade 1B). For women with inherited thrombophilia and a history of pregnancycomplications, we suggest not to use antithrombotic prophylaxis (Grade 2C). For women with two or more miscarriages but without APLA orthrombophilia, we recommend against antithrombotic prophylaxis (Grade 1B). CONCLUSIONS: Most recommendations in this guideline are based on observational studies and extrapolation from other populations. There is an urgent need for appropriately designed studies in this population.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278054/pdf/112300.pdf Factores de riesgos trombofílicos hereditarios de pérdida recurrente del embarazo Hereditary thrombophilic risk factors for recurrent pregnancy loss. Bogdanova N, Markoff A. Institute of Human Genetics, Westfalian-Wilhelms University of Muenster, Vesaliusweg 12-14, 48149, Münster, Germany, bogdano@uni-muenster.de. J Community Genet. 2010 Jun;1(2):47-53. doi: 10.1007/s12687-010-0011-3. Epub 2010 Jun 11. Abstract This review summarizes current knowledge about the role of hereditary hypercoagulation factors predisposing to thrombophilia-associated recurrent fetal loss. Thrombophilias are a major cause of adverse pregnancy outcome, playing a role in the etiology of up to 40% of cases worldwide. Hereditary thrombophilic predispositions to recurrent pregnancy wastage include genetic lesions in blood coagulation factors II and V as well as natural anticoagulants antithrombin, protein C, and protein S. Furthermore, methylenetetrahydrofolate reductase gene variants conferring higher thrombophiliarisk in combination with these mutations and the newly described annexin A5 gene M2 promoter allele are associated with repeated fetal loss. The review gives a concise description of the molecular defects arising from the genetic changes, of the role these factors play in the timing and definition of fetal loss, and risk estimates from available studies and meta-analysis. This knowledge is instrumental for a more precise assessment of individual risks for repeated fetal loss and should guide therapeutic strategies, where relevant. Since the average childbearing age increases in Western societies, the importance of a timely diagnosis of fetal loss predisposition is increasing. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185986/pdf/12687_2010_Article_11.pdf    Pérdida recurrente del embarazo y trombofilia  Recurrent pregnancy loss and thrombophilia. D'Uva M, Micco PD, Strina I, Placido GD. Department of Obstetrics and Gynecology and Human Reproduction, Federico II University of Naples, Naples, Italy. J Clin Med Res. 2010 Feb;2(1):18-22. doi: 10.4021/jocmr2010.02.260w. Epub 2010 Feb 26. Abstract Emerging data seem to be available also on the role of active thromboprophylaxis with heparin and pregnancy outcome. In the last decades we found many data concerning the association between a hypercoagulable state and its causes and adverse pregnancy outcome, in particular recurrentpregnancy loss (RPL). First studies which focused on the association between thrombophilia and RPL underlined the role of reduced clotting inhibitors and RPL, and subsequent studies underlined a pathogenetic role of gene variant associated to hypercoagulable state in the occurrence of RPL. On the other hand, acquired thrombophilic abnormalities as antiphipsholipid syndrome are a well known cause of RPL and should be considered for a screening. These data are relevant because recent studies suggested a role of an extensive thromprophilaxis in women with RPL that should be addressed only in case of known thrombophilia and high risk of venous thrombo embolism. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299170/pdf/jocmr-02-18.pdf

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