Hysterectomy is one of the most common surgeries performed worldwide. Identification of modifiable risk factors for complications or readmissions could lead to targeted interventions to improve patient care and reduce health care costs. Preoperative anemia has been identified as a risk factor for adverse postoperative outcomes following noncardiac surgery. However, studies have not focused on young and healthy surgical populations, such as women undergoing gynecologic surgery for benign indications.

The purpose of this study was to evaluate whether preoperative anemia in women undergoing elective hysterectomy or myomectomy for benign indications was associated with increased 30 day postoperative morbidity and mortality.

Preoperative anemia in women undergoing elective hysterectomy/myomectomy was common and is an independent risk factor for 30 day postoperative adverse outcomes, especially in older women.

A anemia tem etiologia multifatorial: patologias genéticas, deficiência da ingestão de micronutrientes (ferro, folato, vitamina B12) ou outras condições que induzem perda ou necessidade aumentada ou absorção diminuída dos mesmos (infeção aguda ou crónica, doença inflamatória intestinal, insuficiência cardíaca crónica, doença renal crónica, neoplasias, doenças autoimunes). A anemia na gravidez é definida por valores de hemoglobina (Hb) <11 g/dL e hematócrito (Hct) <33% no 1º e no 3º trimestres da gravidez; Hb <10,5 g/dL e Hct <32% no 2º trimestre, e Hb <10 g/dL no puerpério. A anemia constitui um problema global de saúde pública, afetando cerca de um quarto da população mundial. Em 2011, a OMS estimou uma prevalência de anemia gestacional de 38%, sendo de 26% na Europa. Em Portugal, um estudo prospetivo de 2016 refere uma prevalência de anemia na grávida de 2,5% (mas com uma prevalência de défice de ferro >38%), enquanto que o estudo EMPIRE descreveu uma prevalência de
anemia de 54,2% nas mulheres grávidas, com variações regionais. Assim, a SPOMMF recomenda que se realize o rastreio de anemia e ferropénia na gravidez, através do hemograma e da determinação da ferritina sérica.

Anaemia is a frequent condition during pregnancy, particularly among women in low- and middle-income countries. Traditionally, gestational anaemia has been prevented with daily iron supplements throughout pregnancy, but adherence to this regimen due to side eGects, interrupted supply of the supplements, and concerns about safety among women with an adequate iron intake, have limited the use of this intervention. Intermittent (i.e. two or three times a week on non-consecutive days) supplementation has been proposed as an alternative to daily supplementation.

This review includes 27 trials from 15 countries, but only 21 trials (with 5490 women) contributed data to the review. All studies compared daily versus intermittent iron supplementation. The methodological quality of included studies was mixed and most had high levels of attrition.The overall assessment of the quality of the evidence for primary infant outcomes was low and for maternal outcomes very low. Of the 21 trials contributing data, three studies provided intermittent iron alone, 14 intermittent iron + folic acid and four intermittent iron plus multiple vitamins and minerals in comparison with the same composition of supplements provided in a daily regimen.

This review is the most comprehensive summary of the evidence assessing the benefits and harms of intermittent iron supplementation in pregnant women on haematological and pregnancy outcomes. Findings suggest that intermittent regimens produced similar maternal and infant outcomes as daily supplementation but were associated with fewer side eGects and reduced the risk of high levels of Hb in mid and late pregnancy, although the risk of mild anaemia near term was increased. While the quality of the evidence was assessed as low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.

Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions,particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia.However, its long-term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teethstaining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation forpreventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent.

We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessingrisk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded byinternational organisations, universities, and ministries of health within the countries. Approximately one third of the included studies didnot provide a funding source.

Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations withdifferent anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittentlyis probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), sideeffects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base rangedfrom very low to moderate quality, suggesting that we are uncertain about these effects.

Each year, worldwide about 530,000 women die from causes related to pregnancy and childbirth. Of the deaths 99% are in low and middle income countries. Obstetric haemorrhage is the leading cause of maternal mortality, most occurring in the postpartum period. Systemic antifibrinolytic agents are widely used in surgery to prevent clot breakdown (fibrinolysis) in order to reduce surgical blood loss. At present there is little reliable evidence from randomised trials on the effectiveness of tranexamic acid in the treatment of postpartum haemorrhage.

The main analyses will be on an 'intention to treat' basis, irrespective of whether the allocated treatment was received or not. Subgroup analyses for the primary outcome will be based on type of delivery; administration or not of prophylactic uterotonics; and on whether the clinical decision to consider trial entry was based primarily on estimated blood loss alone or on haemodynamic instability. A study with 15,000 women will have over 90% power to detect a 25% reduction from 4% to 3% in the primary endpoint of mortality or hysterectomy.

Estes consensos têm como objetivo fornecer uma ferramenta alicerçada na evidência científica atual, que possa ter aplicabilidade prática e que contribua para a abordagem multidisciplinar, transversal e sistemática, da hemorragia em obstetrícia. Constituem uma revisão das recomendações existentes, visando facilitar a sua divulgação e implementação, e introduzir consistência na prática clínica. Estas orientações foram elaboradas, sob a égide da Sociedade Portuguesa de Anestesiologia, por consenso multidisciplinar, entre especialistas de Anestesiologia, Ginecologia/Obstetrícia, Imunohemoterapia e Hematologia. A hemorragia em obstetrícia é a principal causa de morbimortalidade materna, mesmo em países desenvolvidos, sendo a causa mais evitável de mortalidade. A hemorragia pós-parto é a sua forma mais frequente (5% - 10% dos partos), tendo vindo a aumentar na última década.  Os fatores que contribuem para outcomes adversos são: atraso no tratamento pela subestimação das perdas, atraso na disponibilidade de componentes sanguíneos, ausência de algoritmos de atuação, falta de conhecimentos/treino, comunicação interdisciplinar insuficiente e organização inadequada.

É fundamental identificar os fatores de risco para hemorragia obstétrica.

A definição clássica de hemorragia pós-parto minor é perdas sanguíneas > 500 mL após parto vaginal e > 1000 mL após cesariana e hemorragia pós-parto major com perdas > 1000 mL. A hemorragia pós-parto major pode, ainda, ser subdividida em moderada (1000-2000 mL) e severa (> 2000 mL), no entanto o American College of Obstetricians and Gynecologists reviu recentemente esta definição como sendo perdas sanguíneas cumulativas ≥ 1000 mL ou perdas hemáticas acompanhadas de sinais e sintomas de hipovolemia nas 24 horas após o parto. Esta definição vai de encontro à definição de hemorragia massiva da European Society of Anesthesiologists e da Direção Geral de Saúde. Todas as Unidades Obstétricas devem ter um protocolo institucional multidisciplinar para gestão da hemorragia em obstetrícia, devendo envolver precocemente uma equipa multidisciplinar. Este protocolo deve dar origem a um algoritmo de atuação, prático e sucinto, cujo objetivo é sistematizar e organizar a resposta dos profissionais e da instituição, de acordo com a gravidade da hemorragia.  É recomendável monitorização “point-of-care” para orientação terapêutica e a possibilidade de utilização imediata de ácido tranexâmico, concentrado de fibrinogénio e balões hemostáticos.

Todos os profissionais envolvidos nos cuidados maternos devem realizar regularmente treino multidisciplinar na hemorragia em obstetrícia.

Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis, and minimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommendations on the prevention and treatment of postpartum haemorrhage as part of PBM in obstetrics. A multidisciplinary panel of physicians with expertise in obstetrics, anaesthesia, haematology, and transfusion medicine was convened by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO), the European Board and College of Obstetrics and Gynaecology (EBCOG), and the European Society of Anaesthesiology (ESA). Members of the task force assessed the quantity, quality and consistency of the published evidence, and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group.
The recommendations in this consensus statement are intended for use by clinical practitioners managing perinatal care of women in all settings, and by policymakers in charge of decision making for the update of clinical practice in health care establishments.

Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed tomaintain haemoglobin concentration, optimise haemostasis andminimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommenda-tions on the management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period as part of PBM in obstetrics. A multidisciplinary panel of physicians with exper-tise in obstetrics, anaesthesia, haematology, policy making and epidemiology was convened by the Network for the Advance-ment of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federationof Gynaecology and Obstetrics (FIGO) and the European Boardand College of Obstetrics and Gynaecology (EBCOG). Members of the task force assessed the quantity, quality and consistency of the published evidence and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. The recommendations in this consensus statement are intended for use by clinical practitioners managing the perinatalcare of women in all settings and by policy makers in charge of decision making for the update of clinical practice in health-care establishments. They need to be tailored for application in individual patients or any population after consideration of the values and preferences of both health-care providers and patients,as well as equity issues; explicit assessment of harms and benefits of each recommendation; feasibility including resources, capacity and equipment; and implementability.

In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies.

However, it is unclear whether national and international obstetric societies’ PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland; an international multidisciplinary consensus group; and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies’ recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.

Intraoperative blood cell salvage is an efficacious technique for blood replacement and its use is well established in other areas of medicine, but there are theoretical safety concerns when it is used in obstetric practice. Data
collection is therefore important and clinicians should report all complications to the Medicines and Healthcare products Regulatory Agency. Whenever possible, patients should be fully informed of the potential complications. In addition, use of the Institute's information for the public is recommended.
This procedure should only be performed by multidisciplinary teams who develop regular experience of intraoperative blood cell salvage.

Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.

Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.

Em 2001, a Sociedade Portuguesa de Ginecologia, por intermédio da sua Secção de Ginecologia Oncológica, promoveu o primeiro Consenso sobre Hemorragias Uterinas Anormais (HUA).
Em aplicação de conceitos que vigoravam à época, as hemorragias anormais com origem no corpo uterino classificavam-se em menorragia/hipermenorreia, metrorragia e menometrorragias.
O impacto da HUA é muito variável, podendo em fase aguda provocar disrupções severas com risco de vida para a mulher. Atendendo a que as situações que atinjam essa fase requerem da parte dos profissionais atuações rigorosas e concertadas considerou-se útil abordá-las em capítulo próprio.
Procurando fazer uma revisão temática exaustiva e abrangente, optou-se por incluir neste documento o tratamento da anemia ferropénica, inevitavelmente ligada a quadros clínicos de hemorragia e que muitas vezes é negligenciada.
Os consensos registados no presente documento foram obtidos com base numa ampla pesquisa bibliográfica, permitindo estabelecer níveis de evidência e graduações em relação a cada recomendação aplicando o sistema GRADE.
Os consensos obtidos deverão ser vistos como instrumentos de reflexão para os profissionais que se confrontam com casos dessa natureza proporcionando informação utilizável no exercício da sua prática clínica, designadamente, nas fases de diagnóstico e da escolha da terapêutica a adotar na HUA.

There has been an explosion of interest in the ability of tranexamic acid to reduce morbidity and mortality in surgical and traumatic bleeding. Tranexamic acid has been shown to reduce mortality due to traumatic bleeding by a third, without apparent safety issues. It is now clearly established that intravenous tranexamic acid reduces blood loss in patients with surgical bleeding and the need for transfusion. It can also be used topically to reduce bleeding. Its use is being explored further in large pragmatic trials in traumatic head injury, postpartum haemorrhage and in upper gastro-intestinal haemorrhage. There are few side effects from the use of tranexamic acid except when administered in high dose where neurological events have been noted, possibly relating to tranexamic acid interfering with cerebral GABA and glycine receptors. However, clinical studies suggest that there is no increased efficacy in using a higher dose, and that a dose of 1 g intravenously in an adult patient has maximal efficacy, which is not increased by higher doses. The CRASH-2 trauma trial clearly showed no increase in thrombotic events after its use in trauma, indeed there was a significant reduction in myocardial infarction. However, trials of tranexamic acid in surgery have failed to adequately study its effects on the risk of postoperative venous and possible reduction in arterial thrombo-embolism, and this needs to be the subject of future research.

The management of perioperative bleeding involves multiple assessments and strategies to ensure appropriate patient care. Initially, it is important to identify those patients with an increased risk of perioperative bleeding. Next, strategies should be employed to correct preoperative anaemia and to stabilise macrocirculation and microcirculation to optimise the patient's tolerance to bleeding. Finally, targeted interventions should be used to reduce intraoperative and postoperative bleeding, and so prevent subsequent morbidity and mortality. The objective of these updated guidelines is to provide healthcare professionals with an overview of the most recent evidence to help ensure improved clinical management of patients. For this update, electronic databases were searched without language restrictions from 2011 or 2012 (depending on the search) until 2015. These searches produced 18 334 articles. All articles were assessed and the existing 2013 guidelines were revised to take account of new evidence. This update includes revisions to existing recommendations with respect to the wording, or changes in the grade of recommendation, and also the addition of new recommendations. The final draft guideline was posted on the European Society of Anaesthesiology website for four weeks for review. All comments were collated and the guidelines were amended as appropriate. This publication reflects the output of this work. pré-operatórios

Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.

AA presente Norma aborda o diagnóstico e tratamento das deficiências de ferro no adulto. Considera-se como adulto os maiores ou iguais a 18 anos.

A anemia por deficiência de ferro, constitui a deficiência mais prevalente no mundo segundo a OMS que define anemia se: 1) Hemoglobina <13g/dl no homem e <12g/dl na mulher.

A deficiência de ferro vai desde o estado de depleção de ferro sem anemia à anemia ferropénica.