Gestational diabetes mellitus and obesity are related to persistent hyperglycemia in the postpartum period / Diabetes mellitus gestacional e obesidade estão relacionados à hiperglicemia persistente no período pós-parto

Abstract Objective To evaluate the obstetric and sociodemographic characteristics of gestational diabetic women who maintained hyperglycemia in the postpartum period (6-12 weeks postpartum). Methods This is a longitudinal cohort study with women who have had gestational diabetes and/or macrosomic children between March 1st, 2016 and March 1st, 2017. Between 6 and 12 weeks after birth, women who had gestational diabetes collected fasting glycemia, glucose tolerance test, and glycated hemoglobin results. The data were collected from medical records and during an interview in the first postpartum consultation. A statistical analysis was performed using frequency, percentage, Chi- Squared test, Fisher exact test, Mann-Whitney test, and multivariate Poisson regression. The significance level adopted for the statistical tests was 5%. Results One hundred and twenty-two women were included. Most of the women were younger than 35 years old (70.5%), white, multiparous, and with no history of gestational diabetes. Thirteen percent of the participants developed persistent hyperglycemia. A univariate analysis showed that maternal age above 35 years, being overweight, having grade 1 obesity and weight gain under 5 kg was related to the persistence of hyperglycemia in the postpartum period. Conclusion Maternal age above 35 years, obesity and overweight, and the diagnosis of gestational diabetes in the first trimester of pregnancy are associated with hyperglycemia during the postpartum period.

Resumo Objetivo Avaliar características sociodemográficas e obstétricas de mulheres com diabetes gestacional que mantêm hiperglicemia no período pós-parto (6-12 semanas pós-parto). Métodos Este é um estudo longitudinal de coorte com mulheres com diagnóstico de diabetes gestacional e/ou macrossomia fetal entre 1° de março de 2016 a 1° de março de 2017. As mulheres coletaram glicemia de jejum, teste de tolerância a glicose e hemoglobina glicada entre 6 a 12 semanas pós-parto. Os dados foram coletados de prontuários médicos e durante entrevista na primeira consulta de revisão pós-parto. Uma análise estatística foi realizada através do cálculo de frequências, porcentagens, teste do qui-quadrado, teste exato de Fisher, teste de Mann-Whitney e regressão multivariada de Poisson. A significância estatística adotada foi de 5%. Resultados Cento e vinte e duas mulheres foram incluídas. A maioria delas tinha menos de 35 anos de idade (70,5%), eram brancas, multíparas, e não tinham história de diabetes gestacional. Treze por cento das participantes desenvolveu hiperglicemia persistente. A análise univariada mostrou que os fatores relacionados com a persistência de hiperglicemia no período pós-natal foram: idade materna acima de 35 anos, sobrepeso, obesidade grau 1 e ganho de peso abaixo de 5 quilos. A análisemultivariada incluiu o diagnóstico no primeiro trimestre como fator de risco para hiperglicemia persistente. Conclusão Mulheres acima de 35 anos, obesidade, sobrepeso e diagnóstico de diabetes gestacional no primeiro trimestre estão relacionados com hiperglicemia persistente no período pós-parto.

Venous thromboembolism and route of delivery - review of the literature / Tromboembolismo venoso e via de parto - revisão da literatura

Abstract Venous thromboembolism events are important causes of maternal death during pregnancyandthepostpartumperiodworldwide.Are view of the literature with the objective of evaluating venous thromboembolism events in the puerperium according to the route of delivery was performed through a bibliographic survey in the Medline, LILACS and Scielo databases. We observed that patients submitted to cesarean sections present a significantlyhigher riskofdeveloping venousthromboembolismwhencomparedwiththose who undergo spontaneous vaginal delivery. The pathophysiological bases for this difference were explored and described in this review, as well as the indications of prophylaxis and treatment. Doctors and health professionals must be continuously vigilant regarding this condition, since it is associated with high morbidity and mortality.

Resumo Os eventos de tromboembolismo venoso são causas importantes de morte materna durante a gravidez e o período do pós-parto em todo o mundo. Foi realizada uma revisão da literatura com o objetivo de avaliar os eventos de tromboembolismo venoso no puerpério de acordo com a via de parto utilizada, por meio de uma pesquisa bibliográfica nas bases de dados Medline, LILACS e Scielo. Observou-se que as pacientes submetidas a cesariana apresentam um risco significativamente maior de desenvolver tromboembolismo venoso do que aquelas que se submetem a parto vaginal espontâneo. As bases fisiopatológicas desta diferença foram exploradas e descritas nesta revisão, bem como as indicações de profilaxia e tratamento. O alerta contínuo dos médicos e profissionais de saúde é necessário, uma vez que se trata de uma condição comum associada a alta morbidade e mortalidade.

Complicações puerperais precoces e tardias associadas à via de parto em uma coorte no Brasil / Early and late puerperal complications associated with the mode of delivery in a cohort in Brazil

RESUMO: Introdução: As taxas de cesárea aumentaram significativamente no Brasil e no mundo nos últimos anos; e junto delas o interesse em estudar as complicações relacionadas a esse procedimento. Objetivo: Avaliar as complicações maternas precoces e tardias relacionadas à via de parto, por até seis anos após o parto. Métodos: Trata-se de um estudo tipo coorte prospectiva que acompanhou todos os nascimentos da cidade de Pelotas, no Sul do Brasil (4.244 mães), no ano de 2004, por um período de 6 anos. Foram realizadas análises descritivas e de associação entre o desfecho e a via de parto. O controle para potenciais fatores de confusão foi realizado através da regressão de Poisson com variância robusta. Resultados: Cerca da metade das mulheres (44,9%) foram submetidas à cesárea. O parto cesárea foi associado a um risco 56% maior de complicações precoces, 2,98 vezes maior de infecção pós-parto, 79% mais risco de infecção urinária, 2,40 vezes maior de dor, 6,16 vezes maior de cefaleia e mais de 12 vezes maior de complicações anestésicas, quando comparado ao parto vaginal. A cesárea foi proteção contra a presença de hemorroidas. A via de parto não foi associada a nenhuma das complicações tardias estudadas. Conclusão: Devido ao risco de complicações associado, as cesáreas devem ser realizadas com cautela, quando seus benefícios superam os riscos.

ABSTRACT: Introduction: The rates of cesarean section births significantly increased in Brazil and worldwide in recent years; and along with them, the interest in studying the complications related to this procedure. Objective: To assess the early and late maternal complications associated with the mode of delivery in up to six years after labor. Methods: This is a prospective cohort study that followed all births in the city of Pelotas, in Southern Brazil (4,244 mothers) in 2004, for a period of 6 years. Descriptive analyses and the association between the outcome and mode of delivery were performed. The control for potential confounding factors was performed using Poisson regression with robust error variance. Results: About half (44.9%) of the women underwent cesarean section. Cesarean sections were associated with a 56% higher risk of early complications, 2.98 times higher risk of postpartum infection, 79% higher risk of urinary tract infection, 2.40 times higher risk of pain, 6.16 times higher risk of headaches, and 12 times higher risk of anesthetic complications compared to the vaginal delivery. Cesarean section was a protection factor against the presence of hemorrhoids. The mode of delivery was not associated with any of the late complications studied. Conclusions: Due to the risk of associated complications, cesarean sections should be performed with caution, when their benefits outweigh the risks.

Maternal complications and cesarean section without indication: systematic review and meta-analysis / Complicações maternas e cesárea sem indicação: revisão sistemática e meta-análise

ABSTRACT OBJECTIVE The objective of this study was to determine the risks of severe acute maternal complications associated with cesarean section without medical indication. METHODS A systematic review was carried out with meta-analysis. The literature search was performed systematically, in multiple stages, in the PubMed, Lilacs, and Web of Science databases using the following descriptors: (postpartum period) and (cesarean section or natural childbirth) and ((morbidity or mortality) or (postpartum hemorrhage) or (puerperal infection) or (surgical infection) or (puerperal disorders)). The protocol of the study was registered at PROSPERO as CRD42016032933. A total of 1,328 articles were found; after selection, eight publications that met the study objective and inclusion criteria were selected, with information on 1,051,543 individuals. RESULTS The results obtained in the meta-analyses indicate that women with cesarean section have a higher chance of maternal death (OR = 3.10, 95%CI 1.92-5.00) and postpartum infection (OR = 2.83, 95%CI, 1.585.06), but they have a lower chance of hemorrhage (OR = 0.52, 95%CI 0.48-0.57). For the blood transfusion outcome, the group effect was not associated with the type of delivery (95%CI 0.88-2.81). CONCLUSIONS The quality of evidence was considered low for hemorrhage and blood transfusion and moderate for postpartum infection and maternal death. Thus, cesarean sections should be performed with caution and safety, especially when its benefits outweigh the risks of a surgical procedure.

RESUMO OBJETIVO Determinar os riscos de complicações maternas agudas graves associadas ao parto cesárea sem indicação médica. MÉTODOS Foi conduzida uma revisão sistemática com meta-análise. A busca na literatura ocorreu de forma sistemática, em múltiplas etapas, nas bases de dados PubMed, Lilacs e Web of Science, utilizando os descritores: (postpartum period) and (cesarean section or natural childbirth) and ((morbidity or mortality) or (postpartum hemorrhage) or (puerperal infection) or (surgical infection) or (puerperal disorders)). O protocolo de estudo foi registrado na PROSPERO sob o número CRD42016032933. Foram encontrados 1.328 artigos, permanecendo, após seleção, oito publicações que atendiam ao objetivo do estudo e critérios de inclusão, com informações de 1.051.543 indivíduos. RESULTADOS Os resultados obtidos nas meta-análises indicam que mulheres de parto cesárea tem maior chance de morte materna (OR = 3,10; IC95% 1,92-5,00) e infecção pós-parto (OR = 2,83; IC95% 1,58-5,06), mas possuem menor chance de hemorragia (OR = 0,52; IC95% 0,48-0,57). Para o desfecho transfusão de sangue, o efeito agrupado não foi associado à via de parto (IC95% 0,88-2,81). CONCLUSÕES A qualidade da evidência foi considerada baixa para os desfechos hemorragia e transfusão de sangue e moderada para infecção pós-parto e morte materna. Assim, as cesáreas devem ser realizadas com prudência e segurança, principalmente quando seus benefícios superam os riscos de um procedimento cirúrgico.

Risk factors for postpartum urinary incontinence / Factores de riesgo para incontinencia urinaria en el puerperio / Fatores de risco para incontinência urinária no puerpério

Abstract OBJECTIVE: To investigate the risk factors for postpartum urinary incontinence (UI) and its characteristics. METHOD: This was a case-control study with 344 puerperal women (77 cases and 267 controls) with up to 90 days postpartum. In a single session, participants were given a questionnaire with sociodemographic and clinical data and two others that assessed urine leakage, leakage situations, and type of UI. RESULTS: Stress UI was present in 45.5% of the women, incidents of urine leakage several times a day in 44.2%, of which 71.4% were in small amounts and 57.1% when coughing or sneezing. In 70.1% of cases, UI began during pregnancy and remained through the postpartum period. After running a binary logistic regression model, the following factors remained in the final model: UI during pregnancy (OR 12.82, CI 95% 6.94 - 23.81, p<0.0001), multiparity (OR 2.26, CI 95% 1.22 - 4.19, p=0.009), gestational age at birth greater or equal to 37 weeks (OR 2.52, CI 95% 1.16 - 5.46, p=0.02) and constipation (OR 1.94, CI 95% 1.05 - 5.46, p=0.035). CONCLUSION: Most often, UI first appeared during pregnancy and remained through the postpartum period. Urinary incontinence during pregnancy, multiparity, gestational age at birth greater or equal to 37 weeks, and constipation were presented as risk factors. In the studied group, stress UI was more frequent.

Resumen OBJETIVO: Investigar los factores de riesgo para incontinencia urinaria (IU) en el puerperio y sus características. MÉTODO: Se trata de estudio de caso-control con 344 puérperas (77 casos y 267 controles), con hasta 90 días post parto. Se aplicó, en un solo momento, un cuestionario para los datos sociodemográficos y clínicos, y dos otros para evaluar la pérdida urinaria, situaciones de pérdida y el tipo de IU. RESULTADOS: Presentaron IU de esfuerzo el 45,5%, pérdida urinaria diversas veces al día el 44,2%, siendo el 71,4% en pequeña cantidad y el 57,1% al toser o estornudar. En el 70,1% de los casos la IU se inició en la gestación y permaneció en el puerperio. Al ajustarse un modelo de regresión logística binaria, solo IU en la gestación (OR 12,82, IC 95% 6,94 - 23,81, p<0,0001), multiparidad (OR 2,26, IC 95% 1,22 - 4,19, p=0,009), edad gestacional en el parto mayor o igual que 37 semanas (OR 2,52, IC 95% 1,16 - 5,46, p=0,02) y constipación (OR 1,94, IC 95% 1,05 - 5,46, p=0,035) permanecieron en el modelo final. CONCLUSIÓN: La IU se inicia a menudo en la gestación y permanece en el puerperio. La presencia de IU en la gestación, multiparidad, edad gestacional en el parto mayor o igual que 37 semanas y constipación fueron factores de riesgo. En el grupo estudiado la IU de esfuerzo fue la más frecuente.

Resumo OBJETIVO: Investigar os fatores de risco para a incontinência urinária (IU) no puerpério e as suas características. MÉTODO: Trata-se de estudo caso-controle com 344 puérperas (77 casos e 267 controles), com até 90 dias pós-parto. Foi aplicado, em um único momento, um questionário para os dados sociodemográficos e clínicos, e dois outros para avaliar a perda urinária, situações de perda e o tipo de IU. RESULTADOS: Apresentaram IU de esforço 45,5%, perda urinária diversas vezes ao dia 44,2%, sendo 71,4% em pequena quantidade e 57,1% ao tossir ou espirrar. Em 70,1% dos casos a IU iniciou-se na gestação e permaneceu no puerpério. Ao ajustar-se um modelo de regressão logística binária, apenas IU na gestação (OR 12,82, IC 95% 6,94 - 23,81, p<0,0001), multiparidade (OR 2,26, IC 95% 1,22 - 4,19, p=0,009), idade gestacional no parto maior ou igual a 37 semanas (OR 2,52, IC 95% 1,16 - 5,46, p=0,02) e constipação (OR 1,94, IC 95% 1,05 - 5,46, p=0,035) permaneceram no modelo final. CONCLUSÃO: A IU iniciou-se frequentemente na gestação e permaneceu no puerpério. A presença de IU na gestação, multiparidade, idade gestacional no parto maior ou igual a 37 semanas e constipação foram fatores de risco. No grupo estudado a IU de esforço foi a mais frequente.

Obstetric profile of pregnant adolescents in a public hospital: risk at beginning of labor, at delivery, postpartum, and in puerperium / Perfil obstétrico de adolescentes grávidas em um hospital público: risco no início do trabalho de parto, parto, pós-parto e puerpério / Perfil obstétrico de adolescentes embarazadas en un hospital público: riesgo al inicio del trabajo de parto, parto, posparto y puerperio

Objective: describe the obstetric profile of adolescents at beginning of labor, at delivery, postpartum, and in puerperium.Method: Cross-sectional descriptive study with 85 pregnant adolescents, selected by convenience, referred by health centers to a public hospital in Mexico City. Risks were evaluated before, during and after delivery and in puerperium, and measured respectively with the "Previgenes" that compose the Reproductive and Perinatal Risk Assessment System.Results: socioeconomic status, occupation and education level had influence on the emotionality of adolescents in relation to labor, whose obstetric risk was low for 55%, medium for 35%, and high for 10%. Risk in labor was low for 55%, medium for 18%, and high for 27%. Risk postpartum was low for 50%, medium for 25%, and high for 25%. In puerperium, most adolescents (90%) had low risk.Conclusion: most adolescents had low risk in the stages evaluated. The study contributed to identify strategies to approach risk considering the vulnerability inherent in this type of population and favored the conduct of appropriate interventions for the respective needs.

Objetivo: descrever o perfil obstétrico das adolescentes no início do trabalho de parto, durante o parto, pós-parto e puerpério.Método: estudo descritivo transversal, com 85 adolescentes grávidas, escolhidas por conveniência, encaminhadas dos Centros de Saúde a um Hospital Público na Cidade do México. Foram avaliados os riscos antes, durante e depois do parto e no puerpério, medidos respectivamente com os "Previgenes" que compõem o Sistema de Avaliação de Risco Reprodutivo e Perinatal.Resultados: o nível socioeconômico, a ocupação e a escolaridade tiveram influência sobre a emotividade das adolescentes em relação ao trabalho de parto, cujo risco obstétrico foi 55% baixo, 35% médio e 10% alto. O risco no trabalho de parto foi baixo em 55%, médio em 18% e alto em 27%. O risco no pós-parto foi de 50% risco baixo, 25% risco médio e 25% risco alto. No puerpério, a maioria das adolescentes (90%) apresentou baixo risco.Conclusão: a maioria das adolescentes apresentou baixo risco nas etapas avaliadas. O estudo contribuiu para identificar estratégias para a abordagem de riscos devido à vulnerabilidade inerente a este tipo de população e favoreceu a realização de intervenções adequadas para as suas necessidades.

Objetivo: escribir el perfil obstétrico de las adolescentes al inicio del trabajo de parto, durante el parto, el posparto y el puerperio.Método: estudio descriptivo transversal, con 85 adolescentes embarazadas elegidas por conveniencia, referidas de los Centros de Salud a un Hospital Público en la Ciudad de México. Fue evaluado el riesgo antes, durante, después del parto y en el puerperio, medidos respectivamente con los "Previgenes" que componen el Sistema de Evaluación de Riesgo Reproductivo y Perinatal.Resultados: el nivel socioeconómico, la ocupación y la escolaridad influyeron en la emotividad de las adolescentes ante el trabajo de parto, cuyo riesgo obstétrico fue de 55% bajo, 35% medio y 10% alto. El riesgo en el parto fue bajo en 55%, medio en 18% y alto en 27%. El riesgo en el posparto fue 50% riesgo bajo, 25% riesgo medio y 25% riesgo alto. En el puerperio, la mayoría de las adolescentes (90%) presentó riesgo bajo.Conclusión: la mayoría de las adolescentes presentaron bajo riesco en las etapas avaluadas. El estudio contribuyó a identificar las estrategias para el abordaje de riesgos por la vulnerabilidad propia en este tipo de población y favoreció la realización de intervenciones acorde a sus necesidades.

Perfil epidemiológico das alterações dermatológicas observadas em mulheres em período de puerpério imediato atendidas no Hospital São José, em Criciúma, Santa Catarina / Epidemiological profile of dermatological changes observed in early postpartum women cared for at São José Hospital in Criciúma, Santa Catarina

Introdução: Durante o período gestacional, o corpo feminino passa por profundas alterações hormonais e mecânicas, em que a pele também sofre alterações. O objetivo deste trabalho foi conhecer a prevalência das principais alterações dermatológicas no período gestacional de gestantes atendidas no Hospital São José, de Criciúma-SC. Métodos: Estudo transversal com 188 gestantes. Foram entrevistadas e examinadas as mulheres em período de puerpério imediato no Hospital São José, de Criciúma, Santa Catarina, no mês de dezembro de 2010. Foram estudadas as seguintes variáveis: idade; peso antes e ao fi nal da gestação; número de gestações; queda de cabelos; alterações ungueais; manchas de pele; aparecimento de estrias ou pápulas pruriginosas. Resultados: Foram identificados 104 casos de estrias (55,31%) e 61 casos de melasma (32,44%). Os locais de maior frequência de estrias foram em abdome 71 (51,45%), seios 35 (25,36%), nádegas 8 (5,8%) e pernas 24 (17,39%). A distribuição do melasma foi mais frequente em região centro-facial 52 (77,61%) e em região malar 7 (10,44%). Conclusões: Pacientes jovens, que tiveram maior ganho ponderal, foram as mais acometidas com estrias. Melasma acometeu pouco mais de um quarto da amostra e ocorreu com maior frequência em gestantes de faixa etária mais baixa (AU)

Introduction: During pregnancy a woman's body undergoes profound hormonal and mechanical changes, where the skin also undergoes changes. The aim of this study was to determine the prevalence of major skin changes during pregnancy among women cared for at Hospital São José, Criciúma, SC. Methods: Cross-sectional study involving 188 pregnant women. We interviewed and examined women in the early postpartum period at Hospital São José, Criciúma, SC in December 2010. The following variables were considered: age, weight before and at the end of pregnancy, number of pregnancies, hair loss, nail changes, skin blemishes, appearance of stretch marks or pruritic papules. Results: We identified 104 cases of stretch marks (55.31%) and 61 cases of melasma (32.44%). Stretch marks were most often found in the abdomen (71 cases, 51.45%), breasts (35, 25.36%), buttocks (8, 5.8%) and legs (24, 17.39%). Melasma was more frequent in the center-facial region (52, 77.61%) and malar region (7, 10.44%). Conclusions: Young patients who had greater weight gain were the most affected with stretch marks. Melasma struck just over a quarter of the sample and occurred more frequently in younger women (AU)

Facility-based care for delivery and management of complications related to pregnancy and childbirth in Mexico

OBJECTIVE: To describe the incidence and management of severe maternal and newborn complications in selected health facilities in Mexico. MATERIALS AND METHODS: As part of the WHO Multicountry Survey on Maternal and Newborn health, information was collected from medical records of women with deliveries and/or severe maternal complications during pregnancy or puerperium in 14 hospitals in Mexico City and the state of Guanajuato, Mexico. RESULTS: Of 13 311 women, 157 (12 per 1 000 live births) had severe maternal complications including 4 maternal deaths. The most frequent complications were preeclampsia, postpartum hemorrhage, and chronic hypertension. Adverse perinatal outcomes were more frequent among women with severe maternal complications. A high use of uterotonics and parenteral antibiotics was found. A small proportion of women with eclampsia received magnesium sulfate. CONCLUSION: This study provides indicators on the incidence and management of maternal and neonatal complications in Mexico, which may be useful in studying and evaluating the performance of obstetric services.

OBJETIVO: Describir la incidencia y manejo de complicaciones maternas y neonatales severas en hospitales seleccionados de México. MATERIAL Y MÉTODOS: En el marco de la Encuesta Multipaís de la OMS sobre Salud Materna y Neonatal, se recolectó información de los expedientes médicos de las mujeres que tuvieron su parto o experimentaron complicaciones maternas severas durante el embarazo o puerperio en 14 hospitales de la Ciudad de México y el estado de Guanajuato, México. RESULTADOS: De 13 311 mujeres, 157 (12/1 000 nacidos vivos) tuvieron complicaciones maternas severas, incluyendo 4 muertes maternas. Las complicaciones más frecuentes fueron preeclampsia, hemorragia postparto e hipertensión crónica. Los resultados perinatales adversos fueron más frecuentes en las mujeres con complicaciones severas. Hubo un uso amplio de uterotónicos y antibióticos parenterales. Una baja proporción de mujeres con eclampsia recibió sulfato de magnesio. CONCLUSIONES: Esta encuesta proporciona indicadores sobre la incidencia y manejo de las complicaciones maternas y neonatales en México, los cuales pueden ser de utilidad para estudiar y evaluar el desempeño de los servicios obstétricos.

Incontinência urinária autorreferida no pós-parto: características clínicas / Self-reported urinary incontinence in the postpartum period: clinical characteristics / Incontinencia urinaria autorreferida en el posparto: características clínicas

Este estudo transversal teve como objetivo caracterizar as manifestações de incontinência urinária autorreferida no pós-parto. Foram entrevistadas 288 mulheres atendidas em um Centro de Saúde Escola do município de São Paulo, entre janeiro e agosto de 2009. Os dados indicaram que, dentre as 71 mulheres incontinentes (24,6%), 44 destas (62%) referiram incontinência urinária aos esforços, 65 (91,5%) sentiam a urina escoar, 33 mulheres (46,5%) apresentavam perdas por mais de uma vez na semana e 24 (33,8%) acusaram perda urinária persistente no momento da entrevista. A gravidade, classificada como incontinência urinária moderada, foi constatada em 53 mulheres (74,7%). Os achados realçam a importância de investigações sobre incontinência urinária no período pós-parto, assim como sua abordagem no ensino e na assistência à mulher no período reprodutivo.

The objective of this cross-sectional study was to characterize the manifestations of self-reported urinary incontinence in the postpartum period. We interviewed 288 women who were clients of a teaching health center in São Paulo, between the months of January and August of 2009. The data showed that among the 71 incontinent women (24.6%), 44 (62%) reported stress urinary incontinence, 65 (91.5%) were aware of urine leakage, 33 women (46.5%) experienced urine loss more than once a week, and 24 (33.8%) reported persistent urinary incontinence at the time of interview. The severity classified as moderate urinary incontinence was identified in 53 women (74.7%). The findings highlight the importance of studies on urinary incontinence in the postpartum period, as well as approaching this issue in education and health care interventions with women in the reproductive stage.

Este estudio transversal tuvo como objetivo caracterizar las manifestaciones de incontinencia urinaria autorreferida en el posparto. Fueron entrevistadas 288 mujeres atendidas en un Centro de Salud Escuela del municipio de São Paulo, entre enero y agosto de 2009. Los datos demostraron que de las 71 mujeres con incontinencia (24,6%). 44 de ellas (62%) refirieron incontinencia ante los esfuerzos, 65 (91,5%) sentían el escurrimiento de la orina, 33 mujeres (46,5%) presentaban pérdidas más de una vez a la semana, y 24 (33,8%) refirieron perdida urinaria persistente en el momento de la entrevista. La gravedad, clasificada como incontinencia urinaria moderada, se constató en 53 mujeres (74,7%). Los hallazgos realzan la importancia de investigaciones sobre incontinencia urinaria en el período de posparto, así como su abordaje en la enseñanza y atención a la mujer en el período reproductivo.

Comportamiento patológico del puerperio / Pathologic behavior of puerperium

INTRODUCCIÓN: La muerte materna es uno de los indicadores primordiales que miden el nivel socioeconómico y estado de salud poblacional y resulta muy compleja su evaluación. Durante el puerperio pueden ocurrir complicaciones que evolucionen hacia la muerte, originando consecuencias negativas a la familia, la población y sistema de salud. OBJETIVOS: Caracterizar el puerperio patológico durante un trienio en el hospital ginecobstétrico provincial. Determinar la incidencia y causas de las complicaciones en el puerperio señalando la frecuencia de las mismas. Identificar la vía del parto y edad de la puérpera complicada, teniendo en cuenta la estadía post parto y reingreso. MÉTODOS: Se realizó un estudio observacional descriptivo prospectivo de las puérperas que tuvieron alguna complicación durante el período de enero 2007 a diciembre 2009, en el Hospital Ginecobstétrico Dr. Julio Rafael Alfonso Medina de Matanzas, que tuvieron su parto o cesárea en el hospital. Se recolectaron los datos a través de un modelo confeccionado al efecto, previo consentimiento escrito de las pacientes, se describieron variables operacionalizadas. RESULTADOS: La incidencia de las complicaciones puerperales fue del 3,05 por ciento, las principales complicaciones halladas fueron la mastitis aguda (19,2 por ciento) y endometritis puerperal (15,7 por ciento). Las complicaciones se relacionaron con el parto vaginal en el 64,5 por ciento, estadía hospitalaria entre 2 y 7 días ocurrió en el 66,3 por ciento. CONCLUSIONES: Se logró caracterizar el puerperio, considerando que las complicaciones tienen baja incidencia, con riesgo significativo en adolescentes y mujeres muy jóvenes, fueron frecuentes las complicaciones mamarias, con mayor incidencia en pacientes con partos vaginales lo que implica estadías prolongadas

INTRODUCTION: Mother death is one the fundamental indicators measuring the socioeconomic level and the population health status whose evaluation is very complex. During puerperium period may to be present complications evolving to death, leading to negative consequences for the family the population and the health system. OBJECTIVES: The aim of present study was to characterize the pathological puerperium during three years in the provincial gynecology and obstetrics hospital as well as to determine the incidence and causes of complications at puerperium as well as their frequency and to identify the labor route and re-admission. METHODS: A prospective, descriptive and observational study was conducted in puerperal patients suffered some complication during January, 2007 to December, 2009 in the Dr. Julio Rafael Alfonso Medina Gynecology and Obstetrics Hospital of Matanzas province whose labor or cesarean section were at hospital. Data were collected by means of a form designed to that end, previous writing informed consent of patients, describing the operational variables. RESULTS: The incidence of puerperium complications was of 3.05 percent, the major complications found were acute mastitis (19.2 percent) and puerperium endometritis (15.7 percent). Complications are related with vaginal labor in the 64.5 percent, hospital stay from 2 to 7 days in the 66.3 percent. CONCLUSIONS: It was possible to characterize the puerperium, taking into account that complications have a low incidence, with a significant risk in adolescents and very young women, the breast complications were the more frequent ones with a high incidence in patients with vaginal labors leading to lengthy stays

Morbidade neonatal e maternas relacionada ao tipo de parto / Neonatal and maternal morbidity related to the type of delivery

Foi realizada uma análise da morbidade neonatal e materna e a mortalidade neonatal de acordo com o tipo de parto, cesariana ou vaginal. Foram estudadas prospectivamente 170 parturientes sem complicações gestacionais e com nascimento a termo: Grupo 1 (n = 95), puérpera com parto por via vaginal, Grupo 2 (n = 75), puérpera submetida à cesariana. Parâmetros maternos e fetais foram avaliados. Foi observada maior incidência de partos por via vaginal nas pacientes que estudaram até o ensino fundamental incompleto (p = 0,0045). Houve prevalência maior de partos prévios por via vaginal no Grupo 1 e de cesáreas no Grupo 2 (p < 0,001). Observou preferência de 78 (82,1 por cento) das mulheres do Grupo 1 pelo parto vaginal contra apenas 28 (37,3 por cento) das mulheres do Grupo 2, pela cesárea (p = 0,0002). Houve dor intensa no pós-operatório nas pacientes submetidas a parto cesáreo (oito casos) (p = 0,018). Traumas obstétricos foram verificados em catorze recém-nascidos do Grupo 1 e em sete do Grupo 2 (p = 0,28). Concluímos que existe maior morbidade neonatal em recém-natos de parto por via vaginal quando comparada com neonatos de cesárea e maior morbidade materna em puérperas com parto cesariana.

An evaluation of infant morbimortality and mother morbidity was undertaken according to the type of delivery. A prospective study was undertaken on 170 puerperal patients divided into two groups: Group 1 (n = 95), natural or vaginal delivery, Group 2 (n = 75), submitted to caesarean delivery. Complications in mothers were classified in small, moderate and severe. The infant parameters were: period of pregnancy, weight on birth, Apgar score, necessity of intensive care and neurological disorders. Mothers who had not completed elementary school (p=0.0045) had more vaginal delivery. Previous vaginal deliveries were more common in Group 1 than caesarean section in Group 2 (p = < 0.001) (OR = 104.00; 21.11 < OR < 610.99). In Group 1, vaginal delivery was preferred by 78 (82,1 percent) of mothers comparing to 28 (37.3 percent) from Group 2, who preferred caesarean section (p = 0.0002) (OR = 4; 1.77 < OR < 9.17). Post-operative was more intense and frequent after caesarean section (8 cases) than patients of Group 1 (2 cases) (p = 0.018) (OR = 0.18; 0.03 < OR < 0.96). Obstetric trauma was found in 14 deliveries of Group 1 and 7 of Group 2 (p = 0.28). Infant hospitalization was greater in Group 2 (3.43 +/- 0.70 days) in comparison with Group 1 (2.71 +/- 0.67 days) (p < 0.0001). The infant morbidity was greater after vaginal deliveries, but maternal morbidity was greater after caesarean deliveries.

Pathology in children of HIV women.

Objective. To assess the frequency of perinatal pathology in children exposed to antiretrovirals in perinatal period. Methods. Retrospective observational cohort study. Data collected among uninfected children born to HIV-infected women followed up from 1994 to 2006 in a tertiary Hospital. 220 uninfected children were studied. Factors studied included maternal, obstetrical and pediatric variables. Results. The most common disorder found among children exposed to antiretroviral drugs was anemia (84%); 6,4% of children had neutropenia and more than 24% had thrombocytosis, a finding never described before. Prematurity (24%) and low birth weight (23.6%) rates were high. Several congenital malformations were found: Poland syndrome, angiomas, hypospadias, Pierre-Robin sequence, trisomy 8, craniostosis and others. Long-term follow-up revealed neurological, cardiological and ophthalmological pathologies. Conclusion. Some pathologies are frequent among children exposed to antiretroviral agents during perinatal life. It is crucial to carry out long-term studies to assess the safety of this therapy.

Early hospital discharge and early puerperal complications / Egreso temprano postparto y complicaciones en el puerperio mediato

OBJECTIVE:To evaluate the association between time of postpartum discharge and symptoms indicative of complications during the first postpartum week. MATERIALS AND METHODS: Women with vaginal delivery at a Mexico City public hospital, without complications before the hospital discharge, were interviewed seven days after delivery. Time of postpartum discharge was classified as early (<24 hours) or late (>25 hours). The dependent variable was defined as the occurrence and severity of puerperal complication symptoms. RESULTS:Out of 303 women, 208 (68%) were discharged early. However, women with early discharge and satisfactory prenatal care had lower odds of presenting symptoms in early puerperium than women without early discharge and inadequate prenatal care (OR 0.36; 95% confidence intervals = 0.17-0.76). CONCLUSIONS:There was no association between early discharge and symptoms of complications during the first postpartum week; the odds of complications were lower for mothers with early discharge and satisfactory prenatal care.

OBJETIVO:Evaluar la asociación entre el tiempo de egreso posparto y las posibles complicaciones en el puerperio mediato. MATERIAL Y MÉTODOS:Mujeres con parto vaginal atendidas en un hospital público de la Ciudad de México, sin complicaciones antes del egreso hospitalario, fueron entrevistadas a los siete días de egreso. La variable dependiente fue la ocurrencia y severidad de complicaciones. Se calcularon media y desviación estándar para las variables continuas, y proporciones para las categóricas. Las variables relacionadas con egreso temprano en el análisis bivariado (con p<0.15) fueron incluidas en un modelo de regresión logística. RESULTADOS:Se analizó información de 303 partos, de los cuales 208 (68%) tuvieron egreso temprano posparto. Las mujeres que fueron egresadas en forma temprana con un control prenatal adecuado reportaron menos síntomas de complicaciones en el puerperio mediato (RM= 0.36; IC 95% = 0.17-0.76). CONCLUSIONES:Aunque no se encontró asociación entre el egreso temprano y los síntomas de complicaciones durante la primera semana del posparto, el riesgo de complicaciones fue menor en mujeres con egreso temprano y con cuidado prenatal adecuado, comparadas con las mujeres que presentaron egreso tardío sin control prenatal.

Practices of rural Egyptian birth attendants during the antenatal, intrapartum and early neonatal periods.

Neonatal deaths account for almost two-thirds of infant mortality worldwide; most deaths are preventable. Two-thirds of neonatal deaths occur during the first week of life, usually at home. While previous Egyptian studies have identified provider practices contributing to maternal mortality, none has focused on neonatal care. A survey of reported practices of birth attendants was administered. Chi-square tests were used for measuring the statistical significance of inter-regional differences. In total, 217 recently-delivered mothers in rural areas of three governorates were interviewed about antenatal, intrapartum and postnatal care they received. This study identified antenatal advice of birth attendants to mothers about neonatal care and routine intrapartum and postpartum practices. While mothers usually received antenatal care from physicians, traditional birth attendants (dayas) conducted most deliveries. Advice was rare, except for breastfeeding. Routine practices included hand-washing by attendants, sterile cord-cutting, prompt wrapping of newborns, and postnatal home visits. Suboptimal practices included lack of disinfection of delivery instruments, unhygienic cord care, lack of weighing of newborns, and lack of administration of eye prophylaxis or vitamin K. One-third of complicated deliveries occurred at home, commonly attended by relatives, and the umbilical cord was frequently pulled to hasten delivery of the placenta. In facilities, mothers reported frequent use of forceps, and asphyxiated neonates were often hung upside-down during resuscitation. Consequently, high rates of birth injuries were reported. Priority areas for behaviour change and future research to improve neonatal health outcomes were identified, specific to type of provider (physician, nurse, or daya) and regional variations in practices.

Dispareunia en mujeres después del parto: estudio de casos y controles en un hospital de Acapulco, México / Women's dyspareunia after childbirth: a case study in a hospital in Acapulco, Mexico

OBJETIVO: Identificar los factores asociados con la dispareunia entre 60 y 180 días después del parto en mujeres con antecedentes de uno o dos partos. MÉTODOS: Estudio de casos y controles, pareados por la edad y la paridad en 304 mujeres que acudieron al servicio de planificación familiar de un hospital de Acapulco, Guerrero, México, entre los 60 y 180 días después del parto. Se aplicó un cuestionario con preguntas sobre su situación socioeconómica (edad, escolaridad propia y de su pareja, estado civil, situación laboral, de seguridad social y de tenencia de su casa) y sus antecedentes obstétricos (características del parto, paridad, lugar de atención, desgarros, episiotomía y complicaciones) y ginecológicos (sensación de estrechez del introito, presencia de cicatriz queloide de la episiorrafia, síntomas de vaginitis, resequedad vaginal, métodos anticonceptivos empleados y tipo y duración de la lactancia). Se consideraron como casos a las mujeres que refirieron dolor, ardor o sangrado al tener relaciones sexuales con penetración vaginal después del parto. Se aplicó un modelo de regresión logística no condicionada y se calcularon las razones de posibilidades (odds ratios, OR) y los intervalos de confianza de 95 por ciento (IC95 por ciento). RESULTADOS: De 368 mujeres que habían reiniciado relaciones sexuales, 152 (41,3 por ciento) refirieron dispareunia. Los factores asociados con dispareunia fueron haber tenido infección con o sin dehiscencia de la episiorrafia (OR = 34,09; IC95 por ciento: 10,59 a 109,78), presentar síntomas de vaginitis (OR = 7,43; IC95 por ciento: 3,68 a 14,99), tener sensación de estrechez del introito vaginal (OR = 6,38; IC95 por ciento: 2,92 a 13,94) y practicar la lactancia exclusiva (OR = 4,86; IC95 por ciento: 2,44 a 9,69). CONCLUSIONES: La dispareunia estuvo relacionada con las complicaciones de la episiotomía y sus posibles secuelas, como la infección, la dehiscencia de la episiorrafia y la estrechez del introito vaginal. Se debe realizar una mejor vigilancia de la episiorrafia durante el puerperio y seleccionar más apropiadamente las mujeres a quienes se les realiza la episiotomía.

OBJECTIVE: To identify the factors associated with dyspareunia, during the 60-180 days following childbirth, in women with a history of one or two childbirths. METHODS: A case study of 304 women, matched by age and parity who visited family planning services in a hospital in Acapulco, State of Guerrero, Mexico, 60-180 days after giving birth. A questionnaire was administered to assess socioeconomic status (age, level of education, partner’s level of education, marital status, employment, social security, and homeownership), obstetric history (type of birth, parity, location of the birth, tearing, episiotomy, and complications), and gynecological status (constricted introitus, scar tissue at the episiotomy site, symptoms of vaginitis, vaginal dryness, contraceptive use, and breast feeding duration). Cases were defined as those women who related pain, burning, or bleeding following vaginal intercourse after childbirth. An unconditional logistic regression model was applied and odd ratios (OR) and 95 percent confidence interval were calculated. RESULTS: Of the 368 women who had reinitiated sexual relations, 152 (41.3 percent) mentioned dyspareunia. The factors associated with dyspareunia were: an infection with or without episiorrhaphy dehiscence (OR = 34.09; CI95 percent: 10.59-109.78); symptoms of vaginitis (OR = 7.43; CI95 percent: 3.68-14.99); tightness in the introitus of the vagina (OR = 6.38; CI95 percent: 2.92-13.94), and breast feeding exclusively (OR = 4.86; CI95 percent: 2.44- 9.69). CONCLUSIONS: Dyspareunia was related to complications with episiotomy and its possible sequelae, such as infection, episiorrhaphy dehiscence, and constricted introitus. More attention should be given to the episiotomy site during the postpartum period and greater selectivity is needed when deciding which women require an episiotomy.

Delivery practices of traditional birth attendants in Dhaka slums, Bangladesh.

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on delivery-location, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birth-location. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity.

Incontinencia fecal por lesiones ocultas del mecanismo de esfínter anal y factores asociados en pacientes primíparas sin episiotomía media de rutina / Fecal incontinence, occult lesions to the anal sphincter and related factors in primiparous patients without median routine episiotomy

Introducción: la incontinencia fecal es más frecuente en mujeres, principalmente por la relación con el trauma obstétrico. Los factores que favorecen estas lesiones obstétricas han sido estudiados ampliamente; la Norma Oficial Mexicana ha cancelado el uso rutinario de la episiotomía media en los partos. Los objetivos de esta investigación fueron determinar la frecuencia de lesiones al esfínter anal e incontinencia fecal en mujeres primíparas sin episiotomía media, así como los factores maternos, obstétricos y del recién nacido que pudieran predisponer a estas lesiones. Material y métodos: se estudiaron primíparas atendidas en el periodo de mayo de 2002 a mayo de 2004, de cualquier edad, sanas, con embarazos a término no complicados. Se realizó interrogatorio de incontinencia, examen clínico y ultrasonido endoanal previos al parto, y se repitió el procedimiento seis semanas después del parto. Se utilizó χ2 para análisis estadístico. Resultados: de 122 pacientes, se eliminaron 62 (22 por cesárea y 40 por no acudir al seguimiento). Se observó incontinencia posparto en 14 pacientes (23 %), menor en 13 (22 %) y mayor en una (1.6 %), lesión a esfínteres en siete (12 %), lesiones ocultas en tres (5 %), incontinencia sin lesión a esfínteres en 10 (71 %) y lesión advertida al canal de parto en 45 (75 %). Conclusiones: hallamos alto índice de lesiones del esfínter anal en primíparas sin episiotomía de rutina, con menor índice de lesiones graves e incontinencia fecal mayor. Hubo probable relación de las lesiones con el tamaño y peso del producto, duración del segundo periodo del parto, lesión advertida y experiencia de quien atiende (no demostrado estadísticamente en este estudio).

BACKGROUND: Fecal incontinence is more frequent among women, mainly because of obstetrical trauma. The factors that induce these lesions have been widely studied. The Mexican Official Medical Regulations cancelled the routine use of episiotomy during vaginal delivery, taking into account many of these studies. We undertook this study to determine the frequency of anal sphincter lesions and fecal incontinence in primiparous women without episiotomy and related these lesions to maternal, obstetrical and newborn factors that could predispose to the origin of these lesions. METHODS: Primiparous women attended between May 2002 and May 2004, of any age, healthy, with uncomplicated term pregnancies were included. Before labor, a clinical examination, incontinence questionnaire and anal ultrasound were performed and the procedure was repeated 6 weeks after labor. Maternal, delivery and newborn factors were evaluated and compared in cases with fecal incontinence or anal sphincter lesions. Chi square test was utilized for categorical variables. RESULTS: We studied a total 122 patients, 62 were excluded (22 required Cesarean section and 40 failed to attend follow-up). Of these, postpartum incontinence was reported in 14 (23%) (minor in 13, 22%) and major in 1, 1.6%), sphincter lesion in 7 (12%), occult lesion in 3 (5%); incontinence without sphincter lesion in 10 (71%), and adverted partum canal lesion in 45 (75%). CONCLUSIONS: We found a high incidence of anal sphincter lesions in primiparous women without routine episiotomy but a reduced incidence of severe lesions and major fecal incontinence. There is a probable relation of lesions with newborn birthweight and height, duration of 2nd partum period, adverted lesion and attending physician (not statistically demonstrated).

Transtornos psiquiátricos na gestação e no puerpério: classificação, diagnóstico e tratamento / Psychiatry disorders in pregnancy and puerperium: classification, diagnosis and treatment

Diversas questões ainda estão em aberto no que se refere a um tema tão amplo quanto a saúde mental das mulheres em período de gestação e puerpério. Por mais contraditório que possa parecer, muitas pacientes apresentam tristeza ou ansiedade em vez de alegria nessas fases de suas vidas. Os limites entre o fisiológico e o patológico podem ser estreitos, o que pode gerar dúvidas em obstetras, clínicos ou psiquiatras. Muitas pacientes também sentem-se culpadas, prejudicando a aderência ao tratamento e a aceitação de uma patologia em uma fase que, em tese, deveria ser de alegria. Nas últimas décadas, estudos têm investigado um pouco mais sobre o tema, mas algumas questões ainda estão em debate: os transtornos puerperais poderiam ser uma manifestação de um transtorno prévio não adequadamente tratado? Seriam a gestação ou o puerpério fatores protetores ou de risco para o desencadeamento de transtornos psiquiátricos? As alterações hormonais que ocorrem nesse período poderiam estar envolvidas na sua etiologia? Quais seriam os principais fatores de risco? Em quais situações seria adequado usar psicofármacos como medida de tratamento? Neste artigo, serão abordadas algumas dessas questões, sobre um tema que ainda precisa ser muito investigado para que tenhamos conclusões mais precisas.

Several questions regarding mental health during the period of pregnancy and puerperium are still open. Even this seems contradictory, many patient present sadness or anxiety instead of joy in these phases of life. The limits between physiological and the pathological one can be narrow, what it may generate doubts in obstetricians, physicians or psychiatrists. Many patients also feel guilty, harming the treatment and the acceptance of her pathology in a phase that theoretically would have to be of joy. Few decades ago till today, there are studies that investigate deeper on this topic, but some questions still are in discussion: the puerperal diseases could be a manifestation of a previous disease not adequately treated? Would be the pregnancy or the puerperium protective factors or risk factors for the psychiatric diseases development? Could be involved in the etiology the hormonal alterations that occur in this period? Which would be the main factors of risk? In which situations it would be adjusted to use medications as treatment? This article has the proposal to discuss some of these questions that are immersed on a topic that is still opening to investigation to let us with more accuracy conclusions.

Risk factors for retained placenta and the effect of retained placenta on the occurrence of postpartum diseases and subsequent reproductive performance in dairy cows

The objectives of this study were to determine the risk factors for retained placenta by evaluating several reproductive factors in individual cows, and to determine the effects of retained placenta on the occurrence of postpartum diseases and subsequent reproductive performance in dairy herds. The health status, cow parity, calving, and breeding dates were recorded from 805 calvings in nine dairy herds from October 2000 to March 2004. We used logistic regression to evaluate the effects of these factors on the incidence of retained placenta. A stepwise procedure, used to obtain the appropriate model with alpha = 0.05, revealed that abnormal partus and gestation length were important risk factors for retained placenta. The occurrence of endometritis and metabolic disorders was greater (p<0.01) in the group with retained placentas than in the control group. The mean intervals from calving to first service and conception were prolonged (p<0.05) by 7 and 18 days, respectively, in the group with retained placentas compared to the control group. These results suggest that abnormal partus and gestation length are strongly correlated with the development of retained placenta, which increases the occurrence of postpartum diseases and subsequently decreases reproductive performance in dairy herds.

Emerging insights into peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is relatively common in the Hospital Albert Schweitzer (HAS) district of Haiti. This investigation was carried out to expand epidemiologic data aiming at identifying risk factors for PPCM in this population. The HAS District PPCM Registry with 74 PPCM patients, enrolled from 1 February 2000 to 1 September 2002, served to identify the PPCM patients involved in this study. Thirty-seven non-PPCM Haitian mothers from the HAS district served as controls in the case-control study I and 32 non-PPCM Haitian mothers from the HAS district served as controls for the case-control study II. Following informed consent, patients and controls participated in clinical examination, echocardiography, epidemiologic questionnaire interviews, and immunohaematologic testing. Findings revealed: increased parity in PPCM vs control mothers (4.6 vs 3.3, p = 0.0252); 47% of the PPCM mothers had their initial diagnosis with the 5th or more pregnancy; increased number of patients with some hospital prenatal care in PPCM vs control mothers (42% vs 0%, p = 0.00001); and increased valley unit PPCM vs control mothers with no formal schooling (54% vs 24%, p = 0.0054). However, when hill-unit controls were included, there was no statistical difference in this category. Taking drinking-water from the river was found in 11% of the valley PPCM mothers vs 0% of the valley control mothers (p = 0.0509). Although the first 59 PPCM cases identified came from the valley units, recent identification of PPCM mothers in the hill unit indicates similar incidence of PPCM in mothers of remote hill area compared to the valley mothers--approximately 1 per 350 to 400 livebirths. Although the cause of PPCM and reasons for increased incidence in the HAS district of Haiti remain unknown, initial data present emerging insights and avenues to pursue in subsequent studies.