Infecciones del tracto urinario bajo en adultos y embarazadas: consenso para el manejo empírico / Lower Urinary Tract Infections in Adults and Pregnant Women: A Consensus for Empirical Treatment

Introducción: La infección no complicada del tracto urinario bajo y la bacteriuria asintomática son causas frecuentes de consulta médica ambulatoria y en el servicio de urgencias en Colombia y el mundo. La falta de pautas y consenso para el manejo, así como la emergencia de resistencia a las múltiples opciones terapéuticas disponibles en los uropatógenos provenientes de la comunidad, hacen necesario elaborar unas recomendaciones que orienten al clínico sobre el abordaje óptimo de estas entidades. Objetivo: Definir un consenso sobre el manejo empírico de la bacteriuria asintomática y la infección del tracto urinario (ITU) bajo en adultos y mujeres embarazadas en Colombia. Metodología: Se lleva a cabo una metodología de consenso con expertos en urología, infectología, medicina interna, ginecología y microbiología basada en la revisión de las referencias bibliográficas disponibles en los términos de búsqueda relacionados, haciendo énfasis en estudios locales. Resultados: Se elaboró un algoritmo de manejo para el tratamiento empírico de la ITU baja no complicada en adultos con antisépticos urinarios como nitrofurantoína y fosfomicina trometamol como primera línea, con recomendaciones terapéuticas específicas para el tratamiento de la bacteriuria asintomática en mujeres embarazadas. Adicionalmente, se formuló un algoritmo de decisión para el procesamiento de cultivos de orina. La recurrencia o recaída frecuente justifica remisión a urología e infectología. Conclusiones: Se generan recomendaciones prácticas de fácil implementación en el diagnóstico y manejo de la ITU bajo en adultos y embarazadas, y de los casos donde es necesario tratar la bacteriuria asintomática, con opciones terapéuticas efectivas y de espectro reducido.

Background: Uncomplicated infection of the lower urinary tract and asymptomatic bacteriuria are frequent causes of visits to outpatient clinics and emergency departments in Colombia and worldwide. The lack of guidelines and a consensus for their management, and the emergence of resistance of community-based uropathogens to the available therapeutic options, make it necessary to develop recommendations to guide clinicians on the optimal approach to these entities. Objective: Define a consensus for the empiric management of asymptomatic bacteriuria and Urinary Tract Infection (UTI) in adults and pregnant women in Colombia. Methods: We carried out a consensus methodology with experts in urology, infectious diseases, internal medicine, gynecology and clinical microbiology; based on reviewing the available literature on the related terms, and emphasizing local studies. Results: We developed a management algorithm for the empirical treatment of uncomplicated lower UTI in adults with urinary antiseptics such as nitrofurantoin and fosfomycin trometamol as first line, with specific therapeutic recommendations for the treatment of asymptomatic bacteriuria in pregnant women. Additionally, we created a decision algorithm for processing urine cultures. Frequent recurrence or relapse justifies referral to urology and infectious disease professionals. Conclusions: We generated straightforward and easy-to-implement recommendations for the diagnosis and management of UTI in adults and pregnant women, and in cases where it is necessary to treat asymptomatic bacteriuria, with effective therapeutic and narrow spectrum options.

Efectividad y seguridad del esquema genérico lamivudina/zidovudina/efavirenz en pacientes VIH (+). Estudio fase IV y comparación con el mismo esquema de medicamentos innovadores / Effectiveness and safety of generic lamivudine/zidovudine/efavirenz in HIV (+) patients. Phase IV study and comparison with generic and innovator drugs

Antecedentes: El fortalecimiento de la política de productos competidores (genéricos) se puede acompañar de interrogantes sobre la calidad y, por tanto, sobre la efectividad de algunos de estos medicamentos. Los estudios fase IV son una opción válida para valorar la efectividad y seguridad de estos medicamentos. Objetivos: Valorar la efectividad y seguridad del esquema genérico Lamivudina/Zidovudina/Efavirenz en pacientes con VIH/SIDA que no han recibido terapia antirretroviral, que son atendidos en un programa de atención integral ambulatoria especializada, y comparar estos resultados con los datos de eficacia y seguridad reportados en un estudio de referencia (que utiliza el mismo esquema de medicamentos innovadores y fue realizado con pacientes con condiciones similares). Métodos: Se realizó un estudio clínico abierto no controlado del tipo fase IV. Se valoró la efectividad (disminución de carga viral en plasma y aumento de linfocitos CD4+) y seguridad (reacciones adversas) del esquema genérico Lamivudina/Zidovudina/Efavirenz durante 12 meses en pacientes mayores de 18 años VIH (+), que no habían recibido terapia antirretroviral y con indicación para recibirla. Los seguimientos clínicos y el seguimiento farmacoterapéutico fueron utilizados como estrategias de valoración y recolección de datos. Los resultados fueron comparados con los resultados reportados en un estudio referencia, contrastando la hipótesis de no inferioridad de dichos resultados. Resultados: El estudio incluyó 47 pacientes, de los cuales 33 estuvieron presentes hasta el final del estudio. Al año de tratamiento, en 28 pacientes (el 85%) la carga viral (valorada por indetectabilidad de las copias de RNAm viral/mL) alcanzó una disminución estadísticamente significativa, mientras que en 30 pacientes (el 91%) el recuento de linfocitos T-CD4+ mayor a 200 células/mm3 alcanzó un aumento progresivo y estadísticamente significativo. Para la comparación se halló un artículo que cumplió con...

Evidence-based intrapartum care in Cali, Colombia: a quantitative and qualitative study.

OBJECTIVES: To measure the rate of use of selected intrapartum obstetric practices and to explore the factors associated with their use. DESIGN: Prospective quantitative and qualitative study. SETTING: Fifteen public and private hospitals in Cali, Colombia. SAMPLE: Quantitative arm: 1,767 low-risk women delivering a single live baby; qualitative arm: 36 intrapartum care providers. METHODS: Quantitative analysis of women's clinical charts for measuring the rates of obstetric practices. Qualitative analysis of audiotaped semi-structured interviews with intrapartum care providers. MAIN OUTCOME MEASURES: Rates of use of ten intrapartum obstetric practices and associated factors and intrapartum care providers' views on evidence-based obstetric practice. RESULTS: Rates for the ineffective practices of enema use, perineal/pubic shaving, and routine intravenous infusion during labour were around 75%. Episiotomy rates for primiparae and multiparae were 70 and 22%, respectively. Rates for the beneficial practices of active management of the third stage of labour and allowing women's choice of position during the first stage of labour were around 45%. Companionship during labour, external cephalic version for breech presentation at term, and absorbable synthetic sutures for episiotomy showed rates of utilisation lower than 15%. Hospital characteristics, type of intrapartum care provider, and women's medical insurance status were associated with use of selected practices. Barriers and opportunities for implementing evidence-based practices in routine obstetric care were identified. CONCLUSIONS: Intrapartum care in Cali, Colombia, is not guided by the best available evidence. Effective change strategies should be undertaken to encourage the adoption of obstetric practices clearly demonstrated as effective and to discard those that are ineffective.

Caracterización electroquímica de cuatro biomateriales metálicos de uso odontológico / Electrochemical characterization of four metallic biomaterials used in dentistry

En la literatura médica se ha sugerido el uso de aleaciones con un mínimo de 50 por ciento de contenido de oro para minimizar la corrosión en la unión implante-restauración. Sin embargo, las implicaciones clínicas a largo plazo de la colocación de dos metales diferentes en restauraciones sobre implantes es aún desconocido. El objetivo de este estudio es realizar la caracterización electroquímica de cuatro biomateriales metálicos de uso odontológico para determinar la posibilidad de corrosión entre ellos cuando se ponen en contacto durante los procedimientos restauradores sobre implantes. Se realizó un estudio in vitro de tipo descriptivo, prospectivo y comparativo. Se trabajó con cuatro tipos de biomateriales metálicos: titanio comercialmente puro, tomando como muestra un implante SuperCAT® de la casa Lifecore (Lifecore Biomedical Inc., Chaska, MN.); metal altamente noble, con un colado que se realizó a partir de un pilar plástico tipo UCLA® (Lifecore Biomedical Inc., Chaska, MN), con aleación IPS d.sign 91® (Williams, Ivoclar Vivadent AG, Liechtenstein); aleación de metal base con un colado que se realizó a partir de un pilar plástico tipo UCLA® con aleación IPS d.sign 15®, y aleación de titanio (Ti6Al 4V), usando un aditamento protésico tipo COC® de la casa comercial Lifecore. Se hizo la caracterización electroquímica de las cuatro aleaciones metálicas mediante un potenciostato Bas Zãhner, con una celda de tres electrodos, usando como electrodo de referencia el electrodo de Ag/AgCl, obteniendo tres curvas de polarización para cada grupo en su forma pasivada y sin pasivar. La lectura de las curvas potenciodinámicas realizadas en este estudio, con cuatro biomateriales metálicos, y tomando como criterio el potencial de corrosión, concluye un excelente comportamiento para la aleación de titanio y de metales altamente nobles. La mejor combinación, teniendo en cuenta los criterios de potencial de corrosión y corriente a potenciales anódicos, se da con el titanio...

Effect of the interpregnancy interval after an abortion on maternal and perinatal health in Latin America.

OBJECTIVE: To investigate whether the length of the interval between an abortion and the next pregnancy is associated with increased risks of adverse maternal and perinatal outcomes in Latin America. METHOD: Retrospective cross-sectional study using information from 258,108 women delivering singleton infants and whose previous pregnancy resulted in abortion recorded in the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development, Montevideo, Uruguay, between 1985 and 2002. Adjusted odds ratios were obtained through logistic regression analysis. RESULT: Compared with the post-abortion interpregnancy intervals of 18 to 23 months, intervals shorter than 6 months were significantly associated with increased risks of maternal anemia, premature rupture of membranes, low birth weight, very low birth weight, preterm delivery, and very preterm delivery. CONCLUSION: In Latin America, post-abortion interpregnancy intervals shorter than 6 months are independently associated with increased risks of adverse maternal and perinatal outcomes in the next pregnancy. DEFINITION: Post-abortion interpregnancy interval (PAII): the time elapsed between the day of the abortion and the first day of the last menstrual period for the index pregnancy.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.

BACKGROUND: Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. OBJECTIVES: To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional care after the initial period of stabilization with conventional care. SEARCH STRATEGY: We used the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. MEDLINE, EMBASE, LILACS, POPLINE and CINAHL databases (to December 2002), and the Cochrane Controlled Trials Register (The Cochrane Library), were searched using the key words terms "kangaroo mother care" or "kangaroo care" or "kangaroo mother method" or "skin-to-skin contact" and "infants" or "low birthweight infants". SELECTION CRITERIA: Randomized trials comparing KMC and conventional neonatal care in LBW infants. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Statistical analysis was conducted using the standard Cochrane Collaboration methods. MAIN RESULTS: Three studies, involving 1362 infants, were included. All the trials were conducted in developing countries. The studies were of moderate to poor methodological quality. The most common shortcomings were in the areas of blinding procedures for those who collected the outcomes measures, handling of drop outs, and completeness of follow-up. The great majority of results consist of results of a single trial. KMC was associated with the following reduced risks: nosocomial infection at 41 weeks' corrected gestational age (relative risk 0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95% confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months follow-up (relative risk 0.37, 95% confidence interval 0.15 to 0.89), not exclusively breastfeeding at discharge (relative risk 0.41, 95% confidence interval 0.25 to 0.68), and maternal dissatisfaction with method of care (relative risk 0.41, 95% confidence interval 0.22 to 0.75). KMC infants had gained more weight per day by discharge (weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Scores on mother's sense of competence according to infant stay in hospital and admission to NICU were better in KMC than in control group (weighted mean differences 0.31 [95% confidence interval 0.13 to 0.50] and 0.28 [95% confidence interval 0.11 to 0.46], respectively). Scores on mother's perception of social support according to infant stay in NICU were worse in KMC group than in control group (weighted mean difference -0.18 (95% confidence interval -0.35 to -0.01). Psychomotor development at 12 months' corrected age was similar in the two groups. There was no evidence of a difference in infant mortality. However, serious concerns about the methodological quality of the included trials weaken credibility in these findings. REVIEWER'S CONCLUSIONS: Although KMC appears to reduce severe infant morbidity without any serious deleterious effect reported, there is still insufficient evidence to recommend its routine use in LBW infants. Well designed randomized controlled trials of this intervention are needed.

Loci geneticos asociados al trastorno bipolar: estudios en poblacion colombiana / Genetic loci associated to bipolar disorder: studies in colombian population

Objetivos: Caracterizar una muestra de familias y tríos de una población colombiana aislada para mapear loci involucrados en la vulnerabilidad al Trastorno Afectivo Bipolar tipo I (TAB- I). Métodos: Se recolectan tríos y genealogías utilizando las entrevistas FIGS-DIGS en miembros de las familias y posibles afectados. El poder para detectar ligamiento (PDL) se estima por simulación. El modelo utilizado asume una frecuencia para el alelo afectado de 0.003, penetrancias de 0.01,0.81 y 0.9 y un marcador de cuatro alelos a 5cM del locus. Resultados: Se identificaron 28 familias con TAB-I, con 3.603 individuos y 160 afectados, y 246 tríos. Asumiendo homogeneidad genética y teniendo en cuenta la evidencia genética del mestizaje, las simulaciones mostraron PDL significativos de 100 por ciento para un LOD-score>3. Estamos examinando el desequilibrio promedio en tríos y tamizando en familias los cromosomas 12,18 y 21. Conclusión: Tenemos un grupo significativo de familias y trios pertenecientes a una población aislada con un poder para detectar ligamiento al Trastorno Afectivo Bipolar. Esto permite realizar estudios de ligamiento buscando genes involucrados en la vulnerabilidad al TAB-I en población Colombiana

Oseointegración: una cascade de eventos / Osseointegration: a cascade of events

Por medio de esta revisión bibliográfica se pretende mostrar lo que existe en la actualidad sobre la biocompatibilidad, las características del titanio y su uso para implantes dentales y los eventos celulares y moleculares que se desencadenan con la colocación de un implante intraóseo en los maxilares. Se discute la terminología de: biotolerante, bioinerte, bioactivo, biointegración, bioaceptabilidad. Se establecen las características que hacen del titanio el material de eleción para su uso en los implantes dentales y los factores que permiten que se logre con ellos la oseointegración. En cuanto a los fenómenos celulares, se destaca el papel del osteoblasto como el blanco perfecto que permite desencadenar el proceso biológico que lleva a la oseointegración. A la vez se discute a nivel molecular todo el proceso de fenomenologías que ocurre desde el momento de la colocación del implante para permitir por parte del organismo una cicatrización normal alrededor de un cuerpo extraño. Esta información nos lleva a pensar que el entendimiento y manejo de todos estos eventos celulares y moleculares serían de gran utilidad para mejorar el éxito de los implantes dentales y extender su uso a sitios anatómicos que presentan dificultad a la terapéutica actual

Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study.

OBJECTIVE: To study the impact of interpregnancy interval on maternal morbidity and mortality. DESIGN: Retrospective cross sectional study with data from the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development, Montevideo, Uruguay. SETTING: Latin America and the Caribbean, 1985-97. PARTICIPANTS: 456 889 parous women delivering singleton infants. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios of the effects of short and long interpregnancy intervals on maternal death, pre-eclampsia, eclampsia, gestational diabetes mellitus, third trimester bleeding, premature rupture of membranes, postpartum haemorrhage, puerperal endometritis, and anaemia. RESULTS: Short (<6 months) and long (>59 months) interpregnancy intervals were observed for 2.8% and 19.5% of women, respectively. After adjustment for major confounding factors, compared with those conceiving at 18 to 23 months after a previous birth, women with interpregnancy intervals of 5 months or less had higher risks for maternal death (odds ratio 2.54; 95% confidence interval 1.22 to 5.38), third trimester bleeding (1.73; 1.42 to 2.24), premature rupture of membranes (1.72; 1.53 to 1.93), puerperal endometritis (1.33; 1.22 to 1.45), and anaemia (1.30; 1.18 to 1.43). Compared with women with interpregnancy intervals of 18 to 23 months, women with interpregnancy intervals longer than 59 months had significantly increased risks of pre-eclampsia (1.83; 1.72 to 1.94) and eclampsia (1.80; 1.38 to 2.32). CONCLUSIONS: Interpregnancy intervals less than 6 months and longer than 59 months are associated with an increased risk of adverse maternal outcomes.

An association study of bipolar mood disorder (type I) with the 5-HTTLPR serotonin transporter polymorphism in a human population isolate from Colombia.

The short variant of a functional length polymorphism in the promoter region of the serotonin transporter has been associated with several behavioural and psychiatric traits, including bipolar mood disorder. The same short allele has also been implicated as a modifier of the bipolar phenotype. Here we evaluate the etiologic/modifier role of this polymorphism in a case (N=103) / control (N=112) sample for bipolar mood disorder (type I) collected from an isolated South American population. We did not detect an association between bipolar disorder and the 5-HTT promoter polymorphism in this sample. However, an excess of the short allele was seen in younger cases and in cases with psychotic symptoms. When combined with data from the literature, the increased frequency of the short allele in patients with psychotic symptoms was statistically significant.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.

BACKGROUND: Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. OBJECTIVES: To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional care after the initial period of stabilization with conventional care. SEARCH STRATEGY: We used the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. MEDLINE, EMBASE, LILACS, POPLINE and CINAHL databases, and the Cochrane Controlled Trials Register (Cochrane Library) up to Issue 2, 2000, were searched using the key words terms "kangaroo mother care" or "kangaroo mother method" or "skin-to-skin contact" and "infants" or "low birthweight infants". SELECTION CRITERIA: Randomised trials comparing KMC and conventional neonatal care in LBW infants. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Statistical analysis was conducted using the standard Cochrane Collaboration methods. MAIN RESULTS: Three studies, involving 1362 infants, were included. All the trials were conducted in developing countries. The studies were of moderate to poor methodological quality. The most common shortcomings were in the areas of blinding procedures for those who collected the outcomes measures, handling of drop outs, and completeness of follow-up. The great majority of results consist of results of a single trial. KMC was associated with the following reduced risks: nosocomial infection at 41 weeks' corrected gestational age (relative risk 0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95% confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months follow-up (relative risk 0.37, 95% confidence interval 0.15 to 0.89), not exclusively breastfeeding at discharge (relative risk 0.41, 95% confidence interval 0.25 to 0.68), and maternal dissatisfaction with method of care (relative risk 0.41, 95% confidence interval 0.22 to 0.75). KMC infants had gained more weight per day by discharge (weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Scores on mother's sense of competence according to infant stay in hospital and admission to NICU were better in KMC than in control group (weighted mean differences 0.31 [95% confidence interval 0.13 to 0.50] and 0.28 [95% confidence interval 0.11 to 0.46], respectively). Scores on mother's perception of social support according to infant stay in NICU were worse in KMC group than in control group (weighted mean difference -0.18 (95% confidence interval -0.35 to -0.01). There was no evidence of a difference in infant mortality. However, serious concerns about the methodological quality of the included trials weaken credibility in these findings. REVIEWER'S CONCLUSIONS: Although KMC appears to reduce severe infant morbidity without any serious deleterious effect reported, there is still insufficient evidence to recommend its routine use in LBW infants. Well designed randomized controlled trials of this intervention are needed.

Valores del factor de crecimiento similar a la insulina tipo I y su proteína fijadora tipo 3 en la leche materna: relación con los valores séricos maternos / Value of insulin-like growth factor I

Para valorar los niveles del factor de crecimiento similar a la insulina tipo I (IGF-I) y su proteína fijadora (BP3) en la leche materna y su correlación con los nivles maternos, se tomó una muestra sérica en la primera semana postparto y simultáneamente una muestra de leche materna a 52 madres. Conclusión: la leche materna en la etapa postparto temprana contiene niveles elevados de IGF-I y BP3. Hay correlación positiva entre los niveles de IGF-I en sangre y en leche materna

Maternal morbidity and mortality associated with multiple gestations.

OBJECTIVE: To test the hypothesis that women with multiple gestations are at increased risk of adverse maternal outcomes. METHODS: We studied the association between multiple gestation and frequency of adverse maternal outcomes in 885,338 pregnancies recorded in the Perinatal Information System database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay, between 1985 and 1997. Relative risks (RRs) were adjusted for 14 potential confounding factors through multiple logistic regression models. RESULTS: There were 15,484 multiple gestations. Among parous women, multiple gestation was associated with a twofold increase in risk of death compared with singleton gestations [adjusted RR 2.1; 95% confidence interval (CI) 1.1, 3.9]. Compared with singleton gestations, women with multiple gestations had adjusted RRs of 3.0 (95% CI, 2.9, 3.3) for eclampsia, 2.2 (95% CI, 1. 9, 2.5) for preeclampsia, and 2.0 (95% CI, 1.9, 2.0) for postpartum hemorrhage. Likewise, there was significant association between multiple gestation and increased incidence of preterm labor, anemia, urinary tract infection, puerperal endometritis, and cesarean delivery. The incidences of premature rupture of membranes, third-trimester bleeding, and gestational diabetes mellitus were not statistically different for singleton and multiple gestations. CONCLUSION: Multiple gestation increases the risk of significant maternal morbidity and mortality.

Epidemiology of fetal death in Latin America.

BACKGROUND: To identify risk factors associated with fetal death, and to measure the rate and the risk of fetal death in a large cohort of Latin American women. METHODS: We analyzed 837,232 singleton births recorded in the Perinatal Information System Database of the Latin American Center for Perinatology and Human Development (CLAP) between 1985 and 1997. The risk factors analyzed included fetal factors and maternal sociodemographic, obstetric, and clinical characteristics. Adjusted relative risks were obtained, after adjustment for potential confounding factors, through multiple logistic regression models based on the method of generalized estimating equations. RESULTS: There were 14,713 fetal deaths (rate=17.6 per 1000 births). The fetal death risk increased exponentially as pregnancy advanced. Thirty-seven percent of all fetal deaths occurred at term, and 64% were antepartum. The main risk factors associated with fetal death were lack of antenatal care (adjusted relative risk [aRR]=4.26; 95% confidence interval, 3.84-4.71) and small for gestational age (aRR=3.26; 95% CI, 3.13-3.40). In addition, the risk of death during the intrapartum period was almost tenfold higher for fetuses in noncephalic presentations. Other risk factors associated with stillbirth were: third trimester bleeding, eclampsia, chronic hypertension, preeclampsia, syphilis, gestational diabetes mellitus, Rh isoimmunization, interpregnancy interval<6 months, parity > or =4, maternal age > or =35 years, illiteracy, premature rupture of membranes, body mass index > or =29.0, maternal anemia, previous abortion, and previous adverse perinatal outcomes. CONCLUSIONS: There are several preventable factors that should be dealt with in order to reduce the gap in fetal mortality between Latin America and developed countries.

Intrafascial abdominal hysterectomy: outcomes and complications of 867 operations.

OBJECTIVE: To prospectively evaluate the results and complications of the surgical technique of intrafascial abdominal hysterectomy. METHODS: From March 1993 to February 1998, 867 women at four institutions from the Department of Valle del Cauca, Colombia, underwent intrafascial abdominal hysterectomy. Information on sociodemographic and clinical characteristics before hysterectomy, indications for hysterectomy, surgical outcomes and intra- and post-operative complications were collected. Patients were evaluated at 1, 3, and 12 months post-operatively and annually thereafter. RESULTS: The follow-up period ranged from 6 to 63 months (median=45 months). The mean blood loss was 286+/-112 ml. Operative time averaged 71+/-11 min. The overall operative site infection rate was 4%. Intra- and post-operative hemorrhage occurred in 0.2 and 1.0% of patients, respectively. The transfusion rate was 0.7%. The incidences of ureteral, bladder, and bowel injury were 0.1, 0.4 and 0.0%, respectively. To date, none of the patients followed up between 1 and 5 years have had evidence of vaginal vault prolapse. CONCLUSIONS: Intrafascial abdominal hysterectomy is a safe technique with a low rate of complications.

Risk factors for pre-eclampsia in a large cohort of Latin American and Caribbean women.

OBJECTIVE: To study risk factors for pre-eclampsia in a large cohort of Latin American and Caribbean women. DESIGN: Retrospective cross-sectional study from the Perinatal Information System, the database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay. SETTING: Latin America and the Caribbean, 1985-1997. Population 878,680 pregnancies at 700 hospitals; of these 42,530 were complicated by pre-eclampsia and 1,872 by eclampsia. MAIN OUTCOME MEASURES: Crude and adjusted relative risks (RR) of risk factors for pre-eclampsia. Adjusted relative risks were obtained after adjustment for potential confounding factors through multiple logistic regression models based on the method of generalised estimating equations. RESULTS: The following risk factors were significantly associated with increased risk of pre-eclampsia: nulliparity (RR 2 x 38; 95% CI 2 x 28-2 x 49); multiple pregnancy (RR 2 x 10; 95% CI 1 x 90-2 x 32); history of chronic hypertension (RR 1 x 99; 95% CI 1 x 78-2 x 22); gestational diabetes mellitus (RR 1 x 93; 95% CI 1 x 66-2 x 25); maternal age > or = 35 years (RR 1 x 67; 95% CI 1 x 58-1 x 77); fetal malformation (RR 1 x 26; 95% CI 1 x 16-1 x 37); and mother not living with infant's father (RR 1 x 21; 95% CI 1 x 15-1 x 26). Pre-eclampsia risk increased according to pre-pregnancy body mass index (BMI). In comparison with women with a normal pre-pregnancy BMI (19 x 8 to 26 x 0), the RR estimates were 1 x 57 (95% CI 1 x 49-1 x 64) and 2 x 81 95% CI 2 x 69-2 x 94), respectively, for overweight women (pre-pregnancy BMI = 26 x 1 to 29 x 0) and obese women (pre-pregnancy BMI > 29 x 0). Cigarette smoking during pregnancy and a pre-pregnancy BMI < 19 x 8 were significant protective factors against the development of pre-eclampsia. The pattern of risk factors among nulliparous and multiparous women was quite similar. CONCLUSIONS: Risk factors for pre-eclampsia observed among Latin American and Caribbean women are similar to those found among North American and European women.

Cigarette smoking during pregnancy and risk of preeclampsia: a systematic review.

In this systematic review of the existing evidence regarding the relationship between cigarette smoking during pregnancy and preeclampsia, studies were found through searches of MEDLINE (1966-October 31, 1998), Embase, Popline, CINAHL, Lilacs, bibliographies of identified studies, and proceedings of meetings on preeclampsia, and also through contact with relevant researchers. No language restrictions were imposed. Only cohort and case-control studies dealing with the relationship between cigarette smoking and preeclampsia were considered. Assessment of methodologic quality and data extraction of each study were carried out by 2 authors working independently. Typical relative risks and odds ratios with 95% confidence intervals were calculated for cohort and case-control studies, respectively, with both fixed and random effects models. Twenty-eight cohort studies and 7 case-control studies including a total of 833,714 women were included. All cohort studies reported an inverse association between cigarette smoking during pregnancy and incidence of preeclampsia (typical relative risk, 0.68; 95% confidence interval, 0.67-0.69). The findings were similar for case-control studies (typical odds ratio, 0.68; 95% confidence interval, 0.57-0.81). An inverse dose-response relationship was also found. Pooled data from cohort and case-control studies showed a lower risk of preeclampsia associated with cigarette smoking during pregnancy.

Cervical cerclage: an alternative for the management of placenta previa?

OBJECTIVE: Our purpose was to determine whether cervical cerclage reduces the maternal and neonatal morbidity in women with placenta previa. STUDY DESIGN: Thirty-nine pregnant women with an initial diagnosis of placenta previa at 24 to 30 weeks' gestation were randomly assigned to cervical cerclage (n = 19) or conservative management (n = 20). Subjects were followed up until delivery. Primary outcome measure was gestational age at delivery. Secondary outcome measures were prolongation of pregnancy, number of patients bleeding after being randomly assigned, units of blood transfused, birth weight, hospital stay and costs, and admission to neonatal intensive care unit. Statistical significance was calculated by the Student t test, Fisher's exact probability test, and the chi2 with Yates' correction factor. RESULTS: No statistically significant differences were observed between the two groups studied. CONCLUSION: Cervical cerclage does not appear to be an adequate alternative for the management of placenta previa.

Epidemiology of eclampsia in Colombia.

OBJECTIVE: To measure the incidence of eclampsia, its maternal and perinatal outcomes and patterns of presentation of this disease in our environment. METHOD: Retrospective descriptive study of 164 cases of eclampsia managed at the Hospital Universitario del Valle, Cali, Colombia from September 1993 to August 1995. Information was collected from reviews of hospital case-notes. RESULTS: The incidence of eclampsia was 8.1/1000 deliveries. Maternal mortality was 6.1%. Fifty-seven percent of seizures occurred antepartum, 22% during labor, and 21% after delivery. Sixty-nine cases (42%) presented preterm. Ninety-eight women (60%) were nulliparous. Approximately one quarter of the women did not have hypertension or significant proteinuria at the time of seizures. Twenty percent of all women had at least one major complication. Perinatal mortality was 12.8%. Antepartum and postpartum cases were more severe than intrapartum cases. CONCLUSION: Eclampsia occurs in one in 124 deliveries in Cali, Colombia and is associated with high maternal and perinatal morbidity and mortality.