Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence.

Objective: Postpartum hemorrhage (PPH) is the leading cause of maternal death globally. Therefore, prevention strategies have been created. The study aimed to evaluate the occurrence of PPH and its risk factors after implementing a risk stratification at admission in a teaching hospital. Methods: A retrospective cohort involving a database of SISMATER® electronic medical record. Classification in low, medium, or high risk for PPH was performed through data filled out by the obstetrician-assistant. PPH frequency was calculated, compared among these groups and associated with the risk factors. Results: The prevalence of PPH was 6.8%, 131 among 1,936 women. Sixty-eight (51.9%) of them occurred in the high-risk group, 30 (22.9%) in the medium-risk and 33 (25.2%) in the low-risk group. The adjusted-odds ratio (OR) for PPH were analyzed using a confidence interval (95% CI) and was significantly higher in who presented multiple pregnancy (OR 2.88, 95% CI 1.28 to 6.49), active bleeding on admission (OR 6.12, 95% CI 1.20 to 4.65), non-cephalic presentation (OR 2.36, 95% CI 1.20 to 4.65), retained placenta (OR 9.39, 95% CI 2.90 to 30.46) and placental abruption (OR 6.95, 95% CI 2.06 to 23.48). Vaginal delivery figured out as a protective factor (OR 0.58, 95% CI 0.34 to 0.98). Conclusion: Prediction of PPH is still a challenge since its unpredictable factor arrangements. The fact that the analysis did not demonstrate a relationship between risk category and frequency of PPH could be attributable to the efficacy of the strategy: Women classified as "high-risk" received adequate medical care, consequently.

Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence

Abstract Objective: Postpartum hemorrhage (PPH) is the leading cause of maternal death globally. Therefore, prevention strategies have been created. The study aimed to evaluate the occurrence of PPH and its risk factors after implementing a risk stratification at admission in a teaching hospital. Methods: A retrospective cohort involving a database of SISMATER® electronic medical record. Classification in low, medium, or high risk for PPH was performed through data filled out by the obstetrician-assistant. PPH frequency was calculated, compared among these groups and associated with the risk factors. Results: The prevalence of PPH was 6.8%, 131 among 1,936 women. Sixty-eight (51.9%) of them occurred in the high-risk group, 30 (22.9%) in the medium-risk and 33 (25.2%) in the low-risk group. The adjusted-odds ratio (OR) for PPH were analyzed using a confidence interval (95% CI) and was significantly higher in who presented multiple pregnancy (OR 2.88, 95% CI 1.28 to 6.49), active bleeding on admission (OR 6.12, 95% CI 1.20 to 4.65), non-cephalic presentation (OR 2.36, 95% CI 1.20 to 4.65), retained placenta (OR 9.39, 95% CI 2.90 to 30.46) and placental abruption (OR 6.95, 95% CI 2.06 to 23.48). Vaginal delivery figured out as a protective factor (OR 0.58, 95% CI 0.34 to 0.98). Conclusion: Prediction of PPH is still a challenge since its unpredictable factor arrangements. The fact that the analysis did not demonstrate a relationship between risk category and frequency of PPH could be attributable to the efficacy of the strategy: Women classified as "high-risk" received adequate medical care, consequently.

Reflexo disfórico da ejeção do leite: conhecimento e diferenciação com transtornos mentais puerperais entre ginecologistas e obstetras paranaenses / Dysphoric milk ejection reflex: knowledge and differentiation with puerperal mental disorders between gynecologists and obstetricians from Paraná

Objetivo: Identificar o conhecimento dos médicos ginecologistas e obstetras do Paraná sobre o reflexo disfórico da ejeção do leite e seus diagnósticos diferenciais. Métodos: Estudo observacional transversal com médicos ginecologistas e obste- tras associados ao Conselho Regional de Medicina do Paraná. A coleta de dados foi realizada por questionário online compreendendo perguntas de identificação do profissional, tempo de formação, conhecimento e experiência com reflexo disfóri- co da ejeção do leite, dificuldades de diferenciação entre os transtornos mentais puerperais, além da abordagem das questões psicológicas puerperais com as pa- cientes. Os resultados foram expressos por frequências e percentuais. Valores de p menores que 0,05 foram considerados significativos. Resultados: Entre os partici- pantes, 39,1% desconhecem o reflexo disfórico da ejeção do leite. Dos profissionais que já fizeram o diagnóstico, 72,4% apresentaram dificuldade em realizá-lo. Houve acerto majoritário em relação ao momento de ocorrência dos sintomas (90,6%) e tempo de duração (90,6%), mas deficiência no reconhecimento de todos os sin- tomas (3,1%), início das manifestações clínicas (12,6%) e tratamento (44%) pelos profissionais que conhecem o reflexo disfórico da ejeção do leite. Entre os especia- listas, 21,5% sentem-se capazes para diferenciar os três distúrbios e 24,1% têm difi- culdade na diferenciação entre as patologias. Apenas 65,5% dos médicos abordam as dificuldades emocionais na amamentação e, segundo 78,1% dos profissionais, poucas pacientes perguntam ou nunca perguntam sobre essas dificuldades. Con- clusão: O reflexo disfórico da ejeção do leite é uma condição pouco conhecida e confundida com outros transtornos mentais puerperais. É necessária maior divul gação sobre o tema entre os ginecologistas e obstetras, a fim de melhorar a assistência às puérperas, refletindo na persistência da amamentação e seus benefícios.

Objective: To identify the knowledge of gynecologists and obstetricians in Paraná about the dysphoric milk ejection re- flex and its differential diagnosis. Methods: Cross-sectional observational study was conducted with gynecologists and obstetricians associated in the Regional Council of Medicine of Paraná. Data collection was dove through an online question- naire with questions about professional identification, years of experience, knowledge and experience with the dysphoric milk ejection reflex, differentiation puerperal mental disorders difficulties, as well as the approach of postpartum psycholo- gical issues with patients. Results were expressed in frequen- cies and percentages. P values less than 0.05 were considered significant. Results: 39.1% of the participants unknown the dysphoric milk ejection reflex. Among the professionals who had diagnosed dysphoric milk ejection reflex, 72.4% reported difficulties in making the diagnosis. There was a high level of correct answers regarding the timing of symptoms (90.6%) and duration (90.6%), but deficiencies were observed in recognizing all symptoms (3.1%), onset of clinical manifestations (12.6%), and treatment (44%) by professionals who were familiar with dysphoric milk ejection reflex. 21.5% of specialists felt capab- le of differentiating between the three disorders, while 24.1% had difficulty in differentiating between the pathologies. Only 65.5% of doctors approach emotional difficulties in breastfee- ding and, according to 78.1% of professionals, few patients ask or never ask about these difficulties. Conclusion: Dysphoric milk ejection reflex is a condition that is poorly known and of- ten confused with other postpartum mental disorders. Greater awareness about this topic is necessary among gynecologists and obstetricians to improve care for postpartum women, lea- ding to the continuation of breastfeeding and its benefits.

Uterine tamponade in postpartum hemorrhage with handmade balloons: Comparison of manufacturing, infusion, and total times.

OBJECTIVE: To compare the manufacturing, infusion, and total times of handmade balloons for uterine tamponade using the El Hennawy and Alves techniques, given the failure of initial measures and uterotonic therapy to control postpartum hemorrhage. METHODS: An open clinical trial (clinical article) was conducted among 30 physicians, residents, and assistants in an Obstetrics Department. Each participant manufactured and infused one of two different balloons compared in the study, in a randomly predefined sequence. The manufacturing and infusion times were timed by the researchers and their medians were compared using the t test or Mann-Whitney U test. RESULTS: The manufacturing time of the El Hennawy balloon was 72 s lower in relation to the Alves balloon (P < 0.010). Regarding the infusion time, the Alves balloon was filled faster than the El Hennawy balloon (P < 0.010). The total time (manufacturing and infusion) of Alves balloon was also lower than the El Hennawy device (P < 0.010). CONCLUSIONS: Although the El Hennawy balloon was manufactured more quickly, the total time of manufacturing and infusing the Alves balloon was much faster, which makes it the most suitable device to be used in critical situations of postpartum hemorrhage.

Sleep Bruxism in Puerperal Women: Data from a Population-Based Survey.

OBJECTIVE: To evaluate the self-reported SB prevalence and explore associated risk factors in puerperal women who had given birth in Rio Grande, Southern Brazil. METHODS: A single, standardized questionnaire was given within the 48 h postpartum period. Self-reported SB was the main outcome investigated. Chi-square test was used to compare proportions, and Poisson regression with robust variance adjustment was used in the multivariate analysis. RESULTS: A total of 2225 women were included. Only 79 (3.6%) of these reported clenching or grinding their teeth during sleep. Adjusted analysis showed that the higher education level of the mothers (PR = 3.07; 95% CI 1.49-6.28; P = 0.006); living with three or more persons in the household (PR = 0.54; 95% CI 0.34-0.84; P = 0.007); medication intake during pregnancy (PR = 1.68; 95% CI 1.09-2.58; P = 0.017); smoking (PR = 1.93; 1.16-3.23; P = 0.024), or ever smoked (PR = 1.82; 95% CI 0.85-3.90; P = 0.024); severe anxiety (PR = 1.36; 95% CI 0.61-3.02; P = 0.005); and headache upon waking (PR = 4.19; 95% CI 1.95-9.00; P < 0.001) were significantly associated with self-reported SB. CONCLUSION FOR PRACTICE: Our data pointed towards new factors in a specific group of women that may be relevant for preventing sleep-related behaviors in the pregnancy-puerperal cycle. The higher levels of education, medication intake, smoking or even smoked, severe anxiety, the higher the probability of puerperal woman to self-report SB. The nighttime tooth clenching strongly increased headache upon waking.

Factores asociados a anemia en post-cesareadas con y sin COVID-19 en el Hospital Nacional Alberto Sabogal Sologuren

Objetivo. Conocer los factores intrínsecos y extrínsecos asociados a anemia en pacientes post-operadas atendidas en las áreas de obstetricia COVID-19 y no COVID-19, del Hospital Nacional Alberto Sabogal Sologuren, EsSalud. Métodos. El estudio fue observacional, retrospectivo y transversal, enfoque cuantitativo, nivel explicativo, de modelo caso control, aplicado a 358 puérperas; de las cuales 179 fueron los casos, es decir aquellas puérperas con anemia en el post parto y 179 los controles, tomados de ambas áreas. Los datos fueron procesados con el estadístico SPSS 25. Resultados. Los factores intrínsecos: alimentación sin variación, sobrepeso u obesidad mórbida, paridad de 4 a más, número de cesáreas de 3 a más, y el periodo intergenésico menor de 2 años, fueron condiciones que representaron riesgo doble de producir anemia en el puerperio entre las mujeres del estudio, en relación a las que no tuvieron estas características. Además, el factor intrínseco o condición de haber tenido anemia durante el embarazo, resultó en una probabilidad 5 veces mayor a producir anemia en el puerperio entre las mujeres del estudio (Odds Ratio 5,156), en comparación a las mujeres que no tuvieron anemia. La ingesta de ácido fólico tuvo una probabilidad 3,4 veces menor (Odds Ratio de 3,408) de desarrollar la anemia respecto de aquellas que no lo hicieron y las complicaciones en el puerperio inmediato (Odds Ratio de 3,397) estuvieron asociados a la anemia en puérperas. Conclusiones. Los factores intrínsecos como el diagnóstico de anemia durante el embarazo y los factores extrínsecos como la no ingesta de ácido fólico y complicaciones en el puerperio inmediato, estuvieron asociados a la anemia en puérperas en el área de obstetricia COVID-19 y no COVID-19 del Hospital Alberto Sabogal.

Objective. To know the intrinsic and extrinsic factors associated with anemia in post-cesarean women treated in the COVID-19 and non-COVID-19 obstetric area of the Alberto Sabogal Hospital. Methods. The study was observational, retrospective and cross-sectional, quantitative approach, explanatory level, case- control model, applied to 358 puerperal women; of which 179 were the cases, that is, those puerperal women with postpartum anemia and 179 were controls, taken from both areas. The data were processed with the SPSS 25 statistic. Results. The intrinsic factors: diet without variation, overweight or morbid obesity, parity of 4 or more, number of cesarean sections of 3 or more, and the intergenetic period of less than 2 years, were conditions that represented a double risk of producing anemia in the puerperium among women in the study, in relation to those who did not have these characteristics. Also, the intrinsic factor or condition of having had anemia during pregnancy, resulted in a 5 times greater probability of producing anemia in the puerperium among the women in the study (Odds Ratio 5.156), compared to the women who did not have anemia. Folic acid intake was 3.4 times less likely (Odds Ratio of 3.408) to develop anemia compared to those who did not, and complications in the immediate puerperium (Odds Ratio of 3.397) were associated with anemia in puerperal women. Conclusions. Intrinsic factors such as the diagnosis of anemia during pregnancy and extrinsic factors such as folic acid not ingest and complications in the immediate puerperium were associated with anemia in puerperal women in the COVID-19 and non-COVID-19 obstetric area of Hospital Alberto Sabogal.

Analysis of early and late maternal complications associated with delivery using propensity score / Análise das complicações maternas precoces e tardias associadas à via de parto utilizando escore de propensão

ABSTRACT: Objective: To analyze early and late maternal complications associated with the mode of delivery in a birth cohort in Brazil, using the propensity score technique for analysis. Methods: This is a prospective cohort study, using data from the Pelotas Birth Cohort, RS, 2004. A total of 4,189 women were included and a descriptive analysis of the data and subsequent calculation of the propensity and pairing score of vaginal delivery women and cesarean delivery women with similar scores (1,366 pairs). We then assessed the difference in outcome risk between the groups. Results: Women in the cesarean group had 2.9 percentage points (pp) more risk of postpartum infection, 1.13 p.p. more risk of urinary infection, 1.10 p.p. more risk of anesthetic complications and 1.24 p.p. higher risk of headache compared to vaginal delivery, but less risk of anemia (-2.43 pp) and hemorrhoids (-1.24 p.p.). The use of propensity scores is extremely useful for reducing bias and increasing accuracy in observational studies when experimental studies cannot be performed. Conclusion: Cesarean sections have been associated with a higher prevalence of postpartum and urinary tract infections, anesthetic complications and headache and lower prevalence of anemia and hemorrhoids, so they should be performed with clear indications and when their benefits outweigh potential risks.

RESUMO: Objetivo: Analisar as complicações maternas precoces e tardias, associadas à via de parto, em uma coorte de nascimentos no Brasil, utilizando para a análise a técnica de escores de propensão. Métodos: Trata-se de estudo do tipo coorte prospectiva, utilizando dados da Coorte de Nascimentos de Pelotas (RS), de 2004. Incluíram-se 4.189 mulheres, e realizaram-se análise descritiva dos dados e posterior cálculo do escore de propensão e pareamento das mulheres de parto vaginal com as mulheres de parto cesárea com escores semelhantes (1.366 pares), avaliando a diferença no risco do desfecho entre os grupos. Resultados: As mulheres do grupo cesárea apresentaram 2,9 pontos percentuais (p.p.) a mais de risco de infecção pós-parto, 1,13 p.p. a mais de risco de infecção urinária, 1,10 p.p. a mais de risco de complicações anestésicas e 1,24 p.p. a mais de risco de cefaleia que as de parto vaginal, porém apresentaram menor risco de anemia (-2,43 p.p.) e hemorroidas (-1,24 p.p.). A utilização de escores de propensão é extremamente útil para a redução de vieses e o aumento da precisão em estudos observacionais, quando estudos experimentais não podem ser realizados. Conclusão: As cesáreas associaram-se a maiores prevalências de infecções pós-parto e urinária, complicações anestésicas e cefaleia e menores prevalências de anemia e hemorroidas, portanto devem ser realizadas com indicações claras e quando seus benefícios superam potenciais riscos.

Hospital-acquired conditions and length of stay in the pregnancy and puerperal cycle / Condições hospitalares adquiridas e tempo de permanência no ciclo gravídico-puerperal

ABSTRACT OBJECTIVE To analyze the impact of the Hospital-Acquired Conditions (HAC) in women in the puerperal and pregnancy cycle during length of stay. METHODS This cross-sectional study was conducted with 113,456 women, between July 2012 and July 2017, in Brazil's national hospitals of the supplementary healthcare networks and philanthropists accredited to the Unified Health System (SUS). Data on hospital discharges were collected using the Diagnosis-Related Groups (DRG Brasil®) system. All DRGs of the major diagnostic category 14 (MDC14), including pregnancy, childbirth and puerperium, were included. The impact of HAC on length of stay was estimated by Student's t-test, and the effect size by Cohen's d, which allows to assess clinical relevance. RESULTS The most prevalent diagnostic categories related to MDC14 were vaginal and cesarean deliveries without complicating diagnoses, both at institutions accredited to SUS and those for supplementary health care. The prevalence of HAC was 3.8% in supplementary health and 2.5% in SUS. Hospitals providing services to supplementary health care providers had a longer length of stay considering HAC for patients classified as DRG: cesarean section with complications or comorbidities at admission (p < 0.001; Cohen's d = 0.74), cesarean section without complications or comorbidities at admission (p < 0.001, Cohen's d = 0.31), postpartum and post abortion without listed procedure (p < 0.001, Cohen's d = 1.05), and other antepartum diagnoses with medical complications (p < 0.001; Cohen's d = 0.77). CONCLUSIONS This study showed that the prevalence of HAC was low both in the institutions accredited to attend by SUS and in those of supplementary health; however, its presence contributes to increasing the length of stay in cases of cesarean sections without complications or comorbidities in supplementary health institutions.

RESUMO OBJETIVO Analisar o impacto das condições hospitalares adquiridas em mulheres no ciclo gravídico puerperal no tempo de permanência. MÉTODOS Este estudo transversal foi conduzido com 113.456 mulheres, entre julho de 2012 e julho de 2017, em hospitais nacionais da rede suplementar de saúde e filantrópicos credenciados para atendimento pelo Sistema Único de Saúde (SUS). Os dados das altas hospitalares foram coletados utilizando o sistema Diagnosis-Related Groups (DRG Brasil®). Foram incluídos todos os DRG que compõem a grande categoria diagnóstica 14 (MDC14), abrangendo gestação, parto e puerpério. O impacto das condições hospitalares adquiridas no tempo de permanência foi estimado por meio do teste t de Student, e o tamanho do efeito pelo d de Cohen, que permite avaliar a relevância clínica. RESULTADOS As categorias diagnósticas relacionadas à MDC14 mais prevalentes foram partos vaginais sem diagnósticos complicadores e cesáreas, tanto nas instituições credenciadas para atendimento pelo SUS quanto nas de saúde suplementar. A prevalência de condições hospitalares adquiridas foi de 3,8% na saúde suplementar e 2,5% no SUS. Observou-se maior tempo de permanência nos hospitais que prestam serviços a operadoras da saúde suplementar do Brasil na presença de CHA para as pacientes categorizadas nos DRG: cesariana com complicações ou comorbidades presentes à admissão (p < 0,001; d de Cohen = 0,74), cesariana sem complicações ou comorbidades presentes à admissão (p < 0,001; d de Cohen = 0,31), doenças puerperais e pós-aborto sem cirurgia (p < 0,001; d de Cohen = 1,05) e outras doenças da gravidez com complicações clínicas (p < 0,001; d de Cohen = 0,77). CONCLUSÕES O presente estudo revelou que a prevalência de condições adquiridas foi baixa tanto nas instituições credenciadas para atendimento pelo SUS quanto nas de saúde suplementar; entretanto, sua presença contribui para o aumento do tempo de permanência hospitalar em casos de cesáreas sem complicações ou comorbidades nas instituições de saúde suplementar.

Resistant Hypertension in Pregnancy: How to Manage?

PURPOSE OF REVIEW: The concept of resistant hypertension may be changed during pregnancy by the physiological hemodynamic changes and the particularities of therapy choices in this period. This review discusses the management of pregnant patients with preexisting resistant hypertension and also of those who develop severe hypertension in gestation and puerperium. RECENT FINDINGS: The main cause of severe hypertension in pregnancy is preeclampsia, and differential diagnosis must be done with secondary or primary hypertension. Women with preexisting resistant hypertension may need pharmacological therapy adjustment. Several drugs can be used to treat severe hypertension, with exception of angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The most used drugs are methyldopa, beta-blockers, and calcium channel antagonists. There is a general agreement that severe hypertension must be treated, but there are still debates over the goals of the treatment. Delivery is indicated in viable pregnancies in which blood pressure control is not achieved with three drugs in full doses. Resistant hypertension may arise in postpartum. The management of resistant hypertension in pregnancy must regard the possible etiology, the fetal well-being, and the mother's risk. Good care is mandatory to reduce maternal mortality risk.

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.

Associação entre sintomas emocionais da tensão pré-menstrual e o risco de desenvolvimento de sintomas depressivos no pós-parto / Association between emotional symptoms of premenstrual syndrome and the risk of developing depressive symptoms in the postpartum period

Este estudo verificou a possível associação entre a situação emocional no pré-menstrual (TPM emocional) e risco de depressão puerperal. Foram estudadas 94 mulheres no pós-parto imediato na Maternidade do Hospital das Clínicas da Universidade Federal de Minas Gerais, entre julho de 2011 e agosto de 2012. Foram aplicados questionários para avaliação da sintomatologia pré-menstrual e do Escore de Edimburgo relativo ao risco de desenvolvimento de depressão puerperal. O relato de três ou mais sintomas emocionais no pré-menstrual e a pontuação de 12 ou mais no escore de Edimburgo foram correlacionados pelo teste do qui-quadrado, considerando-se significativo p<0,05. Calculou-se o risco relativo (RR) de a sintomatologia emocional pré-menstrual associar-se ao mais alto risco de depressão puerperal. Houve significância entre as alterações emocionais e o RR de 3,78 diante de TPM emocional com risco aumentado de desenvolver depressão puerperal. É possível que ambas as situações tenham semelhança fisiopatológica na liberação de neurotransmissores afetados particularmente pelas variações hormonais que ocorrem em ambos os momentos. A TPM emocional bem caracterizada predispõe a elevado risco de depressão puerperal.

This study verified a possible association between emotional status in the pre-menstrual period (emotional PMS) and the risk of postnatal depression. Were included 94 women in the immediate postpartum period at the Maternity Hospital of the Universidade Federal de Minas Gerais Hospital das Clinicas from July 2011 to August 2012. Questionnaires were used to assess pre-menstrual symptoms and to determine the Edinburgh Scale for the risk of developing postnatal depression. Reports of three or more emotional symptoms in the premenstrual period and a score of 12 or more in the Edinburgh Scale were correlated using chi-square test, with a p<0.05 considered for relevance. The Relative Risk (RR) for an association between emotional PMS and a higher risk of postnatal depression was calculated and considered significant. Emotional changes were associated to a 3.78 RR of emotional PMS and increased risk to develop postnatal depression. It is possible that both situations have pathophysiologic similarities in the release of neurotransmitters particularlyaffected by hormonal changes that happen in both the moments. A well-defined emotional PMS predisposes to increased risk of puerperal depression.

Depression with postpartum onset: a prospective cohort study in women undergoing elective cesarean section in Brasilia, Brazil / Depressão com início após o parto: estudo de corte prospectivo em mulheres submetidas à cesárea eletiva em Brasília, Brasil

PURPOSE: It was to determine the prevalence of depressive symptoms in a sample of puerperal women from Brasília, Brazil, distinguishing cases with onset after delivery from those already present during pregnancy. METHODS: A prospective cohort study with convenience sampling of patients submitted to elective cesarean section at two private hospitals. As an instrument for assessing depressive symptoms, the Edinburgh Postnatal Depression Scale with cutoff >13 was applied shortly before delivery and four to eight weeks after childbirth. RESULTS: Among the 107 women who completed the study, 11 (10.3%) had significant depressive symptoms during pregnancy and 12 (11.2%) during the postpartum period. Among the 12 patients with postpartum symptoms, 6 had symptoms during pregnancy, so that 5.6% of the sample had postpartum onset of depression. The higher overall frequency of depression was significantly among single women than among married women (p=0.04), a fact mainly due to a higher frequency of single women experiencing persistent depressive symptoms both before and after delivery (p=0.002). The risk of depression was not influenced by age, parity or educational level. CONCLUSION: Women with depression identified during the postpartum period comprise a heterogeneous group, in which symptoms may have started before pregnancy, during pregnancy or after childbirth. In this sample, half of the postpartum depression cases already presented symptoms during late pregnancy. Since depression can arise before and after childbirth, it may have different etiologies and, therefore, a different response to treatment, a possibility that should be considered by clinicians and researchers.

OBJETIVO: Foi determinar a prevalência de sintomas depressivos em uma amostra de puérperas da cidade de Brasília, Brasil, discriminando os casos com surgimento após o parto daqueles já presentes durante a gestação. MÉTODOS: Estudo de corte prospectivo. Amostragem por conveniência de pacientes que seriam submetidas à cesariana eletiva em dois hospitais privados. Como instrumento para avaliar os sintomas depressivos, foi utilizada a Escala de Depressão Pós-natal de Edimburgo, com ponto de corte >13, aplicada momentos antes do parto e quatro a oito semanas após o nascimento da criança. RESULTADOS: Das 107 mulheres que completaram o estudo, 11 (10,3%) apresentaram sintomas depressivos significativos na gestação e 12 (11,2%) no período pós-parto. Das 12 pacientes com sintomas no pós-parto, 6 já tinham os sintomas durante a gestação, de modo que 5,6% da amostra teve depressão com início após o parto. A frequência global de depressão foi significativamente maior entre as mulheres solteiras em comparação com mulheres casadas (p=0,04) por causa principalmente da maior frequência de mulheres solteiras apresentando sintomas depressivos persistentes, antes e depois do parto (p=0,002). O risco de depressão não foi influenciado pela idade, paridade e escolaridade. CONCLUSÃO: As mulheres com depressão reconhecida no período pós-parto compõem um grupo heterogêneo, no qual o quadro pode ter tido início antes da gestação, durante a gestação ou após o parto. Na amostra estudada, metade dos casos de depressão reconhecida após o parto já apresentava os sintomas no final da gestação. Uma vez que a depressão que surge antes e após o parto pode ter etiologia diferente e, portanto, apresentar resposta ao tratamento diferente, os clínicos e pesquisadores devem estar atentos a essa possibilidade.

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.

Percepção materna sobre transtornos psiquiátricos no puerpério: implicações na relação mãe-filho / Maternal perception about postpartum psychiatric disorders: implications in mother-child relationship / Percepción materna sobre trastornos psiquiátricos en el puerperio: implicaciones en la relación madre-hijo

Objetivou-se analisar as implicações dos transtornos psiquiátricos na relação mãe-filho na percepção da mulher em puerpério. Utilizou-se abordagem qualitativa descritiva com dados colhidos em entrevista semiestruturada aplicada a dez puerperas, selecionadas pelo diagnóstico de transtorno psíquico no puerpério. Os dados coletados foram discutidos pela técnica de análise de conteúdo. Os resultados apontam dificuldades das pacientes em se perceber doentes, devido a fatores culturais e sociais que agem frente aos fatores biológicos na definição de diagnóstico e tratamento dos transtornos, havendo prejuízo no prognóstico, acarretando danos na relação mãe-filho. Concluiu-se que, apesar da incidência e gravidade dos transtornos psiquiátricos no ciclo gestacional, os serviços e profissionais de saúde precisam ser provocados na efetivação de ações preventivas para minimizar o sofrimento psíquico a mulheres acometidas.

That is a descriptive qualitative research that aimed to analyze the implications of the psychiatric disorders in the mother-child relationship, according to the maternal perception. Data were collected though semi-structured interview with ten women, selected by the diagnosis of mental disorders in the postpartum period. The collected data were discussed through the content analysis technique. The results pointed difficulties of the mothers to feel themselves sick, due to cultural and social factors that act in the presence of biological factors in the definition of the diagnosis and treatment of the disorders; determining impairment in the prognosis and, causing damages in the mother-child relationship. One concluded that, although the incidence and gravity of psychiatric disorders in the gestational cycle, the professionals and health services still need to be provoked for the implementation of preventive actions to minimize the psychic suffering of the women affected.

Se objetivó analizar implicaciones de trastornos psiquiátricos en la relación madre-hijo, en la percepción de la mujer puérpera. Se utilizó enfoque cualitativo descriptivo con datos recogidos por entrevista semiestructurada en diez madres diagnosticadas con trastorno psíquico en puerperio. Los datos recogidos fueran discutidos por la técnica de analice de contenido. Los resultados muestran dificultades de las pacientes en percibirse enfermas, debido a factores culturales y sociales que ajen frente a los biológicos en la definición de diagnóstico y tratamiento de trastornos, habiendo prejuicio en el pronóstico, y trayendo danos para la relación madre-hijo. Se concluye que, aunque exista incidencia y gravitad de trastornos psiquiátricos en el posparto, los servicios y profesionales de salud precisan ser provocados para la efectuación de acciones preventivas, que disminuyan el sufrimiento de las mujeres acometidas.

A intervenção de enfermagem: relaxamento e seus efeitos no sistema imunológico de puérperas / A nursing intervention relaxation, and its effects on the immune system of postpartum women

OBJETIVOS: Avaliar os efeitos da técnica de relaxamento nos níveis de Imunoglobulina A (IgA) salivar em puérperas e a relação com as variáveis: idade, grau de instrução, estado civil, tipo de parto e paridade. MÉTODOS: Estudo experimental randomizado realizado em uma maternidade do Espírito Santo (Brasil). A amostra constituiu-se de 60 puérperas. O grupo experimental composto por 30 puérpuras seguiu a técnica de relaxamento proposta por Benson. As variáveis foram coletadas por meio de formulário específico e o nível de IgA salivar por imunoturbidimetria em dois momentos: até 24 horas pós-parto e 7 dias depois. RESULTADOS: Verificou-se aumento significativo dos níveis de IgA no grupo experimental (p= 0,01) após a prática do relaxamento e ausência de relação entre as variáveis de controle e a IgA. CONCLUSÃO: O relaxamento pode ajudar a aumentar a resistência imunológica de puérperas.

OBJECTIVES: To evaluate the effects of relaxation techniques in the levels of immunoglobulin A (IgA) in saliva of postpartum women, in relationship to the variables: age, education level, marital status, type of delivery and parity. METHODS: This experimental, randomized trial was conducted in a maternity ward of Espirito Santo (Brazil). The sample consisted of 60 postpartum women. The experimental group consisted of 30 postpartum women who received the relaxation technique proposed by Benson. The levels were collected using a specific form and level of salivary IgA by immunoturbidimetry in two stages: up to 24 hours postpartum, and 7 days later. RESULTS: We observed a significant increase of IgA levels in the experimental group (p = 0.01) after the practice of relaxation, and a lack of relationship between the control variables and IgA. CONCLUSIONS: Relaxation can help increase immunological resistance in postpartum women.

OBJETIVOS: Evaluar los efectos de la técnica de relajación en los niveles de Inmunoglobulina A (IgA) salival en puérperas y la relación con las variables: edad, grado de instrucción, estado civil, tipo de parto y paridad. MÉTODOS: Estudio experimental randomizado realizado en una maternidad de Espírito Santo (Brasil).La muestra se constituyó de 60 puérperas. El grupo experimental compuesto por 30 puérperas siguió la técnica de relajación propuesta por Benson. Las variables fueron recolectadas por medio de un formulario específico y el nivel de IgA salival por imunoturbidimetria en dos momentos: hasta 24 horas post-parto y 7 días después. RESULTADOS: Se verificó aumento significativo de los niveles de IgA en el grupo experimental (p= 0,01) después de la práctica de relajación y ausencia de relación entre las variables de control y la IgA. CONCLUSIÓN: La relajación puede ayudar a aumentar la resistencia inmunológica de puérperas.

Complicações puerperais associadas à via de parto / Puerperal diseases associated to delivery

É necessária a realização de estudos para avaliar as complicações inerentes à cesariana, capazes de excluir fatores sociais, econômicos, infecções prévias e doenças preexistentes. Objetivo: avaliar a frequência de complicações precoces associadas exclusivamente à via de parto (cesariana ou parto normal). Casuística e Métodos: este é um trabalho retrospectivo, realizado pela análise de 314 prontuários de pacientes atendidas em clínica privada, para avaliar as complicações no pós-parto imediato, em 157 e 157 pacientes submetidas ao parto vaginal ou cesariana, respectivamente. Resultados: as cesarianas não foram associadas à mastite, endometrite, infecção urinária, trombose venosa e hemorragia (p>0,05). A comparação da infecção da ferida operatória perineal (episiotomia) com a da ferida operatória abdominal permitiu identificar índice mais alto de infecção na ferida operatória abdominal (p 0<05), entretanto, todos os casos apresentaram boa evolução após a terapeutica adequada, não se verificando óbito materno. Conclusão: a cesariana mostrou-se procedimento seguro, que pode ser executado sempre que seu benefício for superior ao seu risco.

To assess the complications in the immediate post-partum, a study was conducted with314 records of patients attended at a private clinic, where 157 patients had progressed tovaginal delivery and 157 patients were undergoing cesarean sections. The cesarean sectionswere not associated with mastitis, endometritis, urinary infection, hemorrhage andvenous thrombosis (p> 0.05). However, comparison of the perineal wound (episiotomy)infection with the abdominal wound has identified the highest rate of infection in the abdominalwound (p <0.05), however, all cases showed good progress after the appropriatetherapy, and there is no case of maternal death. Thus, the cesarean section proved tobe a safe procedure, which can be implemented where the benefit is greater than the risk of their achievement.

Associação entre via de parto e complicações maternas em hospital público da Grande São Paulo, Brasil / Association between mode of delivery and maternal complications in a public hospital in Greater Metropolitan São Paulo, Brazil

O estudo objetivou avaliar associação entre via de parto e complicações maternas. Realizou-se coorte retrospectiva com partos ocorridos durante o ano de 2003, em um hospital público. As complicações avaliadas foram: infecção, hemorragia, histerectomia, rotura uterina, lesão de órgão contíguo, trombose venosa profunda e embolia pulmonar. Utilizou-se a odds ratio (OR) e os testes de qui-quadrado de Pearson e de Fisher, além da regressão logística. Estabeleceu-se o nível de 0,05 como significante. Foram encontradas 15 complicações. Tomando-se o parto vaginal como referência, encontrou-se associação entre cesárea e as complicações tomadas em conjunto. Analisando-se variáveis confundidoras, encontrou-se associação das complicações com hipertensão, soropositividade para HIV, placenta prévia e descolamento prematuro de placenta. Após controle para estas quatro variáveis, manteve-se a associação entre cesárea e complicações (OR = 9,7; p = 0,04). Encontrou-se também associação entre complicações e cesárea eletiva comparada ao parto vaginal (OR = 4,7; p = 0,02), e maior proporção de complicações, no limite da significância estatística, nas cesáreas eletivas comparadas à "tentativa de parto vaginal" (OR = 3; p = 0,058). Conclui-se que a cesárea associa-se a complicações maternas, mesmo após a realização de vários ajustes.

The purpose of this study was to assess the relationship between mode of delivery and maternal complications, based on a retrospective cohort of all births at a public hospital in 2003. Complications included: infection, hemorrhage, hysterectomy, uterine rupture, lesions in adjacent organs, deep venous thrombosis, and pulmonary embolism. The analysis used odds ratio (OR), chi-squared test, and Fisher's exact test, besides logistic regression. Fifteen complications were identified. Taking vaginal delivery as the reference, an association was found between cesarean section and overall complications. Analysis of confounding showed an association between hypertension, HIV, placenta previa, and abruptio placentae. After controlling for these variables, an association remained between overall complications and cesarean section (OR = 9.7; p = 0.04). Another analysis comparing elective cesareans and vaginal deliveries also showed an increased risk for cesarean (OR = 4.7; p = 0.02). Finally, comparing elective cesareans with trial of labor, we found an increased proportion of complications in elective cesareans, with borderline significance (OR = 3; p = 0.058). We concluded that cesarean section is associated with maternal morbidity, even after controlling for confounders.