Risk Factors for Postpartum Hemorrhage and its Severe Forms with Blood Loss Evaluated Objectively - A Prospective Cohort Study.

OBJECTIVE: To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively. METHODS: This is a complementary analysis of a prospective cohort study that included pregnant women delivering vaginally. The total blood loss was obtained through the sum of the volume collected from the drape with the weight of gauzes, compresses and pads used by women within 2 hours. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. The risk factors for postpartum bleeding were evaluated using linear and logistic regression. RESULTS: We included 270 women. The mean blood loss at 120 minutes was 427.49 mL (±335.57 mL). Thirty-one percent (84 women) bled > 500 mL and 8.2% (22 women) bled > 1,000 mL within 2 hours. Episiotomy, longer second stage of labor and forceps delivery were related to blood loss > 500 mL within 2 hours, in the univariate analysis. In the multivariate analysis, only forceps remained associated with bleeding > 500 mL within 2 hours (odds ratio [OR] = 9.5 [2.85-31.53]). Previous anemia and episiotomy were also related to blood loss > 1,000mL. CONCLUSION: Prolonged second stage of labor, forceps and episiotomy are related to increased incidence of PPH, and should be used as an alert for the delivery assistants for early recognition and prompt treatment for PPH.

OBJETIVO: Identificar os fatores de risco para hemorragia pós-parto e hemorragia pós-parto grave com o sangramento pós-parto avaliado objetivamente. MéTODOS: Trata-se de uma análise complementar de um estudo de coorte prospectivo que incluiu somente mulheres que evoluíram para parto vaginal. O total de perda sanguínea foi avaliado objetivamente durante 24 horas pós-parto através da soma da quantidade de sangue mensurada através de um coletor de sangue pós-parto somado ao peso de compressas, gases e absorventes utilizados no período pós-parto. Análises exploratórias dos dados foram realizadas através do cálculo de médias, desvio-padrão (DP), frequência, porcentagem e percentis. Os fatores de risco foram avaliados através de regressão linear e logística. RESULTADOS: Foram incluídas 270 mulheres. A média de perda sanguínea pós-parto após 120 minutos foi de 427.49 mL (±335.57 mL). Trinta e um por cento (84 mulheres) sangraram > 500 mL e 8,2% (22 mulheres) sangraram > 1.000 mL em 2 horas. Episiotomia, segundo período do parto prolongado e uso de fórceps estiveram associados a perda sanguínea > 500 mL em 2 horas. Na análise multivariada, somente fórceps manteve-se entre os fatores de risco para sangramentos superiores a 500 mL em 2 horas (odds ratio [OR] = 9.5 [2.85­31.53]). Anemia prévia e episiotomia estiveram associadas com perda sanguínea > 1.000 mL. CONCLUSãO: Segundo período do parto prolongado, fórceps e episiotomia estão associados a aumento da incidência de hemorragia pós-parto e devem ser usados como um alerta para os profissionais de saúde para o reconhecimento precoce e tratamento imediato da patologia.

Correction: Shock index and heart rate standard reference values in the immediate postpartum period: A cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0217907.].

Shock index and heart rate standard reference values in the immediate postpartum period: A cohort study.

OBJECTIVE: To determine Shock Index (SI) reference values in the first two hours of the postpartum period after objectively measuring postpartum bleeding. MATERIALS AND METHODS: A complementary analysis using data from a prospective cohort study at Women's Hospital of the University of Campinas, Brazil, between 1 February 2015 and 31 March 2016. It included women giving birth vaginally unless they had one of these conditions: gestational age below 34 weeks, hypertension, hypo- or hyperthyroidism without treatment, any cardiac disease, infections with fever or sepsis, history of coagulopathy or delivery by C-section. Blood loss was measured by adding the blood volume collected in the drape placed under the women's buttocks and the weight of gauzes and compresses used (excluding the dry weight). Vital signs were measured every 5-15 min after delivery. Exploratory data analysis was performed to assess the mean, standard deviation, median, and percentiles (5th, 10th, 25th, 50th, 75th, 90th, 95th). To identify variation among the periods after delivery, the mean SI and heart rate (HR) values observed for the following intervals were used in the analysis: 0-20 min, 21-40 min, 41-60 min, 61-90 min and 91-120 min. RESULTS: One hundred eighty-six women were included. The mean age ± SD was 24.9 ± 6.1 years and the mean gestational age at birth was 39.2 ± 1.8 weeks. At the puerperal period, the mean SI values ranged from 0.68 ± 0.14 to 0.74 ± 0.15. The percentile distribution ranged from 0.46 (5th percentile) to 1.05 (95th percentile). The mean HR values ranged from 80.8 ± 12.7 bpm to 92.3 ± 14.4 bpm. The percentile distribution ranged from 62.0 bpm (5th percentile) to 117 bpm (95th percentile). CONCLUSION: Reference ranges were established for SI and HR values which showed small variations throughout the postpartum period.

Factors associated with child sexual abuse confirmation at forensic examinations.

The aim of this study is identify potential factors associated with child sexual abuse confirmation at forensic examinations. The forensic files of children under 12 years of age reporting sexual abuse at the Nina Rodrigues Institute of Forensic Medicine in Salvador, Bahia, Brazil between January 2008 and December 2009 were reviewed. A multivariate analysis was conducted to identify factors associated with finding evidence of sexual abuse in forensic examinations. The proportion of cases confirmed by the forensic physician based on material evidence was 10.4%. Adjusted analysis showed that the variables place of birth, type of abuse reported, family relationship between the child and the perpetrator, and the interval between the reported abuse and the forensic examination were not independently associated with finding forensic evidence of sexual abuse. A report of penetration was associated with a five-fold greater likelihood of confirmation, while the victim being 10-11 years of age was associated with a two-fold of abuse confirmation than younger children. These findings should be taken into consideration when drawing up guidelines for the multidisciplinary evaluation of children suspected of being victims of sexual abuse and in deciding whether to refer the child for forensic examination.

Risk factors for postpartum hemorrhage and its severe forms with blood loss evaluated objectively - a prospective cohort study / Fatores de risco para hemorragia pós-parto e suas formas graves com perda sanguínea avaliada objetivamente - Um estudo de coorte prospectivo

Abstract Objective To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively. Methods This is a complementary analysis of a prospective cohort study that included pregnant women delivering vaginally. The total blood loss was obtained through the sum of the volume collected from the drape with the weight of gauzes, compresses and pads used by women within 2 hours. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. The risk factors for postpartum bleeding were evaluated using linear and logistic regression. Results We included 270 women. Themean blood loss at 120 minutes was 427.49 mL (±335.57 mL). Thirty-one percent (84 women) bled > 500mL and 8.2% (22 women) bled > 1,000 mL within 2 hours. Episiotomy, longer second stage of labor and forceps delivery were related to blood loss > 500mL within 2 hours, in the univariate analysis. In the multivariate analysis, only forceps remained associated with bleeding > 500 mL within 2 hours (odds ratio [OR] = 9.5 [2.85-31.53]). Previous anemia and episiotomy were also related to blood loss > 1,000mL. Conclusion Prolonged second stage of labor, forceps and episiotomy are related to increased incidence of PPH, and should be used as an alert for the delivery assistants for early recognition and prompt treatment for PPH.

Resumo Objetivo Identificar os fatores de risco para hemorragia pós-parto e hemorragia pósparto grave com o sangramento pós-parto avaliado objetivamente. Métodos Trata-se de uma análise complementar de umestudo de coorte prospectivo que incluiu somente mulheres que evoluíram para parto vaginal. O total de perda sanguínea foi avaliado objetivamente durante 24 horas pós-parto através da soma da quantidade de sangue mensurada através de um coletor de sangue pós-parto somado ao peso de compressas, gases e absorventes utilizados no período pós-parto. Análises exploratórias dos dados foram realizadas através do cálculo de médias, desvio-padrão (DP), frequência, porcentagem e percentis. Os fatores de risco foram avaliados através de regressão linear e logística. Resultados Foram incluídas 270 mulheres. A média de perda sanguínea pós-parto após 120 minutos foi de 427.49 mL (±335.57 mL). Trinta e umpor cento (84 mulheres) sangraram> 500mL e 8,2% (22 mulheres) sangraram > 1.000mL em 2 horas. Episiotomia, segundo período do parto prolongado e uso de fórceps estiveram associados a perda sanguínea > 500mL em 2 horas. Na análise multivariada, somente fórceps manteve-se entre os fatores de risco para sangramentos superiores a 500mL em 2 horas (odds ratio [OR] = 9.5 [2.85-31.53]). Anemia prévia e episiotomia estiveram associadas com perda sanguínea > 1.000 mL. Conclusão Segundo período do parto prolongado, fórceps e episiotomia estão associados a aumento da incidência de hemorragia pós-parto e devem ser usados como um alerta para os profissionais de saúde para o reconhecimento precoce e tratamento imediato da patologia.

Factors associated with child sexual abuse confirmation at forensic examinations / Fatores associados à confirmação por exame médico legal de abuso sexual infantil

Abstract The aim of this study is identify potential factors associated with child sexual abuse confirmation at forensic examinations. The forensic files of children under 12 years of age reporting sexual abuse at the Nina Rodrigues Institute of Forensic Medicine in Salvador, Bahia, Brazil between January 2008 and December 2009 were reviewed. A multivariate analysis was conducted to identify factors associated with finding evidence of sexual abuse in forensic examinations. The proportion of cases confirmed by the forensic physician based on material evidence was 10.4%. Adjusted analysis showed that the variables place of birth, type of abuse reported, family relationship between the child and the perpetrator, and the interval between the reported abuse and the forensic examination were not independently associated with finding forensic evidence of sexual abuse. A report of penetration was associated with a five-fold greater likelihood of confirmation, while the victim being 10-11 years of age was associated with a two-fold of abuse confirmation than younger children. These findings should be taken into consideration when drawing up guidelines for the multidisciplinary evaluation of children suspected of being victims of sexual abuse and in deciding whether to refer the child for forensic examination.

Resumo O Objetivo deste estudo é identificar potenciais fatores associados à confirmação de abuso sexual infantil no exame médico legal. Foram revisados os laudos de sexologia forense realizados em crianças menores que 12 anos que relataram abuso sexual no Instituto Médico Legal de Salvador, Brasil, no período de janeiro de 2008 a dezembro de 2009. Análise multivariada foi utilizada para identificar fatores relacionados à confirmação de abuso sexual pelo exame médico forense. A proporção de casos confirmados pelo médico legista com base em evidencia material foi de 10,4%. A análise ajustada demostrou que as variáveis naturalidade, tipo do relato de abuso, parentesco com o agressor, e intervalo entre o abuso relatado e a perícia não estão independentemente relacionadas à confirmação de abuso sexual em exame de corpo de delito. A presença de relato de penetração estava associada a uma chance cinco vezes maior de confirmação, e a faixa etária de 10 a 11 anos apresentou uma chance duas vezes maior de ter casos confirmados do que crianças menores. Estes dados devem ser levados em conta no planejamento de diretrizes para a avaliação multidisciplinar de crianças com suspeita de serem vítimas de abusos sexual e na decisão de encaminhamento para exame de corpo de delito.

Doenças e variações anatômicas confundidas com abuso sexual em crianças - Estudo descritivo / Disorders and anatomical variations confused with sexual abuse in children - A descriptive study

Objetivo: Descrever as doenças e variações anatômicas confundidas com abuso sexual em crianças. Método: Estudo descritivo com dados secundários. Foram revisados os laudos de crianças menores de 12 anos periciadas no Instituto Médico Legal Nina Rodrigues, entre 2005 e 2010, por suspeita de abuso sexual baseada em queixa ou alteração anogenital, sem relato de abuso sexual no histórico da perícia. O critério utilizado para identificar os casos foi a conclusão do médico legista no laudo. Resultados: Foram encontrados 410 casos sem relato ou testemunho de abuso sexual. Neste grupo, em 31 casos (7,6%) a conclusão do laudo identificou uma doença ou variação anatômica, baseado na queixa ou alteração anogenital que gerou a suspeita de abuso sexual. Foram encontrados 16 casos de prolapso uretral (52%). As outras condições médicas identificadas incluíram sinéquia de ninfas, neoplasia vaginal, dermatites, variação anatômica, doença de Crohn, enterobíase, corpo estranho vaginal, fenda perineal e infecção urinária. Conclusão: Foram encontrados casos de doença ou variação anatômica confundidos com abuso sexual em 7,6% das crianças em que a origem da suspeita foi uma queixa ou alteração anogenital, sem relato de abuso no histórico. Prolapso uretral representou 52% dos casos de equivoco...