49 Keypoints • Preeclampsia (PE) is an important cause of maternal and perinatal mortality worldwide, accounts for 10% to 15% of direct maternal deaths, and 99% of these deaths are in low-income countries. • Preeclampsia is defined as systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥90 mmHg on at least two occasions, measured four hours apart in previously normotensive women, and is accompanied by one or more of the following new-onset conditions after 20 weeks’ gestation: (1) proteinuria, (2) evidence of other maternal organ dysfunction, or (3) uteroplacental dysfunction. • Preeclampsia is classified into: (1) early PE (delivery < 34+0 weeks’ gestation); (2) preterm PE (delivery < 37+0 weeks’ gestation); (3) late-onset PE (delivery ≥ 34+0 weeks’ gestation); (4) term PE (delivery ≥ 37+0 weeks’ gestation). • In Brazil, the incidence of PE varies from 1.5% to 7%; of preterm PE is 2% and of eclampsia is 0.6%. However, these statistics are likely to be underestimated and vary according to the region studied. • Screening strategies for PE vary depending on the parameters used, pre-test risk, outcome stratification, and the gestational age at which screening is performed. However, there is consensus in the literature that no single-parameter screening test has been shown to adjust the preexisting maternal risk for PE with sufficient specificity and sensitivity for clinical use.
Unplanned pregnancy continues to be a public health problem in Brazil, particularly for the most vulnerable segment of the population. According to data from the Birth in Brazil study, 55% of pregnancies are unplanned, a proportion that reaches 65.3% among adolescents. Although the copper IUD is a highly effective long-term contraceptive method, it is still little used in Brazil for several reasons, including access barriers in outpatient clinics. The offer of IUD insertion immediately after childbirth or abortion is a window of opportunity to avoid unplanned pregnancies.
Abstract Objective The present study aims to establish a risk profile for high-grade cervical lesions and cervical cancer (CIN2 + ) in women undergoing colposcopy at the Hospital do Câncer de Barretos, through the analysis of Human Papillomavirus (HPV) infection, cervical cytology, and patient's age. Methods Retrospective cross-sectional study based on a computerized database of women aged ≥ 18 years old who underwent colposcopy at the Prevention Department of the Hospital do Câncer de Barretos from 2017 to 2019. Results A total of 3,411 women were included, 58.0% were positive for high-risk-HPV test, with a higher prevalence of CIN2+ for HPV16 (30.3%) and other HPV (45.0%). Cytological findings that suggest invasive cervical cancer (squamous cells or adenocarcinoma), regardless of the status of HPV test, showed 100% diagnosis of CIN2 + , while atypias that suggest high-grade lesions, HSIL and ASC-H, positive for HPV test, showed in 86 and 55.2%, respectively, diagnosis of CIN2 + . ASC-H cytological results among women aged > 40 years old and negative HPV were mainly associated with benign findings. We observed that ≤ CIN1 has a higher prevalence among older women with negative HPV, while for high-grade lesions there is an increase among young women HPV16- and/or 18-positive. In cancer diagnosis, we observed a predominance of HPV 16/18 regardless of the age group. Conclusion The highest risks of precursor lesions and cervical cancer were found among women with positive HPV 16/18 tests and severe cytological atypia in population screening tests. In addition, cytological findings of ASC-H HPV negative in women > 40 years old usually represent benign findings in histological investigation.
The Latin American Center for Perinatology-PAHO aims to strengthen healthcare since 1970. For timely surveillance of maternal health, a perinatal information system (SIP) was implemented to enable monitoring trends of severe morbidity/mortality. It is time for integrated interventions to translate surveillance into health policies to address preventable maternal/perinatal deaths.
Objective This study focused on pregnant and postpartum women during the COVID-19 pandemic, aiming to determine the attitudes and behaviors of vaccinated and unvaccinated groups, and the vaccination behaviors in the groups with and without the disease. The reasons for refusing the vaccine were also questioned.Methods This cross-sectional study was performed from September 2021 to October 2021. The study data were collected using a face-to-face questionnaire. The participants were pregnant women who applied to the hospital for routine antenatal care and were hospitalized, and women in the postpartum period. Additionally, pregnant and postpartum patients who were diagnosed with COVID-19 at the time of admission and were hospitalized and admitted to the intensive care unit due to this disease were also included in the study.Results A total of 1,146 pregnant and postpartum women who completed the questionnaire were included in our study. Only 43 (3.8%) of the participants were vaccinated; 154 (13.4%) of the participants had comorbidities. The number of COVID-19-positive patients was 153. The lack of sufficient information about the safety of the COVID-19 vaccine is the most common reason for the refusal.Conclusion Vaccine refusal can significantly delay or hinder herd immunity, resulting in higher morbidity and mortality. Considering the adverse effects of COVID-19 on pregnancy, it is essential to understand pregnant and postpartum women's perceptions toward vaccination to end the pandemic.
Objective To review the current state of knowledge on the impact of the surgical treatment on the sexual function and dyspareunia of deep endometriosis patients. Data Source A systematic review was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted systematic searches in the PubMed, EMBASE, LILACS, and Web of Science databases from inception until December 2022. The eligibility criteria were studies including: preoperative and postoperative comparative analyses; patients with a diagnosis of deep endometriosis; and questionnaires to measure sexual quality of life. Study Selection Two reviewers screened and reviewed 1,100 full-text articles to analyze sexual function after the surgical treatment for deep endometriosis. The risk of bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration's tool for randomized controlled trials. The present study was registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration CRD42021289742). Data Collection General variables about the studies, the surgical technique, complementary treatments, and questionnaires were inserted in an Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, United States) spreadsheet. Synthesis of Data We included 20 studies in which the videolaparoscopy technique was used for the excision of deep infiltrating endometriosis. A meta-analysis could not be performed due to the substantial heterogeneity among the studies. Classes III and IV of the revised American Fertility Society classification were predominant and multiple surgical techniques for the treatment of endometriosis were performed. Standardized and validated questionnaires were applied to evaluate sexual function. Conclusion Laparoscopic surgery is a complex procedure that involves multiple organs, and it has been proved to be effective in improving sexual function and dyspareunia in women with deep infiltrating endometriosis.
Objective Recurrent miscarriage has been linked to hormonal disturbance due to dysregulation of its receptors rather than to the availability of the hormone. We aimed to investigate endometrial expression of progesterone and estrogen receptors in relation to serum and endometrial hormonal levels in unexplained recurrent miscarriage.Methods The present case control study included 20 cases with unexplained recurrent miscarriage and 20 parous women as controls. Ovulation was confirmed using an ovulation kit and 10 to 12 days after detecting the urinary luteinizing hormone surge, all women were subjected to a blood sample and to an endometrial biopsy. Progesterone and estrogen levels were measured in serum and in endometrial tissue and receptor concentrations were in the endometrial sample.Results Women with recurrent miscarriage showed significantly lower concentration of receptors in both the cytoplasm and the nucleus of endometrial tissue compared with controls. The nuclear/cytoplasm ratio of progesterone receptor was significantly higher in cases compared with controls, implicating that recurrent miscarriage is probably linked to nongenomic activity of the hormone; this was also significant for estrogen receptor. Serum progesterone and estrogen hormonal levels were comparable between groups while both hormones were significantly reduced in the endometrium of recurrent miscarriage cases. Receptors significantly correlated with endometrial hormonal level but not to serum level.Conclusion Recurrent miscarriage might be linked to reduced endometrial progesterone and estrogen receptors and appears to be more related to nongenomic activity of progesterone. Endometrial receptors expression correlates to tissue hormonal level rather than to serum hormonal level.
Abstract Objective Currently, uteroplacental vascular disorders are considered one of the main mechanisms of spontaneous preterm delivery (PTD). Low-dose aspirin is used to prevent pre-eclampsia, which has a similar mechanism; hence, the present study aimed to investigate the effect of low-dose aspirin on the prevention of PTD in women with a history of spontaneous PTD. Methods The present pilot randomized clinical trial was conducted on 54 pregnant women in the aspirin group (taking 80 mg daily until the 36th week and classic treatment) and 53 patients in the control group (only receiving classic treatment). Results Forty-three patients (40%) presented before 37 weeks due to symptoms of PTL. Preterm delivery (< 37 weeks) occurred in 28 patients (26%), and there was no significant difference between the aspirin and control groups (10 patients [19%] and 18 patients [34%], respectively; p = 0.069). The time of preterm delivery was early (< 34 weeks) in 6 patients (21%), and its cause was spontaneous labor in 23 patients (82%) which was not significantly different between the two groups (p > 0.05). Out of 40 patients with spontaneous labor, 25 patients (63%) had a PTD, which was significantly lower in the aspirin group than in the control group (9 patients [45%] versus 16 patients [80%], respectively; p = 0.022). Conclusion The findings of the present study demonstrated that despite the reduction in the incidence of PTD using low-dose aspirin, the reduction rate was not statistically significant. On the other hand, in patients with spontaneous labor prone to PTD, aspirin was effective in reducing the incidence of PTD.
Endometriosis, from a pathophysiological standpoint, can be defined as active endometrium-like tissue outside the uterus. However, to better understand and approach this complex disease, it should be addressed as a chronic inflammatory disease that can cause pelvic pain during a long period of a women's reproductive lifetime.[1] Due to nociplasty, women affected by endometriosis can also maintain pain despite adequate organic treatment, especially considering that this disease has no objective cure.[1] [2] On the other hand, chronic pelvic pain(CPP) can be defined as pain perceived in the lower abdomen, lasting for at least six months, that has a negative impact on quality of life and that demands treatment.[2] CPP may have a gynecologic etiology such as endometriosis, but most frequently has a multifactorial nature, involving gastrointestinal, urinary, psychological, and musculoskeletal systems.
This study is a bibliographic review in order to overview the use, indications and contraindications of misoprostol in obstetrics. Thirty three academic articles in Portuguese, Spanish, and English in the range 2005 to 2014 wer collected and analysed. Misoprostol is a methyl analogue of PGE1 and has anti-secretory action and protective properties of the mucosa, and cause increased uterine contractility, induce the development of contractions and cause cervical effacement, facilitating the expansion necessary to carry out obstetric procedures. It is an important drug in obstetric practice and is indicated for treatment of missed abortion, labor induction, shortens the operatory time in situations where the cervix has no dilation, reduce the frequency of complications and caesarean indications, and can be used in prophylaxis of post-partum hemorrhage. Attention should be paid to its misuse as an abortifacient and the existence of reports of congenital malformations, especially the Moebius Syndrome. It is a stable product, safe, effective, inexpensive and easy management, ensuring broad employability of its clinical use in current obstetrics.
Isthmocele is a discontinuation of the myometrium at the uterine scar site in a patient with a previous cesarian section (CS). The cause of isthmocele appears to be multifactorial. Poor surgical technique, low incision location, uterine retroflection, obesity, smoking, inadequate healing of scars, and maternal age are possible related factors. Most patients with this condition are asymptomatic. However, women can present with postmenstrual bleeding, pelvic pain, subfertility, dysmenorrhea, infertility, and scar abscess. Brazil has one of the world's highest cesarean section rates. One of the consequences of the rising rate of CS is the isthmocele, an emerging female health problem. Here we report a case of mucinous cystadenoma arising in a uterine isthmocele, a complication, as far as we could investigate, not yet described in the literature.
Cesarean section (CS) is the most commonly performed surgical procedure in the United States (more than a million surgeries per year) and one of the most frequently performed procedures worldwide.[1] Although CS is a potentially life-saving procedure when correctly indicated, its worldwide use has steadily increased over the last decades (currently 21.1% globally, ranging from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean). Moreover, it will continue increasing worldwide (2030 projection: 28.5% globally, ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia).[2] Dominican Republic, Brazil, Cyprus, Egypt and Turkey are the worldwide leaders, with CS rates ranging from 58.1% to 50.8%, respectively, which points to a worrying trend towards overmedicalization of childbirth and overuse of CS.[2] Other surgical procedures such as dilation, curettage, myomectomy, and surgical hysteroscopy are less frequent than CS. Still, due to the trend towards more advanced maternal age, the number of pregnant women previously submitted to these procedures also tends to increase. These data point to a growing number of pregnancies in surgically manipulated uteruses.
Abstract Objective To evaluate the continuation rates of the 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) during the first 5 years of use, reasons for its discontinuation, bleeding patterns, and new contraceptive choice after the 5th year, in adolescents and young women. Methods The present study was a 5-year prospective cohort conducted in a Family Planning Service of a tertiary hospital in Brazil. We selected 100 healthy women between 15 and 24 years old who used 52-mg LNG-IUS for contraception. The clinical follow-up of these women took place from June 2017 to December 2022. The study evaluated the continuation rates of the method, reasons for its discontinuation, bleeding patterns, and new contraceptive choice after the 5th year. Continuous data were reported as mean ± standard deviation (SD) and range (minimum-maximum). Categorical variables were described as percentages. Results The continuation rates of LNG-IUS were 89.1% (82/92), 82.9% (72/87), 75.3% (64/85), 70.5% (60/85), and 64.2% (54/84) in the 1st, 2nd, 3rd, 4th, and 5th years of use, respectively. The main reason for discontinuation was acne (11/30). Amenorrhea rates were 50, 54.1, 39, 35.7, and 51.8% at 12, 24, 36, 48, and 60 months, respectively. All patients who completed the study and needed contraception after the 5th year opted for long-acting contraceptive methods (LARC). Conclusion The LNG-IUS showed high continuation rates in adolescents and young women in the first 5 years of use. Most patients who completed the study chose a LARC method after the 5th year.
Infertility is the inability to achieve a clinical pregnancy even after engaging in regular and unprotected sexual intercourse for 12 months[1] [2] during the fertile days; roughly 8% to 12% of couples of reproductive age worldwide are believed to be affected by infertility. While males are solely responsible for around 20% to 30% of infertility cases, overall, they contribute to half of the cases.[2] It is well known that infertility may induce stress on couples who fail to conceive, but it is unclear whether psychological stress causes infertility.[3] Determining the emotional and psychological impact of male infertility and knowing whether it can improve outcomes if addressed is one of the priorities of male infertility research.[4] Infertile men generally suffer silently, and consequently report lower levels of psychological distress in questionnaires;[5] considering that the concepts of male fertility and virility are part of the perception of masculinity, it is not illogical to assume that there is a social concern that could influence male sexual and reproductive health.[6] A study[7] has found that the pessimism and psychological distress reported by male partners in couples undergoing in vitro fertilization had a negative linear correlation with clinical pregnancy. This might be due to the fact that psychological stress reduces sperm count, progressive motility, and increases abnormal morphology.[8] Another study[9] found an inverse relationship between erectile dysfunction and quality of life measured through the fertility quality of life tool (FertiQoL) and a significant relationship between depression and erectile dysfunction. Additionally, a prospective study[10] suggested infertile men are generally less healthy than their fertile counterparts when considering overall health.
Abstract Objective The aim of the present study is to compare the cavum septum pellucidi (CSP) z-score in euploid and aneuploid fetuses and to investigate the performance of the CSP width/length and CSP width/biparietal diameter (BPD) ratios as a diagnostic marker in aneuploidy. Methods A total of 54 patients, 20 aneuploid and 35 euploid fetuses, between 18 and 37 weeks of gestation, were included in this retrospective study. The CSP width z-score was compared between the two groups. Receiver operating characteristic (ROC) curves were calculated for the CSP width/length and CSP width/BPD ratios to predict aneuploidy. Results The median CSP width was 4.8 mm (range, 1.8 to 8.5 mm) in the euploid group, and 5.4 mm (range 3.1 to 8.4 mm) in the aneuploid group. Cavum septum pellucidi width z-score, CSP width/length ratio, and CSP width/BPD ratio were significantly higher in fetuses with aneuploidy than in fetuses with normal karyotype (p= 0.001; p= 0.013; p= 0.028). In the ROC analysis, the CSP width/length ratio had the optimal cutoff value of 0.59, with 72.0% sensitivity and 58.0% specificity, and for the CSP width/BPD ratio, the cutoff value was 0.081 with 83.0% sensitivity and 61.0% specificity for detection of aneuploidy. Conclusion CSP width z-score was found to be increased in aneuploid fetuses. The CSP width /BPD ratio can be used as a new marker for predicting aneuploidy.
Abstract Objective To assess the knowledge, attitude, and practice of Brazilian physicians about immediate postpartum and postabortion intrauterine device insertion. Methods Cross-sectional online survey involving physicians on duty in public Brazilian hospitals. Participants answered an anonymous questionnaire with close-ended questions to assess their knowledge, attitude, and experience on the immediate postpartum and postabortion insertion of copper intrauterine devices. Results One hundred twenty-seven physicians working in 23 hospitals in the 5 geographic regions of Brazil completed the questionnaire. Most were female (68.5%) and worked in teaching hospitals (95.3%). The mean (standard deviation) knowledge score (0–10 scale) was 5.3 (1.3); only 27.6% of the participants had overall scores ≥7.0. Most physicians (73.2%) would insert a postpartum intrauterine device in themselves/family members. About 42% of respondents stated that they had not received any training on postpartum or postabortion intrauterine device insertion. In the past 12 months, 19.7%, 22.8%, and 53.5% of respondents stated they had not inserted any intrauterine device during a cesarean section, immediately after a vaginal delivery, or after an abortion, respectively. Conclusion Most study participants have a positive attitude toward the insertion of intrauterine devices in the immediate postpartum period, but they have limited knowledge about the use of this contraceptive method. A large percentage of respondents did not have previous training on postpartum and postabortion intrauterine device insertion and had not performed any such insertions in the last 12 months. Strategies are needed to improve the knowledge, training, and experience of Brazilian physicians on immediate postpartum and postabortion intrauterine device insertion.
Abstract Objective The availability of reliable and inexpensive markers that can be used to determine the risk of rupture during methotrexate (MTX) treatment in ectopic pregnancies (EPs) is considerable. The aim of the present study is to investigate the role of systemic inflammatory markers such as leukocytes (or white blood cells, WBCs), the neutrophil-to-lymphocyte ratio (NLR), and platelet distribution width (PDW), which are among the parameters of the complete blood count (CBC), in the prediction of rupture of EPs under MTX treatment. Materials and Methods A total of 161 patients with tubal EP who underwent a single-dose methotrexate (MTX) protocol were retrospectively analyzed, and the control group (n = 83) included patients cured by MTX, while the ruptured group (n = 78) included patients who were operated on for tubal rupture during the MTX treatment. The features of EP, beta-human chorionic gonadotropin (β-hCG) levels, sonographic findings, and CBC-derived markers such as WBC, NLR, and PDW, were investigated by comparing both groups. Results The NLR was found to be higher in the ruptured group, of 2.92 ± 0.86%, and significantly lower in the control group, of 2.09 ± 0.6%. Similarly, the PDW was higher (51 ± 9%) in the ruptured group, and it was significantly lower a (47 ± 13%) in the control group (p < 0.05). Other CBC parameters were similar in both groups (p > 0.05). Conclusion Systemic inflammation markers derived from CBC can be easily applied to predict the risk of tubal rupture in Eps, since the CBC is an inexpensive and easy-to-apply test, which is first requested from each patient during hospitalization.
Dear Editor, We have read with interest the article by Silva et al.1 The study concluded that in a real-life setting there was no difference in the intensity of labor pain between patients who used nonpharmacologicalmethods during the active phase of labor and those who did not. We appreciate the efforts of the research team, as their study undoubtedly contributes to enhance knowledge about labor and childbirth care. We find it crucial to highlight the widespread use of non-pharmacologicalmethods for pain control in the institution inwhich the study was conducted, a highly recommended practice2 that is not frequently available in Brazilian settings.3 Whilewe acknowledge the importance of their results, we would like to raise some concerns we believe are relevant for a more accurate understanding of their findings. Measuring pain is challenging because pain is a personal, subjective, andmultifaceted experience. Labor pain presents additional difficulties because of all the emotions and concerns involved in the process, the duration of the painful sensations (which can last several hours), and the increasing intensity of the pain during the progression of dilation and fetus descent through the maternal pelvis.4,5 We have considered that one single evaluation using the Visual Analog Scale (VAS) after the deliverywould not suffice to measure all multifaceted, variable, and usually longlasting aspects of labor pain. In most of the studies using VAS included in the Cochrane Systematic Reviews, the tool was applied several times throughout the course of labor and/or before and after the intervention.6,7 Additionally, although the VAS is widely used, more comprehensive instruments that enable multidimensional assessments of pain and the experience of the parturient are necessary.5 Furthermore, regarding the interpretation of results, it would be important to consider not only pain, but also satisfaction, the perception of a safe environment, personal achievement, and situation control.8,9 Moreover, there is a comparative issue that needs to be taken into consideration. The study compares groups that are not analogous in terms of the time of exposure to nonpharmacological methods. It is important to note that one group had little to no time to become familiar with the resources, and even use them, while the other group had a more extensive opportunity to become familiar with the pain control methods, and a longer active phase period. Moreover, the abstract and conclusions of the aforementioned study may lead readers to believe that non-pharmacological methods are ineffective, when the measurement of painwas imprecise, and the groupswere not comparable.We
Mammography is the method of choice for breast cancer screening and the only one that demonstrates a reduction in mortality in the population at usual risk.
