Original Article Archives - Revista Brasileira de Ginecologia e Obstetrícia
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo47
, , , , , , , In Brazil, postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. Data on the profile of women and risk factors associated with PPH are sparse. This study aimed to describe the profile and management of patients with PPH, and the association of risk factors for PPH with severe maternal outcomes (SMO).
A cross-sectional study was conducted in Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) obstetric intensive care unit (ICU) between January 2012 and March 2020, including patients who gave birth at the hospital and that were admitted with PPH to the ICU.
The study included 358 patients, of whom 245 (68.4%) delivered in the IMIP maternity, and 113 (31.6%) in other maternity. The mean age of the patients was 26.7 years, with up to eight years of education (46.1%) and a mean of six prenatal care. Uterine atony (72.9%) was the most common cause, 1.6% estimated blood loss, 2% calculated shock index (SI), 63.9% of patients received hemotransfusion, and 27% underwent hysterectomy. 136 cases of SMO were identified, 35.5% were classified as maternal near miss and 3.0% maternal deaths. Multiparity was associated with SMO as an antepartum risk factor (RR=1.83, 95% CI1.42-2.36). Regarding intrapartum risk factors, abruptio placentae abruption was associated with SMO (RR=2.2 95% CI1.75-2.81). Among those who had hypertension (49.6%) there was a lower risk of developing SMO.
The principal factors associated with poor maternal outcome were being multiparous and placental abruption.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo47
, , , , , , , In Brazil, postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. Data on the profile of women and risk factors associated with PPH are sparse. This study aimed to describe the profile and management of patients with PPH, and the association of risk factors for PPH with severe maternal outcomes (SMO).
A cross-sectional study was conducted in Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) obstetric intensive care unit (ICU) between January 2012 and March 2020, including patients who gave birth at the hospital and that were admitted with PPH to the ICU.
The study included 358 patients, of whom 245 (68.4%) delivered in the IMIP maternity, and 113 (31.6%) in other maternity. The mean age of the patients was 26.7 years, with up to eight years of education (46.1%) and a mean of six prenatal care. Uterine atony (72.9%) was the most common cause, 1.6% estimated blood loss, 2% calculated shock index (SI), 63.9% of patients received hemotransfusion, and 27% underwent hysterectomy. 136 cases of SMO were identified, 35.5% were classified as maternal near miss and 3.0% maternal deaths. Multiparity was associated with SMO as an antepartum risk factor (RR=1.83, 95% CI1.42-2.36). Regarding intrapartum risk factors, abruptio placentae abruption was associated with SMO (RR=2.2 95% CI1.75-2.81). Among those who had hypertension (49.6%) there was a lower risk of developing SMO.
The principal factors associated with poor maternal outcome were being multiparous and placental abruption.
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo48
, , , , Evaluate the prevalence of macrosomic newborns (birth weight above 4000 grams) in a high-risk maternity from 2014 to 2019, as well as the maternal characteristics involved, risk factors, mode of delivery and associated outcomes, comparing newborns weighing 4000-4500 grams and those weighing above 4500 grams.
This is an observational study, case-control type, carried out by searching for data in hospital’s own system and clinical records. The criteria for inclusion in the study were all patients monitored at the service who had newborns with birth weight equal than or greater than 4000 grams in the period from January 2014 to December 2019, being subsequently divided into two subgroups (newborns with 4000 to 4500 grams and newborns above 4500 grams). After being collected, the variables were transcribed into a database, arranged in frequency tables. For treatment and statistical analysis of the data, Excel and R software were used. This tool was used to create graphs and tables that helped in the interpretation of the results. The statistical analysis of the variables collected included both simple descriptive analyzes as well as inferential statistics, with univariate, bivariate and multivariate analysis.
From 2014 to 2019, 3.3% of deliveries were macrosomic newborns. The average gestational age in the birth was 39.4 weeks. The most common mode of delivery (65%) was cesarean section. Diabetes mellitus was present in 30% of the deliveries studied and glycemic control was absent in most patients. Among the vaginal deliveries, only 6% were instrumented and there was shoulder dystocia in 21% of the cases. The majority (62%) of newborns had some complication, with jaundice (35%) being the most common.
Birth weight above 4000 grams had a statistically significant impact on the occurrence of neonatal complications, such as hypoglycemia, respiratory distress and 5th minute APGAR less than 7, especially if birth weight was above 4500 grams. Gestational age was also shown to be statistically significant associated with neonatal complications, the lower, the greater the risk. Thus, macrosomia is strongly linked to complications, especially neonatal complications.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo48
, , , , Evaluate the prevalence of macrosomic newborns (birth weight above 4000 grams) in a high-risk maternity from 2014 to 2019, as well as the maternal characteristics involved, risk factors, mode of delivery and associated outcomes, comparing newborns weighing 4000-4500 grams and those weighing above 4500 grams.
This is an observational study, case-control type, carried out by searching for data in hospital’s own system and clinical records. The criteria for inclusion in the study were all patients monitored at the service who had newborns with birth weight equal than or greater than 4000 grams in the period from January 2014 to December 2019, being subsequently divided into two subgroups (newborns with 4000 to 4500 grams and newborns above 4500 grams). After being collected, the variables were transcribed into a database, arranged in frequency tables. For treatment and statistical analysis of the data, Excel and R software were used. This tool was used to create graphs and tables that helped in the interpretation of the results. The statistical analysis of the variables collected included both simple descriptive analyzes as well as inferential statistics, with univariate, bivariate and multivariate analysis.
From 2014 to 2019, 3.3% of deliveries were macrosomic newborns. The average gestational age in the birth was 39.4 weeks. The most common mode of delivery (65%) was cesarean section. Diabetes mellitus was present in 30% of the deliveries studied and glycemic control was absent in most patients. Among the vaginal deliveries, only 6% were instrumented and there was shoulder dystocia in 21% of the cases. The majority (62%) of newborns had some complication, with jaundice (35%) being the most common.
Birth weight above 4000 grams had a statistically significant impact on the occurrence of neonatal complications, such as hypoglycemia, respiratory distress and 5th minute APGAR less than 7, especially if birth weight was above 4500 grams. Gestational age was also shown to be statistically significant associated with neonatal complications, the lower, the greater the risk. Thus, macrosomia is strongly linked to complications, especially neonatal complications.
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo60
, , , , , , , , , , , , , , , , , , , To analyze marital outcomes, divorce or separation, and its association with demographic, socioeconomic, and clinicopathological factors among breast cancer (BC) survivors after 2-years of diagnosis.
We performed a retrospective analysis of marital status at baseline and at years 1 and 2 of follow-up of women aged ≥ 18 years diagnosed with invasive BC participating in the AMAZONA III (GBECAM0115) study. The BC diagnosis occurred between January 2016 and March 2018 at 23 institutions in Brazil.
Of the 2974 women enrolled in AMAZONA III, 599 were married or living under common law at baseline. Divorce or separation occurred in 35 (5.8%) patients at 2 years of follow-up. In the multivariate analysis, public health insurance coverage was associated with a higher risk of marital status change (8.25% vs. 2.79%, RR 3.09, 95% CI 1.39 - 7.03, p = 0.007). Women who underwent mastectomy, adenomastectomy or skin-sparing mastectomy were associated with a higher risk of divorce or separation (8.1% vs. 4.49%, RR 1.97, 95 CI 1.04 – 3.72, p = 0.0366) than those who underwent breast-conserving surgery.
Women covered by the public health system and those who underwent mastectomy, adenomastectomy or skin-sparing mastectomy were associated with a higher risk of divorce or separation. This evidence further supports the idea that long-term marital stability is associated with a complex interplay between socioeconomic conditions and stressors, such as BC diagnosis and treatment. ClinicalTrials Registration: NCT02663973.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo60
, , , , , , , , , , , , , , , , , , , To analyze marital outcomes, divorce or separation, and its association with demographic, socioeconomic, and clinicopathological factors among breast cancer (BC) survivors after 2-years of diagnosis.
We performed a retrospective analysis of marital status at baseline and at years 1 and 2 of follow-up of women aged ≥ 18 years diagnosed with invasive BC participating in the AMAZONA III (GBECAM0115) study. The BC diagnosis occurred between January 2016 and March 2018 at 23 institutions in Brazil.
Of the 2974 women enrolled in AMAZONA III, 599 were married or living under common law at baseline. Divorce or separation occurred in 35 (5.8%) patients at 2 years of follow-up. In the multivariate analysis, public health insurance coverage was associated with a higher risk of marital status change (8.25% vs. 2.79%, RR 3.09, 95% CI 1.39 - 7.03, p = 0.007). Women who underwent mastectomy, adenomastectomy or skin-sparing mastectomy were associated with a higher risk of divorce or separation (8.1% vs. 4.49%, RR 1.97, 95 CI 1.04 – 3.72, p = 0.0366) than those who underwent breast-conserving surgery.
Women covered by the public health system and those who underwent mastectomy, adenomastectomy or skin-sparing mastectomy were associated with a higher risk of divorce or separation. This evidence further supports the idea that long-term marital stability is associated with a complex interplay between socioeconomic conditions and stressors, such as BC diagnosis and treatment. ClinicalTrials Registration: NCT02663973.
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo52
, , , To analyze the death of Brazilian pregnant and postpartum women due to COVID-19 or unspecific cause.
This is retrospective, descriptive-exploratory, population-based study carried out with the Sistema de Informação de Vigilância Epidemiológica da Gripe (SIVEP-Gripe) database, with pregnant and postpartum women of reproductive age who died from confirmed COVID-19 between 2020 and 2021. The chosen variables were: age, gestational period, type and number of comorbidities, skin color, using the statistical software R Foundation for Statistical Computing Platform, version 4.0.3 and Statistical Package for Social Science, version 29.0 for analysis.
A total of 19,333 cases of pregnant and postpartum women aged between 10 and 55 years diagnosed with SARS were identified, whether due to confirmed COVID-19 or unspecific causes. Of these, 1,279 died, these cases were classified into two groups according to the cause of death: deaths from COVID-19 (n= 1,026) and deaths from SARS of unspecific cause (n= 253).
The risk of death increased among black and brown women, in the postpartum period and with the presence of comorbidities, mainly diabetes, cardiovascular diseases and obesity. The data presented here draw attention to the number of deaths from SARS, especially among sociodemographic profiles, precarious access to health, such as the black population. In addition, limitations in adequate access to health care are reinforced by even lower rates of ICU admissions among women who died from SARS of an unspecified cause.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo52
, , , To analyze the death of Brazilian pregnant and postpartum women due to COVID-19 or unspecific cause.
This is retrospective, descriptive-exploratory, population-based study carried out with the Sistema de Informação de Vigilância Epidemiológica da Gripe (SIVEP-Gripe) database, with pregnant and postpartum women of reproductive age who died from confirmed COVID-19 between 2020 and 2021. The chosen variables were: age, gestational period, type and number of comorbidities, skin color, using the statistical software R Foundation for Statistical Computing Platform, version 4.0.3 and Statistical Package for Social Science, version 29.0 for analysis.
A total of 19,333 cases of pregnant and postpartum women aged between 10 and 55 years diagnosed with SARS were identified, whether due to confirmed COVID-19 or unspecific causes. Of these, 1,279 died, these cases were classified into two groups according to the cause of death: deaths from COVID-19 (n= 1,026) and deaths from SARS of unspecific cause (n= 253).
The risk of death increased among black and brown women, in the postpartum period and with the presence of comorbidities, mainly diabetes, cardiovascular diseases and obesity. The data presented here draw attention to the number of deaths from SARS, especially among sociodemographic profiles, precarious access to health, such as the black population. In addition, limitations in adequate access to health care are reinforced by even lower rates of ICU admissions among women who died from SARS of an unspecified cause.
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo64
, , , , To evaluate whether there were differences in the presentation of patients with tubal ectopic pregnancy (EP) during the first year of the COVID-19 pandemic.
We performed a retrospective cohort study of all cases of tubal EP between March 2019 and March 2020 (pre-pandemic) and between March 2020 and March 2021 (pandemic). We compared between these two groups the risk factors, clinical characteristics, laboratory data, sonographic aspects, treatment applied and complications.
We had 150 EP diagnoses during the two years studied, of which 135 were tubal EP. Of these, 65 were included in the pre-pandemic and 70 in the pandemic period. The prevalence of lower abdominal pain was significantly higher in the pandemic compared to the pre-pandemic period (91.4% vs. 78.1%, p=0.031). There was no significant difference in shock index, initial beta-hCG level, hemoglobin level at diagnosis, days of menstrual delay, aspect of the adnexal mass, amount of free fluid on ultrasound, and intact or ruptured presentation between the groups. Expectant management was significantly higher during the pandemic period (40.0% vs. 18.5%, p=0.008), surgical management was lower during the pandemic period (47.1% vs. 67.7%, p=0.023), and number of days hospitalized was lower in the pandemic period (1.3 vs. 2.0 days, p=0.003).
We did not observe a significant difference in patient history, laboratory and ultrasound characteristics. Abdominal pain was more common during the pandemic period. Regarding treatment, we observed a significant increase in expectant and a decrease in surgical cases during the pandemic period.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo64
, , , , To evaluate whether there were differences in the presentation of patients with tubal ectopic pregnancy (EP) during the first year of the COVID-19 pandemic.
We performed a retrospective cohort study of all cases of tubal EP between March 2019 and March 2020 (pre-pandemic) and between March 2020 and March 2021 (pandemic). We compared between these two groups the risk factors, clinical characteristics, laboratory data, sonographic aspects, treatment applied and complications.
We had 150 EP diagnoses during the two years studied, of which 135 were tubal EP. Of these, 65 were included in the pre-pandemic and 70 in the pandemic period. The prevalence of lower abdominal pain was significantly higher in the pandemic compared to the pre-pandemic period (91.4% vs. 78.1%, p=0.031). There was no significant difference in shock index, initial beta-hCG level, hemoglobin level at diagnosis, days of menstrual delay, aspect of the adnexal mass, amount of free fluid on ultrasound, and intact or ruptured presentation between the groups. Expectant management was significantly higher during the pandemic period (40.0% vs. 18.5%, p=0.008), surgical management was lower during the pandemic period (47.1% vs. 67.7%, p=0.023), and number of days hospitalized was lower in the pandemic period (1.3 vs. 2.0 days, p=0.003).
We did not observe a significant difference in patient history, laboratory and ultrasound characteristics. Abdominal pain was more common during the pandemic period. Regarding treatment, we observed a significant increase in expectant and a decrease in surgical cases during the pandemic period.
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo44
, , , , , , To describe Top-hat results and their association with margin status and disease relapse in a referral facility in Brazil.
A retrospective study of 440 women submitted to LEEP to treat HSIL, in which 80 cases were complemented immediately by the top hat procedure (Top-hat Group - TH). TH Group was compared to women not submitted to Top-hat (NTH). The sample by convenience included all women that underwent LEEP from January 2017 to July 2020. The main outcome was the histological result. Other variables were margins, age, transformation zone (TZ), depth, and relapse. The analysis used the Chi-square test and logistic regression.
The TH Group was predominantly 40 and older (NTH 23.1% vs. TH 65.0%, p<0.001). No difference was found in having CIN2/CIN3 as the final diagnosis (NTH 17.0% vs. TH 21.3%, p=0.362), or in the prevalence of relapse (NTH 12.0% vs. TH 9.0%, p=0.482). Of the 80 patients submitted to top hat, the histological result was CIN2/CIN3 in eight. A negative top hat result was related to a negative endocervical margin of 83.3%. A CIN2/CIN3 Top-hat result was related to CIN2/CIN3 margin in 62.5% (p=0.009). The chance of obtaining a top hat negative result was 22.4 times higher (2.4-211.0) when the endocervical margin was negative and 14.5 times higher (1.5-140.7) when the ectocervical margin was negative.
The top hat procedure did not alter the final diagnosis of LEEP. No impact on relapse was observed. The procedure should be avoided in women of reproductive age.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo44
, , , , , , To describe Top-hat results and their association with margin status and disease relapse in a referral facility in Brazil.
A retrospective study of 440 women submitted to LEEP to treat HSIL, in which 80 cases were complemented immediately by the top hat procedure (Top-hat Group - TH). TH Group was compared to women not submitted to Top-hat (NTH). The sample by convenience included all women that underwent LEEP from January 2017 to July 2020. The main outcome was the histological result. Other variables were margins, age, transformation zone (TZ), depth, and relapse. The analysis used the Chi-square test and logistic regression.
The TH Group was predominantly 40 and older (NTH 23.1% vs. TH 65.0%, p<0.001). No difference was found in having CIN2/CIN3 as the final diagnosis (NTH 17.0% vs. TH 21.3%, p=0.362), or in the prevalence of relapse (NTH 12.0% vs. TH 9.0%, p=0.482). Of the 80 patients submitted to top hat, the histological result was CIN2/CIN3 in eight. A negative top hat result was related to a negative endocervical margin of 83.3%. A CIN2/CIN3 Top-hat result was related to CIN2/CIN3 margin in 62.5% (p=0.009). The chance of obtaining a top hat negative result was 22.4 times higher (2.4-211.0) when the endocervical margin was negative and 14.5 times higher (1.5-140.7) when the ectocervical margin was negative.
The top hat procedure did not alter the final diagnosis of LEEP. No impact on relapse was observed. The procedure should be avoided in women of reproductive age.
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo45
, , , , , To explore women's experiences with postpartum intrauterine device (PPIUD) insertion and the decision-making process in the postpartum period.
A qualitative design was employed with face-to-face interviews using a semi-structured script of open questions. The sample was intentionally selected using the concept of theoretical information saturation.
Interviews were conducted (1) in the immediate postpartum period, and (2) in the postpartum appointment. 25 women (N = 25) over 18 years old who had a birth followed by PPIUD insertion were interviewed between October 2021 and June 2022. Three categories were constructed: (1) Choice process, (2) Relationship with the health team at the time of birth and the postpartum period, and (3) To know or not to know about contraception, that is the question.
Professionals’ communication management, popular knowledge, advantages of the PPIUD and the moment PPIUD is offered play a fundamental role in the construction of knowledge about the IUD. Choice process did not end in the insertion.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo45
, , , , , To explore women's experiences with postpartum intrauterine device (PPIUD) insertion and the decision-making process in the postpartum period.
A qualitative design was employed with face-to-face interviews using a semi-structured script of open questions. The sample was intentionally selected using the concept of theoretical information saturation.
Interviews were conducted (1) in the immediate postpartum period, and (2) in the postpartum appointment. 25 women (N = 25) over 18 years old who had a birth followed by PPIUD insertion were interviewed between October 2021 and June 2022. Three categories were constructed: (1) Choice process, (2) Relationship with the health team at the time of birth and the postpartum period, and (3) To know or not to know about contraception, that is the question.
Professionals’ communication management, popular knowledge, advantages of the PPIUD and the moment PPIUD is offered play a fundamental role in the construction of knowledge about the IUD. Choice process did not end in the insertion.
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Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo40
, , , , , , , , To evaluate and compare the sexual function and pelvic floor muscles (PFM) function of women with endometriosis and chronic pelvic pain (CPP) with and without Myofascial Pelvic Pain Syndrome (MPPS).
Cross-sectional study conducted between January 2018 and December 2020. Women with deep endometriosis underwent assessments for trigger points (TP) and PFM function using the PERFECT scale. Electromyographic activity (EMG) and sexual function through Female Sexual Function Index (FSFI) were assessed. Statistical analyses included chi-square and Mann-Whitney tests.
There were 46 women. 47% had increased muscle tone and 67% related TP in levator ani muscle (LAM). Weakness in PFM, with P≤2 was noted in 82% and P≥3 in only 17%. Incomplete relaxation of PFM presented in 30%. EMG results were resting 6.0, maximal voluntary isometric contraction (MVIC) 61.9 and Endurance 14.2; FSFI mean total score 24.7. We observed an association between increased muscle tone (P<.001), difficulty in relaxation (P=.019), and lower Endurance on EMG (P=.04) in women with TP in LAM. Participants with TP presented lower total FSFI score (P=.02). TP in the right OIM presented increased muscle tone (P=.01). TP in the left OIM presented lower values to function of PFM by PERFECT (P=.005), and in MVIC (P=.03) on EMG.
Trigger points (TP) in pelvic floor muscles (PFM) and obturator internus muscle (OIM) correlates with poorer PFM and sexual function, particularly in left OIM TP cases. Endometriosis and chronic pelvic pain raise muscle tone, weaken muscles, hinder relaxation, elevate resting electrical activity, lower maximum voluntary isometric contraction, and reduce PFM endurance.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2024;46:e-rbgo40
, , , , , , , , To evaluate and compare the sexual function and pelvic floor muscles (PFM) function of women with endometriosis and chronic pelvic pain (CPP) with and without Myofascial Pelvic Pain Syndrome (MPPS).
Cross-sectional study conducted between January 2018 and December 2020. Women with deep endometriosis underwent assessments for trigger points (TP) and PFM function using the PERFECT scale. Electromyographic activity (EMG) and sexual function through Female Sexual Function Index (FSFI) were assessed. Statistical analyses included chi-square and Mann-Whitney tests.
There were 46 women. 47% had increased muscle tone and 67% related TP in levator ani muscle (LAM). Weakness in PFM, with P≤2 was noted in 82% and P≥3 in only 17%. Incomplete relaxation of PFM presented in 30%. EMG results were resting 6.0, maximal voluntary isometric contraction (MVIC) 61.9 and Endurance 14.2; FSFI mean total score 24.7. We observed an association between increased muscle tone (P<.001), difficulty in relaxation (P=.019), and lower Endurance on EMG (P=.04) in women with TP in LAM. Participants with TP presented lower total FSFI score (P=.02). TP in the right OIM presented increased muscle tone (P=.01). TP in the left OIM presented lower values to function of PFM by PERFECT (P=.005), and in MVIC (P=.03) on EMG.
Trigger points (TP) in pelvic floor muscles (PFM) and obturator internus muscle (OIM) correlates with poorer PFM and sexual function, particularly in left OIM TP cases. Endometriosis and chronic pelvic pain raise muscle tone, weaken muscles, hinder relaxation, elevate resting electrical activity, lower maximum voluntary isometric contraction, and reduce PFM endurance.