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11 articles
  • Editorial

    Maternal Mortality and the Public Health Service in Brazil

    Rev Bras Ginecol Obstet. 2021;43(9):645-647

    Summary

    Editorial

    Maternal Mortality and the Public Health Service in Brazil

    Rev Bras Ginecol Obstet. 2021;43(9):645-647

    DOI 10.1055/s-0041-1736537

    Views3
    Maternal mortality (MM) has been a serious problem for public health worldwide and the subject of many debates internationally. In addition to health issues, this indicator also reflects the social conditions of victimized women. Maternal mortality represents a family and social tragedy, and many of these deaths result from avoidable causes. About 70% are caused […]
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  • Original Article

    Understanding How Health Providers Identify Women with Postpartum Hemorrhage: A Qualitative Study

    Rev Bras Ginecol Obstet. 2021;43(9):648-654

    Summary

    Original Article

    Understanding How Health Providers Identify Women with Postpartum Hemorrhage: A Qualitative Study

    Rev Bras Ginecol Obstet. 2021;43(9):648-654

    DOI 10.1055/s-0041-1733997

    Views1

    Abstract

    Objective

    To identify how health providers recognize postpartum hemorrhage early and the difficulties involved in it.

    Methods

    An exploratory, descriptive study using a qualitative approach through a semi-structured interview technique. In total, 27 health professionals (nursing tech nicians, nurses, medical residents in Gynecology and Obstetrics, hired medical doctors, and medicine professors) working in a tertiary-level hospital of reference in women’s health care in the State of São Paulo, Brazil, participated in the study through an invitation. After they accepted the invitation, they signed the free and informed consent form. All interviews were recorded and transcribed, and a thematic analysis was conducted. We found three analysis categories: a) perception of the severity: “there is something wrong with the women”; b) difficulties in the early diagnosis of postpartum hemorrhage; and c) the process to improve obstetrical care.

    Results

    Caregivers believe teamwork and communication should be improved. Besides the visual estimation of blood loss, the nursing team is attentive to behavioral symptoms like irritability, while the medical staff follow protocols and look for objective signs, such as altered vital signs.

    Conclusion

    Besides the objective evaluations, the subjective perceptions of the providers are involved in the clinical judgement regarding the diagnosis of postpartum hemorrhage, and this should be included in a broader diagnosis strategy.

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  • Original Article

    Clinical Experience Over 15 Years with the B-Lynch Compression Suture Technique in the Management of Postpartum Hemorrhage

    Rev Bras Ginecol Obstet. 2021;43(9):655-661

    Summary

    Original Article

    Clinical Experience Over 15 Years with the B-Lynch Compression Suture Technique in the Management of Postpartum Hemorrhage

    Rev Bras Ginecol Obstet. 2021;43(9):655-661

    DOI 10.1055/s-0041-1735228

    Views2

    Abstract

    Objective

    To describe the clinical experience with the B-Lynch technique in the management of postpartum hemorrhage as well as the factors related to the indication of the technique and to present the success rates of the application of the B-Lynch technique.

    Methods

    Observational, retrospective, cross-sectional, and analytical study. Patient data was obtained through the study of medical records. The study population comprised of patients who underwent hemostatic suture using the B-Lynch technique, including 104 patients within the period from January 1, 2005, to December 31, 2019.

    Results

    Of the total of 104 patients, 82.7% did not present any complications. Blood transfusion and intensive care unit admission were the most prevalent complications, with 13.5% and 15.4%, respectively. Only 1% of the patients had puerperal and surgical site infections. The factors most related to the application of the technique were the presence of previous cesarean section (30.8%), use of oxytocin (16.3%), and pre-eclampsia (11.6%). Puerperal hysterectomy was performed in 4.8% of the patients due to failure of the method.

    Conclusion

    The clinical experience with the B-Lynch technique was satisfactory since it presented few complications, with excellent results in hemorrhagic control. Previous cesarean section, the use of oxytocin, and preeclampsia stood out as factors related to the indication of the application of the technique, and the success rate in controlling postpartum hemorrhage was 95.2%.

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  • Original Article

    Temporal Evolution of Maternal Mortality: 1980-2019

    Rev Bras Ginecol Obstet. 2021;43(9):662-668

    Summary

    Original Article

    Temporal Evolution of Maternal Mortality: 1980-2019

    Rev Bras Ginecol Obstet. 2021;43(9):662-668

    DOI 10.1055/s-0041-1735300

    Views7

    Abstract

    Objective

    To determine the profile of maternal deaths occurred in the period between 2000 and 2019 in the Hospital de Clínicas de Porto Alegre (HCPA, in the Portuguese acronym) and to compare it with maternal deaths between 1980 and 1999 in the same institution.

    Methods

    Retrospective study that analyzed 2,481 medical records of women between 10 and 49 years old who died between 2000 and 2018. The present study was approved by the Ethics Committee (CAAE 78021417600005327).

    Results

    After reviewing 2,481 medical records of women who died in reproductive age, 43 deaths had occurred during pregnancy or in the postpartum period. Of these, 28 were considered maternal deaths. The maternal mortality ratio was 37.6 per 100,000 live births. Regarding causes, 16 deaths (57.1%) were directly associated with pregnancy, 10 (35.1%) were indirectly associated, and 2 (7.1%) were unrelated. The main cause of death was hypertension during pregnancy (31.2%) followed by acute liver steatosis during pregnancy (25%). In the previous study, published in 2003 in the same institution4, the mortality rate was 129 per 100,000 live births, and most deaths were related to direct obstetric causes (62%). The main causes of death in this period were due to hypertensive complications (17.2%), followed by postcesarean infection (16%).

    Conclusion

    Compared with data before the decade of 2000, there was an important reduction in maternal deaths due to infectious causes.

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    Temporal Evolution of Maternal Mortality: 1980-2019
  • Original Article

    Association between Adverse Maternal Clinical Outcomes and Imbalance of Cytokines and Angiogenic Factors in Preterm Preeclampsia

    Rev Bras Ginecol Obstet. 2021;43(9):669-675

    Summary

    Original Article

    Association between Adverse Maternal Clinical Outcomes and Imbalance of Cytokines and Angiogenic Factors in Preterm Preeclampsia

    Rev Bras Ginecol Obstet. 2021;43(9):669-675

    DOI 10.1055/s-0041-1735157

    Views2

    Abstract

    Objective

    Preeclampsia (PE) is a pregnancy-specific syndrome characterized by abnormal levels of cytokines and angiogenic factors, playing a role in the disease development. The present study evaluated whether immunological markers are associated with the gestational age and with the disease severity in preeclamptic women.

    Methods

    Ninety-five women who developed PE were stratified for gestational age as preterm PE (< 37 weeks) and term PE (≥ 37 weeks of gestation) and compared for disease severity as well as plasma concentration of angiogenic factors and cytokines. The concentrations of placental growth factor (PlGF), vascular endothelial growth factor (VEGF), Fms-like soluble tyrosine kinase (sFlt-1) and soluble endoglin (sEng), as well as the cytokines, tumor necrosis factor-α (TNF-α) and interleukin 10 (IL-10), were determined by enzyme-linked immunosorbent assay (ELISA).

    Results

    The comparison between preeclamptic groups showed a higher percentage of severe cases in preterm PE (82.1%) than in term PE (35.9%). Similarly, the concentrations of TNF-α, sFlt-1, and sEng, as well as TNF-α/IL-10 and sFlt-1/PlGF ratios were significantly higher in the preterm PE group. In contrast, concentrations of PlGF, VEGF, and IL-10 were significantly lower in women with preterm PE. Negative correlations between TNF-α and IL-10 (r = 0.5232) and between PlGF and sFlt1 (r = 0.4158) were detected in the preterm PE.

    Conclusion

    In pregnant women with preterm PE, there is an imbalance between immunological markers, with the predominance of anti-angiogenic factors and TNF-α, associated with adverse maternal clinical outcomes.

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    Association between Adverse Maternal Clinical Outcomes and Imbalance of Cytokines and Angiogenic Factors in Preterm Preeclampsia
  • Original Article

    Psychological Problems Experienced by Patients with Bowel Endometriosis Awaiting Surgery

    Rev Bras Ginecol Obstet. 2021;43(9):676-681

    Summary

    Original Article

    Psychological Problems Experienced by Patients with Bowel Endometriosis Awaiting Surgery

    Rev Bras Ginecol Obstet. 2021;43(9):676-681

    DOI 10.1055/s-0041-1735938

    Views0

    Abstract

    Objective

    To assess the most common psychological disturbances in women with deep endometriosis and bowel involvement who are waiting surgical treatment and to evaluate what forms of coping are used to solve the problem.

    Methods

    This was a cross-sectional observational study of 40 women diagnosed with deep endometriosis and intestinal symptoms. They completed two questionnaires: one for anxiety and depression (Hospital Anxiety and Depression Scale [ HADS]) and the Scale of Mode of Confronting Problems (EMEP, in the Portuguese acronym).

    Results

    We found that 77.1% of the patients had anxiety and depression, with anxiety being the most prevalent (87.5% of the patients); 90% of the patients used problem focused and religious introspection as their main modes of confronting problems.

    Conclusion

    In the use of the HADS questionary, two psychological aspects were the most present in women with deep endometriosis awaiting surgical treatment: anxiety and depression. The most used forms of coping to solve the problem were problem coping and religious practices.

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  • Original Article

    Pathways of IFN-alpha Activation in Patients with Cervical Intraepithelial Neoplasia (CIN)

    Rev Bras Ginecol Obstet. 2021;43(9):682-689

    Summary

    Original Article

    Pathways of IFN-alpha Activation in Patients with Cervical Intraepithelial Neoplasia (CIN)

    Rev Bras Ginecol Obstet. 2021;43(9):682-689

    DOI 10.1055/s-0041-1735301

    Views1

    Abstract

    Objective

    The aim of the present study was to compare the local and systemic expression of the factors linked to the interferon alpha (IFN-α) activation pathway in different degrees of cervical intraepithelial neoplasia (CIN) and cervical cancer.

    Methods

    A total of 128 patients with CIN I, CIN II, CIN III and cervical cancer was evaluated. The real-time polymerase chain reaction (RT-PCR) technique was used to evaluate the gene expression of IFNR1, IFNR2, IFN-α, oligoadenylate synthase (2’5′OAS), cytokine signal suppressor 1 (SOCS) 1, SOCS3, signal transducer and transcription activator 1 (STAT1), and IRF9 from 128 biopsies. A total of 46 out of 128 samples were evaluated by flow cytometry for IFNAR1, IFNAR2, STAT1, IRF7 and IFN-α in peripheral blood cells.

    Results

    Patients with CIN II and III (63 samples) had a low local expression of IFNR1, but not IFNR2. Patients with some degree of injury showed high expression of SOCS1 and SOCS3. Systemically, patients with CIN II and III (20 samples) had a significant increase in IFNR1, IFNR2, STAT1, IRF7, and IFN-α in helper, cytotoxic T lymphocytes, and in monocytes.

    Conclusion

    Patients with high-grade lesions have increased systemic expression of IFN-α and its activation pathways in helper and cytotoxic T lymphocytes, as well as in monocytes due to an exacerbation of the immune response in these patients. This phenomenon is not accompanied by resolution of the lesion due to a defect in the IFN-α activation pathway that revealed by low local IFNAR1 expression and high local expression of SOCS1 and SOCS3.

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    Pathways of IFN-alpha Activation in Patients with Cervical Intraepithelial Neoplasia (CIN)
  • Original Article

    Exposed Implant after Immediate Breast Reconstruction – Presentation and Analysis of a Clinical Management Protocol

    Rev Bras Ginecol Obstet. 2021;43(9):690-698

    Summary

    Original Article

    Exposed Implant after Immediate Breast Reconstruction – Presentation and Analysis of a Clinical Management Protocol

    Rev Bras Ginecol Obstet. 2021;43(9):690-698

    DOI 10.1055/s-0041-1735939

    Views2

    Abstract

    Objective

    Infection and exposure of the implant are some of the most common and concerning complications after implant-based breast reconstruction. Currently, there is no consensus on the management of these complications. The aim of the present study was to review our cases and to present a clinical protocol.

    Methods

    We conducted a retrospective review of consecutive patients submitted to implant-based breast reconstruction between 2014 and 2016. All patients were managed according to a specific and structured protocol.

    Results

    Implant exposure occurred in 33 out of 277 (11.9%) implant-based reconstructions. Among these, two patients had history of radiotherapy and had their implant removed; Delayed reconstruction with a myocutaneous flap was performed in both cases. Signs of severe local infection were observed in 12 patients, and another 5 presented with extensive tissue necrosis, and they were all submitted to implant removal; of them, 8 underwent reconstruction with a tissue expander, and 2, with a myocutaneous flap. The remaining 14 patients had no signs of severe infection, previous irradiation or extensive tissue necrosis, and were submitted to primary suture as an attempt to salvage the implant. Of these, 8 cases (57.1%) managed to keep the

    Conclusion

    Our clinical protocol is based on three key points: history of radiotherapy, severe infection, and extensive tissue necrosis. It is a practical and potentially-reproducible method of managing one of the most common complications of implant-based breast reconstruction.

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    Exposed Implant after Immediate Breast Reconstruction – Presentation and Analysis of a Clinical Management Protocol

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