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, , , , Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2023;45(10):562-567
, , , , Pregnancy after bariatric surgery is a reality of the 21st century and therefore is essential that all obstetricians know how to manage it. The most prevalent nutritional deficiency is iron deficiency and, consequently, anemia. Although bariatric surgery and pregnancy are already risk factors for anemia, we evaluated in our study if there were any other risk factors and actions to improve hemoglobin levels in this population.
We performed a retrospective cohort study, and performed frequency measurements and analyzes of odds ratio, X2 and Fisher exact test to evaluate the risk factors.
We evaluated 44 pregnancies after bariatric surgery, with an incidence of anemia of 62%, and the only identifiable risk factor for anemia was being black. As for the treatment, the iron salt used for oral supplementation did not associate with anemia risk, and in 27% of the patients, the adjustment of the oral dosage was enough for improvement in hemoglobin levels, but in 36% supplementation with intravenous iron was necessary.
Being black is a risk factor for anemia. The type of iron salt does not correlate with the incidence of anemia, and for the treatment and improvement of iron dosages, it seems an effective increase in iron intake.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2023;45(10):562-567
, , , , Pregnancy after bariatric surgery is a reality of the 21st century and therefore is essential that all obstetricians know how to manage it. The most prevalent nutritional deficiency is iron deficiency and, consequently, anemia. Although bariatric surgery and pregnancy are already risk factors for anemia, we evaluated in our study if there were any other risk factors and actions to improve hemoglobin levels in this population.
We performed a retrospective cohort study, and performed frequency measurements and analyzes of odds ratio, X2 and Fisher exact test to evaluate the risk factors.
We evaluated 44 pregnancies after bariatric surgery, with an incidence of anemia of 62%, and the only identifiable risk factor for anemia was being black. As for the treatment, the iron salt used for oral supplementation did not associate with anemia risk, and in 27% of the patients, the adjustment of the oral dosage was enough for improvement in hemoglobin levels, but in 36% supplementation with intravenous iron was necessary.
Being black is a risk factor for anemia. The type of iron salt does not correlate with the incidence of anemia, and for the treatment and improvement of iron dosages, it seems an effective increase in iron intake.
, , , , , Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2023;45(4):171-178
, , , , , , To describe a reference curve for cervical length (CL) in mid-trimester twin gestations using transvaginal ultrasound (TVU) and to investigate whether short CL increases spontaneous preterm birth (sPTB) in asymptomatic twin pregnancies.
This was a prospective cohort study performed at 17 outpatient antenatal facilities of Brazil with women at 18 0/7 to 22 6/7 weeks of gestation who participated in a randomized clinical trial screening phase (P5 trial) between July 2015 and March 2019. TVU was performed to provide CL measurement in all screened women. Almost all women with CL ≤ 30 mm received vaginal progesterone 200mg/day and they were also randomized to receive cervical pessary or not. We considered data from the CL distribution among asymptomatic twin pregnancies and analyzed CL and its association with PTB generating receiver operating characteristics (ROC) curves and Kaplan-Meier curves.
A total of 253 pregnant women with twins were included in the distribution curve. The mean CL was 33.7 mm and median was 35.5mm. The 10th percentile was 17.8mm. We identified a PTB rate of 73.9% (187/253) with 33.6% of sPTB < 37 (85/253) and 15% (38/253) of sPTB < 34 weeks. The best cutoff point to predict sPTB < 37 was 24.15 mm. However, the ROC curve showed a poor performance (0.64). The Kaplan-Meier survival curves identified that only CL values ≤ 20mm were associated to sPTB < 34 weeks.
A cutoff point of CL ≤ 20 mm can be interesting point to identify short cervix in Brazilian twin pregnancies. However, in Brazilian asymptomatic twin pregnancies, CL does not show a good performance to predict PTB.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2023;45(4):171-178
, , , , , , To describe a reference curve for cervical length (CL) in mid-trimester twin gestations using transvaginal ultrasound (TVU) and to investigate whether short CL increases spontaneous preterm birth (sPTB) in asymptomatic twin pregnancies.
This was a prospective cohort study performed at 17 outpatient antenatal facilities of Brazil with women at 18 0/7 to 22 6/7 weeks of gestation who participated in a randomized clinical trial screening phase (P5 trial) between July 2015 and March 2019. TVU was performed to provide CL measurement in all screened women. Almost all women with CL ≤ 30 mm received vaginal progesterone 200mg/day and they were also randomized to receive cervical pessary or not. We considered data from the CL distribution among asymptomatic twin pregnancies and analyzed CL and its association with PTB generating receiver operating characteristics (ROC) curves and Kaplan-Meier curves.
A total of 253 pregnant women with twins were included in the distribution curve. The mean CL was 33.7 mm and median was 35.5mm. The 10th percentile was 17.8mm. We identified a PTB rate of 73.9% (187/253) with 33.6% of sPTB < 37 (85/253) and 15% (38/253) of sPTB < 34 weeks. The best cutoff point to predict sPTB < 37 was 24.15 mm. However, the ROC curve showed a poor performance (0.64). The Kaplan-Meier survival curves identified that only CL values ≤ 20mm were associated to sPTB < 34 weeks.
A cutoff point of CL ≤ 20 mm can be interesting point to identify short cervix in Brazilian twin pregnancies. However, in Brazilian asymptomatic twin pregnancies, CL does not show a good performance to predict PTB.
, , , Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2022;44(12):1094-1101
, , , To assess maternal and neonatal outcomes in women with chronic kidney disease (CKD) at a referral center for high-risk pregnancy.
A retrospective cohort of pregnant women with CKD was followed at the Women's Hospital of Universidade Estadual de Campinas, Brazil, between 2012 and 2020. Variables related to disease etiology, treatment duration, sociodemographic variables, lifestyle, other associated diseases, obstetric history, and perinatal outcomes were assessed. The causes of CKD were grouped into 10 subgroups. Subsequently, we divided the sample according to gestational age at childbirth, as preterm and term births, comparing maternal and neonatal outcomes, and baseline characteristics as well as outcomes among such groups.
A total of 84 pregnancies were included, in 67 women with CKD. Among them, six pregnancies evolved to fetal death, five to miscarriage, and one was a twin pregnancy. We further analyzed 72 single pregnancies with live births; the mean gestational age at birth was 35 weeks and 3 days, with a mean birth weight of 2,444 g. Around half of the sample (51.39%) presented previous hypertension, and 27.7% developed preeclampsia. Among the preterm births, we observed a higher frequency of hypertensive syndromes, longer maternal intensive care unit (ICU) stay in the postpartum period, higher incidence of admission to the neonatal ICU, higher neonatal death, lower 5-minute Apgar score, and lower birth weight.
This study demonstrates increased adverse outcomes among pregnancies complicated by CKD and expands the knowledge on obstetric care among such women in an attempt to reduce maternal risks and identify factors related to prematurity in this population.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2022;44(12):1094-1101
, , , To assess maternal and neonatal outcomes in women with chronic kidney disease (CKD) at a referral center for high-risk pregnancy.
A retrospective cohort of pregnant women with CKD was followed at the Women's Hospital of Universidade Estadual de Campinas, Brazil, between 2012 and 2020. Variables related to disease etiology, treatment duration, sociodemographic variables, lifestyle, other associated diseases, obstetric history, and perinatal outcomes were assessed. The causes of CKD were grouped into 10 subgroups. Subsequently, we divided the sample according to gestational age at childbirth, as preterm and term births, comparing maternal and neonatal outcomes, and baseline characteristics as well as outcomes among such groups.
A total of 84 pregnancies were included, in 67 women with CKD. Among them, six pregnancies evolved to fetal death, five to miscarriage, and one was a twin pregnancy. We further analyzed 72 single pregnancies with live births; the mean gestational age at birth was 35 weeks and 3 days, with a mean birth weight of 2,444 g. Around half of the sample (51.39%) presented previous hypertension, and 27.7% developed preeclampsia. Among the preterm births, we observed a higher frequency of hypertensive syndromes, longer maternal intensive care unit (ICU) stay in the postpartum period, higher incidence of admission to the neonatal ICU, higher neonatal death, lower 5-minute Apgar score, and lower birth weight.
This study demonstrates increased adverse outcomes among pregnancies complicated by CKD and expands the knowledge on obstetric care among such women in an attempt to reduce maternal risks and identify factors related to prematurity in this population.
, , , , Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2021;43(9):648-654
, , , , To identify how health providers recognize postpartum hemorrhage early and the difficulties involved in it.
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.
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.
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.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2021;43(9):648-654
, , , , To identify how health providers recognize postpartum hemorrhage early and the difficulties involved in it.
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.
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.
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.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2021;43(2):113-118
To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively.
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.
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.
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.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2021;43(2):113-118
To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively.
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.
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.
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.
, , , , , Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2021;43(2):107-112
, , , , , , , To evaluate the obstetric and sociodemographic characteristics of gestational diabetic women who maintained hyperglycemia in the postpartum period (6-12 weeks postpartum).
This is a longitudinal cohort study with women who have had gestational diabetes and/or macrosomic children between March 1st, 2016 and March 1st, 2017. Between 6 and 12 weeks after birth, women who had gestational diabetes collected fasting glycemia, glucose tolerance test, and glycated hemoglobin results. The data were collected from medical records and during an interview in the first postpartum consultation. A statistical analysis was performed using frequency, percentage, Chi- Squared test, Fisher exact test, Mann-Whitney test, and multivariate Poisson regression. The significance level adopted for the statistical tests was 5%.
One hundred and twenty-two women were included. Most of the women were younger than 35 years old (70.5%), white, multiparous, and with no history of gestational diabetes. Thirteen percent of the participants developed persistent hyperglycemia. A univariate analysis showed that maternal age above 35 years, being overweight, having grade 1 obesity and weight gain under 5 kg was related to the persistence of hyperglycemia in the postpartum period.
Maternal age above 35 years, obesity and overweight, and the diagnosis of gestational diabetes in the first trimester of pregnancy are associated with hyperglycemia during the postpartum period.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2021;43(2):107-112
, , , , , , , To evaluate the obstetric and sociodemographic characteristics of gestational diabetic women who maintained hyperglycemia in the postpartum period (6-12 weeks postpartum).
This is a longitudinal cohort study with women who have had gestational diabetes and/or macrosomic children between March 1st, 2016 and March 1st, 2017. Between 6 and 12 weeks after birth, women who had gestational diabetes collected fasting glycemia, glucose tolerance test, and glycated hemoglobin results. The data were collected from medical records and during an interview in the first postpartum consultation. A statistical analysis was performed using frequency, percentage, Chi- Squared test, Fisher exact test, Mann-Whitney test, and multivariate Poisson regression. The significance level adopted for the statistical tests was 5%.
One hundred and twenty-two women were included. Most of the women were younger than 35 years old (70.5%), white, multiparous, and with no history of gestational diabetes. Thirteen percent of the participants developed persistent hyperglycemia. A univariate analysis showed that maternal age above 35 years, being overweight, having grade 1 obesity and weight gain under 5 kg was related to the persistence of hyperglycemia in the postpartum period.
Maternal age above 35 years, obesity and overweight, and the diagnosis of gestational diabetes in the first trimester of pregnancy are associated with hyperglycemia during the postpartum period.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2019;41(10):607-612
Almost 80% of adolescent pregnancies are unplanned, and between 28 and 63% of adolescent mothers had a repeated pregnancy within 18 months. Among girls with repeated pregnancies, two-thirds reported that the pregnancy was unplanned. We aim to assess contraceptive use by adolescent mothers with increasing choice for long-acting reversible contraception (LARC) methods in postpartum consultation after a semistructured group intervention involving adolescent mothers.
Retrospective observational study conducted at the Universidade Estadual de Campinas, Campinas, state of São Paulo, Brazil, involving new antenatal and postpartum education groups for adolescents. At postpartum consultations, the adolescents chose their contraceptive. The datawas compared with previous series followed in a period before the implementation of the education group - a historical control group.
We included 129 adolescent after childbirth from January 1st, 2015 through July 31st, 2017. Out of this total, 63% had ever used contraceptive methods before pregnancy, and the most frequent method was combined oral contraceptives (33%) followed by condoms (21%). At the first postpartum consultation, the most common contraceptive chosen was intrauterine contraception (IUC) (37.2%) and depot-medroxyprogesterone acetate (DMPA) (34.1%).When comparing the rates before and after the education interventions, there was a 3-fold increase in the use of IUCs.
Antenatal and postpartum education have shown a significant increase in the choice for LARC methods among adolescent mothers, with very high acceptability after a period using the method. The educational groups performed during the antenatal care and beyond the gestational period are easy to be applied worldwide with low dependence on funding.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2019;41(10):607-612
Almost 80% of adolescent pregnancies are unplanned, and between 28 and 63% of adolescent mothers had a repeated pregnancy within 18 months. Among girls with repeated pregnancies, two-thirds reported that the pregnancy was unplanned. We aim to assess contraceptive use by adolescent mothers with increasing choice for long-acting reversible contraception (LARC) methods in postpartum consultation after a semistructured group intervention involving adolescent mothers.
Retrospective observational study conducted at the Universidade Estadual de Campinas, Campinas, state of São Paulo, Brazil, involving new antenatal and postpartum education groups for adolescents. At postpartum consultations, the adolescents chose their contraceptive. The datawas compared with previous series followed in a period before the implementation of the education group - a historical control group.
We included 129 adolescent after childbirth from January 1st, 2015 through July 31st, 2017. Out of this total, 63% had ever used contraceptive methods before pregnancy, and the most frequent method was combined oral contraceptives (33%) followed by condoms (21%). At the first postpartum consultation, the most common contraceptive chosen was intrauterine contraception (IUC) (37.2%) and depot-medroxyprogesterone acetate (DMPA) (34.1%).When comparing the rates before and after the education interventions, there was a 3-fold increase in the use of IUCs.
Antenatal and postpartum education have shown a significant increase in the choice for LARC methods among adolescent mothers, with very high acceptability after a period using the method. The educational groups performed during the antenatal care and beyond the gestational period are easy to be applied worldwide with low dependence on funding.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2018;40(10):587-592
To evaluate the effects of pregnancy in systemic lupus erythematosus (SLE) patients.
The present article is a retrospective cohort study. Datawere collected from medical records of pregnant women with SLE from January 2002 to December 2012 at Universidade Estadual de Campinas, in the city of Campinas, state of São Paulo, Brazil. Systemic lupus erythematosus and disease activity were defined according to the American College of Rheumatology and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) criteria respectively. The means, standard deviations (SDs), percentages and correlations were performed using the SAS software, version 9.4 (SAS Institute Inc., Cary, NC, US).
We obtained data from 69 pregnancies in 58 women. During pregnancy, a new flare was observed in 39.2% (n = 27). The manifestations were most common in patients with prior kidney disease, and mainly occurred during the third quarter and the puerperium. Renal activity occurred in 24.6% (n = 17), and serious activity, in 16% (n = 11). Of all deliveries, 75% (n = 48) were by cesarean section. Twomaternal deaths occurred (3%). Preterm birth was themain complication in the newborns. The abortion rate was 8.7%. Severe SLEDAI during pregnancy was associated with prematurity (100%) and perinatal death (54%).
Thematernal-fetal outcome is worse in SLE when thewomen experience a flare during pregnancy. The best maternal-fetal outcomes occur when the disease is in remission for at least 6 months before the pregnancy.
Summary
Revista Brasileira de Ginecologia e Obstetrícia. 2018;40(10):587-592
To evaluate the effects of pregnancy in systemic lupus erythematosus (SLE) patients.
The present article is a retrospective cohort study. Datawere collected from medical records of pregnant women with SLE from January 2002 to December 2012 at Universidade Estadual de Campinas, in the city of Campinas, state of São Paulo, Brazil. Systemic lupus erythematosus and disease activity were defined according to the American College of Rheumatology and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) criteria respectively. The means, standard deviations (SDs), percentages and correlations were performed using the SAS software, version 9.4 (SAS Institute Inc., Cary, NC, US).
We obtained data from 69 pregnancies in 58 women. During pregnancy, a new flare was observed in 39.2% (n = 27). The manifestations were most common in patients with prior kidney disease, and mainly occurred during the third quarter and the puerperium. Renal activity occurred in 24.6% (n = 17), and serious activity, in 16% (n = 11). Of all deliveries, 75% (n = 48) were by cesarean section. Twomaternal deaths occurred (3%). Preterm birth was themain complication in the newborns. The abortion rate was 8.7%. Severe SLEDAI during pregnancy was associated with prematurity (100%) and perinatal death (54%).
Thematernal-fetal outcome is worse in SLE when thewomen experience a flare during pregnancy. The best maternal-fetal outcomes occur when the disease is in remission for at least 6 months before the pregnancy.