Espectro do acretismo placentário: recomendações atualizadas da perspectiva do profissional de imagem pré-natal / Placenta accreta spectrum disorders: current recommendations from the perspective of antenatal imaging

O parto cesáreo (PC) é o procedimento cirúrgico mais comumente realizado nos Estados Unidos (mais de 1 milhão de cirurgias por ano) e um dos procedimentos mais realizados em todo o mundo.(1) Embora o PC seja um procedimento potencialmente salvador de vidas, quando corretamente indicado, sua frequência aumentou constantemente nas últimas décadas (atualmente 21,1% globalmente, variando de 5%, na África Subsaariana, a 42,8%, na América Latina e no Caribe). Além disso, estudos demonstram tendência continuada de aumento (projeção para 2030: 28,5% globalmente, variando de 7,1%, na África Subsaariana, a 63,4%, no leste da Ásia).(2) República Dominicana, Brasil, Chipre, Egito e Turquia são os líderes mundiais, com taxas de PC variando de 58,1% a 50,8%, respectivamente, o que aponta para uma tendência preocupante de medicalização do parto e indicação excessiva do PC.(2) Outros procedimentos cirúrgicos como dilatação, curetagem, miomectomia e histeroscopia cirúrgica são menos frequentes que o PC. Ainda assim, devido à tendência de maior idade materna, o número de gestantes previamente submetidas a esses procedimentos também tende a aumentar. Esses dados apontam para um número crescente de gestações em úteros manipulados cirurgicamente Gestantes com cicatrizes uterinas prévias correm risco de aumento da morbimortalidade. Complicações como placenta prévia, rotura uterina espontânea, deiscência uterina (com ou sem intrusão placentária), gestação em cicatriz de cesariana (GCC) e distúrbios do espectro do acretismo placentário (EAP) estão associadas a sangramento uterino potencialmente fatal, lesões extrauterinas e parto pré-termo

Conhecimento das puérperas em relação ao parto humanizado e às vias de parto / Knowledge of puerperal women towards humanized delivery and modes of delivery

Objetivo: Avaliar o conhecimento das puérperas em relação ao parto humanizado e às vias de parto. Métodos: Estudo observacional transversal com 369 puérperas que realizaram seu parto em um hospital público de Curitiba, Paraná, Brasil. Aplicação de dois questionários que avaliaram características demográficas e socioeconômicas, informações sobre a gestação e o pré-natal, conhecimento de humanização e vias de parto, e atitude em relação às vias de parto. Resultados: Entre as puérperas, 72% afirmaram já terem ouvido falar no termo "parto humanizado", porém, dessas, 52,6% deram uma definição inadequada. E 48,2% obtiveram baixo conhecimento acerca das vias de parto, e 58,2% expressaram atitude positiva em relação à cesárea. Houve associação entre conhecimento prévio sobre parto humanizado e renda (p = 0,001), escolaridade (p < 0,0001), número de consultas de pré-natal (p = 0,023), busca de informações sobre as vias de parto (p < 0,0001) e preferência de parto (p = 0,011). Houve correlação do conhecimento acerca das vias de parto com renda (p = 0,044), escolaridade (p = 0,003), busca de informações sobre as vias de parto (p = 0,007) e atitude em relação à cesárea (p < 0,0001). Conclusão: Observou-se baixo conhecimento acerca das vias de parto e parto humanizado, e características como renda, escolaridade, busca por informações de forma independente e número de consultas de pré-natal possuem associação com esses conhecimentos. Um pré-natal com adequada transmissão de conhecimento relaciona-se à preferência pelo parto normal, sendo essa uma estratégia para a redução das taxas de cesárea e, consequentemente, da morbimortalidade materno-fetal.

Objective: To evaluate the knowledge of postpartum women in relation to humanized del ivery and delivery methods. Methods: Cross-sectional observational study with 369 postpartum women who delivered in a public hospital in Curitiba, Paraná, Brazil. Application of two questionnaires, which evaluated demographic and socioeconomic characteristics, information about pregnancy and prenatal care, knowledge of humanization and delivery methods, attitude towards delivery methods. Results: 72% of postpartum women said they had already heard the term "humanized childbirth", however, of these 52.6% gave an inadequate definition. 48.2% had low knowledge about delivery methods. 58.2% expressed a positive attitude towards cesarean section. There was an association between prior knowledge about humanized childbirth and income (p = 0.001), schooling (p < 0.0001), number of prenatal consultations (p = 0.023), search for information about delivery methods (p < 0 .0001), birth preference (p = 0.011). There was a correlation between knowledge about the modes of delivery with income (p = 0.044), education (p = 0.003), search for information about the modes of delivery (p = 0.007), attitude towards cesarean section (p < 0.0001). Conclusion: There was a low knowledge about the ways of delivery and humanized delivery, and characteristics such as income, education, search for information independently and the number of prenatal consultations have an association with this knowledge. A prenatal care with adequate transmission of knowledge is related to the preference for normal delivery, which is a strategy for reducing cesarean rates and, consequently, maternal-fetal morbidity and mortality.

As dificuldades na amamentação de recém-nascidos: análise quanto à via de parto / Difficulties in newborn breastfeeding: analysis regarding the delivery route

A amamentação é uma prática recomendada pela Organização Mundial de Saúde devido aos seus inúmeros benefícios para mãe e recém-nascido, porém seu estabelecimento e manutenção vêm sendo um grande desafio nos dias atuais. Objetivo: Identificar comportamentos indicativos de dificuldades maternas e neonatais relacionadas à amamentação considerando a via de parto. Casuística e Métodos: A amostra foi composta por 240 binômios mãe-bebê, por amostragem aleatória simples e os dados obtidos através da aplicação do instrumento de observação e avaliação da mamada, proposto pelo Fundo das Nações Unidas para Infância (Unicef), com realização de entrevista semiestruturada e coleta de dados complementares por análise documental de prontuários. Estes foram analisados pelo programa SPSS versão 3.5 por meio do teste X2, exato de Fisher e aplicada a correção de Yates quando cabível, sendo os resultados estatisticamente significativos quando p<0,05. Resultados: Constatou-se no estudo uma elevada prevalência de participantes com comportamentos indicativos de dificuldades, sendo "posição" e "sucção" os mais prevalentes. Foram encontradas, ainda, significativas associações entre parto normal e comportamentos favoráveis à amamentação relacionados ao aspecto "resposta", assim como entre cesárea e comportamentos favoráveis relacionados à "posição". Conclusão: Foi possível identificar comportamentos sugestivos de dificuldades durante a amamentação, auxiliando a população, oportunizando reflexões e fornecendo subsídios para profissionais da saúde no incentivo e promoção do aleitamento materno

Breastfeeding is a practice recommended by the World Health Organization due to its numerous benefits for mother and newborn, but its establishment and maintenance have been a major challenge nowadays. Objective: To identify behaviors that indicate maternal and neonatal difficulties related to breastfeeding, considering the mode of delivery. Casuistry and Methods: The sample consisted of 240 mother-baby binomials, by simple random sampling and the data obtained through the application of the instrument of observation and evaluation of breastfeeding, proposed by the United Nations Children's Fund (Unicef), with the performance of semi-structured interview and collection of complementary data through document analysis of medical records. These were analyzed using the SPSS version 3.5 program using Fisher's exact X2 test and Yates correction was applied when applicable, with statistically significant results when p<0.05. Results: The study found a high prevalence of participants with behaviors indicative of difficulties, with "position" and "sucking" being the most prevalent. Significant associations were also found between vaginal delivery and favorable breastfeeding behaviors related to the "response" aspect, as well as between cesarean sections and favorable behaviors related to "position". Conclusion: It was possible to identify behaviors that suggest difficulties during breastfeeding, helping the population, providing opportunities for reflection and providing subsidies for health professionals in encouraging and promoting breastfeeding

Chinese Medicine Plaster as A New Treatment for Surgical Site Infection in Patients with Cesarean Delivery: A Randomized, Double-Blind, Controlled Trial / 中国结合医学杂志

OBJECTIVE@#To evaluate the efficacy of Chinese plaster containing rhubarb and mirabilite on surgical site infection (SSI) in patients with cesarean delivery (CD) by performing a randomized controlled trial.@*METHODS@#This randomized controlled trial included 560 patients with CD due to fetal head descent enrolled at a tertiary teaching center between December 31, 2018 and October 31, 2021. Eligible patients were randomly assigned to a Chinese medicine (CM) group (280 cases) or a placebo group (280 cases) by a random number table, and were treated with CM plaster (made by rhubarb and mirabilite) or a placebo plaster, respectively. Both courses of treatment lasted from the day 1 of CD, followed day 2 until discharge. The primary outcome was the total number of patients with superficial, deep and organ/space SSI. The secondary outcome was duration of postoperative hospital stay, antibiotic intake, and unplanned readmission or reoperation due to SSI. All reported efficacy and safety outcomes were confirmed by a central adjudication committee that was unaware of the study-group assignments.@*RESULTS@#During the recovery process after CD, the rates of localized swelling, redness and heat were significantly lower in the CM group than in the placebo group [7.55% (20/265) vs. 17.21% (47/274), P<0.01]. The durution of postoperative antibiotic intake was shorter in the CM group than in the placebo group (P<0.01). The duration of postoperative hospital stay was significantly shorter in the CM group than in the placebo group (5.49 ± 2.68 days vs. 8.96 ± 2.35 days, P<0.01). The rate of postoperative C-reactive protein elevation (≽100 mg/L) was lower in the CM group than in the placebo group [27.6% (73/265) vs. 43.8% (120/274), P<0.01]. However, there was no difference in purulent drainage rate from incision and superficial opening of incision between the two groups. No intestinal reactions and skin allergies were found in the CM group.@*CONCLUSIONS@#CM plaster containing rhubarb and mirabilite had an effect on SSI. It is safe for mothers and imposes lower economic and mental burdens on patients undergoing CD. (Registration No. ChiCTR2100054626).

Endometriosis de la pared abdominal en relación con cicatriz de operación cesárea: serie de casos / Abdominal wall endometriosis in relation to cesarean section scar: number of cases

RESUMEN: La endometriosis (E), se define como presencia de glándulas endometriales y estroma fuera del útero. Ocasionalmente se presenta como masa sensible en la pared abdominal (PA), en relación con una cicatriz quirúrgica (EPA). Aunque el tratamiento es quirúrgico, existe poca información respecto de la morbilidad postoperatoria (MPO) y la recurrencia de la EPA. El objetivo de este estudio fue determinar MPO y recurrencia en pacientes resecadas quirúrgicamente por EPA. Serie de casos de pacientes con EPA, sometidos a cirugía de forma consecutiva, en Clínica RedSalud Mayor, entre 2011 y 2021. Las variables resultados MPO y recurrencia. Otras variables de interés fueron: tiempo quirúrgico, estancia hospitalaria y mortalidad. Las pacientes fueron seguidas de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión. Se intervinieron 14 pacientes, con una mediana de edad de 33 años. La medianas del tiempo quirúrgico y estancia hospitalaria; fueron 55 min y 2,5 días respectivamente. La MPO fue 14,2 % (2 casos). Con una mediana de seguimiento de 31 meses, no se verificó recurrencia. Aunque la EPA es poco común, estas lesiones deben sospecharse en mujeres en edad reproductiva con masa palpable en relación con una cicatriz de cirugía ginecológica u obstétrica. Los resultados obtenidos, en términos de MPO y recurrencia, fueron similares a series internacionales.

SUMMARY: Endometriosis (E) is defined as the presence of endometrial glands and endometrial stroma outside the uterus. Occasionally it presents as a sensitive mass in the abdominal wall (AW), in relation to a surgical scar (AWE). Although the treatment is surgical, there is scarce information regarding postoperative morbidity (POM) and recurrence of AWE. The aim of this study was to determine POM and recurrence in patients surgically resected by AWE. Case series of patients with AWE, consecutively submitted to surgery, at RedSalud Mayor Clinic, between 2011 and 2021. Outcome variables were POM and recurrence. Other variables of interest were surgical time, hospital stay and mortality. Patients were followed-up clinically. Descriptive statistics were used, applying central tendency and dispersion measures. 14 patients were intervened, with a median age of 33 years. Median of surgical time and hospital stay were 55 min and 2,5 days respectively. POM was 14.2 % (2 cases). With a median follow-up of 31 months no recurrence was verified. Although AWE is uncommon, these lesions should be suspected in women in fertile age with a palpable mass associated with a scar from gynecologic or obstetric surgery. The results obtained, in terms of POM and recurrence, were like international series.

Opciones e indicaciones en el manejo del istmocele / Options and indications in the management of isthmocele

INTRODUCCIÓN: El istmocele es un defecto en la cicatrización del sitio de una histerotomía, que puede cursar con sangrado posmenstrual, dolor pélvico, dismenorrea, dispareunia e infertilidad secundaria. Esta patología ha ido incrementando su prevalencia dado el aumento de la tasa de cesáreas en todo el mundo. OBJETIVO: Se realizó una revisión sobre el istmocele y su manejo, presentando sus indicaciones específicas y las complicaciones asociadas a esta patología. MÉTODO: Se llevó a cabo una búsqueda en PubMed, Embase, Scopus y Google Scholar, en la que se encontraron 868 artículos, de los cuales se revisaron 30 al aplicar los criterios de inclusión y exclusión. DISCUSIÓN: El istmocele es cada vez más frecuente. Tiene una prevalencia cercana al 60% posterior a la realización de una cesárea y aumenta hasta valores del 100% con tres de ellas. Los métodos diagnósticos más utilizados son la ecografía transvaginal y la histerosonografía. Su abordaje es habitualmente quirúrgico, aunque existe la posibilidad de intentar tratamiento médico en algunos casos. CONCLUSIONES: Es necesario determinar el grosor miometrial para poder establecer un plan de manejo adecuado. Además, se ameritan estudios que realicen un seguimiento a largo plazo y que aporten mayor evidencia para la realización de cada procedimiento. Después de clasificar el tipo de defecto, el tratamiento quirúrgico del istmocele se debe ofrecer a pacientes sintomáticas y a aquellas con defectos grandes y que desean mantener la fertilidad.

INTRODUCTION: The isthmocele is a defect in the healing of the site of a hysterotomy, which can present with post-menstrual bleeding, pelvic pain, dysmenorrhea, dyspareunia and secondary infertility. This pathology has been increasing its prevalence given the increase in the rate of cesarean sections worldwide. OBJECTIVE: A review will be carried out of the isthmocele and its management, presenting its specific indications and the complications associated with this pathology. METHOD: A search was carried out in databases such as PubMed, Embase, Scopus and Google Scholar, finding a total of 868 articles, of which 30 of them were reviewed when applying the inclusion and exclusion criteria. DISCUSSION: Isthmocele is an increasingly frequent pathology, having a prevalence of 60% after performing a cesarean section and increasing to 100% with 3 of them. There are multiple diagnostic methods, mainly transvaginal ultrasound and sono-hysterosonography. The approach to this pathology is usually surgical, although there is the possibility of trying medical treatment in some cases. CONCLUSIONS: It is necessary to determine the myometrial thickness in order to establish an adequate management plan. Additionally, long-term follow-up studies are warranted and provide more evidence for the performance of each procedure. After classifying the type of defect, surgical treatment of the isthmocele should be offered to symptomatic patients or those with large defects and who desire future fertility.

Drug utilization study in neonatal intensive care unit at tertiary care hospital

SUMMARY OBJECTIVE: Neonates are more susceptible to drug interactions and adverse effects, and special care should be taken when prescribing medication to them. This study aimed to investigate drug usage in the neonatal intensive care unit of a tertiary care hospital. METHODS: This prospective observational study was conducted on 98 patients at the Apollo tertiary care hospital (Bannerghatta, Bangalore, India) in a period of 6 months. The most common indications for neonatal intensive care unit admission, average number of drugs per patient, the most frequently used medication, distribution of patients based on the birth procedure, and possible drug interactions were collected from patient profiles. RESULTS: Among the patients, 52% were males and 48% were females. Notably, 38% of patients were preterm, 60% were term, and only 2% were post-term. Also, 80.6% were born by cesarean section and 19.4% were born by normal vaginal delivery. The highest mean of drug use was in the patient of 1,000-1,500 g (8.06 per patient). Preterm was the most frequent indication for admission in neonatal intensive care unit, followed by hyperbilirubinemia and then respiratory distress syndrome. The most frequently used medication was vitamin K (99%) and antibiotics followed by dextrose. In different types of antibiotics, amikacin (41%), cefoperazone+sulbactam (35%), cephalosporin (1%), ceftriaxone (0.7%), and amoxicillin (0.3%) were commonly administered. There were some possible interactions, such as aminoglycoside with furosemide and calcium gluconate. CONCLUSION: Premature birth and resulting low birth weight were the main reasons for drug prescription. High administration of antibiotics is probably an area of concern and should be seriously considered.

Associação entre a técnica de fechamento uterino na cesárea e a istmocele: uma visão global / Association between uterine closure technique after cesarean and isthmocele: an overview

A istmocele (ou "defeito cicatricial de cesariana") é uma alteração anatômica na parede uterina responsável por formar um "nicho", que é visualizado como uma área hipoecoica por histerografia ou por outros métodos de imagem, devido a uma cicatrização inapropriada de uma cesárea anterior. Essa modificação leva a complicações ginecológicas e obstétricas. Este estudo pretendeu analisar, entre os fatores de risco, a relação da istmocele com a técnica de fechamento uterino, comparando a sutura em camada simples com a dupla. Foi realizada uma revisão de literatura por meio de pesquisa bibliográfica em diferentes bases de dados eletrônicos. Foram encontrados 31 artigos, todavia apenas 13 estudos foram incluídos no presente estudo após avaliação criteriosa. A técnica de fechamento uterino é um dos fatores de risco possível de prevenir, sendo que a sutura em camada simples é associada a maior chance de se desenvolver a istmocele. A sutura de camada simples (ancorada) incluindo o endométrio está relacionada a menor espessura miometrial residual, associada a probabilidade de ruptura uterina e a istmocele, que a camada dupla não ancorada com a exclusão do endométrio.(AU)

The isthmocele is an anatomical alteration in the uterine wall responsible for forming a "niche", which is visualized as a hypoechoic area by hysterography or other imaging methods, due to inappropriate healing of a previous cesarean section. This modification leads to gynecological and obstetric complications. This study aimed to analyze among the risk factors the relation of isthmocele and the uterine closure technique comparing the single- and double-layer suture. It was conducted an electronic based search in different electronic databases. The research led to the retrieval of 31 articles; however only 13 studies were included in the present research after careful reading. The uterine closure technique is one of the possible risk factors to be modified; the single-layer suture is associated with a greater chance of developing isthmocele. The locked single-layer suture including the decidua is related to the decreased residual myometrial thickness, associated with the likelihood of uterine rupture and the isthmocele, than the double-layer unlocked excluding the decidua.(AU)

Cesarean section and body mass index in children: is there a causal effect? / Parto cesáreo e índice de massa corporal em crianças: existe um efeito causal? / Operación de cesárea e índice de masa corporal en niños: ¿existe un efecto causal?

Obesity is considered a global public health problem. Cesarean section has been associated with high body mass index (BMI) and increased obesity throughout life. However, this association has been challenged by some studies. This study aims to assess the causal effect of cesarean section on the BMI of children aged 1-3 years. This is a cohort study of 2,181 children aged 1-3 years, born in 2010, obtained from the BRISA Birth Cohort, in São Luís, state of Maranhão, Brazil. Sociodemographic variables, maternal characteristics, type of childbirth, morbidity, anthropometric measurements, and BMI were assessed. Marginal structural models with a counterfactual approach were used to check the causal effect of the type of childbirth on obesity, weighted by the inverse probability of selection and exposure. Out of the 2,181 children assessed (52% female), 50.6% were born by cesarean section, 5.9% of the newborn infants were large for gestational age, and 10.7% of them had excess weight. No causal effect of cesarean section on BMI was observed (coefficient = -0.004; 95%CI: -0.136; 0.127; p = 0.948). Cesarean section did not have a causal effect on the BMI of children aged 1-3 years.

A obesidade é considerada um problema de saúde pública global. Alguns estudos têm mostrado associação entre índice de massa corporal (IMC) elevado e aumento da obesidade em todas as fases da vida. Entretanto, essa mesma associação tem sido contestada por outros estudos. O objetivo foi de avaliar o efeito causal do parto cesáreo sobre o IMC das crianças entre 1 e 3 anos de idade. O estudo de coorte analisou 2.181 crianças de 1 a 3 anos de idade, nascidas em 2010, com dados obtidos da Coorte de Nascimentos BRISA em São Luís, Maranhão, Brasil. Foram avaliados dados sociodemográficos, características maternas, tipo de parto, morbidades, medidas antropométricas e IMC. Foram usados modelos estruturais marginais com abordagem contrafactual para verificar o efeito causal do tipo de parto sobre a obesidade, ponderado pela probabilidade inversa de seleção e exposição. Entre as 2.181 crianças avaliadas 52% eram do sexo feminino, 50,6% nascidas de parto cesáreo, 5,9% grandes para a idade gestacional e 10,7% com excesso de peso. Não foi observado efeito causal da cesariana sobre o IMC da criança (coeficiente = -0,004; IC95%: -0,136; 0,127; p = 0,948). O parto cesáreo não teve efeito causal sobre o IMC de crianças entre 1 e 3 anos de idade.

La obesidad está considerada un problema global de salud pública. El parto por cesárea ha sido asociado con un alto índice de masa corporal (IMC) y mayor obesidad en todos los estadios de la vida. Esta asociación, sin embargo, ha sido recusada en algunos estudios. El objetivo fue evaluar el efecto causal del parto por cesárea en el IMC de niños con edades de 1 a 3 años. Esta es una cohorte de estudio de 2.181 niños con edades de 1 a 3 años, nacidos en 2010, obtenidos de la Cohorte de Nacimientos BRISA, en São Luís, estado de Maranhão, Brasil. Se evaluaron las variables sociodemográficas, características maternales, tipo de parto, morbilidad, medidas antropométricas, e IMC. Se usaron modelos marginales estructurales con un enfoque contrafactual para comprobar el efecto causal del tipo de parto en la obesidad, ponderado por la probabilidad inversa de selección y exposición. Aparte de los 2.181 niños evaluados (52% mujeres), 50,6% nacieron por parto por cesárea, 5,9% de los niños recién nacidos fueron grandes para la edad gestacional, y 10,7% de ellos tenían exceso de peso. No se observó un efecto causal del parto por cesárea en el índice de masa corporal (coeficiente = -0,004; IC95%: -0,136; 0,127; p = 0,948). El parto por cesárea no tuvo un efecto a causal en el IMC de niños con edades entre 1 a 3 años.

Risk factors of perinatal complications in patients with pulmonary hypertension underwent cesarean section in 4 Chinese centers / 中华心血管病杂志

Objective: To identify the risk factors related to perinatal complications in patients with pulmonary hypertension underwent cesarean section. Methods: We retrospectively analyzed the medical records of all pregnant women with pulmonary hypertension hospitalized in 4 different hospitals in Shandong province and underwent cesarean section between May 2010 and May 2020. Patients were divided into perinatal complication group and control group according to the presence or absence of perinatal complications. Perinatal complications included aggravated heart function, new onset arrythmias, sudden cardiac arrest, all-cause death within 42 days post cesarean section, postpartum bleeding and thrombotic events. Risk factors of perinatal complications were analyzed. Results: A total of 167 patients (47 cases in the perinatal complication group and 120 cases in the control group) were included in this study. The average age of this cohort was 28(24, 32) years, and 75(44.9%) patients suffered newly diagnosed pulmonary hypertension during pregnancy. The main cause of pulmonary hypertension was congenital heart disease (137(82.0%)). Age, pregnant weeks, percent of primipara, intra-cardiac shunt, and receiving targeted medication therapy, cardiac dimensions were similar between the two groups. A total of 62 complications were recorded in the complication group including 28 cases of aggravated heart function, 4 cases of new onset arrythmias, 2 cases of cardiac arrest, 11 cases of bleeding or thrombotic events and 17 patients were dead. Prevalence of idiopathic pulmonary hypertension and general anesthesia was significantly higher, functional capacity was significantly lower in perinatal complication group than in control group (all P<0.05). The estimated systolic pulmonary artery pressure, serum N-terminal pro-B type natriuretic peptide and total bilirubin (TBIL) levels were significantly higher in perinatal complication group than in control group (all P<0.05). Logistic analysis demonstrated WHO Function Class(FC) Ⅲ/Ⅳ (OR=2.416,95%CI 1.016-5.743, P=0.046) and TBIL level (OR=6.874,95%CI 1.643-28.757, P=0.008) were the independent risk factors of perinatal complications. Conclusion: TBIL and WHO FC are independent risk factors of perinatal complications in pregnant women with pulmonary hypertension underwent cesarean section.

Características relacionadas à ocorrência de infecção puerperal em mulheres submetidas ao parto cesáreo / Characteristics related to the occurrence of puerperal infection in women submitted to cesarrel delivery

Objetivo: Este artigo de revisão sistemática tem como objetivo analisar as principais características relacionadas à infeção puerperal em mulheres submetidas ao parto cesáreo. Fonte dos dados: Foi realizada busca nas bases de dados on-line Biblioteca Virtual de Saúde (BVS) e PubMed. Seleção dos estudos: Selecionaram-se artigos publicados nos últimos 11 anos (2010-2021), totalizando 12 artigos analisados. Coleta de dados: Realizou-se a busca dos artigos a partir dos descritores infecção puerperal, mortalidade materna, cesárea, fatores de risco em inglês e português. Em seguida à adequação aos critérios de inclusão (artigos em inglês, português e espanhol, com publicação nos últimos 11 anos, realizados em humanos) e exclusão (artigos duplicados, revisão de literatura, estudos de caso e dissertações), a análise dos títulos e dos resumos dos artigos encontrados permitiu a exclusão daqueles que se afastavam do tema em estudo. Síntese dos dados: Dentre os fatores sociodemográficos, destacam-se mulheres nos extremos de idade, negras, residentes na zona rural, com baixo nível econômico e escolar, primíparas e tabagistas. Em relação aos fatores clínicos, obesidade, HIV, diabetes mellitus, doenças cardiovasculares, hipertensão arterial, pré-eclâmpsia e eclâmpsia, anemia e infecções geniturinárias apresentaram-se como fatores de risco para infecção puerperal. Fatores obstétricos também foram avaliados, identificando-se como variáveis importantes o parto cesáreo, rotura prematura de membranas, tempo de membrana rota, trabalho de parto maior que 12 horas, parto prematuro e trabalho de parto induzido, hemorragia pós-parto, transfusão prévia e mecônio em líquido amniótico. Por fim, as características assistenciais trazem o baixo número de consultas de pré-natal e número de toques vaginais antes e após a ruptura de membranas como variáveis de risco. Conclusão: Muitos dos fatores identificados são passíveis de controle, e a sua reversão contribui para a redução dos índices de infecção puerperal e, consequentemente, de mortalidade materna.(AU)

Objective: This systematic review article aims to analyze the main characteristics related to puerperal infection in women undergoing cesarean delivery. Source of data: A search was performed in the online databases Virtual Health Library (VHL) and Pub- Med. Selection of studies: Articles published in the last 11 years were selected, totaling 12 analyzed articles. Data collection: Articles were searched based on the keywords puerperal infection, maternal mortality, cesarean section, risk factors in English and Portuguese. Following the adaptation to the inclusion criteria (articles in English, Portuguese and Spanish, publication in the last 11 years, carried out in humans) and exclusion (duplicates, literature review, case studies and dissertations), the analysis of the titles and abstracts of the found articles allowed the exclusion of those who departed from the topic under study. Summary of the findings: Among the sociodemographic factors, women of extreme age, blacks, residents in the rural area, with low economic and educational status, primiparous women and smokers, stand out. Regarding clinical factors, obesity, HIV, Diabetes Mellitus, Cardiovascular Diseases, Hypertension, Pre-eclampsia and Eclampsia, Anemia and genitourinary infections were risk factors for puerperal infection. Obstetric factors were also evaluated, identifying as important variables cesarean delivery, premature rupture of membranes, ruptured membrane time, labor longer than 12 hours, premature labor and induced labor, postpartum hemorrhage, previous transfusion and meconium in amniotic fluid. Finally, the care characteristics bring the low number of prenatal consultations, the number of vaginal touches before and after rupture of membranes as risk variables. Conclusion: Many of the identified factors are possible to control and their reversion contributes to the reduction of puerperal infection rates and consequently maternal mortality.(AU)

Clinical Experience Over 15 Years with the B-Lynch Compression Suture Technique in the Management of Postpartum Hemorrhage / Experiência clínica ao longo de 15 anos com a técnica de sutura compressiva de B-Lynch no manejo da hemorragia pós-parto

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%.

Resumo Objetivo Descrever a experiência clínica com a técnica de B-Lynch no manejo da hemorragia pós-parto e os fatores relacionados à indicação da técnica bem como apresentar as taxas de sucesso da aplicação da técnica de B-lynch. Métodos Estudo observacional, retrospectivo, de corte transversal e analítico. Os dados foram obtidos por estudo de prontuário. A população do estudo foi constituída de pacientes submetidas à sutura hemostática com a técnica de B-Lynch, sendo incluídas 104 pacientes dentro do período de 01 de janeiro de 2005 a 31 de dezembro de 2019. Resultados Do total de 104 pacientes, 82,7% não apresentaram qualquer complicação. A transfusão de sangue e a internação na UTI foram as complicações mais prevalentes, com 13,5% e 15,4%, respectivamente. Apenas 1% teve infecção puerperal e do sítio cirúrgico. Os fatores mais relacionados com a aplicação da técnica foram a presença de cesárea anterior (30,8%), uso de ocitocina (16,3%) e pré-eclâmpsia (11,6%). A histerectomia puerperal foi realizada em 4,8% das pacientes por falha do método. Conclusão A experiência clínica com a técnica de B-Lynch foi satisfatória, pois apresentou poucas complicações, com excelentes resultados no controle hemorrágico. A cesárea anterior, o uso de ocitocina e a pré-eclâmpsia se destacaram como fatores relacionados à indicação da aplicação da técnica. A taxa de sucesso avaliada foi de 95,2%.

Adherencia a las recomendaciones de tromboprofilaxis post-cesárea: estudio de corte transversal / Compliance with post-cesarean section thromboprophylaxis recommendations. A cross sectional study in 233 women

Background: Cesarean section increases four times the risk of venous thromboembolism compared to vaginal delivery. The Royal College of Obstetricians and Gynecologists guidelines are used at our service. A written alert was designed to stratify patients at high, intermediate or low risk making a suggestion for thromboprophylaxis. Aim: To assess the compliance with the guidelines and to evaluate the impact of a written alert in the thromboprophylaxis compliance in women subjected to caesarean section. Patients and Methods: Review of medical records of 233 women aged 19 to 32 years, subjected to a caesarean section in a Gynecology Service, between 2016-2017. Results: Compliance with recommendations was observed in 29% of patients (68/233), 86% in the low-risk group, 26% in the intermediate risk group and 100% in the high risk group. In 41/233 (18%) of patients, a written alert was included in the medical record. Compliance with recommendations in the presence of the written alert was 61% (25/41 women) compared to 22% (43/192) in those lacking the alert (p < 0.01). In women whose emergency caesarean section was the only risk factor, the compliance with the recommendation was 8%, compared with 30% among those who had at least one thrombotic risk factor associated with caesarean section (p < 0.01). Conclusions: In this cross-sectional study, we observed a low compliance with thromboprophylaxis guidelines in cesarean women. We observed that the use of a written alert improved the compliance with thromboprophylaxis.

Effect of closure of anterior abdominal wall layers on early postoperative findings at cesarean section: A prospective cross-sectional study

Abstract Objective To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings. Methods The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and duringmobilization), analgesia requirement, and return of bowel motility. Results The postoperative pain scores were similar at the 2nd, 6th, 12th, and 18th hours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times. Conclusion In the group with only parietal peritoneum closure, the pain scores at the 6th and 12th hours were higher. Rectus abdominismuscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility.

Is there a role for antenatal corticosteroids in term infants before elective cesarean section?

Abstract Objective Cesarean section (CS) delivery, especially without previous labor, is associated with worse neonatal respiratory outcomes. Some studies comparing neonatal outcomes between term infants exposed and not exposed to antenatal corticosteroids (ACS) before elective CS revealed that ACS appears to decrease the risk of respiratory distress syndrome (RDS), transient tachypnea of the neonate (TTN), admission to the neonatal intensive care unit (NICU), and the length of stay in the NICU. Methods The present retrospective cohort study aimed to compare neonatal outcomes in infants born trough term elective CS exposed and not exposed to ACS. Outcomes included neonatal morbidity at birth, neonatal respiratory morbidity, and general neonatal morbidity. Maternal demographic characteristics and obstetric data were analyzed as possible confounders. Results A total of 334 newborns met the inclusion criteria. One third of the population study (n=129; 38.6%) received ACS. The present study found that the likelihood for RDS (odds ratio [OR]=1.250; 95% confidence interval [CI]: 0.454-3.442), transient TTN (OR=1.,623; 95%CI: 0.556-4.739), and NIUC admission (OR=2.155; 95%CI: 0.474-9.788) was higher in the ACS exposed group, although with no statistical significance. When adjusting for gestational age and arterial hypertension, the likelihood for RDS (OR=0,732; 95%CI: 0.240-2.232), TTN (OR=0.959; 95%CI: 0.297--3.091), and NIUC admission (OR=0,852; 95%CI: 0.161-4.520) become lower in the ACS exposed group. Conclusion Our findings highlight the known association between CS-related respiratory morbidity and gestational age, supporting recent guidelines that advocate postponing elective CSs until 39 weeks of gestational age.

A scary complication: single-center study on management and outcome of cesarean scar pregnancy

Abstract A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases.We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.

Tratamiento del embarazo ectópico en cicatriz de cesárea: revisión de la literatura a propósito de 3 casos / Treatment of ectopic pregnancy in a cesarean scar: review of the literature regarding 3 cases

INTRODUCCIÓN Y OBJETIVOS: El embarazo en cicatriz de cesárea previa (ECC) es una entidad poco frecuente que puede tener graves consecuencias. Hasta la fecha no existen esquemas estandarizados de tratamiento y su manejo óptimo sigue siendo controvertido. Nuestro objetivo es realizar una revisión de la literatura publicada sobre el manejo del ECC y proponer un algoritmo. También exponemos tres casos de ECC resueltos con diferentes tratamientos en el Hospital Universitario Infanta Elena MÉTODOS: Búsqueda de la literatura en bases de datos utilizando las palabras clave: "embarazo en cicatriz cesárea"," gestación ectópica en cicatriz cesárea", "tratamiento", "manejo". RESULTADOS: Las opciones terapéuticas pueden ser médicas, quirúrgicas o una combinación de ambas. Los tratamientos quirúrgicos tienen altas tasas de éxito, sin embargo, son más invasivos y no están exentos de riesgo. La combinación de tratamientos parece aumentar la tasa de éxito, no obstante, podría implicar un mayor riesgo de efectos secundarios y costes. CONCLUSIONES: El manejo de los ECC debe de ser individualizado, basado en la evidencia científica, en los medios disponibles y la experiencia de los profesionales en los distintos procedimientos, guiándonos por el tipo de ECC y su grado de vascularización e invasión, grosor del miometrio, niveles de beta-hCG, presencia de actividad cardiaca, clínica y estabilidad hemodinámica de la paciente. Deben tenerse en cuenta las circunstancias y patología intercurrente de la mujer, así como su deseo genésico o de preservación del útero.

INTRODUCTION AND OBJECTIVES: Cesarean scar pregnancy (CSP) is a rare entity that can cause serious consequences. Up to now, there are no standardized treatment schemes, and its optimal management remains controversial. Our objetive is to review the literature regarding CSP management and propose an algorithm. We also present three cases of CSP resolved with different treatments at Hospital Universitario Infanta Elena. METHODS: Literature search in databases using the following keywords: pregnancy with cesarean section, ectopic pregnancy with cesarean section, treatment, management. RESULTS: The therapeutic options can be medical, surgical or a combination of both. Surgical treatments have high success rates; however, they are more invasive and are not without risk. The combination of treatments seems to increase the success rate; however, it could imply a higher risk of side effects and costs. CONCLUSIONS: The management of CSP must be individualized; based on scientific evidence, on the means available, and on the experience of the professionals in the different procedures; guided by the type of CSP and its degree of vascularization and invasion, by the thickness of the myometrium, beta-hCG levels, presence of cardiac activity, and by clinical and hemodynamic stability of the patient. The circumstances and intercurrent pathology of the patient must be considered, as well as her desire for future pregnancy or preservation of the uterus.