Adherencia a métodos anticonceptivos postevento obstétrico en adolescentes / Method Adherence post-event contraceptives obstetric in adolescents

Introducción: en nuestra institución, durante el año 2019 y 2020, hubo un total de 2811 nacimientos; de ellos, el 11.2% (N=317) fueron de mujeres adolescentes de entre 10 a 19 años. Abordar a esta población desde el enfoque de su adherencia a los métodos anticonceptivos (MAC) nos permitiría poder realizar acciones tendientes a evitar los embarazos no intencionales. La importancia de este objetivo radica en que la gestación en adolescentes impacta directamente en las posibilidades de desarrollo educativo, laboral y personal de estas mujeres, ya que las posiciona en un rol de cuidado que las aleja de los principales espacios de inserción social y construcción ciudadana. Objetivo: conocer el número de mujeres adolescentes que continuaron con el MAC elegido en el alta hospitalaria, 6 meses postevento obstétrico. Establecer cuál fue el método más elegido por esta población, conocer las causas que llevaron a la discontinuidad del método elegido y determinar si hubo embarazo no deseado luego del evento obstétrico. Materiales y método: estudio de tipo descriptivo, observacional, retrospectivo y de corte transversal. Se extrajeron datos del Sistema Informático Perinatal y, luego, se realizó actividad extramural mediante llamados telefónicos para recolectar los datos sobre la adherencia de los métodos anticonceptivos. Resultados: el 41,9% de la muestra (N=148) eligió un método de larga duración al alta (implante subdérmico y dispositivo intrauterino ­DIU­). El 51,4% continúa con el método elegido, un 35,8% optó por cambiarse de método y el 12,4% refirió haber cursado algún embarazo. De las mujeres que accedieron al implante subdérmico, un 97,2% continúa con este, y de las que accedieron al DIU, un 46,2% sigue utilizándolo. Esto se contrapone a los anticonceptivos orales, cuya adherencia fue del 34.4%. Algunos de los motivos por los cuales no continuaron con el método elegido fueron: preferencia de un método de larga duración (22,6%), incomodidad por efectos adversos (17%), olvidos en a toma de los anticonceptivos orales y expulsión de DIU (20,8%), por falta de insumos (3,8%) y otros (15,1%). Conclusiones: de esta investigación, pudimos establecer que existe una fuerte aceptación de las adolescentes por los LARCs: más de un tercio los elige al momento del alta obstétrica y, de aquellas que decidieron cambiar de MAC, casi 23% nos especificó que deseaba un método de larga duración, pero reversible. Dentro de ellos, se destacó tanto la elección como la adherencia en el tiempo del implante subdérmico. Gracias a la realización de extramurales, este trabajo nos permitió volver a conectar con las mujeres a las que habíamos brindado atención determinado tiempo atrás. Este hecho nos posibilitó no solo lograr los objetivos planteados, sino también poder conocer, de primera mano, el uso de los MAC en adolescentes y todo lo que su adherencia implica, para así poder mejorar nuestra propia consejería en Salud Sexual y Reproductiva. Una estrategia posible sería la citación de ellas a los 3 y 6 meses postevento obstétrico(AU)

SUMMARY Introduction: in our Institution, during 2019 and 2020, there were a total of 2811 births, of which 11.2% (N = 317) were of adolescent women between 10 and 19 years of age. Addressing this population from the approach of their adherence to contraceptive methods (MAC) would allow us to carry out actions aimed at avoiding unintended pregnancies. The importance of this objective lies in the fact that pregnancy in adolescents has a direct impact on the possibilities of educational, work and personal development of these women since it positions them in a caring role that distances them from the main spaces of social insertion and civic construction. Objective: to know the number of adolescent women who continued with the chosen MAC at hospital discharge 6 months after obstetric event, to establish which was the method most chosen by this population, to know the causes that led to the discontinuity of the chosen method and to determine if there was an unwanted pregnancy after the obstetric event. Materials and method: descriptive, observational, retrospective and crosssectional study. Data were extracted from the Perinatal Computer System and then extramural activity was carried out through telephone calls to collect data on adherence to contraceptive methods. Results: 41.9% of the sample (N = 148) chose a long-term method at discharge (subdermal implant and intrauterine device -DIU-). 51.4% continued with the chosen method, 35.8% opted to change the method and 12.4% reported having had a pregnancy. Of the women who accessed the subdermal implant, 97.2% continue with it and of those who accessed the IUD, 46.2% continue to use it, in contrast to oral contraceptives, whose adherence was 34.4%. Some of the reasons why they did not continue with the chosen method were: preference for a long-term method (22.6%), discomfort due to adverse effects (17%), forgetting to take oral contraceptives and expulsion of IUD (20.8%), for lack of inputs (3.8%) and others (15.1%). Conclusions: from this research we were able to establish that there is a strong acceptance of adolescents by LARCs: more than a third choose them at the time of obstetric discharge and of those who decided to change MAC, almost 23% specified that they wanted a long-lasting but reversible method . Among them, both the choice and the adherence over time of the subdermal implant stood out. Thanks to the performance of extramurals, this work allowed us to reconnect with the women to whom we had provided care a certain time ago. This fact enabled us not only to achieve the objectives set, but also to know first-hand the use of MAC in adolescents and all that their adherence implies, in order to improve our own counseling on Sexual and Reproductive Health (AU)

"Tabela Periódica" da Anticoncepção ­ uma ferramenta na escolha contraceptiva / "Periodic Table" of Contraception ­ a tool in the contraceptive choice

Estima-se que 40% das gestações no mundo sejam não planejadas. Em países de baixa renda, complicações no parto são a maior causa de morte entre mulheres de 15 a 19 anos. A disponibilidade de métodos contraceptivos reversíveis é necessária para o adequado planejamento reprodutivo. Entre os métodos reversíveis, os de longa ação (LARCs) são os mais efetivos. Métodos de curta ação (SARCs) são preferenciais para pacientes que desejam gestar a curto prazo e para as quais a gestação não será indesejada. O presente estudo é uma revisão narrativa da literatura, de artigos em inglês e português publicados entre 2009 e 2020, utilizando as bases de dados SciELO, Medline e Embase. O objetivo desta revisão é apresentar os LARCs e SARCs em uma tabela com dados comparativos que auxiliem na tomada de decisão do médico e da paciente e permita estabelecer estratégias para um planejamento familiar adequado.(AU)

It is estimated that 40% of pregnancies in the world are unplanned. In low-income countries, complications in childbirth are the major cause of death among women aged 15 to 19 years. The availability of reversible contraceptive methods is necessary for proper reproductive planning. Among the reversible methods, long-acting reversible contraception (LARCs) is the most effective. Short-acting reversible contraception (SARCs) methods are preferred for patients who wish to become pregnant in the short term and for whom pregnancy will not be undesirable. The present study is a narrative review of the literature, of articles in English and Portuguese published between 2009 and 2020, using the databases SciELO, Medline and Embase. The purpose of this review is to present the LARCs and SARCs in a table with comparative data that assist in the decision making of the doctor and the patient and allow to establish strategies for adequate family planning.(AU)

Prevención del embarazo reiterado en adolescentes: una experiencia clínica exitosa / Prevention of repeated pregnancy in teenagers: a successful experience

INTRODUCCIÓN: el embarazo adolescente tiene consecuencias para la madre y su hijo/a. Además del riesgo propio de la gestación índice, ser madre en esta etapa vital predice la ocurrencia de otra(s) gestación(es) antes de cumplir 20 años, lo que aumenta aún más la vulnerabilidad de todo el grupo familiar. La evidencia actual señala que el inicio postparto inmediato de un método anticonceptivo de larga duración (LARC, por sus siglas en inglés: long acting reversible contraceptive) es la intervención más efectiva para prevenir el embarazo reiterado en adolescentes. OBJETIVOS: evaluar la estrategia de iniciar un LARC inmediato post parto en un hospital público de la región metropolitana de nuestro país. MÉTODOS: en el Hospital El Carmen Dr. Luis Valentín Ferrada de Maipú se realiza consejería en anticoncepción a todas las madres adolescentes y se les ofrece inicio de implante anticonceptivo previo al alta. Durante el 2015 el 53.4% de las puérperas adolescentes decidieron iniciar implante (Implanon ®) en forma inmediata. El 2017 se logró contactar a 92 pacientes de este grupo: un 90.3% se mantenía usando el mismo método. De las adolescentes que se lo habían retirado, todas reportaban uso de algún otro método anticonceptivo. En el grupo intervenido no hubo ningún nuevo embarazo, en el grupo control (sin anticoncepción postparto) se observÓ un 7% de gestaciones reiteradas durante el periodo evaluado. CONCLUSIONES: el inicio de un método LARC en el postparto inmediato parece ser una herramienta exitosa para reducir de la tasa de embarazo repetido en la adolescencia.

INTRODUCTION: adolescent pregnancy has consequences for the mother and her child. In addition to the risk of the index pregnancy, being a mother at this stage of life predicts the occurrence of other pregnancies before the age of 20, which further increases the vulnerability of the entire family group. Current evidence suggests that immediate postpartum initiation of long-acting reversible contraceptive (LARC) is the most effective intervention to prevent repeat pregnancy in adolescents. OBJECTIVES: to evaluate the strategy of starting an immediate postpartum LARC in a public hospital in the metropolitan region of our country. METHODS: at the Hospital El Carmen Dr. Luis Valentín Ferrada de Maipú, contraception counseling is given to all adolescent mothers and they are offered the start of a contraceptive implant before discharge. During 2015, 53.4% ​​of adolescent puerperal women decided to start an implant (Implanon ®) immediately. In 2017, 92 patients from this group were contacted: 90.3% continued using the same method. Of the adolescents who had withdrawn it, all reported use of some other contraceptive method. In the intervened group there were no new pregnancies, in the control group (without postpartum contraception) 7% of repeated pregnancies were observed during the evaluated period. CONCLUSIONS: the initiation of a LARC method in the immediate postpartum seems to be a successful tool to reduce the rate of repeat pregnancy in adolescence.

Predictors of pathological response and clinical outcome following chemoradiation for locally advanced rectal cancer - a systematic review / Preditores de resposta patológica e de outcome clinico após quimioradioterapia neoadjuvante para cancro do reto localmente avançado - uma revisão sistemática

Abstract Background: Colorectal cancer is one of the most common types of cancer and is associated with a high lethality rate. Treatment is multidisciplinary, and neoadjuvant chemoradiation is recommended in locally advanced rectal cancer. About 15% of patients answer favorably to neoadjuvant chemoradiation, so it is important to determine the predictors of response. Objective: To review the results of studies that analyzes the predictors of complete pathological response to neoadjuvant chemoradiation in patients with locally advanced rectal cancer. Search methods: We searched for eligible articles in data bases Pubmed and Scopus, between the 12th and the 20th of March 2020. The following key words were used: "predictors of response", "chemoradiation" and "locally advanced rectal cancer". Selection criteria: Inclusion criteria: Studies including patients with locally advanced rectal cancer, patients receiving neoadjuvant chemoradiation as treatment, studies including predictors of response to neodjuvant chemoradiation, overall survival as an outcome and regarding language restrictions, only articles in English were accepted, only studies published until the 31st of December 2019 were accepted. Main results: Fourteen studies fulfilled the inclusion criteria. Thirteen are cohort studies and one is a clinical trial. Four groups of predictors were defined: blood markers, tumors, histopathological and patients' characteristics. Author's conclusions: During the analysis of the articles, there were several predictors identified as potential candidates for clinical practice, such as high pre neoadjuvant chemoradiation Carcinoembryonic Antigen levels and small post neoadjuvant chemoradiation tumor size. Nevertheless, it is difficult to make definitive conclusions about the most reliable predictors. That is why it is crucial to initiate further studies with standardized cut-off values and a methodology homogenization.

Resumo Introdução: O cancro colorretal é um dos cancros mais prevalentes em Portugal e tem associada uma alta taxa de letalidade. Atualmente, o tratamento é multidisciplinar, e a quimioradioterapia neoadjuvante está indicada no Cancro do Reto Localmente Avançado. Sabe-se que cerca de 15% dos doentes responde favoravelmente à quimioradioterapia neoadjuvante, sendo por isso importante determinar quais os preditores de resposta a este tipo de tratamento. Objetivo: Rever os resultados dos estudos que analisam os preditores de resposta completa à quimioradioterapia em pacientes com Cancro do Reto Localmente Avançado. Métodos de pesquisa: Pesquisamos artigos elegíveis nos bancos de dados Pubmed e Scopus, desde o dia 12 a 20 de Março de 2020. Foram utilizadas as seguintes palavras chave: "preditores de resposta", "quimioradioterapia neoadjuvante" e "Cancro do Reto Localmente Avançado". Critérios de seleção: Critérios de inclusão: Estudos que incluam pacientes com Cancro do Reto Localmente Avançad, pacientes sujeitos a quimioradioterapia neoadjuvante, preditores de resposta à quimioradioterapia, que avaliem a sobrevivência como outcome, escritos em inglês e publicados até dia 31 de Dezembro de 2019. Resultados principais: Catorze estudos preencheram os critérios de inclusão. De todos os artigos, treze são Cohort e um é Clinical Trial. Foram definidos quatro grupos de preditores: marcadores de sangue e caraterísticas do tumor, histopatológicas e dos pacientes. Conclusões dos autores: Durante a análise dos artigos, foram identificados vários preditores como potenciais candidates para a prática clínica, tais como o valor elevado de antigénio carcinoembrionário pré- quimioradioneoaajuvância e tamanho reduzido. Contudo, é arriscado elaborar conclusões concretas relativamente aos preditores mais confiáveis. Por isso, é crucial iniciar novos estudos com valores de cut-off estandardizados e métodos com maior homogeneidade.

The effect of tumor volume on the prognosis of locally advanced rectal cancer / 中国肿瘤临床

Objective: To evaluated the prognostic effect of tumor volume in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (NCRT) and total mesorectal excision (TME). Methods: This was a retrospective analysis of 128 patients with newly diagnosed rectal cancer who received preoperative concurrent chemoradiation plus TME from January 2011 to September 2016 in Hunan Cancer Hospital. The receiver-operating characteristic (ROC) curve was used to analyze the gross tumor volume (GTV) cut-off point. Prognostic analysis was performed using Kaplan-Meier, Log-rank, and Cox regression models. Results: After NCRT, T-stage declined 58.6%, N-stage declined 69.5%, and the overall TNM stage declined 77.3%. After NCRT, the pathological complete response (pCR) rate was 16.4% and the anus-protection rate was 57.03%. The GTV cut-off point was 79.31 mL. There were significant differences in OS, DFS, LRFS and DMFS between patients with GTV ≥79.31 mL and patients with GTV <79.31 mL over three years. GTV was significantly related to MRI-T staging (ρ=0.236; P=0.007), T downstaging (ρ=0.229; P=0.009),TNM downstaging (ρ=0.219; P=0.013), and tumor regression grade (TRG) (ρ=0.517; P<0.001); however, GTV was not significantly related to MRI-N staging and N downstaging. Conclusions: GTV is closely related to local recurrence and distant metastasis of LARC, and is an important prognostic factor. Tumor volume was significantly related to pretreatment MRI-T staging, T downstaging, TNM downstaging after NCRT, and TRG, but not to pretreatment MRI-N staging and N downstaging.

Knowledge, attitude and practice of long acting reversible hormonal contraception (LARHC) among women in urban upper Egypt

Background: The current study aims to assess the knowledge, attitude and practice of long acting reversible hormonal contraception (LARHC) among women in urban upper Egypt.Methods: A cross sectional study which included 902 married women, in the reproductive age, attending the outpatient clinics (Gynecology and family planning) of: 1-Assiut University Maternity Hospital, 2- Sohag University Hospital, and 3-Gehina General Hospital (MOH hospital) with current or previous use of any method of LARHC methods. A Questionnaire file was designed to assay knowledge attitude and practice of clients towards contraceptive methods. All data collected from clients reviewed separately to assess knowledge, attitude and practice of women towards contraceptive methods.Results: The most popular contraceptive method is COCs followed by IUD then DMPA. 99% of studied sample heard with good description about different types of LARHC. 54.9% of studied sample most popular/famous LARHC DMPA, most sources of information on LARHC were, Hospital, Relative/friends and health workers. 94.24% of the studied sample were in favor to use of LARHC, 94.2% of them agree to take a space between births, about 55.4% of them were health child and 61% comfortable lifestyle benefit from birth spacing, 33% of studied sample were maternal health, 68% of them were think/prefer to use implants, 64.5% of them didn’t pregnant while breastfeeding. 11% of sample women never used any contraception before and most reasons for not using contraception are fear of side effects, desire for more children, irregular sexual relationship, and husband opposition. Only 16.6 % of studied sample used LARHC before and most of them used DMPA, however 3 women who used DMPA get pregnant while using it.Conclusions: There is a good level of knowledge between upper Egypt women about LARHC methods.

Métodos contraceptivos reversíveis de longa duração no Sistema Único de Saúde: o debate sobre a (in)disciplina da mulher / Long-acting reversible contraception methods in the Brazilian Unified National Health System: the debate on women's (in)discipline

Resumo Recentemente a Federação Brasileira das Associações de Ginecologia e Obstetrícia submeteu ao Ministério da Saúde uma solicitação para oferta no Sistema Único de Saúde de métodos contraceptivos reversíveis de longa duração (LARC), para jovens mulheres de 15 a 19 anos. Os dois dispositivos a serem incluídos seriam o implante subdérmico liberador de etonogestrel, com duração de três anos, e o sistema intrauterino liberador de levonorgestrel, com duração de cinco anos. O Ministério da Saúde abriu então consulta pública para avaliar tal introdução, terminando por decidir contrariamente à inclusão destes métodos na rede pública de saúde. O artigo discute as estratégias discursivas utilizadas para fundamentar e justificar a aceitação e aplicabilidade destes métodos em "populações especiais". O debate sobre o planejamento reprodutivo precisa compreender melhor as descontinuidades contraceptivas no uso de métodos, a centralidade da contracepção de emergência e o quanto as hierarquias de gênero dificultam uma prática contraceptiva segura. Ao contrário, a ênfase na (in)disciplina da mulher no tocante aos cuidados com a utilização de métodos contraceptivos de uso regular termina por reforçar sua condição de menoridade social.

Abstract Recently, the Brazilian Federation of Gynecology and Obstetrics Associations submitted a request to the Brazilian Ministry of Health for an introduction of long-acting reversible contraception (LARC) methods for young women aged 15 to 19 years in the Brazilian Unified National Health System. The two devices to be included were the etonogestrel-releasing subdermal implant (ENG implant), with a duration of three years, and the levonorgestrel-releasing intrauterine system (LNG-IUS), lasting five years. The Ministry of Health then launched a public inquiry to evaluate this introduction, deciding against the inclusion of these methods in the public health services. The article discusses the discursive strategies used to justify the acceptance and applicability of these methods in "special populations." The debate on family planning needs to understand fully the discontinuity of contraception in the use of such methods, the central concept of emergency contraception, and how gender hierarchies prejudice safe contraceptive practice. On the contrary, the emphasis on the (in)discipline of women regarding care with regular-use contraceptive methods effectively reinforces their condition of social minority.

Los métodos reversibles de larga duración (LARC), una real opción anticonceptiva en el Perú" / Long-acting reversible contraception (LARC), a real contraception option in Peru

En esta presentación analizamos que no existe mayor diferencia en la eficacia y la efectividad entre los métodos anticonceptivos de larga duración reversibles (implantes, dispositivos intrauterinos-DIU) -conocidos como los métodos LARC- y los métodos anticonceptivos quirúrgicos, de larga duración definitivos (vasectomía, ligadura de trompas). La diferencia entre ambas metodologías anticonceptivas está relacionada con la temporalidad y reversibilidad del método, y con los efectos secundarios que se pueden originar. La baja demanda de los LARC probablemente se debe a los mitos y barreras que existen entre algunos prestadores de salud y la población. También a una falla en la asesoría anticonceptiva, poca disponibilidad o costos para algunas poblaciones vulnerables, como son los adolescentes. Los métodos anticonceptivos reversibles de larga duración (LARC) son una alternativa de primera línea para prevenir un embarazo no planificado, en cualquier grupo etario que tiene relaciones sexuales. Su eficacia y efectividad, comparable a los métodos anticonceptivos quirúrgicos, debe ser difundida entre la población, ya que les da la protección de un método definitivo sin serlo.

We analyze In this presentation there is no big difference in the efficiency and effectiveness between the long-acting reversible contraceptive methods (implants, IUD) known as the LARC methods (by its abbreviation in English) and the definitive long-acting surgical contraception (vasectomy, tubal ligation). The difference between both contraceptive methodologies is related with the temporality and reversibility of one method and the side effects that might originate from this. The low demand of LARC is probably due to the myths and barriers existing among some health providers and the population. Also to the failure in contraceptive advice, limited availability, or high costs for some vulnerable populations like the adolescents. The long-acting reversible contraceptives are a first line alternative to prevent an unplanned pregnancy in any age group in sexual activity. The efficiency and effectiveness comparable to that of the surgical contraceptive methods should be shared with the people as these methods give protection similar to a definitive method without being one. In Peru, they are included in the contraceptive mix offered by the ministry of health.