Endometritis puerperal en nuestro medio / Postpartum endometritis incidence and risk factors

la infección genital postparto causa importante morbimortalidad. Se realizó un estudio de cohortes prospectivo observacional, que incluyó pacientes con parto vaginal o abdominal desde 19/04/2010 hasta 19/07/2010, para determinar la incidencia de endometritis y delimitar la población en riesgo. Se definió endometritis con al menos 2 de los siguientes: temperatura >38ºC, dolor uterino, dolor abdominal, loquios fétidos o ecografía patológica, sin otra causa de infección. Se registraron 1.472 partos. La inicidencia global de endometritis fue 2,5% (IC95%: 1,7-3,3); en partos vaginales 1,4% (IC95%: 0,7 - 2,1) y abdominales 4,8% (IC95%: 2,9-6,8). la diferencia fue estadísticamente significativa (p<0,001). En el análisis multivariado los factores de riesgo independientemente asociados fueron edad menor a 20 años y parto abdominal. Se descartó colinealidad entre ambas variables. Parto abdominal fue el único factor modificable. En este sentido deberían dirigirse las medidas de prevención y vigilancia.

Postpartum infection is cause of morbidity and mortality. To determine the incidence of postpartum endometritis and define the population at risk we performed a prospective observational study that included all the patients admitted for delivery to the Maternity service between 19/04/2010 and 19/07/2010. Endometritis was defined by at least two of the sequent: temperature >38ºC, uterine and lower abdominal pain, abnormal vaginal or cervical discharge or transvaginal ultrasound pathological findings. We registered 1,472 deliveries. Global incidence of postpartum endometritis was 2.5 % (95% Cl: 1.7-3.3); for spontaneous labor it was 1.4% (95% Cl:-2.1) and for cesarean deliveries 4.8% (95 %CL: 2.9-6.8) and this difference was statistically significant (p<0.001). Independent risk factors were age of 20 years or less and cesrean delivery. There was no colineality between both variables. Cesarean delivery was found the only modifiable risk factor for endometritis.

Risk factor analysis of peri-neonatal mortality in rural Guatemala.

Peri-neonatal mortality is a serious health problem in Guatemala, especially in rural areas where most deliveries occur at home and are overseen by traditional birth attendants (TBAs) who function in the role of midwives. The three aims of the work reported here were to identify important predictors of peri-neonatal mortality within a rural area of Guatemala; to assess the effects of traditional and modern health care providers on such mortality; and to find ways of identifying high-risk women who might benefit from transfer to a hospital or clinic. For these purposes a case-control study was conducted of 120 women in the rural department of Quetzaltenango who had lost their babies from the 20th week of pregnancy through the 28th day of life. These women and 120 controls were interviewed in their homes by trained physicians, using questionnaires in Spanish or the appropriate Indian dialect, and the results were analyzed through a series of statistical tests. It was found that the complications of pregnancy and delivery with the greatest statistical significance were prematurity, malpresentation, and prolonged labor. Population-based attributable risks of these complications demonstrated that they accounted for significant proportions of the observed peri-neonatal mortality. While these conditions cannot be eliminated, within the rural Guatemalan context it appears that early referral of women with these complications to more specialized care settings could result in improved delivery outcomes.

[Maternal morbidity in the Bolivian highlands. Body mapping, case analyses, and case-control study: tools of local epidemiology in primary health provision]. / Muttersterblichkeit im Hochland Boliviens. Body mapping, Fallanalysen und Fall-Kontroll-Studie: Werkzeuge der lokalen Epidemiologie in der primaren Gesundheitsversorgung.

PIP: The investigated region was Carabuco, Bolivia, with 31 communities and 9000 inhabitants. Since 1985 a project of basic health care has been in place there to ameliorate the existing situation where 40% of deliveries were performed by relatives, 30% by husbands, 15% by traditional midwives, and 10% by other health personnel. Maternal mortality had been 920/100,000 in the previous 6 years, twice as high as the national rate. This raised questions about harmful traditional practices, the typical case of maternal mortality, and whether significant risk factors existed relative to complications that prevented health care interventions. Semi-structured interviews and body mapping with sketches were employed as used in rapid rural appraisal. The discussions between the nurse and the midwife were taped. Traditional birth practices consisted of massage and the use of ergot tea concoctions. Verbal autopsy (post-mortem interview) explored the exact causes of death. Every 6 months these verbal autopsies were reexamined in Carabuco to detect any obstacles to timely prevention of death. These had to do with family and dependents, neighbors, traditional healers, village health workers, the doctor on duty, and the referral hospital. The causes of such obstacles were: lack of knowledge about any cure, lack of means of arresting the disease, feeling of shame, rejection of modern medicine, lack of trust, and lack of money or transportation. Six typical examples were detailed. A case control study was also presented involving 17 women whose deaths occurred between January 1985 and December 1992. Controls were 79 women who had survived a potentially deadly obstetrical diagnosis. The role of puerperal infections was significant in deaths; bleeding and the retention of placenta in comparison with other diagnoses produced a higher chance of survival; eclampsia's role was minor; and poverty was associated with a higher mortality risk.^ieng

Experience with an active labour management protocol and reduction of caesarean section rate in Nicaragua.

Prospective data are presented on the outcome of labour in 67 women with uncomplicated pregnancy, who attended a rural Nicaraguan hospital and were managed actively in labour. No dystocia occurred and the caesarean section rate was 0%. Active management of labour is safe and feasible in a rural hospital setting. It results in a low caesarean section rate and reduced maternal mortality and morbidity, without compromising perinatal outcome.

PIP: 67 nulliparous women aged 20-29 delivering during a 1-year period in 1987 and 1988 were evaluated to study the incidence of cesarean section in developing countries, as this procedure is associated with high maternal mortality (1/100 operations). If cervical dilatation was less than 1 cm/hour iv oxytocin was administered. Fetal heart rate was monitored. Pudendal block anesthesia was given for forceps delivery and spinal anesthesia was administered for cesarean section. Labor lasted less than 6 hr in 26 (39%), it lasted 6-12 hr in 30 (45%), and it lasted 12 hr in 11 cases (16%). There were 6 (9%) forceps deliveries for fetal distress. In 31 (46%) women spontaneous rupture of the membranes occurred. Oxytocin was applied in 12 (18%) cases. 5 infants (7.5%) weighed less than 2500 g and 61 (91%) weighed between 2500 g and 3999 g. A regional hospital had 283 cesarean sections (12.6%) mostly for dystocia and previous cesarean over a 1-year period out 2240 births. Active management of labor reduces the use of cesarean operations. Recognition of inefficient uterine action minimizes dystocia, however, the use of oxytocin in multiparous women poses the risk of uterine rupture. A large prospective study is needed to evaluate the effect of active management of labor on the rate of cesarean sections.

[Adolescent fertility. 1. Pregnancy and childbirth]. / Fertilidad en la adolescente. 1. Embarazo y parto.

PIP: Women aged 15-19 represent a high proportion of the female population of the Dominican Republic, and their rate of consensual unions of 24.6% leads to high rates of adolescent pregnancy. A retrospective study was made of the records of 600 adolescent pregnancies followed between 1975- 80 at a maternity hospital in Santo Domingo. The adolescents were classified into 3 age groups. Group 1 included 27 adolescents aged 12- 14, group 2 included 305 aged 15-17, and group 3 included 268 aged 18- 19. 3 adolescents in group 1, 64 in group 2, and 108 in group 3 had already had a child, while 10 in group 2 and 38 in group 3 had 2 previous children. 7 in group 3 had 3 or more children. 1 mother in group 1, 7 in group 2, and 12 in group 3 had a history of cesarean section. 331 of the 600 had no form of prenatal care. 202 had 1-4 prenatal visits and 67 had 5 or more. Among the 331 adolescents with no prenatal care, there were 92 cases of threatened premature delivery, 30 of slight and 31 of moderate to severe toxemia, and 7 of eclampsia. Among the 269 patients with prenatal care, there were 19 cases of slight and 2 of moderate toxemia during pregnancy. On admission to the hospital, there were 58 cases of threatened premature deliver, 23 of slight and 14 of moderate to severe toxemia, and 14 of premature rupture of membranes. Among the total group of 600 adolescents, 25% had threatened premature delivery, 8.8% had slight and 7.5% had moderate to severe toxemia, 1.1% had eclampsia, 4.2% had premature rupture of membranes, 1.3% had abortions, and .5% had syphilis. 428 deliveries occurred at 38-40 weeks. There were 57 caesareans and 8 abortions. 214 newborns had Apgar scores of under 7 points. There were 15 fetal deaths in utero, 28 hemorrhages during delivery, and 3 cases of retention of the placenta. There were 3 maternal deaths due to sepsis. It is apparent that adolescent pregnancy entails a high degree of risk.^ieng

Traditional midwives, tetanus immunization, and infant mortality in rural Haiti.

PIP: Lessons learned from Haiti's integration of a training program for traditional birth attendants with the maternal and child health and family planning program are reported. The available data on illness and deaths reveal that Haiti has continuing problems of gastroenteritis, malnutrition, tuberculosis, malaria, and tetanus. The latter is of particular interest since neonatal tetanus derived from umbilical cord contamination continues to affect up to 10-20% of Haitian newborns in rural areas lacking health programs. Neonatal tetanus has largely disappeared in the Artibonite Valley due to a mass immunization program for the entire population, including young women, against tetanus. In the Albert Schweitzer Hospital program for indigenous midwives in Artibonite Valley, at least 36 midwives were reached on a regular basis in 1968 -- less than 1/3 of the midwives operating in the Artibonite Valley. There was a rapid decline in neonatal tetanus admissions during the period following 1968. This decline has been attributed to the use of rural health auxiliaries in immunizing the women in the hospital district, but indigenous midwives may have played a role. By 1970, the Albert Schweitzer Hospital program had grown from 36 midwives regularly attending midwife classes to 175 registered with the program during 1970. Although direct supervision proved difficult due to lack of communication and transport to the scene of delivery, some deliveries were observed and indirect supervision by the community became evident. An important finding of the traditional midwife training program of the Albert Schweitzer Hospital was the amount of time required for an indigenous midwife to have referred 50 newborns to the hospital for BCG vaccination. At the end of the 1st year of this program, only 2 midwives reached this goal. Another surprise was the increase in demand for "cord cut" services at the outpatient clinic rather than increased use of the nearby maternity unit. The elimination of neonatal tetanus as a cause of infant mortality was the most important outcome of the maternal and child health component of the community health program.^ieng

Access to postpartum sterilization in southeast Brazil.

All women hospitalized for delivery over a ten-week period at the largest maternity hospital in Campinas in the State of São Paulo, Brazil, were questioned about their interest in and plans for sterilization. Results from a categorical data analysis indicate that among the study variables, cesarean delivery was the necessary condition for postpartum sterilization and was significantly associated with the patient's ability to pay for services. Further, the variability in the proportion of women sterilized postpartum was almost perfectly explained by a linear model with main effects for parity and for the patient's ability to pay for services.

PIP: A study was undertaken at a large maternity hospital in Campinas in the State of Sao Paulo, Brazil in an effort to obtain more information concerning access to sterilization. This hospital was chosen because it serves patients of widely varied socioeconomic status, and, consequently of different abilities to pay for surgery. The study was conducted over the December 1979 through February 1980 period. Interviews were completed with 2194 women after they gave birth and before discharge from the hospital. Analysis proceeds in 3 steps: a description concerning distributions of age, parity (after delivery), monthly family income, type of payment for medical services, and method of delivery among the 927 women who desire no more children; a description of how the population desiring no more children chooses sterilization as the preferred family planning method; and focus on the subset of women preferring sterilization services, making use of methods of estimation and hypothesis testing from cross-classified data. Almost 9 of 10 women who want no more children have heard of sterilization. Indigent patients are least likely (79%) and private patients are most likely (98%) to have heard of sterilization. Women who had cesarean deliveries are more likely to have heard of sterilization (95%) than those giving birth vaginally (86%). Of all women who want no more children and have heard of sterilization, 58% stated that they had planned to be sterilized. Of the 375 women who planned to be sterilized and knew about available services, 40% were not sterilized postpartum. The most frequent reason given was type of delivery (38%). Of the women who had vaginal deliveries, 48% gave this as a reason for failure to be sterilized. Study data show that the method of payment for care substantially influences the eventuality of sterilization. Wealthier women who are private or convenio (all women who pay for their care through a privately financed insurance plan but do not stay in a private room) patients are more likely to be sterilized than are the poor, whose care is financed through government insurance or who are indigent. Results also show that women sterilized postpartum almost always have had cesarean deliveries. Regardless of whether she is sterilized, a cesarean delivery is more likely as the socioeconomic status of the woman rises. A more liberal interpretation of the Medical Ethics Code that would consider women to be at high risk for reasons other than those associated with previous cesarean birth would improve access to postpartum sterilization.