Herbal medications for anxiety, depression, pain, nausea and vomiting related to preoperative surgical patients: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: To summarise the effects of herbal medications for the prevention of anxiety, depression, pain, and postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic, obstetrical/gynaecological or cardiovascular surgical procedures. METHODS: Searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and LILACS up until January 2018 were performed to identify randomised controlled trials (RCTs). We included RCTs or quasi-RCTs evaluating any herbal medication among adults undergoing laparoscopic, obstetrical/gynaecological or cardiovascular surgeries. The primary outcomes were anxiety, depression, pain and PONV. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate overall certainty of the evidence for each outcome. RESULTS: Eleven trials including 693 patients were eligible. Results from three RCTs suggested a statistically significant reduction in vomiting (relative risk/risk ratio (RR) 0.57; 95% CI 0.38 to 0.86) and nausea (RR 0.69; 95% CI 0.50 to 0.96) with the use of Zingiber officinale (ginger) compared with placebo in both laparoscopic and obstetrical/gynaecological surgeries. Results suggested a non-statistically significantly reduction in the need for rescue medication for pain (RR 0.52; 95% CI 0.13 to 2.13) with Rosa damascena (damask rose) and ginger compared with placebo in laparoscopic and obstetrical/gynaecological surgery. None of the included studies reported on adverse events (AEs). CONCLUSIONS: There is very low-certainty evidence regarding the efficacy of both Zingiber officinale and Rosa damascena in reducing vomiting (200 fewer cases per 1000; 288 fewer to 205 fewer), nausea (207 fewer cases per 1000; 333 fewer to 27 fewer) and the need for rescue medication for pain (666 fewer cases per 1000; 580 fewer to 752 more) in patients undergoing either laparoscopic or obstetrical/gynaecological surgeries. Among our eligible studies, there was no reported evidence on AEs. PROSPERO REGISTRATION NUMBER: CRD42016042838.

Spontaneous heterotopic triplet pregnancy with a two viable intrauterine embryos and an ectopic one with right tubal rupture / Gravidez heterópica tripla espontânea com dois embriões intrauterinos viáveis e um ectópico com ruptura da tuba uterina direita

Abstract Heterotopic pregnancy (HP) is defined as the simultaneous development of an intra- and an extra uterine gestation. The occurrence of a spontaneous triplet HP is an exceptionally rare medical condition. We report the case of a young woman with spontaneous heterotopic triplets at 8weeks of gestation, with amisdiagnosis of topic twins and acute appendicitis. The ectopic tubal pregnancy was ruptured and a salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed uneventfully. The two healthy babies were delivery by cesarean section at 36 ± 2 weeks of gestation. Heterotopic triplets with ruptured tubal ectopic pregnancy represent a special diagnostic and therapeutic challenge for the obstetrician. A high rate of clinical suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Resumo A gravidez heterotópica é definida como o desenvolvimento simultâneo de uma gestação intra- e extra-uterina. A ocorrência de gravidez tripla heterotópica espontânea é uma condição médica excepcionalmente rara. Relatamos o caso de uma jovem com gravidez tripla espontânea, às 8 semanas de gestação, com um diagnóstico errôneo de gêmeos tópicos e apendicite aguda. A gravidez tubária ectópica estava rota e uma salpingectomia foi realizada por laparotomia. A gravidez intrauterina progrediu sem intercorrências. Os bebês nasceramsaudáveis por cesariana realizada às 36 semanas de gestação.Agravidez de heterotópicos comectopia e rotura tubária é umdesafio diagnóstico e terapêutico.Umalto índice de suspeita e tratamento oportuno por laparotomia ou laparoscopia podem preservar a gestação intrauterina com um resultado bem sucedido da gravidez tópica.

Herbal medications for surgical patients: a systematic review protocol.

INTRODUCTION: Postoperative nausea and vomiting (PONV) affect approximately 80% of surgical patients and is associated with increased length of hospital stay and systemic costs. Preoperative and postoperative pain, anxiety and depression are also commonly reported. Recent evidence regarding their safety and effectiveness has not been synthesised. The aim of this systematic review is to evaluate the efficacy and safety of herbal medications for the treatment and prevention of anxiety, depression, pain and PONV in patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgical procedures. METHODS AND ANALYSIS: The following electronic databases will be searched up to 1 October 2016 without language or publication status restrictions: CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and LILACS. Randomised clinical trials enrolling adult surgical patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgeries and managed with herbal medication versus a control group (placebo, no intervention or active control) prophylactically or therapeutically will be considered eligible. Outcomes of interest will include the following: anxiety, depression, pain, nausea and vomiting. A team of reviewers will complete title and abstract screening and full-text screening for identified hits independently and in duplicate. Data extraction, risk of bias assessments and evaluation of the overall quality of evidence for each relevant outcome reported will be conducted independently and in duplicate using the Grading of Recommendations Assessment Development and Evaluation classification system. Dichotomous data will be summarised as risk ratios; continuous data will be summarised as standard average differences with 95% CIs. ETHICS AND DISSEMINATION: This is one of the first efforts to systematically summarise existing evidence evaluating the use of herbal medications in laparoscopic, obstetrical/gynaecological and cardiovascular surgical patients. The findings of this review will be disseminated through peer-reviewed publications and conference presentations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016042838.

Safety, efficacy, and acceptability of medical abortion in China, Cuba, and India: a comparative trial of mifepristone-misoprostol versus surgical abortion.

OBJECTIVE: We investigated safety, efficacy, and acceptability of an oral regimen of medical abortion compared with surgical abortion in three developing countries. STUDY DESIGN: Women (n = 1373) with amenorrhea < or = 56 days chose either surgical abortion (as provided routinely) or 600 mg of mifepristone followed after 48 hours by 400 micrograms of misoprostol. This is the appropriate design for studying safety, efficacy, and acceptability among women selecting medical abortion over available surgical services. RESULTS: The medical regimen had more side effects, particularly bleeding, than did surgical abortion but very few serious side effects. Failure rates for medical abortion, although low, exceeded those for surgical abortion: 8.6% versus 0.4% (China), 16.0% versus 4.0% (Cuba), and 5.2% versus 0% (India). Nearly half of failures among medical clients were not true drug failures, however, but surgical interventions not medically necessary (acceptability failures or misdiagnoses). Women were satisfied with either method, but more preferred medical abortion. CONCLUSION: Medical abortion can be safe, efficacious, and acceptable in developing countries.

PIP: A multi-center comparative study of medical compared to surgical abortion confirmed that medical abortion can be safe, effective, and acceptable in developing countries. A total of 1373 women from medical centers in China, Cuba, and India with pregnancies of 56 days' gestation or less were given the choice of surgical abortion or 600 mg of mifepristone followed after 48 hours by 400 mcg of misoprostol. Since the majority selected medical abortion, researchers in China and Cuba assigned some of these women to the surgical group to equalize the size of the two groups. The surgical abortion failure rates in China, Cuba, and India were 0.4%, 4%, and 0%, respectively, while the failure rates for medical abortion were 8.6%, 16.0%, and 5.2%, respectively. In all sites, both medical failures (an adverse effect resulting in a medically indicated surgical intervention) and acceptability failures (failure to complete the entire regimen) contributed substantially to the gross failure rates for medical abortion. Medical abortion failure rates increased with gestational age. Although cramping, nausea, and vomiting were more frequent among women in the medical abortion group and bleeding was heavier, general assessments of well-being reported at exit interviews did not differ between the two treatment groups at any site. Regardless of abortion method, the majority of women were either satisfied or highly satisfied with the procedure. In all countries, a higher number of medical than surgical abortion patients indicated they would opt again for the same procedure. Neither the bleeding pattern nor the higher failure rate associated with medical abortion justify withholding this option from women in developing countries.

[Mother-infant rooming-in and beginning of breast feeding in a tertiary care hospital]. / Alojamiento conjunto madre-hijo e inicio de amamantamiento, en un hospital de tercer nivel de atención.

OBJECTIVE: To establish a mother-baby's rooming-in program (RI) in a hospital that provides a tertiary level of care. MATERIAL AND METHODS: Babies born to healthy mothers were included, both delivered vaginally (P) and by cesarean section (C). Information was gathered on the cause for RI suspension, the type of infant's feeding and the mother's opinion about the program. RESULTS: Sixty-eight per cent of P infants and 98% of C infants participated in the program. The time from delivery to RI was uncovered; for P babies it was 5.8 hours and for C babies it was 17 hours. The RI was suspended in 1% of P and 6.7% of C infants, but with no justifiable medical reason in the infants. The mother's opinion about RI was very favorable. Only 50% of the infants started breast feeding within the first 6 hours after birth; however, all of them were breastfed at the time of discharge. CONCLUSIONS: It is possible to establish RI and initiate breast feeding in a tertiary care hospital, even in mothers with cesarean section.

PIP: The objective of this study was to establish a mother-baby rooming-in program (RI) in a hospital that provides a tertiary level of care. Babies born to healthy mothers were included, both delivered vaginally (P) and by cesarean section (C). Information was gathered on the cause for RI suspension, the type of infant feeding, and the mother's opinion about the program. 68% of P infants and 98% of C infants participated in the program. The time from delivery to RI was determined; for P babies it was 5.8 hours and for C babies it was 17 hours. The RI was suspended in 1% of P and 6.7% of C infants, but with no justifiable medical reason. The mothers' opinion about RI was very favorable. Only 50% of the infants started breast feeding within the first 6 hours after birth; however, all of them were breast feeding at the time of discharge. The authors conclude that it is possible to establish RI and initiate breast feeding in a tertiary care hospital, even in mothers who had a cesarean section.

Multidisciplinary experience in the selection of patients for tubal sterilization.

Results of the use of a special protocol for evaluation of patients requiring tubal ligation is presented after applied by a multidisciplinary group. The authors conclude that the use of defined parameters of age, parity, marital union duration, number of children alive and the presence of maternal clinical pathology are useful to identify patients with smaller chances of regret after surgery.

PIP: 27% of reproductive-age women in Brazil have chosen surgical sterilization as their contraceptive method. Most of these women who have undergone tubal sterilization opted for cesarean surgery. However, given the young ages of many of these women, many regret having been sterilized. This paper summarizes the experience of a multidisciplinary group in evaluating women who apply for surgical sterilization at the Department of Tocogynecology, Faculdade de Ciencas Medicas, Universidade Estadual de Campinas in Sao Paulo. Detailed descriptions are presented of the medical and social characteristics of cases seen between June 1988 and July 1989. The authors conclude that the use of the defined parameters of age, parity, marital union duration, number of living children, and the presence of maternal clinical pathology are useful in identifying the patients who are least likely to regret undergoing surgical sterilization.

[IUD insertion during cesarean section and its most frequent complications]. / DIU transcesárea y sus complicaciones más frecuentes.

A prospective and cooperative study was done in 152 patients that were submitted to cesarean section. Seventy eight patients received intrauterine device (IUD) T CU 220 during cesarean section, and the other 74 patients only got the cesarean section without IUD. The events that were analyzed during the puerperium were pain, bleeding and infection. We didn't find any difference in the results between both groups, these were analyzed with the help of the square chi (X2). These results suggest that with an adequate selection of the patients, the insertion of the IUD during the cesarean section is a secure and helpful method for the fertility control for patients with high risk of reproduction.

PIP: 78 women were fitted with copper T 220 IUDs during cesarean deliveries at a Mexican Institute of Social Security hospital in Cardenas, Tabasco, between August 1991 and December 1992 in a study of the suitability of IUD insertion during cesareans. A control group consisted of 74 women undergoing cesarean deliveries who did not have IUDs inserted. The average age was 20.6 years for IUD acceptors and 24.9 years for controls. The average number of pregnancies including the current one was 1.3 for the IUD group and 3.2 for the control group. Average gestational age at the time of delivery was 38.5 weeks for the IUD group and 40.1 weeks for the control group. The indication for cesarean was fetopelvic disproportion for 51.2% of the IUD group and 40.5% of controls. The volume of bleeding was normal for 98.7% of IUD acceptors and all in the control group. The IUD was vaginally removed two hours postpartum in the one IUD acceptor with postpartum hemorrhage. The average duration of bleeding was 23.8 days for the IUD group and 22.0 days for the control group. Pain during the postpartum period was described as light for 91.0% and moderate for 9.0% in the IUD group and as light for 93.2% and moderate for 6.8% in the control group. Four cases of endometritis (5.1%) were observed in the IUD group. Three cases of endometritis and one of abscess of the abdominal incision were observed in the control group, for an overall infection rate of 5.4%. One IUD expulsion occurred on the fifteenth postpartum day, for a rate of 1.28%. The strings could be seen in only 21.7% of cases at the six-week check-up. The IUD was visualized by X-ray for 71.7% at the control visit. IUD insertion did not significantly increase postoperative pain, hospital stay, the volume or duration of bleeding, or frequency of infection. The results suggest that IUD insertion during cesarean is a safe and effective method of fertility control for patients at high reproductive risk.

Prevalence and determinants of caesarean section in Jamaica.

The prevalence and determinants of primary caesarean section in Jamaica were estimated from a survey of women aged 14-49 years. Among 2328 women reporting 2395 live hospital births during the period January 1984 to May 1989, the prevalence of caesarean section was 4.1%. Repeat caesarean sections accounted for 1.3% of the hospital births during that period. Of the medical complications studied, prolonged labour and/or cephalopelvic disproportion carried the highest risks of primary caesarean section, followed by breech presentation, maternal diabetes, a high birth-weight baby, maternal hypertension, and a low birth-weight baby. The risk of primary caesarean section increased with maternal age, decreased with parity, was higher for urban than for rural residents, and was higher for births in private versus government hospitals.

PIP: Researchers analyzed data on 2395 hospital births which occurred to 2328 14-49 year old women between January 1984 and May 1989 living in 7 parishes of Jamaica to determine the prevalence and factors of cesarean section. The primary cesarean section rate for the 5.5-year period was 4.1% which is lower than the rates of some developing countries and of some developed countries such as the US. The repeat cesarean section rate was 1.3%. Cephalopelvic disproportion and/or prolonged labor (abnormal labor) accounted for 17.4% of all primary cesarean sections. Abnormal labor carried the greatest risk of primary cesarean section (logistic regression model beta=1.9). Other delivery complications which posed considerable risk of cesarean section included breech presentation (beta=1.68), maternal diabetes (beta=0.84), maternal hypertension (beta=0.47), large birth weight infant (beta=0.4), and low birth weight infant (beta=-0.15). These complications made up 22.3%, 7.1%, 7.4%, and 5.3% of all primary cesarean sections, respectively. Nonmedical determinants of primary cesarean section included 30-year old women (beta=1.04), 1-2 births (beta=-1.27), urban residence (beta=0.75), and delivering in a private hospital (beta=0.59). 5.3% of 30-year old mothers underwent a cesarean section compared with 3.8% of 30-year old mothers. 5.2% of women of parity 1-2 had a cesarean section whereas only 2.3% of those of parity =or 3 did. Urban mothers were more likely to have a cesarean section than were rural mothers (5.4% vs. 3.3%). 7.6% of mothers delivering at a private hospital underwent a cesarean section compared with 3.9% of those delivering at a government hospital. Well-designed studies of infant mortality in Jamaica can determine whether the country can attain low levels of early infant mortality while keeping its current low rate of cesarean section.

IPPF Brazil program confronts sterilization accusations.

PIP: Even though Brazil's BEMFAM program stopped providing sterilization services over a year ago, many sources hostile to BEMFAM in the Brazilian government are still accusing it of misconduct. BEMFAM is sponsored by the International Federation of PLANNED Parenthood and was investigated and cleared of any wrong doing by the Brazilian government. In Brazil it is against the law to perform sterilization for the purposes of birth control, yet it is estimated that there are between 6-20 million such operations each year. Over 65% of the births in Brazil are by Caesarian section and it is common for women to ask their doctors to perform a tubal ligation at the same time. Abortion is illegal in Brazil, but there are an estimated 1.4-2.4 million abortions each year. 56% of Brazilian women use contraceptives, with 90% using either the pill or illegal sterilization. 90% of those who use the pill obtain it over the counter at pharmacies with inadequate knowledge on how to use it. 80% of the people receive their health care from the Brazilian government.^ieng

Maternal mortality at Mount Hope Women's Hospital, Trinidad.

A ten-year survey of the magnitude and causes of obstetrical deaths at Mount Hope revealed a maternal mortality rate of 33.3 per 100,000 live births. The leading causes of death were the hypertensive disorders, and the most common identifiable factors were inadequate antenatal care and substandard clinical management.

PIP: Obstetrical deaths at the Mount Hope Women's Hospital, Trinidad, were reexamined from records over 1981-1990, and discussed under the categories poor prenatal care, clinical management or provision of medical facilities. There were 19 obstetrical deaths out of 57,012 live births, giving a maternal mortality rate of 33.3/100,000 in this tertiary care hospital. Most of the deaths occurred in women aged 30-34, para 5 or more. 73.7% were related to hypertension in pregnancy, 8 with severe eclampsia and 6 with eclampsia, and the other 5 were due to placental abruption, postpartum hemorrhage, anesthesia complication, acute fatty liver and amniotic fluid embolism. Cases classified as substandard care included the 14 women with hypertensive disorders, none of whom had antenatal care at this specialized unit. In 3 referral by the practitioner was delayed, and 3 others did not comply. A woman listed under failed medical facilities had massive abruptio placenta, and no fresh blood was available, and another had an anaphylactic reaction to a mismatched blood transfusion. Other avoidable deaths were 3 associated with general anesthesia: one woman having emergency cesarean section for severe pre-eclampsia had anoxia and severe brain damage; another short, obese woman had cardiac arrest during a failed attempt at endotracheal intubation; a third died from aspiration of gastric fluid. The high mortality among women with hypertensive disorders is regrettable, considering lack of referral to this specialized unit, but the prognosis of eclamptics even with expert aggressive treatment is poor. This maternal mortality rate ranks midway between those of developed countries and developing countries. It is about four times that of the U.S.

Epidemic of caesarean sections in Brazil.

Brazil has one of the highest rates of caesarean section in the world. Patterns of caesarean sections were studied in a cohort of 5960 mothers followed from 1982 to 1986 in southern Brazil. Overall, 27.9% were delivered by caesarean section in 1982, this proportion being 30% for nulliparae, 80% for second deliveries when the first was by caesarean, and over 99% for third births when the first two were by caesarean. Socioeconomic status and requests for sterilisation by tubal ligation were important underlying factors. 9.4% of the women were sterilised during a caesarean section (3.7% in the lowest income group and 20.2% in the highest). 31% of women who had had their first child by a caesarean section and who were having a second operative delivery were sterilised. The high rates of caesarean sections and accompanying sterilisations reflect the lack of appropriate reproductive and contraceptive policies in the country.

Early neonatal mortality and cesarean delivery in Mexico City.

The relationship between cesarean delivery and neonatal mortality is presented with information from 292 early neonatal deaths (cases) and 3098 survivors (controls) born in 25 hospitals in Mexico City during the summer of 1984. The overall rate of cesarean delivery was 27%. Variations between health agencies and different social groups were not related to obstetric risk, suggesting that a sizable proportion of the operations were probably unjustified. Babies of normal birth weight (greater than or equal to 2500 gm) delivered by cesarean section were 2.5 times more likely to die in the early neonatal period compared with vaginally delivered babies of the same weight. The excess of mortality could not be explained by the effect of maternal characteristics or complications or by differences in birth weight or gestational age. It is suggested that the conditions under which the operation was performed probably explain the increased risk of early neonatal death. It is likely that poor quality of resuscitation and respiratory care are implicated in the link between "unnecessary" cesarean section and early neonatal mortality.

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.

Subsequent pregnancies: who has them and who wants them? Observations from an urban center in southern Brazil.

Subsequent pregnancies in mothers of a birth cohort from Pelotas, Southern Brazil, were studied in relation to maternal and socio-economic factors. Within about 3 1/2 years of the cohort child's birth, 39% of mothers had experienced at least one further pregnancy. This proportion decreased with increasing maternal age, years of schooling and family income. A U-shaped trend was observed with respect to parity. Mothers who had delivered the cohort child by caesarean section were also less likely to have another pregnancy within that time. Logistic regression analysis showed that each of these factors remained significantly associated with further pregnancies after controlling for the remaining variables. Analysis of the first subsequent pregnancy showed that a high proportion of mothers had not wanted the pregnancy. Unwanted pregnancies were also significantly associated with older women, low educational status, higher parity and low family income.

PIP: Researchers followed 5914 children born in 1982 in Pelotas, an urban center in southern Brazil, and interviewed the mothers about subsequent pregnancies between 35-52 months of the cohort child's age to gather data on these pregnancies. 39% of the mothers had at least 1 pregnancy after the cohort child. 78% of them had =or+ 1 child while the remainder had at least 1 abortion. Additional pregnancies occurred more often among lower income women (p.001). In addition, as age and years of schooling rose, the number of subsequent pregnancies fell (p =or- .001). If the cohort child was the 3rd child, the mother was less likely to have a subsequent pregnancy, but the odds ratio fell up to the 3rd child then increased (p.001). This U shaped trend was especially pronounced after adjusting for other factors. A possible explanation for this trend could be due to desired family size and access to sterilization. Other than women who had undergone sterilization, women who delivered their cohort child by cesarean section were least likely to have a subsequent birth, even after adjusting age, income, parity, and education (p.001). This may be due to fear of surgery or these women followed medical advice. The percentage of women who did not want the subsequent pregnancy fell as income, education, and age climbed (p.001). Moreover it increased with parity, especially among richer women. In fact, women of high parity and high income were more likely to have experienced an unwanted subsequent pregnancy than those of high parity and moderate and low income (p.01).

Cesarean section.

PIP: The leading cause of maternal mortality and morbidity in developing countries is the lack of cesarean section deliveries due to the tremendous logistical, cost, and training problems associated with this procedure. This article describes the need for raising cesarean section rates in developing countries and what can be done with existing inadequate health care in these countries to increase these rates. 5 to 10% of all births should be done by cesarean section, yet only 0.3% of births in rural Zaire are cesarean sections. To help educate health officials about women who may need a cesarean section, this article provides: 5 basic warning signs of pregnancy complications, characteristics of high risk women, and women in their 3rd trimester who need to be referred. Crucial factors that delay mothers from getting prenatal care include cultural obstacles and undereducated traditional birth attendants. Complication signs include severe vomiting, swelling of face, feet and hands, vaginal bleeding, headache and fever. High risk mothers are age 18 or 35 years, have had 5 or more previous births, and under 150 cm. in height, experienced an abortion or stillbirth with previous pregnancy or delivered by cesarean section, had previous cephalo-pelvic disproportion or in labor 12 hours, or has chronic medical problems. Third trimester women experiencing or developing hypertensive diseases, non-vertex presentation, severe anemia, multiple birth or antepartum bleeding should be referred to a health center where a cesarean can be done if necessary.^ieng

[Women's health]. / Saude da mulher.

PIP: The National Council of Women's Rights (CNDM) launched a campaign to improve the prevailing low level of health of Brazilian women. This is especially appropriate in view of feminine holidays: March 8 is International Day and April 30 is the National Day of Women. The components of a systematic gynecological assistance program should focus on pregnancy, delivery, and puerperium, maternal nursing, menopause and infertility, and regulation of fertility. Health is a fundamental right, but despite this in 1988 40% of the 2.8 million births occurred via cesarean section, most of which were unnecessary. 20% of women under 25 are sterilized based on disinformation. Maternal morality is extremely high: 100/100.00 births vs. 8-10 in developed countries, and 35 in Costa Rica, 40 in Cuba, 49 in Uruguay, and even in El Salvador it is 71/100.000. Gynecological and obstetrical programs should identify problems related to multiparity, less than 18 months between pregnancies, late or early pregnancies (under 20 or over 35 years of age), and those vulnerable should receive the requisite medical attention. Family planning services have the task of eliminating biological risks of pregnancy, disseminating information about fertility control, considering abortion as a public health issue, and calling attention to the distortion inherent in existing fertility regulations.^ieng

Peru 1986: results from the Demographic and Health Survey.

PIP: The Peru Demographic and Health Survey, conducted in 1986-87, collected data from 4666 households and included complete interviews with 4999 women 15-49 years of age. The survey was national in scope, covering 93% of the population. This article presents summary statistics from the survey. The 26 tables and figures that comprise this article cover the following topics: general characteristics of the population; distribution of survey sample population by socioeconomic characteristics; fertility trends; fertility differentials, 1983-85; age-specific fertility; ideal number of children by age and number of living children for currently married women; desire to stop childbearing among currently married women; planning status of births in last 12 months, by birth order; contraceptive prevalence differentials; contraceptive prevalence by age and parity; source of current method or information about method; knowledge and use of methods among currently married women; nonuse among exposed currently married women by desire for more children; reasons for nonuse among exposed nonusers; current marital status; differentials in age at 1st union; exposure status of currently married women; duration of postpartum interval by current status; differentials in breastfeeding and amenorrhea; postpartum status by duration since birth; infant mortality trends; infant mortality differentials, 1981-86; children ever born and surviving; percent of children under 5 years of age with health card, and percent immunized; prevalence and treatment of diarrhea among children under 5 years of age; and type of assistance during delivery for births in 5 years prior to survey. The ideal number of children averaged 2.8 among survey respondents. 46% of respondents were current users of a contraceptive method.^ieng

[Premature rupture of membranes and chorioamnionitis]. / Ruptura prematura de membranas y corioamnionitis.

PIP: Despite advances in perinatal medicine in the past decade, the diagnosis and treatment of premature rupture of membranes remain controversial. Premature rupture occurs in 2.7-7.0% of pregnancies and most cases occur spontaneously without apparent cause. The disparity in reported rates of premature rupture is due to differences in the definition and diagnostic criteria for premature rupture and lack of comparability in the populations studied. Mexico's National Institute of Perinatology has adopted the definition of the American COllege of Gynecology and Obstetrics which views premature rupture as that occurring before regular uterine contractions that produce cervical dilation. 8.8% of its patients have premature rupture according to this definition. 20% of cases occur before the 36th week of pregnancy. Treatment of rupture occurring before 37 weeks must balance the threat of amniotic infection with the dangers of premature birth. Infections appear more common in low income patient populations. Chorioamnionitis is a serious complication of pregnancy and is the main argument against conservative treatment of premature rupture. The rate of maternal infection is directly related to the time elapsing between rupture of the membranes and birth. The rate increases after the 1st 24 hours and is at least 10 times higher after 72 hours. But recent studies suggest that there is no considerable increase in infection if vaginal explorations are avoided and careful techniques are used in treating the patient. Those who advise conservative treatment believe that prenatal outcomes are better because respiratory disease syndrome due to prematurity is avoided. Conservative management requires a white cell count at least every 24 hours and measurement of pulse, maternal temperature, and fetal heart rate ideally every 4 hours. Perinatal mortality rates due to premature rupture of membranes range from 2.5-50%. The principal causes are respiratory disease syndrome, infection, asphyxia, and congenital malformations. Neonatal sepsis occurs in about 5% of live births following premature rupture, but the rate triples after 24 hours, especially in premature infants. The rate of neonatal asphyxia also increases considerable after 24 hours. Congenital malformations, prolapse of the cord, and pelvic presentation are positively associated with premature rupture of membranes. If the decision is made to interrupt the pregnancy, it should be done between 12-24 hours after rupture because the risks of infection and respiratory difficulty are most balanced at that point. Vaginal deliveries should be preferred only if conditions are favorable for a prompt delivery. The gestational age, presence of infection, obstetric condition of the mother, and indication for hysterectomy are the most important points to consider i management of premature rupture.^ieng

Utilization of health services by Mexican immigrant women in San Diego.

The limited empirical data available on maternal health problems among Mexican immigrant women in the United States suggest that they underutilize health services, especially general preventive care. Research conducted among legal and undocumented women in the Mexican immigrant population in San Diego, California, support these findings. Among undocumented mothers, 11.5% of their births in the U.S. occurred with no prenatal care or care sought in the third trimester, which is much higher than Mexican women legally in the country (3.6%) and the general San Diego maternal population (3.8%). When we examine births which occurred within the last five years by immigration status, we find that women legally in the country have a much higher rate of cesarean delivery of both undocumented women and women in the general San Diego maternal population. Undocumented women in our sample were much less likely than their legal counterparts to return for postpartum examinations for themselves, to seek neonatal care for their infants, and to have had Pap examinations or carry out breast self-examinations.

PIP: Between March 1981 and February 1982, personal in-home interviews were conducted with 2,103 adults born in Mexico who were living or working in San Diego County, California, regardless of their legal status in the US. Both documented, (legal) and undocumented respondents exhibited a number of socioeconomic characteristics which could influence their utilization of US medical services. The data indicate that underutilization of prenatal care exists in this population. Among undocumented mothers, 11.5% of their births in the US occurred with no prental care sought in the 3rd trimester, which is much higher than Mexican women legally in the country (3.6%) and the general San Diego maternal population (3.8%). When births which occurred within the last 5 years are examined by immigration status, it is found that women legally in this country have a much higher rate of cesarean delivery for both undocumented women and women in the general San Diego maternal population. Undocumented women in our sample were much less likely than their legal counterparts to return for postpartnum examinations for themselves, to seek neonatal care for their infants, and to have had Pap examinations or carry out breast self-examinations.

[Pregnancy in the adolescent. IV. Borderline reproductive age risk among adolescents]. / Gravidez na adolescencia. IV. Idade limite de risco reprodutivo entre adolescentes.

PIP: This study examined the cases of 557 primiparous adolescents, between the ages of 9 and 19, who gave birth at the Obstetric Clinic of the Medical School of the University of Sao Paulo, Brazil, from January 1975 to June 1980. During this period 13,961 deliveries took place, producing an adolescent pregnancy incidence of 3.9%. Based on previous work, 2 groups were established: Group I, composed of 242 women aged 9 to 16, and Group II, composed of 315 women aged 17 to 19. The greatest number of unwed mothers occurred in Group I, the younger age group (98.4%), compared to 54.3% in Group II. An important characteristic in the younger age group was lack of adequate prenatal care. In Group I only 12% received adequate prenatal care, while in Group II, 28.6% received adequate care. Clearly the greatest frequency of prematurity was in the younger group (28.1% of Group I vs. 12.4% of Group II), along with a higher rate of perinatal mortality (4.9% in Group I vs. 2.5% in Group II). Cases of eclampsia occurred more frequently in the younger adolescents (3.3% of Group I vs 1.6% of Group II), but hypertension was more prevalent among the older adolescents (35.9% in Group II vs. 22.7% in Group I). The authors conclude that during pregnancy all adolescents reach similar biologic and endocrine maturity and display similar obstetric performance. The less satisfactory performance among patients in Group I is primarily due to socioeconomic conditions, inadequate resolution of problems related to acceptance of pregnancy, lack of family support, and inadquate prenatal care. The authors believe that the risks associated with adolescent pregnancy could be substantially reduced if adolescents were better informed and received psychological support and adequate prenatal care.^ieng