Aurélio Antônio Ribeiro Costa

Mortalidade materna na cidade do Recife

Purpose: to determine the Maternal Mortality Ratio (MMR) among women living in the city of Recife, Brazil through the analysis of all death certificates of women aged 10-49 years from 1994 to 2000. To determine the underreporting rate and to study the main characteristics, basic causes, classification and avoidance of maternal deaths. Methods: a descriptive population-based study was conducted and all death certificates of women aged 10-49 years were analyzed and classified as declared or presumed (Laurenti criteria). Clinical records and autopsy data, when available, were studied and basic cause and underreporting rate were determined. Maternal Mortality Ratio was calculated using information on live births from SINASC (Sistema de Informacoes dos Nascidos Vivos). Results: a total of 144 maternal deaths were identified (declared=104; presumed and confirmed after investigation=44). The Maternal Mortality Ratio was 75.5 per 100,000 live births. The underreporting rate was 27.8%. A predominance of direct causes was observed (about 69%) and the most frequent causes of death were hypertension (19%), hemorrhage (16%) and infection (11%). About 82% of the deaths were considered avoidable by adequate antenatal, delivery and post-partum care. Conclusions: Maternal Mortality Ratio is high in the city of Recife, Brazil and the underreporting rate is still high. Direct obstetric causes and avoidable deaths are predominant. There is a lack of adequate antenatal, delivery and post-partum care.

Vaginal Misoprostol Prior to Diagnostic Hysteroscopy in Patients of Reproductive Age: A Randomized Clinical Trial

STUDY OBJECTIVEnTo assess pain during and after diagnostic hysteroscopy in patients of reproductive age according to use of vaginal misoprostol.nnnDESIGNnA randomized, triple-masked, controlled clinical trial (Canadian Task Force classification I).nnnSETTINGnDiagnostic center at Instituto Materno Infantil de Pernambuco-Brazil.nnnPATIENTSnA total of 45 women of reproductive age underwent diagnostic anesthesia-free hysteroscopy.nnnINTERVENTIONSnIn all, 400 mg of vaginal misoprostol or placebo was administered to randomized patients before diagnostic hysteroscopy.nnnMEASUREMENTS AND MAIN RESULTSnThe clinical trial was interrupted in patients receiving misoprostol because of significant vaginal bleeding precluding the procedure (p = .0006). No significant difference existed in pain scores between the groups. Vaginal bleeding was the main side effect occurring in 11 patients of the misoprostol group. No vaginal bleeding occurred in the placebo group (p = .00002).nnnCONCLUSIONnIn the doses used, vaginal misoprostol induced vaginal bleeding and precluded diagnostic hysteroscopy in patients of reproductive age that limits continuation of this line of research. Further studies are needed to reassess the use of the drug in patients of this age group.

Óbitos fetais e neonatais entre casos de near miss materno

OBJECTIVEnTo determine the prevalence of fetal and neonatal deaths among patients with maternal near miss and the factors associated with this fatal outcome.nnnMETHODSnThe authors conducted a descriptive, cross-sectional, analyzing medical records of patients admitted to the ICU of a tertiary obstetric Recife (Brazil), between January 2007 and December 2010, who had at least one criterion of near miss defined by WHO. Statistical analysis was performed with Epi-Info 3.3.2, using chi-square and Fishers exact test, considering a significance level of 5%. For multivariate analysis was constructed as a hierarchical model with the response variable fetal and neonatal deaths.nnnRESULTSnWe included 246 cases of maternal near miss. Among women in the study, hypertensive disorders occurred in 62.7% to 41.2% in HELLP syndrome and the laboratory criteria for near miss in 59.6%. There were 48 (19.5%) stillbirths and 19 (7.7%) neonatal deaths. After analyzing the variables that remained statistically associated with fetal and neonatal deaths were: severe preeclampsia, placental abruption, endometritis, cesarean delivery, prematurity and the laboratory criteria for maternal near miss.nnnCONCLUSIONnThe high incidence of fetal and neonatal deaths among patients with maternal near miss. Among these women there is an overlap of factors contributing to this fatal outcome, in our study, those who had severe preeclampsia, placental abruption, endometritis, premature birth or laboratory criteria positively associated with deaths.

Transdermal nitroglycerin versus oral nifedipine administration for tocolysis: a randomized clinical trial.

PURPOSEnto compare the effectiveness of transdermal nitroglycerin with oral nifedipine in the inhibition of preterm delivery.nnnMETHODSna clinical essay has been performed with 50 women in preterm delivery, randomly divided into two groups, 24 receiving oral nifedipine (20 mg), and 26, transdermal nitroglycerin (10 mg patch). Patients with a single gestation, between the 24th and the 34th weeks and diagnosis of preterm delivery were selected. Women with fetal malformation and clinical or obstetric diseases were excluded. The variables analyzed were: effective tocolysis, time needed for tocolysis, recurrence frequency, progression to preterm delivery, and side effects.nnnRESULTSntocolysis efficacy in the first 12 hours was similar between the groups (nitroglycerin: 84.6% versus nifedipine: 87.5%; p=0.50). The time average time needed for tocolysis was also similar (6.6 versus 5.8 hours; p=0.30). There was no difference between the groups, concerning the recurrence of preterm delivery (26.9 versus 16.7%; p=0.30), and neither in the rate of preterm delivery within 48 hours (15.4 versus 12.5%; p=0.50). Nevertheless, the cephalea rate was significantly higher in the Nitroglycerin Group (30.8 versus 8.3%; p=0.04).nnnCONCLUSIONSntransdermal nitroglycerin has presented similar effectiveness to oral nifedipine to inhibit preterm delivery in the first 48 hours, however with higher cephalea frequency.PURPOSE: to compare the effectiveness of transdermal nitroglycerin with oral nifedipine in the inhibition of preterm delivery. METHODS: a clinical essay has been performed with 50 women in preterm delivery, randomly divided into two groups, 24 receiving oral nifedipine (20 mg), and 26, transdermal nitroglycerin (10 mg patch). Patients with a single gestation, between the 24th and the 34th weeks and diagnosis of preterm delivery were selected. Women with fetal malformation and clinical or obstetric diseases were excluded. The variables analyzed were: effective tocolysis, time needed for tocolysis, recurrence frequency, progression to preterm delivery, and side effects. RESULTS: tocolysis efficacy in the first 12 hours was similar between the groups (nitroglycerin: 84.6% versus nifedipine: 87.5%; p=0.50). The time average time needed for tocolysis was also similar (6.6 versus 5.8 hours; p=0.30). There was no difference between the groups, concerning the recurrence of preterm delivery (26.9 versus 16.7%; p=0.30), and neither in the rate of preterm delivery within 48 hours (15.4 versus 12.5%; p=0.50). Nevertheless, the cephalea rate was significantly higher in the Nitroglycerin Group (30.8 versus 8.3%; p=0.04). CONCLUSIONS: transdermal nitroglycerin has presented similar effectiveness to oral nifedipine to inhibit preterm delivery in the first 48 hours, however with higher cephalea frequency.

Infecção por Chlamydia em pacientes com e sem lesões intra-epiteliais cervicais

OBJECTIVES: To determine the frequency of Chlamydia trachomatis infection in patients with and without intraepithelial cervical lesions attended at specialized ambulatory in Recife (2007) and its association with biologic and demographic variables, habits, reproductive, clinical and gynecologic characteristics. METHODS: A cross-sectional study was conducted including 70 women (35 with cytological cervical lesions and 35 with normal smears). Colposcopy and biopsy when necessary were performed and Chlamydia infection was determined by direct immunofluorescence. Analysis variables were age, race, precedence, schooling, marital status, menarche, age at first sexual intercourse, parity, number of sexual partners, vaginal discharge, previous Pap smear, STD episodes, cervical cauterization, contraceptive methods, familial antecedents of cervical cancer, alcohol intake, use of illicit and immunosuppressive drugs, Papanicolaou result and cervical Chlamydia l infection. To determine the strength of association prevalence ratio (PR) and its 95% confidence interval were calculated. Multivariate analysis was performed for controlling potentially confounding variables. RESULTS: the frequency of Chlamydia l infection was significantly greater in patients with intraepithelial cervical lesions (80.0% vs. 14.3%; PR = 5.60; 95% CI = 2,44 - 12,82). When the factors associated with Chlamydia l infection were analyzed, the only variable that remained significantly associated after multivariate analysis was previous episode of STD (OR=63,47; 95% CI = 13,93 - 289,09). CONCLUSION: Chlamydia trachomatis infection is associated with intraepithelial cervical lesions and history of STD should be considered for treatment and follow-up of these patients.

Maternal near miss in the intensive care unit: clinical and epidemiological aspects

Objective To analyze the epidemiological clinical profile of women with maternal near miss according to the new World Health Organization criteria. Methods A descriptive crosssectional study was conducted, in which the records of patients admitted to the obstetric intensive care unit of a tertiary hospital in Recife (Brazil) over a period of four years were analyzed. Women who presented at least one near miss criterion were included. The variables studied were age, race/color, civil status, education, place of origin, number of pregnancies and prenatal consultations, complications and procedures performed, mode of delivery, gestational age at delivery, and maternal near miss criteria. The descriptive analysis was performed using the program Epi-Info 3.5.1. Results Two hundred fifty-five cases of maternal near miss were identified, with an overall ratio of maternal near miss of 12.8/1,000 live births. Among these cases, 43.2% of the women had incomplete primary education, 44.7% were primiparous, and 20.5% had undergone a previous cesarean section. Regarding specific diagnoses, there was a predominance of hypertensive disorders (62.7%), many of which were complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (41.2%). The laboratory near miss criteria were the most often observed (59.6%), due mainly to the high frequency of acute thrombocytopenia (32.5%). Conclusions A high frequency of women who had a low level of education and who were primiparous was observed. According to the new criteria proposed by the World Health Organization, hypertensive pregnancy disorders are still the most common among maternal near miss cases. The high frequency of HELLP syndrome was also striking, which contributed to acute thrombocytopenia being the most frequent near miss criterion.

Histerectomia vaginal versus histerectomia abdominal em mulheres sem prolapso genital, em maternidade-escola do Recife: ensaio clínico randomizado

PURPOSE: to compare intra- and postoperative results of vaginal hysterectomy with those of abdominal hysterectomy in women without genital prolapse or adnexal pathology. METHODS: a randomized, open clinical trial was conducted, involving 35 patients without genital prolapse scheduled for total hysterectomy due to benign disease, at IMIP, Recife, Brazil. These patients were randomly assigned to vaginal hysterectomy (19 patients) or abdominal hysterectomy (16 patients). Main outcome measures included estimated blood loss, rate of blood transfusion, duration of surgery, postoperative pain (intensity and analgesic requirement), time in hospital, postoperative complications, recovery time and patient satisfaction. Statistical analysis was performed using c2, exact Fisher and Mann-Whitney tests at a 5% level of significance. RESULTS: estimated blood losses were significantly lower in vaginal hysterectomy (median of 520 mL) than in abdominal hysterectomy (median 902 mL). There was no blood transfusion among patients of the vaginal hysterectomy group, in contrast to 19% of the abdominal hysterectomy group. Duration of surgery was similar (median of 120 min in both groups). Postoperative pain, as measured by visual analog scale and analgesic requirement, was lower for vaginal hysterectomy than for abdominal hysterectomy. There was no statistically significant difference regarding frequency of postoperative complications. There was one case of infection in each group and one case of thrombosis in the vaginal hysterectomy group. Postoperative hospital stay was shorter in the vaginal group. Recovery time was significantly shorter in the vaginal group (median of 35 days) versus the abdominal group (median 40 days). Overall patient satisfaction with the operation was similar in the two groups. CONCLUSIONS: patients without genital prolapse submitted to vaginal hysterectomy for treatment of benign diseases had some advantages in relation to those submitted to abdominal hysterectomy: lower intraoperative blood loss, lower postoperative pain and faster recovery time. Vaginal hysterectomy may replace abdominal hysterectomy in most patients who require hysterectomy.

Fatores associados à bacteriúria após sondagem vesical na cirurgia ginecológica

OBJETIVOS: Determinar a frequencia e os principais fatores associados a bacteriuria apos a sondagem vesical em mulheres submetidas a cirurgia ginecologica eletiva. METODOS: Realizou-se um estudo do tipo coorte em mulheres submetidas a cirurgia ginecologica apos sondagem vesical no Instituto de Medicina Integral Prof. Fernando Figueira, no periodo de janeiro a maio de 2007. As uroculturas foram coletadas ate 24 horas apos a retirada da sonda e 7/10 dias apos a sondagem vesical. A analise estatistica bivariada e multivariada foi realizada calculando-se a razao de risco e os seus intervalos de confianca a 95%. RESULTADOS: Foram incluidas no estudo 249 mulheres. A frequencia de uroculturas positivas ate 24 horas depois da retirada da sonda foi de 23,6%, diminuindo para 11,1% 7/10 dias apos a sondagem. Destas, apenas 2,4% eram sintomaticas. Verificou-se menor risco de bacteriuria com 7/10 dias apos a sondagem vesical quando a paciente referiu vulvovaginite tratada nos ultimos tres meses, nao permanecendo estatisticamente significativa apos a analise multivariada. Nao houve associacao significativa com idade, escolaridade, numero de gestacoes, paridade, fase da vida reprodutiva, tipo e duracao da cirurgia, tipo da anestesia, uso de antibiotico profilatico, profissional que colocou a sonda e o tempo de permanencia da sonda vesical. CONCLUSAO: A frequencia de bacteriuria foi de 23,6% e 11,1% com 24 horas e 7/10 dias, respectivamente. Nao se encontrou associacao significativa das variaveis pesquisadas com a bacteriuria evidenciada na urocultura com 7/10 dias.

Achados de laparoscopias ginecológicas realizadas em mulheres com dificuldade reprodutiva atendidas em um hospital-escola: série de casos

PURPOSE: to identify the main characteristics of the diagnostic and surgical gynecological laparoscopies carried out in patients with reproductive difficulties at a teaching hospital in Recife, from 2000 and 2004. METHODS: a hospital based descriptive case-series study was carried out with 295 patients who had undergone gynecological laparoscopy for either infertility or tube recanalization in the Mother and Child Health Professor Fernando Figueira Institute. Information was obtained from the surgical records of the laparoscopies carried out from January 2000 to December 2004. The inclusion criteria was infertility or pre-recanalization study as a surgical indication. The information was typed twice into a data bank. Tables with central measurements and dispersion tendency were created for the quantitative variables and frequency distribution for the categorical variables. The statistical program, Epi Info 3.3.2., was used to analyze the data. RESULTS: along the study, 462 gynecological laparoscopies were analyzed, 295 (63.8%) of them having as an indication either infertility (41.1%) or the study of possible tube recanalization (18.8%). The patientsx92 average age in both groups was from 30 to 34 years old. Among the 87 patients with desire of tube recanalization, 55.2% had one or both tubes inadequate for the procedure, and from those, 52.1% was diagnosed with tube amputation (fimbrectomy). In the infertility cases, the most observed findings were adherences (60.6%), tube obstruction (40.9%) and endometriosis (36.1%). Among the procedures carried out, lysis of adherences (34.2%) and biopsies (21%) were the most frequent, followed by endometriosis treatment (10.8%) and salpingostomy (10.8%). CONCLUSION: videolaparoscopy is an important tool in the study and treatment of patients with infertility and before tube recanalization, especially in those hospitals where advanced reproductive techniques are not available.