Claudio Sosa

Risk Factors for Postpartum Hemorrhage in Vaginal Deliveries in a Latin-American Population

OBJECTIVE: To identify risk factors for immediate postpartum hemorrhage after vaginal delivery in a South American population. METHODS: This was a prospective cohort study including all vaginal births (N=11,323) between October and December 2003 and October and December 2005 from 24 maternity units in two South American countries (Argentina and Uruguay). Blood loss was measured in all births using a calibrated receptacle. Moderate postpartum hemorrhage and severe postpartum hemorrhage were defined as blood loss of at least 500 mL and at least 1,000 mL, respectively. RESULTS: Moderate and severe postpartum hemorrhage occurred in 10.8% and 1.9% of deliveries, respectively. The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were: retained placenta (33.3%) (adjusted odds ratio [OR] 6.02, 95% confidence interval [CI] 3.50–10.36), multiple pregnancy (20.9%) (adjusted OR 4.67, CI 2.41–9.05), macrosomia (18.6%) (adjusted OR 2.36, CI 1.93–2.88), episiotomy (16.2%) (adjusted OR 1.70, CI 1.15–2.50), and need for perineal suture (15.0%) (adjusted OR 1.66, CI 1.11–2.49). Active management of the third stage of labor, multiparity, and low birth weight were found to be protective factors. Severe postpartum hemorrhage was associated with retained placenta (17.1%) (adjusted OR 16.04, CI 7.15–35.99), multiple pregnancy (4.7%) (adjusted OR 4.34, CI 1.46–12.87), macrosomia (4.9%) (adjusted OR 3.48, CI 2.27–5.36), induced labor (3.5%) (adjusted OR 2.00, CI 1.30–3.09), and need for perineal suture (2.5%) (adjusted OR 2.50, CI 1.87–3.36). CONCLUSION: Many of the risk factors for immediate postpartum hemorrhage in this South American population are related to complications of the second and third stage of labor. LEVEL OF EVIDENCE: II

Association between tumor diameter and lymphovascular space invasion among women with early-stage endometrial cancer

To investigate the association between tumor diameter and intratumoral risk factors that might predict the need for full surgical staging among women with endometrial cancer (EC).

Use of oxytocin during early stages of labor and its effect on active management of third stage of labor

OBJECTIVE The purpose of this study was to evaluate whether the use of oxytocin during the first and second stages of labor is associated with a higher incidence of postpartum hemorrhage (PPH) in pregnant women who received active management of third stage of labor (AMTSL). STUDY DESIGN A secondary data analysis from vaginal deliveries in a hospital-based cohort study from 24 maternity hospitals in South America. The primary outcomes that were analyzed were moderate PPH (≥500 mL of blood loss), severe PPH (≥1000 mL of blood loss), and need of blood transfusion. RESULTS A total of 11,323 vaginal deliveries were included. The incidence of moderate and severe PPH was 10.8% and 1.86%, respectively. Overall, 36% of deliveries received AMTSL. There was no association between induced/augmented labor and moderate PPH (P = .753), severe PPH (P = .273), and blood transfusion (P = .603) in the population that received AMTSL. CONCLUSION AMTSL should be recommended, regardless of whether pregnant women received oxytocin during the first and second stages of labor.

Controlled cord traction in the third stage of labor. Systematic review

Active management of the third stage of labor is the current standard evidence-based recommendation for the management of the third stage of labor to prevent postpartum hemorrhage (PPH) [1]. Despite the beneficial effects of active management as a whole, it is important to assess the effects of its individual components (uterotonic agents, late cord clamping, controlled cord traction (CCT), and uterine massage) in order to use and recommend the simplest, most effective, efficient, and safe intervention. CCT is promoted without solid evidence of its effectiveness, while its safety is uncertain. The CCT technique currently used and recommended was described by Spencer, as a modification of the Brandt-Andrews technique [2]. The technique consist of elevating the uterus suprapubically while maintaining steady traction on the cord and not waiting for clinical signs of placental separation. Through a systematic bibliographic search in Medline and in Cochrane CENTRAL, we found only

Carotid-radial pulse wave velocity as an alternative tool for the evaluation of endothelial function during pregnancy: Potential role in identifying hypertensive disorders of pregnancy

Preeclampsia/eclampsia syndrome, a major cause of maternal mortality and morbidity, has been recognized as a condition with a globally impaired endothelial function (EF). The possibility of identifying early subclinical endothelial damage during pregnancy could be of value in classifying the different hypertensive states of pregnancy, and have a positive impact in the understanding of this syndrome, as well as on the appropriate treatment of these patients. Reactive hyperemia-related changes in carotid-radial pulse wave velocity (PWVcr) were proposed as an alternative tool for the evaluation of EF in patients with cardiovascular risk factors. If impaired EF, which follows hypertensive disorders of pregnancy can be assessed using PWVcr changes remains still unknown. Aims: To assess and compare reactive hyperemia-related changes in PWVcr and FMD in pregnant women (healthy and with hypertensive disorders) and non pregnant women. Methods: Healthy pregnant (HP; n=13), preeclamptic (PE; n=7), non-proteinuric hypertensive (NPH; n=6) and non-pregnant (NP; n=32) women were included. Left PWVcr (strain gauge mechano-transducers), left brachial arterial diameter (B-Mode ultrasound) and blood flow velocity (Doppler ultrasound) were measured before (baseline) and after the transient ischemia of the left forearm were determined. Results: One minute after the cuff deflation, PWVcr decreased in HP (6.9 ± 1.5 to 6.0 ± 0.9 m/s, <;0.001) and in NP (8.1 ± 0.9 to 7.4 ± 0.9 m/s; <;0.001). NPH showed a blunted hyperemic PWVcr response (6.6 ± 1.4 to 6.7 ± 1.0 m/s; p=0.91), whereas PE showed a tendency to increase (6.0 ± 0.7 to 6.4 ± 0.8 m/s; p=0.10). Reactive hyperemia PWVcr response (ΔPWVcr in %) differed comparing HP with NPH (-12% vs. +2%; <;0.01) and with PE (-12 vs. +6%; p<;0.01), whereas no differences were found between NHP and PE (p=1.00). Conclusion: HP showed an enhanced PWVcr reduction, whereas PE and NPH showed a blunted hyperemic PWVcr response. Carotid-radial PWVcr analysis could have a potential role in the assessment of pregnancy to study EF with a potential clinical application in predicting pregnancy induced hypertension and preeclampsia.

Preeclampsia Is Associated with Increased Central Aortic Pressure, Elastic Arteries Stiffness and Wave Reflections, and Resting and Recruitable Endothelial Dysfunction.

Introduction. An altered endothelial function (EF) could be associated with preeclampsia (PE). However, more specific and complementary analyses are required to confirm this topic. Flow-mediated dilation (FMD), low-flow-mediated constriction (L-FMC), and hyperemic-related changes in carotid-radial pulse wave velocity (PWVcr) offer complementary information about “recruitability” of EF. Objectives. To evaluate, in healthy and hypertensive pregnant women (with and without PE), central arterial parameters in conjunction with “basal and recruitable” EF. Methods. Nonhypertensive (HP) and hypertensive pregnant women (gestational hypertension, GH; preeclampsia, PE) were included. Aortic blood pressure (BP), wave reflection parameters (AIx@75), aortic pulse wave velocity (PWVcf) and PWVcr, and brachial and common carotid stiffness and intima-media thickness were measured. Brachial FMD and L-FMC and hyperemic-related change in PWVcr were measured. Results. Aortic BP and AIx@75 were elevated in PE. PE showed stiffer elastic but not muscular arteries. After cuff deflation, PWVcr decreased in HP, while GH showed a blunted PWVcr response and PE showed a tendency to increase. Maximal FMD and L-FMC were observed in HP followed by GH; PE did not reach significant arterial constriction. Conclusion. Aortic BP and wave reflections as well as elastic arteries stiffness are increased in PE. PE showed both “resting and recruitable” endothelial dysfunctions.

Vaginal group B streptococcus status during intrapartum antibiotic prophylaxis

To assess maternal group B streptococcus (GBS) colonization status and the pharmacokinetic profile of penicillin G in the umbilical cord and amniotic fluid compartment during 4 hours of intrapartum antibiotic prophylaxis (IAP).

Comparison of placental alpha microglobulin-1 in vaginal fluid with intra-amniotic injection of indigo carmine for the diagnosis of rupture of membranes

Abstract Aims: The purpose of this study was to compare the diagnostic performance of an immunoassay for placental alpha microglobulin-1 (PAMG-1) in vaginal fluid with the intra-amniotic instillation of indigo carmine for the diagnosis of membrane rupture in patients with an equivocal status. Methods: A prospective multi-site study was performed involving women reporting signs, symptoms, or complaints suggestive of rupture of membrane (ROM) between 21 and 42 weeks of gestation without obvious leakage of fluid from the cervical os during sterile speculum examination and without confirmation of ROM by traditional methods. Results: A total of 140 patients were recruited with a prevalence of ROM of 19.3%. The PAMG-1 test had a sensitivity of 100.0% [confidence interval (CI) 0.87–1.0], specificity of 99.1% [(CI) 0.95–0.99], positive predictive value of 96.3% [(CI) 0.82–0.99], negative predictive value of 100.0% [(CI) 0.97–1.0], and ± likelihood ratios of 74.6 [(CI) 20.31–274.51] and 0.0 [(CI) 0.00–0.98]. Conclusions: The PAMG-1 immunoassay in vaginal fluid yielded results that were comparable to those of the instillation of indigo carmine into the amniotic cavity; therefore, we propose that PAMG-1 is a sensitive and specific test to assess ROM in patients with an equivocal diagnosis based on simple tests. This finding prompts consideration for the use of the noninvasive PAMG-1 test in situations where the use of the invasive dye test is not practical.

Group B streptococcus colonization among pregnant women in Uruguay

Group B streptococcus (GBS) is one of the most common causes of neonatal sepsis. In the United States, 5%–10% of neonatal deaths are caused by this organism [1]. Early-onset GBS disease is defined as an infection occurring in the first week of life and accounts for approximately 70% of all GBS diseases in the first 3 months of life [2]. Sepsis develops in approximately 1% of neonates born to colonized women. It has been estimated that between 10%–30% of pregnant women are colonized by GBS. These figures have been reported mainly from high-income countries, with few studies from Latin America [1]. The objective of the present study was to determine the prevalence of GBS colonization in pregnant women using the method recommended by the Centers for Disease Control and Prevention (CDC) [2].

Spreading Latin American research at a global level

To mark the 2018 International Federation of Gynecology and Obstetrics (FIGO) Congress that will take place in Brazil, the International Journal of Gynecology and Obstetrics (IJGO) made a call for papers to publish in a special issue with a focus on Latin America. It is my pleasure to introduce the epidemiological studies and systematic reviews that were selected to be published in this issue, covering most areas within the obstetrics and gynecology specialty from five countries of Latin America (Brazil, Colombia, Puerto Rico, Guatemala, and Mexico). Some of the articles revisit timehonored obstetric subjects, such as intrauterine growth restriction, preeclampsia, maternal sepsis, diabetes, retained placenta, and delivery preferences. Other articles address contemporary gynecologic topics, including pelvic floor dysfunction and interventions, cervical cytology anomalies and the HPV vaccine, hysteroscopy and endometrial assessment, and polycystic ovary syndrome and endometriosis. The topics of mental health, sexual reproductive health, and quality of obstetric care are also included. Each article adds significant knowledge to the body of literature on each topic. IJGO is the official journal of FIGO, with a 2017 impact factor of 2.072. The journal publishes clinical and basic research on obstetrics and gynecology, with a special emphasis on issues of global concern. One of IJGO’s main purposes is to communicate, to an international audience, scientific papers originating from lowand middleincome countries (LMICs) that emphasize important obstetric and gynecologic problems, such as maternal and perinatal mortality, family planning, and women’s health. Submissions are received from all world regions and close to 1400 manuscripts are received per year. The Editorial Board aims to ensure that IJGO represents different regions and countries equitably through priority reports on regional research. Nevertheless, for regular journal issues, Latin America is still the region that submits the lowest number of papers to IJGO, representing between 5% and 7% of all manuscripts received by the editorial office. Similar to the present special issue, Brazil submits the most papers to IJGO (more than half of the total) among all Latin American countries, followed by Spanishspeaking countries. Editorial statistics show that one in three papers submitted to IJGO from Latin America is accepted for publication, representing a rate compared with the global acceptance rate, which is one acceptance per five papers submitted. This suggests that peer reviewers consider studies from Latin America to be of good quality. To support this, of the 12 best original papers submitted from LMICs during 2017 that were selected for the IJGO Prize Paper Award, two papers came from Latin American countries. Although it is the continent with the lowest number of articles submitted, the quality of the research originating from Latin America is high. One of the potential limitations for authors submitting articles is the requirement of translating articles into English. Nevertheless, this should not be a deterrent; the Editorial Board and the reviewers consider the relevance of the topic and the study’s methodological quality to be of primary significance, and that poor language should not be the basis for a reject decision. Authors receive advice and collaborate with the editorial team to improve language during the editorial process. Regarding study type, authors should not be averted if their studies are not clinical trials or analytical epidemiological studies because good descriptive research articles that report data from regional realities are also valuable. Through the present special issue, the IJGO Editorial Board would like to communicate its desire to motivate clinicians and researchers to submit articles to IJGO for consideration and potential publication. The Editorial Board is keen to achieve its goal of promoting and disseminating articles on important topics in obstetrics and gynecology from all world regions to a global audience. I strongly encourage all obstetrician/gynecologists and training residents from our region to consider the publication of original studies, as well as systematic reviews and metaanalyses, in important topics for our countries. Thesis dissertation and monographies during the training period may be a good starting point to produce an original paper in which the results are presented to the global community.