Silvana Maria Quintana

Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study.

BACKGROUND The effects of etonogestrel (ETG)-releasing contraceptive implant during the immediate postpartum period on maternal safety are unknown. STUDY DESIGN Forty healthy women exclusively breastfeeding were randomized to receive either ETG-releasing implant 24-48 h after delivery (n=20) or depot medroxyprogesterone acetate (DMPA group; n=20) at the sixth week postpartum. We measured blood pressure, maternal and neonatal weight, body mass index (BMI; kg/m(2)), waist circumference (WC), complete blood count, C-reactive protein, interleukin-6, tumor necrosis factor (TNF-alpha), lipid profile, fasting serum glucose and maintenance of exclusive lactation up to the 12th week postpartum. RESULTS Decreases in mean maternal weight, BMI (kg/m(2)) and WC were significantly greater in the ETG-releasing implant group than in the DMPA group during the first 6 weeks postpartum (-4.64+/-2.71 kg vs. -2.6+/-2.45 kg mean+/-SD, p=.017; -1.77+/-1.06 kg/m(2) vs. -0.97+/-0.95 kg/m(2), p=.026; -15.3+/-6.72 cm vs. -9.05+/-5.84 cm, p=.003, respectively). In addition, total cholesterol and HDL, were lower in DMPA users, and TNF-alpha and leukocytes were higher in DMPA users compared to in the implant group, between 6 and 12 weeks after delivery. The newborns of implant users showed a trend towards gaining more weight, as compared with the infants of the DMPA mothers during the first 6 weeks of life (implant group: +1460.50+/-621.34 g vs. DMPA group: +1035.0+/-562.43 g, p=.05). The remaining variables, including the duration of exclusive breastfeeding, were similar between the groups. CONCLUSION The insertion of ETG-releasing contraceptive implant during the immediate postpartum period was not associated with deleterious maternal clinical effects or with significant maternal metabolic alterations or decreased infant weight gain.

Visceral leishmaniasis (kala-azar) and pregnancy

OBJECTIVE: The aim of the present review was to close the gap in the approach to pregnant women with visceral leishmaniasis (kala-azar) by providing up-to-date information to obstetricians about physiopathology, epidemiology, vertical transmission, drugs and treatment during pregnancy. BACKGROUND: Infection with Leishmania chagasi during pregnancy is rare and deserves special attention since little information is available regarding the occurrence of visceral leishmaniasis during gestational period and the real possibility of vertical transmission of this disease. Because specific areas in the world are endemic for the disease and considering the continuous growth of the population, cases of pregnant women with visceral leishmaniasis are becoming more frequent. Unfortunately, textbooks on infectious diseases do not include this specific group of patients, and studies in the literature on aspects related to pregnancy and visceral leishmaniasis are scarce. CONCLUSIONS: Vertical transmission of leishmaniasis is possible and the institution of treatment is imperative in cases of pregnant women with kala-azar. Amphotericin B is strongly recommended as the first choice drug due to its fewer maternal-fetal adverse effects.

HLA-G polymorphisms in women with squamous intraepithelial lesions harboring human papillomavirus

Human papillomavirus (HPV) infection is etiologically associated with low- (LSIL) and high-grade squamous intraepithelial lesions (HSIL) and with cervical cancer. The progression or regression of the lesions may depend, among other factors, on the host heritable immune response. Because human leukocyte antigen (HLA)-G molecules are involved in the modulation of innate and adaptive immune responses, and because no previous studies have evaluated HLA-G polymorphism in patients with SIL, we conducted a study to assess the association between HLA-G polymorphisms and cervical lesions harboring HPV infection. Cervico-vaginal scrapings and blood samples were collected from 125 women with SIL (68 LSIL and 57 HSIL) and from 94 healthy women without HPV infection and cytological abnormalities. HPV type and HLA-G polymorphisms in exons 2, 3 and 8 (14 bp insertion/deletion) were evaluated by PCR methodology, and digested with restriction endonucleases. The Genepop software and the EM and PHASE algorithms were used for statistical analysis. A significant protective association was observed between the presence of the G*0103 allele and SIL and between the G0101/G0104 genotype and HSIL in the group of patients compared to control. The presence of the G0104/+14 bp and G0104/−14 bp haplotypes conferred susceptibility to SIL compared to control. In addition, patients possessing the G0104/+14 bp haplotype and harboring HPV-16 and -18 co-infections were particularly associated with HSIL. These findings suggest that HLA-G polymorphisms may be associated with HPV infection and SIL, consequently representing a profile of predisposition to cervical cancer.

Infecção urinária na gravidez

Several factors cause urinary tract infection (UTI) to be a relevant complication of the gestational period, aggravating both the maternal and perinatal prognosis. For many years, pregnancy has been considered to be a factor predisposing to all forms of UTI. Today, it is known that pregnancy, as an isolated event, is not responsible for a higher incidence of UTI, but that the anatomical and physiological changes imposed on the urinary tract by pregnancy predispose women with asymptomatic bacteriuria (AB) to become pregnant women with symptomatic UTI. AB affects 2 to 10% of all pregnant women and approximately 30% of these will develop pyelonephritis if not properly treated. However, a difficult-to-understand resistance against the identification of AB during this period is observed among prenatalists. The diagnosis of UTI is microbiological and it is based on two urine cultures presenting more than 10(5) colonies/mL urine of the same germ. Treatment is facilitated by the fact that it is based on an antibiogram, with no scientific foundation for the notion that a pre-established therapeutic scheme is an adequate measure. For the treatment of pyelonephritis, it is not possible to wait for the result of culture and previous knowledge of the resistance profile of the antibacterial agents available for the treatment of pregnant women would be the best measure. Another important variable is the use of an intravenous bactericidal antibiotic during the acute phase, with the possibility of oral administration at home after clinical improvement of the patient. At our hospital, the drug that best satisfies all of these requirements is cefuroxime, administered for 10-14 days. Third-generation cephalosporins do not exist in the oral form, all of them involving the inconvenience of parenteral administration. In view of their side effects, aminoglycosides are considered to be inadequate for administration to pregnant women. The inconsistent insinuation of contraindication of monofluorinated quinolones, if there is an indication, norfloxacin is believed to be a good alternative to cefuroxime. In cases in which UTI prophylaxis is indicated, chemotherapeutic agents are preferred, among them nitrofurantoin, with care taken to avoid its use at the end of pregnancy due to the risk of kernicterus for the neonate.

Effect of antiretroviral therapy including lopinavir/ritonavir or efavirenz on etonogestrel-releasing implant pharmacokinetics in HIV-positive women.

Objective:Data on the interaction between the etonogestrel (ENG) implant and antiretroviral therapy are lacking. We evaluated the effect of 2 highly active antiretroviral therapy (HAART) regimens (1 including efavirenz and the other ritonavir-boosted lopinavir) on the pharmacokinetic (PK) parameters of an ENG-releasing implant in HIV-positive women. Design:Prospective nonrandomized PK study. Methods:Forty-five HIV-positive women who desired to use ENG implants were included: 15 had received zidovudine/lamivudine + lopinavir/ritonavir for ≥3 months (LPV/r-based HAART group), 15 had received zidovudine/lamivudine + efavirenz for ≥3 months (EFV-based HAART group), and 15 had not received HAART (non-HAART group). PK parameters were measured using ultra-performance liquid chromatography–mass spectrometry at baseline and 2, 4, 6, 8, 10, 12, 16, 20, and 24 weeks after implant placement. Results:The EFV-based HAART regimen was associated with a reduction in the bioavailability of ENG, which showed decreases of 63.4%, 53.7%, and 70% in the area under the curve (AUC), maximum concentration (Cmax), and minimum concentration (Cmin) of ENG, respectively, compared with the non-HAART group. The LPV/r-based HAART regimen was associated with an increase in ENG bioavailability, which showed 52%, 60.6%, and 33.8% increases in the ENG AUC, Cmax, and Cmin, respectively, compared with the non-HAART group. Conclusions:The coadministration of EFV decreased the bioavailability of ENG released from the implant, which could impair contraceptive efficacy. However, the coadministration of LPV/r increased the bioavailability of ENG released from the implant, which suggests that this antiretroviral combination does not impair the ENG implant efficacy.

Infecção urinária na gravidez: análise dos métodos para diagnóstico e do tratamento

Objetivos: avaliar os aspectos diagnosticos, terapeuticos e as complicacoes dos casos de infeccao do trato urinario (ITU) sintomatica durante a gestacao, que necessitaram de internacao hospitalar. Metodos: foram incluidas 136 gravidas com diagnostico clinico de pielonefrite. Foram avaliados: a idade e paridade da paciente, idade gestacional em que foi feito o diagnostico, antecedentes de importância epidemiologica, propedeutica laboratorial para avaliacao da infeccao urinaria, tratamento e evolucao clinica, antimicrobianoprofilaxia e complicacoes. Resultados: pielonefrite foi diagnosticada, nas mesmas proporcoes, em todas as idades gestacionais. Houve maior incidencia de ITU entre as primigestas. Apenas 29,3% das gestantes apresentaram historia previa de ITU. Observou-se que 57,0% das pacientes apresentaram anemia e 93,0% mostraram analise urinaria alterada. A Escherichia coli foi o uropatogeno mais prevalente (75,8% dos casos), com baixos percentuais de sensibilidade a ampicilina (60,6%) e a cefalotina (63,6%) e altos percentuais de sensibilidade a cefuroxima (95,5%). A maior taxa de melhora clinica foi obtida entre as gestantes tratadas com cefuroxima (95,7%). A antimicrobianoprofilaxia foi necessaria em 11,0% das pacientes. O trabalho de parto pre-termo ocorreu em 33,3% das gestantes que deram a luz em nosso servico, e o parto pre-termo em 18,9%. Conclusoes: esses resultados reforcam a necessidade do diagnostico precoce e tratamento efetivo da ITU em gestantes, a fim de evitar a ocorrencia frequente de complicacoes perinatais, como o trabalho de parto e o parto pre-termo. Destaca-se a necessidade de avaliacao periodica do padrao de sensibilidade dos agentes etiologicos prevalentes aos antimicrobianos de uso permitido durante a gestacao, adotando-se a cefuroxima como o antimicrobiano de escolha para o tratamento das ITU na gestacao.Purpose: to assess the diagnostic and therapeutic aspects and the complications of symptomatic urinary tract infections (UTI) during pregnancy of patients who were hospitalized. Methods: a total of 136 pregnant women with a clinical diagnosis of pyelonephritis were studied. The studied parameters were: age and parity of patients, gestational age of diagnosis, epidemiologic aspects, laboratory evaluation for UTI, treatment and clinic evolution, prophylaxis and complications. Results: pyelonephritis was diagnosed at the same proportions at all gestational ages. The incidence of UTI was higher among primigravidae. Only 29.3% of the pregnant women had a previous history of UTI; 57.0% were anemic and 93.0% had altered urinalysis. Escherichia coli was the most prevalent uropathogen (75.8% of cases), with low percentages of sensitivity to ampicillin (60.6%) and high percentages of sensitivity to cefuroxime (95,5%). The highest rate of clinical improvement was obtained for the pregnant women treated with cefuroxime (95.7%). Prophylaxis was needed in 11.0% of the patients. Preterm labor occurred in 33.3% of the pregnant women who delivered in our service and preterm delivery occurred in 18.9%. Conclusions: the present results support the need for an early diagnosis and effective treatment of UTI in pregnant women in order to prevent the frequent occurrence of perinatal complications such as premature labor and delivery. We emphasize the need of a periodical evaluation of the pattern of sensitivity of the etiologic agents to the antimicrobials allowed for use during pregnancy, with cefuroxime being adopted as the antibiotic of choice for the treatment of UTI during pregnancy.

Effect of pelvic floor muscle training on labour and newborn outcomes: a randomized controlled trial

BACKGROUND The use of the pelvic floor muscle training for urinary incontinence treatment is well established but little is known about its effects in labor and newborn outcomes. OBJECTIVES To evaluate the effects of antenatal pelvic floor muscle training and strength in labor and newborn outcomes in low-income pregnant women. METHODS This is a randomized controlled trial that recruited forty-two nulliparous healthy pregnant women aged between 18-36 years old and able to contract the pelvic floor muscles. The participants were included in the study with 20 weeks of gestational age and had their pelvic floor muscles measured by vaginal squeeze pressure. They were randomly allocated into two groups: training group and a non-intervention control group. Then, all participants had their labor and newborn outcomes evaluated through consultation of medical records by a blinded researcher. RESULTS There were no statistically significant differences between the groups regarding gestational age at birth, type of labor, duration of the second stage of labor, total time of labor, prevalence of laceration, weight and size of the baby, and Apgar score. No correlation was observed between pelvic floor muscle strength and the second stage or the total length of labor. CONCLUSIONS This randomized controlled trial did not find any effect of pelvic floor muscle training or pelvic floor muscle strength on labor and newborn outcomes.

Antiretroviral Therapy During Pregnancy and Early Neonatal Life: Consequences for HIV-Exposed, Uninfected Children

Women have emerged as the fastest growing human immunodeficiency virus (HIV) infected population worldwide, mainly because of the increasing occurrence of heterosexual transmission. Most infected women are of reproductive age and one of the greatest concerns for both women and their physicians is that more than 1,600 infants become infected with HIV each day. Almost all infections are a result of mother-to-child transmission of HIV. With the advent of combination antiretroviral therapies, transmission rates lower than 2% have been achieved in clinical studies. Antiretroviral compounds differ from most other new pharmaceutical agents in that they have become widely prescribed in pregnancy in the absence of proof of safety. We reviewed antiretroviral agents used in pregnant women infected with human immunodeficiency virus, mother-to-child transmission, and their consequences for infants.

Visceral leishmaniasis and pregnancy: analysis of cases reported in a central-western region of Brazil.

ObjectivesBecause of the large number of cases of visceral leishmaniasis (VL) recorded in Brazil over the last few years, this disease has been showing characteristics different from previously known ones. We report cases of pregnant women treated for VL, describing their course and outcome and the chemotherapeutic medication used according to the clinical signs and symptoms of each patient.Study designWe report five cases of pregnant women treated for VL in a central-western region of Brazil.ResultsNo case of vertical transmission was observed, even in patients who were treated after delivery. One of the patients with a late diagnosis made after the onset of symptoms died. Thus, the treatment of VL during pregnancy reduces maternal mortality and the rate of vertical transmission of the disease, being safe and effective as long as the disease is diagnosed early.ConclusionAt present, amphotericin B and its derivatives appear to be the best therapeutic option for the mother–child binomial.

Massage reduced severity of pain during labour: a randomised trial.

QUESTION Does massage relieve pain in the active phase of labour? DESIGN Randomised trial with concealed allocation, assessor blinding for some outcomes, and intention-to-treat analysis. PARTICIPANTS 46 women pregnant at ≥ 37 weeks gestation with a single fetus, with spontaneous onset of labour, 4-5cm of cervical dilation, intact ovular membranes, and no use of medication after admission to hospital. INTERVENTION Experimental group participants received a 30-min lumbar massage by a physiotherapist during the active phase of labour. A physiotherapist attended control group participants for the same period but only answered questions. Both groups received routine perinatal care. OUTCOME MEASURES The primary outcome was pain severity measured on a 100mm visual analogue scale. Secondary outcomes included the Short Form McGill Pain Questionnaire, pain location, and time to analgesic medication use. After labour, a blinded researcher also recorded duration of labour, route of delivery, neonatal outcomes, and the participants satisfaction with the physiotherapist during labour. RESULTS At the end of the intervention, pain severity was 52mm (SD 20) in the experimental group and 72mm (SD 15) in control group, which was significantly different with a mean difference of 20mm (95% CI 10 to 31). The groups did not differ significantly on the other pain-related outcome measures. Obstetric outcomes were also similar between the groups except the duration of labour, which was 6.8hr (SD 1.6) in the experimental group and 5.7hr (SD 1.5) in the control group, mean difference 1.1hr (95% CI 0.2 to 2.0). Patients in both groups were satisfied with the care provided by the physiotherapist. CONCLUSION Massage reduced the severity of pain in labour, despite not changing its characteristics and location.