Sirlei Siani Morais

Maternal near miss and maternal death in the World Health Organization's 2005 global survey on maternal and perinatal health

OBJECTIVE To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. METHODS In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latters association with maternal characteristics and perinatal outcomes. FINDINGS Of the 97,095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. CONCLUSION Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

Qualidade de vida em mulheres após tratamento da incontinência urinária de esforço com fisioterapia

PURPOSE: to compare womens quality of life (QoL) before and after physical therapy treatment for stress urinary incontinence (SUI). METHODS: an uncontrolled clinical trial of 26 women, who had mainly complaints of SUI. Post-menopausal women with overactive bladder, cystocele >grade II and previous surgical/conservative treatments were excluded from the study. The physiotherapy treatment relied on 12 individual pelvic floor exercises assisted by electromyographyc-biofeedback sessions. A total of 200 contractions were carried out, divided in phasic (quick) and tonic (slow). The tool used to evaluate QoL was the Kings Health Questionnaire (KHQ), before and after the treatment. RESULTS: there was a decrease in the urinary symptoms, particularly in urinary frequency, nocturia, urgency and urinary incontinence. Regarding the QoL, there was a significant improvement in the following domain scores: general health perception (49.0±24.0 versus 26.9±15.7; p=0.0015), incontinence impact (78.2±28.2 versus 32.1±30.5; p=0.001), activity limitation (75.0±28.2 versus 13.5±22.6; p<0.001), physical limitation (72.4±29.4 versus 15.4±24.5; p<0.001), social limitations (38.3±28.6 versus 6.4±14.5; p<0.001), emotions (59.0±33.8 versus 14.1±24.7; p=0.0001, sleep/energy (34.0±23.8 versus 6.4±16.4; p=0.001) and severity measures (66.9±19.6 versus 22.3±24.2; p<0.001), except for personal relationships (60.5±33.9 versus 41.7±16.7; p=0.0679). CONCLUSIONS: there was an improvement in several aspects of womens QoL treated by physiotherapy, when evaluated with a specific tool, the KHQ.

Variations in body mass index of users of depot-medroxyprogesterone acetate as a contraceptive

BACKGROUND Weight gain is a frequent reason for discontinuing the contraceptive with depot-medroxyprogesterone acetate (DMPA). STUDY DESIGN This 3-year retrospective cohort study assessed body mass index (BMI; kg/m(2)) variations in 379 current or past DMPA users compared to TCu380A intrauterine device (IUD) users matched for age and BMI, categorized into G1 (normal weight), G2 (overweight) or G3 (obese) according to baseline BMI. Variations in weight and BMI were evaluated using analysis of variance. RESULTS BMI increased progressively in all groups but significantly more in G1 and G2 DMPA users compared to nonusers and according to duration of use. In the G3 subgroup, weight trends were similar in the DMPA and IUD users. CONCLUSIONS Normal and overweight women increased BMI with DMPA use; however, obese women did not increase weight. Weight increase in DMPA users could be associated with metabolic alterations related to duration of use in normal and overweight women and to alterations already present in obese women. Prospective studies are required to determine triggering factors. DMPA use <or=3 years was not associated with weight increase in women with BMI (kg/m(2)) >or=30.

Management of Stress Urinary Incontinence With Surface Electromyography–Assisted Biofeedback in Women of Reproductive Age

Background and Purpose Although surgery has been widely accepted as the treatment of choice for stress urinary incontinence (SUI), there has recently been an increased interest in the conservative management of this condition. The aims of this study were to test the ability of a biofeedback-assisted pelvic-floor muscle exercise (PFME) program to affect symptoms of SUI in premenopausal women and to evaluate a training program that might lead to successful outcomes in a relatively limited number of sessions. Subjects Twenty-six women with SUI were treated with PFME with surface electromyography (sEMG)–assisted biofeedback. All participants were of reproductive age and were treated individually for 12 sessions. Methods Results were evaluated with a 7-day voiding diary, a 1-hour pad test, pelvic-floor muscle strength measurements, sEMG amplitudes, a leakage index, and a quality-of-life questionnaire. These variables were compared before and after the intervention. Results The frequency of urine loss, the occurrence of nocturia, and the number of pads required decreased significantly after the intervention. Objective cure was found in 61.5% of women. There was a significant improvement in the quality of life, in pelvic-floor muscle strength, and in the sEMG amplitudes of all contractions throughout the intervention. Discussion and Conclusion A relatively short-term intervention of PFME with sEMG-assisted biofeedback appeared to be helpful in relieving symptoms of SUI in premenopausal women and represents a reasonable conservative management option.

Menopause symptoms in women infected with HIV: Prevalence and associated factors

Objective. To evaluate the prevalence and factors associated with menopause symptoms in HIV-infected women. Methods. A cross-sectional study of two groups of women was conducted: 96 with HIV and 155 without HIV. Women aged 40 years or older, non-users of hormone therapy in the last 6 months and native Brazilians were included. The prevalence of menopause symptoms was calculated according to the studied variables. Symptoms were grouped into six categories: vasomotor, psychological, genitourinary, weight gain, palpitations and insomnia. The generalized estimating equation model was applied to identify the factors associated with menopause symptoms in all women and for HIV-infected women only. Results. The mean (±standard deviation) age of women with and without HIV was 48.9 ± 7.4 and 51.0 ± 8.7 years (p = 0.07), respectively. The median age at menopause for HIV-infected women was 47.5 years. Menopause symptoms were more frequent in HIV-infected women, highlighting psychological and vasomotor symptoms. HIV infection was associated with menopause symptoms (odds ratio (OR) = 1.65, p = 0.03), as well as age ranging from 45 to 54 years (OR = 1.77, p = 0.01), higher parity (OR = 2.38, p = 0.01) and self-perception of health as fair/poor (OR = 2.07, p < 0.01). Among HIV-infected women, the likelihood of presenting symptoms decreased in those aged 55 or older (OR = 0.16, p = 0.03) and increased in retired women (OR = 2.61, p = 0.02). Conclusion. Menopause symptoms were common in HIV-infected women. HIV infection was independently associated with menopause symptoms, whereas age and being retired were associated with the occurrence of these symptoms in HIV-infected women.

Factors associated with the prevalence of periodontal disease in low-risk pregnant women

ObjectiveTo evaluate the prevalence of periodontal disease (PD) among Brazilian low-risk pregnant women and its association with sociodemographic factors, habits and oral hygiene.MethodThis cross-sectional study included 334 low-risk pregnant women divided in groups with or without PD. Indexes of plaque and gingival bleeding on probing, probing pocket depth, clinical attachment level and gingival recession were evaluated at one periodontal examination below 32 weeks of gestation. Independent variables were: age, race/color, schooling, marital status, parity, gestational age, smoking habit, alcohol and drugs consumption, use of medication, presence of any systemic diseases and BMI (body mass index). Statistical analyses provided prevalence ratios and their respective 95%CI and also a multivariate analysis.ResultsThe prevalence of PD was 47% and significantly associated with higher gestational age (PR 1.40; 1.01 - 1.94 for 17-24 weeks and PR 1.52; 1.10 - 2.08 for 25-32 weeks), maternal age 25-29 years, obesity (PR 1.65; 1.02 - 2.68) and the presence of gingival bleeding on probing (ORadj 2.01, 95%CI 1.41 - 2.88). Poor oral hygiene was associated with PD by the mean values of plaque and bleeding on probing indexes significantly greater in PD group.ConclusionsThe prevalence of PD is high and associated with gingival bleeding on probing, more advanced gestational age and obesity. A program of oral health care should be included in prenatal care for early pregnancy, especially for low-income populations.

Evaluation of the secretory immunoglobulin A levels in the colostrum and milk of mothers of term and pre-trerm newborns

OBJECTIVE To determine and to compare the levels of secretory immunoglobulin A in samples of colostrum and milk of mothers of term and preterm neonates. MATERIAL AND METHODS The levels of secretory immunoglobulin A of 10 mothers of term neonates and 10 mothers of preterm neonates were determined from 5 mL of colostrum or milk collected on the 1st, 4th, 10th and 15th days of the puerperal period, using the radial immunodiffusion technique. We employed anamnesis, as well as physical and gynecological exams in women in the puerperal period. All the patients were attended at the Januário Cicco Maternity College. RESULTS The secretory immunoglobulin A levels were significantly higher in the colostrum and milk of mothers of preterm neonates when compared with the levels found in colostrum and milk of mothers of term neonates (Mann-Whitney test, p<0.0001). There was a significant decline in the secretory immunoglobulin A levels of the colostrum and milk of the mothers of term and preterm neonates during the four periods (Kruskal-Wallis test, p<00001). CONCLUSIONS The secretory immunoglobulin A levels in colostrum and milk of mothers of preterm neonates were significantly higher than in the mothers of term neonates, demonstrating immunological adaptation in preterm neonate breast-feeding.

Factors and outcomes associated with the induction of labour in Latin America

Objective  To describe the prevalence of labour induction, together with its risk factors and outcomes in Latin America.

Quality of life and menopausal and sexual symptoms in gynecologic cancer survivors: a cohort study

Objectives:The aims of this study were to investigate the frequency of menopausal and sexual symptoms and the proportion of sexually active women and to assess and identify quality of life (QOL) predictors in gynecologic cancer survivors. Methods:A prospective case series following a cohort of women under radiation therapy was conducted, including 107 women (aged 21-75 y) with gynecologic cancer (cervical or endometrial cancer) who underwent pelvic radiotherapy in the Radiotherapy Division of the Womens Integral Healthcare Center at the Universidade Estadual de Campinas. Adverse effects of radiotherapy were evaluated using the Common Terminology Criteria Adverse Event Scale. QOL was measured using the abbreviated version of the World Health Organizations Quality of Life instrument before radiotherapy (T0) and at 4 months (T1), 1 year (T2), and 3 years (T3) after radiotherapy. QOL scores were assessed over time using the Wilcoxon signed-rank test. Multiple linear regression analysis was used to identify QOL predictors. Results:A decrease in the frequency of vaginal dryness (26.7% in T0 vs 8.3% in T3; P < 0.01) and an increase in the proportion of sexually active women (21.5% in T0 vs 44.2% in T3; P < 0.01) were observed. A significant increase in QOL scores was observed in the psychological domain and general health and overall QOL. Dyspareunia negatively affected the physical (P < 0.01), psychological (P < 0.01), and social relationship domains (P < 0.01); overall QOL (P = 0.01); and general health (P = 0.04). Family income was positively related to environment domain (P < 0.01), overall QOL (P = 0.04), and general health (P < 0.01). Conclusions:Data derived from this study indicated that gynecologic cancer survivors had a lower frequency of vaginal dryness and a higher proportion of these women were sexually active 3 years after completion of radiotherapy. Furthermore, QOL improved and dyspareunia negatively affected various QOL dimensions.

Prognostic markers of high-grade squamous intraepithelial lesions: the role of p16INK4a and high-risk human papillomavirus.

Background. p16INK4a seems to be an indicator of the grade of Human Papillomavirus‐induced lesions and a possible predictor of the lesion evolution. There are few studies about the role of HPV test and p16INK4a in diagnosis of high‐grade cervical lesions in South‐American women. The aim of the present study was to evaluate the presence of p16INK4a and high‐risk HPV‐DNA expression in cases diagnosed as squamous intra‐epithelial lesion and evaluate their role in the approach of high‐grade squamous intra‐epithelial lesion. Methods. p16INK4a and high‐risk Human papillomavirus were investigated in 96 samples of the cervix (13 cases of high grade squamous intraepithelial lesions, 26 cases of low grade intraepithelial lesions and 57 normal tissues). The p16INK4a was identified by immunohistochemistry using the p16INK4a kit (E6H4 clone, DakoCytomation, Carpinteria, CA) and Human papillomavirus DNA was classified by hybrid capture (Digene®). Associations were evaluated by the KAPPA index. Results. The p16INK4a was detected in 92.3% of the high‐grade squamous intraepithelial lesions, in 15.4% of the low‐grade and in none of the normal tissues. The sensitivity, specificity, positive predictive value and negative predictive value for high‐grade lesion were 92.3%, 100%, 100%, and 98.3%, respectively when considering p16INK4a expression, and 100%, 70.2%, 43.3% and 100%, respectively when considering high‐risk HPV. Conclusions. p16INK4a test was better associated with high‐grade intraepithelial lesion (κ = 0.95) than was the presence of high‐risk HPV (κ = 0.47). Both tests could be complementary to high‐grade squamous intra‐epithelial lesion screening and help to define the diagnosis of the inconclusive low‐grade/high‐grade squamous intraepithelial lesion cases.