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BACKGROUND: Both progestogens and cerclage are individually effective in preterm birth prevention in high risk pregnancies. However, national and international guidelines cite a lack of data available to comment on the potential benefit of concurrent progestogen therapy after cerclage has been placed. Studies to date have been small with mixed results regarding benefit of concurrent progestogen with cerclage leaving uncertainty regarding best clinical practice. OBJECTIVE: This study aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth in singleton pregnancies. METHODS: This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016 to June 2020. Exclusion criteria were lack of documentation regarding whether progestogen was prescribed, unavailable delivery outcome, and pregnancy termination (spontaneous or induced) before 16 weeks' gestation. The exposure of interest was progestogen use with cerclage placement, which included those who continued to use progestogen or who started progestogen after cerclage. The comparison group consisted of those without progestogen use after cerclage placement, which included those who had no progestogen use during the entire pregnancy or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. The primary outcome was spontaneous preterm birth at <37 weeks. The secondary outcomes were spontaneous preterm birth at <34 weeks, gestational age at delivery, and a composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia. There were planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate), preterm birth history, and site. Continuous variables were compared in adjusted analyses with analysis of covariance, and categorical variables were compared with multivariable logistic regression, adjusting for potential confounders with adjusted odds ratio. A Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. RESULTS: During the study period, a total of 699 singletons met the inclusion criteria: 561 in the progestogen with cerclage group and 138 with cerclage alone. Baseline characteristics were similar, except the higher likelihood of previous spontaneous preterm birth in the progestogen group (61% vs 41%; P<.001). Within the progestogen group, 52% were on 17-hydroxyprogesterone caproate weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of spontaneous preterm birth <37 weeks (31% vs 39%; adjusted odds ratio, 0.59 [0.39-0.89]; P=.01) and <34 weeks (19% vs 27%; adjusted odds ratio, 0.55 [0.35-0.87]; P=.01), increased latency to spontaneous delivery (hazard ratio for spontaneous preterm birth <37 weeks, 0.66 [0.49-0.90]; P=.009), and lower frequency of perinatal death (7% vs 16%; adjusted odds ratio, 0.37 [0.20-0.67]; P=.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a previous preterm birth, those with ultrasound- or examination-indicated cerclage, those who started progestogen therapy before cerclage, and in sites restricted to the United States. CONCLUSION: Use of progestogen with cerclage was associated with reduced rates of spontaneous preterm birth and early spontaneous preterm birth compared with cerclage alone. Although this study was not sufficiently powered for subgroup analysis, the strength of evidence for benefit appeared greatest for those with ultrasound- or examination-indicated cerclage, and with vaginal progesterone. El resumen está disponible en Español al final del artículo.
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Cerclagem Cervical , Nascimento Prematuro , Progestinas , Humanos , Feminino , Cerclagem Cervical/métodos , Estudos Retrospectivos , Gravidez , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/epidemiologia , Progestinas/administração & dosagem , Adulto , Estados Unidos/epidemiologia , Colômbia/epidemiologia , Recém-Nascido , Estudos de CoortesRESUMO
Introducción: La segunda causa de muerte a nivel mundial corresponde a los ataques cerebrovasculares (ACV), de los cuales más de dos terceras partes son de origen isquémico. Causan discapacidad a largo plazo por lo que conocer la anatomía de la circulación cerebral y las posibles manifestaciones clínicas del ACV isquémico permite sospechar, diagnosticar y brindar un manejo oportuno y apropiado, reduciendo el impacto en la salud y la calidad de vida del paciente y sus cuidadores. Objetivo: relacionar los últimos hallazgos en la anatomía arterial cerebral, los mecanismos fisiopatológicos y las manifestaciones clínicas del ACV isquémico de la arteria cerebral media (ACM). Materiales y métodos: revisión de la literatura mediante la búsqueda con términos MeSH en la base de datos Medline, incluyendo estudios, ensayos y metaanálisis publicados entre 2000 y 2020 en inglés y español, además de otras referencias para complementar la información. Resultados: se seleccionaron 59 publicaciones, priorizando las de los últimos 5 años y las más relevantes del rango temporal consultado. Conclusiones: son escasos los estudios sobre la presentación clínica de los ACV, lo que sumado a la variabilidad interindividual de la irrigacióncerebral, dificulta la determinación clínica de la localización de la lesión dentro del lecho vascular. La reperfusión del área de penumbra isquémica como objetivo terapéutico se justifica por los mecanismos fisiopatológicos de la enfermedad.
Introduction: Cerebrovascular accidents (CVAs) are the second leading cause of death worldwide, of which more than two thirds are ischemic. They cause long-term disability, therefore, knowledge on the cerebral circulation anatomy and possible clinical manifestations of ischemic CVAs allows us to suspect, diagnose and provide timely and appropriate management, reducing the negative impact on the health and quality of life of patients and caregivers. Objective: to list the latest findings on cerebral arterial anatomy, pathophysiological mechanisms and clinical manifestations of ischemic middle cerebral artery (MCA) CVAs. Materials and methods: a literature review using a MeSH terms search in the Medline database, including studies, trials and meta-analyses published in English and Spanish between 2000 and 2020, using other complementary references. Results: 59 publications were selected prioritizing those published in the past 5 years and the most relevant in said period. Conclusions: there are few studies on the clinical presentation of CVAs, which, added to the interindividual variability of cerebral circulation anatomy, makes clinical identification of lesion location, within the vascular bed, difficult. Reperfusion of the ischemic penumbra region, as a therapeutic objective, is based on the pathophysiological mechanisms of the disease.
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Artéria Cerebral Média , Acidente Vascular Cerebral , Sinais e Sintomas , AnatomiaRESUMO
OBJECTIVES: We aimed to establish new cut-off values for SIRS (Systemic Inflammatory Response Syndrome) variables in the obstetric population. METHODS: A prospective cohort study in pregnant and postpartum women admitted with systemic infections between December 2017 and January 2019. Patients were divided into three cohorts: Group A, patients with infection but without severe maternal outcomes (SMO); Group B, patients with infection and SMO or admission to the intensive care unit (ICU); and Group C, a control group. Outcome measures were ICU admission and SMO. The relationship between SIRS criteria and SMO was expressed as the area under the receiver operating characteristics curve (AUROC), selecting the best cut-off for each SIRS criterion. RESULTS: A total of 541 obstetric patients were enrolled, including 341 with infections and 200 enrolled as the reference group (Group C). The patients with infections included 313 (91.7%) in Group A and 28 (8.2%) in Group B. There were significant differences for all SIRS variables in Group B, compared with Groups A and C, but there were no significant differences between Groups A and C. The best cut-off values were the following: temperature 38.2 °C, OR 4.1 (1.8-9.0); heart rate 120 bpm, OR 2.9 (1.2-7.4); respiratory rate 22 bpm, OR 4.1 (1.6-10.1); and leukocyte count 16,100 per mcl, OR 3.5 (1.6-7.6). CONCLUSIONS: The cut-off values for SIRS variables did not differ between healthy and infected obstetric patients. However, a higher cut-off may help predict the population with a higher risk of severe maternal outcomes.
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Infecções , Complicações do Trabalho de Parto , Infecção Puerperal , Risco Ajustado/métodos , Síndrome de Resposta Inflamatória Sistêmica , Adulto , Estudos de Coortes , Colômbia/epidemiologia , Diagnóstico Precoce , Feminino , Humanos , Infecções/complicações , Infecções/diagnóstico , Infecções/epidemiologia , Infecções/fisiopatologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Contagem de Leucócitos/métodos , Mortalidade Materna , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/etiologia , Complicações do Trabalho de Parto/mortalidade , Gravidez , Resultado da Gravidez/epidemiologia , Infecção Puerperal/sangue , Infecção Puerperal/etiologia , Infecção Puerperal/mortalidade , Infecção Puerperal/terapia , Medição de Risco/métodos , Avaliação de Sintomas/métodos , Síndrome de Resposta Inflamatória Sistêmica/sangue , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Síndrome de Resposta Inflamatória Sistêmica/terapiaRESUMO
BACKGROUND: The Shock Index is a clinical tool to evaluate the hemodynamic status during hemorrhage. The impact of labor and pre-existing anaemia is unknown. The objective was to describe and discuss its clinical utility in this context. METHODS: This was a prospective cross-sectional study. The Shock Index (ratio between heart rate and systolic blood pressure) was measured in pregnant women at term, before or during labor. They were stratified according to the presence of anemia. RESULTS: The median Shock Index was significantly lower in women in labor than in those not in labor (0.72 (IQR: 0.64-0.83) vs. 0.85 (IQR: 0.80-0.94); p < 0.001). In women in labor, the Shock Index was not significantly different if anemia was present (0.72 (0.63-0.83) vs. 0.73 (0.65-0.82); p = 0.67). CONCLUSIONS: Values of the Shock Index are affected by labor, which may hinder its utility in identifying hemorrhage during this period. However, the values were not altered by maternal anaemia. Therefore, an abnormal postpartum Shock Index should not be attributed to an abnormal antepartum Shock Index due to mild/moderate anemia.
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OBJECTIVE: Assess if video-based contraceptive education could be an efficient adjunct to contraceptive counseling and attain the same contraceptive knowledge acquisition as conversation-based counseling. STUDY DESIGN: This was a multicenter randomized, controlled trial examining contraceptive counseling during labor and maternity hospitalization regarding the options of immediate postpartum contraception. At two urban public hospitals, we randomized participants to a structured conversation with a trained counselor or a 14-min video providing the same information. Both groups received written materials and were invited to ask the counselor questions. Our primary outcome was to compare mean time for video-based education and conversational counseling; secondary outcomes included intended postpartum contraceptive method, pre- and postintervention contraceptive knowledge, and perceived competence in choosing a method of contraception. RESULTS: We enrolled 240 participants (conversation group=119, video group=121). The average time to complete either type of counseling was similar [conversational: 16.3â¯min, standard deviation (SD) ±3.8â¯min; video: 16.8â¯min, SD ±4.6â¯min, p=.32]. Of women intending to use nonpermanent contraception, more participants intended to use a long-acting reversible contraceptive (LARC) method after conversational counseling (72/103, 70% versus 59/105, 56%, p=.041). Following counseling, mean knowledge assessment scores increased by 2 points in both groups (3/7 points to 5/7 correct). All but two participants in the video group agreed they felt equipped to choose a contraceptive method after counseling. CONCLUSIONS: Compared to in-person contraceptive counseling alone, video-based intrapartum contraceptive education took a similar amount of time and resulted in similar contraceptive knowledge acquisition, though with fewer patients choosing LARC. IMPLICATIONS: Video-based contraceptive education may be useful in settings with limited personnel to deliver unbiased hospital-based, contraceptive counseling for women during the antepartum period.
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Anticoncepção , Serviços de Planejamento Familiar/educação , Conhecimentos, Atitudes e Prática em Saúde , Educação de Pacientes como Assunto/métodos , Assistência Perinatal , Adolescente , Adulto , Feminino , Hospitalização , Humanos , Contracepção Reversível de Longo Prazo , Gravação em Vídeo , Adulto JovemRESUMO
OBJECTIVE: To determine the diagnostic accuracy of tests developed for use at the point of care for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and syphilis in women having symptoms of lower urinary tract infection. METHODS: Cross-sectional study involving sexually active 14-49-year-old women with lower urinary tract infection symptoms consulting during 2010 at a private health clinic and at two public hospitals in Bogotá, Colombia. Pregnant women, those with a previous hysterectomy or those who received antibiotics during the previous 7â days were excluded. Sequential sampling was used; sample size: 1500 women. The ACON NG and CT duo test combo and the ACON individual test plates for NG and separately for CT were used. The QuickVue Chlamydia rapid test (RT) was also used. All of them were compared with nucleic acid amplification methods. The SD Bioline 3.0 and ACON test for syphilis were evaluated and compared with serological tests. Sensitivity and specificity were estimated. RESULTS: CT RTs had a sensitivity that ranged between 22.7% and 37.7% and specificity between 99.3% and 100%. Sensitivity for NG with ACON Duo was 12.5% and specificity 99.8%. Tests for syphilis had a sensitivity of 91.6-100% and a specificity of 99.7-97.8%. CONCLUSIONS: The RTs studied are not useful for screening for NG at the point of care. In case of CT a recommendation about their use in routine care should be supported by a cost-effectiveness analysis. In screening populations at high risk of sexually transmitted infections or pregnant women, the RTs for syphilis should be used.
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Infecções por Chlamydia/diagnóstico , Gonorreia/diagnóstico , Testes Imediatos , Sífilis/diagnóstico , Infecções Urinárias/diagnóstico , Adolescente , Adulto , Infecções por Chlamydia/prevenção & controle , Infecções por Chlamydia/transmissão , Colômbia/epidemiologia , Estudos Transversais , Feminino , Gonorreia/prevenção & controle , Gonorreia/transmissão , Humanos , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sífilis/prevenção & controle , Sífilis/transmissão , Infecções Urinárias/microbiologia , Saúde da MulherRESUMO
OBJECTIVE: To evaluate whether racial and ethnic disparities exist in obstetric care and adverse outcomes. METHODS: We analyzed data from a cohort of women who delivered at 25 hospitals across the United States over a 3-year period. Race and ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, or Asian. Associations between race and ethnicity and severe postpartum hemorrhage, peripartum infection, and severe perineal laceration at spontaneous vaginal delivery as well as between race and ethnicity and obstetric care (eg, episiotomy) relevant to the adverse outcomes were estimated by univariable analysis and multivariable logistic regression. RESULTS: Of 115,502 studied women, 95% were classified by one of the race and ethnicity categories. Non-Hispanic white women were significantly less likely to experience severe postpartum hemorrhage (1.6% non-Hispanic white compared with 3.0% non-Hispanic black compared with 3.1% Hispanic compared with 2.2% Asian) and peripartum infection (4.1% non-Hispanic white compared with 4.9% non-Hispanic black compared with 6.4% Hispanic compared with 6.2% Asian) than others (P<.001 for both). Severe perineal laceration at spontaneous vaginal delivery was significantly more likely in Asian women (2.5% non-Hispanic white compared with 1.2% non-Hispanic black compared with 1.5% Hispanic compared with 5.5% Asian; P<.001). These disparities persisted in multivariable analysis. Many types of obstetric care examined also were significantly different according to race and ethnicity in both univariable and multivariable analysis. There were no significant interactions between race and ethnicity and hospital of delivery. CONCLUSION: Racial and ethnic disparities exist for multiple adverse obstetric outcomes and types of obstetric care and do not appear to be explained by differences in patient characteristics or by delivery hospital. LEVEL OF EVIDENCE: II.
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Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Lacerações/etnologia , Períneo/lesões , Hemorragia Pós-Parto/etnologia , Complicações Infecciosas na Gravidez/etnologia , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Asiático/estatística & dados numéricos , Parto Obstétrico/efeitos adversos , Episiotomia/estatística & dados numéricos , Feminino , Hispânico ou Latino/estatística & dados numéricos , Humanos , Lacerações/etiologia , Período Periparto , Gravidez , Estados Unidos/epidemiologia , População Branca/estatística & dados numéricos , Adulto JovemRESUMO
The majority of abortions in Colombia continue to take place outside the formal health system under a range of conditions, with the majority of women obtaining misoprostol from a thriving black market for the drug and self-administering the medication. We conducted a cost analysis to compare the costs to the health system of three approaches to the provision of abortion care in Colombia: post-abortion care for complications of unsafe abortions, and for legal abortions in a health facility, misoprostol-only medical abortion and vacuum aspiration abortion. Hospital billing records from three institutions, two large maternity hospitals and one specialist reproductive health clinic, were analysed for procedure and complication rates, and costs by diagnosis. The majority of visits (94%) were to the two hospitals for post-abortion care; the other 6% were for legal abortions. Only one minor complication was found among the women having legal abortions, a complication rate of less than 1%. Among the women presenting for post-abortion care, 5% had complications during their treatment, mainly from infection or haemorrhage. Legal abortions were associated not only with far fewer complications for women, but also lower costs for the health system than for post-abortion care. We calculated based on our findings that for every 1,000 women receiving post-abortion care instead of a legal abortion within the health system, 16 women experienced avoidable complications, and the health system spent US $48,000 managing them. Increasing women's access to safe abortion care would not only reduce complications for women, but would also be a cost-saving strategy for the health system.
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Aborto Induzido , Aborto Legal , Custos de Cuidados de Saúde , Abortivos não Esteroides/uso terapêutico , Aborto Induzido/economia , Aborto Induzido/métodos , Aborto Induzido/estatística & dados numéricos , Aborto Legal/economia , Aborto Legal/métodos , Aborto Legal/estatística & dados numéricos , Adulto , Instituições de Assistência Ambulatorial , Colômbia , Técnicas de Apoio para a Decisão , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Reforma dos Serviços de Saúde , Maternidades , Humanos , Misoprostol/uso terapêutico , Gravidez , Curetagem a Vácuo , Saúde da MulherRESUMO
OBJECTIVE: Until 2006, legal induced abortion was completely banned in Colombia. Few facilities are equipped or willing to offer abortion services; often adolescents experience even greater barriers of access in this context. We examined post abortion care (PAC) and legal induced abortion in two large public hospitals. We tested the association of hospital site, procedure type (manual vacuum aspiration vs. sharp curettage), and age (adolescents vs. women 20 years and over) with service type (PAC or legal induced abortion). STUDY DESIGN: Retrospective cohort study using 2010 billing data routinely collected for reimbursement (N=1353 procedures). We utilized descriptive statistics, multivariable logistic regression and predicted probabilities. RESULTS: Adolescents made up 22% of the overall sample (300/1353). Manual vacuum aspiration was used in one-third of cases (vs. sharp curettage). Adolescents had lower odds of documented PAC (vs. induced abortion) compared with women over age 20 (OR=0.42; 95% CI=0.21-0.86). The absolute difference of service type by age, however, is very small, controlling for hospital site and procedure type (.97 probability of PAC for adolescents compared with .99 for women 20 and over). Regardless of age, PAC via sharp curettage is the current standard in these two public hospitals. CONCLUSION: Both adolescents and women over 20 are in need of access to legal abortion services utilizing modern technologies in the public sector in Colombia. Documentation of abortion care is an essential first step to determining barriers to access and opportunities for quality improvement and better health outcomes for women. IMPLICATIONS: Following partial decriminalization of abortion in Colombia, in public hospitals nearly all abortion services are post-abortion care, not induced abortion. Sharp curettage is the dominant treatment for both adolescents and women over 20. Women seek care in the public sector for abortion, and must have access to safe, quality services.