Revista Brasileira de Hematologia E Hemoterapia

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ISSN / EISSN: 15168484 / 18060870
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Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1122-1125; https://doi.org/10.1055/s-0042-1759635

Abstract:
In 2020, Brazil and the whole world faced the COVID-19 pandemic, which caused a high number of deaths. This disease was particularly severe for pregnant and postpartum women and determined a significant increase in the Maternal Death Ratio (MMR). To face the disease and assist health professionals in the qualification of the best care to the maternal-fetal binomial, the Ministry of Health and Febrasgo developed a working group formed by professors and researchers from several universities who worked to establish recommendations for the care of pregnant women and puerperal women by the time of the COVID-19 pandemic. In 2022, while we are still experiencing the COVID-19 pandemic, we are surprised by another disease caused by a virus that has been alarming the population and worrying public health authorities and gynecology and obstetrics societies in Brazil and worldwide. It is the infection that is caused by monkeypox virus (MPXV), which is still a not well-known disease, with many of its characteristics not well determined. The knowledge of this disease is fundamental for health professionals working in Obstetrics to plan forms of prevention, as well as the establishment of the diagnosis and treatment of the monkeypox (MPX) disease, preserving the health of the maternal-perinatal binomial. For this reason, the Brazilian Ministry of Health requested the same working group that acted diligently by the time of COVID-19 to establish recommendations for facing MPX, to provide adequate care for pregnant women and puerperal women. These recommendations, based on the knowledge that exists so far, are what guide these orientations and may change depending on new findings that may be presented over time. The MPXV was named after being identified in laboratory monkeys in 1958. The first case of this virus in humans was recorded in 1970 in a child in Congo and since then has become an endemic disease in West and Central Africa.[1] In 2003, the first cases were registered outside the African continent, in the United States,[2] [3] [4] but that was contained through hygienic measures and stock vaccines. In 2017, there was a major outbreak started in Nigeria and spread to some African countries. In early May 2022, another outbreak of MPXV was identified, this time in several countries outside the African continent, with fast dissemination of cases. As a result, on May 21, 2022, the World Health Organization (WHO) declared the existence of an emerging global outbreak of MPXV infection, and on July 23 has determined that this outbreak constituted a Public Health emergency of international concern. Pregnant women present clinically with similar characteristics to nonpregnant women, but may evolve with greater severity, being therefore considered a risk group. In addition to maternal clinical repercussions, there are also concerns specific to the pregnancy period, such as fetal vitality, the possibility of vertical transmission and perinatal outcome. It has been verified that MPXV infection can lead to adverse results in pregnancy, such as fetal death and spontaneous abortion.[5] [6] A recent publication on the evolution of pregnancy in 4 MPXV-infected women showed spontaneous 1st trimester abortion in 2 pregnant women, without testing of the conception products; an intrauterine death in the 2nd trimester, with clinical, histological and laboratory evidence of intrauterine fetal infection evidencing the very probable vertical transmission of the disease, and a pregnant woman with MPXV infection that evolved with full-term delivery of healthy conceptus.[7] Close and prolonged skin-to-skin contact, including during sexual activity, seems to be the main means of transmission of MPXV. There are suspicions of transmission of this virus by droplets and aerosols. There is also transmission through biting of rodent animals or even the ingestion of those animals. In addition, contagion by phositis, especially used clothing, can transmit the disease. The quick identification and isolation of affected individuals is fundamental to prevent the spreading of the disease.[8] Transmission of MPXV occurs in the phase of active skin lesions and only ends when they heal completely, which usually requires isolation of 21 to 28 days.[7] [9] [10] There are doubts as to whether the contagion could be prior to the phase of skin lesions, since viral DNA has already been identified in the blood and respiratory system of patients prior to the lesions.[5] [7] Sexual transmission has been discussed not only by contact, but also because the virus has been identified in seminal material.[5] [11] Patients with MPXV should be isolated in a separate area of their home or in hospital services, especially if they present extensive lesions and/or respiratory symptoms. Skin lesions should be covered (for example, with the use of long sleeves and trousers) to minimize the risk of contact. Everyone should wear a face mask in the presence of an infected person. Sexual abstinence is also recommended in the phase of unhealed lesions and condom use for any form of sexual act (anal, oral, or vaginal) in the 12 weeks following the healing of the lesions.[7] Most patients with MPXV will have mild disease and can be cared for at home, where they should remain isolated. Standard cleaning and disinfection procedures should be performed, taking care of clothes and used objects. The diagnosis of infection can be made by anamnesis and clinical findings, with epidemiological suspicion. The incubation period is, on average, 6 to 13 days, and can be from 5 to 21 days. Next to this, a prodromal period occurs, when fever, sweating, headache, myalgia, fatigue and lymphadenomegaly, which is quite characteristic of the disease, are manifested. About 1 to 3 days later, the rash, which usually affects the face, genitals, and extremities, and has a centrifugal character, appears. The lesion evolves from macules to papules, vesicles, pustules...
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1083-1089; https://doi.org/10.1055/s-0042-1759728

Abstract:
Objective To compare the efficacy of quadratus lumborum (QL) block and intrathecal morphine (M) for postcesarean delivery analgesia. Methods Thirty-one pregnant women with ≥ 37 weeks of gestation submitted to elective cesarean section were included in the study. They were randomly allocated to either the QL group (12.5 mg 0.5% bupivacaine for spinal anesthesia and 0.3 ml/kg 0.2% bupivacaine for QL block) or the M group (12.5 mg bupivacaine 0.5% and 100 mcg of morphine in spinal anesthesia). The visual analog scale of pain, consumption of morphine and tramadol for pain relief in 48 hours, and side effects were recorded. Results Median pain score and/or pain variation were higher in the morphine group than in the QL group (p = 0.02). There was no significant difference in the consumption of morphine or tramadol between groups over time. Side effects such as pruritus, nausea, and vomiting were observed only in the morphine group. Conclusion Quadratus lumborum block and intrathecal morphine are effective for analgesia after cesarean section. Patients undergoing QL block had lower postoperative pain scores without the undesirable side effects of opioids such as nausea, vomiting, and pruritus.
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1126-1133; https://doi.org/10.1055/s-0042-1760215

Abstract:
Objective The present review aimed to synthesize the evidence regarding mercury (Hg) exposure and hypertensive disorders of pregnancy (HDP). Data Sources The PubMed, BVS/LILACS, SciELO and UFRJ's Pantheon Digital Library databases were systematically searched through June 2021. Study Selection Observational analytical articles, written in English, Spanish, or Portuguese, without time restriction. Data Collection We followed the PICOS strategy, and the methodological quality was assessed using the Downs and Black checklist. Data Synthesis We retrieved 77 articles, of which 6 met the review criteria. They comprised 4,848 participants, of which 809 (16.7%) had HDP and 4,724 (97.4%) were environmentally exposed to Hg (fish consumption and dental amalgam). Mercury biomarkers evaluated were blood (four studies) and urine (two studies). Two studies found a positive association between Hg and HDP in the group with more exposure, and the other four did not present it. The quality assessment revealed three satisfactory and three good-rated studies (mean: 19.3 ± 1.6 out 28 points). The absence or no proper adjustment for negative confounding factor, such as fish consumption, was observed in five studies. Conclusion We retrieved only six studies, although Hg is a widespread toxic metal and pregnancy is a period of heightened susceptibility to environmental threats and cardiovascular risk. Overall, our review showed mixed results, with two studies reporting a positive association in the group with more exposure. However, due to the importance of the subject, additional studies are needed to elucidate the effects of Hg on HDP, with particular attention to adjusting negative confounding.
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1134-1140; https://doi.org/10.1055/s-0042-1759742

Abstract:
Gestational diabetes mellitus (GDM)is an entity with evolving conceptual nuances that deserve full consideration. Gestational diabetes leads to complications and adverse effects on the mother's and infants' health during and after pregnancy. Women also have a higher prevalence of urinary incontinence (UI) related to the hyperglycemic status during pregnancy. However, the exact pathophysiological mechanism is still uncertain. We conducted a narrative review discussing the impact of GDM on the women's pelvic floor and performed image assessment using three-dimensional ultrasonography to evaluate and predict future UI.
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1081-1082; https://doi.org/10.1055/s-0042-1760208

Abstract:
Although rare, vaginal agenesis is a relevant condition for gynecologists, who must be familiar with its current treatment. It results from agenesis of the Mullerian ducts, known as Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS), and the incidence is 1:5000 women. In this congenital malformation, genetic alterations affect the development of Mullerian ducts during the embryonic period and there is complete absence or significant hypoplasia of the uterus and vagina, with normal development of the external genitalia and breasts. More rarely, the absence of the uterus and vagina is identified in patients with 46, XY Disorders of Sex Development (DSD) in which the presence of anti-Mullerian hormone inhibits the formation of the Mullerian ducts. In complete androgen insensitivity (Morris syndrome), the absence of testosterone action on its receptors leads to female differentiation of the external genital organs, and the conversion of testosterone to estrogen in peripheral tissues leads to the development of breasts at puberty. The clinical picture is similar to that of Rokitansky Syndrome, and in most cases, this is the initial diagnosis. The gynecologist will differentiate one from the other; in some cases, the suspicion is based on the lack of pubic and axillary hair and/or the presence of palpable gonads in the inguinal canal, but is confirmed by elevated levels of testosterone and the karyotype. Treatment will be the same as that of Rokitansky's syndrome, except for the recommendation to evaluate the gonads, given the higher risk of developing gonadoblastoma. The current recommendation is to wait for the end of puberty to consider gonadectomy, so that secondary characteristics can develop without the need for hormone replacement therapy.[1] As soon as the diagnosis is confirmed, the treatment of vaginal agenesis involves the steps established by the American College of Obstetricians and Gynecologists (ACOG). It begins by informing and advising the patient and her family about the condition, options and timing of treatment, and explaining about sexual relationships and reproductive future. It also involves referrals to psychological support and encouraging participation in support groups.[1] The approach regarding the formation of the neovagina is well established. The time to perform it is decided by the woman, when she manifests the desire to start a sexual relationship and demonstrates maturity and motivation to understand and participate in treatment, which generally occurs at the end of adolescence. Individual aspects inherent to this decision must be considered, such as the family context, religion and sexual orientation. Since 2006, the ACOG recommends that “Nonsurgical creation of the vagina is the appropriate first-line approach in most patients”.[2] This approach is based on a success rate greater than 90%, which is similar to surgery, although with unquestionably smaller morbidity and costs.[1] [3] Dilation is performed by the patient at home, on a daily basis, after detailed guidance from the gynecologist and supervision and follow-up throughout the process. Monitoring with a specialized physiotherapist is always beneficial, and essential when hypertonicity of the pelvic floor muscles is identified. In Brazil, it is difficult to acquire rigid dilators, which are made of resistant material such as polylactic acid, since they are not commercially available in the country. Adapted devices such as acrylic candles and silicone dilators are commonly used. The use of Additive Manufacturing (AM) technology and the three-dimensional printing device (3D Printer) have shown great potential for contribution and innovation in the health area. The 3D printer can create an object through its digital design. The model is evaluated and recognized by the three-dimensional printing device (3D Printer) through Computer Aided Manufacturing (CAM), the software that performs the processes of reading, analysis and digital slicing. Additive manufacturing technology is based on the deposition of layers to build the physical object.[4] The high customization capacity and the possibility of creating prototypes quickly, as well as the production of objects with complex geometries, have enabled the use of this technology in the development of products in the medical field. Additive manufacturing is also an economically viable technology in the production of small batches of customized products compared to conventional methods, making it an interesting alternative in the production and research of customized products.[4] According to a study by Fernandes et al.[5] published in the current issue, the application of this technology in the production of dilators for vaginal agenesis proved to be effective, economically viable, accessible and reproducible. Therefore, dilators can be produced in a gynecological care service equipped with a 3D printer and a qualified professional, allowing women with vaginal agenesis to have access to the recommended treatment for their condition. In addition to women with agenesis, these molds can also be used in other conditions in which dilation may be necessary, such as strictures and shortening of the vagina after radiotherapy or surgery. There is also the possibility of using it in the manufacture of other devices in Urogynecology, such as customized pessaries for the treatment of genital prolapse and urinary incontinence. The use of 3D printing technology reveals the importance of combining knowledge in the field of technology and health, as it enables the development of products with direct impact on medical treatment, in addition to opening up promising perspectives in other areas of Gynecology. Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted...
Venina Viana de Barros, Eliane Azeka Hase, Cristiano Caetano Salazar, Ana Maria Kondo Igai, , Paulo Francisco Ramos Margarido
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1161-1168; https://doi.org/10.1055/s-0042-1760235

Abstract:
The National Commission Specialized in Venous Thromboembolism and Hemorrhage in Women of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) endorses this document. The production of content is based on scientific evidence on the proposed theme and the results presented contribute to clinical practice. Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil
Savas Ozdemir, Gul Ozel Dogan
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1117-1121; https://doi.org/10.1055/s-0042-1759632

Abstract:
Objective Although obesity can result in high morbidity and mortality in surgical outcomes because of multiple comorbidities, determinants of outcome in obese patients who underwent endometrial cancer surgery remain unclear. The aim of this study is to assess the relationship between body mass index (BMI) and surgical outcomes in obese patients with endometrial cancer. Methods An institutional retrospective review of the demographic details, clinical characteristics, and follow-up data of 142 patients with endometrial cancer who underwent surgery during a 72-month period was performed. The patients were divided into three groups based on their BMI; patients with BMI < 25 were identified as normal weight, patients with BMI between 25 and 30 were accepted as overweight, and those with BMI ≥ 30 kg/m2 were identified as obese. The groups' demographic and clinical variables were compared. Results Of the 142 patients, 42 were in the normal weight group, 55 in the overweight group, and 45 in the obese group. Age, surgical procedures, blood loss, preoperative health status, and metastatic lymph nodes did not show a significant difference between groups. However, surgery time and total lymph nodes were higher in the obese group. (p = 0.02, p = 0.00, and p = 0.00, respectively). Common complications were anemia, fever, intestinal injury, deep vein thrombosis, fascial dehiscence and urinary infection. There was no significant difference according to the complications. Conclusion Our results indicated that higher BMI was significantly associated with a longer duration of endometrial cancer surgery. Minimally invasive surgeries and conventional laparotomy could be performed safely in obese patients. S. O. and G. O. D. designed the study. S. O. and G. O. D. collected the data. S. O. analyzed and interpreted the data. G. O. D. drafted the manuscript. All authors were comprehensively involved in all aspects of the study and in the preparation of the manuscript. All authors have read and approved the final version of the it. Received: 22 May 2022 Accepted: 02 September 2022 Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1141-1158; https://doi.org/10.1055/s-0042-1759774

Abstract:
Objective Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide. Methods This is a review of the literature published in the 21st century on commercial surrogacy. Results A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers. Conclusion Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated. Objetivo A gestação de substituição é o processo no qual uma mulher engravida e entrega um bebê a outra pessoa ou casal, conhecidos como pais pretendidos. Quando as gestantes são pagas, isto é conhecido como gestação de substituição comercial. O objetivo do presente trabalho é rever os aspectos legais, éticos, sociais e culturais da gestação de substituição comercial, bem como o panorama atual em todo o mundo. Métodos Trata-se de uma revisão da literatura publicada no século XXI sobre a gestação de substituição comercial. Resultados Um total de 248 artigos foi incluído nesta revisão. A demanda por tratamentos com gestação de substituição por mulheres sem útero ou com distúrbios uterinos importantes, homens solteiros e casais masculinos está aumentando constantemente em todo o mundo. Este tratamento reprodutivo tem dilemas éticos importantes. Além disso, a legislação é amplamente adiada em todo o mundo e está em constante mudança. Portanto, os pacientes procuram cada vez mais por tratamentos no exterior, o que pode levar a importantes problemas legais entre países com leis diferentes. A gestação de substituição comercial é praticada em vários países, na maioria dos quais não há legislação específica. Alguns países tomaram medidas restritivas contra esta técnica por causa de relatos de exploração destas mulheres. Conclusão A gestação de substituição comercial é uma prática comum, apesar de importantes dilemas éticos e legais. Como consequência de diversas legislações nacionais, os pacientes frequentemente recorrem a programas de gestação de substituição comercial internacionais. Atualmente, não existe um contexto jurídico internacional padrão e esta prática permanece em grande parte não regulamentada. Received: 16 May 2022 Accepted: 25 August 2022 Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil
, Rita López, Luis Altamirano, Sugey Bravo Cabrera, Gusmara Porras Rosales, Sergio Chamorro, Karen González, Amparo Morales, Juliana Maya, Stiven Sinisterra, et al.
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1090-1093; https://doi.org/10.1055/s-0042-1758712

Abstract:
Objective To describe the clinical results of patients admitted and managed as cases of placenta accreta spectrum (PAS) at a Central American public hospital and the influence of the prenatal diagnosis on the condition. Materials and Methods A retrospective analysis of PAS patients treated at Hospital Bertha Calderón Roque, in Managua, Nicaragua, between June 2017 and September 2021. The diagnostic criteria used were those of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French). The population was divided into patients with a prenatal ultrasonographic diagnosis of PAS (group 1) and those whose the diagnosis of PAS was established at the time of the caesarean section (group 2). Results: During the search, we found 103 cases with a histological and/or clinical diagnosis of PAS; groups 1 and 2 were composed of 51 and 52 patients respectively. Regarding the clinical results of both groups, the patients in group 1 presented a lower frequency of transfusions (56.9% versus 96.1% in group 2), use of a lower number of red blood cell units (RBCUs) among those undergoing transfusions (median: 1; interquartile range: [IQR]: 0–4 versus median: 3; [IQR]: 2–4] in group 2), and lower frequency of 4 or more RBCU transfusions (29.4% versus 46.1% in group 2). Group 1 also exhibited a non-significant trend toward a lower volume of blood loss (1,000 mL [IQR]: 750–2,000 mL versus 1,500 mL [IQR]: 1,200–1,800 mL in group 2), and lower requirement of pelvic packing (1.9% versus 7.7% in group 2). Conclusion Establishing a prenatal diagnosis of PAS is related to a lower frequency of transfusions. We observed a high frequency of prenatal diagnostic failures of PAS. It is a priority to improve prenatal detection of this disease.
, Lorgio Rudy Aguilera
Revista Brasileira de Hematologia E Hemoterapia, Volume 44, pp 1159-1160; https://doi.org/10.1055/s-0042-1760216

Abstract:
Dear Editor, We thank Professor Chikazawa et al.[1] for their interest in our paper[2] and for highlighting the importance of simulation during training for the management of placenta accreta spectrum (PAS). There are multiple options to manage PAS and although the disease exhibits a wide variety of clinical presentations (spectrum), most groups choose a single therapeutic alternative and apply it to all their patients, making it difficult to respond when deviations from the original plan arise. Few publications propose a clear sequence of interventions applicable to all types of PAS. Our group uses the protocolized approach described by Palacios-Jaraquemada et al.[3] applicable to patients with suspected prenatal PAS, but also to those diagnosed intraoperatively, considering the nature (predominantly hypervascularization or presence of vesicouterine fibrosis) and the topography of the lesion (which uterine wall is affected, and which is the relationship of the lesion with the vesicouterine peritoneal fold).[3] [4] This protocol includes four steps ([Fig. 1]). First, the evaluation of the available resources and the clinical situation of the patient (to define whether or not to go ahead with the surgery). Doctor Chikazawa et al.[1] rightly point out that the process of training to manage PAS is a long one, and that obstetricians without such training are likely to be faced with the intraoperative finding of PAS. As useful as training in what to do, it is necessary to be very clear about what to avoid in the event of a PAS intraoperative finding, without the appropriate resources (human or technological), the greatest success of the obstetrician would be to avoid a high number of interventions when the clinical situation of the patient allows it. Second, intraoperative staging through 4 actions: opening of the parametrium (to evaluate the lateral uterine wall), digital evaluation of the retrovesical space (Pelosi maneuver), dissection of the retrovesical space by ligating the vesicouterine pedicles (to evaluate the anterior uterine wall), and exteriorization of the uterus to evaluate the posterior uterine wall. Third, the recommended treatment will be chosen (one step conservative surgery, total hysterectomy or modified subtotal hysterectomy) based on the topographic classification,[3] [4] and after answering the three following questions: Is it possible to separate the bladder from the uterus? Is there > 2 cm of healthy myometrium cephalic to the cervix and caudal to the PAS area? Does > 50% of the circumference of the uterus (in an axial section at the level of the PAS area) has healthy myometrium? ([Fig. 1]). Fourth and last, it is essential to have photographic and video recording elements of the surgical procedures to later on debrief, self-assess, and provide research activities that facilitate learning and continuous improvement of the performance of the group. A standardized approach facilitates the construction of a mental map that obstetricians can internalize or consult immediately, facilitating decision-making in the face of a planned or unexpected PAS case. Received: 15 September 2022 Accepted: 26 September 2022 Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil
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