Effectiveness of photobiomodulation therapy on pain intensity in postpartum women with nipple or perineal trauma: protocol for a multicentre, double-blinded, parallel-group, randomised controlled trial

INTRODUCTION

Photobiomodulation (PBM) using low-level laser can affect tissue repair mechanisms and seems promising in reducing pain intensity. However, few studies support the effectiveness of PBM on postpartum period complications, such as nipple and/or perineal trauma and pain, probably due to the low doses used. The primary objective of this study is to analyse the effectiveness of PBM on pain intensity in the nipple and perineal trauma in women in the immediate postpartum period. Secondary objectives are to evaluate the effect on tissue healing and the women's satisfaction.

METHODS AND ANALYSIS

A double-blind, multicentre, parallel-group, randomised controlled trial will be performed in two public referral maternity hospitals in Brazil with 120 participants, divided into two arms: 60 participants in the nipple trauma arm and 60 participants in the perineal trauma arm. Participants will be women in the immediate postpartum period, who present with nipple trauma or perineal trauma and report pain intensity greater than or equal to 4 points on the Numerical Rating Scale for Pain. Block randomisation will be performed, followed by blinding allocation. In the experimental group, one application of PBM will be performed between 6 hours and 36 hours after birth. For the sham group, the simulation will be carried out without triggering energy. Both participants and the research evaluator will be blinded to the allocation group. Intention-to-treat method and the between-group and within-group outcome measures analysis will be performed.

ETHICS AND DISSEMINATION

This research protocol was approved by the Research Ethics Committees of the University of Campinas, Brazil, and of the School Maternity Assis Chateaubriand, Brazil (numbers CAAE: 59400922.1.1001.5404; 59400922.1.3001.5050). Participants will be required to sign the informed consent form to participate. Results will be disseminated to the health science community.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (RBR-2qm8jrp).

Physical Exercise Pattern for Undergraduate Students and Its Importance in the Quality of Life, Well-Being, and Future Patient Orientation

Background

This study evaluated physical activity (PA), physical exercise (PE), quality of life (QoL), PE barriers and benefits, contents learned about PA, and related factors of PE practice among undergraduate medical and nursing students.

Methods

This cross-sectional study conducted an online survey. We collected sociodemographic data and previous knowledge regarding PA/PE. We applied the International Physical Activity Questionnaire (IPAQ), Well-being and Quality of Life Index (WHO-5), and scale of benefits and barriers for PE. We performed bivariate, univariate, and multivariate logistic regression analyses.

Results

Participants who exercised were identified as "active" and "very active" by the IPAQ, had better health self-perception, higher general total metabolic equivalent, and higher WHO-5 scores, perceived more PE benefits than barriers, and desired more information about PA/PE.

Conclusion

Undergraduate students should be encouraged to participate in PE. Adequate knowledge could be a resource they value and disseminate to their future patients.

Self-reported exercise or physical activity level: what matters to a better quality of life in the third trimester of pregnancy?

This study evaluated the relationship of self-reported exercise, physical activity (PA) level, and Quality of Life (QoL) among women in their third trimester of pregnancy and verified which factors are associated with physical exercise (PE) and QoL. A cross-sectional study was performed with women who have been pregnant for at least 28 weeks and who can engage in PE. Data on self-reported exercise, sociodemographic characteristics, PA level, and QoL were collected through the International Physical Activity Questionnaire (IPAQ) and the World Health Organization Quality of Life Questionnaire BREF version (WHOQOL-BREF). Frequencies, bivariate analyses, and logistic and linear regression were performed. Among 405 pregnant women, 103 (25.43 percent) reported practicing PE. The self-reported PE was associated with better scores in the physical and environmental domains of the WHOQOL-BREF. Several IPAQ variables and the WHOQOL-BREF environmental score were associated with self-reported exercise. The majority classified as "active" by the IPAQ was due to employment and not the PE practice. A correct conceptual approach to PA and PE during antenatal care has a different impact on health and QoL during pregnancy.

Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis

AIM

Vaginal delivery is a well-known risk factor for pelvic floor muscle (PFM) injuries, mainly when associated to prolonged labor, instrumental birth and perineal trauma such as episiotomy and perineal tears. The purpose of this meta-analysis was to test the hypothesis that episiotomy and severe perineal tear may increase the risk of pelvic floor damage.

METHODS

We performed a systematic literature search through electronic databases including MEDLINE via PubMed, LILACS via BVS, Embase via Elsevier and Cochrane Library up to January 2019. We included articles that reported as outcome one or more morphological aspects of the PFM evaluated by ultrasonography in primiparous women three to 24 months postpartum. This review is registered in the PROSPERO database (registration number: CRD42017075750).

RESULTS

the final selection was composed of 18 articles for the systematic review, and 10 for the meta-analysis. Women with levator ani muscle (LAM) avulsion were 1.77 times more likely to have undergone episiotomy (OR = 1.77, CI 95% 1.25-2.51, five trials), 4.31 times more likely to have severe perineal tear (OR = 4.31, CI 95% 2.34-7.91, two trials). Women with defects in the anal sphincters were 2.82 times more likely to have suffered severe perineal tear (OR = 2.82, 95% CI 1.71-4.67, three trials).

CONCLUSIONS

Both episiotomy and severe perineal tear are risk factors for LAM avulsion and anal sphincter injury, and this can be useful for identifying women who are at greater risk of developing PFM dysfunctions.

Relationship between maternal adverse childhood experiences and infant development: A systematic review (protocol)

INTRODUCTION

Twenty years ago, the first study was conducted to access adverse childhood experiences (ACEs) and their relation to outcomes in adulthood. The effects of exposure to childhood trauma can also be transmitted to other generations. There are some studies that suggest the hypothesis that intergenerational transmission may begin during intrauterine life through the change in placental-fetal physiology due to maternal exposure to adverse events in childhood. Those exposures can lead to a variety of conditions such as altered brain architecture, increase in placental corticotrophin hormone (pCRH) at the end of gestation, or emotional and behavioral changes during childhood and adolescence. The systematic review, therefore, is established to determine if there is a reliable association between maternal ACEs in childhood and altered child development.

METHOD

We will conduct a systematic review according to the guidelines of the meta-analysis of observational studies in epidemiology (MOOSE) and with the preferred reporting items for systematic review with a focus on health equity (PRISMA-E). A comprehensive search strategy will be conducted in the following databases: MEDLINE, EMBASE, CINAHL, Web of Science, SCOPUS, Lilacs, and SciELO. Following a 2-step screening process, data including the full reference, objectives, target population, description of the exposure (ACEs), outcome measures, study design, length of follow-up period, and the study results will be extracted, synthesized, and reported. Risk of bias and quality of the studies will also be assessed.

DISSEMINATION AND ETHICS

The results of this review will be disseminated through peer-reviewed publication. Because all of the data used in this systematic review has been published, this review does not require ethical approval.

DISCUSSION

This systematic review of the last 20 years will summarize and present the evidence for the relationship between maternal ACEs and the development of her child.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO #CRD42018111456.

Body Mass Index Changes during Pregnancy and Perinatal Outcomes - A Cross-Sectional Study

OBJECTIVE

 To evaluate the relation between changes the body mass index (BMI) percentile, reflected in the Atalah curve, and perinatal outcomes.

METHODS

 A cross-sectional study with 1,279 women was performed. Data regarding gestational weight, sociodemographic characteristics and perinatal outcomes were collected through medical charts, prenatal card and interviews in the postpartum period. Women could be classified according to the Atalah curve in the following categories: low weight, adequate weight, overweight, and obese. The BMI was calculated at the first and at the last prenatal care visits, and these values were compared.

RESULTS

 An increase in the BMI category according to the Atalah classification occurred in 19.9% of pregnant women, and an increase of 3.4, 5.8 and 6.4 points of BMI were found for women respectively classified in the adequate weight, overweight and obese categories at the first prenatal visit. Women with high school education presented a lower chance of increasing their BMI (odds ratio [OR] 0:47 [0.24- 0.95]). Women who evolved with an increase in the the Atalah classification were associated with cesarean section (OR 1.97-2.28), fetal macrosomia (OR 4.13-12.54) and large for gestational age newborn (OR 2.88-9.83).

CONCLUSION

 Pregnant women who gained enough weight to move up in their BMI classification according to the Atalah curve had a higher chance of cesarean section and macrosomia. Women classified as obese, according to the Atalah curve, at the first prenatal visit had a high chance of cesarean section and delivering a large for gestational age newborn.

The misleading choice for safer births in Brazilian's most developed region: a cross-sectional study

PURPOSE

To analyze the Cesarean Section (CS) rate in Brazilian women according to category of health insurance and individual characteristics associated with the mode of delivery.

MATERIALS AND METHODS

A cross-sectional study was performed in three maternity services (one public tertiary referral center, one maternity service for both public and private care, and one private maternity service) in Campinas city, Brazil. Eligibility criteria were: inpatient during the immediate postpartum period, hospital birth, single pregnancy, and live newborn. Sociodemographic and anthropometric data, reproductive history, pregnancy planning, and prenatal care information was obtained from participants. Comorbidities, type of birth, and newborn data were collected from medical records. The mode of delivery was categorized as either CS or vaginal delivery.

RESULTS

A total of 1276 women were included in this study. The overall CS rate was 57.5%. CS rates were 41.6, 54.8, and 90.1% for public, mixed (public and private), and private maternity services, respectively. Mean age was higher in women who had a CS (28.0 ± 6.0 years versus 25.9 ± 6.5 years, p < .0001) as was the mean Body Mass Index (25.2 ± 5.3 kg/m² versus 23.8 ± 4.5 kg/m², p < .0001). CS was related to higher education, employment, white skin color, planned pregnancy, antenatal care in a private service, and primiparity.

CONCLUSIONS

The overall CS rate was high (greater than 50%); in the private service, almost all participants had a CS delivery (90.1%). Better socioeconomic conditions and primiparity were associated with higher CS rates in Brazil. Political pressure for the management of unnecessary CSs is vital in Brazil. Together with the provision of real incentives for normal deliveries in public and, most importantly, private services.

Influence of body mass index on the frequency of lymphedema and other complications after surgery for breast cancer

ABSTRACT Objective: this study assessed the influence of pre-operative body mass index (BMI) has upon lymphedema, scar tissue adhesion, pain, and heaviness in the upper limb at two years after surgery for breast cancer. Methods: retrospective analysis of 631 medical records of women who underwent surgery for breast cancer and were referred to the Physiotherapy Program at Prof. Dr. José Aristodemo Pinotti Women's Hospital of the Center for Integral Women's Health Care, CAISM/UNICAMP between January 2006 and December 2007. Results: mean age of women was 56.5 years (±13.7 years) and the most part (55%) were overweight or obese, surgical stages II and III were present in 63% of women studied. Radical mastectomy was the most frequent surgery (54.4%), followed by quadrantectomy (32.1%). In the first year after surgery, there was no significant association between BMI categories and incidence of scar tissue adhesion, pain, heaviness and lymphedema. In the second year, overweight and obese women had higher rates of heaviness in the upper limb and lymphedema. For lymphedema, there was a significant difference among BMI categories (p=0.0268). Obese women are 3.6 times more likely to develop lymphedema in the second year after surgery (odds ratio 3.61 95% CI 1.36 to 9.41). Conclusion: BMI ≥25kg/m2 prior to treatment for breast cancer can be considered a risk factor for developing lymphedema in the two years after surgery. There was no association between BMI and the development of other complications.

Physical Activity Patterns and Factors Related to Exercise during Pregnancy: A Cross Sectional Study

Objective

To assess the physical activity levels of pregnant women and to examine the characteristics associated with the practice of exercise and the activities of daily living during pregnancy.

Methods

For this cross-sectional study, 1,279 women were recruited within 72 hours postpartum. They were interviewed about their socio-demographic data and obstetric history and were administered self-report questionnaires about exercise and daily physical activities during pregnancy. Data on the current pregnancy, labor, delivery, and newborn outcomes were collected from participants’ medical records. To analyze factors related to the practice of exercise, we used the student t-test, X², and odds ratio (OR), with a corresponding 95% confident interval (CI), followed by a multiple logistic regression. The significance level was 5%.

Results

Compared to the pre-pregnancy period, the prevalence of physical activity among participants was lower throughout pregnancy (20.1%) (p = 0.01). Half of the women interrupted practicing physical exercise due to pregnancy. The lowest prevalence of exercise was observed in the first (13.6%) and third trimesters (13.4%). Less than half of women received exercise guidance during prenatal care meetings (47.4%). Walking was the most commonly reported exercise, followed by water aerobics. Factors positively associated with exercise practice were higher educational level (OR= 1.82; CI 95% 1.28–2.60), primiparity (OR=1.49; CI 95% 1.07–2.07), exercising before pregnancy (OR= 6.45; CI 95% 4.64–8.96), and exercise guidance during prenatal care (OR=2.54; CI 95% 1.80–3.57). Mildly intense exercise and domestic activities were most frequently reported among pregnant women. There were no differences in maternal and perinatal outcomes between active and sedentary pregnant women.

Conclusion

The findings indicate that promoting physical activity remains a priority in public health policy, and women of childbearing age, especially those planning a pregnancy, should be encouraged to adopt an exercise routine or maintain an active lifestyle during pregnancy in order to avoid sedentary- and obesity-associated risks.

Postpartum Women's Perspectives on the Donation of Placentas for Scientific Research in Campinas, Brazil

Little is known about public perspectives of scientific and therapeutic uses of placentas. Gaps in knowledge potentiate ethical and clinical problems regarding collection and applications. As such, this study sought to assess the perspectives of placenta donation of a sample of women. Postpartum women's perspectives on placental donation were assessed at the State University of Campinas in the Centro de Atençäo Integral a Saúde da Mulher (CAISM) maternity hospital using a cross-sectional survey (n = 384) and semi-structured interviews (n = 12). Surveys were analyzed quantitatively and interviews were analyzed qualitatively using grounded coding; results were compared. The average age of respondents was 27. Fifty-six percent had more than one child, 45% were Caucasian, 38% were mixed-race, 74% identified with a Christian faith, 52% had high school education or higher, 13% regarded the placenta as spiritually important, 72% felt that knowing what happens to the placenta after birth was somewhat or very important, 78% supported the use of the placenta in research and medicine, 59% reported that consent to collect the placenta was very or somewhat important, 78% preferred their doctor to invite donation, and only 7% preferred the researcher to invite donation. Interviews suggested women appreciate being part of research and that receiving information about studies was important to them. Informed by these results, we argue that women support scientific and therapeutic uses of placentas, want to be included in decision making, and desire information about the placenta. Placentas should not be viewed as "throwaway" organs that are poised for collection without the involvement and permission of women. Women want to be meaningfully included in research processes.

OS020. Effects of exercise on maternal and neonatal outcomes in pregnantwomen with chronic hypertension and/or previous preecampsia: A randomized clinical trial

INTRODUCTION

Chronic hypertension (CH) and previous preeclampsia (PE) are considered risk factors for developing PE. Physical activity (PA) has been proposed as an important part of hypertension's treatment and has been studied as a possibility for the prevention of PE and its complications.PA is recommended during pregnancy because it may be beneficial to maternal health.Furthermore, it is considered a safe activity for the mother and fetus.

OBJECTIVES

The objective of this study was to assess the association between exercise in pregnant women with CH and/or previous PE and type of delivery, maternal and neonatal outcomes.

METHODS

Randomized clinical trial performed between January, 2008 and November, 2011, at the Women's Hospital Dr.José Aristodemo Pinotti-CAISM/Unicamp, Brazil, enrolled 116 pregnant women presenting CH, previous PE or both factors associated.Women from 12 to 20 gestational weeks were selected from the prenatal outpatient clinic and randomly allocated to the study (SG) or non-interventional group (NIG). Women at the SG performed physical exercise using stationary bicycle (horizontal bench model) during 30min, once a week, under physical therapist supervision.The HR was maintained at 20% above resting heart rate and up to 140 beats per minute.The NIG followed regular prenatal routine.After birth the data related to type of delivery, maternal and neonatal outcomes were collected from medical records and analyzed comparing groups.The statistical analyzes was performed by Chi-square test and Fisher'sexact test.The program was SAS 9.1 version.Significance was assumed as p<0.5%.

RESULTS

We had 6 drop-outs and 7 that did not deliver at our hospital and we could not retrieve the data.A total of 103 pregnant women were analyzed (53 in the SG and 50 in the NIG). The mean age was 31.4±5.9 and mean of Body Mass Index (BMI) was 34.9±7.9kg/m(2).Considering the sociodemographic and clinical characteristics the SG and NIG were similar and homogeneous.The average exercise sessions conducted by the SG was 10.11 sessions.The cesarean rate was 69.9% in this study, and the most prevalent indication was cephalopelvic disproportion with 34.3%.However, no statistical differences was observed between groups on type of delivery (p= 0.1901), indications for cesarean delivery and maternal outcomes, including maternal morbidity, rate of PE events and admission in the Intensive Unit Care (ICU). The neonatal outcomes were no significant differences:newborn weigh (p=0.69), adequacy for gestational age (p=0.40), gestational age by recent ultrasound (p=0.20), Apgar 1 min scores (p=0.12), Apgar 5 min score (p=0.24), admission to the ICU (p=0.95) and neonatal morbidity (p=0.39).

CONCLUSION

Exercise using stationary bicycle in pregnant women of high risk for PE (CH and/or previous PE) performed once a week, under physical therapist supervision does not seem to interfere in the type of delivery or maternal and neonatal outcomes. This study suggests that exercise with controlled intensity is safe, with no additional harm towards newborn health and with possible benefits to women's future health.

The effect of an antenatal physical exercise programme on maternal/perinatal outcomes and quality of life in overweight and obese pregnant women: a randomised clinical trial

OBJECTIVE

To evaluate the effectiveness and safety of physical exercise in terms of maternal/perinatal outcomes and the perception of quality of life (QoL) in pregnant obese and overweight women.

DESIGN

A randomised controlled clinical trial.

SETTING

The Prenatal Outpatient Clinic of the Women's Integral Healthcare Centre (CAISM-UNICAMP) at the University of Campinas, Campinas, Brazil.

POPULATION

Eighty-two pregnant women (age ≥ 18 years; pre-gestational body mass index ≥ 26 kg/m(2) ; gestational age 14-24 weeks).

METHODS

Women were randomised into two groups: women in one group exercised under supervision and received home exercise counselling (the 'study group'; n = 40) and women in the other group followed the routine prenatal care programme (the 'control group'; n = 42).

MAIN OUTCOME MEASURES

Primary outcomes were gestational weight gain during the programme and excessive maternal weight gain. Secondary outcomes were increased arterial blood pressure, perinatal outcomes and QoL (WHOQOL-BREF).

RESULTS

In the study group, 47% of pregnant women had weight gains above the recommended limit, compared with 57% of women in the control group (P = 0.43). There was no difference in gestational weight gain between the groups. Overweight pregnant women who exercised gained less weight during the entire pregnancy (10.0 ± 1.7 kg versus 16.4 ± 3.9 kg, respectively; P = 0.001) and after entry into the study (5.9 ± 4.3 kg versus 11.9 ± 1.5 kg, respectively; P = 0.021) compared with women in the control group. Arterial blood pressure was similar between the groups over time. There was no difference in perinatal outcome or QoL.

CONCLUSIONS

The exercise programme was not associated with control of gestational weight gain in our sample as a whole, but was beneficial for lower gestational weight gain in overweight women. Exercise was not associated with adverse perinatal outcomes and did not affect variation in arterial blood pressure or the perception of QoL.