Indirect causes of severe maternal morbidity in Brasil : results from a national cross-section multicenter study

Orientadores: Fernanda Garanhani de Castro Surita, Maria Laura Costa do NascimentoDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Introdução: A mortalidade e morbidade maternas podem ser classificadas segundo suas causas como direta, indireta e acidental (incidentais). As causas indiretas são definidas como condições pré-existentes ou recentemente adquiridas durante a gravidez e que não são causadas por condições obstétricas. Cerca de 27% das mortes maternas podem ser atribuídas às causas indiretas. Além disso, as causas indiretas possuem um potencial de aumento das complicações obstétricas e morbidade perinatal. Há uma dicotomia quando tentamos analisar as causas indiretas em países com alto índice de desenvolvimento e países em desenvolvimento. Em países com alto índice de desenvolvimento as causas indiretas de mortalidade materna são causas de difícil redução como cardiopatias, doenças cerebrovasculares e tromboembolismo. Já em países subdesenvolvidos refletem condições de saúde precárias na população geral, como doenças infecciosas.Objetivo: Identificar a prevalência, principais diagnósticos, resultados perinatais e fatores associados as causas indiretas de morbidade materna grave na Rede Brasileira de Vigilância da Morbidade Materna Grave. Métodos: Análise secundária de Estudo de corte transversal, multicêntrico, implantado em 27 hospitais de diversas regiões do país - Rede Nacional de Vigilância de Morbidade Materna Grave. Foram incluídas gestantes com morbidade materna grave. Definiram-se causas indiretas exclusivas como aquelas em que toda ou qualquer relação com as causas diretas foram excluídas. A partir disso, foram selecionados em 2 grupos para comparação dos dados. Foram definidas as variáveis sociodemográficas, obstétricas, condições clinicas e de manejo. Análise bivariada foi realizada para identificar fatores preditores associados, estimar razões de prevalência (RP) e seus respectivos intervalos de 95% de confiança (IC), ajustados para efeito cluster. Os resultados perinatais e o tipo de parto foram avaliados pela razão de prevalência. Foi realizada análise de regressão múltipla de Poisson. Foram identificados todos os casos de morte materna por causas indiretas. Os softwares utilizados para a análise foram SPSS versão 17 (SPSS, Chicago, IL, EUA) e Stata versão 7.0 (StataCorp, College Station, TX, EUA). Nível sig p 7dias(RP 2.57 [1.74 ¿ 3.81]). 37,8% das mulheres com causas indiretas permaneceram gravidas RP (95%CI) 7.93 [6.04-10.41]. Obesidade apareceu como fator protetor para causas indiretas exclusivas RP (95%CI) 0.45 [0.29 ¿ 0.69] enquanto baixo peso como fator de risco RP (95%CI) 3.23 [1.70 ¿ 6.14]. Número de consultas de pré natal menor que 6 e seguro saúde privado se apresentaram como fator de risco, respectivamente, RP (95%CI) 1.68 [1.36 ¿ 2.06], RP (95%CI) 2.04 [1.35 ¿ 3.08]. As causas indiretas mais prevalentes associadas à morte materna foram H1N1, Sepsis, Câncer e Doença Cardiovascular. Conclusão: A gravidade das causas indiretas exclusivas se evidencia nos indicadores de saúde, onde para cada 2.9 casos de Near Miss Materno ocorreu 1 morte. Mulheres com baixo peso, menor número de consultas de PN e PN fora do SUS apresentaram maior prevalência de Morbidade Materna Grave por causas indiretas exclusivas. O uso de drogas ilícitas aumentou o risco de quadros mais graves (NM+MM). Nos desfechos , permanecer gestante após uma internação por MMG e apgar de 5º minuto 7 days (RP 2.57 [1.74 - 3.81]). 37.8% of the women with indirect causes remained pregnant, presenting a PR (95% CI) 7.93 [6.04-10.41]. Obesity appeared as a protective factor for exclusive indirect causes PR (95% CI) 0.45 [0.29 - 0.69] while underweight as a risk factor PR (95% CI) 3.23 [1.70 - 6.14]. Number of pre-natal consultations less than 6 and private health insurance presented as a risk factor, respectively, PR (95% CI) 1.68 [1.36 - 2.06], PR (95% CI) 2.04 [1.35 - 3.08]. The most prevalent indirect causes associated with maternal death were H1N1, Sepsis, Cancer and Cardiovascular Disease. Conclusion: The severity of exclusive indirect causes is evident in the health indicators, where for each 2.9 cases of NMM there was 1 death among the exclusive indirect causes versus 7.4 cases of NMM for each MM among the other causes. Women with low weight, fewer PN and PN visits outside the SUS showed a higher prevalence of MMG due to exclusive indirect causes. The use of illicit drugs increased the risk of more severe conditions (NM + MM). In the outcomes of these women, remaining pregnant after admission for MMG and apgar of 5 m <7 were more prevalent among MMG due to exclusive indirect causes. The main causes of MM among the exclusive IC of MMg were infection of the H1N1 virus, sepsis, cancer and heart diseaseMestradoSaúde Materna e PerinatalMestra em Ciências da Saúd

Colocando conhecimento em prática: o desafio de adquirir hábitos saudáveis durante a gravidez

Objective: The aim of this study was to investigate the knowledge concerning gestational weight gain (GWG), nutrition, and physical exercise (PE) in pregnant women, and how to put them into practice. Methods: A cross-sectional study with 61 pregnant women above 26 weeks of gestation, at the Woman's Hospital, CAISM, University of Campinas. Questionnaires regarding the knowledge of healthy habits (HH) during pregnancy, sociodemographic data, and previous obstetric outcomes were applied. An educational guide with advice on HH during pregnancy and in the postpartum period was offered. Results: The average age of women was 28.7 +/- 6.23 years, with 85% of them being married; 32% nulliparous; the average body mass index (BMI) before pregnancy was 25.4 +/- 9.8 kg/m(2), and the mean number of years of schooling was 11.2 +/- 3.8. Only 61% of the subjects had received any previous information about GWG during their antenatal care and were aware as to how many pounds they should gain during pregnancy. Among the 61 women, 85% understood that they did not need to "eat for 2" and 99% knew that PE had benefits for their body and was safe for their baby. Half of the women practiced PE prior to pregnancy; however, only 31% continued the practice of PE during the pregnancy. Conclusion: Despite understanding the need for HH during pregnancy, women still need encouragement to practice PE during pregnancy, as well as more information about GWG.418469475Objetivo: O objetivo deste estudo foi investigar os conhecimentos sobre ganho de peso gestacional (GPG), nutrição, e exercício físico (EF) em gestantes e o quanto elas os colocam em prática. Métodos: Estudo transversal realizado no Hospital da Mulher, CAISM, Unicamp, com 61 gestantes acima das 26 semanas gestacionais. Questionários sobre conhecimento de hábitos saudáveis (HS) durante a gestação, dados sociodemográficos, e antecedentes obstétricos foram aplicados. Um guia educacional com conselhos sobre HS durante a gravidez e período pós-parto foi oferecido. Resultados: A idade média das mulheres foi de 28,7 ± 6,23 anos, sendo 85% casadas, 32% nulíparas, o índice de massa corporal (IMC) médio antes da gestação foi de 25,4 ± 9,8 kg/m2, e a média de anos de escolaridade foi de 11,2 ± 3,8. Apenas 61% das mulheres entrevistadas haviam recebido informações prévias sobre o GPG durante o pré-natal e sabiam quantos quilos deveriam ganhar durante a gravidez. Entre as mulheres, 85% sabiam que não precisavam “comer por dois,” e 99% sabiam que o EF tinha benefícios para seu corpo e era seguro para seu bebê. Metade das mulheres praticava EF antes da gravidez, mas apenas 31% continuaram praticando durante a gravidez. Conclusão: Apesar de compreender a necessidade de HS durante a gravidez, as mulheres ainda precisam de incentivo para praticar EF durante a gravidez, bem como mais informações sobre o GPG

Prevalence of sexually transmitted infections and bacterial vaginosis among lesbian women: systematic review and recommendations to improve care

Our aim was to systematically review data about the risk of sexually transmitted infections (STI) and bacterial vaginosis among lesbian women and to suggest strategies to improve prevention, diagnosis and treatment. A search strategy for lesbian, STI and bacterial vaginosis was applied to PubMed, LILACS and BDENF databases. Of 387 unique references retrieved, 22 fulfilled the inclusion criteria (cross-sectional studies reporting prevalence for 8 STIs/bacterial vaginosis and history of a STI). The most frequent infection reported was bacterial vaginosis, and none study reported data on hepatitis B. A wide range of prevalence was observed for most infections. In terms of risk factors, the number of sexual partners, the past or current smoking, a history of forced sex and sexual stigma seem to increase the risk of STI and bacterial vaginosis. The findings of this review are discussed considering guidelines directly addressing the LGBT community’s health and relevant studies investigating both safe sexual practices and the intricate relationship between LGBT people and their care providers. A set of recommendations to improve preventive care for lesbian women is proposed. Affirming that little is known about the extent of STIs and bacterial vaginosis transmission in female-to-female sexual activities or about the risk factors for STI and bacterial vaginosis among lesbian women is reasonable. In fact, the overall quality of the studies was low or very low with significant uncertainty around their findings. However, we consider that the available knowledge indicates some paths to be followed by care providers and policy decision-makers to improve their actions towards better sexual health of lesbian women

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)