Pré-eclâmpsia : rastreamento universal ou prevenção universal para países de baixa e média-renda?

Pre-eclampsia (PE) is a severe disorder that affects up to 8% of all pregnancies and represents an important cause of maternal and perinatal morbidity and mortality. The screening of the disease is a subject of studies, but the complexity and uncertainties regarding its etiology make this objective a difficult task. In addition, the costs related to screening protocols, the heterogeneity of the most affected populations and the lack of highly effective prevention methods reduce the potential of current available algorithms for screening. Thus, the National Specialized Commission of Hypertension in Pregnancy of the Brazilian Association of Gynecology and Obstetrics Federation (Febrasgo, in the Portuguese acronym) (NSC Hypertension in Pregnancy of the Febrasgo) considers that there are no screening algorithms to be implemented in the country to date and advocates that Aspirin and calcium should be widely used.A Pré-eclâmpsia (PE) é uma doença grave que acomete ~8% das gestações e representa importante causa de morbimortalidade, tanto materna quanto perinatal. O rastreamento da doença émotivo de estudos, porém a complexidade e as incertezas quanto a sua etiologia tornam esse objetivo bastante difícil. Além disso, os custos relacionados com o rastreamento, a heterogeneidade das populações mais afetadas e ainda a falta de métodos de prevenção de grande eficácia reduzem o potencial dos algoritmos de rastreamento. Assim, a Comissão Nacional Especializada sobre Hipertensão na Gravidez da Federação Brasileira das Associações de Ginecologia e Obstetrícia (CNE Hipertensão na Gravidez da FEBRASGO) considera que não há algoritmos de rastreamento que possam ser aplicados no país nesse momento e defende a utilização dos métodos de prevenção como ácido acetilsalicílico e cálcio de maneira ampla

Pré-eclâmpsia/Eclâmpsia

Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age in < 24 weeks, between 24 and less than 34 weeks, and ≥ 34 weeks of gestation, and guidance on route of delivery. An immediate puerperium approach and repercussions in the future life of pregnant women who develop preeclampsia is also presented.A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A pré-eclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgão-alvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas

Avaliação de custos das internações de gestantes hipertensas em Hospital Universitário do interior paulista

This study aimed at identifying the hospitalization costs for delivery of hypertensive pregnant women at Maternity of University Hospital in inner São Paulo state. It is a quantitative, descriptive and exploratory study. For data collection, the direct and indirect costs were identifi ed in order to determine the hospitalization costs of patients diagnosed with arterial hypertension during pregnancy and delivery. After analyzing the results, it was observed that the hospitalization period was of one day during pregnancy and fi ve days for delivery; cesarean section was performed in 64.9% of hypertensive pregnant women; the mean total cost was of R$348,87 (US$ 187.56)/ hospitalization during pregnancy, R$2.656,60 (US$ 1,428.27)/hospitalization for the cesarean section and R$2.316.09 (US$ 1,245.20)/ hospitalization for vaginal delivery. It can be concluded that the analysis of hypertensive patients’ hospitalizations cost is important, since these are hospitalizations that require a special care, leading to increased service costs.Este estudo objetivou identifi car os custos das internações de gestantes portadoras de Hipertensão Arterial na Maternidade de Hospital Universitário do interior de São Paulo. Trata-se de um estudo quantitativo, descritivo e exploratório. Para coleta de dados, foram identifi cados os custos diretos e indiretos para determinação dos custos das internações de pacientes com diagnóstico de Hipertensão Arterial durante a gestação e parto. Após análise dos resultados, verifi cou-se que o tempo de internação foi de um dia durante a gestação e cinco dias para o parto; a incidência de cesárea foi de 64,9% entre as hipertensas; o custo médio total foi de R$348,87/ internação durante a gestação, R$ 2.656,60/internação para o parto cesárea e R$ 2.316,09/internação para o parto vaginal. Conclui-se que é importante a realização de análise dos custos das internações de pacientes hipertensas, pois são internações que necessitam de cuidados especiais e podem elevar os custos do serviço

Applying the maternal near miss approach for the evaluation of quality of obstetric care : a worked example from a multicenter surveillance study

Objective. To assess quality of care of women with severe maternal morbidity and to identify associated factors. Method. This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. Results. 17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase inmaternalmortality ratio, themain factors associated with nonadequate performance were geographic difficulty in accessing health services ( < 0.001), delays related to quality of medical care ( = 0.012), absence of blood derivatives ( = 0.013), difficulties of communication between health services ( = 0.004), and any delay during thewhole process ( = 0.039). Conclusions. This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care

Applying the maternal near miss approach for the evaluation of quality of obstetric care : a worked example from a multicenter surveillance study

Objective. To assess quality of care of women with severe maternal morbidity and to identify associated factors. Method. This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. Results. 17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase inmaternalmortality ratio, themain factors associated with nonadequate performance were geographic difficulty in accessing health services ( < 0.001), delays related to quality of medical care ( = 0.012), absence of blood derivatives ( = 0.013), difficulties of communication between health services ( = 0.004), and any delay during thewhole process ( = 0.039). Conclusions. This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care