A systematic review and meta-analysis of gestational weight gain recommendations and related outcomes in Brazil

Worldwide, different guidelines are used to assess the adequacy of gestational weight gain. This study identified the recommendations for gestational weight gain in Brazilian women. We also determined the proportion of women with adequate weight gain in accordance with these recommendations and the associated perinatal outcomes. A systematic review was performed. A computerized search was conducted utilizing the following databases: PubMed, MEDLINE, Web of Science, Embase, SciELO and Google Scholar. Observational studies of healthy, Brazilian, pregnant women were included. Studies were excluded if they did not provide pregestational weight and gestational weight gain or if they studied women with comorbid conditions. A meta-analysis was performed to evaluate the odds ratio of inadequate (insufficient or excessive) gestational weight gain. Seventeen studies were included in the systematic review and four studies were included in the meta-analysis. The most widely used recommendations were from the Institute of Medicine. Excessive gestational weight gain was associated with fetal macrosomia and high rates of cesarean delivery. Overweight women had a higher risk of excessive gestational weight gain than eutrophic women (OR=2.80, 95%CI=2.22-3.53). There are no standardized recommendations concerning gestational weight gain based on Brazilian population-based data. Many Brazilian women are overweight or obese at the beginning of pregnancy. Overweight pregnant women have a higher risk of excessive gestational weight gain. Excessive gestational weight gain was associated with cesarean delivery and fetal macrosomia

Maternal mortality in Campinas: evolution, under-registration and avoidanc

CONTEXT: Up until a few years ago, maternal mortality did not merit much attention as a worldwide public health issue. The health and social development indicator almost exclusively used was infant death.OBJECTIVE: To study the number, characteristics, basic causes and avoidance of maternal mortality (MM) among women living in the city of Campinas, which occurred between 1985 and 1991, identified from all death certificates of women aged 10 through 49 years. DESIGN: Retrospective and descriptive population-based study. SETTING: University Referal Center.SAMPLES: All eligible death certificates classified as declared and presumed maternal deaths according to the Laurenti criteria for the cause of death were selected and complementary studies of the clinical records were performed. MAIN MEASURES: Day of the week and place of occurrence of death; period of occurrence; transfer from another hospital; number of days from delivery/abortion to death; blood transfusion; opportunity for transfusion; complications; autopsy; basic cause of death.RESULTS: Initially 39 declared maternal deaths were identified and a total of 62 were confirmed by the end of the study. This corresponds to an under-registration rate of 37.1% and to an MM ratio of 45.5 per 100,000 live births. Around three-fourths of these maternal deaths were due to a direct obstetrical cause and were considered avoidable.CONCLUSION: Maternal mortality still is high in the municipality of Campinas, although lower than the mean estimated for Brazil. The predominance of direct obstetric causes and avoidable deaths reinforces the need for public health interventions directed towards avoiding themOBJETIVOS: Estudar o número e as características das mortes maternas, suas causas e evitabilidade, entre mulheres residentes no município de Campinas no período de 1985 a 1991, identificadas entre todas as declarações de óbito de mulheres com idade entre 10 e 49 anos. TIPO DE ESTUDO: Estudo descritivo de base populacional, retrospectivo. MÉTODO: Selecionaram-se, dentre todas as D.O. elegíveis ao estudo, as classificadas quanto à causa básica do óbito como mortes maternas declaradas e presumíveis, segundo os critérios de Laurenti, que foram complementarmente estudadas através de seus prontuários clínicos. RESULTADOS: Identificaram-se 39 mortes maternas declaradas e um total de 62 confirmadas ao fim do estudo, correspondendo a uma subenumeração de 37,1% e a uma RMM de 45,5 por 100.000 NV. Cerca de três quartos dos óbitos maternos aconteceram por uma causa obstétrica direta e foram considerados evitáveis. CONCLUSÃO:A mortalidade materna ainda é elevada no município de Campinas, embora bem menor que a média estimada para o Brasil. O predomínio de causas obstétricas diretas e de óbitos evitáveis reforça a necessidade de medidas de saúde pública para evitá-los.51

A novel body mass index reference range - an observational study

OBJECTIVE: To generate a new body mass index curve of reference values and ranges for body mass index and weight gain during pregnancy and to compare the new curve and weight gain ranges with the currently used references. METHODS: A prospective observational study was conducted with a total of 5,656 weight and body mass index measurements in 641 women with single pregnancy who attended their first prenatal visit before 12 weeks. All the women were over 18 years old and had no medical conditions that would influence body mass index. Data were collected using prenatal charts and medical records during hospitalization for childbirth. A linear regression method was used for standard curve smoothing in the general population and for specific curves according to the baseline body mass index classification. Curves were obtained for the 5th, 10th, 50th, 85th, 90th and 95th percentiles. Concordance between the classification of women using the newly generated and currently used curves was evaluated by percentages and kappa coefficients. The weight gain was compared with the reference values of the Institute of Medicine using Student’s T test. The data were analyzed using SAS software version 9.2, and the significance level was set at 5%. RESULTS: A general reference curve of percentiles of body mass index by gestational age was established. Additionally, four specific curves were generated according to the four baseline body mass index categories. The new general curve offered percentile limits for women according to their initial body mass index and according to the Centers for Disease Control and Prevention limits, showing poor agreement with the currently used curve (48.3%). Women who were overweight or obese when starting prenatal care had higher weight gain than the Institute of Medicine recommendation. CONCLUSIONS: The new proposed curve for body mass index during pregnancy showed weak agreement with the currently used curve. The new curve provided more information regarding body mass index increase using percentiles for general and specific groups of body mass index. Overweight pregnant women showed an upward body mass index trend throughout pregnancy that increased more dramatically than those of other groups of pregnant women, and they also presented a major mean difference between weight gain and the Institute of Medicine recommendation

Pregnancy In Women Undergoing Hemodialysis: Case Series In A Southeast Brazilian Reference Center.

To describe maternal and neonatal outcomes in pregnant women undergoing hemodialysis in a referral center in Brazilian Southeast side. Retrospective and descriptive study, with chart review of all pregnancies undergoing hemodialysis that were followed-up at an outpatient clinic of high- risk prenatal care in Southeast Brazil. Among the 16 women identified, 2 were excluded due to follow-up loss. In 14 women described, hypertension was the most frequent cause of chronic renal failure (half of cases). The majority (71.4%) had performed hemodialysis treatment for more than one year and all of them underwent 5 to 6 hemodialysis sessions per week. Eleven participants had chronic hypertension, 1 of which was also diabetic, and 6 of them were smokers. Regarding pregnancy complications, 1 of the hypertensive women developed malignant hypertension (with fetal growth restriction and preterm delivery at 29 weeks), 2 had acute pulmonary edema and 2 had abruption placenta. The mode of delivery was cesarean section in 9 women (64.3%). All neonates had Apgar score at five minutes above 7. To improve perinatal and maternal outcomes of women undergoing hemodialysis, it is important to ensure multidisciplinary approach in referral center, strict control of serum urea, hemoglobin and maternal blood pressure, as well as close monitoring of fetal well-being and maternal morbidities. Another important strategy is suitable guidance for contraception in these women.375-

Applying the new concept of maternal near-miss in an intensive care unit

OBJECTIVES: The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria. METHODS: In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate's correction or Fisher's exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals. RESULTS: Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially lifethreatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths). CONCLUSIONS: Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care

Systemic Lupus Erythematosus And Pregnancy: Clinical Evolution, Maternal And Perinatal Outcomes And Placental Findings.

Systemic lupus erythematosus is a chronic disease that is more frequent in women of reproductive age. The relationship between lupus and pregnancy is problematic: maternal and fetal outcomes are worse than in the general population, and the management of flare-ups is difficult during this period. The aim here was to compare the outcomes of 76 pregnancies in 67 women with lupus, according to the occurrence or absence of flare-ups. An observational cohort clinical study evaluating the evolution of pregnant women with lupus who were receiving care at the prenatal outpatient clinic, Centro de Atenção Integral à Saúde da Mulher, Universidade Estadual de Campinas (CAISM/Unicamp), between 1995 and 2002. Data were collected on a precoded form. The women were divided into two groups according to the occurrence or absence of flare-ups, as defined by the systemic lupus erythematosus disease activity index (SLEDAI). The presence or absence of flare-ups and renal involvement was considered to be the independent variable and the other results were dependent variables. Flare-ups occurred in 85.3% of cases, and were most significant when there was renal involvement. This was related to greater numbers of women with preeclampsia and poor perinatal outcome. Intrauterine growth restriction was more common in the women with active disease. Placental weight was significantly lower in the women with renal involvement. Flare-ups and renal involvement in lupus patients during pregnancy are associated with increased maternal and perinatal complications.12591-

Conhecimento de adolescentes gestantes sobre o papilomavírus humano

To evaluate the level of information possessed by pregnant adolescents regarding the human papillomavirus (HPV). Methods Descriptive study developed in the adolescent prenatal outpatient clinic of a tertiary hospital from the state of 55o Paulo, Brazil. Data were collected between June and December 2017 following approval from the ethics and research committee (CAAE: 1.887.892/2017). Pregnant adolescents, <= 18 years old, who attended the abovementioned outpatient section, composed the sample. Those diagnosed with a psychiatric disorder and those with hearing or cognitive disabilities were excluded. After acceptance to participate in the present study, the pregnant adolescents signed an Informed Consent Form. Regarding the statistical analysis, the chi-squared test and the Fisher exact test were used. Results Regarding the knowledge about HPV, 123 (80.92%) of the participants had already heard about the subject; for 77 (50.66%), their schools had been the source of the information; 101 (66.45%) did not know how they could be infected by the virus. Age variation did not influence their knowledge on how to prevent themselves from HPV (p = 0.2562). The variable vaccine is associated with HPV prevention (p < 0.0001). Conclusion The pregnant adolescents composing the sample have shown to have knowledge about HPV. However, they do not prevent themselves from it appropriately, given that little more than half of the sample was vaccinated, had not reported an understanding that the use of preservatives and vaccination are effective means of prevention, and did not correlate HPV with uterine cervical cancer415291297Avaliar o nível de informação que as adolescentes gestantes possuem em relação ao papilomavírus humano (HPV). Métodos Estudo descritivo desenvolvido no ambulatório pré-natal adolescente de um hospital terciário do estado de São Paulo, Brasil. Os dados foram coletados entre junho e dezembro de 2017, após a aprovação do comitê de ética e pesquisa (CAAE: 1.887.892/2017). A amostra foi composta por adolescentes gestantes com 18 anos que frequentaram o ambulatório. Foram excluídas as com transtorno psiquiátrico diagnosticado e as portadoras de deficiência auditiva ou de cognição. Após aceitarem participar do presente estudo, as adolescentes grávidas assinaram o termo de assentimento e consentimento livre e esclarecido. Para as análises estatísticas, foram utilizados os testes de qui-quadrado e exato de Fisher. Resultados Em relação ao conhecimento sobre o HPV, 123 (80,92%) já tinham ouvido falar sobre o assunto; destas adolescentes, 77 (50,66%) receberam as informações que tinham através de suas escolas, e 101 (66,45%) pacientes não sabiam como poderiam contrair o vírus. A variação da idade das adolescentes entrevistadas não influenciou se estas sabiam ou não como se prevenir contra o HPV (p ¼ 0,2562). A variável vacina está associada à prevenção contra o HPV (p < 0,0001). Conclusão As gestantes avaliadas possuem conhecimento sobre o HPV, mas não fazem a prevenção adequada, visto que um pouco mais da metade se vacinaram, não relataram o preservativo e a vacina como métodos eficazes de prevenção, e não relacionaram o HPV com o câncer de colo de útero

Situational analysis of facilitators and barriers to availability and utilization of magnesium sulfate for eclampsia and severe preeclampsia in the public health system in Brazil

Background: Eclampsia is the main cause of maternal death in Brazil. Magnesium sulfate is the drug of choice for seizure prevention and control in the management of severe preeclampsia and eclampsia. Despite scientific evidence demonstrating its effectiveness and safety, there have been delays in managing hypertensive disorders, including timely access to magnesium sulfate. To conduct a general situational analysis on availability and use of magnesium sulfate for severe preeclampsia and eclampsia in the public health system. Method: A situational analysis was conducted with two components: a documental analysis on information available at the official websites on the policy, regulation and availability of the medication, plus a cross sectional study with field analysis and interviews with local managers of public obstetric health services in Campinas, in the southeast of Brazil. We used the fishbone cause and effect diagram to organize study components. Interviews with managers were held during field observations using specific questionnaires. Results: There was no access to magnesium sulfate in primary care facilities, obstetric care was excluded from urgency services and clinical protocols for professional guidance on the adequate use of magnesium sulfate were lacking in the emergency mobile care service. Magnesium sulfate is currently only administered in referral maternity hospitals. Conclusion: The lack of processes that promote the integration between urgency/emergency care and specialized obstetric care possibly favors the untimely use of magnesium sulfate and contributes to the high maternal morbidity/mortality rates16sem informaçã

Maternal morbidity and near miss associated with maternal age: the innovative approach of the 2006 Brazilian demographic health survey

OBJECTIVE: To study the prevalence of potentially life-threatening maternal conditions and near miss in Brazil according to maternal age. METHODS: A secondary analysis of the 2006 Brazilian demographic health survey database using a validated questionnaire to evaluate maternal morbidity with a focus on age extremes. The study included 5,025 women with at least 1 live birth in the 5-year reference period preceding their interviews. Three age range periods were used: 15-19 years (younger age), 20-34 years (control), and 35-49 years (advanced maternal age). According to a pragmatic definition, any woman reporting eclampsia, hysterectomy, blood transfusion, or admission to the intensive care unit during her pregnancy/childbirth was considered a near-miss case. The associations between age and severe maternal morbidity were further assessed. RESULTS: For the 6,833 reported pregnancies, 73.7% of the women were 20-34 years old, 17.9% were of advanced maternal age, and only 8.4% were of younger age. More than 22% of the women had at least one of the complications appraised, and blood transfusion, which was more prevalent among the controls, was the only variable with a significant difference among the age groups. The overall rate of maternal near miss was 21.1 per 1000 live births. There was a trend of higher maternal near miss with increasing age. The only significant risk factor identified for maternal near miss was a lower literacy level among older women. CONCLUSIONS: There is a trend towards worse results with increasing age. The investigation of the determinants of maternal near miss at the community level using an innovative approach through a demographic health survey is an example suggested for under-resourced settings

Early menarche and teenager pregnancy as risk factors for morbid obesity among reproductive-age women: A case-control study

OBJECTIVES: The aim of this study was to evaluate potential risk factors, including non-communicable diseases, for morbid obesity in women between 20 and 49 years of age. METHODS: We performed a case-control study with 110 morbidly obese women and 110 women with adequate weight who were matched by age and with a 1:1 case to control ratio. All women were between 20 to 49 years old and non-menopausal. Possible risk factors were evaluated through a self-report questionnaire assessing socio-demographic, obstetric and gynecological characteristics, presence of non-communicable diseases and habits. Multiple logistic regression was used to estimate the odds ratio with respective confidence intervals. RESULTS: Menarche under 12 years old, teenage pregnancy and lower educational level were shown to be risk factors for morbid obesity among women of reproductive age. Incidences of non-communicable diseases (diabetes, hypertension, dyslipidemia, liver disease, lung disease, thyroid dysfunction, and joint pain) were increased in women with morbid obesity. CONCLUSIONS: Early menarche, teenage pregnancy and low education level are risk factors for the occurrence of morbid obesity in women of reproductive age. Some non-communicable diseases were already more prevalent in women with morbid obesity even before 50 years of age