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

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-

Physical exercise, weight gain, and perinatal outcomes in overweight and obese pregnant women: a systematic review of clinical trials

This study aimed to evaluate the effects of exercise on weight gain and perinatal outcomes among overweight and obese pregnant women, through a systematic review in MEDLINE/PubMed, EMBASE, LILACS, and SciELO. We included ten clinical trials that evaluated the effectiveness of exercise with or without combined diet in the control of gestational weight gain. Three studies were randomized, and methodological quality was assessed using the CONSORT 2010 Checklist, but none met all the criteria. Four studies showed weight gain differences between groups. The majority (60%) of studies showed no differences in perinatal outcomes (mode of delivery, gestational age at birth, birth weight). In conclusion, few studies confirmed the positive effect of exercise in controlling weight gain during pregnancy, thus requiring more research in this direction. Regarding perinatal outcomes, mild to moderate exercise does not appear to be decisive for perinatal outcomes, and is safe for pregnant women with overweight and obesity.Esta revisão objetivou avaliar os efeitos do exercício físico no ganho de peso e nos resultados perinatais de gestantes com sobrepeso e obesidade, através de revisão sistemática da literatura em bases de dados específicas: MEDLINE/PubMed, EMBASE, SciELO e LILACS. Foram incluídos dez ensaios clínicos que avaliaram a efetividade do exercício combinado ou não com dieta no controle do ganho de peso gestacional. Três estudos são randomizados e a qualidade metodológica foi avaliada através do CONSORT 2010 Checklist, porém nenhum deles cumpriu todos os critérios. Quatro estudos obtiveram diferença quanto ao ganho de peso entre os grupos. A maioria dos estudos (60%) não demonstrou diferença quanto aos resultados perinatais (via de parto, idade gestacional ao nascer, peso do recém-nascido). Poucos estudos confirmam o efeito positivo do exercício no controle do ganho de peso gestacional, necessitando mais pesquisas neste sentido. O exercício em intensidade leve a moderada parece não ser determinante nos resultados perinatais, sendo uma prática segura para gestantes com sobrepeso e obesidade.40741

Comparison of two methods for the investigation of maternal mortality in a municipality of the Brazilian Southeast

PURPOSE: to compare maternal death data from the National Death Information System (DIS), with a death survey of 10 to 49 year-old women at reproductive age (RAMOS), in order to identify sub-notification and to search for causes of maternal death (MD) from 1999 to 2006. METHODS: population based temporal series taken from death certificate (DC) information from Fundação Sistema Estadual de Análise de Dados (SEADE) database, with the death causes codified by the International Classification of Diseases (ICD), tenth revision, and the number of born alive babies (BA). Death was categorized into declared, presumptive MD and non-maternal. The identification of cases was done from a list with both the birth and death dates in the municipal morgues, and further information was obtained in the epidemiological sector of the Municipal Committee of Surveillance of Maternal Death (MCSMD). Information on MD was raised in the DIS. Sub-notification rates in cases of declared and non-declared MD were identified, maternal official death rates (MDR) and the adjusted factor for the period were calculated and corrected, and MD cases were reviewed and classified. RESULTS: twelve MD were identified, six of them declared and six non-declared. Sub-notification rate was 50%, giving an adjusting factor equal to 2. The official MDR was 14.7 and the corrected one was 29.4 deaths by 100,000 born alive. In most of the cases, the basic causes of death were mistaken. Direct obstetric causes were more prevalent, among them eclampsia and HELLP syndrome, followed by infections. CONCLUSIONS: political and administrative measures are needed for the effective action of MD survey committees. The prevalence of direct obstetric causes indicates failures in maternal and perinatal care.OBJETIVO: comparar a mortalidade materna declarada pelo Sistema Nacional de Informação sobre Mortalidade (SIM) com a investigação pela pesquisa de óbitos de mulheres em idade reprodutiva (RAMOS), de 10 a 49 anos; identificar a subnotificação e investigar as causas de morte materna (MM) no período de 1999 a 2006. MÉTODOS: série temporal e de base populacional a partir das informações das declarações de óbito (DO), fornecidas em banco de dados pela Fundação Sistema Estadual de Análise de Dados (SEADE) e com as causas de morte codificadas pela Classificação Internacional de Doenças (CID), décima revisão e o número de nascidos vivos (NV). Os óbitos foram categorizados em MM declarada, presumível e não-materna. A identificação dos casos foi feita a partir de listagem com a data de nascimento e de óbito no velório municipal, e as informações complementares ao estudo foram obtidas no Setor de Vigilância Epidemiológica do Comitê Municipal de Investigação da MM (CMIMM). Foram levantadas informações sobre MM contidas no SIM. Nos casos de MM declaradas e não-declaradas, foi identificado o percentual de subnotificação; foram calculadas as razões de mortalidade materna (RMM) oficial e corrigida e o fator de ajuste para o período, e as causas de MM foram revisadas e classificadas. RESULTADOS: foram identificadas 12 MM, sendo seis declaradas e seis não-declaradas. A subnotificação foi de 50%, o que correspondeu a um fator de ajuste igual a dois. A RMM oficial foi 14,7 e a corrigida de 29,4 mortes por 100.000 NV. As causas básicas foram mal atribuídas na maioria dos casos. As causas obstétricas diretas foram mais prevalentes, dentre elas a eclâmpsia e a síndrome HELLP, seguida por infecções. CONCLUSÕES: são necessárias medidas políticas e administrativas para a efetiva atividade dos Comitês de Investigação das MM. A prevalência de causas obstétricas diretas é indicativa de falhas na assistência materna e perinatal.55956

Calcified abdominal pregnancy with eighteen years of evolution: case report

CONTEXT: The lithopedion (calcified abdominal pregnancy) is a rare phenomenon and there are less than 300 cases reported in the medical literature. CASE REPORT: In this case, a 40 year-old patient had had her only pregnancy 18 years earlier, without medical assistance since then. She came to our hospital with pain and tumoral mass of approximately 20 centimeters in diameter. Complementary examinations (abdominal X-ray, ultrasonography and computerized tomography) demonstrated an extra-uterine abdominal 31-week pregnancy with calcification areas. Exploratory laparotomy was performed, with extirpation of a well-conserved fetus with partially calcified ovular membranes.CONTEXTO: O Litopédio (gestação abdominal calcificada) é um fenômeno raro, com menos de 300 casos descritos na literatura. RELATO DE CASO: Uma paciente de 40 anos, teve uma única gestação há 18 anos e não procurou serviço médico desde então. Chegou com dor em baixo ventre e massa tumoral de aproximadamente 20 centímetros. Os exames complementares (radiografia abdominal, ecografia e tomografia computadorizada) evidenciaram gestação de aproximadamente 31 semanas extra-uterina e com áreas de calcificação. Foi realizada laparotomia com extração do feto em bom estado de conservação, envolvido pela membrana parcialmente calcificada.19219

Hialuronidase versus sonda de Foley para o preparo cervical em gestações com indicação de indução de parto

Orientadores : Jose Guilherme Cecatti, Mary Angela ParpinelliTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasDoutorad

Misoprostol versus laminaria no preparo cervical em gestações com obito fetal

Orientador: Jose Guilherme CecattiDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Sabe-se que um colo uterino amadurecido é muito importante para o sucesso de uma indução de parto. Muitos métodos, mecânicos e químicos, de preparo cervical são estudados mundialmente com esse propósito. Entre os primeiros destacam-se as laminárias que mostraram desempenho satisfatório, sendo eficazes e seguras. Dentre os métodos bioquímicos, utilizaram-se estrogênios, relaxina e prostaglandinas (PG). Na atualidade, as PG são utilizadas rotineiramente em muitos países, com eficácia e segurança comprovadas. Não se dispõe no Brasil de nenhum desses métodos para uso comercial de rotina, provavelmente por facilitarem a prática do aborto ilegal. A única PG comercializada com outras finalidades terapêuticas, é a PGE1 metil-análoga (misoprostol), em comprimidos de 200 mcg. Seu uso na prática obstétrica tem aumentado recentemente pelo baixo custo em relação às demais, sem desvantagens em termos de eficácia. Tendo por objetivo de avaliar o grau de modificação cervical com o uso de dois diferentes métodos, realizou-se na Disciplina de Obstetrícia da FCM/UNICAMP um ensaio clínico randomizado e cego, com 60 gestantes que apresentaram óbito fetal, idade gestacional de 16 semanas ou mais e colo uterino com índice de Bishop menor ou igual a cinco, sem atividade uterina. As gestantes foram aleatoriamente divididas em dois grupos, sem diferença significativa com relação às variáveis de controle. Elas tiveram um comprimido de misoprostol ou uma laminaria inseridos intracervicalmente, 24 horas antes de se iniciar a indução ocitócica. Houve diferença de efeitos entre os dois grupos, sendo que 78,9% das mulheres que utilizaram misoprostol evoluíram para parto durante as 24 horas reservadas para o preparo cervical. Não houve diferença significativa quanto às complicações maternas nos dois grupos, tendo sido menores a quantidade de ocitocina utilizada, o tempo de internação e o custo hospitalar no grupo que utilizou misoprostol. Conclui-se que ambos os métodos foram eficazes e seguros e que o misoprostol, na dose e via em que foi utilizado, resultou não só como método eficaz de preparo cervical, mas também de indução de parto nessa população estudada.Abstract: It is recognized the importance of cervical ripening for successful labor induction. Several mechanical and biochemical agents for ripening the cervix are studied all over the world with this purpose. Among the first it is highlighted the laminaria tents which showed a satisfactory performance and are safe and effective. Among the biochemical methods, the estrogen, relaxin and prostaglandins were used. Currently the prostaglandins are routinely used in several countries and their efficacy and safety are documented (PGE2 and PGF2a). In Brazil there are any of such a method available for commercial use because they would make easier the practice of induced abortion. The only prostaglandin available is the PGE, metil-analogue (misoprostol), in tablets with 200 mcg. Recently its use in obstetric practice has been increased by it's low cost compared to others prostaglandins, without disadvantages in terms of efficacy. With the purpose of evaluating the degree of cervical ripening using two different methods, a randomized and blind clinical trial was performed at the Obstetrics Unit of FCM/UNICAMP, including 60 pregnant women who had fetal death, gestational age above 15 weeks and the cervix with a Bishop's score below 6, with no uterine contractions. The women were randomly allocated into two groups, without any significant difference concerning the variables for control. They had a misoprostol tablet or a laminaria tent inserted in the cervical channel 24 hours before starting a labor induction with oxytocin. There was a shift in the effects between both groups and 78.9% of women who used misoprostol were lead to a vaginal delivery within the 24 hours reserved for cervical ripening. There was no significant difference concerning maternal side effects between the two groups. The total amount of oxytocin used, the time of hospitalization and the total hospital costs were lower for the group which used misoprostol. It is concluded that both methods were effective and safe and, in addition, that misoprostol, in the amount and way which was used, has performed not only as an effective method for ripening the cervix, but also as an effective agent for labor induction in this population.MestradoTocoginecologiaMestre em Medicin

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 the