Delays in obstetric care increase the risk of neonatal near-miss morbidity events and death: a case-control study.

BACKGROUND: To evaluate the association between delays in obstetric care and neonatal near-miss mortality events and death in a public maternity referral center. METHODS: This case-control study enrolled 142 neonates, meeting the near-miss criteria of 5-min Apgar < 7, weight < 1500 g, gestational age < 32 weeks, and use of mechanical ventilation or congenital malformation, as well as 284 controls (without the near-miss criteria), at a ratio of 1:2. After follow-up, the following outcomes were reclassified: survival of the neonatal period without the near-miss criteria (true "controls"), "near-miss," and "neonatal death." Maternal sociodemographic characteristics, prenatal care, and pregnancy resolution were evaluated. Pearson's chi-square and Fisher's exact tests were used. Simple logistic regression was performed to determine the association between the three delay factors with near-miss outcomes and/or neonatal death. The variables that had maintained values of p < 0.05 were subjected to multinomial logistic regression. RESULTS: Comparisons revealed the following associations: for controls and near-miss events, delayed access to health services due to a lack of specialized services (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.8-5.1) and inappropriate conduct with the patient (OR, 12.1; 95% CI, 1.3-108.7); for controls and death, absent or inadequate prenatal care (OR, 3.3; 95% CI, 1.6-7.1) and delayed access to health services due to a lack of specialized services (OR, 2.5; 95% CI, 1.1-5.6); and for near-miss events and death, absent or inadequate prenatal care (OR, 2.2; 95% CI, 1.0-5.0). Logistic regression for the combined outcome (near-miss plus neonatal deaths) revealed absent or inadequate prenatal care (OR, 1.9; 95% CI, 1.2-2.8), lack of specialized services (OR, 2.8; 95% CI, 1.7-4.5), and improper conduct with the patient (OR, 10.6; 95% CI, 1.2-91.8). CONCLUSIONS: The delays in obstetric care associated with the presence of near-miss and/or neonatal death included absent or inadequate prenatal care, delayed access to health services due to a lack of specialized services, and inappropriate conduct with the patient.

Maternal predictors related to quality of life in pregnant women in the Northeast of Brazil.

BACKGROUND: Gestation is a period that can positively or negatively influence the life of a woman in the pregnancy-puerperal cycle. Thus, evaluating the quality of life of this population can redirect the implementation of innovative practices, with the goal of making them more effective and practical or the promotion of humanized care. The present study aimed to evaluate the predictors that influence the health-related quality of life of low-risk pregnant women, as well as to describe the main areas affected in the quality of life of pregnant women. METHODS: A correlational, quantitative and cross-sectional study was carried out in two public units that provide prenatal care services and a private unit in the city of Fortaleza, a municipality in the Northeast of Brazil. The sample consisted of 261 pregnant women who were interviewed from September to November 2014. The collection instruments were a questionnaire covering sociodemographic, obstetric and quality of life variables, in addition to the Brazilian version of the Mother-Generated Index (MGI). The data were compiled and analyzed through the Statistical Package for the Social Sciences (SPSS) software, version 20.0. A descriptive analysis was performed through the application of Pearson's chi-square test, Fisher's exact test and one-way ANOVA. Maternal predictors for the quality of life of pregnant woman were identified through a multivariate analysis/multiple regression. RESULTS: The response rate was 100%, corresponding to 261 respondents. Occupation, parity, partner support, marital status and persons with whom the women live were the predictors that positively interfered in the quality of life of pregnant women. In contrast, gestational age, type of housing, occupation, use of illicit drugs, non-receipt of partner support and maternal age were the predictors that negatively influenced quality of life. CONCLUSION: Our results indicate that happiness to become a mother and body image were areas with the greatest positive and negative influence on health-related quality of life, which suggests being relevant aspects in the planning and implementation of actions aimed at its improvement.

Comparison between near miss criteria in a maternal intensive care unit.

OBJECTIVE: The aim of this study was to compare the incidence of different criteria of maternal near miss in women admitted to an obstetric intensive care unit and their sensitivity and specificity in identifying cases that have evolved to morbidity. METHOD: A cross-sectional analytical epidemiological study was conducted with women admitted to the intensive care unit of the Maternity School Assis Chateaubriand in Ceará, Brazil. The Chi-square test and odds ratio were used. RESULTS: 560 records were analyzed. The incidence of maternal near miss ranged from 20.7 in the Waterstone criteria to 12.4 in the Geller criteria. The maternal near-miss mortality ratio varied from 4.6:1 to 7.1:1, showing better index in the Waterstone criteria, which encompasses a greater spectrum of severity. The Geller and Mantel criteria, however, presented high sensitivity and low specificity. Except for the Waterstone criteria, there was an association between the three other criteria and maternal death. CONCLUSION: The high specificity of Geller and Mantel criteria in identifying maternal near miss considering the World Health Organization criteria as a gold standard and a lack of association between the criteria of Waterstone with maternal death.

Reference Ranges of Fetal Cardiac Biometric Parameters Using Three-Dimensional Ultrasound with Spatiotemporal Image Correlation M Mode and Their Applicability in Congenital Heart Diseases.

To determine reference values for fetal heart biometric parameters using the spatiotemporal image correlation (STIC) M mode and their applicability in congenital heart diseases (CHDs). A cross-sectional prospective study was conducted with 300 singleton pregnancies between 20 and 33 + 6 weeks of gestation. Right ventricular wall thickness (RVWT), interventricular septum thickness (IVST), and left ventricular wall thickness (LVWT) were measured off-line using the STIC-M mode with the cursor perpendicular to the interventricular septum. Polynomial regressions adjusted with the coefficient of determination (R 2) were performed. The curves were applied to 14 fetuses with structural CHD. For the reproducibility calculations, the concordance correlation coefficient (CCC) was used. The mean RVWT, IVST, and LVWT were 0.34 ± 0.09 cm, 0.28 ± 0.09 cm, and 0.30 ± 0.07 cm, respectively. There was correlation between RVWT, IVST, and LVWT and gestational age (GA): RVWT = -0.002 + 0.013 × GA (R 2 = 0.33), IVST = -0.011 + 0.011 × GA (R 2 = 0.25), and LVWT = 0.056 + 0.009 × GA (R 2 = 0.26). RVWT, IVST, and LVWT were altered (<5th or >95th percentile) in 5/14, 5/14, and 7/14 of the fetuses with CHD, respectively. For RVWT, IVST, and LVWT, intra-observer (CCC = 0.86, 0.85, and 0.87, respectively) and inter-observer (CCC = 0.86, 0.86, and 0.86, respectively) reproducibility were good/moderate. The reference ranges determined for fetal heart biometric parameters using STIC-M had good intra- and inter-observer reproducibility and were applicable to fetuses with CHD.

Associated ultrasonographic findings in fetuses with microcephaly because of suspected Zika virus (ZIKV) infection during pregnancy.

OBJECTIVE: To describe fetal ultrasonographic findings and outcomes in a series of cases of fetal microcephaly associated with Zika virus infection. METHODS: Retrospective case series of microcephaly with definite (laboratory evidence) or highly probable (specific neuroimaging findings and negative laboratory results) maternal Zika virus infection. Microcephaly was graded as mild if the head circumference was between 2 and 3 standard deviation (SD) below the mean, and severe if 3 or more SD below the mean. Associated central nervous system (CNS) and extracranial malformations are described. RESULTS: Nineteen singleton pregnancies fulfilling the inclusion criteria were identified. Severe microcephaly and mild microcephaly were identified in 14 and 5 fetuses, respectively. Additional CNS malformations were present in 17 cases and 7 had extracranial congenital anomalies. Symptoms were reported in 13/19 cases at a gestational age between 5 and 16 weeks. Mean (±SD) gestational age at ultrasound diagnosis was 32.3 ± 5.1 weeks. Amniocentesis was performed in five cases at a median gestational age of 31 weeks (range 28-38) and was positive for Zika virus RT-PCR in two cases. There were three neonatal deaths and one stillbirth. CONCLUSION: In the presence of fetal microcephaly associated with Zika virus infection, CNS malformations are frequently detected. © 2016 John Wiley & Sons, Ltd.

Ductus venosus versus cerebral transverse sinus Doppler velocimetry for predicting acidemia at birth in pregnancies complicated by placental insufficiency.

OBJECTIVES: The objectives of this study is to compare ductus venosus (DV) and cerebral transverse sinus (CTS) Doppler velocimetry for predicting acidemia at birth in pregnancies complicated by placental insufficiency. METHODS: A prospective cross-sectional study involving 69 cases. Doppler assessment of the DV and CTS was carried out in the last 24 hours prior to delivery. The sensitivity, specificity, positive and negative predictive values, and the accuracy and false-positive and false-negative rates were calculated for those parameters considered to be good predictors of acidemia. The McNemar test was used to compare the various parameters. RESULTS: The DV pulsatility index(PI), S/A, and (S - A)/S ratios as well as the CTS PI and the (S - A)/S ratio were good predictors of acidemia. The comparison between DV and CTS showed that for pulsatility index for veins, the sensitivity was 52.4% versus 66.7%, p = 0.508; the specificity was 81.2% versus 77.1%, p = 0.774; and the accuracy was 72.5% versus 73.9%, p = 1.00. For the (S - A)/S ratio the sensitivity was 52.4% versus 52.4%, p = 1.00; the specificity was 85.4% versus 79.2%, p = 0.508; and the accuracy was 75.4% versus 71%, p = 0.647. CONCLUSIONS: In pregnancies with placental insufficiency, the PI and the (S - A)/S ratio of both DV and CTS were equally effective in predicting acidemia at birth.

Maternal-fetal alloimmunization: perinatal outcomes in a reference hospital in Northeastern Brazil.

OBJECTIVE: To assess the prevalence of maternal alloantibodies in pregnant women at a maternity hospital in northeastern Brazil and describe their perinatal outcomes. METHODS: A retrospective cohort study reviewed maternal and newborn medical records between January 2017 and October 2018 to assess for the presence of maternal alloantibodies. RESULTS: The following maternal alloantibodies were found in the 41 cases surveyed: anti-D, 28 cases (45%); anti-C, 7 cases (11%); anti-c, 1 case (1.6%); anti-E, 4 cases (6.4%); anti-Cw, 1 case (1.6%); anti-K, 2 cases (3.2%); anti-Jka, 1 case (1.6%); anti-M, 3 cases (4.8%); anti-Fya, 2 cases (3.2%); anti-Fyb, 1 case (1.6%); anti-Lea, 5 cases (8%); anti-Leb, 3 cases (4.8%); and anti-Dia, 4 cases (6.4%). Anti-D antibodies were the most frequent cause of erythrocyte alloimmunization (80%). Fetal anemia was observed in four pregnancies based on the peak systolic velocity of the middle cerebral artery. In one case, the mother showed anti-M, and anti-Lea alloimmunization, but the direct antiglobulin test results for the newborn were negative, and no unfavorable neonatal outcomes were observed. In one case of a mother with anti-C and anti-D alloimmunization, the neonate showed anti-D antibodies only in the serological panel and required phototherapy. Neonates with plasma antibodies and jaundice requiring phototherapy only had a serological panel with anti-D, anti-C, anti-c, and anti-E antibodies. Intervention was required for 2.5% of pregnant women with positive antibody screens and 81% of newborns with positive direct antiglobulin test results. CONCLUSION: Despite being a rare condition, maternal alloimmunization by irregular antibodies can result in high perinatal morbidity and mortality.

Ultrasound evaluation of subcutaneous and visceral abdominal fat as a predictor of gestational diabetes mellitus: a systematic review.

OBJECTIVE: Studies of subcutaneous and visceral abdominal fat thickness evaluated by ultrasound as a predictor of gestational diabetes mellitus (GDM) have been published, but the best technique and standardization are unknown. To identify, critically evaluate, and analyze studies using subcutaneous and visceral abdominal fat as a model for predicting GDM in the first and second trimesters of pregnancy and evaluate their methodological quality. METHODS: PubMed, Scopus, and Web of Science databases were searched from May to July 2019. We included studies of any sample size performed for any duration and in any configuration. Model development and validation studies were eligible for inclusion. Two authors independently performed the eligibility assessment of the studies by reviewing the titles and abstracts. Data on study design, gestational age, diagnostic criteria for GDM, device, ultrasound fat measurement technique, and cutoff point for GDM prediction were extracted. RESULTS: The electronic search resulted in 1331 articles, of which 14 were eligible for systematic review. Different criteria for diagnosing GDM and fat measurement techniques were used. The cutoff point for subcutaneous, visceral, and total abdominal fat for predicting GDM in the first and second trimesters varied between the studies. CONCLUSION: No study validated the model for predicting GDM using subcutaneous and visceral abdominal fat measurements. External validation studies are recommended to improve the generalization of this GDM predictor in clinical practice.

Low-dose acetylsalicylic acid does not modify maternal vascular reactivity in nulliparas.

OBJECTIVE: To assess if the low-dose acetylsalicylic acid (ASA) would be capable of modifying endothelial function throughout pregnancy in nulliparous patients. METHODS: A double-blind, randomized clinical trial with 277 were included. A total of 139 were orally administered 100 mg/day of ASA, and 138 received placebo. Endothelial function was assessed by flow-mediated dilation (FMD) in the brachial artery before the start of medication (11-14 weeks) and 20-24 and 30-34 weeks of gestation. The intervention was maintained until 34 weeks. The Mann-Whitney U test was used to compare the placebo and ASA groups. The comparison of FMD during pregnancy was performed using the Friedman test. RESULTS: The groups (ASA and placebo) were similar regarding to age, weight, height, and body mass index (BMI) (p > .005). The comparison of values of FMD (%) between placebo vs. ASA at 11 and 14 weeks (8.9 vs. 9.7%, p: .253), 20 and 24 weeks (8.8 vs. 10.7%, p: .152), and 30 and 34 weeks (10.7 vs. 9.8%, p: .314) did not show significant changes throughout pregnancy. We observed a significant prevalence of PE in the placebo regarding to ASA group [14 (10.2%) vs. 8 (5.8%), p: .171]. CONCLUSION: Acetylsalicylic acid did not modify the endothelial function assessed by FMD of the brachial artery during pregnancy in nulliparous women.

Evaluation of ultrasound measurements of abdominal fat for the prediction of gestational diabetes in the first and second trimesters of pregnancy.

OBJECTIVE: To evaluate whether ultrasound abdominal fat measurements in the first and second trimesters can predict adverse gestational outcomes, particularly gestational diabetes mellitus (GDM), and identify early patients at higher risk for complications. METHODS: A prospective cohort study of 126 pregnant women at 11-14 and 20-24 weeks of gestation with normal fasting glucose levels during early pregnancy. From 126 participants with complete data, 13.5% were diagnosed with GDM, based on the cutoffs established for the peripherical blood glucose. Subcutaneous, visceral, and maximum preperitoneal abdominal fat were measured using ultrasound techniques. GDM status was determined by oral glucose tolerance test (OGTT) with 75 g glucose overload, and the following values were considered abnormal: fasting glucose ≥92 mg/dl and/or 1 h after overload ≥180 mg/dl and/or 2 h after overload ≥153 mg/dl. The receiver operator characteristic (ROC) curve was used to determine the optimal threshold to predict GDM. RESULTS: Maximum preperitoneal fat measurement was predictive of GDM, and subcutaneous and visceral abdominal fat measurements did not show significant differences in the prediction of GDM. According to the ROC curve, a threshold of 45.25 mm of preperitoneal fat was identified as the optimal cutoff point, with 87% sensitivity and 41% specificity to predict GDM. The raw and adjusted odds ratios for age and pre-pregnancy body mass index were 0.730 (95% confidence interval [CI], 0.561-0.900) and 0.777 (95% CI, 0.623-0.931), respectively. CONCLUSION: The use of a 45.25 mm threshold for maximum preperitoneal fat, measured by ultrasound to predict the risk of GDM, appears to be a feasible, inexpensive, and practical alternative to incorporate into clinical practice during the first trimester of 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.

Assessment of the angle of progression and distance perineum-head in the prediction of type of delivery and duration of labor using intrapartum ultrasonography.

OBJECTIVE: To evaluate the relevance of the angle of progression (AOP) and head-perineum distance (HPD) for predicting the type of delivery and duration of the second stage of labor using intrapartum ultrasonography. METHODS: In total, 221 women in labor with a single gestational sac at ≥37 weeks of gestation and fetuses in cephalic presentation underwent two-dimensional ultrasonography by transperineal route for measurements of AOP and HPD. Correlations between the type of delivery (vaginal or surgical (cesarean section and forceps)), duration of the second stage of labor, and fetal and maternal characteristics were assessed. AOP and HPD variables were separately studied in the first and second stages of labor. Multivariate logistic regression was followed in stages to identify the predictors for the surgical delivery outcome - stepwise forward method. RESULTS: In total, 153 (69.2%) women underwent vaginal deliveries, 7 (3.2%) underwent forceps deliveries, and 61 (27.6%) underwent cesarean deliveries. AOP was a statistically significant parameter in first and second stages of labor (107.8 ± 12.1° versus 100.8 ± 13.7°; p = .017), with an inverse correlation with the occurrence of vaginal delivery. HPD was a statistically significant parameter in the second stage of labor (3.42 ± 0.84 cm versus 4.17 ± 0.54 cm; p < .003), with a direct correlation with the occurrence of surgical delivery. The value of AOP that optimized the curve was 129.9° with 85% specificity and 63% sensitivity for the vaginal delivery endpoint. The value of HPD that optimized the curve was 4.3 cm with 69% specificity and 89% sensitivity for the surgical delivery endpoint. In the first phase, the variables defining the type of delivery were the following: height, body mass index, and AOP. In the second phase, the variables defining were the following: height, labor analgesia, HPD, and position of the fetal occiput. CONCLUSION: AOP and HPD determined by intrapartum ultrasonography were associated with duration of labor, which may aid in predicting the type of delivery in association with clinical parameters.

Associated factors with neonatal near miss in twin pregnancies in a public referral maternity unit in Brazil

Objective: The aim was to analyze the factors associated with neonatal near miss (NNM) in twin pregnancies in a public referral maternity unit in Brazil. Material and Methods: This retrospective, cross-sectional study included 697 twin newborns. Cases of fetal and neonatal deaths were excluded. Neonates were divided into those meeting NNM criteria (5 min Apgar score <7, birth weight <1,500 g, gestational age at delivery <32 weeks, use of mechanical ventilation or congenital malformation, transfer before 28 days of life) and those who did not. In the bivariate analysis, the chi-square and Fisher's exact tests were used. Variables with a p-value ≤0.20 were subjected to the multiple analyses, which followed the Poisson regression model. Results: The cohort consisted of 130 (18.7%) neonates meeting NNM criteria and 567 (81.3%) with no NNM criteria after multiple analyses, the following variables were associated with NNM: no previous pregnancy, prevalence ratio (PR): 1.38 [95% confidence interval (CI), 1.03-1.85]; >3 previous pregnancies, PR: 1.93 (95% CI, 1.38-2.69); premature rupture of membranes, PR: 1.50 (95% CI, 1.70-2.12); intrauterine growth restriction, PR: 2.28 (95% CI, 1.53-3.33); premature labor, PR: 1.63 (95% CI, 1.13-2.35); resuscitation in the delivery room, PR: 1.80 (95% CI, 1.24-2.62); and transfusion of blood products, PR: 4.44 (95% CI, 3.14-6.28). Conclusion: The study findings indicate that having had 0 or >3 previous pregnancies, premature rupture of the membranes, intrauterine growth restriction, resuscitation in the delivery room, premature labor, and transfusion of blood products were associated with NNM in twin pregnancies.

COVID-19 and mental health of pregnant women in Ceará, Brazil.

OBJECTIVE: To assess the perceptions of pregnant women about COVID-19 and the prevalence of common mental disorders during the implemented social distancing period. METHODS: This was an observational, cross-sectional study using digital media, of pregnant women exposed to social distancing due to the COVID-19 pandemic, in Fortaleza, Ceará, Northeastern Brazil. Common mental disorders were estimated using the modified Self-Report Questionnaire-20 (SRQ-20) scale, and the feelings towards COVID-19 were assessed using the Fear of COVID-19 scale through telephone calls made in May 2020. COX multivariate regression models were used to verify the associations. RESULTS: Of the 1,041 pregnant women, 45.7% (95%CI: 42.7-48.8) had common mental disorders (CMD). All items of the Fear of COVID-19 Scale showed a significant association with the prevalence of CMD (p < 0.001). A CMD risk gradient was observed, going from a prevalence ratio of 1.52 (95%CI: 1.13-2.04) in pregnant women with two positive items to 2.70 (95%CI: 2.08-3.51) for those with four positive items. Early gestational age and the lack of prenatal care were also associated with CMD. CONCLUSIONS: The prevalence of common mental disorders in pregnant women was high during the period of social distancing and was aggravated by negative feelings towards COVID-19.

Influence of evening/night-time birth on maternal/perinatal outcomes in a low-risk population

Objective: To compare maternal and perinatal outcomes between day-time and evening/night-time births in a low-risk population. Material and Methods: The present study had a retrospective and cross-sectional design. The study recruited 421 pregnant women admitted for spontaneous or induced labor, with singleton, full-term pregnancy, without comorbidities, and with birthweight between 2,500 and 4,499 g. Maternal data, including severe bleeding, need for blood transfusion, puerperal infection, and admission to the intensive care unit, and neonatal data including birthweight, Apgar scores at first and fifth minute, oxygen administration, resuscitation, admission to the neonatal care unit, infection, and blood transfusion, were evaluated. Univariate and multivariate analysis and calculation of the prevalence ratio (PR) were performed with a 95% confidence interval (CI). Results: There were no differences in factors of maternal morbidity between delivery times. Newborns delivered during the evening/night-time had a higher prevalence of infection (15.3% vs 7.9%, p=0.019, PR: 2.11, CI 95% 1.13-3.93) and hospitalization in the neonatal care unit (25.8% vs 10.4%, p<0.001, PR: 2.99, CI 95% 1.76-5.10). There was no difference in other perinatal morbidities examined. Conclusion: Evening/night-time births were associated with a higher prevalence of infection and the need for admission to an intensive care unit.

Gestational Outcomes in Patients with Severe Maternal Morbidity Caused by Hypertensive Syndromes.

PURPOSE: To evaluate the impact of the presence of criteria for severe maternal morbidity and maternal near miss associated with hypertensive disorders on maternal and perinatal outcomes in a maternity school. METHODS: The present is a sub-analysis of a larger study involving 27 centers in Brazil that estimated the prevalence of serious maternal morbidity and near miss. It is an analytical and cross-sectional study with a quantitative approach, involving 928 women who were cared for at Maternidade Escola Assis Chateaubriand (MEAC, in Portuguese), Universidade Federal do Ceará (UFC, in Portuguese), from July 2009 to June 2010. The women were diagnosed with near miss according to the World Health Organization (WHO) criteria. The sample was divided into 2 groups: patients with (n = 827) and without hypertension (n = 101). The results were considered statistically significant when p < 0.05. The Pearson chi-squared and Fisher Exact tests were used for the categorical variables, and the Mann-Whitney U test was used for the continuous variables. RESULTS: In total, 51 participants with maternal near miss criteria were identified, and 36 of them had hypertensive disorders. Of these, 5 died and were obviously excluded from the near miss final group. In contrast, we observed 867 cases with non-near miss maternal morbidity criteria. During this period, there were 4,617 live births (LBs) in the institution that was studied. CONCLUSION: In the severe morbidity/maternal near miss population, the presence of hypertensive complications was prevalent, constituting a risk factor for both the mother and the fetus.

OBJETIVO: Avaliar o impacto da presença de critérios de morbidade materna grave e potencial evento adverso materno associados a distúrbios hipertensivos nos desfechos maternos e perinatais em uma maternidade escola. MéTODOS: Trata-se de uma subanálise de um estudo maior, envolvendo 27 centros, que estimou a prevalência de morbidade materna grave e potencial evento adverso no Brasil. Realizou-se um estudo analítico e transversal, com abordagem quantitativa, envolvendo 928 mulheres atendidas na Maternidade Escola Assis Chateaubriand (MEAC), na Universidade Federal do Ceará (UFC), no período de julho de 2009 a junho de 2010, diagnosticadas com potencial evento adverso de acordo com os critérios da Organização Mundial da Saúde (OMS). A amostra foi dividida em dois grupos: pacientes com (n = 827) e sem hipertensão (n = 101). Os resultados foram considerados estatisticamente significativos quando p < 0,05. O teste do Qui-quadrado de Pearson e o teste exato de Fisher foram usados para as variáveis categóricas, e o teste U de Mann-Whitney, para as variáveis contínuas. RESULTADOS: Foram identificados 51 participantes com critérios de potencial evento adverso materno, sendo 36 mulheres com distúrbios hipertensivos. Destas, 5 morreram e foram obviamente excluídas do grupo final do potencial evento adverso. Foram observados 867 casos com critérios de morbidade materna que não caracterizavam potencial evento adverso. Nesse período, houve 4.617 nascidos vivos (NVs) na instituição estudada. CONCLUSãO: Na população com morbidade grave/potencial evento adversomaterno, a presença de complicações hipertensivas é prevalente, constituindo fator de risco para o binômio materno-fetal.

Pubic Arch Angle Measurement by Transperineal Ultrasonography: A Prospective Cross-Sectional Study.

OBJECTIVE: To evaluate the ability of the pubic arch angle (PAA) as measured by transperineal ultrasonography during labor to predict the delivery type and cephalic pole disengagement mode. METHODS: The present prospective cross-sectional study included 221 women in singleton-gestational labor ≥ 37 weeks with cephalic fetuses who underwent PAA measurement using transperineal ultrasonography. These measurements were correlated with the delivery type, cephalic pole disengagement mode, and fetal and maternal characteristics. RESULTS: Out of the subjects, 153 (69.2%) had spontaneous vaginal delivery, 7 (3.2%) gave birth by forceps, and 61 (27.6%) delivered by cesarean section. For the analysis, deliveries were divided into two groups: vaginal and surgical (forceps and cesarean). The mean PAA was 102 ± 7.5° (range, 79.3-117.7°). No statistically significant difference was observed in delivery type (102.6 ± 7.2° versus 100.8 ± 7.9°, p = 0.105). The occipitoanterior position was seen in 94.1% of the fetuses and the occipitoposterior position in 5.8%. A narrower PAA was found in the group of surgical deliveries (97.9 ± 9.6° versus 102.6 ± 7.3°, p = 0.049). Multivariate regression analysis showed that PAA was a predictive variable for the occurrence of head disengagement in occipital varieties after birth (odds ratio, 0.9; 95% confidence interval, 0.82-0.99; p = 0.026). CONCLUSION: Ultrasonographic measurement of the PAA was not a predictor of delivery type, but was associated with the persistence of occipital varieties after birth.

OBJETIVO: Avaliar a medida do ângulo do arco púbico (AAP) por ultrassonografia transperineal durante trabalho de parto em predizer tipo de parto e modo de desprendimento do polo cefálico. MéTODOS: Um estudo prospectivo transversal foi conduzido com 221 mulheres em trabalho de parto com gestação única ≥ 37 semanas, com fetos em apresentação cefálica, foram submetidas à avaliação ultrassonográfica por via transperineal para aferição do AAP. Correlações com tipo de parto, modo de desprendimento do polo cefálico e características fetais e maternas foram realizadas. RESULTADOS: Um total de 153 (69,2%) mulheres apresentaram parto vaginal espontâneo, 7 (3,2%) parto a fórceps e 61 (27,6%) parto cesárea. Para fins de análise, dividiu-se os partos em dois grupos: partos vaginais e cirúrgicos (fórceps e cesáreas). A média do AAP foi 102 ± 7,5° (variação: 79,3­117,7°). Não foi observada significância estatística do AAP em relação ao tipo de parto (102,6 ± 7,2° versus 100,8 ± 7,9°; p = 0,105). Um total de 94,1% dos fetos desprenderam em variedade de posição occipito anterior e 5,8% em occipito posterior. Encontrou-se AAP mais estreitado no grupo de partos cirúrgicos (97,9 ± 9,6° versus 102,6 ± 7,3°; p = 0,049). A análise de regressão multivariada demonstrou que AAP foi uma variável de proteção para a ocorrência de desprendimento da cabeça em variedades occipito posteriores ao nascimento (odds ratio [OR]= 0,9; índice de confiança (IC) 95%: 0,82­0,99; p = 0,026). CONCLUSãO: A medida ultrassonográfica do AAP não foi preditora do tipo de parto, porém demonstrou associação com persistência de variedades occipito posteriores ao nascimento.

SNAPPE II: ANALYSIS OF ACCURACY AND DETERMINATION OF THE CUTOFF POINT AS A DEATH PREDICTOR IN A BRAZILIAN NEONATAL INTENSIVE CARE UNIT.

OBJECTIVE: To analyze the accuracy of the Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE II) as a death predictor, to determine the cutoff point for mortality, and to analyze the association of independent variables with death. METHODS: Prospective, longitudinal, hospital-based study on newborns admitted to the Neonatal Intensive Care Unit (NICU) for the first time from November 1, 2016 to April 30, 2017. Newborns with less than 12 hours of length of stay at the NICU, out-of-hospital births, major congenital malformations, and inter-hospital transfer were excluded. Variables were grouped according to hierarchical framework, related to maternal characteristics (distal level), prenatal and childbirth care (intermediate level), and birth conditions (proximal level). Descriptive analyses of SNAPPE II score ranges, Receiver Operating Characteristics Curve (ROC curve) to define the cutoff point for mortality, and bivariate analysis by the Wald test and multiple logistic regression were conducted. RESULTS: After selection, the sample consisted of 247 newborns. In this study, the SNAPPE II cutoff point for mortality was 27, with sensitivity of 84.1% and specificity of 82.4%. 61% of those with a score ≥27 died. Multiple logistic regression showed an association between death and proximal-level variables: sepsis (Odds Ratio [OR] 10.68; 95% confidence interval [95%CI] 2.82-40.48; p<0.001); SNAPPE II ≥27 (OR 5.85; 95%CI 1.90-18.05; p=0.002); birth weight 750-999 g (OR 4.15; 95%CI 1.06-16.14; p=0.040); and nonuse of surfactant (OR 0.159; 95%CI 0.04-0.53; p=0.003). CONCLUSIONS: Neonatal mortality was directly proportional to increase in SNAPPE II. Score≥27 increased the odds of dying by six times compared with neonates with lower scores. The proximal variables related to health conditions and neonatal care were associated with death.

Late umbilical cord clamping does not increase rates of jaundice and the need for phototherapy in pregnancies at normal risk.

Objective: To verify the relationship between the time of clamping of the umbilical cord and the development of neonatal jaundice, the dosage of bilirubin and the need for phototherapy. Methods: Cross-sectional, retrospective study with 398 parturients at normal risk (single term gestation, no complications during gestation or delivery, birth weight between 2500 and 4499 g). The population was divided into three groups regarding the time of cord clamping: <1 min(117, 29.4%), between 1 and 3 min(228, 57.3%) and >3 min(53, 13.3%). Sociodemographic, clinical and obstetric characteristics, birth and delivery data, and maternal and perinatal outcomes were evaluated. Pearson's chi-square test, Fisher's exact test and the Kruskal-Wallis test were used for comparison between the groups. Statistical significance was considered p < .05. Results: The groups were similar in the development of jaundice (p = .370), bilirubin dosage (p = .342) and need for phototherapy (p = .515). Late clamping was more prevalent in vaginal deliveries when compared to cesarean sections (1-3 min: 64 versus 21.4%, >3 min: 16.6 versus 1%) (p < .001). There was no difference in other maternal or perinatal variables. Conclusion: The clamping time of the umbilical cord showed no association with jaundice, bilirubin dosage, or phototherapy needs in neonates at normal risk. The adoption of late clamping was more prevalent in vaginal deliveries.