How to classify BMI among pregnant adolescents? A prospective cohort.

OBJECTIVE: Pregnancy in adolescence is a global health issue, especially in developing countries. Additionally, the recommended gestational weight gain (GWG) is usually based on pre-pregnancy BMI and that might be complex for pregnant teens. The study objective was to compare three different methods of BMI classification and suggest the best way of determining pre-pregnancy BMI and monitoring GWG among pregnant adolescents. DESIGN: Pre-pregnancy weight, weight at first prenatal visit, height, sociodemographic, reproductive and perinatal data were collected. Weighted kappa and McNemar statistics were used to assess agreement between the classification methods. SETTING: Prof. Dr Jose Aristodemo Pinotti Women's Hospital, University of Campinas, Brazil.ParticipantsPrimiparas younger than 19 years of age and with less than 20 weeks of gestational age (n 150). RESULTS: BMI of the primiparas was determined according to the WHO recommendation for adult women, the Child Growth Standards (CGS) and their gynaecological age (GA). The WHO and GA measurements presented a strong agreement with each other (κ w=0·99; 95 % CI 0·97, 1·00), but did not agree with the CGS classification (κ w=0·62; 95 % CI 0·50, 0·74 by WHO; κ w=0·62; 95 % CI 0·51, 0·74 by GA). Also, inadequate GWG was observed in 72·2 % of cases and was correlated with a higher rate of caesarean birth. CONCLUSIONS: BMI classification according to the CGS differed from WHO and GA. However, CGS and WHO agreed on perinatal outcomes. We recommend using BMI classification by WHO to assess pregnant adolescents, since it is easily applied and better known among health professionals.

Severe maternal morbidity and maternal near miss in the extremes of reproductive age: results from a national cross- sectional multicenter study.

BACKGROUND: The aim of this study was to assess severe maternal morbidity (SMM) and near miss (NM) cases among adolescent girls and women over 35 years of age in the Brazilian Network for Surveillance of Severe Maternal Morbidity, using a set of standard criteria, compared to pregnant women aged 20 to 34 years. METHODS: A cross-sectional multicenter study conducted in 27 referral obstetric units in Brazil. All pregnant women admitted to these centers during a one-year period of prospective surveillance were screened to identify cases of maternal death (MD), NM and other SMM. Indicators of maternal morbidity and mortality were evaluated for the three age groups. Sociodemographic, clinical and obstetric characteristics, gestational and perinatal outcomes, main causes of morbidity and delays in care were also compared. Two multiple analysis models were performed, to estimate the adjusted prevalence ratio for identified factors that were independently associated with the occurrence of severe maternal outcome (SMO = MNM + MD). RESULTS: Among SMM and MD cases identified, the proportion of adolescent girls and older women were 17% each. The risk of MNM or death was 25% higher among older women. Maternal near miss ratio and maternal mortality ratios increased with age, but these ratios were also higher among adolescents aged 10 to 14, although the absolute numbers were low. On multivariate analysis, younger age was not identified as an independent risk factor for SMO, while this was true for older age (PR 1.25; 1.07-1.45). CONCLUSIONS: SMO was high among women below 14 years of age and increased with age in Brazilian pregnant women.

The impact of prior preeclampsia on the risk of superimposed preeclampsia and other adverse pregnancy outcomes in patients with chronic hypertension.

OBJECTIVE: We sought to compare the rates of superimposed preeclampsia and adverse outcomes in women with chronic hypertension with or without prior preeclampsia. STUDY DESIGN: We conducted secondary analysis of 369 women with chronic hypertension (104 with prior preeclampsia) enrolled at 12-19 weeks as part of a multisite trial of antioxidants to prevent preeclampsia (no reduction was found). Outcome measures were rates of superimposed preeclampsia and other adverse perinatal outcomes. RESULTS: Prepregnancy body mass index, blood pressure, and smoking status at enrollment were similar between groups. The rates of superimposed preeclampsia (17.3% vs 17.7%), abruptio placentae (1.0% vs 3.1%), perinatal death (6.7% vs 8.7%), and small for gestational age (18.4% vs 14.3%) were similar between groups, but preterm delivery <37 weeks was higher in the prior preeclampsia group (36.9% vs 27.1%; adjusted risk ratio, 1.46; 95% confidence interval, 1.05-2.03; P = .032). CONCLUSION: In women with chronic hypertension, a history of preeclampsia does not increase the rate of superimposed preeclampsia, but is associated with an increased rate of delivery at <37 weeks.

Postpartum dexamethasone for women with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a double-blind, placebo-controlled, randomized clinical trial.

OBJECTIVE: The purpose of this study was to determine the effectiveness of postpartum dexamethasone in patients with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. STUDY DESIGN: A prospective, randomized, double-blind trial was conducted in which 105 women with HELLP syndrome were enrolled and assigned randomly to treatment or placebo groups following delivery. Duration of hospital stay, maternal morbidity, and laboratory and clinical parameters were evaluated. RESULTS: There was no difference in maternal morbidity or mortality between the 2 groups. There was also no difference in duration of hospitalization and the need for rescue scheme or the use of blood products between groups. Linear model adjustments showed no significant difference between groups with respect to the pattern of platelet count recovery, aspartate aminotransferase, lactate dehydrogenase, hemoglobin, or diuresis. CONCLUSION: These findings do not support the use of dexamethasone in the puerperium for recovery of patients with HELLP syndrome.

Serum inhibin A and angiogenic factor levels in pregnancies with previous preeclampsia and/or chronic hypertension: are they useful markers for prediction of subsequent preeclampsia?

OBJECTIVE: Our objective was to determine whether measurement of placenta growth factor (PLGF), inhibin A, or soluble fms-like tyrosine kinase-1 (sFlt-1) at 2 times during pregnancy would usefully predict subsequent preeclampsia (PE) in women at high risk. STUDY DESIGN: We analyzed serum obtained at enrollment (12(0/7) to 19(6/7) weeks) and follow-up (24-28 weeks) from 704 patients with previous PE and/or chronic hypertension (CHTN) enrolled in a randomized trial for the prevention of PE. Logistic regression analysis assessed the association of log-transformed markers with subsequent PE; receiver operating characteristic analysis assessed predictive value. RESULTS: One hundred four developed preeclampsia: 27 at 37 weeks or longer and 77 at less than 37 weeks (9 at less than 27 weeks). None of the markers was associated with PE at 37 weeks or longer. Significant associations were observed between PE at less than 37 weeks and reduced PLGF levels at baseline (P = .022) and follow-up (P < .0001) and elevated inhibin A (P < .0001) and sFlt-1 (P = .0002) levels at follow-up; at 75% specificity, sensitivities ranged from 38% to 52%. Using changes in markers from baseline to follow-up, sensitivities were 52-55%. Associations were observed between baseline markers and PE less than 27 weeks (P < or = .0004 for all); sensitivities were 67-89%, but positive predictive values (PPVs) were only 3.4-4.5%. CONCLUSION: Inhibin A and circulating angiogenic factors levels obtained at 12(0/7) to 19(6/7) weeks have significant associations with onset of PE at less than 27 weeks, as do levels obtained at 24-28 weeks with onset of PE at less than 37 weeks. However, because the corresponding sensitivities and/or PPVs were low, these markers might not be clinically useful to predict PE in women with previous PE and/or CHTN.

Antioxidant supplementation and premature rupture of the membranes: a planned secondary analysis.

OBJECTIVE: The purpose of this study was to determine if antioxidant supplementation during pregnancy reduces the incidence of premature rupture of the membranes (PROM). STUDY DESIGN: A placebo-controlled, double-blind trial was conducted. PROM and preterm PROM (PPROM) were planned secondary outcomes of the trial. Women between 12(0/7) and 19(6/7) weeks of gestation and diagnosed to have chronic hypertension or a prior history of preeclampsia were randomized to daily treatment with both vitamin C (1000 mg) and E (400 IU) or placebo. RESULTS: Outcome data for PROM were available for 697 of 739 patients. The rates of PROM (37/349 [10.6%] vs 19/348 [5.5%]; adjusted risk ratio [RR] 1.89 [95.42% CI, 1.11-3.23]; P = .015), and PPROM (16/349 [4.6%] vs 6/348 [1.7%]; RR 2.68 [1.07-6.71]; P = .025) were increased in the antioxidant group. CONCLUSION: Contrary to expectations, vitamins C and E supplementation in this dose combination may be associated with an increased risk of PROM and PPROM.

Feticide does not modify duration of labor induction in cases of medical termination of pregnancy.

OBJECTIVES: To compare the general characteristics and clinical outcome of women who underwent medical termination of pregnancy preceded or not by feticide. METHODS: A total of 146 women of diverse gestational ages, who had received a sonographic or genetic diagnosis of fetal abnormality incompatible with postnatal life and chose to legally terminate their pregnancy, had labor induced following feticide (n = 82) or without having feticide performed (n = 64). RESULTS: The number of obstetrical procedures was higher (p = 0.001) in the feticide group. Time of labor induction and complications were similar in both groups. CONCLUSION: Feticide does not alter the clinical obstetrical course of women undergoing medical termination of pregnancy, and poses no risk to maternal health regardless of gestational age.

[Knowledge of pregnant adolescents about reproductive anatomy and physiology in a municipality of Southern Brazil]. / Conhecimento de adolescentes grávidas sobre anatomia e fisiologia da reprodução.

OBJECTIVES: To study knowledge of some aspects of the female reproductive anatomy and physiology and their association with socio-demographic and reproductive "choices" of pregnant adolescents. METHODS: A cross-sectional study was performed with 200 first time pregnant adolescents who attended a public women's health clinic in the municipality of Indaiatuba, Sao Paulo, Brazil. During their first prenatal care visit, face-to-face interviews were conducted using a structured questionnaire and a three-dimensional handmade female model. Bivariate data analyses were performed using Pearson's Chi-square or Fisher's Exact test. Data were also analyzed using multivariate logistic regression models to test for associations of indicators of knowledge of female reproductive anatomy, physiology of female reproductive organs and physiology of reproduction with socio-demographic characteristics and reproductive "choices". RESULTS: The majority had little knowledge of anatomy (55.5%), with external organs more easily identified and placed than the internal; of physiology of reproductive organs (61.0%), and of physiology of reproduction (76.5%). Associations were found between knowledge and age of partner, couple difference of age, maintenance of the relationship with partner after pregnancy, religious affiliation, and level of education. No association was found between indicators of knowledge with use of contraceptives at first intercourse and with intention of having the baby at that time. CONCLUSION: This study addressed the complexity of the relationship between knowledge of reproductive anatomy and physiology and the theme of adolescent pregnancy, and emphasized the need for more contextualized approaches of programmatic contents on sexual education, in view of the intention to reduce early pregnancy.

Antioxidant therapy to prevent preeclampsia: a randomized controlled trial.

OBJECTIVE: To study whether antioxidant supplementation will reduce the incidence of preeclampsia among patients at increased risk. METHODS: A randomized, placebo-controlled, double-blind clinical trial was conducted at four Brazilian sites. Women between 12 0/7 weeks and 19 6/7 weeks of gestation and diagnosed to have chronic hypertension or a prior history of preeclampsia were randomly assigned to daily treatment with both vitamin C (1,000 mg) and vitamin E (400 International Units) or placebo. Analyses were adjusted for clinical site and risk group (prior preeclampsia, chronic hypertension, or both). A sample size of 734 would provide 80% power to detect a 40% reduction in the risk of preeclampsia, assuming a placebo group rate of 21% and alpha=.05. The alpha level for the final analysis, adjusted for interim looks, was 0.0458. RESULTS: Outcome data for 707 of 739 randomly assigned patients revealed no significant reduction in the rate of preeclampsia (study drug, 13.8% [49 of 355] compared with placebo, 15.6% [55 of 352], adjusted risk ratio 0.87 [95.42% confidence interval 0.61-1.25]). There were no differences in mean gestational age at delivery or rates of perinatal mortality, abruptio placentae, preterm delivery, and small for gestational age or low birth weight infants. Among patients without chronic hypertension, there was a slightly higher rate of severe preeclampsia in the study group (study drug, 6.5% [11 of 170] compared with placebo, 2.4% [4 of 168], exact P=.11, odds ratio 2.78, 95% confidence interval 0.79-12.62). CONCLUSION: This trial failed to demonstrate a benefit of antioxidant supplementation in reducing the rate of preeclampsia among patients with chronic hypertension and/or prior preeclampsia. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.ClinicalTrials.gov, NCT00097110 LEVEL OF EVIDENCE: I.

Anemia in pregnant adolescents: impact of treatment on perinatal outcomes.

OBJECTIVE: This study sought to evaluate the anemia prevalence and effect of anemia treatment in pregnant adolescents. METHODS: A cross-sectional study. Data from perinatal outcomes, serum hemoglobin level and iron supplementation were collected. Samples were divided into three groups: pregnant adolescents without anemia, with treated anemia and with untreated anemia. Frequencies, means, standard deviations and Chi-squared values were calculated. The significance level was 5%, and the software used was Epi-info 7. RESULTS: The study included 458 pregnant adolescents. The mean age was 16 years old, and the prevalence of anemia was 41.27% (189). Mild, moderate or severe anemia were presented in 65.60%, 33.86% and 0.52%, respectively, of study participants. Among pregnant adolescents with anemia, 87.24% received treatment with iron supplementation. Preterm labor (p = 0.003), gestational age at birth <37 weeks (p = 0.036) and stillbirth (p = 0.004) showed an association with nontreated anemia. Positive HIV was more prevalent in adolescents with nontreated anemia (p = 0.018). The cesarean rate was 36.90%, with no difference between groups. CONCLUSION: Anemia is a public health problem among pregnant adolescents, and iron supplementation reduces negative neonatal outcomes. Treatment adherence by a multidisciplinary and qualified prenatal care team can be key in reducing adverse neonatal outcomes associated with pregnancy during adolescence.

Translational studies for exercise in high-risk pregnancy: Pre-eclampsia model.

OBJECTIVE: Reviewed literature regarding exercise effects on pregnancy-related hypertensive disorders, analyzing basic science perspectives and clinical studies. METHODS: Scientific databases were accessed by research strategy combining Medical Subject Headings terms. Studies published between 2000 and 2015, in English, Portuguese, and Spanish language, were considered. RESULTS: Studies were classified into: recommendations for exercise on high-risk pregnancy; animal models for hypertension in pregnancy; exercise on hypertensive disorders in animal models and pregnant women. CONCLUSION: There are several animal models to mimic hypertensive disorders in pregnancy; however, clinical studies are still needed for exercise recommendation in pregnant women with hypertensive disorders.

Adolescent Contraception Before and After Pregnancy-Choices and Challenges for the Future.

Objective To determine methods of contraception used by adolescents before and after pregnancy. Methods A cross-sectional study was performed, and data were collected from medical records of all teens in puerperal consultation at the Hospital da Mulher - José Aristodemo Pinotti (Caism), Universidade Estadual de Campinas (CAISM), São Paulo, Brazil, between July 2011 and September 2013. The inclusion criterion was being 10 to 19 years old, and the exclusion criterion was having a first consultation 90 days after childbirth. Statistical analyses were performed with averages, standard deviations, percentages, correlations and Fisher's exact tests using the SAS program, version 9.4. Results A total of 196 adolescents in postpartum consultation were included (44 days after childbirth on average). The majority was older than 14 years (89%), with an average age of 16.2 years, and the most were exclusively breast-feeding (70%). Before pregnancy, the use of any contraceptive methods was mentioned by 74% adolescents; the most frequent use was combined oral contraceptive followed by condom. The main reason for abandoning the use of contraception was the occurrence of an unintended pregnancy (41%), followed by reports of side effects (22%), behavior issues (18%) and desire for pregnancy (16%). A positive correlation was found between the age of the adolescent at the moment of childbirth, the age of menarche (r = 0.3), and the first sexual intercourse (r = 0.419). Vaginal delivery occurred in 76% of the cases. After birth, depot medroxyprogesterone acetate (DMPA) was the contraception method most frequently used (71%), followed by oral contraceptives (11.8%) and intrauterine devices (IUDs, 11.2%). Conclusions The most prescribed contraceptive method before pregnancy in adolescents who had childbirth was combined oral contraceptives. Many of the study participants had an unintended pregnancy. After childbirth, the most used contraceptive method was DMPA. To improve contraception and reduce the chance of unintended pregnancies among adolescents, we should promote the use of long-acting reversible contraceptives (LARCS).

Pregnancy-associated venous thromboembolism in combined heterozygous factor V Leiden and prothrombin G20210A mutations.

CONTEXT: Pregnancy and puerperium raise the risk of thromboembolic events, and these risks are increased in women who are carriers of thrombophilia factors. Prothrombin (FII) G20210A and factor V Leiden heterozygous mutations are associated with moderate risk of thrombosis. The association of these thrombophilic conditions is very rare in pregnancy, and the real risk of thrombosis is unknown. CASE REPORT: We describe a case of a pregnant woman who was found to be carrier of heterozygous factor V Leiden and prothrombin (FII) G20210A mutations. Five years before pregnancy she had had an episode of extensive deep venous thrombosis in the ileofemoral region, while using hormonal contraceptives. Anticardiolipin antibody (ACA), lupus anticoagulant and deficiencies of protein C, protein S and antithrombin III were evaluated by means of enzyme-linked immunosorbent assay (ELISA), dilute Russell Viper Venom time (dRVVT), coagulometric and chromogenic methods. Deoxyribonucleic acid (DNA) was amplified using the polymerase chain reaction (PCR) to study the factor V Leiden and G20210A mutations in the prothrombin gene and C677T mutation in the methylene tetrahydrofolate reductase (MTHFR) gene. In the sixth week of her first pregnancy, she developed another episode of deep venous thrombosis in the femoropopliteal veins of the right leg. She was treated with low-molecular weight heparin (nadroparin) until parturition (0.3 ml or 2,850 UI/day). The pregnancy evolved without any significant obstetric morbidity. The patient delivered a healthy baby by cesarean section. During the puerperium, she used prophylactic doses of nadroparin for (0.3 ml or 2,850 UI/day) six weeks and had no complications. We suggest that women who have an association of thrombophilia factors and a prior episode of venous thromboembolism must have antepartum anticoagulation management using unfractioned or low-molecular weight heparin and postpartum management using low-molecular weight heparin or oral anticoagulants. Anticoagulation is recommended during pregnancy because the real magnitude of the risk of major and life-threatening thromboembolic events in these women is unknown.

Association of anticardiolipin antibody and C677T in methylenetetrahydrofolate reductase mutation in women with recurrent spontaneous abortions: a new path to thrombophilia?

CONTEXT: Recurrent spontaneous abortion (RSA) has been associated with venous thrombosis in the mother. Acquired and inherited thrombophilia factors are possible causes. OBJECTIVE: To evaluate the association between thrombogenic factors and recurrent spontaneous abortion. TYPE OF STUDY: Case-control study. SETTING: Centro de Atenção Integral à Saúde da Mulher, Universidade Estadual de Campinas. METHODS: 40 ml of blood was collected from 88 women attending an RSA clinic and 88 fertile women attending a family planning clinic, to evaluate the presence of acquired and inherited thrombophilia factors. Anticardiolipin antibodies (ACA), lupus anticoagulant and deficiencies of proteins C and S and antithrombin III were evaluated by enzyme-linked immunosorbent assay (ELISA), dilute Russell Viper Venom time (dRVVT), coagulometric and chromogenic methods. DNA was amplified by the polymerase chain reaction (PCR) to study factor V Leiden and G20210A mutations in the prothrombin gene and C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene. Data were analyzed using odds ratios and a regression model for age adjustment. Fishers exact test was used to evaluate statistical relationships between associated factors and RSA. RESULTS: ACA was detected in 11 women with RSA and one fertile woman. Heterozygous C677T was detected in 59 women with RSA and 35 fertile women. Concomitant presence of ACA and C677T was found in eight women with RSA and no fertile women (p < 0.01). DISCUSSION: The meaning of the association between C677T mutation in the MTHFR gene and ACA is still not clear. It is possible that an inherited factor that alone would not strongly predispose a woman to thrombosis could, when associated with an acquired factor, start the process and increase the likelihood of thrombosis expression. CONCLUSIONS: ACA and C677T in the MTHFR gene are statistically associated with RSA. The association of these two conditions is a new finding in thrombogenic factors and RSA.

Accuracy of the serological ELISA test compared with the polymerase chain reaction for the diagnosis of cytomegalovirus infection in pregnancy.

CONTEXT: The most frequently used methods for detecting antibodies are the indirect immunofluorescence test and the enzymatic immunoassay (ELISA). The polymerase chain reaction is a molecular biology technique in which the production of large amounts of specific DNA fragments is induced from very low concentrations of complex substrates aloowing the detection of very low amounts of viral particles. OBJECTIVE: To assess the accuracy of serological/ELISA tests in comparison with the polymerase chain reaction in maternal blood to diagnose cytomegalovirus infection. DESIGN: A descriptive study was performed. SETTING: High-risk outpatient clinic of Campinas University (Unicamp). PARTICIPANTS: We selected 243 pregnant women. All of them had been indicated for blood sampling because of suspicions of cytomegalovirus infection and also because of other infections. MAIN MEASUREMENTS: The group was tested for cytomegalovirus. Serological tests were run and compared to the polymerase chain reaction, which was considered to be the gold standard. Status analyses were done using Fisher's exact test, via the SAS software. RESULTS: The previous cytomegalovirus infection rate was 94.6%. The main reasons for inclusion in the study were fetal nervous system malformation (25.5%), maternal toxoplasmosis (25.5%) and Rh isoimmunization (14.8%). Only two women were included because of positive serological immunoglobulin M test for cytomegalovirus. The sensitivity and specificity of the serological tests were 94% and 6% for immunoglobulin G. CONCLUSION: Serological tests had lower sensitivity in comparison with the polymerase chain reaction test when diagnosing cytomegalovirus infection. The consequences of positive polymerase chain reaction and negative immunoglobulin M in women remain unknown.

Treatment of pregnancy-related lumbar and pelvic girdle pain by the yoga method: a randomized controlled study.

OBJECTIVE: Pregnancy-related lumbopelvic pain is a major problem for the majority of pregnant women. Complementary medicine has been used to alleviate pain, and yoga is one of the most commonly chosen alternative methods. The objective of this study was to assess the effectiveness of Hatha yoga in the reduction of lumbopelvic pain in pregnancy. METHODS: A randomized controlled trial with 60 pregnant women (age range, 14-40 years) who reported lumbopelvic pain at 12 to 32 weeks of gestation was conducted from June 2009 to June 2011. Pregnant women who had twin pregnancies, had medical restrictions for exercise, used analgesics, and participated in physical therapy were excluded from the study. Pregnant women were divided into two groups: the yoga group, practicing exercises guided by this method, and the postural orientation group, performing standardized posture orientation according to instructions provided in a pamphlet. Treatment in each group lasted 10 weeks. A visual analog scale (VAS) was used to measure pain intensity. Lumbar pain and posterior pelvic pain provocation tests were used to confirm the presence of pain. Statistical analysis included the Mann-Whitney test, the McNemar test, a paired Wilcoxon test, and analysis of covariance. RESULTS: The median pain score was lower in the yoga group (p<.0058) than the postural orientation group. Lumbar pain provocation tests showed a decreased response in relation to posterior pelvic pain provocation tests and a gradual reduction in pain intensity during 10 yoga sessions (p<.024). CONCLUSIONS: The yoga method was more effective at reducing lumbopelvic pain intensity compared with postural orientation.

[Recommendations for physical exercise practice during pregnancy: a critical review]. / Recomendações para a prática de exercício físico na gravidez: uma revisão crítica da literatura.

Physical exercise is recommended for all healthy pregnant women. Regular practice of exercises during pregnancy can provide many physical and psychological benefits, with no evidence of adverse outcomes for the fetus or the newborn when exercise is performed at mild to moderate intensity. However, few pregnant women engage in this practice and many still have fears and doubts about the safety of exercise. The objective of the present study was to inform the professionals who provide care for Brazilian pregnant women about the current recommendations regarding physical exercise during pregnancy based on the best scientific evidence available. In view of the perception that few systematic models are available about this topic and after performing several studies in this specific area, we assembled practical information of interest to both the professionals and the pregnant women. We also provide recommendations about the indications, contraindications, modalities (aerobics, resistance training, stretching and pelvic floor training), frequency, intensity and duration indicated for each gestational trimester. The review addresses physical exercise recommendation both for low risk pregnant women and for special populations, such as athletes and obese, hypertensive and diabetic subjects. The advantages of an active and healthy lifestyle should be always reinforced during and after gestation since pregnancy is an appropriate period to introduce new habits because pregnant women are usually more motivated to adhere to recommendations. Thus, routine exams, frequent returns and supervision are recommended in order to provide new guidelines that will have long-term beneficial effects for both mother and child.

Awareness about a life-threatening condition: ectopic pregnancy in a network for surveillance of severe maternal morbidity in Brazil.

OBJECTIVE: To assess occurrence of severe maternal complications associated with ectopic pregnancy (EP). METHOD: A multicenter cross-sectional study was conducted, with prospective surveillance of potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD). EP complications, patient sociodemographic/obstetric characteristics, and conditions of severity management were assessed, estimating prevalence ratios with respective 95% CI. Factors independently associated with greater severity were identified using multiple regression analysis. RESULTS: Of the 9.555 severe maternal morbidity patients, 312 women (3.3%) had complications after EP: 286 (91.7%) PLTC, 25 (8.0%) MNM, and 1 (0.3%) MD. Severe maternal outcome ratio (SMOR) was 0.3/1000 LB among EP cases and 10.8/1000 LB among other causes. Complicated EP patients faced a higher risk of blood transfusion, laparotomy, and lower risk of ICU admission and prolonged hospitalization than women developing complications resulting from other causes. Substandard care was the most common in more severe maternal morbidity and EP cases (22.7% MNM and MD versus 15% PLTC), although not significant. CONCLUSION: Increased maternal morbidity due to EP raised awareness about the condition and its impact on female reproductive life. No important risk factors for greater severity were identified. Care providers should develop specific guidelines and interventions to prevent severe maternal morbidity.

Maternal and Perinatal Outcomes of Exercise in Pregnant Women with Chronic Hypertension and/or Previous Preeclampsia: A Randomized Controlled Trial.

Objectives. To evaluate the association between physical exercise supervised in pregnant women with chronic hypertension and/or previous preeclampsia and maternal and neonatal outcomes. Method. Randomized controlled trial, which included 116 pregnant women with chronic hypertension and/or previous preeclampsia, considered risk of preeclampsia development. They were divided into two groups: study group that performed physical exercise with a stationary bicycle once a week, for 30 minutes; the intensity was controlled (heart rate 20% above resting values), under professional supervision and a control group that was not engaged in any physical exercise. The data was retrieved from medical charts. Significance level assumed was 5%. Results. Women from study group performed 9.24 ± 7.03 of physical exercise sessions. There were no differences between groups comparing type of delivery and maternal outcomes, including maternal morbidity and hospitalization in intensive unit care, and neonatal outcomes, including birth weight, adequacy of weight to gestational age, prematurity, Apgar scale at first and fifth minutes, hospitalization in intensive unit care, and neonatal morbidity. Conclusions. Physical exercise using a stationary bicycle in pregnant women with chronic hypertension and/or previous preeclampsia, once a week, under professional supervision, did not interfere in the delivery method and did not produce maternal and neonatal risks of the occurrence of morbidity. This trial is registered with ClinicalTrials.gov NCT01395342.

Effect of hormonal contraceptives during breastfeeding on infant's milk ingestion and growth.

OBJECTIVE: To measure infants' breast milk intake and infant growth when their mothers initiated either combined oral contraceptive (COC), levonorgestrel-releasing intrauterine system, or etonogestrel-releasing implant, or copper intrauterine device (IUD) as a reference group. DESIGN: Prospective trial. SETTING: University-based hospital. PATIENT(S): On postpartum day 42, 40 women initiated a contraceptive method according to their choice. INTERVENTION(S): Deuterium (D2O; 0.5 g/kg mother's weight) was ingested by mothers on postpartum days 42, 52, and 63 as a marker of total body fluid. MAIN OUTCOME MEASURE(S): Infants' milk intake from 42 to 63 postpartum days was assessed by measurement of D2O levels in infants' saliva and infant growth by measuring their body weight, height, and tibia length. Women recorded all infant feed and changes of diapers wet with urine. Breastfeeding continuation was assessed at 6 months postpartum. RESULT(S): Infant mean milk intake, mean growth increase, mean number of breastfeeding episodes, daily wet diaper changes, and mean duration of exclusively breastfeeding (~5 months) were similar in the four groups. CONCLUSION(S): Use of a COC, the two progestin-only contraceptives, or copper IUD did not affect the amount of infant milk intake and growth up to 9 weeks of age. The incidence of full breastfeeding and breastfeeding continuation was similar with contraceptive hormonal use and no use. CLINICAL TRIALS REGISTRATION NUMBER: NCT01388582.