Tendência da mortalidade materna (2022-2030): uma análise baseada em séries temporais / Maternal mortality trend (2022-2030): an analysis based on time series

A morte materna é definida como aquela que ocorre, por qualquer causa na gravidez, parto ou puerpério (até 42 dias após o parto), ou até 1 ano, por causas obstétricas. A maioria destes óbitos poderiam ser evitadas com estratégias de cuidado voltadas para as principais causas de óbitos. Sendo assim, este Relatório de Tendência de Indicadores Estratégicos analisa a série histórica de RMM (Razão da Mortalidade Materna) com a finalidade de traçar sua tendência até 2030 para o nível estadual, identificar os principais grupos de morbidades que provocam os óbitos maternos na série histórica 2011-2021 e avaliar o impacto dos óbitos que tiveram a COVID-19 como informação da causa da morte entre os óbitos ocorridos nos anos de 2020 e 2021

Maternal death is defined as that which occurs, from any cause during pregnancy, childbirth or the postpartum period (up to 42 days after birth), or up to 1 year, due to obstetric causes. The majority of these deaths could be avoided with care strategies aimed at the main causes of death. Therefore, this Strategic Indicator Trend Report analyzes the historical series of MMR (Maternal Mortality Ratio) with the purpose of tracing its trend until 2030 at the state level; identify the main groups of morbidities that cause maternal deaths in the 2011-2021 historical series and assess the impact of deaths caused by COVID-19 as information on the cause of death among deaths occurring in the years 2020 and 2021

Prediction of Preeclampsia-Related Adverse Outcomes With the sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor)-Ratio in the Clinical Routine: A Real-World Study.

This retrospective real-world study investigated the clinical use of the sFlt-1 (soluble fms-like tyrosine kinase 1)/PlGF (placental growth factor) ratio alone or in combination with other clinical tests to predict an adverse maternal (maternal death, kidney failure, hemolysis elevated liver enzymes low platelets-syndrome, pulmonary edema, disseminated intravascular coagulation, cerebral hemorrhage, or eclampsia) or fetal (delivery before 34 weeks because of preeclampsia and/or intrauterine growth restriction, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, placental abruption or intrauterine fetal death or neonatal death within 7 days post natum) pregnancy outcome in patients with signs and symptoms of preeclampsia. We evaluated the sFlt-1/PlGF-ratio cutoff values of 38 and 85 and evaluated its integration into a multimarker model. Of 1117 subjects, 322 (28.8%) developed an adverse fetal or maternal outcome. Patients with an adverse versus no adverse outcome had a median sFlt-1/PlGF-ratio of 177 (interquartile range, 54-362) versus 14 (4-64). Risk-stratification with the sFlt-1/PlGF cutoff values into high- (>85), intermediate- (38-85), and low-risk (<38) showed a significantly shorter time to delivery in high- and intermediate- versus low-risk patients (4 versus 8 versus 29 days). When integrating all available clinical information into a multimarker model, an area under the curve of 88.7% corresponding to a sensitivity, specificity, positive and negative predictive value of 80.0%, 87.3%, 75.0%, and 90.2% was reached. The sFlt-1/PlGF-ratio alone was inferior to the full model with an area under the curve of 85.7%. As expected, blood pressure and proteinuria were significantly less accurate with an area under the curve of 69.0%. Combining biomarker measurements with all available information in a multimarker modeling approach increased detection of adverse outcomes in women with suspected disease.

Maternal and Perinatal Outcomes Associated With Extremely High Values for the sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor) Ratio.

Background There is little knowledge about the significance of extremely high values (>655) for the ratio of sFlt-1 (soluble fms-like tyrosine kinase 1) to PlGF (placental growth factor). We aim to describe the time-to-delivery interval and maternal and perinatal outcomes when such values are demonstrated while assessing suspected or confirmed placental dysfunction based on clinical or sonographic criteria. Methods and Results A multicenter retrospective cohort study was performed on 237 singleton gestations between 20+0 and 37+0 weeks included at the time of first demonstrating a sFlt-1/PlGF ratio >655. Clinicians were aware of this result, but standard protocols were followed for delivery indication. Main outcomes were compared for women with and without preeclampsia at inclusion. In those with preeclampsia (n=185, of whom 77.3% had fetal growth restriction), severe preeclampsia features and fetal growth restriction in stages III or IV were present in 49.2% and 13.5% cases, respectively, at inclusion and in 77.3% and 28.6% cases, respectively, at delivery. In the group without preeclampsia (n=52, 82.7% had fetal growth restriction), these figures were 0% and 30.8%, respectively, at inclusion and 21.2% and 50%, respectively, at delivery. Interestingly, 28% of women without initial preeclampsia developed it later. The median time to delivery was 4 days (interquartile range: 1-6 days) and 7 days (interquartile range: 3-12 days), respectively (P<0.01). Overall, perinatal mortality was 62.1% before 24 weeks; severe morbidity surpassed 50% before 29 weeks but became absent from 34 weeks. Maternal serious morbidity was high at any gestational age. Conclusions An sFlt-1/PlGF ratio >655 is almost invariably associated with preeclampsia or fetal growth restriction that progresses rapidly. In our tertiary care settings, we observed that maternal adverse outcomes were high throughout gestation, whereas perinatal adverse outcomes diminished as pregnancy advanced.

An Observational Pilot Study Evaluating the Utility of Minimally Invasive Tissue Sampling to Determine the Cause of Stillbirths in South African Women.

BACKGROUND: Despite approximately 2.6 million stillbirths occurring annually, there is a paucity of systematic biological investigation and consequently knowledge on the causes of these deaths in low- and middle-income countries (LMICs). We investigated the utility of minimally invasive tissue sampling (MITS), placental examination, and clinical history, in attributing the causes of stillbirth in a South African LMIC setting. METHODS: This prospective, observational pilot study undertook sampling of brain, lung, and liver tissue using core biopsy needles, blood and cerebrospinal fluid collection, and placental examination. Testing included microbial culture and/or molecular testing and tissue histological examination. The cause of death was determined for each case by an international panel of medical specialists and categorized using the World Health Organization's International Classification of Diseases, Tenth Revision application to perinatal deaths. RESULTS: A cause of stillbirth was identifiable for 117 of 129 (90.7%) stillbirths, including an underlying maternal cause in 63.4% (n = 83) and an immediate fetal cause in 79.1% (n = 102) of cases. The leading underlying causes of stillbirth were maternal hypertensive disorders (16.3%), placental separation and hemorrhage (14.0%), and chorioamnionitis (10.9%). The leading immediate causes of fetal death were antepartum hypoxia (35.7%) and fetal infection (37.2%), including due to Escherichia coli (16.3%), Enterococcus species (3.9%), and group B Streptococcus (3.1%). CONCLUSIONS: In this pilot, proof-of-concept study, focused investigation of stillbirth provided granular detail on the causes thereof in an LMIC setting, including provisionally highlighting the largely underrecognized role of fetal sepsis as a dominant cause.

[Maternal deaths in Sweden: Diagnostics and clinical management could be improved]. / Mödradöd i Sverige: Vården hade många gånger kunnat vara bättre - Lärdomar från 11 års extern kollegial granskning.

MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions.  MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny.  A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.

Human chorionic gonadotropin and risk of pre-eclampsia: prospective population-based cohort study.

OBJECTIVES: Abnormal placentation in early pregnancy may play a role in the pathogenesis of pre-eclampsia. Human chorionic gonadotropin (hCG) regulates placental development and angiogenesis and may affect the ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) in the serum. The aims of this study were to investigate the association of total hCG with the risk of pre-eclampsia and to examine the potential effect of pro- and anti-angiogenic factors on this association. METHODS: This was a population-based prospective cohort study of 7754 women with a singleton pregnancy. Total hCG was measured in the first available sample (median gestational age, 14.4 weeks; 95% range, 10.1-26.1 weeks) and sFlt-1 and PlGF concentrations in early (< 18 weeks; median, 13.2 weeks; 95% range, 9.6-17.6 weeks) and in mid- (18-25 weeks; median, 20.4 weeks; 95% range, 18.5-23.5 weeks) pregnancy. We tested the association of hCG concentration and risk of pre-eclampsia using regression analysis, adjusting for maternal age, ethnicity, body mass index, parity, education level, smoking status and fetal sex. Additionally, we assessed whether this association was affected by the sFlt-1/PlGF ratio. RESULTS: High hCG concentration was associated with a 1.5-2.7-fold increased risk of pre-eclampsia (P = 0.0001), depending on the cut-off used, and with increased sFlt-1/PlGF ratio during early pregnancy (P < 0.0001). The association between high hCG and pre-eclampsia attenuated by roughly 40% after adjustment for early-pregnancy sFlt-1/PlGF ratio (ß-estimate change from 0.19 ± 0.10 (P = 0.052) to 0.12 ± 0.10 (P = 0.22)). CONCLUSIONS: High total hCG concentration in early pregnancy is associated with an increased risk of pre-eclampsia. The effect of high hCG concentration on the balance between pro- and anti-angiogenic factors during pregnancy may have a role in the pathophysiology of pre-eclampsia. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Hepatic rupture associated with preeclampsia, report of three cases and literature review.

BACKGROUND: Hepatic rupture is a complication during pregnancy that, although rare, accounts for high morbidity and mortality rates. It is mainly associated with severe preeclampsia and HELLP syndrome. Incidence is estimated to be at one per 67,000 births or one per 2000 patients with preeclampsia/eclampsia/HELLP, mainly in multiparous women; women in their 40s; after 32 weeks of gestation; and during the first 15 h postpartum. CASES: This article exposes the institutional experience at Fundación Valle del Lili in Cali, Colombia, in managing and treating hepatic rupture associated with severe preeclampsia and HELLP syndrome in three patients in the 30th, the 26th, and the 27th week of gestation, not resulting in maternal death. DISCUSSION: A search in Pubmed, Embase, and Ovid from 2000 to 2017 resulted in 35 cases reported in either pregnant or puerperal women. Hepatic rupture is a rare complication in pregnancy associated with preeclampsia and HELLP syndrome. Its pathophysiology is attributed to the presence of vasospasm due to an increase in concentration and sensitivity to circulating vasopressors during pregnancy. There is no standard management, but surgery reduces mortality significantly. It includes endovascular management, partial hepatectomy, or transplant (only one patient required a liver transplant in our search). The most used techniques have been ligation of the hepatic artery, embolization of the hepatic artery, and examination, packing, and drainage of hepatic lesion for bleeding control (27 cases were treated with laparotomy with evacuation of hematoma and hemostasis and four cases were treated with embolization of the hepatic artery). Hepatic artery occlusion both by surgery ligation and by embolization through interventional radiology has reported successful and failing results during pregnancy Conclusion: Management of pathologies as hepatic rupture associated with severe preeclampsia and HELLP syndrome has to be clearly protocolized for prompt diagnosis and early management. Furthermore, it has to be carried out through multidisciplinary teams in high-complexity obstetrics scenarios.

Soluble fms-like tyrosine kinase-1 to placental growth factor ratio: ruling out pre-eclampsia for up to 4 weeks and value of retesting.

OBJECTIVES: The soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio is generally elevated some time before and at the clinical onset of pre-eclampsia. The PROGNOSIS study validated a sFlt-1/PlGF ratio cut-off of ≤ 38 to rule out the onset of pre-eclampsia within 1 week of testing in women with suspected disease. The aim of this study was to assess the predictive value of the sFlt-1/PlGF ratio to rule out the onset of pre-eclampsia for up to 4 weeks, and to assess the value of repeat measurements. METHODS: This was an exploratory post-hoc analysis of data from the PROGNOSIS study performed in pregnant women aged ≥ 18 years with suspected pre-eclampsia, who were at 24 + 0 to 36 + 6 weeks' gestation at their first clinic visit. Serum samples were collected at the first visit and weekly thereafter. sFlt-1 and PlGF levels were measured using Elecsys® sFlt-1 and PlGF immunoassays. Whether the sFlt-1/PlGF ratio cut-off of ≤ 38 used to rule out the onset of pre-eclampsia within 1 week could predict the absence of pre-eclampsia 2, 3, and 4 weeks post-baseline was assessed. The value of repeat sFlt-1/PlGF testing was assessed by examining the difference in sFlt-1/PlGF ratio 2 and 3 weeks after the first measurement in women with, and those without, pre-eclampsia or adverse fetal outcome. RESULTS: On analysis of 550 women, sFlt-1/PlGF ratio ≤ 38 ruled out the onset of pre-eclampsia 2 and 3 weeks post-baseline with high negative predictive values (NPV) of 97.9% and 95.7%, respectively. The onset of pre-eclampsia within 4 weeks was ruled out with a high NPV (94.3%) and high sensitivity and specificity (66.2% and 83.1%, respectively). Compared with women who did not develop pre-eclampsia, those who developed pre-eclampsia had significantly larger median increases in sFlt-1/PlGF ratio at 2 weeks (∆, 31.22 vs 1.45; P < 0.001) and at 3 weeks (∆, 48.97 vs 2.39; P < 0.001) after their initial visit. Women who developed pre-eclampsia and/or adverse fetal outcome compared with those who did not had a significantly greater median increase in sFlt-1/PlGF ratio over the same period (∆, 21.22 vs 1.40; P < 0.001 at 2 weeks; ∆, 34.95 vs 2.30; P < 0.001 at 3 weeks). CONCLUSION: The Elecsys® immunoassay sFlt-1/PlGF ratio can help to rule out the onset of pre-eclampsia for 4 weeks in women with suspected pre-eclampsia. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Oral antioxidant therapy for prevention and treatment of preeclampsia: Meta-analysis of randomized controlled trials.

AIMS: To determine whether oral antioxidant therapies, of various types and doses, are able to prevent or treat women with preeclampsia. DATA SYNTHESIS: The following databases were searched: MEDLINE, CENTRAL, LILACS, and Web of Science. Inclusion criteria were: a) randomized clinical trials; b) oral antioxidant supplementation; c) study in pregnant women; d) control group, treated or not with placebo. Papers were excluded if they evaluated antioxidant nutrient supplementation associated with other non-antioxidant therapies. Data were extracted and the risk of bias of each study was assessed. Heterogeneity was analyzed using the Cochran Q test, and I2 statistics and pre-specified sensitivity analyses were performed. Meta-analyses were conducted on prevention and treatment studies, separately. The primary outcome was the incidence of preeclampsia in prevention trials, and of perinatal death in treatment trials. Twenty-nine studies were included in the analysis, 19 for prevention and 10 for treatment. The antioxidants used in these studies were vitamins C and E, selenium, l-arginine, allicin, lycopene and coenzyme Q10, none of which showed beneficial effects on the prevention of preeclampsia (RR: 0.89, CI 95%: [0.79-1.02], P = 0.09; I2 = 39%, P = 0.04) and other outcomes. The antioxidants used in the treatment studies were vitamins C and E, N-acetylcysteine, l-arginine, and resveratrol. A beneficial effect was found in intrauterine growth restriction. CONCLUSIONS: Antioxidant therapy had no effects in the prevention of preeclampsia but did show beneficial effects in intrauterine growth restriction, when used in the treatment of this condition.

Perinatal outcome of hypertensive pregnant women is related to the severity of preeclampsia

Introduction: Hypertension in pregnancy plays a key role in perinatal morbidity and mortality. This study aims to analyze maternal and perinatal outcomes associated with hypertension in pregnant women. Methods: A prospective longitudinal study was conducted at the University Hospital of Santa Maria, RS, Brazil, involving hypertensive pregnant women admitted for delivery. The results were analyzed using the chi-square test and the Mann-Whitney test. Results: Of the 162 hypertensive pregnant women studied, 61.1% were diagnosed with preeclampsia. Cesarean section was the most frequent mode of delivery (79.6%). Overall, 46.2% of newborns were premature; of these, 23.4% required intensive neonatal care. Preeclampsia and severe preeclampsia were associated with prematurity in 56.2% of cases (p = 0.011) and 75.7% of cases (p = 0.004), respectively. Severe preeclampsia was associated with neonatal complications (45.9%), and no neonatal complications were associated with mild preeclampsia in 78% (p = 0.014) and gestational hypertension in 96% (p = 0.001). Neonatal deaths occurred in 11.1% of cases admitted to the neonatal intensive care unit, corresponding to a neonatal mortality rate of 24 per 1,000 live births. Conclusions: The association of severe preeclampsia with prematurity and adverse perinatal outcomes corroborates the need . (AU)

Hematoma subcapsular hepático roto en el curso de un síndrome de HELLP / Broken hepatic subcapsular hematoma in the course of HELLP syndrome

Se presenta un caso poco frecuente de un hematoma subcapsular hepático roto en el curso de un síndrome de HELLP, en una paciente como complicación de la preeclampsia que resultó en una mortalidad materna. Se realizó, además, una revisión de la literatura(AU)

We report a rare case of a ruptured hepatic subcapsular hematoma in the course of in a patient with HELLP syndrome as a complication of preeclampsia resulting in maternal mortality. A review of the literature was also carried out(AU)

Maternal and neonatal outcomes in women with severe early onset pre-eclampsia before 26 weeks of gestation, a case series.

OBJECTIVE: To describe the maternal and neonatal outcomes and prolongation of pregnancies with severe early onset pre-eclampsia before 26 weeks of gestation. DESIGN: Nationwide case series. SETTING: All Dutch tertiary perinatal care centres. POPULATION: All women diagnosed with severe pre-eclampsia who delivered between 22 and 26 weeks of gestation in a tertiary perinatal care centre in the Netherlands, between 2008 and 2014. METHODS: Women were identified through computerised hospital databases. Data were collected from medical records. MAIN OUTCOME MEASURES: Maternal complications [HELLP (haemolysis, elevated liver enzyme levels, and low platelet levels) syndrome, eclampsia, pulmonary oedema, cerebrovascular incidents, hepatic capsular rupture, placenta abruption, renal failure, and maternal death], neonatal survival and complications (intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis, bronchopulmonary dysplasia, and sepsis), and outcome of subsequent pregnancies (recurrent pre-eclampsia, premature delivery, and neonatal survival). RESULTS: We studied 133 women, delivering 140 children. Maternal complications occurred frequently (54%). Deterioration of HELLP syndrome during expectant care occurred in 48%, after 4 days. Median prolongation was 5 days (range: 0-25 days). Neonatal survival was poor (19%), and was worse (6.6%) if the mother was admitted before 24 weeks of gestation. Complications occurred frequently among survivors (84%). After active support, neonatal survival was comparable with the survival of spontaneous premature neonates (54%). Pre-eclampsia recurred in 31%, at a mean gestational age of 32 weeks and 6 days. CONCLUSIONS: Considering the limits of prolongation, women need to be counselled carefully, weighing the high risk for maternal complications versus limited neonatal survival and/or extreme prematurity and its sequelae. The positive prospects regarding maternal and neonatal outcome in future pregnancies can supplement counselling. TWEETABLE ABSTRACT: Severe early onset pre-eclampsia comes with high maternal complication rates and poor neonatal survival.

Evidence-Based Revised View of the Pathophysiology of Preeclampsia.

Preeclampsia is a life-threatening vascular disorder of pregnancy due to a failing stressed placenta. Millions of women risk death to give birth each year and globally each year, almost 300,000 lose their life in this process and over 500,000 babies die as a consequence of preeclampsia. Despite decades of research, we lack pharmacological agents to treat it. Maternal endothelial oxidative stress is a central phenomenon responsible for the preeclampsia phenotype of high maternal blood pressure and proteinuria. In 1997, it was proposed that preeclampsia arises due to the loss of VEGF activity, possibly due to elevation in anti-angiogenic factor, soluble Flt-1 (sFlt-1). Researchers showed that high sFlt-1 and soluble endoglin (sEng) elicit the severe preeclampsia phenotype in pregnant rodents. We demonstrated that heme oxygenase-1 (HO-1)/carbon monoxide (CO) pathway prevents placental stress and suppresses sFlt-1 and sEng release. Likewise, hydrogen sulphide (H2S)/cystathionine-γ-lyase (Cth) systems limit sFlt-1 and sEng and protect against the preeclampsia phenotype in mice. Importantly, H2S restores placental vasculature, and in doing so improves lagging fetal growth. These molecules act as the inhibitor systems in pregnancy and when they fail, preeclampsia is triggered. In this review, we discuss what are the hypotheses and models for the pathophysiology of preeclampsia on the basis of Bradford Hill causation criteria for disease causation and how further in vivo experimentation is needed to establish 'proof of principle'. Hypotheses that fail to meet the Bradford Hill causation criteria include abnormal spiral artery remodelling and inflammation and should be considered associated or consequential to the disorder. In contrast, the protection against cellular stress hypothesis that states that the protective pathways mitigate cellular stress by limiting elevation of anti-angiogenic factors or oxidative stress and the subsequent clinical signs of preeclampsia appear to fulfil most of Bradford Hill causation criteria. Identifying the candidates on the roadmap to this pathway is essential in developing diagnostics and therapeutics to target the pathogenesis of preeclampsia.

Blood laboratory testing for early prediction of preeclampsia: chasing the finish line or at the starting blocks?

Preeclampsia (PE) affects 2-8% of pregnancies worldwide, thus representing an important cause of maternal and neonatal morbidity, up to death. Many studies have been designed to identify putative biomarkers for accurate and timely diagnosing PE, but only some of them were focused on specific and sensitive biomarkers for early prediction of this life-threatening condition. In particular, some prospective studies aimed to investigate the predictive role of circulating biomarkers before 20 weeks of gestation in the general pregnant population yielded conflicting results. This article is hence centered on results obtained in studies investigating the predictive performances of angiogenic, anti-angiogenic, inflammatory, endocrine, and epigenetic biomarkers. The available evidence suggests that angiogenic and anti-angiogenic molecules, in particular the sFlt1:PlGF ratio, may be considered the biomarkers with the best diagnostic performance in the second trimester. However, doubts remain about their use in clinical settings before the 20th gestational week. Even lower evidence is available for other biomarkers, due to the fact that some positive results have not been confirmed in ensuing investigations, whereas unresolved analytical issues still contribute to make their clinical reliability rather questionable. Differential expression of microRNAs seems also a promising evidence for early prediction of PE, but additional research and well-designed prospective studies are needed to identify and validate routine predictive tests. KEY MESSAGES Preeclampsia affects 2-8% of pregnant women worldwide, thus remaining one of the leading causes of maternal and neonatal morbidity and mortality. Several studies have investigated the predictive role of circulating biomarkers before 20th week of gestation with conflicting results. Additional research and well-designed prospective studies are needed to identify and validate predictive tests in clinical practice.

Resultados perinatales en gestantes con trastornos hipertensivos del embarazo, Hospital Regional Santa Teresa, 2015 / Perinatal Outcome in Pregnant Women with Hypertensive Disorders of Pregnancy, Regional Hospital Santa Teresa, 2015

Antecedente. Las enfermedades hipertensivas del embarazo representan una alta incidencia de morbimortalidad materna y perinatal, por lo que es necesario conocer las características de los recién nacidos de madres con trastornos hipertensivos para intervenir de forma precoz y oportuna. Objetivo. Describir las características clínicas y epidemiológicas de los recién nacidos de madres con trastornos hipertensivos del embarazo de la sala de labor y parto del Hospital Regional Santa Teresa, Comayagua, durante el año 2015. Métodos. Estudio observacional descriptivo. En este período ingresaron 6,090 gestantes, de las cuales 361 (5.9%) presentaron enfermedad hipertensiva del embarazo. Se estimó un tamaño de muestra de 186 (51.5%, IC95%). Las variables estudiadas fueron: datos maternos, datos clínicos y del nacimiento, complicaciones perinatales. La información recolectada fue ingresada en Epiinfo versión 7.1.5 (CDC, Atlanta). Los resultados se presentan como frecuencias y porcentajes. La información personal de los casos se manejó confidencialmente. Resultados. El 58.6%(109) eran gestantes entre 19-35 años, 73.1%(136) procedentes de área rural, 65.1%(121) con más de cinco consultas prenatales. La vía de parto más frecuente vaginal en 63.4%(118) y el trastorno hipertensivo más frecuente fue preeclampsia-eclampsia con 65.1%(121). El 53.2%(99) de los recién nacidos fueron del género masculino, 94.1%(175) presentaron puntaje de Apgar normal, 84.4(157) peso al nacer entre 2500 ­ 3999 gr. La complicación materna y perinatal más frecuente fue el síndrome de Hellp con 3.8%(7) y síndrome de distress respiratorio 10.2%(19). Discusión. El 58.1% de los recién nacidos presentó alguna complicación al momento del nacimiento...(AU)

Costo efectividad del suplemento de calcio para reducir la mortalidad materna asociada a preeclampsia en Colombia / Cost effectiveness of calcium supplement in reducing preeclampsia-related maternal mortality in Colombia

Objetivo Estimar el costo-efectividad de la administración de calcio (1 200 mg diarios) a partir de la semana 14 de gestación a todas las gestantes, comparada con no administrarlo, para reducir la incidencia de preeclampsia. Métodos Se construyó un árbol de decisión en TreeAge® con desenlace en años de vida ganados (AVG). Los costos se incluyeron desde la perspectiva del sistema de salud colombiano, en pesos (COP) de 2014. La tasa de descuento fue de 0%. Se realizaron análisis de sensibilidad univariados y probabilísticos para costos y efectividad. Resultados El suplemento de calcio es una alternativa dominante frente a la no intervención. Si la incidencia de preeclampsia es menor a 51,7 por 1 000 gestantes o el costo por tableta de calcio de 600 mg es mayor a COP$ 507,85, el suplemento de calcio deja de ser una alternativa costo-efectiva en Colombia para un umbral de 3 veces el PIB per cápita de 2013 (COP$ 45 026 379) por AVG. Conclusiones La administración de calcio a todas las gestantes a partir de la semana 14 de gestación es una alternativa dominante frente a la no intervención, que permite ganar 200 años de vida, al tiempo que disminuye costos del orden de COP$ 5 933 millones por 100 000 gestantes.(AU)

Objectives To estimate the cost-effectiveness of administering calcium (1200 mg per day) starting in week 14 of pregnancy to all pregnant women compared to not supplying it to reduce the incidence of preeclampsia. Methods A decision tree was built in TreeAge® with outcome measured in life years gained (LYG) associated with the reduction in maternal deaths. Costs were included from the perspective of the health system in Colombia and expressed in Colombian pesos in 2014 (COP). The discount rate was 0 %. We performed sensitivity univariate and probabilistic analyses for costs and effectiveness. Results Compared to no intervention, calcium supplement is a dominant alternative. If the incidence of preeclampsia is lower than 51.7 per 1 000 pregnant women or the cost per tablet of calcium of 600 mg is greater than COP $507.85, calcium supplement is no longer a cost-effective alternative in Colombia for a threshold of COP $ 45 026 379 (3 times the Colombian per capita GDP of 2013 per LYG). Conclusions Supplying calcium to all pregnant women from week 14 of gestation is a dominant alternative compared to no intervention, which saves 200 LYG, while it decreases costs to the order of COP$5 933 million per 100.000 pregnant women.(AU)

Maternal deaths in Iceland over 25 years.

INTRODUCTION: Maternal death, during pregnancy or within 42 and 365 days from the end of pregnancy, was evaluated for a small high-income nation with comprehensive healthcare. MATERIAL AND METHODS: Cases were identified using record linkage by running national census information on all deaths of women aged 15-49 years during 1985-2009 against the national birth register and computerized hospital admission files for pregnancy-related diagnoses as well as actual case records where needed. Death certificates and hospital records were reviewed. RESULTS: Thirty deaths were identified; 26 at ≥ 22 weeks (= birth) and four earlier in pregnancy. For 107,871 deliveries, the overall mortality was 27.8/100,000. There were five direct deaths (4.6/100,000 deliveries), five indirect deaths (4.6/100,000 deliveries) and 19 coincidental deaths (17.6/100,000 deliveries). Using WHO criteria (direct and indirect in pregnancy or at ≤ 42 days postpartum) the ratio was 5.6/100,000 deliveries (95% confidence interval 1.1-10.1) and 5.5/100,000 live births (maternal mortality ratio, based on six deaths). Direct deaths were caused by sepsis, severe preeclampsia and choriocarcinoma, indirect by suicide, pre-existing cardiac and diabetic illness. No woman died of postpartum hemorrhage, anesthesia or ectopic pregnancy. Suboptimal care occurred. CONCLUSION: Maternal mortality in Iceland over a 25-year period up to the end of year 2010 was low, between 5 and 6/100,000 births. A comprehensive national healthcare system with accessible antenatal care in a society with good general living conditions and universal education probably contributed to this.

Clinical and pathogenetic features of early- and late-onset pre-eclampsia.

BACKGROUND: PE is present in ∼2-8% of all pregnant women worldwide. Placental bed disorders at early and late PE have been not carried out yet. However, these studies help to explore details of the pathogenesis of PE, and to optimize the prognosis and obstetric management. OBJECTIVE: To identify clinical and morphological differences between early- and late-onset PE based on a comprehensive observation of pregnant women with regard to morphological and immunohistochemical characteristics of the placental bed. MATERIALS AND METHODS: One hundred fifty patients aged 18-43 years old delivered by cesarean section due to severe PE. The samples of placental bed tissue were studied by morphological and immunohistochemical methods. RESULTS: The violation of invasion trophoblast, remodeling of spiral arteries were expressed in early onset PE; the degree of compensation of chronic hypoxia tissue in the area of the placental site was typical for late PE and was absent of an early onset PE. CONCLUSION: Our studies confirm the need for separation of early- and late-onset PE, being justified in terms of different pathogenetic mechanisms of formation, and therefore the possibility of therapeutic effects, duration of pregnancy prolongation, forecasting, search early diagnostic markers of the disease, and personalized approaches.

Asociación de factores de riesgo de preeclampsia en mujeres mexiquenses / Association preeclampsia risk factors in mexiquenses women

Introducción: La preeclampsia es aún uno de los mayores problemas obstétricos en países en vías de desarrollo.Objetivo: Identificar los principales factores de riesgo para desarrollar preeclampsia en mujeres mexiquenses atendidas en el Hospital Materno Perinatal "Mónica Pretelini Sáenz".Material y métodos: Estudio de casos y controles, se incluyeron dos grupos, el grupo A casos (n=138) y el grupo B controles (n=276) con relación caso-control de 1:2.Los criterios de definición para los casos fueron: mujeres con diagnóstico inicial de preeclampsia y que cuenten con las siguientes mediciones: Tensión Arterial Sistólica (TAS)=140 ó Tensión Arterial Diastólica (TAD)=90 mmHg más una de las siguientes: concentración de proteínas en orina de 24 h =300 ó Proteinuria =++. El grupo de controles quedó conformado por mujeres que acudieron al hospital para atención del embarazo sin preeclampsia. Resultados: La media de edad fue de 27.5±8.0 para los casos (grupo A) y 25.3±6.7 para los controles (grupo B) (P<0.01). El tener 1 o más óbitos (P<0.045), las cifras iniciales y finales de TAS y TAD, el índice de masa corporal pregestacional (IMCPG), el peso al final del embarazo, y la hipertensión arterial sistémica crónica (P<0.01) así como el haber padecido preeclampsia en algún embarazo previo fueron estadísticamente significativo (P<0.01) para tener preeclampsia. Conclusiones: En nuestra población, además de los factores de riesgo tradicionales para preeclampsia se agrega el antecedente de óbitos como otro factor de riesgo para padecer preeclampsia.

Introduction: Preeclampsia is still a major obstetric problem in developing countries. Objective: To identify the main risk factors to develop preeclampsia in women from the State of Mexico attended at the Maternal Perinatal Hospital "MónicaPreteliniSáenz". Materials and methods: In this case-control study, two groups were included, group A patients (n = 138) and B controls (n = 276) with a case-control ratio of 1: 2. The criteria for defining cases were women initially diagnosed with preeclampsia and who had the following measurements: Systolic Blood Pressure (SBP) =140 or diastolic blood pressure (DBP) =90 mmHg plus one of the following: =300 protein concentration in a 24-h urine sample or proteinuria = ++. The control group was made up of women attended at the hospital who did not develop preeclampsia. Results: The mean age was 27.5 ± 8.0 years for the cases (group A) and 25.3 ± 6.7 years for controls (group B) (P <0.01). Having 1 or more stillbirth (P <0.045), initial and final measures of SBP and DBP, the pre-pregnancy body mass index (IMCPG), weight in late pregnancy, and chronic hypertension (P <0.01) as well as having had preeclampsia in a previous pregnancy were statistically significant (P <0.01) to have preeclampsia. Conclusions: In our population, in addition to the traditional risk factors for preeclampsia, history of stillbirthswas is another risk factor to develop preeclampsia.