Association of cardiovascular risk factors and myocardial hypertrophy in women with preeclampsia history.

AIMS: A historic of preeclampsia (PE) has been associated with cardiovascular disease (CVD) in women. There are substantial evidences that cardiovascular changes resulting from PE can persist even after pregnancy end. Therefore, the aims was to evaluate the prevalence of myocardial hypertrophy in young women 12 months after PE event as well as try to identify risk factors for these changes. MATERIALS AND METHODS: Single-center observational prospective cross-sectional study that included 118 consecutive patients after 12 months of PE. Clinical and laboratory evaluations, echocardiogram were performed. Myocardial hypertrophy (LVH) was defined as an index myocardial mass ≥ 45 g/m2.7, for women. Classical risk factors for CVD were considered. Analysis included linear or logistic regression and Spearman's correlation coefficient. Significance level of 5 %. KEY FINDINGS: Systemic arterial hypertension (SAH) was identified in 52 patients (44 %), overweight/obesity (OOB) in 82 (69 %), dyslipidemia in 68 (57 %) and metabolic syndrome in 47 patients (40 %). LVH was present in 35 cases (29 %) and associated with OOB (OR = 4.51; CI95%:1.18-17.17, p < 0.001), in a model corrected for age and SAH diagnosis. When only the metabolic syndrome components were analyzed, in the multiple logistic regression model, the abdominal circumference was the only clinical variable associated with LVH (OR = 17.65; CI95%:3.70-84.17; p < 0.001). SIGNIFICANCE: It was observed a high prevalence of ventricular hypertrophy in young women with a history of pre-eclampsia. This condition was associated with the presence of obesity.

Uncorrected pentalogy of Fallot with successful pregnancy-A case report.

Pentalogy of Fallot (PoF) is a congenital heart disease comprising tetralogy of Fallot plus an atrial septal defect (ASD). Patients are diagnosed early in life and submitted to reparative surgery. Without it, the prognosis is poor. This female patient, initially diagnosed with transposition of great arteries (TGA), ASD and a ventricular septal defect, got pregnant at 26 years old and had an early delivery due to fetal distress. She resumed follow-up, and her last echocardiogram put in doubt the diagnosis of TGA. Cardiac CT then revealed a PoF as well as pulmonary arteriovenous fistulas and a persistent left superior vena cava.

Evolution of Myocardial Hypertrophy Associated With Pregnancy in Hypertensive Women Six Months Postpartum.

Systemic arterial hypertension (SAH) is one of the principal risk factors for developing cardiovascular disease. When a hypertensive woman becomes pregnant, new hemodynamic condition is installed, with addition from chronic pressure overload to chronic volume overload. This new hemodynamic condition can provide greater myocardial hypertrophy(LVH), whose postpartum evolution has been little studied in the literature. To evaluate LVH in hypertensive women in the third trimester of pregnancy and 6 months postpartum and to establish which clinical variables are associated with elevated risk of LVH. Prospective longitudinal study including 41 pregnant women beyond 35 gestational weeks and with previous SAH. They were submitted to clinical and echocardiographic evaluation at the gestational period and 6 months postpartum. Statistical analysis: multivariate logistic regression with the exposures most strongly associated with maintenance of hypertrophy in univariate analysis. Significance level: P<0.05. The mean age was 29±6.2 years. The majority of the women were white(85.4%). Before pregnancy 23(59%) women used antihypertensive drugs and 28(71.8%) used during pregnancy. At the end of gestation, all women presented LVH, 79% maintained hypertrophy 6 months postpartum. In multivariate analysis, exposures significantly associated with hypertrophy maintenance: systolic blood pressure(SBP) at the end of gestation, OR=1.16(1.03-1.30);P=0.013 and SBP increase at 6 months postpartum in relation to end of gestation, OR=22.9(1.8-294);P=0.016. In hypertensive pregnant women, LVH frequency is elevated at the end of pregnancy, and recovery frequency of this hypertrophy, at 6 months postpartum, is very low. The increase of SBP 6 months postpartum was associated with maintenance of hypertrophy.

Association between Adverse Maternal Clinical Outcomes and Imbalance of Cytokines and Angiogenic Factors in Preterm Preeclampsia.

OBJECTIVE: Preeclampsia (PE) is a pregnancy-specific syndrome characterized by abnormal levels of cytokines and angiogenic factors, playing a role in the disease development. The present study evaluated whether immunological markers are associated with the gestational age and with the disease severity in preeclamptic women. METHODS: Ninety-five women who developed PE were stratified for gestational age as preterm PE (< 37 weeks) and term PE (≥ 37 weeks of gestation) and compared for disease severity as well as plasma concentration of angiogenic factors and cytokines. The concentrations of placental growth factor (PlGF), vascular endothelial growth factor (VEGF), Fms-like soluble tyrosine kinase (sFlt-1) and soluble endoglin (sEng), as well as the cytokines, tumor necrosis factor-α (TNF-α) and interleukin 10 (IL-10), were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS: The comparison between preeclamptic groups showed a higher percentage of severe cases in preterm PE (82.1%) than in term PE (35.9%). Similarly, the concentrations of TNF-α, sFlt-1, and sEng, as well as TNF-α/IL-10 and sFlt-1/PlGF ratios were significantly higher in the preterm PE group. In contrast, concentrations of PlGF, VEGF, and IL-10 were significantly lower in women with preterm PE. Negative correlations between TNF-α and IL-10 (r = 0.5232) and between PlGF and sFlt1 (r = -0.4158) were detected in the preterm PE. CONCLUSION: In pregnant women with preterm PE, there is an imbalance between immunological markers, with the predominance of anti-angiogenic factors and TNF-α, associated with adverse maternal clinical outcomes.

OBJETIVO: A pré-eclâmpsia (PE) é uma síndrome específica da gravidez caracterizada por níveis anormais de citocinas e fatores angiogênicos, que desempenham um papel no desenvolvimento da doença. Este estudo avaliou se os marcadores imunológicos estão associados à idade gestacional e à gravidade da doença em mulheres com pré-eclâmpsia. MéTODOS: Noventa e cinco mulheres que desenvolveram PE foram estratificadas pela idade gestacional em PE pré-termo (< 37 semanas) e PE a termo (≥ 37 semanas de gestação) e comparadas quanto à gravidade da doença, bem como à concentração plasmática de fatores angiogênicos e citocinas. As concentrações de fator de crescimento placentário (PlGF), fator de crescimento endotelial vascular (VEGF), tirosina quinase solúvel semelhante a Fms (sFlt-1) e endoglina solúvel (sEng), bem como as citocinas, fator de necrose tumoral alfa (TNF- α) e interleucina 10 (IL-10), foram determinados porensaio de imunoabsorção enzimática (ELISA, na sigla em inglês). RESULTADOS: A comparação entre os grupos com pré-eclâmpsia mostrou maior porcentagem de casos graves em PE pré-termo (82,1%) do que em PE a termo (35,9%). Da mesma forma, as concentrações de TNF-α, sFlt-1 e sEng, bem como as razões TNF-α/IL-10 e sFlt-1/PlGF foram significativamente maiores no grupo de PE pré-termo. Em contraste, as concentrações de PlGF, VEGF e IL-10 foram significativamente menores em mulheres com PE pré-termo. Correlações negativas entre TNF-α e IL-10 (r = 0.5232) e entre PlGF e sFlt1 (r = −0.4158) foram detectadas no grupo de PE pré-termo. CONCLUSãO: Em gestantes com PE pré-termo, ocorre um desequilíbrio entre os marcadores imunológicos, com predomínio de fatores antiangiogênicos e TNF-α, associados a desfechos clínicos maternos adversos.

Increased Risk for Maternal Anxiety during the COVID-19 Outbreak in Brazil among Pregnant Women without Comorbidities.

OBJECTIVE: To study maternal anxiety in pregnant women without comorbidities in the context of the COVID-19 outbreak in Brazil and to study maternal knowledge and concerns about the pandemic. METHODS: This is a secondary analysis from a national multicenter cross-sectional study performed in 10 cities, from June to August, 2020, in Brazil. Interviewed postpartum women, without medical or obstetrical comorbidities, were included in the present subanalysis. A structured questionnaire and the Beck Anxiety Inventory (BAI) were applied. RESULTS: Out of the 1,662 women, 763 (45.9%) met the criteria for the current analysis and 16.1% presented with moderate and 11.5% with severe maternal anxiety. Moderate or severe maternal anxiety was associated with high school education (odds ratio [OR]:1.58; 95% confidence interval [CI]:1.04-2.40). The protective factor was cohabiting with a partner (OR: 0.46; 95%CI: 0.29-0.73). There was a positive correlation between the total BAI score and receiving information about care in the pandemic (rpartial 0.15; p < 0.001); concern about vertical transmission of COVID-19 (rpartial 0.10; p = 0.01); receiving information about breastfeeding (rpartial 0.08; p = 0.03); concerns about prenatal care (rpartial 0.10; p = 0.01), and concerns about the baby contracting COVID-19 (rpartial 0.11; p = 0.004). The correlation was negative in the following aspects: self-confidence in protecting from COVID-19 (rpartial 0.08; p = 0.04), having learned (rpartial 0.09; p = 0.01) and self-confidence in breastfeeding (rpartial 0.22; p < 0.001) in the context of the pandemic. CONCLUSION: The anxiety of pregnant women without medical or obstetrical comorbidities was associated to high school educational level and not living with a partner during the COVID-19 pandemic. Self-confidence in protecting against COVID-19 and knowledge about breastfeeding care during the pandemic reduced maternal anxiety.

OBJETIVO: Estudar a ansiedade materna em gestantes sem comorbidades no contexto do surto de COVID-19 no Brasil e estudar o conhecimento e as preocupações maternas sobre a pandemia. MéTODOS: Trata-se de análise secundária de um estudo transversal multicêntrico nacional realizado em 10 cidades, de junho a agosto de 2020, no Brasil. Mulheres no pós-parto entrevistadas, sem comorbidades médicas ou obstétricas, foram incluídas nesta subanálise. Foram aplicados um questionário estruturado e o Inventário de Ansiedade de Beck (BAI, na sigla em inglês). RESULTADOS: Das 1.662 mulheres, 763 (45,9%) atenderam aos critérios da análise atual e 16,1% apresentaram ansiedade materna moderada e 11,5% ansiedade materna grave. A ansiedade materna moderada ou grave foi associada à escolaridade no ensino médio (odds ratio [OR]: 1,58; intervalo de confiança [IC] 95%: 1,04­2,40). O fator protetor foi coabitar com companheiro (OR: 0,46; IC95%: 0,29­0,73). Houve correlação positiva entre a pontuação total do BAI e o recebimento de informações sobre cuidados na pandemia (rparcial 0,15; p < 0,001); preocupação com a transmissão vertical de COVID-19 (rparcial 0,10; p = 0,01); receber informações sobre amamentação (rparcial 0,08; p = 0,03); preocupações sobre cuidados pré-natais (rparcial 0,10; p = 0,01) e preocupações sobre o bebê contrair COVID-19 (rparcial 0,11; p = 0,004). A correlação foi negativa com os seguintes aspectos: ter autoconfiança para se proteger (rparcial 0,08; p = 0,04), aprender (rparcial 0,09; p = 0,01) e ter autoconfiança para amamentar (rparcial 0,22; p < 0,001) no contexto da pandemia. CONCLUSãO: A ansiedade de gestantes sem comorbidades médicas ou obstétricas esteve associada à escolaridade no ensino médio e não morar com companheiro durante a pandemia de COVID-19. A autoconfiança na proteção contra COVID-19 e o conhecimento sobre os cuidados com a amamentação durante a pandemia reduziram a ansiedade materna.

Increased TLR4 pathway activation and cytokine imbalance led to lipopolysaccharide tolerance in monocytes from preeclamptic women.

Preeclampsia (PE) is a pregnancy syndrome characterized by a systemic inflammatory response, and endogenous activation of monocytes. This study aimed to determine whether the activation of monocytes from preeclamptic women might interfere with the response to lipopolysaccharide (LPS)-in vitro stimulation. Fifty-two preeclamptic women and 32 normotensive (NT) pregnant women were included. Monocytes from peripheral blood were cultured with or without LPS. TLR4 expression was analyzed by flow cytometry, NF-κB activity was determined in nuclear extracts and cytokines production was evaluated by ELISA. Endogenous TLR4 ligands such as Hyaluronan, HMGB1 and Hsp70 were determined in plasma. The endogenous TLR4 expression and activation of NF-κB were statistically higher in monocytes from women with PE compared to NT group. Early-onset PE showed higher TLR4 expression compared to late-onset PE. Plasma levels of Hyaluronan, HMGB1, and Hsp70, as well as endogenous production of inflammatory cytokines, were elevated whilst lower production of IL-10 was observed in the PE group. After culture with LPS, monocytes presented lower NF-κB activation, TNF-α and IL-12 production in PE groups than in the NT group. The study demonstrates endogenous activation of monocytes from preeclamptic women, accompanied by higher expression of TLR4, NF-κB activation and elevated production of pro-inflammatory cytokines. The higher plasma levels of the TLR4 ligands hyaluronan, HMGB1 and hsp70, as well as the high concentration of TNF-α endogenously produced by monocytes, could induce the LPS tolerance phenomenon in these cells. These results suggest that monocytes play an important role in the maternal excessive systemic inflammatory response in PE.

Pre-eclampsia/Eclampsia.

Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age in < 24 weeks, between 24 and less than 34 weeks, and ≥ 34 weeks of gestation, and guidance on route of delivery. An immediate puerperium approach and repercussions in the future life of pregnant women who develop preeclampsia is also presented.

A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A pré-eclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgão-alvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas.

Platelet aggregation and TGF-beta(1) plasma levels in pregnant women with preeclampsia.

OBJECTIVES: Platelets and transforming growth factor-beta(1) (TGF-beta(1)) are thought to be involved in the pathogenesis of preeclampsia. Our objectives were to determine plasma concentration of TGF-beta(1) in normotensive and preeclamptic women in the third trimester of pregnancy and to evaluate the correlation of TGF-beta(1) plasma levels with platelet count and agonist-induced aggregation capacity. METHODS: Thirty-three women with preeclampsia were compared with 36 healthy women with uncomplicated pregnancies. Peripheral venous blood samples were obtained, and TGF-beta(1) plasma levels measured by an enzyme-linked immunoassay. Platelet aggregation was induced by the agonist agents adenosine diphosphate (ADP), collagen and epinephrine, and was determined in platelet-rich plasma by aggregometry. RESULTS: Plasma concentrations of active TGF-beta(1) were significantly higher in preeclamptic women (10.41+/-2.07ng/mL) compared with normotensive pregnant women (7.01+/-3.29ng/mL). Platelet number and platelet agonist-induced aggregation percent were significantly lower in patients with preeclampsia than in healthy pregnant women. A significant correlation was observed between TGF-beta(1) plasma levels and platelet agonist-induced aggregation percent as between plasma levels of TGF-beta(1) and platelet number in preeclamptic patients. CONCLUSION: The association between impairment in platelet responsiveness and higher levels of TGF-beta(1) in the plasma of patients with preeclampsia suggests that this cytokine may play a role in the pathophysiological events of preeclampsia that are dependent on platelet activation.

Assessment of healthcare accessibility and travel distance on intrapartum fetal death: a retrospective cohort study / Relación de la accesibilidad de la atención de salud y la distancia de desplazamiento con la muerte fetal durante el parto: un estudio de cohorte retrospectivo / Avaliação do impacto do acesso ao sistema de saúde e da distância percorrida na morte fetal intraparto: estudo retrospectivo de coorte

ABSTRACT Objective. To determine if there was an association between intrapartum stillbirths and both traveled distance for delivery and delivery care accessibility, assessing periods before and during the COVID-19 pandemic. Methods. This is a population-based cohort study. Patients had birth occurring after the onset of labor; the primary outcome was intrapartum stillbirth. City of residence was classified according to the ratio between deliveries performed and total births among its residents; values lower than 0.1 indicated low delivery care accessibility. Travel distance was calculated using the Haversine formula. Education level, maternal age, and birth sex were included. In each period, relative risk was assessed by generalized linear model with Poisson variance. Results. There were 2 267 534 deliveries with birth occurring after the onset of labor. Most patients were between age 20 and 35 years, had between 8 and 11 years of education, and resided in cities with high delivery care accessibility. Low delivery care accessibility increased risk of intrapartum stillbirth in the pre-pandemic (relative risk [RR] 2.02; 95% CI [1.64, 2.47]; p < 0.01) and the pandemic period (RR 1.69; 95% CI [1.09, 2.55]; p = 0.015). This was independent of other risk-increasing factors, such as travel distance and fewer years of education. Conclusions. Low delivery care accessibility is associated with the risk of intrapartum stillbirths, and accessibility reduced during the pandemic. Delivery of patients by family physicians and midwives, as well as official communication channels between primary care physicians and specialists, could improve patient healthcare-seeking behavior.

RESUMEN Objetivo. Determinar si hubo una asociación entre la mortinatalidad durante el parto y la distancia recorrida o la accesibilidad de la atención para el parto, mediante la evaluación de un período anterior y de otro coincidente con la pandemia de COVID-19. Métodos. Se realizó un estudio de cohorte de base poblacional. Se incluyó a las pacientes que dieron a luz tras el inicio de un trabajo de parto; el criterio de valoración principal fue la mortinatalidad durante el parto. Se clasificaron las ciudades de residencia conforme al cociente entre el número de partos atendidos y el total de partos habidos entre sus residentes; los valores inferiores a 0,1 indican que la accesibilidad de la atención del parto es baja. La distancia recorrida para el parto se calculó utilizando la fórmula de Haversine. Se utilizaron datos del nivel de estudios y la edad de la madre y del sexo biológico neonatal. Para cada período, se evaluó el riesgo relativo mediante un modelo lineal generalizado con varianza de Poisson. Resultados. Hubo 2 267 534 partos que se produjeron tras el inicio de un trabajo de parto. La mayoría de las pacientes tenían edades comprendidas entre 20 y 35 años, tenían entre 8 y 11 años de estudios y residían en ciudades donde la accesibilidad de la atención del parto era alta. Una accesibilidad baja de la atención del parto se asoció a un aumento del riesgo de mortinatalidad durante el parto en el período prepandémico (riesgo relativo [RR] = 2,02; IC del 95% = [1,64, 2,47]; p < 0,01) y también durante la pandemia (RR = 1,69; IC del 95% = [1.09, 2.55]; p = 0,015). Este resultado fuer independiente de otros factores que incrementan el riesgo, como la distancia recorrida para dar a luz y un menor nivel de estudios. Conclusiones. Una accesibilidad baja de la atención del parto se asocia a un mayor riesgo de mortinatalidad durante el parto; y se observó una reducción de la accesibilidad durante la pandemia. Los partos asistidos por personal de medicina de familia o de partería y los canales de comunicación oficiales entre el personal médico de atención primaria y el especializado podrían mejorar el comportamiento de las pacientes a la hora de buscar atención de salud.

RESUMO Objetivo. Determinar se existe alguma relação entre a morte fetal intraparto e dois fatores: a distância percorrida para o parto e o acesso à assistência ao parto, avaliando o período antes e durante a pandemia de COVID-19. Métodos. Este é um estudo de coorte de base populacional. As pacientes tiveram parto após o início do trabalho de parto; o desfecho primário foi morte fetal intraparto. A cidade de residência foi classificada de acordo com a razão entre os partos realizados e o total de nascimentos entre os residentes; valores inferiores a 0,1 indicavam baixo acesso à assistência ao parto. A distância percorrida foi calculada usando a fórmula de Haversine. Foram incluídos o nível de escolaridade, a idade materna e o sexo de nascimento. Em cada período, o risco relativo foi avaliado usando um modelo linear generalizado com variância de Poisson. Resultados. Foram registrados 2 267 534 partos com nascimento após o início do trabalho de parto. A maioria das pacientes tinha entre 20 e 35 anos de idade, entre 8 e 11 anos de escolaridade e residia em cidades com alto nível de acesso à assistência ao parto. O baixo acesso à assistência ao parto aumentou o risco de morte fetal intraparto no período anterior à pandemia (risco relativo [RR]: 2,02; intervalo de confiança [IC] de 95%: 1,64-2,47; p < 0,01) e durante a pandemia (RR: 1,69; IC 95%: 1,09-2,55; p = 0,015). Isso ocorreu independentemente de outros fatores de aumento de risco, como a distância percorrida e menor escolaridade. Conclusões. O baixo acesso ao atendimento de parto está associado ao risco de morte fetal intraparto, e a acessibilidade diminuiu durante a pandemia. A realização do parto por médicos de família e obstetrizes, bem como a existência de canais oficiais de comunicação entre médicos de atenção primária e especialistas, poderiam melhorar o comportamento de busca de saúde por parte das pacientes.

Association between Adverse Maternal Clinical Outcomes and Imbalance of Cytokines and Angiogenic Factors in Preterm Preeclampsia / Associação entre desfechos maternos adversos e desbalanço de citocinas e fatores angiogênicos em pré-eclâmpsia pré-termo

Abstract Objective Preeclampsia (PE) is a pregnancy-specific syndrome characterized by abnormal levels of cytokines and angiogenic factors, playing a role in the disease development. The present study evaluated whether immunological markers are associated with the gestational age and with the disease severity in preeclamptic women. Methods Ninety-five women who developed PE were stratified for gestational age as preterm PE (< 37 weeks) and term PE (≥ 37 weeks of gestation) and compared for disease severity as well as plasma concentration of angiogenic factors and cytokines. The concentrations of placental growth factor (PlGF), vascular endothelial growth factor (VEGF), Fms-like soluble tyrosine kinase (sFlt-1) and soluble endoglin (sEng), as well as the cytokines, tumor necrosis factor-α (TNF-α) and interleukin 10 (IL-10), were determined by enzyme-linked immunosorbent assay (ELISA). Results The comparison between preeclamptic groups showed a higher percentage of severe cases in preterm PE (82.1%) than in term PE (35.9%). Similarly, the concentrations of TNF-α, sFlt-1, and sEng, as well as TNF-α/IL-10 and sFlt-1/PlGF ratios were significantly higher in the preterm PE group. In contrast, concentrations of PlGF, VEGF, and IL-10 were significantly lower in women with preterm PE. Negative correlations between TNF-α and IL-10 (r = 0.5232) and between PlGF and sFlt1 (r = 0.4158) were detected in the preterm PE. Conclusion In pregnant women with preterm PE, there is an imbalance between immunological markers, with the predominance of anti-angiogenic factors and TNF-α, associated with adverse maternal clinical outcomes.

Resumo Objetivo A pré-eclâmpsia (PE) é uma síndrome específica da gravidez caracterizada por níveis anormais de citocinas e fatores angiogênicos, que desempenham um papel no desenvolvimento da doença. Este estudo avaliou se os marcadores imunológicos estão associados à idade gestacional e à gravidade da doença em mulheres com pré-eclâmpsia. Métodos Noventa e cinco mulheres que desenvolveram PE foram estratificadas pela idade gestacional em PE pré-termo (< 37 semanas) e PE a termo (≥ 37 semanas de gestação) e comparadas quanto à gravidade da doença, bem como à concentração plasmática de fatores angiogênicos e citocinas. As concentrações de fator de crescimento placentário (PlGF), fator de crescimento endotelial vascular (VEGF), tirosina quinase solúvel semelhante a Fms (sFlt-1) e endoglina solúvel (sEng), bem como as citocinas, fator de necrose tumoral alfa (TNF- α) e interleucina 10 (IL-10), foram determinados porensaio de imunoabsorção enzimática (ELISA, na sigla em inglês). Resultados A comparação entre os grupos com pré-eclâmpsia mostrou maior porcentagem de casos graves em PE pré-termo (82,1%) do que em PE a termo (35,9%). Da mesma forma, as concentrações de TNF-α, sFlt-1 e sEng, bem como as razões TNF-α/IL-10 e sFlt-1/PlGF foram significativamente maiores no grupo de PE pré-termo. Em contraste, as concentrações de PlGF, VEGF e IL-10 foram significativamente menores em mulheres com PE pré-termo. Correlações negativas entre TNF-α e IL-10 (r = 0.5232) e entre PlGF e sFlt1 (r = 0.4158) foram detectadas no grupo de PE pré-termo. Conclusão Em gestantes com PE pré-termo, ocorre um desequilíbrio entre os marcadores imunológicos, com predomínio de fatores antiangiogênicos e TNF-α, associados a desfechos clínicos maternos adversos.

Increased Risk for Maternal Anxiety during the COVID-19 Outbreak in Brazil among Pregnant Women without Comorbidities / Aumento do risco de ansiedade materna durante o surto de COVID-19 no Brasil entre gestantes sem comorbidades

Abstract Objective To study maternal anxiety in pregnant women without comorbidities in the context of the COVID-19 outbreak in Brazil and to study maternal knowledge and concerns about the pandemic. Methods This is a secondary analysis from a national multicenter cross-sectional study performed in 10 cities, from June to August, 2020, in Brazil. Interviewed postpartum women, without medical or obstetrical comorbidities, were included in the present subanalysis. A structured questionnaire and the Beck Anxiety Inventory (BAI) were applied. Results Out of the 1,662 women, 763 (45.9%) met the criteria for the current analysis and 16.1% presented with moderate and 11.5% with severe maternal anxiety. Moderate or severe maternal anxiety was associated with high school education (odds ratio [OR]:1.58; 95% confidence interval [CI]:1.04-2.40). The protective factor was cohabiting with a partner (OR: 0.46; 95%CI: 0.29-0.73). There was a positive correlation between the total BAI score and receiving information about care in the pandemic (rpartial 0.15; p < 0.001); concern about vertical transmission of COVID-19 (rpartial 0.10; p = 0.01); receiving information about breastfeeding (rpartial 0.08; p = 0.03); concerns about prenatal care (rpartial 0.10; p = 0.01), and concerns about the baby contracting COVID-19 (rpartial 0.11; p = 0.004). The correlation was negative in the following aspects: self-confidence in protecting from COVID-19 (rpartial 0.08; p = 0.04), having learned (rpartial 0.09; p = 0.01) and self-confidence in breastfeeding (rpartial 0.22; p < 0.001) in the context of the pandemic. Conclusion The anxiety of pregnant women without medical or obstetrical comorbidities was associated to high school educational level and not living with a partner during the COVID-19 pandemic. Self-confidence in protecting against COVID-19 and knowledge about breastfeeding care during the pandemic reduced maternal anxiety.

Resumo Objetivo Estudar a ansiedade materna em gestantes sem comorbidades no contexto do surto de COVID-19 no Brasil e estudar o conhecimento e as preocupações maternas sobre a pandemia. Métodos Trata-se de análise secundária de um estudo transversal multicêntrico nacional realizado em 10 cidades, de junho a agosto de 2020, no Brasil. Mulheres no pós-parto entrevistadas, sem comorbidades médicas ou obstétricas, foram incluídas nesta subanálise. Foram aplicados um questionário estruturado e o Inventário de Ansiedade de Beck (BAI, na sigla em inglês). Resultados Das 1.662 mulheres, 763 (45,9%) atenderam aos critérios da análise atual e 16,1% apresentaram ansiedade materna moderada e 11,5% ansiedade materna grave. A ansiedade materna moderada ou grave foi associada à escolaridade no ensino médio (odds ratio [OR]: 1,58; intervalo de confiança [IC] 95%: 1,04-2,40). O fator protetor foi coabitar com companheiro (OR: 0,46; IC95%: 0,29-0,73). Houve correlação positiva entre a pontuação total do BAI e o recebimento de informações sobre cuidados na pandemia (rparcial 0,15; p < 0,001); preocupação com a transmissão vertical de COVID-19 (rparcial 0,10; p = 0,01); receber informações sobre amamentação (rparcial 0,08; p = 0,03); preocupações sobre cuidados pré-natais (rparcial 0,10; p = 0,01) e preocupações sobre o bebê contrair COVID-19 (rparcial 0,11; p = 0,004). A correlação foi negativa com os seguintes aspectos: ter autoconfiança para se proteger (rparcial 0,08; p = 0,04), aprender (rparcial 0,09; p = 0,01) e ter autoconfiança para amamentar (rparcial 0,22; p < 0,001) no contexto da pandemia. Conclusão A ansiedade de gestantes sem comorbidades médicas ou obstétricas esteve associada à escolaridade no ensino médio e não morar com companheiro durante a pandemia de COVID-19. A autoconfiança na proteção contra COVID-19 e o conhecimento sobre os cuidados com a amamentação durante a pandemia reduziram a ansiedade materna.

Partial HELLP Syndrome: maternal and perinatal outcome.

CONTEXT: HELLP syndrome is a severe complication of pregnancy characterized by hemolysis, elevated liver enzymes and low platelet count. Some pregnant women develop just one or two of the characteristics of this syndrome, which is termed Partial HELLP Syndrome (PHS). OBJECTIVE: The objective of this study was to evaluate the repercussions on maternal and perinatal outcomes among women that developed PHS and to compare these women with those whose gestational hypertension or preeclampsia did not show alterations for HELLP syndrome in laboratory tests. DESIGN: Observational, retrospective and analytical study. SETTING: Maternity Department of Hospital das Cl nicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, S o Paulo, Brazil. SAMPLE: Pregnant or post-delivery women who had a blood pressure elevation that was first detected after mid-pregnancy, with or without proteinuria, between January 1990 and December 1995. MAIN MEASUREMENTS: Analysis was made of maternal age, race, parity, hypertension classification, gestational age at the PHS diagnosis, alterations in laboratory tests for HELLP syndrome, time elapsed to discharge from hospital, maternal complications, mode of delivery, incidence of preterm birth, intrauterine growth restriction, stillborn and neonatal death. RESULTS: Three hundred and eighteen women were selected; forty-one women (12.9%) had PHS and 277 of them (87.1%) did not develop any of the alterations of the HELLP syndrome diagnosis. Preeclampsia was a more frequent type of hypertension in the PHS group than in the hypertension group. None of the women with isolated chronic hypertension developed PHS. The rate of cesarean delivery, eclampsia, and preterm delivery was significantly greater in the PHS group than in the hypertension group. CONCLUSION: We observed that aggressive procedures had been adopted for patients with PHS. These resulted in immediate interruption of pregnancy, with elevated cesarean rates and preterm delivery. Such decisions need to be reviewed, in order to reduce the cesarean rate and the incidence of preterm delivery.

Pré-eclâmpsia/eclâmpsia / Pre-Eclampsia/Eclampsia

A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A pré-eclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgão-alvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas.(AU)

Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age in < 24 weeks, between 24 and less than 34 weeks, and ≥ 34 weeks of gestation, and guidance on route of delivery. An immediate puerperium approach and repercussions in the future life of pregnant women who develop preeclampsia is also presented.(AU)

"Café com Educação Médica" - Breve Relato de uma Experiência para o Desenvolvimento da Docência / "Medical Education with Coffee" - a Brief Report of an Experience for Faculty Development

RESUMO O desenvolvimento docente é uma necessidade nas escolas para adequar o ensino médico às intensas e contínuas transformações do mundo e da sociedade contemporânea. Iniciativas de desenvolvimento docente precisam avançar para além de cursos de capacitação, evoluindo para comunidades de prática. Com o intuito de incorporar princípios da educação médica ao cotidiano do professor, em diversos níveis, desde o planejamento até a avaliação dos processos de ensino, entendemos que ambientes informais também podem constituir espaços para o desenvolvimento da docência. Assim, a Faculdade de Medicina de Botucatu, da Universidade Estadual Paulista, criou o "café com educação médica", uma reunião matinal quinzenal para discussão de aportes teóricos para subsidiar as ações de pesquisa e prática do Núcleo de Apoio Pedagógico. A reunião tem configuração semelhante à dos clubes de revista tradicionais no ensino de graduação e residência médica, mas com particularidades voltadas à educação em saúde. O êxito da experiência se deve à possibilidade de ocorrer desenvolvimento docente em contexto acolhedor e informal. Tendo em vista os relatos de transformação da prática docente motivados por iniciativas semelhantes ao redor do mundo e observando como nossa experiência tem sido oportuna, encorajamos as escolas médicas brasileiras a compartilharem também seus clubes de revista em educação médica e os resultados com eles obtidos.

ABSTRACT Faculty development is needed if medical schools are to adapt to the intense and constant changes taking place in the world, and in society. Initiatives for faculty development should go beyond workshops, evolving into communities of practice. To incorporate the principles of medical education into all levels of the curriculum, from planning through to assessment, the assimilation of faculty development is needed, including in informal scenarios. To this end, Botucatu School of Medicine of the Universidade Estadual Paulista created "medical education with coffee", a morning meeting that is held twice a month to discuss theoretical approaches to medical education that supports the practices and research of the institutional center for educational support. The meetings are similar to the traditional journal clubs for undergraduate and residency programs, except that they are specially geared towards medical education. The success of these meetings lies in their capacity to develop faculty, in a cozy and informal environment. Based on reports of improvements in teaching practices around the world due to similar initiatives, we encourage other Brazilian medical schools to adopt of medical education journal clubs, and to share their results.