Sexual and reproductive health (SRH) needs for forcibly displaced adolescent girls and young women (10-24 years old) in humanitarian settings: a mixed-methods systematic review.

BACKGROUND: Globally, there are 42 million women and girls estimated to be forcibly displaced. Adolescent girls and young women in humanitarian settings have their sexual and reproductive health (SRH) neglected. This systematic review aimed to describe SRH obstacles that adolescent girls and young women (10-24 years old) face in humanitarian settings in line with the Sustainable Development Goals. METHODS: We conducted a mixed-methods systematic review in six databases, focusing on migrant women ages 10 - 24and their SRH outcomes. The mixed-methods appraisal tool was used to evaluate the quality of the studies. This review follows PRISMA and the Systematic Review Guidelines from the Centre for Reviews and Dissemination recommendations. RESULTS: Among the 1290 studies screened by abstracts, 32 met the eligibility criteria: 15 were qualitative, 10 were quantitative and seven were mixed-methods studies. Most studies were performed in the last four years, in African countries. They discussed the increased frequency of adolescent pregnancies (16-23%), lack of contraceptive use and access (8-32%), poor menstrual hygiene management (lack of water, shortage of menstrual hygiene supplies), ignorance and stigma about sexually transmitted infections and HIV, a higher number of child, early and forced marriage or partnership and sexual and gender-based violence, challenging to obtain SRH information/knowledge/access, and unmet SRH needs. CONCLUSION: Migration is a current issue. Although there is a growing number of studies on adolescent girls and young women's SRH in humanitarian settings, this population remains overlooked, and face several challenges in SRH. There is a need for targeting interventions on SRH.

This systematic review describes the available evidence on the sexual and reproductive health (SRH) challenges faced by adolescent girls and young women in humanitarian settings. Thirty-two studies were analyzed, demonstrating poor SRH outcomes: higher incidence of adolescent pregnancy, lack of access to contraceptives and low rates of its use, precarious menstrual hygiene management (MHM), ignorance and stigma about sexually transmitted infections (STIs) and HIV, higher rates of child, early and forced marriage or partnership (CEFMP) and sexual and gender-based violence (SGBV). Identifying these challenges can help humanitarian actors address the SRH needs of these populations.

Impacts of childbirth on anxiety, disability, and depression: Results from a Brazilian cohort.

Conditions such as violence, drug abuse, sexual satisfaction, anxiety, depression, and disability interfere with a healthy pregnancy and can also account for maternal morbidity. The instrument WOICE was built by WHO to measure it. We applied WOICE in a prospective cohort of 125 pregnant women, using a before-after approach, during the third trimester of pregnancy, and after 42 until 90 days of childbirth. 60% had anxiety during pregnancy, decreasing to 48.8% after delivery (p = 0.07), and depression scores decreased from 7.56 to 5.80 (p = 0.014). Disability affected 62.4% and 56, respectively. 9.6% used drugs during pregnancy, reducing to 4.0% after delivery (RR 0.69, IC 0.49 - 0.69).

Using the WHO-INTEGRATE evidence-to-decision framework to develop recommendations for induction of labour.

BACKGROUND: In 2019, WHO prioritized updating recommendations relating to three labour induction topics: labour induction at or beyond term, mechanical methods for labour induction, and outpatient labour induction. As part of this process, we aimed to review the evidence addressing factors beyond clinical effectiveness (values, human rights and sociocultural acceptability, health equity, and economic and feasibility considerations) to inform WHO Guideline Development Group decision-making using the WHO-INTEGRATE evidence-to-decision framework, and to reflect on how methods for identifying, synthesizing and integrating this evidence could be improved. METHODS: We adapted the framework to consider the key criteria and sub-criteria relevant to our intervention. We searched for qualitative and other evidence across a variety of sources and mapped the eligible evidence to country income setting and perspective. Eligibility assessment and quality appraisal of qualitative evidence syntheses was undertaken using a two-step process informed by the ENTREQ statement. We adopted an iterative approach to interpret the evidence and provided both summary and detailed findings to the decision-makers. We also undertook a review to reflect on opportunities to improve the process of applying the framework and identifying the evidence. RESULTS: Using the WHO-INTEGRATE framework allowed us to explore health rights and equity in a systematic and transparent way. We identified a lack of qualitative and other evidence from low- and middle-income settings and in populations that are most impacted by structural inequities or traditionally excluded from research. Our process review highlighted opportunities for future improvement, including adopting more systematic evidence mapping methods and working with social science researchers to strengthen theoretical understanding, methods and interpretation of the evidence. CONCLUSIONS: Using the WHO-INTEGRATE evidence-to-decision framework to inform decision-making in a global guideline for induction of labour, we identified both challenges and opportunities relating to the lack of evidence in populations and settings of need and interest; the theoretical approach informing the development and application of WHO-INTEGRATE; and interpretation of the evidence. We hope these insights will be useful for primary researchers as well as the evidence synthesis and health decision-making communities, and ultimately contribute to a reduction in health inequities.

Gas6 drives Zika virus-induced neurological complications in humans and congenital syndrome in immunocompetent mice.

Zika virus (ZIKV) has the ability to cross placental and brain barriers, causing congenital malformations in neonates and neurological disorders in adults. However, the pathogenic mechanisms of ZIKV-induced neurological complications in adults and congenital malformations are still not fully understood. Gas6 is a soluble TAM receptor ligand able to promote flavivirus internalization and downregulation of immune responses. Here we demonstrate that there is a correlation between ZIKV neurological complications with higher Gas6 levels and the downregulation of genes associated with anti-viral response, as type I IFN due to Socs1 upregulation. Also, Gas6 gamma-carboxylation is essential for ZIKV invasion and replication in monocytes, the main source of this protein, which was inhibited by warfarin. Conversely, Gas6 facilitates ZIKV replication in adult immunocompetent mice and enabled susceptibility to transplacental infection. Our data indicate that ZIKV promotes the upregulation of its ligand Gas6, which contributes to viral infectivity and drives the development of severe adverse outcomes during ZIKV infection.

Placental transcriptome profile of women with sickle cell disease reveals differentially expressed genes involved in migration, trophoblast differentiation and inflammation.

Sickle cell disease (SCD) is a group of disorders whose common characteristic is the presence of hemoglobin (Hb) S in erythrocytes. The main consequence of this abnormality is vaso-occlusion, which can affect almost all organs including the placenta. This study aimed to evaluate the gene expression profile in placentas of women with SCD by means of total RNA sequencing. For this, we proposed a case-control study, with three groups of pregnant women: HbSS (n = 10), HbSC (n = 14) and HbAA (n = 21). The results showed differences in expression in a number of genes such as NOS2 (fold change, FC = 4.52), HLAG (FC = 5.56), ASCL2 (FC = 3.61), CXCL10 (FC = -3.66) and IL1R2 (FC = 3.92) for the HbSC group and S100A8 (FC = -3.82), CPXM2 (FC = 4.57), CXCL10 (FC = -4.59), CXCL11 (FC = -3.72) and CAMP (FC = -4.55) for the HbSS group. Differentially expressed genes are mainly associated with migration, trophoblast differentiation and inflammation. The causes leading to altered gene expression in placentas of sickle cell patients are not fully understood, but the presence of intravascular hemolysis and vaso-occlusion, with cycles of ischemia and reperfusion, may contribute to the emergence of an environment which can be very harmful for placental physiology, altering the nutrient supply and metabolic exchange for fetal growth.

Prediction of Severe Maternal Outcome Among Pregnant and Puerperal Women in Obstetric ICU.

OBJECTIVE: World Health Organization recommends the use of maternal near miss as a tool to monitor and improve quality of obstetric care. Severe maternal outcome corresponds to the sum of maternal near miss and maternal death cases. This study was aimed at validating Acute Physiology and Chronic Health Evaluation II and IV, Simplified Acute Physiology Score III, and Sequential Organ Failure Assessment in pregnant and postpartum women in predicting severe maternal outcome. DESIGN: A retrospective cohort study. SETTING: Obstetric ICU in a tertiary care hospital in Brazil. PATIENTS: Pregnant and postpartum women admitted to the obstetric ICU during a 3-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 279 women were admitted to ICU, an admission rate of 34.6/1,000 live births, and the mortality index to severe maternal outcome (maternal death/maternal near miss + maternal death) was 7.7%. Total Sequential Organ Failure Assessment had a better overall performance than remaining scores for total hospitalizations (area under the curve, 0.86; standardized mortality ratio, 0.96; 95% CI, 0.74-1.22), for hypertensive direct causes (area under the curve, 0.81; standardized mortality ratio, 0.73; 95% CI, 0.31-1.43), and indirect causes (area under the curve, 0.89; standardized mortality ratio, 0.85; 95% CI, 0.59-1.19). The Acute Physiology and Chronic Health Evaluation II had a better overall performance than total Sequential Organ Failure Assessment for hemorrhagic causes (area under the curve, 0.75; standardized mortality ratio, 1.0; 95% CI, 0.61-1.54). CONCLUSIONS: Total Sequential Organ Failure Assessment may be used to predict severe maternal outcome in obstetric populations admitted to ICU. The Acute Physiology and Chronic Health Evaluation II may be applied to predict severe maternal outcome in hemorrhagic complications. We do not recommend Acute Physiology and Chronic Health Evaluation IV and Simplified Acute Physiology Score III for the prediction of severe maternal outcome.

Specific Biomarkers Associated With Neurological Complications and Congenital Central Nervous System Abnormalities From Zika Virus-Infected Patients in Brazil.

Background: Zika virus (ZIKV) infections have been linked to different levels of clinical outcomes, ranging from mild rash and fever to severe neurological complications and congenital malformations. Methods: We investigated the clinical and immunological response, focusing on the immune mediators profile in 95 acute ZIKV-infected adult patients from Campinas, Brazil. These patients included 6 pregnant women who later delivered during the course of this study. Clinical observations were recorded during hospitalization. Levels of 45 immune mediators were quantified using multiplex microbead-based immunoassays. Results: Whereas 11.6% of patients had neurological complications, 88.4% displayed mild disease of rash and fever. Several immune mediators were specifically higher in ZIKV-infected patients, and levels of interleukin 10, interferon gamma-induced protein 10 (IP-10), and hepatocyte growth factor differentiated between patients with or without neurological complications. Interestingly, higher levels of interleukin 22, monocyte chemoattractant protein 1, TNF-α, and IP-10 were observed in ZIKV-infected pregnant women carrying fetuses with fetal growth-associated malformations. Notably, infants with congenital central nervous system deformities had significantly higher levels of interleukin 18 and IP-10 but lower levels of hepatocyte growth factor than those without such abnormalities born to ZIKV-infected mothers. Conclusions: This study identified several key markers for the control of ZIKV pathogenesis. This will allow a better understanding of the molecular mechanisms of ZIKV infection in patients.

Oleate attenuates palmitate-induced endoplasmic reticulum stress and apoptosis in placental trophoblasts.

Pre-pregnancy obesity is increasingly common and predisposes pregnant women and offspring to gestational diabetes, pre-eclampsia, fetal growth abnormalities and stillbirth. Obese women exhibit elevated levels of the two most common dietary fatty acids, palmitate and oleate, and the maternal blood containing these nutrients bathes the surface of trophoblasts of placental villi in vivo We test the hypothesis that the composition and concentration of free fatty acids modulate viability and function of primary human villous trophoblasts in culture. We found that palmitate increases syncytiotrophoblast death, specifically by caspase-mediated apoptosis, whereas oleate does not cause enhanced cell death. Importantly, exposure to both fatty acids in equimolar amounts yielded no increase in death or apoptosis, suggesting that oleate can protect syncytiotrophoblasts from palmitate-induced death. We further found that palmitate, but not oleate or oleate with palmitate, increases endoplasmic reticulum (ER) stress, signaling through the unfolded protein response, and yielding CHOP-mediated induction of apoptosis. Finally, we show that oleate or oleate plus palmitate both lead to increased lipid droplets in syncytiotrophoblasts, whereas palmitate does not. The data show palmitate is toxic to human syncytiotrophoblasts, through the induction of ER stress and apoptosis mediated by CHOP, whereas oleate is not toxic, abrogates palmitate toxicity and induces fat accumulation. We speculate that our in vitro results offer pathways by which the metabolic milieu of the obese pregnant woman can yield villous trophoblast dysfunction and sub-optimal placental function.

Abnormal expression of inflammatory genes in placentas of women with sickle cell anemia and sickle hemoglobin C disease.

Sickle cell disease (SCD) is a complex disease that is characterized by the polymerization of deoxyhemoglobin S, altered red blood cell membrane biology, endothelial activation, hemolysis, a procoagulant state, acute and chronic inflammation, and vaso-occlusion. Among the physiological changes that occur during pregnancy, oxygen is consumed by fetal growth, and pregnant women with SCD are more frequently exposed to low oxygen levels. This might lead to red blood cells sickling, and, consequently, to vaso-occlusion. The mechanisms by which SCD affects placental physiology are largely unknown, and chronic inflammation might be involved in this process. This study aimed to evaluate the gene expression profile of inflammatory response mediators in the placentas of pregnant women with sickle cell cell anemia (HbSS) and hemoglobinopathy SC (HbSC). Our results show differences in a number of these genes. For the HbSS group, when compared to the control group, the following genes showed differential expression: IL1RAP (2.76-fold), BCL6 (4.49-fold), CXCL10 (-2.12-fold), CXCR1 (-3.66-fold), and C3 (-2.0-fold). On the other hand, the HbSC group presented differential expressions of the following genes, when compared to the control group: IL1RAP (4.33-fold), CXCL1 (3.05-fold), BCL6 (4.13-fold), CXCL10 (-3.32-fold), C3 (-2.0-fold), and TLR3 (2.38-fold). Taken together, these data strongly suggest a differential expression of several inflammatory genes in both SCD (HbSS and HbSC), indicating that the placenta might become an environment with hypoxia, and increased inflammation, which could lead to improper placental development.

Situational analysis of facilitators and barriers to availability and utilization of magnesium sulfate for eclampsia and severe preeclampsia in the public health system in Brazil.

BACKGROUND: Eclampsia is the main cause of maternal death in Brazil. Magnesium sulfate is the drug of choice for seizure prevention and control in the management of severe preeclampsia and eclampsia. Despite scientific evidence demonstrating its effectiveness and safety, there have been delays in managing hypertensive disorders, including timely access to magnesium sulfate. To conduct a general situational analysis on availability and use of magnesium sulfate for severe preeclampsia and eclampsia in the public health system. METHOD: A situational analysis was conducted with two components: a documental analysis on information available at the official websites on the policy, regulation and availability of the medication, plus a cross sectional study with field analysis and interviews with local managers of public obstetric health services in Campinas, in the southeast of Brazil. We used the fishbone cause and effect diagram to organize study components. Interviews with managers were held during field observations using specific questionnaires. RESULTS: There was no access to magnesium sulfate in primary care facilities, obstetric care was excluded from urgency services and clinical protocols for professional guidance on the adequate use of magnesium sulfate were lacking in the emergency mobile care service. Magnesium sulfate is currently only administered in referral maternity hospitals. CONCLUSION: The lack of processes that promote the integration between urgency/emergency care and specialized obstetric care possibly favors the untimely use of magnesium sulfate and contributes to the high maternal morbidity/mortality rates.

Robson Ten Group Classification System applied to women with severe maternal morbidity.

OBJECTIVE: To evaluate the distribution of women with severe maternal morbidity according to Robson Ten Group Classification System (RTGCS). METHODS: Secondary analysis of a multicenter cross-sectional study in 27 obstetric units in Brazil, using RTGCS. Cases were classified into potentially life-threatening condition or a maternal near miss or death, according to severity. Certain groups were subdivided for further analysis. Cesarean delivery (CD) rates were reported. RESULTS: Among 7,247 women with severe maternal morbidity, 73.2 percent underwent CD. Group 10 (single, cephalic, preterm) was the most prevalent (33.9%). Groups mostly associated with a severe maternal outcome were: 7 (multiparous, breech), 9 (all abnormal lies, single, term), 8 (all multiple), and 10. Groups 1 (nulliparous, single, cephalic, term, spontaneous) and 3 (multiparous, single, cephalic, term, spontaneous) were associated with better maternal outcome. Group 3 had one severe maternal morbidity to 29 cases of potentially life-threatening, but the ratio was 1:10 for women undergoing CD, indicating a worse outcome. Group 4a (multiparous, no previous CD, single, cephalic, term, induced labor) had a better maternal outcome than those delivered by CD before labor (group 4b). Hypertension was the most common condition of severity. CONCLUSIONS: The RTGCS was useful to consider severe maternal morbidity, showing groups with higher CD rates and worse maternal outcomes.

Preeclampsia: Reflections on How to Counsel About Preventing Recurrence.

Preeclampsia is one of the most challenging diseases of pregnancy, with unclear etiology, no specific marker for prediction, and no precise treatment besides delivery of the placenta. Many risk factors have been identified, and diagnostic and management tools have improved in recent years. However, this disease remains one of the leading causes of maternal morbidity and mortality worldwide, especially in under-resourced settings. A history of previous preeclampsia is a known risk factor for a new event in a future pregnancy, with recurrence rates varying from less than 10% to 65%, depending on the population or methodology considered. A recent review that performed an individual participant data meta-analysis on the recurrence of hypertensive disorders of pregnancy in over 99 000 women showed an overall recurrence rate of 20.7%; when specifically considering preeclampsia, it was 13.8%, with milder disease upon recurrence. Prevention of recurrent preeclampsia has been attempted by changes in lifestyle, dietary supplementation, antihypertensive drugs, antithrombotic agents, and others, with much uncertainty about benefit. It is always challenging to treat and counsel a woman with a previous history of preeclampsia; this review will be based on hypothetical clinical cases, using common scenarios in obstetrical practice to consider the available evidence on how to counsel each woman during pre-conception and prenatal consultations.

La prééclampsie constitue l'une des complications de la grossesse les plus difficiles à prendre en charge, compte tenu de son étiologie floue, de l'absence de marqueur spécifique permettant d'en prédire la manifestation et de l'absence de traitement précis (outre la délivrance du placenta). De nombreux facteurs de risque ont été identifiés et les outils de diagnostic et de prise en charge ont connu une amélioration au cours des dernières années. Quoi qu'il en soit, cette complication demeure l'une des principales causes de morbidité et de mortalité maternelles à l'échelle mondiale, particulièrement au sein des milieux ne disposant que de faibles ressources. La présence d'antécédents de prééclampsie constitue un facteur de risque connu pour ce qui est de la survenue d'un nouvel événement dans le cadre d'une future grossesse, les taux de récurrence variant de moins de 10 % à 65 % (selon la population ou la méthodologie envisagée). Une récente méta-analyse de données individuelles portant sur la récurrence des troubles hypertensifs de la grossesse chez plus de 99 000 femmes a indiqué un taux global de récurrence de 20,7 %; lorsque l'on s'attardait plus particulièrement à la prééclampsie, ce taux passait à 13,8 %, une complication de moindre gravité étant constatée au moment de la récurrence. Des tentatives de prévenir la récurrence de la prééclampsie ont fait appel à des modifications du mode de vie, à une supplémentation alimentaire et à l'utilisation d'antihypertenseurs, d'antithrombotiques et d'autres agents, le tout étant marqué par une grande incertitude quant à l'efficacité de telles mesures. Il est toujours difficile de traiter et de conseiller une femme présentant des antécédents de prééclampsie; cette analyse se fonde sur des cas cliniques hypothétiques, en utilisant des scénarios courants de la pratique obstétricale pour soupeser les données disponibles quant à la façon de conseiller les patientes dans le cadre des consultations préconceptionnelles et prénatales.

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.

Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study.

BACKGROUND: Hypertensive disorders represent the major cause of maternal morbidity in middle income countries. The main objective of this study was to identify the prevalence and factors associated with severe maternal outcomes in women with severe hypertensive disorders. METHODS: This was a cross-sectional, multicenter study, including 6706 women with severe hypertensive disorder from 27 maternity hospitals in Brazil. A prospective surveillance of severe maternal morbidity with data collected from medical charts and entered into OpenClinica®, an online system, over a one-year period (2009 to 2010). Women with severe preeclampsia, severe hypertension, eclampsia and HELLP syndrome were included in the study. They were grouped according to outcome in near miss, maternal death and potentially life-threatening condition. Prevalence ratios and 95% confidence intervals adjusted for cluster effect for maternal and perinatal variables and delays in receiving obstetric care were calculated as risk estimates of maternal complications having a severe maternal outcome (near miss or death). Poisson multiple regression analysis was also performed. RESULTS: Severe hypertensive disorders were the main cause of severe maternal morbidity (6706/9555); the prevalence of near miss was 4.2 cases per 1000 live births, there were 8.3 cases of Near Miss to 1 Maternal Death and the mortality index was 10.7% (case fatality). Early onset of the disease and postpartum hemorrhage were independent variables associated with severe maternal outcomes, in addition to acute pulmonary edema, previous heart disease and delays in receiving secondary and tertiary care. CONCLUSIONS: In women with severe hypertensive disorders, the current study identified situations independently associated with a severe maternal outcome, which could be modified by interventions in obstetric care and in the healthcare system. Furthermore, the study showed the feasibility of a hospital system for surveillance of severe maternal morbidity.

Professional activity and experience after a residency training program in ObGyn: A 10-year analysis.

OBJECTIVE: To describe the profile and professional trajectory of the obstetrics and gynecology (ObGyn) graduates over the past decade, at a referral university hospital. METHODS: A cross-sectional study was conducted, utilizing a survey that targeted graduates of the ObGyn residency program from the last decade, asking about demographics, medical undergraduate, residency details, post-residency trajectory, satisfaction levels, and social media usage. A descriptive analysis was performed. Comparative analyses, including gender-based differences, were assessed using chi-squared or Fisher exact tests (P < 0.05). RESULTS: Among 126 graduates, 84 agreed to participate (66.67%), predominantly comprising females with an average age of 33 years. Most identified themselves as white. The majority had pursued their undergraduate studies at the same institution (78.6%) and subsequently acquired specialized titles in ObGyn from the national society. Most of them were employed in both public and private sectors (71.08%). Male graduates held the majority of medical shifts in obstetrics. A significant gender-based salary discrepancy was noted, favoring males. More than half of the professionals utilized social media for work-related purposes. Many expressed the necessity for supplementary education beyond public health, particularly career management. CONCLUSION: The findings highlight a predominance of female and white individuals among the graduates. Overall, graduates expressed contentment with their education and professional engagements. A gender-based income disparity was identified, favoring male graduates. Studies like this can provide insights for improving medical residency education.

Hypertensive disorders of pregnancy and long-term maternal cardiovascular risk: Bridging epidemiological knowledge into personalized postpartum care and follow-up.

Cardiovascular disease (CVD) is globally the leading cause of death and disability. Sex-specific causes of female CVD are under-investigated. Pregnancy remains an underinvestigated sex-specific stress test for future CVD and a hitherto missed opportunity to initiate prevention of CVD at a young age. Population-based studies show a strong association between female CVD and hypertensive disorders of pregnancy. This association is also present after other pregnancy complications that are associated with placental dysfunction, including fetal growth restriction, preterm delivery and gestational diabetes mellitus. Few women are, however, offered systematic cardio-preventive follow-up after such pregnancy complications. These women typically seek help from the health system at first clinical symptom of CVD, which may be decades later. By this time, morbidity is established and years of preventive opportunities have been missed out. Early identification of modifiable risk factors starting postpartum followed by systematic preventive measures could improve maternal cardiovascular health trajectories, promoting healthier societies. In this non-systematic review we briefly summarize the epidemiological associations and pathophysiological hypotheses for the associations. We summarize current clinical follow-up strategies, including some proposed by international and national guidelines as well as user support groups. We address modifiable factors that may be underexploited in the postpartum period, including breastfeeding and blood pressure management. We suggest a way forward and discuss the remaining knowledge gaps and barriers for securing the best evidence-based follow-up, relative to available resources after a hypertensive pregnancy complication in order to prevent or delay onset of premature CVD.

Sickle cell disease and increased adverse maternal and perinatal outcomes in different genotypes.

BACKGROUND: Sickle cell disease (SCD) comprises a heterogeneous group of inherited hemolytic disorders that increases the risk of maternal and perinatal complications due to chronic systemic inflammatory response, endothelial damage and vaso-occlusion. The contribution of genotypes to the severity of outcomes during pregnancy is not completely established. METHODS: A retrospective study of medical charts was performed to compare maternal and perinatal outcomes in Hb SS, Hb SC disease and sickle-beta thalassemia (Hb Sß) pregnancies followed at a high-risk antenatal care unit over a 6-year period. A descriptive analysis of morphological findings was performed of the placenta when pathology reports were available. RESULTS: Sixty-two SCD pregnant women [25 Hb SS (40 %), 29 Hb SC (47 %) and 8 Hb Sß (13 %)] were included. Overall, SCD was associated with maternal complications (77 %), preterm birth (30 %), cesarean section (80 %) and a need of blood transfusion. In general there were no statistically significant differences between genotypes. The only significant difference was the hemoglobin level at first antenatal care visit which was lower for the homozygous genotype (7.7 g/dL) compared to Hb SC and Hb Sß (9.7 g/dL and 8.4 g/dL, respectively; p-value = 0.01). Ten of 15 evaluated placentas showed abnormal morphological findings CONCLUSION: SCD, regardless of the underlying genotype, is associated with increased adverse maternal and perinatal outcomes and placental abnormalities associated with maternal vascular malperfusion.

Hypertensive disorders during pregnancy as a major cause of preterm birth and adverse perinatal outcomes: findings from a Brazilian National Survey.

OBJECTIVE: This study aimed to evaluate the prevalence of hypertensive disorders during pregnancy among Brazilian women with preterm births and to compare the epidemiological characteristics and perinatal outcomes among preterm births of women with and without hypertension. METHODS: This was a secondary cross-sectional analysis of the Brazilian Multicenter Study on Preterm Birth. During the study period, all women with preterm births were included and further split into two groups according to the occurrence of any hypertensive disorder during pregnancy. Prevalence ratios were calculated for each variable. Maternal characteristics, prenatal care, and gestational and perinatal outcomes were compared between the two groups using χ2 and t-tests. RESULTS: A total of 4,150 women with preterm births were included, and 1,169 (28.2%) were identified as having hypertensive disorders. Advanced maternal age (prevalence ratio (PR) 2.49) and obesity (PR= 2.64) were more common in the hypertensive group. The gestational outcomes were worse in women with hypertension. Early preterm births were also more frequent in women with hypertension. CONCLUSION: Hypertensive disorders of pregnancy were frequent among women with preterm births, and provider-initiated preterm births were the leading causes of premature births in this group. The factors significantly associated with hypertensive disorders among women with preterm births were obesity, excessive weight gain, and higher maternal age.