Maternal prepregnancy obesity and gestational diabetes influence on adverse perinatal outcomes.

Objective: Evaluate the influence of isolated and associated prepregnancy obesity and gestational diabetes mellitus (GDM) on adverse perinatal outcomes. Materials and methods: Cross-sectional observational study with women who delivered at a Brazilian Maternity Hospital, between August and December 2020. Data were collected by interview with application form, and medical records. Sample was stratified by body mass index (BMI) and GDM screening in four groups: no obesity (BMI < 30 kg/m2) no GDM - reference; isolated GDM; isolated obesity (BMI ≥ 30 kg/m2); and obesity with GDM. Preeclampsia (PE), cesarean section (CS), large-for-gestational-age (LGA) newborn and admission to neonatal intensive care unit (NICU) were analyzed by odds ratio (OR) adjusted for confounding factors, adopting 95% confidence interval (CI) and P < 0.05 statistically significant. Results: From 1,618 participants, isolated obesity group (233/14.40%) had high chance of PE (OR = 2.16; CI: 1.364-3.426; P = 0.001), isolated GDM group (190/11.74%) had high chance of CS (OR = 1.736; CI: 1.136-2.652; P = 0.011) and NICU admission (OR = 2.32; CI: 1.265-4.261; P = 0.007), and obesity with GDM group (121/7.48%) had high chance of PE (OR = 1.93; CI: 1.074-3.484; P = 0.028), CS (OR = 1.925; CI: 1.124-3.298; P = 0.017) and LGA newborn (OR = 1.81; CI: 1.027-3.204; P = 0.040), compared with reference (1,074/66.38%). Conclusion: Obesity and GDM enhances the chance of different negative outcomes, worsening this prognosis when associated.

Desfechos materno-fetais adversos relacionados a paridade em uma maternidade do sul do Brasil / Adverse maternal-fetal outcomes related to parity in a maternity hospital in Southern Brazil

Avaliar os desfechos adversos perinatais relacionados à primiparidade. Trata-se de um estudo de corte transversal, realizado na Maternidade Darcy Vargas em Joinville­SC, no período de agosto a dezembro de 2020. Dividiu-se as pacientes em 2 grupos, primíparas e multíparas. Através da análise do Prontuário Único do Paciente (PUP), os desfechos perinatais adversos foram avaliados com cálculo de razão de chance ajustado, utilizando intervalo de confiança de 95%. Os fatores de confusão adotados foram: idade, tabagismo, alcoolismo e outras drogas. As puérperas foram divididas em primíparas (n=522/31,2%) e multíparas (n=1148/68,7%). Após o cálculo de razão de chance ajustado, primíparas tiveram aumento da chance de episiotomia (RC=7,069 IC95% 4,275-11,690), prematuridade (RC=1,784 IC95% 1,011-3,148) e redução da chance de recém-nascidos Grandes para a Idade Gestacional (GIG) (RC=0,555 IC95% 0,388-0,793), não interferiu nos demais desfechos. Pacientes primíparas apresentaram maior chance de episiotomia, prematuridade e menor chance de recém-nascidos GIG.

To investigate the effects of perinatal primiparity. This was a cross-sectional cohort study, carried out at the Darcy Vargas Maternity Hospital in Joinville, state of Santa Catarina, from August to December 2020. Patients were assigned to 2 groups, primiparous and multiparous. With the analysis of electronic medical records, perinatal adverse outcomes were evaluated using the adjusted odds ratio, using a 95% confidence interval. Confounding factors adopted were: age, smoking, alcoholism, and other drugs. Postpartum women were divided into primiparous (n=522/31.2%) and multiparous (n=1,148/68.7%) women. After calculating the adjusted odds ratio, primiparous women had an increased chance of having an episiotomy (OR= 7,069 CI95% 4,275-11,690), prematurity (OR=1,784 CI95% 1,011-3,148) and reduced chance of Large for Gestational Age (LAG) newborns (OR=0,555 CI95% 0,388-0,793). Primiparous patients had a higher chance of having an episiotomy, prematurity, and a lower chance of LAG newborns.

Maternal prepregnancy obesity and gestational diabetes influence on adverse perinatal outcomes

ABSTRACT Objective: Evaluate the influence of isolated and associated prepregnancy obesity and gestational diabetes mellitus (GDM) on adverse perinatal outcomes. Materials and methods: Cross-sectional observational study with women who delivered at a Brazilian Maternity Hospital, between August and December 2020. Data were collected by interview with application form, and medical records. Sample was stratified by body mass index (BMI) and GDM screening in four groups: no obesity (BMI < 30 kg/m2) no GDM - reference; isolated GDM; isolated obesity (BMI ≥ 30 kg/m2); and obesity with GDM. Preeclampsia (PE), cesarean section (CS), large-for-gestational-age (LGA) newborn and admission to neonatal intensive care unit (NICU) were analyzed by odds ratio (OR) adjusted for confounding factors, adopting 95% confidence interval (CI) and P < 0.05 statistically significant. Results: From 1,618 participants, isolated obesity group (233/14.40%) had high chance of PE (OR = 2.16; CI: 1.364-3.426; P = 0.001), isolated GDM group (190/11.74%) had high chance of CS (OR = 1.736; CI: 1.136-2.652; P = 0.011) and NICU admission (OR = 2.32; CI: 1.265-4.261; P = 0.007), and obesity with GDM group (121/7.48%) had high chance of PE (OR = 1.93; CI: 1.074-3.484; P = 0.028), CS (OR = 1.925; CI: 1.124-3.298; P = 0.017) and LGA newborn (OR = 1.81; CI: 1.027-3.204; P = 0.040), compared with reference (1,074/66.38%). Conclusion: Obesity and GDM enhances the chance of different negative outcomes, worsening this prognosis when associated.

Espiritualidade e dor em pacientes com câncer de mama metastático / Spirituality and pain in patients with metastatic breast cancer / Espiritualidad y dolor en pacientes con cáncer de mama metastásico

Resumo Mediante estudo observacional, transversal e quantitativo que utilizou os instrumentos de avaliação Brief Pain Inventory (dor), Functional Assessment of Chronic Illness Therapy Spiritual Well-Being (bem-estar espiritual) e Beck Depression Inventory - Short Form (depressão), busca-se avaliar a influência da espiritualidade e da depressão na percepção de dor de pacientes acometidas por neoplasia de mama metastática. A idade média foi 57,3 anos e, das 30 participantes, 24 (80%) tratavam-se em serviço público; 17 (57%) tinham diagnóstico de câncer de mama há mais de cinco anos; e 27 (90%) realizavam alguma prática religiosa/espiritual. Pacientes com escore de bem-estar espiritual acima da mediana apresentaram menor escore dos sintomas depressivos (3 vs . 6; p =0,021). Não houve diferença significativa em relação à mediana do escore total do bem-estar espiritual quando estratificado pela mediana da percepção de dor (31,5% vs . 28,5%; p =0,405). Maior manifestação de bem-estar espiritual pode estar relacionada a menores índices de depressão.

Abstract This observational, cross-sectional and quantitative study, by means of the assessment instruments Brief Pain Inventory, Functional Assessment of Chronic Illness Therapy Spiritual Well-Being and Beck Depression Inventory - Short Form, evaluated the influence of spirituality and depression in the pain perception of patients with metastatic breast cancer. Mean age was 57.3 years. Of the 30 participants, 24 (80%) were treated in a public service, 17 (57%) had been diagnosed with breast cancer for more than 5 years, and 27 (90%) were religious or spiritual. Patients with spiritual well-being scores above the median had lower depressive symptom scores (3 vs. 6; p =0.021). The median total score of spiritual well-being showed no significant difference when stratified by median pain perception (31.5% vs. 28.5%; p =0.405). Greater spiritual well-being may be related to lower rates of depression.

Resumen Este estudio observacional, transversal y cuantitativo utilizó los instrumentos Brief Pain Inventory (dolor), Functional Assessment of Chronic Illness Therapy Spiritual Well-Being (bienestar espiritual) y Beck Depression Inventory - Short Form (depresión), para evaluar si la espiritualidad y la depresión influencian en la percepción del dolor en pacientes con cáncer de mama metastásico. La edad promedio fue de 57,3 años; de las 30 participantes, 24 (80%) recibían atención pública; 17 (57%) tenían diagnóstico de cáncer de mama hace más de cinco años; y 27 (90%) solían tener alguna práctica religiosa/espiritual. Aquellas con puntuación de bienestar espiritual superior a la mediana tuvieron una puntuación más baja de síntomas depresivos (3 vs. 6; p =0,021). No hubo diferencias significativas en la mediana de la puntuación total de bienestar espiritual cuando se estratificó por la percepción mediana del dolor (31,5% vs. 28,5%; p =0,405). Una mayor sensación de bienestar espiritual se relacionó a bajas tasas de depresión.

Exosome-Enriched Plasma Analysis as a Tool for the Early Detection of Hypertensive Gestations.

Hypertensive disorders of pregnancy are closely associated with prematurity, stillbirth, and maternal morbidity and mortality. The onset of hypertensive disorders of pregnancy (HDP) is generally noticed after the 20th week of gestation, limiting earlier intervention. The placenta is directly responsible for modulating local and systemic physiology by communicating using mechanisms such as the release of extracellular vesicles, especially exosomes. In this study, we postulated that an analysis of exosome-enriched maternal plasma could provide a more focused and applicable approach for diagnosing HDP earlier in pregnancy. Therefore, the peripheral blood plasma of 24 pregnant women (11 controls, 13 HDP) was collected between 20th and 24th gestational weeks and centrifuged for exosome enrichment. Exosome-enriched plasma samples were analyzed by Raman spectroscopy and by proton nuclear magnetic resonance metabolomics (1H NMR). Principal component analysis (PCA) and orthogonal partial least squares discriminant analysis (OPLS-DA) were used to analyze the Raman data, from the spectral region of 600-1,800 cm-1, to determine its potential to discriminate between groups. Using principal component analysis, we were able to differentiate the two groups, with 89% of all variances found in the first three principal components. In patients with HDP, most significant differences in Raman bands intensity were found for sphingomyelin, acetyl CoA, methionine, DNA, RNA, phenylalanine, tryptophan, carotenoids, tyrosine, arginine, leucine, amide I and III, and phospholipids. The 1H NMR analysis showed reduced levels of D-glucose, L-proline, L-tyrosine, glycine, and anserine in HDP, while levels of 2-hydroxyvalerate, polyunsaturated fatty acids, and very-low-density lipoprotein (VLDL) were increased. 1H NMR results were able to assign an unknown sample to either the control or HDP groups at a precision of 88.3% using orthogonal partial least squares discriminant analysis and 87% using logistic regression analysis. Our results suggested that an analysis of exosome-enriched plasma could provide an initial assessment of placental function at the maternal-fetal interface and aid HDP diagnosis, prognosis, and treatment, as well as to detect novel, early biomarkers for HDP.

Evaluation of prenatal care according to indicators for the Prenatal and Birth Humanization Program / Avaliação da assistência pré-natal segundo indicadores do Programa de Humanização no Pré-natal e Nascimento

Abstract Objectives: to evaluate prenatal care provided to low-risk pregnant women users of the Sistema Único de Saúde (SUS) (Public Health System) in the city of Joinville, SC. Methods: this is a cross-sectional observational study carried out from March 2018 to February 2019, through interview and analysis of the Pregnant Card of puerperal over 18 years old, from Joinville, who underwent prenatal care at SUS, excluding recent given up puerperal. Prenatal care was evaluated according to the recommended criteria by the Prenatal and Birth Humanization Program. Results: 683 mothers were interviewed. The criteria with the highest levels of adequacy were accessibility (99.6%), early initiation on prenatal care (92.7%) and 6 or more consultations (87.1%) and the criteria with the lowest rates of adequacy were the set of guidelines (17.7%) and the third and first trimester exams (42.5% and 63.5% respectively). Conclusion: it is concluded that the prenatal care provided by SUS in the city of Joinville, despite the almost universal accessibility, the early onset and the prevalence of puerperal women with more than 6 consultations, showed a sharp decline in the analysis of the recommended indicators.

Resumo Objetivos: avaliar a assistência pré-natal prestada a gestantes de baixo risco usuárias do Sistema Único de Saúde da cidade de Joinville - SC. Métodos: trata-se de um estudo observacional transversal realizado de março de 2018 a fevereiro de 2019, mediante entrevista e análise do Cartão da Gestante de puérperas maiores de 18 anos, procedentes de Joinville, que realizaram o pré-natal no SUS, sendo excluídas puérperas desistentes. Avaliou-se a assistência pré-natal mediante critérios preconizados pelo Programa de Humanização no Pré-natal e Nascimento. Resultados: foram entrevistadas 683 puérperas. Os critérios com maiores índices de adequação foram acessibilidade (99,6%), início precoce do pré-natal (92,7%) e realização de 6 ou mais consultas (87,1%) e os critérios que apresentaram as menores taxas de adequação foram o conjunto de orientações (17,7%) e os exames do terceiro e primeiro trimestre (42,5% e 63,5% respectivamente). Conclusão: conclui-se que a assistência pré-natal realizada pelo SUS da cidade de Joinville, não obstante da acessibilidade praticamente universal, do início precoce e da prevalência de puérperas com mais de 6 consultas, demonstrou declínio acentuado na análise dos indicadores preconizados.

Prevalência de depressão gestacional em uma maternidade do sul do Brasil / Prevalence of antenatal depression in a maternity of south of Brazil

Depression is the most prevalent psychiatric disorder during the pregnancy. Therefore, the aim of the study was to identify the prevalence of antenatal depression and related with neonatal adverse outcome in a maternity hospital in the south of Brazil. Consequently, we proposed a case-control by means of a systematic revision of medical records and appliance the Edinburg Postnatal Depression Scale to the patients in immediate postpartum period. A total of 804 patients were selected and located in two groups: pregnant woman carrier of antenatal depression (case) and absence of depression (control). A multinominal logistic regression model were used to measure the Odds ratio. It demonstrated that 176 patients (21,9%) had antenatal depression according to the scale applied, and non-significant adverse outcome, as prematurity [1,13 (0,45-2,86); p = 0,78], low birth weight [0,776 (0,370-1,631); p = 0,503], low Ápgar at 1º minute [1,58 (0,68-3,69); p = 0,28] and 5º minute [0,79 (0,07-9,11); p = 0,85], neonatal ICU [0,54 (0,13-2,29); p = 0,41], were found. Given the results obtained, the prevalence of antenatal depression was 21,9%. Besides it, we did not identify a significant relation between negative outcomes and depression.

A depressão é o transtorno psíquico mais prevalente durante a gestação. Sendo assim, objetivou-se identificar a prevalência de depressão gestacional e relacionar a possíveis desfechos neonatais desfavoráveis em uma maternidade pública do sul do Brasil. Para isso, foi realizado estudo do tipo caso-controle através da revisão de prontuários e carteirinhas pré-natais, e aplicação de um questionário padronizado (Edinburgh Postnatal Depression Scale) às pacientes no período de pós-parto imediato. Foram selecionadas 804 gestantes, alocadas em dois grupos: portadoras de depressão gestacional (casos) e ausência de depressão (controle). Os modelos de regressão logística multinominal para cálculo de razão de chance demonstraram que 176 pacientes (21,9%) apresentaram depressão gestacional, e que a amostra não obteve resultados significantes quanto aos desfechos negativos para o recém-nascido, como prematuridade [1,13 (0,45-2,86); p = 0,78], baixo peso ao nascer [0,776 (0,370-1,631); p = 0,503], Apgar baixo no 1º [1,58 (0,68-3,69); p = 0,28] e no 5º minuto [0,79 (0,07-9,11); p = 0,85] e encaminhamento para UTI neonatal [0,54 (0,13-2,29); p = 0,41].O nível de significância estatística adotado foi de 5% (p < 0,05). Diante dos resultados obtidos, encontrou-se prevalência de 21,9% de depressão na população estudada. Todavia, não foi possível correlacionar a depressão gestacional aos desfechos negativos para o recém-nascido.

Taxa de parto normal versus cesárea em gestantes com uma cesárea anterior e fatores associados / Normal birth rate versus cesarean in pregnant women and associated factors

Objetivo: Calcular taxa de parto vaginal e cesárea em pacientes com uma cesárea anterior e gestação a termo, bem como fatores associados à recorrência de cesaria- na. Métodos: Estudo caso-controle, por meio de dados de prontuário de gestantes a termo com uma cesárea prévia admitidas para parto na Maternidade Darcy Vargas do município de Joinville (SC), em 2019. Resultados: Foram analisadas 788 pacientes, das quais 331 (42,00%) tiveram parto normal (PN) e 457 (58,00%), cesárea (CS). O grupo PN foi composto por mulheres mais velhas (29; 28) e com mais gestações que o grupo CS, possuindo pelo menos um parto normal prévio (171; 57; p < 0,001). Como fator de risco para recorrência de cesárea, destacou-se a presença de colo desfavorável no momento do parto (47; 356; p < 0,001). Internação por trabalho de parto (284; 92; p < 0,001) e ruptura prematura de membranas (RUPREME) (33; 79; p = 0,030) estão entre os fatores de proteção para ocorrência de uma nova cesariana. Conclusão: A taxa de parto vaginal pós-cesariana (VBAC) foi de 42% e a de parto cesáreo foi de 58%, condi- zente com valores de referência mundiais. O fato de ter um ou mais partos normais anteriores e internar-se em trabalho de parto ou com RUPREME foi fator protetor contra a repetição da cesárea, enquanto o colo desfavorável no momento da inter- nação foi fator de risco. Há grande divergência na literatura, sendo necessários mais estudos para elaborar estratégias que auxiliem profissionais e pacientes a decidirem pela melhor via de parto após cesariana anterior.(AU)

Objective: To calculate the rate of vaginal and cesarean delivery in patients with pre- vious cesarean section and pregnancy to term, as well as factors associated with recur- rent abdominal delivery. Methods: Case-control study, by medical records of pregnant women to term with a previous cesarean section admitted for delivery at Maternity Dar- cy Vargas in the city of Joinville (SC) in 2019. Results: 788 patients, of which 331 (42,00%) had a normal delivery (PN) and 457 (58,00%) cesarean section (CS). The PN group was composed of older women (29;28), and who had more pregnancies than the CS group, having at least 1 previous vaginal birth (171; 57; p < 0,001). As a risk factor for cesarean recurrence, the presence of an unfavorable cervix at the time of delivery was highlighted (47; 356; p < 0,001). Hospitalization for labor (284; 92; p < 0,001) and premature rupture of membranes (33; 79; p = 0,030) are among the protective factors for the occurrence of a new cesarean section. Conclusion: The post-cesarean vaginal birth (VBAC) rate was 42% and the cesarean delivery rate was 58%, consistent with world reference values. The fact of having one or more previous normal bir- ths, hospitalization in labor or with premature rupture of fetal membranes were protective factors against the repetition of cesarean section, while the unfavorable cervix at the time of hospitalization was a risk factor. There is divergence in litera- ture, therefore more studies are needed to develop strategies that help professionals and patients to decide on the best way of delivery after a previous cesarean section.(AU)

Impacto da estrogenização vaginal no seguimento de citologia oncótica de significado indeterminado na pós-menopausa / Impact of vaginal estrogenization in follow-up of oncotic cytology of undetermined significance in postmenopausal women

Avaliar a estrogenização tópica vaginal no seguimento de citologia oncótica de significado indeterminado, tipo ASC-H, na pós-menopausa. Estudo, tipo caso-controle, que avaliou mulheres menopausadas com diagnóstico de ASC-H, divididas em dois grupos, com e sem uso de estrogênio tópico vaginal (GE e GNE). Foi calculada razão de chance a partir de tabelas de contingência construídas com variação robusta. Foram analisados 128 prontuários, sendo 27% de pacientes do GNE e 72% do GE. Houve aumento de diagnósticos ASC-H no GNE. No GE, aproximadamente 68 vezes menos colposcopias inadequadas e diminuição do número de colposcopias e Cirurgia de Alta Frequência (CAF), com evidência na redução em 21 e 12,5 vezes, respectivamente. Diminuição do número de colposcopias com melhor adequação ao exame, número de biópsias inalterado e diminuição do número de cirurgias de alta frequência, no grupo com uso de estrogênio tópico vaginal durante o seguimento.

Current paper evaluates topic vaginal estrogenization following oncotic cytology of undetermined significance, type ASC-H, in postmenopausal women. A case-control study evaluated menopausal women diagnosed with ASC-H, divided into two groups, with and without the use of topic vaginal estrogen (GE and GNE). Odds ratios were calculated from contingency tables built with robust variation. 128 medical records were analyzed, 27% of which were from the GNE and 72% from the GE. There was an increase in ASC-H diagnoses in GNE. In GE, approximately 68 times less inappropriate colposcopies and a decrease in the number of colposcopies and High Frequency Surgery (HFS), with a reduction of 21 and 12.5 times, respectively. Decrease in the number of colposcopies with better adaptation to the exam, unchanged number of biopsies and decrease in the number of high-frequency surgeries, in the group using topic vaginal estrogen during the follow-up.

No effect of a low dose of metformin on the lipid profile, body mass index and weight gain in pregnant women with obesity: A randomized trial.

OBJECTIVE: Evaluate the lipid profile, Body Mass Index (BMI) and weight gain of pregnant women with obesity and the effect of a low dose (1000 mg/day) of metformin hydrochloride on these parameters. METHODS: A randomized clinical trial was performed from October 31th, 2014 to January 25th, 2018 with pregnant women diagnosed with obesity by arrival BMI ≥ 30.0 kg/m2. The participants were randomized into two groups: metformin and control. All pregnant women received standard prenatal follow-up and the same instructions of diet and physical exercise. Laboratory tests were performed at three different times: first moment with gestational age (GA) < 20 weeks, second (GA 24-28 weeks) and third (GA 32-34 weeks) measuring maternal serum levels of total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides (TG) as well as weight gain and BMI were monitored. RESULTS: A total of 424 pregnant women with obesity were evaluated. Of these, 218 (51.41%) composed the control group and 206 (48.59%) the metformin group. There was no difference of lipid profile, BMI and weight gain values between groups during the 1st, 2nd and 3rd evaluation moments. A significant difference was observed, only in the BMI, HDL and TG values from 1st to 3rd evaluation moments. CONCLUSION: Low dose (1000 mg/day) of the drug showed no effect on the lipid profile, BMI and weight gain in pregnant women with obesity in metformin group during the evaluation moments.

COVID-19: distanciamento social e seus desafios no contexto Brasileiro / COVID-19: social distancing and its challenges in the Brazilian context

A pandemia do novo coronavírus (COVID-19), que surgiu em Wuhan, China, e rapidamente, se espalhou pelo mundo inteiro exigiu a tomada de inúmeras medidas de proteção, tais como a higiene das mãos, uso de álcool em gel, uso de máscaras faciais individuais e a recomendação do distanciamento social, visto. Este estudo apresenta os aspectos do distanciamento social para enfrentamento da pandemia COVID-19 e os desafios de sua implantação no brasil. Foi realizada uma revisão da literatura especializada, publicada em 2019 e 2020 nas bases de dados Medline, Lilacs, Scielo, Google Acadêmico e Periódicos Capes. Na ausência de medidas farmacológicas eficazes a restrição de movimento combinado com isolamento de casos, rastreamento rigoroso de contato e quarentena de todos os contatos, teve um impacto substancial na interrupção da cadeia de transmissão do COVID-19. No entanto tais estratégias podem representar riscos socioeconômicos importantes como a redução do emprego e renda, afetando desproporcionalmente as populações menos favorecidas: políticas para diminuir tais riscos são urgentemente necessárias.

The new coronavirus (COVID-19) pandemic, which emerged in Wuhan, China, and quickly spread throughout the world required numerous protective measures, such as hand hygiene, use of alcohol gel, individual face masks and the recommendation of social distancing. This study presents the aspects of social distancing to cope with the COVID-19 pandemic and the challenges of its implementation in Brazil. A review of the specialized literature was carried out on published data in 2019 and 2020 in Medline, Lilacs, Scielo, google scholar and Capes journals. In the absence of effective pharmacological measures, a movement restriction combined with case isolation, strict contact tracking and quarantine of all contacts had a substantial impact on the interruption of the COVID-19 transmission chain. However, such strategies may pose important socioeconomic risks such as the reduction of employment and income, disproportionately affecting the less favored populations: policies to reduce such risks are urgently needed.

A Influência do Exercício Físico no Desfecho Materno Fetal / The Influence of Physical Exercise in the Fetal Maternal Outcome

RESUMO O objetivo do artigo foi analisar a influência do exercício físico durante a gestação, correlacionando a sua prática com o desfecho materno fetal. O estudo realizado foi de caráter observacional, descritivo, quantitativo e retrospectivo, com entrevistas realizadas com as puérperas primigestas internadas no serviço de pós-parto em uma maternidade pública de Joinville, SC. Os questionários perguntavam sobre informações prévias da puérpera, condições da gestação, exercícios físicos realizados durante a gestação e dados acerca do recém-nascido (RN). As puérperas foram divididas em dois grupos: ativo (n=110) e inativo (n=122), possibilitando, desta maneira, a análise dos diferentes desfechos entre os grupos. Evidenciou-se que o grupo ativo apresentou maiores chances de obter ganho de peso adequado durante a gestação (RC 1,556) e de realização de parto normal (RC 1,899). Em contrapartida, apresentou maiores chances de o RN ser pequeno para a idade gestacional (PIG) (RC 2,436), considerando o intervalo de confiança de 95%. Os dados do presente estudo sugerem que a atividade física durante o período gestacional traz benefícios tanto para a saúde materna quanto para o recém-nascido, desde que realizado de maneira programada, bem orientada e dentro de um limite de intensidade e duração.

ABSTRACT The aim of the article was to analyze the influence of physical exercise during pregnancy, correlating its practice with the fetal maternal outcome. The study was observational, descriptive, quantitative and retrospective, with interviews conducted with primiparous mothers who were in the postpartum service in a public maternity hospital in Joinville, SC. The questionnaires asked about previous information on the postpartum women, pregnancy conditions, physical exercises performed during pregnancy and data about the newborn (NB). The postpartum women were divided into two groups: active (n = 110) and inactive (n = 122), allowing the analysis of the different outcomes between the groups. It was shown that the active group was more likely to obtain adequate weight gain during pregnancy (OR 1,556) and normal delivery (OR 1,899). On the other hand, it was more likely that the newborn was small for gestational age (SGA) (OR 2,436), considering the 95% confidence interval. The data from the present study suggest that physical activity during pregnancy brings benefits to both maternal and newborn health, provided that it is performed in a regular, well-oriented manner and within a limit of intensity and duration.

Metformin for prevention of cesarean delivery and large-for-gestational-age newborns in non-diabetic obese pregnant women: a randomized clinical trial.

OBJECTIVE: To evaluate the use of metformin for preventing cesarean deliveries and large-for-gestational-age (LGA) newborn (NB) outcomes in non-diabetic obese pregnant women. SUBJECTS AND METHODS: This is a randomized clinical trial with obese pregnant women, divided into 2 groups: metformin group and control group, with followed-up prenatal routine. The gestational age of participants was less than or equal to 20 weeks and were monitored throughout entire prenatal period. For outcomes of delivery and LGA newborns, absolute risk reduction (ARR) and the number needed to treat (NNT) were calculated with a 95% confidence interval (CI). RESULTS: 357 pregnant women were evaluated. From the metformin group (n = 171), 68 (39.8%) subjects underwent cesarean delivery, and 117 (62.9%) subjects from the control group (n = 186) had intercurrence (p < 0.01). As for the mothers' general characteristics, there was significance for marital status (p < 0.01). Maternal-fetal results presented reduced preeclampsia (p < 0,01). Primary prophylactic results presented an ARR of 23.1 times (95% CI: 13.0-33.4) with NNT of 4 (95% CI: 3.0-7.7) and no significant values for LGA NB (p > 0.01). Secondary prophylactic outcomes presented decreased odds ratio for preeclampsia (OR = 0.17, 95% CI: 0.10-0.41). CONCLUSION: The use of metformin reduced cesarean section rates, resulted in a small number of patients to be treated, but it did not reduce LGA NB. Administering a lower dosage of metformin from the early stages to the end of treatment may yield significant results with fewer side effects. Arch Endocrinol Metab. 2020;64(3):290-7.

Metformin for prevention of cesarean delivery and large-for-gestational-age newborns in non-diabetic obese pregnant women: a randomized clinical trial

ABSTRACT Objective To evaluate the use of metformin for preventing cesarean deliveries and large-for-gestational-age (LGA) newborn (NB) outcomes in non-diabetic obese pregnant women. Subjects and methods This is a randomized clinical trial with obese pregnant women, divided into 2 groups: metformin group and control group, with followed-up prenatal routine. The gestational age of participants was less than or equal to 20 weeks and were monitored throughout entire prenatal period. For outcomes of delivery and LGA newborns, absolute risk reduction (ARR) and the number needed to treat (NNT) were calculated with a 95% confidence interval (CI). Results 357 pregnant women were evaluated. From the metformin group (n = 171), 68 (39.8%) subjects underwent cesarean delivery, and 117 (62.9%) subjects from the control group (n = 186) had intercurrence (p < 0.01). As for the mothers' general characteristics, there was significance for marital status (p < 0.01). Maternal-fetal results presented reduced preeclampsia (p < 0,01). Primary prophylactic results presented an ARR of 23.1 times (95% CI: 13.0-33.4) with NNT of 4 (95% CI: 3.0-7.7) and no significant values for LGA NB (p > 0.01). Secondary prophylactic outcomes presented decreased odds ratio for preeclampsia (OR = 0.17, 95% CI: 0.10-0.41). Conclusion The use of metformin reduced cesarean section rates, resulted in a small number of patients to be treated, but it did not reduce LGA NB. Administering a lower dosage of metformin from the early stages to the end of treatment may yield significant results with fewer side effects. Arch Endocrinol Metab. 2020;64(3):290-7

Physical exercise and metformin in gestational obesity and prevention on gestational diabetes mellitus: a systematic review / Exercício físico e metformina na obesidade gestacional e prevenção diabetes mellitus gestacional: revisão sistemática

Abstract Objectives: identify the action of metformin and physical activities to reduce weight gain and prevent mellitus diabetes in obese pregnant women. Methods: the electronic search was performed in PubMed / MEDLINE, LILACS, Web of Science, Scopus and Cochrane library databases between 2008 and 2018. The selection took place between April and July 2018, through the descriptors "pregnancy, obesity, metformin, treatment, exercise". A protocol was programmed and consecutively a selective research on the inclusion / exclusion phase. The "PICO" strategy was used. Population: obese pregnant women. Intervention: physical exercises and metformin. Control: The main indicator established was therapeutic outcomes with physical activity and metformin. Outcome of interest: body weight control. Results: by selecting the database, 3,983 articles were identified on the topic of interest. After selecting and eligibility, only 16 scientific studies were selected, of which 81.25% were clinical trials related to diet programs, physical activity, metformin use and possible outcomes, 18.75% were prospective cohort on causes of obesity in gestation and its association with gestational mellitus diabetes and preventive therapies. The study pointed out the possibility of adapting physical therapy programs with the correct metformin dosage for a greater control in gestational weight gain. However, there is a need for greater awareness and changes in habits for obese woman during the gestational period. Conclusions: the drug presents similarity to physical activity by activating AMPK and may be added to treatments that propose changes in pregnant women's lifestyle to reduce weight gain and prevent gestational diabetes mellitus with a better understanding of the optimal dosage. Thus, the study suggests the use of metformin is not only for the prevention and the intercurrence of gestational diabetes mellitus, but a strictly careful investigation allowing its use to non-diabetic obese pregnant women.

Resumo Objetivos: identificar a ação da metformina e da atividade física para redução do ganho de peso e prevenção do diabetes mellitus em gestantes obesas. Métodos: a busca eletrônica foi realizada nas bases de dados PubMed/MEDLINE, LILACS, Web of Science, Scopus e biblioteca Cochrane entre 2008 e 2018. A seleção ocorreu entre abril e julho de 2018, através dos descritores "gravidez, obesidade, metformina, tratamento, exercício". Programou-se um protocolo e consecutivamente uma etapa seletiva de inclusão/exclusão das pesquisas. Utilizou-se a estratégia "PICO". População: gestantes obesas. Intervenção: exercícios fisicos e metformina. Controle: o principal comparador estabelecido foi o desfecho terapêutico com atividade fisica e metformina. Desfecho de interesse: controle do peso corporal. Resultados: através da seleção do banco de dados, 3.983 artigos foram identificados sobre o tema de interesse. Após as etapas de seleção e elegibilidade, apenas 16 estudos científicos foram selecionados, dos quais 81,25% ensaios clinicos referentes aos programas de dieta, atividade física, uso da metformina e possíveis desfechos, 18,75% coorte prospectiva sobre as causas da obesidade na gestação e sua associação com o diabetes mellitus gestacional e terapêutica preventiva. O estudo apontou a possibilidade de se adequar programas de terapias físicas com a dosagem correta de metformina para um maior controle no ganho de peso gestacional. No entanto, existe a necessidade de uma maior concientização e mudanças de hábitos da mulher obesa durante o período gestacional. Conclusões: a droga apresenta semelhança com a atividade física ao ativar o AMPK e pode somar aos tratamentos que propõem mudanças no estilo de vida das gestantes para reduzir o ganho de peso e prevenir o diabetes mellitus gestacional com a necessidade de um melhor entendimento sobre a dosagem ideal. Desta forma, o estudo sugere que o uso da metformina não seja apenas para prevenção e intercorrências do DMG, mas também com uma investigação estritamente cuidadosa para possibilitar o seu uso em grávidas obesas não diabéticas.

Perinatal mortality: epidemiological profile, causes and avoidable factors at a reference public maternity hospital in the State of Santa Catarina, Brazil, 2011-2015.

Background This study aimed to identify the perinatal mortality coefficient, the epidemiological profile, causes and avoidable factors at a reference public maternity hospital in southern Brazil. Methods In this cross-sectional study, 334 medical records of postpartum women and newborns were evaluated between January 1st, 2011 and December 31st, 2015. The Expanded Wigglesworth Classification was used to assess the causes of perinatal mortality and the International Statistical Classification of Diseases and Related Health Problems (ICD-10/SEADE Foundation) was used for the preventable perinatal mortality analysis. Absolute numbers and percentages were used for data analysis. The perinatal mortality formula was used to calculate the perinatal mortality rate. Results The perinatal mortality rate was 13.2/1000 total births, with a predominance of white race/color; mothers were 21-30 years of age, had experienced their first pregnancy and had completed their high school education. Conclusion The main factors associated with perinatal death were antepartum fetal death in 182 (54.49%) cases, and avoidable death through appropriate prenatal care in 234 (70.05%) cases.

Progress Test in Medical School: a Systematic Review of the Literature / Teste de Progresso na Escola Médica: uma Revisão Sistemática acerca da Literatura

Abstract: Progress Test is an objective assessment, consisting of 60 to 150 multiple-choice questions, designed to promote an assessment of the cognitive skills expected at the end of undergraduate school. This test is applied to all students on the same day, so that it is possible to compare the results between grades and analyze the development of knowledge performance throughout the course. This study aimed to carry out a systematic and literary review about Progress Test in medical schools in Brazil and around the world, understanding the benefits of its implementation for the development of learning for the student, the teacher and the institution. The study was carried out from July 2018 to April 2019, which addressed articles published from January 2002 to March 2019. The keywords used were: "Progress Test in Medical Schools" and "Item Response Theory in Medicine" in the PubMed, Scielo, and Lilacs platforms. There was no language limitation in article selection, but the research was carried out in English. A total of 192,026 articles were identified, and after applying advanced search filters, 11 articles were included in the study. The Progress Test (PTMed) has been applied in medical schools, either alone or in groups of partner schools, since the late 1990s. The test results build the students' performance curves, which allow us to identify weaknesses and strengths of the students in the several areas of knowledge related to the course. The Progress Test is not an exclusive instrument for assessing student performance, but it is also important as an assessment tool for academic management use and thus, it is crucial that institutions take an active role in the preparation and analysis of this assessment data. Assessments designed to test clinical competence in medical students need to be valid and reliable. For the evaluative method to be valid it is necessary that the subject be extensively reviewed and studied, aiming at improvements and adjustments in test performance.

Resumo: O Teste de Progresso é uma avaliação objetiva, estruturada com 60 a 150 questões de múltipla escolha, elaborada com o objetivo de promover uma avaliação das competências cognitivas esperadas no final do curso de graduação. Esse teste é aplicado a todos os discentes no mesmo dia, de modo que seja possível comparar os resultados entre as séries e analisar a performance evolutiva do conhecimento no decorrer do curso. Este trabalho teve como objetivo realizar uma revisão sistemática e literária acerca do Teste de Progresso nas escolas médicas no Brasil e no mundo, compreendendo os benefícios de sua implantação para o desenvolvimento do aprendizado, tanto para o aluno quanto para o docente e para a instituição. A pesquisa foi realizada no período de julho de 2018 a abril de 2019 e abordou artigos publicados no período de janeiro de 2002 a março de 2019. Utilizaram-se os descritores "Teste de Progresso nas escolas médicas" e "Teoria de Resposta ao Item em Medicina" nas plataformas PubMed, SciELO e Lilacs. Não houve limitação de idioma na seleção dos artigos, porém a pesquisa foi realizada em inglês. Foram encontrados 192.026 artigos, e, após a aplicação de filtros de busca avançada, incluíram-se 11 artigos no estudo. O Teste de Progresso (TP) vem sendo aplicado nas escolas médicas, de forma isolada ou em grupos de escolas parceiras, desde o final da década de 1990. Os resultados do teste constroem curvas de desempenho dos acadêmicos, o que permite identificar fragilidades e qualidades dos estudantes nas diversas áreas do conhecimento relacionadas ao curso. O Teste de Progresso não é um instrumento exclusivo de avaliação do desempenho dos estudantes, mas assume também um significado como ferramenta avaliativa para uso na gestão acadêmica, e para isso é fundamental que as instituições assumam papel ativo na elaboração e na análise dos dados dessa avaliação. Os exames desenvolvidos para testar a competência clínica em estudantes de Medicina necessitam ser válidos e confiáveis. Para que o método avaliativo seja válido, é necessário que o assunto seja amplamente revisado e estudado, visando a melhorias e adequações na execução dos testes.

O impacto do uso da metformina para gestantes obesas na prevenção da pré-eclâmpsia / The impact of the use of metformine for obese pregnant women in prevention

Objetivos: o artigo objetiva avaliar o uso de metformina em gestantes obesas na prevenção da pré-eclâmpsia. Métodos: trata-se de um ensaio clínico randomizado com mulheres grávidas obesas com índice de massa corporal superior ou igual a 30 kg/m2 divididos em dois grupos ­ um grupo de estudo, que utilizou metformina, e um grupo controle, que seguiu a rotina de pré-natal. As gestantes entraram no estudo com idade gestacional menor que 20 semanas e foram acompanhadas durante todo o período pré-natal. O diagnóstico de pré-eclâmpsia foi feito de acordo com os critérios da Organização Mundial de Saúde. Resultados: verificou-se a redução de risco absoluto e o número necessário para tratar em um intervalo de confiança de 95% para o resultado pré-eclâmpsia. Nos resultados, 272 gestantes foram avaliadas. No grupo de estudo (n = 127), oito (6,3%) desenvolveram pré-eclâmpsia. No grupo controle (n = 145), 31 (21,4%) tiveram a doença (p <0,01). Conclusão: o estudo apontou uma redução de risco absoluto de 15,1 vezes (IC95%: 7,1-22,9) e número necessário para tratar de sete (IC95%: 4,4-13,9). O uso de 1000 miligramas diárias de metformina indicou uma redução de 15,1 vezes no risco absoluto de pré-eclâmpsia na população estudada, com a necessidade de tratar sete gestantes para evitar um desfecho.

Aims: The article aims to evaluate the use of metformin in obese pregnant women in the prevention of pre-eclampsia. Methods: This is a randomized clinical trial with obese pregnant women with a body mass index greater than or equal to 30 kg / m2 divided into two groups: a study group that used metformin and a control group that followed the prenatal routine. The pregnant women entered the study with gestational age less than 20 weeks and were followed throughout the prenatal period. The diagnosis of pre-eclampsia was made according to World Health Organization criteria. Results: The absolute risk reduction and number needed to treat in a 95% confidence interval for the preeclampsia result were checked. In the results, 272 pregnant women were evaluated. In the study group (n = 127) eight (6.3%) developed preeclampsia, in the control group (n = 145) 31 (21.4%) obtained the disease (p <0.01). Conclusions: The study indicated an absolute risk reduction of 15.1 times (95% CI: 7.1-22.9) and number needed to treat of 7 (95%CI: 4.4-13.9). The use of 1000 milligrams daily metformin indicated a 15.1 x reduction in the absolute risk of preeclampsia in the study population, with the need to treat seven pregnant women to avoid an outcome.

Factors Associated with the Need for Insulin as a Complementary Treatment to Metformin in Gestational Diabetes Mellitus.

OBJECTIVE: To evaluate the factors associated with the need for insulin as a complementary treatment to metformin in pregnant women with gestational diabetes mellitus (GDM). METHODS: A case-control study was performed from April 2011 to February 2016 with pregnant women with GDM who needed complementary treatments besides diet and physical exercise. Those treated with metformin were compared with those who, in addition to metformin, also needed the combination with insulin. Maternal characteristics and glycemic control were evaluated. Multinomial logistic regression models were developed to evaluate the influence of different therapies on neonatal outcomes. RESULTS: A total of 475 pregnant women who needed pharmacological therapy were evaluated. Of these, 366 (77.05%) were submitted to single therapy with metformin, and 109 (22.94%) needed insulin as a complementary treatment. In the analysis of the odds ratio (OR), fasting glucose (FG) < 90 mg/dL reduced the odds of needing the combination (OR: 0.438 [0.235-0.815]; p = 0.009], as well as primiparity (OR: 0.280 [0.111-0.704]; p = 0.007]. In obese pregnant women, an increased chance of needing the combination was observed (OR: 2,072 [1,063-4,039]; p = 0,032). CONCLUSION: Obesity resulted in an increased chance of the mother needing insulin as a complementary treatment to metformin, while FG < 90 mg/dL and primiparity were protective factors.

OBJETIVO: Avaliar os fatores associados à necessidade de insulina como tratamento complementar à metformina em gestantes com diabetes mellitus gestacional (DMG). MéTODOS: Um estudo caso-controle foi realizado de abril de 2011 a fevereiro de 2016 com gestantes portadoras de DMG que necessitaram de tratamentos complementares além de dieta e exercícios físicos. Aquelas tratadas com metformina foram comparadas com aquelas que, além da metformina, também precisaram de combinação com insulina. Foram avaliadas as características maternas e de controle glicêmico. Modelos de regressão logística multinomial foram construídos para avaliar a influência das diferentes terapias nos desfechos neonatais. RESULTADOS: Foram avaliadas 475 gestantes que necessitaram de terapia farmacológica. Destas, 366 (77,05%) utilizaram terapia única com metformina, e 109 (22,95%) necessitaram de insulina como tratamento complementar. Na análise da razão de possibilidades (RP), a glicemia de jejum (GJ) < 90 mg/dL reduziu as chances de necessidade da combinação (RP: 0,438 [0,235­0,815]; p = 0,009), bem como a primiparidade (RP: 0,280 [0,111­0,704]; p = 0,007). Em gestantes obesas, foi observada uma chance maior de necessidade da combinação (RP: 2.072 [1.063­4.039]; p = 0,032). CONCLUSãO: A obesidade resultou em um aumento na chance de a mãe precisar de insulina como tratamento complementar à metformina, enquanto a GJ < 90 mg/dL e a primiparidade foram fatores de proteção.

Factors associated with the need for insulin as a complementary treatment to metformin in gestational diabetes mellitus / Fatores associados à necessidade de insulina como tratamento complementar à metformina na diabetes mellitus gestacional

Abstract Objective To evaluate the factors associated with the need for insulin as a complementary treatment to metformin in pregnant women with gestational diabetes mellitus (GDM). Methods A case-control study was performed from April 2011 to February 2016 with pregnant women with GDM who needed complementary treatments besides diet and physical exercise. Those treated with metformin were compared with those who, in addition to metformin, also needed the combination with insulin. Maternal characteristics and glycemic control were evaluated. Multinomial logistic regression models were developed to evaluate the influence of different therapies on neonatal outcomes. Results A total of 475 pregnant women who needed pharmacological therapy were evaluated. Of these, 366 (77.05%) were submitted to single therapy with metformin, and 109 (22.94%) needed insulin as a complementary treatment. In the analysis of the odds ratio (OR), fasting glucose (FG)<90 mg/dL reduced the odds of needing the combination (OR: 0.438 [0.235-0.815]; p=0.009], as well as primiparity (OR: 0.280 [0.111-0.704]; p=0.007]. In obese pregnant women, an increased chance of needing the combination was observed (OR: 2,072 [1,063-4,039]; p=0,032). Conclusion Obesity resulted in an increased chance of the mother needing insulin as a complementary treatment to metformin, while FG<90 mg/dL and primiparity were protective factors.

Resumo Objetivo Avaliar os fatores associados à necessidade de insulina como tratamento complementar à metformina em gestantes com diabetes mellitus gestacional (DMG). Métodos Um estudo caso-controle foi realizado de abril de 2011 a fevereiro de 2016 comgestantes portadoras de DMG que necessitaram de tratamentos complementares além de dieta e exercícios físicos. Aquelas tratadas commetformina foram comparadas com aquelas que, além da metformina, também precisaram de combinação com insulina. Foram avaliadas as características maternas e de controle glicêmico. Modelos de regressão logística multinomial foram construídos para avaliar a influência das diferentes terapias nos desfechos neonatais. Resultados Foram avaliadas 475 gestantes que necessitaram de terapia farmacológica. Destas, 366 (77,05%) utilizaram terapia única com metformina, e 109 (22,95%) necessitaram de insulina como tratamento complementar. Na análise da razão de possibilidades (RP), a glicemia de jejum (GJ)<90mg/dL reduziu as chances de necessidade da combinação (RP: 0,438 [0,235-0,815]; p=0,009), bem como a primiparidade (RP: 0,280 [0,111-0,704]; p=0,007). Em gestantes obesas, foi observada uma chance maior de necessidade da combinação (RP: 2.072 [1.063-4.039]; p=0,032). Conclusão A obesidade resultou em um aumento na chance de a mãe precisar de insulina como tratamento complementar à metformina, enquanto a GJ<90 mg/dL e a primiparidade foram fatores de proteção.