Maternal near miss and maternal death in the World Health Organization's 2005 global survey on maternal and perinatal health.

OBJECTIVE: To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. METHODS: In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter's association with maternal characteristics and perinatal outcomes. FINDINGS: Of the 97,095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. CONCLUSION: Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

Understanding the factors associated with differences in caesarean section rates at hospital level: the case of Latin America.

As in many other regions of the world, caesarean section (CS) rates in Latin America are increasing. Studies elsewhere have shown that providing feedback to caregivers regarding their own performance relative to their peers can significantly reduce the rates. Our objectives are to calculate risk-adjusted CS rates for hospitals in Latin America and to identify factors associated with differences among risk-adjusted rates. We included 120 randomly selected institutions in eight countries of Latin America, representing 97 095 pregnancies. We used random-effects models to calculate a risk-adjusted rate for each hospital and to identify hospitals significantly higher or lower than a benchmark rate. We conducted a regression analysis to identify characteristics of hospitals associated with differences among risk-adjusted rates. The overall CS rate was 35%, ranging from 0% to 85%. Risk-adjusted CS rates ranged from 11% to 78%. Three-quarters of hospitals had risk-adjusted rates significantly above the previously identified benchmark of 20%. Characteristics of institutions explained 48% of the variability among risk-adjusted rates, including being a private as opposed to a public institution, having some economic incentive for CS as opposed to no incentive, and having > or = 50 maternity beds. Strategies to halt further increases in CS rates and reduce rates to levels that reflect the best quality of care, are urgently needed worldwide. The involvement of local quality control departments is an essential component in achieving success. Our results can be used to identify institutions that can be targets for further interventions to reduce CS rates.

WHO global survey on maternal and perinatal health in Latin America: classifying caesarean sections.

BACKGROUND: Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time. METHODS: We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates. RESULTS: The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively. CONCLUSION: The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care.

Coagulation and inflammation markers during atypical or typical antipsychotic treatment in schizophrenia patients and drug-free first-degree relatives.

BACKGROUND: Clinical studies suggest that the second generation antipsychotics (APs) clozapine and olanzapine and to a lesser extent the typical antipsychotics may be associated with a procoagulant and proinflammatory state that promotes venous thromboembolism. We evaluated here several blood factors associated with coagulation and inflammation in AP-treated schizophrenia patients and their first-degree relatives. METHODS: Procoagulant factors (fibrinogen and plasminogen activator inhibitor [PAI-1]), the anticoagulant factor antithrombin III [AT-III], and inflammation-related factors (C-reactive protein [CRP] and leptin) were assessed in patients chronically treated with clozapine (n=29), olanzapine (n=29), typical APs (n=30) and first degree relatives of clozapine (n=23) and olanzapine subjects (n=11). RESULTS: The typical AP group had the highest CRP level (p=0.013) in spite of having the lowest body mass index (BMI). Patients as a single group had higher CRP levels than relatives (p=0.003). The typical AP group also had the highest AT-III levels (p=0.021). Fibrinogen levels did not differ between the groups (p=0.13). Olanzapine patients displayed the highest PAI-1 and leptin levels among the drug-treated subjects, but values were similar to those observed in their relatives, and were significantly correlated with the BMI. CONCLUSIONS: A homogeneous negative profile of high inflammation and procoagulant factors along with low levels of anticoagulants was not detected in any group. While preliminary, our results suggest that the observed abnormalities were not related to a direct drug effect, but to elevated BMI (high PAI-1 and leptin in olanzapine-treated patients). We speculate that the high CRP in the typical AP group might be related to poor lifestyle habits, but this must we confirmed in future studies.

Intracluster correlation coefficients from the 2005 WHO Global Survey on Maternal and Perinatal Health: implications for implementation research.

Cluster-based studies involving aggregate units such as hospitals or medical practices are increasingly being used in healthcare evaluation. An important characteristic of such studies is the presence of intracluster correlation, typically quantified by the intracluster correlation coefficient (ICC). Sample size calculations for cluster-based studies need to account for the ICC, or risk underestimating the sample size required to yield the desired levels of power and significance. In this article, we present values for ICCs that were obtained from data on 97,095 pregnancies and 98,072 births taking place in a representative sample of 120 hospitals in eight Latin American countries. We present ICCs for 86 variables measured on mothers and newborns from pregnancy to the time of hospital discharge, including 'process variables' representing actual medical care received for each mother and newborn. Process variables are of primary interest in the field of implementation research. We found that overall, ICCs ranged from a minimum of 0.0003 to a maximum of 0.563 (median 0.067). For maternal and newborn outcome variables, the median ICCs were 0.011 (interquartile range 0.007-0.037) and 0.054 (interquartile range 0.013-0.075) respectively; however, for process variables, the median was 0.161 (interquartile range 0.072-0.328). Thus, we confirm previous findings that process variables tend to have higher ICCs than outcome variables. We demonstrate that ICCs generally tend to increase with higher prevalences (close to 0.5). These results can help researchers calculate the required sample size for future research studies in maternal and perinatal health.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study.

OBJECTIVE: To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. DESIGN: Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. SETTING: 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data PARTICIPANTS: 106,546 deliveries reported during the three month study period, with data available for 97,095 (91% coverage). MAIN OUTCOME MEASURES: Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. RESULTS: Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. CONCLUSIONS: Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America.

BACKGROUND: Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS: For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS: We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

[Superficial mycoses: comparative study between type 2 diabetic patients and a non-diabetic control group]. / Frecuencia de micosis superficiales: estudio comparativo en pacientes diabéticos tipo 2 y en individuos no diabéticos.

Superficial mycoses are considered to affect more frequently patients with type 2 diabetes mellitus (DM-2), specially onychomycosis and Tinea pedis. The purpose of this study was to compare the dermatophytoses, candidiasis and Pitiriasis versicolor frequency between 40 patients with DM-2 and 40 healthy persons of either sex, 40 years old or more. Clinical, metabolic, mycologic and inmunologic studies against Candida albicans, were carried out. Both diabetics 75% (30/40) and controls 65% (26/40) presented a high frequency of superficial mycoses (no significant difference p = 0.329). Pitiriasis versicolor was not detected in diabetic patients. They presented Tinea unguium, concomitant with Tinea pedis, with a higher frequency. The predominant dermatophyte was Trichophyton rubrum 18/23 (78%) in diabetics and 8/16 (50%) in non diabetics. Candida was isolated as commensal from oral mucous: 23/40 (58%) in diabetics and 21/40 (52%) in non diabetics (serotipo A was the more frequent), and from onychomycosis: 11/40 (28%) in diabetics and 12/40 (30%) in non diabetics. The immunological response was the same in both groups: celular 100%, humoral 20%. No statistical correlation among superficial mycoses, blood glucose level, glycosylated hemoglobin values or the time suffering the disease was observed. The high susceptibility to dermatophytes and Candida sp. infection showed to be associated with age and no with the diabetic type 2 condition in those patients.

Frecuencia de micosis superficiales: estudio comparativo en pacientes diabéticos tipo 2 y en individuos no diabéticos / Superficial mycoses: comparative study between type 2 diabetic patients and a non-diabetic control group

Se considera que las micosis superficiales son más frecuentes en pacientes diabéticos tipo 2 (DM-2) especialmente la onicomicosis y la Tinea pedis. El objetivo de este estudio fue comparar la frecuencia de dermatofitosis, candidiasis y pitiriasis versicolor entre 40 pacientes DM-2 y 40 personas sanas, de ambos sexos con 40 años de edad o más. Se realizó examen clínico, metabólico, micológico e inmunológico con antígenos de Candida albicans. Treinta diabéticos (75 por ciento) y 26 (65 por ciento) individuos del grupo control presentaron una alta frecuencia de micosis superficiales (diferencia no significativa p=0,329). No se detectó ningún caso de pitiriasis versicolor en los diabéticos. Estos presentaron con mucho mayor frecuencia Tinea unguium concomitante a Tinea pedis. Trichophyton rubrum fue el dermatofito predominante 18/23 (78 por ciento) en diabéticos y 8/16 (50 por ciento) en no diabéticos. Se aisló Candida como comensal en mucosa oral: en 23 (58 por ciento) diabéticos y en 21/(52 por ciento) no diabéticos (el serotipo A fue el más frecuente), y en onicomicosis: 11/40 (28 por ciento) diabéticos y 12/40 (30 por ciento) no diabéticos. La respuesta inmunitaria fue la misma en ambos grupos: celular 100 por ciento y humoral 20 por ciento. No se observó correlación estadística entre la frecuencia de las micosis superficiales, los niveles de glucosa en sangre, los valores de hemoglobina glicosilada ni el tiempo de evolución de la diabetes. La alta susceptibilidad a infecciones por dermatofitos y Candida sp. estaría relacionada con la edad y no con la condición de diabético tipo 2 en estos pacientes

Niveles de homocisteína plasmática en diabéticos tipo 2 y controles sanos / Levels of plasmatic homocisteína in diabetic type 2 and healthy controls

La homocisteína es un producto del metabolismo de la metionina, considerado comoun factor de riesgo cardiovascular. Estudio no experimental, transversal, comparativo, caso-control, con una muestra aleatoria de 20 diabéticos tipo 2 pareados según sexo, índice masa corporal e índice de cintura/cadera con controles sanos. Se determinó a todos glicemia, homocisteína; hemoglobina glicosilada en los diabéticos. Análisis estadístico: prueba t de Student además de cálculo de radio de odds y aplicación de la correlación de Pearson. Hipermocisteinemia en 6 diabéticos (30 por ciento) con homocisteína = 13 ñ 1.88 µmo/L en diabéticos y en los sanos homocisteína = 10ñ 1,78 µol/L y según Mc Nemar = 6 (P<0,05). Se aplicó la correlación de Pearson: índice de masa corporal - homocisteína r=0,111 (P=0,642), índice cintura/cadera - homocisteína r= 0.241 (P =0,307), glicemia - homocisteína r= 0,222 (P= 0,615), años de diagnóstico de diabetes mellitus tipo 2 - homocisteína r= -0,012 (P= 0,960), edad - homocisteína r=0,17 (P=0,473). Los diabéticos tuvieron una homocisteína mayor que los no diabéticos. Se observó una tendencia de la homocisteína de ser un factor independiente de los marcadores de control metabólico abriendo la posibilidad de un tratamiento individualizado para este factor.

Determinación de lipemia postprandial en adolescentes hipertensos / Determination of postprandial lipemia in adolescent hypertension

El metabolismo lipídico postprandial se ha asociado al desarrollo de aterogénesis, por lo que se considera un factor de riesgo independiente para enfermedad cardiovascular. El objetivo de este estudio, de tipo descriptivo transversal, es determinar lipemia postprandial en dos grupos de adolescentes, uno con hipertensión arterial y otro normotenso. Participando en el mismo 65 individuos de 12 a 18 años de ambos sexos (34 hipertensos y 31 normotensos). Se practican exámenes de laboratorio determinando el perfil lipídico en ayunas y posterior a una carga grasa (60 gr/m² SC) se determinan a las 2, 4 y 6 horas postprandiales niveles de triglicéridos y de HDL-c, además se realizan mediciones del índice de masa corporal y del índice cintura cadera. Encontrándose una prevalencia de obesidad en la población del 40 por ciento, con una distribución de la grasa de tipo central en un 23.08 por ciento. Las dislipidemias se encontraron en un 35.38 por ciento de la población, siendo la más frecuente la tipo IV (65.22 por ciento); tipo II a (17.39 por ciento) y tipo II b (17.39 por ciento). En relación a la lipemia postprandial se observa el pico de trigliceridemia a las 4 horas en ambos grupos, mostrando los hipertensos una media de 233 mg/dl y el grupo control de 160 mg/dl, con una diferencia estadísticamente significativa de P: 0,02 entre ambos grupos. La fracción HDL-c muestra su mayor disminución a las 4 horas en ambos grupos con una media en los hipertensos de 35.47 mg/dl y el grupo control de 34.77 mg/dl

Curvas estándares de peso al nacimiento para neonatos del Paraguay

Presenta las curvas de peso al nacimiento para la población Paraguaya elaborada con el procesamiento de los datos brutos obtenidos de la oficina de bioestadística del Ministerio de Salud Pública, correspondiente a cinco años desde el 1991 a 1995, Incluyew los valores correspondientes a los percentilos 5º, 10º, 25º, 50º, 75º, y 90º de peso al nacimiento correspondiente a embarazos que finalizaron entre las 27 y las 44 semanas. Contiene tres tablas: la primera con los valores de todos los nacimientos registrados en dicho periodo de tiempo, la segunda corresponde a los recién nacidos de sexo macuslino y la tercera a aquellos del sexo femenino

Estudio comparativo entre la historosalpingografia y la endoscopia en la evaluacion de la mujer infertil

Este trabajo presenta la experiencia del autor con endoscopia e histeroslpingografia en la evaluacion de la funcion tubarica en paciente con infertilidad primnaria o secundaria de por lomenos un año de duracion