Clinical, epidemiological and laboratory characteristics of cases of Covid-19-related maternal near miss and death at referral units in northeastern Brazil: a cohort study.

Objective: Covid-19 poses a major risk during pregnancy and postpartum, resulting in an increase in maternal mortality worldwide, including in Brazil; however, little research has been conducted into cases of a near miss. This study aimed to describe the frequency of COVID-19-related near miss and deaths during pregnancy or in the postpartum in referral centers in northeastern Brazil, as well as the clinical, epidemiological, and laboratory characteristics of the women who experienced a severe maternal outcome.Methods: A retrospective and prospective cohort study was performed between April 2020 and June 2021 with hospitalized pregnant and postpartum women with a diagnosis of COVID-19 confirmed by real-time polymerase chain reaction (RT-PCR). Data from five tertiary hospitals in northeastern Brazil were evaluated. Descriptive statistical analysis was performed using Epi Info, version 7.2.5.0.Results: A total of 463 patients were included. Of these, 64 (14% of the sample) had a severe maternal outcome, with 42 cases of near miss (9%) and 22 maternal deaths (5%). Patients who had a severe maternal outcome were predominantly young (median age 30 years) and 65.6% were black or brown-skinned. The women had between 6 and 16 years of schooling; 45.3% had a stable partner; 81.3% were pregnant at the time of admission to the study; and 76.6% required a Cesarean section. The great majority (82.8%) had severe acute respiratory syndrome (SARS). Other complications included hypertensive syndromes (40.6%), pneumonia (37.5%), urinary tract infections (29.7%), acute renal failure (25.0%) and postpartum hemorrhage (21.9%). Sepsis developed in 18.8% of cases, neurological dysfunction in 15.6%, and hepatic dysfunction and septic shock in 14.1% of cases each. The relative frequency of admission to an intensive care unit was 87.5%, while 67.2% of the patients required assisted mechanical ventilation, and 54.7% required noninvasive ventilation. Antibiotics were prescribed in 93.8% of cases and corticosteroids in 71.9%, while blood transfusion was required in 25.0% of cases and renal replacement therapy in 15.6%. Therapeutic anticoagulants were administered to 12.5% of the patients. Of the patients who had a severe maternal outcome, the frequency of respiratory dysfunction was 93.8%, with 50.0% developing neurological dysfunction and 37.5% cardiovascular dysfunction. Hematological dysfunction was found in 29.7%, renal dysfunction in 18.8%, and uterine dysfunction in 14.1%. Hepatic dysfunction occurred in 7.8% of the sample. The near-miss ratio for Covid-19 was 1.6/1000 live births and the maternal mortality ratio for Covid-19 was 84.8/100,000 live births, with a mortality index of 34.4% in the sample.Conclusion: This study revealed a low Covid-19-related maternal near miss (MNM) ratio of 1.6/1000 live births and a high Covid-19-related maternal mortality ratio (MMR) of 84.81/100,000 live births. The mortality index was also high. Most of the patients were admitted while pregnant, were young, married and black or brown-skinned, and none had completed university education. The majority had SARS and required admission to an intensive care unit and mechanical ventilation. Most were submitted to a Cesarean section.

Factors associated with severe maternal outcome in patients admitted to an intensive care unit in northeastern Brazil with postpartum hemorrhage: a retrospective cohort study.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide, particularly in low- and middle-income countries; however, the majority of these deaths could be avoided with adequate obstetric care. Analyzing severe maternal outcomes (SMO) has been a major approach for evaluating the quality of the obstetric care provided, since the morbid events that lead to maternal death generally occur in sequence. The objective of this study was to analyze the clinical profile, management, maternal outcomes and factors associated with SMO in women who developed PPH and were admitted to an obstetric intensive care unit (ICU) in northeastern Brazil. METHODS: This retrospective cohort study included a non-probabilistic, consecutive sample of postpartum women with a diagnosis of PPH who were admitted to the obstetric ICU of the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between January 2012 and March 2020. Sociodemographic, biological and obstetric characteristics and data regarding childbirth, the management of PPH and outcomes were collected and analyzed. The frequency of maternal near miss (MNM) and death was calculated. Multiple logistic regression analysis was performed to determine the adjusted odd ratios (AOR) and their 95% confidence intervals (95% CI) for a SMO. RESULTS: Overall, 136 cases of SMO were identified (37.9%), with 125 cases of MNM (34.9%) and 11 cases of maternal death (3.0%). The factors that remained associated with an SMO following multivariate analysis were gestational age ≤ 34 weeks (AOR = 2.01; 95% CI: 1.12-3.64; p < 0.02), multiparity (AOR = 2.20; 95% CI: 1.10-4.68; p = 0.02) and not having delivered in the institute (AOR = 2.22; 955 CI: 1.02-4.81; p = 0.04). CONCLUSION: Women admitted to the obstetric ICU with a diagnosis of PPH who had had two or more previous deliveries, gestational age ≤ 34 weeks and who had delivered elsewhere were more likely to have a SMO.

Factors associated with severe acute respiratory syndrome in pregnant/postpartum women with COVID-19 receiving care at referral centers in northeastern Brazil: Secondary analysis of a cohort study.

Background: At the beginning of the COVID-19 pandemic, the greater risks associated with the new SARS-CoV-2 pathogen in pregnant women were as yet unclear. This study analyzed factors associated with severe acute respiratory syndrome (SARS) in pregnant/postpartum women with COVID-19. Methods: A prospective and retrospective cohort study was conducted in eight referral centers in northeastern Brazil between April 2020 and December 2021 involving pregnant/postpartum women with a positive COVID-19 RT-PCR test. A multivariate analysis was then conducted using a hierarchical logistic regression model to evaluate the association between the independent variables and the presence of SARS. Findings: Of 611 patients included, 522 were pregnant and 83 were postpartum, at the time of admission. Criteria for SARS were present in 215 patients (35·2%). Factors associated with SARS included overweight and/or obesity (adjusted odds ratio/AOR: 1·95; 95%CI: 1·21-3·12; p = 0·0054), parity ≥2 (AOR: 1·72; 95%CI: 1·21-2·45; p = 0·0025), gestational age <34 weeks (AOR: 3·54; 95%CI: 2·47-5·07; p < 0·0001) and duration of symptoms >7 days (AOR: 1·97; 95%CI: 1·35-2·89; p = 0·0004). SARS increased the likelihood of requiring oxygen therapy (RR = 8·80; 95%CI: 6·25-12·40; p = 0·0000), mechanical ventilation (RR = 8·15; 95%CI: 4·67-14·21; p = 0·0000), and admission to an ICU (RR = 6·54; 95%CI: 4·70-9·11; p = 0·0000), and of maternal near miss (RR = 10·82; 95%CI: 1·20-22·47; p = 0·0000) and maternal death (RR = 8·12; 95%CI: 3·11-21·09; p = 0·0000). Interpretation: In patients with COVID-19, parity ≥2, overweight/obesity, gestational age <34 weeks and duration of symptoms >7 days increased the risk of SARS. Cesarean sections, oxygen therapy, and mechanical ventilation were more common in patients with SARS.

Sleep in children from northeastern Brazil with congenital Zika syndrome: assessment using polysomnography.

STUDY OBJECTIVES: We performed this study to describe the characteristics of sleep in children with congenital Zika syndrome through polysomnographic assessment. METHODS: Polysomnography with neurological setup and capnography was performed. Respiratory events were scored according to American Academy of Sleep Medicine criteria. Children were classified based on neuroclinical examination as having corticospinal plus neuromuscular abnormalities or exclusively corticospinal abnormalities. Neuroradiological classification was based on imaging exams, with children classed as having supratentorial plus infratentorial abnormalities or exclusively supratentorial abnormalities. RESULTS: Of 65 children diagnosed with congenital Zika syndrome, sleep apnea was present in 23 children (35.4%), desaturation in 26 (40%), and snoring in 13 (20%). The most prevalent apnea type was central in 15 children (65.2%), followed by obstructive apnea in 5 (21.7%) and mixed type in 3 (13%). The average of the lowest saturation recorded was slightly below normal (89.1 ± 4.9%) and the mean partial pressure of end-tidal carbon dioxide value was normal. Periodic leg movements were present in 48 of 65 children. Lower ferritin levels were observed in 84.6% of children. Palatine and pharyngeal tonsils (adenoids) were small in most children and not associated with the presence of obstructive apnea. Ventriculomegaly and subcortical and nucleus calcification were the most frequent neuroimaging findings. Supratentorial and infratentorial anomalies were present in 26.7% (16 of 60) and exclusively supratentorial changes in 73.3% (44 of 60). In the neuroclinical classification, isolated corticospinal changes were more frequent and the mean peak in capnography was lower in this group. There was no difference regarding the presence of apnea for children in the neuroclinical and neuroradiological classification groups. CONCLUSIONS: Sleep disorders were frequent in children with congenital Zika syndrome, with central sleep apnea being the main finding. CITATION: Brandão Marquis V, de Oliveira Melo A, Pradella-Hallinan M, et al. Sleep in children from northeastern Brazil with congenital Zika syndrome: assessment using polysomnography. J Clin Sleep Med. 2023;19(10):1759-1767.

Symptoms of anxiety and depression in women with gestational trophoblastic disease compared to women who had a miscarriage: a cross-sectional study.

This study was conducted between March 2020 and February 2021 to analyze anxiety and depression symptoms in 64 women with gestational trophoblastic disease (GTD) and 99 women who had miscarried. The Hospital Anxiety and Depression Scale (HADS) was applied by telephone three months after pregnancy loss. Multivariate analysis was performed using hierarchical logistic regression to evaluate associations between variables. Probable anxiety (HADS-A ≥ 8) and depression (HADS-D ≥ 8) were found in 53.1% and 43.8% of the GTD group and 49.5% and 39.4% of the miscarriage group, with no difference between the groups. Severe symptoms of anxiety (HADS-A 15-21) and depression (HADS-D 15-21) were found, respectively, in 12.5% and 4.7% of the GTD group and in 9.1% and 4.0% of the miscarriage group, also with no difference between the groups. Lack of partner support proved a risk factor for anxiety and depression, while poor education increased the risk of depression symptoms 3.43-fold following pregnancy loss. In conclusion, three months after pregnancy loss the frequency of anxiety and depression symptoms was similarly high in both groups, with poor education and lack of partner support being significant risk factors for the subsequent development of psychiatric morbidity.

Analysis of the Measurement Properties of the Female Sexual Function Index 6-item Version (FSFI-6) in a Postpartum Brazilian Population.

OBJECTIVE: We evaluated internal consistency, test-retest reliability, and criterion validity of the Brazilian Portuguese version of the Female Sexual Function Index 6-item Version (FSFI-6) for postpartum women. METHODS: Therefore, questionnaires were applied to 100 sexually active women in the postpartum period. The Cronbach α coefficient was used to evaluate the internal consistency. Test-retest reliability was analyzed by Kappa for each item of the questionnaire and by the Wilcoxon parametric test, comparing the total scores of each evaluation. For the assessment of criterion validity, the FSFI was used as the gold standard and the receiver operating characteristic (ROC) curve was constructed. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY, USA). It was found that the internal consistency of the FSFI-6 questionnaire was considerably high (0.839). RESULTS: The test-retest reliability results were satisfactory. It can also be stated that the FSFI-6 questionnaire presented excellent discriminant validity (area under the curve [AUC] = 0.926). Women may be considered as having sexual dysfunction if the overall FSFI-6 score is < 21, with 85.5% sensitivity, 82.2% specificity, positive likelihood ratio of 4.81 and negative likelihood ratio of 0.18. CONCLUSION: We conclude that the Brazilian Portuguese version of FSFI-6 is valid for use in postpartum women.

OBJETIVO: Avaliamos a consistência interna, a confiabilidade teste-reteste e a validade de critério do questionário FSFI-6 para a população brasileira no pós-parto. MéTODOS: Foram aplicados questionários em 100 mulheres sexualmente ativas no pós-parto. O coeficiente alfa de Cronbach foi utilizado para avaliar a consistência interna. A confiabilidade teste-reteste foi analisada pelo Kappa para cada item do questionário e pelo teste paramétrico de Wilcoxon, comparando-se os escores totais de cada avaliação. Para avaliar a validade de critério, o FSFI foi utilizado como padrão-ouro e a curva característica de operação de receptor (ROC, na sigla em inglês) foi construída. As análises estatísticas foram realizadas utilizando-se o software IBM SPSS Statistics for Windows, versão 21.0 (IBM Corp., Armonk, NY, USA). RESULTADOS: Os resultados da confiabilidade teste-reteste foram satisfatórios. O FSFI-6 apresentou uma excelente validade discriminante (área sob a curva [AUC, na sigla em inglês] = 0,926). Considera-se presente a disfunção sexual se o escore geral do FSFI-6 for < 21, com sensibilidade de 85,5%, especificidade de 82,2%, razão de verossimilhança positiva de 4,81 e razão de verossimilhança negativa de 0,18. CONCLUSãO: Concluímos que a versão em português do FSFI-6 se mostrou válida para uso em mulheres no pós-parto.

Analysis of the Measurement Properties of the Female Sexual Function Index 6-item Version (FSFI-6) in a Postpartum Brazilian Population / Análise das propriedades de medição do female sexual function index 6-item version (FSFI-6) em uma população brasileira de pós-parto

Abstract Objective We evaluated internal consistency, test-retest reliability, and criterion validity of the Brazilian Portuguese version of the Female Sexual Function Index 6-item Version (FSFI-6) for postpartum women. Methods Therefore, questionnaires were applied to 100 sexually active women in the postpartum period. The Cronbach α coefficient was used to evaluate the internal consistency. Test-retest reliability was analyzed by Kappa for each item of the questionnaire and by the Wilcoxon parametric test, comparing the total scores of each evaluation. For the assessment of criterion validity, the FSFI was used as the gold standard and the receiver operating characteristic (ROC) curve was constructed. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY, USA). It was found that the internal consistency of the FSFI-6 questionnaire was considerably high (0.839). Results The test-retest reliability results were satisfactory. It can also be stated that the FSFI-6 questionnaire presented excellent discriminant validity (area under the curve [AUC] = 0.926). Women may be considered as having sexual dysfunction if the overall FSFI-6 score is < 21, with 85.5% sensitivity, 82.2% specificity, positive likelihood ratio of 4.81 and negative likelihood ratio of 0.18. Conclusion We conclude that the Brazilian Portuguese version of FSFI-6 is valid for use in postpartum women.

Resumo Objetivo Avaliamos a consistência interna, a confiabilidade teste-reteste e a validade de critério do questionário FSFI-6 para a população brasileira no pós-parto. Métodos Foram aplicados questionários em 100 mulheres sexualmente ativas no pós-parto. O coeficiente alfa de Cronbach foi utilizado para avaliar a consistência interna. A confiabilidade teste-reteste foi analisada pelo Kappa para cada item do questionário e pelo teste paramétrico de Wilcoxon, comparando-se os escores totais de cada avaliação. Para avaliar a validade de critério, o FSFI foi utilizado como padrão-ouro e a curva característica de operação de receptor (ROC, na sigla em inglês) foi construída. As análises estatísticas foram realizadas utilizando-se o software IBM SPSS Statistics for Windows, versão 21.0 (IBM Corp., Armonk, NY, USA). Resultados Os resultados da confiabilidade teste-reteste foram satisfatórios. O FSFI-6 apresentou uma excelente validade discriminante (área sob a curva [AUC, na sigla em inglês] = 0,926). Considera-se presente a disfunção sexual se o escore geral do FSFI-6 for < 21, com sensibilidade de 85,5%, especificidade de 82,2%, razão de verossimilhança positiva de 4,81 e razão de verossimilhança negativa de 0,18. Conclusão Concluímos que a versão em português do FSFI-6 se mostrou válida para uso em mulheres no pós-parto.

The Impact of COVID-19 Pandemic and Social Distancing on Motor Function and Growth of Children with Congenital Zika Syndrome: A Prospective Cohort Study.

This article describes the impact of social distancing during the COVID-19 pandemic on the motor function and growth of children with congenital Zika syndrome (CZS). Children's motor function, weight, height and joint range of movement (ROM) were evaluated before the onset of the pandemic and soon after their return to face-to-face activities at a rehabilitation center. Fifty-two children (Mean 46.07 months, SD 3.76 months) were assessed. Results showed a reduction in proportion of children with adequate body mass index (p = .04), an increase in proportion with adequate height (p < 0.001), deterioration in gross motor function in children with severe motor impairment (p < .01), and a reduction in the maximum ROM for shoulder (p < .01) and wrist flexion (p = .046), elbow (p = .01), knee (p = .03) and ankle extension (p < .01), and an increase in hip flexion (p = .04). The social distancing period appears to have contributed to important losses in motor function and joint mobility of children with CZS; however, this period of time appeared to have less impact on their growth.

Vocalization during the second stage of labor to prevent perineal trauma: A randomized controlled trial.

BACKGROUND AND PURPOSE: Most women suffer some degree of perineal trauma during vaginal delivery. Second stage management strategies, including vocalization, to protect the perineum have been investigated. OBJECTIVE: To compare the frequency and degree of perineal trauma at vaginal delivery, with and without use of the vocalization maneuver during the second stage of labor. MATERIALS AND METHODS: This is an open-label, randomized controlled trial. We conducted the study at the Center for Normal Deliveries of IMIP. We included low-risk women without prior cesarean deliveries. Women who met the inclusion criteria and signed the informed consent form were randomized to one of two groups: Group A (experimental) and Group B (control). A physical therapist encouraged women in Group A to maintain an open glottis during pushing and to emit sounds when exhaling (vocalization). Women in Group B underwent routine humanized vaginal deliveries. The outcomes of the study were perineal integrity and degree of perineal laceration. These were measured by the study team immediately after completion of the third stage of labor. RESULTS: Women in Group A tended to have less severe perineal tear (less second and third degree lacerations) and smaller lacerations than women in group B. The vocalization maneuver reduced the risk of a perineal tear greater than 2 cm by 68% (NNT 2.2). There was no difference in other outcomes. CONCLUSION: Encouraging women to follow a vocalization protocol coached by a physical therapist during the second stage of labor can be a helpful labor assistance technique, since this study showed that vocalization is associated with less extensive perineal tears. CLINICAL TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov (www. CLINICALTRIAL: gov) registration number: NCT03605615.

Urological outcomes in children with congenital Zika syndrome: The experience of a cohort in Campina Grande, Brazil.

OBJECTIVE: To describe the urological outcomes in children with congenital Zika syndrome (CZS) and investigate the relationship between clinical and urological findings in this population. METHODS: This cross-sectional study involved children with CZS followed up by a referral centre for children with microcephaly in the state of Paraiba in northeast Brazil. The urological evaluation included clinical history, urine culture results, ultrasonography of the urinary tract, and urodynamic evaluation, following the protocol proposed by Costa Monteiro et al. (2017). Descriptive statistical analysis was performed in addition to association and correlation tests, considering clinical and urodynamic variables. RESULTS: Among the 88 children with CZS (35.5 ± 5.5 months), 97.7% had microcephaly, and 51% presented urinary tract infection (UTI) confirmed with clinical history and lab tests. The number of confirmed UTI episodes varied from one to 14 per child. The urodynamic evaluation confirmed the presence of an overactive bladder in 78 children and incomplete voiding in 50. Urodynamic findings were associated with the number of confirmed UTI episodes, child's sex, and actual weight, in addition to the use of anticonvulsant and myorelaxant drugs. CONCLUSIONS: UTIs were confirmed in most children. Other urological outcomes observed were overactive bladder and low bladder capacity, which were associated with the number of confirmed UTI episodes, use of anticonvulsants and myorelaxants, and the child's sex and weight. These are treatable conditions, and it is paramount that paediatricians, neonatologists, and infectious disease specialists are aware of them to make clinical decisions and help reduce the risk of renal damage and other morbidities.

Association of sFlt-1 and C-reactive protein with outcomes in severe preeclampsia: A cohort study.

ABSTRACT: To determine the association between soluble FMS-like tyrosine kinase-1 (sFlt-1) and high-sensitivity C-reactive protein (hs-CRP) with maternal and perinatal outcomes in patients with preeclampsia (PE) with severe features.A cohort study was conducted on 100 patients, 60 with PE with severe features, and 40 healthy women in the third trimester of pregnancy. Admission serum levels of sFlt-1 and hs-CRP and clinical and epidemiological parameters were evaluated to quantify the predictive ability of adverse maternal and perinatal outcomes using hierarchical multiple regression and receiver operating characteristic curves.Compared to controls, patients with PE and severe features had significantly higher levels of sFlt-1 but not hs-CRP. sFlt-1 and hs-CRP proved to be reasonable parameters for the prediction of composite adverse maternal outcomes. However, we found no correlation between these 2 biomarkers. PE integrated estimate of risk scores were correlated only with sFlt-1 levels. Regarding fetal outcomes, unlike hs-CRP, sFlt-1 was strongly associated with birth weight and Apgar score < 7 at 5 minutes. Following multivariate analysis, maternal age, previous hypertension, sFlt-1, and hs-CRP levels remained independently associated with composite adverse maternal outcomes.sFlt-1 levels were elevated in patients with PE and severe features. Both sFlt-1 and hs-CRP may predict composite adverse maternal outcomes but do not correlate with each other and differ in perinatal morbidity patterns. These data support the hypothesis that the varied outcomes in PE may result from different pathogenic pathways.

[Prenatal care for normal-risk pregnant women by obstetric nurses and midwives: cost-effectiveness from the perspective of the Supplementary Health System in Brazil]. / Pré-natal de gestantes de risco habitual por enfermeira obstetra e obstetriz: custo-efetividade sob a perspectiva do Sistema de Saúde Suplementar.

In several countries, primary care for pregnant women is performed by obstetric nurses and/or midwives. In Brazil's Supplementary Health System (private health insurance and out-of-pocket care), coverage of prenatal care is mandatory and is performed by medical obstetricians. The objective of this study is to conduct a cost-effectiveness analysis, comparing clinical outcomes and costs associated with the incorporation of prenatal care by obstetric nurses and midwives in the Supplementary Health System, from the perspective of the operator of health plans as the payment source. A decision tree was built, based on data from a Cochrane Collaboration meta-analysis that showed a reduction in the risk of premature birth in the group of normal-risk pregnant women accompanied by obstetric nurses and midwives. The analysis only considered the direct medical costs covered by health plan operators for essential appointments and tests, according to the prevailing Ministry of Health protocol. The study assumed equal unit costs of consultations by medical professionals and applied an increase in the overall cost of prenatal tests associated with medical follow-up, based on data from the literature. Incremental cost-effective ratio was estimated at -BRL 10,038.43 (savings of BRL 10,038.43) per premature birth avoided. This result was consistent with the sensitivity analyses, with savings associated with the substitution ranging from -BRL 2,544.60 to -BRL 31,807.46 per premature death avoided. In conclusion, prenatal care provided by obstetric nurses and midwives was superior to that provided by medical obstetricians for the prevention of premature birth, besides resulting in cost savings.

Em diversos países, a atenção primária às gestantes é conduzida por enfermeiras obstetras e/ou obstetrizes. No Sistema Suplementar de Saúde no Brasil, a cobertura da assistência pré-natal é obrigatória e realizada por médicos obstetras. O objetivo deste estudo é conduzir análise de custo-efetividade, comparando desfechos clínicos e custos associados à incorporação do pré-natal por enfermeiras obstetras e obstetrizes no âmbito do Sistema de Saúde Suplementar, sob a perspectiva da operadora de planos de saúde como fonte pagadora. Foi construída uma árvore de decisão, baseada nos dados de metanálise da Colaboração Cochrane que mostrou redução do risco de parto prematuro no grupo de gestantes de risco habitual acompanhado por enfermeiras obstetras e obstetrizes. Foram considerados apenas os custos médicos diretos cobertos pelas operadoras de planos de saúde para a realização de consultas e exames essenciais, conforme protocolo do Ministério da Saúde vigente. Assumiu-se custo unitário de consulta com cada profissional como iguais e aplicou-se um aumento do custo global com exames pré-natais associado ao acompanhamento médico, conforme dado obtido na literatura. Estimou-se a razão de custo-efetividade incremental de -R$ 10.038,43 (economia de R$ 10.038,43) por parto prematuro evitado. Esse resultado mostrou-se consistente nas análises de sensibilidade, com economias associadas à substituição variando de -R$ 2.544,60 até -R$ 31.807,46 por parto prematuro evitado. Como conclusão, observou-se que o cuidado pré-natal por enfermeiras obstetras e obstetrizes é superior ao prestado por médicos obstetras para o desfecho prevenção de parto prematuro, resultando ainda em economia de recursos.

En diversos países, la atención primaria a las gestantes se realiza con enfermeras obstetras y/o parteras. En el Sistema Suplementario de Salud en Brasil, la cobertura de la asistencia prenatal es obligatoria y la realizan médicos obstetras. El objetivo de este estudio es realizar un análisis de costo-efectividad, comparando resultados clínicos y costes asociados a la incorporación en el período prenatal de enfermeras obstetras y parteras, en el ámbito del Sistema de Salud Suplementaria, desde la perspectiva de una operadora de planes de salud como fuente pagadora. Se construyó un árbol de decisión, basado en datos de metaanálisis de la Colaboración Cochrane, que mostró una reducción del riesgo de parto prematuro en el grupo de gestantes de riesgo habitual, con un seguimiento de enfermeras obstetras y parteras. Se consideraron solo los costes médicos directos, cubiertos por las operadoras de planes de salud para la realización de consultas y exámenes esenciales, conforme el protocolo vigente del Ministerio de Salud. Se asumió el coste unitario de consulta con cada profesional como iguales, y se aplicó un aumento del coste global con exámenes prenatales asociado al seguimiento médico, conforme los datos obtenidos en la literatura. Se estimó la razón de costo-efectividad incremental de -BRL 10.038,43 (economía de BRL 10.038,43) por parto prematuro evitado. Este resultado se mostró consistente en los análisis de sensibilidad, con ahorros asociados a la sustitución, variando de -BRL 2.544,60 hasta -BRL 31.807,46 por parto prematuro evitado. Como conclusión, se observó que el cuidado prenatal por parte de enfermeras obstetras y parteras es superior al prestado por médicos obstetras para el desenlace de prevención de parto prematuro, resultando incluso en un ahorro de recursos.

Factors associated with severe maternal outcomes in patients with eclampsia in an obstetric intensive care unit: A cohort study.

ABSTRACT: To describe the clinical profile, management, maternal outcomes and factors associated with severe maternal outcome (SMO) in patients admitted for eclampsia.A retrospective cohort study was carried out. All women admitted to the Obstetric Intensive Care Unit (ICU) at Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Northeast of Brazil, from April 2012 to December 2019 were considered for inclusion and patients with the diagnosis of eclampsia were selected. Patients who, after reviewing their medical records, did not present a diagnosis of eclampsia were excluded from the study. Severe maternal outcome (SMO) was defined as all cases of near miss maternal mortality (MNM) plus all maternal deaths during the study period. The Risk Ratio (RR) and its 95% confidence interval (95% CI) were calculated as a measure of the relative risk. Multiple logistic regression analysis was performed to control confounding variables. The institute's internal review board and the board waived the need of the informed consent.Among 284 patients with eclampsia admitted during the study period, 67 were classified as SMO (23.6%), 63 of whom had MNM (22.2%) and 5 died (1.8%). In the bivariate analysis, the following factors were associated with SMO: age 19 years or less (RR = 0.57 95% CI 0.37-0.89, P = .012), age 35 years or more (RR = 199 95% CI 1.18-3.34, P = .019), the presence of associated complications such as acute kidney injury (RR = 3.85 95% CI 2.69-5.51, P < .001), HELLP syndrome (RR = 1.81 95% CI 1.20-2.75, P = .005), puerperal hemorrhage (PPH) (RR = 2.15 95% CI 1.36-3.40, P = .003) and acute pulmonary edema (RR = 2.78 95% CI 1.55-4.96, P = .008). After hierarchical multiple logistic regression analysis, the factors that persisted associated with SMO were age less than or equal to 19 years (ORa = 0.46) and having had PPH (ORa = 3.33).Younger age was a protective factor for developing SMO, while those with PPH are more likely to have SMO.

Zika Brazilian Cohorts (ZBC) Consortium: Protocol for an Individual Participant Data Meta-Analysis of Congenital Zika Syndrome after Maternal Exposure during Pregnancy.

Despite great advances in our knowledge of the consequences of Zika virus to human health, many questions remain unanswered, and results are often inconsistent. The small sample size of individual studies has limited inference about the spectrum of congenital Zika manifestations and the prognosis of affected children. The Brazilian Zika Cohorts Consortium addresses these limitations by bringing together and harmonizing epidemiological data from a series of prospective cohort studies of pregnant women with rash and of children with microcephaly and/or other manifestations of congenital Zika. The objective is to estimate the absolute risk of congenital Zika manifestations and to characterize the full spectrum and natural history of the manifestations of congenital Zika in children with and without microcephaly. This protocol describes the assembly of the Consortium and protocol for the Individual Participant Data Meta-analyses (IPD Meta-analyses). The findings will address knowledge gaps and inform public policies related to Zika virus. The large harmonized dataset and joint analyses will facilitate more precise estimates of the absolute risk of congenital Zika manifestations among Zika virus-infected pregnancies and more complete descriptions of its full spectrum, including rare manifestations. It will enable sensitivity analyses using different definitions of exposure and outcomes, and the investigation of the sources of heterogeneity between studies and regions.

Maternal mortality by COVID-19 in Brazil / Mortalidade materna pela COVID-19 no Brasil

Abstract SARS-CoV-2, the new coronavirus of severe acute respiratory syndrome, which causes a predominantly respiratory disease called COVID-19, quickly caused a pandemic, due to its high transmissibility, leaving a trail of deaths around the world. Initially, the pregnancy puerperal cycle was not associated with complications and mortality, only later was recognized as a risk group. As the disease progressed, the maternal mortality rate by COVID-19 increased, Brazil is responsible for an important portion. This rate may be even higher due to underreporting, difficulties in performing laboratorial tests and possible false negative results and depends on the health policies adopted by each region or country. It is important to carry out studies on maternal mortality so that the prognostic factors can be recognized and so avoid them.

Resumo O SARS-CoV-2, novo coronavírus da síndrome respiratória aguda grave, que causa uma doença predominantemente respiratória denominada COVID-19, rapidamente ocasionou pandemia, devido a sua alta transmissibilidade, deixando um rastro de mortes pelo mundo. Inicialmente, o ciclo gravídico puerperal não foi associado a complicações e mortalidade, sendo posteriormente reconhecido como grupo de risco. Com o avançar da doença a taxa de mortalidade materna pela COVID-19 aumentou, sendo o Brasil responsável por uma parcela importante. Essa taxa pode ser ainda maior devido a subnotificação, dificuldades na realização dos exames laboratoriais e possíveis resultados falsos negativos e depende das políticas de saúde adotadas de cada região ou país. É importante a realização de estudos sobre a mortalidade materna para que se possa reconhecer fatores prognósticos e assim evita-las.

General aspects of the COVID-19 pandemic / Aspectos gerais da pandemia de COVID-19

Abstract Objectives: to review the available literature on the general aspects of SARS-CoV-2 infec-tion. Methods: this is a narrative literature review carried out from March to September 2020. Results: COVID-19 caused by the new coronavirus or SARS-CoV-2, grows with devas-tating effects worldwide. The literature describes epidemiological data and mortality risk groups of the disease, which presents a high rate of transmission. Prevention is the most effective way to fight the disease, persisting the absence of strong evidence on the treatment. Vaccines are not yet available. Dexamethasone is effective in reducing mortality in severe forms. Conclusions: despite great efforts, as the number of confirmed cases increases, evidence on transmission, incidence, disease progression, lethality, effects and outcomes remain limited and without any high levels of evidence. Studies are still necessary for all aspects of the disease.

Resumo Objetivos: revisar a literatura disponível sobre os aspectos gerais dainfecção por SARS-CoV-2. Métodos: trata-se de uma revisão narrativa de literatura realizada nos meses de março asetembro de 2020. Resultados: a COVID-19, causada pelo novo coronavírus ou SARS-CoV-2, cresce com efeitos devastadores em todo o mundo. A literetura descreve dados epidemiológicos e sobre grupos de riscos para mortalidade da doença, a qual apresenta uma alta velocidade de trans-missão. A prevenção é a forma mais eficaz de combate à doença, persistindo ausências de fortes evidências sobre o tratamento. Vacinas ainda não estão disponíveis A dexametasona é efetiva para redução da mortalidade nas formas graves. Conclusão: apesar dos grandes esforços, à medida que o número de casos confirmados aumenta, evidências sobre transmissão, incidência, evolução da doença, letalidade, efeitos e os desfechos permanecem limitados e sem grandes níveis de evidência. Estudos ainda são necessários sobre todos os aspectos da doença.