Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care.

OBJECTIVE: To identify cases of severe maternal morbidity (SMM) during pregnancy and childbirth, their characteristics, and to test the feasibility of scaling up World Health Organization criteria for identifying women at risk of a worse outcome. DESIGN: Multicentre cross-sectional study. SETTING: Twenty-seven referral maternity hospitals from all regions of Brazil. POPULATION: Cases of SMM identified among 82 388 delivering women over a 1-year period. METHODS: Prospective surveillance using the World Health Organization's criteria for potentially life-threatening conditions (PLTC) and maternal near-miss (MNM) identified and assessed cases with severe morbidity or death. MAIN OUTCOME MEASURES: Indicators of maternal morbidity and mortality; sociodemographic, clinical and obstetric characteristics; gestational and perinatal outcomes; main causes of morbidity and delays in care. RESULTS: Among 9555 cases of SMM, there were 140 deaths and 770 cases of MNM. The main determining cause of maternal complication was hypertensive disease. Criteria for MNM conditions were more frequent as the severity of the outcome increased, all combined in over 75% of maternal deaths. CONCLUSIONS: This study identified around 9.5% of MNM or death among all cases developing any severe maternal complication. Multicentre studies on surveillance of SMM, with organised collaboration and adequate study protocols can be successfully implemented, even in low-income and middle-income settings, generating important information on maternal health and care to be used to implement appropriate health policies and interventions. TWEETABLE ABSTRACT: Surveillance of severe maternal morbidity was proved to be possible in a hospital network in Brazil.

PP041. The effect of exercise in pregnant women with chronic hypertension and/or previous preeclampsia on blood pressure and heart rate variability.

INTRODUCTION: Hypertensive disorders during pregnancy are an important issue in global public health. Physical activity has been proposed as an important part of hypertension's treatment and has been studied as a possibility for the prevention of PE and its complications. OBJECTIVES: To assess the effect of exercise using stationary bicycle through blood pressure (BP) and heart rate (HR) measurements in pregnant women with CH, previous PE pregnancies or both factors associated. METHODS: This randomized clinical trial (preliminary data) performed at the Women's Hospital Dr. José Aristodemo Pinotti - CAISM/Unicamp, Brazil, enrolled 52 pregnant women presenting with CH, previous PE experience or both. Women from 12 to 20 gestational weeks were selected from the prenatal outpatient clinic and randomly allocated to the study (SG) or non-interventional group (NIG). Women at the SG performed physical exercise using stationary bicycle (horizontal bench model) during 30min, once a week, under a physical therapist supervision. The HR was maintained at 20% above resting heart rate and up to 140 beats per minute. BP and HR measurements were evaluated before and after exercise in sitting position. The NIG followed a regular prenatal routine with weekly returns for HR and BP measurements. The BP (systolic and diastolic) and HR were analyzed comparing groups. The BP measurement was analyzed comparing before and after exercise in the SG. Significance was assumed as p<5%. RESULTS: We had 6 drop-outs in the SG and 5 in the NIG. A total of 41 pregnant women were analyzed (16 in the SG and 25 in the NIG). The mean age was 32years and mean Body Mass Index (BMI) was 34.2±7.0kg/m(2) in the SG and 34.5±8.4kg/m(2) in the NIG (p=0.91). Considering the sociodemographic and clinical characteristics the SG and NIG were similar and homogeneous. No statistical differences were observed between groups on systolic and diastolic BP and HR. However, BP at the end of the study in the interventional group was lower compared to pre-study BP. CONCLUSION: Pregnant women with CH, previous PE or both factors associated who did exercise using stationary bicycle, under supervision, once a week, did not present HR and BP changes in these preliminary data.

The effect of an antenatal physical exercise programme on maternal/perinatal outcomes and quality of life in overweight and obese pregnant women: a randomised clinical trial.

OBJECTIVE: To evaluate the effectiveness and safety of physical exercise in terms of maternal/perinatal outcomes and the perception of quality of life (QoL) in pregnant obese and overweight women. DESIGN: A randomised controlled clinical trial. SETTING: The Prenatal Outpatient Clinic of the Women's Integral Healthcare Centre (CAISM-UNICAMP) at the University of Campinas, Campinas, Brazil. POPULATION: Eighty-two pregnant women (age ≥ 18 years; pre-gestational body mass index ≥ 26 kg/m(2) ; gestational age 14-24 weeks). METHODS: Women were randomised into two groups: women in one group exercised under supervision and received home exercise counselling (the 'study group'; n = 40) and women in the other group followed the routine prenatal care programme (the 'control group'; n = 42). MAIN OUTCOME MEASURES: Primary outcomes were gestational weight gain during the programme and excessive maternal weight gain. Secondary outcomes were increased arterial blood pressure, perinatal outcomes and QoL (WHOQOL-BREF). RESULTS: In the study group, 47% of pregnant women had weight gains above the recommended limit, compared with 57% of women in the control group (P = 0.43). There was no difference in gestational weight gain between the groups. Overweight pregnant women who exercised gained less weight during the entire pregnancy (10.0 ± 1.7 kg versus 16.4 ± 3.9 kg, respectively; P = 0.001) and after entry into the study (5.9 ± 4.3 kg versus 11.9 ± 1.5 kg, respectively; P = 0.021) compared with women in the control group. Arterial blood pressure was similar between the groups over time. There was no difference in perinatal outcome or QoL. CONCLUSIONS: The exercise programme was not associated with control of gestational weight gain in our sample as a whole, but was beneficial for lower gestational weight gain in overweight women. Exercise was not associated with adverse perinatal outcomes and did not affect variation in arterial blood pressure or the perception of QoL.

Hyaluronidase versus Foley catheter for cervical ripening in high-risk term and post term pregnancies.

OBJECTIVE: To evaluate the effectiveness and safety of Foley catheter and hyaluronidase for cervical ripening. METHOD: Randomized controlled trial where 140 pregnant women, with gestational age > or = 37 weeks, indication for labor induction and an unripe cervix, were enrolled, allocated in two groups according to the method of cervical ripening before labor induction. Statistical analysis used Student's t-test, Mann-Whitney, Chi-square test, survival analysis, risk ratios and number needed to treat. RESULTS: Time of induction, dose of oxytocin and mode of delivery had better results in the Foley catheter group. Comfort with the method was higher in the hyaluronidase group. CONCLUSIONS: Both methods were effective and safe for cervical ripening. The Foley catheter group experienced a shorter period of induction, required a lower dose of oxytocin and had higher vaginal delivery rates, while the women who used hyaluronidase declared greater comfort with the method.

Dilatation of the urinary tract during pregnancy: proposal of a curve of maximal caliceal diameter by gestational age.

OBJECTIVE: Dilatation of the urinary tract is common during pregnancy, but the limits between physiologic and pathologic dilatation are unknown. Our purpose was to establish the pattern of physiologic urinary tract dilatation during pregnancy. STUDY DESIGN: This was a cross-sectional study. The maximal caliceal diameter was measured by ultrasonography at different weeks' gestational age in 1506 pregnant and 181 postpartum women. A curve with the 90th, 75th, and 50th percentiles was drawn for each kidney. RESULTS: Fifty-three (6%) pregnant and postpartum women had some degree of dilatation. The right kidney was more frequently and severely affected, as were nulliparous women. The 90th percentile of maximal caliceal diameter of the right kidney increased about 0.5 mm/wk up to 24 to 26 weeks, about 0.3 mm/wk up to 31 to 32 weeks, and remained stable until term. The left maximal caliceal diameter attained 8 mm around week 20 to 24 and remained stable until term. Only 6% had dilatation in the postpartum period. CONCLUSION: A normal curve of dilatation of the urinary tract is proposed.

Anticardiolipin antibody in recurrent spontaneous aborting and fertile women.

OBJECTIVE: To determine the association between the presence of anticardiolipin antibody and a history of recurrent spontaneous abortion. STUDY DESIGN: Clinical controlled study. LOCATION: Department of Gynecology and Obstetrics-University of Campinas (UNICAMP). SUBJECTS: 52 individuals with recurrent spontaneous abortion were included in Group 1 and 104 individuals with at least one live born child in Group 2. Elapsed time from last delivery to blood sampling varied from six months to two years. METHOD: Between November 1993 and November 1994, patients' blood samples were screened for anticardiolipin antibody by ELISA, as described by Triplett, Barna and Unger (1993). ANALYSIS: Chi-square and Fisher's Exact tests were used for statistical analysis. Student's "t" test was used to compare the means. RESULTS: There was no statistical difference in the presence of the anticardiolipin antibody between Group 1 (zero and 2.9%) and Group 2 (7.7 and 5.8%). CONCLUSION: There was no association between the presence of anticardiolipin antibody and recurrent spontaneous abortion.

Pregnancy during adolescence: wanted vs. unwanted.

Pregnancy among adolescents is an important problem in most developing countries. The phenomenon in Brazil seems numerically stable for the age group from 15 to 19 years old, with a trend of increase in the first segment of adolescence, below 15. The majority of pregnancies are unwanted, with medical, psychological and mainly social repercussions. The disadvantages are clearer for multipara adolescents. The main immediate consequences of an unwanted pregnancy are: induced abortion, lack of prenatal care, personal and family disruption, adoption and abandonment. Some intervention policies are suggested for the reduction of this phenomenon through programs of sexual education, services for special care of adolescents, access to orientation and contraceptive methods, and support for the pregnancies to be carried on until term.

Prevalence of HIV and Treponema pallidum infections in pregnant women in Campinas and their association with socio-demographic factors.

The anonymous seroprevalence of HIV and syphilis was studied by collecting umbilical cord blood samples from 5,815 women who gave birth in Campinas' hospitals throughout a six-month period. ELISA and Western blot were used for HIV, and VDRL and TPHA for Treponema pallidum screening. While maintaining the anonymity of the women, information was recorded on the hospital of origin, divided into university (public) and private hospitals, as well as on the form of payment (social security, private insurance or direct payment), age, marital status, education, employment and place of residence. Seroprevalence was 0.42 percent for HIV and 1.16 percent for syphilis. There was a significant correlation between a positive reaction to the two infections (p = 0.02). After univariate and logistic regression analysis, only university hospitals were shown to be associated with seropositivity for HIV, whereas the same variable and an older age were associated with syphilis. All positive reactions were found either in public hospitals or among social security patients treated at private institutions. The conclusion was that HIV infection is becoming almost as prevalent as syphilis among this population, and affects primarily the lower socio-economic strata. This suggests that routine, voluntary HIV serology should be considered and discussed with patients during prenatal or delivery care whenever a population shows a seroprevalence close to or greater than 1 percent.

[Risk factors for uterine cervix condyloma in sexually active adolescent women]. / Fatores de risco para condiloma do colo uterino em mulheres adolescentes sexualmente ativas.

Factors most commonly associated with cervical cancer are early start of sexual activity and papillomavirus infection. PURPOSE--Studying risk factors for cervical condyloma in sexually active adolescents in the region of Campinas, SP, Brazil. METHOD--131 adolescents with condyloma and 131 without disease, controlled by age and pregnancy state, were compared according to social-demographical, sexual-behavioral and gynecological/obstetrical variables. Relative risk evaluation was performed for each variable and multivariate analysis with logistic regression was made to determine confunding factors. RESULTS--Tobacco smoking and nulliparity were identified as independent risk factors for cervical condyloma in this population. More than two sexual partners and low level of schooling were identified as risk factors in the univariate analysis, however, these factors were highly correlated with tobacco smoking and parity, respectively. All other variables were similar in both groups. CONCLUSION--Although tobacco smoking and nulliparity were identified as risk factors for cervical condyloma, it is very difficult to characterize a sexually active adolescent group without risk for infection.

[Biological and social aspects of pregnancy in adolescence]. / Aspectos biologicos e sociais da gravidez na adolescencia.

PIP: The objective of this work was to compare a population of pregnant adolescents with an older group on various biological and social factors, and to relate the findings to earlier published work on the topic. 539 patients aged under 20 years and 1298 aged 20-29 years were studied among 2367 consecutive births at the Maternity Hospital of the State University of Campinas Faculty of Medical Sciences. The prospective study utilized a precoded obstetrical record form. 6 subjects were aged 12-13 years, 17 were 14, 27 were 15, 84 were 16, 98 were 17, 159 were 18, and 148 were 19 yeares old. 399 of the 1298 controls were aged 26-29 years. The average age at menarche of subjects was 12.7 years and of controls, 13.2 years. The average number of pregnancies was 1.5 for adolescents and 3.3 for controls. 62.1% of adolescents but 19.2% of controls were primaparas, although 1 adolescent had 7 pregnancies, 3 each had 5 or 6 and 13 had 4. The average number of previous births was .429 for adolescents and 1.914 for controls. The average number of spontaneous and induced abortions was .1 for adolescents and .3 for controls. No significant difference was reported in the menstrual regularity, incidence or prior morbidity, or average height of the 2 groups. 46.1% of adolescents were not currently married, compared to 25.8% of controls. 15.9% of adolescents and 20.9% of controls had no schooling. 15.4% of adolescents and 37.1% of controls had used contraception before their pregnancies.^ieng

Aspectos biologicos e sociais da gravidez na adolescencia. / Biological and social aspects of pregnancy in adolescence

O estudo compara uma populacao de adolescentes de 539 pacientes com uma populacao de mulheres de 20 a 29 anos, em aspectos pre-concepcionais biologicos e sociais. De carater prospectivo, utiliza um modelo de ficha obstetrica pre-codificada para o recolhimento dos dados, controlando por pariedade algumas das variaveis estudadas.Conclui pelas condicoes sociais desfavoraveis que cercam a gravidez nesta faixa etaria, menarca mais precoce, condicao civil instavel e menor utilizacao de anticoncepcionais

Aspectos pediatricos da gravidez na adolescencia. / Pediatric aspects of pregnancy in adolescence

Destacam-se os aspectos pediatricos da gravidez na adolescencia, comparando um grupo de mulheres de 20 a 29 anos (1.298), com um grupo de adolescentes de ate 19 anos (539), num estudo de carater prospectivo. Estudou-se o peso dos RN, o indice de Apgar, a idade gestacional, a morbidade neonatal, a presenca de malformacoes congenitas e o estado de saude do RN, demonstrando-se que os filhos de maes adolescentes tem um desempenho perinatal semelhante aos de mulheres em idade considerada adequada para dar a luz. Apenas a prematuridade foi mais frequente entre RN de maes adolescentes multiparas

[Risk of sexual hormones administration during pregnancy. Pt 1. Pregnancy hormonal test and oral contraceptives (author's Transl)]. / O risco da administracao de hormonios sexuais na gravidez. Pt 1. Testes hormonais de gravidez e anticonceptivos orais.

PIP: The authors review the published literature on the use of hormonal pregnancy tests, and of the possible consequences on the formation of the fetus. Since it appears that hormonal pregnancy tests have no advantages over immunologic pregnancy tests, the use of the last ones is strongly recommended. The dangers of involuntary use of hormonal contraceptives during the first period of pregnancy are also discussed.^ieng