Indicadores de salud perinatal en una región española entre los años 2015 y 2020 / Perinatal health indicators in a region of Spain corresponding to the period 2015 to 2020

Fundamentos: La disponibilidad en la literatura de datos relacionados con variables perinatales en la población española son muy escasos. El objetivo de este estudio fue conocer la evolución de los indicadores de salud perinatal atendiendo a los grupos de riesgo de prematuridad y de peso al nacimiento, la proporción de parto múltiple, de cesárea y de mortinatos. Métodos: Se realizó un estudio transversal poblacional de los partos en once hospitales de Castilla y León (enero de 2015 a junio de 2020). Hubo 70.024 recién nacidos (RN) procedentes de 68.769 partos. Se utilizó el análisis de regresiónJointpoint para identificar cambios en la tendencia a lo largo de los años, y la regresión logística binomial para ajustar la potencial interacción del tipo de hospital, el sexo, el tipo de parto y el parto múltiple en las frecuencias de prematuridad y de fallecimiento. Resultados: Hubo un descenso de partos del 19,9% y de los múltiples del 42%, sin cambios en los RN prematuros (7,7%) ni en los mortinatos (0,44%). El porcentaje de cesáreas fue del 21,5% con una ligera tendencia temporal descendente. El fallecimiento (mortinato) se asoció al parto múltiple pretérmino; especialmente a la combinación varón-varón (p<0,05). Los RN pretérminos tardíos y términos precoces mostraron mayor riesgo de fallecer frente a los RN a término: OR 7,7 (IC95% 5,6-10,7) y 2,4 (IC95% 1,6-3,6), respectivamente; así como el grupo de bajo peso (OR 17,6; IC95% 13,9-22,2) y el pequeño para la edad gestacional (OR 3,4; IC95% 1,9-5,8), frente a los de peso adecuado. Conclusiones: Previo al desarrollo de la pandemia por COVID-19 existe un descenso de la natalidad, incluidos los partos múltiples, sin cambios en los mortinatos ni en la prematuridad. Los RN pretérminos tardío y términos precoces tienen mayor riesgo de fallecer intraútero.(AU)

Backgorund: The availability in the literature of data related to perinatal variables in the Spanish population is very scarce. The aim of this study was to know the evolution of perinatal health indicators according to the risk groups of prematurity and birth weight, the proportion of multiple births, caesarean section and stillbirths. Methods: We conducted a population-based cross-sectional study of births in eleven hospitals in Castilla y León (January 2015 to June 2020). There were 70,024 newborns from 68,769 deliveries. Jointpoint regression analysis was used to identify changes in trend over the years, and binomial logistic regression was used to adjust for the potential interaction of hospital type, sex, type of delivery and multiple births on the frequencies of prematurity and death. Results: There was a 19.9% decrease in deliveries and a 42% decrease in multiple births, with no change in preterm (7.7%) and stillbirths (0.44%). The percentage of caesarean sections was 21.5% with a slight downward trend over time. Death (stillbirth) was associated with preterm multiple birth; especially with the male-male combination (p<0.05). Late preterm and early term newborns showed higher risk of death compared to term newborns: OR 7.7 (95%CI 5.6-10.7) and 2.4 (95%CI 1.6-3.6), respectively; as well as the low birth weight group (OR 17.6; 95%CI 13.9-22.2) and small for gestational age (OR 3.4; 95%CI 1.9-5.8), compared to those of adequate weight. Conclusions: Prior to the development of the COVID-19 pandemic there is a decline in births, including multiple births, with no change in stillbirths or prematurity. Late preterm and early term newborns are at increased risk of intrauterine death.(AU)

Review: Bovine foetal mortality - risk factors, causes, immune responses and immuno-prophylaxis.

This review of bovine foetal mortality (>42 d gestation) concluded that while the majority of risk factors associated with sporadic loss operate at animal-level, e.g. foetal plurality, those that operate at herd-level, e.g. some foetopathogenic infections, are more likely to result in abortion outbreaks. While the causes of foetal mortality have traditionally been classified as infectious and non-infectious, in fact, the latter category is a diagnosis of exclusion, generally without determination of the non-infectious cause. This review has also established that the traditional dichotomisation of infectious agents into primary and secondary pathogens is based on a flawed premise and these terms should be discontinued. The delicate balance of the maternal gestational immune system between not rejecting the allograft (conceptus) but rejecting (attacking) foetopathogens is stage-of-pregnancy-dependent thus the timing of infection determines the clinical outcome which may result in persistent infection or foetal mortality. Utilisation of our knowledge of the materno-foetal immune responses to foetopathogenic infection has resulted in the development of numerous mono- and polyvalent vaccines for metaphylactic or prophylactic control of bovine foetal mortality. While some of these have been shown to significantly contribute to reducing the risk of both infection and foetal mortality, others have insufficient, or conflicting evidence, on efficacy. However, recent developments in vaccinology, in particular the development of subunit vaccines and those that stimulate local genital tract immunity, show greater promise.

Fetal Mortality: United States, 2021.

Objectives-This report presents 2021 fetal mortality data by maternal race and Hispanic origin, age, tobacco use during pregnancy, and state of residence, as well as by plurality, sex, gestational age, birthweight, and selected causes of death. Trends in fetal mortality are also examined. Methods-Descriptive tabulations of data are presented and interpreted for all fetal deaths reported for the United States for 2021 with a stated or presumed period of gestation of 20 weeks or more. Cause-of-fetal-death data are restricted to residents of the 41 states and the District of Columbia, where cause of death was based on the 2003 fetal death report revision and less than 50% of deaths were attributed to Fetal death of unspecified cause (P95). Results-A total of 21,105 fetal deaths at 20 weeks of gestation or more were reported in the United States in 2021. The 2021 U.S. fetal mortality rate was 5.73 fetal deaths at 20 weeks of gestation or more per 1,000 live births and fetal deaths, which was essentially unchanged from the rate of 5.74 in 2020. The fetal mortality rate in 2021 for deaths occurring at 20-27 weeks of gestation was 2.95, essentially unchanged from 2020 (2.97). For deaths occurring at 28 weeks of gestation or more, the rate in 2021 (2.80) was not significantly different from 2020 (2.78). In 2021, the fetal mortality rate ranged from 3.94 for non-Hispanic, single-race Asian women to 9.89 for non-Hispanic, single-race Black women. Fetal mortality rates were highest for females under age 15 and aged 40 and over, for women who smoked during pregnancy, and for women with multiple gestation pregnancies. Five selected causes accounted for 89.9% of fetal deaths in the 41-state and District of Columbia reporting area.

Prevalence and Mode of Birth in Late Fetal Mortality in Spain, 2016-2019.

(1) Background: The rate of cesarean sections in late fetal mortality remains high. We aimed to determine the prevalence of late fetal mortality in Spain and risk factors for cesarean birth in women with stillbirth ≥ 28 weeks gestation between 2016-2019. (2) Methods: A retrospective observational study with national data between 2016-2019. A total of 3504 births with fetal dead were included. Sociodemographic, obstetrical and neonatal variables were analyzed using univariate and multivariate logistic regression (MLR), with cesarean birth with a stillborn ≥ 28 weeks gestation as the dependent variable. (3) Results: The late fetal mortality rate was 2.8 × 1000; 22.7% of births were by cesarean section. Factors associated with cesarean were having a multiple birth (aOR 6.78); stillbirth weight (aOR 2.41); birth taking place in towns with over 50,000 inhabitants (aOR 1.34); and mother's age ≥ 35 (aOR 1.23). (4) Conclusions: The late fetal mortality rate increased during the period. The performance of cesarean sections was associated with the mother's age, obstetric factors and place of birth. Our findings encourage reflection on how to best put into practice national clinical and socio-educational prevention strategies, as well as the approved protocols on how childbirth should be correctly conducted.

Mortalidade fetal em gestantes com COVID-19 e outros desfechos materno-fetais: uma revisão integrativa da literatura / Fetal mortality in pregnant women with COVID-19 and other maternal-fetal outcomes: an integrative literature review

Objetivo: Analisar os resultados apresentados sobre a relação entre COVID-19 e gravidez, com foco no desfecho fetal. Fontes dos dados: Foi realizada a busca de artigos publicados entre 1 de janeiro de 2020 e 1 de junho de 2021 nas bases de dados PubMed, Embase e Cochrane, utilizando os seguintes descritores: "coronavirus infections", "coronavirus disease 2019", "COVID-19", "fetal mortality" e "fetus mortality". Seleção dos estudos: Foram encontrados 99 artigos, sendo selecionados 28 artigos para leitura completa por meio dos critérios de inclusão e exclusão. Ao final, 14 artigos foram escolhidos para serem incluídos na presente revisão. Coleta de dados: Para a extração dos dados dos artigos selecionados, utilizou-se o instrumento validado por Ursi (2005), modificado para se adequar à demanda do tema em questão. Síntese dos dados: Encontrou-se que a infecção por COVID-19 aumentou a morbimortalidade das gestantes, principalmente aquelas que já possuíam algum fator de risco para a doença grave. Além disso, a maioria dos estudos mostrou uma taxa aumentada de nascimentos prematuros entre os filhos de mães infectadas. Não foram demonstrados resultados consistentes de aumento nas taxas de aborto, mortalidade fetal ou transmissão vertical. Conclusão: Ações de saúde devem priorizar o cuidado materno-fetal com o objetivo de prevenir a doença nas gestantes e acompanhar de forma mais cuidadosa aquelas infectadas pelo vírus, de forma a prevenir a morbimortalidade materna e a prematuridade, que são importantes marcadores de saúde pública.(AU)

Objective: To analyze the results presented on the relationship between COVID-19 and pregnancy, focusing on fetal outcome. Data sources: We searched for articles published between January 1, 2020 and June 1, 2021 in PubMed, Embase and Cochrane databases, using the following descriptors: "coronavirus infections", "coronavirus disease 2019", "COVID-19", "fetal mortality" and "fetus mortality". Selection of studies: 99 articles were found, and 28 articles were selected for full reading through inclusion and exclusion criteria. In the end, 14 articles were chosen to be included in this review. Data collection: To extract data from selected articles, the instrument validated by Ursi (2005) was used, modified to suit the demand of the topic in question. Data synthesis: It was found that COVID-19 infection increased the morbidity and mortality of pregnant women, especially those who already had some risk factor for severe disease. In addition, most studies have shown an increased rate of preterm births among children of infected mothers. No consistent results of increased rates of miscarriage, fetal mortality or mother-to-child transmission have been demonstrated. Conclusion: Health actions should prioritize maternal- fetal care in order to prevent the disease in pregnant women and more carefully monitor those infected with the virus, in order to prevent maternal morbidity and mortality and prematurity, which are important public health markers.(AU)

Percepção sobre o cuidado à perda gestacional: estudo qualitativo com casais brasileiros / Perceptions on pregnancy loss care: a qualitative study with brazilian couples / Percepción sobre la atención a la pérdida del embarazo: estudio cualitativo con parejas brasileñas

Este artigo analisou a percepção e os sentimentos de casais sobre o atendimento recebido nos serviços de saúde acessados em função de perda gestacional (óbito fetal ante e intraparto). O convite para a pesquisa foi divulgado em mídias sociais (Instagram e Facebook). Dos 66 casais que contataram a equipe, 12 participaram do estudo, cuja coleta de dados ocorreu em 2018. Os casais responderam conjuntamente a uma ficha de dados sociodemográficos e uma entrevista semiestruturada, realizada presencialmente (n=4) ou por videochamada (n=8). Os dados foram gravados em áudio e posteriormente transcritos. A Análise Temática indutiva das entrevistas identificou cinco temas: sentimento de impotência, iatrogenia vivida nos serviços, falta de cuidado em saúde mental, não reconhecimento da perda como evento com consequências emocionais negativas, e características do bom atendimento. Os achados demonstraram situações de violência, comunicação deficitária, desvalorização das perdas precoces, falta de suporte para contato com o bebê falecido e rotinas pouco humanizadas, especialmente durante a internação após a perda. Para aprimorar a assistência às famílias enlutadas, sugere-se qualificação profissional, ampliação da visibilidade do tema entre diferentes atores e reorganização dos serviços, considerando uma diretriz clínica para atenção ao luto perinatal, com destaque para o fortalecimento da inserção de equipes de saúde mental no contexto hospitalar.(AU)

This study analyzed couples' perceptions and feelings about pregnancy loss care (ante and intrapartum fetal death). A research invitation was published on social media (Instagram and Facebook) and data collection took place in 2018. Of the 66 couples who contacted the research team, 12 participated in the study by filling a sociodemographic questionnaire and answering a semi-structured interview in person (n=04) or by video call (n=08). All interviews were audio recorded, transcribed, and examined by Inductive Thematic Analysis, which identified five themes: feelings of impotence, iatrogenic experiences in health services, lack of mental health care, not recognizing pregnancy loss as an emotionally overwhelming event, and aspects of good healthcare. Analysis showed experiences of violence, poor communication, devaluation of early losses, lack of support for contact with the deceased baby, and dehumanizing routines, especially during hospitalization after loss. Professional qualification, extended pregnancy loss visibility among different stakeholders, and reorganization of health services are needed to improve the care offered to grieving families, considering a clinical guideline for perinatal grief care with emphasis on strengthening the insertion of mental health teams in the hospital context.(AU)

Este estudio analizó las percepciones y sentimientos de parejas sobre la atención recibida en los servicios de salud a los que accedieron debido a la pérdida del embarazo (muerte fetal ante e intraparto). La invitación al estudio se publicó en las redes sociales (Instagram y Facebook). De las 66 parejas que se contactaron con el equipo, 12 participaron en el estudio, cuya recolección de datos se realizó en 2018. Las parejas respondieron un formulario de datos sociodemográficos y realizaron una entrevista semiestructurada presencialmente (n=4) o por videollamada (n=08). Los datos se grabaron en audio para su posterior transcripción. El análisis temático inductivo identificó cinco temas: Sentimiento de impotencia, experiencias iatrogénicas en los servicios, falta de atención a la salud mental, falta de reconocimiento de la pérdida como un evento con consecuencias emocionales negativas y características de buena atención. Los hallazgos evidenciaron situaciones de violencia, comunicación deficiente, desvalorización de las pérdidas tempranas, falta de apoyo para el contacto con el bebé fallecido y rutinas poco humanizadas, especialmente durante la hospitalización tras la pérdida. Para mejorar la atención a las familias en duelo, se sugiere capacitación profesional, ampliación de la visibilidad del tema entre los diferentes actores y reorganización de los servicios, teniendo en cuenta una guía clínica para la atención del duelo perinatal, enfocada en fortalecer la inserción de los equipos de salud mental en el contexto hospitalario.(AU)

Mort in utero tardive: fréquence, facteurs associés et méthodes de déclenchement du travail à Kisangani, République Démocratique du Congo / Late fetal death: frequency, associated factors and methods of labor induction in Kisangani, Democratic Republic of Congo

La mort fœtale tardive fait référence à la mort in utéro (MIU) de survenue spontanée à partir de 22 semaines d'aménorrhée (SA), mais avant tout début du travail d'accouchement, ce qui constitue une tragédie pour la mère, les membres de la famille et du personnel soignant. La présente étude a déterminé l'ampleur, les facteurs associés et les méthodes de déclenchement artificiel du travail d'accouchement sur MIU. Méthodes : Il s'est agi d'une étude transversale descriptive, multicentrique menée dans 3 hôpitaux de Kisangani, pendant une période de 3 ans. La collecte des données était rétrospective, des cas de MIU à partir de 28 SA. Résultats : La fréquence de MIU tardive était de 6,48%. Les principaux facteurs associés étaient l'infection urinaire (35,4%), le paludisme sur grossesse (27,5%) et l'hypertension artérielle gravidique (27,5%). Le taux de participation aux consultations prénatales (CPN) n'était que de 63,5 %. Les méthodes de déclenchement artificiel du travail d'accouchement utilisées étaient le Misoprostol (42,7%), l'ocytocine (17,7%) soit les deux combinées (25%). La césarienne était indiquée à un taux de 26,4%. Conclusion : la fréquence de MIU tardive est élevée à Kisangani. L'infection urinaire, le paludisme et l'hypertension artérielle en constituaient les principaux facteurs associés. Le Misoprostol était la méthode de déclenchement du travail les plus utilisées. Un suivi régulier des CPN pourrait réduire le taux de MIU.

Boletim epidemiológico do estado do Rio Grande do Sul: mortalidade materna, infantil e fetal / Epidemiological bulletin for the state of Rio Grande do Sul: maternal, infant and fetal mortality

Estudo epidemiológico sobre as taxas de mortalidade materna, infantil e fetal no estado do Rio Grande do Sul. Apresenta estratégias e ações para qualificação dos serviços preventivos de saúde. (AU)

Violência sexual e aborto legal: possibilidades e desafios da atuação psicológica / Sexual offence and legal abortion: opportunities and challenges from psychological working / Violencia sexual y aborto legal: posibilidades y desafíos de la atención psicológica

A violência sexual e o aborto legal são temas tabus em nossa sociedade. No campo da saúde, a(o) psicóloga(o) atua em fases distintas, seja na avaliação psicológica do pedido pelo aborto legal, que culminará ou não em sua aquiescência; seja no momento posterior à solicitação, no atendimento em enfermarias ou ambulatorial. Partindo de relato de experiência, este artigo tem como objetivo refletir sobre as possibilidades e desafios da atuação psicológica no atendimento em saúde para pessoas em situação de gestação decorrente de violência sexual e que buscam pelo aborto legal. Para tanto, dividimos o artigo em três momentos. No primeiro deles, será possível encontrar dados conceituais, estatísticos e históricos sobre ambos os temas, trazendo recortes nacionais e internacionais. No segundo, trazemos apontamentos sobre o que chamamos de "eixos norteadores", ou seja, dialogamos com aspectos fundamentais para o trabalho nesta seara, sendo eles gênero, família, sexualidade e trauma. Por fim, no terceiro, aprofundamos a reflexão sobre o atendimento psicológico atrelado aos conceitos já discutidos, analisando de forma crítica principalmente um dos pontos mais espinhosos da atuação: a avaliação para aprovação (ou recusa) do pedido pelo aborto. Apoiamo-nos no referencial psicanalítico e defendemos que esta atuação psicológica é primordialmente uma oferta de cuidado, comprometido com as demandas das pessoas atendidas e com a promoção de saúde mental, e consideramos que o papel da psicologia é essencial para o reconhecimento do sofrimento e dos efeitos do abandono socioinstitucional na vida do público atendido.(AU)

Sexual abuse and legal abortion are taboo subjects in our society. On the health area, the psychologist works on different fields, such as psychological evaluation from the request of legal abortion, that will end or not on its approval, and also in a further moment, either the care on wards or ambulatorial treatment. Relying on a case report, this article aims to contemplate the possibilities and challenges from psychological work on healthcare to pregnant women from sexual violence and seek legal abortion. For this purpose, we divide this article in three moments. On the first, it will find definitions, statistics, and historical data about both issues, including national and international information. On the second, we bring notes called 'guiding pillar,' that is, we interact with fundamental aspects from this area, such as gender, family, sexuality, and trauma. On the third one, in-depth discussions we dwell on psychological care tied to the concepts previously addressed, critically analyzing one of the hardest moments of working in this area: the evaluation to approve (or refuse) the request for abortion. We lean over psychoanalytic thoughts and argue that this psychological work is primarily an offer of care, committed to the needs from those who seek us and to promoting good mental health and, also, we consider that psychology is essential to acknowledge the suffering and the effects of social and institutional neglect on the lives of the people seen.(AU)

La violencia sexual y el aborto son temas tabús en nuestra sociedad. En el campo de la salud, el(la) psicólogo(a) actúa en diferentes fases: en la evaluación psicológica de la solicitud del aborto legal, que culminará o no en su obtención, y/o en el momento posterior a la solicitud en la atención en enfermería o ambulatorio. Desde un reporte de experiencia, este artículo pretende reflexionar sobre las posibilidades y los desafíos de la Psicología en la atención en salud para personas en estado de embarazo producto de violencia sexual y que buscan un aborto legal. Para ello, este artículo está dividido en tres momentos. En el primer, presenta datos conceptuales, estadísticos e históricos sobre los dos temas, trayendo recortes nacionales e internacionales. En el segundo, comenta los llamados "ejes temáticos", es decir, se establece un diálogo con aspectos fundamentales para el trabajo en este ámbito, como género, familia, sexualidad y trauma. Por último, en el tercer, profundiza en la reflexión sobre la atención psicológica asociada a los conceptos discutidos, analizando de forma crítica uno de los puntos más espinosos de la actuación: la evaluación para la aprobación (o negativa) de la solicitud de aborto. Se utilizó el referencial psicoanalítico y se argumenta que esta atención psicológica es sobre todo una forma de cuidado, comprometida con las demandas de las personas atendidas y la promoción de la salud mental, y el papel de la Psicología es esencial para reconocer el sufrimiento y los efectos del abandono socioinstitucional en la vida del público atendido.(AU)

Assessment of healthcare accessibility and travel distance on intrapartum fetal death: a retrospective cohort study / Relación de la accesibilidad de la atención de salud y la distancia de desplazamiento con la muerte fetal durante el parto: un estudio de cohorte retrospectivo / Avaliação do impacto do acesso ao sistema de saúde e da distância percorrida na morte fetal intraparto: estudo retrospectivo de coorte

[ABSTRACT]. Objective. To determine if there was an association between intrapartum stillbirths and both traveled distance for delivery and delivery care accessibility, assessing periods before and during the COVID-19 pandemic. Methods. This is a population-based cohort study. Patients had birth occurring after the onset of labor; the primary outcome was intrapartum stillbirth. City of residence was classified according to the ratio between deliveries performed and total births among its residents; values lower than 0.1 indicated low delivery care accessibility. Travel distance was calculated using the Haversine formula. Education level, maternal age, and birth sex were included. In each period, relative risk was assessed by generalized linear model with Poisson variance. Results. There were 2 267 534 deliveries with birth occurring after the onset of labor. Most patients were between age 20 and 35 years, had between 8 and 11 years of education, and resided in cities with high delivery care accessibility. Low delivery care accessibility increased risk of intrapartum stillbirth in the pre-pandemic (relative risk [RR] 2.02; 95% CI [1.64, 2.47]; p < 0.01) and the pandemic period (RR 1.69; 95% CI [1.09, 2.55]; p = 0.015). This was independent of other risk-increasing factors, such as travel distance and fewer years of education. Conclusions. Low delivery care accessibility is associated with the risk of intrapartum stillbirths, and accessibility reduced during the pandemic. Delivery of patients by family physicians and midwives, as well as official communication channels between primary care physicians and specialists, could improve patient health- care-seeking behavior.

[RESUMEN]. Objetivo. Determinar si hubo una asociación entre la mortinatalidad durante el parto y la distancia recorrida o la accesibilidad de la atención para el parto, mediante la evaluación de un período anterior y de otro coin- cidente con la pandemia de COVID-19. Métodos. Se realizó un estudio de cohorte de base poblacional. Se incluyó a las pacientes que dieron a luz tras el inicio de un trabajo de parto; el criterio de valoración principal fue la mortinatalidad durante el parto. Se clasificaron las ciudades de residencia conforme al cociente entre el número de partos atendidos y el total de partos habidos entre sus residentes; los valores inferiores a 0,1 indican que la accesibilidad de la atención del parto es baja. La distancia recorrida para el parto se calculó utilizando la fórmula de Haversine. Se utilizaron datos del nivel de estudios y la edad de la madre y del sexo biológico neonatal. Para cada período, se evaluó el riesgo relativo mediante un modelo lineal generalizado con varianza de Poisson. Resultados. Hubo 2 267 534 partos que se produjeron tras el inicio de un trabajo de parto. La mayoría de las pacientes tenían edades comprendidas entre 20 y 35 años, tenían entre 8 y 11 años de estudios y residían en ciudades donde la accesibilidad de la atención del parto era alta. Una accesibilidad baja de la atención del parto se asoció a un aumento del riesgo de mortinatalidad durante el parto en el período prepandémico (riesgo relativo [RR] = 2,02; IC del 95% = [1,64, 2,47]; p < 0,01) y también durante la pandemia (RR = 1,69; IC del 95% = [1.09, 2.55]; p = 0,015). Este resultado fuer independiente de otros factores que incrementan el riesgo, como la distancia recorrida para dar a luz y un menor nivel de estudios. Conclusiones. Una accesibilidad baja de la atención del parto se asocia a un mayor riesgo de mortinatalidad durante el parto; y se observó una reducción de la accesibilidad durante la pandemia. Los partos asistidos por personal de medicina de familia o de partería y los canales de comunicación oficiales entre el personal médico de atención primaria y el especializado podrían mejorar el comportamiento de las pacientes a la hora de buscar atención de salud.

[RESUMO]. Objetivo. Determinar se existe alguma relação entre a morte fetal intraparto e dois fatores: a distância percorrida para o parto e o acesso à assistência ao parto, avaliando o período antes e durante a pandemia de COVID-19. Métodos. Este é um estudo de coorte de base populacional. As pacientes tiveram parto após o início do trabalho de parto; o desfecho primário foi morte fetal intraparto. A cidade de residência foi classificada de acordo com a razão entre os partos realizados e o total de nascimentos entre os residentes; valores inferiores a 0,1 indicavam baixo acesso à assistência ao parto. A distância percorrida foi calculada usando a fórmula de Haversine. Foram incluídos o nível de escolaridade, a idade materna e o sexo de nascimento. Em cada período, o risco relativo foi avaliado usando um modelo linear generalizado com variância de Poisson. Resultados. Foram registrados 2 267 534 partos com nascimento após o início do trabalho de parto. A maioria das pacientes tinha entre 20 e 35 anos de idade, entre 8 e 11 anos de escolaridade e residia em cidades com alto nível de acesso à assistência ao parto. O baixo acesso à assistência ao parto aumentou o risco de morte fetal intraparto no período anterior à pandemia (risco relativo [RR]: 2,02; intervalo de confiança [IC] de 95%: 1,64–2,47; p < 0,01) e durante a pandemia (RR: 1,69; IC 95%: 1,09–2,55; p = 0,015). Isso ocorreu independentemente de outros fatores de aumento de risco, como a distância percorrida e menor escolaridade. Conclusões. O baixo acesso ao atendimento de parto está associado ao risco de morte fetal intraparto, e a acessibilidade diminuiu durante a pandemia. A realização do parto por médicos de família e obstetrizes, bem como a existência de canais oficiais de comunicação entre médicos de atenção primária e especialistas, poderiam melhorar o comportamento de busca de saúde por parte das pacientes.

Unveiling the evolution of fetal death in pregnancy in different cultures / Desvelando em diferentes culturas a evolução da gestação em óbito fetal

Abstract Objectives: to describe the identification of fetal death during pregnancy in Brazilian and Canadian women. Methods: clinical-qualitative study with women who experienced the outcome of fetal death in their pregnancies, living in Maringá (Brazil) and participating in the Center d'intervention familiale (Canada). Data collection was performed through a semi-structured interview with the question: How did you find out about your baby's death? Readings were performed and the relevant aspects were categorized into themes according to the places where the death was confirmed. Results: in both countries, the main causes of death were the same, related to complications in pregnancy and childbirth, and health problems of the pregnant woman or fetus. Brazilian women had a higher frequency of deaths in the third trimester and Canadian women experienceda majority of deaths in the second trimester. The stillbirthswere found in different places, times and moments categorized at prenatal routine consultation, emergency care, expected death from congenital malformations of poor prognosis and labor. Conclusions: the determination of fetal death during pregnancy was due to possible intrinsic intercurrences of the pregnancy period. Based on the women's experiences, it was possible to demonstrate the clinical practice of identifying fetal death according to the cultural scenario. Continuous studies on prenatal care for women who had stillbirths are necessary for early detection of pathological conditions and appropriate interventions.

Resumo Objetivos: descrever a identificação do óbito fetal durante a gestação em brasileiras e canadenses. Métodos: estudo clínico-qualitativo com mulheres que vivenciaram o desfecho do óbito fetal nas suas gestações, residentes em Maringá (Brasil) e participantes do Centre d'Intervention Familiale (Canadá). A coleta de dados foi realizada por meio de entrevista semidirigida com a pergunta: Como ficou sabendo da morte do seu bebê? Foram realizadas leituras e os aspectos relevantes foram categorizados em temas conforme os locais da confirmação do óbito. Resultados: nos dois países, as principais causas dos óbitos foram relacionadas às complicações na gravidez e parto, problemas de saúde da gestante ou do feto. As brasileiras com frequência maior dos óbitos no terceiro trimestre e as canadenses, no segundo trimestre. As categorias foram identificadas nos consultórios na rotina pré-natal, nos serviços de emergência, e nos serviços de imagem, ao detectar o óbito esperado nos casos de malformações congênitas de prognóstico ruim. Conclusão: a determinação óbito fetal durante a gestação foi em razão das possíveis intercorrências intrínsecas do período gravídico. A partir das experiências das mulheres, foi possível mostrar a prática clínica da identificação do óbito fetal de acordo com o cenário cultural. Contínuos estudos, sobre a assistência pré-natal das mulheres que tiveram óbito fetal, são necessários para detecção precoce das condições patológicas e intervenções adequadas.

Refreshing the Perinatal Periods of Risk: A New Reference Group and Nationwide Large-County-Level Analyses.

INTRODUCTION: The Perinatal Periods of Risk approach (PPOR) is designed for use by communities to assess and address the causes of high fetal-infant mortality rates using vital records data. The approach is widely used by local health departments and their community and academic partners to inform and motivate systems changes. PPOR was developed and tested in communities based on data years from 1995 to 2002. Unfortunately, a national reference group has not been published since then, primarily due to fetal death data quality limitations. METHODS: This paper assesses data quality and creates a set of unbiased national reference groups using 2014-2016 national vital records data. Phase 1 and Phase 2 analytic methods were used to divide excess mortality into six components and create percentile plots to summarize the distribution of 100 large US counties for each component. RESULTS: Eight states with poor fetal death data quality were omitted from the reference groups to reduce bias due to missing maternal demographic information. There are large Black-White disparities among reference groups with the same age and education restrictions, and these vary by component. PPOR results vary by region, maternal demographics, and county. The magnitude of excess mortality components varies widely across US counties. DISCUSSION: New national reference groups will allow more communities to do PPOR. Percentile plots of 100 large US counties provide an additional benchmark for new communities using PPOR and help emphasize problem areas and potential solutions.

Fetal Mortality: United States, 2020.

Objectives-This report presents 2020 fetal mortality data by maternal race and Hispanic origin, age, tobacco use during pregnancy, and state of residence, as well as by plurality, sex, gestational age, birthweight, and selected causes of death. Trends in fetal mortality are also examined.

Características ecográficas y anomalías congénitas en fetos con síndrome de Down / Ultrasound features and congenital anomalies in fetuses with Down syndrome

Resumen Objetivo: Describir y analizar los hallazgos ecográficos en 97 fetos portadores de síndrome de Down (SD) confirmado. Método: Se incluyeron todas las gestantes con diagnóstico prenatal de SD de nuestro centro, realizado por cariograma o reacción en cadena de la polimerasa cuantitativa fluorescente para aneuploidía. Se analizaron los informes genéticos y ecográficos, y se realizó un seguimiento posnatal. Resultados: De los 97 casos de SD, el 73% de los diagnósticos fueron entre las 11 y 14 semanas. El promedio de edad de las madres fue de 35,7 años. El 83% de los fetos con SD, evaluados a las 11-14 semanas, tuvieron una translucencia nucal ≥ 3,5 mm. Del total de los casos analizados, el 33% fueron portadores de una cardiopatía congénita, correspondiendo el 58% de estas a defectos mayores, principalmente anomalías del tabique auriculoventricular. Un 7,6% de los casos terminaron como mortinato, principalmente durante el tercer trimestre. Conclusiones: El ultrasonido es una herramienta muy sensible para la sospecha prenatal de SD y la detección de sus anomalías asociadas. Consideramos que la información aportada será útil para programar estrategias de pesquisa, organizar el control perinatal y precisar el consejo a los padres de fetos portadores de esta condición.

Abstract Objective: To describe and analyze the ultrasound findings in 97 fetuses with confirmed Down syndrome (DS). Method: All pregnant women with prenatal diagnosis of DS in our center, performed by karyotype or quantitative fluorescent polymerase chain reaction for aneuploidy, were included. Genetic and ultrasound reports were analyzed, as well as postnatal follow-up. Results: Of the 97 cases of DS, 73% of the diagnoses were between 11-14 weeks. The average age of the mothers was 35.7 years. 83% of our fetuses with DS, evaluated between 11-14 weeks, had a nuchal translucency ≥ 3.5 mm. Of the total of the fetuses analyzed, 33% were carriers of congenital heart disease, 58% of these correspond to a major defect, mainly anomalies of the atrioventricular septum. 7.6% of cases ended as stillbirth, mainly during the third trimester. Conclusions: Ultrasound is a very sensitive tool for prenatal suspicion of DS and the detection of its associated abnormalities. We believe that the information provided will be useful to program screening strategies, organize perinatal control and to counselling parents of fetuses carrying this condition.

El adiós más difícil de decir: Pérdida gestacional / The Hardest Goodbye to Say: Gestational Loss

La muerte fetal es una de las instancias más complejas de atravesar para una persona gestante. Lo es también para los equipos de salud que intervienen en se momento. Uno de los capítulos de la serie New Amsterdam aborda este tema, invisibilizado, no autorizado y silenciado que interpela a los/as profesionales de salud: la pérdida gestacional. Varios interrogantes se abren .Qué les sucede a esas mujeres que deben ser sometidas a procedimientos médicos luego de enterarse del fallecimiento de su hijo/a? ¿Cuál es el impacto en su subjetividad? ¿Cómo les afecta a los/as profesionales de salud estas pérdidas? ¿Cómo intervenir ante el duelo? ¿Cuál es el rol de los y las profesionales de la salud mental en estos casos. ¿Qué se puede decir cuando no hay palabras?

Fetal death is one of the most complex instances to go through for a pregnant person, it is also for the health teams involved at the time. One of the chapters of the New Amsterdam series addresses this issue, invisible, unauthorized and silenced that gestational loss.Several questions arise: What happens to thosez women who must undergo medical procedures after learning of the death of their child? What is the impact on their subjectivity? How do these losses affect health professionals? How to intervene in the duel? What is the role of mental health professionals in these cases? What can you say when there are no words?

Boletín epidemiológico 22 - 2022. Semana epidemiológica del 29 de mayo al 4 de junio del 2022 / Epidemiological bulletin 22 - 2022. Epidemiological week from May 29 to June 4, 2022

La defunción del feto y el neonato son eventos altamente frecuentes, trágicos y evitables. Esta situación no tuvo suficiente relevancia entre los años 2000 y 2015, periodo en el cual los países desplegaron diversas estrategias para la reducción de la mortalidad infantil y materna. Las metas 4 y 5 de los Objetivos de Desarrollo del Milenio (ODM) promovieron la reducción de la muerte en menores de 5 años y menores de 1 año, pero no se establecieron metas para disminuir la mortalidad de los recién nacidos y fetos. La reducción de estos eventos ha sido lenta y sobre todo la mortalidad fetal pareciera estar desatendida en la salud pública

Timing of cardiac surgery during pregnancy: a patient-level meta-analysis.

AIMS: To investigate the association between the timing of cardiac surgery during pregnancy and both maternal and foetal outcomes. METHODS AND RESULTS: Studies published up to 6 February 2021 on maternal and/or foetal mortality after cardiac surgery during pregnancy that included individual patient data were identified. Maternal and foetal mortality was analysed per trimester for the total population and stratified for patients who underwent caesarean section (CS) prior to cardiac surgery (Caesarean section (CaeSe) group) vs. patients who did not (Cardiac surgery (CarSu) group). Multivariable logistic regression analysis was performed to evaluate predictors of both maternal and foetal mortality. In total, 179 studies were identified including 386 patients of which 120 underwent CS prior to cardiac surgery. Maternal mortality was 7.3% and did not differ significantly among trimesters of pregnancy (P = 0.292) nor between subgroup CaeSe and CarSu (P = 0.671). Overall foetal mortality was 26.5% and was lowest when cardiac surgery was performed during the third trimester (10.3%, P < 0.01). CS prior to surgery was significantly associated with a reduced risk of foetal mortality in a multivariable model [odds ratio 0.19, 95% confidence interval [0.06-0.56)]. Trimester was not identified as an independent predictor for foetal nor maternal mortality. CONCLUSION: Maternal mortality after cardiac surgery during pregnancy is not associated with the trimester of pregnancy. Cardiac surgery is associated with high foetal mortality but is significantly lower in women where CS is performed prior to cardiac surgery. When the foetus is viable, CS prior to cardiac surgery might be safe. When CS is not feasible, trimester stage does not seem to influence foetal mortality.

Preeclampsia and eclampsia: the conceptual evolution of a syndrome.

Preeclampsia, one of the most enigmatic complications of pregnancy, is considered a pregnancy-specific disorder caused by the placenta and cured only by delivery. This article traces the condition from its origins-once thought to be a disease of the central nervous system, recognized by the occurrence of seizures (ie, eclampsia)-to the present time when preeclampsia is conceptualized primarily as a vascular disorder. We review the epidemiologic data that led to the recommendation to use diastolic hypertension and proteinuria as diagnostic criteria, as their combined presence was associated with an increased risk of fetal death and the birth of small-for-gestational-age neonates. However, preeclampsia is a multisystemic disorder with protean manifestations, and the condition can be present even in the absence of hypertension and proteinuria. Toxins gaining access to the maternal circulation have been proposed to mediate the clinical manifestations-hence, the term "toxemia of pregnancy," which was used for several decades. The search for putative toxins has challenged investigators for more than a century, and a growing body of evidence suggests that products of an ischemic or a stressed placenta are responsible for the vascular changes that characterize this syndrome. The discovery that the placenta can produce antiangiogenic factors, which regulate endothelial cell function and induce intravascular inflammation, has been a major step forward in the understanding of preeclampsia. We view the release of antiangiogenic factors by the placenta as an adaptive response to improve uterine perfusion by modulating endothelial function and maternal cardiovascular performance. However, this homeostatic response can become maladaptive and lead to damage of target organs during pregnancy or the postpartum period. Early-onset preeclampsia has many features in common with atherosclerosis, whereas late-onset preeclampsia seems to result from a mismatch of fetal demands and maternal supply, that is, a metabolic crisis. Preeclampsia, as it is understood today, is essentially vascular dysfunction unmasked or caused by pregnancy. A subset of patients diagnosed with preeclampsia are at greater risk of the subsequent development of hypertension, ischemic heart disease, heart failure, vascular dementia, and end-stage renal disease. However, these adverse events may be the result of a preexisting vascular pathologic process; it is not known if the occurrence of preeclampsia increases the baseline risk. Therefore, the understanding, prediction, prevention, and treatment of preeclampsia are healthcare priorities.

Does the use of Doppler ultrasound reduce fetal mortality? A population study of all deliveries in Norway 1990-2014.

BACKGROUND: The aim of the present study was to examine the effect that the introduction of Doppler ultrasound in obstetric care has had on fetal death in Norway. One mechanism by which Doppler ultrasound may reduce fetal death may be through the increased use of Caesarean delivery. Therefore, we also examined the effect that the use of Doppler ultrasound has had on the use of Caesarean delivery. METHODS: The Medical Birth Registry of Norway provided detailed medical information for ∼1.2 million deliveries from 1990 to 2014. Information about the year of introduction of Doppler ultrasound was collected directly from the maternity units, using a questionnaire. The data were analysed using a hospital fixed-effects regression model with fetal death as the outcome measure. The key independent variable was the introduction of Doppler ultrasound at each maternity ward. Hospital-specific trends and risk factors of the mother for fetal death were included as covariates. RESULTS: For pre-term deliveries, the introduction of Doppler ultrasound contributed to a reduction in fetal death of ∼30% and to an increase in planned Caesarean section of ∼15%. There were no effects for emergency Caesarean sections or inductions pre-term. The introduction of Doppler ultrasound had no effect on fetal death or Caesarean section for term deliveries. CONCLUSIONS: The introduction of Doppler ultrasound during the 1990s and 2000s made a significant contribution to the decline in the number of pre-term fetal deaths in Norway. Increased use of Caesarean section may have contributed to this reduction.