Perspectives of healthcare workers on the morality of abortion: a multicenter study in seven Brazilian public hospitals.

We used the questionnaire "Mosaic of Opinions on Induced Abortion" to conduct a multi-centered study to evaluate the perspectives of physicians, nurses, social workers, psychologists and pharmacists on the morality of abortion. In all, 254 participants constituted the sample. The inadequate knowledge on Brazilian abortion laws was the only determinant negatively associated with the construct "Sexual and Reproductive Rights", corroborating the hypothesis that a better understanding of abortion legislation could mitigate the opposition of some professionals to the ethical perspective that access to safe abortion should be seen as a sexual and reproductive right.

Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial.

BACKGROUND: Despite all the evidence corroborating the selective use of episiotomy and although routine use of the procedure is contraindicated, there are no evidences corroborating if episiotomy is necessary in any circumstance. The present clinical randomized trial was performed to compare maternal and perinatal outcomes in women submitted to a non-episiotomy protocol versus one of selective episiotomy. METHODS: An open-labelled, randomized clinical trial was carried out in a tertiary teaching hospital in Recife, Northeastern Brazil. Women in labor with a full-term live foetus, dilatation of 6 to 8 cm and cephalic presentation (vertex position) were included. Exclusion criteria consisted of bleeding disorders and an indication for a caesarean section. After signing the consent form, 241 women were randomized to a non-episiotomy protocol (the experimental group) or to a selective episiotomy group (the control group). No episiotomies were to be performed in the experimental group except under exceptional circumstances. In the control group, selective episiotomies were to be performed in accordance with the healthcare professionals' clinical judgement. Maternal and perinatal outcomes were evaluated. Ratio Risk (RR) and the 95% confidence interval (95% CI) were calculated for our outcomes. RESULTS: The analysis include 115 women assigned to a non-episiotomy protocol and 122 to selective episiotomy. There was no difference between the two groups with respect to maternal or perinatal outcomes. The episiotomy rate was similar (two cases in each group, about 1.7%), as was the duration of the second stage of labor, the frequency of perineal tears, severe perineal trauma, need for perineal suturing and blood loss at delivery. CONCLUSIONS: A non-episiotomy protocol appears to be safe for mother and child, and highlights the need to investigate whether there is, in fact, any indication for this procedure. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov under reference number ( NCT02178111 ).

Diuretics vs. placebo for postpartum blood pressure control in preeclampsia (DIUPRE): a randomized clinical trial.

BACKGROUND: Hypertension affects about 10% of pregnancies and is responsible for both maternal and neonatal devastating complications such as eclampsia, HELLP syndrome, prematurity and maternal and neonatal death. The resolution of the disease occurs in the first twelve weeks postpartum. The behavior of blood pressure and occurrence of very high blood pressure episodes among women with severe preeclampsia is related to remodeling of the dynamics of body fluids with consequent increase in intravascular volume. The persistence of hypertension in critical levels results in increased puerperal morbidity. OBJECTIVES: To evaluate the effectiveness of furosemide in accelerating blood pressure recovery among women with severe preeclampsia. METHODS/DESIGN: A triple-masked placebo controlled clinical trial, will be conducted including 120 postpartum women with severe preeclampsia, after eclampsia prophylaxis with magnesium sulfate and with adequate diuresis. Women with chronic hypertension and users of diuretics will be deleted. Informed consent will be obtained from all participants. Patients will be randomized to receive furosemide (40 mg orally every twenty four hours) or placebo. The variables are systolic and diastolic blood pressure, frequency of hypertensive crises, need for maintenance of antihypertensive therapy, number of antihypertensive agents used to control blood pressure, urine output, length of hospital stay, adverse effects and maternal complications. This study was approved by the Research Ethics Committee in humans of our institution. All participants will be duly informed about the aims of the project and will be included only if they agree to participate voluntarily, signing the informed consent. TRIAL REGISTRATION: This study was registered on Clinical Trials.gov under the number NCT02163655. ( http://clinicaltrials.gov/show/NCT02163655).

Selective episiotomy vs. implementation of a non episiotomy protocol: a randomized clinical trial.

BACKGROUND: World Health Organization (WHO) recommends that the episiotomy rate should be around 10%, which is already a reality in many European countries. Currently the use of episiotomy should be restricted and physicians are encouraged to use their clinical judgment to decide when the procedure is necessary. There is no clinical evidence corroborating any indication of episiotomy, so until the present moment it is not yet known whether episiotomy is indeed necessary in any context of obstetric practice. OBJECTIVES: To compare maternal and perinatal outcomes in women undergoing a protocol of not performing episiotomy versus selective episiotomy. METHODS/DESIGN: An open label randomized clinical trial will be conducted including laboring women with term pregnancy, maximum dilation of 8 cm, live fetus in cephalic vertex presentation. Women with bleeding disorders of pregnancy, indication for caesarean section and those without capacity to consent and without legal guardians will be excluded. Primary outcomes will be frequency of episiotomy, delivery duration, frequency of spontaneous lacerations and perineal trauma, frequency of instrumental delivery, postpartum blood loss, need for perineal suturing, number of sutures, Apgar scores at one and five minutes, need for neonatal resuscitation and pH in cord blood. As secondary outcomes frequency complications of perineal suturing, postpartum perineal pain, maternal satisfaction, neonatal morbidity and admission newborn in NICU will be assessed. Women will be invited to participate and those who agree will sign the consent form and will be then assigned to a protocol of not conducting episiotomy (experimental group) or to a group that episiotomy is performed selectively according to the judgment of the provider of care delivery (control Group). The present study was approved by IMIP's Research Ethics Committee. TRIAL REGISTRATION: Clinical Trials Register under the number and was registered in ClinicalTrials.gov under the number NCT02178111.

Factors associated with the persistence/recurrence of CIN2/3 in women submitted to loop electrosurgical excision procedure in a teaching hospital in northeastern Brazil: a case-control study.

OBJECTIVE: This study aimed to identify risk factors associated with the persistence/recurrence of cervical intraepithelial neoplasia (CIN) 2/3 in women submitted to loop electrosurgical excision procedure (LEEP) in a hospital in northeastern Brazil. MATERIALS AND METHODS: A case-control study included 50 women with and 50 women without persistence/recurrence of CIN2/3 after LEEP at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between 2004 and 2011. Data were collected from June to December 2011. Inclusion criteria were diagnosis of CIN2/3 during follow-up (cases) and women free of CIN2/3 after a follow-up of 2 years or longer (controls). Exclusion criteria (cases/controls) were LEEP performed at another hospital, LEEP performed for persistent CIN1, invasive carcinoma in the cone specimen or at cytology, and/or histopathology within a 2-year follow-up period. Persistence was defined as residual disease detected in the first year after LEEP, and recurrence was defined as the reappearance of a lesion more than 1 year after surgery. Bivariate analysis was performed for biological, sociodemographic, sexual, reproductive, lifestyle, and clinical variables. Odds ratios (ORs) and their 95% confidence intervals (95% CIs) were calculated, and a multiple logistic regression analysis was performed to control for potential confounding factors. The study was approved by IMIP's internal review board. RESULTS: Multiple logistic regression analysis showed a significant association between persistence/recurrence of CIN2/3 and living outside the capital city (OR=3.11, 95% CI=1.14-8.41), smoking (OR=4.22, 95% CI=1.18-15.05), and positive endocervical margins (OR=6.58, 95% CI=2.37-18.28). CONCLUSIONS: Women with persistence/recurrence of CIN2/3 are more likely to live outside the state capital, be smokers, and have positive endocervical margins, so these women should be followed up more closely.

Clonidine versus captopril for treatment of postpartum very high blood pressure: study protocol for a randomized controlled trial (CLONCAP).

BACKGROUND: The behavior of arterial blood pressure in postpartum of women with hypertension and pregnancy and the best treatment for very high blood pressure in this period still need evidence. The Cochrane systematic review assessing prevention and treatment of postpartum hypertension found only two trials (120 patients) comparing hydralazine with nifedipine and labetalol for the treatment of severe hypertension and did not find enough evidence to know how best to treat women with hypertension after birth. Although studies have demonstrated the effectiveness of treatment with captopril, side effects were reported. Because of these findings, new classes of antihypertensive drugs began to be administered as an alternative therapy. Data on the role of clonidine in this particular group of patients, its effects in the short and long term are still scarce in the literature. OBJECTIVES: To determine the effectiveness of clonidine, compared to captopril, for the treatment of postpartum very high blood pressure in women with hypertension in pregnancy. METHODS/DESIGN: The study is a triple blind randomized controlled trial including postpartum women with diagnosis of hypertension in pregnancy presenting very high blood pressure, and exclusion criteria will be presence of heart disease, smoking, use of illicit drugs, any contraindication to the use of captopril or clonidine and inability to receive oral medications.Eligible patients will be invited to participate and those who agree will be included in the study and receive captopril or clonidine according to a random list of numbers. The subjects will receive the study medication every 20 minutes until blood pressure is over 170 mmHg of systolic blood pressure and 110 mmHg diastolic blood pressure. A maximum of six pills a day for very high blood pressure will be administered. In case of persistent high blood pressure levels, other antihypertensive agents will be used.During the study the women will be subject to strict control of blood pressure and urine output. This proposal has already obtained approval of the local Institutional Review Board of the coordinating center (IMIP, Recife, Brazil) and of the National Council for Ethics in Research (CONEP) of the Brazilian Ministry of Health. TRIAL REGISTRATION: Clinical Trials Register under the number NCT01761916.

A qualitative analysis of the nurturing care environment of families participating in Brazil's Criança Feliz early childhood program.

Investing in early childhood programs such as Brazil's Criança Feliz Program (PCF) to support low-income families in providing a nurturing care environment is critical to ensure that children reach their full developmental potential. We aimed to analyze the influence of the PCF on the nurturing care environment provided by families enrolled in the program in the Federal District, Brazil. A qualitative case study was conducted based on in-depth interviews with a purposive sampling of 22 caregivers enrolled in the PCF for at least six months. Eighteen subthemes emerged from the thematic analysis following the five components of the Nurturing Care Framework (i.e., good health, adequate nutrition, responsive care, early learning, and security and safety). Caregivers recognized the benefits of the PCF on children's mental health (good health) and reported challenges in providing adequate nutrition due to food insecurity (adequate nutrition). A bond between the home visitor and families was identified as critical to promote responsive parenting practices (responsive care). Caregivers appreciated the early stimulation activities provided during PCF home visits (opportunities for early learning). Access to social welfare programs, such as conditional cash transfer and food assistance, were facilitated through PCF multisectoral actions (safety and security). On the other hand, families reported not receiving support from PCF for issues such as breastfeeding, maternal mental health, and disciplinary practices. In summary, PCF enhanced the components of the nurturing care environment provided by families. However, their vulnerabilities and contextual implementation barriers may prevent families from fully benefiting from PCF activities.

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.

Aspirin-Loaded Polymeric Films for Drug Delivery Systems: Comparison between Soaking and Supercritical CO2 Impregnation.

Polymeric implants loaded with drugs can overcome the disadvantages of oral or injection drug administration and deliver the drug locally. Several methods can load drugs into polymers. Herein, soaking and supercritical CO2 (scCO2) impregnation methods were employed to load aspirin into poly(l-lactic acid) (PLLA) and linear low-density polyethylene (LLDPE). Higher drug loadings (DL) were achieved with scCO2 impregnation compared to soaking and in a shorter time (3.4 ± 0.8 vs. 1.3 ± 0.4% for PLLA; and 0.4 ± 0.5 vs. 0.6 ± 0.5% for LLDPE), due to the higher swelling capacity of CO2. The higher affinity of aspirin explained the higher DL in PLLA than in LLDPE. Residual solvent was detected in LLDPE prepared by soaking, but within the FDA concentration limits. The solvents used in both methods acted as plasticizers and increased PLLA crystallinity. PLLA impregnated with aspirin exhibited faster hydrolysis in vitro due to the catalytic effect of aspirin. Finally, PLLA impregnated by soaking showed a burst release because of aspirin crystals on the PLLA surface, and released 100% of aspirin within 60 days, whereas the PLLA prepared with scCO2 released 60% after 74 days by diffusion and PLLA erosion. Hence, the scCO2 impregnation method is adequate for higher aspirin loadings and prolonged drug release.

[Epidemiological profile and postpartum outcome in severe preeclampsia]. / Perfil epidemiológico e evolução clínica pós-parto na pré-eclâmpsia grave.

BACKGROUND: To describe maternal characteristics and blood pressure behavior in the puerperium of women admitted, during pregnancy, with diagnosis of severe preeclampsia. METHODS: A cohort study was conducted including pregnant women with gestational age of 28 weeks or more, with diagnosis of preeclampsia, not in labor, at the Instituto Materno Infantil Professor Fernando Figueira (IMIP) from November 2006 to September 2007. Patients with chronic hypertension, autoimmune diseases, gestational diabetes, multiple pregnancy and signs of clinical instability were excluded. Biological, demographic and obstetrical characteristics were analyzed, as well as the behavior of systolic and diastolic blood pressure post partum. RESULTS: 154 patients with severe preeclampsia were included. The mean maternal age was 25.1 + 6.5 years. Regarding education only 45.5% had completed 11 years of schooling. Only 20.1% of deliveries were vaginal and preterm newborns occurred in 59.8% of cases. Two cases of eclampsia, eighteen cases of HELLP syndrome and 43 cases of oliguria were registered. Length of post partum hospital stay varied from one to 30 days, and 45% of patients were in hospital until the seventh day after delivery. Hypertensive emergencies were registered in 53.9% of the patients during puerperium and use of antihypertensive drugs was maintained in 76.5% of the women. CONCLUSIONS: Preeclamptic women tend to have controlled blood pressures after the third day of puerperium and are likely to be discharged from hospital still using anti-hypertensive drugs. Key-words: Severe preeclampsia, post partum period complications.

Sociodemographic, clinical and obstetric characteristics of women with acute kidney injury in the pregnancy-puerperal cycle: a case series / Características sociodemográficas, clínicas e obstétricas de mulheres com lesão renal aguda no ciclo gravido-puerperal: uma série de casos

Abstract Introduction: to report cases of women with acute kidney injury (AKI) in the pregnancy-puerperal cycle, admitted to a maternity teaching hospital in Recife, Pernambuco, Brazil. Description: a case-series study reviewing the records of 100 patients with AKI admitted to the maternity hospital of the Institute of Integrative Medicine Professor Fernando Figueira (IMIP - Portuguese acronym). Discussion: the majority of patients (65.1%): were brown-skinned and the mean age was 25.5years; were primiparas (65.1%) and had cesarean section (75.5%). The most common hypertensive disorder was preeclampsia (74.0%), followed by chronic arterial hypertension (11.0%) and eclampsia (6.0%). Hemorrhage occurred in 19% of women. The most common form of treatment was fluid therapy (70.0%) and oliguria was one of the most common AKI consequences (84.8%). Hemodialysis was necessary in 13% of cases and 4.0% died. Kidney function was restored prior to discharge from hospital in almost 70.0% of cases. The main causes of AKI were hypertensive disorders and hemorrhage/hemorrhagic shock.

Resumo Introdução: relato de casos de mulheres com lesão renal aguda (LRA) no ciclo grávido-puerperal internadas em uma maternidade escola do Recife-PE. Descrição: realizou-se um estudo do tipo série de casos, por meio da análise dos prontuários de 100 pacientes que cursaram com LRA na maternidade do Instituto de Medicina Integral Prof. Fernando Figueira (IMIP). Discussão: a maioria das pacientes era parda (65,1%) e a idade média foi 25,5 anos, primíparas (65,1%) e tinham sido submetidas à cesariana (75,5%). O distúrbio hipertensivo mais prevalente foi a pré-eclâmpsia (74,0%) seguido da hipertensão arterial crônica (11,0%) e eclâmpsia (6,0%). Hemorragia foi observada em 19,0% das mulheres. O tratamento mais utilizado foi a hidratação (70,0%) e oligúria representou uma das consequências da LRA mais prevalente (84,8%). Hemodiálise foi necessária em 13,0% dos casos e 4,0% evoluíram para o óbito. A recuperação da função renal ocorreu até a alta em quase 70,0% dos casos. As principais causas de LRA foram os distúrbios hipertensivos e hemorragia/choque hemorrágico.

Factors associated with spontaneous perineal lacerations in deliveries without episiotomy in a university maternity hospital in the city of Recife, Brazil: a cohort study.

Objectives: The objective of this study is to determine factors associated with spontaneous perineal laceration in low-risk pregnant women who delivered vaginally without episiotomy in a university maternity hospital in Recife, Pernambuco, Brazil. Methods: A prospective cohort study was conducted with 222 low-risk, full-term pregnant women admitted in labor with a single fetus in cephalic presentation. Women with malformed fetuses were excluded from the study. The variables analyzed were: the frequency and severity of lacerations, the women's biological, sociodemographic, clinical and obstetrical characteristics, neonatal characteristics, and data on their deliveries and procedures. For the data analysis, risk ratios and their 95% confidence intervals were calculated. A significance level of 5% was adopted and multiple regression analysis was performed. Results: Spontaneous first-degree perineal tears were registered in 47% of the women, second-degree tears in 31%, and third degree tears in only 1.8%. There were no cases of fourth-degree tears. Having experienced normal childbirth previously constituted a protective factor against vaginal tearing (OR = 0.46; 95%CI: 0.23-0.91; p = .027). Conclusion: The principal protective factor against spontaneous lacerations was having experienced normal childbirth previously. Intrapartum strategies aimed at protecting the perineum and pelvic floor muscle training during prenatal care should be encouraged in these women.

Uterine exteriorization compared with in situ repair at cesarean delivery: a randomized controlled trial.

OBJECTIVE: To compare extra-abdominal to intra-abdominal repair of the uterine incision at cesarean delivery. METHODS: This is a randomized controlled trial conducted at the Instituto Materno-Infantil Prof. Fernando Figueira (Recife, Brazil). Inclusion criteria were indication for cesarean delivery and gestational age of 24 weeks or more. Patients with two or more cesarean deliveries, chorioamnionitis, hemorrhage, inability to consent, and previous abdominal surgery were excluded. Variables analyzed were nausea, vomiting, mean operative time, intraoperative blood loss, number of surgical sutures for uterine repair, postoperative pain evaluated by the visual analog scale, number of postoperative analgesic doses, surgical site infection, and endometritis. RESULTS: The analysis included 325 patients randomized for exteriorized uterine repair and 312 patients randomized for in situ uterine repair. A significant difference was observed in duration of surgery: lasting less than 45 minutes (44% with exteriorized uterus compared with 35.3% with in situ uterus, P=.02; number needed to treat=12) and less need of sutures (18.2% requiring one suture in the exteriorized group compared with 11.9% in the in situ group, P=.03; number needed to treat=16). The frequency of moderate or severe pain 6 hours after surgery was low [corrected] in women with in situ [corrected] repair (23.1%) when compared to those with the uterus exteriorized [corrected] (32.6%) (P=.026; number needed to treat=11). There was no difference between the groups in relation to other variables. CONCLUSION: There is no significant difference between extra-abdominal and intra-abdominal repair of the uterine incision at cesarean delivery, but the number of sutures is lower and surgical time is shorter with extra-abdominal repair, although moderate and severe pain at 6 hours is less frequent with in situ uterine repair. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00550888.

Placental cord drainage in the third stage of labor: Randomized clinical trial.

METHODS: An open randomized clinical trial was developed at Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) in Recife and at Petronila Campos Municipal Hospital in São Lourenço da Mata, both in Pernambuco, northeastern Brazil, including 226 low-risk pregnant women bearing a single, full-term, live fetus after delayed cord clamping, 113 randomized to placental cord drainage and 113 to a control group not submitted to this procedure. Women incapable of understanding the study objectives and those who went on to have an instrumental or cesarean delivery were excluded. RESULTS: Duration of the third stage of labor did not differ between the two groups (14.2±12.9 versus 13.7±12.1 minutes (mean ± SD), p = 0.66). Likewise, there was no significant difference in mean blood loss (248±254 versus 208±187ml, p = 0.39) or in postpartum hematocrit levels (32.3±4.06 versus 32.8±4.25mg/dl, p = 0.21). Furthermore, no differences were found between the groups for any of the secondary outcomes (postpartum hemorrhage >500 or >1000ml, therapeutic use of oxytocin, third stage >30 or 60 minutes, digital evacuation of the uterus or curettage, symptoms of postpartum anemia and maternal satisfaction). CONCLUSION: Placental cord drainage had no effect in reducing duration or blood loss during the third stage of labor. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov: www.clinicaltrial.gov, NCT01655576.

Measurement properties of the questionnaire "Mosaic of opinions on induced abortion": a multicenter study in seven Brazilian hospitals.

OBJECTIVE: In Brasil, abortion is legal in cases of rape, when there is a risk of maternal death, and in cases of fetal anencephaly. However, the literature reports that some doctors refuse to care for women with such demands or come to perform it in a discriminatory manner. Pretest, test and evaluate the measurement properties of the "Mosaic of Opinions on Induced Abortion," a questionnaire developed to investigate the perspectives of Brazilian healthcare professionals about the morality of abortion. METHODS: Firstly, the questionnaire was pretested in an intentional sample of specialists. Secondly, it was tested in a randomized sample of 32 healthcare professionals. Finally, we conducted a multi-center study in seven university hospitals to evaluate the measurement properties of the questionnaire. RESULTS: Combined samples of the three phases totalized 430 individuals. In pretest and test, all the evaluated aspects obtained satisfactory results. In the multicenter phase, confirmatory factorial analysis led to an important reduction of the questionnaire, which also obtained good indicators of reliability, beyond the validation of construct and criteria. CONCLUSION: Questionnaire has been validated and is suitable for use in other surveys in Brasil.

Validation of fullPIERS model for prediction of adverse outcomes among women with severe pre-eclampsia.

OBJECTIVE: To evaluate the accuracy of the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) model for the prediction of complications among patients with severe pre-eclampsia in northeastern Brazil. METHODS: A retrospective study was conducted of data for all patients with severe pre-eclampsia admitted to a center in Recife in 2014. The fullPIERS model was applied to calculate the predicted probability of complications. A receiver operating characteristic curve was constructed to determine the accuracy of the model, and the area under the curve was calculated. Multiple logistic regression analysis was performed. RESULTS: Among 325 included women, 55 (16.9%) had one or more complication before discharge. The area under the curve was 0.72 (P<0.001), determining a cutoff point for fullPIERS probability of 1.7%. Sensitivity was 60.0% and specificity was 65.1%; the positive likelihood ratio was 1.72 and the negative likelihood ratio was 0.61. In multivariate analysis, the only variable that remained significantly associated with complications was a fullPIERS probability of more than 1.7% (odds ratio 5.87, 95% confidence interval 3.16-10.89; P<0.001). CONCLUSION: The fullPIERS model is a useful tool for predicting complications in women with severe pre-eclampsia, with the cutoff point of 1.7%.

Clonidine versus Captopril for Severe Postpartum Hypertension: A Randomized Controlled Trial.

BACKGROUND: Changes during the puerperium are still unclear, particularly in women with hypertension. The choice of antihypertensives, both to control very high blood pressure episodes and to keep blood pressure stable, also requires further elucidation. Currently, there are no clear data to guide the decision for the choice of postpartum antihypertensives. Captopril plays an important role in the treatment of very high blood pressure episodes and may be used postpartum. Clonidine has been used as an alternative in pregnant or postpartum women with contraindications to captopril, with satisfactory effect. The objective of the present study was to evaluate the effectiveness and safety of clonidine compared to captopril for treating severe postpartum hypertension. METHODS AND FINDINGS: A randomized, drug-controlled, triple-blind clinical trial evaluating postpartum women receiving captopril or clonidine. Inclusion criteria consisted of: women with hypertensive disorders of pregnancy systolic blood pressure (SBP) ≥180 mmHg and/or diastolic blood pressure (DBP) ≥110 mmHg], requiring magnesium sulfate. Exclusion criteria were: heart disease, smoking, illicit drug use, contraindications to captopril, clonidine or oral medication, and having used captopril/clonidine previously. The primary outcome was the frequency of very high blood pressure episodes while in the obstetric intensive care unit. A total of 90 postpartum women met the study inclusion criteria, with 45 randomized to each group. There were fewer very high blood pressure episodes during hospitalization (2.1 ± 2.1 vs. 3.5 ± 4.7, p = 0.08), greater percentage reduction in SBP (14.0% ± 8.6% vs. 10.8% ± 8.8%, p = 0.08) and fewer women requiring sodium nitroprusside (2.3% vs. 13.3%; RR: 0.17; 95%CI: 0.02-1.39; p = 0.06) in the clonidine group compared to the captopril group; however, these differences were not significant. The groups were similar regarding daily mean SBP or DBP; however, on the third postpartum day, mean SBP was lower in the clonidine compared to the captopril group (151.9 ± 11.8 mmHg vs. 158.1 ± 13.6 mmHg, p = 0.02). Although not statistically significant, adverse reactions were more common in the captopril group (28.8%) compared to the clonidine group (18.6%). CONCLUSION: Clonidine and captopril represent safe, effective treatments for severe postpartum hypertension. TRIAL REGISTRATION: clinicaltrials.gov: www.clinicaltrial.gov, NCT01761916.

High Levels of CXCL8 and Low Levels of CXCL9 and CXCL10 in Women with Maternal RhD Alloimmunization.

Maternal RhD alloimmunization is an inflammatory response against protein antigens in fetal red blood cells (RBC). However, not all women become alloimmunized when exposed to RhD+ fetal RBC. Thus, this study aimed to evaluate levels of inflammatory chemokines in RhD- pregnant women with erythrocyte alloimmunization. CXCL8, CXCL9, CCL5, and CXCL10 levels were determined from cell culture supernatants by flow cytometry in 46 (30 non-alloimmunized RhD- and 16 previously alloimmunized RhD-) pregnant women. CXCL8 levels were significantly higher (P < 0.004), and CXCL9 (P < 0.008) and CXCL10 (P < 0.003) levels were significantly lower in alloimmunized pregnant women. No significant difference in CCL5 levels was detected between the groups. Fetal RHD genotyping was performed in the alloimmunized RhD- group by real-time PCR. Anti-D alloantibody was detected in 10 mothers and anti-D and -C in six mothers. Twelve fetuses were RHD positive and four were RHD negative. Further studies of serum chemokines and placenta tissue could provide a better understanding of the cells involved in the pathogenesis of maternal erythrocyte alloimmunization.

[New formulation of sublingual misoprostol (25 mcg) for induction of labor]. / Nova formulação de misoprostol sublingual na indução do trabalho de parto.

OBJECTIVES: To determine effectiveness and safety of sublingual misoprostol in tablets of 25 mcg, given every 6 hours for induction of labor in high-risk pregnant women hospitalized in two teaching hospitals in the Northeast of Brazil. METHODS: An open, non-randomized clinical trial was conducted, including 40 women with high-risk pregnancies hospitalized at "Maternidade-Escola Assis Chateaubriand" and "Instituto Materno-Infantil de Pernambuco". All of them had gestational age >or= 37 weeks, alive fetus with good vitality and Bishop scores