Cláudio Sérgio Medeiros Paiva

Applying the Maternal Near Miss Approach for the Evaluation of Quality of Obstetric Care: A Worked Example from a Multicenter Surveillance Study

Objective. To assess quality of care of women with severe maternal morbidity and to identify associated factors. Method. This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. Results. 17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase in maternal mortality ratio, the main factors associated with nonadequate performance were geographic difficulty in accessing health services (P < 0.001), delays related to quality of medical care (P = 0.012), absence of blood derivatives (P = 0.013), difficulties of communication between health services (P = 0.004), and any delay during the whole process (P = 0.039). Conclusions. This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care.

Curva da altura uterina por idade gestacional em gestantes de baixo risco

PURPOSE: to build a curve of fundal height according to gestational age among low-risk pregnant women and to compare it with the official standards used in Brazil. METHODS: a prospective observational study was carried out. A sample of 227 low-risk pregnant women with gestational age from 13 to 39 weeks was followed-up in the prenatal care sector of two public health services from Joao Pessoa, PB. Women with a known gestational age, a single live fetus, without malformation, with no known maternal-fetal pathological condition that could possibly affect fetal growth, with a normal body weight, and non-smokers were included in the study. Their fundal height was measured in a standard way, after a previous ultrasound done to confirm the gestational age. The same investigator performed 1206 measurements and each woman had a mean of 5.3 measurements. Statistical tests were performed with a significance level of 5%. Tables and graphs of fundal height were built according to the gestational age with the 10th, 50th and 90th percentiles. RESULTS: the values of percentiles 10, 50 and 90 of fundal height in each gestational age allowed the construction of a pattern curve of fundal height by gestational age among low-risk pregnant women. A clear visual difference was observed between this new and the official fundal height curve. Statistical analyses showed significant differences between them from the 19th week on. CONCLUSION: the results suggest different normal fundal height and fetal growth patterns among low-risk pregnant women on prenatal assistance compared to the used standard curve, thus with different performances when used for diagnosing fetal growth deviations. Future studies should validate the current fundal height curve by gestational age in order to possibly use it as a reference pattern.

Symphysis-fundal height curve in the diagnosis of fetal growth deviations

OBJETIVO: Validar la curva de referencia de altura uterina por edad de gestacion para el rastreo de desvios del crecimiento fetal y comparar su performance con la curva estandar adoptada por el Ministerio de la Salud de Brasil. METODOS: Estudio observacional que envolvio 753 gestantes de bajo riesgo de Joao Pessoa, Noreste de Brasil, entre marzo y octubre de 2006, con edad de gestacion por encima de 27 semanas. La altura uterina fue medida de acuerdo con tecnica recomendada por el Ministerio de la Salud. El patron-oro fue el peso fetal, estimado por el ultrasonido con base en la curva de referencia brasilera por edad de gestacion. Una sub-muestra de 122 casos con pesos neonatales obtenidos hasta siete dias despues de la estimacion del peso fetal, la clasificacion de la altura uterina fue comparada con la curva de Lubchenco como estandar-oro. La sensibilidad, la especificidad y los valores predictivos positivo y negativo fueron calculados. Para comparar el desempeno de la sensibilidad entre ambas curvas de altura uterina, se utilizo la prueba chi-cuadrado de McNemar. RESULTADOS: La sensibilidad de la nueva curva para la deteccion de fetos pequenos para la edad de gestacion fue de 51,6%, mientras que la curva del patron-oro fue significativamente menor (12,5%). En la sub-muestra que tuvo el peso neonatal como estandar-oro, la sensibilidad de la nueva curva de referencia fue de 87,7%, mientras que la del Ministerio de la Salud exhibio 42,9% de sensibilidad para la deteccion de fetos pequenos para la edad de gestacion. CONCLUSIONES: La capacidad diagnostica de la nueva curva de referencia para detectar fetos pequenos para la edad de gestacion fue significativamente mejor que la curva recomendada por el Ministerio de la Salud.OBJECTIVE To validate a new symphysis-fundal curve for screening fetal growth deviations and to compare its performance with the standard curve adopted by the Brazilian Ministry of Health. METHODS Observational study including a total of 753 low-risk pregnant women with gestational age above 27 weeks between March to October 2006 in the city of João Pessoa, Northeastern Brazil. Symphisys-fundal was measured using a standard technique recommended by the Brazilian Ministry of Health. Estimated fetal weight assessed through ultrasound using the Brazilian fetal weight chart for gestational age was the gold standard. A subsample of 122 women with neonatal weight measurements was taken up to seven days after estimated fetal weight measurements and symphisys-fundal classification was compared with Lubchenco growth reference curve as gold standard. Sensitivity, specificity, positive and negative predictive values were calculated. The McNemar χ2 test was used for comparing sensitivity of both symphisys-fundal curves studied. RESULTS The sensitivity of the new curve for detecting small for gestational age fetuses was 51.6% while that of the Brazilian Ministry of Health reference curve was significantly lower (12.5%). In the subsample using neonatal weight as gold standard, the sensitivity of the new reference curve was 85.7% while that of the Brazilian Ministry of Health was 42.9% for detecting small for gestational age. CONCLUSIONS The diagnostic performance of the new curve for detecting small for gestational age fetuses was significantly higher than that of the Brazilian Ministry of Health reference curve.

Correlation between estimated fetal weight by ultrasound and neonatal weight

PURPOSE to evaluate the correlation between the estimated fetal weight (EFW) by ultrasonography and the neonatal weight (NW), as well as the EFWs capacity to predict changes in NW among pregnant women in João Pessoa, Paraíba, Brazil. METHODS a diagnostic validation study, including 122 pregnant women who have had the EFW calculated by ultrasonography up to seven days before delivery and the NW established immediately after birth, with a specific newborns scale. The correlation between EFW and NW measurements was assessed by Pearsons correlation coefficient and by the mean difference between them. EFW and NW were classified as: low for the gestational age (LGA), adequate for the gestational age (AGA) and high for the gestational age (HGA), according to the percentiles 10 and 90 of the respective reference curves. The diagnosis of EFW deviation has been validated using the values of the Alexanders NW reference curve as gold-standard, by estimating the sensitivity, specificity, and positive and negative predictive values. RESULTS there has been a high linear correlation between the EFW and NW (R=0.96), and the difference between them has varied from -474 g to +480 g, with an average of +3 g. Most of the highest percent weight estimate variations were between 10 and 15%. EFW has had 85.7% of sensitivity and 100% of specificity for the detection of LGA, and 100 and 77.2%, respectively, for the detection of HGA. CONCLUSIONS EFW is able to predict NW adequately, and the reference EFW tested has had a good performance in the screening of fetal growth deviation, in the population studied.

A altura uterina é capaz de diagnosticar os desvios do volume de líquido amniótico

PURPOSE To evaluate the performance of a Brazilian reference curve of fundal height (FH) regarding its capacity of screening the deviations of volume of amniotic fluid using a Brazilian reference curve of amniotic fluid index (AFI) as gold standard. METHODS This was a cross-sectional study evaluating 753 pregnant women receiving prenatal care at the public health services of João Pessoa (PB), from March to October 2006, who had a routine ultrasound exam scheduled for after 26 weeks of gestational age. Cases with diagnoses of twin pregnancy, intrauterine fetal death and major fetal malformations were excluded. Besides socio-demographic information, data regarding fundal height measured in a standard way, estimated fetal weight, AFI and gestational age at the time of the ultrasound exam were also collected. The capacity of the FH curve to predict deviations of the amniotic fluid volume was assessed using the Brazilian curve of AFI according to gestational age as the gold standard. For this purpose, sensitivity, specificity, positive and negative predictive values were estimated for different cut-off points. RESULTS The measurement of FH identified 10.5% of women as having low FH possibly associated with oligohydramnios and 25.2% as having high FH possibly associated with polyhydramnios. Using a Brazilian reference curve of AFI, the FH was able to poorly predict the occurrence of oligohydramnios (sensitivity ranging from 37 to 28%) and to reasonably predict the occurrence of polyhydramnios (sensitivity ranging from 88 to 69%). CONCLUSIONS The measurement of fundal height showed a poor performance for predicting oligohydramnios and a reasonable performance for predicting polyhydramnios. Its use for this purpose is then only supported in settings where the ultrasound exam is not easily or routinely available in order to help define priorities for cases that should have this exam performed.

Curva de altura uterina por edad de gestación y diagnóstico de desvíos del crecimiento fetal

OBJETIVO: Validar la curva de referencia de altura uterina por edad de gestacion para el rastreo de desvios del crecimiento fetal y comparar su performance con la curva estandar adoptada por el Ministerio de la Salud de Brasil. METODOS: Estudio observacional que envolvio 753 gestantes de bajo riesgo de Joao Pessoa, Noreste de Brasil, entre marzo y octubre de 2006, con edad de gestacion por encima de 27 semanas. La altura uterina fue medida de acuerdo con tecnica recomendada por el Ministerio de la Salud. El patron-oro fue el peso fetal, estimado por el ultrasonido con base en la curva de referencia brasilera por edad de gestacion. Una sub-muestra de 122 casos con pesos neonatales obtenidos hasta siete dias despues de la estimacion del peso fetal, la clasificacion de la altura uterina fue comparada con la curva de Lubchenco como estandar-oro. La sensibilidad, la especificidad y los valores predictivos positivo y negativo fueron calculados. Para comparar el desempeno de la sensibilidad entre ambas curvas de altura uterina, se utilizo la prueba chi-cuadrado de McNemar. RESULTADOS: La sensibilidad de la nueva curva para la deteccion de fetos pequenos para la edad de gestacion fue de 51,6%, mientras que la curva del patron-oro fue significativamente menor (12,5%). En la sub-muestra que tuvo el peso neonatal como estandar-oro, la sensibilidad de la nueva curva de referencia fue de 87,7%, mientras que la del Ministerio de la Salud exhibio 42,9% de sensibilidad para la deteccion de fetos pequenos para la edad de gestacion. CONCLUSIONES: La capacidad diagnostica de la nueva curva de referencia para detectar fetos pequenos para la edad de gestacion fue significativamente mejor que la curva recomendada por el Ministerio de la Salud.OBJECTIVE To validate a new symphysis-fundal curve for screening fetal growth deviations and to compare its performance with the standard curve adopted by the Brazilian Ministry of Health. METHODS Observational study including a total of 753 low-risk pregnant women with gestational age above 27 weeks between March to October 2006 in the city of João Pessoa, Northeastern Brazil. Symphisys-fundal was measured using a standard technique recommended by the Brazilian Ministry of Health. Estimated fetal weight assessed through ultrasound using the Brazilian fetal weight chart for gestational age was the gold standard. A subsample of 122 women with neonatal weight measurements was taken up to seven days after estimated fetal weight measurements and symphisys-fundal classification was compared with Lubchenco growth reference curve as gold standard. Sensitivity, specificity, positive and negative predictive values were calculated. The McNemar χ2 test was used for comparing sensitivity of both symphisys-fundal curves studied. RESULTS The sensitivity of the new curve for detecting small for gestational age fetuses was 51.6% while that of the Brazilian Ministry of Health reference curve was significantly lower (12.5%). In the subsample using neonatal weight as gold standard, the sensitivity of the new reference curve was 85.7% while that of the Brazilian Ministry of Health was 42.9% for detecting small for gestational age. CONCLUSIONS The diagnostic performance of the new curve for detecting small for gestational age fetuses was significantly higher than that of the Brazilian Ministry of Health reference curve.

Curva de altura uterina por idade gestacional e diagnóstico de desvios do crescimento fetal

OBJETIVO: Validar la curva de referencia de altura uterina por edad de gestacion para el rastreo de desvios del crecimiento fetal y comparar su performance con la curva estandar adoptada por el Ministerio de la Salud de Brasil. METODOS: Estudio observacional que envolvio 753 gestantes de bajo riesgo de Joao Pessoa, Noreste de Brasil, entre marzo y octubre de 2006, con edad de gestacion por encima de 27 semanas. La altura uterina fue medida de acuerdo con tecnica recomendada por el Ministerio de la Salud. El patron-oro fue el peso fetal, estimado por el ultrasonido con base en la curva de referencia brasilera por edad de gestacion. Una sub-muestra de 122 casos con pesos neonatales obtenidos hasta siete dias despues de la estimacion del peso fetal, la clasificacion de la altura uterina fue comparada con la curva de Lubchenco como estandar-oro. La sensibilidad, la especificidad y los valores predictivos positivo y negativo fueron calculados. Para comparar el desempeno de la sensibilidad entre ambas curvas de altura uterina, se utilizo la prueba chi-cuadrado de McNemar. RESULTADOS: La sensibilidad de la nueva curva para la deteccion de fetos pequenos para la edad de gestacion fue de 51,6%, mientras que la curva del patron-oro fue significativamente menor (12,5%). En la sub-muestra que tuvo el peso neonatal como estandar-oro, la sensibilidad de la nueva curva de referencia fue de 87,7%, mientras que la del Ministerio de la Salud exhibio 42,9% de sensibilidad para la deteccion de fetos pequenos para la edad de gestacion. CONCLUSIONES: La capacidad diagnostica de la nueva curva de referencia para detectar fetos pequenos para la edad de gestacion fue significativamente mejor que la curva recomendada por el Ministerio de la Salud.OBJECTIVE To validate a new symphysis-fundal curve for screening fetal growth deviations and to compare its performance with the standard curve adopted by the Brazilian Ministry of Health. METHODS Observational study including a total of 753 low-risk pregnant women with gestational age above 27 weeks between March to October 2006 in the city of João Pessoa, Northeastern Brazil. Symphisys-fundal was measured using a standard technique recommended by the Brazilian Ministry of Health. Estimated fetal weight assessed through ultrasound using the Brazilian fetal weight chart for gestational age was the gold standard. A subsample of 122 women with neonatal weight measurements was taken up to seven days after estimated fetal weight measurements and symphisys-fundal classification was compared with Lubchenco growth reference curve as gold standard. Sensitivity, specificity, positive and negative predictive values were calculated. The McNemar χ2 test was used for comparing sensitivity of both symphisys-fundal curves studied. RESULTS The sensitivity of the new curve for detecting small for gestational age fetuses was 51.6% while that of the Brazilian Ministry of Health reference curve was significantly lower (12.5%). In the subsample using neonatal weight as gold standard, the sensitivity of the new reference curve was 85.7% while that of the Brazilian Ministry of Health was 42.9% for detecting small for gestational age. CONCLUSIONS The diagnostic performance of the new curve for detecting small for gestational age fetuses was significantly higher than that of the Brazilian Ministry of Health reference curve.