Eliana Amaral

Appropriate criteria for identification of near-miss maternal morbidity in tertiary care facilities: A cross sectional study

BackgroundThe study of severe maternal morbidity survivors (near miss) may be an alternative or a complement to the study of maternal death events as a health care indicator. However, there is still controversy regarding the criteria for identification of near-miss maternal morbidity. This study aimed to characterize the near miss maternal morbidity according to different sets of criteria.MethodsA descriptive study in a tertiary center including 2,929 women who delivered there between July 2003 and June 2004. Possible cases of near miss were daily screened by checking different sets of criteria proposed elsewhere. The main outcome measures were: rate of near miss and its primary determinant factors, criteria for its identification, total hospital stay, ICU stay, and number and kind of special procedures performed.ResultsThere were two maternal deaths and 124 cases of near miss were identified, with 102 of them admitted to the ICU (80.9%). Among the 126 special procedures performed, the most frequent were central venous access, echocardiography and invasive mechanical ventilation. The mean hospital stay was 10.3 (± 13.24) days. Hospital stay and the number of special procedures performed were significantly higher when the organ dysfunction based criteria were applied.ConclusionThe adoption of a two level screening strategy may lead to the development of a consistent severe maternal morbidity surveillance system but further research is needed before worldwide near miss criteria can be assumed.

A population-based surveillance study on severe acute maternal morbidity (near-miss) and adverse perinatal outcomes in Campinas Brazil: the Vigimoma Project.

BackgroundAuditing of sentinel health events based on best-practice protocols has been recommended. This study describes a population-based investigation on adverse perinatal events including severe acute maternal morbidity (near-miss), maternal and perinatal mortality, as a health intervention to help improve the surveillance system.MethodsFrom October to December 2005, all cases of maternal death (MD), near-miss (NM), fetal deaths (FD), and early neonatal deaths (END), occurring in Campinas, Brazil, were audited by maternal mortality committees.ResultsA total of 4,491 liveborn infants (LB) and 159 adverse perinatal events (35.4/1000 LB) were revised, consisting of 4 MD (89/100.000 LB) and 95 NM (21.1/1000 LB), 23.7 NM for each MD. In addition, 32 FD (7.1/1000 LB) and 28 END (6.2/1000 LB) occurred. The maternal death/near miss rate was 23.7:1. Some delay in care was recognized for 34%, and hypertensive complications comprised 57.8% of the NM events, followed by postpartum hemorrhage.ConclusionAuditing near miss cases expanded the understanding of the spectrum from maternal morbidity to mortality and the importance of promoting adhesion to clinical protocols among maternal mortality committee members. Hypertensive disorders and postpartum hemorrhage were identified as priority topics for health providers training, and organization of care.

HIV infection in women: impact on contraception.

A study was performed to evaluate the impact of knowledge of HIV infection (diagnosis) on contraception information and choices for HIV infected women. A questionnaire was given to 140 HIV infected women. Most of the studied population included young women with a low educational level. A significant increase in the knowledge of contraceptive methods was observed after diagnosis of being HIV infected. The data suggested that the women who received information had never received it before, or that the diagnosis created a stronger motivation to listen to the counseling offered. A significant increase in the use of contraceptive methods was also found, especially male condoms and tubal ligation. Total number of children had a strong impact on contraceptive method at the time of interview. Only 5 of 23 HIV infected women who had no children used hormonal contraceptives, while 15 of 23 preferred condom use, and 3 of 23 chose not to use any contraceptive method. Tubal ligation was performed in approximately 9% of the women who had only one child. However, 12.4% of the sexually active HIV infected women were still not using any contraceptive method at the time of the interview. A combined method (male condom plus another contraceptive) was used by only 27% of sexually active HIV infected women, despite health service counseling. In conclusion, the realization of being HIV infected had a strong impact on contraceptive practice among these women. It is expected that HIV and family planning clinics will address HIV infected womens needs and be prepared to integrate contraception and gynecological care.

Effect of antiretroviral therapy including lopinavir/ritonavir or efavirenz on etonogestrel-releasing implant pharmacokinetics in HIV-positive women.

Objective:Data on the interaction between the etonogestrel (ENG) implant and antiretroviral therapy are lacking. We evaluated the effect of 2 highly active antiretroviral therapy (HAART) regimens (1 including efavirenz and the other ritonavir-boosted lopinavir) on the pharmacokinetic (PK) parameters of an ENG-releasing implant in HIV-positive women. Design:Prospective nonrandomized PK study. Methods:Forty-five HIV-positive women who desired to use ENG implants were included: 15 had received zidovudine/lamivudine + lopinavir/ritonavir for ≥3 months (LPV/r-based HAART group), 15 had received zidovudine/lamivudine + efavirenz for ≥3 months (EFV-based HAART group), and 15 had not received HAART (non-HAART group). PK parameters were measured using ultra-performance liquid chromatography–mass spectrometry at baseline and 2, 4, 6, 8, 10, 12, 16, 20, and 24 weeks after implant placement. Results:The EFV-based HAART regimen was associated with a reduction in the bioavailability of ENG, which showed decreases of 63.4%, 53.7%, and 70% in the area under the curve (AUC), maximum concentration (Cmax), and minimum concentration (Cmin) of ENG, respectively, compared with the non-HAART group. The LPV/r-based HAART regimen was associated with an increase in ENG bioavailability, which showed 52%, 60.6%, and 33.8% increases in the ENG AUC, Cmax, and Cmin, respectively, compared with the non-HAART group. Conclusions:The coadministration of EFV decreased the bioavailability of ENG released from the implant, which could impair contraceptive efficacy. However, the coadministration of LPV/r increased the bioavailability of ENG released from the implant, which suggests that this antiretroviral combination does not impair the ENG implant efficacy.

The Impact of Simulated Medical Consultations on the Empathy Levels of Students at One Medical School

Purpose To examine the impact of simulated medical consultations using standardized patients (SPs) on the empathy levels of fourth- and sixth-year students at the Unicamp medical school in Brazil. Method Throughout 2011 and 2012, the authors conducted this study with two classes of fourth-year (n = 124) and two classes of sixth-year (n = 123) medical students. Students completed the medical student version of the Jefferson Scale of Physician Empathy before and after simulated medical consultations with SPs, followed by an in-depth debriefing dealing with the feelings of the patient about the disease, such as fear, guilt, anger, and abandonment; the feelings of the doctor towards the patient; and other topics as they arose. Results The simulation activity increased the empathy scores of the fourth-year students (from 115.8 to 121.1, P < .001, effect size = 0.61) and of the sixth-year students (from 117.1 to 123.5, P < .001, effect size = 0.64). Conclusions Although the study results were obtained via self-report—a limitation—they suggest that the effective simulation of medical consultations with SPs may improve medical students’ empathy levels. One unexpected result was that this activity, during the debriefing, became a forum for debating topics such as the doctor–patient relationship, the hidden curriculum, negative role models, and emotionally significant experiences of students in medical school. This kind of activity in itself may influence young doctors to become more empathetic and compassionate with their patients and foster a more meaningful way of practicing medicine.

Morbidade materna grave em um hospital universitário de referência municipal em Campinas, Estado de São Paulo

PURPOSE to assess the prevalence and risk factors associated with near miss and other severe maternal morbidity at a reference tertiary maternity. METHODS this is a cross-sectional study on severe maternal morbidity at the Hospital e Maternidade Celso Pierro, Campinas, São Paulo, between October 2005 and July 2006, identified from infirmary, admission and delivery unit logbooks. Pregnant and post-partum women with severe maternal morbidity were identified according to clinical criteria proposed by Waterstone. Later, cases with more severe morbidity, called extremely severe maternal morbidity, were reclassified using Mantel criteria, based on organic dysfunction and clinical management. RESULTS there were 114 severe maternal morbidity cases among 2,207 birth deliveries, with a ratio of other severe morbidity and extremely severe morbidity near miss of 44.9 and 6.8 cases/1,000 live births, respectively. Mean gestational age at delivery was 35 weeks, and 87% came from the reference area for the maternity service. Hypertension (severe pre-eclampsia) represented 96% of other severe morbidity, while hemorrhage represented 60% of all extremely severe cases, followed by hypertension. The prevalence of extremely severe morbidity among the severe morbidity cases was not associated with marital status, schooling, maternal age, type of delivery, parity, gestational age at birth and home place. CONCLUSIONS the other morbidities were 6.6 times more frequent than near miss, and it was not possible to differentiate both groups by epidemiological risk factors.

Population surveys using validated questionnaires provided useful information on the prevalence of maternal morbidities

OBJECTIVES To evaluate the ability of population surveys to estimate the occurrence of maternal morbidities. STUDY DESIGN AND SETTING A literature search was conducted using MEDLINE, EMBASE, POPLINE references from relevant papers and proceedings of scientific meetings. No restrictions were made regarding language, date, design, journal, or country. Potentially relevant papers were independently evaluated by two reviewers. Eligible studies were critically evaluated, particularly with respect to complications: eclampsia and other hypertensive complications, hemorrhages, dystocias, and infections. The questions with the highest combined values for sensitivity and specificity were identified in each study. RESULTS Seven hospital-based studies involving 2,907 women were included. The gold standard was the clinical records, and the validation strategy consisted of applying questionnaires and comparing them with the gold standard. Questions regarding eclampsia and other hypertensive complications performed satisfactorily in four studies; questions on dystocia and infection in two studies each, and questions regarding hemorrhagic complications in only one study. In general, when the actual prevalence of the condition is low (<or=5%), surveys tend to overestimate prevalence. CONCLUSIONS Prior validation of questionnaires on maternal morbidity is fundamental to assure adequate information. Population surveys using validated questionnaires may provide useful information on the prevalence of maternal morbidities.

Mother-to-child transmission of human immunodeficiency virus in aten years period

Objectivesto evaluate mother-to-child transmission (MTCT) rates and related factors in HIV-infected pregnant women from a tertiary hospital between 2000 and 2009.Subjects and methodcohort of 452 HIV-infected pregnant women and their newborns. Data was collected from recorded files and undiagnosed children were enrolled for investigation. Statistical analysis: qui-square test, Fisher exact test, Student t test, Mann-Whitney test, ANOVA, risk ratio and confidence intervals.ResultsMTCT occurred in 3.74%. The study population displayed a mean age of 27 years; 86.5% were found to have acquired HIV through sexual contact; 55% were aware of the diagnosis prior to the pregnancy; 62% were not using HAART. Mean CD4 cell-count was 474 cells/ml and 70.3% had undetectable viral loads in the third trimester. HAART included nevirapine in 35% of cases and protease inhibitors in 55%; Zidovudine monotherapy was used in 7.3%. Mean gestational age at delivery was 37.2 weeks and in 92% by caesarian section; 97.2% received intravenous zidovudine. Use of AZT to newborn occurred in 100% of them. Factors identified as associated to MTCT were: low CD4 cell counts, elevated viral loads, maternal AIDS, shorter periods receiving HAART, other conditions (anemia, IUGR (intra uterine growth restriction), oligohydramnium), coinfecctions (CMV and toxoplasmosis) and the occurrence of labor. Use of HAART for longer periods, caesarian and oral zidovudine for the newborns were associated with a decreased risk. Poor adhesion to treatment was present in 13 of the 15 cases of transmission; in 7, coinfecctions were diagnosed (CMV and toxoplasmosis).ConclusionUse of HAART and caesarian delivery are protective factors for mother-to-child transmission of HIV. Maternal coinfecctions and other conditions were risk factors for MTCT.

Implementação oportuna de intervenções para reduzir a transmissão vertical do HIV: uma experiência brasileira bem-sucedida

OBJETIVO: Descrever o impacto da implementacao oportuna de novas condutas recomendadas por consensos clinicos nacionais dirigidos a prevencao da transmissao vertical de HIV na maternidade de um hospital universitario publico no Brasil. METODO: Realizou-se um estudo retrospectivo de coorte dos partos de mulheres infectadas pelo HIV atendidos na instituicao de 1990 a 2000. As condutas adotadas nesse periodo foram: 1) ate 1994, amamentacao contra-indicada, sem uso de drogas anti-retrovirais; 2) de 1995 a 1996, uso de zidovudina (AZT) pela gestante e pelo recem-nascido; 3) de 1997 a 1998, uso de AZT conforme protocolo ACTG 076; e 4) de 1999 a 2000, terapia anti-retroviral multipla e cesarea eletiva. Em todos os periodos, a distribuicao das drogas foi gratuita. Foram calculadas as taxas de transmissao nas quatro fases e as razoes de risco de transmissao congenita para as fases e para cada intervencao profilatica (amamentacao, tipo de terapia anti-retroviral, tipo de parto). RESULTADOS: Foram estudadas 197 gestacoes. Houve reducao na transmissao vertical da primeira para a quarta fase, de 32,3 para 25,7, 2,2 e 2,9%. A maior queda, observada na terceira fase, ocorreu apos a introducao do esquema completo do ACTG 076. O uso de terapia anti-retroviral combinada aumentou de 0% na primeira fase para 46,4% na quarta fase. Nao houve nenhum caso de transmissao vertical nas gestantes tratadas com multiplas drogas. O risco de transmissao vertical foi 5 vezes maior com amamentacao do que sem amamentacao (razao de risco = 5,06), 5 vezes maior sem terapia anti-retroviral contra uso do esquema ACTG completo (razao de risco = 5,29) e 4 vezes maior para parto com forcipe contra cesarea eletiva (razao de risco = 4,13). CONCLUSAO: A adocao oportuna de intervencoes atualizadas, recomendadas por consenso nacional de especialistas, com provisao gratuita de drogas, mostrou-se eficiente para reduzir a transmissao congenita do HIV.

The prolongation of somatic support in a pregnant woman with brain-death: a case report

BackgroundMedical literature has increasingly reported cases of maternal brain death during pregnancy. This is a rare situation which demands the decision and, depending on the gestational age, the implementation of a set of measures to prolong the homeostasis of the human body after brain death for the purpose of maintaining the foetus alive until its viability.Case presentationA 40 year old woman suffered an intracranial haemorrhage during the 25th week of pregnancy. Despite neurosurgical drainage of a gross intraparenchymatous haematoma, the patient developed brain death. Upon confirmation of this diagnosis, she received full ventilatory and nutritional support, vasoactive drugs, maintenance of normothermia, hormone replacement and other supportive measures required to prolong gestation and improve the survival prognosis of her foetus. All decisions regarding the patients treatment were taken in consensus with her family. She also received corticosteroids to accelerate foetal lung maturity. During the twenty-five days of somatic support, the womans condition remained stable; however, during the last seven days the foetus developed oligohydramnios and brain-sparring, which led the medical team to take the decision to perform a Caesarean section at that moment. After delivery, the patients organs were removed for donation. The male infant was born weighing 815 g, with an Apgar score of 9 and 10 at the first and fifth minutes, respectively. The infant was admitted to the neonatal intensive care unit, but did not require mechanical ventilation and had no major complications. He was discharged at 40 days of life, with no sequelae and weighing 1850 g.ConclusionThese results are in accordance with findings from previous studies and case reports suggesting the appropriateness and safety of extended somatic support during pregnancy under certain circumstances. They also suggest the need for prompt diagnosis of brain death before the occurrence of physiological degeneration, rapid evaluation of foetal status and the decision of the family together with the medical team to prolong maternal somatic support. The occurrence of maternal brain death is a tragedy, but it may also represent a challenging opportunity to save the life of the foetus and, in addition, permit donation of the maternal organs.