Fernanda Rebelo

High cesarean prevalence in a national population‐based study in Brazil: the role of private practice

Background. Excessive use of cesarean sections (CSs) is a serious problem worldwide. Objective. To estimate the frequency and identify factors associated with cesarean deliveries in Brazil. Design. Cross‐sectional study conducted in 2006–2007 as part of the third edition of the Childrens and Womens National Demographic and Health Survey. Setting. Brazil. Sample. Brazilian women in reproductive age. Methods. Socioeconomic and demographic data were utilized, including maternal age, education level, per capita income, skin color, smoking habit, marital status, age at first delivery, parity, and type of prenatal services. Main outcome measures. Adjusted estimate of the prevalence ratios of the type of delivery performed (cesarean or vaginal). Results. Cesarean prevalence was 43.9% (95% CI: 40.9–46.9), 68.7% for women who had per capita income greater than US

C-reactive protein and later preeclampsia: systematic review and meta-analysis taking into account the weight status.

125 per month, and 77.2% for those who had attended private or privately insured prenatal services. In the adjusted analysis, the variables that presented significant prevalence ratios (95% confidence interval) were macro‐region [southeast = 1.45 (1.21–1.73); south = 1.48 (1.24–1.77), and midwest = 1.43 (1.21–1.71)], maternal age above 25 years [26–30 years = 1.57 (1.25–1.97); ≥ 31 years = 1.77 (1.39–2.27)], education levels ≥ 9 years (PR = 1.86, 95% CI: 1.55–2.23), and having attended private or privately insured prenatal services (PR = 1.87, 95% CI: 1.65–2.12) and parity [primipara = 1.87 (1.47–2.36)]. Conclusions. CS rates are generally very high in Brazil. They are significantly higher than the average among women attending private/insured antenatal care, among the highly educated, and in provinces with higher socioeconomic levels.

Fatores associados à retenção de peso pós-parto em uma coorte de mulheres, 2005-2007

Objectives: This study aims to determine whether high C-reactive protein (CRP) concentration during pregnancy is associated with later preeclampsia and whether weight status (BMI) is a potential modifier of the relation between CRP and preeclampsia. Methods: Twenty-three studies were included in a systematic literature review and a subset of 18 in a meta-analysis. Weighted mean difference (WMD) [with their 95% confidence intervals (CI)] of CRP in preeclampsia and control groups was the estimator. A quality assessment was carried out using a scale specifically developed for this study. Meta-regression with estimates for study characteristics and inter-arm differences and sensitivity and subgroup analysis was employed. Statistical heterogeneity was investigated using I2 statistic. Results: The pooled estimated CRP between 727 women, who developed preeclampsia and 3538 controls was 2.30 mg/l (95% CI: 1.27–3.34). The heterogeneity among studies was high (I2 = 92.8). The WMD was found to be lower in studies comprising preeclampsia and control groups with similar BMI [WMD = 0.85 (95% CI: 0.10–1.61); I2 = 25.3%] compared with studies among which BMI was significantly elevated in the preeclampsia group [2.01 (95% CI: 1.23–2.78); I2 = 0.0%], which may explain the high heterogeneity of pooled data. Meta-regression results confirmed that difference in BMI between groups modifies the association of CRP and preeclampsia. High quality studies represented 30%. Conclusion: The pooled WMD suggest that women with higher levels of CRP may have an increased risk of developing preeclampsia. This association seems to be modified by confounders, such as BMI. Further studies of high methodological quality are needed.

Association of Prepregnancy Dietary Patterns and Anxiety Symptoms from Midpregnancy to Early Postpartum in a Prospective Cohort of Brazilian Women

OBJETIVO: investigar fatores associados a retencao de peso pos-parto. METODOS: estudo de coorte com 104 gestantes recrutadas em uma Unidade Basica de Saude no municipio do Rio de Janeiro, da 8a a 13a semana de gestacao e acompanhadas ate aproximadamente 55 dias pos-parto. As variaveis incluiram informacoes socio-demograficas, economicas, bioquimicas, antropometricas e reprodutivas. A retencao de peso pos-parto (diferenca entre o peso pos-parto e o peso pre-gestacional) foi utilizada como variavel dependente. RESULTADOS: a media de peso retido foi 3,2 kg ± 3,7 kg. As mulheres com ganho de peso gestacional (GPG) excessivo retiveram 5,0 kg ± 3,9 em comparacao a 3,6 kg ± 3,0 em mulheres com GPG adequado e 1,4 kg ± 3,1 para as com GPG insuficiente. O GPG e o Indice de Massa corporal (IMC) pre-gestacional mantiveram associacao significativa com a retencao de peso no modelo final. Observou-se que a cada quilo de peso ganho na gestacao, quase 50% ficaram retidos no pos-parto (β = 0,494; p<0,001) e a cada 1,0 kg/m2 a menos no IMC pre-gestacional correspondeu a uma retencao de aproximadamente 150g (β = -0,149;p<0,05). CONCLUSAO: o GPG esta positivamente e o IMC pre-gestacional inversamente associado a retencao de peso pos-parto. Orientacoes nutricionais sobre o controle do ganho ponderal podem ajudar a minimizar a incidencia de obesidade entre mulheres no pos-parto.

Blood Pressure Variation Throughout Pregnancy According to Early Gestational BMI: A Brazilian Cohort

BACKGROUND Adherence to unhealthy dietary patterns may alter the risk of mental disorders during pregnancy and the postpartum period. OBJECTIVE To analyze the association between prepregnancy dietary patterns and prospective variations on anxiety symptoms from midpregnancy to early postpartum. METHODS A prospective cohort of 207 healthy pregnant women was followed at 5 to 13, 20 to 26, and 30 to 36 gestational weeks, and once at 30 to 45 days postpartum. The State-Trait Anxiety Inventory was used to evaluate anxiety symptoms at the second and third gestational trimesters and during the postpartum period. Dietary intake was assessed using a food frequency questionnaire administered during the first trimester of pregnancy that referred to the 6 months before pregnancy. Principal components analysis was used to identify dietary patterns and three prepregnancy dietary patterns were identified: common-Brazilian, healthy, and processed. Three longitudinal mixed-effect models were estimated to verify the association between dietary patterns and anxiety symptoms, adjusted for confounding variables. RESULTS The mean anxiety symptom scores were 40.4, 40.5, and 37.2 for the second trimester, third trimester, and postpartum, respectively. The rate of variation of the State-Trait Anxiety Inventory score was 0.535 (95% CI -0.035 to 1.107; P=0.066) and -0.010 (95% CI -0.018 to -0.002; P=0.019) when accounting for gestational age and quadratic gestational age, respectively. The common-Brazilian pattern, comprised mainly of rice and beans (β=-1.200, 95% CI -2.220 to -0.181; P=0.021), and the healthy pattern comprised mostly of vegetables, fruits, fish, and tea (β=-1.290, 95% CI -2.438 to -0.134; P=0.029), were negatively associated with prospective changes in anxiety symptoms. CONCLUSIONS High adherence to the common-Brazilian or healthy patterns was negatively associated with higher anxiety symptom scores from mid-pregnancy to early postpartum in this group of Brazilian women.

Factors associated with maternal serum C-reactive protein throughout pregnancy: A longitudinal study in women of Rio de Janeiro, Brazil.

Background The maternal cardiovascular system undergoes progressive adaptations throughout pregnancy, causing blood pressure fluctuations. However, no consensus has been established on its normal variation in uncomplicated pregnancies. Objective To describe the variation in systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels during pregnancy according to early pregnancy body mass index (BMI). Methods SBP and DBP were measured during the first, second and third trimesters and at 30-45 days postpartum in a prospective cohort of 189 women aged 20-40 years. BMI (kg/m2) was measured up to the 13th gestational week and classified as normal-weight (<25.0) or excessive weight (≥25.0). Longitudinal linear mixed-effects models were used for statistical analysis. Results A decrease in SBP and DBP was observed from the first to the second trimester (βSBP=-0.394; 95%CI: -0.600- -0.188 and βDBP=-0.617; 95%CI: -0.780- -0.454), as was an increase in SBP and DBP up to 30-45 postpartum days (βSBP=0.010; 95%CI: 0.006-0.014 and βDBP=0.015; 95%CI: 0.012-0.018). Women with excessive weight at early pregnancy showed higher mean SBP in all gestational trimesters, and higher mean DBP in the first and third trimesters. Excessive early pregnancy BMI was positively associated with prospective changes in SBP (βSBP=7.055; 95%CI: 4.499-9.610) and in DBP (βDBP=3.201; 95%CI: 1.136-5.266). Conclusion SBP and DBP decreased from the first to the second trimester and then increased up to the postpartum period. Women with excessive early pregnancy BMI had higher SBP and DBP than their normal-weight counterparts throughout pregnancy, but not in the postpartum period.

Total cholesterol and leptin concentrations are associated with prospective changes in systemic blood pressure in healthy pregnant women.

OBJECTIVES The aim of this study was to evaluate the longitudinal changes of C-reactive protein (CRP) concentrations during pregnancy and to assess whether socioeconomic, anthropometric, dietary, behavioral, and biochemical factors are associated with these changes. METHODS This was a prospective cohort study of 115 adult pregnant women, followed at gestational weeks 5 to 13, 20 to 26, and 30 to 36. Serum concentrations of CRP (mg/L) were measured by the immunoturbidimetric method with ultrasensitive kits (sensitivity 0.05 mg/dL). The statistics included descriptive analysis (mean + SD) and longitudinal linear mixed-effects models, reporting the β coefficient and 95% confidence intervals (CI). RESULTS Serum CRP concentrations progressively increased throughout pregnancy (β = 0.121; 95% CI, 0.071-0.171). Parity (β = 1.579; 95% CI, 0.731-2.427) and prepregnancy body mass index (BMI) (β = 0.316; 95% CI, 0.053-0.587) were positively associated and dietary glycemic load was negatively associated (β = -0.203; 95% CI, -0.380 to -0.026) with CRP concentrations in the multiple model. Prepregnancy obese women presented a more pronounced increase of CRP concentrations compared with normal weight women (β = 0.210; 95% CI, 0.059-0.360 versus 0.115, respectively; 95% CI, 0.049-0.181). A statistically significant interaction was observed between parity and gestational age (β = -0.045; 95% CI, -0.084 to -0.005), indicating that the variation of CRP throughout pregnancy differed according to parity categories. CONCLUSION CRP concentrations increased throughout pregnancy. Parity and prepregnancy BMI were positively associated and dietary glycemic load was negatively associated with concentrations of CRP.

Blood Pressure in Healthy Pregnancy and Factors Associated With No Mid-Trimester Blood Pressure Drop: A Prospective Cohort Study

Background: Lipids and leptin have been associated with high blood pressure (BP) levels during pregnancy. The aim was to evaluate the associations between serum lipids and leptin concentrations during the first trimester and longitudinal changes of SBP and DBP in healthy pregnancies. Methods: Prospective cohort of pregnant women followed at a public healthcare center in Rio de Janeiro, Brazil. SBP and DBP were obtained at the ⩽13th, 20–26th, and 30–36th weeks of gestation and were the dependent variables. Serum lipids and plasma leptin concentrations were collected at 13 weeks or less of gestation and were the main independent variables. Statistical analyses included longitudinal linear mixed-effects regression models, with (&bgr;) coefficients and their 95% confidence intervals (CI). Results: Mean BPs were 109.8/66.9, 107.8/64.3, and 111.2/66.9 mmHg, respectively in the 1st, 2nd, and 3rd trimester. Multiple longitudinal regressions revealed that leisure time physical activity before pregnancy (&bgr;SBP = −3.003, 95% CI = −5.034 to −0.971; &bgr;DBP = −2.620, 95% CI = −4.177 to −1.064), baseline BMI (&bgr;SBP = 4.003, 95% CI = 1.924–6.081; &bgr;DBP = 1.862, 95% CI = 0.252–3.412), parity (&bgr;SBP = −2.778, 95% CI = −4.627 to −0.929; &bgr;DBP = −1.780, 95% CI = −3.168 to −0.392), and Homeostasis model of assessment-Insulin Resistance (HOMA-IR; &bgr;SBP = 2.554, 95% CI = 0.552–4.557; &bgr;DBP = 2.962, 95% CI = 1.436–4.489) were the covariates independently associated with SBP and DBP changes. Monthly per-capita family income (&bgr;SBP = −0.006, 95% CI = −0.010 to −0.001), total cholesterol (&bgr;SBP = 2.094, 95% CI = 0.223–3.965), and leptin (&bgr;SBP = 2.211, 95% CI = 0.159–4.263) were associated only with SBP changes. Conclusion: Serum total cholesterol and leptin concentrations, HOMA-IR, and BMI were positively associated with changes in BP during healthy pregnancies, whereas physical activity, parity, and family income were negatively associated.

Plasma adiponectin is inversely associated with antenatal anxiety: Results from a Brazilian cohort

BACKGROUND The well-known mid-trimester drop in blood pressure (BP) during normal pregnancy was recently questioned. OBJECTIVE To describe longitudinal changes in BP during healthy pregnancies and to investigate factors associated with no mid-trimester drop in BP. METHODS A prospective cohort with 158 healthy pregnant women was followed up in a public health care center in Rio de Janeiro, Brazil. We used linear mixed-effects models to estimate longitudinal changes in systolic BP (SBP) and diastolic BP (DBP) during pregnancy. Poisson regression models were performed to identify factors associated with no mid-trimester drop in BP. RESULTS Significant mid-trimester increase in SBP (5.6 mm Hg; 95% confidence interval (CI) = 4.6-6.7) and DBP (4.4 mm Hg; 95% CI = 3.4-5.3) was observed in 44.3% and 39.9% of the sample, respectively. Women (37.1%) who had not a mid-trimester SBP drop still had a DBP drop. White skin color (incidence ratio (IR): 1.71; 95% CI = 1.22-2.39), family history of hypertension (IR: 1.93; 95% CI = 1.29-2.89), early pregnancy obesity (IR: 2.29; 95% CI = 1.27-4.11), outside temperature variation (IR: 1.45; 95% CI = 1.00-2.10), and gestational weight gain from the first to second trimester (IR: 1.71; 95% CI = 1.01-2.88 and IR: 2.32; 95% CI = 1.39-3.89 for second and third tertiles) were characteristics associated with no mid-trimester drop in SBP. The same characteristics were associated with no mid-trimester drop in DBP, except family history of hypertension and outside temperature variation. CONCLUSIONS Some women without a mid-trimester SBP drop still present a DBP drop. The different patterns of mid-trimester change in BP seem to be determined by preexisting and pregnancy-related factors.

Lower Inter-Partum Interval and Unhealthy Life-Style Factors Are Inversely Associated with n-3 Essential Fatty Acids Changes during Pregnancy: A Prospective Cohort with Brazilian Women

Antenatal anxiety may increase the risk of undesirable birth outcomes. Studies have demonstrated an association between adiponectin and anxiety, but this issue has not been investigated during pregnancy. This study aimed to evaluate the association between plasma adiponectin, measured throughout gestation, and the occurrence of anxiety at late pregnancy (30-36th weeks). A prospective cohort was investigated in Rio de Janeiro, Brazil. Healthy pregnant women, aged 20-40 years, were evaluated between gestational weeks 5-13, 22-26 and 30-36. State anxiety was measured using a validated version of the State-Trait Anxiety Inventory, and women were categorized as high (score≥50, n=30) or low anxiety (score<50, n=129). Plasma samples for all trimesters were analyzed using commercial ELISA kits to determine adiponectin concentrations (U/mL). Statistical analysis involved students t-tests, chi-square, Pearson correlation, multiple logistic regression and linear mixed effects (LME) regression to model longitudinal trends of adiponectin, stratified for anxiety categories. Women with higher anxiety scores had lower mean concentrations of 3rd trimester adiponectin compared with those with lower scores (7.9; 95% CI: 7.0-8.9 vs. 9.9; 95% CI: 9.1-10.7). Women with 3rd trimester adiponectin values within the third tertile (10.47-26.57U/mL) were less likely to have high antenatal anxiety (adjusted OR=0.30; 95% CI: 0.09-0.98) compared with those within the first tertile (2.25-7.08U/mL). Unlike women with low levels of anxiety, those with high levels had a significant decrease of plasma adiponectin throughout pregnancy (β=-0.07; 95% CI: -0.13-[-0.01] vs. β=-0.01; 95% CI: -0.05 to 0.03). Multiple LME model indicated higher adiponectin throughout pregnancy for women with low anxiety (β=-1.57; 95% CI: -2.78-[-0.37]). In conclusion, plasma adiponectin throughout pregnancy was inversely associated with antenatal anxiety.