Marília da Glória Martins

Impact of maternal age on perinatal outcomes and mode of delivery

OBJETIVO: analisar a associacao entre idade materna, resultados perinatais e via de parto. METODOS: foram analisadas as informacoes de todas as pacientes atendidas no Servico de Obstetricia e Ginecologia de um hospital universitario terciario do Maranhao, no periodo de Julho a Dezembro de 2006. Foram alocadas em tres grupos: adolescentes (10 a 19 anos), adultas (20 a 34 anos) e mulheres de idade avancada (>35 anos). As variaveis estudadas foram cor, escolaridade, situacao conjugal, renda familiar, paridade, numero de consultas no pre-natal, idade gestacional no inicio do pre-natal, local do pre-natal, duracao da gestacao, tipo de parto, indice de Apgar no quinto minuto e peso ao nascer. Os dados foram processados no programa Epi-Info versao 3.4.1 e foram analisadas as associacoes entre as variaveis pela razao dos produtos cruzados, a Odds Ratio (OR), com intervalo de confianca (IC) de 95%. O nivel de significância adotado foi de 0,05. RESULTADOS: em 2.196 pacientes, foi verificada frequencia de 25% dos partos em adolescentes, 69% em adultas e 6% de mulheres em idade avancada. Entre as adolescentes foi verificado maior risco de prematuridade (OR=1,46;IC95%=1,14-1,88) e baixo peso ao nascer (OR=1,47; IC95%=1,13-1,90), maior frequencia de partos normais entre todos os grupos (65,2%), alem da associacao com inicio tardio do pre-natal (OR=1,86; IC95%=1,43-2,43), menor numero de consultas (OR=2,03;IC95%=1,57-2,63) e uso de abortivo no inicio da gestacao (OR=2,34; IC95%=1,38-3,98). Em mulheres com idade avancada constatamos forte associacao com diabetes mellitus (OR=9,00; IC95%=3,18-25,19), pre-eclâmpsia (OR=4,38; IC95%=3,02-6,34), ruptura prematura de membranas (OR=5,81; IC95%=3,08-10,89), alem de maior chance do indice de Apgar no quinto minuto ser menor que sete (OR=2,90; IC95%=1,37-6,01) e maior frequencia de parto operatorio cesareo (60,3%). CONCLUSOES: a gravidez na adolescencia esteve associada a inicio tardio e menor numero de consultas no pre-natal, uso de abortivo no inicio da gestacao, baixa escolaridade, ausencia de companheiro, baixo peso ao nascer, prematuridade e menor incidencia de desproporcao cefalo-pelvica e pre-eclâmpsia. No grupo de gestantes com idade avancada houve maior frequencia de diabetes, pre-eclâmpsia, ruptura prematura das membranas, indice de Apgar no quinto minuto menor que sete e maior frequencia de parto operatorio cesareo.

Gravidez na adolescência e fatores associados com baixo peso ao nascer

OBJETIVO: analisar a associacao da gravidez na adolescencia com o baixo peso ao nascer (BPN). METODOS: foram incluidas todas as pacientes que tiveram parto num hospital terciario universitario do Maranhao no periodo de julho a dezembro de 2006, alocando-as em dois grupos: adolescentes (dez a 19 anos de idade) e adultas (20 a 34 anos). As variaveis estudadas foram: cor, escolaridade, situacao conjugal, renda familiar, numero de consultas no pre-natal, idade gestacional no inicio do pre-natal, local do pre-natal, duracao da gestacao, tipo de parto e peso ao nascer. Os dados foram processados no programa Epi-Info, versao 3.4.1, e foram analisadas as associacoes entre as variaveis pela razao dos produtos cruzados, a Odds Ratio (OR), com intervalo de confianca (IC) de 95%; utilizaram-se tambem modelos de regressao logistica. O nivel de significância adotado foi de 0,05. RESULTADOS: foram avaliadas 1.978 pacientes. Verificou-se frequencia de 25,4% de partos em adolescentes, que apresentaram baixa escolaridade, ausencia de companheiro, menor numero de consultas no pre-natal, inicio tardio do pre-natal, BPN e prematuridade. Realizando a analise, tendo como variavel desfecho o BPN e associacao com prematuridade (OR=29,0), verificou-se nitida associacao com baixo numero de consultas do pre-natal (OR=2,98; IC95%= 2,23-4,00) e inicio tardio do pre-natal (OR=1,91; IC95%=1,3-2,6), baixa escolaridade (OR=1,95; IC95%=1,4-2,5) em relacao com a adolescencia (OR=1,50; IC95%=1,1-1,9). Obtiveram-se resultados similares quando se excluiu a variavel prematuridade. As adolescentes tiveram menor incidencia de cesarea (33,3%) que as adultas (49,4%), com diferenca significativa, alem de menor associacao com pre-eclâmpsia e desproporcao cefalo-pelvica. CONCLUSOES: a gravidez na adolescencia esteve associada a inicio tardio do pre-natal e baixo numero de consultas pre-natal, alem de baixa escolaridade, BPN e menor incidencia de desproporcao cefalo-pelvica e pre-eclâmpsia.

Associação de gravidez na adolescência e prematuridade

PURPOSE To analyze the association of pregnancy in adolescence and prematurity. METHODS The study included all the patients who delivered at a teaching hospital in Maranhão State, from July to December 2006. The patients were divided into two groups: adolescents (10 to 19 years old) and adults (20 to 34 years old). The variables studied were: educational level, marital status, number of prenatal visits, gestational age at the onset of prenatal care, duration of gestation, delivery route and birth weight. Statistical analysis was performed using the Epi-Info software, version 3.4.1, and the associations between variables were analyzed by the odds ratio (OR), with a 95% confidence interval (CI). Models of logistic regression were also used. The level of significance adopted was 0.05. RESULTS The study evaluated 1,978 patients. The frequency of deliveries in adolescents was 25.4%. This group presented low educational level, no mates, low number of prenatal visits, late onset of prenatal care, low birth weight and prematurity. In the analysis of prematurity as the outcome variable, there was a clear association with low number of prenatal visits (OR 3.0; 95%CI 2.2-4.0) and late onset of prenatal care (OR 1.9; 95%CI 1.3-2.6) and low educational level (OR 1.9; 95%CI 1.4-2.5) related to adolescence (OR 1.5; 95%CI 1.1-1.9). The incidence of caesarean delivery was significantly lower among adolescents (33.3%) than among adults (49.4%), with a lower association with pre-eclampsia and cephalo-pelvic disproportion. CONCLUSIONS Pregnancy in adolescence was associated with late onset of prenatal care and low number of visits, as well as low educational level, low birth weight, prematurity and a lower incidence of cephalo-pelvic disproportion and pre-eclampsia.

Proteinúria nas síndromes hipertensivas da gestação: prognóstico materno e perinatal

AIM: The purpose of this study was to determine the role of proteinuria on pregnancy outcome in hypertensive syndrome with singleon pregnancies. METHODS: Transversal study with retrospective data of 334 pregnancies complicated by hypertensive syndromes who were delivered in the Department of Obstetrics of UNIFESP/EPM from January 1, 1999 to December 31, 2002. RESULTS: The patients were divided into four groups: (I) without proteinuria (n-203); (II) with proteinuria of 0.3 to 1.0g (n-39); (III) 1.0 to 2.0g (n-45); and (IV) 2.0g or more. Without proteinuria there was one case of placental abruption. The presence of proteinuria predicted adverse maternal outcome with increase of complications proportional to his elevation; among them, HELLP syndrome was the most frequent with 30.5% (40/131) followed by eclampsia with 3.8% (5/131), DPP 3.1% (4/131) and renal insufficiency with 0.7% (1/131). It was confirmed one maternal death in that group, when Maternal Mortality of 763/100.000nv was added up. As to the perinatal effects there was not increase of adverse effects without proteinuria. In the presence of proteinuria and its levels was observed the worst perinatal outcome with the elevation of the following indicatives: increase prematurety (62.2% vs 11.5%), newborn with weight < 2500g (6.5% vs 1.5%), newborn with Apgar < 7 in the 5th minute (30.4% vs 3.5%), concepts with growing restriction of intrauterine (41.9% vs 6.5%), newborn interned in the neonatal undid, (59.8% vs 15.5%) stillborn (14.4% vs 1.4%), neonatal deaths (6.1% vs 0.98%). The Perinatal Mortality was greater with proteinuria (175 vs 19,7) and, when = 2.0g (297.8 vs 19.6). CONCLUSIONS: The presence of proteinuria in the hipertensives syndromes during gestation and the elevation of their levels increase the risks of maternal complications, especially HELLP syndromes and eclampsia. Besides, it was observed a significative incidence of premature birth, newborn with Apgar < 7, weight < 2500g, IUGR, stillborn and neonatal deaths.

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.

Violência sexual e associação com a percepção individual de saúde entre mulheres gestantes

OBJECTIVE To estimate the prevalence of sexual violence history among pregnant women and its association with the self-perception of health status. METHODS Cross-sectional study including a total of 179 pregnant women older than 14 years old at gestation week 14 to 28 attending public health services in the city of São Paulo, Southeastern Brazil, between 2006 and 2007. Data collection instruments included: questionnaire on sexual violence; questionnaire on sociodemographic data; and an assessment of health-related quality of life using the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12(R)). Age, skin color, education, occupational and marital status, and self-perception of physical and mental health were compared between women with and without a lifetime history of sexual violence. Sexual violence was categorized as penetrative and non-penetrative sex. RESULTS Among all women interviewed, the prevalence of sexual violence was 39.1%, of which 20% were of penetrative type by known perpetrators. In 57% of cases, the first episode of violence was before the age of 14. There were no sociodemographic differences between women with and without history of sexual violence. Mean scores of self-perception of physical health among women with history of sexual violence were lower (42.2; SD= 8.3) compared to those without history of sexual violence (51.0; SD= 7.5) (p<0.001). Mean scores of self-perception of mental health were 37.4 (SD= 11.2) and 48.1 (SD= 10.2) (p<0.001), respectively. CONCLUSIONS There was found high prevalence of sexual violence among pregnant women studied. Women with history of sexual violence showed poorer self-perception of health status compared to those without history of sexual violence.

Microvessel density in the placental bed among preeclampsia patients

CONTEXT AND OBJECTIVE Morphological changes in the spiral arteries of the placental bed have been studied in patients with preeclampsia, one of the largest causes of maternal and perinatal morbidity and mortality. The reports show that vasospasm and vascular endothelial injury were two major pathological conditions for preeclampsia. The aim of this study was to investigate the microvessel density of spiral arteries in the placental bed, in pregnancies complicated by hypertension and proteinuria, and in normal pregnancies. DESIGN AND SETTING This was a cross-sectional survey of immunohistochemical studies on biopsies from the spiral arteries of the placental bed, among women undergoing cesarean sections for clinical and obstetrical reasons at Universidade Federal de São Paulo, São Paulo, Brazil. METHODS Placental bed biopsies were obtained during cesarean section after placenta removal, with direct viewing of the central area of placenta insertion. The microvessel density of spiral arteries was measured by immunohistochemical methods in decidual and myometrial segments, using CD34 antibody. RESULTS Biopsies containing spiral arteries were obtained from 34 hypertensive pregnant women with proteinuria, and 26 normotensive pregnant women. The microvessel densities in decidual and myometrial segments of the placental bed were compared between the groups. It was observed that, with increasing blood pressure and proteinuria, the microvessel density gradually decreased. CONCLUSION The presence of high levels of hypertension and proteinuria may be associated with a progressive decrease in microvessel density in the placental bed.

Prenatal diagnosis of sacrococcygeal teratoma using two and three-dimensional ultrasonography.

Sacrococcygeal teratoma accounts for half of all fetal tumors, with a prevalence of 1 : 40,000 births. It is believed to originate from pluripotent cells in Hensens nodule. Although most are benign, they are associated with high morbidity and mortality rates because the fetus develops congestive heart failure and hydrops. Factors leading to poor prognosis include solid components in the mass, and hydrops diagnosed before the 30th week. A case of prenatal sacrococcygeal teratoma diagnosed using B-mode and color Doppler two-dimensional ultrasonography (2DUS) is described, in which three-dimensional ultrasonography (3DUS) enabled characterization of the extent of fetal lesions and allowed the parents to understand the pathological condition better. A 20-year-old primigravida was referred with a solid mass diagnosed in the lumbosacral spine. Examinations performed at our institution revealed pregnancy of 23 weeks and 4 days, with a female fetus presenting a bulky solid mass with cystic components and calcifications, measuring 7.7 × 9.1 × 12.2 cm, starting from the sacral region, with internal flow seen on color Doppler. A new ultrasound confirmed fetal death at 25 weeks and 4 days. Postnatal findings confirmed the diagnosis of sacrococcygeal teratoma. 3DUS can be used in cases of sacrococcygeal teratoma to assess the development of tumor during the prenatal and to allow better understanding of this anomaly by the parents.

Anormalidades do primeiro trimestre da gravidez: ensaio iconográfico

As anormalidades do primeiro trimestre da gravidez sao detectadas pela ultrassonografia transvaginal em exame de rotina ou em caso de sangramento vaginal anormal. A ameaca de abortamento e uma afeccao comum no primeiro trimestre da gestacao, ocorrendo em mais de um terco dos casos. O advento de sondas vaginais de alta resolucao vem revolucionando nossa compreensao da fisiopatologia e o manejo da gestacao inicial. Trata-se de ferramenta essencial para determinar a viabilidade da gestacao nos casos de ameaca de abortamento. Uma conduta expectante no abortamento poderia reduzir significativamente o numero de esvaziamentos desnecessarios de produtos retidos, dependendo dos criterios utilizados.

Sexual violence and its association with health self-perception among pregnant women

OBJECTIVE To estimate the prevalence of sexual violence history among pregnant women and its association with the self-perception of health status. METHODS Cross-sectional study including a total of 179 pregnant women older than 14 years old at gestation week 14 to 28 attending public health services in the city of São Paulo, Southeastern Brazil, between 2006 and 2007. Data collection instruments included: questionnaire on sexual violence; questionnaire on sociodemographic data; and an assessment of health-related quality of life using the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12(R)). Age, skin color, education, occupational and marital status, and self-perception of physical and mental health were compared between women with and without a lifetime history of sexual violence. Sexual violence was categorized as penetrative and non-penetrative sex. RESULTS Among all women interviewed, the prevalence of sexual violence was 39.1%, of which 20% were of penetrative type by known perpetrators. In 57% of cases, the first episode of violence was before the age of 14. There were no sociodemographic differences between women with and without history of sexual violence. Mean scores of self-perception of physical health among women with history of sexual violence were lower (42.2; SD= 8.3) compared to those without history of sexual violence (51.0; SD= 7.5) (p<0.001). Mean scores of self-perception of mental health were 37.4 (SD= 11.2) and 48.1 (SD= 10.2) (p<0.001), respectively. CONCLUSIONS There was found high prevalence of sexual violence among pregnant women studied. Women with history of sexual violence showed poorer self-perception of health status compared to those without history of sexual violence.