Patricia Moretti Rehder

Brazilian multicentre study on preterm birth (EMIP): prevalence and factors associated with spontaneous preterm birth.

Background Preterm birth rate is increasing and is currently a worldwide concern. The purpose of this study was to estimate the prevalence of preterm birth in a sample of health facilities in Brazil and to identify the main risk factors associated with spontaneous preterm births. Methods and Findings This was a multicentre cross sectional study on preterm births in 20 referral obstetric hospitals with a case-control component to identify factors associated with spontaneous preterm birth. Surveillance was implemented at all centres to identify preterm births. For eligible consenting women, data were collected through a post-delivery questionnaire completed with information from all mother-newborn medical records until death or discharge or at a maximum of 60 days post-delivery, whichever came first. The risk of spontaneous preterm birth was estimated with OR and 95%CI for several predictors. A non-conditional logistic regression analysis was then performed to identify independently associated factors. The overall prevalence of preterm birth was 12.3%. Among them, 64.6% were spontaneous and 35.4% therapeutic. In the case-control component, 2,682 spontaneous preterm births were compared to a sample of 1,146 term births. Multivariate analyses identified the following as risk factors for spontaneous preterm birth among women with at least one previous birth: a previous preterm birth (ORadj = 3.19, 2.30–4.43), multiple pregnancy (ORadj = 29.06, 8.43–100.2), cervical insufficiency (ORadj = 2.93, 1.07–8.05), foetal malformation (ORadj = 2.63, 1.43–4.85), polyhydramnios (ORadj = 2.30, 1.17–4.54), vaginal bleeding (ORadj = 2.16, 1.50–3.11), and previous abortion (ORadj = 1.39, 1.08–1.78). High BMI (ORadj = 0.94, 0.91–0.97) and weight gain during gestation (ORadj = 0.92, 0.89–0.95) were found to be protective factors. Conclusions The preterm birth rate in these health facilities in Brazil is high and spontaneous preterm births account for two thirds of them. A better understanding of the factors associated with spontaneous preterm birth is of utmost importance for planning effective measures to reduce the burden of its increasing rates.

The Burden of Provider-Initiated Preterm Birth and Associated Factors: Evidence from the Brazilian Multicenter Study on Preterm Birth (EMIP)

Background About 15 million children are born under 37 weeks of gestation worldwide. Prematurity is the leading cause of neonatal deaths and short/long term morbidities, entailing consequences not only for the individual, but also their family, health agencies, facilities and all community. The provider-initiated preterm birth is currently one of the most important obstetric conditions related to preterm births, particularly in middle and high income countries, thus decreasing the need for therapeutic preterm birth is essential to reduce global prematurity. Therefore detailed knowledge on the factors associated with provider-initiated preterm birth is essential for the efforts to reduce preterm birth rates and its consequences. In this current analysis we aimed to assess the proportion of provider-initiated (pi-PTB) among preterm births in Brazil and identify associated factors. Methods and Findings This is an analysis of a multicenter cross-sectional study with a nested case-control component called Brazilian Multicenter Study on Preterm Birth (EMIP). EMIP was conducted in 20 referral obstetric hospitals located in the three most populated of the five Brazilian regions. We analysed data of women with pi-PTB, defined as childbirth occurring at less than 37 weeks, medically indicated for maternal/fetal compromise or both; and women with term birth, childbirth at or after 37 weeks. Maternal, sociodemographic, obstetric, prenatal care, delivery, and postnatal characteristics were assessed as possible factors associated with pi-PTB, compared to term births. The overall prevalence of preterm births was 12.3%. Of these, approximately one-third of cases were initiated by the provider. Hypertensive disorders, placental abruption, and diabetes were the main maternal conditions leading to pi-PTB. Caesarean section was the most common mode of delivery. Chronic hypertension (OR 7.47; 95%CI 4.02–13.88), preeclampsia/eclampsia/HELLP syndrome (OR 15.35; 6.57–35.88), multiple pregnancy (OR 12.49; 4.86–32.05), and chronic diabetes (OR 5.24; 2.68–10.25) were the most significant factors independently associated with pi-PTB. Conclusions pi-PTB is responsible for about one-third of all preterm births, requiring special attention. The decision-making process relative to the choice of provider-initiated birth is complex, and many factors should be elucidated to improve strategies for its prevention, including evidence-based guidelines on proper management of the corresponding clinical conditions.

Progestin-only contraception prevents bone loss in postpartum breastfeeding women

BACKGROUND There are an increase in bone loss during the first 6 months postpartum and a complete recovery postweaning. A few studies of steroid contraceptive use during this period provide some evidence towards protection of bone loss with progestin-only contraceptive methods. OBJECTIVE The study was conducted to evaluate forearm bone mineral density (BMD) of breastfeeding postpartum women using nonhormonal and progestin-only contraceptive methods. STUDY DESIGN A prospective cohort study of postpartum women had an analysis performed at 6 months postpartum correlating BMD with contraceptive use. Forearm BMD was measured 7-10 days, 3 months and 6 months postpartum. Eighty-two women were analyzed, comparing nonhormonal (54) and progestin-only (28) contraceptive methods. Information about breastfeeding duration, amenorrhea and body mass index was collected. RESULTS Baseline characteristics of the study population showed no statistical differences between the groups. The median duration of breastfeeding for both groups was 183 days. A significant BMD decrease was observed for the nonhormonal group (p<.001); however, no statistical difference was detected for the progestin-only group. Body mass index, BMD at 7-10 days postpartum and total duration of breastfeeding were positively correlated with BMD at 6 months. CONCLUSIONS Our findings suggest a preventive effect towards postpartum bone loss with progestin-only contraception in breastfeeding women.

Maternal mortality in a reference center in the Brazilian Southeast

PURPOSE To describe the prevalence of maternal mortality at a tertiary care hospital and to assess its preventability. METHODS This study, through the analysis of maternal deaths that occurred during the period from 1999 to 2010 at a reference in Campinas--Brazil, CAISM/ UNICAMP, discusses some of the factors associated with the main causes of death and some structural problems of structure of the health services. It is a retrospective descriptive study with evaluation of sociodemographic variables and the medical and obstetric history of women, and the causes of death. RESULTS The majority of maternal deaths occurred due to direct obstetric (45%) and avoidable (36%) causes, in women with preterm gestation, who delivered by cesarean section (56%) and received various management procedures, including blood transfusion, ICU admission and need for laparotomy and/or hysterectomy. The hospital transfer was associated with the predominance of direct obstetric (19 versus 6, p=0.02) and avoidable causes (22 versus 9, p=0.01). CONCLUSIONS We conclude that, despite current advances in Obstetrics, infections and hypertensive disorders are still the predominant causes of maternal mortality. We observed an increase of clinical-surgical conditions and neoplasms as causes of death among women during pregnancy.

Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100g normal

PURPOSE to determine the prevalence of adverse gestational and neonatal outcomes in women with a positive screening and negative diagnosis for gestational diabetes mellitus (GDM). METHODS a retrospective descriptive cross-sectional study was conducted from 2000 to 2009 on 409 women with positive screening for GDM. The maternal variables studied were: age, body mass index, history of cesarean section, macrosomia or diabetes mellitus in a previous pregnancy and a personal or family history of diabetes mellitus and chronic arterial hypertension. The neonatal variables studied were: polyhydramnios, gestational age at birth, prematurity, cesarean delivery, large for gestational age (LGA) newborn, macrosomia, Apgar score, neonatal respiratory distress syndrome, hypoglycemia and hyperbilirubinemia. Uni- and multivariate descriptive analyses were first performed regarding risk factors and neonatal outcome and the prevalences and respective 95% confidence intervals were determined. RESULTS the route of delivery was cesarian section in 255 cases (62.3%), preterm birth occurred in 14.2% of cases and 19.3% of the newborns were LGA. The risk factors correlated with LGA newborns were overweight or obesity, maternal age and a history of macrosomia in a previous pregnancy. CONCLUSIONS a high rate of LGA newborns was observed in the population with positive risk factors or altered fasting glycemia on the occasion of the first prenatal visit, even when the glycemia curve was normal, with cesarean rates above those habitually observed in populations considered to be of low risk. Pregnant women with these characteristics represent a differential group.OBJETIVO: avaliar a frequencia de resultados gestacionais e neonatais desfavoraveis em mulheres com rastreamento positivo e diagnostico negativo para diabetes mellitus gestacional. METODOS: trata-se de um estudo de corte transversal, retrospectivo e descritivo realizado entre 2000 e 2009. Foram incluidas no estudo 409 gestantes com rastreamento positivo para diabetes mellitus. As variaveis estudadas foram: maternas (idade, indice de massa corporea, antecedente de cesarea, macrossomia ou diabetes mellitus em gestacao anterior, antecedente pessoal e familiar de diabetes mellitus e hipertensao arterial cronica) e neonatais (poli-hidrâmnio, idade gestacional por ocasiao do parto, prematuridade, cesarea, recem-nascido (RN) grande para idade gestacional (GIG), macrossomia, indice de Apgar, sindrome do desconforto respiratorio, hipoglicemia e hiperbilirrubinemia). Inicialmente foi realizada analise descrita uni e multivariada para a ocorrencia de fatores de risco e desfechos neonatais. Foram descritas as prevalencias e respectivos intervalos de confianca a 95%. RESULTADOS: em 255 (62,3%) das gestantes a via de parto foi cesarea. Quanto aos resultados perinatais, 14,2% dos RN foram classificados como prematuros e 19,3% dos RN como GIG. Os fatores de risco correlacionados com RN GIG foram sobrepeso ou obesidade, idade materna e antecedente de macrossomia em gestacao anterior. CONCLUSOES: na populacao com fatores de risco positivos ou glicemia de jejum alterada na primeira consulta do pre-natal, mesmo com curva glicemica normal observa-se taxa de RN GIG elevada assim como indice de cesarea acima dos valores habitualmente presentes nas populacoes consideradas de baixo risco. As gravidas com tais caracteristicas constituem um grupo diferenciado.

Methodological issues on planning and running the Brazilian Multicenter Study on Preterm Birth.

Objectives. Assuming that the occurrence of preterm births and their maternal and neonatal associated conditions in Brazil are not completely known, a multicenter study was proposed. The purpose of this paper is to describe the methods used, its processes, achievements, and challenges. Study Design. A multicenter cross-sectional study on preterm births in Brazilian facilities plus a nested case-control study to assess their associated factors. A description of all steps of planning and implementing such a nationwide study, including strategies for dealing with problems arising during the process, is presented. Results. 20 referral hospitals in different regions of Brazil participated in the study. A detailed questionnaire for data collection, an electronic platform for data transcription and monitoring, research materials, and specific monitoring tools were developed; then data management and analyses were performed. Finally, we got information on 4,150 preterm births and 1,146 term births. Conclusions. This study represented the first step of a planned comprehensive assessment of preterm birth in Brazil, with detailed information that will lead to several analyses and further studies, bringing the knowledge to improve screening, diagnosis, and treatment practices in maternal and perinatal health with the final purpose of reducing the burden of this condition in the country.

The prognostic value of a normal oral glucose tolerance test in pregnant women who tested positive at screening: a validation study

BackgroundControversies surround a diagnosis of gestational diabetes mellitus (GDM). The objective of this study was to evaluate the oral glucose tolerance test (OGTT) for the prediction of adverse gestational and perinatal outcomes in pregnant women with a positive screening test for diabetes mellitus and a negative diagnosis, i.e. a normal 3-hour OGTT.MethodsThis validation study evaluated 409 pregnant women who tested positive for diabetes mellitus at screening. Perinatal and maternal outcomes were considered. Sensitivity and specificity were calculated for each of the values of the OGTT as a diagnostic test, with the gold standard being perinatal outcome.ResultsThe most frequent risk factors were obesity, arterial hypertension and advanced maternal age. The most common neonatal outcomes were large-for-gestational-age infants, Cesarean delivery and preterm birth. A fasting blood glucose level of 87 mg/dL was the most powerful predictor of adverse perinatal outcome.ConclusionsAt the cut-off level adopted by the American Diabetes Association, gestational OGTT was able to successfully identify in which pregnant women outcome would be unfavorable.

Prevalência de anticorpos antifosfolípides em diabéticas gestacionais e pré-gestacionais

OBJETIVO: identificar e descrever a prevalencia de anticorpos antifosfolipides (anticorpo anticardiolipina e anticoagulante lupico) em gestantes diabeticas. METODOS: estudo prospectivo de prevalencia, realizado no periodo de julho de 2003 a marco de 2004. Foram estudadas 56 gestantes diabeticas gestacionais e pre-gestacionais que ingressaram ao pre-natal e aceitaram participar do estudo. Nenhuma gestante foi excluida. Se um ou outro anticorpo estivesse presente, a gestante seria tratada com heparina e acido acetilsalicilico. Foram caracterizados os perfis da gestante, a evolucao da gestacao e o recem-nascido. RESULTADOS: foram diagnosticados anticorpos antifosfolipides em apenas quatro gestantes das 56 estudadas, o que representou prevalencia de 7% (IC 95% - 0,1-13,9). Nas gestantes diabeticas com anticorpos antifosfolipides a duracao do diabetes foi de cinco anos ou mais. A idade variou de 27 a 38 anos, sendo uma primigesta, outra secundigesta e as outras duas multiparas. As gestantes com anticorpos antifosfolipides, que foram tratadas, tiveram recem-nascidos vivos, de termo, cujos pesos variaram entre 2.650 g e 4.000 g. CONCLUSAO: a prevalencia de anticorpos antifosfolipides em gestantes diabeticas gestacionais e baixa, e similar a populacao geral de gravidas. Esta prevalencia aumenta quando a gestante e diabetica pre-gestacional.

Tocolysis among Women with Preterm Birth: Associated Factors and Outcomes from a Multicenter Study in Brazil

OBJECTIVE  To evaluate the use of tocolysis in cases of preterm birth due to spontaneous preterm labor in a Brazilian sample. METHODS  A sample of 1,491 women with preterm birth due to spontaneous preterm labor were assessed, considering treatment with tocolysis or expectant management, according to gestational age at birth (< 34 weeks and 34 to 36 + 6 weeks) and drugs prescribed. The study took place in 20 Brazilian hospitals from April 2011 to July 2012. Bivariate analyses were conducted to evaluate associations with sociodemographic and obstetric characteristics and odds ratios with their respective 95% confidence intervals were estimated for maternal and neonatal outcomes. RESULTS  A total of 1,491 cases of preterm birth were considered. Tocolysis was performed in 342 cases (23%), 233 of which (68.1%) were delivered before 34 weeks. Within the expectant management group, 73% was late preterm and with more advanced labor at the time of admission. The most used drugs were calcium channel blockers (62.3%), followed by betamimetics (33%). Among the subjects in the tocolysis group, there were more neonatal and maternal complications (majority non-severe) and an occurrence of corticosteroid use that was 29 higher than in the expectant management group. CONCLUSION  Tocolysis is favored in cases of earlier labor and also among those with less than 34 weeks of gestation, using preferably calcium channel blockers, with success in achieving increased corticosteroid use. Tocolysis, in general, was related to higher maternal and neonatal complication rates, which may be due to the baseline difference between cases at admission. However, these results should raise awareness to tocolysis use.

Evaluation of prenatal corticosteroid use in spontaneous preterm labor in the Brazilian Multicenter Study on Preterm Birth (EMIP)

To evaluate prenatal corticosteroid use in women experiencing spontaneous preterm labor and preterm delivery.