Ricardo Porto Tedesco

Fatores determinantes para as expectativas de primigestas acerca da via de parto

OBJETIVO: conhecer as expectativas de primigestas com relacao a via de parto, bem como os motivos de sua escolha, procurando melhorar a qualidade do relacionamento medico-paciente. METODOS: foi realizado estudo do tipo qualitativo por meio da analise do sujeito coletivo, incluindo primigestas atendidas de setembro a novembro de 2003 nos pronto-socorros dos servicos da Faculdade de Medicina de Jundiai. Foi aplicado questionario especialmente elaborado para responder aos objetivos propostos pela pesquisa o questionario e baseado nas duvidas apresentadas por pacientes que frequentaram o servico meses antes da elaboracao do projeto. O consentimento livre e esclarecido, assinado pela gestante e por um dos pesquisadores responsaveis. Foi obtido para fins de padronizacao da amostra a selecao das pacientes seguiu criterios de inclusao: idade maior que 16 anos, primigestas, que estivessem recebendo assistencia pre-natal e consentimento pos-informado lido e esclarecido. Foram considerados criterios de exclusao pacientes mentalmente incapacitadas e gestantes de alto risco com doencas que pudessem interferir na escolha da paciente. RESULTADOS: a populacao estudada teve como perfil mais prevalente mulheres com mais de 21 anos, brancas, casadas, com segundo grau completo e que estavam no terceiro trimestre da gestacao. A via de parto de preferencia da maioria das mulheres (90%) foi o parto vaginal normal, sendo que as principais justificativas foram: a praticidade para sua realizacao (94%) e o medo do sofrimento e dor no pos-parto causados pela cesarea. Encontramos relacao entre a preferencia pelo parto vaginal com mulheres de maior idade, casadas, nao havendo diferenca significativa entre as racas. CONCLUSAO: estes resultados nos mostram enorme contraste entre a preferencia das mulheres e os altos indices de cesarea no Brasil. Concluimos que deve haver falha de informacao, falta de dialogo entre os profissionais da saude e a paciente sobre as possiveis dificuldades, duvidas e anseios que permeiam a escolha por determinada via de parto. Do ponto de vista etico concluimos que os obstetras devem questionar cada indicacao para a realizacao de uma cesarea e respeitar a autonomia da escolha materna sem ignorar os verdadeiros criterios clinicos que levam a decisao medica pela via de parto.

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.

Brazilian multicenter study on prevalence of preterm birth and associated factors

BackgroundThe occurrence of preterm birth remains a complex public health condition. It is considered the main cause of neonatal morbidity and mortality, resulting in a high likelihood of sequelae in surviving children. With variable incidence in several countries, it has grown markedly in the last decades. In Brazil, however, there are still difficulties to estimate its real occurrence. Therefore, it is essential to establish the prevalence and causes of this condition in order to propose prevention actions. This study intend to collect information from hospitals nationwide on the prevalence of preterm births, their associated socioeconomic and environmental factors, diagnostic and treatment methods resulting from causes such as spontaneous preterm labor, prelabor rupture of membranes, and therapeutic preterm birth, as well as neonatal results.Methods/DesignThis proposal is a multicenter cross-sectional study plus a nested case-control study, to be implemented in 27 reference obstetric centers in several regions of Brazil (North: 1; Northeast: 10; Central-west: 1; Southeast: 13; South: 2). For the cross sectional component, the participating centers should perform, during a period of six months, a prospective surveillance of all patients hospitalized to give birth, in order to identify preterm birth cases and their main causes. In the first three months of the study, an analysis of the factors associated with preterm birth will also be carried out, comparing women who have preterm birth with those who deliver at term. For the prevalence study, 37,000 births will be evaluated (at term and preterm), corresponding to approximately half the deliveries of all participating centers in 12 months. For the case-control study component, the estimated sample size is 1,055 women in each group (cases and controls). The total number of preterm births estimated to be followed in both components of the study is around 3,600. Data will be collected through a questionnaire all patients will answer after delivery. The data will then be encoded in an electronic form and sent online by internet to a central database. The data analysis will be carried out by subgroups according to gestational age at preterm birth, its probable causes, therapeutic management, and neonatal outcomes. Then, the respective rates, ratios and relative risks will be estimated for the possible predictors.DiscussionThese findings will provide information on preterm births in Brazil and their main social and biological risk factors, supporting health policies and the implementation of clinical trials on preterm birth prevention and treatment strategies, a condition with many physical and emotional consequences to children and their families.

Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil

To evaluate the reported occurrence of spontaneous and induced abortion, and abortion‐associated severe maternal morbidity in Brazil.

Effectiveness and safety of a new vaginal misoprostol product specifically labeled for cervical ripening and labor induction

Objective. The purpose of this study was to evaluate the effectiveness and safety of misoprostol in two different formulations: vaginal tablets of 25 μg and one‐eighth of a 200‐μg oral tablet, also administered intravaginally, for cervical ripening and labor induction of term pregnancies with an indication for that. Methods. A single‐blind, randomized, controlled clinical trial was carried out in 120 pregnant women who randomly received one of the two formulations. The main dependent variables were mode of delivery, need for additional oxytocin, time between beginning of induction and delivery, perinatal results, complications, and maternal side effects. Students t, Mann–Whitney, χ2, Fishers Exact, Wilcoxon and Kolmogorov‐Smirnoff tests, as well as survival analysis, were used in the data analysis. Results. There were no significant differences between the groups in terms of general characteristics, uterine contractility, and fetal well‐being during labor, cesarean section rates, perinatal outcomes, or maternal adverse events. The mean time between the beginning of cervical ripening and delivery was 31.3 h in the vaginal tablet group and 30.1 h in the oral tablet group, a difference that was not statistically significant. Conclusion. The results showed that the 25‐μg vaginal tablets of misoprostol were as effective and safe for cervical ripening and labor induction as the dose‐equivalent fraction of 200‐μg oral tablets.

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.

Cervical ripening methods for labor induction.

Tem sido mundialmente crescente a indicacao de inducao do trabalho de parto. Sabe-se que as condicoes do colo uterino estao diretamente relacionadas com o sucesso da inducao. O conhecimento da anatomia e fisiologia do colo uterino durante a gestacao, bem como as dos diversos metodos de preparo cervical, sao de fundamental importância para que possa ser indicado o melhor metodo para o preparo de colo em uma situacao especifica e consequentemente obter-se melhores resultados nas inducoes do trabalho de parto. Esse e um desafio para os obstetras de um pais em que nem todos os metodos estao disponiveis e acessiveis e com taxas de cesarianas tao elevadas quanto o Brasil. Sao discutidos alguns metodos incluindo a estimulacao dos mamilos, descolamento de membranas, relaxina, ocitocina, prostaglandinas, hialuronidase, mefiprestone, laminaria e sonda Foley.

Intracluster correlation coefficients for the Brazilian Multicenter Study on Preterm Birth (EMIP): methodological and practical implications

BackgroundCluster-based studies in health research are increasing. An important characteristic of such studies is the presence of intracluster correlation, typically quantified by the intracluster correlation coefficient (ICC), that indicate the proportion of data variability that is explained by the way of clustering. The purpose of this manuscript was to evaluate ICC of variables studied in the Brazilian Multicenter Study on Preterm Birth.MethodsThis was a multicenter cross-sectional study on preterm births involving 20 referral hospitals in different regions of Brazil plus a nested case–control study to assess associated factors with spontaneous preterm births. Estimated prevalence rates or means, ICC with 95% confidence intervals, design effects and mean cluster sizes were presented for more than 250 maternal and newborn variables.ResultsOverall, 5296 cases were included in the study (4,150 preterm births and 1,146 term births). ICC ranged from <0.001 to 0.965, with a median of 0.028. For descriptive characteristics (socio-demographic, obstetric history and perinatal outcomes) the median ICC was 0.014, for newborn outcomes the median ICC was 0.041 and for process variables (clinical management and delivery), it was 0.102. ICC was <0.1 in 78.4% of the variables and <0.3 for approximately 95% of them. Most of ICC >0.3 was found in some clinical management aspects well defined in literature such as use of corticosteroids, indicating there was homogeneity in clusters for these variables.ConclusionsClusters selected for Brazilian Multicenter Study on Preterm Birth had mainly heterogeneous findings and these results can help researchers estimate the required sample size for future studies on maternal and perinatal health.

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.

Efetividade de duas diferentes doses de misoprostol por via vaginal para preparo cervical e indução do parto

PURPOSE: to compare the effectiveness and safety of two different doses of misoprostol (12.5 mg and 25 mg) administered vaginally for cervical ripening and labor induction in term pregnancies with an indication for interruption. METHODS: this was a pilot randomized controlled single blinded trial, including 40 pregnant women treated with one of the two different doses of misoprostol. The independent variable was the dose of misoprostol and the main dependent variables were the mode of delivery, time between induction and delivery, perinatal complications and maternal side effects. The main control variables were maternal age, gestational age, literacy, parity, skin color and conditions of the cervix at the beginning of induction. For data analysis Students t test, c2, exact Fisher, Wilcoxon and Kolmogorov-Smirnof tests were used, besides survival analysis. RESULTS: the groups using 12.5 and 25 mg were similar and did not present any significant difference regarding time for onset of uterine contractions (20.9±20.4 and 16.6±9.8 h, respectively), time between onset of uterine contractions and delivery (7.8±3.4 and 6.9±5.0 h), vaginal delivery (65 and 80%) and maternal and perinatal side effects (similar Apgar scores and hyperstimulation syndrome in both groups). CONCLUSION: the higher percentage of vaginal births and the shorter time for delivery using 25 mg, although not significant, does not allow to recommend the dose of 12.5 mg as more advantageous for cervical ripening and labor induction in term pregnancies.