Management of maternal pulse and blood pressure abnormalities during labour and childbirth: evidence-based algorithms for intrapartum care decision support

AIMS

To develop evidence-based clinical algorithms for assessment and management of abnormal maternal pulse and blood pressure during the intrapartum period.

POPULATION

Low risk singleton, term, pregnant women in labour.

SETTING

Institutional births in low- and middle-income countries.

SEARCH STRATEGY

A review of the literature was performed to retrieve evidence-based guidelines, systematic reviews, and papers on maternal pulse and blood pressure during labour. We searched a number of international clinical guidelines and PubMed using the corresponding key terms in November 2018 and updated the search in May 2020.

CASE SCENARIOS

Four common intrapartum case scenarios of abnormal pulse and blood pressure were identified for which algorithms were developed: hypertension, hypotension, tachycardia and bradycardia. Algorithms were constructed after reviewing guidelines and relevant papers, with input from a panel of experts. Thresholds for upper and lower limits of normal maternal pulse and blood pressure measurements are defined, evidence-based interventions for the initial management of abnormal parameters are described (resuscitation and monitoring) and guidance is provided on exploration of the potential causes for each case scenario, with links to pathways for their management.

CONCLUSIONS

Evidence-based algorithms to support the identification, and management of deviations in pulse and blood pressure during intrapartum care have been developed for hypertension, hypotension, tachycardia and bradycardia. The algorithms focus on initial resuscitation and monitoring, with an exploration of causes and early identification of underlying maternal conditions. These algorithms will help provide a standardised approach to investigation and management of these abnormal parameters to guide clinical practice.

TWEETABLE ABSTRACT

Algorithms for abnormal maternal pulse and blood pressure during labour allow standardised approach to early identification and management of complications.

Resilience and Stress during Pregnancy: A Comprehensive Multidimensional Approach in Maternal and Perinatal Health

This narrative review addresses resilience and stress during pregnancy, which is part of a broader concept of maternal health. Pregnancy and postpartum are opportune periods for health promotion interventions, especially because the close contact of the women with health professionals. In this way, it can be considered a useful window of opportunity to identify women at higher risk for adverse outcomes. Integrated health is a concept that aims at providing comprehensive care related to the promotion of individuals' physical, mental, and social well-being. In this context, stress during pregnancy has been targeted as a remarkable condition to be addressed whether due to individual issues, social issues, or specific pregnancy issues, since it is directly and indirectly associated with pregnancy complications. Stress is associated with preterm birth, postpartum depression, anxiety, child neurodevelopment, and fetal distress. The way that an individual faces a stressful and adverse situation is called resilience; this reaction is individual, dynamic, and contextual, and it can affect maternal and fetal outcomes. Low resilience has been associated with poorer pregnancy outcomes. The social context of pregnancy can act as a protective or contributory (risk) factor, indicating that environments of high social vulnerability play a negative role in resilience and, consequently, in perceived stress. A given stressor can be enhanced or mitigated depending on the social context that was imposed, as well as it can be interpreted as different degrees of perceived stress and faced with a higher or lower degree of resilience. Understanding these complex mechanisms may be valuable for tackling this matter. Therefore, in the pregnancy-puerperal period, the analysis of the stress-resilience relationship is essential, especially in contexts of greater social vulnerability, and is a health-promoting factor for both the mother and baby.

Giving women WOICE postpartum: prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument

Background

There are no accurate estimates of the prevalence of non-severe maternal morbidities. Given the lack of instruments to fully assess these morbidities, the World Health Organization (WHO) developed an instrument called WOICE. We aimed to evaluate the prevalence of non-severe maternal morbidities in puerperal women and factors associated to impaired clinical, social and mental health conditions.

Method

A cross-sectional study with postpartum women at a high-risk outpatient clinic in southeast Brazil, from November 2017 to December 2018. The WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. Data collection was supported by Tablets with REDCAP software. Initially, a descriptive analysis was performed, with general prevalence of all variables contained in the WOICE, including scales on anxiety and depression (GAD-7 and PHQ-9- impaired if ≥10), functionality (WHODAS- high disability scores when ≥37.4) and data on violence and substance use. Subsequently, an evaluation of cases with positive findings was performed, with a Poisson regression to investigate factors associated to impaired non-clinical and clinical conditions.

Results

Five hundred seventeen women were included, majority (54.3%) multiparous, between 20 and 34 years (65.4%) and with a partner (75,6%). Over a quarter had (26.2%) preterm birth. Around a third (30.2%) reported health problems informed by the physician, although more than 80% considered having good or very good health. About 10% reported any substance use and 5.9% reported exposure to violence. Anxiety was identified in 19.8% of cases, depression in 36.9% and impaired functioning in 4.4% of women. Poisson regression identified that poor overall health rating was associated to increased anxiety/depression and impaired functioning. Having a partner reduced perception of women on the presence of clinical morbidities.

Conclusion

During postpartum care of a high-risk population, over one third of the considered women presented anxiety and depression; 10% reported substance use and around 6% exposure to violence. These aspects of women’s health need further evaluation and specific interventions to improve quality of care.

Cervical length varies considering different populations and gestational outcomes: Results from a systematic review and meta-analysis

BACKGROUND

The uterine cervical length is an important risk factor for preterm birth. The aim of this study was to assess cervical length distribution in women with singleton pregnancies, measured by transvaginal ultrasound between 16 and 24 weeks, and its association with population characteristics.

MATERIALS AND METHODS

We searched electronic databases and other sources for studies published from April 1, 1990 to July 21, 2020. Of the 2019 retrieved publications, full-text versions of 137 articles were considered. We included 77 original articles that reported cervical length measurements of 363,431 women. The main aim of this study was to identify the pattern of cervical length in different populations. We collected demographic and clinical data concerning the population, in addition to information regarding the ultrasound examination and cervical length measurement. Regarding study bias, 56 were at low risk of bias and 21 were at medium risk of bias.

RESULTS

The meta-analysis included 57 articles with data from 158,346 women. The mean cervical length was 37.96. mm (95% CI [36.68, 39.24]). Cervical length was shorter in women from Africa and Asia, in those from low-income countries, with a lower body weight, and in those who delivered before 37 gestational weeks. We found that the cervical length from pooled studies is longer than that usually discussed in the literature. Regarding limitations, we had difficulty assessing our main variable because there was no consistent pattern in the way authors reported cervical length measurement. Another limitation was the great heterogeneity between studies.

CONCLUSIONS

The use of a single cutoff value to define a short cervix diagnosis, an important risk factor for preterm birth, may not be correct and cervical length must be considered according to maternal population characteristics. Future studies should identify different specific curves and cutoff values for cervical length in different populations. This meta-analysis was registered in the PROSPERO database under CRD42017070246 at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=70246.

Preeclampsia in 2018: Revisiting Concepts, Physiopathology, and Prediction

Preeclampsia currently remains one of the leading causes of death and severe maternal morbidity. Although its prevalence is still underestimated in some places due to underreporting, preeclampsia is a disease that health professionals need to know how to deal with and take action. For this reason, the studies about the theme remain along with the advances in their understanding that often implies improvement and change of concepts and conducts. The complexity of its etiology is a challenge and requires further studies for its full understanding. Apparently, poor adaptation of the maternal organism to the conceptus, marked by the nonoccurrence of changes in the uterine spiral arteries, determines a series of systemic repercussions that compound the various forms of preeclampsia presentation. In recent years, the use of acetylsalicylic acid to prevent cases of early onset of the disease has been consolidated and, alongside, studies have advanced the development of accessible and effective methods of identifying women at risk of preeclampsia. The aim of this review is to discuss updates on the occurrence, concept, pathophysiology, repercussion, prevention, and prediction of preeclampsia.

Postpartum hemorrhage: new insights for definition and diagnosis

The current definition of is inadequate for early recognition of this important cause of maternal death that is responsible for >80,000 deaths worldwide in 2015. A stronger definition of postpartum hemorrhage should include both blood loss and clinical signs of cardiovascular changes after delivery, which would help providers to identify postpartum hemorrhage more promptly and accurately. Along with the amount of blood loss, clinical signs, and specifically the shock index (heart rate divided by systolic blood pressure) appear to aid in more accurate diagnosis of postpartum hemorrhage.

Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn Health

Objective

To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low‐ and middle‐income countries.

Design

Secondary analysis of a multi‐country cross‐sectional study.

Setting

29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

258 215 singleton deliveries in 286 hospitals.

Methods

We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries.

Main outcome measures

Preterm delivery.

Results

In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2–34.6%)] compared with medium (4.3%, 3.0–6.7%), and high‐HDI countries (4.8%, 4.4–5.5%).

Conclusion

Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low‐HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary.

Tweetable abstract

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Severe maternal morbidity due to respiratory disease and impact of 2009 H1N1 influenza A pandemic in Brazil: results from a national multicenter cross-sectional study

BACKGROUND

The aim of this study was to assess the burden of respiratory disease, considering the influenza A pandemic season (H1N1pdm09), within the Brazilian Network for Surveillance of Severe Maternal Morbidity, and factors associated with worse maternal outcome.

METHODS

A multicenter cross-sectional study, involving 27 referral maternity hospitals in five Brazilian regions. Cases were identified in a prospective surveillance by using the WHO standardized criteria for potentially life-threatening conditions (PLTC) and maternal near miss (MNM). Women with severe complications from respiratory disease identified as suspected or confirmed cases of H1N1 influenza or respiratory failure were compared to those with other causes of severe morbidity. A review of suspected H1N1 influenza cases classified women as non-tested, tested positive and tested negative, comparing their outcomes. Factors associated with severe maternal outcome (SMO = MNM + MD) were assessed in both groups, in comparison to PLTC, using PR and 95 % CI adjusted for design effect of cluster sampling.

RESULTS

Among 9555 cases of severe maternal morbidity, 485 (5 %) had respiratory disease. Respiratory disease occurred in one-quarter of MNM cases and two-thirds of MD. H1N1 virus was suspected in 206 cases with respiratory illness. Around 60 % of these women were tested, yielding 49 confirmed cases. Confirmed H1N1 influenza cases had worse adverse outcomes (MNM:MD ratio < 1 (0.9:1), compared to 12:1 in cases due to other causes), and a mortality index > 50 %, in comparison to 7.4 % in other causes of severe maternal morbidity. Delay in medical care was associated with SMO in all cases considered, with a two-fold increased risk among respiratory disease patients. Perinatal outcome was worse in cases complicated by respiratory disease, with increased prematurity, stillbirth, low birth weight and Apgar score < 7.

CONCLUSIONS

Respiratory disease, especially considering the influenza season, is a very severe cause of maternal near miss and death. Increased awareness about this condition, preventive vaccination during pregnancy, early diagnosis and treatment are required to improve maternal health.

The role of infection and sepsis in the Brazilian Network for Surveillance of Severe Maternal Morbidity

OBJECTIVE

To identify the burden of severe infection within the Brazilian Network for Surveillance of Severe Maternal Morbidity and factors associated with worse maternal outcomes.

METHODS

This was a multicentre cross-sectional study involving 27 referral maternity hospitals in Brazil. WHO's standardised criteria for potentially life-threatening conditions and maternal near miss were used to identify cases through prospective surveillance and the main cause of morbidity was identified as infection or other causes (hypertension, haemorrhage or clinical/surgical). Complications due to infection were compared to complications due to the remaining causes of morbidity. Factors associated with a severe maternal outcome were assessed for the cases of infection.

RESULTS

A total of 502 (5.3%) cases of maternal morbidity were associated with severe infection vs. 9053 cases (94.7%) with other causes. Considering increased severity of cases, infection was responsible for one-fourth of all maternal near miss (23.6%) and nearly half (46.4%) of maternal deaths, with a maternal near miss to maternal death ratio three times (2.8:1) that of cases without infection (7.8:1) and a high mortality index (26.3%). Within cases of infection, substandard care was present in over one half of the severe maternal outcome cases. Factors independently associated with worse maternal outcomes were HIV/AIDS, hysterectomy, prolonged hospitalisation, intensive care admission and delays in medical care.

CONCLUSIONS

Infection is an alarming cause of maternal morbidity and mortality and timely diagnosis and adequate management are key to improving outcomes during pregnancy. Delays should be addressed, risk factors identified, and specific protocols of surveillance and care developed for use during pregnancy.

Network for Surveillance of Severe Maternal Morbidity: a powerful national collaboration generating data on maternal health outcomes and care

OBJECTIVE

To identify cases of severe maternal morbidity (SMM) during pregnancy and childbirth, their characteristics, and to test the feasibility of scaling up World Health Organization criteria for identifying women at risk of a worse outcome.

DESIGN

Multicentre cross-sectional study.

SETTING

Twenty-seven referral maternity hospitals from all regions of Brazil.

POPULATION

Cases of SMM identified among 82 388 delivering women over a 1-year period.

METHODS

Prospective surveillance using the World Health Organization's criteria for potentially life-threatening conditions (PLTC) and maternal near-miss (MNM) identified and assessed cases with severe morbidity or death.

MAIN OUTCOME MEASURES

Indicators of maternal morbidity and mortality; sociodemographic, clinical and obstetric characteristics; gestational and perinatal outcomes; main causes of morbidity and delays in care.

RESULTS

Among 9555 cases of SMM, there were 140 deaths and 770 cases of MNM. The main determining cause of maternal complication was hypertensive disease. Criteria for MNM conditions were more frequent as the severity of the outcome increased, all combined in over 75% of maternal deaths.

CONCLUSIONS

This study identified around 9.5% of MNM or death among all cases developing any severe maternal complication. Multicentre studies on surveillance of SMM, with organised collaboration and adequate study protocols can be successfully implemented, even in low-income and middle-income settings, generating important information on maternal health and care to be used to implement appropriate health policies and interventions.

TWEETABLE ABSTRACT

Surveillance of severe maternal morbidity was proved to be possible in a hospital network in Brazil.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

Objective

To generate a global reference for caesarean section (CS) rates at health facilities.

Design

Cross‐sectional study.

Setting

Health facilities from 43 countries.

Population/Sample

Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.

Methods

We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.

Main outcome measures

Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results

According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions

This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Mode and timing of twin delivery and perinatal outcomes in low- and middle-income countries: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To describe the mode and timing of delivery of twin pregnancies at ≥34 weeks of gestation and their association with perinatal outcomes.

DESIGN

Secondary analysis of a cross-sectional study.

POPULATION

Twin deliveries at ≥34 weeks of gestation from 21 low- and middle-income countries participating in the WHO Multicountry Survey on Maternal and Newborn Health.

METHODS

Descriptive analysis and effect estimates using multilevel logistic regression.

MAIN OUTCOME MEASURES

Stillbirth, perinatal mortality, and neonatal near miss (use of selected life saving interventions at birth).

RESULTS

The average length of gestation at delivery was 37.6 weeks. Of all twin deliveries, 16.8 and 17.6% were delivered by caesarean section before and after the onset of labour, respectively. Prelabour caesarean delivery was associated with older maternal age, higher institutional capacity and wealth of the country. Compared with spontaneous vaginal delivery, lower risks of neonatal near miss (adjusted odds ratio, aOR, 0.63; 95% confidence interval, 95% CI, 0.44-0.94) were found among prelabour caesarean deliveries. A lower risk of early neonatal mortality (aOR 0.12; 95% CI 0.02-0.56) was also observed among prelabour caesarean deliveries with nonvertex presentation of the first twin. The week of gestation with the lowest rate of prospective fetal death varied by fetal presentation: 37 weeks for vertex-vertex; 39 weeks for vertex-nonvertex; and 38 weeks for a nonvertex first twin.

CONCLUSIONS

The prelabour caesarean delivery rate among twins varied largely between countries, probably as a result of overuse of caesarean delivery in wealthier countries and limited access to caesarean delivery in low-income countries. Prelabour delivery may be beneficial when the first twin is nonvertex. International guidelines for optimal twin delivery methods are needed.

Sonographic measurement of the umbilical cord area and the diameters of its vessels during pregnancy

The objective was to determine the cross-sectional area of the umbilical cord, its diameter and the diameter of its vessels to establish a reference curve for these parameters during pregnancy, through a prospective cross-sectional study, including 2,310 low-risk pregnancies between 12 and 40 weeks' gestation. Means and standard deviations (SDs), plus the 10th, 50th and 90th percentiles for each measurement were calculated using polynomial regression analysis. Mann-Whitney, Kruskal-Wallis and Wilcoxon tests were used for statistical analysis. These parameters increased significantly with gestational age. The area of the cord also varied significantly with parity. Their new reference curves for low risk pregnancies were calculated using polynomial regression, and an almost linear increase in values was found up to 32 weeks of pregnancy, tending to stabilise from then onwards. The regression equation of the umbilical cord area according to gestational age (GA) was: -1.417 + 0.3026*GA-0.008*GA(2) + 0.000007*GA(3) and the degree of adjustment (R(2)) was 0.89.

Forearm bone mineral density changes during postpartum and the effects of breastfeeding, amenorrhea, body mass index and contraceptive use

Prospective cohort study performed to evaluate bone mineral density (BMD) changes up to 12 months postpartum of healthy women and its association with breastfeeding, contraceptive methods, amenorrhea, and body mass index (BMI). There is a trend in bone loss during the first 6 months with posterior recovery, with evidence of a protective effect of hormonal contraception.

INTRODUCTION

This study was conducted to evaluate bone mineral density (BMD) changes during postpartum period among healthy women and its association with breastfeeding, use of contraceptive methods, amenorrhea and body mass index (BMI).

METHODS

A prospective cohort study including 100 healthy women. Distal BMD was measured 7-10 days, 3, 6, and 12 months postpartum at the nondominant forearm using dual-energy X-ray absorptiometry. Data about breastfeeding duration, amenorrhea, contraceptive use and BMI were collected.

RESULTS

Seventy-eight women had a complete set of BMD measurements. The mean duration of exclusive breastfeeding was 125.9 (±66.6) days, with a median total lactation period of 263.5 days. The mean duration of amenorrhea was 164.2 (±119.2) days. BMD measurements showed a significant decrease in the distal radius, however with no significance in the ultradistal radius. When considering only the nonhormonal contraceptive users, the difference at 12 months was significant. Multivariate analysis of variance showed that both BMI and contraceptive use were significantly correlated with BMD. Multiple linear regression analysis showed significant correlation of distal radius with baseline BMD at the same site, pregestational BMI, age, years of schooling and difference in BMI. For ultradistal radius, there was a significant direct correlation with its baseline BMD and pregestational BMI.

CONCLUSIONS

There was a trend in bone loss during the first 6 months postpartum with posterior recovery. Also, hormonal contraceptive methods provided protection of bone loss. However, the long duration of breastfeeding and the follow-up were not sufficient to draw definitive conclusions on postweaning BMD conditions.

Pregnancy outcome in female liver transplant recipients

Transplantation has become an available and successful treatment option for numerous congenital and acquired hepatic disorders. Studies have shown that when the prepregnancy recipient graft function is stable and adequate, pregnancy is normally well tolerated with favorable neonatal outcomes. However, there are reports of increased incidences of hypertension and preeclampsia as well as lower birth weights and prematurity. Patients administered tacrolimus-based therapies seem to have lower incidences of these complications.

CASE REPORTS

The 5 reported patients, aged 23–37 years at the time of conception, were 2–11 years posttransplantation. A preterm delivery for fetal distress was the most clinically important complication among these patients. One episode of acute genital herpes infection, 1 liver hematoma in a patient who was anticoagulated owing to a history of deep vein thrombosis, and 1 case of wound infection postpartum were also observed. Despite these complications, all 5 pregnancies were successful. The mean gestational age at delivery was 35.2 weeks. No structural malformations or early complications were observed in the neonates. All cases showed stable liver parameters.

Maternal morbidity and near miss in the community: findings from the 2006 Brazilian demographic health survey

OBJECTIVE

To obtain an estimate of the prevalence of potentially life-threatening maternal conditions and near-miss events in Brazil, and to explore the factors associated with these complications.

DESIGN

A demographic health survey (DHS) focusing on reported maternal complications.

SETTING

Data from the five geographical regions of Brazil.

POPULATION

A total of 5025 women with at least one live birth in the 5-year reference period preceding their interview in the DHS.

METHODS

A secondary analysis of the 2006 Brazilian DHS database was carried out using a validated questionnaire to evaluate the occurrence of maternal complications and related key interventions. According to a pragmatic definition, any woman reporting the occurrence of eclampsia, hysterectomy, blood transfusion or admission to the intensive care unit was considered as having experienced a near-miss event. Associations between the sociodemographic characteristics of the women and severe maternal morbidity were evaluated.

MAIN OUTCOME MEASURES

Proportions and ratios of complications and related interventions defined as maternal near miss in pregnancy, and estimated risk factors for maternal morbidities.

RESULTS

Around 22% of women reported complications during pregnancy. The prevalence of maternal near miss in Brazil, using the pragmatic definition, was 21.1 per 1000 live births. An increased risk of severe maternal morbidity was found in women aged ≥40 years and in those with low levels of education.

CONCLUSIONS

Nearly 70,000 maternal near-miss cases and approximately 750,000 cases with potentially life-threatening conditions are estimated to occur in Brazil per year. A pragmatic definition of maternal near miss was useful to obtain more reliable information at the community level. This approach could be used to gather information on maternal morbidity in settings in which such data are not routinely collected.

Factors and outcomes associated with the induction of labour in Latin America

OBJECTIVE

To describe the prevalence of labour induction, together with its risk factors and outcomes in Latin America.

DESIGN

Analysis of the 2005 WHO global survey database.

SETTING

Eight selected Latin American countries.

POPULATION

All women who gave birth during the study period in 120 participating institutions.

METHODS

Bivariate and multivariate analyses.

MAIN OUTCOME MEASURES

Indications for labour induction per country, success rate per method, risk factors for induction, and maternal and perinatal outcomes.

RESULTS

Of the 97,095 deliveries included in the survey, 11,077 (11.4%) were induced, with 74.2% occurring in public institutions, 20.9% in social security hospitals and 4.9% in private institutions. Induction rates ranged from 5.1% in Peru to 20.1% in Cuba. The main indications were premature rupture of membranes (25.3%) and elective induction (28.9%). The success rate of vaginal delivery was very similar for oxytocin (69.9%) and misoprostol (74.8%), with an overall success rate of 70.4%. Induced labour was more common in women over 35 years of age. Maternal complications included higher rates of perineal laceration, need for uterotonic agents, hysterectomy, ICU admission, hospital stay>7 days and increased need for anaesthetic/analgesic procedures. Some adverse perinatal outcomes were also higher: low 5-minute Apgar score, very low birthweight, admission to neonatal ICU and delayed initiation of breastfeeding.

CONCLUSIONS

In Latin America, labour was induced in slightly more than 10% of deliveries; success rates were high irrespective of the method used. Induced labour is, however, associated with poorer maternal and perinatal outcomes than spontaneous labour.

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

Background

The 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.

Methods

A 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.

Results

There 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.

Conclusion

The 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.

Predictors of preterm birth

OBJECTIVE

This is a systematic review to assess published scientific evidence on preterm birth predictors.

METHODS

An Internet search for predictors of preterm birth was performed and the evidence level of each method was evaluated.

RESULTS

There is strong evidence that preterm birth can be predicted using vaginal sonography to evaluate cervical characteristics, fetal fibronectin in cervicovaginal secretions and interleukin-6 in amniotic fluid. There is consistent evidence that digital cervical examination is a weak predictor, and controversy regarding home uterine activity monitoring. There is scanty evidence about the predictive ability of maternal history and perceptions of symptoms since the study design fails to provide high evidence level.

CONCLUSION

Cervical evaluation by vaginal sonography, fetal fibronectin and interleukin-6 are the best methods for predicting preterm birth.

Hyaluronidase versus Foley catheter for cervical ripening in high-risk term and post term pregnancies

OBJECTIVE

To evaluate the effectiveness and safety of Foley catheter and hyaluronidase for cervical ripening.

METHOD

Randomized controlled trial where 140 pregnant women, with gestational age > or = 37 weeks, indication for labor induction and an unripe cervix, were enrolled, allocated in two groups according to the method of cervical ripening before labor induction. Statistical analysis used Student's t-test, Mann-Whitney, Chi-square test, survival analysis, risk ratios and number needed to treat.

RESULTS

Time of induction, dose of oxytocin and mode of delivery had better results in the Foley catheter group. Comfort with the method was higher in the hyaluronidase group.

CONCLUSIONS

Both methods were effective and safe for cervical ripening. The Foley catheter group experienced a shorter period of induction, required a lower dose of oxytocin and had higher vaginal delivery rates, while the women who used hyaluronidase declared greater comfort with the method.

[Curve of normal fetal weight values estimated by ultrasound according to gestation age]

OBJECTIVE

to evaluate the evolution of estimated fetal weight in normal pregnancies in Campinas, Brazil, between 20 to 42 weeks.

DESIGN AND METHODS

A descriptive study was performed, including 2,874 normal pregnant women studied through routine obstetric ultrasound with fetal biometry, using the Hadlock (1991) formula for fetal weight estimation. Data were evaluated by fitting a curve with the 10th, 50th, and 90th percentiles of fetal weight for gestational age, subsequently submitted to a smoothing procedure by quadratic polynomial adjustment.

RESULTS

the 50th percentile was 368g at 20th week, 1,512g at 30th, and 3,417g at 42nd week. There was a mean weight increase of 200g per week from the 27th to 38th week, when the gain decreased.

CONCLUSIONS

The availability of a Brazilian curve of normal estimated fetal weight will allow for prenatal ultrasound diagnosis of deviations.

[Mortality in childbearing-age women in Campinas, São Paulo (1985-1994)]

To provide a profile of the main health problems in childbearing-age women, we studied all 3,086 death certificates from the SEADE Foundation for women from 10 to 49 years of age and residing in the municipality of Campinas, from January 1, 1985, to December 31, 1994. The primary cause of death was identified and classified according to the 10th review of the ICD. Population data were obtained from the Laboratory for Epidemiological Analyses and Research, UNICAMP. One-fourth of the deaths were cardiovascular in origin, one-fifth were from external causes, and almost 20% were due to neoplasms. Maternal mortality was the ninth cause of death. External causes predominated in the 10-to-34-year age group, as compared to cardiovascular diseases and neoplasms in the 35-to-49-year group. Most alarming were the predominance of traffic accidents among causes of death in women up to age 34 (greater than AIDS during the study period) and the high mortality rate from homicides.

[Factors associated to the trial of labor in primipara women with one previous cesarean section]

OBJECTIVE

The purpose of this study was to identify medical and non-medical factors associated to the performance of a trial of labor during the second delivery of women with one previous cesarean section.

METHODS

This was a nested case control study, with a secondary data analysis from a retrospective population based cohort study. It was primarily performed on a population of women who had had their first children in Campinas, SP, Brazil, during 1985. The study population was constituted of the 1,352 women of the cohort study who had had their first deliveries by cesarean section and also had their second deliveries no matter when. The group of cases (333 women, almost 25%) was constituted of those women who had a trial of labor during their second deliveries and the control group (1,019 women) of those who had not had it. For each possible associated factor evaluated, the Odds Ratio and its respective 95% Confidence Interval were calculated. For the ordered categorical variables, the chi2 for trend was also calculated. Finally, a non conditional multivariate regression analysis was performed, identifying the significant factors and then estimating their adjusted Odds Ratio.

RESULTS

The main factors associated with the trial of labor in this situation were a low monthly family income, having public medical insurance by the national health system, a low maternal age, the occurrence of rupture of membranes during the second delivery, and having been in childbirth during the first delivery.

CONCLUSION

It is concluded that the main determinants for a trial of labor among primipara women with one previous cesarean section were basically social and economic factors, rather than medical ones.

Reasons for hospitalization due to abortion and pregnancy termination

The aim of this study was to identify the reasons for hospitalization associated with abortion and pregnancy termination among women attending the Maternity Unit of IMIP, Recife, Brazil. In a case-control study, 230 women who were hospitalized consecutively between August 1994 and June 1995 due to causes related to pregnancy termination or abortion were chosen as cases. Four controls per case were selected randomly out of a total of 920 women who delivered at the same hospital. For each potential cause considered, the odds ratio (OR) and respective 95 per cent confidence interval (CI) were calculated. Multiple logistic regression analysis was then used to control for confounders. Among all potential causes studied, those that showed significant association with pregnancy termination or abortion were: being single, absence of emotional support from partner, being a working woman, literacy up to the fourth year of school, failure of contraceptive method employed, and experience of previous pregnancies, children, and abortions.

Maternal mortality in Campinas: evolution, under-registration and avoidance

CONTEXT

Up until a few years ago, maternal mortality did not merit much attention as a worldwide public health issue. The health and social development indicator almost exclusively used was infant death.

OBJECTIVE

To study the number, characteristics, basic causes and avoidance of maternal mortality (MM) among women living in the city of Campinas, which occurred between 1985 and 1991, identified from all death certificates of women aged 10 through 49 years.

DESIGN

Retrospective and descriptive population-based study.

SETTING

University Referal Center.

SAMPLES

All eligible death certificates classified as declared and presumed maternal deaths according to the Laurenti criteria for the cause of death were selected and complementary studies of the clinical records were performed.

MAIN MEASURES

Day of the week and place of occurrence of death; period of occurrence; transfer from another hospital; number of days from delivery/abortion to death; blood transfusion; opportunity for transfusion; complications; autopsy; basic cause of death.

RESULTS

Initially 39 declared maternal deaths were identified and a total of 62 were confirmed by the end of the study. This corresponds to an under-registration rate of 37.1% and to an MM ratio of 45.5 per 100,000 live births. Around three-fourths of these maternal deaths were due to a direct obstetrical cause and were considered avoidable.

CONCLUSION

Maternal mortality still is high in the municipality of Campinas, although lower than the mean estimated for Brazil. The predominance of direct obstetric causes and avoidable deaths reinforces the need for public health interventions directed towards avoiding them.

Risk factors associated to fetal death

OBJECTIVE

The purpose of this study was to investigate risk factors associated to fetal death in a Brazilian population.

DESIGN

A case control study.

SETTING

The Hospital Maternidade Leonor Mendes de Barros in São Paulo.

PARTICIPANTS

122 pregnant women with diagnosis of fetal death and gestation age of 20 or more weeks and 244 controls of pregnant women who delivered liveborns.

VARIABLES STUDIED

The fetal death (dependent variable), independent variable (the social demographic factors, clinical and obstetrical history, prenatal care indicators and pathological conditions).

RESULTS

The risk factors associated to fetal death were abruptio placentae, syphilis, few prenatal care visits, one or more previous stillbirths, hospitalization during pregnancy, diabetes, age above or equal to 25 years, hypertension during pregnancy, anemia and age below 20 years.

CONCLUSIONS

Results of the current study might be useful to orientate a primary prevention health program, specially those concerning antenatal care.

Contraceptive use and pregnancy before and after introducing lactational amenorrhea (LAM) in a postpartum program

There is good evidence that lactational amenorrhea (LAM) is an effective method of fertility regulation during the first 6 months postpartum, provided no other food is given to the baby and the mother remains amenorrheic. However, although breast-feeding is strongly promoted in many maternity hospitals that also run postpartum family planning programs, LAM is rarely included among the contraceptive options being offered. This paper presents the results of an operational study which compared the prevalence of contraceptive use and the cumulative pregnancy rate at 12-months postpartum among 350 women observed before and 348 women studied after introducing LAM as an alternative contraceptive option offered to women following delivery at the Instituto Materno Infantil de Pernambuco (IMIP), in Recife, Brazil. The percentage of women not using any contraceptive method was significantly lower (p<0.0001) after the intervention (7.4%) than before (17.7%). This difference remained statistically significant after controlling for age, number of living children, marital status and years of schooling. The proportion pregnant one year postpartum was also significantly lower (p<0.0001) after the introduction of LAM (7.4%) than before (14.3%), but the difference was no longer significant after controlling for the same variables. It is concluded that LAM is a useful addition to family planning postpartum programs.

A operação cesárea no Brasil: incidência, tendências, causas, conseqüências e propostas de ação

Os autores fazem uma análise sobre a situação da operação cesárea no Brasil, que atingiu, na última década, níveis de incidência extremamente elevados, superiores aos de qualquer outro país. A partir dos dados disponíveis a nível nacional sobre a incidência de cesáreas ao longo dos anos, tenta-se caracterizar esta tendência e estabelecer suas diferenças sócio-econômicas e regionais, que mostram uma incidência mais alta para os indivíduos e regiões mais favorecidos economicamente. Consideram-se, também, os fatores que influenciam esta alta incidência, incluindo os fatores sócio-culturais, de organização da atenção obstétrica e fatores institucionais e legais. Enfatiza-se a esterilização cirúrgica que, sendo proibida no país, é realizada disfarçadamente através de uma indicação inadequada de cesárea. São analisadas, ainda, as conseqüências sobre a morbidade e mortalidade materna e perinatal, seus efeitos sobre a fecundidade da população e dos gastos extras para os cofres públicos decorrentes desta situação. Finalmente, propõem-se uma série de intervenções e mudanças que seriam necessárias a diversos níveis para reverter esta indesejável tendência de aumento da incidência de operações cesáreas.

[Myasthenia gravis and pregnancy: review of the literature and report of 2 cases]

Two cases of women with myasthenia gravis are presented. These women had three pregnancies followed by the authors, and description is made of clinical follow-up, therapeutic complications, termination of pregnancy, puerperal and perinatal outcome. A review of the literature is made due to the rarity of this condition and emphasis is given to the specialized knowledge required to adequately manage these cases. Myasthenia gravis, when associated to pregnancy, presents aspects that make it a high risk disease, decompensations of myasthenia being more common. Aspects relative to diagnosis and therapy of myasthenia in pregnancy and in the newly-born are reviewed, and considerations about anesthesia in the myasthenic pregnant woman.

[The experience of the Resting Home at the Center for Integral Women's Health Care of the State University of Campinas, Brazil]

The CAISM--Center for Integral Women's Health Care, of the Unicamp--State University of Campinas created a low complexity unit called a "Resting Home" according to the model adopted by other tertiary care centers in Brazil and in other countries. With 35 beds, the Resting Home staff includes two registered nurses, one social worker, and one occupational therapist. The institution admits women who have a high risk of acute complications of pregnancy or who require frequent check-up, mothers of premature babies under care in neonatal units who require their mother's breast feeding, and gynecological cancer patients who are in the process of staging and final diagnosis, or who are under frequent sessions of radiotherapy or chemotherapy. The common characteristic is that all of them need to go frequently to the outpatient services of the hospital, they live far away from the hospital, and they cannot afford rapid and easy transportation from their homes. The Resting Home offers them lodging and food, and a minimum of comfort (occupational therapy, TV, reading) at a cost that is only a small fraction of the cost of an inpatient. The authors present the statistics for the first 31 months of operation.