Análise de casos de mortes maternas em Manaus nos anos 2001 a 2010

Pós-graduação em Ginecologia, Obstetrícia e Mastologia - FMB

Acute fatty liver of pregnancy associated with severe acute pancreatitis: a case report

Acute fatty liver of pregnancy is a rare disease that affects women in the third trimester of pregnancy. Although infrequent, the disease can cause maternal mortality. The diagnosis is not always clear until the pregnancy is terminated, and significant complications, such as acute pancreatitis, can occur. Pancreatic involvement typically only occurs in severe cases after the development of hepatic and renal impairment. To date, little knowledge is available regarding how the disease causes pancreatitis. Treatment involves supportive measures and pregnancy interruption. In this report, we describe a case of a previously healthy 26-year-old woman at a gestational age of 27 wk and 6 d who was admitted with severe abdominal pain and vomiting. This case illustrates the clinical and laboratory overlap between acute fatty liver of pregnancy and pancreatitis, highlighting the difficulties in differentiating each disease. Furthermore, the hypothesis for this overlapping is presented, and the therapeutic options are discussed.

Mortalidade Materna: uma abordagem atualizada

Purpose: to review literature, highlighting current aspects of maternal mortality.  Method: research initiated through electronic data base PubMed [http:// www.ncbi.nlm.nih.gov/pubmed], limited to the last 10 years. The selected cases which related to pre-defined aspects of interest to the study, such as vulnerable population, risk factors, causes, difficulties in obtaining data, preventive measures e new approaches to the problem, among them, ‘near misses’ and severe maternal morbidity.  Results: maternal death is directly related to the quality of life of the population, with relevant disparities among the different social economic areas. Although maternal mortality is the proper indicator to the female population health, its numbers are presented in unrealistic manners due to the difficulties in identifying the cases through death certificates. Preventive measures associated to early and adequate diagnose and treatment are benefic factors in decreasing those maternal deaths. Apart from these, identification and classification of ‘near misses’ and maternal morbidity are featured in the contemporary approach to the issue.  Final considerations: In spite of advanced technology and recognition of preventive measures, a large number of women die daily due to complications in the pregnancy and puerperal cycle. To decrease such tragedy political, social and economical commitment to Health is necessary, in order to promote the needed reforms in the assistance of such cycle.

Fatores de risco relacionados à pré-eclâmpsia

Introduction: Preeclampsia is a major cause of maternal and perinatal morbidity and mortality in Brazil and worldwide. It is a heterogeneous disorder, multifactorial, with no clear etiology and pathophysiology. The identification of risk factors for its development can assist in prevention and early diagnosis of the clinical onset of the disease Objective: To identify risk factors related to the development of preeclampsia aimed at identifying pregnant women at risk for early disease and to offer specialized treatment to them Methodology: A bibliographic survey of scientific articles indexed in the following databases: CAPES (Ovid external Link), Scientific Eletronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), and Medical Literature Analysis and Retrieval System Online (Medline) of the National Library of Medicine over the last tem years (2001-2011) was carried out with the addition of certain classic and priority references.

Birth in Brazil: national survey into labour and birth

Background: Caesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction. Methods: Nationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients' medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson's groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design. Discussion: This study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it's consequences on postnatal health.

Behavioral Economics and Physician Behavior

This study seeks to answer whether the availability heuristic leads physicians to utilize more medical care than is economically efficient. Do rare, salient events alter physicians' perceptions about the probability of patient harm? Do these events lead physicians to overutilize certain medical procedures? This study uses Pennsylvania inpatient hospital admissions data from 2009 aggregated at the physician level to investigate these questions. The data come from the 2009 Pennsylvania Health Care Cost Containment Council (PHC4). The study is divided into two parts. In Part I, we examine whether bad outcomes during childbirth (defined as maternal mortality, an obstetric fistula or a uterine rupture) lead physicians to utilize more cesarean sections on future patients. In Part II, we examine whether bad outcomes associated with appendicitis (defined as patient death, a perforated or ruptured appendix or sepsis) lead physicians to perform more negative appendectomies (appendectomies performed when the patient did not have appendicitis) on future patients. Overall the study does not find evidence to support the claim that the availability heuristic leads physicians to overutilize medical care on future patients. However, the study does find evidence that variations in health care utilization are strongly correlated with individual physician practice patterns. The results of the study also imply that physicians' financial incentives may be a source of variation in health care utilization.

The influence of ideological interest groups on congressional financial support of international family planning

The World Health Organization estimates there are about 585,000 maternal deaths each year, with 98% of the maternal deaths in developing countries. Access to family planning methods is one method to decrease maternal mortality and morbidity. ^ The U.S. was the leader in providing financial and technical assistance to developing countries to enable women to have this access. The election of Ronald Regan changed the course of U.S. support; abortion became a central factor in the political decision-making with regards to the financial support of international family planning. ^ One factor that may sway policy-makers' decisions is the influence of ideological interest groups, Political Action Committees funding of candidates in relation to votes on bills that impacted on financial support of international family planning and the amount spent by these groups on lobbyist was reviewed. Pro-choice funding of candidates was greater for the four of the fives votes supporting family planning. Pro-Choice lobbyist spending was $185,000 vs. $8,184,000 spent by Pro-Life ideological groups. ^

Comparing the quality of three models of postabortion care in public hospitals in Mexico City

artículo publicado en la revista Int Fam Plan Perspect. 2003 Sep;29(3):112-20

A educação permanente em saúde para a institucionalização de uma rede-rizoma

Esta dissertação é resultado de uma pesquisa-intervenção cuja produção de dados ocorreu com o Grupo Condutor Regional da Rede Cegonha (GCR) no DRS III de Araraquara - SP, parte do Projeto de Pesquisa para o Sistema Único de Saúde (PPSUS): O processo de implantação da rede de atenção à saúde materno infantil no DRS III de Araraquara: a atenção básica como ordenadora da atenção em rede. Nosso objetivo foi compreender este coletivo como espaço de Educação Permanente em Saúde (EPS) para a institucionalização dessa Rede, e também caracterizar a EPS no território de abrangência deste DRS, compreender suas fragilidades-potencialidades e também os processos de EPS produzidos no interior do GCR para a implementação da Rede Cegonha (RC), diante de desafios como a redução da morbimortalidade materno infantil e o atendimento integral e humanizado a mulheres e crianças. Esta pesquisa qualitativa compreendeu a análise de documentos e a pesquisa-intervenção, utilizando método cartográfico, e a produção dos dados ocorreu no ano de 2014 com os integrantes do GCR e outros pesquisadores PPSUS. As análises tiveram como referenciais o Processo de Trabalho em Saúde e conceitos do movimento institucionalista, das correntes da Análise Institucional e da Esquizoanálise. Esta pesquisa de cunho cartográfico explorou o contexto sócio-histórico da EPS e da RC no DRS III e paisagens que compõem o mapa do aprendizado no que chamamos Rede-rizoma, entremeadas por análises de implicações e aprendizados na experiência, tanto de construção da pesquisa como da RC. Nos planos do rizoma houve momentos de aprendizado significativo, ecos nos municípios, interferências da pesquisa-intervenção, dentre outros componentes de tessitura da rede que envolveram seus atores, seus pontos de conexão, de tensão, de apoio. Nesse emaranhado quente e frio, interessou-nos explorar as singularidades do encontro e os movimentos de forças instituintes e do instituído com o compromisso de entender a EPS como ferramenta de trabalho para a institucionalização da RC. Percebemos a existência de microprocessos de institucionalização disparados no cotidiano do GCR, caracteristicamente paralisantes e mobilizadores, como a importância da participação social, ainda tímida, as tensões com a imobilidade municipal, as fragilidades-potencialidades dos recursos humanos e financeiros, e também resultados que refletem em alargamento e participação de novos atores, cooperação intermunicipal, fortalecimento dos Grupos Condutores Municipais da rede cegonha e uma gestão estadual disposta a deflagrar processos de formação participativos. Trata-se de movimentos que se revelaram em implicações de múltiplas bifurcações e em processos de EPS que se fazem de forma mutante, conformando a rede-rizoma

La salud materno-infantil durante el franquismo: notas bibliométricas sobre el programa «Al servicio de España y del niño español»

La investigación aporta un estudio bibliométrico de la Colección de 252 monografías, publicadas entre 1938 y 1964, que aparecieron en la colección Al Servicio de España y del Niño Español. Dicha iniciativa formaba parte del programa de lucha contra la mortalidad infantil y maternal que puso en marcha el régimen franquista, desde sus presupuestos totalitarios y sus políticas pronatalistas.

Assessment of the Association of Health with the Liberalisation of Trade in Services under the World Trade Organisation

Background: The liberalisation of trade in services which began in 1995 under the General Agreement on Trade in Services (GATS) of the World Trade Organisation (WTO) has generated arguments for and against its potential health effects. Our goal was to explore the relationship between the liberalisation of services under the GATS and three health indicators – life expectancy (LE), under-5 mortality (U5M) and maternal mortality (MM) - since the WTO was established. Methods and Findings: This was a cross-sectional ecological study that explored the association in 2010 and 1995 between liberalisation and health (LE, U5M and MM), and between liberalisation and progress in health in the period 1995–2010, considering variables related to economic and social policies such as per capita income (GDP pc), public expenditure on health (PEH), and income inequality (Gini index). The units of observation and analysis were WTO member countries with data available for 2010 (n = 116), 1995 (n = 114) and 1995–2010 (n = 114). We conducted bivariate and multivariate linear regression analyses adjusted for GDP pc, Gini and PEH. Increased global liberalisation in services under the WTO was associated with better health in 2010 (U5M: 20.358 p,0.001; MM: 20.338 p = 0.001; LE: 0.247 p = 0.008) and in 1995, after adjusting for economic and social policy variables. For the period 1995–2010, progress in health was associated with income equality, PEH and per capita income. No association was found with global liberalisation in services. Conclusions: The favourable association in 2010 between health and liberalisation in services under the WTO seems to reflect a pre-WTO association observed in the 1995 data. However, this liberalisation did not appear as a factor associated with progress in health during 1995–2010. Income equality, health expenditure and per capita income were more powerful determinants of the health of populations.

Murine Model for Preclinical Studies of Var2CSA-Mediated Pathology Associated with Malaria in Pregnancy

Plasmodium falciparum infection during pregnancy leads to abortions, stillbirth, low birth weight, and maternal mortality. Infected erythrocytes (IEs) accumulate in the placenta by adhering to chondroitin sulfate A (CSA) via var2CSA protein exposed on the P. falciparum IE membrane. Plasmodium berghei IE infection in pregnant BALB/c mice is a model for severe placental malaria (PM). Here, we describe a transgenic P. berghei parasite expressing the full-length var2CSA extracellular region (domains DBL1X to DBL6ε) fused to a P. berghei exported protein (EMAP1) and characterize a var2CSA-based mouse model of PM. BALB/c mice were infected at midgestation with different doses of P. berghei-var2CSA (P. berghei-VAR) or P. berghei wild-type IEs. Infection with 10(4) P. berghei-VAR IEs induced a higher incidence of stillbirth and lower fetal weight than P. berghei At doses of 10(5) and 10(6) IEs, P. berghei-VAR-infected mice showed increased maternal mortality during pregnancy and fetal loss, respectively. Parasite loads in infected placentas were similar between parasite lines despite differences in maternal outcomes. Fetal weight loss normalized for parasitemia was higher in P. berghei-VAR-infected mice than in P. berghei-infected mice. In vitro assays showed that higher numbers of P. berghei-VAR IEs than P. berghei IEs adhered to placental tissue. Immunization of mice with P. berghei-VAR elicited IgG antibodies reactive to DBL1-6 recombinant protein, indicating that the topology of immunogenic epitopes is maintained between DBL1-6-EMAP1 on P. berghei-VAR and recombinant DBL1-6 (recDBL1-6). Our data suggested that impairments in pregnancy caused by P. berghei-VAR infection were attributable to var2CSA expression. This model provides a tool for preclinical evaluation of protection against PM induced by approaches that target var2CSA.

Anaemia and vitamin A deficiency in poor urban pregnant women of Bangladesh

This cross-sectional study investigated the prevalence of anaemia and vitamin A deficiency (VAD) among pregnant women in a poor urban population of Bangladesh. It also examined the association of various socio-economic and dietary factors with anaemia and vitamin A status. A maternal and child health clinic in Dhaka city, Bangladesh was used to obtain the sample. Three hundred and eighty three pregnant women, aged 20-30 years, of 20-30 weeks gestation were randomly selected from women on their first presentation for antenatal care. Socio-economic, pregnancy related information, usual dietary pattern, and anthropometric data were collected. Blood haemoglobin and serum retinol (vitamin A) concentrations were determined. About 40% of the pregnant women were anaemic (haemoglobin <11.0 g/dl) and 45% had low serum vitamin A levels (<30 mug/dl); with 8.6% having sub-clinical VAD (serum retinol <20 μg/dl). The women with low serum vitamin A levels had 1.8 times greater risk of being anaemic than did the women with normal vitamin A status. Food frequency data revealed that a large proportion of these women did not consume egg (49%), milk (25%), meat (31%), liver (83%), large fish (32%), small fish (39%) and sweet pumpkin (52%) at all; while about 25% of the women reported consuming dark green leafy vegetables (DGLV) and 64% reported an intake of fruit at least four servings a week. The pregnant women who were either illiterate or received only informal education (up to grade ten) had significantly lower haemoglobin and serum vitamin A levels compared to those who completed at least a secondary school certificate. The women whose husbands were illiterate or received only informal education had significantly (P=0.01) lower serum vitamin A levels than those whose husbands had received at least a secondary school certificate. The women who came from families with a per-capita income below the poverty line had significantly lower haemoglobin and serum vitamin A levels compared to those who came from families with a per-capita income above the poverty line. The women who consumed three servings or less of DGLV and fruit per week had significantly lower haemoglobin and serum vitamin A levels than those who consumed four or more servings a week. The women who never consumed large fish had significantly lower haemoglobin compared to those who reported at least one serving a week. Furthermore, the women who never consumed sweet pumpkin had significantly lower serum vitamin A than the women who ate at least one serving a week. By multiple regression analysis, intake of meat, DGLV and fruit, and serum vitamin A levels were found to have a significant independent relationship with haemoglobin. The overall F-ratio (9.9) was highly significant (P=0.000), the adjusted R-square was 0.086 (multiple R=0.309). Multiple regression analysis for serum vitamin A also revealed a significant independent relationship with per capita income, haemoglobin levels, intakes of DGLV and sweet pumpkin. The overall F-ratio (10.2) was highly significant (P=0.000), the adjusted R-square was 0.10 (multiple R=0.312). In conclusion, anaemia and vitamin A deficiency were highly prevalent among poor urban pregnant women in Bangladesh. Various socio-economic and dietary factors may influence the anaemia and vitamin A status of these women. The present study emphasizes the need for a comprehensive intervention strategy, which include both nutritional and environmental factors, to improve the nutritional status of this population.

Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics

Registration of births, recording deaths by age, sex and cause, and calculating mortality levels and differentials are fundamental to evidence-based health policy, monitoring and evaluation. Yet few of the countries with the greatest need for these data have functioning systems to produce them despite legislation providing for the establishment and maintenance of vital registration. Sample vital registration (SVR), when applied in conjunction with validated verbal autopsy, procedures and implemented in a nationally representative sample of population clusters represents an affordable, cost-effective, and sustainable short- and medium-term solution to this problem. SVR complements other information sources by producing age-, sex-, and cause-specific mortality data that are more complete and continuous than those currently available. The tools and methods employed in an SVR system, however, are imperfect and require rigorous validation and continuous quality assurance; sampling strategies for SVR are also still evolving. Nonetheless, interest in establishing SVR is rapidly growing in Africa and Asia. Better systems for reporting and recording data on vital events will be sustainable only if developed hand-in-hand with existing health information strategies at the national and district levels; governance structures; and agendas for social research and development monitoring. If the global community wishes to have mortality measurements 5 or 10 years hence, the foundation stones of SVR must be laid today.

Are marginalized women being left behind? A population-based study of institutional deliveries in Karnataka, India

Background While India has made significant progress in reducing maternal mortality, attaining further declines will require increased skilled birth attendance and institutional delivery among marginalized and difficult to reach populations. Methods A population-based survey was carried out among 16 randomly selected rural villages in rural Mysore District in Karnataka, India between August and September 2008. All households in selected villages were enumerated and women with children 6 years of age or younger underwent an interviewer-administered questionnaire on antenatal care and institutional delivery. Results Institutional deliveries in rural areas of Mysore District increased from 51% to 70% between 2002 and 2008. While increasing numbers of women were accessing antenatal care and delivering in hospitals, large disparities were found in uptake of these services among different castes. Mothers belonging to general castes were almost twice as likely to have an institutional birth as compared to scheduled castes and tribes. Mothers belonging to other backward caste or general castes had 1.8 times higher odds (95% CI: 1.21, 2.89) of having an institutional delivery as compared to scheduled castes and tribes. In multivariable analysis, which adjusted for inter- and intra-village variance, Below Poverty Line status, caste, and receiving antenatal care were all associated with institutional delivery. Conclusion The results of the study suggest that while the Indian Government has made significant progress in increasing antenatal care and institutional deliveries among rural populations, further success in lowering maternal mortality will likely hinge on the success of NRHM programs focused on serving marginalized groups. Health interventions which target SC/ST may also have to address both perceived and actual stigma and discrimination, in addition to providing needed services. Strategies for overcoming these barriers may include sensitization of healthcare workers, targeted health education and outreach, and culturally appropriate community-level interventions. Addressing the needs of these communities will be critical to achieving Millennium Development Goal Five by 2015.