Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal / Patologia do espectro do acretismo placentário - O impacto da criação de uma equipa multidisciplinar nos desfechos maternos em Portugal

Abstract Objective To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). Methods Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. Results During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. Conclusion After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.

Resumo Objetivo Descrever uma coorte de casos do espectro do acretismo placentário (PAS) de uma instituição terciária e comparar os resultados maternos antes e depois da criação de uma equipa multidisciplinar (MDT). Métodos Estudo retrospectivo utilizando bancos de dados hospitalares. Identificação de casos de PAS com confirmação patológica entre 2010 e 2021. Divisão em dois grupos: grupo Standard Care (SC) - 2010-2014; e grupo MDT - 2015-2021. Análise descritiva de suas características e desfechos maternos. Resultados Durante o período do estudo, houve 53 casos de PAS (24 - grupo SC; 29 - grupo MDT). Grupo Standard Care: 1 placenta increta e 3 percretas; 12,5% (3/24) tiveram suspeita anteparto; 4 casos tiveram histerectomia periparto - uma eletiva devido à suspeita anteparto de PAS; 3 devido a hemorragia pós-parto. A média de perda hemática estimada (EBL) foi de 2.469 mL; transfusão de concentrado eritrocitário (PRBC) em 25% (6/24) - mediana 7,5 unidades. Equipa multidisciplinar: 4 casos de placenta increta e 3 percretas. A taxa de suspeita anteparto foi de 24,1% (7/29); foram realizadas 9 histerectomias, 7 eletivas por suspeita anteparto de PAS, 1 após diagnóstico intraparto de PAS e 1 após rotura uterina após interrupção da gravidez no segundo trimestre. A EBL média foi de 1.250 mL, com transfusão de PRBC em 37,9% (11/29) - mediana de 2 unidades. Conclusão Após a criação da MDT, houve redução na média de EBL e na mediana do número de unidades de PRBC transfundidas, apesar do maior número de PAS invasivos.

MATERNAL NEAR MISS: AN INDIAN TERTIARY CARE CENTRE AUDIT

BACKGROUND: Despite advances in medical sciences and increased awareness of measures for safe child birth, unacceptably high maternal morbidity and mortality continues in developing countries like India. Ours being a tertiary care centre, draws a lot number of high risk pregnancies and referrals. By auditing the near miss cases2 i.e., a critically ill pregnant or recently delivered woman who was on the verge of death but survived a problem during pregnancy, childbirth, or within 42 days of the pregnancy's termination, we aim to identify the causes, factors leading to near miss2 and the management given to near miss2 and maternal deaths. The AIMS AND OBJECTIVES: present study aims to determine the magnitude, as well as to identify the pattern of Maternal Near Miss2 (MNM), at Siddhartha Medical College, Vijayawada, during the study period of two years. To anal OBJECTIVES: yse 1)Adverse events leading to a maternal near-miss2, 2) Disorders underlying these cases, 3)Sociodemographic factors and 4)Contributing factors A hospital based retros METHODOLOGY: pective observational study to assess the frequency and nature of maternal near miss2 events among the obstetric cases managed at Siddhartha Medical College, Vijayawada over a period of two years. The followi RESULTS: ng are the major causes identified leading to maternal near miss2 during our study Severe Eclampsia 17%, Post-partum Haemorrhage 17%, Pulmonary Edema due to severe pre eclampsia3 9%, Antepartum Eclampsia 9%, HELLP 9%, Ruptured ectopic pregnancy 7%, Cardiac failure 7%, Postpartum Eclampsia 7%, Imminent Eclampsia 4%, Abruption 4%, Rupture uterus 2%. In our study Maternal near miss2 ratio incidence: 0.0254, Severe maternal outcomes ratio : 3, Maternal near miss2 to mortality ratio: 0.433 CONCLUSION: We observed in majority of the cases level 1 and level 2 delays in reporting to our institution

The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System

Background: Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS. Methods: Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity. Results: Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%). Conclusion: Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR. (AU)

Maternal Near Miss in Patients with Systemic Lupus Erythematosus / Near miss materno em pacientes com lupus eritematoso sistêmico

Abstract Objective Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity. Methods This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM). Results The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5-96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2-10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0-50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6-1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7-7.9 and p = 0.0009; OR: 17.68; 95%CI: 2-153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3-440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2-26.3]). Conclusion Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.

Resumo Objetivo Lúpus eritematoso sistêmico (LES) pode causar danos irreversíveis aos órgãos. A gravidez com LES pode ter riscos para condições ameaçadoras à vida. O presente estudo teve como objetivo determinar a prevalência de MMG em pacientes com LES e analisar os parâmetros que contribuíram para os casos de maior gravidade. Métodos Trata-se de um estudo transversal retrospectivo a partir da análise de dados obtidos de prontuários de gestantes com LES atendidas em um Hospital Universitário no Brasil. As gestantes foram divididas em grupo controle sem intercorrências, grupo com condições potencialmente ameaçadoras a vida (CPAV) e grupo com near miss materno (NMM). Resultados A taxa de NMM foi de 112,9 por 1.000 nascidos vivos. A maioria dos casos de CPAV (83,9%) e NMM (92,9%) teve partos prematuros com risco aumentado estatisticamente significativo em comparação com o grupo controle (p = 0,0042; odds ratio [OR]: 12,05; intervalo de confiança [IC]: 1,5-96,6 para o grupo NMM e p = 0,0001; OR: 4,84; IC95%: 2,2-10,8 para o grupo CPAV). MMG aumenta o risco de maior tempo de internação (p < 0,0001; OR: 18,8; IC95%: 7,0-50,6 e p < 0,0001; OR: 158,17; IC95%: 17,6-1424,2 para os grupos CPAV e NMM, respectivamente), recémnascidos com baixo peso (p = 0,0006; OR: 3,67; IC95%: 1,7-7,9 e p = 0,0009; OR: 17,68; IC95%: 2-153,6 para os grupos CPAV e NMM, respectivamente), bem como doenças renais (CPAV: 58,9%; 33/56; p = 0,0069 e NMM: 78,6%; 11/14; p = 0,0026)]. Os casos de NMM apresentaram risco aumentado para óbito neonatal (p = 0,0128; OR: 38,4; IC95%: 3,3-440,3), natimorto e aborto espontâneo (p = 0,0011; OR: 7,68; IC95%: 2,2-26,3). Conclusão Lúpus eritematoso sistêmico foi significativamente associado à morbidade materna grave, internações mais longas e risco aumentado de desfechos obstétricos e neonatais ruins.

Decision-to-delivery interval and obstetric outcomes of emergency caesarean sections in a Nigerian teaching hospital

Prolonged Decision-to-Delivery interval (DDI) is associated with adverse maternal-foetal outcomes following emergency Caesarean section (EmCS). Objectives: To determine the DDI, predictive factors, and the foeto-maternal outcomes of patients that had EmCS in a Nigerian Teaching Hospital. Methods: A descriptive study of all EmCS performed at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, from 1st June 2020 to 31st May 2021, was conducted. Relevant data were extracted from the documentations of doctors, nurses and anaesthetists using a designed proforma. The data obtained were analysed using the IBM SPSS Statistics for Windows, version 25. Results: The median (IQR) DDI was 297 (175-434) minutes. Only one patient was delivered within the recommended DDI of 30 minutes. The most common cause of prolonged DDI was delay in procuring materials for CS by patients' relatives(s)/caregiver(s) (264, 85.2%). Repeat CS (AOR = 4.923, 95% CI 1.09-22.36; p = 0.039), prolonged decision-to-operating room time (AOR = 8.22, 95% CI 1.87-8.66; p<0.001), and junior cadre of surgeon (AOR = 25.183, 95% CI 2.698-35.053; p = 0.005) were significant predictors of prolonged DDI. Prolonged DDI > 150 minutes was significantly associated with maternal morbidity (p = 0.001), stillbirth (p = 0.008) and early neonatal death (p = 0.049). Conclusion: The recommended DDI of 30 minutes for CS is challenging in the setting studied. To improve foetomaternal outcomes, efforts to reduce the DDI should be pursued vigorously, using the recommended 30 minutesas a benchmark.

Risk Association of the Development of Disseminated Intravascular Coagulation (DIC) in Obstetrical Cases

Background: Disseminated intravascular coagulation (DIC) is a syndrome that can be initiated by a myriad of medical, surgical, and obstetric disorders. Also known as consumptive coagulopathy, DIC is a common contributor to maternal morbidity and mortality and is associated with up to 25% of maternal deaths.Aim of the study: To determine the risk factors associated with the development of disseminated intravascular coagulation (DIC) in obstetrical cases.Material & Methods:This descriptive type of study was carried out in the Department of Obstetrics and Gynecology of Janaki Medical College Teaching Hospital, RamdaiyaBhawadi, Janakpurdham, Nepal from January 2016 to December 2021. A total of 500 pregnant women complicated with DIC admitted for termination of pregnancy were included in this study. History and clinical examination were completed. The adverse obstetrical event that causes DIC is identified from clinical diagnosis and relevant investigations. Statistical analysis of the results was obtained by using windows computer software with Statistical Packages for Social Sciences (SPSS-version 26).Results:More than half (58.0%) of the patients did not receive any antenatal checkup. Regarding the risk factors for the development of DIC; abruptio placenta was associated with 185(37.0%) cases followed by PPH 147(29.4%) and preeclampsia and eclampsia 119(23.8%). Patients with risk factors of DIC were hypertension 360(72.0%), Antepartum heamorrhage 227(45.4%) and PPH 193(38.6%) these are the most common presenting features. More than two-thirds of the patients (68.0%) had spontaneous vaginal delivery. Almost two-thirds (64.0%) of patients stayed in the hospital for 8-14 days. Maternal death was found in 60(12.0%) cases and perinatal death in 121(24.2%) cases.Conclusion:Maternal and perinatal mortality in patients with DIC were 12.0% and 24.0% respectively. The major determinant of survival is prompt identification of the underlying trigger, elimination of the cause and appropriate management.

Determinantes sociales de la salud relacionados con la morbilidad materna extrema departamento de Sucre 2018-2019

Objetivo: Describir los determinantes sociales de la salud relacionados con la aparición de morbilidad materna extrema en gestantes de una institución de salud del departamento de Sucre durante 2018 - 2019. Materiales y métodos: Estudio mixto con fuentes secundarias (Sistema de vigilancia epidemiológica), observación directa en los sitios de residencia y la aplicación de una entrevista semiestructurada al grupo de sobrevivientes. Resultados: La incidencia del evento fue de 1.4 % de gestantes atendidas. El promedio de edad fue de 24 años, pertenece a una etnia el 37.5 %, proceden de área rural el 69.7 %, con niveles educativos bajos (38 %), conviviendo en unión libre (68.7 %), primigestantes (56.2 %), ingreso tardío a los controles prenatales (68.7 %), promedio de asistencias de 3.5 controles. Los determinantes que guardan relación estadística para la aparición del evento fueron: nivel educativo, la pertenencia étnica, tenencia de compañero sentimental y número de controles a los que asiste. La calidad de los servicios de salud, la pobreza, inaccesibilidad geográfica y barreras administrativas de las aseguradoras fueron las más destacadas para las gestantes. Conclusión: El evento se presenta principalmente en gestantes jóvenes, con bajo nivel educativo y de zonas rurales, los determinantes que se asociaron fueron: la etnia, el número de controles prenatales a los que asiste, el nivel educativo y el estado conyugal; para las gestantes con Morbilidad materna los bajos ingresos económicos, la inaccesibilidad a los servicios de salud y la mala calidad en la prestación de estos fueron los más importantes.

Objective: To describe the social determinants of health related to the appearance of extreme maternal morbidity in pregnant women from a health institution in the department of Sucre, for the 2018 - 2019 period. Materials and methods: Mixed study with secondary sources (Epidemiological surveillance system), direct observation at the places of residence, and the application of a semi-structured interview to the group of survivors. Results: The incidence of the event was 1.4% of pregnant women attending. The average age was 24 years old, 37.5% belong to an ethnic group, 69.7% from rural areas, with low educational levels (38%), living together in a free union (68.7%), first pregnancy (56.2%), late admission to prenatal controls (68.7%), average attendance of 3.5 controls. The determinants that are statistically related to the occurrence of the event were: educational level, ethnicity, possession of a romantic partner, and number of controls attended. The quality of health services, poverty, geographic inaccessibility, and administrative barriers of insurance companies were the most prominent for pregnant women. Conclusion: The event occurs mainly in young pregnant women, with a low educational level, and in rural areas. The determinants that were associated were: ethnicity, the number of prenatal check-ups attended, educational level, and marital status; for pregnant women with maternal morbidity, low income, inaccessibility to health services, and the presence of previous illnesses were the most important.

Study Of Maternal Near Miss Events At The Tertiary Care Hospital

Background:A maternal near miss case is defined as a “a woman who nearly died but survived a complication that occurred during pregnancy,child birth or within 42 days of termination of pregnancy”1.MMR is defined as ratio of number of maternal deaths per 1000 live births. All pregnant women deserve a good quality of care especially Emergency Obstetric Care including proper infrastructure, human resources that can detect and manage such complications earliest. The objective of this study was to evaluate the causes of maternal near miss cases, various management modalities performed and maternal and fetal outcome in near miss cases. Material And Methods:A retrospective study was carried out in obstetrics and gynaecology department of SCL municipal general hospital, Ahmedabad for identification of MNM as per MNM-R operational guidelines (2014) in a tertiary care hospital from August 2020 to March 2022. Result:Total deliveries during our study period were 9266 out of which 535 number of patients developed complications, 75 patients ended up becoming near miss cases and 30 maternal mortalities were observed.Hypertensive disorders (38.6%) followed by severe anemia (18.6%) and haemorrhage (13.3%) were the commonest underlying causes leading to MNM. More than one management modality was followed in one case. 25% of patients required blood transfusion. Out of which 11 patients required massive blood transfusion (>5 units of blood) and 16% of patients required blood products along with blood resulting from either severe anemia or altered coagulopathy (DIC). 69.3% of patients required ICU stay of <5 days and majority of patients required hospital stay of 9-14 days.63.6% of patients required ICU stay of 1-4 days.Live birth rate was 82.6%.Conclusion:Maternal health is the direct indicator of prevailing health status in a country. Reduction in maternal mortality is one of the targets of MILLENIUM DEVELOPMENT GOALS13for 2015 but in spite of full efforts by all the health care professionals, it still remains a challenge in developing countries.There should be prompt and proper management of high-risk groups by frequent antenatal visits. Aggressive management of each complication and close monitoring of women in labour, decision making in mode and time of termination of pregnancy are important to prevent further complications.

Main Complications during Pregnancy and Recommendations for Adequate Antenatal Care in Sickle Cell Disease: A Literature Review / Principais complicações durante a gestação e recomendações para o cuidado antenatal na doença falciforme: Revisão da literatura

Abstract Sickle cell disease (SCD) is the most common monogenic disease worldwide, with a variable prevalence in each continent. A single nucleotide substitution leads to an amino-acid change in the β-globin chain, altering the normal structure of hemoglobin, which is then called hemoglobin S inherited in homozygosity (HbSS) or double heterozygosity (HbSC, HbSβ), and leads to chronic hemolysis, vaso-occlusion, inflammation, and endothelium activation. Pregnant women with SCD are at a higher risk of developing maternal and perinatal complications. We performed a narrative review of the literature considering SCD and pregnancy, the main clinical and obstetrical complications, the specific antenatal care, and the follow-up for maternal and fetal surveillance. Pregnant women with SCD are at a higher risk of developing clinical and obstetric complications such as pain episodes, pulmonary complications, infections, thromboembolic events, preeclampsia, and maternal death. Their newborns are also at an increased risk of developing neonatal complications: fetal growth restriction, preterm birth, stillbirth. Severe complications can occur in patients of any genotype. We concluded that SCD is a high-risk condition that increases maternal and perinatal morbidity and mortality. A multidisciplinary approach during pregnancy and the postpartum period is key to adequately diagnose and treat complications.

Resumo Doença falciforme (DF) é a condição genética mais comum no mundo, com uma prevalência variável nos continentes. A substituição de um nucleotídeo muda um aminoácido na cadeia da β globina, e altera a estrutura normal da hemoglobina, que é então chamada de hemoglobina S, e pode ser herdada em homozigose (HbSS) ou heterozigose (HbSC, HbSβ), e leva a hemólise crônica, vaso-oclusão, inflamação, e ativação endotelial. Realizou-se uma revisão narrativa da literatura considerando doença falciforme e gestação, as complicações clínicas e obstétricas, o cuidado antenatal específico, e o seguimento para monitoramento materno e fetal. Gestantes com DF têm maior risco de desenvolver complicações clínicas e obstétricas, como crises dolorosas, complicações pulmonares, infecções, eventos tromboembólicos, préeclâmpsia, e morte materna. E seus recém-nascidos correm maior risco de desenvovler complicações neonatais: restrição de crescimento fetal, prematuridade e óbito fetal/ neonatal. Complicações graves podem ocorrer em qualquer genótipo da doença. Concluiu-se que DF é uma condição de alto risco que aumenta a morbimortalidade materna e perinatal. Um seguimento com abordagem multidisciplinar na gestação e puerpério é fundamental para o diagnóstico e o tratamento das complicações.

Maternal Near Miss-Experience At A Tertiary Care Teaching Hospital In Western India

Background:Pregnancy-related morbidity and mortality continue to have a huge impact on the lives of Indian women and their newborns. Any pregnant woman can develop life-threatening complications with little or no advance warning. All women need access to quality maternal health services that can detect and manage such complications1. Complications during pregnancy and childbirth remain a leading cause of death among women of reproductive age in India2. Each year in India, roughly 28 million women experience pregnancy and 26 million have a live birth. Of these estimated 67000 maternal and 10,00000 newborn deaths occur every year3. The maternal near-miss event was defined as “any acute obstetric complication that immediately threatens a woman’s survival but does not result in her death either by chance or because of hospital care she receives during pregnancy, labor or within 6 weeks of termination of pregnancy4.Maternal mortality data in practical terms is the tip of an iceberg while the maternal near-miss data is invisible and whic h is a very important tool to reduce maternal mortality.Material And Methods:This is a retrospective observational study carried out among 80 maternal near-miss cases who were admitted in obstetric ICU fulfilling criteria for identification for maternal near-miss cases as per Maternal Near Miss Review Operational Guideline (December 2014)in the Department of Obstetrics and Gynecology, in our tertiary care teaching hospital, between October 1, 2018, to October 31,2020.Patient fulfilling criteria for identification of near-miss cases as per Maternal Near miss Review Operational Guideline (December, 2014)Minimum 3 criteria were included in the study.Result:During the study period total of 18360 obstetric patients were admitted, out of which 80 patients ended up becoming maternal near-miss cases. Among them majority of patients were in age group of 18-25 years and occurrence was high in multipara women. In many patients more than one underlying disorder was present. Hemorrhage (67.5%) followed by a hypertensive disorder of pregnancy (30.0%) was the commonest presenting disorder in near-miss cases. In spite of being highly preventable, maternal sepsis (6.2%) also contributes to being a major cause of morbidity.In our study, 15% of near-miss cases had associated medical conditions. 5 % of cases (n=4) in the present study faced acute severe respiratory depression (ARDS) after getting infected with covid-19 infection. There was need for massive blood transfusions in 63.75 %, magnesium sulfate therapy in 17.25%, use of cardiotonic /vasopressor drugs in 10.0%, obstetric hysterectomy in 23.75 % of cases. More than one management modality was followed in many patients. All the near-miss cases were covered with broad spectrum antibiotic therapy. Total 21 near-miss cases (26.25%) were identified to have delays. Delay in the decision to seek care (Delay 1) occurred in 2.5% of women. Educational backwardness, ignorance of pregnancy itself, lack of regular antenatal care, and failure to give importance to warning signals may be the contributing factors. Delay in accessing adequate care (Delay 2) was identified in 7.5% of women. Conclusion: Hemorrhage, hypertensive disorders of pregnancy, abnormalities of labor, anemia, and sepsis are still major contributing factors for maternal near-miss cases. Anticipation, early diagnosis, and prompt treatment of maternal complications can reduce maternal morbidity and mortality. Sensitization of the population for proper utilization of available maternal health care facilities is very vital for reducing maternal near-miss cases.All the maternal near-miss cases are living le ssons, who de spite their misery show us our deficiencies.

Resultados del embarazo en mujeres con y sin COVID-19 en un hospital nacional de nivel III de Perú / Pregnancy outcomes among women with and without COVID-19 in a national level III hospital in Peru

OBJETIVO: Comparar los resultados del embarazo entre mujeres con y sin COVID-19 atendidas en un hospital nacional de nivel III de Perú. MÉTODO: Estudio observacional, retrospectivo y comparativo. Participaron gestantes con RT-PCR positiva y negativa en razón 1:1, y 1:2 con gestantes del año 2019. Se recogió información materna y perinatal. Se usó la prueba exacta de Fisher con significancia de 0,05 y razones de prevalencia (RP) con intervalo de confianza del 95% (IC95%). RESULTADOS: Participaron 51 gestantes con RT-PCR positiva, 51 gestantes con RT-PCR negativa y 102 gestantes del año 2019. Se observó asociación entre los resultados de la RT-PCR y el parto pretérmino (p < 0,05). La RP de parto pretérmino en las gestantes con RT-PCR positiva fue de 3,14 (IC95%: 1,29-7,64) veces en comparación con las gestantes de 2019 y de 4,0 (IC95%: 1,13-14,17) veces en comparación con las gestantes con RT-PCR negativa. CONCLUSIONES: Los hallazgos sugieren que puede existir asociación entre COVID-19 y parto pretérmino. Sin embargo, se requieren estudios más amplios para analizar el papel de otros factores maternos en esta asociación.

OBJECTIVE: To compare pregnancy outcomes among women with and without COVID-19 infection attended in a national level III hospital in Peru. METHOD: Observational, retrospective and comparative study. RT-PCR positive pregnant women participated in a 1:1 ratio with negative RT-PCR, and 1:2 with pregnant women of 2019. Maternal and perinatal information was collected. Fishers exact test was used with a significance level of 0.05 and prevalence ratios (PR) with their confidence interval of 95% (CI95%). RESULTS: 51 pregnant women with positive RT-PCR, 51 with negative RT-PCR and 102 pregnant women in 2019 participated. RT-PCR test were associated to preterm delivery (p < 0.05). The PR for preterm delivery in women with positive RT-PCR compared to pregnant women in 2019 was 3.14 (CI95%: 1.29-7.64); and compared to women with negative RT-PCR was 4.0 (CI95%: 1.13-14.17). CONCLUSIONS: The studys findings suggest the existence of an association between maternal COVID-19 and preterm birth. However, more studies are required to analyze the role of maternal factors.

Temporal Evolution of Maternal Mortality: 1980-2019 / Evolução temporal da mortalidade materna: 1980-2019

Abstract Objective To determine the profile of maternal deaths occurred in the period between 2000 and 2019 in the Hospital de Clínicas de Porto Alegre (HCPA, in the Portuguese acronym) and to compare it with maternal deaths between 1980 and 1999 in the same institution. Methods Retrospective study that analyzed 2,481 medical records of women between 10 and 49 years old who died between 2000 and 2018. The present study was approved by the Ethics Committee (CAAE 78021417600005327). Results After reviewing 2,481 medical records of women who died in reproductive age, 43 deaths had occurred during pregnancy or in the postpartum period. Of these, 28 were considered maternal deaths. The maternal mortality ratio was 37.6 per 100,000 live births. Regarding causes, 16 deaths (57.1%) were directly associated with pregnancy, 10 (35.1%) were indirectly associated, and 2 (7.1%) were unrelated. The main cause of death was hypertension during pregnancy (31.2%) followed by acute liver steatosis during pregnancy (25%). In the previous study, published in 2003 in the same institution4, the mortality rate was 129 per 100,000 live births, and most deaths were related to direct obstetric causes (62%). The main causes of death in this period were due to hypertensive complications (17.2%), followed by postcesarean infection (16%). Conclusion Compared with data before the decade of 2000, there was an important reduction in maternal deaths due to infectious causes.

Resumo Objetivo Determinar o perfil dos óbitos maternos ocorridos no período de 2000 a 2019 no Hospital de Clínicas de Porto Alegre (HCPA) e comparar com os óbitos maternos entre 1980 e 1999 na mesma instituição. Métodos Estudo retrospectivo que analisou 2.400 prontuários de mulheres entre 10 e 49 anos que morreram entre 2000 e 2019. O presente estudo foi aprovado pelo Comitê de Ética (CAAE 78021417600005327). Resultados Após revisão de 2.481 prontuários de mulheres que morreram em idade reprodutiva, 43 mortes ocorreram durante a gravidez ou no período pós-parto. Destas, 28 foram considerados óbitos maternos. A taxa de mortalidade materna foi de 37.6 por 100.000 nascidos vivos. Em relação às causas, 16 óbitos (57.1%) estiveram diretamente associados à gravidez, 10 (35.1%) estiveram indiretamente associados e 2 (7.1%) não estiveram relacionados. A principal causa de morte foi hipertensão na gravidez (31.2%) seguida de esteatose hepática aguda da gravidez (25%). No estudo anterior, publicado em 2003 na mesma instituição4, a taxa de mortalidade foi de 129 por 100.000 nascidos vivos, e a maioria dos óbitos estava relacionada a causas obstétricas diretas (62%). As principais causas de óbito neste período foram por complicações hipertensivas (17.2%), seguidas de infecção pós-cesárea (16%). Conclusão Em comparação com os dados anteriores à década de 2000, houve uma redução importante das mortes maternas por causas infecciosas.

Morbilidad materna en el servicio de Obstetricia del Hospital General Docente "Dr. Agostinho Neto" / Maternal morbidity attended in the Obstetric service at the Hospital General Docente "Dr. Agostinho Neto" / Morbidade materna no Serviço de Obstetrícia do Hospital General Docente "Dr. Agostinho Neto"

RESUMEN Introducción: En el servicio de Obstetricia del Hospital General Docente "Dr. Agostinho Neto" de Guantánamo no se ha precisado cómo ha sido la morbilidad materna en el periodo 2015 - 2019. Objetivo: Caracterizar la morbilidad materna en el servicio de Obstetricia y la Unidad de Cuidados Intensivos del Hospital General Docente "Dr. Agostinho Neto" de Guantánamo durante el periodo 2015 - 2019. Método: Se realizó un estudio descriptivo, transversal, y retrospectivo en todas las pacientes obstétricas ingresadas en el periodo antes mencionado (N=733). Se identificaron en estas las variables sociodemográficas, clínicas y las relacionadas con los criterios de morbilidad materna extrema. La información para el desarrollo del estudio se obtuvo de la base de datos de egresos del servicio de Obstetricia, los registros estadísticos del hospital y las historias clínicas de cada gestante. Resultados: Ingresaron 733 pacientes, el 100 % por la necesidad de manejo en la unidad. La preeclampsia-eclampsia (33,6 %) fue la enfermedad más frecuente. El 71,7 % requirió tratamiento quirúrgico y, de estas, se reintervino el 29,8 %. La histerectomía obstétrica fue la técnica quirúrgica más usual (62,9 %). Conclusiones: Se caracterizó la morbilidad materna en este servicio de salud, lo que revela que la letalidad es baja pero la frecuencia es notable.

ABSTRACT Introduction: In the obstetric care service, at the Hospital General Docente "Dr. Agostinho Neto", it has not been specified how maternal morbidity index has behaved during the period 2015-2019. Objective: To characterize the maternal morbidity index in the obstetric care service and the intensive care unit (ICU) at the Hospital General Docente "Dr. Agostinho Neto", in Guantanamo, from 2015 through 2019. Method: A descriptive, cross-sectional, and retrospective study was conducted to all admitted obstetrics patients (N=733). The sociodemographic, clinical and those related to the criteria for extreme maternal morbidity were the baseline variables identified. The information used in the study was acquired from the updated obstetric care service database (discharged patients database), the hospital's statistical records and the history of each pregnant woman. Results: The total of obstetrics patients (N=733) were admitted, it was a priority to be manage for the ICU. Preeclampsia-eclampsia was the most frequent disease (33.6%). Surgical treatment was required in the 71.7% and 29.8% of them needed to re-intervene. The hysterectomy was the most common surgical technique used (62.9%). Conclusions: The maternal morbidity in the obstetric care service was successfully characterized, which reveals that the lethality is low but the frequency is remarkable.

RESUMO Introdução: No serviço de Obstetrícia do Hospital General Docente "Dr. Agostinho Neto" de Guantánamo não foi especificado como está a morbidade materna no período 2015-2019. Objetivo: Caracterizar a morbidade materna no serviço de Obstetrícia e na Unidade de Terapia Intensiva do Hospital General Docente "Dr. Agostinho Neto" de Guantánamo durante o período 2015-2019. Método: Foi realizado um estudo descritivo, transversal e retrospectivo em todas as pacientes obstétricas admitidas no período mencionado (N=733). Neles foram identificadas variáveis sociodemográficas, clínicas e aquelas relacionadas a critérios de morbidade materna extrema. As informações para o desenvolvimento do estudo foram obtidas no banco de dados de altas do serviço de Obstetrícia, nos prontuários estatísticos do hospital e nos prontuários de cada gestante. Resultados: Foram internadas 733 pacientes, 100% devido à necessidade de gerenciamento na unidade. A pré-eclâmpsia-eclâmpsia (33,6%) foi a doença mais comum. 71,7% necessitaram de tratamento cirúrgico e, destes, 29,8% foram reoperadas. A histerectomia obstétrica foi a técnica cirúrgica mais comum (62,9%). Conclusões: A morbidade materna foi caracterizada neste serviço de saúde, o que revela que a mortalidade é baixa mas a frequência é notável.

Morbilidad materna en pacientes adscritas al Policlínico Universitario "Omar Ranedo Pubillones", Guantánamo / Maternal morbidity in patients of the Policlínico Universitario "Omar Ranedo Pubillones", Guantánamo / Morbidade materna em pacientes alocadas ao Policlínico Universitario "Omar Ranedo Pubillones", Guantánamo

RESUMEN Introducción: Se desconoce cómo influyen las pacientes maternas adscritas al Policlínico Universitario "Omar Ranedo Pubillones" en la morbilidad materna de la provincia Guantánamo. Objetivo: Precisar la influencia de las pacientes maternas adscritas a esta institución en la morbilidad materna de la provincia Guantánamo durante el trienio 2017-2019. Método: Durante octubre y noviembre de 2020 se realizó un estudio descriptivo, transversal, y retrospectivo de todas las pacientes maternas ingresadas en el Hospital General Docente "Dr. Agostinho Neto" que pertenecían a dicho policlínico (n=71). Se precisaron la edad biológica y gestacional, situación obstétrica, relación de la morbilidad con el embarazo, parto o puerperio, modo de terminar el embarazo, tratamiento quirúrgico y criterio de morbilidad materna extrema. Resultados: Ingresaron 71 pacientes adscritas a dicho policlínico (9,7 %). El 66,2 % tenía entre 19 a 34 años; el 70,4 % era puérperas, el 47,6 % eran gestantes en el tercer trimestre del embarazo. El 56,0 % fueron cesareadas, el 52,1 % ingresó por enfermedades no obstétricas. La principal causa fue la hemorragia posparto (28,2 %). El 57,7 % de las enfermedades que determinó el criterio de morbilidad materna extrema se clasificó como difícilmente evitables en la atención primaria de salud. Conclusiones: Fue baja la influencia de pacientes adscritas al mencionado policlínico en el perfil de morbilidad materna de la provincia Guantánamo durante el periodo 2017-2019, y las causas determinantes de esta morbilidad se agruparon sobre todo como difícilmente evitables con el desarrollo de acciones en el nivel primario de atención a la salud.

ABSTRACT Introduction: It remains unknown how maternal patients assigned to the Policlínico Universitario "Omar Ranedo Pubillones" influence the figures of maternal morbidity in Guantánamo province. Objective: To specify the influence of maternal patients assigned to this institution on maternal morbidity in the Guantánamo province during the 2017-2019 triennium. Method: A descriptive, cross-sectional and retrospective study was carried out during October and November 2020 on every maternal patient admitted to the Hospital General Docente "Dr. Agostinho Neto" who belonged to the clinic (n=71). The biological and gestational age, obstetric situation, relationship of morbidity with pregnancy, childbirth or puerperium, type of delivery, surgical treatment and criteria of extreme maternal morbidity were specified. Results: 71 patients of the clinic were admitted (9.7%). 66.2% were between 19 and 34 years old; 70.4% were puerperal women; 47.6% were pregnant in the third trimester of pregnancy. 56.0% were cesarean deliveries; 52.1% were admitted for non-obstetric diseases. The main cause of hospitalization was postpartum hemorrhage (28.2%). 57.7% of the diseases were classified in the extreme maternal morbidity criterion as difficult to avoid in primary health care. Conclusions: The influence of patients assigned to the clinic was low on the maternal morbidity profile of the Guantánamo province during the period 2017-2019, and the determining causes of this morbidity were grouped mainly as difficult to avoid in the primary level of health care.

RESUMO Introdução: desconhece-se a influência das pacientes maternas alocadas ao Policlínico Universitario "Omar Ranedo Pubillones" na morbidade materna na província de Guantánamo. Objetivo: especificar a influência das pacientes maternas alocadas nesta instituição na morbidade materna na província de Guantánamo durante o triênio 2017-2019. Método: Durante outubro e novembro de 2020, foi realizado um estudo descritivo, transversal e retrospectivo de todas as pacientes maternas internadas no Hospital General Docente "Dr. Agostinho Neto" que pertenciam à referida policlínica (n=71). Foram especificados a idade biológica e gestacional, situação obstétrica, relação da morbidade com a gravidez, parto ou puerpério, forma de interrupção da gravidez, tratamento cirúrgico e morbidade materna extrema. Resultados: foram internadas 71 pacientes alocadas na referida policlínica (9,7%). 66,2% tinham entre 19 e 34 anos; 70,4% eram puérperas, 47,6% estavam grávidas no terceiro trimestre de gestação. 56,0% foram cesáreos, 52,1% internadas por doenças não obstétricas. A principal causa foi hemorragia pós-parto (28,2%). 57,7% das doenças determinadas pelo critério de morbidade materna extrema foram classificadas como difíceis de evitar na atenção primária à saúde. Conclusões: a influência das pacientes alocadas na citada policlínica foi baixa no perfil de morbidade materna da província de Guantánamo durante o período 2017-2019, e as causas determinantes dessa morbidade foram agrupadas sobretudo como difíceis de evitar com o desenvolvimento de ações no nível primário de atenção à saúde.

Vertical transmission of SARS-CoV-2: A systematic review / Transmissão vertical do SARS-CoV-2: Revisão sistemática

Abstract Objective The evaluation of the available evidence on vertical transmission by severe acute respiratory syndrome coronavirus 2 (SARS-CoV)-2. Data Sources An electronic search was performed on June 13, 2020 on the Embase, PubMed and Scopus databases using the following search terms: (Coronavirus OR COVID-19 OR COVID19 OR SARS-CoV-2 OR SARS-CoV2 OR SARSCoV2) AND (vertical OR pregnancy OR fetal). Selection of Studies The electronic search resulted in a total of 2,073 records. Titles and abstracts were reviewed by two authors (WPM, IDESB), who checked for duplicates using the pre-established criteria for screening (studies published in English without limitation regarding the date or the status of the publication). Data Collection Data extraction was performed in a standardized way, and the final eligibility was assessed by reading the full text of the articles. We retrieved data regarding the delivery of the potential cases of vertical transmission, as well as themain findings and conclusions of systematic reviews. Data Synthesis The 2,073 records were reviewed; 1,000 duplicates and 896 clearly not eligible records were excluded. We evaluated the full text of 177 records, and identified only 9 suspected cases of possible vertical transmission. The only case with sufficient evidence of vertical transmission was reported in France. Conclusion The risk of vertical transmission by SARS-CoV-2 is probably very low. Despite several thousands of affected pregnant women, we have identified only one case that has fulfilled sufficient criteria to be confirmed as a case of vertical transmission. Well-designed observational studies evaluating large samples are still necessary to determine the risk of vertical transmission depending on the gestational age at infection.

Resumo Objetivo Avaliar a evidência disponível acerca da transmissão vertical do coronavírus da síndrome respiratória aguda grave 2 (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, em inglês). Fontes de Dados Foi realizada uma busca eletrônica em 13 de junho de 2020 nas plataformas Embase, PubMed e "Scopus utilizando os seguintes termos de busca: (Coronavirus OU COVID-19 OU COVID19 OU SARS-CoV-2 OU SARS-CoV2 OU SARSCoV2) E (vertical OU pregnancy OU fetal). Seleção dos Estudos A busca eletrônica resultou em um total de 2.073 registros. Títulos e resumos foram revisados por dois autores (WPM, IDESB), que verificaram a ocorrência de duplicidade e utilizaram critérios preestabelecidos para o rastreamento (estudos publicados em inglês sem limitações quanto à data ou à situação da publicação). Aquisição dos Dados A extração de dados foi realizada de forma padrão, e a eligibilidade final foi definida poir meio da leitura do artigo completo. Foram coletados dados dos partos de casos com potencial transmissão vertical, bem como os principais achados e conclusões de revisões sistemáticas. Síntese dos Dados Foram revisados os 2.073 registros; 1.000 duplicatas e 896 registros claramente não elegíveis foram excluídos. Avaliamos os artigos completos de 177 registros, e identificamos apenas 9 casos de potencial transmissão vertical. O único caso com evidência suficiente de transmissão vertical foi relatado na França. Conclusão O risco de transmissão vertical pelo vírus SARS-CoV-2 é provavelmente muito baixo. Apesar de milhares de gestantes afetadas, identificamos apenas um caso que preencheu critérios suficientes para que fosse confirmado como um caso de transmissão vertical. Estudos observacionais bem desenhados que avaliem grandes amostras ainda são necessários para se determinar o risco de transmissão vertical, a depender da idade gestacional na infecção.

Perfil clínico-epidemiológico de la neumonía grave adquirida en la comunidad en gestantes / Clinical-epidemiological profile of severe community-acquired pneumonia in pregnant women / Perfil clínico-epidemiológico da pneumonia grave adquirida na comunidade em mulheres grávidas

RESUMEN Introducción: La neumonía adquirida en la comunidad durante el embarazo no se ha caracterizado en el Hospital General Docente "Dr. Agostinho Neto". Objetivo: Caracterizar este tipo de neumonía en gestantes ingresadas en el citado hospital durante el 2015-2019. Método: Se realizó un estudio descriptivo, aplicado, y retrospectivo. Se estudiaron indicadores relacionados con la morbilidad y mortalidad por esta enfermedad, edad biológica y gestacional, procedencia, comorbilidad, estadía, y estado al egreso de las gestantes; así como variables clínico- epidemiológicas relacionadas con la neumonía. Los datos se resumieron mediante análisis de frecuencias. Resultados: Ingresaron 67 gestantes con esta afección (9,1 % y 0,24 % respecto al total de pacientes maternas y al total de pacientes ingresados en la unidad por todas las causas, respectivamente). Sobre todo, tenían entre 20 y 29 años de edad (92,5 %) y entre 28 y 42 semanas de gestación (59,7 %), procedieron de áreas urbanas (89,5 %) y presentaron comorbilidad (31,3 %). La forma clínica-radiológica típica fue la más común (92,5 %), el germen causal más usual fue el Streptococcus pneumoniae (41,8 %), el 100 % se trató con fármacos antimicrobianos antivirales, cefalosporinas y macrólidos, el 73,1 % evolucionó de modo satisfactorio. Falleció una paciente. Conclusiones: Se caracterizó la neumonía adquirida en la comunidad durante el embarazo en pacientes del Hospital General Docente "Dr. Agostinho Neto" de Guantánamo durante el periodo 2015-2019, lo que posibilita reconocer que no significa un problema de salud, pero impacta en el perfil de morbilidad materna pues es la primera causa de ingreso de gestantes por enfermedades no obstétricas.

ABSTRACT Introduction: Pneumonia acquired in the community during pregnancy has not been characterized in the Hospital General Docente "Dr. Agostinho Neto". Objective: To characterize this type of pneumonia in pregnant women admitted to the aforementioned hospital during 2015-2019. Method: A descriptive, retrospective and applied study was carried out. Indicators related to morbidity and mortality, biological and gestational age, origin, comorbidity, stay and status at the time discharge of the pregnant women were studied; as well as clinical-epidemiological variables related to pneumonia. Data were summarized using frequency analysis. Results: 67 pregnant women with this condition were admitted (9.1% and 0.24% with respect to the total number of maternal patients and the total number of patients admitted to the unit for all causes, respectively). They were mostly between 20 and 29 years of age (92.5%) and between 28 and 42 weeks of gestation (59.7%); 89.5% came from urban areas and 31.3% presented comorbidity. The typical clinical-radiological form was the most common (92.5%); the most common causative germ was Streptococcus pneumoniae (41.8%); 100% were treated with antiviral antimicrobial drugs, cephalosporins and macrolides; 73.1% evolved satisfactorily. One patient passed away. Conclusions: Community-acquired pneumonia during pregnancy was characterized in patients from the Hospital General Docente "Dr. Agostinho Neto" in Guantánamo during the period 2015-2019, which makes it possible to recognize that this condition does not constitute a health problem, but it impacts on the maternal morbidity profile since it is the first cause of admission of pregnant women due to non-obstetric diseases.

RESUMO Introdução: Pneumonia adquirida na comunidade durante a gravidez não foi caracterizada no Hospital General Docente "Dr. Agostinho Neto". Objetivo: Caracterizar este tipo de pneumonia em gestantes internadas no referido hospital durante 2015-2019. Método: Foi realizado um estudo descritivo, aplicado e retrospectivo. Foram estudados indicadores relacionados à morbimortalidade por essa doença, idade biológica e gestacional, procedência, comorbidade, permanência e estado de alta das grávidas; bem como variáveis clínico-epidemiológicas relacionadas à pneumonia. Os dados foram resumidos por análise de frequência. Resultados: Foram internadas 67 grávidas com essa condição (9,1% e 0,24% do total de pacientes maternos e do total de pacientes internados na unidade por todas as causas, respectivamente). Acima de tudo, tinham entre 20 e 29 anos (92,5%) e entre 28 e 42 semanas de gestação (59,7%), eram procedentes da zona urbana (89,5%) e apresentavam comorbidade (31,3%). A forma clínico-radiológica típica foi a mais comum (92,5%), o germe causador mais comum foi Streptococcus pneumoniae (41,8%), 100% foram tratados com antimicrobianos antivirais, cefalosporinas e macrolídeos, 73,1% evoluíram de forma satisfatória. Um paciente faleceu. Conclusões: A pneumonia adquirida na comunidade durante a gravidez foi caracterizada em pacientes do Hospital General Docente "Dr. Agostinho Neto" de Guantánamo no período 2015-2019, o que permite reconhecer que não se trata de um problema de saúde, mas impacta no perfil de morbidade materna por ser a principal causa de internamento de grávidas por doenças não obstétricas.

Maternal and Fetal Outcomes in Caesarean Sectıons Repeated Fourth and Fıfth Tımes

ABSTRACT Objective: To evaluate the maternal and fetal outcomes associated with caesarean sections (CS) repeated fourth and fifth times. Methods: We performed a retrospective study of 110 patients undergoing CS repeated fourth and fifth times between May 2014 and May 2015. The patients were divided into two groups: group 1 had CS repeated four times (n = 90) and group 2 had CS repeated five times (n = 20), and the maternal and fetal outcomes of the groups were retrospectively evaluated. Results: There were no statistically significant differences between fourth and fifth CS groups with regard to the maternal age, gravida, body mass index, gestational age at birth, birth-weight, and Apgar scores at 5 minutes (p > 0.05). We found no significant differences between the fourth and fifth CS groups in terms of injury to peripheral organs, intra-abdominal adhesions, caesarean hysterectomy, uterine dehiscence or rupture, time during operation, length of hospital stay, and need for blood transfusions (p > 0.05). Compared with the elective cases, perioperative complications and length of hospital stay were significantly higher in the urgent group (p = 0.034 and p = 0.005). Conclusion: Women with CS repeated four or five times have increased risks for perioperative complications. Placenta previa with or without accreta and intra-abdominal adhesions seem to be the major causes of increased morbidity.

Is vaginal breech delivery still a safe option? / Será o parto pélvico vaginal uma opção segura?

Abstract Objective: To determine whether there was any difference in neonatal and maternal outcomes between breech vaginal delivery and cephalic vaginal delivery. Methods: A retrospective, case-control study was conducted between January 2015 and December 2017 in a Portuguese hospital. A total of 26 cases of breech vaginal delivery were considered eligible and 52 pregnant women formed the control group. Results: Induced labor was more frequent in the breech vaginal delivery group (46% versus 21%, p = 0.022). Episiotomy was more common in the breech vaginal delivery group (80% versus 52%, p = 0.014), and one woman had a 3rd degree perineal laceration. Newborns in the study group had a lower birthweight (2,805 g versus 3,177 g, p < 0.001). There was no significant difference in the neonatal outcomes. Conclusion: The present study showed that breech vaginal delivery at term compared with cephalic presentation was not associated with significant differences in neonatal and maternal morbidity. It also suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician.

Resumo Objetivo: Avaliar se existem diferenças nos desfechos perinatal e materno entre os partos pélvicos vaginais e eutócicos. Métodos: Realizou-se um estudo retrospectivo, caso controle, entre janeiro de 2015 e dezembro de 2017 em um hospital terciário em Portugal. Foram incluídos 26 casos de parto pélvico vaginal e o grupo controle foi formado por 52 grávidas. Resultados: A indução do trabalho de parto ocorreu com mais frequência no grupo do parto pélvico vaginal (46% versus 21%, p = 0.022), bem como a realização de episiotomia (80% versus 52%, p = 0.014). Verificou-se um caso de laceração perineal de 3° grau. Os recém-nascidos do grupo de estudo apresentaram um peso inferior ao nascimento (2.805 g versus 3.177 g, p < 0.001). Em relação aos desfechos perinatais, não se observaram diferenças estatisticamente significativas. Conclusão: O presente estudo mostrou que o parto pélvico vaginal no termo quando comparado com o parto eutócico não se associou a diferenças estatisticamente significativas na morbidade perinatal e materna, e sugere ainda que o parto pélvico vaginal parece ser uma opção segura em casos rigorosamente selecionados e na presença de um obstetra experiente.

Active versus expectant management for preterm premature rupture of membranes at 34-36 weeks of gestation and the associated adverse perinatal outcomes / Manejo ativo versus expectante para ruptura prematura de membranas entre 34 e 36 semanas de gestação e os resultados perinatais adversos associados

Abstract Objective: To compare the type of management (active versus expectant) for preterm premature rupture of membranes (PPROM) between 34 and 36 + 6 weeks of gestation and the associated adverse perinatal outcomes in 2 tertiary hospitals in the southeast of Brazil. Methods: In the present retrospective cohort study, data were obtained by reviewing the medical records of patients admitted to two tertiary centers with different protocols for PPROM management. The participants were divided into two groups based on PPROM management: group I (active) and group II (expectant). For statistical analysis, the Student t-test, the chi-squared test, and binary logistic regression were used. Results: Of the 118 participants included, 78 underwent active (group I) and 40 expectant management (group II). Compared with group II, group I had significantly lower mean amniotic fluid index (5.5 versus 11.3 cm, p = 0.002), polymerase chain reaction at admission (1.5 versus 5.2 mg/dl, p = 0.002), time of prophylactic antibiotics (5.4 versus 18.4 hours, p < 0.001), latency time (20.9 versus 33.6 hours, p = 0.001), and gestational age at delivery (36.5 versus 37.2 weeks, p = 0.025). There were no significant associations between the groups and the presence of adverse perinatal outcomes. Gestational age at diagnosis was the only significant predictor of adverse composite outcome (x2 [1] = 3.1, p = 0.0001, R2 Nagelkerke = 0.138). Conclusion: There was no association between active versus expectant management in pregnant women with PPROM between 34 and 36 + 6 weeks of gestation and adverse perinatal outcomes.

Resumo Objetivo: Comparar o tipo de manejo (ativo versus expectante) para ruptura prematura de membranas (PPROM, na sigla em inglês) entre 34 e 36 semanas e 6 dias de gestação e os resultados perinatais adversos relacionados, em 2 hospitais terciários do sudeste brasileiro. Métodos: No presente estudo de coorte retrospectivo, os dados foram obtidos através da revisão dos prontuários de gestantes internadas em dois centros terciários com protocolos diferentes para o seguimento da PPROM. As gestantes foram divididas em dois grupos com base no manejo da PPROM: grupo I (ativo) e grupo II (expectante). Para análise estatística, foram utilizados o teste t de Student, qui-quadrado e regressão logística binária. Resultados: Das 118 gestantes incluídas, 78 foram submetidas a tratamento ativo (grupo I) e 40 a seguimento expectante (grupo II). Comparado ao grupo II, o grupo I apresentou índice de líquido amniótico médio significativamente menor (5,5 versus 11,3 cm, p = 0,002), reação em cadeia da polimerase na admissão (1,5 versus 5,2 mg/dl, p = 0,002), tempo de antibióticos profiláticos (5,4 versus 18,4 horas, p < 0,001), tempo de latência (20,9 versus 33,6 horas, p = 0,001) e idade gestacional no parto (36,5 versus 37,2 semanas, p = 0,025). Não houve associações significativas entre os grupos e a presença de resultados perinatais adversos. A idade gestacional no diagnóstico foi o único preditor significativo de desfecho composto adverso (x2 [1] = 3,1, p = 0,0001, R2 Nagelkerke = 0,138). Conclusão: Não houve associação entre manejo ativo e expectante em gestantes com PPROM entre 34 e 36 semanas e 6 dias de gestação e resultados perinatais adversos.

Reporte de caso: manejo multidisciplinario en gestante con embarazo de 31 semanas y COVID-19 positivo con evolución grave / Case report: multidisciplinary management in case of 31 weeks pregnant woman and COVID 19 infection with severe disease presentation

INTRODUCCIÓN: En diciembre de 2019 se reporta un brote de neumonía atípica causada por un nuevo coronavirus: SARS-CoV-2 (Severe Acute Respiratory Syndrome-Coronavirus-2), cuya enfermedad se denomina COVID-19 (Coronavirus Disease 2019). Desde entonces su distribución se ha ampliado mundialmente causando una emergencia en los sistemas de salud. MÉTODO: Corresponde al reporte de caso clínico. Este estudio es descriptivo y se basa en el manejo realizado a paciente embarazada con COVID-19 confirmado. Esta publicación cuenta con la autorización del comité de ética local para la revisión de ficha clínica. CASO: Mujer de 40 años con un embarazo de 31 semanas, se le diagnostica COVID-19 tras contacto estrecho con caso confirmado. Evoluciona con disnea y por posibilidad de interrupción del embarazo se traslada a centro de mayor complejidad. Allí se pesquisa compromiso de función pulmonar, uso de musculatura accesoria y alteración sensorial, requiriendo oxigenoterapia. Se evalúa interdisciplinariamente decidiendo intubar y realizando manejo en unidad de cuidados intensivos (UCI). Se realiza cesárea de urgencia a las 31+4 semanas debiendo realizarse histerectomía total por inercia uterina. Tras el procedimiento evoluciona tórpidamente con deterioro de función pulmonar, describiéndose un pronóstico catastrófico con probabilidad de fallecer por insuficiencia respiratoria. Un mes después despierta con una mejoría en su función pulmonar, sin otra falla orgánica. Actualmente se encuentra en buenas condiciones y es tratada multidisciplinariamente para lograr una rehabilitación integral. DISCUSIÓN: En epidemias pasadas, las embarazadas mostraron altas tasas de letalidad y riesgo de ingreso a UCI. Basados en una revisión de reportes de casos, parece ser que COVID-19 durante el embarazo se asocia a morbilidad materna severa, riesgo que aumenta en mujeres con comorbilidades, lo cual hace cuestionarnos si la infección por COVID-19 intensifica el riesgo materno o estos casos ya eran embarazos de riesgo. Se necesitan futuras investigaciones al respecto.

INTRODUCTION: The coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, was first reported in december 2019 in China as an atypipical pneumonia. Since then its distribution has globally expanded causing a public health emergency. METHOD: Corresponds to a case report. A descriptive study about the management of a pregnant woman whith COVID-19. CASE: A 40 year old pregnant woman, 31 weeks gestational age, was admitted with a diagnosis of COVID-19. She developed dyspnea and preterm birth risk that needed a more complex hospital level. Thereafter, the patient developed respiratory distress, use of accessory breathing muscles and neurological alteration, requiring oxygen therapy. An interdisciplinary medical team evaluation decided to manage her condition at intensive care unit (ICU). Cesarean delivery was performed at 31+4 weeks. After the procedure, the pulmonary function declined to a life threatening condition. A month later, the patient woke up with improved pulmonary function, without any organ failure. Currently the patient is in a good general condition with a multidisciplinary rehabilitation treatment ongoing. DISCUSSION: In previous epidemic outbrakes, pregnant women presented high fatality rates and intensive care tratment risk. Based on a case report review, COVID-19 in pregnancy is associated with severe maternal morbidity, specially in women with associated comorbidities. This situation raises the question whether the COVID-19 infection intensifies the maternal risk or whether these cases were already a high risk pregnancies. Additional studies are needed to answer this issue.