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1.
Actual. SIDA. infectol ; 30(108): 58-67, 20220000. graf, tab
Article in Spanish | LILACS, BINACIS | ID: biblio-1363381

ABSTRACT

ntroducción: La información sobre la evolución de la infección por COVID-19 en personas gestantes (PG) continúa en desarrollo.Objetivos: Describir la presentación de la infección por Sars-CoV-2 en PG y determinar variables asociadas a mayor gravedad.Materiales y métodos: Estudio observacional retrospectivo. Periodo: 01/03/2020-31/07/2021. Se incluyeron PG con diagnóstico de COVID-19 asistidas en una maternidad de gestión pública: se clasificaron según gravedad y se dividieron en dos grupos: Grup o1 leve y de manejo ambulatorio; Grupo 2 moderado, severo y crítico, con internación. Se analizó la relación entre gravedad y obesidad, DBT, hipertensión inducida por el embarazo (HIE), edad gestacional, edad materna, vacunación antigripal. Recién nacidos (RN) de madres infectadas se estudiaron con PCR para Sars-CoV-2 24-48 hs postnacimiento. Análisis estadístico: Chi-cuadrado o test exacto de Fisher. Significancia= p<0,05. Aprobado porComité Ética Institucional.Resultados: 52 PG con diagnóstico de COVID-19. Edadmediana 29,6 años. Grupo 1: 29 PG (55,5%). Grupo 2: 23 PG(44%), 19 (36,5%) moderados, 2 (4%) severos y 2 (4%) críticos. No hubo fallecimientos maternos ni fetales. Edad gestacional ≥ 28 semanas fue la única variable asociada a mayor gravedad,p=0,00004. 48% de los embarazos finalizaron por cesárea.48/52 RN fueron estudiados con PCR para Sars-CoV-2, siendo 1 (2%) positivo (fue el único RN sintomático).Conclusiones: La infección por COVID-19 en PG se asoció a presentaciones clínicas más graves cuando la infecciónse cursó en el tercer trimestre de gestación y se asociócon mayor incidencia de cesáreas


ntroduction: The information concerning the impact of COVID-19 infection in pregnant people (PP) continues to be established.Aim: to describe the evolution of the Sars-CoV-2 infection in pregnant people and to determine variables associated with clinical severity.Materials and Methods: Retrospective observational study. Period: 01-03-2020 to 31-07-2021. We included PP with diagnosis of COVID-19, assisted in a public maternity hospital. The cases were classified according to clinical severity based on the NIH guidelines. The patients were divided into 2 groups: Group 1: mild (ambulatory manage-ment). Group 2: moderate, severe and critical (requiring hospitalization). The relationship between variables and clinical severity was analyzed. Variables studied: obesity, DBT, gestational hypertension, gestational age, maternal age, influenza vaccination. Newborns of infected mothers were studied with PCR for Sars-CoV-2 24 to 48 hours af-ter birth. Statistical analysis: Chi-square or Fisher's exact test, significance = p <0.05. Study approved by the Institu-tional Ethics Committee.Results: 52 PP with diagnosis of COVID-19 were includ-ed. Median age 29.6 years. 23 patients (44%) required hospitalization and 2 (4%) MRA (mechanical respiratory assistance). 29 (55.5%) were mild, 19 (36.5%) moderate, 2 (4%) severe, and 2 (4%) critical. There were no mater-nal or fetal deaths. Gestational age ≥ 28 weeks was the only variable associated with more severe clinical forms, p = 0.0001. 48% of the pregnancies ended by cesarean section. 48/52 newborns were studied with PCR for Sars-CoV-2, with only 1 (2%) being positive. This was the only symptomatic newborn.Conclusions: In our study, Sars-CoV-2 infection during pregnancy was associated with more severe clinical pre-sentations when the infection occurred in the 3rd trimes-ter of pregnancy. COVID-19 was also associated with a higher incidence of ter


Subject(s)
Humans , Female , Pregnancy , Adolescent , Adult , Pregnancy Complications/prevention & control , Pregnancy Trimester, Third , Severity of Illness Index , Retrospective Studies , Pregnant Women , COVID-19/complications , Obesity/complications
2.
Nursing (Säo Paulo) ; 24(279): 6053-6062, ago.-2021.
Article in Portuguese | LILACS, BDENF | ID: biblio-1343581

ABSTRACT

Objetivo: apresentar as evidências científicas sobre a atuação da(o) enfermeira(o) na classificação de risco em obstetrícia. Método: trata-se de um estudo qualitativo, do tipo revisão integrativa, realizado nas bases de dados SciELO e PubMed, na série temporal de 2011 a 2021, no idioma português, com os descritores e operadores boleanos. Resultados: Identificou-se um conjunto de 105 publicações sobre a temática no SciELO e 86 na PubMed. Do total de 191 publicações identificadas, segundo a combinação dos descritores e acréscimos de booleanos, 4 foram consideradas para análise, que demonstravam a(o) enfermeira(o) como principal profissional na classificação de risco às gestantes devido à sua assistência eficaz, ágil e resolutiva, reduzindo os riscos à saúde do binômio e impactando sobre a mortalidade materno-infantil. Conclusão: percebe-se que a utilização da Classificação de Risco às gestantes e à sua realização pela Enfermagem, proporciona melhorias no serviço, promovendo eficácia no atendimento as urgências e emergências obstétricas.(AU)


Objective: to present the scientific evidence on the role of the nurse in the classification of risk in obstetrics. Method: this is a qualitative study, integrative review type, carried out in the SciELO and PubMed databases, in the time series from 2011 to 2021, in Portuguese, with Boolean descriptors and operators. Results: A set of 105 publications on the subject in SciELO and 86 in PubMed were identified. Of the 191 publications identified, according to the combination of descriptors and additions of Booleans, 4 were considered for analysis, which showed the nurse as the main professional in the risk classification of pregnant women due to their effective, agile and resolution, reducing the health risks of the binomial and impacting on maternal and child mortality. Conclusion: it is noticed that the use of the Risk Classification for pregnant women and its performance by Nursing, provides improvements in the service, promoting effectiveness in attending obstetric urgencies and emergencies.(AU)


Objetivo: presentar la evidencia científica sobre el rol de la enfermera en la clasificación de riesgo en obstetricia. Método: se trata de un estudio cualitativo, de tipo revisión integradora, realizado en las bases de datos SciELO y PubMed, en la serie temporal de 2011 a 2021, en portugués, con descriptores y operadores booleanos. Resultados: Se identificó un conjunto de 105 publicaciones sobre el tema en SciELO y 86 en PubMed. De las 191 publicaciones identificadas, de acuerdo a la combinación de descriptores y adiciones de booleanos, se consideraron para análisis 4, que mostraron al enfermero como el principal profesional en la clasificación de riesgo de la gestante por su eficacia, agilidad y resolución, reduciendo la salud. riesgos del binomio y que impactan en la mortalidad materna e infantil. Conclusión: se advierte que el uso de la Clasificación de Riesgo para gestantes y su desempeño por parte de Enfermería, brinda mejoras en el servicio, promoviendo la efectividad en la atención de urgencias y emergencias obstétricas.(AU)


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/prevention & control , Risk Factors , Delivery, Obstetric , Nurses , Obstetric Nursing
3.
Rev. cuba. anestesiol. reanim ; 20(1): e656, ene.-abr. 2021. graf
Article in Spanish | LILACS, CUMED | ID: biblio-1156370

ABSTRACT

Introducción: La hipertensión arterial pulmonar es una enfermedad con una baja incidencia en la gestante, aunque trae consigo una alta mortalidad una vez presentada. Un diagnóstico oportuno y un manejo perioperatorio adecuado minimizan el riesgo de desenlace fatal tanto para la madre como el feto. Objetivo: Describir el comportamiento de la hipertensión arterial pulmonar en la gestante a término y su conducción anestésica. Presentación del caso: Paciente de 23 años, antecedentes de salud, edad gestacional de 35.2 semanas. Luego de presentar dolor de espalda y ardor en el pecho relacionado con el esfuerzo, palpitaciones, disnea y bloqueo de rama derecha en electrocardiograma, se ingresa en UTI con sospecha de tromboembolismo pulmonar, el cual queda descartado tras diagnóstico confirmatorio de hipertensión pulmonar después de realizar angio TAC y ecocardiografía. Se decide realizar cesárea programada bajo técnica regional peridural, sin complicaciones tanto para la madre como el niño. Después de 2 días bajo vigilancia intensiva se traslada a su centro hospitalario de cabecera. Conclusiones: La vía del parto, así como una elección adecuada de la técnica anestésica, puede ser la diferencia entre el éxito y la fatalidad. Las técnicas regionales suelen recomendarse por encima de la técnica de anestesia general siempre que no se presenten contraindicaciones(AU)


Introduction: Pulmonary arterial hypertension is a disease with low incidence in the pregnant woman, although it brings about high mortality once presented. Timely diagnosis and adequate perioeprative management minimize the risk of fatal outcome for both mother and fetus. Objective: To describe pulmonary arterial hypertension and its anesthetic management in the term pregnant woman. Case presentation: 23-year-old female patient, with health history and gestational age of 35.2 weeks. After presenting back pain and chest burning associated with exertion, palpitations, dyspnea and right bundle branch block in the electrocardiogram, the patient was admitted to the intensive care unit with suspected pulmonary thromboembolism, which was ruled out due to the confirmatory diagnosis of pulmonary hypertension after performing computerized tomography angiography and echocardiography. Scheduled cesarean section was decided to be perform using the regional peridural technique, without complications for both the mother and the child. After two days under intensive surveillance, she was transferred to her primary hospital. Conclusions: The route of delivery, as well as an adequate choice of the anesthetic technique, can be the difference between success and fatality. Regional techniques are usually recommended over the general anesthesia technique, as long as there are no contraindications(AU)


Subject(s)
Humans , Female , Pregnancy , Young Adult , Pulmonary Arterial Hypertension/complications , Pulmonary Arterial Hypertension/diagnostic imaging , Anesthesia, General/methods , Pregnancy Complications/prevention & control , Cesarean Section/methods
4.
Rev. bras. ginecol. obstet ; 43(2): 97-106, Feb. 2021. tab, graf
Article in English | LILACS | ID: biblio-1156097

ABSTRACT

Abstract Cases of maternal near miss are those in which women survive severe maternal complications during pregnancy or the puerperium. This ecological study aimed to identify the temporal trend of near-miss cases in different regions of Brazil between 2010 and 2018, using data fromtheHospital Information System(HIS) of theUnified BrazilianHealth System (SUS, in the Portuguese acronym). Hospital admission records of women between 10 and 49 years old with diagnosis included in the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and codes indicating nearmiss events were selected. From 20,891,040 admissions due to obstetric causes, 766,249 (3.66%) near-miss cases were identified, and 31,475 women needed admission to the intensive care unit (ICU). The cases were found to be more predominant in black women over 35 years old from the North and Northeast regions. There was a trend of increase in near-miss rates of ~ 13.5% a year during the period of the study. The trend presented a different behavior depending on the level of development of the region studied. The main causes of near miss were preeclampsia (47%), hemorrhage (24%), and sepsis (18%).


Resumo Casos de near miss materna são aqueles em que as mulheres sobrevivem a graves complicações maternas durante a gravidez ou o puerpério. Este estudo ecológico teve comoobjetivo identificar a tendência temporal de casos de near missemdiferentes regiões do Brasil entre 2010 e 2018, utilizando dados do Sistema de Informações Hospitalares (SIH) do Sistema Único de Saúde (SUS). Foram selecionados registros de internação demulheres entre 10 e 49 anos comdiagnóstico incluído na 10ª revisão daClassificação Internacional de Doenças e Problemas Relacionados à Saúde (CID-10) e códigos indicando eventos de near miss. Das 20.891.040 internações por causas obstétricas, 766.249 (3,66%) casos de near miss foram identificados, e 31.475mulheres necessitaramde internação na unidade de terapia intensive (UTI). Constatou-sequeos casos sãomaispredominantesemmulheres negras commais de 35 anos da região Norte e Nordeste. Houve uma tendência de aumento nas taxas de near miss de aproximadamente 13,5% ao ano durante o período do estudo. A tendência apresentou um comportamento diferente, dependendo do nível de desenvolvimento da região estudada. As principais causas de near miss foram pré-eclâmpsia (47%), hemorragia (24%), e sepse (18%).


Subject(s)
Humans , Male , Female , Pregnancy , Adolescent , Adult , Young Adult , Pregnancy Complications/epidemiology , Prenatal Care , Near Miss, Healthcare/statistics & numerical data , Obstetric Labor Complications/epidemiology , Patient Admission , Pregnancy Complications/prevention & control , Brazil/epidemiology , Demography , Maternal Mortality , Hospital Information Systems , Diagnosis-Related Groups , Near Miss, Healthcare/trends , Obstetric Labor Complications/prevention & control , Middle Aged
5.
Rev. Ateneo Argent. Odontol ; 64(1): 51-55, 2021.
Article in Spanish | LILACS | ID: biblio-1252692

ABSTRACT

La mujer gestante sufre cambios fisiológicos y psicológicos durante los meses de embarazo que pueden derivar en problemas de salud bucal. A través de diversos estudios se observó que múltiples factores actúan como determinantes en lo que a la atención odontológica de la embarazada respecta, entre los cuales se pueden encontrar, la realidad sociocultural de la paciente, su nivel de instrucción educativo, sus conocimientos en cuanto a la atención odontológica, factores de riesgos, entre otros. El profesional odontólogo, tiene en sus manos recursos que pueden ser de gran ayuda por lo que su papel es de suma importancia, desde la educación preventiva, brindando conocimientos técnicos hasta la atención odontológica en sectores vulnerables. El objetivo de este trabajo consistió en reunir la evidencia que se corresponda con el análisis de los conocimientos y prácticas de salud bucal en mujeres embarazadas con el fin de organizar los trabajos hallados en un cuerpo de conocimiento fundamentado (AU)


The pregnant woman suffers physiological and psychological changes during the months of pregnancy that can lead to oral health problems. Through various studies it was observed that multiple factors act as determinants regarding dental care of the pregnant woman, among which can be found the sociocultural reality of the patient, her educational level of instruction, her knowledge regarding dental care, risk factors, among others. The dental professional has resources in her hands that can be of great help, so her role is of the utmost importance, from preventive education, providing technical knowledge to dental care in vulnerable sectors. The objective of this work was to gather the evidence that corresponds to the analysis of oral health knowledge and practices in pregnant women to organize the studies found in a well-founded body of knowledge (AU)


Subject(s)
Humans , Female , Pregnancy , Pregnancy/physiology , Health Knowledge, Attitudes, Practice , Oral Health , Comprehensive Dental Care , Diagnosis, Oral , Pregnancy Complications/prevention & control , Health Education, Dental , Risk Factors , Databases, Bibliographic
6.
Rev. cuba. med. trop ; 72(3): e518, sept.-dic. 2020.
Article in Spanish | LILACS, CUMED | ID: biblio-1156545

ABSTRACT

Introducción: La infección por malaria durante el embarazo es un importante problema de salud en la mayoría de las regiones tropicales. Esta condición puede tener incidencia negativa tanto en la gestante como en el feto. Objetivo: Indagar en el impacto del tratamento preventivo intermitente con el medicamento antimalárico sulfadoxina-pirimetamina en la mujer embarazada. Métodos: Se realizó una revisión bibliográfica en la base de datos Medline/Pub Med y en artículos relevantes relacionados al tema de los últimos cinco años. Además, se tomó como referencia las guías para el tratamiento de malaria de la Organización Mundial de la Salud, verisón 2016-2017. Análisis y síntesis de los resultados: Durante el período 2015-2017 no se lograron avances significativos en la reducción del número de enfermos palúdicos. No obstante, se señala la anemia como causa de mortalidad en el curso de la malaria. También, se destacan los nuevos enfoques y compromisos para reducir la morbilidad atribuible al paludismo en la mujer embarazada en sus tres vertientes: tratamiento eficaz de los casos de paludismo, el uso de mosquiteros tratados con insecticidas, y la utilización del tratamiento preventivo intermitente con el antimalárico sulfadoxina-pirimetamina a partir del segundo trimestre del embarazo. La indicación de este tratamiento inlcuye mínimo dos dosis del fármaco antipalúdico, con un intervalo de un mes entre cada dosis, con independencia de que las embarazadas muestren o no síntomas de la enfermedad. Conclusiones: Esta intervención para prevenir el paludismo en el embarazo es una cuestión prioritaria en la iniciativa de salud materna, infantil y reproductiva; además, ayuda a mejorar y aumentar la cobertura de las medidas de control de esta enfermedad durante la gestación(AU)


Introduction: Malaria infection during pregnancy is an important health problem in most tropical regions. This condition may have a negative incidence on pregnant women and fetuses. Objective: Inquire into the effect of the intermittent preventive treatment with the malarial sulfadoxine / pyrimethamine in pregnant women. Methods: A bibliographic review was conducted in the database Medline / PubMed and in relevant papers about the topic published in the last five years. The Guidelines for the Treatment of Malaria 2016-2017 of the World Health Organization were also used as reference. Analysis and synthesis of results: Significant progress was not achieved in reducing the number of malaria patients in the period 2015-2017. However, anemia is reported as the cause of mortality during the course of malaria. New approaches and commitments are proposed to reduce malaria-related morbidity among pregnant women, namely effective treatment of malaria cases, use of insecticide-treated mosquito nets, and intermittent preventive treatment with the antimalarial sulfadoxine / pyrimethamine as of the second quarter of pregnancy. Indication of this treatment includes at least two doses of the malarial, with a separation of one month between the doses, regardless of whether the pregnant women have symptoms of the disease. Conclusions: The intervention to prevent malaria during pregnancy is a first-priority aspect of the mother, child, reproductive health initiative. It also helps improve and broaden the coverage of measures for the control of this disease during pregnancy(AU)


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/prevention & control , Sulfadoxine/therapeutic use , Malaria/prevention & control , Pyrimethamine/therapeutic use
7.
Femina ; 48(9): 574-576, 20200930.
Article in Portuguese | LILACS | ID: biblio-1122590

ABSTRACT

Os dispositivos intrauterinos (DIUs) são os métodos contraceptivos reversíveis de longa duração mais utilizados no mundo, apresentando altas taxas de eficácia e segurança. Na presença de gestação, o DIU pode ser retirado com uma leve tração dos fios, quando visíveis. Na impossibilidade de visualização dos fios, há a opção de retirada por histeroscopia, que tem se mostrado segura e eficaz para a retirada de DIU retido na cavidade. Foram pesquisados os termos: "intrauterine device", "pregnancy" e "hysteroscopy". Dos 378 artigos encontrados, foram selecionados 18 artigos que cumpriam os objetivos desta revisão. A presença de DIU durante a gestação se mostra um fator de risco independente para desfechos desfavoráveis como abortamento, corioamnionite, parto prematuro e maior taxa de admissão em unidade de terapia intensiva neonatal. A histeroscopia ambulatorial se mostra uma alternativa segura e eficaz na retirada do DIU no primeiro trimestre.(AU)


Intrauterine devices (IUDs) are the most widely used reversible contraceptive methods in the world, with high rates of efficacy and safety. In the presence of pregnancy, the IUD can be removed by gently traction of the threads, when visible. If the wires cannot be visualized, we have the option of hysteroscopy removal, which has been shown to be safe and effective for the removal of an IUD retained in the cavity. The terms "intrauterine device", "pregnancy" and "hysteroscopy" were searched. Of the 378 articles found, 18 articles were selected that met the objectives of this review. The presence of IUDs during pregnancy is an independent risk factor for unfavorable outcomes such as abortion, chorioamnionitis, premature birth and a higher rate of admission to a neonatal intensive care unit. Ambulatory hysteroscopy is a safe and effective alternative for IUD removal in the first trimester.(AU)


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/prevention & control , Hysteroscopy , Intrauterine Devices , Intrauterine Devices, Copper , Pregnancy Trimester, First , Risk Factors , Databases, Bibliographic , Copper/therapeutic use , Contraceptive Effectiveness
8.
Guatemala; MSPAS; 9 jul 2020. 27 p. graf.
Non-conventional in Spanish | LILACS, LIGCSA | ID: biblio-1151484

ABSTRACT

Uniendo esfuerzo entre el equipo del MSPAS y asociaciones médicas, elaboraron una guía médica sobre la manera de abordar el tratamiento a pacientes adultos, niños y mujeres embarazadas enfermos de COVID. Es una guía detallada sobre la información obtenida hasta ese momento y tiene como objetivo: apoyar a los distintos centros proveedores de servicios de salud a nivel nacional proporcionando una guía básica para la atención de pacientes con COVID-19


Subject(s)
Humans , Male , Female , Pregnancy , Infant, Newborn , Infant , Child, Preschool , Child , Adult , Pneumonia, Viral/diagnosis , Pneumonia, Viral/drug therapy , Pregnancy Complications/prevention & control , Coronavirus Infections/diagnosis , Coronavirus Infections/drug therapy , Respiratory Insufficiency/diagnosis , Shock/drug therapy , Infection Control/organization & administration , Clinical Laboratory Techniques/methods , Personal Protective Equipment/standards , Intubation/methods
9.
Guatemala; MSPAS; [2020]. 18 p. graf.
Non-conventional in Spanish | LILACS, LIGCSA | ID: biblio-1151724

ABSTRACT

Enumera síntomas, protocolos de ingreso a clínica, así como la categorizar la necesidad de oxigenación con pruebas específicas, comentarios sobre los fármacos que se han utilizado. Incluye una sección específica para niños menores de 2 meses, la atención a embarazadas y a las madres, sean positivo o negativo. E incluye: Factores de Riesgo en Paciente Adulto y Mujer Embarazada por categorías y Guía rápida de fármacos en el manejo de paciente COVID-19, entre otros.


Subject(s)
Humans , Male , Female , Pregnancy , Infant, Newborn , Infant , Adult , Aged , Pneumonia, Viral/drug therapy , Pregnancy Complications/prevention & control , Respiratory Distress Syndrome , Coronavirus Infections/diagnosis , Coronavirus Infections/drug therapy , Pneumonia, Viral/diagnosis , Infant, Newborn , Risk Factors , Triage , Deep Sedation/methods , Rapid Sequence Induction and Intubation/methods , Guatemala
10.
Guatemala; MSPAS; [2020?]. 78 p. graf.
Non-conventional in Spanish | LILACS, LIGCSA | ID: biblio-1151708

ABSTRACT

Elaborados por MSPAS y asociaciones de médicos especialistas en mayo del 2020 y actualizados en julio del mismo año, estos protocolos pretenden orientar a los profesionales a cargo de la atención de pacientes moderados y críticos con COVID-19. Esta seccionado en una parte general, que incluye los síntomas de las condiciones de alto riesgo, flujogramas y detalles de lo que puede presentarse, así como la sección de adultos, niños y mujeres embarazadas. El estudio afirma que, "el 14% acaba presentando un cuadro grave que requiere hospitalización y oxigenoterapia, y el 5% tiene que ser ingresado en una unidad de cuidados intensivos" Incluye flujogramas de Factores de Riesgo en Paciente Adulto y Mujer Embarazada por categorías, así como notas, comentarios y recomendaciones de los médicos participantes.


Subject(s)
Humans , Male , Female , Pregnancy , Infant, Newborn , Infant , Child, Preschool , Child , Adult , Aged , Pneumonia, Viral/diagnosis , Respiratory Insufficiency/complications , Shock/complications , Shock/drug therapy , Oxygenation/methods , Coronavirus Infections/diagnosis , Coronavirus Infections/drug therapy , Pediatrics/organization & administration , Pneumonia, Viral/drug therapy , Pregnancy Complications/prevention & control , Respiratory Distress Syndrome , Respiratory Insufficiency/drug therapy , Coronavirus Infections/mortality , Pandemics/prevention & control , Betacoronavirus , Guatemala , Intensive Care Units , Intubation
11.
Brasília; Ministério da Saúde; 2020. 66 p.
Monography in Spanish | PIE, LILACS, PIE | ID: biblio-1096583

ABSTRACT

No mundo, os principais motivos dos óbitos maternos são as causas diretas, com destaque para os distúrbios hipertensivos e a eclampsia (SAY et al., 2014). No Piauí não é diferente, já que as principais causas diretas de óbito na gravidez, parto e puerpério são: eclampsia (16,4%), hemorragias obstétricas (15%) e transtornos hipertensivos (11,3%) (BRASIL, 2018). A mortalidade materna vem reduzindo no Brasil, alcançando seu valor mínimo de 57,6 óbitos por 100 mil nascidos vivos em 2015. Entretanto, pelas metas dos Objetivos de Desenvolvimento do Milênio (ODM), esse número deveria ter sido reduzido para no máximo 35 óbitos por 100 mil nascidos vivos (NVs). Se mantida a velocidade com que a mortalidade materna vem sendo reduzida, dificilmente a meta de reduzir a Razão de Mortalidade Materna (RMM), no Brasil, para 30 óbitos por 100 mil nascidos vivos até 2030 será alcançada (SILVA et al., 2016; LEAL et al., 2018). Além disso, as disparidades regionais quanto à mortalidade materna são grandes, destacando-se o Norte e o Nordeste com as maiores RMMs. Na avaliação dos Objetivos de Desenvolvimento Sustentável (ODS) de 2017, o Piauí apresentou o terceiro pior desempenho do País e o segundo pior desempenho na Região Nordeste, com RMM Vigilância de 103,6 por 100 mil NVs e RMM Direta de 83,2 por 100 mil NVs em 2015 (BRASIL, 2018b). Em 2018, no Piauí, a RMM direta foi estimada em 80,1 por 100 mil NVs, mais do que dobro da taxa máxima aceitável, e justifica intervenções complementares às que já


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/prevention & control , Pregnancy Complications/epidemiology , Maternal Mortality , Maternal-Child Health Services/organization & administration , Brazil/epidemiology , Health Policy
12.
Rev. cuba. anestesiol. reanim ; 18(3): e505, sept.-dic. 2019.
Article in Spanish | LILACS, CUMED | ID: biblio-1093115

ABSTRACT

Introducción: El paro cardiaco en gestantes y la cesárea perimorten son infrecuentes. Estas constituyen catástrofes médicas que precisan atención inmediata. Realizar este proceder según normas adecuadas brinda mejores opciones a la madre y el feto. Cuba presta especial atención al binomio materno fetal, para ello emplea grandes recursos humanos y tecnológicos. Objetivo: Actualizar la información acerca de cesárea perimorten. Métodos: Se realizó una revisión en bases de datos que permitiese encontrar descripciones epidemiológicas, informes de casos, series de casos, comunicaciones personales, y estudios en diferentes contextos sanitarios, los cuales sirvieran de evidencia científica del tema. Resultados: El paro cardiaco en embarazadas es un evento infrecuente, la realización de una cesárea perimorten con tiempo reducido (4-5 min) resultó una opción efectiva. El trabajo del equipo multidisciplinario basado en protocolos tiene una función que beneficia tanto a la madre como al feto. Actualmente se recomienda el concepto de histerotomía resucitadora que refleja la optimización de los esfuerzos realizados en la reanimación. La muerte materna por anestesia es una emergencia médica que requiere especial atención. Existen asociaciones médicas que preconizan las escalas de cuidados precoces en gestantes graves, con un entrenamiento actualizado y con estrategias novedosas para obtener mejores resultados. Conclusiones: El estudio del paro cardiaco en gestantes, la cesárea perimorten y la muerte materna relacionada con la anestesia son importantes. La creación de grupos multidisciplinarios y grupos bien entrenados son la mejor opción en estas circunstancias. Se recomienda incrementar el estudio y entrenamiento para ofrecer las mejores opciones al binomio materno-fetal(AU)


Introduction: Cardiac arrest in pregnant women and perimortem cesarean section are rare. These are medical catastrophes that require immediate attention. Performing this procedure according to adequate standards provides better options for both the mother and the fetus. Cuba pays special attention to the maternal-fetal binomial, for which large amounts of human and technological resources are used. Objective: To update the information about perimortem cesarean section. Methods: A database review was carried out to find epidemiological descriptions, case reports, case series, personal communications, and studies in different health contexts, which would serve as scientific evidence on the subject. Results: Cardiac arrest in pregnant women is a rare event; the performance of a perimortem cesarean section with reduced time (4-5 min) was an effective option. The work of the multidisciplinary team based on protocols has a function that benefits both the mother and the fetus. Currently, the concept of resuscitative hysterotomy is recommended, which reflects the optimization of the resuscitation efforts. Maternal death by anesthesia is a medical emergency that requires special attention. There are medical associations that advocate the scales of early care in pregnant women, with updated training and innovative strategies to obtain better outcomes. Conclusions: The study of cardiac arrest in pregnant women, perimortem caesarean section and anesthesia-related maternal death are important. The creation of multidisciplinary groups and well-trained groups are the best option in these circumstances. It is recommended to increase the study and training to offer the best options to the maternal-fetal binomial(AU)


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/prevention & control , Cesarean Section/mortality , Hysterotomy/methods , Heart Arrest/complications , Anesthesia, Obstetrical/mortality , Pregnancy Complications/mortality
13.
Rev. cuba. obstet. ginecol ; 45(1): 66-73, ene.-mar. 2019.
Article in Spanish | LILACS, CUMED | ID: biblio-1093624

ABSTRACT

La osteogénesis imperfecta o huesos de cristal es una enfermedad genética de transmisión autosómica dominante; en específico la tipo IV. Las pacientes nacen con fracturas y curvaturas de los huesos largos de los miembros inferiores, muestran dentinogénesis imperfecta, escleróticas grises o blancas, no hay sordera y suele presentar cifoescoliosis y laxitud ligamentosa. Se reporta el caso de una paciente embarazada 24 años de edad, blanca. Los síntomas principalmente se observan en el sistema musculoesquelético, visión, neurológico. Se le realizó una cesárea primitiva electiva, bebé sano, buena puntuación de Apgar. No hubo complicaciones maternas ni neonatales, transoperatorio y puerperio quirúrgico: inmediato, mediato y tardío sin complicaciones. El propósito de escribir el artículo fue reportar el caso de una embarazada con enfermedad de amplia heterogeneidad genética que determina también variabilidad fenotípica, que permite encarar una certera atención prenatal a partir de mostrar las manifestaciones clínicas de la osteogénesis imperfecta tipo IV observadas en ésta embarazada(AU)


Osteogenesis imperfecta or crystal bones is a genetic disease of autosomal dominant transmission, particularly type IV. Patients are born with fractures and curvatures of the long bones of the lower limbs, they show dentinogenesis imperfecta, gray or white sclerotic, there is no deafness and usually kyphoscoliosis and ligamentous laxity are present. We report the case of a white 24-year-old pregnant patient. Symptoms are mainly observed in the vision and in musculoskeletal and neurological system. An elective caesarean section was performed, which resulted in a healthy baby with a good Apgar score. There were no maternal or neonatal complications. The transoperative, immediate, middle and late surgical puerperium did not have complications. The purpose of this article is to report a case of a pregnant woman with a genetic wide heterogeneity illness that determines the phenotype variability allowing facing a prenatal good care from showing the clinical manifestations of OI type IV in this patient(AU)


Subject(s)
Humans , Female , Pregnancy , Adult , Young Adult , Osteogenesis Imperfecta/complications , Pregnancy Complications/prevention & control
14.
Rev. cuba. invest. bioméd ; 38(1): e146, Jan.-Mar. 2019. tab, graf
Article in English | LILACS, CUMED | ID: biblio-1093380

ABSTRACT

Background: Neural tube defects (NTDs) are important causes of infant mortality, which result from a complex interaction between genetics and environmental factors such as trace elements, which play and crucial role in the epigenetic regulation in the embryo fetal developmental program. Objectives: To measure the maternal serum levels of copper, zinc, calcium and magnesium in mothers with offspring affected by NTDs, and to examine a possible relationship between the serum concentrations of these micronutrients and occurrence of NTDs. Design: Case-controls study. Subjects and Methods: Maternal serum blood samples were obtained from 72 healthy pregnant women and 36 mothers who had NTDs affected offspring, including those alive, stillbirths and elective pregnancy' termination at Centro Provincial de Genetica in Villa Clara. Copper, zinc, calcium and magnesium levels in serum were measured by flame atomic absorption spectrometry and were compared between the two groups of mothers. Results: Serum zinc levels were determined to be significantly lower in the study group compared with the control group, while copper levels were significant elevated in the study group (all p values < .05). There was a negative correlation between serum zinc levels and serum copper levels. However, no association between calcium and magnesium serum levels and increased risk for the development of NTDs was observed. Conclusions: High maternal serum levels of copper and lower level of zinc during pregnancy were associated with NTDs in offspring. If folic acid supplementation is given, additional zinc supplementation should be considered for the further decrease in the recurrence risk of NTDs(AU)


Subject(s)
Pregnancy Complications/prevention & control , Infant Mortality , Zinc/adverse effects , Neural Tube Defects/genetics
15.
Rev. cuba. obstet. ginecol ; 45(1): 147-163, ene.-mar. 2019.
Article in Spanish | LILACS, CUMED | ID: biblio-1093631

ABSTRACT

El angioedema hereditario es una rara enfermedad genética autosómica dominante que constituye una Inmunodeficiencia primaria por déficit del sistema del complemento. Se caracteriza por edemas recurrentes de la piel, mucosas y tejidos submucosos, que puede afectar cualquier parte del cuerpo; vía respiratoria y aparato digestivo. La complicación más temida es el edema de las vías respiratorias altas, que puede provocar la muerte por asfixia. El dolor abdominal puede simular un abdomen agudo. Los ataques pueden ser desencadenados por traumatismos, estrés, fármacos o infecciones. El diagnóstico se basa en el reconocimiento de las características clínicas y las alteraciones de laboratorio: presencia de C4 disminuido en suero y la ausencia o gran reducción del nivel o la función de C1 inhibidor. La enfermedad es más dura en las mujeres debido a que varía mucho con las hormonas, la menstruación y el embarazo; y es importante que los profesionales médicos sepan qué hacer cuando una paciente con esta enfermedad desea usar contraceptivos o está embarazada. El embarazo es una situación especial donde es vital el conocimiento del ginecobstetra sobre la enfermedad, su manejo profiláctico y terapéutico, pues no responde al tratamiento habitual del edema alérgico. Existen drogas contraindicadas durante la gestación. Su tratamiento de elección es la infusión de factor inhibidor de C1 del complemento. El plasma fresco congelado es una opción a considerar en caso de profilaxis a corto plazo o ataque agudo(AU)


Hereditary angioedema is a rare autosomal dominant genetic disease that constitutes a primary immunodeficiency due to deficiency of the complement system. It is characterized by recurrent edema of the skin, mucous membranes and submucosal tissues, which can affect any part of the body, respiratory tract and digestive system. The most feared complication is edema of the upper respiratory tract, which can cause death by asphyxia. Abdominal pain can simulate acute abdomen. Trauma, stress, drugs or infections can trigger seizures. The diagnosis is based on the recognition of the clinical characteristics and the laboratory alterations as the presence of decreased C4 in serum and the absence or great reduction of the level or inhibitor function of C1. This disease is more severe in women because it varies with hormones, menstruation and pregnancy; and it is important for medical professionals to know what to do when a patient with this disease wishes to use contraceptives or is pregnant. Pregnancy is a special moment when the obstetrician's knowledge of this disease, its prophylactic and therapeutic management are vital because this entity does not respond to the usual treatment of allergic edema, considering there are contraindicated drugs during pregnancy. Its treatment of choice is the infusion of complement C1 Inhibitor factor. Fresh frozen plasma is an option to consider in case of short-term prophylaxis or acute attack(AU)


Subject(s)
Humans , Female , Pregnancy , Plasma/physiology , Pregnancy Complications/prevention & control , Angioedemas, Hereditary/complications
16.
Rev. latinoam. enferm. (Online) ; 27: e3160, 2019. tab, graf
Article in Portuguese | LILACS, BDENF | ID: biblio-1020701

ABSTRACT

Objetivo analisar a tendência e a distribuição espacial de algumas doenças de notificação compulsória em gestantes. Método estudo ecológico, com dados do Sistema Nacional de Agravos de Notificação, das incidências das seis doenças de notificação mais frequentes em gestantes. O modelo de Prais-Winsten foi utilizado para a análise da tendência classificada em estável, decrescente e crescente, segundo macrorregiões. Para a análise espacial, foram calculadas as incidências distribuídas em percentis, em mapas coropléticos, por Regiões de Saúde. Resultados as infecções mais frequentes foram sífilis, dengue, Human Immunodeficiency Virus, influenza, hepatites e toxoplasmose. A incidência para sífilis, toxoplasmose, dengue e Human Immunodeficiency Virus aumentou 30,8%, 30,4%, 15,4% e 2,6% ao ano, em média, respectivamente. Em média, ao ano, a incidência de sífilis aumentou 40,5% na Macrorregional Norte e 38% na Macrorregional Noroeste. A análise espacial mostrou, no último quadriênio, incidência elevada para dengue, sífilis e infecção pelo Human Immunodeficiency Virus que chegaram, respectivamente, a 180,2, 141,7 e 100,8 casos por 10.000 nascidos vivos. Conclusão houve aumento da incidência de infecção em gestantes por sífilis, toxoplasmose e Human Immunodeficiency Virus, com diferenças em sua distribuição espacial, indicando que esses agravos devem ser prioridade no atendimento à gestante em regiões mais acometidas.


Objective to analyze the trend and spatial distribution of some diseases that require compulsory notification in pregnant women. Method ecological study, with data from the National Notifiable Diseases Surveillance System, of the incidence of the six most frequent diseases that, require compulsory notification, in pregnant women. The Prais-Winsten model was used to analyze the trend classified as stable, decreasing and increasing, according to macro-regions. For the spatial analysis, the incidences distributed in percentiles, in choropleth maps, by Health Regions were calculated. Results the most frequent infections were syphilis, dengue, Human Immunodeficiency Virus, influenza, hepatitis and toxoplasmosis. Incidence increased by 30.8%, 30.4%, 15.4% and 2.6%, on average, for syphilis, toxoplasmosis, dengue and Human Immunodeficiency Virus, respectively. On average, the incidence of syphilis increased by 40.5% in Macro-regional North and 38% in Macro-regional Northwest. The spatial analysis showed, in the last four years, high incidence of dengue, syphilis and infection by Human Immunodeficiency Virus, which reached 180.2, 141.7 and 100.8 cases per 10,000 live births, respectively. Conclusion there were increased incidences of infection in pregnant women due to syphilis, toxoplasmosis and Human Immunodeficiency Virus, with differences in their spatial distribution, indicating that these diseases should be a priority in the care of pregnant women in more affected regions.


Objetivo analizar la tendencia y la distribución espacial de algunas enfermedades de notificación obligatoria en gestantes. Método estudio ecológico, con datos del Sistema Nacional de Agravios de Notificación, de las incidencias de las seis enfermedades de notificación más frecuentes en gestantes. El modelo de Prais-Winsten fue utilizado para el análisis de la tendencia clasificada en estable, decreciente y creciente, según macrorregiones. Para el análisis espacial, se calcularon las incidencias, distribuidas en percentiles, en mapas coropléticos, por Regiones de Salud. Resultados las infecciones más frecuentes fueron sífilis, dengue, Human Immunodeficiency Virus, influenza, hepatitis y toxoplasmosis. Hubo aumento de la incidencia para sífilis, toxoplasmosis, dengue y Human Immunodeficiency Virus de 30,8%, 30,4%, 15,4% y 2,6% al año, en promedio, respectivamente. En promedio, al año, la incidencia de sífilis aumentaron un 40,5% en la Macrorregional Norte y un 38% en el Noroeste. El análisis espacial mostró, en el último cuadrienio, incidencias elevadas para dengue, sífilis e infección por el Human Immunodeficiency Virus que llegaron, respectivamente, a 180,2, 141,7 y 100,8 casos por 10.000 nacidos vivos. Conclusión hubo aumento de la incidencia de infección en gestantes por sífilis, toxoplasmosis y Human Immunodeficiency Virus, con diferencias en su distribución espacial, indicando que esos agravios deben ser prioridad en la atención a la gestante en regiones más acometidas.


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/prevention & control , HIV Infections/epidemiology , Disease Notification/statistics & numerical data , Dengue/epidemiology , Hepatitis/epidemiology , Brazil/epidemiology , Toxoplasmosis/epidemiology , Influenza, Human/prevention & control
17.
Rev. cuba. reumatol ; 21(supl.1): e66, 2019.
Article in Spanish | LILACS, CUMED | ID: biblio-1099113

ABSTRACT

Introducción: La artritis reumatoide es una enfermedad inflamatoria sistémica y crónica que, aunque suele tener su pico de incidencia en edades superiores, también puede presentar en edades más tempranas de la vida. La gestación es estas pacientes es considerada una situación de elevado riesgo debido a la misma actividad de la enfermedad y al posible efecto teratogénico que pueden devenirse del uso de muchos de los fármacos que generalmente se utilizan en estos casos. Sin embargo, una correcta planificación, un adecuado seguimiento ginecobstétrico y reumatológico y la valoración sistemática de la actividad de la enfermedad, constituyen los elementos básicos de la atención médica durante este periodo. Objetivo: dar a conocer los elementos fundamentales del seguimiento de la gestación en pacientes con artritis reumatoide. Caso clínico: se presenta el caso de una paciente de 23 años de edad con diagnóstico de artritis reumatoide de 5 años de evolución que concibe una gestación que con todos los cuidados médicos se logra llegar a un feliz término. Conclusiones: al ser la artritis reumatoide una enfermedad de compleja evolución las pacientes jóvenes tienen cierto temor a la gestación, sin embargo, durante el embarazo se produce cierta mejoría clínica de la artritis. Es imprescindible garantizar la menor actividad posible para que no afecte el pronóstico y la salud materna y fetal(AU)


Introduction: Rheumatoid arthritis is a systemic and chronic inflammatory disease that, although it usually has its peak of incidence in older ages, can also present at younger ages of life. The pregnancy is these patients is considered a situation of high risk due to the same activity of the disease and the possible teratogenic effect that can be derived from the use of many of the drugs that are generally used in these cases. However, proper planning, adequate gynecobysteometric and rheumatological follow-up, and systematic assessment of disease activity are the basic elements of medical care during this period. Objective: to present the fundamental elements of the pregnancy follow-up in patients with rheumatoid arthritis. Clinical case: We present the case of a 23-year-old patient with a diagnosis of rheumatoid arthritis of 5 years of evolution who conceives a pregnancy that with all medical care is achieved a happy term. Conclusions: as rheumatoid arthritis is a disease of complex evolution young patients have some fear of pregnancy, however, during pregnancy there is some clinical improvement of arthritis. It is essential to guarantee as little activity as possible so that it does not affect prognosis and maternal and fetal health(AU)


Subject(s)
Humans , Female , Pregnancy , Young Adult , Pregnancy Complications/prevention & control , Arthritis, Rheumatoid/complications , Maternal Health , Planning
19.
Rev. cuba. obstet. ginecol ; 44(2): 1-11, abr.-jun. 2018. tab
Article in Spanish | LILACS, CUMED | ID: biblio-1003948

ABSTRACT

Introducción: Algunos de los cambios fisiológicos del embarazo, implican el riesgo de sufrir diferentes trastornos, entre ellos la anemia, la cual está altamente asociada a mortalidad materno-fetal. La Organización Mundial de la Salud estima que aproximadamente 42 por ciento de las gestantes sufren de anemia en algún momento del embarazo. Los tipos de anemia más frecuentes son la ferropénica, megaloblástica y de células falciformes. La anemia por deficiencia de hierro es la de mayor incidencia durante el embarazo. Objetivo: Actualizar la información existente en la literatura científica internacional acerca de la anemia fisiológica y patológica en el embarazo, con énfasis en el diagnóstico y tratamiento. Métodos: Se realizó una búsqueda exhaustiva de la literatura mediante los MeSH: anemia, embarazo, deficiencia de hierro, vitamina B12, ácido fólico y fisiología en inglés y en español. Para la búsqueda, se usaron las bases de datos PubMed, MedLine, SciELO y Google Académico. Resultados: Se hallaron más de 18 321 artículos, de los cuales 40 cumplieron los criterios de inclusión para ser seleccionados. Conclusiones: Si bien un número considerable de cuadros de anemia gestacional corresponden a anemias dilucionales fisiológicas sin ningún tipo de repercusión clínica, es de fundamental importancia el reconocimiento de cuadros patológicos, por la asociación que estos tienen a desenlaces maternos y perinatales adversos(AU)


Introduction: Some of the physiological changes of pregnancy may imply a risk of suffering different kind of disorders, among them anemia, which is highly associated with maternal-fetal mortality. The World Health Organization estimates that approximately 42 percent of pregnant women suffer from anemia at some point of pregnancy. The most frequent types of anemia are iron deficiency, megaloblastic and sickle cell anemia. Iron deficiency anemia has the highest incidence during pregnancy. Objective: To update existing information in the international scientific literature about physiological and pathological anemia in pregnancy, emphasing on diagnosis and treatment. Methods: An exhaustive search of the literature was performed using MeSH Anemia, Pregnancy, Iron Deficiency, Vitamin B12, Folic acid and physiology in English and Spanish. For the search, PubMed, Medline, SciELO and Google Scholar databases were used. Results: More than 18321 articles were found. Forty of them met the inclusion criteria to be selected. Conclusions: Although considerable number of cases of gestational anemia correspond to physiological dilutional anemia with no clinical repercussions, the recognition of pathological conditions is fundamental due to the association they have with adverse maternal and perinatal outcomes(AU)


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/physiopathology , Pregnancy Complications/prevention & control , Anemia, Iron-Deficiency/prevention & control , Anemia/epidemiology
20.
Rev. cuba. obstet. ginecol ; 44(1): 1-9, ene.-mar. 2018. tab
Article in Spanish | LILACS | ID: biblio-978443

ABSTRACT

Introducción: El índice de masa corporal y la ganancia ponderal materna excesiva durante el embarazo son factores de riesgo para el desarrollo de complicaciones perinatales. Objetivo: Determinar la relación entre el índice de masa corporal pregestacional y la ganancia ponderal materna durante el embarazo, y la aparición de complicaciones y efectos adversos perinatales materno-fetales. Métodos: Estudio observacional prospectivo de cohortes con 500 gestantes controladas en el HUV Macarena de Sevilla durante el primer trimestre del año 2012. Las pacientes se han categorizado en función de su índice de masa corporal pregestacional y de su ganancia ponderal durante el embarazo. El análisis asociativo entre variables se ha realizado mediante el test de la chi cuadrado (significación estadística p< 0,05). Resultados: De las 500 gestantes incluidas en nuestro estudio, 137 (28 por ciento) presentaban sobrepeso y 79 (16,1 por ciento) algún tipo de obesidad. Según la ganancia ponderal, 216 (44,1 por ciento) tuvieron una ganancia ponderal superior a la recomendada. De las gestantes que desarrollaron patología, 37,7 por ciento tenía un peso bajo o normal al inicio de la gestación, mientras que en 62,3 por ciento de los casos tenían sobrepeso (34,4 por ciento) u obesidad (27,9 por ciento) (p= 0,001). La hipertensión gestacional (3,4 por ciento) y la diabetes gestacional (1,4 por ciento) fueron las patologías más frecuentes. El grupo de gestantes con ganancia ponderal excesiva tuvo una mayor tasa de inducciones del parto (p= 0,027), recién nacidos con mayores pesos al nacer y mayor número de ingresos en UCI neonatal. Conclusiones: Un elevado índice de masa corporal pregestacional y una ganancia ponderal excesiva en el embarazo puede conllevar resultados adversos tanto para la madre como para el neonato(AU)


Introduction: Excessive body mass index (BMI) and gestational weight gain (GWG) are risk factors for the development of perinatal complications. Objectives: Determine the association between the pregestational BMI and GWG and maternal-fetal perinatal complications and adverse effects. Methods: A prospective observational cohort study of 500 controlled pregnant women was conducted at Virgen Macarena University Hospital from Seville during 2012 first trimester. Patients have been categorized according to their pregestational BMI and GWG. Analysis of association between variables has been performed through Chi-Square Test (statistical significance: p< 0.05). Results: Out of 500 pregnant women, 137 (28 percent) were overweight and 79 (16.1 percent) were obese. Regarding GWG, 216 (44.1 percent) had higher GWG than recommended. 37.7 percent pregnant women, who developed pathology, presented low or normal weight at the beginning of pregnancy, whereas 62.3 percent of cases were overweight (34.4 percent) or obese (27.9 percent) (p= 0.001). Gestational hypertension (3.4 percent) and gestational diabetes (1.4 percent) were the most frequent pathologies. The group of pregnant women with excessive GWG had a higher pregnancy induction rate (p= 0.027), newborns with higher weight and higher number of admissions in neonatal ICU. Conclusions: A high pre-pregnancy BMI and GWG in pregnancy can lead to adverse outcomes for both, the mother and the neonate(AU)


Subject(s)
Humans , Female , Pregnancy , Pregnancy Complications/prevention & control , Weight by Height/physiology , Body Mass Index , Prospective Studies , Cohort Studies , Observational Study , Obesity/complications
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