Adverse clinical and obstetric outcomes among pregnant women with different sickle cell disease genotypes.

OBJECTIVE: To compare clinical and obstetric adverse events among pregnant women with sickle cell disease (SCD) according to genotype. METHODS: The present cross-sectional study enrolled women aged 15-49 years with SCD and prior pregnancy attending a hematology center in Recife, Brazil, between September 1, 2015, and April 30, 2016. Associations between sickle cell genotype (HbSS, HbSC, Sß-thalassemia) and adverse events were evaluated. RESULTS: Overall, 89 women were included; 74 (83%) had HbSS genotype, 8 (9%) had HbSC genotype, and 7 (8%) had Sß-thalassemia genotype. Fifty-three (60%) self-reported being of mixed race, and 27 (30%) self-reported they were black. Blood transfusion was observed more frequently among women with HbSS than among those with HbSC genotype (P=0.007). Postpartum adverse events were more frequent in the Sß-thalassemia than in the HbSS group (P=0.030). Fetal intrauterine death occurred only among women with the HbSS genotype (11 [15%]). In the HbSS group, there was a higher frequency of blood transfusion (P=0.004) and lower rate of spontaneous abortion (P=0.001) among women with six or more consultations. CONCLUSION: The HbSS genotype was associated with a higher frequency of blood transfusion. Sß-thalassemia was associated with a higher frequency of postpartum adverse events. Prenatal care was associated with a lower rate of spontaneous abortion in the HbSS group.

Pushing/bearing down methods for the second stage of labour.

BACKGROUND: Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterine contraction. There is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on the mother and fetus. OBJECTIVES: To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion, but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. MAIN RESULTS: In this updated review, we included 21 studies in total, eight (884 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. Our GRADE assessments of evidence ranged from moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Overall, the included studies varied in their risk of bias; most were judged to be at unclear risk of bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingThere was no clear difference in the duration of the second stage of labour (mean difference (MD) 10.26 minutes; 95% confidence interval (CI) -1.12 to 21.64 minutes, six studies, 667 women, random-effects, I² = 81%) (very low-quality evidence). There was no clear difference in 3rd or 4th degree perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) (low-quality evidence), episiotomy (average RR 1.05; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I² = 81%), duration of pushing (MD -9.76 minutes, 95% CI -19.54 to 0.02; two studies; 169 women; I² = 88%) (very low-quality evidence), or rate of spontaneous vaginal delivery (RR 1.01, 95% CI 0.97 to 1.05; five studies; 688 women; I² = 2%) (moderate-quality evidence). For primary neonatal outcomes such as five-minute Apgar score less than seven, there was no clear difference between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants) (very low-quality evidence), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, 393 infants) (very low-quality evidence) also showed no clear difference between spontaneous and directed pushing. No data were available on hypoxic ischaemic encephalopathy. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 56 minutes in the duration of the second stage of labour (MD 56.40, 95% CI 42.05 to 70.76; 11 studies; 3049 women; I² = 91%) (very low-quality evidence), but no clear difference in third or 4th degree perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) (moderate-quality evidence) or episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 19-minute decrease in the duration of pushing (MD -19.05, 95% CI -32.27 to -5.83; 11 studies; 2932 women; I² = 95%) (very low-quality evidence) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.02 to 1.11, 12 studies, 3114 women) (moderate-quality evidence).For the primary neonatal outcomes, there was no clear difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) (low-quality evidence) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00; three studies; 413 infants) (very low-quality evidence). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68, 4 studies, 2145 infants) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). AUTHORS' CONCLUSIONS: This updated review is based on 21 included studies of moderate to very low quality of evidence (with evidence mainly downgraded due to study design limitations and imprecision of effect estimates).Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and an increased risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no clear difference in serious perineal laceration and episiotomy, and in other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing.Therefore, for the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style as part of routine clinical practice, and in the absence of strong evidence supporting a specific method or timing of pushing, the woman's preference and comfort and clinical context should guide decisions.Further properly well-designed RCTs, addressing clinically important maternal and neonatal outcomes are required to add evidence-based information to the current knowledge. Such trials will provide more complete data to be incorporated into a future update of this review.

Placental Transfer of Dengue Virus (DENV)-Specific Antibodies and Kinetics of DENV Infection-Enhancing Activity in Brazilian Infants.

BACKGROUND: Maternal-fetal transferred dengue virus (DENV)-specific antibodies have been implicated in the immunopathogenesis of dengue during infancy. METHODS: A prospective birth cohort was established in a dengue-endemic area in the Northeast Region of Brazil. DENV-specific immunoglobulin G (IgG) and DENV-1-4 serotype-specific neutralizing antibody (NAb) levels were assessed in 376 paired maternal and umbilical cord blood samples. The kinetics of enhancing activity by maternally acquired DENV antibodies was determined in serum samples from children enrolled in the cohort. RESULTS: Mothers were mostly immune to DENV-3 alone (53.7%) or combined with DENV-4 (30.6%). Levels of DENV-specific IgG, DENV-3 NAbs, and DENV-4 NAbs were significantly higher in newborns than in their respective mothers. Mothers immune to a single serotype transferred greater levels of DENV-specific IgG (P = .02) and DENV-3 NAbs (P = .04) than mothers immune to multiple DENV serotypes. Maternally acquired DENV-3 NAbs disappeared in >90% of the children by the age of 4 months. The peak enhancing activity was detected by the age of 2 months (P < .0001) and rapidly declined by the age of 4 months (P = .0035). CONCLUSIONS: Unlike Asian infants, the enhancing activity of DENV infection by maternally transferred DENV antibodies occurs at earlier ages in Brazilian children. These findings might explain the low occurrence of severe dengue among infants in our setting.

Pushing/bearing down methods for the second stage of labour.

BACKGROUND: Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterus contraction. Currently, there is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on mother and fetus. OBJECTIVES: To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion.We considered the following comparisons.Timing of pushing: to compare pushing, which begins as soon as full dilatation has been determined versus pushing which begins after the urge to push is felt.Type of pushing: to compare pushing techniques that involve the 'Valsalva Manoeuvre' versus all other pushing techniques. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias. Two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS: We included 20 studies in total, seven studies (815 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 studies (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. The results come from studies with a high or unclear risk of bias, especially selection bias and selective reporting bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingOverall, for this comparison there was no difference in the duration of the second stage (mean difference (MD) 11.60 minutes; 95% confidence interval (CI) -4.37 to 27.57, five studies, 598 women, random-effects, I(2): 82%; T(2): 220.06). There was no clear difference in perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) and episiotomy (average RR 1.05 ; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I(2) = 81%; T(2) = 0.14). The primary neonatal outcomes such as five-minute Apgar score less than seven was no different between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, n = 393) also showed no difference between spontaneous and directed pushing and no data were available on hypoxic ischaemic encephalopathy.The duration of pushing (secondary maternal outcome) was five minutes less for the spontaneous group (MD -5.20 minutes; 95% CI -7.78 to -2.62, one study, 100 women). Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 54 minutes in the duration of the second stage of labour (MD 54.29 minutes; 95% CI 38.14 to 70.43; 10 studies, 2797 women, random-effects; I(2) = 91%; T(2) = 543.38), and there was no difference in perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) and episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 20-minute decrease in the duration of pushing (MD - 20.10; 95% CI -36.19 to -4.02, 10 studies, 2680 women, random-effects, I(2) = 96%; T(2) = 604.37) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.03 to 1.11, 12 studies, 3114 women).For the primary neonatal outcomes, there was no difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00, three studies, n = 413). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). AUTHORS' CONCLUSIONS: This review is based on a total of 20 included studies that were of a mixed methodological quality.Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and double the risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no difference in the caesarean and instrumental deliveries, perineal laceration and episiotomy, and in the other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing. Futhermore, the adverse effects on maternal pelvic floor is still unclear.Therefore, there is insufficient evidence to justify routine use of any specific timing of pushing since the maternal and neonatal benefits and adverse effects of delayed and immediate pushing are not well established.For the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style or recommendation as part of routine clinical practice. Women should be encouraged to bear down based on their preferences and comfort.In the absence of strong evidence supporting a specific method or timing of pushing, patient preference and clinical situations should guide decisions.Further properly well-designed randomised controlled trials are required to add evidence-based information to the current knowledge. These trials should address clinically important maternal and neonatal outcomes and will provide more complete data to be incorporated into a future update of this review.

Dengue infection in pregnancy and transplacental transfer of anti-dengue antibodies in Northeast, Brazil.

BACKGROUND: Dengue affects nearly 400 million people annually worldwide and considered one of the most serious health threats in tropical and subtropical countries. OBJECTIVE: To analyze the occurrence of dengue infection among the parturient who have formed the baseline of an ongoing birth cohort study in the city of Recife, Northeast of Brazil. STUDY DESIGN: From March 2011 to May 2012, we recruited 417 parturients with low-risk pregnancies at maternity ward who agreed to a follow-up of their babies. Dengue infection was accessed through DENV RT-PCR and anti-dengue antibodies (IgM and IgG). The prevalence of IgG antibodies in the parturients and their concepts were determined. The concordance among the pairs was tested using Kappa. The association of recent infection (IgM and/or DENV RT-PCR positive) with the maternal characteristics and clinical features of the neonates was analyzed through logistic regression. RESULTS: The prevalence of IgG antibodies in the maternal and cord blood samples was 95.1% (95% CI: 92.6-96.9%) and 95.8% (95% CI: 93.4-97.5%), respectively, with high agreement between maternal-cord pairs (Kappa=0.93). The prevalence of recent infection was 10.6% (95% CI: 7.9-14.2%) in the parturients. Reported fever during pregnancy was associated to recent infection (p=0.023). CONCLUSION: The data draw attention for the high frequency of anti-dengue antibodies in the women studied and for the high occurrence of infection during pregnancy in this region of Brazil. There is a need for further studies to better characterize dengue infection in pregnant women.

Choices on contraceptive methods in post-abortion family planning clinic in the northeast Brazil.

BACKGROUND: In Brazil, a Ministry of Health report revealed women who underwent an abortion were predominantly in the use of contraceptive methods, but mentioned inconsistent or erroneously contraceptive use. Promoting the use of contraceptive methods to prevent unwanted pregnancies is one of the most effective strategies to reduce abortion rates and maternal morbidity and mortality. Therefore, providing post-abortion family planning services that include structured contraceptive counseling with free and easy access to contraceptive methods can be suitable. So the objective of this study is to determine the acceptance and selection of contraceptive methods followed by a post-abortion family planning counseling. METHODS: A cross-sectional study was carried out from July to October 2008, enrolling 150 low income women to receive post-abortion care at a family planning clinic in a public hospital located in Recife, Brazil. The subjects were invited to take part of the study before receiving hospital leave from five different public maternities. An appointment was made for them at a family planning clinic at IMIP from the 8th to the 15th day after they had undergone an abortion. Every woman received information on contraceptive methods, side effects and fertility. Counseling was individualized and addressed them about feelings, expectations and motivations regarding contraception as well as pregnancy intention. RESULTS: Of all women enrolled in this study, 97.4% accepted at least one contraceptive method. Most of them (73.4%) had no previous abortion history. Forty of the women who had undergone a previous abortion, 47.5% reported undergoing unsafe abortion. Slightly more than half of the pregnancies (52%) were unwanted. All women had knowledge of the use of condoms, oral contraceptives and injectables. The most chosen method was injectables, followed by oral contraceptives and condoms. Only one woman chose an intrauterine device. CONCLUSION: The acceptance rate of post-abortion contraceptive methods was greater and the most chosen method was the best-known one. Implementing a specialized family planning post abortion service may promote an acceptance, regardless of the chosen method. Most important is they do receive contraception if they do not wish for an immediate pregnancy.

Erythrocyte indices in the second trimester of pregnancy: are reference values well established? / Índices eritrocitários no segundo trimestre da gravidez: os valores de referência estão bem estabelecidos?

The erythrocyte index values in the pregnancy-puerperal cycle behave in a particular manner, however, the physiological or nosological meaning of such alterations are not well established. This study was aimed at analyzing the distribution of erythrocyte indices in the second trimester of pregnancy. The study was carried out with secondary data from 347 pregnant women in the 2nd trimester of low-risk prenatal care at the Instituto Materno Infantil Professor Fernando Figueira (Recife, Brazil) between May 2000 and June 2001. Measurements were performed using an automatic counter. Frequency distribution curves of erythrocyte indices (means and standard deviations) and correlation curves of hematocrit (HTC) and hemoglobin (Hb) concentrations were constructed. The mean red blood cell number (RBC) was 3.7 x 10(12)cells/L; mean HTC was 32.9 percent and mean Hb was 10.8 g/dL; the values exhibited Gaussian distributions. The mean morphological values were 88.4 fL for the mean corpuscular volume; 29.0 pg for the mean corpuscular hemoglobin and 32.8 g/dL for the mean corpuscular hemoglobin concentration; these values were not adjusted to Normal distributions. HTC values were three times higher than Hb values. Mean RBC, HTC and Hb values (used in the diagnosis of anemia) were lower than thresholds considered normal and exhibited Gaussian distributions. Morphological indices remained within normal ranges, but without delineating a Normal curve. As expected HTC and Hb values behaved following a linear correlation.

Os valores dos índices eritrocitários comportam-se de maneira particular no ciclo grávido-puerperal, entretanto, o significado fisiológico ou nosológico de tais alterações não está bem estabelecido. Este estudo objetivou analisar as distribuições dos índices eritrocitários no segundo trimestre da gestação. O estudo foi realizado baseando-se em dados secundários de 347 gestantes de 2º trimestre do pré-natal de baixo risco do Instituto Materno Infantil Prof. Fernando Figueira (Recife - Brasil), entre maio de 2000 e junho de 2001. Foram construídas curvas de distribuição de freqüências dos índices eritrocitários, com médias e desvios-padrão, e curva de correlação dos valores de hematócrito (HTC) e de concentração de hemoglobina (Hb), mensurados por contador automático. O valor médio da hematimetria foi 3,7 x 10(12) células/L; do HTC, 32,9 por cento e da Hb, 10,8 g/dL, apresentando distribuições gaussianas. As médias foram para volume corpuscular médio de 88,4 fL; hemoglobina corpuscular média de 29,0 pg e concentração de hemoglobina corpuscular média de 32,8 g/dL, não ajustadas à distribuição normal. Os valores de HTC corresponderam a três vezes os de Hb. Hematimetria, HTC e Hb - utilizados para diagnóstico de anemia - foram, em média, inferiores aos limites considerados normais, apresentando distribuições gaussianas. Os índices morfológicos mantiveram-se nas faixas consideradas normais, porém sem delinear curva Normal. O HTC e Hb apresentaram a correlação linear esperada.

Alteraçöes hematológicas e gravidez / Hematological changes and pregnancy

Os autores apresentam neste relato uma revisäo das alteraçöes hematológicas na gestaçäo. Apresentam dados conhecidos da literatura como a reduçäo dos parâmetros eritrocitários, hemoglobina e hematócrito e o aumento da produçäo de eritropoetina sem que ocorra alteraçäo da massa eritrocitária em relaçäo ao peso corporal. Descrevem as alteraçöes leucocitárias e as alteraçöes humorais e suas repercussöes imulógicas, assim como do nível das citocinas mensuráveis em nosso organismo durante o período gestacional. Descrevem também outras alteraçöes do sistema hematológico durante a gestaçäo e enfatizando além das mudanças hematimétricas, as mudanças do metabolismo do ferro e especulam sobre a sua necessidade de suplementaçäo em gestantes normais e nos países em desenvolvimento. Fazem ainda uma análise crítica da chamada "anemia fisiológica", considerada uma hemodiluiçäo fisiológica que ocorre neste período, e ponderam a necessidade do uso indiscriminado de compostos ferrosos durante a gestaçäo