Saúde Sexual e Reprodutiva: Guias para a Atenção Continuada da Mulher e do Recém-Nascido focalizadas na APS

[Extraído do Prólogo]. "O presente manual tem como antecedente o livro “Atendimento Pré-natal e Parto de Baixo Risco”, que foi publicado pelo CLAP em 1995, sendo atualizado em todos os assuntos e com o seu enfoque ampliado, aprofundando os conteúdos dos cuidados pré-gestacionais com um critério de promoção e de prevenção que procura melhorar o estado de saúde da mulher, do seu parceiro e do seu filho/a, com medidas relativamente simples. Incorpora também novos aspectos sobre planejamento familiar com um enfoque de direitos, onde é incluída a anticoncepção de emergência e o conceito de atendimento integral para evitar as oportunidades perdidas e melhorar a eficiência dos contatos do pessoal de saúde com a mulher e seu filho/a" .

¿Qué actitud adoptaremos los pediatras respecto al uso del chupete en el lactante? Reflexiones y comentarios en relación con su potencial papel protector en el síndrome de muerte súbita del lactante / What should paediatricians recommend regarding the use of pacifier in infants? Reflections and comments on its role in the reduction of sudden infant death syndrome

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[Ponderal index to describe a term neonatal population]. / Indice ponderal para calificar a una población de recién nacidos a término.

INTRODUCTION: The terms small, appropriate, and large for gestational age cannot identify some alterations in body composition that might be identified by the ponderal index. The aim of the present study was to correlate birth weight with ponderal index to identify other patterns of intrauterine growth. POPULATION AND METHODS: We performed a cross-sectional, descriptive study in which only one curve of the ponderal index was created for each week of gestational age (weeks 33 to 42) and including the 10th, 50th and 90th centiles because sex does not influence this index. This curve was based on 26,770 healthy infants born in Uruguay and registered in the Perinatal Information System of the Latin American Center for Perinatology. The database consisted of 194,908 infants born between 1995 and 1999. Exclusion criteria were mothers aged less than 15 years or more than 35 years, primiparas, those with > 4 pregnancies, smokers, a diagnosis of intrauterine growth retardation, chronic and pregnancy-related hypertension, cardiac problems, anemic and diabetic mothers, twins with congenital malformations, and intervals between pregnancies of less than 2 years or more than 5 years. Finally, the ponderal index of 43,189 neonates with a gestational age of 40 weeks was compared with the centiles of weight for gestational age to establish alterations in intrauterine growth. RESULTS: Relating the ponderal index with birth weight revealed altered patterns of intrauterine growth in 13 %, 10.3 % and 7.9 % of neonates with appropriate, small and large birth weights, respectively. Moreover, six unusual patters were identified. CONCLUSIONS: Use of the ponderal index curve for gestational age together with other growth curves improves the nutritional assessment of newborns. Further studies should be designed to develop strategies for the immediate, medium- and long-term management of identified risk groups.

Índice ponderal para calificar a una población de recién nacidos a término / Ponderal index to describe a term neonatal population

Introducción: La definición clásica de pequeño, adecuado o grande para la edad la gestacional, no permite identificar algunas alteraciones de la composición corporal, que el índice ponderal para la edad gestacional puede lograr. Este trabajo propone patrones de crecimiento intrauterino al relacionar índice ponderal y peso al nacimiento. Población y métodos: Es un estudio descriptivo transversal, en el que se crea una sola curva de índice ponderal según la edad gestacional (ya que el sexo no influye sobre este índice), que incluye las semanas 33 a 42 de vida intrauterina y determina los percentiles 10, 50 y 90. La curva se diseñó sobre la base de 26.770 datos de Uruguay, recogidos mediante el sistema informático perinatal (SIP) del Centro Latinoamericano de Perinatología y Desarrollo Humano (CLAP). Para su elaboración se analizaron 194.908 registros del SIP de terminaciones de embarazo entre 1995 y 1999, de los cuales se excluyeron madres menores de 15 y mayores de 35 años, primíparas, con más de cuatro gestas, fumadoras, con gestación múltiple, diagnosticadas de retraso del crecimiento intrauterino, hipertensión crónica o inducida por el embarazo, cardíacas, anémicas, diabéticas, con intervalos entre embarazos menores a un año y mayores de 5 años o que tuvieron productos con malformaciones congénitas mayores. Finalmente, se seleccionaron 43.189 registros correspondientes a la semana 40 de edad gestacional y se relacionaron los valores de índice ponderal y los percentiles de peso según edad gestacional para establecer su proporción e identificar alteraciones de crecimiento intrauterino. Resultados: Los recién nacidos de 40 semanas de edad gestacional de peso adecuado, bajo y elevado presentaron respectivamente 13, 10,3 y 7,9 por ciento de patrones de crecimiento alterados cuando se relaciona peso al nacimiento con índice ponderal y se presentan las definiciones de los probables grupos de recién nacidos comprendidos en seis patrones de crecimiento intrauterino. Conclusiones: La curva de índice ponderal para la edad gestacional, junto a las curvas de crecimiento intrauterino ya existentes, permiten una mejor valoración del estado nutricional del recién nacido. Es necesario diseñar nuevos estudios para desarrollar estrategias de manejos inmediatos, mediatos y a largo plazo en los grupos de riesgo identificados (AU)

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.

BACKGROUND: Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. OBJECTIVES: To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional care after the initial period of stabilization with conventional care. SEARCH STRATEGY: We used the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. MEDLINE, EMBASE, LILACS, POPLINE and CINAHL databases (to December 2002), and the Cochrane Controlled Trials Register (The Cochrane Library), were searched using the key words terms "kangaroo mother care" or "kangaroo care" or "kangaroo mother method" or "skin-to-skin contact" and "infants" or "low birthweight infants". SELECTION CRITERIA: Randomized trials comparing KMC and conventional neonatal care in LBW infants. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Statistical analysis was conducted using the standard Cochrane Collaboration methods. MAIN RESULTS: Three studies, involving 1362 infants, were included. All the trials were conducted in developing countries. The studies were of moderate to poor methodological quality. The most common shortcomings were in the areas of blinding procedures for those who collected the outcomes measures, handling of drop outs, and completeness of follow-up. The great majority of results consist of results of a single trial. KMC was associated with the following reduced risks: nosocomial infection at 41 weeks' corrected gestational age (relative risk 0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95% confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months follow-up (relative risk 0.37, 95% confidence interval 0.15 to 0.89), not exclusively breastfeeding at discharge (relative risk 0.41, 95% confidence interval 0.25 to 0.68), and maternal dissatisfaction with method of care (relative risk 0.41, 95% confidence interval 0.22 to 0.75). KMC infants had gained more weight per day by discharge (weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Scores on mother's sense of competence according to infant stay in hospital and admission to NICU were better in KMC than in control group (weighted mean differences 0.31 [95% confidence interval 0.13 to 0.50] and 0.28 [95% confidence interval 0.11 to 0.46], respectively). Scores on mother's perception of social support according to infant stay in NICU were worse in KMC group than in control group (weighted mean difference -0.18 (95% confidence interval -0.35 to -0.01). Psychomotor development at 12 months' corrected age was similar in the two groups. There was no evidence of a difference in infant mortality. However, serious concerns about the methodological quality of the included trials weaken credibility in these findings. REVIEWER'S CONCLUSIONS: Although KMC appears to reduce severe infant morbidity without any serious deleterious effect reported, there is still insufficient evidence to recommend its routine use in LBW infants. Well designed randomized controlled trials of this intervention are needed.

[Health care of very low birth weight infants in Montevideo, Uruguay: a comparison between public and private sectors] / Atenção à saúde de crianças de peso muito baixo ao nascer, em Montevidéu, Uruguai: comparação entre os setores público e privado.

OBJECTIVE: To compare morbidity and mortality in very low birthweight infants admitted to public and private intensive care units in Montevideo, Uruguay. METHODS: Longitudinal design. All very low birth weight infants born in public hospitals of Montevideo between May 1st and October 31st, 1999, were included in the study and followed up until they were discharged from hospital, or died. The quality of care, and morbidity and mortality rates obtained in private intensive care units were compared with those observed in public intensive care units (infants who were never transferred). RESULTS: Of 141 infants, 19 were excluded from the study (13 died at the delivery room and six were transferred to intensive care units of other public hospitals). Of the remaining 122 infants, 61 were kept at the intensive care units of public hospitals, and 61 were transferred to a private unit. The infants who were transferred presented lower gestational age and increased neonatal depression. However, mortality among infants treated at intensive care units of public hospitals was twice as high (Hazard Ratio 1.8; 95%CI 1.1-3.4; P=0.04), especially in infants who weighed less than 1,000g (Hazard Ratio 2.4; 95%CI 1.1-5.5; P=0.04). CONCLUSIONS: The health status of very low birth weight infants treated at intensive care units of public and private hospitals in Montevideo, Uruguay, was assessed. Mortality was lower, and health care was better in neonatal units of private hospitals.

[Perinatal Information System. Incorporation latency and impact on perinatal clinical registry]. / Sistema Informático Perinatal. Latencia de incorporación e impacto en el registro clínico perinatal.

The Perinatal Information System (SIP) is a clinical record, local management and quality assurance software standard in Latin America and the Caribbean. The time to implement SIP in a Maternity Hospital is evaluated as well as the effect of statistics on perinatal health indicators in subsequent years. In the sample of 20 Maternity Hospitals (5 Countries, 40% Private and 60% Public) 85% had a reliable information system by the third year of use of SIP. 15% of hospitals still had problems at that time that were already clear during the second year, a time corrective measures can still be taken. The evaluation of the impact of yearly reports shows that 58% of recommendations were fulfilled, specially those regarding the complete filling-in of clinical records (62%) and to a lesser extent variables that reflect clinical practices and organization of services (52%). The conclusion is that Maternity Hospitals in Latin America and the Caribbean have the capacity to adopt a complex tool of computerized clinical records for quality assurance of perinatal care and monitoring of health indicators.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.

BACKGROUND: Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. OBJECTIVES: To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional care after the initial period of stabilization with conventional care. SEARCH STRATEGY: We used the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. MEDLINE, EMBASE, LILACS, POPLINE and CINAHL databases, and the Cochrane Controlled Trials Register (Cochrane Library) up to Issue 2, 2000, were searched using the key words terms "kangaroo mother care" or "kangaroo mother method" or "skin-to-skin contact" and "infants" or "low birthweight infants". SELECTION CRITERIA: Randomised trials comparing KMC and conventional neonatal care in LBW infants. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Statistical analysis was conducted using the standard Cochrane Collaboration methods. MAIN RESULTS: Three studies, involving 1362 infants, were included. All the trials were conducted in developing countries. The studies were of moderate to poor methodological quality. The most common shortcomings were in the areas of blinding procedures for those who collected the outcomes measures, handling of drop outs, and completeness of follow-up. The great majority of results consist of results of a single trial. KMC was associated with the following reduced risks: nosocomial infection at 41 weeks' corrected gestational age (relative risk 0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95% confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months follow-up (relative risk 0.37, 95% confidence interval 0.15 to 0.89), not exclusively breastfeeding at discharge (relative risk 0.41, 95% confidence interval 0.25 to 0.68), and maternal dissatisfaction with method of care (relative risk 0.41, 95% confidence interval 0.22 to 0.75). KMC infants had gained more weight per day by discharge (weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Scores on mother's sense of competence according to infant stay in hospital and admission to NICU were better in KMC than in control group (weighted mean differences 0.31 [95% confidence interval 0.13 to 0.50] and 0.28 [95% confidence interval 0.11 to 0.46], respectively). Scores on mother's perception of social support according to infant stay in NICU were worse in KMC group than in control group (weighted mean difference -0.18 (95% confidence interval -0.35 to -0.01). There was no evidence of a difference in infant mortality. However, serious concerns about the methodological quality of the included trials weaken credibility in these findings. REVIEWER'S CONCLUSIONS: Although KMC appears to reduce severe infant morbidity without any serious deleterious effect reported, there is still insufficient evidence to recommend its routine use in LBW infants. Well designed randomized controlled trials of this intervention are needed.

Epidemiology of fetal death in Latin America.

BACKGROUND: To identify risk factors associated with fetal death, and to measure the rate and the risk of fetal death in a large cohort of Latin American women. METHODS: We analyzed 837,232 singleton births recorded in the Perinatal Information System Database of the Latin American Center for Perinatology and Human Development (CLAP) between 1985 and 1997. The risk factors analyzed included fetal factors and maternal sociodemographic, obstetric, and clinical characteristics. Adjusted relative risks were obtained, after adjustment for potential confounding factors, through multiple logistic regression models based on the method of generalized estimating equations. RESULTS: There were 14,713 fetal deaths (rate=17.6 per 1000 births). The fetal death risk increased exponentially as pregnancy advanced. Thirty-seven percent of all fetal deaths occurred at term, and 64% were antepartum. The main risk factors associated with fetal death were lack of antenatal care (adjusted relative risk [aRR]=4.26; 95% confidence interval, 3.84-4.71) and small for gestational age (aRR=3.26; 95% CI, 3.13-3.40). In addition, the risk of death during the intrapartum period was almost tenfold higher for fetuses in noncephalic presentations. Other risk factors associated with stillbirth were: third trimester bleeding, eclampsia, chronic hypertension, preeclampsia, syphilis, gestational diabetes mellitus, Rh isoimmunization, interpregnancy interval<6 months, parity > or =4, maternal age > or =35 years, illiteracy, premature rupture of membranes, body mass index > or =29.0, maternal anemia, previous abortion, and previous adverse perinatal outcomes. CONCLUSIONS: There are several preventable factors that should be dealt with in order to reduce the gap in fetal mortality between Latin America and developed countries.

Health services research, outcomes, and perinatal information systems.

The progress in information and communication technology, together with the search for the most effective and efficient ways to use the limited resources for health care, are opening new areas for research and development in perinatal care. Information systems and practice oriented by evidence-based medicine are modifying the operation of health services, and the quality of their management is being monitored by the success of their outcomes. As a study case, a Perinatal Information System widely used in Latin America and the Caribbean is discussed in some detail. Future challenges in the compatibility of information systems and databanks, the need for longer follow-up periods and measurement of health-related quality of life as outcomes for perinatal care, and the strategies to integrate all these concepts for the improvement of daily practice are discussed.

PIP: The success in information and communication technology, together with the search for the most effective and efficient ways to use the limited resources for health care, are opening new areas for research and development in perinatal care. The quality of the population-based databanks and individual patient care may benefit from improvements in the design of the clinical records. Information systems and practice oriented by evidence-based medicine are modifying the operation of health services, and the quality of their management is being monitored by the success of their outcomes. This paper discusses in detail the experiences of the two countries--Latin America and the Caribbean--in using the Perinatal Information System. Furthermore, this paper discusses the future challenges in the compatibility of information systems and databanks, the need for longer follow-up periods and measurement of health-related quality of life as outcomes for perinatal care, and the strategies to integrate all these concepts for the improvement of daily practice.

Suction patterns in preterm infants.

The suction pattern for breast and bottle feeding in two groups of preterm infants is described. The time elapsed between birth and the moment of suction was longer in preterm neonates born at lower gestational ages for both groups studied, breast and bottle fed (figure 1). The evolution of suckling in breastfeeding was analyzed in a composite study (longitudinal and transverse) in a group of 16 neonates starting from 32 weeks of gestation. The velocity of milk extraction during suckling varied with gestational age. It was uniform at lower gestational ages, then it became faster in the first minutes and at the 36th week, it was very similar to that of mature neonates (figure 2 and table I). The evaluation of bottle feeding was performed in a transverse study in 46 preterm neonates which had been exclusively bottle fed during 1 or 2 weeks. All of them had previously been fed using an orogastric tube. Nourishing time was shorter than in breastfeeding; the average duration was 3.7 minutes (table II). The greatest volume was ingested in the first minute, 40% (range between 44 and 25%) (figure 3). The frequency of suction did not change the duration of feeding, but it was found that the efficiency of suction (number of suctions to ingest 1 cc) was significantly lower in the first minute (Anova, p < 0.05) (figure 4).