Assessing the risks for stillbirth in São Paulo, Brazil: protocol for a multidisciplinary case-control study - FetRisks.

Stillbirth is a fundamental component of childhood mortality, but its causes are still insufficiently understood. This study aims to explore stillbirth risk factors by using a multidisciplinary approach to stimulate public policies and protocols to prevent stillbirth, improve maternal care and support bereaved families. METHODS AND ANALYSIS: In this case-control study with stillbirths and live births in 14 public hospitals in São Paulo, mothers are interviewed at hospitals after delivery, and hospital records and prenatal care registries are reviewed. Maternal and umbilical cord blood samples and placentas are collected to analyse angiogenesis and infection biomarkers, and the placenta's anatomopathological exam. Air pollutant exposure is estimated through the participant's residence and work addresses. Traditional and non-invasive autopsies by image-guided histopathology are conducted in a subset of stillbirths. Subsample mothers of cases are interviewed at home 2 months after delivery on how they were dealing with grief. Information contained in the official prenatal care registries of cases and controls is being compiled. Hospital managers are interviewed about the care offered to stillbirth mothers. Data analysis will identify the main risk factors for stillbirth, investigate their interrelations, and evaluate health services care and support for bereaved families. We hope this project will contribute to the understanding of stillbirth's risk factors and related health services in Brazil, providing new knowledge about this central public health problem, contributing to the improvement of public policies and prenatal and puerperal care, helping to prevent stillbirths and improve the healthcare and support for bereaved families. ETHICS AND DISSEMINATION: This study protocol was approved by the Ethics Committee of the Municipal Health Secretary (process no 16509319.0.3012.5551) and of the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (process no 16509319.0.0000.0068). Results will be communicated to the study participants, policy-makers and the scientific community.

Individual exposure to urban air pollution and its correlation with placental angiogenic markers in the first trimester of pregnancy, in São Paulo, Brazil.

Pollution of the atmosphere is known that may lead to adverse obstetric outcomes, including fetal growth restriction, gestational hypertension, and preeclampsia. Such disorders are correlated with imbalances in angiogenic factors, which may also be involved in the pathological mechanism as the pollutants impact placental and maternal physiology. In the first trimester of gestation, this study assessed the outcomes of personal maternal short period exposure to air pollution on soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PLGF) of pregnant women blood concentrations. This was a cross-sectional study, held in the city of São Paulo, Brazil, and conducted with low-risk pregnant women, who carried personal passive nitrogen dioxide (NO2) and ozone (O3) monitors for about a few days preceding the ultrasound evaluation, and on this day, the venous blood sample was collected to measure the angiogenic factors sFlt1 and PLGF and their ratio (sFlt1/PLGF) by enzyme-linked immunosorbent assay (ELISA). By means of multiple regression models, the effect of the studied pollutants on the log-transformed concentrations of the angiogenic factors was evaluated. One hundred thirty-one patients were included. The log of the sFlt1/PLGF ratio increased with rising NO2 levels (p = 0.021 and beta = 0.206), and the log of the PLGF concentration showed a negative correlation with NO2 (p = 0.008 and beta = - 0.234). NO2, an indicator of the levels of primary air pollutants, presented significant positive correlation with an increased sFlt1/PLGF ratio and diminished PLGF levels, which may reflect an antiangiogenic state generated by air pollution exposure.

Longitudinal study of lung function in pregnant women: Influence of parity and smoking.

OBJECTIVES: To evaluate pulmonary function in the first and third trimesters of pregnancy and analyze the influence of parity and smoking on spirometry parameters. METHODS: This longitudinal prospective study included a cohort of 120 pregnant women. The inclusion criteria were as follows: singleton pregnancy, gestational age less than 13.86 weeks, and no preexisting maternal diseases. The exclusion criteria were as follows: change of address, abortion, and inadequate spirometry testing. ClinicalTrials.gov: NCT02807038. RESULTS: A decrease in values of forced vital capacity and forced expiratory volume were noted in the first second from the first to third trimester. In the first and third trimesters, multiparous women demonstrated lower absolute forced vital capacity and forced expiratory volume values in the first second compared with nulliparous women (p<0.0001 and p=0.001, respectively). Multiparous women demonstrated reduced forced expiratory flow in 25% to 75% of the maneuver compared with nulliparous women in the first (p=0.005) and third (p=0.031) trimesters. The absolute values of forced expiratory flow in 25% to 75%, forced expiratory volume in the first second and predicted peak expiratory flow values in the third trimester were higher in smokers compared with nonsmokers (p=0.042, p=0.039, p=0.024, and p=0.021, respectively). CONCLUSION: There was a significant reduction in forced vital capacity and forced expiratory volume values in the first second during pregnancy. Parity and smoking significantly influence spirometric variables.

Longitudinal study of lung function in pregnant women: Influence of parity and smoking

OBJECTIVES: To evaluate pulmonary function in the first and third trimesters of pregnancy and analyze the influence of parity and smoking on spirometry parameters. METHODS: This longitudinal prospective study included a cohort of 120 pregnant women. The inclusion criteria were as follows: singleton pregnancy, gestational age less than 13.86 weeks, and no preexisting maternal diseases. The exclusion criteria were as follows: change of address, abortion, and inadequate spirometry testing. ClinicalTrials.gov: NCT02807038. RESULTS: A decrease in values of forced vital capacity and forced expiratory volume were noted in the first second from the first to third trimester. In the first and third trimesters, multiparous women demonstrated lower absolute forced vital capacity and forced expiratory volume values in the first second compared with nulliparous women (p<0.0001 and p=0.001, respectively). Multiparous women demonstrated reduced forced expiratory flow in 25% to 75% of the maneuver compared with nulliparous women in the first (p=0.005) and third (p=0.031) trimesters. The absolute values of forced expiratory flow in 25% to 75%, forced expiratory volume in the first second and predicted peak expiratory flow values in the third trimester were higher in smokers compared with nonsmokers (p=0.042, p=0.039, p=0.024, and p=0.021, respectively). CONCLUSION: There was a significant reduction in forced vital capacity and forced expiratory volume values in the first second during pregnancy. Parity and smoking significantly influence spirometric variables.

Short-Term Exposure to Urban Air Pollution and Influences on Placental Vascularization Indexes.

BACKGROUND: It has been widely demonstrated that air pollution can affect human health and that certain pollutant gases lead to adverse obstetric outcomes, such as preeclampsia and fetal growth restriction. OBJECTIVES: We evaluated the influence of individual maternal exposure to air pollution on placental volume and vascularization evaluated in the first trimester of pregnancy. METHODS: This was a cross-sectional study on low-risk pregnant women living in São Paulo, Brazil. The women carried passive personal NO2 and O3 monitors in the week preceding evaluation. We employed the virtual organ computer-aided analysis (VOCAL) technique using three-dimensional power Doppler ultrasound to evaluate placental volume and placental vascular indexes [vascularization index (VI), flow index (FI), and vascularization flow index (VFI)]. We analyzed the influence of pollutant levels on log-transformed placental vascularization and volume using multiple regression models. RESULTS: We evaluated 229 patients. Increased NO2 levels had a significant negative association with log of VI (p = 0.020 and beta = -0.153) and VFI (p = 0.024 and beta = -0.151). NO2 and O3 had no influence on the log of placental volume or FI. CONCLUSIONS: NO2, an estimator of primary air pollutants, was significantly associated with diminished VI and VFI in the first trimester of pregnancy.

Avaliação da espirometria de gestantes expostas à poluição atmosférica da Região Metropolitana de São Paulo / Spirometric evaluation of pregnant women exposed to air pollution in the metropolitan region of São Paulo

Introdução: A poluição do ar pode levar a alterações no sistema respiratório, especialmente entre certos grupos, como as gestantes, que são mais vulneráveis aos efeitos de poluentes atmosféricos. A gravidez é um período que envolve alterações funcionais e anatômicas no corpo da mulher, incluindo alterações na função pulmonar, o que pode ser avaliado por espirometria, um método simples, barato e eficaz. Objetivos: Os objetivos deste estudo foram a usar a espirometria para avaliar a função pulmonar de mulheres no primeiro trimestre (T1) e no terceiro trimestre (T3) de gravidez e analisar a influência da exposição a poluição do ar sobre os parâmetros espirométricos. Metodologia: O estudo foi realizado no Ambulatório de Obstetrícia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) entre Maio de 2011 e Agosto de 2013. Foram aplicados os seguintes critérios de inclusão: gestação única, idade gestacional no dia da primeira espirometria inferior a 13,86 semanas, ausência de doenças maternas préexistentes, preparação adequada para o teste de espirometria e amostradores passivos individuais (APIs) adequados para análise. Os critérios de exclusão foram a mudança de endereço, o aborto, o teste de espirometria inadequado e desistência de participar do projeto. Os APIs contendo dois filtros de celulose embebidos com solução absorvente para capturar os níveis de NO2 e outros dois filtros embebidos com solução de índigo blue para medir os níveis de O3 foram entregues às gestantes cerca de 12 dias antes da realização do teste de espirometria. Dados do relatório anual da Companhia Ambiental do Estado de São Paulo (CETESB) para o mesmo período dos amostradores passivos, foram utilizados. Para a espirometria, um espirômetro Koko foi utilizado, sendo considerada as duas melhores curvas para avaliar os resultados da função pulmonar. Análise estatística: Foi utilizado o teste Mann-Whitney para grupos independentes e Wilcoxon para...

Introduction - Air pollution can lead to alterations to the respiratory system, particularly among certain groups, such as pregnant women, which are more vulnerable to the effects of air pollutants. Pregnancy is a period involving functional and anatomical changes in a woman's body. These changes include pulmonary function, which can be assessed by spirometry, a simple, inexpensive and effective method. Objectives - The aims of this study were to use spirometry to evaluate pulmonary function in pregnant women in the first trimester (T1) and the third trimester (T3) of pregnancy and to analyze the influence of air pollution exposure on the spirometry parameters. Methodology - This study was carried out at the Obstetrics Clinic of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) between May 2011 and August 2013. The following inclusion criteria were applied: singleton pregnancy, 13.86 weeks gestational age at the first spirometry, no preexisting maternal diseases, adequate preparation for the spirometry test and individual passive samplers (IPAs) suitable for analysis. The exclusion criteria were change of address, abortion, inadequate spirometry testing and withdrawal from the project. The exposure to pollutants prior to the spirometry tests was assessed in T1 and T3. The passive samplers containing two cellulose filters soaked with absorbent solution to capture NO2 levels and two other filters soaked with indigo solution to measure O3 levels were provided to the pregnant women roughly 12 days prior to the spirometry test. Data from the environmental Company of São Paulo State (CETESB) annual report for the same period the passive samplers were used. For the spirometry, a Koko spirometer was used, taking the two best curves to assess lung function results. Statistical Analysis - We used Mann- Whitney tests for independent groups and Wilcoxon for the dependent ones. Due to the small variation in the...