This thesis aims to undertake health technology assessments in high risk pregnancies through the following objectives: 1. In women with pre-eclampsia, a) To evaluate the association of maternal genotype and severe pre-eclampsia b) To assess the accuracy of tests in predicting adverse pregnancy outcomes c) To develop composite outcomes for reporting in trials on late onset pre-eclampsia 2. In women with multiple pregnancy, a) To study the association between chorionicity and stillbirth b) To identify the optimal timing of delivery in monochorionic and dichorionic twin pregnancies 3. In the field of prediction research in obstetrics a) To provide an overview of the existing prognostic models and their qualities b) To evaluate the methodological challenges and potential solutions in developing a prognostic model for complications in pre-eclampsia Methods The following research methodologies were used: Delphi survey, systematic reviews and meta-analyses. Results 1. a) Maternal genotype and severe pre-eclampsia: 57 studies evaluated 50 genotypes; increased risk of severe pre-eclampsia with thromobophilic genes. b) Accuracy of tests in predicting pre-eclampsia complications: 37 studies evaluated 13 tests. No single test showed high sensitivity and specificity. c) Delphi survey of 18/20 obstetricians and 18/24 neonatologists identified clinically important maternal and neonatal outcomes and maternal and neonatal composite outcomes were developed. 2. Prospective risk of stillbirth and neonatal deaths in uncomplicated monochorionic and dichorionic twin pregnancies: 32 studies were included. In dichorionic twin pregnancies, the risk of stillbirths was balanced against neonatal death at 37 weeks' gestation. In monochorionic pregnancies, there was a trend towards increase in stillbirths after 36 weeks but this was not significant. 3. a) From 177 studies included, 263 obstetric prediction models were developed for 40 different outcomes, most commonly pre-eclampsia, preterm delivery, mode of delivery and small for gestational age neonates. b) The obstetric prognostic model challenge of dealing with treatment paradox was explored and seven potential solutions proposed by expert consensus. Conclusion I have identified the strength of association for genes associated with complications in pre-eclampsia, components for composite outcomes for reporting in studies on pre-eclampsia, and the optimal timing of delivery for twin pregnancies. My work has highlighted the gaps in prediction research in obstetrics and the limitations of individual tests in pre-eclampsia.

Submitted by CAROLINE DE PAULA VENEZIAN RICCETTO (carol_venezian@hotmail.com) on 2017-08-30T02:23:37Z No. of bitstreams: 1 Dissertação Mestrado Final Reservatório - Caroline de Paula Venezian Riccetto.pdf: 1192284 bytes, checksum: 70d4763a62fcf9cfaa5cf750dc451f3c (MD5) / Approved for entry into archive by Luiz Galeffi (luizgaleffi@gmail.com) on 2017-08-30T17:33:13Z (GMT) No. of bitstreams: 1 riccetto_cpv_me_bot.pdf: 1192284 bytes, checksum: 70d4763a62fcf9cfaa5cf750dc451f3c (MD5) / Made available in DSpace on 2017-08-30T17:33:13Z (GMT). No. of bitstreams: 1 riccetto_cpv_me_bot.pdf: 1192284 bytes, checksum: 70d4763a62fcf9cfaa5cf750dc451f3c (MD5) Previous issue date: 2017-08-21 / Objetivo: Determinar o efeito do uso da sonda de Foley para o preparo de colo uterino, em gestantes tratadas em regime ambulatorial versus internação. Sujeitos e métodos: Foi realizado um estudo prospectivo, randomizado e do tipo ensaio clínico. Trinta e sete mulheres com gestação de baixo risco foram randomizadas para o preparo de colo uterino, com sonda de Foley, em dois grupos: ambulatorial (n=17) e internação (n=20). Os principais desfechos avaliados foram: índice de Bishop final, número de gestantes que modificaram o índice de Bishop de desfavorável para favorável, tipo de parto, uso de ocitocina, tempo de internação, morbidade materna e neonatal grave, óbito neonatal, taquissistolia com alteração da frequência cardíaca fetal e Apgar de quinto minuto ≤ 7. Para a análise estatística foram utilizados o teste de qui-quadrado para comparar proporções e o teste t de Student para a comparação de médias. O nível de significância estabelecido foi de 5% ( = 0,05). Resultados: Não houve diferença estatística significativa entre os dois grupos quanto ao índice de Bishop final, tipo de parto, necessidade de uso de ocitocina, morbidade materna e neonatal grave, óbito neonatal, taquissistolia com alteração da frequência cardíaca fetal e Apgar de quinto minuto ≤ 7. Como esperado, as gestantes do grupo internação tiveram mais horas dentro do ambiente hospitalar do que as do grupo ambulatorial (77,7 horas no grupo ambulatorial versus 93,1 horas no grupo internação), entretanto não houve diferença estatística. Conclusão: Gestantes do grupo ambulatorial apresentaram os mesmos desfechos que gestantes do grupo internação, com diminuição do tempo de internação e, consequentemente, redução do custo de tratamento, além da possibilidade de permanecer maior tempo no conforto do lar e na convivência familiar. / Objective: To determine the effect of the use of the Foley catheter for the cervical ripening, in pregnant women treated on an outpatient basis versus hospitalization. Subjects and methods: A prospective, randomized clinical trial was conducted. Thirty-seven women with low-risk pregnancies were randomized to the cervical ripening with a Foley catheter in two groups: outpatient (n = 17) and hospitalization (n = 20). The main outcome measures were: Bishop's final index, number of pregnant women who modified Bishop's ratio from unfavorable to favorable, type of delivery, oxytocin use, hospitalization time, severe maternal and neonatal morbidity, neonatal death, tachysystole with alteration of Fetal heart rate and fifth-minute Apgar ≤ 7. For the statistical analysis the chi-square test was used to compare proportions and Student's t-test for comparison of means. The level of significance was set at 5% ( = 0.05). Results: There was no statistically significant difference between the two groups regarding the final Bishop index, type of delivery, need for oxytocin use, severe maternal and neonatal morbidity, neonatal death, tachysystole with altered fetal heart rate, and fifth-minute Apgar ≤ 7. As expected, the pregnant women in the hospitalization group had more hours within the hospital setting than the outpatient group (77.7 hours in the outpatient group versus 93.1 hours in the hospitalization group), however there were no statistical differences. Conclusion: Pregnant women in the outpatient group presented the same outcomes as pregnant women in the hospitalization group, with a reduction in the length of hospital stay and, consequently, a reduction in the cost of treatment, as well as the possibility of remaining longer in the comfort of the home and in the family support.

Orientador: Vera Therezinha Medeiros Borges / Resumo: Objetivo: Determinar o efeito do uso da sonda de Foley para o preparo de colo uterino, em gestantes tratadas em regime ambulatorial versus internação. Sujeitos e métodos: Foi realizado um estudo prospectivo, randomizado e do tipo ensaio clínico. Trinta e sete mulheres com gestação de baixo risco foram randomizadas para o preparo de colo uterino, com sonda de Foley, em dois grupos: ambulatorial (n=17) e internação (n=20). Os principais desfechos avaliados foram: índice de Bishop final, número de gestantes que modificaram o índice de Bishop de desfavorável para favorável, tipo de parto, uso de ocitocina, tempo de internação, morbidade materna e neonatal grave, óbito neonatal, taquissistolia com alteração da frequência cardíaca fetal e Apgar de quinto minuto ≤ 7. Para a análise estatística foram utilizados o teste de qui-quadrado para comparar proporções e o teste t de Student para a comparação de médias. O nível de significância estabelecido foi de 5% ( = 0,05). Resultados: Não houve diferença estatística significativa entre os dois grupos quanto ao índice de Bishop final, tipo de parto, necessidade de uso de ocitocina, morbidade materna e neonatal grave, óbito neonatal, taquissistolia com alteração da frequência cardíaca fetal e Apgar de quinto minuto ≤ 7. Como esperado, as gestantes do grupo internação tiveram mais horas dentro do ambiente hospitalar do que as do grupo ambulatorial (77,7 horas no grupo ambulatorial versus 93,1 horas no grupo internação), entretanto não hou... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Objective: To determine the effect of the use of the Foley catheter for the cervical ripening, in pregnant women treated on an outpatient basis versus hospitalization. Subjects and methods: A prospective, randomized clinical trial was conducted. Thirty-seven women with low-risk pregnancies were randomized to the cervical ripening with a Foley catheter in two groups: outpatient (n = 17) and hospitalization (n = 20). The main outcome measures were: Bishop's final index, number of pregnant women who modified Bishop's ratio from unfavorable to favorable, type of delivery, oxytocin use, hospitalization time, severe maternal and neonatal morbidity, neonatal death, tachysystole with alteration of Fetal heart rate and fifth-minute Apgar ≤ 7. For the statistical analysis the chi-square test was used to compare proportions and Student's t-test for comparison of means. The level of significance was set at 5% ( = 0.05). Results: There was no statistically significant difference between the two groups regarding the final Bishop index, type of delivery, need for oxytocin use, severe maternal and neonatal morbidity, neonatal death, tachysystole with altered fetal heart rate, and fifth-minute Apgar ≤ 7. As expected, the pregnant women in the hospitalization group had more hours within the hospital setting than the outpatient group (77.7 hours in the outpatient group versus 93.1 hours in the hospitalization group), however there were no statistical differences. Conclusion: Pregnant women ... (Complete abstract click electronic access below) / Mestre