Orientador: Egberto Ribeiro Turato / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-08T02:11:49Z (GMT). No. of bitstreams: 1 Santos_ShirleyNunesdos_M.pdf: 763247 bytes, checksum: adf64d2991413d498cdb52bf978d9dfc (MD5) Previous issue date: 2007 / Resumo: As propostas de políticas de saúde para a população negra têm uma história recente no cenário político brasileiro, com um destaque especial para o Programa Nacional de Anemia Falciforme. A anemia falciforme é a doença hereditária mais comum no Brasil e constitui um problema de saúde pública. Alguns trabalhos buscaram destacar a relevância do enfoque epidemiológico da anemia falciforme entre as mulheres e suas repercussões na saúde reprodutiva dessa população. Mulheres portadoras de anemia falciforme apresentam maior risco de abortamento e complicações durante o parto, fatos que geram repercussões emocionais na gestante. O objetivo desta pesquisa foi conhecer significados das vivências da gravidez relatados por mulheres portadoras de anemia falciforme. Utilizamos o método clínico-qualitativo, tendo sido a amostra fechada por saturação das informações, composta por nove pacientes acompanhadas no Ambulatório de Alto Risco e na enfermaria de patologias obstétricas do Centro de Atenção Integral à Saúde da Mulher (CAISM). Suas idades variaram de 19 a 35 anos de idade, com períodos gestacionais entre 16 e 30 semanas. Foram realizadas entrevistas semidirigidas com questões abertas, gravadas, transcritas e submetidas à análise qualitativa de conteúdo. Os resultados foram categorizados em tópicos, dos quais elegemos dois para discussão neste trabalho: (1) o significado da maternidade parece permitir que o desejo de ser mãe se manifeste mais forte do que sentimentos comuns de medo relacionados à doença e os seus agravamentos; (2) a presença da doença no cotidiano dessas mulheres, as várias complicações e internações foram percebidas de maneira ambivalente, como um ¿mal necessário¿. Como esperado, o apoio de familiares e de profissionais da saúde foram cruciais para que a gestação dessas mulheres fosse enfrentada de forma mais tranqüila. O estudo sugere que apesar da vivência de angústias existenciais e psicológicas que envolvem normalmente a gravidez, das limitações da doença para o desempenho de funções profissionais e sociais e do conhecimento das possibilidades de complicações clínicas para a mãe e/ou para o bebê, estes sentimentos não interferiram na manifestação do desejo do exercício da maternidade / Abstract: The political proposals concerning the health of the black population have a recent history in the Brazilian political scenery with a special focus on the Sickle Cell Anemia National Program. The sickle cell anemia is the most common hereditary disease in Brazil and it is a public health problem. Some works have tried to emphasize the epidemiological aspect of the sickle cell anemia among women and its repercussions for the reproductive health of that population. Women with sickle cell anemia have higher miscarriage risks, besides higher risks of complications during childbirth. These risks have an emotional impact on pregnant women. The objective of this research was to have a better understanding of the experience of pregnant women with sickle cell anemia. We used the clinical-qualitative method; the sample included nine patients who had their follow-up done at the ¿Clinic of High Risk and in the Infirmary of Obstetric Pathologies at the Center of Integral Attention to the Woman's Health¿ (CAISM). Their ages ranged from 19 to 35, and the gestational age ranged from the 16th to the 30th weeks. Data were collected through semidirected interviews with open-ended questions; they were recorded, transcribed and underwent qualitative content analysis. The results were classified in topics, of which we chose two for discussion in this work: (1) the importance of maternity seems to make the desire of being a mother stronger than the fears related to the disease and its aggravations; (2) the presence of the disease in the daily lives of these women, the several complications and hospitalizations were faced with mixed feelings, as a "necessary evil". As expected, the support of relatives and health professionals was crucial for these women to withstand their pregnancy with more tranquility. The study suggests that in spite of the feelings of existential and psychological anguishes that usually involve these kind of pregnancy, and in spite of the professional and social limitations caused by the disease and in spite of the awareness of the possibilities of clinical complications for the mother and/or for the baby, there was still a strong desire of being a mother / Mestrado / Ciencias Biomedicas / Mestre em Tocoginecologia

Le placenta est l’organe central de la grossesse et son bon fonctionnement est essentiel pour mener à une grossesse à terme sans complication. L’inflammation joue un rôle très important dans les différentes étapes de la grossesse, de l’implantation à l’accouchement. Lorsque cette inflammation est débalancée au niveau du placenta, cela peut causer plusieurs altérations de ses fonctions. L’inflammation peut être induite par deux différents stimuli, soient par une intervention externe, donc infectieux (via les Pathogen-Associated Molecular Patterns, PAMPs) ou de façon endogène (via les Damage-Associated Molecular Patterns, DAMPs). L’augmentation de l’inflammation est aussi associée avec les complications de la grossesse, qui touchent 5-12% de toutes les grossesses et qui peuvent mener à des conséquences dévastatrices sur la santé de la mère et du nouveau-né. Ces complications comprennent la prééclampsie (PE), l’accouchement prématuré (AP) et le retard de croissance intra-utérin (RCIU). Malgré que ces pathologies aient des étiologies différentes, elles partagent un facteur commun qui joue un rôle essentiel soit, l’inflammation. Dans le but de mieux comprendre le rôle et les effets de l’inflammation sur le placenta humain et dans les complications de la grossesse, nous avons évalué les effets d’un PAMP (LPS) et d’un DAMP (IL-1) classiques dans un modèle d’explants placentaires humains et nous avons réalisé une étude transcriptomique non biaisée de placentas issus de chaque pathologie. Tout d’abord, nous avons démontré que le LPS induisait une plus grande quantité de cytokines pro-inflammatoire comparativement à l’IL-1 et que l’inhibition de la voie de signalisation de l’IL-1 par son antagoniste (IL-1Ra) diminuait leur expression et leur sécrétion. De plus, le LPS induisait une augmentation de la mort cellulaire dans les explants et la prolifération des cellules de Hofbauer, macrophages placentaires. Par la suite, l’étude du transcriptome de placentas provenant de complications de la grossesse (PE, AP et RCIU) a permis de constater que les pathologies ne forment pas de groupes (clusters) basés sur l’expression globale des gènes comparativement placentas issus de grossesses sans complication qui se regroupaient majoritairement ensemble. Il a été possible d’identifier les gènes significativement différents dans chaque pathologie et l’ontologie génique de ceux-ci. Nous avons identifié 198 gènes communs à toutes les complications de la grossesse qui sont majoritairement associés à des processus inflammatoires tels que l’interaction entre les cellules lymphoïdes et non lymphoïdes, l’activation leucocytaire et la régulation de la production de cytokines. Enfin, en plus de confirmer les modulations connues de certains gènes dans chaque complication de la grossesse, nous avons été en mesure d’identifier de nouveaux gènes qui n’avaient jamais été associés avec les pathologies, tels que FUT9, SLAMF7 et TGM3. En conclusion, les travaux présentés dans cette thèse démontrent que l’inflammation induite par le LPS et l’IL-1 n’a pas les mêmes effets au niveau du placenta. L’inflammation est une composante commune aux différentes complications de la grossesse et une meilleure compréhension des processus inflammatoires modulés dans chaque pathologie pourrait permettre le développement de nouvelles approches thérapeutiques. Des travaux futurs pourraient s’intéresser au potentiel prolifératif des cellules de Hofbauer et à l’investigation des nouveaux gènes identifiés par les résultats transcriptomiques. / The placenta is the central organ of pregnancy and its adequate functioning is essential to ensure term delivery without complications. Inflammation plays a key role in every step of pregnancy, from implantation to delivery. When this inflammation is unbalanced in the placenta, it can alter its functions. Inflammation can be induced by two different stimuli, either by external intervention like an infection (with Pathogen-Associated Molecular Patterns, PAMPs), or endogenously (with Damage-Associated Molecular Patterns, DAMPs). Increased inflammation is also associated with pregnancy complications and they affect 5-12% of all pregnancies and can have deleterious effects on maternal and infant health. These complications include preeclampsia (PE), preterm birth (PTB) and intrauterine growth restriction (IUGR). Even if these pathologies have different etiologies, they share a common factor that plays an essential role, inflammation. In order to better understand the role and the effects of inflammation on the human placenta and in pregnancy complications, we have evaluated the effects of classical PAMP (LPS) and DAMP (IL-1) on human placental explant model and we have realized an unbiased transcriptomic study of the placentas from each pregnancy complication. First of all, we demonstrated that LPS induced a higher production of pro-inflammatory cytokines compared to IL-1 and by inhibiting the IL-1 pathway using its antagonist (IL-1Ra), we decreased their expression and their secretion. Moreover, LPS treatment induced more cell death in the explants and proliferation of Hofbauer cells, macrophages of the placenta. Thereafter, transcriptomic study of placentas from pregnancy complications (PE, PTB and IUGR) allowed us to demonstrate that the pathologies were not clustering together based on their global gene expression compared to placentas from uncomplicated pregnancies which the majority of them were clustering together. It was possible to identify genes that were significantly modulated in each pathology and their gene ontology. We identified 198 genes common to all pregnancy complications and they were mostly related to inflammatory processes like interaction between lymphoid and non-lymphoid cells, leukocyte activation and regulation of cytokine production. Finally, in addition to confirming gene modulations previously known in each pregnancy complications, we were able to identify new genes that have never been associated with the pathologies such as FUT9, SLAMF7 and TGM3. To conclude, the work presented in this thesis show that inflammation induced by LPS and IL-1 did not have the same effect on the placenta. Inflammation is a key component to pregnancy complications and a better understanding of the inflammatory processes modulated in every pathology could help the development of new therapeutic strategies. Future work could investigate the proliferative potential of the Hofbauer cells and explore the new genes identified by the transcriptomic results.

Poor pregnancy outcomes such as prematurity, low birth weight and infant mortality are societal indicators of a nation’s health status. These indicators have remained at exceptionally high rates in the United States despite the levels of resources and technology. In the quest to understand that discrepancy, among the ranges of theories and models for explaining poor pregnancy outcomes an emerging concept is coming to attention: social capital. In order to test whether maternal social capital has an impact on pregnancy outcome, women in a Healthy Start program were surveyed over a 13-month period to assess their social capital levels and then their pregnancy outcomes. What emerged was that maternal social capital can predict up to 47% of the variance in pregnancy outcome. That is a powerful research result considering that previously there has been no literature tracing a link between maternal social capital and pregnancy outcome. In this study, maternal risk factors adversely affect up to 30% of the variance in pregnancy outcomes. Previous research has focused on maternal risk factors as the primary reason for high rates of preterm delivery, low birth weight, and infant mortality in the United States. However, this research found that in the sample of women at risk for adverse pregnancy outcomes, maternal risk factors had a very strong influence on maternal social capital (R-square=65%) while their effects on pregnancy outcomes were about half of their effects on social capital. This result suggests that social capital mediates the effects of maternal risk factors on pregnancy outcomes. It appears that one of the reasons that the high rates of adverse pregnancy outcomes in the United States have remained a mystery is that maternal social capital has not been taken into account.

No description available.

Thesis (MPH.) -- University of Limpopo, 2022 / The burden of labour and delivery-related complications are health problems that are life-threatening for the fetus and pregnant women. Mokopane hospital in Waterberg of Limpopo Province reports many maternal health complications. There has not been an investigation into the burden of delivery complications and therefore this study aims to investigate the burden of labour and delivery complication experienced by women giving birth at Mokopane hospital of Limpopo province. Purpose: of this study was to explore the burden of labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo province. Methods: A cross-sectional, retrospective descriptive study was conducted. The study followed a quantitative approach and the researcher completed a questionnaire using clinical records from all delivery files of mothers delivered at maternity between January 2017 to December 2019 Mokopane hospital. Findings: The major finding of this study was the majority of women were at a low risk of pregnancy (69%) followed by a high risk of pregnancy (24%). The study further revealed that (73.7%) of women at Mokopane hospital were delivered through the normal virginal procedure and (25.8%) delivered through Caesarean section. Moreover, about 86% of the mothers were normal after delivery whilst 14% were sick or had complications. Conclusion: This study, therefore, recommends that educational programs about labour and delivery-related complications and related programs should be prioritised for pregnant women. KEY CONCEPTS The burden: Is the intensity or severity of disease and its possible impact on daily life (Gidron 2013). In the context of this study, the burden will refer to the death and loss of health due to labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo Province. Labour: This is the process of rhythmic uterine contractions which results in cervical dilatation, a descent of the presenting part; and delivery of the fetus, placenta, and membrane. (Anthony & Van Der Spuy, 2002; Clark, Van de Velde, & Fernando, 2016). In the context of this study, labour will be defined as a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus. Delivery related complication: Is an acute condition arising from a direct cause of maternal death, such as antepartum or postpartum haemorrhage, obstructed labour, postpartum sepsis, a complication of abortion, pre-eclampsia or eclampsia, ectopic pregnancy and ruptured uterus, or indirect causes such as anaemia, malaria and tuberculosis. (WHO, 2018). In the context of this study, delivery related complications will include amongst others severe antenatal bleeding, Postpartum haemorrhage, nonconvulsive hypertensive disorder of pregnancy (pre-eclampsia), Eclampsia: preeclampsia plus convulsions, Convulsions, Prolonged labour, Premature rupture of the membranes, Retained placenta. Pregnant women: Is a woman who is in the period from conception to birth in which the egg is fertilised by a sperm and then implanted in the lining of the uterus then develops into the placenta and embryo, and later into a foetus (Martin, 2015). In the context of this study, a pregnant woman will be described as a woman who is carrying a developing embryo or fetus within her body.

This dissertation consists of three chapters exploring challenges that many developing countries face in augmenting state capacity and accumulating human capital. In particular, I focus on difficulties in developing state capacity and human capital induced by political violence, natural disasters, and over-reliance on income from foreign countries. The first chapter explores the effects of losing local politicians on the fiscal and personnel capacity of local governments using the outcome of the assassination attempts on mayors in Mexico. The second chapter investigates the effects of exposure to natural disasters on birth outcomes in Indonesia, using the Indian Ocean Tsunami as a natural experiment. In the final chapter, I use a cross-country analysis to study the link between reliance on remittances and the capacity of a country to collect taxes efficiently. The first chapter investigates the effects of losing mayors to successful assassinations on the capacity of local governments. By leveraging the randomness in the outcomes of assassination attempts against mayors in Mexico in 2002-21, I find that the loss of mayors negatively affects the fiscal and personnel capacities of the local governments. Municipal tax collection decreases by 29\%. The share of expenditure on primary services falls by 3 percentage points and is crowded out toward investment in construction. Municipal workers at productive stages in their careers leave the position. The back-of-the-envelope calculation shows that wages should increase by 13\% to retain them after assassinations. Organized criminal groups take advantage of the loss of mayors by increasing their presence in municipalities with successful assassinations. The results are not explained by non-political violence, levels of economic activities, or population changes. The results speak to the significance of leaders in maintaining fiscal capacity and retaining capable personnel in the workforce even in a violent environment. In the second chapter, co-authored with Elizabeth Kayoon Hur (Michigan State University), I evaluate the effect of in-utero exposure to the 2004 Indian Ocean Tsunami on short-term childbirth outcomes in Indonesia. Exploiting variation in the timing of exposure, I find that the probability of successful pregnancies drops by 5.9 percentage points (pp), while miscarriages increase by 5.5 pp for those exposed in the earliest stage of pregnancy. I find suggestive evidence that post-disaster health investments by households may have shielded later cohorts from harmful effects. The results suggest the importance of considering fetal loss in developing countries and highlight that facilitating household investment in health through various policies may mitigate negative birth effects in the aftermath of natural disasters. The third chapter investigates the relationship between a country's reliance on remittances from abroad and its ability to collect taxes from various domestic sources. Despite the increasing flow of remittances in volume and proportion, particularly among developing countries, their role in determining the state's capacity to collect taxes has received little attention. This chapter explores the link between remittances and various tax revenue categories using country-level data. Two-way panel regressions suggest that a 1 percentage point (pp) increase in the inflow of remittances explains a 0.12 pp rise in consumption tax revenues. The same estimate derived from IV methods proxying for migrant network strength and openness of borders increases to 0.9 pp. Decomposing this result reveals that the increase in household consumption expenditure explains all of the statistical association, not the efficient tax-collecting mechanisms such as VAT. Subsample regressions by income category suggest that the association between remittances and consumption tax revenue is stronger in countries with lower income.

Os objetivos deste estudo foram: avaliar as freqüências de partos vaginais e cesáreas em mulheres portadoras de cardiopatias, bem como a distribuição dos partos nos diferentes subgrupos de doenças cardíacas: arritmias (A), cardiopatias congênitas (CC) e cardiopatias adquiridas (CA); analisar os fatores clínicos e obstétricos que estiveram relacionados à determinação da via de parto no grupo total de cardiopatas e também nos subgrupos, e avaliar a associação entre o tipo de parto e complicações clínicas e obstétricas. Foram analisados retrospectivamente os dados referentes a 571 gestações de 556 mulheres internadas para parto na Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 2001 e 2005. A composição dos grupos foi: A - 57 casos (10%), CC - 163 casos (28,6%) e CA - 351 casos (61,4%). A taxas de cesárea foram 57,2% (total), 45,6% (A), 64,2% (CC) e 55,7% (CA). A indicação da cesárea foi obstétrica em 77% dos casos. Analisando os 425 casos sem cesáreas anteriores, as taxas de cesárea foram: 47,1% (total), 37,8% (A), 57,8% (CC) e 43,3% (CA). A probabilidade de parto cesáreo esteve relacionada à presença de cesárea anterior, idade gestacional no parto inferior a 37 semanas, presença de intercorrências obstétricas, diagnóstico de cardiopatia congênita, insuficiência cardíaca classe funcional (CF) III ou IV, e uso de medicamentos de ação cardiovascular. A paridade maior ou igual a um diminuiu a probabilidade de cesárea. A presença de cesárea anterior foi o principal fator relacionado à probabilidade de parto cesáreo nesta população. Nos subgrupos de cardiopatia (sem cesárea anterior) a probabilidade de cesárea esteve aumentada na presença dos seguintes fatores: A - uso de medicação cardiovascular; CC - CF III/IV e intercorrências obstétricas; CA -intercorrências obstétricas e idade gestacional no parto inferior a 37 semanas. A ocorrência de complicações obstétricas foi 6,8% (total), sendo maior em A (18,6%) e nos partos vaginais (10,7%); complicações clínicas maiores ocorreram em 2,5% dos casos e foram mais freqüentes nos casos de cesárea (3,8%). Conclusão: As taxas de cesárea observadas em gestante com cardiopatia foram elevadas (em especial nos casos de cardiopatia congênita) e correlacionadas à presença de cesárea anterior, insuficiência cardíaca CF III/IV, uso de medicamentos de ação cardiovascular, presença de intercorrências obstétricas e idade gestacional no parto inferior a 37 semanas. / This study reviewed the data of 571 pregnancies in 556 pregnant women with heart disease admitted for delivery in a tertiary university hospital between 2001 and 2005. The objectives were to assess the prevalence of cesarean sections and vaginal births among the whole group of cases and in three subgroups: patients with arrhythmias (A - 57 cases / 10%), congenital diseases (CD - 163 cases / 28,6%) and acquired diseases (AD - 351 cases / 61,4%), and to determine the clinical and obstetrical factors related to the mode of delivery in the whole population and in the subgroups, as well as the association between the mode of delivery and clinical and obstetrical complications. The frequencies of cesarean sections were: 57,2% (whole population), 45,6% (A), 64,2% (CD) and 55,7% (AD); the cesarean sections were performed due to obstetrical reasons in 77% of the cases. In the 425 cases with no previous cesarean sections, the frequencies of c-sections deliveries were 47,1% (whole group), 37,8% (A), 57,8% (CD) and 43,3% (AD). The factors related to a higher probability of cesarean section were: previous cesarean section, gestational age at delivery of less than 37 weeks, presence of obstetrical events, diagnosis of congenital heart disease, heart failure (NYHA functional class III/IV) and use of cardiovascular drugs. The parity above 1 was related to a lesser probability of csections, and previous cesarean was the main factor related to the risk of abdominal delivery. In the cases with no previous cesarean sections, according to the subgroups of heart disease, the probability of cesarean section was heightened in the presence of the following factors: group A: use of cardiovascular drugs, CD: functional class III/IV and obstetrical events and AD: obstetrical events and gestational age in delivery less than 37 weeks. The rate of obstetrical complications was 6,8%, most of them in group A and in vaginal birth. Major clinical complications occurred in 2,5% of the cases, and were more related to cesarean sections (3,8%). Conclusion: the rates of cesarean sections observed in pregnant women with heart disease were high (mainly in the CD group), and related to previous cesarean sections, heart failure, use of cardiovascular drugs, presence of obstetrical events and gestational age at delivery less than 37 weeks.

Os objetivos deste estudo foram: avaliar as freqüências de partos vaginais e cesáreas em mulheres portadoras de cardiopatias, bem como a distribuição dos partos nos diferentes subgrupos de doenças cardíacas: arritmias (A), cardiopatias congênitas (CC) e cardiopatias adquiridas (CA); analisar os fatores clínicos e obstétricos que estiveram relacionados à determinação da via de parto no grupo total de cardiopatas e também nos subgrupos, e avaliar a associação entre o tipo de parto e complicações clínicas e obstétricas. Foram analisados retrospectivamente os dados referentes a 571 gestações de 556 mulheres internadas para parto na Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 2001 e 2005. A composição dos grupos foi: A - 57 casos (10%), CC - 163 casos (28,6%) e CA - 351 casos (61,4%). A taxas de cesárea foram 57,2% (total), 45,6% (A), 64,2% (CC) e 55,7% (CA). A indicação da cesárea foi obstétrica em 77% dos casos. Analisando os 425 casos sem cesáreas anteriores, as taxas de cesárea foram: 47,1% (total), 37,8% (A), 57,8% (CC) e 43,3% (CA). A probabilidade de parto cesáreo esteve relacionada à presença de cesárea anterior, idade gestacional no parto inferior a 37 semanas, presença de intercorrências obstétricas, diagnóstico de cardiopatia congênita, insuficiência cardíaca classe funcional (CF) III ou IV, e uso de medicamentos de ação cardiovascular. A paridade maior ou igual a um diminuiu a probabilidade de cesárea. A presença de cesárea anterior foi o principal fator relacionado à probabilidade de parto cesáreo nesta população. Nos subgrupos de cardiopatia (sem cesárea anterior) a probabilidade de cesárea esteve aumentada na presença dos seguintes fatores: A - uso de medicação cardiovascular; CC - CF III/IV e intercorrências obstétricas; CA -intercorrências obstétricas e idade gestacional no parto inferior a 37 semanas. A ocorrência de complicações obstétricas foi 6,8% (total), sendo maior em A (18,6%) e nos partos vaginais (10,7%); complicações clínicas maiores ocorreram em 2,5% dos casos e foram mais freqüentes nos casos de cesárea (3,8%). Conclusão: As taxas de cesárea observadas em gestante com cardiopatia foram elevadas (em especial nos casos de cardiopatia congênita) e correlacionadas à presença de cesárea anterior, insuficiência cardíaca CF III/IV, uso de medicamentos de ação cardiovascular, presença de intercorrências obstétricas e idade gestacional no parto inferior a 37 semanas. / This study reviewed the data of 571 pregnancies in 556 pregnant women with heart disease admitted for delivery in a tertiary university hospital between 2001 and 2005. The objectives were to assess the prevalence of cesarean sections and vaginal births among the whole group of cases and in three subgroups: patients with arrhythmias (A - 57 cases / 10%), congenital diseases (CD - 163 cases / 28,6%) and acquired diseases (AD - 351 cases / 61,4%), and to determine the clinical and obstetrical factors related to the mode of delivery in the whole population and in the subgroups, as well as the association between the mode of delivery and clinical and obstetrical complications. The frequencies of cesarean sections were: 57,2% (whole population), 45,6% (A), 64,2% (CD) and 55,7% (AD); the cesarean sections were performed due to obstetrical reasons in 77% of the cases. In the 425 cases with no previous cesarean sections, the frequencies of c-sections deliveries were 47,1% (whole group), 37,8% (A), 57,8% (CD) and 43,3% (AD). The factors related to a higher probability of cesarean section were: previous cesarean section, gestational age at delivery of less than 37 weeks, presence of obstetrical events, diagnosis of congenital heart disease, heart failure (NYHA functional class III/IV) and use of cardiovascular drugs. The parity above 1 was related to a lesser probability of csections, and previous cesarean was the main factor related to the risk of abdominal delivery. In the cases with no previous cesarean sections, according to the subgroups of heart disease, the probability of cesarean section was heightened in the presence of the following factors: group A: use of cardiovascular drugs, CD: functional class III/IV and obstetrical events and AD: obstetrical events and gestational age in delivery less than 37 weeks. The rate of obstetrical complications was 6,8%, most of them in group A and in vaginal birth. Major clinical complications occurred in 2,5% of the cases, and were more related to cesarean sections (3,8%). Conclusion: the rates of cesarean sections observed in pregnant women with heart disease were high (mainly in the CD group), and related to previous cesarean sections, heart failure, use of cardiovascular drugs, presence of obstetrical events and gestational age at delivery less than 37 weeks.

Thesis (MCurr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: The availability and provision of good antenatal care services ensure early detection and prompt management of any complication or disease that may adversely affect pregnancy outcome. To ensure high quality care, an ongoing health education and empowerment of pregnant women with pregnancy related information, need to be provided by midwives throughout pregnancy. The purpose of this study, therefore, was to explore the pregnant women`s experiences and perceptions regarding health education given during the antenatal period. The objectives set were to - explore the content of the health education given to pregnant women by midwives during the antenatal period - determine whether the health education offered by midwives is understood by pregnant women - determine whether information regarding Health Education during antenatal period is applicable and is used by pregnant women. A qualitative approach with an explorative descriptive design was applied for the purpose of this study. The population included pregnant women who attended an antenatal clinic for the second time in 2012. Ten pregnant women were selected purposively who consented to participate in the study. The trustworthiness of this study was assured by using Lincoln and Guba`s criteria of credibility, transferability, dependability and confirmability. A pretest was done with one participant not included in the actual study. Ethics approval was obtained from the Ethics Committee of the Faculty of Medicine and Health Sciences at Stellenbosch University, reference: S12/05/136. Informed written consent was obtained from each participant which included a recording of the interview. Data was collected through semi-structured interviews using an interview guide and a tape recorder. The researcher approached two women per day for five days. A total of ten (10) pregnant women were interviewed until data saturation reached. The use of Tesch's eight steps of data analysis was used to analyse the transcribed data as described in De Vos et al. (2004:331). Findings revealed that health education was given to pregnant women at the institution under study but with minimum explanations. The midwives were perceived as supportive and regarded as a source of information and self-care agents. Antenatal attendance was regarded as important by participants. Participants indicated that their unborn babies were monitored by the midwives in order to detect abnormalities early. However, midwives emphasised non-pregnancy related complications specifically HIV/AIDS and neglected to give basic antenatal care, such as antenatal exercises, personal hygiene and diet. Language was found to be a barrier and contributed to a lack of information. Recommendations include basic antenatal aspects to be covered in the health education, such as emphasis on personal hygiene, exercises, diet and avoidance of harmful sociocultural practices. With the implementation of appropriate teaching principles language, age and involvement of influential people during health education should be considered. In conclusion, to reduce maternal morbidity and mortality rates and promoting self-care reliance, antenatal care services should be accessible to facilitate ongoing health education by midwives throughout pregnancy. / AFRIKAANSE OPSOMMING: Die beskikbaarheid en voorsiening van goeie voorgeboortesorgdienste verseker die vroeë en vinnige bestuur van enige komplikasie of siekte wat swangerskap-uitkomste nadelig mag beïnvloed. Om hoë gehalte sorg te verseker, moet gesondheidsvoorligting en bemagtiging van swangervroue rakende swangerskap inligting deurlopend deur vroedvroue verskaf word. Die doel van hierdie studie was om vervolgens die swangervrou se ervaringe en persepsies ten opsigte van gesondheidsopvoeding gedurende die voorgeboortelike stadium te ondersoek. .Die doelwitte soos gestel was om: - die inhoud van die gesondheidsvoorligting wat deur vroedvroue gedurende die voorgeboorte periode aan swangervroue verskaf word, te ondersoek - te bepaal of die gesondheidsvoorligting wat verskaf word deur vroedvroue deur swangervroue verstaan word - vas te stel of die ligting aan swangervroue gepas is en te bepaal of dit toegepas word deur swangervroue. ’n Kwalitatiewe benadering met ’n beskrywende ontwerp is vir die doel van hierdie studie toegepas. Die populasie het swangervroue ingesluit wat ’n voorgeboortekliniek vir die tweede keer gedurende 2012 besoek het. Tien vrouens is doelgerig geselekteer wat daartoe ingestem het om aan die navorsing deel te neem. Die betroubaarheid van hierdie studie was verseker deur van Lincoln en Guba se kriteria van geloofwaardigheid, oordraagbaarheid, betroubaarheid en bevestigbaarheid gebruik te maak. ’n Loodsondersoek was met een deelnemer wat nie in die werklike studie ingesluit was nie, gedoen. Etiese goedkeuring is verkry van die Etiese Komitee van die Fakulteit van Geneeskunde en Gesondheidswetenskappe aan die Universiteit van Stellenbosch, verwysing: S12/05/136. Ingeligte skriftelike toestemming is verkry van elke deelnemer wat ook ’n opname van die onderhoud ingesluit het. Data is ingesamel deur van semi-gestruktureerde onderhoude gebruik te maak met behulp van ’n onderhoudsgids en ’n bandopnemer. Die gebruik van Tesch se ag stappe van data-analise is gebruik om die getranskribeerde data te analiseer (De Vos et al., 2004:331). Bevindinge het getoon dat gesondheidsvoorligting wel aan swangervroue by die inrigting onder die soeklig met die minimum verduidelikings verskaf is. Die vroedvroue is as ondersteunend en as ’n bron van inligting, asook as selfsorgagente waargeneem. Voorgeboorte bywoning is as belangrik deur deelnemers gesien. Deelnemers het aangedui dat hulle ongebore babas gemonitor is deur vroedvroue om abnormaliteite vroeg op te spoor. Nietemin, vroedvroue het nie-verwante swangerskap komplikasies, spesifiek MIV/VIGS beklemtoon en het nagelaat om aandag te gee aan basiese voorgeboortesorg soos voorgeboorte oefeninge, persoonlike higiëne en dieet. Daar is bevind dat taal ’n hindernis is en dat dit bygedra het tot ’n gebrek aan inligting. Aanbevelings sluit in basiese voorgeboorte aspekte wat gedek moet word in gesondheidsvoorligting, soos die beklemtoning van persoonlike higiëne, oefeninge, dieet en die vermyding van nadelige sosio-kulturele praktyke. Met die implimentering van doeltreffende onderrigbeginsels moet taal, ouderdom en die betrokkenheid van invloedryke mense gedurende gesondheidsvoorligting in ag geneem word. Ten slotte, om moeder-morbiditeit en-mortaliteitsyfers te verminder en selfsorgvertroue te bevorder, behoort voorgeboortesorgdienste toeganklik te wees, sodat vroedvroue volgehoue gesondheidsvoorligting tydens swangerskap kan fasiliteer.

O objetivo do estudo foi avaliar os aspectos clínicos epidemiológicos, as principais complicações maternas e os resultados perinatais nas gestações gemelares. Foi realizado estudo retrospectivo com análise de gestações gemelares, com idade gestacional maior que 20 semanas e parto no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de janeiro de 2003 a dezembro de 2006. Das 303 gestações gemelares, 289 apresentavam dados completos. A incidência de gestação gemelar foi de 3,3% e 96,2% naturalmente concebidas. Em relação à corionicidade, 60,5% eram dicoriônicas (DC), 30,8% monocoriônicas diamnióticas (MCDA), 6,6% monocoriônicas monoamnióticas (MCMA) e em 2,1% dos casos a corionicidade não foi determinada. A idade materna média foi de 29,1 anos e 39,4% eram nulíparas. Cerca de 30% das pacientes apresentavam patologia clínica prévia e as mais prevalentes foram: hipertensão arterial crônica (12,5%), cardiopatias (4,8%) e pneumopatias (4,5%). Complicações gestacionais foram observadas em 85,1% dos casos, sendo as principais: parto prematuro (65,7%), doença hipertensiva específica da gestação (15,6%) e rotura prematura de membranas (13,5%). Ocorreram 395 internações e tempo médio de internação de 6,1 dias. Dessas, 45,8% foram para resolução da gestação por trabalho de parto ou por indicação materno-fetal. A idade gestacional média no parto foi de 34,6 semanas, significativamente menor nas gestações monocoriônicas (MC) do que nas DC (33,5 versus 35,4 semanas, p< 0,001). A via de parto mais freqüente foi à cesárea (84,8%). Dos 578 produtos conceptuais, três eram acárdicos (0,5%), 35 natimortos (6,0%) e 540 nativivos (93,5%). A proporção de óbitos durante a internação no berçário foi de 11,5%, sendo 2,8 vezes maior nas gestações MC em relação às DC. As complicações neonatais mais freqüentes foram: prematuridade (65,7%), baixo peso ao nascer (71,8), restrição do crescimento fetal (18,7%) e as malformações (13,6%). Todos esses parâmetros apresentaram resultado significativamente piores para os recém-nascidos das gestações MC em relação às DC. No presente estudo, concluiu-se que, as gestações gemelares apresentam elevada incidência de complicações maternas, principalmente relacionadas ao parto prematuro, hipertensão arterial sistêmica e rotura prematura de membranas. O resultado perinatal adverso esteve relacionado à prematuridade, malformações e às complicações inerentes à monocorionicidade. A taxa de sobrevida nas gestações gemelares DC e MC sem malformações ou síndrome da transfusão feto-fetal é semelhante / The aims of this retrospective study were to describe clinical and epidemiological aspects of twin pregnancies delivered between January 2003 and December 2006 at the Hospital das Clínicas, São Paulo University Medical School. Maternal complications and perinatal outcome were also studied. Amongst 303 twin pregnancies delivered at a gestational age of more than 20 weeks, 289 cases had completed medical records. The incidence of twin deliveries was 3.3% and 96.2% were naturally conceived. 60.5% were dichorionic (DC), 30.8% monochorionic diamniotic (MCDA), 6.6% monochorionic monoamniotic (MCMA) and in 2.1% of cases, chorionicity was unknown. Mean maternal age was 29.1 years and 39.4% were nulliparous. About 30% of women had a prior clinical history and the most frequent conditions were: chronic hypertension (12.5%), cardiac disease (4.8%) and respiratory complications (4.5%). Pregnancy complications were observed in 85.1% of the cases, and the most common were preterm delivery (65.7%), pregnancy induced hypertension (15.6%) and premature rupture of membranes (13.5%). In this group, there were 395 hospital admissions (1.4 admissions per patient) and the average length of stay was 6.1 days (range 1 to 65 days). Of these, 45.8% were for pregnancy resolution due to labor or maternal-fetal complications. Mean gestational age at delivery was 34.6 weeks, being significantly lower in monochorionic compared to dichorionic twins (33.5 versus 35.4 weeks, p<0001). Cesarean section was the most common route of delivery (84.8%). Amongst the 578 fetuses/newborns, three were acardiac (0.5%), 35 were stillbirths (6.0%) and 540 were born alive (93.5%). Neonatal death occurred in 11.5%, and was 2.8 times higher in MC pregnancies compared to DC. The most common perinatal complications were preterm birth (65.7%), low birth weight (71.8%), fetal growth restriction (18.7%) and fetal malformations (13.6%). All these complications were significantly worse in MC compared to DC pregnancies. Twin pregnancies show high rates of maternal and perinatal complications, such as preterm birth, hypertension, premature rupture of membranes, fetal birth defects and complications inherent to monochorionicity