Background and objectives There has been a steady annual increase in the number of deliveries performed at Chris Hani Baragwanath Hospital in recent years. A 2004 audit found that approximately one third of deliveries conducted at the hospital were of women who had referred themselves and were low risk and as such did not require delivery at a specialist centre. A triage down-referral system back to midwife obstetric units was implemented in 2008 to address the problem of low-risk self-referrals at the hospital. This study was conducted after the establishment of the triage system to find out whether the establishment of the triage system had been accompanied by a decrease in the proportion of self-referred women presenting to Chris Hani Baragwanath Hospital in labour, and to assess delivery outcomes in these patients. Literature review The literature review was conducted using Pubmed and MDConsult using the key words self referral, triage, gatekeeper, low-risk pregnancy, maternity / labour and referral systems. Relevant references were accessed via the University of the Witwatersrand eJournal portal. Appropriate articles cited by other authors were also reviewed. Appropriate websites were also used and referenced. Methods This was a retrospective descriptive study which included all women presenting in labour to the hospital maternity admissions area. The study population was clinical case-files of all births that were admitted in labour from 1 May to 31 May 2010. A simple random sample of these files was drawn. Results One hundred and eighty two intra-partum admissions were sampled. Thirty-five (19%) of these women were self-referred. Seven out of the 35 (20%) required caesarean sections. Five more (14%) needed oxytocin augmentation of labour, and one more (3%) had a vacuum delivery. Twenty women (57%) did not develop any complications during labour and could have been delivered at their midwife obstetrics units. During the month of the study, the triage down-referral system attended to 171 women and down-referred 83 (49%). Conclusion The establishment of a triage down- referral system has been accompanied by a curtailment in the number of low-risk pregnancies presenting self-referred at the referral hospital labour ward, compared with the audit in 2004.

Advanced maternal age (AMA) is linked to several adverse pregnancy outcomes, hence these pregnancies are considered to be "high risk." Risk perception impacts pregnant women’s health care use, health behaviors, and adherence to medical recommendations. Yet, a gap remains in the understanding of perception of pregnancy risk and its contributing factors. This mixed methods research study was developed to address this gap, using a conceptual framework based on a literature review and the Psychometric Model of risk perception. The specific objectives of this study were to compare risk perception in nulliparous women of AMA with younger women, determine the factors influencing perception of pregnancy risk, and gain an understanding of women’s perspectives of risks associated with AMA. Between December 2009 and January 2011, a sample of 159 participants (105 women aged 20-29 years and 54 women aged 35 years or older) was recruited from a variety of settings in Winnipeg, Manitoba. Several questionnaires were completed by participants. Descriptive statistics, chi square, t tests, Pearson's r correlations, and stepwise multivariate linear regressions were used to analyze data. Fifteen women of AMA were chosen purposefully to participate in individual and semi-structured interviews. Interviews were audio-taped and transcribed verbatim, and content analysis was used to identify themes. Results revealed that pregnancy-related anxiety, maternal age, medical risk, perceived control (internal), and gestational age were significant predictors of perception of pregnancy risk accounting for 47-49% of the variance in risk perception. Maternal age interacted in a synergistic manner with pregnancy-related anxiety to increase perception of pregnancy risk levels. In the qualitative component, four main themes emerged from the data: definition of pregnancy risk, factors influencing risk perception, risk alleviation strategies, and risk communication with health professionals. Women of AMA perceived higher pregnancy risk for both themselves and their fetuses than younger women. However, they were not a homogenous group in their pregnancy risk appraisal. This study contributed to the field by proposing pregnancy-related anxiety as a pregnancy dread factor in risk perception theories. Risk communication is an important element of developing care plans for women of AMA and should be integrated into prenatal care visits.

Advanced maternal age (AMA) is linked to several adverse pregnancy outcomes, hence these pregnancies are considered to be "high risk." Risk perception impacts pregnant women’s health care use, health behaviors, and adherence to medical recommendations. Yet, a gap remains in the understanding of perception of pregnancy risk and its contributing factors. This mixed methods research study was developed to address this gap, using a conceptual framework based on a literature review and the Psychometric Model of risk perception. The specific objectives of this study were to compare risk perception in nulliparous women of AMA with younger women, determine the factors influencing perception of pregnancy risk, and gain an understanding of women’s perspectives of risks associated with AMA. Between December 2009 and January 2011, a sample of 159 participants (105 women aged 20-29 years and 54 women aged 35 years or older) was recruited from a variety of settings in Winnipeg, Manitoba. Several questionnaires were completed by participants. Descriptive statistics, chi square, t tests, Pearson's r correlations, and stepwise multivariate linear regressions were used to analyze data. Fifteen women of AMA were chosen purposefully to participate in individual and semi-structured interviews. Interviews were audio-taped and transcribed verbatim, and content analysis was used to identify themes. Results revealed that pregnancy-related anxiety, maternal age, medical risk, perceived control (internal), and gestational age were significant predictors of perception of pregnancy risk accounting for 47-49% of the variance in risk perception. Maternal age interacted in a synergistic manner with pregnancy-related anxiety to increase perception of pregnancy risk levels. In the qualitative component, four main themes emerged from the data: definition of pregnancy risk, factors influencing risk perception, risk alleviation strategies, and risk communication with health professionals. Women of AMA perceived higher pregnancy risk for both themselves and their fetuses than younger women. However, they were not a homogenous group in their pregnancy risk appraisal. This study contributed to the field by proposing pregnancy-related anxiety as a pregnancy dread factor in risk perception theories. Risk communication is an important element of developing care plans for women of AMA and should be integrated into prenatal care visits.

Background: Pregnancy associated cardiovascular pathologies have a significant impact on outcome for mother and child. Bioimpedance cardiography may provide additional outcome-relevant information early in pregnancy and may also be used as a predictive instrument for pregnancy-associated diseases. Methods: We performed a prospective longitudinal cohort trial in an outpatient setting and included 242 pregnant women. Cardiac output and concomitant hemodynamic data were recorded from 11th-13th week of gestation every 5th week as well as at two occasions post partum employing bioimpedance cardiography. Results: Cardiac output increased during pregnancy and peaked early in the third trimester. A higher heart rate and a decreased systemic vascular resistance were accountable for the observed changes. Women who had a pregnancy-associated disease during a previous pregnancy or developed hypertension or preeclampsia had a significantly increased cardiac output early in pregnancy. Furthermore, an effect of cardiac output on birthweight was found in healthy pregnancies and could be confirmed with multiple linear regression analysis. Conclusions: Cardiovascular adaptation during pregnancy is characterized by distinct pattern described herein. These may be altered in women at risk for preeclampsia or reduced birthweigth. The assessment of cardiac parameters by bioimpedance cardiography could be performed at low costs without additional risks.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23384号 / 社医博第117号 / 新制||社医||11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 佐藤 俊哉, 教授 滝田 順子, 教授 万代 昌紀 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Magister Artium (Psychology) - MA(Psych) / The presence of a supportive and attentive father has been shown to hold a myriad of positive health outcomes for a pregnancy, and benefits the wellbeing of the mother, child, and the father himself. Pregnancy is a key period for fathers to become invested in their children’s lives. However, obstetric research continues to be largely feminised, therefore neglects the experiences of men. Considering that existing research shows that the antenatal period is a turbulent time for men, the aim of this research was to explore fathers’ subjective lived experiences of their partner’s medically high-risk pregnancy.

Os trabalhos que visam estudar as relações entre a saúde materna e a saúde perinatal são de um modo geral parciais e também restritos à mortalidade perinatal. Visando conhecer melhor esta relação, o presente estudo se propôs a acompanhar 160 mulheres no ciclo gravídico-puerperal desde o parto até a criança completar 7 dias de vida. As principais variáveis foram idade materna, paridade, idade gestacional, estado nutricional e morbidade materna, peso ao nascer do recém-nascido, morbimortalidade do concepto, assistência pré-natal, trabalho de parto e parto. Após a análise dos dados pôde-se observar que a população estudada apresentou uma mortalidade perinatal de 67,9 por cento nascimentos, taxa bastante elevada, sugerindo, no caso, um alto risco de mortes no período. Em relação ao baixo peso ao nascer este foi de aproximadamente 11 por cento . Quanto à assistência pré-natal, 13,3 por cento das gestantes não fizeram este controle, tendo as crianças destas mulheres apresentado uma maior incidência de prematuridade, baixo peso ao nascer e mortes no período perinatal (eventos negativos) do que as que o controlaram. Das gestantes estudadas, 15,33 por cento tinham idade de 19 anos e menos e 10,22 por cento 35 anos e mais. As mulheres com 35 anos e mais apresentaram maior número de patologias durante a gestação; a paridade também foi elevada e suas crianças apresentaram mais eventos negativos que as demais. Além da alta mortalidade perinatal a morbidade neste período também foi elevada, uma vez que cerca de 73 por cento das crianças que sobreviveram apresentaram problemas na 1ª semana de vida, sendo que nestas 90 por cento dos problemas apareceram ainda durante a permanência do recém-nascido no hospital e nas 10 por cento restantes o problema surgiu no domicílio. As condições sócio-econômicas desta população mostraram uma importante variável de risco de morbimortalidade perinatal bem como de morbidade materna, pois observou-se uma estreita relação entre o status sócio-econômico e os problemas de saúde apresentados por esta população. O peso ao nascer do concepto também se associou a variáveis tanto orgânicas como sócio-econômicas, podendo ser indicado como um elemento importante no estudo do risco de saúde do recém-nascido. Finalmente a assistência ao trabalho de parto como ao parto se apresentou como sendo um determinante de traumatismo de nascimento que se somou às demais variáveis de risco, expondo o recém-nascido a um risco ainda mais elevado de morbimortalidade perinatal. / Researches which have studied the relationships between maternal and perinatal health are, as a rule, incomplete and restricted to questions of perinatal mortality. This present study sought to follow the pregnancy-infancy cycle of 160 women through from the delivery to the end of the first week of life. The principal variables studied were maternal age, parity, gestational age, maternal nutritional state and morbidity, birthweight, morbidity and mortality of the child, antenatal care, labour and delivery. After an analysis of the data it was discovered that the population studied presented the very high perinatal mortality rate of 61.9 per thousand births, which suggests a high level of risk in this period for this population. As for low birth-weigh, this was of the order of approximately 11 per cent . 13.3 per cent of the pregnant women did not receive antenatal care and their children presented a higher incidence of prematurity, low birth-weight and deaths in the perinatal period (negative events) than those who had received such care. Of the pregnant women studied 15.33 per cent were of 19 years of age or less and 10.22 per cent were of 35 or more. Those women of 35 or more presented a greater number of diseases during pregnancy, parity also was higher and their children presented more negative events than those born to the lower age groups. Beyond the high perinatal mortality the morbidity in this period was also high as 73 per cent of the surviving children presented problems in their first week of life, 90 per cent of these appearing while the child was still in hospital, the remaining 10 per cent arising later in the home. The socio-economic conditions of the population were seen to be an important variable for risk of perinatal morbidity and mortality, as also of maternal morbidity, because a close relationship between social strata and the health problems presented by this population was observed. The birthweight of the child (still or live-born) was also associated with both organic and socio-economic variables and was thus shown to be an important element in the study of the health-risks to the new-born. Finally, assistance during labour and at delivery was shown to be determinative of the incidence of traumatism at the birth which, added to the other high-risk variables, lead to the attribution of an even higher risk of perinatal morbidity and mortality to the new-born.

A gestação pode ser considerada, dentro das etapas de desenvolvimento, para o homem, mas principalmente para a mulher, como um dos momentos de crise dentro desse processo contínuo e dinâmico. É um momento transitório existencial que envolve necessidade de reestruturações e reajustamentos em várias dimensões, verificando-se necessidade de mudança de identidade e redefinição de papéis. Nesse período, existem alguns estados emocionais que são peculiares, com uma variedade de mudanças e nuances cuja etiologia ainda é bastante discutida, pois envolvem complexas inter-relações entre fatores hormonais e psicológicos. Encontra-se na literatura estreita vinculação entre intercorrências clínico-obstétricas e estados emocionais específicos, o que nos levou, neste trabalho, à investigar o porquê de algumas mulheres desenvolverem o quadro hipertensivo durante a gravidez e outras não. Haveria alguma coisa em seu perfil psicológico que as diferenciasse das grávidas normais? A gravidez acompanhada de hipertensão é uma das principais causas de morte materna em todo o mundo e por constituir-se numa gravidez de alto risco, todas as características peculiares a uma gravidez normal mostram-se exacerbadas. Dentro desse contexto, ainda existe o agravante do risco real de morte para a gestante e/ou o bebê e muitas vezes, a mulher responsabiliza-se por tal situação. Considerando-se todos estes aspectos, investigou-se neste trabalho o contexto social das gestantes, ou seja, sua estrutura familiar, condição sócio-econômica, relação com pai da criança, se houve ou não planejamento da gravidez e o perfil psicológico das gestantes hipertensas, comparando-as com as mulheres com gestação normal. Participaram deste estudo 20 gestantes primíparas, com idade gestacional a partir de 10 semanas, divididas em 2 grupos: 10 gestantes normais (grupo A) e 10 hipertensas (grupo B), sendo 5 hipertensas crônicas (B1) e 5 portadoras da Doença Hipertensiva Específica da Gravidez (DHEG)- B2. Utilizou-se um roteiro de entrevista semi-estruturado, o Desenho da Figura Humana (DFH), o DFH com tema e o Psicodiagnóstico de Rorschach. Todas as gestantes foram atendidas nos Ambulatórios de Gestação de Alto Risco (AGAR) e de Ginecologia e Obstetrícia do HC-FMRP/USP. A análise dos dados foi quantitativa e qualitativa e posteriormente, foi feita uma validação cruzada dos índices significativos das técnicas projetivas. Quanto ao tratamento dos dados: as entrevistas foram transcritas e elaboradas categorias de respostas; os protocolos dos desenhos analisados por 2 juízes e os protocolos do Rorschach codificados dentro da nomenclatura francesa, seguindo normas regionais. A análise das entrevistas demonstra que há características comuns aos dois grupos, relacionados ao fato da gravidez não ter sido planejada porém desejada e à não utilização, por parte da maioria, de métodos contraceptivos. Entretanto, observou-se diferenças entre os grupos em relação à: estabilidade na relação com o companheiro - no grupo A predominaram relações estáveis enquanto que no grupo B predominaram as relações instáveis; reação do companheiro e familiares em relação à gravidez - predominaram reações positivas no grupo A e negativas no grupo B; sentimentos da grávida em relação ao seu filho as mães do grupo A referem sentimentos positivos, enquanto que no grupo B, os sentimentos são mais negativos; e aos medos as gestantes do grupo A relatam medos referentes ao parto, enquanto que as do grupo B, referem-se à possibilidade de perda fetal. Em relação às técnicas projetivas, foi possível observar os seguintes resultados: há nos três grupos uma característica de coartação, ou seja, a existência de recursos adaptativos internos que, no momento, apresentam-se recolhidos, frente à forte tentativa de manter o controle racional sobre as vivências afetivas. Esse recolhimento pode ser decorrente da inabilidade em lidar com os seus afetos de forma mais equilibrada e satisfatória. Frente ao temor de perder o controle sobre esses impulsos, que se mostram neste momento em intensidade elevada, recorrem ao fechamento como forma de autoproteção. Todas as gestantes (grupo A e B) apresentaram uma forma mais introversiva na vivência de seus afetos, o que denota tendência em utilizar os recursos de forma mais voltada à reflexão. No grupo das gestantes normais, este esforço mostra-se eficiente na utilização de seus recursos, entretanto, apresentaram sentimentos de insegurança, egocentrismo, angústia e comportamentos regressivos, sentimentos esses esperados e considerados normais durante o período da gravidez. O grupo B1 (HAC), apresentou apego minucioso da realidade, ou seja, o ambiente é visto e vivenciado através de um estreitamento perceptivo, dificultando a comunicação com a realidade, num esforço de abarcá-la através da minuciosidade, gerando sentimentos de insatisfação pessoal e elevando os níveis de ansiedade. O grupo B2 (DHEG), apresenta uma tendência à ampliação do campo de atuação, tentando controlar a situação de forma ampla, deixando-as sobrecarregadas. Frente à imensidão de seus afetos, mostra-se insuficiente no controle dos mesmos, gerando sentimentos de insatisfação interna e conseqüente elevação dos níveis de ansiedade. Portanto, podemos afirmar que os perfis de personalidade apresentados no grupo de hipertensas, aliados aos aspectos sociais, sugerem diferenças importantes que podem estar atuando no desenvolvimento do quadro hipertensivo na gravidez. Seria adequado que, no atendimento prestado a essas gestantes, houvesse uma diferenciação na forma de abordagem de cada grupo atendido, respeitando-se as respectivas qualidades e as dificuldades, com o objetivo de favorecer a adesão ao tratamento e manter os quadros estabilizados, aproximando-os o mais que possível da gestação normal. / The pregnancy is one of the most critical stages of the human development not only for women but also men. Thats a transient moment of the existency that requires a personal adjustments in various aspects of life. This, showing the necessity of a change of identity as well as reevaluation of roles. During pregnancy, there are peculiar emocional status and a variety of changes which at the etiology is still very debated due to the fact those changes envolve complexes such as hormonal and psychological factors. Previous works, have shown a very tight relation between clinical and obstetric occurrences and specific emocional status. This lead us, in this work, to investigate why some women had presented hypertension during their pregnancy while others did not. A question can be raised, is there anything in their psychological profile making them different from the normal pregnancy? The hypertension during pregnancy is one of the major causes of maternal mortality worldwide, besides the fact of being considered a highers risk pregnancy showing an exacerbation of all features of a normal pregnancy. In this context, there is still another agravating factor, the real risk of death of both mother and baby (son). This, sometimes evokes a guilty feeling by the mother. Taking all the aspects decribed so far into account, we have tried in this work to investigate the social context of the mother (pregnant women), such as family structure, social-economic status , relationship with the babies fathers, if the pregnancy was planned or not, as well as the psychological profile of normal and hypertensive pregnant women. Took part in this study 20 primiparous women with at least 10 weeks of pregnancy or olders divided into two groups. Group A, 10 normal women and 10 hypertense (group B). In the group B, 5 women were cronic hypertense (B1) while the remainder were Gestational Hypertension, group B2. A semi-structured interview, Draw a Person Test, and Rorschach Test were applied. All women were followed, in the clinic of higher risk preganncy (AGAR) in the department of ginecology and obstetrics of the HC-FMRP/USP (General Hospital). The data analysis was quanlitative and quantitative including a cross-validation of the signification index of projective techniques. Also, regarding, the data of all interviews were transcribed and categorized, drawing protocols are analyzed by two judges and the Rorschachs protocols were encoded following the French nomenclature and local rules. These analyses showed that are common aspects in the two groups, like the fact of unexpected but accepted pregnancy as well as the neglected use of contraceptive methods in the majority of the pregnancies. However, we observed diferences between the groups when the rob stability of the relationship is concerned. In the group A, the majority of the relationship could be considered stable, while the opposite was observed in the group B. Also, in the group A positive reaction to the pregnancy was dominant for both father and family. Once again, the opposite was observed in B. Regarding mothers feeling, in group A, again, positive feeling are dominant while negative ones are shown by the majority of B. Group A shows fear mostly robted to the birth, while in B, a fear of fetus death is clear. Regarding projective techniques, it was possible to observe the following: all groups have shown the existence of self-adaptative resources, hidden at the moment due to the necessity of keeping a rational control over the affective experiences. This ca be an effect of inability of managing affectiveness in a balanced way. Other fact that contributes for that is the fear of loosing control of these feeling now much stronger, leading to an introspection as self-protection. This introspection was observed in all women regarding their affective feelings, denotating a resource towards reflection. The women in group A this effort had shown efficient when using the resources, however, they showed insecurity egocentrism, anguish, and regressive behaviours. All these feeling are expected and considered normal during pregnancy. In the group B1 shows a meticulous attachment to reality thus, the enviroment is seen and experienced through a perception narrowing. This feeling disturbes the conexion to reality and generate insatisfaction which in terms increase the ansiety. The B2 group shows tendency of widening their acting field what makes them overwhelmed. Also, this group shows an insufficient control of their affectivity what causes insatisfaction and increased anxiety. Thus, we can state that the personality profiles presented in hypertension women as well as the social aspects suggest important differences that play a role in the occurency hypertension during pregnancy. It would be adequate to develop a differencial approach during the following of the pregnancy for these two groups trying qualities and dificulties in order to facilitate adheson to the treatment and maintenance of stabel condition towards a more normal pregnancy.

A gestação de alto risco apresenta maior probabilidade de evolução desfavorável e está relacionada a fatores socioeconômicos, demográficos e de ordem médica. A crescente necessidade de medicamentos por gestantes de alto risco e o potencial teratogênico destes tornam os estudos epidemiológicos indispensáveis para fornecer dados para subisidiar medidas que garantam o uso racional desses medicamentos, prevenindo efeitos indesejáveis. Este estudo pretende descrever o perfil farmacoepidemiológico das gestantes de alto risco no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP) e correlacionar a utilização dos medicamentos com suas características socioeconômicas, demográficas e clínicas. Uma amostra de 386 gestantes foi entrevistada entre maio de 2014 e outubro de 2015. Dados socioeconômicos e demográficos; de acesso a serviços de saúde; sobre a gravidez; hábitos relacionados à saúde e informações sobre medicamentos e correlatos foram coletados. A idade média foi 28,7 anos (DP 6,2) e a mediana da renda per capita foi R$ 600,00 (IQ 550,00). A maioria das mulheres era branca (47,7%), possuía mais de nove anos de estudo (69,7%), não exercia atividade remunerada (54,7%), era casada ou morava com companheiro (76,9%), não possuía plano de saúde privado (87,6%), não planejou a gestação (61,9%), não era primigesta (68,8%), tinha filhos (55,7%), não teve aborto prévio (70,7%), confirmou a gestação (88,6%) e iniciou o pré-natal (86,8%) no primeiro trimestre, não fazia acompanhamento com outro médico além do ginecologista (75,1%) ou com outro professional de saúde (75,6%), recebeu orientações sobre o risco do uso de medicamentos durante a gestação (58%) e não era aderente à farmacoterapia (63%). Os diagnósticos mais prevalentes entre as entrevistadas foram hipertensão arterial (20,5%), diabetes mellitus (19,7%), obesidade (14,8%) e infecção no trato urinário (9,6%). A minoria consumia álcool (6%), fumava (8,8%), tomava café (39,6%), consumia adoçantes (14,2%), utilizava tinturas/produtos químicos capilares (9,6%), plantas medicinais (26%), praticava exercícios físicos (9,3%) e automedicação (12,7%). O consumo de medicamentos foi relatado por 99,7% das entrevistadas, com uma média de 5,1 (DP 2,1) por mulher. Os medicamentos mais utilizados pelas gestantes foram antianêmicos (88,9%), analgésicos (63,2%), antibacterianos de uso sistêmico (26,7%), medicamentos para distúrbios gastrintestinais (20,2%), anti-histamínicos de uso sistêmico (19,7%), anti-hipertensivos (19,4%), medicamentos para desordens relacionadas à acidez (18,1%), antinfecciosos e antissépticos ginecológicos (17,4%) e vitaminas (16,8%). De acordo com as categorias de risco para uso na gestação da Food and Drug Administration (FDA), 2,5% dos medicamentos utilizados são da categoria A, 25% da B, 35% da C, 11,3% da D e 1,2% da X. Segundo a classificação de risco de Briggs; Freeman e Yaffe (2015), a maioria dos medicamentos são classificados nas categorias \"compatível\" (25,6%) e \"dados humanos sugerem baixo risco\" (10,6%). Na categoria \"contraindicado\", encontram-se 10% dos medicamentos. Não foram encontradas evidências de associação entre o número de medicamentos utilizados pelas gestantes e as demais características estudadas. Os dados obtidos neste estudo podem contribuir para o desenvolvimento de estratégias para melhorar o atendimento e o uso racional de medicamentos pelas gestantes de alto risco, aumentando a qualidade de vida desta população / High risk pregnancy is more likely to be unfavorable and is related to socioeconomic, demographic and medical factors. The increasing need for medicines by high-risk pregnant women and its teratogenic potential make epidemiological studies indispensable to provide data to subsidize measures that guarantee the rational use of these drugs, preventing undesirable effects. This study aims to describe the pharmacoepidemiological profile of high-risk pregnant women at the Clinical Hospital of the Faculty of Medicine of Ribeirão Preto of the University of São Paulo (HCFMRP-USP) and to correlate the use of medicines with their socioeconomic, demographic and clinical characteristics. A sample of 386 high-risk pregnant women was interviewed between May 2014 and October 2015. Socioeconomic and demographic data; access to health services data; pregnancy data; health-related habits data and medicines and correlated data were collected. The mean age was 28.7 years (SD 6.2) and the median per capita income was R$ 600.00 (IQ 550.00). The majority of the women were white (47.7%), had more than nine years of study (69.7%), were not emplyed (54.7%), were married or lived with a partner (76.9%), did not have a private health plan (87.6%), did not plan the pregnancy (61.9%), were not primigravida (68.8%), had children (55.7%), had no previous abortion (70.7%), confirmed gestation (88.6%) and started prenatal care (86.8%) in the first trimester, did not follow up with another physician other than the gynecologist (75.1%) or another health professional (75.6%), received guidance on the risk of using medication during pregnancy (58%) and was not adherent to pharmacotherapy (63%). The most prevalent diagnoses among the interviewees were hypertension (20.5%), diabetes mellitus (19.7%), obesity (14.8%) and urinary tract infection (9.6%). The minority consumed alcohol (6%), smoked (8.8%), drank coffee (39.6%), consumed sweeteners (14.2%), used tinctures/chemical hair products (9.6%), medicinal plants (26%), practiced physical exercises (9.3%) and self-medication (12.7%). Consumption of medicines was reported by 99.7% of the interviewees, with an average of 5.1 (SD 2.1) per woman. The medicines most used by pregnant women were antianemics (88.9%), analgesics (63.2%), systemic antibacterials (26.7%), medications for gastrointestinal disorders (20.2%), antihistamines (19.7%), antihypertensives (19.4%), medications for acidity-related disorders (18.1%), gynecological anti-infectives and antiseptics (17.4%) and vitamins (16.8%). According to the Food and Drug Administration (FDA) pregnancy risk categories, 2.5% of the drugs used are of category A, 25% of B, 35% of C, 11,3% of D and 1.2% of X. According to Briggs, Freeman and Yaffe\'s risk classification (2015), most medicines are classified in the categories \"compatible\" (25.6%) and \"human data suggest low risk\" (10.6%). In the \"contraindicated\" category, there are 10% of the medicines used. No evidence of association was found between the number of medications used by pregnant women and the other characteristics studied. The data obtained in this study may contribute to the development of strategies to improve care and rational use of medications by high-risk pregnant women, increasing the quality of life of this population

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.