Considera-se prematuridade, o nascimento de uma criança antes das 37 semanas completas de idade gestacional. Estas crianças são denominadas de recém-nascidos pré-termos ou prematuros. Os prematuros tardios são aqueles nascidos com idade gestacional entre 34 e 36 semanas e 6 dias, representando em torno de 70% dos nascimentos na prematuridade. A avaliação da atenção pré-natal torna-se questão central na prevenção desses nascimentos prematuros, e prevenção da morbimortalidade tanto materna como neonatal, e sua qualificação, faz-se necessária. O objetivo do presente estudo foi conhecer o cuidado na gestação de mulheres que tiveram prematuros tardios, e seus atendimentos no âmbito do Sistema Único de Saúde. Trata-se de um estudo qualitativo, do tipo exploratório, cuja coleta de dados realizou-se em três unidades de Estratégia de Saúde da Família, no período de novembro de 2011 a dezembro de 2012, na cidade de Porto Alegre, RS, com 13 informantes, mães desses prematuros tardios. Os dados foram analisados sob o referencial da Análise Temática e de Padrões, compondo dois temas: negligência no cuidado durante a gestação do prematuro tardio e insuficiência do atendimento pré-natal na prematuridade tardia. Observou-se no relato das informantes um distanciamento entre as orientações que deveriam ser seguidas no pré-natal e as que realmente são, caracterizando o modo individual dessas mães vivenciarem esse processo. Constatou-se que as gestantes encontraram estratégias para acessar recursos de saúde por vias próprias, dentro do sistema público ou por intermédio da saúde suplementar, com o objetivo de resolverem demandas percebidas no transcorrer da gestação. Observaram-se diversificadas situações que comprometeram a saúde das gestantes, tais como as doenças por elas desenvolvidas e não adequadamente diagnosticadas, tratadas e acompanhadas (como pré-eclâmpsia, sífilis e infecção do trato urinário); a dificuldade na solicitação, acesso e resultados dos exames em tempo oportuno; a inexistência de articulação entre os serviços que realizam atendimento pré-natal sob a ótica da referência e contrarreferência; a falta de continuidade no atendimento pré-natal; a dificuldade na realização da busca ativa das gestantes (mesmo quando as mesmas têm risco gestacional diagnosticado como maior que o habitual); a não valorização da escuta pelo profissional de saúde no atendimento a essas gestantes; entre tantas outras condições que ocorreram. Neste contexto destaca-se a negligência, que não esteve somente associada ao caráter individual, tampouco ao desejo em relação a estar grávida, mas sim ao contexto social e cultural no qual as gestantes estavam inseridas; e a insuficiência do atendimento pré-natal, que se refere à falta de qualidade, à função inadequada e pouco resolutiva de um atendimento que deveria ser direito garantido às gestantes. Reitera-se a relevância do atendimento pré-natal para diminuição dos fatores de risco que contribuem para a prematuridade. / Prematurity is considered the birth of a child before 37 completed weeks of gestation. The group called late preterm infants refers to gestational age between 34 and 36 weeks and 6 days, representing around 70% of preterm births. Evaluation of prenatal care becomes central issue in the prevention of these premature births, and prevention of morbidity and mortality, both maternal and neonatal, and its qualification is necessary. The aim of this study was to know the pregnancy care of women who delivered late preterm infants and their health care attention in Brazil’s Unique Health System. This is an exploratory-qualitative study, whose data collection held in three units of the Family Health Strategy, from November 2011 to December 2012, in Porto Alegre, RS, with 13 informants, mothers of late preterm infants. The data were analyzed under the Thematic and Patterns Analysis, and composed two themes: negligence of care during pregnancy of late premature infants; and, inadequacy of prenatal care in late prematurity. It was noted a gap between the guidelines that should be followed in the prenatal care and the ones that really are, showing the individual way of these mothers experience this process. It was found that pregnant women create strategies to access health resources by their own way, within the health system or with supplementary care, with the aim of resolving the perceived demands in the course of pregnancy. Diverse situations that compromised the health of pregnant women were observed, such as the diseases they developed and did not properly were diagnosed, treated and monitored (such as preeclampsia, syphilis and urinary infection), difficulties in the request, access and results of laboratorial exams in appropriate time, the lack of coordination between services providing antenatal care from the perspective of the reference and counter-reference, the lack of continuity in prenatal care, the difficulty of active search of pregnant women (even when the pregnant women has risk diagnosed as greater than usual), the devaluation of listening by the part of health professionals in the care of these pregnant women, among many other conditions that occurred. In this context, stands out the neglect, that was not only associated with individual character or in relation to the desire to be pregnant, but associated to the social and cultural context in which pregnant women lived; and the insufficiency of prenatal care, which refers to lack of quality, inadequate function and little resolute of a service that should be right guaranteed to pregnant women. Reiterate the importance of prenatal care to decrease the risk factors that contribute to prematurity. / Se considera prematuridad el nacimiento previo a las 37 semanas de edad gestacional completas. Estos niños son denominados pretérminos o prematuros. El grupo llamado de los prematuros tardíos, que se refiere a la edad gestacional entre 34 y 36 semanas y 6 días, es lo que representa alrededor del 70% de los nacimientos prematuros. Evaluación de la atención prenatal hace convertido en un tema central en la prevención de estos nacimientos prematuros, e de la prevención de la morbimortalidad materna y neonatal, entonces se necesitan intervenciones para la cualificación de la atención en los niveles primarios y secundarios de la atención a la salud apuntando a reducir este tipo de nacimiento. El objetivo de este estudio se fue conocer la atención en el embarazo de mujeres que tuvieron hijos prematuros tardíos, y sus atendimientos dentro del Sistema Único de Salud. Se trata de un estudio cualitativo, exploratorio, cuya colección de datos fue realizada en tres unidades de la Estrategia de Salud de la Familia, de noviembre 2011 hasta diciembre 2012, en Porto Alegre, RS, con 13 informantes, madres de los prematuros tardíos. Los datos fueron analizados en el marco del Análisis Temática de Normas, e compusieron dos temas: negligencia en el cuidado durante el embarazo de lo prematuro tardío; y, insuficiencia de la atención prenatal en la prematuridad tardía. Se observó que existe una brecha entre las directrices que se deben seguir en el prenatal y las que realmente son seguidas, caracterizando una forma individual de las madres experimentaren este proceso. Se encontró que las mujeres embarazadas desarrollan estrategias de acceso a los recursos de salud por sus propios medios, dentro del sistema o por medio de los servicios complementarios, con el objetivo de resolver las demandas percibidas en el curso del embarazo. Se han observado diversas situaciones que comprometieron la salud de las mujeres embarazadas, como las enfermedades que se desarrollan y no fueran correctamente diagnosticadas, tratadas y controladas (como la pre eclampsia, la sífilis y la infección del tracto urinario), las dificultades en la solicitación, acceso y resultados de exámenes de laboratorio en tiempo oportuno, la falta de coordinación entre los servicios que prestan la atención prenatal en la perspectiva de la referencia y contra-referencia, la falta de continuidad en la atención prenatal, las dificultades para llevar a cabo una búsqueda activa de las mujeres (incluso cuando tienen riesgo de embarazo diagnosticado como mayor de lo normal), la disminución de la escucha de los profesionales de la salud en la atención de estas mujeres embarazadas, entre muchas otras condiciones que ocurren. En este contexto, la negligencia, que no sólo hace sido asociada con la conducta individual, o en relación con el deseo de estar embarazada, pero a el contexto social y cultural en que se incluyeron las mujeres embarazadas; y la insuficiencia de la atención prenatal, el cual se refiere a la falta de calidad, inadecuada funcionalidad, e poca resolución de un servicio que debe ser derecho garantizado a las mujeres embarazadas. Entonces se reitera la importancia de la atención prenatal para disminuir los factores de riesgo que contribuyen a la prematuridad.

Objective: To identify the epidemiological characteristics of early fetal and neonatal deaths in maternal near miss patients and the associated elements to this outcome. Method: Cross-sectional study including 79 women with features near miss, identified in a one-year period, and their newborns. Semi-structured interviews and the study of patients’ records were conducted. The variables were analyzed through simple frequency and percentage. To evaluate the association between those variables, the Fisher’s Exact Test was used. For the multivariate analysis the perceptual map constructed from the multiple correspondence examination was used, using the variables that were significant to 20%. Results: Amongst the near miss mothers, hypertensive disorders (severe pre-eclampsia, eclampsia, hypertension) totalized 32 cases (40,5%) and, of those, 14 (58,3%) had fetal and neonatal adverse outcome (p 0,046). The highest prevalence of fetal and neonatal adverse outcome was derived from cesarean delivery (20, 83,3%), of women with 2 or 3 children (11, 45,8%), and without previous stillbirths (17, 70,8%), this last variable with significance p 0,038. In the fetal and neonatal adverse outcome analysis significant levels were verified in newborns admitted in Neonatal Intensive Care Unit (17, 70,8%, p < 0,001); children with gestational age < 32 weeks (10, 41,6%, p < 0,001); birth weight < 2500 (16, 66,7%, p 0,001); APGAR score at 5 minutes < 7 (9, 52,9%, p < 0,001); neonatal asphyxia, 9 (50,00%, p < 0,001); and early respiratory distress syndrome, 13 (72,2%, p 0,002). Conclusion: The characteristic of early fetal and neonatal deaths in maternal near miss patients had a close association with fetal and neonatal adverse outcome. Among the mothers with hypertensive disorders the significant characteristics to the outcome in newborns were prematurity, neonatal asphyxia and early respiratory distress syndrome. / Objetivo: Identificar as características epidemiológicas dos óbitos fetais e neonatais precoces em pacientes com near miss materno e os fatores associados a este desfecho. Método: Estudo transversal, cuja população foi composta por 79 mulheres com características de near miss (NM), identificadas no período de um ano, e dos seus respectivos recém-nascidos. Foram realizadas entrevistas semiestruturadas e investigação dos prontuários. As variáveis foram analisadas por meio de frequências simples e percentual. Para avaliar associação entre as variáveis, utilizou-se o teste Exato de Fisher. Para análise multivariada, foi usado o mapa perceptual construído a partir da análise de correspondência múltipla e utilizadas as variáveis que foram significativas a 20%. Resultados: Entre as mães classificadas com NM, as desordens hipertensivas (pré-eclâmpsia grave, eclâmpsia, hipertensão) totalizaram 32 casos (40,5%) e, destes, 14 (58,3%) tiveram desfecho fetal e neonatal adverso (DFNA) com p-valor =0,046. A maior prevalência de DFNA foi proveniente de parto cesáreo (20, 83,3%), de mulheres com dois a três filhos (11, 45,8%) e sem natimortos anteriores (17, 70,8%), verificando-se significância para esta última variável p =0,038. Na análise dos DFNA, foi observada significância estatística para os recém-nascidos admitidos na UTIN (17, 70,8%, p <0,001); crianças com idade gestacional < 32 semanas (10, 41,6%, p <0,001); peso ao nascer < 2500 (16, 66,7%, p =0,001); APGAR de 5 minutos < 7 contabilizaram 9 (52,9%, p <0,001); asfixia neonatal, 9 (50%, p <0,001); e desconforto respiratório precoce, 13 (72,2%, p =0,002). Conclusão: As características dos óbitos fetais e neonatais precoces em pacientes com near miss materno tiveram associação forte com o desfecho fetal e neonatal adverso. Nas mães com desordens hipertensivas, as características estatisticamente significantes para o desfecho entre os recém-nascidos foram a prematuridade, asfixia neonatal e desconforto respiratório precoce.

O prognóstico da gestação é influenciado pelo estado nutricional materno. Sabe-se que, desde a infância, as pessoas portadoras da doença falciforme apresentam crescimento deficiente. Pouco se conhece sobre a evolução do estado nutricional materno na anemia falciforme. O objetivo foi analisar o estado nutricional de gestantes portadoras de anemia falciforme, avaliando o ganho de peso, o consumo dietético materno e os resultados adversos maternos e perinatais. Métodos: Foram avaliadas 26 gestantes portadoras de anemia falciforme SS e 23 SC, a partir do início do pré-natal especializado até o puerpério. Como grupo controle foram utilizadas 63 gestantes, sem comorbidades. O estado nutricional das gestantes foi avaliado de acordo com índice de massa corporal, pré-gestacional e ao final da gravidez, bem como analisado o ganho de peso materno. O consumo dietético foi analisado utilizando-se questionário de frequência alimentar, em cada trimestre, caracterizando-se o valor energético total e a ingestão de macronutrientes e micronutrientes. As complicações maternas e perinatais foram investigadas. O nível de significância foi 0,05 (alfa=5%). Resultados: O IMC pré-gestacional foi significativamente menor no grupo SS (mediana 20,3 kg/m2) quando comparado com os grupos SC (22,7 kg/m2, p < 0,05) e controle (23,2 kg/m2, p < 0,05). O baixo peso pré-gestacional (IMC < 18,5 kg/m2) foi significativamente mais frequente no grupo SS (15,4%) quando comparado aos grupos SC (4,4%) e controle (1,6%, p=0,009). Ao final da gestação, o grupo SS apresentou menor IMC (mediana 23,1 kg/m2) quando comparado com o grupo SC (26,1 kg/m2, p < 0,05) e controle (28,5 kg/m2, p < 0,05). O ganho ponderal na gestação foi menor no grupo SS (mediana 8,0 kg) quando comparado com o grupo SC (11,9 kg, p < 0,05) e Controle (13,7 kg, p < 0,05). Na análise do consumo dietético no 2º trimestre, constatou-se que os grupos SS e SC apresentaram menor consumo de proteínas (medianas, 73 g/d e 69 g/d) quando comparados aos controles (96 g/d, p < 0,05); e o consumo de cálcio foi menor no grupo SS comparado ao controle (mediana, 410 vs. 748 g/d, p<0,05). No 3º trimestre, houve menor consumo de proteínas pelo grupo SS quando comparado com os controles (mediana, 68 g/d vs. 93 g/d, p < 0,05); o consumo de vitamina A foi menor no grupo SS quando comparado aos controles (mediana, 447 vs. 940 mcg/d, p < 0,05); o consumo de vitamina E foi menor no grupo SS (mediana, 6 mg/d) quando comparado aos grupos SC (10 mg/d) e controle (7 mg/d, p < 0,05). As complicações maternas mais frequentes foram: crise álgica, 58% no grupo SS e 44% no SC (p=NS); infecção urinária, 31% no SS e 17% no SC (p=NS); e infecção pulmonar, 35% no SS e 9% no SC (p=NS). Houve diferença significativa no diagnóstico de sofrimento fetal: SS (36%), SC (14%) e controle (13%, p=0,032). Resultados perinatais adversos foram mais frequentes nos grupos SS e SC quando comparados aos controles. Conclusões: O estado nutricional das gestantes portadoras de doença falciforme SS caracterizou-se pela desnutrição materna, com baixo ganho ponderal na gestação. O consumo dietético de macronutrientes demonstrou ingestão inadequada de proteínas nos 2º e 3º trimestres. As complicações maternas e resultados perinatais adversos foram eventos frequentes nas gestantes portadoras de doença falciforme / The prognosis of pregnancy is influenced by the mother\'s nutritional status. It is known that, from childhood, people with sickle cell disease have deficient growth. Little is known about the evolution of maternal nutritional status in sickle cell anemia. The objective was to analyze the nutritional status of pregnant women with sickle cell anemia, assessing their weight gain, maternal dietary intake, and adverse maternal and perinatal outcomes. Methods: A total of 26 pregnant women with sickle cell anemia SS and 23 SC, from the start of pre-natal to the postpartum period. It was used as a control group 63 pregnant women without comorbidities. The nutritional status of pregnant women was evaluated according to body mass index, prepregnancy and late pregnancy and maternal weight gain. Dietary intake was assessed by food frequency questionnaire in each quarter, characterizing the total energy, macronutrients and micronutrients intake. Maternal and perinatal complications were investigated. The significance level was 0.05 (alpha=5%). Results: The pre-pregnancy BMI was significantly lower in the SS group (median 20.3 kg/m2) compared to the SC group (22.7 kg/m2, p < 0.05) and control (23.2 kg/m2, p < 0.05). The low pre-pregnancy weight (BMI < 18.5 kg/m2) was significantly more frequent in the SS group (15.4%) when compared with the SC group (4.4%) and control (1.6%, p=0.009). At the end of pregnancy, the SS group had lower BMI (median 23.1 kg/m2) compared to the SC group (26.1 kg/m2, p < 0.05) and control (28.5 kg/m2, p < 0.05). Weight gain during pregnancy was lower in the SS group (median 8.0 kg) compared with the SC group (11.9 kg, p < 0.05) and control (13.7 kg, p < 0.05). The dietary intake analysis in the 2nd quarter showed that the SS and SC groups have a lower protein intake (median, 73 g/d and 69 g/d) compared to controls (96 g/d, p < 0.05); and calcium intake is lower in the SS group compared with controls (median, 410 vs. 748 g/d, p < 0.05). In the 3rd quarter, the protein intake was lower in the SS group compared with controls (median, 68 g/d vs. 93 g/d, p < 0.05); the vitamin A intake was lower in the SS group compared to controls (median, 447 vs. 940 mcg/d, p<0.05); the consumption of vitamin E was lower in the SS group (median, 6 mg/d) groups when compared to SC (10 mg/d) and control (7 mg/d, p < 0.05). The most frequent maternal complications were: a pain crisis, 58% in the SS group and 44% in SC (p=NS); urinary tract infection in 31% of SS and 17% of SC (p=NS); and pulmonary infection, 35% in the SS and 9% in the SC group (p = NS). There were significant differences in the diagnosis of fetal distress: SS (36%), SC (14%) and control (13%, p=0.032). Adverse perinatal outcomes were more common in SS and SC groups when compared to controls. Conclusions: The nutritional status of pregnant women with sickle cell disease SS is characterized by maternal malnutrition with low weight gain during pregnancy. Dietary intake of macronutrients demonstrates inadequate protein intake in the second and third quarters. Maternal complications and adverse perinatal outcomes are frequent events in pregnant women with sickle cell disease

Objetivos. Avaliar as repercussÃes maternas e perinatais das gestantes com cardiopatia, comparando os dados sociodemogrÃficos, obstÃtricos e resultados perinatais pelo tipo de cardiopatia (congÃnita versus adquirida) e pela via de parto (parto vaginal versus abdominal). Metodologia. Trata-se de estudo transversal, retrospectivo, descritivo e analÃtico, realizado por meio da pesquisa de 70 prontuÃrios de pacientes que tiveram o parto no Hospital Geral CÃsar Cals nos anos de 2007 (26 casos) e 2008 (44 casos) por meio do preenchimento de questionÃrios. Foram usados os testes estatÃsticos Qui-quadrado de Yates e de Pearson e Exato de Fisher para anÃlise bivariada dos dados. Foi considerado nÃvel de significÃncia p < 0,05. Resultados. A idade das pacientes variou de 15 a 42 (mÃdia de 25,8Â6,5) anos; 25 (35,7%) eram primigestas, 22 (31,4%) secundigestas e 23 (32,9%) delas eram multigestas, dezesseis pacientes (22,9 %) tinham cardiopatia congÃnita e 45 cardiopatia adquirida (64,3%). Houve 15 partos prematuros (21,7%); 24 (34,3%) delas teve parto vaginal e 46 (65,7%) parto abdominal. A taxa de prematuridade foi de 21,7%. Verificou-se a presenÃa de 27,1% de RN com baixo peso ao nascer, 8,6% de restriÃÃo do crescimento fetal, 17,1% de Apgar < 7 no primeiro e 11,4% no quinto minuto de vida. Houve um Ãbito materno e cinco Ãbitos perinatais. NÃo houve diferenÃa estatÃstica entre as cardiopatias congÃnitas e as adquiridas, exceto pela maior presenÃa de patologias clÃnicas prÃvias à gestaÃÃo no grupo das cardiopatias congÃnitas. As pacientes que tiveram parto vaginal apresentaram maior paridade e menor escolaridade, maior taxa de prematuridade, de RN com baixo peso ao nascer e menores Ãndices de Apgar no primeiro minuto quando comparadas Ãquelas submetidas a parto abdominal. A frequÃncia de descompensaÃÃo clÃnica durante o trabalho de parto e/ou parto foi de 5,7%, sem diferenÃa estatÃstica entre os partos vaginais ou abdominais. ConclusÃes. Houve frequÃncia elevada de cesariana, parto prematuro, baixo peso ao nascer, Apgar < 7 no primeiro minuto de vida e necessidade de internamento em UTI neonatal. NÃo houve diferenÃa clara entre os tipos de cardiopatias. O piores resultados neonatais encontrados para o parto vaginal podem ser atribuÃdos à prÃpria prematuridade; ou seja, nÃo necessariamente à via de parto. / Aims. To evaluate maternal and peri-natal outcomes of pregnant women with heart disease, comparing the socio - demographic, obstetric data and peri-natal results by the type of heart disease (congenital versus acquired) and the route of delivery (vaginal versus abdominal). Methodology. This is a cross sectional, retrospective, descriptive and analytical research carried out by the records of 70 patients who delivered at Hospital Geral Cesar Cals in the years 2007 ( 26 cases) and 2008 (44 cases) by completing questionnaires. We used the Yates chi-square test, Pearson and Fisher Exact test for bi-varied analysis of data. We considered the level of significance p < 0.05. Results. The age of patients ranged from 15 to 42 (mean 25.8 + 6.5) years; on twenty five (35.7%) were first pregnancy, 22 (31.4%) second pregnancy and 23 (32.9%) were multi â pregnancy. Sixteen patients (22.9%) had congenital heart disease and 45 had acquired heart disease (64.3%). There were 15 premature births (21.7%). Twenty four (34.3%) of the women had vaginal deliveries and 46 (65.7%) cesarean section. The rate of pre term births was 21.7%. There was 27.1% of infants with low birth weight, 8.6% of fetal growth restriction, 17.1% of Apgar score < 7 in the first and 11.4% in the fifth minute of life. There was one maternal death and 5 peri-natal deaths. There was no statistical difference between congenital and acquired heart disease except for a greater presence of clinical pathologies previous to the pregnancy in the group of congenital heart disease. Patients who had vaginal deliveries presented higher parity and lower education, higher rates of prematurity in infants with low birth weight and lower Apgar scores in the first minute when compared to those who were submitted to cesarean section. The frequency of clinical discompensation during labor and / or delivery was 5.7% without statistical difference between the vaginal or abdominal. Conclusions. There was a high frequency of cesarean section, premature birth, low birth weight, Apgar score < 7 in the first minute of life and need to be admitted in the neonatal UTI. There was no clear differencebetween the types of heart disease. The worst neonatal results found for the vaginal delivery can be attributed to the very pre-term birth, that is, not necessarily the mode of delivery. .

Orientador: Jose Guilherme Cecatti / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T09:14:57Z (GMT). No. of bitstreams: 1 Guerra_GlauciaVirginiadeQueirozLins_D.pdf: 2929113 bytes, checksum: 54c7b830383d166f725dcf970e08b726 (MD5) Previous issue date: 2008 / Resumo: Objetivo: Avaliar a prevalência da indução médica e eletiva do trabalho de parto, métodos utilizados, índice de sucesso, fatores associados e resultados maternos e perinatais em oito países da América Latina. Método: Foi realizada a análise referente à indução do trabalho de parto no banco de dados da Pesquisa "2005 WHO global survey on maternal and perinatal health", referente a oito países aleatoriamente selecionados da América Latina. Obtiveram-se os dados individuais de todas as mulheres que tiveram seus partos em 120 instituições, no período do estudo. Avaliaram-se as indicações de indução por país, a taxa de sucesso por método, os fatores associados à indução e os resultados maternos e perinatais comparativamente aos partos iniciados espontaneamente (primeira abordagem). Após foi feita uma análise independente da indução eletiva comparada com o início espontâneo do trabalho de parto entre gestações de baixo risco, para avaliar os fatores associados a essa prática e seus resultados maternos e perinatais (segunda abordagem). Foram estimados os odds ratios (OR) para os possíveis fatores associados à indução e as razões de risco (RR) para os resultados maternos e perinatais, com seus respectivos intervalos de confiança (IC95%). Posteriormente, foram aplicados os modelos de regressão logística múltipla para o ajuste dos riscos estimados. Resultados: Do total de 97.095 partos do inquérito, 11.077 (11,4%) foram induzidos. Os hospitais públicos foram responsáveis por 74,2% das induções. A ruptura prematura das membranas (25,3%) e a indução eletiva (28,9%) foram as indicações mais freqüentes. A taxa de sucesso de parto vaginal foi de 70.4%, com 69.9% para a ocitocina e 74.8% para o misoprostol, os principais métodos isoladamente utilizados. O risco de indução do parto foi maior em mulheres com mais de 35 anos, com companheiro, nulíparas, sem cesárea no parto anterior, com rotura de membranas, hipertensão arterial, baixa altura uterina, diabetes, anemia grave, com menor número de consultas de pré-natal, pós-datismo, apresentação cefálica e naquelas que deram a luz em hospitais do seguro social. As complicações maternas mais associadas com a indução do parto foram a necessidade de uterotônicos no período pós-parto, laceração perineal, histerectomia, admissão em unidade de terapia intensiva, permanência hospitalar maior que 7 dias e maior necessidade de procedimentos analgésicos. Já os resultados perinatais desfavoráveis mais freqüentes foram Apgar menor que sete ao quinto minuto, ocorrência de muito baixo peso, admissão em UTI neonatal e início mais tardio da amamentação. Em relação à análise da indução eletiva entre gestantes de baixo risco, não foi encontrada diferença na taxa de cesariana e nos resultados perinatais, porém ocorreu maior necessidade do uso de uterotônico no pós-parto, risco cinco vezes maior de histerectomia pós-parto e maior necessidade de procedimentos de anestesia/analgesia. Conclusão: Na América Latina a taxa global de indução do trabalho de parto foi um pouco maior que 10%, enquanto a de indução eletiva entre gestantes de baixo risco foi de 4,9%. A taxa de sucesso para o parto vaginal foi elevada independentemente do método e da indicação da indução. Há, contudo, alguns riscos maternos e perinatais associados com essa prática, seja ela eletiva ou não / Abstract: Objective: To evaluate the prevalence of both medical and elective labor induction as well as employed methods, success rates, associated factors and maternal and perinatal outcomes in eight Latin American countries. Methods: it was performed an analysis on labor induction in the database of the "2005 WHO global survey on maternal and perinatal health" on deliveries occurring in eight randomly allocated Latin American countries. Data of all women who gave birth to children in the 120 included institutions during the period of the study were collected. The indications for labor induction according to the country, the success rate for each method, the factors associated with labor induction as well as maternal and perinatal outcomes were compared with deliveries with spontaneous onset of labour (Approach 1). A second independent analysis on elective induction compared with spontaneous onset of labor in low-risk pregnancies was performed in order to evaluate factors associated with elective labor induction and also maternal and perinatal outcomes (Approach 2). The odds ratios (OR) for possible factors associated with labor induction and the risk ratios (RR) for maternal and perinatal outcomes, with respective confidence interval (95%CI) for all types of labor induction and for elective induction were estimated. Additionally, multiple logistic regressions were applied to adjust the estimated risks. Results: Among the total 97,095 deliveries included in the survey, 11,077 (11.4%) underwent labor induction. Public hospitals accounted for 74.2% of them. Premature rupture of membranes (25.3%) and elective induction (28.9%) were the most frequent indications. The success rate in obtaining vaginal delivery was 70.4%. Oxitocin and misoprostol - the most employed methods - had success rates of 69.9% and 74.8%, respectively. Labor induction occurred more frequently in women older than 35 years, with a partner, nulipara, without cesarean section in the last pregnancy, ruptured membranes, hypertension, low fundal height, diabetes, severe anemia, vaginal bleeding, few prenatal visits, post term, cephalic presentation and those who gave birth in social security hospitals. The most frequent maternal complications associated with labor induction were need for uterotonic agents in postpartum period, perineal laceration, need for hysterectomy, and admission to intensive care unit, length of hospital stay above seven days and increased need of anesthetic/analgesic procedures. The most frequent adverse perinatal outcomes were low 5-minute Apgar score, very low birth-weight, admission to neonatal intensive care unit and delayed initiation of breastfeeding. Concerning elective induction in low-risk pregnancies there was no difference in cesarean section rate or perinatal outcome. However, there were increased needs for uterotonic agents in the postpartum period and for analgesic/anesthetic procedures, and a further than fivefold risk for postpartum hysterectomy. Conclusions: In Latin America, the overall labor induction rate was slightly more than 10%, while for elective indication among low risk pregnancies it was 4.9%. The vaginal delivery rate was high irrespective of the method or indication. However, there are some maternal and perinatal risks associated with this intervention, in spite of medically or electively indicated. / Doutorado / Tocoginecologia / Doutor em Tocoginecologia

In this work, we found that proliferation-related prognostic gene signatures could aid treatment decision-making independent of age. This is clinically relevant for the younger breast cancer population given the potential long-term side effects of adjuvant systemic chemotherapy and hence the need to identify patients who are less likely to benefit adjuvant chemotherapy. In addition, it was clear that young age at diagnosis adds extra biological complexity, which is independent of differences in breast cancer subtype distribution. This includes enrichment with known breast cancer targets like RANKL. Whilst these results require further validation, either experimentally or in other clinical data sets, it suggests that separate therapeutic approaches may need to be specifically designed in order to improve outcomes for breast cancer arising in young women. In this regard, and based on our results and supportive evidence from other studies, we initiated a proof-of-concept prospective phase II neoadjuvant study investigating the role of denosumab, a RANKL inhibitor on modulating tumor biology in young premenopausal breast cancer patients. <p>We found that diagnosis during pregnancy does not significantly influence the classic pathological features or the prevalence of breast cancer subtypes. We also did not find obvious differences in the distribution of PIK3CA mutations. However, we found that tumors diagnosed during pregnancy have activated serotonin receptor signaling and high expression of potential breast cancer targets; of particular interest IGF1, and PDL1. Such differences appeared to be reflected in the normal pregnant breast underscoring the potential role of the pregnant breast microenvironment on the tumor transcriptome. We were not able to associate these genes with prognosis, which could be partly due to lack of statistical power. Of note, we cannot confirm whether any of these aberrations are key drivers of the biology of tumors diagnosed during pregnancy. Nevertheless, this remains the first study to look into the biology of this relatively rare disease and hence we believe it would serve as a very valuable resource for future research in this field. We are planning to perform targeted gene sequencing to further refine our understanding of the potential effect of pregnancy on the biology of these tumors. <p>In the last part of this work addressing the safety of pregnancy following breast cancer diagnosis, we identified that available studies suffered major limitations related to study design including selection bias and lack of information on patients with history of an ER-positive disease. This has resulted in advising against pregnancy in women with prior history of breast cancer. Our subsequent study has robustly addressed most of the limitations in older studies and clearly showed that pregnancy following breast cancer is safe even in women with a history of ER-positive disease. Hence, this study would provide a very important resource for the oncology community, which would aid adequate fertility counseling for young breast cancer survivors. This work is currently serving as the basis for a new prospective study by the IBCSG to test the safety of early interruption of tamoxifen in young women with early breast cancer seeking subsequent pregnancy. <p> / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

Pregnancy induces maternal metabolic adaptations including mild glucose intolerance and weight gain in order to support fetal development and lactation. Adipose tissue (AT) function in gestation is featured by reduced insulin sensitivity and fat mass accrual which partly accounts for the weight gain in pregnant women and adaptation of glucose metabolism. A common metabolic pregnancy complication is gestational diabetes mellitus (GDM), a disease characterized by impaired glucose tolerance with onset in gestation. However, the relationship between AT expandability and glucose metabolism in gestation is not well understood. The goal of this thesis was to investigate the adaptations of human AT expansion induced by pregnancy, how these changes are reflected in pregnancies complicated with GDM and characterize a mouse model to study the mechanisms underlying this disease. This dissertation illustrates that pregnancy promotes AT expandability by a signaling mechanism between placental pregnancy-associated plasma protein-A (PAPP-A) and AT- insulin-like growth factor binding protein-5 (IGFBP5). In addition, gravidas with GDM showed impaired AT expansion. Studies investigating the relationship between PAPP-A and glycemic state demonstrated that low levels of PAPP-A in the 1sttrimester are highly associated with the development of GDM. Moreover, PAPP-A knockout mice exhibit reduced insulin sensitivity and impaired AT growth exclusively in gestation. These results expand the knowledge of AT biology in gestation and have the potential to improve maternal care by proposing PAPP-A as an early biomarker and possible therapeutic for GDM. It also introduces a new mouse model to study the etiology of gestational diabetes.

Background: Symptomatic knee osteoarthritis (OA) is an incurable condition that affects nearly 50% of adults, and women are twice as likely as men to develop OA. Throughout pregnancy, women experience large changes in morphology and gait mechanics, as well as changes in joint loading. It is possible these adaptations could cause lasting changes postpartum, which may potentially contribute to initiation of OA, thereby increasing the overall risk of OA for women. Purpose: This exploratory study looked to identify differences between lower limb gait mechanics of healthy nulliparous women and healthy parous women. Methods: 28 healthy female participants (14 parous, 14 nulliparous) were recruited for the study. Nulliparous participants had never given birth to a child, and were self-reported not pregnant. Parous participants had given birth to at least one full term infant (37 – 42 weeks) without complications between one to five years before data collection. Kinematic and kinetic data was collected for the lower body, using motion capture and in-ground force plates. Participants completed one quiet standing trial, and walked over-ground through the motion capture space at their preferred, fast, and set walking speeds (1.4 m/s). An ANOVA was performed to test if there were significant differences in between groups. Results: Q angle did not differ between groups. There was a significant main effect of group indicating a larger knee flexion angle at toe off (p = 0.060), smaller knee extension moment at heel strike (p = 0.0006), smaller first peak knee flexion moment (p = 0.040), and smaller peak hip adduction moment for the parous group compared to the nulliparous group (p = 0.003). Conclusions: Our data revealed a decrease in the moments experienced, which could possibly lead to degradation of cartilage due to under loading of the joint. We think this may be an indication that pregnancy could increase risk of OA, and therefore more research into this possibility is warranted.

Chlamydia is the most common bacterial sexually transmitted infection in the United States and worldwide. It often goes unnoticed due to lack of symptoms and left untreated it can ascend the female genital tract to cause sequelae like pelvic inflammatory disease and irreversible tubal infertility. In reproductive-aged women, female sex hormones estrogen (E2) and progesterone (P4) concentrations fluctuate during the menstrual cycle and are influenced by hormonal contraceptives and hormone replacement therapy. E2 and P4 influence genital Chlamydia infection in women and mice, but these multifactorial interactions are not entirely mapped out. The complex interplay of E2 and P4 with Chlamydia and the host response demand further study to determine the effect of hormonal environment and host susceptibility to Chlamydia. E2 primarily signals through estrogen receptors (ER) ERα and ERβ. We used ERα or ERβ knockout (KO) mice to study the role of E2 and ERs in chlamydial progression and examined the host immune response at day 9 post-infection, when we expected the immune response to be the most robust. ERαKO, but not ERβKO mice had significant differences in the progression of Chlamydia and the host immune response. Future studies should test the immune response at additional timepoints, and a model should be utilized wherein ERα and ERβ are simultaneously silenced by chemical knockdown of ERβ in ERα knockout mice using ER agonist ICI 182, 680. 3 Mice are widely used in Chlamydia research, but due to its short estrus cycle, infection cannot be established naturally before infected cells are shed. To overcome this, mice are pretreated with depot medroxyprogesterone acetate (DMPA), an exogenous progesterone that halts the estrus cycle. However, a mouse model not reliant on DMPA pretreatment is needed because 1.) DMPA can affect the immune response and 2.) the hormonal environment in women is not static. Our model uses mice that are ovariectomized to stop the production of endogenous E2 and P4, then treated with physiologically relevant levels of E2 and P4 via implantation of a hormone-filled capsule. We observed that E2 protected mice from Chlamydia, making our model a good alternative for in vivo Chlamydia studies.

The description and interpretation of Latinas’ experience with chemotherapyinduced premature menopause from breast cancer treatment were explored in this study, which utilized an interpretive descriptive method from a feminist lens, and Knobf’s (1998, 2002) “Carrying on” theory. The specific aims of the study and the interview questions were guided by the state of the science literature. Overall, the impact of physiological effects, psychosocial effects, barriers, influencing factors that made their experience easier or harder, and how participants adjusted to a cancer diagnosis, treatment course, and menopause transition were described as bigger than the menopause experience alone. Participants also described a period of uncertainty or “ever-changing landscape” that began at the time of diagnosis and continued through survivorship. The impact of information, access to healthcare, acculturation levels, support, and a sense of control were elucidated as important factors in “working through” the experience. A range of collateral data sources were employed. Study limitations and future implications for practice, research, and health policy were demarcated.