Identification and analysis of therapy used by pregnant women II. Author: Eliška Vachudová1 Tutor: PharmDr. Josef Malý, Ph.D.1 1 Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University Introduction and objective: Taking medication during pregnancy often implies higher risk of adverse effects for pregnant woman as well as for the foetus. In the Czech Republic, there is not enough information for rational drug taking during gravidity yet. The purpose of the practical part was to identify and analyze therapy used by pregnant women by questionnaires, in which respondents could show their knowledge and awareness of over-the-counter drugs, medical devices, food supplements and herbal and homeopatic remedies. Methods: The data collection lasted from August 2017 to March 2018 and was performed in the form of questionnaires at the Domažlice Hospital, Department of Gynecology and Obstetrics. Nurses played a vital role to distribute the questionnaires and instruct every newly admitted woman how to fill them. The questionnaire was anonymous, contained 50 questions of open, semi-open and closed types and included introduction letter with the entrance criteria. After filling in, they were transformed into electronic ones using Google Forms. Collected data were...

There has been a global rise in obesity in the last three decades, and at present one in five women are obese at antenatal booking. Maternal obesity is associated with an increased risk of adverse pregnancy outcomes, including increased fetal size and prolonged pregnancy. In the longer-term, offspring of obese are at increased risk of premature death from a cardiovascular event in their adulthood. One mechanism that has been linked to these outcomes is fetal exposure to glucocorticoids in utero. During normal pregnancy, the maternal hypothalamic pituitary adrenal (HPA) axis undergoes major changes, resulting in exponentially increasing levels of the major circulating glucocorticoid cortisol, and other HPA axis hormones, such as corticotrophin releasing hormone (CRH). Cortisol and CRH are vital for normal fetal growth and length of gestation, but in excess they are associated with fetal growth restriction and preterm labour. In non-pregnant obesity, it is thought that the HPA axis is dysregulated, although evidence is inconclusive. Little is known about the effects of maternal obesity in pregnancy on the HPA axis. The work in this Thesis used clinical studies to test the hypothesis that the HPA axis is dysregulated in obese pregnant women with altered release, clearance and placental metabolism of cortisol. Associations with clinical outcomes related to fetal size and length of gestation were also studied. The HPA axis activity during pregnancy was investigated in a prospective case-control study cohort. Fasting serum cortisol levels were measured at 16, 28 and 36 weeks of gestation (obese n=276, lean n=135). In a subset (obese n=20, lean n=20), corticosteroid binding globulin (CBG), CRH, estrogens and progesterone were measured. Salivary cortisol was measured in samples collected at bedtime, waking and 30 minutes after waking at 16 weeks. Urinary glucocorticoid metabolites were measured at 19 weeks and 36 weeks (obese n=6, lean n=5) and non-pregnant (obese n=7, lean n=7) subjects. All circulating hormone levels rose similarly in obese and lean during pregnancy, but were significantly lower in obese women. The diurnal rhythm of cortisol was maintained. Urinary glucocorticoids increased with gestation in lean, but not in obese, indicating a lesser activation of the HPA axis in obese compared with lean pregnancy. These findings associated with increased birthweight and longer gestation in obese pregnancy, suggesting that decreased HPA axis activity may underlie these obese related adverse pregnancy outcomes. Whether or not lower glucocorticoids in obese pregnancies are maintained at delivery was investigated by measuring active glucocorticoids (cortisol and corticosterone) and their inactive versions (cortisone and 11- dehydrocorticosterone, respectively) from matched maternal and cord plasma samples (n=259, BMI 18 – 55 kg/m2). Active glucocorticoids were significantly higher in maternal than cord blood, and inactive versions were significantly higher in cord than maternal blood. Increased maternal BMI associated with lower maternal cortisol, corticosterone and 11-dehydrocorticosterone. Despite significant correlations between maternal and cord blood glucocorticoid levels, increased maternal BMI did not associate with lower cord blood glucocorticoids. This suggests that conditions at delivery may overcome any potential negative effects of low maternal glucocorticoids on the fetus in the short-term. However, it may not preclude the longer-term effects of fetal exposure to lower glucocorticoid levels during obese pregnancy, and offspring follow-up studies are required. Potential mechanisms leading to altered HPA axis activity in obese pregnancy were explored by studying the pulsatile release and placental metabolism of glucocorticoid hormones. Glucocorticoid pulsatility is thought to be important for transcriptional regulation of glucocorticoid responsive genes, and disruptions to pulsatility have been reported in some disease processes. Glucocorticoids were measured in 10-minute serum sampling between 08.00h-11.00h and 16.00h- 19.00h. Peripheral tissue cortisol was measured from 20-minute sampling of interstitial fluid, over 24-hours, at 16-24 weeks and 30-36 weeks (obese n=7, lean n=8), and non-pregnant controls (obese n=4, lean n=3). Total circulating serum cortisol levels were higher in pregnancy than non-pregnancy in lean and obese, and increased significantly with advancing gestation in lean but not in obese. Pulsatility of cortisol was demonstrated in interstitial fluid in both non-pregnancy and pregnancy. In obese pregnancy, interstitial fluid pulse frequency was lower with advancing gestation. This may be a novel mechanism underlying the observed decreased HPA axis activity in obese pregnancy. Placental cortisol metabolism and transport was studied using an ex vivo placental perfusion model, perfused with a deuterium-labelled cortisol tracer combined with computational modeling. The findings challenge the concept that maternal cortisol diffuses freely across the placenta, but confirmed that 11β- HSD2 acts as major ‘barrier’ to cortisol transfer to the fetus, protecting the fetus from the high maternal circulating cortisol levels. In addition we showed preliminary evidence of local cortisol production within the placenta. The model is able to predict maternal-fetal cortisol transfer and can now be used in future experimental design. In conclusion, in obese pregnancy, lower maternal cortisol and urinary clearance suggested reduced HPA axis activity. Altered glucocorticoid pulsatility may underlie this change. Future studies of placental cortisol metabolism in maternal obesity could be conducted using an ex vivo perfusion model. The lower HPA axis activity in obese pregnancy represents a novel pathway underlying increased fetal growth.

Made available in DSpace on 2015-12-10T14:22:19Z (GMT). No. of bitstreams: 0 Previous issue date: 2015-02-27. Added 1 bitstream(s) on 2015-12-10T14:28:22Z : No. of bitstreams: 1 000851295_20160101.pdf: 444910 bytes, checksum: 19cd7816190ec81bd428c22f310a5a70 (MD5) Bitstreams deleted on 2016-01-04T10:26:49Z: 000851295_20160101.pdf,. Added 1 bitstream(s) on 2016-01-04T10:28:39Z : No. of bitstreams: 1 000851295.pdf: 3923793 bytes, checksum: 5062f0d4878e4fd01c2e5449fa419de5 (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / A pré-eclâmpsia (PE) é uma síndrome específica da gravidez, caracterizada por hipertensão arterial e proteinúria, identificadas após a 20a semana de gestação. Essa patologia está associada com hiperuricemia, valores séricos elevados de citocinas inflamatórias, ativação de leucócitos e estresse oxidativo. Cristais de ácido úrico podem ativar um complexo intracelular denominado inflamassoma, uma estrutura multi-proteica importante para o processamento e liberação das citocinas inflamatórias interleucina-1 beta (IL-1β) e IL-18. Este estudo investigou, em gestantes portadoras de PE, o estado de ativação de monócitos, tanto endógeno como estimulado por urato monossódico (MSU), por meio da expressão gênica dos inflamassomas NLRP1 e NLRP3, bem como a associação destes complexos com a expressão de citocinas inflamatórias por estas células. Monócitos foram obtidos do sangue periférico de 23 gestantes pré-eclâmpticas e 23 gestantes normotensas (GN) no terceiro trimestre de gestação e de 23 mulheres saudáveis, não grávidas (MNG) e cultivados na presença ou ausência de 50 μg/mL de MSU por 18 h. A presença do inflamassoma foi avaliada por meio da expressão gênica de NLRP1, NLRP3, caspase-1, IL-1β, IL-18 e TNF-α por RT-qPCR em células não estimuladas (expressão endógena) ou após estímulo com MSU (expressão estimulada). A concentração das citocinas foi avaliada pelo método de ELISA. Os resultados foram analisados por meio de testes não-paramétricos com nível de significância de 5%. Em gestantes pré-eclâmpticas, a expressão gênica de NLRP1, NLRP3, caspase-1, IL-1β e TNF-α em monócitos estimulados ou não com MSU, foi significativamente maior do que nos grupos GN e MNG. Além disso, observou-se maior expressão endógena de IL-18 em gestantes com PE em comparação às gestantes normotensas, enquanto a expressão estimulada da citocina foi maior no grupo PE em relação aos grupos GN e... / Preeclampsia (PE) is a specific syndrome of pregnancy, characterized by hypertension and proteinuria, identified after the 20th week of pregnancy. This pathology is associated with hyperuricemia, elevated serum levels of inflammatory cytokines, leukocyte activation and oxidative stress. Uric acid crystals may activate an intracellular complex called inflammasome, a multi-protein structure which is important for processing and release of inflammatory cytokines such as interleukin-1 beta (IL-1β) and IL-18. This study investigated, in pregnant women with PE, the state of monocyte activation both endogenous and stimulated with monosodium urate (MSU), by gene expression of NLRP1 and NLRP3 inflammassomes as well as their association with inflammatory cytokines expression by these cells. Monocytes were obtained from peripheral blood of 23 preeclamptic pregnant women, 23 normotensive pregnant women (NT) in the third trimester of pregnancy and 23 healthy non-pregnant women (NP), and cultured in the presence or absence of 50 μg/mL of MSU for 18 h. Inflammasome activation was evaluated by the gene expression of NLRP1, NLRP3, caspase-1, IL-1β, IL-18 and TNF-α by RT-qPCR in unstimulated monocytes (endogenous expression), or after cell stimulation with MSU (stimulated expression). The concentration of cytokines was assessed by enzyme-linked immunosorbent assay (ELISA). The results were analyzed using non-parametric tests at 5% significance level. In preeclamptic pregnant women, gene expression of NLRP1, NLRP3, caspase-1, IL-1β and TNF-α by monocytes, stimulated or not with MSU, was significantly higher than in NT and NP groups. In addition, there was a higher endogenous expression of IL-18 in pregnant women with PE compared with NT pregnant women, while the stimulated cytokine expression was higher in the PE group than in the other two groups studied. Stimulation of monocytes from preeclamptic and non-pregnant women with MSU induced increased ... / FAPESP: 2012/21287-3

Made available in DSpace on 2014-06-11T19:27:26Z (GMT). No. of bitstreams: 0 Previous issue date: 2007-12-20Bitstream added on 2014-06-13T19:35:34Z : No. of bitstreams: 1 cabrera_smp_me_ia.pdf: 1903723 bytes, checksum: d59a4b33dee2ca26053532c4f3677e40 (MD5) / Durante a gestação, é comum que a mulher fique mais sensível, física e emocionalmente, ao meio. Os sentidos ficam mais aguçados e a emoção à flor da pele. No entanto, pouco se comenta sobre o aumento da sensibilidade auditiva, e são escassos os dados específicos sobre a influência do meio sonoro sobre a saúde da gestante e do bebê. Esta pesquisa busca entender como se dá a relação da gestante com o meio sonoro: os fatores positivos – relacionados ao prazer – e os negativos, relacionados ao estresse, que pode ser causado tanto pelo excesso de ruídos, como pela associação subjetiva a determinados sons e músicas, e com essa relação pode afetar sua saúde, e conseqüentemente, a do bebê, e tem como ponto de partida a necessidade de averiguar o possível aumento da sensibilidade auditiva durante o período de gestação. Para essa finalidade, foi utilizada a Internet como meio de contato com as gestantes, e criada uma comunidade virtual para discussão dos aspectos do ambiente sonoro ligados à gestação. Deste modo, formou-se um grupo com mulheres de diversas partes do Brasil, de formação, classe social e idades diversificadas, dispostas a falar sobre sua gestação e a percepção do ambiente sonoro. A investigação do tema fundamenta-se, principalmente, no trabalho de Murray Schafer , precursor do estudo da ecologia acústica, e em pesquisa da área médica, com o objetivo de realçar a relação entre a paisagem sonora e a gestação, e para dar sustentação à hipótese de que o ambiente sonoro possa influenciar a saúde da gestante, tanto positiva como negativamente, dependendo do tipo de som que o forme, e que sua percepção adequada possa se tornar um instrumento auxiliar na prevenção de problemas e na promoção do bem-estar durante esse período. / It's usual that women get emotionally and fiscally more sensible to the environment during pregnancy. Their senses get more accurate, and they are emotionally touchier. However, little is said about hearing sensibility, and there is hardly any specific data about how sounds from environment interfere whit baby and mother healthy. This research intends to undersand how these sounds from environment possitively and negativily affect a pregnant woman. Sounds can positively affect pregnancy providing pleasant sensations, and negativily, thei can be related either to stress caused by noise excess or to subjective reactions to certain sounds or music. As environment sounds can affect pregnancy and therefore the baby's healty there's need to check as much as possible, the increase of hearing sensibility during pregnancy. Communication with pregnant women was established through Internet, and through a virtual community for discussion on how sounds from environment can affect pregnancy. This community was made up of women from all over Brazil, of different ages and from social levels who were willing to talk about their pregnancy and influence of sounds on it. This investigation is based on Murray Schafer's work who first studied acoustic ecology and medical area researches with the intention of approachling soundscape and pregnancy. This study is used to fundament the idea that souds from the environment can positively or negatively influence harthy in pregnancy, according to what kind of souns the woman is exposed to, and it explains that its appropriat use can be an instrument of prevention to problems and can also promote well being during the pregnancy time.

Resumo: Alterações anatômicas e fisiológicas da gravidez predispõem gestantes a infecções do trato urinário (ITU). O não tratamento ou o tratamento inadequado dessas infecções pode levar a complicações obstétricas e neonatais, como amniorexe prematura, trabalho de parto e parto prematuros. Considerando a relevância das complicações, a possibilidade de ocorrência de bacteriúria assintomática e a demora para obtenção do resultado da urocultura, padrão-ouro para diagnóstico de ITU, muitos profissionais optam por iniciar o tratamento de ITU em gestantes, caso o exame de urina simples mostre-se alterado, mesmo na ausência de sinais clínicos inequívocos. Identificar a acurácia do exame de urina simples para diagnóstico de infecção do trato urinário em gestantes de baixo risco. Material e Método: Foi realizado estudo analítico e transversal no município de Botucatu/SP. A propedêutica de atendimento incluiu a realização do exame de urina simples e urocultura, os dados foram colhidos de outubro de 2006 a março de 2008 nos serviços de atenção básica. Resultados: Foram incluídas no estudo 230 gestantes, com mediana de idade de 25,2 anos (14 - 43), 79,2% casadas ou em união estável. A prevalência de ITU foi de 10%, sendo o microrganismo de maior freqüência a Escherichia coli (47,8%). A sensibilidade foi 95,6% e a especificidade 63,3% do exame de urina simples em relação ao diagnóstico de ITU. A acurácia foi de 66,5%. A análise dos valores preditivos positivo e negativo (VPP e VPN) mostrou que na vigência de exame de urina simples normal, a chance de haver ITU foi pequena (VPN 99,2%), frente ao resultado alterado deste exame, a probabilidade de haver ITU foi baixa (VPP 22,4%). Conclui-se que a acurácia do exame de urina simples como meio diagnóstico de infecção urinária foi baixa; alterações no exame de urina simples, mesmo na presença... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Anatomic and physiological alterations during pregnancy predispose pregnant women to urinary tract infections (UTI). Poor treatment or no treatment at all of these infections may lead to neonatal and obstetric complications like premature amniorexis, premature labor and delivery. Considering complications relevance and the possibility of asymptomatic bacteriuria occurrence and the delay from uroculture results, gold standard for UTI diagnosis, many professionals choose to begin UTI treatment in the pregnant woman, if simple urine examination is altered even in the absence of clear clinical signals. Objective: Identify simple urine examination accuracy to diagnose urinary tract infection in low risk pregnant women. Material and Methods: An analytical and transversal study was performed in Botucatu/SP. The service began with simple urine examination and uroculture, data collected from October 2006 to March 2008 in the basic health service. Results: 230 pregnant women were included in the study with an average age of 25,2 years (14 - 43), 79,2% married or under stable relationship. UTI prevalence was 10%, Escherichia coli as a more frequent organism (47, 8%). Sensitiveness was 95,6% and specificity 63,3% of simple urine examination related to UTI diagnosis. Accuracy was 66,5%. The analysis of predictive positive and negative values (PPV e NPV) showed that during a normal and simple urine examination UTI occurrence was lower (NPV 99,2%), against the altered result of this examination the likely of UTI occurrence was low (PPV 22,4%). One conclude that simple urine examination accuracy as a way of urinary infection diagnosis was low; alterations in simple urine examination, even in the presence of clinical signals do not necessarily means UTI and uroculture is extremely necessary for a right diagnosis. / Orientador: Cristina Maria de Lima Parada / Coorientador: Márcia Guimarães da Silva / Banca: Vera Therezinha Medeiros Borges / Banca: Maria José Clapis / Mestre

Made available in DSpace on 2014-06-11T19:29:51Z (GMT). No. of bitstreams: 0 Previous issue date: 2012-08-27Bitstream added on 2014-06-13T18:06:38Z : No. of bitstreams: 1 baccarin_sm_me_botfm.pdf: 253817 bytes, checksum: 14fabe755f6fe5058ef74442d65c4734 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / No passado, as gestantes eram aconselhadas a reduzirem suas atividades de trabalho ocupacional ou muitas vezes a interrompê-las, especialmente durante os estágios finais da gestação. Acreditava-se que essas atividades aumentariam o risco de trabalho de parto prematuro. Atualmente, entende-se que, apenas determinadas atividades laborais podem ser fatores de risco para intercorrências como parto prematuro e baixo peso ao nascer. Por outro lado, verifica-se que o gasto energético de nível médio pode ser vantajoso para o ganho de peso do recém-nascido e contribui para a redução do risco de complicações no parto. Em contrapartida, a baixa atividade física acarreta maiores chances de prematuridade. Caracterizar o perfil das atividades cotidianas e determinar o desfecho materno-perinatal de gestantes nulíparas. Foram avaliada 106 gestantes nulíparas, acompanhadas no Serviço de Obstetrícia do Hospital das Clínicas da Faculdade de Medicina de Botucatu – Unesp. Foram considerados critérios de inclusão ter: gestação única e não ser portadora de doença clínica ou intercorrência obstétrica. Todas as gestantes responderam a um interrogatório com intuito de determinar o perfil de atividades cotidianas desempenhadas pelas mesmas, bem como a energia gasta ao realizar essas atividades. Foram analisados os desfechos maternos (evolução da gestação e tipo de parto) e perinatais (peso, índice de Apgar e peso em relação à idade gestacional). Os grupos de gestantes com atividade física leve e sedentária foram comparados em relação às variáveis numéricas pelo teste de Mann-Whitney e em relação às variáveis categóricas pelo teste Qui-quadrado ou pelo teste exato de Fisher. Considerou-se o nível de significância de 5%. Observou-se predomínio de adolescentes (57,5%) e alta taxa de... / In the past, pregnant women were advised to reduce their occupational work activities or often break them, especially during the final stages of pregnancy. It was believed that these activities might increase the risk of premature labor. Currently, it is understood that only certain activities can be risk factors for complications such as premature delivery and low birthweight. On the other hand, it appears that the average energy expenditure can be advantageous for the weight gain of the newborn and contributes to reducing the risk of complications at birth. In contrast, low physical activity leads to greater chances of prematurity. To characterize the profile of daily activities and determine the maternal and perinatal outcome of nulliparous women. We evaluated 106 nulliparous pregnant women attended at the Obstetric Service of Clinical Hospital of Botucatu Medical School - UNESP. The inclusion criteria were: single pregnancy and not show clinical disease or obstetric complications. All pregnant women completed the interrogation aiming to determine the profile of daily activities performed by them, as well as the energy expended to perform these activities. We analyzed the maternal (pregnancy outcome and type of birth) and perinatal (weight, Apgar score and weight for gestational age) outcomes. The groups of pregnant women with mild physical activity and sedentary were compared to the numerical variables by the Mann-Whitney test and for categorical variables by chi-square test or Fisher's exact test. The significance level was set at 5%. It was observed the predominance of adolescents (57.5%) and high inactivity rate (69.8%), with a large percentage of daily activity represented by watching television over 4 hours daily (41,5%). Comparison between sedentary and light physical activity or less active groups showed that... (Complete abstract click electronic access below)

Made available in DSpace on 2014-06-11T19:29:51Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-02-24Bitstream added on 2014-06-13T18:39:55Z : No. of bitstreams: 1 medeiros_ltl_me_botfm.pdf: 283518 bytes, checksum: dbcb08c9c963c43e9e5990d9795fb85f (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Monócitos do sangue periférico de gestantes portadoras de pré-eclâmpsia encontram-se ativados endogenamente e secretam níveis elevados de radicais livres e citocinas inflamatórias. Este trabalho teve como objetivo avaliar se o estado inflamatório de monócitos, observado na pré-eclâmpsia, está associado à polarização da subpopulação de monócitos de perfil M1 no sangue periférico, correlacionando a expressão de receptores de superfície CD64, TLR2, TLR4, CD163 e CD206 com a produção de citocinas. Foram estudadas 90 gestantes, sendo 30 normotensas e 60 portadoras de pré-eclâmpsia, pareadas pela idade gestacional. Monócitos de sangue periférico obtidos de gestantes normais ou com pré-eclâmpsia foram cultivados por 18h na ausência ou presença de lipopolissacáride de Escherichia coli (LPS) ou de peptidoglicano (PG) de bactéria Gram-positiva. A expressão de receptores presentes na superfície da subpopulação de monócitos inflamatórios M1 (TLR2, TLR4 e CD64) e de monócitos supressores M2 (CD163 e CD206) foi detectada por de citometria de fluxo, empregando-se anticorpos monoclonais específicos, marcados com fluorocromos. Os resultados foram expressos como média da intensidade de fluorescência. Além disso, a produção de citocinas pró-inflamatórias associadas a padrão M1 (TNF-, IL-12p70 e IL-23) e anti-inflamatória, associada a perfil M2 (IL-10) foi avaliada no sobrenadante de cultura de monócitos pela técnica de ELISA. Os resultados foram analisados por testes não paramétricos, com nível de significância de 5%. A expressão de CD64 e TLR4 em monócitos, não estimulados, de gestantes com pré-eclâmpsia foi significativamente maior, enquanto a expressão de CD163 e CD206 foi significativamente menor em relação às gestantes normotensas, sugerindo a expressão de um perfil M1 de... / Monocytes from peripheral blood of pregnant women with preeclampsia are endogenously activated and secrete high levels of free radicals and inflammatory cytokines. This work aimed to evaluate whether the inflammatory state of monocytes observed in preeclampsia is associated with the polarization of monocyte to M1 profile in peripheral blood, correlating the expression of surface receptors CD64, TLR2, TLR4, and CD163 and CD206 with cytokine production. We studied 90 pregnant women, 30 normotensive and 60 with preeclampsia, matched for gestational age. Peripheral blood monocytes obtained from normotensive pregnant or preeclamptic pregnant women were cultured for 18h in the absence or presence of Escherichia coli lypopolysacharide (LPS) or peptidoglycan (PG) of Gram-positive bacteria, and the expression of surface receptors on M1 inflammatory monocyte subpopulation (TLR2, TLR4 and CD64) and M2 suppressor monocyte subpopulation (CD163 and CD206) were evaluated by flow cytometry, using specific monoclonal antibodies, labeled with fluorochromes. The values were expressed as the mean fluorescence intensity. Moreover, the production of proinflammatory cytokines associated with M1 profile (TNF-, IL-12p70 and IL-23) and the anti-inflammatory cytokine associated with M2 profile (IL-10) were evaluated in the monocyte supernatant of culture by enzyme immunoassay. Results were analyzed using nonparametric tests with significance level set at 5%. The expression of CD4 and TLR4 on non-stimulated monocytes, from women with preeclampsia was significantly higher, while the expression of CD163 and CD206 was significantly decreased compared with normotensive pregnant women, suggesting the predominance of monocyte M1 profile. Endogenous production of TNF-, IL-12p70 and IL-23 by monocytes was increased, while synthesis of IL-10 was lower in women with... (Complete abstract click electronic access below)

Over 18 million caesarean sections (CS) are performed around the world each year, with many being planned repeat CS which may lack absolute indications. Abdominal delivery on this scale demands an appreciation of the lasting impact, positive or negative, on the health of women and children. Maternal outcomes of planned CS birth have been extensively investigated, but knowledge of outcomes for offspring is largely limited to those occurring in the neonatal period. Avoiding labour and vaginal birth may protect offspring from birth injuries, but could also adversely affect their later health due to avoidance of physiological processes which aid immunity and gut function. Concern that CS may compromise offspring health has arisen from studies which demonstrate an increased risk of chronic health problems following CS compared with vaginal birth. However, the clinical implications of existing studies are unclear due to high risk of selection bias, confounding and lack of power. Studies which can overcome these issues are required. Studies focusing on offspring of women with a history of CS mean the risk of confounding by indication for CS is minimised, as the majority of repeat CS are planned due to maternal preference rather than medical indications. At present, it is not known whether perceived offspring health outcomes of mode of delivery drive women's birth choices after a previous CS, and if so, whether such beliefs reflect evidence-based information on offspring risks. The existing literature highlights a number of factors that may play a role in shaping these birth choices, but no studies have attempted to identify beliefs which independently predict birth preferences after a CS. Such a study has potential to identify key beliefs to target in future interventions designed to optimise women's birth choices. This project investigated both the health of offspring delivered by planned repeat CS and women's beliefs which predict their preferred mode of delivery after CS. Offspring health was investigated using a population-based cohort study. Pregnant women's beliefs about birth after CS were investigated using a synthesis of qualitative literature and a theory based interview and questionnaire study.

A vacinação contra a rubéola tem como objetivo único, a proteção de futuras gerações de crianças em desenvolver a rubéola congênita. Gregg40, em 1941, levantou a hipótese de a rubéola ser a causa do nascimento de crianças com graves malformações congênitas. A confirmação etiológica só foi possível em 1962, com o isolamento do vírus, o que permitiu o desenvolvimento da vacina. A vacina foi utilizada, a partir de 1969, nos Estados Unidos e na Inglaterra e, atualmente, faz parte dos programas de vacinação de rotina na maioria dos países desenvolvidos. As experiências de mais de duas décadas no uso da vacina nos programas de controle da SÍNDROME DA RUBÉOLA CONGÊNITA (SRC) mostraram que a epidemiologia da rubéola, assim como a operacionalização das metas propostas para a cobertura vacinal são bastante complexas. As características do vírus, na sua interação com a população humana, determinam um padrão de transmissibilidade que propicia a formação de bolsões de indivíduos suscetíveis na idade adulta. Em condições naturais, a rubéola infecta cerca de 80 por cento a 90 por cento das pessoas até os 20 anos de idade, deixando um resíduo de indivíduos suscetíveis a partir desta idade, que, aparentemente, se mantém mesmo com epidemias sucessivas. O nascimento de crianças com SRC está condicionado à infecção rubeólica durante a gestação das mães destas crianças, portanto, a existência de mulheres suscetíveis à rubéola na idade fértil é uma condição fundamental à ocorrência da doença. O óbito de crianças malformadas detectadas em alguns meses do ano de 1986 chamou a atenção dos epidemiologistas do Município de Bauru para uma possível associação com a epidemia de rubéola ocorrida na cidade em 1985. Conhecer a proporção de suscetibilidade à rubéola entre gestantes é uma das maneiras para se estimar o risco de ocorrência de SRC. Em 1987, 689 gestantes residentes no Município de Bauru foram entrevistadas e submetidas a teste de inibição de hemaglutinação para determinação de suscetibilidade à rubéola. Destas gestantes, 66 (9,7 por cento ) foram consideradas suscetíveis à rubeóla. Não houve diferença estatisticamente significante na proporção de suscetibilidade das gestantes em relação à idade, número de gestações, paridade e idade gestacional, o que de certa forma confirma a dificuldade do vírus da rubéola em infectar todas as pessoas até o início da idade adulta, mesmo após uma epidemia. Este resíduo de suscetibilidade dificilmente seria eliminado naturalmente, como mostram as diferentes experiências nos países que iniciaram um programa de controle da SRC. Seria necessária uma alta cobertura vacinal (cerca de 95 por cento ) de todas as coortes de crianças e adolescentes para se conseguir a quebra na cadeia do processo infeccioso. Concomitantemente, é decisiva a proteção de todas as mulheres em idade fértil até que, estas coortes de indivíduos bem imunizados atinjam a idade fértil. Uma intervenção desta natureza não poderia ser implementada sem o respaldo de um sistema de vigilância epidemiológica fortalecido e atuante, capaz de monitorar não apenas o andamento do programa, mas, fundamentalmente, medir o impacto desta intervenção em termos de incidência de SRC. Considerando as características de polimorfismo da SRC e as dificuldades em se medir a magnitude da infecção congênita, a avaliação de um programa que envolve pelo menos duas gerações de indivíduos é um grande desafio para os administradores de saúde, principalmente, nos países em desenvolvimento. / The vaccination against rubella has as the only objectif to protect the future generations of children from the congenital rubella. Gregg, in 1941, supposed that the rubella should be the cause of birth of children with serious congenital abnormalities. The etiologial confirmation was only possible in 1962, by the isolation of virus, which allowed the development of vaccine. Firstly, utilized in the United States and Great Britain, in 1969, nowadays the vaccine is used in most developed countries. Experiences performed during more than two decades in usage of the vaccines during the Congenital Rubella Syndrome Control Program, showed that the epidemiology of the rubella, as well as, the exequibility of proposed aims for the vaccinal coverture are quite complex. The virus characteristics and its interactions with the population, determine a transmissibility pattern, which provides the formation of susceptible \"cluster\" in the adult age. In natural conditions, the rubella infects about 80 per cent to 90 per cent of people up to the age of twenty, leaving a susceptible remains after this age, which, apparently, it is maintained even with continuous epidemics. As the CRS children birth is connected to the rubella infection during the gestacional age of those mothers, the existence of susceptible childbearing age women is the most important condition for the disease to break out. In 1985, in the City of Bauru (São Paulo), abnormal number of death of congenital abnormalities children was focused by local epidemilogists. This fact was supposed, by the epidemiologists, being associated to a rubella epidemic in the year before. One of the ways to estimate the risk of occurance of RCS is to know the level of susceptibility among pregnant women. In 1987, 689 pregnant women, dwelling in the City of Bauru, were interviewed and went through a haemagglutination-inibition test in order to determine the susceptibility to rubella. Sixty-six out of these pregnant women was considered susceptible to rubella. There was not any difference statistically significant in the susceptible proportion of the pregnant women related to age, number of pregnancies, number of deliveries and gestacional age which somehow confirm the difficult of the rubella virus to infect all people up the beginning of the adult age, even after an epidemic. This susceptible remains would hardly ever be eliminated naturaly, as it is shown in the different experiences in countries, which began the RCS Control Program. The experiences showed that it would possibly, be necessary a high vaccinal coverture (about 95 per cent ) of all generations of children and adolescents in order to get the break of the infection process chain. Concomitantly, the protection of all women in childbearing age is important, until these generations of well vaccinated individuais reach the childbearing age. Such intervention should not be implemented without the agreement of an epidemiological surveillance system, both dynamic and strong, in order to monitore not only, the follow up of the program, but also, to measure the impact of this intervention in terms of RCS incidence. Considering the RCS characterists of polimorfism and the difficulties to evaluate the magnitude of congenital infection, the evaluation of a program that involves, at least, two generations of individuais, is a great challenge for the health administars, specially, in developing countries.

nÃo hà / Este estudo objetivou conhecer as percepÃÃes de mÃdicos, enfermeiros e dentistas da EstratÃgia SaÃde da FamÃlia-ESF sobre a atenÃÃo à saÃde bucal das gestantes, utilizando uma abordagem qualitativa. A coleta dos dados foi realizada em Unidades BÃsicas de SaÃde da Regional III, no municÃpio de Fortaleza-CE, no perÃodo de setembro a novembro de 2013, por meio de entrevistas, utilizando roteiro semiestruturado, as quais foram gravadas, transcritas e posteriormente analisadas à luz da anÃlise temÃtica de Minayo. O conteÃdo e o significado das falas foram agrupados em nÃcleos temÃticos e, posteriormente, considerando as semelhanÃas e diferenÃas, organizados em trÃs categorias: Condutas da equipe da ESF em relaÃÃo à saÃde bucal da gestante; PercepÃÃes de profissionais da ESF sobre a saÃde bucal da gestante e Estrutura e organizaÃÃo dos serviÃos. Os resultados mostraram a necessidade da atuaÃÃo conjunta dos profissionais nas atividades de promoÃÃo da saÃde bucal de gestantes, tendo sido ressaltada a importÃncia da realizaÃÃo do tratamento odontolÃgico durante o perÃodo gestacional, considerando que a saÃde bucal da gestante pode impactar em sua saÃde geral e do bebÃ. Enquanto alguns mÃdicos e enfermeiros da ESF realizam instruÃÃes de higiene oral e, ou encaminham a gestante para o serviÃo odontolÃgico, outros sà adotam esta conduta diante de alguma queixa ou problema bucal. O autocuidado da gestante em relaÃÃo à saÃde bucal foi considerado deficiente pelos profissionais, devendo ser reforÃado durante as consultas e atividades coletivas. Ainda persistem mitos entre as gestantes de que nÃo podem se submeter a tratamento odontolÃgico e que a gravidez causa problemas bucais. A grande demanda, a falta de insumos e equipamentos constantemente danificados foram dificuldades apontadas para inÃcio, seguimento e conclusÃo dos tratamentos e realizaÃÃo de atividades educativas. Conclui-se que na ESF encontram-se condiÃÃes para a atenÃÃo integrada à saÃde bucal da gestante devido à presenÃa de equipe multiprofissional e a grande possibilidade de interaÃÃo entre o dentista e os profissionais que realizam o prÃ-natal. Contudo, hà necessidade de organizar a demanda e investir na capacitaÃÃo permanente dos profissionais, estrutura fÃsica, equipamentos e insumos das unidades. / This study has investigated the perceptions of physicians, nurses and dentists from the Family Health Strategy â FHS, on attention to the oral health of pregnant women, using a qualitative approach. Data collection was performed at Basic Health Units of Regional III, in the city of Fortaleza, in the period September-November 2013, by using semi-structured interviews, which were taped, transcribed and then analyzed through thematic analysis of Minayo. The content and meaning of the statements were grouped into thematic groups and then considering the similarities and differences, were organized into three categories: The way of working of the FHS team for the oral health of pregnant women; Perceptions of FHS professionals about oral health during pregnancy and the structure and organization of services. The results showed the need for joint work of professionals in activities to promote oral health of pregnant women, having been stressed the importance of performing dental treatment during pregnancy, considering that oral health of pregnant women can affect their overall health and of your baby. While some doctors and nurses FHS perform oral hygiene instructions and either refer the pregnant women to dental services, others simply adopt this approach considering any oral complaints or problems. Pregnant womenâs self-care in relation to oral health was deemed deficient by professionals and should be reinforced during the consultations and collective activities. Myths still persist among pregnant women who understand that they cannot undergo dental treatment and that pregnancy causes oral problems. The great demand, lack of supplies and equipment damaged were constantly difficulties for beginning, follow-up and completion of the treatments and educational activities. We conclude that the FHS presents the conditions for integrated oral health of pregnant women because the presence of a multidisciplinary team and the great possibility of interaction between the dentist and the professionals who perform prenatal. However, there is need to organize demand and invest in ongoing professional training, physical structure, equipment and inputs of units.