ABSTRACT Objective This study aimed to evaluate the prevalence of hypertensive disorders during pregnancy among Brazilian women with preterm births and to compare the epidemiological characteristics and perinatal outcomes among preterm births of women with and without hypertension. Methods This was a secondary cross-sectional analysis of the Brazilian Multicenter Study on Preterm Birth. During the study period, all women with preterm births were included and further split into two groups according to the occurrence of any hypertensive disorder during pregnancy. Prevalence ratios were calculated for each variable. Maternal characteristics, prenatal care, and gestational and perinatal outcomes were compared between the two groups using χ2 and t-tests. Results A total of 4,150 women with preterm births were included, and 1,169 (28.2%) were identified as having hypertensive disorders. Advanced maternal age (prevalence ratio (PR) 2.49) and obesity (PR= 2.64) were more common in the hypertensive group. The gestational outcomes were worse in women with hypertension. Early preterm births were also more frequent in women with hypertension. Conclusion Hypertensive disorders of pregnancy were frequent among women with preterm births, and provider-initiated preterm births were the leading causes of premature births in this group. The factors significantly associated with hypertensive disorders among women with preterm births were obesity, excessive weight gain, and higher maternal age. hypertension crosssectional cross sectional Birth period variable care χ ttests. ttests t tests. tests t-tests 4150 4 150 4,15 1169 1 169 1,16 28.2% 282 28 2 (28.2% PR (PR 2.49 249 49 PR= 2.64 264 64 group providerinitiated provider initiated gain 415 15 4,1 116 16 1,1 28.2 (28.2 2.4 24 2.6 26 6 41 4, 11 1, 28. (28. 2. (28 (2 (

Abstract Objective To identify the opinion of coordinators and members about the essential characteristics and to understand the research networks characteristics, to facilitate their implementation, sustainability and effectiveness so it can be replicated in low and middle-income countries. Methods A qualitative study using a semi-structured interview technique was conducted. We selected potential members, managers and participants of networks from publications identified in PubMed. After checking the FIGO congress program, we identified authors who were assigned as speakers at the event. An invitation was sent and interviews were scheduled. Results In total, eleven interviews were performed. Coordinators and members of networks have the same goal when they decide to participate in a network. In general, they cited that these individuals had to be committed, responsible and enthusiastic people. The network should be composed also of postgraduate students. A network should allow multi-leadership, co-responsibility, autonomy and empowerment of its members. Effective communication was mentioned as an important pillar for network maintenance. Another motivation is being an author or coauthor in publications. One way to maintain a network running is social or governmental commitment, after resources expire, studies continue. Conclusion Networks are different due to the social context where they are inserted, however, some characteristics are common to all of them, such as having engaged leaders. For an effective and sustainable network, commitment and motivation in a leader and members are more in need than financial resources. Ideally, to ensure the operation of the network, the institution where the leader is linked should support this network. implementation middleincome middle income countries semistructured semi structured conducted PubMed program event scheduled total performed general committed people students multileadership, multileadership multi leadership, leadership multi-leadership coresponsibility, coresponsibility co responsibility, responsibility co-responsibility maintenance expire continue inserted however them leaders Ideally

ABSTRACT Objective The objective was to compare the maternal and perinatal characteristics and outcomes between women with and without diabetes in a Brazilian cohort of women with preterm births. Methods This was an ancillary analysis of the Brazilian Multicenter Study on Preterm Birth, which included 4,150 preterm births. This analysis divided preterm births into two groups according to the presence of diabetes; pregestational and gestational diabetes were clustered in the same Diabetes Group. Differences between both groups were assessed using χ 2 or Student’s t tests. Results Preterm births of 133 and 4,017 women with and without diabetes, respectively, were included. The prevalence of diabetes was 3.2%. Pregnant women aged ≥35 years were more common in the Diabetes Group (31.6% versus 14.0% non-diabetic women, respectively). The rate of cesarean section among patients with diabetes was 68.2% versus 52.3% in non-diabetic cases), with a gestational age at birth between 34 and 36 weeks in 78.9% of the cases and 62.1% of the controls. Large-for-gestational-age babies were 7 times more common in the Diabetes Group. Conclusion Preterm birth among Brazilian women with diabetes was more than twice as prevalent; these women were older and had regular late preterm deliveries, usually by cesarean section. They also had a greater frequency of fetal morbidities, such as malformations and polyhydramnios, and a higher proportion of large-for-gestational-age and macrosomic neonates. Birth 4150 4 150 4,15 Students Student s tests 13 4017 017 4,01 respectively 32 3 3.2% 35 ≥3 31.6% 316 31 6 (31.6 140 14 0 14.0 nondiabetic non diabetic respectively. . respectively) 682 68 68.2 523 52 52.3 cases, , cases) 789 78 9 78.9 621 62 1 62.1 controls Largeforgestationalage Large for prevalent deliveries morbidities polyhydramnios largeforgestationalage large neonates 415 15 4,1 401 01 4,0 3.2 ≥ 31.6 (31. 14. 68. 5 52. 78. 62. 41 4, 40 3. 31. (31 (3 (

Resumo Objetivo Lúpus eritematoso sistêmico (LES) pode causar danos irreversíveis aos órgãos. A gravidez com LES pode ter riscos para condições ameaçadoras à vida. O presente estudo teve como objetivo determinar a prevalência de MMG em pacientes com LES e analisar os parâmetros que contribuíram para os casos de maior gravidade. Métodos Trata-se de um estudo transversal retrospectivo a partir da análise de dados obtidos de prontuários de gestantes com LES atendidas em um Hospital Universitário no Brasil. As gestantes foram divididas em grupo controle sem intercorrências, grupo com condições potencialmente ameaçadoras a vida (CPAV) e grupo com near miss materno (NMM). Resultados A taxa de NMM foi de 112,9 por 1.000 nascidos vivos. A maioria dos casos de CPAV (83,9%) e NMM (92,9%) teve partos prematuros com risco aumentado estatisticamente significativo em comparação com o grupo controle (p = 0,0042; odds ratio [OR]: 12,05; intervalo de confiança [IC]: 1,5–96,6 para o grupo NMM e p = 0,0001; OR: 4,84; IC95%: 2,2–10,8 para o grupo CPAV). MMG aumenta o risco de maior tempo de internação (p < 0,0001; OR: 18,8; IC95%: 7,0–50,6 e p < 0,0001; OR: 158,17; IC95%: 17,6–1424,2 para os grupos CPAV e NMM, respectivamente), recémnascidos com baixo peso (p = 0,0006; OR: 3,67; IC95%: 1,7–7,9 e p = 0,0009; OR: 17,68; IC95%: 2–153,6 para os grupos CPAV e NMM, respectivamente), bem como doenças renais (CPAV: 58,9%; 33/56; p = 0,0069 e NMM: 78,6%; 11/14; p = 0,0026)]. Os casos de NMM apresentaram risco aumentado para óbito neonatal (p = 0,0128; OR: 38,4; IC95%: 3,3–440,3), natimorto e aborto espontâneo (p = 0,0011; OR: 7,68; IC95%: 2,2–26,3). Conclusão Lúpus eritematoso sistêmico foi significativamente associado à morbidade materna grave, internações mais longas e risco aumentado de desfechos obstétricos e neonatais ruins. (LES órgãos gravidade Tratase Trata se Brasil intercorrências (CPAV NMM. . (NMM) 1129 112 9 112, 1000 1 000 1.00 vivos 83,9% 839 83 (83,9% 92,9% 929 92 (92,9% 0,0042 00042 0 0042 OR [OR] 12,05 1205 12 05 IC [IC] 15966 5 96 6 1,5–96, 0,0001 00001 0001 4,84 484 4 84 IC95% IC95 22108 2 10 8 2,2–10, CPAV. CPAV) 18,8 188 18 70506 7 50 7,0–50, 158,17 15817 158 17 17614242 1424 17,6–1424, respectivamente, respectivamente , respectivamente) 0,0006 00006 0006 3,67 367 3 67 1779 1,7–7, 0,0009 00009 0009 17,68 1768 68 21536 153 2–153, 58,9% 589 58 33/56 3356 33 56 00069 0069 0,006 78,6% 786 78 11/14 1114 11 14 0,0026. 00026 0,0026 0026 0,0026)] 0,0128 00128 0128 38,4 384 38 3,3–440,3, 334403 3,3–440,3 440 3,3–440,3) 0,0011 00011 0011 7,68 768 2,2–26,3. 22263 2,2–26,3 26 2,2–26,3) grave ruins (NMM 100 00 1.0 83,9 (83,9 92,9 (92,9 0,004 0004 004 [OR 12,0 120 [IC 1596 1,5–96 0,000 0000 4,8 48 IC9 2210 2,2–10 18, 7050 7,0–50 158,1 1581 15 1761424 142 17,6–1424 3,6 36 177 1,7–7 17,6 176 2153 2–153 58,9 33/5 335 006 0,00 78,6 11/1 111 0002 0,002 002 0,0026) 0,012 0012 012 38, 33440 3,3–440, 44 0,001 001 7,6 76 2226 2,2–26, 1. 83, (83, 92, (92, 12, 159 1,5–9 4, 221 2,2–1 705 7,0–5 158, 176142 17,6–142 3, 1,7– 17, 215 2–15 58, 33/ 0,0 78, 11/ 0,01 01 3344 3,3–440 7, 222 2,2–26 (83 (92 1,5– 22 2,2– 70 7,0– 17614 17,6–14 1,7 21 2–1 0, 334 3,3–44 2,2–2 (8 (9 1,5 2,2 7,0 1761 17,6–1 1, 2– 3,3–4 ( 2, 17,6– 3,3– 3,3

Abstract Objective Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity. Methods This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM). Results The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5–96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2–10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0–50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6–1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7–7.9 and p = 0.0009; OR: 17.68; 95%CI: 2–153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3–440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2–26.3]). Conclusion Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes. (SLE damage lifethreatening life threatening risks SMM (SMM severity crosssectional cross sectional Brazil complications PLTC, , (PLTC) MNM. . (MNM) 1129 112 9 112. 1000 1 000 1,00 births 83.9% 839 83 (83.9% 92.9% 929 92 (92.9% 0.0042 00042 0 0042 OR [OR] 12.05 1205 12 05 95 CI [CI] 15966 5 96 6 1.5–96. 0.0001 00001 0001 4.84 484 4 84 95%CI 95CI 22108 2 10 8 2.2–10. group. group) 18.8 188 18 70506 7 50 7.0–50. 158.17 15817 158 17 17614242 1424 17.6–1424, groups respectively, respectively respectively) 0.0006 00006 0006 3.67 367 3 67 1779 1.7–7. 0.0009 00009 0009 17.68 1768 68 2–153.6 21536 153 8.9% 89 [8.9% 33/56 3356 33 56 0.0069 00069 0069 78.6% 786 78 [78.6% 11/14 1114 11 14 0.0026. 00026 0.0026 0026 0.0026]) 0.0128 00128 0128 38.4 384 38 3.3–440.3, 334403 3.3–440.3 440 3.3–440.3]) 0.0011 00011 0011 7.68 768 2.2–26.3. 22263 2.2–26.3 26 2.2–26.3]) hospitalizations outcomes (MNM 100 00 1,0 83.9 (83.9 92.9 (92.9 0.004 0004 004 [OR 12.0 120 [CI 1596 1.5–96 0.000 0000 4.8 48 2210 2.2–10 18. 7050 7.0–50 158.1 1581 15 1761424 142 17.6–1424 3.6 36 177 1.7–7 17.6 176 2–153. 2153 8.9 [8.9 33/5 335 0.006 006 78.6 [78.6 11/1 111 0002 0.002 002 0.0026] 0.012 0012 012 38. 33440 3.3–440. 44 3.3–440.3] 0.001 001 7.6 76 2226 2.2–26. 2.2–26.3] 1, 83. (83. 92. (92. 0.00 12. 159 1.5–9 4. 221 2.2–1 705 7.0–5 158. 176142 17.6–142 3. 1.7– 17. 2–153 215 8. [8. 33/ 78. [78. 11/ 0.01 01 3344 3.3–440 7. 222 2.2–26 (83 (92 0.0 1.5– 22 2.2– 70 7.0– 17614 17.6–14 1.7 2–15 21 [8 [78 334 3.3–44 2.2–2 (8 (9 0. 1.5 2.2 7.0 1761 17.6–1 1. 2–1 [ [7 3.3–4 ( 2. 17.6– 2– 3.3– 3.3

Resumo Objetivo Investigar as características das mulheres com parto pré-termo e os respectivos resultados de acordo com a etnia. Métodos Uma análise secundária de umestudo de corte transversalmulticêntrico no Brasil. Mulheres com parto pré-termo foram classificadas por autodefinição como brancas ou não brancas. Dados maternos, clínicos, e da gestação foram coletados por entrevista pós-parto e revisão de prontuários. As características sociodemográficas, obstétricas e clínicas das mulheres, o tipo de parto, e os resultados neonatais dos grupos étnicos foram comparados por análise bivariada. Resultados Das 4.150 mulheres que tiveram parto pré-termo, 2.317 (55,8%) eram não brancas, que com mais frequência: eram menores de 19 anos de idade (razão de prevalência [RP]: 1,05; intervalo de confiança de 95% [IC95%]: 1,01-1,09); não tinham parceiro; eramde baixa renda; tinham baixa escolaridade; tinham ≥ 2 filhos; realizavam trabalho extenuante; provinhammais do Nordeste do que do Sul; tinham histórico de ≥ 3 partos; tinham intervalo interpartal<12 meses; e tiveram complicações gestacionais como aborto, parto pré-termo, rotura prematura de membranas pré-termo (RPM-PT) e baixo peso ao nascimento; iniciaram as consultas de pré-natal no segundo ou terceiro trimestres; comparecerama um número inadequado de consultas; viviam sob contínua exaustão; fumaram no primeiro e segundo ou terceiro trimestres; e tiveram anemia e hipertensão gestacional. Os resultados maternos e neonatais não diferiram entre os grupos, exceto pelamaior taxa de baixo peso ao nascimento (73,7% versus 69,0%) entre as crianças das mulheres não brancas, e e a maior taxa de convulsões (4,05% versus 6,29%) entre as das brancas. Conclusão Condições desfavoráveis foram mais comuns entre não brancas do que entre brancas. Políticas apropriadas são necessárias para diminuir as diferenças, especialmente no contexto da prematuridade, quando mulheres e seus neonatos têm necessidades específicas.

Abstract Objective To investigate the characteristics of women who had preterm birth (PTB) and related outcomes according to ethnicity. Methods A secondary analysis of a multicenter cross-sectional study conducted in Brazil. Women who had PTB were classified by self-report as white and non-white. Clinical, pregnancy, and maternal data were collected through postpartum interviews and reviews of medical charts. The sociodemographic, obstetric and clinical characteristics of the women, as well as the mode of delivery and the neonatal outcomes among different ethnic groups were compared through a bivariate analysis. Results Of the 4,150 women who had PTB, 2,317 (55.8%) were non-white, who were more likely: to be younger than 19 years of age (prevalence ratio [PR]: 1.05; 95% confidence interval [95%CI]: 1.01-1.09); to be without a partner; to live on low income; to have lower levels of schooling; to have ≥ 2 children; to perform strenuous work; to be fromthe Northeastern region of Brazil rather than the from Southern region; to have a history of ≥ 3 deliveries; to have an interpregnancy interval<12 months; to have pregnancy complications such as abortion, PTB, preterm premature rupture of membranes (pPROM), and low birth weight; to initiate antenatal care (ANC) visits in the second or third trimesters; to have have an inadequate number of ANC visits; to be under continuous overexertion; to smoke in the first and second or third trimesters; and to have anemia and gestational hypertension. The maternal and neonatal outcomes did not differ between the groups, except for the higher rate of low birth weight (73.7% versus 69.0%) in infants born to non-white women, and the higher rate of seizures (4.05% versus 6.29%) in infants born to white women. Conclusion Unfavorable conditions weremore common in non-whites than inwhites. Proper policies are required to decrease inequalities, especially in the context of prematurity, when women and their neonates have specific needs.

Resumo Objetivo Avaliar o efeito da utilização de unidades de terapia intensiva (UTIs) na mortalidade materna (MM) entre mulheres com morbidade materna grave (MMG). Materiais e Métodos Foi realizada uma análise secundária de um estudo transversal de vigilância de morbidade materna grave em 27 centros de referência obstétrica no Brasil. O foco desta análise foi a associação entre a utilização de UTI e morte materna segundo características individuais e condições de gravidade. Análises múltiplas considerando as variáveis uso de UTI, idade, etnia, adequação do cuidado e índice de desenvolvimento humano foram realizadas para identificar os fatores associados à morte materna e near-miss materno. Resultados Dos 82.388 partos ocorridos durante o período de estudo, 9.555 (11,6%) mulheres apresentaram MMG, e a razão de MM foi de 170,4/100 mil nascidos vivos. Neste grupo, 8.135 (85,1%) pacientes foram atendidas em instituições com disponibilidade de leitos de UTI, mas apenas 2.059 (25,3%) foram de fato admitidas em leitos de UTI. Na análise de regressão multivariada, quando se considerou a gravidade do caso pelo maternal severity score (pontuação de severidade materna, MMS, na sigla em inglês), houve uma grande redução da força de associação entre utilização de UTI e morte materna, além da inadequação do cuidado e não disponibilidade de UTI na instituição. Na avaliação considerando apenas os casos de maior gravidade (desfecho materno grave, DMG), observou-se o mesmo padrão de associação entre UTI e MM. Nos modelos utilizados, apenas a inadequação do cuidado e o MSS apresentam associação significativa com a MM. Conclusão O presente estudo aponta que as principais variáveis associadas à morte materna são a gravidade e a adequação do manejo do caso, mais frequentes nas internações em UTI. A utilização dos leitos de UTI sem a estratificação da gravidade da paciente pode não trazer benefícios esperados para uma parte das mulheres.

Abstract Objective To assess the use of the intensive care unit (ICU) and its effect on maternal mortality (MM) among women with severe maternal morbidity (SMM). Materials and Methods A secondary analysis of a cross-sectional study on surveillance of SMM in 27 Brazilian obstetric referral centers. The analysis focused on the association between ICU use and maternal death according to individual characteristics and disease severity. Two multivariate regressions considering use of the ICU, age, ethnicity, adequacy of care and the human development index were performed to identify the factors associated to maternal death and maternal near-miss. Results Out of 82,388 deliveries during the period, there were 9,555 (11.6%) women with SMM, and the MM ratio was of 170.4/100 thousand live births. In total, 8,135 (85.1%) patients were managed in facilities in which ICUs were available; however, only 2,059 (25.3%) had been admitted to the ICU. On the multivariate analysis, when the severity of the maternal disease was measured by the maternal severity score (MMS), the strength of the association between the use of the ICU and maternal death was greatly reduced, along with inadequate care and non-availability of the ICU at the facility. On the assessment of only the more critical cases (SMO, severe maternal outcome), the same pattern of association between ICU and MM was observed. In the models used, only inadequate care and MSS were significantly associated with MM. Conclusion The current study indicates that the main variables associated with maternal death are the severity and adequacy of the case management, which is more frequent in ICU admissions. The use of the ICU without the stratification of the patients by severity may not produce the expected benefits for part of the women.

Resumo Parto prematuro é uma complicação obstétrica de grande impacto para saúde perinatal e neonatal, tendo consequências tambémpara a infância e a vida adulta. Pouco se sabe sobre sua etiologia e fatores determinantes, o que limita osmétodos de rastreamento, predição e prevenção. Esta revisão integrativa traz a discussão sobre o conhecimento atual sobre fatores de risco para parto prematuro espontâneo, as diferenças entre métodos de rastreamento e predição, as limitações das atuais intervenções preventivas, a importância de se aplicar conceitos padronizados para exposição e desfecho na investigação de parto prematuro espontâneo, e porque é importante desenvolver métodos precisos e reprodutíveis para predizer o parto prematuro. Por fim, introduzimos o conceito demetabolômica e da tecnologia envolvida nessa técnica, e discutimos como ela tem se mostrado uma abordagem prosmissora para identificar biomarcadores associados ao parto prematuro espontâneo.

Abstract Pretermbirth is amajormaternal complication that has a great impact on perinatal and neonatal health, with consequences suffered during childhood and adulthood. Little is known about its etiology and development, resulting in poor screening, prediction and preventive methods. The present integrative review discusses the current knowledge regarding some risk factors for preterm birth, the differences between screening and prediction methods, the limitations of some current preventive interventions, the importance of applying standardized concepts for exposures and outcomes, and why it is important to develop more accurate and reproducible methods to predict preterm birth. In addition, the authors introduce the concept of metabolomics and the technology involved in this technique, and discuss about how it has become a promising approach to identify biomarkers for spontaneous preterm birth.

Resumo Objetivo Diversos fatores podem afetar a saúde e a qualidade de vida das mulheres que tiveram um episódio de morbidade materna grave (MMG) ou near-miss materno (NMM). O objetivo do presente estudo foi explorar as perspectivas dos profissionais sobre as repercussões da MMG ou do NMM após terem entrevistados mulheres que sobreviveram a um desses episódios. Métodos Casos selecionados que chamaram a atenção dos profissionais foram relatados. Estes profissionais construíram individualmente 10 narrativas, que foram analisadas com a técnica de análise de conteúdo. Resultados Segundo as perspectivas dos profissionais, asmulheres que sobreviveram a uma condição materna grave e suas famílias vivenciaram consequências clínicas e psicológicas. Alguns casos relataram um intenso estresse psicológico no luto pela perda do feto ou de sua capacidade reprodutiva e de mudanças da dinâmica familiar, gerando sobrecarga emocional, depressão e violência de gênero. Conclusão A análise das narrativas pode oferecer uma ideia sobre a complexidade da percepção do cuidado de profissionais e sobre a necessidade de um seguimento interdisciplinar das mulheres sobreviventes de um episódio de MMG ou de NMM.

Abstract Objective Several factors might affect the health and the quality of life of women who had a severe maternal morbidity (SMM) or a maternal near-miss (MNM) episode. The objective of the present study was to explore the perspectives of the professionals on the repercussions of SMM or of MNM after interviewing women who survived such episodes. Method Selected cases that captured the attention of professionals were reported. The professionals built individually 10 narratives, which were analyzed with the technique of content analysis. Results According to the perspectives of the professionals, women surviving a severe maternal condition and their families experienced clinical and psychosocial consequences. Some cases portrayed the intense psychological distress in mourning for the loss of the fetus or of their reproductive capacity and changes in family dynamics generating emotional overload, depression, and gender violence. Conclusion The analysis of narratives may offer an idea on the complexity of the perception of care by professionals and on the need for an interdisciplinary follow-up of women surviving an SMM or an MNM episode.

The prediction or early diagnosis of maternal complications is challenging mostly because the main conditions, such as preeclampsia, preterm birth, fetal growth restriction, and gestational diabetes mellitus, are complex syndromes with multiple underlying mechanisms related to their occurrence. Limited advances in maternal and perinatal health in recent decades with respect to preventing these disorders have led to new approaches, and “omics” sciences have emerged as a potential field to be explored. Metabolomics is the study of a set of metabolites in a given sample and can represent the metabolic functioning of a cell, tissue or organism. Metabolomics has some advantages over genomics, transcriptomics, and proteomics, as metabolites are the final result of the interactions of genes, RNAs and proteins. Considering the recent “boom” in metabolomic studies and their importance in the research agenda, we here review the topic, explaining the rationale and theory of the metabolomic approach in different areas of maternal and perinatal health research for clinical practitioners. We also demonstrate the main exploratory studies of these maternal complications, commenting on their promising findings. The potential translational application of metabolomic studies, especially for the identification of predictive biomarkers, is supported by the current findings, although they require external validation in larger datasets and with alternative methodologies.

Resumo Objetivo Avaliar a relação entre o uso de substâncias psicoativas na gestação e a ocorrência de morbidade materna grave (MMG), resultados perinatais e repercussões no desenvolvimento neuropsicomotor das crianças expostas. Métodos Estudo de caso-controle a partir de uma coorte de morbidade materna grave (COMMAG). Mulheres com MMG foram consideradas casos. Controles foram mulheres com gestação de baixo risco, admitidas no mesmo período que os casos. Os dados da coorte foram coletados retrospectivamente em prontuários de internação para o parto e entrevistas presenciais conduzidas com 638 mulheres e seus filhos da gestação-índice, entre 6 meses e 5 anos após o parto. Na entrevista, o uso de substâncias na gestação foi avaliado com uma pergunta modificada introduzida no questionário para triagem do uso de álcool, tabaco e outras substâncias 2.0 (ASSIST, na sigla em inglês) e o desenvolvimento neuropsicomotor das crianças foi avaliado pelo teste de triagem do desenvolvimento Denver II. Resultados A prevalência do uso de drogas lícitas ou ilícitas na gestação foi de cerca de 17%. Das usuárias, 63,9% usaram álcool, 58,3% usaram tabaco, 9,2% usaram cocaína/crack e 4,6% usaram maconha. Não houve associação entre o uso de drogas na gestação eMMG. Contudo, o uso de tabaco foi associado a hemorragia, presença de critérios clínicos de near miss e alteração no desenvolvimento infantil. O uso de álcool foi associado à asfixia neonatal e o uso de cocaína/crack à ocorrência de alguma complicação clínica na gestação. Conclusão O abuso de substâncias lícitas ou ilícitas na gestação é frequente e associado a piores desfechos maternos, perinatais e do desenvolvimento infantil.

Abstract Objective To assess the relationship between the use of psychoactive substances during pregnancy and the occurrence of severe maternal morbidity (SMM), perinatal outcomes and repercussions on the neuropsychomotor development of exposed children. Methods A case-control study nested within a cohort of severe maternal morbidity (COMMAG) was performed. Women with SMM were considered cases. Controls were thosewith low-risk pregnancy,without SMMand admitted during the same time period as the cases. Cohort data were collected retrospectively in hospital records for childbirth. A face-to-face interview was also performed with 638 women (323 without SMM and 315 with SMM) and their children of the index pregnancy between 6 months and 5 years after childbirth. During the interview, substance abuse during pregnancy was assessed by a modified question from the Alcohol, Smoking and Substance Involvement Screening Test 2.0 (ASSIST) and the neuropsychomotor development in the children was assessed by the Denver Developmental Screening Test, 2nd edition. Results The prevalence of licit or illicit drug use during pregnancy was ~ 17%. Among drug users, 63.9% used alcohol, 58.3% used tobacco, 9.2% used cocaine/crack and 4.6% used marijuana. There was no association between drug use during pregnancy and SMM, although tobacco use during pregnancy was associated with bleeding, presence of near-miss clinical criteria (NMCC) and alteration in infant development; alcohol use was associated with neonatal asphyxia; and cocaine/crack use was associated with the occurrence of some clinical complications during pregnancy. Conclusion The use of psychoactive substances during pregnancy is frequent and associated with worse maternal, perinatal and child development outcomes.

Resumo A gestação gemelar é responsável por 2 a 4% do total de nascimentos, com uma prevalência variando de 0,9 a 2,4% no Brasil. Ela é associada a piores resultados maternos e perinatais. Muitas condições, como amorbidade materna grave (condições potencialmente ameaçadoras da vida e near-miss materno) e near-miss neonatal ainda não foram investigadas de forma apropriada na literatura. A dificuldade na determinação de condições associadas com a gestação gemelar provavelmente reside em sua ocorrência relativamente baixa e na necessidade de estudos populacionais maiores. O uso da população total e de bancos de dados de grandes estudosmulticêntricos podem então fornecer resultados sem precedentes. Considerando que esta é uma condição rara, ela émais facilmente avaliada usando estatísticas vitais de registros eletrônicos de

Abstract Twin pregnancy accounts for 2 to 4% of total births, with a prevalence ranging from 0.9 to 2.4% in Brazil. It is associated with worse maternal and perinatal outcomes. Many conditions, such as severe maternal morbidity (SMM) (potentially life-threatening conditions and maternal near-miss) and neonatal near-miss (NNM) still have not been properly investigated in the literature. The difficulty in determining the conditions associated with twin pregnancy probably lies in its relatively low occurrence and the need for larger population studies. The use of the whole population and of databases from large multicenter studies, therefore, may provide unprecedented results. Since it is a rare condition, it ismore easily evaluated using vital statistics from birth e-registries. Therefore, we have performed a literature review to identify the characteristics of twin pregnancy in Brazil and worldwide. Twin pregnancy has consistently been associated with SMM, maternal near-miss (MNM) and perinatal morbidity, with still worse results for the second twin, possibly due to some characteristics of the delivery, including safety and availability of appropriate obstetric care to women at a high risk of perinatal complications.

Resumo Objetivo O objetivo deste estudo é avaliar a importância das causas indiretas da morbidade/mortalidade materna no Brasil. Métodos Análise secundária de um estudo transversal multicêntrico realizado em 27 unidades obstétricas de referência da Rede Brasileira de Vigilância da Morbidade Materna Grave. Resultados Um total de 82.388 mulheres foram avaliadas, sendo que 9.555 foram incluídas com morbidade materna grave, 942 (9,9%) delas com causas indiretas de morbidade/mortalidade. Houve risco aumentado de maior gravidade entre o grupo das causas indiretas, que apresentou risco de morte materna 7,56 vezes maior (razão de prevalência [RP]: 7.56; intervalo de confiança de 95% [IC95%]: 4.99-11.45). As principais causas indiretas de óbitos maternos foram a gripe H1N1, sepses, câncer e doença cardiovascular. Atenção pré-natal não pública (RP: 2,52; IC95%: 1,70-3,74), diabetes (RP: 1,90; IC95%: 1,24-2,90), neoplasia (RP: 1,98; IC95%: 1,25-3,14), doenças Renais (RP: 1,99; IC95%: 1,14-3,49), anemia falciforme (RP: 2,50; IC95%: 1,16-5,41) e toxicodependência (PR 1,98; IC95%: 1,03-3,80) foram associados independentemente com piores resultados no grupo de causas indiretas. Alguns procedimentos para o manejo da gravidade foram mais comuns para o grupo de causas indiretas. Conclusão As causas indiretas de morbidade mortalidade materna ocorreram em menos de 10% dos casos, mas foram responsáveis por mais de 40% das mortes maternas no presente estudo. As causas indiretas da morbidade mortalidade materna também se relacionaram com maior gravidade, e estiveram associadas a piores resultados maternos e perinatais. Nos países de renda média, há uma combinação de causas indiretas de morbidade/mortalidade materna que apontam para alguns avanços na escala de transição obstétrica, mas também mostram a fragilidade dos sistemas de saúde.

Abstract Objective The aim of this study is to evaluate the burden of indirect causes of maternal morbidity/mortality in Brazil. Methods Secondary analysis of a multicenter cross-sectional study conducted in 27 referral obstetric units within the Brazilian Network for Surveillance of Severe Maternal Morbidity. Results A total of 82,388 women were surveilled: 9,555 women with severe maternal morbidity were included, and 942 (9.9%) of them had indirect causes of morbidity/ mortality. There was an increased risk of higher severity among the indirect causes group, which presented 7.56 times increased risk of maternal death (prevalence ratio [PR]: 7.56; 95% confidence interval [95%CI]: 4.99-11.45). The main indirect causes of maternal death were H1N1 influenza, sepsis, cancer and cardiovascular disease. Non-public antenatal care (PR: 2.52; 95%CI: 1.70-3.74), diabetes (PR: 1.90; 95%CI: 1.24-2.90), neoplasia (PR: 1.98; 95%CI: 1.25-3.14), kidney diseases (PR: 1.99; 95%CI: 1.14-3.49), sickle cell anemia (PR: 2.50; 95%CI: 1.16-5.41) and drug addiction (PR: 1.98; 95%CI: 1.03-3.80) were independentlyassociatedwithworseresultsintheindirectcausesgroup.Someprocedures for the management of severity were more common for the indirect causes group. Conclusion Indirect causes were present in less than 10% of the overall cases, but they represented over 40% of maternal deaths in the current study. Indirect causes of maternal morbidity/mortality were also responsible for an increased risk of higher severity, and they were associated with worse maternal and perinatal outcomes. In middle-income countries there is a mix of indirect causes of maternal morbidity/ mortality that points to some advances in the scale of obstetric transition, but also reveals the fragility of health systems.

Resumo Objetivo Elaborar curvas de referências de medidas ultrassonográficas de colo uterino por idade gestacional (IG) em gestações de baixo risco. Métodos Coorte de gestantes de baixo risco, submetidas a ultrassom transvaginal repetido a cada 4 semanas, com medida do comprimento, dos diâmetros anteroposterior e transverso, da distância entre a entrada da artéria uterina no colo e o orifício interno, e do volume do colo. Foi avaliada a variabilidade inter e intraobservador entre as medidas com o coeficiente de correlação linear e teste t de Student. Para cada faixa de IG, estimaram-se os percentis 2,5, 10, 50, 90 e 97,5 dos valores das medidas, com a variação por IG avaliada por análise de variância para amostras dependentes. As comparações dos valores por variáveis de controle foram feitas por meio dos cálculos de médias e teste t de Student. Resultados Assegurada a alta reprodutibilidade do método, as 172 mulheres acompanhadas na coorte apresentaram redução das medidas de comprimento de colo com o decorrer da gestação, com aumento de volume e dos diâmetros anteroposterior e transverso. O menor comprimento cervical foi associado à menor idade materna, menor paridade, e ausência de cesárea prévia. Conclusão Na população estudada foi observada redução no comprimento cervical com o decorrer da gestação, sugerindo encurtamento fisiológico principalmente à custa da porção vaginal do colo. Há a necessidade de validar tais curvas de referência e pontos de corte específicos para uma melhor predição de risco de parto pré-termo, insuficiência cervical, e amniorrexe prematura.

Abstract Objective To define transvaginal ultrasound reference ranges for uterine cervix measurements according to gestational age (GA) in low-risk pregnancies. Methods Cohort of low-risk pregnantwomen undergoing transvaginal ultrasound exams every 4 weeks, comprisingmeasurements of the cervical length and volume, the transverse and anteroposterior diameters of the cervix, and distance fromthe entrance of the uterine artery into the cervix until the internal os. The inter- and intraobserver variabilities were assessed with the linear correlation coefficient and the Student t-test. Within each period of GA, 2.5, 10, 50, 90 and 97.5 percentiles were estimated, and the variation by GA was assessed with analysis of variance for dependent samples. Mean values and Student t-test were used to compare the values stratified by control variables. Results After confirming the high reproducibility of the method, 172 women followed in this cohort presented a reduction in cervical length, with an increase in volume and in the anteroposterior and transverse diameters during pregnancy. Smaller cervical lengths were associated with younger age, lower parity, and absence of previous cesarean section (C-section). Conclusion In the studied population, we observed cervical length shortening throughout pregnancy, suggesting a physiological reduction mainly in the vaginal portion of the cervix. In order to better predict pretermbirth, cervical insufficiency and premature rupture of membranes, reference curves and specific cut-off values need to be validated.

Resumo Objetivo Estima-se que em 2013 tenham ocorrido 289.000 mortes maternas no mundo. Observou-se uma redução na razão de mortalidade materna em muitos países nas últimas décadas, e isso se deveu à identificação e tratamento precoce das complicações obstétricas, embora de forma não similar entre os diversos locais e populações. As mulheres negras, por exemplo, sempre estiveram mais sujeitas à ocorrência de mortalidade materna e de morbidade grave. Então, o objetivo desse estudo foi avaliar a cor da pele como fator preditor de Near Miss materno (NMM) em uma amostra de mulheres brasileiras entrevistadas na Pesquisa Nacional de Demografia e Saúde (PNDS) de 2006. Método Análise secundária do banco de dados da PNDS, um estudo transversal de base populacional e com representatividade nacional, sendo este banco de dados de domínio público. Avaliou-se o risco de complicações maternas por grupo de cor da pele e as características sociodemográficas associadas. Para a análise dos dados, as razões de possibilidades e os respectivos intervalos de confiança de 95% foram calculados. Resultados Na amostra entrevistada, 59% das mulheres eram negras ou pardas. Aproximadamente 23% das mulheres apresentaram alguma complicação, e 2% delas, pelo menos um critério pragmático de NMM. A taxa de NMM foi de 31 por 1.000 nascidos vivos, e sua ocorrência não foi estatisticamente diferente entre os grupos de cor da pele. Os únicos fatores identificados como associados à ocorrência de NMM foram a idade materna acima de 40 anos e não estar atualmente estudando, mas apenas entre as mulheres brancas. Conclusão Os resultados da PNDS 2006 não mostraram uma maior ocorrência de complicações maternas e especificamente de NMM associadas à cor da pele negra/ parda.

Abstract Purpose In 2013, it was estimated that 289,000 maternal deaths occurred worldwide. The maternal mortality ratio has decreased in many countries in the past decades, due to early identification and treatment of obstetric complications, despite the dissimilarities observed in diverse locations and populations. Black women, for instance, have always been more susceptible to the occurrence of maternal mortality and severe morbidity. Therefore, the objective of this study is to assess skin color as a predictive factor for maternal near miss (MNM) in a sample of Brazilian women interviewed in the Brazilian National Demographic and Health Survey (DHS) of 2006. Method A secondary analysis of the DHS database, a population-based crosssectional nationally representative study was conducted. This database is of public domain. The risk of maternal complications according to ethnic group and the associated sociodemographic characteristics were evaluated. For the data analysis, the odds ratios and respective 95% confidence intervals were calculated. Results In the sample interviewed, 59% of women were black or brown (mixed-race). Approximately 23% of women had some complication, and 2% of these women had at least one MNM pragmatic criterion. The MNM rate was 31 per 1,000 live births, and its occurrence was not statistically different among the ethnic groups. The only factors identified that were considered to be associated with the occurrence of MNM were maternal age above 40 and women not currently attending school, but only among white women. Conclusion The 2006 DHS results did not show a higher occurrence of maternal complications, and specifically of MNM associated with black/brown skin color.

Resumo Objetivo Validar a versão adaptada para o português brasileiro do instrumento World Health Organizaton Disability Assessment Schedule 2.0 (WHODAS 2.0), em seu conteúdo e estrutura (construto), em uma população de mulheres após a gravidez. Métodos Trata-se de validação de um instrumento para incapacidade e funcionalidade, incluindo suas propriedades psicométricas, realizada em uma maternidade de referência em gestação de alto risco no Brasil. Incluiu uma amostra de 638mulheres em diferentes períodos pós-parto que tiveram uma gravidez normal ou com complicações. A estrutura foi avaliada por análise fatorial exploratória (AFE) e análise fatorial confirmatória (AFC), enquanto o conteúdo e as associações entre os domínios foram avaliados por meio do coeficiente de correlação de Pearson. Foram identificadas características sociodemográficas, e os escores médios do WHODAS 2.0 para as 36 questões foram calculados. A consistência interna foi avaliada pelo método α de Cronbach. Resultados O α de Cronbach foi maior do que 0,79 para os dois conjuntos de perguntas do questionário. A AFE e a AFC para as 32 questões apresentaram uma variância total de 54,7% (medida de adequação da amostra de Kaiser-Meyer-Olkin [KMO] = 0,934; p < 0,001) e 53,47% (KMO = 0,934; p < 0,001), respectivamente. Houve uma correlação significativa entre os 6 domínios (r = 0,571-0,876), e moderada correlação entre todos os domínios (r = 0,476-0,694). Conclusão O instrumento WHODAS 2.0, adaptado para o português do Brasil, mostrou boas propriedades psicométricas nessa amostra e, portanto, pode ser aplicado a populações de mulheres com relação à sua história reprodutiva.

Abstract Objective To validate the translation and adaptation to Brazilian Portuguese of 36 items from the World Health Organizaton Disability Assessment Schedule 2.0 (WHODAS 2.0), regarding their content and structure (construct), in a female population after pregnancy. Methods This is a validation of an instrument for the evaluation of disability and functioning and an assessment of its psychometric properties, performed in a tertiary maternity and a referral center specialized in high-risk pregnancies in Brazil. A sample of 638 women in different postpartum periods who had either a normal or a complicated pregnancy was included. The structure was evaluated by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), while the content and relationships among the domains were assessed through Pearson's correlation coefficient. The sociodemographic characteristics were identified, and the mean scores with their standard deviations for the 36 questions of the WHODAS 2.0 were calculated. The internal consistency was evaluated byCronbach's α. Results Cronbach's α was higher than 0.79 for both sets of questons of the questionnaire. The EFA and CFA for the main 32 questions exhibited a total variance of 54.7% (Kaiser-Meyer-Olkin [KMO] measure of sampling adequacy = 0.934; p < 0.001) and 53.47% (KMO = 0.934; p < 0.001) respectively. There was a significant correlation among the 6 domains (r = 0.571-0.876), and a moderate correlation among all domains (r = 0.476-0.694). Conclusion The version of the WHODAS 2.0 instrument adapted to Brazilian Portuguese showed good psychometric properties in this sample, and therefore could be applied to populations of women regarding their reproductive history.