ABSTRACT Objective: To present the methodology used in the development of two products for maternal health surveillance and its determinants and discuss their possible uses. Methods: Based on a theoretical model of the determinants of maternal death and databases of Brazilian health information systems, two free products were developed: an interactive panel “surveillance of maternal health” and an educational material “Aparecida: a story about the vulnerability of Brazilian women to maternal death”, both available on the website of the Brazilian Obstetric Observatory. Results: More than 30 indicators were calculated for the period 2012-2020, containing information on socioeconomic conditions and access to health services, reproductive planning, prenatal care, delivery care, conditions of birth and maternal mortality and morbidity. The indicators related to severe maternal morbidity in public hospitalizations stand out, calculated for the first time for the country. The panel allows analysis by municipality or aggregated by health region, state, macro-region and country; historical series analysis; and comparisons across locations and with benchmarks. Information quality data are presented and discussed in an integrated manner with the indicators. In the educational material, visualizations with national and international data are presented, aiming to help in the understanding of the determinants of maternal death and facilitate the interpretation of the indicators. Conclusion: It is expected that the two products have the potential to expand epidemiological surveillance of maternal health and its determinants, contributing to the formulation of health policies and actions that promote women’s health and reduce maternal mortality.

RESUME Objetivo: Apresentar a metodologia utilizada no desenvolvimento de dois produtos para a vigilância da saúde materna e seus determinantes e discutir as suas possíveis utilizações. Métodos: A partir de modelo teórico dos determinantes do óbito materno e bases de dados dos sistemas de informação em saúde brasileiros, foram desenvolvidos dois produtos gratuitos: um painel interativo denominado “Vigilância da saúde materna” e um material educativo chamado “Aparecida: uma história sobre a vulnerabilidade da mulher brasileira à morte materna”, ambos disponíveis no site do Observatório Obstétrico Brasileiro. Resultados: Foram calculados mais de 30 indicadores para o período 2012-2020, contendo informações sobre condições socioeconômicas e de acesso a serviços de saúde, planejamento reprodutivo, assistência pré-natal, assistência ao parto, condições de nascimento e mortalidade e morbidade materna. Destacam-se os indicadores relacionados à morbidade materna grave em internações públicas, calculados pela primeira vez para o país. O painel permite análises por município ou agregadas por região de saúde, unidade da federação, macrorregião e país; análises de série histórica; e comparações entre localidades e com padrões de referência. Dados de qualidade da informação são apresentados e discutidos de forma integrada aos indicadores. No material educativo, visualizações com dados nacionais e internacionais são apresentadas, visando auxiliar na compreensão dos determinantes do óbito materno e facilitar a interpretação dos indicadores. Conclusão: Espera-se que os produtos tenham o potencial de ampliar a vigilância epidemiológica da saúde materna e seus determinantes, contribuindo para a formulação de políticas e ações de saúde que promovam a saúde das mulheres e reduzam a mortalidade materna.

Abstract Objective To analyze the impact of the COVID-19 pandemic on the residency of gynecology and obstetrics in São Paulo. Methods Cross-sectional study developed by representatives of residents of the Association of Gynecology and Obstetrics of the State of São Paulo (SOGESP, in the Portuguese acronym). Data were collected from questionnaires applied to gynecology and obstetrics residents registered on the SOGESP website in February 2022. The interviewees answered about the repercussions of the pandemic on medical residency and whether they had technical and psychological support during the period. Results A total of 247 questionnaires were collected from residents of gynecology and obstetrics. The residents had an age of 28.3 ± 3 years old, and most of them were female (88.4%). The displacement to COVID care was reported by 62.34% of the students, but only 35.6% reported completely adequate personal protective equipment and only 7.7% reported complete theoretical and technical instruction to support these patients. Almost all of the interviewees stated that the gynecology sector was the most affected. The majority of the interviewees considered that the second-year residents had the greatest loss, and more than half of the residents in the 1st and 2nd year said they wished to give up their residency during the pandemic. More than 80% of the residents reported online theoretical classes and/or presentation of articles, reinforcing the fact that virtual activities gained a greater space within the medical residency. Conclusion The pandemic impacted the residency in greater proportion in outpatient clinics and gynecological surgeries, also interfering with the physician's desire to continue with the program.

Resumo Objetivo Analisar o impacto pandemia de COVID-19 sobre a residência de ginecologia e obstetrícia do Estado de São Paulo. Métodos Estudo transversal desenvolvido por representantes dos residentes da Associação de Ginecologia e Obstetrícia do Estado de São Paulo (SOGESP). Foram coletados dados de questionários aplicados aos residentes de ginecologia e obstetrícia cadastrados no site da SOGESP em fevereiro de 2022. Os entrevistados responderam sobre repercussões da pandemia sobre a residência médica e se tiveram suporte técnico e psicológico durante o período. Resultados Foram levantados 247 questionários de residentes de ginecologia e obstetrícia. Os residentes apresentaram idade de 28,3 ± 3 anos, sendo a maioria do sexo feminino (88,4%). O deslocamento para “covidários” foi referido por 62,34% dos avaliados, porém somente 35,6% referiram equipamento de proteção individual completamente adequado e apenas 7,7% referiram instrução completa teórica e técnica para o suporte destes pacientes. Quase a totalidade dos entrevistados afirmou que o setor de ginecologia foi o mais afetado. A maioria dos entrevistados considerou que o os residentes do segundo ano foram os que tiveram maior prejuízo, sendo que mais da metade dos residentes do 1° e 2° ano afirmou ter desejado desistir da residência durante a pandemia. Mais de 80% dos residentes referiram aulas teóricas e/ou apresentação de artigos online, reforçando o fato de que as atividades virtuais ganharam um espaço maior dentro da residência médica. Conclusão A pandemia impactou nas residências em maior proporção nos ambulatórios e cirurgias ginecológicas, interferindo também sobre o desejo do médico de seguir com o programa.

ABSTRACT Objectives: To analyze the perinatal outcomes of Perinatally acquired HIV Infection (PHIV) in pregnant women. Method: This retrospective cohort study included singleton pregnancies in Women Living with HIV (WLH) between 2006 and 2019. Patient charts were revised, and maternal characteristics, type of HIV infection (perinatal vs. behavioral), Antiretroviral Therapy (ART) exposure, and obstetric and neonatal outcomes were assessed. The HIV-related aspects considered were: Viral Load (VL), CD4+ cell count, opportunistic infections, and genotype testing. Laboratory analyses were performed at baseline (first appointment) and 34 weeks of gestation. Results: There were 186 WLH pregnancies, and 54 (29%) patients had PHIV. Patients with PHIV were younger (p < 0.001), had less frequently stable partnerships (p < 0.001), had more commonly serodiscordant partners (p < 0.001), had a longer time on ART (p < 0.001), and had lower rates of undetectable VL at baseline (p = 0.046) and at 34 weeks of gestation (p < 0.001). No association was observed between PHIV and adverse perinatal outcomes. Among patients with PHIV, third trimester anemia was associated with preterm birth (p = 0.039). Genotype testing was available only for 11 patients with PHIV, who presented multiple mutations related to ART resistance. Conclusions: PHIV did not seem to increase the risk of adverse perinatal outcomes. However, PHIV pregnancies have a higher risk of viral suppression failure and exposure to complex ARTs.

Abstract Objectives: To determine the incidence and risk of adverse obstetric and neonatal outcomes according to SARS-CoV-2 infection severity in pregnant women. Method: Open prospective study of pregnant women tested for SARS-CoV-2 by serological and molecular assays during pregnancy or delivery in two hospitals in Sao Paulo, Brazil from April 12, 2020, to February 28, 2021. Five groups were considered for analysis: C0, negative COVID-19 results and no COVID-19 symptoms; C1, positive COVID-19 results, and no symptoms; C2, positive COVID-19 results with mild symptoms; C3, positive COVID-19 results with moderate symptoms; and C4, positive COVID-19 results with severe symptoms. The association between obstetric and neonatal outcomes and COVID-19 severity was determined using multivariate analysis. Results: 734 eligible pregnant women were enrolled as follows: C0 (n = 357), C1 (n = 127), C2 (n = 174), C3 (n = 37), and C4 (n = 39). The following pregnancy and neonatal outcomes were associated with severe COVID-19: oligohydramnios (adjusted Odds Ratio [aOR] = 6.18; 95% CI 1.87‒20.39), fetal distress (aOR = 4.01; 95% Confidence Interval [CI] 1.84‒8.75), preterm birth (aOR = 5.51; 95% CI 1.47‒20.61), longer hospital stay (aOR = 1.66; 95% CI 1.36‒2.02), and admission to the neonatal intensive care unit (aOR = 19.36; 95% CI, 5.86‒63.99). All maternal (n = 6, 15.4%, p < 0.001) and neonatal (n = 5, 12.5%, p < 0.001) deaths and most fetal deaths (n = 4, 9.8%, p < 0.001) occurred in C4 group. Moderate COVID-19 was associated with oligohydramnios (aOR = 6.23; 95% CI 1.93‒20.13) and preterm birth (aOR = 3.60; 95% CI 1.45‒9.27). Mild COVID-19 was associated with oligohydramnios (aOR=3.77; 95% CI 1.56‒9.07). Conclusion: Adverse pregnancy and neonatal outcomes were associated with maternal symptomatic COVID-19 status, and risk increased with disease severity. HIGHLIGHTS COVID-19 increases the rates of adverse pregnancy and neonatal outcomes. Serious cases are associated with oligohydramnios, fetal distress, prematurity, neonatal ICU admission, maternal and neonatal deaths. The maternal clinical status dictates obstetric and neonatal outcomes.

Abstract Objective: To identify risk factors for Oxygen (O2) needs in pregnant and postpartum women with COVID-19. Methods: Prospective cohort involving pregnant women hospitalized with COVID-19 from April to October 2020. The oxygen need was analyzed regarding risk factors: demographic characteristics, clinical and laboratory parameters at hospital admission, and chest Computer Tomography (CT) findings. Poisson univariate analysis was used to estimate the Relative Risk (RR) and 95% Confidence Intervals. Results: 145 patients, 80 who used and 65 who did not use O2, were included. Body mass index ≥ 30, smoking, and chronic hypertension increased the risk of O2 need by 1.86 (95% CI 1.10–3.21), 1.57 (95% CI 1.16‒2.12), and 1.46 (95% CI 1.09‒1.95), respectively. Patients who were hospitalized for COVID-19 and for obstetric reasons had 8.24 (95% CI 2.8‒24.29) and 3.44 (95% CI 1.05‒11.31) times more use of O2 than those admitted for childbirth and abortion. Respiratory rate ≥ 24 breaths/min and O2 saturation < 95% presented RR for O2 requirements of 2.55 (1.82‒3.56) and 1.68 (95% CI 1.27-2.20), respectively. Ground Glass (GG) < 50% and with GG ≥ 50%, the risk of O2 use were respectively 3.41-fold and 5.33-fold higher than in patients who haven’t viral pneumonia on CT. The combination of C-reactive protein ≥ 21 mg/L, hemoglobin < 11.0 g/dL, and lymphopenia < 1500 mm3 on hospital admission increased the risk of O2 use by 4.97-times. Conclusions: In obstetric patients, clinical history, laboratory, clinical and radiological parameters at admission were identified as a risk for O2 need, selecting the population with the greatest chance of worsening. HIGHLIGHTS In unvaccinated pregnant and postpartum women, any need for oxygen supply increases the risk of invasive ventilation. Obesity, smoking and chronic arterial hypertension proved to be risk factors for the use of oxygen in pregnant and postpartum women with COVID-19. The combination of C-reactive protein ≥ 21 mg/L, hemoglobin < 11.0 g/dL, and lymphopenia < 1500 mm on hospital admission and the presence of ground glass ≥ 50% in computer tomography increased the risk of O2 use by 4.97 and 5.33 times respectively in pregnant and postpartum women with COVID-19.

Abstract Objective To evaluate objective criteria of Magnetic Resonance Imaging (MRI) of Placenta Accreta Spectrum disorder (PAS) analyzing interobserver agreement and to derive a model including imaging and clinical variables to predict PAS. Methods A retrospective review including patients submitted to MRI with suspicious findings of PAS on ultrasound. Exclusion criteria were lack of pathology or surgical information and missing or poor-quality MRI. Two radiologists analyzed six MRI features, and significant clinical data were also recorded. PAS confirmed on pathology or during intraoperative findings were considered positive for the primary outcome. Variables were tested through logistic regression models. Results Final study included 96 patients with a mean age of 33 years and 73.0% of previous C-sections. All MRI features were significantly associated with PAS for both readers. After logistic regression fit, including MRI signs with a moderate or higher interobserver agreement, intraplacental T2 dark band was the most significant radiologic criteria, and ROC analysis resulted in an AUC = 0.782. After including the most relevant clinical data (previous C-section) to the model, the ROC analysis improved to an AUC = 0.893. Conclusion Simplified objective criteria on MRI, including intraplacental T2 dark band associated with clinical information of previous C-sections, had the highest accuracy and was used for a predictive model of PAS.

Abstract Purpose The authors aim to carry out an investigation on the impact of cervical oncogenic Human Papillomavirus (HPV) detection in pregnant adolescents, to clarify the prevalence and risk factors, considering the importance and lack of data on this topic in Brazil. Methods A cross-sectional study was conducted with adolescents receiving prenatal care in a tertiary hospital in São Paulo, Brazil, with routine Pap smear and oncogenic HPV detection test in the uterine cervix. The authors sought to associate the results of these tests with demographic and obstetric variables. Results A total of 303 pregnant adolescents whose mean age was 15.30 ± 1.22 years comprised the study subjects. The frequency of high-risk HPV cervical detection was 50.50%. Multivariate analysis revealed that a large number of partners in their lifetime (OR = 1.27) and having a religion (OR = 2.05) were risk factors for cervical detection of oncogenic HPV, while schooling appeared as a protective factor (OR = 0.85). There was an association between this detection and colpocytological alterations, reaching almost 30% of patients, but without association with obstetric and neonatal outcomes. Conclusion The prevalence found is one of the highest in Brazil and worldwide. A greater number of partners during their lifetime and having religion were detected as possible factors associated with cervical HPV detection. Detection of cervical HPV-DNA did not influence obstetric and neonatal outcomes. The findings of this study reinforce the need to implement educational measures capable of modifying the incidence of sexually transmitted infections in this population and capable of promoting adherence to HPV vaccination programs.

Abstract Introduction Limited data are available on pregnant women with COVID-19 and their neonates. Objective This study aimed to describe clinical characteristics and evolution from birth to discharge of a retrospective cohort of 71 neonates, with one set of twins, born to women with COVID-19 diagnosed at the end of pregnancy. The authors included all newborns admitted into a neonatal unit of a tertiary hospital in Brazil, between March 2020 and March 2021, whose unvaccinated mothers had COVID-19 symptoms and RT-PCR (Real-Time Polymerase Chain Reaction) for SARS-CoV-2 positive within fourteen days prior to delivery. Newborns to mothers with COVID-19 symptoms and negative tests for SARS-CoV-2 were excluded. Results The main route of birth delivery was cesarean, corresponding to 60 pregnant women (84.5%). The foremost indications for cesarean were pregnant with critical disease (24.6%) and acute fetal distress (20.3%). The mean birth weight was 2452 g (865‒3870 g) and the mean gestational age was 345/7weeks (25‒40 weeks). There were 45 premature newborns (63.3%), of which 21 newborns (29.5%) were less than 32 weeks of gestational age. RT-PCR for SARS-CoV-2 on oropharyngeal swabs was positive in 2 newborns (2.8%) and negative in the other 69 newborns (97.2%). Most newborns (51.4%) needed respiratory support. Therapeutic interventions during hospitalization were inotropic drugs (9.9%), antibiotics (22.8%), parenteral nutrition (26.8%), and phototherapy (46.5%). Conclusion Maternal COVID-19 diagnosticated close to delivery has an impact on the first days of neonatal life.

BACKGROUND: Even students with previous academic success may face challenges that affect their academic performance. Many medical schools offer programs to students at the risk of academic failure, to ensure that they succeed in the course. OBJECTIVE AND METHODS: In this report we describe a pioneering academic tutoring program developed at a Brazilian medical school and discuss the initial results of the program based on the feedback from tutors and data regarding the progression of students in the medical course. RESULTS: In 2018, 33 students enrolled into the program. Students' performance difficulties were mainly associated with mental health problems and socioeconomic vulnerability. Of the 33 students, 27 (81.8%) were assisted by the Mental Health Support Service and 16 (48.5%) were assisted by the Social Assistance Service. In addition to the planning academic activity class load, tutors were able to assist students in solving socioeconomic issues, carrying out personal support interventions with the promotion of self-esteem, and presenting suggestions for behavioral changes in their routine. For most students (72%), the action plan proposed by the tutors was successful. Eight of the 14 (57%) students in the fourth year progressed to the final two years of in-hospital practical training (internship). CONCLUSIONS: The Academic Tutoring Program showed positive results for most of the students. Close monitoring and tutor intervention allowed students with poor academic performance to overcome the low performance cycle. These important tasks demand time and energy from tutors, and institutional recognition of these professionals is essential for the successful maintenance of the program.

Resumo Objetivo O objetivo do presente estudo foi comparar a história obstétrica e os parâmetros bi- e tridimensionais ultrassonográficos de acordo com os diferentes comprimentos cervicais. Métodos O presente estudo transversal analisou 248 gestantes no segundo trimestre de acordo com o comprimento cervical e comparou os dados com a história obstétrica e os parâmetros ultrassonográficos 2D/3D. As pacientes foram divididas em 3 grupos de acordo com o comprimento do colo uterino: grupo Colo Curto para comprimentos cervicais ≥ 15mm e < 25mm (n = 68), grupo Colo Muito Curto para comprimentos cervicais < 15mm (n = 18) e grupo Controle, composto por 162 gestantes com comprimento cervical uterino ≥ 25 mm. Resultados Ao analisar a história obstétrica apenas de pacientes não nulíparas, foi relatadauma associação significativa entre a presença de colo uterino curto na gravidez atual e pelo menos um episódio de parto prematuro anterior (p = 0,021). Comprimento e volume do colo uterino foram correlacionados positivamente (coeficiente de Pearson = 0,587, p < 0,0001). O parâmetro índice de fluxo (IF) da vascularização cervical foi significativamente diferente entre os grupos Controle e Colo Muito Curto. Entretanto, após regressão linear, na presença de informações de volume, não encontramos associação entre os grupos e o parâmetro IF. Também não foi encontrada relação entre o Doppler da artéria uterina e o encurtamento cervical. Conclusão O presente estudo mostrou uma associação significativa entre a presença de colo uterino curto na gravidez atual e pelo menos um episódio de parto prematuro anterior. Nenhum dos índices de vascularização se correlaciona com o comprimento cervical como parâmetro independente, assim como o Doppler da artéria uterina também não está relacionado ao comprimento do colo uterino.

Abstract Objective The aim of the present study was to compare the obstetric history and both two- and tri-dimensional ultrasound parameters according to different cervical lengths. Methods The present cross-sectional study analyzed 248 midtrimester pregnant women according to cervical length and compared the data with the obstetric history and 2D/3D ultrasound parameters. Patients were divided into 3 groups according to cervical length: The Short Cervix group for cervical lengths ≥ 15mm and< 25mm(n= 68), the Very Short Cervix group for cervical lengths< 15mm (n = 18) and the Control group, composed of 162 pregnant women with uterine cervical lengths ≥ 25mm. Results When analyzing the obstetric history of only non-nulliparous patients, a significant association between the presence of a short cervix in the current pregnancy and at least one previous preterm birth was reported (p = 0.021). Cervical length and volume were positively correlated (Pearson coefficient = 0.587, p < 0.0001). The flow index (FI) parameter of cervical vascularization was significantly different between the Control and Very Short Cervix groups. However, after linear regression, in the presence of volume information, we found no association between the groups and FI. Uterine artery Doppler was also not related to cervical shortening. Conclusion The present study showed a significant association between the presence of a short cervix in the current pregnancy and at least one previous preterm birth. None of the vascularization indexes correlate with cervical length as an independent parameter. Uterine artery Doppler findings do not correlate with cervical length.