Introduction: Spinal anesthesia combined with sedation and general anesthesia combined with epidural are two techniques often used for patients undergoing abdominal hysterectomy. There is no consensus that one of these techniques is superior regarding the perception of patients towards the quality of postoperative recovery. This observational cross-sectional study aimed to assess the quality of postoperative recovery in women undergoing open abdominal hysterectomy by comparing both anesthetic techniques. Method: We recruited 162 women aged between 30 and 74 years to be submitted to abdominal hysterectomy. The anesthetic technique used followed the preference of the attending anesthesiologist without interference of the investigators. After applying the exclusion criteria, 80 patients underwent spinal anesthesia combined with sedation (Group 1) and 62 women underwent epidural anesthesia combined with general anesthesia (Group 2). The quality of postoperative recovery was evaluated using the questionnaire Quality of Recovery-40 (QoR-40) completed 24 hours after the end of the surgery. Results: Eighty patients in Group 1 answered the QoR-40 questionnaire with an average rating of 179.4 points, median of 186.5, standard deviation of 17.4 and a confidence interval of 3.8. The 60 patients in Group 2 answered the QoR-40 with an average of 174.9 points, median of 178 points, standard deviation of 16 points and a confidence interval of 4.0 (p = 0.024). Conclusion: Women who received spinal anesthesia combined with sedation considered quality of postoperative recovery better. (c) 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

BACKGROUND:The two most common general anesthesia techniques are total intravenous anesthesia (TIVA) and venous/inhalation balanced general anesthesia (BGA). It is unclear whether any of these two techniques affect patient perception of the quality of recovery. The aim of this randomized, double-blinded clinical trial was to assess the quality of postoperative recovery of women undergoing laparoscopic cholecystectomy under general anesthesia. We compared patients who received TIVA with those who received BGA. We also evaluated the factors that may decrease patient-perceived quality of postoperative recovery.METHODS:We prospectively recruited 121 women aged 18-65 years who were scheduled for elective laparoscopic cholecystectomy due to cholelithiasis. These patients were randomized to receive TIVA (target-controlled infusion of propofol and remifentanil) or BGA (continuous remifentanil infusion and sevoflurane inhalation). To measure the quality of postanesthetic and postoperative recovery, we administered the Quality of Recovery-40 (QoR-40) questionnaire 24 hours after the patient awoke from anesthesia.RESULTS:All 60 patients in the TIVA group responded to QoR-40 (median, 188 points; minimum 128; maximum 200). Sixty-one patients in the BGA group had a mean QoR-40 score of 186 points (median, 188 points; minimum 146; maximum 200). There was no significant difference in the QoR-40 score between the two groups (p = 0.577). The patients who presented postoperative nausea and vomiting (PONV) and pain had worse perception of the quality of postoperative recovery.CONCLUSIONS:Both TIVA and BGA had a similar effect on the perception of the quality of postoperative recovery in women undergoing elective laparoscopic cholecystectomy. PONV and pain may negatively affect patient perception of the quality of postoperative recovery.

Background. Taking into account the probable role that race/skin color may have for determining outcomes in maternal health, the objective of this study was to assess whether maternal race/skin color is a predictor of severe maternal morbidity. Methods. This is a secondary analysis of the Brazilian Network for Surveillance of Severe Maternal Morbidity, a national multicenter cross-sectional study of 27 Brazilian referral maternity hospitals. A prospective surveillance was performed to identify cases of maternal death (MD), maternal near miss (MNM) events, and potentially life-threatening conditions (PLTC), according to standard WHO definition and criteria. Among 9,555 women with severe maternal morbidity, data on race/skin color was available for 7,139 women, who were further divided into two groups: 4,108 nonwhite women (2,253 black and 1,855 from other races/skin color) and 3,031 white women. Indicators of severe maternal morbidity according to WHO definition are shown by skin color group. Adjusted Prevalence Ratios (PRadj - 95%CI) for Severe Maternal Outcome (SMO=MNM+MD) were estimated according to sociodemographic/obstetric characteristics, pregnancy outcomes, and perinatal results considering race. Results. Among 7,139 women with severe maternal morbidity evaluated, 90.5% were classified as PLTC, 8.5% as MNM, and 1.6% as MD. There was a significantly higher prevalence of MNM and MD among white women. MNMR (maternal near miss ratio) was 9.37 per thousand live births (LB). SMOR (severe maternal outcome ratio) was 11.08 per 1000 LB, and MMR (maternal mortality ratio) was 170.4 per 100,000 LB. Maternal mortality to maternal near miss ratio was 1 to 5.2, irrespective of maternal skin color. Hypertension, the main cause of maternal complications, affected mostly nonwhite women. Hemorrhage, the second more common cause of maternal complication, predominated among white women. Nonwhite skin color was associated with a reduced risk of SMO in multivariate analysis. Conclusion. Nonwhite skin color was associated with a lower risk for severe maternal outcomes. This result could be due to confounding factors linked to a high rate of Brazilian miscegenation.

Objective: To verify the effect of psychological preparation on the relief of preoperative anxiety in children and to correlate parents' and children's levels of anxiety. Method: After the approval of the institutional Research Ethics Committee and written consent of the children's parents or guardians, 118 children of both genders were prospectively selected, aged between 2 and 8 years, physical condition classification ASA I, who were treated in the pre-anesthetic evaluation ambulatory of the University Hospital and who underwent ambulatory surgeries at the same hospital. Two controlled groups of 59 children were randomized: control group basic preparation and psychological preparation group. On the day of surgery, all selected children were evaluated regarding their level of anxiety using the modified Yale Preoperative Anxiety Scale and their parents were evaluated regarding their level of anxiety through the Visual Analog Scale. The evaluator was blinded to which study group the child and family member belonged to. Results: Nine children and their family members were excluded per group when the results were analyzed. Children from the prepared group showed significant reductions in their level of anxiety in relation to the control group (p= 0.04). There was no correlation between the level of anxiety of children and their parents' levels (p= 0.78). Conclusion: The psychological preparation was effective in reducing the level of anxiety of children. However, there was no relation between the level of anxiety of children and their parents' level. (C) 2018 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda.

RESUMO Objetivo: a satisfação do paciente é um conceito complexo e multifatorial que ganhou muita importância nas últimas décadas, através dos processos de acreditação. Além disso, a satisfação do paciente influencia o relacionamento com a equipe multidisciplinar e, até mesmo, a adesão ao tratamento proposto. A percepção do paciente quanto à qualidade de recuperação pós-operatória é um dos componentes que influenciam essa satisfação. O objetivo dessa revisão foi avaliar os fatores relacionados ao ato anestésico e cirúrgico que interferem na percepção do paciente quanto à qualidade de recuperação pós-operatória. Método: durante o período entre 01 de março e 31 julho de 2018, a presente revisão integrativa pesquisou os descritores nas bases de dados e encontrou 52000 citações de artigos publicados entre janeiro de 2011 e julho de 2018. Através dos operadores booleanos, combinaram-se os termos da pesquisa e excluíram-se os artigos duplicados; 256 artigos foram avaliados e 51 foram selecionados para essa revisão. Conclusão: a utilização de medicamentos e técnicas que minimizem a permanência hospitalar ou evitem efeitos colaterais como dor, náuseas e vômitos, melhora a percepção do paciente quanto à qualidade de recuperação. ABSTRACT Objective: patient satisfaction is a complex and multifactorial concept that has gained much importance in the last decades, through the accreditation processes. In addition, patient satisfaction influences the relationship with the multidisciplinary team and, even, adherence to the proposed treatment. The patient's perception of the quality of postoperative recovery is one of the components that influence this satisfaction. The purpose of this review was to evaluate the factors related to the anesthetic and surgical procedure that interfere in the patient's perception of the quality of postoperative recovery. Method: during the period between March 1 and July 31, 2018, this integrative review researched the descriptors in the databases and found 52,000 citations of articles published between January 2011 and July 2018. Through the Boolean operators, the search terms were combined and the duplicate articles were deleted; 256 articles were evaluated and 51 were selected for this review. Conclusion: the use of drugs and techniques that minimize hospital stay or prevent side effects such as pain, nausea and vomiting, improves the patient's perception of the quality of recovery.

Objective: To assess functioning and disability related to severe maternal morbidity (SMM) via the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Methods: In a retrospective cohort study, women with or without a history of SMM who delivered at a tertiary public hospital in Brazil between July 2008 and June 2012, completed the WHODAS 2.0 questionnaire by individual interview between August 2012 and November 2013. General WHODAS scores were evaluated by maternal and neonatal characteristics, and specific domain scores according to SMM event. Results: Overall, 638 women were enrolled (315 with SMM and 323 without SMM). The mean general WHODAS score was higher among women with SMM (19.04 +/- 16.18) than among women without SMM (15.77 +/- 14.46; P = 0.015). Domain scores were also higher in the SMM group for mobility (16.00 +/- 20.22 vs 11.63 +/- 17.51; P = 0.003), household activities (26.79 +/- 30.16 vs 20.09 +/- 26.08; P = 0.005), participation (23.55 +/- 21.72 vs 17.27 +/- 19.17; P < 0.001), and work/school activities for women currently studying or working (20.52 +/- 26.64 vs 11.66 +/- 19.67; P = 0.001). Excluding SMM, a parity of two or more was the only factor significantly associated with higher scores overall (P = 0.013) and for domain 4 (getting along with people; P = 0.017). Conclusion: By comparison with women without childbirth complications, SMM impaired self-reported functioning among women 1-5 years after delivery. (C) 2016 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

Background: Triggering receptors expressed on myeloid cells-1 (TREM-1) are innate immune receptors that mediate inflammatory response. In recent times, the role of these receptors has become the focus of several studies in the gestational context. Evaluation of soluble TREM-1 concentration in normal pregnancy is scarce, and no data are available on the levels of this receptor in the last weeks of normal pregnancy. Method: Amniotic fluid (AF) samples were obtained from 77 patients in the last weeks of normal pregnancy during cesarean section, and the soluble form of TREM-1 (sTREM-1) levels determined using specific sandwich enzyme-linked immunosorbent assay kit. Results: sTREM-1 was detectable in all AF samples, and its levels did not vary in the last weeks of third trimester pregnancy. There was no correlation between sTREM-1 levels in AF and advancing gestational age. Conclusion: sTREM-1 is a physiologic constituent of AF and its levels are not temporally regulated in pregnancies at term.

Objective. To assess occurrence of severe maternal complications associated with ectopic pregnancy (EP). Method. A multicenter cross-sectional study was conducted, with prospective surveillance of potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD). EP complications, patient sociodemographic/obstetric characteristics, and conditions of severity management were assessed, estimating prevalence ratios with respective 95% CI. Factors independently associated with greater severity were identified using multiple regression analysis. Results. Of the 9.555 severe maternal morbidity patients, 312 women (3.3%) had complications after EP: 286 (91.7%) PLTC, 25 (8.0%) MNM, and 1 (0.3%) MD. Severe maternal outcome ratio (SMOR) was 0.3/1000 LB among EP cases and 10.8/1000 LB among other causes. Complicated EP patients faced a higher risk of blood transfusion, laparotomy, and lower risk of ICU admission and prolonged hospitalization than women developing complications resulting from other causes. Substandard care was the most common in more severe maternal morbidity and EP cases (22.7% MNM and MD versus 15% PLTC), although not significant. Conclusion. Increased maternal morbidity due to EP raised awareness about the condition and its impact on female reproductive life. No important risk factors for greater severity were identified. Care providers should develop specific guidelines and interventions to prevent severe maternal morbidity.

Objective: To evaluate the concentration of PTX3 in amniotic fluid (AF) during the final weeks of normal pregnancies and in pregnancies complicated by preterm delivery (PTD).Study design: A cross-sectional study was conducted with 95 pregnant women followed to term and 25 who presented with PTD. Samples of AF from all patients were obtained during cesarean section and the PTX3 concentration was determined by enzyme immunoassay (ELISA). Maternal characteristics were compared by ANOVA and the Kruskal-Wallis and Chi square tests. Comparison between PTX3 concentrations in the "PTD in labor" and "PTD not in labor" groups were performed using the Mann-Whitney test. A p value <0.05 was considered statistically significant.Results: Regarding term pregnancies, PTX3 concentrations were not statistically different across the period studied (37 weeks to 40 weeks). Among preterm pregnancies, those in preterm labor (PTL) presented higher PTX3 levels than those not in labor (p = 0.001) and the risk of occurrence of PTL increased by 1% with a rise of 1 pg/mL in PTX3.Conclusion: PTX3 is a physiological constituent of the AF, and its concentration is elevated in the presence of spontaneous PTL, reinforcing the theory that PTX3 plays a role in the innate immune response during gestational complications associated with infectious/inflammatory conditions. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

To determine the prevalence of preterm birth from self-reports by Brazilian women, to assess complications, interventions and outcomes, to identify factors associated with preterm birth, and to improve the preterm birth rates estimates. This is a secondary analysis of data from a Demographic Health Survey. It interviewed a sample of 4,743 Brazilian women who had 6,113 live births from 2001 to 2007. Estimates of preterm birth rates were obtained per region and per year according to self-reported gestational age. The prevalence rate and 95 % confidence interval (CI) for preterm was determined according to the characteristics of mothers and offspring. Odds ratios and 95 % CI were estimated for complications such as severe maternal morbidity. The preterm birth rate was 9.9 %, with regional variations. Preterm birth was more likely to be associated with neonatal death, low birth weight, and longer hospital stay. Maternal factors associated with preterm birth were: white ethnicity, living in an urban area, history of hypertension or heart disease, twin gestation, non-elective Cesarean section, medical insurance for delivery, low number of antenatal visits, and severe morbidity. A self-report survey has indicated that the preterm birth rate in Brazil is higher than official data suggest, with an increasing trend in more developed areas, and is associated with poor neonatal and maternal outcomes.

Unsafe abortions remain a major public health problem in countries with very restrictive abortion laws. In Brazil, parliamentarians - who have the power to change the law - are influenced by "public opinion", often obtained through surveys and opinion polls. This paper presents the findings from two studies. One was carried out in February-December 2010 among 1,660 public servants and the other in February-July 2011 with 874 medical students from three medical schools, both in São Paulo State, Brazil. Both groups of respondents were asked two sets of questions to obtain their opinion about abortion: 1) under which circumstances abortion should be permitted by law, and 2) whether or not women in general and women they knew who had had an abortion should be punished with prison, as Brazilian law mandates. The differences in their answers were enormous: the majority of respondents were against putting women who have had abortions in prison. Almost 60% of civil servants and 25% of medical students knew at least one woman who had had an illegal abortion; 85% of medical students and 83% of civil servants thought this person(s) should not be jailed. Brazilian parliamentarians who are currently reviewing a reform in the Penal Code need to have this information urgently.

Objective: To assess the knowledge of Brazilian medical students regarding medical abortion (MA) and the use of misoprostol for MA, and to investigate factors influencing their knowledge. Methods: All students from 3 medical schools in Sao Paulo State were invited to complete a. pretested structured questionnaire with precoded response categories. A set of 12 statements on the use and effects of misoprostol for MA assessed their level of knowledge. Of about 1260 students invited to participate in the study, 874 completed the questionnaire, yielding a response rate of 69%. The chi(2) test was used for the bivariate analysis, which was followed by multiple regression analysis. Results: Although all students in their final year of medical school had heard of misoprostol for termination of pregnancy, and 88% reported having heard how to use it, only 8% showed satisfactory knowledge of its use and effects. Academic level was the only factor associated with the indicators of knowledge investigated. Conclusion: The very poor knowledge of misoprostol use for MA demonstrated by the medical students surveyed at 3 medical schools makes the review and updating of the curriculum urgently necessary. (C) 2012 Intemational Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Objective: To evaluate the occurrence of severe maternal complications associated with abortion in Brazil. Methods: In a cross-sectional multicenter study, prospective surveillance was done for cases of potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD) among 9555 women with obstetric complications between June 2009 and May 2010. Abortion was evaluated as a cause, and sociodemographic and obstetric characteristics, safety conditions where the abortion was performed, and the medical procedures used were also assessed. Prevalence ratios adjusted for the cluster effect of the design were calculated with 95% confidence intervals. Multiple logistic regression analysis was performed to identify factors independently associated with greater severity. Results: For 237 women (2.5%), abortion resulted in severe complications including PLTC (81.9%), MNM (15.2%), and MD (3%). When abortion was unsafe, infectious causes were more common for PLTC, whereas management criteria were more important for MNM and MD. In multivariate analysis, the presence of previous matemal conditions (sickle cell disease, low weight, neoplasm), being transferred or referred, previous uterine scar, and delays were associated with greater severity. Conclusion: Abortion was responsible for only a small percentage of the complications associated with pregnancy; however, the risk of abortion-related complications progressing unfavorably was higher. (c) 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

The objective of this study was to evaluate the feasibility of using computer assisted telephone interviewing (CATI) as a method for obtaining information on reproductive health in Brazil. A total of 998 eligible women for the study were selected to answer a questionnaire through computer- assisted telephone interviewing undertaken by trained interviewers. The outcomes of each telephone contact attempt were described. Differences between groups were assessed using the χ(2) test. Phone contact was made in 60.3% of the attempts and 57.5% of the interviews were completed. The success rate improved with the decrease in time from hospitalization to interview and with the higher numbers of telephones available. A total of 2,170 calls were made, comprising of one to sixteen attempts per woman. The majority of situations where extra calls were necessary were due to the number being busy or to the fact that the woman was not available at the time of the call. CATI can prove be a valuable procedure for obtaining information on reproductive health among Brazilian women, particularly for relatively recent events and when more than one alternative telephone number is available.

BACKGROUND:Improving maternal health is one of the Millennium Development Goals for 2015. Recently some progress has been achieved in reducing mortality. On the other hand, in developed regions, maternal death is a relatively rare event compared to the number of cases of morbidity; hence studying maternal morbidity has become more relevant. Electronic surveillance systems may improve research by facilitating complete data reporting and reducing the time required for data collection and analysis. Therefore the purpose of this study was to describe the methods used in elaborating and implementing the National Network for the Surveillance of Severe Maternal Morbidity in Brazil.METHODS:The project consisted of a multicenter, cross-sectional study for the surveillance of severe maternal morbidity including near-miss, in Brazil.RESULTS:Following the development of a conceptual framework, centers were selected for inclusion in the network, consensus meetings were held among the centers, an electronic data collection system was identified, specific software and hardware tools were developed, research material was prepared, and the implementation process was initiated and analyzed.CONCLUSION:The conceptual framework developed for this network was based on the experience acquired in various studies carried out in the area over recent years and encompasses maternal and perinatal health. It is innovative especially in the context of a developing country. The implementation of the project represents the first step towards this planned management. The system online elaborated for this surveillance network may be used in further studies in reproductive and perinatal health.

OBJECTIVE: To evaluate the long-term reproductive consequences that affect women who have experienced potentially life-threatening or life-threatening (near-miss) maternal complications. INTRODUCTION: Although advances have been made in reducing maternal death, few studies have investigated the long-term repercussions of significant events such as severe maternal morbidity and maternal near-misses. These repercussions may be long-lasting and negatively affect quality of life. METHODS: A total of 382 women who had experienced a potentially life-threatening pregnancy-related condition within the last five years were analyzed in this retrospective cohort study. A control group of 188 women who gave birth without complications was also included. Trained interviewers contacted the subjects by telephone and completed a pre-coded, structured questionnaire on reproductive health. Data were analyzed using odds ratios adjusted for age. The main outcome measures were occurrence and outcome of subsequent pregnancies. RESULTS: The estimated risk of becoming infertile as a result of tubal ligation or hysterectomy was 3.5 times higher in women who experienced a maternal near-miss or severe maternal morbidity during the index pregnancy as compared to controls. Likewise, the risk of complications in subsequent pregnancies was five times greater in women who had experienced severe maternal morbidity. However, no differences were found in the occurrence or number of subsequent pregnancies or perinatal outcome. CONCLUSION: The occurrence of a life-threatening or potentially life-threatening maternal condition reduces future reproductive potential and increases the risk of complications in subsequent pregnancies.

OBJECTIVE:to develop and validate a questionnaire on severe maternal morbidity and to evaluate the maternal recall of complications related to pregnancy and childbirth.DESIGN:validity of a questionnaire as diagnostic instrument.SETTING:a third level referral maternity in Campinas, Brazil.POPULATION:386 survivors of severe maternal complications and 123 women that delivered without major complications between 2002 and 2007.METHODS:eligible women were traced and interviewed by telephone on the occurrence of obstetric complications and events related to their treatment. Their answers were compared with their medical records as gold standard. Sensitivity, specificity and likelihood ratios plus their correspondent 95% confidence intervals were used as main estimators of accuracy.MAIN OUTCOMES:diagnosis of severe maternal morbidity associated with past pregnancies, including hemorrhage, eclampsia, infections, jaundice and related procedures (hysterectomy, admission to ICU, blood transfusion, laparotomy, inter-hospital transfer, mechanical ventilation and post partum stay above seven days).RESULTS:Women did not recall accurately the occurrence of obstetric complications, especially hemorrhage and infection. The likelihood ratios were < 5 for hemorrhage and infection, while for eclampsia it almost reached 10. The information recalled by women regarding hysterectomy, intensive care unit admission and blood transfusion were found to be highly correlated with finding evidence of the event in the medical records (likelihood ratios ranging from 12.7-240). The higher length of time between delivery and interview was associated with poor recall.CONCLUSION:Process indicators are better recalled by women than obstetric complication and should be considered when applying a questionnaire on severe maternal morbidity.

Recent advances in health care mean that women survive severe conditions and events related to pregnancy that would previously have resulted in death. Therefore, a greater number of women will experience significant maternal morbidity with significant consequences. Little is known, however, about these long-term consequences. Some investigators have evaluated the repercussions of severe biological or traumatic events, and have reported that survivors are at an increased risk of death in the five years after the event. In addition, they continue to experience both organic and emotional problems such as clinical, cardiac, respiratory, and neurological complications, as well as anxiety and depression, following discharge from hospital. Following a maternal "near-miss" incident, various life domains may be affected (organic, mental, cognitive, and social function), and these must be evaluated in addition to the related economic issues and quality of life. However, because of the diversity of methods and instruments used to evaluate possible repercussions, comparisons between the few studies available on the subject are difficult. An in-depth debate should be initiated to discuss the methodological aspects of such investigation. We propose a conceptual and methodological discussion on the long-term repercussions of severe maternal morbidity based on the evaluation of the following variables: reproductive health, quality of life, posttraumatic stress syndrome, sexual function, postpartum depression, daily functioning, and the physical, neurological, and psychomotor development of the children born after a complicated pregnancy.

OBJECTIVE:To evaluate the reported occurrence of spontaneous and induced abortion, and abortion-associated severe maternal morbidity in Brazil. METHODS:A secondary analysis of the 2006 Brazilian Demographic Health Survey was conducted. Interview data on women's experience of spontaneous/induced abortion and associated factors were analyzed overall and by geographic region. Multinomial logistic regression was performed to identify factors independently associated with abortion. The risk of associated severe maternal morbidity was estimated. RESULTS:The reported lifetime rates of spontaneous and induced abortion were 13.3% and 2.3%, respectively, and were highest in the north (4.3%) and northeast (3.5%). The rate of spontaneous abortion was higher among women aged 40-49 years (odds ratio [OR] 1.15; 95% confidence interval [CI], 1.03-1.30) and among those with 0 or 1 children or delivery (OR 1.97; 95% CI, 1.36-2.85 vs OR 1.98; 95% CI, 1.37-2.86). Induced abortion was not associated with sociodemographic factors. Abortion significantly increased the risk of complications (hemorrhage and infection). CONCLUSION:Spontaneous abortion was significantly associated with parity and maternal age. Abortion in general carried a higher risk of severe maternal complications.