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Miele MJ, Souza RT, Vieira MC, Pacagnella RC, Cecatti JG. Maternal diet and interactions with nutritional evaluation during pregnancy. Int J Gynaecol Obstet 2023; 163:782-789. [PMID: 37401116 DOI: 10.1002/ijgo.14974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/06/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
This narrative review aims to describe the knowledge regarding nutritional evaluation and monitoring in pregnant women. We discuss care provided by non-specialists in nutrition, regarding dietary information and risks during pregnancy, from a theoretical or conceptual viewpoint. A narrative review was conducted following a literature search when scientific databases were investigated, including SciELO, LILACS, Medline, PubMed, theses, government reports, books, and chapters in books. Finally, the material was fully read, categorized, and critically analyzed. National and international protocols of prenatal nutritional care were included and discussed. Different protocols describe the complexity of evaluating and monitoring nutrition among pregnant women during the prenatal period according to each country. The understanding of social conditions and eating habits has an important role in providing nutritional advice during pregnancy. The lack of dietitians in care overwhelms the healthcare workers and characterizes a missed opportunity. Therefore, it is important to consider rapid support tools that can track adverse nutritional status, and ways to recommend a diet that meets eating habit dynamics, according to the reality of each public health system.
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Affiliation(s)
- Maria J Miele
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil
| | - Renato T Souza
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil
| | - Matias C Vieira
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil
- Division of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, UK
| | - Rodolfo C Pacagnella
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil
| | - José G Cecatti
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil
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Ursache A, Bujor IE, Cristofor AE, Zelinschi DO, Nemescu D, Matasariu DR. Maternal Body Mass Index Trends and Weight Gain in Singleton Pregnancies at the Time of Fetal Anatomic Survey: Changes in the Last Decade and New Trends in the Modern Era. Nutrients 2023; 15:4788. [PMID: 38004185 PMCID: PMC10674181 DOI: 10.3390/nu15224788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
(1) Background: the worldwide impact of overweight and obesity is rising, increasingly resembling an epidemic (a price we have to pay for our new way of living). (2) Methods: our study aims to evaluate the temporal trends and patterns of singleton pregnant women's BMI (body mass index) in our region during a 12-year time frame between 2010 and 2021. (3) Results: We noticed a statistically significant difference between the BMIs of nulliparous and multiparous women and a significantly increased pregestational BMI in women with previous ART (assisted reproductive technology) procedures. Smoking pregnant women had a higher second trimester weight gain, regardless of parity. Women with folic acid supplementation alone had a higher BMI than those with folic acid and multivitamin intake. The weight of both nulliparous and multiparous women with chronic hypertension was statistically significantly higher in all three timeframes. Global weight gain did not reveal any statistically significant changes concerning women with pregestational diabetes, regardless of parity and the pregnancy trimester. (4) Conclusions: our article describes the trends in obesity and overweight in our middle-income country, in which this pathology is continuously growing, negatively influencing our reproductive-aged women and future generations.
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Affiliation(s)
- Alexandra Ursache
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iasi, Romania; (A.U.); (I.E.B.); (D.O.Z.); (D.R.M.)
- Department of Obstetrics and Gynecology, Cuza Voda Hospital, 700038 Iasi, Romania
| | - Iuliana Elena Bujor
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iasi, Romania; (A.U.); (I.E.B.); (D.O.Z.); (D.R.M.)
| | - Alexandra Elena Cristofor
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iasi, Romania; (A.U.); (I.E.B.); (D.O.Z.); (D.R.M.)
| | - Denisa Oana Zelinschi
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iasi, Romania; (A.U.); (I.E.B.); (D.O.Z.); (D.R.M.)
- Department of Obstetrics and Gynecology, Cuza Voda Hospital, 700038 Iasi, Romania
| | - Dragos Nemescu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iasi, Romania; (A.U.); (I.E.B.); (D.O.Z.); (D.R.M.)
- Department of Obstetrics and Gynecology, Cuza Voda Hospital, 700038 Iasi, Romania
| | - Daniela Roxana Matasariu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iasi, Romania; (A.U.); (I.E.B.); (D.O.Z.); (D.R.M.)
- Department of Obstetrics and Gynecology, Cuza Voda Hospital, 700038 Iasi, Romania
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Miele MJ, Souza RT, Calderon I, Feitosa F, Leite DF, Rocha Filho E, Vettorazzi J, Mayrink J, Fernandes KG, Vieira MC, Pacagnella RC, Cecatti JG. Proposal of MUAC as a fast tool to monitor pregnancy nutritional status: results from a cohort study in Brazil. BMJ Open 2021; 11:e047463. [PMID: 34031116 PMCID: PMC8149442 DOI: 10.1136/bmjopen-2020-047463] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/07/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE In Brazil, although the assessment of maternal nutritional status is recommended using body mass index (BMI), this is only possible in settings adequately prepared. Midupper arm circumference (MUAC) is another biological variable identified as a tool for rapid assessment of nutritional status that is correlated with BMI. Therefore, we aim to surrogate BMI by MUAC cut-offs for rapid screening of maternal nutritional status starting at midpregnancy. DESIGN Analysis of the multicentre cohort study entitled 'Preterm SAMBA' using an approach of validation of diagnostic test. SETTING Outpatient prenatal care clinics from five tertiary maternity hospitals from three different Brazilian regions. PARTICIPANTS 1165 pregnant women attending prenatal care services from 2015 to 2018 and with diverse ethnic characteristics who were enrolled at midpregnancy and followed in three visits at different gestational weeks. PRIMARY AND SECONDARY OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive values, likelihood ratio and accuracy of MUAC being used instead of BMI for the assessment of nutritional status of women during pregnancy. RESULTS We found a strong correlation between MUAC and BMI, in the three set points analysed (r=0.872, 0.870 and 0.831, respectively). Based on BMI categories of nutritional status, we estimated the best MUAC cut-off points, finding measures according to each category: underweight <25.75 cm (19-39 weeks); overweight 28.11-30.15 cm (19-21 weeks), 28.71-30.60 cm (27-29 weeks) and 29.46-30.25 cm (37-39 weeks); and obese >30.15 cm (19-21 weeks), >30.60 cm (27-29 weeks) and >30.25 cm (37-39 weeks) per gestational week. Therefore, we defined as adequate between 25.75-28.10 cm (19-21 weeks), 25.75-28.70 cm (27-29 weeks) and 25.75-29.45 cm (37-39 weeks) of MUAC. CONCLUSION We conclude that MUAC can be useful as a surrogate for BMI as a faster screening of nutritional status in pregnant women.
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Affiliation(s)
- Maria J Miele
- Obstetrics and Gynecology, State University of Campinas, Campinas, Brazil
| | - Renato T Souza
- Obstetrics and Gynecology, State University of Campinas, Campinas, Brazil
| | - Imp Calderon
- Department of Gynecology and Obstetrics, UNESP Campus de Botucatu, Botucatu, Brazil
| | - Francisco Feitosa
- Obstetric Department of MEAC, Federal University of Ceara, Fortaleza, Brazil
| | - Debora F Leite
- Obstetrics and Gynecology, Federal University of Pernambuco, Recife, Brazil
| | | | - Janete Vettorazzi
- Obstetrics and Gynecology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Jussara Mayrink
- Obstetrics and Gynecology, State University of Campinas, Campinas, Brazil
| | | | - Matias C Vieira
- Division of Women's Health, King's College London School of Life Course Sciences, London, UK
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Carrilho TRB, Farias DR, Batalha MA, Costa NCF, Rasmussen KM, Reichenheim ME, Ohuma EO, Hutcheon JA, Kac G. Brazilian Maternal and Child Nutrition Consortium: establishment, data harmonization and basic characteristics. Sci Rep 2020; 10:14869. [PMID: 32913200 PMCID: PMC7483530 DOI: 10.1038/s41598-020-71612-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/18/2020] [Indexed: 12/03/2022] Open
Abstract
Pooled data analysis in the field of maternal and child nutrition rarely incorporates data from low- and middle-income countries and existing studies lack a description of the methods used to harmonize the data and to assess heterogeneity. We describe the creation of the Brazilian Maternal and Child Nutrition Consortium dataset, from multiple pooled longitudinal studies, having gestational weight gain (GWG) as an example. Investigators of the eligible studies published from 1990 to 2018 were invited to participate. We conducted consistency analysis, identified outliers, and assessed heterogeneity for GWG. Outliers identification considered the longitudinal nature of the data. Heterogeneity was performed adjusting multilevel models. We identified 68 studies and invited 59 for this initiative. Data from 29 studies were received, 21 were retained for analysis, resulting in a final sample of 17,344 women with 72,616 weight measurements. Fewer than 1% of all weight measurements were flagged as outliers. Women with pre-pregnancy obesity had lower values for GWG throughout pregnancy. GWG, birth length and weight were similar across the studies and remarkably similar to a Brazilian nationwide study. Pooled data analyses can increase the potential of addressing important questions regarding maternal and child health, especially in countries where research investment is limited.
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Affiliation(s)
- Thaís Rangel Bousquet Carrilho
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho 373/CCS, bloco J, 2 andar, sala 29, Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Dayana Rodrigues Farias
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho 373/CCS, bloco J, 2 andar, sala 29, Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Mônica Araújo Batalha
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho 373/CCS, bloco J, 2 andar, sala 29, Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Nathalia Cristina Freitas Costa
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho 373/CCS, bloco J, 2 andar, sala 29, Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Kathleen M Rasmussen
- Division of Nutritional Sciences, Cornell University, 227 Savage Hall, Ithaca, NY, 14850, USA
| | - Michael E Reichenheim
- Department of Epidemiology, Institute of Social Medicine, Rio de Janeiro State University, Rua São Francisco Xavier, 524, 7 andar, Bloco D, Sala 7018, Maracanã, Rio de Janeiro, RJ, 20550-013, Brazil
| | - Eric O Ohuma
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Peter Medawar Building for Pathogen Research (PMB), South Parks Road, Oxford, OX1 3SY, UK
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC, V6Z 2K8, Canada
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho 373/CCS, bloco J, 2 andar, sala 29, Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Nicolosi BF, Souza RT, Mayrink J, Feitosa FE, Rocha Filho EA, Leite DF, Vettorazzi J, Sousa MH, Costa ML, Baker PN, Kenny LC, Cecatti JG, Calderon IM. Incidence and risk factors for hyperglycemia in pregnancy among nulliparous women: A Brazilian multicenter cohort study. PLoS One 2020; 15:e0232664. [PMID: 32401767 PMCID: PMC7219776 DOI: 10.1371/journal.pone.0232664] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/02/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To assess the incidence and risk factors for hyperglycemia in pregnancy in a cohort of Brazilian nulliparous pregnant women. MATERIALS AND METHODS This is a secondary analysis of a multicenter cohort study that enrolled 1,008 nulliparous pregnant women at 19-21 weeks. Exclusion criteria included chronic exposure to corticosteroids and previous diabetes. Bivariate and multivariate analyses by Poisson regression were used to identify associated factors. RESULTS The incidence of hyperglycemia in pregnancy was 14.9% (150/1,008), and 94.7% of these cases were gestational diabetes mellitus (142/150). Significant associated factors included a family history of diabetes mellitus, maternal overweight or obesity at enrollment, and previous maternal conditions (polycystic ovarian syndrome, thyroid dysfunctions and hypertensive disorders). A BMI ≥ 26.3Kg/m2 (RRadj 1.87 [1.66-2.10]) and a family history of diabetes mellitus (RRadj 1.71 [1.37-2.15]) at enrollment were independent risk factors for HIP. CONCLUSIONS A family history of diabetes mellitus and overweight or obesity (until 19-21 weeks of gestation) may be used as selective markers for HIP in Brazilian nulliparous women. Given the scarcity of results in nulliparous women, our findings may contribute to determine the optimal diagnostic approach in populations of similar socioeconomic characteristics.
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Affiliation(s)
- Bianca F. Nicolosi
- Department of Obstetrics and Gynecology, Botucatu Medical School, Unesp, Botucatu, SP, Brazil
| | - Renato T. Souza
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
| | - Jussara Mayrink
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
| | - Francisco E. Feitosa
- MEAC–Maternity School of the Federal University of Ceará, in Fortaleza, CE, Brazil
| | - Edilberto A. Rocha Filho
- Department of Maternal and Child Health, Maternity of Clinic Hospital, Federal University of Pernambuco, Recife, PE, Brazil
| | - Débora F. Leite
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
- Department of Maternal and Child Health, Maternity of Clinic Hospital, Federal University of Pernambuco, Recife, PE, Brazil
| | - Janete Vettorazzi
- Department of Obstetrics and Gynecology, Maternity of the Clinic Hospital, Federal University of RS, Porto Alegre, RS, Brazil
| | - Maria H. Sousa
- Statistics Unit, Jundiai School of Medicine, Jundiaí, SP, Brazil
| | - Maria L. Costa
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
| | - Philip N. Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Louise C. Kenny
- Faculty of Health and Life Sciences, Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jose G. Cecatti
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
- * E-mail:
| | - Iracema M. Calderon
- Department of Obstetrics and Gynecology, Botucatu Medical School, Unesp, Botucatu, SP, Brazil
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Agudelo-Espitia V, Parra-Sosa BE, Restrepo-Mesa SL. Factors associated with fetal macrosomia. Rev Saude Publica 2019; 53:100. [PMID: 31800911 PMCID: PMC6863107 DOI: 10.11606/s1518-8787.2019053001269] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/13/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To evaluate the clinical factors, as well as weight gain, in a group of pregnant women, associating them with fetal macrosomia in a public institution in Antioquia, Colombia, from 2010-2017. METHODS A case-control study, using secondary information registries. Cases were defined using newborn weight of ≥ 4000g, while controls were defined as newborn weight between 3000–3999g. A proportion ratio (PR) was established to evaluate factors associated with macrosomia, and a generalized linear model (GLM) of Poisson regression with robust variance was used to evaluate the aspects that best explained macrosomia in the neonate. RESULTS 122 pregnant women participated in the study, of which 611 were cases and 61 were controls. Of the participants, 44.3% had pre-pregnancy overweight and 48.4% had excess gestational weight gain. Statistically significant differences were found between the groups in the following variables: pre-pregnancy BMI (p = 0.004), gestational weight gain (p = 0.000), gestational diabetes (p = 0.000), and type of delivery (p = 0.004). According to the regression model, a macrosomic newborn is 3.5 times more likely in women with excessive gestational weight gain (95%CI 1.78-7.18) and twice more likely in women who have gestational diabetes (95%CI 1.51-2.76). Of women with pre-pregnancy excess weight, 63% had excess gestational weight gain. CONCLUSIONS Within this cohort, pre-pregnancy BMI, excess weight gain in pregnancy, and the presence of gestational diabetes were associated with an increased risk of neonatal macrosomia. pre-pregnancy BMI and weight gain in pregnancy are modifiable risk factors that are responsive to nutrition interventions, which can minimize adverse perinatal outcomes.
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Affiliation(s)
| | - Beatriz Elena Parra-Sosa
- Universidad de Antioquia. Escuela de Nutrición y Dietética. Grupo de Investigación Alimentación y Nutrición Humana. Magíster en Ciencias Básicas Biomédicas. Colombia
| | - Sandra L Restrepo-Mesa
- Universidad de Antioquia. Escuela de Nutrición y Dietética. Grupo de Investigación Alimentación y Nutrición Humana. Magíster en Salud Colectiva. Colombia
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Mayrink J, Souza RT, Feitosa FE, Rocha Filho EA, Leite DF, Vettorazzi J, Calderon IM, Sousa MH, Costa ML, Baker PN, Cecatti JG. Incidence and risk factors for Preeclampsia in a cohort of healthy nulliparous pregnant women: a nested case-control study. Sci Rep 2019; 9:9517. [PMID: 31266984 PMCID: PMC6606578 DOI: 10.1038/s41598-019-46011-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/18/2019] [Indexed: 12/19/2022] Open
Abstract
The objective of this study is to determine the incidence, socio-demographic and clinical risk factors for preeclampsia and associated maternal and perinatal adverse outcomes. This is a nested case-control derived from the multicentre cohort study Preterm SAMBA, in five different centres in Brazil, with nulliparous healthy pregnant women. Clinical data were prospectively collected, and risk factors were assessed comparatively between PE cases and controls using risk ratio (RR) (95% CI) plus multivariate analysis. Complete data were available for 1,165 participants. The incidence of preeclampsia was 7.5%. Body mass index determined at the first medical visit and diastolic blood pressure over 75 mmHg at 20 weeks of gestation were independently associated with the occurrence of preeclampsia. Women with preeclampsia sustained a higher incidence of adverse maternal outcomes, including C-section (3.5 fold), preterm birth below 34 weeks of gestation (3.9 fold) and hospital stay longer than 5 days (5.8 fold) than controls. They also had worse perinatal outcomes, including lower birthweight (a mean 379 g lower), small for gestational age babies (RR 2.45 [1.52-3.95]), 5-minute Apgar score less than 7 (RR 2.11 [1.03-4.29]), NICU admission (RR 3.34 [1.61-6.9]) and Neonatal Near Miss (3.65 [1.78-7.49]). Weight gain rate per week, obesity and diastolic blood pressure equal to or higher than 75 mmHg at 20 weeks of gestation were shown to be associated with preeclampsia. Preeclampsia also led to a higher number of C-sections and prolonged hospital admission, in addition to worse neonatal outcomes.
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Affiliation(s)
- Jussara Mayrink
- Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
| | - Renato T Souza
- Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
| | - Francisco E Feitosa
- MEAC - Maternity School of the Federal University of Ceará, Fortaleza, CE, Brazil
| | - Edilberto A Rocha Filho
- Department of Maternal and Child Health, Maternity Hospital, Federal University of Pernambuco, Recife, PE, Brazil
| | - Débora F Leite
- Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil.,Department of Maternal and Child Health, Maternity Hospital, Federal University of Pernambuco, Recife, PE, Brazil
| | - Janete Vettorazzi
- Department of Obstetrics and Gynaecology, Maternity Hospital, Federal University of RS, Porto Alegre, RS, Brazil
| | - Iracema M Calderon
- Department of Obstetrics and Gynaecology, Botucatu School of Medicine, Unesp, Botucatu, SP, Brazil
| | - Maria H Sousa
- Statistics Unit, Jundiai School of Medicine, Jundiaí, SP, Brazil
| | - Maria L Costa
- Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil
| | - Philip N Baker
- College of Life Sciences, Maurice Shock Building, University of Leicester, Leicester, UK
| | - Jose G Cecatti
- Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) School of Medical Sciences, Campinas, SP, Brazil.
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