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Rationale, Aims and Objectives: Continuing health education is essential but challenged. In 2006, the Brazilian Cochrane Center, in collaboration with the Ministry of Health, launched a mass teaching initiative in evidence-based health care (EBH) for public-sector professionals via teleconferencing. This 152-hour, interactive EBH course has enrolled over 4500 professionals. This study aimed to assess the acquisition EBH knowledge and skills, as well as the attitudes and perceptions of a sample of students enrolled in the 2009 course via teleconferencing., Methods: This prospective cohort study analyzed three aspects of this 152-hour EBH course that recruited 1040 volunteer participants, all public health sector employees working in 131 different hospitals or health agencies. Pre- and post-course tests using a modified version of the Berlin questionnaire with 20 multiple-choice questions were used to examine knowledge acquisition in a sample of 297 students. Tests were completed upon registration and at course completion. The research projects submitted by 872 participants were evaluated to assess skill acquisition. Answers to an anonymous survey assessed the attitudes and perceptions of 914 participants., Results: There was a significant increase in knowledge from baseline to course completion (mean scores 8.2 ± 3.3 versus 13.7 ± 3.0, P < 0.001). Over 90% of the research projects were judged to be of adequate quality (appropriate rationale for the study, well-formulated research question and feasible execution); over 95% of the participants were satisfied with the course., Conclusion: The Brazilian EBH course via teleconference improved the knowledge and skills of public-sector health professionals and was approved by the vast majority of students., (© 2013 John Wiley & Sons Ltd.)

Problem: Gestational diabetes mellitus (GDM) is an inflammatory condition that involves unbalanced cytokine production. We carried out a systematic review on the relationship between GDM and maternal circulating levels of cytokines in the 2nd/3rd trimesters., Method of Study: Three electronic databases (MEDLINE, EMBASE and LILACS), were searched. Duplicate study selection, extraction and quality assessment was performed., Results: Twenty-two studies with 1982 participants reporting levels of 9 cytokines (IL-1B, IL-2, IL-6, IL-10, IL-13, IL-18, IFN-G, TGF-B and TNF-A) were included. Most studies differed considerably in selection criteria, sampling and assay methods and in reporting their results. Consequently, only two studies could be pooled: TNF-A concentration was slightly higher in GDM than in control patients, although not significant (WMD=0.45, 95% CI -0.34-1.23)., Conclusions: New studies with well-defined, more homogeneous methodological parameters are needed to detect whether there are significant differences in circulating levels of cytokines in patients with GDM., (© 2013 John Wiley & Sons Ltd.)

Objectives: To assess the quality of systematic reviews and clinical trials on women's health recently published in a Brazilian evidence-based health journal., Method: All systematic reviews and clinical trials on women's health published in the last five years in the Brazilian Journal of Evidence-based Health were retrieved. Two independent reviewers critically assessed the methodological quality of reviews and trials using AMSTAR and the Cochrane Risk of Bias Table, respectively., Results: Systematic reviews and clinical trials accounted for less than 10% of the 61 original studies on women's health published in the São Paulo Medical Journal over the last five years. All five reviews were considered to be of moderate quality; the worst domains were publication bias and the appropriate use of study quality in formulating conclusions. All three clinical trials were judged to have a high risk of bias. The participant blinding, personnel and outcome assessors and allocation concealment domains had the worst scores., Conclusions: Most of the systematic reviews and clinical trials on women's health recently published in a Brazilian evidence-based journal are of low to moderate quality. The quality of these types of studies needs improvement.

Gestational diabetes (GD) exposes mothers and infants to the risk of immediate and later adverse outcomes. Increased insulin resistance is a common feature of GD and obesity. Because of its critical role in regulating insulin sensitivity, resistin has been implicated in the physiopathology of GD. The aim of this study was to review the existing literature on the relationship between circulating maternal resistin levels and GD. Three electronic databases (MEDLINE, EMBASE, and LILACS) were searched for pertinent studies published from 2001 to 2012, without language restrictions. Eleven studies, with a total of 639 participants between 23 and 41 weeks of gestation, were included. The number of GD patients per study ranged from 11 to 81, with varying degrees of disease severity and several different GD diagnostic criteria. Mean concentrations of resistin varied widely both in control women (0.05-22.21 ng/ml) and in GD patients (0.05-62.38 ng/ml). We performed a meta-analysis including a total of 10 studies, and also subgroup analyses according to gestational age at sample collection (up to 32 and >33 weeks). The pooled absolute mean difference (WMD) in resistin levels was slightly lower in GD patients than in controls, but this did not reach statistical significance (WMD=-0.02, 95% CI -0.07 to 0.04). According to the data from the 11 studies analyzed, there was no association between circulating resistin levels and GD. However, this result should be interpreted with caution owing to the large heterogeneity amongst the existing published studies., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: We sought to describe obstetric care capacity of nongovernment organization (NGO)-/faith-based organization (FBO)-run institutions compared to government-run institutions in 3 African countries using the World Health Organization Global Survey. We also compared delivery characteristics and outcomes., Study Design: This is a descriptive analysis of the 22 NGO-/FBO-run institutions in Uganda, Kenya and Democratic Republic of Congo delivering 11,594 women, compared to 20 government-run institutions delivering 25,825 women in the same countries and period., Results: Infrastructure, obstetric services, diagnostic facilities, and anesthesiology at NGO/FBO institutions were comparable to government institutions. Women delivering at NGO/FBO institutions had more antenatal care, antenatal complications, and cesarean delivery. NGO/FBO institutions had higher obstetrician attendance and lower rates of eclampsia, preterm birth, stillbirth, Apgar <7, and neonatal near miss., Conclusion: NGO/FBO institutions are comparable to government institutions in capacity to deliver obstetric care. NGO/FBOs have been found effective in providing delivery care in developing countries and should be appropriately recognized by stakeholders in their efforts to assist nations achieve international goals., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Introduction: Sexual difficulties and questions regarding sexual function are frequent in pregnancy, yet they are infrequently discussed in academic communities, medical schools, and residency programs. Embarrassment, lack of experience, inadequate communication skills and insufficient knowledge on how to deal with sexual complaints, and questions in pregnancy are common, especially among young health professionals., Aim: The aim of this study was to assess and compare the attitude and behavior of Brazilian residents in three different medical programs (obstetrics-gynecology, internal medicine, and psychiatry) toward sexual health issues of pregnant patients., Methods: Survey conducted in a single Brazilian university using anonymous self-responsive questionnaires on how residents deal with sexual health issues of obstetric patients. A total of 154 residents from the three different programs (47 obstetrics-gynecology, 33 psychiatry, 74 internal medicine) participated., Main Outcome Measures: Attitude and practice of medical residents regarding sexual health issues of pregnant patients., Results: Less than 20% of the residents reported that they routinely asked obstetric patients about their sexual health, although almost 70% stated this should be part of every history. Psychiatry residents were significantly more likely to actively seek information about the sexual health of obstetric patients than others (57.6%, 17%, 4.1%, psychiatry, obstetrics-gynecology, internal medicine, respectively, P<0.001). Although over 80% answered that most obstetric patients react well or indifferently to questions about sexual function, less than 25% of the residents reported being completely confident answering these questions, and 71% of them admitted that they lacked specific knowledge in the area of sexual dysfunctions. The two main obstacles in evaluating patients' sexuality were lack of specific knowledge and not enough time to explore these aspects in medical consultations, reported by 71% and 20% of all participants, respectively., Conclusions: Most residents do not feel comfortable or confident and lack specific knowledge and skills to deal with questions related to sexual problems during pregnancy., (© 2012 International Society for Sexual Medicine.)

Purpose: To investigate differences in pre-pregnancy BMI status in patients with spontaneous preterm birth (PTB) compared with term birth and assess the role of ethnicity as a risk modifier in BMI-associated PTB., Methods: A case-control study involving self-reported African American and Caucasian women delivering singletons in Nashville, TN, USA, 2003-2009. Maternal pre-pregnancy BMI was recorded in 447 PTB-cases (African American = 145, Caucasian = 302) and 1315 term-birth controls (African American = 522; Caucasian = 793). Crude and adjusted odds ratio (OR and AOR) for PTB were calculated using normal BMI (18.5-24.9 kg/m(2)) as reference. Age, education, marital status, income, smoking, parity, previous PTB and pregnancy weight gain were included as covariates in logistic regression., Results: No significant differences were noted in the OR for PTB among different BMI categories when women of different ethnicity were combined. Odds of PTB were greater in obese than in normal weight Caucasian women, even after adjusting for confounders (AOR = 1.84, 95%CI [1.15, 2.95]). Obese African American women had a decreased crude OR for PTB, although this was not significant after adjusting for confounders (AOR = 0.72, 95%CI [0.38, 1.40]). The odds for early PTB (<32 weeks) were decreased in obese compared with normal weight African American women (OR = 0.23, 95%CI [0.08, 0.70]), whereas they were increased in obese compared with normal weight Caucasian women (OR = 2.30, 95%CI [1.32, 4.00])., Conclusion: The risk for PTB in women with different pre-pregnancy BMI categories differs according to ethnicity.

Problem: Our study aimed to assess in vitro production of IL-10, IL-6, TNF-A, and adiponectin serum levels in pregnant women with and without gestational diabetes mellitus (GDM) and to investigate a possible association between GDM and IL-10-1082 A>G (rs1800896), IL-6-174 G>C (rs1800795), TNF-A-308 G>A (rs1800629), adiponectin +45 T>G (rs2241766), and adiponectin-11377 C>G (rs266729) gene polymorphisms., Method of Study: This case-control study included 79 women with GDM and 169 healthy controls (C) grouped according to pre-pregnancy BMI. IL-10, IL-6, and TNF-A culture supernatant and adiponectin serum levels were assessed by ELISA. DNA genotype was performed by PCR-RFLP., Results: Adiponectin levels were significantly higher in C than GDM women, even within the same BMI category. Cytokines levels were similar between the groups. There were no associations between GDM and the analyzed gene polymorphisms., Conclusions: Women with GDM have significantly lower adiponectin levels in the third trimester, regardless of BMI., (© 2011 John Wiley & Sons A/S.)

Introduction: The number of women with gestational diabetes mellitus (GDM) is growing worldwide in parallel with the obesity epidemic. The diagnosis of GDM leads to substantial modifications in the daily routine of these women, and these adjustments could potentially affect their sexual function. There are no previous studies on the sexual function of patients with GDM., Aim: The aim of this study was to investigate the sexual function of patients with GDM in comparison with healthy pregnant women at the same gestational age., Methods: Brazilian women in the third trimester of pregnancy with and without GDM were invited to participate in this cross-sectional study while waiting for their antenatal care visits at a single public tertiary teaching institution between March and December 2010. The Brazilian version of the Female Sexual Function Index (FSFI) questionnaire was used to assess sexual function., Main Outcome Measures: Desire, arousal, lubrication, orgasm, sexual satisfaction, and pain during and after coitus in the last 4 weeks, measured according to a standardized and validated questionnaire., Results: A total of 87 participants were enrolled (43 healthy women and 44 with GDM). There were no significant differences in the sociodemographic characteristics of both groups. The total FSFI scores of GDM patients was 21.0±9.59 compared with 22.3±9.17 for healthy women (P=0.523). Difficulty in desire was the most common sexual dysfunction symptom in both groups, being reported by 42% and 50% of GDM and healthy women, respectively (P=0.585)., Conclusion: The sexual function of Brazilian patients with GDM does not differ significantly from that of healthy pregnant women at the same gestational age., (© 2011 International Society for Sexual Medicine.)

Background: Understanding spontaneous preterm birth ([PTB] < 37 weeks) is difficult due to heterogeneities associated with multitudes of risk factors and pathophysiological pathways. Several biomarkers are routinely used clinically for predicting preterm labor; however, these factors are either nonspecific or detected too late., Objective: Systematic review of literature on PTB biomarkers in the last 40 years to map out the existing knowledge and gaps in understanding PTB biomarkers., Search Strategies: Five electronic databases were searched for human studies on PTB biomarkers published in any language between 1965 and 2008., Selection Criteria: The phenotype of interest for final data extraction was exclusively spontaneous PTB with no rupture of membranes. Data extraction included (a) general characteristics of the study (clinical setting, period, and study design), (b) study/participant characteristics (inclusion and exclusion criteria, race/ethnicity, number of participants, gestational age at sampling, (c) characteristics of the biomarker (type, rationale for its selection, type of biological sample, and assay used, and (d) concentration of biomarkers in cases and controls., Data Collection and Analysis: The search yielded 7255 citations and data were extracted from 217 articles which met our inclusion and exclusion criteria., Main Results: A total of 116 different biomarkers were reported and these were assayed 578 times in the 217 included studies. Over two thirds of the 217 studies were performed on North American or European populations. No reliable biomarkers emerged as a risk predictor of PTB., Conclusions: Identifying similar studies on biomarkers for the prediction of PTB was a very challenging task due heterogeneities in study design, sampling issues (types, timing and processing), assay methods, and analyses. Major areas of concern identified in this review include poor phenotype definition, nonideal study designs and poor rationale for biomarker selection and assays and population stratification issues.

Aim: Assess possible adverse effects of the chronic use of indinavir during pregnancy in a rat model., Methods: 40 pregnant EOM-1 albino rats were randomly allocated into four groups of 10 animals each: a control (Ctr) group (without any handling) and three experimental groups (Exp 1, Exp 2 e Exp 3) which received indinavir 9, 27 e 81 mg/kg, respectively). Rats were treated by gavage once daily. The treatment period extended from day 0 until the 20th day of pregnancy. Body weights were recorded on days 0, 7, 14 and 20. At term, the rats were sacrificed, and the implantation sites, number of live and dead fetuses and placentas, resorptions, fetal and placental weights were recorded. The fetuses were evaluated for external abnormalities under a stereomicroscope., Results: Weight gain during pregnancy did not differ significantly between the groups. Average weight gains between the 7th and 20th day were 7.95-42.70 g; 7.22-45.27 g; 7.12-46.26 g and 8.05-42.29 g in groups Ctr, Exp 1, Exp 2 and Exp 3, respectively. All other parameters assessed did not differ significantly between groups., Conclusions: Chronic use of various dosages of indinavir during pregnancy was not associated significant adverse outcomes., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

The incidence of gestational diabetes (GD) is rising worldwide, in parallel with obesity and type 2 diabetes. Obesity and GD are conditions that have in common a state of chronic, low-grade subclinical inflammation characterized by abnormal production of cytokines and mediators. Genetic polymorphisms may influence the production of inflammatory mediators and predispose to different disorders, including diabetes. The aim of this study was to review the existing literature on the relationship between inflammatory mediator gene polymorphisms and GD. The search in PubMed was restricted to articles published in English, from January 1990 to December 2010. Eight studies were included. These publications evaluated 13 different SNPs and six inflammatory mediators in the blood of women with GD. Gene polymorphisms related to leptin, mannose-binding lectin (MBL) and RAGE (receptor for advanced glycation end products) were individually evaluated in a single study each. Leptin and MBL plasma levels were also evaluated in two studies. The participants included in the studies were ethnically different, but matched with controls. Different criteria were adopted to select the participants. Seven of the eight studies included took into consideration the BMI of patients and controls. Due to the heterogeneity and limited number of studies on GD and inflammatory gene polymorphisms, we could not pool together any of the results or perform any additional analyses of the existing data. Since the existing findings come from isolated studies with mostly small sample sizes, there is a need for new, larger, properly designed studies of good methodological quality., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To compare the sexual function of healthy adult pregnant women with that of gestational diabetes patients (GDM) in the third trimester., Methods: This cross-sectional study enrolled two groups of women managed antenatal care clinics. Inclusion criteria were: maternal age .20 years, gestational age at least 28 weeks, being in a heterosexual relationship with the same partner for at least 6 months, and being able to read. We excluded women with a medical recommendation for sexual abstinence due to clinical or obstetric disorders; hypertension controlled through medications; pregnancy resulting from rape; absent or sexually unavailable partner in the last month; hospital admission in the last month; use of vaginal creams in the last 30 days; multiple pregnancy, regular use of alcohol or illicit drugs or use of medications that can interfere with sexual function. Eighty-seven patients fulfilled the selection criteria and were included in the study. The Sexual Quotient . Feminine Version (QS-F) questionnaire was used to assess sexual function. Student's t and χ² tests were used to compare differences between groups and p<0.05 was considered significant., Results: The mean gestational age of the participants was 34 weeks. There were no significant differences in the mean QS-F scores between groups (62.5 healthy vs 62.8 GDM women, p=0.9). Approximately half the participants (47 and 47.5% of the healthy and GDM women, respectively, p=0.9) had total scores up to 60, indicative of dysfunction in one of the assessed domains (desire, sexual satisfaction, arousal, orgasm, dyspareunia and vaginismus)., Conclusions: The prevalence of sexual dysfunction was high among women in the third trimester of pregnancy and did not differ significantly between healthy women and women with GDM.

Objective: To assess the quality and comprehensiveness of the information on caesarean section provided in Brazilian women's magazines., Design: Review of articles published during 1988-2008 in top selling women's magazines., Setting: Brazil, one of the countries with the highest caesarean section rates in the world., Data Sources: Women's magazines with the largest distribution during the study period, identified through the official national media indexing organisations., Selection Criteria: Articles with objective scientific information or advice, comments, opinions, or the experience of ordinary women or celebrities on delivery by caesarean section., Main Outcome Measures: Sources of information mentioned by the author of the article, the accuracy and completeness of data presented on caesarean section, and alleged reasons why women would prefer to deliver though caesarean section., Results: 118 articles were included. The main cited sources of information were health professionals (78% (n=92) of the articles). 71% (n=84) of the articles reported at least one benefit of caesarean section, and 82% (n=97) reported at least one short term maternal risk of caesarean section. The benefits most often attributed to delivery by caesarean section were reduction of pain and convenience for family or health professionals. The most frequently reported short term maternal risks of caesarean section were increased time to recover and that it is a less natural way of giving birth. Only one third of the articles mentioned any long term maternal risks or perinatal complications associated with caesarean section. Fear of pain was the main reported reason why women would prefer to deliver by caesarean section., Conclusions: Most of the articles published in Brazilian women's magazines do not use optimal sources of information. The portrayal of caesarean section is mostly balanced, not explicitly in favour of one or another route of delivery, but incomplete and may be leading women to underestimate the maternal/perinatal risks associated with this route of delivery.

We assessed the vascular indices of the anterior territory of the middle cerebral artery (MCA) in normal pregnancies using 3-D power Doppler (3DPD). A cross-sectional study was carried out on 90 normal pregnancies between 24 and 35 weeks. All examinations were performed by a single operator using a volumetric transducer. The anterior territory of the MCA was scanned and the volumes were captured using 3DPD. The sphere mode of the VOCAL program was used to calculate the following vascular indices: vascularization index (VI), flow index (FI) and vascularization and flow index (VFI). Models of polynomial regression and Pearson's correlation coefficient were used to evaluate the correlation between gestational age (GA) and the vascular indices. The 3DPD vascular indices had a low correlation with gestational age (VI - r = 0.324, p = 0.002; FI - r = 0.375, p < 0.001; VFI - r = 0.374, p < 0.001). There was a low correlation between GA and the 3DPD vascular indices of the anterior territory of the MCA.

Objective: To establish normative data for the peak systolic velocity of the middle cerebral artery (MCA-PSV) of fetuses in the second half of pregnancy using multiples of the median and percentile reference range., Methods: A cross-sectional study was performed in 90 healthy fetuses at between 23 and 35 weeks of gestation. A bi-dimensional axial scan of the brain, including the thalami and cavitas septi pellucidi was obtained. The circle of Willis was visualized using color flow mapping. Pulsed-wave Doppler velocimetry of the MCA was performed close to the artery's origin, with a beam-vessel angle below 20 degrees . A table with the multiples of the median (MoM) of the MCA-PSV for each gestational age was generated and Pearson's correlation coefficient (r) was calculated. Regression modeling across gestational age was performed to obtain the reference values., Results: There was a strong correlation between the MCA-PVS and gestational age (r = 0.70; p < 0.001). Values for the MCA-PSV for the following MoM were calculated: 1.0, 1.29, 1.50, and 1.55. The MCA-PSV 2.5(th) and 97.5(th) centiles ranged from 24.33 cm(2)/s to 78.36 cm(2)/s, respectively, between weeks 23 and 35., Conclusions: A nomogram for the fetal MCA-PSV during the second half of pregnancy was generated.

Objective: Evaluate and compare the perinatal mortality of Rh-negative pregnancies managed at São Paulo Federal University during a 9-year period, using either amniocentesis or middle cerebral artery peak systolic velocity., Method: Descriptive observational study involving 291 consecutive Rh-negative pregnancies managed between January 1995 and January 2004. The perinatal mortality of 99 alloimmunized patients was compared with 192 Rh-negative unimmunized patients (control group). The perinatal mortality of patients managed with amniocenteses was compared to those managed with Doppler studies., Results: There were 74 patients managed with amniocenteses and 25 managed with Doppler studies. Perinatal mortality was significantly higher in the 99 Rh-negative isoimmunized patients than in the 192 unimmunized patients (12.1% versus 1%, p=0.0001) and did not differ according to the management protocol used (amniocentesis 13.5% versus cerebral Doppler 8.0%, p=0.725). Mean gestational age and mean weight at birth in pregnancies managed with amniocenteses (35.7 weeks and 2586 g) did not differ significantly from those managed with Doppler (36.3 weeks and 2647 g)., Conclusions: Perinatal mortality in Rh-negative alloimmunized patients remains high and does not differ whether pregnancies are managed through amniocentesis or cerebral Doppler evaluation.

Objective: Compare the results of amniocentesis and those of middle cerebral artery peak systolic velocity to detect anemic fetuses in Rh alloimmunized pregnancies., Method: Descriptive observational study involving 99 consecutive Rh-negative pregnancies: 74 alloimmunized patients submitted to amniotic fluid spectrophotometry (group 1) and 25 alloimmunized cases managed with Doppler ultrasonography (group 2). Variables analyzed were the following: need for neonatal transfusion and neonatal hematocrit., Result: Neonatal hematocrit was significantly lower and the need for neonatal transfusion was significantly higher in cases managed with spectrophotometry compared to those managed with Doppler., Conclusion: Infants managed with Doppler velocimetry had higher hematocrit and less need for neonatal transfusion, suggesting that this non-invasive method of monitoring fetal anemia may best preserve the neonate.

Objectives: To investigate the possibility of predicting acidemia at birth in pregnancies with placental insufficiency by Doppler velocimetry of the ductus venosus and to establish the best parameter and cut-off points in this prediction., Methods: This was a prospective cross-sectional study, involving 47 single pregnancies with placental insufficiency after 26 weeks of gestation, carried out at the "Hospital São Paulo (UNIFESP) and Maternidade-Escola Assis Chateaubriand (UFC)". Placental insufficiency was defined as the umbilical artery pulsatility index above the 95th percentile for gestational age. Fetuses with chromosomal or structural anomalies were excluded. The time interval between the Doppler velocimetry and the birth was of less than 24 hours. The umbilical arterial blood samples were collected immediately after birth. Acidemia was defined as umbilical arterial pH < 7.2 in the absence of uterine contractions and < 7.15 in the presence of contractions. Metabolic or mixed acidemia at birth was considered pathological. Receiver operating characteristics (ROC) curves were calculated for S, D and A-velocities, pulsatility index for veins and the S/A ratio and (S-A)/S ratio of the ductus venosus. Parameters were compared using the MacNemar Test, Results: S, D and A-velocities of the ductus venosus were poor predictors of acidemia at birth. The pulsatility index for veins (area under the curve 0.79, p=0.003), S/A ratio and (S-A)/S ratio (area under the curve 0.818, p=0.001) of the DV were strongly related to fetal acidemia. The cut-off points calculated were: pulsatility index for veins = 0.76; S/A ratio = 2.67 and (S-A)/S ratio = 0.63., Conclusions: The angle-independent indices of the DV Doppler are adequate for the diagnosis of fetal acidemia in gestations with placental insufficiency. No statistically significant differences were observed between these parameters.