PDF herunterladen
CC BY 4.0 · Rev Bras Ginecol Obstet 2019; 41(05): 318-332
DOI: 10.1055/s-0039-1687859
Febrasgo Statement
Thieme Publicações Ltda Rio de Janeiro, Brazil

Pre-eclampsia/Eclampsia

Pré-eclâmpsia/Eclâmpsia
José Carlos Peraçoli 
1   Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, SP, Brazil
,
Vera Therezinha Medeiros Borges
1   Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, SP, Brazil
,
José Geraldo Lopes Ramos
2   Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
,
Ricardo de Carvalho Cavalli
3   Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
,
Sérgio Hofmeister de Almeida Martins Costa
2   Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
,
Leandro Gustavo de Oliveira
1   Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, SP, Brazil
,
Francisco Lazaro Pereira de Souza
4   Department of Tocoginecology, Centro Universitário Lusíada, Santos, SP, Brazil
,
Henri Augusto Korkes
5   Department of Obstetrics and Gynecology, Faculty of Medicine, Pontifícia Universidade Católica de São Paulo, São Paulo, SP, Brazil
,
Ione Rodrigues Brum
6   Department of Maternal and Child Health, Faculty of Medicine, Universidade Federal do Amazonas, Manaus, AM, Brazil
,
Maria Laura Costa
7   Department of Gynecology and Obstetrics, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
,
Mário Dias Corrêa Junior
8   Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
,
Nelson Sass
9   Paulista School of Medicine, Universidade Federal de São Paulo, São Paulo, SP, Brazil
,
Angélica Lemos Debs Diniz
10   Department of Obstetrics and Gynecology, Faculty of Medicine, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil
,
Caio Antonio de Campos Prado
3   Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
,
Edson Viera da Cunha Filho
11   Gynecology and Obstetrics Training Center, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
› Institutsangaben
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
10. Juni 2019 (online)

   Lizenzen und Reprints

Erratum zu diesem Artikel:

Pre-eclampsia/EclampsiaRev Bras Ginecol Obstet 2019; 41(05): e1-e2
DOI: 10.1055/s-0040-1702167

Abstract

Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age in < 24 weeks, between 24 and less than 34 weeks, and ≥ 34 weeks of gestation, and guidance on route of delivery. An immediate puerperium approach and repercussions in the future life of pregnant women who develop preeclampsia is also presented.

Resumo

A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A pré-eclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgão-alvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas.

Keywords

gestation - hypertensive disorders - pre-eclampsia - eclampsia

Palavras-chave

gestação - distúrbios hipertensivos - hipertensão arterial - pré-eclâmpsia - eclâmpsia
 

  • References

  • 1 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122 (05) 1122-1131 . Doi: 10.1097/01.AOG.0000437382.03963.88
    CrossrefPubMedSuche in Google Scholar
  • 2 Amaral LM, Wallace K, Owens M, LaMarca B. Pathophysiology and current clinical management of preeclampsia. Curr Hypertens Rep 2017; 19 (08) 61 . Doi: 10.1007/s11906-017-0757-7
    CrossrefPubMedSuche in Google Scholar
  • 3 Norwitz ER. Eclampsia. December 2017 https://www.uptodate.com/contents/eclampsia . Accessed December 27, 2017.
    PubMedSuche in Google Scholar
  • 4 Abalos E, Cuesta C, Grosso AL, Chou D, Say L. Global and regional estimates of preeclampsia and eclampsia: a systematic review. Eur J Obstet Gynecol Reprod Biol 2013; 170 (01) 1-7 . Doi: 10.1016/j.ejogrb.2013.05.005
    CrossrefPubMedSuche in Google Scholar
  • 5 Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Gynecol 2004; 190 (06) 1520-1526 . Doi: 10.1016/j.ajog.2003.12.057
    CrossrefPubMedSuche in Google Scholar
  • 6 Giordano JC, Parpinelli MA, Cecatti JG. , et al. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One 2014; 9 (05) e97401 . Doi: 10.1371/journal.pone.0097401
    CrossrefPubMedSuche in Google Scholar
  • 7 World Health Organization. WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia. Geneva: World Health Organization; 2011
    Suche in Google Scholar
  • 8 Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol 2009; 33 (03) 130-137 . Doi: 10.1053/j.semperi.2009.02.010
    CrossrefPubMedSuche in Google Scholar
  • 9 Ananth CV, Vintzileos AM. Medically indicated preterm birth: recognizing the importance of the problem. Clin Perinatol 2008; 35 (01) 53-67, viii . Doi: 10.1016/j.clp.2007.11.001
    CrossrefPubMedSuche in Google Scholar
  • 10 Maynard SE, Min JY, Merchan J. , et al. Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia. J Clin Invest 2003; 111 (05) 649-658 . Doi: 10.1172/JCI17189
    CrossrefPubMedSuche in Google Scholar
  • 11 Roberts JM, Hubel CA. The two stage model of preeclampsia: variations on the theme. Placenta 2009; 30 (Suppl A): S32-S37 . Doi: 10.1016/j.placenta.2008.11.009
    CrossrefPubMedSuche in Google Scholar
  • 12 Quinn MJ. Pre-eclampsia - The “uterine reinnervation” view. Med Hypotheses 2014; 83 (05) 575-579 . Doi: 10.1016/j.mehy.2014.08.020
    CrossrefPubMedSuche in Google Scholar
  • 13 Abou El Hassan M, Diamandis EP, Karumanchi SA, Shennan AH, Taylor RN. Preeclampsia: an old disease with new tools for better diagnosis and risk management. Clin Chem 2015; 61 (05) 694-698 . Doi: 10.1373/clinchem.2014.230565
    CrossrefPubMedSuche in Google Scholar
  • 14 Tanrikulu L, Naraghi R, Ernst V. , et al. Neurovascular compression of medulla oblongata - association for gestation-induced hypertension. Med Hypotheses 2015; 84: 605-610 . Doi: 10.1016/j.mehy.2015.03.024
    CrossrefPubMedSuche in Google Scholar
  • 15 Gathiram P, Moodley J. Pre-eclampsia: its pathogenesis and pathophysiolgy. Cardiovasc J Afr 2016; 27 (02) 71-78 . Doi: 10.5830/CVJA-2016-009
    CrossrefPubMedSuche in Google Scholar
  • 16 Brew O, Sullivan MH, Woodman A. Comparison of normal and pre-eclamptic placental gene expression: a systematic review with meta-analysis. PLoS One 2016; 11 (08) e0161504 . Doi: 10.1371/journal.pone.0161504
    CrossrefPubMedSuche in Google Scholar
  • 17 Cunningham GF, Leveno KJ, Bloom SL. , et al. Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill Education; 2014
    Suche in Google Scholar
  • 18 Ngene NC, Moodley J. Role of angiogenic factors in the pathogenesis and management of pre-eclampsia. Int J Gynaecol Obstet 2018; 141 (01) 5-13 . Doi: 10.1002/ijgo.12424
    CrossrefPubMedSuche in Google Scholar
  • 19 Redman CW, Sargent IL. Latest advances in understanding preeclampsia. Science 2005; 308 (5728): 1592-1594 . Doi: 10.1126/science.1111726
    CrossrefPubMedSuche in Google Scholar
  • 20 Jauniaux E, Burton GJ. [The role of oxidative stress in placental-related diseases of pregnancy]. J Gynecol Obstet Biol Reprod (Paris) 2016; 45 (08) 775-785 . Doi: 10.1016/j.jgyn.2016.02.012
    CrossrefPubMedSuche in Google Scholar
  • 21 Walsh SW. Obesity: a risk factor for preeclampsia. Trends Endocrinol Metab 2007; 18 (10) 365-370 . Doi: 10.1016/j.tem.2007.09.003
    CrossrefPubMedSuche in Google Scholar
  • 22 Spradley FT, Palei AC, Granger JP. Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms. Am J Physiol Regul Integr Comp Physiol 2015; 309 (11) R1326-R1343 . Doi: 10.1152/ajpregu.00178.2015
    CrossrefPubMedSuche in Google Scholar
  • 23 Villa PM, Marttinen P, Gillberg J. , et al. Cluster analysis to estimate the risk of preeclampsia in the high-risk Prediction and Prevention of Preeclampsia and Intrauterine Growth Restriction (PREDO) study. PLoS One 2017; 12 (03) e0174399 . Doi: 10.1371/journal.pone.0174399
    CrossrefPubMedSuche in Google Scholar
  • 24 Womack J, Tien PC, Feldman J. , et al. Obesity and immune cell counts in women. Metabolism 2007; 56 (07) 998-1004 . Doi: 10.1016/j.metabol.2007.03.008
    CrossrefPubMedSuche in Google Scholar
  • 25 Aye IL, Lager S, Ramirez VI. , et al. Increasing maternal body mass index is associated with systemic inflammation in the mother and the activation of distinct placental inflammatory pathways. Biol Reprod 2014; 90 (06) 129 . Doi: 10.1095/biolreprod.113.116186
    PubMedSuche in Google Scholar
  • 26 Brown MA, Magee LA, Kenny LC. , et al; International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension 2018; 72 (01) 24-43 . Doi: 10.1161/HYPERTENSIONAHA.117.10803
    CrossrefPubMedSuche in Google Scholar
  • 27 Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000; 183 (01) S1-S22 . Doi: 10.1067/mob.2000.107928
    CrossrefPubMedSuche in Google Scholar
  • 28 von Dadelszen P, Magee LA, Roberts JM. Subclassification of preeclampsia. Hypertens Pregnancy 2003; 22 (02) 143-148 . Doi: 10.1081/PRG-120021060
    CrossrefPubMedSuche in Google Scholar
  • 29 Huppertz B. Placental origins of preeclampsia: challenging the current hypothesis. Hypertension 2008; 51 (04) 970-975 . Doi: 10.1161/HYPERTENSIONAHA.107.107607
    CrossrefPubMedSuche in Google Scholar
  • 30 Murphy DJ, Stirrat GM. Mortality and morbidity associated with early-onset preeclampsia. Hypertens Pregnancy 2000; 19 (02) 221-231 . Doi: 10.1081/PRG-100100138
    CrossrefPubMedSuche in Google Scholar
  • 31 Ness RB, Sibai BM. Shared and disparate components of the pathophysiologies of fetal growth restriction and preeclampsia. Am J Obstet Gynecol 2006; 195 (01) 40-49 . Doi: 10.1016/j.ajog.2005.07.049
    CrossrefPubMedSuche in Google Scholar
  • 32 Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet 2005; 365 (9461): 785-799 . Doi: 10.1016/S0140-6736(05)17987-2
    CrossrefPubMedSuche in Google Scholar
  • 33 Wright WL. Neurologic complications in critically ill pregnant patients. Handb Clin Neurol 2017; 141: 657-674 . Doi: 10.1016/B978-0-444-63599-0.00035-1
    CrossrefPubMedSuche in Google Scholar
  • 34 Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ 2005; 330 (7491): 565 . Doi: 10.1136/bmj.38380.674340.E0
    CrossrefPubMedSuche in Google Scholar
  • 35 von Dadelszen P, Payne B, Li J. , et al; PIERS Study Group. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model. Lancet 2011; 377 (9761): 219-227 . Doi: 10.1016/S0140-6736(10)61351-7
    CrossrefPubMedSuche in Google Scholar
  • 36 Henderson JT, Whitlock EP, O'Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2014; 160 (10) 695-703 . Doi: 10.7326/M13-2844
    CrossrefPubMedSuche in Google Scholar
  • 37 Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2014; (06) CD001059 . Doi: 10.1002/14651858.CD001059.pub4
    PubMedSuche in Google Scholar
  • 38 Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C. , et al; European Society of Gynecology (ESG); Association for European Paediatric Cardiology (AEPC); German Society for Gender Medicine (DGesGM); ESC Committee for Practice Guidelines. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32 (24) 3147-3197 . Doi: 10.1093/eurheartj/ehr218
    CrossrefPubMedSuche in Google Scholar
  • 39 Meher S, Abalos E, Carroli G. Bed rest with or without hospitalisation for hypertension during pregnancy. Cochrane Database Syst Rev 2005; (04) CD003514 . Doi: 10.1002/14651858.CD003514.pub2
    PubMedSuche in Google Scholar
  • 40 Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2014; (02) CD002252 . Doi: 10.1002/14651858.CD002252.pub3
    PubMedSuche in Google Scholar
  • 41 Webster LM, Conti-Ramsden F, Seed PT, Webb AJ, Nelson-Piercy C, Chappell LC. Impact of antihypertensive treatment on maternal and perinatal outcomes in pregnancy complicated by chronic hypertension: a systematic review and meta-analysis. J Am Heart Assoc 2017; 6 (05) e005526 . Doi: 10.1161/JAHA.117.005526
    CrossrefPubMedSuche in Google Scholar
  • 42 Magee LA, von Dadelszen P, Singer J. , et al; CHIPS Study Group*. The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study): is severe hypertension just an elevated blood pressure?. Hypertension 2016; 68 (05) 1153-1159 . Doi: 10.1161/HYPERTENSIONAHA.116.07862
    CrossrefPubMedSuche in Google Scholar
  • 43 von Dadelszen P, Magee LA. Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: an updated metaregression analysis. J Obstet Gynaecol Can 2002; 24 (12) 941-945 . Doi: 10.1016/S1701-2163(16)30592-8
    CrossrefPubMedSuche in Google Scholar
  • 44 Cooper WO, Hernandez-Diaz S, Arbogast PG. , et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med 2006; 354 (23) 2443-2451 . Doi: 10.1056/NEJMoa055202
    CrossrefPubMedSuche in Google Scholar
  • 45 Collins R, Yusuf S, Peto R. Overview of randomised trials of diuretics in pregnancy. Br Med J (Clin Res Ed) 1985; 290 (6461): 17-23 . Doi: 10.1136/bmj.290.6461.17
    CrossrefPubMedSuche in Google Scholar
  • 46 American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013; 121 (04) 908-910 . Doi: 10.1097/01.AOG.0000428648.75548.00
    CrossrefPubMedSuche in Google Scholar
  • 47 Too GT, Hill JB. Hypertensive crisis during pregnancy and postpartum period. Semin Perinatol 2013; 37 (04) 280-287 . Doi: 10.1053/j.semperi.2013.04.007
    CrossrefPubMedSuche in Google Scholar
  • 48 Sass N, Itamoto CH, Silva MP, Torloni MR, Atallah AN. Does sodium nitroprusside kill babies? A systematic review. Sao Paulo Med J 2007; 125 (02) 108-111 . Doi: 10.1590/S1516-31802007000200008
    CrossrefPubMedSuche in Google Scholar
  • 49 Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. ; Canadian Hypertensive Disorders of Pregnancy Working Group. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can 2014; 36 (05) 416-441 . Doi: 10.1016/S1701-2163(15)30588-0
    CrossrefPubMedSuche in Google Scholar
  • 50 Committee on Obstetric Practice. Committee Opinion No. 692: emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol 2017; 129 (04) e90-e95 . Doi: 10.1097/AOG.0000000000002019
    CrossrefPubMedSuche in Google Scholar
  • 51 Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 1995; 345 (8963): 1455-1463 . Doi: 10.5555/uri:pii:S0140673695910344
    CrossrefPubMedSuche in Google Scholar
  • 52 Duley L, Gulmezoglu AM. Magnesium sulphate versus lytic cocktail for eclampsia. Cochrane Database Syst Rev 2001; (01) CD002960 . Doi: 10.1002/14651858.CD002960
    PubMedSuche in Google Scholar
  • 53 Duley L, Henderson-Smart D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database Syst Rev 2003; (04) CD000127 . Doi: 10.1002/14651858.CD000127
    PubMedSuche in Google Scholar
  • 54 Duley L, Henderson-Smart D. Magnesium sulphate versus phenytoin for eclampsia. Cochrane Database Syst Rev 2003; (04) CD000128 . Doi: 10.1002/14651858.CD000128
    PubMedSuche in Google Scholar
  • 55 van der Tuuk K, Holswilder-Olde Scholtenhuis MA, Koopmans CM. , et al; HYPITAT study group. Prediction of neonatal outcome in women with gestational hypertension or mild preeclampsia after 36 weeks of gestation. J Matern Fetal Neonatal Med 2015; 28 (07) 783-789 . Doi: 10.3109/14767058.2014.935323
    CrossrefPubMedSuche in Google Scholar
  • 56 Broekhuijsen K, van Baaren GJ, van Pampus MG. , et al; HYPITAT-II study group. Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial. Lancet 2015; 385 (9986): 2492-2501 . Doi: 10.1016/S0140-6736(14)61998-X
    CrossrefPubMedSuche in Google Scholar
  • 57 Guida JPS, Surita FG, Parpinelli MA, Costa ML. Preterm preeclampsia and timing of delivery: a systematic literature review. Rev Bras Ginecol Obstet 2017; 39 (11) 622-631 . Doi: 10.1055/s-0037-1604103
    Thieme ConnectPubMedSuche in Google Scholar
  • 58 Magee LA, Hall D, van der Merwe JL, Qureshi R, Rey E, Escobar Vidarte MF. Fluids, drugs and transfusion. In: Magee LA, von Dadelszen P, Stones W, Mathai M. , eds. The FIGO Textbook of Pregnancy Hypertension: an Evidence-Based Guide to Monitoring, Prevention and Management. London: The Global Library of Women's Medicine; 2016: 133-166
    Suche in Google Scholar
  • 59 Ganzevoort W, Sibai BM. Temporising versus interventionist management (preterm and at term). Best Pract Res Clin Obstet Gynaecol 2011; 25 (04) 463-476 . Doi: 10.1016/j.bpobgyn.2011.01.004
    CrossrefPubMedSuche in Google Scholar
  • 60 Mosca L, Benjamin EJ, Berra K. , et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the american heart association. Circulation 2011; 123 (11) 1243-1262 . Doi: 10.1161/CIR.0b013e31820faaf8
    CrossrefPubMedSuche in Google Scholar
  • 61 Maxwell MH, Waks AU, Schroth PC, Karam M, Dornfeld LP. Error in blood-pressure measurement due to incorrect cuff size in obese patients. Lancet 1982; 2 (8288): 33-36 . Doi: 10.1016/S0140-6736(82)91163-1
    CrossrefPubMedSuche in Google Scholar
  • 62 Secretaria da Saúde do Estado de São Paulo. Coordenadoria de Planejamento em Saúde. Assessoria Técnica em Saúde da Mulher. Atenção à Gestante e à Puérpera no SUS-SP: Manual Técnico do Pré-Natal e Puerpério. São Paulo, SP: SES/SP; 2010
    Suche in Google Scholar