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Rev Bras Ginecol Obstet. 2018;40(4):171-179
To evaluate the use of tocolysis in cases of preterm birth due to spontaneous preterm labor in a Brazilian sample.
A sample of 1,491 women with preterm birth due to spontaneous preterm labor were assessed, considering treatment with tocolysis or expectant management, according to gestational age at birth (< 34 weeks and 34 to 36 þ 6 weeks) and drugs prescribed. The study took place in 20 Brazilian hospitals from April 2011 to July 2012. Bivariate analyses were conducted to evaluate associations with sociodemographic and obstetric characteristics and odds ratios with their respective 95% confidence intervals were estimated for maternal and neonatal outcomes.
A total of 1,491 cases of preterm birth were considered. Tocolysis was performed in 342 cases (23%), 233 of which (68.1%) were delivered before 34 weeks. Within the expectant management group, 73% was late preterm and with more advanced labor at the time of admission. The most used drugs were calcium channel blockers (62.3%), followed by betamimetics (33%). Among the subjects in the tocolysis group, there were more neonatal and maternal complications (majority non-severe) and an occurrence of corticosteroid use that was 29 higher than in the expectant management group.
Tocolysis is favored in cases of earlier labor and also among thosewith less than 34 weeks of gestation, using preferably calcium channel blockers, with success in achieving increased corticosteroid use. Tocolysis, in general, was related to higher maternal and neonatal complication rates, which may be due to the baseline difference between cases at admission. However, these results should raise awareness to tocolysis use.
Summary
Rev Bras Ginecol Obstet. 2018;40(4):171-179
To evaluate the use of tocolysis in cases of preterm birth due to spontaneous preterm labor in a Brazilian sample.
A sample of 1,491 women with preterm birth due to spontaneous preterm labor were assessed, considering treatment with tocolysis or expectant management, according to gestational age at birth (< 34 weeks and 34 to 36 þ 6 weeks) and drugs prescribed. The study took place in 20 Brazilian hospitals from April 2011 to July 2012. Bivariate analyses were conducted to evaluate associations with sociodemographic and obstetric characteristics and odds ratios with their respective 95% confidence intervals were estimated for maternal and neonatal outcomes.
A total of 1,491 cases of preterm birth were considered. Tocolysis was performed in 342 cases (23%), 233 of which (68.1%) were delivered before 34 weeks. Within the expectant management group, 73% was late preterm and with more advanced labor at the time of admission. The most used drugs were calcium channel blockers (62.3%), followed by betamimetics (33%). Among the subjects in the tocolysis group, there were more neonatal and maternal complications (majority non-severe) and an occurrence of corticosteroid use that was 29 higher than in the expectant management group.
Tocolysis is favored in cases of earlier labor and also among thosewith less than 34 weeks of gestation, using preferably calcium channel blockers, with success in achieving increased corticosteroid use. Tocolysis, in general, was related to higher maternal and neonatal complication rates, which may be due to the baseline difference between cases at admission. However, these results should raise awareness to tocolysis use.
Summary
Rev Bras Ginecol Obstet. 2017;39(5):235-248
From the discovery of the Zika virus (ZIKV) in 1947 in Uganda (Africa), until its arrival in South America, it was not known that it would affect human reproductive life so severely. Today, damagetothe central nervous system is known to be multiple, and microcephaly is considered the tip of the iceberg. Microcephaly actually represents the epilogue of this infection’s devastating process on the central nervous system of embryos and fetuses. As a result of central nervous system aggression by the ZIKV, this infection brings the possibility of arthrogryposis, dysphagia, deafness and visual impairment. All of these changes of varying severity directly or indirectly compromise the future life of these children, and are already considered a congenital syndrome linked to the ZIKV. Diagnosis is one of the main difficulties in the approach of this infection. Considering the clinical part, it has manifestations common to infections by the dengue virus and the chikungunya fever, varying only in subjective intensities. The most frequent clinical variables are rash, febrile state, non-purulent conjunctivitis and arthralgia, among others. In terms of laboratory resources, there are also limitations to the subsidiary diagnosis. Molecular biology tests are based on polymerase chain reaction (PCR)with reverse transcriptase (RT) action, since the ZIKV is a ribonucleic acid (RNA) virus. The RT-PCR shows serum or plasma positivity for a short period of time, no more than five days after the onset of the signs and symptoms. The ZIKVurine test is positive for a longer period, up to 14 days. There are still no reliable techniques for the serological diagnosis of this infection. If there are no complications (meningoencephalitis or Guillain-Barré syndrome), further examination is unnecessary to assess systemic impairment. However, evidence is needed to rule out other infections that also cause rashes, such as dengue, chikungunya, syphilis, toxoplasmosis, cytomegalovirus, rubella, and herpes. There is no specific antiviral therapy against ZIKV, and the therapeutic approach to infected pregnant women is limited to the use of antipyretics and analgesics. Anti-inflammatory drugs should be avoided until the diagnosis of dengue is discarded. There is no need to modify the schedule of prenatal visits for pregnant women infected by ZIKV, but it is necessary to guarantee three ultrasound examinations during pregnancy for low-risk pregnancies, and monthly for pregnant women with confirmed ZIKV infection. Vaginal delivery and natural breastfeeding are advised.
Summary
Rev Bras Ginecol Obstet. 2017;39(5):235-248
From the discovery of the Zika virus (ZIKV) in 1947 in Uganda (Africa), until its arrival in South America, it was not known that it would affect human reproductive life so severely. Today, damagetothe central nervous system is known to be multiple, and microcephaly is considered the tip of the iceberg. Microcephaly actually represents the epilogue of this infection’s devastating process on the central nervous system of embryos and fetuses. As a result of central nervous system aggression by the ZIKV, this infection brings the possibility of arthrogryposis, dysphagia, deafness and visual impairment. All of these changes of varying severity directly or indirectly compromise the future life of these children, and are already considered a congenital syndrome linked to the ZIKV. Diagnosis is one of the main difficulties in the approach of this infection. Considering the clinical part, it has manifestations common to infections by the dengue virus and the chikungunya fever, varying only in subjective intensities. The most frequent clinical variables are rash, febrile state, non-purulent conjunctivitis and arthralgia, among others. In terms of laboratory resources, there are also limitations to the subsidiary diagnosis. Molecular biology tests are based on polymerase chain reaction (PCR)with reverse transcriptase (RT) action, since the ZIKV is a ribonucleic acid (RNA) virus. The RT-PCR shows serum or plasma positivity for a short period of time, no more than five days after the onset of the signs and symptoms. The ZIKVurine test is positive for a longer period, up to 14 days. There are still no reliable techniques for the serological diagnosis of this infection. If there are no complications (meningoencephalitis or Guillain-Barré syndrome), further examination is unnecessary to assess systemic impairment. However, evidence is needed to rule out other infections that also cause rashes, such as dengue, chikungunya, syphilis, toxoplasmosis, cytomegalovirus, rubella, and herpes. There is no specific antiviral therapy against ZIKV, and the therapeutic approach to infected pregnant women is limited to the use of antipyretics and analgesics. Anti-inflammatory drugs should be avoided until the diagnosis of dengue is discarded. There is no need to modify the schedule of prenatal visits for pregnant women infected by ZIKV, but it is necessary to guarantee three ultrasound examinations during pregnancy for low-risk pregnancies, and monthly for pregnant women with confirmed ZIKV infection. Vaginal delivery and natural breastfeeding are advised.
Summary
Rev Bras Ginecol Obstet. 2003;25(4):255-260
DOI 10.1590/S0100-72032003000400006
PURPOSE: to compare maternal morbidity, neonatal results and some clinical and epidemiological characteristics among primiparous women who had one previous cesarean section, according to the performance of elective cesarean (EC) section or trial of labor (TL) during the second delivery. PATIENTS AND METHODS: this is a retrospective cross-sectional study on the second delivery of women who previously had a cesarean section and were assisted at the Center for Integral Assistance to Women's Health (CAISM/UNICAMP), from 1986 to 1998. Data were collected from 2068 clinical records corresponding to 322 cases of EC and 1746 of TL. Data analysis was performed through percentage distribution of the EC and TL cases and also the distribution of variables between these two groups, using the chi2, chi2 for trend and Fisher exact tests to evaluate the statistical difference, with a significance level of 95%. RESULTS: the indication of EC decreased progressively with time, from 22.6% in 1986 to 5% in 1998. Maternal morbity was similar and low in both groups (1.24% and 1.21%). There was no significant difference between groups regarding Apgar score and stillbirths, but there was a significantly higher proportion of premature newborns and with birth weight below 2.500 g and above 4.000 g in the group who underwent EC. The prevalence of EC was significantly higher in women 35 or more years old, with previous or current history of hypertensive disorder, diabetes or with a first dead child, as well as with changes in the volume of amniotic fluid. CONCLUSIONS: performing TL progressively increased during this period of thirteen years, without any increase of maternal and/or neonatal morbidity. The indication for EC followed medical criteria related to unfavorable maternal and/or fetal clinical conditions for vaginal delivery.
Summary
Rev Bras Ginecol Obstet. 2003;25(4):255-260
DOI 10.1590/S0100-72032003000400006
PURPOSE: to compare maternal morbidity, neonatal results and some clinical and epidemiological characteristics among primiparous women who had one previous cesarean section, according to the performance of elective cesarean (EC) section or trial of labor (TL) during the second delivery. PATIENTS AND METHODS: this is a retrospective cross-sectional study on the second delivery of women who previously had a cesarean section and were assisted at the Center for Integral Assistance to Women's Health (CAISM/UNICAMP), from 1986 to 1998. Data were collected from 2068 clinical records corresponding to 322 cases of EC and 1746 of TL. Data analysis was performed through percentage distribution of the EC and TL cases and also the distribution of variables between these two groups, using the chi2, chi2 for trend and Fisher exact tests to evaluate the statistical difference, with a significance level of 95%. RESULTS: the indication of EC decreased progressively with time, from 22.6% in 1986 to 5% in 1998. Maternal morbity was similar and low in both groups (1.24% and 1.21%). There was no significant difference between groups regarding Apgar score and stillbirths, but there was a significantly higher proportion of premature newborns and with birth weight below 2.500 g and above 4.000 g in the group who underwent EC. The prevalence of EC was significantly higher in women 35 or more years old, with previous or current history of hypertensive disorder, diabetes or with a first dead child, as well as with changes in the volume of amniotic fluid. CONCLUSIONS: performing TL progressively increased during this period of thirteen years, without any increase of maternal and/or neonatal morbidity. The indication for EC followed medical criteria related to unfavorable maternal and/or fetal clinical conditions for vaginal delivery.
Summary
Rev Bras Ginecol Obstet. 2000;22(1):27-32
DOI 10.1590/S0100-72032000000100005
Purpose: to identify and quantify the underreporting of maternal mortality, from death certificates (DC) in Campinas, São Paulo, from 1992 to 1994. Methods: a total of 216 DC whose causes of death were maternal (declared and/or presumed) were selected among the 1032 DC of 10 to 49-year-old women. A complementary investigation was performed on hospital records, at the death verifying units, and in households. Results: eight additional maternal deaths were identified among the 204 DC with presumed maternal death. This corresponded to an underreporting rate of 40% or to a correction factor of 1.67 for the official MMR. The first cause of underreporting was abortion (71.5% or 05/07) and indirect maternal deaths represented the second cause (66.6% or 02/03). Conclusions: the death certificate cannot be considered the only source to identify maternal death. Complementary investigation of the presumable causes of maternal death should be performed. Legislation, social and religious factors might influence the underreporting of abortion as the cause of maternal death.
Summary
Rev Bras Ginecol Obstet. 2000;22(1):27-32
DOI 10.1590/S0100-72032000000100005
Purpose: to identify and quantify the underreporting of maternal mortality, from death certificates (DC) in Campinas, São Paulo, from 1992 to 1994. Methods: a total of 216 DC whose causes of death were maternal (declared and/or presumed) were selected among the 1032 DC of 10 to 49-year-old women. A complementary investigation was performed on hospital records, at the death verifying units, and in households. Results: eight additional maternal deaths were identified among the 204 DC with presumed maternal death. This corresponded to an underreporting rate of 40% or to a correction factor of 1.67 for the official MMR. The first cause of underreporting was abortion (71.5% or 05/07) and indirect maternal deaths represented the second cause (66.6% or 02/03). Conclusions: the death certificate cannot be considered the only source to identify maternal death. Complementary investigation of the presumable causes of maternal death should be performed. Legislation, social and religious factors might influence the underreporting of abortion as the cause of maternal death.
Summary
Rev Bras Ginecol Obstet. 2009;31(6):273-278
DOI 10.1590/S0100-72032009000600002
PURPOSE: to evaluate the evolution of monochorionic-diamniotic twin pregnancies with and without the twin-twin transfusion syndrome (TTTS), followed up in an expectant way. METHODS: retrospective study in which the pregnancies with and without TTTS and with mild (Quintero's stage I) and severe (Quintero's stages II, III, IV and V) disease manifestations were compared according to extreme preterm delivery, neurological impairment and the twins' nursery discharge. The extreme preterm twins who had had TTTS, or not, were compared whether they had or not neurological impairment. The χ2 or Fisher's exact test were used. RESULTS: among 149 monochorionic-diamniotic twin pregnancies, 15 presented TTTS, 11 (11/15 - 73.3%) in the severe form and 4 (4/15 - 26.7%) at stage I. The extreme preterm delivery was more frequent (p<0.001) in the cases with the disease (11/15 - 73.3%) than in the cases without it (25/134 - 18.7%), and more common (p=0.033) in severe (10/11 - 91.1%) than in mild cases (1/4 - 25.0%). Neurological impairment in at least one twin was more frequent in cases with (5/8 - 62.5%) than in cases without (9/134 - 6.7%) the disease (p<0.001). Nursery discharge of at least one twin was more common (p<0.001) in cases without (132/134 - 98.5%) than in cases with the disease (8/15 - 53.0%). Neurological impairment in at least one of the twins was more frequent (p=0.04) in the severe (5/5 - 100%) than in the mild (1/4 - 25%) form of the disease. Nursery discharge of both twins was more common (p=0.004) at stage I (4/4 - 100%), than in the severe form of the disease (1/11 - 9.0%). Among the 47 extreme preterm twins, the neurological impairment was more frequent (p=0.001) among the ones who had (6/6 - 100%), than among those who did not have TTTS (11/41 - 26.8%). CONCLUSIONS: cases with twin-twin transfusion syndrome, followed up in an expectant way have bad perinatal prognosis, with high neonatal mortality and high rates of neurological arrest among the survivors.
Summary
Rev Bras Ginecol Obstet. 2009;31(6):273-278
DOI 10.1590/S0100-72032009000600002
PURPOSE: to evaluate the evolution of monochorionic-diamniotic twin pregnancies with and without the twin-twin transfusion syndrome (TTTS), followed up in an expectant way. METHODS: retrospective study in which the pregnancies with and without TTTS and with mild (Quintero's stage I) and severe (Quintero's stages II, III, IV and V) disease manifestations were compared according to extreme preterm delivery, neurological impairment and the twins' nursery discharge. The extreme preterm twins who had had TTTS, or not, were compared whether they had or not neurological impairment. The χ2 or Fisher's exact test were used. RESULTS: among 149 monochorionic-diamniotic twin pregnancies, 15 presented TTTS, 11 (11/15 - 73.3%) in the severe form and 4 (4/15 - 26.7%) at stage I. The extreme preterm delivery was more frequent (p<0.001) in the cases with the disease (11/15 - 73.3%) than in the cases without it (25/134 - 18.7%), and more common (p=0.033) in severe (10/11 - 91.1%) than in mild cases (1/4 - 25.0%). Neurological impairment in at least one twin was more frequent in cases with (5/8 - 62.5%) than in cases without (9/134 - 6.7%) the disease (p<0.001). Nursery discharge of at least one twin was more common (p<0.001) in cases without (132/134 - 98.5%) than in cases with the disease (8/15 - 53.0%). Neurological impairment in at least one of the twins was more frequent (p=0.04) in the severe (5/5 - 100%) than in the mild (1/4 - 25%) form of the disease. Nursery discharge of both twins was more common (p=0.004) at stage I (4/4 - 100%), than in the severe form of the disease (1/11 - 9.0%). Among the 47 extreme preterm twins, the neurological impairment was more frequent (p=0.001) among the ones who had (6/6 - 100%), than among those who did not have TTTS (11/41 - 26.8%). CONCLUSIONS: cases with twin-twin transfusion syndrome, followed up in an expectant way have bad perinatal prognosis, with high neonatal mortality and high rates of neurological arrest among the survivors.
Summary
Rev Bras Ginecol Obstet. 2016;38(6):301-307
Episiotomy is a controversial procedure, especially because the discussion that surrounds it has gone beyond the field of scientific debate, being adopted as an indicator of the "humanization of childbirth". The scientific literature indicates that episiotomy should not be performed routinely, but selectively.
To review the literature in order to assess whether the implementation of selective episiotomy protects against severe perineal lacerations, the indications for the procedure, and the best technique to perform it.
A literature search was performed in PubMed using the terms episiotomy or perineal lacerations, and the filter clinical trial. The articles concerning the risk of severe perineal lacerations with or without episiotomy, perineal protection, or episiotomy techniques were selected.
A total of 141 articles were identified, and 24 of them were included in the review. Out of the 13 studies that evaluated the risk of severe lacerations with and without episiotomy, 5 demonstrated a protective role of selective episiotomy, and 4 showed no significant differences between the groups. Three small studies confirmed the finding that episiotomy should be performed selectively and not routinely, and one study showed that midline episiotomy increased the risk of severe lacerations. The most cited indications were primiparity, fetal weight greater than 4 kg, prolonged second stage, operative delivery, and shoulder dystocia. As for the surgical technique, episiotomies performed with wider angles (> 40°) and earlier in the second stage (before "crowning ") appeared to be more protective.
Selective episiotomy decreases the risk of severe lacerations when compared with the non-performance or the performance of routine episiotomy. The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure. Not performing the episiotomy when indicated or not applying the correct technique may increase the risk of severe perineal lacerations.
Summary
Rev Bras Ginecol Obstet. 2016;38(6):301-307
Episiotomy is a controversial procedure, especially because the discussion that surrounds it has gone beyond the field of scientific debate, being adopted as an indicator of the "humanization of childbirth". The scientific literature indicates that episiotomy should not be performed routinely, but selectively.
To review the literature in order to assess whether the implementation of selective episiotomy protects against severe perineal lacerations, the indications for the procedure, and the best technique to perform it.
A literature search was performed in PubMed using the terms episiotomy or perineal lacerations, and the filter clinical trial. The articles concerning the risk of severe perineal lacerations with or without episiotomy, perineal protection, or episiotomy techniques were selected.
A total of 141 articles were identified, and 24 of them were included in the review. Out of the 13 studies that evaluated the risk of severe lacerations with and without episiotomy, 5 demonstrated a protective role of selective episiotomy, and 4 showed no significant differences between the groups. Three small studies confirmed the finding that episiotomy should be performed selectively and not routinely, and one study showed that midline episiotomy increased the risk of severe lacerations. The most cited indications were primiparity, fetal weight greater than 4 kg, prolonged second stage, operative delivery, and shoulder dystocia. As for the surgical technique, episiotomies performed with wider angles (> 40°) and earlier in the second stage (before "crowning ") appeared to be more protective.
Selective episiotomy decreases the risk of severe lacerations when compared with the non-performance or the performance of routine episiotomy. The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure. Not performing the episiotomy when indicated or not applying the correct technique may increase the risk of severe perineal lacerations.
Summary
Rev Bras Ginecol Obstet. 2011;33(11):361-366
DOI 10.1590/S0100-72032011001100007
PURPOSE: to compare the accuracy of transvaginal ultrasonographic measurement of the uterine cervix with Bishop’s score for the prediction of vaginal delivery after labor induction, with 25 mcg of misoprostol. METHODS: a prospective study for the validation of a diagnostic test was conducted on 126 pregnant women with indication for labor induction. The patients were evaluated by Bishop’s score and transvaginal ultrasonography for cervical measurement. They also undergone obstetric transabdominal ultrasound to evaluate static and fetal weight, as well as the amniotic fluid index, and basal cardiotocography for the evaluation of fetal vitality. Labor was induced with vaginal and sublingual misoprostol, one of the tablets containing 25 mcg of the drug and the other only placebo. The tablets were administered every six hours, with a maximum number of eight. Frequency tables were obtained, and measures of central tendency and dispersion were calculated. ROC curves were constructed for the evaluation of Bishop’s score and ultrasonographic measurement of the uterine cervix for the prediction of vaginal delivery. RESULTS: the area under the ROC curve was 0.5 (p=0.8) for the ultrasonographic measurement of the uterine cervix, and 0.6 (p=0.02) for Bishop’s score (cut point ³4). Bishop’s score had a sensitivity of 56.2% and specificity of 67.9% for prediction of vaginal delivery, with a positive likelihood ratio of 1.75 and a negative one of 0.65. CONCLUSIONS: ultrasonographic measurement of the uterine cervix was not a good predictor of evolution to vaginal delivery among patients with misoprostol-induced labor. Bishop’s score was a better predictor of vaginal delivery under these circumstances.
Summary
Rev Bras Ginecol Obstet. 2011;33(11):361-366
DOI 10.1590/S0100-72032011001100007
PURPOSE: to compare the accuracy of transvaginal ultrasonographic measurement of the uterine cervix with Bishop’s score for the prediction of vaginal delivery after labor induction, with 25 mcg of misoprostol. METHODS: a prospective study for the validation of a diagnostic test was conducted on 126 pregnant women with indication for labor induction. The patients were evaluated by Bishop’s score and transvaginal ultrasonography for cervical measurement. They also undergone obstetric transabdominal ultrasound to evaluate static and fetal weight, as well as the amniotic fluid index, and basal cardiotocography for the evaluation of fetal vitality. Labor was induced with vaginal and sublingual misoprostol, one of the tablets containing 25 mcg of the drug and the other only placebo. The tablets were administered every six hours, with a maximum number of eight. Frequency tables were obtained, and measures of central tendency and dispersion were calculated. ROC curves were constructed for the evaluation of Bishop’s score and ultrasonographic measurement of the uterine cervix for the prediction of vaginal delivery. RESULTS: the area under the ROC curve was 0.5 (p=0.8) for the ultrasonographic measurement of the uterine cervix, and 0.6 (p=0.02) for Bishop’s score (cut point ³4). Bishop’s score had a sensitivity of 56.2% and specificity of 67.9% for prediction of vaginal delivery, with a positive likelihood ratio of 1.75 and a negative one of 0.65. CONCLUSIONS: ultrasonographic measurement of the uterine cervix was not a good predictor of evolution to vaginal delivery among patients with misoprostol-induced labor. Bishop’s score was a better predictor of vaginal delivery under these circumstances.
Summary
Rev Bras Ginecol Obstet. 2007;29(7):370-375
DOI 10.1590/S0100-72032007000700008
Studies have shown possible risk relations among oral illnesses, mainly periodontal disease and adverse pregnancy outcomes, such as prematurity, low birth weight and preeclampsia. The explanation for this hypothesis is based on the fact that periodontal disease is an infectious state, which may increase maternal serum cytokines through the release of such agents directly from the periodontal pocket or by through the dissemination of pathogenic bacteria, inducing systemic production. This assumption is based on the knowledge that the physiopathology of the pregnancy complications cited above is associated with the presence of some cytokines in the maternal serum. The present study work has the objective to review literature in search of evidence to these alleged associations. Although a number of clinical studies have been found in this review, we noticed a lack of methodological standards, what limits the conclusions about this topic. On the other side, the fact that periodontal disease is not yet a confirmed risk factor for adverse pregnancy outcomes does not reduce the importance of oral health maintenance during pregnancy, since it is important to allow adequate feeding without pain and bleeding in order to maintain an adequate nutritional supply.
Summary
Rev Bras Ginecol Obstet. 2007;29(7):370-375
DOI 10.1590/S0100-72032007000700008
Studies have shown possible risk relations among oral illnesses, mainly periodontal disease and adverse pregnancy outcomes, such as prematurity, low birth weight and preeclampsia. The explanation for this hypothesis is based on the fact that periodontal disease is an infectious state, which may increase maternal serum cytokines through the release of such agents directly from the periodontal pocket or by through the dissemination of pathogenic bacteria, inducing systemic production. This assumption is based on the knowledge that the physiopathology of the pregnancy complications cited above is associated with the presence of some cytokines in the maternal serum. The present study work has the objective to review literature in search of evidence to these alleged associations. Although a number of clinical studies have been found in this review, we noticed a lack of methodological standards, what limits the conclusions about this topic. On the other side, the fact that periodontal disease is not yet a confirmed risk factor for adverse pregnancy outcomes does not reduce the importance of oral health maintenance during pregnancy, since it is important to allow adequate feeding without pain and bleeding in order to maintain an adequate nutritional supply.