Dos Santos Vitorino Modesto 1 , 2 *, Dos Santos Lister Arruda Modesto 3
1 Armed Forces Hospital. Department of Internal Medi-
cine. Brasília – Brazil.
2 Catholic University of Brasília. Department of Inter-
nal Medicine. Brasília – Brazil.
3 Instituto de Assistência Médica ao Servidor Público
Estadual - IAMSPE. Department of Advanced General
Surgery and Oncosurgery. São Paulo – Brazil.
In Latin America, complications occurring during the pregnancy and
puerperium constitute major causes of maternal-infant morbidity and
mortality. Preeclampsia and eclampsia are the main disorders in this
scenery. Risk factors include nulliparity, obesity, dyslipidemia, diabetes,
hypertension, anti-phospholipid syndrome, heart or kidney disease, urinary
infection, anemia, and lack of prenatal care. Authors from Ecuador,
Colombia, Panamá, Peru, Bolivia, and Honduras have contributed with
current studies focusing on the preventable predisposing risk factors.
The objective of the herein commented studies is to stimulate further
investigations in low-income regions including diverse age groups of
hypertensive pregnant women.
En América Latina, las complicaciones que ocurren durante el embarazo
y el puerperio constituyen las principales causas de morbilidad y
mortalidad materno infantil. La preeclampsia y la eclampsia son los
principales trastornos en este escenario. Los factores de riesgo incluyen
nuliparidad, obesidad, dislipidemia, diabetes, hipertensión, síndrome
antifosfolípido, enfermedad cardíaca o renal, infección urinaria, anemia
y falta de atención prenatal. Autores de Ecuador, Colombia, Panamá,
Perú, Bolivia y Honduras han contribuido con estudios actuales que se
centran en los factores de riesgo predisponentes prevenibles. El objetivo
de los estudios aquí comentados es estimular nuevas investigaciones
en regiones de bajos ingresos, incluyendo diversos grupos de edad de
mujeres embarazadas hipertensas.
Dear Editor:
In some Latin American countries, complications occurring during the
pregnancy-puerperal cycle are included in main causes of maternal-
infant morbidity and mortality (1-4). Preeclampsia (PE), eclampsia, and
peripartum cardiomyopathy are among these disorders (1-4). Ecuador,
Colombia, Panamá, Peru, Bolivia, and Honduras are countries where
risk factors in pregnant women are receiving special attention of public
health programs to protect women. Risks include nulliparity, obesity,
dyslipidemia, diabetes, hypertension, anti-phospholipid syndrome,
heart or kidney disease, urinary infection, anemia, and lack of prenatal
care (1-4). The aim is to comment some manuscripts with focus on
preventable predisposing risk factors.
We appreciated the cohort retrospective study by Quezada Galindo et
al., about the validation of the MAMÁ and MACAS score in pregnant
women of Equatorian Amazon (3). They compared the two score keys
among1259 patients with the following average data: 24.93 year-old,
27.61 Kg/m2 of BMI, and 111.19/ 70.22 mmHg of arterial blood pressure.
Arterial hypertension and postpartum bleeding were the two main
activated obstetric keys, and the authors emphasize the role of serum
lactate determination in metabolic assessment (3). The sensitivity and
specicity of MAMÁ and MACAS scores to determine the Blue Obstetric
Revista Médica Vozandes
Volumen 33, Número 1, 2022
* Corresponding author:
Vitorino Modesto dos Santos
E-mail: vitorinomodesto@gmail.com.
Key words: Hypertension; Pregnancy; Prevention/control; Risk factors
Palabras clave: Hipertensión; Embarazo; Prevención/ control; Factores de riesgo
Forma de citar este artículo: Dos Santos
VM, Dos Santos LAM. Pregnancy risk
factors in Latin America. Rev Med
Vozandes. 2022; 33 (1): 14- 15
Dos Santos Vitorino Modesto:
Dos Santos Lister Arruda Modesto:
Conflict of interest: The authors declare no
conict of interest.
Financial disclosure: The authors have no nan-
cial relationships relevant to this article to disclose.
Este artículo está bajo una
licencia de Creative Com-
mons de tipo Reconocimien-
to – No comercial – Sin obras
derivadas 4.0 International.
DOI: 10.48018/rmv.v33.i1.le
Received: 06 – Sep – 2021
Accepted: 19 – Jan – 2022
Publish: 01 – Mar – 2022
Revista Médica Vozandes
Volumen 33, Número 1, 2022
Code were compared. MAMÁ score 3 was yes: 29 (63.0%),
and no: 117 (14.6%), with a sensitivity: 63%, and specicity:
85%; and the score < 3 was yes: 17 (37%), and no: 1036
(85.4%). The MACAS score 3 was yes: 30 (65.2%), and no: 162
(13.4%), with a sensitivity: 65%, and specicity: 87%; and the
score < 3 was yes: 16 (34.8%), and no: 1051 (86.6%). Logistic
regressions revealed that the MAMÁ score ≥ 3 increased the
probability of requiring obstetric key activation by 18 times,
and the same MACAS score increased by 20 times (3).
The conclusion based on logistic evaluation was that
MACAS score has higher specicity, but prospective
researches involving larger cohorts must be performed to
better validation (3).
In Colombia, Ayala-Ramírez et al. have given important
contributions in the eld of hypertensive pregnancy
disorders inuencing fetal, neonatal and maternal
morbimortality (1,2). Their studies deserve special attention
because the cited disorders cause near 26% of maternal
deaths in Latin America, while severe maternal morbidity in
Colombia may reach 59% (1). From July 2017 to November
2018 these authors compared the data directly obtained
from 215 Colombian women who developed PE, with
those from 256 normal pregnant controls. Potential risks of
PE were previous PE, intrauterine growth restriction-small for
gestational age, pregestational obesity, weight gain over
than 12 Kg during pregnancy, maternal age lower than 20
or over than 35 years, and familiar diabetes; and folic acid
can reduce the risks. The newborns of PE mothers had lower
Apgar score at 5 minutes, and lower birth weight; which
can be related to poor neurodevelopment, and diabetes
or hypertension in adulthood (1). The authors highlighted
the need of better pregestational care about maternal
obesity control. More recently, they described the results of
a study of placenta samples from 14 patients with PE who
had cesarean section; 7 with early-onset (EO) PE, and 7 with
late-onset (LO) PE (2). Placentas of 7 women with normal
pregnancies and healthy newborns were the control group.
They studied placental extracellular vesicles (EV) carry Fas-
ligand (FasL) and tumor necrosis factor-related apoptosis-
inducing ligand (TRAIL) levels to assess the apoptosis power.
Women with EO-PE presented with higher blood pressure
levels and premature births, and lower birth weights. The
placental explants of this group had a higher release
of EV in vitro. There was increased FasL and TRAIL in EV
from placentas of women with PE, and higher apoptosis-
inducing capability in Jurkat T cells, consistent with
the pathophysiology of PE (2).
The authors commented the possible role of EV, FasL,
and TRAIL in the immune tolerance regulation both in
normal and complicated pregnancies, which should
be further evaluated.
The multicenter study by Vigil De-Garcia et al.,
including pregnant adolescents from ve Latin
American countries also contribute to manage
PE and gestational hypertension (4). The research
was performed in regions with elevated rates of
adolescent pregnancy and PE. They compared
data of 12 to 19-year-old pregnant females
presenting hypertension disorders of pregnancy
(HDP) with normal pregnant paired controls, from
August 2017 to March 2018. Patients with pressure
levels equal to or higher than 140 mmHg systolic or
90 mmHg diastolic; and a proteinuria level of 300
mg/24 hours or higher were diagnosed with PE.
Severe PE was characterized by at least one of these
criteria: hypertension of 160/110 mm Hg or higher,
persistent headache, epigastric pain, visual disorders
elevated liver enzymes, thrombocytopenia, HELLP
syndrome, acute pulmonary or brain edema, or
retinal detachment. Cases without the cited severe
conditions were considered to have gestational
hypertension. The conclusion was that increases
equal or superior to 20 mmHg above the systolic or
diastolic blood pressure baseline values before 25
weeks of pregnancy can diagnose PE (4). Besides,
adolescents with PE and blood pressure levels
equal to or higher than 140/90 mmHg should be
managed as severe and need magnesium sulfate
for anticonvulsant prophylaxis (4).
The aim of the comments is to stimulate investigations
in low-income areas including diverse age groups
of hypertensive pregnant women, and to enhance
the knowledge of rural, general, and family
physicians, besides specialists in gyneco-obstetrics
and paramedic staff of emergency care, on the
prevention and management of the severe PE or
Eclampsia (blue key).
1. Ayala-Ramírez P, Serrano N, Barrera V, Beja-
rano JP, Silva JL, Martínez R, et al. Risk factors
and fetal outcomes for preeclampsia in a Co-
lombian cohort, Heliyon. 2020;6(9):e05079. doi:
2. Ayala-Ramírez P, Machuca-Acevedo C, Gámez
T, Quijano S, Barreto A, Silva JL, et al. Assessment
of placental extracellular vesicles-associated
Fas Ligand and TNF-related apoptosis-inducing
ligand in pregnancies complicated by early
and late onset preeclampsia. Front Physiol.
2021;12:708824. doi: 10.3389/fphys.2021.708824.
3. Quezada Galindo JL, Garay García LM, Pillco
Buestan SP, Peralta Verdugo JT, Paguay Pare-
des DC. Validación del score Mamá y Macas
en pacientes de la región amazónica del
Ecuador. Rev Med Vozandes. 2020;31(2):11-17.
doi: 10.48018/rmv.v31.i2.2.
4. Vigil-De Gracia P, Olaya-Garay SX, Mata Her-
nández C, Cabrera S, Reyes-Tejada O, Asturi-
zaga-Soto P, et al. Blood pressure changes in
adolescents with preeclampsia: a multicentre,
case-control study in Latin American hospitals.
J Obstet Gynaecol Can. 2021;43(1):50-57. doi: