what to expect at an anesthesia consult for pregnancy

Keywords

Pregnancy; Anxiety; Stress; Pre-coldhearted consultation

Introduction

Adventure pregnancy may lead to a vulnerability condition due to concrete, social and psychological changes on woman's life, and it can also result in agin outcomes. Elective interruption of pregnancy may be an obstetric procedure to prevent and minimize potential negative obstetric outcomes. Still, this procedure can outcome in elevated levels of stress and anxiety, peculiarly in the last trimester of gestation, when female parent´s expectations and anxiety may increase due to the proximity of baby arrival and the commitment [i,2].

Stress is a pattern of responses with concrete and psychological components when the equilibrium between the organism and surround is disturbed [3-5]. Co-ordinate to the General Adaptation Syndrome (GAS) model, stress can exist studied as a process with stages: alarm, resistance and exhaustion [4]. In the phase of alarm, the adrenaline increases, resulting on free energy and vigor that prepare individuals to deal with a critical state of affairs. The second stage of stress is the resistance stage, when stressor agents persist, and the organism tries to resist and cope with stress. In this stage, individuals can present memory deficits, and physical and mental fatigue. The exhaustion is the most negative stage of stress and tin can result in meaning imbalance that affects the overall wellness and quality of life. According to Lipp [four], in that location is also an intermediate stage of stress, the near-burnout stage, characterized by a libido decrease, cognitive deficits, apathy, and self-doubt beliefs. Information technology is estimated that 25% of women present some type of stress during pregnancy [3,half-dozen]. Unlike studies advise that there are associations between prenatal stress and negative clinical outcomes, such as postpartum depression, premature birth, low birth weight, and cognitive impairments on children [seven-10].

Significant women with indication for constituent delivery can show anxiety symptoms, such equally tension, worries, difficulty in relaxing, and even panic attacks. Infirmary anxiety is a blazon of anxiety presented in the infirmary setting, specially confront to clinic, surgical or anesthetics procedures [eleven,12]. The infirmary anxiety may be higher when the patient does not take articulate noesis and proper information most procedures [xi]. High levels of hospital anxiety tin have negative impact on pregnant women, who may not feel the pregnancy and birth as positive events, with repercussions throughout postoperative and puerperium periods [7,11-13]. Literature highlights that the pre-anesthetic consultation can support meaning women to deal with the hospital anxiety and stress symptoms offering individualized assist based on data about surgical procedures [13-15].

The pre-anesthetic consultation in the tertiary trimester of pregnancy has been adopted as a routine assistance in the Motherhood School Hospital of Universidade Federal practice Rio de Janeiro since 2014. This consultation is office of the Prenatal care multi professional service of this maternity and follows the policy of Federal Medical Quango of Brazil, which states that the pre-anesthetic consultation should promote a good relationship between medico and patient, also equally provide information about anesthetic options and their risks and advantages. Based on this, the pre-anesthetic consultation may likewise be an opportunity to institute a rapport between patient and wellness professional in order to forestall infirmary anxiety. Because that elevated levels of anxiety and stress in pregnancy are related to negative obstetric outcomes [6-10], information technology is important to place infirmary anxiety and stress in the pregnancy, especially in women facing an constituent interruption of pregnancy. In that location are few studies about hospital anxiety and its relations with prenatal stress and gestational and mail service-partum outcomes in this specific population in Brazil. The objective of this study was to identify stress and hospital anxiety in pregnant women indicated for an elective interruption of pregnancy and attended in a preanesthetic consultation, and discuss associations betwixt stress and hospital feet, and metabolic, obstetric, neonatal and puerperal outcomes.

Methods

The study followed the guidelines of Ethical Committee for Research with Homo Beings [16] and was approved past the Upstanding Commission of the institution (CAAE 29114914.3.0000.5275). It is a prospective cohort written report based on a descriptive quantitative pattern conducted during 17 months with a sample of 42 women at 35th week of gestation with indication of elective interruption of pregnancy. All significant women were attended at the pre-anesthetic consultation from the prenatal care service of the Maternity School Hospital of Universidade Federal do Rio de Janeiro. This is a tertiary maternity hospital that attends patient on demand, specialized on chance pregnancy.

The written report sample included pregnant women with single pregnancy, normal results for maternal, fetal, clinical and laboratory tests (fasting glucose≥ 95 mg/dl; postprandial glucose ≤ 140 mg/dl; cardiotocography with skillful vitality and obstetric ultrasound with normal fetal weight and liquid book), and minimum levels of anxiety co-ordinate to the Beck Anxiety Inventory - BAI [17]. All participants were indicated for elective commitment co-ordinate to the post-obit clinical criteria: term pregnancy with balmy or moderate hypertension (diastolic and systolic claret pressures: <110 and 160 mm Hg, respectively); controlled diabetes mellitus; previous cesarean section, and fetal breech presentation. Patients in use of anxiolytic, allaying, or psychoactive drugs, and with severe psychiatric illness, previous surgical complication, corticotherapy, and ongoing labor were excluded from the study.

The pre-anesthetic consultation followed an institutional protocol, which is based on the policy of Resolution 1802/2006 of the Federal Medical Council of Brazil. In this consultation, a clinical evaluation is performed, and an intervention strategy is planned for each pregnant woman to set her for the perioperative menstruation. Also, patients are informed almost the anesthetic options and their consent for anesthesia is required in an informed consent form.

Earlier the information collection, all participants signed the Free and Informed Consent Form approved past the Upstanding Commission of institution. All participants were evaluated by a psychology professional to place psychological symptoms of stress and hospital feet during the pre-coldhearted consultation conducted by the anesthesiologist.

The Lipp's Stress Symptoms Inventory for Adults (LSSI) [3] was used to evaluate prenatal stress at 35th week of gestation, and during the pre-anesthetic consultation. Stress was also evaluated using LSSI at puerperium medical date occurred around 1 month after childbirth. The LSSI is a Brazilian normative scale to evaluate signs and symptoms of stress with expert psychometric properties (Cronbach's blastoff, 0.91) validated on a study with 1853 people from xv to 75 years old [3,18]. It classifies the stress into four stages (alarm, resistance, almost-exhaustion, and exhaustion) based on the identification of physical, psychological and mixed symptoms that are typical of each stage of stress.

The infirmary anxiety was evaluated at the delivery moment using the Brazilian version of Hospital Anxiety and Depression Scale-HADS [11]. The HADS is a Likert scale with xiv items, and two subscales (7 items for anxiety and 7 items for depression). Each calibration item tin be scored from 0 to 3, with a maximum score of 21 points for each subscale. Original report of HADS recommends a cut-off betoken of ≥ 9 scores for classification of anxiety or depression, for both subscales [12]. The same classification was recommended for Brazilian version [eleven]. The HADS has been used in different studies that investigate preoperative infirmary feet, including researches with meaning women [2,19].

Socio-demographic and psychological data were nerveless from medical patient reports and in private interviews. Data on metabolic (fasting blood glucose level), obstetric (delivery route), and neonatal (Apgar scores and nativity weight) outcomes were collected from medical patient records. All data were processed and analyzed using the SPSS (Statistical Parcel for Social Sciences) version 17.0 (SPSS Inc., Chicago, IL, USA). Socio-demographic and psychosocial information were analyzed descriptively in terms of means and standard deviations.

Associations among stress, infirmary anxiety, and those outcomes and socio-demographic and psychosocial data were investigated using the Wilcoxon, Chi-Foursquare and Kruskal-Wallis tests, adopting p≤0.05 as significance level.

Results

Socio-demographic data are summarized in Table 1. The hateful age of pregnant women ranged from 17 to 44 years (Chiliad = 33.7; SD = vi.2).

Variables	Range	One thousand ± SD
Historic period	17-44	33.4 ± 6.2
-	n	%
Education
Elementary School	26	61.9
High School	11	26.2
Higher Education	v	eleven.9
Marital Status
Married	38	90.5
Unmarried	four	9.five
Parity
Primiparous	11	26.2
Multiparous	31	73.8
Working status
Employed	28	66.6
Unemployed	14	33.four

One thousand=mean; SD=Standard Difference;

Table 1: ÃÆ'‚ Socio-demographic data of meaning women (n= 42).

Regarding educational activity level, 26 (61.nine%) women had Elementary school, eleven (26.2%) had High Schoolhouse, and 5 (11.9%) had Higher instruction levels. Related to the marital status, the majority of women (90.5%) were married, and multiparous (73.8%). More than than half of sample were employed (66.6%).

Data from metabolic, obstetric, neonatal and puerperal outcomes are summarized in Tabular array two. The majority of sample was diagnosed with Gestational Diabetes Mellitus (GDM) (88%). Likewise, eight women were balmy or moderate hypertension (diastolic and systolic blood pressures: <110 and 160 mm Hg, respectively) and two were obese.

Outcomes		n	Range	M ± SD
Metabolic
Claret Glucose	Pre-consult.	39	-	92.9 ± 14.iii
	Mail service-consult.	30	-	95.eight ± 22.7
Obstetric
Birth route	Vaginal delivery	xi	-	26.2
	Cesarean	28	-	66.iv
Neonatal
Apgar scores	1st infinitesimal	39	iv-ix	8.4 ± 0.96
	5th infinitesimal	39	8-10	8.ix ± 0.49
Birth weight (gr)		39	2545-4110	3265 ± 396

1000=mean; SD=Standard Deviation;

Table 2: Metabolic, obstetric, neonatal and puerperal outcomes of pregnant women.

From the sample, 3 meaning women were not evaluated for hospital feet and obstetric (delivery route) and neonatal (Apgar scores and birth weight) outcomes were not obtained because their delivery not occur in our maternity. The more than frequent type of delivery route for 39 participants was elective cesarean section (66.7%). The range of Apgar scores was iv-ix (8.4 ± 0.96) at the 1st minute and 8-10 (8.9 ± 0.49) at 5th minute; and the birth weight ranged from 2545 chiliad to 4110 1000 (3264 ± 396 one thousand).

The fasting claret glucose levels data were obtained from medical reports for pregnant women because it is a routine according to the prenatal care protocol of our maternity. Statistically significant differences were not found between fasting blood glucose levels earlier and after the preanesthetic consultation (p>0.05; r=0.63).

Prenatal stress data (e.g. stress levels evaluated at 35th week of gestation and at the pre-coldhearted consultation) can exist observed in Figure 1. It was observed that 48.nine% (n=18) of pregnant women showed stress symptoms during prenatal period. Amid those, the majority showed symptoms of resistance stress (94.iv%). At the puerperium, stress was not assessed in 8 women because they did not attend the puerperium medical engagement. For 34 women reevaluated for stress, 31 (73.8%) did non present stress.

Figure 1: Stages of stress symptoms by LSSI (n=34).

Statistically meaning differences were found between prenatal stress (at pre-coldhearted consultation) and puerperium stress (at medical date) levels (p>0.05).

Related to hospital anxiety, 37 meaning women (88.1%) did non testify symptoms of feet with scores ≥ 9 by the Hospital Anxiety and Depression Scale (HADS). Statistically significant associations among stress, infirmary anxiety and sociodemographic and psychosocial data and those outcomes were not found.

Word

Considering the pre-anesthetic consultation equally an important moment to manage a rapport with women facing an elective interruption of pregnancy, the main objective of this study was to place stress and hospital feet in pregnant women indicated for an elective interruption of pregnancy and attended in a pre-anesthetic consultation, and talk over associations among prenatal stress, hospital anxiety, and metabolic, obstetric, neonatal and puerperal outcomes. It was observed that less than one-half (48.9%) showed stress symptoms at the pre-anesthetic consultation cess. In addition, most of them did not present meaning levels of hospital anxiety at the elective delivery moment (afterwards pre-anesthetic consultation). These information may be related to the quality of the routine service of the maternity, in which the prenatal intendance has been conducted by a multi professional team. This care can promote adaptive strategies for adult female to cope with their pregnancy demands. The prenatal assistance, that included a pre-anesthetic consultation, was centered on individual needs, and can event on the development of positive coping strategies. This hypothesis must be analyzed in future studies, considering that coping process is a multi and circuitous phenomenon that should be investigated on a multimethodological design using different measures, like coping scales combined with interviews, for example.

Also, 11.nine% of patients showed symptoms of infirmary anxiety evaluated at the delivery moment. Information technology is important to highlight that the pre-anesthetic consultation in our motherhood is mandatory to provide information near anesthetic options, its risks and advantages for all meaning women with indication for elective delivery. According to the literature, it tin be a helpful strategy to identify and support patients to manage stress and hospital anxiety at the preoperative menstruation [xiii-fifteen,20], and change their beliefs related to anesthesia. These beliefs normally are associated with feelings of fearfulness and insecurity almost anesthetic procedures and constituent delivery. Frequently the contact between the anesthesiologist and patient occurs only at the mean solar day of surgical effect, and the preanesthetic consultation can be efficient to provide information about surgical procedures before the elective delivery to back up the women cope with stress and hospital anxiety. Studies confirmed that an adequate data prior to surgery can reduce the perception of pain at post-surgical period [13-fifteen]. And then, the informative communication by anesthesiologist can minimize an excessive anxiety and concerns related to surgical procedures and pre and postoperative periods. Moreover, the pre-anesthetic consultation tin aid meaning woman to experience the period before and during the commitment in a positive way. Even so, we cannot depict large conclusions about the role of pre-coldhearted consultation to reduce hospital anxiety or its event on puerperium outcomes. We suggest time to come studies with command groups to provide further data well-nigh the preanesthetic consultation as a potential intervention to manage infirmary feet of patients with indication of elective delivery.

Significant differences (p>0.05) were found between stress levels from prenatal (at pre-anesthetic consultation) and puerperium (at medical engagement). This finding can suggest that the stress experienced was closely related to the condition of risk gestation and/or to typical demands of pregnancy period. The identification and evaluation of stress symptoms during the puerperal and pregnancy periods is commonly neglected in perinatal wellness care in Brazil. However, literature highlights the relationship between maternal mental health and negative outcomes in gestation [vii-13]. Thus, it is important that prenatal assistance also addresses women'southward mental health. A multi professional team tin assume an important role in prenatal assistance promoting women mental wellness and preventing negative outcomes for the infant. Even though it is expected that stress levels can relieved after delivery for pregnant women who need elective suspension due gestational risks, the reduction of stress in the puerperium tin can exist considered a positive outcome related to the institutional protocol that include the pre-coldhearted consultation.

Despite no significant correlations were found among stress, hospital anxiety and socio-demographic and psychosocial data, the literature confirm that women expectations about her pregnancy, and social and psychological changes in her personal and familiar routine tin can increase prenatal stress [x,21,22] peculiarly on adventure pregnancy. In these cases, the proximity of labor and an indication of elective delivery may also result in hospital anxiety. Schetter and Tanner assert that some stressors, such as few material resource, unfavorable employment conditions, excessive family and domestic responsibilities, tensions in marital relationships, and pregnancy complications, can bear upon all pregnant women [23]. However, considering that the bulk of our sample was married (90.5%) and had children (73.8%), the partner and family can be too a source of social and emotional back up in pregnancy [22]. These findings tin be related to 51.one% of patients not stressed at pre-coldhearted consultation. Also, the prenatal stress can be predominantly related to gestational demands, and because of this did not increment in puerperium. Factors, like be married and having children, can help women adopt adaptive strategies to cope with the demands of risk pregnancy, and to manage stress during pregnancy [22,24]. Moreover, 66.six% of pregnant women were employed. The employment, associated with marital status, educational level and prenatal care, is a protective mechanism confronting prenatal stress [22,24].

On the other hand, almost half of participants (40.v%) showed stress symptoms in the resistance phase. For them, the experience of stress was more intense, and result on a abiding attempting to maintain the physical and psychological balance to resist big periods of stress [three]. As well, the resistance stress may take related to events earlier pregnancy, like the demands with other children, for case. The stress in the resistance stage contributes to an increase and chronification of psychological symptoms, such as tiredness, retentivity deficits and irritability. Stress should not be neglected in pregnancy due to its repercussions on the woman wellbeing and baby evolution, peculiarly the resistance stress [6-10,23].

Considering the relationship betwixt high levels of prenatal stress and negative obstetric outcomes [6-10] our objective was also to investigate associations betwixt stress and obstetric outcomes, in lodge to hash out how prenatal care service can aid to identify stress in pregnancy and its impact on puerperium. Stress results on physiological responses (neural and endocrine) that are related to metabolic, cardiovascular and autonomic nervous organisation functioning [25]. Associations betwixt stress levels and metabolic outcomes (fasting blood glucose levels before and afterwards the pre-anesthetic consultation) were investigated. Different from the literature [25], no significant correlations were found between stress and metabolic outcomes. Those outcomes tin can be interpreted as a positive consequence in our report. The mean values of fasting blood glucose levels before and after the preanesthetic consultation (92.8 mg/dl and 95.eight mg/dl, respectively) indicated a practiced glucose level control, according to the Brazilian prenatal protocol [26].

Neonatal outcomes, such equally Apgar scores in the 1st and fifth minutes and nativity weight, were also analyzed. Likewise, no pregnant correlations were found amongst stress, hospital anxiety and neonatal outcomes. The hateful scores of Apgar at 1st infinitesimal (K=eight.four) and 5th minute (One thousand=8.9), and the mean of nascency weight (3264 g), indicated a proficient health condition for newborns of those participants. These findings highlight the importance of regular prenatal care for at-risk significant women and her concept. According to the Brazilian policies [27], at least six medical appointments are mandatory to guarantee a proficient prenatal care. A prenatal care service must attend all pregnant women based on a preventive arroyo for supporting the maternal mental and concrete health during and later on pregnancy. This arroyo can prevent postpartum disorders, such as postpartum depression, which may be associated with stress during pregnancy [8,28]. Relations between prenatal stress and postpartum depression may be investigated in lodge to discuss and confirm the effect prenatal care service in our establishment on mental wellness and other outcomes.

Some limitations of the study should exist highlighted. Get-go, the limited sample size and the dropout charge per unit exercise non allow robust statistical assay. The 2d limitation is related to the methodological design of the written report: no control group was recruited, and we suggest comparative studies with pregnant women who did not attend on a pre-coldhearted consultation in order to study the role of the pre-coldhearted consultation equally an intervention mensurate to manage hospital anxiety levels. For instance, in our maternity, the control group could be recruited among women who are attended at the emergency room merely did not attended the long term prenatal intendance service in the institution. Consequently, nosotros must exist careful to describe further conclusions almost the benefits of pre-anesthetic consultation on infirmary anxiety and stress. Finally, none child development outcomes were studied. Because the association between stress and negative outcomes for children'due south evolution [7-10], we propose future studies based on a longitudinal and clinical randomized trial design.

Conclusion

Literature supports that stress and hospital feet are common in significant women. [1,ii,5,8] and high levels of stress and anxiety are related to negative obstetric outcomes [6-10,19]. Hospital anxiety evaluated at the commitment moment occurred in eleven,nine% of cases and stress reduced significantly from the pre-anesthetic consultation to puerperal period. However, no associations amid stress, hospital anxiety, social-demographic and psychosocial data, and metabolic, obstetric and neonatal outcomes were institute. The preanesthetic consultation based on a practiced medico-patient advice and relationship can be considered as a moment in which it is possible to appraise stress and hospital anxiety in risk meaning women. Further randomized controlled trials must investigate the effect of pre-anesthetic consultation to reduce stress and infirmary anxiety in this population.

References

1. Ferreira CR, Orsini MC, Vieira CR, practice Amarante AMP, Silva RR (2014) Prevalence of feet symptoms and low in the third gestational trimester. Arch WomenÃÆ'‚´s Ment Health 17: 221-228.
2. Rubertsson C, Hellstrom J, CrÃÆ'ƒÂ¶ss M, SydsjÃÆ'ƒÂ¶ G (2014) Anxiety in early on pregnancy: prevalence and contributing factors. Curvation WomenÃÆ'‚´s Mental Health 17: 221-228.
3. Lipp MEN (2000) Manual do InventÃÆ'ƒÂ¡rio de Sintomas de Stress para Adultos de Lipp (ISSL). Casa practise PsicÃÆ'ƒÂ³logo, SÃÆ'ƒÂ£o Paulo.
4. Selye H (1956) The Stress of life. McGraw-Hill, New York, Us.
5. Ranabir S, Reetu Thousand (2011) Stress and hormones. Indian J Endocrinol Metab 15: 18-22.
6. Loomans EM, van Dijk AE, Vrijkotte TG, van Eijsden M, Stronks Thousand, et al. (2012) Psychosocial stress during pregnancy is related to adverse nascency outcomes: results from a large multi-ethinic community-based birth cohort. Eur J Public Health 23: 485-491.
7. Glover (2014) Maternal depression, feet and stress during pregnancy and kid outcome; what needs to be done. Best Exercise & Research Clinical Obstetrics and Gynecology 28: 25-35.
8. Rodrigues OMPR, Schiavo RA (2011) Stress na gestaÃÆ'ƒÂ§ÃÆ'ƒÂ£o e no puerpÃÆ'ƒÂ©rio: uma correlaÃÆ'ƒÂ§ÃÆ'ƒÂ£o com a depressÃÆ'ƒÂ£o pÃÆ'ƒÂ³s-parto. Rev Bras Ginecol Obstet 33: 252-257.
9. Sanchez SE, Puente GC, Atencio Yard, Qiu C, Yanez D, et al. (2013) Risk of spontaneous preterm birth in relation to maternal depressive, anxiety, and stress symptoms. J Reprod Med 58: 25-33.
10. Zucchi FCR, Youli Y, Ward ID (2013) Maternal stress induces epigenetic signatures of psychiatric and neurological diseases in the offspring PLoS One eight: e56967.
11. Marcolino JAM, Mathias LAST, Piccinini Filho L, Guaratini AA, Suzuki FM, et al. (2007) Escala Hospitalar de Ansiedade e depressÃÆ'ƒÂ£o: Estudo da Validade de CritÃÆ'ƒÂ©rio e da Confiabilidade com Pacientes no PrÃÆ'ƒÂ©-operatÃÆ'ƒÂ³rio. Revista Brasileira de Anestesiologia. 57:52-62.
12. Zigmond AS, Snaith RP (1983) The hospital feet and depression calibration. Acta Psychiatr Scand 67: 361-370.
13. SjÃÆ'ƒÂ¶ling M, Nordahl Chiliad, Olofsson Due north, Asplund Thou (2003) The impact of preoperative information on state anxiety, postoperative pain and satisfaction with hurting management. Patient Educ Couns 51:169-176.
14. Kiyohara LY, Kayano LK, Oliveira LM, Yamamoto MU, Inagaki MM, et al. (2004) Surgery information reduces feet in the pre-operative period. Rev Hosp Clin Fac Med Sao Paulo 59:51-56.
15. Lithner M, Zilling T (2000) Pre and postoperative information needs. Patient Educ Couns 40: 29-37.
16. Conselho Nacional de SaÃÆ'ƒÂºde (Brasil). ResoluÃÆ'ƒÂ§ÃÆ'ƒÂ£o nÃÆ'‚º 466, de 12 de dezembro de (2012) DiÃÆ'ƒÂ¡rio Oficial da UniÃÆ'ƒÂ£o. xiii de junho de 2013; SeÃÆ'ƒÂ§ÃÆ'ƒÂ£o i.
17. Brook AT, Steer RA (1993) Beck Anxiety Inventory Manual. Psychological Corporation, San Antonio, TX, United states of america.
18. Lipp MEN, Guevara AJH (1994) ValidaÃÆ'ƒÂ§ÃÆ'ƒÂ£o empÃÆ'ƒÂ­rica do InventÃÆ'ƒÂ¡rio de Sintomas de Stress (ISS). Estudos de Psicologia 11: 43-49.
19. Qiao Y, Wang J, Li J (2012) Effects of depressive and anxiety symptoms during pregnancy on pregnant, obstetric and neonatal outcomes: A follow-upward study. J Obstet Gynaecol 32: 237-240.
20. Haines HM, Rubertsson C, Pallant JF, Hildingsson I (2012) The influence of womenÃÆ'¢Â€Âââ€Å¾Â¢due south fear, attitudes and beliefs of childbirth on mode and feel of nativity. Pregnancy and Childbirth 12:55.
21. Brummelte S, Galea LAM (2010) Depression during pregnancy and postpartum: Contribution of stress and ovarian hormones. Prog Neuropsychopharmacol Biol Psychiatry 34: 766-776.
22. Cardwell MS (2013) Stress: Pregnancy considerations. Obstet Gynecol Survey 68: 119-129.
23. Schetter CD, Tanner 50 (2012) Anxiety, low and stress in pregnancy: implications for mothers, children, research and practice. Curr Opin Psychiatry 25: 141-148.
24. Ditzen B, Heinrichs Yard (2014) Psychobiology of social support: The social dimension of stress buffering. Restor Neurol Neurosci 32: 149-162.
25. Horsch A, Kang JS, Vial Y, Ehlert U, Borghini A, et al. (2016) Stress exposure and psychological stress responses are related to glucose concentrations during pregnancy. Br J Health Psychol 21: 712-729.
26. MinistÃÆ'ƒÂ©rio da SaÃÆ'ƒÂºde (2013) EstratÃÆ'ƒÂ©gias para o cuidado da pessoa com doenÃÆ'ƒÂ§a crÃÆ'ƒÂ´nica: diabetes mellitus. Cadernos de AtenÃÆ'ƒÂ§ÃÆ'ƒÂ£o BÃÆ'ƒÂ¡sica, 36, BrasÃÆ'ƒÂ­lia, Distrito Federal. BRASIL. MinistÃÆ'ƒÂ©rio da SaÃÆ'ƒÂºde. Secretaria de AtenÃÆ'ƒÂ§ÃÆ'ƒÂ£o ÃÆ'ƒÂ  SaÃÆ'ƒÂºde. Departamento de AtenÃÆ'ƒÂ§ÃÆ'ƒÂ£o BÃÆ'ƒÂ¡sica. SaÃÆ'ƒÂºde da crianÃÆ'ƒÂ§a: nutriÃÆ'ƒÂ§ÃÆ'ƒÂ£o infantil: aleitamento materno e alimentaÃÆ'ƒÂ§ÃÆ'ƒÂ£o complementar.
27. MinistÃÆ'ƒÂ©rio da SaÃÆ'ƒÂºde (2011) AtenÃÆ'ƒÂ§ÃÆ'ƒÂ£o ÃÆ'ƒÂ  saÃÆ'ƒÂºde do RecÃÆ'ƒÂ©thou-Nascido: guia para bone profissionais de saÃÆ'ƒÂºde. Cuidados Gerais. SÃÆ'ƒÂ©rie A. Normas due east Manuais TÃÆ'ƒÂ©cnicos. BrasÃÆ'ƒÂ­lia, DF 1.
28. Rock SL, Diop H, Declercq E, Cabral HJ, Trick MP, et al. (2015) Stressful Events during Pregnancy and Postpartum Depressive Symptoms. J Womens Health 24: 384-393.

shanleywhitis.blogspot.com

Source: https://www.primescholars.com/articles/preanesthetic-consultation-stress-and-preoperative-anxiety-in-risk-pregnant-women-95185.html

Share this post