SANTANA, Marly Maria de. CABRAL, Ewelyn Rafaela Santos. Analysis of the quality of records in the medical records of pregnant women with positive VDRL in Itamaracá-Pernambuco. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year. 07, Ed. 02, Vol. 04, p. 164-175. February 2022. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/health/analysis-of-the-quality
Sexually Transmitted Infections (STIs) constitute a public health problem, which cause social, economic and health damages. Given this, as syphilis is an infectious disease, transmitted sexually, it is necessary to develop proposals that seek to systematize adequate prenatal care for pregnant women, paying special attention to the records in the patient’s medical records and card, aiming at a better systematic follow-up. In this context, the following guiding question was raised: What is the quality of the records in the medical records of pregnant women with reagent VDRL exams in Itamaracá-PE through the notifications recorded in medical records, from January 2016 to January 2019? Thus, the objective of this research is to evaluate reagent VDRL exams in pregnant women in the municipality of Ilha de Itamaracá – Pernambuco through the notifications recorded in medical records, from January/2016 to January/2019. This is a cross-sectional, descriptive study with a quali-quantitative approach. The analysis of the quality of the medical records of pregnant women with a reactive VDRL test from January/2016 to January/2019 revealed disorder and underreporting, demonstrating a worrying scenario. The municipality has 09 UBS, where in addition to prenatal care, care for other patients with basic health needs and prevention in general are carried out. Regarding prenatal care, doctors and nurses provide care and follow-up. It was possible to perceive that many cases of congenital syphilis could be avoided with timely programs created and directed by the Ministry of Health (MS). More attention is recommended when filling out medical records, as they are extremely important regardless of the patient’s problem or case. It is concluded, therefore, the need to complete the medical records of pregnant women for a better medical follow-up for her and her partner. The assessment of the quality of medical records allows us to reflect on the impacts generated by this fact and on how this situation can be reversed or improved.
Keywords: Maternal and child health, Congenital syphilis, Underreporting.
Sexually Transmitted Infections (STIs) constitute a major public health problem, as they cause social, economic and health damages (SILVA et al., 2020; FELICIO et al., 2019; BERTONCELI, 2018). Causing social, economic and health damage of great repercussion to populations, especially among women and children. Among the STIs, syphilis deserves to be highlighted, as it is an infectious and systemic disease, with worldwide scope and chronic evolution caused by Treponema pallidum, with humans as the only host, transmitter and reservoir (MAGALHÃES et al., 2013). About 2 million pregnant women worldwide are infected with syphilis annually (BECK; SOUZA, 2018; NONATO et al., 2015).
Public policies aimed at maternal and child health contributed to an increase in early diagnosis and notifications in pregnant women, such as the use of the rapid test for syphilis. However, the quality of records in the medical records of pregnant women with reactive VDRL tests is often incipient or poorly performed, which leads to underreporting of diagnosis and treatment, or interruption of treatment. Putting municipalities on alert, where often this may not be exactly the case. The municipality of Itamaracá registered 183 cases of congenital syphilis in the last 10 years. With 30 cases registered between January 2016 and January 2019 (BOLETIM SÍFILIS, 2019).
In view of the above, what is the quality of the records in the medical records of pregnant women with reagent VDRL exams in Itamaracá – PE through the notifications recorded in medical records, from January 2016 to January 2019?
The present work aims to evaluate reagent VDRL exams in pregnant women in the municipality of Ilha de Itamaracá – Pernambuco through the notifications recorded in medical records, from January 2016 to January 2019.
First, a letter of consent was requested from the head of the institution. As this is data collection, the use of the Free and Informed Consent Term (TCLE) was waived. Data were collected from medical records and analyzed their quality based on the data contained in the medical records of Health Centers in the Municipality of Ilha de Itamaracá – Pernambuco in March 2021. Where an analysis was carried out on the quality of records in the records of pregnant women with exams Reagent VDRL in Itamaracá-PE from January 2016 to January 2019.
Data were collected through the analysis of medical records and their quality, which identified socioeconomic data such as: race/color, age, education, among others, and guiding questions such as: treatment performed, partner treated and main missing or incomplete data.
RESULTS AND DISCUSSION
The analysis of the quality of the medical records of pregnant women with a positive VDLR test from January/2016 to January/2019 revealed disorder and underreporting and an extremely worrying scenario.
According to IBGE data (2010), the economy of the municipality of Ilha de Itamaracá is based on the service sector (trade and tourism) which is the most representative in the Itamaracá economy, followed by agriculture.
The municipality has 09 UBS, where in addition to prenatal care, care for other patients with basic health needs and prevention in general are carried out. Regarding prenatal care, doctors and nurses provide care and follow-up.
As described by the Ministry of Health (MS), from 2005 onwards, syphilis in pregnant women became a condition of compulsory notification with the publication of Ordinance MS/SVS No. 33 of July 14, 2005, with the objective of identifying existing cases subsidizing prevention and control actions; in addition to knowing the epidemiological profile and trends (SARACENI et al., 2007).
According to the data, it is understood that several occurrences of congenital syphilis can be avoided through adequate plans created and directed by the Ministry of Health (MS). If each region is aware of its own restrictions, government plans can become more efficient, which will ensure better health for all. Without the exact knowledge of where the flaws are, health actions can lose the main focus, and end up going unnoticed (CABRAL et al., 2017).
Analysis of the medical records of the Basic Health Units (UBS’s) in the municipality of Ilha de Itamaracá during the period from January/2016 to January/2019, revealed that 30 patients were treated with a reagent VDRL exam, however it was possible to collect data from only 25 (twenty and five) pregnant women. The municipality’s UBS’s are located in the following neighborhoods: Alto da Felicidade, Forte Orange, Rio Ambar, Baixa Verde/Pilar, Biquinha, Salinas/Chié, Jaguaribe, Vila Velha, and Sossego. However, only 17 notifications according to the UBS records were found. Where, it was possible to observe that of the 09 (nine) primary care units, 6 (six) received pregnant women with positive VDRL results for Syphilis in the studied period, as can be seen in Table 1.
Table 1. All confirmed cases of syphilis in pregnant women recorded in the analyzed medical records of the Basic Health Units for the Municipality of Ilha de Itamaracá, from 2016 to 2019.
|Basic units||Total confirmed cases|
|Alto da Felicidade||5|
|Baixa Verde / Pilar||2|
|Forte Orange /Bela Vista||1|
Source: Information according to field research carried out by the Author.
The largest number of VDRL pregnant women attended was related to UBS Alto da Felicidade, an urban area of the municipality. Of these, 50% start prenatal care in the 2nd trimester of pregnancy, 50% had elementary education. However, only 60% of them performed the treatment correctly only of those who started prenatal care, and the remaining 40% started treatment without performing the follow-up. In addition, 100% of the partners refused to undergo treatment, either in the maternity hospital or in primary care.
The lack of completion of medical records observed was extremely high, where they only counted data such as name, date of birth, address and telephone number, making it impossible to collect any other sociodemographic data, such as: education, marital status, color/race and occupation. In addition, of the 30 pregnant women reported with positive VDRL, only 25 had the aforementioned data actually completed. Where, it was possible to observe the predominance of pregnant women of urban origin in relation to the rural one, with only 4% of pregnant women coming from the rural population, as can be seen in Table 2 below.
Table 2- Distribution of VDRL-reactive pregnant women according to the neighborhood of origin of the Basic Health Units for the Municipality of Ilha de Itamaracá, from 2016 to 2019.
|Alto da felicidade||6||24%|
|Sítio Bom Jesus||1||4%|
|Ignored / unfilled||2||8%|
|Total pregnant women||25||100%|
Source: Information according to field research carried out by the Author.
The quality of filling out the compulsory notification forms of investigation is crucial for the planning of interventions. For pregnant women with syphilis, the investigative process takes place in primary care, as it is what happens with the diagnosis of the disease and prenatal care. Therefore, primary care is the moment when the notification and investigation of the case occurs (BRASIL, 2006). In the same way, it is the time when prenatal care must act and avoid the case of congenital syphilis. Primary care is expanded by the USF, recommended by the Ministry of Health. They reported the presence of the USF in 94% of Brazilian cities in 2008, representing about 48% of the population (GIOVANELLA et al., 2009). The strategy includes antenatal care, which includes screening pregnant women for syphilis and subsequent treatment of pregnant women and their partners if they are positive (BRASIL, 2006).
The same situation appears in the following years, according to confirmed cases of syphilis in pregnant women in the municipality of Ilha de Itamaracá for the years 2017 to 2019, according to the Ministry of Health/SVS – Notifiable Diseases Information System, as presented in Table 3 below.
Table 3. All confirmed cases of Syphilis in pregnant women registered in the Notifiable Diseases Information System – Brazil, in the State of Pernambuco, for the Municipality of Ilha de Itamaracá, through notifications, in the period from 2017 to 2019, according to age group.
|Years||Age group||Total confirmed cases||Total cases|
|2017||15 a 19||2||7|
|20 a 39||5|
|2018||15 a 19||7||20|
|20 a 39||13|
|2019||nothing contained||nothing contained||0|
Source: Ministry of Health/SVS – Notifiable Diseases Information System – Sinan Net, excluding cases not residing in Brazil.
- Available Periods or period – Corresponds to the years of notification of cases.
- To tabulate epidemiological data for a given year, select the variable of interest in the column Year of diagnosis in the row; under Available Periods, tick the initial year of the series and all subsequent years up to the current year (to include cases notified with delay) and under Available Selections, tick the years of diagnosis (ex: number of cases 2007: select in the line UF of residence, in the Column Year of diagnosis, in Available periods 2007 to the current year and in Selections, tick Year of diagnosis of 2007).
- 2009 data updated on 08/01/2011.
- 2010 data updated on 11/20/2013.
- 2011 data updated on 11/20/2013.
- Date for 2012 and 2013 updated on 07/05/2018.
- 2014 data updated on 01/30/2019.
- Data from 2015 to 2018 updated on 01/30/2019, data subject to review.
The quality of filling out the compulsory notification forms of investigation is crucial for the planning of interventions. For pregnant women with syphilis, the investigation process takes place in primary care, since this is the scenario in which the diagnosis of the disease and prenatal care take place. Therefore, primary care is the period of events of the notification and investigation of the case. In the same way, it is the time when prenatal care must act and avoid the case of congenital syphilis.
This occurrence prevents the epidemiological control of the disease, going against current public policies, especially the Rede Cegonha, which in addition to the qualification of obstetric-neonatal health, contributes to the improvement of the epidemiological surveillance system, through the expansion of the distribution of rapid tests for syphilis, a tool that allows the screening of the disease (SOARES et al., 2017).
In addition to the problems exposed above, this research also shows that the number of consultations that pregnant women receive during prenatal care is not enough to guarantee the control of this infection, since the quality of care needs to be evaluated, in addition to the intention and gestures to expand access and the recommended minimum number of consultations. Its content, especially in primary health care, requires monitoring and adequate treatment of pregnant women and partners. It also exposes the precariousness of basic and emergency care services where the pregnant woman uses benzathine during treatment (FIGUEIREDO et al., 2015). According to the author, there are difficulties that the Family Health Strategy team faces, the referral and treatment of pregnant women and partners was mentioned because, although it could be sought through community health units, the professionals showed a lack of positive attitudes towards the partner’s participation in services and indecision in referring pregnant women. Women are treated in specialized services. Nor did they mention the mandatory notification of cases of syphilis and congenital syphilis in pregnant women (FIGUEIREDO et al., 2015).
That is to say, the inadequate approach to the needs, subjectivities and social vulnerabilities of each pregnant woman at the time of prenatal care makes it difficult both for the pregnant woman to understand the importance of the GS treatment and her adherence to it. In addition to the lack of treatment of sexual partners. Combined, these factors result in high rates of syphilis reinfection in patients (VIANA FILHO et al., 2020).
In this way, it is evident the importance of performing a quality prenatal care, of carrying out early treatments during pregnancy, of health education through actions that aim to clarify the population about the importance of condom use, about the appropriate treatment for the pregnant woman and her partner, avoiding transmission to the fetus so that fetal compromise is not reached.
Returning to the guiding question: What is the quality of the records in the medical records of pregnant women with reagent VDRL exams in Itamaracá-PE through the notifications recorded in medical records, from January 2016 to January 2019? It was concluded that the lack of completion of the medical records observed was extremely high, where they only counted on data such as name, date of birth, address and telephone number, making it impossible to collect any other sociodemographic data, such as: schooling, marital status, color/race and occupation. In addition, of the 30 pregnant women reported with a reactive VDRL, only 25 had the aforementioned data actually filled in, making the medical records of reactive pregnant women of low quality.
The analysis of medical records shows great resistance to adherence to treatment, both on the part of pregnant women and on the part of their partners. There are reports of pregnant women who underwent previous treatment and in a new pregnancy and tested positive again for syphilis, especially if they remain with the same partner and have not undergone treatment.
Of the medical records analyzed throughout the city, only two pregnant women had the treatment carried out properly, with a return to the unit for follow-up and referral after the completion of the treatment for a new evaluation and who had their partner also treated.
There is a lot of resistance regarding the acceptance and initiation of treatment by pregnant women, but mainly by their partners. Sometimes the economic condition for their displacement to the unit where the treatment is carried out, makes this acceptance difficult.
Most professionals reported knowing that syphilis in pregnant women is a disease of compulsory notification, however, few carry out the notification, a factor that corroborates with previous studies that alert to underreporting and, mainly, to the increase in notification numbers of congenital syphilis and reduction of cases in pregnant women.
The nurse in the health unit is the professional committed and committed to the reception and prenatal care of pregnant women at any stage. He is responsible for ordering the VDRL exam for all pregnant mothers, in the three trimesters of pregnancy; and also, perform Rapid Tests (RT) to detect HIV and syphilis to pregnant women in the first consultation. It is important and indispensable a care and humanized look at all stages, for the health of pregnant women. Even the implementation of precautionary and health promotion practices, in addition to the analysis and appropriate procedure of the difficulties that occur in this phase.
The control of syphilis in pregnant women requires greater engagement from the professionals involved, especially those who are in primary care, as they understand that it is at this level of complexity that prenatal care and first care for the prevention of vertical transmission of the pathology exist.
Thus, it is urgently and continuously necessary to update and guide health professionals involved in the UBSs and in the care, treatment and management of pregnant women, related or not to syphilis, for this, the Ministry of Health together with the state government and municipalities, need to launch updating programs, as well as periodicals, booklets and/or manuals, so that there is an improved practice and can thus considerably reduce syphilis infections, being essential to correctly fill out medical records in order to contribute to better care for pregnant women and their partner.
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APPENDIX – FOOTNOTE
3.The Free and Informed Consent Term – Termos de Consentimento Livre e Esclarecido (TCLE) are intended to enable the research subjects to have the broadest clarification on the investigation to be be carried out, its risks and benefits, so that its manifestation of will towards to participate (or not), is effectively free and conscious.
4. Federative unit.
5. Gestational sac.
 Master in Public Health; Postgraduate in Emergency ICU PSF and Graduate in Nursing. ORCID: 0000-0002-5606-2636.
 Advisor. ORCID: 0000-0002-5250-2876.
Sent: December, 2021.
Approved: February, 2022.