Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015

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Tipo de recurso:
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2022
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Universidad de Caldas
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Repositorio Institucional U. Caldas
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eng
spa
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Palabra clave:
Obstetricia
Polución ambiental
Embarazo
Preeclampsia
Contaminación aérea
Material particulado
Medio ambiente
Exposición prenatal
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dc.title.none.fl_str_mv Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
title Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
spellingShingle Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
Obstetricia
Polución ambiental
Embarazo
Preeclampsia
Contaminación aérea
Material particulado
Medio ambiente
Exposición prenatal
title_short Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
title_full Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
title_fullStr Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
title_full_unstemmed Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
title_sort Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015
dc.contributor.none.fl_str_mv Henao Navarro , Leidy Diana
Arias Ortiz, Nelson Enrique
Aristizábal Zuluaga, Beatriz Helena
dc.subject.none.fl_str_mv Obstetricia
Polución ambiental
Embarazo
Preeclampsia
Contaminación aérea
Material particulado
Medio ambiente
Exposición prenatal
topic Obstetricia
Polución ambiental
Embarazo
Preeclampsia
Contaminación aérea
Material particulado
Medio ambiente
Exposición prenatal
description Gráficas
publishDate 2022
dc.date.none.fl_str_mv 2022-07-01T13:27:49Z
2022-07-01T13:27:49Z
2022-06-29
dc.type.none.fl_str_mv Trabajo de grado - Especialización
http://purl.org/coar/resource_type/c_7a1f
Text
info:eu-repo/semantics/bachelorThesis
dc.type.coarversion.fl_str_mv http://purl.org/coar/version/c_970fb48d4fbd8a85
dc.identifier.none.fl_str_mv https://repositorio.ucaldas.edu.co/handle/ucaldas/17817
Universidad de Caldas
Repositorio Universidad de Caldas
https://repositorio.ucaldas.edu.co/mydspace
url https://repositorio.ucaldas.edu.co/handle/ucaldas/17817
https://repositorio.ucaldas.edu.co/mydspace
identifier_str_mv Universidad de Caldas
Repositorio Universidad de Caldas
dc.language.none.fl_str_mv eng
spa
language eng
spa
dc.relation.none.fl_str_mv 1. Creasy RK, Resnik R. Maternal-fetal medicine : principles and practice 7° edición. 2013) SE 7 (6 de noviembre de, editor. Philadelphia, PA, Estados Unidos : Saunders; 2015. 214-230 p.
2. F. Gary Cunningham, Kenneth J. Leveno, Steven L. Bloom, Catherine Y. Spong, Jodi S. Dashe, Barbara L. Hoffman, Brian M. Casey JSS. Williams. Obstetricia, 24e. 2017
3. Walsh SW, Ph D. Maternal-Placental interactions of oxidative stress and antioxidants in preeclampsia. Semin Reprod Endocrinol. 1998;16:93–104.
4. Institute, Health Effects TI for HM and E. State of Global Air 2019. Special Report. Boston; 2019.
5. Disorders PH, Pedersen M, Halldorsson TI, Sjurdur F. Impact of road traffic pollution on pre-eclampsia. Epidemiology. 2017; 28(1):99–106.
6. Hooven EH Van Den, Kluizenaar Y De, Pierik FH, Hofman A, Ratingen SW Van, Zandveld PYJ. Air pollution, blood pressure, and the risk of hypertensive complications during pregnancy. AHA. 2011; 57(3):406–12.
7. Wang Q, Zhang H, Liang Q, Knibbs LD. Effects of prenatal exposure to air 55 pollution on preeclampsia in Shenzhen, China. Environ Pollut. 2018; 237(0269-7491):18–27
8. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A, Daniels J, et al. Global causes of maternal death : a WHO systematic analysis. Lancet Glob Heal. 2014;2:323–33.
9. Herrera JA, Herrera Escobar JP. Mortalidad materna evitable: meta del milenio como propósito nacional. Monitoreo estratégico, Colombia. 2014;2–7.
10. Cinets A. Guía de práctica clínica para el abordaje de las complicaciones hipertensivas asociadas al embarazo, Colombia. Rev Colomb Obstet Ginecol. 2013;64(3):289–326.
11. Chappell LC, Cluver CA, Kingdom J, Tong S. Pre-eclampsia. Lancet. 2021; 6736 (20):1–14.
12. Jung E, Romero R, Yeo L, Gomez-lopez N. Expert review the etiology of preeclampsia. Am J Obstet Gynecol 2022;226(2):S844–66. Available from: https://doi.org/10.1016/j.ajog.2021.11.1356
13. Arango R, Peláez V, Agudelo V. Impacto clínico de la contaminación aérea. Arch Med. 2016;16(1657–320X):373–84.
14. Brook RD, Rajagopalan S, Pope CA, Brook JR, Bhatnagar A, Diez-Roux A V., et al. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the american heart association. AHA Sci Statement Part. 2010;121(21):2331–78.
15. Chen LH, Knutsen SF, Shavlik D, Beeson WL, Petersen F, Ghamsary M. The association between fatal coronary heart disease and ambient particulate air pollution : are females at greater risk ? Environ Health Perspect. 2005;113(12):1723–9.
16. Kristin A. Miller, David S. Siscovick, Lianne Sheppard, Kristen Shepherd, Jeffrey H. Sullivan, Garnet L. Anderson, Joel D. Kaufman. Long-term exposure to air pollution and incidence of cardiovascular events in women. N Engl J 56 Med. 2007;356:447–58
17. Montiel-dávalos A, Ibarra-sánchez MDJ, Ventura-gallegos JL, Alfaro-moreno E, López-marure R. Toxicology in Vitro oxidative stress and apoptosis are induced in human endothelial cells exposed to urban particulate matter. Toxicol Vitr. 2010;24(1):135–41.
18. Pereira G, Haggar F, Shand AW, Bower C, Cook A, Nassar N. Association between pre-eclampsia and locally derived traffic-related air pollution : a retrospective cohort study. J Epidemiol Community Heal. 2013;67:147–52.
19. Dadvand P, Ostro B, Amato F, Figueras F, Minguillón M, Martinez D, et al. Particulate air pollution and preeclampsia : a source-based analysis. Occup Environ Med. 2014;71:570–7.
20. Pedersen M, Stayner L, Slama R, Sørensen M, Figueras F, Nieuwenhuijsen MJ, et al. Ambient Air Pollution and Pregnancy-Induced Hypertensive Disorders A Systematic Review and Meta-Analysis. Hypertension. 2014;64:494–500.
21. Manuel J, Calderón S, Torres OF. Informe del estado de la calidad del aire en Colombia 2017. Ministerio de Ambiente - IDEAM.
22. Erez O, Romero R, Jung E, Chaemsaithong P. Preeclampsia and eclampsia: the conceptual evolution of a syndrome. Am J Obstet Gynecol 2022;226(2):S786–803
23. Vidaeff A, Pettker CM, Simhan H. Gestational Hypertension and Preeclampsia. Clin Manag Guidel Obstet – Gynecol ACOG. 2019;133(1):1– 25.
24. Wu J, Ren C, Delfino RJ, Chung J, Wilhelm M, Ritz B. Association between local traffic-generated air pollution and preeclampsia and preterm delivery in the South Coast Air basin of California. Environ Health Perspect. 2009;117(11):1773–9.
25. Wang W, Xie X, Yuan T, Wang Y, Zhao F, Zhou Z, et al. Epidemiological trends 57 of maternal hypertensive disorders of pregnancy at the global, regional, and national levels: a population‐based study. BMC Pregnancy Childbirth. 2021;21(1):1–10.
26. Mortalidad materna [Internet]. WHO. 2019 [cited 2022 Apr 12]. p. 1. Available from: https://www.who.int/es/news-room/fact-sheets/detail/maternal-mortality
27. Boletín Epidemiológico Semanal 2 al 8 de junio de 2019. Instituto Nacional de Salud de Colombia. 2019;2–5
28. Stones W, Lim W, Al-Azzawi F, Kelly M. An investigation of maternal morbidity with identification of life-threatening “near miss” episodes. Health Trends 1991 Jan 123(1):13–5. Available from: https://europepmc.org/article/med/10113878
29. Protocolo de Vigilancia de Morbilidad Materna Extrema. Instituto Nacional de Salud de Colombia. 2022;112–7
30. WHO. Millennium Development Goals (MDGs) [Internet]. 19 February 2018. 2018 [cited 2022 Apr 12]. p. 1–3. Available from: https://www.who.int/newsroom/fact-sheets/detail/millennium-development-goals-(mdgs)
31. Gyselaers W. Hemodynamic pathways of gestational hypertension and preeclampsia. Am J Obstet Gynecol 2022;226(2):S988–1005. Available from: https://doi.org/10.1016/j.ajog.2021.11.022
32. Castillo-marco N, Cordero T, Simo C, Garrido-go T. Decidualization resistance in the origin of preeclampsia. Am J Obstet Gynecol 2022;226(2):S886–94. Available from: https://doi.org/10.1016/j.ajog.2020.09.039
33. Dekker GA, Sibai BM. Etiology and pathogenesis of preeclampsia : Current concepts. Clin Manag Guidel Obstet – Gynecol ACOG. 1998;179:1359–75.
34. WHO. Health consequences of air pollution on populations [Internet]. 15 de november. 2019 [cited 2022 Apr 12]. Available from: https://www.who.int/news/item/15-11-2019-what-are-health-consequencesof-air-pollution-on-populations
35. Brulle RJ, Pellow DN. Environmental justice: human health and environmental inequalities. Rev Public Heal. 2006;27(103–124).
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37. Chen RJ, Lee YH, Chen TH, Chen YY, Yeh YL, Chang CP. Carbon monoxidetriggered health effects: the important role of the inflammasome and its possible crosstalk with autophagy and exosomes. Arch Toxicol 2021;95(4):1141–59. Available from: https://doi.org/10.1007/s00204-021- 02976-7
38. Chen K, Breitner S, Wolf K, Stafoggia M, Sera F, Vicedo-Cabrera AM. Ambient carbon monoxide and daily mortality: a global time-series study in 337 cities. Lancet Planet Heal. 2021;5(4):e191–9
39. Censo Nacional de Población y Vivienda - CNPV - 2018 - Datos Abiertos Colombia [Internet]. 2018 [cited 2022 Apr 12]. p. 1. Available from: https://www.datos.gov.co/Estad-sticas-Nacionales/Censo-Nacional-dePoblaci-n-y-Vivienda-CNPV-2018/qzc6-q9qw?category=Estad-sticasNacionales&view_name=Censo-Nacional-de-Poblaci-n-y-Vivienda-CNPV2018
40. Gómez CD, González CM, Osses M, Aristizábal BH. Spatial and temporal disaggregation of the on-road vehicle emission inventory in a medium-sized Andean city. Comparison of GIS-based top-down methodologies. Atmos Environ 2018; Available from: https://doi.org/10.1016/j.atmosenv.2018.01.049
41. Mukherjee A, Agrawal M. A global perspective of fine particulate matter pollution and its health effects. Rev Env Contam Toxicol. 2017;12(244):5–51.
42. Romieu I, Gouveia N C LA. Multicity study of air pollution and mortality in Latin America (the ESCALA study). HEI Heal Rev Committee. 2012;171(5–86).
43. Jedrychowski WA, Perera FP, Maugeri U. Prohypertensive effect of gestational personal exposure to fine particulate matter . Prospective cohort 59 study in Non-smoking and Non-obese Pregnant Women. Cardiovasc Toxicol J. 2012;12:216–25.
44. Brook RD, Rajagopalan S. Particulate matter, air pollution, and blood pressure. J Am Soc Hypertens [Internet]. 2009;3(5):332–50. Available from: http://dx.doi.org/10.1016/j.jash.2009.08.005
45. Senoner T, Dichtl W. Oxidative stress in cardiovascular diseases: still a therapeutic target?. Nutrients 2019;11(9):4–15.
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47. Nobles CJ, Williams A, Ouidir M, Sherman S, Mendola P. Preeclampsia differential effect of ambient air pollution exposure on risk of gestational hypertension and preeclampsia. AHA journals. 2019;2:384–90.
48. Xia B, Zhou Y, Zhu Q, Zhao Y, Wang Y, Ge W, et al. Personal exposure to PM 2.5 constituents associated with gestational blood pressure and endothelial dysfunction. Environ Pollut. 2019;250:346–56. Available from: https://doi.org/10.1016/j.envpol.2019.04.024
49. Choe S, Jun Y, Kim S. Exposure to air pollution during preconceptional and prenatal periods and risk of hypertensive disorders of pregnancy : a retrospective cohort study in Seoul , Korea. BMC Pregnancy Childbirth. 2018;18(340):1–10
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56. Jia L, Liu Q, Hou H, Guo G, Zhang T, Fan S, et al. Association of Ambient air Pollution with risk of preeclampsia during pregnancy : a retrospective cohort study. BMC Public Health. 2020;20(1663):1–10.
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dc.publisher.none.fl_str_mv Facultad de Ciencias para la Salud
Manizales
Especialización en Obstetricia y Ginecología
publisher.none.fl_str_mv Facultad de Ciencias para la Salud
Manizales
Especialización en Obstetricia y Ginecología
institution Universidad de Caldas
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spelling Exposición prenatal a emisiones vehiculares y su asociación con preeclampsia, en mujeres gestantes en S.E.S Hospital de Caldas entre julio de 2014 y julio de 2015ObstetriciaPolución ambientalEmbarazoPreeclampsiaContaminación aéreaMaterial particuladoMedio ambienteExposición prenatalGráficasspa: Objetivo: Determinar la asociación entre la exposición prenatal de mujeres gestantes a emisiones vehiculares de PM10 y CO y preeclampsia Material y método: se trata de un estudio relacional, retrospectivo, de casos y controles en pacientes con embarazo complicado por preeclampsia, residentes en la zona urbana de Manizales entre julio de 2014 y julio de 2015. Se usó el sitio de residencia para estimación de exposición y la concentración de contaminantes a través de un instrumento de determinación de exposición a emisiones de PM10 y CO (toneladas por año por cada 250 metros cuadrados). Se utilizaron dos definiciones de exposición: cuartil superior (Q4) vs los cuartiles restantes (Q1 – Q3) y otra: comparación de los cuatro cuartiles tomando como referencia el primero (Q1). Se ajustaron modelos de regresión logística con el objetivo de explorar el efecto de la exposición. Resultados: Se incluyeron 222 pacientes, 74 casos y 148 controles. No se observó relación entre la concentración de PM10 en el área de residencia de la madre y la probabilidad de presentar preeclampsia tanto con la primera definición de exposición (OR de 1,013 (IC 95% 0,35 a 2,97) p=0,981) como con la segunda (Q2 (p=0,562), Q3 (p= 0,347), Q4 (p=0.887)). Para el caso de CO tampoco se encontró relación estadística en las dos definiciones (OR: 0,829 (IC 95% 0,29 a 2,39) p=0,729.). Conclusiones: no se observó asociación entre los niveles de exposición a PM10 y CO y la aparición de preeclampsia en mujeres gestantes durante los tiempos descritos.eng: Objective: To determine the association between prenatal exposure of pregnant women to vehicular emissions of PM10 and CO and preeclampsia. Material and method: This is a relational, retrospective, case-control study in patients with pregnancy complicated by preeclampsia, residents of Manizales-Colombia between July 2014 and July 2015. The place of residence was used to estimate exposure and the concentration of pollutants through an instrument for determining exposure to PM10 and CO emissions (tons per year for every 250 square meters). Two definitions of exposure were used: upper quartile (Q4) vs the remaining quartiles (Q1 – Q3) and another: comparison of the four quartiles taking the first quartile (Q1) as a reference. Logistic regression models were fitted in order to explore the effect of exposure. Results: 222 patients were included, 74 cases and 148 controls. No relationship was observed between the concentration of PM10 in the mother's area of residence and the probability of presenting preeclampsia with both the first definition of exposure (OR of 1.013 (95% CI 0.35 to 2.97) p=0.981) as with the second (Q2 (p=0.562), Q3 (p= 0.347), Q4 (p=0.887)). In the case of OC, no statistical relationship was found in the two definitions (OR: 0.829 (95% CI 0.29 to 2.39) p=0.729). Conclusions: No association was observed between the levels of exposure to PM10 and CO and the appearance of preeclampsia in pregnant women during the times described.1. Resumen / 2. Introducción / 3. Planteamiento del problema y justificación / 4. Marco teórico / 4.1 Generalidades /4.2 Epidemiología. / 4.3 Fisiopatología de la preeclampsia. / 4.4 Contaminación aérea /4.5 Relación entre contaminación aérea y preeclampsia / 5. Objetivos / 5.1 Objetivo general. / 5.2 Objetivos específicos. /6. Metodología / 6.1 Tipo de estudio /6.2 Hipótesis / 6.2.1 Hipótesis nula / 6.2.2 Hipótesis alterna / 6.3 Población de estudio / 6.4 Muestra / 6.5 Criterios de inclusión y exclusión / 7. Operacionalización de las variables /8. Proceso metodológico / 9. Análisis estadístico / 10. Resultados /10.1 Análisis descriptivo / 10.2 Análisis bivariado / 10.3 Análisis multivariado / 11. Discusión / 12. Conclusiones /13. Recomendaciones.EspecializaciónEspecialista en Obstetricia y GinecologíaFacultad de Ciencias para la SaludManizalesEspecialización en Obstetricia y GinecologíaHenao Navarro , Leidy Diana Arias Ortiz, Nelson EnriqueAristizábal Zuluaga, Beatriz HelenaNarvaez Enriquez, Nancy Elizabeth2022-07-01T13:27:49Z2022-07-01T13:27:49Z2022-06-29Trabajo de grado - Especializaciónhttp://purl.org/coar/resource_type/c_7a1fTextinfo:eu-repo/semantics/bachelorThesishttp://purl.org/coar/version/c_970fb48d4fbd8a85application/pdfapplication/pdfapplication/pdfapplication/pdfhttps://repositorio.ucaldas.edu.co/handle/ucaldas/17817Universidad de CaldasRepositorio Universidad de Caldashttps://repositorio.ucaldas.edu.co/mydspaceengspa1. Creasy RK, Resnik R. Maternal-fetal medicine : principles and practice 7° edición. 2013) SE 7 (6 de noviembre de, editor. Philadelphia, PA, Estados Unidos : Saunders; 2015. 214-230 p.2. F. Gary Cunningham, Kenneth J. Leveno, Steven L. Bloom, Catherine Y. Spong, Jodi S. Dashe, Barbara L. Hoffman, Brian M. Casey JSS. Williams. Obstetricia, 24e. 20173. Walsh SW, Ph D. Maternal-Placental interactions of oxidative stress and antioxidants in preeclampsia. Semin Reprod Endocrinol. 1998;16:93–104.4. Institute, Health Effects TI for HM and E. State of Global Air 2019. Special Report. Boston; 2019.5. Disorders PH, Pedersen M, Halldorsson TI, Sjurdur F. Impact of road traffic pollution on pre-eclampsia. Epidemiology. 2017; 28(1):99–106.6. Hooven EH Van Den, Kluizenaar Y De, Pierik FH, Hofman A, Ratingen SW Van, Zandveld PYJ. Air pollution, blood pressure, and the risk of hypertensive complications during pregnancy. AHA. 2011; 57(3):406–12.7. Wang Q, Zhang H, Liang Q, Knibbs LD. Effects of prenatal exposure to air 55 pollution on preeclampsia in Shenzhen, China. Environ Pollut. 2018; 237(0269-7491):18–278. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A, Daniels J, et al. Global causes of maternal death : a WHO systematic analysis. Lancet Glob Heal. 2014;2:323–33.9. Herrera JA, Herrera Escobar JP. Mortalidad materna evitable: meta del milenio como propósito nacional. Monitoreo estratégico, Colombia. 2014;2–7.10. Cinets A. Guía de práctica clínica para el abordaje de las complicaciones hipertensivas asociadas al embarazo, Colombia. Rev Colomb Obstet Ginecol. 2013;64(3):289–326.11. Chappell LC, Cluver CA, Kingdom J, Tong S. Pre-eclampsia. Lancet. 2021; 6736 (20):1–14.12. Jung E, Romero R, Yeo L, Gomez-lopez N. Expert review the etiology of preeclampsia. Am J Obstet Gynecol 2022;226(2):S844–66. Available from: https://doi.org/10.1016/j.ajog.2021.11.135613. Arango R, Peláez V, Agudelo V. Impacto clínico de la contaminación aérea. Arch Med. 2016;16(1657–320X):373–84.14. Brook RD, Rajagopalan S, Pope CA, Brook JR, Bhatnagar A, Diez-Roux A V., et al. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the american heart association. AHA Sci Statement Part. 2010;121(21):2331–78.15. Chen LH, Knutsen SF, Shavlik D, Beeson WL, Petersen F, Ghamsary M. The association between fatal coronary heart disease and ambient particulate air pollution : are females at greater risk ? Environ Health Perspect. 2005;113(12):1723–9.16. Kristin A. Miller, David S. Siscovick, Lianne Sheppard, Kristen Shepherd, Jeffrey H. Sullivan, Garnet L. Anderson, Joel D. Kaufman. Long-term exposure to air pollution and incidence of cardiovascular events in women. N Engl J 56 Med. 2007;356:447–5817. Montiel-dávalos A, Ibarra-sánchez MDJ, Ventura-gallegos JL, Alfaro-moreno E, López-marure R. Toxicology in Vitro oxidative stress and apoptosis are induced in human endothelial cells exposed to urban particulate matter. Toxicol Vitr. 2010;24(1):135–41.18. Pereira G, Haggar F, Shand AW, Bower C, Cook A, Nassar N. Association between pre-eclampsia and locally derived traffic-related air pollution : a retrospective cohort study. J Epidemiol Community Heal. 2013;67:147–52.19. Dadvand P, Ostro B, Amato F, Figueras F, Minguillón M, Martinez D, et al. Particulate air pollution and preeclampsia : a source-based analysis. Occup Environ Med. 2014;71:570–7.20. Pedersen M, Stayner L, Slama R, Sørensen M, Figueras F, Nieuwenhuijsen MJ, et al. Ambient Air Pollution and Pregnancy-Induced Hypertensive Disorders A Systematic Review and Meta-Analysis. Hypertension. 2014;64:494–500.21. Manuel J, Calderón S, Torres OF. Informe del estado de la calidad del aire en Colombia 2017. Ministerio de Ambiente - IDEAM.22. Erez O, Romero R, Jung E, Chaemsaithong P. Preeclampsia and eclampsia: the conceptual evolution of a syndrome. Am J Obstet Gynecol 2022;226(2):S786–80323. Vidaeff A, Pettker CM, Simhan H. Gestational Hypertension and Preeclampsia. Clin Manag Guidel Obstet – Gynecol ACOG. 2019;133(1):1– 25.24. Wu J, Ren C, Delfino RJ, Chung J, Wilhelm M, Ritz B. 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BMC Public Health. 2020;20(1663):1–10.info:eu-repo/semantics/closedAccessinfo:eu-repo/semantics/closedAccessinfo:eu-repo/semantics/closedAccessinfo:eu-repo/semantics/closedAccesshttp://purl.org/coar/access_right/c_14cboai:repositorio.ucaldas.edu.co:ucaldas/178172024-07-16T21:49:47Z

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