Alessandra Cristina Marcolin

Incidência de cesáreas segundo fonte de financiamento da assistência ao parto

OBJECTIVE: To study the types of delivery according to the category of patient admission and the most frequently reported indications for cesarean sections. METHODS: In a retrospective survey of deliveries performed in the municipality of Ribeirao Preto, Sao Paulo, Brazil, from 1986 to 1995, the type of delivery, category of admission and recorded diagnoses were assessed. Data were obtained from the Center of Hospital Data Processing of the Department of Social Medicine in the University of Sao Paulo, Ribeirao Preto. RESULTS: A total of 86,120 deliveries were registered during the study period; 5.4% were allocated in the private category, 28.7% in the prepayment category, and 65.9% in the public health system (SUS). It was observed a decrease in the private and SUS categories and an increase in the prepayment category. During the study period, the percentage of cesarean deliveries increased from 68.3% to 81.8% in the private category and from 69.1% to 77.9% in the prepayment category, and decreased from 38.7% to 32.1% in the SUS category. The major indications for cesarean section were fetal distress, with the incidence of 9.5%, 10.9% and 9.0% in the private, prepayment and SUS categories, respectively; and cephalopelvic dystocia, at the rates of 5.8%, 6.5% and 3.9%, respectively. CONCLUSION: The incidence of cesarean section varied according to admission category, with a rising trend as the pregnant womans social status increased, but without a correlation with the obstetrical risk.

A Adolescente Grávida: Alguns Indicadores Sociais

Purpose: the objective of the present study was to determine the number and type of deliveries, category of admission to the hospital, occupation and obstetrical diagnosis for adolescents from the municipality of Ribeirao Preto, from January 1992 to December 1996. Methods: the information obtained from hospital discharge forms was analyzed at the Hospital Data Processing Center. The 6.04a-text processor Epi-Info System, a data bank and statistics for epidemiology produced by the Centers of Disease Control and Prevention (Atlanta, GA, USA), and Dbase IV were used to process the information. The association between variables was tested by the c2 test, with the level of significance set at 5%. The analyzed parameters were: number and type of delivery, category of hospital admission, occupation and obstetric diagnosis. Results: a total of 42,969 deliveries occurred during the study period, among which 7,134 (16.6%) corresponded to adolescent deliveries. An increase in the number of deliveries by girls in this age range occurred over the years, from 1,225 in 1992 to 1,538 in 1996. Deliveries were reported starting from 12 years of age, with a gradual increase in this number, especially after 14 years of age, when a 104.2% increase occurred for deliveries at this age, followed by 48.8% at 15 years, 36.1% at 16 years, 14.0% at 17 years, 52.8% at 18 years, and with practically no increase among 19-year-old girls. The highest number of deliveries (5,709) was recorded for the unified health system category of admission, followed by 1,277 deliveries for the prepaid category and 148 deliveries for the private category. With respect to occupation, 14.1% of the patients belonged to the economically active population, while 85.8% did not. Of the total deliveries, 59.2% were normal, 5.6% were forceps deliveries, and 35.2% were cesarean sections. The most frequent obstetrical diagnoses were: problems of fetus or placenta affecting maternal management (7.9%), fetus-pelvis disproportion (6.0%), problems with the amniotic cavity and membranes (5.0%), hypertension complicating delivery and puerperium (3.5%), and premature or false labor (3.4%). Conclusions: most deliveries were normal and occurred more frequently at the end of adolescence, especially among girls belonging to the unified health system. There was a predominance of adolescents not belonging to the economically active population. Some obstetrical complications were diagnosed at the time of resolution of pregnancy.

Infecção urinária na gravidez

Several factors cause urinary tract infection (UTI) to be a relevant complication of the gestational period, aggravating both the maternal and perinatal prognosis. For many years, pregnancy has been considered to be a factor predisposing to all forms of UTI. Today, it is known that pregnancy, as an isolated event, is not responsible for a higher incidence of UTI, but that the anatomical and physiological changes imposed on the urinary tract by pregnancy predispose women with asymptomatic bacteriuria (AB) to become pregnant women with symptomatic UTI. AB affects 2 to 10% of all pregnant women and approximately 30% of these will develop pyelonephritis if not properly treated. However, a difficult-to-understand resistance against the identification of AB during this period is observed among prenatalists. The diagnosis of UTI is microbiological and it is based on two urine cultures presenting more than 10(5) colonies/mL urine of the same germ. Treatment is facilitated by the fact that it is based on an antibiogram, with no scientific foundation for the notion that a pre-established therapeutic scheme is an adequate measure. For the treatment of pyelonephritis, it is not possible to wait for the result of culture and previous knowledge of the resistance profile of the antibacterial agents available for the treatment of pregnant women would be the best measure. Another important variable is the use of an intravenous bactericidal antibiotic during the acute phase, with the possibility of oral administration at home after clinical improvement of the patient. At our hospital, the drug that best satisfies all of these requirements is cefuroxime, administered for 10-14 days. Third-generation cephalosporins do not exist in the oral form, all of them involving the inconvenience of parenteral administration. In view of their side effects, aminoglycosides are considered to be inadequate for administration to pregnant women. The inconsistent insinuation of contraindication of monofluorinated quinolones, if there is an indication, norfloxacin is believed to be a good alternative to cefuroxime. In cases in which UTI prophylaxis is indicated, chemotherapeutic agents are preferred, among them nitrofurantoin, with care taken to avoid its use at the end of pregnancy due to the risk of kernicterus for the neonate.

Infecção urinária na gravidez: análise dos métodos para diagnóstico e do tratamento

Objetivos: avaliar os aspectos diagnosticos, terapeuticos e as complicacoes dos casos de infeccao do trato urinario (ITU) sintomatica durante a gestacao, que necessitaram de internacao hospitalar. Metodos: foram incluidas 136 gravidas com diagnostico clinico de pielonefrite. Foram avaliados: a idade e paridade da paciente, idade gestacional em que foi feito o diagnostico, antecedentes de importância epidemiologica, propedeutica laboratorial para avaliacao da infeccao urinaria, tratamento e evolucao clinica, antimicrobianoprofilaxia e complicacoes. Resultados: pielonefrite foi diagnosticada, nas mesmas proporcoes, em todas as idades gestacionais. Houve maior incidencia de ITU entre as primigestas. Apenas 29,3% das gestantes apresentaram historia previa de ITU. Observou-se que 57,0% das pacientes apresentaram anemia e 93,0% mostraram analise urinaria alterada. A Escherichia coli foi o uropatogeno mais prevalente (75,8% dos casos), com baixos percentuais de sensibilidade a ampicilina (60,6%) e a cefalotina (63,6%) e altos percentuais de sensibilidade a cefuroxima (95,5%). A maior taxa de melhora clinica foi obtida entre as gestantes tratadas com cefuroxima (95,7%). A antimicrobianoprofilaxia foi necessaria em 11,0% das pacientes. O trabalho de parto pre-termo ocorreu em 33,3% das gestantes que deram a luz em nosso servico, e o parto pre-termo em 18,9%. Conclusoes: esses resultados reforcam a necessidade do diagnostico precoce e tratamento efetivo da ITU em gestantes, a fim de evitar a ocorrencia frequente de complicacoes perinatais, como o trabalho de parto e o parto pre-termo. Destaca-se a necessidade de avaliacao periodica do padrao de sensibilidade dos agentes etiologicos prevalentes aos antimicrobianos de uso permitido durante a gestacao, adotando-se a cefuroxima como o antimicrobiano de escolha para o tratamento das ITU na gestacao.Purpose: to assess the diagnostic and therapeutic aspects and the complications of symptomatic urinary tract infections (UTI) during pregnancy of patients who were hospitalized. Methods: a total of 136 pregnant women with a clinical diagnosis of pyelonephritis were studied. The studied parameters were: age and parity of patients, gestational age of diagnosis, epidemiologic aspects, laboratory evaluation for UTI, treatment and clinic evolution, prophylaxis and complications. Results: pyelonephritis was diagnosed at the same proportions at all gestational ages. The incidence of UTI was higher among primigravidae. Only 29.3% of the pregnant women had a previous history of UTI; 57.0% were anemic and 93.0% had altered urinalysis. Escherichia coli was the most prevalent uropathogen (75.8% of cases), with low percentages of sensitivity to ampicillin (60.6%) and high percentages of sensitivity to cefuroxime (95,5%). The highest rate of clinical improvement was obtained for the pregnant women treated with cefuroxime (95.7%). Prophylaxis was needed in 11.0% of the patients. Preterm labor occurred in 33.3% of the pregnant women who delivered in our service and preterm delivery occurred in 18.9%. Conclusions: the present results support the need for an early diagnosis and effective treatment of UTI in pregnant women in order to prevent the frequent occurrence of perinatal complications such as premature labor and delivery. We emphasize the need of a periodical evaluation of the pattern of sensitivity of the etiologic agents to the antimicrobials allowed for use during pregnancy, with cefuroxime being adopted as the antibiotic of choice for the treatment of UTI during pregnancy.

Antiretroviral Therapy During Pregnancy and Early Neonatal Life: Consequences for HIV-Exposed, Uninfected Children

Women have emerged as the fastest growing human immunodeficiency virus (HIV) infected population worldwide, mainly because of the increasing occurrence of heterosexual transmission. Most infected women are of reproductive age and one of the greatest concerns for both women and their physicians is that more than 1,600 infants become infected with HIV each day. Almost all infections are a result of mother-to-child transmission of HIV. With the advent of combination antiretroviral therapies, transmission rates lower than 2% have been achieved in clinical studies. Antiretroviral compounds differ from most other new pharmaceutical agents in that they have become widely prescribed in pregnancy in the absence of proof of safety. We reviewed antiretroviral agents used in pregnant women infected with human immunodeficiency virus, mother-to-child transmission, and their consequences for infants.

Massage reduced severity of pain during labour: a randomised trial.

QUESTION Does massage relieve pain in the active phase of labour? DESIGN Randomised trial with concealed allocation, assessor blinding for some outcomes, and intention-to-treat analysis. PARTICIPANTS 46 women pregnant at ≥ 37 weeks gestation with a single fetus, with spontaneous onset of labour, 4-5cm of cervical dilation, intact ovular membranes, and no use of medication after admission to hospital. INTERVENTION Experimental group participants received a 30-min lumbar massage by a physiotherapist during the active phase of labour. A physiotherapist attended control group participants for the same period but only answered questions. Both groups received routine perinatal care. OUTCOME MEASURES The primary outcome was pain severity measured on a 100mm visual analogue scale. Secondary outcomes included the Short Form McGill Pain Questionnaire, pain location, and time to analgesic medication use. After labour, a blinded researcher also recorded duration of labour, route of delivery, neonatal outcomes, and the participants satisfaction with the physiotherapist during labour. RESULTS At the end of the intervention, pain severity was 52mm (SD 20) in the experimental group and 72mm (SD 15) in control group, which was significantly different with a mean difference of 20mm (95% CI 10 to 31). The groups did not differ significantly on the other pain-related outcome measures. Obstetric outcomes were also similar between the groups except the duration of labour, which was 6.8hr (SD 1.6) in the experimental group and 5.7hr (SD 1.5) in the control group, mean difference 1.1hr (95% CI 0.2 to 2.0). Patients in both groups were satisfied with the care provided by the physiotherapist. CONCLUSION Massage reduced the severity of pain in labour, despite not changing its characteristics and location.

Changes in Fetal and Maternal Doppler Parameters Observed During Acute Severe Hypertension Treatment with Hydralazine or Labetalol: A Randomized Controlled Trial

We evaluated 16 pregnant women with gestational age between 20 and 32 weeks in acute severe hypertension which were randomly allocated to receive either hydralazine or labetalol. Blood pressure and Doppler ultrasound parameters from maternal uterine and fetal middle cerebral and umbilical arteries were assessed during acute severe hypertension and after treatment. A significant reduction in systolic and diastolic blood pressure was observed in both groups. A significant change in Doppler parameters was observed only in pregnant women who received hydralazine: an increase in uterine arteries resistance index. We concluded that both drugs were highly effective in reducing blood pressure in these women. Despite the observed increase in resistance index of uterine arteries associated with hydralazine, the use of hydralazine and labetalol were not related to any significant changes in fetal Doppler, which is reassuring about the safety of these drugs when treating acute severe hypertension in pregnancy.

Diagnosis and treatment of cervical cancer during pregnancy

CONTEXT AND OBJECTIVE One third of all cervical carcinomas occur during the reproductive period. Cervical carcinoma is the second greatest cause of death due to cancer during this phase. The estimated frequency of cervical cancer during pregnancy is one case for every 1,000 to 5,000 pregnancies. The aim here was to provide information about the difficulties in diagnosing and managing cervical neoplasia during pregnancy. MATERIALS A systematic review of the literature was undertaken through the PubMed, Cochrane, Excerpta Medica (Embase), Literatura Latino Americana e do Caribe em Ciências da Saúde (Lilacs) and Scientific Electronic Library Online (SciELO) databases, using the following words: pregnancy, cervical cancer, diagnosis and management. RESULTS There was a consensus in the literature regarding diagnosis of cervical carcinoma and management of preneoplastic lesions during pregnancy. However, for management of invasive carcinoma, there was great divergence regarding the gestational age taken as the limit for observation rather than immediate treatment. CONCLUSION All patients with cytological abnormalities should undergo colposcopy, which will indicate and guide biopsy. Conization is reserved for patients with suspected invasion. High-grade lesions should be monitored during pregnancy and reevaluated after delivery. In cases of invasive carcinoma detected up to the 12th week of pregnancy, patient treatment is prioritized. Regarding diagnoses made during the second trimester, fetal pulmonary maturity can be awaited, and the use of chemotherapy to stabilize the disease until the time of delivery appears to be viable.

Avaliação da frequência de realização do exame físico das mamas, da colpocitologia cervical e da ultrassonografia obstétrica durante a assistência pré-natal: uma inversão de valores

INTRODUCAO: Embora o exame de ultrassonografia seja um procedimento frequente na gravidez, o seu uso rotineiro nao demonstrou efetividade sobre a reducao da morbi-mortalidade materna ou perinatal. OBJETIVOS: Avaliar a cobertura do exame das mamas e da citologia oncotica cervical entre os exames de pre-natal, comparando-se com o numero de ultrassonografias obstetricas realizadas. METODOS: Constituiu-se de uma avaliacao transversal, realizada na cidade de Rio Grande (RS), entre maio e julho de 2007. Os dados obtidos por meio de um questionario estruturado foram digitados no programa Epi-Info 6.04 e analisados no software SPSS. RESULTADOS: Entre as 230 puerperas entrevistadas, 99,1% realizaram ultrassonografia durante a gravidez, enquanto 37,5% e 33,6% realizaram exame clinico das mamas ou colpocitologia cervical, respectivamente. Houve significância estatistica (p-valor < 0,001) entre o local do pre-natal e o numero de exames ecograficos realizados na gravidez. As pacientes que realizaram consultas por convenios ou particular foram mais submetidas a cografias. Tambem observou-se que o maior numero de ecografias obstetricas aumentou a probabilidade da gestante ter sido submetida ao exame clinico das mamas. Por sua vez, a realizacao da colpocitologia nao foi influenciada pelo numero de ultrassonografias. CONCLUSAO: A realizacao da ecografia obstetrica foi priorizada e realizada como exame rotineiro, ao passo que o exame clinico das mamas e o exame colpocitologico cervical nao o foram, apesar de serem orientados como obrigatorios durante o pre-natal. Este fato demanda novos estudos e avaliacoes dos programas de saude e o impacto desta inversao nos indices de saude populacional.

Teste rápido para detecção da infecção pelo HIV-1 em gestantes

Purpose: to evaluate the results of a rapid diagnostic test for HIV-1 infection made available by the Health Ministry for the identification of pregnant women contaminated by this virus. Methods: we evaluated prospectively 443 pregnant women with no prenatal serologic anti-HIV test seen at the Department of Gynecology and Obstetrics of the Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, from February to June, 2000. Samples from these patients were submitted to the rapid immunochromatographic test, which was compared with ELISA and submitted to a confirmatory agglutination test. Results: among the 443 pregnant women submitted to the rapid test (20.1% of the deliveries performed during the study period), 16 showed positive results (3.6%). No sample with a negative result by the rapid test was positive by ELISA. However, of the 16 samples that were positive by the rapid test, two were negative by the confirmatory tests. Thus, the rapid test showed 100.0% sensitivity, 99.5% specificity, 87.5% positive predictive value, and 100.0% negative predictive value. Conclusions: the results obtained by evaluation of the test for a rapid diagnosis of HIV-1 infection in pregnant women revealed sensitivity, specificity and predictive values that qualify it as an extremely important resource for the indication of measures that will reduce perinatal transmission of this virus.