Alfredo de Almeida Cunha

Fatores associados à asfixia perinatal

PURPOSE: to assess risk factors for low Apgar score. METHODS: this was a cross-sectional study preformed in a random sample of patients admitted to a level III maternity hospital in 2001. The outcome was low Apgar score defined as an Apgar score 1-6 (study group) versus Apgar score 7-10 (control group) in the first minute of life. The first step was the evaluation of the association of each possible risk factor with low Apgar score. The second step was multivariate analysis with the backward stepwise logistic regression model. RESULTS: there were 39 (14%) depressed newborns which were compared to 238 (86%) not depressed babies. The final analysis (multivariate) showed an association between low Apgar score and previous case of stillbirth (OR=52.6), preterm labor threat (OR=33.8), low birth weight, less than 2,500 g body weight (OR=11.2) and previous cesarean section (OR=7.4). Some factors acted as a protection, including birth weight, in grams (OR=0.9), female sex of the newborn (OR=0.1), medical complications (OR=0.4) and prematurity (gestational age < 37 weeks, OR=0.1). CONCLUSION: the study may help in the identification of fetuses at great risk of asphyxia, allowing proper reference within the health system and planning of effective assistance in neonatal intensive care units.

Gestações complicadas por sífilis materna e óbito fetal

PURPOSE: To describe the characteristics of pregnancies complicated by maternal syphilis and fetal death. METHODS: Retrospective descriptive study performed by reviewing the medical records of 48 pregnant women with maternal syphilis and fetal death outcome admitted to Hospital Geral de Nova Iguacu, Baixada Fluminense, State of Rio de Janeiro, during the period from 2005 to 2008. Birth weight >500 g and fetal death documented by Death Certificate were the inclusion criteria. The following aspects were analyzed: sociodemographic factors, reproductive history, aspects of the current pregnancy, prenatal care, Venereal Disease Research Laboratory (VDRL) testing, and other gestational conditions, in addition to syphilis. The fetal deaths were classified as maternal, placental or fetal. Percentage, mean, standard deviation (SD), maximum and minimum values were reported. RESULTS: The mean maternal age was 22.7 years (SD=0.9 years), and at least 50% of the patients had low educational level. At hospital admission, 68.8% of the subjects were in the third trimester, with a mean gestational age of 29.2 weeks (SD=0.5), and more than 50% were in labor. The vast majority of fetal deaths (93%) occurred before maternal hospitalization. Among the patients who received prenatal care (54.2%), 30.8% had no VDRL test, 30.8 and 15.4% had a reactive and non-reactive result, respectively, and none had more than one prenatal VDRL test. At the time of childbirth, most of the mothers (95.8%) carried out VDRL testing. Overall, the VDRL titers varied from 1:1 to 1:512, with predominant values >1:4 (91.7%). In 23% of cases other clinical conditions related to fetal death, in addition to syphilis, were found. CONCLUSIONS: The infection was the main clinically identified cause of fetal death in this patient series. Fetal death occurred during the preterm period and in the presence of high titers of maternal infection, suggesting recent syphilis infection.

Características de um grupo de adolescentes com suspeita de neoplasia intra-epitelial cervical

OBJETIVO: avaliar a prevalencia de alteracoes citologicas, colposcopicas e histopatologicas observadas no colo uterino de adolescentes com suspeita de neoplasia cervical e as correlacoes epidemiologicas, compararando com mulheres adultas jovens. METODOS: estudo transversal, retrospectivo de revisao de 366 prontuarios de mulheres encaminhadas para esclarecimento diagnostico com suspeita de neoplasia cervical. As pacientes foram classificadas em dois grupos definidos por idade. O grupo Adolescente foi composto por 129 mulheres de 13 a 19 anos e o grupo Adulta foi composto por 237 mulheres de 20 a 24 anos. Foram calculados razao de prevalencia (RP), respectivos intervalos de confianca (IC) a 95% para cada variavel, teste c2 ou teste exato de Fisher quando aplicavel para comparacao das proporcoes. RESULTADOS: a sexarca ocorreu em media aos 15,0 anos no grupo Adolescente e 16,6 anos no grupo Adulta. A chance de diagnostico de alteracoes citologicas no primeiro exame realizado (RP=2,61; IC 95%: 2,0-3,4), a condicao neoplasia intra-epitelial cervical (NIC) a esclarecer (RP=1,78; IC 95%: 1,26-2,52) e a colposcopia de baixo grau (RP=1,42; IC 95%: 1,08-1,86) foram estatisticamente significantes no grupo Adolescente. A analise histopatologica nao mostrou diferencas para qualquer grau de NIC. Entretanto, foram identificados dois casos de carcinoma microinvasor, sendo um em cada grupo, e tres casos de carcinoma invasor no grupo Adulta. CONCLUSAO: nosso estudo sugere que o câncer de colo uterino e raro na adolescencia, mas verificamos que alteracoes a ele associadas aconteceram em mulheres muito jovens. A investigacao da neoplasia intra-epitelial cervical com a aplicacao criteriosa dos mesmos metodos utilizados para a mulher adulta foi apropriada tambem na adolescencia.

Misoprostol use under routine conditions for termination of pregnancies with intrauterine fetal death

OBJECTIVE To analyze the misoprostol use in pregnancies with intrauterine fetal death (IUFD), considering mode of delivery and induction-delivery interval. METHODS Descriptive study including 171 pregnant women with IUFD, in the second or third trimester, submitted to labor induction with vaginal misoprostol and/or induction/augmentation with intravenous oxytocin, from 2005 to 2008, at a teaching-hospital of the Brazilian Unified Health System (Sistema Único de Saúde - SUS). RESULTS Misoprostol alone (treatment A), misoprostol plus oxytocin (treatment B), and oxytocin alone (treatment C) were administered in 9.3%, 19.9%, and 70.8% of the cases, respectively. One-third of pregnancies were less than 28 weeks, and 2.9% required a caesarean section. The percentage of vaginal delivery in treatments A and B combined (98.0%) was similar to treatment C (96.7%). The mean induction-delivery interval was 15.4hours. Comparing multiple groups, the mean induction-delivery interval was significantly shorter in treatment A (20.1hours) than in treatment B (33.3hours), and was longer than in treatment C (9.7hours). The majority (71%) of cases required a single administration of misoprostol, and the total dosage was lower in treatment A (mean: 98.4μg) compared with treatment B (mean: 157.0μg). CONCLUSION Misoprostol effectively contributed to delivery of IUFD by vaginal route assisted under routine conditions of a public health service in Brazil, demonstrating its importance in cases resistant to usual induction methods, and its availability in Brazilian public health services is recommended.

Complicações da gestação e do parto como fatores de risco de óbito perinatal

Objetivo: avaliar as complicacoes clinicas da gestacao e as complicacoes do parto como fatores de risco de obito perinatal. Metodologia - Pacientes: os casos (obitos perinatais) foram identificados a partir de 3.031 partos assistidos em maternidade de nivel terciario (Hospital da Policia Militar do Estado do Rio de Janeiro, PMERJ). Apos cada caso foram selecionados 3 controles de forma sequencial. Metodos: o delineamento foi de caso-controle aninhado. Casos (n = 82) foram obitos perinatais com minimo de 28 semanas de idade gestacional ou 1.000 g de peso. Controles (n = 246) foram recem-nascidos vivos ate uma semana de vida. A variavel dependente foi obito perinatal (28 sem - 7 dias de nascido). Foram variaveis independentes (fatores de risco): idade gestacional, peso do recem-nascido, complicacoes da gravidez e complicacoes do parto. A analise foi feita em tres etapas: univariada, estratificada e multivariada (regressao logistica). Resultados: foi observada uma razao de chances de 4,21 para as complicacoes da gravidez e de 5,26 para as complicacoes do parto. O peso do recem-nascido mostrou OR = 0,999 por grama acima de 1.000 g. A idade gestacional mostrou OR = 0,729 por semana acima de 28. Conclusoes: as complicacoes da gravidez e as complicacoes do parto sao fatores de risco para obito perinatal. A idade gestacional e o peso do recem-nascido comportaram-se como fatores de protecao para o obito perinatal.

Clinical management of the induction of labor in intrauterine fetal death: evaluation of incidence of cesarean section and related conditions

OBJECTIVE To assess the incidence and conditions associated with cesarean section in a cohort of pregnant women with intrauterine fetal death (IUFD), and clinical management to anticipate the childbirth. METHODS It was a retrospective cohort study with 163 mothers with IUFD, at the second half of pregnancy, who were managed to anticipate childbirth using pharmacological preparations and/or a mechanical method (Foley catheter) in a teaching hospital in Rio de Janeiro State, Brazil. Cox regression was used to evaluate the effect of the clinical methods on the kind of delivery. RESULTS The Subgroups A (misoprostol or Oxytocin), B (misoprostol and Oxytocin), and C (Foley catheter alone or combined with misoprostol and/or Oxytocin) were formed according to the applied methods. Nine out of 163 cases ended with cesarean section. The incidence of cesarean section was 3.5 per 1,000 people-hours, meaning that a pregnant woman with IUFD had a 15.6% risk of cesarean section during the first 48 hours of clinical management to anticipate childbirth. The conditions significantly associated with the mode of delivery were placental abruption (HR: 44.97), having two or more previous cesarean deliveries (HR: 10.03), and mechanical method with Foley catheter (HR: 5.01). CONCLUSION Cesarean section was an essential conduct in this cohort and followed previous cesarean delivery and placental abruption. The effect of the mechanical method on the abdominal route suggests that the Foley catheter method was used in the most difficult cases and that the surgery was performed to ensure maternal health.