Ana Lúcia Letti Müller

Variation in the urinary protein/creatinine ratio at four different periods of the day in hypertensive pregnant women.

Objective. To assess the urine protein/creatinine ratio in urine samples of pregnant women with hypertension in regard to: 1) the presence of significant variation at different periods of the day; 2) the differences if they exist, to identify the most reliable period of the day for sampling; and 3) whether the first sample, obtained when the patient arrives at the clinic, correlates with the same accuracy, with the 24-hour proteinuria. Design. Cross-sectional study. Place. Obstetrics Emergency Department, Hospital de Clínicas de Porto Alegre, a teaching hospital in Porto Alegre, Brazil. Population. Seventy-five women with hypertension with 20-week gestation or over. Methods. Urine samples for determination of the protein/creatinine ratio were obtained on arrival (first specimen) and every 6 hours thereafter, totaling four samples in 24 hours. Four sampling periods were established: 1) from 8 am to 2 pm, 2) from 2 pm to 8 pm, 3) from 8 pm to 2 am, and 4) from 2 am to 8 am. The protein/creatinine ratio in the four different day periods were compared with the 24-hour proteinuria obtained simultaneously. The results were analyzed by the Spearman correlation and the receiver-operator characteristic (ROC) curve. Results. The urine protein/creatinine ratio is strongly correlated (Spearman correlation equal to 0.8 or greater) with the 24-hour proteinuria at all four periods of the day (p < 0.001), as well as the first sample obtained on arrival (p = 0.003). These findings were corroborated by the ROC curve in which the values of four day periods and that of the first sample were equal to or greater than 0.930. Conclusion. In hypertensive pregnant women, the single voided urine sample protein/creatinine ratio, irrespective of sampling time, is strongly correlated with the 24-hour proteinuria, as is the sample obtained on arrival.

Are insulin resistance index, IGF-1 and metabolic syndrome components correlates with severe preeclampsia?

Objective. Analyse the relation between insulin resistance and severe preeclampsia (SPE). Methods. Case control study paired by body mass index and gestational age; including 16 patients with severe SPE and 16 normotensive controls. Insulin resistance was assessed through the HOMA-IR and QUICKI-IS indexes. Results. There was no significant difference between the groups regarding the HOMA-IR and QUICKI-IS indexes and HDL cholesterol. Triglyceride levels were higher and the IGF-1 was lower in the SPE group than in the control group. Conclusions. There were no differences in the insulin resitance indexes between the group with SPE and normal controls.

Hidropisia fetal não imune: experiência de duas décadas num hospital universitário

PURPOSE: To identify the etiology of nonimmune hydrops fetalis cases in pregnant women diagnosed and referred for prenatal care. METHODS: Retrospective analysis of cases with nonimmune hydrops fetalis that were monitored between March 1992 and December 2011. Diagnosis was confirmed by the presence of fetal subcutaneous edema (≥5 mm) with effusion in at least one serous cavity using obstetric ultrasound, and etiological investigation was conducted with cytogenetic (karyotype), infectious (syphilis, parvovirus B19, toxoplasmosis, rubella, cytomegalovirus, adenovirus and herpes simplex), hematologic and metabolic (inborn errors) analysis and fetal echocardiography. Twin pregnancies were excluded. Statistical analysis was performed using the χ2 test for adhesion (software R 2.11.1). RESULTS: We included 116 patients with nonimmune hydrops fetalis; the etiology was elucidated in 91 cases (78.5%), while 25 cases (21.5%) were classified as idiopathic. Most cases had a chromosomal etiology, for a total of 26 cases (22.4%), followed by lymphatic etiology with 15 cases (12.9% with 11 cases of cystic hygroma), and cardiovascular and infectious etiology with 14 cases each (12.1%). In the remaining cases, the etiology was thoracic in 6.9% (eight cases), malformation syndromes in 4.3% (five cases), extrathoracic tumors in 3.4% (four cases), metabolic in 1.7% (two cases), and hematologic, gastrointestinal and genitourinary in 0.9% (one case each). During the postnatal period, 104 cases were followed up until the 40th day of life, and 12 cases had intrauterine fetal death. The survival rate of these 104 newborns was 23.1% (24 survived). CONCLUSION: An attempt should be made to clarify the etiology of hydrops diagnosed during pregnancy since the condition is associated with a wide spectrum of diseases. It is especially important to determine whether a potentially treatable condition is present and to identify disease at risk for recurrence in future pregnancies for adequate pre-conception counseling.PURPOSE To identify the etiology of nonimmune hydrops fetalis cases in pregnant women diagnosed and referred for prenatal care. METHODS Retrospective analysis of cases with nonimmune hydrops fetalis that were monitored between March 1992 and December 2011. Diagnosis was confirmed by the presence of fetal subcutaneous edema (≥ 5 mm) with effusion in at least one serous cavity using obstetric ultrasound, and etiological investigation was conducted with cytogenetic (karyotype), infectious (syphilis, parvovirus B19, toxoplasmosis, rubella, cytomegalovirus, adenovirus and herpes simplex), hematologic and metabolic (inborn errors) analysis and fetal echocardiography. Twin pregnancies were excluded. Statistical analysis was performed using the χ² test for adhesion (software R 2.11.1). RESULTS We included 116 patients with nonimmune hydrops fetalis; the etiology was elucidated in 91 cases (78.5%), while 25 cases (21.5%) were classified as idiopathic. Most cases had a chromosomal etiology, for a total of 26 cases (22.4%), followed by lymphatic etiology with 15 cases (12.9% with 11 cases of cystic hygroma), and cardiovascular and infectious etiology with 14 cases each (12.1%). In the remaining cases, the etiology was thoracic in 6.9% (eight cases), malformation syndromes in 4.3% (five cases), extrathoracic tumors in 3.4% (four cases), metabolic in 1.7% (two cases), and hematologic, gastrointestinal and genitourinary in 0.9% (one case each). During the postnatal period, 104 cases were followed up until the 40th day of life, and 12 cases had intrauterine fetal death. The survival rate of these 104 newborns was 23.1% (24 survived). CONCLUSION An attempt should be made to clarify the etiology of hydrops diagnosed during pregnancy since the condition is associated with a wide spectrum of diseases. It is especially important to determine whether a potentially treatable condition is present and to identify disease at risk for recurrence in future pregnancies for adequate pre-conception counseling.

Prevalência das malformações congênitas identificadas em fetos com trissomia dos cromossomos 13, 18 e 21

PURPOSE To describe the prevalence of malformations found in fetuses with trisomy of chromosomes 13, 18 and 21 by identifying the most frequent within each condition. METHODS A retrospective cross-sectional study with the analysis of trisomy cases of chromosomes 13, 18 and 21 diagnosed through fetal karyotype obtained by amniocentesis/cordocentesis, between October 1994 and May 2014, at a Teaching Hospital in Brazil Southern Region. Malformations identified through morphological ultrasonography were described and, subsequently, confirmed in newborn examinations and/or fetal autopsy. The results were analyzed using Fishers test and analysis of variance (ANOVA), with a 5% level of significance (p=0.05). RESULTS Sixty-nine cases of trisomy were diagnosed among 840 exams; nine were excluded due to outcome outside Hospital de Clínicas de Porto Alegre or incomplete records, remaining 60 cases (nine cases of chromosome 13 trisomy, 26 of chromosome 18, and 25 of chromosome 21). In all three groups, heart disease occurred in most cases; the ventricular septal defect was more prevalent and occurred in 66.7% of the trisomy 13 group. Gastrointestinal abnormalities were more prevalent in the trisomy 18 group, especially omphalocele (38.5%; p<0.01). Genitourinary anomalies were more significantly frequent in the trisomy 13 group (pyelectasis, 55.6% - p<0.01; ambiguous genitalia, 33.3% - p=0.01). Central nervous system defects were identified in all cases of trisomy 13. Facial cracks were significantly more prevalent among fetuses with trisomy 13 (66.7%; p<0.01). Hand and feet malformations significantly differed among the trisomy groups. Hand defects occurred in 50% of trisomy 18 cases, and in 44.4% of all trisomy 13 cases (p<0.01); congenital clubfoot was more common in the trisomy 18 group, being detected in 46.2% of fetuses (p<0.01). The abnormalities were found in 50.9, 27.3 and 21.7% of trisomy 18, 13 and 21 cases respectively. CONCLUSION Many fetal malformations identified at ultrasound are suggestive of trisomy and represent an important tool for etiologic diagnosis and prenatal and pre-conception genetic counseling.OBJETIVO: Descrever a prevalencia das malformacoes encontradas nos fetos com trissomia dos cromossomos 13, 18 e 21, identificando as mais frequentes em cada condicao. METODOS: Estudo transversal retrospectivo, com analise dos casos de trissomias dos cromossomos 13, 18 e 21 que foram diagnosticados pelo cariotipo fetal obtido por amniocentese/cordocentese, entre outubro de 1994 e maio de 2014, em um Hospital de Ensino da regiao Sul do Brasil. Foram descritas as malformacoes identificadas no exame ultrassonografico morfologico e, posteriormente, confirmadas em exames do recem-nascido e/ou por necropsia fetal. Os resultados foram analisados por meio do teste de Fisher e da analise de variância (ANOVA). O nivel de significância empregado foi 5% (p=0,05). RESULTADOS: Em 840 exames realizados, foram diagnosticados 69 casos de trissomias; nove deles foram excluidos por desfecho ocorrido fora do Hospital de Clinicas de Porto Alegre ou prontuario incompleto, restando 60 casos (nove de trissomia do cromossomo 13, 26 do cromossomo 18 e 25 do cromossomo 21). As cardiopatias ocorreram, na maioria dos casos, nos tres grupos; a comunicacao interventricular foi mais prevalente, em 66,7% do grupo da trissomia 13. As anomalias gastrintestinais aconteceram mais no grupo da trissomia 18, principalmente a onfalocele (38,5%; p<0,01). As anomalias geniturinarias foram significativamente mais frequentes no grupo da trissomia 13 (pielectasia com 55,6% - p<0,01; genitalia ambigua com 33,3% - p=0,01). Defeitos do sistema nervoso central foram identificados em todos os casos de trissomia 13. Fendas faciais foram mais prevalentes dentre os fetos com trissomia 13 (66,7%; p<0,01). Malformacoes nas maos e nos pes tiveram diferencas estatisticas entre os grupos de trissomia. Os defeitos nas maos ocorreram em 50% dos casos de trissomia 18 e em 44,4% dos casos de 13 (p<0,01); pe torto congenito foi mais comum no grupo da trissomia 18, descrito em 46,2% dos fetos (p<0,01). As malformacoes foram identificadas em 50,9; 27,3 e 21,7% dos casos de trissomias 18, 13 e 21, respectivamente. CONCLUSAO: Muitas malformacoes identificadas na ultrassonografia sao sugestivas de trissomias e mostram-se ferramentas importantes para o diagnostico etiologico e aconselhamento genetico pre-natal e pre-concepcional.

Spleen rupture during labor

Background: A ruptured splenic artery aneurysm is rare but potentially fatal and has a greater chance of occurring during pregnancy. Case: A 38-year-old pregnant woman was admitted to hospital in labor and presented with dyspnea and hypovolemic shock during the expulsion stage. After delivery, a bedside ultrasound was performed and showed a large amount of free fluid in the abdominal cavity. The patient was submitted to an exploratory laparotomy, which found a ruptured splenic hilum, and anatomopathological examination confirmed a ruptured splenic artery aneurysm. Both mother and baby survived without sequelae. Conclusion: Ruptured aneurysm must be considered among the causes of hypovolemic shock in pregnancy, and early detection can reduce the morbidity and mortality of this event.

Fatores associados à mortalidade em recém-nascidos com gastrosquise

PURPOSE: To analyze the perinatal mortality rate in cases of gastroschisis and possible associated factors. METHODS: A retrospective cohort study was conducted between 1992 and 2012. All cases of gastroschisis born in Hospital de Clinicas de Porto Alegre (HCPA) during that period were included. The diagnosis of gastroschisis was obtained by morphological ultrasound examination or clinical examination at birth in prenatally unknown cases. The variables of birth (birthweight, gestational age and Apgar score, mode of delivery, type of gastroschisis and associated anomalies) and the surgical ones (type of surgical closure, reintervention and sepsis) were compared between surviving cases and deaths. The results of this comparison were analyzed according to the type of variable using parametric and non-parametric tests (Mann-Whitney or Students t-test, χ2 or Fishers exact test), with the level of significance set at 5% (p=0.05). RESULTS: Sixty-four newborns with gastroschisis were included, 59 of them (92.2%) diagnosed during the prenatal period. Twenty-six patients (40.6%) had only exposed intestines, classified as simple gastroschisis, 22 had exposure of the intestines and stomach (34.4%) and 16 had exposure of the intestine and other organs (25%), for a total of 38 cases of complex gastroschisis. Primary surgical repair was performed in 44 cases (68.8%). The mortality rate was 23.4% (15 deaths). Babies who died had significantly lower birth weight (p=0.001), gestational age (p=0.03) and Apgar score (p=0.03) than survivors. There was no difference in mode of delivery (p=0.8) and, with respect to gut contents, there was no difference between the cases of simple and complex gastroschisis (p=0.06). Mortality was significantly higher in patients with sepsis (p=0.008) and reintervention (p=0.001). CONCLUSION: in the present study, perinatal mortality due to gastroschisis seemed to depend mainly on prematurity, low birth weight, and surgical complications.