Ana Maria Kondo Igai

Avaliação da vitalidade fetal e resultados perinatais em gestações após gastroplastia com derivação em Y de Roux

OBJETIVO: Analisar os resultados da avaliacao da vitalidade fetal de gestacoes apos gastroplastia com derivacao em Y de Roux, verificando as complicacoes maternas e os resultados perinatais. METODOS: No periodo de julho de 2001 a setembro de 2009, foram analisados, retrospectivamente, dados de prontuario de pacientes com gestacao apos gastroplastia com derivacao em Y de Roux, acompanhadas em pre-natal especializado e cujo parto foi realizado na instituicao. Foram analisados os exames de avaliacao da vitalidade fetal (cardiotocografia, perfil biofisico fetal e dopplervelocimetria das arterias umbilicais) realizada na semana anterior ao parto. As variaveis maternas investigadas foram: dados demograficos, complicacoes clinicas maternas, tipo de parto, complicacoes no parto e pos-parto, exames hematimetricos maternos e resultados perinatais. RESULTADOS: Trinta gestacoes apos gastroplastia com derivacao em Y de Roux foram identificadas e 24 delas foram submetidas a avaliacao da vitalidade fetal. Todas as pacientes apresentaram resultados normais na cardiotocografia, no perfil biofisico fetal e na dopplervelocimetria das arterias umbilicais. Houve um caso de oligohidrâmnio. A principal complicacao observada foi anemia materna (Hb < 11,0 g/dL, 86,7%). A cesarea foi realizada em 21 pacientes (70%). As complicacoes do parto incluiram um caso de aderencias, um de hematoma e infeccao de parede e um de histerectomia pos-parto por miomatose e atonia uterina. A proporcao de recem-nascidos pequenos para a idade gestacional foi de 23,3%. CONCLUSAO: Nao houve comprometimento do bem-estar fetal em gestacoes apos gastroplastia com derivacao em Y de Roux. A principal complicacao materna foi a anemia e essas mulheres requerem aconselhamento nutricional especifico com ampla avaliacao das deficiencias de micronutrientes desde o inicio da gravidez.

Resultados maternos e perinatais em gestações complicadas por doenças falciformes

PURPOSE: the aim of this study was to describe perinatal and maternal outcomes of pregnancies complicated by sickle cell disease (SCD), comparing to pregnancies of women with sickle cell trait (SCT). METHODS: this was a retrospective cohort study, covering the period from March 2001 to April 2008, which included all pregnant women with SCD (n=42) followed up at a university hospital in the Southeast region of Brazil. The maternal and perinatal outcomes were compared to those of pregnant women with SCT (n=56) who were followed up at the same service. RESULTS:SCD-SS was diagnosed in 42 (82.4%) pregnant women and SC in 9 (17.6%). Mean (±SD) maternal age was significantly lower in the SCD group (26.0 years) compared to SCT women (28.7±7.1 years; p=0.018). The following maternal complications were more common among women with SCD in comparison to SCT: urinary tract infection (25.5 versus 8.9%; p=0.04), pneumonia (23.5 versus 1.8%; p=0.002), pulmonary hypertension (15.7 versus 0%; p=0.002), and blood transfusion during delivery or postpartum (33.3 versus 5.4%; p=0.001). Adverse perinatal outcome was more frequent in the SCD group compared to the SCT group: prematurity (49 versus 25%, p=0.01); mean gestational age at delivery (35.2 versus 37.9 weeks, p<0.001); fetal distress (56.9 versus 28.6%, p=0.006); birth weight <2,500 g (62.7 versus 17.9%, p<0.001); mean birth weight (2,183 versus 2,923 g, p<0.001), and small for gestational age infants (29.4 versus 10.7%, p=0.029). Two maternal deaths (3.9%) occurred in the group with SCD. CONCLUSION: Pregnant women with SCD are at greater risk for maternal morbidity and for adverse perinatal outcomes than women with SCT.

Acute chest syndrome in pregnant women with hemoglobin SC disease

discomfort, hypotension, and shortness of breath (oxygen saturation 90%). An emergency cesarean was performed. Placental abruption was detected, and a stillborn weighing 1,630 g was delivered. The laboratory test results showed hemoglobin electrophoresis of S 51%, C 47.5%, and F 1.5%, hemoglobin 8.4 g/dL, white blood cell count (WBCC) 34.3x10 9 /L, platelet count 142,000/mm 3 , alanine aminotransferase (ALT) 35 U/L, aspartate aminotransferase (AST) 54 U/L, total bilirubin 1.5 mg/dL, and lactate dehydrogenase (LDH) 791 U/L. The patient was transferred to the ICU immediately post-cesarean, where examination revealed that the uterus was contracted and without abnormal bleeding. At the fifth hour post-partum, she presented with bradycardia and hypotension. An intravenous infusion of vasoactive drugs and broad-spectrum antibiotics were administered. A red blood cell transfusion was performed. At the eighth hour post-partum, she was hemodynamically unstable, and echocardiography was used to diagnose diffuse hypokinesis of the right ventricle with dilatation of the right chambers. At the tenth hour post-cesarean, she presented with cardiovascular shock, bradycardia, hypotension, and cardiac arrest. The autopsy revealed bone marrow pulmonary emboli.

Avaliação da vitalidade fetal em gestações complicadas pela plaquetopenia materna moderada ou grave

PURPOSE To analyze the results of assessment of fetal well-being in pregnancies complicated by moderate or severe maternal thrombocytopenia. METHODS Data from April 2001 to July 2011 of 96 women with a diagnosis of thrombocytopenia in pregnancy were retrospectively analyzed. We analyzed the following tests performed during the antepartum period for fetal assessment: cardiotocography, fetal biophysical profile, amniotic fluid index and umbilical artery Doppler velocimetry. RESULTS A total of 96 pregnancies with the following diagnoses were analyzed: gestational thrombocytopenia (n=37, 38.5%) hypersplenism (n=32, 33.3%), immune thrombocytopenic purpura (ITP, n=14, 14.6%), secondary immune thrombocytopenia (n=6, 6.3%), bone marrow aplasia (n=3, 3.1%), and others (n=4, 4.1%). Cardiotocography showed normal results in 94% of cases, a fetal biophysical profile with an index of 8 or 10 in 96.9% and an amniotic fluid index >5.0 cm in 89.6%. Doppler umbilical artery velocimetry showed normal results in 96.9% of cases. In the analysis of the major groups of thrombocytopenia, the diagnosis of oligohydramnios was found to be significantly more frequent in the group with ITP (28.6%) compared to the other groups (gestational thrombocytopenia: 5.4% and hypersplenism: 9.4%, p=0.04). CONCLUSIONS This study indicates that in pregnancies complicated by moderate or severe maternal thrombocytopenia, even though the fetal well-being remains preserved in most cases, fetal surveillance is important in pregnant women with ITP, with emphasis on amniotic fluid volume evaluation due to its association with oligohydramnios.

Resultados maternos e perinatais em gestantes portadoras de leucemia

PURPOSE To describe the maternal and perinatal outcomes of pregnant women diagnosed with leukemia who were followed up for prenatal care and delivery at a university hospital. METHODS A retrospective study of the period from 2001 to 2011, which included 16 pregnant women with a diagnosis of leukemia followed by antenatal care specialists in hematological diseases and pregnancy. For acute leukemia diagnosed after the first trimester, the recommendation was to perform chemotherapy despite the current pregnancy. For chronic leukemia, patients who were controlled in hematological terms were maintained without medication during pregnancy, or chemotherapy was introduced after the first trimester. We analyzed the maternal and perinatal outcome. RESULTS Acute lymphoblastic leukemia (ALL) was diagnosed in five cases (31.3%), acute myeloid leukemia (AML) in two cases (12.5%) and chronic myeloid leukemia (CML) in nine cases (56.3%). Of the cases of acute leukemia, two (28.6%) were diagnosed in the first trimester, two (28.6%) in the second and three (42.9%) in the third. Two patients with ALL diagnosed in the first trimester opted for therapeutic abortion. Four patients with acute leukemia received chemotherapy during pregnancy, with a diagnosis established after the 20th week. In one case of ALL with a late diagnosis (30 weeks), chemotherapy was started after delivery. All pregnant women with acute leukemia developed anemia and thrombocytopenia, and four (57.1%) developed febrile neutropenia. Of nine pregnant women with CML, four were treated with imatinib mesylate when they became pregnant, with treatment being interrupted in the first trimester in three of them and in the second trimester in one. During pregnancy, three patients (33.3%) required no chemotherapy after discontinuation of imatinib, and six (66.7%) were treated with the following drugs: interferon (n=5) and/or hydroxyurea (n=3 ). In the group of pregnant women with CML, anemia occurred in four (44.4%) cases and thrombocytopenia in one (11.1%). The perinatal outcomes of pregnancies complicated by acute leukemia were as follows: mean gestational age at delivery was 32 weeks (standard deviation - SD=4.4) and the mean birth weight was 1476 g (SD=657 g), there were 2 (40.0%) perinatal deaths (a fetal one and a neonatal one). In pregnancies complicated by CML, the mean gestational age at delivery was 37.6 weeks (SD=1.1) and the mean birth weight was 2870 g (SD=516 g). There was no perinatal death and no fetal abnormality was detected. CONCLUSIONS Maternal and fetal morbidity is high in pregnancies complicated by acute leukemia. Whereas, in pregnancies complicated by CML, the maternal and fetal prognosis appears to be more favorable, with greater ease in management of complications.

Efeitos da anemia materna na cardiotocografia computadorizada e perfil biofísico fetal

PURPOSES To evaluate the influence of maternal hemoglobin (Hb) levels in the patterns of fetal heart rate (FHR) and in the fetal biophysical profile (FBP) in term gestations. METHODS Pregnant women with anemia (Hb<11.0 g/dL) were prospectively evaluated between the 36(th) and the 40(th) week of gestation, from January 2008 to March 2009. The Control Group was composed of term and healthy pregnant women, with normal values of hemoglobin (Hb>11,0 g/dL). Cases of anomalies or fetal growing restrictions were excluded. The FHR evaluation was performed by computerized cardiotocography (8002 System-Sonicaid), and by record analysis during 30 minutes of exam. The FBP was done in all the patients. Students, chi2 and Fishers exact tests were used, with 0.05 significance level. RESULTS The average of maternal Hb in the group with anemia (n=18) was 9.4 g/dL (DP=1.4 g/dL), and in the control group, 12.4 g/dL (DP=1.3 g/dL). There has been no significant mean differences between groups concerning the cardiotocography parameters, respectively: basal FHR(131.3 versus 133.7 bpm, p=0.5), FHR accelerations > 10b pm (7.9 versus 8.2, p=0.866), FHR accelerations > 15 bpm (5.2 versus. 5.4, p=0.9), episodes of high variation of the FHR (17.1 versus 15.5 min, p=0.5), episodes of variation of the FHR (4.4 versus 3.6 min, p=06), and short term variation (10.5 versus 10.9 ms, p=0.5). In both groups, all patients presented normal FBP. CONCLUSIONS This study suggests that light or moderate maternal anemia, without other maternal or fetal comorbidity, is not associated with abnormalities in the parameters of fetal biophysical profile and of the FHR analyzed by computerized cardiotocography.

Resultados gestacionais e trombofilias em mulheres com historia de obito fetal de repeticao

PURPOSE: To evaluate pregnancy outcome and thrombophilia frequency in women with recurrent fetal death. METHODS: Evaluation of obstetric outcomes in a retrospective cohort of pregnant women with recurrent stillbirth after the 20th week, from 2001 to 2013. Antithrombin activity, protein C and S activity, factor V Leiden, prothrombin gene mutation and antiphospholipid syndrome were analyzed. RESULTS: We included 20 patients who had recurrent fetal death. Thrombophilia were found in 11 of them, 7 diagnosed with antiphospholipid syndrome, 3 with protein S deficiency and 1 with prothrombin gene mutation. All of them were treated with subcutaneous heparin (unfractionated heparin or enoxaparina) and 14 of them with acetylsalicylic acid (AAS) during pregnancy. Obstetric complications occurred in 15 patients and included: intrauterine fetal growth restriction (25%), placenta previa (15%), reduced amniotic fluid index (25%), severe preeclampsia (10%), fetal distress (5%), and stillbirth (5%). The mean gestational age at delivery was 35.8±3.7 weeks and newborn weight averaged 2,417.3±666.2 g. CONCLUSION: Thrombophilia screening should be performed in all pregnant women with recurrent fetal death after the 20th week as a way to identify possible causal factors suitable for treatment.

Manejo clínico e obstétrico em gestantes portadoras de hepatite autoimune complicada pela plaquetopenia moderada ou grave

OBJECTIVE: To describe the management of prenatal care and delivery in patients bearing autoimmune hepatitis associated with moderate or severe thrombocytopenia. METHODS: This study was performed in a tertiary level university hospital. Thirteen pregnancies in ten patients diagnosed with autoimmune hepatitis, complicated by thrombocytopenia, were retrospectively analyzed. The inclusion criteria were as follows: clinical diagnosis of autoimmune hepatitis, moderate or severe thrombocytopenia (platelet count < 100 x 103/mm3), gestational age at birth over 22 weeks, and patient followed-up by a specialized team at the institution. The variables studied were: maternal age, parity, treatment regimen, platelet count, examinations for investigation of hepatic function, type of delivery, weight at birth, and gestational age at the time of delivery. RESULTS: The average maternal age was 24.5 years (SD = 5.3) and six (50%) occurred in nulliparous women. During pregnancy, monotherapy with prednisone was adopted in 11 cases (92%). According to the autoantibody profiles, seven pregnancies (58%) had the autoimmune hepatitis type I diagnosis, two pregnancies had type II (17%), and three pregnancies (25%) had cryptogenic chronic hepatitis (undetectable titers of autoantibodies). Portal hypertension was featured in 11 pregnancies (92%). The average gestational age at delivery was 36.9 weeks (SD = 1.5 weeks), with an average weight at birth of 2,446 g (SD = 655 g). Eight infants (67%) were small for gestational age. At the time of delivery, severe thrombocytopenia was featured in four cases (33%) and cesarean surgery was performed in seven cases (58%). Complications at delivery occurred in three cases (25%), one patient presented uterine atony, and two patients presented perineal bruising. There was no perinatal or maternal death. CONCLUSION: The complications of thrombocytopenic patients with autoimmune hepatitis are elevated; nevertheless, with appropriate attention and care, they can be resolved. The association between two severe pathologies appears to increase the risk of prematurity and fetal growth restriction, demanding specialized prenatal care, as well as surveillance of newborn well-being.

Clinical and obstetrical management of pregnant women with autoimmune hepatitis complicated by moderate or severe thrombocytopenia

OBJECTIVE To describe the management of prenatal care and delivery in patients bearing autoimmune hepatitis associated with moderate or severe thrombocytopenia. METHODS This study was performed in a tertiary level university hospital. Thirteen pregnancies in ten patients diagnosed with autoimmune hepatitis, complicated by thrombocytopenia, were retrospectively analyzed. The inclusion criteria were as follows: clinical diagnosis of autoimmune hepatitis, moderate or severe thrombocytopenia (platelet count < 100 x 103/mm3), gestational age at birth over 22 weeks, and patient followed-up by a specialized team at the institution. The variables studied were: maternal age, parity, treatment regimen, platelet count, examinations for investigation of hepatic function, type of delivery, weight at birth, and gestational age at the time of delivery. RESULTS The average maternal age was 24.5 years (SD = 5.3) and six (50%) occurred in nulliparous women. During pregnancy, monotherapy with prednisone was adopted in 11 cases (92%). According to the autoantibody profiles, seven pregnancies (58%) had the autoimmune hepatitis type I diagnosis, two pregnancies had type II (17%), and three pregnancies (25%) had cryptogenic chronic hepatitis (undetectable titers of autoantibodies). Portal hypertension was featured in 11 pregnancies (92%). The average gestational age at delivery was 36.9 weeks (SD = 1.5 weeks), with an average weight at birth of 2,446 g (SD = 655 g). Eight infants (67%) were small for gestational age. At the time of delivery, severe thrombocytopenia was featured in four cases (33%) and cesarean surgery was performed in seven cases (58%). Complications at delivery occurred in three cases (25%), one patient presented uterine atony, and two patients presented perineal bruising. There was no perinatal or maternal death. CONCLUSION The complications of thrombocytopenic patients with autoimmune hepatitis are elevated; nevertheless, with appropriate attention and care, they can be resolved. The association between two severe pathologies appears to increase the risk of prematurity and fetal growth restriction, demanding specialized prenatal care, as well as surveillance of newborn well-being.

Complicações do parto e resultados perinatais em gestantes portadoras da doença de von Willebrand

OBJETIVO: Analisar as complicacoes maternas associadas ao parto e puerperio, bem como os resultados perinatais, em gestantes portadoras da doenca de von Willebrand. METODOS: Foram analisados os prontuarios de todas as gestantes com diagnostico de doenca de von Willebrand, cujo parto foi realizado nesta instituicao no periodo compreendido entre marco de 2001 e agosto de 2007. Foram investigadas caracteristicas relativas a via de parto, incidencia de complicacoes hemorragicas no parto e no puerperio imediato, perfil dos exames laboratoriais maternos e resultados perinatais. As variaveis foram estudadas descritivamente, calculando-se frequencias absolutas e relativas, medias, medianas e desvios padrao. RESULTADOS: Foram revisadas 13 gestacoes em oito pacientes portadoras da doenca. No periodo ocorreram 13.037 partos na instituicao, perfazendo incidencia de 0,1%. Seis pacientes (75%) apresentavam o tipo 1 da doenca, e duas (25%) o tipo 2. No terceiro trimestre, a media da atividade do fator VIIIc foi de 98,5%. A cesarea foi realizada em nove casos (69%), cuja anestesia foi do tipo raquidiana em sete casos. Como complicacao do parto, um caso evoluiu com descolamento prematuro da placenta e foi realizada a cesarea. Um caso apresentou sangramento no primeiro pos-parto, necessitando reposicao do fator VIII. Em dois casos foi realizada a reposicao profilatica do fator VIII antes da cesarea. A restricao do crescimento fetal ocorreu em cinco casos (38,5%). O peso dos RNs apresentou media de 2676 gramas e um caso (7,8%) apresentou Apgar de 1o minuto inferior a sete. CONCLUSAO: O parto em gestantes com diagnostico de doenca de von Willebrand tem evolucao favoravel quando cuidados sao tomados procurando oferecer assistencia especifica. O crescimento fetal deve ser monitorizado nessas gestantes.OBJECTIVE To study maternal complication associated to delivery and the puerperium period in pregnancies affected by von Willebrands disease. METHODS Chart data of all the pregnant women with diagnosis of von Willebrand disease were retrospectively reviewed. All cases with von Willebrands disease that had given birth at this institution, between March 2001 and August 2007, were analyzed. The following variables were investigated: mode of delivery, hemorrhage complications during delivery and postpartum, maternal blood exams and perinatal results. Variables were studied descriptively, using absolute and relative frequencies, means, medians and standard deviations. RESULTS 13 pregnancies of eight women with the disease were reviewed. During this sane period, there were 13,037 deliveries in the institution, resulting in an incidence of 0.1%. Six women (75%) were type 1 disease and, two (25%) were type 2. The last Factor VIIIc activity presented a mean value of 98.5%. A Cesarean section was performed in nine pregnancies, with epidural anesthesia in seven. Delivery complication occurred in two cases: one presented placental abruption and a Cesarean was performed. The other, presented postpartum hemorrhage in the first day and required reposition with factor VIII. Two cases received factor VIII before Cesarean section. Fetal growth restriction was detected in five pregnancies (38.5%). Mean birth weight was of 2676 grams and one case presented 1st minute Apgar score below seven. CONCLUSION Delivery in patients with von Willebrand disease has a favorable evolution when specific assistance is provided. In these pregnancies,fetal growth should be monitored.