Antonio Henriques Franca Neto

Oncological repercussions of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine disorder that has been associated with insulin resistance and metabolic syndrome. Evidence has suggested that PCOS may be associated with the appearance of certain types of cancer, particularly endometrial, ovarian and breast cancer. The objective of this review was to collect further evidence of these correlations and to identify their possible mechanisms.

A exposição fetal à cabergolina em mulheres com hiperprolactinemia promove riscos

Recente e interessante estudo observacional prospectivo1 conduzido por Colao et al. (2008) analisou a evolução de 329 gestações em mulheres tratadas com cabergolina desde 1994. C o nstataram 258 (78%) nascimento s e 71 (22%) abortos. Entre os 258 nascimentos, 250 (97%) foram nativivos, quatro (2%) natimorto s e em relação aos casos restantes não havia referências. Dos 250 nativivos, 193 (77%) tinham idade gestacional superior a 37 semanas, enquanto em 45 (18%) a idade gestacional era inferior a 37 semanas. No tocante ao peso, 62% dos recém-nascidos exibiram valores entre 3Kg 4 kg. Anormalidades neonatais foram constatadas em 23 (9%) dos recém nascidos, porém sem qualquer padrão, tanto no tipo como na severidade. O s autores concluíram que a exposição fetal à cabergolina no início da gestação não induz a qualquer risco de aborto, parto prematuro ou malformação fetal. Comentário A hiperprolactinemia representa condição freqüente na prática clínica, acometendo 20-30% das jovens com amenorréia secundária e refletindo uma alteração no eixo hipotalâmico -hipofisário. C aracteriza-se pelo aumento persistente da prolactina sérica, decorrente de causas fisiológicas como gravidez, lactação, estímulo mamário, estresse, exercícios, uso de fármacos (antidepressivos, hipotensores, antipsicó ticos) e causas pato lógicas como tumores hipofisários, lesões hipotalâmicas, hipotireoidismo primário e insuficiência renal crônica2. O aumento da prolactina pode promover quadro de hipogonadismo em função da diminuição da liberação do GnRH, com conseqüente redução nos pulsos de LH e FSH; dessa forma, a depender da severidade da hiperprolactinemia, podem surgir alterações menstruais (oligo e amenorréia), redução da densidade mineral óssea, galactorréia e infertilidade. Nos casos de prolactinomas, além das repercussões mencionadas, podem ocorrer outros sintomas decorrentes de fenômenos compressivos, como cefaléia, perturbações visuais e até hipopituitarismo. O s agonistas dopaminérgicos bromoergocriptina e cabergolina – são o s fármaco s indicados para tratar os quadro s de hiperprolactinemia. Nos casos de infertilidade conseqüentes à hiperprolactinemia, os ago nistas dopaminérgico s são freqüentemente prescritos para reduzir as concentrações séricas de prolactina, o que permite corrigir desde sutis disfunções lúteas até quadros de anovulação crônica. O s estudo s clínicos revelam que a cabergolina, apesar de seu maior custo, é mais eficaz e apresenta meno s efeitos co laterais do que a bromoercocriptina3; de fato , ao se comparar as taxas de gestação nas po r tadoras de microprolactinomas usuárias de cabergolina e bromoergocriptina, constatou-se nítida superioridade da cabergolina (83% contra 58% de gestações). De forma geral, tanto a cabergo lina quanto a bromoergocriptina são usualmente descontinuadas após a confirmação da gestação; no entanto, há situações, como nos caso s de crescimento dos prolactinomas durante a gravidez que se impõe o uso dos agonistas dopaminérgicos. Nesses casos, no entanto, as evidências desvelavam que a bromoercocriptina poderia ser mantida e ser a primeira escolha na gestação; tal fato se apoiava na análise de 1.410 gestações em usuárias desse agonista dopaminérgico, em que não se tinha evidenciado qualquer aumento no risco de malformações congênitas, abortos espontâneos, nem de alterações no desenvolv imento psicomotor de crianças acompanhadas até nove anos4. No to cante à cabergolina, apesar de ela ser usada desde a década de 90, os estudos pertinentes à sua segurança relacionada à exposição materna fetal ainda eram limitados e controversos5. Diante disso, emergia uma questão: afinal, cabergolina poderia ser usada durante a gestação? O s resultados do estudo de Colao et al., em 2008, contribuem de forma significativa para esclarecer esta questão e permite emitir uma mensagem final para o s clínico s: Frente às prolactinomas que crescem durante a gestação, além da bromoergocriptina, a cabergolina passa a representar uma alternativa não só segura para o concepto e evolução da gestação, mas de alta eficácia, po is estudos anteriores em mulheres não grávidas já mostravam mais de 50% na redução do vo lume de macroprolactinomas em 96% de suas usuárias 2.

Thigh Measurement and Adiposity Fetal Accumulation: A Cohort Study [7R]

INTRODUCTION: The evaluation of the thigh measurement and fetal adipose tissue accumulation has been used to supplement fetal weight as a way to evaluate the muscular and subcutaneous compartments. To evaluate the accumulation and the factors associated with fetal adiposity. METHODS: Cohort study with 200 pregnant women followed in primary care units. The fetal adiposity was assessed by ultrasound, with 28 and 36 weeks of pregnancy, as well as anthropometry, the sociodemographic and obstetric aspects. The results were analyzed using the Epi-Info 7.0, with 5% significance level. RESULTS: The mean fetal thigh circumference (FTC) was 11.2 cm±1.1 and 17±1.8 cm, at 28 and 36 weeks, respectively (P<.0001). There was a positive correlation between the FTC and birth weight (r=0.60; 95% CI=0.49–0.69, P<.0001), the maternal circumference arm (r=0.15 95% CI=0.003–0.29, P<.05), the maternal waist circumference (r=0.34; 95% CI=0.19–0.48, P<.0001) and skin fold (r=0.19 95% CI=0.04–0.37, P=.01), triglyceride (r=0.20; 95% CI=0.04–0.35, P<.01) and insulinemia (r=0.24; 95% CI=0.07–0.39, P=.006). There was no correlation with fasting glucose (P=.13) and total cholesterol and fractions. CONCLUSION: The nutritional status and the accumulation of fat in pregnancy are positively associated with fetal thigh circumference, reflecting the nutritional status at birth.

Accumulation of Adiposity Fetal During Pregnancy: A Cohort Study [5P]

INTRODUCTION: Maternal nutritional status and gestational weight gain may impact on fetal growth and metabolic responses, increasing the accumulation of fetal adiposity and risk of future obesity. To evaluate the fetal adipose tissue accumulation during pregnancy and fetal and maternal factors associated. METHODS: Cohort study with 200 pregnant women. The fetal adiposity was assessed by ultrasound at 28 and 36 weeks gestation. Furthermore, maternal anthropometry was evaluated. RESULTS: The mean fetal abdominal circumference (FAC) and fetal thigh circumference were was 24±1.1 cm and 11.2±1.1 cm (28 weeks) and 32.2±1.6 cm and 17 cm±1.8 (36 weeks), respectively. Correlation between the FAC and the weight of the pregnant was observed in 28 and 36 weeks (P<.0001; P<.0001). There was a correlation between fetal visceral adiposity (FVA) at 28 weeks pregnant and the following variables: weight (P<.0001), waist circumference (P<.0001), weight gain (P<.001), fat subcutaneous (P<.0001), BMI (P<.0001), pre-pregnancy weight (P<.0001), visceral adiposity at 16 weeks (P<.0001) and after partum (P<.0001). At 36 weeks was also correlation between FVA and the following maternal variables: weight (P<.0001), waist circumference (P<.0001), weight gain (P<.0001), subcutaneous fat (P<.0001), BMI (P<.0001) and with pre-pregnancy weight (P<.0001). There was still at 28 weeks association fetal weight and subcutaneous fat of pregnant women (P=.02). CONCLUSION: The nutritional status and maternal weight gain influenced the accumulation of fetal adiposity during pregnancy.

Correlation Between Maternal Abdominal Adiposity and Anthropometric and Metabolic Profile During Pregnancy [29O]

INTRODUCTION: Excessive accumulation of central fat is associated with increased risk of developing cardiometabolic complications and has affected women in various stages of life, including pregnancy. To evaluate the evolution of maternal adiposity and factors associated with fat accumulation during pregnancy. METHODS: A cohort including 200 pregnant women evaluated at 16 weeks and the immediate postpartum period. Visceral adiposity (VA), subcutaneous (SA), anthropometric measurements and the metabolic profile were analyzed. For analysis, Epi-Info 7.0 was used. RESULTS: The VA averages were 5.2±1.3 cm at 16 weeks and 5.6±1.6 cm on postpartum (P=.007). At 16 weeks, there was a correlation between VA and weight (r=0.32, P<.0001), BMI (r=0.28, P<.0001), insulin (r=0.22, P=.004), and abdominal circumference (AC), arm and thigh (r=0.31, P<.0001; r=0.25, P<.0001, r=0.15, P=.03). In the immediate postpartum period, correlation was observed between VA and weight in the 16th and postpartum (r=0.37, P<.0001; r=0.31, P=.001), total cholesterol and glycated hemoglobin postpartum (r=0.22, P=.01; r=0.18, P=.03), insulin and LDL at 16 weeks (r=0.23, P=.01 and r=0.22, P=.01), AC and arm (r=0.43, P<.0001 and r=0.35, P<.0001) and CC at 16 weeks (r=0.20, P=.013). CONCLUSION: There was a correlation between abdominal fat and the main variables.

Clonidine Compared With Captopril for Severe Postpartum Hypertension [114]

INTRODUCTION: The choice of antihypertensives, both to control very high blood pressure episodes and to keep blood pressure stable, in postpartum women is controversial and requires further elucidation. OBJECTIVE: To evaluate the effectiveness and safety of clonidine compared with captopril for treating severe postpartum hypertension. METHODS: A randomized, drug-controlled, triple-blind clinical trial evaluating 90 postpartum women receiving 25 mg oral captopril or 0.1 mg clonidine for treatment of severe postpartum hypertension. Students t test, Pearson &khgr;2 test, and Fishers exact test were used in the statistical analysis. Repeated-measures analysis was performed. All P values were two-tailed and significance level was established at 5%. RESULTS: There were fewer very high blood pressure episodes during hospitalization, greater percentage reduction in systolic blood pressure, and fewer women requiring sodium nitroprusside in the clonidine group compared with the captopril group; however, these differences were not significant. The groups were similar regarding daily mean systolic blood pressure or diastolic blood pressure; however, on the third postpartum day, mean systolic blood pressure was lower in the clonidine compared with the captopril group. Although not statistically significant, adverse reactions were more common in the captopril group (28.8%) compared with the clonidine group (18.6%). CONCLUSION: Both clonidine and captopril represent safe, effective treatments for severe postpartum hypertension. We consider that antihypertensive treatment with clonidine may constitute a good alternative for avoiding postpartum very high blood pressure episodes with certain advantages such as a shorter hospital stay and lower treatment costs. In addition, clonidine can be used in women with acute renal injury for whom captopril is contraindicated.

Selective Episiotomy Compared With Implementation of a Nonepisiotomy Protocol: A Randomized Clinical Trial [113]

INTRODUCTION: An episiotomy rate of approximately 10% is recommended by the World Health Organization. However, there is no clinical evidence corroborating any indication of episiotomy, so it is not yet known whether it is in fact necessary in any context in modern obstetric practice. OBJECTIVE: To compare maternal and perinatal outcomes in women undergoing a protocol of not conducting episiotomy compared with selective episiotomy. METHODS: A randomized open clinical trial was conducted at Instituto de Medicina Integral Prof. Fernando Figueira, Brazil. Women in labor with term pregnancy with a live fetus in vertex cephalic presentation and maximum cervical dilation between 6 and 8 cm were included. Women with bleeding disorders of pregnancy and cesarean delivery indication were excluded. RESULTS: A total of 115 women were allocated for a protocol of not conducting episiotomy and 122 to a group in which episiotomy could be performed selectively. There was no difference between the two groups regarding maternal or perinatal outcomes. Episiotomy rate was similar (two cases in each group, 1.7% of total) as well as the duration of the second stage, frequency of perineal lacerations, and blood loss at delivery. CONCLUSION: A protocol of not conducting an episiotomy seems to be safe for mother and neonate and points to the need of investigating if there is in fact any indication of this procedure in current obstetrics practice. Further research should evaluate the need of episiotomies in the situations commonly described as indications, like a nonreassuring fetal heart rate, instrumental deliveries, macrosomia, shoulder dystocia, and prolonged second stage of labor.

Effect of Amniotic Fluid Volume on Perinatal and Maternal Outcomes in Women With Preterm Premature Rupture of Membranes [390].

INTRODUCTION: Amniotic fluid volume can have a role in predicting the prognosis in women with preterm premature rupture of membranes (PROM). OBJECTIVE: To describe the potential influence of amniotic fluid on perinatal and maternal outcome of preterm PROM. METHODS: An observational cohort study was conducted, including 86 pregnant women with preterm PROM and gestational age from 24 to 35 weeks. The amniotic fluid index (AFI) was used to measure amniotic fluid volume. Pregnant women were compared in two cutoffs: AFI less than 5.0 cm and greater than 5.0 cm and AFI less than 3.0 cm and greater than 3.0 cm. We excluded women with hypertensive disorders, diabetes mellitus, fetal malformations, and a diagnosis of infections at admission. &khgr;2 or Fishers exact test and simple linear regression analysis were used, adopting a significance level of 5%. We calculated the risk ratio (RR) and its confidence interval (CI) at 95%. RESULTS: When compared with AFI greater than 5.0 cm and less than 5.0 cm, greater general perinatal mortality was observed in the AFI less than 5-cm group (RR 3.02, 95% CI 1.10–8.3). However, in relation to the AFI less than 3.0 cm and greater than 3.0 cm, there was an increased risk of chorioamnionitis (36.7×10.7%, RR 3.42, 95% CI 1.40–8.34, P=.004), 1-minute Apgar score less than 7 (RR 2.09, 95% CI 1.19–3.68), neonatal sepsis (RR 3.6, 95% CI 1.01–13.3), and early mortality (RR 3.60, 95% CI 1.18–10.0). There was also statistically significant positive correlation between AFI and gestational age at delivery and birth weight and 1-minute and 5-minute Apgar scores. CONCLUSION: An amniotic fluid index less than 3.0 cm increases the risk for negative perinatal and maternal outcomes; the higher the AFI, the higher the gestational age at delivery.

Intrapartum Diagnosis and Treatment of Longitudinal Vaginal Septum

Longitudinal vaginal septum is a rare Müllerian malformation that may be associated with dyspareunia, dysmenorrhea, primary amenorrhea, and infertility. In this report, the authors present a case of longitudinal vaginal septum in a 15-year-old patient with a full-term pregnancy whose diagnosis was only made during labor following bidigital vaginal and speculum examination. Septoplasty was performed during the second stage of labor. Both mother and child progressed satisfactorily and were discharged from hospital in good health. Six months later, ultrasonography, hysterosalpingography, and hysteroscopy were carried out and no other associated abnormality was found.