Belmiro Gonçalves Pereira

Pregnancy after bariatric surgery: a current view of maternal, obstetrical and perinatal challenges.

With the increase in the number of bariatric surgeries being performed in women of childbearing age, physicians must have concerns regarding the safety of pregnancy after bariatric surgery. The aim of this review is to summarize the literature reporting on maternal, obstetrical and perinatal implications of pregnancy following BS.MethodsEnglish, Spanish and Portuguese-language articles were identified in a PUBMED search from 2005 to February 2011 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.ResultsThe studies show improved fertility and a reduced risk of gestational diabetes, pregnancy-induced hypertension and pre-eclampsia, macrosomia in pregnant women after bariatric surgery. The incidence of intrauterine growth restriction and small for gestational age are increased. No conclusions can be drawn concerning the risk for cesarean delivery and the best surgery-to-conception interval. Deficiencies in iron, vitamin A, vitamin B12, vitamin K, folate and calcium can result in maternal and fetal complications.ConclusionsPregnancy outcome of women who delivered after BS, as compared to obese populations, is better and safer and comparable to the general population. Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient’s individual requirements can prevent nutrition-related complications and improve maternal and fetal health.

Dysglycemias in pregnancy: from diagnosis to treatment. Brazilian consensus statement

There is an urgent need to find consensus on screening, diagnosing and treating all degrees of DYSGLYCEMIA that may occur during pregnancies in Brazil, considering that many cases of DYSGLYCEMIA in pregnant women are currently not diagnosed, leading to maternal and fetal complications. For this reason the Brazilian Diabetes Society (SBD) and the Brazilian Federation of Gynecology and Obstetrics Societies (FEBRASGO), got together to introduce this proposal. We present here a joint consensus regarding the standardization of clinical management for pregnant women with any degree of Dysglycemia, on the basis of current information, to improve medical assistance and to avoid related complications of Dysglycemia in pregnancy to the mother and the fetus. This consensus aims to standardize the diagnosis among general practitioners, endocrinologists and obstetricians allowing the dissemination of information in basic health units, public and private services, that are responsible for screening, diagnosing and treating disglycemic pregnant patients.

Association of anticardiolipin antibody and C677T in methylenetetrahydrofolate reductase mutation in women with recurrent spontaneous abortions: a new path to thrombophilia?

CONTEXT Recurrent spontaneous abortion (RSA) has been associated with venous thrombosis in the mother. Acquired and inherited thrombophilia factors are possible causes. OBJECTIVE To evaluate the association between thrombogenic factors and recurrent spontaneous abortion. TYPE OF STUDY Case-control study. SETTING Centro de Atenção Integral à Saúde da Mulher, Universidade Estadual de Campinas. METHODS 40 ml of blood was collected from 88 women attending an RSA clinic and 88 fertile women attending a family planning clinic, to evaluate the presence of acquired and inherited thrombophilia factors. Anticardiolipin antibodies (ACA), lupus anticoagulant and deficiencies of proteins C and S and antithrombin III were evaluated by enzyme-linked immunosorbent assay (ELISA), dilute Russell Viper Venom time (dRVVT), coagulometric and chromogenic methods. DNA was amplified by the polymerase chain reaction (PCR) to study factor V Leiden and G20210A mutations in the prothrombin gene and C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene. Data were analyzed using odds ratios and a regression model for age adjustment. Fishers exact test was used to evaluate statistical relationships between associated factors and RSA. RESULTS ACA was detected in 11 women with RSA and one fertile woman. Heterozygous C677T was detected in 59 women with RSA and 35 fertile women. Concomitant presence of ACA and C677T was found in eight women with RSA and no fertile women (p < 0.01). DISCUSSION The meaning of the association between C677T mutation in the MTHFR gene and ACA is still not clear. It is possible that an inherited factor that alone would not strongly predispose a woman to thrombosis could, when associated with an acquired factor, start the process and increase the likelihood of thrombosis expression. CONCLUSIONS ACA and C677T in the MTHFR gene are statistically associated with RSA. The association of these two conditions is a new finding in thrombogenic factors and RSA.

Colonização bacteriana do canal cervical em gestantes com trabalho de parto prematuro ou ruptura prematura de membranas

PURPOSE to study cervical colonization in women with preterm labor or premature rupture of membranes. METHODS two hundred and twelve pregnant women with preterm labor or premature rupture of membranes were studied. Two cervical samples from each woman were collected and bacterioscopy and culture were performed. Association of cervical microorganisms and urinary tract infection, chorioamnionitis, fetal stress, antibiotic use, prematurity, neonatal infection, and neonatal death were evaluated. RESULTS the prevalence of endocervical colonization was 14.2% (CI95%=9.5-18.9%), with similar results in preterm labor or premature rupture of membranes. Group B streptococcus was the most prevalent organism (9.4%). Other organisms isolated were Candida sp, Streptococcus sp, Streptococcus pneumoniae, Escherichia coli and Enterococcus sp. The most common findings of bacterioscopy were a reduced number of lactobacilli and a great number of leukocytes. Endocervical colonization was associated with a higher occurrence of urinary tract infection (23.8 versus 5.4%; p<0.01), early-onset neonatal infection (25.0 versus 7.3%; p<0.01) and neonatal mortality (two cases in colonized women; p<0.02) when compared with a negative culture of endocervical mucus. CONCLUSIONS this study showed high prevalence of endocervical colonization despite the use of a nonselective culture media. The main microorganism isolated was group B streptococcus, but other organisms were present in one third of the studied population. More studies are needed to evaluate the influence of endocervical colonization on obstetrical outcome and on neonatal infection and mortality.

Análise da Mortalidade Evitável de Mulheres em Idade Reprodutiva

Purpose: to evaluate the avoidable mortality among women in reproductive age, living in Campinas, SP, comparing two five-year periods: 1985-89 and 1990-94. Methods: death certificates of 3.086 women aged 10 to 49 years were studied, representing the total number of deaths during the period from January 1985 through December 1994. The criteria for avoidance were applied to these deaths using preventive, sanitary, early diagnosis and treatment, and mixed measures. The deaths were also classified as: with hardly avoidable causes, not well-defined causes and other causes. The specific mortality coefficient for each period of five years and the ratio between these coefficients were calculated. Results: there was a 20% increase in the avoidable mortality rate from the first to the second period. The main failure was observed among the group of avoidable causes by preventive and sanitary measures. The main increase in death causes by preventive measures resulted from AIDS. Among the causes of death avoidable by mixed measures, the increase of 50% in maternal mortality caused by abortion, as well as causes due to violence specially homicides, are emphasized. Conclusion: there was an increase in the proportion of avoidable death causes. Measures to prevent AIDS, abortion and to reduce violent deaths, specially homicides, should be political and social priorities in our Country.

Fetal cardiotocography before and after water aerobics during pregnancy

ObjectiveTo evaluate the effect of moderate aerobic physical activity in water on fetal cardiotocography patterns in sedentary pregnant women.MethodIn a non-randomized controlled trial, 133 previously sedentary pregnant women participated in multiple regular sessions of water aerobics in a heated swimming pool. Cardiotocography was performed for 20 minutes before and just after the oriented exercise. Cardiotocography patterns were analyzed pre- and post-exercise according to gestational age groups (24-27, 28-31, 32-35 and 36-40 weeks). Students t and Wilcoxon, and McNemar tests were used, respectively, to analyze numerical and categorical variables.ResultsNo significant variations were found between pre- and post-exercise values of fetal heart rate (FHR), number of fetal body movements (FM) or accelerations (A), FM/A ratio or the presence of decelerations. Variability in FHR was significantly higher following exercise only in pregnancies of 24-27 weeks.ConclusionsModerate physical activity in water was not associated with any significant alterations in fetal cardiotocography patterns, which suggests no adverse effect on the fetus.

Calcified abdominal pregnancy with eighteen years of evolution: case report

CONTEXT The lithopedion (calcified abdominal pregnancy) is a rare phenomenon and there are less than 300 cases reported in the medical literature. CASE REPORT In this case, a 40 year-old patient had had her only pregnancy 18 years earlier, without medical assistance since then. She came to our hospital with pain and tumoral mass of approximately 20 centimeters in diameter. Complementary examinations (abdominal X-ray, ultrasonography and computerized tomography) demonstrated an extra-uterine abdominal 31-week pregnancy with calcification areas. Exploratory laparotomy was performed, with extirpation of a well-conserved fetus with partially calcified ovular membranes.

Mortalidade materna na cidade de Campinas, no período de 1992 a 1994

Objetivos: identificar e investigar as causas de mortes maternas ocorridas no municipio de Campinas, no periodo de 1992 a 1994. Metodos: foram selecionadas 204 declaracoes de obito (DO), cuja causa de morte foi materna declarada e/ou presumivel, dentre as 1.032 DO de mulheres de 10 a 49 anos, correspondentes ao total de mortes nesta faixa etaria, ocorridas no periodo. Realizou-se investigacao complementar em prontuarios hospitalares, nos Servicos de Verificacao de Obito e em domicilios. Resultados: foram confirmadas 20 mortes maternas, o que correspondeu a uma razao de mortalidade materna (RMM) de 42,2 mortes por 100.000 nascidos vivos. As causas obstetricas diretas foram responsaveis por 85% dos obitos (17 casos). As complicacoes do aborto foram a principal causa de morte (7 casos), seguidas por hemorragias (4 casos), pre-eclâmpsia (3 casos) e infeccao puerperal (3 casos). Conclusoes: apesar do aparente progresso quanto a reducao de obitos maternos por sindromes hipertensivas na gravidez, que constituiam a primeira causa em periodos anteriores, nao houve reducao da RMM no periodo estudado. Passaram a predominar, entretanto, as causas relacionadas as complicacoes do aborto. A maior cobertura e eficiencia dos programas de planejamento familiar, alem da necessaria implantacao de real vigilância epidemiologica da morte materna, bem como protecao social mais eficiente a gravida, mae e recem-nascidos, podera reduzir a ocorrencia de morte materna e, em especial, as decorrentes de aborto.

Via de Parto e Resultados Perinatais em Gestantes Diabéticas

Objetivo: apresentar os resultados perinatais obtidos a partir da aplicacao de um protocolo de assistencia as gestantes diabeticas no Centro de Atencao Integral a Saude da Mulher (CAISM) da UNICAMP. Metodos: foram estudadas 90 gestantes diabeticas que iniciaram controle pre-natal na instituicao e foram submetidas a este protocolo. Foram comparadas com dois grupos controles de 180 gestantes cada: um constituido por gestantes pareadas por idade e numero de gestacoes (controle A) e outro por gestantes aleatoriamente selecionadas (controle B). Nos tres grupos foram avaliadas as seguintes variaveis: tipo de parto, indicacoes de cesarea, idade gestacional, indice de Apgar ao primeiro e quinto minuto de vida, peso e adequacao de peso para idade gestacional, morbidade e mortalidade perinatal. Para a analise estatistica utilizaram-se medias, desvio-padrao, os testes t de Student e do c2. Resultados: entre as gestantes diabeticas ocorreu maior incidencia de cesareas, recem-nascidos prematuros e grandes para a idade gestacional (GIG), assim como uma maior frequencia de patologias neonatais (hipoglicemia, hipocalcemia, hiperbilirrubinemia, desconforto respiratorio e depressao neonatal). A incidencia de Apgar <7 e a mortalidade perinatal foram significativamente maiores do que no grupo controle aleatoriamente selecionado, mas a diferenca desapareceu quando se comparou ao grupo controle pareado por idade e numero de gestacoes. Conclusoes: apesar de o protocolo visar um perfeito controle metabolico nas gestantes diabeticas, os resultados perinatais ainda sao desfavoraveis em comparacao as gestantes nao-diabeticas.

Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100g normal

PURPOSE to determine the prevalence of adverse gestational and neonatal outcomes in women with a positive screening and negative diagnosis for gestational diabetes mellitus (GDM). METHODS a retrospective descriptive cross-sectional study was conducted from 2000 to 2009 on 409 women with positive screening for GDM. The maternal variables studied were: age, body mass index, history of cesarean section, macrosomia or diabetes mellitus in a previous pregnancy and a personal or family history of diabetes mellitus and chronic arterial hypertension. The neonatal variables studied were: polyhydramnios, gestational age at birth, prematurity, cesarean delivery, large for gestational age (LGA) newborn, macrosomia, Apgar score, neonatal respiratory distress syndrome, hypoglycemia and hyperbilirubinemia. Uni- and multivariate descriptive analyses were first performed regarding risk factors and neonatal outcome and the prevalences and respective 95% confidence intervals were determined. RESULTS the route of delivery was cesarian section in 255 cases (62.3%), preterm birth occurred in 14.2% of cases and 19.3% of the newborns were LGA. The risk factors correlated with LGA newborns were overweight or obesity, maternal age and a history of macrosomia in a previous pregnancy. CONCLUSIONS a high rate of LGA newborns was observed in the population with positive risk factors or altered fasting glycemia on the occasion of the first prenatal visit, even when the glycemia curve was normal, with cesarean rates above those habitually observed in populations considered to be of low risk. Pregnant women with these characteristics represent a differential group.OBJETIVO: avaliar a frequencia de resultados gestacionais e neonatais desfavoraveis em mulheres com rastreamento positivo e diagnostico negativo para diabetes mellitus gestacional. METODOS: trata-se de um estudo de corte transversal, retrospectivo e descritivo realizado entre 2000 e 2009. Foram incluidas no estudo 409 gestantes com rastreamento positivo para diabetes mellitus. As variaveis estudadas foram: maternas (idade, indice de massa corporea, antecedente de cesarea, macrossomia ou diabetes mellitus em gestacao anterior, antecedente pessoal e familiar de diabetes mellitus e hipertensao arterial cronica) e neonatais (poli-hidrâmnio, idade gestacional por ocasiao do parto, prematuridade, cesarea, recem-nascido (RN) grande para idade gestacional (GIG), macrossomia, indice de Apgar, sindrome do desconforto respiratorio, hipoglicemia e hiperbilirrubinemia). Inicialmente foi realizada analise descrita uni e multivariada para a ocorrencia de fatores de risco e desfechos neonatais. Foram descritas as prevalencias e respectivos intervalos de confianca a 95%. RESULTADOS: em 255 (62,3%) das gestantes a via de parto foi cesarea. Quanto aos resultados perinatais, 14,2% dos RN foram classificados como prematuros e 19,3% dos RN como GIG. Os fatores de risco correlacionados com RN GIG foram sobrepeso ou obesidade, idade materna e antecedente de macrossomia em gestacao anterior. CONCLUSOES: na populacao com fatores de risco positivos ou glicemia de jejum alterada na primeira consulta do pre-natal, mesmo com curva glicemica normal observa-se taxa de RN GIG elevada assim como indice de cesarea acima dos valores habitualmente presentes nas populacoes consideradas de baixo risco. As gravidas com tais caracteristicas constituem um grupo diferenciado.