Carlos Augusto Alencar Júnior

Differences in Neonatal Outcome in Fetuses with Absent versus Reverse End-Diastolic Flow in Umbilical Artery Doppler

Objectives: It was the aim of this study to evaluate differences in the prognosis of fetuses with absent (AED) and reverse end-diastolic (RED) flow in the umbilical artery based on neonatal outcomes. Methods: We performed a cross-sectional study based on the records of 143 patients attending at Assis Chateaubriand Teaching Maternity between 1 January 1999 and 31 December 2005. Patients were classified according to diagnosis as having either fetal centralization (FC), AED or RED. Obstetrical findings and perinatal outcomes were compared for the 3 groups and between AED and RED by Fisher’s exact test. Perinatal outcomes were analyzed quantitatively with logistic or multinomial regression. Odds ratios were calculated for significant risk factors. Results: There was a statistically significant difference in gestational age at diagnosis, Apgar scores at 1 and 5 min, Capurro score, use of surfactant and mechanical ventilation, admission to the neonatal intensive care unit, perinatal and neonatal death. When comparing RED with AED, the odds of neonatal intensive care unit admission, mechanical ventilation, use of surfactant, neonatal mortality and perinatal mortality were 3.2, 1.4, 1.0, 5.1 and 5.3 times higher for RED. Only perinatal mortality kept statistically significant with odds of 5.2 (p = 0.043) when adjusted by gestational age (multivariate analysis). Conclusion: The incidence of perinatal mortality was observed to increase with the severity of Doppler findings, with significant differences between the AED and RED groups.

Mortalidade materna por hipertensão: índice e análise de suas características em uma maternidade-escola

OBJETIVO: estudar a mortalidade materna por hipertensao na gestacao, estimando a razao de mortalidade e o perfil das pacientes que foram a obito por esta causa. METODOS: estudo retrospectivo dos obitos maternos devidos a hipertensao ocorridos na Maternidade-Escola Assis Chateaubriand da Universidade Federal do Ceara - MEAC/UFC, no periodo de 1981 a 2003. Foram avaliadas as razoes de mortalidade materna geral (RMM) e especifica para hipertensao e, nesta populacao de hipertensas, os dados epidemiologicos e clinicos. RESULTADOS: registraram-se 296 casos de obitos maternos e 184.672 nascidos vivos (NV), resultando em RMM de 160,28/100.000 NV. A causa de obito mais frequente foi hipertensao (41,2%), com 122 casos e media anual de 5,3 obitos e RMM para hipertensao de 60,10/100.000 NV. Analisando-se o grupo de mortes por hipertensao verificou-se que a idade materna variou de 13 a 42 anos, com media de 26 anos. A maioria das pacientes originou-se do interior do estado. As mortes aconteceram principalmente nas primeiras 24 horas apos a admissao hospitalar (50,9%). Houve predominio de mortes em primigestas (40,3%) e na faixa entre 31 e 38 semanas (48,2%). A eclâmpsia ocorreu em 73 pacientes (64,1%), sendo mais prevalente durante a gestacao (53,4%). Aconteceram 101 obitos no periodo puerperal. Houve predominio de cesarea (62,3%) e de anestesia geral (45,1%). A assistencia pre-natal nao foi realizada em 61,4% das pacientes. CONCLUSOES: as razoes de mortalidade materna geral e por hipertensao foram elevadas, sendo a hipertensao a principal causa de obito materno em nossa maternidade.

Avaliação ultra-sonográfica da hidrocefalia fetal: associação com mortalidade perinatal

Purpose: to evaluate the ultrasonographic parameters associated with perinatal mortality increase in cases of fetal hydrocephalus. Method: 45 cases of fetal hydrocephalus were followed-up between January 1996 and December 1999. Fetal hydrocephalus was diagnosed when the ratio of lateral ventricles and the corresponding cerebral hemispheres was above 0.35 or when the measurement of the atrium of the lateral ventricles was above 10 mm. In all examinations the type of hydrocephalus, severity, symmetry, evolution and time of diagnosis were defined. The patients were submitted to morphologic ultrasound in the search of other anatomical abnormalities. The amniotic fluid index and fetal deaths were registered. The main ultrasonographic findings were correlated with perinatal mortality. For statistical analysis, c2 test and exact Fisher test were used. The value of p<0,05 was considered to be significant. Results: a total of 20 deaths were observed (44.4%), 6 occurred intra-uterus and 14 in the neonatal period. The diagnosis of hydrocephalus was established at a mean gestational age of 29 weeks. There was no association between perinatal mortality and alterations in the amniotic fluid volume, time of diagnosis, symmetry and type of hydrocephalus and the presence of other intra- or extracranial anomalies. On the other hand, the severity of the disease was associated significantly with perinatal death (p<0.0001). Conclusion: among all the analyzed ultrasonographic parameters, only the severity of hydrocephalus presented statistical association with perinatal death.

Estudo Comparativo dos Resultados Maternos e Perinatais entre Pacientes com Diabetes Pré-gestacional Tipo I e Tipo II

Purpose: to evaluate the evolution of gestation, metabolic control and perinatal outcome of pregestational diabetic patients and to perform a comparative study of the results of patients with insulin-dependent diabetes (type I) and non-insulin-dependent diabetes (type II). Methods: retrospective analysis of 57 pregestational diabetic woman charts who began a prenatal follow-up in the Service of Maternofetal Medicine of the Maternidade-Escola Assis Chateaubriand of the Universidade Federal do Ceara, in the period from January 1995 to December 1998. The 57 pregnant women included in the study were divided into groups: the first, composed of 28 patients with insulin-dependent diabetes (type I), and the second with 29 pregnant women with non-insulin-dependent diabetes (type II), controlled with diet or with oral hypoglycemics before pregnancy. Results: there was no statistically significant difference between the two groups in relation to the need of hospitalization for glycemia control (39.2% x 27.5%) and maternal complications, such as: chronic arterial hypertension (14.2% x 27.5%), pregnancy-induced hypertension (14.2% x 17.2%), premature rupture of membranes (3.5% x 10.3%), urinary tract infection (10.7% x 6.8%), and preterm labor (3.5% x 6.8%). However, episodes of maternal hypoglycemia were more frequent among insulin-dependent patients (35.7% x 3.4%). The perinatal results were similar. We observed a great number of congenital anomalies and increased perinatal morbidity and mortality. Conclusion: there was no difference in the incidence of obstetric and clinical complications between insulin-dependent and non-insulin-dependent patients, except for maternal hypoglycemia.

Uso de misoprostol retal para indução do parto em gestantes com amniorrexe prematura: ensaio clínico fase II

PURPOSE: to investigate whether rectally administered misoprostol is an effective method for induction of labor in patients with premature ruptured membranes at term. METHODS: a pilot trial was conducted, enrolling 32 women with alive, singleton, cephalic fetus and ruptured membranes between 36 and 41 weeks of pregnancy, with Bishop score 18 h received antibiotics (crystalline penicillin) for prophylaxis of streptococcal infeccion. Outcomes included time from induction to labor and induction to delivery, incidence of tachysystole, mode of delivery, incidence of chorioamnionitis and neonatal outcome. Statistical analysis was performed using the public domain software Epi-Info 2002. Means and standard deviations were calculated, as well as frequency distributions. Survival analysis was performed to determine percent of deliveries according to time (hours) since the administration of the first tablet. RESULTS: the mean (±SD) induction-to-labor and induction-to-delivery intervals were 299.8±199.9 and 681±340.5 min, respectively. The frequency of tachysystole was 9.4%. About 72% of patients achieved vaginal delivery. Chorioamnionitis was diagnosed in 12.5% of the patients. Median Apgar scores at 1st and 5th min were 8 and 9, respectively. There was no case of Apgar <7 at the 5th min. Neonatal sepsis occurred in 12.5% of the neonates. CONCLUSION: induction of labor with rectal misoprostol in the setting of premature rupture of membranes was effective, with 72% of vaginal deliveries and a low rate of chorioamnionitis. These findings must be confirmed by large randomized controlled trials.

Predictor parameters of neonatal death in gestations with absent or reverse end-diastolic flow in the umbilical artery doppler velocimetry.

PURPOSE To evaluate the antenatal and postnatal risk factors of neonatal death in pregnancies with absent (DZ) or reverse (DR) end-diastolic flow in the umbilical artery. METHODS A cross-sectional retrospective study based on data from 48 medical records of singleton pregnancies with DZ or DR, and gestational age of 24 to 34 weeks, at a maternity in the Brazilian Northeast. Mean age was 27.3 (SD: 7.9) years. Twenty (41.7%) patients were primiparas. Hypertensive disorders were found in 44 (91.7%) cases. Thirty-five women (72.9%) had DZ and 13 (27.1%) had DR. Univariate analysis was firstly done (Students t-test and Fishers exact test) correlating the parameters with the assessed outcome (neonatal death). Variables that showed significant association were included in the logistic regression model (Wald statistics). The level of significance was set at 5%. RESULTS The perinatal mortality rate was 64.6% (31/48). There were five stillbirths and 26 neonatal deaths. The mean gestational age at diagnosis was 27.9 (SD: 2.8) weeks. Deliveries before 24 hours after diagnosis occurred in 52.1% of the cases. Cesarean section was performed in 85.4% of the sample. The newborns weighed 975.9 g on average (SD: 457.5). Twenty-four (57.1%) presented Apgar scores below 7 in the first minute and 21.4% in the fifth minute. Gestational age at diagnosis, birth weight and Apgar of the first minute proved to be variables significantly related to neonatal death (p values were: 0.008, 0.004, and 0.020, respectively). The Odds Ratio was 6.6, 25.3 and 13.8 for neonatal death, when the diagnosis was established at the 28th week, weight was <1000 g and first minute Apgar score was <7, respectively. CONCLUSIONS Gestational age at diagnosis, birth weight and Apgar score at the first minute were factors that could predict neonatal death in pregnancies with DV or DR determined by umbilical artery Doppler velocimetry.

Baixas doses de misoprostol vaginal (12,5 versus 25 mcg) para indução do parto a termo

PURPOSE: to compare the effectiveness of low doses of vaginal misoprostol (12.5 versus 25 µg) for induction of labor. METHODS: a double-blind, randomized, controlled clinical trial was performed in Santa Casa de Misericordia de Sobral, from May 2005 to April 2006. Sixty-two term pregnant women, with intact membranes and with indication for labor induction, were included. They randomly received 25 µg (32) or 12.5 µg (30) of vaginal misoprostol each four hours, until the maximum of eight doses. Mode of delivery, time between induction and delivery, perinatal complications, and maternal side effects were studied. The control variables were maternal and gestational ages, parity and Bishop score. The statistical tests used were average calculations, shunting line-standards and Student t-test (numerical continuous variables), c2 (categorical variables) and Mann-Whitney test (discrete variables). RESULTS: the two groups, 12.5 and 25 µg, did not differ in relation to the interval of time between the induction onset and delivery (1524 versus 1212 min, p=0.333), in the frequency of vaginal delivery (70 versus 71.8%, p=0.720), Apgar scores below seven at the fifth minute (3,3 versus 6,25%, p=0.533) and tachysystole frequency (3.3 versus 9.3%, p=0.533). The average of total dose administered was significantly higher in the 25 µg group (40 versus 61.2 µg, p=0.03). CONCLUSIONS: vaginal misoprostol in the dose of 12.5 µg was efficient, with collateral effects similar, to the 25 µg of vaginal misoprostol, for induction of labor at term.

Doença de Wilson e Gravidez: Relato de Caso

Wilsons disease (hepatolenticular degeneration) is a rare autosomal recessive disorder that usually occurs between the first and third decades. The condition is characterized by excessive deposition of copper in the liver and brain. It is fatal if the diagnosis and treatment are not performed early in life. The authors describe one case of pregnancy and Wilsons disease, showing the good evolution of the patient, who used D-penicillamine until the seventh week of gestation, discontinuing thereafter until the 20th week of gestation. The mother evolved with no signs of clinic and obstetric problems. The newborn did not present any problem and was healthy in his first year of life.

Diagnóstico pré-natal da artrogripose múltipla congênita: relato de caso

A artrogripose multipla congenita e caracterizada pela presenca, ao nascimento, de multiplas contraturas articulares. O diagnostico pre-natal e dificil, existindo poucos relatos na literatura. Baseia-se, especialmente, na combinacao de acinesia fetal, posicao anormal dos membros, retardo de crescimento intra-uterino e polidrâmnio. Descrevemos um caso de artrogripose multipla congenita diagnosticado pela ultra-sonografia no terceiro trimestre gestacional. Os principais achados foram a ausencia de movimentacao fetal, polidrâmnio e concepto com retardo de crescimento intra-uterino, tipo misto, com acentuada diminuicao da circunferencia abdominal e toracica, implantacao baixa dos pavilhoes auriculares, micrognatia, flexao continua dos membros inferiores e superiores, rotacao interna dos femures e pe torto a direita.

Diagnóstico da restrição de crescimento fetal pela relação diâmetro transverso do cerebelo e circunferência abdominal

PURPOSE: to evaluate the validity of transverse cerebellar diameter (TCD)/abdominal circumference (AC) ratio in the diagnosis of fetal growth restriction (FGR), determining its best cutoff value and accuracy in symmetric and asymmetric FGR. METHOD: a prospective cross-sectional study, carried out in 250 pregnant women with singleton pregnancies, gestational age between 20 and 42 weeks, with ultrasound confirmation. The TCD measurement was obtained by placing the calipers at the outer margins of the cerebellum, after its localization in the posterior fossa, and slightly rotating the transducer below the plane of the thalami. The abdominal circumference was measured at the on junction of the left portal and umbilical veins. The best TCD/AC cutoff ratio was established by the receiver operator characteristic (ROC) curve. Neonates with TCD/AC ratio greater than the cutoff value were diagnosed as having FGR. We classified as gold standard for FGR the newborn infants who presented birth weight below the 10th percentile. Neonates showing FGR and Rohrer ponderal index between 2.2 and 3 were labeled as symmetric and below 2.2, asymmetric. RESULTS: the cutoff value calculated by the ROC curve for TCD/AC ratio was 16.15. The sensitivity, specificity, accuracy, positive and negative predictive values, and likelihood ratio for positive and negative tests were 77.4, 82.6, 38.7, 96.3, 82, 4.5 and 3.7%, respectively. In the symmetric FGR, sensitivity and specificity were 80.8 and 81.7%, respectively. In the asymmetric FGR, sensitivity and specificity were 60 and 75%, respectively. CONCLUSION: TCD/AC ratio is an effective method in symmetric and asymmetric FGR diagnosis.