Carlos Noronha Neto

Pre-eclampsia treatment according to scientific evidence

As sindromes hipertensivas na gestacao merecem especial destaque no cenario da saude publica mundial. Atualmente, respondem como terceira causa de mortalidade materna no mundo e primeira no Brasil. Do ponto de vista pratico, a pre-eclâmpsia continua sendo uma sindrome que leva a graves repercussoes maternas e fetais, conhecendo-se ainda pouco sobre sua etiologia. Atualmente, tem-se discutido a melhor terapeutica para os quadros de pre-eclâmpsia em diversos momentos do ciclo gravidico-puerperal, visando sempre a reducao de altos indices de morbimortalidade materna e fetal. O parto, considerando-se a fisiopatologia do evento, representa a melhor forma de tratamento. O uso de sulfato de magnesio e recomendado em todos os casos de pre-eclâmpsia grave e eclâmpsia para prevencao e tratamento das crises convulsivas. Da mesma forma, o tratamento dos picos hipertensivos e recomendado. Hidralazina, nifedipina e labetalol tem sido as drogas mais utilizadas com essa finalidade, mas seu uso dependente da familiaridade do medico assistente. A corticoterapia antenatal esta indicada sempre que existe risco iminente de prematuridade entre a 24o e 34o semana. Em contrapartida, nao ha evidencias suficientes para recomendar repouso e administracao de expansores plasmaticos de rotina, assim como ha necessidade urgente de ensaios clinicos randomizados para determinar se o tratamento anti-hipertensivo de manutencao nas gestantes apresenta beneficios ou riscos para maes e fetos, em todas as formas clinicas da doenca, em particular nos casos de pre-eclâmpsia pura.Hypertensive disorders in pregnancy deserve special attention in the setting of global public health. Currently, they represent the third cause of maternal mortality in the world and first in Brazil. From a practical standpoint, pre-eclampsia remains a syndrome that leads to serious repercussions on maternal and fetal mortality and its etiology is not well known. Currently, the best treatment for forms of pre-eclampsia is being discussed at different times in pregnancy and puerperium, with the objective to reduce the high rates of maternal and fetal morbidity and mortality. Considering the pathophysiology of the event, anticipation of delivery is the best treatment for pre-eclampsia. The use of magnesium sulfate is recommended in all cases of severe pre-eclampsia and eclampsia for prevention and treatment of seizures. Likewise, treatment of hypertensive crises is recommended. Hydralazine, nifedipine and labetalol have been the most commonly used drugs for this purpose, but their use depends on the familiarity of the treating physician. Antenatal corticoid therapy is indicated whenever there is an imminent risk of preterm delivery between 24 and 34 weeks. In contrast, there is insufficient evidence to recommend bed rest and routine plasma volume expansion, and there is an urgent need for randomized clinical trials to determine whether maintenance antihypertensive treatment in pregnant women has benefits or risks for mothers and fetuses in all clinical forms of disease, particularly in cases of pure pre-eclampsia.

Abbreviated (12-hour) versus traditional (24-hour) postpartum magnesium sulfate therapy in severe pre-eclampsia

To compare the use of magnesium sulfate for 12 hours versus 24 hours in postpartum women with stable severe pre‐eclampsia.

Risk factors for episiotomy: a case-control study

Objective: obtaining information on the factors associated with episiotomy will be useful in sensitizing professionals to the need to minimize its incidence. Therefore, the objective of this study was to evaluate risk factors for episiotomy in pregnant women who had undergone vaginal delivery at a university maternity hospital in northeastern Brazil. Methods: a case-control study was conducted with pregnant women submitted to episiotomy (cases) and pregnant women not submitted to episiotomy (controls) between March 2009 and July 2010 at the Professor Fernando Figueira Integral Medicine Institute (IMIP) in Recife, Brazil, in a ratio of 1 case to 2 controls. The study variables consisted of: whether episiotomy was performed, demographic, obstetric and fetal characteristics (primiparity, analgesia, instrumental delivery, fetal distress, etc.), external factors (day and time of delivery, professional attending delivery) and factors directly related to delivery. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated. Multivariate analysis was performed to determine the adjusted risk of episiotomy. Results: a total of 522 women (173 cases and 349 controls) were included. It was found that deliveries with episiotomy were more likely to have been attended by staff physicians (OR = 1.88; 95%CI: 1.01 - 3.48), to have required forceps (OR = 12.31; 95%CI: 4.9 - 30.1) and to have occurred in primiparas (OR = 4.24; 95%CI: 2.61 - 6.89). The likelihood of a nurse having attended the delivery with episiotomy was significantly lower (OR = 0.29; 95%CI: 0.16 - 0.55). Conclusion: episiotomy was found to be strongly associated with deliveries attended by staff physicians, with primiparity, and with instrumental delivery, and was less common in deliveries attended by nurses.

Fatores associados à indução do parto em gestantes com óbito fetal após a 20ª semana

OBJECTIVES: to determine the factors associated with induced delivery in pregnant women carrying a dead fetus. METHODS: a cross-sectional study with 258 pregnant women past the 20th week of gestation diagnosed by ultrasound as carrying a dead fetus, between January 2005 and December 2008, at the Hospital Barao de Lucena maternity hospital, in Recife, Brazil. Socio-demographic characteristics, causes and types of fetal death, prior obstetric data and characteristics of birth were the variables studied. The chi-square test, Fishers exact test and Students t test were used. The rate of prevalence was calculated and multiple logistic regression was carried out. The level of significance was 5%. RESULTS: birth was induced in 83 (32.2%) of the pregnant women. Following multivariate analysis, it was found that a gestational age of over 40 weeks (OR= 126.5; CI95%= 3.83-4,201.5) and late fetal death (OR= 6.86; CI95%= 2.55-18.47) were the risk factors that continued to be associated with induced delivery. Caesarian section (OR= 0.02; CI95%= 0.004-0.09), funiculopathy (OR= 0.12; CI95%= 0.02-0.68), having had one or more previous pregnancies (OR= 0.34; CI95%= 0.14-0.81) and one or more previous caesarian sections (OR= 0.16; IC95%= 0.04-0.71) were negatively associated with induced delivery. CONCLUSIONS: a gestational age of over 40 weeks and late fetal death are the risk factors that could be associated with induced delivery in pregnant women carrying a dead fetus.

P99 Clinical complications in patients with near miss criteria admitted at an obstetric intensive care unit in Pernambuco, Brazil: preliminary result

Objectives: Describe the major clinic complications in patient with near miss criteria who were admitted at the maternal intensive care unit from Pernambuco State, Northeast Brazil. Methods: A cross-sectional study was conducted including 100 women with diagnosis of severe maternal morbidity admitted at an obstetrical intensive care unit in Pernambuco, Brazil. The main previous complications were analyzed. Univariable analysis was performed with frequency distribution tables and measures of central tendency and dispersion. Results: From all the patients analyzed 23.9% lived in Recife, 65.9% were African American, 85.6% were admitted at the hospital during pregnancy, 44.7% were primigravid and almost all women (94.5%) attended a prenatal care. The major complication found was pre-eclampsia (72.5%) while eclampsia occurred in 6.6% of women. There were also found cases of hemorrhage (12.6), puerperal infection (6.6%), embolic events (3.0%), respiratory insufficiency (4.2%) and congestive cardiac failure (3.6%). Conclusions: The major complications related to maternal morbidity found in this study is in agreement with current literature.