Fabiana da Graça Krupa

Predictors of preterm birth

Objective: This is a systematic review to assess published scientific evidence on preterm birth predictors. Methods: An Internet search for predictors of preterm birth was performed and the evidence level of each method was evaluated. Results: There is strong evidence that preterm birth can be predicted using vaginal sonography to evaluate cervical characteristics, fetal fibronectin in cervicovaginal secretions and interleukin‐6 in amniotic fluid. There is consistent evidence that digital cervical examination is a weak predictor, and controversy regarding home uterine activity monitoring. There is scanty evidence about the predictive ability of maternal history and perceptions of symptoms since the study design fails to provide high evidence level. Conclusion: Cervical evaluation by vaginal sonography, fetal fibronectin and interleukin‐6 are the best methods for predicting preterm birth.

Systemic lupus erythematosus and pregnancy: clinical evolution, maternal and perinatal outcomes and placental findings

CONTEXT AND OBJECTIVE Systemic lupus erythematosus is a chronic disease that is more frequent in women of reproductive age. The relationship between lupus and pregnancy is problematic: maternal and fetal outcomes are worse than in the general population, and the management of flare-ups is difficult during this period. The aim here was to compare the outcomes of 76 pregnancies in 67 women with lupus, according to the occurrence or absence of flare-ups. DESIGN AND SETTING An observational cohort clinical study evaluating the evolution of pregnant women with lupus who were receiving care at the prenatal outpatient clinic, Centro de Atenção Integral à Saúde da Mulher, Universidade Estadual de Campinas (CAISM/Unicamp), between 1995 and 2002. METHODS Data were collected on a precoded form. The women were divided into two groups according to the occurrence or absence of flare-ups, as defined by the systemic lupus erythematosus disease activity index (SLEDAI). The presence or absence of flare-ups and renal involvement was considered to be the independent variable and the other results were dependent variables. RESULTS Flare-ups occurred in 85.3% of cases, and were most significant when there was renal involvement. This was related to greater numbers of women with preeclampsia and poor perinatal outcome. Intrauterine growth restriction was more common in the women with active disease. Placental weight was significantly lower in the women with renal involvement. CONCLUSIONS Flare-ups and renal involvement in lupus patients during pregnancy are associated with increased maternal and perinatal complications.

Misoprostol versus expectant management in premature rupture of membranes at term

Objective  To compare the effectiveness of immediate induction of labour with vaginal misoprostol versus expectant management for 24 hours followed by oxytocin induction in women with premature rupture of membranes at term (term PROM).

Progestin-only contraception prevents bone loss in postpartum breastfeeding women

BACKGROUND There are an increase in bone loss during the first 6 months postpartum and a complete recovery postweaning. A few studies of steroid contraceptive use during this period provide some evidence towards protection of bone loss with progestin-only contraceptive methods. OBJECTIVE The study was conducted to evaluate forearm bone mineral density (BMD) of breastfeeding postpartum women using nonhormonal and progestin-only contraceptive methods. STUDY DESIGN A prospective cohort study of postpartum women had an analysis performed at 6 months postpartum correlating BMD with contraceptive use. Forearm BMD was measured 7-10 days, 3 months and 6 months postpartum. Eighty-two women were analyzed, comparing nonhormonal (54) and progestin-only (28) contraceptive methods. Information about breastfeeding duration, amenorrhea and body mass index was collected. RESULTS Baseline characteristics of the study population showed no statistical differences between the groups. The median duration of breastfeeding for both groups was 183 days. A significant BMD decrease was observed for the nonhormonal group (p<.001); however, no statistical difference was detected for the progestin-only group. Body mass index, BMD at 7-10 days postpartum and total duration of breastfeeding were positively correlated with BMD at 6 months. CONCLUSIONS Our findings suggest a preventive effect towards postpartum bone loss with progestin-only contraception in breastfeeding women.

Curve of amniotic fluid index measurements in low-risk pregnancy

Objectives. To establish a curve of amniotic fluid index [AFI] measurements from the 20th to the 42nd week of pregnancy. Methods. A prospective and descriptive study was performed, in which an independent sample of 2,868 low‐risk pregnant women were studied using routine ultrasound, including fetal biometry and measurement of AFI. Data were analysed using multiple linear regression, and constructing a curve using 2.5th, 10th, 50th, 90th and 97.5th percentiles of the AFI measurements, according to gestational age, and after submitting values to smoothing process using quadratic polynomial adjustment. Results. There was a significant variation in AFI measurements at the different gestational ages. The 50th percentile remained practically constant at approximately 150 mm between the 20th and 33rd week, after which there was a decline in volume, which became evident after the 38th week. At the 40th week, the 10th percentile was around 62 mm and the 2.5th percentile around 33 mm. Conclusions. The curve of percentiles of AFI measurements in low‐risk pregnant women showed significant decrease with gestational age, especially after the 33rd week. These data should be validated for a diagnosis of increased or decreased volumes of amniotic fluid at specific gestational ages.

Validation study of the capacity of the reference curves of ultrasonographic measurements of the umbilical cord to identify deviations in estimated fetal weight

Background. The objective of this study was to evaluate the capacity of the cross‐sectional area and diameter of the umbilical cord, and the area of Whartons jelly (WJ), to predict abnormalities in estimated fetal weight (EFW) in 20–40 week, low‐risk pregnancies. Methods. A validation study was performed in 1,828 pregnant women. Fetal weight was estimated by ultrasonography and classified as: small for gestational age (SGA), appropriate for gestational age (AGA) or large for gestational age (LGA) according to the 10th and 90th percentiles of the reference curve. Measurements of the parameters of the cord were used to classify it as thin, normal or thick using the 10th and 90th percentiles of the reference curves as limits. The capacity of the diameter and total area of the cord and the area of WJ to predict abnormal EFW was calculated for different gestational ages. Results. The capacity of the diameter of thin cords to predict SGA fetuses (S =8.3%, PPV =16.5%) or thick cords to predict LGA fetuses (S =5.5%, PPV =30.1) was weak, similar to the capacity of the area of the umbilical cord to predict SGA (S =8.3%; PPV =16.3%) or LGA fetuses (S =5.5%; PPV =27.8%). The capacity of the area of WJ to predict SGA fetuses (S =5.7%, PPV =11.7%) was similar to its capacity to predict LGA fetuses (S =4%, PPV =27.1%). Conclusion. Despite the correlation between the diameter and cross‐sectional area of the cord and EFW, these measurements were not found to be useful in predicting alterations in EFW and should not be used for this purpose.

Validação da curva normal de peso fetal estimado pela ultra-sonografia para o diagnóstico do peso neonatal

PURPOSE: tocompare the ultrasound estimation of fetal weight (EFW) with neonatal weight and to evaluate the performance of the normal EFW curve according to gestational age for the diagnosis of fetal/neonatal weight deviation and associated factors. METHODS: one hundred and eighty-six pregnant women who delivered at the institution from November 1998 to January 2000 and who had one ultra-sonographic evaluation performed until three days prior to delivery with estimation of the amniotic fluid index were included. EFW was calculated and classified in to small for gestational age (SGA), adequate for gestational age (AGA) and large for gestational age (LGA) through the normal EFW curve for this population. Neonatal weight was similarly classified. The variability of the measures and the degree of linear correlation between EFW and neonatal weight, as well as sensitivity, specificity and predictive values for the use of the normal EFW curve in the diagnosis of neonatal weight deviations were calculated. RESULTS: the difference between EFW and neonatal weight ranged from -540 to +594 g, with a mean of +46.9 g, and the two measures presented a linear correlation coefficient of 0.94. The normal EFW curve had a sensitivity of 100% and specificity of 90.5% in detecting SGA neonates and of 94.4 and 92.8%, respectively, in detecting LGA; however, the predictive positive values were low for both conditions. CONCLUSIONS:ultrasound EFW was in agreement with the neonatal weight, with a mean overweight of approximately 47 g, and its normal curve showed a good performance in the screening of SGA and LGA neonates.

Comparison of estimated fetal weight by ultrasound with neonatal weight

Objectives: To compare the ultrasound estimation of fetal weight with neonatal weight and to evaluate the performance of the normal curve of estimated fetal weight (EFW) for the diagnosis of fetal/neonatal weight deviation. Study Methods: 186 pregnant women who delivered at the institution during the period from November 1998 until January 2000 were included in the study if they have an ultrasound evaluation performed until two days prior delivery, with EFW and amniotic fluid index (AFI) estimated and without any major fetal problem. The EFW was calculated by the Hadlock’s formula and classified in Small for Gestational Age (SGA), Adequate for Gestational Age (AGAO or Large for Gestational Age (LGA) through the normal curve of EFW for the same population. The neonatal weight was similarly classified through the Lubchenco’s curve. The variability between EFW and neonatal weight was calculated through the mean of their difference and correlation coefficient. Sensitivity, specificity and predictive values of the normal curve of EFW for the diagnosis of SGA and LGA were also calculated, with the Lubchenco’s curve as the gold standard. These estimates were controlled by time from ultrasound to delivery and AFI. Results: The difference between SFW and neonatal weight ranged from -540 to +594g, with a mean of +46.9g (p<O,OO2), with a correlation coefficient of 0.94 and without any significant variation with time from ultrasound to delivery and AFI. The normal curve of EFW had a sensitivity of 100% and specificity of 90.5% in detecting SGA and of 94.4% and 92.8%, respectively, in detecting LGA. Conclusions: The ultrasound EFW showed to overweight the neonatal weight in around 47g, and its normal curve showed a good performance in diagnosing SGA and LGA.