Fábio Roberto Cabar

Emergency contraception and ectopic pregnancy: report of 2 cases

The incidence of ectopic pregnancy has been increasing over the last few years, reaching a value of 1 case in 80 pregnancies, and it continues to be the main cause of maternal death during the first trimester in the United States. The main causes of tubal ectopic pregnancy, which generally results from damage to or dysfunction of the fallopian tubes, are salpingitis, previous tubal surgeries, and alteration in tubal motility mainly due to the use of certain contraceptive methods. Emergency [...]

Cardiac troponin T as a biochemical marker of cardiac dysfunction and ductus venosus Doppler velocimetry

OBJECTIVES The aim of this study was to determine the correlation between ductus venosus (DV) Doppler velocimetry and fetal cardiac troponin T (cTnT). STUDY DESIGN Between March 2007 and March 2008, 89 high-risk pregnancies were prospectively studied. All patients delivered by cesarean section and the Doppler exams were performed on the same day. Multiple regression included the following variables: maternal age, parity, hypertension, diabetes, gestational age at delivery, umbilical artery (UA) S/D ratio, diagnosis of absent or reversed end-diastolic flow velocity (AREDV) in the UA, middle cerebral artery (MCA) pulsatility index (PI), and DV pulsatility index for veins (PIV). Immediately after delivery, UA blood samples were obtained for the measurement of pH and cTnT levels. Statistical analysis included the Kruskal-Wallis test and multiple regressions. RESULTS The results showed a cTnT concentration at birth >0.05 ng/ml in nine (81.8%) of AREDV cases, a proportion significantly higher than that observed in normal UA S/D ratio and UA S/D ratio >p95 with positive diastolic blood flow (7.7 and 23.1%, respectively, p<0.001). A positive correlation was found between abnormal DV-PIV and elevated cTnT levels in the UA. Multiple regression identified DV-PIV and a diagnosis of AREDV as independent factors associated with abnormal fetal cTnT levels (p<0.0001, F(2.86)=63.5, R=0.7722). CONCLUSION DV-PIV was significantly correlated with fetal cTnT concentrations at delivery. AREDV and abnormal DV flow represent severe cardiac compromise, with increased systemic venous pressure, and a rise in right ventricular afterload, demonstrated by myocardial damage and elevated fetal cTnT.

Serum markers in the diagnosis of tubal pregnancy

The introduction of highly sensitive methods, such as transvaginal sonography and measurement of serum β-human chorionic gonadotropin, has dramatically improved ectopic pregnancy diagnosis in recent years. Early diagnosis is the key to successful and conservative management of women with ectopic pregnancy; however, approximately 50 percent of such women are initially misdiagnosed, resulting in significant morbidity and mortality. In order to improve diagnosis, several serum markers are being investigated including progesterone, CA 125, pregnancy-associated plasma protein-A, vascular endothelial growth factor, and maternal creatine kinase. Measurement of serum vascular endothelial growth factor, alone or together with other markers, could be a promising method for earlier and more accurate differential diagnosis. However, the clinical applicability of these findings remains to be evaluated in larger prospective studies.

Vascular endothelial growth factor and β-human chorionic gonadotropin are associated with trophoblastic invasion into the tubal wall in ectopic pregnancy

OBJECTIVE To assess the association between the depth of trophoblastic penetration into the tubal wall with serum concentrations of vascular endothelial growth factor (VEGF) and β-hCG and to assess its predictive value. DESIGN Prospective study. SETTING Tertiary care university hospital. PATIENT(S) Thirty patients with ampullary pregnancy undergoing salpingectomy were analyzed. INTERVENTION(S) Trophoblastic invasion was histologically classified as stage I when limited to the tubal mucosa, stage II when extending to the muscle layer, and stage III in the case of complete tubal wall infiltration. MAIN OUTCOME MEASURE(S) The relation between depth of trophoblastic infiltration into the tubal wall with VEGF and β-hCG serum concentrations on the day of surgery. RESULT(S) An association between the depth of trophoblastic invasion and maternal serum concentrations of VEGF and β-hCG was observed. VEGF levels of 297.2 pg/mL showed 100.0% sensitivity and 90.0% specificity for stage I, and levels of 440.1 pg/mL showed 81.8% sensitivity and 88.8% specificity for stage III. Beta-hCG levels of 2590.0 mIU/mL showed 88.9% sensitivity and 80.0% specificity for stage I, and levels of 10,827.0 mUI/mL showed 72.7% sensitivity and 88.9% specificity for stage III. CONCLUSION(S) Maternal serum VEGF and β-hCG concentrations are associated with depth of trophoblastic penetration into the tubal wall.

Tratamento do abortamento incompleto por aspiração manual ou curetagem

OBJETIVOS: Comparar aspiracao manual intra-uterina (AMIU) com curetagem uterina (DC anestesia foi realizada em todos os casos. O tempo para realizacao de cada procedimento cirurgico foi cronometrado. RESULTADOS: Os grupos eram semelhantes quanto a idade gestacional (9,93±2,40; 9,73±2,58, p 0,71), espessura endometrial antes da cirurgia (22,14±4,80; 22,68±5,68, p 0,65). Nao foram observadas complicacoes cirurgicas ou anestesicas em nenhum grupo. Os tempos de realizacao do procedimento e internacao foram significativamente menores nas pacientes do grupo AMIU (3,71; 10,18 min, p < 0,001) (14,18; 23,06 h, p 0,03). O decrescimo nos niveis de hemoglobina apos o procedimento cirurgico foi maior no grupo D&C (p= 0,02). CONCLUSAO: A AMIU possibilita menor perda sanguinea, requer menor tempo de realizacao do procedimento e menor tempo de internacao hospitalar. Entretanto, ambos os procedimentos cirurgicos mostraram-se eficientes para o tratamento de abortamentos incompletos no primeiro trimestre da gestacao, nao havendo complicacoes apos a realizacao dos tratamentos.

Intrauterine pregnancy after salpingectomy for tubal pregnancy due to emergency contraception: a case report.

Ectopic pregnancy (EP) is the fourth most frequent cause of maternal death in the United Kingdom, and it is the main cause of maternal death during the first trimester in the United States. The Fallopian tubes are the most frequently affected site by EP. The main causes of tubal pregnancy are salpingitis, previous tubal surgeries, and alteration in tubal motility mainly due to the use of certain contraceptive methods. Most recently, the use of 750 μg of levonorgestrel as an emergency contraceptive method has been identified as another risk factor for EP. The diagnosis of an EP before rupture permits conservative treatment in order to preserve subsequent patient fertility. However, the conservative approach might be questioned because it is associated with a higher recurrence rate when compared with salpingectomy. Additionally, salpingectomy does not change subsequent patient fertility when (i) the contralateral tube seems to be healthy, (ii) the patients are younger than 30 years, and (iii) there is no previous history of infertility. In these patients, subsequent intrauterine pregnancy rate reaches approximately 70% at 2 years. We report here a case of intrauterine pregnancy (IUP) that occurred after salpingectomy in a patient previously undergoing tubal pregnancy without any apparent risk factors for EP other than the use of emergency contraceptive pills containing 0.75 mg levonorgestrel (Postinor 2).

Association between ultrasound findings and extent of trophoblastic invasion into the tubal wall in ampullary pregnancy

Predictive factors of damage to the Fallopian tube may guide the treatment of patients with tubal pregnancy. The aim of the present study was to investigate the association between the depth of trophoblastic invasion into the tubal wall, assessed on postoperative histological examination, with the findings obtained on transvaginal sonography (TVS) in women with ampullary pregnancy.

Óbito fetal no descolamento prematuro da placenta: comparação entre dois períodos

OBJECTIVE: To compare the incidence of placental abruption (PA), fetal death and the profile of maternal factors associated with fetal death in pregnancies affected by placental abruption during two different time periods in the same hospital. METHODS: retrospective study between January 1, 1994 and December 31, 1997 and April 1, 2001 and March 31, 2005, including singleton pregnancies with a birth weight higher than 500g and gestational age of more than 20 weeks. Factors analyzed were maternal age, race, obstetric history, presence of arterial hypertension or premature rupture of membranes, presence of genital bleeding, presence of amniotic fluid contaminated with blood, characteristics of uterine tonus, occurrence of renal insufficiency, postpartum coagulopathy, puerperal anemia, gestational age and weight at birth. RESULTS: there were7692 births in the 1994-1997 period, placental abruption incidence of 0.78% (60 cases); 8644 births occurred in the 2001-2005 period, placental abruption incidence of 0.59% (51 cases), with no statistical difference. During the 1994-1997 period, proportion of cases without genital bleeding was significantly higher in the group whose fetuses died compared to cases of live born fetuses (57.9% vs 22.0%; p=0.01). During the 2001-2005 period, proportion of cases with uterine hypertonia was significantly higher in the group whose fetuses died compared to cases of live born fetuses (66.7% vs 29.3%; p=0.04). Postpartum maternal complications were more frequent in cases of fetal death during both periods (31.6% vs 4.9%; p=0.009; and 50% vs 5.1%; p=0.001, respectively). CONCLUSION: Placental abruption continues to be a serious obstetric problem, with fatal consequences, especially when the placental abruption area is large. Maternal clinical symptoms are more severe in cases of fetal death.

Ectopic pregnancy following levonorgestrel emergency contraception

This letter to the editor reports on a case of intrauterine pregnancy that occurred after salpingectomy in a patient previously undergoing tubal pregnancy without any apparent risk factors for ectopic pregnancy (EP) other than the use of emergency contraceptive pills containing 0.75 mg levonorgestrel. It emphasizes that salpingectomy does not impede future intrauterine pregnancy especially when the contralateral tube seems normal; in turn conservative treatment should be offered to selected cases.

Cesárea prévia como fator de risco para o descolamento prematuro da placenta

OBJETIVO: investigar a relacao entre o antecedente de cesarea e a ocorrencia do descolamento prematuro da placenta (DPP). METODOS: estudo retrospectivo em que foram avaliados os dados referentes a 6495 partos realizados no periodo entre abril de 2001 e janeiro de 2004. Foram adotados como criterios de inclusao: diagnostico de DPP confirmado por exame da placenta apos o parto, gestacao unica, peso do recem-nascido superior a 500 g e idade gestacional acima de 22 semanas e ausencia de historia de trauma abdominal na gestacao atual. Para cada caso de DPP incluido no estudo foram selecionados cinco controles, obedecendo ao seguinte pareamento: paridade, idade gestacional ( 30 semanas), diagnostico materno de sindrome hipertensiva na gestacao indice, antecedente de cicatriz uterina previa nao relacionada a operacao cesariana, diagnostico de rotura prematura de membranas ou diagnostico de polidrâmnio. A analise univariada das variaveis continuas foi realizada utilizando-se o teste t de Student e as variaveis categoricas foram avaliadas por meio de teste exato de Fisher ou teste de c2, com niveis descritivos (p) menores que 0,05 considerados significantes. RESULTADOS: 34 casos de pacientes com diagnostico de DPP preencheram os criterios de inclusao (incidencia de 0,52%). Para o grupo controle foram selecionadas 170 pacientes que obedeceram aos criterios de pareamento propostos. No grupo de pacientes com DPP, 26,5% apresentavam antecedente de parto cesarea (9 casos), ao passo que, no grupo controle, esse antecedente foi observado em 21,2% das pacientes (36 casos). Nao houve diferenca estatisticamente significativa na incidencia de cesarea previa entre os dois grupos estudados (p=0,65, OR=1,34, IC 95%=0,53-3,34). CONCLUSAO: o aspecto abordado neste estudo, isto e, a associacao do DPP em pacientes com cicatriz uterina de cesarea, nao pode ser confirmado com a presente casuistica.