Francisco Edson de Lucena Feitosa

Comparison of sublingual versus vaginal misoprostol for the induction of labour: a systematic review

Background  The induction of full‐term labour in women with a live fetus remains a major challenge in modern obstetrics.

Sublingual vs. vaginal misoprostol for induction of labor

Objective: To compare sublingual with vaginal misoprostol for the induction of labor. Methods: This double‐blind clinical trial randomized 150 women to receive every 6 h 25 μg of sublingual misoprostol and vaginal placebo or 25 μg of vaginal misoprostol and sublingual placebo. Maternal and neonatal outcomes were analyzed and risk ratios (RRs) with 95% confidence intervals (CIs) calculated. The significance level was 5%. Results: Vaginal delivery rates were 57% in the sublingual group and 69% in the vaginal group (RR, 0.8; 95% CI, 0.6–1.1). There were 11 cases of fetal distress in the sublingual group and 4 cases in the vaginal group (RR, 2.7; 95% CI, 0.9–8.2). There were no significant differences in the number of doses needed, interval between first dose and delivery, incidence of contractility disturbances, or neonatal results. Conclusion: The administration of misoprostol 25 μg by the sublingual route was neither more effective nor safer than the same dose administered vaginally.

Associated ultrasonographic findings in fetuses with microcephaly because of suspected Zika virus (ZIKV) infection during pregnancy

To describe fetal ultrasonographic findings and outcomes in a series of cases of fetal microcephaly associated with Zika virus infection.

Reincidência de gravidez em adolescentes

OBJETIVO: avaliar os aspectos epidemiologicos na reincidencia de gravidez na adolescencia. METODOS: estudo de coorte que incluiu 187 adolescentes gravidas, atendidas e acompanhadas durante cinco anos apos o parto em um servico de atendimento de adolescentes do Estado do Ceara. Foram analisados: faixa etaria, estar ou nao estudando, morar com os pais, escolaridade, condicao marital e condicao do companheiro atual. Os dados foram digitados e analisados no programa EPI-INFO. Foram feitas analises estatisticas das variaveis independentes (idade, escolaridade, estudar, trabalhar, morar com os pais, estado civil e mudanca de parceiro) e comparadas quanto a variavel dependente (ter ou nao uma nova gravidez cinco anos depois). O teste exato de Fisher foi utilizado para avaliar associacao entre os fatores que poderiam influenciar a repeticao da gravidez, considerado como tendo associacao quando o p<0,05. Foram calculados os riscos relativos para a escolaridade, condicao marital e mudanca de parceiro por serem fatores que se mostraram significativos para a reincidencia de gravidez. RESULTADOS: foi verificado que 61% das adolescentes engravidaram nos cinco anos seguintes ao primeiro parto. Nao foram fatores protetores: idade, estudar, trabalhar ou morar com os pais. Entretanto, quando as adolescentes tinham oito anos ou menos de escolaridade, o risco de engravidar quase duplicou (risco relativo (RR)=1,8 (IC95%=1,3-2,6)). Novas gestacoes foram mais frequentes entre as solteiras sem companheiro estavel (RR=1,3 (IC95%=1,1-1,6)) e aquelas que mudaram de parceiro (RR=1,4 (IC95%=1,1-1,7)). CONCLUSOES: a baixa escolaridade, a mudanca de parceiros e unioes nao estaveis foram fatores de risco para reincidencia de gravidez.PURPOSE To evaluate epidemiological aspects in recurrent adolescence pregnancy. METHODS Cohort study including 187 pregnant adolescents attended and followed-up for five years after delivery in an adolescents attendance service in Ceará state. Age group, being or not at school, living with parents, schooling, marital status and the present partners condition were analyzed. Data were processed by the EPI-INFO program. Statistical analysis of the independent variables (age, schooling, being at school, having a job, living with parents, marital status and switching partners) was done and compared to the dependent variable (being or not pregnant after five years). The Fishers exact test was used to evaluate the association among factors which could influence the pregnancy recurrence, the association being present when p<0.05. Risks related to schooling, marital status and multiple partners have been calculated, since these were significant factors for pregnancy recurrence. RESULTS 61% of the adolescents got pregnant in the five years after the first delivery. Factors such as age, school, work or living with parents were not protective. Nevertheless, when the adolescents had eight or less years of schooling, the risk of getting pregnant has almost duplicated (relative risk (RR)=1.8 (CI 95%=1.3-2.6)). New pregnancies were more frequent among the single adolescents without a stable partner (RR=1.3 (CI 95%=1.1-1.6) and among the ones who had multiple partners (RR=1.4 (CI 95%=1.1-1.7)). CONCLUSIONS Low schooling, multiple partners and non-stable bonds were risk factors for pregnancy recurrence.

Métodos para indução do parto

The interest of modern obstetrics in labor induction can be demonstrated by the huge amount of scientific articles published during the last few years. The advances of medicine in general and particularly of obstetrics allowed that more risky pregnancies reach term or near term, with a maternal or fetal indication for pregnancy interruption before the spontaneous onset of labor and delivery. This leads the obstetrician to the situation of choosing between cesarean section and labor induction. With the aim of helping the obstetrician to make the choice for labor induction and thus collaborate with the reduction in cesarean section rates, it is necessary that an accessible, cheap, safe, effective, easy to be used method with good acceptability is available. Although several methods of labor induction reported in medical literature do exist, it is known that there is no ideal method. However, among them, two are highlighted. The first is oxytocin, which has the advantages of promoting physiologic uterine contractions of labor and reverting uterine hypercontractility when suspended. The other method is misoprostol, nowadays the most used, which ripens the uterine cervix and induces uterine contractions of labor. However, there are still some controversies regarding its ideal dose, route and safety.

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.

Applying the Maternal Near Miss Approach for the Evaluation of Quality of Obstetric Care: A Worked Example from a Multicenter Surveillance Study

Objective. To assess quality of care of women with severe maternal morbidity and to identify associated factors. Method. This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. Results. 17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase in maternal mortality ratio, the main factors associated with nonadequate performance were geographic difficulty in accessing health services (P < 0.001), delays related to quality of medical care (P = 0.012), absence of blood derivatives (P = 0.013), difficulties of communication between health services (P = 0.004), and any delay during the whole process (P = 0.039). Conclusions. This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care.

Titrated oral misoprostol solution versus vaginal misoprostol for labor induction

To determine the efficacy and safety of a titrated oral misoprostol solution compared with vaginal misoprostol tablets for labor induction.

Titrated oral solution of misoprostol for labour induction: a pilot study

PURPOSE To test effectiveness and safety of the oral administration of a new misoprostol formulation in titrated doses for the induction of delivery of a live fetus at term. METHODS An open pilot multicenter, non-randomized clinical trial was conducted from July to December 2008. A total of 30 patients with indications for induction of labor were included. The patients had a live fetus, Bishop score <6, vertex presentation, fetal weight <4,000g estimated by ultrasonography and amniotic fluid index >5. Exclusion criteria were previous uterine scar, non-reassuring fetal heart rate tracing, multiple pregnancy, fetal growth restriction, genital hemorrhage and presence of genital tumors, ulcerations or malformations. An initial dose of 20 µg/hour of the oral misoprostol solution was used in the first 6 hours, and was increased progressively to 20 µg/hour every 6 hours if labor did not start, up to a maximum dose of 80 µg/h in the first 24 hours, maintained for additional 24 hours if necessary. RESULTS Labor was satisfactorily induced in 96.7% of patients. The interval between the first dose and the beginning of uterine contractions was 3.8 ± 1.8 hours. The interval between the initial dose and delivery varied from 6 to 24 hours. The frequency of vaginal delivery was 80% (24 cases). Most of the patients (60%; n=18) initiated labor with a dose of 20 mg/hour. Tachysystole occurred in 13.3% of women and meconium-stained fluid was detected in 20% of cases. There were two cases of Apgar scores < 7 in the first minute and no Apgar score < 7 in the fifth minute. CONCLUSIONS The oral solution of misoprostol was effective and safe for the induction of labor. However, further randomized controlled trials are needed to compare this new formulation with misoprostol administered by the vaginal route.

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.