Helaine Maria Besteti Pires

Factors associated with vaginal birth after previous cesarean section in Brazilian women

OBJECTIVE To identify factors associated with a vaginal second delivery in women who had one previous cesarean section. METHODS A nested case-control study was carried out as a secondary data analysis of an original retrospective, population-based cohort study of women who delivered their first child during 1985 in the city of Campinas, São Paulo, Brazil, and who were interviewed 10 years later in 1995. The study population consisted of 1352 women who had their first delivery by cesarean section and who had also had at least one subsequent delivery. The group of cases (150 women, around 11% of the sample) consisted of women who had a vaginal second delivery, and the control group was made up of 1202 women who had a cesarean section at second delivery. For each possible associated factor we calculated the odds ratio and 95% confidence interval. For ordered categorical variables the c2 test for trend was used. Unconditional multivariate regression analysis was used to estimate the adjusted odds ratio for each associated factor. RESULTS The factors significantly associated with vaginal delivery were monthly family income below 5-fold the Brazilian minimum monthly wage, reliance on the Brazilian national health system for healthcare, low maternal age, and first cesarean section indicated because of fetal breech or transverse presentation, or twin pregnancy. Among those women who also had a cesarean section at their second delivery, only 11% had undergone a trial of labor. CONCLUSIONS The main determining factors for a vaginal second delivery in women with a previous cesarean section were unfavorable social and economic factors.

Effectiveness and safety of a new vaginal misoprostol product specifically labeled for cervical ripening and labor induction

Objective. The purpose of this study was to evaluate the effectiveness and safety of misoprostol in two different formulations: vaginal tablets of 25 μg and one‐eighth of a 200‐μg oral tablet, also administered intravaginally, for cervical ripening and labor induction of term pregnancies with an indication for that. Methods. A single‐blind, randomized, controlled clinical trial was carried out in 120 pregnant women who randomly received one of the two formulations. The main dependent variables were mode of delivery, need for additional oxytocin, time between beginning of induction and delivery, perinatal results, complications, and maternal side effects. Students t, Mann–Whitney, χ2, Fishers Exact, Wilcoxon and Kolmogorov‐Smirnoff tests, as well as survival analysis, were used in the data analysis. Results. There were no significant differences between the groups in terms of general characteristics, uterine contractility, and fetal well‐being during labor, cesarean section rates, perinatal outcomes, or maternal adverse events. The mean time between the beginning of cervical ripening and delivery was 31.3 h in the vaginal tablet group and 30.1 h in the oral tablet group, a difference that was not statistically significant. Conclusion. The results showed that the 25‐μg vaginal tablets of misoprostol were as effective and safe for cervical ripening and labor induction as the dose‐equivalent fraction of 200‐μg oral tablets.

Fatores Associados à Realização de Cesárea em Primíparas com uma Cesárea Anterior

SUMMARY Purpose: to evaluate the route of delivery in a group of low-income primipara pregnant women with a previous cesareansection, and the factors associated with the repetition of thecesarean section on the second delivery. Patients and Methods: it was a case-control study including356 women who were assisted at the Maternity of CAISM/UNICAMP during the period between January 1993 andJanuary 1996. The cases were 153 women whose seconddelivery was through a cesarean section and the controlswere 203 women whose second delivery was vaginal. Foranalysis, means, standard deviation, Student t -test, Mann-’s Whitney test,c 2 test and odds ratio (OR) with 95% CI for each factor possibly associated with cesarean section on thesecond delivery were used. Results: the route of the second delivery was vaginal for 57%of the women. Among the several variables studied, thosewhich showed to be significantly associated with a cesareansection on the second delivery were: higher maternal age(for women over 35 years, OR = 16.4), previous abortions(OR = 2.09), induced labor (OR = 3,83), premature ruptureof membranes (OR = 2.83), not having an epidural analgesiaperformed during labor (OR = 5.3), the finding of somealteration in fetal well-being (OR = 2.7) and the deliveryoccurring during the afternoon (OR = 1.92).

Fatores associados à prova de trabalho de parto em primíparas com uma cesárea anterior

OBJETIVO: Identificar fatores medicos e nao medicos associados a realizacao da prova de trabalho de parto na segunda gestacao de primiparas com uma cesarea anterior. METODOS: Estudo de caso-controle aninhado, com uma analise secundaria de dados de um estudo de coorte retrospectivo previamente desenvolvido numa populacao de mulheres que deu a luz ao primeiro filho em Campinas, no ano de 1985. RESULTADOS: Os principais fatores que estiveram associados a realizacao da prova de trabalho de parto em 333 gestantes dentre as 1.352 secundigestas com uma cesarea anterior foram: renda familiar mensal inferior a 5 salarios-minimos, seguro-saude pelo Sistema Unico de Saude, baixa idade materna, presenca de rotura de membranas e ocorrencia de trabalho de parto no primeiro parto. CONCLUSAO: Os fatores socioeconomicos sao fundamentalmente os principais determinantes da realizacao da prova de trabalho de parto em secundigestas, com uma cesarea anterior.

Via de Parto e Resultados Perinatais em Gestantes Diabéticas

Objetivo: apresentar os resultados perinatais obtidos a partir da aplicacao de um protocolo de assistencia as gestantes diabeticas no Centro de Atencao Integral a Saude da Mulher (CAISM) da UNICAMP. Metodos: foram estudadas 90 gestantes diabeticas que iniciaram controle pre-natal na instituicao e foram submetidas a este protocolo. Foram comparadas com dois grupos controles de 180 gestantes cada: um constituido por gestantes pareadas por idade e numero de gestacoes (controle A) e outro por gestantes aleatoriamente selecionadas (controle B). Nos tres grupos foram avaliadas as seguintes variaveis: tipo de parto, indicacoes de cesarea, idade gestacional, indice de Apgar ao primeiro e quinto minuto de vida, peso e adequacao de peso para idade gestacional, morbidade e mortalidade perinatal. Para a analise estatistica utilizaram-se medias, desvio-padrao, os testes t de Student e do c2. Resultados: entre as gestantes diabeticas ocorreu maior incidencia de cesareas, recem-nascidos prematuros e grandes para a idade gestacional (GIG), assim como uma maior frequencia de patologias neonatais (hipoglicemia, hipocalcemia, hiperbilirrubinemia, desconforto respiratorio e depressao neonatal). A incidencia de Apgar <7 e a mortalidade perinatal foram significativamente maiores do que no grupo controle aleatoriamente selecionado, mas a diferenca desapareceu quando se comparou ao grupo controle pareado por idade e numero de gestacoes. Conclusoes: apesar de o protocolo visar um perfeito controle metabolico nas gestantes diabeticas, os resultados perinatais ainda sao desfavoraveis em comparacao as gestantes nao-diabeticas.

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.