Isabela Coutinho

Effectiveness of antenatal corticosteroids in reducing respiratory disorders in late preterm infants: randomised clinical trial

Objectives To determine the effectiveness of corticosteroids in reducing respiratory disorders in infants born at 34-36 weeks’ gestation. Design Randomised triple blind clinical trial. Setting A large tertiary teaching hospital in northeast of Brazil. Participants Women at 34-36 weeks of pregnancy at risk of imminent premature delivery. Interventions Betamethasone 12 mg or placebo intramuscularly for two consecutive days. Main outcomes measures Primary outcome was the incidence of respiratory disorders (respiratory distress syndrome and transient tachypnoea of the newborn). Secondary outcomes included the need for ventilatory support, neonatal morbidity, and duration of stay in hospital. Results 320 women were randomised, 163 of whom were assigned to the treatment group and 157 to the controls. Final analysis included 143 and 130 infants, respectively. The rate of respiratory distress syndrome was low (two (1.4%) in the corticosteroid group; one (0.8%) in the placebo group; P=0.54), while the rate of transient tachypnoea was high in both groups (34 (24%) v 29 (22%); P=0.77). There was no reduction in the risk of respiratory morbidity with corticosteroid use even after adjustment for subgroups of gestational age (34-34+6 weeks, 35-35+6 weeks, and ≥36 weeks). The adjusted risk of respiratory morbidity was 1.12 (95% confidence interval 0.74 to 1.70). The need for ventilatory support was around 20% in both groups. There was no difference in neonatal morbidity (88 (62%) v 93 (72%); P=0.08) or in the duration of stay in hospital between the two groups (5.12 v 5.22 days; P=0.87). Phototherapy for jaundice was required less often in babies whose mothers received corticosteroids (risk ratio 0.63, 0.44 to 0.91). Conclusions Antenatal treatment with corticosteroids at 34-36 weeks of pregnancy does not reduce the incidence of respiratory disorders in newborn infants. Trial registration Clinical Trials NCT00675246.

Fatores associados à recorrência da gravidez na adolescência em uma maternidade escola: estudo caso-controle

Recorrencia da gravidez na adolescencia e uma situacao frequente, sendo considerada como um fator agravante tanto para o aumento da morbidade materna e fetal quanto para aumento de problemas sociais. O objetivo desta pesquisa foi identificar fatores associados a recorrencia de gravidez em adolescentes. Realizou-se estudo caso-controle com puerperas, incluindo 90 adolescentes com mais de uma gravidez (caso) e 90 adultas, mulheres que tiveram uma gestacao na adolescencia, mas que nao recorreram (controle). Para analise estatistica, utilizou-se regressao logistica hierarquizada, com nivel de significância de 5%. Os fatores que permaneceram associados a recorrencia da gravidez na adolescencia foram: coitarca < 15 anos, idade da primeira gestacao < 16 anos, mudanca de parceiro, nao cuidar dos filhos e renda familiar < um salario minimo. A recorrencia de gravidez na adolescencia foi associada especialmente a fatores reprodutivos e socioeconomicos. A mudanca de parceiro foi fator de protecao. No puerperio de adolescentes, devem ser intensificados os cuidados para que seja evitada a recorrencia.Repeat teen pregnancy is a frequent issue and is considered an aggravating factor for increased maternal and fetal morbidity and social problems. The aim of the study was to identify factors associated with repeat teen pregnancy. A case-control study was conducted in 90 postpartum adolescents with more than one pregnancy (cases) and 90 adult women with a history of only one pregnancy during adolescence (controls). Statistical analysis used hierarchical logistic regression with 5% significance. Early sexual initiation (< 15 years), early age at first pregnancy (< 16 years), not raising the children themselves, and low family income (< one minimum wage) were associated with repeat teenage pregnancy, while partner change was inversely associated. Repeat teen pregnancy was mainly associated with reproductive and socioeconomic factors. Partner change appeared as a protective factor. Measures should be adopted during the postpartum period of teenage mothers in order to avoid repeat pregnancy.

Transdermal nitroglycerin versus oral nifedipine administration for tocolysis: a randomized clinical trial.

PURPOSE to compare the effectiveness of transdermal nitroglycerin with oral nifedipine in the inhibition of preterm delivery. METHODS a clinical essay has been performed with 50 women in preterm delivery, randomly divided into two groups, 24 receiving oral nifedipine (20 mg), and 26, transdermal nitroglycerin (10 mg patch). Patients with a single gestation, between the 24th and the 34th weeks and diagnosis of preterm delivery were selected. Women with fetal malformation and clinical or obstetric diseases were excluded. The variables analyzed were: effective tocolysis, time needed for tocolysis, recurrence frequency, progression to preterm delivery, and side effects. RESULTS tocolysis efficacy in the first 12 hours was similar between the groups (nitroglycerin: 84.6% versus nifedipine: 87.5%; p=0.50). The time average time needed for tocolysis was also similar (6.6 versus 5.8 hours; p=0.30). There was no difference between the groups, concerning the recurrence of preterm delivery (26.9 versus 16.7%; p=0.30), and neither in the rate of preterm delivery within 48 hours (15.4 versus 12.5%; p=0.50). Nevertheless, the cephalea rate was significantly higher in the Nitroglycerin Group (30.8 versus 8.3%; p=0.04). CONCLUSIONS transdermal nitroglycerin has presented similar effectiveness to oral nifedipine to inhibit preterm delivery in the first 48 hours, however with higher cephalea frequency.PURPOSE: to compare the effectiveness of transdermal nitroglycerin with oral nifedipine in the inhibition of preterm delivery. METHODS: a clinical essay has been performed with 50 women in preterm delivery, randomly divided into two groups, 24 receiving oral nifedipine (20 mg), and 26, transdermal nitroglycerin (10 mg patch). Patients with a single gestation, between the 24th and the 34th weeks and diagnosis of preterm delivery were selected. Women with fetal malformation and clinical or obstetric diseases were excluded. The variables analyzed were: effective tocolysis, time needed for tocolysis, recurrence frequency, progression to preterm delivery, and side effects. RESULTS: tocolysis efficacy in the first 12 hours was similar between the groups (nitroglycerin: 84.6% versus nifedipine: 87.5%; p=0.50). The time average time needed for tocolysis was also similar (6.6 versus 5.8 hours; p=0.30). There was no difference between the groups, concerning the recurrence of preterm delivery (26.9 versus 16.7%; p=0.30), and neither in the rate of preterm delivery within 48 hours (15.4 versus 12.5%; p=0.50). Nevertheless, the cephalea rate was significantly higher in the Nitroglycerin Group (30.8 versus 8.3%; p=0.04). CONCLUSIONS: transdermal nitroglycerin has presented similar effectiveness to oral nifedipine to inhibit preterm delivery in the first 48 hours, however with higher cephalea frequency.

Uterine Artery Doppler in the Third Trimester of Pregnancy and Postnatal Outcome of Patients with Severe Preeclampsia

Objectives: To assess uterine artery Doppler velocimetry performed in the third trimester of pregnancy in women with severe preeclampsia as a predictor of adverse postpartum outcome. Methods: A cohort study including 154 women, conducted in a teaching hospital in Recife, Brazil. Uterine artery Doppler was performed at admission to hospital and postpartum outcome was evaluated. Results: High-resistance uterine artery Doppler was predictive of prolonged hospitalization and of being discharged from hospital under antihypertensive medication. No other correlation with maternal complications was found. Conclusion: High-resistance uterine artery Doppler in the third trimester of pregnancy is able to predict adverse postpartum outcome.

Perfil epidemiológico e evolução clínica pós-parto na pré-eclâmpsia grave

BACKGROUND: To describe maternal characteristics and blood pressure behavior in the puerperium of women admitted, during pregnancy, with diagnosis of severe preeclampsia. METHODS: A cohort study was conducted including pregnant women with gestational age of 28 weeks or more, with diagnosis of preeclampsia, not in labor, at the Instituto Materno Infantil Professor Fernando Figueira (IMIP) from November 2006 to September 2007. Patients with chronic hypertension, autoimmune diseases, gestational diabetes, multiple pregnancy and signs of clinical instability were excluded. Biological, demographic and obstetrical characteristics were analyzed, as well as the behavior of systolic and diastolic blood pressure post partum. RESULTS: 154 patients with severe preeclampsia were included. The mean maternal age was 25.1 + 6.5 years. Regarding education only 45.5% had completed 11 years of schooling. Only 20.1% of deliveries were vaginal and preterm newborns occurred in 59.8% of cases. Two cases of eclampsia, eighteen cases of HELLP syndrome and 43 cases of oliguria were registered. Length of post partum hospital stay varied from one to 30 days, and 45% of patients were in hospital until the seventh day after delivery. Hypertensive emergencies were registered in 53.9% of the patients during puerperium and use of antihypertensive drugs was maintained in 76.5% of the women. CONCLUSIONS: Preeclamptic women tend to have controlled blood pressures after the third day of puerperium and are likely to be discharged from hospital still using anti-hypertensive drugs. Key-words: Severe preeclampsia, post partum period complications.BACKGROUND To describe maternal characteristics and blood pressure behavior in the puerperium of women admitted, during pregnancy, with diagnosis of severe preeclampsia. METHODS A cohort study was conducted including pregnant women with gestational age of 28 weeks or more, with diagnosis of preeclampsia, not in labor, at the Instituto Materno Infantil Professor Fernando Figueira (IMIP) from November 2006 to September 2007. Patients with chronic hypertension, autoimmune diseases, gestational diabetes, multiple pregnancy and signs of clinical instability were excluded. Biological, demographic and obstetrical characteristics were analyzed, as well as the behavior of systolic and diastolic blood pressure post partum. RESULTS 154 patients with severe preeclampsia were included. The mean maternal age was 25.1 + 6.5 years. Regarding education only 45.5% had completed 11 years of schooling. Only 20.1% of deliveries were vaginal and preterm newborns occurred in 59.8% of cases. Two cases of eclampsia, eighteen cases of HELLP syndrome and 43 cases of oliguria were registered. Length of post partum hospital stay varied from one to 30 days, and 45% of patients were in hospital until the seventh day after delivery. Hypertensive emergencies were registered in 53.9% of the patients during puerperium and use of antihypertensive drugs was maintained in 76.5% of the women. CONCLUSIONS Preeclamptic women tend to have controlled blood pressures after the third day of puerperium and are likely to be discharged from hospital still using anti-hypertensive drugs. Key-words: Severe preeclampsia, post partum period complications.

Combined spinal-epidural anesthesia and non-pharmacological methods of pain relief during normal childbirth and maternal satisfaction: a randomized clinical trial

OBJECTIVE The objective of this study was to compare maternal satisfaction with childbirth according to whether or not combined spinal-epidural anesthesia (CSE) of pain relief was used during labor. METHODS A randomized, open clinical trial was performed with 70 pregnant women, 35 of whom received CSE anesthesia while 35 received only non-pharmacological forms of pain relief during labor. The variables evaluated were visual analogue scale (VAS) pain score, maternal satisfaction with the technique of pain relief used during childbirth and with delivery, the patients intention to request the same technique in a subsequent delivery, and loss of control during delivery. RESULTS VAS pain score decreased significantly in patients receiving CSE during vaginal delivery. Furthermore, maternal satisfaction with the technique of pain relief and with delivery was higher in the CSE group, and around 97% of the patients would repeat the same technique at future deliveries compared to 82.4% of the women in the group using only non-pharmacological methods. With respect to the womens impressions of their control during delivery, approximately half the women in both groups felt that they had lost control at some point during the process. CONCLUSION The use of CSE was associated with a significant reduction in VAS pain scores during delivery and with greater maternal satisfaction with the pain relief method and with the childbirth process.

Análise Comparativa de Testes Diagnósticos para Diabete Gestacional

Purpose: to analyze the perinatal results of patients submitted to a 100 g oral glucose tolerance test (OGTT) during prenatal care at the Instituto Materno-Infantil de Pernambuco (IMIP), according to three different criteria. Methods: a cross-sectional study was conducted involving 210 pregnant patients attended at the IMIP, who were tested by a 100 g OGTT and had a singleton, topic pregnancy, without history of diabetes or glucose intolerance before pregnancy, and who delivered at the IMIP. The patients were classified into one of the following categories according to the levels found by OGTT: controls, mild hyperglycemia, Bertinis group, Carpenters group and the National Diabetes Data Group (NDDG). These classes were then compared and association between the categories and preeclampsia, large for gestational age (LGA) newborns, rate of cesarean delivery, stillbirth, and mean birth weight was investigated. Results: the frequency of gestational diabetes was 48.1, 18.1, and 9% according to Bertinis, Carpenter and Coustans and NDDG criteria, respectively, and mild hyperglycemia was present in 10.5%. Age of patients increased with a higher degree of carbohydrate intolerance. The groups did not differ regarding frequency of LGA, C-section, stillbirths, and birth weight. There was an increased frequency of preeclampsia among women with hyperglycemia and gestational diabetes according to Carpenter and Coustans criteria. Conclusions: prevalence of gestational diabetes varied between 9 and 48% according to the different criteria, but maternal and perinatal results did not differ significantly among the groups. Strict diagnostic criteria can determine overdiagnosis without improvement of perinatal outcome.

[A case-control study of factors associated with repeat teen pregnancy based on a sample from a university maternity hospital]

Recorrencia da gravidez na adolescencia e uma situacao frequente, sendo considerada como um fator agravante tanto para o aumento da morbidade materna e fetal quanto para aumento de problemas sociais. O objetivo desta pesquisa foi identificar fatores associados a recorrencia de gravidez em adolescentes. Realizou-se estudo caso-controle com puerperas, incluindo 90 adolescentes com mais de uma gravidez (caso) e 90 adultas, mulheres que tiveram uma gestacao na adolescencia, mas que nao recorreram (controle). Para analise estatistica, utilizou-se regressao logistica hierarquizada, com nivel de significância de 5%. Os fatores que permaneceram associados a recorrencia da gravidez na adolescencia foram: coitarca < 15 anos, idade da primeira gestacao < 16 anos, mudanca de parceiro, nao cuidar dos filhos e renda familiar < um salario minimo. A recorrencia de gravidez na adolescencia foi associada especialmente a fatores reprodutivos e socioeconomicos. A mudanca de parceiro foi fator de protecao. No puerperio de adolescentes, devem ser intensificados os cuidados para que seja evitada a recorrencia.Repeat teen pregnancy is a frequent issue and is considered an aggravating factor for increased maternal and fetal morbidity and social problems. The aim of the study was to identify factors associated with repeat teen pregnancy. A case-control study was conducted in 90 postpartum adolescents with more than one pregnancy (cases) and 90 adult women with a history of only one pregnancy during adolescence (controls). Statistical analysis used hierarchical logistic regression with 5% significance. Early sexual initiation (< 15 years), early age at first pregnancy (< 16 years), not raising the children themselves, and low family income (< one minimum wage) were associated with repeat teenage pregnancy, while partner change was inversely associated. Repeat teen pregnancy was mainly associated with reproductive and socioeconomic factors. Partner change appeared as a protective factor. Measures should be adopted during the postpartum period of teenage mothers in order to avoid repeat pregnancy.

Clonidine versus Captopril for Severe Postpartum Hypertension: A Randomized Controlled Trial

Background Changes during the puerperium are still unclear, particularly in women with hypertension. The choice of antihypertensives, both to control very high blood pressure episodes and to keep blood pressure stable, also requires further elucidation. Currently, there are no clear data to guide the decision for the choice of postpartum antihypertensives. Captopril plays an important role in the treatment of very high blood pressure episodes and may be used postpartum. Clonidine has been used as an alternative in pregnant or postpartum women with contraindications to captopril, with satisfactory effect. The objective of the present study was to evaluate the effectiveness and safety of clonidine compared to captopril for treating severe postpartum hypertension. Methods and findings A randomized, drug-controlled, triple-blind clinical trial evaluating postpartum women receiving captopril or clonidine. Inclusion criteria consisted of: women with hypertensive disorders of pregnancy systolic blood pressure (SBP) ≥180 mmHg and/or diastolic blood pressure (DBP) ≥110 mmHg], requiring magnesium sulfate. Exclusion criteria were: heart disease, smoking, illicit drug use, contraindications to captopril, clonidine or oral medication, and having used captopril/clonidine previously. The primary outcome was the frequency of very high blood pressure episodes while in the obstetric intensive care unit. A total of 90 postpartum women met the study inclusion criteria, with 45 randomized to each group. There were fewer very high blood pressure episodes during hospitalization (2.1 ± 2.1 vs. 3.5 ± 4.7, p = 0.08), greater percentage reduction in SBP (14.0% ± 8.6% vs. 10.8% ± 8.8%, p = 0.08) and fewer women requiring sodium nitroprusside (2.3% vs. 13.3%; RR: 0.17; 95%CI: 0.02–1.39; p = 0.06) in the clonidine group compared to the captopril group; however, these differences were not significant. The groups were similar regarding daily mean SBP or DBP; however, on the third postpartum day, mean SBP was lower in the clonidine compared to the captopril group (151.9 ± 11.8 mmHg vs. 158.1 ± 13.6 mmHg, p = 0.02). Although not statistically significant, adverse reactions were more common in the captopril group (28.8%) compared to the clonidine group (18.6%). Conclusion Clonidine and captopril represent safe, effective treatments for severe postpartum hypertension. Trial registration clinicaltrials.gov: www.clinicaltrial.gov, NCT01761916.

Hypertension, pregnancy and weather: is seasonality involved?

OBJECTIVE The present study aimed at assessing the association between environmental temperature and the relative humidity of the air with frequency of hypertensive disorders of pregnancy. METHODS A prospective and retrospective, descriptive, ecological study was held at a teaching maternity in Recife, Brazil. Data from all 26.125 pregnant women admitted between 2000 and 2006 were analysed and 5.051 had the diagnosis of hypertensive disorder of pregnancy. The incidence percentages were calculated monthly per deliveries. Data on mean monthly temperature and relative humidity of the air were collected and monthly comparisons were conducted. February was chosen as the reference month due to its lowest incidence of the disease. The relative chance of hypertensive disorders of pregnancy for each other month was estimated by odds ratio and Pearsons correlation coefficient was used to calculate the relation between the incidence of hypertensive disorders of pregnancy and the mean monthly temperature and relative air humidity. RESULTS February presented the lowest mean monthly incidence (9.95%) and August the highest (21.54%). Pearson correlation coefficient revealed a higher incidence of hypertensive disorders of pregnancy in the cooler months (r= -0.26; p=0.046) and no significant effect of relative air humidity (r=0.20; p=0.128). CONCLUSION The incidence of hypertensive disorders of pregnancy may be affected by variations in temperature, increasing during cooler periods.