Marcelo Luís Nomura

Quality of life, depression and anxiety among pregnant women with previous adverse pregnancy outcomes

CONTEXT AND OBJECTIVE Previous adverse pregnancy outcomes (recurrent spontaneous abortion, fetal death, preterm birth or early neonatal death) can affect the quality of life of pregnant women. The objective of this study was to compare the quality of life and the prevalence of symptoms of anxiety and depression among pregnant women with and without these antecedents. DESIGN AND SETTING An analytical cross-sectional study was performed in four settings (two high-risk and two low-risk prenatal clinics) in the city of Campinas, São Paulo, Brazil. METHODS A total of 240 women were interviewed by a single investigator between the 18th and 24th weeks of gestation: 120 women with prior adverse pregnancy outcomes (group 1) and 120 women with no such history (group 2), matched according to their numbers of living children. Sociodemographic variables were collected and two questionnaires were used: the Short Form-36 quality-of-life questionnaire and the Depression and Anxiety Scale. RESULTS The women in group 1 had lower scores in all the items on the quality-of-life questionnaire. Depression and anxiety were more frequent in group 1 (P < 0.0001). An inverse correlation was found between the Short Form-36 domains and anxiety and depression. CONCLUSIONS Women with histories of recurrent spontaneous abortion, fetal death, preterm birth or early neonatal death seem to have poorer quality of life and more symptoms of anxiety and depression during their subsequent pregnancy, compared with those without such antecedents.

Fetoscopic laser ablation of placental anastomoses in twin-twin transfusion syndrome using 'Solomon technique'.

To document perinatal outcomes following use of the ‘Solomon technique’ in the selective photocoagulation of placental anastomoses for severe twin–twin transfusion syndrome (TTTS).

Brazilian multicentre study on preterm birth (EMIP): prevalence and factors associated with spontaneous preterm birth.

Background Preterm birth rate is increasing and is currently a worldwide concern. The purpose of this study was to estimate the prevalence of preterm birth in a sample of health facilities in Brazil and to identify the main risk factors associated with spontaneous preterm births. Methods and Findings This was a multicentre cross sectional study on preterm births in 20 referral obstetric hospitals with a case-control component to identify factors associated with spontaneous preterm birth. Surveillance was implemented at all centres to identify preterm births. For eligible consenting women, data were collected through a post-delivery questionnaire completed with information from all mother-newborn medical records until death or discharge or at a maximum of 60 days post-delivery, whichever came first. The risk of spontaneous preterm birth was estimated with OR and 95%CI for several predictors. A non-conditional logistic regression analysis was then performed to identify independently associated factors. The overall prevalence of preterm birth was 12.3%. Among them, 64.6% were spontaneous and 35.4% therapeutic. In the case-control component, 2,682 spontaneous preterm births were compared to a sample of 1,146 term births. Multivariate analyses identified the following as risk factors for spontaneous preterm birth among women with at least one previous birth: a previous preterm birth (ORadj = 3.19, 2.30–4.43), multiple pregnancy (ORadj = 29.06, 8.43–100.2), cervical insufficiency (ORadj = 2.93, 1.07–8.05), foetal malformation (ORadj = 2.63, 1.43–4.85), polyhydramnios (ORadj = 2.30, 1.17–4.54), vaginal bleeding (ORadj = 2.16, 1.50–3.11), and previous abortion (ORadj = 1.39, 1.08–1.78). High BMI (ORadj = 0.94, 0.91–0.97) and weight gain during gestation (ORadj = 0.92, 0.89–0.95) were found to be protective factors. Conclusions The preterm birth rate in these health facilities in Brazil is high and spontaneous preterm births account for two thirds of them. A better understanding of the factors associated with spontaneous preterm birth is of utmost importance for planning effective measures to reduce the burden of its increasing rates.

Brazilian multicenter study on prevalence of preterm birth and associated factors

BackgroundThe occurrence of preterm birth remains a complex public health condition. It is considered the main cause of neonatal morbidity and mortality, resulting in a high likelihood of sequelae in surviving children. With variable incidence in several countries, it has grown markedly in the last decades. In Brazil, however, there are still difficulties to estimate its real occurrence. Therefore, it is essential to establish the prevalence and causes of this condition in order to propose prevention actions. This study intend to collect information from hospitals nationwide on the prevalence of preterm births, their associated socioeconomic and environmental factors, diagnostic and treatment methods resulting from causes such as spontaneous preterm labor, prelabor rupture of membranes, and therapeutic preterm birth, as well as neonatal results.Methods/DesignThis proposal is a multicenter cross-sectional study plus a nested case-control study, to be implemented in 27 reference obstetric centers in several regions of Brazil (North: 1; Northeast: 10; Central-west: 1; Southeast: 13; South: 2). For the cross sectional component, the participating centers should perform, during a period of six months, a prospective surveillance of all patients hospitalized to give birth, in order to identify preterm birth cases and their main causes. In the first three months of the study, an analysis of the factors associated with preterm birth will also be carried out, comparing women who have preterm birth with those who deliver at term. For the prevalence study, 37,000 births will be evaluated (at term and preterm), corresponding to approximately half the deliveries of all participating centers in 12 months. For the case-control study component, the estimated sample size is 1,055 women in each group (cases and controls). The total number of preterm births estimated to be followed in both components of the study is around 3,600. Data will be collected through a questionnaire all patients will answer after delivery. The data will then be encoded in an electronic form and sent online by internet to a central database. The data analysis will be carried out by subgroups according to gestational age at preterm birth, its probable causes, therapeutic management, and neonatal outcomes. Then, the respective rates, ratios and relative risks will be estimated for the possible predictors.DiscussionThese findings will provide information on preterm births in Brazil and their main social and biological risk factors, supporting health policies and the implementation of clinical trials on preterm birth prevention and treatment strategies, a condition with many physical and emotional consequences to children and their families.

Previable preterm rupture of membranes: gestational and neonatal outcomes

IntroductionPreviable (less than 24 weeks) premature rupture of membranes complicates about 1 in every thousand births and is responsible for substantial perinatal mortality.Subjects and methodsIn this paper, we retrospectively analyzed one twin and 35 singleton pregnancies.ResultsTwenty cases occurred before and 16 after 20 weeks. Latency period ranged from 0 to 137 days, with an average of 35 days. Amniotic fluid index was reduced in 27 cases and normal in 6 cases. Expectant management was adopted in 31 cases (86%), five patients declined and opted for termination (14%) at admission or during the course of pregnancy. Steroids were prescribed for 12 patients at or after 24 weeks (39%), leukocyte count at admission varied from 6,000 to 16,200/mm3, with an average of 11,310, in only 9% it was greater than 15,000, immature forms were present in 10 cases (28%). Clinical chorioamnionitis occurred in 71%, being three times more frequent in parous women. Bacteriuria was present in 2 of 30 cases (6.6%). Two women developed laboratorial and clinical signs of sepsis, none of them needed hysterectomy. There were no maternal deaths. Mean gestational age at delivery was 24 weeks, ranging from 16 to 39 weeks. In the expectant group, preterm delivery rate was 68%. There was one case of abruption. Cesarean rate was 31%. Neonatal mortality was 42% (8 cases). Overall neonatal survival was 35% (11 in 32 newborns).ConclusionPerinatal mortality is high in pregnancies complicated by previable rupture of membranes, however gestational age at occurrence is a strong predictor of outcome. An individualized approach is the best management option regarding maternal risks and fetal outcomes.

Selective versus non-selective culture medium for group B streptococcus detection in pregnancies complicated by preterm labor or preterm-premature rupture of membranes

The objective of this study was to identify group B streptococcus (GBS) colonization rates and compare detection efficiency of selective versus non-selective culture media and anorectal versus vaginal cultures in women with preterm labor and preterm-premature rupture of membranes (PROM). A prospective cohort study of 203 women was performed. Two vaginal and two anorectal samples from each woman were collected using sterile swabs. Two swabs (one anorectal and one vaginal) were placed separately in Stuart transport media and cultured in blood-agar plates for 48 hours; the other two swabs were inoculated separately in Todd-Hewitt selective media for 24 hours and then subcultured in blood-agar plates. Final GBS identification was made by the CAMP test. A hundred thirty-two cultures out of 812 were positive. The maternal colonization rate was 27.6%. Colonization rates were 30% for preterm PROM and 25.2% for preterm labor. Todd-Hewitt selective medium detected 87.5% and non-selective medium 60.7% GBS-positive women. Vaginal samples and anorectal samples had the same detection rate of 80.3%. Anorectal selective cultures detected 75% of carriers; 39% of GBS-positive women were detected only in selective medium. A combined vaginal-anorectal selective culture is appropriate for GBS screening in this population, minimizing laboratory costs.

Congenital hydrocephalus: gestational and neonatal outcomes

PurposeTo evaluate gestational and neonatal outcomes in pregnancies complicated by fetal hydrocephalus.MethodsRetrospective analysis of 287 cases of fetal hydrocephalus followed at the Fetal Medicine Unit of the University of Campinas in the period of 1996 to 2006.ResultsMean maternal age was 25 years, mean gestational age at diagnosis was 27 weeks. There were 50 cases of isolated ventriculomegaly, 95 cases of Chiari II malformation and 142 cases of ventriculomegaly associated with other malformations. Preterm delivery and vaginal delivery were more frequent in the group of ventriculomegaly associated with other malformations. Cardiac, skeletal and renal malformations were the most common associated malformations. Cesarean section was common (95%) in the Chiari II group. Fetal and neonatal death occurred more frequently (29 and 68%, respectively) in the group of ventriculomegaly associated with other malformations. Chromosomal anomalies were present in 15% of 165 investigated cases.ConclusionsFetal and neonatal prognosis and outcome are associated with the presence of associated anomalies and aneuploidy.

Non‐immune hydrops fetalis: A prospective study of 53 cases

Non‐immune hydrops fetalis (NIHF) is a symptom caused by a heterogeneous group of conditions. Diagnostic investigations may constitute a real challenge. This study aimed to evaluate prospectively and systematically a series of NIHF cases using a research protocol expanded for studying inborn errors of metabolism (IEM) during 2 years—2010 and 2011. We also reviewed the frequency of IEM among the NIHF reported in literature. A clinical or etiopathogenic diagnosis was reached in 46 (86.8%) of the 53 studied cases. The main diagnostic groups were chromosomal anomalies (28.3%), syndromic (18.9%), isolated cardiovascular anomaly (7.5%) and congenital infection (7.5%). Metabolic causes were found in 5.7%, all lysosomal storage disorders (LSD). In seven (13.2%), no diagnosis was found in part because of incomplete evaluation. The hydrops was identified prenatally in 90.5% of cases. In 5.7% a spontaneous and complete resolution of the hydrops occurred during pregnancy. Overall mortality was 75.5%. The IEM frequency in the present study (5.7%) was higher than that usually reported. We suggest performing studies directed to IEMs if the more common causes are excluded.

Body stalk anomaly: adverse maternal outcomes in a series of 21 cases

To evaluate the demographic characteristics of cases with body stalk anomaly (BSA) and describe the obstetric outcome.

Group B streptococcus maternal and neonatal colonization in preterm rupture of membranes and preterm labor

PURPOSE To identify the prevalence and risk factors of maternal colonization by group B streptococcus (GBS) in pregnant women with premature labor (PL) and/or premature membrane rupture (PMR). METHODS Two anal and two vaginal swabs were collected from 203 pregnant women with diagnosis of PL or PMR assisted at the practice along one year. Pregnant women with imminent labor at admission were excluded. One swab of each source was placed in a transfer milieu and sent for culture in blood-agar plates; the two remaining swabs were incubated for 24 hours in Todd-Hewitt milieu for further sowing in blood-agar plates. Risk factors were analyzed by the chi-square test, Students t-test (p-value set at 0.05 and 95% confidence interval) and logistic regression. The following variables were analyzed: age, race, parity and mother schooling; culture results by source and type of culture; admission diagnosis; gestational age at admission; asymptomatic bacteriuria; gestational age at delivery; type of delivery; neonatal GBS colonization rate and immediate neonatal condition. RESULTS Prevalence of maternal GBS colonization was 27.6% (56 cases). The colonization rates according to gestational complications were 30% for PMR, 25.2% for PL and 17.8% for PL + PMR. Univariate analysis has shown that the variables Caucasian race, low level of schooling and bacteriuria were associated with higher colonization rates. Multivariate analysis showed that the presence of urinary infection was the only variable associated with maternal colonization. The GBS detection rate was significantly higher with the use of a selective milieu and collection from both anal and vaginal sources. The neonatal colonization rate was 3.1%. Two cases of early sepsis by GBS occurred in the sample, with prevalence of 10.8 cases per one thousand live births and 50% mortality rate. CONCLUSION The studied sample showed high maternal colonization rates by Streptococcus agalactiae. To increase GBS detection rate, it is necessary to use a selective culture milieu and to combine anal-rectal and vaginal cultures. There was a high incidence of early neonatal sepsis.