Márcia Maria Auxiliadora de Aquino

Risk factors associated to fetal death

OBJECTIVE The purpose of this study was to investigate risk factors associated to fetal death in a Brazilian population. DESIGN A case control study. SETTING The Hospital Maternidade Leonor Mendes de Barros in São Paulo. PARTICIPANTS 122 pregnant women with diagnosis of fetal death and gestation age of 20 or more weeks and 244 controls of pregnant women who delivered liveborns. VARIABLES STUDIED The fetal death (dependent variable), independent variable (the social demographic factors, clinical and obstetrical history, prenatal care indicators and pathological conditions). RESULTS The risk factors associated to fetal death were abruptio placentae, syphilis, few prenatal care visits, one or more previous stillbirths, hospitalization during pregnancy, diabetes, age above or equal to 25 years, hypertension during pregnancy, anemia and age below 20 years. CONCLUSIONS Results of the current study might be useful to orientate a primary prevention health program, specially those concerning antenatal care.

Misoprostol versus oxytocin for labor induction in term and post-term pregnancy: randomized controlled trial.

CONTEXT Misoprostol, a synthetic E1 methyl analog prostaglandin, is at present receiving attention as a cervical modifier and labor induction agent. However, there is still a need for better determination of its safety and effectiveness. OBJECTIVE To compare intravaginal misoprostol versus intravenous oxytocin for cervical ripening and labor induction in pregnant women with unripe cervices. DESIGN Randomized controlled trial. SETTING The study was performed at the Leonor Mendes de Barros Maternity Hospital between November 1998 and December 2000. PARTICIPANTS 210 pregnant women with intact membranes and indication for labor induction were selected. PROCEDURES The women randomly received 25 g of vaginal misoprostol every 4 hours, not exceeding 8 doses (105 women), or oxytocin in a continuous infusion (105 women). MAIN MEASUREMENTS The main parameters measured were: latent period, time from induction to vaginal delivery, delivery route, occurrence of vaginal delivery with time, occurrence of uterine tonus alterations, hypoxia and neonatal morbidity. To verify the statistical significance of the differences between the groups, the chi-squared, Student t and log-rank tests were used. RESULTS There were no significant differences between the groups concerning conditions for labor induction, age, parity, race, marital status, family income, initial Bishop Index and number of prenatal visits. The cesarean section rate, latent period and period from induction to vaginal delivery were significantly lower for the misoprostol group. With regard to uterine tonus alterations, tachysystole was significantly more common in the misoprostol group. However, there was no difference in hypoxia and neonatal morbidity between the groups. CONCLUSION 25 g of misoprostol used vaginally every 4 hours is safer and more efficient for cervical ripening and labor induction than oxytocin.

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).

Epidemiologia do abortamento na adolescência

Purpose: to evaluate the social, demographic and obstetrical profile of adolescents as compared with adult women hospitalized for abortion complications. Material and methods: this is a descriptive study that evaluated 230 women with abortion complications. Among them, 59 were adolescents hospitalized at the IMIP Maternity (Recife, Brazil) from August 1994 to July 1995. The variables studied were: educational level, marital status, any paid activity, gestation age, number of pregnancies, desire to become pregnant, use of anticonceptive method, kind of relationship, reason for voluntary interruption, clinical classification of abortion and associated complications. The procedure for data analysis was the distribution of variables among adolescents and adults, the differences being evaluated through c2 and c2 for trend. Results: compared with the adult women who aborted, the adolescents showed a lower number of paid activity and multiparity and a higher number of pregnancies resulting from an unstable relationship. Conclusions: the results indicated that biologicallly the adolescents who were hospitalized for abortion have a similar profile to adult women. What differentiates them are the unfavorable social and demographic conditions that they are faced with at their generally unplanned first pregnancies.Objetivo: avaliar o perfil socio-demografico e obstetrico das adolescentes internadas por abortamento, comparativamente ao das mulheres adultas internadas pela mesma causa. Material e metodos: Trata-se de um estudo descritivo que avaliou 230 mulheres com complicacoes por abortamento, das quais 59 eram adolescentes, internadas na Maternidade do IMIP (Instituto Materno-Infantil de Pernambuco) no periodo de agosto de 1994 a julho de 1995. As variaveis estudadas foram: grau de escolaridade, situacao marital, atividade remunerada, idade gestacional, numero de gestacoes, desejo de gravidez, uso de MAC, tipo de relacionamento, motivo da interrupcao voluntaria, classificacao clinica do abortamento e complicacoes associadas. Para a analise dos dados, procedeu-se a distribuicao das variaveis entre adolescentes e adultas, utilizando-se os testes estatisticos do χ 2 e χ 2 para tendencia. Resultados: comparativamente a mulheres adultas que abortaram, as adolescentes apresentaram uma menor proporcao de atividade remunerada e de multiparidade e uma maior proporcao de gestacoes resultantes de um relacionamento nao-estavel. Conclusoes: os resultados deste estudo permitem concluir que biologicamente as adolescentes que sao internadas por abortamento tem um perfil semelhante ao das mulheres adultas. O que as diferenciam destas sao as condicoes sociais e demograficas desfavoraveis que enfrentam em suas primeiras gestacoes, geralmente nao planejadas. PALAVRAS-CHAVE: Aborto. Adolescencia. Mortalidade materna.

O Impacto da Idade Materna Avançada sobre os Resultados da Gravidez

Objetivo: identificar o efeito da idade sobre os resultados maternos e perinatais das gestacoes ocorridas em mulheres com 40 anos ou mais. Metodos: comparamos 494 gestantes com mais de 40 anos, com 988 gestantes com idade entre 20 e 29 anos, pareando-as por paridade. Apos controlar possiveis variaveis confundidoras pela analise multivariada, a idade materna avancada manteve associacao com a maior prevalencia de hipertensao arterial, apresentacao anomala, parto por cesaria, hemorragia puerperal, indice de Apgar baixo, morte perinatal, natimortalidade e sofrimento fetal intraparto. Resultados: a idade materna avancada esteve isoladamente associada a hipertensao arterial, apresentacao anomala, diagnostico de sofrimento fetal intraparto, parto por cesaria e hemorragia puerperal. Com relacao aos resultados neonatais, a idade materna avancada estava associada independentemente apenas ao baixo indice de Apgar, morte perinatal e obito fetal. Conclusoes: esses achados mostram a necessidade de assistencia obstetrica adequada com atencao especial a esses fatores para procurar melhorar os resultados maternos e perinatais das gestantes com idade avancada.

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.

Conduta obstétrica no óbito fetal

Although 80 to 90% of all dead fetuses may be spontaneously eliminated after two to three weeks from death, labor induction has been the mostly used management. The purpose of the current study was to evaluate the results of labor induction for pregnancies with fetal death and gestation age above 20 weeks. It was a descriptive clinical study which was performed at the Hospital e Maternidade Leonor Mendes de Barros in Sao Paulo, Brazil. One hundred and twenty-two pregnancies with fetal death were evaluated regarding their social and demographic characteristics, causes of fetal death, previous pregnancies history and delivery (induction, route, complications). The statistical procedures used were estimation of mean and standard deviation and c2. The main causes of fetal death were hypertension and infections. The mostly used drug for labor induction was misoprostol (37.7%) followed by oxytocin (19.7%), while 27% of cases had spontaneous onset of labor. The mean time of induction was 3 hours. The majority of women had vaginal delivery and cesarean section was performed in 9.1% of them. It is concluded that labor induction for fetal death is safe and efficient, irrespective of the method used. Misoprostol when used in the vagina is specially useful for cases with an unripe cervix because of the modifying effect of the drug on the cervix.

Epidemiologia do óbito fetal em população de baixa renda

A morte fetal nao e uma entidade rara e, em paises em desenvolvimento, suas causas mais prevalentes continuam sendo passiveis de controle e/ou tratamento. O objetivo deste estudo foi investigar causas de morte fetal em uma populacao brasileira. Foi um estudo descritivo realizado no Hospital Maternidade Leonor Mendes de Barros, em Sao Paulo. Foram estudadas 122 gestantes com diagnostico de obito fetal e idade gestacional de vinte semanas ou mais. Os procedimentos estatisticos utilizados foram media e desvio-padrao. As principais causas de morte identificadas foram hipertensao arterial e infeccoes e em um quarto dos casos a causa nao foi determinada. Concluiu-se que uma proporcao importante de obitos era prevenivel e que houve taxa significativa de causas nao-identificadas. Os resultados deste estudo poderao ser uteis para orientacao de programas de prevencao primaria, principalmente quanto a assistencia pre-natal.

Eficácia de dinoprostone e misoprostol para indução do trabalho de parto em nulíparas

PURPOSE: to determine the efficacy and safety of dinoprostone and misoprostol for the induction of vaginal childbirth, with or without the use of oxytocin in nulliparous women. METHODS: in this retrospective observational study, 238 patients were subjected to the induction of delivery from January 2008 to February 2010 with the use of misoprostol 25 mcg by the vaginal route or a pessary containing 10 mg of dinoprostone. A total of 184 patients were selected, with the following characteristics: nulliparous, gestational age of 37-42 weeks, singleton pregnancies, cephalic presentation, intact membranes, and Bishop score < 3. Obstetric and neonatal data were analyzed and compared between groups. The Student t-test, chi-square test and Fishers exact test were used for statistical analysis, with the level of significance set at p<0.05. RESULTS: the rate of vaginal childbirth did not differ significantly in patients who used misoprostol and dinoprostone (43.2% versus 50%; p = 0.35, respectively). The ripening of cervix was higher in the group treated with misoprostol (87.3% versus 75.6%, p=0.04). The use of oxytocin was necessary in 58.8% of the misoprostol group and 57.3% in the dinoprostone group after the ripening of cervix. Failed induction was the primary indication of caesarean section delivery in both groups, with no significant difference between them. Fetal and maternal adverse events, such as tachysystole and Apgar scores were similar. CONCLUSION: dinoprostone and misoprostol are both effective for vaginal childbirth induction, although they need to be combined with oxytocin. They showed a similar safety profile, with misoprostol being more efficient regarding cervical ripening.

Anticorpos anticardiolipina entre gestantes com óbito fetal

Objetivo: avaliar a prevalencia de anticorpos anticardiolipina entre gestantes com obito fetal intra-uterino. Pacientes e Metodos: foi um estudo de corte transversal que avaliou 109 gestantes hospitalizadas com o diagnostico de morte fetal intra-uterina e idade gestacional de 20 semanas ou mais, durante o periodo de maio de 1998 a setembro de 1999, da Maternidade da Universidade Estadual de Campinas e do Hospital Maternidade Leonor Mendes de Barros, em Sao Paulo. Estas mulheres foram submetidas a exames laboratoriais de rotina para a identificacao da causa do obito, incluindo a determinacao serica do anticorpo anticardiolipina, por meio dos niveis de IgG e IgM. Os resultados de IgG sao expressos em unidades GPL e os de IgM em unidades MPL, sendo considerados positivos, nos dois casos, os valores acima de 10 unidades. Os procedimentos estatisticos utilizados foram o calculo de medias, desvio padrao e comparacao dos grupos por testes t de Student, Fisher e c2. Resultados: a prevalencia de positividade para o anticorpo anticardiolipina foi de 18,3%. As mulheres eram predominantemente jovens, com media de idade em torno de 27 anos. As principais causas identificadas de morte foram: hipertensao (26,1%), hemorragia durante o terceiro trimestre de gestacao (9,9%) e malformacao fetal (8,1%). Em cerca de um terco dos casos, a causa da morte fetal nao foi identificada. Considerando os 20 casos com positividade para anticorpo anticardiolipina, a proporcao de causas nao identificadas caiu para 29%. Conclusoes: e importante determinar a presenca de anticorpos anticardiolipina em mulheres com perdas fetais com o proposito de elucidar outras causas de morte fetal, especialmente a sindrome antifosfolipide e demais situacoes correlatas. Para estes casos e necessario o aconselhamento e o tratamento destas mulheres em gravidezes futuras.Objetivo: avaliar a prevalencia de anticorpos anticardiolipina entre gestantes com obito fetal intra-uterino. Pacientes e Metodos: foi um estudo de corte transversal que avaliou 109 gestantes hospitalizadas com o diagnostico de morte fetal intra-uterina e idade gestacional de 20 semanas ou mais, durante o periodo de maio de 1998 a setembro de 1999, da Maternidade da Universidade Estadual de Campinas e do Hospital Maternidade Leonor Mendes de Barros, em Sao Paulo. Estas mulheres foram submetidas a exames laboratoriais de rotina para a identificacao da causa do obito, incluindo a determinacao serica do anticorpo anticardiolipina, por meio dos niveis de IgG e IgM. Os resultados de IgG sao expressos em unidades GPL e os de IgM em unidades MPL, sendo considerados positivos, nos dois casos, os valores acima de 10 unidades. Os procedimentos estatisticos utilizados foram o calculo de medias, desvio padrao e comparacao dos grupos por testes t de Student, Fisher e χ 2 . Resultados: a prevalencia de positividade para o anticorpo anticardiolipina foi de 18,3%. As mulheres eram predominantemente jovens, com media de idade em torno de 27 anos. As principais causas identificadas de morte foram: hipertensao (26,1%), hemorragia durante o terceiro trimestre de gestacao (9,9%) e malformacao fetal (8,1%). Em cerca de um terco dos casos, a causa da morte fetal nao foi identificada. Considerando os 20 casos com positividade para anticorpo anticardiolipina, a proporcao de causas nao identificadas caiu para 29%. Conclusoes: e importante determinar a presenca de anticorpos anticardiolipina em mulheres com perdas fetais com o proposito de elucidar outras causas de morte fetal, especialmente a sindrome antifosfolipide e demais situacoes correlatas. Para estes casos e necessario o aconselhamento e o tratamento destas mulheres em gravidezes futuras.