Maria Célia Mendes

Incidência de cesáreas segundo fonte de financiamento da assistência ao parto

OBJECTIVE: To study the types of delivery according to the category of patient admission and the most frequently reported indications for cesarean sections. METHODS: In a retrospective survey of deliveries performed in the municipality of Ribeirao Preto, Sao Paulo, Brazil, from 1986 to 1995, the type of delivery, category of admission and recorded diagnoses were assessed. Data were obtained from the Center of Hospital Data Processing of the Department of Social Medicine in the University of Sao Paulo, Ribeirao Preto. RESULTS: A total of 86,120 deliveries were registered during the study period; 5.4% were allocated in the private category, 28.7% in the prepayment category, and 65.9% in the public health system (SUS). It was observed a decrease in the private and SUS categories and an increase in the prepayment category. During the study period, the percentage of cesarean deliveries increased from 68.3% to 81.8% in the private category and from 69.1% to 77.9% in the prepayment category, and decreased from 38.7% to 32.1% in the SUS category. The major indications for cesarean section were fetal distress, with the incidence of 9.5%, 10.9% and 9.0% in the private, prepayment and SUS categories, respectively; and cephalopelvic dystocia, at the rates of 5.8%, 6.5% and 3.9%, respectively. CONCLUSION: The incidence of cesarean section varied according to admission category, with a rising trend as the pregnant womans social status increased, but without a correlation with the obstetrical risk.

A Adolescente Grávida: Alguns Indicadores Sociais

Purpose: the objective of the present study was to determine the number and type of deliveries, category of admission to the hospital, occupation and obstetrical diagnosis for adolescents from the municipality of Ribeirao Preto, from January 1992 to December 1996. Methods: the information obtained from hospital discharge forms was analyzed at the Hospital Data Processing Center. The 6.04a-text processor Epi-Info System, a data bank and statistics for epidemiology produced by the Centers of Disease Control and Prevention (Atlanta, GA, USA), and Dbase IV were used to process the information. The association between variables was tested by the c2 test, with the level of significance set at 5%. The analyzed parameters were: number and type of delivery, category of hospital admission, occupation and obstetric diagnosis. Results: a total of 42,969 deliveries occurred during the study period, among which 7,134 (16.6%) corresponded to adolescent deliveries. An increase in the number of deliveries by girls in this age range occurred over the years, from 1,225 in 1992 to 1,538 in 1996. Deliveries were reported starting from 12 years of age, with a gradual increase in this number, especially after 14 years of age, when a 104.2% increase occurred for deliveries at this age, followed by 48.8% at 15 years, 36.1% at 16 years, 14.0% at 17 years, 52.8% at 18 years, and with practically no increase among 19-year-old girls. The highest number of deliveries (5,709) was recorded for the unified health system category of admission, followed by 1,277 deliveries for the prepaid category and 148 deliveries for the private category. With respect to occupation, 14.1% of the patients belonged to the economically active population, while 85.8% did not. Of the total deliveries, 59.2% were normal, 5.6% were forceps deliveries, and 35.2% were cesarean sections. The most frequent obstetrical diagnoses were: problems of fetus or placenta affecting maternal management (7.9%), fetus-pelvis disproportion (6.0%), problems with the amniotic cavity and membranes (5.0%), hypertension complicating delivery and puerperium (3.5%), and premature or false labor (3.4%). Conclusions: most deliveries were normal and occurred more frequently at the end of adolescence, especially among girls belonging to the unified health system. There was a predominance of adolescents not belonging to the economically active population. Some obstetrical complications were diagnosed at the time of resolution of pregnancy.

Doppler Study of the Uterine Arteries and Ovarian Stroma in Patients with Polycystic Ovary Syndrome

Doppler analysis of the uterine arteries and ovarian stroma was performed by transvaginal ultrasound in 24 patients with polycystic ovary syndrome (PCOS) and 22 ovulatory women. Vascularization of the ovarian stroma was more abundant in patients with PCOS than in control women, but no significant difference in the mean pulsatility index (PI) was observed between groups (1.14 ± 0.28 for the PCOS group and 1.05 ± 0.19 for the control group). The mean PI of the uterine arteries was significantly higher in the PCOS group (PI = 3.7 ± 0.8) than in the control group (PI = 2.9 ± 0.4). In the patients with PCOS, no correlation was observed between PI and luteinizing hormone, testosterone or androstenedione levels. Obesity had no effect on uterine artery PI, with no significant differences in this index when the 3 groups were subdivided into obese and non-obese groups.

First trimester fetal echocardiography.

Objective: The aims of this study were to assess the feasibility of performing a complete fetal echocardiographic study during the first trimester of pregnancy, to establish the best week to accomplish a complete evaluation, and to find a relationship between the diameters of the cardiac valves and gestational age. Methods: 46 fetuses with normal nuchal translucency and venous duct Doppler velocimetry were submitted to echocardiographic studies by the transvaginal approach between the 11 + 0 and 14 + 6 weeks of gestation. A complete echocardiographic evaluation was defined as an examination in which the three basic planes, four-chamber, longitudinal and short-axis views, were obtained. Results: The rates of complete echocardiography evaluation were 37, 85 and 100% at 11, 12 and 13–14 weeks, respectively. The longitudinal view was the easiest to obtain and the short-axis view was the most difficult one. The diameter of the cardiac valves was compared with the crown-rump length (CRL) and there was no statistically significant difference between either the diameters of the mitral and tricuspid or the aortic and pulmonary valves. A linear growth curve was constructed to demonstrate the diameter correlations. Conclusions: The study demonstrated the feasibility of a complete fetal echocardiographic evaluation by the transvaginal approach during the first trimester of gestation. The rate of a complete evaluation increased along the period and reached100% when the CRL was 64 mm or 13 weeks of gestational age. There was a linear correlation between the cardiac valve diameters and the CRL revealing a relationship between the cardiac and fetal development. The absence of a statistically significant difference between the left and right valve dimensions possibly means that there is no predominance of right or left chambers during this period of evaluation.

A mulher e o uso de álcool

Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto da Universidade de Sao Paulo – USP – Ribeirao Preto (SP), Brasil. 1 Professora Doutora do Departamento de Ginecologia e Obstetricia da Fundacao de Apoio ao Ensino, Pesquisa e Assistencia do Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto da Universidade de Sao Paulo – USP – Ribeirao Preto (SP), Brasil. 2 Mestrando do Departamento de Ginecologia e Obstetricia da Faculdade de Medicina de Ribeirao Preto da Universidade de Sao Paulo – USP – Ribeirao Preto (SP), Brasil. 3 Professor Doutor do Departamento de Ginecologia e Obstetricia da Faculdade de Medicina de Ribeirao Preto da Universidade de Sao Paulo – USP – Ribeirao Preto (SP), Brasil. Correspondencia:

Low-dose transdermal hormone therapy does not interfere with the blood pressure of hypertensive menopausal women: a pilot study

ObjectivesTo determine the effects of low-dose transdermal hormone therapy (HT) on systolic (SBP) and diastolic (DBP) blood pressure (BP) evaluated by 24-h ambulatory blood pressure monitoring (ABPM) in hypertensive postmenopausal women. MethodsThe study was conducted on 24 hypertensive postmenopausal women aged, on average, 54 years and under treatment with enalapril maleate (10–20 mg/day) combined or not with hydrochlorothiazide (25 mg/day). Thirteen women used a transdermal adhesive containing estradiol and norethisterone (25 and 125 μg active substance/day, respectively) and 11 did not receive HT. ABPM, lipid profile, and climacteric symptoms were evaluated before and 3 and 6 months after treatment. ResultsAfter 3 and 6 months of follow-up, there was a statistically significant reduction of the Blatt–Kupperman menopausal index in the treated group (19.6±8.3 vs. 9.6±5.9 vs. 9.7±7.0; P=0.01). No significant difference in any of the ABPM variables (areas under the systolic and diastolic curves, mean SBP and DBP, SBP and DBP loads and wakefulness-sleep variation) or in the lipid profile was observed between or within groups at the three time points studied. ConclusionLow-dose transdermal HT administered for 6 months was effective in improving climacteric symptoms and did not change BP values or circadian pattern in postmenopausal women with mild-to-moderate arterial hypertension taking antihypertensive medications.

Rastreamento e diagnóstico ecocardiográfico das arritmias e cardiopatias congênitas fetais

PURPOSE: to analyze the results of a screening and diagnostic program of arrhythmias and congenital heart disease in a reference hospital and the relevance of early diagnosis in the fetal and neonate evolution. METHODS: cardiac evaluation of 1159 fetuses was done in two different levels. Level I: by morphological ultrasound examination with the objective to detect the existence of either arrhythmias or structural cardiac malformations. Level II: by fetal echocardiography to establish the differential diagnosis. The results of level I in the arrhythmia group were compared with those of level II, and in the group with malformations the results of both levels were confronted with the neonate echocardiogram or necropsy. The kappa index was calculated to evaluate the concordance between the two levels. RESULTS: all detected arrhythmias in level I were confirmed in level II, there were no false negative cases and five patients with severe arrhythmia required pharmacological therapy. The diagnosis of structural malformation by level I had sensitivity of 72% and specificity of 98% and there were 28% of false-positive cases. In level II, the sensitivity and specificity of the diagnosis of congenital heart disease were 100 and 99%, respectively. The kappa index was 57% and indicated a moderate degree of concordance between the two levels. Fifty-one percent of the fetuses with diagnosis of cardiac malformations required pharmacological or invasive intervention immediately after birth. CONCLUSION: morphological ultrasound examination is a important tool in the screening of arrhythmias and congenital heart defects during fetal life. The sensitivity and specificity of the fetal echocardiogram were very high and the early diagnosis made it possible to treat the fetus with severe cardiac disease either during pregnancy or immediately after birth.

Padrão endometrial em mulheres submetidas à laqueadura tubária

PURPOSE: to study the histological modifications that occur in the endometrium of women before and six months after tubal ligation (TL) and to correlate these findings with progesterone (P4) levels. METHODS: the study was conducted on 16 women with normal menstrual cycles who were evaluated before and in the sixth cycle after TL. P4 levels were determined from the 8th day at 2-day intervals until ovulation and on the 8th, 10th and 12th day after ovulation or on the 24th day of the cycle. An endometrial biopsy was obtained between the 10th and 12th day after ovulation or on the 24th day of the cycle and a correlation with P4 was determined. Data were analyzed statistically by the nonparametric McNemar test for the evaluation of hormonal determination and by the exact Fisher test for the histological evaluation of the endometrium, with the level of significance set at p 10 ng/ml and 3/8 (37.5%) had P4 10 ng/ml in 4/7 (57.1%) and 0.05). CONCLUSION: six months after TL, the intermenstrual interval and the duration of bleeding were unchanged. P4 levels decreased during the luteal phase although this did not interfere in the endometrial response.

Fetal cardiac rhabdomyoma: analysis of five cases

PURPOSE to analyze the differential diagnosis, follow-up and therapeutic approach in five cases of primary cardiac tumors diagnosed during the prenatal period. METHODS during the period from January 1997 to December 2008, 7989 pregnant women were submitted to morphological ultrasound due to the presence of risk factors for fetal malformations. Fetuses with hyperechogenic intracardiac masses larger than 1 mm diagnosed by ultrasound evaluation of the fetal heart, were selected for study. The differential diagnosis between the different tumor types was made on the basis of the ultrasound characteristics of the masses. RESULTS five fetuses with hiperechogenic intracardiac masses were diagnosed, corresponding to a 0.06% prevalence rate. Gestational age ranged from 28 to 36 weeks (mean: 31), and maternal age ranged from 23 to 45 years (mean: 34.2). The most frequent location of the masses was the left ventricle (100%). Echographically, all masses were single or multiple, hyperechogenic, homogeneous and well delimited, compatible with a diagnosis of rhabomyoma. In cases in which the diameters of the masses were less than 20 mm, an expectant conduct was followed and no complications occurred during the prenatal period. One case with a huge tumor presented arrhythmia and cardiac insufficiency during the 35 gestational weeks, and the interruption of pregnancy was indicated. Tuberous sclerosis was associated in four cases (80%) and the diagnosis was confirmed during the postnatal follow-up. CONCLUSIONS fetal morphological ultrasonography is the main form of early detection of primary cardiac tumors. The fetal cardiac evaluation is of fundamental importance for the differential morphological characterization of cardiac masses and for the evaluation of cardiac function. Rhabdomyomas are the most common type of fetal tumor. An expectant pre and postnatal conduct is followed, with a low risk of complications and with the possibility of spontaneous regression in most cases. Postnatal clinical follow-up is mandatory due to the high frequency of associated tuberous sclerosis.

Nutritional Counseling Promotes Changes in the Dietary Habits of Overweight and Obese Adolescents with Polycystic Ovary Syndrome

Objective To evaluate the effects of nutritional counseling on the dietary habits and anthropometric parameters of overweight and obese adolescents with polycystic ovary syndrome (PCOS). Methods This was a prospective, longitudinal and auto-controlled study. Thirty adolescents aged 13-19 years-old, diagnosed with PCOS received nutritional counseling and were followed-up for 6 months. After the follow-up period, the results were evaluated through body weight, body mass index (BMI) and waist circumference (WC). Results Sixty-percent of the adolescents adhered to the nutritional counseling and, of these, 50% lost weight. Adolescents who lost weight changed their dietary habits by adopting hypocaloric diets and eating more meals per day, as per nutritional counseling. The waist circumference (WC) decreased significantly, although the body weight decreased non-significantly after adoption of a hypocaloric diet. Conclusion Although there was no significant weight loss, there was a considerable reduction in the WC associated with hypocaloric diets and with eating a greater number of meals per day.