Renato Augusto Moreira de Sá

Síndromes hipertensivas da gestação e repercussões perinatais

OBJECTIVES: to assess perinatal effects of pregnancy hypertensive syndromes. METHODS: hospital-based observational and retrospective study of a tertiary Brazilian center, from January, 1996 to October, 2003. Twelve thousand and two hundred and seventy two (12.272) pregnancies met the inclusion criteria. Two types of hypertension were considered: gestational hypertension (GH) and chronic hypertension (CH). Results of the study demonstrated that newborns of mothers with gestational hypertension and chronic hypertension were small for gestational age (SGA), had low Apgar score in the 1o and 5o minutes, neonatal infection, meconium aspiration syndrome (MAS), prematurity and respiratory distress syndrome (RDS). RESULTS: 1259 (10.26%) had hypertension, 344 (2.80%) were classified as GH, 915 (7.45%) as CH and 11.013 (89.74%) had no hypertension. GH was risk factor for SGA, low Apgar score in the first and fifth minutes, neonatal infection and prematurity, but not for MAS and RDS. CH was a risk factor for SGA, low Apgar score in the first minute, MAS, prematurity and RDS, but not for low Apgar score in the fifth minute and neonatal infection. When comparing the relative risk between CH and GH an increased risk for prematurity in CH was determined. CONCLUSIONS: our data suggest that CH and GH increased the risks for the outcomes studied. An increased risk for prematurity in CH was noted.

Changes in Ophthalmic Artery Doppler Indices in Hypertensive Disorders During Pregnancy

To compare the ophthalmic artery Doppler indices observed in women with singleton pregnancies complicated by hypertension and to correlate the indices observed in hypertensive pregnant women with those observed in healthy pregnant women.

Neonatal outcome in women with preterm premature rupture of membranes (PPROM) between 18 and 26 weeks

Abstract Objective: The aim of this study was to identify adverse neonatal outcomes and identifies the predictors of adverse neonatal outcomes in premature rupture of membranes before 26 weeks. Methods: Data were collected between January 2005 and December 2011 from all pregnant women who presented preterm premature rupture of membranes (PPROM) between 18 and 26 complete weeks of gestation and were admitted to one of three Brazilian institutes. The adverse outcomes included mortality or the development of a severe morbidity during the length of stay in the neonatal intensive care unit (NICU). The descriptive statistics of the population were reported. A multiple logistic regression was performed for each predictor of neonatal adverse outcomes. The area under the receiver operating characteristics curves for the birth weight was calculated. Results: Composite adverse outcomes during the NICU stay occurred in 82.1% (n = 23) of the cases and included 33 (54%) neonatal deaths, 19 (67.8%) cases of retinopathy of prematurity (ROP), 13 (46.4%) cases of pulmonary hypoplasia (BPD), 8 (28.5%) cases of periventricular-intraventricular hemorrhage (PIH) and 3 (10.7%) cases of periventricular leukomalacia (PVL). Only 17.8% (n = 5) of the neonates survived without morbidity. The area under the curve for the birth weight was 0.90 (95% IC: 0.81–0.98) for the prediction of mortality. Conclusions: PPROM before 26 weeks has a high morbidity and mortality, and the significant predictors of neonatal mortality and adverse outcomes were antibiotic prophylaxis, latency period, GA at birth and birth weight. Nevertheless, the only independent significant predictor of survival rate was birth weight.

Ultrasound in Africa: what can really be done?

Abstract Today we are living in a globalized world in which information on what is happening in one part of the world is easily communicated to other parts of the world. This happens thanks to advancement in science and technology. One area where technology has made the greatest impact is heath care provision. Ultrasound technology is now playing a critical role in health care provision particularly in Obstetrics and Gynaecology. This has significantly assisted in provision of quality health care to pregnant women and their unborn infants and in reducing maternal and neonatal morbidity and mortality in the developed world. Africa the continent with greatest health care challenges and with the highest maternal and neonatal mortalities is yet to fully utilize this important technology. The need for this technology is great as the conditions requiring its application abound. The effective application of Ultrasound however faces serious challenges in Africa. To successfully entrench Ultrasound in quality Obstetrics and Gynaecology care various approaches must be adopted to overcome the challenges. The aim of this paper is to identify the benefits and the challenges inimical to the application Ultrasound in Obstetrics and Gynecology in Africa. It also examines what needs to be done to achieve better application of Ultrasound in Obstetrics and Gynecology.

Doppler Velocimetry of the Ophthalmic Artery Reproducibility of Blood Flow Velocity Measurements

The aim of this study was to investigate the interobserver reliability for measuring ophthalmic artery Doppler indices.

Is intrauterine surgery justified? Report from the working group on ultrasound in obstetrics of the World Association of Perinatal Medicine (WAPM)

Abstract Fetal surgery involves a large number of heterogeneous interventions that vary from simple and settled procedures to very sophisticated or still-in-development approaches. The overarching goal of fetal interventions is clear: to improve the health of children by intervening before birth to correct or treat prenatally diagnosed abnormalities. This article provides an overview of fetal interventions, ethical approaches in fetal surgery, and benefits obtained from antenatal surgeries.

PP082. Ophthalmic artery doppler for identification of severe preeclampsia in pregnancies complicated by hypertension

INTRODUCTION Hypertension is the most common disorder that occurs during pregnancy and one of the main causes of maternal mortality worldwide. Among the hypertensive disorders that affect pregnancy, preeclampsia (PE) is the major cause of maternal mortality, maternal morbidity, perinatal death, prematurity and intrauterine growth restriction. The acute cerebral complications in PE account for at least 75% of maternal death. Central nervous system hemodynamic modifications in PE are a controversial issue. Neurological involvement in PE-eclampsia syndrome fulfills the criteria of posterior reversible encephalopathy syndrome (PRES). The pathophysiology of PRES is still under investigation. Assessment of cerebral circulation is challenging. Noninvasive techniques, especially transcranial Doppler sonography, are becoming more widely used to evaluate cerebral flow. Ophthalmic artery Doppler is a noninvasive examination used to study central vascular flow that has been shown to be a promising method in the evaluation of pregnant women with hypertension. OBJECTIVES The aim of this study was to compare the ophthalmic artery Doppler indices observed in singleton pregnant women complicated by hypertension (study group) and to correlate the indices observed in hypertensive pregnant women with those observed in normal pregnant women (control group). METHODS Ophthalmic artery Doppler indices of 30 mild and 30 severe pre-eclamptic women and 30 pregnant women with chronic hypertension (CH) at 20-40weeks of gestational age (GA) were compared. The control group consisted of 289 healthy pregnant women. Resistance index (RI), pulsatility index (PI), and peak ratio (PR) were determined in the right eye. The mean and SD were calculated for each group. Analysis of variance (ANOVA) was used to compare Doppler indexes means between groups. As significant differences were determined by ANOVA analysis, each group was compared by the Tukey method. Receiver operating characteristics (ROC) curves were used to determine the predictive power of ophthalmic artery Doppler indexes for the identification of severe pre-eclamptic women. P<0.05 was considered statistically significant. RESULTS Significant differences were found between the values obtained for RI, PI, and PR in severe PE women compared to the other groups (study and control). The mean and SD for IR, IP and PR in mild PE, severe PE and CH groups were respectively 0.73 (±0.06), 1.63 (±0.35) and 0.65 (±0.10); 0.63 (±0.09), 1.13 (±0.31) and 0.89 (±0.12); 0.73 (±0.07), 1.66 (±0.49) and 0.66 (±0.14). The mean and SD for IR, IP and PR in normotensive pregnant women were 0.75 (±0.05), 1.88 (±0.43), 0.52 (±0.10). The optimal cut-off values for IR, IP and PR for the identification of severe pre-eclamptic women determined by roc curves was 0.657, 1.318, 0.784 (sensitivity and specificity were 0.633 and 0.919, 0.733 and 0.888, 0.833 and 0.974, respectively). The area under the ROC curve for IR was 0.787(95% CI: 0.68-0.89), for IP was 0.797 (95% CI: 0.69-0.90) and for PR was 0.886 (95% CI: 0.80-0.96). CONCLUSION Ophthalmic Doppler is a useful method in the identification of severe PE. PR was best ophthalmic Doppler index at discriminating between severe PE and pregnant women with mild PE or chronic hypertension as determined by roc curve.

3 – Myasthenia Gravis and Pregnancy

Publisher Summary Myasthenia gravis (MG) is a chronic autoimmune disorder in which autoantibodies against the acetylcholine receptor (AChR Abs) at the neuromuscular junction impair neuromuscular transmission, causing weakness of skeletal muscles. It is considered a rare disease in the general population and also in pregnancy. Women are more affected than men at a ratio of 6:4. Main signs and symptoms include diplopia and ptosis that represent involvement of extrinsic ocular muscles. Fifteen percent of patients will only have this ocular involvement, but it may progressively affect the bulbar muscles used for swallowing. In addition, when limbs are affected, fluctuating weakness and easy fatigability of skeletal muscles are seen. The onset of MG can be triggered during pregnancy or postpartum. In pre-existing MG, exacerbations are frequently unpredictable and not unusual during pregnancy, labor, or the postpartum period. So it is recommended to myasthenic patients considering pregnancy should seek preconception counseling in order to improve their clinical condition, minimize the use of immunosuppressive drugs, and address the need for thymectomy.

Doppler Sonography of Maternal Cerebral Arteries in Pregnancy: Side-to-Side Differences

Background/Aims: To study side-to-side differences in blood flow of the common and internal carotid arteries, and the vertebral arteries (VAs) in women with uncomplicated pregnancies as a first step to build a reference values chart. Methods: A total of 155 healthy pregnant women between 20 and 40 weeks’ gestation were included. Doppler sonography of the common and internal carotid arteries and VAs was performed on both sides. Parameters measured included diameter, peak systolic velocity, systolic-diastolic ratio, end-diastolic velocity, pulsatility index and resistance index. Statistical analysis was performed using the S-Plus 8.0 program. Normality was determined using the Kolmogorov-Smirnov test. Differences between sides were tested using Student’s paired t test, association using linear correlation, and agreement using the Bland-Altman method. Results: Mean values were equal between sides for all parameters with the exception of the end-diastolic velocity in the VAs. The association and agreement between the measurements taken from the right and left sides were poor. Bland-Altman plots also indicated low agreement between sides. All parameters showed significant right-to-left differences. Conclusion: Despite the equality between means, right and left flows through the vessels studied differed as there was poor association and agreement.

OC16.02: Percutaneous fetoscopic 3‐layer closure of large open spina bifida defects using a bilaminar skin substitute

83 to 450 minutes. A total of 42 cases already delivered (4 uneventful vaginal), no uterine dehiscence observed. PPROM occurred in 34/42 (81%) cases. Fetuses remained in utero on average for 6,1w (5d to 13w). Mean GA at delivery was 32,6w, only 16,7% below 30w, mean birthweight was 1906g (890 to 2960g). No intrauterine demise occurred. Two neonatal deaths due to sepsis occurred. VP shunt was placed in 42% cases and two infants died due to shunt related infection. Long-term follow up was obtained in 38 cases, mean 8,9 months. The functional level of the lesion was assessed in total 23 cases and was found to be one or more levels better than the anatomical level in 70%. Conclusions: Entirely percutaneous fetoscopic correction is feasible and safer than open fetal approach; however, it is associated with an increased risk of PPROM. Fetoscopic correction can be used in cases were open surgery cannot. The CECAM technique statistically significantly improves motor outcome, when compared to MOMS trial results, so it is not only safer for mothers but also better for babies.