Rossana Pulcinelli Vieira Francisco

Dopplervelocimetria dos Compartimentos Arterial e Venoso da Circulação Fetal e Umbilical em Gestação de Alto-Risco: Análise dos Resultados Perinatais

Purpose: to study the fetal hemodynamic profile in high-risk pregnancy and correlate it with perinatal results. Methods: transverse prospective study of 108 patients of the Obstetric Clinic of the Hospital das Clinicas, Sao Paulo University School of Medicine. The patients were evaluated at the Fetal Surveillance Unit, and Doppler examinations of umbilical, aorta, middle cerebral artery, inferior vena cava and ductus venosus were performed. The criteria for inclusion were patients whose delivery was in the next 24 hours after evaluation. Twin pregnancies and fetal malformations were excluded. Results: the hemodynamic implications in the fetal circulation were demonstrated by changes in the Doppler ultrasonographic results in the umbilical artery, aorta, middle cerebral artery, ductus venosus and in the inferior vena cava. The Doppler examinations were abnormal in the umbilical artery (25.9%), fetal aorta (24%), middle cerebral artery (34.2%), ductus venosus (18.2%) and inferior vena cava (46,6%). Segments of the fetal circulation which best correlated with the perinatal results were the umbilical artery and the ductus venosus. The abnormal results in the umbilical artery were significantly associated with 1st minute Apgar score <7 in 42.8% and need of neonatal intensive care unit in 50% of the cases. The abnormal results in the ductus venosus Doppler ultrasonography showed statistical association with 1st minute Apgar score <7 (52.6%), 5th min Apgar <7 (15.7%), acidemia at birth (60%), need of neonatal intensive care unit (52.6%) and neonatal death (21.1%). The predictive values of the ductus venosus Doppler for fetal acidemia were: sensitivity of 39.1; specificity of 90.4; positive predictive value of 60.0 and negative predictive value of 80.2. Conclusion: the Doppler ultrasonography allowed us to evaluate the fetal hemodynamics in the most varied situations and the study of the venous duct is an important examination in the evaluation of fetal hemodynamic response to hypoxia.

Hematological indices at birth in relation to arterial and venous Doppler in small‐for‐gestational‐age fetuses

Objective. To correlate Doppler results with hematological indices at birth in small‐for‐gestational‐age (SGA) fetuses. Design. Prospective study. Setting. Tertiary teaching hospital, Sao Paulo, Brazil. Population. One hundred singleton pregnancies with SGA fetuses of >27 weeks gestational age. Methods. All women had Doppler velocimetry of the umbilical arteries, middle cerebral artery, and ductus venosus within <72 hours prior to delivery. After birth, umbilical artery blood was collected for hematological analysis. Main outcome measures. The association between fetal Doppler velocimetry pulsatility index (PI) and some hematological indices. Results. Umbilical artery PI showed a positive correlation with nucleated red blood cell count in the umbilical cord (r = 0.46; p<0.01), and a negative correlation with platelet count (r= − 0.53; p<0.01) and white blood cell count (r= − 0.42; p<0.01). Middle cerebral artery PI was positively correlated with platelet count (r = 0.43; p<0.01) and white blood cell count (r = 0.38; p<0.01), and was negatively correlated with nucleated red blood cell count (r= − 0.39; p<0.01). The ductus venosus pulsatility index showed a positive correlation with nucleated red blood cell count (r = 0.36; p<0.01), and a negative correlation with platelet count (r= − 0.37; p<0.01) and white blood cell count (r= − 0.26; p<0.01). Conclusion. A significant positive or negative correlation between nucleated red blood cell, platelet and white blood cell counts, and Doppler indices suggests an association between placental insufficiency and the fetal hematological response.

Placental Transfer of IgG Antibodies Specific to Klebsiella and Pseudomonas LPS and to Group B Streptococcus in Twin Pregnancies

Group B Streptococcus (GBS), Klebsiella spp. and Pseudomonas spp. are important aetiological agents of neonatal infections in Brazil. There is a lack of data in the literature regarding the specific transport of immunoglobulin G (IgG) against these pathogens in multiple pregnancies. Maternal (n = 55) and umbilical cord (n = 110) blood samples were prospectively collected at birth from 55 twin pregnancies. The factors associated with cord levels and transfer ratios of IgG against GBS, Klebsiella and Pseudomonas were examined. The IgG umbilical cord serum levels specific to GBS, Klebsiella LPS and Pseudomonas LPS were significantly associated with maternal‐specific IgG concentrations and the presence of diabetes. The anti‐Klebsiella IgG cord serum concentrations were also related to birthweight and the presence of hypertension. The transfer ratios against GBS and Pseudomonas LPS were associated with maternal‐specific IgG concentrations. The transfer ratios for GBS and Pseudomonas LPS were associated with gestational age at delivery and the presence of diabetes, respectively. None of the examined parameters were related to Klebsiella LPS transfer ratios. We conclude that in twin pregnancies, specific maternal IgG serum concentrations and diabetes were the parameters associated with umbilical cord serum IgG concentrations reactive with the three pathogens investigated. All the other parameters investigated showed different associations with neonatal‐specific IgG levels according to the antigen studied. There was no uniformity of the investigated parameters regarding association with placental IgG transfer ratios against the GBS, Pseudomonas LPS and Klebsiella LPS.

Association between ultrasound findings and serum levels of vascular endothelial growth factor in ampullary pregnancy

OBJECTIVE To assess the association between ultrasound images and serum concentrations of vascular endothelial growth factor (VEGF) in ampullary pregnancies. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Fifty patients with ampullary pregnancy. INTERVENTION(S) Criteria for inclusion in the study were: singleton pregnancy from spontaneous conception; diagnosis of tubal pregnancy in the ampullary region; radical surgical treatment (salpingectomy); and measurement of serum VEGF, human chorionic gonadotropin, and progesterone on the day of surgery. An additional criterion was description of an ectopic mass by transvaginal ultrasound, as follows: [1] ectopic gestational sac containing an embryo with cardiac activity; and [2] tubal ring: a paraovarian formation similar to a gestational sac, not containing a viable embryo (an anechoic structure surrounded by a peripheral hyperechogenic halo); an empty ectopic gestational sac; a sac containing an embryo without cardiac activity; or a vitelline vesicle. MAIN OUTCOME MEASURE(S) Association between ultrasound images and serum concentrations of VEGF. RESULT(S) An association was found between ultrasonographic images and VEGF serum concentrations. Ectopic embryos with cardiac activity were associated with higher levels of serum VEGF. CONCLUSION(S) In ampullary pregnancy, higher serum levels of VEGF are associated with the finding of an embryo with cardiac activity on transvaginal ultrasound. Greater production of VEGF likely creates development conditions more conducive to ectopic embryos.

Fetal venous circulation in monochorionic twin pregnancies with placental insufficiency: prediction of acidemia at birth or intrauterine fetal death

To investigate fetal venous Doppler measurements in monochorionic twin pregnancies complicated by placental insufficiency and the relationship between fetal venous flow and acidemia at birth or intrauterine fetal death.

Avaliação da maturidade fetal em gestações de alto risco: análise dos resultados de acordo com a idade gestacional

OBJETIVO: Estudar a avaliacao da maturidade fetal em gestacoes de alto risco e analisar os resultados neonatais. METODOS: Entre julho de 1998 e agosto de 1999 foram realizadas, no Setor de Vitalidade Fetal da Clinica Obstetrica do HC-FMUSP, 180 amniocenteses para avaliacao da maturidade fetal, sendo realizados os testes de Clements em tres tubos e a contagem de celulas orangiofilas coradas com Azul de Nilo a 0,1%. Os resultados perinatais foram correlacionados com a maturidade fetal em 75 casos cujo parto ocorreu ate sete dias apos a puncao. RESULTADOS: Na macroscopia, 91% das amostras apresentavam liquido amniotico claro, 3,3% meconial e 5,6% hemorragico. A maturidade foi observada em 28% dos exames realizados. Na avaliacao dos resultados perinatais, quando a maturidade estava ausente, a necessidade de intubacao do recem-nascido ocorreu em tres casos (13%) e nos fetos maduros isto ocorreu em um caso (2,5%) (p<0,05). A necessidade de internacao em UTI neonatal ocorreu em 65% dos recem-nascidos que apresentavam liquido imaturo e em apenas 10% dos maduros (p<0,0001). CONCLUSOES: Os recem-nascidos das gestantes com maturidade fetal presente apresentaram com menor frequencia necessidade de intubacao na sala de parto e de internacao em UTI neonatal, demonstrando menor morbidade perinatal. Entre a 29a e a 32a semana de gestacao, foram observados cerca de 10% de fetos maduros, demonstrando que, quando necessario, a avaliacao da maturidade pode ser realizada neste periodo da gravidez. Nao observamos casos com maturidade fetal abaixo de 29 semanas, limitando a realizacao deste exame neste periodo.

Diástole zero ou reversa à dopplervelocimetria das artérias umbilicais

A diastole zero ou reversa a dopplervelocimetria das arterias umbilicais representam um grave comprometimento da funcao placentaria, evoluindo frequentemente com sofrimento fetal cronico e elevadas taxas de morbidade e mortalidade perinatais. A avaliacao da vitalidade fetal e de fundamental importancia, principalmente nas gestacoes longe do termo, onde as sequelas da prematuridade podem repercutir de forma grave na sobrevida fetal. Os autores relatam a conduta obstetrica frente estes diagnosticos

Can thrombophilia worsen maternal and perinatal outcomes in cases of severe preeclampsia

OBJECTIVE To evaluate whether thrombophilia worsens maternal and foetal outcomes among patients with severe preeclampsia (PE). METHOD From October 2009 to October 2014, an observational retrospective cohort study was performed on pregnant women with severe PE diagnosed before 34 weeks of gestation and their newborns hospitalized at the Clinics Hospital, FMUSP. Patients who had no heart disease, nephropathies, pre-gestational diabetes, gestational trophoblastic disease, foetal malformation, or twin pregnancy and who underwent thrombophilia screening during the postnatal period were included. New pregnancies of the same patient; cases of foetal morphological, genetic, or chromosomal abnormalities after birth; and women who used heparin or acetylsalicylic acid during pregnancy were excluded. Factor V Leiden, G20210A prothrombin mutation, antithrombin, protein C, protein S, homocysteine, lupus anticoagulant, and anticardiolipin IgG and IgM antibodies were analysed. The groups with and without thrombophilia were compared regarding their maternal clinical and laboratory parameters and perinatal outcomes. RESULTS Of the 127 patients selected, 30 (23.6%) had thrombophilia (hereditary or acquired). We found more white patients in thrombophilia group (p = .036). Analysis of maternal parameters showed a tendency of thrombophilic women to have more thrombocytopenia (p = .056) and showed worsening of composite laboratory abnormalities (aspartate aminotransferase ≥ 70 mg/dL, alanine aminotransferase ≥ 70 mg/dL, platelets < 100,000/mm3, serum creatinine ≥ 1.1 mg/dL; p = .017). There were no differences in foetal perinatal outcomes. CONCLUSION The presence of thrombophilia leads to worsening of maternal laboratory parameters among patients with severe forms of PE but without worsening perinatal outcomes.

An unfavorable intrauterine environment may determine renal functional capacity in adulthood: a meta-analysis

Since studies show that an unfavorable environment during intrauterine development predisposes individuals to several diseases in adulthood, our objective is to assess the relation between fetal growth restriction and chronic renal disease in adults. We searched four different electronic databases through November 2017: CENTRAL, EMBASE, LILACS and MEDLINE. We selected studies with longitudinal or transversal designs associating kidney function in adulthood with low birth weight. Two reviewers evaluated the inclusion criteria and the risk of bias and extracted data from the included papers. Thirteen studies were selected for the systematic review and meta-analysis. We observed increased risks of presenting end-stage renal disease (risk ratio 1.31, 95% confidence interval: 1.17, 1.47), a lower glomerular filtration rate (ml/min) (mean difference 7.14; 95% confidence interval: -12.12, -2.16), microalbuminuria (risk ratio 1.40; 95% confidence interval: 1.28, 1.52) and a small increase in the albumin/creatinine ratio (mean difference 0.46; 95% confidence interval: 0.03, 0.90) in the low birth weight patients, compared with control group. These findings suggest that low birth weight is associated with renal dysfunction in adults.

Risk assessment of venous thromboembolism and thromboprophylaxis in pregnant women hospitalized with cancer: Preliminary results from a risk score

OBJECTIVES: Hospitalized patients with cancer are at high risk of developing venous thromboembolism, and the risk increases with pregnancy. The aim of this study was to apply a thromboprophylaxis protocol with a venous thromboembolism risk score for hospitalized pregnant women with cancer and to evaluate the effects on maternal morbidity and mortality. METHODS: A longitudinal and prospective study was conducted from December 2014 to July 2016. The venous thromboembolism risk score was modified from the guidelines of the Royal College of Obstetricians and Gynaecologists. Patients were classified as low (score <3) or high risk (score ≥3). The high-risk group received thromboprophylaxis with low-molecular-weight heparin, unless the patient had a contraindication for anticoagulation. One patient could have undergone more than one evaluation. RESULTS: Fifty-two ratings were descriptively analyzed: 34 (65.4%) were classified as high risk, and 28/34 (82.3%) received low-molecular-weight heparin, 1 received unfractionated heparin, and 5 did not receive intervention. Most patients (23/52; 44.2%) had breast cancer. The main risk factors for venous thromboembolism in the high-risk group were chemotherapy (within 6 months; 22/34; 64.7%). No patient exhibited venous thromboembolism, adverse effects of anticoagulation or death up to three months after hospitalization. CONCLUSIONS: Most pregnant women with cancer had a high risk for venous thromboembolism at the time of hospitalization. Breast cancer was the most prevalent cancer, and recent chemotherapy was the main risk factor for anticoagulation. The application of a thromboprophylaxis protocol and determination of a venous thromboembolism risk score for these patients was useful for the prevention of maternal morbidity and mortality due to venous thromboembolism.