Sandra Maria Alexandre

Obstetric and perinatal effects of active and/or passive smoking during pregnancy

CONTEXT Cigarette smoke, whether inhaled voluntarily or not, causes damage to the mother-infant pair. The antenatal period may present the best opportunity for performing effective anti-smoking campaigns. OBJECTIVE To study the obstetric and perinatal effects of smoking on pregnancy and the infant. TYPE OF STUDY Prospective study, interviewing pregnant women who were randomly selected at the maternity hospital as they were being discharged after giving birth. SETTING Hospital Municipal Vereador José Storópolli, São Paulo, Brazil. METHODS 758 patients were interviewed regarding smoke inhalation before being discharged from the maternity hospital. The groups were formed by 42 active smokers, 272 passive smokers, 108 who inhaled smoke both actively and passively, and 336 non-smokers. The groups were compared regarding age, parity, school education, incidence of spontaneous abortion, rate of caesarian births, average gestational age at birth, rate of low birth weight and adequacy of weight in relation to the gestational age of newborn infants. For all variables we considered p < 0.05 as statistically significant. RESULTS There was a high rate (55.7%) of pregnant smokers, including 5.5% active, 35.9% passive and 14.3% active-passive smokers. Active and active-passive smokers were older and had higher parity. Active smokers had lower education levels and higher rates of previous spontaneous abortion. The weights of newborn babies were lower for smoking mothers. DISCUSSION The study was performed among patients that were mostly of low economic, social and cultural levels, thus possibly explaining the high incidence of smokers. Worse still was that 35.9% of the non-smokers were actually passive smokers. These rates we report were similar to those from the literature. The typical receptiveness of teenage girls to unrestricted advertising in the media contributes towards an early start to acquiring the habit of smoking, including during pregnancy in our country. We emphasize the difficulties in quantifying exposure to cigarettes even among active smokers. CONCLUSIONS Cigarette smoke, whether inhaled voluntarily or not, has an unfavorable effect on the mother-infant pair.

Cytokine Levels in Gestational Diabetes Mellitus: a Systematic Review of the Literature

Gestational diabetes mellitus (GDM) is an inflammatory condition that involves unbalanced cytokine production. We carried out a systematic review on the relationship between GDM and maternal circulating levels of cytokines in the 2nd/3rd trimesters.

Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography

The abdominal hypopressive technique (AHT) is performed mainly via transversus abdominis (TrA) activation and has been indicated for pelvic floor muscle (PFM) disorders. In some European countries, this technique has become widely used. This study aimed to investigate PFM and TrA activation during the AHT through surface electromyography.

Effects of the Paula method in electromyographic activation of the pelvic floor: a comparative study

Introduction and hypothesisTo determine if Paula method of circular muscles contraction e.g., those surrounding the eyes, mouth and fingers, could increase pelvic floor muscle (PFM) activity.MethodsThirty-four healthy, nulliparous volunteers were included, with an average age of 28 (±5.9) years and body mass index of 23.8 (±3.3) kg/m2. They were assigned to randomly perform the sequence: a PFM maximal voluntary contraction, a contraction of circular muscles, followed by a simultaneous combination of PFM and circular muscle contraction. The PFM were evaluated using surface electromyography.ResultsPFM activity at baseline was 22.6 (±10.9) μv. It was unchanged with Paula method contraction (p = 0.322). There were also no differences between values of PFM maximal voluntary contraction alone, 99.8 (±44.3) μv and in combination with the Paula method, 91.8 (±35.3) μv (p = 0.093).ConclusionsThe Paula method seems not to increase PFM activity in nulliparous women.

Electromyographic evaluation of pelvic floor muscles in pregnant and nonpregnant women.

Introduction and hypothesisWe compared the maximal voluntary contraction (MVC) and strength of pelvic floor muscles (PFM) of pregnant and nonpregnant women using surface electromyography (SEMG).MethodsFifteen pregnant primiparous women and 15 nulliparous nonpregnant women were evaluated. The healthy pregnant women were in the third trimester of pregnancy with a single fetus and did not have any neuromuscular alterations. The nonpregnant women did not present with PF dysfunctions and, as with the pregnant women, did not have any previous gynecological surgeries or degenerative neuromuscular alterations. The evaluation methods used were digital palpation (Oxford Grading Scale, which ranges from 0 to 5) and SEMG. In the EMG exam, MVC activity was evaluated, and the better of two contractions was chosen. Before the evaluation, all women received information about PFM localization and function and how to correctly contract PFM.ResultsIn the EMG evaluation, MVC was significantly greater in the nonpregnant group (90.7 μv) than in the pregnant group (30 μv), with p < 0.001. The same results were observed after vaginal palpation, measured by the Oxford scale, which presented an average of 2.1 in the pregnant group and 4.5 in the nonpregnant group (p = 0.005).ConclusionIn comparison to nulliparous women, pregnant women demonstrated worse PFM function with decreased strength and electrical activity.

Cord blood cardiac troponin I, fetal Doppler velocimetry, and acid base status at birth

To analyze the association between umbilical cord cardiac troponin I (cTnI), obstetric Doppler, and birth acidemia. Method: This prospective observational study was conducted on 58 singleton pregnancies at 3 Brazilian hospitals. Umbilical and middle cerebral artery Doppler velocimetry were performed 24 h prior to birth. At delivery, cord blood was collected for pH, blood gas analysis, and cTnI measurement. Results: Cardiac troponin I ≥ 0.20 ng/mL was detected in 5 neonates (8.6%). Centralization was recorded in 12 fetuses; 4 of these (33.3%) had detectable cTnI compared with 1/46 (2.2%) fetuses with normal Doppler (P = 0.005). Acidemia was present in 60% of the neonates with detectable cTnI, compared with 15% of the neonates with undetectable cTnI (P = 0.042). Conclusion: Centralization and birth acidemia are associated with detectable cTnI in cord blood supporting the possibility of myocardial ischemia in these fetuses.

Immunoregulatory molecules in patients with gestational diabetes mellitus

Induction of maternal-fetal immune tolerance is essential for the development of normal pregnancy. Impaired expression of costimulatory molecules may lead to intense inflammatory reaction, a mechanism involved in the pathophysiology of gestational diabetes mellitus (GDM). The aim of this study was to investigate whether immunoregulatory molecules are involved in the physiopathology of GDM. This case–control study included 30 healthy pregnant women and 20 GDM patients. Flow cytometry was used to assess peripheral blood T subpopulations (CD4+ and CD8+), the expression of immunoregulatory molecules (CD28, ICOS, CTLA-4, and PD-1) and activation markers (CD69 and HLA-DR). Compared to healthy women, GDM patients had a significantly higher frequency of CD4+CD69+ and CD8+CD69+ T cells; only patients with insulin-treated GDM had increased numbers of CD4+HLA-DR+ T cells. We also observed significantly higher percentages of CD4+CD28+HLA-DR+, CD3+CD4+ICOS+, CD3+CD4+PD-1+, CD8+CD28+CD69+, CD8+CD28+HLA-DR+, CD8+CTLA-4+HLA-DR+, and CD3+CD8+ICOS+ T cells and lower frequency of CD3+CD4+CTLA-4+, CD3+CD8+CTLA-4+, and CD8+ICOS+HLA-DR+ T cells in GDM patients compared to healthy pregnant women. This first study assessing costimulatory molecules in GDM patients shows that these patients have exacerbated markers of T cell activation along with CTLA-4 deficiency, findings that indicate that the maternal-fetal tolerance is compromised in these patients.

Distensibility and Strength of the Pelvic Floor Muscles of Women in the Third Trimester of Pregnancy

Objective. The objective of this study was to compare the role of the pelvic floor muscles between nulliparous and multiparous women in the third trimester of pregnancy, by analyzing the relationship between electrical activity (surface electromyography—EMG), vaginal palpation (modified Oxford scale), and perineal distensibility (Epi-no). Methods. This was an observational cross-sectional study on a sample of 60 healthy pregnant women with no cervical dilation, single fetus, gestational age between 35 and 40 weeks, and maternal age ranging from 15 to 40 years. The methods used were bidigital palpation (modified Oxford scale, graded 0–5), surface EMG (electrical activity during maximal voluntary contraction), and perineal distensibility (Epi-no device). The Pearson correlation coefficient (r) was used to analyze the Epi-no values and the surface EMG findings. The Kruskal-Wallis test was used to compare the median values from surface EMG and Epi-no, using the modified Oxford scale scores. Results. Among the 60 patients included in this study, 30 were nulliparous and 30 multiparous. The average maternal age and gestational age were 26.06 (±5.58) and 36.56 (±1.23), respectively. It was observed that nulliparous women had both higher perineal muscle strength (2.53 ± 0.57 versus 2.06 ± 0.64; P = 0.005) and higher electrical activity (45.35 ± 12.24 μV versus 35.79 ± 11.66 μV; P = 0.003), while among the multiparous women, distensibility was higher (19.39 ± 1.92 versus 18.05 ± 2.14; P = 0.013). We observed that there was no correlation between perineal distensibility and electrical activity during maximal voluntary contraction (r = − 0.193; P = 0.140). However, we found a positive relationship between vaginal palpation and surface electromyography (P = 0.008), but none between Epi-no values (P = 0.785). Conclusion. The electrical activity and muscle strength of the pelvic floor muscles of the multiparous women were damaged, in relation to the nulliparous women, while the perineal distensibility was lower in the latter group. There was a positive relationship between surface EMG and the modified Oxford scale.

Parturient perineal distensibility tolerance assessed by EPI-NO: an observational study

ABSTRACT Objective: To determine how parturient women tolerate the use of a perineal distensibility assessment technique using the EPI-NO device. Methods: An observational study with a total of 227 full-term parturient women was performed. During the evaluation with EPI-NO, parturient patients were asked about their sensation of discomfort. The degree of discomfort was measured using the Visual Analogue Scale, with a score from zero to 10. The Mann-Whitney test was applied to assess perineal distensibility measured by EPI-NO and the degree of discomfort caused by the test according to parity. The relation between perineal distensibility and discomfort was analyzed by using the Spearman correlation test (r). Results: The test with EPI-NO caused only slight discomfort (mean Visual Analogue Scale of 3.8), and primiparous women reported significantly greater discomfort (mean Visual Analogue Scale of 4.5) than did multiparous (mean Visual Analogue Scale=3.1), with p<0.001 women. A negative correlation was observed, in other words, the greater the perineal distensibility on the EPI-NO, the lower the pain reported by the patients (r=-0.424; p<0.001). Conclusion: The assessment of perineal distensibility with EPI-NO was well tolerated by the parturient women.

Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil

PURPOSE To evaluate changes to the pelvic floor of primiparous women with different delivery modes, using three-dimensional ultrasound. METHODS A prospective cross-sectional study on 35 primiparae divided into groups according to the delivery mode: elective cesarean delivery (n=10), vaginal delivery (n=16), and forceps delivery (n=9). Three-dimensional ultrasound on the pelvic floor was performed on the second postpartum day with the patient in a resting position. A convex volumetric transducer (RAB4-8L) was used, in contact with the large labia, with the patient in the gynecological position. Biometric measurements of the urogenital hiatus were taken in the axial plane on images in the rendering mode, in order to assess the area, anteroposterior and transverse diameters, average thickness, and avulsion of the levator ani muscle. Differences between groups were evaluated by determining the mean differences and their respective 95% confidence intervals. The proportions of levator ani muscle avulsion were compared between elective cesarean section and vaginal birth using Fishers exact test. RESULTS The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm(2), respectively, versus 12.4 cm(2) in the Control Group (elective cesarean). Avulsion of the levator ani muscle was observed in women who underwent vaginal delivery (3/25), however there was no statistically significant difference between cesarean section and vaginal delivery groups (p=0.5). CONCLUSION Transperineal three-dimensional ultrasound was useful for assessing the pelvic floor of primiparous women, by allowing pelvic morphological changes to be differentiated according to the delivery mode.