Silvio Martinelli

Resultados perinatais em grávidas com mais de 35 anos: estudo controlado

OBJETIVO: avaliar os resultados perinatais em gestantes com mais de 35 anos e verificar diferencas nos grupos entre 35 e 39 anos e acima de 40 anos. METODOS: entre janeiro de 2000 e julho de 2003, realizou-se estudo retrospectivo por analise de fichas obstetricas de 3093 gestantes, excluindo-se 933 gestantes. As pacientes foram divididas em 3 grupos: 18 a 29 anos (grupo controle), 30 a 39 anos e mais de 40 anos. A coleta de dados foi realizada por meio de formulario padronizado e os dados foram transferidos para uma planilha eletronica (Excel - Microsoft Office 2000). Para a analise estatistica, foram utilizados o teste do c2 e o teste de Fisher, sendo considerado risco a (alfa) menor ou igual a 5% e intervalo de confianca de 95%. RESULTADOS: a via de parto mais utilizada para essas pacientes foi a cesarea, tanto no grupo de 35 a 39 anos (438/792; 55,3%), quanto nas gestantes com mais de 40 anos (153/236; 64,8%). A taxa de prematuridade (39/236; 16,5%), o baixo peso ao nascer (37/236; 15,7%) e a restricao de crescimento fetal (38/236; 16,1%) foram mais altas entre as gestantes tardias, com mais de 40 anos, com diferenca significante em relacao aos demais grupos. Quanto a ocorrencia de obito fetal, foi constatado nas gestantes de 40 anos incidencia cinco vezes maior quando comparado aos outros grupos (diferenca estatisticamente significante). CONCLUSAO: a comparacao entre o grupo de gestantes de 35 a 39 anos com o grupo controle apenas diferiu significantemente quanto ao indice de cesareas, o que nos permite sugerir acompanhamento pre-natal diferenciado para o grupo de gestantes acima de 40 anos.

Predicting preterm delivery in asymptomatic patients with prior preterm delivery by measurement of cervical length and phosphorylated insulin-like growth factor-binding protein-1

To evaluate the efficacy of cervical length measurement in combination with a bedside assessment of phosphorylated insulin‐like growth factor‐binding protein‐1 (phIGFBP‐1) as a predictor of preterm delivery in asymptomatic pregnant women with a history of preterm birth.

Proposta de Nova Curva de Altura Uterina para Gestações entre a 20ª e a 42ª Semana

Purpose: to create a uterine height growth curve, according to gestational age, to verify differences among the existing curves and to evaluate the influence of color, parity and maternal weight on the variation of uterine height. Methods: during the period from July 1997 to July 1999, 100 normal pregnant women were submitted to uterine height measurements between the 20th and 42nd week of gestation. All the pregnant women had ultrasonically confirmed gestational age. A total of 726 measurements of uterine height were carried out by the same examiner, using a metric tape from the upper border of the symphysis pubis to the fundus uteri. Results: curves and tables of uterine height according to gestational age were obtained. The average uterine height growth was 0.7 cm/week. The study revealed different average uterine height values in relation to other uterine height growth curves. No statistically significant variations were found between the distributions of uterine heights according to color, parity and weight. Conclusion: the construction of a methodologically accepted uterine height growth curve aimed to detect, as a clinical method, the fetal growth disturbances. This should be analyzed in a posterior study.

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.

Prevenção do parto prematuro: emprego do toque vaginal e da ultra-sononografia transvaginal

Objective: to evaluate the uterine cervix by digital and transvaginal ultrasound examinations in pregnant women at high risk of having premature delivery. Methods: during the period between February 1995 and September 1997, 38 pregnant women at high risk of having premature delivery between the 20th and 36th week of gestation were examined. These patients were submitted weekly to both digital and transvaginal ultrasound examinations. The digital examination evaluated the uterine cervix using two parameters: length and dilation. The transvaginal ultrasound studied the length and the anteroposterior diameter of the uterine cervix. The behavior of these cervical measurements was analyzed throughout the pregnancies. The two methods were compared regarding cervical evaluation and accuracy of premature birth diagnosis. Results: the rate of premature deliveries was 18.4% (7/38). Digital examination resulted in cervical evaluations with variation coefficients of 30.3% for length and 193% for dilation. Transvaginal ultrasound resulted in cervical evaluations with variation coefficients of 14.7% and 26.5% for the anteroposterior diameter and length, respectively. The cervical length measures obtained on ultrasound were always greater than those obtained on digital examination. Through analysis with the hypothesis test, an indirect relationship was observed between the cervical length and the gestational period for digital examination and ultrasound study (p<0.05 and p<0.01, respectively), and a direct relationship between the cervical dilation and the gestational age observed on the digital examination (p<0.01). Conclusions: among the parameters studied by means of the digital and transvaginal ultrasound examinations, the ultrasound cervical length presented the best accuracy in the diagnosis of premature birth, proving to be more reliable for the evaluation of cervical alterations in pregnant women at high risk of premature delivery.

Predição da restrição do crescimento fetal pela medida da altura uterina

OBJECTIVE: to evaluate the measurement of uterine height in order to predict fetal growth restriction (FGR), according to a local curve. METHODS: from July 2000 to February 2003, 238 high-risk pregnant women were submitted to uterine height measurements between the 20th and the 42nd week of gestation. The gestational age of all the women was well known, confirmed by early ultrasound. Fifty (21%) women gave birth to infants considered small for their gestational age. The measures were performed by a single observer, who took 1617 uterine height measurements, from the upper border of the symphysis pubis to the fundus uteri, using tape measurement. The diagnosis of FGR was confirmed after birth according to the Ramoss curve. The women were divided into two groups according to their infants birth weight and the data were statistically analyzed by the Fishers exact test or Kruskal-Walliss test. The sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) were calculated. The test for two proportions with normal approximation was performed to analyze the continuous variables. RESULTS: one measurement below the 10th percentile, according to gestational age, resulted in SE = 78.0%, SP = 77.1%, PPV = 47.6%, and NPV = 88.8% for the identification of FGR. If one measurement was below the 5th percentile, the SE, SP, PPV, and NPV were 64.0, 89.9, 62.7 and 90.4%, respectively. CONCLUSIONS: one measurement below the 10th percentile for the gestational age, according to the local curve, proved to be a good predictor of FGR.

Comparação entre duas curvas de crescimento para o diagnóstico de recém-nascidos pequenos para a idade gestacional

PURPOSE It was to compare the use of two growth curves for the diagnosis of small-for-gestational-age (SGA) infants, having the 10th percentile as reference. METHODS In a retrospective study, data of 20,567 singleton live births from January 2003 to June 2014 were analyzed, and divided according to gestational age: (a) 23 to 26, (b) 26 to 29, (c) 29 to 32, (d) 32 to 35, (e) 35 to 38, (f) 38 to 41 and (g) >41 weeks. Data were paired and analyzed using the McNemar test, with the level of significance set at 0.05. RESULTS The curve designed by Alexander indicated a higher percentage of diagnosis of SGA than the curve constructed by Fenton for every category of gestational age up to 41 weeks, more markedly in the 32-35 week group (18.5%). Between 37 and 40 weeks of gestational age, Alexanders curve exceeded Fentons curve in 9.1% of the cases in the diagnosis of SGA. CONCLUSIONS The Fenton curve provides a more accurate evaluation of an infants growth since it is gender-specific and allows measurement of three parameters. It has also been constructed with newer data and more sophisticated statistical tools.OBJETIVO:Foi comparar a aplicacao de duas curvas de crescimento para o diagnostico de recem-nascidos pequenos para a idade gestacional (PIG), utilizando o percentil 10 como referencia.METODOS:Estudo retrospectivo com informacoes do parto de 20.567 recem-nascidos vivos, de gestacoes unicas, ocorridos entre janeiro de 2003 e junho de 2014, divididos em grupos por idade gestacional: (a) 23 a 26, (b) 26 a 29, (c) 29 a 32, (d) 32 a 35, (e) 35 a 38, (f) 38 a 41 e (g) >41 semanas. Os dados foram pareados e os grupos comparados por teste de igualdade de proporcoes segundo metodo de McNemar. O nivel de significância foi estabelecido em p<0,05.RESULTADOS:A curva de Alexander apresentou maior taxa de diagnostico de PIG do que a curva de Fenton em todas as faixas de idade gestacional ate a 41asemana, com maior diferenca entre as curvas entre 32 e 35 semanas (18,5%). No periodo entre 37 e 40 semanas, o diagnostico de PIG, empregando-se a curva de Alexander, superou o de Fenton em 9,1% dos casos. Com excecao dos grupos entre 23 e 26 semanas, todas as outras faixas de idade gestacional mostraram-se significativamente diferentes quanto ao diagnostico de RN PIG.CONCLUSAO:A curva de Fenton e um instrumento estatistico mais robusto, construida com informacoes mais recentes, e permite a avaliacao do crescimento por tres parâmetros e por sexo.

Relação entre a contagem de eritroblastos no sangue do cordão umbilical e os resultados obstétricos e neonatais em fetos pequenos para a idade gestacional e com Doppler de artéria umbilical normal

PURPOSE To analyze the obstetrical and neonatal outcomes of pregnancies with small for gestation age fetuses after 35 weeks based on umbilical cord nucleated red blood cells count (NRBC). METHODS NRBC per 100 white blood cells were analyzed in 61 pregnancies with small for gestation age fetuses and normal Doppler findings for the umbilical artery. The pregnancies were assigned to 2 groups: NRBC≥10 (study group, n=18) and NRBC<10 (control group, n=43). Obstetrical and neonatal outcomes were compared between these groups. The χ(2) test or Students t-test was applied for statistical analysis. The level of significance was set at 5%. RESULTS The mean ± standard deviation for NRBC per 100 white blood cells was 25.0 ± 13.5 for the study group and 3.9 ± 2.2 for the control group. The NRBC≥10 group and NRBC<10 group were not significantly different in relation to maternal age (24.0 versus 26.0), primiparity (55.8 versus 50%), comorbidities (39.5 versus 55.6%) and gestational age at birth (37.4 versus 37.0 weeks). The NRBC≥10 group showed higher rate of caesarean delivery (83.3 versus 48.8%, p=0.02), fetal distress (60 versus 0%, p<0.001) and pH<7.20 (42.9 versus 11.8%, p<0.001). The birth weight and percentile of birth weight for gestational age were significantly lower on NRBC≥10 group (2,013 versus 2,309 g; p<0.001 and 3.8 versus 5.1; p=0.004; respectively). There was no case described of 5th minute Apgar score below 7. CONCLUSION An NRBC higher than 10 per 100 white blood cells in umbilical cord was able to identify higher risk for caesarean delivery, fetal distress and acidosis on birth in small for gestational age fetuses with normal Doppler findings.

Dosagem de folatos maternos e fetais, séricos e eritrocitários em malformações por defeito de fechamento do tubo neural no feto

Objetivos: avaliar os niveis de folatos maternos e fetais gestacoes com malformacoes por defeitos de fechamento do tubo neural (DFTN). Metodos: o estudo foi do tipo caso-controle, no qual 14 casos de fetos com DFTN (grupo estudo) e 14 casos de fetos com outras malformacoes (grupo controle) foram estudados em gestantes de baixo risco para DFTN. Propusemo-nos a dosar o acido folico, na sua forma total e metilada, nos compartimentos fetal e materno, utilizando dosagens sericas e tissulares (eritrocitarias), assim como o volume corpuscular medio, o hematocrito e a hemoglobina. As coletas foram realizadas imediatamente antes da interrupcao da gestacao. Os resultados nos dois grupos foram comparados pelo teste t de Student, metodo de amostras pareados pela idade gestacional. Resultados: nao se encontrou diferenca nas taxas de folatos fetais e nos parâmetros hematologicos dos fetos, entre os dois grupos. Por outro lado, taxas anormalmente baixas de folatos foram encontradas nos eritrocitos das maes portadoras de fetos com DFTN, tanto para as formas totais(293,9 ng/mL contra 399,1 ng/mL no grupo controle, p=0,01) quanto para as formas metiladas (201,9 ng/mL contra 314,0 ng/mL para o grupo controle, p=0,02). Os folatos sericos maternos nao se mostraram diferentes nos grupos estudo e controle. Conclusao: este estudo demonstrou que ha uma menor taxa de folatos intratissulares, nas maes de fetos acometidos por DFTN, porem com taxas de folatos sericos semelhantes em relacao ao grupo controle.Objetivos: avaliar os níveis de folatos maternos e fetais gestações com malformações por defeitos de fechamento do tubo neural (DFTN). Métodos: o estudo foi do tipo caso-controle, no qual 14 casos de fetos com DFTN (grupo estudo) e 14 casos de fetos com outras malformações (grupo controle) foram estudados em gestantes de baixo risco para DFTN. Propusemo-nos a dosar o ácido fólico, na sua forma total e metilada, nos compartimentos fetal e materno, utilizando dosagens séricas e tissulares (eritrocitárias), assim como o volume corpuscular médio, o hematócrito e a hemoglobina. As coletas foram realizadas imediatamente antes da interrupção da gestação. Os resultados nos dois grupos foram comparados pelo teste t de Student, método de amostras pareados pela idade gestacional. Resultados: não se encontrou diferença nas taxas de folatos fetais e nos parâmetros hematológicos dos fetos, entre os dois grupos. Por outro lado, taxas anormalmente baixas de folatos foram encontradas nos eritrócitos das mães portadoras de fetos com DFTN, tanto para as formas totais (293,9 ng/mL contra 399,1 ng/mL no grupo controle, p=0,01) quanto para as formas metiladas (201,9 ng/mL contra 314,0 ng/mL para o grupo controle, p=0,02). Os folatos séricos maternos não se mostraram diferentes nos grupos estudo e controle. Conclusão: este estudo demonstrou que há uma menor taxa de folatos intratissulares, nas mães de fetos acometidos por DFTN, porém com taxas de folatos séricos semelhantes em relação ao grupo controle.

The role of three-dimensional ultrasound in pregnancies submitted to cerclage

OBJECTIVE Cervical cerclage is the standard treatment for cervical incompetence (CI); however, there is still a high risk of preterm birth for women who undergo this treatment. The aim of this study was to longitudinally evaluate findings on two-dimensional transvaginal ultrasonography (2DTVUS) and three-dimensional transvaginal ultrasonography (3DTVUS) that could be related to gestational age at birth. METHODS A total of 68 pregnant women who were treated with cerclage were evaluated by 2DTVUS and 3DTVUS in the second and third trimesters of pregnancy. Log-rank tests and Cox regression analyses were used to identify significant findings related to gestational age at delivery. RESULTS A cervical length lower than 281 mm (p= 0.0083), a proximal cervical length lower than 10 mm (p= 0.0151), a cervical volume lower than 18.17 cm3 (p= 0.0152), a vascularization index (VI) under 2.153 (p= 0.0044), and a vascularization-flow index (VFI) under 0.961 (p= 0.0059) in the second trimester were all related to earlier delivery. In the third trimester, a cervical length lower than 20.4 mm (p= 0.0009), a VI over 0.54 (p= 0.0327) and a VFI over 2.275 (p= 0.0479) were all related to earlier delivery. Cervical funnelling in the second and third trimesters and proximal cervical length in the third trimester were not related to gestational age at birth. The COX regression analyses showed that cervical volume in the second trimester; FI and VFI in the third trimester were significantly associated with gestational age at birth. CONCLUSION In women treated with history-indicated cerclage or ultrasound-indicated cerclage, 2nd trimester cervical volume and 3rd trimester FI and VFI are independent significant sonographic findings associated with time to delivery.