Soubhi Kahhale

Fetal nasal bone length: reference range and clinical application in ultrasound screening for trisomy 21

Fetuses with trisomy 21 typically present with subtle facial abnormalities, including a hypoplastic nasal bone. The aim of this study was to provide a reference range for the length of the fetal nasal bone and to test its value in second‐trimester ultrasound screening for trisomy 21.

Postpartum depression: in relation to life events and patterns of coping.

SummaryThe purpose of this study was to estimate the prevalence of postpartum depression (PPD) and its relationship with life events (LE) and patterns for coping. We performed a cross-sectional study of 113 women, on the 10th day of puerperium, at the Obstetric Clinic of the São Paulo University Medical School. The study was based on the following: Pitt (1967) and Stein (1980) Scales, Beck Depression Inventory (1961), Holmes and Rahe Schedule of Recent Events (1967), Folkman and Lazarus Ways of Coping (1985) and questionnaire of social-demographic and obstetric data. Logistic regression was performed to calculate prevalence of PPD and its association with several risk factors. The significance level was defined at 5%. The prevalence of PPD was 15.9% (IC 9.7% to 24.0%). According to the multivariate analyses, the variables of coping with distancing, number of children and ethnic origin were significant. There were no association between PPD and LE. The depressed puerperal women have a low educational level, greater number of children and resort to inadequate coping strategies, such as distancing. This pattern of coping might be an etiological factor of the PPD as well as a reaction to their difficult life environment.

Maternal mortality due to arterial hypertension in São Paulo City (1995-1999).

AIM To describe the case profile of maternal death resulting from hypertensive disorders in pregnancy and to propose measures for its reduction. METHODS The Committee on Maternal Mortality of São Paulo City has identified 609 cases of obstetric maternal death between 1995 and 1999 with an underreporting rate of 52.2% and a maternal mortality rate of 56.7/100,000 live births. Arterial hypertension was the main cause of maternal death, corresponding to 142 (23.3%) cases. RESULTS Ninety-five (66.9%) of the deaths occurred during the puerperal period and 34 (23.9%) occurred during pregnancy. The time of death was not reported in 13 (9.2%) cases. Seizures were observed in 41 cases and magnesium sulfate was used in four of them. The causes of death were ruled to be cerebrovascular accident (44.4%), acute pulmonary edema (24.6%), and coagulopathies (14.1%). Cesarean section was performed in 85 (59.9%) cases and vaginal delivery in 15 (16.0%). CONCLUSION Complications of arterial hypertension are responsible for the high rates of pregnancy-related maternal death in São Paulo City. Quality prenatal care and appropriate monitoring of the hypertensive pregnant patient during and after delivery are important measures for better control of this condition and are essential to reduce disorders in pregnancy.

Stress-related preeclampsia: an evolutionary maladaptation in exaggerated stress during pregnancy?

The authors hypothesize that preeclampsia is a stress-related disease and an evolutionary maladaptation of exaggerated stress during human pregnancy. Epidemiologic studies show that relative risk for preeclampsia is increased in many stressful situations. Many risk factors for preeclampsia are stress-related. Low-stress situations, on the contrary, are protective. Stress in pregnancy corroborates all physiopathologic theories for preeclampsia; it does not contradict them. Animals exposed to intense stress show many characteristics of preeclampsia, and some animal models for human preeclampsia have been proposed. The stress-alarm reaction is protective for survival in animals. But the evolutionary maladaptation of this intense stress could lead to preeclampsia in humans.

The effect of chronic nitric oxide inhibition on vascular reactivity and blood pressure in pregnant rats

CONTEXT The exact mechanism involved in changes in blood pressure and peripheral vascular resistance during pregnancy is unknown. OBJECTIVE To evaluate the importance of endothelium-derived relaxing factor (EDRF) and its main component, nitric oxide, in blood pressure and vascular reactivity in pregnant rats. DESIGN Clinical trial in experimentation animals. SETTING University laboratory of Pharmacology. SAMPLE Female Wistar rats with normal blood pressure, weight (152 to 227 grams) and age (90 to 116 days). INTERVENTION The rats were divided in to four groups: pregnant rats treated with L-NAME (13 rats); pregnant control rats (8 rats); virgin rats treated with L-NAME (10 rats); virgin control rats (12 rats). The vascular preparations and caudal blood pressure were obtained at the end of pregnancy, or after the administration of L-NAME in virgin rats. MAIN MEASUREMENTS The caudal blood pressure and the vascular response to acetylcholine in pre-contracted aortic rings, both with and without endothelium, and the effect of nitric oxide inhibition, Nw-L-nitro-arginine methyl-ester (L-NAME), in pregnant and virgin rats. The L-NAME was administered in the drinking water over a 10-day period. RESULTS The blood pressure decreased in pregnancy. Aortic rings of pregnant rats were more sensitive to acetylcholine than those of virgin rats. After L-NAME treatment, the blood pressure increased and relaxation was blocked in both groups. The fetal-placental unit weight of the L-NAME group was lower than that of the control group. CONCLUSION Acetylcholine-induced vasorelaxation sensitivity was greater in pregnant rats and that blood pressure increased after L-NAME administration while the acetylcholine-induced vasorelaxation response was blocked.

Glycemia in newborns of hypertensive mothers according to maternal treatment

PURPOSE To evaluate the evolution of glycemic levels in newborns of hypertensive mothers according to maternal treatment. METHODS Prospective randomized study, including 93 newborns of mothers treated with isradipine (n = 39), atenolol (n = 40), or low sodium diet (control group - n=14). Glycemia was determined at birth (mother and newborn by the oxidase glucose method) and in the 1st, 3rd, 6th, 12th, and 24th hours after birth (newborn by a test strip method). The evolution of glycemia was analyzed in each group (Friedman test). The groups were compared regarding glycemia (Kruskall-Wallis test), and linear regression models were constructed for the analyses (independent variable = maternal glycemia; dependent variables = umbilical cord, 3rd, and 6th hour glycemia). RESULTS There were no statistically significant differences among the mean blood glucose levels of the 3 groups in any of the assessments. There was a correlation between maternal and umbilical cord blood glucose in the isradipine (r = 0.61; P <.05) and control (r = 0.84; P <.05) groups. Regarding glycemia levels of the mothers and newborns in the third and sixth hours postpartum, this correlation was present only in the control group (maternal x third hour: r = 0.65; P <.05; maternal x sixth hour: r = 0.68; P <.05). There were no correlations in the atenolol group. Hypoglycemia was detected in 51.3% of the isradipine group, 60% of the atenolol group, and 35.7% of the control group, and it was more frequent in the first hour postpartum in all groups. CONCLUSIONS The results suggest a similar effect of the 3 types of treatment upon newborn glycemia. The correlation analysis suggests that isradipine could have effects upon newborn glycemia only after birth (correlation only in umbilical cord blood), whereas atenolol could act earlier (there was no correlation at any moment). The results also point to the need for glycemic control from the first hour postpartum of newborns of hypertensive mothers whether they have or have not undergone treatment with antihypertensive drugs.

Management of pregnancy in a University Hospital: a 6-year study

In order to evaluate the obstetric care in the Obstetric Clinic of the Gynaecology and Obstetrics Department of University of Sao Paulo, the authors present a survey of the management of pregnancy during the 6-year period from 1993 to 1998. The number of deliveries increased during the study by 45% over the 6 years. During this same period the number of fetal deaths was 526 (4.48%), but there was a significant decrease (p < 0.05) in the incidence of fetal death. However, there was no concomitant increase in the proportion of pregnant women with prenatal care that could explain this improvement. Incidence of premature labor also decreased considerably. The authors believe that the increment in the number of deliveries was due mainly to the increasing number of pregnant women referred to our service. The efforts made by the service towards decreasing the time of hospitalization of both newborns in the nursery and the mothers in the hospital made this possible. Despite the increasing number of deliveries, there was a significant improvement in the management of pregnancy during the period of study. This improvement may be a consequence of the standardization of a protocol of management of pregnancy based on the recent progress in scientific and technological knowledge.

Estresse e pré-eclampsia

A correlacao entre estresse e pre-eclampsia foi revisada, avaliada e discutida neste artigo.A pre-eclampsia nao tem ainda etiologia completamente definida. Varios fatores de risco para pre-eclampsia foram identificados e varios mecanismos fisiopatologicos foram descritos...

Uso do Verapamil em Gestantes Hipertensas Crônicas: análise do Fluxo das Artérias Uterinas e Umbilical

Objetivo: este trabalho, utilizando verapamil, um bloqueador dos canais lentos de calcio, constituiu ensaio clinico randomizado, duplo-cego e placebo controlado, e objetivou procurar variacao do fluxo uteroplacentario e fetoplacentario durante uso oral cronico do farmaco em gestantes com hipertensao cronica leve para moderada. Metodos: 123 pacientes divididas em dois grupos: grupo estudo (n = 61), submetidas a 240 mg/dia de verapamil, e grupo controle (n = 62), submetidas ao placebo. As pacientes randomizadas em grupos de quatro utilizaram a medicacao ou placebo durante trinta dias. Um exame do fluxo das arterias uterinas e da arteria umbilical pela dopplervelocimetria foi registrado. Pelo calculo da media e desvio padrao, foram comparados os valores dos indices de resistencia (IR) e pulsatilidade (IP) e da relacao sistole/diastole (A/B) das arterias em estudo apos administracao dos comprimidos. Resultados: o grupo verapamil apresentou os seguintes valores medios para as arterias uterinas: IR = 0,82 (0,28), IP de 1,06 (0,12) e A/B de 2,42 (0,51). O grupo placebo mostrou: IR de 0,75 (0,35), IP de 1,00 (0,18) e A/B de 2,30 (0,38). Quando analisada a arteria umbilical, os valores foram para o grupo verapamil: IR = 0,73 (0,12), IP = 1,04 (0,13) e A/B = 2,94 (0,32). No grupo placebo, IR = 0,70 (0,14), IP = 1,03 (0,07) e A/B = 3,02 (0,78). A analise estatistica das diferencas das medias por meio da razao F mostrou nao haver diferenca entre os dois grupos avaliados. Conclusao: este trabalho referenda o uso do verapamil entre gestantes com hipertensao cronica (leve para moderada), pois nao oferece prejuizos no fluxo uteroplacentario e fetoplacentario.

Endothelial Mechanisms in Preeclampsia

Abstract Hypertensive syndromes are the most common complication in pregnancy, and are the number one cause of death in Brazil, especially in severe cases. Preeclampsia may be responsible for acute renal failure, cerebral hemorrhage, coagulopathy, and placenta abruptio. Several studies indicate endothelial dysfunction in preeclampsia. Recently, high endothelin-1 plasma levels were noted in preeclampsia, which could be the cause of resistant hypertension and multiple organ failure. Causes of endothelial dysfunction are controversial. Poorly perfused trophoblast produces toxic substances in endothelial cells, causing preeclampsia. Preeclampsia occurs in the presence of placental tissue and is influenced by environmental and immunological factors as well as genetic constitution. Hence inadequate trophoblastic invasion and poorly perfused trophoblasts elaborate toxic substances to the endothelium. The success of physiological performance of placenta depends on angiogenic (PLGF) and antiangiogenic factors (sFlt-1). More recent work indicates decreases in PLGF and increases in sFlt-1, as well as increased sFt-1/PLGF as markers for the prediction, diagnosis, and prognosis of preeclampsia. Further studies will better clarify the role of endothelium in preeclampsia.