Umberto Gazi Lippi

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.

Reference ranges for cervical length by transvaginal scan in singleton pregnancies

Objective. The aim was to construct a chart for cervical length measured by transvaginal ultrasound. Research design and methods. Singleton pregnant women underwent a transvaginal scan to measure the cervical length (CxL) from 20 to 34 weeks. Exclusion criteria were preterm delivery, preterm rupture of membranes, multiple pregnancies, cerclage, and those who have taken vaginal progesterone. For statistical evaluation, we used regression analysis and calculation of 5th, 50th, and 95th centiles was performed. Results. In the 1061 women with follow up, there were 94 (8.8%) spontaneous and 27 (2.5%) iatrogenic preterm delivery before 37 weeks. The CxL decreased with gestational age (r2 = 0.0799). The coefficient for the interpolated median is y = 37.754 − 0.0148 × (GA)2 + 0.2556 × (GA) (r2 = 0.7247); for the 5th centile is y = 5.9171 − 0.0467 × (GA)2 + 1.7059 × (GA) (r2 = 0.6502); and for the 95th centile is y = 114.72 + 0.0758 × (GA)2 − 4.6706 × (GA) (r2 = 0.7783). Conclusion. CxL shortened throughout the pregnancy. The chart present 5th, 50th, and 95th centile, respectively, at 23 weeks of 20 mm, 36 mm, and 47 mm; at 28 weeks of 17 mm, 33 mm, and 43 mm; and at 34 weeks of 10 mm, 29 mm, and 43 mm.

Pain evaluation in office hysteroscopy: comparison of two techniques

PURPOSE to compare the pain reported by patients submitted to hysteroscopy by the standard technique with carbon dioxide (CO2) and to vaginal hysteroscopy with physiological saline (0.9% NaCl). METHODS this was a prospective cohort study conducted at an ambulatory hysteroscopy service. A total of 117 patients with indication for the exam were included, being randomly assigned to one of the groups. All patients answered an epidemiological questionnaire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10. A speculum, traction of the cervix, insertion of a 30 masculine light source and a diagnostic shirt with a total diameter of 5 mm were used for the standard technique. The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator, and a biopsy was obtained with a Novak curette. Vaginoscopy was performed without a touch by distention of the vagina with fluid, direct visualization of the cervix and introduction of the light source with two continuous-flow shirts, with an accessory channel with an oval profile, the whole set measuring 5 mm in diameter. The medium distention was 0.9% NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer. The biopsy was obtained in a directed manner using an endoscopic clamp. The mean and standard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables. The Students t-test was used to compare the means, and the chi-square or exact Fisher test was used (when n<5) for the categorical analysis using the SPSS 15.0 software. The study was designed for a 95% test power, with the level of significance set at p<0.05. RESULTS the groups were similar regarding age, parity, previous uterine surgeries, menopausal status, and the need for a biopsy. In comparison to the group submitted to the standard technique, the vaginoscopy group involved a lower technical difficulty (5.1 versus 17.2%, p=0.03), a higher rate of exams considered to be satisfactory (98.3 versus 89.7%, p=0.04) and a lower pain index (4.8 versus 6.1; p=0.01), as the difference were more evident when patients who never had a previous normal delivery were compared (4.9 versus 7.1; p=0.0001). When the pain scale was stratified as mild (0-4), moderate (5-7) or intense (8-10), the vaginoscopy technique was found to be associated with a 52% reduction of the frequency of intense pain (p=0.005). CONCLUSIONS vaginohysteroscopy was proved to be a less painful procedure than the technique based on the use of a speculum and CO2, regardless of age, menopause or parity, with more satisfactory results and lower technical difficulty.

A violência doméstica como indicador de risco no rastreamento da depressão pós-parto

PURPOSE: to assess the prevalence of the risk of post-partum depression in women in the post-natal ward of a hospital in Sao Paulo city, in the southeastern region of Brazil, and analyze the associated factors, including domestic violence (DV). METHODS: this was a descriptive, cross-sectional study. The participants were 133 women with at least 20 weeks of gestation age, who delivered their babies from August to September 2005 in a tertiary maternity in the city of Sao Paulo (Brazil). They were interviewed using the Portuguese version of the Abuse Assessment Screen for the diagnosis of violence and filled out a self-evaluation questionnaire for post-partum depression (Edinburgh Postnatal Depression Scale). Variables were presented as absolute and relative frequencies. The c2 or Fisher exact tests were used to analyze possible associations between the variables of interest and post-partum depression. The value of 5% was considered significant. RESULTS: risk for post-partum depression was detected in 24 women (18%). A total of 38.3% of the participants interviewed had a history of abuse. There was an association between DV after they were 15 years old and risk of depression (p=0.036). The prevalence of abuse in the group of women at risk for post-partum depression was 58.3% and this was significantly higher than the 33.9% observed in the control group. CONCLUSIONS: the probability of presenting depression was high among the post-partum women attended at a tertiary maternity in the southeast of Brazil. The DV after they were 15 years old was significantly associated with risk of post-partum depression.

Polipectomia endometrial histeroscópica: tratamento ambulatorial versus convencional

OBJECTIVE To compare results of hysteroscopic polypectomy of the endometrium performed in an outpatient clinic, under no anesthesia, to conventional hysteroscopic polypectomy under anesthesia in the operating theatre, assessing success rate, procedure time and complications; and to measure pain referred by patients in both groups. METHODS An observational cross-sectional study of 60 patients with hysteroscopic diagnosis of endometrial polyps, divided into two groups: the Outpatient Group, comprising patients submitted to outpatients hysteroscopic polypectomy by continuous flow vaginoscopy using endoscopic forceps under no anesthesia, and the Conventional Group with patients submitted to hysteroscopic polypectomy in the operating theater, using a monopolar resectoscope under anesthesia. RESULTS The groups were similar as to age, parity, mode of delivery and menopausal status. Both groups presented 100% efficacy in exeresis of polyps. The mean time of procedure was 7 minutes in the Outpatient Group and 35.16 minutes in the Conventional Group. In the Outpatient Group, menopausal patients (p=0.04) and those with polyps >1cm (p=0.01) had longer procedures. Using the Verbal Analog Scale of Pain, the mean score of pain referred by patients during the procedure was 2.93 in the Outpatient Group and, after anesthetic effect, 1.42 in the Conventional Group. There were no complications in the Outpatient Group. There was one case of uterine perforation and one case of false passage in the Conventional Group. CONCLUSION Hysteroscopic polypectomy performed in an outpatient setting under no anesthesia is a well-tolerated procedure. As compared to conventional treatment, it displays the same efficacy, but the procedure time is shorter and the complication rate is lower.

Stress and anxiety in pregnant women exposed to ultrasound

Aim. To investigate the levels of anxiety and stress during pregnancy among women who are routinely offered ultrasound at first and second trimesters. Methods. This is a cross-sectional study involving 296 women, in which 146 pregnant women without any medical problem were compared with 150 nonpregnant women. Both groups were submitted to the Lipp Inventory of Stress Symptoms for Adults and to the State-Trait Anxiety Inventory. Logistic regression analysis was used to evaluate the effect of pregnancy on the anxiety and stress levels. Results. There was no statistical difference between pregnant and nonpregnant women [56.8% (83/146) vs. 48.6% (73/150), odds ratio (OR) 1.39 95% confidence interval (CI) 0.88–2.19] regarding the level of stress. Logistic regression analysis demonstrated that the only significant independent predictor of stress was maternal age (OR 0.95, 95% CI 0.91–0.96; P = 0.045) for the pregnant women and monthly income and religious belief for the nonpregnant group. Pregnant women had a higher level of anxiety compared with the nonpregnant (15.7% vs. 2.6%, P = 0.0002) and ultrasound examination decreased the anxiety level. Conclusion. Pregnant women did not have a higher level of stress compared with the nonpregnant women, and maternal age is the only significant independent predictor of stress. Pregnant women are more anxious, and after the ultrasound examination, the level of anxiety decreased.

Índice de risco de malignidade para tumores do ovário incorporando idade, ultra-sonografia e o CA-125

PURPOSE: to estimate the sensitivity, specificity and accuracy of patient age, ultrasound result and CA-125 marker variables for the differential diagnosis between malignant and benign ovarian tumors. In addition, to establish a risk of malignancy index (RMI) incorporating these three variables and to estimate its sensitivity, specificity and accuracy for the differential diagnosis. METHODS: one hundred patients with ovarian tumors with surgical indication were included. The age, ultrasonographic findings and CA-125 level variables were evaluated separately and later on together as the RMI. The study was performed based on the evaluation of the sensitivity, specificity and diagnostic accuracy and the use of the measurements: likelihood ratio, odds ratio, and the Students t test, c2, and logistic regression with univariate and multivariate analysis. RESULTS: for the age variable, sensitivity, specificity and diagnostic accuracy were 58.8, 68.2 and 65.0%, respectively. For ultrasound, 88.2, 77.3 and 81.0%. For CA-125 dosage, the values were 64.7, 74.2 and 71.0%. When the three variables were put together, as the RMI, a sensitivity of 76.5%, a specificity of 87.9% and a diagnostic accuracy of 84.0% were observed. CONCLUSIONS: RMI, made up of the association of patient age, ultrasound results and CA-125 dosage variables is a valuable indicator to distinguish between malignant and benign ovarian tumor, especially in regard to its specificity.

Hysteroscopic findings in patients with post-menstrual spotting with prior cesarean section

OBJECTIVE To identify uterine hysteroscopic findings among patients with prior cesarean section and whom had post-menstrual bleeding spotting type. METHODS We conducted a descriptive and prospective study between June 2008 and December 2009 involving women admitted to our clinic in Ji-Paraná (RO), Brazil, and who complained of prolonged genital bleeding after menstrual period. A total of 20 women with the simultaneous following characteristics were selected: at least one prior cesarean section, aged between 18 and 45 years, no use of hormonal contraceptives, and no history of uterine surgery that could change the cavity anatomy. All participants underwent a hysteroscopic examination. RESULTS During hysteroscopy, in 90% of the patients, the presence of a cesarean section scar was observed in the last third of the cervix. This scarring causes an anomaly in the uterine cavity anatomy, characterized by the viewing of an enlargement followed by a retraction of the anterior wall, which affords the presence of a pseudocavity with depth and lumen narrowing in variable degrees. Two patients did not present the pseudocavity. CONCLUSION Pseudocavities in cesarean section scar are usually found in hysteroscopic examination of patients with prior cesarean section and abnormal uterine spotting.

Comparative study of the results from conventional cervico-vaginal oncotic cytology and liquid-based cytology

OBJECTIVE To compare two oncotic cervical cytology techniques, the conventional and the liquid-based cytology, in low risk patients for uterine cervical cancer. METHODS Comparative prospective study with 100 patients who came to their annual gynecological exam, and were submitted simultaneously to both techniques. We used the McNemar test, with a significance level of p < 0.05 to compare the results obtained related to adequacy of the smear quality, descriptive diagnosis prevalence, guided biopsy confirmation and histology. RESULTS Adequacy of the smear was similar for both methods. The quality with squamocolumnar junction in 93% of conventional cytology and in 84% of the liquid-based cytology had statistical significance. As for the diagnosis of atypical cells they were detected in 3% of conventional cytology and in 10% of liquid-based cytology (p = 0.06). Atypical squamous cells of undetermined significance were the most prevalent abnormality. The liquid-based cytology performance was better when compared with colposcopy (guided biopsy), presenting sensitivity of 66.7% and specificity of 100%. There was no cytological and histological concordance for the conventional cytology. CONCLUSIONS Liquid-based cytology had a better performance to diagnose atypical cells and the cytohistological concordance was higher than in the conventional cytology.

Perinatal outcomes in women over 40 years of age compared to those of other gestations

Objective To clarify if older pregnant women were more likely to have adverse perinatal outcomes when compared to women at an ideal age to have a child. Methods The groups were divided according to age groups: under 20 years, ≥20 to <40 years, and ≥40 years. Results During the period from January 1st, 2008, to December 31st, 2008, there were 76 births from patients younger than 20 years and 91 births from patients aged 40 years or over. To form a third group with intermediate age, the data of 92 patients aged 20 to 40 years were obtained, totaling 259 patients. Patients aged 40 or older had a statistically greater number of cesarean sections and less use of forceps or normal deliveries (p<0.001). The use of spinal anesthesia was statistically higher among those aged 40 years or more (p<0.001). The frequency of male newborns was statistically higher in older patients, a group with statistically fewer first pregnancies (p<0.001). The frequency of premature newborns was statistically higher in patients aged 40 years or more (p=0.004). Conclusion It is crucial to give priority to aged women, so that prenatal care will be appropriate, minimizing maternal complications and improving perinatal outcomes in this unique group.