Vanessa Marcon de Oliveira

Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis.

OBJECTIVE We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes. STUDY DESIGN We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI. RESULTS Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1). CONCLUSION Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Variaveis perinatais e associacao de recem-nascidos de muito baixo peso ao nascer em hospital publico universitario do Brasil

PURPOSE To investigate the association of perinatal variables with the birth of very low birth weight (VLBW) preterm newborns. METHODS It was a retrospective study of the medical records of infants born after spontaneous preterm labor with admission to a neonatal intensive care unit. Preterm infants were divided into two groups: very low birth weight (VLBW) group (weight <1,500 g) and low birth weight (LBW) group (weight ≥1,500 g and <2,500 g). Prenatal variables such as maternal complications during pregnancy and childbirth/postpartum, and fetal/neonatal complications were investigated. Statistical analysis was performed using the Fisher exact test or χ2 test, with calculation of relative risk (RR), and the Student t test for comparison of group means, with the level of significance set at p≤0.05. RESULTS Hemorrhagic comorbidities (p=0.006; RR=1.2) and hypertension (p=0.04; RR=1.5), surgical delivery (p=0.001; RR=0.5), gestational age <33 weeks (p< 0.001; RR=16.7) and Apgar score at 1st and 5th minute (p=0.006; RR=1.6; p=0.01; RR=1.9) were associated with the occurrence of VLBW. Infants with VLBW had a significant association with the occurrence of metabolic comorbidities (p=0.01; RR=1.8), neurological (p=0.01; RR=1.7) and infectious diseases (p=0.001; RR=1.9), hospitalization >4 weeks (p=0.02; RR=1.8) and early neonatal death (p=0.0001; RR=2.9). CONCLUSIONS Factors such as hypertension and bleeding comorbidities during delivery and management of gestational age of less than 33 weeks were associated with the birth of VLBW newborns. This group of infants also showed higher RR for the occurrence of early neonatal death.

Toxoplasmose e gestação: resultados perinatais e associação do teste de avidez de IgG com infecção congênita em gestantes com IgM anti-Toxoplasma gondii reagente

OBJETIVOS: verificar os desfechos perinatais em gestantes com toxoplasmose aguda e se houve associacao entre os resultados dos testes de avidez para anticorpos IgG anti- Toxoplasma gondii e a presenca ou ausencia de infeccao fetal/neonatal. METODOS: um estudo transversal incluiu gestantes com diagnostico sorologico de toxoplasmose apresentando IgM especifica reagente, atendidas no Ambulatorio de Gestacao de Alto Risco da Faculdade de Medicina da Universidade Federal de Mato Grosso do Sul, no periodo de novembro de 2002 a novembro de 2007. Resultados do teste de avidez de IgG demonstrando indices superiores a 30% foram considerados alta avidez, enquanto valores inferiores a 30% foram considerados baixa avidez. Definiram-se como sendo de infeccao fetal e/ou neonatal os casos com resultado positivo para a reacao em cadeia da polimerase no liquido amniotico ou com IgM especifica para toxoplasmose reagente no sangue do recem-nascido. RESULTADOS: considerando-se todas as gestantes referidas para o ambulatorio de gestacao de alto risco no periodo estudado, a frequencia de gestantes com IgM anti- Toxoplasma gondii reagente foi de 10,8% (176/1.634). A taxa de infeccao congenita nessas pacientes foi de 4% (7/176). O teste de avidez de IgG foi realizado em 162 gestantes (92%), encontrando-se avidez alta em 144 (88,9%). Houve associacao (p=0,003) entre avidez alta e ausencia de toxoplasmose fetal/neonatal na amostra estudada, com razao de prevalencia de 13,4 (intervalo de confianca [IC] 95% 2,2-86,6). O Valor preditivo positivo do teste de avidez (probabilidade de infeccao congenita com avidez baixa) foi de 22% (IC 95% 6%-47%), enquanto o valor preditivo negativo (probabilidade de ausencia da infeccao congenita com avidez alta) foi de 98% (IC 95% 94%-99%). CONCLUSOES: neste estudo a taxa de infeccao congenita em gestantes com diagnostico de toxoplasmose aguda foi de 4%. Nas gestantes com IgM anti- Toxoplasma gondii positiva, o resultado do teste de avidez de IgG anti- Toxoplasma gondii associou-se a presenca ou ausencia de infeccao congenita, com elevado valor preditivo negativo (ausencia de infeccao fetal/neonatal quando a avidez era alta).

Eficácia de intervenção com enoxaparina baseada em sistema de pontuação nos desfechos perinatais de gestantes com trombofilias

PURPOSES To assess whether an enoxaparin-based intervention using a score system was effective in improving perinatal outcome in women with thrombophilia. METHODS STUDY DESIGN Prospective, not randomized, uncontrolled, performed at a Clinic of High-Risk Pregnancy from November 2009 to November 2011. We included women with a diagnosis and therapeutic intervention for thrombophilia acquired and/or inherited in the current pregnancy. The obstetric and perinatal outcomes of pregnant women before the intervention were compared with outcomes after the intervention, and statistically analyzed using the χ2 test with Yates correction, considered significant when p<0.05. The initial dose of low-molecular-weight Heparin (LMWH) was guided by a scoring system based on the clinical and gestational history of the patients and screening tests for acquired and/or inherited thrombophilia. RESULTS We included 84 pregnant women with 175 pregnancies before diagnosis, 20.0% of which resulted in fetal ou perinatal death, 40.0% resulted in abortion, 17.7% developed preeclampsia/eclampsia, 10.3% resulted in full-term births, and 29.7% in premature births. In the 84 pregnancies after intervention, 6.0% resulted in fetal ou perinatal death, 1.2% in abortion, 4.8% developed preeclampsia/eclampsia, 22.6% resulted in premature birth, and 70.2% in full-term birth. A significant reduction in the rate of stillbirths/perinatal death (p<0.05) and abortion (p<0.0001) and a significant increase (p<0.05) in the number of live births were observed after intervention. CONCLUSION Enoxaparin-based intervention using a score system in pregnant women with thrombophilia is effective in improving perinatal outcome.

UrinarY tract inFection in HigH riSK Pregnant WoMen

Background: In this study, we aimed to verify the frequency of urinary tract infection (UTI) in pregnant women, the main etiologic agents and their antibiotic susceptibilities. Moreover, to confirm UTI as a risk factor for maternal and fetal complications. Methodology: Data collection was performed using medical records from pregnant women suffering from UTIs (the Study Group) and pregnant women without UTIs (the Control Group). Both groups of patients visited the Department of High Risk Pregnancy, University Hospital, Federal University of Mato Grosso do Sul during the period of April 2005 to April 2010. Results: Of the 864 pregnant women studied, 15.6% (135/864) had a UTI. Escherichia coli was the most frequent cause of urinary tract infections, with a frequency of 34.8% (47/135). The E. coli strains were most sensitive to norfloxacin (91.4%), nitrofurantoin (80.8%) and ceftriaxone (74.4%) and most resistant to ampicillin (42.5%), trimethoprim-sulfamethoxazole (31.1%) and first-generation cephalosporins (14.8%). There was a significant association between preterm delivery, low birth weight and UTI in pregnant women. There was no significant association with premature rupture of membranes, admission to Neonatal Intensive Care Unit (Neo ICU) and Apgar of less than 7 at 5 min. Conclusion: The use of urine culture as routine prenatal laboratorial screening allows for the early diagnosis and treatment of UTIs in pregnant women, thereby providing better perinatal conditions.

Recurrence of hypertensive disorders of pregnancy

OBJECTIVE We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes. STUDY DESIGN We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI. RESULTS Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1). CONCLUSION Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Marcadores séricos de trombofilias hereditárias e anticorpos antifosfolípides em gestantes com antecedentes de pré-eclâmpsia grave

PURPOSE To determine the frequency and the association of serum markers for inherited and acquired thrombophilias in pregnant women with a history of severe pre-eclampsia in previous pregnancies. METHODS Case-control study consisting of 81 pregnant women with a history of severe pre-eclampsia in previous pregnancies (study group) and 32 women with no history of severe pre-eclampsia in previous pregnancies (control group). The presence of inherited thrombophilia and antiphospholipid antibodies was screened in both groups. We used the chi-square test with Yates correction to assess associations and calculate the relative risks. RESULTS The presence of thrombophilia was detected in 60.0% of patients with a previous history of pre-eclampsia and in 6.0% of the control patients. A significant association was found between pre-eclampsia in a previous pregnancy and the presence of markers for hereditary thrombophilia/antiphospholipid antibodies (p<0.05). The relative risk to develop pre-eclampsia was found to be 1.57 (1.34<RR<1.84) for pregnant women with antiphospholipid antibodies, 1.53 (1.26<RR<1.86) for women with hereditary thrombophilia markers and 1.86 (1.45<RR<2.38) considering the presence of hereditary thrombophilia and/or antiphospholipid antibodies. CONCLUSION Women with serum markers for inherited or acquired thrombophilia showed a high relative risk to develop pre-eclampsia.

High vertical HIV transmission rate in the Midwest region of Brazil

OBJECTIVES To estimate vertical HIV transmission rate in a capital city of the Midwest region of Brazil and describe the factors related to transmission. METHODS A descriptive epidemiological study based on the analysis of secondary data from the Notifiable Diseases Information System (SINAN). The analysis considered all HIV-infected pregnant women with delivery in Campo Grande-MS in the years 2007-2013 and their HIV-exposed infants. RESULTS A total of 218 births of 176 HIV-infected pregnant women were identified during the study period, of which 187 infants were exposed and uninfected, 19 seroconverted, and 12 were still inconclusive in July 2015. Therefore, the overall vertical HIV transmission rate in the period was 8.7%. Most (71.6%) of HIV-infected pregnant women were less than 30 years at delivery, housewives (63.6%) and studied up to primary level (61.9%). Prenatal information was described in 75.3% of the notification forms and approximately 80% of pregnant women received antiretroviral prophylaxis. Among infants, 86.2% received prophylaxis, but little more than half received it during the whole period recommended by the Brazilian Ministry of Health. Among the exposed children, 11.3% were breastfed. CONCLUSION The vertical HIV transmission rate has increased over the years and the recommended interventions have not been fully adopted. HIV-infected pregnant women need adequate prophylactic measures in prenatal, intrapartum and postpartum, requiring greater integration among health professionals.

Thromboprophylaxis and maternal-fetal outcomes of women with serum markers for hereditary thrombophilia and previous obstetric complications

Objectives: to evaluate the maternal-fetal outcomes of thromboprophylaxis with enoxaparin based on scoring system in women with serum markers for hereditary thrombophilia and previous obstetric complications. Methods: a retrospective study was undertaken based on data collected from clinical records. We included 54 pregnant women with serum markers for hereditary thrombophilia undergoing therapeutic intervention with enoxaparin in the period from November 2009 to December 2013. The initial dose of low molecular weight heparin was guided by a scoring system. The maternal-fetal outcomes of previous pregnancies and, subsequently, the treatment were compared using the chi-square (χ2) test with the Yates correction and Fishers Exact Test; p<0.05 was considered significant. Results: we observed significant reduction in fetal/perinatal deaths (p<0.05) and spontaneous abortions (p<0.001) after intervention. The live births at full-term delivery (p<0.001) and live births at preterm delivery (p<0.05) increased significantly after intervention. Conclusions: the therapeutic intervention with enoxaparin based on scoring system during pregnancy seems to improve the fetal prognosis.

Doppler velocimetry in fetal rats exposed to enoxaparin and unfractionated heparin (UFH) during pregnancy

Purpose: To evaluate the effects of enoxaparin and unfractionated heparin (UFH) administered in prophylactic and therapeutic doses on fetal vessels in healthy pregnant Wistar rats, according to Doppler velocimetry measurements. Methods: Fifty animals were assigned to one of five groups: controls (saline), prophylactic and therapeutic enoxaparin (1 and 2 mg/kg/day, respectively), and prophylactic and therapeutic UFH (72 and 400 UI/kg/day, respectively). Uterine horns were examined by ultrasound for identification of live fetuses. A sample of these fetuses underwent Doppler velocimetry. Spectral curves, peak systolic velocity (PSV), pulsatility index (PI), and resistance index (RI) of the middle cerebral artery, ductus venosus, and umbilical artery were investigated. Differences were considered statistically significant when p<0.05. Results: No significant differences in PSV, PI, or RI values were observed among the groups. Conclusion: Doppler velocimetry measurements revealed no significant effects of enoxaparin or unfractionated heparin on fetal vessels in pregnant Wistar rats.