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It has been observed that air pollution can affect newborn health due to the negative effects of pollutants on pregnancy development. However, few studies have evaluated the impact of maternal exposure to urban air pollution on head circumference (HC) at birth. Reduced head growth during pregnancy may be associated with neurocognitive deficits in childhood. The objectives of this study were to evaluate the association between maternal exposure to air pollution and HC at birth and to provide context with a systematic review to investigate this association. This was a prospective study of low-risk pregnant women living in Sao Paulo, Brazil. Exposure to pollutants, namely, nitrogen dioxide (NO2) and ozone (O3), was measured during each trimester using passive personal samplers. We measured newborn HC until 24 h after birth. We used multiple linear regression models to evaluate the association between pollutants and HC while controlling for known determinants of pregnancy. To perform the systematic review, four different electronic databases were searched through November 2018: CENTRAL, EMBASE, LILACS, and MEDLINE. We selected longitudinal or transversal designs associating air pollution and HC at birth. Two reviewers evaluated the inclusion criteria and risk of bias and extracted data from the included papers. Thirteen studies were selected for the systematic review. We evaluated 391 patients, and we did not observe a significant association between air pollution and HC. Regarding the systematic review, 13 studies were selected for the systematic review, 8 studies showed an inverse association between maternal exposure to pollutants and HC, 4 showed no association, and one observed a direct association. In the city of Sao Paulo, maternal exposure to pollutants was not significantly associated with HC at birth. The systematic review suggested an inverse association between air pollution and HC at birth.

Background: Fetal malformations are diagnosed prenatally in nearly 3% of pregnancies, and ∼1.2% are major malformations. After prenatal diagnosis, it is imperative to consider families' values and to support their decision-making process. Prenatal palliative care is a growing field mainly based on family conferences. The prenatal care setting is unique and differs from postnatal and adult care. There are no descriptions of family conferences in prenatal palliative care. The descriptions of themes that emerge from the prenatal care conference charts may guide professionals in this delicate task, and help determine the causes of suffering and identify family values before the birth of the infant. Aim: To perform a content analysis of medical records of family conferences and to describe the main themes observed during prenatal palliative care follow-up after the diagnosis of a life-limiting fetal condition. Design: This is a retrospective study of medical records of family conferences from a perinatal palliative care group, the GAI group, between May 2015 and September 2016. Setting/Participants: Families with estimated perinatal mortality >50% and eligibility for follow-up at our tertiary fetal medicine center were enrolled. We included women who participated in at least one family conference with the GAI group and who had given birth at the clinic or delivered at another center and returned for the postnatal family conference. Results: Fifty women met the inclusion criteria. Five main themes and 18 categories emerged from the charts and are described in detail. A model of follow-up in prenatal palliative care is proposed based on the themes and categories identified. Conclusions: This analysis may guide health professionals who seek to better identify family needs and values and organize follow-up during prenatal palliative care.

It has been widely demonstrated that air pollution can affect human health and that some pollutant gases can have negative impacts on female fertility rates and cause adverse obstetric outcomes, such as premature birth and low birth weight. Few studies have evaluated the impact of maternal exposure to urban air pollution on the number of female births. To evaluate the association between maternal exposure to air pollution during the year before conception and sex determination. This was a prospective study using low-risk pregnant women living in Sao Paulo, Brazil. The pollutants were measured by a fixed station during a 1-year period before conception. Sex was confirmed after birth. We used multiple logistic regression models to evaluate the association between the pollutants and the sex determination and to estimate the odds ratio (OR) and the 95% confidence interval (CI) of being female based on a quantitative increase in pollutant concentration. We evaluated 371 patients. Elevated exposure to nitrogen dioxide (NO2) and particulate matter lower than 10 μm (PM10) prior to conception were associated with increased odds of being female. Each unit increase of NO2 exposure increased the odds of being female by 8% (OR = 1.08, 95% CI = 1.02, 1.15, p = 0.008), and each unit increase of PM10 increased the odds of being female by 14% (OR = 1.14, 95% CI 1.02 to 1.28, p = 0.021). In Sao Paulo, maternal exposure to pollutants was significantly associated with the odds of being female.

Background: Breaking bad news is a frequent task in high-risk obstetrics clinics. Few studies have examined the role of training in improving such a difficult medical task. Aim: To evaluate the influence of a training program on the participants' perceptions of bad news communication at a high-risk obstetrics center. Design: This prospective study was conducted at the Department of Obstetrics/Gynecology, Hospital das Clinicas, from March 2016 to May 2017. Setting/Participants: Maternal-fetal health specialists were invited to complete an institutional questionnaire based on the SPIKES protocol for communicating bad news before and after training. The training consisted of theoretical lectures and small group practice using role play. The questionnaire responses were compared using nonparametric tests to evaluate the differences in physicians' perceptions at the two timepoints. The questionnaire items were evaluated individually and in groups following the communication steps of the SPIKES protocol. Results: In total, 110 physicians were invited to participate. Ninety completed the pretraining questionnaire and 40 answered the post-training questionnaire. After training, there were significant improvements in knowing how to prepare the environment before delivering bad news (p = 0.010), feeling able to transmit bad news (p

Objective To compare maternal complications and describe neonatal outcomes in women with severe preeclampsia at ≤ 26+0 weeks in two countries with different management policies: expectant management (Brazil) versus termination of pregnancy (France). Methods We conducted a retrospective comparative study by reviewing the medical records of women with severe preeclampsia at ≤ 26+0 weeks, from January 2010 to June 2018, in two centers: Hospital das Clínicas da Faculdade de Medicina, in Sao Paulo, Brazil (where medical abortion is forbidden in this indication) and Hôpital Antoine-Béclère, Clamart, France (where medical termination is accepted). We collected information on maternal characteristics, laboratory tests, maternal complications and fetal and newborn characteristics. We used Student’s t-test and the Mann-Whitney U nonparametric test to compare quantitative variables, and Chi-square test or Fisher's exact test to evaluate the associations between the qualitative variables. Results There was no between-group difference in maternal complications during hospitalization (p = 0.846). In Brazil, the rate of cesarean section was 66.7%, and 20% of patients had vertical incision. The rate of spontaneous fetal death was 35.6% and among the live-born infants 26.6% were discharged from hospital. In France, one patient had a cesarean section with vertical incision. Conclusion When comparing termination of pregnancy to expectant management in severe preeclampsia before 26 weeks, maternal complications were equivalent but maternal reproductive future might have been compromised in 20% of cases due to a higher risk of uterine rupture in subsequent pregnancies for patients having classic cesarean (vertical incision). 26.6% of children survived the neonatal period when pregnancy was pursued, however we lack information on their long-term follow-up.

Pollution of the atmosphere is known that may lead to adverse obstetric outcomes, including fetal growth restriction, gestational hypertension, and preeclampsia. Such disorders are correlated with imbalances in angiogenic factors, which may also be involved in the pathological mechanism as the pollutants impact placental and maternal physiology. In the first trimester of gestation, this study assessed the outcomes of personal maternal short period exposure to air pollution on soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PLGF) of pregnant women blood concentrations. This was a cross-sectional study, held in the city of Sao Paulo, Brazil, and conducted with low-risk pregnant women, who carried personal passive nitrogen dioxide (NO2) and ozone (O3) monitors for about a few days preceding the ultrasound evaluation, and on this day, the venous blood sample was collected to measure the angiogenic factors sFlt1 and PLGF and their ratio (sFlt1/PLGF) by enzyme-linked immunosorbent assay (ELISA). By means of multiple regression models, the effect of the studied pollutants on the log-transformed concentrations of the angiogenic factors was evaluated. One hundred thirty-one patients were included. The log of the sFlt1/PLGF ratio increased with rising NO2 levels (p = 0.021 and beta = 0.206), and the log of the PLGF concentration showed a negative correlation with NO2 (p = 0.008 and beta = − 0.234). NO2, an indicator of the levels of primary air pollutants, presented significant positive correlation with an increased sFlt1/PLGF ratio and diminished PLGF levels, which may reflect an antiangiogenic state generated by air pollution exposure.

OBJECTIVE To identify the correlation between the renal vascularization index (VI), the flow index (FI) and the vascularization and flow index (VFI) and placental and fetal hemodynamics in fetuses with growth restriction. METHOD Bidimensional ultrasound and three-dimensional power Doppler with the VOCAL technique were used to determine the renal vascular indexes and fetal and placental hemodynamics in fetuses below the 10th percentile for fetal weight. Partial correlation analysis (controlled for renal depth and gestational age) was performed. The fetuses were divided into four groups according to their hemodynamic picture, and renal indexes were compared between the groups. RESULTS Eighty-one fetuses were evaluated. VI, FI and VFI showed negative correlation with the ductus venosus pulsatility index. VI and VFI showed positive correlations with the amniotic fluid index. The group of fetuses with the worst hemodynamic picture (abnormal umbilical artery, middle cerebral artery and ductus venosus pulsatility indexes) showed significantly lower VI and VFI than the group with no changes in these pulsatility indexes. CONCLUSIONS Renal vascularization indexes were inversely correlated with ductus venosus pulsatility indexes and were diminished in fetuses showing hemodynamic compromise. These changes might be related to postnatal renal impairment. © 2017 John Wiley & Sons, Ltd.

OBJECTIVES Renal development is impaired in fetal growth restriction (FGR). Renal size can be considered a surrogate of renal function in childhood, and could be impaired in that condition. Our aim was to evaluate the ratio of total renal volume, measured by three-dimensional ultrasound, to estimated fetal weight (TRV/EFW) among fetuses with and without growth restriction. Furthermore, we correlated TRV/EFW with fetal Doppler velocimetry and renal vascularization indexes and evaluated the association of renal volume and vascular parameters with adverse neonatal events in growth-restricted fetuses. METHODS In a retrospective cohort, TRV and renal vascularization of growth-restricted and normal fetuses were evaluated by three-dimensional ultrasonography and VOCAL technique. Independent samples t-tests and Mann-Whitney test were used for comparisons between groups. Logistic regression model was applied to evaluate the association between renal characteristics and adverse neonatal events. RESULTS Seventy-one growth-restricted fetuses were compared to 194 controls. The TRV/EFW was lower in the growth-restricted group (P

Background: It has been widely demonstrated that air pollution can affect human health and that certain pollutant gases lead to adverse obstetric outcomes, such as preeclampsia and fetal growth restriction. Objectives: We evaluated the influence of individual maternal exposure to air pollution on placental volume and vascularization evaluated in the first trimester of pregnancy. Methods: This was a cross-sectional study on low-risk pregnant women living in São Paulo, Brazil. The women carried passive personal NO2 and O3 monitors in the week preceding evaluation. We employed the virtual organ computer-aided analysis (VOCAL) technique using three-dimensional power Doppler ultrasound to evaluate placental volume and placental vascular indexes [vascularization index (VI), flow index (FI), and vascularization flow index (VFI)]. We analyzed the influence of pollutant levels on log-transformed placental vascularization and volume using multiple regression models. Results: We evaluated 229 patients. Increased NO2 levels had a significant negative association with log of VI (p = 0.020 and beta = –0.153) and VFI (p = 0.024 and beta = –0.151). NO2 and O3 had no influence on the log of placental volume or FI. Conclusions: NO2, an estimator of primary air pollutants, was significantly associated with diminished VI and VFI in the first trimester of pregnancy. Citation: Hettfleisch K, Bernardes LS, Carvalho MA, Pastro LD, Vieira SE, Saldiva SR, Saldiva P, Francisco RP. 2017. Short-term exposure to urban air pollution and influences on placental vascularization indexes. Environ Health Perspect 125:753–759; http://dx.doi.org/10.1289/EHP300

Supplemental Digital Content is Available in the Text., Introduction: Although pain facial assessment is routinely performed in term and preterm newborns by the use of facial expression–based tools such as the Neonatal Facial Coding System, the assessment of pain during the intrauterine life has not been extensively explored. Objective: Describe for the first time, an experimental model to assess and quantify responses due to acute pain in fetuses undergoing anaesthesia for intrauterine surgery recorded by high-resolution 4D ultrasound machines. Methods/results-case report: A 33-year-old pregnant woman had congenital left diaphragmatic hernia of poor prognosis diagnosed, and her fetus was treated by fetoscopic endotracheal occlusion. Later, during the removal of the fetal endotracheal balloon by ultrasound-guided puncture, we have recorded facial expressions of the foetus before and after the anaesthetic puncture by the use of 4D ultrasound recordings, which were presented to 3 blinded coders instructed to use the Neonatal Facial Coding System for acute pain facial coding. The procedure was safe and feasible. Conclusion: This is the first description of a recordable acute pain model in the human fetus by the use of a facial expression–based tool. The possibility to assess pain-related intrauterine behaviours would allow not only for the monitoring of the efficacy of anaesthetic procedures in the fetus but would also open the way to explore the evolution of pain-related facial responses during the fetal neurodevelopment. This method may pave the way for objective assessments of pain in fetuses, should it endure the steps of formal validation studies.

To identify the correlation between the renal vascularization index (VI), the flow index (FI) and the vascularization and flow index (VFI) and placental and fetal hemodynamics in fetuses with growth restriction.Bidimensional ultrasound and three-dimensional power Doppler with the VOCAL technique were used to determine the renal vascular indexes and fetal and placental hemodynamics in fetuses below the 10th percentile for fetal weight. Partial correlation analysis (controlled for renal depth and gestational age) was performed. The fetuses were divided into four groups according to their hemodynamic picture, and renal indexes were compared between the groups.Eighty-one fetuses were evaluated. VI, FI and VFI showed negative correlation with the ductus venosus pulsatility index. VI and VFI showed positive correlations with the amniotic fluid index. The group of fetuses with the worst hemodynamic picture (abnormal umbilical artery, middle cerebral artery and ductus venosus pulsatility indexes) showed significantly lower VI and VFI than the group with no changes in these pulsatility indexes.Renal vascularization indexes were inversely correlated with ductus venosus pulsatility indexes and were diminished in fetuses showing hemodynamic compromise. These changes might be related to postnatal renal impairment. © 2017 John WileySons, Ltd.

Fetal malformations occur in 2% of gestations and are the fifth most common cause of neonatal death in the world. In many cases, fetal malformations result in neonatal death or long stay in intensive care facilities. Families that continue the pregnancy in such a situation need to make choices and cope with an overwhelming number of potential issues. Palliative care starting at the prenatal period is a growing field that allows the entire family to prepare for this difficult situation.To perform a systematic review of published data on palliative care in the prenatal period.PubMed and the Cochrane Library were searched using the keywords ("perinatal" OR "prenatal" OR "fetal") AND "palliative care" and also ("perinatal" OR "prenatal" OR "fetal") AND "hospice."Studies focusing on the long-term impact of prenatal palliative care published up to December 2015 were used.Quantitative and qualitative studies.In total, 541 studies were retrieved; 29 articles met the inclusion criteria. Studies were organized into different categories according to the design or main focus. The majority of studies retrieved were reflexives or presented a narrative proposal on palliative care started in the prenatal period (45%). Clinical studies comprised 17% of all articles found. No studies were found on the long-term impact of prenatal palliative care.Prenatal palliative care is a growing field and an important supportive care measure that can help grieving parents and families who do not want to or cannot interrupt their pregnancy. More studies should be carried out, specifically concerning long-term impact of prenatal palliative care. Guidelines and training of health professionals must be developed so that more families can benefit from this type of care.

Polyhydramnios is a common complication of fetal malformations and has been described to have high risk of pregnancy complications such as prematurity and placental abruption. In a subgroup of women severe polyhydramnios may lead to maternal dyspnea or untreatable pain, and amnioreduction is the procedure indicated to relieve those symptoms. There is a lack of information concerning the increase in the risk for the pregnancy when the procedure is indicated. Therefore, this study sought to evaluate the risk of complications in pregnancies with severe polyhydramnios that needed amnioreduction in relation to the basal risk for the pregnancy of having polyhydramnios without the need for the procedure.Patients with singleton pregnancies and severe polyhydramnios followed in our fetal medicine center were evaluated retrospectively. Pregnancy complications (prematurity rate, fetal death, premature rupture of membranes, placental abruption and chorioamnionitis) were studied in the group of patients needing the procedure and their risk was compared to the risk of having a pregnancy with severe polyhydramnios but with no need for the procedure.One hundred and thirty-five patients were evaluated. Forty-four patients (32.6%) needed amnioreduction. There was no increase in the risk of having complications when the procedure was needed OR = 1.4 (CI 0.46-1.26).Amnioreduction performed to relieve maternal symptoms did not statistically increase the risk of pregnancy complications with severe polyhydramnios in single pregnancies.

Doppler ultrasound is a non-invasive method for evaluating vascularization and is widely used in clinical practice. Gestational trophoblastic neoplasia includes a group of highly vascularized malignancies derived from placental cells. This review summarizes data found in the literature regarding the applications of Doppler ultrasound in managing patients with gestational trophoblastic neoplasia. The PubMed/Medline, Web of Science, Cochrane and LILACS databases were searched for articles published in English until 2014 using the following keywords: “Gestational trophoblastic disease AND Ultrasonography, Doppler.” Twenty-eight articles met the inclusion criteria and were separated into the 4 following groups according to the aim of the study. (1) Doppler ultrasound does not seem to be capable of differentiating partial from complete moles, but it might be useful when evaluating pregnancies in which a complete mole coexists with a normal fetus. (2) There is controversy in the role of uterine artery Doppler velocimetry in the prediction of development of gestational trophoblastic neoplasia. (3) Doppler ultrasound is a useful tool in the diagnosis of gestational trophoblastic neoplasia because abnormal myometrial vascularization and lower uterine artery Doppler indices seem to be correlated with invasive disease. (4) Lower uterine artery Doppler indices in the diagnosis of gestational trophoblastic neoplasia are associated with methotrexate resistance and might play a role in prognosis. CONCLUSION: Several studies support the importance of Doppler ultrasound in the management of patients with gestational trophoblastic neoplasia, particularly the role of Doppler velocimetry in the prediction of trophoblastic neoplasia and the chemoresistance of trophoblastic tumors. Doppler findings should be used as ancillary tools, along with human chorionic gonadotropin assessment, in the diagnosis of gestational trophoblastic neoplasia.

Purpose The aim of this study was to evaluate the ability of prenatal ultrasound markers to predict postnatal renal prognosis in fetuses with posterior urethral valves. Methods Medical files on fetuses with prenatal diagnosis of posterior urethral valves from 2000 to 2006 were reviewed retrospectively. Data from prenatal follow-up included gestational age at diagnosis, ultrasound renal parenchyma evaluation, and presence and time of oligohydramnios onset. Prenatal parameters studied were correlated to postnatal renal function. Results Thirty-one male fetuses were included. Six pregnancies were terminated. Of the remaining 25 pregnancies that were continued, 4 children had abnormal creatine and 21 normal creatinine levels at follow-up. Presence and time of oligohydramnios onset did not differ between groups ( P = .43). Ultrasound detected bilateral renal abnormalities in 3 fetuses (75%) with altered renal function, and 10 fetuses (55%) with normal creatinine, at follow-up. Conclusions None of the ultrasound parameters evaluated were able to reliably predict postnatal renal function.

Objective To report the prevalence of the association between gastroschisis and other anomalies, their prenatal characteristics and the postnatal follow-up. Method Prenatal and postnatal data from all patients with gastroschis prenatally diagnosed between January 1998 and December 2006 were reviewed concerning the presence of associated anomalies. Results Gastroschisis was prenatally diagnosed in 108 fetuses. Associated anomalies were identified in 14 cases (prevalence of 13.0%), with prenatal diagnosis being made in 5 (35.7%) patients. Postnatal examination revealed the association of other anomalies in nine other newborns not observed during prenatal examinations. Maternal age, parity, gestational age at diagnosis and birth, delivery mode and birth weight were similar in cases with ‘isolated gastroschisis’ and associated anomalies (p > 0.05). Survival rates in the ‘isolated gastroschisis group’ and ‘associated anomaly group’ were 91.5 and 78.6% (p > 0.05), respectively. The median time before oral feeding tended to be longer (but not statistical significantly) in the ‘associated anomaly group’ (32, range: 5–720 days) compared to the ‘isolated gastroschisis group’ (22, range: 5–180 days; p = 0.06), but with a significantly longer permanence in neonatal intensive care unit (p = 0.04). Conclusion This study highlights the importance of identifying other anomalies when evaluating fetuses with gastroschisis to permit counselling concerning the postnatal outcomes. Copyright © 2011 John Wiley & Sons, Ltd.

A cirurgia fetal é, hoje, uma realidade em grandes centros especializados na área da medicina fetal. Surgiu por volta da década de 1960, inicialmente atrelada à necessidade de melhor conhecer e entender as patologias fetais, e teve desenvolvimento exponencial impulsionado pelo aprimoramento das técnicas diagnósticas pré-natais. Foi aos poucos se consolidando e tornando-se o tratamento de escolha para algumas patologias específicas, mudando definitivamente o curso dessas doenças. Nesse estudo, encontra-se um breve histórico das cirurgias fetais mais comumente realizadas em todo o mundo, como elas surgiram e como foram evoluindo com o passar do tempo, os principais estudos que as validaram e a técnica cirúrgica mais amplamente utilizada em cada caso. Entre as principais cirurgias, são citadas a fotocoagulação a laser de anastomoses placentárias na síndrome de transfusão feto-fetal, a correção intrauterina a céu aberto da mielomeningocele fetal e a oclusão endotraqueal fetal por balão nos casos de hérnia diafragmática congênita. Também são abordados cirurgias e procedimentos cujos benefícios são menos evidentes e os resultados ainda um tanto controversos, como as intervenções urinárias nos casos de obstrução ao trato urinário inferior, procedimentos cardíacos em casos de estenose aórtica crítica, derivações tóracoamnióticas para tratamento de derrames pleurais compressivos, além de ressecções intrauterinas de teratomas sacrococcígeos e de massas pulmonares. Também é feita uma avaliação a respeito do futuro da cirurgia fetal.

Malformações fetais acometem cerca de 3% das gestações, e a possibilidade desse diagnóstico é uma das principais preocupações vivenciadas pelos pais e familiares. Quando é diagnosticado uma malformação que implique em possível mortalidade da criança, é necessário o planejamento do seguimento da gestação, o que abrange diversos aspectos que incluem avaliação minuciosa do prognóstico, organização do cuidado após o parto, e seguimento da família de forma abrangente e integrada. Recentemente os conceitos de cuidados paliativos foram introduzidos na perinatologia com essa finalidade, e o presente artigo tem como objetivo discutir o modelo de cuidado paliativo aplicado no atendimento a gestantes e familiares de fetos com malformação.

Purpose. To build nomograms of fetal thyroid circumference (FTC), fetal thyroid area (FTA), and fetal thyroid transverse diameter (FTTD) throughout gestational age (GA). Method. Between January 2006 and July 2006, FTC, FTA, and FTTD were measured once in 196 normal fetuses examined at a GA of 22–35 weeks. Inclusion criteria were a healthy mother with normal maternal thyrotropin level during pregnancy, a singleton pregnancy with normal fetal morphology on sonography, and GA confirmed via first-trimester sonographic examination. Results. Mean FTC, FTA, and FTTD ranged from 3.21 cm, 0.58 cm2, and 1.19 cm at 22 weeks to 5.11 cm, 1.69 cm2, and 1.89 cm at 35 weeks, respectively. Linear regression analysis yielded the following formulas for FTC, FTA, and FTTD according to GA: FTC (cm) = 0.146 × GA (weeks); FTA (cm2) = −1.289 + 0.085 × GA (weeks); FTTD (cm) = 0.054 × GA (weeks). The following logarithmic formulas were obtained for the expected fetal thyroid measurements according to estimated fetal weight (FW): FTC (cm) = −4.791 + 1.265 × logN FW; FTA (cm2) = −1.676 + 0.455 × logN FW; and FTTD (cm) = 0.399 + 0.001 × logN FW. Conclusion. We describe new nomograms of fetal thyroid measurements throughout gestation that may be useful in case of thyroid dysfunction. © 2008 Wiley Periodicals, Inc. J Clin Ultrasound, 2008.

INTRODUÇÂO: O funcionamento da tireóide fetal se inicia em torno de dez semanas de vida embrionária, e está intimamente relacionado ao funcionamento tireoidiano materno. Em gestantes com doenças tireodianas (principalmente hipertireoidismo), a passagem de anticorpos e medicações maternas pode provocar o mau funcionamento da tireóide fetal, acarretando bócio fetal. Além disso, algumas doenças fetais podem cursar com bócio antenatal. O funcionamento inadequado da tireóide fetal pode ter conseqüências severas (restrição de crescimento intra-uterino, craniosinostose, alterações na produção de líquido intra-âmniótico, insuficiência cardíaca ou até óbito fetal). Além disso, o bócio fetal avançado pode funcionar como obstrução à via de parto, podendo acarretar problemas na evolução do parto. A ultra-sonografia da tireóide fetal vem sendo descrita como um bom método para avaliação de tireóide fetal, porém existem poucas curvas de normalidade da tireóide fetal descritas atualmente, nenhuma em população brasileira. O objetivo desse estudo é construir curvas de normalidade do perímetro, área e diâmetro transverso da tireóide fetal em população brasileira através da utilização da ultra-sonografia bidimensional. MÉTODOS: Foram avaliadas 239 gestantes sem doenças sistêmicas e sem história de doença tireoidiana do pré-natal do Hospital das Clínicas da Universidade de São Paulo. Todas as gestantes realizaram dosagem de TSH durante a gestação para descartar doença tireoidiana. A idade gestacional foi calculada pela data da última menstruação, e confirmada por ultrasonografia de primeiro ou segundo trimestre. Foram construídas curvas de normalidade do perímetro, área e diâmetro transverso da tireóide fetal. Das 239 pacientes inicialmente avaliadas, 43 (18%) foram excluídas. A prevalência de hipotireoidismo subclínico entre as gestantes foi de 0,9%, e a de hipotireoidismo franco de 2,2%. Em 5,4% das pacientes não foi possível a visualização adequada da tireóide fetal. Foram incluídas 196 pacientes. A avaliação foi realizada por dois operadores independentes. Foram realizadas três medidas de cada parâmetro, e considerada a média dos valores para a construção das curvas. Para o cálculo da variação intra-observador, foram avaliadas 159 pacientes e realizadas três medidas subseqüentes de cada parâmetro. Para o cálculo da variação inter-observador foram avaliadas 34 pacientes, nas quais cada operador realizou uma medida de cada parâmetro. RESULTADOS: Foram construídas curvas de normalidade do perímetro (P), área (A) e diâmetro transverso (DT) da tireóide fetal em relação à idade gestacional (IG) em nossa população de gestantes. As equações que melhor representaram a média esperada por idade gestacional foram equações lineares: P = 0,146 x IG; A = -1,289 + 0,085 x IG; DT = 0,054 x IG. INTRODUCTION: The functioning of fetal thyroid initiates around ten weeks of embryonic life, and is intimately related to maternal thyroid functioning. In pregnant women with thyroid disease (especially hyperthyroidism), maternal antibodies and medications provoke malfunctioning of the fetal thyroid gland, causing fetal goiter. Moreover, primary fetal anomalies may course with antenatal goiter (i.e.: congenital fetal hypothyroidism). The inadequate functioning of fetal thyroid causes severe consequences such as intrauterine growth restriction, craniosinostosis, altered production of intra-amniotic liquid, cardiac insufficiency and even fetal death. Moreover, large fetal goiters may cause a mass effect, causing difficulties during vaginal delivery. Ultrasound evaluation of fetal thyroid has recently been described as a sensible method for fetal screening of thyroid anomalies. Few normality curves have been described until now, none of them in Brazilian fetuses. The aim of this study was to build normality curves of fetal thyroid perimeter, area and transverse diameter through the use of bidimensional ultrasonography. METHODS: 239 pregnant women without systemic disease and without previous thyroid disease were evaluated in the prenatal care unity of the Hospital of the Clinics of the University of São Paulo. All women had TSH measured during pregnancy in order to exclude thyroid disease. Gestational age was calculated by the date of the last menses, and confirmed by first or second trimester ultrasonography. Normality curves of fetal thyroid perimeter, area and transverse diameter were constructed. From the 239 patients initially evaluated, 43 (18%) were excluded. The prevalence of thyroid hormone disorders was 0.9% for subclinical hypothyroidism, and 2.2% for hypothyroidism. One patient had a TSH value below normal. In 5.4% of patients the adequate visualization of fetal thyroid was not possible. The evaluation was carried out in 196 patients by two independent operators. Three different measures of each parameter were performed. The average values were used to build the curves. Intra-observer variation analysis was made using 159 patients in whom three measures were made for each parameter. For the inter-observer variation, 34 patients were evaluated. RESULTS: Normality curves of the perimeter (P), area (A) and transverse diameter (TD) were constructed in relation to gestational age (GA) in our population. The 95% confidence interval was calculated. The equations that better represented the average value expected for each gestational age were linear regressions: P = 0,146 x GA; A= -1,289 + 0,085 x GA; TD = 0,054 x GA. The method was considered to be reproductive.

Objective: To evaluate the role of exposure to urban air pollution on regulation of fetal amniotic fluid volume. Methods: The sample was selected in West region of the city of Sao Paulo and integra...

Objective To evaluate glycemic control in women receiving metformin or insulin for gestational diabetes, and to identify factors predicting the need for supplemental insulin in women initially treated with metformin. Study Design Women with gestational diabetes who failed to achieve glycemic control with diet and exercise were randomized to receive metformin (n = 47) or insulin (n = 47). Criteria for inclusion were singleton pregnancy, diet, and exercise for a minimum period of 1 week without satisfactory glycemic control, absence of risk factors for lactic acidosis, and absence of anatomic and/or chromosome anomalies of the conceptus. Patients who were lost to prenatal follow-up were excluded. Results Comparison of mean pretreatment glucose levels showed no significant difference between groups ( P = .790). After introduction of the drug, lower mean glucose levels were observed in the metformin group ( P = .020), mainly because of lower levels after dinner ( P = .042). Women using metformin presented less weight gain ( P = .002) and a lower frequency of neonatal hypoglycemia ( P = .032). Twelve women in the metformin group (26.08%) required supplemental insulin for glycemic control. Early gestational age at diagnosis (odds ratio, 0.71; 95% confidence interval, 0.52–0.97; P = .032) and mean pretreatment glucose level (odds ratio, 1.061; 95% confidence interval, 1.001–1.124; P = .046) were identified as predictors of the need for insulin. Conclusion Metformin was found to provide adequate glycemic control with lower mean glucose levels throughout the day, less weight gain and a lower frequency of neonatal hypoglycemia. Logistic regression analysis showed that gestational age at diagnosis and mean pretreatment glucose level were predictors of the need for supplemental insulin therapy in women initially treated with metformin.

INTRODUÇÃO: Não há, até o momento, método ideal de avaliação da função renal em fetos com dilatação de vias urinárias. A ultrassonografia é utilizada como um método não invasivo e alguns parâmetros, como o índice de líquido amniótico, foram descritos na predição de insuficiência renal. Entretanto, a sensibilidade é baixa e a detecção de alterações, muitas vezes, ocorre tardiamente na gestação. A avaliação bioquímica da urina ou sangue fetais acrescenta risco à gestação e, apesar de melhorar a detecção de insuficiência renal, tem sensibilidade e especificidade baixas. O Power Doppler tridimensional é um método capaz de quantificar fluxo em órgãos parenquimatosos e tem sido utilizado na quantificação de fluxo sanguíneo de órgãos fetais e placenta. Como fetos com obstrução de vias urinárias e insuficiência renal apresentam diminuição no número de glomérulos, a quantificação do fluxo renal ao Power Doppler tridimensional poderia aprimorar a avaliação da função renal desses fetos. OBJETIVOS: quantificar o fluxo renal ao Power Doppler tridimensional em fetos com suspeita de obstrução de vias urinárias e naqueles com morfologia renal normal, avaliar a influência da profundidade nos índices vasculares e comparar os índices nos fetos que evoluíram com e sem insuficiência renal no período pós-natal. MÉTODOS: fetos com hidronefrose bilateral e/ou dilatação vesical foram prospectivamente comparados com fetos sem malformações em relação à quantificação do fluxo renal ao Power Doppler tridimensional. Os parâmetros avaliados foram IV, IVF, IF e a profundidade. Após o nascimento, as crianças foram seguidas por uma equipe de nefrologia e urologia e, de acordo com a função renal, foram classificadas em 2 grupos: insuficiência renal e função renal normal. A vascularização renal foi avaliada em cada grupo e comparada ao grupo controle. RESULTADOS: vinte e três fetos com dilatação de vias urinárias e setenta e três com morfologia renal normal foram considerados para a análise estatística. Cinco crianças (21,7%) apresentaram insuficiência renal após o nascimento. IV e IVF foram significativamente mais baixos nos casos que apresentaram insuficiência renal do que naqueles com função renal normal (p=0,009 e 0,036, respectivamente). Os três índices corrigidos pela profundidade (IVCP, IFCP e IVFCP) variaram com a idade gestacional e a variação inter-observador melhorou quando eles foram utilizados. A porcentagem do IVCP e do IVFCP em relação à controles de mesma idade gestacional foi menor nos casos que desenvolveram insuficiência renal do que naqueles que evoluíram com função renal normal. CONCLUSÕES: IV e IVF foram significativamente mais baixos em fetos que evoluíram com insuficiência renal pósnatal, porém a profundidade foi um fator interferente importante. Desta forma, IVCP e IVFCP são potencialmente melhores na avaliação de fetos com suspeita de obstrução de vias urinárias. Como os índices corrigidos pela profundidade variam de acordo com a idade gestacional, é necessária a construção de curvas de normalidade por idade gestacional para que os referidos índices possam ser avaliados na prática clínica INTRODUCTION: There is no ideal method for prenatal evaluation of renal function whether there is a urinary tract dilatation in the fetus. Although ultrasound is a noninvasive method and some parameters have been described to evaluate fetal renal function, as amniotic fluid index, there is a lack of sensitivity to renal failure when ultrasound is used alone. Furthermore, ultrasound changes may appear late in pregnancy. Biochemical evaluation of fetal urine or blood may expose the fetus to some risk, and still lack sensitivity and specificity for renal failure. Threedimensional Power Doppler evaluation has been used to quantify blood flow in fetal organs and placenta. As urinary tract obstruction lead to decrease in renal glomeurli and consequently to a decrease in parenchymal renal flow, three-dimensional quantification of renal flow may improve the evaluation of fetal renal function in fetuses with renal dilatation. OBJECTIVES: To evaluate the ability of threedimensional evaluation of renal vascularization to predict postnatal renal prognosis in fetuses with suspicion of urinary obstruction and to analyze depth influence in vascular indexes. METHODS: Fetuses with bilateral hydronephrosis and/or bladder dilatation had renal vascularization evaluated by three-dimensional ultrasound and VOCAL and were prospectively compared to healthy fetuses. Parameters evaluated were VI, VFI, FI and the distance between the probe and the renal cortex. Follow up by urologists and nephrologists allowed us to allocate these fetuses in two groups: renal impairment and normal renal function. Renal vascularization was evaluated in each group and compared to controls. RESULTS: Twenty-three fetuses with urinary dilatation and seventy-three fetuses with normal renal morphology where considered for statistical analysis. Five fetuses (21,7%) developed renal impairment. VI and VFI where significantly lower in fetuses that developed renal impairment than in those with normal renal function (p=0.009 and 0.036 respectively). Depth-corrected indexes (VIDC, FIDC and VFIDC) varied with gestational age and inter-observer variability was improved when depth was taken into account. The percentage of VIDC and VFIDC of cases in relation to gestational aged matched controls were lower in fetuses that developed post-natal renal impairment than in fetuses with normal renal function. CONCLUSION: Although VI and VFI were significantly lower in fetuses that developed post-natal renal impairment, depth seemed to be an important confounding variable. Thus, VIDC and VFIDC were potentially useful in this context. However, since depth-corrected indexes are related to gestational age, nomograms are needed to further evaluate the role of these parameters in predicting renal impairment

Objective To evaluate the applicability of 3-dimensional evaluation of renal vascularization for predicting postnatal renal function in fetuses with suspected urinary obstruction. Study Design Fetuses were evaluated by 3-dimensional power-Doppler histogram, and vascular indices were estimated. Depth between the probe and the renal cortex was also evaluated. Postnatal follow-up was obtained in all cases and the main outcome was renal impairment. Results Twenty-three fetuses with urinary dilatation (cases) and 73 with normal renal morphology (controls) were included in the current study. Five (21.7%) cases developed renal impairment. Vascularization index and vascularization and flow index were significantly lower in fetuses that developed renal impairment compared with those with normal renal function ( P = .009 and P = .036 , respectively). The 3 vascular indexes correlated with depth. Percentage of depth-corrected vascularization index and vascularization flow index were lower in fetuses developing postnatal renal failure. Conclusion Fetal renal vascularity (vascularization index and vascularization and flow index) was significantly lower in fetuses that developed renal impairment.

using the VOCAL (Virtual Organ Computer-aided AnaLysis) imaging program which is integrated into the Voluson E8 ultrasound system. The intrauterine content was sent for microscopic examination. The findings were compared with corresponding volumes and findings from women with uncomplicated postpartum periods from a previous study. Results: In 17 of the 20 cases placental remnants were verified by the microscopic examination. Five of these women had a uterine volume that exceeded the largest interquartile volume observed in women with a normal puerperium and in 4 the volume exceeded the largest volume observed in the normal puerperium. The other 12 women had normal uterine volumes. Fifteen of the 17 women with placental remnants had a uterine cavity volume that exceeded the interquartile volume observed in women with a normal puerperium and in 13 the volume exceeded the largest volume observed in the normal puerperium. In all 9 cases examined 42 days or more after delivery the uterine cavity volume exceeded the largest volume observed in the normal puerperium. In all examined women an echogenic mass was seen in the uterine cavity. Conclusions: The uterine and especially the uterine cavity volumes are often larger in women with placental remnants compared to women with an uneventful postpartum course. This knowledge can be of help when placental remnants are to be verified or ruled out. A finding of an echogenic mass in the cavity has a strong correlation with the presence of placental remnants.

OBJETIVO: Identificar as variáveis associadas ao nascimento prematuro espontâneo e eletivo em fetos com malformações. MÉTODOS: Foi realizado um estudo retrospectivo no Setor de Medicina Fetal do Departamento de Obstetrícia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo em São Paulo, Brasil (de dezembro de 2013 a maio de 2017), incluindo 505 gestantes com fetos únicos com diagnóstico ultrassonográfico de malformação não letal com planejamento de nascimento em centro terciário. A associação entre as variáveis e o nascimento prematuro (espontâneo e eletivo) foi analisada por meio de modelos de regressão logística multinomial e binária. No modelo final, as variáveis relacionadas foram selecionadas e o odds ratio (OR) foi considerado uma medida de associação de cada variável com o desfecho. RESULTADOS: As variáveis significativas que se associaram ao nascimento prematuro espontâneo foram: parto prematuro espontâneo anterior (OR = 5,74; IC95% 1,82-18,07), oligoidrâmnio no último exame (OR = 5,35; IC95% 1,77- 16,18), polidrâmnio no último exame (OR = 4,0; IC 95% 1,83-9,02), malformações do trato respiratório (OR = 2,80; IC95% 1,16-6,76); e malformações gastrointestinais e de parede abdominal (OR = 6,05; IC95% 2,81-13,01); para o parto prematuro eletivo, as variáveis significativas foram alteração de vitalidade indicativa de parto (OR = 15,48; IC95% 6,88-34,81), restrição de crescimento intrauterino (OR = 2,90; IC95% 1,31- 6,44) e polidrâmnio no último exame (OR = 4,49; IC95% 1,44-13,96). Uma vez que a alteração de vitalidade foi associada ao nascimento prematuro eletivo, também investigamos essa variável como desfecho. Os fatores independentes para alteração de vitalidade indicativa de parto foram: restrição de crescimento intrauterino (OR = 1,92; IC 95% 1,16-3,19) e oligoidrâmnio no último exame (OR = 9,52; IC95% 3,95-22,90), diabetes mellitus pré-gestacional (OR = 5,58; IC95% 2,25-13,85) e gastrosquise (OR = 2,44; IC95% 1,27-4,69). CONCLUSÕES: Os fatores de risco que predizem o nascimento prematuro espontâneo e eletivo em fetos com malformações foram demonstrados, além de fatores associados à alteração de vitalidade indicativa de parto. Esses achados são de extrema importância para o manejo pré-natal cuidadoso desses casos para que possamos identificar precocemente os fatores que levam ao parto prematuro, a fim de melhorar o prognóstico neonatal e a morbimortalidade OBJECTIVE: To identify the variables associated with spontaneous and medically induced preterm births in fetuses with birth defects. STUDY DESIGN: This was a retrospective study with 505 pregnant women with singleton pregnancy and diagnosis of nonlethal birth defects. The risk factors for preterm birth (spontaneous and medically induced) were analyzed using multinomial and binary logistic regression models. In the final model, the related variables were selected, and the odds ratio (OR) was considered a measure of the association of each variable with the outcome. RESULTS: In our study, 14,5% of women had spontaneous preterm birth and 9,3% had medically induced preterm birth. Variables associated with spontaneous preterm birth were previous spontaneous preterm birth (OR=5.74; 95%CI 1.82-18.07), oligohydramnios (OR=5.35; 95%CI 1.77-16.18) and polyhydramnios (OR=4.0; 95%CI 1.83-9.02) in the last exam, respiratory tract defects (OR=2.80; 95%CI 1.16-6.76), and gastrointestinal defects together with abdominal wall anomalies (OR=6.05; 95%CI 2.81-13.01). For medically induced preterm birth the significant variables were abnormal antepartum fetal surveillance indicating delivery (OR=15.48; 95%CI 6.88-34.81), intrauterine growth restriction (IUGR) (OR=2.90; 95%CI 1.31-6.44), and polyhydramnios (OR=4.49; 95%CI 1.44-13.96) in the last exam. Since abnormal antepartum surveillance was strongly associated with medically induced preterm birth, we also investigated this variable as an outcome variable. The independent factors associated with abnormal antepartum fetal surveillance were IUGR (OR= 1.92; 95%CI 1.16-3.19), oligohydramnios (OR=9.52; 95%CI 3.95-22.90) in the last exam, pregestational diabetes mellitus (OR=5.58; 95%CI 2.25-13.85), and fetal gastroschisis (OR=2.44; 95%CI 1.27-4.69). CONCLUSIONS: Risk factors predicting spontaneous and medically induced preterm births in fetuses with birth defects were demonstrated, and so were factors associated with abnormal antepartum fetal surveillance indicative of delivery. These findings are extremely important for careful prenatal management of cases of fetuses with birth defects. The identification of the factors leading to preterm birth in this specific population may improve neonatal prognosis, thereby decreasing morbidity and mortality

Introdução: Historicamente, a maneira como os ocidentais lidaram com a morte apresenta mudanças significativas. O avanço da Medicina, que permitiu o prolongamento da vida, e do ambiente hospitalar são dois marcadores importantes na transição da relação com a morte e com o morto, e, consequentemente, da expressão do sofrimento e do processo de luto. Nesse contexto, o cuidado paliativo perinatal, após o diagnóstico de anomalia fetal letal, surge como uma possibilidade para as gestantes e seus familiares de reaproximação da morte. Objetivo: Este estudo se propõe a descrever a vivência do luto, apresentar os rituais realizados diante da morte, avaliar a correlação entre luto, depressão e desesperança, e descrever a percepção acerca do atendimento recebido em cuidado paliativo perinatal. Método: Foram convidadas a participar desse estudo todas as mulheres que, entre os anos de 2015 e 2018, durante a gestação, receberam diagnóstico de anomalia fetal letal na Divisão de Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da USP e foram assistidas pelo Grupo de Apoio Integral às gestantes e familiares de fetos com malformação fetal (GAI). Os instrumentos utilizados foram: prontuário, entrevista semidirigida, Primary Care Evaluation of Mental Disorders (PRIME-MD), uma adaptação do Texas Revised Inventory of Grief (TRIG) e Escala de Desesperança de Beck (BHS). Trata-se de uma pesquisa qualitativa e quantitativa. A análise qualitativa foi realizada a partir da análise de conteúdo proposta por Minayo. As variáveis quantitativas foram analisadas por meio de média, mediana, desvio padrão, e valores mínimo e máximo. O nível de significância adotado foi de 0,05 e, quando apropriado, foi utilizado o teste exato de Fisher. Resultados: Foi observada significância estatística na relação entre a pontuação para luto complicado na época do óbito e nascimento do filho vivo (p=0,012), e entre pontuação para luto complicado na época da entrevista e gestante no momento da entrevista (p = 0,018). Entre a idade materna e pontuação para luto complicado na época do óbito foi identificada correlação linear negativa fraca e inversamente proporcional (r = -0,440; p = 0,015). Já as horas de vida do recém-nascido e pontuação para luto complicado na época do óbito apresentou correlação linear positiva moderada (r = 0,527; p = 0,005). A associação entre luto complicado na época do óbito; luto complicado no momento da entrevista; depressão e desesperança apresentou significância estatística entre: luto complicado na época do óbito e presença de depressão maior (p < 0,001); luto complicado no momento da entrevista e presença de depressão maior (p = 0,006); e luto complicado no momento da entrevista e desesperança (p = 0,005). Foram identificados oito temas na análise do discurso: A perda do filho(a) saudável; (Des)esperança e luto; Cuidado Paliativo Perinatal; Mães de anjo, Parto e perdas; Tradicionais ritos fúnebres; Novos ritos fúnebres; Memória e luto. Conclusão: Foi possível observar que as pacientes se beneficiaram do atendimento do cuidado paliativo perinatal e todos avaliaram que indicariam o serviço para uma outra pessoa gestante em situação semelhante Background: Historically, the way westerners have dealt with death has undergone significant changes. The advancement of medicine, which allowed the extension of life, and the hospital environment are two important markers in the transition of the relationship with death, with the deceased and consequently the expression of suffering and the grieving process. In this context, perinatal palliative care, after the diagnosis of lethal fetal anomaly, appears as a possibility for pregnant women and their families to approach death again. Objective: This study aims to describe the experience of mourning, present the rituals performed in the face of death, assess the correlation between grief, depression and hopelessness and describe the perception about the care received in perinatal palliative care. Methods: All women who between the years 2015 and 2018, during pregnancy, were diagnosed with a lethal fetal anomaly at the Obstetric Clinic Division of the Hospital das Clínicas of the Medical School of USP and were assisted by the group of palliative care Grupo de Apoio Integral às gestantes e familiares de fetos com malformação fetal (GAI). The instruments used were: medical record, semi-directed interview, Primary Care Evaluation of Mental Disorders (PRIME-MD), an adaptation of the Texas Revised Inventory of Grief (TRIG) and Beck\'s Hopelessness Scale (BHS). It is a qualitative and quantitative research. The qualitative analysis was carried out based on the content analysis proposed by Minayo. Quantitative variables were analyzed using means, medians, standard deviations, minimum and maximum values. The significance level adopted was 0.05 and Fisher\'s exact test was applied, when appropriate. Results: Statistical significance was observed between the score for complicated mourning at the time of death and the birth of a living child (p = 0.012) and between the score for complicated mourning at the time of the interview and the pregnant woman at the time of the interview (p = 0.018). Between the maternal age and the score for complicated mourning at the time of death, a weak and inversely proportional negative linear correlation was identified (r = -0.440; p = 0.015). The hours of life of the newborn and the score for complicated mourning at the time of death, on the other hand, presented a moderate positive linear correlation (r = 0.527; p = 0.005). The association between complicated mourning at the time of death; complicated mourning at the time of the interview; depression and hopelessness showed statistical significance between: complicated grief at the time of death and the presence of major depression (p < 0.001); complicated mourning at the time of death and hopelessness (p = 0.005) and complicated mourning at the time of the interview and the presence of major depression (p = 0.006). Eight themes were identified in the discourse analysis: The loss of a healthy child; Hope (lessness) and mourning; Perinatal Palliative Care; Angel mothers, Childbirth and losses; Traditional funeral rites; New funeral rites; Memory and mourning. Conclusion: It was possible to observe that the patients benefited from the perinatal palliative care and all evaluated that they would recommend the service to another pregnant woman in a similar situation

Introdução: Hipoxia é uma das principais causas de morbimortalidade do feto e recém-nascido (RN), tanto pela prematuridade que provoca quanto pelas lesões no período perinatal. Monitorização eletrônica da frequência cardíaca fetal é o método utilizado para rastreio de hipoxia, mas tem baixo valor preditivo positivo. Redistribuição hemodinâmica é um mecanismo adaptativo do feto frente à hipoxia, que pode preceder e tem o potencial de predizer resultados adversos perinatais (RAP). Objetivo: Investigar a influência de variáveis demográficas maternas, da ultrassonografia obstétrica anteparto, incluindo a relação cerebroplacentária (RCP) fetal, obstétricas e neonatais, com eventos adversos perinatais relacionados à hipoxia. Casuística e Métodos: Estudo de coorte retrospectivo, que incluiu 613 parturientes admitidas para resolução da gestação antes da fase ativa do trabalho de parto, cujos fetos haviam sido submetidos à ultrassonografia com Dopplervelocimetria nas 72 horas que antecederam o nascimento, com fetos únicos, vivos, sem anomalias congênitas e idade gestacional (IG) superior a 26 semanas. Os desfechos investigados foram: indicação de cesárea por sofrimento fetal agudo (SFA), Apgar p95 para a IG foi um preditor de cesárea por suspeita de SFA, assim como uma RCP abaixo de 0,98, independente da IG. A IG foi o preditor mais relevante de Apgar 29 semanas, IR da AU>0,84 também foi preditor desse resultado. IG p95 for GA was a predictor of cesarean section on suspicion of AFD, as well as a CPR below 0.98, regardless of GA. GA was the most relevant predictor of Apgar 29 weeks, UA >IR 0.84 was also predictor of this result. GA

INTRODUÇÃO: A diferenciação entre fetos com restrição de crescimento fetal (RCF) de início tardio (após 32 semanas) e fetos pequenos constitucionais (PqC) mostra-se essencial na prática clínica, pois os resultados perinatais são diferentes. A definição de peso fetal abaixo do percentil 10 para a idade gestacional chama atenção para esse grupo, mas outros métodos para essa identificação são necessários. Em ambos os casos, a dopplervelocimetria da artéria umbilical usualmente encontra-se normal. A falha na invasão trofoblástica pode aumentar a produção de citocinas pró-inflamatórias, fatores angiogênicos e antiangiogênicos pelo trofoblasto. O fator de crescimento placentário (PlGF), angiogênico, tem níveis menores detectados no sangue materno e expressão placentária também diminuída nessa situação. OBJETIVOS: Os objetivos desse estudo foram comparar os resultados obstétricos e neonatais entre dois grupos de gestantes com valores de PlGF normais e divididas de acordo com o peso de nascimento e também as concentrações de PlGF entre eles. MÉTODOS: Estudo clínico, prospectivo, transversal, do tipo caso-controle, realizado entre outubro de 2014 e julho de 2018, em que foram selecionadas 100 gestantes e divididas em 2 grupos: 50 gestantes do grupo PIG e 50 gestantes do grupo AIG. O grupo PIG compreendeu os casos de peso de nascimento abaixo do percentil 10 e dopplervelocimetria da artéria umbilical normal e o grupo AIG os casos de peso entre os percentis 10 e 90 para a idade gestacional, segundo a curva de Fenton et al. O PlGF foi dosado no sangue materno entre 35 e 37 semanas e definido como normal quando seus valores estavam acima do percentil 5 segundo a curva de Knudsen et al (2012). A detecção das concentrações de PlGF circulante foi realizada por meio do teste Triage® PlGF (Rapid Quantitative Test for Placental Growth Factor) ALERE. O grupo PIG apresentou 8 casos de PlGF anormal e todos esses casos foram excluídos após a análise, resultando num total de 42 casos. Os seguintes resultados perinatais foram estudados: Apgar de 5o minuto, icterícia neonatal, necessidade de fototerapia, transfusão sanguínea, hemorragia sanguínea, hemorragia intracraniana, enterocolite necrotizante, sepse neonatal, hipoglicemia neonatal, Unidade de terapia Intensiva (UTI), Intubação orotraqueal (IOT) e óbito neonatal. Para a análise estatística foram utilizados os testes de Qui-Quadrado e teste não paramétrico de Mann Whitney e foi adotado o nível de significância de 5%. RESULTADOS: A idade materna média no grupo PIG foi de 26,90 ± 7,14 anos e no grupo AIG de 29,08 ± 5,74 anos. No grupo PIG 32 (76,2%) pacientes e no grupo AIG 28 (56%) eram primigestas. A idade gestacional média do parto foi de 38,61 ± 1,39 semanas e 39,68 ± 0,99 semanas, no grupo PIG e no grupo AIG, respectivamente (p < 0,01). Não houve diferença significativa em relação aos grupos quanto a idade materna, gestações e partos anteriores e tipo de parto realizado. A média dos valores de PlGF foi de 323,98 e ± 477,44 pg/mL para o grupo PIG e 404,06 e ± 393,80 pg/mL para o grupo AIG (p=0,36). Entre os resultados perinatais avaliados, apenas a icterícia neonatal e a necessidade de fototerapia foram significativamente maiores no grupo PIG (p < 0,01). Os fetos do grupo PIG apresentaram chance 3,67 vezes maior de icterícia em relação aos fetos do grupo AIG (p=0,03). As taxas de icterícia foram maiores quando a idade gestacional do parto era menor, de forma independente. Cada semana adicional para o parto diminuiu em 64% a chance de icterícia (p < 0,01). CONCLUSÃO: Os achados demonstram não haver diferença em relação a resultados perinatais, com exceção de maiores taxas de icterícia neonatal e necessidade de fototerapia para o grupo PIG. Além da alteração no crescimento, a menor idade gestacional do parto foi preditora independente da ocorrência deste evento. A concentração de PlGF entre os grupos PIG e AIG, após a exclusão dos casos alterados, foi também semelhante. O uso de marcadores angiogênicos, como o PlGF, pode dar mais segurança no acompanhamento destas gestações e ser um instrumento na diferenciação entre fetos restritos e pequenos constitucionaisVildagliptin, Valsartan INTRODUCTION: The differentiation between fetuses with early-onset fetal growth restriction (FGR) (after 32 weeks) and constitutionally small fetuses (CSF) is essential in clinical practice, because the perinatal outcomes are different. The definition of fetal weight below the 10th percentile for gestational age draws attention to this group, but other methods for such identification are necessary. In both cases, the umbilical artery Doppler velocimetry is usually normal. Failure of trophoblastic invasion may increase the production of proinflammatory cytokines, angiogenic and antiangiogenic factors by trophoblast. Placental growth factor (PlGF),angiogenic, has lower levels detected in maternal blood and the placental expression is also diminished in this situation. OBJECTIVES: The objectives of this study were: comparing the obstetric and neonatal outcomes between two groups of pregnant women with normal PlGF values, and divided according to birth weight and according to the concentrations of PlGF between them. METHODS: A clinical, prospective, cross-sectional, case-control study was conducted between October 2014 and July 2018, in which 100 pregnant women were selected and divided into 2 groups: 50 pregnant women in the SGA group and 50 pregnant women in the AGA group. The SGA group comprised the cases of birth weight below the 10th percentile and normal umbilical artery Doppler velocimetry and the AGA group comprised the cases with of birth weight between the 10th and 90th percentiles for gestational age, according to the curve of Fenton et al. PlGF was measured in maternal blood between 35 and 37 weeks and defined as normal when its values were above the 5th percentile according to the curve of Knudsen et al. (2012). The detection of circulating PlGF concentrations was performed using the Triage® PlGF (Rapid Quantitative Test for Placental Growth Factor) ALERE test. The SGA group presented 8 cases of abnormal PlGF and all these cases were excluded after the analysis, resulting in a total of 42 cases. The following perinatal outcomes were studied: Fifth minute Apgar, neonatal jaundice, need for phototherapy, blood transfusion, blood hemorrhage, intracranial hemorrhage, necrotizing enterocolitis, neonatal sepsis, neonatal hypoglycemia, Intensive Care Unit (ICU), orotracheal intubation (OTI) and neonatal death. For the statistical analysis, Chi-Square and non-parametric Mann Whitney tests were used and a significance level of 5% was used. RESULTS: the mean maternal age in the SGA group was 26.90 ± 7.14 years. In the SGA group 32 (76.2%) patients were primigravidae and in the AGA group 28 (56%). The mean gestational age at delivery was 38.61 ± 1.39 weeks and 39.68 ± 0.99 weeks, in the SGA group and in the AGA group, respectively (p < 0.01). There were no significant differences between the groups regarding maternal age, previous pregnancies and births and type of delivery performed. The mean values of PlGF were 323.98 and ± 477.44 pg / mL for the SGA group and 404.06 and ± 393.80 pg / mL for the AGA group (p = 0.36). Among the perinatal outcomes evaluated, only neonatal jaundice and the need for phototherapy were significantly higher in the SGA group (p < 0.01). Fetuses of the SGA group showed 3.67 times greater chance of jaundice in relation to the fetuses of the AGA group (p=0.03). The rates of jaundice were higher when the gestational age of delivery was lower, independently. Each additional week for delivery reduced the chance of jaundice by 64% (p < 0,01). CONCLUSION: The findings demonstrate no difference in relation to perinatal outcomes, except for higher rates of neonatal jaundice and need for phototherapy in the SGA group. Besides the change in growth, the lower gestational age of the delivery was an independent predictor of the occurrence of this event. The concentration of PlGF between the SGA and AGA groups after the exclusion of the altered cases was also similar. The use of angiogenic markers, such as PlGF, may give more security in the follow-up of these pregnancies and may be an instrument in the differentiation between restricted fetuses and constitutionally small fetuses

Introdução: A poluição atmosférica é proveniente de complexas interações que envolvem emissões de poluentes atmosféricos e que sabidamente causam consequências negativas para a saúde humana. De acordo com alguns estudos, a exposição à poluição, durante a gestação, pode causar baixo peso ao nascimento e prematuridade. Contudo, não há ainda consenso sobre os períodos de maior susceptibilidade para a exposição à poluição, e quais seriam os seus efeitos nos desfechos do gestação e na determinação do sexo do recém-nascido (RN). Objetivos: Com a finalidade de investigar o impacto da poluição na gestação e, consequentemente, no RN, os objetivos deste projeto são avaliar a influência da exposição à poluição, antes da concepção, na determinação do sexo do RN, e, durante a gestação, nos desfechos do parto e na curva de crescimento da circunferência cefálica (CC) entre o terceiro trimestre e o parto. Métodos: Um estudo prospectivo com 371 gestantes, intitulado ProcriAR, foi realizado na cidade de São Paulo. Os poluentes dióxido de nitrogênio (NO2) e ozônio (O3) foram medidos durante cada trimestre da gestação por meio da utilização de amostradores passivos individuais (APIs). Simultaneamente, foi realizada a análise dos poluentes NO2 e material particulado com tamanho menor que 10 Micro m (MP10) medidos pela estação fixa de ar de Taboão da Serra da Companhia Ambiental do Estado de São Paulo (CETESB), localizada na zona oeste de São Paulo e a mais próxima da residência das gestantes do projeto. Os desfechos avaliados foram: idade gestacional, peso, comprimento e medida da CC do RN; sexo do RN e crescimento do polo cefálico entre o terceiro trimestre e o parto. Quando a variável desfecho era contínua, foi realizada análise linear multivariada, controle de idade gestacional, sexo do RN, idade materna no momento da concepção, índice de massa corporal (IMC), paridade, tabagismo, consumo de álcool, cor, nível de escolaridade completado, estado civil, índice de pulsatilidade (IP) da artéria umbilical no terceiro trimestre, e via de parto para a variável CC. Resultados: Não foram observadas associações entre a exposição ao NO2 e O3, avaliados em cada trimestre da gestação, e a idade gestacional, o peso, o comprimento, a CC ao nascer e o crescimento do polo cefálico fetal entre o terceiro trimestre e o parto. A exposição ao NO2 e MP10 no ano prévio à concepção influenciou na chance de ser do sexo feminino, ou seja, para cada aumento de 1 unidade do poluente do NO2, constatou-se um aumento de 10% na chance de ser do sexo feminino (Razão de chances (RC) = 1,100; intervalo de confiança (IC) de 95% = 1,040, 1,164; p = 0,001). Em relação ao MP10, para cada aumento de 1 unidade desse poluente, observou-se um aumento de 18 % na chance de ser do sexo feminino (RC = 1,176; IC de 95% = 1,054, 1,311; p = 0,004). Conclusão: Nossos resultados sugerem que, no ambiente de São Paulo, a exposição à poluição no ano prévio à concepção esteve associada à determinação do sexo do RN Background: Ambient pollution may lead to adverse obstetric outcomes, such as premature birth and low birth weight. Objectives: To determine the influence of maternal air pollution exposure on sex ratio, on birth outcomes and on the growth curve of cephalic pole between the third trimester and the birth. Methods: ProcriAR, a prospective cohort study of 371 pregnant women, was conducted in the city of São Paulo. Nitrogen dioxide (NO2) and ozone (O3) were measured during each trimester using passive personal monitors. At the same time, NO2 and particulate matter lower than 10 Micro m (PM10) were measured by a fixed station. We evaluated the gestational age, birth weight, birth lenght, head circumference, newborn sex and the growth curve of cephalic pole between the third trimester and the birth. When the outcome variable was continuous, multivariate analysis was performed, controlling for gestational age, newborn sex, maternal age at conception, body mass index, parity, smoking, alcohol consumption, race, highest education level completed, marital status, umbilical artery pulsatility values at third trimester and type of delivery for the outcome head circumference. We used multiple logistic regression models to evaluate the association of being female based on a quantitative increase in pollutant concentration, controlling for maternal age at conception, parity and smoking. Results: Elevated exposure to pollutants NO2 and PM10 were associated with increased odds of being female. Each unit increase of NO2 exposure increased the odds of being female by 10% (odds ratio (OR) = 1,100, 95% confidence interval (CI) = 1,040, 1,164; p = 0,001) and each unit increase of PM10 increased by 18% (OR = 1,176, 95% CI 1,054, 1,311, p = 0,004). Conclusion: In São Paulo, maternal exposure to pollutants prior to conception was significantly associated with the odds of being female

Introdução: O termo \"má notícia\" designa qualquer informação transmitida ao paciente ou a seus familiares que implique, direta ou indiretamente, de forma negativa sobre expectativas de seu futuro. A forma como a notícia é transmitida pode impactar negativamente no seguimento da paciente. A despeito disto, pouco tempo é despendido para tal função durante a formação médica, o que torna esta tarefa ainda mais árdua para o profissional responsável por esta comunicação. Na área da Obstetrícia, poucos são os trabalhos que descrevem programas de treinamentos na comunicação de más notícias, assim como seu impacto na percepção dos profissionais de saúde. Objetivo: Avaliar o impacto de treinamento institucional em comunicação de más notícias na percepção dos profissionais de saúde. Métodos: Estudo prospectivo envolvendo médicos especialistas em saúde materno-fetal do Hospital das Clínicas da Universidade de São Paulo. Estes foram convidados a preencher um questionário institucional baseado no protocolo SPIKES para comunicação de más notícias antes e após o treinamento formal para a transmissão de más notícias na instituição. O treinamento foi dividido em teórico e prático. As respostas do questionário foram comparadas usando testes não paramétricos para avaliar as diferenças nas percepções dos médicos nas duas etapas. Os itens do questionário foram avaliados individualmente e em grupos seguindo as etapas de comunicação do protocolo SPIKES. As avaliações dos médicos em relação ao treinamento proposto foram analisadas usando metodologia quantitativa. Resultados: Cento e dez médicos foram convidados a participar. Noventa médicos completaram o questionário antes do treinamento proposto e quarenta médicos responderam o questionário após o treinamento completo. Após o treinamento, houve melhora significativa em saber como preparar o ambiente antes de transmitir a má notícia (P = 0,010), na percepção de sentir-se preparado e capacitado em transmitir más notícias (P < 0,001), sentir-se capaz de discutir o prognóstico (P = 0,026), sentir-se capaz de discutir o término da gravidez ou início de cuidados paliativos (P = 0,003), sentir-se capaz de discutir questões de fim de vida (P = 0,007) e sentir-se confiante para responder questões difíceis (P = 0,004). A comparação das respostas agrupadas seguindo os passos do protocolo SPIKES mostrou diferenças significativas entre as etapas para os seguintes passos: \"Knowledge\" (P < 0,001), \"Emotions\" (P = 0,004) e \"Strategy and Sumarize\" (P = 0,002). Conclusão: A implementação de treinamento formal em caráter institucional para a transmissão de más notícias foi capaz de modificar a percepção dos profissionais em relação a esta comunicação Background: \"Bad News\" refers to any information transmitted to the patient or his family that implies negative expectations about their future. The way that bad news is transmitted can negatively impact patient follow-up. Despite this, low time spent for this function during medical training, which makes this task even more arduous for the responsible for this communication. In Obstetrics settings, there are few studies describing breaking bad news training programs, as well as their impact on the perception of health professionals. Objective: To evaluate the influence of a training program on the participants\' perceptions of bad news communication. Methods: Prospective study involving maternal-fetal health specialists from the Hospital das Clinicas at the University of São Paulo. Who were invited to complete an institutional questionnaire based on the SPIKES protocol for breaking bad news before and after formal training in breaking bad news was delivered in the institution. The training consisted in two parts: theoretical and practical. The questionnaire responses were compared using nonparametric tests to evaluate the differences in physicians\' perceptions at the two timepoints. The questionnaire items were evaluated individually and in groups following the communication steps of the SPIKES protocol. Physicians\' evaluations of the training program were analyzed using quantitative methodology. Results: A total of 110 physicians were invited to participate. Ninety physicians completed the pre-training questionnaire and forty physicians answered the posttraining questionnaire. After training, there were significant improvements in knowing how to prepare the environment before delivering bad news (P = 0.010), feeling prepared and able to transmit bad news (P < 0.001), feeling able to discuss the prognosis (P = 0.026), feeling capable of discussing ending the pregnancy or the initiation of palliative care (P = 0.003), feeling capable of discussing end-of-life issues (P = 0.007), and feeling confident about answering difficult questions (P = 0.004). The comparison of the grouped responses following the steps of the SPIKES protocol showed significant differences between groups for the following steps: \"Knowledge\" (P < 0.001), \"Emotions\" (P = 0.004) and \"Strategy and Summary\" (P = 0.002). Conclusion: The implementation of institutional formal training in breaking bad news changed the perception of the physicians in the communication setting

INTRODUÇÃO: Na restrição de crescimento intrauterino, a resposta adaptativa a hipóxia, com priorização do fluxo sanguíneo para órgãos nobres, causa vasoconstricção periférica, com aumento da resistência nas artérias renais. Com isso, o desenvolvimento renal é prejudicado e fetos restritos apresentam volumes renais menores. No entanto, a literatura é escassa em estudos que utilizem a ultrassonografia tridimensional na avaliação renal e não descreve a relação desse possível dano renal com desfechos neonatais adversos. Tal técnica tem sido utilizada para mensurar volumes de órgãos e quantificar fluxos sanguíneos de baixa resistência, podendo ser também aplicada para melhorar a avaliação do volume e vascularização renal na restrição de crescimento. OBJETIVOS: Comparar a razão entre o volume renal total e o peso fetal estimado (VRT/PFE) entre fetos com e sem restrição. Além disso, correlacionar o VRT/PFE com a dopplervelocimetria fetal e os índices de vascularização renal e avaliar a associação dos parâmetros renais com eventos neonatais adversos nos fetos restritos. MÉTODOS: O volume total e a vascularização renal de fetos restritos e normais foram avaliados pela ultrassonografia tridimensional e a técnica VOCAL. Os índices de vascularização renal foram corrigidos pela profundidade renal (IVcp, IVFcp and IFcp). Os testes t para amostras independentes e Mann-Whitney foram utilizados para a comparação entre os grupos. Modelos lineares generalizados foram aplicados para avaliar a associação entre as características renais e os eventos neonatais adversos. RESULTADOS: Setenta e um fetos restritos foram comparados a 194 fetos com crescimento normal. O VRT/PFE foi menor no grupo restrito (p < 0,001). Porém essa razão não se correlacionaou com os parâmetros dopplervelocimétricos, os índices vasculares renais ou qualquer evento neonatal adverso. CONCLUSÃO: A razão entre o volume renal total e o peso fetal estimado tende a diminuir na restrição de crescimento intrauterino INTRODUCTION: In fetal growth restriction, the adaptive response to hypoxia, with prioritization of blood flow to noble organs, causes peripheral vasoconstriction, such as increased resistance in the renal arteries. Then, renal development is impaired and restricted fetuses have lower renal volumes. However, the literature is scarse in studies using three-dimensional ultrasound in renal assessment and does not describe the relationship of this potential renal damage with adverse neonatal outcomes. That technique has been used to mesure volumes and quantify blood flows of low resistance and could also be applied to improve the evaluation of renal volume and vascularization in fetal growth restriction. OBJECTIVES: To compare the ratio of total renal volume to estimated fetal weight (TRV/EFW) among fetuses with and without grown restriction. Fhurthermore, we aim to correlate TRV/EFW with fetal dopplervelocimetry and renal vascularization indexes and to evaluate the association of renal parameters with adverse neonatal events in restricted fetuses. METHODS: Total renal volume and renal vascularization of restricted and normal fetuses were evaluated by three-dimensional ultrasonography and the VOCAL technique. Renal vascularization indexes were corrected for renal depth (VIcd, VFIcd and FIcd). The t-tests for independent samples and Mann-Whitney test were used for comparisons between groups. Generalized linear models were applied to evaluate the association between renal characteristics and adverse neonatal events. RESULTS: Seventy-one restricted fetuses were compared to 194 normally growing fetuses. The TRV/EFW was lower in the restricted group (p < 0.001). However, this ratio did not correlate with Doppler velocimetric parameters, renal vascular indexes or any adverse neonatal events. CONCLUSION: The ratio of total renal volume to estimated fetal weight tends to decrease in intrauterine growth restriction

Objetivo: avaliar a ingestão de nutrientes no período pré-concepcional e níveis séricos de ácidos graxos, durante a gestação, em gestantes portadoras de fetos com gastrosquise e gestantes portadoras de fetos normais. Métodos: estudo prospectivo caso-controle realizado no período de Julho de 2013 a Julho de 2015 no setor de Medicina Fetal do Hospital das Clínicas. O grupo gastrosquise (GG) foi constituído de 57 gestantes com gestações únicas, idade gestacional inferior a 34 semanas e feto com gastrosquise isolada. O grupo controle (GC) foi constituído de 114 gestantes portadoras de fetos normais pareadas de acordo com idade materna (± 2 anos), idade gestacional (± 2 semanas) e mesma classificação de índice de massa corpórea (IMC) no período pré-concepcional. Os dados referentes ao consumo dietético das gestantes foram obtidos a partir do questionário de frequência e consumo alimentar (QFCA) e o cálculo da ingestão dos nutrientes (macronutrientes; micronutrientes, ácidos graxos e aminoácidos) foi obtido a partir de programas específicos: Dietwin Profissional 2.0® and Virtuanutri®. Para a avaliação de níveis séricos de ácidos graxos (AG), as gestantes foram submetidas à coleta de sangue na entrada no estudo e no momento do parto. A comparação de AG foi realizada durante a gestação e no momento do parto. Com o objetivo de avaliar se as diferenças entre os grupos eram mais frequentes na primeira ou na segunda metade da gestação, uma nova análise foi realizada subdividindo o período gestacional 25 semanas e < 34 semanas. Resultados: no período pré-concepcional, a media diária de calorias ingerida foi maior (2382,43 vs. 2198,81; p = 0,041) no GG em comparação com GC. O consumo médio de metionina (763,89 vs 906,34; p = 0,036), treonina (1248,34 vs. 1437,01; p = 0,018) e crômio (54,66 vs. 59,49 p = 0,014) foi menor no GG em comparação ao GC. Na análise de ácidos graxos, observa-se que o total AG (p = 0,008), AG insaturados (p = 0,002) e a razão C18:1n9/C18:00 (p = 0,021) foi menor no GG em comparação ao GC durante a gestação; entretanto, a razão C16:00 / C18:2n6 (p = 0,018) foi maior no GG em comparação ao GC no mesmo período. Total AG (p = 0,044) e AG insaturados (p = 0,024) foi menor no GG em comparação ao GC no período 25 semanas e < 34 semanas. Conclusão: gestantes portadoras de fetos com gastrosquise apresentam dieta de baixa qualidade nutricional, com alto valor calórico e pobre em aminoácidos essenciais, no período pré-concepcional, e baixos níveis séricos de ácidos graxos durante a gestação Objective: To evaluate the nutrients intake during the preconceptional period and the serum fatty acid levels during the gestation period of pregnant women with fetuses with gastroschisis and pregnant women with normal fetuses. Methods: A prospective case-control study was conducted at the Fetal Medicine Unit at Hospital das Clínicas from July 2013 to July 2015. The gastroschisis group (GG) comprised 57 pregnant women with singleton pregnancies of less than 34 weeks with fetuses with isolated gastroschisis, and the control group (CG) comprised 114 pregnant women with normal fetuses matched for maternal age (± 2 years), gestational age (± 2 weeks), and the same preconceptional body mass index (BMI). Nutritional assessments related to the preconceptional period were obtained using the Food Consumption Frequency Questionnaire and nutrient intakes (macronutrient, micronutrient, fatty acid and amino acid) were calculated using nutrition programs: Dietwin Profissional 20 ® and Virtuanutri ®. For the evaluation of serum fatty acid levels (FA), a blood sample was collected from each subject at the time they entered the study and at the time of delivery. The FA comparison was performed during gestation and at the time of delivery. In order to evaluate whether the differences between both groups were more frequent in the first or second half of gestation, a new analysis was performed, subdividing gesta 25 weeks and < 34 weeks. Results: during the preconceptional period, the median daily calorie intake was higher (2382.43 versus 2198.81; p = 0.041) in the GG than in the CG. The median intakes of methionine (763.89 versus 906.34; p = 0.036), threonine (1248.34 versus 1437.01; p = 0.018) and chromium (54.66 versus 59.49 p = 0.014) were lower in the GG than in the CG. By analyzing the serum fatty acid levels, total FA (p = 0.008), unsaturated FA (p = 0.002) and the C18:1n9/C18:00 ratio (p = 0.021) were lower in the GG than in the CG during gestation; however, the C16:00 / C18:2n6 ratio (p = 0.018) was higher in the GG than in the CG during the indicated period. Total FA (p = 0.044) and unsaturated FA (p = 0.024) were lower in the GG than in the CG at period 25 weeks and < 34 weeks. Conclusion: Pregnant women with fetuses with gastroschisis have low-nutritional-quality diet, which is both high in calories and poor in essential amino acids during the preconceptional period, and have low serum FA levels during pregnancy

Introdução: A maioria dos fetos com lesão pulmonar congênita (LPC) são assintomáticos e apresentam baixa morbidade ao nascimento. No entanto, alguns neonatos apresentam desconforto respiratório e necessitam receber de cuidados especiais neste período. Decidir quais casos com LPC precisam nascer em um centro de referência é um desafio. Objetivo: O objetivo deste estudo foi predizer a morbidade neonatal em fetos com LCP sem hidropisia avaliados pela ultrassonografia tridimensional (US3D). Método: Estudo observacional, entre janeiro de 2005 e janeiro de 2016, com fetos com LPC e sem hidropisia. Os volumes pulmonares foram mensurados pela US3D, técnica VOCAL, em dois períodos: entre 20 e 28 semanas (1o momento) e entre 29 e 34 semanas (2o momento). A variação intra e inter-operador foi analisada para os volumes pulmonares. As relações volumétricas testadas foram: volume pulmonar observado / esperado (VPTo/e); volume da lesão pulmonar / circunferência cefálica (LVR) e volume da lesão / volume pulmonar observado (VL/VPTo). As relações volumétricas foram usadas na predição da morbidade neonatal (admissão em unidade de terapia intensiva neonatal (UTI), necessidade de intubação (IOT); necessidade de cirurgia no período neonatal por sintomatologia respiratória). Regressão logística múltipla e curva ROC foram aplicadas para determinar a acurácia na predição dos resultados. Resultados: Dos 45 fetos não hidrópicos com LPC incluídos no estudo, 18 (40%) foram admitidos na UTI, 14 (31,1%) necessitaram de IOT, e sete (15,6%) cirurgia neonatal. A variação intra e inter-operador para os volumes pulmonares apresentou boa reprodutibilidade e não houve diferença estatística (p > 0,05). No 1o momento (IG: 20 - 28 semanas) observou-se que todas as relações volumétricas (1oVPTo/e, 1oLVR e 1oVL/VPTo) foram preditoras para admissão na UTI e necessidade de IOT. No 2o momento (IG: 29 - 34 semanas), apenas o 2oVPTo/e, e, 2oVL/VPTo foram preditores para IOT. Nenhuma das razões volumétricas (VPTo/e, LVR e VL/VPTo) foram preditoras para a cirurgia neonatal. No 1º momento, o melhor preditor para UTI foi 1º VPTo/e (ASC 0,86; p < 0,001) e para IOT foi 1º VL/VPTo (ASC 0,94; p < 0,001). Os cut-off escolhidos para a admissão na UTI foi 1º VPTo/e 1,18 (s:91,7%; e:62,5%, a:72%). Para o 2o momento, a melhor relação volumétrica preditora para admissão na UTI foi 2º VL/VPTo (ASC 0,92; p < 0,001) e para necessidade de IOT foi 2º VPTo/e (ASC 0,87; p < 0,001). O cutoff escolhido foi 2ºVL/VPTo > 0,42 para a admissão na UTI (s:94,1%; e:82,3%; a:88%); e 2ºVPTo/e < 0,50 para IOT (s:92,9%; e:75%; a:82,3%). Conclusão: As relações volumétricas pulmonares mensuradas pela US3D podem predizer as morbidades neonatais em fetos não hidrópicos com LPC. O VPTo/e e VL/VPTo foram os melhores preditores da morbidade neonatal. Esses dados podem auxiliar no aconselhamento aos pais e na escolha do local mais adequado para o parto Introduction: Most fetuses with congenital lung malformation (CLM) are asymptomatic and have low morbidity. However, some newborns present respiratory discomfort and need special care. Therefore, decide which cases need to be delivered in a referring center is challenging. Objectives: The purpose of this study was to predict neonatal morbidity in non-hydropic fetuses with CLM assessed by threedimensional ultrasonography (3DUS). Method: Observational study, between January 2005 and January 2016, involving non-hydropic fetuses with CLM. The fetal lung volumes were assessed by 3DUS, by VOCAL technique, in two moments: between 20 and 28 weeks (1st moment) and between 29 and 34 weeks (2nd moment). Intra- and inter-operator variabilities were also evaluated in estimating fetal lung volumes by 3DUS. The following volumetric ratios were assessed: observed / expected normal fetal lung volume (oeTLV), fetal lung lesion volume ratio (LVR), and lesion-to-lung volume ratio (LLV). The lung volumetric ratios were used for the prediction of neonatal morbidity (admission to NICU, need of orotracheal intubation (OTI), or need for lung surgery in neonatal period due to respiratory symptoms). Multivariate regression analyses and receiver operator characteristic curve (ROC) were applied to determine the best volumetric ratio to predict the neonatal morbidity. Results: Forty-five non-hydropic fetuses with CLM were selected for the study. Eighteen (40%) were admitted to the NICU, 14 (31.1%) needed intubation and seven (15.6%) needed neonatal surgery. The variation intra and inter-operator for lung volumes showed good reproducibility and no statistical difference (p>0.05). In the 1st moment (GA: 20 - 28 weeks), all 3DUS ratios (1st oeTLV, 1st LVR, and 1st LLV) demonstrated strong prediction for NICU admission and need of intubation. In the 2nd moment (GA: 29 - 34 weeks), only 2nd oeTLV and 2nd LLV correlated with need of intubation. None of the volumetric ratios (oeTLV, LVR and LLV) were predictive of neonatal surgery. In the 1st moment the best volume ratio for the prediction of NICU admission was 1st oeTLV (AUC 0.86, p < 0.001) and for the need of intubation was 1st LLV (AUC 0.94, p < 0.001). The cut-off chosen for NICU admission was 1st oeTLV < 0.53 (sensitivity 91.7%, specificity 70.8%, accuracy 77.8%); and for the prediction of the need of intubation was 1st LLV > 1.18 (sensitivity 91.7%, specificity 62.5%, accuracy 72%). In the 2nd moment, the best volume ratio for the prediction of NICU admission was 2nd LLV (AUC 0.92, p < 0.001) and the prediction of the need of intubation was 2nd oeTLV (AUC 0.87, p < 0.001). The cut-off chosen for the prediction of NICU admission was 2ndLLV > 0.42 (sensitivity 94.1%, specificity 82.3%, accuracy 88%); and for the prediction of the need of intubation was 2nd oeTLV < 0.50 (sensitivity 92.9%, specificity 75%, accuracy 82.3%). Conclusion: Lung volume ratio measured by 3DUS can predict neonatal morbidity in nonhydropic fetuses with CLM. The oeTLV and LLV were the best predictors of neonatal morbidity. These findings can be useful in counseling parents and in choosing the most appropriate place for delivery

OBJETIVO: Avaliar a influência dos efeitos da poluição atmosférica sobre o volume e a vascularização placentários no primeiro trimestre. MÉTODOS: O presente estudo é uma coorte prospectiva realizada de outubro de 2011 a março de 2014, em São Paulo, Brasil. Os critérios de inclusão foram: feto único, idade gestacional entre 11 semanas e 13 semanas e 6 dias, ausência de doença materna, ausência de malformações e utilização correta do amostrador passivo individual de poluentes. Os critérios de exclusão foram: gestação gemelar, malformações e abortamento diagnosticados à ultrassonografia, mudança de endereço para fora da área de recrutamento, desistência da paciente, doença materna diagnosticada durante o acompanhamento. A exposição à poluição foi avaliada por 7 a 18 dias, antes da avaliação ultrassonográfica, utilizando-se amostrador passivo individual dos poluentes NO2 e de O3. Após uso do filtro, as gestantes eram avaliadas na Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina de São Paulo (FMUSP). Nesse local, elas foram submetidas à ultrassonografia morfológica entre 11 semanas e 13 semanas e 6 dias e à avaliação placentária pela técnica tridimensional associada ao power Doppler. Por meio desse exame foram avaliados quantitativamente o volume da placenta e seus índices vasculares placentários (com o software VOCAL), os quais compreendem: índice de vascularização (IV), índice de fluxo (IF) e índice de vascularização e fluxo (IVF). A influência dos níveis de poluentes na vascularização e volume placentários log-transformada foi analisada utilizando modelos de regressão linear múltipla que controlavam a idade gestacional, índice de massa corpórea, tabagismo, localização da placenta e paridade. RESULTADOS: Foram avaliadas 229 gestantes no primeiro. O aumento dos níveis de NO2 no primeiro trimestre teve um efeito negativo significativo sobre o IV (p = 0,012 e beta = 0,160) e IVF (p = 0,015 e beta = -0,159). Não houve influência de NO2 e O3 no volume placentário ou IF. CONCLUSÃO: A exposição materna ao NO2 foi significativamente associada com diminuição do índice de vascularização e do índice de vascularização e fluxo no primeiro trimestre da gravidez, o que sugere que esse poluente e outros poluentes primários e secundários, os quais estão associados ao NO2, influenciam na placentação, reduzindo sua vascularização OBJECTIVE: To evaluate the influence of air pollution on the volume and placental vascularization in the first trimester. METHODS: This study is a prospective cohort conducted from October 2011 to March 2014 in São Paulo, Brazil. The inclusion criteria were single fetus, gestational age between 11 weeks and 13 weeks and 6 days, the absence of maternal disease, fetal defects and correct use of passive personal monitors pollutants. The exclusion criteria were twin pregnancy, abortion and malformations diagnosed on ultrasound, change of address out of the area of recruitment, patient abandonment, and maternal disease diagnosed during follow-up. The pollution exposure was evaluated by 7 to 18 days, before the ultrasound evaluation, using passive personal monitors pollutants of NO2 and O3. After using the filter, the pregnant women were evaluated at Obstetrics Department from Hospital das Clinicas of Faculdade de Medicina de São Paulo (FMUSP). In this place, they were subjected to morphological ultrasound between 11 weeks and 13 weeks and 6 days and placental evaluation by the three dimensional ultrasound power Doppler. Through the ultrasound examination were quantitatively evaluated the volume of the placenta and their placental vascular indices (with VOCAL software), which comprise the vascularization index (VI), flow index (FI) and vascularization flow index (VFI). The influence of pollutant levels on logtransformed placental vascularization and volume was analyzed using multiple linear regression models that controlled for gestational age, body mass index, smoking status, placental location and parity. RESULTS: In the first trimester 229 pregnant women were evaluation. NO2 levels increased in the first trimester had a significant negative effect on the VI (p=0.012 and beta= -0.160) and the VFI (p = 0.015 and beta= -0.159). No effect of NO2 and O3 on the log of placental volume or FI was observed. CONCLUSION: NO2 exposure was significantly associated with a diminished Vascularization Index and Vascularization and Flow Index in the first trimester of pregnancy, which suggests that this pollutant and other primary and secondary pollutants that are associated with NO2 influence placentation and decrease vascularization

INTRODUÇÃO: A associação entre restrição do crescimento fetal (RCF) e alterações renais envolvem questões como a relação entre a redução da vascularização renal nesses fetos e a hemodinâmica fetal durante a gestação que, até o momento, não estão suficientemente exploradas. Considerando que a causa primária da redução nefrônica nesses fetos seria o hipofluxo renal causado pela redistribuição da hemodinâmica fetal frente a estímulos hipoxêmicos, seria de esperar que a gravidade do acometimento fetal levasse a menor vascularização renal em fetos com RCF. OBJETIVOS: Este estudo objetivou avaliar fetos com restrição de crescimento fetal e, assim, (1) descrever o índice de pulsatilidade das artérias renais, o volume renal e os índices de vascularização renal, bem como (2) verificar correlações entre os achados dopplervelocimétricos das artérias umbilicais, da artéria cerebral média e do ducto venoso e o índice de pulsatilidade das artérias renais, o volume renal e os índices de vascularização renal (IV, IF, IVF) e entre o índice de pulsatilidade das artérias renais, o volume renal, os índices de vascularização e o índice de líquido amniótico. MÉTODOS: Oitenta e um fetos com RCF foram avaliados por Power Doppler tridimensional, no sentido de se determinarem dados relativos ao índice de pulsatilidade das artérias renais, o volume renal, os índices de vascularização renal, os índices de pulsatilidade das artérias umbilicais, da artéria cerebral média e do ducto venoso, e o índice de líquido amniótico. Os valores identificados foram submetidos a análises estatísticas com o intuito de se determinarem eventuais correlações entre os parâmetros renais avaliados. RESULTADOS: O índice de pulsatilidade das artérias renais variou entre 1,50 e 3,44, com mediana de 2,39 + 0,41; o volume renal variou de 1,90 a 18,90, com mediana de 8,54 + 3,43; o IV renal variou de 0,05 a 7,75, com mediana de 1,57 + 1,58; o IF variou de 19,04 a 40,0, com mediana de 28,29 + 5,06; e o IVF variou de 0,03 a 5,18, com mediana de 0,96 + 1,3. Não houve correlação entre o índice de pulsatilidade das artérias renais e o índice de pulsatilidade das artérias umbilicais, da artéria cerebral média e do ducto venoso; tampouco foi observada correlação entre o volume renal e o índice de pulsatilidade das artérias umbilicais, da artéria cerebral média e do ducto venoso. O IV renal e o IVF renal foram negativamente correlacionados com o índice de pulsatilidade do ducto venoso, e positivamente correlacionados com o índice de líquido amniótico. Não houve correlação entre os índices de vascularização e os achados dopplervelocimétricos das artérias umbilicais e da artéria cerebral média, nem entre o índice de pulsatilidade das artérias renais, do volume renal e do IF renal com o ILA. CONCLUSÕES: O índice de pulsatilidade do ducto venoso se mostrou melhor preditor de alterações nos índices de vascularização renal, indicando que essas alterações se tornam mais evidentes em fetos com RCF com maior comprometimento hemodinâmico INTRODUCTION: The association between intrauterine growth restriction (IUGR) and renal alterations refers to issues such as the relation between reduced renal vascularization in these fetuses and the fetal hemodynamics during pregnancy, which were not sufficiently investigated so far. Considering that the primary cause of nefrons reduction in these fetuses would be the renal hypoflow caused by the redistribution of the fetal hemodynamics resulting from hypoxic stimuli, it would be expected that the severety of the fetal impairment could result in worse renal vascularization in IUGR fetuses. OBJECTIVES: This study aimed at evaluating IUGR fetuses in order to (1) describe the pulsatility index of renal arteries, the renal volume and the renal vascularization indexes, as well as (2) verify correlations of the doppler findings in the umbilical arteries, middle cerebral artery, and venous duct with the pulsatility index of the renal arteries, the renal volume, and the renal vascularization indexes (VI, FI, VFI), and of the pulsatility index of the renal arteries, the renal volume, and the renal vascularization indexes with the amniotic liquid index. METHODS: 81 fetuses with IUGR were assessed with tridimentional power doppler in order to determine data regarding the pulsatility index of the renal arteries, the renal volume, the renal vascularization indexes, the pulsatility indexes of umbilical arteries, middle cerebral artery and venous duct, and the amniotic liquid index. Data were undertaken to statistical analysis for establishing eventual correlations among such assessed parameters. RESULTS: Pulsatility index of renal arteries ranged from 1.50 to 3.44 (median of 2.39 + 0.41); renal volume ranged from 1.90 to 18.90 (median of 8.54 + 3.43); renal VI ranged from 0.05 to 7.75 (median of 1.57 + 1.58); renal FI ranged from 19.04 to 40.0 (median of 28.29 + 5.06); and renal VFI ranged from 0.03 to 5.18 (median of 0.96 + 1.3. There was no correlation between the pulsatility index of renal arteries and the pulsatility indexes of the umbilical arteries, middle cerebral artery, and venous duct; correlations were not observed as well between the renal volume and the pulsatility indexes of the umbilical arteries, middle cerebral artery, and venous duct. Renal VI and VFI correlated negatively with the pulsatility index of the venous duct, and positively with the amniotic liquid index. There was no correlation betweem renal vascularization indexes and doppler findings in umbilical arteries and in middle cerebral artery, neither between pulsatility index of renal arteries, renal volume and renal FI and the amniotic liquid index. CONCLUSION: The pulsatility index of the venous duct was better predictive of alterations in renal vascularization index, suggesting that such alterations are more evident in IUGR fetuses with more severe hemodynamic impairments

Objetivos: Determinar quais características ultrassonográficas obtidas por meio da ultrassonografia transvaginal bidimensional (USG TV 2D) e da ultrassonografia transvaginal tridimensional (USG TV 3D) associam-se ao parto prematuro em gestantes submetidas à cerclagem profilática e terapêutica. Métodos: Sessenta e seis gestações únicas, submetidas a cerclagem profilática ou terapêutica, e acompanhadas no ambulatório de Aborto Habitual da Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), entre 1 de junho de 2012 e 30 de outubro de 2015, foram avaliadas longitudinalmente, por meio da USG TV 2D e USG TV 3D associado ao power Doppler, nos três trimestres da gestação. Na análise dos resultados, as gestantes foram primeiramente avaliadas longitudinalmente nos três trimestres da gestação. Depois, foram classificadas de acordo com a idade gestacional de parto (IG parto) = 34 semanas. As gestantes também foram avaliadas considerando-se a IG parto como uma variável contínua. Resultados: Na avaliação longitudinal, o comprimento do colo uterino (CC) e a distância do ponto de cerclagem ao orifício cervical interno (POI) diminuíram significativamente entre o segundo e o terceiro trimestres (32,6 vs 28,3 mm; p < 0,001 e 14,3 vs 10,7 mm; p=0,001, respectivamente) enquanto a largura do afunilamento cervical aumentou significativamente no mesmo período (13,6 vs 20,7 mm; p= 0,011). Dez gestantes (15,2%) tiveram idade gestacional de parto < 34 semanas. O CC, a POI e a presença do afunilamento cervical, avaliados no terceiro trimestre da gestação, tiveram relação significativa com a IG parto < 34 semanas (16,27 mm, p= 0,009; zero, p= 0,003; 66,67%, p= 0,041, respectivamente). O CC < 28,1 mm, p= 0,0083, o volume do colo uterino (VOL) < 18,17 cm3, p= 0,0152, a POI < 10 mm, p= 0,0151, e os índices vasculares do colo uterino, FI < 33,83, p= 0,0338, VI < 2,153%, p= 0,0044, e VFI < 0,961, p= 0,0059 avaliados no segundo trimestre tiveram relação significativa com idades gestacionais de parto mais precoces, assim como, o CC < 20,4 mm, p= 0,0009, o VOL >= 47,48 cm3, p= 0,0107, FI < 44,336, p= 0,0038, VI>= 0,54 %, p= 0,0327 e o VFI >= 2,275, p= 0,0479 avaliados no terceiro trimestre. Nos modelos de regressão de COX, em que a variável de interesse foi o tempo até o parto, o VOL no segundo trimestre foi significativo, ao passo que no terceiro trimestre, o FI e o VFI foram significativos. Conclusões: Em gestantes submetidas a cerclagem profilática e terapêutica, o VOL do colo avaliado no segundo trimestre, e o FI e o VFI avaliados no terceiro trimestre foram as únicas variáveis independentes que se relacionaram com o tempo até o parto Objectives: To determine which cervical sonographic characteristics on twodimensional transvaginal ultrasonography (2DTVUS) and three-dimensional transvaginal ultrasonography (3DTVUS) could be related to gestational age at birth after placement of history-indicated cerclage or ultrasound-indicated cerclage. Methods: Sixty six pregnant women, with a singleton gestation, submitted to history-indicated cerclage or ultrasound-indicated cerclage and followed at the Recurrent Miscarriage Clinic of Department of Obstetrics and Gynecology of São Paulo University Medical School between June 1, 2012 and October 30, 2015, were longitudinaly evaluated by 2DTVUS and 3DTVUS associated to power Doppler, in the three trimesters of pregnancy. For the analysis, pregnant women were, firstly, evaluated longitudinally, in the three trimesters of pregnancy. After that, they were classified according to gestational age (GA) at delivery = 34 weeks. Pregnant women were evaluated considering GA at delivery as a continuous variable already. Results: In the longitudinal evaluation, cervical length (CL) and proximal cervical length decreased between the second and the third trimestrers (32.6 vs 28.3 mm, p < 0.001; 14.3 vs 10.7, p= 0.001, respectivelly), while width of funneling increased at the same period (13.6 vs. 20.7 mm; p = 0.011). Ten pregnant women (15.2%) delivered < 34 weeks. CL, proximal cervical length and present cervical funneling, in the third trimester, were significantly related to GA at delivery < 34 weeks (16.27 mm, p= 0.009; zero, p= 0.003; 66.67%, p= 0.041, respectively). CL < 28.1mm, p=0.0083, cervical volume < 18.17 cm3, p= 0.0152, proximal cervical length < 10 mm, p = 0.0151, and cervical vascularization index, FI < 33.83, p= 0.0338, VI < 2.153 %, p= 0.0044, VFI < 0.961, p = 0.0059, in the second trimester, were related to earlier delivery, as, CL < 20.4 mm, p= 0.0009, cervical volume >= 47.48 cm3, p = 0.0107, FI < 44.336, p: 0.0038, VI >= 0.54, p = 0.0327 and VFI >= 2.275, p= 0.479 in the third trimester. Using COX regression analysis, it was demonstrated that cervical volume in the second trimester, and FI and VFI in the third trimester were significantly associated to gestational age at birth .Conclusions: In women with history-indicated cerclage or ultrasound indicated cerclage, 2nd trimester cervical volume and 3rd trimester FI and VFI are the only indenpendent significant sonographic findings associated whith time to delivery