Search

ABSTRACT Objective This study aimed to evaluate the prevalence of hypertensive disorders during pregnancy among Brazilian women with preterm births and to compare the epidemiological characteristics and perinatal outcomes among preterm births of women with and without hypertension. Methods This was a secondary cross-sectional analysis of the Brazilian Multicenter Study on Preterm Birth. During the study period, all women with preterm births were included and further split into two groups according to the occurrence of any hypertensive disorder during pregnancy. Prevalence ratios were calculated for each variable. Maternal characteristics, prenatal care, and gestational and perinatal outcomes were compared between the two groups using χ2 and t-tests. Results A total of 4,150 women with preterm births were included, and 1,169 (28.2%) were identified as having hypertensive disorders. Advanced maternal age (prevalence ratio (PR) 2.49) and obesity (PR= 2.64) were more common in the hypertensive group. The gestational outcomes were worse in women with hypertension. Early preterm births were also more frequent in women with hypertension. Conclusion Hypertensive disorders of pregnancy were frequent among women with preterm births, and provider-initiated preterm births were the leading causes of premature births in this group. The factors significantly associated with hypertensive disorders among women with preterm births were obesity, excessive weight gain, and higher maternal age.

ABSTRACT Objective The objective was to compare the maternal and perinatal characteristics and outcomes between women with and without diabetes in a Brazilian cohort of women with preterm births. Methods This was an ancillary analysis of the Brazilian Multicenter Study on Preterm Birth, which included 4,150 preterm births. This analysis divided preterm births into two groups according to the presence of diabetes; pregestational and gestational diabetes were clustered in the same Diabetes Group. Differences between both groups were assessed using χ 2 or Student’s t tests. Results Preterm births of 133 and 4,017 women with and without diabetes, respectively, were included. The prevalence of diabetes was 3.2%. Pregnant women aged ≥35 years were more common in the Diabetes Group (31.6% versus 14.0% non-diabetic women, respectively). The rate of cesarean section among patients with diabetes was 68.2% versus 52.3% in non-diabetic cases), with a gestational age at birth between 34 and 36 weeks in 78.9% of the cases and 62.1% of the controls. Large-for-gestational-age babies were 7 times more common in the Diabetes Group. Conclusion Preterm birth among Brazilian women with diabetes was more than twice as prevalent; these women were older and had regular late preterm deliveries, usually by cesarean section. They also had a greater frequency of fetal morbidities, such as malformations and polyhydramnios, and a higher proportion of large-for-gestational-age and macrosomic neonates.

Abstract From the discovery of the Zika virus (ZIKV) in 1947 in Uganda (Africa), until its arrival in South America, it was not known that it would affect human reproductive life so severely. Today, damagetothe central nervous system is known to be multiple, and microcephaly is considered the tip of the iceberg. Microcephaly actually represents the epilogue of this infection’s devastating process on the central nervous system of embryos and fetuses. As a result of central nervous system aggression by the ZIKV, this infection brings the possibility of arthrogryposis, dysphagia, deafness and visual impairment. All of these changes of varying severity directly or indirectly compromise the future life of these children, and are already considered a congenital syndrome linked to the ZIKV. Diagnosis is one of the main difficulties in the approach of this infection. Considering the clinical part, it has manifestations common to infections by the dengue virus and the chikungunya fever, varying only in subjective intensities. The most frequent clinical variables are rash, febrile state, non-purulent conjunctivitis and arthralgia, among others. In terms of laboratory resources, there are also limitations to the subsidiary diagnosis. Molecular biology tests are based on polymerase chain reaction (PCR)with reverse transcriptase (RT) action, since the ZIKV is a ribonucleic acid (RNA) virus. The RT-PCR shows serum or plasma positivity for a short period of time, no more than five days after the onset of the signs and symptoms. The ZIKVurine test is positive for a longer period, up to 14 days. There are still no reliable techniques for the serological diagnosis of this infection. If there are no complications (meningoencephalitis or Guillain-Barré syndrome), further examination is unnecessary to assess systemic impairment. However, evidence is needed to rule out other infections that also cause rashes, such as dengue, chikungunya, syphilis, toxoplasmosis, cytomegalovirus, rubella, and herpes. There is no specific antiviral therapy against ZIKV, and the therapeutic approach to infected pregnant women is limited to the use of antipyretics and analgesics. Anti-inflammatory drugs should be avoided until the diagnosis of dengue is discarded. There is no need to modify the schedule of prenatal visits for pregnant women infected by ZIKV, but it is necessary to guarantee three ultrasound examinations during pregnancy for low-risk pregnancies, and monthly for pregnant women with confirmed ZIKV infection. Vaginal delivery and natural breastfeeding are advised.

Recent Zika outbreaks in South America, accompanied by unexpectedly severe clinical complications have brought much interest in fast and reliable screening methods for ZIKV (Zika virus) identification. Reverse-transcriptase polymerase chain reaction (RT-PCR) is currently the method of choice to detect ZIKV in biological samples. This approach, nonetheless, demands a considerable amount of time and resources such as kits and reagents that, in endemic areas, may result in a substantial financial burden over affected individuals and health services veering away from RT-PCR analysis. This study presents a powerful combination of high-resolution mass spectrometry and a machine-learning prediction model for data analysis to assess the existence of ZIKV infection across a series of patients that bear similar symptomatic conditions, but not necessarily are infected with the disease. By using mass spectrometric data that are inputted with the developed decision-making algorithm, we were able to provide a set of features that work as a “fingerprint” for this specific pathophysiological condition, even after the acute phase of infection. Since both mass spectrometry and machine learning approaches are well-established and have largely utilized tools within their respective fields, this combination of methods emerges as a distinct alternative for clinical applications, providing a diagnostic screening—faster and more accurate—with improved cost-effectiveness when compared to existing technologies.

O objetivo deste artigo é apresentar uma revisão das pesquisas brasileiras quantitativas e qualitativas sobre opiniões, conhecimentos e atitudes de profissionais da saúde sobre o aborto induzido publicadas entre 2001 e 2011. Admitiram-se publicações com amostras compostas por profissionais com quaisquer graus de formação. Os trabalhos foram categorizados segundo características metodológicas: abordagem dos dados, técnica e instrumento para coleta de dados, categorias profissionais incluídas, local da pesquisa, tamanho amostral e técnica de amostragem. Na etapa seguinte, categorizaram-se os temas centrais das pesquisas (por exemplo, aconselhamento genético e anticoncepção de emergência). Finalmente, categorizaram-se os resultados das pesquisas: conhecimento técnico e legal, perspectiva moral, opiniões sobre a lei, opiniões sobre o Sistema Único de Saúde, e atitudes hipotéticas e concretas. As publicações identificadas sugerem ampla aprovação dos casos de aborto atualmente permitidos por lei, mas larga rejeição da criminalização em casos de malformações fetais graves. A maioria das publicações relatou ter investigado profissionais de medicina (especialmente gineco-obstetras) ou de enfermagem, sendo poucos ou inexistentes dados sobre assistentes sociais e psicólogos. Não foram identificados quaisquer instrumentos apresentando dados mínimos de validade, análise de confiabilidade ou adaptação transcultural. Acredita-se que, no futuro, o desenvolvimento de instrumentos com essas qualidades possa facilitar a realização de novas pesquisas sobre esse tema, inclusive com maior abrangência e diversificação das categorias profissionais a serem estudadas.

OBJETIVO: estudar a colonização bacteriana do canal cervical em gestantes com trabalho de parto prematuro ou com ruptura prematura de membranas. MÉTODOS: foram avaliadas 212 gestantes com trabalho de parto prematuro ou ruptura prematura de membranas. Na admissão hospitalar foram coletadas duas amostras do conteúdo endocervical e realizadas bacterioscopia e cultura em meios ágar sangue e ágar chocolate. Foram analisadas associações da colonização endocervical com infecção do trato urinário materno, corioamnionite, utilização de antibióticos, sofrimento fetal, prematuridade e infecção e óbito neonatais. RESULTADOS: a prevalência de colonização endocervical foi 14,2% (IC95%=9,5-18,9%), com resultados similares entre os casos com trabalho de parto prematuro ou ruptura prematura de membranas. O microorganismo mais prevalente na população estudada foi o estreptococo do grupo B (9,4%), sendo também isolados Candida sp, Streptococcus sp, Streptococcus pneumoniae, Escherichia coli e Enterococcus sp. Das bacterioscopias analisadas, os achados mais freqüentes foram baixa prevalência de bacilos de Döderlein e elevado número de leucócitos. Em mulheres colonizadas, houve maior prevalência de infecção do trato urinário (23,8 versus 5,4%; pPURPOSE: to study cervical colonization in women with preterm labor or premature rupture of membranes. METHODS: two hundred and twelve pregnant women with preterm labor or premature rupture of membranes were studied. Two cervical samples from each woman were collected and bacterioscopy and culture were performed. Association of cervical microorganisms and urinary tract infection, chorioamnionitis, fetal stress, antibiotic use, prematurity, neonatal infection, and neonatal death were evaluated. RESULTS: the prevalence of endocervical colonization was 14.2% (CI95%=9.5-18.9%), with similar results in preterm labor or premature rupture of membranes. Group B streptococcus was the most prevalent organism (9.4%). Other organisms isolated were Candida sp, Streptococcus sp, Streptococcus pneumoniae, Escherichia coli and Enterococcus sp. The most common findings of bacterioscopy were a reduced number of lactobacilli and a great number of leukocytes. Endocervical colonization was associated with a higher occurrence of urinary tract infection (23.8 versus 5.4%; p

We report a case of placenta percreta diagnosed by ultrasound and color doppler image at the fourteenth week of gestation. Initial approach was a trial of IM methotrexate followed by total hysterectomy, during which was observed a rupture of the uterus with the adherence of the placenta to the posterior region of the bladder. We also present a literature review on the incidence of placenta percreta, etiology, diagnosis, treatment, and complications.

CONTEXT AND OBJECTIVE: Previous adverse pregnancy outcomes (recurrent spontaneous abortion, fetal death, preterm birth or early neonatal death) can affect the quality of life of pregnant women. The objective of this study was to compare the quality of life and the prevalence of symptoms of anxiety and depression among pregnant women with and without these antecedents. DESIGN AND SETTING: An analytical cross-sectional study was performed in four settings (two high-risk and two low-risk prenatal clinics) in the city of Campinas, São Paulo, Brazil. METHODS: A total of 240 women were interviewed by a single investigator between the 18th and 24th weeks of gestation: 120 women with prior adverse pregnancy outcomes (group 1) and 120 women with no such history (group 2), matched according to their numbers of living children. Sociodemographic variables were collected and two questionnaires were used: the Short Form-36 quality-of-life questionnaire and the Depression and Anxiety Scale. RESULTS: The women in group 1 had lower scores in all the items on the quality-of-life questionnaire. Depression and anxiety were more frequent in group 1 (P < 0.0001). An inverse correlation was found between the Short Form-36 domains and anxiety and depression. CONCLUSIONS: Women with histories of recurrent spontaneous abortion, fetal death, preterm birth or early neonatal death seem to have poorer quality of life and more symptoms of anxiety and depression during their subsequent pregnancy, compared with those without such antecedents.

CONTEXT: Recurrent spontaneous abortion (RSA) has been associated with venous thrombosis in the mother. Acquired and inherited thrombophilia factors are possible causes. OBJECTIVE: To evaluate the association between thrombogenic factors and recurrent spontaneous abortion. TYPE OF STUDY: Case-control study. SETTING: Centro de Atenção Integral à Saúde da Mulher, Universidade Estadual de Campinas. METHODS: 40 ml of blood was collected from 88 women attending an RSA clinic and 88 fertile women attending a family planning clinic, to evaluate the presence of acquired and inherited thrombophilia factors. Anticardiolipin antibodies (ACA), lupus anticoagulant and deficiencies of proteins C and S and antithrombin III were evaluated by enzyme-linked immunosorbent assay (ELISA), dilute Russell Viper Venom time (dRVVT), coagulometric and chromogenic methods. DNA was amplified by the polymerase chain reaction (PCR) to study factor V Leiden and G20210A mutations in the prothrombin gene and C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene. Data were analyzed using odds ratios and a regression model for age adjustment. Fisher’s exact test was used to evaluate statistical relationships between associated factors and RSA. RESULTS: ACA was detected in 11 women with RSA and one fertile woman. Heterozygous C677T was detected in 59 women with RSA and 35 fertile women. Concomitant presence of ACA and C677T was found in eight women with RSA and no fertile women (p < 0.01). DISCUSSION: The meaning of the association between C677T mutation in the MTHFR gene and ACA is still not clear. It is possible that an inherited factor that alone would not strongly predispose a woman to thrombosis could, when associated with an acquired factor, start the process and increase the likelihood of thrombosis expression. CONCLUSIONS: ACA and C677T in the MTHFR gene are statistically associated with RSA. The association of these two conditions is a new finding in thrombogenic factors and RSA.

CONTEXT AND OBJECTIVE: Recurrent spontaneous abortion (RSA) is defined as three or more consecutive pregnancy losses before 20 weeks and is associated with several etiological factors related to genetics, anatomy, hormones, infections and immunology, for example. Many cases of RSA remain unclear. New factors or their associations may influence gestational results. The aim was to identify possible single or associated causes of RSA that could predict gestational prognosis for women undergoing investigation and treatment. DESIGN AND SETTING: Case-control study, at the Recurrent Abortion Outpatient Clinic, Department of Obstetrics and Gynecology School of Medicine, Universidade Estadual de Campinas (Unicamp). METHODS: Two hundred and forty-six medical records of women with RSA seen at the Recurrent Abortion Outpatient Clinic, Department of Obstetrics and Gynecology School of Medicine, Universidade Estadual de Campinas (Unicamp), between 1994 and 2003, were evaluated. Data on age, obstetric history, possible etiological factors, treatment and pregnancy outcomes were evaluated. Statistical analysis was performed using odds ratios (OR), logistic regression analysis and decision trees. RESULTS: Two hundred and twenty-nine women were included in the study. The most frequently found etiological factors were immunological, particularly alloimmune factors (93.9%). Women with a single alloimmune factor had better gestational results (77.7% deliveries) than those with other associated factors. Autoimmune factors were associated with a higher abortion rate (OR: 4.30; 95% confidence interval, CI: 1.36-13.63). No association was found between the number of abortions prior to treatment and pregnancy results. Women aged 40 or over presented the highest rate of spontaneous abortion (OR: 5.83; 95% CI: 1.12-30.40). CONCLUSION: Age over 40 years old, immunological factors and two or more concomitant factors were associated with poor gestational outcomes among the women studied.

Abstract Objective To evaluate the use of tocolysis in cases of preterm birth due to spontaneous preterm labor in a Brazilian sample. Methods A sample of 1,491 women with preterm birth due to spontaneous preterm labor were assessed, considering treatment with tocolysis or expectant management, according to gestational age at birth (< 34 weeks and 34 to 36 þ 6 weeks) and drugs prescribed. The study took place in 20 Brazilian hospitals from April 2011 to July 2012. Bivariate analyses were conducted to evaluate associations with sociodemographic and obstetric characteristics and odds ratios with their respective 95% confidence intervals were estimated for maternal and neonatal outcomes. Results A total of 1,491 cases of preterm birth were considered. Tocolysis was performed in 342 cases (23%), 233 of which (68.1%) were delivered before 34 weeks. Within the expectant management group, 73% was late preterm and with more advanced labor at the time of admission. The most used drugs were calcium channel blockers (62.3%), followed by betamimetics (33%). Among the subjects in the tocolysis group, there were more neonatal and maternal complications (majority non-severe) and an occurrence of corticosteroid use that was 29 higher than in the expectant management group. Conclusion Tocolysis is favored in cases of earlier labor and also among thosewith less than 34 weeks of gestation, using preferably calcium channel blockers, with success in achieving increased corticosteroid use. Tocolysis, in general, was related to higher maternal and neonatal complication rates, which may be due to the baseline difference between cases at admission. However, these results should raise awareness to tocolysis use.

Abstract Introduction Episiotomy is a controversial procedure, especially because the discussion that surrounds it has gone beyond the field of scientific debate, being adopted as an indicator of the "humanization of childbirth". The scientific literature indicates that episiotomy should not be performed routinely, but selectively. Objectives To review the literature in order to assess whether the implementation of selective episiotomy protects against severe perineal lacerations, the indications for the procedure, and the best technique to perform it. Methods A literature search was performed in PubMed using the terms episiotomy or perineal lacerations, and the filter clinical trial. The articles concerning the risk of severe perineal lacerations with or without episiotomy, perineal protection, or episiotomy techniques were selected. Results A total of 141 articles were identified, and 24 of them were included in the review. Out of the 13 studies that evaluated the risk of severe lacerations with and without episiotomy, 5 demonstrated a protective role of selective episiotomy, and 4 showed no significant differences between the groups. Three small studies confirmed the finding that episiotomy should be performed selectively and not routinely, and one study showed that midline episiotomy increased the risk of severe lacerations. The most cited indications were primiparity, fetal weight greater than 4 kg, prolonged second stage, operative delivery, and shoulder dystocia. As for the surgical technique, episiotomies performed with wider angles (> 40°) and earlier in the second stage (before "crowning ") appeared to be more protective. Conclusions Selective episiotomy decreases the risk of severe lacerations when compared with the non-performance or the performance of routine episiotomy. The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure. Not performing the episiotomy when indicated or not applying the correct technique may increase the risk of severe perineal lacerations.

Objective: this study aimed to review the literature regarding late preterm births (34 weeks to 36 weeks and 6 days of gestation) in its several aspects. Sources: the MEDLINE, LILACS, and Cochrane Library databases were searched, and the references of the articles retrieved were also used, with no limit of time. Data synthesis: numerous studies showed a recent increase in late preterm births. In all series, late preterm comprised the majority of preterm births. Studies including millions of births showed a strong association between late preterm birth and neonatal mortality. A higher mortality in childhood and among young adults was also observed. Many studies found an association with several neonatal complications, and also with long-term disorders and sequelae: breastfeeding problems, cerebral palsy, asthma in childhood, poor school performance, schizophrenia, and young adult diabetes. Some authors propose strategies to reduce late preterm birth, or to improve neonatal outcome: use of antenatal corticosteroids, changes in some of the guidelines for early delivery in high-risk pregnancies, and changes in neonatal care for this group. Conclusions: numerous studies show greater mortality and morbidity in late preterm infants compared with term infants, in addition to long-term disorders. More recent studies evaluated strategies to improve the outcomes of these neonates. Further studies on these strategies are needed.

OBJETIVO: comparar a acurácia da mensuração ultrassonográfica transvaginal do colo uterino com o escore de Bishop para predição do parto vaginal após indução do trabalho de parto com misoprostol a 25 mcg. MÉTODOS: realizou-se estudo de validação de técnica diagnóstica com 126 gestantes com indicação para indução do trabalho de parto, as quais foram avaliadas pelo escore de Bishop e por ultrassonografia transvaginal para mensuração cervical. As pacientes foram submetidas, também, à ultrassonografia obstétrica transabdominal para avaliação da estática, pesos fetais e índice de líquido amniótico, e à cardiotocografia basal para avaliação da vitalidade fetal. Procedeu-se à indução do trabalho de parto com misoprostol vaginal e sublingual, um dos comprimidos contendo 25 mcg da droga e o outro apenas placebo. Os comprimidos foram administrados a cada seis horas, em um número máximo de oito. Construíram-se tabelas de distribuição de frequência e calcularam-se medidas de tendência central e de dispersão. Curvas ROC foram construídas para avaliação do escore de Bishop e da medida ultrassonográfica do colo uterino para predição de parto vaginal. RESULTADOS: obteve-se uma área sob a curva ROC de 0,5 (p=0,8) para medição do colo uterino pela ultrassonografia transvaginal, enquanto a curva ROC do escore de Bishop (ponto de corte ³4) apresentou área de 0,6 (p=0,02). O escore de Bishop ³4 apresentou sensibilidade de 56,2% e especificidade de 67,9% para predição de parto vaginal, com razão de verossimilhança positiva de 1,75 e negativa de 0,65. CONCLUSÕES: a medida ultrassonográfica transvaginal do colo uterino não foi boa preditora da evolução para parto vaginal em pacientes com trabalho de parto induzido com misoprostol. O escore de Bishop foi melhor preditor para parto vaginal nestas circunstâncias.PURPOSE: to compare the accuracy of transvaginal ultrasonographic measurement of the uterine cervix with Bishop’s score for the prediction of vaginal delivery after labor induction, with 25 mcg of misoprostol. METHODS: a prospective study for the validation of a diagnostic test was conducted on 126 pregnant women with indication for labor induction. The patients were evaluated by Bishop’s score and transvaginal ultrasonography for cervical measurement. They also undergone obstetric transabdominal ultrasound to evaluate static and fetal weight, as well as the amniotic fluid index, and basal cardiotocography for the evaluation of fetal vitality. Labor was induced with vaginal and sublingual misoprostol, one of the tablets containing 25 mcg of the drug and the other only placebo. The tablets were administered every six hours, with a maximum number of eight. Frequency tables were obtained, and measures of central tendency and dispersion were calculated. ROC curves were constructed for the evaluation of Bishop’s score and ultrasonographic measurement of the uterine cervix for the prediction of vaginal delivery. RESULTS: the area under the ROC curve was 0.5 (p=0.8) for the ultrasonographic measurement of the uterine cervix, and 0.6 (p=0.02) for Bishop’s score (cut point ³4). Bishop’s score had a sensitivity of 56.2% and specificity of 67.9% for prediction of vaginal delivery, with a positive likelihood ratio of 1.75 and a negative one of 0.65. CONCLUSIONS: ultrasonographic measurement of the uterine cervix was not a good predictor of evolution to vaginal delivery among patients with misoprostol-induced labor. Bishop’s score was a better predictor of vaginal delivery under these circumstances.

OBJETIVO: identificar a prevalência e os fatores de risco de colonização materna por estreptococo do grupo B (EGB) em gestantes com trabalho de parto prematuro (TPP) e/ou ruptura prematura pré-termo de membranas (RPM). MÉTODOS: foram colhidos dois swabs anais e dois swabs vaginais de 203 gestantes com diagnóstico de TPP ou RPM entre 22 e 36 semanas completas de gestação atendidas no serviço em um período de um ano. Foram excluídas as gestantes que deram entrada com parto iminente. Um swab de cada local foi colocado em meio de transporte, sendo posteriormente enviados para cultura em placas de ágar-sangue, os outros dois foram incubados por 24 horas em meio de Todd-Hewitt para posterior semeadura em placas de ágar-sangue. Foram analisados fatores de risco com o uso do teste do qui-quadrado, t de Student (p ajustado a 0,05 e intervalo de confiança 95%) e de regressão logística. Foram analisadas as seguintes variáveis: idade, raça, paridade e escolaridade maternas; resultados das culturas por local de coleta e tipo de cultura; diagnóstico de admissão; idade gestacional de admissão; bacteriúria assintomática; idade gestacional no parto; tipo de parto; taxa de colonização neonatal por EGB e resultado neonatal imediato. RESULTADOS: a prevalência de colonização materna por EGB foi de 27,6% (56 gestantes). As taxas de colonização segundo as complicações da gestação foram 30% para RPM, 25,2% para TPP e 17,8% para TPP + RPM. As variáveis "raça branca", "baixo nível de escolaridade" e "bacteriúria" foram associadas a maiores taxas de colonização na análise univariada. A presença de infecção urinária foi a única variável significativamente associada à colonização materna na análise multivariada. A taxa de detecção do estreptococo do grupo B foi significativamente maior com o uso do meio seletivo e com a associação de coleta de culturas anais e vaginais. A taxa de colonização neonatal foi de 3,1%. Ocorreram dois casos de sepse precoce por EGB nesta amostra, com prevalência de 10,8 casos por mil nascidos vivos e mortalidade de 50%. CONCLUSÕES: a amostra avaliada apresenta altas taxas de colonização materna por Streptococcus agalactiae. São necessários o uso de meio de cultura seletivo e a associação de culturas ano-retais e vaginais para aumentar a taxa de detecção do EGB. A incidência de sepse neonatal precoce foi elevada nesta população.PURPOSE: to indentify the prevalence and risk factors of maternal colonization by group B streptococcus (GBS) in pregnant women with premature labor (PL) and/or premature membrane rupture (PMR). METHODS: two anal and two vaginal swabs were collected from 203 pregnant women with diagnosis of PL or PMR assisted at the practice along one year. Pregnant women with imminent labor at admission were excluded. One swab of each source was placed in a transfer milieu and sent for culture in blood-agar plates; the two remaining swabs were incubated for 24 hours in Todd-Hewitt milieu for further sowing in blood-agar plates. Risk factors were analyzed by the chi-square test, Student's t-test (p-value set at 0.05 and 95% confidence interval) and logistic regression. The following variables were analyzed: age, race, parity and mother schooling; culture results by source and type of culture; admission diagnosis; gestational age at admission; asymptomatic bacteriuria; gestational age at delivery; type of delivery; neonatal GBS colonization rate and immediate neonatal condition. RESULTS: prevalence of maternal GBS colonization was 27.6% (56 cases). The colonization rates according to gestational complications were 30% for PMR, 25.2% for PL and 17.8% for PL + PMR. Univariate analysis has shown that the variables Caucasian race, low level of schooling and bacteriuria were associated with higher colonization rates. Multivariate analysis showed that the presence of urinary infection was the only variable associated with maternal colonization. The GBS detection rate was significantly higher with the use of a selective milieu and collection from both anal and vaginal sources. The neonatal colonization rate was 3.1%. Two cases of early sepsis by GBS occurred in the sample, with prevalence of 10.8 cases per one thousand live births and 50% mortality rate. CONCLUSION: the studied sample showed high maternal colonization rates by Streptococcus agalactiae. To increase GBS detection rate, it is necessary to use a selective culture milieu and to combine anal-rectal and vaginal cultures. There was a high incidence of early neonatal sepsis.

OBJETIVO: avaliar a evolução de gestações gemelares monocoriônicas diamnióticas com e sem síndrome de transfusão feto-fetal (STFF), acompanhadas de forma expectante. MÉTODOS: estudo retrospectivo no qual as gestações sem e com STFF e com as formas leve (estágio I de Quintero) e grave (estágios II, III, IV e V de Quintero) da doença foram comparadas quanto a parto pré-termo extremo, comprometimento neurológico e alta dos gêmeos do berçário. Os gêmeos pré-termo extremo que tiveram ou não STFF foram comparados quanto à ocorrência de comprometimento neurológico. Foram utilizados os testes do χ2 ou exato de Fisher. RESULTADOS: quinze entre 149 gestações gemelares monocoriônicas diamnióticas apresentaram STFF, 11 (11/15-73,3%) na forma grave e 4 (4/15-26,7%) no estágio I. O parto pré-termo extremo foi mais frequente (pPURPOSE: to evaluate the evolution of monochorionic-diamniotic twin pregnancies with and without the twin-twin transfusion syndrome (TTTS), followed up in an expectant way. METHODS: retrospective study in which the pregnancies with and without TTTS and with mild (Quintero's stage I) and severe (Quintero's stages II, III, IV and V) disease manifestations were compared according to extreme preterm delivery, neurological impairment and the twins' nursery discharge. The extreme preterm twins who had had TTTS, or not, were compared whether they had or not neurological impairment. The χ2 or Fisher's exact test were used. RESULTS: among 149 monochorionic-diamniotic twin pregnancies, 15 presented TTTS, 11 (11/15 - 73.3%) in the severe form and 4 (4/15 - 26.7%) at stage I. The extreme preterm delivery was more frequent (p

Estudos têm apontado possíveis relações de risco existentes entre doenças bucais, principalmente a doença periodontal, e complicações gestacionais, como parto prematuro, nascimento de recém-nascidos de baixo peso e pré-eclâmpsia. As explicações para tais hipóteses baseiam-se no fato de a doença periodontal ser de origem infecciosa, o que poderia provocar aumento de citocinas inflamatórias no sangue materno, por liberação direta da bolsa periodontal ou por disseminação de bactérias patogênicas, induzindo sua produção sistêmica. Esta suposição fundamenta-se no conhecimento de que a fisiopatologia das complicações obstétricas citadas está associada à presença de algumas citocinas no sangue materno. O presente trabalho teve como objetivo realizar revisão da literatura em busca de evidências para estas supostas associações. Apesar do grande número de estudos clínicos encontrados nesta revisão, observa-se a falta de padronização metodológica dos mesmos, fato que limita conclusões definitivas a respeito. Por outro lado, o fato de a doença periodontal ainda não ser comprovadamente um fator de risco para as complicações obstétricas não diminui a importância da manutenção da saúde bucal das gestantes, que devem apresentar condições orais que propiciem adequada alimentação, sem dor e sangramento, e assim manter seu aporte nutricional adequado.Studies have shown possible risk relations among oral illnesses, mainly periodontal disease and adverse pregnancy outcomes, such as prematurity, low birth weight and preeclampsia. The explanation for this hypothesis is based on the fact that periodontal disease is an infectious state, which may increase maternal serum cytokines through the release of such agents directly from the periodontal pocket or by through the dissemination of pathogenic bacteria, inducing systemic production. This assumption is based on the knowledge that the physiopathology of the pregnancy complications cited above is associated with the presence of some cytokines in the maternal serum. The present study work has the objective to review literature in search of evidence to these alleged associations. Although a number of clinical studies have been found in this review, we noticed a lack of methodological standards, what limits the conclusions about this topic. On the other side, the fact that periodontal disease is not yet a confirmed risk factor for adverse pregnancy outcomes does not reduce the importance of oral health maintenance during pregnancy, since it is important to allow adequate feeding without pain and bleeding in order to maintain an adequate nutritional supply.

OBJETIVOS: avaliar os fatores indicativos (parâmetros clínicos e índices de gravidade fisiológicos e anatômicos) da evolução materna e fetal entre gestantes vítimas de trauma abdominal submetidas à laparotomia e discutir as particularidades do atendimento nesta situação. MÉTODOS: análise retrospectiva dos prontuários de 245 mulheres com trauma abdominal e tratamento operatório, atendidas entre 1990 e 2002. Foram identificadas 13 gestantes com lesão abdominal submetidas à laparotomia. Para registro e análise estatística dos dados foram utilizados o protocolo Epi-Info 6.04 e o teste exato de Fisher, com intervalo de confiança de 95%. Foram relacionados com a mortalidade fetal: escore na escala de coma de Glasgow, pressão arterial sistólica, índices de trauma (RTS, ATI, ISS) e lesão uterina. RESULTADOS: a idade variou de 13 a 34 anos (média de 22,5). Seis mulheres (46,2%) estavam no terceiro trimestre de gestação. O trauma penetrante correspondeu a 53,8% das lesões e em seis dessas pacientes o mecanismo de trauma foi ferimento por projétil de arma de fogo. Três pacientes tiveram lesões uterinas, associadas com óbito fetal. Não houve óbito materno e a mortalidade fetal foi de 30,7%. Não houve associação entre os índices de trauma e a mortalidade materna e fetal. A lesão uterina foi o único fator preditivo de risco para perda fetal (p=0,014). CONCLUSÕES: apesar da casuística pequena e de se tratar de estudo retrospectivo de gestantes com trauma grave, os achados deste estudo mostram que não há indicadores com boa acurácia para indicação da evolução materna e fetal.PURPOSE: to evaluate the predictors (clinical findings and physiological and anatomical scores) of the maternal and fetal outcomes among pregnant women victims of abdominal trauma who were submitted to laparotomy and to discuss particularities of assessment in this situation. METHODS: retrospective analysis of the medical records of 245 women with abdominal trauma and surgical treatment, from 1990 to 2002. Thirteen pregnant women with abdominal injury were identified. All cases were registered in the Epi-Info 6.04 protocol and data were analyzed statistically by the Fisher exact test, with confidence interval of 95%. RESULTS: ages ranged from 13 to 34 years (mean of 22.5). Six women (46.2%) were in the third trimester of pregnancy. Penetrating trauma accounted for 53.8% of injuries and in six of these patients the mechanism of trauma was gunshot wounds. Three patients had uterine injuries associated with fetal death. There were no maternal deaths and fetal mortality was 30.7%. The use of trauma scores was not associated with maternal and fetal mortality. Uterine injury was the only predictive risk factor for fetal loss (p=0.014). CONCLUSIONS: this is a retrospective study analyzing a small number of pregnant women victims of severe trauma. However, the results show that there are no predictive accuracy scores to evaluate maternal and fetal outcomes.

A hemoglobinúria paroxística noturna é doença rara, causada por mutação adquirida de um gene no sistema hematopoético com 16-18% dos casos diagnosticados durante a gravidez. Descrevemos dois casos de gestantes portadoras de hemoglobinúria paroxística noturna com diagnóstico anterior à gestação. A mortalidade materna é de 8-10%, devido principalmente a tromboembolismo e, em menor escala, transformação leucêmica. As perdas fetais chegam a 30% das gestações. Estes dois casos ilustram situação grave e extremamente complexa, que é a conduta obstétrica em mulheres portadoras de doença hematológica muito rara, grave e potencialmente fatal. Com uma abordagem multidisciplinar em serviços terciários é possível obter bons resultados maternos e perinatais.Paroxysmal nocturnal hemoglobinuria is a rare disease caused by an acquired gene mutation of the hematopoietic system, with 16-18% of the cases diagnosed during pregnancy. We describe two cases of pregnancy in women with paroxysmal nocturnal hemoglobinuria. Maternal mortality reaches 8-10%, mainly due to thromboembolism and, less frequently, to leukemic transformation. Fetal losses may reach 30%. These two cases illustrate a serious and extremely complex situation, which is the obstetrical management of a patient with a very rare, serious and potentially fatal hematological condition. Using a multidisciplinary approach in tertiary care centers, it is possible to attain good maternal and perinatal outcomes.

OBJETIVO: descrever os resultados gestacionais de uma série de gestantes submetidas a circlagem cervical eletiva. MÉTODOS: estudo retrospectivo descritivo de 123 gestações em 116 pacientes submetidas a circlagem eletiva por insuficiência cervical, pelas técnicas de Espinosa-Bahamondes, Palmer ou MacDonald, e acompanhadas no Ambulatório de Pré-Natal Especializado do CAISM/UNICAMP. As variáveis foram analisadas por meio frequência, média e desvio-padrão e comparadas pelo teste de c² ou o teste exato de Fisher. RESULTADOS: 73% das pacientes apresentavam pelo menos um abortamento prévio, 17,9% tinham 3 ou mais abortamentos anteriores e 48% tinham antecedente de parto prematuro. A idade gestacional média de realização da circlagem foi 16 semanas. Houve predomínio de utilização da técnica cirúrgica de Espinosa modificada por Bahamondes (94,3%). A incidência de complicações durante a gestação foi de 69%; a do trabalho de parto prematuro (31,7%) foi a mais freqüente, seguido de vaginites/vaginose (26%), ruptura prematura pré-termo de membranas (10,5%) e óbito fetal (8,7%), As principais intercorrências clínicas associadas foram infecção do trato urinário (5,6%), síndromes hipertensivas (4%) e diabete gestacional (2,4%). O índice de perdas gestacionais foi de 8,9% (11 óbitos fetais). Houve 18% de partos prematuros e o antecedente de parto prematuro associou-se à ocorrência de partos prematuros na gestação em estudo. CONCLUSÕES: os antecedentes obstétricos compatíveis com insuficiência istmocervical foram freqüentes e o antecedente de parto prematuro associou-se a ocorrência de partos prematuros na gestação em estudo. A utilização de circlagem a Espinosa-Bahamondes resultou em taxa de 18% de partos prematuros e de 104 em mil de morte perinatal. São necessários estudos prospectivos controlados para avaliar o real benefício da circlagem cervical durante a gravidez.PURPOSE: to describe the pregnancy outcome of women submitted to cervical cerclage during pregnancy. METHODS: a series of 123 pregnancies in 116 women submitted to elective cervical cerclage by Espinosa-Bahamondes, Palmer and MacDonald techniques and followed at the High-Risk Antenatal Care Unit at CAISM/UNICAMP is described. Variables were analyzed through frequency, mean and standard deviation, comparisons were made using c² or Fisher exact tests. RESULTS: 73% had at least one previous abortion, 17.9% had had 3 prior abortions, and 48% had prior preterm deliveries. The mean gestational age at cerclage was 16 weeks. Cerclage by the Espinosa-Bahamondes technique predominated (94.3%). The overall complication rate was 69%, with preterm labor as the most frequent (31.7%), followed by vaginitis (26%), preterm premature rupture of membranes (10.5%) and fetal death (8.7%). Other clinical complications were less common and included urinary tract infections (5.6%), hypertensive disorders (4%) and gestational diabetes (2.4%). Fetal loss occurred in 8.9% of pregnancies (11 stillbirths). Premature deliveries were present in 18%. History of previous premature deliveries was associated with the occurrence of premature deliveries. CONCLUSION: Obstetrical history compatible with cervical incompetence was frequent, and prior preterm delivery was associated with a preterm delivery in the pregnancy under analysis. The use of cerclage by the Espinosa-Bahamondes technique resulted in 18% of premature newborns, and 104 per thousand rate of perinatal death. Prospective, controlled trials are needed to evaluate the real benefits of cervical cerclage performed during pregnancy.

OBJETIVO: comparar a morbidade materna e os resultados neonatais, bem como algumas características clínicas e epidemiológicas de primíparas com uma cesárea anterior, segundo a realização de cesárea eletiva (CE) ou prova de trabalho de parto (PTP) no segundo parto. PACIENTES E MÉTODO: trata-se de estudo de corte transversal retrospectivo do segundo parto em mulheres com uma cesárea prévia, atendidas no Centro de Atenção Integral à Saúde da Mulher (CAISM)/UNICAMP, no período de 1986 a 1998. Os dados foram obtidos de 2068 prontuários clínicos que correspondiam a 322 casos de CE e 1746 de PTP. A análise dos dados foi realizada pela distribuição percentual dos casos de CE e PTP e das categorias das variáveis nestes dois grupos, com a diferença estatística avaliada pelos testes chi2, chi2 para tendência (chi2 trend) e exato de Fisher, com nível de significância de 95%. RESULTADO: a indicação de CE diminuiu progressivamente com o tempo, passando de 22,6% em 1986 para 5% em 1998. A morbidade materna foi semelhante e reduzida nos dois grupos (1,24 e 1,21%). Não houve diferença significativa entre os grupos quanto ao índice de Apgar e natimortalidade, mas notou-se proporção significativamente maior de RN prematuros e com peso 4.000 g no grupo submetido à CE. A prevalência de CE foi significativamente maior em mulheres com idade >35 anos, história pregressa ou atual de síndrome hipertensiva, diabetes ou primeiro filho morto, bem como com alterações no volume do líquido amniótico. CONCLUSÕES: A realização da PTP aumentou progressivamente ao longo dos treze anos, sem aumento na morbidade materna e/ou neonatal. As indicações de CE obedeceram critério médico relacionado às condições clínicas maternas e/ou fetais desfavoráveis ao parto vaginal.

Objetivos: avaliar a mortalidade evitável de mulheres em idade reprodutiva, residentes em Campinas, SP, comparando os qüinqüênios de 1985-89 com 1990-94. Métodos: foram estudadas 3.086 declarações de óbito de mulheres de 10 a 49 anos, que foi o número total de mortes no período de janeiro de 1985 a dezembro de 1994. Foram aplicados os critérios de evitabilidade, segundo medidas preventivas, medidas de diagnóstico e tratamento precoces, medidas de saneamento e medidas mistas. Foram ainda classificadas de causa dificilmente evitável, as mal definidas e as por outras causas. Procedeu-se ao cálculo dos coeficientes de mortalidade específicos para cada período de cinco anos e da razão entre estes coeficientes. Resultados: houve aumento na taxa de mortalidade evitável em 20% na comparação entre os dois períodos. As maiores falhas ocorreram no grupo de causas evitáveis por medidas preventivas e de saneamento. O maior aumento em causa de morte por medidas preventivas foi resultado da AIDS. Dentre as mortes evitáveis por medidas mistas, deve-se ressaltar o aumento de 50% tanto para mortalidade materna por aborto, quanto nas mortes violentas, principalmente homicídios. Conclusões: houve aumento na proporção de mortes por causas evitáveis. Medidas para prevenção da AIDS, do aborto provocado e para redução das mortes violentas, principalmente homicídios, deveriam ser prioridades político-sociais no país.

Objetivos: identificar e investigar a subnotificação da mortalidade materna, a partir das declarações de óbito (DO) com causa presumível para morte materna em mulheres de 10 a 49 anos, residentes em Campinas, São Paulo, no período de 1992 a 1994. Métodos: foram selecionadas, dentre as 1032 DO de mulheres com idade entre 10 e 49 anos, 216 cuja causa de morte era associada à gravidez declarada ou presumível. Procedeu-se então à busca ativa da causa materna em prontuários clínicos, serviço de verificação de óbito e domicílios. Resultados: foram identificados oito casos adicionais de morte materna dentre as 204 DO com causa materna presumível, o que correspondeu a uma subnotificação de 40% ou a um fator de correção de 1,67 sobre a RMM "oficial". A principal causa de óbito com subnotificação (71,5% ou 5/7 casos) correspondeu a complicações infecciosas do aborto, seguida pela morte materna obstétrica indireta (66,6% ou 2/3 casos). Conclusões: a DO não pode ser considerada como única fonte para identificação da morte materna, sendo necessária a investigação complementar das causas presumíveis. A falta de legislação local, além dos aspectos religiosos e sociais, pode estar influindo na omissão do aborto como causa de morte materna.Purpose: to identify and quantify the underreporting of maternal mortality, from death certificates (DC) in Campinas, São Paulo, from 1992 to 1994. Methods: a total of 216 DC whose causes of death were maternal (declared and/or presumed) were selected among the 1032 DC of 10 to 49-year-old women. A complementary investigation was performed on hospital records, at the death verifying units, and in households. Results: eight additional maternal deaths were identified among the 204 DC with presumed maternal death. This corresponded to an underreporting rate of 40% or to a correction factor of 1.67 for the official MMR. The first cause of underreporting was abortion (71.5% or 05/07) and indirect maternal deaths represented the second cause (66.6% or 02/03). Conclusions: the death certificate cannot be considered the only source to identify maternal death. Complementary investigation of the presumable causes of maternal death should be performed. Legislation, social and religious factors might influence the underreporting of abortion as the cause of maternal death.

Objetivo: avaliar os métodos para diagnóstico, características da gestação, complicações maternas e resultados perinatais em casos de hidrocefalia congênita, correlacionando-os com variáveis gestacionais e do parto. Método: avaliaram-se 116 gestações com este diagnóstico antes ou após o parto, dos quais 112 ocorridos na Maternidade do CAISM da UNICAMP no período de 1986 a 1995. Para as variáveis perinatais, utilizaram-se os dados completos de 82 recém-nascidos. Para a análise dos dados, calcularam-se as distribuições e médias, usando-se os testes de c² e exato de Fisher. Resultados: geralmente o diagnóstico foi anterior ao parto, confirmado pelo exame ecográfico, e o parto foi por cesárea na maioria dos casos. A cefalocentese foi realizada em 11 casos e as complicações no parto vaginal foram mais freqüentes que na cesárea. O índice de Apgar baixo foi mais freqüente entre os recém-nascidos de parto vaginal. A hidrocefalia congênita esteve também associada a importante morbidade e mortalidade neonatal e perinatal, outras malformações e número muito pequeno de crianças sem seqüelas. Conclusões: a avaliação destes fatores pode ser de grande utilidade para o obstetra acompanhar gestantes com esta malformação fetal, dando maior respaldo às decisões que, além de médicas e éticas, devem levar em conta a relação risco-benefício das medidas a serem tomadas.Objective: to evaluate the diagnosis, characteristics of pregnancy, maternal complications and perinatal outcome in cases of congenital hydrocephalus, and to associate them with pregnancy and delivery variables. Methods: 116 pregnancies with this diagnosis were evaluated before or after delivery, 112 of them occurring at the Maternity ward of CAISM/UNICAMP during the period between 1986 and 1995. For perinatal variables, complete data of 82 newborns were used. For data analysis, distributions and means were calculated and c² and Fisher exact tests were applied. Results: generally the diagnosis was made before delivery, confirmed by ultrasound and the delivery was through a cesarean section in cases. Cephalocentesis was performed in 11 cases and complications were more frequent in vaginal delivery than cesarean section. Low Apgar scores were more frequent among newborn babies delivered vaginally. Congenital hydrocephalus was also associated with important neonatal and perinatal morbidity and mortality, with other malformations, and a very low number of children without sequelae. Conclusions: the evaluation of these factors may be of great value for the obstetrician who is following pregnant women with this fetal malformation. This could better support the decisions that, although medical and ethical, should take into account the risk-benefit ratio of measures to be taken.

CONTEXT: The lithopedion (calcified abdominal pregnancy) is a rare phenomenon and there are less than 300 cases reported in the medical literature. CASE REPORT: In this case, a 40 year-old patient had had her only pregnancy 18 years earlier, without medical assistance since then. She came to our hospital with pain and tumoral mass of approximately 20 centimeters in diameter. Complementary examinations (abdominal X-ray, ultrasonography and computerized tomography) demonstrated an extra-uterine abdominal 31-week pregnancy with calcification areas. Exploratory laparotomy was performed, with extirpation of a well-conserved fetus with partially calcified ovular membranes.

The objective of this study was to identify group B streptococcus (GBS) colonization rates and compare detection efficiency of selective versus non-selective culture media and anorectal versus vaginal cultures in women with preterm labor and preterm-premature rupture of membranes (PROM). A prospective cohort study of 203 women was performed. Two vaginal and two anorectal samples from each woman were collected using sterile swabs. Two swabs (one anorectal and one vaginal) were placed separately in Stuart transport media and cultured in blood-agar plates for 48 hours; the other two swabs were inoculated separately in Todd-Hewitt selective media for 24 hours and then subcultured in blood-agar plates. Final GBS identification was made by the CAMP test. A hundred thrity-two cultures out of 812 were positive. The maternal colonization rate was 27.6%. Colonization rates were 30% for preterm PROM and 25.2% for preterm labor. Todd-Hewitt selective medium detected 87.5% and non-selective medium 60.7% GBS-positive women. Vaginal samples and anorectal samples had the same detection rate of 80.3%. Anorectal selective cultures detected 75% of carriers; 39% of GBS-positive women were detected only in selective medium. A combined vaginal-anorectal selective culture is appropriate for GBS screening in this population, minimizing laboratory costs.