Routine Ultrasound at 30th-33rd weeks versus 30th-33rd and 35th-37th weeks in Low-Risk Pregnancies: A Randomized Trial.

INTRODUCTION: The aim of this study was to evaluate the accuracy of 35-37 weeks' ultrasound for fetal growth restriction (FGR) detection and the impact of 30th-33rd weeks versus 30th-33rd and 35th-37th weeks' ultrasound on perinatal outcomes. METHODS: This was a randomized controlled trial that enrolled 1,061 low-risk pregnant women: 513 in the control group (routine ultrasound performed at 30th-33rd weeks) and 548 in the study group (with an additional ultrasound at 35th-37th weeks). FGR was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile. p values < 0.05 were considered statistically significant. RESULTS: The ultrasound at 35-37 weeks had an overall accuracy of FGR screening of 94%. Spearman's correlation coefficient between EFW and birthweight centile was higher for at 35-37 weeks' ultrasound (ρ = 0.75) compared with 30-33 weeks' ultrasound (ρ = 0.44). The study group had a lower rate of operative vaginal deliveries (24.4% vs. 39.3%, p = 0.005) and cesarean deliveries for nonreassuring fetal status (16.8% vs. 38.8%, p < 0.001). DISCUSSION/CONCLUSION: A later ultrasound (35-37 weeks) had a high accuracy for detection of FGR and had a higher correlation between EFW and birthweight centiles. Furthermore, it was also associated with lower adverse perinatal outcomes compared to an earlier ultrasound.

Alpha-Lipoic Acid and Its Enantiomers Prevent Methemoglobin Formation and DNA Damage Induced by Dapsone Hydroxylamine: Molecular Mechanism and Antioxidant Action.

Dapsone (DDS) therapy can frequently lead to hematological side effects, such as methemoglobinemia and DNA damage. In this study, we aim to evaluate the protective effect of racemic alpha lipoic acid (ALA) and its enantiomers on methemoglobin induction. The pre- and post-treatment of erythrocytes with ALA, ALA isomers, or MB (methylene blue), and treatment with DDS-NOH (apsone hydroxylamine) was performed to assess the protective and inhibiting effect on methemoglobin (MetHb) formation. Methemoglobin percentage and DNA damage caused by dapsone and its metabolites were also determined by the comet assay. We also evaluated oxidative parameters such as SOD, GSH, TEAC (Trolox equivalent antioxidant capacity) and MDA (malondialdehyde). In pretreatment, ALA showed the best protector effect in 2.5 µg/mL of DDS-NOH. ALA (1000 µM) was able to inhibit the induced MetHb formation even at the highest concentrations of DDS-NOH. All ALA tested concentrations (100 and 1000 µM) were able to inhibit ROS and CAT activity, and induced increases in GSH production. ALA also showed an effect on DNA damage induced by DDS-NOH (2.5 µg/mL). Both isomers were able to inhibit MetHb formation and the S-ALA was able to elevate GSH levels by stimulating the production of this antioxidant. In post-treatment with the R-ALA, this enantiomer inhibited MetHb formation and increased GSH levels. The pretreatment with R-ALA or S-ALA prevented the increase in SOD and decrease in TEAC, while R-ALA decreased the levels of MDA; and this pretreatment with R-ALA or S-ALA showed the effect of ALA enantiomers on DNA damage. These data show that ALA can be used in future therapies in patients who use dapsone chronically, including leprosy patients.

Is There a Cumulative Effect for Congenital Heart Defects in Monochorionic Twins after Assisted Reproduction? - A Retrospective Analysis at a Tertiary Referral Center.

Introduction: The aim of our study was to compare maternal, chorionicity and neonatal complications in monochorionic (MC) twins between spontaneously conceived (SC) and assisted reproductive technologies (ART) pregnancies. Material and Methods: This was a retrospective cohort study between January 2010 to December 2019 at a tertiary referral University center. All consecutive pregnancies with MC twins that delivered at our University hospital were included. Maternal, chorionicity and neonatal complications were recorded and compared between SC and ART pregnancies. Results: 393 MC pregnancies were included for final analysis, including 353 (89.8%) SC and 40 (10.2%) pregnancies conceived after ART. Hypothyroidism was the only maternal condition seen significantly more often in ART pregnancies (35.0% vs 12.5%, p = 0.001). There were no significant differences in chorionicity complications, such as twin-twin transfusion syndrome, selective fetal growth restriction and twin anemia-polycythemia sequence (40.0% in ART pregnancies vs 31.6% in SC pregnancies, p = 0.291). At least one congenital anomaly in one twin was seen significantly more often in ART pregnancies (18.8% vs 8.1%, p = 0.004), especially congenital heart defects (16.3% vs 6.2%, p = 0.005). There were no other significant differences in neonatal outcomes between both groups, however, there were non-significant trends in gestational age at delivery (34 weeks in ART pregnancies vs 35 weeks, p = 0.078) and birthweight (1951 g ± 747 in ART pregnancies vs 2143 g ± 579, p = 0.066). Conclusion: This is the largest cohort study to date comparing maternal, chorionicity and neonatal complications between MC twin pregnancies after ART and after SC. Hypothyroidism was the only maternal condition occurring more frequently in pregnancies conceived after ART. There were no significant differences in chorionicity complications, in contrast to previously reported studies. While MC twins and ART pregnancies per se are known to be at risk for congenital heart defects, there seems to be a cumulative effect in MC pregnancies conceived after ART.

Maternal morbidity and mortality due to placenta accreta spectrum disorders.

Placenta accreta spectrum (PAS) disorders are an increasing health problem in many parts of the world. They are an important risk factor for adverse maternal outcomes related to delivery, with a reported 18-fold increase in maternal morbidity. Profuse haemorrhage after attempting to remove the placenta is the most frequent complication and can lead to major maternal morbidity and ultimately to maternal death. Morbidity can also arise from the multiple procedures required to treat PAS disorders. Intensive care unit admission, mechanical ventilation, infection, and prolonged hospitalization are common in these patients. Long-term complications related to infertility and psychological disturbances can also occur and may have a strong and long-lasting impact on women's health. Antenatal diagnosis allows for appropriate scheduling of delivery and referral to a specialized centre and has been shown to reduce maternal morbidity and mortality.

Glucose intolerance in the third trimester is not predictive of adverse outcomes.

OBJECTIVE: To evaluate the incidence of abnormal third trimester oral glucose tolerance tests (OGTT) results in non-diabetic women and to compare the obstetric and neonatal outcomes with those of women with normal OGTT results. METHODS: Women with third trimester singleton pregnancies with negative gestational diabetes test results earlier in their pregnancy were enrolled into an observational prospective study at a tertiary care hospital between June 1, 2014 and September 30, 2017. All underwent an additional 75 g OGTT between 32 and 36 weeks and were classified as having normal or abnormal results. Healthcare professionals were blinded to the results. Pregnancy and perinatal outcomes were compared. RESULTS: Four hundred and sixty-seven women agreed to participate and 334 fulfilled the inclusion criteria. Forty-five (13.5%) had an abnormal third trimester OGTT result. In this group, post-term induction of labor was more frequent (70.6% vs 38.1%, adjusted odds ratio (aOR) 4.28, 95% confidence interval (CI) 1.33-13.77, P=0.015) as was cesarean delivery (31.1% vs 15.2%, aOR 2.57, 95% CI 1.14-5.81, P=0.023), regardless of surgery indication. Macrosomia was more common, but not significantly after adjusting for confounders (17.8% vs 4.2%, aOR 3.80, 95% CI 0.60-24.17, P=0.157). No other significant differences were found. CONCLUSION: Post-term induction of labor and cesarean delivery were more frequent in women with an abnormal third trimester OGTT result, but there was no increased risk of serious maternal or perinatal adverse outcomes.

Small-for-gestational-age babies of low-risk term pregnancies: does antenatal detection matter?

OBJECTIVES: To compare delivery route and admission rate to neonatal intensive care unit between small- and appropriate-for-gestational-age babies among low-risk term pregnancies. METHODS: A retrospective study was conducted using the database of deliveries in 2014 at a tertiary hospital. Babies delivered at ≥37 weeks with birthweight <10th centile were considered small-for-gestational-age (SGA) and >90th centile were considered large-for-gestational-age. Fetal weight estimation at 30-33 weeks ultrasound <10th centile was considered antenatal detection of SGA. RESULTS: Among 1429 low-risk term pregnancies, 11% (151/1429) had SGA babies and 5% (75/1429) had large-for-gestational-age. SGA babies were associated with higher rate of cesarean sections for nonreassuring fetal status (18/151 versus 8/1202, p < .001) and higher rate of admissions to neonatal intensive care unit (16/151 versus 18/1202, p < .001) compared to appropriate-for-gestational-age. Within SGA group, antepartum detected fetuses were associated with lower rate of operative deliveries for nonreassuring fetal status than undetected group (3/31 versus 39/120, p = .01) Conclusions: In our series, women with SGA term babies were associated with more adverse obstetric and neonatal outcome than appropriate-for-gestational age, especially among those undetected prenatally.

Impact of maternal weight on the intra-observer and inter-observer reproducibility of fetal ultrasonography measurements in the third trimester.

OBJECTIVE: To evaluate the effect of maternal weight on the intra- and inter-observer reproducibility of third-trimester ultrasonography fetal measurements. METHODS: The present prospective study, performed at a tertiary hospital, enrolled patients at between 35+0  weeks and 36+6  weeks of singleton pregnancies between January 1, 2015, and July 1, 2016. Fetal ultrasonography measurements were evaluated twice by a first observer and a third time by a second observer. Intra- and inter-observer consistency were analyzed using the Cronbach α reliability coefficient, and measurement reproducibility was compared with patients stratified by a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of below 25 or at least 25. RESULTS: The study included 197 patients (133 with BMI <25 and 64 with BMI ≥25). Among patients with a BMI below 25, the reliability coefficients for bi-parietal diameter, head circumference, abdominal circumference, and femur length measurements were 0.97, 0.95, 0.98, and 0.96, respectively, for intra-observer consistency, and were 0.97, 0.93, 0.98, and 0.95, respectively, for inter-observer consistency. Among patients with a BMI of at least 25, these values were 0.97, 0.96, 0.98, and 0.97, respectively, for intra-observed consistency, and 0.97, 0.94, 0.98, and 0.96, respectively, for inter-observer consistency. CONCLUSION: High intra- and inter-observer reproducibility was observed for third-trimester fetal ultrasonography measurements, including for patients who were overweight.

A retrospective analysis of the effectiveness of anterior pelvic organ prolapse repair with Prolift versus Elevate vaginal mesh.

OBJECTIVE: To compare the effectiveness of anterior pelvic organ prolapse (POP) repair using Prolift (Ethicon, Somerville, NJ, USA) or Elevate (American Medical Systems, Minnetonka, MN, USA) vaginal mesh at 12 months of follow-up. METHODS: A retrospective study was undertaken using the records for the first 50 Prolift procedures in 2007-2009 and the first 50 Elevate procedures in 2013-2015 performed at a tertiary urogynecology unit in Lisbon, Portugal. Postoperative follow-up occurred at 3, 6, and 12 months. The primary outcome was surgical efficacy using subjective and objective measures (vaginal bulge symptoms and POP quantification system according to the Weber criteria, respectively) at 12 months. RESULTS: Improvement according to the Weber criteria was noted for 10 (25%) of 40 women in the Prolift group and 21 (48%) of 44 in the Elevate group at 12 months (P=0.032). Additionally, the Ba point was higher with Elevate than with Prolift (-2.2 ± 1.1 vs -1.5 ± 1.5; P=0.031). Vaginal bulge symptoms were reported at 12 months by 7 (18%) women in the Prolift group and 3 (7%) in the Elevate group (P=0.021). CONCLUSION: Differences in anatomic results were apparent between the two vaginal mesh groups 12 months after surgery.

Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes?

INTRODUCTION: The best route of delivery for the term breech fetus is still controversial. We aim to compare maternal and neonatal outcomes between vaginal and cesarean term breech deliveries. MATERIAL AND METHODS: Multicentric retrospective cohort study of singleton term breech fetuses delivered vaginally or by elective cesarean section from January 2012 - October 2014. Primary outcomes were maternal and neonatal morbidity or mortality. RESULTS: Sixty five breech fetuses delivered vaginally were compared to 1262 delivered by elective cesarean. Nulliparous women were more common in the elective cesarean group (69.3% vs 24.6%; p < 0.0001). Gestational age at birth was significantly lower in the vaginal delivery group (38 ± 1 weeks vs 39 ± 0.8 weeks; p = 0.0029) as was birth weight (2928 ± 48.4 g vs 3168 ± 11.3 g; p < 0.0001). Apgar scores below seven on the first and fifth minutes were more likely in the vaginal delivery group (1st minute: 18.5% vs 5.9%; p = 0.0006; OR 3.6 [1.9 - 7.0]; 5th minute: 3.1% vs 0.2%; p = 0.0133; OR 20.0 [2.8 - 144.4]), as was fetal trauma (3.1% vs 0.3%: p = 0.031; OR 9.9 [1.8-55.6]). Neither group had cases of fetal acidemia. Admission to the Neonatal Intensive Care Unit, maternal postpartum hemorrhage and the incidence of other obstetric complications were similar between groups. DISCUSSION: Although vaginal breech delivery was associated with lower Apgar scores and higher incidence of fetal trauma, overall rates of such events were low. Admission to the neonatal intensive care unit and maternal outcomes were similar. CONCLUSION: Both delivery routes seem equally valid, neither posing high maternal or neonatal complications' incidence.

Introdução: A melhor via de parto do feto pélvico de termo ainda é controversa. Pretendemos comparar desfechos maternos e neonatais entre partos vaginais e cesarianas de fetos pélvicos de termo. Material e Métodos: Estudo de coorte, multicêntrico e retrospetivo, incluindo gestações de feto único de termo, em apresentação pélvica, que terminaram em parto vaginal ou cesariana eletiva entre janeiro de 2012 e outubro de 2014. Os desfechos primários foram a morbilidade e mortalidade maternas e neonatais. Resultados: Sessenta e cinco partos vaginais foram comparados com 1262 cesarianas eletivas. As nulíparas foram mais frequentes no grupo das cesarianas (69,3% vs 24,6%; p < 0,0001). A idade gestacional foi inferior nos partos vaginais (38 ± 1 semanas vs 39 ± 0,8 semanas; p = 0,0029), verificando-se o mesmo para o peso ao nascer (2928 ± 48,4 g vs 3168 ± 11,3 g; p < 0,0001). Índices de Apgar < 7 foram mais frequentes nos partos vaginais (1º minuto: 18,5% vs 5,9%; p = 0,0006; OR 3,6 [1,9 - 7,0]; 5º minuto: 3,1% vs 0,2%; p = 0,0133; OR 20,0 [2,8 - 144,4]). Verificou-se também uma maior incidência de traumatismo fetal neste grupo (3,1% vs 0,3%; p = 0,031; OR 9,9 [1,8 - 55,6]). Nenhum grupo teve casos de acidemia fetal. As taxas de internamento na unidade de cuidados intensivos neonatais, de hemorragia materna pós-parto ou de outras complicações obstétricas foram idênticas. Discussão: O parto vaginal associou-se a índices de Apgar inferiores e a uma maior incidência de traumatismo fetal, com taxas globalmente baixas. Não se verificaram diferenças nas taxas de internamento neonatal nem nos desfechos maternos. Conclusão: Ambas as vias de parto parecem adequadas, nenhuma condicionando incidências elevadas de complicações maternas ou neonatais.

Polymorphisms in STK17A gene are associated with systemic lupus erythematosus and its clinical manifestations.

Systemic lupus erythematosus (SLE) is an autoimmune disorder with several clinical manifestations. SLE etiology has a strong genetic component, which plays a key role in disease's predisposition, as well as participation of environmental factors, such and UV light exposure. In this regard, we investigated whether polymorphisms in STK17A, a DNA repair related gene, encoding for serine/threonine-protein kinase 17A, are associated with SLE susceptibility. A total of 143 SLE patients and 177 healthy controls from Southern Brazil were genotyped for five STK17A TagSNPs. Our results indicated association of rs7805969 SNP (A and G/A genotype, OR=1.40 and OR=1.73, respectively) with SLE predisposition and the following clinical manifestations: arthritis, cutaneous and immunological alterations. When analyzing haplotypes distribution, we found association between TGGTC, TAGTC and AAGAT haplotypes and risk to develop SLE. When considering clinical manifestations, the haplotypes TGGTT and TAGTC were associated with protection against cutaneous alterations and the haplotype TAGTC to hematological alterations. We also observed association between SLE clinical manifestations and ethnicity, with the European-derived patients being more susceptible to cutaneous and hematological alterations.

Doença renal macroglobulinemia de Waldenstrõm / Waldenstrom mscroglobulinemia in the chronic renal insufficiency

Hipertensão grave e insuficiência renal não-oligúrica se desenvolveram em homem branco de 69 anos de idade. Biopsia renal mostrou glomérulos com luzes capilares ocluídas por trombos hialinos. O exame à microscopia de imunofluorescência mostrou deposição globular focal deIgM associada predominantemente a deposição de Kappa light-chain. As características imunológicas da proteína plasmática anormal e os achadoshistológicos permitiram o diagnóstico de macroglobulinemia de Waldenstrõm acompanhada por insuficiência renal crônica

O imaginário cognitivo: uma fronteira entre consciência e inconsciente / The cognitive imaginary: a frontier between consciousness and unconscious

Este artigo apresenta e discute uma concepçäo do imaginário como atividade mental básica do ser humano. Rejeita-se a proposiçäo comum na filosofia e na psicologia da cópia do real, afirmando-se uma tese de construçäo do real no próprio imaginário. Uma avaliaçäo fenomenológica pautada em Husserl mostra o caráter protensional e retencional - primário e secundário - da consciência que permite mostrar quanto o imaginário precede protensionalmente qualquer açäo ou decisäo. Uma rápida resenha das principais posturas teóricas do passado desde Platäo, M. Ficino, G. Bruno, R. Descartes, B. Spinoza leva a análise até Kant e a importância da imaginaçäo transcendental. No presente discute-se a néantisation de J.P. Sartre, a imagem criadora de G. Bachelard, a perspectiva junguiana de G. Durand, a postura de J. Chateau, e principalmente o logicismo piagetiano que suprime a autonomia do imaginário, em contraposiçäo à valorizaçäo de M. Klein. Um aceno a J. Lacan evidencia as diferenças entre a conhecida tese do imaginário por ele proposta e a perspectiva defendida aqui. O artigo conclui apontando uma estrutura e desenvolvimento do imaginário a partir de um dispositivo cognitivo inato, entendido como causalidade apta a conectar em episódios (e paralelamente em frases) o que é construído sobre os insumos de um real incognoscível. Uma síntese da teoria que fundamenta esta tese e do trabalho experimental realizado e em curso aponta a estrutura do imaginário em seu eixo sintagmático e paradigmático, e seu desenvolvimento em três fases: pré-episódica, intermediária e episódica