Three-dimensional real and virtual models in fetal surgery: reality or a futuristic vision?

While relatively new, fetal surgery has become an indispensable part of the field of Obstetrics as it allows potentially life-threatening conditions to be corrected in utero. Imaging modalities such as ultrasound, magnetic resonance imaging, and computer tomography have become staples in fetal imaging, as they allow for comprehensive analysis of the fetal anatomy. Uses of these modalities can range from chromosomal diagnosis to surgical planning. Scientific development has not only allowed for visualization in the three-dimensional plane, but the implementation of virtual reality technology is also now a possibility. It is our belief that integrating virtual reality technology will help overcome hurdles currently faced by fetal surgeons including candidate selection and clearly observing fetal anatomy. Training opportunities are also probably, as surgeons and residents can use models created during these virtual reality experiences to study and prepare for complications that may arise during surgical intervention. This article is protected by copyright. All rights reserved.

Noninvasive prenatal testing: benefits and limitations of the available tests.

BACKGROUND: The „gold standard“ for prenatal diagnosis of aneuploidies is provided by the karyotype, which has high accuracy, but is dependent on invasive procedures, which generate risk of fetal loss. Different methodologies of development of noninvasive prenatal genetic tests (NIPT) for tracking aneuploidies, including sex chromosomes, have been made available for clinical use, for some microdeletions and triploids and for exclusion of paternity. These exams make use of three methodological tools: s-MPS, t-MPS and SNP. Genetic tests, despite the high cost, cover a broader range of clinical applications, have the advantage that can be performed early, with high accuracy, and low false positive rate. Type of article: Review. SETTING: Department of Obstetrics and Gynecology, Science College of Santa Casa of São Paulo (FSMSCSP), São Paulo-SP, Brazil. DESIGN AND METHODS: This study was a non-asystematic review, which searched PubMed / MEDLINE as a research source and aimed at the compilation of data, which allowed approaching the evolution, the technical and methodological advances of the available tests, the recognition of its benefits, limitations and future perspectives on NIPT. CONCLUSION: NIPT stand out for being applied earlier during the pregnancy with high accuracy and low false-positive rates, including a broad spectrum of clinical applications. The t-MPS is a recent technique used to evaluate aneuploidy that shows greater accuracy and lower cost than the s-MPS, but that is limited to being applied only to the most common aneuploidies. The SNP technique can search for more genetic conditions, besides presenting better accuracy.

Comparison of obstetrical interventions in women with vaginal and cesarean section delivered: cross-sectional study in a reference tertiary center in the Northeast of Brazil.

OBJECTIVE: To compare the performance of obstetrical interventions and maternal and perinatal outcomes between vaginal and cesarean delivery routes in pregnant women at normal risk. Type of article: Original article. Desing: Cross-sectional study with 421 participants admitted for spontaneous or induced labor with full-term singleton gestations and fetuses weighing between 2,500 and 4,499 g. SETTING: Maternal Fetal-Medicine Service, Assis Chateaubriand Maternity, Federal University of Ceará (UFC), Fortaleza-CE, Brazil. METHODS: The instrument of data collection was divided into socio-demographic, clinical, and obstetric characteristics; data of labor and delivery; maternal morbidity; maternal outcome and perinatal outcomes. Pearsons chi-square test and Fishers exact test were used to verify associations between the groups. RESULTS: The mean age was 22.8 ± 6.0 (vaginal) and 22.9 ± 4.9 (cesarean section). Overall, 44.5% of vaginal deliveries and 85.5% of cesarean sections were monitored electronically (p < 0.001). Immediate skin-to-skin contact (84.1%) and first-hour breastfeeding (80.4%) were more frequent in vaginal deliveries compared with cesarean deliveries (27% vs. 61.0%, p < 0.001). The prevalence of puerperal infections was 1.2% (vaginal) and 5.0% (cesarean section) with a p value of 0.02; 40% of cesarean-delivered newborns and 9.7% of vaginally-delivered newborns were referred to the neonatal intensive care unit (p < 0.001). CONCLUSION: The cesarean section was associated with a lower frequency of useful practices, a higher frequency of harmful practices, worse neonatal outcomes, and a higher rate of postpartum infections.

Reproducibility of quantitative sensory testing applied to musculoskeletal orofacial region: Site and sex differences.

BACKGROUND: This study estimated the inter-rater reliability and agreement of the somatosensory assessment performed at masseter and temporomandibular joint (TMJ) region in a group of healthy female and male participants. METHODS: Forty healthy participants (20 men and 20 women) were evaluated in two sessions by two different examiners. Cold detection threshold (CDT), warm detection threshold (WDT), thermal sensory limen (TSL), cold pain threshold (CPT), heat pain threshold (HPT), mechanical detection threshold (MDT), mechanical pain threshold (MPT), wind-up ratio (WUR) and pressure pain threshold (PPT) were assessed on the skin overlying TMJ and masseter body. Mixed ANOVA, intraclass correlation coefficients (ICC) and standard error of measurement (SEM) were applied to the data (α = 5%). Nonoverlapping 95% confidence intervals (95% CI) of ICCs were considered significantly different. RESULTS: The ICCs of 77% of all quantitative sensory testing (QST) measurements were considered fair to excellent (ICCs: 0.47-0.97), and WUR presented the lowest values. The reliability of WDT, TSL and HPT of masseter was significantly higher than TMJ, whereas the MDT reliability of TMJ was higher than masseter. In addition, the following combination of test/sites presented significantly lower ICCs for women: HPT, MDT of TMJ and MPT of both TMJ and masseter. Finally, the highest SEM values were presented for CPT and MPT. CONCLUSION: The overall somatosensory assessment of the masticatory structures performed by two examiners can be considered sufficiently reliable to discriminate participants, except WUR. Possible site and sex influences on the reproducibility parameters should be taken into account for an appropriate interpretation and clinical application of QST. SIGNIFICANCE: The test site and participant's sex can significantly influence the relative reliability and agreement of quantitative sensory testing applied to musculoskeletal orofacial region, which affect the capacity to discriminate participants and to evaluate changes over time.

Impact of cesarean section in a private health service in Brazil: indications and neonatal morbidity and mortality rates.

OBJECTIVE: To evaluate the incidence of, indications of, and maternal and neonatal morbidity and mortality rates in cesarean sections in a private health service in Brazil. DESIGN: Retrospective and observational study. SETTING: Private health service in Vitória, Espírito Santo, Brazil. METHODS: The patients were interviewed using a structured questionnaire to determine maternal age, gestational age at the time of delivery, number of previous deliveries, type of delivery performed, duration of labor, indications for cesarean delivery, point at which cesarean section was performed, physician responsible for delivery, and maternal morbidity, fetal morbidity, and fetal mortality rates. A descriptive analysis of the data was conducted. Students t-test was performed to compare quantitative variables, and Fishers exact test was performed for categorical variables. RESULTS: A total of 584 patients were evaluated. Of these, 91.8% (536/584) had cesarean sections, while only 8.2% (48/584) had vaginal deliveries. There were no reports of forceps-assisted vaginal deliveries. In 87.49% of the deliveries, the number of gestational weeks was more than 37. In terms of indications for performing cesarean section, 48.5% were for maternal causes, 30.41% were for fetal causes, and 17.17% were elective. Maternal re-hospitalization due to puerperal complications was necessary in 10.42% of the vaginal deliveries and in 0.93% of the cesarean deliveries (p<0.001). Complications were observed in 18.75% of the vaginally delivered newborns and in 17.16% of those delivered by cesarean section. Of the newborns with complications at birth, 40.59% (41/101) had to be admitted to the neonatal intensive care unit. There were no cases of maternal death. There were seven cases of fetal/neonatal death. CONCLUSION: We observed that the vast majority of deliveries in the private sector are performed by cesarean section, without labor, and by the patients obstetrician. We found no serious maternal complications or increased neonatal morbidity rates associated with cesarean section.

Effects of cervical cerclage on cervical length and the impact of changes in cervical length on pregnancy prognosis.

OBJECTIVE: To identify any cervix-related morphological and functional marker that can be correlated with pregnancy prognosis in patients who have undergone cerclage for cervical incompetence. DESIGN: An observational and prospective study. SETTING: Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (UNIFESP-EPM). METHODS: Patients with cervical incompetence who underwent cervical cerclage using a modified version of the McDonald procedure during or before the 22nd week of pregnancy. The patients were examined by transvaginal ultrasound in the preoperative period, the immediate postoperative period, and between 20 and 24 weeks, 24 weeks + 1 day and 28 weeks, and 28 weeks + 1 day and 32 weeks. Cervical length and the presence of funneling were evaluated during all examinations. Changes in cervical length, presence or absence of funneling, percent increase or decrease in cervical length, and cervical length of less than established values (.

Ectopic pregnancies: a retrospective cohort analysis in a tertiary reference center in the Northeast Region of Brazil.

OBJECTIVE: The objective of this study was to investigate the clinical and epidemiological characteristics of patients with ectopic pregnancy admitted to a tertiary center in the Northeast Region of Brazil and the aspects related to the treatment and outcomes in these women. DESIGN: This was a retrospective cohort study of 101 patients diagnosed with ectopic pregnancy between February 2016 and February 2017. SETTING: Assis Chateaubriand Maternity School, Fortaleza, Ceará, Brazil Methods: The data collected included demographic characteristics, gynecological-obstetric history, symptoms at admission, complementary examinations [chorionic gonadotropin (β-hCG) blood test, transvaginal ultrasound, and hemoglobin level], and treatment given. RESULTS: The mean patient age was 28 ± 6.6 years (14-48 years). Abdominal pain (96%) and vaginal bleeding (82.4%) were the most prevalent symptoms. No risk factors were identified in most of the patients (53.5%), whereas the most frequently identified risk factor (16.9%) was a history of previous ectopic pregnancy. At admission, 63.4% of patients presented ruptured ectopic pregnancy and 5.9% had hemodynamic instability. Among the patients with ruptured ectopic pregnancy, 61% had already sought care at another center. With regard to the therapeutic options, 78.2% underwent surgery (27.2%, laparoscopy), 16.8% used methotrexate (MTX), and 5% underwent expectant management. Among those who received MTX, 41.2% needed subsequent surgery because of elevated blood β-hCG level (57.1%) and clinical signs of ruptured ectopic pregnancy (42.9%). CONCLUSION: The patients were admitted at an advanced stage of ectopic pregnancy, which made a more conservative and less costly treatment difficult. However, the outcomes were clinically satisfactory, with low complication rates and no maternal deaths. Keywords ectopic pregnancy, methotrexate, epidemiology, laparoscopy, laparotomy.

Test-retest reliability of quantitative sensory testing for mechanical somatosensory and pain modulation assessment of masticatory structures.

Assessing the reliability of medical measurements is a crucial step towards the elaboration of an applicable clinical instrument. There are few studies that evaluate the reliability of somatosensory assessment and pain modulation of masticatory structures. This study estimated the test-retest reliability, that is over time, of the mechanical somatosensory assessment of anterior temporalis, masseter and temporomandibular joint (TMJ) and the conditioned pain modulation (CPM) using the anterior temporalis as the test site. Twenty healthy women were evaluated in two sessions (1 week apart) by the same examiner. Mechanical detection threshold (MDT), mechanical pain threshold (MPT), wind-up ratio (WUR) and pressure pain threshold (PPT) were assessed on the skin overlying the anterior temporalis, masseter and TMJ of the dominant side. CPM was tested by comparing PPT before and during the hand immersion in a hot water bath. anova and intra-class correlation coefficients (ICCs) were applied to the data (α = 5%). The overall ICCs showed acceptable values for the test-retest reliability of mechanical somatosensory assessment of masticatory structures. The ICC values of 75% of all quantitative sensory measurements were considered fair to excellent (fair = 8·4%, good = 33·3% and excellent = 33·3%). However, the CPM paradigm presented poor reliability (ICC = 0·25). The mechanical somatosensory assessment of the masticatory structures, but not the proposed CPM protocol, can be considered sufficiently reliable over time to evaluate the trigeminal sensory function.