Effectiveness of expectant management versus methotrexate in tubal ectopic pregnancy: a double-blind randomized trial.

PURPOSE: To compare the effectiveness of expectant management versus methotrexate in selected cases of tubal ectopic pregnancy. METHODS: A double-blind randomized trial included 23 selected patients with a confirmed diagnosis of tubal pregnancy who met the inclusion criteria (hemodynamic stability, initial serum ß-hCG concentration <2,000 mIU/mL, declining titers of ß-hCG 48 h prior to treatment, visible tubal pregnancy on transvaginal ultrasound, a tubal mass <5.0 cm and fertility desire). The patients were divided into two groups: 10 patients in the methotrexate group (MTX 50 mg/m(2) administered as a single intramuscular dose) and 13 patients in the placebo group (saline solution administered in a single intramuscular dose). Quantitative variables were expressed as means ± standard deviations and compared by Student's t test or Mann-Whitney test. Dichotomous variables (success/treatment failure) were presented as proportions and compared by the Fisher exact test. RESULTS: Successful treatment with negative titers of ß-hCG occurred in 9 cases (90.0%) of the methotrexate group and in 12 (92.3%) of the placebo group (p > 0.999). The ß-hCG values became undetectable at 22 ± 15.4 days in the methotrexate group and 20.6 ± 8.4 days in the placebo group (p = 0.80). CONCLUSION: This study showed no statistically significant difference between the treatment with methotrexate and placebo, with similar success rates and similar time interval for ß-hCG to become undetectable.

Histomorphometry and detection of glycosaminoglycans in the endocervical epithelium of pregnant rats after local administration of hyaluronidase.

OBJECTIVE: The aim of the study was to detect the presence of glycosaminoglycans and to investigate histomorphometric aspects of the endocervical epithelium in pregnant rats after local administration of hyaluronidase. MATERIALS AND METHODS: Ten pregnant rats were randomly distributed into two groups. On day 18 of pregnancy 1 mL of distilled water and 0.02 mL of hyaluronidase were administered to the control group (CG) and the study group (SG), respectively On day 20 the rats were sacrificed, followed by dissection and removal of the uterine cervix, which was prepared for histomorphometry (endocervical epithelium thickness and leucocyte infiltration) and for immunohistochemistry with alcian blue reaction and its respective blockers. The paired Student t test was used to compare the groups. RESULTS: The SG was characterized by reduced epithelial thickness (mean: 291.01 +/- 71.1 vs. 764.30 +/- 50.94; p < 0.0001) and a larger number of eosinophils (mean: 3.72 +/- 1.60 vs. 0.54 +/- 0.70; p < 0.0001). Alcian blue staining (pH 0.5) indicated a very strong reaction (3+) for the CG. With pH 2.5, the staining was also very intense (4+) in the CG. With methylation, both groups showed negative reactions after alcian blue staining (pH 2.5). With the methylation reaction followed by saponification and with enzymatic digestion of the lamina, staining showed a weak reaction (1+) in both groups. CONCLUSION: The SG presented with significant alterations related to the reduction of epithelial thickness and an increase in leucocyte infiltration. Furthermore, the use of hyaluronidase resulted in a significant decrease of the sulfated glycosaminoglycans.

Noninvasive determination of fetal rh blood group, D antigen status by cell-free DNA analysis in maternal plasma: experience in a Brazilian population.

We evaluated the diagnostic accuracy of Rh blood group, D antigen (RHD) fetal genotyping, using real-time polymerase chain reaction in maternal blood samples, in a racially mixed population. We performed a prospective study conducted between January 2006 and December 2007, analyzing fetal RHD genotype in the plasma of 102 D- pregnant women by real-time polymerase chain reaction, targeting exons 7 and 10 of the RHD gene. Genotype results were compared with cord blood phenotype obtained after delivery or before the first intrauterine transfusion when necessary. Most of the participants (75.5%) were under 28 weeks of pregnancy, and 87.5% had at least one relative of black ancestry. By combining amplification of two exons, the accuracy of genotyping was 98%, sensitivity was 100%, and specificity was 92%. The positive likelihood ratio was 12.5, and the negative likelihood ratio was 0. The two false-positive cases were confirmed to be pseudogene RHD by real-time polymerase chain reaction. There were no differences between the patients with positive or negative Coombs test ( P = 0.479). Determination of fetal RHD status in maternal peripheral blood was highly sensitive in this racially mixed population and was not influenced by the presence of antierythrocyte antibodies.

[Cesarean uterine scar evaluation by the grey-level histogram]. / Estudo da cicatriz uterina de cesariana avaliada pelo histograma escala-cinza.

OBJECTIVE: To evaluate the Cesarean uterine scar by the grey-level histogram (GLH) in women with a previous Cesarean section, performed either during labor or before labor (elective Cesarean). METHODS: A prospective study was conducted with 40 women between 11 and 14 weeks of gestation, who were allocated to three groups: 15 pregnant women with a previous elective Cesarean (group A); 9 with a previous Cesarean section performed during labor (group B); and 16 with a single previous vaginal delivery (group C). The pregnant women were examined by transvaginal ultrasound, to obtain an image corresponding to the 'shadow' formed by the uterine scar in groups A and B. In group C GLH was accomplished in the region of the uterine isthmus. After capture of the image, the region-of-interest (ROI) was delimited and the option 'histogram' was activated, to automatically obtain graphic representation. The mean, median and standard deviation (SD) were calculated. for each group under study Mean values of the control group histograms were used as the normality parameter for comparison with the other groups. To compare averages of the three groups, the ANOVA test was used. A (p) value of < 0.05 was considered statistically significant. RESULTS: GLH in group A varied from 7.0 to 40.5 (mean: 24.9 and DP: 11.2), in group B from 23,1 to 47.2 (mean: 34,. and DP: 9.6) and in group C from 21.6 to 58.8 (mean: 40.3 and DP: 11.3). CONCLUSION: There was a significant difference of GLH in the region of the uterine scar of previous Cesareans, when it was elective and when performed during labor, suggesting a larger tissue change in the elective Cesarean.

[Morphology of the vascular placental bed in chronic arterial hypertension]. / Estudo da morfologia vascular do leito placentário na hipertensão arterial crônica.

OBJECTIVES: To analyze histopathological patterns of placental bed arteries in pregnancies complicated by chronic arterial hypertension. Alterations were considered according to clinical classification of the hypertensive disorders as mild (MG); moderate (MoG) and severe (SG) for comparison with uncomplicated pregnancies, control group (CG). METHODS: Placental bed biopsy was performed in 60 pregnant women; the study group was comprised of pregnant women with hypertension, subdivided in 13 with severe chronic hypertension (CH), 11 with moderate CH and 11 with mild CH, and results were compared to 25 placental bed biopsies from uncomplicated pregnancies. All the pregnant women had a gestational age of at least 28 weeks of gestation with a live fetus and were submitted to cesarean section. Hypertension was considered mild with diastolic blood pressure (DBP) 90 I? 100 mmHg, moderate DBP 100 I? 110 mmHg and severe DBP=110 mmHg. Placental bed variables selected for histological analysis were: unaltered patterns, physiological changes, medial layer disorganization, medial and intimal hyperplasic changes, acute necrosis and atherosis. RESULTS: In cases with SG and MoG there was predominance of abnormal histophysiological findings: medial layer disorganization and hyperplasic changes, with a statistically significant difference when compared to MG and CG. Alteration in the medial layer was observed in these cases. The normal pattern, unaltered patterns and physiologic changes were more frequent in CG and MG. Physiological changes were the most usual finding, further, there was no acute necrosis or atherosis. CONCLUSION: 1. Abnormal histophysiological findings were predominant in hypertensive pregnant women compared to the normotensive ones; 2. These patterns were more frequent, according to the severity of the hypertensive disorders: Severe, Moderate and Mild; 3. More significant abnormal findings were a change in the medial layer, mainly in the group with severe hypertensive disorders; 4. The groups with moderate and severe hypertensive disorders when compared had similar results; 5. The normal histological pattern was higher in the control group and patients with mild hypertensive disorders and disclosed a similarity between them 6. The most usual pattern was physiologic changes, which was more frequent in the control group.

Perinatal mortality in Rh alloimmunized patients.

OBJECTIVE: Evaluate and compare the perinatal mortality of Rh-negative pregnancies managed at São Paulo Federal University during a 9-year period, using either amniocentesis or middle cerebral artery peak systolic velocity. METHOD: Descriptive observational study involving 291 consecutive Rh-negative pregnancies managed between January 1995 and January 2004. The perinatal mortality of 99 alloimmunized patients was compared with 192 Rh-negative unimmunized patients (control group). The perinatal mortality of patients managed with amniocenteses was compared to those managed with Doppler studies. RESULTS: There were 74 patients managed with amniocenteses and 25 managed with Doppler studies. Perinatal mortality was significantly higher in the 99 Rh-negative isoimmunized patients than in the 192 unimmunized patients (12.1% versus 1%, p=0.0001) and did not differ according to the management protocol used (amniocentesis 13.5% versus cerebral Doppler 8.0%, p=0.725). Mean gestational age and mean weight at birth in pregnancies managed with amniocenteses (35.7 weeks and 2586 g) did not differ significantly from those managed with Doppler (36.3 weeks and 2647 g). CONCLUSIONS: Perinatal mortality in Rh-negative alloimmunized patients remains high and does not differ whether pregnancies are managed through amniocentesis or cerebral Doppler evaluation.

[Frequencies of blood groups, ABO and Rh D incompatibility in post-delivery women and their liveborn]. / Freqüências dos grupos sangüíneos e incompatibilidades ABO e RhD em puérperas e seus recém-nascidos.

OBJECTIVE: This study aimed to assess the frequency of different blood phenotypes and to predict the risk of Rh D alloimmunization and maternal-fetal incompatibility in a Brazilian population living in the West zone of the city of São Paulo-Brazil. METHODS: This descriptive study evaluated 2,372 post-delivery women and their liveborn during one year. Blood types were analyzed by means of tube agglutination tests. RESULTS: The blood type frequencies were: 50.67 O, 32.17 A, 13.45 B, 3.75 AB, 90.34 Rh D(+) and 9.66 Rh D(-). ABO maternal-fetal incompatibility was detected in 18.4% and Rh D incompatibility in 7%. CONCLUSION: The fraction of Rh D(-) population at high risk for Rh D alloimmunization was 82%, emphasizing the importance of Rh D alloimmunization profilaxis.

Unruptured tubal pregnancy: different treatments for early and late diagnosis.

CONTEXT AND OBJECTIVE: There is evidence that ectopic pregnancies present different behavioral patterns. These distinct evolutions of ectopic pregnancies represent two different natural histories. To evaluate these evolution patterns, we compared patients undergoing medical treatment and expectant management according to their gestational age and initial beta-hCG levels. DESIGN AND SETTING: Prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHODS: Among 119 cases of unruptured ectopic pregnancies diagnosed from April 1999 to February 2004, 57 received systemic treatment with methotrexate 50 mg/m(2) (body surface area) intramuscularly and 62 were managed expectantly. In this study we evaluated the beta-hCG levels at presentation and amenorrhea duration. RESULTS: There was a significant difference between the two groups regarding amenorrhea duration and initial beta-hCG levels (p < 0.001). The group with decreasing beta-hCG levels (managed expectantly) had longer amenorrhea (mean: 8.87 +/- 1.71 weeks) and lower initial beta-hCG levels (mean: 648.8 +/- 754.7 mIU/ml). On the other hand, the group treated with methotrexate had shorter amenorrhea (mean: 6.81 +/- 1.88 weeks) and higher beta-hCG levels at presentation (2642.7 +/- 2315.1 mIU/ml). CONCLUSIONS: The data suggest that ectopic pregnancies can be categorized into two groups: those with early diagnosis and shorter amenorrhea, increasing or maintained beta-hCG levels over 24 and 48-hour intervals and higher beta-hCG levels requiring medical treatment; and those with late diagnosis and longer amenorrhea, decreased beta-hCG levels over 24 and 48-hour intervals and lower beta-hCG levels requiring expectant management.

Tubal patency following surgical and clinical treatment of ectopic pregnancy.

CONTEXT AND OBJECTIVE: As there is little information about fertility outcomes among women following clinical treatment (methotrexate and expectant management) and surgery (salpingectomy) consequent to ectopic pregnancy, we evaluate the results from hysterosalpingography subsequent to treatment. The objective was to evaluate contralateral tubal patency using hysterosalpingography following surgery and clinical treatment of tubal pregnancy. DESIGN AND SETTING: This was a prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHOD: Among 115 patients who underwent hysterosalpingography following surgery and clinical treatment of tubal pregnancy between April 1994 and February 2002, 30 were treated with a single intramuscular dose of methotrexate (50 mg/m(2)), 50 were followed up expectantly and 35 underwent salpingectomy. RESULTS: The patency of the ipsilateral tube was 84% after methotrexate treatment and 78% after expectant management. In addition, contralateral tubal patency was 97% after methotrexate treatment, 92% after expectant management and 83% after salpingectomy. There were no statistically significant differences between the clinical treatment and surgery groups. CONCLUSIONS: The findings from this study suggest similar contralateral tubal patency rates following salpingectomy, methotrexate treatment and expectant management.

Microvessel density in the placental bed among preeclampsia patients.

CONTEXT AND OBJECTIVE: Morphological changes in the spiral arteries of the placental bed have been studied in patients with preeclampsia, one of the largest causes of maternal and perinatal morbidity and mortality. The reports show that vasospasm and vascular endothelial injury were two major pathological conditions for preeclampsia. The aim of this study was to investigate the microvessel density of spiral arteries in the placental bed, in pregnancies complicated by hypertension and proteinuria, and in normal pregnancies. DESIGN AND SETTING: This was a cross-sectional survey of immunohistochemical studies on biopsies from the spiral arteries of the placental bed, among women undergoing cesarean sections for clinical and obstetrical reasons at Universidade Federal de São Paulo, São Paulo, Brazil. METHODS: Placental bed biopsies were obtained during cesarean section after placenta removal, with direct viewing of the central area of placenta insertion. The microvessel density of spiral arteries was measured by immunohistochemical methods in decidual and myometrial segments, using CD34 antibody. RESULTS: Biopsies containing spiral arteries were obtained from 34 hypertensive pregnant women with proteinuria, and 26 normotensive pregnant women. The microvessel densities in decidual and myometrial segments of the placental bed were compared between the groups. It was observed that, with increasing blood pressure and proteinuria, the microvessel density gradually decreased. CONCLUSION: The presence of high levels of hypertension and proteinuria may be associated with a progressive decrease in microvessel density in the placental bed.

[Profile of denounced physicians that practice obstetrics and gynecology in the state of São Paulo]. / O perfil dos médicos denunciados que exercem ginecologia e obstetrícia no estado de São Paulo.

OBJECTIVE: Evaluate the number of ethical and professional complaints involving obstetricians and gynecologists (OBGYNs) and the profile of the physicians denounced. METHODS: Retrospective descriptive study of all 4,138 ethical and professional complaints registered at the medical board of the state of São Paulo between January 1, 1994 and December 31, 2004. The following variables were collected: number of complaints involving OBGYNs, number of OBGYNS involved gender and age (< 30, 31 to 45, 46 to 60, > 60 years) of the physicians denounced, number of involved physicians with residence training (RT) and with specialist certificates (TEGO). The last four variables were compared with a control group of 8,466 OBGYNs practicing in the state of São Paulo who were not denounced to the state medical board. Data collected was submitted to statistical analysis. RESULTS: A total of 503 complaints (12.16%) involved OBGYNs and 781 OBGYNs were denounced. The majority of these physicians were male (599, 76.70%). Regardless of their gender, most physicians denounced (505, 64.66%) were under 45 years of age. Most of the OBGYNs denounced had no residence training (487, 62.36%) and were not board certified specialists (572, 73.24%). Other relevant variables were analyzed and will be presented in future publications. CONCLUSIONS: Between January 1, 1994 and December 31, 2004, 4,138 formal complaints were registered at the medical board of the state of São Paulo A total of 503 complaints (12.16%) involved Obstetrics and Gynecology and 781 OBGYNs were denounced. The typical profile of the physicians denounced was: male, under 45 years of age, without residence training and with no specialist certificate. This study was the first of a series involving the complex investigation of OBGYNs involved in ethical or professional complaints. These preliminary results pointed out deficiencies and important information that probably will be useful for the implementation of actions to improve the practice of obstetrics and gynecology and consequently reduce the number of complaints.

[Evaluation of fetomaternal hemorrhage in postpartum patients with indication for administration of anti-D immunoglobulin]. / Avaliação da hemorragia feto-materna em puérperas com indicação para ministração de imunoglobulina anti-D.

This study evaluated fetomaternal hemorrhage (FMH) in 343 postpartum patients who required prophylaxis of Rh alloimmunization with anti-D immunoglobulin. The rosette test was applied to screen for patients needing quantitative determination of fetal blood transferred from the maternal circulation, which was then measured by the Kleihauer-Betke test (K-B). The rosette test was positive in 22 cases (6.4%). In five of these cases, K-B did not show fetomaternal hemorrhage (a 1.45% false-positive rate for the rosette test), and in one case the test was inconclusive. There were 8 cases with FMH < 10 ml (2.3%), 6 cases with FMH from 10 to 30 ml (1.7%), and two cases with FMH > 30 ml (0.58%), requiring a supplementary dose of anti-D. The study concludes that following the rosette test, additional evaluation of FMH using a quantitative test was unnecessary in 93.6% of the cases.

Assessment of fetal lung maturity by ultrasound: objective study using gray-scale histogram.

OBJECTIVE: To evaluate lung maturity using ultrasound (US), comparing the subjective and gray-scale histogram (GSH) techniques. METHODS: A total of 77 single pregnancies were evaluated and divided into the following two groups: 11 women of gestational age 28 to 35 + 6 weeks and 66 women ≥ 36 weeks. The women underwent to emergency or planned cesarean section, according to fetal-maternal indications. The US was performed on the mean sagittal plane of the fetal torso, in order to observe the lung and hepatic areas. Fetal lung maturity was evaluated subjectively and through GSH. After delivery, the incidence of respiratory distress in the newborn was evaluated. The analyses were considered to be correct or incorrect, and comparisons were made using the McNemar test. In order to compare lung/hepatic echogenicity using GSH in groups with and without respiratory distress, the Student's t-test was used. RESULTS: The subjective evaluation identified 41 cases (53.2%) correctly and 36 (46.8%) incorrectly, while GSH found 58 (75.3%) correctly and 19 (24.7%) incorrectly (p = 0.006). There was a significant difference in mean lung/hepatic echogenicity between the groups with and without respiratory distress (1.05 versus 1.26; p = 0.002). In the group of 28 to 35 + 6 weeks, GSH presented sensitivity, specificity and accuracy in predicting respiratory distress of 61.9%, 89.1% and 81.6%, respectively. CONCLUSION: The evaluation of fetal lung maturity through GSH was more effective than the subjective method in predicting respiratory distress among newborns.

Associations between cytokine gene polymorphisms and recurrent pregnancy loss.

Since certain cytokines may play a role in unexplained recurrent pregnancy loss (RPL) and also some cytokine gene polymorphisms may affect the level of cytokine production, the aim of the present study was to investigate the relationship between RPL and polymorphisms of the genes coding for TNF-alpha (-308 G-->A), IL-10 (-1082 G-->A), IL-6 (-174 G-->C), and IFN-gamma (+874 A-->T). Genotyping was performed in 48 RPL women and 108 ethnically matched healthy individuals. In addition, we performed a meta-analysis encompassing the present results and those from studies on the association of TNF-alpha, IL-10 and IFN-gamma polymorphisms with RPL published in the literature until December 2001. The results showed: (1) no evidence of association with IL-6 gene polymorphisms; (2) significant associations, revealed by the meta-analysis, with the high cytokine production genotypes of IFN-gamma (+874 T/T: odds ratio (OR)=1.92, P=0.04) and IL-10 (-1082 G/G: OR=1.75, P=0.03), and a trend for association with the high TNF-alpha production genotypes -308 A/A and A/G (OR=1.61; P=0.18). We believe that the associations of these genotypes with RPL are interesting not only as risk factors but also because they represent another piece of evidence that these cytokines might be important in the pathogenesis of RPL.

Cytokines in recurrent pregnancy loss.

Cytokines seem to play a critical role in the pathogenesis of unexplained recurrent pregnancy loss (RPL). Th1 cytokines have been shown to exert deleterious effects on pregnancy, inhibiting foetal growth and development. On the other hand, Th2 cytokines have been associated with successful pregnancy. The purpose of this study was to evaluate cytokine production in women with RPL. The studied group comprised 29 women with RPL, with at least three consecutive spontaneous abortions. The control group included 27 women with a history of successful pregnancies and no miscarriage. We determined IL-6 and TNF-alpha production in peripheral blood cultured with LPS, as well as IFN-gamma and TGF-beta induced by PHA stimulation. Cytokines were measured by enzyme-linked immunoabsorbant assay (ELISA) using commercial kits (RD, Amersham-Pharmacia). Mann-Whitney test was applied to compare differences between groups. The level of significance was defined at P < 0.05. We observed significantly higher levels of IFN-gamma (355.8 pg/ml versus 98.0 pg/ml; P = 0.01) and a trend toward increased TNF-alpha production (2410.2 pg/ml versus1980.2 pg/ml; P = 0.07) in RPL women as compared to controls. In relation to IL-6 and TGF-beta, no significant difference was detected between RPL and control groups. In agreement with experimental observations, our data support the hypothesis of Th1 cytokine involvement in the pathogenesis of RPL.

Meditation in health: an operational definition.

Despite its evergrowing use in health-related areas, procedures characterized as meditation have been little or not at all defined operationally, which hinders its use in a standardized manner. In the present study, the authors present a possible operational definition of meditation, which has been used in social and academic projects, developed in Universidade Federal de São Paulo. In this proposal, it is emphasized that, in order to be characterized as meditation, the procedure should encompass the following requirements: (1) the use of a specific technique (clearly defined), (2) muscle relaxation in some moment of the process and (3) "logic relaxation"; (4) it must necessarily be a self-induced state, and (5) use of "self-focus" skill (coined "anchor").

Antenatal treatment with corticosteroids for preterm neonates: impact on the incidence of respiratory distress syndrome and intra-hospital mortality.

CONTEXT: Although the benefits of antenatal corticosteroids have been widely demonstrated in other countries, there are few studies among Brazilian newborn infants. OBJECTIVE: To evaluate the effectiveness of antenatal corticosteroids on the incidence of respiratory distress syndrome and intra-hospital mortality among neonates with a gestational age of less than 34 weeks. TYPE OF STUDY: Cross-sectional. SETTING: A tertiary-care hospital. PARTICIPANTS: Neonates exposed to any dose of antenatal corticosteroids for fetal maturation up to 7 days before delivery, and newborns paired by sex, birth weight, gestational age and time of birth that were not exposed to antenatal corticosteroids. The sample obtained consisted of 205 exposed newborns, 205 non-exposed and 39 newborns exposed to antenatal corticosteroids for whom it was not possible to find an unexposed pair. PROCEDURES: Analysis of maternal and newborn records. MAIN MEASUREMENTS: The primary clinical outcomes for the two groups were compared: the incidence of respiratory distress syndrome and intra-hospital mortality; as well as secondary outcomes related to neonatal morbidity. RESULTS: Antenatal corticosteroids reduced the occurrence of respiratory distress syndrome (OR: 0.33; 95% CI: 0.21-0.51) and the protective effect persisted when adjusted for weight, gestational age and the presence of asphyxia (adjusted OR: 0.27; 95% CI: 0.17-0.43). The protective effect could also be detected through the reduction in the need for and number of doses of exogenous surfactant utilized and the number of days of mechanical ventilation needed for the newborns exposed to antenatal corticosteroids. Their use also reduced the occurrence of intra-hospital deaths (OR: 0.51: 95% CI: 0.38-0.82). However, when adjusted for weight, gestational age, presence of prenatal asphyxia, respiratory distress syndrome, necrotizing enterocolitis and use of mechanical ventilation, the antenatal corticosteroids did not maintain the protective effect in relation to death. With regard to other outcomes, antenatal corticosteroids reduced the incidence of intraventricular hemorrhage grades III and IV (OR: 0.28; 95% CI: 0.10-0.77). CONCLUSIONS: Antenatal corticosteroids were effective in the reduction of morbidity and mortality among premature newborns in the population studied, and therefore their use should be stimulated within our environment.

[Proteinuria in hypertensive syndrome of pregnancy: maternal and perinatal outcome]. / Proteinúria nas síndromes hipertensivas da gestação: prognóstico materno e perinatal.

AIM: The purpose of this study was to determine the role of proteinuria on pregnancy outcome in hypertensive syndrome with singleon pregnancies. METHODS: Transversal study with retrospective data of 334 pregnancies complicated by hypertensive syndromes who were delivered in the Department of Obstetrics of UNIFESP/EPM from January 1, 1999 to December 31, 2002. RESULTS: The patients were divided into four groups: (I) without proteinuria (n-203); (II) with proteinuria of 0.3 to 1.0g (n-39); (III) 1.0 to 2.0g (n-45); and (IV) 2.0g or more. Without proteinuria there was one case of placental abruption. The presence of proteinuria predicted adverse maternal outcome with increase of complications proportional to his elevation; among them, HELLP syndrome was the most frequent with 30.5% (40/131) followed by eclampsia with 3.8% (5/131), DPP 3.1% (4/131) and renal insufficiency with 0.7% (1/131). It was confirmed one maternal death in that group, when Maternal Mortality of 763/100.000nv was added up. As to the perinatal effects there was not increase of adverse effects without proteinuria. In the presence of proteinuria and its levels was observed the worst perinatal outcome with the elevation of the following indicatives: increase prematurely (62.2% vs 11.5%), newborn with weight < 2500g (6.5% vs 1.5%), newborn with Apgar < 7 in the 5th minute (30.4% vs 3.5%), concepts with growing restriction of intrauterine (41.9% vs 6.5%), newborn interned in the neonatal undid, (59.8% vs 15.5%) stillborn (14.4% vs 1.4%), neonatal deaths (6.1% vs 0.98%). The Perinatal Mortality was greater with proteinúria (175 vs 19,7) and, when = 2.0g (297.8 vs 19.6). CONCLUSIONS: The presence of proteinuria in the hipertensives syndromes during gestation and the elevation of their levels increase the risks of maternal complications, especially HELLP syndromes and eclampsia. Besides, it was observed a significative incidence of premature birth, newborn with Apgar < 7, weight < 2500g, IUGR, stillborn and neonatal deaths.

Values of beta-human chorionic gonadotrofin as a risk factor for tubal pregnancy rupture evaluated by histopathology.

OBJECTIVE: To evaluate the depth of trophoblastic infiltration in tubal wall in ectopic pregnancy (EP) assessed by histopathology and their correlation with initial values of ß-hCG. METHODS: A prospective study including 27 patients with diagnosis of EP was realized. The tubal pregnancies were histologically classified according to the depth of infiltration of trophoblastic tissue on the wall of the tube (stage I: limited to mucosa; stage II: reaching the muscularis layer; stage III: complete infiltration of the tubal wall). The comparison between groups for numeric variables was performed by ANOVA. The receiver operating characteristic (ROC) curve was performed to obtain the cutoff value of ß-hCG associated with the degree of trophoblast invasion into the wall of the tube evaluated by histology. RESULTS: The mean ß-hCG in patients evaluated by histopathology as stage I + II was 2868 mIU/ml and stage III was 11 202 mIU/ml (p = 0.017). ß-hCG levels that best predicted for stage III was 2906 mIU/ml, with a sensitivity of 85.7% and a specificity of 69.2%. CONCLUSION: There is a direct correlation between serum ß-hCG and the depth of trophoblast infiltration of the tube wall at histopathology.

Trophoblastic infiltration in tubal pregnancy evaluated by immunohistochemistry and correlation with variation of Beta-human chorionic gonadotropin.

Objective. To evaluate trophoblastic cell proliferation and angiogenesis in tubal pregnancy assessed by immunohistochemical study and their correlation with an average variation of ß -hCG in an interval of 48 hours before surgery. Methods. A prospective study was conducted on 18 patients with a diagnosis of tubal pregnancy. The patients were divided into two groups of ectopic pregnancy of which 11 showed rise of ß -hCG levels and 7 patients showed declining ß -hCG levels in an interval of 48 hours prior to surgery. Trophoblastic cell proliferation and angiogenesis were assessed by Ki-67 and VEGF, respectively. Trophoblastic cell proliferation was assessed by Ki-67 and was classified into three groups (grade I: less than 1/3 of stained nuclei, grade II: 1/3 to 2/3 of the stained nuclei, and grade III: more than 2/3 of the nuclei stained). The cases analyzed for VEGF were divided into three groups (grade I: less than 1/3 of the stained cytoplasm; grade II: 1/3 to 2/3 of the stained cytoplasm; grade III: more than 2/3 of the stained cytoplasm). Statistical analysis was performed using the chi-square, ANOVA, and Kruskal-Wallis tests. Results. The mean variation in the serum ß -hCG levels in 48 hours in tubal pregnancy patients correlated with trophoblastic cell proliferation assessed by Ki-67 and showed a decline of 13.46% in grade I, a rise of 45.99% in grade II, and ascension of 36.68% in grade III (P = 0.030). The average variation in the serum ß -hCG in 48 hours, where angiogenesis was evaluated by VEGF, showed a decline of 18.35% in grade I, a rise of 32.95% in grade II, and ascension of 37.55% in grade III (P = 0.047). Conclusions. Our observations showed a direct correlation of increased levels of serum ß -hCG in 48h period prior to surgery with higher trophoblastic cell proliferation assessed by Ki-67 and angiogenesis assessed by VEGF in tubal pregnancy.