Impact of an intrapartum care quality improvement intervention in Brazilian private hospitals on care safety measures and adverse outcomes.

BACKGROUND: In 2015, a quality improvement (QI) intervention to reduce cesarean sections (CS)-the Adequate Childbirth Project (PPA)-was implemented in the private sector in Brazil. This analysis aims to compare safety care measures and adverse outcomes between women exposed to the PPA intervention to those receiving standard care. METHODS: The analysis included a convenience sample of 12 private hospitals that participated in the PPA (2017-2018). Data collection was performed through chart review and interviews. Differences in 15 outcomes were examined using Pearson's chi-square test and multiple logistic regressions. RESULTS: The final weighted sample was comprised of 4789 births, 2570 in the PPA group (53.5%) and 2227 in the standard care group (46.5%). CS rate was significantly lower in the PPA group (67.3% vs 88.8%). After adjusting for potential confounders, PPA model was associated with decreased overall CS rate (OR = 0.30, 95% CI 0.24 to 0.36), as well as prelabor (OR = 0.41, 0.34 to 0.48) and repeated CS (OR = 0.45, 0.29 to 0.70). In terms of other safety care measures, women in the PPA model had an increased chance of absence of antibiotic prophylaxis in Group B Streptococcus (GBS) + women (OR = 4.63, 1.33 to 16.14) and for CSs (OR = 1.75, 1.38 to 2.22), while those with severe hypertension were less likely to not receiving magnesium sulphate (OR = 0.27, 0.09 to 0.77). Regarding obstetric and neonatal outcomes, PPA model was associated with a decreased chance of having an obstetric anal sphincter injury (OASI) following an episiotomy (OR = 0.34, 0.13 to 0.89), requiring antibiotics other than routine prophylaxis (OR = 0.84, 0.70 to 0.99), having a late preterm (OR = 0.36, 0.27 to 0.48) or early term baby (OR = 0.81, 0.70 to 0.94). There were no statistically significant differences for other outcomes. CONCLUSIONS: The PPA intervention was able to reduce CS rates, late preterm and early term deliveries without increasing the chance of adverse outcomes. The bidirectional effect on safety care measures reinforces that QI initiatives includes closer observation of routine care when implementing interventions to reduce C-section rates.

Cesarean section rates in Brazil are among the highest in the world, particularly in private hospitals. In 2015, a quality improvement project was implemented in private hospitals aiming to reduce the cesarean section (CS) rates (the Adequate Childbirth Project­PPA). In the 2017­2018 period, the Healthy Birth Study (HBS) was proposed to assess the effect of the PPA project in CS rates, as well as use of obstetric interventions, adoption of good practices during labor and birth care and outcomes for both women and their babies. This article presents the comparison of 4873 births analyzed in the HBS, 2589 who were exposed to the PPA project and 2284 who received standard care. The analysis aim was to compare CS rates at the same time to assess if women who were part of the PPA intervention were less likely to have a negative event for themselves or their babies. A group of 15 measures of safety of obstetric care and negative outcomes for women and their babies was compared. Women who were exposed to the PPA intervention had a lower chance of CS, late preterm and early term deliveries. At the same time, the PPA group did not have worse outcomes for women or babies. In terms of safety care, the PPA intervention was associated with both positive and negative effects. For instance, women exposed to the PPA group had a higher chance of not receiving antibiotics to prevent infections when they needed, when compared to standard care.

Fetal giant liver hemangioma: Ultrasound, magnetic resonance imaging, three-dimensional reconstruction findings and perinatal outcomes of two cases.

In this case report, we present two cases of fetal liver giant hemangioma assessed using ultrasound, magnetic resonance imaging and three-dimensional reconstructions with their respective postnatal outcomes.

Venolymphatic malformations: prenatal diagnosis using magnetic resonance imaging, perinatal outcomes and long-term follow-up.

BACKGROUND: Venolymphatic malformations are benign. Fetal MRI can more precisely demonstrate an infiltrative pattern of malformations than US. OBJECTIVE: To evaluate perinatal outcomes and long-term follow-up of fetal venolymphatic malformations treated in different medical facilities using fetal MRI. MATERIALS AND METHODS: This retrospective cohort study evaluated 20 pregnant women between 22 weeks and 37 weeks of gestation who were referred from different institutions. They presented with fetuses with various diagnoses of cystic masses on routine US. The cases were studied using MRI. We analyzed prenatal data, perinatal outcomes and long-term follow-up. RESULTS: We reviewed the MRI scans of 20 patients with venolymphatic malformation. Referral diagnosis was changed in 40% (8/20) of cases, with postnatal concordance of 100% (20/20). Moreover, 65% (13/20) presented with venolymphatic malformation in more than one body segment. The neck was affected in 70% (14/20) of fetuses, while the head and thorax were affected in 30% (6/20) and 45% (9/20), respectively. There were intrathoracic lesions in 35% (7/20), lesions in the abdomen in 30% (6/20), and lesions in the perineum and extremities in 10% (2/20) each. Tracheal displacement, neck deflection and anatomical displacement caused by tumoral compression were present in 15% (3/20) of cases. Moreover, 25% (5/20) of newborns required neonatal intensive care unit admission, and all presented with cervical or thoracic venolymphatic malformation. Furthermore, 50% (10/20) of cases presented with complete resolution after medical therapy. The intrathoracic and cervical residuals (35%, 7/20) were monitored and treated. CONCLUSION: MRI showed good correlation with postnatal examination of venolymphatic malformation, was useful in the differential diagnosis of fetal cysts on US, and presented a significant postnatal correlation with thoracic infiltration. The outcomes of prenatally diagnosed venolymphatic malformations are good despite the varying protocols among medical facilities.

Pregnancy-induced hypertension, preterm birth, and cord blood adipokine levels.

Maternal hypertension may alter physiological parameters, dysregulating the release of hormones such as adipokines, thus influencing the fetal growth course. This study investigated whether hypertensive disorders of pregnancy alter cord blood adipokine levels and correlate these with anthropometric parameters in preterm infants. This is a prospective cohort study with pregnant women < 37-week gestation with and without hypertension and their offspring. Cord blood leptin, adiponectin, and ghrelin were analyzed by LUMINEX®. These adipokines were compared between the groups exposed or not to gestational hypertension using non-parametric statistical tests. The hypertensive pregnancies had significantly higher cord blood leptin (1.00 (IQR 0.67-1.20 ng/mL)) and adiponectin (18.52 (IQR 17.52-25.13 µg/mL)) levels than those without hypertension (0.07 (IQR 0.06-0.08 ng/mL) and 8.13 (IQR 6.50-8.68 µg/mL), respectively, p < 0.0001). The adipokine levels were higher in AGA and SGA infants in the exposed group for both moderate and late preterm. SGA had significantly higher ghrelin levels than the AGA infants. Ghrelin levels were negatively correlated with birth weight (r = - 0.613, p < 0.001), birth length (r = - 0.510, p < 0.001), head circumference (- 0.346, p < 0.002), and gestational age (r = - 0.612, p < 0.001).Conclusions: Our findings demonstrate an increase in adipokine levels in the cord blood of preterm newborn infants exposed to maternal hypertension. What is Known: • Clinical evidence suggests that concentration of the serum adipokines may be affected by risk of hypertension in both adults and pregnant women. • Maternal profile as hypertension alters intrauterine environment and could affect the function of fetal metabolism, impairing fetal growth. What is New: • Gestational hypertension modifies the adipokine profile, with higher rates already present at birth in cord blood samples. • Within the hypertensive group and stratifying for gestation age, ghrelin concentrations were higher in SGA newborns, both in the moderate and late preterm, compared with AGA newborns.

3D Virtual Broncoscopy before FETO Procedure in a Fetus with Severe, Isolated Left Congenital Diaphragmatic Hernia.

INTRODUCTION: Congenital diaphragmatic hernia (CDH) is a life-threatening event in severe forms and fetuses affected may benefit from in utero treatment by fetoscopic endotracheal occlusion (FETO). MATERIALS AND METHODS: Application of 3D virtual bronchoscopy in a case of severe, isolated, left CDH before performing FETO procedure at 27 week's gestation is reported. RESULTS: The 3D virtual imaging of the fetal trachea was technically useful in planning the real FETO procedure. FETO successfully promoted fetal lung growth by decreasing the herniation of abdominal organs into the thorax and decreasing the risk of pulmonary hypoplasia. Ultrasound calculation of lung to head ratio (LHR) and fetal-MRI were used to assess lung development following FETO procedure. CONCLUSION: 3D virtual fetal reality enabled the fetal surgeon to review and navigate on demand inside the upper airway, reducing the risk of unexpected intervention complications.

3D ultrasonography to evaluate fetal urinary production rates in twin gestation: construction of a normal value curve.

OBJECTIVE: The aim of this study was to assess fetal urinary production rates (FUPR) in twin gestations using 3D ultrasonography with VOCAL® (virtual organ computer-aided analysis) and to develop a curve of normal values for the target population. METHODS: A cross-sectional study was performed in 30 normal twin pregnancies with gestational ages ranging from 20 to 34 weeks. FUPR was measured using a three-dimensional ultrasound (3D US) virtual organ computer-aided analysis (VOCAL) system. FUPR (ml/hour) was calculated during the filling phase using the equation UPR = (VFB(2) - VFB(1))/time. The values for UPR were plotted as a function of fetal biometry (biparietal diameter) to generate a nomogram. RESULTS: A total of 41 normal twin fetuses with gestational ages between 20 and 34 weeks were investigated. Eleven were excluded because of inadequate bladder contour image quality and/or the observation of micturition in one or both fetuses. Linear regression analysis of FUPR as a function of biparietal diameter (BPD) shows the normal range for UPR by fetal biometry and is expressed by the following equation: Ln(UPR) = -5.0121 + 0.0548 BPD (R(2) 0.3386, p value <.001). There was no statistically significant difference when the UPR was stratified by chorionicity. CONCLUSIONS: The use of biometric parameters to predict fetal FUPR seems to be useful. In twin pregnancies, BPD is the variable that is most closely related to FUPR. For each 1 mm increase in BPD, there is a 5% increase in FUPR. Chorionicity did not affect FUPR.

Effects of osteopathic manipulative treatment on maternal-fetal hemodynamics in third trimester pregnant women: A prospective study.

OBJECTIVE: To evaluate the maternal-fetal hemodynamic effects after osteopathic manipulative treatment by measuring vital signs and Doppler velocimetry in third-trimester pregnant women. MATERIALS AND METHODS: This is a prospective study with pregnant women undergoing outpatient follow-up and hospitalized in a ward at Instituto Fernandes Figueira/Fiocruz, between August 2021 to August 2022, during the SARS-CoV-2 pandemic. This study was registered in REBEC under Register Number RBR-9q7kvg and approved by the ethics committee under number 32216620.0.0000.5269. The study population was composed of 51 pregnant women between 28 and 40 weeks of gestation, over 18 years of age, allocated in a single group. Pregnancies with multiple fetuses, malformations, premature rupture of the membrane, and active labor were excluded. The procedures evaluated maternal-fetal hemodynamics using three consecutive measures of ultrasound examination with Doppler velocimetry, and three maternal vital signs measured by an electronic blood pressure monitor. RESULTS: Most vital signs changed after osteopathic treatment. However, only the systolic blood pressure (109.92 ±14.42 to 110.71±12.8, p = 0.033), diastolic blood pressure (79.8±11.54 to 77.57±9.44, p = 0.018) and heart rate (87.59±11.93 to 81.12±10.26, p = 0.000) in the sitting position, systolic blood pressure (110.75±13.26 to 108.59±13.07; p = 0.034) in the supine, and heart rate (83.22±11.29 to 80.39±11.0; p = 0.013) in left lateral decubitus reached statistical significance. The oximetry measures (98.55±0.64 to 98.67±0.68; p = 0.098) stayed stable during all three positions. All artery values remained stable after treatment, and no statistically significant difference was recorded in the artery results. CONCLUSION: Responses to osteopathic treatment in women in the third trimester of pregnancy did not affect uteroplacental and fetoplacental circulation. However, some maternal vital signs had statistically significant results, with a decrease in diastolic blood pressure and heart rate, and an increase in systolic blood pressure in the sitting position, a decrease of heart rate in the left lateral decubitus position, and systolic blood pressure in the supine position. All the results observed were maintained in the normal parameters. The study responses attest to the safety of using the osteopathic manipulative treatment for the fetus and for pregnant women with comorbidities.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study.

Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical (AU) e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Normal range for fetal urine production rate customized by biometry.

OBJECTIVE: The aim of this study was to develop a nomogram for fetal urine production (UPR) using biometric parameters. METHODS: A cross-sectional study was performed in 110 normal singleton fetuses with gestational ages ranging from 20 to 40 weeks. UPR was measured using tridimensional ultrasound (3-DUS) virtual organ computer-aided analysis. UPR (ml/h) was calculated during the filling phase using the equation, UPR = (VFB2-VFB1)/time. The values for UPR were plotted as a function of fetal biometry (femur, humerus, abdominal circumference, and head circumference and biparietal diameter) to obtain a nomogram for each parameter. RESULTS: A total of 110 normal singleton fetuses with gestational age between 20 and 40 weeks were investigated. Five of them were excluded because the image quality was insufficient for correct visualization of the bladder contour. Linear regression analysis of UPR as a function of femur, humerus, abdominal circumference, and head circumference and biparietal diameter generated curves that represents the normal range for UPR by fetal biometry, and expressed by the following equations: (1) Humerus length (HL): ln (UPR) = -5.9546 + 0.0958 × HL (mm); (R(2) 0.6422); (2) abdominal circumference: ln (UPR) = -1.0981 + 0.158 × AC (mm); (R(2) 0.6328); (3) femur length: ln (UPR) = -1.5133 + 0.0803 × FL (mm); (R(2) 0.6611); (4) biparietal diameter ln (UPR) = -7.8779 + 0.2368 × BPD-0.0012 × DBP(2); (R(2) 0.7066). Although BPD has the highest correlation coefficient (R(2) 0.7066) there was no statistical significant difference between the parameters investigated for UPR prediction. CONCLUSION: The use of biometric parameters for prediction of fetal UPR seems to be useful and can avoid the necessity of building local nomograms for different populations. The same strategy should be considered to other fields in fetal medicine.

Influence of Osteopathic Manipulative Treatment on the Quality of Life and the Intensity of Lumbopelvic Pain in Pregnant Women in the Third Trimester: A Prospective Observational Study.

During pregnancy, the various changes women undergo can affect their health status. Manual therapies are important aids because they do not use medication. This study aimed to evaluate the influence of osteopathic manipulative treatment on the intensity of lumbar and pelvic pain and changes in quality of life. This prospective study included women over 18 years old and between 27 and 41 weeks pregnant, and excluded women with fetal malformations, multiple fetuses, premature rupture of membranes, and in labor. Forty-six pregnant women were selected and divided into two groups of ≤3 and ≥4 visits. Statistically significant improvements were observed in the intensity of maximum low back pain (7.54 ± 1.47 vs. 3.815 ± 1.73, p ≤ 0.01) and minimum low back pain (5.67 ± 2.03 vs. 3.111 ± 1.67, p ≤ 0.01), maximum pelvic pain (6.54 ± 2.22 vs. 2.77 ± 1.64, p = 0.01), and minimum pelvic pain (5.615 ± 2.21 vs. 2.615 ± 1.66, p = 0.01). Both groups achieved improvements in quality of life indices, with the improvements achieved by the ≥4-visits group being statistically significant. Osteopathic treatment was effective in reducing the intensity of lumbar and pelvic pain and in improving the quality of life of pregnant women in the third trimester.

Effects of intra-abdominal hypertension on maternal-fetal outcomes in term pregnant women: A systematic review.

OBJECTIVE: To carry out a systematic review to assess the effects of intra-abdominal hypertension on maternal-fetal outcomes. METHODS: The search was carried out between 28th June to 4th July 2022 on the Biblioteca Virtual em Saúde, Pubmed, Embase, Web of Science, and Cochrane databases. The study was registered in PROSPERO (CRD42020206526). The systematic review was performed according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. To assess the methodological quality and control the risk of bias, New Castle was used. RESULTS: A total of 6203 articles were found. Of these, 5 met the selection criteria for a full reading. The selected studies included a total of 271 pregnant women, of which 242 underwent elective cesarean section and measurement of intra-abdominal pressure via a bladder catheter. In both pregnant women groups, the lowest intra-abdominal pressure values were found in the supine position with left lateral tilt. Prepartum values in normotensive women with singleton pregnancy (7.3±1.3 to 14.1 ± 1 mmHg) were lower than in gestational hypertensive disorders (12.0±3.3 to 18.3±2.6 mmHg). In postpartum, the values decreased in both groups but were even lower in normotensive women (3.7±0.8 to 9.9 ± 2.6 mmHg vs 8.5 ± 3.6 to 13.6 ± 3.3 mmHg). The same was true for twin pregnancies. The Sequential Organ Failure Assessment index ranged from 0.6 (0.5) to 0.9 (0.7) in both groups of pregnant women. The placental malondialdehyde levels were statistically (p < 0.05) higher in pregnant women with pre-eclampsia (2.52±1.05) than normotensive (1.42±0.54). CONCLUSIONS: Prepartum intra-abdominal pressure values in normotensive women were close or equal to intra-abdominal hypertension and compatible with gestational hypertensive disorders even in the postpartum period. IAP values were consistently lower in supine position with lateral tilt in both groups. Significant correlations were found between prematurity, low birth weight, pregnant women with hypertensive disorders, and increased intra-abdominal pressure. However, there was no significant association of dysfunction in any system in the relationship between intra-abdominal pressure and Sequential Organ Failure Assessment. Despite the higher malondialdehyde values in pregnant women with pre-eclampsia, the findings were inconclusive. Given the observed data on maternal and fetal outcomes, it would be recommended that intra-abdominal pressure measurements be standardized and used as a diagnostic tool during pregnancy. TRIAL REGISTRATION: PROSPERO registration: October 9th, 2020, CRD42020206526.

Prenatal diagnosis of Pallister-Hall syndrome: ultrasound, magnetic resonance imaging, and three-dimensional reconstructions of phenotypical findings.

Pallister - Hall syndrome is a rare malformation that involves the presence of a suprasellar hamartoma and associated malformations. Prenatal diagnosis is also rare, and few cases have been reported using magnetic resonance imaging (MRI). A 35-year-old G5P2A2 woman at the 35th week of gestation was referred to our service. Fetal MRI showed an isointense image in the suprasellar region, pushing the brainstem up and backward, and compressing the vermis and cerebellum on T2-weighted images. On T1-weighted images, the hypointense signal of the tumor was similar to that of the brain parenchyma. Ultrasound images showed a suprasellar mass, which was more echogenic than the normal cerebral parenchyma, posteriorly pushing the brain stem, with involvement of the vermis of the tumor and compression of the posterior fossa. Three-dimensional reconstruction using MRI scan data showed a space view of the tumor and its relationships with the other brain tissues allowing better understanding by parents and multidisciplinary team.

Prenatal diagnosis of rhabdoid tumor: Ultrasound, magnetic resonance imaging, 3D reconstruction and review of the literature.

Extrarenal tumors are rare malignant tumors and generally are lethal when diagnosed during the pregnancy. Some reports described this condition, using ultrasound. In this report, we describe the prenatal characteristics of an extrarenal rhabdoid tumor, evaluated by ultrasound, magnetic resonance imaging (MRI), and three-dimensional (3D) reconstructions. This report describes the longest period between prenatal diagnosis and delivery of a fetus affected by extrarenal tumor, compares the imaging technologies used during and after the pregnancy and discuss the results of the prenatal study compared to the postnatal images, an important information for parental counseling.

Historical Clinical Outcomes of Children with Myelomeningocele Meeting the Criteria for Fetal Surgery: A Retrospective Cohort Survey of Brazilian Patients.

OBJECTIVE: To analyze the historical clinical outcomes of children with myelomeningocele (MMC) meeting the criteria for fetal surgery, but who underwent postnatal primary repair. METHODS: Data from children undergoing postnatal MMC repair between January 1995 and January 2015 were collected from the Neurosurgery Outpatient Clinic's medical records. Children were included if they had ≥ 1 year of postoperative follow-up and met the criteria for fetal surgery. The children's data were then stratified according to whether they received a shunt or not. The primary outcome was mortality, and secondary outcomes were educational delays, hospitalization, recurrent urinary tract infections (UTIs), and renal failure. RESULTS: Over the 20-year period, 231 children with MMC were followed up. Based on clinical data recorded at the time of birth, 165 (71.4%) qualify of fetal surgery. Of the 165 patients, 136 (82.4%) underwent shunt placement. The mortality rate was 5.1% in the group with shunt and 0% in the group without, relative risk (RR) 3.28 (95% confidence interval, 95% CI, 0.19-55.9). The statistically significant RRs for adverse outcomes in the shunted group were 1.86 (95% CI, 1.01-3.44) for UTI, 30 (95% CI, 1.01-537) for renal failure, and 1.77 (95% CI, 1.09-2.87) for hospitalizations. CONCLUSION: Children with MMC qualifying for fetal surgery who underwent shunt placement were more likely to have recurrent UTIs, develop renal failure, and be hospitalized. Since approximately half of the shunt procedures could be avoided by fetal surgery, there is a clinical benefit and a possible financial benefit to the implementation of this technology in our setting.

OBJETIVO: Analisar os resultados clínicos históricos de crianças com mielomeningocele (MMC) com critérios para cirurgia fetal, mas que foram submetidas a cirurgia pós-natal. MéTODOS: Dados de crianças submetidas à correção de MMC pós-natal entre janeiro de 1995 e janeiro de 2015 foram coletados nos prontuários do Ambulatório de Neurocirurgia. Foram incluídas crianças se tivessem ≥ 1 ano de acompanhamento pós-operatório e atendessem os critérios para cirurgia fetal. As informações dessas crianças foram então estratificadas de acordo com se receberam ou não derivação do líquido cefalorraquidiano. O desfecho primário foi a mortalidade e os desfechos secundários foram atrasos educacionais, hospitalização, infecções recorrentes do trato urinário e insuficiência renal. RESULTADOS: Durante o período de 20 anos, 231 crianças com MMC foram acompanhadas. Com base nos dados clínicos registrados no momento do nascimento, 165 (71,4%) atendiam critérios para a cirurgia fetal. Dos 165 pacientes, 136 (82,4%) foram submetidos à colocação de derivação do líquido cefalorraquidiano. A taxa de mortalidade foi de 5,1% no grupo com derivação do líquido cefalorraquidiano e 0% no grupo sem risco relativo (RR) 3,28 (intervalo de confiança 95%, IC 95%, 0,19­55,9). Os RRs estatisticamente significativos para resultados adversos no grupo com derivação do líquido cefalorraquidiano foram 1,86 (IC 95%, 1,01­3,44) para infecção do trato urinário, 30 (IC 95%, 1,01­537) para insuficiência renal e 1,77 (IC 95%, 1,09­2,87) para hospitalizações. CONCLUSãO: Crianças com MMC com critérios para cirurgia fetal submetidas à colocação de derivação do líquido cefalorraquidiano eram mais propensas a ter infecções recorrentes do trato urinário, desenvolver insuficiência renal e serem hospitalizadas. Como aproximadamente metade dos procedimentos de derivação poderiam ser evitados por cirurgia fetal, há um benefício clínico e um possível benefício financeiro com a implementação dessa tecnologia em nosso meio.

Normal range for fetal urine production rate by 3-D ultrasound in Brazilian population.

OBJECTIVE: The aim of the present study was to establish the normal range for fetal UPR in the Brazilian population. METHODS: A cross-sectional study was performed in 167 normal singleton fetuses with gestational ages ranging from 20 to 40 weeks. UPR was measured using 3-D US virtual organ computer-aided analysis (VOCAL). UPR (in ml/h) was calculated during the filling phase by using the equation UPR = (VFB(2) - VFB(1))/time. The values for UPR were plotted as a function of gestational age to obtain a nomogram. Interobserver reliability was also investigated by using Spearman's rank correlation for comparison of paired samples in cases of replication between observers. Bland and Altman's graphical approach was utilized to investigate the agreement between observers. RESULTS: A total of 167 normal singleton fetuses with gestational age between 20 and 40 weeks were investigated. Nine of them were excluded because the image quality was insufficient for correct visualization of the bladder contour. Linear regression analysis of UPR as a function of gestational age generated a curve that represents the normal range for fetal UPR in the Brazilian population, and is expressed by the equation: Ln (UPR) = -13.7508 + 0.7094 × GA - 0.0092 × GA(2) (R (2) 0.60). A correlation coefficient of 0.9994 (Spearman) was obtained. Bland and Altman's graphic plots confirm the significant agreement between observers. CONCLUSION: Small differences were observed between the values for UPR observed in our sample and the normal values described in previous studies. These differences were observed mainly in late third trimester and are probably related to population biometric differences.

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

STUDY OBJECTIVE: To assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance. METHODS: This preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail. RESULTS: Preoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P < .001) by 3 points or more in 75.8% (95%CI: 64.7-86.2) and disappeared totally in 59.7% of cases (95%CI:47.8-71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0-10.7) and the probability of a woman with no DDyspareunia developing "de novo" moderate or severe DDyspareunia was 7.7% (95%CI: 1.8-15.8) and 5.8% (95%CI: 0.0-13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region. CONCLUSION: Endometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.

Prognostic factors of death in children during the first year of life due to congenital diaphragmatic hernia: analysis of a hospital cohort from 2005 to 2015.

OBJECTIVE: To describe and analyze the prognosis of children during the first year of life with a diagnosis of congenital diaphragmatic hernia admitted between the years 2005 and 2015 in the Neonatal Intensive Care Unit. METHOD: In a retrospective cohort, 129 children with a diagnosis of congenital diaphragmatic hernia were studied. The prognostic factors were analyzed, whereupon prenatal, delivery, and postnatal exposure variables were associated with death during the first year of life. The odds ratio and the confidence interval (95% CI) were calculated for all the studied variables, using the chi-squared test and Student's t-test. RESULTS: The study included 129 children hospitalized from January of 2005 to December of 2015. Seventy-nine (61%) patients died, 50 survived, and 33 had other associated malformations. Among the prognostic factors, the following were significant and increased the chance of death: polyhydramnios (p=0.001), gestational age of the earliest diagnosis (p=0.004), associated congenital abnormalities (OR: 3.013, p=0.022), pO2 of the first gasometry (p=0.000), pCO2 of the first gasometry (p=0.000), presence of pulmonary hypoplasia (OR: 3.074, p=0.000), use of preoperative vasoactive drugs (OR: 2.881, p=0.000), and use of nitric oxide (OR: 1.739, p=0.000). The presence of only intestines in the hernia content was a protective factor (OR: 0.615, p=0.001). CONCLUSION: The mortality in the first year of life in patients with congenital diaphragmatic hernia in this study was 61% in the years 2005-2015. Among the prognostic factors that demonstrated a significant effect, pulmonary hypoplasia had the greatest impact.

Prenatal diagnosis of Pentalogy of Cantrell in the first trimester: is 3-dimensional sonography needed?

We report the prenatal diagnosis of 2 cases of Pentalogy of Cantrell in the first trimester. In case 1, sonographic evaluation revealed ectopia cordis, omphalocele, and cystic hygroma at 10 weeks' gestation. In case 2, sonographic assessment during the first trimester detected ectopia cordis and omphalocele at 11 weeks' gestation. In both cases, the patient opted for elective pregnancy termination, and Pentalogy of Cantrell was confirmed in 2 male fetuses. We discuss the role of Doppler imaging and 3-dimensional sonography as complementary methods to conventional sonographic assessment of abdominal wall defects at early pregnancy.

Sonographic findings in a case of tetrasomy 9p associated with increased nuchal translucency and Dandy-Walker malformation.

We report a case of a 23-year-old pregnant woman, who underwent amniocentesis after ultrasound (US) examination in the first trimester which revealed a nuchal translucency thickness of 2.9 mm. Cytogenetic analysis revealed complete tetrasomy of the short arm of chromosome 9. Further US evaluation in the second trimester revealed Dandy-Walker malformation, ventriculomegaly, bilateral clubfoot, lip and palate clefts, arthrogryposis and hyperechoic kidneys with bilateral pelvic dilatation. At 30 weeks of gestation, a placental abruption was noted and a Cesarean section was performed. The infant died shortly after birth. A review of previous cases of tetrasomy 9p shows that the remarkable sonographic findings are ventriculomegaly, intrauterine growth restriction, genitourinary anomaly, Dandy-Walker malformation, cleft lip/palate and limb malformation, but the association of tetrasomy 9p and increased nuchal translucency had not been reported.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study / Efeitos do corticoide antenatal na hemodinâmica fetal: um estudo longitudinal

Abstract Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Resumo Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.