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.

Association of serum levels of vascular endothelial growth factor and early ectopic pregnancy.

BACKGROUND: This study evaluated serum vascular endothelial growth factor (VEGF) concentrations in women with ectopic pregnancy (EP), miscarriage, and normal pregnancy (NP). MATERIALS AND METHODS: This was a case-control study comparing serum VEGF concentrations among 72 women with ectopic pregnancy (n = 35), miscarriage (n = 15), and normal pregnancy (n = 22) matched for gestational age. For the determination of serum VEGF concentration a solid phase sandwich enzyme-linked immunosorbent assay (ELISA) was used. Patients were stratified according to serum VEGF above or below 200 pg/ml. RESULTS: The serum level of VEGF was significantly higher in women with EP (median 211.1 pg/ml; range 5-1,017.0 pg/ml) than in women with normal pregnancy (median 5 pg/ml; range 5-310.6 pg/ml) p < 0.0001. Serum VEGF concentrations did not show any statistically significant difference between women with miscarriage (median 231.9 pg/ml; range 5-813.7 pg/ml) and EP (median 211.1 pg/ml; range 5-1,017.0 pg/ml). When threshold concentrations of serum VEGF level > 200 pg/ml were used, an EP could be distinguished from a normal pregnancy with a sensitivity of 51.4%, a specificity of 90.9%, and a positive predictive value of 90%. Between EP and miscarriage, the sensitivity was 51.4%, specificity 42.8%, and a positive predictive value of 69.2%. CONCLUSIONS: Serum VEGF could not distinguish an EP from a miscarriage. However, serum VEGF concentrations could discriminate a normal intrauterine pregnancy (IUP) from an unviable pregnancy (EP or miscarriage).

Anti-Lewis alloimmunization: report of seven cases.

OBJECTIVE: The purpose of this study was to investigate the perinatal results of seven pregnant women with anti-Lewis antibodies and evaluate the need to screen for these antigens during routine prenatal care. SETTING: São Paulo Universtity Hospital, São Paulo, Brazil. POPULATION: 200 Rh-negative pregnant women with a positive indirect Coombs test, managed during a 6-year period. METHODS: The charts of all patients were reviewed to collect pertinent data and the variables were analyzed. MAIN OUTCOME MEASURES: Indirect Coombs test titer, intrauterine transfusion, mode of delivery, gestational age at birth, birthweight, neonatal transfusion, duration of neonatal hospitalization and perinatal mortality. RESULTS: All newborn infants were classified as adequate for gestational age at birth and none needed intrauterine or neonatal transfusions. All infants, except one, were discharged in good health on the third day after birth. CONCLUSIONS: Alloimmunized pregnancies (Levis antigens) have good perinatal results.

Pregnancy outcome for Rh-alloimmunized women.

OBJECTIVE: To compare perinatal results of Rh-alloimmunized pregnancies managed with spectrophotometric amniotic fluid analysis or fetal middle cerebral artery Doppler ultrasonographic velocimetry. METHOD: A descriptive observational study involving 291 consecutive Rh-negative pregnancies. Group 1 consisted of 74 isoimmunized women managed with amniotic fluid spectrophotometry; group 2 of 25 isoimmunized women managed with Doppler ultrasonography; and group 3 of 192 nonimmunized Rh-negative women. The variables analyzed were need for intrauterine or neonatal transfusion, mode and time of delivery, birth weight, neonatal hematocrit, and perinatal mortality. RESULTS: Need for intrauterine transfusion, birth weight, prematurity, rate of cesarean section, and perinatal mortality were similar in groups 1 and 2. Neonatal hematocrit was significantly lower and the need for neonatal transfusion was significantly higher when spectrophotometry rather than Doppler ultrasonographic velocimetry was used. CONCLUSION: Fetuses managed with Doppler ultrasonographic velocimetry had a higher hematocrit at birth and a lesser need for neonatal transfusion, suggesting that this noninvasive method of monitoring fetal anemia is a better choice.

Tubal patency after clinical treatment of unruptured ectopic pregnancy.

OBJECTIVE: To evaluate tubal patency using hysterosalpingography after clinical treatment of tubal pregnancy. METHOD: Of 80 patients who underwent hysterosalpingography after clinical treatment of tubal pregnancy from April 1994 to February 2002, 30 were treated with a single 50 mg/m(2) dose of methotrexate intramuscularly (n=30) and 50 were followed up expectantly. RESULTS: 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 and 92% after expectant management. There were no statistically significant differences between the groups. CONCLUSION: Findings from this study suggest similar tubal patency rates after methotrexate treatment and expectant management.

Morphological and morphometric changes in the cervix uteri of the rat at term pregnancy induced by hyaluronidase.

Intracervix injection of hyaluronidase during pregnancy has been proposed to accelerate cervix ripening. We evaluated the morphological and morphometric changes of the uterine cervix of pregnant rats, caused by the action of this enzyme. Ten female rats were equally divided between an experimental group (G II) and a control group (G I). On the 20th day of pregnancy, under light microscopy, a greater thinning of the superficial muciferous epithelium, with lamina propria rich in blood vessels and in eosinophils was found in G II. The histometric count of G II showed a smaller number of collagen fibers (average 248 vs 552 in the control group) and a greater concentration of eosinophils (average 18.20 vs 9.20 in the control group). The Student's t-test showed a significant difference in collagen fibers (p < 0.0001) and in eosinophils (p < 0.0007). The action of this enzyme caused a predominance of flaccid connective tissue, a lower concentration of collagen fibers and an increased concentration of eosinophils, confirming its utilization in cervix ripening.

Detection of fetal fibronectin in twin pregnancies in relation to gestational age.

CONTEXT: The presence of fetal fibronectin in the cervix or vagina has been investigated as a possible marker for the risk of preterm birth. Fetal fibronectin in cervical fluid can provide direct evidence of pathologic changes at the interface of fetal and maternal tissues. OBJECTIVE: To evaluate the presence of fetal fibronectin as a predictor of premature delivery in twin pregnancies in relation to gestational age. DESIGN: Accuracy study. SETTING: University referral unit. PARTICIPANTS: 52 pregnant women with twin pregnancies and gestational age of between 24 and 34 weeks. MAIN MEASUREMENTS: Sensitivity, specificity, predictive values and relative risk ratios of the correlation between fetal fibronectin and preterm birth before 34 and 37 weeks using an immediate-reading membrane test on cervicovaginal secretions obtained from participants. RESULT: The sensitivity varied between 66.7% and 85.7%, whereas the specificity was from 58.3% to 81.8% according to gestational age at the time of sampling. The relative risk of spontaneous preterm birth after a positive fetal fibronectin test, as compared with a negative fetal fibronectin test, rose from 2.8 at 24-26 weeks to 4.1 at 27-30 weeks. Analyses of the risk of delivery before 34 weeks were not statistically significant. CONCLUSION: Fetal fibronectin in the cervicovaginal secretions of patients with twin pregnancies is a useful tool for the early identification of twin pregnancies likely to deliver before 37 weeks. However, the clinical value of the fibronectin test is limited because of low indices for prediction of delivery before 34 weeks. The best period for performing the fetal fibronectin test in twin pregnancies to predict preterm delivery is between 27 and 30 weeks.

Predictive score for the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate.

OBJECTIVE: To evaluate the efficacy of a predictive score for the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate in order to select the best cases for the medical treatment. METHOD: Our study included 40 patients. The inclusion criteria were: hemodynamic stability; adnexal mass < or = 3.5 cm; desire of future pregnancy; and a written permission to participate in the study. All patients were treated with a single dose of methotrexate (50 mg/m2 i.m.). A predictive score was elaborated based on four parameters: initial levels of beta-hCG, aspects of the image at ultrasound (hematosalpinx, tubal ring or live embryo), size of the mass, vascular flow of the color Doppler. Each parameter received a grade from 0 to 2. Grade 0 represented an unfavorable situation, grade 1 a borderline situation and grade 2 a favorable situation. RESULTS: The success rate with a single dose of methotrexate was 75% (30/40). In the present study the cut off grade was 5, because the majority of patients with grade > or = 5 were treated successfully (29/30 - 97%), while those with grade < 5 failed. CONCLUSION: The predictive score helps us to indicate the best cases for the medical treatment. Therefore, we do not advise it when the grade is < 5. However, we can predict a good evolution of the treatment when the grade is > or = 5. Federation of Gynecology and Obstetrics.

Fetal fibronectin as a predictor of preterm delivery in twin gestations.

OBJECTIVE: To evaluate fetal fibronectin as a predictor of premature delivery in twin pregnancies. METHOD: Cervicovaginal secretions were obtained from 52 pregnant women with twin pregnancies between 24 and 34 weeks of gestation. The secretions were analyzed to detect the presence of fetal fibronectin by immediate-reading membrane test. The correlation between the presence of fetal fibronectin and preterm birth was evaluated. In addition, cervical dilatation and effacement were evaluated with each sampling. RESULT: The sensitivity, specificity, positive predictive value and negative predictive value to predict preterm delivery were 89.3, 50.0, 67.6, and 80.0%, respectively. A positive fetal fibronectin result was associated with a relative risk (RR) for preterm birth of 3.4 (95% CI, 1.2-9.5). A positive fetal fibronectin test associated with cervical dilatation or effacement increased the RR for preterm birth to 4.3 and 7.7, respectively, when compared with those with negative test and without cervical dilatation and effacement. CONCLUSION: Fetal fibronectin in the cervicovaginal secretions of patients with twin pregnancies is a sensitive predictor of preterm delivery. However, because of its low specificity, the fetal fibronectin test should be evaluated along with cervical changes for better identification of twins likely to develop preterm labor.

[Evolution of beta-hCG titers after systemic treatment of unruptured ectopic pregnancy]. / Evolução dos níveis de beta-hCG após tratamento sistêmico da gravidez ectópica íntegra.

OBJECTIVE: The follow-up of this treatment is done by monitorization of beta-hCG titers. The objective of this study is to evaluate the beta-hCG titers after treatment with MTX. METHODS: Twenty four women were included in the study. The inclusion criteria were: ectopic pregnancy < or = 4.5 cm, beta-hCG < or = 15.000 mIU/mL, desire of future pregnancy and a written permission to participate in the study. All patients were treated with a single dose of methotrexate (50 mg/m2 IM). Patients were monitored with beta-hCG titers on days 1, 4 and 7 after the MTX injection, and then weekly until the beta-hCG was less than 25 mIU/mL. RESULTS: The variation of the titers of beta-hCG between day 1 and day 4 after MTX was the following: increase 50.0%, decrease 33.3% and in levels less than 25 mUI/mL in 16.7% of the cases. The variation of the titers of beta-hCG between day 4 and day 7 after MTX was the following: decline > or = 15% in 85.7% of the cases, and decline < 15% in 14.3%. There was the necessity of a second dose of MTX in only two cases (8.4%), since the levels of beta-hCG declined less than 15%, in this period. CONCLUSION: The titers of beta-hCG increase in 50.0% of the cases, so it is a frequent event. The understanding of this evolution of beta-hCG titers avoids surgery in the first week of the treatment.

Incidência da mola hidatiforme na Escola Paulista de Medicina / Incidence of hydatidiform mole at the Escola Paulista de Medicina

No período de janeiro de 1980 a dezembro de 1989 foram atendidas na Escola Paulista de Medicina, um centro de referência, 75 pacientes com mola hidatiforme, das quais 65 se submeteram a esvaziamento em nosso serviço, e dez em outros. Para o cálculo da freqüência da mola hidatiforme utilizamos somente as 65 pacientes cujo esvaziamento molar se procedeu na Escola Paulista de Medicina em relaçäo a 13.986 gravidezes (partos, abortos e gravidezes sectópicas) ocorridas no período estudado. Deste modo, a freqüência da mola hidatiforme foi de 1:215 gravidezes, valor comparável aos países asiáticos e africanos

Juvenile dermatomyositis and pregnancy: report and literature review.

Reports of dermatomyositis (DM) and polymyositis complicating pregnancy are rare. Only nineteen cases have been published. We describe the first case in which juvenile DM appeared during pregnancy. An emergency cesarean section had to be performed due to fetal distress at 37 weeks of gestation. Patient and infant are doing well after 8 months of followup.

[Incidence of hydatidiform mole at the Paulista Medical School]. / Incidência da mola hidatiforme na Escola Paulista de Medicina.

Between January 1980 and December 1989, at Escola Paulista de Medicina, a referral centre, 75 patients with hydatiform mole were assisted. The frequency of the hydatiform mole was calculated in 65 patients, whose treatment was performed in our Hospital, out of 13,986 pregnancies, which had occurred in this period of study. Thus, the incidence was 1:215 pregnancies, similar to that found in Asian and African countries.

Perinatal factors associated with neural tube defects (anencephaly [correction of anancephaly], spina bifida and encephalocele).

The objective of the present study was to determine the presence of risk factors for the occurrence of neural tube defects. Data for 33,535 births which occurred at Hospital do Servidor Público Estadual de São Paulo from July 1973 to December 1986 were collected in a prospective manner as recommended by "Estudo Colaborativo Latino-Americano de Malformações Congênitas" (ECLAMC, Collaborative Latin American Study on Congenital Malformations). Twenty-six cases of neural tube defects were detected (0.77/1000 births). Of these, 11 were cases of spina bifida (0.39/1000 births), 9 of anencephaly (0.27/1000 births) and 6 of encephalocele (0.18/1000 births). We observed a higher frequency of polyhydramnios, premature labor, Apgar scores of less than 7 at the first and fifth minutes, low birth weight and intrauterine growth retardation.