Intervenções psicológicas necessárias: a prática como residente no serviço de medicina fetal / Necessary psychological interventions: the practice as a resident in the fetal medicine service / Intervenciones psicológicas necesarias: la práctica como residente en el servicio de medicina fetal

Com os avanços tecnológicos e o aprimoramento da prática médica via ultrassonografia, já é possível detectar possíveis problemas no feto desde a gestação. O objetivo deste estudo foi analisar a prática do psicólogo no contexto de gestações que envolvem riscos fetais. Trata-se de um estudo qualitativo sob formato de relato de experiência como psicólogo residente no Serviço de Medicina Fetal da Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ). Os registros, feitos por observação participante e diário de campo, foram analisados em dois eixos temáticos: 1) intervenções psicológicas no trabalho em equipe em consulta de pré-natal, exame de ultrassonografia e procedimento de amniocentese; e 2) intervenções psicológicas em casos de bebês incompatíveis com a vida. Os resultados indicaram que o psicólogo nesse serviço é essencial para atuar de forma multiprofissional na assistência pré-natal para gravidezes de alto risco fetal. Ademais, a preceptoria do residente é relevante para sua formação e treinamento para atuação profissional no campo da psicologia perinatal.(AU)

Face to the technological advances and the improvement of medical practice via ultrasound, it is already possible to detect possible problems in the fetus since pregnancy. The objective of this study was to analyze the psychologist's practice in the context of pregnancies which involve fetal risks. It is a qualitative study based on an experience report as a psychologist trainee at the Fetal Medicine Service of the Maternity School of UFRJ. The records, based on the participant observation and field diary, were analyzed in two thematic axes: 1) psychological interventions in the teamwork in the prenatal attendance, ultrasound examination and amniocentesis procedure; and 2) psychological interventions in cases of babies incompatible to the life. The results indicated that the psychologist in this service is essential to work in a multidisciplinary way at the prenatal care for high fetal risk pregnancies. Furthermore, the resident's preceptorship is relevant to their education and training for professional performance in the field of Perinatal Psychology.(AU)

Con los avances tecnológicos y la mejora de la práctica médica a través de la ecografía, ya se puede detectar posibles problemas en el feto desde el embarazo. El objetivo de este estudio fue analizar la práctica del psicólogo en el contexto de embarazos de riesgos fetal. Es un estudio cualitativo basado en un relato de experiencia como residente de psicología en el Servicio de Medicina Fetal de la Escuela de Maternidad de la Universidade Federal do Rio de Janeiro (UFRJ). Los registros, realizados en la observación participante y el diario de campo, se analizaron en dos ejes temáticos: 1) intervenciones psicológicas en el trabajo en equipo, en la consulta prenatal, ecografía y los procedimientos de amniocentesis; y 2) intervenciones psicológicas en casos de bebés incompatibles con la vida. Los resultados señalaron como fundamental la presencia del psicólogo en este servicio trabajando de forma multidisciplinar en la atención prenatal en el contexto de embarazos de alto riesgo fetal. Además, la tutela del residente es relevante para su educación y formación para el desempeño profesional en el campo de la Psicología Perinatal.(AU)

Real-world pharmacological treatment patterns of patients with threatened miscarriage in China from 2014 to 2020: A cross-sectional analysis.

WHAT IS KNOWN AND OBJECTIVE: Approximately half of the patients with threatened miscarriage suffer an abortion, and consistent medication therapy to prevent threatened miscarriage is lacking. Our goal was to investigate the real-world pharmacological treatment patterns of patients with threatened miscarriage in China, with a focus on the trend and rationality of progestogen use over the last 7 years. METHODS: We performed a cross-sectional analysis of data from the Hospital Prescription Analysis Cooperation Project that is overseen by the Chinese Pharmaceutical Association. Information was extracted from prescriptions of outpatients with threatened miscarriage between January 2014 and December 2020. We quantified the types of medications using the first level anatomical therapeutic chemical (ATC) classification code and the frequency of use of medicines classified as category X by the United States Food and Drug Administration (FDA). We also calculated the prevalence of the most frequently used progestogens by assessing prescription rates, determined the sum of the defined daily doses (DDDs) and defined daily cost (DDC) and evaluated the rationality of progestogens according to drug labels and guidelines. RESULTS AND DISCUSSION: Of the 91,464 patients included in this study, 69.4% were from the eastern region, 92.5% were from tertiary hospitals, and 72.9% were between 25 and 34 years old. The average number of medications per patient was 1.4. The following types of medicines were the most prevalent: "genitourinary system and sex hormones" (90.7%), "alimentary tract and metabolism" (10.8%) and "blood and blood-forming organs" (9.9%). Progestogens were prescribed for 81,080 patients (88.6%), among which oral progesterone (39.7%) was the most commonly used, followed by oral dydrogesterone (34.4%), progesterone injection (26.0%), oral allylestrenol (0.7%) and progesterone gel (0.4%). In other words, 10,991 (12.0%) patients used more than one progestogen, and the top three combinations were oral dydrogesterone plus progesterone injection (5.6%), oral progesterone plus progesterone injection (4.7%) and oral dydrogesterone plus oral progesterone (1.1%). The prescription rate of dydrogesterone increased gradually, whereas that of progesterone, especially progesterone injection, obviously decreased. Among 34,760 prescriptions of progestogens with complete usage information, the primary errors of progestogen use were "low frequency" (18.4%), "high single dose" (15.9%) and "low single dose" (11.3%). In addition, 137 prescriptions were identified with drug-progestogen interactions, and 61 were identified with contraindications for progestogens. A total of 4.5% of prescriptions included FDA category X medicines. WHAT IS NEW AND CONCLUSION: Our findings are the first to provide information on medication use in patients with threatened miscarriage over the last seven years in China. Medicines targeting the "genitourinary system and sex hormones," especially progestogens, were the most commonly prescribed medications, among which dydrogesterone was the most prevalent. However, it is remarkable that the use of progestogens for the treatment of threatened abortion is still controversial; thus, high-quality large sample studies are still required, especially among Chinese patients. Since usage errors in progestogen records and exposure to category X medicines were common, more efforts are needed to guarantee the safety and rationality of medicines used in pregnant women.

Doppler and biochemical assessment for the prediction of early pregnancy outcome in patients experiencing threatened spontaneous abortion.

OBJECTIVE: To evaluate the usefulness of Doppler indices of the corpus luteum and uterine artery in combination with serum progesterone and cancer antigen 125 (CA125) as prognostic tools in first-trimester threatened spontaneous abortion. METHODS: Pregnant women with threatened spontaneous abortion at a pregnancy duration 8-10 weeks were enrolled into an observational prospective clinical trial at a university hospital in Egypt during 2015. Doppler indices (uterine artery/corpus luteum resistance index and pulsatility index) and biochemical markers (CA125, progesterone) were determined and compared by pregnancy outcome (spontaneous abortion vs continuing pregnancy at 20 weeks). RESULTS: Of 100 women included, 16 had a spontaneous abortion. These women had a higher CA125 value than did women without an abortion (P<0.001), whereas the progesterone level among women with an abortion was lower (P<0.001). The Doppler indices were not significantly different between the groups, but calculation of the uterine artery resistance index as a percentage of the normal standard value at a given pregnancy duration revealed significant differences (P<0.001) between the two groups. CONCLUSION: Serum progesterone and CA125 are useful provisional predictors of spontaneous abortion, whereas the Doppler indices are not. The two biomarkers could be used as a basis to counsel anxious couples. CLINICALTRIALS.GOV: NCT02420769.

Threatened preterm labour: Women's experiences of risk and care management: A qualitative study.

BACKGROUND: Preterm birth is a major cause of neonatal death and severe morbidity, so pregnant women experiencing symptoms of threatened preterm labour may be very anxious. The risk assessment and management that follows recognition of threatened preterm labour has the potential to either increase or decrease this anxiety. The aim of this study was to explore women's experience of threatened preterm labour, risk assessment and management in order to identify potential improvements in practice. DESIGN: One-to-one semi-structured interviews with 19 women who experienced assessment for threatened preterm labour took place between March 2015 and January 2017. A purposive sample approach was employed to ensure participants from different risk and demographic backgrounds were recruited at an inner city UK NHS hospital. Interviews were recorded and transcribed. Data was managed with NVivo software and analysed using the Framework Approach. A public and patient involvement panel contributed to the design, analysis and interpretation of the findings. FINDINGS: Data saturation was achieved after 19 interviews. 11 women were low risk and 8 were high risk for preterm birth. All high risk women had experience of being supported by a specialist preterm team. Four main themes emerged: (i) coping with uncertainty; (ii) dealing with conflicts; (iii) aspects of care and (iv) interactions with professionals. Both low and high risk women experiencing TPTL struggle to cope with the uncertainty of this unpredictable state. The healthcare management they receive can both help and hinder their ability to cope with this extremely stressful experience. High risk women were less likely to receive conflicting advice. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Clinicians should acknowledge uncertainty, minimize conflicting information and advice, and promote continuity of care models for all women, including those attending high risk clinics and in the ward environment.

Bed rest in pregnancy.

The use of bed rest in medicine dates back to Hippocrates, who first recommended bed rest as a restorative measure for pain. With the formalization of prenatal care in the early 1900s, maternal bed rest became a standard of care, especially toward the end of pregnancy. Antepartum bed rest is a common obstetric management tool, with up to 95% of obstetricians utilizing maternal activity restriction in some way in their practice. Bed rest is prescribed for a variety of complications of pregnancy, from threatened abortion and multiple gestations to preeclampsia and preterm labor. Although the use of bed rest is pervasive, there is a paucity of data to support its use. Additionally, many well-documented adverse physical, psychological, familial, societal, and financial effects have been discussed in the literature. There have been no complications of pregnancy for which the literature consistently demonstrates a benefit to antepartum bed rest. Given the well-documented adverse effects of bed rest, disruption of social relationships, and financial implications of this intervention, there is a real need for scientific investigation to establish whether this is an appropriate therapeutic modality. Well-designed randomized, controlled trials of bed rest versus normal activity for various complications of pregnancy are required to lay this debate to rest once and for all.

Incidencia de Amenaza de Parto Pretérmino en el Hospital de Quillacollo, durante los meses de Marzo, Abril y Mayo de la gestión 2009 (Hospital de Quillacollo - Villa Moderna) / Incidence of preterm labor in Quillacollo Hospital during the months of March, April and May 2009 management (Quillacollo Hospital - Villa Moderna)

Durante los meses mencionados asistieron 268 pacientes con complicaciones durante el embarazo de los cuales el 69,9% corresponde a hemorragias de la primera mitad, un 5,2% eclampsia û preeclampsia. Las complicaciones de la segunda mitad del embarazo: Placenta previa con 7,4%, desprendimiento de placenta y otros con 3,7%. Pacientes con Amenaza de Parto Pretérmino en un porcentaje de 10,8 representando a 29 pacientes; es la población que se estudió con mayor detalle.De un total de 29 pacientes registradas con Amenaza de Parto Pretérmino en el hospital de Quillacollo, en el gráfico # 2 se observa que el mes de marzo hubo una incidencia de 13,7% y el mes de mayo 51,6%, estos porcentajes muestran que fue aumentando gradualmente la incidencia. Estas pacientes asistieron al hospital de Quillacollo por diferentes circunstancias como ser referidas de los diferentes centros de salud que pertenecen a la Red de Quillacollo y algunas por presentar sintomatología de Amenaza de Parto Pretérmino.Se puede observar que el porcentaje mayor de la población de mujeres que asistieron al servicio de dilatantes corresponde al grupo de 21 a 25 años de edad con 34,4%, con un porcentaje de 6,8% las mujeres de 31 a 35 años.

Conforme va avanzando la edad va disminuyendo el porcentaje de Amenaza de Parto Pretérmino. La mayor incidencia de Amenaza de Parto Pretérmino ocurre en primigestas con un porcentaje de 41,3% y en mujeres con 4º gestas con 13,7%. Estos datos coinciden con las causas, que la mayoría de las mujeres padecen de infección del tracto urinario, ya que durante la gestación la mujer es más suceptible a contraer las mismas por diferentes causas.Se observa que el 58,6% de mujeres con Amenaza de Parto Pretérmino realizaron de 1 a 3 controles prenatales y algunas pacientes realizaron 7 a 8 controles prenatales en un porcentaje de 13,7%. Tomando en cuenta que toda mujer durante su gestación (nueve meses) debe realizar cuatro controles prenatales, más aun si es un embarazo de alto riesgo. Se observó que el 62% de mujeres con Amenaza de Parto Pretérmino se presenta durante las 31 a 37 semansa gestacionales, en pacientes con 22 a 25 semanas gestacionales un 17,2%. En muchos de estos casos se logra evitar el parto pretérmino con las medidas de prevención que se realiza en el hospital de Quillacollo.La causa principal para la Amenaza de Parto Pretérmino es la infección del tracto urinario alta con un porcentaje de 34,4%, seguida de infecciones del tracto urinario baja con un 24,1%, en muchas ocasiones con dos causas como ser ruptura prematura de membranas y oligohidramnios con 20,6%; en un porcentaje de 10,3% pacientes con ruptura prematura de membranas, de igual forma con polihidramnios. Como ya se mencionó anteriormente la causa con mayor porcentaje son las infecciones del tracto urinario durante el embarazo, lo cual nos concientiza para educar a la población sobre los cuidados durante el embarazo y cuan importantes son los controles prenatales.

Se observa que las pacientes internadas con Amenaza de Parto Pretérmino en el servicio de obstetricia del hospital de Quillacollo se quedaron entre 1 a 3 dias en un porcentaje de 68,9% y un 10,3% por 6 días o más; la mayoría de éstas dejaron el servicio por alta médica y algunas referidas a tercer nivel. Durante su permanencia en el hospital de las mantuvo en reposo absoluto, con úteroinhibición, maduración fetal, monitoreando constantemente la frecuencia cardiaca materna y fetal, la dinámica uterina y el sangrado transvaginal.

[Emergency obstetrical care in Benin referral hospitals: 'near miss' patients' views]. / La qualité de prise en charge des urgences obstétricales dans les maternités de référence au Bénin: le point de vue des "Echappées Belles" et leurs attentes.

OBJECTIVE: To evaluate emergency obstetric care and the perceptions and expectations of women who experienced 'near miss' events to improve maternal health in Benin. METHODS: Qualitative survey in seven hospitals at the three referral levels of the health pyramid from July to October 2003. We used two methods: 557 women with near miss events were interviewed in hospital and a standard questionnaire completed; then semi-structured individual interviews were conducted at home with 42 of these 557 women. RESULTS: Provided care, accommodation, facilities, costs and modalities of recovery, hygiene of the premises, dynamism, expertise, social support, behaviours and attitude of staff were the criteria used to express patients' satisfaction. Most women interviewed in hospital were happy with physical access, organization, functioning and environment. However, excessive costs and coercive recovery of the expenses, failure of the referral system, lack of empathy and discrimination of the nursing staff, lack of resources for emergencies, lack of hygiene and comfort of the premises were criticized by the women interviewed at home. CONCLUSION: The current maternal care system fails to effectively deal with obstetric complications. It needs to be better resourced, more easily available, cheaper and take into account the women's needs.

Ultrasound assessment of first-trimester bleeding.

OBJECTIVE: To assess the outcome (to the end of the first trimester) of pregnancies with vaginal bleeding and the influence of ultrasound-acquired information on care and cost of care. METHODS: A chart review was performed of 1,240 patients receiving care at an integrated medical center for threatened abortion from 1998-2000. Records from 715 patients with adequate follow-up data were reviewed and outcomes studied. Charges for outpatient and inpatient care were obtained from the data warehouse. RESULTS: Main findings include that on endovaginal ultrasonography, 44% of the pregnancies were viable, of which 86% continued to the end of the first trimester and that of the 33% of pregnancies that were nonviable, 74% successfully miscarried without intervention. Charges for the care varied significantly, based on outcome and choice of site of care. CONCLUSION: Endovaginal ultrasonography for the evaluation of early pregnancy bleeding has a significant effect on care decisions and costs. LEVEL OF EVIDENCE: II-3.

Atenção humanizada ao abortamento: norma técnica / Humanized attention to the abortion: tecnical rule

O Ministério da Saúde consolida, com a publicação desta norma, instrumento de ação para produzir resultados práticos que reflitam respeito à cidadania feminina e expressem os cumprimentos das Resoluções da Cúpula do Milênio das Ações Unidas (Nova Yorque, 2000) que definiu como uma de suas metas a redução dos níveis de mortalidade materna.Essa norma é dirigida aos gestores, serviços e profissionais de sáude e a todas as pessoas comprometidas com a garantia dos direitos humanos de mulheres e adolescentes no Brasil

Ultrasound assessment of cervical length in threatened preterm labor.

OBJECTIVE: More than 70% of women presenting with threatened preterm labor do not progress to active labor and delivery. The aim of this study was to investigate the hypothesis that in women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor. METHODS: We examined 216 women with singleton pregnancies presenting with regular and painful uterine contractions at 24-36 (mean, 32) weeks of gestation. Women in active labor, defined by the presence of cervical dilatation > or = 3 cm, and those with ruptured membranes were excluded. On admission to the hospital a transvaginal scan was performed to measure the cervical length. The subsequent management was determined by the attending obstetrician. The primary outcome was delivery within 7 days of presentation. RESULTS: In 173 cases the cervical length was > or = 15 mm and only one of these women delivered within 7 days. In the 43 cases with cervical length < 15 mm delivery within 7 days of presentation occurred in 16 (37%) including 6/14 (42%) treated with tocolytics and 10/29 (35%) managed expectantly. Logistic regression analysis demonstrated that the only significant contributor in the prediction of delivery within 7 days was cervical length < 15 mm (odds ratio = 101, 95% CI 12-800, P < 0.0001) with no significant contribution from ethnic group, maternal age, gestational age, body mass index, parity, previous history of preterm delivery, cigarette smoking, contraction frequency or use of tocolytics. CONCLUSIONS: In women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor.

Perfil sócio demográfico e gestacional de pacientes com a seqüência de Möbius / Social demographics and pregnancy profile of patiens with Möbius sequence

Analisar o perfil sócio-demográfico e gestacional de uma amostra de pacientes com a sequência de Möbius. Aplicou-se um questionário estruturado em genitores de pacientes com diagnóstico de sequência de Möbius, atendidos em três centros de referência do Estado de Permancuco. Os pacientes foram analisados quanto a dados sócio-demofráficos e gestacionais. Dividiram-se os pacientes em dois grupos, de acordo com a exposição ao misoprostol durante a gestação, sendo o grupo I composto de pacientes não expostos e o II de casos expostos. Dos 28 pacientes estudados, 16 (57,1por cento) eram mulheres. A média de idade dos pacientes foi de 60,5 meses. O grupo II era composto de 17 casos (60,7por cento), sendo que o misoprostol foi utilizado via oral e vaginal em 14 casos (82,4por cento), com dose variandode três (600µg) a 14 comprimifos (2.800µg).nos pacientes do grupo I, não houve queixa de dores na gravidez, e em quatro (14,3por cento), houve sangramento, entretanto, nos do grupo II, houve dor em oito casos (47,1por cento) e hemorragia em 15 (88,2por cento) (p=0,010). O período do dano ao embrião através do uso do misoprostol foi, em média, na quinta semana pós fertilização. História de aborto prévio provocado foi referido em quatro casos (36,4por cento) no grupo I e em um 5,9por cento) no II. Em 25 casos entrevistados a média de idade das genitora foi de 29,3 anos no grupo I, e de 27,6 anos no grupo II, e a dos genitores foi de 30,9 anos no grupo I, e de 25,7 anos no grupo II. Observou-se que 10(66,7por cemto) genitores do grupo II não eram casados, e a profissão paterna mais frequente era comerciante, dois eram desempregados (p=0,049). A avaliação do perfil soció-demográfico e gestacional das genitoras de pacientes com a seqüência de Möbius, mostrou-se como um instrumento válido na análise dos possíveis fatores elucidativos da problemática dessa entidade, observando-se a associação entre o uso do misoprostol no primeiro trimestre da gestação com maior prevalência desses casos, o que foi visto principalmente em pacientes pertencentes a classe social menos privilegiada, com menor freqüência de parceiro estável

Assessment of the fetomaternal circulation in threatened abortion by transvaginal color Doppler.

Transvaginal color Doppler was used to investigate blood flow in the fetomaternal circulation of 60 women with threatened abortion and 90 women with normal intrauterine pregnancy. The obtained Doppler sonograms were analyzed and the resistance index (RI) was calculated in the maternal circulation, while in the fetal circulation the pulsatility index (PI) was used. There was no significant difference in the RI values of the maternal circulation between women with normal pregnancies and pregnancies complicated by bleeding, but with normal pregnancy outcome (p > 0.05). No differences in RI values of the uterine, arcuate and radial arteries were found between pregnancies with threatened abortion and normal pregnancy outcome and women with abnormal outcome (p > 0.05). In 9 of 21 women with visible retrochorionic hematoma, the RI of the spiral arteries was higher on the hematoma side in comparison to the opposite side (p < 0.01). This could be a consequence of the mechanical compression caused by the hematoma. In 3 of 4 cases of missed abortion, the RI of the spiral arteries was lower in comparison to the control group. Such findings could be caused by the vasodilatating products of inflammation which probably exist in such areas. There was no significant difference in terms of the PI of fetal blood vessels between normal pregnancy and threatened abortions with normal outcome, as well as between threatened abortions with normal outcome and subsequent abortions of live fetuses (p > 0.05).

[The current method of early recognition and treatment of threatened premature labor]. / A fenyegetö koraszülés korai felismerésének és kezelésének korszerü módszere.

The authors, following a short review of the currently available diagnostic and therapy methods of threatening premature delivery, introduce their own method. The most important feature of this method is a two-level, computerized telecommunicative system. According to the risk factors, physical examination and the patient's complaints (clinical parameters) a risk score analysis is made by the central computer of the outpatient clinic. Those pregnants who fall into the high-risk group are followed-up by means of a portable contraction monitor. The treatment is introduced according to the registered spontaneous contraction activity. (hospitalisation, beta-mimetic etc.). After institution of the therapy the patient can be emitted to her home under the care of the portable monitor. Data of the registered and stored contraction activity from the patient's home can be transmitted to the central computer of the out-patient clinic via phone. If the telephone connection is not possible, the physician can read out the stored data from the memory of the portable monitor on its own display during regular visits. Finally the authors make preliminary cost-benefit calculation on the basis of the literature and their own data and conclude that their method can be very cost effective as well.

Ultrasonic assessment of complications during first trimester of pregnancy.

624 women were referred to an emergency gynaecological ultrasound clinic with a provisional diagnosis of threatened miscarriage based on a history of amenorrhoea and vaginal bleeding with or without abdominal pain. High-resolution abdominal sector scanning was used to assess fetal size and viability, as well as uterine and placental size, to identify features which might indicate imminent fetal death. In 158 women there was no evidence of pregnancy; 60 women had an ectopic pregnancy. In the remaining 406 women ultrasound examination correctly identified the underlying cause of vaginal bleeding at first presentation in all but the 6 who subsequently aborted. 3.9% of the patients had a second empty sac and 5.4% had an intrauterine haematoma; none of these women subsequently aborted. 2 patients had early-onset oligohydramnios and spontaneous abortion occurred in both.

Prognostic value of biochemical tests in the assessment of fetal outcome in threatened abortion.

Maternal concentrations of serum progesterone, oestradiol, chorionic gonadotrophin, Schwangerschaftsprotein 1 and placental protein 5 were measured in 67 patients with threatened abortion. The levels of all biochemical variables were significantly reduced in those patients who had an unfavourable outcome. The clinical efficiency of each of these tests was very similar.