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)

Joubert Syndrome with Severe Hypotonia: A case report

Joubert syndrome first described by Joubert et al. in 1969 is a very rare congenital disorder, characterized by episodic hyperpnea, abnormal eye movement, hypotonia, ataxia, and mental retardation. This syndrome generally represents as autosomal recessive inheritance and main neuropathological finding is agenesis or aplasia of the cerebellar vermis. This patient represents significant generalized muscle hypotonia which is not affected by any other tone-modifying maneuvers. And so there is no significant neuromotor improvement with neurodevelopmental treatment such as Bobath method, Vojta method, or proprioceptive nerve facilitation technique and so on. We report the Joubert syndrome showing typical features with delayed development.

Neural tube defect and folic acid.

PIP: Neural tube defect (NTD) is a group of congenital anomalies, which include anencephaly, encephalocele, iniencephaly, meningocele, myelomeningocele, myeloschisis, lipomeningocele, and rashischisis. Congenital malformations of the central nervous system constitute more than half of all congenital malformations with an incidence of 1-2/1000 births. The condition is thought to arise from multifactorial etiology with a distinct genetic predisposition. This paper discusses the pathogenesis of NTD and explores the use of folic acid for the prevention of this serious congenital malformation. Two studies, which have shown a significant protective effect of folic acid use on NTD prevention in high-risk mothers, are cited. In considering the effectiveness of folic acid supplementation on NTD prevention, obstetricians, pediatricians, neonatologists, and family doctors are called to initiate a collective effort to increase awareness among women in the childbearing age on the need of daily multivitamin intake with folic acid prior to pregnancy.^ieng

Folic acid supplementation for the prevention of neural tube defects. Should it be a priority for developing countries?

PIP: Folic acid supplementation during pregnancy has been widely advocated for the prevention of neural tube defects in developing countries. The author of this letter, however, argues that such a strategy is unwarranted and a misuse of scarce resources. Folic acid deficiency is not the primary cause of neural tube defects and the incidence of this defect is similar in developed and developing countries. It has been estimated that folic acid fortification of cereal-based products--an exceedingly difficult, expensive intervention--would prevent only about 1000 neural tube defect cases per year. Moreover, additional folic acid can prevent neural tube defects only if consumed during the periconceptional period. Although women at risk of neural tube defect recurrence are advised to take 4 mg of folic acid per day when they plan to become pregnant, the recommendation for the vast majority of women in developing countries is increased consumption of beans, oranges, and green leafy vegetables.^ieng

Uses and misuses of vitamin A.

PIP: Vitamin A, which is available from dietary sources, vitamin supplements, and fortified products, affects numerous bodily processes through its impact on cellular differentiation. More than 300 genes are regulated by the rapid action of the vitamin. It has recently been recognized that mild vitamin A deficiency is widespread among children and pregnant women in developing countries. This deficiency increases severity of infectious diseases, iron-related anemia, and growth disturbances. Improving the vitamin A status of all deficient children could avert a million or more deaths annually, and administration of high-dose vitamin A has been advised for treatment of measles. There is also an apparent association between high beta carotene status (which may represent vitamin A status) and lower rates of some forms of cancer, but this has yet to be confirmed. Supplementation programs in developing countries rely on periodic administration of high-dose vitamin A in doses of 100,000 IU orally for those under 1 year old and 200,000 IU for those older once every 3-6 months. The optimal dosing schedule is unknown, but no cases of death have been linked to isolated vitamin A toxicity. Experts also disagree about the window of safety during which a high-dose of vitamin A can be given to pregnant and postpartum women without causing teratogenicity. It is unwise to administer high-dose vitamin A to women of reproductive age after the first 6 weeks postpartum. All women at risk should receive small daily doses or 20,000 IU weekly doses. In the US, where general dietary status is good, women should not use more than 8000 IU supplements except when indicated for a specific reason.^ieng

Experience with training of traditional midwives on the prevention and management of birth asphyxia in a rural district in Zimbabwe.

PIP: In Zimbabwe's Chimanimani district, 51% of deliveries take place at home under the supervision of traditional midwives. (vanambuya). The vanambuya are viewed by rural mothers as more caring than clinic staff and more supportive of rituals during delivery aimed at protecting the infant from evil. Given the wealth of experience accumulated by midwives and their respect within rural communities, it was decided to provide these practitioners with training. Of particular concern was the prevention and management of birth asphyxia, which accounted or half of the handicaps in children born in the district in 1980 (118/250) and was the leading cause of perinatal deaths (754/2287). The training, which is voluntary, is carried out at the rural health center or at 1 of the 65 outreach centers in the district. Recruitment is done by village community workers, village development committees, party organs and school teachers. The main objectives of the training are to enable traditional midwives to recognize the risk factors in pregnancy, labor, and after delivery and refer women at risk to a health facility; prevent the practice of rituals that can lead to birth asphyxia (e.g., administration of oxytocic herbs to speed up labor); and to encourage greater collaboration and respect between clinic staff and traditional workers. Between 1983-88, a total of 645 traditional midwives completed this 2-session course. Unfortunately, follow-up strategies of refresher seminars 2-3 times/year at the health center and regular supervision by a nurse-midwife at the clinic have been hindered by transportation problems. The lack of an ambulance service in the district has also impeded the goal of encouraging the vanambuya to make rapid referrals of high risk women.^ieng

Improving neonatal care: women as health providers.

PIP: In a project in India, women play a major role in efforts to provide pregnant women with prenatal care, safe deliveries and reduce perinatal mortality. Undertaken in 1986 with the support of the Ford Foundation and the State government of Tamil Nadu in the Kanchipuam district, it demonstrates the feasibility of establishing a low-cost neonatal care unit at a rural district hospital to make services for neonates accessible to families living in the surrounding rural areas. Design of the project was based on changes implemented at a government hospital used for training medical staff, the Institute of Child Health in Madras, where mothers were admitted with their babies to provide dad-to-day care. While the new unit, which contained 10 cots, was prepared, training was given to a range of health providers including medical officers, pediatricians, obstetricians, nursing personnel and paramedical staff from the rural hospital by a neonatologist and a medical officer trained in neonatology. Anganwadi workers (local women who ran the preschool child care centers) who had completed high school were selected to be trained as a new category of workers called neonatal nursing aides. Month long initial training and refresher courses were given. Operations were begun in July 1987 and referral links established to the district hospital from the subcenter and primary health center levels. A project extension team undertook a neonatal morbidity and mortality survey covering a population of 10,000 in the 2 subcenter areas as well as information on traditional practices of neonatal care to identify harmful practices. TBAs in the population conduct 53.9% of deliveries, auxiliary nurse midwives/multipurpose workers 13.2% and doctors 20%. Home delivery was the major mode. Current training for TBAs was reviewed and shifted from the primary health center to the hospitals to give experience with complicated cases and the results of traditional practices These practices were modified and the TBAs helped put together a kit for their own use. Several were observed in the field following training and showed improved care and knowledge.^ieng

Canada: conflict as well as consensus.

KIE: The director and a research associate at Montreal's Center for Bioethics report on the bioethical concerns of Canadians in one of four Hastings Center Report country reports. Roy and Williams discuss the legal and public policy developments in four areas: sterilization of the mentally retarded, withholding life-prolonging treatment from the dying, research with human subjects, and balancing needs and resources when financing and allocating health care services. They identify two factors in their culture that influence decision making on these and other bioethical issues: the pluralistic nature of Canadian society that prevents one ideology from dominating the country's law and social policy, and the increasing interaction of law, ethics, and medicine.^ieng

Effects of OCs on various nutrients is among top priority research areas.

PIP: In fiscal 1974 and fiscal 1975, $650000 will be spent on contracts for studies of birth control methods and their relationship to birth defects. The effect of oral contraceptives (OCs) on various nutrients is among top interest. It has been shown that OCs increase blood levels of Vitamin-A, copper and iron while they decrease folic acid, zinc and Vitamin-B12 and B6. The decrease of Vitamin-B6 interfers with the tryptophan mechanism and affects glucose tolerance as well as neurotransmitters which can be directly related to reports of depression and a higher rate of bladder cancer. A question arose as to whether dietary supplements would counteract the nutritional depletion. The group of unanswered questions was summed up by a question: "So, the question is, is it the pill or the pill user?"^ieng