Weight Changes and Adverse Pregnancy Outcomes With Dolutegravir- and Tenofovir Alafenamide Fumarate-Containing Antiretroviral Treatment Regimens During Pregnancy and Postpartum.

BACKGROUND: We evaluated associations between antepartum weight change and adverse pregnancy outcomes and between antiretroviral therapy (ART) regimens and week 50 postpartum body mass index in IMPAACT 2010. METHODS: Women with human immunodeficiency virus (HIV)-1 in 9 countries were randomized 1:1:1 at 14-28 weeks' gestational age (GA) to start dolutegravir (DTG) + emtricitabine (FTC)/tenofovir alafenamide fumarate (TAF) versus DTG + FTC/tenofovir disoproxil fumarate (TDF) versus efavirenz (EFV)/FTC/TDF. Insufficient antepartum weight gain was defined using Institute of Medicine guidelines. Cox-proportional hazards regression models were used to evaluate the association between antepartum weight change and adverse pregnancy outcomes: stillbirth (≥20 weeks' GA), preterm delivery (<37 weeks' GA), small size for GA (<10th percentile), and a composite of these endpoints. RESULTS: A total of 643 participants were randomized: 217 to the DTG + FTC/TAF, 215 to the DTG + FTC/TDF, and 211 to the EFV/FTC/TDF arm. Baseline medians were as follows: GA, 21.9 weeks; HIV RNA, 903 copies/mL; and CD4 cell count, 466/µL. Insufficient weight gain was least frequent with DTG + FTC/TAF (15.0%) versus DTG + FTC/TDF (23.6%) and EFV/FTC/TDF (30.4%). Women in the DTG + FTC/TAF arm had the lowest rate of composite adverse pregnancy outcome. Low antepartum weight gain was associated with higher hazard of composite adverse pregnancy outcome (hazard ratio, 1.44 [95% confidence interval, 1.04-2.00]) and small size for GA (1.48 [.99-2.22]). More women in the DTG + FTC/TAF arm had a body mass index ≥25 (calculated as weight in kilograms divided by height in meters squared) at 50 weeks postpartum (54.7%) versus the DTG + FTC/TDF (45.2%) and EFV/FTC/TDF (34.2%) arms. CONCLUSIONS: Antepartum weight gain on DTG regimens was protective against adverse pregnancy outcomes typically associated with insufficient weight gain, supportive of guidelines recommending DTG-based ART for women starting ART during pregnancy. Interventions to mitigate postpartum weight gain are needed.

Prevalence of macrosomic newborn and maternal and neonatal complications in a high-risk maternity.

Objective: Evaluate the prevalence of macrosomic newborns (birth weight above 4000 grams) in a high-risk maternity from 2014 to 2019, as well as the maternal characteristics involved, risk factors, mode of delivery and associated outcomes, comparing newborns weighing 4000-4500 grams and those weighing above 4500 grams. Methods: This is an observational study, case-control type, carried out by searching for data in hospital's own system and clinical records. The criteria for inclusion in the study were all patients monitored at the service who had newborns with birth weight equal than or greater than 4000 grams in the period from January 2014 to December 2019, being subsequently divided into two subgroups (newborns with 4000 to 4500 grams and newborns above 4500 grams). After being collected, the variables were transcribed into a database, arranged in frequency tables. For treatment and statistical analysis of the data, Excel and R software were used. This tool was used to create graphs and tables that helped in the interpretation of the results. The statistical analysis of the variables collected included both simple descriptive analyzes as well as inferential statistics, with univariate, bivariate and multivariate analysis. Results: From 2014 to 2019, 3.3% of deliveries were macrosomic newborns. The average gestational age in the birth was 39.4 weeks. The most common mode of delivery (65%) was cesarean section. Diabetes mellitus was present in 30% of the deliveries studied and glycemic control was absent in most patients. Among the vaginal deliveries, only 6% were instrumented and there was shoulder dystocia in 21% of the cases. The majority (62%) of newborns had some complication, with jaundice (35%) being the most common. Conclusion: Birth weight above 4000 grams had a statistically significant impact on the occurrence of neonatal complications, such as hypoglycemia, respiratory distress and 5th minute APGAR less than 7, especially if birth weight was above 4500 grams. Gestational age was also shown to be statistically significant associated with neonatal complications, the lower, the greater the risk. Thus, macrosomia is strongly linked to complications, especially neonatal complications.

Effects of Initiating Raltegravir-Based Versus Efavirenz-Based Antiretroviral Regimens During Pregnancy on Weight Changes and Perinatal Outcomes: NICHD P1081.

BACKGROUND: Integrase inhibitors have been associated with excess gestational weight gain that may lead to adverse pregnancy outcomes (APOs). This post hoc analysis of NICHD P1081 compared antepartum changes in weight and body mass index (BMI) in pregnant women initiating raltegravir- or efavirenz-based combined antiretroviral therapy (cART) and examined associations between rates of weight gain and APOs. SETTING: NICHD P1081 enrolled antiretroviral-naive pregnant women living with HIV in the second and third trimester in Brazil, Tanzania, South Africa, Thailand, Argentina, and the United States. METHODS: Two hundred eighty-one women enrolled between 20 and 31 gestational weeks were randomized to raltegravir- or efavirenz-based cART and followed for ≥4 weeks. A low rate of weight gain was defined as <0.18 kg/wk and high as >0.59 kg/wk. We compared weight gain and BMI increase between treatment arms using Kruskal-Wallis tests. Logistic regression was used to investigate the association between weight gain and APOs. RESULTS: Raltegravir-based cART was associated with significantly higher antepartum weight gain (median 0.36 kg/wk versus 0.29 kg/wk, P = 0.01) and BMI increase (median 0.14 kg/m 2 /wk versus 0.11 kg/m 2 /wk, P = 0.01) compared with efavirenz-based treatment. Women on raltegravir had less low weight gain (18% versus 36%) and more high weight gain (21% versus 12%) ( P = 0.001). Women with low weight gain were more likely than those with normal weight gain to have small for gestational age infants or a composite of APOs. CONCLUSIONS: A raltegravir-based antiretroviral regimen was associated with significantly higher antepartum rate of weight gain and BMI increase compared with efavirenz-based treatment in antiretroviral-naive pregnant women.

Use of the Pessary in the Prevention of Preterm Delivery.

OBJECTIVE: The gestational complication most associated with perinatal mortality and morbidity is spontaneous preterm birth with gestational age < 37 weeks. Therefore, it is necessary to identify its risk factors and attempt its prevention. The benefits of the pessary in prematurity are under investigation. Our objective was to analyze the use of the pessary in the prevention of preterm births in published studies, and to compare its efficacy with other methods. METHODS: Randomized clinical trials published between 2010 and 2018 were selected from electronic databases. Studies on multiple gestations were excluded. RESULTS: Two studies were in favor of the pessary as a preventive method, one study was contrary to the method and another two showed no statistically significant difference. The meta-analysis showed no statistical difference with the use of a cervical pessary in the reduction of births < 37 (odds ratio [OR]: 0.63; confidence interval [95% CI]: 0.38-1.06) and < 34 weeks (OR: 0.74; 95% CI: 0.35-1.57) CONCLUSION: The pooled data available to date seems to show a lack of efficacy of the cervical pessary in the prevention of preterm birth, although the heterogeneity of the studies made comparisons more difficult.

OBJETIVO: O parto com idade gestacional < 37 semanas é a complicação gestacional mais associada à mortalidade e morbidade perinatal, sendo necessária a identificação de seus fatores de risco e a tentativa de sua prevenção. Os benefícios do pessário na prematuridade estão sendo investigados. Nosso objetivo foi analisar os estudos publicados sobre uso do pessário na prevenção do parto pretermo e comparar sua eficácia perante outros métodos. MéTODOS: Foram selecionados estudos clínicos randomizados publicados entre 2010 e 2018, extraídos de bases eletrônicas de dados. Estudos de gestações múltiplas foram excluídos. RESULTADOS: Dois estudos se mostraram a favor do pessário como método preventivo, um estudo foi contrário ao método, e outros dois não demonstraram diferença estatisticamente significativa. A meta-análise não mostrou diferença significativa no uso do pessário na redução de nascimentos < 37 (razão de chance [RC]: 0,63; intervalo de confiança [IC 95%]: 0,38­1,06) e < 34 semanas (RC: 0,74; IC 95%: 0,35­1,57). CONCLUSãO: Os dados agrupados disponíveis até o momento parecem mostrar uma falta de eficácia do pessário cervical na prevenção do parto pretermo, embora a heterogeneidade dos estudos tenha dificultado as comparações.

Resolution of inflammation pathways in preeclampsia-a narrative review.

Preeclampsia (PE) is one of the leading causes of maternal morbidity and mortality worldwide. This disease is believed to occur in two stages with placental dysfunction in early pregnancy leading to maternal clinical findings after 20 weeks of gestation, as consequence of systemic inflammation, oxidative stress, and endothelial dysfunction. Much evidence suggests that PE women display an overshooting inflammatory response throughout pregnancy due to an unbalanced regulation of innate and adaptive immune responses. Recently, it has been suggested that dysregulation of endogenous protective pathways might be associated with PE etiopathogenesis. Resolution of inflammation is an active process coordinated by mediators from diverse nature that regulate key cellular events to restore tissue homeostasis. Inadequate or insufficient resolution of inflammation is believed to play an important role in the development of chronic inflammatory diseases, like PE. In this narrative review, we discuss possible pro-resolution pathways that might be compromised in PE women, which could be targets to novel therapeutic strategies in this disease.

[Illicit drug use by pregnant women infected with HIV]. / Uso de drogas ilícitas por gestantes infectadas pelo HIV.

PURPOSE: To determine if illicit drug use increases the vertical transmission of HIV, to identify the risk factors involved in mother and child health and the prevalence of illicit drug use among these pregnant women. METHODS: Sixty-four (7.6%) of 845 pregnant women from the metropolitan region of Belo Horizonte, Minas Gerais, Brazil, attended in the service between October 1997 and February 2012 reported the use of illicit drugs. Cases were HIV-positive drug users (n=64) and controls were women who did not use drugs (n=192). Three controls were selected for each case. Several conditions of exposure were considered in the control group such as tobacco use, alcohol use, alcohol and tobacco use, maternal age, educational level, ethnicity, and marital status. Problems during the prenatal period, delivery and postpartum, vertical HIV transmission and neonatal outcomes were also investigated. RESULTS: Univariate analysis showed as significant variables: maternal age, tobacco use, number of prenatal care visits, antiretroviral therapy, mode of infection, and viral load at delivery. Logistic regression revealed as significant variables: maternal age (less than 25 years); tobacco use, and number of prenatal care visits (less than 6). The vertical transmission of HIV was 4,8% (95%CI 1.7-13.3) among drug users and 2,1% (95%CI 0.8-5.2) in the control group, with no statistically significant difference between groups. Neonatal complications were more frequent among drug users, but also with no statistically significant difference between groups. CONCLUSION: The use of illicit drug is frequent during pregnancy among HIV-infected women. The approach to illicit drug use should be routine during prenatal care visits. These women are more discriminated against and tend to deny their habits or do not seek prenatal care. There was no difference in vertical virus transmission between groups, probably indicating adherence to antiretroviral use for antiretroviral therapies during pregnancy.

Fisiopatologia da pré-eclâmpsia: aspectos atuais / Physiopathology of pre-eclampsia: new insights

A pré-eclâmpsia, principal causa de morte materna no mundo, é conhecida como a doença das teorias. Nos últimos anos, diversos avanços no área médica permitiram aprofundar nossos conhecimentos sobre a sua etiopatogenia. Sabemos, atualmente, que fatores genéticos, como a interação entre HLA paterno e linfócitos NK maternos, estão envolvidos na origem da placentação deficiente, um dos principais fatores de risco da pré-eclâmpsia. Fatores imunológicos, como a falha do estabelecimento da reação inflamatória tipo 2 na implantação do embrião, também poderiam dificultar a invasão trofoblástica. O conceito de que a pré-eclâmpsia não é uma doença única, mas um conjunto de doenças com manifestações clínicas comuns veio para ajudar na elucidação do problema. A pré-eclâmpsia é considerada, hoje em dia, um estado imflamatório com disfunção endotelial sistêmica. Nesta revisão, os autores compilam as teorias mais recentes sobre a fisiopatologia dessa doença tão intrigante.

Pre-eclampsia, the leading cause of maternal death around the world, is also known as the disease of theories. Several developments in the last years allowed us to improve our knowledge over its etiopathogeny. It is known that genetic factors, as the interaction between paternal HLA antigens and maternal natural killer lynfocytes, are involved in the origin of incomplete placentation, one of the most powerful risk factors for the development of pre-eclampsia. Imunological factors, as the failure in the establishment of inflammatory Reaction type 2, at implantation time, could also difficult the trophoblastic invasion. The conception of pre-eclampsia as a group of diseases with a common set of clinical manifestations help us to further understand the problem. Pre-eclampsia is considered to be an inflammatory state with systemic endothelial dysfunction. In this review paper, the authors gather the most recent theories about the physiopathology of such intriguing disease.

Arterite de Takayasu e gestação: relato de caso / Takayasu's arteritis and pregnancy: a case report

A arterite de Takayasu é caracterizada pela oclusão idiopática da aorta e de seus principais ramos. A doença apresenta uma predileção por mulheres jovens, sendo, dessa forma, ocasionalmente encontrada associada a gestação. Apresentamos o caso de uma gestante portadora de um grau avançado de arterite de Takayasu cuja gravidez foi acompanhada por uma equipe formada por obstetras e cardiologistas e apresentou evolução satisfatória. Ocorreu apenas uma hospitalização por exacerbação dos sintomas na 32ª semana de gestação, que foram controlados com tratamento clínico. O parto vaginal ocorreu na 37ª semana, com nascimento de uma criança pesando 2.750 g. A paciente evoluiu sem complicações clínicas

Cesariana: incidência ideal / Cesarean section: incidence ideal

O autor salienta a elevaçäo acentuada das taxas de cesariana e questiona as principais razöes apontadas para isso: segurança da intervençäo e seu papel nas taxas de mortalidade perinatal. Analisa as principais indicaçöes obstétricas responsáveis pela elevaçäo da incidência de parto operatório e enumera as razöes näo obstétricas que também têm contribuído para esse aumento.

Evoluçäo da idade e paridade da populaçäo obstétrica em hospital universitário / Age and parity survey of obstetric population at the university hospital

Os autores avaliaram a evoluçäo da idade e paridade das mulheres cesariadas no período de 1970 a 1987, no Hospital Universitário, e constataram que a evoluçäo foi semelhante nas duas vias de parto. O risco de cesariana foi duas vezes maior para as primíparas em relaçÒo Ós multíparas, mas a idade e paridade sugerem näo ter influenciado a elevaçäo das taxas de cesariana.

Evoluçäo da incidência de cesariana e utilizaçäo do fórceps em hospital universitário / Evolution of the incidence of cesarean section and forceps use in university hospital

Os autores analisam a evoluçäo da incidência de cesariana e a utilizaçäo do fórceps em hospital universitário, no período de 1970 a 1987. Constatam que a taxa de cesariana passou de 11,9 por cento para 30,4 por cento, enquanto a utilizaçäo do fósceps representou 4,8 por cento dos partos. O estudo näo sugere correlaçäo entre a utilizaçäo do fórceps e o índice de cesariana.

Indicaçöes de cesariana no Hospital das Clínicas da UFMG durante duas décadas / Cesarian section indications at the University Hospital during two decades

O autor analisa as indicaçoes de cesarianas no período de 1970 a 1989. As principais indicaçoes foram cesariana de repetiçao, distócia e sindromes hipertensivas. As síndromes hipertensivas, como indicaçao de cesariana, elevaram-se em dez vezes nessas duas décadas.

Complicaçöes da operaçäo cesariana em Hospital Universitário: análise da dificuldade de extraçäo fetal / Cesarian section complications in University Hospital: analysis of difficult foetal extraction

Foram analisadas prospectivamente, quanto a complicaçöes, 309 pacientes submetidas a operaçäo cesariana. A mais freqüente complicaçäo foi a dificuldade de extraçäo fetal (8,3%). Constituíram fatores de risco a esta complicaçäo a repetiçäo da operaçäo (a partir da terceira) e a ausência de trablaho de parto. Além disso, verificou-se que fetos com menos de 1500g apresentam a complicaçäo com maior freqüência e, por serem mais sensíveis à mesma, devem ser considerados como especialmente em risco com a dificuldade de extraçäo

Movimento respiratório fetal e trabalho de parto / Relation between fetal breathing movements and labour

Os movimentos respiratóriosfetais (MRF)têm sido relacionados com ritmo circadiano, alteraçöes na glicemia materna e uso de drogas e fumo durante a gestaçåo. A ausência de MRF tem sido demonstrada durante o trablho de parto. A proposta deste trabalho é fazer uma revisåo de literatura sobre os MRF e o trabalho de parto

Cardiotocografia no seguimento de fetos submetidos à transfusäo intra-uterina / Cardiotocography in the follow-up of fetus subjected to intrauterine transfusion

Foram realizadas 13 transfusöes intra-uterinas em sete fetos afetados pela incompatibilidade Rh. Em todos os procedimentos realizaram-se exames cardiotocográficos pré e pós-transfusäo. Analisaram-se os cardiotocogramas obtidos quanto aos seguintes parâmetros: linha de base, variabilidade, desaceleraçöes, aceleraçöes e resposta ao estímulo sonoro. Encontrou-se uma nítida recuperaçäo fetal nos parâmetros analisados, coincidindo com a reversäo do estado de hipóxia fetal, promovido pela transfusäo intra-uterina. É sugerido que a cardiotocografia pode consistir-se em método para determinaçäo do momento da repetiçäo das transfusöes intra-útero nos fetos comprometidos pela incompatibilidade Rh

Correlaçäo entre a cardiotocografia e a espectrofotometria do líquido amniótico, na gestante Rh negativo imunizada / Correlationship between cardiotocography and amniotic fluid analysis, in the rhesus isoimunization

Foram acompanhadas 38 gestantes sensibilizadas pelo fator Rh, com o intuito de correlacionar os resultados cardiotocográficos ao estudo espectrofotométrico do líquido amniótico, com base nos critérios de Liley. As cardiotocografias foram classificadas em reativo, hiporreativo e näo-reativo. Foi verificada uma sensibilidade de 80% para o método, com um valor preditivo positivo de 86,8% e preditivo negativo de 77,4%

Transfusäo sanguínea fetal: experiência do Centro de Medicina Fetal da UFMG / Fetal blood transfusion: experience in Centro de Medicina Fetal da UFMG

Os autores apresentam sua experiência com transfusäo sanguínea fetal, realizada no Centro de Medicina Fetal da UFMG. A mortalidade perinatal variou de 44 por cento para fetos hidrópicos a 75 por cento para fetos näo hidrópicos.

Evoluçäo ecográfica do perímetro abdominal de fetos submetidos à transfusäo intra-uterina / Echographic evolution of abdominal perimeter of foetuses undergoing intrauterine transfusion

Avaliou-se ecograficamente o perímetro abdominal de três fetos submetidos a cinco transfusöes intra-útero, por doença hemolítica perinatal. Foi feita correlaçäo da reduçäo do perímetro abdominal com modificaçöes no padräo da cardiotocografia, portanto, da oxigenaçäo fetal. Foi verificado que fetos näo hidrópicos apresentam ritmo regular de reduçäo do perímetro abdominal e que a cardiotocografia passa de näo reativa à reativa quando a reduçäo do perímetro abdominal é maior que 20%. Na visäo dos autores a medida seriada do perímetro abdominal é um bom método de avaliar o ritmo de absorçäo do sangue injetado na cavidade peritoneal de fetos transfundidos

Cardiotocografia no acompanhamento de fetos submetidos à transfusäo intravascular / Cardiotocography in the follow-up of foetuses submitted to intravascular transfusion

Foram acompanhados quatro fetos hidrópicos, submetidos à transfusäo intravascular (cordocentese) para o tratamento da anemia, decorrente de isoimunizaçäo materna pelo fator RH. A cardiotocografia realizada previamente ao procedimento revelou padräo näo reativo em três casos e ritmo sinusoidal em um caso. Após a transfusäo intravascular todos os fetos tornaram-se reativos nas primeiras doze horas após o procedimento

Avaliaçäo da fórmula de cálculo da hemoglobina plasmática de fetos submetidos a transfusöes intra-uterinas / Evaluation of the formula to calculate plasma hemoglobin of fetuses subjected to intrauterine transfusions

Avaliou-se uma fórmula para cálculo da hemoglobina plasmática de fetos transfundidos pela via intraperitoneal, em decorrência de doença hemolítica perinatal. Os níveis da hemoglobina calculada foram comparados com as da hemoglobina do sangue do cordäo ao nascimento. Observou-se que, em fetos näo hidrópicos, o desvio médio entre os valores comparados foi de 0,6%, revelando grande acuidade do método. Nos casos em que havia hidropsia fetal o cálculo de hemoglobina foi pouco fidedigno. Os autores concluem que o método de cálculo da hemoglobina pode ser usado em fetos näo hidrópicos, para monitorizaçäo do momento da repetiçäo da transfusäo intra-uterina em csos de doença hemolítica perinatal