The impact of the distance traveled between residence and gestational trophoblastic neoplasia reference center and clinical outcomes in Brazilian women.

OBJECTIVE: To relate the distance traveled from the patient's residence to the gestational trophoblastic neoplasia (GTN) reference center (RC) and the occurrence of unfavorable clinical outcomes, as well as to estimate the possible association between this distance and the risk of metastatic disease at presentation, the need for multiagent chemotherapy to achieve remission and loss to follow-up before remission. STUDY DESIGN: Retrospective historical cohort study of patients with GTN followed at 8 Brazilian GTN-RC, from January 1st, 2000 - December 31st, 2017. RESULTS: Evaluating 1055 cases of GTN, and using a receiver operating characteristic curve, we found a distance of 56 km (km) from the residence to the GTN-RC (sensitivity = 0.57, specificity = 0.61) best predicted the occurrence of at least one of the following outcomes: occurrence of metastatic disease, need for multiagent chemotherapy to achieve remission, or loss to follow-up during chemotherapy. Multivariate logistic regression adjusted by age, ethnicity, marital status and the reference center location showed that when the distance between residence and GTN-RC was ≥56 km, there was an increase in the occurrence of metastatic disease (relative risk - RR:3.27; 95%CI:2.20-4.85), need for multiagent chemotherapy (RR:1.36; 95%CI:1.05-1.76), loss to follow-up during chemotherapy (RR:4.52; 95CI:1.93-10.63), occurrence of chemoresistance (RR:4.61; 95%CI:3.07-6.93), relapse (RR:10.27; 95%CI:3.08-34.28) and death due to GTN (RR:3.62; 95%CI:1.51-8.67). CONCLUSIONS: The distance between the patient's residence and the GTN-RC is a risk factor for unfavorable outcomes, including death from this disease. It is crucial to guarantee these patients get prompt access to the GTN-RC and receive follow-up support.

Influence of COVID-19 pandemic on molar pregnancy and postmolar gestational trophoblastic neoplasia: An observational study.

OBJECTIVE: To assess whether the incidence and aggressiveness of molar pregnancy (MP) and postmolar gestational trophoblastic neoplasia (GTN) changed during the COVID-19 pandemic. DESIGN: Observational study with two separate designs: retrospective multicentre cohort of patients with MP/postmolar GTN and a cross-sectional analysis, with application of a questionnaire. SETTING: Six Brazilian Reference Centres on gestational trophoblastic disease. POPULATION: 2662 patients with MP/postmolar GTN treated from March-December/2015-2020 were retrospectively evaluated and 528 of these patients answered a questionnaire. METHODS: Longitudinal retrospective multicentre study of patients diagnosed with MP/ postmolar GTN at presentation and a cross-sectional analysis, with application of a questionnaire, exclusive to patients treated during the period of study, to assess living and health conditions during the COVID-19 pandemic compared with previous years. MAIN OUTCOME MEASURES: The incidence of MP/postmolar GTN. RESULTS: Compared with the last 5 pre-pandemic years, MP/postmolar GTN incidence remained stable during 2020 (COVID-19 pandemic). Multivariable logistic regression, adjusted for the patient age, showed that during 2020, presentation with MP was more likely to be >10 weeks of gestation (adjusted odds ratio [aOR] 2.50, 95% confidence interval [CI] 1.90-3.29, P < 0.001), have a pre-evacuation hCG level ≥100 000 iu/l (aOR 1.77, 95% CI 1.38-2.28, P < 0.001) and time to the initiation of chemotherapy ≥7 months (aOR 1.86, 95% CI 1.01-3.43, P = 0.047) when compared with 2015-2019. CONCLUSIONS: Although the incidence of MP/postmolar GTN remained stable during the COVID-19 pandemic in Brazil, the pandemic was associated with greater gestational age at MP diagnosis and more protracted delays in initiation of chemotherapy for postmolar GTN.

Perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic neoplasia: a systematic review of observational studies and meta-analysis.

OBJECTIVE: To assess perinatal outcomes of first pregnancy after remission from gestational trophoblastic neoplasia and the impact of the time between the end of chemotherapy and the subsequent pregnancy. DATA SOURCES: The Medical Subject Headings related to perinatal outcomes, chemotherapy, and gestational trophoblastic neoplasia were used alone or in combination to retrieve relevant articles. We searched all references registered until April, 2019 in Embase, LILACS, MEDLINE, the Cochrane Central Register of Controlled Trials, and Web of Science. STUDY ELIGIBILITY CRITERIA: We included any observational or interventional studies that evaluated perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic neoplasia. Animal studies, narrative reviews, expert opinions, and previous treatments with potential risks for future perinatal outcomes which may introduce confounding bias were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers independently screened all identified references for eligibility and data extraction. Methodological quality and bias of included studies were assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Institutes of Health. For the meta-analysis, the measures of association were calculated using bivariate random-effects models. Statistical heterogeneity was evaluated with I2 statistics and explored through sensitivity analysis. Publication bias was assessed by visual inspection of the funnel plot or Egger's test, according to the number of articles included. For all analyses, a P value of <.05 indicated statistical significance. This study was registered on PROSPERO (CRD42018116513). RESULTS: A total of 763 studies were identified after literature search and 23 original studies were included in the systematic review and in the meta-analysis. The combined data from the subgroup meta-analysis (outcome vs time after chemotherapy) showed an incidence of spontaneous abortion of 15.28% (95% confidence interval, 12.37-18.74; I2=73%), 3.30% of malformation (95% confidence interval, 2.27-4.79; I2=31%), 6.19% of prematurity (95% confidence interval, 5.03-7.59; I2=0), and 1.73% of stillbirth (95% confidence interval, 1.17-2.55; I2=0%). These results were not influenced by the time between the end of chemotherapy and the subsequent pregnancy in most of the studied outcomes, including malformation (P=.14, I2=31%), prematurity (P=.46, I2=0), and stillbirth (P=.66, I2=0). However, there was a higher occurrence of spontaneous abortion (P<.01, I2=73%) in pregnancies that occurred ≤6 months after chemotherapy. CONCLUSION: Chemotherapy for gestational trophoblastic neoplasia does not appear to increase the chance of unfavorable perinatal outcomes, except for the higher occurrence of spontaneous abortion in pregnancies occurring ≤6 months after chemotherapy.

Gestational trophoblastic neoplasia lethality among Brazilian women: A retrospective national cohort study.

OBJECTIVE: To investigate GTN lethality among Brazilian women comparing cases of death by GTN with those who survived, thereby identifying factors associated with GTN lethality. METHODS: We retrospectively reviewed medical records of women with GTN treated at ten Brazilian GTN Reference Centers, from January 1960 to December 2017. We evaluated factors associated with death from GTN and used Cox proportional hazards regression models to identify independent variables with significant influence on the risk of death. RESULTS: From 2186 patients with GTN included in this study, 2092 (95.7%) survived and 89 (4%) died due to GTN. When analyzing the relative risk (RR), adjusted for WHO/FIGO score, patients with low risk disease had a significantly higher risk of death if they had choriocarcinoma (RR: 12.40), metastatic disease (RR: 12.57), chemoresistance (RR: 3.18) or initial treatment outside the Reference Center (RR: 12.22). In relation to patients with high-risk GTN, these factors were significantly associated with death due to GTN: the time between the end of antecedent pregnancy and the initiation of chemotherapy (RR: 4.10), metastatic disease (RR: 14.66), especially in brain (RR: 8.73) and liver (RR: 5.76); absence of chemotherapy or initial treatment with single agent chemotherapy (RR: 10.58 and RR: 1.81, respectively), chemoresistance (RR: 3.20) and the initial treatment outside the Reference Center (RR: 28.30). CONCLUSION: The risk of mortality from low and high-risk GTN can be reduced by referral of these patients to a Reference Center or, if not possible, to involve clinicians in a Reference Center with consultation regarding management.

Is chemotherapy always necessary for patients with nonmetastatic gestational trophoblastic neoplasia with histopathological diagnosis of choriocarcinoma?

OBJECTIVE: To evaluate expectant management versus immediate chemotherapy following pathological diagnosis of gestational choriocarcinoma (GCC) in patients with nonmetastatic disease. METHODS: Multicenter retrospective cohort that included patients with histological diagnosis of GCC with nonmetastatic disease followed at one of thirteen Brazilian referral centers for gestational trophoblastic disease from January 2000 to December 2016. RESULTS: Among 3191 patients with gestational trophoblastic neoplasia, 199 patients with nonmetastatic GCC were identified. Chemotherapy was initiated immediately in 152 (76.4%) patients per FIGO 2000 guideline, while 47 (23.6%) were managed expectantly. Both groups presented with similar characteristics and outcomes. All patients (n=12) who had normal human chorionic gonadotropin (hCG) in the first 2-3weeks of expectant management achieved complete sustained remission with no chemotherapy. Only 44.7% (21 patients) of patients who were expectantly managed needed to receive chemotherapy due to plateauing or rising hCG level in the first 2-3weeks of follow up. The outcome of patients receiving chemotherapy after initial expectant management was similar to those who received chemotherapy immediately after the diagnosis in terms of need for multi-agent chemotherapy or number of cycles of chemotherapy. There was no case of relapse or death in either group. Logistic regression analysis showed that age≥40years and hCG≥92,428IU/L at GCC diagnosis were risk factors for needing chemotherapy after initial expectant management of nonmetastatic GCC. CONCLUSION: In order to avoid exposing patients unnecessarily to chemotherapy, close surveillance of women with pathological diagnosis of nonmetastatic GCC seems to be a safe practice, particularly for those who have a normal hCG at the time of diagnosis. If confirmed by other studies, the FIGO guidelines may need to be revised.

Experience With the Use of an Online Community on Facebook for Brazilian Patients With Gestational Trophoblastic Disease: Netnography Study.

BACKGROUND: The term gestational trophoblastic disease (GTD) includes both complete and partial moles, which are uncommon nonviable pregnancies with the potential to evolve into a malignancy known as gestational trophoblastic neoplasia. While highly curable, the potential for malignancy associated with molar pregnancies worries the patients, leading them to seek information on the internet. A Facebook page headed by Brazilian specialized physicians in GTD was created in 2013 to provide online support for GTD patients. OBJECTIVE: The objective of our study was to describe the netnography of Brazilian patients with GTD on Facebook (FBGTD) and to evaluate whether their experiences differed depending on whether they received care in a Brazilian gestational trophoblastic disease reference center (BRC) or elsewhere. METHODS: This was a cross-sectional study using G Suite Google Platform. The members of FBGTD were invited to participate in a survey from March 6 to October 5, 2017, and a netnographic analysis of interactions among the members was performed. RESULTS: The survey was answered by 356 Brazilian GTD patients: 176 reference center patients (RCP) treated at a BRC and 180 nonreference center patients (NRCP) treated elsewhere. On comparing the groups, we found that RCP felt safer and more confident at the time of diagnosis of GTD (P=.001). RCP were more likely to utilize FBGTD subsequent to a referral by health assistants (P<.001), whereas NRCP more commonly discovered FBGTD through Web searches (P<.001). NRCP had higher educational levels (P=.009) and were more commonly on FBGTD for ≥ 6 months (P=.03). NRCP were more likely to report that doctors did not adequately explain GTD at diagnosis (P=.007), had more doubts about GTD treatment (P=.01), and were less likely to use hormonal contraception (P<.001). Overall, 89% (317/356) patients accessed the internet preferentially from home and using mobile phones, and 98% (349/354) patients declared that they felt safe reading the recommendations posted by FBGTD physicians. CONCLUSIONS: This netnographic analysis of GTD patients on FBGTD shows that an Web-based doctor-patient relationship can supplement the care for women with GTD. This resource is particularly valuable for women being cared for outside of established reference centers.

Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6months after uterine evacuation?

OBJECTIVE: To compare the outcomes of Brazilian patients with molar pregnancy who continue human chorionic gonadotropin (hCG) surveillance with those treated with chemotherapy when hCG was still positive, but falling at 6months after uterine evacuation. METHODS: Retrospective chart review of 12,526 patients with hydatidiform mole treated at one of nine Brazilian reference centers from January 1990 to May 2016. RESULTS: At 6months from uterine evacuation, 96 (0.8%) patients had hCG levels raised but falling. In 15/96 (15.6%) patients, chemotherapy was initiated immediately per FIGO 2000 criteria, while 81/96 (84.4%) patients were managed expectantly. Among the latter, 65/81 (80.2%) achieved spontaneous remission and 16 (19.8%) developed postmolar gestational trophoblastic neoplasia (GTN). Patients who received chemotherapy following expectant management required more time for remission (11 versus 8months; p=0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6months; p<0.001), and presented with a median WHO/FIGO risk score higher than women treated according to FIGO 2000 criteria (4 versus 2, p=0.04), but there were no significant differences in the need for multiagent treatment regimens (1/15 versus 3/16 patients, p=0.60). None of the women relapsed, and no deaths occurred in either group. CONCLUSION: In order to avoid unnecessary exposure of women to chemotherapy, we no longer follow the FIGO 2000 recommendation to treat all patients with molar pregnancy and hCG raised but falling at 6months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients.

Centralized Coordination of Decentralized Assistance for Patients with Gestational Trophoblastic Disease in Brazil: A Viable Strategy for Developing Countries.

OBJECTIVE: To report on the Brazilian Association of Gestational Trophoblastic Disease's (GTD) formation of a network of regional care at specialized centers for women with GTD. STUDY DESIGN: We developed a questionnaire composed of 15 questions, which was sent by email to the 38 Brazilian GTD Reference Center (BGTDRC) Directors who are members of the Brazilian Association of GTD, in order to characterize the professionals involved in the care of patients with GTD and the type of assistance provided. RESULTS: The Directors of the BGTDRCs are usually specialists in Gynecology and Obstetrics (97%), with a median experience of a decade in treating women with GTD. The BGTDRCs are linked to university hospitals in 75% of centers and provide completely free medical care in 87%. However, 52% of centers do not perform chemotherapy in their reference center, and patients are referred elsewhere for chemotherapy. Despite some difficulties, the rate of patients lost to follow-up before human chorionic gonadotropin remission is 9%, and the GTD mortality rate is 0.9%. CONCLUSION: Due to large regional disparities, the BGTDRCs are not uniformly organized. However, under the coordination of the Brazilian Association of GTD there is now strong communication and collaboration among reference centers, which has significantly advanced both patient care and research into the management of these diseases.

Gestational trophoblastic neoplasia after spontaneous human chorionic gonadotropin normalization following molar pregnancy evacuation.

OBJECTIVE: To evaluate the risk of gestational trophoblastic neoplasia (GTN) after spontaneous human chorionic gonadotropin normalization in postmolar follow-up. METHODS: Retrospective chart review of 2284 consecutive cases of hydatidiform mole with spontaneous normalization of hCG following uterine evacuation treated at one of five Brazilian reference centers from January 2002 to June 2013. RESULTS: After hCG normalization, GTN occurred in 10/2284 patients (0.4%; 95% CI 0.2%-0.8%). GTN developed in 9/1424 patients (0.6%; 95% CI 0.3%-1.2%) after a complete hydatidiform mole, in 1/849 patients (0.1%; 95% CI<0.01%-0.7%) after a partial hydatidiform mole, and in 0/13 patients (0%; 95% CI 0%-27%) after a twin molar pregnancy. The median time to GTN diagnosis after hCG normalization was 18months, and no diagnoses were made before six months of postmolar surveillance. Patients who required more than 56days to achieve a normal hCG value had a ten-fold increased risk of developing GTN after hCG normalization (9/1074; 0.8%; 95% CI 0.4%-1.6%) compared to those who reached a normal hCG level in fewer than 56days (1/1210;0.08%; 95% CI<0.01%-0.5%; p=0.008). All patients presented with symptoms at the time of GTN diagnosis. CONCLUSION: GTN after spontaneous hCG normalization following molar pregnancy is exceedingly rare, and the few patients who do develop GTN after achieving a normal hCG value are likely to be diagnosed after completing the commonly recommended six months of postmolar surveillance. Current recommendations for surveillance after hCG normalization should be revisited.

Epidemiological report on the treatment of patients with gestational trophoblastic disease in 10 Brazilian referral centers: results after 12 years since International FIGO 2000 Consensus.

OBJECTIVE: To evaluate treatment of Brazilian patients with gestational trophoblastic disease (GTD). STUDY DESIGN: A retrospective cohort study with analysis of medical reports performed in 10 Brazilian referral centers from January 2000 to December 2011. RESULTS: Of 5,250 patients 3 died (0.06%) at the time of uterine evacuation. Spontaneous remission of GTD (group G1) was observed in 4,103 cases, and 1,144 (21.8%) progressed to gestational trophoblastic neoplasia (GTN) (G2). In G1 2,716 (66.2%) had complete hydatidiform mole (HM) and 1,210, partial HM (29.5%); 3,772 patients (92.7%) recovered as noted in December 2012. In G2, of 1,118 patients treated, initial histopathological results of previous gestation were complete HM (77.5% [n = 886]), partial HM (8.8% [n = 100]), and choriocarcinoma (8.0% [n = 92]); 930 (81.3%) were low-risk, 200 (17.5%) were high-risk GTN, and 14 had placental site trophoblastic tumor (PSTT) (1.2%); cure was achieved in 1,078 cases (96.4%), but 26 patients (2.3%) died (4 low-risk [0.4%], 19 high-risk [9.5%], and 3 PSTT [21.4%]). CONCLUSION: The highest death rates were due to high-risk GTN and PSTT. Patients with molar pregnancy should be referred to a referral center for an early diagnosis and prompt treatment of GTN in order to reduce the morbidity and mortality found in advanced stages.

Does a human chorionic gonadotropin level of over 20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole constitute an indication for chemotherapy for gestational trophoblastic neoplasia?

OBJECTIVE: To evaluate whether a human chorionic gonadotropin (hCG) level ≥20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole (CHM) is an appropriate indicator for initiating chemotherapy for the treatment of gestational trophoblastic neoplasia (GTN). STUDY DESIGN: Historical database review of 1228 women with CHM who received treatment and follow-up between January 2000 and June 2013 at four Brazilian trophoblastic disease centers. The primary outcome measure was the progression from CHM to GTN. The secondary outcomes were the occurrence of uterine perforation, staging of GTN, WHO/FIGO risk score, and treatment (use of single- or multiagent chemotherapy). RESULTS: An hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM, while occurring in only 6.1% of women, was the most important risk factor for the development of postmolar GTN (adjusted RR = 5.83; p < 0.01; CI: 3.47-9.79), with a sensitivity of 36.8%, a specificity of 98.6%, a positive predictive value of 80%, and a negative predictive value of 91.1%. On the other hand, there were no differences in postmolar GTN stage, prognostic score, or need for multiagent chemotherapy relative to hCG level ≥20,000 IU/L versus <20,000 IU/L. CONCLUSIONS: Although hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM was very predictive of development of post-molar GTN, delay in treatment until hCG plateau or increase did not affect outcomes, with no uterine perforations or treatment failures.

Adesão ao seguimento ambulatorial de pacientes com doença trofoblástica gestacional atendidas em um centro de referência / Adherence to follow­up in patients with gestational trophoblastic disease treated at a referral center

Objetivo Avaliar a adesão das pacientes com doença trofoblástica gestacional (DTG) ao seguimento ambulatorial pós­molar em um centro de referência na região Centro­Oeste do Brasil. Métodos Estudo observacional, retrospectivo, que incluiu todas as pacientes diagnosticadas com DTG na Maternidade­Escola da Universidade Federal de Goiás em um ano. Foram colhidos dados referentes a idade, paridade e valores de B­hCG. A adesão ao seguimento ambulatorial e o exame histopatológico do produto do esvaziamento uterino foram obtidos pela revisão de prontuários. Resultados Entre as 55 pacientes incluídas no estudo, apenas 27 (49%) prosseguiram com o tratamento de forma completa; das quais 11 (40,7%) tiveram indicação de quimioterapia segundo o protocolo do Serviço. Conclusão A taxa de adesão ao seguimento ambulatorial foi baixa. O alto índice de pacientes com necessidade de quimioterapia determina um cenário alarmante sobre o prognóstico das pacientes que não concluíram o seguimento pós­molar. Esse estudo aponta a necessidade de estratégias efetivas para o manejo e o controle da doença.

Objective To evaluate the adherence to outpatient follow­up among patients with gestational trophoblastic disease (GTD) in a reference center in the Midwest region of Brazil. Methods This was an observational, retrospective study that included all patients diagnosed with GTD in the Maternity School of the Universidade Federal de Goiás in one year. Data were collected regarding age, parity and B­hCG values. Adherence to follow­up and histopathological examination of the uterine evacuation product were obtained by chart review. Results Among the 55 patients included in the study, only 27 (49%) continued with the treatment properly; of which 11 (40.7%) had chemotherapy indication by the protocol service. Conclusion The adherence rate to outpatient follow­up was low. The high rate of patients in need of chemotherapy determines an alarming scenario on the prognosis of patients who did not complete the follow­up. This study highlights the need for effective strategies for the management and control of the disease.

Gestação gemelar com mola hidatiforme completa e feto vivo / Twin pregnancy with a complete hydatidiform mole and live fetus

A gestação gemelar com mola hidatiforme completa que coexiste com feto vivo (GGMC) é uma entidade rara. Embora as recomendações sejam de conduta expectante, são descritas diversas complicações maternas e fetais, como o aumento da incidência de abortamento espontâneo, de parto prematuro, de sangramento vaginal, de pré-eclampsia grave e de doença trofoblástica persistente, entre outras complicações. Neste trabalho, descrevemos a evolução clínica de um caso de GGMC que evoluiu para crise tireotóxica, pré-eclâmpsia grave, interrupção da gestação e necessidade de cuidados intensivos maternos. A necropsia fetal evidenciou feto do sexo feminino, sem malformações aparentes, com alterações placentárias que favorecem cromossomopatia. A avaliação dos restos ovulares evidenciou vilosidades com hiperplasia do trofoblasto e vesículas, achados compatíveis com mola hidatiforme completa. Atualmente, após 15 meses de seguimento, a paciente permanece assintomática e com níveis indetectáveis de gonadotrofina coriônica.

Twin pregnancy with complete hydatidiform mole coexisting with a live fetus is a rare entity, and although the recommendations are expectant management of various maternal and fetal complications are described, such as increasing the number of spontaneous abortion, premature delivery, vaginal bleeding, pre-eclampsia and severe persistent trophoblastic disease, among other complications. In this paper, we describe the clinical course of a case of GGMC who developed thyrotoxic crisis, preeclampsia severe, termination of pregnancy and maternal need for intensive care. Fetal autopsy showed a female fetus with no apparent defects; with placental changes favoring chromosomal disorders. The evaluationof ovular remains showed villi with trophoblastic hyperplasia and vesicles, suggestive of complete mole. Currently, after 15 months of follow up, the patient remains asymptomatic with undetectable levels of chorionic gonadotropin.

Necessidade de cuidados intensivos em maternidade pública terciária / Necessity of intensive care in a tertiary public maternity hospital

Objetivos: avaliar os aspectos epidemiológicos e os relacionados ao parto de gestantes e puérperas transferidas para unidades de terapia intensiva (UTI's) e a freqüência com que estas pacientes necessitam de cuidados intensivos. Métodos: estudo observacional e descritivo das transferências obstétricas para UTI's, entre janeiro de 1999 e dezembro de 2001. A análise incluiu as seguintes variáveis: idade materna, paridade, indicações obstétricas e não-obstétricas para as transferências, momento em que estas ocorrem no ciclo gravídico-puerperal, tipo de parto, desfecho materno e freqüência com que estas transferências ocorrem em relação ao número total de partos (razão de morte iminente -RMI). A análise estatística foi realizada pelo teste do X² ou teste exato de Fisher, com nível de significância fixado em 5 por cento. Resultados: no período de 36 meses, ocorreram 86 transferências maternas (em 4.560 partos). Entre as pacientes transferidas, 52,3 por cento (n=45) eram nulíparas e 63 (73,2 por cento) tinham idade entre 19 e 35 anos. As síndromes hipertensivas representaram 57,7 por cento (n=41) das indicações e as síndromes hemorrágicas, 19,7 por cento (n=14). Eclâmpsia (n=23), síndrome HELLP (n=13) e descolamento prematuro da placenta normalmente inserida (n =5) foram as causas obstétricas mais prevalentes na determinação destas transferências. As cardiopatias maternas somaram 4 casos entre as indicações não-obstétricas. Houve predomínio das transferências puerperais (82,35 por cento). Cinqüenta e cinco pacientes (72,3 por cento) tiveram seus partos realizados através de cesarianas. O tempo médio de internação nas UTI's foi 5,1 dias. A mortalidade materna encontrada neste estudo correspondeu a 24,2 por cento, sendo que as síndromes hipertensivas foram responsáveis por 52,9 por cento (9/17) das mortes obstétricas diretas. Não houve diferença significante (p=0,81) entre os decessos matemos e suas causas (síndromes hipertensivas, hemorrágicas, infecciosas ou outras) ou entre mortalidade materna e duração da internação (< ou > 48 horas) nas UTI's (p=0,08). A RMI encontrada foi de 18,8/1.000 partos. Conclusões: a necessidade de cuidados intensivos estimada pela RMI foi de 18,8/1.000 partos, sendo que as síndromes hipertensivas induzidas pela gestação foram responsáveis pela maioria das indicações para as transferências maternas.

Tabagismo materno durante a gravidez - implicações na prática obstétrica / Maternal smoking during pregnancy - implications in obstetric practice

O consumo materno de cigarros durante a gestação está associado a aumento na morbimortalidade perinatal, em função da elevação nos coeficientes de natimortalidade, restrição de crescimento fetal, prematuridade e morte neonatal. Os eventos patológicos relacionam-se às alterações hemodinâmicas no concepto e útero, tempo de tabagismo, quantificação do número de cigarros consumidos durante o período gestacional e exposição fetal. Novos estudos são necessários, especialmente em prevenção, prognóstico e possibilidades de tratamento do tabagismo na gestação para adequação da assistência materno-fetal.

Doppler na neoplasia trofoblástica gestacional / Doppler in gestational trophoblastic tumor

Este estudo descreve método seguro e reproduzível para se obter onda de velocidade de fluxo das artérias uterinas baseado na observaçåo de 21 pacientes com tumor trofoblástico gestacional (TTG). O índice de pulsatilidade foi 1,35 (média), mostrando característico perfil dopplerfluxométrico que sugere a presença de vasos sangüíneos de muito baixa resistência. A ultra-sonografica e o doppler såo modalidades complementares que podem detectar o TTG, e o doppler parece ser mais sensível do que a ultra-sonografia em fazer este diagnóstico. Concluímos que a ultra-sonografia transvaginal, com ou sem imagem colorida, e a análise do fluxo sangüíneo podem ser usadas para assegurar a hemodinâmica da artéria uterina e do miométrio, e na propedêutica inicial destes tumores antes da quimioterapia

Gravidez ectópica / Ectopic pregnancy

Durante o período de março de 1974 a abril de 1984, 89 casos de gravidez ectópica foram tratados no Hospital Geral de Goiânia/INAMPS. A média de gestaçöes de cada paciente foi de 3,4, a paridade de 1,8, de aborto 0,7 e a idade gestacional de 7,5 semanas. Todas as pacientes relataram dor abdominal. A punçäo do fundo de saco de Douglas deu resultados negativos em 6,4% dos casos, a ultra-sonografia deu resultados positivos em 80% dos casos. Nos antecedentes 37,5% relataram laqueadura prévias, e 31,4% prenhez tubária anterior. A maioria das gravidezes ectópicas estavam localizadas na tuba. Gravidez abdominal foi observada em um caso, do qual nasceu um feto vivo, através de laparotomia. A salpingectomia foi realizada em 73% dos casos