Use of clomiphene citrate protocol for controlled ovarian stimulation impairs endometrial maturity.

INTRODUCTION: Despite recent advances in assisted reproduction techniques and recent knowledge regarding embryo and endometrium quality, implantation and birth rates remain low. The objective of this study was to investigate whether clomiphene citrate alters endometrial maturation in infertile patients. METHODS: In a prospective self-matched cohort study, we assessed the ovulation of women in spontaneous and stimulated cycles (with clomiphene citrate). We determined the ovulation day by ultrasound scanning. In both cycles, we took four blood samples (BS1 - at early proliferative phase, BS2 - at mid proliferative phase, BS3 - after ovulation and BS4 - at mid luteal phase) to determine the serum concentrations of FSH, LH, estradiol and progesterone. We retrieved an endometrial biopsy five days after ovulation, followed by blinded analysis and classification according to Noyes criteria, in both cycles. RESULTS: Twenty-two participants completed the study. There were significant differences in FSH BS3 (p=0.001), in LH BS3 and BS4 (p<0.001 and p=0.049, respectively), in estradiol BS2, BS3 and BS4 (p<0.001, p=0.024 and p<0.001, respectively) and in progesterone BS3 and BS4 (p=0.028 and p<0.001, respectively). Considering Noyes criteria, there was a one-day delay when comparing the stimulated cycle with the spontaneous cycle (p=0.004), and a two-day delay when comparing the stimulated cycle with the biopsy day. CONCLUSION: This study indicates that ovarian stimulation with clomiphene citrate delays the endometrial maturity, and could possibly impair the implantation process due to asynchrony.

Follow-up of Toxoplasmosis during Pregnancy: Ten-Year Experience in a University Hospital in Southern Brazil.

OBJECTIVE: To describe a population of pregnant women diagnosed with toxoplasmosis and their respective newborns, describing the hospital protocol for treatment and follow-up. METHODS: Retrospective cohort of pregnant women with acute toxoplasmosis infection and risk of transplacental transmission who were sent to the Fetal Medicine Group of Hospital de Clínicas de Porto Alegre (HCPA) between - January 1, 2006 and December 31, 2016. All patients with confirmed disease were included. The diagnostic protocol and treatment were applied; a polymerase chain reaction (PCR) analysis of the amniotic fluid was used to diagnose toxoplasmosis and determine the treatment. The newborns were followed up at the pediatric outpatient clinic specializing in congenital infection. The patients who were not followed up or were not born in the HCPA were excluded. RESULTS: A total of 65 patients were confirmed to have gestational toxoplasmosis; 40 performed amniocentesis, and 6 (15%) were identified as having positive PCR in the amniotic fluid. In five of those cases, this result associated with the gestational age defined the triple therapy during pregnancy, and in one case, it defined the monotherapy (advanced gestational age). A total of 4 of these newborns were treated from birth with triple therapy for 10 months, 1 was not treated (due to maternal refusal), and 1 progressed to death within the first 54 hours of life due to complications of congenital toxoplasmosis. Of the 34 remaining cases with a negative PCR, 33 were treated with monotherapy and 1 was treated with triple therapy (ultrasound findings); of these children, 9 (26.5%) presented negative immunoglobulin G (IgG), 24 (70.6%) presented positive IgG (but none presented positive immunoglobulin M [IgM]), and 1 (2,9%) presented alterations compatible with congenital disease and started treatment with the triple therapy soon after birth. Out of the total sample of 60 patients, among the 25 who did not perform amniotic fluid PCR, 5 were treated with triple therapy (ultrasound findings/prior treatment) and 20 patients were submitted to monotherapy; only two newborns underwent treatment for congenital toxoplasmosis. Among the 65 cases of gestational toxoplasmosis, 6 (9,2%) children had a diagnosis of congenital toxoplasmosis, and 2 patients with triple therapy felt severe adverse effects of the medications. CONCLUSIONS: The present study suggests that research on PCR screening of the amniotic fluid may be useful to identify patients with a higher potential for fetal complications, who may benefit from the poly-antimicrobial treatment. Patients with negative PCR results must continue to prevent fetal infection with monotherapy, without risk of fetal or maternal impairment.

OBJETIVO: Descrever uma população de pacientes diagnosticadas com toxoplasmose na gestação e seus respectivos recém-nascidos, relatando o protocolo do hospital durante o tratamento e seguimento. MéTODOS: Coorte retrospectiva de gestantes com infecção aguda por toxoplasmose e risco de transmissão transplacentária, encaminhadas para acompanhamento pelo Grupo de Medicina Fetal do Hospital de Clínicas de Porto Alegre (HCPA) entre 1o de janeiro de 2006 e 31 de dezembro de 2016. Todas as pacientes com doença confirmada foram incluídas. O protocolo de diagnóstico e tratamento foi aplicado; uma análise da reação em cadeia da polimerase (RCP) no líquido amniótico foi utilizada para diagnosticar a toxoplasmose e determinar o tratamento. Os recém-nascidos foram acompanhados no ambulatório de pediatria especializado em infecções congênitas. Pacientes que não foram seguidas ou cujo parto não foi feito no hospital foram excluídas. RESULTADOS: A toxoplasmose gestacional foi confirmada em 65 pacientes; 40 realizaram amniocentese, e 6 (15%) foram identificadas com RCP positiva no líquido amniótico. Este resultado associado à idade gestacional definiu a terapia tríplice durante a gestação em 5 casos, e a monoterapia em 1 caso (por idade gestacional avançada). Quatro destas crianças foram tratadas desde o nascimento com terapia tríplice por 12 meses, 1 não foi tratada (por recusa materna), e 1 evoluiu com óbito dentro das primeiras 54 horas de vida devido a complicações da toxoplasmose congênita. Dos 34 casos remanescentes com RCP negativa, 33 foram tratados com monoterapia, e 1 foi tratado com terapia tríplice (por achados ultrassonográficos); destes recém-nascidos, 9 (26,5%) tiveram imunoglobulina G (IgG) negativa, 24 (70,6%) tiveram IgG positiva, mas nenhum apresentou imunoglobulina M (IgM) positiva, e 1 (2,9%) apresentou alterações compatíveis com doença congênita e iniciou a terapia tríplice logo após o nascimento. Entre as 25 pacientes que não fizeram RCP no líquido amniótico, 5 foram tratadas com terapia tríplice (por achados ultrassonográficos/tratamento prévio) e 20 receberam monoterapia; somente 2 recém-nascidos receberam tratamento para toxoplasmose congênita. Entre os 65 casos de toxoplasmose gestacional, 6 (9,2%) recém-nascidos tiveram o diagnóstico de toxoplasmose congênita. Um total de 2 pacientes submetidas à terapia tríplice apresentaram efeitos adversos severos das medicações utilizadas. CONCLUSãO: Este estudo sugere que a triagem da RCP para toxoplasmose do líquido amniótico pode ser útil no rastreamento de pacientes com maior potencial para complicações fetais, que podem se beneficiar do tratamento poli antimicrobiano. Pacientes com RCP negativa devem continuar a prevenir a infecção fetal com monoterapia, sem risco de comprometimento fetal ou materno.

The natural history of pregnancies with prenatal diagnosis of Trisomy 18 or Trisomy 13: Retrospective cases of a 23-year experience in a Brazilian public hospital.

Trisomy 18 (T18) and trisomy 13 (T13) are polymalformative syndromes associated with a high rate of spontaneous abortions, intrauterine death, and short postnatal life. This study describes the overall outcome in a country where the therapeutic interruption of pregnancy is not available. The medical records of women with prenatal diagnosis of full trisomy of T13 or T18 between October 1994 and October 2017 were analyzed in order to describe their natural outcomes. Thirteen cases of T13 and 29 cases of T18 were included. The miscarriage rate was 9% for T18 and no cases for T13. Intrauterine fetal death occurred in 46% and 52% of cases for T13 and T18, respectively. The rate of live births for T13 was 54%, and the median survival was one day (95% CI -33.55 - 90.40) and 71% died in the first 24 hours of life. The rate of live births for T18 was 37% and the median survival was two days (95% CI -1.89 - 13.17); 90% of the affected babies died within first week of life. For the affected babies reaching the first year of life and for those who lived longer, multiple invasive and expensive procedures were required, without success in prolonging life beyond 180 days. This large series provides information for professionals and women regarding the natural histories of T13 and T18. Results of this study are consistent with those referenced in the literature, emphasizing the need of structured protocols and guidelines aiming early T13 and T18 diagnosis, prenatal care, gestation/parents follow-up, and counseling processes. For those couples with earlier diagnosis, a better follow-up and counseling during the prenatal care lead to the option for a support or palliative management of the newborn. Finally, when the counseling process is appropriate, it becomes easier to take decisions respecting the parent's autonomy and to look for better outcomes for both, the mother and the fetus.

[How a group of women perceives gestational hypertension disease]. / Percepções de um grupo de mulheres sobre a doença hipertensiva específica da gestação.

This study aims to identify the knowledge women in childbirth (puerperas) have regarding gestational hypertension disease (GHD), to learn how they perceive its risk and gravity, and to understand the repercussions of GHD for these women and their families. This is a descriptive exploratory study using qualitative research methods. Data collection took place through individual semi-structured interviews with ten women in childbirth (puerperas) who were diagnosed with GHD. The analysis of the data was performed using Content Analysis. Thematic categories emerged addressing the women's knowledge of GHD; how they perceive diagnosis and the professional care offered; and the repercussions GHD had for them and their families. The study highlights the necessity to rethink and to reorganize the model of perinatal care, not only at the tertiary level but also at primary healthcare centers.

Percepções de um grupo de mulheres sobre a doença hipertensiva específica da gestação / Impresión de un grupo de mujeres sobre la enfermedad hipertensiva específica de la gestación / Perceptions of a group of women about gestational hypertension disease

Objetivou-se identificar o conhecimento das puérperas em relação à doença hipertensiva específica da gestação (DHEG), conhecer suas percepções quanto ao risco e gravidade da doença e conhecer as repercussões da DHEG para estas mulheres e suas famílias. Trata-se de uma pesquisa qualitativa na perspectiva de um estudo exploratório descritivo. A coleta de informações ocorreu com dez puérperas com diagnóstico de DHEG por meio de entrevistas individuais semi-estruturadas, analisadas conforme referencial da Análise de Conteúdo. Assim, emergiram categorias temáticas abordando o conhecimento sobre DHEG, percepções sobre o diagnóstico e o cuidado profissional, e repercussões da DHEG para as mulheres e suas famílias. O estudo aponta a necessidade de se repensar e reorganizar o modelo de assistência perinatal, não apenas a nível terciário, mas nas unidades básicas de saúde.

Tuvo como objetivo identificar los conocimientos de las puérperas en relación a la enfermedad hipertensiva específica de la gestación (DHEG); saber sus impresiones sobre el riesgo y la gravedad de la enfermedad; y para saber las repercusiones de la DHEG para estas mujeres y sus familias. Se trata de una investigación cualitativa en la perspectiva de un estudio exploratorio descriptivo. La colecta de la información ocurrió a través de entrevistas individuales semiestructuradas con diez puérperas con diagnosis de DHEG, en el análisis fue usado el referencial de Análisis de Contenido. Así surgieron las categorías temáticas acercar de los conocimientos sobre la DHEG; impresiones sobre el diagnostico y el cuidado profesional; y las repercusiones de la DHEG para las mujeres y sus familias. El estudio apunta la necesidad de reconsiderar y reorganizar el modelo de asistencia perinatal, no solamente a nivel terciario, pero en las unidades básicas de salud.

The objective of this study was to identify the knowledge women in childbirth have regarding gestational hypertension disease (DHEG); to learn their perceptions of its risk and gravity; and to understand the repercussions of DHEG for these women and their families. This is a qualitative research aiming at an exploratory study. Data collection took place through individual semi-structured interviews with ten women in childbirth who were diagnosed with DHEG and data analysis was performed using the Analysis of Content. So, thematic categories emerged addressing the women´s knowledge of DHEG; their perceptions about the diagnosis and the professional care offered; and the repercussions DHEG had for them and their families. The study highlights the necessity to rethink and to reorganize the model of perinatal care, not only at the tertiary level but also at the basic health centers.