Risk factors for episiotomy: a case-control study / Fatores de risco para a episiotomia: um estudo de caso-controle

Objective: obtaining information on the factors associated with episiotomy will be useful in sensitizing professionals to the need to minimize its incidence. Therefore, the objective of this study was to evaluate risk factors for episiotomy in pregnant women who had undergone vaginal delivery at a university maternity hospital in northeastern Brazil. Methods: a case-control study was conducted with pregnant women submitted to episiotomy (cases) and pregnant women not submitted to episiotomy (controls) between March 2009 and July 2010 at the Professor Fernando Figueira Integral Medicine Institute (IMIP) in Recife, Brazil, in a ratio of 1 case to 2 controls. The study variables consisted of: whether episiotomy was performed, demographic, obstetric and fetal characteristics (primiparity, analgesia, instrumental delivery, fetal distress, etc.), external factors (day and time of delivery, professional attending delivery) and factors directly related to delivery. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated. Multivariate analysis was performed to determine the adjusted risk of episiotomy. Results: a total of 522 women (173 cases and 349 controls) were included. It was found that deliveries with episiotomy were more likely to have been attended by staff physicians (OR = 1.88; 95%CI: 1.01 - 3.48), to have required forceps (OR = 12.31; 95%CI: 4.9 - 30.1) and to have occurred in primiparas (OR = 4.24; 95%CI: 2.61 - 6.89). The likelihood of a nurse having attended the delivery with episiotomy was significantly lower (OR = 0.29; 95%CI: 0.16 - 0.55). Conclusion: episiotomy was found to be strongly associated with deliveries attended by staff physicians, with primiparity, and with instrumental delivery, and was less common in deliveries attended by nurses. .

Objetivo: avaliar os fatores de risco para a episiotomia em mulheres grávidas que passaram por parto normal em uma maternidade de uma universidade no nordeste do Brasil. Métodos: um estudo de caso-controle foi realizado com gestantes submetidas à episiotomia (casos) e mulheres grávidas não submetidas à episiotomia (controles) entre março de 2009 e julho de 2010, no Instituto de Medicina Integral Fernando Figueira (IMIP), Recife, Brasil, em uma proporção de um caso para dois controles. As variáveis do estudo foram: se episiotomia foi realizada, demográficos, obstétricos e características fetais (primiparidade, analgesia, parto instrumental, sofrimento fetal, etc.), fatores externos (dia e hora do parto, profissional que realizou o parto) e fatores diretamente relacionados ao par-to. Odds ratio (OR) e intervalos de confiança de 95% (IC 95%) foram calculados. A análise multivariada foi realizada para determinar o risco ajustado de episiotomia. Resultados: um total de 522 mulheres (173 casos e 349 controles) foi incluído. Verificou-se que os partos com episiotomia eram mais propensos a ter sido atendidos por médicos do staff (OR = 1,88, IC 95%: 1,01 - 3,48), necessidade de fórceps (OR = 12,31, IC 95%: 4,9 - 30,1) e ter ocorrido em primíparas (OR = 4,24, 95% CI: 2,61 - 6,89). A probabilidade de uma enfermeira ter assistido o parto com realização de episiotomia foi significativamente me-nor (OR = 0,29, 95% CI: 0,16 - 0,55). Conclusão: a episiotomia foi considerada fortemente associada a partos assistidos por médicos da equipe, primiparidade e a parto instrumental, e foi menos comum em partos assistidos por enfermeiros. .

[Prevalence and factors associated with violence suffered by incarcerated women for drug trafficking in the state of Pernambuco, Brazil: a cross-sectional study]. / Prevalência e fatores associados à violência sofrida em mulheres encarceradas por tráfico de drogas no Estado de Pernambuco, Brasil: um estudo transversal.

The scope of this study was to estimate the prevalence and factors associated with the violence suffered by women accused of drug trafficking in the 24 months prior to incarceration in the Women's Penal Colony in the State of Pernambuco. A cross-sectional study including 290 women aged 18 and above, with up to twelve months imprisonment, was performed for the data collection period. A questionnaire was applied to research the socioeconomic and demographic variables and the characteristics of violence and drug trafficking. All of the participants signed a consent form. The association between variables and intensity of exposure and response were determined by the chi-square test and the values (p < 0.05) were considered statistically significant. The study revealed that 71.4% of women were young; 78.9% non white, 85.8% unmarried with children, 83.3% had low education and 72.6% had income below the minimum wage. Furthermore, 56.9% were users of illicit drugs and 67.5% participated by performing some role in drug trafficking. A high prevalence of some form of violence suffered were observed in the population studied and the partner was the most frequent perpetrator (44.1%), calling for the authorities to pay greater attention in the actions of prevention of such violence.

Prevalência e fatores associados à violência sofrida em mulheres encarceradas por tráfico de drogas no Estado de Pernambuco, Brasil: um estudo transversal / Prevalence and factors associated with violence suffered by incarcerated women for drug trafficking in the state of Pernambuco, Brazil: a cross-sectional study

Este estudo objetivou estimar a prevalência e os fatores associados à violência sofrida nos 24 meses anteriores ao encarceramento de mulheres por tráfico de drogas em Colônia Penal Feminina no Estado de Pernambuco. Realizou-se um estudo de corte transversal incluindo 290 mulheres com 18 ou mais anos de idade e com até doze meses de encarceramento no período da coleta de dados. Utilizou-se como instrumento um questionário pesquisando variáveis socioeconômicas e demográficas e características da violência e do tráfico de drogas. Todas as participantes assinaram o Termo de Consentimento Livre e Esclarecido. A associação e a intensidade entre as variáveis de exposição e resposta foram determinadas pelo teste qui-quadrado e valores (p < 0,05) considerados estatisticamente significantes. O estudo mostrou que 71,4% das mulheres eram jovens; 78,9% não brancas; 85,8% solteiras com filhos; 83,3% tinham baixa escolaridade e 72,6% recebiam renda inferior ao salário mínimo. Usaram drogas ilícitas 47,3% e desenvolveram algum papel no tráfico de drogas 67,5%. Prevalências elevadas para algum tipo de violência sofrida foram observadas na população estudada e o companheiro foi identificado como perpetrador mais frequente (44,1%), sugerindo maior atenção das autoridades nas ações de prevenção desses agravos.

The scope of this study was to estimate the prevalence and factors associated with the violence suffered by women accused of drug trafficking in the 24 months prior to incarceration in the Women's Penal Colony in the State of Pernambuco. A cross-sectional study including 290 women aged 18 and above, with up to twelve months imprisonment, was performed for the data collection period. A questionnaire was applied to research the socioeconomic and demographic variables and the characteristics of violence and drug trafficking. All of the participants signed a consent form. The association between variables and intensity of exposure and response were determined by the chi-square test and the values (p < 0.05) were considered statistically significant. The study revealed that 71.4% of women were young; 78.9% non white, 85.8% unmarried with children, 83.3% had low education and 72.6% had income below the minimum wage. Furthermore, 56.9% were users of illicit drugs and 67.5% participated by performing some role in drug trafficking. A high prevalence of some form of violence suffered were observed in the population studied and the partner was the most frequent perpetrator (44.1%), calling for the authorities to pay greater attention in the actions of prevention of such violence.

Clonidine versus captopril for treatment of postpartum very high blood pressure: study protocol for a randomized controlled trial (CLONCAP).

BACKGROUND: The behavior of arterial blood pressure in postpartum of women with hypertension and pregnancy and the best treatment for very high blood pressure in this period still need evidence. The Cochrane systematic review assessing prevention and treatment of postpartum hypertension found only two trials (120 patients) comparing hydralazine with nifedipine and labetalol for the treatment of severe hypertension and did not find enough evidence to know how best to treat women with hypertension after birth. Although studies have demonstrated the effectiveness of treatment with captopril, side effects were reported. Because of these findings, new classes of antihypertensive drugs began to be administered as an alternative therapy. Data on the role of clonidine in this particular group of patients, its effects in the short and long term are still scarce in the literature. OBJECTIVES: To determine the effectiveness of clonidine, compared to captopril, for the treatment of postpartum very high blood pressure in women with hypertension in pregnancy. METHODS/DESIGN: The study is a triple blind randomized controlled trial including postpartum women with diagnosis of hypertension in pregnancy presenting very high blood pressure, and exclusion criteria will be presence of heart disease, smoking, use of illicit drugs, any contraindication to the use of captopril or clonidine and inability to receive oral medications.Eligible patients will be invited to participate and those who agree will be included in the study and receive captopril or clonidine according to a random list of numbers. The subjects will receive the study medication every 20 minutes until blood pressure is over 170 mmHg of systolic blood pressure and 110 mmHg diastolic blood pressure. A maximum of six pills a day for very high blood pressure will be administered. In case of persistent high blood pressure levels, other antihypertensive agents will be used.During the study the women will be subject to strict control of blood pressure and urine output. This proposal has already obtained approval of the local Institutional Review Board of the coordinating center (IMIP, Recife, Brazil) and of the National Council for Ethics in Research (CONEP) of the Brazilian Ministry of Health. TRIAL REGISTRATION: Clinical Trials Register under the number NCT01761916.

Fatores associados à indução do parto em gestantes com óbito fetal após a 20ª semana / Factors associated with induced delivery in pregnant women with a dead fetus after the 20th week of gestation

OBJETIVOS: determinar os fatores associados à indução do trabalho de parto em gestantes com óbito fetal. MÉTODOS: estudo seccional, com 258 gestantes após a 20ª semana e diagnóstico ultrassonográfico de óbito fetal, no período de janeiro/2005 a dezembro/2008, na maternidade do Hospital Barão de Lucena, Recife, Brasil. Características sociodemográficas, causas e tipos de óbito fetal, antecedentes obstétricos e características do parto foram variáveis estudadas. Foram utilizados testes qui-quadrado, exato de Fisher e ´t´ de Student. Razão de prevalência e análise de regressão logística múltipla também foram realizados. O nível de significância foi de 5 por cento. RESULTADOS: a indução do parto ocorreu em 83 (32,2 por cento) gestantes. Após análise multivariada, observou-se que a idade gestacional acima da 40ª semana de gravidez (OR= 126,5; IC95 por cento= 3,83-4.201,5) e óbito fetal tardio (OR= 6,86; IC95 por cento= 2,55-18,47) foram fatores de risco que permaneceram associados à indução do parto. Cesariana (OR= 0,02; IC95 por cento= 0,004-0,09), funiculopatias (OR= 0,12; IC95 por cento= 0,02-0,68), presença de uma ou menos gestações anteriores (OR= 0,34; IC95 por cento= 0,14-0,81) e uma ou mais cesáreas anteriores (OR= 0,16; IC95 por cento= 0,04-0,71) foram negativamente associados à indução. CONCLUSÕES: idade gestacional acima da 40ª semana e óbito fetal tardio são fatores de risco que podem estar associados à indução do parto em gestantes com óbito fetal.

OBJECTIVES: to determine the factors associated with induced delivery in pregnant women carrying a dead fetus. METHODS: a cross-sectional study with 258 pregnant women past the 20th week of gestation diagnosed by ultrasound as carrying a dead fetus, between January 2005 and December 2008, at the Hospital Barão de Lucena maternity hospital, in Recife, Brazil. Socio-demographic characteristics, causes and types of fetal death, prior obstetric data and characteristics of birth were the variables studied. The chi-square test, Fisher's exact test and Student's t test were used. The rate of prevalence was calculated and multiple logistic regression was carried out. The level of significance was 5 percent. RESULTS: birth was induced in 83 (32.2 percent) of the pregnant women. Following multivariate analysis, it was found that a gestational age of over 40 weeks (OR= 126.5; CI95 percent= 3.83-4,201.5) and late fetal death (OR= 6.86; CI95 percent= 2.55-18.47) were the risk factors that continued to be associated with induced delivery. Caesarian section (OR= 0.02; CI95 percent= 0.004-0.09), funiculopathy (OR= 0.12; CI95 percent= 0.02-0.68), having had one or more previous pregnancies (OR= 0.34; CI95 percent= 0.14-0.81) and one or more previous caesarian sections (OR= 0.16; IC95 percent= 0.04-0.71) were negatively associated with induced delivery. CONCLUSIONS: a gestational age of over 40 weeks and late fetal death are the risk factors that could be associated with induced delivery in pregnant women carrying a dead fetus.

Conduta obstétrica na centralização da circulação fetal / Obstetric management in fetal brain sparing effect

A centralização do fluxo sanguíneo fetal é um fenômeno de compensação vascular bastante estudado na atualidade. Trata-se de alterações na resistência da circulação fetal, caracterizada pela redistribuição hemodinâmica do fluxo sanguíneo, com perfusão preferencial para órgãos nobres (cérebro, coração e glândulas adrenais) em detrimento dos pulmões, rins, baço e esqueleto, o que pode ser diagnosticado pelo estudo dopplervelocimétrico. O momento ideal para intervenção obstétrica ainda não é consenso. Uma das grandes preocupações, em relação à avaliação da vitalidade fetal, diz respeito ao momento ideal para interrupção da gravidez, uma vez que alguns dos métodos utilizados apresentam uma alta frequência de resultado falso-positivos, podendo ocasionar um nascimento prematuro, por vezes, desnecessário. Em fetos muito prematuros a opção pela interrupção da gravidez pode trazer consequências irreversíveis. Na tentativa de minimizar os danos, optou-se pela realização de uma revisão, baseada nas melhores evidências sobre a conduta nos fetos centralizados.

Fetal brain-sparing effect is a vascular compensation phenomenon widely studied today. Diagnosed by Doppler study it consists of changes on resistance in the fetal circulation characterized by hemodynamic redistribution of blood flow, with preferential perfusion to brain, heart and adrenal glands compared to the lungs, kidneys, spleen and skeleton. There is no consensus over ideal time for obstetric intervention. Ideal time for pregnancy termination is of major concern when assessing fetal vitality since methods used today have high false positives rate, leading to unnecessary prematurity. In extreme prematurity the decision to terminate pregnancy can lead to irreversible consequences. In an attempt to minimize damage, it was decided to carry out a review, based on the best evidence regarding conduct in fetal brain sparing effect.

Tratamento da pré-eclâmpsia baseado em evidências / Pre-eclampsia treatment according to scientific evidence

As síndromes hipertensivas na gestação merecem especial destaque no cenário da saúde pública mundial. Atualmente, respondem como terceira causa de mortalidade materna no mundo e primeira no Brasil. Do ponto de vista prático, a pré-eclâmpsia continua sendo uma síndrome que leva a graves repercussões maternas e fetais, conhecendo-se ainda pouco sobre sua etiologia. Atualmente, tem-se discutido a melhor terapêutica para os quadros de pré-eclâmpsia em diversos momentos do ciclo gravídico-puerperal, visando sempre à redução de altos índices de morbimortalidade materna e fetal. O parto, considerando-se a fisiopatologia do evento, representa a melhor forma de tratamento. O uso de sulfato de magnésio é recomendado em todos os casos de pré-eclâmpsia grave e eclâmpsia para prevenção e tratamento das crises convulsivas. Da mesma forma, o tratamento dos picos hipertensivos é recomendado. Hidralazina, nifedipina e labetalol têm sido as drogas mais utilizadas com essa finalidade, mas seu uso dependente da familiaridade do médico assistente. A corticoterapia antenatal está indicada sempre que existe risco iminente de prematuridade entre a 24º e 34º semana. Em contrapartida, não há evidências suficientes para recomendar repouso e administração de expansores plasmáticos de rotina, assim como há necessidade urgente de ensaios clínicos randomizados para determinar se o tratamento anti-hipertensivo de manutenção nas gestantes apresenta benefícios ou riscos para mães e fetos, em todas as formas clínicas da doença, em particular nos casos de pré-eclâmpsia pura.

Hypertensive disorders in pregnancy deserve special attention in the setting of global public health. Currently, they represent the third cause of maternal mortality in the world and first in Brazil. From a practical standpoint, pre-eclampsia remains a syndrome that leads to serious repercussions on maternal and fetal mortality and its etiology is not well known. Currently, the best treatment for forms of pre-eclampsia is being discussed at different times in pregnancy and puerperium, with the objective to reduce the high rates of maternal and fetal morbidity and mortality. Considering the pathophysiology of the event, anticipation of delivery is the best treatment for pre-eclampsia. The use of magnesium sulfate is recommended in all cases of severe pre-eclampsia and eclampsia for prevention and treatment of seizures. Likewise, treatment of hypertensive crises is recommended. Hydralazine, nifedipine and labetalol have been the most commonly used drugs for this purpose, but their use depends on the familiarity of the treating physician. Antenatal corticoid therapy is indicated whenever there is an imminent risk of preterm delivery between 24 and 34 weeks. In contrast, there is insufficient evidence to recommend bed rest and routine plasma volume expansion, and there is an urgent need for randomized clinical trials to determine whether maintenance antihypertensive treatment in pregnant women has benefits or risks for mothers and fetuses in all clinical forms of disease, particularly in cases of pure pre-eclampsia.

Métodos farmacológicos de indução do trabalho de parto: qual o melhor? / Pharmacological methods for induction of labor: what's the best?

A indução do parto consiste em estimular artificialmente as contrações uterinas coordenadas e efetivas antes de seu início espontâneo, levando ao desencadeamento do trabalho de parto em mulheres que ultrapassaram a 22ª semana de gravidez. A antecipação do parto pode ser necessária em diversas situações obstétricas, como gestação prolongada, diabetes, ruptura prematura das membranas e pré-eclâmpsia. Estima-se que mais de 15% de todas as gestantes apresentem alguma indicação de indução do parto. Vários métodos de indução do parto são propostos, tanto naturais como artificiais e, dentre estes, os métodos farmacológicos merecem especial destaque. Realizou-se uma revisão da literatura baseada nos melhores níveis de evidências e considerando os graus de recomendação. De acordo com a literatura, a utilização de estrogênio, propranolol, relaxina, mefepristone e hialuronidade não deve ser estimulada por não existirem evidências suficientes para a sua recomendação. O seu uso, portanto, deve ser limitado a protocolos de pesquisas. Ocitocina é um método de indução efetivo que pode ser usado em pacientes com ruptura das membranas amnióticas. Prostaglandinas (PG) e misoprostol (um éster sintético da PGE1) são efetivos para a indução do parto independentemente da integridade das membranas. Prostaglandinas devem ser administradas preferencialmente por via vaginal. Habitualmente, o misoprostol é preferido devido a questões práticas, como o baixo custo e a facilidade de administração e estocagem. Doses baixas de misoprostol devem ser utilizadas e a atualmente recomendada é de 25 g a cada 4 ou 6 horas. Tanto a via oral como a via vaginal podem ser utilizadas.

Induction of labor consists of stimulation of effective and coordinated uterine contractions before their spontaneous onset for the purpose of bring on labor in women who have surpassed the 22nd week of pregnancy. In several obstetrical situations, such as prolonged pregnancy, diabetes, premature rupture of membranes and preeclampsia, anticipation of labor and delivery may be necessary. It is estimated that more than 15% of all pregnant women eventually present any indication for induction of labor. Several natural and artificial methods for induction are proposed. Among them, pharmacological methods are the most relevant. A literature review was carried out based on the highest levels of evidence and on the grade of recommendations. According to the literature, the use of estrogens, relaxin, mifepristone and hyaluronidade should not be stimulated because there are not enough evidences for their recommendation, so their utilization should be limited to research protocols. Oxytocin is an effective method for induction of labor that may be used in patients with ruptured membranes. On the other hand, prostaglandins and misoprostol (a prostaglandin E1 analog) are effective for induction of labor independently on the membrane integrity. Vaginal administration should be preferred for prostaglandins. Misoprostol is habitually preferred due to practical questions, such as low cost and facility for storage and administration. Low doses of misoprostol should be used, and the currently recommended dose is 25 g every four or six hours. Both vaginal and oral routes of administration can be used.

Indução do trabalho de parto: conceitos e particularidades / Induction of labor: concepts and particularities

O manejo das pacientes em indução do parto deve ser cuidadoso, observando-se as principais contraindicações, os riscos e as precauções. São contraindicações absolutas para indução do parto: a presença de causas obstrutivas do parto, o risco de morbidade perinatal grave e o risco materno. As contraindicações relativas são: frequência cardíaca fetal não-tranquilizadora, macrossomia fetal, gestação gemelar, apresentação pélvica, doença cardíaca materna, polidrâmnio, grande multiparidade, oligo-hidrâmnio e cesariana segmentar anterior. Suas possíveis complicações são a ruptura uterina, infecção intracavitária, prolapso de cordão umbilical, prematuridade iatrogênica, sofrimento ou morte fetal e falha da indução. A explicação e a discussão do que ocorrerá com a gestante, a seleção do local para a realização da indução do parto (de preferência com uma enfermeira por paciente) e a monitorização da vitalidade fetal são precauções importantes para evitar complicações. Diante de taquissistolia ou hiperestimulação uterina decorrente da indução do trabalho de parto, algumas medidas devem ser realizadas. Retirar o agente indutor resolve a maioria das situações. Não resolvendo, a tocólise é indicada. Caso ocorram alterações na frequência cardíaca fetal, medidas de ressuscitação intrauterina, apesar de não haver evidências suficientes de seu real benefício, podem ser tentadas. A indução em gestações com cesariana anterior é bastante controversa na literatura. Apesar de não haver evidências suficientes quanto aos riscos e benefícios, a atual recomendação é de que a indução com misoprostol seja evitada, podendo ser utilizada a ocitocina e sonda de Foley.

Management of patients submitted to labor induction must be careful with special attention to the main contraindications, risks and precautions. Absolute contraindications for labor induction include obstructive factors and increased risk of maternal or perinatal morbidity and mortality. Relative contraindications are non-reassuring fetal heart rate, fetal macrosomia, twin pregnancy, breech presentation, maternal cardiac disease, polyhydramnios, GREAT multiparity, oligohydramnios and previous segmental cesarean section. Possible complications are uterine rupture, intrauterine infectious, cord prolapsed, iatrogenic prematurity, fetal distress or death and failed induction. Some precautions are essential to avoid complications, such as discussing all the procedures with the pregnant women, defining the best local to conduct the induction (if possible, with one nurse by patient) and monitoring fetal well-being. When tachysystole or uterine hyperstimulation syndrome occurs as consequence of labor induction, some measures should be taken. Suspension of induction agent solves most of the cases, but acute tocolysis is indicated when the pattern of abnormal uterine contractility remains. In the presence of non-reassuring fetal heart rate, intrauterine resuscitation techniques may be carried out, although there is not enough evidence of their real benefits. Induction of labor in pregnancies with previous cesarean section remains controversial. Even though enough evidences about risks and benefits are not available yet, the current recommendation is to avoid induction with misoprostol but oxytocin and Foley catheter could be used in such cases.

Análise crítica dos métodos não-farmacológicos de indução do trabalho de parto / Critical analysis of non-pharmacological methods for induction of labor

A indução do trabalho de parto tem se tornado prática corrente na Obstetrícia moderna. Vários métodos têm sido propostos, e dentre eles os não-farmacológicos merecem destaque. Estes métodos podem ser classificados como naturais e artificiais. Os estudos realizados para avaliar os diversos métodos naturais, como homeopatia, acupuntura, óleo de rícino, enema, banho quente de imersão, relações sexuais e estimulação mamária para indução do trabalho de parto, são heterogêneos e ainda não existe evidência suficiente de que possam ser utilizados na prática clínica. Dentre os métodos artificiais, o descolamento das membranas encontra-se associado à indução efetiva do parto, porém, o procedimento é doloroso e pode ser desconfortável para as mulheres. A capacidade máxima de dilatação da laminária ocorre entre 12 e 24 horas, entretanto tem sido pouco utilizada devido ao surgimento de métodos mais efetivos. A sonda de Foley constitui um procedimento efetivo que pode ser usado na presença de contraindicações para os métodos farmacológicos, especialmente em gestantes com cesárea anterior, porém persistem preocupações quanto ao risco de infecção materna e fetal. Por outro lado, a ruptura artificial das membranas e os métodos mecânicos ainda não podem ser recomendados, porque as evidências sobre sua efetividade e segurança são insuficientes, mesmo quando associados à administração intravenosa de ocitocina.

Induction of labor has been currently a routine practice in Obstetrics. Several methods have been proposed and among them the non-pharmacological methods deserve consideration. These methods are classified as natural and artificial ones. Studies conducted to evaluate natural methods, such as homeopathy, acupuncture, ricin oil, enema, hot water immersion, sexual intercourse and nipple stimulation for labor induction, are heterogeneous and there is no enough evidence yet to support their use in clinical practice. Among artificial methods, membrane sweeping is associated with success on labor induction but can be a painful procedure, which is considered uncomfortable by several women. The maximum dilation of laminaria occurs between 12 and 24 hours, but this method has been less used because other methods are more effective. Foley catheter is a safe and effective procedure that can be used in the presence of contraindications for pharmacological methods, especially in pregnant women with previous cesarean section. Notwithstanding, there are still concerns about the risk of maternal/fetal infection. On the other hand, artificial rupture of membranes (amniotomy) cannot be recommended so far because evidences about its effectiveness and safety are insufficient, even when associated with intravenous administration of oxytocin.

Effect of the loading dose of magnesium sulfate (MgSO4) on the parameters of Doppler flow velocity in the uterine, umbilical and middle cerebral arteries in severe preeclampsia.

OBJECTIVE: To evaluate Doppler velocimetry parameters (resistance index [RI], pulsatility index [PI] and systolic/diastolic [S/D] ratio) of maternal-fetal circulation before and after magnesium sulfate administration in pregnant women with severe preeclampsia. METHODS: A prospective observational cohort analysis of 40 women with severe preeclampsia was performed. Doppler ultrasonography scans were performed before and 20 minutes after intravenous administration of magnesium sulfate. Maternal parameters such as heart rate, and systolic, diastolic and mean arterial pressure were recorded. Doppler flow velocity parameters (RI, PI and S/D ratio) were evaluated in the uterine, umbilical and middle cerebral arteries. The different mean values obtained before and after magnesium sulphate were analyzed using the paired t-test. RESULTS: There was a statistically significant increase in mean maternal heart rate and a statistically significant decrease in systolic, diastolic and mean maternal blood pressure before and after administration of magnesium sulphate (p < 0.001). Resistance index decreased in the umbilical (p = 0.003; 95% CI: 0.008 - 0.03) and middle cerebral artery (p = 0.001; 95% CI: 0.01 - 0.05) and in both uterine arteries. Likewise, there was a significant reduction in the PI and S/D ratio in all the arteries assessed. CONCLUSIONS: Maternal administration of intravenous magnesium sulfate in preeclampsia leads to an increase in maternal heart rate and a decrease in systolic, diastolic and mean arterial blood pressure. A reduction in the resistance index, pulsatility index and S/D ratio was recorded in the uterine, umbilical and cerebral arteries.

[Pre-eclampsia treatment according to scientific evidence]. / Tratamento da pré-eclâmpsia baseado em evidências.

Hypertensive disorders in pregnancy deserve special attention in the setting of global public health. Currently, they represent the third cause of maternal mortality in the world and first in Brazil. From a practical standpoint, pre-eclampsia remains a syndrome that leads to serious repercussions on maternal and fetal mortality and its etiology is not well known. Currently, the best treatment for forms of pre-eclampsia is being discussed at different times in pregnancy and puerperium, with the objective to reduce the high rates of maternal and fetal morbidity and mortality. Considering the pathophysiology of the event, anticipation of delivery is the best treatment for pre-eclampsia. The use of magnesium sulfate is recommended in all cases of severe pre-eclampsia and eclampsia for prevention and treatment of seizures. Likewise, treatment of hypertensive crises is recommended. Hydralazine, nifedipine and labetalol have been the most commonly used drugs for this purpose, but their use depends on the familiarity of the treating physician. Antenatal corticoid therapy is indicated whenever there is an imminent risk of preterm delivery between 24 and 34 weeks. In contrast, there is insufficient evidence to recommend bed rest and routine plasma volume expansion, and there is an urgent need for randomized clinical trials to determine whether maintenance antihypertensive treatment in pregnant women has benefits or risks for mothers and fetuses in all clinical forms of disease, particularly in cases of pure pre-eclampsia.

Farmacocinética e farmacodinâmica do misoprostol em Obstetrícia / Pharmacokinetics and pharmacodynamics of misoprostol in Obstetrics

Nos últimos anos a antecipação do parto vem sendo uma prática frequente na Obstetrícia. O misoprostol é um produto sintético, metil análogo da prostaglandina E1 que tem recebido maior atenção, principalmente para a indução do trabalho de parto e do abortamento, além de outras indicações, como controle da hemorragia pós-parto e para promover modificações na cérvice uterina, facilitando a realização de procedimentos como histeroscopia e colocação de dispositivo intrauterino. A administração do misoprostol atualmente é realizada por diferentes vias: oral, vaginal, bucal, sublingual e retal. Assim, é prudente o conhecimento da farmacologia, dos efeitos e mecanismos de ação do misoprostol nas diferentes formas de administração, com base nas evidências científicas e de acordo com os graus de recomendação. O maior pico do nível plasmático de misoprostol, em ordem decrescente, é do grupo sublingual, oral, vaginal com adição de água e vaginal. A biodisponibilidade é também maior na via sublingual. Entretanto, o nível plasmático é mantido por um maior período de tempo quando a via vaginal é utilizada.

Anticipation of delivery has been a frequent practice in Obstetrics nowadays. Misoprostol is a synthetic metyl analogue of prostaglandin E1 that has been used mainly for induction of labor and abortion, as well as for other indications like prevention and control of postpartum hemorrhage. In Gynecology, its use has been introduced to induce cervical modifications for facilitating gynecologic procedures as hysteroscopy and intrauterine device insertion. Misoprostol administration can be done by different routes: oral, vaginal, buccal, sublingual and rectal. Therefore, it is prudent to study pharmacokinetics and pharmacodynamics of this drug and its various routes of administration, according to scientific evidences and grades of recommendation. The highest plasmatic peak of misoprostol, in decreasing order, is sublingual, oral, vaginal and vaginal plus water administration route. Bioavailability is also greater for sublingual route. Notwithstanding, plasmatic levels are maintained for more time when vaginal route is used.

[Validation of ultrasound diagnosis of fetal anomalies at a reference center in Pernambuco]. / Validação do diagnóstico ultrassonográfico de anomalias fetais em centro de referência.

OBJECTIVE: To validate ultrasound diagnoses of fetal anomalies made in a Fetal Medicine Center in Pernambuco. METHODS: A cross sectional study was performed to validate the diagnosis test, including all high risk pregnant women submitted to obstetrical morphological ultrasound at the 'Instituto de Medicina Integral Professor Fernando Figueira (I.M.I.P.)', from March 2002 to March 2006. Prenatal diagnosis was confirmed after birth. Socio demographic characteristics and pre and postnatal frequencies of fetal anomalies were the variables studied. Agreement between pre and postnatal diagnoses from congenital anomalies were evaluated with the Kappa indicator. Youden's test was applied to validate prenatal ultrasound diagnoses. RESULTS: Nine hundred and eighty nine patients were eligible. After evaluation of inclusion and exclusion criteria 457 patients were included in study. The average maternal age was 24.8 + 6.5 years. Fetal anomaly diagnoses postnatal were confirmed in 257 (56.2%) pregnant women. Prenatal ultrasound diagnosis of fetal anomalies disclosed 96% of sensibility and 79% of specificity, good agreement (K=0.76) between pre and postnatal diagnoses when compared to postnatal results and good diagnostic validity (Y=0.75). CONCLUSION: Prenatal diagnoses of fetal anomalies at a Fetal Medicine center in Pernambuco demonstrate good sensibility, specificity, agreement pre and postnatal and good diagnostic validity.

[Amniotic fluid volume associated with fetal anomalies diagnosed in a reference center in the Brazilian Northeast]. / Volume do líquido amniótico associado às anomalias fetais diagnosticadas em um centro de referência do nordeste brasileiro.

PURPOSE: to determine factors associated to amniotic fluid volume and frequencies of fetal anomalies, in a reference center in Pernambuco. METHODS: a transversal study performed in high-risk pregnant women submitted to obstetrical morphological ultrasound, from March 2002 to March 2006, at an institution from Recife, Pernambuco, Brasil. The intrauterine diagnosis was confirmed after birth. Sociodemographic and obstetrical characteristics, amniotic liquid volume and presence of fetal anomalies were the variables studied. Fisher's exact, chi2, and Student's t tests, at a significance level of 5% were applied to verify the correlation among the variables. Prevalence rate and confidence interval at 95% were calculated. Multiple logistic regression analysis was performed at a significance level of 5%. RESULTS: Two hundred and fifty-seven pregnant women (56.2%) with congenital anomalies and 200 (43.8%) without anomalies, confirmed in the postnatal, were included in the study. The average of maternal ages and gestation periods were 24.8+/-6.5 years and 35.9+/-3.7 weeks, respectively. The fetal anomalies were discovered in the central nervous system (50.6%) and genitourinary tract (23.0%). The presence of congenital anomalies were significantly linked with reduced liquid/oligohydramnios (p=0.0002) and increased liquid/polyhydramnios (p<0.0001). Intrauterine mortality was more frequent in the group with anomalies, as compared to the healthy fetuses (10.5 versus 2.5%; p<0.01). CONCLUSIONS: The rate of congenital anomalies in the high-risk pregnant women group was 56.2%. Most of the central nervous system malformations were diagnosed intrauterus. Changes in the amniotic fluid were the factors more strongly associated with congenital anomalies.

[Effect of magnesium sulfate on pulsatility index of uterine, umbilical and fetal middle cerebral arteries according to the persistence of bilateral diastolic notch of uterine arteries in patients with severe preeclampsia]. / Efeito do sulfato de magnésio sobre o índice de pulsatilidade das artérias uterinas, umbilical e cerebral média fetal de acordo com a persistência da incisura protodiastólica da artéria uterina na pré-eclâmpsia grave.

PURPOSE: To evaluate the effect of magnesium sulphate on the pulsatility index (PI) of the uterine, umbilical and fetal middle cerebral arteries, according to the persistency or not of the bilateral protodiastolic notch of the uterine arteries in severe pre-eclampsia. METHODS: A cohort study including 40 pregnant women with severe pre-eclampsia, 23 of them presenting bilateral protodiastolic notch, and 17, unilateral/absent notch. The patients were submitted to Doppler velocimetry before and 20 minutes after the intravenous administration of 6 g of magnesium sulphate. The examination was carried out with the patient in semi-Fowler position, the sonograms being obtained during fetal inactivity, in apnea and absent uterine contraction periods. All the exams were performed by two researchers, the average being considered as the final result. Wilcoxon's test was used to compare the PI, before and after magnesium sulphate in both groups. The difference between the two measurements (before and after magnesium sulphate) was compared between the groups (bilateral incision and unilateral/absent incision) using the Mann-Whitney test. RESULTS: There was a significant increase in the maternal heart rate (MHR) and decrease in the maternal blood pressure, and in the PI medians of the two uterine arteries and in the fetal middle cerebral artery, after magnesium sulphate in both groups. There was a significant decrease in the PI of the left uterine artery and in the umbilical artery, only in the protodiastolic unilateral/absent notch group. Nevertheless, it was not found any significant difference regarding the PI of the right uterine artery, or the cerebral/umbilical relationship, before and after magnesium sulphate in each group. No difference between the groups was found, before and after magnesium sulphate, for any of the studied outcomes. CONCLUSIONS: After the intravenous administration of 6 g of magnesium sulphate to patients with severe pre-eclampsia, a decrease in blood pressure and in the PI of the uterine, umbilical and fetal middle cerebral arteries occurs, besides the increase in the MHR, not influenced by the presence of bilateral protodiastolic notch in the uterine arteries.

Importância da ultrassonografia de rotina na prática obstétrica segundo as evidências científicas / Importance of routine ultrasonography in obstetrics according to scientific evidence

O diagnóstico ultrassonográfico é empregado desde 1960 e não há relatos de efeitos deletérios maternos ou fetais produzidos com os níveis de energia usados clinicamente. A ultrassonografia favorece a exploração do embrião e, posteriormente, do feto com o seu ambiente, acompanhando seu desenvolvimento físico e funcional com grande riqueza de detalhes, considerando-se o concepto um verdadeiro paciente. As doenças da gestação e do feto podem ser diagnosticadas precocemente e, em consequência, podem-se acompanhar suas influências sobre o desenvolvimento morfológico fetal. Outro aspecto importante do exame ultrassonográfico refere-se ao estudo da placenta, do cordão umbilical e do líquido amniótico. A estimativa do peso pela ultrassonografia é importante para avaliar a evolução do crescimento no decorrer da gestação, assim como para reduzir a morbimortalidade associada aos desvios do crescimento intraútero por meio do seguimento e da adoção de protocolos específicos para vigilância da vitalidade fetal.

Obstetric evaluation through ultrasound has been used since 1960 and there are no reports of deleterious effects on the mother or the fetus with the usual level of energy used in clinical practice. Ultrasonography allows the exploration of the embryo and, further on, of the fetus and its environment, observing its physical and physiological development with many details. In this occasion, the fetus is considered to be a real patient. The diseases of gestation and of the fetus may be early detected and, in consequence, it is possible to follow its influence on the fetal morphological development. Another important aspect of the ultrasonography exam is with regard to the study of the placenta, the umbilical cord and the amniotic fluid. The fetal weight estimative through ultrasonography is important to evaluate the fetus development of growth throughout the pregnancy and to reduce perinatal mortality associated with deviations of normal intrauterine growth, for it allows a more precise following and adoption of specific protocols for the follow-up of the fetus vitality.

Volume do líquido amniótico associado às anomalias fetais diagnosticadas em um centro de referência do nordeste brasileiro / Amniotic fluid volume associated with fetal anomalies diagnosed in a reference center in the Brazilian Northeast

OBJETIVO: determinar fatores associados ao volume de líquido amniótico e frequências de anomalias fetais em um centro de referência. MÉTODOS: realizou-se um estudo de corte transversal, com gestantes de risco, avaliadas pela ultrassonografia morfológica, no período de março de 2002 a março de 2006, em uma instituição em Recife (PE) Brasil. O diagnóstico intraútero foi confirmado no pós-parto. As características sociodemográficas e obstétricas, o índice de líquido amniótico e a presença de anomalias fetais foram variáveis estudadas. Para verificar associação entre variáveis, foram utilizados testes χ2, exato de Fisher e t de Student, a um nível de significância de 5%. Foram calculados a razão de prevalência e o intervalo de confiança a 95%. Análise de regressão logística múltipla foi realizada, a um nível de significância de 5%. RESULTADOS: foram incluídas no estudo 257 (56,2%) gestantes com anomalias congênitas e 200 sem anomalias confirmadas no pós-natal. As médias das idades maternas e gestacionais do parto foram 24,8±6,5 anos e 35,9±3,7 semanas, respectivamente. As anomalias fetais foram mais encontradas no sistema nervoso central (50,6%) e trato geniturinário (23,0%). A presença de anomalias congênitas esteve associada significativamente ao líquido diminuído/oligohidrâmnio (p=0,0002) e líquido aumentado/polihidrâmnio (p<0,0001). A mortalidade intraútero foi mais frequente no grupo com anomalias, quando comparada aos fetos saudáveis (10,5 versus 2,5%; p<0,01). CONCLUSÕES: a frequência de anomalias congênitas em um grupo de gestações de alto risco foi de 56,2%. As malformações do sistema nervoso central foram mais frequentemente diagnosticadas intraútero. Os fatores que permaneceram fortemente associados às anomalias congênitas foram as alterações do volume do líquido amniótico.

PURPOSE: to determine factors associated to amniotic fluid volume and frequencies of fetal anomalies, in a reference center in Pernambuco. METHODS: a transversal study performed in high-risk pregnant women submitted to obstetrical morphological ultrasound, from March 2002 to March 2006, at an institution from Recife, Pernambuco, Brasil. The intrauterine diagnosis was confirmed after birth. Sociodemographic and obstetrical characteristics, amniotic liquid volume and presence of fetal anomalies were the variables studied. Fisher’s exact, χ2, and Student’s t tests, at a significance level of 5% were applied to verify the correlation among the variables. Prevalence rate and confidence interval at 95% were calculated. Multiple logistic regression analysis was performed at a significance level of 5%. RESULTS: Two hundred and fifty-seven pregnant women (56.2%) with congenital anomalies and 200 (43.8%) without anomalies, confirmed in the postnatal, were included in the study. The average of maternal ages and gestation periods were 24.8±6.5 years and 35.9±3.7 weeks, respectively. The fetal anomalies were discovered in the central nervous system (50.6%) and genitourinary tract (23.0%). The presence of congenital anomalies were significantly linked with reduced liquid/oligohydramnios (p=0.0002) and increased liquid/polyhydramnios (p<0.0001). Intrauterine mortality was more frequent in the group with anomalies, as compared to the healthy fetuses (10.5 versus 2.5%; p<0.01). CONCLUSIONS: The rate of congenital anomalies in the high-risk pregnant women group was 56.2%. Most of the central nervous system malformations were diagnosed intrauterus. Changes in the amniotic fluid were the factors more strongly associated with congenital anomalies.

Efeito do sulfato de magnésio sobre o índice de pulsatilidade das artérias uterinas, umbilical e cerebral média fetal de acordo com a persistência da incisura protodiastólica da artéria uterina na pré-eclâmpsia grave / Effect of magnesium sulfate on pulsatility index of uterine, umbilical and fetal middle cerebral arteries according to the persistence of bilateral diastolic notch of uterine arteries in patients with severe preeclampsia

OBJETIVO: avaliar o efeito do sulfato de magnésio sobre o índice de pulsatilidade (IP) das artérias uterinas, umbilicais e cerebral média fetal, de acordo com a persistência ou não da incisura protodiastólica bilateral das artérias uterinas na pré-eclâmpsia grave. MÉTODOS: foi desenvolvido um estudo do tipo coorte, incluindo 40 gestantes com pré-eclâmpsia grave, das quais 23 apresentavam incisura protodiastólica bilateral e 17, incisura ausente/unilateral. As pacientes foram submetidas a doplervelocimetria antes e depois de 20 minutos da administração intravenosa de 6 g do sulfato de magnésio. O exame foi realizado com a paciente em posição semi-Fowler, obtendo-se os sonogramas durante a inatividade fetal, em períodos de apneia e ausência de contrações uterinas. Todos os exames foram realizados por dois pesquisadores, considerando a média como resultado final. A comparação dos IP antes e depois do sulfato de magnésio em cada grupo foi realizada pelo teste de Wilcoxon. A diferença das duas medidas (antes e depois do sulfato de magnésio) foi comparada entre os grupos (incisura bilateral e incisura ausente/unilateral) utilizando-se o teste de Mann-Whitney. RESULTADOS: houve um aumento significativo da frequência cardíaca materna e uma diminuição da pressão arterial materna e da mediana dos IP das duas artérias uterinas e da artéria cerebral média fetal depois da utilização do sulfato de magnésio em ambos os grupos. Houve redução significativa do IP da artéria uterina esquerda e da artéria umbilical apenas no grupo com incisura protodiastólica unilateral/ausente. No entanto, não foram encontradas diferenças significativas em relação ao IP da artéria uterina direita e relação umbilical/cerebral antes e depois do sulfato de magnésio em cada grupo. Não se encontrou diferença entre os grupos, antes e depois do sulfato de magnésio, para nenhum dos desfechos estudados. CONCLUSÕES: após a administração intravenosa de 6 g do sulfato de magnésio nas...

PURPOSE: to evaluate the effect of magnesium sulphate on the pulsatility index (PI) of the uterine, umbilical and fetal middle cerebral arteries, according to the persistency or not of the bilateral protodiastolic notch of the uterine arteries in severe pre-eclampsia. METHODS: a cohort study including 40 pregnant women with severe pre-eclampsia, 23 of them presenting bilateral protodiastolic notch, and 17, unilateral/absent notch. The patients were submitted to Doppler velocimetry before and 20 minutes after the intravenous administration of 6 g of magnesium sulphate. The examination was carried out with the patient in semi-Fowler position, the sonograms being obtained during fetal inactivity, in apnea and absent uterine contraction periods. All the exams were performed by two researchers, the average being considered as the final result. Wilcoxon's test was used to compare the PI, before and after magnesium sulphate in both groups. The difference between the two measurements (before and after magnesium sulphate) was compared between the groups (bilateral incision and unilateral/absent incision) using the Mann-Whitney test. RESULTS: there was a significant increase in the maternal heart rate (MHR) and decrease in the maternal blood pressure, and in the PI medians of the two uterine arteries and in the fetal middle cerebral artery, after magnesium sulphate in both groups. There was a significant decrease in the PI of the left uterine artery and in the umbilical artery, only in the protodiastolic unilateral/absent notch group. Nevertheless, it was not found any significant difference regarding the PI of the right uterine artery, or the cerebral/umbilical relationship, before and after magnesium sulphate in each group. No difference between the groups was found, before and after magnesium sulphate, for any of the studied outcomes. CONCLUSIONS: after the intravenous administration of 6 g of magnesium sulphate to patients with severe pre-eclampsia...