Zika Brazilian Cohorts (ZBC) Consortium: Protocol for an Individual Participant Data Meta-Analysis of Congenital Zika Syndrome after Maternal Exposure during Pregnancy.

Despite great advances in our knowledge of the consequences of Zika virus to human health, many questions remain unanswered, and results are often inconsistent. The small sample size of individual studies has limited inference about the spectrum of congenital Zika manifestations and the prognosis of affected children. The Brazilian Zika Cohorts Consortium addresses these limitations by bringing together and harmonizing epidemiological data from a series of prospective cohort studies of pregnant women with rash and of children with microcephaly and/or other manifestations of congenital Zika. The objective is to estimate the absolute risk of congenital Zika manifestations and to characterize the full spectrum and natural history of the manifestations of congenital Zika in children with and without microcephaly. This protocol describes the assembly of the Consortium and protocol for the Individual Participant Data Meta-analyses (IPD Meta-analyses). The findings will address knowledge gaps and inform public policies related to Zika virus. The large harmonized dataset and joint analyses will facilitate more precise estimates of the absolute risk of congenital Zika manifestations among Zika virus-infected pregnancies and more complete descriptions of its full spectrum, including rare manifestations. It will enable sensitivity analyses using different definitions of exposure and outcomes, and the investigation of the sources of heterogeneity between studies and regions.

Prenatal factors associated with fetal visceral adiposity / Fatores pré-natais associados à adiposidade visceral fetal

Abstract Objective: To assess fetal visceral adiposity and associated factors during pregnancy. Methods: Secondary analysis of prospective cohort data with 172 pairs (pregnant woman/fetus) treated at public health units. Anthropometric data, metabolic (glucose, glycated hemoglobin, insulin, insulin resistance, total cholesterol and fractions, triglycerides) measures, fetal biometry, and visceral and subcutaneous adiposity in the binomial (pregnant woman/fetus) were evaluated at the 16th, 28th and 36th gestational weeks by ultrasonography. Pearson's correlation coefficient and multiple linear regression were used, with a significance level of 5%. Results: At the 16th week, the mean age of the pregnant women was 26.6 ± 5.8 years and mean weight was 62.7 ± 11.5 kg; 47.0% had normal weight, 28.3% were overweight, 13.3% were underweight, and 11.2% were obese. At 36 weeks, 44.1% had inadequate gestational weight gain, 32.5% had adequate gestational weight gain, and 23.3% had excessive gestational weight gain. Fetal visceral adiposity at week 36 showed a positive correlation with maternal variables: weight (r = 0.15) and body mass index (r = 0.21) at the 16th; with weight (r = 0.19), body mass index (r = 0.24), and gestational weight gain (r = 0.21) at the 28th; and with weight (r = 0.22), body mass index (r = 0.26), and gestational weight gain (r = 0.21) at the 36th week. After multiple linear regression, adiposity at the 28th week remained associated with fetal variables: abdominal circumference (p < 0.0001), head circumference (p = 0.01), area (p < 0.0001), and thigh circumference (p < 0.001). At the 36th week, adiposity remained associated with the abdominal circumference of the 28th (p = 0.02) and 36th weeks (p < 0.001). Conclusion: Adiposity was positively correlated with the measurements of the pregnant woman. After the multivariate analysis, the persistence of the association occurred with the abdominal circumference, a central adiposity measurement with a higher metabolic risk.

Resumo Objetivo: Avaliar a adiposidade visceral fetal e fatores associados na gestação. Métodos: Análise secundária de dados de coorte prospectiva com 172 pares (gestantes/fetos) atendidas em unidades públicas de saúde. Foram avaliadas nas gestantes na 16a, 28a e 36a semana gestacional: medidas antropométricas, metabólicas (glicose, hemoglobina glicada, insulina, resistência à insulina, colesterol total e frações, triglicerídeos), biometria fetal e adiposidade visceral e subcutânea no binômio (gestantes/feto) por ultrassonografia. Utilizamos o coeficiente de correlação de Pearson e regressão linear múltipla, com nível de significância de 5%. Resultados: Na 16ª semana a média de idade das gestantes foi de 26,6 ± 5,8 anos e peso 62,7 ± 11,5 quilogramas, 47,0% eram eutróficas, 28,3% sobrepeso, 13,3% baixo peso e 11,2% obesas. Na 36a semana, 44,1% tiveram ganho ponderal gestacional insuficiente, 32,5% adequado e 23,3% excessivo. A adiposidade visceral fetal na 36a semana apresentou correlação positiva com variáveis maternas: peso (r = 0,15) e índice de massa corpórea (r = 0,21) na 16a; com peso (r = 0,19), índice de massa corpórea (r = 0,24) e ganho ponderal gestacional (r = 0,21) na 28a; com peso (r = 0,22), índice de massa corpórea (r = 0,26) e ganho ponderal gestacional (r = 0,21) na 36a semana. Após regressão linear múltipla a adiposidade na 28a semana permaneceu associada com variáveis fetais: circunferência abdominal (p < 0,0001), circunferência cefálica (p = 0,01), área (p < 0,0001) e circunferência da coxa (p < 0,001). Na 36a semana com circunferência abdominal da 28a (p = 0,02) e 36a semana (p < 0,001). Conclusão: A adiposidade foi positivamente correlacionada com medidas da gestante, após análise multivariada a persistência da associação deu-se com a circunferência abdominal, medida de adiposidade central, de maior risco metabólico.

Prenatal factors associated with fetal visceral adiposity.

OBJECTIVE: To assess fetal visceral adiposity and associated factors during pregnancy. METHODS: Secondary analysis of prospective cohort data with 172 pairs (pregnant woman/fetus) treated at public health units. Anthropometric data, metabolic (glucose, glycated hemoglobin, insulin, insulin resistance, total cholesterol and fractions, triglycerides) measures, fetal biometry, and visceral and subcutaneous adiposity in the binomial (pregnant woman/fetus) were evaluated at the 16th, 28th and 36th gestational weeks by ultrasonography. Pearson's correlation coefficient and multiple linear regression were used, with a significance level of 5%. RESULTS: At the 16th week, the mean age of the pregnant women was 26.6±5.8 years and mean weight was 62.7±11.5kg; 47.0% had normal weight, 28.3% were overweight, 13.3% were underweight, and 11.2% were obese. At 36 weeks, 44.1% had inadequate gestational weight gain, 32.5% had adequate gestational weight gain, and 23.3% had excessive gestational weight gain. Fetal visceral adiposity at week 36 showed a positive correlation with maternal variables: weight (r=0.15) and body mass index (r=0.21) at the 16th; with weight (r=0.19), body mass index (r=0.24), and gestational weight gain (r=0.21) at the 28th; and with weight (r=0.22), body mass index (r=0.26), and gestational weight gain (r=0.21) at the 36th week. After multiple linear regression, adiposity at the 28th week remained associated with fetal variables: abdominal circumference (p<0.0001), head circumference (p=0.01), area (p<0.0001), and thigh circumference (p<0.001). At the 36th week, adiposity remained associated with the abdominal circumference of the 28th (p=0.02) and 36th weeks (p<0.001). CONCLUSION: Adiposity was positively correlated with the measurements of the pregnant woman. After the multivariate analysis, the persistence of the association occurred with the abdominal circumference, a central adiposity measurement with a higher metabolic risk.

Disproportionate impact of COVID-19 among pregnant and postpartum Black Women in Brazil through structural racism lens

Tai e colaboradores levantaram questões importantes sobre os possíveis fatores biomédicos e determinantes sociais que desempenham um papel nas disparidades raciais observadas nos resultados do COVID-19 nos EUA. Evidências desse impacto desproporcional também estão surgindo em grupos étnicos historicamente oprimidos no Brasil, atual epicentro mundial da pandemia. Nosso grupo está monitorando de perto um número esmagador de mortes maternas relacionadas à SARS-CoV-2 no país. As disparidades raciais entre mulheres em idade fértil no sistema de saúde têm sido amplamente descritas e já representam desafios difíceis para melhorar os resultados maternos no país. Assim, era esperado que mulheres grávidas e puérperas brasileiras negras enfrentassem desafios adicionais durante a pandemia.

Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial.

Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive. Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema. Methods A double-bind randomized controlled clinical trial (UTN number: U1111-1131-8433) was conducted in a hospital in Northeastern, Brazil. Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15 ° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature was monitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables. Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered. Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments.

Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial / Manejo da dor perineal com crioterapia no pós-parto vaginal: ensaio clínico randomizado

Abstract Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive. Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema. Methods A double-bind randomized controlled clinical trial (UTN number: U1111- 1131-8433) was conducted in a hospital in Northeastern, Brazil.Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature wasmonitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables. Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered. Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments.

Resumo Introdução Revisões sistemáticas que avaliam a crioterapia perineal para redução da dor no pós-parto por via vaginal são inconclusivas. Objetivo Avaliar a efetividade clínica da crioterapia para controlar a dor e o edema perineais após parto vaginal humanizado. Métodos Ensaio clínico (n° UTN: U1111-1131-8433) randomizado controlado duplocego, realizado em uma maternidade no Nordeste do Brasil. Incluíram-se mulheres após parto vaginal humanizado, de gestação única, cefálica, a termo, e foram excluídas aquelas com lesão perineal prévia, episiotomia no parto atual, parto instrumental e hemorragia perineal ativa. O grupo experimental foi submetido a seis aplicações de bolsa de gelo triturado na região do períneo, por 20minutos, reduzindo a temperatura entre 10 e 15°C, com 60 minutos entre as aplicações. O grupo sem crioterapia recebeu uma bolsa de água, que não reduzia a temperatura a esse nível, respeitando o mesmo protocolo de aplicação do primeiro grupo. Amonitorização da temperatura perineal foi realizada nos minutos zero, 10 e 20 de aplicação, emambos os grupos. Para determinar a associação entre as variáveis, foramrealizadas avaliações imediatamente antes e após as aplicações e 24 horas após o parto. Resultados Foram incluídas 80 puérperas no estudo, sendo 40 em cada grupo. Não houve diferença significativa para os escores de dor e edema perineais entre os grupos comou sem crioterapia até 24 horas após o parto. Não houve diferença entre os grupos quando realizada análise de medidas repetidas em todas as avaliações, considerando a mediana dos escores de dor (p = 0,3) e edema (p = 0,9) perineais. A crioterapia perineal não influenciou na quantidade de analgésicos utilizados (p = 0,07) e nenhum efeito adverso foi registrado. Conclusões A utilização da crioterapia após parto vaginal humanizado, minimamente intervencionista, nãomodifica escores de dor e edema perineais, por já serem, substancialmente, baixos, tampouco altera a necessidade de medicamentos analgésicos.

Distocia de ombro: proposta de um novo algorítmo para conduta em partos em posições não supinas / Shoulder dystocia: proposal for a new algorithm of management in births in non-supine positions

Distocia de ombro é um evento imprevisível e profissionais habilitados para assistir ao parto devem estar capacitados para diagnosticar e instituir manobras efetivas para sua resolução. Tais manobras têm por objetivo aumentar a pelve funcional, reduzir o diâmetro biacromial e melhorar a relação feto-pélvica, facilitando o desprendimento do concepto dentro de sete minutos do diagnóstico, para prevenir complicações. Vários algoritmos têm sido propostos, com o desenvolvimento de mnemônicos para treinamento profissional, sendo o mais famoso o do Advanced Life Support in Obstetrics (ALSO), conhecido como HELPERR(em inglês) ou ALEERTA (em português). No entanto, estes são úteis quando a parturiente se encontra em decúbito dorsal. Propõe-se um novo protocolo, considerando os benefícios associados aos partos em posição não supina e a necessidade de iniciar a conduta das manobras menos para as mais invasivas. O mnemônico proposto é A SAIDA e consiste em: A = chamar ajuda, avisar parturiente, aumentar agachamento; S = pressãosuprapúbica; A = alterar posição para quatro apoios (manobra de Gaskin); I = manobras internas (Rubin II, Wood,parafuso invertido); D = desprender ombro posterior; A = avaliar manobras de resgate...

Shoulder dystocia is an unpredictable event and skilled birth attendants should be trained to diagnose and implement effective maneuvers to solve it. These maneuvers aim to increase the functional pelvis, to reduce biacromial diameter and to improve the relationship between the pelvis and the fetus, favoring the conceptus release within seven minutes of the diagnosis, in order to prevent complications.Several algorithms have been proposed including mnemonics for professional training, being the most famous the one developed by Advanced Life Support in Obstetrics (ALSO), known as HELPERR (in English) or ALEERTA(in Portuguese). However, these sequences of maneuvers are useful when the mother is in a supine position.A new protocol is proposed, considering the benefits of deliveries in non-supine positions, as well as the need for implementing less invasive maneuvers first. The proposed mnemonic is A SAÍDA and consists of A = ask for help, acquaint the mother, augment the squat; S = suprapubic pressure; A = alter the position to all fours (Gaskinmaneuver); I = internal maneuvers (Rubin II, Wood, inverted spin); D = deliver the posterior arm; A = assess theneed for rescue maneuvers...

Características maternas em gestações com risco de prematuridade tardia / Maternal characteristics in pregnancies at risk for late preterm childbirth

Avaliar as características maternas na prematuridade tardia. MÉTODOS: foi realizado um estudo do tipo corte transversal, com análise secundária das gestantes incluídas em um ensaio clínico randomizado realizado no Nordeste do Brasil, no período de 2008 a 2010, entre 34 e 36 semanas. Analisadas as variáveis maternas: idade, paridade, idade gestacional, antecedentes de prematuridade e condições clínicas associadas. A análise estatística foi realizada no programa Epi-Info 3.5.3. Foram construídas tabelas de distribuição de frequência para as variáveis categóricas e calculadas medidas de tendência central e de dispersão para as numéricas. Para determinação da associação entre a frequência das morbidades por estratos de idade gestacional, utilizou-se o teste qui-quadrado de associação. Considerou-se o nível de significância de 5 por cento. RESULTADOS: foram analisadas 273 mulheres no IMIP com risco iminente de prematuridade tardia. A idade média foi 23,1 anos, 28,6 por cento eram adolescentes e 53,8 por cento primíparas. A idade gestacional média foi 35 semanas. Cerca de 12 por cento tinham antecedentes de prematuridade. As condições associadas à prematuridade tardia foram: trabalho de parto prematuro (67 por cento), ruptura prematura das membranas (39,6 por cento), síndromes hipertensivas (25,3 por cento), sem haver diferença da frequência por subgrupos de idade gestacional. CONCLUSÕES: trabalho de parto prematuro espontâneo, ruptura prematura das membranas e síndromes hipertensivas foram as condições clínicas mais frequentemente associadas com prematuridade tardia...

To evaluate maternal characteristics in cases of late prematurity. METHODS: we carried out a cross-sectional study with secondary analysis of pregnant women admitted to a randomized clinical trial conducted in Northeast of Brazil from 2008 to 2010, between 34 and 36 weeks. We analyzed the maternal variables: age, parity, gestational age, history of prematurity and associated medical conditions. Statistical analysis was performed using Epi-Info 3.5.3, with distribution of frequency tables for categorical variables and central tendency and dispersion measures for numerical. Chi-square test was used to determine the association between frequency of morbidities by stratum of gestational age. A significance level of 5 percent was adopted. RESULTS: a total of 273 women in IMIP with conditions leading to imminent risk of late preterm births. The mean age was 23.1 years and 28.6 percent were teenagers and primipara were 53.8 percent. The mean gestational age was 35 weeks. About 12 percent had a history of prematurity. The conditions associated with late prematurity were: preterm labor (67 percent), ruptured membranes (39.6 percent), hypertensive disorders (25.3 percent). There was no difference in frequency of these conditions by subgroups of gestational age. CONCLUSIONS: spontaneous preterm labor, ruptured membranes and hypertensive disorders were the most common clinical conditions associated with late prematurity...

Ultrassonografia do colo uterino versus índice de Bishop como preditor do parto vaginal / Cervical ultrasonography versus Bishop score as a predictor of vaginal delivery

OBJETIVO: comparar a acurácia da mensuração ultrassonográfica transvaginal do colo uterino com o escore de Bishop para predição do parto vaginal após indução do trabalho de parto com misoprostol a 25 mcg. MÉTODOS: realizou-se estudo de validação de técnica diagnóstica com 126 gestantes com indicação para indução do trabalho de parto, as quais foram avaliadas pelo escore de Bishop e por ultrassonografia transvaginal para mensuração cervical. As pacientes foram submetidas, também, à ultrassonografia obstétrica transabdominal para avaliação da estática, pesos fetais e índice de líquido amniótico, e à cardiotocografia basal para avaliação da vitalidade fetal. Procedeu-se à indução do trabalho de parto com misoprostol vaginal e sublingual, um dos comprimidos contendo 25 mcg da droga e o outro apenas placebo. Os comprimidos foram administrados a cada seis horas, em um número máximo de oito. Construíram-se tabelas de distribuição de frequência e calcularam-se medidas de tendência central e de dispersão. Curvas ROC foram construídas para avaliação do escore de Bishop e da medida ultrassonográfica do colo uterino para predição de parto vaginal. RESULTADOS: obteve-se uma área sob a curva ROC de 0,5 (p=0,8) para medição do colo uterino pela ultrassonografia transvaginal, enquanto a curva ROC do escore de Bishop (ponto de corte ³4) apresentou área de 0,6 (p=0,02). O escore de Bishop ³4 apresentou sensibilidade de 56,2 por cento e especificidade de 67,9 por cento para predição de parto vaginal, com razão de verossimilhança positiva de 1,75 e negativa de 0,65. CONCLUSÕES: a medida ultrassonográfica transvaginal do colo uterino não foi boa preditora da evolução para parto vaginal em pacientes com trabalho de parto induzido com misoprostol. O escore de Bishop foi melhor preditor para parto vaginal nestas circunstâncias.

PURPOSE: to compare the accuracy of transvaginal ultrasonographic measurement of the uterine cervix with Bishop’s score for the prediction of vaginal delivery after labor induction, with 25 mcg of misoprostol. METHODS: a prospective study for the validation of a diagnostic test was conducted on 126 pregnant women with indication for labor induction. The patients were evaluated by Bishop’s score and transvaginal ultrasonography for cervical measurement. They also undergone obstetric transabdominal ultrasound to evaluate static and fetal weight, as well as the amniotic fluid index, and basal cardiotocography for the evaluation of fetal vitality. Labor was induced with vaginal and sublingual misoprostol, one of the tablets containing 25 mcg of the drug and the other only placebo. The tablets were administered every six hours, with a maximum number of eight. Frequency tables were obtained, and measures of central tendency and dispersion were calculated. ROC curves were constructed for the evaluation of Bishop’s score and ultrasonographic measurement of the uterine cervix for the prediction of vaginal delivery. RESULTS: the area under the ROC curve was 0.5 (p=0.8) for the ultrasonographic measurement of the uterine cervix, and 0.6 (p=0.02) for Bishop’s score (cut point ³4). Bishop’s score had a sensitivity of 56.2 percent and specificity of 67.9 percent for prediction of vaginal delivery, with a positive likelihood ratio of 1.75 and a negative one of 0.65. CONCLUSIONS: ultrasonographic measurement of the uterine cervix was not a good predictor of evolution to vaginal delivery among patients with misoprostol-induced labor. Bishop’s score was a better predictor of vaginal delivery under these circumstances.

[Comparison of Doppler indexes to predict small infants for gestational age in pregnant women with hypertensive syndromes]. / Comparação entre os índices doplervelocimétricos na predição de recém-nascidos pequenos para idade gestacional em gestantes com síndromes hipertensivas.

PURPOSE: to determine the best Doppler flow velocimetry index to predict small infants for gestational age (SGAI), in pregnant women with hypertensive syndromes. METHODS: a cross-sectional study was conducted enrolling 129 women with high blood pressure, submitted to doppler velocimetry up to 15 days before delivery. Women with multiple fetuses, fetal malformations, genital bleeding, placental abruption, premature rupture of fetal membranes, smoking, use of illicit drugs, and chronic diseases were excluded. A receiver operating characteristic (ROC) curve for each Doppler variable was constructed to diagnose SGAI and the sensitivity (Se), specificity (Sp), positive (PLR) and negative (NLR) likelihood ratio were calculated. RESULTS: the area under the ROC curve for the middle cerebral artery resistance index was 52% (p=0.79) with Se, Sp, PLR, and NLR of 25.0, 89.1, 2.3 and 0.84% for a resistance index lower than 0.70, respectively. While the area under the ROC curve for the resistance index of the umbilical artery was 74% (p=0.0001), with Se=50.0%, Sp=90.0%, PLR=5.0 and NLR=0.56, for a resistance index higher or equal to 0.70. The area under the ROC curve for the resistance index umbilical artery/middle cerebral artery ratio was 75% (p=0.0001). When it was higher than 0.86, the Se, Sp, PLR and NLR were 70.8, 80.0, 3.4 and 0.36%, respectively. For the resistance index of the middle cerebral artery/uterine artery ratio, the area under the ROC curve was 71% (p=0.0001). We found a Se=52.2%, Sp=85.9%, PLR=3.7 and NLR=0.56, when the ratio was lower than 1.05. When we compared the area under the ROC curve of the four doppler velocimetry indexes, we observed that only the resistance index umbilical artery/middle cerebral artery, resistance index middle cerebral artery/uterine artery and resistance index umbilical artery ratios seem to be useful for the prediction of SGA. CONCLUSION: in patients with high blood pressure during pregnancy, all doppler velocimetry parameters, except the middle cerebral artery resistance index, can be used to predict SGAI. The umbilical artery/middle cerebral artery ratio seems to be the most recommended one.

Comparação entre os índices doplervelocimétricos na predição de recém-nascidos pequenos para idade gestacional em gestantes com síndromes hipertensivas / Comparison of Doppler indexes to predict small infants for gestational age in pregnant women with hypertensive syndromes

OBJETIVO: determinar o melhor parâmetro doplervelocimétrico para predição de recém-nascidos pequenos para a idade gestacional (RNPIG), em gestantes com síndromes hipertensivas. MÉTODOS: realizou-se um estudo transversal, envolvendo 129 mulheres com pressão sanguínea elevada, as quais foram submetidas à doplervelocimetria, até quinze 15 dias antes do parto. Mulheres com gravidez múltipla, malformações fetais, sangramento genital, descolamento prematuro de placenta, rotura prematura das membranas, tabagismo, uso ilícito de drogas e doenças crônicas foram excluídas. A curva ROC para cada parâmetro doplervelocimétrico foi construída para predição de RNPIG. Foram calculadas: a sensibilidade (S), especificidade (E), razão de verossimilhança positiva (RVP) e negativa (RVN). RESULTADOS: a área sob a curva ROC do índice de resistência da artéria cerebral média foi de 52 por cento (p=0,79), com S, E, RVP e RVN de 25,0, 89,1, 2,3 e 0,84 por cento, respectivamente, para um índice de resistência menor que 0,70. Enquanto a área sob a curva ROC para o índice de resistência da artéria umbilical foi 74 por cento (p=0,0001), com S=50,0 por cento, E=90,0 por cento, RVP=5,0, RVN=0,56, para um índice de resistência maior ou igual a 0,70. A área sob a curva ROC para a relação do índice de resistência da artéria umbilical/artéria cerebral média foi 75 por cento (p=0,0001), para uma relação maior que 0,86, a S, E, RVP e RVN foram de 70,8, 80,0, 3,4 e 0,36 por cento, respectivamente. Quanto à relação do índice de resistência da artéria cerebral média/artéria uterina, a área sob a curva ROC foi 71 por cento (p=0,0001), encontrando-se S=52,2 por cento, E=85,9 por cento, RVP=3,7 e RPN=0,56, quando a relação foi menor que 1,05...

PURPOSE: to determine the best Doppler flow velocimetry index to predict small infants for gestational age (SGAI), in pregnant women with hypertensive syndromes. METHODS: a cross-sectional study was conducted enrolling 129 women with high blood pressure, submitted to dopplervelocimetry up to 15 days before delivery. Women with multiple fetuses, fetal malformations, genital bleeding, placental abruption, premature rupture of fetal membranes, smoking, use of illicit drugs, and chronic diseases were excluded. A receiver operating characteristic (ROC) curve for each Doppler variable was constructed to diagnose SGAI and the sensitivity (Se), specificity (Sp), positive (PLR) and negative (NLR) likelihood ratio were calculated. RESULTS: the area under the ROC curve for the middle cerebral artery resistance index was 52 percent (p=0.79) with Se, Sp, PLR, and NLR of 25.0, 89.1, 2.3 and 0.84 percent for a resistance index lower than 0.70, respectively. While the area under the ROC curve for the resistance index of the umbilical artery was 74 percent (p=0.0001), with Se=50.0 percent, Sp=90.0 percent, PLR=5.0 and NLR=0.56, for a resistance index higher or equal to 0.70. The area under the ROC curve for the resistance index umbilical artery/middle cerebral artery ratio was 75 percent (p=0.0001). When it was higher than 0.86, the Se, Sp, PLR and NLR were 70.8, 80.0, 3.4 and 0.36 percent, respectively. For the resistance index of the middle cerebral artery/uterine artery ratio, the area under the ROC curve was 71 percent (p=0.0001). We found a Se=52.2 percent, Sp=85.9 percent, PLR=3.7 and NLR=0.56, when the ratio was lower than 1.05...

Analgesia de parto e febre materna: revisão baseada em evidências / Labor analgesia and maternal fever: evidence-based review

A ocorrência de febre durante o trabalho de parto leva a suspeitar de algum quadro infeccioso, principalmente corioamnite. Atualmente, a anestesia peridural durante o trabalho de parto vem sendo associada à febre materna na ausência de infecção, resultando inevitavelmente na administração de antibióticos para mãe e neonato. Após selecionar os bancos de dados Medline/Pubmed, LILACS/SciELO e biblioteca Cochrane à procura de artigos nacionais, internacionais e das melhores evidências científicas disponíveis para pesquisa, observamos que, apesar de ser clara a associação entre febre e anestesia peridural, a associação entre febre e anestesia combinada ainda não está estabelecida. A causa deste aumento da temperatura materna produzida pela peridural permanece desconhecida, mas acredita-se que ocorra uma alteração na termorregulação. Não existem evidências de que este aumento da temperatura produza efeitos deletérios para mãe e concepto, entretanto, a presença de febre pode levar a investigações dispensáveis de infecção e prescrição desnecessária de antibióticos. Portanto, é importante conhecer a associação entre analgesia e aumento de temperatura durante o trabalho de parto, que deve ser levada em conta para diminuir a administração desnecessária de antibióticos.

Fever during labor leads to suspicion of infection, mainly chrorioamnionitis. Epidural anesthesia during labor is currently associated with maternal fever in the absence of infection, inevitably resulting in the administration of antibiotics to the mother and fetus. A search on Medline/Pubmed, LILACS/Scielo and Cochrane Library databases was conducted for articles published in Brazil and abroad aiming at identifying the best scientific evidence available on this matter. Despite the clear association between fever and epidural anesthesia, the association between fever and combined anesthesia still needs to be established. The mechanism of this increase in maternal temperature produced by epidural anesthesia is to be clarified; however, an alteration is believed to occur in maternal thermoregulation. There is no evidence that this increase in temperature produces harmful effects on the mother or infant; nevertheless, the presence of fever may lead to an unnecessary investigation for infection and prescription of antibiotics. Therefore, it is important to be aware of the association between analgesia and elevated body temperature during labor, which should be taken into account in order to minimize the unnecessary use of antibiotics.

Perfil clínico e microbiológico de mulheres com vaginose bacteriana / Clinical and microbiological profile of women with bacterial vaginosis

OBJETIVO: estudar o perfil clínico e microbiológico de mulheres portadoras de vaginose bacteriana participantes de um ensaio clínico randomizado, duplamente mascarado, que comparou aroeira e metronidazol, em uso vaginal, para tratamento do corrimento genital. MÉTODOS: o estudo constitui-se em uma série de casos de 277 mulheres portadoras de vaginose bacteriana diagnosticada, concomitantemente, pelos critérios de Amsel e Nugent, selecionadas a partir de um total de 462 recrutadas, utilizando as informações colhidas antes da intervenção. A análise dos dados foi efetuada utilizando-se o programa Epi-Info 3.32. Para comparar as frequências dos desfechos entre os grupos de intervenção, foi utilizado o teste do χ2 e foi calculada a razão de risco e o intervalo de confiança a 95 por cento. Foi feita análise por intenção de tratar. Além dos parâmetros de diagnósticos, foram também colhidas cultura do conteúdo vaginal e uma citologia de Papanicolaou. RESULTADOS: entre as queixas clínicas, as mais frequentes foram o corrimento genital, observado em 206 participantes (74,4 por cento) e o odor de peixe da secreção vaginal, que ocorreu em 68,6 por cento dos casos (190 pacientes). Dentre os critérios clínicos de diagnósticos, a presença de clue-cells foi positiva em 275 mulheres (99,3 por cento), o teste de Whiff positivo apareceu em 266 participantes (96,0 por cento), seguido do pH >4,5, que ocorreu em 92,8 por cento dos casos e da presença de corrimento fluido e acinzentado, citado por 206 participantes (74,4 por cento). Com relação ao critério de Nugent, a mediana dos escores foi o valor 8,0. As culturas de conteúdo vaginal permitiram a identificação de Gardnerella vaginalis em 96,8 por cento e de Mobiluncus, em 53,1 por cento dos casos. Apenas uma terça parte dos exames mostrou a presença de Lactobacillus (89 mulheres - 32,1 por cento). Houve crescimento de fungos em culturas de 14 participantes (5,1 por cento). Na maior parte dos casos, os ...

PURPOSE: to study the clinical and microbiological profile of women with bacterial vaginosis participating in a randomized, double-blind clinical trial, which compared the vaginal use of preparations from red pepper tree and metronidazole for the treatment of genital discharge. METHODS: the study was conducted on a series of 277 women with bacterial vaginosis concomitantly diagnosed by the criteria of Amsel and Nugent, selected from a total of 462 recruited patients using the information obtained before intervention. Data were analyzed with the Epi-Info 3.32 software. In order to compare the outcomes frequencies between the intervention groups, the χ2 test was used and the risk ratio and 95 percent confidence interval were calculated. The intention to treat analysis was performed. In addition to the determination of diagnostic parameters, the culture of vaginal content and a Papanicolaou cytology test were also performed. RESULTS: the most frequent clinical complaints were genital discharge, observed in 206 participants (74.4 percent) and the fish odor of the vaginal secretion, which occurred in 68.6 percent of the cases (190 patients). Among the diagnostic clinical criteria, the presence of clue-cells was positive in 275 women (99.3 percent), the Whiff test, in 266 (96.0 percent), followed by pH >4.5, which occurred in 92.8 percent of the cases, and by the presence of fluid grayish discharge reported by 206 participants (74.4 percent). Regarding the Nugent criterion, the median score was 8.0. Culture of the vaginal content permitted the identification of Gardnerella vaginalis in 96.8 percent of cases and of Mobiluncus in 53.1 percent. Only one third of the exams showed the presence of Lactobacillus (89 women - 32.1 percent). Fungal growth occurred in the cultures of 14 participants (5.1 percent). In most cases, culture revealed the presence of Corynebacterium (94.2 percent), Gram-positive cocci (98.2 percent), as well as Gram-positive ...

[Factors associated with stillbirth in a school maternity in Pernambuco: a case control study]. / Fatores associados à natimortalidade em uma maternidade escola em Pernambuco: estudo caso-controle.

PURPOSE: to investigate the main factors associated with fetal death in the city of Recife, Pernambuco, Brazil. METHODS: an observational, case-control study, including cases attended from June 1st 2004 to 31st March 2005. A number of 116 stillbirth cases and 472 live birth controls, with deliveries assisted at the service, were included. The cases were identified in the record book from the delivery room. The puerperium women were identified by the name and register number at a puerperium infirmary. The controls were selected, using the puerperium infirmary neighborhood criterion, identifying the beds with numbers immediately lower (two patients) and higher (two patients) than the patient's, as far as they had delivered live babies. In case they did not agree to participate in the research, the next beds with numbers consecutively lower or higher were approached. The chi2 association and Fisher's exact tests were used when necessary to test the association between the independent (predictive) and dependent (stillborn) variables, considering 5% as the significance level. To determine the association strength, the estimate of relative risk for case-control cases, Odds Ratio (OR) was used, with 95% as the confidence interval (CI). Logistic regression analysis according to the hierarchy model was done to control confounding factors. RESULTS: the fetal mortality rate corresponded to 24.4 by 1,000 births. After the multivariate analysis, the variables which kept significantly associated with fetal death were: malformation (OR=7.5; CI=3.2-17.4), number of pre-natal appointments lower than six (OR=4.4; CI=2.5-7.5), hemorrhagic syndromes (OR=2.9; CI=1.4-5.7), attendance in another hospital unit along the 24 hours which preceded the patient's admission in the institution (OR=2.9; CI=1.8-4.6), mothers' age over or equal to 35 years old (OR=2.2; CI=1.0-4.9) and schooling lower than eight years (OR=1.6; CI=1.02-2.6). CONCLUSIONS: it was found a high fetal mortality coefficient, the main factors associated with death were: malformation, number of pre-natal appointments lower than six, hemorrhagic syndromes, history of attendance previous to the hospital admission, mothers' age over or equal to 35 and schooling lower than eight years.