Epidemiological profile of patients with preterm premature rupture of membranes at a tertiary hospital in São Paulo, Brazil.

OBJECTIVE: To perform a descriptive analysis of preterm premature rupture of membranes (PPROM) cases attended in a tertiary hospital. METHOD: Retrospective analysis of medical records and laboratory tests of patients admitted to a Brazilian tertiary hospital between 2006 and 2011, with a confirmed diagnosis of PPROM and gestational age (GA) at delivery <37 weeks. RESULTS: A total of 299 pregnant women were included in the study. Nine patients evolved to abortion, and 290 pregnant women remained for the final analysis. There was initial diagnostic doubt in 17.6% of the cases. The oligohydramnios rate [amniotic fluid index (AFI) <5] was 27.9% on admission. Chorioamnionitis was initially diagnosed in 10.8% of the patients and was retrospectively confirmed in 22.9% of the samples. The latency period had a mean of 9.1 days. The main reasons for interruption were premature labor (55.2%), GA ≥36 weeks (27.2%), and fetal distress (6.9%). The delivery method was cesarean section in 55% of cases. The mean birth weight was 2,124 grams, and 67% of the neonates had a low birth weight (<2500 g). The GA at delivery averaged 33.5 weeks. The stillbirth rate was 5.3%, and the early neonatal mortality rate was 5.6%. There were complications at delivery in 18% of mothers. CONCLUSION: In one of the few Brazilian reports on the epidemiological profile of PPROM, with GA until 37 weeks and intercurrences generally excluded from assessments (such as twinning and fetal malformations), there is a favorable evolution, with an acceptable rate of complications.

Epidemiological profile of patients with preterm premature rupture of membranes at a tertiary hospital in São Paulo, Brazil

OBJECTIVE: To perform a descriptive analysis of preterm premature rupture of membranes (PPROM) cases attended in a tertiary hospital. METHOD: Retrospective analysis of medical records and laboratory tests of patients admitted to a Brazilian tertiary hospital between 2006 and 2011, with a confirmed diagnosis of PPROM and gestational age (GA) at delivery <37 weeks. RESULTS: A total of 299 pregnant women were included in the study. Nine patients evolved to abortion, and 290 pregnant women remained for the final analysis. There was initial diagnostic doubt in 17.6% of the cases. The oligohydramnios rate [amniotic fluid index (AFI) <5] was 27.9% on admission. Chorioamnionitis was initially diagnosed in 10.8% of the patients and was retrospectively confirmed in 22.9% of the samples. The latency period had a mean of 9.1 days. The main reasons for interruption were premature labor (55.2%), GA ≥36 weeks (27.2%), and fetal distress (6.9%). The delivery method was cesarean section in 55% of cases. The mean birth weight was 2,124 grams, and 67% of the neonates had a low birth weight (<2500 g). The GA at delivery averaged 33.5 weeks. The stillbirth rate was 5.3%, and the early neonatal mortality rate was 5.6%. There were complications at delivery in 18% of mothers. CONCLUSION: In one of the few Brazilian reports on the epidemiological profile of PPROM, with GA until 37 weeks and intercurrences generally excluded from assessments (such as twinning and fetal malformations), there is a favorable evolution, with an acceptable rate of complications.

Spontaneous prematurity in fetuses with congenital diaphragmatic hernia: a retrospective cohort study about prenatal predictive factors.

BACKGROUND: To evaluate possible predictive factors of spontaneous prematurity in fetuses with congenital diaphragmatic hernia (CDH). METHODS: A retrospective cohort study was performed. Inclusion criteria were presence of CDH; absence of fetoscopy; absence of karyotype abnormality; maximum of one major malformation associated with diaphragmatic hernia; ultrasound monitoring at the Obstetrics Clinic of Clinicas Hospital at the University of São Paulo School of Medicine, from January 2001 to October 2014. The data were obtained through the electronic records and ultrasound system of our fetal medicine service. The following variables were analyzed: maternal age, primiparity, associated maternal diseases, smoking, previous spontaneous preterm birth, fetal malformation associated with hernia, polyhydramnios, fetal growth restriction, presence of intrathoracic liver, invasive procedures performed, side of hernia and observed-to- expected lung to head ratio (o/e LHR). On individual analysis, variables were assessed using the Chi-square test and the Mann-Whitney test. A multiple logistic regression model was applied to select variables independently influencing the prediction of preterm delivery. A ROC curve was constructed with the significant variable, identifying the values with best sensitivity and specificity to be suggested for use in clinical practice. RESULTS: Eighty fetuses were evaluated, of which, 21 (26.25%) were premature. O/e LHR was the only factor associated with prematurity (p = 0.020). The ROC curve showed 93% sensitivity with 48.4% specificity for the cutoff of 40%. CONCLUSION: O/e LHR was the only predictor of prematurity in this sample.

Fetal thrombotic vasculopathy: A case report and literature review.

INTRODUCTION:: Fetal thrombotic vasculopathy is a recently described placental alteration with varying degrees of involvement and often associated with adverse perinatal outcomes. The diagnosis is made histologically and therefore is postnatal, which makes it a challenge in clinical practice. METHOD:: Case report and review of literature on the subject. RESULTS:: The present case refers to a pregnant woman presenting fetal growth restriction, with poor obstetrical past, and sent late to our service. Even with weekly assessments of fetal vitality (fetal biophysical profile and Doppler velocimetry) and prenatal care, the patient progressed with fetal death at 36 weeks and 1 day. There was no association with inherited and acquired thrombophilia. Pathological examination of the placenta revealed fetal thrombotic vasculopathy. CONCLUSION:: The fetal thrombotic vasculopathy may be associated with adverse perinatal outcomes including fetal death, but much remains to be studied regarding its pathogenesis. Diagnosis during pregnancy is not possible and there is still no proven treatment for this condition. Future studies are needed so that strategies can be developed to minimize the impact of fetal thrombotic vasculopathy.

Fetal thrombotic vasculopathy: A case report and literature review / Vasculopatia trombótica fetal: relato de caso e revisão da literatura

Summary Introduction: Fetal thrombotic vasculopathy is a recently described placental alteration with varying degrees of involvement and often associated with adverse perinatal outcomes. The diagnosis is made histologically and therefore is postnatal, which makes it a challenge in clinical practice. Method: Case report and review of literature on the subject. Results: The present case refers to a pregnant woman presenting fetal growth restriction, with poor obstetrical past, and sent late to our service. Even with weekly assessments of fetal vitality (fetal biophysical profile and Doppler velocimetry) and prenatal care, the patient progressed with fetal death at 36 weeks and 1 day. There was no association with inherited and acquired thrombophilia. Pathological examination of the placenta revealed fetal thrombotic vasculopathy. Conclusion: The fetal thrombotic vasculopathy may be associated with adverse perinatal outcomes including fetal death, but much remains to be studied regarding its pathogenesis. Diagnosis during pregnancy is not possible and there is still no proven treatment for this condition. Future studies are needed so that strategies can be developed to minimize the impact of fetal thrombotic vasculopathy.

Resumo Introdução: a vasculopatia trombótica fetal é uma alteração placentária recentemente descrita, com espectro variado de acometimento e, muitas vezes, associada a resultado perinatal adverso. Trata-se de diagnóstico histopatológico e, portanto, pós-natal, o que a torna um desafio para a prática clínica. Método: apresentação de um relato de caso e revisão da literatura. Resultados: o caso apresentado é de uma gestante com restrição do crescimento fetal, encaminhada tardiamente ao serviço, com histórico obstétrico ruim. Apesar da avaliação semanal da vitalidade fetal (perfil biofísico fetal e dopplervelocimetria) e dos cuidados pré-natais, o caso evoluiu a óbito fetal com 36 semanas e 1 dia. Não houve associação com trombofilias hereditárias e adquiridas. O anatomopatológico da placenta revelou vasculopatia trombótica fetal. Conclusão: sabe-se que a vasculopatia trombótica fetal pode estar associada a resultado perinatal adverso, incluindo óbito fetal. Ainda há muito a ser estudado acerca de sua etiopatogenia. Não é possível o diagnóstico durante a gestação e não existe ainda qualquer tratamento comprovado para essa condição. Estudos futuros são necessários para que estratégias que minimizem o impacto da vasculopatia trombótica fetal sejam desenvolvidas.

Relação entre a contagem de eritroblastos no sangue do cordão umbilical e os resultados obstétricos e neonatais em fetos pequenos para a idade gestacional e com Doppler de artéria umbilical normal / Relation between nucleated red blood cell count in umbilical cord and the obstetric and neonatal outcomes in small for gestational age fetuses and with normal dopplervelocimetry of umbilical artery

OBJETIVO: Avaliar resultados obstétricos e neonatais em gestantes com fetos pequenos para a idade gestacional após 35 semanas segundo a contagem de eritroblastos (EB) no sangue de cordão umbilical.MÉTODOS: A contagem de EB por 100 leucócitos no sangue do cordão umbilical foi obtida de 61 gestantes com fetos pequenos para a idade gestacional e Doppler umbilical normal. Estas foram divididas em 2 grupos: EB≥10 (grupo estudo, n=18) e EB<10 (grupo controle, n=43). Resultados obstétricos e neonatais foram comparados entre os grupos. Para a análise estatística, foram utilizados teste do χ2e t de Student, com nível de significância adotado de 5%.RESULTADOS: A média±desvio padrão de EB por 100 leucócitos foi de 25,0±13,5 para o grupo estudo e de 3,9±2,2 para o grupo controle. Os grupos EB≥10 e EB<10 não diferiram estatisticamente em relação à idade materna (24,0 versus 26,0 anos), primiparidade (55,8 versus 50%), comorbidades (39,5 versus 55,6%) e idade gestacional no parto (37,4 versus 37,0 semanas). O grupo EB≥10 apresentou maior taxa de cesárea (83,3 versus 48,8%, p=0,02), sofrimento fetal (60 versus 0%, p<0,001) e pH<7,20 (42,9 versus11,8%, p<0,001). O peso de nascimento e o percentil de peso para a idade gestacional foram significativamente menores no grupo EB≥10 (2.013 versus 2.309 g; p<0,001 e 3,8 versus 5,1; p=0,004; respectivamente). Não houve nenhum caso de Apgar de 5º minuto abaixo de 7.CONCLUSÃO: A contagem de EB acima de 10 por 100 leucócitos no sangue do cordão umbilical foi capaz de identificar maior risco de parto cesárea, sofrimento fetal e acidose de nascimento em fetos pequenos para a idade gestacional com dopplervelocimetria de artéria umbilical normal.

PURPOSE: To analyze the obstetrical and neonatal outcomes of pregnancies with small for gestation age fetuses after 35 weeks based on umbilical cord nucleated red blood cells count (NRBC).METHODS: NRBC per 100 white blood cells were analyzed in 61 pregnancies with small for gestation age fetuses and normal Doppler findings for the umbilical artery. The pregnancies were assigned to 2 groups: NRBC≥10 (study group, n=18) and NRBC<10 (control group, n=43). Obstetrical and neonatal outcomes were compared between these groups. The χ2 test or Student's t-test was applied for statistical analysis. The level of significance was set at 5%.RESULTS: The mean±standard deviation for NRBC per 100 white blood cells was 25.0±13.5 for the study group and 3.9±2.2 for the control group. The NRBC≥10 group and NRBC<10 group were not significantly different in relation to maternal age (24.0 versus 26.0), primiparity (55.8 versus 50%), comorbidities (39.5 versus55.6%) and gestational age at birth (37.4 versus 37.0 weeks). The NRBC≥10 group showed higher rate of caesarean delivery (83.3 versus 48.8%, p=0.02), fetal distress (60 versus 0%, p<0.001) and pH<7.20 (42.9 versus11.8%, p<0.001). The birth weight and percentile of birth weight for gestational age were significantly lower on NRBC≥10 group (2,013 versus 2,309 g; p<0.001 and 3.8 versus 5.1; p=0.004; respectively). There was no case described of 5th minute Apgar score below 7.CONCLUSION: An NRBC higher than 10 per 100 white blood cells in umbilical cord was able to identify higher risk for caesarean delivery, fetal distress and acidosis on birth in small for gestational age fetuses with normal Doppler findings.

[Relation between nucleated red blood cell count in umbilical cord and the obstetric and neonatal outcomes in small for gestational age fetuses and with normal Doppler velocimetry of umbilical artery]. / Relação entre a contagem de eritroblastos no sangue do cordão umbilical e os resultados obstétricos e neonatais em fetos pequenos para a idade gestacional e com Doppler de artéria umbilical normal.

PURPOSE: To analyze the obstetrical and neonatal outcomes of pregnancies with small for gestation age fetuses after 35 weeks based on umbilical cord nucleated red blood cells count (NRBC). METHODS: NRBC per 100 white blood cells were analyzed in 61 pregnancies with small for gestation age fetuses and normal Doppler findings for the umbilical artery. The pregnancies were assigned to 2 groups: NRBC≥10 (study group, n=18) and NRBC<10 (control group, n=43). Obstetrical and neonatal outcomes were compared between these groups. The χ(2) test or Student's t-test was applied for statistical analysis. The level of significance was set at 5%. RESULTS: The mean ± standard deviation for NRBC per 100 white blood cells was 25.0 ± 13.5 for the study group and 3.9 ± 2.2 for the control group. The NRBC≥10 group and NRBC<10 group were not significantly different in relation to maternal age (24.0 versus 26.0), primiparity (55.8 versus 50%), comorbidities (39.5 versus 55.6%) and gestational age at birth (37.4 versus 37.0 weeks). The NRBC≥10 group showed higher rate of caesarean delivery (83.3 versus 48.8%, p=0.02), fetal distress (60 versus 0%, p<0.001) and pH<7.20 (42.9 versus 11.8%, p<0.001). The birth weight and percentile of birth weight for gestational age were significantly lower on NRBC≥10 group (2,013 versus 2,309 g; p<0.001 and 3.8 versus 5.1; p=0.004; respectively). There was no case described of 5th minute Apgar score below 7. CONCLUSION: An NRBC higher than 10 per 100 white blood cells in umbilical cord was able to identify higher risk for caesarean delivery, fetal distress and acidosis on birth in small for gestational age fetuses with normal Doppler findings.

[Comparison between two growth curves for small for gestational age diagnosis]. / Comparação entre duas curvas de crescimento para o diagnóstico de recém-nascidos pequenos para a idade gestacional.

PURPOSE: It was to compare the use of two growth curves for the diagnosis of small-for-gestational-age (SGA) infants, having the 10th percentile as reference. METHODS: In a retrospective study, data of 20,567 singleton live births from January 2003 to June 2014 were analyzed, and divided according to gestational age: (a) 23 to 26, (b) 26 to 29, (c) 29 to 32, (d) 32 to 35, (e) 35 to 38, (f) 38 to 41 and (g) >41 weeks. Data were paired and analyzed using the McNemar test, with the level of significance set at 0.05. RESULTS: The curve designed by Alexander indicated a higher percentage of diagnosis of SGA than the curve constructed by Fenton for every category of gestational age up to 41 weeks, more markedly in the 32-35 week group (18.5%). Between 37 and 40 weeks of gestational age, Alexander's curve exceeded Fenton's curve in 9.1% of the cases in the diagnosis of SGA. CONCLUSIONS: The Fenton curve provides a more accurate evaluation of an infant's growth since it is gender-specific and allows measurement of three parameters. It has also been constructed with newer data and more sophisticated statistical tools.

Comparação entre duas curvas de crescimento para o diagnóstico de recém-nascidos pequenos para a idade gestacional / Comparison between two growth curves for small for gestational age diagnosis

OBJETIVO: Foi comparar a aplicação de duas curvas de crescimento para o diagnóstico de recém-nascidos pequenos para a idade gestacional (PIG), utilizando o percentil 10 como referência. MÉTODOS: Estudo retrospectivo com informações do parto de 20.567 recém-nascidos vivos, de gestações únicas, ocorridos entre janeiro de 2003 e junho de 2014, divididos em grupos por idade gestacional: (a) 23 a 26, (b) 26 a 29, (c) 29 a 32, (d) 32 a 35, (e) 35 a 38, (f) 38 a 41 e (g) >41 semanas. Os dados foram pareados e os grupos comparados por teste de igualdade de proporções segundo método de McNemar. O nível de significância foi estabelecido em p<0,05. RESULTADOS: A curva de Alexander apresentou maior taxa de diagnóstico de PIG do que a curva de Fenton em todas as faixas de idade gestacional até a 41a semana, com maior diferença entre as curvas entre 32 e 35 semanas (18,5%). No período entre 37 e 40 semanas, o diagnóstico de PIG, empregando-se a curva de Alexander, superou o de Fenton em 9,1% dos casos. Com exceção dos grupos entre 23 e 26 semanas, todas as outras faixas de idade gestacional mostraram-se significativamente diferentes quanto ao diagnóstico de RN PIG. CONCLUSÃO: A curva de Fenton é um instrumento estatístico mais robusto, construída com informações mais recentes, e permite a avaliação do crescimento por três parâmetros e por sexo. .

PURPOSE: It was to compare the use of two growth curves for the diagnosis of small-for-gestational-age (SGA) infants, having the 10th percentile as reference. METHODS: In a retrospective study, data of 20,567 singleton live births from January 2003 to June 2014 were analyzed, and divided according to gestational age: (a) 23 to 26, (b) 26 to 29, (c) 29 to 32, (d) 32 to 35, (e) 35 to 38, (f) 38 to 41 and (g) >41 weeks. Data were paired and analyzed using the McNemar test, with the level of significance set at 0.05. RESULTS: The curve designed by Alexander indicated a higher percentage of diagnosis of SGA than the curve constructed by Fenton for every category of gestational age up to 41 weeks, more markedly in the 32-35 week group (18.5%). Between 37 and 40 weeks of gestational age, Alexander's curve exceeded Fenton's curve in 9.1% of the cases in the diagnosis of SGA. CONCLUSIONS: The Fenton curve provides a more accurate evaluation of an infant's growth since it is gender-specific and allows measurement of three parameters. It has also been constructed with newer data and more sophisticated statistical tools. .

[Can genital infections alter the results of preterm birth predictive tests?]. / As infecções genitais podem alterar os resultados dos testes preditivos do parto prematuro?

PURPOSE: To determine if the presence of infectious agents in vaginal or cervical content can alter the results of the insulin-like growth factor binding protein-1 (phIGFBP-1) test and the measurement of cervical length (CC) by transvaginal ultrasonography. METHODS: A total of 107 pregnant women with a history of spontaneous preterm birth were submitted to the phIGFBP-1 test and to measurement of CC by transvaginal ultrasonography every 3 weeks, between 24 and 34 weeks of gestation. Genital infections were determined immediately before testing. The patients were distributed into four groups (GA, GB, GC, and GD) and the correlation between genital infection and changes in the tests was determined within each group based on the odds ratio (OR) and the Pearson correlation coefficient. RESULTS: In each group, over 50% of the patients had genital infections (GA 10/17; GB 28/42; GC 15/24; GD 35/53), with bacterial vaginosis being the main alteration of the vaginal flora. Positive results for phIGFBP-1(GA 10/10; GB 18/28; GC 15/15; GD 19/35) and CC ≤ 20 mm (GA 10/10; GB 20/28; GC 10/15; GD 20/35) were obtained more frequently in patients with genital infection in all groups. Nonetheless, when applying the Pearson correlation coefficient we detected a poor correlation between genital infection and positivity for markers. CONCLUSION: The presence of changes in the vaginal flora and of other genital infections does not significantly alter the results of phIGFBP-1 and the measurement of cervical length when compared to cases without infection. However, more studies with larger samples are necessary to confirm these results.

As infecções genitais podem alterar os resultados dos testes preditivos do parto prematuro? / Can genital infections alter the results of preterm birth predictive tests?

OBJETIVOS: Verificar se a presença de agentes infecciosos no conteúdo vaginal ou cervical pode alterar os resultados dos testes da proteína-1 fosforilada ligada ao fator de crescimento insulina-símile (phIGFBP-1) e das medidas do comprimento do colo uterino (CC) pela ultrassonografia transvaginal. MÉTODOS: Um total de 107 gestantes com antecedente de prematuridade espontânea foram submetidas ao teste da phIGFBP-1 e à realização da ultrassonografia transvaginal para medida do comprimento do colo uterino, a cada três semanas, entre 24 e 34 semanas. As infecções genitais foram pesquisadas imediatamente antes da realização dos testes. As pacientes foram distribuídas em quatro grupos (GA, GB, GC e GD) e dentro de cada grupo foi avaliada a correlação entre infecção genital e alteração nos testes utilizando a análise das razões de chance (OR) e o coeficiente de correlação de Pearson. RESULTADOS: Em cada grupo, mais de 50% das pacientes apresentaram infecção genital (GA 10/17; GB 28/42; GC 15/24; GD 35/53), sendo a vaginose bacteriana a principal alteração de flora vaginal. O resultado positivo para phIGFBP-1 (GA 10/10; GB 18/28; GC 15/15; GD 19/35) e CC≤20 mm (GA 10/10; GB 20/28; GC 10/15; GD 20/35) foram os resultados encontrados com maior frequência nas pacientes com infecção genital em todos os grupos. Porém, aplicando o coeficiente de correlação de Pearson foi identificada correlação entre infecção genital e positividade para os marcadores. CONCLUSÃO: A presença de alteração da flora vaginal e de outras infecções genitais não alteram significativamente os resultados do teste da phIGFBP-1 e da medida do colo uterino quando comparados aos casos sem infecção. No entanto, é necessária ...

PURPOSE: To determine if the presence of infectious agents in vaginal or cervical content can alter the results of the insulin-like growth factor binding protein-1 (phIGFBP-1) test and the measurement of cervical length (CC) by transvaginal ultrasonography. METHODS: A total of 107 pregnant women with a history of spontaneous preterm birth were submitted to the phIGFBP-1 test and to measurement of CC by transvaginal ultrasonography every 3 weeks, between 24 and 34 weeks of gestation. Genital infections were determined immediately before testing. The patients were distributed into four groups (GA, GB, GC, and GD) and the correlation between genital infection and changes in the tests was determined within each group based on the odds ratio (OR) and the Pearson correlation coefficient. RESULTS: In each group, over 50% of the patients had genital infections (GA 10/17; GB 28/42; GC 15/24; GD 35/53), with bacterial vaginosis being the main alteration of the vaginal flora. Positive results for phIGFBP-1(GA 10/10; GB 18/28; GC 15/15; GD 19/35) and CC≤20 mm (GA 10/10; GB 20/28; GC 10/15; GD 20/35) were obtained more frequently in patients with genital infection in all groups. Nonetheless, when applying the Pearson correlation coefficient we detected a poor correlation between genital infection and positivity for markers. CONCLUSION: The presence of changes in the vaginal flora and of other genital infections does not significantly alter the results of phIGFBP-1 and the measurement of cervical length when compared to cases without infection. However, more studies with larger samples are necessary to confirm these results. .

[Factors associated with false diagnosis of fetal growth restriction]. / Fatores associados ao falso diagnóstico pré-natal da restrição de crescimento fetal.

PURPOSE: The aim of this study was to analize and describe some characteristics related to a false diagnosis of intrauterine growth restriction (IUGR). METHODS: We retrospectively included 48 pregnant women referred to our service with a suspected diagnosis of IUGR that was not confirmed after birth and we compared them to another group with confirmed IUGR. We then analyzed the characteristics of the false-positive results. The results of the study were divided into continuous and categorical variables for analysis. The χ2test or Fisher exact test was applied to compare proportions. The level of significance was set at p<0.05 for all tests. RESULTS: In our sample, pregnant women with a false diagnosis of IUGR had the following characteristics: they were referred earlier (mean gestational age of 32.8 weeks); were submitted to 2 to 6 ultrasound examinations before been registered in our service; in 25% of cases ultrasound examination was performed before 12 weeks; in 66.7% of cases the symphysis-fundal height measurement was normal; in 52.1% of cases they had at least 1 sonographic exam above the 10th percentile; on average, the last ultrasound examination (performed on average at 36 weeks) was above the 18th percentile; the women were submitted to a mean number of 5 ultrasound examinations and to a mean number of 4.6 vitality exams. CONCLUSION: The false diagnosis of IUGR involves high hospital costs and higher demand for specialists. The symphysis-fundal height measurement must be valued, and the diagnosis of IUGR must be confirmed with ultrasonography in the last weeks of pregnancy before any obstetric management is taken.

Fatores associados ao falso diagnóstico pré-natal da restrição de crescimento fetal / Factors associated with false diagnosis of fetal growth restriction

OBJETIVO: Descrever os fatores relacionados ao falso diagnóstico de restrição de crescimento fetal (RCF). MÉTODOS: Foram incluídas 48 gestantes encaminhadas ao nosso serviço com suspeita de RCF, não confirmada após o nascimento. Estas foram comparadas ao grupo de gestantes com RCF confirmada e foram descritas características relacionadas a esses falso-positivos. Os dados foram analisados utilizando-se o programa Statplus para Mac(r), versão 5.8. Os resultados obtidos no estudo foram divididos em variáveis categóricas e contínuas para análise. Para comparação entre proporções, foi aplicado o teste do χ2 ou o teste exato de Fisher. O nível de significância foi estabelecido em p<0,05 para todos os testes. RESULTADOS: As gestantes com falso diagnóstico de restrição de crescimento fetal apresentavam as seguintes características: chegaram ao serviço em idade gestacional mais precoce (média de 32,8 semanas); entre 2 e 6 exames de ultrassonografia antes da matrícula no hospital terciário (média 3,8); foram submetidas à ultrasonografia até a 12ª semana em apenas 25% dos casos; tinham medida da altura uterina normal em 66,7% dos casos; foram submetidas a pelo menos 1 ultrassonografia com percentil normal em 52,1% dos casos; tinham a última ultrassonografia (média de 36 semanas) com percentil médio de 18; foram submetidas em média a 5 exames de ultrassonografia e 4,6 exames de vitalidade após ingressarem no serviço. CONCLUSÃO: O falso diagnóstico da RCF envolve custos hospitalares altos e demanda maior de especialistas. Deve-se valorizar a medida da altura uterina, por meio de exame físico cuidadoso e confirmar esse diagnóstico com a ultrassonografia nas últimas semanas de gestação, antes que a conduta ...

PURPOSE: The aim of this study was to analize and describe some characteristics related to a false diagnosis of intrauterine growth restriction (IUGR). METHODS: We retrospectively included 48 pregnant women referred to our service with a suspected diagnosis of IUGR that was not confirmed after birth and we compared them to another group with confirmed IUGR. We then analyzed the characteristics of the false-positive results. The results of the study were divided into continuous and categorical variables for analysis. The χ2test or Fisher exact test was applied to compare proportions. The level of significance was set at p<0.05 for all tests. RESULTS: In our sample, pregnant women with a false diagnosis of IUGR had the following characteristics: they were referred earlier (mean gestational age of 32.8 weeks); were submitted to 2 to 6 ultrasound examinations before been registered in our service; in 25% of cases ultrasound examination was performed before 12 weeks; in 66.7% of cases the symphysis-fundal height measurement was normal; in 52.1% of cases they had at least 1 sonographic exam above the 10th percentile; on average, the last ultrasound examination (performed on average at 36 weeks) was above the 18th percentile; the women were submitted to a mean number of 5 ultrasound examinations and to a mean number of 4.6 vitality exams. CONCLUSION: The false diagnosis of IUGR involves high hospital costs and higher demand for specialists. The symphysis-fundal height measurement must be valued, and the diagnosis of IUGR must be confirmed with ultrasonography in the last weeks of pregnancy before any obstetric management is taken. .

Avaliação da artéria cerebral média na restrição do crescimento fetal de início tardio / Assessment of middle cerebral artery in late fetal growth restriction

Desde a última década, a restrição do crescimento fetal tem sido classificada em duas formas: de início precoce e tardio. Este último, em geral, tem início após 32 semanas e cursa com maior morbidade perinatal. Um grande desafio nos dias atuais consiste na diferenciação dos fetos pequenos constitucionais dos restritos de início tardio. Apesar do Doppler da artéria umbilical ser normal em ambos os casos, nas formas tardias de restrição de crescimento fetal, outros parâmetros podem estar associados a resultados perinatais adversos e à morbidade neurológica. Entre eles, destacam-se as alterações do Doppler da artéria cerebral média e a relação cérebro-placentária. Vários estudos foram publicados utilizando estes parâmetros no seguimento de fetos com restrição de crescimento fetal tardia, mas ainda as evidências não se mostram suficientes para a sua incorporação na prática clínica.(AU)

Since the last decade, fetal growth restriction has been classified in two ways: early or late beginning. The last one generally starts after 32 weeks and is followed by higher perinatal death rates. A great challenge nowadays consists in the differentiation of constitutional small fetuses from late growth restriction ones. Even though the Doppler of the umbilical artery is normal in both cases, in the late fetal growth restriction other parameters could be associated with adverse perinatal results and neurological morbidity. Among these, the most relevant are the alterations of the Doppler of the middle cerebral artery and the cerebroplacental ratio. Several studies have been published using these parameters in the follow-up of fetuses with late growth restriction, but the evidences are still not enough for their incorporation into clinical practice.(AU)

[Preterm birth prediction: sequential evaluation of the cervix and the test for phosphorylated protein-1 linked to insulin-like growth factor]. / Predição do parto prematuro: avaliação sequencial do colo uterino e do teste para proteína-1 fosforilada ligada ao fator de crescimento insulina-símile.

PURPOSE: To investigate the usefulness of the measurement of cervical length and of the test for phosphorylated insulin-like growth factor binding protein-1 (phIGFBP-1) performed sequentially in the prediction of preterm birth and the correlation between tests. METHODS: We analyzed data from 101 asymptomatic pregnant women with a history of premature delivery. The ultrasound measurement of cervical length and phIGFBP-1 test were performed in parallel every three weeks, between 24 and 34 week. The best cutoff value for each cervical evaluation was established by the ROC curve, and the two tests were compared using nonparametric tests. We determined the sensitivity, specificity and predictive values of each test and of the association of the exams for the occurrence of delivery before the 37th weeks. RESULTS: There were 25 preterm births (24.8%). The cervix length showed the highest sensitivity and was able to predict preterm birth in all evaluations, with similar accuracy at different gestational ages. The test for phIGFBP-1 was not helpful at 24 weeks, but was able to predict prematurity when performed at 27, 30 and 33 weeks. The combination of tests increased the sensitivity (81.8%) and negative predictive value (93.7%) when compared to the separate use of each test. The mean cervical length was lower in women with a positive test. CONCLUSIONS: Both cervical length and the test for phIGFBP-1 were able to predict premature delivery, and sequential combination of both tests showed a high sensitivity and high negative predictive value.

Predição do parto prematuro: avaliação sequencial do colo uterino e do teste para proteína-1 fosforilada ligada ao fator de crescimento insulina-símile / Preterm birth prediction: sequential evaluation of the cervix and the test for phosphorylated protein-1 linked to insulin-like growth factor

OBJETIVOS: Averiguar a utilidade da medida do comprimento do colo uterino e do teste para proteína-1 fosforilada ligada ao fator de crescimento insulina-símile (phIGFBP-1), realizados de maneira sequencial, na predição do parto prematuro e a existência de correlação entre os testes. MÉTODOS: Foram submetidos a análise secundária os dados de 101 gestantes assintomáticas com antecedente de prematuridade. A medida ultrassonográfica do comprimento do colo e o teste para phIGFBP-1 foram realizados em paralelo a cada três semanas, entre a 24ª e a 34ª semana. O melhor valor de corte do colo uterino para cada avaliação foi estabelecido por meio de curva ROC, e ambos os testes foram comparados entre si por meio de testes não paramétricos. Foram obtidas a sensibilidade, a especificidade e os valores preditivos de cada teste e da associação dos exames para a ocorrência de parto antes de 37 semanas. RESULTADOS: Houve 25 partos prematuros (24,8%). O comprimento do colo apresentou maior sensibilidade e foi capaz de predizer o parto prematuro em todas as avaliações, com acurácia semelhante em diferentes idades gestacionais. O teste para phIGFBP-1 não foi útil na 24ª semana, porém foi capaz de predizer independentemente a prematuridade na 27ª à 30ª e 33ª semana. A associação dos exames elevou a sensibilidade (81,8%) e o valor preditivo negativo (93,7%) quando comparada à utilização isolada dos testes. O comprimento cervical médio foi menor em gestantes com teste positivo. CONCLUSÕES: Tanto o comprimento cervical quanto o teste para phIGFBP-1 foram capazes de predizer independentemente o parto prematuro, e a associação sequencial de ambos os exames apresentou elevada sensibilidade e alto valor preditivo negativo.

PURPOSE: To investigate the usefulness of the measurement of cervical length and of the test for phosphorylated insulin-like growth factor binding protein-1 (phIGFBP-1) performed sequentially in the prediction of preterm birth and the correlation between tests. METHODS: We analyzed data from 101 asymptomatic pregnant women with a history of premature delivery. The ultrasound measurement of cervical length and phIGFBP-1 test were performed in parallel every three weeks, between 24 and 34 week. The best cutoff value for each cervical evaluation was established by the ROC curve, and the two tests were compared using nonparametric tests. We determined the sensitivity, specificity and predictive values of each test and of the association of the exams for the occurrence of delivery before the 37th weeks. RESULTS: There were 25 preterm births (24.8%). The cervix length showed the highest sensitivity and was able to predict preterm birth in all evaluations, with similar accuracy at different gestational ages. The test for phIGFBP-1 was not helpful at 24 weeks, but was able to predict prematurity when performed at 27, 30 and 33 weeks. The combination of tests increased the sensitivity (81.8%) and negative predictive value (93.7%) when compared to the separate use of each test. The mean cervical length was lower in women with a positive test. CONCLUSIONS: Both cervical length and the test for phIGFBP-1 were able to predict premature delivery, and sequential combination of both tests showed a high sensitivity and high negative predictive value.