Does antenatal supplementation with omega-3 affect child development and behavior during the first six months of life? A randomized double-blind placebo-controlled trial.

BACKGROUND: Omega-3 fatty acids, especially docosahexaenoic acid (DHA), are found in different cell membranes, but more concentrated in the brain, playing an important role in child's behavior and development. AIMS: To evaluate the effect of antenatal omega-3 supplementation on child development and behavior during the first six months of life. STUDY DESIGN: Randomized double-blind placebo-controlled trial. SUBJECTS: Low-risk pregnant women with gestational age between 22 and 24 weeks were randomized in placebo (olive oil; n = 30) or omega-3 (fish oil; 1440 mg/day of DHA; n = 30) groups and supplemented until childbirth. OUTCOME MEASURES: Child development was assessed using the Survey of Well-being of Young Children in the first, fourth and sixth month of life. RESULTS: The comparison between groups showed no differences in the Developmental Milestones score at any time, but when compared to the first month, the omega-3 group showed an increase at the fourth and sixth month. Such increase was not observed in the placebo group. No differences were found between groups for Irritability and Inflexibility scores, however, higher scores for Difficulty with Routine were observed in the placebo group when compared to omega-3 at first, fourth and sixth month. CONCLUSION: There were no differences between groups for child development, but the omega-3 group showed an increase in this score over time. The placebo group had greater difficulty with routine than the omega-3 group, indicating a beneficial effect of antenatal supplementation on child behavior. TRIAL REGISTRATION: ReBec U1111-1215-7952 (June 16th 2018).

Pregnant Users' Perceptions of the Birth Plan Interface in the "My Prenatal Care" App: Observational Validation Study.

BACKGROUND: Birth plans are meant to be a declaration of the expectations and preferences of pregnant woman regarding childbirth. The My Prenatal Care app engages pregnant women in an educational intervention for a healthy pregnancy. We hypothesized that users' positive perception of an in-app birth plan is a relevant step for establishing direct communication between pregnant women and the health care team, based on an online report available on the app. OBJECTIVE: This study aimed to evaluate pregnant women's perception about the communicability of birth-plan preparation using a mobile app. METHODS: This was an observational, exploratory, descriptive study. The methodology was user centered, and both qualitative and quantitative approaches were employed. The tools of the communicability evaluation method were applied. Overall, 11 pregnant women evaluated their experience of using a birth-plan prototype interface. The evaluation was performed in a controlled environment, with authorized video recording. There were 8 task-oriented interactions proposed to evaluate interface communicability with users when using the Birth Plan menu. For evaluating perceptions and experiences, a survey with structured and open-ended questions in addition to the free expression of participants was conducted. The primary outcomes assessed were interface communicability and user's perception of the Birth Plan prototype interface in the My Prenatal Care mobile app. Secondarily, we involved users in the prototyping phase of the interface to identify bottlenecks for making improvements in the app. RESULTS: Regarding users' performance in accomplishing previously prepared tasks, we found that 10 of 11 (91%) women were capable of completing at least 6 of 8 (75%) tasks. A positive relationship was found between the number of communicability problems and the success of completing the tasks. An analysis of the records revealed three communicability breakdowns related to the data entry, save, and scrollbar functions. The participants freely expressed suggestions for improvements such as for the save function and the process of sharing the birth-plan form upon completion. CONCLUSIONS: Users had a positive perception of the Birth Plan menu of the My Prenatal Care app. This user-centered validation enabled the identification of solutions for problems, resulting in improvements in the app.

Uromodulin: a new biomarker of fetal renal function?

INTRODUCTION: Obstructive uropathies are main diseases affecting the fetus. Early diagnosis allows to establish the appropriate therapy to minimize the risk of damage to kidney function at birth. Biochemical markers have been used to predict the prognosis of renal function in fetuses. Uromodulin, also known by Tamm-Horsfall protein (THP) is exclusively produced in the kidneys and in normal conditions is the protein excreted in larger amounts in human urine. It plays important roles in kidneys and urinary tract. Also it participates in ion transport processes, interact with various components of the immune system and has a role in defense against urinary tract infections. Moreover, this protein was proved to be a good marker of renal function in adult patients with several renal diseases. OBJECTIVE: To evaluate if uromodulin is produced and eliminated by the kidneys during fetal life by analyzing fetal urine and amniotic fluid and to establish correlation with biochemical parameter of renal function already used in Fetal Medicine Center at the Clinic Hospital of UFMG (CEMEFE/HC). METHODS: Between 2013 and 2015, were selected 29 fetuses with indication of invasive tests for fetal diagnosis in monitoring at the CEMEFE/HC. RESULTS: The determination of uromodulin was possible and measurable in all samples and showed statistically significant correlation with the osmolarity. CONCLUSION: There was a tendency of lower levels of Uromodulin values in fetuses with severe renal impairment prenatally. Thus, high levels of this protein in fetal amniotic fluid or fetal urine dosages possibly mean kidney function preserved.

Uromodulin: a new biomarker of fetal renal function? / Uromodulina: um novo biomarcador de função renal fetal?

Abstract Introduction: Obstructive uropathies are main diseases affecting the fetus. Early diagnosis allows to establish the appropriate therapy to minimize the risk of damage to kidney function at birth. Biochemical markers have been used to predict the prognosis of renal function in fetuses. Uromodulin, also known by Tamm-Horsfall protein (THP) is exclusively produced in the kidneys and in normal conditions is the protein excreted in larger amounts in human urine. It plays important roles in kidneys and urinary tract. Also it participates in ion transport processes, interact with various components of the immune system and has a role in defense against urinary tract infections. Moreover, this protein was proved to be a good marker of renal function in adult patients with several renal diseases. Objective: To evaluate if uromodulin is produced and eliminated by the kidneys during fetal life by analyzing fetal urine and amniotic fluid and to establish correlation with biochemical parameter of renal function already used in Fetal Medicine Center at the Clinic Hospital of UFMG (CEMEFE/HC). Methods: Between 2013 and 2015, were selected 29 fetuses with indication of invasive tests for fetal diagnosis in monitoring at the CEMEFE/HC. Results: The determination of uromodulin was possible and measurable in all samples and showed statistically significant correlation with the osmolarity. Conclusion: There was a tendency of lower levels of Uromodulin values in fetuses with severe renal impairment prenatally. Thus, high levels of this protein in fetal amniotic fluid or fetal urine dosages possibly mean kidney function preserved.

Resumo Introdução: Uropatias obstrutivas estão entre as principais doenças que acometem o feto. O diagnóstico precoce destas doenças permite estabelecer a terapêutica adequada, visando minimizar os riscos de danos à função renal no nascimento. Os marcadores bioquímicos têm sido utilizados na predição do prognóstico da função renal em fetos. A uromodulina, também chamada de proteína de Tamm-Horsfall (THP), é produzida exclusivamente nos rins, e em condições normais, é a proteína excretada em maior volume na urina humana. Ela desempenha importantes funções nos rins e trato urinário. Participa dos processos de transporte de íons, interage com vários componentes do sistema imunológico e possui papel na defesa contra infecções do trato urinário. Além disso, se mostrou um bom biomarcador de função renal em adultos portadores de diversas doenças renais. Objetivos: Avaliar se a uromodulina é produzida e eliminada pelos rins durante a vida fetal através da análise de urina fetal e líquido amniótico, além de estabelecer correlação com o parâmetro bioquímico de função renal já utilizado no Centro de Medicina Fetal do Hospital das Clínicas da UFMG (CEMEFE/HC). Métodos: Entre 2013 e 2015, foram selecionados 29 fetos com indicação de exames invasivos para diagnóstico fetal em acompanhamento no CEMEFE/HC. Resultados: A dosagem da uromodulina foi possível e quantificável em todas as amostras e mostrou correlação significativa com a osmolaridade. Conclusão: A uromodulina mostrou uma tendência em apresentar valores reduzidos em fetos com grave comprometimento renal no pré-natal. Assim, valores elevados desta proteína em dosagens de urina fetal ou líquido amniótico podem significar uma função renal preservada.

Proposição de plano de parto informatizado para apoio a interoperabilidade e humanização / The computerized birth plan proposition to support interoperability and humanization

O Plano de Parto permite o registro das expectativas e preferências da gestante em relação ao parto. Este estudo tem como objetivo formalizar um modelo de referência para o Plano de Parto informatizado e identificar um conjunto de arquétipos para representar seus conceitos. MÉTODO: Trata-se de um estudo observacional, exploratório e descritivo. Foram identificados e analisados diversos modelos de Plano de Parto. Posteriormente foi realizada a modelagem do documento em dois níveis: um modelo de referência estruturado e a construção do template nas especificações openEHRa partir de arquétipos disponíveis em uma base de conhecimento clínico. RESULTADOS: Os conceitos clínicos do documento foram estruturados a partir de ajustes em arquétipos pré-existentes. A composição foi estruturada em sete seções abordando-se as expectativas das gestantes. CONCLUSÃO: Espera-se que esta proposta seja um ponto de partida, após sua validação na prática clínica, para viabilizar o acesso ao Plano de Parto em canais informatizados do pré-natal ao parto.

The Birth Plan enables the registry of pregnant women expectations and preferences for childbirth. This studyaims to formalize a standardized model for a computerized Delivery Plan and identify a set of archetypes to representits concepts. METHOD: This is an exploratory and descriptive observational study. We identified and analyzed several Birth Plan models and subsequently performed the document modeling at two LEVELS: a structured template and then a reference template based on openEHR specifications available in a clinical database. RESULTS: We structured the clinical concepts of the document based on pre-existing archetypes adjustments. The composition structure considered sevensections covering up the expectations of pregnant women. CONCLUSION: We expect that this standardized model serveas a starting point, after its validation in clinical practice, to enable access to the Birth Plan through computerized channels from pre-natal to childbirth.

Diagnosis of severe fetal anemia based on perinatal outcomes: a comparative analysis of the current reference values.

Objectives. To compare current criteria for severe fetal anemia diagnosis. Methodology. A cohort study analyzed 105 alloimmunized fetuses that underwent cordocentesis due to risk of anemia. Concordance among the diagnostic criteria for severe fetal anemia, hemoglobin deficit >7 g/dL, hemoglobin deficit ≥5 g/dL, and hemoglobin concentration <0.55 MoM, was analyzed using Cohen's Kappa index. Perinatal mortality, fetal hydrops, and fetal acidosis were used to discuss discordances. Results. There was fair concordance among the three criteria analyzed: 0.80 (Kappa index, IC 95%: 0.67 to 0.93) when comparing hemoglobin deficit >7.0 g/dL and hemoglobin concentration <0.55 MoM criteria, 0.63 (Kappa index, IC 95%: 0.47 to 0.69) when comparing hemoglobin deficit ≥5.0 g/dL and hemoglobin deficit >7.0 g/dL reference, and 0.77 (Kappa index, IC 95%: 0.64 to 0.90) when comparing hemoglobin deficit≥5.0 g/dL and hemoglobin concentration <0.55 MoM standards. Eighteen cases were classified differently depending on the criteria used. The cut-off point of hemoglobin deficit ≥5 g/dL was the best criterion to discriminate fetuses with poor perinatal outcome in our study. Conclusions. Relevant discordances in classification of severe fetal anemia were pointed out. Some criteria may underestimate the real gravity of fetal anemia.

Predictive factors of perinatal mortality in transfused fetuses due to maternal alloimmunization: what really matters?

INTRODUCTION: Alloimmunization is the main cause of fetal anemia. There are not many consistent analyses associating antenatal parameters to perinatal mortality in transfused fetuses due to maternal alloimmunization. The study aimed to determine the prognostic variables related to perinatal death. MATERIAL AND METHODS: A cohort study analyzed 128 fetuses treated with intrauterine transfusion (IUT), until the early neonatal period. Perinatal mortality was associated with prognostic conditions related to prematurity, severity of fetal anemia and IUT procedure by univariated logistic regression. Multiple logistic regression was used to compute the odds ratio (OR) for adjusting the hemoglobin deficit at the last IUT, gestational age at birth, complications of IUT, antenatal corticosteroid and hydrops. RESULTS: Perinatal mortality rate found in this study was 18.1%. The hemoglobin deficit at the last IUT (OR: 1.26, 95% CI: 1.04-1.53), gestational age at birth (OR: 0.53, 95% CI: 0.38-0.74) and the presence of transfusional complications (OR: 5.43, 95% CI: 142-20.76) were significant in predicting fetal death. CONCLUSION: Perinatal mortality prediction in transfused fetuses is not associated only to severity of anemia, but also to the risks of IUT and prematurity.

Determining the volume of blood required for the correction of foetal anaemia by intrauterine transfusion during pregnancies of Rh isoimmunised women.

BACKGROUND: Severe anaemic foetuses of Rhesus (Rh) isoimmunised mothers are usually treated by intrauterine transfusion (IUT). It is helpful to determine the volume of blood necessary to raise the concentration of haemoglobin by 1.0 g/dL in response to intrauterine transfusions. METHODS: In this cross-sectional, observational study we evaluated 107 first IUT for the correction of anaemia caused by haemolysis triggered by maternal Rh immunisation. The concentration of foetal haemoglobin was determined in umbilical cord blood before and after the IUT. The variation in foetal concentration of haemoglobin after transfusion was compared between groups of hydropic and non-hydropic foetuses, between groups of foetuses with different degrees of anaemia and with groups of gestational age less than or more than 28 weeks. The t-test for averages and ANOVA were used to compare average differences among the groups. p values less than 0.05 were considered statistically significant. RESULTS: Fifty-five (61.4%) foetuses were found to be anaemic while hydrops was observed in 40 (44%) at the time of the IUT. The volume of red blood cell concentrate infused varied from 5 to 90 mL, with 11.2±1.5 mL being necessary to raise the circulating concentration of haemoglobin by 1.0 g/dL. The foetal response was not influenced significantly by either the degree of foetal anaemia (p=0.56) or the presence of hydrops (p=0.17). The foetuses with a gestational age of 28 weeks or less required a smaller volume of red blood cell concentrate than those with a gestational age of more than 28 weeks (9.3±5.4 mL and 13.4±4.8 mL, respectively; p<0.0001) in order to raise their concentration of circulating haemoglobin by 1.0 g/dL. CONCLUSION: The volume of red blood cell concentrate necessary to correct anaemia in pregnancies complicated by Rh isoimmunisation must be considered carefully, since the response to the infusion of blood is peculiar in extremely premature infants. Hydrops and the degree of anaemia were not determinants of the change in the final concentration of circulating haemoglobin following the blood transfusion.

Combined use of the cardiofemoral index and middle cerebral artery Doppler velocimetry for the prediction of fetal anemia.

OBJECTIVE: To assess the accuracy of the combined use of the cardiofemoral index (CFI) and the middle cerebral artery peak systolic velocity (MCA-PSV), converted to multiples of the median (MoM), as noninvasive means to detect severe fetal anemia. METHOD: We measured CFI and MCA-PSV MoM in 37 fetuses just before their first (n=37), second (n=22), and third (n=14) cordocenteses and transfusions. Then, using 2 different criteria for severe fetal anemia detection (Hb deficit ≥7 g/dL and hemoglobin level ≤0.55 of MoM), we assessed their hemoglobin status during cordocentesis and the accuracy of CFI and MCA-PVS was determined. RESULTS: At the first cordocentesis the mean hemoglobin level was 8.5±3.6 g/dL and 15 fetuses (40.5%) had hydrops. In a total of 81 fetal evaluations, 58 (71.6%) of the CFIs and 34 (42.0%) of the MCA-PSV MoM measurements were abnormal. The result of one of these tests was abnormal in 65 evaluations (80.3%) and the results of both tests were abnormal in 27 evaluations (33.3%). All fetuses diagnosed as being severely anemic by at least one of the hemoglobin criteria during cordocentesis had an abnormal result by at least one of the noninvasive tests. Before the second and third transfusions, the combined use of the CFI and MCA-PSV MoM predicted severe fetal anemia with 100% sensitivity. When the CFI and MCA-PSV MoM measurements were normal, the negative likelihood ratio was zero. CONCLUSION: When associated, CFI and MCA-PSV MoM were accurate predictors of severe fetal anemia.

Aspectos atuais da fisiopatologia da pré-eclâmpsia com repercussões na conduta / Current aspects in the pathophysiology of preeclampsia with repercussions in the management

A pré-eclâmpsia é a principal causa de morte materna nos países em desenvolvimento e contribui para a prematuridade e outras complicações perinatais. Sua etiologia ainda é desconhecida e exitem diversas formulações fisiopatológicas que se aplicam à doença. Um dos pontos centrais da fisiopatologia da doença é a lesão endotelial generalizada. Esse evento vem sendo estudado no Centro de Medicina Fetal da Universidade Federal de Minas Gerais, e diversos marcadores de lesão endotelial já foram descobertos e correlacionados com a ocorrência da pré-eclâmpsia. A literatura clássica e estudos realizados neste centro indicam e confirmam a teoria da placentação secundária deficiente, como causa da lesão endotelial dos vasos placentários. Uma exacerbação do sistema renina-angiotensina seria responsável pelo acometimento generalizado do organismo materno. Um método promissor para se verificar essa lesão endotelial generalizada é a dilatação fluxo-mediada da artéria braquial. É assumida a lesão endotelial como ponto central da fisiopatologia da doença; então, estão em andamento diversos estudos para se avaliar tratamentos que recuperem o endotélio e ofereçam sua proteção.

Preeclampsia is the main cause of maternal mortality in developing countries and it contributes to pre-term birth and other perinatal complications. Its etiology is still unknown and there are lots of physiopathology formulations that apply to this disease. One of the central points of this disease's physiopathology is the systemic endothelial lesion. This event has been studied in the Fetal Medicine Center of Universidade Federal de Minas Gerais and a great number of markers of endothelial lesion has been discovered, and correlated with the presence of preeclampsia. Classic literature and other studies, performed by our center, point out and confirm the theory of the deficient secondary placentation as cause of endothelial lesion in placentary vessels. An uncontrolled activity of the renin-angiotensin system would be responsible for the systemic compromise of the maternal organism. A promising method to verify this systemic endothelial lesion is the flow-mediated dilation of the brachial artery. It is assumed the endothelial lesion as the central point of this disease's physiopathology; thus, there are several studies to evaluate treatments which provide recovery and protection to the vascular endothelium.

[Assessment of the correlation between hemoglobin concentration and the echographic measurement of biventricular outer diameter in anemic fetuses of isoimmunized women]. / Avaliar a correlação entre a concentração da hemoglobina e a medida ecográfica do diâmetro biventricular externo em fetos anêmicos de gestantes isoimunizadas.

OBJECTIVE: To assess whether a significant correlation exists between the echographic measurement of biventricular outer diameter and the pretransfusional serum concentration of fetal hemoglobin and whether that echographic measurement can be used as a noninvasive marker of fetal anemia. METHODS: A prospective cross-sectional study was carried out comprising 65 cordocenteses performed in 36 anemic fetuses of mothers with isoimmunization to the Rh antigen. The biventricular outer diameter (BOD) was obtained by M-mode evaluation. Previous to the transfusion, a 0.5-mL fetal blood sample was obtained for hemoglobin measurement with spectrophotometry in the Hemocue device. The minimum square regression was used with p < 0.05 and multivariate analysis were used as statistical analysis. RESULTS: An inverse correlation was observed between the fetal hemoglobin concentration before transfusion and the BOD measurement, and a direct correlation was observed between the BOD measurement and gestational age. In addition, multivariate analysis showed that fetal hemoglobin concentration decreases as BOD increases, independently of the influence of gestational age on that parameter. CONCLUSION: An inverse correlation exists between fetal hemoglobin concentration and BOD measurement, regardless of gestational age. The findings suggest that BOD may become an echographic predictor of the hemoglobin level of fetuses of isoimmunized pregnant women.

Avaliar a correlação entre a concentração da hemoglobina e a medida ecográfica do diâmetro biventricular externo em fetos anêmicos de gestantes isoimunizadas / Assessment of the correlation between hemoglobin concentration and the echographic measurement of biventricular outer diameter in anemic fetuses of isoimmunized women

OBJETIVO: Verificar se existe correlação significativa entre a medida ecográfica do diâmetro biventricular externo e a concentração sérica da hemoglobina fetal pré-transfusional e se essa medida ecográfica poderá vir a ser utilizada como marcador não invasivo da anemia fetal. MÉTODOS: Estudo transversal prospectivo, no qual foram selecionadas 65 cordocenteses realizadas em 36 fetos anêmicos de mães portadoras de isoimunização pelo fator Rh. Obteve-se a medida do diâmetro biventricular externo (DBVE), por meio do modo M, utilizando-se aparelho de ultra-som convencional. Anterior à transfusão foi obtida amostra de 0,5ml de sangue fetal, para dosagem da hemoglobina, sendo a medida imediatamente realizada através de espectrofotometria, no equipamento Hemocue®. Como análise estatística foi utilizada a regressão dos mínimos quadrados, aceitando-se p<0,05 e análise multivariada. RESULTADOS: Foram observadas correlação inversa entre a concentração da hemoglobina no sangue fetal no momento prévio à transfusão e a medida do DBVE e correlação direta entre a medida do DBVE e a idade gestacional, e, também, através da análise multivariada que, à medida que a concentração de hemoglobina fetal cai, o DBVE aumenta, independentemente da influência da idade gestacional nesse parâmetro. CONCLUSAO: Existe correlação inversa entre a concentração da hemoglobina no sangue fetal e a medida do DBVE, independente da idade gestacional. Os achados sugerem que o DBVE poderá vir a ser um marcador ecográfico de predição do nível de hemoglobina de fetos de gestantes isoimunizadas.

Estudo das causas da isoimunização materna por antígenos eritrocitáros entre gestantes acompanhadas no Serviço de Medicina Fetal do HC-UFMG / Study of the causes of maternal erithrocytic antigen isoimmunization among pregnant women followed at the Fetal Medicine Service - HC-UFMG

Objetivo: Analisar as causas da isoimunização materna por antígenos entrocitários entre as gestantes acompanhadas no Serviço de Medicina Fetal do HC-UFMG, no período de junho de 1996 a junho /2003. Pacientes e Método: Trata-se de estudo prospectivo, qual 256 gestantes sensibilizadas por antígenos eritrocitários foram acompanhadas no Centro de Medicina Fetal do HC-UFMG. As pacientes foram avaliadas quanto ao passado obstétrico, visando identificar as causas de isoimunização. Resultados: Entre os 256 casos acompanhados, em 185(72,3%) a causa de isoimunização foi a ausência de profilaxia pós-parto; a transfusão sangüínea incompatível foi a responsável por 34 casos (13,3%) e a falta de profilaxia pós-aborto, por 29 casos (11,3%). Os oito casos restantes (3,1%) ocorreram durante o período gestacional. Conclusão: As principais causas de isoimunização materno-fetal continuam se relacionando à etiologia obstétrica, principalmente à falta de imunoprofilaxia no pás-parto e no pós-aborto. Portanto, a isoimunização, em nosso meio, pode ser facilmente prevenível com o uso da imunoglobulina anti-Rh (D), conforme rotina já estabelecida há décadas.

Objective: To analyze the causes of maternal erithrocytic antigen isoimmunization among pregnant women followed at the Fetal Medicine Service Hospital das Clínicas - Universidade Federal de Minas Gerais (FMSHC), from June/1996 to June/2003. Methods and Material: A prospective study, consisting of 256 pregnant women with sensitization by erithrocytic antigen were followed at the FMSHC. These patients were evaluated regarding the obstetric history, in order to identify the causes of isoimmunization. Results: In 185 cases (72.3%), isoimmunization was caused by lack of postpartum prophilaxy. Incompatibility in blood transfusion and absence of post-abortion prophilaxy were responsible for 34 (13.3%) and 29 cases (11.3%), respectively. The remaining eight cases (3.1%) occurred during gestational period. Conclusion: The main cause of fetal-maternal isoimmunization is still related to obstetric etiology, mainly to absence of postpartum or post-abortion immunoprophilaxy. Therefore, isoimmunization, in our population, can be easily prevented by the use of anti-Rh (D) immune globulin according to established routines.