Balloon catheters versus vaginal prostaglandins for labour induction (CPI Collaborative): an individual participant data meta-analysis of randomised controlled trials.

BACKGROUND: Induction of labour is one of the most common obstetric interventions globally. Balloon catheters and vaginal prostaglandins are widely used to ripen the cervix in labour induction. We aimed to compare the effectiveness and safety profiles of these two induction methods. METHODS: We did an individual participant data meta-analysis comparing balloon catheters and vaginal prostaglandins for cervical ripening before labour induction. We systematically identified published and unpublished randomised controlled trials that completed data collection between March 19, 2019, and May 1, 2021, by searching the Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and PubMed. Further trials done before March 19, 2019, were identified through a recent Cochrane review. Data relating to the combined use of the two methods were not included, only data from women with a viable, singleton pregnancy were analysed, and no exclusion was made based on parity or membrane status. We contacted authors of individuals trials and participant-level data were harmonised and recoded according to predefined definitions of variables. Risk of bias was assessed with the ROB2 tool. The primary outcomes were caesarean delivery, indication for caesarean delivery, a composite adverse perinatal outcome, and a composite adverse maternal outcome. We followed the intention-to-treat principle for the main analysis. The primary meta-analysis used two-stage random-effects models and the sensitivity analysis used one-stage mixed models. All models were adjusted for maternal age and parity. This meta-analysis is registered with PROSPERO (CRD42020179924). FINDINGS: Individual participant data were available from 12 studies with a total of 5460 participants. Balloon catheters, compared with vaginal prostaglandins, did not lead to a significantly different rate of caesarean delivery (12 trials, 5414 women; crude incidence 27·0%; adjusted OR [aOR] 1·09, 95% CI 0·95-1·24; I2=0%), caesarean delivery for failure to progress (11 trials, 4601 women; aOR 1·20, 95% CI 0·91-1·58; I2=39%), or caesarean delivery for fetal distress (10 trials, 4441 women; aOR 0·86, 95% CI 0·71-1·04; I2=0%). The composite adverse perinatal outcome was lower in women who were allocated to balloon catheters than in those allocated to vaginal prostaglandins (ten trials, 4452 neonates, crude incidence 13·6%; aOR 0·80, 95% CI 0·70-0·92; I2=0%). There was no significant difference in the composite adverse maternal outcome (ten trials, 4326 women, crude incidence 22·7%; aOR 1·02, 95% CI 0·89-1·18; I2=0%). INTERPRETATION: In induction of labour, balloon catheters and vaginal prostaglandins have comparable caesarean delivery rates and maternal safety profiles, but balloon catheters lead to fewer adverse perinatal events. FUNDING: Australian National Health and Medical Research Council and Monash Health Emerging Researcher Fellowship.

Performance of ophthalmic artery Doppler velocimetry in the complementary diagnosis of preeclampsia.

OBJECTIVES: To calculate the accuracy (A) and establish the best cutoff value for ophthalmic artery (OA) Doppler velocimetry indexes in patients diagnosed with preeclampsia (PE), compared with healthy pregnant women. METHODS: This prospective experimental study enrolled 268 women: 133 with PE and 135 healthy pregnant women. All patients were evaluated by OA Doppler sonography, bilaterally, to assess their pulsatility index (PI), resistance index (RI), peak systolic velocity (PVS), second peak systolic velocity (P2), end-diastolic velocity (EDV), and peak ratio (PR). Means were compared using Student's T-test. Receiver Operating Characteristics (ROC) curve was used to establish the cutoff value and estimate the sensitivity (S), specificity (Sp), accuracy (A) of all variables, and a significance of 95% was adopted. RESULTS: ROC curve analysis showed that P2 and PR were superior to the other parameters for PE diagnosis. We tested two cutoff values: (1) using PR ≥0.70, obtained A: 88.72%, S: 81.95%, and Sp: 95.48% and (2) using PR ≥0.75, and A: 86.24%, S: 74.43%, and Sp: 99.24%. By adopting P2 ≥ 21.5 cm/s, we obtained A: 87.59%, S: 84.96%, and Sp: 90.22% and when the cutoff point was P2 ≥ 22 cm/s, there was a slight decrease in A to 86.46% and S to 81.20%, with Sp: 91.89.3%. CONCLUSION: Ophthalmic artery Doppler demonstrated to be an effective and high-performance imaging method for the diagnosis of PE and the indexes P2 and PR demonstrated superior accuracy to the other Doppler parameters assessed. Higher performance occurred when the cutoff values with greater specificity were adopted, PR ≥ 0.75 and P2 ≥ 22 cm/s, considering that the proposed OA Doppler is to be a complementary method for preeclampsia.

Clinical Experience Over 15 Years with the B-Lynch Compression Suture Technique in the Management of Postpartum Hemorrhage.

OBJECTIVE: To describe the clinical experience with the B-Lynch technique in the management of postpartum hemorrhage as well as the factors related to the indication of the technique and to present the success rates of the application of the B-Lynch technique. METHODS: Observational, retrospective, cross-sectional, and analytical study. Patient data was obtained through the study of medical records. The study population comprised of patients who underwent hemostatic suture using the B-Lynch technique, including 104 patients within the period from January 1, 2005, to December 31, 2019. RESULTS: Of the total of 104 patients, 82.7% did not present any complications. Blood transfusion and intensive care unit admission were the most prevalent complications, with 13.5% and 15.4%, respectively. Only 1% of the patients had puerperal and surgical site infections. The factors most related to the application of the technique were the presence of previous cesarean section (30.8%), use of oxytocin (16.3%), and preeclampsia (11.6%). Puerperal hysterectomy was performed in 4.8% of the patients due to failure of the method. CONCLUSION: The clinical experience with the B-Lynch technique was satisfactory since it presented few complications, with excellent results in hemorrhagic control. Previous cesarean section, the use of oxytocin, and preeclampsia stood out as factors related to the indication of the application of the technique, and the success rate in controlling postpartum hemorrhage was 95.2%.

OBJETIVO: Descrever a experiência clínica com a técnica de B-Lynch no manejo da hemorragia pós-parto e os fatores relacionados à indicação da técnica bem como apresentar as taxas de sucesso da aplicação da técnica de B-lynch. MéTODOS: Estudo observacional, retrospectivo, de corte transversal e analítico. Os dados foram obtidos por estudo de prontuário. A população do estudo foi constituída de pacientes submetidas à sutura hemostática com a técnica de B-Lynch, sendo incluídas 104 pacientes dentro do período de 01 de janeiro de 2005 a 31 de dezembro de 2019. RESULTADOS: Do total de 104 pacientes, 82,7% não apresentaram qualquer complicação. A transfusão de sangue e a internação na UTI foram as complicações mais prevalentes, com 13,5% e 15,4%, respectivamente. Apenas 1% teve infecção puerperal e do sítio cirúrgico. Os fatores mais relacionados com a aplicação da técnica foram a presença de cesárea anterior (30,8%), uso de ocitocina (16,3%) e pré-eclâmpsia (11,6%). A histerectomia puerperal foi realizada em 4,8% das pacientes por falha do método. CONCLUSãO: A experiência clínica com a técnica de B-Lynch foi satisfatória, pois apresentou poucas complicações, com excelentes resultados no controle hemorrágico. A cesárea anterior, o uso de ocitocina e a pré-eclâmpsia se destacaram como fatores relacionados à indicação da aplicação da técnica. A taxa de sucesso avaliada foi de 95,2%.

Clinical Experience Over 15 Years with the B-Lynch Compression Suture Technique in the Management of Postpartum Hemorrhage / Experiência clínica ao longo de 15 anos com a técnica de sutura compressiva de B-Lynch no manejo da hemorragia pós-parto

Abstract Objective To describe the clinical experience with the B-Lynch technique in the management of postpartum hemorrhage as well as the factors related to the indication of the technique and to present the success rates of the application of the B-Lynch technique. Methods Observational, retrospective, cross-sectional, and analytical study. Patient data was obtained through the study of medical records. The study population comprised of patients who underwent hemostatic suture using the B-Lynch technique, including 104 patients within the period from January 1, 2005, to December 31, 2019. Results Of the total of 104 patients, 82.7% did not present any complications. Blood transfusion and intensive care unit admission were the most prevalent complications, with 13.5% and 15.4%, respectively. Only 1% of the patients had puerperal and surgical site infections. The factors most related to the application of the technique were the presence of previous cesarean section (30.8%), use of oxytocin (16.3%), and pre-eclampsia (11.6%). Puerperal hysterectomy was performed in 4.8% of the patients due to failure of the method. Conclusion The clinical experience with the B-Lynch technique was satisfactory since it presented few complications, with excellent results in hemorrhagic control. Previous cesarean section, the use of oxytocin, and preeclampsia stood out as factors related to the indication of the application of the technique, and the success rate in controlling postpartum hemorrhage was 95.2%.

Resumo Objetivo Descrever a experiência clínica com a técnica de B-Lynch no manejo da hemorragia pós-parto e os fatores relacionados à indicação da técnica bem como apresentar as taxas de sucesso da aplicação da técnica de B-lynch. Métodos Estudo observacional, retrospectivo, de corte transversal e analítico. Os dados foram obtidos por estudo de prontuário. A população do estudo foi constituída de pacientes submetidas à sutura hemostática com a técnica de B-Lynch, sendo incluídas 104 pacientes dentro do período de 01 de janeiro de 2005 a 31 de dezembro de 2019. Resultados Do total de 104 pacientes, 82,7% não apresentaram qualquer complicação. A transfusão de sangue e a internação na UTI foram as complicações mais prevalentes, com 13,5% e 15,4%, respectivamente. Apenas 1% teve infecção puerperal e do sítio cirúrgico. Os fatores mais relacionados com a aplicação da técnica foram a presença de cesárea anterior (30,8%), uso de ocitocina (16,3%) e pré-eclâmpsia (11,6%). A histerectomia puerperal foi realizada em 4,8% das pacientes por falha do método. Conclusão A experiência clínica com a técnica de B-Lynch foi satisfatória, pois apresentou poucas complicações, com excelentes resultados no controle hemorrágico. A cesárea anterior, o uso de ocitocina e a pré-eclâmpsia se destacaram como fatores relacionados à indicação da aplicação da técnica. A taxa de sucesso avaliada foi de 95,2%.

Pre-eclampsia: Universal Screening or Universal Prevention for Low and Middle-Income Settings?

Pre-eclampsia (PE) is a severe disorder that affects up to 8% of all pregnancies and represents an important cause of maternal and perinatal morbidity and mortality. The screening of the disease is a subject of studies, but the complexity and uncertainties regarding its etiology make this objective a difficult task. In addition, the costs related to screening protocols, the heterogeneity of the most affected populations and the lack of highly effective prevention methods reduce the potential of current available algorithms for screening. Thus, the National Specialized Commission of Hypertension in Pregnancy of the Brazilian Association of Gynecology and Obstetrics Federation (Febrasgo, in the Portuguese acronym) (NSC Hypertension in Pregnancy of the Febrasgo) considers that there are no screening algorithms to be implemented in the country to date and advocates that Aspirin and calcium should be widely used.

A Pré-eclâmpsia (PE) é uma doença grave que acomete ∼ 8% das gestações e representa importante causa de morbimortalidade, tanto materna quanto perinatal. O rastreamento da doença é motivo de estudos, porém a complexidade e as incertezas quanto a sua etiologia tornam esse objetivo bastante difícil. Além disso, os custos relacionados com o rastreamento, a heterogeneidade das populações mais afetadas e ainda a falta de métodos de prevenção de grande eficácia reduzem o potencial dos algoritmos de rastreamento. Assim, a Comissão Nacional Especializada sobre Hipertensão na Gravidez da Federação Brasileira das Associações de Ginecologia e Obstetrícia (CNE Hipertensão na Gravidez da FEBRASGO) considera que não há algoritmos de rastreamento que possam ser aplicados no país nesse momento e defende a utilização dos métodos de prevenção como ácido acetilsalicílico e cálcio de maneira ampla.

Pre-eclampsia: Universal screening or universal prevention for low and middle-income settings? / Pré-eclâmpsia: Rastreamento universal ou prevenção universal para países de baixa e média-renda?

Abstract Pre-eclampsia (PE) is a severe disorder that affects up to 8% of all pregnancies and represents an important cause of maternal and perinatal morbidity and mortality. The screening of the disease is a subject of studies, but the complexity and uncertainties regarding its etiology make this objective a difficult task. In addition, the costs related to screening protocols, the heterogeneity of the most affected populations and the lack of highly effective prevention methods reduce the potential of current available algorithms for screening. Thus, the National Specialized Commission of Hypertension in Pregnancy of the Brazilian Association of Gynecology and Obstetrics Federation (Febrasgo, in the Portuguese acronym) (NSC Hypertension in Pregnancy of the Febrasgo) considers that there are no screening algorithms to be implemented in the country to date and advocates that Aspirin and calcium should be widely used.

Resumo A Pré-eclâmpsia (PE) é uma doença grave que acomete ~ 8% das gestações e representa importante causa de morbimortalidade, tanto materna quanto perinatal. O rastreamento da doença émotivo de estudos, porém a complexidade e as incertezas quanto a sua etiologia tornam esse objetivo bastante difícil. Além disso, os custos relacionados com o rastreamento, a heterogeneidade das populações mais afetadas e ainda a falta de métodos de prevenção de grande eficácia reduzem o potencial dos algoritmos de rastreamento. Assim, a Comissão Nacional Especializada sobre Hipertensão na Gravidez da Federação Brasileira das Associações de Ginecologia e Obstetrícia (CNE Hipertensão na Gravidez da FEBRASGO) considera que não há algoritmos de rastreamento que possam ser aplicados no país nesse momento e defende a utilização dos métodos de prevenção como ácido acetilsalicílico e cálcio de maneira ampla.

Coronavirus 2019, Thrombocytopenia and HELLP Syndrome: Association or Coincidence?

The present report describes the case of a 31-year-old primigravida, with dichorionic twins at 31 weeks. She presented with history of myalgia, jaundice, and abdominal discomfort. No flu-like symptoms as fever or cough. She was not aware of exposure to COVID-19. Normal blood pressure and O2 saturation. Laboratory tests showed platelet count of 218,000 mm3, alanine aminotransferase (ALT) 558 IU and serum creatinine 2.3 mg/dl. Doppler ultrasound in one twin was compatible with brain sparing. Partial hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome was the hypothesis, and a cesarean section was performed. On day 2, the white-cell count reached 33,730, with decreased consciousness and mild respiratory distress. Tomography revealed both lungs with ground-glass opacities. Swab for COVID-19 polymerase chain reaction (PCR) was positive. Thrombocytopenia in patients with COVID-19 appears to be multifactorial, similar to what occurs in preeclampsia and HELLP syndrome. We assume that the synergism of these pathophysiological mechanisms could accelerate the compromise of maternal conditions and could be a warning to the obstetric practice.

O presente relato descreve o caso de uma gestante de 31 anos, gemelar dicoriônica com 31 semanas, com queixa de mialgia, icterícia e desconforto abdominal. A paciente não apresentava sintomas gripais como febre ou tosse e não tinha conhecimento de exposição ao COVID-19. Pressão arterial e saturação de oxigênio normais. Os exames laboratoriais apresentaram contagem de plaquetas de 218,000 mm3, ALT 558 IU e creatinina 2.3 mg/dl. Doppler compatível com centralização de um dos fetos. Síndrome de hemolysis, elevated liver enzymes, low platelet count (HELLP) parcial foi a hipótese diagnóstica inicial e a cesariana foi realizada. No segundo dia, a paciente apresentou leucócitos de 33.730 com queda do nível de consciência e desconforto respiratório leve. A tomografia revelou opacidade pulmonar em vidro fosco bilateralmente. A pesquisa de COVID-19 por polymerase chain reaction (PCR)/swab teve resultado positivo. Trombocitopenia em pacientes com COVID-19 é multifatorial, semelhante ao que ocorre na pré-eclâmpsia e na síndrome HELLP. Acreditamos que o sinergismo da fisiopatologia das doenças em questão pode acelerar o comprometimento materno e deve servir de alerta para a prática obstétrica.

Coronavirus 2019, thrombocytopenia and HELLP syndrome: association or coincidence? / Coronavírus 2019, trombocitopenia e síndrome HELLP: Associação ou coincidência?

Abstract The present report describes the case of a 31-year-old primigravida, with dichorionic twins at 31 weeks. She presented with history of myalgia, jaundice, and abdominal discomfort. No flu-like symptoms as fever or cough. She was not aware of exposure to COVID-19. Normal blood pressure and O2 saturation. Laboratory tests showed platelet count of 218,000 mm3, alanine aminotransferase (ALT) 558 IU and serum creatinine 2.3 mg/dl. Doppler ultrasound in one twin was compatible with brain sparing. Partial hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome was the hypothesis, and a cesarean section was performed. On day 2, the white-cell count reached 33,730, with decreased consciousness and mild respiratory distress. Tomography revealed both lungs with ground-glass opacities. Swab for COVID-19 polymerase chain reaction (PCR) was positive. Thrombocytopenia in patients with COVID-19 appears to be multifactorial, similar to what occurs in preeclampsia and HELLP syndrome. We assume that the synergism of these pathophysiological mechanisms could accelerate the compromise of maternal conditions and could be a warning to the obstetric practice.

Resumo O presente relato descreve o caso de uma gestante de 31 anos, gemelar dicoriônica com 31 semanas, com queixa de mialgia, icterícia e desconforto abdominal. A paciente não apresentava sintomas gripais como febre ou tosse e não tinha conhecimento de exposição ao COVID-19. Pressão arterial e saturação de oxigênio normais. Os exames laboratoriais apresentaram contagem de plaquetas de 218,000 mm3, ALT 558 IU e creatinina 2.3 mg/dl. Doppler compatível com centralização de um dos fetos. Síndrome de hemolysis, elevated liver enzymes, low platelet count (HELLP) parcial foi a hipótese diagnóstica inicial e a cesariana foi realizada. No segundo dia, a paciente apresentou leucócitos de 33.730 com queda do nível de consciência e desconforto respiratório leve. A tomografia revelou opacidade pulmonar em vidro fosco bilateralmente. A pesquisa de COVID-19 por polymerase chain reaction (PCR)/swab teve resultado positivo. Trombocitopenia em pacientes com COVID-19 é multifatorial, semelhante ao que ocorre na pré-eclâmpsia e na síndrome HELLP. Acreditamos que o sinergismo da fisiopatologia das doenças em questão pode acelerar o comprometimento materno e deve servir de alerta para a prática obstétrica.

Phosphatidylethanol Levels in Postpartum Women and Their Newborns in Uruguay and Brazil.

BACKGROUND: There is increasing interest in the development of newborn screening tests to identify children at risk of fetal alcohol spectrum disorder (FASD) in order to provide these children with early intervention. Phosphatidylethanol (PEth) has emerged as a potential universal newborn screening candidate. METHODS: The aim of this report was to present the results of a study designed to compare PEth levels in 1,140 postpartum women and their newborn infants in Montevideo, Uruguay, and Sao Paulo, Brazil. Self-report alcohol use during pregnancy data was collected, along with both maternal and newborn dried blood spot samples for PEth analysis. RESULTS: The average age and parity of the women in the sample were 26 years of age and 2.3 pregnancies. For the Uruguay sample (n = 611), 45.8% of postpartum women had PEth levels ≥ 8 ng/ml with a mean positive PEth of 43.6 ng/ml. In contrast, 86.8% of the newborns had PEth levels ≥ 8 ng/ml, with a mean positive PEth of 77.4 ng/ml. For the Brazil sample (n = 529), 33.2% of women had PEth levels ≥ 8 ng/ml with a mean positive PEth of 31 ng/ml. In contrast, 76.9% of the Brazil newborns had PEth levels ≥ 8 ng/ml and 43.9% with a mean positive PEth of 61.1 ng/ml. PEth levels were significantly higher in newborns compared with their postpartum mothers in both the Uruguay and Brazil samples. Self-reported third-trimester alcohol was 6% in the Uruguay sample and 9.1% in the Brazil sample compared with positive maternal PEth levels in 45.8% and 33.2%, respectively. CONCLUSIONS: Clinicians may want to consider newborn PEth screening in high-risk populations where prenatal alcohol use is common. The mechanism underlying significantly higher PEth levels in newborns compared with their mothers is not known.

Trends associated with stillbirth in a maternity hospital school in the north zone of são paulo: a cross-sectional study / Tendências associadas à natimortalidade em umamaternidadeescola na zona norte de São Paulo: um estudo transversal

Abstract Objective To evaluate conditions associated with stillbirth (SB), and possible trends related with it, in a maternity hospital school in the North zone of São Paulo. Methods An observational, cross-sectional study conducted at the Hospital Maternidade- escola de Vila Nova Cachoeirinha with 1,139 SBs in the period of 2003 to 2017. Cases of intermediate SB (ISB) (weight between 500 and 999 g) and late SB (LSB) (weight ≥ 1,000 g) were compared. We evaluated clinical data, laboratory tests, and fetal and placental studies. Data were stored in Windows Excel (Microsoft Corp., Redmond, WA, USA) worksheets, according to which graphs and tables were constructed. We used the statistical software SPSS for Windows version 18.0 (SPSS In., Chicago, IL, USA), estimating the prevalence ratio (PR) and odds ratio (OR), considering the 95% confidence interval (95% CI). Results The general SB rate was 11.9%, and the in-hospital SB rate was 2.8%. Pregnant women younger than 16 years of age were more likely to have ISB (OR 0.32, 0.15- 0.76), while patients older than 40 years old had a higher chance of LSB (PR 0.85, 0.72- 0.99). A total of 25.7% of the general population did not have prenatal care, and 77.1% of the cases presented fetal death at admission. The cases of ISB had a statistically significant association with home birth (OR 0.61, 0.46-0.80). Cesarean section was performed in 16.1% of the subjects, and misoprostol was the most used method for induction. Necropsy and placental study of the fetuses were performed, respectively, in 94.2% and 97.3% of the cases. Associated causes were not identified in 22.1% of the cases, and the main causes identified were amniotic sac infections (27.9%), fetal malformations (12.5%), placental abruption (11.2%), hypertensive syndromes (8.5%), and maternal syphilis (3.9%), the latter with an increasing trend. Conclusion Among the factors associated to SB were: hypertensive syndromes, amniotic sac infections, fetal malformations, placental abruption and syphilis. There was a growing trend in the number of cases of syphilis, which translates an alert. Diagnostic limitations justify indeterminate causes.

Resumo Objetivo Avaliar aspectos relacionados à ocorrência da condição de natimortalidade em uma maternidade-escola na zona norte de São Paulo e possíveis tendências associadas aos fatores causais. Métodos Estudo observacional, transversal, realizado no Hospital Maternidadeescola Vila Nova Cachoeirinha com 1.139 óbitos fetais (OF) no período de 2003 a 2017. Foram comparados os casos de OF intermediários (OFI) (peso entre 500 e 999 g) e OF tardios (OFT) (≥ 1,000 g). Avaliamos dados clínicos, exames laboratoriais, e estudos do feto e da placenta; estes foram armazenados em planilhas de Windows Excel (Microsoft Corp., Redmond, WA USA0, utilizando-se para avaliação estatística o programa SPSS v.18 (SPSS Inc., Chicago, IL, EUA). Foram ainda estimadas a razão de prevalência (RP) e a razão de chances (RC), com intervalo de confiança de 95% (IC 95%). Resultados Ocoeficiente de natimortalidade geral foi de 11,9% e o intra-hospitalar foi de 2,8%. Gestantes com menos de 16 anos de idade apresentaram maior chance de ter OFI (RC 0.32, 0.15-0.76) enquanto que pacientes com mais de 40 anos de idade apresentaram maior chance de OFT (RP 0,85; 0,72-0,99). Não fizeram prenatal 25,7% da população geral, sendo que em 77,1% dos casos, a morte fetal já tinha sido apresentada na internação. Os casos de OFI apresentaram associação estatisticamente significante com parto domiciliar (RC 0,42; 0,23-0,75). A cesárea foi realizada em 16,1% das pacientes, sendo o misoprostol o método mais utilizado para indução. Necropsia foi feita em 94,2% dos fetos, e 97,3% das placentas foram para estudo. As causas associadas não foram identificadas em 22,1% dos casos, sendo que as principais causas identificadas foram infecções do saco amniótico e membranas (27,9%), malformações (12,5%), descolamento prematuro de placenta (11,2%), síndromes hipertensivas (8,5%), e sífilis (3,9%), sendo esta última com uma tendência crescente. Conclusão Destacaram-se como fatores associados à natimortalidade: síndromes hipertensivas, corioamnionites, malformações fetais, descolamento placentário e sífilis. Houve tendência de aumento no número de casos de sífilis, o que traduz uma alerta. Limitações diagnósticas justificam as causas indeterminadas.

Trends Associated with Stillbirth in a Maternity Hospital School in the North Zone of São Paulo: A Cross-Sectional Study.

OBJECTIVE: To evaluate conditions associated with stillbirth (SB), and possible trends related with it, in a maternity hospital school in the North zone of São Paulo. METHODS: An observational, cross-sectional study conducted at the Hospital Maternidade-escola de Vila Nova Cachoeirinha with 1,139 SBs in the period of 2003 to 2017. Cases of intermediate SB (ISB) (weight between 500 and 999 g) and late SB (LSB) (weight ≥ 1,000 g) were compared. We evaluated clinical data, laboratory tests, and fetal and placental studies. Data were stored in Windows Excel (Microsoft Corp., Redmond, WA, USA) worksheets, according to which graphs and tables were constructed. We used the statistical software SPSS for Windows version 18.0 (SPSS In., Chicago, IL, USA), estimating the prevalence ratio (PR) and odds ratio (OR), considering the 95% confidence interval (95% CI). RESULTS: The general SB rate was 11.9%, and the in-hospital SB rate was 2.8%. Pregnant women younger than 16 years of age were more likely to have ISB (OR 0.32, 0.15-0.76), while patients older than 40 years old had a higher chance of LSB (PR 0.85, 0.72-0.99). A total of 25.7% of the general population did not have prenatal care, and 77.1% of the cases presented fetal death at admission. The cases of ISB had a statistically significant association with home birth (OR 0.61, 0.46-0.80). Cesarean section was performed in 16.1% of the subjects, and misoprostol was the most used method for induction. Necropsy and placental study of the fetuses were performed, respectively, in 94.2% and 97.3% of the cases. Associated causes were not identified in 22.1% of the cases, and the main causes identified were amniotic sac infections (27.9%), fetal malformations (12.5%), placental abruption (11.2%), hypertensive syndromes (8.5%), and maternal syphilis (3.9%), the latter with an increasing trend. CONCLUSION: Among the factors associated to SB were: hypertensive syndromes, amniotic sac infections, fetal malformations, placental abruption and syphilis. There was a growing trend in the number of cases of syphilis, which translates an alert. Diagnostic limitations justify indeterminate causes.

OBJETIVO: Avaliar aspectos relacionados à ocorrência da condição de natimortalidade em uma maternidade-escola na zona norte de São Paulo e possíveis tendências associadas aos fatores causais. MéTODOS: Estudo observacional, transversal, realizado no Hospital Maternidade-escola Vila Nova Cachoeirinha com 1.139 óbitos fetais (OF) no período de 2003 a 2017. Foram comparados os casos de OF intermediários (OFI) (peso entre 500 e 999 g) e OF tardios (OFT) (≥ 1,000 g). Avaliamos dados clínicos, exames laboratoriais, e estudos do feto e da placenta; estes foram armazenados em planilhas de Windows Excel (Microsoft Corp., Redmond, WA USA0, utilizando-se para avaliação estatística o programa SPSS v.18 (SPSS Inc., Chicago, IL, EUA). Foram ainda estimadas a razão de prevalência (RP) e a razão de chances (RC), com intervalo de confiança de 95% (IC 95%). RESULTADOS: O coeficiente de natimortalidade geral foi de 11,9% e o intra-hospitalar foi de 2,8%. Gestantes com menos de 16 anos de idade apresentaram maior chance de ter OFI (RC 0.32, 0.15­0.76) enquanto que pacientes com mais de 40 anos de idade apresentaram maior chance de OFT (RP 0,85; 0,72­0,99). Não fizeram prenatal 25,7% da população geral, sendo que em 77,1% dos casos, a morte fetal já tinha sido apresentada na internação. Os casos de OFI apresentaram associação estatisticamente significante com parto domiciliar (RC 0,42; 0,23­0,75). A cesárea foi realizada em 16,1% das pacientes, sendo o misoprostol o método mais utilizado para indução. Necropsia foi feita em 94,2% dos fetos, e 97,3% das placentas foram para estudo. As causas associadas não foram identificadas em 22,1% dos casos, sendo que as principais causas identificadas foram infecções do saco amniótico e membranas (27,9%), malformações (12,5%), descolamento prematuro de placenta (11,2%), síndromes hipertensivas (8,5%), e sífilis (3,9%), sendo esta última com uma tendência crescente. CONCLUSãO: Destacaram-se como fatores associados à natimortalidade: síndromes hipertensivas, corioamnionites, malformações fetais, descolamento placentário e sífilis. Houve tendência de aumento no número de casos de sífilis, o que traduz uma alerta. Limitações diagnósticas justificam as causas indeterminadas.

Pre-eclampsia/Eclampsia.

Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age in < 24 weeks, between 24 and less than 34 weeks, and ≥ 34 weeks of gestation, and guidance on route of delivery. An immediate puerperium approach and repercussions in the future life of pregnant women who develop preeclampsia is also presented.

A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A pré-eclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgão-alvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas.

Pre-eclampsia/Eclampsia / Pré-eclâmpsia/Eclâmpsia

Abstract Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age

Resumo A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A préeclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgãoalvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas.

Pré-eclâmpsia/eclâmpsia / Pre-Eclampsia/Eclampsia

A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A pré-eclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgão-alvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas.(AU)

Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age in < 24 weeks, between 24 and less than 34 weeks, and ≥ 34 weeks of gestation, and guidance on route of delivery. An immediate puerperium approach and repercussions in the future life of pregnant women who develop preeclampsia is also presented.(AU)

Pregnancy in renal transplant patients: Renal function markers and maternal-fetal outcomes.

OBJECTIVES: We aimed to evaluate laboratory markers in women who got pregnant after renal transplantation. STUDY DESIGN: Cross-sectional prospective study. MAIN OUTCOME MEASURES: Renal function parameters and maternal and fetal data were assessed in renal transplant recipients. RESULTS: Forty-three women who got pregnant after renal transplantation (mean age, 28.5 years; mean gestational age, 35.6 weeks) were included. Most patients (53.5%) received a renal transplant from a deceased donor. Podocyturia was not significantly correlated with other renal function markers. Mean period from transplantation to pregnancy was approximately 5 years; this period was not associated with obstetric complications or changes in renal markers. A gradual increase was observed in the following parameters during pregnancy and puerperium: serum creatinine levels (P < 0.001), proteinuria (P < 0.001), urinary protein/creatinine ratio (P < 0.001), and albumin/creatinine ratio (P < 0.001). The sensitivity and specificity of protein/creatinine ratio in predicting preeclampsia were high (96.0% and 94.0%, respectively). Elevated serum creatinine levels, urinary albumin/creatinine ratio, and retinol-binding protein levels in the third trimester were associated with prematurity (P < 0.001). Preeclampsia was the main cause of renal function decline at the end of pregnancy (65.0% of cases). Approximately four (9.5%) pregnant women presented with premature rupture of membranes and 18 (42.0%) with a urinary tract infection. CONCLUSIONS: Proteinuria, urinary protein/creatinine ratio, and retinol-binding protein levels were elevated in patients with preeclampsia. Using these markers to assess renal function during pregnancy may be clinically useful for detecting and monitoring renal injury in renal transplant recipients.