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

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

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

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

PURPOSE: to compare the accuracy of transvaginal ultrasonographic measurement of the uterine cervix with Bishop's score for the prediction of vaginal delivery after labor induction, with 25 mcg of misoprostol. METHODS: a prospective study for the validation of a diagnostic test was conducted on 126 pregnant women with indication for labor induction. The patients were evaluated by Bishop's score and transvaginal ultrasonography for cervical measurement. They also undergone obstetric transabdominal ultrasound to evaluate static and fetal weight, as well as the amniotic fluid index, and basal cardiotocography for the evaluation of fetal vitality. Labor was induced with vaginal and sublingual misoprostol, one of the tablets containing 25 mcg of the drug and the other only placebo. The tablets were administered every six hours, with a maximum number of eight. Frequency tables were obtained, and measures of central tendency and dispersion were calculated. ROC curves were constructed for the evaluation of Bishop's score and ultrasonographic measurement of the uterine cervix for the prediction of vaginal delivery. RESULTS: the area under the ROC curve was 0.5 (p=0.8) for the ultrasonographic measurement of the uterine cervix, and 0.6 (p=0.02) for Bishop's score (cut point ≥4). Bishop's score had a sensitivity of 56.2% and specificity of 67.9% for prediction of vaginal delivery, with a positive likelihood ratio of 1.75 and a negative one of 0.65. CONCLUSIONS: ultrasonographic measurement of the uterine cervix was not a good predictor of evolution to vaginal delivery among patients with misoprostol-induced labor. Bishop's score was a better predictor of vaginal delivery under these circumstances.

Differences in neonatal outcome in fetuses with absent versus reverse end-diastolic flow in umbilical artery Doppler.

OBJECTIVES: It was the aim of this study to evaluate differences in the prognosis of fetuses with absent (AED) and reverse end-diastolic (RED) flow in the umbilical artery based on neonatal outcomes. METHODS: We performed a cross-sectional study based on the records of 143 patients attending at Assis Chateaubriand Teaching Maternity between 1 January 1999 and 31 December 2005. Patients were classified according to diagnosis as having either fetal centralization (FC), AED or RED. Obstetrical findings and perinatal outcomes were compared for the 3 groups and between AED and RED by Fisher's exact test. Perinatal outcomes were analyzed quantitatively with logistic or multinomial regression. Odds ratios were calculated for significant risk factors. RESULTS: There was a statistically significant difference in gestational age at diagnosis, Apgar scores at 1 and 5 min, Capurro score, use of surfactant and mechanical ventilation, admission to the neonatal intensive care unit, perinatal and neonatal death. When comparing RED with AED, the odds of neonatal intensive care unit admission, mechanical ventilation, use of surfactant, neonatal mortality and perinatal mortality were 3.2, 1.4, 1.0, 5.1 and 5.3 times higher for RED. Only perinatal mortality kept statistically significant with odds of 5.2 (p = 0.043) when adjusted by gestational age (multivariate analysis). CONCLUSION: The incidence of perinatal mortality was observed to increase with the severity of Doppler findings, with significant differences between the AED and RED groups.

Resultados perinatais em fetos com alterações ao estudo dopplervelocimétrico / Perinatal results of fetuses with alterations on doppler velocimetry

Os Métodos de avaliação da vitalidade fetal são amplamente utilizados em obstetrícia. A dopplervelocimetria (Doppler) torna possível avaliar o fluxo sanguíneo, podendo-se estudar a vascularização útero-placentário-fetal de forma fácil e não invasiva. O fluxo sanguíneo é analisado de forma indireta pela onda de velocidade de fluxo ou por meio de índices que refletem a resistência vascular. Estes índices relacionam a sístole, a diástole e a velocidade média do fluxo sanguíneo. Os mais utilizados são a relação sístole/diástole, o índice de pulsatilidade e o índice de resistência. O feto saudável, quando submetido à hipoxemia, pode adaptar-se para tentar diminuir o impacto da queda na concentração de oxigênio circulante. Mecanismos de defesa fetais vão privilegiar os órgãos mais nobres (cérebro, coração e adrenais) em detrimento dos demais, caracterizando a centralização do fluxo. Com a persistência do estado hipoxêmico, o quadro deve agravar-se progressivamente, surgindo a diástole zero, diástole reversa (artéria umbilical), alteração do Doppler venoso e a descentralização do fluxo fetal; podendo ocorrer o óbito intra-útero. Esta revisão tem o objetivo de comparar os resultados perinatais dos fetos com alterações ao estudo dopplervelocimétrico. O conhecimento do padrão de modificações hemodinâmicas nestas situações é de fundamental importância para o tratamento perinatal mais apropriado