Accuracy of supervised measurement of fetal weight in a residency program.

OBJECTIVES: To evaluate the accuracy of ultrasound estimates of fetal weight made by residents. METHODS: A cross-sectional study was conducted on consecutive pregnancies attended in an obstetric ward. All participants provided their consent to participate. Inclusion criteria were singleton pregnancies with ultrasound evaluation and delivery within 14 days. Congenital abnormalities and stillbirths were excluded. Ultrasound scans were performed by two residents, one observer per subject, following standardized methodology and supervised by senior staff. Fetal weight was calculated using the four-parameter Hadlock 1985 formula. Birth weight was measured using a standard clinical scale. Bland-Altman and mixed-effects analyses were performed. RESULTS: In a 6-month period, 95 gestations were recruited at 30-41 weeks, and birth weights ranged from 1200 to 4080 g. The bias between methods was -28 g (CI95%, -74 to 18) with 95% limits of agreement of ±440 g. The 95% deviation between methods was of ±16%. Parity had the most significant effect on the bias between methods; operator and maternal weight had no significant effect. CONCLUSIONS: Supervised measurement of fetal weight by residents demonstrated high accuracy. Parity bias may be associated with visceral fat deposition independent of maternal weight gain. A methodology for medical evaluation is presented.

Prevalence of macrosomic newborn and maternal and neonatal complications in a high-risk maternity.

Objective: Evaluate the prevalence of macrosomic newborns (birth weight above 4000 grams) in a high-risk maternity from 2014 to 2019, as well as the maternal characteristics involved, risk factors, mode of delivery and associated outcomes, comparing newborns weighing 4000-4500 grams and those weighing above 4500 grams. Methods: This is an observational study, case-control type, carried out by searching for data in hospital's own system and clinical records. The criteria for inclusion in the study were all patients monitored at the service who had newborns with birth weight equal than or greater than 4000 grams in the period from January 2014 to December 2019, being subsequently divided into two subgroups (newborns with 4000 to 4500 grams and newborns above 4500 grams). After being collected, the variables were transcribed into a database, arranged in frequency tables. For treatment and statistical analysis of the data, Excel and R software were used. This tool was used to create graphs and tables that helped in the interpretation of the results. The statistical analysis of the variables collected included both simple descriptive analyzes as well as inferential statistics, with univariate, bivariate and multivariate analysis. Results: From 2014 to 2019, 3.3% of deliveries were macrosomic newborns. The average gestational age in the birth was 39.4 weeks. The most common mode of delivery (65%) was cesarean section. Diabetes mellitus was present in 30% of the deliveries studied and glycemic control was absent in most patients. Among the vaginal deliveries, only 6% were instrumented and there was shoulder dystocia in 21% of the cases. The majority (62%) of newborns had some complication, with jaundice (35%) being the most common. Conclusion: Birth weight above 4000 grams had a statistically significant impact on the occurrence of neonatal complications, such as hypoglycemia, respiratory distress and 5th minute APGAR less than 7, especially if birth weight was above 4500 grams. Gestational age was also shown to be statistically significant associated with neonatal complications, the lower, the greater the risk. Thus, macrosomia is strongly linked to complications, especially neonatal complications.

Association between maternal cardiometabolic markers and fetal growth in non-complicated pregnancies: a secondary analysis of the PRINCESA cohort.

The objective of this study was to evaluate the association of maternal cardiometabolic markers trajectories (glucose, triglycerides (TG), total cholesterol, systolic blood pressure (SBP) and diastolic blood pressure (DBP)) with estimated fetal weight trajectories and birth weight in Mexican pregnant women without medical complications. Cardiometabolic marker trajectories were characterized using group-based trajectory models. Mixed-effect and linear regression models were estimated to assess the association of maternal trajectories with estimated fetal weight and birth weight. The final sample comprised 606 mother-child dyads. Two trajectory groups of maternal cardiometabolic risk indicators during pregnancy were identified (high and low). Fetuses from women with higher values of TG had higher weight gain during pregnancy ( ß ^ = 24.00 g; 95%CI: 12.9, 35.3), were heavier at the sixth month ( ß ^ =48.24 g; 95%CI: 7.2, 89.7) and had higher birth weight ( ß ^ = 89.08 g; 95%CI: 20.8, 157.4) than fetuses in the low values trajectory. Fetuses from mothers with high SBP and DBP had less weight in the sixth month of pregnancy ( ß ^ = - 42.4 g; 95%CI: - 82.7, - 2.1 and ß ^ = - 50.35 g; 95%CI: - 94.2, - 6.4), and a higher DBP trajectory was associated with lower birth weight ( ß ^ = - 101.48 g; 95%CI: - 176.5, - 26.4). In conclusion, a longitudinal exposition to high values of TG and BP was associated with potentially adverse effects on fetal growth. These findings support the potential modulation of children's phenotype by maternal cardiometabolic conditions in pregnancies without medical complications.

Valoración del margen de error ecográfico entre el peso fetal estimado y el peso al nacer en la Maternidad del Hospital de Clínicas / Assessment of the ultrasound margin of error between the estimated fetal weight and the weight at birth in the Maternity of the Hospital de Clínicas / Avaliação da margem de erro ultrassonográfica entre o peso fetal estimado e o peso ao nascer na Maternidade do Hospital de Clínicas

Introducción: La valoración ultrasonográfica del peso fetal permite valorar el crecimiento y bienestar fetal pudiendo estimar el peso al nacimiento, factor determinante para el pronóstico vital. Objetivos: Determinar el margen de error ecográfico del peso fetal estimado (PFE) en relación con el peso al nacer de los neonatos de la Maternidad del Hospital de Clínicas entre los años 2020 y 2022 Materiales y Métodos: Se realizó un estudio observacional, descriptivo y transversal en mujeres que tuvieron un parto en el lugar y el período mencionado, y que contaban con ecografía obstétrica de crecimiento realizada con menos de 7 días respecto al nacimiento. Se calculó el error del PFE mediante la fórmula: (Peso al Nacer - Peso Fetal Estimado) / Peso al Nacer) x 100. Se contrastó el error del peso fetal estimado con el índice de masa corporal, diabetes y estados hipertensivos del embarazo, utilizando t de Student y con la edad gestacional y edad materna mediante el índice de Pearson tomando valores estadísticamente significativos menores a 0,05. Resultados: Se incluyeron 258 pacientes. El margen de error ecográfico del PFE fue de 8,3% DE ± 7. Se obtuvo un valor p para el IMC de 0,228, diabetes p 0,915, estados hipertensivos p 0,967, días en que se realizaba la ecografía p 0,5 y edad gestacional el p 0,001. Conclusiones: El margen de error ecográfico del PFE se encuentra por debajo de los parámetros internacionales. Se encontró asociación estadísticamente significativa con la edad gestacional, no así con las otras variables.

Introduction: Ultrasonographic assessment of fetal weight allows assessment of fetal growth and well-being and can estimate birth weight, a determining factor for vital prognosis. Objectives: Determine the ultrasound margin of error of the estimated fetal weight (EFP) in relation to the birth weight of neonates at the Maternity Hospital of the Hospital de Clínicas between the years 2020 and 2022. Materials and Methods: An observational, descriptive and cross-sectional study was carried out on women who had their birth in the aforementioned place and period and who had an obstetric growth ultrasound performed less than 7 days after birth. The error of the EPF was calculated using the formula: (Birth Weight - Estimated Fetal Weight) / Birth Weight) x 100. The error of the estimated fetal weight was contrasted with the body mass index, diabetes and hypertensive state of pregnancy, using Student's t and with gestational age and maternal age using the Pearson index taking statistically significant values ​​less than 0.05. Results: 258 patients were included. The ultrasound margin of error of the EPF was 8.3% SD ± 7. A p value was obtained for BMI of 0.228, diabetes p 0.915, hypertensive states p 0.967, days in which the ultrasound was performed p 0.5 and age gestational p 0.001. Conclusions: The ultrasound margin of error of the EPF is below the international parameters. Statistically significant associations were found with gestational age, but not with the other variables.

Introdução: A avaliação ultrassonográfica do peso fetal permite avaliar o crescimento e bem-estar fetal e pode estimar o peso ao nascer, fator determinante para o prognóstico vital. Objetivos: Determinar a margem de erro ultrassonográfica do peso fetal estimado (PFE) em relação ao peso ao nascer dos neonatos atendidos na Maternidade do Hospital de Clínicas entre os anos de 2020 e 2022. Materiais e Métodos: Foi realizado um estudo observacional, descritivo e transversal com mulheres que tiveram o parto no local e período mencionados e que realizaram ultrassonografia obstétrica de crescimento menos de 7 dias após o nascimento. O erro do PFE foi calculado pela fórmula: (Peso ao Nascer - Peso Fetal Estimado) / Peso ao Nascer) x 100. O erro do peso fetal estimado foi contrastado com o índice de massa corporal, diabetes e estado hipertensivo da gestação, utilizando-se o teste de Student. t e com idade gestacional e idade materna utilizando o índice de Pearson assumindo valores estatisticamente significativos menores que 0,05. Resultados: foram incluídos 258 pacientes. A margem de erro ultrassonográfica do PFE foi de 8,3% DP ± 7. Obteve-se valor de p para IMC de 0,228, diabetes p 0,915, estados hipertensivos p 0,967, dias em que foi realizada a ultrassonografia p 0,5 e idade gestacional p 0,001. Conclusões: A margem de erro ultrassonográfica do PFE está abaixo dos parâmetros internacionais. Foram encontradas associações estatisticamente significativas com a idade gestacional, mas não com as demais variáveis.

Prevalence of macrosomic newborn and maternal and neonatal complications in a high-risk maternity

Abstract Objective Evaluate the prevalence of macrosomic newborns (birth weight above 4000 grams) in a high-risk maternity from 2014 to 2019, as well as the maternal characteristics involved, risk factors, mode of delivery and associated outcomes, comparing newborns weighing 4000-4500 grams and those weighing above 4500 grams. Methods This is an observational study, case-control type, carried out by searching for data in hospital's own system and clinical records. The criteria for inclusion in the study were all patients monitored at the service who had newborns with birth weight equal than or greater than 4000 grams in the period from January 2014 to December 2019, being subsequently divided into two subgroups (newborns with 4000 to 4500 grams and newborns above 4500 grams). After being collected, the variables were transcribed into a database, arranged in frequency tables. For treatment and statistical analysis of the data, Excel and R software were used. This tool was used to create graphs and tables that helped in the interpretation of the results. The statistical analysis of the variables collected included both simple descriptive analyzes as well as inferential statistics, with univariate, bivariate and multivariate analysis. Results From 2014 to 2019, 3.3% of deliveries were macrosomic newborns. The average gestational age in the birth was 39.4 weeks. The most common mode of delivery (65%) was cesarean section. Diabetes mellitus was present in 30% of the deliveries studied and glycemic control was absent in most patients. Among the vaginal deliveries, only 6% were instrumented and there was shoulder dystocia in 21% of the cases. The majority (62%) of newborns had some complication, with jaundice (35%) being the most common. Conclusion Birth weight above 4000 grams had a statistically significant impact on the occurrence of neonatal complications, such as hypoglycemia, respiratory distress and 5th minute APGAR less than 7, especially if birth weight was above 4500 grams. Gestational age was also shown to be statistically significant associated with neonatal complications, the lower, the greater the risk. Thus, macrosomia is strongly linked to complications, especially neonatal complications.

Repercusión del síndrome metabólico sobre el crecimiento de fetos de ratas Wistar / Repercussion of the metabolic syndrome on the growth of Wistar rat fetuses

Introducción: El síndrome metabólico es un conjunto de anomalías metabólicas como obesidad, dislipidemia, intolerancia a la glucosa e hipertensión arterial. Se realizó estudio experimental, longitudinal prospectivo en la Unidad de Toxicología Experimental de Villa Clara, periodo septiembre del 2016 y julio del 2019. Objetivo: Evaluar las modificaciones del crecimiento de los fetos de ratas con síndrome metabólico, con respecto al grupo control. Métodos: Se crearon dos grupos, uno de control y otro de estudio con síndrome metabólico inducido. Las variables estudiadas fueron: peso, talla y diámetros craneanos. Se utilizó el programa Excel 2010 y el SPSS versión 15.0 para Windows, la prueba Chi Cuadrado, y como estadístico de decisión, la significación de Monte Carlo. Resultados: Los fetos de ratas con síndrome metabólico inducido tuvieron mayor peso y talla. Conclusiones: El síndrome metabólico influyó en la ganancia del peso y la talla en los fetos en vida prenatal, al incrementar la probabilidad de macrosomía al momento del nacimiento.

Introduction: metabolic syndrome is a group of metabolic abnormalities such as obesity, dyslipidemia, glucose intolerance and arterial hypertension. An experimental, longitudinal and prospective study was carried out in the Villa Clara Experimental Toxicology Unit from September 2016 to July 2019. Objective: to evaluate the changes in the growth of rat fetuses with metabolic syndrome, with respect to the control group. Methods: two groups with induced metabolic syndrome were created, one for control and the other for study. Weight, height and cranial diameters were the studied variables. The Excel 2010 program and SPSS version 15.0 for Windows and the Chi Square test were used, as well as the Monte Carlo significance as statistical decision. Results: rat fetuses with induced metabolic syndrome had greater weight and height. Conclusions: the metabolic syndrome influenced the weight and height gain in prenatal fetuses, increasing the probability of macrosomia at birth.

Abdominal circumference growth velocity as a predictor of adverse perinatal outcomes in small-for-gestational-age fetuses.

OBJECTIVE: To assess the predictive value of abdominal circumference growth velocity (ACGV) between the second and third trimesters to predict adverse perinatal outcomes in a cohort of small-for-gestational-age fetuses without evidence of placental insufficiency (i.e. fetal growth restriction). MATERIAL AND METHODS: This is a single-center retrospective cohort study of all singleton pregnancies with small-for-gestational-age fetuses diagnosed and delivered at a quaternary institution. Crude and adjusted odds ratios (ORs) and corresponding confidence intervals (CIs) were calculated via logistic regression models to assess the potential association between abnormal ACGV (i.e. ≤10th centile) and adverse perinatal outcomes defined as a composite outcome (i.e. umbilical artery pH <7.1, 5-min Apgar score <7, admission to the neonatal intensive care unit, hypoglycemia, intrapartum fetal distress requiring expedited delivery, and perinatal death). Furthermore, the area under the receiver-operating characteristic curve (AUC) of three logistic regression models based on estimated fetal weight and ACGV for predicting the composite outcome is also reported. RESULTS: A total of 154 pregnancies were included for analysis. The median birthweight for the cohort was 2,437 g (interquartile range [IQR] 2280, 2635). Overall, the primary composite outcome was relatively common (29.2%). In addition, there was a significant association between abnormal ACGV and adverse perinatal outcomes (OR 3.37, 95% CI 1.60, 7.13; adjusted OR 4.30, 95% CI 1.77, 10.49). Likewise, the AUC for the ACGV was marginally higher (0.64) than the estimated fetal weight (0.54) and ACGV + estimated fetal weight (0.54). Still, no significant difference was detected between the curves (p = 0.297). CONCLUSIONS: Our results suggest that an ACGV below the 10th centile is a risk factor for adverse perinatal outcomes among small-for-gestational-age fetuses.

Capacidad del diámetro biparietal para predecir los recién nacidos grandes para edad gestacional. Estudio de cohorte retrospectivo / Ability of biparietal diameter to predict large for gestational age newborns. A retrospective cohort study

Fundamento: Predecir el recién nacido grande para la edad gestacional es una acción de salud que necesita de herramientas tecnológicas de probada eficiencia. Objetivo: Determinar la capacidad predictiva del diámetro biparietal en los recién nacidos grandes para la edad gestacional. Metodología: Estudio de cohorte retrospectivo que incluyó 1959 gestantes cubanas con embarazo simple con captación y término del embarazo entre enero del 2009 y diciembre de 2017. En cada trimestre de gestación se compararon las condiciones tróficas adecuado para la edad gestacional (AEG) y grandes para la edad gestacional (GEG) mediante estadígrafos de tendencia central (media) y de dispersión (rango, desviación estándar) correspondientes al diámetro biparietal. Se calculó además el intervalo de confianza (IC) de 95 % para la diferencia de medias del diámetro biparietal. Asimismo, se realizó un análisis de curvas ROC para determinar si el diámetro biparietal y el peso fetal predicen la condición trófica grande para la edad gestacional en el segundo y tercer trimestre de gestación. Los datos fueron recogidos del libro registro de genética del área de salud. Resultados: El diámetro biparietal en el segundo y tercer trimestre de gestación tuvo un área bajo curva de 0.60 (IC 95 %: 0.54-0.65) y 0.59 (IC 95 %: 0.54-0.64) respectivamente. Los puntos de corte establecidos (T2: 56.55 mm, T3: 81.55 mm) tienen una especificidad y exactitud superior al 78 %. Conclusiones: El diámetro biparietal y los modelos de regresión de Shepard y de Hadlock V mostraron capacidad para discriminar el nacimiento grande para la edad gestacional del adecuado para la edad gestacional, a partir del segundo trimestre de gestación siendo más eficaces en el tercero.

Background: Predicting large for gestational age newborns is a medical action that requires technological tools with proven efficiency. Objective: To determine the predictive ability of biparietal diameter in large newborns for gestational age. Methodology: Retrospective cohort study that included 1959 Cuban pregnant women with a singleton pregnancy, with recruitment and pregnancy term between January 2009 and December 2017. In each gestational trimester, trophic conditions appropriate for gestational age (GAW) were compared and large for gestational age (GA) using central tendency (mean) and dispersion (range, standard deviation) statistics corresponding to the biparietal diameter. The 95% confidence interval (CI) for mean biparietal diameter difference was also calculated. In addition, an analysis of ROC curves was performed to determine if biparietal diameter and fetal weight predict large trophic condition for gestational age in the second and third gestational trimester. Data were gathered from the health area genetics registry book. Results: Biparietal diameter in the second and third trimester of gestation had an area under curve of 0.60 (95% CI: 0.54-0.65) and 0.59 (95% CI: 0.54-0.64) respectively. The established cut-off points (T2: 56.55 mm, T3: 81.55 mm) have a specificity and accuracy greater than 78%. Conclusions: Biparietal diameter and the Shepard and Hadlock V regression models showed ability to discriminate large for gestational age birth from adequate for gestational age birth from the second trimester of gestation onward, being more effective in the third trimester.

Relación entre biometría fetal, producto de acumulación de los lípidos y condición trófica al nacer / Relationship between fetal biometry, lipid accumulation product and the trophic condition at birth

Fundamento: Las alteraciones del estado nutricional materno generalmente se relacionan con desviaciones del crecimiento fetal, que pueden detectarse por los parámetros biofísicos fetales e identifican la posible condición trófica al nacer. Objetivo: Determinar la posible relación entre los parámetros biométricos fetales, la condición trófica al nacer y el producto de acumulación de los lípidos. Metodología: Se realizó un estudio transversal en el Policlínico Chiqui Gómez Lubian del municipio Santa Clara, durante el año 2019, en una población de 253 gestantes normopeso supuestamente sanas al inicio de la gestación. La muestra no probabilística fue de 144 gestantes. Las variables de estudio fueron: producto de acumulación de los lípidos, biometría fetal y condición trófica al nacer. Se utilizaron métodos teóricos, empíricos y estadísticos. Resultados: En el segundo trimestre ningún parámetro biométrico coincidió con la condición al nacer de pequeño, mientras que para el grande coincidieron las circunferencias cefálica y abdominal. En el tercer trimestre la longitud del fémur y la circunferencia abdominal coinciden en la identificación del pequeño y del grande. El PAL se correlacionó con la circunferencia abdominal del tercer trimestre y con el peso al nacer; presentando mayor frecuencia de valores en el tercer tertil para los nacimientos grandes. Conclusiones: La circunferencia abdominal fue el parámetro biométrico con mayor coincidencia con la condición trófica al nacer, la que se asoció con valores en el tercer tertil del PAL para la detección de nacimientos grandes, relacionándose el fenotipo normopeso metabólicamente obeso con el crecimiento fetal por exceso.

Background: Maternal nutritional status disorders are usually related to fetal growth deviations, which can be detected by fetal biophysical parameters and identify the possible trophic condition at birth. Objective: To determine the possible relationship between fetal biometric parameters, the birth trophic state and lipid accumulation product. Methodology: A cross-sectional study was conducted at the Chiqui Gómez Lubian Polyclinic in Santa Clara municipality, during 2019, in a population of 253 normal-weight pregnant women who were apparently healthy at the beginning of their gestation. The non-probability sample was made up of 144 pregnant women. Study variables were: lipid accumulation product, fetal biometry and trophic condition at birth. Theoretical, empirical and statistical methods were used. Results: In the second trimester, none of the biometric parameters matched the condition at birth as a small child, while in the large one the head and abdominal circumferences matched. In the third trimester, femoral length and abdominal circumference coincide in identifying the small one and the large one. LAP correlated with third trimester abdominal circumference and birth weight, presenting higher frequency of values in the third tertile for large births. Conclusions: Abdominal circumference was the biometric parameter with the highest coincidence with trophic condition at birth, associated with values in the third tertile of the LAP for detecting large births, relating the metabolically obese normal weight phenotype with excessive fetal growth.

Estimated fetal weight standards of the INTERGROWTH-21st project for the prediction of adverse outcomes: a systematic review with meta-analysis.

OBJECTIVE: To systematically review and assess the risk of bias in the literature evaluating the performance of INTERGROWTH-21st estimated fetal weight (EFW) standards to predict maternal, fetal and neonatal adverse outcomes. METHODS: Searches were performed in seven electronic databases (Scopus, Web of Science, Medline, Embase, Lilacs, Scielo and Google Scholar) using citation tools and keywords (intergrowth AND (standard OR reference OR formula OR model OR curve); all from 2014 to the last search on April 16th, 2021). We included full-text articles investigating the ability of INTERGROWTH-21st EFW standards to predict maternal, fetal or neonatal adverse outcomes in women with a singleton pregnancy who gave birth to infants with no congenital abnormalities. The study was registered on PROSPERO under the number CRD42020115462. Risk of bias was assessed with a customized instrument based on the CHARMS checklist and composed of 9 domains. Meta-analysis was performed using relative risk (RR [95%CI]) and summary ROC curves on outcomes reported by two or more methodologically homogeneous studies. RESULTS: Sixteen studies evaluating fifteen different outcomes were selected. The risk of bias was high (>50% of studies with high risk) for two domains: blindness of assessment (81.3%) and calibration assessment (93.8%). Considering all the outcomes investigated, for 95% of the results, the specificity was above 73.0%, but the sensitivity was below 64.1%. Pooled results demonstrated a higher RR of neonatal small for gestational age (6.71 [5.51-8.17]), Apgar <7 at 5 min (2.17 [1.48-3.18]), and neonatal intensive care unit admission (2.22 [1.76-2.79]) for fetuses classified <10th percentile when compared to those classified above this limit. The limitation of the study is the absence of heterogeneity exploration or publication bias investigation, whereas no outcomes were evaluated by more than five studies. CONCLUSIONS: The IG-21 EFW standard has low sensitivity and high specificity for adverse events of pregnancy. Classification <10th percentile identifies a high-risk group for developing maternal, fetal and neonatal adverse outcomes, especially neonatal small for gestational age, Apgar <7 at 5 min, and neonatal intensive care unit admission. Future studies should include blind assessment of outcomes, perform calibration analysis with continuous data, and evaluate alternative cutoff points.

Maternal visceral adiposity and fetal biometry in women with obesity and diabetes

SUMMARY OBJECTIVE: The aim of this study was to compare the correlation of maternal visceral adiposity with sonographic variables related to fetal biometry in the second trimester of pregnancy in mothers who were previously obese versus nonobese and gestational diabetic versus nondiabetic. METHODS: This cross-sectional study included 583 pregnant women who received prenatal care between October 2011 and September 2013 at the Instituto de Medicina Integral Prof. Fernando Figueira, northeast of Brazil. Maternal visceral adiposity was measured by ultrasound examination at the same time as fetal biometry. Gestational age was 14.9±3.2 weeks. The correlation between maternal visceral adiposity and fetal biometric variables was evaluated using Pearson's correlation coefficient. Among the groups, the correlation coefficients were compared using Fisher's Z-test. This test was also used to evaluate the null hypothesis of correlation coefficients between pairs of variables. RESULTS: Maternal visceral adiposity positively correlated with fetal abdominal circumference, estimated fetal weight, head circumference, femur length, and biparietal diameter in pregnant women with obesity, nonobesity, gestational diabetes, and nondiabetes, but the correlation coefficients were statistically similar among the groups. CONCLUSION: Maternal visceral adiposity positively correlated with fetal biometry in the second trimester of pregnancy in the same manner in pregnant women previously obese and nonobese, as well as in pregnant women with gestational diabetes and nondiabetes.

Factores predictores del éxito del parto vaginal posterior a cesárea

Objetivo : Determinar los predictores del éxito del parto vaginal posterior a cesárea segmentaria transversal primaria por causa no recurrente. Diseño : Estudio de casos y controles. Institución: Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Métodos : Gestantes con inicio espontáneo del trabajo de parto y antecedentes de cesárea con incisión transversal en el segmento inferior por causa no iterativa. La prueba de parto fue considerada exitosa si terminaba en parto vaginal. Principales medidas de estudio : Edad materna, paridad, frecuencia de trabajo de parto previo a la cesárea anterior, edad gestacional al momento del parto, estación de la presentación cefálica fetal al ingreso y peso fetal. Resultados : Se seleccionó 126 gestantes, de las cuales 85 (67,4%) tuvieron pruebas exitosas (parto vaginal), mientras que 41 (32,5%) tuvieron prueba fallida. No se encontraron diferencias en las características generales entre los grupos (p = ns). El análisis univariante mostró que el peso fetal igual o menor de 3,500 gramos, la estación de la presentación cefálica fetal fija o encajada y la edad gestacional menor de 40 semanas fueron predictores significativos del resultado exitoso de la prueba de parto (p < 0,05). El análisis de regresión logística demostró que el peso fetal igual o mayor de 3,500 gramos (p = 0,04) y la estación de la presentación cefálica fetal flotante insinuada (p = 0,03) conservaron importancia como predictores. Conclusión : Los predictores para una prueba exitosa de parto vaginal posterior a cesárea fueron peso fetal menor o igual a 3,500 gramos y la estación de la presentación cefálica fetal fija o encajada.

Objective : To determine predictors of successful vaginal delivery following primary transverse segmental cesarean section for non-recurring cause. Design : Casecontrol study. Institution: Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Methods : Pregnant women with spontaneous onset of labor and history of cesarean section with transverse incision in the lower segment for non-recurrent cause. The trial of labor was considered successful if it ended in vaginal delivery. Main study measures : Maternal age, parity, frequency of labor prior to previous cesarean section, gestational age at delivery, station of fetal cephalic presentation at admission, and fetal weight. Results : A total of 126 pregnant women were selected, of whom 85 (67.4%) had successful trials (vaginal delivery), while 41 (32.5%) had a failed trial. No differences in general characteristics were found between groups (p = ns). Univariate analysis showed that fetal weight equal to or less than 3,500 grams, station of fixed or engaged fetal cephalic presentation, and gestational age less than 40 weeks were significant predictors of successful trial of labor outcome (p < 0.05). Logistic regression analysis showed that fetal weight equal to or greater than 3,500 grams (p = 0.04) and station of floating insinuated fetal cephalic presentation (p = 0.03) retained significance as predictors. Conclusion : Predictors for a successful trial of vaginal delivery following cesarean section were fetal weight less than or equal to 3,500 grams and station of fixed or engaged fetal cephalic presentation.

Impact of maternal periodontal health on fetus weight in Iraqi pregnant women: a clinical study / Impacto da saúde periodontal materna no peso fetal em gestantes iraquianas: um estudo clínico

Objective: the aim of this study was to investigate the relationship between periodontal health condition and the weight of fetuses in Iraqi pregnant women in order to magnify the importance of periodontal health maintenance during pregnancy. Material and Methods: fetus weight was determined using ultrasound scanning for 222 pregnant women, accordingly they were divided into two groups: group A: normal fetus weight and group B: below normal fetal weight. Their periodontal condition was examined by means of Plaque index (PI), Gingival index (GI), Bleeding on probing (BOP) and Clinical Attachment loss (CAL) using WHO CPITN periodontal probe. WHO charts of normal fetal weight for each week were considered to determine the normality of fetus weight. Results: significant value p=0.00 was obtained when comparing the examined periodontal parameters between groups A and B, mean of periodontal parameters of PI, GI and BOP were higher in group B (1.1964: 1.4541), (1.1877: 1.4925), (0.3553: 1.3748) respectively. Q2 and IQR of PI, BOP and GI in group A were (1.190:0.3), (0.30:0.5), (1.160:0.3) respectively. And (1.460:0.24) (1.50:0.7) (1.460:0.26) in Group B. There were 4 cases of CAL in group A as opposed to 88 cases in group B, Q2 of CAL in group A=0.00, Q2 in group B=1.00. IQR=0.00 in both groups. Non-significant value p=0. 503(p>0.05) was seen when comparing the incidence of low fetal weight between the three trimesters. Conclusion: it is important to maintain a good periodontal condition and oral Hygiene status in pregnant women for healthier fetal weight and healthier pregnancy with less complications. (AU)

Objetivo: o objetivo deste estudo foi investigar a relação entre a condição de saúde periodontal e a peso dos fetos em gestantes iraquianas para ampliar a importância da manutenção da saúde periodontal durante a gravidez. Material e Métodos: o peso do feto foi determinado por ultrassonografia 222 As gestantes, consequentemente, foram divididas em dois grupos: grupo A: peso normal do feto e grupo B: abaixo do peso fetal normal. Sua condição periodontal foi examinada por meio de índice de placa (IP), gengival índice (GI), Sangramento na sondagem (BOP) e Perda de Inserção Clínica (CAL) usando a sonda periodontal CPITN da OMS. Os gráficos da OMS de peso fetal normal para cada semana foram considerados para determinar a normalidade do peso feto. Resultados: obteve-se valor significativo p=0,00 quando comparados os parâmetros periodontais examinados entre nos grupos A e B, as médias dos parâmetros periodontais do IP, GI e BOP foram maiores no grupo B (1,1964: 1,4541), (1,1877: 1,4925), (0,3553: 1,3748), respectivamente. Q2 e IQR do PI, BOP e GI no grupo A foram (1,190:0,3), (0.30:0.5), (1.160:0.3) respectivamente.E (1.460:0.24) (1.50:0.7) (1.460:0.26) no Grupo B. Houve 4 casos de CAL no grupo A em oposição a 88 casos no grupo B, Q2 de CAL no grupo A=0,00, Q2 no grupo B=1,00. IQR=0,00 em ambos os grupos. Valor não significativo p=0. 503(p>0,05) foi observado quando comparada a incidência de baixo nível fetal peso entre os três trimestres. Conclusão:é importante manter uma boa condição periodontal e Estado de higiene bucal em gestantes para maior peso fetal e gravidez mais saudável com menos complicações. (AU)

Efecto de la suplementación del zinc sobre el peso fetal en ratas diabéticas gestadas / Effect of zinc supplementation on fetal weight in pregnant diabetic rats

RESUMEN Introducción: La relación entre la deficiencia de Zn y la elevada incidencia de alteraciones en el crecimiento intrauterino en la diabetes materna aún no se ha dilucidado. En la literatura consultada no existen reportes del efecto de la suplementación con el micronutriente sobre el crecimiento fetal en modelos de diabetes con hiperglucemias moderadas. Objetivo: Determinar el efecto sobre el peso fetal de la suplementación con zinc a ratas con diabetes moderada durante la gestación. Métodos: Se utilizó un modelo de diabetes moderada inducida en ratas Wistar al segundo día de nacidas por inducción subcutánea con estreptozotocina (100mg/kg-pc). En la adultez las ratas sanas y diabéticas fueron apareadas con machos sanos. Según correspondiera recibieron durante 20 días de gestación un suplemento de sulfato de zinc (50mg/kg). Se estudiaron 395 fetos de cuatro grupos: fetos de ratas sanas sin suplemento, de ratas sanas suplementadas, de ratas diabéticas sin suplemento y de ratas diabéticas suplementadas. Los fetos se clasificaron en pequeños (PEG), adecuados (AEG) y grandes (GEG) para la edad gestacional. Resultados: La descendencia de las ratas diabéticas suplementadas mostró valores del peso fetal similares a ambos grupos sanos al término de la gestación, presentando menor porcentaje de fetos PEG y GEG, así como mayor porcentaje de AEG respecto al grupo diabético no suplementado. Conclusiones: La suplementación con Zn durante la gestación a ratas diabéticas con hiperglucemias moderadas causó efectos positivos sobre su descendencia al aumentar el porcentaje de fetos con peso adecuado.

ABSTRACT Introduction: the relationship between Zn deficiency and the high incidence of abnormal intrauterine growth in maternal diabetes has not yet been elucidated. There are no reports in the consulted literature of the effect of micronutrient supplementation on fetal growth in models of diabetes with moderate hyperglycemia. Objective: to determine the effect of zinc supplementation on fetal weight in rats with moderate diabetes during pregnancy. Methods: a model of mild diabetes was used in Wistar rats on the second day of birth by subcutaneous streptozotocin induction (100mg/kg-bw). As adults, healthy and diabetic rats were mated with healthy males. As appropriate, they received a zinc sulfate supplement (50mg/kg) during 20 days of gestation. A number of 395 fetuses from four groups were studied: fetuses from healthy rats without supplementation, from healthy rats supplemented, from diabetic rats without supplementation and from diabetic rats supplemented. Fetuses were classified as small (SGA), adequate (AGA), and large (LGA) for gestational age. Results: the offspring of the supplemented diabetic rats showed similar fetal weight values to both healthy groups at the end of pregnancy, having a lower percentage of SGA and LGA fetuses, as well as a higher percentage of AGA compared to the non-supplemented diabetic group. Conclusions: Zn supplementation during pregnancy in diabetic rats with moderate hyperglycemia had positive effects on their offspring by increasing the percentage of fetuses with adequate weight.

Altura uterina versus ecografía obstétrica para detectar macrosomía fetal. Hospital San Juan de Kimbiri, Perú

RESUMEN Fundamento Aunque la ecografía obstétrica es ampliamente utilizada en los niveles primario y secundario de salud para la detección de macrosomía fetal, la altura uterina también puede resultar útil, sobre todo, en contextos sanitarios desprovistos de equipamiento tecnológico. Objetivo determinar la correlación entre altura uterina versus ecografía obstétrica y el diagnóstico de macrosomía fetal. Métodos estudio descriptivo, correlacional, en madres no diabéticas de partos a término con neonatos macrosómicos, realizado en un hospital público del Valle de los ríos Apurímac, Ene y Mantaro, Perú. Las variables del estudio: edad materna, índice de masa corporal pregestacional, número de embarazos, edad gestacional al parto, y vía del parto. Se emplearon los coeficientes de correlación Rho de Spearman, y Pearson, ambos con intervalos de confianza al 95 % y error del 5 %. Resultados la estimación del peso fetal y la macrosomía se correlacionaron con la altura uterina (R Pearson 0,05). Entre las características maternas asociadas a neonatos macrosómicos, se hallaron la obesidad pregestacional (Rho = 0,009) y la condición de multigesta (Rho = 0,04). La estimación del peso fetal mayor a 4000 g tuvo mayor porcentaje de acierto (26,3 %) por ecografía obstétrica. Conclusión la ecografía obstétrica mostró mayor correlación que la altura uterina con el diagnóstico de macrosomía fetal.

ABSTRACT Background Although obstetric ultrasound is widely used at primary and secondary health levels for the detection of fetal macrosomia, uterine height can also be useful, especially in health contexts lacking technological equipment. Objective to determine the correlation between uterine height versus obstetric ultrasound and the diagnosis of fetal macrosomia. Methods descriptive, correlational study in non-diabetic mothers of full-term deliveries with macrosomic neonates, carried out in a public hospital in the Valley of the Apurímac, Ene and Mantaro rivers, Peru. The study variables: maternal age, pre-pregnancy body mass index, number of pregnancies, gestational age at delivery, and route of delivery. Spearman's Rho and Pearson's correlation coefficients were used, both with 95% confidence intervals and 5% error. Results Fetal weight estimation and macrosomia correlated with uterine height (Pearson's R 0.05). Among the maternal characteristics associated with macrosomic neonates, pregestational obesity (Rho = 0.009) and multigestational condition (Rho = 0.04) were found. The estimation of fetal weight greater than 4000 g had a higher percentage of success (26.3%) by obstetric ultrasound. Conclusion obstetric ultrasound showed a higher correlation than uterine height with the diagnosis of fetal macrosomia.

Performance of local reference curve on the diagnosis of large for gestational age fetuses in diabetic pregnant women.

OBJECTIVE: To evaluate the performance of a local fetal weight curve based on the prediction for large gestational age (LGA) newborns in diabetic pregnant women and to compare it to reference curves established for other populations. METHOD: A reference model for estimated fetal weight was created from a local sample of 2211 singleton low-risk pregnancies. The estimated fetal weight from 194 women with gestational diabetes mellitus was then plotted on this curve, and the results were compared to those obtained by Intergrowth 21st and Hadlock curves. RESULTS: The sensitivity of the proposed model to predict LGA fetuses was 55.6%, the specificity was 82.1%, and the accuracy was 74.7%. The sensitivity, specificity, and accuracy for the Intergrowth 21st curve were 46.3%, 87.9%, and 76.3%, respectively, and no statistically significant difference was observed compared to the proposed model. Conversely, significant differences were observed for the Hadlock curve, which presented a lower sensitivity (24.1%), higher specificity (97.1%), and similar accuracy (76.8%). CONCLUSION: The sensitivity of the proposed model was higher compared to the Hadlock curve for the screening of LGA newborns in diabetic pregnant women. However, no significant differences were observed in comparison to the Intergrowth 21st curve.

Biometría fetal del segundo trimestre: predicción de nacimientos pequeños y grandes para la edad gestacional

Introducción: La biometría médica ha permitido identificar variables predictoras del peso al nacimiento. Objetivo: Determinar el poder discriminatorio local y desempeño de variables biométricas fetales a las 22 semanas sobre la condición trófica del recién nacido. Métodos: Se realizó estudio observacional, analítico y retrospectivo en tres áreas de salud del municipio Santa Clara, en el período comprendido entre enero de 2013 a diciembre de 2019. De una población de 6 035 nacidos se seleccionaron 2 454 por muestreo simple aleatorio. Se obtuvieron datos de registros de las consultas de genética. En el análisis se construyeron áreas bajo la curva Receiver Operating Characteristic y se calcularon indicadores de desempeño para pruebas diagnósticas. Resultados: Las áreas bajo la curva de las variables biométricas discriminan a los nacidos pequeños y grandes para la edad gestacional. En los pequeños sobrepasan a los 0,840 a excepción de la longitud del fémur; en los grandes el peso fetal estimado alcanza una curva de 0,715 el resto son inferiores. Se estiman puntos de corte locales. Los indicadores de desempeño de la biometría mantienen un comportamiento regular; los que se estiman al transformar los valores a partir de las tablas de referencia son más específicos con valores por encima del 80 %; mientras que los calculados después de transformar las variables por los puntos de corte estimados elevan la sensibilidad por encima del 60 %. Conclusiones: Todas las variables biométricas tienen capacidad discriminatoria para las desviaciones de la condición trófica al nacer, de preferencia para los nacimientos pequeños para la edad gestacional. Los puntos de corte óptimo identificados difieren de los establecidos en las tablas de referencias. Los indicadores de desempeño de las variables biométricas fetales demostraron superioridad según los puntos de corte estimados respecto a los de las tablas de referencia.

Introduction: Medical biometrics has made it possible to identify predictive variables of birth weight. Objective: To determine the local discriminatory power and performance of fetal biometric variables at 22 weeks on the trophic condition of the newborn. Methods: An observational, analytical and retrospective study was carried out in three health areas of the Santa Clara municipality, in the period between January 2013 and December 2019. From a population of 6,035 births, 2,454 were selected by simple random sampling. Data were obtained from records of genetic consultations. In the analysis, areas under the Receiver Operating Characteristic curve were constructed and performance indicators for diagnostic tests were calculated. Results: The areas under the curve of the biometric variables discriminate those born small and large for gestational age. In the small ones they exceed 0.840 except for the length of the femur; in the large ones, the estimated fetal weight reaches a curve of 0.715, the rest are lower. Local cut-off points are estimated. The performance indicators of the biometrics maintain a regular behavior; those that are estimated by transforming the values ​​from the reference tables are more specific with values ​​above 80%; while those calculated after transforming the variables by the estimated cut-off points raise the sensitivity above 60%. Conclusions: All biometric variables have discriminatory capacity for deviations of the trophic condition at birth, preferably for small births for gestational age. The optimal cut-off points identified differ from those established in the reference tables. The performance indicators of the fetal biometric variables showed superiority according to the estimated cut-off points with respect to those of the reference tables.

Influencia del sobrepeso y la obesidad pregestacionales en el embarazo y en los desenlaces perinatales / Influence of pre-pregnancy overweight and obesity in pregnancy and perinatal outcomes

Resumen OBJETIVO: Primario: comparar las diferencias en la vía de nacimiento (cesárea, instrumentado o parto eutócico) entre embarazadas con IMC ≥ 25 y menor de 25. Secundario: comparar las diferentes complicaciones gestacionales y puerperales en embarazadas con IMC ≥ 25 y menor que éste. MATERIALES Y MÉTODOS: Estudio analítico, longitudinal, observacional, de cohortes y retrospectivo efectuado en pacientes atendidas entre diciembre de 2010 y diciembre de 2015 en el Hospital Clínico San Carlos, Madrid, España. Parámetros de estudio: concepción natural o asistida, diabetes gestacional, enfermedad hipertensiva e hipotiroidismo gestacionales, peso del feto y semanas de embarazo al momento de su finalización, inducción y sus causas, vía del parto y complicaciones puerperales. RESULTADOS: Se estudiaron 642 embarazadas con límites de edad de 13 y 45 años, con media de 32 años. El riesgo de cesárea fue 1.6 veces superior en embarazadas con IMC ≥ 25. Este grupo tuvo dos veces más diabetes gestacional y fetos macrosómicos y tres veces más hipertensión gestacional que las embarazadas con IMC normal. Las inducciones del parto y las complicaciones del puerperio tuvieron una tendencia mayor en IMC más elevados, sin diferencias estadísticamente significativas. CONCLUSIONES: Se encontró mayor incidencia de cesáreas, diabetes e hipertensión gestacional y fetos macrosómicos en las pacientes que iniciaron el embarazo con sobrepeso u obesidad en comparación con quienes tuvieron peso normal. Los desenlaces obtenidos justifican la importancia de una intervención en estos casos para recomendar hábitos nutricionales adecuados y estilo de vida activo que permitan alcanzar un peso saludable previo al embarazo.

Abstract OBJECTIVE: Primary: to compare the differences in the route of birth (cesarean section, instrumental or euthyroid delivery) between pregnant women with BMI ≥ 25 and less than 25. Secondary: to compare the different gestational and puerperal complications in pregnant women with BMI ≥ 25 and less than 25. MATERIALS AND METHODS: Analytical, longitudinal, observational, cohort and retrospective study performed in patients attended between December 2010 and December 2015 at the Hospital Clínico San Carlos, Madrid, Spain. Study parameters: natural or assisted conception, gestational diabetes, gestational hypertensive disease and hypothyroidism, fetal weight and weeks of pregnancy at termination, induction and its causes, route of delivery and puerperal complications. RESULTS: We studied 642 pregnant women with age limits of 13 and 45 years, mean 32 years. The risk of cesarean section was 1.6 times higher in pregnant women with BMI ≥ 25. This group had twice as many gestational diabetes and macrosomic fetuses and three times more gestational hypertension than pregnant women with normal BMI. Labor inductions and puerperium complications had a higher trend in higher BMIs, with no statistically significant differences. CONCLUSIONS: A higher incidence of cesarean section, diabetes, gestational hypertension and macrosomic fetuses was found in patients who started pregnancy overweight or obese compared to those with normal weight. The outcomes obtained justify the importance of an intervention in these cases to recommend adequate nutritional habits and an active lifestyle to achieve a healthy weight prior to pregnancy.

Performance of a local reference curve for predicting small for gestational age fetuses in pregnant women with HIV/AIDS.

PURPOSE: To compare the performance of a local estimated fetal weight curve with curves established for other populations to predict small for gestational age (SGA) fetuses. METHODS: A retrospective and cross-sectional study involving 231 fetuses in which the performance of a local curve (proposed model) was compared with the Hadlock and Intergrowth-21st curves in the prediction of SGA fetuses, by applying them to a population of high-risk pregnant woman with HIV/AIDS. For each model, a receiver operating characteristic curve was adjusted, considering the SGA classification by the neonatal Intergrowth method as the gold standard, and the area under the curve (AUC) was calculated. RESULTS: The models presented linear correlations with each other. The agreement of the proposed model with Hadlock was very good (kappa = 0.83), whereas the proposed model and Intergrowth-21st had moderate agreement (kappa = 0.44). The SGA fetus detection sensitivities of the proposed model and Hadlock were 61.9% and 57.1%, with specificity of 84.1% and 86.2% and accuracy of 80.1% and 81%, respectively, without statistical difference. The sensitivity of the Intergrowth-21st model was 33.3%, while the accuracy was 85.7% and the specificity was 97.4%. The AUC estimated values for the Hadlock, proposed, and Intergrowth-21st models were 0.834, 0.832, and 0.835, respectively. CONCLUSION: The proposed model and Hadlock were interchangeable in the prediction of SGA fetuses and superior to the Intergrowth-21st model.

Agreement analysis between sonographic estimates and birth weight, by the WHO and intergrowth-21st tables, in newborns of diabetic mothers / Análise de concordância entre estimativas ultrassonográficas e peso ao nascer, pelas tabelas da OMS e Intergrowth-21st, em recém-nascidos de mães diabéticas

Abstract Objective To analyze the agreement, in relation to the 90th percentile, of ultrasound measurements of abdominal circumference (AC) and estimated fetal weight (EFW), between the World Health Organization (WHO) and the International Fetal and Newborn Growth Consortium for the 21st Century (intergrowth-21st) tables, as well as regarding birth weight in fetuses/newborns of diabetic mothers. Methods Retrospective study with data from medical records of 171 diabetic pregnant women, single pregnancies, followed between January 2017 and June 2018. Abdominal circumference and EFW data at admission (from 22 weeks) and predelivery (up to 3 weeks) were analyzed. These measures were classified in relation to the 90th percentile. The Kappa coefficient was used to analyze the agreement of these ultrasound variables between the WHO and intergrowth-21st tables, as well as, by reference table, these measurements and birth weight. Results The WHO study reported 21.6% large-for-gestational-age (LGA) newborns while the intergrowth-21st reported 32.2%. Both tables had strong concordances in the assessment of initial AC, final AC, and initial EFW (Kappa = 0.66, 0.72 and 0.63, respectively) and almost perfect concordance in relation to final EFW (Kappa = 0.91). Regarding birth weight, the best concordances were found for initial AC (WHO: Kappa = 0.35; intergrowth-21st: Kappa= 0.42) and with the final EFW (WHO: Kappa = 0.33; intergrowth- 21st: Kappa = 0.35). Conclusion The initial AC and final EFW were the parameters of best agreement regarding birth weight classification. The WHO and intergrowth-21st tables showed high agreement in the classification of ultrasound measurements in relation to the 90th

Resumo Objetivo Analisar a concordância, em relação ao percentil 90, das medidas ultrassonográficas da circunferência abdominal (CA) e peso fetal estimado (PFE), entre as tabelas da Organização Mundial de Saúde (OMS) e do International Fetal and Newborn Growth Consortium for the 21st Century integrowth-21st, bem como em relação ao peso ao nascer em fetos/recém-nascidos de mães diabéticas. Métodos Estudo retrospectivo com dados de prontuários de 171 gestantes diabéticas, com gestações únicas, seguidas entre Janeiro de 2017 e Junho de 2018. Foram analisados dados da CA e do PFE na admissão (a partir de 22 semanas) e no pré-parto (até 3 semanas). Essas medidas foram classificadas em relação ao percentil 90. O coeficiente Kappa foi utilizado para analisar a concordância entre as tabelas da OMS e Intergrowth-21st, assim como, por tabela de referência, entre as medidas e o peso ao nascer. Resultados O estudo da OMS relatou 21,6% dos recém nascidos grandes para a idade gestacional (GIG) enquanto que o estudo do intergrowth-21st relatou 32,2%. Ambas as tabelas tiveram fortes concordâncias na avaliação da CA inicial e final e PFE inicial (Kappa= 0,66, 0,72 e 0,63, respectivamente) e concordância quase perfeita em relação ao PFE final (Kappa= 0,91).Emrelação ao peso ao nascer, asmelhores concordâncias foram encontradas para aCAinicial (OMS: Kappa= 0,35; intergrowth-21st: Kappa= 0,42) e como PFE final (OMS: Kappa = 0,33; intergrowth-21st: Kappa= 0,35). Conclusão A CA inicial e o PFE final foram os parâmetros de melhor concordância em relação à classificação do peso ao nascer. As tabelas da OMS e intergrowth-21st mostraram alta concordância na classificação das medidas ultrassonográficas em relação ao percentil 90. Estudos são necessários para confirmar se alguma dessas tabelas é superior na previsão de resultados negativos a curto e longo prazo no grupo GIG.