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1.
Medicine (Baltimore) ; 98(48): e18170, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31770267

RESUMO

RATIONALE: The umbilical cord is the way to exchange gas, supply nutrients, excrete metabolized. Thrombosis of the umbilical cord leads to fetal hypoxia, which jeopardizes fetal health and can cause fetal death. Umbilical vessel thrombosis, which is rarely reported, is difficult to detect prenatally. PATIENT CONCERNS: Both pregnant women had an unremarkable pregnancy course until a routine ultrasound scan in the third trimester showed a single umbilical artery. However, one umbilical vein and 2 umbilical arteries were seen during an ultrasound examination at 32 weeks. Case 2 had a better pregnancy outcome because of the timely discovery of this complication. DIAGNOSIS: Both cases were diagnosed as umbilical artery thrombosis. INTERVENTIONS: The first patient received no interventions until they reported decreased fetal movements and gradually disappear. The second patient underwent an emergency cesarean section. OUTCOMES: In Case 1, an emergency ultrasound examination showed intrauterine fetal death, and the patient vaginally delivered a stillborn child weighing 3300 g in a day. In Case 2, a female neonate weighing 2860 g was delivered by cesarean section, and exhibited Apgar scores of 10 and 10 at 1 and 5 minutes. CONCLUSION: In the late-term abortions, obstetricians should be vigilant if ultrasound imaging shows suspected umbilical vascular thrombosis or shows 1 umbilical artery when there had previously been 2. The fetus should be closely monitored and interventions implemented as early as possible to improve the prenatal detection rate of umbilical vessel thrombosis and avoid adverse pregnancy outcomes.


Assuntos
Cesárea/métodos , Intervenção Médica Precoce/métodos , Morte Fetal , Complicações Cardiovasculares na Gravidez , Trombose , Artérias Umbilicais , Adulto , Serviços Médicos de Emergência/métodos , Feminino , Morte Fetal/etiologia , Morte Fetal/prevenção & controle , Monitorização Fetal/métodos , Humanos , Recém-Nascido , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico , Complicações Cardiovasculares na Gravidez/fisiopatologia , Resultado da Gravidez , Natimorto , Trombose/complicações , Trombose/diagnóstico , Trombose/fisiopatologia , Ultrassonografia Pré-Natal/métodos , Artérias Umbilicais/diagnóstico por imagem , Artérias Umbilicais/patologia
2.
Medicine (Baltimore) ; 98(34): e16883, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31441864

RESUMO

Previous adverse pregnancy outcomes (APO) in women with hereditary thrombophilia have emerged as new indications for prophylactic use of low-molecular-weight heparin (LMWH) during pregnancy. Recent meta-analysis conducted to establish if LMWH may prevent recurrent placenta-mediated pregnancy complications point to important therapeutic effect but these findings are absolutely not universal. Furthermore, previous studies regarding LMWH prophylaxis for APO in women with inherited thrombophilia were performed in high risk patients with previous adverse health outcomes in medical, family and/or obstetric history. Therefore, the aim of this study was to investigate the effects of LMWH prophylaxis on pregnancy outcomes in women with inherited thrombophilias regardless of the presence of previous adverse health outcomes in medical, family, and obstetric history.Prospective analytical cohort study included all referred women with inherited thrombophilia between 11 and 15 weeks of gestation and followed-up to delivery. Patients were allocated in group with LWMH prophylaxis (study group) and control group without LWMH prophylaxis. The groups were compared for laboratory parameters and Doppler flows of umbilical artery at 28 to 30th, 32nd to 34th and 36th to 38th gestational weeks (gw), and for obstetric and perinatal outcomes.The study group included 221 women and control group included 137 women. Mean resistance index of the umbilical artery Ri in 28 to 30, 32 to 34, and 36 to 38 gw were significantly higher in the control group compared to study group (0.71 ±â€Š0.02 vs 0.69 ±â€Š0.02; 0.67 ±â€Š0.03 vs 0.64 ±â€Š0.02; and 0.67 ±â€Š0.05 vs 0.54 ±â€Š0.08, respectively). Intrauterine fetal death (IUFD) and miscarriages were statistically significantly more frequent in control group compared to the patients in study (P < .001). The frequencies of fetal growth restriction (FGR) and APO were significantly higher in the control group compared to the study group (P = .008 and P < .001, respectively). In a multivariate regression model with APO as a dependent variable, only Ri was detected as a significant protective factor for APO, after adjusting for age and LMWH prophylaxis (P < .001).We have demonstrated better perinatal outcomes in women with LMWH prophylaxis for APO compared to untreated women.


Assuntos
Anticoagulantes/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Complicações Hematológicas na Gravidez/tratamento farmacológico , Trombofilia/tratamento farmacológico , Aborto Espontâneo/prevenção & controle , Adulto , Estudos de Casos e Controles , Feminino , Morte Fetal/prevenção & controle , Retardo do Crescimento Fetal/prevenção & controle , Humanos , Recém-Nascido , Nascimento Vivo/epidemiologia , Gravidez , Estudos Prospectivos
3.
J Obstet Gynaecol ; 39(6): 748-752, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31008661

RESUMO

The study objective was to evaluate the effect of the California Maternal Quality Care Collaborative (CMQCC) initiative, as implemented in a southwestern U.S. tertiary hospital, on associated patient costs and outcomes. Using a quasi-experimental study design, we collected existing data (cost and patient outcomes) comparing two six-month period at the baseline and one-year follow-up. Following descriptive statistics, Chi-square tests and t-tests were used to compare categorical and continuous variables, respectively. One hundred and eighty-nine women met the inclusion criteria for the study (93 and 96 women in the baseline and follow-up period, respectively). There was no significant difference in maternal health outcomes between both periods. However, there was a significant difference for newborns with almost 90% (95%CI = 0.06-0.92; p = .027) reduction in stillbirths in the follow-up period. There was also a significant reduction in the days between discharge and follow-up appointments (p < .01). Importantly, the initiative bears no additional financial burden on patients, as hospitalisation cost was unchanged. Impact statement What is already known on this subject? In 2013, the California Maternal Quality Care Collaborative (CMQCC) set up a task force to develop guidelines for managing patients with preeclampsia based on global best practices. A previous study showed that despite system-level implementation challenges, the initiative led to significant increase in blood pressure treatments within one-hour and reduced severe maternal morbidity. What do the results of this study add? This study follows patients from admission, beyond the one-hour post-treatment and into the post-partum phase, to understand if outcomes of the initiative extend beyond the admission. While the study findings do not show any statistically significant difference in readmission before and after the initiative, nor any marked difference in maternal outcomes, it shows a significant difference in the prevalence of stillbirths at no additional cost to the patient. What are the implications of these findings for clinical practice and/or further research? Based on these findings, there is a case for scaling-up the initiative as in addition to its evidenced improvements in maternal outcomes; it is effective in improving newborn health outcomes at no additional cost. Further research, using larger sample size and exploring different care levels would be useful to verify these findings.


Assuntos
Pré-Eclâmpsia/economia , Pré-Eclâmpsia/terapia , Melhoria de Qualidade , Resultado do Tratamento , California , Parto Obstétrico/métodos , Feminino , Morte Fetal/prevenção & controle , Gastos em Saúde , Humanos , Recém-Nascido , Saúde Materna , Gravidez , Centros de Atenção Terciária
5.
Khirurgiia (Mosk) ; (1): 70-77, 2019.
Artigo em Russo | MEDLINE | ID: mdl-30789612

RESUMO

Acute appendicitis is the most frequent surgical disease complicating pregnancy. Accurate diagnosis is difficult due to atypical and misleading clinical manifestations. Surgeons frequently do not know about advantages and disadvantages of different diagnostic methods applied during pregnancy. Treatment of acute appendicitis in pregnant women remains the real challenge for surgeons. There are enough researches indicating on benefits and risks of both open and laparoscopic operations. The main risk is due to fetal loss after laparoscopic procedure. Safety of diagnostic techniques and laparoscopic procedures, surgical tactics and independent risk factors of pregnancy loss are touched in the article.


Assuntos
Apendicite/diagnóstico , Apendicite/cirurgia , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/cirurgia , Doença Aguda , Apendicectomia/efeitos adversos , Feminino , Morte Fetal/etiologia , Morte Fetal/prevenção & controle , Humanos , Laparoscopia/efeitos adversos , Gravidez , Fatores de Risco
6.
Ultrasound Obstet Gynecol ; 53(2): 175-183, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30019431

RESUMO

OBJECTIVES: Monoamniotic twin pregnancies are at increased risk of perinatal complications, primarily owing to the risk of cord entanglement. There is no recommendation on whether such pregnancies should be managed in hospital or can be safely managed in an outpatient setting, and the timing of planned delivery is also a subject of debate. The aim of this study was to compare the perinatal outcomes of inpatient vs outpatient fetal surveillance approaches employed among 22 participating study centers, and to calculate the fetal and neonatal death rates according to gestational age, in non-anomalous monoamniotic twins from 26 weeks' gestation. METHODS: The MONOMONO study was a multinational cohort study of consecutive women with monochorionic monoamniotic twin pregnancies, who were referred to 22 university hospitals in Italy, the USA, the UK and Spain, from January 2010 to January 2017. Only non-anomalous uncomplicated monoamniotic twin pregnancies with two live fetuses at 26 + 0 weeks' gestation were included in the study. In 10 of the centers, monoamniotic twins were managed routinely as inpatients, whereas in the other 12 centers they were managed routinely as outpatients. The primary outcome was intrauterine fetal death. We also planned to assess fetal and neonatal death rates according to gestational age per 1-week interval. Outcomes are presented as odds ratio (OR) with 95% CIs. The main outcome was analyzed using both standard logistic regression analysis, in which each fetus was treated as an independent unit, and a generalized mixed-model approach, with each twin pair treated as a cluster unit, considering that the outcome for a twin is not independent of that of its cotwin. RESULTS: 195 consecutive pregnant women with a non-anomalous uncomplicated monoamniotic twin gestation (390 fetuses) were included. Of these, 75 (38.5%) were managed as inpatients and 120 (61.5%) as outpatients. The overall perinatal loss rate was 10.8% (42/390) with a peak fetal death rate of 4.3% (15/348) occurring at 29 weeks' gestation. There was no significant difference in mean gestational age at delivery (31 weeks), birth weight (∼1.6 kg), or emergency delivery rate between the inpatient and outpatient surveillance groups. Based on generalized mixed-model analysis, there was no statistically significant difference in fetal death rates between inpatient management commencing from around 26 weeks compared with outpatient surveillance protocols from 30 weeks (3.3% vs 10.8%; adjusted OR 0.21 (95% CI, 0.04-1.17)). Maternal length of stay in the hospital was 42.1 days in the inpatient group, and 7.4 days in the outpatient group (mean difference 34.70 days (95% CI, 31.36-38.04 days). From 32 + 0 to 36 + 6 weeks, no fetal or neonatal death in either group was recorded. 46 fetuses were delivered after 34 + 0 weeks, and none of them died in utero or within the first 28 days postpartum. CONCLUSION: In uncomplicated monoamniotic twins, inpatient surveillance is associated with similar fetal mortality as outpatient management. After 31 + 6 weeks, and up to 36 + 6 weeks, there were no intrauterine fetal deaths or neonatal deaths. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.


Assuntos
Morte Fetal/prevenção & controle , Morte Perinatal/prevenção & controle , Mortalidade Perinatal , Gravidez de Gêmeos/estatística & dados numéricos , Cuidado Pré-Natal/métodos , Gêmeos Monozigóticos/estatística & dados numéricos , Adulto , Cardiotocografia , Feminino , Humanos , Recém-Nascido , Pacientes Internados/estatística & dados numéricos , Tempo de Internação , Nascimento Vivo/epidemiologia , Pacientes Ambulatoriais/estatística & dados numéricos , Gravidez , Estudos Retrospectivos , Estatísticas não Paramétricas , Ultrassonografia Pré-Natal
9.
Obstet Gynecol ; 132(6): 1407-1411, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30399110

RESUMO

Unexpected antepartum fetal demise remains one of the most tragic complications of pregnancy. Various approaches to antepartum fetal assessment have been developed as a means of either reassuring the clinician of fetal well-being or identifying potential fetal jeopardy and the need for delivery. As additional high-risk groups of women are identified, indications for antenatal testing continue to expand despite a paucity of good-quality data linking such testing to improved outcomes for women with these additional risk factors. The expansion of established antepartum testing protocols to include women with conditions such as advanced maternal age or obesity without additional, well-established indications for testing is not warranted, particularly because baseline rates of stillbirth seen with these conditions before 39 weeks of gestation are already lower than stillbirth rates achieved with current antepartum testing protocols. Beyond 39 weeks of gestation, if the established risks of stillbirth are deemed unacceptable, delivery is a more rational and evidence-based approach than antepartum testing.


Assuntos
Morte Fetal/prevenção & controle , Diagnóstico Pré-Natal/métodos , Natimorto , Feminino , Idade Gestacional , Frequência Cardíaca Fetal , Humanos , Idade Materna , Gravidez , Cuidado Pré-Natal , Fatores de Risco
10.
Trials ; 19(1): 657, 2018 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-30482254

RESUMO

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder specific to pregnancy and presents with maternal pruritus, raised concentrations of serum bile acids and abnormal liver function tests. ICP is associated with increased rates of spontaneous and iatrogenic preterm labour, fetal hypoxia, meconium-stained amniotic fluid and intrauterine death. Some clinicians treat ICP with ursodeoxycholic acid (UDCA) to improve maternal pruritus and biochemical abnormalities. However, there are currently no data to support the use of UDCA to improve pregnancy outcome as none of the trials performed to date have been powered to address this question. METHODS: The PITCHES trial is a triple-masked, placebo-controlled randomised trial, to evaluate UDCA versus placebo in women with ICP between 20 + 0 to 40 + 6 weeks' gestation. The primary objective of the trial is to determine if UDCA treatment of women with ICP between 20 + 0 and 40 + 6 weeks' gestation reduces the primary perinatal outcome: a composite of perinatal death (as defined by in utero fetal death after randomisation or known neonatal death up to 7 days) or preterm delivery (less than 37 weeks' gestation) or neonatal unit admission for at least 4 h (from infant delivery until hospital discharge). The secondary objectives of the trial are (1) to investigate the effect of UDCA on other short-term outcomes for both mother and infant and (2) to assess the impact of UDCA on health care resource use, in terms of the total number of nights for mother and infant, together with level of care. DISCUSSION: Current practice in the UK at the time of trial commencement for the treatment of ICP is inconsistent, with some units routinely prescribing UDCA, others prescribing very little and the remainder offering it variably. Our previous pilot trial of UDCA in women with ICP demonstrated that the trial would be feasible, and the research question remains active and unanswered. Results are highly likely to influence clinical practice, through direct management and impact on national and international guidelines. TRIAL REGISTRATION: ISRCTN registry, ID: ISRCTN91918806 . Prospectively registered on 27 August 2015.


Assuntos
Colagogos e Coleréticos/uso terapêutico , Colestase Intra-Hepática/tratamento farmacológico , Complicações na Gravidez/tratamento farmacológico , Ácido Ursodesoxicólico/uso terapêutico , Colagogos e Coleréticos/efeitos adversos , Colestase Intra-Hepática/sangue , Colestase Intra-Hepática/diagnóstico , Colestase Intra-Hepática/mortalidade , Inglaterra , Feminino , Morte Fetal/prevenção & controle , Idade Gestacional , Humanos , Recém-Nascido , Estudos Multicêntricos como Assunto , Morte Perinatal/prevenção & controle , Gravidez , Complicações na Gravidez/sangue , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/mortalidade , Nascimento Prematuro/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Natimorto , Fatores de Tempo , Resultado do Tratamento , Ácido Ursodesoxicólico/efeitos adversos , País de Gales
11.
Cochrane Database Syst Rev ; 11: CD003402, 2018 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-30480773

RESUMO

BACKGROUND: Higher intakes of foods containing omega-3 long-chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006. OBJECTIVES: To assess the effects of omega-3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer-term outcomes for mother and child. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (16 August 2018), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing omega-3 fatty acids (as supplements or as foods, stand-alone interventions, or with a co-intervention) during pregnancy with placebo or no omega-3, and studies or study arms directly comparing omega-3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach. MAIN RESULTS: In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega-3 LCPUFA interventions (supplements and food) compared with placebo or no omega-3. Overall study-level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper-middle or high-income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes.Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high-quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high-quality evidence) were both lower in women who received omega-3 LCPUFA compared with no omega-3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega-3 LCPUFA compared with no omega-3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate-quality evidence).For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate-quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate-quality evidence - 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high-quality evidence); but a possible small increase in large-for-gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate-quality evidence, for omega-3 LCPUFA compared with no omega-3. Little or no difference in small-for-gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate-quality evidence) was seen.For the maternal outcomes, there is insufficient evidence to determine the effects of omega-3 on induction post-term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low-quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low-quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low-quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low-quality evidence). Mean gestational length was greater in women who received omega-3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate-quality evidence), and pre-eclampsia may possibly be reduced with omega-3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low-quality evidence).For the child/adult outcomes, very few differences between antenatal omega-3 LCPUFA supplementation and no omega-3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low-quality to very low-quality evidence). The effect of omega-3 LCPUFA on body mass index at 19 years (MD 0, 95% CI -0.83 to 0.83; 1 trial, 243 participants; very low-quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants. AUTHORS' CONCLUSIONS: In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega-3 LCPUFA compared with no omega-3. There was a possibly reduced risk of perinatal death and of neonatal care admission, a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega-3 LCPUFA.For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high-quality (e.g. preterm birth) or moderate-quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision.Omega-3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post-term pregnancies. More studies comparing omega-3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega-3 LCPUFA against placebo or no intervention. However, further follow-up of completed trials is needed to assess longer-term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega-3 LCPUFA, timing and doses; or by characteristics of women.


Assuntos
Ácidos Graxos Ômega-3/administração & dosagem , Retardo do Crescimento Fetal/prevenção & controle , Recém-Nascido Pequeno para a Idade Gestacional , Pré-Eclâmpsia/prevenção & controle , Nascimento Prematuro/prevenção & controle , Suplementos Nutricionais , Feminino , Morte Fetal/prevenção & controle , Óleos de Peixe/administração & dosagem , Idade Gestacional , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Criança Pós-Termo , Gravidez , Gravidez de Alto Risco , Ensaios Clínicos Controlados Aleatórios como Assunto , Alimentos Marinhos
12.
Lancet ; 392(10158): 1629-1638, 2018 11 03.
Artigo em Inglês | MEDLINE | ID: mdl-30269876

RESUMO

BACKGROUND: 2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth. METHODS: This stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022. FINDINGS: 37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75-1·07; p=0·23). INTERPRETATION: The RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven. FUNDING: Chief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.


Assuntos
Conscientização , Morte Fetal/prevenção & controle , Movimento Fetal , Gravidez/psicologia , Cuidado Pré-Natal/métodos , Adulto , Feminino , Humanos , Irlanda/epidemiologia , Natimorto/epidemiologia , Reino Unido/epidemiologia
13.
Rev. esp. ped. (Ed. impr.) ; 74(1): 5-7, oct. 2018. ilus
Artigo em Espanhol | IBECS | ID: ibc-179176

RESUMO

Introducción: La vasa previa (VP) es una rara condición obstétrica en la cual los vasos sanguíneos fetales, libres de tejido placentario y no protegidos por gelatina de Wharton, pasan a nivel del segmento uterino inferior entre la presentación fetal y el cérvix, recubiertos solo por membranas amnióticas. Esta condición conlleva un elevado riesgo de mortalidad perinatal (2,4-56,4%), debido al riesgo de la-ceración de los vasos fetales durante el parto o la ruptura de membranas amnióticas, y consecuentemente la exanguinación fetal. Casos clínicos: Presentamos dos casos clínicos de gestaciones con VP sin diagnóstico prenatal, que presentaron hemorragia fetal durante el parto, requiriendo maniobras de reanimación avanzada y transfusión urgente de concentrado de hematíes, con una adecuada evolución. Conclusión: Resaltar la importancia del diagnóstico prenatal de VP, mediante estudio ecográfico según protocolo, que puede mejorar significativamente los resultados perinatales


Introduction. The vasa previa (VP) is a rare obstetric condition in which the fetal blood vessels, free of placental tissue and not protected by Wharton's gelatin, pass at the level of the lower uterine segment between the fetal presentation and the cervix, coated only by amniotic membranes. This condition carries a high risk of perinatal mortality (2.4-56.4%), due to the risk of laceration of the fetal vessels during delivery or the rupture of amniotic membranes, and consequently fetal exanguination. Cases report: We present two clinical cases of pregnancies with VP without prenatal diagnosis, which presented fetal hemorrhage during labor, requiring advanced resuscitation maneuvers and urgent transfusion of packed red blood cells, with an adequate evolution. Conclusion: Highlight the importance of prenatal diag-nosis of VP, by means of an echographic study according to protocol, which can significantly improve perinatal results


Assuntos
Humanos , Feminino , Recém-Nascido , Vasa Previa/diagnóstico por imagem , Ultrassonografia Pré-Natal/métodos , Placenta/ultraestrutura , Sofrimento Fetal/diagnóstico por imagem , Morte Fetal/prevenção & controle , Doenças Fetais/prevenção & controle , Hemorragia Uterina/etiologia
14.
Pregnancy Hypertens ; 13: 154-160, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30177045

RESUMO

OBJECTIVE: Innate immune system activation and excessive inflammation contributes to hypertension during pregnancy (HTN-preg). Activation of Toll-like receptors (TLRs), the primary innate immune system sensor, is evident in women with HTN-preg and is sufficient to induce pregnancy-dependent, proteinuric hypertension in animals. However, whether HTN-preg is a maternal disease, a placental disease, or both is unclear. We hypothesized that activation of TLR3, the double-stranded RNA sensor, in both maternal systemic and placental cells would be necessary for the full development of HTN-preg in mice. STUDY DESIGN: Various mating schemes generated pregnant mice that lacked TLR3 in maternal cells, paternally-derived placental cells, and both. Mice were then injected with a TLR3 agonist on days 13, 15, and 17 of pregnancy. MAIN OUTCOME MEASURES: Blood pressure, urinary protein excretion, fetal development, maternal vascular endothelial function, and immune system activation were all assessed and compared between groups. RESULTS: Pregnant mice lacking TLR3 in maternal cells as well as pregnant mice lacking TLR3 in placental cells had significantly attenuated increases in systolic blood pressure, urinary protein excretion, fetal demise, and endothelial dysfunction compared to wild-type pregnant mice following TLR3 activation. Pregnant mice lacking TLR3 in both maternal systemic and placental cells were completely resistant to the hypertension, proteinuria, fetal demise, endothelial dysfunction, splenomegaly, and increases in pro-inflammatory immune cells induced by TLR3 activation. CONCLUSIONS: These data suggest that both maternal and placental TLR3 activation are crucial for the full development of HTN-preg and that TLR3 antagonists may be beneficial in some women with HTN-preg.


Assuntos
Pressão Sanguínea , Hipertensão Induzida pela Gravidez/metabolismo , Placenta/metabolismo , Proteinúria/metabolismo , Receptor 3 Toll-Like/metabolismo , Animais , Modelos Animais de Doenças , Endotélio Vascular/metabolismo , Endotélio Vascular/fisiopatologia , Feminino , Morte Fetal/prevenção & controle , Hipertensão Induzida pela Gravidez/induzido quimicamente , Hipertensão Induzida pela Gravidez/fisiopatologia , Hipertensão Induzida pela Gravidez/prevenção & controle , Imunidade Inata , Tamanho da Ninhada de Vivíparos , Masculino , Camundongos Endogâmicos C57BL , Camundongos Knockout , Placenta/fisiopatologia , Poli I-C , Gravidez , Proteinúria/genética , Proteinúria/fisiopatologia , Proteinúria/prevenção & controle , Esplenomegalia/metabolismo , Esplenomegalia/prevenção & controle , Receptor 3 Toll-Like/deficiência , Receptor 3 Toll-Like/genética , Vasodilatação
15.
Gynecol Obstet Fertil Senol ; 46(7-8): 598-604, 2018.
Artigo em Francês | MEDLINE | ID: mdl-30041771

RESUMO

Antiphospholipid syndrome is defined by the presence of thrombosis and/or obstetrical adverse events (≥3 recurrent early miscarriage or fetal death or a prematurity<34 weeks of gestation) associated with persistent antiphospholipid antibodies. The pregnancy outcome has been improved by the conventional treatment (aspirin 100mg/day with low molecular weight heparin [LMWH] from 30 to 75% of uncomplicated pregnancies. In PROMISSE study, 19% of pregnancies had at least one obstetrical adverse event despite treatment (maternal, fetal or neonatal complications) in relation with APS. In the European registry of babies born from APS mothers, maternal and foetal adverse events were observed in 13% of cases, with prematurity in 14% despite treatment. The presence of lupus erythematosus, a history of thrombosis, presence of lupus anticoagulant and APL triple positivity are considered as factors associated with unfavorable obstetrical outcome. Hydroxychloroquine (HCQ) has anti-inflammatory and anti-thrombotic properties. Studies in vitro have shown that HCQ is able to restore the placental expression of Annexin V, which has an anticoagulant effect and to prevent the placental injury induced by APL. HCQ used for lupus erythematosus decrease the thrombotic risk and its value for thrombotic APS has been raised in an open labelled French study. In European retrospective study, the addition of HCQ to conventional treatment improved refractory obstetrical APS. Its use during the pregnancy of patients with lupus erythematosus, the evidence of good safety during the pregnancy and follow-up of children born to mothers exposed to HCQ demonstrate an overall good safety profile for mothers and the fetus. This clinical trial is designed to assess the interest of the addition of hydroxychloroquine to conventional treatment in APS during the pregnancy.


Assuntos
Síndrome Antifosfolipídica/complicações , Síndrome Antifosfolipídica/tratamento farmacológico , Hidroxicloroquina/uso terapêutico , Complicações na Gravidez/tratamento farmacológico , Complicações na Gravidez/imunologia , Resultado da Gravidez , Aborto Habitual/imunologia , Aborto Habitual/prevenção & controle , Anexina A5/fisiologia , Aspirina/administração & dosagem , Quimioterapia Combinada , Feminino , Morte Fetal/etiologia , Morte Fetal/prevenção & controle , França , Heparina de Baixo Peso Molecular/administração & dosagem , Humanos , Hidroxicloroquina/administração & dosagem , Recém-Nascido , Placebos , Doenças Placentárias/tratamento farmacológico , Doenças Placentárias/imunologia , Gravidez
16.
JAMA Pediatr ; 172(7): 635-645, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29813153

RESUMO

Importance: Whether vitamin D supplementation during pregnancy is beneficial and safe for offspring is unclear. Objective: To systematically review studies of the effects of vitamin D supplementation during pregnancy on offspring growth, morbidity, and mortality. Data Sources: Searches of Medline, Embase, and the Cochrane Database of Systematic Reviews were conducted up to October 31, 2017. Key search terms were vitamin D, pregnancy, randomized controlled trials, and offspring outcomes. Study Selection: Randomized clinical trials of vitamin D supplementation during pregnancy and offspring outcomes. Data Extraction and Synthesis: Two authors independently extracted data, and the quality of the studies was assessed. Summary risk ratio (RR), risk difference (RD) or mean difference (MD), and 95% CI were calculated using fixed-effects or random-effects meta-analysis. Main Outcomes and Measures: Main outcomes were fetal or neonatal mortality, small for gestational age (SGA), congenital malformation, admission to a neonatal intensive care unit, birth weight, Apgar scores, neonatal 25-hydroxyvitamin D (25[OH]D) and calcium concentrations, gestational age, preterm birth, infant anthropometry, and respiratory morbidity during childhood. Results: Twenty-four clinical trials involving 5405 participants met inclusion criteria. Vitamin D supplementation during pregnancy was associated with a lower risk of SGA (RR, 0.72; 95% CI, 0.52 to 0.99; RD, -5.60%; 95% CI, -0.86% to -10.34%) without risk of fetal or neonatal mortality (RR, 0.72; 95% CI, 0.47 to 1.11) or congenital abnormality (RR, 0.94; 95% CI, 0.61 to 1.43). Neonates with prenatal vitamin D supplementation had higher 25(OH)D levels (MD, 13.50 ng/mL; 95% CI, 10.12 to 16.87 ng/mL), calcium levels (MD, 0.19 mg/dL; 95% CI, 0.003 to 0.38 mg/dL), and weight at birth (MD, 75.38 g; 95% CI, 22.88 to 127.88 g), 3 months (MD, 0.21 kg; 95% CI, 0.13 to 0.28 kg), 6 months (MD, 0.46 kg; 95% CI, 0.33 to 0.58 kg), 9 months (MD, 0.50 kg; 95% CI, 0.01 to 0.99 kg), and 12 months (MD, 0.32 kg; 95% CI, 0.12 to 0.52 kg). Subgroup analysis by doses showed that low-dose vitamin D supplementation (≤2000 IU/d) was associated with a reduced risk of fetal or neonatal mortality (RR, 0.35; 95% CI, 0.15 to 0.80), but higher doses (>2000 IU/d) did not reduce this risk (RR, 0.95; 95% CI, 0.59 to 1.54). Conclusions and Relevance: Vitamin D supplementation during pregnancy is associated with a reduced risk of SGA and improved infant growth without risk of fetal or neonatal mortality or congenital abnormality. Vitamin D supplementation with doses of 2000 IU/d or lower during pregnancy may reduce the risk of fetal or neonatal mortality.


Assuntos
Suplementos Nutricionais , Crescimento/efeitos dos fármacos , Cuidado Pré-Natal/métodos , Vitamina D/uso terapêutico , Desenvolvimento Infantil , Anormalidades Congênitas/etiologia , Suplementos Nutricionais/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Morte Fetal/prevenção & controle , Humanos , Lactente , Morte do Lactente/etiologia , Morte do Lactente/prevenção & controle , Recém-Nascido Pequeno para a Idade Gestacional , Gravidez , Resultado da Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Vitamina D/administração & dosagem , Vitamina D/efeitos adversos , Vitamina D/farmacologia
17.
Am J Public Health ; 108(6): 815-821, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29672142

RESUMO

OBJECTIVES: To evaluate the impact of the Southern Public Health Regions' (Regions IV and IV) Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, supported by the US Health Resources and Services Administration. METHODS: We examined pre-post change (2011-2014) for CoIIN strategies with available outcome data from vital records (early elective delivery, smoking) and the Pregnancy Risk Assessment Monitoring System (safe sleep) as well as preterm birth and infant mortality for Regions IV and VI relative to all other regions. RESULTS: For most outcomes, CoIIN improvements were greater in Regions IV and VI than in other regions. For example, early elective delivery decreased by 22% versus 14% in other regions, smoking cessation during pregnancy increased by 7% versus 2%, and back sleep position increased by 5% versus 2%. Preterm birth decreased by 4%, twice that observed in other regions, but infant mortality reductions did not differ significantly. CONCLUSIONS: The CoIIN approach to public health improvement shows promise in accelerating progress in intermediate outcomes and preterm birth. Impact on infant mortality may require additional strategies and sustained efforts.


Assuntos
Morte Fetal/prevenção & controle , Feminino , Promoção da Saúde , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Gravidez , Complicações na Gravidez/prevenção & controle , Nascimento Prematuro/epidemiologia , Abandono do Hábito de Fumar/estatística & dados numéricos , Estados Unidos/epidemiologia
18.
Eur J Pharmacol ; 824: 48-56, 2018 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-29409911

RESUMO

Accumulating epidemiological evidence indicates that infection with Porphyromonas gingivalis which is a major periodontal pathogen, causes preterm birth and low birth weight. However, virulence factors of P. gingivalis responsible for preterm birth/low birth weight remain to be elucidated. In this study, using P. gingivalis-infected pregnant mice as an in vivo model, we investigated whether gingipains-cysteine proteinases produced by P. gingivalis-affect preterm birth and low birth weight. We found that intravenous infection of pregnant mice with P. gingivalis induced higher accumulation of the bacterium in the placenta than that in other organs. Compared to infection with P. gingivalis wild-type, infection with a gingipain-deficient P. gingivalis mutant KDP136 led to significant reduction in preterm birth and pregnancy loss. Although repetitive low-level infections of P. gingivalis failed to induce preterm birth and fetal death, it induced suppressive effects on IFN-γ production. Therapeutically, treatment with ginginpain inhibitors prevented fetal death and preterm birth caused by P. gingivalis infection and resulted in recovery of IFN-γ suppression caused by repetitive chronic P. gingivalis infection. These results indicate that gingipains are major virulence factors of P. gingivalis responsible for preterm birth/low birth, and gingipain inhibitors may be useful not only as a therapeutic agent for periodontal diseases, but also as a preventive medicine for preterm birth/low birth weight.


Assuntos
Adesinas Bacterianas/metabolismo , Cisteína Endopeptidases/metabolismo , Inibidores de Cisteína Proteinase/farmacologia , Morte Fetal/etiologia , Morte Fetal/prevenção & controle , Porphyromonas gingivalis/fisiologia , Nascimento Prematuro/microbiologia , Nascimento Prematuro/prevenção & controle , Animais , Citocinas/biossíntese , Membranas Extraembrionárias/efeitos dos fármacos , Membranas Extraembrionárias/microbiologia , Feminino , Camundongos , Mutação , Placenta/efeitos dos fármacos , Placenta/microbiologia , Porphyromonas gingivalis/genética , Gravidez , Nascimento Prematuro/metabolismo
19.
Eur J Obstet Gynecol Reprod Biol ; 221: 144-150, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29304392

RESUMO

OBJECTIVES: Low-dose aspirin is recommended for prevention of pre-eclampsia in high-risk pregnant women. Current doses provide a conservative risk reduction and some individuals demonstrate 'aspirin non-responsiveness', with insufficient antiplatelet effects. We aimed to determine if aspirin non-responsiveness could be identified in women at high risk of pre-eclampsia and assess for potential associations with placentally-mediated adverse outcomes. STUDY DESIGN: Prospective cohort study. 180 women at high-risk of pre-eclampsia, by NICE criteria, prescribed 75 mg dispersible aspirin daily were recruited from antenatal clinics of Liverpool Women's Hospital between 17/01/14 and 31/03/16. Platelet function (Multiplate™ impedance aggregometry, VerifyNow™ and 11-dehydrothromboxane B2) and aspirin metabolites (nuclear magnetic resonance and liquid chromatography mass spectrometry) were assessed at 5 + 0-20 + 6 and 33 + 0-35 + 6 weeks. Pearson's chi-square test was used to assess for associations between longitudinal response to aspirin and (1) any pre-eclampsia (2) composite adverse placentally-mediated outcome (one, or combination of pre-eclampsia, placental abruption, IUGR and perinatal mortality). A Bonferroni correction was applied to correct for multiple analyses. RESULTS: 180 women were recruited, there were 4 withdrawals and no women were lost to follow-up. After 15 women delivered prior to the completion of follow-up, sufficient sample volumes for longitudinal platelet function and aspirin adherence testing were obtained from 156 women. There were no consistent aspirin non-responders in the cohort. 59% (n = 92) women exhibited normal response to aspirin, 34% (n = 53) variable response (switching response status between study visits) and in 7% (n = 11) response could not be determined as they exhibited lack of platelet response on a background of undetectable aspirin metabolites. There was no significant association between indeterminate or inconsistent (variable or indeterminate) response to aspirin and either pre-eclampsia (p = 0.59, p = 0.84) or composite outcome (p = 0.95, p = 0.65). CONCLUSIONS: When platelet function was assessed with COX-specific tests that measure the antiplatelet effects of low-dose aspirin and aspirin adherence is accurately accounted for aspirin non-responsiveness was not identified in pregnant women at high-risk of pre-eclampsia. Response to aspirin was not associated with placentally-mediated adverse outcomes. The high-degree of variable and indeterminate aspirin response indicates suboptimal adherence and/or dosing are more pressing factors to address to optimise aspirin effectiveness.


Assuntos
Aspirina/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Pré-Eclâmpsia/tratamento farmacológico , Adulto , Feminino , Morte Fetal/prevenção & controle , Humanos , Pessoa de Meia-Idade , Pré-Eclâmpsia/prevenção & controle , Gravidez , Estudos Prospectivos , Fatores de Risco , Falha de Tratamento
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