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1.
Z Geburtshilfe Neonatol ; 223(6): 373-394, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31801169

RESUMO

AIMS: This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. METHODS: The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). RECOMMENDATIONS: Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.


Assuntos
Ruptura Prematura de Membranas Fetais , Trabalho de Parto Prematuro/prevenção & controle , Guias de Prática Clínica como Assunto , Nascimento Prematuro , Sociedades Médicas , Prevenção Terciária , Incompetência do Colo do Útero , Áustria , Feminino , Ruptura Prematura de Membranas Fetais/prevenção & controle , Ruptura Prematura de Membranas Fetais/terapia , Humanos , Recém-Nascido , Obstetrícia , Gravidez , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/terapia , Sistema de Registros
2.
BJOG ; 126(13): 1569-1575, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31339631

RESUMO

OBJECTIVE: The QUiPP algorithm combines cervical length, quantitative fetal fibronectin (qfFN) and medical history to quantify risk of preterm birth. We assessed the utility of QUiPP to inform preterm birth prevention treatment decisions. DESIGN: A prospective cohort study with a subsequent impact assessment using the QUiPP risk of birth before 34 weeks' gestation. SETTING: A UK tertiary referral hospital. SAMPLE: In all, 119 women with previous spontaneous preterm birth (sPTB) or preterm premature rupture of membranes (PPROM) before 34 weeks' gestation. METHODS: Cervical length and qfFN were measured at 19+0 to 23+0  weeks' gestation. Clinical management was based on history and cervical length. After birth, clinicians were unblinded to qfFN results and QUiPP analysis was undertaken. MAIN OUTCOME MEASURES: Predictive statistics of QUiPP algorithm using 10% risk of sPTB before 34+0  weeks as treatment threshold. RESULTS: Fifteen of 119 women (13%) had PPROM or sPTB before 34 weeks. Of these, 53% (8/15) had QUiPP risk of sPTB before 34+0  weeks above 10%. Applying this treatment threshold in practice would have doubled our treatment rate (20 versus 42%). QUIPP threshold of 10% had positive likelihood ratio (LR) of 1.3 (95% CI 0.76-2.18), and negative LR of 0.8 (95% CI 0.45-1.40) for predicting sPTB before 34+0  weeks. CONCLUSIONS: Use of the QUiPP algorithm in this population may lead to substantial increase in interventions without evidence that currently available treatment options are beneficial for this particular group. TWEETABLE ABSTRACT: Independent study finds that the QUiPP algorithm could lead to substantial increases in treatment without evidence of benefit.


Assuntos
Ruptura Prematura de Membranas Fetais/epidemiologia , Segundo Trimestre da Gravidez/fisiologia , Nascimento Prematuro/epidemiologia , Adulto , Algoritmos , Biomarcadores/análise , Medida do Comprimento Cervical , Tomada de Decisão Clínica , Feminino , Ruptura Prematura de Membranas Fetais/prevenção & controle , Fibronectinas/análise , Humanos , Recém-Nascido , Valor Preditivo dos Testes , Gravidez , Nascimento Prematuro/prevenção & controle , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Reino Unido/epidemiologia
3.
Fetal Diagn Ther ; 45(2): 102-110, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29920508

RESUMO

INTRODUCTION: The benefits of endoscopic fetal surgery are deteriorated by the high risk of iatrogenic preterm prelabor rupture of fetal membranes (iPPROM). While previous studies have reported good sealing candidates to prevent membrane rupture, the delivery of these materials to the location of membrane puncture remains unsolved. MATERIALS AND METHODS: We describe an approach to apply sealing materials onto the amnion through the fetoscopy port. We developed a device composed of an umbrella-shaped polyester coated nitinol mesh and an applicator. The spontaneously unfolding umbrella is pushed through the port, pulled against the amnion, and glued onto the amnion defect site. We tested the adhesion strength of multiple glues and tested the feasibility and reproducibility of this fetal membrane sealing approach in an ex vivo model. RESULTS: The umbrella unfolded and was well positioned in all tests (n = 18). When applied via the fetoscopy port, umbrellas were successfully glued onto the fetal membrane, and all of them completely covered the defect (n = 5). The mean time needed for the whole procedure was 3 min. DISCUSSION: This study is a proof of concept presenting a potential future solution for the precise local application of bioadhesives for the prevention of iPPROM.


Assuntos
Ruptura Prematura de Membranas Fetais/prevenção & controle , Fetoscopia/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Animais , Bovinos , Membranas Extraembrionárias/cirurgia , Feminino , Fetoscopia/instrumentação , Fetoscopia/métodos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Gravidez
4.
Ultrasound Obstet Gynecol ; 53(4): 529-534, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29920812

RESUMO

OBJECTIVE: To investigate whether the classification of a previous spontaneous preterm birth (sPTB) as preterm labor (PTL) with intact membranes (IM) or as preterm prelabor rupture of membranes (PPROM) impacts the efficacy of cervical pessary or vaginal progesterone for prevention of sPTB in pregnant women with short cervix on transvaginal ultrasound. METHODS: This was a retrospective cohort study of asymptomatic high-risk singleton pregnancies with a short cervix and history of sPTB, treated using Arabin pessary or vaginal progesterone for primary PTB prevention, conducted at four European hospitals. A log-rank test on Kaplan-Meier curves was used to assess the difference in performance of pessary and progesterone, according to history of PTL-IM or PPROM. Linear regression analysis was used to evaluate significant predictors of gestational age at delivery. RESULTS: Between 2008 and 2015, 170 women were treated with a pessary and 88 with vaginal progesterone. In women treated with a pessary, rate of sPTB < 34 weeks was 16% in those with a history of PTL-IM and 55% in those with a history of PPROM. In women treated with progesterone, rate of sPTB < 34 weeks was 13% in those with a history of PTL-IM and 21% in those with a history of PPROM. Treatment with a pessary resulted in earlier delivery in women with previous PPROM than in any other subgroup (P < 0.0001). Linear regression analysis showed a clear effect of PPROM history (P < 0.0001), combination of PPROM history and treatment (P = 0.0003) and cervical length (P = 0.0004) on gestational age at birth. CONCLUSIONS: Cervical pessary may be a less efficacious treatment option for women with previous PPROM; however, these results require prospective validation before change in practice is recommended. Phenotype of previous preterm birth may be an important risk predictor and treatment effect modifier; this information should be reported in future clinical trials. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.


Assuntos
Ruptura Prematura de Membranas Fetais/prevenção & controle , Pessários , Nascimento Prematuro/prevenção & controle , Progesterona/administração & dosagem , Progestinas/administração & dosagem , Administração Intravaginal , Adulto , Medida do Comprimento Cervical , Colo do Útero/diagnóstico por imagem , Colo do Útero/patologia , Feminino , Idade Gestacional , Humanos , Gravidez , Estudos Retrospectivos , Resultado do Tratamento
5.
Gynecol Obstet Fertil Senol ; 46(12): 1004-1021, 2018 12.
Artigo em Francês | MEDLINE | ID: mdl-30385352

RESUMO

OBJECTIVES: To synthetize the available evidence regarding the incidence and risk factors of preterm premature rupture of membranes (PPROM). To describe the evolution of pregnancy, neonatal outcomes and the prognosis of infants born in a context of PPROM, according to the existence of an associated intrauterine infection and to the latency duration. METHOD: Consultation of the Medline database, from 1980 to February 2018. RESULTS: PPROM before 37 and before 34 weeks' gestation occur in 2-3% and <1% of pregnancies, respectively (LE2). Although many risk factors are identified, few are modifiable, and the vast majority of patients have no risk factors (LE2). Consequently, individual prediction of the risk of PPROM and primary prevention measures have not been shown to be effective and are not recommended in clinical practice (Grade B). Most women give birth within the week following PPROM (LE2). The main complications of PPROM are prematurity, intrauterine infection and obstetric and maternal complications (LE2). Latency duration and the frequency of complications decrease with increasing gestational age at PPROM (LE2). Neonatal prognosis is largely conditioned by gestational age at birth, with no apparent over-risk of poor outcomes linked to PPROM compared to other causes of preterm birth (LE2). In contrast, intrauterine infection is associated with an increased risk of in utero fetal death (LE3), necrotizing enterocolitis (LE1) and early-onset sepsis (LE2). The association of intrauterine infection with neurological morbidity remains controversial. Prolongation of latency, from gestational age at PPROM, is beneficial for the child (LE2). CONCLUSION: PPROM is a major cause of prematurity and short- and long-term mortality and morbidity. Antenatal care is an important issue for obstetric and pediatric teams, aiming to reduce complications and adverse consequences for both mother and child.


Assuntos
Ruptura Prematura de Membranas Fetais/epidemiologia , Ruptura Prematura de Membranas Fetais/terapia , Feminino , Morte Fetal , Doenças Fetais , Ruptura Prematura de Membranas Fetais/prevenção & controle , França/epidemiologia , Idade Gestacional , Humanos , Recém-Nascido , MEDLINE , Gravidez , Complicações na Gravidez/prevenção & controle , Resultado da Gravidez , Nascimento Prematuro , Prognóstico , Fatores de Risco
6.
BMC Pregnancy Childbirth ; 18(1): 277, 2018 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-29970019

RESUMO

BACKGROUND: The aim of this study was to determine the effect of cerclage in women who underwent cervical conization. METHODS: Study data were collected from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service for 2009-2013. Women who had a conization in 2009 and a subsequent first delivery between 2009 and 2013 in Korea were enrolled. RESULTS: Among the women who had conization in 2009, 1075 women had their first delivery between 2009 and 2013. A cerclage was placed in 161 of the women who were treated by conization. The rate of preterm birth was higher in the women who were treated with cerclage following a conization compared with those without cerclage (10.56 vs 4.27, p < 0.01, respectively). The multivariate regression analysis revealed that the women who were treated cerclage following a conization had an increased risk of preterm delivery compared with women without cerclage (odds ratio (OR), 2.6, 95% confidence interval (CI), 1.4-4.9). CONCLUSION: Our study showed that cerclage associated with an increased risk of preterm birth and preterm premature rupture of membranes in women who underwent conization. Further studies are required to clarify the mechanism by which cerclage affects the risk of preterm birth.


Assuntos
Cerclagem Cervical , Colo do Útero , Conização , Ruptura Prematura de Membranas Fetais/prevenção & controle , Trabalho de Parto Prematuro , Nascimento Prematuro , Adulto , Cerclagem Cervical/efeitos adversos , Cerclagem Cervical/métodos , Cerclagem Cervical/estatística & dados numéricos , Colo do Útero/patologia , Colo do Útero/cirurgia , Conização/efeitos adversos , Conização/métodos , Conização/estatística & dados numéricos , Feminino , Ruptura Prematura de Membranas Fetais/epidemiologia , Ruptura Prematura de Membranas Fetais/etiologia , Humanos , Trabalho de Parto Prematuro/epidemiologia , Trabalho de Parto Prematuro/etiologia , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Nascimento Prematuro/prevenção & controle , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Gestão de Riscos
7.
Taiwan J Obstet Gynecol ; 57(3): 374-378, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29880168

RESUMO

OBJECTIVE: Prediction of delivery latency complicated with preterm premature rupture of membrane (PPROM) is crucial for reducing maternal and neonatal complications. Therefore, we investigated the correlations between latency period and cut-off values of ultrasonographic parameters, ultimately predicting delivery latency. MATERIALS AND METHODS: The retrospective study was performed on 121 PPROM patients enrolled between March 2010 and July 2015. Parameters including amniotic fluid index (AFI), single deepest pocket (SDP) and transvaginal cervical length (TVCL) were measured in 99 singleton pregnancies with PPROM. Latency was defined as the period from sonographic measurements to delivery day. The parameters were analyzed independently by Wilcoxon rank sum test and Fisher's exact test. Cut-off values were determined using a receiver operating characteristic (ROC) curve. RESULTS: In delivery latency within 3 days, AFI and SDP were decreased with significantly shorter TVCL. AFI and SDP had the highest sensitivity (82.2%) and SDP combined with TVCL showed the highest specificity (75.9%) in area under curve (AUC) value. The predicted median latency period was less than 2 days within the cutoff value of parameter (AFI ≤ 7.72, SDP ≤ 3.2 and TVCL ≤ 1.69). CONCLUSION: AFI and SDP combined with TVCL could be useful predictive parameters of the latency interval from PPROM to delivery.


Assuntos
Líquido Amniótico/diagnóstico por imagem , Medida do Comprimento Cervical , Ruptura Prematura de Membranas Fetais/diagnóstico , Adulto , Feminino , Ruptura Prematura de Membranas Fetais/prevenção & controle , Idade Gestacional , Humanos , Recém-Nascido , Valor Preditivo dos Testes , Gravidez , Resultado da Gravidez , Curva ROC , Valores de Referência , Estudos Retrospectivos
8.
J Neonatal Perinatal Med ; 11(3): 295-303, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29843261

RESUMO

OBJECTIVE: Identify which obstetrical diagnoses are associated with suboptimal antenatal betamethasone administration. METHODS: We present a retrospective, cohort study of patients who received betamethasone due to a risk for preterm delivery, between 7/2013 and 9/2016 at our institution. Details of betamethasone administration were recorded including the diagnosis leading to betamethasone. Optimal administration was defined as two doses of betamethasone given 24 hours apart, with delivery occurring at greater than 24 hours but less than seven days after completion of the second dose of betamethasone. Suboptimal administration included any betamethasone dosing that did not meet the optimal criteria. RESULTS: 428 patients were identified for the study with 20.1% of patients receiving optimal betamethasone. Patients presenting with hypertensive disorders of pregnancy (36.1%) and preterm premature rupture of membranes (PPROM) (22.1%) were more likely to receive optimal betamethasone, while patients presenting with preterm labor (PTL) (41.8%) and placental abruption (24.6%) were more likely to receive suboptimal betamethasone (p-value < 0.0001). Among PTL patients, those presenting with contractions and cervical dilation/short cervix (19.15%) were more likely to receive optimal betamethasone (p-value 0.0349). Optimal betamethasone decreased the incidence of respiratory distress syndrome (RDS) among 32.1 to 34 week neonates. CONCLUSION: Hypertensive disorders of pregnancy and PPROM are associated with optimal betamethasone, whereas PTL and placental abruption are associated with suboptimal betamethasone.


Assuntos
Anti-Inflamatórios/uso terapêutico , Betametasona/uso terapêutico , Ruptura Prematura de Membranas Fetais/prevenção & controle , Trabalho de Parto Prematuro/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Nascimento Prematuro/prevenção & controle , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle , Adolescente , Adulto , Revisão de Uso de Medicamentos , Feminino , Ruptura Prematura de Membranas Fetais/fisiopatologia , Hospitais Comunitários , Humanos , Recém-Nascido , Gravidez , Resultado da Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Síndrome do Desconforto Respiratório do Recém-Nascido/fisiopatologia , Estudos Retrospectivos , Adulto Jovem
9.
Prenat Diagn ; 38(2): 99-105, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29178347

RESUMO

OBJECTIVE: To evaluate novel sealing techniques for their biocompatibility and sealing capacity of iatrogenic fetal membrane defects in a pregnant rabbit model. METHOD: At day 23 of gestation (term = d31), a standardized fetoscopy was performed through a 14G cannula. The resulting fetal membrane defect was closed with condensed collagen, collagen with fibrinogen, Tissuepatch, Duraseal, or a conventional collagen plug (Lyostypt) as reference. At d30, the fetuses were harvested and full thickness fetal membrane samples were analyzed. The study consisted of 2 consecutive parts: (1) biocompatibility testing by fetal survival, apoptosis, and infiltration of polymorphonuclear cells in the membranes and (2) the efficacy to seal fetal membrane defects. RESULTS: Three sealants (collagen with fibrinogen, Duraseal, or Lyostypt) were associated with a higher fetal mortality compared to control unmanipulated littermates and hence were excluded from further analysis. Tissuepatch was biocompatible, and amniotic fluid levels were comparable to those of control untouched littermates. Compared to the condensed collagen, Tissuepatch was also easier in surgical handling and induced limited cell proliferation. CONCLUSION: Tissuepatch had the best biocompatibility and efficacy in sealing an iatrogenic fetal membrane defect in the pregnant rabbit compared to other readily available sealants.


Assuntos
Membranas Extraembrionárias/cirurgia , Teste de Materiais , Animais , Colágeno , Modelos Animais de Doenças , Membranas Extraembrionárias/anormalidades , Membranas Extraembrionárias/química , Feminino , Ruptura Prematura de Membranas Fetais/prevenção & controle , Mortalidade Fetal , Fetoscopia , Doença Iatrogênica , Marcação In Situ das Extremidades Cortadas , Gravidez , Coelhos , Engenharia Tecidual
10.
J Matern Fetal Neonatal Med ; 31(23): 3075-3079, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28768450

RESUMO

OBJECTIVES: To report a cohort of dichorionic triamniotic (DCTA) triplets with access to contemporary fetal interventions. DESIGN: Prospective study. SETTING: A regional referral center for the diagnosis and management of complicated multiple pregnancies. POPULATION: All DCTA triplets receiving consultation and prenatal care at our center from 2010 to 2015. METHODS: The following management alternatives for DCTA were offered: 1) expectant management; 2) reduction of one or two fetus of the monochorionic (MC) component using radiofrequency ablation (RFA) after 16 weeks or potassium chloride (KCL) before 16 weeks, respectively; 3) reduction of the isolated fetus using KCL before 16 weeks. MAIN OUTCOME MEASURE: Survival rate of different management alternatives. RESULTS: A total of 47 DCTA triplets were included in this study. After consultations on possible prognosis and management options, 19 patients chose expectant management, 14 patients opted RFA to reduce one fetus of the MC component, 14 patients required KCL to reduce the MC component. Fetal demise per pregnancy occurred more frequently in the subgroup managed expectantly (53%) compared to subgroups managed with RFA (7%, p = .02) or KCL (0%, p = .02). Overall survival was significantly lower in DCTA triplets managed expectantly (58%) compared to subgroup managed with RFA (93%, p < .01) or KCL (100%, p = .04). CONCLUSION: Fetal reduction seems to improve perinatal survival in DCTA triplets.


Assuntos
Cloreto de Potássio , Redução de Gravidez Multifetal/métodos , Gravidez de Alto Risco , Gravidez de Trigêmeos , Adulto , Peso ao Nascer , Feminino , Morte Fetal , Ruptura Prematura de Membranas Fetais/epidemiologia , Ruptura Prematura de Membranas Fetais/etiologia , Ruptura Prematura de Membranas Fetais/prevenção & controle , Idade Gestacional , Humanos , Recém-Nascido , Gravidez , Estudos Prospectivos , Ablação por Radiofrequência/estatística & dados numéricos , Análise de Sobrevida , Ultrassonografia Pré-Natal , Conduta Expectante/estatística & dados numéricos
11.
J Matern Fetal Neonatal Med ; 31(1): 39-46, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28002986

RESUMO

OBJECTIVE: To evaluate the effects of copper (Cu) supplementation during pregnancy on the rupture of membranes and pregnancy outcomes. METHODS: Study was conducted as a triple-blind randomized clinical trial. In one group, Cu in a dose of 1000 mg per day, and in the other group, placebo was prescribed orally from 16th week of pregnancy. RESULTS: The women of the two groups did not have significant difference according to age, gestational age at recruitment, BMI, and socioeconomic conditions. There was no statistically significant difference between case and control group regarding the incidence of PPROM, PROM, preterm labor, vaginal bleeding during pregnancy, preeclampsia, and the incidence of placenta abruption. There was a 75% and 90% decrease in depressive symptoms in 2nd trimester and 3rd trimester in supplemented group, respectively. Also, there was a 45% and 80% decrease in anxiety symptoms in 2nd trimester and 3rd trimester in the supplemented group, respectively The rate of infection during pregnancy was significantly higher in control group (p = 0.046). There was no difference between the two groups according to neonatal outcomes. CONCLUSIONS: Cu supplementation during pregnancy could not influence positively on ROM; however, it could improve some mood status of the women.


Assuntos
Cobre/uso terapêutico , Ruptura Prematura de Membranas Fetais/prevenção & controle , Oligoelementos/uso terapêutico , Adolescente , Adulto , Ansiedade/prevenção & controle , Depressão/prevenção & controle , Feminino , Ruptura Prematura de Membranas Fetais/epidemiologia , Humanos , Incidência , Recém-Nascido , Irã (Geográfico)/epidemiologia , Gravidez , Resultado da Gravidez , Adulto Jovem
12.
Obstet Gynecol ; 131(1): 187-189, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29266069

RESUMO

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm prelabor rupture of membranes (also referred to as premature rupture of membranes) (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.


Assuntos
Ruptura Prematura de Membranas Fetais/prevenção & controle , Ruptura Prematura de Membranas Fetais/terapia , Trabalho de Parto Prematuro/prevenção & controle , Guias de Prática Clínica como Assunto , Resultado da Gravidez , Comitês Consultivos , Feminino , Idade Gestacional , Humanos , Saúde do Lactente , Recém-Nascido , Gravidez , Medição de Risco , Estados Unidos
13.
Obstet Gynecol ; 131(1): e1-e14, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29266075

RESUMO

Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm prelabor rupture of membranes (also referred to as premature rupture of membranes) (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.


Assuntos
Descolamento Prematuro da Placenta/prevenção & controle , Ruptura Prematura de Membranas Fetais/prevenção & controle , Ruptura Prematura de Membranas Fetais/terapia , Guias de Prática Clínica como Assunto , Resultado da Gravidez , Adulto , Comitês Consultivos/normas , Feminino , Idade Gestacional , Humanos , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados Unidos
14.
Am J Obstet Gynecol ; 217(6): 695.e1-695.e14, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29031893

RESUMO

BACKGROUND: The progestogen 17-α hydroxyprogesterone caproate (17-OHPC) is 1 of only 2 agents recommended for clinical use in the prevention of spontaneous preterm delivery, and studies of its efficacy have been conflicting. We have developed an in-vitro model to study the fetal membrane weakening process that leads to rupture in preterm premature rupture of the fetal membranes (pPROM). Inflammation/infection associated with tumor necrosis factor-α (TNF-α) induction and decidual bleeding/abruption associated thrombin release are leading causes of preterm premature rupture of the fetal membranes. Both agents (TNF-α and thrombin) cause fetal membrane weakening in the model system. Furthermore, granulocyte-macrophage colony-stimulating factor (GM-CSF) is a critical intermediate for both TNF-α and thrombin-induced fetal membrane weakening. In a previous report, we demonstrated that 3 progestogens, progesterone, 17-alpha hydroxyprogesterone (17-OHP), and medroxyprogesterone acetate (MPA), each inhibit both TNF-α- and thrombin-induced fetal membrane weakening at 2 distinct points of the fetal membrane weakening pathway. Each block both the production of and the downstream action of the critical intermediate granulocyte-macrophage colony-stimulating factor. OBJECTIVE: The objective of the study was to characterize the inhibitory effects of 17-OHPC on TNF-α- and thrombin-induced fetal membrane weakening in vitro. STUDY DESIGN: Full-thickness human fetal membrane fragments from uncomplicated term repeat cesarean deliveries were mounted in 2.5 cm Transwell inserts and cultured with/without 17-alpha hydroxyprogesterone caproate (10-9 to 10-7 M). After 24 hours, medium (supernatant) was removed and replaced with/without the addition of tumor necrosis factor-alpha (20 ng/mL) or thrombin (10 U/mL) or granulocyte-macrophage colony-stimulating factor (200 ng/mL). After 48 hours of culture, medium from the maternal side compartment of the model was assayed for granulocyte-macrophage colony-stimulating factor and the fetal membrane fragments were rupture strength tested. RESULTS: Tumor necrosis factor-alpha and thrombin both weakened fetal membranes (43% and 62%, respectively) and increased granulocyte-macrophage colony-stimulating factor levels (3.7- and 5.9-fold, respectively). Pretreatment with 17-alpha hydroxyprogesterone caproate inhibited both tumor necrosis factor-alpha- and thrombin-induced fetal membrane weakening and concomitantly inhibited the induced increase in granulocyte-macrophage colony-stimulating factor in a concentration-dependent manner. However, contrary to our prior reports regarding progesterone and other progestogens, 17-alpha hydroxyprogesterone caproate did not also inhibit granulocyte-macrophage colony-stimulating factor-induced fetal membrane weakening. CONCLUSION: 17-Alpha hydroxyprogesterone caproate blocks tumor necrosis factor-alpha- and thrombin-induced fetal membrane weakening by inhibiting the production of granulocyte-macrophage colony-stimulating factor. However, 17-alpha hydroxyprogesterone caproate did not also inhibit granulocyte-macrophage colony-stimulating factor-induced weakening. We speculate that progestogens other than 17-alpha hydroxyprogesterone caproate may be more efficacious in preventing preterm premature rupture of the fetal membranes-related spontaneous preterm birth.


Assuntos
Membranas Extraembrionárias/efeitos dos fármacos , Ruptura Prematura de Membranas Fetais/prevenção & controle , Hidroxiprogesteronas/farmacologia , Progestinas/farmacologia , Caproato de 17 alfa-Hidroxiprogesterona , Feminino , Fator Estimulador de Colônias de Granulócitos e Macrófagos/farmacologia , Hemostáticos/farmacologia , Humanos , Técnicas In Vitro , Modelos Biológicos , Gravidez , Nascimento Prematuro/prevenção & controle , Trombina/farmacologia , Fator de Necrose Tumoral alfa/farmacologia
15.
Ultrasound Obstet Gynecol ; 50(5): 569-577, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28295722

RESUMO

OBJECTIVE: The aim of this systematic review and meta-analysis was to quantify the efficacy of cervical cerclage in preventing preterm birth (PTB) in asymptomatic singleton pregnancies with a short mid-trimester cervical length (CL) on transvaginal sonography (TVS) and without prior spontaneous PTB. METHODS: Electronic databases were searched from inception of each database until February 2017. No language restrictions were applied. All randomized controlled trials (RCTs) of asymptomatic singleton pregnancies without prior spontaneous PTB, found to have short CL < 25 mm on mid-trimester TVS and then randomized to management with either cerclage or no cerclage, were included. Corresponding authors of all the included trials were contacted to obtain access to the data and perform a meta-analysis of individual patient-level data. Data provided by the investigators were merged into a master database constructed specifically for the review. Primary outcome was PTB < 35 weeks. Summary measures were reported as relative risk (RR) with 95% CI. The quality of the evidence was assessed using the GRADE approach. RESULTS: Five RCTs, including 419 asymptomatic singleton gestations with TVS-CL < 25 mm and without prior spontaneous PTB, were analyzed. In women who were randomized to the cerclage group compared with those in the control group, no statistically significant differences were found in PTB < 35 (21.9% vs 27.7%; RR, 0.88 (95% CI 0.63-1.23); I2 = 0%; five studies, 419 participants), < 34, < 32, < 28 and < 24 weeks, gestational age at delivery, preterm prelabor rupture of membranes (PPROM) and neonatal outcomes. In women who received cerclage compared with those who did not, planned subgroup analyses revealed a significantly lower rate of PTB < 35 weeks in women with TVS-CL < 10 mm (39.5% vs 58.0%; RR, 0.68 (95% CI, 0.47-0.98); I2 = 0%; five studies; 126 participants) and in women who received tocolytics (17.5% vs 32.7%; RR, 0.54 (95% CI, 0.31-0.93); I2 = 0%; four studies; 169 participants) or antibiotics (18.3% vs 31.5%; RR, 0.58 (95% CI, 0.33-0.98); I2 = 0%; three studies; 163 participants) as additional therapy to cerclage. The quality of evidence was downgraded two levels because of serious imprecision and indirectness, and therefore was judged as low. CONCLUSIONS: In singleton gestations without prior spontaneous PTB but with TVS-CL < 25 mm in the second trimester, cerclage does not seem to prevent preterm delivery or improve neonatal outcome. However, in these pregnancies, cerclage seems to be efficacious at lower CLs, such as < 10 mm, and when tocolytics or antibiotics are used as additional therapy, requiring further studies in these subgroups. Given the low quality of evidence, further well-designed RCTs are needed to confirm the findings of this study. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.


Assuntos
Cerclagem Cervical/estatística & dados numéricos , Medida do Comprimento Cervical/métodos , Nascimento Prematuro/prevenção & controle , Tocolíticos/administração & dosagem , Doenças Uterinas/terapia , Terapia Combinada , Feminino , Ruptura Prematura de Membranas Fetais/etiologia , Ruptura Prematura de Membranas Fetais/prevenção & controle , Idade Gestacional , Humanos , Gravidez , Segundo Trimestre da Gravidez , Nascimento Prematuro/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Doenças Uterinas/complicações
16.
Reprod Health ; 14(1): 31, 2017 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-28253893

RESUMO

BACKGROUND: Acyclovir (ACV) given to HSV-2 positive women after 36 weeks reduces adverse outcomes but its benefit at lower gestation was undocumented. We determined the effect of oral acyclovir administered from 28 to 36 weeks on premature rupture of membranes (PROM) primarily and preterm delivery risk. METHODS: This was a randomized, double-blind placebo-controlled trial among 200 HSV-2 positive pregnant women at 28 weeks of gestation at Mulago Hospital, Uganda. Participants were assigned randomly (1:1) to take either acyclovir 400 mg orally twice daily (intervention) or placebo (control) from 28 to 36 weeks. Both arms received acyclovir after 36 weeks until delivery. Development of Pre-PROM by 36 weeks and preterm delivery were outcomes. RESULTS: One hundred women were randomised to acyclovir and 100 to placebo arms between January 2014 and February 2015. There was tendency towards reduction of incidence of PROM at 36 weeks but this was not statistically significant (4.0% versus 10.0%; RR 0.35; 95% 0.11-1.10) in the acyclovir and placebo arms respectively. However, there was a significant reduction in the incidence of preterm delivery (11.1% versus 23.5%; RR 0.41; 95% 0.20-0.85) in the acyclovir and placebo arms respectively. CONCLUSIONS: Oral acyclovir given to HSV-2 positive pregnant women from 28 to 36 weeks reduced incidence of preterm delivery but did not significantly reduce incidence of pre-PROM. TRIAL REGISTRATION: www.pactr.org, PACTR201311000558197 .


Assuntos
Aciclovir/administração & dosagem , Parto Obstétrico , Ruptura Prematura de Membranas Fetais/prevenção & controle , Herpes Genital/tratamento farmacológico , Herpesvirus Humano 2/fisiologia , Nascimento Prematuro/prevenção & controle , Adulto , Antivirais/administração & dosagem , Método Duplo-Cego , Feminino , Ruptura Prematura de Membranas Fetais/etiologia , Idade Gestacional , Herpes Genital/complicações , Herpes Genital/virologia , Humanos , Recém-Nascido , Mães , Gravidez , Nascimento Prematuro/etiologia , Uganda
17.
J Matern Fetal Neonatal Med ; 30(5): 551-555, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27072547

RESUMO

OBJECTIVE: To investigate the outcomes of singleton pregnant women with cervical insufficiency undergoing two different cervical cerclages. METHODS: This is a retrospective cohort study of women who underwent a history- or ultrasound-indicated cerclage (either Shirodkar or McDonald) at a tertiary referral center from 2002 to 2014. Outcome parameters (delivery age, postoperative cervical length, preterm premature rupture of membranes, preterm delivery rate and neonatal complications) were compared between the two cerclage procedures. Multivariate logistic regression analysis was applied to control for significant variables of preterm birth. Kaplan-Meier survival analysis was used to demonstrate delivery age to percentage of term delivery by cerclage type. RESULTS: Ninety-four cases were initially included. After excluding cases not meeting the study criteria, 60 pregnancies (Shirodkar 36 and McDonald 24) were recruited for analysis. The mean delivery age in the Shirodkar group was more advanced than that in the McDonald group (37.1 ± 3.3 versus 34.8 ± 4.9 weeks, p = 0.039). There were significantly fewer deliveries <37 gestational weeks in the Shirodkar group than in the McDonald group (30.6% versus 58.3%, p = 0.033) but no significant differences in deliveries <28, 32 and 34 gestational weeks. No significant differences were found in neonatal complications except for respiratory distress syndrome (5.6% in Shirodkar versus 29.2% in McDonald, p = 0.023). CONCLUSION: In the setting of history-indicated or ultrasound-indicated cerclage, Shirodkar was superior to McDonald in the prevention of late preterm birth and neonatal respiratory distress syndrome.


Assuntos
Cerclagem Cervical/métodos , Ruptura Prematura de Membranas Fetais/prevenção & controle , Trabalho de Parto Prematuro/prevenção & controle , Nascimento Prematuro/prevenção & controle , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle , Adulto , Medida do Comprimento Cervical , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Modelos Logísticos , Gravidez , Resultado da Gravidez , Análise de Regressão , Estudos Retrospectivos
18.
Fetal Diagn Ther ; 42(1): 28-34, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27656888

RESUMO

OBJECTIVE: To present the feasibility of fetal myelomeningocele (MMC) repair through a mini-hysterotomy and to describe the perinatal results from our initial experience. METHODS: A descriptive study of cases of fetal MMC correction via mini-hysterotomy performed between 2014 and 2016. RESULTS: Forty-five women underwent fetal surgery and 87% (39/45) delivered. A complete multilayer correction of the MMC was possible in all cases. There were no maternal, fetal or neonatal deaths. No maternal or fetal complications occurred from fetal MMC correction until maternal hospital discharge. The average gestational age (GA) at surgery was 24.5 weeks (standard deviation, SD: 1.7; range: 20.7-26.9). The median hysterotomy length was 3.05 cm (SD: 0.39; range: 2.50-3.50). One patient (1/39; 2.6%) experienced chorioamniotic separation. Nine patients (9/39; 23.1%) had premature preterm rupture of membranes at a median GA of 34.1 weeks (range: 31.1-36.0). The average GA at delivery was 35.3 weeks (SD: 2.2; range: 27.9-39.1). Ninety-five percent (37/39) of our patients had an intact hysterotomy site at delivery. Ventriculoperitoneal shunt placement was necessary for 7.7% (3/39) of the neonates. CONCLUSION: Fetal MMC repair is feasible through a mini-hysterotomy. This approach appears to be associated with reduced risks of very preterm delivery and maternal, fetal and neonatal complications.


Assuntos
Histerotomia/efeitos adversos , Meningomielocele/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Adulto , Malformação de Arnold-Chiari/etiologia , Malformação de Arnold-Chiari/prevenção & controle , Brasil/epidemiologia , Estudos de Viabilidade , Feminino , Ruptura Prematura de Membranas Fetais/epidemiologia , Ruptura Prematura de Membranas Fetais/etiologia , Ruptura Prematura de Membranas Fetais/prevenção & controle , Seguimentos , Idade Gestacional , Humanos , Hidrocefalia/etiologia , Hidrocefalia/prevenção & controle , Hidrocefalia/cirurgia , Incidência , Recém-Nascido , Masculino , Meningomielocele/embriologia , Meningomielocele/fisiopatologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Gravidez , Segundo Trimestre da Gravidez , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Nascimento Prematuro/prevenção & controle , Risco , Derivação Ventriculoperitoneal/efeitos adversos
19.
Fetal Diagn Ther ; 42(1): 9-16, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27577884

RESUMO

INTRODUCTION: Umbilical cord occlusion (UCO) utilizing laser photocoagulation is often not considered an option for selective termination after 20 weeks of gestation due to reported limitations of the procedure because of umbilical cord size. We compared outcomes after laser umbilical cord occlusion (L-UCO) before and after 20 weeks of gestation. MATERIALS AND METHODS: We examined all patients with monochorionic- diamniotic twins and higher-order multiples (monoamniotic excluded) that underwent L-UCO at our facility between 2006 and 2014. Statistical analysis was performed using Fisher's exact and Kruskal-Wallis tests as appropriate. RESULTS: Of 43 L-UCO cases, 11 cases (25.6%) had a discordant anomaly, and 32 cases (74.4%) had twin reversed arterial perfusion (TRAP) sequence. We achieved complete vascular occlusion in 100% (43/43) of cases of attempted L-UCO. There were 22 cases (51.2%) with gestational age ≤20 weeks, and 21 cases (48.8%) with gestational age >20 weeks. Perioperative patient characteristics and outcomes did not differ between the two groups. Survival rates were 90.9% (20/22) and 100% (21/21) at ≤20 weeks of gestation and >20 weeks of gestation, respectively. DISCUSSION: The results of this study suggest that L-UCO is a reasonable surgical modality for patients prior to and beyond 20 weeks of gestation.


Assuntos
Fotocoagulação a Laser/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Redução de Gravidez Multifetal/efeitos adversos , Oclusão Terapêutica/efeitos adversos , Cordão Umbilical/cirurgia , Adulto , Anormalidades Congênitas/diagnóstico por imagem , Anormalidades Congênitas/embriologia , Doenças em Gêmeos/diagnóstico por imagem , Doenças em Gêmeos/embriologia , Feminino , Doenças Fetais/diagnóstico por imagem , Ruptura Prematura de Membranas Fetais/epidemiologia , Ruptura Prematura de Membranas Fetais/etiologia , Ruptura Prematura de Membranas Fetais/prevenção & controle , Humanos , Los Angeles/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/prevenção & controle , Gravidez , Segundo Trimestre da Gravidez , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Nascimento Prematuro/prevenção & controle , Estudos Retrospectivos , Risco , Análise de Sobrevida , Ultrassonografia Doppler em Cores , Ultrassonografia Pré-Natal
20.
Acta Obstet Gynecol Scand ; 96(3): 263-273, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28029178

RESUMO

INTRODUCTION: The incidence of overweight and obesity in pregnancy has risen significantly in the last decades. Overweight and obesity have been shown to increase the risk for some adverse obstetric outcomes. Lifestyle interventions, such as diet, physical activity and behavior changes, may reduce these risks by promoting weight loss and/or preventing excessive weight gain. The possible impact of exercise on the risk of preterm birth (PTB) in overweight or obese women is controversial. Therefore, the aim of our study was to evaluate the effect of exercise on the risk of PTB in overweight or obese pregnant women. MATERIAL AND METHODS: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library were searched from their inception to November 2016. This meta-analysis included only randomized controlled trials (RCTs) of pregnant women assigned or not assigned before 25 weeks to an aerobic exercise regimen. Types of participants included overweight or obese (mean body mass index ≥25 kg/m2 ) women with singleton pregnancies without any contraindication to physical activity. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI). The primary outcome was the incidence of PTB <37 weeks. RESULTS: Nine trials including 1502 overweight or obese singleton gestations were analyzed. Overweight and obese women who were randomized in early pregnancy to aerobic exercise for about 30-60 min three to seven times per week had a lower percentage of PTB <37 weeks (RR 0.62, 95% CI 0.41-0.95) compared with controls. The incidence of gestational age at delivery (MD 0.09 week, 95% CI -0.18 to 0.24) and cesarean delivery (RR 0.93, 95% CI 0.77-1.10) were similar in both groups. Women in the exercise group had a lower incidence of gestational diabetes mellitus (RR 0.61, 95% CI 0.41-0.90) compared with controls. No differences in birthweight (MD 16.91 g, 95% CI -89.33 to 123.19), low birthweight (RR 0.58, 95% CI 0.25-1.34), macrosomia (RR 0.92, 95% CI 0.72-1.18) and stillbirth (RR 2.13, 95% CI 0.22-20.4) between the exercise group and controls were found. CONCLUSIONS: Overweight and obese women with singleton pregnancy can be counseled that, compared with being more sedentary, aerobic exercise for about 30-60 min three to seven times per week during pregnancy is associated with a reduction in the incidence of PTB. Aerobic exercise in overweight and obese pregnant women is also associated with a significant prevention of gestational diabetes mellitus, and should therefore be encouraged.


Assuntos
Exercício , Ruptura Prematura de Membranas Fetais/epidemiologia , Obesidade , Complicações na Gravidez , Feminino , Ruptura Prematura de Membranas Fetais/etiologia , Ruptura Prematura de Membranas Fetais/prevenção & controle , Humanos , Sobrepeso , Gravidez , Cuidado Pré-Natal , Fatores de Risco
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