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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.
PLoS Med ; 16(12): e1002988, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31809499

RESUMO

BACKGROUND: There is widespread, increasing use of magnesium sulphate in obstetric practice for pre-eclampsia, eclampsia, and preterm fetal neuroprotection; benefit for preventing preterm labour and birth (tocolysis) is unproven. We conducted a systematic review and meta-analysis to assess whether antenatal magnesium sulphate is associated with unintended adverse neonatal outcomes. METHODS AND FINDINGS: CINAHL, Cochrane Library, LILACS, MEDLINE, Embase, TOXLINE, and Web of Science, were searched (inceptions to 3 September 2019). Randomised, quasi-randomised, and non-randomised trials, cohort and case-control studies, and case reports assessing antenatal magnesium sulphate for pre-eclampsia, eclampsia, fetal neuroprotection, or tocolysis, compared with placebo/no treatment or a different magnesium sulphate regimen, were included. The primary outcome was perinatal death. Secondary outcomes included pre-specified and non-pre-specified adverse neonatal outcomes. Two reviewers screened 5,890 articles, extracted data, and assessed risk of bias following Cochrane Handbook and RTI Item Bank guidance. For randomised trials, pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), were calculated using fixed- or random-effects meta-analysis. Non-randomised data were tabulated and narratively summarised. We included 197 studies (40 randomised trials, 138 non-randomised studies, and 19 case reports), of mixed quality. The 40 trials (randomising 19,265 women and their babies) were conducted from 1987 to 2018 across high- (16 trials) and low/middle-income countries (23 trials) (1 mixed). Indications included pre-eclampsia/eclampsia (24 trials), fetal neuroprotection (7 trials), and tocolysis (9 trials); 18 trials compared magnesium sulphate with placebo/no treatment, and 22 compared different regimens. For perinatal death, no clear difference in randomised trials was observed between magnesium sulphate and placebo/no treatment (RR 1.01; 95% CI 0.92 to 1.10; 8 trials, 13,654 babies), nor between regimens. Eleven of 138 non-randomised studies reported on perinatal death. Only 1 cohort (127 babies; moderate to high risk of bias) observed an increased risk of perinatal death with >48 versus ≤48 grams magnesium sulphate exposure for tocolysis. No clear secondary adverse neonatal outcomes were observed in randomised trials, and a very limited number of possible adverse outcomes warranting further consideration were identified in non-randomised studies. Where non-randomised studies observed possible harms, often no or few confounders were controlled for (moderate to high risk of bias), samples were small (200 babies or fewer), and/or results were from subgroup analyses. Limitations include missing data for important outcomes across most studies, heterogeneity of included studies, and inclusion of published data only. CONCLUSIONS: Our findings do not support clear associations between antenatal magnesium sulphate for beneficial indications and adverse neonatal outcomes. Further large, high-quality studies (prospective cohorts or individual participant data meta-analyses) assessing specific outcomes, or the impact of regimen, pregnancy, or birth characteristics on these outcomes, would further inform safety recommendations. PROSPERO: CRD42013004451.


Assuntos
Eclampsia/tratamento farmacológico , Sulfato de Magnésio , Trabalho de Parto Prematuro/tratamento farmacológico , Nascimento Prematuro/prevenção & controle , Estudos de Casos e Controles , Eclampsia/prevenção & controle , Feminino , Humanos , Sulfato de Magnésio/efeitos adversos , Sulfato de Magnésio/uso terapêutico , Trabalho de Parto Prematuro/prevenção & controle , Parto/efeitos dos fármacos , Pré-Eclâmpsia/tratamento farmacológico , Gravidez , Cuidado Pré-Natal/métodos , Estudos Prospectivos
3.
Medicine (Baltimore) ; 98(50): e18190, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31852074

RESUMO

The purpose of this study was to evaluate the association between tocolysis for preterm uterine contraction and the risk of nonreassuring fetal status.This was a retrospective cohort study using data from the Taiwan National Health Insurance Research Database. Pregnant women were enrolled if they delivered a baby during January 1, 2003 to December 31, 2011. The occurrence of the nonreassuring fetal status was compared between pregnant women with and without tocolytic treatment for preterm uterine contraction. Multivariable logistic regression models with adjusted cofounders were used to evaluate the association between tocolysis and the risk of nonreassuring fetal status.Of 24,133 pregnant women, 1115 (4.6%) received tocolytic treatment during pregnancy. After adjusting for covariates, pregnant women receiving tocolysis more than one time during pregnancy were found to have significantly higher risk of the nonreassuring fetal status when compared with pregnant women who did not receive tocolysis for uterine contraction (Odds Ratio = 2.70, 95% Confidence Interval: 1.13-6.49).Pregnant women with more frequent tocolysis for preterm uterine contraction during pregnancy had an increased risk of nonreassuring fetal status. Close evaluation of dose and duration of tocolytic treatment is necessary for pregnant women with preterm uterine contraction.


Assuntos
Sofrimento Fetal/prevenção & controle , Trabalho de Parto Prematuro/prevenção & controle , Vigilância da População , Tocólise/métodos , Tocolíticos/uso terapêutico , Adulto , Feminino , Seguimentos , Humanos , Incidência , Recém-Nascido , Trabalho de Parto Prematuro/epidemiologia , Gravidez , Estudos Retrospectivos , Taiwan/epidemiologia
4.
Cochrane Database Syst Rev ; 9: CD007235, 2019 09 25.
Artigo em Inglês | MEDLINE | ID: mdl-31553800

RESUMO

BACKGROUND: Measurement of cervical length by ultrasound is predictive of preterm birth (PTB). There are three methods of ultrasound cervical assessment: transvaginal (TVU), transabdominal (TAU), and transperineal (TPU, also called translabial). Cervical length measured by TVU is a relatively new screening test, and has been associated with better prediction of PTB than previously available tests. It is unclear if cervical length measured by ultrasound is effective for preventing PTB. This is an update of a review last published in 2013. OBJECTIVES: To assess the effectiveness of antenatal management based on transvaginal, transabdominal, and transperineal (also called translabial) ultrasound screening of cervical length for preventing preterm birth. SEARCH METHODS: For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) to 30 August 2018; reviewed the reference lists of all articles, and contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA: We included published and unpublished randomised controlled trials (RCT) including pregnant women between the gestational ages of 14 to 32 weeks, for whom the cervical length was screened for risk of PTB with TVU, TAU, or TPU. This review focused on studies based on knowledge versus no knowledge of cervical length results, or ultrasound versus no ultrasound for cervical length. We excluded studies based on interventions (e.g. progesterone, cerclage) for short cervical length. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. MAIN RESULTS: We included seven RCTs (N = 923): one examined asymptomatic women with twin pregnancies; four included women with singleton pregnancies and symptoms of preterm labour (PTL); one included women with singleton pregnancies and symptoms of preterm premature rupture of membranes (PPROM); and one included asymptomatic singletons. All trials used TVU for screening.We assessed the risk of bias of the included studies as mixed, and the quality of the evidence for primary outcomes as very low for all populations.For asymptomatic women with twin pregnancies, it is uncertain whether knowledge of TVU-measured cervical length compared to no knowledge reduces PTB at less than 34 weeks (risk ratio (RR) 0.62, 95% confidence intervals (CI) 0.30 to 1.25; 1 study, 125 participants) because the quality of the evidence is very low. The results were also inconclusive for preterm birth at 36, 32, or 30 weeks; gestational age at birth, and other maternal and perinatal outcomes.Four trials examined knowledge of TVU-measured cervical length of singletons with symptoms of PTL versus no knowledge. We are uncertain of the effects because of inconclusive results and very low-quality evidence for: preterm births at less than 37 weeks (average RR 0.59, 95% CI 0.26 to 1.32; 2 studies, 242 participants; I² = 66%; Tau² = 0.23). Birth occurred about four days later in the knowledge groups (mean difference (MD) 0.64 weeks, 95% CI 0.03 to 1.25; 3 trials, 290 women). The results were inconclusive for the other outcomes for which there were available data: PTB at less than 34 or 28 weeks; birthweight less than 2500 g; perinatal death; maternal hospitalisation; tocolysis; and steroids for fetal lung maturity.The trial of singletons with PPROM (N = 92) evaluated safety of using TVU to measure cervical length in this population as its primary outcome, not its effect on management. The results were inconclusive for incidence of maternal and neonatal infections between the TVU and no ultrasound groups.In the trial of asymptomatic singletons (N = 296), in which women either received TVU or not, the results were inconclusive for preterm birth at less than 37 weeks (RR 1.27, 95% CI 0.61 to 2.61; I² = 0%), gestational age at birth, and other perinatal and maternal outcomes.We downgraded evidence for limitations in study design, inconsistency between the trials, and imprecision, due to small sample size and wide confidence intervals crossing the line of no effect.No trial compared the effect of knowledge of the CL with no knowledge of CL in other populations, such as asymptomatic women with singleton pregnancies, or symptomatic women with twin pregnancies. AUTHORS' CONCLUSIONS: There are limited data on the effects of knowing the cervical length, measured by ultrasound, for preventing preterm births, which preclude us from drawing any conclusions for women with asymptomatic twin or singleton pregnancies, singleton pregnancies with PPROM, or other populations and clinical scenarios.Limited evidence suggests that knowledge of transvaginal ultrasound-measured cervical length, used to inform the management of women with singleton pregnancies and symptoms of preterm labour, appears to prolong pregnancy by about four days over women in the no knowledge groups.Future studies could look at specific populations separately (e.g. singleton versus twins; symptoms versus no symptoms of PTL), report on all pertinent maternal and perinatal outcomes, and include cost-effectiveness analyses. Most importantly, future studies should include a clear protocol for management of women based on TVU-measured cervical length.


Assuntos
Medida do Comprimento Cervical/métodos , Colo do Útero/diagnóstico por imagem , Trabalho de Parto Prematuro/prevenção & controle , Nascimento Prematuro/prevenção & controle , Feminino , Humanos , Gravidez , Gravidez Múltipla , Gravidez de Gêmeos , Nascimento Prematuro/diagnóstico por imagem , Ensaios Clínicos Controlados Aleatórios como Assunto
5.
Cochrane Database Syst Rev ; 7: CD006843, 2019 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-31356681

RESUMO

BACKGROUND: Fetal fibronectin (FFN) is an extracellular matrix glycoprotein localized at the maternal-fetal interface of the amniotic membranes, between chorion and decidua, where it is concentrated in this area between decidua and trophoblast. In normal conditions, FFN is found at very low levels in cervicovaginal secretions. Levels greater than or equal to 50 ng/mL at or after 22 weeks have been associated with an increased risk of spontaneous preterm birth. In fact, FFN is one of the best predictors of preterm birth in all populations studied so far, and can help in selecting which women are at significant risk for preterm birth. This is an update of a review first published in 2008. OBJECTIVES: To assess the effectiveness of management based on knowledge of FFN testing results for preventing preterm birth. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (7 September 2018), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 September 2018), and reference lists of retrieved studies. SELECTION CRITERIA: Randomized controlled trials of pregnant women screened with FFN for risk of preterm birth. Studies included are based exclusively on knowledge of FFN results versus no such knowledge, and we have excluded studies including women with only positive or only negative FFN results. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: We identified 16 trials, of which six were eligible for inclusion. The six included studies randomized 546 women with singleton gestations and threatened preterm labor (PTL) at 23 0/7 to 34 6/7 weeks. A total of 277 women were randomized to knowledge and 269 to no knowledge of FFN. No trials were identified on asymptomatic women or multiple gestations.The risk of bias of included studies was mixed. For selected important outcomes, preterm birth before 37, 34, and 32 weeks, and maternal hospitalization, we graded the quality of the evidence and created a 'Summary of findings' table. For these outcomes, the evidence was graded as mainly low quality due to the imprecision of effect estimates.Management based on knowledge of FFN results may reduce preterm birth before 37 weeks (21.6%) versus controls without such knowledge (29.2%) (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.52 to 1.01; 4 trials; 357 women; low-quality evidence). However, management based on knowledge of FFN results may make little or no difference to preterm birth before 34 (RR 1.09, 95% CI 0.54 to 2.18; 4 trials; 357 women; low-quality evidence) or maternal hospitalization (RR 1.06, 95% CI 0.79 to 1.43; 5 trials; 441 women; low-quality evidence). The evidence for preterm birth before 32 weeks is uncertain because the quality was found to be very low (average RR 0.79, 95% CI 0.16 to 3.96; 4 trials; 357 women; very low-quality evidence).For all other outcomes, for which there were available data (preterm birth less than 28 weeks; gestational age at delivery (weeks); birthweight less than 2500 g; perinatal death; tocolysis; steroids for fetal lung maturity; time to evaluate; respiratory distress syndrome; neonatal intensive care unit (NICU) admission; and NICU days), knowledge of FFN results may make little or no difference to the outcomes. AUTHORS' CONCLUSIONS: The evidence from this review suggests that management based on knowledge of FFN results may reduce preterm birth before 37 weeks. However, our confidence in this result is limited as the evidence was found to be of low quality. Effects on other substantive outcomes are uncertain due to serious concerns in study design, inconsistency, and imprecision of effect estimates. No trials were identified on asymptomatic women, or multiple gestations.Future studies are needed that include specific populations (e.g. singleton gestations with symptoms of preterm labor), a study group managed with a protocol based on the FFN results, and that report not only maternal but also important perinatal outcomes. Cost-effectiveness analyses are also needed.


Assuntos
Fibronectinas/uso terapêutico , Trabalho de Parto Prematuro/prevenção & controle , Nascimento Prematuro/prevenção & controle , Biomarcadores/análise , Feminino , Fibronectinas/análise , Idade Gestacional , Humanos , Recém-Nascido , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle
6.
Prog. obstet. ginecol. (Ed. impr.) ; 62(3): 303-314, mayo-jun. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-185015

RESUMO

Objetivo: examinar en la literatura científica la influencia del ejercicio físico durante el embarazo en la edad gestacional en semanas al momento del parto y el número de parto a pretérmino. Material y métodos: se llevó a cabo una revisión sistemática y meta-análisis. Se examinaron ensayos clínicos aleatorizados. Se analizó, por un lado la edad gestacional en semanas al momento del parto así como el número y porcentajes de partos a pretérmino en los grupos de estudio. Resultados: se analizaron 43 estudios. Se observó de forma general un efecto mínimo entre la práctica de ejercicio físico moderado durante el embarazo y la duración del embarazo (95% IC= -0.11, .03; I2= 54,1%, Pheterogeneidad= 0.001). Por otro lado, los estudios muestran que las mujeres que permanecen inactivas presentan un 7 % más de probabilidad de experimentar un parto a pretérmino (RR = 0.93 [95% IC= .79 - 1.09] I2= 0.0 %, Pheterogeneidad= 0.918). Conclusiones: el ejercicio físico moderado durante el embarazo no muestra asociación con la duración del embarazo a la hora del parto y reduce levemente la probabilidad de parto a pretérmino en gestantes sanas


Objective: To examine the influence of exercise during pregnancy on the gestational age in weeks at the time of delivery and the number of preterm delivery in the scientific literature. Material and methods: We performed a systematic review and meta-analysis, only randomized clinical trials were examined. Gestational age in weeks and the number and percentage of preterm delivery were analized. Results: We analyzed 43 studies and found a minimal effect between moderate exercise during pregnancy and duration of pregnancy (95% IC= -0.11, .03; I2= 54,1%, Pheterogeneity= 0.001). On the other hand, the studies also showed that the inactive women present a 7 % more probability of suffer a preterm delivery (RR = 0.93 [95% IC= .79 - 1.09] I2= 0.0 %, Pheterogeneity= 0.918). Conclusions: Moderate exercise during pregnancy shows no association with the duration of pregnancy at the time of delivery and reduces the incidence of preterm delivery


Assuntos
Humanos , Feminino , Gravidez , Exercício/fisiologia , Idade Gestacional , Complicações na Gravidez/prevenção & controle , Trabalho de Parto Prematuro/prevenção & controle , Terapia por Exercício/estatística & dados numéricos , Resultado do Tratamento
7.
Int J Gynaecol Obstet ; 146(3): 271-276, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31022300

RESUMO

BACKGROUND: Controversy exists regarding the benefits of treating bacterial vaginosis (BV) during pregnancy to reduce the incidence of preterm labor (PTL). OBJECTIVES: To evaluate whether treatment of BV with vaginal clindamycin or oral metronidazole before 28 weeks of pregnancy reduces PTL incidence. SEARCH STRATEGY: PubMed, Scopus, Web of Science, Science Direct, CENTRAL, and SciELO databases were searched until December 30, 2017. Search terms included "bacterial vaginosis" and "preterm labor." No language restrictions were applied. SELECTION CRITERIA: Randomized clinical trials that evaluated treatment of BV with clindamycin or metronidazole to reduce PTL incidence. DATA COLLECTION AND ANALYSIS: The risk of PTL was evaluated by the odds ratio (OR) and 95% confidence interval (CI). Dichotomous data from each study were combined for meta-analysis using the Mantel-Haenszel model. MAIN RESULTS: Nine reports were included in the systematic review, with eight reports included in the meta-analysis. No reduction in the incidence of PTL was found for either metronidazole (OR 0.94, 95% CI 0.71-1.25) or clindamycin (OR 1.01, 95% CI 0.75-1.36). CONCLUSIONS: Use of oral metronidazole or vaginal clindamycin to treat BV before 28 weeks of pregnancy did not reduce the incidence of PTL. PROSPERO registration: CRD42018086173.


Assuntos
Antibacterianos/administração & dosagem , Clindamicina/administração & dosagem , Metronidazol/administração & dosagem , Trabalho de Parto Prematuro/prevenção & controle , Complicações Infecciosas na Gravidez/tratamento farmacológico , Vaginose Bacteriana/tratamento farmacológico , Administração Intravaginal , Administração Oral , Feminino , Humanos , Incidência , Recém-Nascido , Trabalho de Parto Prematuro/epidemiologia , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
8.
Clin Perinatol ; 46(2): 159-172, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31010553

RESUMO

Preterm birth can be medically-indicated or spontaneous. Almost half of spontaneous preterm deliveries are preceded by preterm labor. Preterm labor is a clinical diagnosis characterized by regular uterine contractions (painful or painless) with concomitant cervical change. This article discusses the prevention and treatment of spontaneous preterm labor utilizing progesterone and tocolytic agents and provides management recommendations in patients with and without a history of prior spontaneous preterm birth.


Assuntos
Trabalho de Parto Prematuro/tratamento farmacológico , Trabalho de Parto Prematuro/prevenção & controle , Progesterona/uso terapêutico , Progestinas/uso terapêutico , Tocolíticos/uso terapêutico , Agonistas Adrenérgicos beta/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Bloqueadores dos Canais de Cálcio , Inibidores de Ciclo-Oxigenase/uso terapêutico , Feminino , Humanos , Sulfato de Magnésio/uso terapêutico , Doadores de Óxido Nítrico/uso terapêutico , Gravidez , Receptores de Ocitocina/antagonistas & inibidores
9.
J Gynecol Obstet Hum Reprod ; 48(7): 501-507, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30980998

RESUMO

INTRODUCTION: Very preterm delivery (22-32 weeks of gestation) remains a major cause of neonatal morbidity and mortality. The objective of this study was to validate a statistical model allowing to predict the risk of preterm delivery to use as a clinical decision-making tool for in utero transfer from a secondary to a tertiary care center. METHODS: Retrospective observational study in a secondary care center (approximately 2500 births) in Paris, France. 137 women were admitted for threatened preterm delivery between 22 and 32 weeks. Women were retrospectively allocated to the following groups based on medical decision: "transfer group" (in utero transfer to a tertiary care unit) and "no transfer group" (no in utero transfer). The risk of preterm delivery within 48 h and before 32 weeks gestation was assessed for each group using a nomogram previously validated in a tertiary care center. The primary objective of the study was to determine the accuracy of the prediction model. RESULTS: The discrimination and calibration of the nomogram were excellent (preterm delivery risk within 48 h, ROC AUC: 0.98, 95% CI: 0.95-1.00; probability of preterm delivery before 32 weeks gestation, ROC AUC: 0.94, 95% CI: 0.89-0.99). A threshold set at 0.16 helped minimize the risk of unnecessary in utero transfers with an excellent negative predictive value of 0.99. CONCLUSIONS: We validated nomograms to predict the individual probability of preterm birth after admission in a secondary care center. Those nomograms could be helpful when making decisions regarding an in utero transfer to a tertiary care unit.


Assuntos
Nomogramas , Trabalho de Parto Prematuro/diagnóstico , Nascimento Prematuro/diagnóstico , Adulto , Tomada de Decisões , Técnicas de Apoio para a Decisão , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido de muito Baixo Peso , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Nascimento Prematuro/prevenção & controle , Prognóstico , Estudos Retrospectivos , Medição de Risco , Centros de Cuidados de Saúde Secundários , Adulto Jovem
10.
PLoS Med ; 16(4): e1002771, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30978205

RESUMO

BACKGROUND: Infants born preterm compared with infants born at term are at an increased risk of dying and of serious morbidities in early life, and those who survive have higher rates of neurological impairments. It remains unclear whether exposure to repeat courses of prenatal corticosteroids can reduce these risks. This individual participant data (IPD) meta-analysis (MA) assessed whether repeat prenatal corticosteroid treatment given to women at ongoing risk of preterm birth in order to benefit their infants is modified by participant or treatment factors. METHODS AND FINDINGS: Trials were eligible for inclusion if they randomised women considered at risk of preterm birth who had already received an initial, single course of prenatal corticosteroid seven or more days previously and in which corticosteroids were compared with either placebo or no placebo. The primary outcomes for the infants were serious outcome, use of respiratory support, and birth weight z-scores; for the children, they were death or any neurosensory disability; and for the women, maternal sepsis. Studies were identified using the Cochrane Pregnancy and Childbirth search strategy. Date of last search was 20 January 2015. IPD were sought from investigators with eligible trials. Risk of bias was assessed using criteria from the Cochrane Collaboration. IPD were analysed using a one-stage approach. Eleven trials, conducted between 2002 and 2010, were identified as eligible, with five trials being from the United States, two from Canada, and one each from Australia and New Zealand, Finland, India, and the United Kingdom. All 11 trials were included, with 4,857 women and 5,915 infants contributing data. The mean gestational age at trial entry for the trials was between 27.4 weeks and 30.2 weeks. There was no significant difference in the proportion of infants with a serious outcome (relative risk [RR] 0.92, 95% confidence interval [CI] 0.82 to 1.04, 5,893 infants, 11 trials, p = 0.33 for heterogeneity). There was a reduction in the use of respiratory support in infants exposed to repeat prenatal corticosteroids compared with infants not exposed (RR 0.91, 95% CI 0.85 to 0.97, 5,791 infants, 10 trials, p = 0.64 for heterogeneity). The number needed to treat (NNT) to benefit was 21 (95% CI 14 to 41) women/fetus to prevent one infant from needing respiratory support. Birth weight z-scores were lower in the repeat corticosteroid group (mean difference -0.12, 95%CI -0.18 to -0.06, 5,902 infants, 11 trials, p = 0.80 for heterogeneity). No statistically significant differences were seen for any of the primary outcomes for the child (death or any neurosensory disability) or for the woman (maternal sepsis). The treatment effect varied little by reason the woman was considered to be at risk of preterm birth, the number of fetuses in utero, the gestational age when first trial treatment course was given, or the time prior to birth that the last dose was given. Infants exposed to between 2-5 courses of repeat corticosteroids showed a reduction in both serious outcome and the use of respiratory support compared with infants exposed to only a single repeat course. However, increasing numbers of repeat courses of corticosteroids were associated with larger reductions in birth z-scores for weight, length, and head circumference. Not all trials could provide data for all of the prespecified subgroups, so this limited the power to detect differences because event rates are low for some important maternal, infant, and childhood outcomes. CONCLUSIONS: In this study, we found that repeat prenatal corticosteroids given to women at ongoing risk of preterm birth after an initial course reduced the likelihood of their infant needing respiratory support after birth and led to neonatal benefits. Body size measures at birth were lower in infants exposed to repeat prenatal corticosteroids. Our findings suggest that to provide clinical benefit with the least effect on growth, the number of repeat treatment courses should be limited to a maximum of three and the total dose to between 24 mg and 48 mg.


Assuntos
Corticosteroides/administração & dosagem , Corticosteroides/efeitos adversos , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/prevenção & controle , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Adulto , Ensaios Clínicos como Assunto/estatística & dados numéricos , Esquema de Medicação , Feminino , Humanos , Recém-Nascido , Trabalho de Parto Prematuro/epidemiologia , Trabalho de Parto Prematuro/prevenção & controle , Parto/efeitos dos fármacos , Gravidez , Nascimento Prematuro/epidemiologia , Efeitos Tardios da Exposição Pré-Natal/induzido quimicamente , Recidiva , Medição de Risco , Fatores de Risco , Adulto Jovem
11.
Am J Obstet Gynecol ; 221(1): 55.e1-55.e14, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30826339

RESUMO

BACKGROUND: No intervention has proved effective to date in reducing the spontaneous preterm birth rate in twin pregnancies following an episode of threatened preterm labor and with a short cervix remaining. This study was designed to ascertain whether cervical pessaries are useful in preventing spontaneous preterm birth in women with twin pregnancies and a short cervix remaining after a threatened preterm labor episode. STUDY DESIGN: This open, randomized, controlled trial was conducted in 132 pregnant women who had not delivered 48 hours after a threatened preterm labor episode and had a short cervix remaining (≤20 mm between 240 and 296 weeks and ≤10 mm between 300 and 336 weeks). Patients were randomly assigned to cervical pessary (n = 67) or routine management (n = 65). The primary outcome was the spontaneous preterm birth rate before 34 weeks. Spontaneous preterm birth before 28 and 37 weeks and neonatal morbidity and mortality were also evaluated in an intention-to-treat analysis. RESULTS: Significant differences were observed in the spontaneous preterm birth rate before 34 weeks between the pessary and routine management groups (11 of 67 [16.4%] in the pessary group vs 21 of 65 [32.3%] in the control group; relative risk, 0.51 [confidence interval, 0.27-0.97]; P = .03). No significant differences were observed in the preterm birth rate < 28 weeks or < 37 weeks between groups. The pessary group less frequently required readmission for new threatened preterm labor episodes (4 of 67 [5.6%] vs 14 of 65 [21.5%]; relative risk, 0.28 [confidence interval, 0.10-0.80]; P = .009). Significant reduction was observed in the number of neonates weighing less than 2500 g (17.9% [24 of 134] vs 70.8% [92 of 130]; relative risk, 0.25 [confidence interval, 0.15-0.43]; P < .0001). CONCLUSION: Pessary use did significantly lower the spontaneous preterm birth rate before 34 weeks in twin pregnancies with maternal short cervix remaining after a threatened preterm labor episode. Pessary use also reduced the threatened preterm labor recurrence and neonates' weight less than 2500 g.


Assuntos
Colo do Útero/diagnóstico por imagem , Trabalho de Parto Prematuro/prevenção & controle , Pessários , Gravidez de Gêmeos , Nascimento Prematuro/prevenção & controle , Adulto , Medida do Comprimento Cervical , Feminino , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Trabalho de Parto Prematuro/tratamento farmacológico , Gravidez , Complicações na Gravidez/diagnóstico por imagem , Complicações na Gravidez/terapia , Recidiva , Tocolíticos/uso terapêutico
12.
BMC Pregnancy Childbirth ; 19(1): 68, 2019 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-30760248

RESUMO

BACKGROUND: Accurate diagnosis of preterm labour is needed to ensure correct management of those most at risk of preterm birth and to prevent the maternal and fetal risks incurred by unnecessary interventions given to the large majority of women, who do not deliver within a week of presentation. Intervention "just-in-case" results in many avoidable admissions, women being transferred out of their local hospital unnecessarily and most women receiving unwarranted drugs, such as steroids and tocolytics. It also precludes appropriate transfers for others as neonatal cots are blocked pre-emptively, resulting in more dangerous ex-utero transfers. We have developed the QUiPP App which is a clinical decision-making aid based on previous outcomes of women, quantitative fetal fibronectin (qfFN) values and cervical length. It is hypothesised that using the QUiPP app will reduce inappropriate admissions and transfers. METHODS: A multi-site cluster randomised trial will evaluate whether the QUiPP app reduces inappropriate management for threatened preterm labour. The 13 participating centres will be randomly allocated to receive either intervention or control. If the QUiPP app calculates risk of delivery within 7 days to be is less than 5%, clinicians are advised that interventions may be withheld. Women's experience of threatened preterm labour assessment will be explored using self-completed questionnaires, with a subset of participants being invited to semi-structured interview. A health economics analysis is also planned. DISCUSSION: We hypothesise that the QUiPP app will improve identification of the most appropriate women for admission and transfer and ensure that therapies known to reduce risk of preterm neonatal morbidities are offered to those who need them. We will determine which women do not require these therapies, thereby reducing over-medicalisation and the associated maternal and fetal risks for these women. The findings will inform future national guidelines on threatened preterm labour. Beyond obstetrics, evaluating the impact of an app in an emergency setting, and our emphasis on balancing harms of over-treatment as well as under-treatment, make EQUIPTT a valuable contribution to translational medicine. TRIAL REGISTRATION: The EQUIPTT trial was prospectively registered on 16th January 2018 with the ISRCTN registry (no. 17846337 ).


Assuntos
Tomada de Decisão Clínica/métodos , Fibronectinas/sangue , Trabalho de Parto Prematuro/prevenção & controle , Diagnóstico Pré-Natal/métodos , Medida do Comprimento Cervical , Feminino , Humanos , Recém-Nascido , Masculino , Estudos Multicêntricos como Assunto , Trabalho de Parto Prematuro/sangue , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Medição de Risco , Triagem
14.
Early Hum Dev ; 130: 57-64, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30677639

RESUMO

BACKGROUND: Betamethasone is widely used to enhance fetal lung maturation in case of threatened preterm birth. Antenatal corticosteroids are known to reduce fetal heart rate variability (fHRV) in the days following administration. Since decreased fHRV is a marker for fetal distress, this transient decrease of fHRV can cause unnecessary medical intervention. AIM: To describe the effect of betamethasone on fHRV, by applying spectral analysis on non-invasive fetal electrocardiogram (fECG) recordings. STUDY DESIGN: Secondary analysis of a prospective cohort study. SUBJECTS: Women with a singleton pregnancy, at risk for preterm delivery and receiving betamethasone, admitted to the obstetric high care unit in the period from March 2013 until July 2016. OUTCOME MEASURES: The primary outcome measure was fHRV in both time- and frequency-domain. Secondary outcome measures included basal fetal heart rate (fHR) and fHR variance. FHRV parameters were then calculated separately for the quiet and active state. RESULTS: Following 68 inclusions, 22 patients remained with complete series of measurements and sufficient data quality. FHRV parameters and fHR showed a decrease on day 2 compared to day 1, significant for short-term variability and high-frequency power. Similar results were found when analyzing for separate behavioral states. The number of segments in quiet state increased during days 1 and 2. Normalized values showed no difference for all behavioral states. CONCLUSION: FHRV decreases on day 2 after betamethasone administration, while periods of fetal quiescence increase. No changes were found in the normalized values, indicating that the influence of autonomic modulation is minor. Clinical trial registration number NL43294.015.13.


Assuntos
Betametasona/efeitos adversos , Glucocorticoides/efeitos adversos , Frequência Cardíaca Fetal/efeitos dos fármacos , Adulto , Betametasona/administração & dosagem , Betametasona/uso terapêutico , Eletrocardiografia/métodos , Feminino , Glucocorticoides/administração & dosagem , Glucocorticoides/uso terapêutico , Humanos , Trabalho de Parto Prematuro/tratamento farmacológico , Trabalho de Parto Prematuro/prevenção & controle , Gravidez
15.
J Matern Fetal Neonatal Med ; 32(22): 3757-3763, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29764255

RESUMO

Objective: To study the effect of McDonald cerclage knot position on the different maternal and neonatal outcomes. Methods: This historical cohort study included women with singleton pregnancy who had a prophylactic McDonald cervical cerclage between 1 May 2010 and 31 September 2017. Maternal and neonatal outcome parameters were compared between the anterior and posterior knot cerclage procedures. The primary outcome measure was the rate of term birth. Results: 550 Women had a prophylactic McDonald cervical cerclage, 306 with anterior knot (Group A) and 244 with posterior knot (Group B). There were no statistically significant differences regarding gestational age (GA) at delivery (36.3 ± 4.2 versus 35.8 ± 5.3 for groups A and B respectively), term birth rate, post-cerclage cervical length, symptomatic vaginitis, urinary tract infection, difficult cerclage removal and cervical lacerations. Similarly, there were no statistically significant differences as regards the studied neonatal outcomes including take home babies, neonatal intensive care admission, respiratory distress syndrome and neonatal sepsis. Survival analysis on GA at delivery demonstrated no statistically significant difference as regards the proportion of term deliveries in the anterior and posterior knot cerclage groups (log-rank test p-value = .478). Conclusions: Knot positioning during McDonald cervical cerclage, anteriorly or posteriorly, didn't significantly impact the studied maternal and neonatal outcomes.


Assuntos
Cerclagem Cervical/métodos , Trabalho de Parto Prematuro/prevenção & controle , Técnicas de Sutura , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/efeitos adversos , Cerclagem Cervical/mortalidade , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Lactente , Mortalidade Infantil , Masculino , Trabalho de Parto Prematuro/mortalidade , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/mortalidade , Nascimento Prematuro/prevenção & controle , Análise de Sobrevida , Técnicas de Sutura/efeitos adversos , Técnicas de Sutura/mortalidade , Incompetência do Colo do Útero/mortalidade , Adulto Jovem
16.
J Matern Fetal Neonatal Med ; 32(20): 3408-3414, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29712493

RESUMO

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes. Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25 kg/m2, overweight: 25-29 kg/m2, obese: 30 kg/m2 or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student's t-test, and multivariable regression analysis. Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0 ± 0.3 weeks; overweight: 36.6 ± 0.7 weeks; obese: 33.0 ± 1.1 weeks; p < .01). Overall, women receiving a Shirodkar cerclage had significantly longer pregnancies than women with a McDonald cerclage (36.7 ± 0.6 weeks versus 33.9 ± 1.0 weeks; p = .02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6 ± 1.0 weeks versus 28.8 ± 0.9 weeks; p < .01). However, there was no significant difference in gestational age at delivery between women categorized as normal/overweight (Shirodkar: 33.5 ± 0.9 weeks; McDonald: 32.9 ± 0.9 weeks; p = .63). Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.


Assuntos
Índice de Massa Corporal , Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Incompetência do Colo do Útero/cirurgia , Adulto , Cerclagem Cervical/mortalidade , Cerclagem Cervical/estatística & dados numéricos , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Mortalidade Materna , Trabalho de Parto Prematuro/epidemiologia , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Incompetência do Colo do Útero/epidemiologia
17.
J Perinat Med ; 47(2): 152-160, 2019 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-30352043

RESUMO

Uterine tachysystole (TS) is a potentially significant intrapartum complication seen most commonly in induced or augmented labors but may also occur in women with spontaneous labor. When it occurs, maternal and perinatal complications can arise if not identified and managed promptly by obstetric care providers. Over recent years, new definitions of the condition have facilitated further research into the field, which has been synthesized to inform clinical management guidelines and protocols. We propose a set of recommendations pertaining to TS in line with contemporary evidence and obstetric practice.


Assuntos
Complicações do Trabalho de Parto , Trabalho de Parto Prematuro , Tocólise/métodos , Contração Uterina , Cardiotocografia/métodos , Feminino , Humanos , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/etiologia , Complicações do Trabalho de Parto/fisiopatologia , Complicações do Trabalho de Parto/terapia , Trabalho de Parto Prematuro/etiologia , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Monitorização Uterina/métodos
18.
BJOG ; 126(6): 763-769, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30461172

RESUMO

OBJECTIVE: To identify the current status of specialist preterm labour (PTL) clinics and identify changes in management trends over the last 5 years following release of the NICE preterm birth (PTB) guidance. DESIGN: Postal Survey of Clinical Practice. SETTING: UK. POPULATION: All consultant-led obstetric units. METHODS: A questionnaire was sent by post to all 187 NHS consultant-led obstetric units. Units with a specialist PTL clinic were asked to answer a further six questions defining their protocol for risk stratification and management. MAIN OUTCOME MEASURES: Current practice in specialist PTL clinics. Changes in treatment trends over 5 years. RESULTS: Thirty-three PTL prevention clinics were identified, with 73% running weekly. NHS staff (84%) have replaced university staff as the lead clinicians (from 69% in 2012 to 21% in 2017), suggesting this clinic has become increasingly integrated with standard care for women at the highest risk of PTB. There has been a large shift from nearly half of clinics offering cerclage as primary treatment for short cervix to offering more choice (30%) between at least two of cerclage, vaginal progesterone or pessary and combinations of primary treatments (18%), demonstrating more equipoise among clinicians regarding therapies for short cervix. CONCLUSIONS: Over 5 years, there has been a 44% increase in the number of specialist PTL clinics in the UK. Although there is a better consensus over the target high-risk population, there is increasing heterogeneity among first-line treatments for short cervix. TWEETABLE ABSTRACT: UK PTB prevention clinics have increased by 44% over 5 years, with increasing clinical equipoise to best Rx for short cervix.


Assuntos
Trabalho de Parto Prematuro , Administração dos Cuidados ao Paciente , Nascimento Prematuro , Adulto , Centros de Assistência à Gravidez e ao Parto/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Trabalho de Parto Prematuro/epidemiologia , Trabalho de Parto Prematuro/prevenção & controle , Trabalho de Parto Prematuro/terapia , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Guias de Prática Clínica como Assunto , Gravidez , Gravidez de Alto Risco , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/prevenção & controle , Nascimento Prematuro/terapia , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Medição de Risco , Inquéritos e Questionários , Reino Unido
19.
BJOG ; 126(6): 729-735, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30315625

RESUMO

OBJECTIVE: To study the tocolytic action of nifedipine combined with sildenafil citrate (SC) and if the combination is superior to nifedipine alone in inhibiting threatened preterm labour (PTL). DESIGN: Prospective randomised study. SETTING: An Egyptian university hospital. POPULATION: Women with threatened PTL who received either nifedipine with SC or nifedipine alone. METHODS: Patients were randomly allocated to receive either (1) nifedipine 20 mg orally (stat dose), followed by 10 mg orally every 6-8 hours at the same time as vaginal administration of SC (25 mg at 8-hourly intervals) or (2) nifedipine alone. Medications were continued for 48-72 hours. MAIN OUTCOME MEASURES: The percentage of women who remained undelivered during hospitalisation. RESULTS: From January 2015 to November 2016, 239 women were randomised. The baseline characteristics of participants were similar. Nifedipine combined with SC was associated with more women remaining undelivered (81.8 versus 68.6%; P = 0.018) during hospitalisation. Regarding secondary outcomes, the addition of SC was also associated with fewer deliveries within 7 days of admission (9.1 versus 20.3%; P = 0.014), prolonged latency (29 versus 7 days; P = 0.002), fewer admissions to neonatal intensive care units (31.4 versus 44.1%; P = 0.043), fewer very preterm deliveries (from 28 to <32 weeks, 20.7 versus 38.1%; P = 0.043), and increased neonatal birthweight (1900 versus 1500 g; P = 0.018). CONCLUSIONS: Vaginal SC combined with nifedipine is an effective option for tocolytic therapy during threatened PTL. TWEETABLE ABSTRACT: Vaginal SC enhances the tocolytic effect of nifedipine.


Assuntos
Nifedipino , Trabalho de Parto Prematuro/prevenção & controle , Nascimento Prematuro/prevenção & controle , Citrato de Sildenafila , Administração Intravaginal , Administração Oral , Adulto , Monitoramento de Medicamentos/métodos , Sinergismo Farmacológico , Feminino , Humanos , Nifedipino/administração & dosagem , Nifedipino/efeitos adversos , Trabalho de Parto Prematuro/diagnóstico , Trabalho de Parto Prematuro/fisiopatologia , Gravidez , Resultado da Gravidez , Citrato de Sildenafila/administração & dosagem , Citrato de Sildenafila/efeitos adversos , Tocólise/métodos , Tocolíticos/administração & dosagem , Tocolíticos/efeitos adversos , Resultado do Tratamento
20.
Z Geburtshilfe Neonatol ; 223(1): 26-32, 2019 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-30513543

RESUMO

INTRODUCTION: Worldwide, 37 million people are infected with HIV; more than 50% are women. Currently, MTCT (mother-to-child transmission) can be reduced to<1%. The intention of the present study was to analyze the development of (1) the course of pregnancy of HIV-infected women, (2) the mode of delivery and (3) the post-exposure prophylaxis of the newborn over the last decade. METHODOLOGY: In this retrospective study, data from HIV-infected women who between 2005 and 2016 received care at the HIV outpatient department and gave birth at the Department of Obstetrics at University Hospital Bonn was analyzed. Furthermore, neonatal data was collected and HIV-MTCT was evaluated. RESULTS: In the 2005-2016 study period, 87 pregnancies in 61 women were identified. Seventy babies were born alive at the Department of Obstetrics, University Hospital Bonn. 53% of these women were of African origin. The median of CD4+ cell count was 510 cells/ml (IQR 444); however, 32 women (52%) had more than 500 cells/ml. During the antenatal period, the HI viral load had been suppressed completely in 77% of women (<50 HIV-1-RNA copies/ml) and was<400 HIV-1-RNA copies/ml in 92% of women. The elective cesarean section rate fell significantly from 77% in the years 2005-2011 to 58% in 2012-2016. The proportion of deliveries after 37 weeks of gestation increased markedly from 60% to 69% after 2012. Additionally, while between 2005-2011 the birth weight of 78% of the newborns was between the 10th and 90th percentile, this proportion increased to 92% after 2012. Fifty-four of 70 newborns (77%) were classified as having low to normal HIV transmission risk. A vertical HIV transmission from mother to child did not occur (0/70). CONCLUSIONS: Between 2005 and 2016 no vertical HIV transmission from mother to child occurred (0/70). Due to the change in treatment strategy, the elective cesarean section rate fell significantly as well the rate of premature births. An optimal interdisciplinary collaboration builds the basis for successful treatment of HIV in pregnancy.


Assuntos
Terapia Antirretroviral de Alta Atividade , Cesárea , Infecções por HIV/tratamento farmacológico , Complicações Infecciosas na Gravidez/tratamento farmacológico , Feminino , Alemanha , Infecções por HIV/diagnóstico , Infecções por HIV/transmissão , Humanos , Recém-Nascido , Doenças do Prematuro/prevenção & controle , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Trabalho de Parto Prematuro/prevenção & controle , Profilaxia Pós-Exposição , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Estudos Retrospectivos
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