Níveis de progesterona e os parâmetros reprodutivos no período periovulatório de vacas Nelore submetidas ao protocolo de IATF / Progesterone levels and reproductive parameters in the periovulatory period of Nellore cows under FTAI protocol

Background: Fixed Time Artificial Insemination (FTAI) has achieved a significant evolution in the last 18 years, however, despite the progress achieved by modern FTAI programs, the conception rates obtained are still low. Therefore, this study aimed to evaluate the interrelation between progesterone levels in the periovulatory period and reproductive parameters of Nellore cows submitted to an FTAI protocol. Materials, Methods & Results: On a random day, called day 0 (D0), 57 cows received a P4 device associated with the intramuscular (IM) application of 2.0 mg of estradiol benzoate. On D9, the P4 devices were removed and then were administered 500 µg of cloprostenol sodium IM; 0.6 mg of estradiol cypionate IM and 300 IUI of Equine Chorionic Gonadotrophin IM. Blood samples were collected for the determination of serum P4 concentrations on D9 and D11 of the protocol. The evaluations of follicular diameter (DFOL), follicular wall area (AFOL) and the vascularization area of the follicle wall (VFOL) were carried out on D11 using B-mode ultrasonography examination and colour Doppler, and then the artificial inseminations were performed. The evaluation of the corpus luteum diameter (CLD), of the total corpus luteum area (CLA), of the area of corpus luteum vascularization (CLV) and blood sampling for determination of postovulatory P4 levels (Post-P4) were performed on D24. For the analysis of the P4 concentration the chemiluminescence method was used, with a sensitivity of 0.1 ng/mL. According to the P4 concentrations on D11, cows were divided into 2 groups, LOW LEVELS OF P4 and HIGH LEVELS OF P4. The diagnosis of pregnancy was performed using transrectal ultrasonography on D45, at this point the cows were divided into 2 groups, PREGNANT and NON-PREGNANT. The correlation between DFOL and P4 dosage on D11 was moderate, negative and significant and between the AFOL and the serum P4 levels on D9, was moderate, negative and significant. As for the other correlations between follicular and luteal parameters and serum P4 levels, these were low to moderate, negative and not significant. Cows in the LOW LEVELS OF P4 group had significantly larger diameter and follicular areas than the cows in the HIGH LEVELS OF P4 group, the other follicular and luteal parameters showed no statistical difference. Of the total 57 cows that were inseminated, 30 cows became pregnant. Cows in the PREGNANT group had serum P4 levels on D9 equivalent to that obtained by the NON-PREGNANT group. However, at D11 the cows that became pregnant presented significantly lower serum P4 levels than cows that did not become pregnant. Discussion: The results of the interrelation between follicular parameters and P4 levels obtained in the present study, pointed out that the lower the levels of P4, the higher the follicular parameters, corroborating with other authors. Thus, larger preovulatory follicles provided high ovulation rates. Periovulatory serum P4 levels did not significantly affect the morphofunctional parameters of the CL. Such findings may be justified by high periovulatory P4 levels resulting from less efficient luteolysis, exert a negative effect on the results of FTAI protocols, because progesterone inhibits the release of LH pulses. It is concluded that lower periovulatory P4 levels established a favourable condition for follicular development and fertility, however, morphofunctional parameters of the corpus luteum were not affected.

Métodos anticonceptivos elegidos por mujeres después de aborto en un hospital público de Honduras / Contraceptive methods chosen by women after abortion in a public hospital in Honduras

Antecedentes: La tasa de embarazos no planeados en Latinoamérica está entre las más altas del mundo. Las adoles- centes están entre los grupos más vulnerables para embarazos no planeados con porcentajes de 32% a 45%. Objetivo: Describir los factores asociados a la elección de un anticonceptivo por las mujeres después de un aborto, en el Hospital Dr. Roberto Suazo Córdova, La Paz, Honduras, en el periodo de julio 2017 a junio 2019. Método: Estudio retrospectivo descriptivo. Los datos fueron obtenidos usando el Sistema Informático Perinatal Aborto (SIP Aborto) en la versión SIP 4.16. Resultados: El 50.0% (67/134) de las adolescentes y 50.1% (281/550) de las mayores de 19 años eligieron un anticonceptivo postaborto. El inicio del anticonceptivo se relacionó con antecedente de aborto (p=0.006). Uso previo de anticonceptivos (p=0.007). Los anticonceptivos más elegidos fueron: Acetato de medroxiprogesterona, anticonceptivos orales combinados y condón. La elección del anticonceptivo se relacionó con evacuación instrumental del aborto (p=0.022) en adolescentes y (p=0.000) en mayores de 19 años. Se eligieron menos los mé- todos reversibles de acción prolongada. Discusión: La elección anticonceptiva postaborto fue baja. El inicio de anticonceptivos se relacionó con antecedente de aborto, uso previo de anticoncepti- vos y evacuación instrumental. Los anticonceptivos más elegidos fueron los temporales de acción corta y los menos elegidos, los temporales de acción prolongada. Se debe fortalecer el acceso a información, mejorar la consejería, garantizar acceso y disponibili- dad de anticonceptivos sobre todo de acción prolongada para ase- gurar el apego al método anticonceptivo...(AU)

Análisis de los resultados del test estresante en gestantes con y sin preeclampsia atendidas en el Instituto Nacional Materno Perinatal durante el primer semestre 2014 / Analysis of the results of the stressful test in pregnant women with and without preeclampsia treated at the National Institute Maternal Perinatal in the first half 2014

Objetivo: Analizar los resultados del test estresante en gestantes con y sin preeclampsia atendidas en el Instituto Nacional Materno Perinatal durante el primer semestre del año 2014. Material y Métodos: Estudio analítico de preeclámpticas y controles, retrospectivo y de corte transversal, que tuvo como muestra a 190 gestantes con resultados cardiotocográficos del test estresante divididas en dos grupos: pacientes con diagnóstico de preeclampsia (n=95) y pacientes sin preeclampsia (n=95). Para el análisis descriptivo o univariado de las variables cuantitativas se estimaron medias y desviación estándar y para las variables cualitativas se estimaron frecuencias y porcentajes. Para el análisis inferencial, se utilizó la prueba Chi-cuadrado, el cual se consideró significativo cuando tenía un valor p<0.05. Resultados: El 86 por ciento tuvo diagnóstico de preeclampsia leve y el 14 por ciento de preeclampsia severa. Los hallazgos cardiotocográficos del test estresante en las gestantes con preeclampsia fueron: línea de base 110-160 lpm (98.9 por ciento), variabilidad mayor o igual a 1 (90.5 por ciento), aceleraciones presentes (85.3 por ciento), desaceleraciones variables (14.7 por ciento), desaceleraciones mayor o igual a 50 por ciento (13.7 por ciento) y contracciones uterinas menor a 5 (98.9 por ciento). En las gestantes sin preeclampsia, los hallazgos cardiotocográficos del test estresante fueron: línea de base 110-160 lpm (100 por ciento), variabilidad mayor o igual a 1 (97.9 por ciento), aceleraciones presentes (85.3 por ciento), desaceleraciones variables (8.4 por ciento), desaceleraciones mayor o igual a 50 por ciento (8.4 por ciento) y contracciones uterinas menor a 5 (100 por ciento). La ausencia de variabilidad estuvo relacionada a la presencia de preeclampsia (p=0.030). Además se encontró relación entre la conclusión dudosa e insatisfactoria y la presencia de preeclampsia (p=0.033). Conclusión: Los resultados del test estresante en gestantes atendidas en...

Objective: Analyze the results of stressful test in pregnant women with and without preeclampsia treated at the National Institute Maternal Perinatal during the first half of 2014. Material and Methods: Analytical study of cases and controls, retrospective and cross-sectional, held as shown at 190 pregnant women with CTG results of stressful test divided into two groups: patients diagnosed with preeclampsia (group cases, n = 95) and patients without preeclampsia (group control, n = 95). For descriptive or univariate analysis of quantitative variables mean and standard deviation were estimated for qualitative variables and frequencies and percentages were estimated. For the inferential analysis, Chi-square test, which was considered significant when p<0.05 value was used. Results: 86 per cent had diagnosis of mild preeclampsia and 14 per cent of severe preeclampsia. The findings cardiotocographic stressful in pregnant women with preeclampsia test were: baseline 110-160 lpm (98.9 per cent), greater than or equal to 1 (90.5 per cent), accelerations present (85.3 per cent), variable decelerations (14.7 per cent) variability, greater than or equal to 50 per cent (13.7 per cent) and regular uterine contractions (91.5 per cent) slowdowns. In pregnant women without preeclampsia, cardiotocographic stressful test findings were: baseline 110-160 lpm (100 per cent), greater than or equal to 1 (97.9 per cent), accelerations present (85.3 per cent), variable decelerations (8.4 per cent) variability greater than or equal to 50 per cent (8.4 per cent) and regular uterine contractions (98.9 per cent) slowdowns. The lack of variability was associated to preeclampsia (p = 0.030). Moreover relationship between doubtful and unsatisfactory conclusion and the presence of preeclampsia (p = 0.033) was found. Conclusions: The results of the stressful test in pregnant women attended at National Institute Materno Perinatal during the first half of 2014 it shows that the variability and...

Métodos e ferramentas para o monitoramento da prenhez de risco em éguas / Methods and tools for monitoring of risk pregnancy in mares / Metodos y herramientas para el seguimiento del embarazo de riesgo en yeguas

Esta revisão tem como objetivo abordar os principais métodos para avaliar uma gestação de risco.A utilização de ferramentas de diagnóstico permite que intervenções adequadas sejam realizadas o mais cedo possível sem trazer prejuízos ou afetar a saúde do feto. O conhecimento desta é fundamental para determinar quando uma intervenção na gestação é necessária, desta forma o acompanhamento por um profissional que proceda de forma adequada pode ser decisivo. O acompanhamento gestacional, através da ultrassonografia fetoplacentária, fornece informações que auxiliam na predição da viabilidade pós-natal. Eletrocardiograma materno-fetal e amniocentese são outras ferramentas importantes no diagnóstico de gestações equinas de risco.

This review aims to approach the main methods to evaluate a risk pregnancy. The use of diagnostictools allow that appropriate interventions are performed early without damages or affect fetus health. This knowledge is essential to determine when a pregnancy intervention is necessary, thus the monitoring by aprofessional who proceed in an adequate way might be decisive. The pregnancy assessment, throughfetoplacental ultrasonography, provide information that help in the postnatal viability prediction. Electrocardiography fetomaternal and amniocentesis are other important tools in the diagnosis of the compromised equine pregnancy.

Esta revisión tiene como meta abordar los métodos clave para evaluar un embarazo de riesgo. EIuso de herramientas de diagnóstico permite intervenciones apropiadas se lIevan a cabo tan pronto como seaposible sin danar o afectar Ia salud dei feto. Saber esto es fundamental para determinar cuándo es necesaria Iaintervención durante el embarazo, por 10 que el seguimiento por parte de un profesional para lIevar a cabo adecuadamente puede ser decisivo. Monitoreo gestacional a través de Ia ecografía de placenta, proporciona información para ayudar en Ia predicción de Ia viabilidad postnatal. Electrocardiograma y Ia amniocentesis materna y fetal son otras herramientas importantes en el diagnóstico de riesgo de embarazos equinos.

Métodos e ferramentas para o monitoramento da prenhez de risco em éguas / Methods and tools for monitoring of risk pregnancy in mares / Metodos y herramientas para el seguimiento del embarazo de riesgo en yeguas

Esta revisão tem como objetivo abordar os principais métodos para avaliar uma gestação de risco.A utilização de ferramentas de diagnóstico permite que intervenções adequadas sejam realizadas o mais cedo possível sem trazer prejuízos ou afetar a saúde do feto. O conhecimento desta é fundamental para determinar quando uma intervenção na gestação é necessária, desta forma o acompanhamento por um profissional que proceda de forma adequada pode ser decisivo. O acompanhamento gestacional, através da ultrassonografia fetoplacentária, fornece informações que auxiliam na predição da viabilidade pós-natal. Eletrocardiograma materno-fetal e amniocentese são outras ferramentas importantes no diagnóstico de gestações equinas de risco. (AU)

This review aims to approach the main methods to evaluate a risk pregnancy. The use of diagnostictools allow that appropriate interventions are performed early without damages or affect fetus health. This knowledge is essential to determine when a pregnancy intervention is necessary, thus the monitoring by aprofessional who proceed in an adequate way might be decisive. The pregnancy assessment, throughfetoplacental ultrasonography, provide information that help in the postnatal viability prediction. Electrocardiography fetomaternal and amniocentesis are other important tools in the diagnosis of the compromised equine pregnancy. (AU)

Esta revisión tiene como meta abordar los métodos clave para evaluar un embarazo de riesgo. EIuso de herramientas de diagnóstico permite intervenciones apropiadas se lIevan a cabo tan pronto como seaposible sin danar o afectar Ia salud dei feto. Saber esto es fundamental para determinar cuándo es necesaria Iaintervención durante el embarazo, por 10 que el seguimiento por parte de un profesional para lIevar a cabo adecuadamente puede ser decisivo. Monitoreo gestacional a través de Ia ecografía de placenta, proporciona información para ayudar en Ia predicción de Ia viabilidad postnatal. Electrocardiograma y Ia amniocentesis materna y fetal son otras herramientas importantes en el diagnóstico de riesgo de embarazos equinos. (AU)

Velocimetría Doppler de las arterias uterinas en el primer y segundo trimestre de gestación y su relación con macrosomía fetal en gestantes atendidas en el INMP año 2011-2012 / Doppler velocimetry of the uterine arteries in the first and second trimester of pregnancy and its relationship with fetal macrosomia in pregnant women at the INMP year 2011-2012

OBJETIVOS: Determinar si existe relación entre la Velocimetría Doppler de las arterias uterinas en el primer y segundo trimestre de gestación y la macrosomía fetal en gestantes atendidas en el lNMP Año 2011-2012. METODOLOGIA: Estudio observacional, descriptivo, longitudinal y prospectivo. Se trabajó 156 gestantes con edad gestacional menor de o igual a 26 semanas atendidas en la Unidad de Medicina Fetal del INMP durante el periodo Octubre 2011-Mayo 2012, Se estimaron las frecuencias absolutas y relativas de las variables de cualitativas y medidas de tendencia central y de dispersión de las cuantitativas. Se utilizó para el análisis bivariado la prueba Chi cuadrado para las variables cualitativas y t-Student para las variables cuantitativas. Se estimaron los valores diagnósticos de los indicadores de Velocimetría Doppler. RESULTADOS: La edad materna promedio de las gestantes es de 27.8 años y la edad gestacional promedio es de 20±4.5 semanas. El 63.5 por ciento de las gestantes se encuentran entre las edades de 20-35 años y el 19.9 por ciento son mayores a 35 años. La edad gestacional de la mayoría de las pacientes se encuentra entre 13-24 semanas (81.4 por ciento). El 4.5 por ciento de los fetos son macrosómicos y el 92.3 por ciento se encuentra entre los pesos de 2500-3999 gramos. La edad gestacional por Capurro de los recién nacidos se encuentra en su mayoría entre 37-40 semanas. La presión sistólica promedio de la ecografía Doppler es 101+/-36.8mmHg y la presión diastólica promedio es 42.6+/-24.4mmHg. El Índice de Pulsatilidad promedio es 1.1+/-0.4 y el Índice de Resistencia es 0.6+/-0.1. La presión sistólica promedio de los recién nacidos con Macrosomía fetal es mayor (146+/-90.3) comparado con la presión sistólica promedio de los recién nacidos que no presentaron Macrosomía (98.9+/-31.4) (p=0.001), la presión diastólica promedio en el grupo de los fetos con macrosomía es 75.9+/-65.9 comparado con los fetos que no presentaron macrosomía 41.1+/-19.9...

OBJECTIVE: To determine the correlation between Doppler velocimetry of the uterine arteries in the first and second trimester of pregnancy with fetal macrosomia in pregnant women at the INMP, during the years 2011-2012. METHODOLOGY: Descriptive, prospective, longitudinal observational study. There were evaluated 156 pregnant women with gestational age less than or equal to 26 weeks attending the Fetal Medicine Unit INMP during the period October 2011-May 2012. There were estimated absolute and relative frequencies for qualitative variables and measures of central tendency and dispersion of the quantitative. We used for bivariate analysis the test Chi-square for categorical variables and t-Student for quantitative variables. We estimated the diagnostic values of Doppler velocimetry indicators. RESULTS: The average maternal age of pregnant women is 27.8 years and the average gestational age is 20+/-4.5 weeks. The 63.5 per cent of pregnant women are between the ages of 20-35 years and 19.9 per cent are older than 35 years. The gestational age of most patients is between 13-24 weeks (81.4 per cent) and the minority, <=12 weeks (5.1 per cent). Abdominal ultrasound is the most commonly technique used (77.6 per cent). The 4.5 per cent of fetus are macrosomic and 92.3 per cent are between the weights of 2500-3999 grams. The gestational age of newborns by Capurro is mostly between 37-40 weeks. The average systolic Doppler ultrasound is 101+/-36.8 mmHg and the average diastolic pressure is 42.6+/-24.4mmHg. The average pulsatility index is 1.1+/-0.4 and resistance index is 0.6+/-0.1. The average systolic blood pressure of newborns with fetal macrosomia is higher (146+/-90.3) compared with the average systolic pressure of infants who are not macrosomic (98.9+/-31.4) (p=0.001), the average diastolic pressure in group of fetus with macrosomia is 75.9+/-65.9 compared with fetus that do not present macrosomia 41.1+/-19.9 (p<0.001). The average pulsatility index in the first...

Efecto de la analgesia epidural sobre la dinámica uterina en la fase activa del trabajo de parto en primigestas atendidas en el Instituto Nacional Materno Perinatal, 2012 / Effect of epidural analgesia on uterine dynamics in the active phase of labor in primigravid attended at the Institute national maternal Perinatal, 2012

Efecto de la analgesia epidural sobre la dinámica uterina en la fase activa del trabajo de parto en primigestas atendidas en el INSTITUTO NACIONAL MATERNO PERINATAL, 2012. Objetivo: Determinar los posibles efectos de la analgesia epidural sobre la dinámica uterina durante la fase activa del trabajo de parto, en primigestas atendidas en el Centro Obstétrico del Instituto Nacional Materno Perinatal, durante el periodo de mayo y junio del año 2012. Materiales y Métodos: Estudio descriptivo, cuantitativo y prospectivo, en el cual se evaluó un grupo de primigestas que recibieron analgesia epidural en la fase activa del trabajo de parto en el servicio de Centro Obstétrico del Instituto Nacional Materno Perinatal durante los meses de mayo y junio del año 2012. Se evalúo un total de 151 pacientes, que cumplieron con los criterios de inclusión y exclusión. El muestreo realizado fue no probabilístico y la técnica es por conveniencia. Resultados: De las 151 gestantes se observó que 104 presentaron disminución en algún parámetro de la dinámica uterina durante la evaluación de los 10 primeros minutos, el 63.46 por ciento mostró disminución en una de las características de la dinámica uterina ya sea duración, frecuencia o intensidad; un 27.89 por ciento tuvo variación en dos parámetros y el 8.65 por ciento restante mostró disminución en todas las características. Durante la evaluación de los siguientes 10 minutos se observó que la mayoría de pacientes que mostraron disminución (duración 44.37 por ciento, frecuencia 24.50 por ciento, intensidad 31.13 por ciento), no recuperaron el patrón que tenían antes de la aplicación de la analgesia. Evaluando los resultados con la Prueba de Friedman se obtuvo que existen cambios significativos tanto en la duración, frecuencia e intensidad de la dinámica uterina evaluada antes y después de la aplicación de la analgesia epidural. Conclusiones: Las pacientes que recibieron analgesia epidural tienen mayor probabilidad de presentar alteraciones en algún parámetro de la dinámica uterina. La duración de la contracción uterina post aplicación de la analgesia epidural durante los 10 primeros minutos disminuyó en la mayoría de pacientes, mientras que la frecuencia y la intensidad se mantuvieron constantes. Evaluándolo individualmente, la duración de la dinámica uterina es el parámetro más afectado, mientras que el menos afectado es la intensidad. Una mínima cantidad de pacientes presenta alteración en las tres características de la contracción uterina evaluadas

Índice de pulsatilidad medio de las arterias uterinas y su relación con preeclampsia y complicaciones perinatales. Instituto Materno Perinatal. Octubre 2010 - Mayo 2011 / Pulsatility index mean of the uterine arteries and its relation to preeclampsia and perinatal complications. Institute Materno Perinatal. October 2010 - May 2011

El objetivo del estudio fue determinar la utilidad del índice de pulsatilidad medio de las arterias uterinas mayor del percentil 95 como predictor de preeclampsia y complicaciones perinatales en gestantes durante el período comprendido entre octubre del 2010 a mayo del 2011. En el Instituto Nacional Materno Perinatal de Lima - Perú se realizó un estudio observacional, transversal, analítico y prospectivo comparando 24 gestantes con índice de pulsatilidad medio mayor del percentil 95 con otras 40 que no lo tuvieron. El análisis estadístico se realizó con el programa IBM Statistics SPSS 19. La media del índice de pulsatilidad fue 1,31+/-0,31 (rango: 0,53 - 2,08) y su distribución siguió una distribución bimodal. El riesgo de preeclampsia y de complicaciones perinatales en pacientes con índice de pulsatilidad medio de las arterias uterinas mayor del percentil 95 fue 5,23 (IC al 95 por ciento: 3,84-9,82) y 4,42 (IC al 95 por ciento: 2,98-6,34); respectivamente, en comparación con pacientes con índice de pulsatilidad medio de las arterias uterinas menor del percentil 95. El análisis multivariado demostró que las complicaciones materno perinatales independientes y significativas en gestantes con índice de pulsatilidad de las arterias uterinas mayor del percentil 95 fueron: morbilidad materna (OR 4,39; 95 por ciento IC 2,02-9,55), restricción de crecimiento intrauterino (OR 7,25; 95 por ciento IC 4,42-15,08), pequeño para la edad gestacional (OR 7,16; 95 por ciento IC 4,42-15,08), Apgar < 7 (OR 5,01; 95 por ciento IC 2,87-8,70), óbito fetal (OR 2,91; 95 por ciento IC 2,01-4,11) e ingreso a UCI (OR 3,39; 95 por ciento IC 2,19-4,30). Se concluyó que el índice de pulsatilidad medio de las arterias uterinas mayor del percentil 95 predice en forma significativa la presencia de preeclampsia y complicaciones materno-perinatales asociadas independientemente de la edad gestacional.

The objective of the study was to determine the usefulness of mean pulsatility index of the uterine arteries greater than 95th percentile as a predictor of preeclampsia and perinatal complications in pregnant women during the period October, 2010 to May, 2011. At Maternal Perinatal National Institute in Lima-Peru is was carried out an observational, cross-sectional and prospective analytical study comparing 24 pregnant women with mean pulsatility index of the uterine arteries greater than 95th percentile with 40 others that did not. Statistical analysis was performed with the IBM SPSS Statistics 19 program. The mean pulsatility index was 1.31+/-0.31 (range: 0.53 to 2.08) and itÆs continued a distribution bimodal distribution. The risk of preeclampsia and perinatal complications in patients with mean pulsatility index of the uterine arteries greater than 95th percentile was 5.23 (95 per centCI: 3.84 to 9.82) and 4.42 (95 per centCI: 2.98 to 6.34), respectively, compared with patients with mean pulsatility index lower uterine artery 95 percentile. Multivariate analysis showed that independent and significant perinatal maternal complications in pregnant with mean pulsatility index of the uterine arteries greater than 95 percentile were: maternal morbidity (OR 4.39, 95 per cent CI 2.02 to 9.55), growth restriction intrauterine (OR 7.25, 95 per cent CI 4.42 to 15.08), small for gestational age (OR 7.16,95 per cent CI 4.42 to 15.08), Apgar<7 (OR 5.01, 95 per cent CI2.87 to 8.70), stillbirth (OR 2.91, 95 per cent CI 2.01 to 4.11) and ICU admission (OR 3.39, 95 per cent CI 2.19 to 4, 30). It was concluded that half the pulsatility index of the uterine arteries predicts the 95th percentile increased significantly in the presence of preeclampsia and perinatal complications associated maternal regardless of gestational age.

Cardiomiopatia hipertrófica e gravidez / Hypertrophic cardiomyophaty and pregnancy

A cardiomiopatia hipertrófica (CMH) é doença incomum na gestação, caracterizada pela hipertrofia do ventrículo esquerdo, com expressão fenotípica e manifestações clínicas variáveis. O diagnóstico pode ser confirmado pelo ecocardiograma com Doppler. Trata-se de enfermidade bem tolerada na gestação, entretanto, pode desencadear insuficiência cardíaca congestiva, com grave comprometimento materno e perinatal. O tratamento para a gestante com CMH depende da obstrução do fluxo do ventrículo esquerdo. Em paciente sintomática portadora da forma obstrutiva, devem-se evitar grandes perdas sanguíneas e uso de drogas vasodilatadoras durante o trabalho de parto. O parto vaginal mostrou-se seguro, mas o período expulsivo deve ser abreviado com uso de fórceps naquelas que apresentam sintomatologia obstrutiva. Raras complicações podem acontecer, o que requer planejamento do parto e adequada monitorização materna e fetal. (AU)

The Hypertrophic Cardiomyopathy (HCM) is an uncommon condition during pregnancy, which attends with a left ventricular hypertrophy, and phenotypic expression and clinical are both variable. The diagnosis can be confirmed by Doppler echocardiography. Several studies show that it is a disease well tolerate during pregnancy, however it may trigger congestive heart failure with severe maternal and perinatal commitment. The treatment of pregnant patients with HCM depends on the presence of symptoms caused by obstruction of the left ventricle. In symptomatic patient carrying the obstructive form should be avoided large blood loss and use of vasodilator drugs during labor. Vaginal delivery is safe, but the expulsive period should be abbreviated with the use of forceps in those with obstructive symptoms. Rare complications can occur and therefore it is necessary a delivery planning and an adequate maternal and fetal monitoring. (AU)

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

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

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

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

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

Cirurgia cardíaca na gravidez / Cardiac surgery during pregnancy

A cirurgia cardíaca na gravidez vem sendo realizada desde 1985 no Instituto Dante Pazzanese de Cardiologia, em São Paulo (SP). Inúmeras melhorias foram desenvolvidas desde essa época. Até os dias de hoje, 80 gestantes foram submetidas a cirurgia, das quais 64 foram acompanhadas (84 por cento). A doença valvar foi a afecção mais frequente (94 por cento), sendo a valvopatia mitral a doença mais prevalente (76,5 por cento). Foi necessário tratamento cirúrgico dessa valva em 82 por cento dos casos (comissurotomia mitral ou troca valvar). A maioria dessas pacientes estava em classe funcional III ou IV da New York Heart Association (NYHA) e a idade gestacional média era de 22 semanas. Houve melhora da classe funcional após a cirurgia (93 por cento dos casos em classe funcional I ou II) e a maioria das pacientes se encontra em ritmo sinusal (70,4 por cento). A reoperação foi necessária em 20 por cento dos casos. Ocorreram 5 óbitos maternos (6,2 por cento) e 11 óbitos fetais (16,2 por cento). A classe funcional é o maior fator de risco para mortalidade materna, mas também devem ser considerados o uso de drogas vasoativas, a idade da paciente, o tipo de afecção e a reoperação. Para a mortalidade fetal, devemos considerar idade materna...

Efeito da analgesia obstétrica combinada raqui-peridural no tônus uterino e na freqüência cardíaca fetal: ensaio clínico randomizado comparativo com a analgesia peridural / The effect of combined spinal-epidural labor analgesia on uterine tone and fetal heart rate: randomized comparison with epidural analgesia

A fim de investigar a associação entre alterações do tônus uterino e a ocorrência de anormalidades da freqüência cardíaca fetal (FCF) após analgesia obstétrica, em especial após o bloqueio combinado raqui-peridural, foi conduzido estudo prospectivo randomizado e encoberto, com setenta e sete parturientes que solicitaram analgesia regional durante o trabalho de parto. As pacientes do grupo estudo (41 casos) receberam duplo bloqueio com sufentanil e bupivacaína e as do grupo controle (36 casos) foram submetidas à peridural com as mesmas drogas. Monitorizou-se o tônus uterino por meio de cateter intra-amniótico de aferição da pressão intra-uterina e a freqüência cardíaca fetal durante 15 minutos antes e 30 minutos após a indução da analgesia. Pesquisaram-se os seguintes desfechos após a administração da analgesia: ocorrência de aumento do tônus uterino superior ou igual a 10mmHg em relação aos valores pré-analgesia e presença de desacelerações prolongadas da FCF ou bradicardia. Foram ainda quantificados os escores maternos de dor, a pressão arterial materna e o uso de ocitocina, antes e após o bloqueio. Observou-se associação significativa tanto do aumento de tônus uterino quanto das alterações da FCF com a analgesia combinada, nos primeiros 15 minutos após sua administração. O aumento de tônus foi encontrado em 17 de 41 casos no grupo estudo e em 6 de 36 pacientes nos controles (p=0,02). Alterações da FCF foram vistas em 11 dos 17 casos de aumento de tônus nas parturientes que receberam analgesia combinada, versus 1 de 6 no grupo peridural (p<0,001). A análise de regressão logística apontou o tipo de analgesia como fator independentemente associado ao aumento de tônus uterino, mesmo inserindo-se o uso de ocitocina como covariável. Também revelou o aumento de tônus como único fator independentemente associado ao desenvolvimento de anormalidades da FCF, mesmo com a hipotensão materna como covariável. Demonstrou-se ainda correlação entre o rápido declínio...

In order to investigate the association between uterine tone elevation and fetal heart rate (FHR) abnormalities following labor analgesia - mainly with combined spinal-epidural (CSE) technique - a prospective double-blinded randomized study was conducted with seventy seven parturients who requested labor analgesia. Study group (41 cases) received CSE with sufentanil and bupivacaine and control group (36 cases) received epidural analgesia with the same drugs. Intra-uterine pressure was monitored with intra-amniotic pressure device and FHR with external transducer, both for at least 15 minutes before and 30 minutes after analgesia induction. The primary outcomes were the occurrence of an elevation of 10mmHg or more on uterine tone compared to the values before analgesia and the presence of prolonged fetal heart rate decelerations or fetal bradycardia. Maternal pain scores, blood pressure and use of oxytocin were also computed. A significant association was noticed between elevation of uterine tone and fetal heart rate abnormalities with combined spinal-epidural analgesia, at the first 15 minutes of administration. Uterine tone elevation was observed in 17 out of 41 CSE subjects and only 6 out of 36 controls (p=0.02). Fetal heart rate abnormalities were seen in 11 out of 17 cases that had hypertonus with combined analgesia and in only one of the 6 epidural patients (p<0.001). Logistic regression analysis revealed the mode of analgesia as the independent factor for the elevation of uterine tone, even with oxytocin use as a covariate. It also pointed out the uterine tone elevation as the only independent factor related to the development of fetal heart rate abnormalities, even with maternal hipotension as a covariate. A correlation was found between the fast onset pain relief provided by CSE analgesia and the estimated probability of uterine tone elevation and simultaneous fetal heart rate abnormalities...

Increasing compliance with maternal and child care quality standards in Ecuador.

OBJECTIVE: To determine the effects of hospital quality assurance interventions on compliance with clinical standards, availability of essential drugs, client satisfaction, and utilization. DESIGN: Quasi-experimental, prospective study with four intervention hospitals and four control hospitals. All eight facilities were purposively selected and of comparable complexity. SETTING: Ministry of Health secondary care facilities in Ecuador. INTERVENTIONS: Facility-based quality improvement teams, job clarification, standards communication, refresher training, strengthening hospital pharmacy committees, monthly monitoring of compliance indicators, and formation of users' committees. MEASURES: Compliance with input and process standards, utilization of services, and patient satisfaction were measured monthly in both groups through review of clinical and administrative records, exit interviews, and patient satisfaction surveys. RESULTS: After 12 months, the quality assurance interventions produced rapid increases in compliance with clinical standards in the intervention hospitals as compared with the control group. These improvements appeared as early as 2 months after the onset of the interventions. No differences were found between intervention and control groups in terms of trends in utilization patterns or client satisfaction. CONCLUSION: Quality assurance interventions made a difference in technical quality of care. Patient satisfaction and utilization do not appear to be directly associated with short-term improvements in compliance with clinical standards. Quality improvement interventions may require longer periods and a specific aim at clients' needs to demonstrate effects on utilization and satisfaction outcome variables.