Prospective Risk of Intrauterine Death of Monochorionic-Diamniotic Twins

OBJECTIVE: The purpose of this study was to calculate the prospective risk of fetal death in monochorionic-diamniotic twins. STUDY DESIGN: We evaluated 193 monochorionic diamniotic twin pregnancies that were followed and delivered after 24 weeks. Surveillance included cardiotocography and sonography performed at least once weekly. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. RESULTS: The fetal death rate was 5 of 193 pregnancies (2.6%; 95% CI, 1.1, 5.9); the prospective risk of stillbirth per pregnancy after 32 weeks of gestation was 1.2% (95% CI, 0.3% - 4.2%). CONCLUSION: Under intensive surveillance, the prospective risk of fetal death in monochorionic-diamniotic pregnancies after 32 weeks of gestation is much lower than reported and does not support a policy of elective preterm delivery.

Morte Fetal de um G��meo. Que Problemas para o G��meo Sobrevivente?

Na gravidez bigemelar, a morte de um dos fetos no segundo e terceiro trimestre �� uma complica����o rara, variando a taxa de incid��ncia entre 2,6 e 6,8%. Este acontecimento determina um aumento das taxas de morbilidade e mortalidade perinatal para o g��meo sobrevivente, especialmente em gravidezes monocori��nicas, quando a morte fetal �� devida �� s��ndroma de tranfus��o feto-fetal. Para alguns autores o atraso de crescimento intrauterino e a prematuridade s��o os principais factores de risco para o aumento da morbilidade e mortalidade do g��meo sobrevivente. A patofisiologia de instala����o dos dist��rbios cerebrais no g��meo sobrevivente ap��s a morte do feto irm��o n��o est�� definida, nem o intervalo de tempo que medeia entre a morte e o estabelecimento das les��es. Tamb��m n��o existe um protocolo definitivo de seguimento destas gravidezes e, posteriormente, do g��meo sobrevivente. No per��odo de 1 de Setembro de 1994 a 31 de Dezembro de 1998, foram seguidas, na consulta de Gravidez M��ltipla da Maternidade Dr. Alfredo da Costa, 235 gravidezes bigemelares. Em nove casos (3,8%) ocorreu morte de um dos fetos com idade gestacional acima das 13 semanas. Em cinco das nove gravidezes foi conhecida a causa de morte, quatro das quais foram atribu��das �� s��ndroma de tranfus��o feto-fetal. A taxa de prematuridade do g��meo sobrevivente foi de 44,4% (4/9) e a de mortalidade de 11,1%(1/9). A taxa de morbilidade neonatal foi de 62,5% (5/8), na maioria dos casos por complica����es inerentes �� prematuridade. A taxa de morbilidade neurol��gica foi de 37,5% (3/8). A taxa de les��es neurol��gicas major foi de 25% (2/8) e ocorreu em rec��m-nascidos de termo. A s��ndroma de transfus��o feto-fetal, como causa de morte fetal, associou-se aos casos com pior progn��stico no que se referiu ao g��meo sobrevivente.O crescimento do g��meo sobrevivente parece depender das les��es provocadas pela morte do feto irm��o. Os autores finalizam com uma proposta de atitudes obst��tricas e pedi��tricas em rela����o ao g��meo sobrevivente.

Primary Antiphospholipid Syndrome: Pregnancy Outcome in a Portuguese Population

Introduction:Women with antiphospholipid syndrome(APS) may suffer from recurrent miscarriage, fetal death, fetal growth restriction (FGR), pre-eclampsia, placental abruption, premature delivery and thrombosis. Treatment with aspirin and low molecular weight heparin (LMWH) combined with close maternal-fetal surveillance can change these outcomes. Objective: To assess maternal and perinatal outcome in a cohort of Portuguese women with primary APS. Patients and Methods: A retrospective analysis of 51 women with primary APS followed in our institution (January 1994 to December 2007). Forty one(80.4%) had past pregnancy morbidity and 35.3%(n=18) suffered previous thrombotic events. In their past they had a total of 116 pregnancies of which only 13.79 % resulted in live births. Forty four patients had positive anticardiolipin antibodies and 33 lupus anticoagulant. All women received treatment with low dose aspirin and LMWH. Results: There were a total of 67 gestations (66 single and one multiple). The live birth rate was 85.1%(57/67) with 10 pregnancy failures: seven in the first and second trimesters, one late fetal death and two medical terminations of pregnancy (one APS related). Mean (�� SD) birth weight was 2837 �� 812 g and mean gestational age 37 �� 3.3 weeks. There were nine cases of FGR and 13 hypertensive complications(4 HELLP syndromes). 54.4% of the patients delivered by caesarean section. Conclusions: In our cohort, early treatment with aspirin and LMWH combined with close maternal-fetal surveillance was associated with a very high chance of a live newborn.

Late Stillbirth: a Ten Year Cohort Study

Introduction: Late fetal death is a desolating event that inspite the effort to implement new surveillance protocols in perinatal continues to defy our clinical pratice. Objective: To examine etiological factors contributing to main causes and conditions associated with fetal death in late pregnancies over a 10-year period. Methods: Retrospective cohort analysis of 208 late singleton stillbirth delived in a tertiary-perinatal referral maternity over a 10-year period. Clinical charts, laboratory data and feto-placental pathology findings were systematically reviewed. Results: The incidence of late fetal demise was 3.5 per 1000 pregnancies. No significant trend in the incidence of stillbirth was demonstrated during the study period. Stillbirth was intrapartum in 12 (5.8%) cases and 72 (35%) were term pregnancies. Fourteen percent of cases were undersurveilled pregnancies. Mean gestacional age at diagnosis was 34 weeks. The primary cause of death was fetal, it was present in 59 cases, 25% were considered small for gestational age. Stillbirths were unexplained in 24.5% of cases. Maternal medical disorders were identified in 21%. Hypertensive disorders were frequent and associated with early gestacional age (p = 0.028). Conclusion: There was no change in the incidence of late stillbirth during the 10 years under evaluation. The incidence was 3.5 ��� which was identical to that described in developed countries. About one quarter of the stillbirths was unexplained. The most frequent maternal pathology was chronic hypertension.

Gravidez ap��s Coloca����o de Banda G��strica para Tratamento da Obesidade M��rbida

Obesity is known to have a negative impact on pregnancy outcome, as it is associated with an increase in the incidence of gestational diabetes, hypertension, preeclampsia, neural tube defects, macrosomia, and late fetal death. Gastric banding is considered an appropriate intervention for morbid obesity when other weight-loss measures are unsuccessful, and this treatment has been shown to be effective in causing a sustainable weight loss. Some women will become pregnant after bariatric surgery, and the nutritional and metabolic challenges brought by gastric banding may have a profound impact on maternal health and pregnancy outcome. The authors report the case of a 27 year old pregnant woman, with a past medical history of gastric banding surgery for morbid obesity. At 18 weeks of gestation, the patient started complaining of severe nausea and vomiting, The situation deteriorated three weeks later when she rapidly developed severe desnutrition, dehydration and early signs of liver and renal failure. Migration of the gastric band was diagnosed, and laparoscopy conducted to remove it. In the day following surgery the patient complained of absent fetal movements, and an intrauterine demise was diagnosed on ultrasound. Pathological examination of the fetus and placenta failed to reveal the cause of death, but no growth restriction was documented, suggesting the occurrence of an acute event.

Restri����o do Crescimento Fetal - Casu��stica de 4 Anos

Overview and aims: Fetal growth restriction (FGR) affects 15% of pregnancies and is associated with both increased perinatal and neonatal morbidity and mortality and long-term effects in adult life. Our aim was to describe cases and outcomes of FGR from a tertiary perinatal care centre and identify the predictors of neonatal morbidity and mortality. Study design: retrospective cohort. Population: pregnancies with early or late FGR caused by placental factors followed from 2006 to 2009 in a tertiary perinatal care centre. Methods: we collected data from clinical records on demographics, clinical history and fetal ultrasound parameters. Perinatal and neonatal outcomes were stratiied according to gestational age (above or below 28 weeks) and we used bivariate analysis to identify any associations with clinical and imaging indings. Results: we included 246 pregnancies; hypertension was the most prevalent maternal risk factor (16%). There were 15 cases of early FGR, 11 of which had cesarean delivery due to deterioration of fetal Doppler parameters. Outcomes in this group included one fetal and three neonatal deaths. Of 231 cases of late FGR, 64% were delivered early given a non-reassuring fetal status i.e. due to changes in Doppler evaluation or altered Manning biophysical proile. There were four cases of perinatal death in this group, three of which delivered at 28 weeks. Neonatal morbidity was associated with lower gestational age, lower birthweight and progressive placental dysfunction (p<0.01). Conclusion: there was an association between neonatal morbidity and gestational age, birthweight and Doppler deterioration, particularly for deliveries below 28 weeks. The assessment of vascular changes through Doppler analysis allows anticipation of fetal deterioration and is a helpful tool in deciding the optimum timing of delivery.

Pr��-Ecl��mpsia Grave. Compromisso Materno e Fetal

Introdu����o: A pr��-ecl��mpsia (PE) �� uma s��ndrome espec��fica da gravidez, associado a morbimortalidade materna e perinatal. M��todos: Estudo retrospectivo descritivo das 134 gesta����es com PE grave, seguidas na nossa institui����o de 2003 a 2005, com o objectivo de avaliar as repercuss��es maternas e fetais desta patologia. Resultados: Na maioria dos casos houve repercuss��o sist��mica, manifestada por sintomatogia (79%) e valores laboratoriais indicativos de gravidade cl��nica. Os dados ecogr��ficos revelaram 22,7% de restri����o de crescimento intra-uterino e 21,3% de fluxometria doppler patol��gica. Decidiu-se interromper electivamente a gravidez em 95,3% dos casos, 60,5% nas primeiras 48h, sendo a s��ndrome materno a principal indica����o. Verificaram-se 4 abortos e 5 mortes fetais. O parto ocorreu antes das 34 semanas em 63,1% dos casos. Em 82,8% a via de parto foi cesariana. Salientam-se 4 casos de insufici��ncia renal aguda e 2 casos de acidente vascular cerebral hemorr��gico com morte materna. 20% dos rec��m-nascidos eram leves para a idade gestacional e verificou-se asfixia neonatal em 7,7%. Conclus��o: A pr��-ecl��mpsia grave continua a ser uma patologia com implica����es importantes no desfecho obst��trico.

Valida����o da Import��ncia dos Crit��rios de Referencia����o Propostos pela Direc����o Geral de Sa��de para Realiza����o de Ecocardiografia Fetal

Introdu����o: A malforma����o cong��nita mais frequente �� a card��aca, afectando cerca de 5-8 rec��m-nascidos/mil nados vivos. Actualmente �� poss��vel obter um diagn��stico pr��-natal destas anomalias atrav��s do ecocardiograma fetal (EcoF), por��m, porque os recursos em Sa��de s��o limitados, este exame deve ser pedido de acordo com os crit��rios estabelecidos pela Direc����o Geral de Sa��de (DGS). Objectivos: Avaliar a import��ncia dos crit��rios de referencia����o propostos pela DGS para detec����o de anomalias card��acas. Determinar as taxas de preval��ncia e mortalidade nos fetos com doen��a card��aca. Material e M��todos: Revis��o casu��stica de uma amostra de 733 fetos aos quais foi realizado EcoF em consulta de Cardiologia Pr��-natal num centro terci��rio de Cardiologia Pedi��trica, no per��odo de 2006 a 2008. Foram avaliados dados demogr��ficos, motivo de referencia����o (MR), resultados da EcoF e evolu����o. Classific��mos os MR em dois grupos: (I) concordantes com as indica����es da DGS- causas major (familiar, materna, fetal) e causas minor (outras situa����es); (II) n��o concordantes. Resultados: Realizaram-se 871 EcoF a 705 gr��vidas. A mediana da idade materna foi de 32 anos (15-45 anos) e a m��dia da idade gestacional foi de 26 semanas (��4 sem). O grupo I incluiu 89% das gr��vidas. Identificaram-se 52 fetos (7%) com anomalias card��acas: 42 estruturais, 8 de ritmo e 2 derrames peric��rdicos. Estas anomalias distribu��ram-se da seguinte forma: grupo I - causa familiar (3), causa materna (3), causa fetal (39), causas minor (5) e no grupo II (2). Observou-se um maior n��mero de anomalias card��acas no grupo I (6,8% vs 0,3%) (p> 0.05), sobretudo nos fetos referenciados por causa fetal (p<0,05). Perderam-se no controlo evolutivo 10 casos positivos, realizaram-se 3 interrup����es m��dicas da gravidez e ocorreram 3 mortes. Mant��m-se em seguimento na consulta de Cardiologia Pedi��trica 11 casos positivos. Conclus��es: Na maioria dos casos cumpriram-se os crit��rios de referencia����o da DGS, no entanto n��o se observou uma diferen��a estatisticamente significativa na preval��ncia de anomalias card��acas fetais nas gr��vidas com e sem factores de risco. A causa fetal foi a que melhor se correlacionou com a presen��a de anomalia card��aca. A preval��ncia destas anomalias e a taxa de mortalidade aferida na amostra pode estar subestimada por perda de casos positivos no controlo evolutivo.

Perinatal Death: Epidemiology and Etiology

Perinatal mortality rate is an important mark to evaluate women and perinatal health care. It is of utmost importance to know causes and the evolution of its two components aiming to improve health care in different fields ��� sanitary conditions, diagnosis and treatment of infectious disease, immunisations, diagnosing and caring for medical diseases induced by pregnancy or directly related to it, providing skilled birth attendance, preventing birth asphyxia, preventing preterm birth complications and infections. In high-income countries the epidemiology varies mainly with social and economic conditions; in low-income countries, paired with poverty, undernutrition, superstition, lack of medical care, deficient basic sanitary conditions are also found. Also, in rich countries, responsible for 1% of deaths, data are published and improvements evaluated, while in low-income countries responsible for 99% of deaths numbers and causes are unknown, making difficult to implement cost effective interventions, a reason why ���stillbirth rates in low-income countries are now where they were in high-income countries 50 to 100 years ago���. Knowledge on causes of death are very important as often what is needed are ���simple��� measures as improvement of sanitary conditions and immunisation programmes rather than high technologies. About four million babies dye each year in the first 28 days of life and another 3 million dye before birth in the third-trimester, with 98% occurring in low-income and middle income countries and more than 1 million occurring during labour and delivery. Classically stillbirths are the major component of perinatal mortality rate. Causes of death are even more difficult to know. In low-income countries a great proportion of women give birth at home. Worldwide the main causes of stillbirth are asphyxia due to obstructed labour, eclampsia, abruption placenta and umbilical cord complications - making valid the assumption that skilled birth attendance would decrease stillbirth; and infection - chorioamnioitis, syphilis and malaria. In high-income countries placental pathology and infection, congenital anomalies, complications of preterm birth and post term delivery, are the most common. If in low-income countries famine and lack of provisions and health care are common, in high-income countries, advanced maternal age and diabetes, obesity, hypertension, smoking, are frequent findings.

Sotalol no Tratamento da Taquicardia Fetal

A taquicardia fetal �� uma situa����o rara, que, quando mantida coloca em risco a vida do feto. O modo de tratamento n��o �� consensual, existindo v��rias modalidades farmacol��gicas. O objectivo deste estudo foi avaliar a efic��cia e seguran��a do sotalol no tratamento de taquicardias fetais. Material e m��todos: Estudo retrospectivo, com base nos registos de consulta e entrevista ��s m��es dos fetos com taquicardia supraventricular, referenciados ao Servi��o de Cardiologia Pedi��trica do Hospital de Santa Marta, durante um per��odo de dez anos. Resultados: Foram diagnosticados oito fetos com taquicardia supraventricular, dos quais seis foram tratados com sotalol. A idade m��dia de gesta����o na apresenta����o foi de 30 semanas. Nenhum feto apresentava cardiopatia estrutural, em dois verificou-se hidropisia fetal e outro apresentou hidrocefalia. A taquicardia era supraventricular em todos, sendo em dois por flutter auricular. Em todos os casos, excepto um, houve convers��o a ritmo sinusal, n��o se registando efeitos secund��rios nas m��es nem mortalidade fetal. No per��odo neonatal em tr��s crian��as foram registados epis��dios de taquicardia supraventricular parox��stica. Conclus��o: O sotalol mostrou-se seguro e eficaz no tratamento das taquicardias fetais, mas, dada a pequenez da amostra, outros estudos mais alargados s��o necess��rios para se tirarem conclus��es v��lidas.

Hipoglic��mia na Gravidez

Hypoglycemia is considered when glycemia values fall below 60 mg/dl and is associated with increased maternal-fetal morbidity and mortality. In a diabetic pregnancy this complication can result from a decrease in caloric ingestion relative to administered insulin. Hypoglycemia can present as a simple adrenergic response or as a neuroglicopenic response that can lead to maternal death and stillbirth. This is the reason why it can rapidly evolve into an obstetric emergency. It is important to possess a pre-defined protocol to guide healthcare professionals regarding the rapid management of this situation. The authors review the scientific literature on the subject of hypoglycemia in pregnancy and propose a protocol to be applied in this situation.

Diabetes e Gravidez. Experi��ncia da Consulta de Medicina Materno-Fetal do Servi��o de Obstetricia e Ginecologia do Hospital de Dona Estef��nia

Os autores realizaram um estudo retrospectivo das 87 gr��vidas vigiadas na Consulta de Diabetes do Hospital de Dona Estef��nia com diabetes pr��-gestacional tipo 1 e 2 e diabetes gestacional, durante um per��odo de 2 anos. Analisararn a idade das gr��vidas, ra��a, paridade, tipo de diabetes, patologia associ ada, antecedentes familiares de diabetes, idade gestacional em que foi feito o diagn��stico de diabetes, insulinoterapia, evolu����o da gravidez, idade gestacional na altura do parto, caracter��sticas do parto e dos rec��m-nascidos e controlo no p��s parto. A maioria das gr��vidas inscritas na consulta tinha idade superior a 30 anos (76%). A diabetes gestacional foi o tipo de diabetes mais frequente na consulta, tendo ocorrido sobretudo no 3�� trirnestre. A hipertens��o arterial cr��nica foi a patologia associada dominante, complicando-se em cinco casos de pr��-ecl��mpsia.Para al��m da pr��-ecl��mpsia, outra das complicac����es mais frequentes foi a infec����oo urin��ria. A cesariana foi o tipo de parto mais frequente. As suas principais indica����es foram a cesariana electiva, a pr��-ecl��mpsia agravada e a disto��cia. A macrossomia fetal s�� ocorreu em 5 dos 60 partos, refletindo um bom controlo metab��lico.

Morte Fetal Tardia: Aspectos Obst��tricos

A morte fetal tardia constitui um desafio para todos os obstetras. Apesar de interven����es efectivas no diagn��stico e terap��utica de algumas patologias como a diabetes gestacional, a pr��-ecl��mpsia e a taxa de morte fetal tardia mant��m-se desde h�� uma d��cada relativamente constante, contribuindo de uma forma significativa para a mortalidade perinatal. Neste artigo �� efectuada uma revis��o de alguns aspectos obst��tricos, uma reflex��o sobre o conhecimento actual do tema.