Cardiotocografia Anteparto e Prognóstico Perinatal em Gestações Complicadas pelo Diabete: Influência do Controle Metabólico Materno

Objetivo: relacionar a qualidade do controle metabólico com os resultados da cardiotocografia (CTG) anteparto e avaliar sua capacidade preditiva no prognóstico perinatal de gestações associadas ao diabete. Pacientes e Métodos: estudo retrospectivo de 125 gestantes, portadoras de diabete gestacional ou clínico, no qual se relacionou a última CTG anteparto (intervalo máximo de 48 horas) à qualidade do controle metabólico materno e aos resultados perinatais. A qualidade do controle metabólico foi definida pela média glicêmica do dia do exame (MGd) e da gestação (MG) e pelo comportamento da requisição de insulina (R/insulina). Para os resultados perinatais foram analisados os índices de Apgar de 1º e 5º minuto, a classificação peso/idade gestacional, o tempo de internação, a necessidade de cuidados de UTI e a ocorrência de óbito neonatal (ONN) precoce. A capacidade diagnóstica da CTG anteparto foi avaliada pelos índices de sensibilidade, especificidade e valor preditivo positivo e negativo. Resultados: a MGd adequada (<120 mg/dL) associou-se a 2,9% dos resultados de CTG anteparto alterados e a inadequada ( > ou = 120 mg/dL), a 26,1% (p<0,005). A MG mantida inadequada se relacionou a 13,7% de CTG anteparto alterada e a adequada, a apenas 2,7% (p<0,005). O comportamento da requisição de insulina não interferiu nos resultados da CTG anteparto. Os índices de Apgar de 1º e 5º minuto, a necessidade de cuidados de UTI e a ocorrência de ONN precoce não dependeram do último traçado da CTG anteparto. O exame diferenciou o tempo de internação dos recém-nascidos: quando normal, 46,4% tiveram alta hospitalar até o 3º dia de vida e, quando alterado, 62,5% deles ficaram internados por mais de sete dias. Conclusões: os resultados alterados da última CTG anteparto relacionaram-se com níveis inadequados de MG, diária e da gestação, e não dependeram da R/insulina. O resultado normal da CTG anteparto foi adequado para garantir a saúde neonatal. Ao contrário, os resultados alterados indicaram risco de complicações nos filhos de mães diabéticas.

Influência do controle metabólico materno nos resultados da cardiotocografia anteparto e sua relação com o prognóstico perinatal, nas gestações complicadas pelo diabete

Pós-graduação em Ginecologia, Obstetrícia e Mastologia - FMB

Percutaneous Laser Ablation of Sacrococcygeal Teratoma in a Hydropic Fetus with Severe Heart Failure - Too Late for a Surgical Procedure?

Sacrococcygeal teratoma (SCT) is the commonest solid fetal tumor. Perinatal prognosis is usually favorable, but sometimes it can be complicated by fetal hydrops being responsible for high risk of mortality. Fetal therapy in such cases has so far not been established. We report a case with a giant solid SCT associated with fetal hydrops and severe heart failure. 2D- and 3D-Doppler ultrasonography revealed great vessels originated from the medial sacral artery. Percutaneous laser ablation of these vessels was performed at 24 weeks of gestation. During the procedure, severe anemia was also diagnosed (hemoglobin 4.3 g/dl). Two days later, the fetus died and pathological examination revealed local tumor necrosis and blood hemorrhage inside the mass. We suggest that in such cases, fetal surgery may not be enough, being too late, and perhaps fetal clinical therapy for anemia and heart failure could be the best option at a gestational age of less than 28 weeks. Copyright (C) 2009 S. Karger AG, Basel

Avaliação do papel da ultra-sonografia obstétrica de rotina, no rastreamento pré-natal das anormalidades cardíacas

A ultra-sonografia obstétrica é um método diagnóstico tradicionalmente utilizado na rotina do atendimento pré-natal, tendo sido estudados de forma ampla suas vantagens e limitações. O advento do diagnóstico intra-uterino de cardiopatias congênitas e de arritmias através da ecocardiografia fetal modificou completamente o prognóstico perinatal dessas afecções, por permitir planejar o adequado manejo cardiológico no período neonatal imediato e, em algumas situações, o tratamento e sua resolução in utero. Sendo muito elevada a prevalência de cardiopatias congênitas durante a vida fetal, sua detecção torna-se fundamental. Considerando a inviabilidade operacional de realizar rotineiramente ecocardiografia fetal em todas as gestações, levando-se em conta as condições locais do sistema de saúde, o encaminhamento para exame por especialista passa a ser otimizado com a possibilidade da suspeita de alterações estruturais ou funcionais do coração e do sistema circulatório durante o exame ultra-sonográfico obstétrico de rotina. Não são conhecidos, em nosso meio, dados que avaliem de forma sistemática a acurácia da ultra-sonografia obstétrica no que se refere à suspeita pré-natal de cardiopatias. A partir deste questionamento, este trabalho foi delineado com o objetivo de avaliar o papel da ultra-sonografia obstétrica de rotina na suspeita pré-natal de cardiopatias congênitas ou arritmias graves e os fatores envolvidos na sua efetividade. A amostra foi constituída de 77 neonatos ou lactentes internados no Instituto de Cardiologia do Rio Grande do Sul / Fundação Universitária de Cardiologia (IC/FUC) no período de maio a outubro de 2000, com diagnóstico pós-natal confirmado de cardiopatia estrutural ou arritmia grave, que tenham sido submetidos, durante a vida fetal, a pelo menos uma ultra-sonografia obstétrica após a 18a semana de gestação. Para a coleta de dados, foi utilizado um questionário padronizado, respondido pelos pais ou responsáveis, após consentimento informado. As variáveis categóricas foram comparadas pelo teste do qui-quadrado ou pelo teste de Fisher, com um alfa crítico de 0,05. Um modelo de regressão logística foi utilizado para determinar variáveis independentes eventualmente envolvidas na suspeita pré-natal de cardiopatia. Em 19 pacientes (24,7%), a ultra-sonografia obstétrica foi capaz de levantar suspeita de anormalidades estruturais ou de arritmias. Ao serem consideradas apenas as cardiopatias congênitas, esta prevalência foi de 19,2% (14/73). Em 73,7% destes, as cardiopatias suspeitadas eram acessíveis ao corte de 4-câmaras isolado. Observou-se que 26,3% das crianças com suspeita pré-natal de cardiopatia apresentaram arritmias durante o estudo ecográfico, enquanto apenas 3,4% dos pacientes sem suspeita pré-natal apresentaram alterações do ritmo (P=0,009). Constituiram-se em fatores comparativos significantes entre o grupo com suspeita pré-natal e o sem suspeita a paridade (P=0,029), o parto cesáreo (P=0,006), a internação em unidade de tratamento intensivo (P=0,046) e a escolaridade paterna (P=0,014). Não se mostraram significativos o número de gestações, a história de abortos prévios, o estado civil, o sexo dos pacientes, o tipo de serviço e a localidade em que foram realizados o pré-natal e a ultra-sonografia obstétrica, a indicação da ecografia, o número de ultra-sonografias realizadas, a renda familiar e a escolaridade materna. À análise multivariada, apenas a presença de alteração do ritmo cardíaco durante a ultra-sonografia obstétrica mostrou-se como variável independente associada à suspeita pré-natal de anormalidade cardíaca. Este trabalho demonstra que a ultra-sonografia obstétrica de rotina ainda tem sido subutilizada no rastreamento pré-natal de cardiopatias congênitas, levantando a suspeita de anormalidades estruturais em apenas um quinto dos casos. Considerando a importância prognóstica do diagnóstico intra-uterino de cardiopatias congênitas e arritmias graves, todos os esforços devem ser mobilizados no sentido de aumentar a eficácia da ecografia obstétrica de rotina para a suspeita de anormalidades cardíacas fetais. O treinamento dirigido dos ultra-sonografistas e a conscientização do meio obstétrico e da própria população são instrumentos para esta ação.

Síndromes hipertensivas da gestação: identificação de casos graves

A hipertensão arterial está entre as causas mais freqüentes de morte materna. Entre os tipos presentes na gravidez destacam-se as manifestações específicas, isto é, a pré-eclâmpsia e a hipertensão gestacional, definidas clinicamente por aumento dos níveis da pressão arterial após a 20ª semana de gestação, associado (pré-eclâmpsia) ou não (hipertensão gestacional) à proteinúria. Na fase inicial a doença é assintomática, porém, quando não tratada ou não se interrompe a gestação, sua evolução natural é desenvolver as formas graves, como a eclâmpsia e a síndrome HELLP. Eclâmpsia é definida pela manifestação de uma ou mais crises convulsivas tônico-clônicas generalizadas e/ou coma, em gestante com hipertensão gestacional ou pré-eclâmpsia, na ausência de doenças neurológicas. Pode ocorrer durante a gestação, durante o trabalho de parto e no puerpério imediato. É comumente precedida pelos sinais e sintomas de eclâmpsia iminente (distúrbios do sistema nervoso central, visuais e gástricos). A associação de hemólise, plaquetopenia e disfunção hepática já era relatada na literatura na década de cinqüenta. em 1982, Weinstein reuniu estas alterações sob o acrônimo de HELLP, significando hemólise (H), aumento de enzimas hepáticas (EL) e plaquetopenia (LP), e denominou-as de síndrome HELLP. A literatura diverge em relação aos valores dos parâmetros que definem a síndrome. Sibai et al. (1986) propuseram sistematização dos padrões laboratoriais e bioquímicos para o diagnóstico da mesma, que foi adotada pelo Ministério da Saúde do Brasil. As manifestações clínicas podem ser imprecisas, sendo comuns queixas como dor epigástrica, mal-estar geral, inapetência, náuseas e vômitos. O diagnóstico precoce é, eminentemente, laboratorial e deve ser pesquisado de maneira sistemática nas mulheres com pré-eclâmpsia grave/eclâmpsia e/ou dor no quadrante superior direito do abdome. Diferenciar a síndrome HELLP de outras ocorrências, com manifestações clínicas e/ou laboratoriais semelhantes, não é tarefa fácil. O diagnóstico diferencial é particularmente difícil para doenças como púrpura trombocitopênica trombótica, síndrome hemolítico-urêmica e fígado gorduroso agudo da gravidez, devido à insuficiente história clínica e à semelhança dos aspectos fisiopatológicos. O conhecimento da fisiopatologia da pré-eclâmpsia, o diagnóstico precoce e a atuação precisa no momento adequado nas situações complicadas pela eclâmpsia e/ou síndrome HELLP permitem melhorar o prognóstico materno e perinatal.

Diabetes and pregnancy: An update of the problem

Pregnancies complicated by diabetes account for about 7% of all pregnancies attended by the Brazilian Unified Healthcare System (SUS) and are one of the main causes of maternal/perinatal morbidity and mortality in Brazil. Considering the importance of this topic, this article presents an update of diabetes classification, diagnostic criteria, maternal/perinatal outcomes, and both clinical and obstetric prenatal care. Even though there is no consensus about screening and diagnostic standards, the investigation of hyperglycemia in all risk pregnancies is recommended. The importance of adequate metabolic control is emphasized in order to improve maternal and neonatal outcomes. Finally, the development of educational programs is encouraged, viewing not only good gestational outcome but also long-term changes in the lifestyle of these women. © by São Paulo State University.

Perinatal care at the limit of viability between 22 and 26 completed weeks of gestation in Switzerland.

Perinatal care of pregnant women at high risk for preterm delivery and of preterm infants born at the limit of viability (22-26 completed weeks of gestation) requires a multidisciplinary approach by an experienced perinatal team. Limited precision in the determination of both gestational age and foetal weight, as well as biological variability may significantly affect the course of action chosen in individual cases. The decisions that must be taken with the pregnant women and on behalf of the preterm infant in this context are complex and have far-reaching consequences. When counselling pregnant women and their partners, neonatologists and obstetricians should provide them with comprehensive information in a sensitive and supportive way to build a basis of trust. The decisions are developed in a continuing dialogue between all parties involved (physicians, midwives, nursing staff and parents) with the principal aim to find solutions that are in the infant's and pregnant woman's best interest. Knowledge of current gestational age-specific mortality and morbidity rates and how they are modified by prenatally known prognostic factors (estimated foetal weight, sex, exposure or nonexposure to antenatal corticosteroids, single or multiple births) as well as the application of accepted ethical principles form the basis for responsible decision-making. Communication between all parties involved plays a central role. The members of the interdisciplinary working group suggest that the care of preterm infants with a gestational age between 22 0/7 and 23 6/7 weeks should generally be limited to palliative care. Obstetric interventions for foetal indications such as Caesarean section delivery are usually not indicated. In selected cases, for example, after 23 weeks of pregnancy have been completed and several of the above mentioned prenatally known prognostic factors are favourable or well informed parents insist on the initiation of life-sustaining therapies, active obstetric interventions for foetal indications and provisional intensive care of the neonate may be reasonable. In preterm infants with a gestational age between 24 0/7 and 24 6/7 weeks, it can be difficult to determine whether the burden of obstetric interventions and neonatal intensive care is justified given the limited chances of success of such a therapy. In such cases, the individual constellation of prenatally known factors which impact on prognosis can be helpful in the decision making process with the parents. In preterm infants with a gestational age between 25 0/7 and 25 6/7 weeks, foetal surveillance, obstetric interventions for foetal indications and neonatal intensive care measures are generally indicated. However, if several prenatally known prognostic factors are unfavourable and the parents agree, primary non-intervention and neonatal palliative care can be considered. All pregnant women with threatening preterm delivery or premature rupture of membranes at the limit of viability must be transferred to a perinatal centre with a level III neonatal intensive care unit no later than 23 0/7 weeks of gestation, unless emergency delivery is indicated. An experienced neonatology team should be involved in all deliveries that take place after 23 0/7 weeks of gestation to help to decide together with the parents if the initiation of intensive care measures appears to be appropriate or if preference should be given to palliative care (i.e., primary non-intervention). In doubtful situations, it can be reasonable to initiate intensive care and to admit the preterm infant to a neonatal intensive care unit (i.e., provisional intensive care). The infant's clinical evolution and additional discussions with the parents will help to clarify whether the life-sustaining therapies should be continued or withdrawn. Life support is continued as long as there is reasonable hope for survival and the infant's burden of intensive care is acceptable. If, on the other hand, the health care team and the parents have to recognise that in the light of a very poor prognosis the burden of the currently used therapies has become disproportionate, intensive care measures are no longer justified and other aspects of care (e.g., relief of pain and suffering) are the new priorities (i.e., redirection of care). If a decision is made to withhold or withdraw life-sustaining therapies, the health care team should focus on comfort care for the dying infant and support for the parents.

MRI following severe perinatal asphyxia: preliminary experience.

In 30 children suffering from severe perinatal asphyxia an attempt was made to determine the early prognostic signs of severe hypoxic-ischemic brain injury with magnetic resonance imaging (MRI). Ten early (1-4 days of age), 16 intermediate (2-4 weeks of age), and 38 late MRI (older than 1 month of age) procedures were performed on a 2.35 T MR-system. Severe cerebral necrosis was suspected by T2 hyperintensity of the white matter, with blurred limits to the cortex in early MRI, and was confirmed by T1 hyperintensity of the cortex in intermediate MRI. Severe cerebral necrosis was established at 3 months of age. Of the 11 children with this pattern (group A), 8 had severe and 3 had moderate cerebral palsy on subsequent examination. Thirteen children (group B) had normal late MRI scans; none developed severe cerebral palsy or marked mental retardation. Two children (group C) had focal ischemic lesions. Four children had intracranial hemorrhage (group D). Groups A and B did not differ in the severity of their perinatal histories and findings, suggesting that MRI during the first 3 months is of significant prognostic value.

Perinatal arrhythmias.

Cardiac arrhythmias are very frequent in fetuses and newborns. The prognosis depends on the nature of the arrhythmias but is most often either spontaneously benign or following short-term medication administration. A correct diagnosis is essential for both management and prognosis. It is based on echocardiography during the fetal period and mainly on history, physical exam, and electrocardiogram after birth, but other modalities are available to record transient arrhythmic events. Irregular rhythms are mostly benign and rarely require therapy. In most fetuses and infants, tachyarrhythmias resolve spontaneously or require short-term administration of antiarrhythmics. Approximately one third of these may recur later on, especially during adolescence. Persistent bradyarrhythmias might require pacemaker implantation when associated with failure to thrive or with risk of sudden death. CONCLUSION: Arrhythmias in fetuses and infants are very common and mostly benign. History, physical exam, and recording of the arrhythmia are essential to make a correct diagnosis and establish an appropriate management for the rare potentially harmful arrhythmias.

Impaired chemical coupling of cerebral blood flow is compatible with intact neurological outcome in neonates with perinatal risk factors.

Early detection of pathophysiological factors associated with permanent brain damage is a major issue in neonatal medicine. The aim of our study was to evaluate the significance of the CO2 reactivity of cerebral blood flow (CBF) in neonates with perinatal risk factors. Fourteen ventilated neonates with perinatal risk factors (pathological cardiotocogramm, low cord pH, postpartal encephalopathy) were enrolled into this prospective study. The study was performed 18-123 h after birth. CBF was measured using the noninvasive intravenous 133Xe method. Two measurements were taken with a minimal PaCO2-difference of 5 mm Hg. From the two CBF values the CO2 reactivity was calculated. Outcome was evaluated 1 year after birth. The CBF values at a lower PaCO2 ranged from 6.6 to 115. 2 ml/100 g brain issue/min (median = 18.2) and at a higher PaCO2 level from 7.1 to 125.7 ml/100 g brain tissue/min (median = 18.75). The calculated CO2 reactivity ranged from -9.6 to 6.6% (median 1.1%) change in CBF/mm Hg change in PaCO2. CO2 reactivity correlated with lowest pH (r2 = 0.35, p = 0.02). Two infants died, one of neonatal sepsis, the other of heart failure. Neurological outcome at the age of 1 year was normal in 11 patients, 1 had severe cerebral palsy. From the 12 surviving patients the patient with severe neurological deficit showed the highest CBF values (125.7 ml/100 g/min). Impaired chemical coupling of cerebral blood flow is compatible with intact neurological outcome in neonates with perinatal risk factors. CO2 reactivity in these newborns correlates with the lowest pH and may reflect the severity of perinatal asphyxia.

Prognostic value of early MR imaging in term infants with severe perinatal asphyxia.

The prognostic significance of magnetic resonance imaging (MRI) in the neonatal period was studied prospectively in 43 term infants with perinatal asphyxia. MRI was performed between 1 and 14 days after birth with a high field system (2.35 Tesla). Neurodevelopmental outcome was assessed by a standardized neurological examination and the Griffiths developmental test at a mean age of 18.9 months. The predictive value of the various MRI patterns was as follows: Severe diffuse brain injury (pattern AII+III; n = 7) and lesions of thalamus and basal ganglia (pattern C; n = 5) were strongly associated with poor outcome and greatly reduced head growth. Mild diffuse brain injury (pattern AI; n = 7), parasagittal lesions (B; n = 7), periventricular hyperintensity (D; n = 2), focal brain necrosis and hemorrhage (E; n = 3) and periventricular hypointense stripes (on T2-weighted images; F; n = 3) led in one third of the infants to minor neurological disturbances and mild developmental delay. Infants with normal MRI findings (G; n = 9) developed normally with the exception of one infant who was mildly delayed at 18 months. The results indicate that MRI examination during the first two weeks of life is of prognostic significance in term infants suffering from perinatal asphyxia. Severe hypoxic-ischemic brain lesions were associated highly significantly with poor neuro-developmental outcome, whereas infants with inconspicuous MRI developed normally.

Hour of birth as a prognostic factor for perinatal death.

The analysis of the 220,540 births and 2152 perinatal deaths recorded in Switzerland between 1979 and 1981 showed a variation of perinatal mortality rates (PMR) according to the hour of birth. The PMR for babies born between 4 pm and 2 am was 12 per 1000, contrasting with a figure of 8.4 per 1000 for babies born between 2 am and 4 pm. This pattern, which was fairly constant throughout the week, was characterised by a slow and steady increase from the very early morning, reaching a maximum in the late evening. There was also an hour-to-hour variation in the proportion of babies born weighing less than 2500 g, with a maximum in the evening and a less pronounced peak in the morning: the mortality rates by birthweight were raised only in the evening. Since the availability of hospital staff and equipment also follows a circadian rhythm, the variation in PMR may be related to a circadian rhythm of quality of care or possibly to chronobiological or selection factors.

Diagnostic and prognostic value of cerebral 31P magnetic resonance spectroscopy in neonates with perinatal asphyxia.

The impact of depressed neonatal cerebral oxidative phosphorylation for diagnosing the severity of perinatal asphyxia was estimated by correlating the concentrations of phosphocreatine (PCr) and ATP as determined by magnetic resonance spectroscopy with the degree of hypoxic-ischemic encephalopathy (HIE) in 23 asphyxiated term neonates. Ten healthy age-matched neonates served as controls. In patients, the mean concentrations +/- SD of PCr and ATP were 0.99 +/- 0.46 mmol/L (1.6 +/- 0.2 mmol/L) and 0.99 +/- 0.35 mmol/L (1.7 +/- 0.2 mmol/L), respectively (normal values in parentheses). [PCr] and [ATP] correlated significantly with the severity of HIE (r = 0.85 and 0.9, respectively, p < 0.001), indicating that the neonatal encephalopathy is the clinical manifestation of a marred brain energy metabolism. Neurodevelopmental outcome was evaluated in 21 children at 3, 9, and 18 mo. Seven infants had multiple impairments, five were moderately handicapped, five had only mild symptoms, and four were normal. There was a significant correlation between the cerebral concentrations of PCr or ATP at birth and outcome (r = 0.8, p < 0.001) and between the degree of neonatal neurologic depression and outcome (r = 0.7). More important, the outcome of neonates with moderate HIE could better be predicted with information from quantitative 31P magnetic resonance spectroscopy than from neurologic examinations. In general, the accuracy of outcome predictability could significantly be increased by adding results from 31P magnetic resonance spectroscopy to the neonatal neurologic score, but not vice versa. No correlation with outcome was found for other perinatal risk factors, including Apgar score.

Resultado perinatal de fetos com malformações do trato urinário

PURPOSE: to evaluate the perinatal outcome of fetuses with congenital anomalies of the urinary tract. METHODS: we reviewed the perinatal outcome of 35 fetuses with congenital anomalies of the urinary tract. The following characteristics related to the uropathy were analyzed: type (hydronephrosis, dysplasia and renal agenesis), side of lesion (bilateral or unilateral), and level of the obstruction (high or low, in hydronephrosis). The perinatal outcome was evaluated according to these characteristics. The data were analyzed by the c² test and by the exact Fisher test. The level of significance was 0.05. RESULTS: the incidence of hydronephrosis was 68.6%. Half of the fetuses had unilateral hydronephrosis. Renal dysplasia occurred in 17.1% of the cases; 83.3% of these were bilateral and 16.7%, unilateral. The incidence of renal agenesis was 14.3%, all bilateral. The fetuses with dysplasia/agenesis had a 91% incidence of oligohydramnios, preterm birth, low birth weight, and death. In the group with bilateral disease the presence of oligohydramnios, preterm birth, low birth weight, death, urinary tract infections, and the need of hospitalization for a period greater than 7 days was significant when compared to the group with unilateral disease. The need of hospitalization for a period greater than 7 days in patients with low obstruction was significantly higher when compared to the patients with high obstruction. CONCLUSIONS: hydronephrosis, bilateral disease, and lower obstruction were the most frequent uropathies. The dysplasia/agenesis group had a worse prognosis when compared with the hydronephrosis group. Bilateral disease had a worse prognosis when compared with the unilateral disease group. In the low obstruction group, the need for a period of hospitalization greater than seven days was higher than in the high obstruction group.

Avaliação das subclasses IgG1 e IgG3 na doença hemolítica perinatal

A doença hemolítica perinatal (DHPN) ainda é um problema clínico. Nenhum teste isolado prediz, com segurança, a gravidade do quadro hemolítico. O objetivo do presente estudo foi determinar as subclasses de anticorpos IgG1 e IgG3 por citometria de fluxo no soro de 42 gestantes isoimunizadas e correlacionar os dados obtidos com a gravidade da DHPN. A distribuição dos fetos ou neonatos segundo a gravidade do quadro hemolítico evidenciou 13 casos com doença leve, 16 casos com doença moderada e 13 com doença grave. As subclasses foram detectadas em 33/42 (79%) amostras. A subclasse IgG1, isoladamente, foi evidenciada em 14/33 (42,4%) casos. Na relação entre gravidade da doença e subclasses de IgG, observou-se que IgG1 isolada foi encontrada em todos os grupos, e os valores da mediana de intensidade de fluorescência (MIF) foram significativamente mais altos nas formas mais graves da DHPN (p<0,01). Contrariamente, os valores da MIF para IgG3 se apresentaram mais homogêneos em todas as categorias (p=0,11). A presença de IgG3 parece, portanto, estar mais associada à hemólise leve. A associação das subclasses IgG1 e IgG3 está relacionada à situação clínica mais grave, o que se deve, possivelmente, à presença de IgG1 associada. Apesar dos altos valores para IgG1 e a associação de IgG1 com IgG3 indicarem maior gravidade da DHPN, sugere-se que outras variáveis sejam analisadas conjuntamente, uma vez que os relatos existentes na literatura, até o momento, não dão suporte para seu uso como instrumento exclusivo de avaliação de gravidade e prognóstico da doença.