Acessibilidade e longitudinalidade no pré-natal : análise de um grupo de puérperas atendidas no Hospital Universitário Cassiano Antônio de Moraes

A atenção primária visa garantir cobertura e acesso a cuidados de saúde abrangentes e aceitáveis pela população enfatizando a prevenção e a educação (STARFIELD, 2004). No Brasil a Estratégia Saúde da Família (ESF) é o modelo implantado pelo Ministério da Saúde (MS) com a finalidade de reestruturação da atenção primária e já abrange cerca de 50% da população. Segundo Starfield (2004) a atenção primária pode ser avaliada através de seus atributos essenciais: atenção de primeiro contato (utilização e acessibilidade), longitudinalidade, integralidade e coordenação de cuidados. No contexto da atenção à saúde brasileira, a mortalidade infantil é fato preocupante, principalmente a mortalidade que ocorre nos primeiros dias de vida. Este componente da mortalidade é intimamente relacionado à qualidade da atenção recebida no período gestacional. A atenção pré-natal deve incluir ações organizadas, amplas, integradas e com cobertura abrangente de promoção e prevenção da saúde, além de diagnóstico e tratamento adequado dos problemas que possam vir a ocorrer nesse período. O objetivo do presente estudo foi analisar o pré-natal de um grupo de puérperas quanto aos atributos da atenção primária acessibilidade e longitudinalidade. Para alcançar este objetivo foram realizadas 80 entrevistas com mulheres que realizaram pré-natal na atenção primária e 19 mulheres que realizaram pré-natal no Hospital Universitário Cassiano Antônio de Moraes (HUCAM). Utilizou-se parcialmente o questionário de avaliação da atenção primária PCATool. As puérperas também foram questionadas quanto à percepção da adequação do pré-natal realizado. A acessibilidade foi baixa para a maioria das entrevistadas. Nas puérperas que realizaram o pré-natal na Atenção primária a acessibilidade foi estatisticamente maior naquelas que realizaram pré-natal na ESF e naquelas que utilizaram as unidades de saúde do município de Vitória (ES). A longitudinalidade se relacionou ao tipo de unidade de saúde do pré-natal, ao número de consultas realizadas e ao índice de Ápgar no primeiro minuto. A percepção de um pré-natal adequado se relacionou com a utilização da ESF como serviço de pré-natal e à realização de seis ou mais consultas. Apesar de as puérperas do grupo que realizou o pré-natal no HUCAM perceberem o atendimento pré-natal como adequado, algumas questões revelaram fragilidades na assistência, principalmente quanto ao acesso ao serviço. A impossibilidade de receber atendimento pela equipe fora dos horários de funcionamento do ambulatório, a falta de um número de telefone no qual possam sanar dúvidas ou falar com o médico responsável pelo pré-natal, a percepção de dificuldade na marcação de consultas e a espera prolongada no dia do atendimento são pontos que devem ser melhorados nessa assistência.

Neonatal mortality in intensive care units of Central Brazil

OBJECTIVE: To identify potential prognostic factors for neonatal mortality among newborns referred to intensive care units. METHODS: A live-birth cohort study was carried out in Goiânia, Central Brazil, from November 1999 to October 2000. Linked birth and infant death certificates were used to ascertain the cohort of live born infants. An additional active surveillance system of neonatal-based mortality was implemented. Exposure variables were collected from birth and death certificates. The outcome was survivors (n=713) and deaths (n=162) in all intensive care units in the study period. Cox's proportional hazards model was applied and a Receiver Operating Characteristic curve was used to compare the performance of statistically significant variables in the multivariable model. Adjusted mortality rates by birth weight and 5-min Apgar score were calculated for each intensive care unit. RESULTS: Low birth weight and 5-min Apgar score remained independently associated to death. Birth weight equal to 2,500g had 0.71 accuracy (95% CI: 0.65-0.77) for predicting neonatal death (sensitivity =72.2%). A wide variation in the mortality rates was found among intensive care units (9.5-48.1%) and two of them remained with significant high mortality rates even after adjusting for birth weight and 5-min Apgar score. CONCLUSIONS: This study corroborates birth weight as a sensitive screening variable in surveillance programs for neonatal death and also to target intensive care units with high mortality rates for implementing preventive actions and interventions during the delivery period.

Neonatal sepsis and meningitis caused by Neisseria meningitidis: a case report

OBJECTIVE: To report a full-term newborn infant that developed a sepsis associated to meningitis caused by Neisseria meningitidis serogroup C on the 14th day of life. CASE DESCRIPTION: The patient was a term female infant, born to a mother with Systemic Lupus Erythematosus, with birth weight of 2,610g, Apgar Score 1, 4 and 8, who needed mechanical ventilation for 24 hours. On the 7th day of life, the neonate was discharged from the hospital with good overall condition. On the 15th day of life, the newborn infant presented fever and respiratory failure. The cerebrospinal fluid showed 1042 cells/mm³, with neutrophilic predominance, protein of 435 mg/dL, and glucose < 10 mg/dL. The blood and the cerebrospinal fluid cultures were positive for Neisseria meningitidis serogroup C. The neonate was hospitalized, needing mechanical ventilation and vasoactive drugs, and received 21 days of crystalline penicillin. After hospital discharge, there were no signs of neurological sequels and the infant was able to be breastfed. The case report presents a unique situation: an uncommon etiology of neonatal meningitis and favorable evolution, despite neurological sequels reported in the literature. This report emphasizes the need to prevent the premature exposure of newborn infants to pathological agents, especially if they presented birth injuries and/or are preterm, due to their lack of immunological capacity.

Congenital diaphragmatic hernia : a European population-based study of epidemiology, prenatal diagnosis and mortality

Aim: To study the epidemiology and the impact of prenatal diagnosis on mortality and morbidity in infants with isolated congenital diaphragmatic hernia (CDH). Methods: Cases were identified in eight population-based registries of congenital malformations (Eurocat) in Europe. Results: A total of 183 live births were included in the study. Sixty per cent died and 67% of all deaths were during the first day of life. CDH was diagnosed prenatally in 39% of cases. Both mortality and morbidity were significantly higher for infants diagnosed prenatally compared to those diagnosed postnatally. The Apgar score was a very sensitive indicator for survival. Gestational age at birth was significantly lower for infants diagnosed prenatally compared to those diagnosed postnatally (37.6 weeks vs. 38.8 weeks, p < 0.01). At the end of follow-up, half of the survivors were leading a normal life. The most frequently reported health problems were respiratory and gastrointestinal symptoms. Conclusions: In this population-based study, mortality for infants with CDH was high (60%) and early prenatal diagnosis was a risk factor for survival. Intervention at the time of birth seems too late for the majority of newborn infants with CDH.

Neonatal mortality in infants with low birth weigh

Objective To evaluate the factors associated with neonatal mortality in infant born with low birth weight. Method Cross-sectional study that analyzed data from 771 live births with low birth weight (<2500 g) in the city of Cuiabá, MT, in 2010, of whom 54 died in the neonatal period. We obtained data from the Information System on Live Births and Mortality, by integrated linkage. Results In multiple logistic regression, neonatal mortality was associated with: number of prenatal visits less than 7 (OR=3.80;CI:1,66-8,70); gestational age less than 37 weeks (OR=4.77;CI:1.48-15.38), Apgar score less than 7 at the 1st minute (OR=4.25;CI:1.84-9.81) and the 5th minute (OR=5.72,CI:2.24-14.60) and presence of congenital anomaly (OR=14.39;IC:2.72-76.09). Conclusion Neonatal mortality in infants with low birth weight is associated with avoidable factors through adequate attention to prenatal care, childbirth and infants.


Effect of physical activity during pregnancy on mode of delivery.

OBJECTIVE: The purpose of this study was to evaluate the effect of structured physical exercise programs during pregnancy on the course of labor and delivery. STUDY DESIGN: We conducted a systematic review and metaanalysis using the following data sources: Medline and The Cochrane Library. In our study, we used randomized controlled trials (RCT) that evaluated the effects of exercise programs during pregnancy on labor and delivery. The results are summarized as relative risks. RESULTS: In the 16 RCTs that were included there were 3359 women. Women in exercise groups had a significantly lower risk of cesarean delivery (relative risk, 0.85; 95% confidence interval [CI], 0.73-0.99). Birthweight was not significantly reduced in exercise groups. The risk of instrumental delivery was similar among groups (relative risk, 1.00; 95% CI, 0.82-1.22). Data on Apgar score, episiotomy, epidural anesthesia, perineal tear, length of labor, and induction of labor were insufficient to draw conclusions. With the use of data from 11 studies (1668 women), our analysis showed that women in the exercise groups gained significantly less weight than women in control groups (mean difference, -1.13 kg; 95% CI, -1.49 to -0.78). CONCLUSION: Structured physical exercise during pregnancy reduces the risk of cesarean delivery. This is an important finding to convince women to be active during their pregnancy and should lead the physician to recommend physical exercise to pregnant women, when this is not contraindicated.

Association of moderate alcohol use and binge drinking during pregnancy with neonatal health.

Background:  Heavy drinking and smoking during pregnancy are known to have a negative impact on the unborn child. However, the impact of low-to-moderate alcohol consumption and binge drinking has been debated recently. The aim of this study was to examine the relationship of moderate prenatal drinking and binge drinking with birthweight, being small for gestational age (SGA) at birth, preterm birth, and neonatal asphyxia. Methods:  Moderate alcohol drinking, binge drinking, and several possible confounders were assessed in 1,258 pregnant women; information on neonatal health was obtained at birth. Results:  Results indicate that 30.8% of the women drank at low levels (<2 glasses/wk), 7.9% drank moderately (2 to 4 glasses/wk), and 0.9% showed higher levels of drinking (≥5 glasses/wk); 4.7% reported binge drinking (defined as ≥3 glasses/occasion). 6.4% of the children were SGA (<10th percentile of birthweight adjusted for gestational age), 4.6% were preterm (<37th week of gestation), and 13.0% showed asphyxia (arterial cord pH <7.10 and/or arterial cord lactate >6.35 mmol and/or Apgar score <7 at 5 minutes). When controlling for maternal age, citizenship, occupational status, parity, smoking, use of prescription/over-the-counter drugs, illicit drug use, and child gender moderate drinking was related to lower birthweight (p < 0.01), and moderate drinking and binge drinking were associated with neonatal asphyxia at trend level (p = 0.06 and p = 0.09). Moderate drinking and binge drinking were not related to length of gestation. Conclusions:  In contrast to recent reviews in the field, our results assume that moderate drinking and binge drinking are risk factors for neonatal health.

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.

Pregnancy in women undergoing hemodialysis: case series in a Southeast Brazilian reference center

PURPOSE: To describe maternal and neonatal outcomes in pregnant women undergoing hemodialysis in a referral center in Brazilian Southeast side.METHODS: Retrospective and descriptive study, with chart review of all pregnancies undergoing hemodialysis that were followed-up at an outpatient clinic of high- risk prenatal care in Southeast Brazil.RESULTS: Among the 16 women identified, 2 were excluded due to follow-up loss. In 14 women described, hypertension was the most frequent cause of chronic renal failure (half of cases). The majority (71.4%) had performed hemodialysis treatment for more than one year and all of them underwent 5 to 6 hemodialysis sessions per week. Eleven participants had chronic hypertension, 1 of which was also diabetic, and 6 of them were smokers. Regarding pregnancy complications, 1 of the hypertensive women developed malignant hypertension (with fetal growth restriction and preterm delivery at 29 weeks), 2 had acute pulmonary edema and 2 had abruption placenta. The mode of delivery was cesarean section in 9 women (64.3%). All neonates had Apgar score at five minutes above 7.CONCLUSIONS: To improve perinatal and maternal outcomes of women undergoing hemodialysis, it is important to ensure multidisciplinary approach in referral center, strict control of serum urea, hemoglobin and maternal blood pressure, as well as close monitoring of fetal well-being and maternal morbidities. Another important strategy is suitable guidance for contraception in these women.

Plasma amino acids in pregnancy, placental intervillous space and preterm newborn infants

Plasma amino acid levels have never been studied in the placental intervillous space of preterm gestations. Our objective was to determine the possible relationship between plasma amino acids of maternal venous blood (M), of the placental intervillous space (PIVS) and of the umbilical vein (UV) of preterm newborn infants. Plasma amino acid levels were analyzed by ion-exchange chromatography in M from 14 parturients and in the PIVS and UV of their preterm newborn infants. Mean gestational age was 34 ± 2 weeks, weight = 1827 ± 510 g, and all newborns were considered adequate for gestational age. The mean Apgar score was 8 and 9 at the first and fifth minutes. Plasma amino acid values were significantly lower in M than in PIVS (166%), except for aminobutyric acid. On average, plasma amino acid levels were significantly higher in UV than in M (107%) and were closer to PIVS than to M values, except for cystine and aminobutyric acid (P < 0.05). Comparison of the mean plasma amino acid concentrations in the UV of preterm to those of term newborn infants previously studied by our group showed no significant difference, except for proline (P < 0.05), preterm > term. These data suggest that the mechanisms of active amino acid transport are centralized in the syncytiotrophoblast, with their passage to the fetus being an active bidirectional process with asymmetric efflux. PIVS could be a reserve amino acid space for the protection of the fetal compartment from inadequate maternal amino acid variations.

Association of NOS3 gene variants and clinical contributors of hypoxic-ischemic encephalopathy

The aim of this study was to analyze the association of different clinical contributors of hypoxic-ischemic encephalopathy with NOS3 gene polymorphisms. A total of 110 children with hypoxic-ischemic encephalopathy and 128 control children were selected for this study. Association of gender, gestational age, birth weight, Apgar score, cranial ultrasonography, and magnetic resonance imaging findings with genotypic data of six haplotype-tagging single nucleotide polymorphisms and the most commonly investigated rs1800779 and rs2070744 polymorphisms was analyzed. The TGT haplotype of rs1800783, rs1800779, and rs2070744 polymorphisms was associated with hypoxic-ischemic encephalopathy. Children with the TGT haplotype were infants below 32 weeks of gestation and they had the most severe brain damage. Increased incidence of the TT genotype of the NOS3 rs1808593 SNP was found in the group of hypoxic-ischemic encephalopathy patients with medium and severe brain damage. The probability of brain damage was twice as high in children with the TT genotype than in children with the TG genotype of the same polymorphism. Furthermore, the T allele of the same polymorphism was twice as frequent in children with lower Apgar scores. This study strongly suggests associations of NOS3 gene polymorphism with intensity of brain damage and severity of the clinical picture in affected children.

Impacto de la cesarea en la morbimortalidad materna y perinatal

Introducción: La cesárea es un procedimiento quirúrgico considerado como inocuo por algunas personas, sin tener en cuenta las posibles consecuencias en los embarazos siguientes. Existe literatura que evidencia un aumento en el riesgo para abrupcio de placenta, acretismo placentario, placenta previa, mortalidad materna, sepsis materna, ingreso a UCI, al igual que apgar bajo, bajo peso neonatal, distress respiratorio,entre otros.El objetivo de este estudio fue evaluar el impacto del antecedente de cesárea en la morbilidad materna y neonatal mediante una revisión sistemática de literatura. Metodología Se realizó una búsqueda en diferentes bases de datos desde 1996 hasta 2011 sobre el antecedente de cesárea y sus posibles riesgos en el desenlace maternos y perinatales. Se utilizaron variaciones de términos MeSH. Resultados La búsqueda arrojó un total de 2.483 artículos, entre los cuales fueron escogidos 247 por criterios de elegibilidad.Estos fueron evaluados en su totalidad. Posteriormente se realizó el análisis metanalítico de cada uno de los desenlaces. Los resultados deben interpretarse con precaución pues la calidad metodológica de algunos estudios fue variable. En el riesgo conjunto se encontraron resultados estadísticamente significativos en placenta previa, apgar bajo, histerectomía periparto. Discusión El antecedente de cesárea presenta un riesgo aumentado para los siguientes embarazos en la morbilidad tanto materna como neonatal. Faltan más estudios analíticos para definir el verdadero papel de la cesarea.

Prevalencia de TSH neonatal elevada y factores perinatales relacionados con asfixia Bogotá 2012

Introducción: la asfixia perinatal es la tercera causa de muerte en menores de 5 años. Las secuelas neurológicas suponen una carga importante para las familias y los sistemas de salud (1). Los estudios que relacionan el efecto de la asfixia perinatal sobre las hormonas tiroideas son escasos. El estudio sobre predictores de asfixia es un tema de investigación permanente. El objetivo principal fue determinar la prevalencia de TSH de cordón elevada y su relación con factores perinatales asociados a asfixia. Métodos: estudio descriptivo retrospectivo. La muestra estuvo conformada por todos los recién nacidos con TSH de cordón elevada y un segundo grupo seleccionado de forma aleatoria con TSH de cordón normal. Tomada de una población de neonatos atendidos en una clínica de Bogotá durante el 2012. Resultados: la prevalencia de TSH de cordón elevada fue de 14,7%. Los resultados sugieren una posible asociación entre alteraciones en las pruebas de bienestar fetal, presencia de infección materna, parto distócico, dificultad respiratoria y APGAR bajo y la presencia de TSH elevada p<0,05. Discusión: La alta prevalencia de TSH de cordón elevada podría relacionarse con las características de alto riesgo que presenta esta población. La elevación transitoria de la TSH neonatal de cordón en neonatos con alteraciones del bienestar fetal asociada a eventos hipóxicos agudos, sugiere que esta hormona podría ser un marcador de asfixia perinatal.

Seguimento clinoceletrográfico de criançcas e adolescentes com crise epiléptica única não-provocada

Os fenômenos convulsivos despertaram o interesse de estudiosos e pensadores já na Antigüidade, quando aspectos mágicos e sobrenaturais eram a eles associados. No século XIX foram lançadas as bases dos conceitos atuais sobre a desestruturação funcional cerebral na epilepsia, e Berger, em 1929, marcou definitivamente a história com a descoberta dos ritmos cerebrais. Crise epiléptica e epilepsia não são sinônimos, já que o último termo refere-se a crises recorrentes espontâneas. Ela costuma iniciar na infância, daí a preocupação com o risco de repetição do primeiro episódio e com a decisão de instituir tratamento medicamentoso. Fatores prognósticos são apontados, mas não há consenso. No Brasil existem poucas pesquisas nesta linha, tanto de prevalência da epilepsia como de fatores envolvidos na recorrência de crises. Este estudo teve como objetivo geral avaliar aspectos clinicoeletrográficos capazes de auxiliar no prognóstico e no manejo da epilepsia da criança e do adolescente. Foram objetivos específicos determinar a incidência de crise epiléptica não provocada recorrente; identificar fatores remotos implicados na ocorrência de crise epiléptica; relacionar tipo de crise com achados eletrencefalográficos; relacionar tipo de crise, duração da crise, estado vigília/sono no momento da crise e achados eletrencefalográficos com possibilidade de recorrência; e identificar os fatores de risco para epilepsia. Foram acompanhados 109 pacientes com idades entre 1 mês e 16 anos, com primeira crise não-provocada, em média por 24 meses, a intervalos trimestrais, no Hospital de Clínicas de Porto Alegre (HCPA). Foram realizados eletrencefalogramas (EEG) após a primeira crise; depois, solicitados anualmente. Não foram incluídos casos com epilepsia ou síndrome epiléptica bem definida, ou que fizeram uso prévio de drogas antiepilépticas. A média de idade foi 6 anos, com predomínio da faixa etária de 6 a 12 anos. Setenta eram meninos e 39, meninas. Os indivíduos brancos eram 92, e os não-brancos, 17. O nível de escolaridade dos casos esteve de acordo com a distribuição da idade e, entre os responsáveis, predominaram 8 anos de escolaridade. Foi possível concluir que as crises únicas não-provocadas mais freqüentes foram generalizadas, e sem predomínio significativo do tipo de EEG. A incidência de crise não-provocada recorrente foi 51,4%. História de intercorrências pré-natais maternas aumentou em 2 vezes o risco de repetição de crises. Via de nascimento, escore de Apgar no 5º minuto, relação peso ao nascer/idade gestacional, intercorrências no período pós-natal imediato e desenvolvimento neuropsicomotor não tiveram influência na recorrência. História familiar de crises mostrou tendência à significância estatística para repetição dos episódios, com risco de 1,7. Não foi encontrada associação entre tipo de crise e achado eletrencefalográfico. A maioria das crises foi de curta duração (até 5 minutos), mas este dado não esteve relacionado com a recorrência. Estado de vigília teve efeito protetor na recorrência. Se a primeira crise foi parcial, o risco de repetição foi 1,62, com tendência à significância. Quando o primeiro EEG foi alterado, houve relação significativa com primeira crise tanto generalizada como parcial. O primeiro EEG com alterações paroxísticas focais apontou risco de repetição de 2,90. Quando as variáveis envolvidas na repetição de crises foram ajustadas pelo modelo de regressão de Cox, EEG alterado mostrou risco de 2,48, com riscos acumulados de 50%, 60%, 62% e 68%; com EEG normal, os riscos foram 26%, 32%, 34% e 36% em 6, 12, 18 e 24 meses respectivamente.

Desenvolvimento neurológico e resposta apendicular ao movimento do tronco de crianças prematuras, durante o primeiro ano de vida

A ausência de estudos de acompanhamento do desenvolvimento neurológico de crianças nascidas prematuras, em nosso meio, motivou a realização desta pesquisa. Com o intuito de estabelecer marcos desse desenvolvimento e de verificar as respostas apendiculares ao movimento do tronco e a uniformidade entre as funções motoras, perceptivas e de linguagem, foram avaliados prematuros aos 3, 6, 9 e 12 meses de idade corrigida, em um estudo de coorte não controlado, com enfoque prognóstico. As respostas apendiculares ao movimento do tronco foram estudadas por meio das reações de paraquedismo e de apoio lateral. A amostra foi constituída de 40 recém-nascidos (RN) prematuros, nascidos no Hospital de Clínicas de Porto Alegre, que foram acompanhados no ambulatório do hospital aos 3, 6, 9 e 12 meses de idade corrigida. Foram incluídos no estudo RN com idade gestacional até 36 semanas e 6 dias, com 2.000g ou menos de peso no nascimento. Foram excluídos os RN com índices de Apgar <7 no 5o minuto, hemorragia cerebral, crises convulsivas, alterações no estado de consciência, infecção do sistema nervoso central (SNC), infecções congênitas, síndromes genéticas e intoxicações pré-natais. Também foram excluídos os RN que apresentaram intercorrências capazes de interferir no desenvolvimento neurológico e os que apresentaram exame neurológico alterado. As reações de paraquedismo e de apoio lateral estavam ambas presentes em 8,1% das crianças aos 6 meses de idade corrigida. Aos 9 meses de idade corrigida, a reação de paraquedismo estava presente em 87% das crianças e a reação de apoio lateral, em 90%. Aos 12 meses de idade corrigida, 100% dos casos apresentaram as reações posturais. Estes resultados não foram semelhantes aos encontrados em RN de termo de 6 e 9 meses de idade. O desenvolvimento do RN prematuro foi uniforme em relação às funções perceptivas e de linguagem para as idades corrigidas de 3, 6, 9 e 12 meses de idade corrigida. O desenvolvimento do equilíbrio estático foi o aspecto motor em desacordo com o esperado para cada idade corrigida. A evolução dos reflexos primitivos coincidiu com o esperado para cada idade corrigida; e o reflexo cutâneo-plantar se tornou flexor simultaneamente ao desaparecimento da preensão plantar.