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.

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.

Partial HELLP Syndrome: maternal and perinatal outcome

CONTEXTO: A síndrome HELLP é uma grave complicação da gestação caracterizada por hemólise, elevação das enzimas hepáticas e plaquetopenia. Algumas gestantes desenvolvem somente uma ou duas dessas características da síndrome HELLP. Esse quadro é denominado de síndrome HELLP parcial (SHP). OBJETIVO: O objetivo deste estudo foi avaliar as repercussões maternas e perinatais das mulheres que desenvolveram SHP e comparar os resultados com mulheres que tiveram hipertensão gestacional ou pré-eclâmpsia sem alterações dos exames laboratoriais para síndrome HELLP. TIPO DE ESTUDO: Observacional, retrospectivo e analítico. LOCAL: Maternidade do Hospital das Clínicas da Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, São Paulo, Brasil. AMOSTRA: Foram selecionadas gestantes ou puérperas que tiveram elevação dos níveis pressóricos detectada pela primeira vez após a primeira metade da gestação com ou sem proteinúria entre janeiro/1990 a dezembro/1995. As mulheres foram divididas em dois grupos: Grupo SHP quando as mulheres com hipertensão arterial tinham pelo menos uma, mas não todas as alterações de exames que demonstravam hemólise, elevação das enzimas hepáticas ou plaquetopenia e Grupo Hipertensas pacientes com hipertensão sem alterações nos exames laboratoriais para síndrome HELLP. PRINCIPAIS VARIÁVEIS: Analisamos idade materna, raça, paridade, classificação da hipertensão, idade gestacional no diagnóstico da SHP, alterações nos exames laboratoriais para síndrome HELLP, tempo de permanência no hospital, complicações maternas, via de parto, incidência de prematuridade, restrição de crescimento intra-uterino, natimortos e neomortos. RESULTADOS: 318 mulheres foram selecionadas, das quais 41 (12,9%) tiveram SHP e 277 (87,1%) não desenvolveram alterações dos exames laboratoriais que compõem o diagnóstico da síndrome HELLP. A pré-eclâmpsia foi um tipo de hipertensão mais freqüente no grupo SHP que no grupo hipertensas. Não houve pacientes com hipertensão crônica isolada que desenvolveram SHP. A taxa de cesárea, eclâmpsia e de partos prematuros foi significativamente mais freqüente no grupo SHP que no grupo hipertensas. CONCLUSÃO: Observamos uma conduta agressiva nas pacientes com SHP, que resultou na interrupção imediata da gestação, com elevada taxa de cesárea e de recém-nascido pré-termo. Esta conduta deve ser revista para a redução desses índices.

PSA and androgen-related gene (AR, CYP17, and CYP19) polymorphisms and the risk of adenocarcinoma at prostate biopsy

The aim of the present study was to examine the impact of polymorphisms in prostate-specific antigen (PSA) and androgen-related genes (AR, CYP17, and CYP19) on prostate cancer (PCa) risk in selected high-risk patients who underwent prostate biopsy. Blood samples and prostate tissues were obtained for DNA analysis. Single-nucleotide polymorphisms in the 50-untranslated regions (UTRs) of the PSA (substitution A > G at position -158) and CYP17 (substitution T > C at 50-UTR) genes were detected by polymerase chain reaction (PCR)-restriction fragment length polymorphism assays. The CAG and TTTA repeats in the AR and CYP19 genes, respectively, were genotyped by PCR-based GeneScan analysis. Patients with the GG genotype of the PSA gene had a higher risk of PCa than those with the AG or AA genotype (OR = 3.79, p = 0.00138). The AA genotype was associated with lower PSA levels (6.44 +/- 1.64 ng/mL) compared with genotypes having at least one G allele (10.44 +/- 10.06 ng/mL) (p = 0.0687, 95% CI - 0.3146 to 8.315, unpaired t-test). The multivariate analysis confirmed the association between PSA levels and PSA genotypes (AA vs. AG+GG; chi(2) = 0.0482) and CYP19 (short alleles homozygous vs. at least one long allele; chi(2) = 0.0110) genotypes. Genetic instability at the AR locus leading to somatic mosaicism was detected in one PCa patient by comparing the length of AR CAG repeats in matched peripheral blood and prostate biopsy cores. Taken together, these findings suggest that the PSA genotype should be a clinically relevant biomarker to predict the PCa risk.

Perinatal factors associated with early deaths of preterm infants born in Brazilian Network on Neonatal Research centers

Objective: To evaluate perinatal factors associated with early neonatal death in preterm infants with birth weights (BW) of 400-1,500 g.Methods: A multicenter prospective cohort study of all infants with BW of 400-1,500 g and 23-33 weeks of gestational age (GA), without malformations, who were born alive at eight public university tertiary hospitals in Brazil between June of 2004 and May of 2005. Infants who died within their first 6 days of life were compared with those who did not regarding maternal and neonatal characteristics and morbidity during the first 72 hours of life. Variables associated with the early deaths were identified by stepwise logistic regression.Results: A total of 579 live births met the inclusion criteria. Early deaths occurred in 92 (16%) cases, varying between centers from 5 to 31%, and these differences persisted after controlling for newborn illness severity and mortality risk score (SNAPPE-II). According to the multivariate analysis, the following factors were associated with early intrahospital neonatal deaths: gestational age of 23-27 weeks (odds ratio - OR = 5.0; 95%CI 2.7-9.4), absence of maternal hypertension (OR = 1.9; 95%CI 1.0-3.7), 5th minute Apgar 0-6 (OR = 2.8; 95%CI 1.4-5.4), presence of respiratory distress syndrome (OR = 3.1; 95%CI 1.4-6.6), and network center of birth.Conclusion: Important perinatal factors that are associated with early neonatal deaths in very low birth weight preterm infants can be modified by interventions such as improving fetal vitality at birth and reducing the incidence and severity of respiratory distress syndrome. The heterogeneity of early neonatal rates across the different centers studied indicates that best clinical practices should be identified and disseminated throughout the country.

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.

Polymorphisms of CYP17A1, CYP19, and androgen in Brazilian women with uterine leiomyomas

Background: Uterine leiomyomas are common, benign, smooth muscle tumors representing a significant public health problem. The aim of this study was to investigate CYP17A1, CYP19, and androgen (AR) polymorphisms, their relative risks for uterine leiomyomas and possible associations with clinical parameters.Methods: Uterine leiomyoma tissues and blood samples were obtained from 87 patients, as were peripheral blood samples from 68 control women. Clinical data were recorded in both groups. The CYP17A1 (rs743572) polymorphism was analyzed by PCR-RFLP, and the CYP19 [TTTA](n) repeat and AR [CAG](n) repeat were analyzed using PCR-based GeneScan analysis. AR loss of heterozygosity (LOH) and microsatellite instability were also evaluated, while samples exhibiting LOH were analyzed for X inactivation.Results: Clinical parameters related to disease development did not differ between cases and controls. CYP17A1 *A2/*A2 genotype was prevalent in non-white women. CYP17A1, CYP19, and AR genotypes and alleles did not differ between groups. However, alleles presenting [TTTA](7) repeats in intron 4 of CYP19 were more frequent in the control group (p=0.0550). Shorter and longer [CAG]n repeat alleles of AR were exclusive to the leiomyoma group. The LOH assay showed allele losses at AR locus in four informative tumors and X chromosome inactivation analysis revealed that these tumors retained the active allele.Conclusions: The overall lack of association between uterine leiomyomas with polymorphisms involved in steroidogenesis or steroid metabolism is consistent with the hypothesis that these polymorphisms do not substantially contribute to the development of these tumors.

Natriorexigenic effect of baclofen is reduced by AT(1) receptor blockade in the lateral parabrachial nucleus

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Central blockade of nitric oxide synthesis reduces moxonidine-induced hypotension

1 Nitric oxide (NO) and alpha(2)-adrenoceptor and imidazoline agonists such as moxonidine may act centrally to inhibit sympathetic activity and decrease arterial pressure.2 In the present study, we investigated the effects of pretreatment with L-NAME ( NO synthesis inhibitor), injected into the 4th ventricle (4th V) or intravenously (i.v.), on the hypotension, bradycardia and vasodilatation induced by moxonidine injected into the 4th V in normotensive rats.3 Male Wistar rats with a stainless steel cannula implanted into the 4th V and anaesthetized with urethane were used. Blood flows were recorded by use of miniature pulsed Doppler flow probes implanted around the renal, superior mesenteric and low abdominal aorta.4 Moxonidine (20 nmol), injected into the 4th V, reduced the mean arterial pressure (-42+/-3 mmHg), heart rate (-22+/-7 bpm) and renal (-62+/-15%), mesenteric (-41+/-8%) and hindquarter (-50+/-8%) vascular resistances.5 Pretreatment with L-NAME (10 nmol into the 4th V) almost abolished central moxonidine-induced hypotension (-10+/-3 mmHg) and renal (-10+/-4%), mesenteric (-11+/-4%) and hindquarter (-13+/-6%) vascular resistance reduction, but did not affect the bradycardia (-18+/-8 bpm).6 the results indicate that central NO mechanisms are involved in the vasodilatation and hypotension, but not in the bradycardia, induced by central moxonidine in normotensive rats. British Journal of Pharmacology (2004).

Brain serotonin blockade and paradoxical salt intake in rats

Serotonin antagonism in the lateral parabrachial nucleus (LPBN) enhances sodium appetite induced by hypovolaemia and angiotensin-mineralocorticoid activation, but produces no sodium intake in euhydrated animals. In the present work, male adult rats (n=21) that received bilateral injections of the serotonergic antagonist methysergide (4 mug/ 0.2 mul) into the LPBN combined to intragastric load of 2 M NaCl (2 ml/rat), ingested hypertonic NaCl (ingestion of 4.3+/-1.6 ml/2 h of 0.3 M NaCl versus vehicle into LPBN: 0.2+/-0.2 ml/2 h, P<0.05). Methysergide- and vehicle-treated animals also ingested water (9.5+/-0.7 and 7.2+/-0.5 ml/2 h, respectively, P>0.05) as expected from the state of cell dehydration produced by the load. Ingestion of water (11.0+/-1.2 ml/2 h), and of 0.3 M NaCl (1.1+/-0.7 ml/2 h) were not altered by methysergide in NaCl loaded rats with misplaced LPBN injections (n=15). The ingestion of hypertonic NaCl by rats with serotonergic blockade in the LPBN suggests that the circuits subserving sodium appetite are activated, but at the same time strongly inhibited through the LPBN, during cell dehydration. (C) 2003 IBRO. Published by Elsevier Ltd. All rights reserved.

Central cholinergic blockade reduces the pressor response to L-glutamate into the rostral ventrolateral medullary pressor area

Injections of the excitatory amino acid L-glutamate (L-glu) into the rostral ventrolateral medulla (RVLM) directly activate the sympathetic nervous system and increase mean arterial pressure (MAP). A previous study showed that lesions of the anteroventral third ventricle region in the forebrain reduced the pressor response to L-glu into the RVLM. In the present study we investigated the effects produced by injections of atropine (cholinergic antagonist) into the lateral ventricle (LV) on the pressor responses produced by L-ghl into the RVLM. Male Holtzman rats (280-320 g, n=5 to 12/group) with stainless steel cannulas implanted into the RVLM, LV or 4th ventricle (4th V) were used. MAP and heart rate (HR) were recorded in unanesthetized rats. After saline into the LV, injections of L-glu (5 nmol/100 nl) into the RVLM increased MAP (51 +/- 4 mm Hg) without changes in HR. Atropine (4 nmol/1 PI) injected into the LV reduced the pressor responses to L-glu into the RVLM (36 +/- 5 mm Hg), However, atropine at the same dose into the 4th V or directly into the RVLM did not modify the pressor responses to L-glu into the RVLM (45 +/- 2 and 49 +/- 4 mm Hg, respectively, vs. control: 50 +/- 4mmHg). Central cholinergic blockade did not affect baro and chemoreflex nor the basal MAP and HR. The results suggest that cholinergic mechanisms probably from forebrain facilitate or modulate the pressor responses to L-glu into the RVLM. The mechanism is activated by acetylcholine in the forebrain, however, the neurotransmitter released in the RVLM to facilitate the effects of glutamate is not acetylcholine. (C) 2007 Elsevier B.V. All rights reserved.