Alterações do fluxo sanguíneo em artéria umbilical na síndrome hipertensiva gestacional e suas implicações nos resultados neonatais

OBJETIVO: Avaliar as características antropométricas, a morbidade e mortalidade de recém-nascidos (RN) prematuros nascidos vivos de mães hipertensas em função da presença ou não de diástole zero (DZ) ou reversa (DR) na doplervelocimetria arterial umbilical. MÉTODOS: Estudo prospectivo, envolvendo RN prematuros nascidos vivos de gestantes hipertensas, com idade gestacional entre 25 e 33 semanas, submetidas à doplervelocimetria da artéria umbilical nos 5 dias que antecederam o parto, realizado no Hospital do Distrito Federal, entre 1º de novembro de 2009 e 31 de outubro de 2010. Os RN foram estratificados em dois grupos, conforme o resultado da doplervelocimetria da artéria umbilical: Gdz/dr=presença de diástole zero (DZ) ou diástole reversa (DR) e Gn=doplervelocimetria normal. Medidas antropométricas ao nascimento, morbidades e mortalidade neonatal foram comparadas entre os dois grupos. RESULTADOS: Foram incluídos 92 RN, assim distribuídos: Gdz/dr=52 RN e Gn=40 RN. No Gdz/dr a incidência de RN pequenos para idade gestacional foi significativamente maior, com risco relativo de 2,5 (IC95% 1,7‒3,7). No grupo Gdz/dr os RN permaneceram mais tempo em ventilação mecânica mediana 2 (0‒28) e no Gn mediana 0,5 (0‒25), p=0,03. A necessidade de oxigênio aos 28 dias de vida foi maior no Gdz/dr do que no Gn (33 versus10%; p=0,01). A mortalidade neonatal foi maior em Gdz/dr do que em Gn (36 versus 10%; p=0,03; com risco relativo de 1,6; IC95% 1,2 - 2,2). Nessa amostra a regressão logística mostrou que a cada 100 gramas a menos de peso ao nascer no Gdz/dr a chance de óbito aumentou 6,7 vezes (IC95% 2,0 - 11,3; p<0,01). CONCLUSÃO: em RN prematuros de mães hipertensas com alteração na doplervelocimetria da artéria umbilical a restrição do crescimento intrauterino é frequente e o prognóstico neonatal pior, sendo elevado o risco de óbito relacionado ao peso ao nascimento.

Prática de atividade física e composição corporal em mulheres na menopausa

OBJETIVO: Analisar a relação entre a prática de atividade física e composição corporal em mulheres na menopausa. METODOS: Participaram do estudo 62 mulheres, com 50 anos ou mais (61,2±7,6 anos), todas na menopausa. A prática de atividade física foi avaliada através do acelerômetro (minutos na semana e counts). A massa magra e massa gorda total e de tronco foram mensuradas com uso da absortimetria de raios X de dupla energia e expressas em valores percentuais. A relação entre as variáveis de composição corporal e a atividade física foi avaliada pela correlação de Spearman e de Pearson. As comparações entre grupos (de acordo com a prática de atividade física e idade) foram realizadas por meio do teste t independente e Mann-Whitney. RESULTADOS: O grupo de idade igual ou inferior a 59 anos apresentou maiores médias de atividade física total em counts (3.572.435 versus 2.843.840) e minutos por semana de atividade física moderada-vigorosa (273 minutos versus 156 minutos). As mulheres que acumularam 150 minutos ou mais de atividade física moderada-vigorosa apresentaram valores inferiores de massa gorda total (43,8 versus 47,2 kg/m²), valores superiores de massa corporal magra (53,8 versus 49,6 kg) e IMC reduzido (27,7 versus 30,46 kg/m²) quando comparadas àquelas com menos de 150 minutos de atividade física na semana. Apenas o tempo em atividades moderadas apresentou correlação negativa com o percentual de gordura total (r=-0,26, p<0,05); já atividade física total em counts correlacionou-se com o percentual de massa magra (r=0,30), percentual de gordura total (r=-0,32), gordura de tronco (r=-0,29), e IMC (r=-0,32), todas as correlações apresentaram significância estatística de p<0,05. CONCLUSÃO: Mulheres na menopausa com idade igual ou superior a 50 anos que apresentam minutos em atividades moderada e vigorosa, e counts de atividade física total superiores possuem níveis inferiores de massa gorda e superiores de massa magra.

Estudo comparativo de vias de acesso cirúrgico na contracepção cirúrgica feminina: Microlaparoscopia versus minilaparotomia

Purpose: to compare in a retrospective way, 51 women who underwent tubal ligation, 30 through microlaparoascopy (Gmicrol) and 21 through minilaparotomy (Gminil). Methods: the analyzed parameters were: total time for accomplishment of the procedure and the surgical technique, time of hospital stay and return to the habitual activities after the surgery, postoperative pain, morbidity, satisfaction degree and esthetic effect, considering values of p<0,05 as significant, and also standard cost. Results: Gmicrol took less time to accomplish the surgery than the Gminil (43 against 57 minutes respectively, p<0,05), less time to accomplish the surgical technique (6.48 against 30.32 minutes respectively, p<0,05), and lower hospital stay (9,90 hours as against 41,7 hours respectively, p <0,05). There was no significant difference between the two groups regarding time to return to the habitual activities after surgery. To evaluate postoperative pain, a scale of 0-10 it was applied. Gmicrol present a lower pain score on the 1st and 2nd postoperative days (1.13 and 0.26 to Gmicrol and 4.52 and 1.14 to Gminil, respectively, p<0,05). There was no significant difference between immediate postoperative the most common complaint being pain at the site of pain and that on the 3rd postoperative day. Gminil presented a higher morbidity rate incision. To evaluate the satisfaction degree and esthetic effect, numeric values were attributed to as good, regular, poor and very bad as answered by the patiets. Gmicrol presented a higher satisfaction degree (p<0,05) and better esthetic effect as compared to Gminil (p <0,05). The microlaparoscopy standard cost was R$ 109.30 being lower than that of minilaparotomy. Conclusions: tubal ligation by microlaparoscopy, under local anesthesia and conscious sedation presented some advantages compared to minilaparotomy.

Incidência de malformações congênitas em crianças concebidas através de injeção intracitoplasmática de espermatozóides

Purpose: to evaluate the incidence and types of major congenital malformations (MCM) in liveborn children conceived by intracytoplasmic sperm injection (ICSI). Methods: a total of 680 liveborn children resulted from 511 couples submitted to ICSI from January, 1999 to December, 2002. Data collection of the children was performed through standardized questionnaire and clinical examination. Of the 511 couples, 366 had been contacted for a sampling of 371 gestations. Of the 680 liveborn, 520 had been evaluated, 250 of them (48.1%) through questionnaire and 270 (51.9%) through questionnaire and physical examination. Two hundred and fifty children were from singleton pregnancies and 270 from multiple pregnancies. Malformations were classified according to the 10th revision of the International Statistical Classification of Diseases and Related Health. Only MCM were analyzed in this study. The incidence of MCM was compared with that of the general population obtained by the Latin American Collaborative Study of Congenital Malformations. The statistical analysis was performed by the χ 2 test (level of significance p<0.05). Results: of the 520 children, 15 presented MCM, resulting in an incidence of 2.9%. There was no difference in relation to the control group (p>0.05), which showed 2.6% incidence of MCM. The most frequent malformations were of cardiac origin (four isolated and two associated), corresponding to 40% of the total. The other types of MCM were: renal (three), neural tube (two), skull (one), cleft lip (one), genital (one), Down syndrome (associated with cardiac malformations) (two), and musculoskeletal (one). Six MCM occurred in children from singleton pregnancies and nine in children from multiple pregnancies. Conclusion: the liveborn children conceived by ICSI presented incidence of major congenital malformations (2.9%) near to the expected for the general population (2.6%). However, to establish the risks of MCM with precision it is necessary to continue the evaluation of the children conceived by ICSI.

Intervenções benéficas no pré-natal para prevenção da mortalidade materna

Maternal mortality rate (MM) is a health quality indicator that is directly influenced by the economic, cultural and technological level of a country. Official data of MM in Brazil, although underestimated, point to the lack of quality in pregnancy, childbirth and puerperium care services. This characteristic is common in developing countries, where poorer pregnant women as well as those facing greater difficulty to quality care access are found. Prenatal care cannot prevent major childbirth complications, which are important causes of MM; however, some interventions during the prenatal period can favor maternal prognosis and prevent MM. In this setting, this study brings a scientifically based update concerning effective interventions for maternal mortality prevention during the prenatal period. The most important strategies consist of a tripod with specific interventions related to maternal health promotion, risk prevention and assurance of nutritional support during gestation, in addition to criteria to investigate gestational risk and inclusion of the pregnant woman in the basic component of the prenatal care model. It ends with the definition of priorities in the prevention of MM related to eclampsia/preeclampsia and reinforces the importance of normalization of reference systems for obstetric emergency cases.

Determinação precoce do sexo fetal pela análise do DNA no plasma materno

Purpose: to verify the viability of early diagnosis of fetal gender in maternal plasma by the real-time polymerase chain reaction (real-time PCR) starting at the 5th week of pregnancy. Methods: peripheral blood was collected from pregnant women with single fetus starting at the 5th week of gestation. After centrifugation, 0.4 mL plasma was separated for fetal DNA extraction. The DNA was analyzed in duplicate by real-time PCR for two genomic regions, one of the Y chromosome and the other common to both sexes, through the TaqMan® method, which uses a pair of primers and a fluorescent probe. Patients who aborted were excluded. Results: a total of 79 determinations of fetal DNA in maternal plasma were performed in 52 pregnant women. The results of the determinations were compared to fetal gender after delivery. Accuracy according to gestational age was 92.6% (25 of 27 cases) at 5 weeks with 87% sensitivity, and 95.6% (22 of 23 cases) at 6 weeks with 92% sensitivity. Starting at the 7th week of pregnancy, accuracy was 100% (29 of 29 cases). Specificity was 100% regardless of gestational age. Conclusion: real-time PCR for the detection of fetal gender in maternal plasma starting at the 5th week of gestation has good sensitivity and excellent specificity. There was agreement of the results in 100% of the cases in which male gender was diagnosed, regardless of gestational age, and from the 7th week of gestation for female gender diagnosis.

Avaliação da resposta à quimioterapia primária em amostra de mulheres brasileiras com tumores de mama localmente avançados

PURPOSE: to evaluate the loco-regional response to primary chemotherapy in patients with breast cancer at stages II and III. METHODS: a retrospective and analytical clinical study carried out in 97 patients with an average age of 52.2 years old, with breast cancer at stages II and III, attended from January 1993 to December 2004, and submitted to 3 to 4 cycles of primary chemotherapy with 5-fl uorouracil - 500 mg/m2, epirubicin - 50 mg/m2 and cyclophosphamide - 500 mg/m2 or doxorubicin - 50 mg/m2 e cyclophosphamide - 500 mg/m2, and then to loco-regional surgical conservative or radical surgical treatment. Chi-square and Fisher's exact tests were used to study the association among the variables (age, menopausal state, pre-chemotherapy tumoral volume, axillary condition, stage, therapeutic scheme and number of cycles), while Pearson's correlation coefficient was used for the quantitative variables (tumoral volume according to the anatomo-pathological study and the post-chemotherapy clinical tumoral volume. The significance level was 5%. RESULTS: there were 56.8% of cases at stage II and 43.2% at stage III. Approximately 50% of the patients received FEC50 and 50% AC. Objective clinical response with primary chemotherapy was obtained in 64.9% of the cases. Full clinical response occurred in 12.3% of patients, while full pathological response occurred in 10.3% of the cases. CONCLUSIONS: there was a statistically significant correlation between the number of cycles and the response to primary chemotherapy. Patients who received 4 cycles had better response than those who received 3 cycles. There was also a statistically significant concordance between the evaluation through clinical examination of the response to primary chemotherapy and the pathological findings. No statistically significant correlation was observed concerning age, menopausal status, tumoral volume, and pretreatment of axillary damage.

Insulinoterapia, controle glicêmico materno e prognóstico perinatal - Diferença entre o diabetes gestacional e o clínico

PURPOSE: to evaluate the insulin therapy protocol and its maternal and perinatal outcome in patients with clinical or gestational diabetes in a high risk reference service. METHODS: descriptive and prospective study including 103 pregnant women with gestational or clinical diabetes treated with insulin and attended by the reference service from October 2003 to December 2005. Gemellarity, miscarriages, unfinished prenatal care and deliveries not attended by the service were excluded. The gestational age at the beginning of the treatment, dosage, doses/day, increment of insulin (UI/kg), glycemic index (GI) and perinatal outcomes were compared. ANOVA, Fisher's exact test and Goodman's test considering p<0.05 were used. RESULTS: multiparity (92 versus 67.9%), pre-gestational body mass index (BMI) >25 kg/m 2 (88 versus 58.5%), weight gain (WG) <8 kg (36 versus 17%) and a high increment of insulin characterized the gestational diabetes. For the patients with clinical diabetes, despite the highest GI (120 mg/dL (39.2 versus 24%)) at the end of the gestational period, insulin therapy started earlier (47.2 versus 4%), lasted longer (56.6 versus 6%) and higher doses of insulin (92 versus 43 UI/day) were administered up to three times a day (54.7 versus 16%). Macrosomia was higher among newborns from the cohort of patients with gestational diabetes (16 versus 3.8%), being the only significant neonatal outcome. There were no neonatal deaths, except for one fetal death in the cohort of patients with clinical diabetes. There were no differences in the other neonatal complications in both cohorts, and most of the newborns were discharged from hospital up to seven days after delivery (46% versus 55.8%). CONCLUSIONS: the analysis of these two cohorts has shown differences in the insulin therapy protocol in quantity (UI/day), dosage (UI/kg weight) and number of doses/day, higher for the clinical diabetes cohort, and in the increment of insulin, higher for the gestational diabetes cohort. Indirectly, the quality of maternal glycemic control and the satisfactory perinatal outcome have proven that the treatment protocol was adequate and did not depend on the type of diabetes.

Efeito do raloxifeno sobre a densidade mamográfica em mulheres na pós-menopausa

PURPOSE: to evaluate changes in mammographic breast density in postmenopausal women using raloxifene. METHODS: in this clinical trial, 80 women (mean age=61.1 years) were studied prospectively. Forty patients received 60 mg/day raloxifene, and 40 women comprised the non-treated group (control), paired by age and time of menopause. The treated group was composed of patients with osteoporosis of the lumbar spine. Those with history of breast surgery and users of hormone therapy up to six months prior to the study were excluded. The breast density was assessed qualitatively (subjective) and quantitatively (objective) in two moments, initial and final, after a 6-month follow-up. The 320 mammograms (craniocaudal and oblique) were interpreted qualitatively by the Breast Imaging Reporting and Data System (BI-RADS) classification and quantitatively by digital scanning and computer-assisted segmentation. For statistical analysis t-test, Wilcoxon Mann-Whitney, Spearman correlation and the kappa index were used. RESULTS: on the initial statistical comparison, the groups were considered homogenous for the variables: analyzed age, time of menopause, parity, breast feeding, previous hormonal therapy and body mass index. Baseline breast density, by qualitative and quantitative methods, correlated negatively with the age in both groups (p<0.05). Concerning the other variables, there was no correlation. After six months, no alteration was observed in the mammographic breast density in 38 women of raloxifene group and 38 of the control group, by qualitative method. However, by quantitative method, no alteration was observed in 30 women of the raloxifene group and 27 controls (p>0.05). It was observed a weak agreement rate (kappa=0.25) between the BI-RADS classification and digital scanning/computer-assisted segmentation. CONCLUSIONS: in post-menopausal women with osteoporosis, submitted to raloxifene treatment for six months, no alterations were observed on the mammographic breast density.

Mecanismo de centralização: Da insuficiência placentária à adaptação circulatória fetal

The application and development of obstetric Dopplervelocimetry provide a basis for the investigation of placental insuf ciency and demonstrate the dynamic behavior of fetal circulation during hypoxia. In clinical practice, assessing hemodynamics in three vascular regions involved in pregnancy, namely the uterine, umbilical and middle cerebral arteries, has become routine. Roughly, the cerebral artery expresses the balance between uterine artery oxygen supply and umbilical artery oxygen uptake. Currently, when such balance is unfavorable, the fetal cardiac reserve is investigated by assessing the venous duct. However, determining and interpreting vascular resistance indexes is not an easy task. The starting point is to know the physiopathology of placental insuf ciency and fetal circulatory adaptation through which Doppler con rmed its role in the assessment of fetal well-being.

Significado da presença de esquizócitos no sangue periférico de gestantes com pré-eclâmpsia

PURPOSE: to evaluate the significance of schizocytes presence in peripheral blood smear of pregnant women with pre-eclampsia, identifying and correlating them with other markers of hemolysis and of the disease severity. METHODS: Seventh six glass slides of peripheral blood smear of pregnant women with pre-eclampsia have been evaluated. After the smear, the slides have been stained with Leishman's dye and stored till they were examined with a Leica, model DLMB microscope, provided with the Qwin Lite 2.5 software that made it possible to record the images of selected fields in CD-ROM. Ten fields with approximately 100 erythrocytes were counted in each glass slide. Schizocytes (irregular fragment or helmet-shaped, bite-shaped or triangular) were considered as present, when their percentage was equal or higher than 0.2%, their presence being correlated with other hemolysis markers (hemoglobin, total bilirubin, lactic desidrogenasis and reticulocytes), pre-eclampsia markers (proteinuria and platelet number). The Statistical Package in Social Science for Windows (SPSS), 10.0 version has been used for statistical analysis, at p<0.05. RESULTS: schizocytes have been present in 31.6% of the pregnant women with pre-eclampsia. In most (75%) of the blood smears there have been three or four schizocytes. There has been no correlation between schizocyte presence and any other hemolysis marker, any pre-eclampsia marker or disease severity. CONCLUSIONS: schizocytes have been identified in a small number and in less than a third of the pregnant women with pre-eclampsia. There has been no correlation with other hemolysis marker parameters or with the disease severity. This way, the presence of schizocytes is not a marker of the clinical evolution of pre-eclampsia.

Avaliação histeroscópica em pacientes com infertilidade

PURPOSE: to describe hysteroscopy findings in infertile patients. METHODS: this was a retrospective series of 953 patients with diagnosis of infertility evaluated by hysteroscopy. A total of 957 patients investigated for infertility were subjected to hysteroscopy, preferentially during the first phase of the menstrual cycle. When necessary, directed biopsies (under direct visualization during the exam) or guided biopsies were obtained using a Novak curette after defining the site to be biopsied during the hysteroscopic examination. Outcome frequencies were determined as percentages, and the χ2 test was used for the correlations. The statistical software EpiInfo 2000 (CDC) was used for data analysis. RESULTS: a normal uterine cavity was detected in 436 cases (45.8%). This was the most frequent diagnosis for women with primary infertility and for women with one or no abortion (p<0.05). Abnormal findings were obtained in 517 of 953 cases (54.2%), including intrauterine synechiae in 185 patients (19.4%), endometrial polyps in 115 (12.1%), endocervical polyps in 66 (6.0%), submucosal myomas in 47 (4.9%), endometrial hyperplasia in 39 (4.1%), adenomyosis in five (0.5%), endometritis (with histopathological confirmation) in four (0.4%), endometrial bone metaplasia in two (0.4%), and cancer of the endometrium in one case (0.1%). Morphological and functional changes of the uterus were detected in 5.6% of the cases, including uterine malformations in 32 (3.4%) and isthmus-cervical incompetence in 21 (2.2%). CONCLUSIONS: intrauterine synechiae were the most frequent abnormal findings in patients evaluated for infertility. Patients with a history of abortion and infertility should be submitted to hysteroscopy in order to rule out intrauterine synechiae as a possible cause of infertility.

Efeito da exposição à fumaça de cigarro durante a prenhez e a lactação de ratas e sua prole sobre parâmetros séricos e morfométricos

PURPOSE: to investigate the effect of cigarette smoke exposure on body and tissue weight gain, serum parameters and milk yield during pregnancy and lactation in rats, and the impact on offspring from birth toil young adulthood. METHODS: 40 Wistar pregnant rats were randomly divided into: CG - not exposed to cigarette smoke and sacrificed at the end of pregnancy; CL - not exposed to cigarette smoke and sacrificed at the end of lactation; FG - exposed to cigarette smoke and sacrificed at the end of pregnancy; FL - exposed to cigarette smoke and sacrificed at the end of lactation. The offspring were separated by gender and divided according to their mothers' groups. Tissue weight, body weight and serum parameters were evaluated in rats and offspring. Milk yield per pup was calculated. RESULTS: body weight was decreased in FL during lactation (CL=267.0±7.2; FL=235.5±7.2 g*, *p<0.05). Adipose tissue was not detected in the CL and FL groups, and was reduced in FG compared to CG (CG=3.3±0.3; FG=2.4±0.3 g*, *p<0.05). Rats exposed to cigarette smoke had higher blood glucose levels (CG=113±17, CL=86±16, FG=177±21*, FL=178±23 mg/dL*, *p<0.05 CG versus FG e CL versus FL), CL and FL groups presented lower HDL-cholesterol with no change in total cholesterol. Finally, rats exposed to cigarette smoke had lower milk yield compared to unexposed rats (CL=6.7±0.4, FL=5.4±0.3 g*, *p<0.05). In offspring from the FG and FL groups, there was a decrease of body weight from birth to young adulthood, with no changes in gastrocnemius, liver or heart weights in any group, and adipose tissue was no detected in female offspring. There was an increase in blood glucose in offspring of both sexes from rats exposed to cigarette smoke (males: Pcg=107±10.5, Pcl=115±8.6, Pfg=148±16.8*, Pfl=172±11.2**; females: Pcg=109±27.2, Pcl=104±9.7, Pfg=134±20.0*, Pfl=126±13.3**; p<0.05 *Pcg versus Pfg and **Pcl versus Pfl). CONCLUSIONS: exposure to cigarette smoke provokes impairment of morphometric and serum parameters during pregnancy and lactation both in mothers and offspring, which is maintained during young adulthood.