Management of pregnancy in a University Hospital: a 6-year study

In order to evaluate the obstetric care in the Obstetric Clinic of the Gynaecology and Obstetrics Department of University of São Paulo, the authors present a survey of the management of pregnancy during the 6-year period from 1993 to 1998. The number of deliveries increased during the study by 45% over the 6 years. During this same period the number of fetal deaths was 526 (4.48%), but there was a significant decrease (p < 0.05) in the incidence of fetal death. However, there was no concomitant increase in the proportion of pregnant women with prenatal care that could explain this improvement. Incidence of premature labor also decreased considerably. The authors believe that the increment in the number of deliveries was due mainly to the increasing number of pregnant women referred to our service. The efforts made by the service towards decreasing the time of hospitalization of both newborns in the nursery and the mothers in the hospital made this possible. Despite the increasing number of deliveries, there was a significant improvement in the management of pregnancy during the period of study. This improvement may be a consequence of the standardization of a protocol of management of pregnancy based on the recent progress in scientific and technological knowledge.

Autoimmune diseases and pregnancy: analysis of a series of cases

BACKGROUND: An autoimmune disease is characterized by tissue damage, caused by self-reactivity of different effector mechanisms of the immune system, namely antibodies and T cells. All autoimmune diseases, to some extent, have implications for fertility and obstetrics. Currently, due to available treatments and specialised care for pregnant women with autoimmune disease, the prognosis for both mother and child has improved significantly. However these pregnancies are always high risk. The purpose of this study is to analyse the fertility/pregnancy process of women with systemic and organ-specific autoimmune diseases and assess pathological and treatment implications. METHODS: The authors performed an analysis of the clinical records and relevant obstetric history of five patients representing five distinct autoimmune pathological scenarios, selected from Autoimmune Disease Consultation at the Hospital of Braga, and reviewed the literature. RESULTS: The five clinical cases are the following: Case 1-28 years old with systemic lupus erythematosus, and clinical remission of the disease, under medication with hydroxychloroquine, prednisolone and acetylsalicylic acid, with incomplete miscarriage at 7 weeks of gestation without signs of thrombosis. Case 2-44 years old with history of two late miscarriages, a single preterm delivery (33 weeks) and multiple thrombotic events over the years, was diagnosed with antiphospholipid syndrome after acute myocardial infarction. Case 3-31 years old with polymyositis, treated with azathioprine for 3 years with complete remission of the disease, took the informed decision to get pregnant after medical consultation and full weaning from azathioprine, and gave birth to a healthy term new-born. Case 4-38 years old pregnant woman developed Behcet's syndrome during the final 15 weeks of gestation and with disease exacerbation after delivery. Case 5-36 years old with autoimmune thyroiditis diagnosed during her first pregnancy, with difficult control over the thyroid function over the years and first trimester miscarriage, suffered a second miscarriage despite clinical stability and antibody regression. CONCLUSIONS: As described in literature, the authors found a strong association between autoimmune disease and obstetric complications, especially with systemic lupus erythematosus, antiphospholipid syndrome and autoimmune thyroiditis.

Pregnant crack addicts in a psychiatric unit

OBJECTIVE: In this study we aim to characterize a sample of 85 pregnant crack addicts admitted for detoxification in a psychiatric inpatient unit. METHOD: Cross-sectional study. Sociodemographic, clinical, obstetric and lifestyle information were evaluated. RESULTS: Age of onset for crack use varied from 11 to 35 years (median = 21). Approximately 25% of the patients smoked more than 20 crack rocks in a typical day of use (median = 10; min-max = 1-100). Tobacco (89.4%), alcohol (63.5%) and marijuana (51.8%) were the drugs other than crack most currently used. Robbery was reported by 32 patients (41.2%), imprisonment experience by 21 (24.7%), trade of sex for money/drugs by 38 (44.7%), home desertion by 33 (38.8%); 15.3% were positive for HIV, 5.9% for HCV, 1.2% for HBV and 8.2% for syphilis. After discharge from the psychiatric unit, only 25% of the sample followed the proposed treatment in the chemical dependency outpatient service. CONCLUSION: Greater risky behaviors for STD, as well as high rates of maternal HIV and Syphilis were found. Moreover, the high rates of concurrent use of other drugs and involvement in illegal activities contribute to show their chaotic lifestyles. Prevention and intervention programs need to be developed to address the multifactorial nature of this problem.

Self-reported psychosocial factors among In Vitro Fertilization patients interviewed alone or with the partner

"Published online: 07 Nov 2015"

24-h urinary free cortisol from mid-pregnancy to 3-months postpartum: gender and parity differences and effects

Background: Pregnancy and postpartum have been associated to several physiological changes;however, empirical evidence was almost exclusively obtained in primiparous women and few studies focus on hormonal changes in men and second-time parents. The main aim of this study is to examine 24-h urinary free cortisol from mid-pregnancy to 3-months postpartum, comparing women/men and first/second-time parents.Methods: Twenty-six women and 22 men (N = 48) were recruited from an antenatal obstetric unit in Porto, Portugal. 24-h urinary free cortisol was measured at the 2nd and 3rd trimester and at 3-months postpartum. Repeated measures analyses of variance were conducted, in order to analyze 24-h urinary free cortisol patterns of change over this period. Gender and parity were included in the analyses as potential modifiers, in order to compare women and men, and first-and second-time parents.Results: An increase from the 2nd to the 3rd trimester (p = .006) and a decrease from the 3rd trimester to 3-months postpartum (p = .005) were reported in all parents’ 24-h urinary free cortisol. The interaction effects for Time * Gender (p = .03) and Time * Parity (p = .02) were found. Women and first-time parents revealed higher levels, while men and second-time parents showed lower 24-h urinary free cortisol levels at the 2nd trimester than at 3-months postpartum.Conclusions: Findings appear to clarify the direction, as well as, the timing, gender and parity extension of 24-h urinary free cortisol changes from mid-pregnancy to 3-months postpartum.The same pattern of change in all parents’ 24-h urinary free cortisol from mid-pregnancy to 3-months postpartum is consistent with the proposed role of hormones in preparation to parenting.

Acute Effects of Maternal Smoking on Fetal-Placental-Maternal System Hemodynamics

OBJECTIVE: To study acute hemodynamic alterations in the fetal-placental maternal system immediately after maternal exposure to nicotine. METHODS: This is a noncontrolled experimental study involving 21 pregnant smoking women, randomly selected, with uncomplicated pregnancies and without risk factors for fetal heart disease. Patients underwent ultrasound and fetal echocardiography before and after smoking a cigarette. They were asked to abstain from smoking for 12 hours before the study. The mean nicotine content of the cigarettes used in the study was 0.5mg of nicotine and 6mg of carbon monoxide. RESULTS: The average number of cigarettes smoked per a day prior to the study was 9.67. Gestational age ranged between 18 and 36 weeks. The mean maternal heart rate was elevated (P<0.001) as was the mean fetal heart rate (P=0.044). Maternal systolic blood pressure (P=0.004) and diastolic blood pressure (P=0.033) were also elevated after smoking. A decrease occurred in the systolic/diastolic ratio in the right uterine artery (P=0.014) and in the left uterine artery (P=0.039). The other hemodynamic variables remained unchanged. CONCLUSION: Cigarette smoking can cause changes in physiologic variables of fetal-placental circulation, but it does not change fetal cardiac function, in the dose of nicotine and its components used in this study. The decrease in systolic/diastolic ratio in the uterine arteries is probably related to a dose-dependent nicotine pattern.

Utentes da Consulta Externa de Ginecologia/Obstetrícia da Maternidade Júlio Dinis

Com o objectivo de fazer a caracterização da situação social e demográfica e das condições de saúde médica e psicológica das utentes da Consulta Externa de Ginecologia/Obstretícia da Maternidade Júlio Dinis e de seus companheiros, duzentas mulheres e cento e setenta e cinco homens (N=375) foram entrevistados com base num questionário desenhado para o efeito, durante o primeiro trimestre de gestação. Observamos o desfavorecimento social e económico da amostra, particularmente no grupo das mulheres. Constatamos que a situação matrimonial e familiar é estável; no entanto, muitos agregados familiares são recentes, incluem outros familiares e este é um primeiro filho do casal. A rede de apoio social e emocional da amostra é geralmente constituída por familiares, estando mais presente para as mulheres do que para os homens e muitas vezes o companheiro não é referido como confidente, sobretudo pelas mulheres. A gestação não é geralmente de risco; não obstante, a presença frequente de problemas psicológicos uma pior aceitação inicial da gravidez no caso das mulheres. Os hábitos de vida tornam-se mais saudáveis com a gestação; no entanto, é ainda elevado o consumo de substâncias, como o tabaco, pela grávida. Problemas ginecológicos e obstétricos foram referidos, assim como a presença de adversidades na história psicológica e desenvolvimental dos participantes. Concluímos que as utentes da Consulta Externa de Ginecologia/Obstetrícia da Maternidade Júlio Dinis e seus companheiros apresentam indicadores relevantes de risco médico, psicológico e social que devem ser considerados na prestação de melhores cuidados de saúde.

Vinculação pré-natal e ansiedade em mães e pais: impacto da ecografia do 1º trimestre de gestação

Com o objectivo de avaliar o impacto da ecografia do 1º trimestre de gravidez na ansiedade e vinculação pré-natal, 22 mães e 22 pais foram recrutados numa Unidade de Medicina Fetal e Diagnóstico Pré-Natal. Foram administrados a Bonding Scale (Taylor, Atkins, Kumar, Adams, & Glover, 2005; versão portuguesa de Figueiredo, Marques, Costa, Pacheco, & Pais, 2005b) e o State-Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983; versão portuguesa de Silva, 2003), antes e depois da ecografia, a ambos os membros do casal. Os resultados revelaram que a vinculação pré-natal aumenta significativamente enquanto a sintomatologia ansiosa diminui, depois da realização da ecografia. Conclui-se que a ecografia pode ter um papel tranquilizador e potenciador da ligação dos pais ao seu bebé por nascer.

Actividade física e qualidade de vida na gravidez

Pouco se conhece acerca da actividade física e qualidade de vida da mulher na gravidez. Este estudo teve como objectivos 1) comparar os padrões de actividade física antes e durante a gravidez, 2) avaliar a percepção da qualidade de vida relacionada com a saúde durante os primeiros seis meses de gestação, e 3) comparar a percepção da qualidade de vida nas mulheres activas e insuficientemente activas considerando as recomendações de saúde pública. Método: Estudo longitudinal com 59 grávidas seleccionadas em consultórios médicos privados. Às 10-15 semanas foi recolhida informação sociodemográfica e médica, bem como informação sobre a actividade física três meses antes da concepção. Medidas de auto-relato foram administradas entre as 10-15 semanas e as 19-24 semanas de gestação para avaliar o tempo de actividade física (QAFG) (no trabalho, lazer, deslocações) e a qualidade de vida (SF-36). Resultados: A prevalência de actividade física recomendada é menor durante do que antes da gravidez (16.7% e 17.5% nos 1.º e 2.º trimestres, respectivamente vs. 47.4% antes da gravidez). Com a gravidez, não se verificaram alterações no tempo médio em diferentes tipos de actividade física, mas a actividade física no lazer registou uma diminuição significativa no 1.º trimestre face ao período anterior à concepção. Em comparação com uma amostra normativa de mulheres portuguesas, as grávidas apresentam, nos dois primeiros trimestres de gestação, uma percepção de qualidade da vida mais positiva na generalidade das dimensões do SF-36. No 2.º trimestre, o nível de limitação é significativamente maior nas dimensões físicas, à excepção da Dor Corporal, e nos resultados sumários do Componentes Físico e Mental. As mulheres que no 1.º trimestre atingem os níveis recomendados de actividade física no lazer (≥150 minutos por semana) apresentam melhor estado de saúde geral e estados de humor mais positivos do que as menos activas. Conclusão: A actividade física no lazer, embora diminua após a concepção, tem um impacto positivo na percepção do estado saúde geral e estados de humor da grávida, o que sugere a sua importância para a saúde da mulher também durante este período da vida.

A clinical recommendation system to maternity care

Nowadays in healthcare, the Clinical Decision Support Systems are used in order to help health professionals to take an evidence-based decision. An example is the Clinical Recommendation Systems. In this sense, it was developed and implemented in Centro Hospitalar do Porto a pre-triage system in order to group the patients on two levels (urgent or outpatient). However, although this system is calibrated and specific to the urgency of obstetrics and gynaecology, it does not meet all clinical requirements by the general department of the Portuguese HealthCare (Direção Geral de Saúde). The main requirement is the need of having priority triage system characterized by five levels. Thus some studies have been conducted with the aim of presenting a methodology able to evolve the pre-triage system on a Clinical Recommendation System with five levels. After some tests (using data mining and simulation techniques), it has been validated the possibility of transformation the pre-triage system in a Clinical Recommendation System in the obstetric context. This paper presents an overview of the Clinical Recommendation System for obstetric triage, the model developed and the main results achieved.

Retinal Detachment in Preeclampsia

Preeclampsia is an obstetric disease of unknown cause that affects approximately 5% of pregnant women. The visual system may be affected with variable intensity, being the retinal detachment a rare complication. The retinal detachment in preeclampsia is usually bilateral and serous, and its pathogenesis is related to the choroidal ischemia secondary to an intense arteriolar vasospasm. The majority of patients have complete recovery of vision with clinical management, and surgery is unnecessary. This is a case report of a 27 year old patient who developed the severe form of preeclampsia on her first pregnancy. She had progressive blurred vision, until she could see only shadows. Ophthalmic examination diagnosed spread and bilateral retinal detachment. With blood pressure control at postpartum, the patient had her retina reattached, and recovery of vision.

Pregnancy and peripartum cardiomyopathy: a comparative and prospective study

OBJECTIVE: To assess pregnancy outcome in women with peripartum cardiomyopathy and to compare it with idiopathic cardiomyopathy. METHODS: Twenty-six pregnant women, aged 28.4±6.1 years, with dilated cardiomyopathy were followed. Eighteen patients had peripartum cardiomyopathy [11 with persistent left ventricular systolic dysfunction (EF=45.2±2) and 7 with recovered ventricular function (EF=62.3±3.6)]. The 8 remaining patients had idiopathic cardiomyopathy (EF= 43.5±4.1). During the prenatal period, limited physical activity and a low-sodium diet were recommended, and hospitalization was recommended when complications occurred. RESULTS: Of the 26 patients, 11 (42.3%) had a normal delivery; 9(35.5%) had cardiac complications, 6 (22.2%) had obstetric complications. Two patients (7.7%) died. Two preterm pregnancies occurred, with 26 health newborns (2 sets of twins). Two miscarriages took place. The cardiac complication rate during pregnancy was lower (p<0.009) in the peripartum cardiomyopathy group without ventricular dysfunction and greater (p=0.01) in the idiopathic group when compared with the peripartum group with ventricular dysfunction. Changes in left ventricular ejection fraction were not observed (p<0.05) in the postpartum period, when compared with that during pregnancy in the 3 groups. CONCLUSION: Pregnancy in patients with dilated cardiomyopathy is associated with maternal morbidity. Left ventricular function is a prognostic factor and must be the most parameter when counseling patients with peripartum cardiomyopathy about a new pregnancy.

Ultrasound Blocks for the Anterior Abdominal Wall - Adult and Pediatric Surgery

Somatic post-surgical pain is invalidating and distressing to patients and carries the risk of important complications. The anterior abdominal wall is involved in most surgical procedures in general, gynecologic, obstetric, urological, vascular and pediatric surgery. Combined multimodal strategies involving nerve blocks, opiates, and non-steroidal anti-inflammatory drugs for systemic analgesia are necessary for optimal pain modulation. Anterior abdominal wall blocks, transverse abdominal plexus block, iliohypogastric and ilioinguinal nerveblock, genitofemoral nerve block and rectus sheath block have an important role as components of multimodal analgesia for somatic intraoperative and postoperative pain control. Ultrasound visualization has improved the efficacy and safety of abdominal blocks and implemented the application in the clinical setting. For this reason, they are a very important tool for all anesthesiologists who aim to treat effectively patients’ pain. This guide provides an evidence based comprehensive and necessary overview of anatomical, anesthesiological and technical information needed to safely perform these blocks.

Risk Prediction of Cardiovascular Complications in Pregnant Women With Heart Disease

Abstract Background: Heart disease in pregnancy is the leading cause of non- obstetric maternal death. Few Brazilian studies have assessed the impact of heart disease during pregnancy. Objective: To determine the risk factors associated with cardiovascular and neonatal complications. Methods: We evaluated 132 pregnant women with heart disease at a High-Risk Pregnancy outpatient clinic, from January 2005 to July 2010. Variables that could influence the maternal-fetal outcome were selected: age, parity, smoking, etiology and severity of the disease, previous cardiac complications, cyanosis, New York Heart Association (NYHA) functional class > II, left ventricular dysfunction/obstruction, arrhythmia, drug treatment change, time of prenatal care beginning and number of prenatal visits. The maternal-fetal risk index, Cardiac Disease in Pregnancy (CARPREG), was retrospectively calculated at the beginning of prenatal care, and patients were stratified in its three risk categories. Results: Rheumatic heart disease was the most prevalent (62.12%). The most frequent complications were heart failure (11.36%) and arrhythmias (6.82%). Factors associated with cardiovascular complications on multivariate analysis were: drug treatment change (p = 0.009), previous cardiac complications (p = 0.013) and NYHA class III on the first prenatal visit (p = 0.041). The cardiovascular complication rates were 15.22% in CARPREG 0, 16.42% in CARPREG 1, and 42.11% in CARPREG > 1, differing from those estimated by the original index: 5%, 27% and 75%, respectively. This sample had 26.36% of prematurity. Conclusion: The cardiovascular complication risk factors in this population were drug treatment change, previous cardiac complications and NYHA class III at the beginning of prenatal care. The CARPREG index used in this sample composed mainly of patients with rheumatic heart disease overestimated the number of events in pregnant women classified as CARPREG 1 and > 1, and underestimated it in low-risk patients (CARPREG 0).