Misoprostol sublingual versus vaginal para indução do parto

Orientador: Renato Passini JuniorTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Objetivo - Comparar a eficácia e segurança da utilização do misoprostol sublingual versus vaginal na indução do parto a termo. Sujeitos e métodos: Realizou-se um ensaio clínico controlado, randomizado e duplo-cego, em dois hospitais-escola (Maternidade-Escola Assis Chateaubriand, da Universidade Federal do Ceará, e Instituto Materno-Infantil de Pernambuco), no período de de 1º. de junho de 2004 a 30 de março de 2005. Para atingir diferença mínima entre os grupos de 20%, erro alfa de 5% e um poder (1 - ß) de 80%, randomizaram-se 150 gestantes, das quais 75 receberam 25mcg de misoprostol sublingual e placebo vaginal a cada 6 horas e 75 receberam 25mcg de misoprostol vaginal e placebo sublingual a cada 6 horas. O desfecho primário avaliado foi freqüência de parto vaginal. A análise estatística utilizou o teste qui-quadrado de associação, teste exato de Fisher e de Mann-Whitney, calculando-se a razão de risco com intervalo de confiança de 95%. Utilizou-se nível de significância de 5%. Resultados: Os grupos do misoprostol sublingual e vaginal foram similares e comparáveis. A proporção de partos vaginais foi de 57,3% no grupo sublingual e 69,3% no grupo vaginal (RR= 1,2; IC95%= 0,8-1,8). A média de intervalo de tempo entre a indução e o parto foi de 18h e 48minutos no grupo sublingual (SL) e 18h e 15 minutos no grupo vaginal (V). Não houve diferença significante na freqüência de partos vaginais após uma única dose de misoprostol (SL 21,3% x V 24%), no número de gestantes que necessitaram de quatro doses de misoprostol (SL 42,7% x V 37,3%), na freqüência de falha de indução (SL 12% x V 16%), na necessidade de utilização de ocitocina (34,7% nos dois grupos), na freqüência de taquissistolia (5,3% nos dois grupos), na presença de mecônio intraparto (SL 16% x V 17,3%;) e nos resultados neonatais. Conclusão: O misoprostol sublingual (25mcg a cada 6 horas) é tão eficaz e seguro quanto a mesma dose do misoprostol vaginal para indução do parto a termoAbstract: Objective - to compare the efficacy and safety of sublingual with vaginal misoprostol for induction of labor at term. Subjects and Methods ¿ A double-blind, randomized, controlled clinical trial was performed in two hospitals (Maternidade-Escola Assis-Chateaubriand from Federal University of Ceara and Instituto Materno-Infantil de Pernambuco), in the period between June 2004 and March 2005. To achieve a minimal 20% of difference means between groups, an alpha error of 5% and an 80% power (1 ¿ ß), 150 women were randomized, of which 75 were assigned to receive 25 mcg of sublingual misoprostol and vaginal placebo and 75 were assigned to receive 25 mcg of vaginal misoprostol and sublingual placebo every 6 hours. Primary outcome measured was vaginal delivery rate. Statistical analysis was made with chi-square, Fisher¿s exact and Mann-Whitney tests, with risk ratio calculation and 95% confidence interval. Significance level was 5%. Results- The groups of sublingual and vaginal misoprostol were similar and comparable. The proportion of vaginal deliveries was 57.3% in the sublingual group and 69,3% in the vaginal group (RR=1.2, IC 95%= 0.8 ¿ 1.8). Mean time interval from induction to delivery was 18 hours 48 minutes in the sublingual group (SL) and 18 hours 15 minutes in the vaginal group (V). There were no significant differences in rates of vaginal delivery after a single dose of misoprostol (SL 21.3% x V 24%), number of women needing four doses of misoprostol (SL 42.7% x V 37.3%), failed induction rate (SL 12% x V 16%), need for oxytocin augmentation (34.7% in both groups), tachysystole rate (5.3% in both groups), meconium passage rate (SL 16% x V 17.3%) and neonatal outcomes. Conclusion - 25 mcg of sublingual misoprostol is as efficacious and safe as the same dose vaginally administered for induction of laborDoutoradoTocoginecologiaDoutor em Tocoginecologi

Complicações clínicas e obstétricas em pacientes com eclampsia com e sem recorrência de convulsões após tratamento com sulfato de magnésio

Objetivo: determinar a prevalência de complicações clínicas e obstétricas em pacientes eclâmpticas com e sem recorrência de crises convulsivas após administração do sulfato de magnésio. Metodologia: através de um coorte retrospectivo, foram avaliados 69 casos de eclampsia atendidos na Maternidade Escola Assis Chateaubriand entre julho/2013 e julho/2016. Os testes x2 de associação e exato de Fisher foram utilizados para a comparação de variáveis. Resultados: seis pacientes apresentaram recorrência da eclampsia após sulfato de magnésio na admissão (8,7%), sendo administrado diazepam em uma, fenitoína em quatro e metade da dose de ataque do sulfato na última. Não houve diferença significativa, entre os grupos com ou sem a presença de recorrência, na idade (p 0,655), paridade (p 0,07) e hipertensão crônica associada (p 0,758). Também não houve diferença significativa entre os dois grupos em relação à síndrome HELLP (hemólise, elevação de enzimas hepáticas e plaquetopenia) (33,3% x 20,6%, p 0,389), insuficiência respiratória (16,7% x 6,3%, p 0,832) e descolamento prematuro da placenta (0% x 6,3%, p 0,689). Conclusão: a recorrência de crise convulsiva (8,7%) foi similar à relatada na literatura mundial (9,7%). Não houve aumento de complicações clínicas e obstétricas nas pacientes com recorrência de eclampsia

Mortalidade materna e qualidade do preenchimento das declarações de óbito em um hospital escola de referência do Ceará

Objetivos: descrever a frequência da mortalidade materna na Maternidade Escola Assis Chateaubriand no período de janeiro de 2011 a julho de 2015 e avaliar o correto preenchimento das respectivas declarações de óbito (DO). Metodologia: estudo descritivo, de coorte, realizado através da coleta de dados de prontuários e das declarações de óbito emitidas no período do estudo. Resultados: sessenta óbitos ocorreram no período do estudo, sendo três excluídos da análise. Dos óbitos, 66,67% foram classificados como de causa obstétrica direta, 26,32% obstétrica indireta e 5,26% não obstétrico. As causas básicas dos óbitos foram distribuídas nos seguintes grupos: hipertensiva 22,81%; hemorrágica 21,05%; infecciosa 17,54%; complicação cirúrgica 7,02%; tromboembolismo pulmonar 7,02%; neoplásica 5,26%; outro 17,54%. De todos os óbitos, 71,7% ocorreram no período do puerpério. Foram encontrados 66,67% de preenchimentos incorretos na causa básica da morte das declarações de óbito emitidas. Dentre os motivos para o preenchimento incorreto, considerou-se o uso de termos vagos (falência ou disfunção de múltiplos órgãos; siglas como AVC) ou uso de termos não classificados na CID-10. Conclusão: sugere-se uma melhor capacitação do profissional médico, uma vez que a DO é um instrumento de preenchimento obrigatório pelo médico, além de principal fonte de informações sobre o perfil de mortalidade do país

Cervical ultrasonography versus Bishop score as a predictor of vaginal delivery

PURPOSE: to compare the accuracy of transvaginal ultrasonographic measurement of the uterine cervix with Bishop?s score for the prediction of vaginal delivery after labor induction, with 25 mcg of misoprostol. METHODS: a prospective study for the validation of a diagnostic test was conducted on 126 pregnant women with indication for labor induction. The patients were evaluated by Bishop?s score and transvaginal ultrasonography for cervical measurement. They also undergone obstetric transabdominal ultrasound to evaluate static and fetal weight, as well as the amniotic fluid index, and basal cardiotocography for the evaluation of fetal vitality. Labor was induced with vaginal and sublingual misoprostol, one of the tablets containing 25 mcg of the drug and the other only placebo. The tablets were administered every six hours, with a maximum number of eight. Frequency tables were obtained, and measures of central tendency and dispersion were calculated. ROC curves were constructed for the evaluation of Bishop?s score and ultrasonographic measurement of the uterine cervix for the prediction of vaginal delivery. RESULTS: the area under the ROC curve was 0.5 (p=0.8) for the ultrasonographic measurement of the uterine cervix, and 0.6 (p=0.02) for Bishop?s score (cut point ³4). Bishop?s score had a sensitivity of 56.2% and specificity of 67.9% for prediction of vaginal delivery, with a positive likelihood ratio of 1.75 and a negative one of 0.65. CONCLUSIONS: ultrasonographic measurement of the uterine cervix was not a good predictor of evolution to vaginal delivery among patients with misoprostol-induced labor. Bishop?s score was a better predictor of vaginal delivery under these circumstances.OBJETIVO: comparar a acurácia da mensuração ultrassonográfica transvaginal do colo uterino com o escore de Bishop para predição do parto vaginal após indução do trabalho de parto com misoprostol a 25 mcg. MÉTODOS: realizou-se estudo de validação de técnica diagnóstica com 126 gestantes com indicação para indução do trabalho de parto, as quais foram avaliadas pelo escore de Bishop e por ultrassonografia transvaginal para mensuração cervical. As pacientes foram submetidas, também, à ultrassonografia obstétrica transabdominal para avaliação da estática, pesos fetais e índice de líquido amniótico, e à cardiotocografia basal para avaliação da vitalidade fetal. Procedeu-se à indução do trabalho de parto com misoprostol vaginal e sublingual, um dos comprimidos contendo 25 mcg da droga e o outro apenas placebo. Os comprimidos foram administrados a cada seis horas, em um número máximo de oito. Construíram-se tabelas de distribuição de frequência e calcularam-se medidas de tendência central e de dispersão. Curvas ROC foram construídas para avaliação do escore de Bishop e da medida ultrassonográfica do colo uterino para predição de parto vaginal. RESULTADOS: obteve-se uma área sob a curva ROC de 0,5 (p=0,8) para medição do colo uterino pela ultrassonografia transvaginal, enquanto a curva ROC do escore de Bishop (ponto de corte ³4) apresentou área de 0,6 (p=0,02). O escore de Bishop ³4 apresentou sensibilidade de 56,2% e especificidade de 67,9% para predição de parto vaginal, com razão de verossimilhança positiva de 1,75 e negativa de 0,65. CONCLUSÕES: a medida ultrassonográfica transvaginal do colo uterino não foi boa preditora da evolução para parto vaginal em pacientes com trabalho de parto induzido com misoprostol. O escore de Bishop foi melhor preditor para parto vaginal nestas circunstâncias.36136

Metabolomics applied to maternal and perinatal health : a review of new frontiers with a translation potential

The prediction or early diagnosis of maternal complications is challenging mostly because the main conditions, such as preeclampsia, preterm birth, fetal growth restriction, and gestational diabetes mellitus, are complex syndromes with multiple underlying mechanisms related to their occurrence. Limited advances in maternal and perinatal health in recent decades with respect to preventing these disorders have led to new approaches, and “omics” sciences have emerged as a potential field to be explored. Metabolomics is the study of a set of metabolites in a given sample and can represent the metabolic functioning of a cell, tissue or organism. Metabolomics has some advantages over genomics, transcriptomics, and proteomics, as metabolites are the final result of the interactions of genes, RNAs and proteins. Considering the recent “boom” in metabolomic studies and their importance in the research agenda, we here review the topic, explaining the rationale and theory of the metabolomic approach in different areas of maternal and perinatal health research for clinical practitioners. We also demonstrate the main exploratory studies of these maternal complications, commenting on their promising findings. The potential translational application of metabolomic studies, especially for the identification of predictive biomarkers, is supported by the current findings, although they require external validation in larger datasets and with alternative methodologies

Incidence and risk factors for preeclampsia in a cohort of healthy nulliparous pregnant women : a nested case-control study

The objective of this study is to determine the incidence, socio-demographic and clinical risk factors for preeclampsia and associated maternal and perinatal adverse outcomes. This is a nested case-control derived from the multicentre cohort study Preterm SAMBA, in fve diferent centres in Brazil, with nulliparous healthy pregnant women. Clinical data were prospectively collected, and risk factors were assessed comparatively between PE cases and controls using risk ratio (RR) (95% CI) plus multivariate analysis. Complete data were available for 1,165 participants. The incidence of preeclampsia was 7.5%. Body mass index determined at the frst medical visit and diastolic blood pressure over 75mmHg at 20 weeks of gestation were independently associated with the occurrence of preeclampsia. Women with preeclampsia sustained a higher incidence of adverse maternal outcomes, including C-section (3.5 fold), preterm birth below 34 weeks of gestation (3.9 fold) and hospital stay longer than 5 days (5.8 fold) than controls. They also had worse perinatal outcomes, including lower birthweight (a mean 379g lower), small for gestational age babies (RR 2.45 [1.52–3.95]), 5-minute Apgar score less than 7 (RR 2.11 [1.03–4.29]), NICU admission (RR 3.34 [1.61–6.9]) and Neonatal Near Miss (3.65 [1.78–7.49]). Weight gain rate per week, obesity and diastolic blood pressure equal to or higher than 75mmHg at 20 weeks of gestation were shown to be associated with preeclampsia. Preeclampsia also led to a higher number of C-sections and prolonged hospital admission, in addition to worse neonatal outcomes

Mean arterial blood pressure : potential predictive tool for preeclampsia in a cohort of healthy nulliparous pregnant women

Background: Prediction of preeclampsia is a challenge to overcome. The vast majority of prospective studies in large general obstetric populations have failed in the purpose of obtain a useful and effective model of prediction, sometimes based on complex tools unavaible in areas where the incidence of preeclampsia is the highest. The goal of this study was to assess mean arterial blood pressure (MAP) levels at 19–21, 27–29 and 37–39 weeks of gestation and performance of screening by MAP for the prediction of preeclampsia in a Brazilian cohort of healthy nulliparous pregnant women. Methods: This was a cohort approach to a secondary analysis of the Preterm SAMBA study. Mean arterial blood pressure was evaluated at three different time periods during pregnancy. Groups with early-onset preeclampsia, late-onset preeclampsia and normotension were compared. Increments in mean arterial blood pressure between 20 and 27 weeks and 20 and 37 weeks of gestation were also calculated for the three groups studied. The accuracy of mean arterial blood pressure in the prediction of preeclampsia was determined by ROC curves. Results: Of the 1373 participants enrolled, complete data were available for 1165. The incidence of preeclampsia was 7.5%. Women with early-onset preeclampsia had higher mean arterial blood pressure levels at 20 weeks of gestation, compared to the normotensive group. Women with late-onset preeclampsia had higher mean arterial blood pressure levels at 37 weeks of gestation, than the normotensive groups and higher increases in this marker between 20 and 37 weeks of gestation. Based on ROC curves, the predictive performance of mean arterial blood pressure was higher at 37 weeks of gestation, with an area under the curve of 0.771. Conclusion: As an isolated marker for the prediction of preeclampsia, the performance of mean arterial blood pressure was low in a healthy nulliparous pregnant women group. Considering that early-onset preeclampsia cases had higher mean arterial blood pressure levels at 20 weeks of gestation, future studies with larger cohorts that combine multiple markers are needed for the development of a preeclampsia prediction model

The food patterns of a multicenter cohort of Brazilian nulliparous pregnant women

Assessment of human nutrition is a complex process, in pregnant women identify dietary patterns through mean nutrient consumption can be an opportunity to better educate women on how to improve their overall health through better eating. This exploratory study aimed to identify a posteriori dietary patterns in a cohort of nulliparous pregnant women. The principal component analysis (PCA) technique was performed, with Varimax orthogonal rotation of data extracted from the 24-h dietary recall, applied at 20 weeks of gestation. We analysed 1.145 dietary recalls, identifying five main components that explained 81% of the dietary pattern of the sample. Dietary patterns found were: Obesogenic, represented by ultra-processed foods, processed foods, and food groups rich in carbohydrates, fats and sugars; Traditional, most influenced by natural, minimally processed foods, groups of animal proteins and beans; Intermediate was similar to the obesogenic, although there were lower loads; Vegetarian, which was the only good representation of fruits, vegetables and dairy products; and Protein, which best represented the groups of proteins (animal and vegetable). The obesogenic and intermediate patterns represented over 37% of the variation in food consumption highlighting the opportunity to improve maternal health especially for women at first mothering