Efeitos maternos do clampeamento tardio do cordão umbilical : um estudo clínico randomizado

Introdução: A anemia durante a gestação é uma comorbidade comum, podendo atingir 80% das gestantes em países em desenvolvimento. A hemorragia pós-parto é frequente no Brasil, podendo acarretar uma piora da anemia. Dentre as medidas preventivas de hemorragia puerperal, está o manejo ativo do 3º período do parto, que inclui o clampeamento imediato do cordão, uso de uterotônicos e tração controlada do cordão para dequitação placentária. Inúmeros estudos demonstram benefícios fetais para adoção rotineira do clampeamento tardio (CT) de cordão, entretanto há poucos estudos sobre possíveis efeitos maternos de tal prática, especialmente em relação ao sangramento pós-parto e grau de anemia. Objetivo: Verificar os efeitos maternos do CT do cordão umbilical, avaliando a variação de hemoglobina materna antes e após o parto com o clampeamento tardio do cordão umbilical. Métodos: Ensaio clínico randomizado entre as parturientes com gestação a termo e de risco habitual do centro obstétrico do HCPA, comparando a realização do CT do cordão umbilical com o clampeamento imediato (CI). No momento do nascimento os casos foram randomizados para clampeamento rotineiro imediato (CI) ou clampeamento tardio (CT) do cordão umbilical. Resultados: Todas as 356 mulheres randomizadas (mediana[P25–P75] de idade, 25,00[21,00–31,00] anos) completaram o estudo. O nível médio (±DP) de hemoglobina e hematócrito no pré-operatório foi de 12,13±1,06 e 35,73±2,97 g/dl, respectivamente, no imediato e de 12,13±1,11 e 35,52±3,08 g/dl, respectivamente, no grupo de clampeamento tardio do cordão umbilical. O nível médio (±DP) de hemoglobina e hematócrito no dia 2 pós-operatório foi de 10,19±1,46 e 30,27±4,29 g/dl, respectivamente, no imediato e 10,24±1,42 e 30,33±4,14 g/dl, respectivamente, no clampeamento tardio do cordão umbilical grupo. A mediana [P25-P75] de dose do uso materno de ocitocina foi maior no grupo tardio (10,00[10,00-40,00]) em relação ao grupo de clampeamento imediato do cordão umbilical (10,00[10,00 - 30,00]) (teste de Mann-Whitney, p=0,019). A mediana [P25 - P75] dos índices APGAR no 1º e no 5º minutos foi menor no grupo tardio (9,00[8,00–9,00] e 9,00[9,00–10,00], respectivamente) em relação ao grupo de clampeamento imediato do cordão umbilical (9,00[9,00–9,00] e 10,00[9,00–10,00], respectivamente) grupo do cordão umbilical (teste de Mann-Whitney, p=0,001 e p=0,005, respectivamente), sem efeitos clínicos significativos. A análise de correlação de Spearman revelou que o fórceps e o uso adicional da dose de ocitocina estavam positivamente relacionados ao clampeamento tardio do cordão umbilical. Além disso, o aumento do uso da dose de ocitocina esteve negativamente relacionado ao nível de hematócrito no pré-operatório, ao hematócrito e aos níveis de hemoglobina no pós-operatório (48 horas). Da mesma forma, episiotomia, uso de fórceps e número de uterotônicos usados foram negativamente relacionados aos níveis de hematócrito e hemoglobina no pós-operatório de 48 horas. Além disso, os níveis de hematócrito e hemoglobina de 48 horas estavam relacionados negativamente com sangramento materno grave e atonia uterina, enquanto positivamente relacionados com laceração e IMC materno. Conclusões: Entre as mulheres submetidas a parto vaginal de risco habitual ou cesariana programada de gestações a termo, o clampeamento tardio do cordão umbilical, em comparação com o clampeamento imediato do cordão umbilical, resultou em uma redução semelhante do nível de hemoglobina materna no dia 2 do pós-operatório. As equipes médicas devem ter uterotônicos adicionais para realizar ou gerenciar, se necessário, o clampeamento do cordão umbilical em partos a termo vaginal e cesáreo, para minimizar possíveis complicações maternas e neonatais.Introduction: Anemia during pregnancy is a common entity and can reach 80% of pregnant women in developing countries. Iron supplementation is indicated during pregnancy to minimize its complications. Another common pathology in third World countries is post-partum bleeding, which may cause a worsening of anemia in the parturient. Among the preventive measures of puerperal hemorrhage, is the active management of the 3rd period of delivery, with administration of oxytocin for all parturients, controlled traction for placental discharge and immediate cord clamping. Numerous studies have demonstrated fetal benefits for routine adoption of delayed cord clamping (DC), however there are few reports on possible maternal effects of such practice, especially in relation to postpartum bleeding. Objective: To verify the maternal effects of DC of the umbilical cord, evaluating maternal hemoglobin variation before and after delivery with delayed clamping of the umbilical cord. Methods: A randomized clinical trial was carried out among pregnant women with full term gestation and habitual risk prenatal care at the HCPA obstetric center, comparing the performance of DC with immediate cord clamping (IC). At the time of birth (by vaginal delivery or cesarean section), cases were randomized to one of two situations: immediate clamping (IC) or delayed clamping (DC) of the umbilical cord. Results: All of the 356 women who were randomized (median [P25–P75] age, 25.00[21.00–31.00] years) completed the trial. The mean (±SD) preoperative hemoglobin and hematocrit level was 12.13±1.06 and 35.73±2.97 g/dl, respectively, in the immediate and 12.13±1.11 and 35.52±3.08 g/dl, respectively, in the delayed umbilical cord clamping group. The mean (±SD) postoperative day 2 hemoglobin and hematocrit level was 10.19±1.46 and 30.27±4.29 g/dl, respectively, in the immediate and 10.24±1.42 and 30.33±4.14 g/dl, respectively, in the delayed umbilical cord clamping group. The median [P25–P75] dose of maternal oxytocin use was higher in delayed (10.00[10.00–40.00]) than in the immediate umbilical cord group (10.00[10.00 – 30.00]) (Mann-Whitney test, p=0.019). The median [P25 – P75] APGAR in the 1st and 5th minutes were lower in the delayed (9.00[8.00–9.00] and 9.00[9.00–10.00], respectively) than the immediate (9.00[9.00–9.00] and 10.00[9.00–10.00], respectively) umbilical cord group (Mann-Whitney test, p=0.001 and p=0.005, respectively), with no significant clinical effects. Spearman’s correlation analysis revealed that forceps and additional use of oxytocin dose was positively related to delayed umbilical cord clamping. Additionally, the increased use of oxytocin dose was negatively related to preoperative hematocrit level, to 48-h postoperative hematocrit and hemoglobin levels. Similarly, episiotomy, forceps and the number of used uterotonic were negatively related to 48-h postoperative hematocrit and hemoglobin levels. Besides, 48-h hematocrit and hemoglobin levels were negatively related to maternal severe bleeding and uterine atony, while it was positively related to laceration and maternal BMI. Conclusions: Among women undergoing low-risk vaginal or scheduled cesarean delivery of term singleton pregnancies, delayed umbilical cord clamping, compared with immediate cord clamping, resulted in a similar maternal hemoglobin level reduction at postoperative day 2. Medical teams should have additional uterotonics to perform or manage, if necessary, umbilical cord clamping in the vaginal and cesarean sections at term deliveries, to minimize possible maternal and neonatal complications

Midline supraumbilical incision as an option for morbidly obese patients? : case report

Background: Nowadays we observe growing rates of obesity, mainly among women. It has a great impact on maternal and fetal morbimortality and requires a specific obstetric approach. Aim: To discuss different approaches to abdominal incision in cesarean section in obese patients. Case presentation: Patient with morbid obesity submitted to an elective cesarean section due to fetal macrosomia and who underwent a cesarean section with a supraumbilical median incision evolving without any postpartum complications. Conclusion: It’s important to evaluate and chose the best incision in morbidly obese pregnant women aiming to reduce difficulties in fetal extraction and postoperative complications. Midline supraumbilical incision is a good choice in these cases, reducing surgical time and postpartum hemorrhage

Acute generalized exanthematous pustulosis during puerperal period induced by azithromycin : case report

Background: The use of antibiotics, especially beta-lactams and macrolides, may be associated with dermatopathies, such as Acute Generalized Exanthematous Pustulosis (AGEP), which is an uncommon cutaneous adverse reaction. Case: We report a case of AGEP, in a 36-year-old multiparous (G5P3C1A1) woman, with 38 weeks of gestation, admitted to the hospital to induce labor. Due to cephalopelvic disproportion, the cesarean section was indicated. In the postoperative period, the patient evolved with cutaneous rash, accompanied by productive cough and dyspnea. Because it was a fever of obscure origin, the treatment with antibiotics, including azithromycin, was initiated. On subsequent days, she presented pustules on the back, abdomen and extremities. Such reaction was attributed to the use of azithromycin. When the drug was discontinued, the lesions regressed significantly. Conclusion: The clinical picture of AGEP may occur with persistent high fever and therefore could be confused with systemic infections, consequently, being treated with wrong medications capable of aggravating the adverse cutaneous reaction, worsening the course of the disease that could be easily treated by stopping the use of the causative drug. This case shows the importance of including AGEP as a differential diagnosis of dermatopathies in the pregnancy-puerperal cycle, especially in women who are using various medications, including antibiotics

Correlation between late cord clamping and phototherapy and other neonatal unfavorable outcomes : a randomized clinical trial

Background: Recently, late umbilical cord clamping is generally recommended, which decreases neonatal anemia; however, it may also increase neonatal jaundice and some other poor outcomes. Objectives: We here attempted to determine whether late clamping actually increases the incidence of phototherapy for jaundice and other poor outcomes of the term “low-risk newborns”. Methods: With the approval of the Brazilian Registry of Clinical Trials (REBEC), a total of 357 low-risk newborns (singleton, uncomplicated pregnancy/delivery, in a Brazilian public institution) were randomized into two groups: group I (n = 114): cord clamping < 1 minute (early clamping) or group II (n = 243): cord clamping between 1 - 3 minutes (late clamping). Statistics were used appropriately (i.e., measures of central tendency, dispersion for continuous variables, Shapiro-Wilk, Mann-Whitney test, or Chi-square test). Results: Phototherapy was performed in 5.3% in both groups. Also, there were no statistical differences in the occurrence of secondary outcomes, such as sepsis, neonatal ICU admission, and transient tachypnea of the newborns: i.e., 0.9%, 15.8%, and 3.5%, respectively for group I versus 1.2%, 15.6%, and 5.8%, respectively for group II. Conclusion: Late umbilical cord clamping does not increase the need for phototherapy in low-risk neonates. This result corroborates the current recommendation of late cord clamping, whenever appropriate

Maternal effects of immediate versus delayed umbilical cord clamping : a randomized clinical trial

OBJECTIVE: To compare maternal preoperative and postoperative hemoglobin variation after cord clamping. METHODS: Randomized clinical trial performed in Porto Alegre, RS from January to December 2012. It was included 356 women with habitual risk gestations. In the immediate cord clamping group, the umbilical cord section was realized between 0 and 60 s (group 1) while in the delayed cord clamping group it was realized >60 s (group 2). RESULTS: The mean (±standard deviation [SD]) preoperative hemoglobin was 12.13 ± 1.06 in the group 1 and 12.13 ± 1.11 in the group 2. The mean (±SD) postoperative day 2 hemoglobin level was 10.19 ± 1.46 in the group 1 and 10.24 ± 1.42 in the group 2. CONCLUSIONS: Delayed umbilical cord clamping resulted in a similar maternal hemoglobin level reduction at postoperative day 2

First experience using Brazilian Ingamed cervical pessary in twin pregnancy : a case series

Background: The rate of prematurity in twin pregnancies is higher than 50%. Due to its multifactorial nature, different strategies are necessary to reduce the incidence of premature birth or to increase the gestational age at birth of pregnancies at risk. In this context, cervical pessary may be indicated in twin pregnancies with short cervix. Methods: In this case series, we describe six twin pregnancies that were considered as high-risk for preterm labor due to short cervix (CL < 30 mm) at second trimester and multiple risk factors for prematurity. Several strategies were associated for the goal of delaying gestational age at birth. The main strategies were: removal of labor activities, treatment of infections, vaginal micronized progesterone 400 mg/day and vaginal pessary insertion (Ingamed Brazil). Results: The gestational age of insertion of the pessary ranged from 16 to 24 weeks. The gestational age of birth ranged from 26 to 34 weeks. Three of the pregnancies were delivered due to spontaneous onset of labor, and three were delivered due to medical reasons. The mean length of pregnancy since pessary insertion to birth was 9 weeks (range 2 to 17 weeks). All infants without severe fetal malformation were discharged from the hospital without major sequelae. Conclusion: The use of cervical pessaries associated to micronized progesterone at a dose of 400 mg/day may be an option in the management of twins at risk for preterm birth. More controlled studies are needed to evaluate the simultaneous use of cervical pessary and progesterone on twin pregnancies

Brain tumor in differential diagnosis of seizures in puerperium : case report

Convulsive crisis is a transient disturbance of cerebral function, and the etiology of which may be manifold. Its clarification is essential for establishing adequate therapy and seizure control. In the pregnancy-puerperal cycle, eclampsia is the most common cause of it, but brain tumor, epilepsy and other disorders are part of the differential diagnosis. We report a case of seizure triggered by tumor in a primigest, 22 years old, at 38 weeks’ gestation with premature rupture of membranes. Cesarean section was performed due to non-reassuring fetal condition. On the second day of puerperium, she presented recurrent episodes of generalized tonic-clonic seizures and elevated blood pressure. She received magnesium sulfate for 24 hours and persisted with severe headache. Magnetic resonance imaging of the brain showed an expansive lesion in the left frontoparietal region. The patient underwent intracranial microsurgery on the eighth day after cesarean section, with complete resection of the lesion and anatomopathological diagnosis of schwannoma. She went through good postoperative evolution, without neurological deficits, and stayed on phenobarbital, with no seizures until 6 months of follow-up. From the case we conclude that although the first diagnosis in pregnant or puerperal women with seizures should be eclampsia, there are other causes, such as brain tumor and Posterior Reversible Encephalopathy Syndrome (PRES). Careful evaluation is required, especially in refractory cases and not responding to usual treatment

Acute generalized exanthematous pustulosis during puerperal period induced by azithromycin : case report

Background: The use of antibiotics, especially beta-lactams and macrolides, may be associated with dermatopathies, such as Acute Generalized Exanthematous Pustulosis (AGEP), which is an uncommon cutaneous adverse reaction. Case: We report a case of AGEP, in a 36-year-old multiparous (G5P3C1A1) woman, with 38 weeks of gestation, admitted to the hospital to induce labor. Due to cephalopelvic disproportion, the cesarean section was indicated. In the postoperative period, the patient evolved with cutaneous rash, accompanied by productive cough and dyspnea. Because it was a fever of obscure origin, the treatment with antibiotics, including azithromycin, was initiated. On subsequent days, she presented pustules on the back, abdomen and extremities. Such reaction was attributed to the use of azithromycin. When the drug was discontinued, the lesions regressed significantly. Conclusion: The clinical picture of AGEP may occur with persistent high fever and therefore could be confused with systemic infections, consequently, being treated with wrong medications capable of aggravating the adverse cutaneous reaction, worsening the course of the disease that could be easily treated by stopping the use of the causative drug. This case shows the importance of including AGEP as a differential diagnosis of dermatopathies in the pregnancy-puerperal cycle, especially in women who are using various medications, including antibiotics

Brain tumor in differential diagnosis of seizures in puerperium : case report

Convulsive crisis is a transient disturbance of cerebral function, and the etiology of which may be manifold. Its clarification is essential for establishing adequate therapy and seizure control. In the pregnancy-puerperal cycle, eclampsia is the most common cause of it, but brain tumor, epilepsy and other disorders are part of the differential diagnosis. We report a case of seizure triggered by tumor in a primigest, 22 years old, at 38 weeks’ gestation with premature rupture of membranes. Cesarean section was performed due to non-reassuring fetal condition. On the second day of puerperium, she presented recurrent episodes of generalized tonic-clonic seizures and elevated blood pressure. She received magnesium sulfate for 24 hours and persisted with severe headache. Magnetic resonance imaging of the brain showed an expansive lesion in the left frontoparietal region. The patient underwent intracranial microsurgery on the eighth day after cesarean section, with complete resection of the lesion and anatomopathological diagnosis of schwannoma. She went through good postoperative evolution, without neurological deficits, and stayed on phenobarbital, with no seizures until 6 months of follow-up. From the case we conclude that although the first diagnosis in pregnant or puerperal women with seizures should be eclampsia, there are other causes, such as brain tumor and Posterior Reversible Encephalopathy Syndrome (PRES). Careful evaluation is required, especially in refractory cases and not responding to usual treatment