Ultrassonografia morfológica de primeiro trimestre: importante ferramenta para rastreio de aneuploidias e pré-eclâmpsia / First-trimester morphological ultrasound: important tool for aneuploidy and pre-eclampsia screening

No início do século 20, as altas taxas de mortalidade materna e infantil estimularam o desenvolvimento de um modelo de atendimento pré-natal que mantivesse características parecidas até os dias atuais. Nesse modelo, haveria maior concentração de visitas durante o final do terceiro trimestre de gestação, devido às maiores taxas de complicações nas fases finais da gestação e à dificuldade de prever a ocorrência de resultados adversos durante o primeiro trimestre. Atualmente, a avaliação clínica durante o primeiro trimestre, com auxílio da ultrassonografia e marcadores bioquímicos, pode prever uma série de complicações que acometem a gestação, incluindo cromossomopatias, pré-eclâmpsia, restrição de crescimento fetal, anomalias fetais e trabalho de parto pré-termo.

At the beginning of the 20th century, the high rates of maternal and infant mortality stimulated the development of a model of prenatal care that maintained similar characteristics until the present day. In this model, there would be a greater concentration of visits during the end of the third trimester of pregnancy, due to the higher rates of complications in the final stages of pregnancy and the difficulty in predicting the occurrence of adverse outcomes during the first trimester. Currently, clinical evaluation during the first trimester, with the aid of ultrasound and biochemical markers, can predict a series of complications that affect pregnancy, including chromosomal disorders, preeclampsia, fetal growth restriction, fetal anomalies and preterm labor.

Gestantes con índice de pulsatilidad alterado en ecografía Doppler / Pregnant women with altered pulsatility index in Doppler echography

Introducción: La ecografía Doppler de las arterias uterinas es una técnica propuesta para predecir el riesgo de preeclampsia, retardo del crecimiento intrauterino y otras alteraciones perinatales adversas. Objetivos: Determinar la frecuencia de gestantes con alteración en las arterias uterinas durante el primer trimestre e identificar la presencia de preeclampsia/eclampsia, así como sus principales características clínicas. Métodos: Se efectuó un estudio descriptivo y longitudinal de 168 gestantes en el primer trimestre de embarazo, pertenecientes al municipio de Tercer Frente en Santiago de Cuba, evaluadas en una pesquisa de Genética realizada en el Policlínico Docente Cruce de los Baños, de abril a noviembre de 2018. A todas se les realizó ecografía Doppler para calcular el índice de pulsatilidad de las arterias uterinas. Resultados: En la casuística, 16 pacientes presentaron alterado el índice de pulsatilidad y, de ellas, solo en 3 se desarrolló preeclampsia, para 18,7 %; la edad promedio en estas últimas fue de 29 años y 2 eran nulíparas (66,6 %). Respecto al índice de pulsatilidad, el promedio fue de 2,5. Conclusiones: Se mantuvo un estrecho seguimiento, hasta el parto, de las pacientes con resultados patológicos, y se destacó la importancia de estudiar el índice de pulsatilidad de las arterias uterinas durante el primer trimestre del embarazo, sobre todo en las nulíparas.

Introduction: The Doppler echography of the uterine arteries is a technique suggested to predict the risk of pre-eclampsia, the intrauterine growth retardation and other adverse perinatal disorders. Objectives: To determine the frequency of pregnant women with disorder in the uterine arteries during the first trimester and to identify the pre-eclampsia/eclampsia presence, as well as their main clinical characteristics. Methods: A descriptive and longitudinal study of 168 pregnant women in the first trimester of pregnancy, belonging to the Tercer Frente municipality in Santiago de Cuba was carried out, they were evaluated by investigation of Genetics in Cruce de los Baños Teaching Polyclinic from April to November, 2018. To determine the pulsatility index of the uterine arteries, a Doppler echography was carried out. Results: In the case material 16 patients presented this parameter altered and just 3 pregnant women presented pre-eclampsia, for 18.7 %; the average age of these last ones was of 29 years and 2 were nonparous (66.6 %). Regarding the pulsatility index, the average was of 2.5. Conclusions: There was a close follow up of the patients with pathological results, until the childbirth, and the importance of studying the pulsatility index of the uterine arteries in the first trimester of the pregnancy, mainly in the nonparous, was emphasized.

Síndrome de encefalopatía posterior reversible en preeclampsia grave / Posterior reversible encephalopathy syndrome in severe preeclampsia

El síndrome de encefalopatía reversible posterior (PRES), es una entidad clínico radiológica caracterizada por déficit neurológico, convulsiones, pudiendo llegar a un estado de coma. Requiere diagnóstico por imagen para evidencia de edema vasogénico proceso fisiopatológico reversible, apoyados por tomografía computarizada o resonancia magnética, esta última con mayor sensibilidad para diferenciarla del edema citotóxico que es irreversible. Fisiopatológicamente está asociada a mala autorregulación cerebral secundaria varios factores, en este caso, preeclampsia grave, donde destaca el compromiso clínico e imagenológico del tronco encefálico. La instauración de un tratamiento adecuado y oportuno permite visualizar la regresión de las lesiones, que de no ser así terminaran infartándose.

The posterior reversible encephalopathy syndrome (PRES) is a clinical radiological entity characterized by neurological deficit, seizures, and may reach a coma. It requires diagnostic imaging for evidence of vasogenic edema reversible pathophysiological process, supported by computerized tomography or magnetic resonance, the latter with greater sensitivity to differentiate it from cytotoxic edema that is irreversible. Pathophysiologically, several factors are associated with poor cerebral self-regulation, in this case, severe preeclampsia, which highlights the clinical and imaging involvement of the brainstem. The establishment of an appropriate and timely treatment allows visualizing the regression of the lesions, which otherwise would end up infracting.

Uterine artery doppler in screening for preeclampsia and fetal growth restriction / Doppler das artérias uterinas no rastreamento para pré-eclâmpsia e restrição do crescimento fetal

Abstract Objective To perform a comprehensive review of the current evidence on the role of uterine artery Doppler, isolated or in combination with other markers, in screening for preeclampsia (PE) and fetal growth restriction (FGR) in the general population. The review included recently published large cohort studies and randomized trials. Methods A search of the literature was conducted usingMedline, PubMed, MeSH and ScienceDirect. Combinations of the search terms "preeclampsia," "screening," "prediction," "Doppler," "Doppler velocimetry," "fetal growth restriction," "small for gestational age" and "uterine artery" were used. Articles in English (excluding reviews) reporting the use of uterine artery Doppler in screening for PE and FGR were included. Results Thirty articles were included. As a single predictor, uterine artery Doppler detects less than 50% of the cases of PE and no more than 40% of the pregnancies affected by FGR. Logistic regression-based models that allow calculation of individual risk based on the combination of multiple markers, in turn, is able to detect ~ 75% of the cases of preterm PE and 55% of the pregnancies resulting in small for gestational age infants. Conclusion The use of uterine artery Doppler as a single predictive test for PE and FGR has poor accuracy. However, its combined use in predictive models is promising, being more accurate in detecting preterm PE than FGR.

Resumo Objetivo Realizar revisão da literatura científica acerca do uso do Doppler das artérias uterinas, de forma isolada ou em combinação com outros marcadores, no rastreamento para pré-eclâmpsia (PE) e restrição do crescimento fetal (RCF) na população geral. A revisão incluiu estudos de coorte e ensaios clínicos randomizados recentemente publicados. Métodos Realizou-se uma pesquisa da literatura nas bases de dados Medline, PubMed, MeSH e ScienceDirect. Diferentes combinações dos termos "preeclampsia," "screening," "prediction," "Doppler," "Doppler velocimetry," "fetal growth restriction," "small for gestational age" e "uterine artery" foram utilizadas. Artigos eminglês, (excluindo-se artigos de revisão) em que o Doppler das artérias uterinas é reportado como ferramenta no rastreamento para PE e RCF foram incluídos. Resultados Trinta artigos foram incluídos. Como teste preditivo isolado, o Doppler das artérias uterinas tem sensibilidade inferior a 50% na detecção de casos de PE e inferior a 40% para identificação de gestações afetadas por RCF. Modelos matemáticos preditivos baseados em equações de regressão logística que permitem o cálculo de risco individual, por sua vez, são mais promissores, permitindo a detecção de 75% dos casos de PE pré-termo, e 55% das gestações que resultarão emparto de recém-nascidos pequenos para a idade gestacional. Conclusão O uso do Doppler das artérias uterinas tem baixa acurácia na identificação de gestações afetadas por PE e RCF. No entanto, seu uso combinado com outros marcadores é mais promissor, apresentando maior acurácia para detecção de PE do que para RCF.

Doppler hepático na pré-eclâmpsia e na síndrome HELLP / Doppler ultrasonography of the liver in pre-eclampsia and HELLP syndrome

O fígado está entre os múltiplos órgãos que podem ser afetados na pré-eclâmpsia, e a função hepática pode ser gravemente prejudicada na síndrome HELLP. A ultrassonografia com Doppler constitui um método não invasivo que pode ser usado para o estudo da circulação hepática durante a gravidez. Com o objetivo de apresentar as evidências científicas disponíveis sobre as alterações do fluxo hepático na gravidez, foi realizada pesquisa da literatura mundial por meio das bases de dados MEDLINE/PubMed e LILACS. Em estudos de Dopplerfluxometria e Dopplervelocimetria, isoladamente ou associados ao eletrocardiograma e cardiografia por impedância, foram observadas alterações na circulação hepática durante a gravidez complicada por pré?eclâmpsia e síndrome HELLP. Entre os desafios para a pesquisa nesse campo destacamos a necessidade de aperfeiçoamento da técnica de exame, o estabelecimento de curvas de normalidade para as gestantes brasileiras, de indicadores de agravamento da pré?eclâmpsia e a aplicação potencial do método para o estudo da hipertensão crônica na gravidez.(AU)

The liver is among multiple organs that may be affected in pre-eclampsia, and liver function can be impaired in HELLP syndrome. Doppler ultrasonography of the liver provides a noninvasive method to study liver circulation during pregnancy. This paper reviews scientific evidence available in MEDLINE/ Pubmed and LILACS databases. Doppler studies on hepatic blood flow, flow velocities and vascular resistance indices, isolated or combined with Doppler?electrocardiography and impedance cardiography, observed changes in pregnancies complicated by pre?eclampsia and HELLP syndrome. Challenges to this research topic include improvements in Doppler examination techniques, establishment of normal values for Brazilian pregnant women, predictors for severe pre?eclampsia and potential use of hepatic Doppler use in chronic hypertension as well.(AU)

Endothelin-1 and leptin as markers of intrauterine growth restriction.

Objective. To explore the role of endothelin-1 (ET-1) and leptin in intrauterine growth restriction (IUGR) among preeclamptic and non-pre-eclamptic women. Methods. Forty three patients with a pregnancy complicated by IUGR, 23 cases with severe pre-eclampsia and 20 cases of non-pre-eclamptic were enrolled. Control group comprised 15 cases with uncomplicated pregnancy. Blood samples from umbilical artery and maternal venous blood were collected at the time of delivery for analysis of ET-1 and leptin levels. Mode of delivery, birth weight and Apgar score were also recorded. Results. The mean maternal and fetal ET-1 level was significantly higher in pregnancies complicated by IUGR than in control group. The mean maternal leptin level was significantly higher in pre-eclamptic patients when compared to nonpreeclamptic and control groups. Mean fetal leptin level was significantly lower in patients compared to control; however, when fetal leptin corrected to fetal weight, it was insignificantly different in the both groups. Conclusion. Maternal plasma ET-1 and leptin correlate with the degree of fetal growth restriction originating from deterioration of placental function. Maternal plasma leptin and ET-1 levels may reflect deterioration in fetal growth.

Value of umbilical artery doppler velocimetry in preeclampsia and pregnancy induced hypertension

One hundred and twelve pregnant patients with preeclampsia or pregnancy-induced hypertension were followed prospectively by a non- stress test, biophysical profile and Doppler velocimetry of the umbilical artery. Gestational age at delivery ranged from 35 to 42 weeks. Adverse perinatal outcome was detected in 15 patients and abnormal antepartum tests were detected in 29 patients. Eight patients had an abnormally elevated resistance index in umbilical artery, 4 of them with an abnormal perinatal outcome. Seven out of 18 patients with low biophysical profile had abnormal perinatal outcome. Four out of 12 patients with an abnormal non-stress test had abnormal perinatal outcome and in eight patients, more antepartum tests were abnormal. Biophysical profile demonstrated the best sensitivity and umbilical artery resistance index demonstrated the best positive predictive value

value of umbilical artery doppler ultrasonography in pregnancy induced hypertension and preeclampsia

One hundred twenty two pregnant patients with pregnancy induced hypertion or preeclampsia were followed prospectively by a nonstress test, biophysical profile and Doppler velocimetery of the umbilical artery. Their gestational age at delivery ranged between 34 to 41 weeks. Adverse perinatal outcome was detected in 16 patients [13.7%]. Abnormal antepartum tests were detected in 32 patients [26.2%]. Nine patients had an abnormally elevated resistance index in the umbilical artery, 4 of them abnormal perinatal outcome. Seven out of 18 patients with low Biophysical profile had abnormal perinatal outcome. Five out of 14 patients with an abnormal non-stress test had abnormal perinatal outcome. In 9 patients, more than one antepartum test was abnormal. Biophysical profile demonstrated the best sensitivity [43.8%] and umbilical artery resistance index demonstrated the best positive predictive value [44.4%]. By considering any abnormal test as a positive test result for a given patient, a market improvement in the sensitivity [81.3%] was obtained. Doppler velocimetry of the umbilical artery added some help to the prediction of fetus at risk and to the follow up of patients with pregnancy induced hypertension and preeclampsia, and when combined with additional antepartum tests, it may our ability to predict the compromised fetus in these increase diseases