Gravidez prolongada: subsídios da literatura médica para uma defesa / Prolonged pregnancy: medical literature support for a defense

A conduta para o atendimento de gestantes com gravidez prolongada sofre variações conforme o serviço pesquisado. Trabalhos de meta-análise mostram que o atendimento ideal da gravidez com mais de 41 semanas ainda requer mais estudos, alguns mostrando vantagens na indução do trabalho de parto e outros não. Por outro lado, observa-se, cada vez mais, processos judiciais contra médicos nas áreas de Ginecologia e Obstetricia, em decorrência de negligência, imperícia e imprudência, muitas vezes de difícil caracterização, no atendimento dessas pacientes. A gestação prolongada, que ocorre, aproximadamente, em torno de 10% das gestações, pode causar acometimentos irreversíveis tanto maternos quanto fetais, aumentando a morbimortalidade de ambos, além de ser um dos motivos de denúncia de erro médico. Este trabalho teve como objetivo buscar evidências científicas na literatura que ofereçam diretrizes para o melhor atendimento dessas pacientes, na tentativa de se evitar danos maternos e fetais e ainda oferecer subsídios para uma defesa profissional, caso o médico sofra denuncia por má pratica quando do atendimento de uma gestante nessa condição

Procedures for the care of pregnant women with prolonged pregnancy can vary according to the service. Meta-analysis show that the ideal treatment of pregnancy over 41 weeks still demands more studies, some of them showing advantages in the induction of delivery and others not. On the other hand, it can be increasingly observed lawsuits against doctors in Obstetrics and Gynecology as a result of negligence, malpractice and imprudent acts - which are difficult to characterize - in the care of these patients.The prolonged gestation, which occurs roughly in around 10% of pregnancies, can cause irreversible maternal and fetal attacks, increasing morbidity and mortality of both. It is also one of the reasons for denunciation of medical error. This work had the purpose of seek evidence in the scientific literature that provide guidelines to ensure a better management of these patients, in an attempt to prevent maternal and fetal damage and give subsidies for a professional defense if the doctor is accused of malpractice in the treatment of a woman in this condition

Prediction of Prolonged Pregnancy in Nulliparous Women by Transvaginal Ultrasonographic Measurement of Cervical Length at 20-24 Weeks and 37 Weeks

This study was done to evaluate transvaginal ultrasonographic measurement of cervical length at 20 to 24 weeks and 37 weeks as a predictor of prolonged pregnancy (defined as a pregnancy that extended beyond 41+2 weeks of gestation [289 days]) in nulliparous women. This prospective observational study enrolled 149 consecutive nulliparous women with singleton gestation at 37 weeks. Cervical length was measured by transvaginal ultrasonography at 20 to 24 weeks and 37 weeks. Cervical length at 37 weeks, but not at 20 to 24 weeks, was significantly longer in women delivered at >41+2 weeks than in those delivered at < or =41+2 weeks (p<0.005). There was a significant correlation between cervical length at 37 weeks and gestational age at delivery (Pearson correlation coefficient, r=0.387, p<0.0001). In the receiver operating curve, the best cut-off value of cervical length at 37 weeks for the prediction of prolonged pregnancy was 30 mm, with a sensitivity of 78% and a specificity of 62%. Cervical length assessed by transvaginal ultrasonography at 37 weeks can predict the likelihood of prolonged pregnancy in nulliparous women. However, there is no association between cervical length at 20 to 24 weeks and the occurrence of prolonged pregnancy.

Color doppler ultrasonography evaluation of nuchal cord before induction of labor in postterm pregnancies

To asses the ability of color Doppler ultrasonography to detect the presence of nuchal cord [NC] before induction of labor in uncomplicated postterm pregnancies, and to investigate whether fetal umbilical artery vascular resistance, mode of delivery, and neonatal outcome are affected by its presence in such cases. In a prospective study, a transabdominal grayscale and color Doppler ultrasound imaging was performed prior to induction of labor in 250 women with uncomplicated postterm pregnancies at 41 weeks to detect the presence of nuchal cord and to measure the umbilical artery [UA] systolic/diastolic ratio [S/D] and resistance index [RI]. The outcomes of labor, delivery and neonates were obtained. Outcome parameters evaluated included presence of nuchal cords at delivery, mode of delivery, non-reassuring fetal heart rate patterns [NRFHR], meconium-stained amniotic fluid, birth weight, 1 and 5 minutes Apgar scores, and admission to neonatal intensive care unit. A total of 250 women were included in this study, of which 71 had sonographic evidence of NC [group I] and 179 without sonographic evidence of NC [group II]. A nuchal cord was present at 26.8% of deliveries. The sensitivity of color Doppler sonography in diagnosing NC was 94%, with specificity, positive and negative predictive values of 95.6%, 88.7%, and 97.7%, respectively. No abnormal UA waveform patterns were detected in either group, and no statistically significant differences in UA S/D or RI values were found between the two study groups. There were also no significant differences between group I and group II with respect to mode of delivery, NRFHR, meconium-stained amniotic fluid, birth weight, 1 and 5 minutes Apgar scores, and neonatal intensive care unit admissions. Color Doppler ultrasonography is highly sensitive and specific method of diagnosing nuchal cord prior to induction of labor in uncomplicated postterm pregnancies. However, fetal umbilical artery vascular resistance, mode of delivery, and neonatal outcome are not affected by cord encirclement in such cases. Therefore, ultrasonographic nuchal cord assessment is neither a necessary nor a useful procedure before labor induction in uncomplicated postterm pregnancies, and intrapartum intervention based on the antenatal diagnosis may not be appropriate

Hallazgos cardiotocograficos en el embarazo cronológico prolongado marzo 1991- febrero 1992 / Prolonged pregnancy: Cardiotopographies findings

Se estudiaron 60 pacientes con embarazo cronológico prolongado y sin ninguna otra complicación, realizándose un monitoreo antenatal no estresante (MANE) en el servicio de estudios especiales del departamento de Gineco-Obstetricia del Hospital Central "Antonio María Pineda" en el lapso de marzo 1991 a febrero 1992 con el fin de revisar y analizar los hallazgos cardiotocográficos en busca de un patrón. Se encontró en el 53,3 por ciento frecuencia cardíaca fetal basal (FCFB) entre 120 y 135 lat/min., variabilidad I a II en el 76,6 por ciento, 3 o más movimientos fetales en el 65 por ciento, ausencia de desaceleraciones de FCFB en 58 por ciento y 3 o más ascensos transitorios de FCFB en el 50 por ciento determinando un patrón reactivo en igual proporción

Utilidad del diagnóstico de placenta grado III por ecografía en el manejo del embarazo prolongado / Usefulness of diagnosis of placenta stage III by echography in the management of prolonged pregnancy

Con el propósito de determinar la importancia de encontrar una placenta grado III por ecografía en embarazos prolongados se revisaron los resultados obtenidos en 75 pacientes con embarazos de 41 semanas, o más, por amenorrea, en los que se practicó eecografía con sistema de ultrasonido de tiempo real, lineal de 3.5 MHz en la Unidad de Perinatología del Hospital Universitario Dr. José E. González, U.A.N.L., del 27 de octubre de 1986 al 17 de febrero de 1987. Se formaron tres grupos según los grados I, II y III de imagen placentaria y se compararon los seguientes parámetros: Apgar, peso, Ballard y presencia de meconio en líquido amniótico. Los resultados obtenidos en nuestro grupo no mostraron diferencias estadísticamente significativas entre las pacientes con placenta grado III y las pacientes con placenta grados I y II respecto a Apgar, peso, Baillard y presencia de meconio; no por lo que consideramos que el diagnosticar una placenta grado III en pacientes con embarazo prolongado no constituye por sí sola una indicación para interrumpir éste. La incidencia de placenta grado III en nuestro grupo (27.3%) fue significativamente mayor que la reportada en la literatura (15%) para embarazos de término. En el grupo de placentas grado III no se presentó ningún producto pretérmino mientras que hubo cuatro prematuros en el resto de los casos; lo que concuerda con la literatura en lo que se especifica que una vez que la totalidad de la imagen placentaria es grado III se debe considerar al producto maduro

Manejo del embarazo prolongado / Manegement of prolonged pregnancy

En vista del gran volume que para un hospsital de concentración como el nuestro, representan las pacientes con embarazo prolongado, la aplicación de protocolos de manejo muy complicados, que en otros lugares han dado buenos resultados, para nuestro medio resultan ser poco prácticos. Es por ello que se inició el tratamiento de estas pacientes con un protocolo de manejo con un enfoque básicamente clínico; se analizan 433 casos donde 269 pacientes fueron manejados con este protocolo y se hace la comparación con 114 pacientes manejadas con otro criterio. En las conclusiones se analiza el avance en el logro de los objetivos iniciales del protocolo y el valor de la amniocentesis en el manejo de esta pacientes