Exploración neuropsicológica en un caso de sufrimiento fetal agudo: diagnóstico e intervención / Neuropsychological exploration in a acute fetal distress case: diagnosis and intervention

En el presente artículo se muestran los resultados del proceso de corrección de una niña de edad escolar que presento sufrimiento fetal agudo a los 6 meses de gestación. Se describe el proceso de evaluación y la interpretación de los resultados a la luz de la teoría neuropsicológica de Luria y la psicología histórico-cultural de Vigotsky. Se presenta la propuesta de un programa de corrección neuropsicológica, el cual tiene como objetivo lograr un mejor funcionamiento de los mecanismos de regulación y control y de análisis y síntesis espacial simultanea. Finalmente, se exponen y contrastan los resultados de la evaluación aplicada después del programa de corrección con el estado inicial de la menor...

The present article shows the correction process result of a girl in school age who presents acute fetal distress at six month of gestation. Describes the evaluation process and the result of the interpretation at the neuropsychology theory light of Luria and Vigotsky Historic-Cultural psychology. Present the proposal of a Neuropsychological correction program, which has as objective achieved a better regulation and control and analysis and simultaneous spatial synthesis mechanism operation. Finally, exposed and contrasts evaluation results applied after the correction program with the initial state of the minor...

Métodos de vigilância fetal intraparto / Methods of intrapartum fetal surveillance

A avaliação do bem-estar fetal durante assistência ao trabalho de parto é um dos principais objetivos da Obstetrícia. O método mais utilizado para essa avaliação é a monitorização eletrônica fetal contínua. Em razão de sua limitada capacidade diagnóstica, outros métodos complementares têm sido investigados para esse fim, como a ausculta intermitente, a estimulação digital no escalpe fetal, a oximetria de pulso, o eletrocardiograma fetal e a coleta de amostras de sangue do couro cabeludo fetal. Após revisão da literatura, foi concluído que são necessários mais estudos para determinar a verdadeira utilidade, na prática clínica, dos métodos complementares à monitorização eletrônica fetal contínua para avaliação fetal intraparto.

The evaluation of intrapartum fetal well-being is one of the main objectives of Obstetrics. The most used method for this assessment is the continuous electronic fetal monitoring. Because of their limited diagnostic capabilities, other complementary methods have been investigated for evaluation of intrapartum surveillance, as intermittent auscultation, digital fetal scalp stimulation, pulse oximetry, fetal electrocardiogram and fetal scalp blood sample. After a review of articles, we concluded that more studies are needed to determine the true usefulness in clinical practice of complementary methods to continuous electronic fetal monitoring for intrapartum fetal monitoring.

Avaliação biofísica complementar da vitalidade fetal / Additional biophysical evaluation of fetal surveillance

O nascimento de um feto saudável sempre constituiu um dos principais objetivos da Obstetrícia. Nos dias atuais, vários procedimentos têm sido utilizados com esta finalidade, porém, apesar da evolução dos métodos diagnósticos e da melhor compreensão da fisiopatologia do sofrimento fetal, ainda existem lacunas no conhecimento sobre o comportamento do feto frente à hipóxia. Outro fator complicador na avaliação do sofrimento fetal é o grande número de doenças maternas com diferentes fisiopatologias que podem interferir no bem-estar fetal. Esta revisão tem como objetivo descrever os principais métodos de avaliação biofísica da vitalidade fetal, com base nas melhores evidências científicas correntemente disponíveis na literatura, e incluindo níveis de evidências e graus de recomendação. Será abordada a avaliação da vitalidade fetal nos casos de insuficiência placentária, não sendo estudadas as situações especiais, como diabetes e gestação múltipla. Evidencia-se uma falta de consenso sobre qual procedimento deve ser utilizado na avaliação da vitalidade fetal, na prática clínica diária. As sociedades internacionais recomendam a realização da doplervelocimetria, da cardiotocografia e do perfil biofísico fetal apenas em gestantes de alto risco, com suspeita de insuficiência placentária ou com restrição de crescimento intrauterino

The birth of a healthy baby has always been an important goal of Obstetrics. Nowadays, many procedures have been used for this purpose, but despite great development in diagnostic methods and better understanding of pathophysiology of fetal distress, there are still gaps in knowledge about fetal behavior in situations of hypoxia. Another complicating factor in the assessment of fetal distress is the large number of maternal diseases with different pathophysiology, which can compromise fetal well-being. This review aims at describing the main methods for fetal assessment, based on the best scientific evidence currently available, including levels of evidence and grades of recommendation. Only fetal evaluation in cases of placental insufficiency will be addressed, and special situations such as diabetes and multiple pregnancies will not be studied. Current evidences show a lack of consensus on what is the best procedure to assess fetal well-being in clinical practice. International societies recommend the performance of Doppler velocimetry, cardiotocography, and fetal biophysical profile only in high-risk pregnancies with suspected placental insufficiency or restricted intrauterine growth

Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time.

OBJECTIVE: To find out the efficacy of continuous fetal heart monitoring by analyzing the cases of cesarean section for nonreassuring fetal heart in labor, detected by cardiotocography (CTG) and correlating these cases with perinatal outcome. To evaluate whether a 30 minute decision to delivery (D-D) interval for emergency cesarean section influences perinatal outcome. METHODS: This was a prospective observational study of 217 patients who underwent cesarean section at > or = 36 weeks for non-reassuring fetal heart in labor detected by CTG. The maternal demographic profile, specific types of abnormal fetal heart rate tracing and the decision to delivery time interval were noted. The adverse immediate neonatal outcomes in terms of Apgar score <7 at 5 minutes, umbilical cord thornH <7.10, neonates requiring immediate ventilation and NICU admissions were recorded. The correlation between non-reassuring fetal heart, decision to delivery interval and neonatal outcome were analyzed. RESULTS: Out of 3148 patients delivered at > or = 36 weeks, 217 (6.8%) patients underwent cesarean section during labor primarily for non-reassuring fetal heart. The most common fetal heart abnormality was persistent bradycardia in 106 (48.8%) cases followed by late deceleration in 38 (17.5%) cases and decreased beat to beat variability in 17 (7.8%) cases. In 33 (15.2%) babies the 5 minutes Apgar score was <7 out of which 13 (5.9%) babies had cord thornH <7.10. Thirty three (15.2%) babies required NICU admission for suspected birth asphyxia. Rest 184 (84.7%) neonates were born healthy and cared for by mother. Regarding decision to delivery interval of < or =30 minutes versus >30 minutes, there was no significant difference in the incidence of Apgar score <7 at 5 minutes, cord pH <7.10 and new born babies requiring immediate ventilation. But the need for admission to NICU in the group of D-D interval < or = 30 minutes was significantly higher compared to the other group where D-D interval was >30 minutes. CONCLUSION: Non-reassuring fetal heart rate detected by CTG did not correlate well with adverse neonatal outcome. There was no significant difference in immediate adverse neonatal outcome whether the D-D time interval was < or = 30 minutes or >30 minutes; contrary to this, NICU admission for suspected birth asphyxia in </= 30 minutes group was significantly higher.

Vascular endothelial growth factor levels in newborns with meconium stained amniotic fluid.

OBJECTIVE: The effects of meconium-stained amniotic fluid (MSAF) on cord blood vascular endothelial growth factor (VEGF) levels have not been explored. The aim of this study was to verify whether MSAF influences cord blood VEGF levels in healthy term neonates and we can use cord blood VEGF levels in infants with MSAF as an indicator of fetal distress. METHODS: Using an enzyme-linked immunosorbent assay double sandwich method, plasma VEGF levels were determined in 18 healthy term neonates with MSAF and in 16 healthy term neonates without MSAF. RESULTS: VEGF plasma levels were not significantly different between healthy term neonates with or without MSAF. CONCLUSION: Intrauterine meconium passage could not affect VEGF levels on cord blood in term newborn infants and VEGF level may not be used as an indicator of fetal distress in infants with MSAF.

Comparison of the manual stimulation test and the nonstress test: a randomized controlled trial.

OBJECTIVE: To evaluate manual fetal stimulation (MST) through the maternal abdomen in comparison to standard nonstress test (NST) in terms of nonreactive rates and testing time. MATERIAL AND METHOD: Five hundred and forty high-risk singleton pregnancies at 28 gestational weeks or more were assigned to have either NST or MST using blocked randomization (270 each). All fetal heart rate (FHR) tracings were analyzed blindly using standard NST criteria by one perinatologist. RESULTS: The MST group provided a significantly higher reactive rate than that of the NST group, 98.9% and 84.4% respectively, p < 0.001. Mean testing time of the reactive results of the MST group was also significantly shorter than that of the NST group, 7.94 +/- 6.27 min and 13.91 +/- 9.58 min respectively, p < 0.001. CONCLUSION: This is the first randomized controlled trial (RCT) to demonstrate the distinctive benefit of the simple and less expensive MST. MST significantly reduces the time to reactivity and increases the frequency of reactivity when compared to NST alone.

Effect of halogen light in fetal stimulation for fetal well-being assessment.

OBJECTIVE: To evaluate the shortening of the time of nonstress test (NST) by using transabdominal fetal stimulation with halogen light. STUDY DESIGN: Experimental research. MATERIAL AND METHOD: The authors enrolled 176 pregnant women between 32 and 42 weeks of gestation indicated for NST at the Division of Maternal Fetal Medicine, Siriraj Hospital, Mahidol University. They were randomly assigned to receive either NST (control) or halogen light stimulation test (LST). The stimulation was performed at the beginning of the test and repeated every 10 minutes until reassuring fetal heart rate (FHR) acceleration was achieved, or up to 3 times. All tracings were interpreted blindly by one investigator at the end of the tests. RESULTS: The mean (+/- SD) duration from starting the test to the first FHR acceleration was not significantly different between the control group and the LST group (5.6 +/- 7.2 and 5.4 +/- 5.2 minutes, respectively). The average testing time (+/- SD) to achieved reactivity was 10.5 +/- 8.8 minutes in the controls and 9.6 +/- 6.7 minutes in the LST group. This was not statistically different. The incidence of nonreactive tests was not significantly different between the LST and the controls (15.9% and 11.4%, respectively). Among the LST subjects, term fetuses and women with BMI < 27 kg/m2 required less time to reach reactivity, 2.4 and 2.3 minutes respectively. CONCLUSION: Transabdominal halogen light stimulation did not shorten the duration of NST in the presented population. However, the presented data suggests that the fetus at term could respond to visual stimulation, especially when the gestational age is more advanced.

Manejo intraparto del registro estresante no reactivo: un estudio randomizado controlado de oximetría de pulso / Intrapartum management of nonreassuring fetal heart rate patterns: a randomized controlled trial of fetal pulse oximetryy

Objetivo: Evaluar si la adición de la oximetría de pulso a la evaluación fetal intraparto con cardiotocografía (CTG) y pH de cuero cabelludo, mejora la precisión del diagnóstico de la condición fetal, permitiendo una reducción segura del número de partos operatorios y de la necesidad de evaluación con pH de cuero cabelludo por sospecha de compromiso fetal. Métodos: Se realizó un estudio randomizado controlado en embarazadas de término en trabajo de parto activo y que tuvieran un monitoreo electrónico fetal sospechoso. Se randomizaron 146 pacientes: 73 embarazadas con CTG y pH de cuero cabelludo (grupo control) y 73 pacientes CTG, pH de cuero cabelludo y oximetría de pulso continua (grupo de estudio). Resultados: Hubo una reducción de más del 50 por ciento en el número de partos operatorios (25 vs 49; p <0,001) y de la necesidad de monitoreo del pH (32 vs 64; p <0,001) en el grupo de estudio vs grupo control. No hubo diferencias significativas en los resultados de morbilidad adversa materna y neonatal, ni tampoco en el número de acidosis metabólicas o necesidad de resucitación. Conclusión: La oximetría de pulso reduce en forma efectiva el número de partos operatorios y mediciones de pH de cuero cabelludo. El alto número de cesáreas por distocia en el grupo de estudio se debe principalmente a prueba de trabajo de parto fracasada, sin embargo, esto no afecta el número total de partos operatorios en este grupo.

Management of prolonged pregnancy: a randomized trial of induction of labour and antepartum foetal monitoring.

BACKGROUND: The two methods of management of prolonged pregnancy, induction of labour and expectant management with foetal surveillance, have pros and cons. Therefore, we compared the induction of labour with serial antenatal foetal monitoring in the management of post-term pregnancy. METHODS: Seventy-four women with uncomplicated pregnancy at 41 weeks (287 days) of gestation were randomly assigned to undergo either induction of labour or serial antenatal foetal monitoring. Labour was induced in the latter group whenever there was evidence of foetal compromise. Antenatal monitoring consisted of the foetal kick count, non-stress test and biophysical profile. RESULTS: Fifty-seven per cent of women went into spontaneous labour by 41 weeks and 4 days (291 days) of gestation and only 14% developed foetal compromise before that. However, when the gestational age was more than 41 weeks and 4 days (291 days), the incidence of meconium staining of amniotic fluid and evidence of uteroplacental insufficiency increased significantly. The rate of caesarean section, instrumental delivery, foetal distress and duration of labour did not differ significantly between the two groups. CONCLUSION: The policy of inducing labour at 41 weeks and 4 days (291 days of gestation) in uncomplicated pregnancies is justified in our population. However, foetal monitoring should begin at 41 weeks of gestation.

Prematuridade eletiva: aspectos obstetricos e perinatais / Elective prematurity: obstetric and perinatal aspects

Analisar as principais patologias maternas e intercorrencias obstetricas determinantes da prematuridade eletiva, os tipos de partos e os resultados perinatais. Foi realizada analise retrospectiva de 90 partos prematuros eletivos ocorridos no periodo de fevereiro de 1993 a outubro de 1994, na Clinica Obstetrica da Faculdade de Medicina da USP. Definimos prematuridade eletiva a interrupcao da gestacao ocorreu antes de 37 semanas, motivada pela presenca de intercorrencias clinicas e ou obstetricas, que comprometessem o bem estar materno e ou fetal...

Conduta obstétrica na diastole zero ou reversa a dopplervelocimetria das arterias umbilicais / Obstetric management in absent or reversed en-diastolic velocity flow in the umbilical arteries dopplervelocimetry

A diastole zero ou reversa a dopplervelocimetria das arterias umbilicais representam um grave comprometimento da funcao placentaria, evoluindo frequentemente com sofrimento fetal cronico e elevadas taxas de morbidade e mortalidade perinatais. A avaliacao da vitalidade fetal e de fundamental importancia, principalmente nas gestacoes longe do termo, onde as sequelas da prematuridade podem repercutir de forma grave na sobrevida fetal. Os autores relatam a conduta obstetrica frente estes diagnosticos

Endoscopia y embarazo: Registro de las alteraciones tococardiográficas del producto durante el procedimiento, como índice de seguridad / Pregnancy and endoscopy: Tococardiographic alteration registered during endocospy

La esofagogastroduodenoscopia (EGD) ha demostrado ser un procedimiento seguro y útil. Su uso durante el embarazo no ha sido aceptado. El registro tococardiográfico de la frecuencia cardíaca fetal es un índice confiable del bienestar del producto, y sus alteraciones muestran el sufrimiento fetal. Se realizo un estudio prospectivo y logitudinal en 75 mujeres embarazadas, con sintomatología gastrointestinal superior, las cuales se sometieron a procedimiento endoscópico con monitoreo tococardiográfico. El promedio de edad fue de 26.6 años. 27 pacientes (49.3 por ciento) se encontraban entre la semana 20 y 27 de gestación 23 (30.6 por ciento) entre la semana 28 y 35). 15 pacientes (20 por ciento) entre la semana 36 y 42. Se registro bradicardía transitoria leve en 45 productos (60 por ciento), taquicardía transitoria en 15 (20 por ciento) y no se presentaron alteraciones 15 productos (20 por ciento). No se registro ninguna complicación durante el procedimiento ni durante el periodo de seguimiento hasta el momento del parto. Concluimos que el procedimiento de EGD realizado en las mujeres embarazadas es un procedimiento seguro y útil, y que no representa riesgo para la madre ni el producto.

Asfixia perinatal moderada y severa: diagnóstico de lesiones cerebrales por ultrasonido / Perinatal asphyxia moderate and severe: diagnosis of brains lesions by ultrasonic

Se realizó un estudio con 40 recién nacidos a término en el Hospital "Dr. Domingo Luciani" de enero a obtubre de 1996 que presentaron asfixias perinatal moderada y severa. Se utilizó el ultrasonido cerebral como método diagnóstico de lesiones cerebrales y se relacionó con los grados de asfixia perinatal. En cuanto al tipo de parto, las formas no eutócicas, y de ellas, la cesárea fue la más frecuente (51 por ciento). En el 72 por ciento de los casos, hubo evidencia de sufrimiento fetal, la asfixia moderada fue la más frecuente. El ultrasonido cerebral se realizó en período neonatal precoz (4 ñ 1,73 días). De la población estudiada 22 recién nacidos (55,00 por ciento) presentaron lesiones cerebral siendo los hallazgos ultrasonográficos: edema (77,27 por ciento), asimetríca ventricular (22,73 por ciento) y hemorragia subependimaria (13,63 por ciento), siendo no significativa su relación con los grados de asfixia. Por lo que concluimos que se justifica el uso del ultrasonido cerebral en RN con asfixia perinatal en los primeros 7 días de vida y sugerimos la utilización de un transductor de 10 MHz para la detección precoz de lesiones en la superficie cortical

Dolor fetal

El dolor es una experiencia multidimensional que incorpora factores sensoriales, emocionales y cognitivos. Sólo hasta hace muy pocos años se le ha prestado algo de atención al dolor que puede sufrir el feto. La década pasada se caracterizó por cambios muy profundos en las actitudes de los anestesiólogos y en la práctica de la Anestesia, planteándose el interrogante de si el feto, el neonato y los niños pueden sentir dolor. Fitzgerald M., en 1995, revisando el desarrollo biológico del feto, planteó la posibilidad deque antes de la 26ava. semana de la gestación no podría el feto experimentar dolor porque la "corteza no es una unidad funcional" y que sus respuestas antes de esta edad son de tipo reflejo. Los niños y los adultos perciben concientemente el dolor a través de un proceso de desarrollo que el feto no ha completado antes de la semana 26 de la gestación. Sinembargo, debemos tener siempre presente que existe un momento del desarrollo fetal, cuando comienza a reaccionar a los estímulos nocivos. Las consecuencias clínicas y morales de este hecho son diferentes y altamente controversiales, pero debemos tenerlas en cuenta siempre

Doppler da artéria cerebral média do feto. Valores normais do índice de pulsatilidade e da velocidade máxima / Doppler of the middle cerebral artery of fettus: normal values of pulsatility index and peak velocity

Objetivo: construir curvas de normalidade do doppler da artéria cerebral média fetal, através dos índices de pulsatilidade (PI) e da velocidade máxima (v.max.), no período compreendido entre 20 e 40 semanas de gestaçäo. Material e método: Procedeu-se investigaçäo de caráter prospectivo, transversal em 701 fetos de gestantes oriundas dos setores de pré-natal da Maternidade-Escola da UFRJ e do Instituto Fernandes Figueira. Incluíram-se na investigaçäo grávidas com data da última menstruaçäo (DUM) conhecida e confirmada pela bimetria ultra-sonográfica, näo apresentando no momento do exame anormalidade de caráter clínico, laboratorial ou ultra-sonográfico. Os exames foram realizados por único examinador, utilizando-se do mapeador ultrasônico dinâmico equipado com doppler-colorido e transdutor de 3.75 MHz (TOSHIBA _ SSH-340A). A obtençäo do sonograma e dos respectivos ...