ABSTRACT
INTRODUCTION: Pregnancy in women on dialysis is associated with a higher risk of adverse events, and the best care for this population remains to be established. METHODS: In this series, we aimed to identify factors associated with the risk of adverse fetal outcomes among 93 pregnancies in women on hemodialysis. Dialysis dose was initially assigned according to the presence of residual diuresis, body weight, and years on dialysis. Subsequent adjustments on dialysis dose were performed according to several parameters. RESULTS: The overall successful delivery rate was 89.2%, with a dialysis regimen of 2.6 ± 0.7 h/d, 15.4 ± 4.0 h/wk, and mean weekly standard urea Kt/V of 3.3 ± 0.6. In the logistic models, preeclampsia, lupus, primigravida, and average midweek blood urea nitrogen (BUN) level were positively related to the risk of a composite outcome of perinatal death or extreme prematurity, whereas polyhydramnios was inversely related to it. In multivariable linear regression, preeclampsia, polyhydramnios, primigravida, average midweek BUN, and residual diuresis remained significantly and independently related to fetal weight, which is a surrogate marker of fetal outcome. An average midweek BUN of 35 mg/dl was the best value for discriminating the composite outcome, and BUN ≥35 mg/dl was associated with a significant difference in a Kaplan-Meier curve (P = 0.01). CONCLUSION: Our results showed that a good fetal outcome could be reached and that preeclampsia, lupus, primigravida, residual diuresis, polyhydramnios, and hemodialysis dose were important variables associated with this outcome. In addition, we suggested that a midweek BUN <35 mg/dl might be used as a target for adjusting dialysis dose until hard data were generated.
ABSTRACT
A gestação em pacientes com insuficiência renal e em terapia dialítica constitui uma situação desafiadora. Desde a sua primeira descrição em 1971, um crescente número de casos é relatado com informações conflitantes e discordantes quanto ao prognóstico materno e fetal. As principais intercorrências clínicas e obstétricas encontradas no manejo dessas pacientes são: hipertensão arterial, polidrâmnio, restrição de crescimento fetal e prematuridade. As consequências neonatais são complicações clínicas diversas, decorrentes, principalmente, da prematuridade tais como: pneumotórax, síndrome da angústia respiratória do recém-nato, sepse, enterocolite necrosante, doença pulmonar crônica, hemorragia intraventricular e surdez. Este artigo tem por objetivo revisar o tema apresentando os resultados maternos e perinatais mais recentes relatados na literatura, discutir as controvérsias no manejo dessas gestantes e apresentar a conduta obstétrica tanto no pré-natal como na assistência ao parto.
Pregnancy in insufficiency renal and dialysis patients is a challenging situation. Since its first description in 1971, a growing number of cases have been described with conflicting information about maternal and fetal outcome. The main obstetrical adverse outcomes on the management of these patients are: arterial hypertension, polihydramnios, intrauterine growth restriction and prematurity. The neonatal complications are consequences of prematurity and include pneumothorax, respiratory distress syndrome, sepsis, necrotizing entercolitis, chronic lung disease, intraventricular hemorrhage and deafness. This article aims to review the literature presenting the outcome of the most recent maternal and perinatal outcomes, discussing the controversies in the treatment of these patients and presenting the main steps in prenatal care as well as during labor.
Subject(s)
Female , Pregnancy , Infant, Newborn , Pregnancy Complications/therapy , Kidney Failure, Chronic/therapy , Renal Insufficiency/therapy , Pregnancy Outcome , Prenatal Care , Renal Dialysis , Fetal Viability/physiologyABSTRACT
AIM: To describe the case profile of maternal death resulting from hypertensive disorders in pregnancy and to propose measures for its reduction. METHODS: The Committee on Maternal Mortality of São Paulo City has identified 609 cases of obstetric maternal death between 1995 and 1999 with an underreporting rate of 52.2% and a maternal mortality rate of 56.7/100,000 live births. Arterial hypertension was the main cause of maternal death, corresponding to 142 (23.3%) cases. RESULTS: Ninety-five (66.9%) of the deaths occurred during the puerperal period and 34 (23.9%) occurred during pregnancy. The time of death was not reported in 13 (9.2%) cases. Seizures were observed in 41 cases and magnesium sulfate was used in four of them. The causes of death were ruled to be cerebrovascular accident (44.4%), acute pulmonary edema (24.6%), and coagulopathies (14.1%). Cesarean section was performed in 85 (59.9%) cases and vaginal delivery in 15 (16.0%). CONCLUSION: Complications of arterial hypertension are responsible for the high rates of pregnancy-related maternal death in São Paulo City. Quality prenatal care and appropriate monitoring of the hypertensive pregnant patient during and after delivery are important measures for better control of this condition and are essential to reduce disorders in pregnancy.
Subject(s)
Hypertension/mortality , Pregnancy Complications, Cardiovascular/mortality , Adolescent , Adult , Age Distribution , Brazil/epidemiology , Child , Eclampsia/drug therapy , Eclampsia/mortality , Epidemiologic Methods , Female , Humans , Hypertension/complications , Maternal Mortality , Middle Aged , Pre-Eclampsia/drug therapy , Pre-Eclampsia/mortality , Pregnancy , Pregnancy Complications, Cardiovascular/prevention & control , Pregnancy Trimesters , Prenatal Care/standards , Prenatal Care/statistics & numerical data , Young AdultABSTRACT
AIM: To describe the case profile of maternal death resulting from hypertensive disorders in pregnancy and to propose measures for its reduction. METHODS: The Committee on Maternal Mortality of São Paulo City has identified 609 cases of obstetric maternal death between 1995 and 1999 with an underreporting rate of 52.2 percent and a maternal mortality rate of 56.7/100,000 live births. Arterial hypertension was the main cause of maternal death, corresponding to 142 (23.3 percent) cases. RESULTS: Ninety-five (66.9 percent) of the deaths occurred during the puerperal period and 34 (23.9 percent) occurred during pregnancy. The time of death was not reported in 13 (9.2 percent) cases. Seizures were observed in 41 cases and magnesium sulfate was used in four of them. The causes of death were ruled to be cerebrovascular accident (44.4 percent), acute pulmonary edema (24.6 percent), and coagulopathies (14.1 percent). Cesarean section was performed in 85 (59.9 percent) cases and vaginal delivery in 15 (16.0 percent). CONCLUSION: Complications of arterial hypertension are responsible for the high rates of pregnancy-related maternal death in São Paulo City. Quality prenatal care and appropriate monitoring of the hypertensive pregnant patient during and after delivery are important measures for better control of this condition and are essential to reduce disorders in pregnancy.
OBJETIVO: Descrever o perfil dos casos de morte materna decorrente de complicações da hipertensão arterial e propor medidas para sua redução. MÉTODOS: De 1995 a 1999 o Comitê de Mortalidade Materna da Cidade de São Paulo identificou 609 casos de morte materna obstétrica, com uma subnotificação de 52,2 por cento e um CMM=56,7/100.000 Nascidos Vivos. A hipertensão arterial foi a principal causa de óbito materno, correspondendo a 142 (23,3 por cento) casos. RESULTADOS: Ocorreram 95 (66,9 por cento) de óbitos no puerpério e 34 (23,9 por cento) durante a gestação. Em 13 (9,2 por cento) casos não se teve referência ao momento do óbito. Houve relato de crises convulsivas em 41 casos com a utilização de sulfato de magnésio em quatro deles. As principais causas determinantes do óbito foram: o acidente vascular cerebral (44,4 por cento), o edema agudo de pulmão (24,6 por cento) e as coagulopatias (14,1 por cento). A cesárea foi realizada em 85 (59,9 por cento) casos e o parto vaginal em 15 (16,0 por cento). Em 28 (19,7 por cento) casos não foi realizada nenhuma conduta para interromper a gravidez e em 14 (9,8 por cento) não se obteve relato do procedimento. CONCLUSÃO: As complicações da hipertensão arterial no ciclo gravídico-puerperal determinam altos índices de mortalidade materna na cidade de São Paulo. A realização de um pré-natal de qualidade e o atendimento apropriado da gestante hipertensa no parto e no pós-parto são medidas de fundamental importância para um melhor controle desse evento, sendo primordial para a redução dessas ocorrências.
Subject(s)
Adolescent , Adult , Child , Female , Humans , Middle Aged , Pregnancy , Young Adult , Hypertension/mortality , Pregnancy Complications, Cardiovascular/mortality , Age Distribution , Brazil/epidemiology , Epidemiologic Methods , Eclampsia/drug therapy , Eclampsia/mortality , Hypertension/complications , Maternal Mortality , Pregnancy Trimesters , Pre-Eclampsia/drug therapy , Pre-Eclampsia/mortality , Pregnancy Complications, Cardiovascular/prevention & control , Prenatal Care/standards , Prenatal Care/statistics & numerical data , Young AdultABSTRACT
PURPOSE: To evaluate the evolution of glycemic levels in newborns of hypertensive mothers according to maternal treatment. METHODS: Prospective randomized study, including 93 newborns of mothers treated with isradipine (n = 39), atenolol (n = 40), or low sodium diet (control group - n=14). Glycemia was determined at birth (mother and newborn by the oxidase glucose method) and in the 1st, 3rd, 6th, 12th, and 24th hours after birth (newborn by a test strip method). The evolution of glycemia was analyzed in each group (Friedman test). The groups were compared regarding glycemia (Kruskall-Wallis test), and linear regression models were constructed for the analyses (independent variable = maternal glycemia; dependent variables = umbilical cord, 3rd, and 6th hour glycemia). RESULTS: There were no statistically significant differences among the mean blood glucose levels of the 3 groups in any of the assessments. There was a correlation between maternal and umbilical cord blood glucose in the isradipine (r = 0.61; P <.05) and control (r = 0.84; P <.05) groups. Regarding glycemia levels of the mothers and newborns in the third and sixth hours postpartum, this correlation was present only in the control group (maternal x third hour: r = 0.65; P <.05; maternal x sixth hour: r = 0.68; P <.05). There were no correlations in the atenolol group. Hypoglycemia was detected in 51.3% of the isradipine group, 60% of the atenolol group, and 35.7% of the control group, and it was more frequent in the first hour postpartum in all groups. CONCLUSIONS: The results suggest a similar effect of the 3 types of treatment upon newborn glycemia. The correlation analysis suggests that isradipine could have effects upon newborn glycemia only after birth (correlation only in umbilical cord blood), whereas atenolol could act earlier (there was no correlation at any moment). The results also point to the need for glycemic control from the first hour postpartum of newborns of hypertensive mothers whether they have or have not undergone treatment with antihypertensive drugs.
Subject(s)
Antihypertensive Agents/therapeutic use , Blood Glucose/drug effects , Hypertension/drug therapy , Isradipine/therapeutic use , Pregnancy Complications, Cardiovascular/drug therapy , Apgar Score , Atenolol/therapeutic use , Blood Glucose/analysis , Epidemiologic Methods , Female , Fetal Blood/chemistry , Humans , Hypertension/blood , Infant, Newborn , Pregnancy , Pregnancy Complications, Cardiovascular/bloodABSTRACT
OBJETIVO: Avaliar o comportamento da glicemia em recém-nascidos (RN) de mães hipertensas conforme o tratamento materno. MÉTODOS: Estudo prospectivo, randomizado, incluindo 93 RN de mães tratadas com isradipina(n=39), atenolol (n=40) ou dieta - controle (n=14). Determinou-se a glicemia ao nascimento (mãe e RN, pela glicose oxidase) e na 1ª., 3ª., 6ª., 12ª. e 24ª. horas (RN, por fita reagente). A evolução da glicemia, em cada grupo, foi analisada (Teste de Friedman). Os grupos foram comparados, quanto às glicemias, em cada momento (Teste de Kruskall-Wallis) e foram ajustados modelos de regressão linear para as glicemias (variável independente = glicemia materna; variáveis dependentes = glicemias de cordão, 3ª. e 6ª. horas). RESULTADOS: Não houve diferença estatisticamente significante entre as glicemias médias dos 3 grupos, em qualquer uma das coletas. Houve correlação entre as glicemias materna e de cordão umbilical nos grupos isradipina (r =0,61; p<0,05) e controle (r =0,84; p<0,05); entre as glicemias materna e 3ª. e 6ª. horas, houve apenas no grupo controle (materna X 3ª.hora: r = 0,65; p<0,05; materna X 6a.hora: r =0,68; p<0,05). Não houve correlação em nenhum momento no grupo atenolol. Detectou-se hipoglicemia em 51,3% (Isradipina), 60% (Atenolol) e 35,7% (Controle), mais freqüentemente na 1ª. hora de vida, em todos os grupos. CONCLUSÕES: Os resultados sugerem efeito semelhante dos 3 tipos de terapêutica sobre a glicemia do RN. As análises de correlação sugerem que a isradipina possa ter efeitos sobre a glicemia somente após o nascimento (correlação apenas em cordão umbilical), enquanto o atenolol, possa atuar mais precocemente (não se correlacionou em nenhum momento). Também reforçam a necessidade de controle glicêmico desde a 1ª. hora de vida em RN de mães hipertensas, submetidas ou não a tratamento medicamentoso.
Subject(s)
Female , Humans , Infant, Newborn , Pregnancy , Antihypertensive Agents/therapeutic use , Blood Glucose/drug effects , Hypertension/drug therapy , Isradipine/therapeutic use , Pregnancy Complications, Cardiovascular/drug therapy , Apgar Score , Atenolol/therapeutic use , Blood Glucose/analysis , Epidemiologic Methods , Fetal Blood/chemistry , Hypertension/blood , Pregnancy Complications, Cardiovascular/bloodABSTRACT
OBJECTIVES: The purpose of this study was to compare the frequency of surgical glove perforation among obstetric and gynecological surgical procedures, and to evaluate surgeons' perceptions. MATERIALS AND METHODS: A cross-sectional study was conducted in which nursing personnel examined the gloves used in obstetric and gynecological procedures, immediately after the surgery, in order to detect perforations. RESULTS: Surgical glove perforation occurred in 20.8% of 817 obstetrics procedures and 24.4% of 131 gynecology procedures. The observed difference between groups was not statistically significant (p=0.35). Obstetricians perceived the occurrence of perforation in 30.6% of the events, and gynecologists in 37.5%. This difference was not statistically significant (p=0.44).
Subject(s)
Gloves, Surgical , Gynecologic Surgical Procedures/adverse effects , Needlestick Injuries/epidemiology , Obstetric Surgical Procedures/adverse effects , Brazil/epidemiology , Cross-Sectional Studies , Humans , Incidence , Perception , Physicians/psychologyABSTRACT
OBJECTIVE: The purpose of this study was to validate diffusion-weighted magnetic resonance imaging in the prediction of the evolutive course of brain edema and to establish its pathophysiologic presence in patients with eclampsia/severe preeclampsia. STUDY DESIGN: Seventeen patients with a clinical diagnosis of severe eclampsia/preeclampsia and T2 hyperintense brain lesions on routine magnetic resonance imaging were evaluated at hospital admission and 8 weeks later. RESULTS: Brain edema was reversible in 13 patients and irreversible in 4 patients, as indicated on follow-up magnetic resonance imaging. Sixteen of 17 patients were differentiated accurately into reversible and irreversible groups on the basis of diffusion imaging on hospital admission. Diffusion-weighted magnetic resonance imaging demonstrated a significant increase in water mobility in abnormal regions compared with normal-appearing brains in patients in the reversible group (1.34+/-0.10 mm(2) vs 0.79+/-0.08 mm(2)/s x 10(-3), P<.001). In the irreversible group, restricted water diffusion was present, which was consistent with cytotoxic edema and early brain infarction in 3 of 4 patients. CONCLUSION: Diffusion-weighted magnetic resonance imaging can predict successfully the evolutive course of brain edema in an acute setting in these patients. Our findings indicate that brain edema is vasogenic, although ischemic/cytotoxic edema was observed less commonly.
Subject(s)
Brain/pathology , Brain/physiopathology , Eclampsia/diagnosis , Pre-Eclampsia/diagnosis , Adolescent , Adult , Brain Edema/diagnosis , Brain Edema/etiology , Brain Edema/physiopathology , Diffusion Magnetic Resonance Imaging , Eclampsia/complications , Female , Humans , Magnetic Resonance Imaging , Pre-Eclampsia/complications , Pregnancy , Prognosis , Sensitivity and Specificity , Severity of Illness IndexABSTRACT
Têm sido descritos efeitos da presença de hipertensão arterial e da terapêutica materna utilizada sobre o recém-nascido (RN). Objetivo: Analisar a influência da terapêutica anti-hipertensiva materna durante a gestação sobre o padrão de crescimento do RN durante o primeiro ano de vida. Métodos: Estudo prospectivo, randomizado, longitudinal, comparando três grupos de pacientes, selecionados de acordo com o tipo de terapêutica materna. Foram incluídos 93 RN, cujas mães receberam tratamento com isradipina (Grupo I), 5 mg duas vezes/dia (n=39); atenolol (Grupo II), 50 mg duas vezes/dia (n=40) ou dieta - grupo controle (Grupo III) (n=14). Em todos os RN foram avaliados o peso e o comprimento, ao termo (40 semanas), e 3, 6, 9 e 12 meses pós-termo. Os valores obtidos foram transformados em escore Z para sexo e idade (referencial NCHS). Os valores de escore Z, em cada idade, das relações peso para a idade, comprimento para idade e índice de massa corpórea, foram comparados por análise de variância (ANOVA) ou Kruskal-Wallis, significância de 5 por cento. Resultados: Analisou-se 64 RN pelo critério mínimo de seleção de pelo menos dois registros. Os grupos passaram a Gr I (31 RN), Gr II (24 RN) e Gr III (9 RN). Dentre estes, 5,1 por cento (Gr I), 12,5 por cento (Gr II) e 14,2 por cento (Gr III) eram pequenos para a idade gestacional. Não foram observadas diferenças entre os grupos quanto ao crescimento durante o 1º ano de vida (escore Z), mas todos apresentaram "catch-up" nos primeiros três meses pós-termo. O índice de massa corpórea também não foi diferente entre os grupos. Conclusões: Os resultados sugerem que o controle da doença durante a gestação, por meio de terapêutica eficaz, poderá minimizar a ocorrência de possíveis efeitos sobre o crescimento.
Subject(s)
Humans , Infant, Newborn , Growth , Hypertension/drug therapyABSTRACT
OBJECTIVE: Our study evaluated the effects of chronic and/or acute stress on pregnant and nonpregnant female rats. STUDY DESIGN: The rats were exposed to the sonic stimulus associated with overpopulation between days 7 and 14 of pregnancy. The rats were immobilized 2 days before the vascular reactivity experiments. RESULTS: In 14-day pregnant rats, chronic stress led to lower weight, increased adrenal weight, lower endothelium-derived relaxing factor release, and lower fetal weight. In 20-day pregnant rats, chronic stress caused decreased weight gain, higher blood pressure, increased vasomotility and proteinuria, lower endothelium-derived relaxing factor release, and lower fetal weight. In the 20-day pregnant group, the higher adrenal weight resulted in higher blood pressure, lower vascular relaxation, and lower average fetal weight. A greater number of fetuses had higher adrenal weight, higher blood pressure, and lower vascular relaxation. CONCLUSION: The alterations found in the rats were similar to those that occur in human preeclampsia. Therefore, we propose a new animal model for human preeclampsia.
Subject(s)
Pre-Eclampsia/etiology , Pregnancy Complications , Stress, Physiological/complications , Acute Disease , Adrenal Glands/pathology , Animals , Blood Pressure , Body Weight , Chronic Disease , Disease Models, Animal , Female , Fetal Weight , Nitric Oxide/metabolism , Organ Size , Pregnancy , Rats , Rats, Wistar , Reference Values , Stress, Physiological/pathology , Stress, Physiological/physiopathology , Time Factors , Vasomotor System/physiopathologyABSTRACT
A nao adesao ao tratamento entre pacientes com hipertensao e estimada em 75 por cento. Este dado e particularmente assustador quando considerado o risco que essa doenca oferece, principalmente quando associada a...
Subject(s)
Humans , Female , Pregnancy , Adult , Hypertension/therapy , Pregnancy Complications, Cardiovascular , Treatment Refusal , Patient Compliance/statistics & numerical dataABSTRACT
A eclampsia e doenca que participa de modo significativo, pelo atual coeficiente de mortalidade materna em nosso pais. A fisiopatogenia parece estar relacionada com a...
Subject(s)
Humans , Female , Pregnancy , Eclampsia , Magnesium Sulfate/therapeutic use , Magnesium Sulfate/metabolismABSTRACT
Segundo relatorios da Organizacao Mundial de Saude, 14 por cento das mortes maternas sao decorrentes de complicacoes de abortamento. Muitas destas mortes podem ser evitadas se houver uma abordagem adequada a...
Subject(s)
Humans , Female , Pregnancy , Infant, Newborn , Abortion, Therapeutic , Maternal Mortality , Pregnancy Complications , Risk FactorsABSTRACT
Trata-se de uma revisao a respeito da mortalidade materna e infeccao puerperal. Sao abordadas formas clinicas desta ultima:endomitrite, parametrite, anexite, tromboflebite pelvica, fasciite e peritonite. Nas diferentes formas clinicas sao...
Subject(s)
Humans , Female , Pregnancy , Puerperal Infection/mortality , Maternal Mortality , Prenatal Care/methods , Risk FactorsABSTRACT
As sindromes hemorragicas sao uma das principais causas de mortalidade materna. Sua classificacao pode ser feita conforme a fase do clico gravidico-puerperal em que ocorre. No periodo pre-parto, destacam-se o deslocamento...
Subject(s)
Humans , Female , Pregnancy , Postpartum Hemorrhage/complications , Puerperal Infection/mortality , Maternal Mortality , Pregnancy Complications , Prenatal Care , Risk FactorsABSTRACT
A ilucidacao da etiologia da pre-eclampsia se faz necessario para prevenir tao grave doenca que ainda hoje acarreta inumeras mortes maternas. A heranca mitocondrial tem sido...
