Intrauterine Transfusion for Rhesus Alloimmunization: A Historical Retrospective Cohort from A Single Reference Center in Brazil.

Objective: This study aimed to describe the historical experience of a single reference center in Brazil with intrauterine transfusion (IUT) for Rhesus (Rh) alloimmunization, evaluating the major complications and the perinatal outcomes of this procedure. Methods: This retrospective cohort study evaluated data from medical records of pregnant women between 20 and 34 weeks of gestation whose fetuses underwent IUT by cordocentesis between January 1991 and June 2021. The same experienced examiner performed all procedures. Univariate and multivariate logistic regression was used to assess the effect of fetal hydrops, duration of IUT, post-transfusion cord bleeding time, and bradycardia on death (fetal or neonatal). Results: We analyzed data from 388 IUTs in 169 fetuses of alloimmunized pregnant women with a mean age of 29.3 ± 5.1 years. Death and fetal hydrops were significantly associated at first IUT (p < 0.001). We had two cases of emergency cesarean section (mean of 0.51% per IUT) and three cases of premature rupture of the ovular membranes (mean of 0.77% per procedure). Thirty-six deaths were recorded, including 14 intrauterine and 22 neonatal. A higher percentage of neonatal deaths was observed in the group with post-transfusion cord bleeding time > 120 s (45.8%). The odds of neonatal death were 17.6 and 12.9 times higher in cases with hydrops and bradycardia than in cases without hydrops and bradycardia, respectively. The odds of death (fetal and neonatal) were 79.9 and 92.3 times higher in cases with hydrops and bradycardia than in cases without hydrops and bradycardia, respectively. Conclusions: The most common complications of IUT for Rh alloimmunization were post-transfusion cord bleeding, fetal bradycardia, premature rupture of ovular membranes, and emergency cesarean section. The IUT complication most associated with death (fetal and neonatal) was bradycardia, and the perinatal outcomes were worse in fetuses with hydrops.

A new model based on artificial intelligence to screening preterm birth.

OBJECTIVE: The objective of this study is to create a new screening for spontaneous preterm birth (sPTB) based on artificial intelligence (AI). METHODS: This study included 524 singleton pregnancies from 18th to 24th-week gestation after transvaginal ultrasound cervical length (CL) analyzes for screening sPTB < 35 weeks. AI model was created based on the stacking-based ensemble learning method (SBELM) by the neural network, gathering CL < 25 mm, multivariate unadjusted logistic regression (LR), and the best AI algorithm. Receiver Operating Characteristics (ROC) curve to predict sPTB < 35 weeks and area under the curve (AUC), sensitivity, specificity, accuracy, predictive positive and negative values were performed to evaluate CL < 25 mm, LR, the best algorithms of AI and SBELM. RESULTS: The most relevant variables presented by LR were cervical funneling, index straight CL/internal angle inside the cervix (≤ 0.200), previous PTB < 37 weeks, previous curettage, no antibiotic treatment during pregnancy, and weight (≤ 58 kg), no smoking, and CL < 30.9 mm. Fixing 10% of false positive rate, CL < 25 mm and SBELM present, respectively: AUC of 0.318 and 0.808; sensitivity of 33.3% and 47,3%; specificity of 91.8 and 92.8%; positive predictive value of 23.1 and 32.7%; negative predictive value of 94.9 and 96.0%. This machine learning presented high statistical significance when compared to CL < 25 mm after T-test (p < .00001). CONCLUSION: AI applied to clinical and ultrasonographic variables could be a viable option for screening of sPTB < 35 weeks, improving the performance of short cervix, with a low false-positive rate.

Cervical pessary plus vaginal progesterone in a singleton pregnancy with a short cervix: an experience-based analysis of cervical pessary's efficacy.

BACKGROUND: Several studies were published about cervical pessary, with controversial results. These studies demonstrated that the patient follow-up after pessary insertion is very different between the study centers and the number of pessary insertions per center was often <30 cases. This study aims to determine cervical pessary performance in singleton pregnancies with a short cervix based on a single center learning curve. METHODS: Between 2011 and 2018, 128 singleton pregnancies between 18 and 24 gestational weeks with a short cervix (<25 mm) were referred to our clinic. All cases were treated with progesterone, and when available in our supplies (due to low resources) cervical pessary was also offered. Three groups were created for statistical analysis: Group 1 (n = 33), treated with progesterone-only; Groups 2 and 3, treated with cervical pessary plus progesterone. Group 2 included the first cases (n = 30) of pessary, defined by a learning curve and cumulative sum analysis, while Group 3 included the subsequent 65 cases. The primary outcome was preterm birth (PTB) < 34 gestational weeks. RESULTS: The learning curve was performed with all cases of pessary plus progesterone, and 30 patients were obtained as the number needed for learning, in our study with two operators. The PTB rate < 34 weeks was 27.3, 20, and 4.6% in groups 1, 2, and 3, respectively. There was no significant difference between Group 1 and 2 (OR 1.1; 95% CI 0.066 - 18.45; p = .945). When comparing Groups 1 and 3 there was a significant difference in PTB rates (OR 0.08; CI95% 0.01-0.42; p = .003). Considering Kaplan-Meyer Survival analysis, we can observe that the performance of progesterone alone (Group 1) was similar to Group 2 (progesterone + first 30 cases of pessary) (p = .432), but the performance of Group 3 (progesterone + subsequent 65 cases of pessary) and Group 1 shows a statistically significant difference (p = .011). CONCLUSION: Learning curve and cumulative sum analysis determined that the application and surveillance of at least 30 patients is required to see significant improvements in the primary outcome of PTB < 34 weeks.

References Values of Fetal Heart Myocardial Volume by Three-Dimensional Ultrasound using Spatiotemporal Image Correlation and Virtual Organ Computer-Aided Analysis Methods and Their Applicability in Pregestational Diabetic Women.

OBJECTIVE: To determine reference values for myocardial volume of the fetal heart using three-dimensional ultrasound with spatiotemporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL) and to assess their applicability in women with pregestational diabetes. STUDY DESIGN: This retrospective cross-sectional study included 177 normal pregnant women with fetuses between 200/7 and 336/7 weeks of age. Fetal cardiac volumes were collected using the STIC method, and myocardial volume was obtained by subtraction of the intracavitary volumes using the VOCAL 30-degree method. Intra- and interobserver reproducibility values were determined using the concordance correlation coefficient (CCC). Sixteen women with pregestational diabetes mellitus were evaluated for validation. RESULTS: There was a strong correlation between fetal myocardial volume and gestational age (R 2 = 0.82). Intra- and interobserver reproducibility values were excellent and moderate, respectively, with CCCs of 0.99 and 0.83, respectively. There was no significant difference in mean fetal myocardial volume between normal pregnant women and those with pregestational diabetes (p = 0.64). CONCLUSION: Reference values for myocardial volume of the fetal heart were determined in normal pregnant women and were not statistically different from those in women with pregestational diabetes mellitus.

Predictive values of clinical parameters and biophysical and biochemical markers in the first trimester for the detection of small-for-gestational age fetuses.

OBJECTIVES: To evaluate the predictive values of maternal characteristics, biophysical parameters (mean arterial pressure [MAP] and Doppler uterine artery measurements), and biochemical parameters (pregnancy-associated plasma protein A [PAPP-A] and placental growth factor [PlGF]) alone and in association for small-for-gestational age (SGA) fetuses. METHODS: We performed a retrospective analysis of a prospective observational study that evaluated 615 pregnant women in the first trimester using ultrasonography. For all the women, information regarding clinical and obstetric histories, MAP, and uterine artery mean pulsatility index (UtA-PI), and blood samples for analysis of biochemical markers (PAPP-A and PlGF) were obtained. The patients were grouped according to birth weight as follows: group I (n=571), >10th percentile (control); group II (n=44), <10th percentile; and group III (n=34), <5th percentile. The predictive values of the variables for the detection of SGA fetuses were calculated using a logistic regression model and an analysis of the area under the receiver-operating characteristic curve (AUC). RESULTS: The sensitivity rates of the maternal characteristics, biophysical markers (MAP and UtA-PI), biochemical markers (PAPP-A and PlGF), and the association between them were: 23.3, 32.5, 25, and 30% respectively, at a false-positive (FP) rate of 10%, in group II and 26.5, 26.5, 23.5, and 23.5%, respectively, at a FP rate of 10% in group III. CONCLUSIONS: The predictive performances of the combination of maternal characteristics and biophysical and biochemical parameters were unsatisfactory, with a slight improvement in the predictive capacity for SGA fetuses <10th percentile.

Reference ranges of filling time and systolic-to-diastolic time index of the left ventricle, right ventricle, and interventricular septum using both spectral and tissue Doppler of fetal heart between 20 and 36 + 6 weeks of gestation.

OBJECTIVE: The objective of this study is to determine the reference ranges for filling time (FT) and systolic-to-diastolic time index (SDI) of the left ventricle (LV) by using spectral Doppler, and FT' and SDI' of the LV, right ventricle, and interventricular septum (IVS) by using tissue Doppler of the fetal heart. STUDY DESIGN: This prospective and cross-sectional study included 360 low-risk singleton pregnancies between 20 and 36 + 6 weeks of gestation. The SDI/SDI' is the sum of the ejection time, isovolumic contraction time, and isovolumic relaxation time (IRT) divided by the FT. We measured FT/FT' from the beginning of the opening click of the E wave of the mitral valve to the closing click of the A wave of the mitral valve. We used regression analysis to obtain the best-fit model polynomial equation for the parameters. Additionally, we assessed intra- and inter-observer reproducibility by using concordance correlation coefficient (CCC). RESULTS: There was a weak correlation among FT LV (r = 0.31, p < 0.0001), SDI LV (r = -0.23, p < 0.0001), and gestational age (GA). Additionally, there was a very weak positive correlation among FT' RV (r = 0.09, p = 0.0001), FT' LV (r = 0.07, p < 0.0001), FT' IVS (r = 0,08, p < 0.0001), and GA. In contrast, there was a very weak negative correlation among SDI' LV (r=-0.09, p < 0.0001), SDI' IVS (r=-0.05, p < 0.0021), and GA. There was no significative correlation between SDI' RV (r=-0.06, p < 0.081) and GA. Poor/very poor intra- and inter-observer reliability was observed for all the parameters (CCC = 0.19-0.79), whereas moderate intra- and inter-observer agreement was observed for all parameters (CCC = 0.37-0.72). CONCLUSIONS: The reference ranges for FT and SDI were determined by using spectral and tissue Doppler of the fetal heart and showed a poor reproducibility.

Prediction of preeclampsia in the first trimester of pregnancy using maternal characteristics, mean arterial pressure, and uterine artery Doppler data in a Brazilian population.

OBJECTIVE: To evaluate the performance of the preeclampsia (PE) screening algorithm of the Fetal Medicine Foundation (FMF) during the first trimester in a Brazilian population using maternal characteristics, mean arterial pressure (MAP), and uterine artery Doppler data. METHODS: This is a prospective cohort study that evaluated 701 pregnant women during the first trimester ultrasound screening for chromosomal abnormalities (11-13+6 weeks). All patients provided information regarding clinical and obstetric history, MAP, and mean uterine artery pulsatility index (mean PI). Patients were assigned to four groups based on the presence of PE and gestational age at delivery: group 1 (control), patients without hypertensive disorders (n=571); group 2, PE and delivery before 34 weeks of gestation (n=7); group 3, PE and delivery before 37 weeks of gestation, including patients from group 2 and patients that presented PE with delivery between 34 and 37 weeks (n=17); and group 4, PE and delivery before 42 weeks of gestation, including patients from both groups 2 and 3 and patients that presented PE with delivery between 37 and 42 weeks of gestation (n=34). RESULTS: After the exclusion of 96 patients, we evaluated the data of 605 patients. By combining maternal characteristics, MAP, and the mean uterine artery PI for the detection of PE, we found a sensitivity of 71.4% in group 2, 50% in group 3, and 41.2% in group 4 (false positive rate=10%). CONCLUSION: Using maternal characteristics, MAP, and uterine artery Doppler data, we were able to identify a significant proportion of patients who developed preterm PE.

Fetal frontomaxillary facial angle between 11 and 13 + 6 weeks of gestation in a Brazilian population: influence of different races.

OBJECTIVE: To evaluate the influence of different races over the measurement of the frontomaxillary facial angle between 11 and 13 + 6 weeks of pregnancy in a Brazilian population. METHODS: A cross-sectional study was conducted with 332 healthy pregnant women, with a crown-rump length (CRL) between 47 and 84 mm. Such measurements were taken abdominally, using the mid-sagittal plane, and the angle was measured by tracing a line over the palate and a line from the anterosuperior maxillary angle all the way to the external part of the forehead. As for the reference intervals, a simple linear regression between the frontomaxillary facial angle and the CRL was used, as well as Pearson's correlation coefficient (r). To evaluate the difference between races, a variance analysis was used (ANOVA). To calculate reproducibility, the intraclass correlation coefficient (ICC) was used. RESULTS: The means for the fetal frontomaxillary facial angle in white, black and mixed races were 81.8 ± 6.6; 82.2 ± 6.1 and 81.4 ± 6.2 mm, respectively. There was no statistical difference between races (p = 0.713). A decreasing correlation between the frontomaxillary facial angle and the CRL was observed for the black (r = -0.450) and mixed (r = -0.212) races. Excellent intraobserver reproducibility was observed, as well as a satisfactory interobserver reproducibility, with ICC of 0.858 and 0.605, respectively. CONCLUSION: There were no significative statistical differences in the measurement of the fetal frontomaxillary facial angle between 11 and 13 + 6 weeks of pregnancy in the different races in a Brazilian population.

Noninvasive determination of fetal rh blood group, D antigen status by cell-free DNA analysis in maternal plasma: experience in a Brazilian population.

We evaluated the diagnostic accuracy of Rh blood group, D antigen (RHD) fetal genotyping, using real-time polymerase chain reaction in maternal blood samples, in a racially mixed population. We performed a prospective study conducted between January 2006 and December 2007, analyzing fetal RHD genotype in the plasma of 102 D- pregnant women by real-time polymerase chain reaction, targeting exons 7 and 10 of the RHD gene. Genotype results were compared with cord blood phenotype obtained after delivery or before the first intrauterine transfusion when necessary. Most of the participants (75.5%) were under 28 weeks of pregnancy, and 87.5% had at least one relative of black ancestry. By combining amplification of two exons, the accuracy of genotyping was 98%, sensitivity was 100%, and specificity was 92%. The positive likelihood ratio was 12.5, and the negative likelihood ratio was 0. The two false-positive cases were confirmed to be pseudogene RHD by real-time polymerase chain reaction. There were no differences between the patients with positive or negative Coombs test ( P = 0.479). Determination of fetal RHD status in maternal peripheral blood was highly sensitive in this racially mixed population and was not influenced by the presence of antierythrocyte antibodies.

Alteracões ultra-sonográficas na gravidez Rh negativo sensibilizada avaliada pela espectrofotometria do líquido amniótico e pela dopplervelocimetria da artéria cerebral média / Ultrasound findings in Rh-alloimmunized pregnancies assessed by spectrophotometric analysis of amniotic fluid and Doppler velocimetry of fetal middle cerebral artery

OBJETIVO: Avaliar e confrontar a presenca de alteracões ultra-sonográficas nas gestacões Rh negativo sensibilizadas, quando a anemia fetal foi determinada ou pela espectrofotometria do líquido amniótico, ou pela dopplervelocimetria da artéria cerebral média. MATERIAIS E MÉTODOS: Observacional descritivo com grupo de comparacão. Nosso grupo de estudo foi constituído por 99 pacientes, avaliadas no período de janeiro de 1995 a janeiro de 2004. Foram analisados e comparados dois grupos: 74 gestantes sensibilizadas pelo fator Rh cuja anemia fetal foi acompanhada pela espectrofotometria (grupo SE) e 25 gestantes sensibilizadas pelo fator Rh cuja anemia fetal foi acompanhada pela dopplervelocimetria (grupo SD). Avaliamos a presenca ou não de alteracões ultra-sonográficas no acompanhamento pré-natal e confrontamos os dois grupos de estudo. RESULTADOS: No grupo cuja anemia fetal foi acompanhada através da espectrofotometria (grupo SE), apuramos modificacões placentárias, principalmente o aumento da espessura e sua alteracão textural, mais assiduamente que as encontradicas no grupo de gestantes sensibilizadas, em que a anemia foi determinada através da dopplervelocimetria (grupo SD) (64 por cento X 32 por cento, p = 6,294). CONCLUSAO: As alteracões ultra-sonográficas foram detectadas em dobro quando a anemia foi avaliada pela espectrofotometria em comparacão com o grupo seguido pela dopplervelocimetria.

Avaliação do desfecho dos conceptos com risco aumentado de ocorrência de anomalias cromossômicas calculado pela medida da translucência nucal / Outcome of fetuses with increased risk of chromosomal anomalies, based on nuchal translucency measurement

OBJETIVO: avaliar o desfecho dos fetos que apresentam risco de anomalia cromossômica superior a 1:300, calculado pela medida da translucência nucal, por meio do programa da Fetal Medicine Foundation. MÉTODOS: nas gestações únicas com risco para aneuploidia fetal superior a 1:300 foram avaliadas variáveis como: cariótipo fetal, abortamento espontâneo e provocado, prematuridade, óbito fetal, óbito neonatal, malformações estruturais e recém-nascidos normais. Usamos o teste exato de Fisher para fazer comparações de diferenças de proporções entre grupos. RESULTADOS: foram observadas 193 (3,6 por cento) gestações únicas com risco de aneuploidia fetal acima de 1:300. Somente 165 gestações preencheram os critérios. Destas, apenas 32,1 por cento foram submetidas a estudo do cariótipo fetal, com 8,5 por cento de anomalias cromossômicas (85,7 por cento de trissomia do cromossomo 21). Foram os seguintes os desfechos das gestações: 4,2 por cento de abortos espontâneos, 4,2 por cento de abortos induzidos, 4,8 por cento de prematuridade, 1,8 por cento de óbito neonatal, 1,8 por cento de óbito fetal e 4,2 por cento de malformações estruturais (85,7 por cento de malformações cardíacas). Aproximadamente 85,0 por cento dos casos eram recém-nascidos normais. Pacientes com cariótipo anormal tiveram significativamente mais abortos induzidos (p<0,001) e mais malformações (p<0,001) que pacientes com cariótipo normal. Nenhum diagnóstico de doença gênica ou perda gestacional relacionada aos procedimentos invasivos foi detectado. Nos fetos com diagnostico no pré-natal de aneuploidia, a gestação foi interrompida em 66,7 por cento. CONCLUSÕES: a translucência nucal mantém seu papel no rastreamento das cromossomopatias, especialmente nas gestantes de baixo risco. Porém, o aconselhamento das gestantes com risco elevado deve ser prudente, uma vez que, apesar de estes casos apresentarem pior prognóstico fetal, a maioria apresenta desfecho favorável da gestação.

Acurácia da dopplervelocimetria das artérias aorta torácica descente e cerebral média isoladas e associadas na detecção da anemia fetal na doen~ca hemolítica perinatal / Accuracy in isolated and associated fetal blood flow velocity measurement, in thoracic aorta and middle cerebral arteries, for the diagnosis of the fetal anemia in the maternal red-cell alloimmunization

Objetivos: Este trabalho tem como proposição estudar a acurácia da Dopplervelocimetria em detectar anemia em fetos com risco pela doença hemolítica perinatal, através do cálculo da velocidade de pico sistólico (VPS) da artéria cerebral média (ACM) , e da velocidade média (Vm) da artéria torácica descendente (ATD) de forma separada e em associação. Método: Foram avaliados 90 casos de funiculocentese de 46 fetos de mães aloimunizadas, de forma retrospectiva transversal entre junho de 1997 e janeiro de 2005.A idade gestacional variou entre 20 e 34 semanas, e o risco de anemia foi determinado pelas normas de assistência do setor de atendimento à gestante sensibilizada ao fator Rh da Disciplina de Medicina Fetal da UNIFESP-EPM. A classificação da anemia do feto foi feita de acordo com tabela de Mari et al(2000) e confirmada quando o valor da hemoglobina estava abaixo de 0,84 múltiplos da mediana. Imediatamente antes da cordocentese foi realizada Dopplervelocimetria das artérias cerebral média e aorta torácica descendente com cálculo da VPS e Vm respectivamente. Estes valores foram classificados como anormais quando acima de 1,5 múltiplos da mediana de acordo com curva de Mari et al. (2000) para a VPS da ACM, e acima de dois desvios padrões de acordo com curva de Nicolaides et al.(1990) para a Vm da ATD. Foi realizada curva de regressão linear para as relações entre VPS da ACM e a concentração de hemoglobina (Hb) e entre a Vm da ATD e Hb, e calculados os índices de eficiência ou seja sensibilidade, especificidade e acurácia para a VPS da ACM, Vm da ATD e a associação das duas artérias. Resultados: A idade materna média das nossas pacientes foi de 27,5 anos, 14 punções do cordão foram realizadas entre 20 e 24 semanas de idade gestacional 33 entre 24 e 28 semanas caracterizando sinais precoces de anemia fetal, 97,7 por cento dos anticorpos eram do tipo anti-D, em 24 fetos foram realizadas punções únicas em 13 duas punções em 3 houve a necessidade de 3 procedimentos em outros 3 , 4 cordocenteses e em mais 4 realizamos 5 funiculocenteses. Dos 90 casos a dosagem da Hb mostrou-se compatível com anemia em 83 (92,2 por cento)...

Prognóstico perinatal, em relaçao ao peso do concepto, no descolamento prematuro da placenta / The relationship between the perinatal prognosis and the conceptus weight, in abruptio placentae

Os autores estudaram a relaçao entre o peso do concepto e o prognóstico perinatal em 91 casos de descolamento prematuro da placenta, ocorrido na Escola Paulista de Medicina, no período de 10 anos (1979-1988). Observaram um grande número (52,7 por cento) de conceptos com menos de 2.500 g, fator este que determinou uma mortalidade perinatal três vezes maior nesta patologia, quando confrontadas com aqueles de peso superior

Comparaçäo do cálculo de idade gestacional através de medida ultra-sonográfica do diâmetro biparietal e do comprimento do fêmur, a partir da 33ª semana / Comparison of the evaluation of the gestacional age throught the ultrasound measurement of biparietal diameter and the femur length since the 33ª week

Devido a grande dificuldade de avaliaçäo da idade gestacional no terceiro trimestre, foi comparada a acurácia dos dois parâmetros ultra-sonográficos mais utilizados para esse fim, o comprimento femoral e o diâmetro biparietal, tomando-se como referencial a idade gestacional estimada pela data da última menstruaçäo. Foram estudadas 80 grávidas de 33 semanas ou mais, que tinham certeza da data do último catemênio. Foi observado que o comprimento femoral mostrou-se um parâmetro mais confiável que o DNP nessa fase da gravidez, podendo, portanto, substituí-lo quando a estimativa da idade gestacional é realizada em única avaliaçäo

A mensuraçäo ultrassonográfica do fêmur no estabelecimento da idade gestacional no último trimestre / The ultrasound femur measurement to establish the gestational age in the last trimester

Comparamos a acurácia em predizer a idade gestacional, entre a medida ultrassonográfica do comprimento do fêmur fetal e o método clínico de Capurro e col (1978), tornando-se como referência a idade gestacional estimada pela data da última menstruaçäo. Foram estudadas 80 grávidas de 33 semanas ou mais, que tinham certeza da data do último catamênio. Pudemos concluir que a idade gestacional calculada pelo exame ultrassonográfico, estatisticamente, mostrou melhor ajustamento à idade estimada pela data da última menstruaçäo que aquela obtida pelo método de Capurro