Associated ultrasonographic findings in fetuses with microcephaly because of suspected Zika virus (ZIKV) infection during pregnancy.

OBJECTIVE: To describe fetal ultrasonographic findings and outcomes in a series of cases of fetal microcephaly associated with Zika virus infection. METHODS: Retrospective case series of microcephaly with definite (laboratory evidence) or highly probable (specific neuroimaging findings and negative laboratory results) maternal Zika virus infection. Microcephaly was graded as mild if the head circumference was between 2 and 3 standard deviation (SD) below the mean, and severe if 3 or more SD below the mean. Associated central nervous system (CNS) and extracranial malformations are described. RESULTS: Nineteen singleton pregnancies fulfilling the inclusion criteria were identified. Severe microcephaly and mild microcephaly were identified in 14 and 5 fetuses, respectively. Additional CNS malformations were present in 17 cases and 7 had extracranial congenital anomalies. Symptoms were reported in 13/19 cases at a gestational age between 5 and 16 weeks. Mean (±SD) gestational age at ultrasound diagnosis was 32.3 ± 5.1 weeks. Amniocentesis was performed in five cases at a median gestational age of 31 weeks (range 28-38) and was positive for Zika virus RT-PCR in two cases. There were three neonatal deaths and one stillbirth. CONCLUSION: In the presence of fetal microcephaly associated with Zika virus infection, CNS malformations are frequently detected. © 2016 John Wiley & Sons, Ltd.

Term angular pregnancy: successful expectant management.

Interstitial pregnancy sometimes is mistakenly referred to as cornual pregnancy and is frequently confused with angular pregnancy. A strict distinction among these three conditions is clinically important because their findings, management and outcomes are different. We report an unusual case of pregnancy where interstitial pregnancy was diagnosed at 6 weeks of pregnancy, located close to the right cornual portion of the uterus. Prenatal monitoring was carried out until birth at 36 weeks' gestation with uterine conservation. Ultrasound scan and magnetic resonance imaging were realized to confirm the diagnosis and to monitor the evolution.

[Titrated oral solution of misoprostol for labour induction: a pilot study]. / Solução oral escalonada de misoprostol para indução do parto: estudo piloto.

PURPOSE: To test effectiveness and safety of the oral administration of a new misoprostol formulation in titrated doses for the induction of delivery of a live fetus at term. METHODS: An open pilot multicenter, non-randomized clinical trial was conducted from July to December 2008. A total of 30 patients with indications for induction of labor were included. The patients had a live fetus, Bishop score <6, vertex presentation, fetal weight <4,000g estimated by ultrasonography and amniotic fluid index >5. Exclusion criteria were previous uterine scar, non-reassuring fetal heart rate tracing, multiple pregnancy, fetal growth restriction, genital hemorrhage and presence of genital tumors, ulcerations or malformations. An initial dose of 20 µg/hour of the oral misoprostol solution was used in the first 6 hours, and was increased progressively to 20 µg/hour every 6 hours if labor did not start, up to a maximum dose of 80 µg/h in the first 24 hours, maintained for additional 24 hours if necessary. RESULTS: Labor was satisfactorily induced in 96.7% of patients. The interval between the first dose and the beginning of uterine contractions was 3.8 ± 1.8 hours. The interval between the initial dose and delivery varied from 6 to 24 hours. The frequency of vaginal delivery was 80% (24 cases). Most of the patients (60%; n=18) initiated labor with a dose of 20 mg/hour. Tachysystole occurred in 13.3% of women and meconium-stained fluid was detected in 20% of cases. There were two cases of Apgar scores < 7 in the first minute and no Apgar score < 7 in the fifth minute. CONCLUSIONS: The oral solution of misoprostol was effective and safe for the induction of labor. However, further randomized controlled trials are needed to compare this new formulation with misoprostol administered by the vaginal route.

Solução oral escalonada de misoprostol para indução do parto: estudo piloto / Titrated oral solution of misoprostol for labour induction: a pilot study

OBJETIVO: avaliar a efetividade e a segurança da administração de uma nova formulação de misoprostol em solução por via oral, com doses escalonadas, para indução do parto de feto vivo a termo. MÉTODOS: realizou-se um estudo multicêntrico, do tipo ensaio clínico, aberto, não-randomizado, no período de Julho a Dezembro de 2008. Foram incluídas 30 pacientes com indicação de indução do trabalho de parto, a termo, com feto vivo, índice de Bishop <6, apresentação cefálica, peso fetal estimado pela ultrassonografia <4.000g e índice de líquido amniótico >5. Foram excluídas mulheres com cicatriz uterina, cardiotocografia alterada, gestação múltipla, restrição de crescimento fetal, hemorragia genital e presença de tumores, ulcerações ou malformações genitais. A dose inicial da solução oral foi de 20µg/h de misoprostol, nas primeiras 6 horas, aumentando em 20µg/h de misoprostol a cada 6 horas, se o trabalho de parto não fosse deflagrado, até uma dose máxima de 80µg/h, nas primeiras 24 horas, mantendo a dose máxima (80µg/h) por mais 24 horas, se necessário. RESULTADOS: o trabalho de parto foi induzido satisfatoriamente em 96,7 por cento das gestantes. O intervalo entre a primeira dose e o início das contrações uterinas foi de 3,8±1,8 horas, enquanto o intervalo entre a dose inicial e o parto variou entre 6 e 24 horas. A frequência de parto vaginal foi de 80 por cento (n=24). A maioria das gestantes iniciou o trabalho de parto com a dose de 20µg/h (60 por cento; n=18). A taquissistolia ocorreu em 13,3 por cento das gestações e líquido meconial foi detectado em 20 por cento dos casos. Houve dois casos de escore de Apgar <7 no primeiro minuto e nenhum no quinto minuto. CONCLUSÕES: a solução oral de misoprostol administrada de forma escalonada foi efetiva e segura para indução do trabalho de parto. No entanto, são necessários estudos controlados para comparação com a via vaginal.

PURPOSE: to test effectiveness and safety of the oral administration of a new misoprostol formulation in titrated doses for the induction of delivery of a live fetus at term. METHODS: an open pilot multicenter, non-randomized clinical trial was conducted from July to December 2008. A total of 30 patients with indications for induction of labor were included. The patients had a live fetus, Bishop score <6, vertex presentation, fetal weight <4,000g estimated by ultrasonography and amniotic fluid index >5. Exclusion criteria were previous uterine scar, non-reassuring fetal heart rate tracing, multiple pregnancy, fetal growth restriction, genital hemorrhage and presence of genital tumors, ulcerations or malformations. An initial dose of 20µg/hour of the oral misoprostol solution was used in the first 6 hours, and was increased progressively to 20µg/hour every 6 hours if labor did not start, up to a maximum dose of 80µg/h in the first 24 hours, maintained for additional 24 hours if necessary. RESULTS: labor was satisfactorily induced in 96.7 percent of patients. The interval between the first dose and the beginning of uterine contractions was 3.8±1.8 hours. The interval between the initial dose and delivery varied from 6 to 24 hours. The frequency of vaginal delivery was 80 percent (24 cases). Most of the patients (60 percent; n=18) initiated labor with a dose of 20mg/hour. Tachysystole occurred in 13.3 percent of women and meconium-stained fluid was detected in 20 percent of cases. There were two cases of Apgar scores <7 in the first minute and no Apgar score <7 in the fifth minute. CONCLUSIONS: the oral solution of misoprostol was effective and safe for the induction of labor. However, further randomized controlled trials are needed to compare this new formulation with misoprostol administered by the vaginal route.

O uso do misoprostol para indução do trabalho de parto / Use of misoprostol for induction of labor

Atualmente, estão disponíveis diversos métodos de indução do parto. Entretanto, ainda não há consenso sobre o mais efetivo e com menor frequência de efeitos adversos. O misoprostol administrado por via vaginal tem sido utilizado rotineiramente tanto para amadurecimento como para indução do parto, porém outras formas de administração vêm sendo propostas, como comprimido oral, sublingual, bucal, retal e, mais recentemente, solução oral com dose escalonada. A via de administração recomendada pelas diretrizes de sociedades de ginecologia e obstetrícia continua sendo a vaginal, porém ainda é necessário definir qual a melhor e a menor dosagem capaz de desencadear o trabalho de parto, com a menor incidência de complicações. A dose recomendada atualmente é de 25 ug a cada quatro ou seis horas. A administração oral do misoprostol apresenta efetividade semelhante à vaginal, porém novos estudos ainda são necessários para determinar o melhor esquema terapêutico. As vias de administração bucal, sublingual e retal devem ser reservadas a protocolos de pesquisas, devendo ser estimulada a realização de novos estudos para determinar se existem vantagens em relação à via vaginal, além de definir a menor dose eficaz e o perfil de segurança.

Currently, several methods for induction of labor are available, but it remains uncertain which is more effective and safe with less frequency of adverse effects. Vaginal misoprostol has been utilized routinely for both preparation of cervix and induction of labor. However, other routes of administration have been proposed, like oral, sublingual, buccal, rectal and, recently, a titrated oral solution. Guidelines continue to recommend vaginal administration, but it is necessary to define the best and lowest dose capable of starting labor with fewer complications. The current recommended dose of vaginal misoprostol is 25 ug each four or six hours. Oral misoprostol has effectiveness similar to vaginal misoprostol, but new trials are still necessary to determine the ideal therapeutic schema. Buccal, sublingual and rectal routes should be restricted to research protocols. Randomized controlled trials should be conducted to determine whether there are advantages of these alternative routes in relation to vaginal administrations and to define their safety profile, as well as the ideal dose for labor induction