RESUMO
OBJECTIVE: To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence. METHODS: Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada. RESULTS: There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p = 0.02), elevated maternal body mass index (BMI; OR: 3.4; p = 0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p = 0.05) and 5-minute low Apgar score (OR: 5.9; p < 0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p = 0.006), postpartum hemorrhage (OR: 13.9; p < 0.001), hysterectomy (OR: 23.0; p = 0.002), and stillbirth (OR: 8.2; p < 0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight. CONCLUSION: This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.
OBJETIVO: Comparar os fatores de risco maternos e perinatais associados à ruptura uterina completa e deiscência uterina. MéTODOS: Estudo transversal de pacientes com ruptura/deiscência uterina no período de janeiro de 1998 a dezembro de 2017 (30 anos) internadas na Unidade de Parto de um hospital universitário terciário no Canadá. RESULTADOS: Ocorreram 174 (0,1%) casos de transtorno uterino (29 rupturas e 145 deiscências) em 169.356 partos. Houve associações entre deiscência e multiparidade (razão de chances [RC]: 3,2; p = 0,02), índice de massa corporal (IMC) materno elevado (RC: 3,4; p = 0,02), tentativa de parto vaginal após cesariana (RC: 2,9; p = 0,05) e baixa pontuação Apgar em 5 minutos (RC: 5,9; p < 0,001). A ruptura uterina foi associada a partos prematuros (36,5 ± 4,9 versus 38,2 ± 2,9; p = 0,006), hemorragia pós-parto (RC: 13,9; p < 0,001), histerectomia (RC: 23,0; p = 0,002) e natimorto (RC: 8,2; p < 0,001). Não houve associação entre ruptura uterina e idade materna, idade gestacional, início do trabalho de parto, ruptura espontânea ou artificial de membranas, uso de ocitocina, tipo de incisão uterina e peso ao nascer. CONCLUSãO: Esta grande coorte demonstrou que existem diferentes fatores de risco associados à ruptura ou à deiscência uterina. A ruptura uterina ainda representa uma grande ameaça à saúde materno-fetal e, diferentemente da crença comum, a deiscência uterina também pode comprometer os desfechos perinatais.
Assuntos
Ruptura Uterina , Nascimento Vaginal Após Cesárea , Canadá/epidemiologia , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Gravidez , Fatores de Risco , Ruptura Uterina/epidemiologia , Ruptura Uterina/etiologiaRESUMO
Abstract Objective To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence. Methods Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada. Results There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p=0.02), elevated maternal body mass index (BMI; OR: 3.4; p=0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p=0.05) and 5-minute low Apgar score (OR: 5.9; p<0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p=0.006), postpartum hemorrhage (OR: 13.9; p<0.001), hysterectomy (OR: 23.0; p=0.002), and stillbirth (OR: 8.2; p<0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight. Conclusion This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.
Resumo Objetivo Comparar os fatores de risco maternos e perinatais associados à ruptura uterina completa e deiscência uterina. Métodos Estudo transversal de pacientes com ruptura/deiscência uterina no período de janeiro de 1998 a dezembro de 2017 (30 anos) internadas na Unidade de Parto de um hospital universitário terciário no Canadá. Resultados Ocorreram 174 (0,1%) casos de transtorno uterino (29 rupturas e 145 deiscências) em 169.356 partos. Houve associações entre deiscência e multiparidade (razão de chances [RC]: 3,2; p=0,02), índice demassa corporal (IMC)materno elevado (RC: 3,4; p=0,02), tentativa de parto vaginal após cesariana (RC: 2,9; p=0,05) e baixa pontuação Apgar em 5minutos (RC: 5,9; p<0,001). A ruptura uterina foi associada a partos prematuros (36,5 ± 4,9 versus 38,2 ± 2,9; p=0,006), hemorragia pós-parto (RC: 13,9; p<0,001), histerectomia (RC: 23,0; p=0,002) e natimorto (RC: 8,2; p<0,001). Não houve associação entre ruptura uterina e idade materna, idade gestacional, início do trabalho de parto, ruptura espontânea ou artificial de membranas, uso de ocitocina, tipo de incisão uterina e peso ao nascer. Conclusão Esta grande coorte demonstrou que existem diferentes fatores de risco associados à ruptura ou à deiscência uterina. A ruptura uterina ainda representa uma grande ameaça à saúde materno-fetal e, diferentemente da crença comum, a deiscência uterina também pode comprometer os desfechos perinatais.
Assuntos
Humanos , Feminino , Gravidez , Recém-Nascido , Ruptura Uterina/etiologia , Ruptura Uterina/epidemiologia , Nascimento Vaginal Após Cesárea , Canadá/epidemiologia , Estudos Transversais , Fatores de RiscoRESUMO
Abstract Objectives: to evaluate the maternalfetal outcomes of thromboprophylaxis with enoxa parin based on scoring system in women with serum markers for hereditary thrombophilia and previous obstetric complications. Methods: a retrospective study was undertaken based on data collected from clinical records. We included 54 pregnant women with serum markers for hereditary thrombophilia undergoing therapeutic intervention with enoxaparin in the period from November 2009 to December 2013. The initial dose of low molecular weight heparin was guided by a scoring system. The maternalfetal outcomes of previous pregnancies and, subsequently, the treatment were compared using the chisquare (χ2) test with the Yates correction and Fisher's Exact Test; p<0.05 was considered significant. Results: we observed significant reduction in fetal/perinatal deaths (p<0.05) and spontaneous abortions (p<0.001) after intervention. The live births at fullterm delivery (p<0.001) and live births at preterm delivery (p<0.05) increased significantly after intervention. Conclusions: the therapeutic intervention with enoxaparin based on scoring system during pregnancy seems to improve the fetal prognosis.
Resumo Objetivos: avaliar os desfechos maternosfetais da tromboprofilaxia com enoxaparina com base em sistema de pontuação em mulheres com marcadores séricos para trombofilia hereditária e antecedentes de complicações obstétricas. Métodos: realizouse estudo retrospectivo com base em dados coletados de prontuários. Foram Incluídas 54 mulheres grávidas com marcadores séricos de trombofilia hereditária submetidos à intervenção terapêutica com enoxaparina no período de novembro de 2009 a dezembro de 2013. A dose inicial de heparina de baixo peso molecular foi norteada por um sistema de pontuação. Os resultados maternosfetais de gestações anteriores e subsequentes ao tratamento foram comparados utilizando Teste quiquadrado com correção de Yates ou Exato de Fisher; p<0,05 foi considerado significativo. Resultados: observouse significativa redução de mortes fetais / perinatais (p<0,05) e abortos espontâneos (p<0,001) após intervenção. Os nascidos vivos com parto a termo (p<0,001) e nascidos vivos no parto prematuro (p<0,05) elevaramse significativamente após a intervenção. Conclusão: a intervenção terapêutica com enoxaparina com base no sistema de pontuação durante a gravidez parece melhorar o prognóstico fetal.
Assuntos
Humanos , Feminino , Trombose/prevenção & controle , Biomarcadores , Enoxaparina , Heparina de Baixo Peso Molecular , Relações Materno-Fetais , Brasil , Resultado da Gravidez , Distribuição de Qui-Quadrado , Aborto Espontâneo , Nascimento a Termo , Nascido Vivo , Morte Fetal , Morte Perinatal , Trabalho de Parto PrematuroRESUMO
Abstract Objectives: to determine the frequency of serum markers for hereditary and acquired thrombophilia and their association with pregnancy in women with Systemic Lupus Erythematosus (SLE). Methods: a case-control study was conducted among 25 pregnant women with SLE (study group) and 32 pregnant women without known disease and with at least one previous pregnancy (control group). The presence of antiphospholipid antibodies and hereditary thrombophilia were examined in both groups. We used the y2 Test with Yates correction or Fisher's Exact Test to verify the associations and calculate the relative risk. Results: thrombophilia was present in 72.0% of pregnant women with SLE and in 6.0% of patients in the control group. A significant association was found between the presence of SLE and serum markers for hereditary thrombophilia / antiphospholipid antibodies (p<0.05). The relative risks for antiphospholipid antibodies were 13.20 (ICR95%= 1.81 - 96.46) in pregnant women with SLE, 7.26 (CI95%= 1.77 - 29.86) for the presence of serum markers of hereditary thrombophilia and 7.92 (CI95%= 2.62 - 3.94) for the presence of hereditary thrombophilia and/or antiphospholipid antibodies. Conclusions: the identification of markers for hereditary and/or acquired thrombophilia in pregnant women with lupus may be clinically useful to determine which patients have a higher risk of obstetric complications.
Resumo Objetivos: determinar a frequência e a associação ente LES em gestantes e a ocorrência de marcadores séricos para trombofilias hereditárias e adquiridas no grupo de gestantes estudadas. Métodos: foi realizado estudo caso-controle com 25 gestantes portadoras de Lúpus Eritematoso Sistêmico (grupo estudo) e 32 gestantes sem doença conhecida, com pelo menos uma gestação anterior (grupo controle). A presença de anticorpos antifosfolípides e trombofilia hereditária foi examinada em ambos os grupos. Utilizamos o Teste y2 com correção de Yates ou Teste Exato de Fisher para verificar as associações e calcular o risco relativo. Resultados: verificou-se a presença de trombofilias em 72,0% das gestantes portadoras de LES e em 6,0% das pacientes do grupo controle. Encontrou-se significante associação entre a presença de LES em gestantes e marcadores séricos para trombofilias hereditárias/anticorpos antifosfolípides (p<0,05). Identificou-se risco relativo para presença de anticorpos antifosfolípides de 13,20 (1,81<RR<96,46) em gestantes portadoras de LES, 7.26 (IC95%=1.77-29.86) para presença de marcadores séricos de trombofilias hereditárias e de 7.92 (IC95%= 2.62 - 23.94) considerando a presença de trombofilias hereditárias e/ou presença de anticorpos antifosfolípides. Conclusões: a identificação de marcadores para trombofilia hereditária e/ou adquirida em gestantes com lúpus pode ser clinicamente útil para determinar quais pacientes apresentam maior risco de complicações obstétricas.
Assuntos
Humanos , Feminino , Gravidez , Complicações Hematológicas na Gravidez , Biomarcadores , Anticorpos Antifosfolipídeos , Trombofilia/sangue , Gestantes , Lúpus Eritematoso Sistêmico/complicações , Complicações na GravidezRESUMO
PURPOSE:: To evaluate the effects of enoxaparin and unfractionated heparin (UFH) administered in prophylactic and therapeutic doses on fetal vessels in healthy pregnant Wistar rats, according to Doppler velocimetry measurements. METHODS:: Fifty animals were assigned to one of five groups: controls (saline), prophylactic and therapeutic enoxaparin (1 and 2 mg/kg/day, respectively), and prophylactic and therapeutic UFH (72 and 400 UI/kg/day, respectively). Uterine horns were examined by ultrasound for identification of live fetuses. A sample of these fetuses underwent Doppler velocimetry. Spectral curves, peak systolic velocity (PSV), pulsatility index (PI), and resistance index (RI) of the middle cerebral artery, ductus venosus, and umbilical artery were investigated. Differences were considered statistically significant when p<0.05. RESULTS:: No significant differences in PSV, PI, or RI values were observed among the groups. CONCLUSION:: Doppler velocimetry measurements revealed no significant effects of enoxaparin or unfractionated heparin on fetal vessels in pregnant Wistar rats.
Assuntos
Anticoagulantes/farmacologia , Velocidade do Fluxo Sanguíneo/efeitos dos fármacos , Enoxaparina/farmacologia , Feto/irrigação sanguínea , Heparina/farmacologia , Artéria Cerebral Média/efeitos dos fármacos , Artérias Umbilicais/efeitos dos fármacos , Artéria Uterina/efeitos dos fármacos , Animais , Ecocardiografia Doppler de Pulso/métodos , Feminino , Artéria Cerebral Média/fisiopatologia , Modelos Animais , Gravidez , Ratos Wistar , Ultrassonografia Pré-Natal/métodos , Artérias Umbilicais/fisiopatologia , Artéria Uterina/fisiopatologia , Aumento de Peso/efeitos dos fármacosRESUMO
Purpose: To evaluate the effects of enoxaparin and unfractionated heparin (UFH) administered in prophylactic and therapeutic doses on fetal vessels in healthy pregnant Wistar rats, according to Doppler velocimetry measurements. Methods: Fifty animals were assigned to one of five groups: controls (saline), prophylactic and therapeutic enoxaparin (1 and 2 mg/kg/day, respectively), and prophylactic and therapeutic UFH (72 and 400 UI/kg/day, respectively). Uterine horns were examined by ultrasound for identification of live fetuses. A sample of these fetuses underwent Doppler velocimetry. Spectral curves, peak systolic velocity (PSV), pulsatility index (PI), and resistance index (RI) of the middle cerebral artery, ductus venosus, and umbilical artery were investigated. Differences were considered statistically significant when p 0.05. Results: No significant differences in PSV, PI, or RI values were observed among the groups. Conclusion: Doppler velocimetry measurements revealed no significant effects of enoxaparin or unfractionated heparin on fetal vessels in pregnant Wistar rats.(AU)
Assuntos
Animais , Ratos , Fluxometria por Laser-Doppler , Enoxaparina/administração & dosagem , Enoxaparina/efeitos adversos , Heparina/administração & dosagem , Heparina/efeitos adversos , Ratos , PrenhezRESUMO
Abstract Purpose: To evaluate the effects of enoxaparin and unfractionated heparin (UFH) administered in prophylactic and therapeutic doses on fetal vessels in healthy pregnant Wistar rats, according to Doppler velocimetry measurements. Methods: Fifty animals were assigned to one of five groups: controls (saline), prophylactic and therapeutic enoxaparin (1 and 2 mg/kg/day, respectively), and prophylactic and therapeutic UFH (72 and 400 UI/kg/day, respectively). Uterine horns were examined by ultrasound for identification of live fetuses. A sample of these fetuses underwent Doppler velocimetry. Spectral curves, peak systolic velocity (PSV), pulsatility index (PI), and resistance index (RI) of the middle cerebral artery, ductus venosus, and umbilical artery were investigated. Differences were considered statistically significant when p<0.05. Results: No significant differences in PSV, PI, or RI values were observed among the groups. Conclusion: Doppler velocimetry measurements revealed no significant effects of enoxaparin or unfractionated heparin on fetal vessels in pregnant Wistar rats.
Assuntos
Animais , Feminino , Velocidade do Fluxo Sanguíneo/efeitos dos fármacos , Heparina/farmacologia , Enoxaparina/farmacologia , Artéria Cerebral Média/efeitos dos fármacos , Feto/irrigação sanguínea , Anticoagulantes/farmacologia , Artérias Umbilicais/fisiopatologia , Gravidez , Aumento de Peso/efeitos dos fármacos , Ultrassonografia Pré-Natal/métodos , Ratos Wistar , Ecocardiografia Doppler de Pulso/métodos , Artéria Cerebral Média/fisiopatologia , Modelos Animais , Artéria Uterina/fisiopatologiaRESUMO
RESUMO Objetivo Conhecer a percepção das pacientes sobre a consulta realizada por estudante de Medicina com supervisão docente indireta. Método Pesquisa observacional realizada com 95 gestantes do ambulatório de gestação de alto risco e 40 mães de prematuros do ambulatório de follow-up, atendidas por estudantes do quinto ou sexto ano. Utilizaram-se dois questionários semiestruturados, antes da consulta (pré-teste) e após a consulta (pós-teste), com questões objetivas e descritivas. Os dados quantitativos foram analisados em tabela de contingência, e a análise estatística foi realizada por meio do Teste Exato de Fisher. Resultados A pesquisa mostrou mudança de atitude das gestantes e das mães de prematuros na comparação entre antes e depois do atendimento da consulta pelo estudante de Medicina sob supervisão indireta, quanto ao sentimento de conforto ao ser consultada e examinada pelo estudante de Medicina e também quanto à confiança na conduta repassada pelo estudante. A análise descritiva das palavras citadas pelas gestantes antes das consultas apontou ansiedade e, depois da consulta, calma e satisfação. Já para as mães de prematuros antes da consulta, apontou preocupação, insegurança e ansiedade. Após a consulta, as palavras predominantes foram satisfação, confiança e tranquilidade. Conclusão Este estudo demonstrou mudança positiva na percepção das pacientes de ambulatório de Obstetrícia de alto risco e Pediatria atendidas com supervisão docente indireta. As pacientes também reconheceram que este modelo de atendimento médico é importante para os estudantes de Medicina como parte de sua formação.
ABSTRACT Objective To learn about patients’ views on consultations they received by medical students under indirect faculty supervision. Method Observational research conducted among 95 pregnant women under outpatient care for high risk pregnancy and 40 mothers of preterm born infants assisted through an outpatient follow-up service, under the care of fifth or sixth year student doctors. Two semi-structured questionnaires were used: prior to consultation (pre-test) and after consultation (post-test), containing objective and descriptive questions. Quantitative data were analyzed in a contingency table and statistical analysis was performed using Fisher’s exact test. Results Our data demonstrated the changing attitudes of pregnant women and mothers of preterm child comparing before and after the student doctor consultation under indirect supervision, in relation to both the sense of comfort when being consulted and examined by a medical student and confidence in the student’s conduct. The descriptive analysis of words quoted by pregnant women before the consultation indicated anxiety and, after consultation, were calmness and satisfaction. As regards the mothers of premature infants, before the consultation the KEYWORDS were: ‘worry’, ‘insecurity’ and ‘anxiety’. After the consultation the words ‘satisfaction’, ‘trust’ and ‘confidence’ predominated. Conclusion This study demonstrated a positive change in the perception of outpatients from high-risk obstetrics and pediatrics units consulted by medical students under indirect faculty supervision. Patients also recognized that this model of medical care is important for medical students’ learning as part of their training.
RESUMO
BACKGROUND: Minimal faculty member supervision of students refers to a method of instruction in which the patient-student encounter is not directly supervised by a faculty member, and presents a feasible solution in clinical teaching. It is unclear, however, how such practices are perceived by patients and how they affect student learning. CONTEXT: We aimed to assess patient and medical student perceptions of clinical teaching with minimal faculty member supervision. Questionnaires focusing on the perception of students' performance were administered to patients pre- and post-consultation. Students' self-perceptions on their performance were obtained using a questionnaire at the end of the consultation. INNOVATION: Before encounters with students, 22 per cent of the 95 patients were not sure if they would feel comfortable or trust the students; after the consultation, almost all felt comfortable (97%) and relied on the students (99%). The 81 students surveyed agreed that instruction with minimal faculty member supervision encouraged their participation and engagement (86%). They expressed interest in knowing patients' opinions about their performance (94%), and they felt comfortable about being assessed by the patients (86%). IMPLICATIONS: The minimal faculty member supervision model was well accepted by patients. Responses from the final-year students support the use of assessments that incorporate feedback from patients in their overall clinical evaluations.
Assuntos
Assistência Ambulatorial , Estágio Clínico/métodos , Ensino/métodos , Adulto , Estágio Clínico/organização & administração , Docentes de Medicina , Feminino , Humanos , Obstetrícia/educação , Organização e Administração , Satisfação do Paciente , Gravidez , Estudantes de Medicina/psicologia , Inquéritos e QuestionáriosRESUMO
PURPOSE: To evaluate the effects of exposure of enoxaparin and unfractionated heparin (UFH) in prophylactic and therapeutic doses on the fertility rates of pregnant healthy Wistar rats. METHODS: Enoxaparin and UFH were administered in prophylactic doses 1 mg/Kg/day 72 UI/Kg/day, and in therapeutic doses at 2 mg/kg/day 400UI/Kg/day. The rats were divided into five groups. The number of live and dead foetuses was quantified. The uterine horns were dissected and the presence of early and late reabsorptions (abortions) was determined. A p<0.05 was considered statistically significant. RESULTS: We did not observe statistically significant differences between groups when comparing the average weight of the foetuses and placentas, rate of female VS males, rates of pre-implantation loss (RPL), rates of efficiency implantation (REI), rates of post-implantation loss (RPIL) and rates of foetal viability (RFV). CONCLUSIONS: There was no significant effect on fertility with the use of anticoagulant drugs in pregnant healthy Wistar rats.