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Magnetic resonance imaging (MRI) can provide additional information in cases of cesarean scar pregnancy beyond the first trimester. MRI and 3D reconstructions can demonstrate the relationships between the uterus, cervix, bladder, and placenta, improving the spatial perspective of the pelvic anatomy in cases requiring surgical management. MRI and 3D reconstructions can also provide more comprehensive images for parental counseling, virtual and face-to-face multidisciplinary team discussion, and medical record storage.

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O parto cesáreo (PC) é o procedimento cirúrgico mais comumente realizado nos Estados Unidos (mais de 1 milhão de cirurgias por ano) e um dos procedimentos mais realizados em todo o mundo.(1) Embora o PC seja um procedimento potencialmente salvador de vidas, quando corretamente indicado, sua frequência aumentou constantemente nas últimas décadas (atualmente 21,1% globalmente, variando de 5%, na África Subsaariana, a 42,8%, na América Latina e no Caribe). Além disso, estudos demonstram tendência continuada de aumento (projeção para 2030: 28,5% globalmente, variando de 7,1%, na África Subsaariana, a 63,4%, no leste da Ásia).(2) República Dominicana, Brasil, Chipre, Egito e Turquia são os líderes mundiais, com taxas de PC variando de 58,1% a 50,8%, respectivamente, o que aponta para uma tendência preocupante de medicalização do parto e indicação excessiva do PC.(2) Outros procedimentos cirúrgicos como dilatação, curetagem, miomectomia e histeroscopia cirúrgica são menos frequentes que o PC. Ainda assim, devido à tendência de maior idade materna, o número de gestantes previamente submetidas a esses procedimentos também tende a aumentar. Esses dados apontam para um número crescente de gestações em úteros manipulados cirurgicamente Gestantes com cicatrizes uterinas prévias correm risco de aumento da morbimortalidade. Complicações como placenta prévia, rotura uterina espontânea, deiscência uterina (com ou sem intrusão placentária), gestação em cicatriz de cesariana (GCC) e distúrbios do espectro do acretismo placentário (EAP) estão associadas a sangramento uterino potencialmente fatal, lesões extrauterinas e parto pré-termo

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Background: Knowledge regarding the risks associated with Zika virus (ZIKV) infections in pregnancy has relied on individual studies with relatively small sample sizes and variable risk estimates of adverse outcomes, or on surveillance or routinely collected data. Using data from the Zika Brazilian Cohorts Consortium, this study aims, to estimate the risk of adverse outcomes among offspring of women with RT-PCR-confirmed ZIKV infection during pregnancy and to explore heterogeneity between studies. Methods: We performed an individual participant data meta-analysis of the offspring of 1548 pregnant women from 13 studies, using one and two-stage meta-analyses to estimate the absolute risks. Findings: Of the 1548 ZIKV-exposed pregnancies, the risk of miscarriage was 0.9%, while the risk of stillbirth was 0.3%. Among the pregnancies with liveborn children, the risk of prematurity was 10,5%, the risk of low birth weight was 7.7, and the risk of small for gestational age (SGA) was 16.2%. For other abnormalities, the absolute risks were: 2.6% for microcephaly at birth or first evaluation, 4.0% for microcephaly at any time during follow-up, 7.9% for neuroimaging abnormalities, 18.7% for functional neurological abnormalities, 4.0% for ophthalmic abnormalities, 6.4% for auditory abnormalities, 0.6% for arthrogryposis, and 1.5% for dysphagia. This risk was similar in all sites studied and in different socioeconomic conditions, indicating that there are not likely to be other factors modifying this association. Interpretation: This study based on prospectively collected data generates the most robust evidence to date on the risks of congenital ZIKV infections over the early life course. Overall, approximately one-third of liveborn children with prenatal ZIKV exposure presented with at least one abnormality compatible with congenital infection, while the risk to present with at least two abnormalities in combination was less than 1.0%.

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Background. Adams-Oliver syndrome is a congenital disease whose main findings are aplasia cutis congenita of the scalp and terminal transverse limb defects. The pathogenesis is unknown, but it is postulated that ischemic events in susceptible tissues cause the lesions in the embryonic period.Case report. We present a newborn with a severe phenotype of Adams-Oliver syndrome. The infant's mother had a SARS-CoV-2 infection in the first trimester of pregnancy. Prenatal ultrasound indicates a probable worsening of the disease after the first trimester.Conclusion. This study shows a previously unpublished severe AOS phenotype in a term newborn. There are some signs that the disease could have progressed beyond the first trimester, either spontaneously or by the inflammatory mechanisms of SARS-CoV-2.

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BACKGROUND: Integrase inhibitors have been associated with excess gestational weight gain that may lead to adverse pregnancy outcomes (APOs). This post hoc analysis of NICHD P1081 compared antepartum changes in weight and body mass index (BMI) in pregnant women initiating raltegravir- or efavirenz-based combined antiretroviral therapy (cART) and examined associations between rates of weight gain and APOs. SETTING: NICHD P1081 enrolled antiretroviral-naive pregnant women living with HIV in the second and third trimester in Brazil, Tanzania, South Africa, Thailand, Argentina, and the United States. METHODS: Two hundred eighty-one women enrolled between 20 and 31 gestational weeks were randomized to raltegravir- or efavirenz-based cART and followed for ≥4 weeks. A low rate of weight gain was defined as <0.18 kg/wk and high as >0.59 kg/wk. We compared weight gain and BMI increase between treatment arms using Kruskal-Wallis tests. Logistic regression was used to investigate the association between weight gain and APOs. RESULTS: Raltegravir-based cART was associated with significantly higher antepartum weight gain (median 0.36 kg/wk versus 0.29 kg/wk, P = 0.01) and BMI increase (median 0.14 kg/m 2 /wk versus 0.11 kg/m 2 /wk, P = 0.01) compared with efavirenz-based treatment. Women on raltegravir had less low weight gain (18% versus 36%) and more high weight gain (21% versus 12%) ( P = 0.001). Women with low weight gain were more likely than those with normal weight gain to have small for gestational age infants or a composite of APOs. CONCLUSIONS: A raltegravir-based antiretroviral regimen was associated with significantly higher antepartum rate of weight gain and BMI increase compared with efavirenz-based treatment in antiretroviral-naive pregnant women.

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Background Studies addressing neuroimaging findings as primary outcomes of congenital Zika virus infection are variable regarding inclusion criteria and confirmatory laboratory testing. Purpose To investigate cranial US signs of prenatal Zika virus exposure and to describe frequencies of cranial US findings in infants exposed to Zika virus compared to those in control infants. Materials and Methods In this single-center prospective cohort study, participants were enrolled during the December 2015-July 2016 outbreak of Zika virus infection in southeast Brazil (Natural History of Zika Virus Infection in Gestation cohort). Eligibility criteria were available cranial US and laboratory findings of maternal Zika virus infection during pregnancy confirmed with RNA polymerase chain reaction testing (ie, Zika virus-exposed infants). The control group was derived from the Zika in Infants and Pregnancy cohort and consisted of infants born to asymptomatic pregnant women who tested negative for Zika virus infection during pregnancy. Two radiologists who were blinded to the maternal Zika virus infection status independently reviewed cranial US scans from both groups and categorized them as normal findings, Zika virus-like pattern, or mild findings. Associations between cranial US findings and prenatal Zika virus exposure were assessed with univariable analysis. Results Two hundred twenty Zika virus-exposed infants (mean age, 53.3 days ± 71.1 [standard deviation]; 113 boys) and born to 219 mothers infected with Zika virus were included in this study and compared with 170 control infants (mean age, 45.6 days ± 45.8; 102 boys). Eleven of the 220 Zika virus-exposed infants (5%), but no control infants, had a Zika virus-like pattern at cranial US. No difference in frequency of mild findings was observed between the groups (50 of 220 infants [23%] vs 44 of 170 infants [26%], respectively; P = .35). The mild finding of lenticulostriate vasculopathy, however, was nine times more frequent in Zika virus-exposed infants (12 of 220 infants, 6%) than in control infants (one of 170 infants, 1%) (P = .01). Conclusion Lenticulostriate vasculopathy was more common after prenatal exposure to Zika virus, even in infants with normal head size, despite otherwise overall similar frequency of mild cranial US findings in Zika virus-exposed infants and in control infants. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Benson in this issue.

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Confirming ZIKV congenital infection is challenging because viral RNA is infrequently detected. We compared the presence of anti-ZIKV-IgM and the persistence of anti-ZIKV-IgG antibodies over 18 months in two cohorts of infants born to ZIKV-infected mothers: Cohort one: 30 infants with typical microcephaly or major brain abnormalities (Congenital Zika Syndrome-CZS); Cohort two: 123 asymptomatic infants. Serum samples obtained within 6 months of age were tested for anti-ZIKV-IgM. Anti-ZIKV-IgG was quantified in sequential samples collected at birth, 3-6 weeks, 3, 6, 12, and 18 months. ZIKV-RNA was never detected postnatally. Anti-ZIKV-IgM antibodies were detected at least once in 15/25 (60.0%; 95%CI: 38.7-78.9) infants with CZS and in 2/115 (1.7%; 95%CI: 0.2-6.1) asymptomatic infants. Although anti-ZIKV-IgG was always positive within 3-6 weeks of age, IgG levels decreased similarly over time in both cohorts. IgG levels decreased similarly in ZIKV-IgM-positive and ZIKV-IgM-negative CZS infants. Differently from other congenital infections, IgM would fail to diagnose 40% of severely symptomatic infants, and the persistence of IgG is not a useful marker for discriminating congenital infection among infants exposed to maternal ZIKV infection.

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O sulfato de magnésio tem sido utilizado em obstetrícia por décadas e milhares de mulheres já foram incluídas em ensaios clínicos que estudaram sua eficácia em uma variedade de condições gestacionais. Os principais usos do medicamento na atual prática obstétrica incluem prevenção e tratamento de convulsões eclâmpticas, prolongamento da gravidez para administração antenatal de corticosteroides e neuroproteção fetal na iminência de interrupção prematura da gravidez. Em função da alta qualidade e da consistência dos resultados de importantes ensaios clínicos, a indicação do sulfato de magnésio para profilaxia e terapia das convulsões eclâmpticas está bem estabelecida. Entretanto, tal unanimidade não ocorre com relação ao seu emprego como tocolítico, tanto pela discussão sobre sua efetividade quanto pelas doses mais altas usualmente utilizadas para esse fim. Em relação à importância do sulfato de magnésio como agente neuroprotetor fetal, a paralisia cerebral é a causa mais comum de deficiência motora na infância e tem como fator de risco mais importante a prematuridade, cuja incidência tem aumentado significativamente. Diretrizes nacionais e internacionais mais recentes, baseadas em resultados de ensaios clínicos randomizados e metanálises de boa qualidade, mostraram que a administração antenatal de sulfato de magnésio na iminência de parto pré-termo precoce é uma intervenção eficiente, viável, segura, com boa relação custo-benefício e pode contribuir para a melhoria dos desfechos neurológicos neonatais.

Magnesium sulfate has been used in obstetrics for decades and thousands of women have already been included in clinical trials that have studied its effectiveness in a variety of gestational conditions. The main uses of the drug in current obstetrical practice include prevention and treatment of eclamptic seizures, prolongation of pregnancy for antenatal administration of corticosteroids, and fetal neuroprotection in the imminence of premature termination of pregnancy. Because of the high quality and consistency of the results of important clinical trials, the indication of magnesium sulfate for prophylaxis and therapy of eclamptic seizures is well established. However, such unanimity does not occur regarding its use as tocolytic, either by the discussion of its effectiveness or by the higher doses usually used for this purpose. Regarding the importance of magnesium sulfate as a fetal neuroprotective agent, cerebral palsy is the most common cause of motor deficits in childhood and has a significantly higher incidence of prematurity as a major risk factor. More recent national and international guidelines, based on results from randomized controlled trials and good quality meta-analyzes, have shown that the antenatal administration of magnesium sulfate at the imminence of early preterm delivery is a cost-effective, viable, efficient intervention and safe and can contribute to the improvement of neonatal neurological outcomes.

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Placental dysfunction has a deleterious influence on fetal size and is associated with higher rates of perinatal morbidity and mortality. This association underpins the strategy of fetal size evaluation as a mechanism to identify placental dysfunction and prevent stillbirth. The optimal method of routine detection of small for gestational age (SGA) remains to be clarified with choices between estimation of symphyseal-fundal height versus routine third-trimester ultrasound, various formulae for fetal weight estimation by ultrasound, and the variable use of national, customized, or international fetal growth references. In addition to these controversies, the strategy for detecting SGA is further undermined by data demonstrating that the relationship between fetal size and adverse outcome weakens significantly with advancing gestation such that near term, the majority of stillbirths and adverse perinatal outcomes occur in normally sized fetuses. The use of maternal serum biochemical and Doppler parameters near term appears to be superior to fetal size in the identification of fetuses compromised by placental dysfunction and at increased risk of damage or demise. Multiparameter models and predictive algorithms using maternal risk factors, and biochemical and Doppler parameters have been developed, but need to be prospectively validated to demonstrate their effectiveness.

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Os principais usos contemporâneos do sulfato de magnésio na prática obstétrica incluem a prevenção e o tratamento de convulsões em portadoras de pré-eclâmpsia e eclâmpsia, o prolongamento da gravidez para administração antenatal de corticosteroides e a neuroproteção fetal na iminência de interrupção prematura da gestação, uma indicação mais recente. A paralisia cerebral é a causa mais comum de deficiência motora na infância e apresenta como fator de risco mais importante o nascimento pré-termo, cuja incidência tem aumentado significativamente. Como consequência, a ocorrência da paralisia cerebral também tem aumentado, a despeito da melhoria da sobrevida dos fetos pré-termos. No atual contexto de procura por estratégias que se mostrem efetivas na redução da paralisia cerebral nos recém-nascidos prematuros e que deveriam ser implementadas com o objetivo de diminuir os seus efeitos danosos nos indivíduos e suas famílias, nos serviços de saúde e na sociedade como um todo, o sulfato de magnésio tem se mostrado como o mais promissor agente neuroprotetor fetal. Desde a década de 1990, estudos resultantes das suas indicações para a prevenção das convulsões eclâmpticas ou para tocólise têm evidenciado redução nas taxas de paralisia cerebral e leucomalácia periventricular em prematuros. Diretrizes nacionais e internacionais mais recentes, baseando-se em resultados de ensaios randomizados controlados e metanálises de boa qualidade, têm avançado na recomendação sobre os regimes terapêuticos e na construção de algoritmos para utilização do sulfato de magnésio na neuroproteção fetal.(AU)

The main contemporary uses of magnesium sulfate in obstetric practice include the prevention and treatment of seizures in patients with preeclampsia and eclampsia, prolongation of pregnancy for antenatal administration of corticosteroids and fetal neuroprotection at the imminence of premature termination of pregnancy, a more recent indication. Cerebral palsy is the most common cause of motor deficits in childhood and has a significant increase in preterm birth as a major risk factor. As a result, the occurrence of cerebral palsy has also increased, despite the improvement in the survival of preterm fetuses. In the current context of search for strategies that are effective in reducing cerebral palsy in preterm newborns and that should be implemented with the aim of reducing their harmful effects on individuals and their families, health services and society as a whole, magnesium sulfate has been shown to be the most promising fetal neuroprotective agent. Since the 1990s, studies arising from its indications for prevention of eclamptic seizures or tocolysis have shown a reduction in the rates of cerebral palsy and periventricular leukomalacia in preterm infants. More recent national and international guidelines, based on results from randomized controlled trials and good quality meta-analyzes, have advanced the recommendation on therapeutic regimens and the construction of algorithms for the use of magnesium sulphate in fetal neuroprotection.(AU)

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A infecção pelo HIV associa-se à anemia e às alterações no perfil de lipídeos de pessoas que vivem com o vírus. O objetivo deste estudo foi descrever a prevalência de anemia e as alterações nos níveis de lipídeos em gestantes que vivem com HIV/aids. O estudo foi do tipo coorte retrospectiva, realizado com 117 gestantes, em uso de terapia antirretroviral combinada, atendidas em ambulatório de pré-natal no período de 2010 a 2012, utilizando-se de dados secundários. A prevalência de anemia foi de 45,6% e nenhuma gestante apresentou anemia severa. Observou-se aumento progressivo das dosagens de colesterol total (p<0,001), HDL (p=0,05), LDL (p<0,001) e triglicérides (p<0,001), com maior aumento dos níveis de triglicérides ao longo dos três trimestres gestacionais. O monitoramento da presença de anemia e dos níveis de lipídeos ao longo da gestação é essencial para a realização de intervenções precoces, quando necessário, evitando complicações gestacionais e desfechos indesejados.

HIV infection is associated with anemia and with changes in the profile of lipids in HIV-infected people. Current retrospective study described the prevalence of anemia and changes in lipid levels in pregnant women living with HIV/AIDS and was performed with 117 pregnant women who were using antiretroviral therapy in pre-natal clinics, between 2010 and 2012, through secondary data. The prevalence of anemia reached 45.6%, although no one had severe anemia. There was a progressive increase in total cholesterol (p<0.001), HDL (p=0.05), LDL (p<0.001) and triglycerides (p<0.001), with greater increase in triglycerides levels throughout pregnancy. Monitoring anemia and lipid levels during pregnancy is crucial for early interventions since undesirable complications and unwanted results are avoided.

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O uso de drogas ilícitas na gravidez é um problema complexo de cunho social e de saúde pública. Com ocorrência crescente na população mundial, resulta no aumento significativo da morbiletalidade materno-fetal, com maiores taxas da exposição às drogas e da síndrome de abstinência neonatal, além de prejuízos no desenvolvimento subsequente das crianças expostas a tais substâncias. Em virtude da variedade de fatores sociais, psicossociais, comportamentais e biomédicos que estão implicados nos resultados neonatais adversos, as usuárias devem receber orientações acerca dos riscos periconcepcionais, anteparto e pósparto causados pelas drogas de abuso. Idealmente, a assistência pré-natal deve ser realizada por uma equipe multidisciplinar. Os tocoginecologistas têm a obrigação ética de aprender e utilizar protocolos para rastreio universal do uso das substâncias ilegais, empreender intervenções iniciais e encaminhar as usuárias e seus familiares para tratamento médico especializado. A construção de uma relação médico-paciente desprovida de preconceitos e baseada em confiança recíproca é também pré-requisito fundamental. A frequência das consultas pré-natais e a avaliação da vitalidade fetal devem ser pautadas pela análise constante e individualizada dos riscos, segundo as diretrizes de assistência às gestações de alto risco. Após o parto, o seguimento das mães, dos recém-nascidos e de suas famílias deve prosseguir em serviços devidamente capacitados.(AU)

Illicit drugs use in pregnancy is a complex social and public health issue. As a growing problem worldwide, it results in significant increase of maternal and fetal morbidity and mortality, with higher rates of drug exposure and neonatal abstinence syndrome, besides loss in the subsequent development of children exposed to such substances. Due to the variety of social, psychosocial, behavioral and biomedical factors that are implicated in adverse neonatal outcomes, users should receive guidance regarding conception, antepartum and postpartum risks caused by illicit drugs. Ideally, prenatal care should be performed by a multidisciplinary team. Obstetricians and gynecologists have an ethical obligation to learn and utilize universal screening protocols for the use of illegal substances, undertake initial interventions and refer users and their families for specialized medical treatment. The construction of a non-judgemental physician-patient relationship based on reciprocal trust is also a fundamental prerequisite. The frequency of antenatal visits and assessment of fetal well-being must be guided by constant and individualized analysis of risks, according to the guidelines of care for high-risk pregnancies. After birth, the follow-up of mothers, newborns and their families should continue in properly prepared health care services.(AU)

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Entre as complicações de longo prazo da operação cesariana, destacam-se o acretismo placentário (placenta acreta, increta e percreta) e, mais recentemente, a implantação embrionária na cicatriz uterina de cesárea prévia. A denominada gravidez ectópica em cicatriz de cesárea persiste como um evento pouco divulgado em função da sua raridade; porém, apresenta incidência crescente devido principalmente ao aumento global das taxas de cesariana. Os atrasos no diagnóstico e no tratamento podem resultar em ruptura uterina, hemorragia grave, necessidade de histerectomia e elevada mortalidade materna. Dessa forma, os objetivos principais na condução dos casos de gravidez ectópica em cicatriz de cesárea devem incluir o diagnóstico ultrassonográfico precoce e acurado e a prevenção de hemorragias graves, além da preservação da fertilidade. Entretanto, devido à sua raridade, ainda não há consenso acerca da melhor forma de tratamento dessa complicação.(AU)

Among the long-term complications of cesarean section stand out the pathologically adherent placenta (accreta, increta and percreta) and, more recently, the embryonic implantation in the uterine scar from previous cesarean. The so-called cesarean scar ectopic pregnancy remains a little known event due to its rarity. But it shows increasing incidence due mainly to the overall increase in cesarean rates. The delay in diagnosis and treatment can result in uterine rupture, severe hemorrhage, need for hysterectomy and high maternal mortality. Thus, the main objectives in the management of cesarean scar ectopic pregnancy should include early and accurate ultrasound diagnosis and prevention of severe blood loss, and the preservation of fertility. However, due to its rarity, there is no consensus about the best treatment for this complication.(AU)

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A paralisia cerebral é a causa mais comum de deficiência motora na infância. É uma doença complexa e de caráter não progressivo, que se caracteriza por distúrbios motores secundários alesões cerebrais ou a anomalias oriundas das fases iniciais de desenvolvimento do cérebro. O fator de risco mais importante para paralisia cerebral é o nascimento pré-termo, cuja incidência tem aumentado significativamente. Como consequência, a ocorrência da paralisia cerebral também tem aumentado, a despeito da melhoria da sobrevida dos fetos pré-termos. O risco da paralisia cerebral é tanto maior quanto menores a idade gestacional e o peso ao nascimento. Dessa forma, estratégias que se mostrarem efetivas para reduzir a paralisia cerebral nesses recém-nascidos deveriam ser implementadas com o objetivo de diminuir os seus efeitos danosos nos indivíduos e suas famílias, nos serviços de saúde e na sociedade como um todo. O sulfato de magnésio tem se mostrado como um promissor agente neuroprotetor fetal. Desde a década de 1990, estudos resultantes das suas indicações para prevenção das convulsões eclâmpticas ou para tocólise têm evidenciado uma redução nas taxas de paralisia cerebral e leucomalácia periventricular em prematuros. Publicações mais recentes, incluindo diretrizes internacionais, têm avançado na recomendação sobre os regimes terapêuticos e na construção de algoritmos para utilização do sulfato de magnésio como agente neuroprotetor fetal.

Cerebral palsy is the most common cause of motor disability in childhood.It is a complex and non-progressive disorder, which is characterized by motor disturbances secundary to brain injuries or anomalies resulting from the early stages of brain development. The most important risk factor forthe occurrence of cerebral palsy is preterm birth, which has increased significantly. As a result, the incidence of cerebral paralysis has also increased despite the improvement in the survival of preterm fetuses. The risk of cerebral palsy increases with the reduction of gestational age and birth weight. Thus, strategies that have proved effective in reducing cerebral palsy in these infants should be implemented in order to decrease their harmful effects on individuals and their families, on health services and society as a whole. Magnesium sulfate has been shown as a promising fetal neuroprotective agent. Since the 1990s, studies arising from its indications for prevention of eclamptic seizures or tocolysis have shown a reduction in the rates of cerebral palsy and periventricular leukomalacia in preterm infants. More recent publications, including international guidelines,have advanced in the recommendation on treatment regimens and the construction of algorithms for use of magnesium sulfate as a fetal agent.

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A infecção pelo estreptococo β-hemolítico do grupo B (EGB) ou Streptococcus agalactiae persiste como uma causa líder de morbimortalidade perinatal. A antibioticoprofilaxia da infecção pelo EGB, baseada no rastreio universal em gestações de 35 a 37 semanas, é mais efetiva do que a estratégia baseada em fatores de risco. A seleção do antibiótico deve se basear na suscetibilidade da cepa do EGB e na história materna de alergia ao medicamento. A penicilina G, administrada por via endovenosa (≥4 horas), continua sendo a droga de escolha para a profilaxia intraparto, enquanto a ampicilina é uma alternativa aceitável. A cefazolina é recomendada para gestantes alérgicas à penicilina, as quais apresentam baixo risco de anafilaxia, enquanto a clindamicina e a eritromicina são indicadas para os casos com alto risco de anafilaxia. A vancomicina deve ser utilizada nas gestantes alérgicas à penicilina, quando houver resistência à clindamicina e à eritromicina ou quando a sensibilidade a essas drogas for desconhecida. No entanto, devido à persistência da morbimortalidade perinatal e ao surgimento de novos dados relevantes nas áreas de epidemiologia, obstetrícia, neonatologia, microbiologia, biologia molecular e farmacologia, em 2010, o Centers of Disease Control and Prevention (CDC) publicou uma terceira revisão das suas diretrizes sobre a doença causada pelo EGB. Este artigo de atualização propõe-se a divulgar de forma comentada e sintética, baseada prioritariamente em algoritmos, as recentes diretrizes do CDC sobre o tema

Group B streptococcus (GBS) or Streptococcus agalactiae remains as a leading cause of perinatal morbidity and mortality. The antibiotic prophylaxis of GBS infection, based on universal screening in pregnancies from 35 to 37 weeks, is more effective than a strategy based on risk factors. The choice of antibiotic should be based on the susceptibility of the strain of GBS and on the maternal history of allergy to the medicine. Penicillin G, administered intravenously (≥4 hours), remains the drug of choice for intrapartum prophylaxis, while ampicillin is an acceptable alternative. Cefazolin is recommended for pregnant women allergic to penicillin, who present low risk of anaphylaxis, while clindamycin and erythromycin are recommended for cases with high risk of anaphylaxis. Vancomycin should be used in pregnant women allergic to penicillin when there is resistance to erythromycin and clindamycin, or the sensitivity to these drugs is unknown. However, due to the persistence of perinatal morbidity and mortality and the emergence of new relevant data in the s of epidemiology, obstetrics, neonatology, microbiology, molecular biology and pharmacology, in 2010, the Centers for Disease Control and Prevention (CDC) published a third revision of the guidelines disease caused by GBS. This update article aims at disseminating the synthetic form - primarily based on algorithms - and commenting on these recent CDC guidelines

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OBJETIVOS: avaliar a evolução da adequação do processo de atendimento às gestantes usuárias do Sistema Único de Saúde (SUS) e consolidar metodologia para monitoramento da assistência pré-natal. MÉTODOS: estudo de séries temporais múltiplas, com auditoria em cartões de gestantes que realizaram pré-natal em município do Sudeste brasileiro (Juiz de Fora, Minas Gerais) nos semestres iniciais de 2002 e 2004 (370 e 1.200 cartões, respectivamente) e utilizaram o SUS no atendimento ao parto a termo (p < 0,05). Obedeceu-se a uma sequência em três níveis complementares: utilização do pré-natal (início e número de atendimentos) no nível 1; utilização do pré-natal e procedimentos clínico-obstétricos obrigatórios em uma consulta pré-natal [aferições de pressão arterial (PA), peso, altura uterina (AU), idade gestacional (IG), batimentos cardiofetais (BCFs) e apresentação fetal] no nível 2; e utilização, procedimentos clínico-obstétricos obrigatórios e exames laboratoriais básicos, segundo o Programa de Humanização no Pré-natal e Nascimento/PHPN [tipagem ABO/Rh, hemoglobina/hematócrito (Hb/Htc), VDRL, glicemia e exame comum de urina] no nível 3. RESULTADOS: confirmou-se a alta cobertura pré-natal (99 por cento), aumento da média de consultas/gestante (6,4 versus 7,2 por cento) e decréscimo da idade gestacional na primeira consulta (17,4 versus 15,7 semanas). Aumentaram significativamente os registros adequados dos procedimentos e exames (exceções: apresentação fetal e tipagem sanguínea): PA (77,8 versus 83,9 por cento); peso (75,4 versus 83,5 por cento); AU (72,7 versus 81,3 por cento); IG (58,1 versus 71,5 por cento); BCFs (79,5 versus 86,7 por cento); Hb/Htc (14,9 versus 29 por cento), VDRL (11,1 versus 20,7 por cento), glicemia (16,5 versus 29,0 por cento) e urinálise (13,8 versus 29,8 por cento). Consequentemente, ocorreu melhoria significativa (p < 0,001) da adequação entre 2002 e 2004: 27,6 versus 44,8 por cento (nível 1); 7,8 versus 15,4 por cento (nível 2); 1,1 versus 4,5 por cento (nível 3). O atendimento na maioria dos serviços/equipes municipais apresentou evolução semelhante. CONCLUSÕES: a persistência da baixa adequação, apesar da boa cobertura e da implantação do PHPN, confirmou a necessidade de incrementar a adesão dos gestores, profissionais de saúde e usuárias às normas/rotinas do atendimento, incluindo a institucionalização de um programa de monitoramento da assistência pré-natal.

PURPOSE: to evaluate the evolution of adequacy of the care process among pregnant users of the Brazilian Single Health System (SUS, acronym in Portuguese) and to consolidate a methodology for monitoring the prenatal care. METHODS: this is a multiple time series study with auditing of prenatal cards of pregnant women who were attended for prenatal care in a city of the Brazilian Southeast (Juiz de Fora, Minas Gerais) in the initial semesters of 2002 and 2004 (370 and 1,200 cards, respectively) and gave birth using SUS services in term pregnancies (p < 0.05). A three complementary level sequence was respected: utilization of prenatal care (beginning and number of visits) at level 1; utilization of prenatal care and obligatory clinical-obstetric procedures during prenatal visits (assessment of blood pressure (BP), weight, uterine fundal height (FH), gestational age (GA), fetal heart rate (FHR) and fetal presentation) at level 2; and utilization of prenatal care, obligatory clinical-obstetric procedures and basic laboratory tests, according to the Humanization Program of Prenatal Care and Birth (PHPN, acronym in Portuguese) (ABO/Rh, hemoglobin/hematocrit (Hb/Htc), VDRL, glycemia and urinalisys) at level 3. RESULTS: it was confirmed the high prenatal care coverage (99 percent), the increased mean number of visits per pregnant woman (6.4 versus 7.2 percent) and the decreased gestational age at the time of the first visit (17.4 versus 15.7 weeks). The proper registration of procedures and exams (exceptions: fetal presentation and blood typing) has significantly increased: BP (77.8 versus 83.9 percent); weight (75.4 versus 83.5 percent); FH (72.7 versus 81.3 percent); GA (58.1 versus 71.5 percent); FHR (79.5 versus 86.7 percent); Hb/Htc (14.9 versus 29 percent), VDRL (11.1 versus 20.7 percent), glycemia (16.5 versus 29 percent) and urinalisys (13.8 versus 29.8 percent). As a result, there was significant (p < 0.001) improvement of the adequacy between 2002 and 2004: 27.6 versus 44.8 percent (level 1); 7.8 versus 15.4 percent (level 2); 1.1 versus 4.5 percent (level 3). This trend was also noted in care provided by the majority of the municipal services/teams. CONCLUSIONS: the persistence of low adequacy, despite good coverage and PHPN implementation, confirmed the need to increase health managers, professionals and users' compliance with the rules and routines of care, including the institutionalization of a monitoring program of prenatal care.

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