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Abstract Objective This study aimed to investigate the effects of the presence of subchorionic hematoma (SH) in early pregnancies with threatened miscarriage (TM) on levels of first-trimester maternal serum markers, pregnancy-associated plasma protein-A (PAPP-A), and free β-human chorionic gonadotropin (β-hCG) levels. Methods The data of TM cases with SH in the first trimester between 2015 and 2021 were evaluated retrospectively. The data of age and gestational age-matched TM cases without SH were also assessed to constitute a control group. Demographic characteristics, obstetric histories, ultrasonographic findings, and free β-hCG and PAPP-A levels of the groups were compared. Results There were 119 cases in the study group and 153 cases in the control group. The median vertical and longitudinal lengths of the SH were 31 mm and 16 mm. The median age of both groups was similar (p=0.422). The MoM value of PAPP-A was 0.088 (.93) in the study group and 0.9 (0.63) in the control group (p=0.519). Similarly, the MoM value of free β-hCG was 1.04 (0.78) in the study group and 0.99 (0.86) in the control group (p=0.66). No significant relationship was found in the multivariate analysis between free β-hCG MoM, PAPP-A MoM, age, gravida, and vertical and longitudinal lengths of the hematoma (p>0.05). Conclusion The level of PAPP-A and free β-hCG were not affected by the SH. Therefore, these markers can be used reliably in TM cases with SH for the first-trimester fetal aneuploidy screening test.

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OBJECTIVE: To describe and compare the annual success rates of medical treatment in the analyzed period and to evaluate the associated factors. METHODS: Retrospective study with 158 women with tubal pregnancy followed up over 17 years. Statistical analysis was performed using the Cochran-Armitage test, the χ2 test, Mann-Whitney test, and multiple logistic regression. RESULTS: The success rate was 47.4%. There was a trend of significant change in the success rate of clinical treatment over time (Z = 2.01, P = 0.044); it was associated to undergoing treatment between 2012 and 2017 (P = 0.028), the absence of abdominal pain (P = 0.020), receiving a higher dose of methotrexate (P < 0.001), and less time hospitalized (P < 0.001). In the final statistical model, we observed that receiving a higher dose of methotrexate (P = 0.025, odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.06), having a low serum ß-HCG concentration before treatment (P = 0.003, OR 0.87, 95% CI 0.79-0.95), and not having abdominal pain (P = 0.004, OR 4.26, 95% CI 1.61-11.28) were factors associated with a higher chance of successful clinical treatment for tubal pregnancy. CONCLUSION: A greater chance of success was observed among women undergoing clinical treatment from 2012 onwards, who used higher doses of methotrexate, were asymptomatic at admission, and had low concentrations of ß-hCG.

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SUMMARY OBJECTIVE: The aim of this study was to investigate serum afamin levels in the first and third trimesters in preeclampsia. METHODS: Serum samples from 118 patients in the first and third trimesters were analyzed. Serum samples were collected from pregnant women who had enrolled in the first trimester. Blood was then collected from pregnant women who had developed preeclampsia and from healthy controls in the third trimester. The collected blood samples were resolved for analysis, and serum afamin concentrations were measured in the first and third trimesters. Preeclampsia and healthy controls were compared. RESULTS: There was no significant difference between the control and preeclampsia groups in terms of age, body mass index, and smoking. Afamin levels in the first and third trimesters were higher in the preeclampsia group than in the control group (p<0.05). In the subgroup analysis of the preeclampsia group, afamin levels were higher in the early-onset preeclampsia group than in the late-onset preeclampsia group in the first and third trimesters (p<0.05). In the receiver operating characteristic analysis afamin levels were 96.23 ng/mL in the first trimester and 123.57 ng/mL in the third trimester as cut-off values for preeclampsia. CONCLUSION: Serum afamin levels are useful for predicting preeclampsia in the first trimester in pregnant women and can be used in clinical practice as a supportive biomarker for the diagnosis of preeclampsia in the third trimester. Meta-analyzes are needed to investigate the effect of afamin levels in the prediction and diagnosis of preeclampsia and to determine the cut-off value.

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Abstract Objective To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital. Methods Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression. Results In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36). Conclusion there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.

Resumo Objetivo Avaliar as diferentes opções de tratamento para gravidez ectópica e a frequencia de complicações graves em um hospital universitário. Métodos Estudo observacional com mulheres com gravidez ectópica admitidas no Hospital da Mulher da UNICAMP, no Brasill, entre 01/01/2000 e 31/12/2017. As variáveis de desfecho foram o tipo de tratamento (primeira escolha) e a presença de complicações graves. As variáveis independents foram dados clínicos e sociodemográficos. A análise estatística foi realizada pelo teste de Cochran-Armitage, teste de qui-quadrado, teste de Mann-Whitney e Regressão de Cox Múltipla. Resulados No total, 673 mulheres foram incluídas no estudo. A idade médica foi de 29.0 anos (± 6.1) e a idade gestacional media foi de 7.7 (± 2.5). A frequencia de tratamento cirúrgico diminuiu significativamente ao longo dos anos(z = -4.69; p < 0.001). Simultaneamente, houve um aumento da frequencia do tratamento clínico(z = 4.73; p < 0.001). Setenta e uma mulheres (10.5%) desenvolveram algum tipo de complicação grave. No modelo estatístico final, a prevalência de complicações graves foi maior nas mulheres que tiveram diagnóstico de gestação ectópica rota à admissão (PR = 2.97; 95%CI: 1.61-5.46), que não apresentaram sangramento vaginal (PR = 2.45; 95%CI: 1.41-4.25), sem antecedentes de laparotomia/laparoscopia (PR = 6.69; 95%CI: 1.62-27.53), com gravidez ectópica não-tubária (PR = 4.61; 95%CI: 1.98-10.74), e não tabagistas (PR = 2.41; 95%CI: 1.08-5.36). Conclusão Houve uma mudança na escolha do primeiro tratamento indicado nos casos de gravidez ectópica durante o período analisado. Os fatores inerentes a doença relacionados a maior dificuldade de tratamento foram associados a maior frequencia de complicações graves.

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RESUMEN Objetivo: Determinar la relación entre la anemia materna del primer trimestre y el bajo peso al nacer de cuatro centros de salud maternos de Lima-Sur durante el 2019. Materiales y métodos: Se realizó un estudio cohorte retrospectivo de una base de datos secundaria donde se incluyeron gestantes atendidas en cuatro Centros de Salud con nivel de complejidad I-4 de Lima-Sur; cuyos partos se registraron durante el 2019, excluyendo a los recién nacidos pretérmino. Una hemoglobina del primer trimestre <11 g/dl se definió como anemia y un peso <2500 g como bajo peso al nacer. Se calculó la incidencia acumulada según anemia y se halló el riesgo relativo (RR) ajustado a potenciales confusores. Resultados: Se incluyó 221 gestantes y el 76 % tuvo una edad entre 18 a 35 años. Un 42 % fue primigesta, un 52 % presentó exceso de peso y el 60 % realizó 6 o más controles prenatales. Un 23,5 % de gestantes presentó anemia en el primer trimestre y se halló una incidencia de 2,7 % casos con bajo peso al nacer. La anemia del primer trimestre elevó en 11 veces la incidencia de recién nacidos con bajo peso, independiente de la edad, índice de masa corporal y paridad (RR ajustado = 11,1; IC 95 % 1,3 - 97,2; p=0,029). Conclusiones: De la muestra estudiada, una de cada cuatro gestantes presenta anemia durante el primer trimestre incrementando la incidencia acumulada de tener un neonato con bajo peso hasta en 11 veces.

ABSTRACT Objective: To determine the relationship between maternal anemia in the first trimester of pregnancy and low birth weight in four mother-and-child-health centers in Southern Lima during 2019. Material and methods: A retrospective cohort study from a secondary database was performed, where pregnant women from 4 middle-complexity Health Centers from Southern Lima were included. Deliveries took place during 2019, excluding preterm newborns. First trimester hemoglobin concentration <11 g/dL was defined as anemia and birth weight <2500 g was defined as low birth weight. Cumulative incidence for anemia was calculated, and relative risk (RR) adjusted for potential confounders was also calculated. Results: Two hundred and twenty one pregnant women were included. Seventy-six per cent were between 18 and 35 years old. Forty-two percent were primigravida, fifty-two percent had excess body weight, and sixty percent had six or more prenatal control visits. Nearly one quarter (23,5%) of all pregnant women had anemia during the first trimester, and there were 2,7% cases of low birth weight. Anemia during the first trimester of pregnancy increased 11 times the frequency of newborns with low birth weight, independently of age, body mass index, and parity (adjusted RR = 11,1; 95% CI: 1,3-97,2; p= 0,029). Conclusions: In the studied sample, one out of four pregnant women had anemia during the first trimester of pregnancy, increasing up to 11 times the cumulative incidence for having a neonate with low birth weight.

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Resumen ANTECEDENTES: El acretismo es la adherencia anormal de la placenta al miometrio debida a la ausencia parcial o total de la decidua basal y desarrollo incompleto de la capa de Nitabuch. CASO CLÍNICO: Paciente de 45 años, con antecedente de tres embarazos, dos abortos, una cesárea y amenorrea de 12 semanas. El padecimiento actual se inició dos días antes, con sangrado transvaginal intermitente. A su ingreso a Urgencias se encontró con datos de bajo gasto e inmediatamente pérdida del estado de alerta; tensión arterial 40-20 mmHg, frecuencia cardiaca de 125 lpm. La parte posterior del cuello uterino se encontró dehiscente, con sangrado transvaginal abundante, prueba inmunológica de embarazo positiva, fracción β-GCH de 2878 mU/mL. Al asociar los datos de la exploración física se integró el diagnóstico de aborto incompleto y se ingresó a la unidad tocoquirúrgica, para legrado uterino instrumentado. CONCLUSIONES: De acuerdo con las búsquedas bibliográficas, todo indica que éste es el primer reporte mexicano de un caso de acretismo placentario en el primer trimestre del embarazo. Se sugiere la búsqueda de factores de riesgo que permitan la sospecha y faciliten establecer el diagnóstico de acretismo placentario a partir de las primeras semanas de embarazo para evitar desenlaces obstétricos fatales.

Abstract BACKGROUND: Accretism is the abnormal adherence of the placenta to the myometrium due to partial or total absence of the basal decidua and incomplete development of the Nitabuch's layer. CLINICAL CASE: 45-year-old patient, with a history of three pregnancies, two abortions and one cesarean section; amenorrhea of 12 weeks. The current condition started two days earlier, with intermittent transvaginal bleeding. On admission to the ED she was found to have low output and immediate loss of alertness; blood pressure 40-20 mmHg, heart rate 125 bpm. The posterior cervix was found to be dehiscent, with abundant transvaginal bleeding, positive immunological pregnancy test, HCG fraction 2878 mU/mL. By associating the physical examination data, the diagnosis of incomplete abortion was integrated, and she was admitted to the tocosurgical unit, for instrumented uterine curettage. CONCLUSIONS: According to the bibliographic searches, everything indicates that this is the first Mexican report of a case of placental accretism in the first trimester of pregnancy. It is suggested to search for risk factors that allow suspicion and facilitate the diagnosis of placental accretism from the first weeks of pregnancy to avoid fatal obstetric outcomes.

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Resumen ANTECEDENTES: En Obstetricia, las imágenes en espejo son artefactos ecográficos infrecuentes que, potencialmente, pueden confundirse con embarazos heterotópicos y propiciar errores diagnósticos e intervenciones iatrógenas. Estas imágenes ficticias se generan por la existencia de una superficie reflectora como, por ejemplo, el intestino distendido o la vejiga repleta. CASO CLÍNICO: Paciente de 39 años, con embarazo por fertilización in vitro, que asiste a evaluación ecográfica del primer trimestre. En la ecografía de rutina a las 11 semanas se observó una imagen en espejo y en la resonancia magnética: útero gestante con una estructura retrouterina hipoecoica, sin feto en el interior. La imagen ecográfica en espejo volvió a reproducirse en el tercer trimestre. El embarazo llegó a término y finalizó por vía abdominal, sin que pudieran demostrarse las estructuras que se advirtieron en la resonancia magnética. CONCLUSIONES: Las imágenes en espejo se han reportado en ultrasonidos de diversas localizaciones pero pocos en la Obstetricia. Todo hizo suponer que la superficie reflectora fue la estructura hipoecoica retrouterina observada, transitoriamente, en la resonancia magnética.

Abstract BACKGROUND: In obstetrics, ultrasonic artifactual mirror images are infrequent, but potentially dangerous since they can be mistakenly interpreted as heterotopic pregnancies, precluding diagnostic errors and iatrogenic interventions. These images require a reflection surface such as dilated bowl or plenty bladder to be generated. OBJECTIVE: We report a first trimester scan ghost twin, diagnosed since first trimester of pregnancy. CLINICAL CASE: 39-year-old patient, with pregnancy due to in vitro fertilization, who attends ultrasound evaluation of the first trimester. Routine ultrasound at 11 weeks showed a mirror image and magnetic resonance imaging: a pregnant uterus with a hypoechoic retrouterine structure, with no fetus inside. The ultrasound mirror image reproduced again in the third trimester. The pregnancy came to an end and ended by abdominal route, without being able to demonstrate the structures that were noticed on the MRI. CONCLUSION: Very few reports of obstetric ultrasound mirror images have been reported. We hypothesize that the transient retrouterine hypoecogenic structure observed by MRI was the reflective surface that create the ghost twin image.

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PURPOSE: The aim of this study was to evaluate whether the presence of an intrauterine hematoma (IUH) on an early pregnancy ultrasound scan showing a live fetus was related to adverse perinatal outcomes. METHODS: We performed a retrospective cohort study to evaluate pregnant women who underwent an ultrasound examination in early pregnancy, between 6 weeks 0 days and 10 weeks 6 days. We compared the perinatal outcomes between women with and without firsttrimester IUH using the Mann-Whitney and Fisher exact tests. Furthermore, we performed a stepwise regression analysis to identify possible predictors of miscarriage among maternal characteristics, ultrasound parameters, and IUH. RESULTS: During the study period, data from 783 pregnancies were included, and the incidence of IUH was 4.5% (35 of 783). We observed a higher proportion of miscarriage following the scan (28.6% vs. 10%, P=0.003) and a larger yolk sac diameter during the scan (4.8 mm vs. 3.8 mm, P<0.001) in the pregnant women with first-trimester IUH. There was no significant difference regard the prevalence of low birth weight (LBW; P=0.091), very LBW (P=0.370), or extremely LBW (P=0.600) between cases with IUH and without IUH, the cesarean section rate (68% vs. 81%, P=0.130), preterm delivery (16% vs. 16%, P>0.999), or the incidence of first-trimester vaginal bleeding (31% vs. 20%, P=0.130). Moreover, heart rate (HR) was the only variable that predicted miscarriage with statistical significance (P=0.017). CONCLUSION: Women with first-trimester IUH had a higher risk of miscarriage after the ultrasound scan. HR was the only variable that predicted miscarriage with statistical significance.

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Background First trimester prenatal care (FTPNC) is associated with improved birth outcomes. U.S.-Mexico border Hispanic women have lower FTPNC than non-border or non-Hispanic women. This study aimed to identify (1) what demographic, knowledge and care-seeking factors influence FTPNC among Hispanic women in border counties served by five Healthy Start sites, and (2) what FTPNC barriers may be unique to this target population. Healthy Starts work to eliminate disparities in perinatal health in areas with high poverty and poor birth outcomes. Methods 403 Hispanic women of reproductive age in border communities of California, Arizona, New Mexico and Texas were surveyed on knowledge and behaviors related to prenatal care (PNC) and basic demographic information. Chi square analyses and logistic regressions were used to identify important relationships. Results Chi square analyses revealed that primiparous women were significantly less likely to start FTPNC than multiparous women (χ2 = 6.8372, p = 0.0089). Women with accurate knowledge about FTPNC were more likely to obtain FTPNC (χ2 = 29.280, p < .001) and more likely to have seen a doctor within the past year (χ2 = 5.550, p = .018). Logistic regression confirmed that multiparity was associated with FTPNC and also that living in Texas was negatively associated with FTPNC (R2 = 0.066, F(9,340) = 2.662, p = .005). Among 27 women with non-FTPNC, barriers included late pregnancy recognition (n = 19) and no medical insurance (n = 5). Conclusions This study supports research that first time pregnancies have lower FTPNC, and demonstrated a strong association between delayed PNC and late pregnancy recognition. Strengthened investments in preconception planning could improve FTPNC in this population.

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ABSTRACT The ovarian hyperstimulation syndrome is the combination of increased ovarian volume, due to the presence of multiple cysts and vascular hyperpermeability, with subsequent hypovolemia and hemoconcentration. We report a case of spontaneous syndrome in a singleton pregnancy. This was a spontaneous pregnancy with 12 weeks of gestational age. The pregnancy was uneventful until 11 weeks of gestational age. After that, the pregnant woman complained of progressive abdominal distention associated with abdominal discomfort. She did not report other symptoms. In the first trimester, a routine ultrasonography showed enlarged ovaries, multiples cysts and ascites. Upon admission, the patient was hemodynamically stable, her serum β-hCG was 24,487mIU/mL, thyroid-stimulating hormone was 2.2µUI/mL and free T4 was 1.8ng/dL. All results were within normal parameters. However, levels of estradiol were high (10,562pg/mL). During hospitalization, she received albumin, furosemide and prophylactic dose of enoxaparin. The patient was discharged on the sixth hospital day.

RESUMO A síndrome de hiperestimulação ovariana é a combinação do aumento dos ovários, devido à presença de múltiplos cistos e de hiperpermeabilidade vascular, com subsequente hipovolemia e hemoconcentração. Relata-se um caso de síndrome espontânea em uma gestação única. Trata-se de gravidez espontânea com 12 semanas de idade gestacional. A gravidez ocorreu sem intercorrências até 11 semanas de idade gestacional. Após, a gestante passou a se queixar de distensão abdominal progressiva, associada com desconforto abdominal. A paciente não relatava outros sintomas. A ultrassonografia de rotina no primeiro trimestre mostrou ovários aumentados com múltiplos cistos e ascite. No momento da internação, a paciente apresentava-se hemodinamicamente estável, com β-hCG sérico de 24.487mUI/mL, hormônio estimulante da tireoide de 2,2µUI/m e T4 livre de 1,8ng/dL, ou seja, valores dentro dos parâmetros normais. Porém, os níveis de estradiol estavam elevados (10.562pg/mL). Durante a internação, a paciente recebeu albumina, furosemida e enoxaparina profilática. A alta hospitalar ocorreu no sexto dia de internação.

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OBJETIVO: Avaliar a artéria subclávia direita durante a ecografia do primeiro trimestre, descrever a técnica para a sua avaliação e, em caso de identificação de artéria subclávia direita aberrante (ARSA), determinar sua associação com alterações cromossómicas e/ou malformações cardíacas e sua orientação. MÉTODOS: Estudo prospectivo que consistiu na avaliação da artéria subclávia direita no primeiro trimestre (comprimento crânio caudal entre 45 e 84 milímetros), em todas as gestações únicas, consecutivas, por um único examinador, ecógrafo Voluson E8 (GE Healthcare, Zipf, Áustria) com sonda transabdominal RAB 4-8-D, 2 a 8 MHz, por um período não superior a 2 minutos, numa população geral de baixo risco. Com a ajuda do power/color Doppler, a artéria subclávia direita foi classificada como normal ou aberrante. Foi utilizada análise de regressão estatística (IBM SPSS Statistics for Windows, versão 20.0) para estudar o grau de associação entre a falha na avaliação/classificação da artéria subclávia direita e o comprimento crânio-caudal fetal e o índice de massa corporal materno. RESULTADOS: A mediana da idade materna foi de 30 anos (variando entre 17 e 43 anos) e a mediana do tempo de gestação no momento da avaliação da artéria subclávia direita foi de 12 semanas de gestação (variando entre 11 e 13 semanas de gestação). A avaliação da artéria subclávia direita foi possível em 138/176 (78,4%) dos casos. ARSA foi diagnosticada em um único caso (0,7%). Esse feto com ARSA também apresentou um foco hiperecogênico no ventrículo cardíaco esquerdo. Foi realizada ecocardiografia fetal às 16 semanas de gestação, que confirmou o diagnóstico de ARSA e foco hiperecogênico. A amniocentese revelou cariótipo normal, 46, XX. CONCLUSÃO: É possível fazer o diagnóstico de ARSA na ecografia do primeiro trimestre. O nosso único caso de ARSA apresentou um cariótipo normal sem malformações cardíacas associadas. .

PURPOSE: To determine the feasibility of evaluation of the right subclavian artery during the first trimester ultrasound scan, as well as to describe the technique for its evaluation and, in case of aberrant right subclavian artery (ARSA) identification, to determine its association with chromosomal abnormalities and/or cardiac malformations and its management. METHODS: A prospective study for evaluation of the right subclavian artery during the first trimester ultrasound scan (crown-to-rump length between 45 and 84 mm), in all consecutive single pregnancies, by a single examiner, using a Voluson E8 system (GE Healthcare, Zipf, Austria) with a 2 to 8 MHz RAB 4-8-D transabdominal probe, within a short period of time (less than 2 minutes), in a general low risk population. Color and/or power Doppler flow mapping was used to classify the right subclavian artery as normal or aberrant. Regression analysis with the IBM SPSS Statistics software for Windows, version 20.0 was used to determine the significance of the association between failure to examine/classify the right subclavian artery and both fetal crown-rump length and maternal body mass index. RESULTS : Median maternal age was 30 years (range: 17-43 years) and median gestational age at the time of evaluation of the right subclavian artery was 12 weeks (range: 11-13 weeks). The evaluation of the right subclavian artery was successful in 138/176 (78.4%) of the cases. ARSA was diagnosed in a single case (0.7%). This fetus with ARSA also presented a hyperechogenic focus on the left cardiac ventricle. Fetal echocardiography at 16 weeks of gestation was performed and confirmed ARSA and the hyperechogenic focus. Amniocentesis revealed a normal 46, XX karyotype. CONCLUSION: ARSA can be identified during a routine first trimester ultrasound scan. Our single ARSA case had a normal karyotype and no associated cardiac malformations. .

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OBJECTIVES: to analyze the Pelvic Floor Muscle Strength (PFMS) of pregnant women with one or more vaginal or cesarean deliveries; to compare the PFMS of these with pregnant women with the PFMS of primiparous women. METHODS: cross-sectional study with women up to 12 weeks pregnant, performed in Itapecerica da Serra, São Paulo state, from December 2012 to May 2013. The sample consisted of 110 pregnant women with one or more vaginal deliveries or cesarean sections and 110 primigravidae. The PFMS was evaluated by perineometry (Peritron(tm)) and vaginal digital palpation (modified Oxford scale). RESULTS: the average PFMS in pregnant women with a history of vaginal delivery or cesarean section was 33.4 (SD=21.2) cmH2O. From the Oxford scale, 75.4% of the pregnant women with previous vaginal or cesarean deliveries presented grade ≤ 2, and 5.5% grade ≥ 4; among the primiparae, 39.9% presented grade ≤ 2, and 50.9% grade ≥ 4, with a statistically significant difference (p<0.001). From the perineometry, there was no statistically significant difference between the PFMS and age, type of delivery, parity, body mass index, and genitourinary tract symptoms, however, there was a statistically significant difference between the pregnant women with and without a history of episiotomy (p=0.04). In the palpation, none of the variables showed a statistically significant difference. CONCLUSION: pregnancy and childbirth can reduce the PFMS. .

OBJETIVOS: analisar a força muscular do assoalho pélvico de gestantes com um ou mais partos normais ou cesarianas; comparar a a força muscular do assoalho pélvico dessas gestantes com a de primigestas. MÉTODO: estudo transversal com gestantes até 12 semanas de gravidez, realizado em Itapecerica da Serra, SP, de dezembro de 2012 a maio de 2013. A amostra foi composta por 110 gestantes, com um ou mais partos normais ou cesarianas e 110 primigestas. A força muscular do assoalho pélvico foi avaliada pela perineometria e palpação digital vaginal (Escala de Oxford modificada). RESULTADOS: a média da força muscular do assoalho pélvico em gestantes com antecedentes de parto normal ou cesariana foi 33,4 (desvio-padrão=21,2) cmH2O. Pela escala de Oxford, 75,4% das gestantes com partos ou cesarianas anteriores apresentaram grau ≤2 e 5,5%, grau ≥4; entre as primigestas, 39,9% apresentaram grau ≤2 e 50,9%, grau ≥4, com diferença estatisticamente significante (p<0,001). Pela perineometria, não houve diferença estatisticamente significante entre a força muscular do assoalho pélvico e idade, tipo de parto, paridade, índice de massa corpórea e sintomas do trato geniturinário, mas houve entre as gestantes com e sem antecedente de episiotomia (p=0,04). Na palpação, nenhuma das variáveis mostrou diferença estatisticamente significante. CONCLUSÃO: a gravidez e o parto podem reduzir a força muscular do assoalho pélvico. .

OBJETIVOS: analizar la Fuerza Muscular del Suelo Pélvico (FMSP) de embarazadas con uno o más partos normales o cesáreas; comparar la FMSP de estas embarazadas con la FMSP de primigestas. MÉTODO: estudio transversal con embarazadas hasta 12 semanas de embarazo, realizado en Itapecerica de la Serra, SP, de diciembre de 2012 a mayo de 2013. La muestra fue de 110 embarazadas con uno o más partos normales o cesáreas y 110 primigestas. La FMSP fue evaluada por la perineometría (Peritron(tm)) y palpación digital vaginal (escala de Oxford modificada). RESULTADOS: el promedio de la FMSP en embarazadas con antecedentes de parto normal o cesárea fue 33,4 (de=21,2) cmH2O. Por la escala de Oxford, 75,4% de las embarazadas con partos o cesáreas anteriores presentaron grado ≤ 2 y 5,5%, grado ≥ 4; entre las primigestas, 39,9% presentaron grado ≤ 2 y 50,9%, grado ≥ 4, con diferencia estadísticamente significativa (p<0,001). Por la perineometría, no hubo diferencia estadísticamente significativa entre la FMSP y edad, tipo de parto, número de partos anteriores, índice de masa corporal y síntomas del tracto genitourinario, pero hubo entre las embarazadas con y sin antecedente de episiotomía (p=0,04). En la palpación, ninguna de las variables mostró diferencia estadísticamente significativa. CONCLUSIÓN: el embarazo y el parto pueden reducir la FMSP. .

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Se presenta el caso de un embrión humano correspondiente al estadio 23 de Carnegie, octava semana, y que pertenece a la Embrioteca de la Facultad de Medicina de Villa Clara, procedente de un aborto voluntario de la gestación por misoprostol, en una mujer de 41 años y con 9,6 semanas de amenorrea, antecedentes de buena salud. El objetivo es informar el hallazgo diagnóstico de polidactilia y sindactilia en edad tan temprana como lo es la octava semana del desarrollo. Se reseñan aspectos básicos y clínicos de ambas malformaciones y se muestra el descubrimiento en imágenes digitales. Se enfatiza en la importancia del estudio morfológico de estos productos, lo cual aportaría juicios de valor al consejo genético en gestaciones futuras.

The case of a human embryo at Carnegie stage 23 (eighth weeks), which belongs to the collection of embryos of the Faculty of Medicine in Villa Clara is presented. It was the result of the elective termination of pregnancy using misoprostol in a 41-year-old woman with 9.6 weeks of amenorrhea and a history of good health. The aim of this paper is to inform the diagnostic finding of polydactyly and syndactyly in a stage as early as the eighth week of development. Basic and clinical aspects of both malformations are described and the finding is shown through digital images. The importance of the morphological study of these products is emphasized, which would provide value judgments to genetic counselling in future pregnancies.

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Resumen El monitoreo ambulatorio de presión arterial es una importante herramienta clínica, ya que mejora el diagnóstico de hipertensión arterial, detecta su presentación enmascarada así como su forma nocturna aislada, al igual que el ascenso matinal exagerado de la presión arterial, situaciones estas con implicancias pronóstico-terapéuticas. Mediante este estudio es posible diagnosticar la hipertensión de túnica blanca, particularmente frecuente en las primeras etapas del embarazo, evitando de esa forma tratamientos innecesarios. Dado que en las mujeres el control de la hipertensión arterial nocturna tiene marcado impacto en la reducción de eventos, este estudio debería ser considerado en todas quienes presentan hipertensión arterial o se tiene sospecha de ello. Todo esto ha llevado a que en el momento actual el monitoreo ambulatorio de presión arterial constituya un valioso aliado en el cuidado de la salud de los pacientes.

Summary Ambulatory blood pressure monitoring is an important clinical tool, as well as improving the diagnosis of hypertension, detect its masked presentation, its isolated nocturnal form and exaggerated morning surge in blood pressure, all situations with therapeutic and prognostic implications. Through this study it is possible to diagnose white coat hypertension, a situation particularly common in early pregnancy, thus avoiding unnecessary treatments. Since in women nocturnal hypertension control has marked impact in reducing events, this study should be considered in all those with hypertension or suspected it. All this makes the ambulatory blood pressure monitoring a valuable associate in patients' health care.

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PURPOSE: To establish reference values for the first trimester uterine artery resistance index (UtA-RI) and pulsatility index (UtA-PI) in healthy singleton pregnant women from Northeast Brazil. METHODS: A prospective observational cohort study including 409 consecutive singleton pregnancies undergoing routine early ultrasound screening at 11 - 14 weeks of gestation was performed. The patients responded to a questionnaire to assess maternal epidemiological characteristics. The left and right UtA-PI and UtA-RI were examined by color and pulsed Doppler by transabdominal technique and the mean UtA-PI, mean UtA-RI and the presence of bilateral protodiastolic notching were recorded. Quartile regression was used to estimate reference values. RESULTS: The mean±standard deviation UtA-RI and UtA-PI were 0.7±0.1 and 1.5±0.5, respectively. When segregated for gestation age, mean UtA-PI was 1.6±0.5 at 11 weeks, 1.5±0.6 at 12 weeks, 1.4±0.4 at 13 weeks and 1.3±0.4 at 14 weeks' gestation and mean UtA-RI was 0.7±0.1 at 11 weeks, 0.7±0.1 at 12 weeks, 0.6±0.1 at 13 weeks and 0.6±0.1 at 14 weeks' gestation. Uterine artery bilateral notch was present in 261 (63.8%) patients. We observed that the 5th and 95th percentiles of the UtA-PI and UtA-RI uterine arteries were 0.7 and 2.3 and, 0.5 and 0.8, respectively. CONCLUSION: Normal reference range of uterine artery Doppler in healthy singleton pregnancies from Northeast Brazil was established. The 95th percentile of UtA-PI and UtA-RI values may serve as a cut-off for future prediction of pregnancy complications studies (i.e., pre-eclampsia) in Northeast Brazil.

OBJETIVO: Estabelecer valores de referência para os índices de resistência (UtA-IR) e de pulsatilidade (UtA-IP) das artérias uterinas em mulheres com gravidezes saudáveis do nordeste do Brasil. MÉTODOS: Um estudo de coorte observacional prospectivo, incluindo 409 gestações únicas consecutivas submetidas a exame de ultrassonografia de rotina entre 11 e 14 semanas de gestação, foi realizado. As pacientes responderam a um questionário para avaliar características epidemiológicas maternas. Os índices UtA-IR e UtA-IP das artérias uterinas esquerda e direita foram examinadas através de Doppler colorido e pulsátil por técnica transabdominal. A média UtA-IP, a média UtA-IR e a presença de incisura protodiastólica bilateral foram registradas. Regressão quartil foi utilizada para estimar os valores de referência. RESULTADOS: A média±desvio-padrão de UtA-IR e UtA-IP foram de 0,7±0,1 e 1,5±0,5, respectivamente. Quando separadas por idade gestacional, a média de UtA-IP foi de 1,6±0,5 com 11 semanas, 1,5±0,6 com 12 semanas, 1,4±0,4 com 13 semanas e 1,3±0,4 em uma gestação de 14 semanas e a média de UtA-IR foi de 0,7±0,1 com 11 semanas, 0,7±0,1 com 12 semanas, 0,6±0,1 com 13 semanas e 0,6±0,1 com 14 semanas de gestação. Incisura bilateral das artérias uterinas estava presente em 261 (63,8%) pacientes. Observou-se que os percentis 5 e 95 de UtA-IP e UtA-IR foram 0,7 e 2,3 e 0,5 e 0,8, respectivamente. CONCLUSÃO: A curva de valores de referência dos índices de dopplervelocimetria das artérias uterinas no primeiro trimestre foi estabelecida para gestações únicas e saudáveis do nordeste do Brasil. Os valores do percentil 95 para os índices UtA-IP e UtA-IR podem servir como ponto de corte para estudos de predição de complicações em gravidezes (por exemplo, pré-eclampsia) no nordeste do Brasil.

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OBJETIVOS: Analisar o desfecho perinatal e pediátrico de fetos que apresentaram translucência nucal (TN) acima do percentil 95 (P95) e cariótipo normal a fim de obter dados que permitam um melhor aconselhamento materno pré-natal. METÓDOS: Análise de fetos em um serviço terciário de obstetrícia apresentaram TN acima do P95 e cariótipo normal entre os anos 2005 e 2011. Analisamos o seguimento ultrassonográfico gestacional, ecocardiografia (ECO) fetal e pós-natal, peso, comprimento e escore de Apgar ao nascimento, além do desenvolvimento neuropsicomotor por meio do Ages and Stages Questionnaire (ASQ) até julho de 2012. RESULTADOS: Durante esse período, foram 116 casos de translucência nucal acima do P95, sendo que em 79 (68%) foi realizado cariótipo fetal. Das análises, 43 foram normais (54,4%) e 36, alteradas (45,6%). Nos fetos com cariótipo normal, houve um abortamento na 15ª semana gestacional com pentalogia de Cantrel, um óbito na 24ª semana com diversas anomalias estruturais, um óbito neonatal sem causa definida e dois casos de comunicação intraventricular (CIV) detectados no ECO fetal. Na avaliação ecocardiográfica pós-natal, persistiu um caso de CIV e foi diagnosticado um caso de comunicação interatrial (CIA) e persistência do canal arterial (PCA). Entre os 40 casos sobreviventes, apenas 1 criança apresentou atraso no desenvolvimento da fala e outra apresentou quadro de autismo. Os demais casos resultaram em desenvolvimento neuropsicomotor normal. CONCLUSÃO: No acompanhamento dos fetos com TN aumentada e cariótipo normal, os pais podem ser mais bem aconselhados de que, frente a um exame morfológico-ecocardiográfico do 2º trimestre sem alterações, a probabilidade de a criança nascer viva e bem é alta (93,5%).

PURPOSE: To analyze the perinatal and pediatric outcome of fetuses that showed nuchal translucency (NT) above the 95th percentile (P95) and a normal karyotype in order to obtain data allowing better maternal prenatal counseling. METHODS: fetuses from a tertiary obstetric service with an NT above P95 and a normal karyotype were analyzed between 2005 and 2011. We analyzed gestational ultrasound follow-up, fetal and postnatal echocardiography (ECHO), weight, length and Apgar score at birth, and neuropsychomotor development by the Ages and Stages Questionnaire (ASQ) up to July 2012. RESULTS: During this period, there were 116 cases of nuchal translucency above the 95th percentile, and the fetal karyotype was determined in 79 of them (68%). Forty-three analyses were normal (54.4%) and 36 were altered (45.6%). Among the fetuses with a normal karyotype, one was miscarried at 15 weeks of gestation with Cantrel pentalogy and one died at 24 weeks with several structural abnormalities. There was one neonatal death of unknown cause and two cases of intraventricular communication (IVC) detected by fetal ECHO. Postnatal echocardiography revealed the persistence of IVC in one case and one case of atrial septal defect (ASD) and patent ductus arteriosus (PDA). Of the 40 surviving children, only 1 showed delayed speech development and another presented autism. The remaining cases resulted in normal neurodevelopment. CONCLUSION: During the monitoring of fetuses with increased NT and a normal karyotype, parents can be best advised that when a 2nd trimester morphological-echocardiography ultrasound study is normal, the probability of the child being born alive and well is high (93.5%).

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OBJETIVO: avaliar os aspectos morfológicos e vasculares do corpo lúteo (CL) por parâmetros ultrassonográficos durante a gestação inicial e sua associação com o abortamento. MÉTODOS: estudo de coorte, prospectivo com 90 gestantes entre 6 e 8 semanas mais 6 dias de gestação. Foram incluídas gestantes de baixo risco, sem doença sistêmica aguda ou crônica, e com concepção espontânea. Critérios de exclusão: uso de medicamentos ou tabagismo, drogas indutoras da ovulação, história de mais de um abortamento, ausência de batimento cardíaco visível no embrião e impossibilidade de visualizar o corpo lúteo. O diâmetro, o volume, os aspectos morfológicos, o índice de resistência e o pico de velocidade sistólica do corpo lúteo foram medidos pela ultrassonografia transvaginal. RESULTADOS: foram incluídas 90 pacientes. A idade variou entre 15 e 41 anos (média de 28,6±5,8 anos). O corpo lúteo foi visualizado em 87 pacientes (96,7 por cento), e 79 pacientes tiveram gestações normais (90,1 por cento), enquanto 8 delas abortaram (9,9 por cento). A comparação entre as gestantes normais e as que sofreram aborto não mostrou diferenças em relação ao diâmetro médio do CL (21,8 versus 20,0 mm; p=0,108, teste de Mann-Whitney), volume médio do CL (4,2 versus 3,0 cm³; p=0,076, teste de Mann-Whitney), índice de resistência médio (0,55 versus 0,58; p=0,220, teste de Mann-Whitney) e velocidade do pico sistólico (15 versus 15 cm/s; p=0,757, teste de Mann-Whitney). Observou-se uma correlação positiva entre a idade materna e o índice de resistência. CONCLUSÕES: nenhuma correlação aparente foi encontrada entre as características morfológicas e vasculares do corpo lúteo nas gestações iniciais normais e nas que evoluíram para o abortamento. versus 3,0 cm³; p=0,076, teste de Mann-Whitney), índice de resistência médio (0,55 versus 0,58; p=0,220, teste de Mann-Whitney) e velocidade do pico sistólico (15 versus 15 cm/s; p=0,757, teste de Mann-Whitney). Observou-se uma correlação positiva entre a idade materna e o índice de resistência. CONCLUSÕES: nenhuma correlação aparente foi encontrada entre as características morfológicas e vasculares do corpo lúteo nas gestações iniciais normais e nas que evoluíram para o abortamento.

PURPOSE: the purpose of this research was to evaluate the morphological aspects and vasculature of the corpus luteum (CL) based on ultrasound parameters during early pregnancy and to assess their relationship with early pregnancy loss. METHODS: this was a prospective cohort study of 90 pregnant patients between 6 and 8 weeks plus 6 days weeks of gestation. We included women at low risk, without acute or chronic systemic disease and with spontaneous conception. Exclusion criteria: use of drugs or smoking, drugs inducing ovulation, history of more than one abortion, no heartbeat visible in the embryo and impossibility of visualization of the corpus luteum. The size, volume, morphological aspects, resistive index, and peak systolic velocity of the corpus luteum were measured by transvaginal sonography. RESULTS: ninety patients were included in the study. Maternal age ranged from 15 to 41 years (mean 28.6±5.8 years). The corpus luteum could be visualized in 87 patients (96.7 percent), 79 patients had normal pregnancies (90.1 percent), whereas spontaneous losses occurred in 8 cases (9.9 percent). In a comparison of the survivors and losses, there was no difference in mean CL diameter (21.8 versus 20.0 mm; p=0.108, Mann-Whitney test), mean CL volume (4.2 versus 3.0 cm³; p=0.076, Mann-Whitney test), mean resistive index (0.55 versus 0,58; p=0.220, Mann-Whitney test), peak systolic velocity (15 versus 15 cm/s; p=0.757, Mann-Whitney test). There was a positive relation between maternal age and resistive index. CONCLUSIONS: no apparent correlation was found between the morphological and vascular aspects of the corpus luteum in early normal pregnancies and first-trimester pregnancy losses.

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OBJETIVO: avaliar a evolução do volume do embrião (VE) entre a sétima e a décima semana de gestação por meio da ultra-sonografia tridimensional. MÉTODOS: realizou-se um estudo de corte transversal com 63 gestantes normais entre a sétima e a décima semana. Os exames ultra-sonográficos foram realizados por meio de um transdutor endocavitário volumétrico. Para o cálculo do VE, utilizou-se o método VOCAL (Virtual Organ Computer-aided Analysis) com ângulo de rotação de 12º, com delimitação de 15 planos seqüenciais. Para o VE foram calculadas médias, medianas, desvios padrão e valores máximo e mínimo em todas as idades gestacionais. Para se avaliar a correlação entre o VE e o comprimento cabeça-nádega (CCN) foi criado gráfico de dispersão, sendo o ajuste realizado pelo coeficiente de determinação (R²). Para se determinarem intervalos de referência do VE em função do CCN, utilizou-se a seguinte fórmula: percentil =VE+K versus dp, com K=1,96. RESULTADOS: o CCN variou de 9,0 a 39,7 mm, com média de 23,9 mm (±7,9 mm), enquanto o VE variou de 0,1 a 7,6 cm³, com média de 2,7 cm³ (±3,2 cm³). O VE foi altamente correlacionado com o CCN, sendo que o melhor ajuste foi obtido com regressão quadrática (VE=0,165 - 0,055 x CCN + 0,005 x CCN²; R²=0,853). O VE médio variou de 0,1 (-0,3 a 0,5 cm³) a 6,7 cm³ (3,8 a 9,7 cm³) no intervalo de 9 a 40 mm do CCN. Neste intervalo o VE aumentou 67 vezes, enquanto o CCN aumentou apenas 4,4 vezes. CONCLUSÕES: o VE é um parâmetro mais sensível que o CCN para avaliar o crescimento embrionário entre a sétima e a décima semana de gestação.

PURPOSE: to evaluate the embryo's volume (EV) between the seventh and the tenth gestational week, through tridimensional ultrasonography. METHODS: a transversal study with 63 normal pregnant women between the seventh and the tenth gestational week. The ultrasonographical exams have been performed with a volumetric abdominal transducer. Virtual Organ Computer-aided Analysis (VOCAL) has been used to calculate EV, with a rotation angle of 12º and a delimitation of 15 sequential slides. The average, median, standard deviation and maximum and minimum values have been calculated for the EV in all the gestational ages. A dispersion graphic has been drawn to assess the correlation between EV and the craniogluteal length (CGL), the adjustment being done by the determination coefficient (R²). To determine EV's reference intervals as a function of the CGL, the following formula was used: percentile=EV+K versus SD, with K=1.96. RESULTS: CGL has varied from 9.0 to 39.7 mm, with an average of 23.9 mm (±7.9 mm), while EV has varied from 0.1 to 7.6 cm³, with an average of 2.7 cm³ (±3.2 cm³). EV was highly correlated to CGL, the best adjustment being obtained with quadratic regression (EV=0.2-0.055 versus CGL+0.005 versus CGL²; R²=0.8). The average EV has varied from 0.1 (-0.3 to 0.5 cm³) to 6.7 cm³ (3.8 to 9.7 cm³) within the interval of 9 to 40 mm of CGL. EV has increased 67 times in this interval, while CGL, only 4.4 times. CONCLUSIONS: EV is a more sensitive parameter than CGL to evaluate embryo growth between the seventh and the tenth week of gestation.

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Um efetivo rastreio para anomalias cromossômicas pode ser realizado no primeiro trimestre da gestação. A associação entre a transluscência nucal (TN) e as concentrações séricas maternas da fração beta-livre da gonadotrofina coriônica humana e da proteína plasmática-A associada à gestação pode identificar 90 por cento dos fetos com trissomia do cromossomo 21 e outras anomalias cromossômicas, com uma taxa de falso-positivo de 5 por cento. Esses números são superiores aos obtidos pelo rastreio utilizando-se apenas a idade materna (30 por cento) ou o rastreio bioquímico materno, no segundo trimestre da gestação (65 por cento). Um rastreio mais eficaz, no primeiro trimestre, pode ser atingido por meio de uma avaliação ecográfica em dois tempos, dividindo-se as pacientes em grupos de alto, intermediário e baixo risco. No grupo de alto risco, o diagnóstico invasivo estaria indicado, ao contrário do grupo de baixo risco, no qual a presença de uma anomalia seria pouco provável. No grupo de risco intermediário (risco de 1 em 101 a 1 em 1.000), seria oferecida uma segunda avaliação ecográfica, para posicionar a paciente no grupo de alto ou baixo risco (presença/ausência do osso nasal ou presença/ausência da regurgitação tricúspide ou presença/ausência de alteração do fluxo sangüíneo no ducto venoso). A biópsia de vilo corial estaria indicada quando, após a realização da segunda abordagem, o risco ajustado da paciente se tornasse maior ou igual a 1 em 100. Essa segunda abordagem ecográfica deveria ser realizada por pessoal treinado, e os seus resultados deveriam ser constantemente avaliados, como um controle de qualidade. Esse processo foi estabelecido pela Fetal Medicine Foudation e aceito internacionalmente.

Screening for major chromosomal abnormalities can be provided in the first trimester of pregnancy. Screening by a combination of fetal nuchal translucency and maternal serum free human chorionic gonadotropin and pregnancy-associated plasma protein-A can identify 90 percent of fetuses with trisomy 21 and other major chromosomal abnormalities for a false-positive rate of 5 percent. This is superior to the 30 percent detection rate achieved by maternal age and 65 percent by second-trimester maternal serum biochemistry. A further improvement in the effectiveness of first-trimester screening is likely to be achieved by a risk-orientated two-stage approach. In this approach, the patients are subdivided into a high-risk group, requiring invasive testing; a low-risk group, which can be reassured that an abnormality is unlikely, and an intermediate-risk group (risk of 1 in 101 to 1 in 1000), in which further assessment is performed by first-trimester ultrasound examination (for presence/absence of the nasal bone or presence/absence of tricuspid regurgitation or normal/abnormal Doppler velocity waveform in the ductus venosus), and chorionic villus sampling is performed if their adjusted risk becomes 1 in 100 or more. Those performing first-trimester scans should be appropriately trained and their results subjected to external quality assurance. This process was well established by the Fetal Medical Foundation several years ago and is widely accepted internationally.

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