Assistência obstétrica à gestação múltipla: análise da morbimortalidade materna e neonatal
Data
2024-11-26
Autores
Sombra, Isabelle Cordeiro de Nojosa 
Orientadores
Elito Júnior, Júlio
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Objetivos: Analisar a morbimortalidade materna e neonatal nas gestações gemelares, associadas à adesão da rotina preconizada para o pré-natal de alto risco e comparar a morbimortalidade materna e neonatal entre gestações gemelares monocoriônicas e dicoriônicas. Métodos: Trata-se de um estudo de coorte prospectivo realizado entre 2019 e 2022 envolvendo gestações gemelares. Foram avaliadas as características socioeconômicas e demográficas das gestantes, bem como os resultados maternos e perinatais. A associação entre as variáveis foi mensurada pelo odds ratio (OR) obtido na regressão logística. Resultados: A amostra foi constituída por 118 gestações gemelares, sendo 72 monocoriônicas (MC) e 46 dicoriônicas (DC). Dos 236 gemelares, houve um total de 27 óbitos, incluindo primeiro gemelar (2,5%) e segundo gemelares (8,9%). Foram considerados os óbitos fetais, neonatais e pós-neonatais. A maioria iniciou o pré-natal no primeiro trimestre (80,5%), mas apenas algumas (24,3%) realizaram ≥ 12 consultas (9,22 ± 2,97). A profilaxia da pré-eclâmpsia com aspirina foi administrada em 20,3% dos casos e suplementação de cálcio em 16,1% dos casos. A maioria das gestantes desenvolveu alguma patologia durante a gestação (69,5%), como restrição do crescimento fetal em 19 (16,1%), pré-eclâmpsia em 32 (27,1%), diabetes mellitus gestacional em 25 (21,2%) e óbito intrauterino de um dos fetos em 13 casos (10,2%). Mais da metade dos partos ocorreram entre 34 e 37 semanas de gestação (53,4%) e 80,5% foram antes de 37 semanas. A adesão à rotina de pré-natal de alto risco funcionou como fator de proteção obtendo associação com os desfechos “patologias desenvolvidas na gestação” (OR=0,27; IC95% 0,10-0,71; p=0,009), “trabalho de parto pré-termo” (OR=0,02; IC95% 0,003-0,19 p=0,000), “Apgar <7 no 1° minuto – segundo gemelar” (OR=0,24; IC95% 0,08-0,68; p=0,007), “Apgar <7 no 5° minuto - segundo gemelar” (OR=0,10; IC95% 0,01-0,95; p=0,045), “complicações logo após o nascimento - segundo gemelar” (OR=0,13; IC95% 0,02-0,59; p=0,008), “transferência para UTI neonatal - primeiro gemelar” (OR=0,25; IC95% 0,11-0,57; p=0,001), “transferência para UTI neonatal - segundo gemelar” (OR=0,14; IC95% 0,05-0,34; p=0,000). As gestações gemelares MC foram associadas a um maior risco para patologias na gestação (p=0,000) e internações na UTI neonatal do primeiro gemelar (p<0,037). Em ambos os tipos de gestação gemelar os segundos gêmeos apresentaram maior risco para nascimento com cianose (32,2%) ou natimorto (12,5%) (p=0,021), bem como para baixo peso ao nascer (83,9%; p=0,047) e alteração do perímetro torácico (99,1%) (p=0,011). A complicação neonatal mais comum foi dificuldade respiratória, que afetou principalmente os segundos gêmeos nas gestações gemelares MC e DC (65,8% e 52,2%, respectivamente). Conclusão: A adesão à rotina para pré-natal de alto risco esteve associada como fator de proteção para prematuridade, patologias desenvolvidas na gestação, complicações após o nascimento e internação na UTI neonatal. As gestações gemelares MC tiveram resultados perinatais mais adversos do que as gestações gemelares DC, assim como os segundo gemelares de ambos os tipos de gestação.
Objective: To analyze maternal and neonatal morbidity and mortality in twin pregnancies, associated with adherence to the recommended routine for high-risk prenatal care and to compare maternal and neonatal morbidity and mortality between monochorionic and dichorionic twin pregnancies. Methods: This is a prospective cohort study carried out between 2019 and 2022 involving twin pregnancies. The socioeconomic and demographic characteristics of pregnant women were evaluated, as well as maternal and perinatal outcomes. The association between the variables was measured by the odds ratio (OR) obtained in logistic regression. Results: The sample consisted of 118 twin pregnancies, 72 monochorionic (MC) and 46 dichorionic (DC). Of the 236 twins, there were a total of 27 deaths, including first twins (2.5%) and second twins (8.9%). Fetal, neonatal and post-neonatal deaths were considered. The majority started prenatal care in the first trimester (80.5%), but only a few (24.3%) had ≥ 12 consultations (9.22 ± 2.97). Preeclampsia prophylaxis with aspirin was administered in 20.3% of cases and calcium supplementation in 16.1% of cases. The majority of pregnant women developed some pathology during pregnancy (69.5%), such as fetal growth restriction in 19 (16.1%), pre-eclampsia in 32 (27.1%), gestational diabetes mellitus in 25 (21 .2%) and intrauterine death of one of the fetuses in 13 cases (10.2%). More than half of births occurred between 34 and 37 weeks of gestation (53.4%) and 80.5% were before 37 weeks. Adherence to the high-risk prenatal routine worked as a protective factor, obtaining an association with the outcomes “pathologies developed during pregnancy” (OR=0.27; 95%CI 0.10-0.71; p=0.009), “preterm labor” (OR=0,02; IC95% 0,003-0,19 p=0,000), “Apgar <7 in the 1st minute – second twin” (OR=0.24; 95%CI 0. 08-0.68; p=0.007), “Apgar <7 in the 5th minute - second twin” (OR=0.10; 95%CI 0.01-0.95; p=0.045), “complications soon after the birth - second twin” (OR=0.13; 95%CI 0.02-0.59; p=0.008), “transfer to neonatal ICU - first twin” (OR=0.25; 95%CI 0.11-0 .57; p=0.001), “transfer to neonatal ICU - second twin” (OR=0.14; 95%CI 0.05-0.34; p=0.000). MC twin pregnancies were associated with a greater risk of pathologies during pregnancy (p=0,000) and admissions to the neonatal ICU of the first twin (p<0.037). In both types of twin pregnancy, the second twins presented a higher risk of being born with cyanosis (32.2%) or stillbirth (12.5%) (p=0,021), as well as low birth weight (83.9%; p=0,047) and changes in chest circumference. (99.1%) (p=0,011). The most common neonatal complication was respiratory distress, which mainly affected second twins in MC and DC twin pregnancies (65.8% and 52.2%, respectively). Conclusion: Adherence to the high-risk prenatal routine was associated with a protective factor for prematurity, pathologies developed during pregnancy, complications after birth and hospitalization in the neonatal ICU. MC twin pregnancies had more adverse perinatal outcomes than DC twin pregnancies, as did second twins of both pregnancy types.
Objective: To analyze maternal and neonatal morbidity and mortality in twin pregnancies, associated with adherence to the recommended routine for high-risk prenatal care and to compare maternal and neonatal morbidity and mortality between monochorionic and dichorionic twin pregnancies. Methods: This is a prospective cohort study carried out between 2019 and 2022 involving twin pregnancies. The socioeconomic and demographic characteristics of pregnant women were evaluated, as well as maternal and perinatal outcomes. The association between the variables was measured by the odds ratio (OR) obtained in logistic regression. Results: The sample consisted of 118 twin pregnancies, 72 monochorionic (MC) and 46 dichorionic (DC). Of the 236 twins, there were a total of 27 deaths, including first twins (2.5%) and second twins (8.9%). Fetal, neonatal and post-neonatal deaths were considered. The majority started prenatal care in the first trimester (80.5%), but only a few (24.3%) had ≥ 12 consultations (9.22 ± 2.97). Preeclampsia prophylaxis with aspirin was administered in 20.3% of cases and calcium supplementation in 16.1% of cases. The majority of pregnant women developed some pathology during pregnancy (69.5%), such as fetal growth restriction in 19 (16.1%), pre-eclampsia in 32 (27.1%), gestational diabetes mellitus in 25 (21 .2%) and intrauterine death of one of the fetuses in 13 cases (10.2%). More than half of births occurred between 34 and 37 weeks of gestation (53.4%) and 80.5% were before 37 weeks. Adherence to the high-risk prenatal routine worked as a protective factor, obtaining an association with the outcomes “pathologies developed during pregnancy” (OR=0.27; 95%CI 0.10-0.71; p=0.009), “preterm labor” (OR=0,02; IC95% 0,003-0,19 p=0,000), “Apgar <7 in the 1st minute – second twin” (OR=0.24; 95%CI 0. 08-0.68; p=0.007), “Apgar <7 in the 5th minute - second twin” (OR=0.10; 95%CI 0.01-0.95; p=0.045), “complications soon after the birth - second twin” (OR=0.13; 95%CI 0.02-0.59; p=0.008), “transfer to neonatal ICU - first twin” (OR=0.25; 95%CI 0.11-0 .57; p=0.001), “transfer to neonatal ICU - second twin” (OR=0.14; 95%CI 0.05-0.34; p=0.000). MC twin pregnancies were associated with a greater risk of pathologies during pregnancy (p=0,000) and admissions to the neonatal ICU of the first twin (p<0.037). In both types of twin pregnancy, the second twins presented a higher risk of being born with cyanosis (32.2%) or stillbirth (12.5%) (p=0,021), as well as low birth weight (83.9%; p=0,047) and changes in chest circumference. (99.1%) (p=0,011). The most common neonatal complication was respiratory distress, which mainly affected second twins in MC and DC twin pregnancies (65.8% and 52.2%, respectively). Conclusion: Adherence to the high-risk prenatal routine was associated with a protective factor for prematurity, pathologies developed during pregnancy, complications after birth and hospitalization in the neonatal ICU. MC twin pregnancies had more adverse perinatal outcomes than DC twin pregnancies, as did second twins of both pregnancy types.
Descrição
Citação
SOMBRA, Isabelle Cordeiro de Nojosa. Assistência obstétrica à gestação múltipla: análise da morbimortalidade materna e neonatal. 2024. 143 f. Tese (Doutorado em Obstetrícia) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2024. -