MCur / Department of Advanced Nursing Science / See the attached abstract below

I Sverige föds ungefär 440 barn döda varje år. Intrauterin fosterdöd kan beskrivas som en stilla födsel och definieras som framfödande av barn som saknar livstecken efter 22 fullgångna graviditetsveckor. En förlossning av ett dödfött barn sker på liknande sätt som en förlossning med ett levande barn. Skillnaden är att fosterhjärtljuden inte behöver övervakas eller registreras. Modern som genomgår förlossningen kan då istället få all uppmärksamhet. Att få ett dödfött barn tillhör inte en vanlig livserfarenhet och innebär en chock för föräldrarna. Intrauterin fosterdöd kan orsaka kraftiga psykiska besvär hos modern. En majoritet har planerat månader och ibland år i förväg för hur livet med ett barn kommer att bli och när barnet sedan dör intrauterint rasar hela deras värld. Sorgen efter ett barn som får en stilla födsel beskrivs som långvarig och djup, speciellt för modern som bär barnet i sin kropp.   Syftet med föreliggande litteraturöversikt var att belysa moderns psykiska hälsa efter att hon mist sitt barn intrauterint.   För att på lämpligt sätt besvara föreliggande studies syfte valdes en litteraturöversikt som metod. Databassökningar gjordes via PubMed, CINAHL och PsychINFO. Resultatet av sökningarna medförde att 18 vetenskapliga artiklar inkluderades. Artiklarna var publicerade från år 2008 till och med år 2018 och både artiklar med kvalitativ och kvantitativ ansats inkluderades i studien. Vetenskaplig kvalitetsgranskning och klassificering genomfördes utifrån Sophiahemmet Högskolas utarbetade bedömningsunderlag. Resultatet framtogs genom integrerad analys av innehåll.   I resultatet framkom det att modern kan drabbas av olika psykiska besvär med varierande svårighetsgrad efter att hon mist sitt barn intrauterint. Ångest, depression, oro, tvångstankar, posttraumatiskt stressyndrom och självmordstankar förekommer. Besvären kan finnas kvar lång tid efter dödfödseln. Känslor av tomhet, olust och skuld beskrevs hos ett flertal mödrar samt skillnader i hur samhället betraktade dem på grund av socioekonomisk och kulturell status. Genom att få stöd från sjukvården och barnmorskor kunde symtomen och besvären minska. Att samla minnen, hålla i barnet, utföra ritualer, mindfulness, stödsamtal eller psykoterapi ledde till att besvären kunde minska.   Slutsatsen som framkommit från föreliggande litteraturöversikt är att den psykiska hälsan hos modern kunde påverkas negativt av den kris som en intrauterin fosterdöd innebär. Hur svåra och långvariga besvären blev var beroende av tillgängligheten och kvaliteten på generellt stöd samt vårdinsatser. / In Sweden, approximately 440 children are stillborn every year. Intrauterine fetal death is sometimes described as a still birth and is defined as the birth of a child who has shown no sign of life after 22 completed pregnancy weeks. The birth of a stillborn child is similar to the birth of a living child. The difference is that the fetal heartbeat does not need to be monitored or recorded. Full attention can be directed at the mother giving birth. Giving birth to a stillborn child is not a normal life experience and is a shock for the parents. Intrauterine fetal death can cause the mother severe mental disorders. A majority has planned months and sometimes years in advance for how life with a child will be and when the child then dies their entire world crumbles. Grieving for a child who is stillborn is described as long lasting and deep, especially for the mother who carried the child in her body.   The aim of this literature review was to illuminate the mother's mental health after she has lost her baby intrauterine.      In order to adequately respond to the purpose of the study, a literature review was chosen as a method. Database searches were made through PubMed, CINAHL and PsychINFO. The result of the searches led to the inclusion of 18 scientific articles. The articles were published from year 2008 to 2018 and both qualitative and quantitative articles were included in the study. Scientific quality review and classification was implemented in the foundation of the Sophiahemmet University Hospital. The result was developed through integrated content analysis.   From the result it emerged that the mother could suffer from various mental disorders with varying degrees of difficulties after she has lost her child intrauterine. Anxiety, depression, worrying, obsessive thoughts, post-traumatic stress disorder and suicidal thoughts occur. The discomfort can last long after the birth of a stillborn child. Feelings of emptiness, unrest and guilt were shown by a number of mothers as well as differences in how society saw them based on their socio-economic and cultural status. By receiving support from health care staff and midwives, the symptoms and disorders could be reduced. Collecting memories, holding the child, performing rituals, mindfulness, counseling or psychotherapy could also lead to reduced symptoms.   The conclusion from the literature review is that the mental health of the mother was adversely affected by the crisis that an intrauterine fetal death implies. How severe and long-lasting problems became, depended on availability and quality of general support and efforts from the healthcare system.

The type and duration of observation and monitoring of mother and fetus after abdominal trauma are dependent on gestational age and severity of trauma. Fetal monitoring is usually not required when the fetus is not viable; the primary consideration is the safety of the mother. When the fetus is viable, 24-hour inpatient fetal monitoring is indicated in cases of major trauma, even when no symptoms of injury are obvious.

Bakgrund: Intrauterin fosterdöd är en sällsynt händelse, av 1000 förlossningar är det cirka tre till fyra förlossningar där det inträffar i Sverige. Som förälder kan det vara svårt att hantera sorgen vid intrauterin fosterdöd och därmed finns det behov av stöd. Föräldrarna uppger att de inte får den rätta vård och stöd som de är i behov av. Det finns bristfällig kommunikation mellan barnmorskor och föräldrar. Stöd till barnmorskor är lika viktigt, vilket är en förutsättning för att kunna hantera svåra situationer. Syftet: Att beskriva barnmorskors erfarenhet av att stödja föräldrar efter förlossning vid intrauterin fosterdöd. Metod: Kvalitativ metod med induktiv ansats. En webbenkät som besvarades av 25 barnmorskor. Resultat: Fyra kategorier och nio subkategorier utformades. Barnmorskorna ansåg att grunden till god vård för föräldrarna vid intrauterin fosterdöd var att vara närvarande och stödja föräldrarna genom hela vårdtiden. Det kan vara en utmaning att hantera egna känslor samtidigt som det är en hög arbetsbelastning på arbetsplatsen. Behovet av fördjupad kunskap kring stödjandet av föräldrarna föreligger. Slutsats: Barnmorskorna ansåg behovet av vidareutbildning inom ämnet för att kunna hantera svåra situationer. Stödet till barnmorskorna var en viktig faktor för att klara av att bemöta föräldrarna vid intrauterin fosterdöd. / Background: Intrauterine fetal death is a rare event, occurring in approximately three to four out of 1000 births in Sweden. As parents, coping with the grief of intrauterine fetal death can be challenging, and the need for support is crucial. Parents report not receiving the proper care and support they require. There is inadequate communication between midwives and parents. Support for midwives is equally crucial, to be able to manage difficult situations. Aim: To describe midwives' experiences in supporting parents after childbirth in cases of intrauterine fetal death. Method: Qualitative method with an inductive approach. A web- based survey was completed by 25 midwives. Results: Four categories and nine subcategories were formed. Midwives believed that the foundation for providing good care to parents in cases of intrauterine fetal death was to be present and support the parents throughout the entire care period. Managing their own emotions while facing a heavy workload at the workplace can be challenging. There is a need for further education regarding supporting parents going through an intrauterine fetal death. Conclusion: Midwives identified the need for further education on the subject to manage difficult situations. Support for midwives was a crucial factor in being able to support parents in cases of intrauterine fetal death.

Det emotionella arbetet vid intrauterin fosterdöd - barnmorskors erfarenheter av att bistå föräldrar under hela förlossningsprocessen Abstrakt Bakgrund: Intrauterin fosterdöd (IUFD) förekommer runt om i hela världen och närmare två miljoner barn föds fram döda varje år. Rökning, högt BMI samt tillväxthämning hos barnet är några av de kända riskfaktorerna kopplat till IUFD och prevalensen av dödfödda barn är högre i låginkomstländer jämfört med höginkomstländer. Barnmorskor bär en viktig roll i mötet med IUFD där deras uppgift dels är att stötta och tillgodose föräldrarnas behov, vilket ställer stora krav på deras emotionella arbete.   Motiv: Att möta föräldrar vars barn har dött intrauterint kan vara ett av de tuffaste möten en barnmorska ställs inför. Det finns få studier i Sverige om barnmorskors erfarenheter i mötet med IUFD, därför är det relevant att fördjupa kunskapen inom ämnet. Syfte: Syftet var att belysa barnmorskors känslor och erfarenheter av att bistå föräldrar innan, under samt efter förlossningen vid intrauterin fosterdöd. Metod: En kvalitativ metod med semistrukturerade intervjuer tillämpades för att besvara syftet med studien. Sju barnmorskor intervjuades och intervjuerna transkriberades ordagrant och analyserades med inspiration av klassisk grundad teori.    Resultat: Det teoretiska perspektivet emotionellt arbete bidrog till framväxten av kärnkategorin: Barnmorskors emotionella arbete i interaktionen med föräldrar vid intrauterin fosterdöd, tre kategorier: Att vara fyren i stormen; En känslomässig berg-och-dalbana; Kunskap och stöd – intrauterin fosterdöd, en del av professionen, samt åtta underkategorier.  Konklusion: Barnmorskors emotionella arbete i interaktionen med föräldrar vid IUFD belyser det känslomässiga engagemanget som krävs från barnmorskorna, vilket resulterar i att många känner sig emotionellt dränerade. I denna studie tydliggörs förståelsen för den känslomässiga påfrestning och behovet av professionellt stöd som barnmorskor upplever vid IUFD. / The emotional work of intrauterin fetal death - midwives' experiences of assisting parents throughout the birth process Abstract Background: Intrauterin fetal death (IUFD) occurs all around the world and approximately two million babies are stillborn every year. Smoking, high Body Mass Index (BMI) and fetal growth retardation are some of the well-known risk factors associated with stillbirth and the prevalence of stillborn babies are higher in low-income countries compared to high-income countries. Midwives play an important role when meeting IUFD, where their tasks are partly to support and meet the parents’ needs, which places great demands on their emotional work.  Motive: Meeting parents whose babies have died in the uterus can be one of the toughest encounters a midwife faces. There are few studies in Sweden about midwives' experiences in meeting with IUFD, therefore it is relevant to deepen the knowledge about the topic. Aim: The aim was to explore midwives' emotions and experiences of assisting parents before, during and after childbirth in case of intrauterine fetal death. Methods: A qualitative method with semi-structured interviews was applied to answer the purpose of the study. Seven midwives were interviewed and the interviews were transcribed verbatim and analyzed with inspiration from classical grounded theory. Result: The theoretical perspective of emotional labor contributed to the emergence of the core category: Midwives' emotional labor in the interaction with parents at intrauterine fetal death, three categories: Being the lighthouse in the storm; An emotional roller coaster; Knowledge and support – intrauterine fetal death, a part of the profession, as well as eight subcategories. Conclusion: Midwives' emotional labor in interacting with parents at IUFD highlights the emotional commitment required from midwives, resulting in many feeling emotionally drained. This study clarifies the understanding of the emotional strain and the need of professional support for midwives who have taken care of parents experiencing an IUFD.

Thesis (MScMedSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background: Sudden infant death syndrome (SIDS) is considered the second most frequent cause of infant mortality worldwide. Research specifically pertaining to SIDS is limited in the South African setting. Identifiable causes for sudden infant death remain challenging despite full medico-legal investigations inclusive of autopsy, scene visit and ancillary studies. Viral infections could contribute to some sudden unexpected death in infancy (SUDI) cases, especially since a multitude of respiratory viruses have been detected from autopsy specimens. The specific contribution of viruses in the events preceding death, including the subsequent involvement of the immature immune response in infants, still warrants deciphering. Infancy is characterised by marked vulnerability to infections due to immaturities of their immune systems that may only resolve as infants grow older when these sudden deaths rarely still occur. In South Africa there is a lack of a standard protocol for investigations into the causes of SIDS, including the lack of standard guidelines as to which specimens should be taken, which viruses should be investigated and which laboratory assays should be utilised. Objectives: In this prospective descriptive study we aimed to investigate the prevalence of viruses in SUDI and SIDS cases at Tygerberg Forensic Pathology Service (FPS) Mortuary over a one year period. The primary aim was to explore possible respiratory viral infections in SUDI and SIDS cases and to determine the usefulness of molecular techniques to detect viruses from SUDI cases. To determine the significance of viruses, we assessed signs of infection from lung histology. The secondary objectives included collecting demographic data to investigate possible risk factors for SUDI and to look for possible similarities between viruses confirmed in living hospitalised infants at Tygerberg, during the study period compared to viruses detected from SUDI cases. Methods: Between May 2012 and May 2013 samples were collected from 148 SUDI cases presenting at Tygerberg FPS Mortuary. As part of the mandatory routine investigations into SUDI, shell vial culture (SVC) results were collected from lung and liver tissue specimens and bacterial culture results were collected from left and right lung and heart swabs at autopsy. To investigate the possibility of viruses implicated in some of the infant deaths we used the Seeplex® RV15 Ace detection multiplex polymerase chain reaction (PCR) assay to establish the frequency of 13 ribonucleic acid (RNA) respiratory viruses (influenza A and B, human parainfluenza 1-4, human coronavirus [OC43, 229E/NL63], human rhinovirus A, B and C, respiratory syncytial virus A and B, human enterovirus and human metapneumovirus) from RNA extracted from tracheal and lower left and right lung lobe swabs. Tissue from the lower left and right lung lobes were also assessed for histology signs of infection. Results: During our study we confirmed multiple known demographic risk factors for SIDS, such as the age peak around 1-3 months, the male predominance, bed-sharing, sleeping in the prone position, heavy wrapping in warm blankets, prenatal smoke exposure, and socio-economic factors. With the Seeplex® RV15 Ace detection assay between one and three viruses were detected in 59.5% (88/148) of cases. Of the 88 cases that had viruses detected, 75% (66/88) had one virus and 25% (22/88) had co-detections of two to three viruses. The most common viruses detected were HRV in 77% (68/88) of cases, RSV in 18% (16/88) of cases and HCoV in 14% (12/88) of cases. Many of the viruses we detected from our cases are included in the SVC test that forms part of the medico-legal laboratory investigation for all SUDI cases at Tygerberg FPS Mortuary. SVCs were positive in 9.5% (14/148) of all cases only. We showed that the SVC method is potentially missing most of the 13 respiratory viruses we investigated that could contribute to death in some of the SUDI cases. Conclusion: In some cases that had a Cause of Death Classification - SIDS, the PCR viruses detected cannot be ignored, especially when it is supported by histological evidence of infection. We thus propose that the use of PCR could alter a Cause of Death Classification from SIDS to Infection in some of these cases. Further research is needed to determine the significance of detecting viruses from SUDI cases wherein no significant histological evidence of infection was observed. This questions whether PCR may be too sensitive and is detecting past and latent viral infections that do not play any role in the cause of death. The histological picture also requires further characterisation to determine if it accurately predicts infections or lethal events and can truly support virology findings, especially in young infants whose immune systems are still maturing. Without determining the true prevalence of viruses in SUDI cases and the viral-specific immune response, the contribution of virus-specific infections to this syndrome will remain largely undetermined. / AFRIKAANSE OPSOMMING: Agtergrond: Wiegiedood (“SIDS/SUDI”) word beskou as die tweede mees algemene oorsaak van sterftes in kinders jonger as een jaar wêreldwyd. Toegewyde SIDS-spesifieke navorsing in die Suid-Afrikaanse samelewing is beperk. Dit bly steeds „n uitdaging om oorsake te probeer identifiseer vir hierdie onverwagte sterftes in kinders (SUDI) ten spyte van volledige medies-geregtelike ondersoeke, insluitende die lykskouing, ondersoek van die doodstoneel en aanvullende ondersoeke. Virusinfeksies kan aansienlik bydra tot sommige onverwagte sterftes in kinders, aangesien verskeie respiratoriese virusse alreeds aangetoon is in monsters verkry tydens outopsies. Die spesifieke rol wat virusse speel in die prosesse wat die dood voorafgaan, asook die bydraende rol van „n onder-ontwikkelde immuunrespons in babas, regverdig verdere ondersoek. Die eerste jaar van lewe word gekenmerk deur verhoogde vatbaarheid vir infeksies weens die ontwikkelende immuunstelsels soos wat babas ouer word, en die voorkoms van SUDI neem stelselmatig af met „n toename in ouderdom. In Suid-Afrika bestaan daar tans geen standaard protokol vir die ondersoek van wiegiedood nie en daar is ook nie standaard riglyne oor die tipe monsters wat geneem moet word, watter virusse ondersoek moet word en watter laboratorium toetse uitgevoer moet word nie. Doelstellings: In hierdie prospektiewe beskrywende studie is gepoog om die virusse wat in gevalle van wiegiedood of SUDI voorkom te ondersoek. Die studie is uitgevoer by die Tygerberg Geregtelike Patologie Dienste lykshuis oor 'n tydperk van een jaar. Molekulêre tegnieke om virusse aan te toon in hierdie gevalle is gebruik om spesifieke virusinfeksies te ondersoek. Die resultate is met histologiese tekens van infeksie in longweefsel gekorreleer. Demografiese data is verder versamel om moontlike risikofaktore vir wiegiedood te ondersoek. Dit is verder vergelyk met virusse wat met dieselfde diagnostiese tegnieke in babas geïdentifiseer is wat tydens die studieperiode in Tygerberg Hospitaal opgeneem was met lugweginfeksies. Metodes: Monsters van 148 SUDI gevalle wat by die Tygerberg lykshuis opgeneem is, is versamel tussen Mei 2012 en Mei 2013. As deel van die roetine ondersoeke in SUDI gevalle, was selkultuur resultate verkry van long en lewer weefsel, asook bakteriële kulture van deppers wat van beide longe en hart geneem was tydens die lykskouings. „n Seeplex® RV15 Ace polimerase kettingreaksie (PKR) toets is gebruik om die teenwoordigheid van virusse te ondersoek wat moontlik by die babasterftes betrokke kon wees. Trageale- en longdeppers wat tydens die lykskouings versamel was, was getoets vir 13 ribonukleïensure (RNS) respiratoriese virusse (influenza A and B, human parainfluenza 1-4, human coronavirus [OC43, 229E/NL63], human rhinovirus A, B and C, respiratory syncytial virus A and B, human enterovirus and human metapneumovirus). Resultate: Ons studie het verskeie bekende demografiese risikofaktore vir SUDI bevestig, byvoorbeeld „n ouderdomspiek tussen een en drie maande ouderdom, manlike predominansie, deel van „n bed met ander persone, slaap posisie op die maag, styf toedraai in warm komberse, blootstelling aan sigaretrook voor geboorte en sosio-ekonomiese faktore. Die Seeplex® RV15 Ace toets het tussen een en drie virusse geïdentifiseer in 59.5% (88/148) van die gevalle. Uit die 88 gevalle waarin virusse opgespoor was, was selgs een virus in 75% (66/88) van gevalle gevind en twee en drie virusse in 25% (22/88). Die mees algemene virusse was HRV in 77% (68/88) van gevalle, RSV in 18% (16/88) van gevalle en HCoV in 14% (12/88) van gevalle. Baie van die virusse wat tydens hierdie studie ondersoek was, was ingesluit in die roetine selkultuur toets wat deel vorm van die standaard medies-geregtelike laboratoriumondersoeke in alle SUDI gevalle by die Tygerberg lykshuis, alhoewel die selkulture positief was in slegs 9.5% (14/148) van gevalle. Ons het gevind dat baie respiratoriese virusse potensieel gemisdiagnoseer word wat „n rol kon speel in of bydra tot die dood van sommige SUDI gevalle. Gevolgtrekking: In sommige gevalle waarin SIDS geklassifiseer is as die oorsaak van dood, kan die virusse wat met PKR toetse opgespoor is nie geïgnoreer word nie, veral waar die bevinding ondersteun word deur histologiese bewyse van infeksie. Ons stel dus voor dat die gebruik van PKR toetse die oorsaak van dood klassifikasie kan verander van SIDS na Infeksie in sommige van hierdie gevalle. Verdere navorsing is nodig om die waarde van gelyktydige opsporing van virusse in SUDI gevalle te bepaal wanneer daar geen noemenswaardige histologiese bewyse van infeksie gevind word nie. Dit bevraagteken of die PKR toets dalk te sensitief is en gevolglik vorige en latente virusinfeksies identifiseer wat nie noodwendig 'n rol in die oorsaak van dood speel nie. Die diagnostiese en kliniese waarde van die histologiese beeld in terme van die rol van virusinfeksies as bydraende oorsaak van dood moet verder ondersoek word, veral in jong kinders wie se immuunstelsels nog nie volledig ontwikkel is nie. Indien die werklike voorkoms van virusse in SUDI gevalle en die virus-spesifieke immuunrespons nie bepaal word nie, sal die rol van virus-spesifieke infeksies in hierdie sindroom grootliks onbekend bly. / Harry Crossley Foundation / Poliomyelitis Research Foundation (PRF) / National Health Laboratory Services Research Trust

O presente estudo tem como objetivo descrever a mortalidade perinatal em gestações trigemelares, e analisar os fatores preditores dos seguintes desfechos: número de crianças vivas no momento da alta hospitalar, nenhuma criança viva no momento da alta hospitalar (desfavorável) e pelo menos uma criança viva no momento da alta hospitalar (favorável). Realizado de forma retrospectiva, envolveu pacientes com gestações trigemelares que apresentavam três fetos vivos na primeira ultrassonografia realizada após 11 semanas, no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), no período de 1998 a 2012. Foram incluídas 67 pacientes das quais 77,6% referiam concepção espontânea. Quanto à corionicidade, 49,2% eram tricoriônicas e 50,8% eram não tricoriônicas; 16,4% apresentavam antecedente clínico prévio à gestação e 49,2% eram nulíparas. Em relação às intercorrências, a incidência de complicações obstétricas e/ou clínicas na gestação foi de 52,2%, e de intercorrências fetais, 25,2%, dentre as quais: 13,4% mal formações, 7,5% sindrome da transfusão feto fetal (STFF), 5,9% óbito fetal (OF), 4,5% insuficiência placentária, 4,4% fetos unidos, 1,5% feto acárdico. A idade gestacional média do parto foi de 31,9 ± 3,1 semanas, dos quais 83,5% foram cesáreas. O peso médio dos recém-nascidos vivos de 1.683 ± 508 g. Em relação à discordância de peso ao nascer: 57% apresentaram até 20%, 23,2% entre 20 e 30% e 19,6% acima de 30%. A taxa de óbitos fetais foi de 31,7%o nascimentos (IC95%: 11,7 - 67,8) e a mortalidade perinatal 249%o nascimentos (IC95%: 189 - 317). O tempo médio de internação dos recém-nascidos, que foram de alta vivos, foi de 29,3 ± 24,7 dias. A predição dos desfechos foi investigada por meio de regressão logística \"stepwise\", e incluiu as seguintes variáveis: idade materna, paridade (nulípara ou um ou mais partos anteriores), antecedente clínico, idade gestacional do primeiro ultrassonografia no HCFMUSP, corionicidade (gestações tricoriônicas e gestações não tricoriônicas), presença de complicação obstétrica ou clínica durante a gestação, intercorrência fetal e idade gestacional do parto. O nível de significância estatística utilizado foi de 0,005. Foram fatores significativos para predição do número de crianças vivas no momento da alta hospitalar: presença de intercorrência fetal (OR 0,1, IC95%: 0,03 - 0,36; p < 0,001) e idade gestacional do parto (OR 1,55, IC95%: 1,31-1,85; p < 0,001). Para a predição dos desfechos favoráveis e desfavoráveis a idade gestacional do parto apresentou significância estatística (OR 1,84, IC95%: 1.26 - 2.7; p=0,002 e OR 0.54, IC 95%: 0.37-0.79; p=0.002, respectivamente) / The present study, involving triplet pregnancies, describes perinatal mortality and investigates predictors of the following outcomes: number of children alive, no child alive (unfavorable outcome) and at least one child alive (favorable outcome) at hospital discharge. It is a retrospective study involving triplet pregnancies with live fetuses at the first ultrasound scan, performed after 11 weeks of gestation, at the Department of Obstetrics and Gynecology, São Paulo University Medical School Hospital, between 1998 and 2012. Final sample included 67 women, 77.6% reported spontaneous conception. Regarding the chorionicity, 49.2% were trichorionic; 16.4% had a medical complication prior to pregnancy, and 49.2% were nulliparous. The incidence of obstetric and/or clinical complications during pregnancy was 52.2%, and fetal complications occurred in 25.2%, (13.4% of major fetal abnormalities, 7.5% twin-to-twin transfusion syndrome, 5.9% stillbirth, 4.5% placental insufficiency, 4.4% conjoined twins and 1.5% acardic twin). The average gestational age at delivery was 31.9 ± 3.1 weeks, and 83.5% were cesarean. The average birthweight was 1683 ± 508 g and birth weight discordance up to 20% occurred in 57% of the cases; 23,2% had 20 to 30% discordance and 19.6%, was greater than 30%. The rate of stillbirth was 31.7%o births (95%CI: 11.7 - 67.8) and the perinatal mortality was 249%o births (95%CI: 189 - 317). The average hospital stay was 29.3 ± 24.7 days amongst children that were discharged alive. Stepwise logistic regression analysis was used to investigate prediction according to: maternal age, parity (nuliparous/multiparous), prior clinical history, gestational age at the first ultrasound scan at HCFMUSP, pregnancy chorionicity (trichorionic/non trichorionic), occurrence of clinical and/or obstetric complications during pregnancy, occurrence of fetal complications and gestational age at delivery. Significance level was set at 0.05. The number of children alive at hospital discharge was correlated with the occurrence of fetal complications (OR 0,1, 95%IC: 0,03 - 0,36; p < 0,001) and gestational age at delivery (OR 1,55, IC95%: 1,31-1,85; p < 0,001). Whereas favorable and unfavorable outcome were associated with gestational age at delivery (OR 1.84, 95%CI: 1.26 - 2.7-; p=0,002 and OR 0.54, 95%CI: 0.37-0.79; p=0.002, respectively)

Objetivos: Descrever a frequência, e investigar fatores preditivos, de óbito fetal espontâneo (OF), em gestações com anomalias cromossômicas. Métodos: Trata-se de estudo retrospectivo, abrangendo o período de novembro de 2004 a maio de 2012, realizado na Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Foram incluídas gestações únicas com diagnóstico pré-natal de trissomia dos cromossomos 21 (T21), 18, 13 (T13/18) e monossomia do X (45X), realizado até a 26ª semana de gestação. Resultados: Foram incluídas 92 gestantes com idade materna média de 32,7 ± 8,7 anos. O diagnóstico das anomalias cromossômicas (T21 n=36, T13/T18 n=25, 45X n=31) foi realizado em idade gestacional média de 18,3 ± 3,7 semanas, por meio de biópsia de vilo corial (n=22, 24%), amniocentese (n=66, 72%) e cordocentese (n=4, 4%). Malformação major estava presente em 45 (49%); e hidropisia foi identificada em 32 (35%) fetos, sendo mais frequente no grupo 45X (n=24/31 (77%) versus T21: n=6/36 (17%) e T13/18: n=2/25 (8%), p < 0,001). Exame ecocardiográfico fetal especializado foi realizado em 60% (55/92) das gestações. Dessas, 60% (33/55) apresentaram alterações na morfologia e/ou função cardíaca, sendo o achado mais frequente a comunicação interventricular (39%). Fetos com T13/18 apresentaram incidência maior de anomalias cardíacas (60% versus 25% (T21) e 29% (45X), p= 0,01). Óbito fetal ocorreu em 55 (60%) gestações e foi mais frequente no grupo 45X (n=26/31 (84%) versus T21: n=13/36 (36%) e T13/18: n=16/25 (64%), p < 0,01). A análise multivariada stepwise demonstrou associação entre hidropisia e OF em fetos com trissomia 21 (LR= 4,29; IC95%= 1,9-8,0, p< 0,0001). Em fetos com monossomia X, a presença de alterações ecocardiográficas esteve associada com menor risco de OF (LR= 0,56; IC95% = 0,27-0,85, p= 0,005). Não foram identificados fatores preditores no grupo T13/18. Conclusão: A letalidade intrauterina de fetos com anomalias cromossômicas é elevada. A presença de hidropisia aumenta o risco de óbito fetal, em gestações com trissomia 21. Enquanto, em gestações com monossomia X, a ocorrência de alterações ecocardiográficas reduz esse risco / Objectives: To describe the frequency, and associated factors, of intrauterine fetal death (IUD), in pregnancies with chromosomal abnormality. Methods: This was a retrospective (November 2004 to May 2012) performed at de department of obstetrics, Hospital das Clínicas, São Paulo University Medical School. Inclusion criteria were: singleton pregnancies with prenatal diagnosis of trisomy 21 (T21), 18, 13 (T13/18) and X monosomy (45X), performed up to 26 weeks gestation. Results: 92 women were included in the study with a mean maternal age of 32.7 ± 8.7 years. Fetal chromosomal abnormalities (T21 n=36, T13/T18 n=25, 45X n=31) were diagnosed at a mean gestational age of 18.3 ± 3.7 weeks, by chorionic villus sampling (n=22, 24%), amniocentesis (n=66, 72%) and cordocentesis (n=4, 4%). Major fetal structural abnormality was present in 45 (49%) cases; hydrops was diagnosed in 32 (35%) fetuses, and was more common in 45X group (n=24/31 (77%) versus T21: n=6/36 (17%) and T13/18: n=2/25 (8%), p < 0.001). Specialist fetal echocardiography was performed in 55 (60%) pregnancies and showed structural and/or functional abnormalities in 33 (60%) fetuses; ventricular septal defect was the most common finding (39%). T13/18 fetuses showed a higher incidence of cardiac abnormalities (60% versus 25% (T21) and 29% (45X), p= 0.01). IUD occurred in 55 (60%) pregnancies and was more common in 45X group (n=26/31 (84%) versus T21: n=13/36 (36%) and T13/18: n=16/25 (64%), p < 0.01). Stepwise logistic regression analysis demonstrated an association between hydrops and IUD in T21 pregnancies (LR= 4.29; 95%CI= 1.9-8.0, p < 0.0001). In 45X pregnancies, cardiac abnormalities were associated with a lower risk of IUD (LR= 0.56; 95%CI = 0.27-0.85, p= 0.005). No predictors of IUD were identified in T13/18 group. Conclusion: Intrauterine death rate is high in pregnancies with a fetal chromosomal abnormality. Presence of hydrops increases the risk of this complication in trisomy 21 fetuses. Whereas the presence of a cardiac abnormality is protective in X monosomy pregnancies

Muitas mulheres estão adiando a maternidade até a 4ª ou 5ª década de vida, um fenômeno mundial. O objetivo do estudo foi avaliar resultado da gestação em 281 mulheres com 40 anos ou mais, atendidas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre Julho de 1998 e Julho de 2005. A incidência de diabetes gestacional e doença hipertensiva específica da gestação (DHEG) foi de 14,6% e 19,6%, respectivamente. Dezessete (6,0%) mulheres tiveram abortamento e 4 (1,4%) óbito fetal. Três recém-nascidos apresentavam síndrome de Down e 6 outras malformações (índice de detecção de 88,9%). Mulheres com DHEG tiveram maior risco para fetos com baixo peso. História prévia de hipertensão não foi fator de risco para DHEG. Gestantes com DHEG ou diabetes gestacional não apresentaram risco maior para parto pré-termo. Obesidade foi fator de risco para diabetes gestacional. Mulheres sem companheiro e nulíparas tiveram maior incidência de malformações e baixos índices de Apgar. Mulheres com idade materna muito avançada (maior ou igual a 45 anos) apresentaram incidência maior de óbito fetal e de índice de Apgar baixo. A assistência pré-natal específica possibilita a detecção das complicações maternas e a instituição precoce do tratamento / Many women are delaying childbearing until the fourth or fifth decade in life, and it has become a common and worldwide phenomenon. The aim of this study is to evaluate pregnancy outcome in women of 40 or older who were care at our institution. During the period from July 1998 to July 2005 a total of 281 women with advanced maternal age presenting at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were studied. The incidence of gestational diabetes and preeclampsia was 14.6% e 19.2%, respectively. Seventeen women had miscarriage (6.0%) and four presented fetal death (1.4%). There were three infants with Down syndrome and six with other anomalies (detection rate of 88.9%). Women presenting preeclampsia were at higher risk for presenting low birthweight. Previous history of hypertension was not a risk factor for preeclampsia. Pregnant women with gestational diabetes or preeclampsia did not carry a higher risk for preterm delivery. Obesity was a significant prognostic factor for gestational diabetes. Nulliparous and single women had higher incidence of fetal anomalies and low Apgar score. Women with very advanced maternal age (>= 45 years old) had higher rate of fetal death and low Apgar score. Prenatal care devoted for women with advanced maternal age allows an early detection and treatment of adverse maternal-fetal outcomes.

Muitas mulheres estão adiando a maternidade até a 4ª ou 5ª década de vida, um fenômeno mundial. O objetivo do estudo foi avaliar resultado da gestação em 281 mulheres com 40 anos ou mais, atendidas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre Julho de 1998 e Julho de 2005. A incidência de diabetes gestacional e doença hipertensiva específica da gestação (DHEG) foi de 14,6% e 19,6%, respectivamente. Dezessete (6,0%) mulheres tiveram abortamento e 4 (1,4%) óbito fetal. Três recém-nascidos apresentavam síndrome de Down e 6 outras malformações (índice de detecção de 88,9%). Mulheres com DHEG tiveram maior risco para fetos com baixo peso. História prévia de hipertensão não foi fator de risco para DHEG. Gestantes com DHEG ou diabetes gestacional não apresentaram risco maior para parto pré-termo. Obesidade foi fator de risco para diabetes gestacional. Mulheres sem companheiro e nulíparas tiveram maior incidência de malformações e baixos índices de Apgar. Mulheres com idade materna muito avançada (maior ou igual a 45 anos) apresentaram incidência maior de óbito fetal e de índice de Apgar baixo. A assistência pré-natal específica possibilita a detecção das complicações maternas e a instituição precoce do tratamento / Many women are delaying childbearing until the fourth or fifth decade in life, and it has become a common and worldwide phenomenon. The aim of this study is to evaluate pregnancy outcome in women of 40 or older who were care at our institution. During the period from July 1998 to July 2005 a total of 281 women with advanced maternal age presenting at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were studied. The incidence of gestational diabetes and preeclampsia was 14.6% e 19.2%, respectively. Seventeen women had miscarriage (6.0%) and four presented fetal death (1.4%). There were three infants with Down syndrome and six with other anomalies (detection rate of 88.9%). Women presenting preeclampsia were at higher risk for presenting low birthweight. Previous history of hypertension was not a risk factor for preeclampsia. Pregnant women with gestational diabetes or preeclampsia did not carry a higher risk for preterm delivery. Obesity was a significant prognostic factor for gestational diabetes. Nulliparous and single women had higher incidence of fetal anomalies and low Apgar score. Women with very advanced maternal age (>= 45 years old) had higher rate of fetal death and low Apgar score. Prenatal care devoted for women with advanced maternal age allows an early detection and treatment of adverse maternal-fetal outcomes.