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Objetivo: A finalidade deste estudo foi avaliar o Doppler venoso em gestações gemelares monocoriônicas (MC) com insuficiência placentária e a relação do fluxo sanguíneo venoso com a acidemia no nascimento ou óbito fetal. Método: Estudo prospectivo que incluiu 18 gestações gemelares MC com insuficiência placentária. Os critérios de inclusão foram: gestação gemelar MC e diamniótica, dopplervelocimetria da artéria umbilical (AU) alterada, membranas integras e ausência de defeitos congênitos fetais. Casos que apresentassem a síndrome de transfusão feto- fetal foram excluídos. Os seguintes parâmetros de Doppler foram avaliados: índice de pulsatilidade (IP) da AU, índice de pulsatilidade para veias (IPV) do ducto venoso (DV), IP e velocidade sistólica máxima (Vmax) da artéria cerebral média (ACM), a média da velocidade máxima (TAMxV) da veia umbilical (VU) e a TAMxV da veia portal esquerda (VPE). Os parâmetros dopplervelocimétricos foram transformados em escore zeta (desvios padrão da média) ou múltiplos da mediana (MoM), de acordo com os valores de referência. Amostras de sangue do cordão umbilical foram obtidas imediatamente após o parto para a mensuração do pH da artéria umbilical no nascimento. Resultado: O pH < 7,20 ocorreu em nove recém nascidos (25%), pH< 7,15 em quatro (11,1%) e em quatro (11,1%) casos houve óbito intrauterino. Os escores zeta da TAMxV da VU e da VPE foram significativamente menores no grupo com pH < 7,2 ou óbito intrauterino (respectivamente: -1,79 vs. - 1,22, p=0,006; -2,26 vs. -1,13, p=0,04). Nos casos com pH< 7,15 ou óbito intrauterino a pulsação da VU foi mais frequente (50% vs. 10,7%, p=0,03) e a TAMxV da VU foi significativamente mais baixa (-1,89 vs. -1,26, p= 0,003). A análise de regressão logística demonstrou que o escore zeta da TAMxV da VU prediz significativamente acidemia com pH< 7,20 ou óbito intrauterino (p=0,019). O parâmetro de Doppler que prediz significativamente pH< 7,15 ou óbito intrauterino foi a pulsação da VU (p=0,023). Conclusão: Os parâmetros de Doppler da VU podem predizer a acidemia no nascimento ou o óbito fetal em gestações gemelares MC complicadas por insuficiência placentária / Objectives: The aim of this study was to investigate fetal venous Doppler in monochorionic (MC) twin pregnancies complicated by placental insufficiency and the relationship between fetal venous flow and acidemia at birth or intrauterine fetal death. Methods: This was a prospective study of 18 MC twin pregnancies with placental insufficiency. Inclusion criteria were MC diamniotic twin pregnancies, abnormal umbilical artery (UA) Doppler, intact membranes, and absence of fetal congenital abnormalities. The twin-to-twin transfusion syndrome cases were excluded. The following Doppler measurements were studied: UA pulsatility index (PI), ductus venosus (DV) pulsatility index for veins (PIV), middle cerebral artery (MCA) PI and peak systolic velocity (PSV), intra-abdominal umbilical vein (UV) timeaveraged maximum velocity (TAMxV), and left portal vein (LPV) TAMxV. Doppler parameters were transformed into z-scores (SD values from the mean) or multiples of median (MoM) according to normative references. Blood samples were obtained from the umbilical cord immediately after delivery to measure the pH of the umbilical artery at birth. Results: pH<7.20 occurred in 9 newborns (25%), pH<7.15 in 4 (11.1%), and intrauterine fetal death in 4 (11.1%). The UV-TAMxV and the LPVTAMxV z-scores were significantly lower in the group presenting pH <7.20 or intrauterine fetal death (respectively: -1.79 vs. -1.22, p=0.006; -2.26 vs. -1.13, p=0.04). In cases with pH <7.15 or intrauterine fetal death, UV pulsations were more frequent (50% vs. 10.7%, p=0.03) and the UV-TAMxV z-score was significantly lower (-1.89 vs. -1.26, p=0.003). Logistic regression demonstrated that the UVTAMxV z-score significantly predicted pH at birth <7.20 or intrauterine fetal death (p=0.019). The Doppler parameter which independently predicted pH < 7.15 or intrauterine fetal death was the presence of pulsation in the umbilical vein (p=0.023). Conclusion: UV Doppler parameters may predict acidemia at birth or intrauterine fetal death in MC twins complicated by placental insufficiency

Objetivo: A finalidade deste estudo foi avaliar o Doppler venoso em gestações gemelares monocoriônicas (MC) com insuficiência placentária e a relação do fluxo sanguíneo venoso com a acidemia no nascimento ou óbito fetal. Método: Estudo prospectivo que incluiu 18 gestações gemelares MC com insuficiência placentária. Os critérios de inclusão foram: gestação gemelar MC e diamniótica, dopplervelocimetria da artéria umbilical (AU) alterada, membranas integras e ausência de defeitos congênitos fetais. Casos que apresentassem a síndrome de transfusão feto- fetal foram excluídos. Os seguintes parâmetros de Doppler foram avaliados: índice de pulsatilidade (IP) da AU, índice de pulsatilidade para veias (IPV) do ducto venoso (DV), IP e velocidade sistólica máxima (Vmax) da artéria cerebral média (ACM), a média da velocidade máxima (TAMxV) da veia umbilical (VU) e a TAMxV da veia portal esquerda (VPE). Os parâmetros dopplervelocimétricos foram transformados em escore zeta (desvios padrão da média) ou múltiplos da mediana (MoM), de acordo com os valores de referência. Amostras de sangue do cordão umbilical foram obtidas imediatamente após o parto para a mensuração do pH da artéria umbilical no nascimento. Resultado: O pH < 7,20 ocorreu em nove recém nascidos (25%), pH< 7,15 em quatro (11,1%) e em quatro (11,1%) casos houve óbito intrauterino. Os escores zeta da TAMxV da VU e da VPE foram significativamente menores no grupo com pH < 7,2 ou óbito intrauterino (respectivamente: -1,79 vs. - 1,22, p=0,006; -2,26 vs. -1,13, p=0,04). Nos casos com pH< 7,15 ou óbito intrauterino a pulsação da VU foi mais frequente (50% vs. 10,7%, p=0,03) e a TAMxV da VU foi significativamente mais baixa (-1,89 vs. -1,26, p= 0,003). A análise de regressão logística demonstrou que o escore zeta da TAMxV da VU prediz significativamente acidemia com pH< 7,20 ou óbito intrauterino (p=0,019). O parâmetro de Doppler que prediz significativamente pH< 7,15 ou óbito intrauterino foi a pulsação da VU (p=0,023). Conclusão: Os parâmetros de Doppler da VU podem predizer a acidemia no nascimento ou o óbito fetal em gestações gemelares MC complicadas por insuficiência placentária / Objectives: The aim of this study was to investigate fetal venous Doppler in monochorionic (MC) twin pregnancies complicated by placental insufficiency and the relationship between fetal venous flow and acidemia at birth or intrauterine fetal death. Methods: This was a prospective study of 18 MC twin pregnancies with placental insufficiency. Inclusion criteria were MC diamniotic twin pregnancies, abnormal umbilical artery (UA) Doppler, intact membranes, and absence of fetal congenital abnormalities. The twin-to-twin transfusion syndrome cases were excluded. The following Doppler measurements were studied: UA pulsatility index (PI), ductus venosus (DV) pulsatility index for veins (PIV), middle cerebral artery (MCA) PI and peak systolic velocity (PSV), intra-abdominal umbilical vein (UV) timeaveraged maximum velocity (TAMxV), and left portal vein (LPV) TAMxV. Doppler parameters were transformed into z-scores (SD values from the mean) or multiples of median (MoM) according to normative references. Blood samples were obtained from the umbilical cord immediately after delivery to measure the pH of the umbilical artery at birth. Results: pH<7.20 occurred in 9 newborns (25%), pH<7.15 in 4 (11.1%), and intrauterine fetal death in 4 (11.1%). The UV-TAMxV and the LPVTAMxV z-scores were significantly lower in the group presenting pH <7.20 or intrauterine fetal death (respectively: -1.79 vs. -1.22, p=0.006; -2.26 vs. -1.13, p=0.04). In cases with pH <7.15 or intrauterine fetal death, UV pulsations were more frequent (50% vs. 10.7%, p=0.03) and the UV-TAMxV z-score was significantly lower (-1.89 vs. -1.26, p=0.003). Logistic regression demonstrated that the UVTAMxV z-score significantly predicted pH at birth <7.20 or intrauterine fetal death (p=0.019). The Doppler parameter which independently predicted pH < 7.15 or intrauterine fetal death was the presence of pulsation in the umbilical vein (p=0.023). Conclusion: UV Doppler parameters may predict acidemia at birth or intrauterine fetal death in MC twins complicated by placental insufficiency

Abstract Abnormal placentation is associated with preeclampsia and placental insufficiency, both of which increase the risk for fetal growth restriction. So far the early recognition of the risk population for preeclampsia has been problematic. The first hypothesis of this study was that in preeclampsia, the maternal serum proteomic profile is different from that in uncomplicated pregnancies, and this difference is detectable already in early pregnancy. The findings of this study demonstrate that in clinical preeclampsia the maternal serum proteomic profile is different from that in uncomplicated pregnancies with increased levels of placental proteins and antiangiogenic factors in pregnancies with clinical preeclampsia. Furthermore, the early pregnancy maternal serum proteomic profile in women who later develop preeclampsia revealed a distinct and different pattern compared with the profile in clinical preeclampsia. In early pregnancy, the differentially expressed proteins belong to placental proteins, vascular and/or transport proteins and matrix and/or acute phase proteins, while angiogenic and antiangiogenic proteins were not significantly expressed in early pregnancy. Preeclampsia, placental insufficiency, fetal growth restriction and type-1 diabetes may have an impact on fetal cardiovascular hemodynamics. The second hypothesis in this thesis was that in placental insufficiency, abnormalities in fetal cardiovascular status correlate with biochemical markers of cardiac dysfunction and chronic hypoxia. In placental insufficiency, increases in fetal N-terminal pro-atrial (NT-proANP) and pro-B-type natriuretic peptide (NT-proBNP) and in fetal erythropoietin concentrations were related to increased pulsatility in the fetal umbilical artery and descending aorta. In addition, these fetuses demonstrated increased pulsatility in their systemic venous blood velocity waveforms. Thus, in placental insufficiency, biochemical markers of cardiac dysfunction and chronic hypoxia are associated with signs of increased fetal cardiac afterload and systemic venous pressure. Increased NT-proANP and NT-proBNP levels were also detected in fetuses of type-1 diabetic mothers with normal umbilical artery velocimetry. In these pregnancies, NT-proANP and NT-proBNP levels were related to poor maternal glycemic control during early pregnancy.

Umbilical flow velocity waveforms (FVW' s) can be measured non-invasively using Doppler ultrasound. Changes in the FVW's occur long before the warning signs from other conventional monitoring methods. Correct interpretation of the changes in the FVW has the potential of providing the clinician with an early warning of foetal distress. A number of indices have been described in the literature to characterise the FVW including the Pulsatility Index (PI), the Resistance Index (RI) and more recently, the High Resistance State Index (HRSI). Researchers have shown a dependence of the FVW, and thus the indices which describe it, on factors such as the placental resistance (Muijsers et al 1990a) blood pressure pulsatility (Mulders et al 1986), and the foetal heart rate (Downing et al 1991). In order to model the foetal circulation, the dimensions of the foetal vessels were required. These were taken from the literature when available, but had to be supplemented by measurements on post mortem specimens. This information, together with blood pressures and flow rates taken from the literature, was used to design electrical analogous models of the foetal arterial circulation (model 1 and model 2), which were implemented using PSpice, which is an electronic circuit simulator package. The Flow Velocity Waveforms (FVW's) simulated were stored and then analyzed using MATLAB, which is a mathematical package to calculate the waveform indices and both the blood pressure and percentage blood flow to the different anatomical regions of the foetus. Model 1 is a simple model of the umbilical placental unit only, which assumes a rectified sine wave with a D.C. offset as an input waveform while Model 2 is a distributed element model of the complete foetal arterial system, including a realistic representation of the foetal heart. AIM: Simulations of the FVW were used to examine the effects of placental obliteration (raised placental resistance), placental size, foetal heart rate (FHR), blood pressure pulsatility (BPPI), mean blood pressure (BP), and site of measurement of the FVW along the umbilical artery and thus on the waveform indices which are used to describe it (RI, PI and HRSI). RESULTS/ DISCUSSION: The investigations using models 1 and 2 showed that the indices were significantly dependent on the placental resistance, the size of the placenta and the type of placental obliteration. Model 1 was also used to investigate the effect of FHR variations on the indices under the original assumption that the input waveform to the umbilical/placental unit was a rectified sinusoid offset by a constant voltage (D.C.) (Thompson and Trudinger 1990). The result obtained, that is, the FHR does not affect the indices (in particular the PI) needed further investigation because the assumption for the input waveform is not true under all conditions. For this reason, the simulations were repeated using model 2, with the interesting result that there is a difference between short term FHR variations and long-term FHR variation. Short term FHR variations had a pronounced effect on the indices. The blood pressure pulsatility and the indices concerned varied by large amounts in this case, which indicated a link between the blood pressure pulsatility and all the indices. Long term FHR variations had an inconsistent but small effect on the blood pressure pulsatility and in turn had a small effect on the RI and PI. The mean blood pressure in these simulations decreased with increasing FHR which resulted in a pronounced increase in the HRSI which indicated the dependency of this index on the mean blood pressure rather than on the blood pressure pulsatility. It was found that the HRSI is a good index of placental resistance and may be particularly useful in evaluating high placental resistance in cases of absent flow during diastole, since, in these cases it is only slightly affected by the FHR. A value of greater than 34 percent is the recommended HRSI value to indicate severe foetal distress. The results also indicate that the FVW shape varies along the umbilical artery and is far more pulsatile at the aortic (proximal) end than the placental end. This is reflected in the indices which thus have worst case values at the placental end. It is thus recommended that, where possible, the indices are measured at the placental end of the umbilical artery.

OBJETIVO: O presente estudo, realizado em gestantes de alto risco com diagnóstico de insuficiência placentária, tem como objetivo avaliar o fluxo sanguíneo fetal na veia portal esquerda (VPE), veia umbilical (VU) e ducto venoso (DV), e estabelecer quais parâmetros associam-se com a acidemia fetal no nascimento. MÉTODO: Pesquisa prospectiva envolvendo 58 gestantes, classificadas segundo a presença ou ausência do diagnóstico de acidemia no nascimento, de acordo com o pH no sangue da artéria umbilical, constituindo-se de: Grupo I: 26 casos (acidemia pH<7,20) e Grupo II: 32 casos (pH normal pH7,20). Foram excluídos da pesquisa os casos com diagnóstico pós-natal de anomalia do RN e aqueles em que não se obteve a mensuração do pH no nascimento. As seguintes variáveis dopplervelocimétricas da VPE e VU foram comparadas entre os grupos: escore-zeta da TAMxV (time averaged maximum velocity) (cm/s), Q/Kg (fluxo sanguíneo por Kg de peso fetal) (ml/min/kg) e presença de pulsatilidade; e o escore-zeta do índice de pulsatilidade para veias (IPV) do DV. RESULTADOS: O escore-zeta da TAMxV (rho=0,392, P=0,002) e o Q/Kg da VPE (rho=0,274, P=0,037), o escore-zeta do IPV do DV (rho=-0,377, P=0,004) e o Q/Kg da VU (rho=0,261, P=0,048) apresentaram correlação significativa com o pH no nascimento. Realizando-se a análise de regressão logística multivariada, as variáveis independentes que restaram no modelo final para a ocorrência de acidemia no nascimento (pH<7,20) foram: escore-zeta da TAMxV da VPE (OR=0,41; IC95% 0,25 a 0,71; P=0,001) e fluxo reverso na VPE (OR=0,004; IC95% 0,00 a 0,15; P=0,003), ambas demonstrando efeito protetor para acidemia. Com o presente modelo, constatou-se que 74,1% dos casos são corretamente classificados para acidemia no nascimento. CONCLUSÕES: pela análise do Doppler venoso fetal na insuficiência placentária constatou-se que a acidemia no nascimento (pH<7,20) está associada de forma independente com o fluxo reverso na VPE e com o escore-zeta da TAMxV da VPE, ambos demonstrando efeito protetor com redução do risco para a acidemia / OBJECTIVE: This study, conducted in high-risk pregnancies with placental insufficiency, aims to avaliate blood flow in the fetal left portal vein (LPV), umbilical vein (UV) and ductus venosus (DV), and establish which parameters are associated with acidemia at birth. METHOD: A prospective research involving 58 pregnant women, classified according to the presence or absence of the diagnosis of fetal acidosis at birth, according to pH in the blood of the umbilical artery, consisting of: Group I: 26 cases (acidemia, pH <7,20) and Group II: 32 cases (normal pH, pH 7,20). Exclusion criteria were patients who had postnatal diagnosis of abnormality of the newborn and those in which the pH measurement was not obtained at birth. The following Doppler variables of LPV and UV were compared between the groups: TAMxV (Time Averaged Maximum Velocity) (cm/s) zeta-score, Q/kg (blood flow per kg of fetal weight) (ml/min/kg) and presence of pulsatility; and DV pulsality index for veins (PIV) zetascore. RESULTS: LPV TAMxV zeta-score (rho=0.392, P=0.002) and Q/kg (rho=0.274, P=0.037), DV PIV zeta-score (rho=-0.377, P=0.004) and UV Q/kg (rho=0.261, P=0.048) showed significant correlation with pH at birth. Performing the multivariate logistic regression analysis, the independent variables that remained in the final model were: TAMxV of LPV zeta-score (OR=0.41; IC95% 0.25 a 0.71; P=0.001) and reverse flow in LPV (OR=0.004; IC95% 0.00 a 0.15; P=0.003), both showing a protective effect to reduce the risk of acidemia. With this model, it was found that 74,1% of cases are correctly classified to birth acidemia. CONCLUSION: by analysis of fetal venous Doppler in placental insufficiency we found that acidemia at birth (pH <7.20) is independently associated with reverse flow in the LPV and LPV TAMxV z-score, both showing a protective effect with reduced risk for the event

Objetivo: Avaliar a relação entre a classificação do fluxo na onda a do ducto venoso no dia do parto e os resultados pós-natais em gestações com diástole zero ou reversa nas artérias umbilicais. Métodos: Analisou-se retrospectivamente a evolução pós-natal de 103 recém-nascidos de gestações com diagnóstico de diástole zero ou reversa à dopplervelocimetria das artérias umbilicais, no período de janeiro de 1997 a dezembro de 2004. Foram incluídas gestações únicas e fetos sem malformações. Nenhum caso recebeu corticoterapia antenatal. Os casos foram divididos em dois grupos de acordo com a classificação do fluxo na onda a do ducto venoso no dia do parto. Grupo A: 20 casos com fluxo ausente ou reverso e Grupo B: 83 casos com fluxo positivo. Foram avaliados os seguintes resultados pós-natais: idade gestacional no dia do parto, peso de nascimento, Apgar de primeiro e quinto minutos, pH e BE do sangue da artéria umbilical ao nascimento, necessidade de intubação orotraqueal e encaminhamento à unidade de terapia intensiva neonatal, além de: ocorrência de restrição de crescimento fetal, doença das membranas hialinas, pneumotórax, hemorragia pulmonar, displasia broncopulmonar, persistência do canal arterial, sepse, enterocolite necrosante, retinopatia da prematuridade, plaquetopenia, hipoglicemia, hiperglicemia, convulsão, exame neurológico anormal em 24 horas de vida, hemorragia intracraniana, os recém-nascidos foram avaliados durante toda a internação no berçário, sendo registrado o tempo de internação, ocorrência de óbito e causas do óbito. Para análise estatística foram utilizados os testes de Qui-Quadrado, exato de Fisher e Mann-Whitney U, adotado nível de significância de 5%. Resultados: Todos os partos foram cesareanos. A idade gestacional foi semelhante nos dois grupos, 30 semanas no grupo A e 30,9 semanas no B (P=0,23). Observou-se no grupo com fluxo ausente ou reverso da onda a do ducto venoso maior freqüência dos seguintes resultados pós-natais adversos: menor peso ao nascimento (831g vs 1.105g, P<0,001), menores índices de Apgar de primeiro minuto (85% vs 20%, P=0,001) e de quinto minuto (45% vs 10,7%, P =0,001), maior necessidade de intubação orotraqueal (100% vs 48,1%, P=0,001), maior ocorrência de acidose ao nascimento (93% vs 36%, P<0,001), hemorragia pulmonar (40% vs 16,8%, P=0,03), plaquetopenia (65% vs 37,3%, P=0,02), hipoglicemia (85% vs 56,6%, P=0,01), hemorragia intracraniana (52,6% vs 26,3%, P=0,02) e óbito pós natal (65% vs 26,5%, P=0,007). Conclusão: O estudo do fluxo no ducto venoso pode fornecer informações adicionais na programação do momento mais adequado para a interrupção de gestações que cursam com diástole zero ou reversa nas artérias umbilicais em gestações com prematuridade extrema. / Objective: This study was undertaken to analyze the relation between absent or reverse flow during atrial contraction in the ductus venosus on the day of delivery in pregnancies complicated by absent or reversed end-diastolic flow in the umbilical artery and postnatal outcome. Methods: Postnatal outcome of 103 pregnant women with absent or reversed end-diastolic flow (ARED flow) in the umbilical arteries was retrospectively analyzed from January 1997 to December 2004. In this study, only singleton pregnancies that did not take prenatal steroids and with no fetal anomalies were included. The outcome was analyzed in two groups: Group A (n=20), fetuses with absent or reversed ductus venosus flow during the A-wave and group B (n=83) fetuses with a positive flow. After delivery, the following immediate neonatal outcomes of interest were obtained: gestational age at the time of delivery, 1-and 5-minute Apgar scores, umbilical artery pH and base excess, birth weight, need of orotraqueal intubation, and referral to the neonatal intensive care unit. We have also analyzed the incidence of fetal growth restriction, hyaline membrane disease, pneumotorax, lung hemorrhage, bronchopulmonary displasia, persistence of the arterial channel, sepses, necrotizing enterocolitis, retinopathy of prematurity, fetal plaquetopenia, hypoglycemia, hyperglycemia, abnormal neurological exam within 24 hours of life, intracranial hemorrhage, seizures, length of hospitalization, postnatal deaths and its causes. Data were compared by chi-square, Fisher\'s exact test and a Mann-Whitney U test, and the level of significance adopted was of 5%. Results: All newborns were delivered by cesarean section. The average gestational age at birth was 30 weeks in group A and 30,9 in group B (P= 0.23). Fetuses of the group A presented lower birth weight (831g vs 1105g, P< 0.001), lower Apgar score at first (85% vs 20%, P= 0.001), and at fifth minutes (45% vs 10.7%, P =0.001), higher incidence of orotraqueal intubation (100% vs 48.1%, P= 0.001) than fetuses of group B. Group A had also more cases of acidosis (93% vs 36%, P<0.001), lung hemorrhage (40% vs 16,8%, P=0,03), plaquetopenia (65% vs 37.3%, P=0.02), hypoglycemia (85% vs 56.6%, P=0.01), intracranial hemorrhage (52.6% vs 26.3%, P=0.02) and postnatal death (65% vs 26.5%, P=0.007). Conclusion: Ductus venous Doppler can supply additional information regarding the better time to deliver pregnant women with earlier gestational age and with absent or reversed end-diastolic flow (ARED flow) in the umbilical artery.

OBJETIVO: O presente estudo, realizado em gestantes de alto risco com diagnóstico de insuficiência placentária, tem como objetivo avaliar o fluxo sanguíneo fetal na veia portal esquerda (VPE), veia umbilical (VU) e ducto venoso (DV), e estabelecer quais parâmetros associam-se com a acidemia fetal no nascimento. MÉTODO: Pesquisa prospectiva envolvendo 58 gestantes, classificadas segundo a presença ou ausência do diagnóstico de acidemia no nascimento, de acordo com o pH no sangue da artéria umbilical, constituindo-se de: Grupo I: 26 casos (acidemia pH<7,20) e Grupo II: 32 casos (pH normal pH7,20). Foram excluídos da pesquisa os casos com diagnóstico pós-natal de anomalia do RN e aqueles em que não se obteve a mensuração do pH no nascimento. As seguintes variáveis dopplervelocimétricas da VPE e VU foram comparadas entre os grupos: escore-zeta da TAMxV (time averaged maximum velocity) (cm/s), Q/Kg (fluxo sanguíneo por Kg de peso fetal) (ml/min/kg) e presença de pulsatilidade; e o escore-zeta do índice de pulsatilidade para veias (IPV) do DV. RESULTADOS: O escore-zeta da TAMxV (rho=0,392, P=0,002) e o Q/Kg da VPE (rho=0,274, P=0,037), o escore-zeta do IPV do DV (rho=-0,377, P=0,004) e o Q/Kg da VU (rho=0,261, P=0,048) apresentaram correlação significativa com o pH no nascimento. Realizando-se a análise de regressão logística multivariada, as variáveis independentes que restaram no modelo final para a ocorrência de acidemia no nascimento (pH<7,20) foram: escore-zeta da TAMxV da VPE (OR=0,41; IC95% 0,25 a 0,71; P=0,001) e fluxo reverso na VPE (OR=0,004; IC95% 0,00 a 0,15; P=0,003), ambas demonstrando efeito protetor para acidemia. Com o presente modelo, constatou-se que 74,1% dos casos são corretamente classificados para acidemia no nascimento. CONCLUSÕES: pela análise do Doppler venoso fetal na insuficiência placentária constatou-se que a acidemia no nascimento (pH<7,20) está associada de forma independente com o fluxo reverso na VPE e com o escore-zeta da TAMxV da VPE, ambos demonstrando efeito protetor com redução do risco para a acidemia / OBJECTIVE: This study, conducted in high-risk pregnancies with placental insufficiency, aims to avaliate blood flow in the fetal left portal vein (LPV), umbilical vein (UV) and ductus venosus (DV), and establish which parameters are associated with acidemia at birth. METHOD: A prospective research involving 58 pregnant women, classified according to the presence or absence of the diagnosis of fetal acidosis at birth, according to pH in the blood of the umbilical artery, consisting of: Group I: 26 cases (acidemia, pH <7,20) and Group II: 32 cases (normal pH, pH 7,20). Exclusion criteria were patients who had postnatal diagnosis of abnormality of the newborn and those in which the pH measurement was not obtained at birth. The following Doppler variables of LPV and UV were compared between the groups: TAMxV (Time Averaged Maximum Velocity) (cm/s) zeta-score, Q/kg (blood flow per kg of fetal weight) (ml/min/kg) and presence of pulsatility; and DV pulsality index for veins (PIV) zetascore. RESULTS: LPV TAMxV zeta-score (rho=0.392, P=0.002) and Q/kg (rho=0.274, P=0.037), DV PIV zeta-score (rho=-0.377, P=0.004) and UV Q/kg (rho=0.261, P=0.048) showed significant correlation with pH at birth. Performing the multivariate logistic regression analysis, the independent variables that remained in the final model were: TAMxV of LPV zeta-score (OR=0.41; IC95% 0.25 a 0.71; P=0.001) and reverse flow in LPV (OR=0.004; IC95% 0.00 a 0.15; P=0.003), both showing a protective effect to reduce the risk of acidemia. With this model, it was found that 74,1% of cases are correctly classified to birth acidemia. CONCLUSION: by analysis of fetal venous Doppler in placental insufficiency we found that acidemia at birth (pH <7.20) is independently associated with reverse flow in the LPV and LPV TAMxV z-score, both showing a protective effect with reduced risk for the event

Objetivo: Avaliar a relação entre a classificação do fluxo na onda a do ducto venoso no dia do parto e os resultados pós-natais em gestações com diástole zero ou reversa nas artérias umbilicais. Métodos: Analisou-se retrospectivamente a evolução pós-natal de 103 recém-nascidos de gestações com diagnóstico de diástole zero ou reversa à dopplervelocimetria das artérias umbilicais, no período de janeiro de 1997 a dezembro de 2004. Foram incluídas gestações únicas e fetos sem malformações. Nenhum caso recebeu corticoterapia antenatal. Os casos foram divididos em dois grupos de acordo com a classificação do fluxo na onda a do ducto venoso no dia do parto. Grupo A: 20 casos com fluxo ausente ou reverso e Grupo B: 83 casos com fluxo positivo. Foram avaliados os seguintes resultados pós-natais: idade gestacional no dia do parto, peso de nascimento, Apgar de primeiro e quinto minutos, pH e BE do sangue da artéria umbilical ao nascimento, necessidade de intubação orotraqueal e encaminhamento à unidade de terapia intensiva neonatal, além de: ocorrência de restrição de crescimento fetal, doença das membranas hialinas, pneumotórax, hemorragia pulmonar, displasia broncopulmonar, persistência do canal arterial, sepse, enterocolite necrosante, retinopatia da prematuridade, plaquetopenia, hipoglicemia, hiperglicemia, convulsão, exame neurológico anormal em 24 horas de vida, hemorragia intracraniana, os recém-nascidos foram avaliados durante toda a internação no berçário, sendo registrado o tempo de internação, ocorrência de óbito e causas do óbito. Para análise estatística foram utilizados os testes de Qui-Quadrado, exato de Fisher e Mann-Whitney U, adotado nível de significância de 5%. Resultados: Todos os partos foram cesareanos. A idade gestacional foi semelhante nos dois grupos, 30 semanas no grupo A e 30,9 semanas no B (P=0,23). Observou-se no grupo com fluxo ausente ou reverso da onda a do ducto venoso maior freqüência dos seguintes resultados pós-natais adversos: menor peso ao nascimento (831g vs 1.105g, P<0,001), menores índices de Apgar de primeiro minuto (85% vs 20%, P=0,001) e de quinto minuto (45% vs 10,7%, P =0,001), maior necessidade de intubação orotraqueal (100% vs 48,1%, P=0,001), maior ocorrência de acidose ao nascimento (93% vs 36%, P<0,001), hemorragia pulmonar (40% vs 16,8%, P=0,03), plaquetopenia (65% vs 37,3%, P=0,02), hipoglicemia (85% vs 56,6%, P=0,01), hemorragia intracraniana (52,6% vs 26,3%, P=0,02) e óbito pós natal (65% vs 26,5%, P=0,007). Conclusão: O estudo do fluxo no ducto venoso pode fornecer informações adicionais na programação do momento mais adequado para a interrupção de gestações que cursam com diástole zero ou reversa nas artérias umbilicais em gestações com prematuridade extrema. / Objective: This study was undertaken to analyze the relation between absent or reverse flow during atrial contraction in the ductus venosus on the day of delivery in pregnancies complicated by absent or reversed end-diastolic flow in the umbilical artery and postnatal outcome. Methods: Postnatal outcome of 103 pregnant women with absent or reversed end-diastolic flow (ARED flow) in the umbilical arteries was retrospectively analyzed from January 1997 to December 2004. In this study, only singleton pregnancies that did not take prenatal steroids and with no fetal anomalies were included. The outcome was analyzed in two groups: Group A (n=20), fetuses with absent or reversed ductus venosus flow during the A-wave and group B (n=83) fetuses with a positive flow. After delivery, the following immediate neonatal outcomes of interest were obtained: gestational age at the time of delivery, 1-and 5-minute Apgar scores, umbilical artery pH and base excess, birth weight, need of orotraqueal intubation, and referral to the neonatal intensive care unit. We have also analyzed the incidence of fetal growth restriction, hyaline membrane disease, pneumotorax, lung hemorrhage, bronchopulmonary displasia, persistence of the arterial channel, sepses, necrotizing enterocolitis, retinopathy of prematurity, fetal plaquetopenia, hypoglycemia, hyperglycemia, abnormal neurological exam within 24 hours of life, intracranial hemorrhage, seizures, length of hospitalization, postnatal deaths and its causes. Data were compared by chi-square, Fisher\'s exact test and a Mann-Whitney U test, and the level of significance adopted was of 5%. Results: All newborns were delivered by cesarean section. The average gestational age at birth was 30 weeks in group A and 30,9 in group B (P= 0.23). Fetuses of the group A presented lower birth weight (831g vs 1105g, P< 0.001), lower Apgar score at first (85% vs 20%, P= 0.001), and at fifth minutes (45% vs 10.7%, P =0.001), higher incidence of orotraqueal intubation (100% vs 48.1%, P= 0.001) than fetuses of group B. Group A had also more cases of acidosis (93% vs 36%, P<0.001), lung hemorrhage (40% vs 16,8%, P=0,03), plaquetopenia (65% vs 37.3%, P=0.02), hypoglycemia (85% vs 56.6%, P=0.01), intracranial hemorrhage (52.6% vs 26.3%, P=0.02) and postnatal death (65% vs 26.5%, P=0.007). Conclusion: Ductus venous Doppler can supply additional information regarding the better time to deliver pregnant women with earlier gestational age and with absent or reversed end-diastolic flow (ARED flow) in the umbilical artery.

Objetivo: Avaliar a relação entre os parâmetros da cardiotocografia computadorizada (cCTG) e da dopplervelocimetria com a lesão miocárdica fetal e com a ocorrência de acidemia no nascimento, em gestações com insuficiência placentária. Métodos: Estudo prospectivo com 49 gestações complicadas pela insuficiência placentária (Doppler de artéria umbilical anormal - índice de pulsatilidade [IP] > p95) diagnosticada entre 26 e 34 semanas. Todas as pacientes foram avaliadas pelo Doppler de artéria umbilical, artéria cerebral média e ducto venoso e pela cCTG (Sonicaid FetalCare, versão 2.2, por 30 minutos). Foi analisada a última avaliação fetal até 48h antes do parto e anterior à corticoterapia. Foi analisado o sangue de cordão umbilical no parto, para detectar a acidemia no nascimento (pH < 7,20) e a lesão miocárdica fetal (Troponina T cardíaca [cTnT] >= 0,09 ng/mL). A cTnT foi obtida em 38 casos e o pH em 46 casos. Resultados: Quinze (39,5%) recém-nascidos apresentaram cTnT >= 0,09 ng/ml e 20 (43,5%) pH < 7,20. Os fetos que evoluíram com acidemia apresentaram menor número de movimentos por hora na cCTG (mediana 2 vs. 15, p=0,019). Houve correlação positiva entre o pH e o número de movimentos fetais por hora (rho=0,35; P=0,019) e com a frequência cardíaca fetal basal (rho 0,37, P=0,011), e correlação negativa entre o pH e o escore zeta do IP para veias (IPV) do ducto venoso (rho= -0,31, P=0,036). A regressão logística identificou o escore-zeta do IPV do ducto venoso (P=0,023) e a frequência cardíaca fetal basal (P=0,040) como variáveis independentes associadas com a acidemia no nascimento. A ocorrência de lesão miocárdica fetal, quando comparada ao grupo com cTnT normal, apresentou associação significativa com o escore zeta do IP da artéria umbilical (mediana 8,8 vs. 4,0; P=0,003), IPV do ducto venoso (mediana 2,6 vs. -1,4; P= 0,007), frequência cardíaca fetal basal (mediana 146 vs. 139 bpm; P=0,033), número de acelerações entre 10-15 bpm (mediana 0 vs. 1; P=0,013), duração dos episódios de baixa variação (mediana 21 vs. 10 min; P=0,038) e a variação de curto prazo (short-term variation-STV) (mediana 3,7 vs. 6,1 ms; P=0,003). Observou-se correlação positiva entre o valor da cTnT no cordão umbilical e a frequência cardíaca fetal basal (rho=0,33; P=0,042), e correlação negativa entre a cTnT e a STV (rho= -0,37; P=0,021). A regressão logística identificou a STV como fator preditor independente para o dano miocárdico fetal (P=0,01), sendo a STV <= 4,3 ms o melhor ponto de corte para predição do evento (sensibilidade de 66,7% e especificidade de 91,3%). Conclusão: Em gestações com insuficiência placentária detectada antes da 34ª semana gestacional, o IPV do ducto venoso e a frequência cardíaca fetal basal analisada pela cCTG são os preditores independentes associados com a acidemia no nascimento; e o valor da STV avaliada pela cCTG é a variável que melhor prediz a lesão miocárdica fetal. A cCTG é ferramenta importante no manejo de fetos com insuficiência placentária, principalmente quando associada a outros métodos propedêuticos como a dopplervelocimetria / Objective: To evaluate the reliability of fetal heart rate parameters analyzed by computerized cardiotocography (cCTG) and fetal Doppler to predict myocardial damage and acidemia at birth in pregnancies complicated by placental insufficiency. Methods: Forty nine patients with placental insufficiency (abnormal umbilical artery Doppler - pulsatility index [PI] > p95) diagnosed between 26-34 weeks of gestation were prospectively studied. All patients were submitted to Dopplervelocimetry of umbilical artery, middle cerebral artery and ductus venosus and to the cCTG (Sonicaid Fetal Care, version 2.2; 30 minutes of duration). We analyzed the last fetal assessment 48h before delivery and prior to steroid therapy.Umbilical cord blood samples were collected at birth to detect acidemia (pH < 7.20) and myocardial damage (cTnT >= 0.09 ng/ml). The results of cTnT were available in 38 cases and in 46 cases we had the pH values. Results: Fifteen (39.5%) newborns had cTnT >= 0.09 ng/ml and 20 (43.5%) had a pH < 7.20. Fetuses who developed acidemia had fewer fetal movements per hour in cCTG (median 2 vs. 15, P=0.019). There was a positive correlation between pH and the number of fetal movements per hour (rho 0.35, P=0.019) and basal fetal heart rate (rho 0.37, P=0.011), and a negative correlation between pH and the zscore of pulsatility index for veins (PIV) of ductus venosus (rho= -0.31, P=0.036). The logistic regression analysis identified the z-score of PIV of ductus venosus (P=0.023) and basal fetal heart rate (P=0.040) as independent variables associated with acidemia at birth. The occurrence of fetal myocardial injury was significantly associated with z-score of PI of umbilical artery (median 8.8 vs. 4.0, P=0.003), PIV of ductus venosus (median 2.6 vs. -1.4, P=0.007), basal fetal heart rate (median 146 vs. 139 bpm, P=0.033), number of accelerations between 10-15 bpm (median 0 vs. 1, P=0.013), duration of episodes of low variation (median 21 vs. 10 min, P=0.038) and short-term variation (STV) (median 3.7 vs. 6.1 ms, P=0.003). We observed a positive correlation between the value of cTnT in the umbilical cord and basal fetal heart rate (rho=0.33, P=0.042), and a negative correlation between cTnT and STV (rho=-0.37, P=0.021). Logistic regression identified the STV as an independent predictor for myocardial damage (P=0.01), and STV <= 4.3 ms was the best cutoff to predict the event (sensitivity 66.7% and specificity of 91.3%). Conclusion: In pregnancies with placental insufficiency detected before the 34th week of gestation, the PIV of ductus venosus and basal fetal heart rate analyzed by cCTG are independent variables associated with acidemia at birth; and the STV is the parameter that best predicts fetal myocardial injury. The cCTG is an important tool in the management of fetuses with placental insufficiency, especially when associated with other diagnostic methods such as Doppler