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Confiabilidade dos Exames de Vitalidade Fetal na Interrupção da Gestação

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CONFIABILIDADE DOS EXAMES
  DO BEM ESTAR FETAL NA
INTERRUPÇÃO DA GESTAÇÃO

     DR. RAFAEL FREDERICO BRUNS
  Departamento de Tocoginecologia da UFPR
            rafa@bruns.med.br
DOPPLER E
                           INTERRUPÇÃO



                                                                                   Christian Doppler
                                                                                     1803 - 1853



Über das farbige Licht der Doppelsterne und einiger anderer Gestirne des Himmels
   (Sobre a luz cromática das estrelas duplas e outras estrelas do firmamento)
Obstetricians are hypnotized by idea that all
fetal risk situations could be assessed by one
single test

In prenatal medicine, just as in postnatal
medicine, we will have to use several tests
simultaneously

                         Geoffrey Dawes, 1992
DOPPLER E
INTERRUPÇÃO
DOPPLER E
INTERRUPÇÃO
DOPPLER E
INTERRUPÇÃO

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Confiabilidade dos Exames de Vitalidade Fetal na Interrupção da Gestação

  • 1. CONFIABILIDADE DOS EXAMES DO BEM ESTAR FETAL NA INTERRUPÇÃO DA GESTAÇÃO DR. RAFAEL FREDERICO BRUNS Departamento de Tocoginecologia da UFPR rafa@bruns.med.br
  • 2. DOPPLER E INTERRUPÇÃO Christian Doppler 1803 - 1853 Über das farbige Licht der Doppelsterne und einiger anderer Gestirne des Himmels (Sobre a luz cromática das estrelas duplas e outras estrelas do firmamento)
  • 3. Obstetricians are hypnotized by idea that all fetal risk situations could be assessed by one single test In prenatal medicine, just as in postnatal medicine, we will have to use several tests simultaneously Geoffrey Dawes, 1992
  • 7. DOPPLER E INTERRUPÇÃO Interrompa muito cedo e você ganha uma garrafa de uísque...
  • 8. DOPPLER E INTERRUPÇÃO Interrompa muito cedo e você ganha uma garrafa de uísque... Interrompa muito tarde e você ganha uma intimação judicial! Thorton, 1996
  • 9. DOPPLER E INTERRUPÇÃO I’m a fetus in the womb I fear it may became my thomb If only I could give a shout To make my doctor get me out! Unknown medical student, Dublin, Br J Obstet Gynaecol
  • 12. “O Doppler é um bom teste para o padrão obstrutivo”
  • 14. DOPPLER E INTERRUPÇÃO PESO IDADE GESTACIONAL
  • 15. DOPPLER E INTERRUPÇÃO PESO IDADE GESTACIONAL
  • 16. DOPPLER E INTERRUPÇÃO PESO IDADE GESTACIONAL
  • 17. DOPPLER E INTERRUPÇÃO “Uma das situações mais frustrantes em obstetrícia é diferenciar o feto CONSTITUCIONALMENTE PEQUENO do feto com RESTRIÇÃO DE CRESCIMENTO INTRA- UTERINO”
  • 18. DOPPLER E INTERRUPÇÃO 40% DOS CONCEPTOS ABAIXO DO PERCENTIL 10 TEM ÍNDICE PONDERAL NORMAL AO NASCIMENTO 50% DOS CONCEPTOS DIAGNOSTICADOS COMO RCIU PELO ÍNDICE PONDERAL TEM PESO ACIMA DO PERCENTIL 10 Weiner, Am J Perinatol 1984
  • 20. “Sua principal aplicação é nos fetos abaixo de 32 semanas”
  • 22. DOPPLER E INTERRUPÇÃO DISTRESS RESPIRATÓRIO 50% AIG PIG 40% Prevalência 30% 20% 10% 0% 27-28s 29-30s 31-32s 33-34s 35-36s 37-38s Idade Gestacional Tyson et al. Pediatrics, 1997
  • 24. “Como avaliar a vitalidade nestes fetos?”
  • 25. DOPPLER E IG > 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 26. DOPPLER E IG > 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 27. DOPPLER E IG > 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 28. DOPPLER E IG > 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 29. DOPPLER E IG > 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 30. DOPPLER E IG > 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 31. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 32. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 33. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 34. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 35. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 36. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM ILA 1.00 PROBABILIADADE 0.75 0.50 0.25 0 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 37. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM 6.00 4.00 DESVIOS PADRÃO 2.00 0 -2.00 -4.00 -6.00 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 38. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM 6.00 4.00 DESVIOS PADRÃO 2.00 0 -2.00 -4.00 -6.00 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 39. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM 6.00 4.00 DESVIOS PADRÃO 2.00 0 -2.00 -4.00 -6.00 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 40. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM 6.00 4.00 DESVIOS PADRÃO 2.00 0 -2.00 -4.00 -6.00 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 41. DOPPLER E IG < 32s INTERRUPÇÃO A Umbilical DV STV ACM 6.00 4.00 DESVIOS PADRÃO 2.00 0 -2.00 -4.00 -6.00 -35 -28 -21 -14 -7 0 DIAS ANTES DO PARTO Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 42. DOPPLER E INTERRUPÇÃO DV, STV e Mortalidade Perinatal Óbito n Vivos Óbito Fetal Neonatal Ambos 13/33 alterados 33 20 6 7 39% Nenhum ou 4/60 apenas um 60 56 - 4 7% alterado Total 93 76 6 11 Hecher, K et al. Ultrasound in obstetrics & gynecology, 2001
  • 44. Devemos usar o Ducto Venoso ou Short Term Variation? Até quando devemos esperar?
  • 45. DOPPLER E INTERRUPÇÃO Doppler Venoso e Mortalidade Perinatal 100% 75% 50% 25% 0% Total Alteração Precoce Alteração Tardia Ferrazzi et al, Ultrasound Obstet Gynaecol, 2002
  • 46. DOPPLER E INTERRUPÇÃO TRUFFLE Trial of Umbilical Flow and Fetal FLow in Europe RANDOMIZAÇÃO EM 3 GRUPOS
  • 47. DOPPLER E INTERRUPÇÃO TRUFFLE Trial of Umbilical Flow and Fetal FLow in Europe RANDOMIZAÇÃO EM 3 GRUPOS CTG COMPUTADORIZADA
  • 48. DOPPLER E INTERRUPÇÃO TRUFFLE Trial of Umbilical Flow and Fetal FLow in Europe RANDOMIZAÇÃO EM 3 GRUPOS CTG ALTERAÇÃO PRECOCE COMPUTADORIZADA DO DUCTO VENOSO
  • 49. DOPPLER E INTERRUPÇÃO TRUFFLE Trial of Umbilical Flow and Fetal FLow in Europe RANDOMIZAÇÃO EM 3 GRUPOS CTG ALTERAÇÃO PRECOCE ALTERAÇÃO TARDIA DO COMPUTADORIZADA DO DUCTO VENOSO DUCTO VENOSO DESFECHO AVALIADO: DESENVOLVIMENTO NEUROLÓGICO AOS 2 ANOS
  • 51. DOPPLER E INTERRUPÇÃO "Die lohnendsten Forschungen sind diejenigen, welche, indem sie den Denker erfreu'n, zugleich der Menschheit nützen." Doppler “As pesquisas mais gratificantes são aquelas que, além de agradar ao pesquisador beneficiam a humanidade.” Doppler
  • 52. DOPPLER E INTERRUPÇÃO GRIT STUDY Growth Restriction Intervention Trial • 69 hospitais em 13 países • 548 gestantes entre 24 e 36 semanas • Médico assistente em dúvida sobre interrupção • Randomização entre interrupção precoce e aguardar até ter certeza BJOG, 2003
  • 53. DOPPLER E INTERRUPÇÃO GRIT STUDY Growth Restriction Intervention Trial Parto Imediato Parto Postergado Intervalo 0,9 dias 4,9 dias Óbito Fetal 0.7% 3.1% Óbito neonatal 9.1% 6.2% BJOG, 2003
  • 54. DOPPLER E INTERRUPÇÃO GRIT STUDY Growth Restriction Intervention Trial Parto Imediato Parto Postergado Intervalo 0,9 dias 4,9 dias Óbito Fetal 0.7% 3.1% 10% 9% Óbito neonatal 9.1% 6.2% BJOG, 2003
  • 55. DOPPLER E INTERRUPÇÃO GRIT STUDY Déficit aos 2 anos de vida; Grupo entre 24 e 30 semanas 20% 15% 10% 5% 0% PC Visual Auditivo Cognitivo Qualquer um Imediato Postergado Lancet, 2004
  • 57. DOPPLER E INTERRUPÇÃO ACIMA DE 32-34 SEMANAS NÃO TEM MUITA UTILIDADE POIS MORBIMORTALIDADE É BAIXA
  • 58. DOPPLER E INTERRUPÇÃO ACIMA DE 32-34 SEMANAS NÃO TEM MUITA UTILIDADE POIS MORBIMORTALIDADE É BAIXA ABAIXO DE 32 SEMANAS AGUARDAMOS RESPOSTAS, MAS DEVEMOS SER CAUTELOSOS PARA NÃO INTERROMPER MUITO CEDO

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