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Several studies were published about cervical pessary, with controversial results. These studies demonstrated that the patient follow-up after pessary insertion is very different between the study centers and the number of pessary insertions per center was often30 cases. This study aims to determine cervical pessary performance in singleton pregnancies with a short cervix based on a single center learning curve.Between 2011 and 2018, 128 singleton pregnancies between 18 and 24 gestational weeks with a short cervix (25 mm) were referred to our clinic. All cases were treated with progesterone, and when available in our supplies (due to low resources) cervical pessary was also offered. Three groups were created for statistical analysis: Group 1 (The learning curve was performed with all cases of pessary plus progesterone, and 30 patients were obtained as the number needed for learning, in our study with two operators. The PTB rate34 weeks was 27.3, 20, and 4.6% in groups 1, 2, and 3, respectively. There was no significant difference between Group 1 and 2 (OR 1.1; 95% CI 0.066 - 18.45;Learning curve and cumulative sum analysis determined that the application and surveillance of at least 30 patients is required to see significant improvements in the primary outcome of PTB34 weeks.

Objective: To compare the changes in the pelvic floor of women with twin pregnancies who practiced muscle stretching with the EPI-NO® vaginal dilator, as assessed using transperineal three-dimensio...

Objective The present study aims to determine if the use of cervical pessary plus progesterone in short-cervix (≤ 25 mm) dichorionic-diamniotic (DC-DA) twin pregnancies is equivalent to the rate of preterm births (PBs) with no intervention in unselected DC-DA twin pregnancies. Methods A historical cohort study was performed between 2010 and 2018, including a total of 57 pregnant women with DC-DA twin pregnancies. The women admitted from 2010 to 2012 (n = 32) received no treatment, and were not selected by cervical length (Non-Treated group, NTG), whereas those admitted from 2013 to 2018 (n = 25), were routinely submitted to cervical pessary plus progesterone after the diagnosis of short cervix from the 18th to the 27th weeks of gestation (Pessary-Progesterone group, PPG). The primary outcome analyzed was the rate of PBs before 34 weeks. Results There were no statistical differences between the NTG and the PPG regarding PB Conclusion In DC-DA twin pregnancies with a short cervix, (which means a higher risk of PB), the treatment with cervical pessary plus progesterone could be considered equivalent in several aspects related to PB in the NTG, despite the big difference between these groups.

Objective To predict birth weight using fetal fractional limb volumes (FLVs) by three-dimensional (3D) ultrasonography in twin pregnancies. Method This prospective observational cohort study evaluated 51 twin pregnancies, including 28 dichorionic and 23 monochorionic pregnancies. Ultrasound examinations were performed up to 5 d before delivery. Birth weight prediction models were developed using the fractional arm volume (FAV), fractional thigh volume (FTV), and Hadlock's formula and were compared with the actual birth weight. Results The mean gestational age at the time of ultrasound examination was 35.3 weeks. The mean birth weight was slightly higher in dichorionic than in monochorionic pregnancies 2391.2 versus 2352.4 g. The measurements using FTV were the closest to actual birth weights. For the total group, the Hadlock formula had mean percentage change of 7.18% while the FTV model presented mean percentage change of 6.62% in relation to birth weight. However, no significant difference was noted between Hadlock's formula and FTV p = .363 and .678 for dichorionic and monochorionic pregnancies, respectively. Conclusions FTV accurately predicted birth weight in twin monochorionic and dichorionic pregnancies. However, Hadlock's formula should still be used.

To compare the changes in the pelvic floor of women with twin pregnancies who practiced muscle stretching with the EPI-NOThis prospective cross-sectional case-control study included nulliparous women in the third trimester of their multiple pregnancies and divided them into the control group (CG,The EpiG showed improved perineal distensibility, which was evidenced by the increase in sagittal diameter at rest (EPI-NO

We report the case of a 20-year-old patient, primigravida, with twin monochorionic pregnancy, with a weight gain of 6 kg in one week and increased blood pressure. During the ultrasound diagnostic investigation, placental edema and hydrops were identified in both fetuses, which, in association with maternal anasarca and pressure control, constitute the triad for mirror syndrome, also known as triple edema. In addition to being hydropic, one of the twins was an acardiac fetus, which is a rare combination of events. Gestation was terminated at 22 weeks and five days because of high maternal risk. The patient progressed with clinical and laboratory improvement. Our study is relevant in that it documents an extremely rare case and discusses relevant aspects of the symptoms and diagnosis of mirror syndrome. It also systematically reviews the condition.

Objective To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil. Methods This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18-26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ2 test and Mann-Whitney U test were used for the statistical analysis. Results The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetuses survived until the end of gestation. Placental insertion location (anterior vs. posterior) did not affect the incidence of iatrogenic septostomy, surface bleeding, and premature rupture of membranes until the end of gestation. The death rate of donor and recipient fetuses before 24th gestational week increased with severity of TTTS. Conclusion The maternal and perinatal outcomes resulting from the implementation of a new minimally invasive surgical technique are in line with those obtained in major centers worldwide, considering the learning curves and infrastructures.

To compare the effectiveness of expectant management versus methotrexate in selected cases of tubal ectopic pregnancy.A double-blind randomized trial included 23 selected patients with a confirmed diagnosis of tubal pregnancy who met the inclusion criteria (hemodynamic stability, initial serum β-hCG concentration2,000 mIU/mL, declining titers of β-hCG 48 h prior to treatment, visible tubal pregnancy on transvaginal ultrasound, a tubal mass5.0 cm and fertility desire). The patients were divided into two groups: 10 patients in the methotrexate group (MTX 50 mg/m(2) administered as a single intramuscular dose) and 13 patients in the placebo group (saline solution administered in a single intramuscular dose). Quantitative variables were expressed as means ± standard deviations and compared by Student's t test or Mann-Whitney test. Dichotomous variables (success/treatment failure) were presented as proportions and compared by the Fisher exact test.Successful treatment with negative titers of β-hCG occurred in 9 cases (90.0%) of the methotrexate group and in 12 (92.3%) of the placebo group (p0.999). The β-hCG values became undetectable at 22 ± 15.4 days in the methotrexate group and 20.6 ± 8.4 days in the placebo group (p = 0.80).This study showed no statistically significant difference between the treatment with methotrexate and placebo, with similar success rates and similar time interval for β-hCG to become undetectable.

OBJECTIVES The purpose of this study was to compare the morphologic characteristics of the pelvic floor musculature between women with twin and singleton pregnancies. METHODS We conducted a cross-sectional case-control study of 40 nulliparous women aged 20 to 38 years to compare women with singleton pregnancies (n = 23) to women with twin pregnancies (n = 17). Biometric measurements of the levator hiatus and the sagittal and coronal diameters were made by transperineal 3-dimensional sonography between the 28th and 38th gestational weeks. Comparisons were statistically assessed by the unpaired Student t test and Mann-Whitney U test. RESULTS For the women with singleton pregnancies, the mean sagittal diameters at rest, during the Valsalva maneuver, and during pelvic floor contraction were 5.3, 5.7, and 4.5 cm, respectively, and the mean coronal diameters under these conditions were 3.8, 4.1, and 3.6 cm. For the women with twin pregnancies, the corresponding values were as follows: mean sagittal diameters, 5.3, 5.8, and 4.6 cm; and mean coronal diameters, 4.3, 4.3, and 3.8 cm. The differences in coronal diameters were statistically significant at rest (P < .01) and during contraction (P = .04). The mean levator hiatal areas for the women with singleton pregnancies were 14.6, 16.9, and 11.7 cm(2) at rest, during Valsalva, and during contraction, respectively; for the women with twin pregnancies, these values were 16.0, 18.6, and 12.6 cm(2). CONCLUSIONS Hiatal measurements were higher in twin than in singleton pregnancies, with coronal diameters reaching significance at rest and during contraction, suggesting that pelvic support undergoes greater changes during twin pregnancy.

Objective The objective of this article is to determine reference values for fetal biometric parameters in twin pregnancies and to compare these values between monochorionic and dichorionic pregnancies. Methods A retrospective cross-sectional study was conducted among 157 monochorionic and 176 dichorionic twin pregnancies between 14 and 38 weeks of gestation. Biometric measurements included the biparietal diameter (BPD), abdominal circumference (AC), femurs length (FL) and estimated fetal weight (EFW). To evaluate the correlation between biometric parameters and gestational age, polynomial regression models were created, with adjustments using the coefficient of determination (R2). Comparison between monochorionic and dichorionic pregnancies was performed using analysis of covariance. Results The mean BPD, AC, FL and EFW for the dichorionic pregnancies were 56.16 mm, 191.1 mm, 41.08 mm and 816.1 g, respectively. The mean BPD, AC, FL and EFW for the monochorionic pregnancies were 57.14 mm, 184.2 mm, 39.29 mm and 723.4 g, respectively. There was a statistical difference between mono and dichorionic pregnancies for all the biometric parameters (BPD p = 0.012; AC p = 0.047; FL p = 0.007; EFW p = 0.011). Conclusion Reference curves of biometric parameters in twin pregnancies were determined. Biometric parameters were statistically different between monochorionic and dichorionic pregnancies. © 2014 John Wiley & Sons, Ltd.

To evaluate the efficacy of conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided local injection.Retrospective case series at University tertiary care Hospital. Eight patients diagnosed with cervical pregnancy with embryonic heart activity managed conservatively. The intervention was ultrasound-guided local injection of methotrexate (1 mg/kg) and potassium chloride (2 meq/mL). Measurements were occurrence of morbidity, necessity for further intervention, the initial titers of beta-hCG, interval of time in which the levels of beta-hCG became negative, period for regression of cervical pregnancy at ultrasound and future pregnancy.All patients were treated successfully. The initial levels of beta-hCG ranged from 3013 to 71199 mUI/mL. One case evaluated with infection. There was no need for additional intervention in our series study. The interval of time for the levels of beta-hCG becomes negative range from 2 to 12 weeks. The period for the regression of the cervical pregnancy at ultrasound range from 3 to 14 weeks. In two cases intrauterine pregnancies occurred after the treatment.Conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided injection is an effective treatment avoiding the need of further intervention.

The objective of this study was to evaluate the feasibility of posterior colpotomy for the surgical treatment of tubal ectopic pregnancy in hemodynamically stable women. We performed a retrospective analysis of medical records obtained over a period of 18 months. Twelve cases were identified, with the following characteristics: mean gestational age, 7.7 weeks; mean serum β-human chorionic gonadotropin level, 7,786 mIU/mL; and greater diameter of the mass, 15–69 mm. Treatment was successful in all cases. Salpingectomy was performed in 10 patients (83.3%) and salpingostomy, in 1 patient. The remaining patient only received peritoneal lavage, as the evidence of ectopic abortion with only a slightly dilated uterine tube was found during surgery. The mean surgical time was 42.5 minutes. In the analyzed cases, posterior colpotomy was found to be a feasible alternative method for the surgical treatment of tubal ectopic pregnancy in hemodynamically stable women.

Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy with high morbidity and mortality. Use of conservative conducts, including medical management with methotrexate, has avoided mutilating surgeries such as hysterectomy and spared the fertility of women. We report the case of a 30-year old patient with a cesarean scar ectopic pregnancy, with a live embryo, who was treated locally with transvaginal ultrasound-guided injection of methotrexate, complemented with various doses of systemic methotrexate. Univ Fed Sao Paulo Unifesp, Gynecol & Obstet, Sao Paulo, SP, Brazil Univ Fed Sao Paulo Unifesp, Fetal Med, Sao Paulo, SP, Brazil Univ Fed Sao Paulo, Human Reprod Dept, Sao Paulo, SP, Brazil Univ Fed Sao Paulo, Dept Obstet, Sao Paulo, SP, Brazil Univ Fed Sao Paulo Unifesp, Gynecol & Obstet, Sao Paulo, SP, Brazil Univ Fed Sao Paulo Unifesp, Fetal Med, Sao Paulo, SP, Brazil Univ Fed Sao Paulo, Human Reprod Dept, Sao Paulo, SP, Brazil Univ Fed Sao Paulo, Dept Obstet, Sao Paulo, SP, Brazil Web of Science

To evaluate the depth of trophoblastic infiltration in tubal wall in ectopic pregnancy (EP) assessed by histopathology and their correlation with initial values of β-hCG.A prospective study including 27 patients with diagnosis of EP was realized. The tubal pregnancies were histologically classified according to the depth of infiltration of trophoblastic tissue on the wall of the tube (stage I: limited to mucosa; stage II: reaching the muscularis layer; stage III: complete infiltration of the tubal wall). The comparison between groups for numeric variables was performed by ANOVA. The receiver operating characteristic (ROC) curve was performed to obtain the cutoff value of β-hCG associated with the degree of trophoblast invasion into the wall of the tube evaluated by histology.The mean β-hCG in patients evaluated by histopathology as stage I + II was 2868 mIU/ml and stage III was 11 202 mIU/ml (p = 0.017). β-hCG levels that best predicted for stage III was 2906 mIU/ml, with a sensitivity of 85.7% and a specificity of 69.2%.There is a direct correlation between serum β-hCG and the depth of trophoblast infiltration of the tube wall at histopathology.

Since the most ancient times, mythical stories concerning twins were described both in religion and art [1]. Examples of twin gods and heroes are numerous: from the twin sons of Zeus to Rome’s founders, Romulus and Remus. Such legendary conception connected to twins may still be found in contemporary primitive societies [2]. The evolution of medicine has led to a different perception of the twinning phenomenon, with several implications for the obstetric care [3].

Objetivos: avaliar a contribuição da medida da espessura endometrial como fator orientador do tratamento clínico da gravidez tubária íntegra. Métodos: estudo observacional longitudinal, no qual se avaliou a maior medida da espessura endometrial em milímetros, no eixo longitudinal uterino, por meio da ultra-sonografia transvaginal, parâmetro que foi correlacionado com a evolução dos casos. Foram incluídas no estudo 181 pacientes que respeitaram os critérios de utilização para o tratamento clínico (expectante ou medicamentoso com metotrexato). Por meio do teste t de Student avaliamos a diferença entre a média da espessura endometrial dos casos que evoluíram com sucesso da terapêutica e a dos casos com fracasso do tratamento. Resultados: a média dos valores da espessura endometrial das pacientes que evoluíram com sucesso do tratamento medicamentoso (31 casos) foi 6,4 mm, ao passo que a média entre as que evoluíram com falha do tratamento foi de foi 11,5 mm. A diferença entre os valores foi significante. Já a média da espessura do grupo com sucesso da conduta expectante (128 casos) foi 9,0 mm, ao passo que a média entre as pacientes para as quais houve fracasso foi 9,6 mm. A análise estatística destes valores mostra que não há diferença significante. Conclusões: a maior medida da espessura endometrial no eixo longitudinal uterino por meio da ultra-sonografia transvaginal mostrou validade como novo fator orientador do tratamento medicamentoso nas pacientes com diagnóstico de gravidez tubária íntegra, podendo se tornar ferramenta útil e auxiliar na indicação do uso do metotrexato. No entanto, a espessura não mostrou validade como fator orientador do estabelecimento da conduta expectante. Purpose: to evaluate the importance of endometrial thickness measurement as an orienting factor for the clinical treatment of unruptured tubal pregnancy. Method: longitudinal observational study, in which the greatest measure of the endometrial thickness was evaluated in millimeters, in the uterine longitudinal axis, through transvaginal ultrasonography. Our study group included 181 patients, all of them respecting the utilization criteria for the clinical treatment (expectant or medicated with methotrexate). Through Student's t test we evaluated the difference between the average thickness of the cases who presented successful results with the treatment and the average of those who failed. Results: the average endometrial thickness of the patients who presented successful results with the medical treatment (31 cases) was 6.4 mm, while the average in the cases of failure was 11.5 mm. These results were significantly different. The average thickness of the successful group with expectant management (128 cases) was 9.0 mm, while the average of those who failed was 9.6 mm. These values were not statistically different. Conclusions: the greatest measure of the endometrial thickness of the uterine longitudinal axis through transvaginal ultrasonography proved to be valuable as a new orienting factor for the medical treatment of patients with a diagnosis of unruptured tubal pregnancy. It may become a useful and auxiliary tool for the recommendation of the use of methotrexate. On the other hand, thickness did not show to be useful as an orienting factor for establishing expectant management. Universidade Federal de São Paulo (UNIFESP) Departamento de Obstetrícia UNIFESP, Depto. de Obstetrícia SciELO

OBJECTIVES The purpose of this study was to establish reference charts of fetal biometric parameters measured by 2-dimensional sonography in a large Brazilian population. METHODS A cross-sectional retrospective study was conducted including 31,476 low-risk singleton pregnancies between 18 and 38 weeks' gestation. The following fetal parameters were measured: biparietal diameter, head circumference, abdominal circumference, femur length, and estimated fetal weight. To assess the correlation between the fetal biometric parameters and gestational age, polynomial regression models were created, with adjustments made by the determination coefficient (R(2)). RESULTS The means ± SDs of the biparietal diameter, head circumference, abdominal circumference, femur length, and estimated fetal weight measurements at 18 and 38 weeks were 4.2 ± 2.34 and 9.1 ± 4.0 cm, 15.3 ± 7.56 and 32.3 ± 11.75 cm, 13.3 ± 10.42 and 33.4 ± 20.06 cm, 2.8 ± 2.17 and 7.2 ± 3.58 cm, and 256.34 ± 34.03 and 3169.55 ± 416.93 g, respectively. Strong correlations were observed between all fetal biometric parameters and gestational age, best represented by second-degree equations, with R(2) values of 0.95, 0.96, 0.95, 0.95, and 0.95 for biparietal diameter, head circumference, abdominal circumference, femur length, and estimated fetal weight. CONCLUSIONS Fetal biometric parameters were determined for a large Brazilian population, and they may serve as reference values in cases with a high risk of intrauterine growth disorders.

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers. O advento da radiologia intervencionista tornou possível avanços notáveis no diagnóstico e no tratamento de diversas situações, na área de ginecologia e obstetrícia. No campo da obstetrícia, esses avanços incluem oclusão temporária das artérias hipogástricas para o manejo de placenta acreta e/ou prévia, embolização de fístulas arteriovenosas após curetagem uterina e manejo de prenhezes ectópicas uterinas e extrauterinas. A gravidez ectópica não tubária, seja cervical, abdominal, ovariana ou na cicatriz de cesárea, muitas vezes representa grande desafio terapêutico, principalmente quando há desejo de manutenção da fertilidade. As opções terapêuticas mais utilizadas para o tratamento de prenhez ectópica não tubária, são: terapia sistêmica com metotrexato e ressecção cirúrgica do saco gestacional ectópico; porém a abordagem intervencionista com injeção direta de metotrexato no saco gestacional ou quimiembolização intra-arterial das artérias uterinas, apresentam-se na literatura recente, como modalidades terapêuticas viáveis, seguras, eficazes, com baixa morbidade, menor tempo de internação e rápida recuperação clínica. Devido ao diminuto arsenal de materiais utilizados e à crescente formação de especialistas na área, a intervenção radiológica, como opção de tratamento nas prenhezes ectópicas, é financeiramente viável e apresenta acessibilidade considerável no mundo e na maioria do centros médicos brasileiros.

Purpose: to evaluate safety and efficacy of intra-amniotic injection of methotrexate (MTX) for treatment of viable cervical pregnancy. Methods: four women with viable cervical pregnancy confirmed by ultrasound (US) were treated with transvaginal injection of MTX (1 mg/kg) under sonographic control. The follow-up was made with serial dosages of beta-hCG on days 1, 4 and 7 after injection and weekly until the titers were negative. Results: the patients were treated with success. The time for the titers of beta-hCG to become negative after the treatment was: 62 days (case 1), 84 days (case 2), 28 days (case 3) and 10 days (case 4). Conclusion: intra-amniotic injection of MTX can be used to avoid surgery in cases of viable cervical pregnancy.

CONTEXT AND OBJECTIVE: As there is little information about fertility outcomes among women following clinical treatment (methotrexate and expectant management) and surgery (salpingectomy) consequent to ectopic pregnancy, we evaluate the results from hysterosalpingography subsequent to treatment. The objective was to evaluate contralateral tubal patency using hysterosalpingography following surgery and clinical treatment of tubal pregnancy. DESIGN AND SETTING: This was a prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHOD: Among 115 patients who underwent hysterosalpingography following surgery and clinical treatment of tubal pregnancy between April 1994 and February 2002, 30 were treated with a single intramuscular dose of methotrexate (50 mg/m²), 50 were followed up expectantly and 35 underwent salpingectomy. RESULTS: The patency of the ipsilateral tube was 84% after methotrexate treatment and 78% after expectant management. In addition, contralateral tubal patency was 97% after methotrexate treatment, 92% after expectant management and 83% after salpingectomy. There were no statistically significant differences between the clinical treatment and surgery groups. CONCLUSIONS: The findings from this study suggest similar contralateral tubal patency rates following salpingectomy, methotrexate treatment and expectant management. CONTEXTO E OBJETIVO: Como existem poucas informações a respeito do futuro reprodutivo das pacientes tratadas de gravidez ectópica através do tratamento clínico (metotrexato e conduta expectante) e da cirurgia (salpingectomia), avaliamos as histerossalpingografias após o tratamento da gravidez ectópica. O objetivo foi avaliar a permeabilidade da tuba contralateral pela histerossalpingografia após o tratamento cirúrgico e clínico da gravidez tubária. TIPO DE ESTUDO E LOCAL: Estudo prospectivo realizado no Departamento de Obstetrícia da Universidade Federal de São Paulo (centro terciário). MÉTODOS: Foram realizadas 115 histerossalpingografias após o tratamento clínico e cirúrgico da gravidez tubária no período de 1994 a 2002, sendo que 30 após o tratamento com dose única de metotrexato (50 mg/m²) intramuscular, 50 após a conduta expectante e 35 após a salpingectomia. RESULTADOS: A permeabilidade tubária ipsilateral foi de 84% após o tratamento com metotrexato e de 78% após a conduta expectante. A permeabilidade da tuba contralateral foi de 97% após o tratamento com metotrexato, 92% após a conduta expectante e 83% após a salpingectomia. Não houve diferença estatisticamente significante entre os grupos de tratamento cirúrgico e clínico. CONCLUSÃO: Os dados deste estudo sugerem que a permeabilidade tubária contralateral é similar após a salpingectomia, o tratamento com metotrexato e a conduta expectante.

The aims of this study were to compare perineal distensibility between women with twin and singleton pregnancies and to correlate these women’s perineal distensibility with anthropometric data. This prospective cross-sectional case-control study was conducted among nulliparous women, of whom 20 were pregnant with twins and 23 with a single fetus. Perineal distensibility was evaluated in the third trimester by means of Epi-no, which was introduced into the vagina and inflated up to the maximum tolerable limit. It was then withdrawn while inflated and its circumference was measured. The unpaired Student’s t-test was used to compare perineal distensibility in the two groups and Pearson’s correlation coefficient (r) was used to correlate the pregnant women’s perineal distensibility with their anthropometric data. There was no difference in perineal distensibility between the twin group (16.51 ± 2.05 cm) and singleton group (16.13 ± 1.67 cm) (P=0.50). There was a positive correlation between perineal distensibility and abdominal circumference (r=0.36; P=0.01). The greater the abdominal circumference was, the greater the perineal distensibility was, regardless of whether the pregnancy was twin or singleton.

Objective. To evaluate trophoblastic cell proliferation and angiogenesis in tubal pregnancy assessed by immunohistochemical study and their correlation with an average variation of β-hCG in an interval of 48 hours before surgery. Methods. A prospective study was conducted on 18 patients with a diagnosis of tubal pregnancy. The patients were divided into two groups of ectopic pregnancy of which 11 showed rise of β-hCG levels and 7 patients showed declining β-hCG levels in an interval of 48 hours prior to surgery. Trophoblastic cell proliferation and angiogenesis were assessed by Ki-67 and VEGF, respectively. Trophoblastic cell proliferation was assessed by Ki-67 and was classified into three groups (grade I: less than 1/3 of stained nuclei, grade II: 1/3 to 2/3 of the stained nuclei, and grade III: more than 2/3 of the nuclei stained). The cases analyzed for VEGF were divided into three groups (grade I: less than 1/3 of the stained cytoplasm; grade II: 1/3 to 2/3 of the stained cytoplasm; grade III: more than 2/3 of the stained cytoplasm). Statistical analysis was performed using the chi-square, ANOVA, and Kruskal-Wallis tests. Results. The mean variation in the serum β-hCG levels in 48 hours in tubal pregnancy patients correlated with trophoblastic cell proliferation assessed by Ki-67 and showed a decline of 13.46% in grade I, a rise of 45.99% in grade II, and ascension of 36.68% in grade III (P=0.030). The average variation in the serum β-hCG in 48 hours, where angiogenesis was evaluated by VEGF, showed a decline of 18.35% in grade I, a rise of 32.95% in grade II, and ascension of 37.55% in grade III (P=0.047). Conclusions. Our observations showed a direct correlation of increased levels of serum β-hCG in 48h period prior to surgery with higher trophoblastic cell proliferation assessed by Ki-67 and angiogenesis assessed by VEGF in tubal pregnancy.

Objective.The objective of this study was to compare the role of the pelvic floor muscles between nulliparous and multiparous women in the third trimester of pregnancy, by analyzing the relationship between electrical activity (surface electromyography—EMG), vaginal palpation (modified Oxford scale), and perineal distensibility (Epi-no).Methods.This was an observational cross-sectional study on a sample of 60 healthy pregnant women with no cervical dilation, single fetus, gestational age between 35 and 40 weeks, and maternal age ranging from 15 to 40 years. The methods used were bidigital palpation (modified Oxford scale, graded 0–5), surface EMG (electrical activity during maximal voluntary contraction), and perineal distensibility (Epi-no device). The Pearson correlation coefficient (r) was used to analyze the Epi-no values and the surface EMG findings. The Kruskal-Wallis test was used to compare the median values from surface EMG and Epi-no, using the modified Oxford scale scores.Results.Among the 60 patients included in this study, 30 were nulliparous and 30 multiparous. The average maternal age and gestational age were 26.06 (±5.58) and 36.56 (±1.23), respectively. It was observed that nulliparous women had both higher perineal muscle strength (2.53 ± 0.57versus2.06 ± 0.64;P = 0.005) and higher electrical activity (45.35 ± 12.24 μV versus35.79 ± 11.66 μV;P = 0.003), while among the multiparous women, distensibility was higher (19.39 ± 1.92versus18.05 ± 2.14;P = 0.013). We observed that there was no correlation between perineal distensibility and electrical activity during maximal voluntary contraction (r = -0.193;P = 0.140). However, we found a positive relationship between vaginal palpation and surface electromyography (P = 0.008), but none between Epi-no values (P = 0.785).Conclusion.The electrical activity and muscle strength of the pelvic floor muscles of the multiparous women were damaged, in relation to the nulliparous women, while the perineal distensibility was lower in the latter group. There was a positive relationship between surface EMG and the modified Oxford scale.

Cesarean scar pregnancy is a rare form of ectopic pregnancy. It is associated with many complications, including a high risk of massive bleeding and hysterectomy under unfavorable conditions. Conservative treatment with systemic methotrexate (MTX) has been used preferentially with the aim of allowing the patient to have a reproductive future. However, cases of complex ectopic masses in a cesarean scar with guarded prognosis demand techniques that are more effective, such as uterine artery embolization (UAE) in association with intra-arterial MTX infusion. We describe the case of a 35-year-old patient in the 8th week of pregnancy who was referred to us because of genital bleeding and suspected ectopic pregnancy in the cesarean scar. After confirmation of the diagnosis, an initial attempt at systemic treatment with MTX was made. This was abandoned due to the elevation of the hepatic transaminase level. In addition, because of the complexity of the mass and the patient’s desire to preserve her reproductive capacity, it was decided to perform UAE with local MTX infusion. The procedure was performed successfully and the patient’s fertility was preserved.

Background: About 22% of IVF-conceived pregnancies result in spontaneous abortion. Therefore, it is important to predict the complicated and poor pregnancy outcome. Serum human chorionic gonadotrophin levels after 2 weeks of embryo transfer is a reliable marker to predict the pregnancy outcome in patients of IVF. Objective was to correlate the evolution curve of B-HCG after embryo transfer in assisted human reproduction techniques and the pregnancy outcome.Methods: A prospective and observational study. In patients who underwent embryo transfer, a collection of quantitative B-HCG in 12th day after transfer was made. In patients who had beta-HCG positive value (beta-HCG>5.0 mUI/ml), there were two new collections of beta-HCG 48 hours and 72 hours after the first collection. All results have been filed and all pregnancies were accompanied to the final outcome.Results: It was found that B-HCG values above 139.5 mIU / ml were associated with a good prognosis gestational.Conclusions: Larger studies are needed to improve these findings and give better information regarding the prognostic value of early pregnancy hCG levels.

O diagnóstico não invasivo da gravidez ectópica deve ser realizado precocemente, antes de ocorrer a ruptura tubária, combinando a ultra-sonografia transvaginal com a dosagem da fração beta do hormônio gonadotrófico coriônico. Diversas opções de tratamento podem ser utilizadas. Devemos respeitar as indicações tanto das intervenções cirúrgicas como do tratamento clínico. A laparotomia está indicada nos casos de instabilidade hemodinâmica. A laparoscopia é a via preferencial para o tratamento da gravidez tubária. A salpingectomia deve ser realizada nas pacientes com prole constituída. A salpingostomia é indicada nas pacientes com desejo reprodutivo, quando os títulos da b-hCG forem inferiores a 5000 mUI/mL e as condições cirúrgicas forem favoráveis. O tratamento com metotrexato (MTX) é uma conduta consagrada, podendo ser indicado como primeira opção de tratamento. Os principais critérios para indicação do MTX são estabilidade hemodinâmica, b-hCG 5.000 mUI/mL e ausência de embrião vivo. A indicação do tratamento local com injeção de MTX (1 mg/kg) guiada por ultra-sonografia transvaginal é na presença de embrião vivo nos casos de localização atípica. A conduta expectante deve ser indicada nos casos de declínio dos títulos da b-hCG em 48 horas antes do tratamento e quando os títulos iniciais são inferiores a 1.500 mUI/mL. Em relação ao futuro reprodutivo, existem controvérsias entre a salpingectomia e a salpingostomia. Até obtermos um consenso na literatura, orientamos às pacientes desejosas de uma futura gestação a optar pelas condutas conservadoras, tanto cirúrgicas como clínicas. It is advisable to do the non-invasive diagnosis of ectopic pregnancy precociously, before there is the tube rupture, combining for that the transvaginal ultrasonography with the dosage of the b-fraction of the chorionic gonadotrophin. A range of treatment options may be used. Either a surgical intervention or a clinical treatment may be taken into consideration. Laparotomy is indicated in cases of hemodynamic instability. Laparoscopy is the preferential route for the treatment of tube pregnancy. Salpingectomy should be performed in patients having the desired number of children, while salpingostomy should be indicated in patients willing to have more children, when the b-hCG titers are under 5,000 mUI/mL and the surgical conditions are favorable. The use of methotrexate (MTX) is a consecrated clinical procedure and should be indicated as the first option of treatment. The main criteria for MTX indication are hemodynamic stability, b-hCG 5,000 mUI/mL and no alive embryo. Indication for local treatment with an injection of MTX (1 mg/kg) guided by transvaginal ultrasonography should occur in cases of alive embryos, but with an atypical localization. An expectant conduct should be indicated in cases of decrease in the b-hCG titers within 48 hous before the treatment, and when the initial titers are under 1,500 mUI/mL. There are controversies between salpingectomy and salpingostomy, concerning the reproductive future. Till we reach an agreement in the literature, the advice to patients who are looking forward to a future gestation, is to choose either surgical or clinical conservative conducts.

To evaluate the increment in beta-hCG levels (%) in the 48-h interval prior to treatment as a predictor of therapeutic success in the management of ectopic pregnancy with methotrexate.A prospective observational study was carried out between April 2002 and November 2006 at the Federal University of São Paulo in 65 patients with an ectopic pregnancy treated with a single dose of 50 mg/m(2) of methotrexate administered intramuscularly. The following predictive factors were evaluated: beta-hCG level on the day of hospital admission and the percent increment in beta-hCG in the 48-h interval prior to treatment.Treatment was successful in 49 cases (75.4%). In these cases, beta-hCG levels at hospitalization were lower when compared to the levels found in cases of therapeutic failure (1,928.9 vs. 4,828.6 mIU/ml, respectively; P0.01), and the increment in beta-hCG level in the 48-h interval prior to treatment was smaller (13.1 vs. 36.3%, respectively; P=0.01). A beta-hCG measurementor=2,685 mIU/ml on the day of hospitalization and an increment in beta-hCG levelor=11.1% in the 48 h preceding treatment were factors indicative of therapeutic success with sensitivity of 79.6 and 61.7%, respectively, and specificity of 75 and 81.3%, respectively.The lower the beta-hCG measurement on the day of hospital admission and the lower its increment in the 48-h interval prior to treatment, the greater the likelihood that treatment of ectopic pregnancy with methotrexate will be successful. The margin of safety for treatment with methotrexate is high when beta-hCG measurement on the day of hospitalization isor=2,685 mIU/ml and its increment in the 48 h prior to treatment isor=11.1%.

CONTEXT AND OBJECTIVE: There is evidence that ectopic pregnancies present different behavioral patterns. These distinct evolutions of ectopic pregnancies represent two different natural histories. To evaluate these evolution patterns, we compared patients undergoing medical treatment and expectant management according to their gestational age and initial beta-hCG levels. DESIGN AND SETTING: Prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHODS: Among 119 cases of unruptured ectopic pregnancies diagnosed from April 1999 to February 2004, 57 received systemic treatment with methotrexate 50 mg/m² (body surface area) intramuscularly and 62 were managed expectantly. In this study we evaluated the beta-hCG levels at presentation and amenorrhea duration. RESULTS: There was a significant difference between the two groups regarding amenorrhea duration and initial beta-hCG levels (p < 0.001). The group with decreasing beta-hCG levels (managed expectantly) had longer amenorrhea (mean: 8.87 ± 1.71 weeks) and lower initial beta-hCG levels (mean: 648.8 ± 754.7 mIU/ml). On the other hand, the group treated with methotrexate had shorter amenorrhea (mean: 6.81 ± 1.88 weeks) and higher beta-hCG levels at presentation (2642.7 ± 2315.1 mIU/ml). CONCLUSIONS: The data suggest that ectopic pregnancies can be categorized into two groups: those with early diagnosis and shorter amenorrhea, increasing or maintained beta-hCG levels over 24 and 48-hour intervals and higher beta-hCG levels requiring medical treatment; and those with late diagnosis and longer amenorrhea, decreased beta-hCG levels over 24 and 48-hour intervals and lower beta-hCG levels requiring expectant management. CONTEXTO E OBJETIVO: A gravidez ectópica apresenta comportamentos diferentes. Para avaliar as diferentes evoluções da gravidez ectópica, nós comparamos as pacientes submetidas ao tratamento medicamentoso e à conduta expectante de acordo com a idade gestacional e os valores iniciais de beta-hCG. TIPO DE ESTUDO E LOCAL: Estudo prospectivo, realizado no Departamento de Obstetrícia da Universidade Federal de São Paulo, hospital terciário. MÉTODOS: Foram diagnosticados 119 casos de gravidez ectópica íntegra no período de abril de 1999 a fevereiro de 2004. O tratamento com metotrexato 50 mg/m² de superfície corpórea intramuscular foi realizado em 57 casos e a conduta expectante, em 62 casos. Neste estudo, nós avaliamos os valores iniciais de beta-hCG e o período de amenorréia. RESULTADOS: Houve diferença estatística significante entre os dois grupos com relação ao período de amenorréia e os valores iniciais de beta-hCG (p < 0,001). O grupo com títulos de beta-hCG em regressão (conduta expectante) apresentaram período de amenorréia mais longo (média:8,87 ± 1,71 semanas) e valores iniciais de beta-hCG mais baixos (648,8 + 754,7 mUI/ml). Por outro lado, o grupo tratado com metotrexato teve período menor de amenorréia (média 6,81 + 1,88 semanas) e valores de beta-hCG mais altos (2642,7 +2315,1 mUI/ml). CONCLUSÕES: Os resultados deste estudo sugerem que a gravidez ectópica pode ser categorizada em dois grupos: aquelas com diagnóstico precoce com período curto de amenorréia e valores elevados de beta-hCG que requerem tratamento com metotrexato, e aquelas com diagnóstico tardio com período longo de amenorréia e valores baixos de beta-hCG que requerem a conduta expectante.

OBJETIVO: avaliar a relação entre os níveis séricos do hormônio gonadotrópico coriônico (beta-hCG) e a medida da espessura endometrial, em pacientes submetidas ao tratamento de gravidez ectópica com metotrexate. MÉTODOS: estudo clínico prospectivo, no qual foram avaliados os títulos do beta-hCG e a maior medida da espessura endometrial no eixo longitudinal uterino por meio da ultra-sonografia transvaginal, em 38 pacientes com gravidez ectópica íntegra, com diâmetro < 3,5 cm, com estabilidade hemodinâmica e aumento dos níveis do beta-hCG num intervalo de 24-48 horas. Todas receberam terapia com dose única de metotrexate (50 mg/m² intra muscular). Foram comparadas as médias dos valores do beta-hCG e da espessura endometrial, das mulheres que evoluíram com sucesso do tratamento e com aquelas que apresentaram insucesso terapêutico. Posteriormente, foi avaliada a diferença entre as médias dos valores séricos do beta-hCG segundo a espessura endometrial (10,0 mm), independente da resposta terapêutica. Para análise estatística foi utilizado o teste t de Student. RESULTADOS: as médias dos valores iniciais do beta-hCG das 28 mulheres que apresentaram resposta terapêutica medicamentosa foi de 1936,2 mUI/ml, significativamente menor do que a média das 10 mulheres sem resposta, 6831,3 mUI/ml (10,0 mm, cuja média foi de 6925,9 mUI/ml. CONCLUSÕES: a medida da espessura endometrial avaliada pela ultra-sonografia sofre influência dos níveis séricos do beta-hCG, se mostrando valiosa como fator orientador adicional na indicação do tratamento medicamentoso com metotrexate na gravidez ectópica íntegra. OBJECTIVE: to evaluate the correlation between the beta-human chorionic gonadotropin (beta-hCG) serum levels and the measurement of the endometrial thickness, in patients under treatment of ectopic pregnancy with methotrexate. METHODS: a prospective study in which the levels of beta-hCG as well as the largest measurement of the endometrial thickness on the uterine longitudinal axis through transvaginal ultrasound were evaluated at 24-48 h intervals in thirty-eight patients with hemodynamic stability, ectopic pregnancy, diameter 10.0 mm) independently of the response to treatment employing the Student t-test. RESULTS: the mean values of beta-hCG and endometrial thickness in patients with successful treatment (28 cases) were 1936.2 mIU/ml and 6.4 mm, respectively, significanlty lower than the mean values for insuccessful cases: 6831.3 mIU/ml and 11.7 mm, respectively (p10.0 mm, whose mean values were 6925.9 mIU/ml (

Objetivo: avaliar a eficiencia da ultra-sonografia (US) transvaginal com Doppler colorido para a previsao dos resultados do tratamento sistemico da gravidez ectopica integra com dose unica de metotrexato. Pacientes e metodo: vinte pacientes com diagnostico de gravidez ectopica foram incluidas no estudo. Os criterios de inclusao foram: estabilidade hemodinâmica, massa anexial com diâmetro < 5,0 cm e queda dos titulos de beta-hCG inferior a 15% num intervalo de 24 horas. Foram excluidas as pacientes que apresentaram doenca hepatica ou renal ou discrasias sanguineas. O acompanhamento foi realizado com dosagens seriadas de beta-hCG nos dias 4 e 7 apos instituido o tratamento, e semanalmente ate que os titulos de beta-hCG se tornassem negativos. As pacientes foram classificadas em tres conjuntos, conforme a US com doppler colorido: elevado risco (fluxo trofoblastico acometendo mais de 2/3 da massa anexial), medio risco (quando o fluxo trofoblastico comprometia de 1/3 a 2/3 do anel tubario) e de baixo risco (fluxos que acometiam menos de 1/3 da massa anexial). Resultados: o sucesso do tratamento com dose unica de MTX foi de 75% (15 pacientes); quando empregamos uma segunda dose, a percentagem de bons resultados foi de 85%. Confrontamos os resultados obtidos pela US transvaginal e Doppler colorido com o sucesso e o insucesso da terapeutica. Observamos que, das 20 pacientes, 4 apresentaram Doppler de elevado risco e todas evoluiram com fracasso, ao passo que em 16 casos o Doppler foi classificado como de medio ou baixo risco, sendo que destes 15 evoluiram com sucesso. Conclusao: a ultra-sonografia transvaginal com Doppler colorido classificado como de elevado risco indica situacao desfavoravel para o tratamento medicamentoso da gravidez ectopica com dose unica de metotrexato, ao passo que o Doppler de medio e baixo risco indica situacao favoravel para o tratamento clinico, porem estes resultados devem sempre ser analisados em conjunto com a curva de evolucao dos titulos de beta-hCG.

RESUMO Objetivo: avaliar os parâmetros de inclusao empregados na selecao dos casos de gravidez tubaria integra para a conduta expectante e avaliar os resultados. Metodos: foi realizado estudo prospectivo em 70 pacientes com diagnostico de gravidez tubaria integra, em que se optou pela conduta expectante. Os principais criterios de inclusao foram: o diâmetro transversal da massa tubaria igual ou inferior a 5,0 cm, titulos de beta-hCG (fracao beta do hormonio gonadotropico corionico) em declinio de pelo menos 2% num intervalo de 48 horas, estabilidade hemodinâmica, desejo de gravidez futura e consentimento escrito para participar do estudo. Todas as pacientes foram observadas em regime de internacao hospitalar e todas receberam alta hospitalar apos se constatar o declinio dos titulos de beta-hCG e foram acompanhadas ambulatorialmente com dosagens semanais dos titulos ate que estes atingissem valores inferiores a 5 mUI/ml, situacao que consideramos como sucesso. Resultados: das 70 pacientes submetidas a conduta expectante, apenas uma precisou de intervencao cirurgica por ruptura tubaria. Os valores iniciais dos titulos de beta-hCG das pacientes variaram de 27 mUI/ml a 41.000 mUI/ml. A media do diâmetro da massa tubaria foi 2,9 cm. Liquido livre na cavidade peritoneal foi observado em 50 pacientes, sendo a quantidade pequena em 26, moderada em 16 e grande em 8 casos. O aspecto ultra-sonografico caracteristico de hematossalpinge ocorreu em 58 pacientes e o anel tubario, em 12. Ao Doppler colorido, 52 foram classificadas como de baixo risco e 18, de medio risco. Conclusao: a conduta expectante pode ser empregada com seguranca nos casos que respeitarem os criterios de inclusao, sendo o indice de sucesso de 98,6%.

Objective : To determine how parturient women tolerate the use of a perineal distensibility assessment technique using the EPI-NO device. Methods : An observational study with a total of 227 full-term parturient women was performed. During the evaluation with EPI-NO, parturient patients were asked about their sensation of discomfort. The degree of discomfort was measured using the Visual Analogue Scale, with a score from zero to 10. The Mann-Whitney test was applied to assess perineal distensibility measured by EPI-NO and the degree of discomfort caused by the test according to parity. The relation between perineal distensibility and discomfort was analyzed by using the Spearman correlation test (r). Results : The test with EPI-NO caused only slight discomfort (mean Visual Analogue Scale of 3.8), and primiparous women reported significantly greater discomfort (mean Visual Analogue Scale of 4.5) than did multiparous (mean Visual Analogue Scale=3.1), with p