Tromboembolismo na gravidez

Em homenagem a sessão científica da Maternidade Climério de Oliveira - UFBA estou postando a referência de um excelente artigo de tromboembolismo e gestação - Apresentada pelo residente MR1 Dr. Anderson.

http://emedicine.medscape.com/article/2056380-overview

Thromboembolism in Pregnancy 

• Author: Edward Henry Springel, MD, FACOG; Chief Editor: Thomas Chih Cheng Peng, MD   more...

 

Reposta do caso - 3 - Timo

Relembrando:
Lactente de 38 dias, foi internado com suspeita de pneumonia e o raio X mostrou uma opacificação no mediastino acima da área cardíaca. Encaminhado para ultrassonografia de tórax onde se identificou na topografia do achado do raio X


Timo é o numero 4.

Tratava-se do timo. Devemos estar atentos para o que é normal e a patologia do timo:

1. Timo normal
2. Hiperplasia
3. Síndrome de DiGeorge
4. Timo Acessório
5. Cisto tímico
6. Variantes anatômicas

Neste caso parecia ter um leve aumento de tamanho. Para melhor aprendizado, recomendo o artigo abaixo com grandes nomes da ultrassonografia brasileira.

Timo: caracterização ultra-sonográfica^*

Thymus: ultrasound characterization

Carmen Silvia Cerqueira do Val Fausto^I; Maria Cristina Chammas^II; Osmar de Cássio Saito^III; Márcio Ricardo Taveira Garcia^IV; Adriana Gonçalves Juliano^V; César Augusto Simões^VI; Giovanni Guido Cerri^VII

http://www.scielo.br/pdf/rb/v37n3/20547.pdf

Tratamento Dermatológico na Gravidez

Frequentemente se tem o questionamento sobre tratamentos dermatológico na gestação, então busquei um artigo onde se faz uma ampla revisão sobre o tratamento dermatológico na gravidez. Publicado na Revista da Sociedade Americana de Cirurgia Dermatologica com artigos de 1960 a 2012:

Dermatol Surg. 2013 Oct 29. doi: 10.1111/dsu.12322. [Epub ahead of print]

Safety of Cosmetic Dermatologic Procedures During Pregnancy.

Lee KC, Korgavkar K, Dufresne RG Jr, William Higgins H 2nd.

Source

Department of Dermatology, Brown University, Providence, Rhode Island; Dermatoepidemiology Unit, Veterans Affairs Medical Center, Providence, Rhode Island.

Abstract

BACKGROUND:

Safety of cosmetic procedures in pregnant women has not been extensively studied. Maternal and fetal health risks are important to consider in any procedure performed. With the increasing popularity of cosmetic procedures, dermatologic surgeons will be faced with scenarios necessitating knowledge regarding the safety of such procedures during pregnancy. Furthermore, dermatologic surgeons may inadvertently perform cosmetic procedures during the first trimester, before the patient is aware of the pregnancy.

OBJECTIVE:

To investigate the safety of cosmetic procedures during pregnancy and the postpartum period.

METHODS AND MATERIALS:

A literature search of PubMed and Google Scholar was conducted of all English-language articles published from 1960 through 2012.

RESULTS:

Definitive recommendations on the safety of procedures such as chemical peels, injectables, fillers, and most laser therapies during pregnancy cannot be made. The safety of onabotulinum toxin usage is well documented in the neurology literature, although isolated events of miscarriage have been reported with high doses of toxin in women with a previous history of miscarriage. Carbon dioxide laser therapy for genital condylomas has considerable evidence supporting its safety during pregnancy.

CONCLUSION:

There is a lack of controlled trials addressing the safety of cosmetic procedures during pregnancy and postpartum periods. It is advisable to delay elective cosmetic procedures until after the baby is born.

© 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.

PMID:

 

24164677

 

[PubMed - as supplied by publisher]

Conclusão: Pela falta de estudos controlados (Ensaios clínicos), durante a gravidez e puerpério, a recomendação é tratar após o parto. 

Mas apresentou uma evidência de provável segurança de uso de laser de dióxido de carbono para o tratamento de condilomas durante a gravidez.

Resposta - Caso 4

As imagens correspondem a doença policística do adulto.
É uma doença autossômico recessiva.
Pobre em sintomatologia, mas deve ser lembra em situações de elevação persistente da pressão arterial e dor abdominal mal definida e suportável. Principalmente a partir da 4ª década de vida.

Diferencial com:

• Doença Policística.
• Doença de Von Hippel Lindau.

Bilateral nephrectomy of huge polycystic kidneys associated with a rectus abdominis diastasis and umbilical hernia
Referência da figura acima: http://www.scielo.br/scielo.php?pid=s1807-59322006000600007&script=sci_arttext

Leitura Complementar:

http://www.lume.ufrgs.br/bitstream/handle/10183/28908/000658779.pdf?sequence=1

Curso no Sírio Libanês Filantropia

Não poderia deixar de manifestar meus agradecimentos a equipe de filantropia do Hospital Sírio Libanês pelos cursos de treinamento em ultrassonografia para os médicos que atendem regiões distantes e replicadores das informações.
Meu muito obrigado pelos ensinamentos!!!!

  

Resposta do caso 2

Foram visibilizadas: uma septação de bexiga, artéria umbilical única e uma massa polipoide na genitália.

Artéria umbilical única - pode estar associada a, principalmente, alterações cardiovasculares e renais, embora possa ter associação com outras anormalidades. Isoladamente é desprovida de importância clínica. A causa é multifatorial - com atrofia ou aplasia no período embrionário. É possível o diagnóstico com condições técnicas favoráveis, no morfológico do 1º trimestre. Pode ser vista num corte transversal de alça livre de cordão (aí, numa idade gestacional mais avançada como 16 semanas) ou num corte coronal da bexiga onde as duas artérias são vistas uma de cada lado da bexiga. A frequência na população geral é de 0,2 a 1,6% e nos fetos aneuploides de 9% a 11% (Predanic M, Perni SC, Friedman A, Chervenak FA, Chasen ST. Fetal growth assessment and neonatal birth weight in fetuses with an isolated single umbilical artery. Obstet Gynecol. 2005;105:1093-1097.).

Para maior aprendizado: http://www.medscape.com/viewarticle/530359

Management of Pregnancy Complicated by Single Umbilical Artery

Mary King, MD, Peter S. Bernstein, MD, MPH, Mary King, MD, and Peter S. Bernstein, MD, MPH

DisclosuresMay 01, 2006__________________________________________________________________________________

Bexiga septada ou duplicação vesical: É difícil, intra-útero, separar duplicação de bexiga de septação. Possíveis explicações patológicas: excessiva constrição entre as porções vesicuretral e urogenital da cloaca ventral e a segunda é um septo cloacal supra-numerário que indenta a parede epitelial da bexiga (obviamente uma alteração embriológica).

Para maior aprendizado: http://radiographics.rsna.org/content/22/5/1139.full

Anomalies of the Distal Ureter, Bladder, and Urethra in Children: Embryologic, Radiologic, and Pathologic Features

1. Teresa Berrocal, MD, PhD, 
2. Pedro López-Pereira, MD, 
3. Antonia Arjonilla, MDand 
4. Julia Gutiérrez, MD

1. ¹From the Departments of Pediatric Radiology (T.B., A.A., J.G.) and Pediatric Urology (P.L.P.), Hospital Infantil La Paz, Paseo de la Castellana 261, Madrid 28046, Spain. Recipient of a Certificate of Merit award for an education exhibit at the 2000 RSNA scientific assembly. Received January 15, 2002; revision requested February 27 and received April 4; accepted April 23. Address correspondence toT.B. (e-mail: cprieto@.hulp.insalud.es).

____________________________________________________________________________

Formação polipoide na genitália: Um suspeita é:  pólipo vaginal, ou de uretra, ou de hímen. Mas, com frequência muito menor:  Sarcoma Botrióide ou Rabdomiosarcoma.

Para maior aprendizado: http://emedicine.medscape.com/article/1016681-overview#a30

Genital Anomalies 

• Author: Luigi Avolio, MD; Chief Editor: Marc Cendron, MD   more..
• 
  

Dica de APP:

                                    

DICA Acadêmica -Artefatos em Ultrassonografia

Para os amantes da ultrassonografia e médicos interessados em conhecer melhor este método complementar, estou colocando um link gratuito para um artigo sobre artefatos e "pitfalls" em ultrassonografia.

http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=2737&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=216&isPDF=YES

 

____________________________________________________________________________

Dica de Clínica que foca em saúde da Mulher mas que também oferece exames para a saúde dos homens:
 

Dica de tratamento otorrinolaringológico (nariz, ouvido e garganta) - INOOA

Amigos temos um estabelecimento em otorrinolaringologia que é referência nesta especialidade, onde podemos fazer tratamento e prevenção com alta qualidade além de poder encaminhar pacientes, amigos e parentes; até gestantes, pois eles têm muito cuidado com o uso de medicações em gestantes, seguem as normas do Food and Drug Administration (FDA).

 

DICA acadêmica - Medscape e Emedicine

Senhores há um site que trás informações atualizadas sobre diversas áreas em saúde e se assemelha ao famoso UpToDate, é o Emedicine que está junto com o Medscape. Apresenta informações muito atualizadas e confiáveis. E tem mais é GRATUITO, basta de cadastrar. Eu uso há anos!! Vejam um dos capítulos!!! Aproveitem!!!
http://emedicine.medscape.com/article/260187-overview

 

Today

News

Reference

Education

Log In

Register

Normal and Abnormal Puerperium 

• Chief Editor: David Chelmow, MD   more...

 

Updated: Mar 28, 2011

 

Overview

Puerperium is defined as the time from the delivery of the placenta through the first few weeks after the delivery. This period is usually considered to be 6 weeks in duration. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state.

An overview of the relevant anatomy and physiology in the postpartum period follows.

Uterus

The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 g. In the 6 weeks following delivery, the uterus recedes to a weight of 50-100 g.

Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. Thereafter, most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to return to the true pelvis. Over the next several

weeks, the uterus slowly returns to its nonpregnant state, although the overall uterine size remains larger than prior to gestation.

The endometrial lining rapidly regenerates, so that by the seventh day endometrial glands are already evident. By the 16th day, the endometrium is restored throughout the uterus, except at the placental site.

The placental site undergoes a series of changes in the postpartum period. Immediately after delivery, the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium ("physiologic ligatures") result in hemostasis. The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced.

Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable. The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba).^[1] The period of time the lochia can last varies, although it averages approximately 5 weeks.^[2]

The amount of flow and color of the lochia can vary considerably. Fifteen percent of women have continue to have lochia 6 weeks or more postpartum. Often, women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. This is the classic time for delayed postpartum hemorrhages to occur.

Cervix

The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. By the end of the first week, the external os closes such that a finger cannot be easily introduced.

Vagina

The vagina also regresses but it does not completely return to its prepregnant size. Resolution of the increased vascularity and edema occurs by 3 weeks, and the rugae of the vagina begin to reappear in women who are not breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10; however, it is further delayed in breastfeeding mothers because of persistently decreased estrogen levels.

Perineum

The perineum has been stretched and traumatized, and sometimes torn or cut, during the process of labor and delivery. The swollen and engorged vulva rapidly resolves within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more improvement over the following few months. The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues.

Abdominal wall

The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on maternal exercise.

Ovaries

The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. The mother who does not breastfeed may ovulate as early as 27 days after delivery. Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks.

In the breastfeeding woman, the resumption of menses is highly variable and depends on a number of factors, including how much and how often the baby is fed and whether the baby's food is supplemented with formula. The delay in the return to normal ovarian function in the lactating mother is caused by the suppression of ovulation due to the elevation in prolactin. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery.

Breasts

The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. If delivery ensues, lactation can be established as early as 16 weeks' gestation. Lactogenesis is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin. If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks.

The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. High in protein content, this liquid is protective for the newborn. The colostrum, which the baby receives in the first few days postpartum, is already present in the breasts, and suckling by the newborn triggers its release. The process, which begins as an endocrine process, switches to an autocrine process; the removal of milk from the breast stimulates more milk production. Over the first 7 days, the milk matures and contains all necessary nutrients in the neonatal period. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.

Next Section: Routine Postpartum Care

Triagem de câncer cervical para Adolescentes - Lembrando de Dra. Marcia Cunha que adora trabalhar com adolescentes.

 Lembrando de Dra. Marcia Cunha (UFBA) que adora trabalhar com adolescentes.

Screening Adolescents and Young Women Review Article
Obstetrics and Gynecology Clinics of North America, Volume 40, Issue 2, June 2013, Pages 257-268
Lori A. Boardman, Katina Robison

Recent guidelines from multiple organizations stress screening initiation no earlier than the age of 21 years and increased screening intervals for women aged 21 to 29 years. Primary prevention with human papillomavirus vaccination has the potential to significantly affect the development of high-grade cervical lesions, including cancer, and will likely affect screening guidelines in the future.

Pontos importantes

1. Cervical cancer screening should begin at age 21 years regardless of a young woman’s risk factors for human papillomavirus (HPV) acquisition.
2. For young women between the ages of 21 and 29 years with normal cytology, screening should be repeated after no sooner than 3 years. Cervical cytology alone should be used for screening in this population
3. The addition of HPV testing to routine cervical cancer screening is not indicated in women aged 21 to 29 years because of the high prevalence of high-risk HPV infection in this population
4. The impact of HPV vaccination in real-world settings is under way in the United States, vaccination status does not change screening guidelines.

Uso de Bebidas Energéticas aumenta a taxa de intoxicação por cafeina e aumenta a lesão causada pelo álcool

Alerta sobre o uso de bebidas energéticas e intoxicação por cafeína e álcool.
Veja a  publicação - está entre os 25 artigos TOP do Science Direct.

Review

Caffeinated energy drinks—A growing problem

• Chad J. Reissig^a, 
• Eric C. Strain^a, 
• Roland R. Griffiths^a, b, , 

• ^a Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
• ^b Department of Neuroscience, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA

Drug and Alcohol Dependence

Volume 99, Issues 1–3, 1 January 2009, Pages 1–10

Abstract

Since the introduction of Red Bull in Austria in 1987 and in the United States in 1997, the energy drink market has grown exponentially. Hundreds of different brands are now marketed, with caffeine content ranging from a modest 50 mg to an alarming 505 mg per can or bottle. Regulation of energy drinks, including content labeling and health warnings differs across countries, with some of the most lax regulatory requirements in the U.S. The absence of regulatory oversight has resulted in aggressive marketing of energy drinks, targeted primarily toward young males, for psychoactive, performance-enhancing and stimulant drug effects. There are increasing reports of caffeine intoxication from energy drinks, and it seems likely that problems with caffeine dependence and withdrawal will also increase. In children and adolescents who are not habitual caffeine users, vulnerability to caffeine intoxication may be markedly increased due to an absence of pharmacological tolerance. Genetic factors may also contribute to an individual's vulnerability to caffeine-related disorders including caffeine intoxication, dependence, and withdrawal. The combined use of caffeine and alcohol is increasing sharply, and studies suggest that such combined use may increase the rate of alcohol-related injury. Several studies suggest that energy drinks may serve as a gateway to other forms of drug dependence. Regulatory implications concerning labeling and advertising, and the clinical implications for children and adolescents are discussed.

http://top25.sciencedirect.com/subject/medicine-and-dentistry/17/archive/45

Guideline de rastreamento de câncer de colo 2013

Sai mais um Guideline (guia) para o rastreamento de câncer de colo uterino.

New Cervical Cancer Screening Guidelines, Again

• Nicole Karjane, MD
, 
• David Chelmow, MD

Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, 1250 East Marshall Street, PO Box 980034, Richmond, VA 23298, USA

published online 13 May 2013.

http://www.obgyn.theclinics.com/article/S0889-8545(13)00025-9/abstract

TABELAS OBSTÉTRICAS ÚTEIS

Tabela de peso de Hadlock - uma da mais usadas para avaliação de peso fetal.

Tabela do índice de pulsatilidade venosa do Ducto Venoso por idade gestacional.

G Mari et al. N Engl J Med 2000; 342: 9-14

Tabela de Pico de Velocidade Sistólica da Artéria Cerebral Média com Múltiplos da mediana para avaliação de anemia fetal.