VERA LUCIA JORNADA KREBS
Projetos de Pesquisa
Unidades Organizacionais
Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina
LIM/36 - Laboratório de Pediatria Clínica, Hospital das Clínicas, Faculdade de Medicina
LIM/36 - Laboratório de Pediatria Clínica, Hospital das Clínicas, Faculdade de Medicina
10 resultados
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- Type II and III Selective Fetal Growth Restriction: Perinatal Outcomes of Expectant Management and Laser Ablation of Placental Vessels(2018) MIYADAHIRA, Mariana Yumi; BRIZOT, Maria de Lourdes; CARVALHO, Mario Henrique Burlacchini de; BIANCOLIN, Sckarlet Ernandes; MACHADO, Rita de Cassia Alam; KREBS, Vera Lucia Jornada; FRANCISCO, Rossana Pulcineli Vieira; PERALTA, Cleisson Fabio AndrioliOBJECTIVES: To describe the perinatal outcomes of type II and III selective fetal growth restriction (sFGR) in monochorionic-diamniotic (MCDA) twin pregnancies treated with expectant management or laser ablation of placental vessels (LAPV). METHODS: Retrospective analysis of cases of sFGR that received expectant management (type II, n=6; type III, n=22) or LAPV (type II, n=30; type III, n=9). The main outcomes were gestational age at delivery and survival rate. RESULTS: The smaller fetus presented an absent/reversed ""a'' wave in the ductus venosus (arAWDV) in all LAPV cases, while none of the expectant management cases presented arAWDV. The median gestational age at delivery was within the 32nd week for expectant management (type II and III) and for type II LAPV, and the 30th week for type III LAPV. The rate of at least one twin alive at hospital discharge was 83.3% and 90.9% for expectant management type II and III, respectively, and 90% and 77.8% for LAPV type II and III, respectively. CONCLUSION: LAPV in type II and III sFGR twins with arAWDV in the smaller fetus seems to yield outcomes similar to those of less severe cases that received expectant management.
- Nonimmune fetal ascites: identification of ultrasound findings predictive of perinatal death(2016) BACCEGA, Felipe; BRIZOT, Maria de Lourdes; KREBS, Vera Lucia Jornada; FRANCISCO, Rossana Pulcineli Vieira; ZUGAIB, MarceloAim: To determine the ultrasonographic findings that predict death in fetal ascites. Methods: This was a retrospective cohort study involving pregnancies with ultrasonographic findings related to fetal ascites. The inclusion criteria were as follows: single pregnancy with a live fetus; ultrasound findings of ascites; ascites unrelated to maternal fetal alloimmunization; and pregnancy follow-up at our institution. The chi(2)-test was used to evaluate the association of ultrasound findings and death. Multiple logistic regression analysis was performed to determine the ultrasound findings that are predictive of death prior to hospital discharge. Results: A total of 154 pregnancies were included in the study. In 8 (5.19%) cases, ascites was an isolated finding, and in 146 cases, other alterations were observed during the ultrasound evaluation. Death before hospital discharge occurred in 117 cases (76.00%). The following ultrasonographic findings were significantly associated with death: gestational age at diagnosis <24 weeks (P < 0.0001); stable/progressive ascites evolution (P = 0.004); the presence of hydrops (P < 0.0001); and the presence of cystic hygroma (P < 0.0001). The presence of hydrops, the presence of respiratory tract malformations, and stable/progressive ascites evolution were significantly associated with the prediction of death. Conclusions: Based on ultrasound examination, the presence of hydrops, malformation of the respiratory tract, and stable/progressive evolution of ascites increase the chances of death in cases of fetal ascites.
- Neonatal infection and passive acquisition of serum total IgG and reactive with ""Streptococcus"" B, anti-LPS of ""Klebsiella spp"" and ""Pseudomonas spp"" antibodies in twins(2020) YOSHIDA, Renato de Arauio Monteiro; PALMEIRA, Patricia; CARNEIRO-SAMPAIO, Magda; BRIZOT, Maria de Lourdes; CARVALHO, Erther Brunow de; KREBS, Vera Lucia JornadaOBJECTIVE: To describe the concentration of total and specific IgG antibodies anti-Streptococcus B, anti-lipopolysaccharide of Klebsiella spp, and anti-lipopolysaccharide of Pseudomonas spp in the umbilical cord of newborn(NB) twins and to analyze the association between neonatal infection and antibody concentration in the umbilical cord blood. METHODS: A prospective cross-sectional study of a cohort of NB twins admitted during the period of 20 months. Patients with malformations and mothers with infection were excluded. Variables analyzed: gestational age(GA); birth weight(BW); antibody concentrations in umbilical cord blood; infection episodes. We used the paired Student t-test, Spearman correlation, and generalized estimation equation. RESULTS: 57 pairs of twins were included, 4 excluded, making the sample of 110 newborns. GA=36 +/- 1.65weeks and BW=2304.8 +/- 460g(mean +/- SD). Antibody concentrations in twins(mean +/- SD): total IgG=835.77 +/- 190.73mg/dL, anti-StreptococcusB IgG=250.66 +/- 295.1 AU/mL, anti-lipopolysaccharide of Pseudomonas spp IgG=280.04 +/- 498.66 AU/mL and anti-lipopolysaccharide of Klebsiella spp IgG=504.75 +/- 933.93 AU/mL. There was a positive correlation between maternal antibody levels and those observed in newborns(p <0.005). The transplacental transfer of maternal total IgG and anti-LPS Pseudomonas IgG antibodies was significantly lower at NB GA <34 weeks(p <0.05). Five newborns were diagnosed with an infection. Infants with infection had significantly lower total IgG concentration(p <0.05). CONCLUSION: This study showed a positive correlation between maternal and newborn antibodies levels. In infants younger than 34 weeks there is less transfer of total IgG and anti-LPS Pseudomonas IgG. The highest incidence of infection in the newborn group who had significantly lower total IgG serum antibodies reinforces the importance of anti-infectious protection afforded by passive immunity transferred from the mother.
- Conjoined twins pregnancies: experience with 36 cases from a single center(2011) BRIZOT, M. L.; LIAO, A. W.; LOPES, L. M.; OKUMURA, M.; MARQUES, M. S.; KREBS, V.; SCHULTZ, R.; ZUGAIB, M.Objective To review a single center's experience in the management of twin pregnancies with conjoined fetuses. Methods Retrospective study describing prenatal findings, delivery details, surgical treatment and perinatal outcome. Results The study included 36 twin pregnancies with conjoined twins seen over a period of 12 years in a single tertiary hospital: 69.4% were thoracopagus, 13.9% parapagus, 8.3% omphaloischiopagus 5.6% omphalopagus and 2.8% cephalopagus. Cardiac defects were present in 91.6% of twin pairs and associated malformations were present in 61.8% of the cases: limb abnormalities in 36.1%, abdominal wall defects in 25.0%, cleft lip and/ or palate in 13.9% and congenital diaphragmatic hernia in 5.5%. Surgical separation was considered not feasible and prognosis lethal in 30 (83.3%) cases. Termination of pregnancy was performed in 12 pregnancies of poor prognosis. Cesarean section was performed in all remaining cases. Five sets of twins underwent surgical separation and six children survived. Overall survival in our series was 8.3% and, among the livebirths, 13.6%. Conclusion Conjoined twin pregnancies should be referred to tertiary centers for detailed fetal anomaly and echocardiographic assessment to evaluate prognosis and determine the possibility of postnatal surgical separation.
- Should We Measure Fetal Omphalocele Diameter for Prediction of Perinatal Outcome?(2014) KIYOHARA, Marina Y.; BRIZOT, Maria L.; LIAO, Adolfo W.; FRANCISCO, Rossana P. V.; TANNURI, Ana C. A.; KREBS, Vera L. J.; ZUGAIB, MarceloObjective: To evaluate the fetal omphalocele diameter/abdominal circumference ratio (OD/AC) as a predictor of adverse perinatal outcome. Methods: Analysis involving 47 singleton pregnancies with fetal omphalocele, normal karyotype and absence of other major abnormalities. The OD/AC ratio was determined antenatally by ultrasound and the best cutoff for the prediction of neonatal death was determined by receiver operating characteristic curve analysis. Additional secondary outcomes included need for oral intubation in the first 24 h of life, two-step surgery or use of synthetic mesh, reoperation, parenteral feeding and need for respiratory assistance >21 days, time to first oral feed, and time to hospital discharge. Results: Fetal OD/AC did not change significantly with gestational age. Postnatal death occurred in 10 (21.3%) cases and the best cutoff for prediction was an OD/AC ratio >= 0.26 In pregnancies with the first ultrasound evaluation performed before 31 weeks' gestation and an OD/AC >= 0.26, the likelihood ratio for needing intubation in the first 24 h of life was 2.6 (95% CI: 1.2-5.7), needing two-step surgery or use of mesh was 4.9 (95% Cl: 1.9-14.4), and postnatal death was 4 (95% Cl: 1.9-7.5). Conclusion: A fetal ultrasound OD/AC ratio >= 0.26 is associated with increased postnatal morbidity and mortality. (C) 2013 S. Karger AG, Basel
- Sonographic Markers in the Prediction of Fetal Complex Gastroschisis(2018) ANDRADE, Walkyria S.; BRIZOT, Maria L.; RODRIGUES, Agatha S.; TANNURI, Ana C.; KREBS, Vera L.; NISHIE, Estela N.; FRANCISCO, Rossana P. V.; ZUGAIB, MarceloObjective: To investigate the ultrasound (US) markers predictive of complex gastroschisis (CG), mortality, and morbidity in fetuses with gastroschisis. Materials and Methods: This was a retrospective cohort study of 186 pregnancies with isolated fetal gastroschisis. Eight US markers were analyzed. The predictions and associations of US markers with CG, mortality, and morbidity were assessed. Combinations of US markers predictive of CG were investigated. Results: Extra-abdominal bowel dilatation (EABD), intra-abdominal bowel dilatation (IABD), and polyhydramnios were predictive of CG. EABD between 25 and 28 weeks had a sensitivity of 64%, a specificity of 89%, a positive predictive value (PPV) of 56.2%, and negative predictive value (NPV) of 91.8%. The predictions of IABD were sensitivity = 26.7%, specificity = 96.7%, PPV = 61.5%, and NPV = 86.8%. The odds ratios for CG in the presence of 1 and 2 US markers, compared with the absence of a US marker, were 18.3 (95% CI, 3.83-87.64) and 73.3 (95% CI, 6.14-876), respectively. Conclusion: US markers predictive of CG were established. The combination of these markers increases the probability of CG. (C) 2017 S. Karger AG, Basel
- Prediction of intrauterine death and severe preterm delivery in twin pregnancies discordant for major fetal abnormality(2014) KANG, Helenice J.; LIAO, Adolfo W.; BRIZOT, Maria L.; FRANCISCO, Rossana P. V.; KREBS, Vera L. J.; ZUGAIB, MarceloObjective: To investigate predictors of spontaneous fetal death and preterm delivery in twin pregnancies with one fetus affected by a major structural malformation. Study design: Retrospective study (1999-2012) conducted at a tertiary teaching hospital involving 51 twin pregnancies (dichorionic = 31, monochorionic diamniotic = 15, monochorionic monoamniotic = 4, not established = 1) with a major fetal abnormality, enrolled before 26 weeks and managed expectantly. Primary outcomes: spontaneous fetal death, and/or delivery before 32 weeks. Prediction was examined with stepwise logistic regression analysis, and independent variables included: maternal age, gestational age at diagnosis, chorionicity, fetal gender, number and type of fetal abnormalities. Significance level was set at 0.15. Results: Fetal abnormalities were diagnosed at a mean gestation of 21.5 3.7 weeks: cardiac abnormalities were observed in 31.4% of abnormal fetuses, abdominal wall defects in 29.4%, central nervous system 21.5%, spine 17.6%, effusions 17.6%, noncardiac thoracic abnormalities 15.7%, genital and urinary system 13.7%, limbs and soft tissue 3.9%, intestinal 1.9% and facial defects 1.9%. Fetal death occurred in 15 (29.4%) abnormal fetuses and was significantly correlated with the number of fetal malformations (p = 0.02, OR = 2.54, 95% CI = 1.14-5.62), presence of effusion/hydrops (p = 0.06, OR = 4.7, 95% CI = 0.95-24) and monochorionic placenta (p = 0.11, OR= 2.8, 95% CI = 0.78-9.8). Normal co-twin fetal death occurred in four cases (7.8%) and was related to monochorionic pregnancies (p = 0.14, OR = 5.8, 95% CI = 0.56-61). Delivery before 32 weeks was observed in 14 (27.5%) pregnancies and was related to presence of effusion/ hydrops (p = 0.04, OR = 5.5, 95% CI = 1.07-28). Conclusion: Spontaneous fetal death and/or delivery before 32 weeks in twin pregnancies with one fetus affected by a major structural malformation are related to the number of abnormalities diagnosed and presence of fetal effusion or hydrops. 2014 Elsevier Ireland Ltd. All rights reserved.
- Twenty-Five Years of Fetal Echocardiography in Conjoined Twins: Lessons Learned(2013) LOPES, Lilian M.; BRIZOT, Maria L.; SCHULTZ, Regina; LIAO, Adolfo W.; KREBS, Vera L. J.; FRANCISCO, Rossana P. V.; ZUGAIB, MarceloBackground: The aim of this study was to determine the accuracy of prenatal echocardiography in the diagnosis of intracardiac malformations and the degree of cardiac fusion in conjoined twins presenting to a single center over a 25-year period. Methods: The study group included 53 sets of conjoined twins from 1987 to 2012, including 38 thoracopagus, six parapagus, six omphalo-ischiopagus, two omphalopagus, and one cephalopagus. Twins were classified according to the degree of cardiac fusion: separate hearts and pericardium (group A, n = 10), separated hearts and common pericardium (group B, n = 2), fused atria and separated ventricles (group C, n = 2), and fused atria and ventricles (group D, n = 39). Postmortem examination was possible in 68 individual cases (98 deaths [69.3%]). Results: Cardiac defects were diagnosed in 47 sets of twins (88.6%). In 10 (18.8%), only one fetus was affected, and in 37 (69.8%), both fetuses were affected (n = 84/106 [79.2%]). There was a high predominance of right-sided lesions (63.0% [53 fetuses in 84 affected]) including pulmonary atresia or stenosis (35.7%), tricuspid atresia (11.9%), and hypoplastic or small right ventricle (21.4%). Autopsy findings added information to fetal echocardiographic findings in nine sets of twins (25.7%). Three pairs classified antenatally in groups A, B, and D were confirmed by autopsy in groups B, C, and C, respectively. Conclusions: This study demonstrates that specialized fetal echocardiography is not a perfect diagnostic tool but is sensitive enough to establish prognosis in the counseling process. Because of complexity, such evaluations should be performed only at tertiary centers by specialists who are familiar with the peculiarities of this rare malformation. The predominance of right-sided lesions is not only an interesting finding, but this information has essential importance in terms of shortening examination times, allowing a more focused analysis of the fetal heart.
- Intrauterine growth restriction in monochorionic-diamniotic twins(2014) MACHADO, Rita de Cassia Alam; BRIZOT, Maria de Lourdes; MIYADAHIRA, Seizo; FRANCISCO, Rossana Pulcineli Vieira; KREBS, Vera Lucia Jornada; ZUGAIB, MarceloObjective: to evaluate neonatal morbidity and mortality in monochorionic-diamniotic (MCDA) twin pregnancies complicated by selective intrauterine growth restriction (sIUGR) and non-selective intrauterine growth resctriction (nsIUGR). Methods: neonatal morbidity parameters and mortality were analyzed in 34 twins with IUGR (< 10th percentile on twins' growth charts): 18 with sIUGR and 16 with nsIUGR. The sIUGR group was made up of 18 pregnancies in which growth was restricted in only one fetus (n = 18). The nsIUGR group was composed of 8 pregnancies in which both fetuses presented restricted growth (n = 16). Cases of twin-to-twin transfusion syndrome and fetal malformation were not included in the study. Results: the MCDA twin pregnancies with sIUGR had a higher rate of orotracheal intubation (p = 0.001) and mechanical ventilation (p = 0.0006), as well as longer than average fasting time (p = 0.014) compared to those in which the fetuses had nsIUGR. A higher incidence was also observed of types II and III umbilical artery Doppler velocimetry patterns in the sIUGR cases (p = 0.002). There was no significant difference between the two groups as to mortality during pregnancy and the neonatal period (p = 0.09). Conclusion: in MCDA twin pregnancies, sIUGR presents more severe umbilical artery Doppler velocimetry abnormalities and worse morbidity than nsIUGR.
- Vaginal progesterone for the prevention of preterm birth in twin gestations: a randomized placebo-controlled double-blind study(2015) BRIZOT, Maria L.; HERNANDEZ, Wagner; LIAO, Adolfo W.; BITTAR, Roberto E.; FRANCISCO, Rossana P. V.; KREBS, Vera L. J.; ZUGAIB, MarceloOBJECTIVE: The purpose of this study was to investigate the use of vaginal progesterone for the prevention of preterm delivery in twin pregnancies. STUDY DESIGN: We conducted a prospective, randomized, doubleblind, placebo-controlled trial that involved 390 naturally conceived twin pregnancies among mothers with no history of preterm delivery who were receiving antenatal care at a single center. Women with twin pregnancies between 18 and 21 weeks and 6 days' gestation were assigned randomly to daily vaginal progesterone (200 mg) or placebo ovules until 34 weeks and 6 days' gestation. The primary outcome was the difference in mean gestational age at delivery; the secondary outcomes were the rate of spontaneous delivery at <34 weeks' gestation and the rate of neonatal composite morbidity and mortality in the treatment and nontreatment groups. RESULTS: The baseline characteristics were similar in both groups. The final analysis included 189 women in the progesterone group and 191 in the placebo group. No difference (P = .095) in the mean gestational age at delivery was observed between progesterone (35.08 +/- 3.19 [SD]) and placebo groups (35.55 +/- 2.85). The incidence of spontaneous delivery at <34 weeks' gestation was 18.5% in the progesterone group and 14.6% in the placebo group (odds ratio, 1.32; 95% confidence interval, 0.24-2.37). No difference in the composite neonatal morbidity and mortality was observed between the progesterone (15.5%) and placebo (15.9%) groups (odds ratio, 1.01; 95% confidence interval, 0.58-1.75). CONCLUSION: In nonselected twin pregnancies, vaginal progesterone administration does not prevent preterm delivery and does not reduce neonatal morbidity and death.