From: Subject: =?Windows-1252?Q?Gesta=E7=E3o_de_Alto_Risco_-_Manual_T=E9cnico?= Date: Thu, 31 Jul 2008 15:22:27 -0300 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C8F321.3E2CC190" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3198 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C8F321.3E2CC190 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.providaanapolis.org.br/gestao.htm Gesta=E7=E3o de Alto Risco - Manual T=E9cnico

Minist=E9rio da Sa=FAde

Secretaria de Pol=EDticas de Sa=FAde

Departamento de Gest=E3o de Pol=EDticas = Estrat=E9gicas=20

=C1rea T=E9cnica de Sa=FAde da Mulher

G E S T A =C7 =C3 O D E = A L T O R I S C=20 O

M a n u a l T =E9 c n i = c=20 o

3=AA EDI=C7=C3O

BRAS=CDLIA 2000

G E S T A =C7 =C3 O D E = A L T O R I S C=20 O

M a n u a l T =E9 c n i = c o=20

3=AA EDI=C7=C3O

MINIST=C9RIO DA SA=DADE

BRAS=CDLIA 2000

Ministro da = Sa=FAde=20

Jos=E9 Serra

Secret=E1rio de = Pol=EDticas de=20 Sa=FAde

Jo=E3o Yunes

Diretora do = Departamento de Gest=E3o=20 de Pol=EDticas Estrat=E9gicas

Ana Maria Figueiredo

COORDENADORA DE = A=C7=D5ES DE SA=DADE DA=20 MULHER

T=E2nia Di Giacomo do Lago

=C1rea T=E9cnica de = SA=DAde da=20 Mulher

Alice Goncalves Mendes Ribeiro

Elcylene Leoc=E1dio

Janine Schirmer

Regina Coeli Viola

Nelson Cardoso de Almeida

Marilena Garcia

Suzanne Serruya

Elabora=E7=E3o: =

3=AA edi=E7=E3o, = 2000=20

Dirlene Mafalda I. Silveira

Jacob Arkader

Janine Schirmer

Jos=E9 Guilherme Cecatti

Jos=E9 J=FAlio Tedesco

Sara Romera Sorrentino

Suzanne Serruya

Colabora=E7=E3o:

Ana L=FAcia Ribeiro de Vasconcelos

Angela de A. Jacob Reichelt

Beatriz Helena Tess

Geraldo Duarte

Maria In=EAs Schmidt

Maria L=FAcia da Rocha Oppermann

Marinice Coutinho

Ricardo Fescina

Valdil=E9a G. Veloso dos Santos

c Minist=E9rio da Sa=FAde, 2000.

=C9 permitida a reprodu=E7=E3o total, desde que = citada a fonte.=20

Tiragem: 30.000 exemplares

Edi=E7=E3o, distribui=E7=E3o e informa=E7=F5es: =

Minist=E9rio da Sa=FAde

=C1rea T=E9cnica da Sa=FAde da Mulher

Esplanada dos Minist=E9rios, Bloco G, 6=BA andar =

CEP: 70.058-900

Tel.: (0xx61) 223-5591

Fax: (0xx61) 322-3912

Gesta=E7=E3o de Alto Risco / Secretaria de = Pol=EDticas, =C1rea=20 T=E9cnica da Sa=FAde da Mulher. _ Bras=EDlia : Minist=E9rio da = Sa=FAde, 2000.

164 p.

1. Gravidez de alto risco. 2. Puerp=E9rio. I. = Brasil.=20 Minist=E9rio da Sa=FAde, Secretaria de Pol=EDticas de Sa=FAde. =

S U M =C1 R I = O

APRESENTA=C7=C3O 9

INTRODU=C7=C3O 11

GESTA=C7=C3O DE ALTO RISCO 13

PARTE 1 _ DOEN=C7AS OBST=C9TRICAS 19

1. S=EDndromes Hipertensivas da Gravidez 21

1.1. Pr=E9-Ecl=E2mpsia 23

1.2. Imin=EAncia de Ecl=E2mpsia/Ecl=E2mpsia 28 =

1.3. S=EDndrome Hellp 30

2. S=EDndromes Hemorr=E1gicas 33

2.1. Hemorragias da primeira metade da gravidez 33 =

2.1.1. Abortamento 33

2.1.2. Abortamento Habitual 35

2.1.3. Gravidez Ect=F3pica 36

2.1.4. Mola Hidatiforme 36

2.1.5. Descolamento c=F3rio-amni=F3tico 38

2.2. Hemorragias da segunda metade da gravidez 38 =

2.2.1. Placenta Pr=E9via 38

2.2.2. Descolamento Prematuro da Placenta 39

2.2.3. Rotura Uterina 40

3. Desvios do Crescimento Fetal 43

3.1. Retardo do Crescimento Intra-Uterino 43

3.2. Macrossomia Fetal 45

4. Altera=E7=F5es da dura=E7=E3o da Gravidez 47 =

4.1. Incompet=EAncia Istmo-cervical 47

4.2. Trabalho de Parto Prematuro 48

4.3. Gesta=E7=E3o Prolongada 51

5. Altera=E7=F5es do Volume de L=EDquido = Amni=F3tico 53

5.1. Oligo=E2mnio 53

5.2. Polidr=E2mnio 54

6. =CAmese E Hiper=EAmese 57

7. Gesta=E7=E3o M=FAltipla 59

8. ALOIMUNIZA=C7=C3O Materno-Fetal 61

9. Amniorrexe Prematura 63

9.1. Corioamnionite 65

10. =D3bito Fetal 67

11. Ces=E1rea Anterior 69

PARTE 2 _ INTERCORR=CANCIAS CL=CDNICAS 71 =

1. InfeC=C7=D5ES 73

1.1. Infec=E7=E3o urin=E1ria 73

1.2. Toxoplasmose 74

1.3. Mal=E1ria 76

1.4. Hansen=EDase 80

1.5. Rub=E9ola 82

1.6. Citomegalia 84

1.7. Doen=E7as Sexualmente Transmiss=EDveis 85 =

1.7.1. S=EDfilis 85

1.7.2. Hepatites B e C 88

1.7.3. Infec=E7=E3o pelo HIV 88

1.7.4. Infec=E7=E3o pelo Papiloma V=EDrus 94

1.7.5. Herpes Simples V=EDrus 95

1.7.6. Vaginose Bacteriana 95

2. Hipertens=E3o arterial cr=F4nica 99

3. Anemias 105

3.1. Anemia Ferropriva 105

3.2. Anemia Megalobl=E1stica 105

3.3. Anemia Falciforme 106

3.4. Talassemias 106

3.5. Anemia Microangiop=E1tica 107

4. Endocrinopatias 109

4.1. Diabete Melito 109

4.2. Tireoidopatias 114

4.2.1. Hipotireoidismo 114

4.2.2. Hipertireoidismo 114 4.2.3. Crise = Tireot=F3xica 115=20

4.2.4. Carcinoma de Tire=F3ide 116

5. Cardiopatias 117

6. Pneumopatias 119

6.1. Asma 119

6.2. Pneumonia 120

6.3. Tuberculose 120

7. Lupus eritematoso sist=EAmico 121

8. S=EDndrome antifosfol=CDPIDE 123

9. Tromboembolismo 125

10. Epilepsia 127

PARTE 3 _ AVALIA=C7=C3O FETAL 129

1. AVALIA=C7=C3O DA Vitalidade 131

1.1. M=E9todos Cl=EDnicos 131

1.1.1. Registro di=E1rio dos movimentos fetais 131 =

1.1.2. Prova de acelera=E7=E3o fetal 132 1.2. = M=E9todos Biof=EDsicos=20 133

1.2.1. Cardiotocografia anteparto de repouso 133 =

1.2.2. Perfil Biof=EDsico Fetal 134

1.2.3. Dopplervelocimetria 135

2. avalia=E7=E3o da maturidade fetal 137

2.1. M=E9todos Cl=EDnicos 137

2.1.1. Estabelecimento da Idade Gestacional 137 =

2.1.2. Exame do L=EDquido Amni=F3tico 138

2.2. M=E9todos Laboratoriais 139

2.2.1. Exame do L=EDquido Amni=F3tico 139

2.2.2. Exame Ultra-sonogr=E1fico 140

PARTE 4 _ ANTECIPA=C7=C3O ELETIVA DO PARTO NA = GESTA=C7=C3O DE=20

ALTO RISCO 143

1. ANTECIPA=C7=C3O ELETIVA DO PARTO 145

PARTE 5 _ ATENDIMENTO =C0 GESTANTE EM RISCO DE = VIDA 149=20

1. ATENDIMENTO =C0 GESTANTE COM RISCO DE VIDA 151 =

PARTE 6 _ ANEXOS 155

1. NORMAS DE BIOSSEGURAN=C7A E PARTO 157

2. CUIDADOS ESPEC=CDFICOS DURANTE O PARTO 159

3. DIAGN=D3STICO SOROL=D3GICO DA INFEC=C7=C3O PELO = HIV 161

8

A P R E S E N T A =C7 =C3 = O=20

Promover a maternidade segura =E9 compromisso do = Minist=E9rio da=20 Sa=FAde e de todos n=F3s. Al=E9m de garantir o pr=E9-natal e = humanizar o=20 atendimento, entre outras a=E7=F5es, =E9 preciso dedicar = aten=E7=E3o especial a uma=20 pequena parcela de mulheres gr=E1vidas, por serem portadoras de = doen=E7as que=20 se agravam com a gesta=E7=E3o ou s=E3o desencadeadas nesse = per=EDodo.

Para atender =E0s necessidades desse segmento, os = estados=20 est=E3o recebendo assessoria t=E9cnica e recursos financeiros com = o objetivo=20 de desenvolver projetos de reorganiza=E7=E3o dos sistemas de = aten=E7=E3o =E0=20 gesta=E7=E3o de risco.

O Manual T=E9cnico de Gesta=E7=E3o de Alto Risco = que o Minist=E9rio=20 da Sa=FAde apresenta vem esclarecer procedimentos e contribuir = para a=20 capacita=E7=E3o dos profissionais de sa=FAde em todo o Brasil. =

JOS=C9 SERRA

Ministro da Sa=FAde

9

I N T R O D U =C7 =C3 = O=20

A mortalidade infantil por causas origin=E1rias do = per=EDodo=20 perinatal vem aumentando no Brasil. Sabe-se que esses =F3bitos = s=E3o=20 preven=EDveis em sua maioria, mas para tal =E9 necess=E1ria = participa=E7=E3o ativa=20 do sistema de sa=FAde. V=E1rios pa=EDses em desenvolvimento j=E1 = conseguiram obter=20 resultados satisfat=F3rios. Isso foi poss=EDvel pela a=E7=E3o = organizada, ampla,=20 integrada e com cobertura abrangente, utilizando tecnologias = simplificadas=20 e economicamente vi=E1veis.

Ap=F3s a Confer=EAncia Internacional de = Popula=E7=E3o e=20 Desenvolvimento, em 1994, no Cairo, evoluiu o conceito de sa=FAde=20 reprodutiva, ganhando enfoque igualmente priorit=E1rio os = indicadores de=20 sa=FAde relativos =E0 morbidade, =E0 mortalidade e ao bem-estar = geral da=20 popula=E7=E3o feminina. Esse conceito lan=E7a novo olhar, = ampliando a cidadania=20 das mulheres para al=E9m da maternidade.

A gesta=E7=E3o =E9 um fen=F4meno fisiol=F3gico e, = por isso mesmo, sua=20 evolu=E7=E3o se d=E1 na maior parte dos casos sem = intercorr=EAncias. Apesar desse=20 fato, h=E1 pequena parcela de gestantes que, por terem = caracter=EDsticas=20 espec=EDficas, ou por sofrerem algum agravo, apresenta maiores=20 probabilidades de evolu=E7=E3o desfavor=E1vel, tanto para o feto = como para a=20 m=E3e. Essa parcela constitui o grupo chamado de "gestantes de = alto risco".=20

Esta vis=E3o do processo sa=FAde-doen=E7a, = denominada Enfoque de=20 Risco, fundamenta-se no fato de que nem todos os indiv=EDduos = t=EAm a mesma=20 probabilidade de adoecer ou morrer, sendo tal probabilidade maior = para uns=20 que para outros.

Essa diferen=E7a estabelece um gradiente de = necessidade de=20 cuidados que vai desde o m=EDnimo, para os indiv=EDduos de baixo = risco ou=20 baixa probabilidade de apresentar esse dano, at=E9 o m=E1ximo, = necess=E1rio para=20 aqueles com alta probabilidade de sofrer danos =E0 sa=FAde. A = identifica=E7=E3o de=20 indiv=EDduos de alto e baixo risco faz com que a equipe de sa=FAde = disponha de=20 instrumentos discriminadores no processo de recomendar, gerar e = fornecer=20 cuidados =E0 sa=FAde, de maneira diferenciada.

As necessidades de sa=FAde do grupo de baixo risco = s=E3o=20 resolvidas, de maneira geral, com procedimentos simples no n=EDvel = prim=E1rio=20 de assist=EAncia. As do grupo de alto risco geralmente requerem = t=E9cnicas=20 mais especializadas. Ainda que alguns casos possam ser = solucionados no=20 n=EDvel prim=E1rio de assist=EAncia, outros necessitar=E3o do = n=EDvel secund=E1rio e=20 terci=E1rio, com equipe de sa=FAde e tecnologia sofisticadas. =

11

As normas de assist=EAncia devem diferir segundo o = grau de=20 risco que o indiv=EDduo apresente. Assim, o controle pr=E9-natal = da gestante=20 de baixo risco ser=E1 diferente daquela de alto risco, seja em = objetivos,=20 conte=FAdos, n=FAmero de consultas pr=E9-natais e tipo de equipe = que presta a=20 assist=EAncia.

A finalidade da presente norma =E9 auxiliar a = equipe de sa=FAde,=20 disponibilizando instrumentos no processo de organiza=E7=E3o da = assist=EAncia=20 materna e perinatal, uniformizando conceitos e crit=E9rios para a = abordagem=20 da gesta=E7=E3o de alto risco. Ela pretende cobrir os aspectos = cl=EDnicos=20 associados =E0 gesta=E7=E3o de risco, sem se superpor =E0s = informa=E7=F5es e=20 recomenda=E7=F5es de outras normas e manuais t=E9cnicos do = Minist=E9rio da Sa=FAde,=20 incluindo o de pr=E9-natal, de parto e puerp=E9rio, de doen=E7as = sexualmente=20 transmiss=EDveis, de emerg=EAncias e outros.

Por outro lado, com a forma esquem=E1tica adotada, = pretende-se=20 facilitar o processo de tomada de decis=F5es no atendimento = obst=E9trico e=20 perinatal, sem dispensar o conhecimento de outras fontes=20 t=E9cnico-cient=EDficas.

12

G E S T A =C7 =C3 O D E A = L T O R I S C=20 O

Toda gesta=E7=E3o traz em si mesma risco para a = m=E3e ou para o=20 feto. No entanto, em pequeno n=FAmero delas esse risco est=E1 = muito aumentado=20 e =E9 ent=E3o inclu=EDdo entre as chamadas gesta=E7=F5es de alto = risco. Desta=20 forma, pode-se conceituar gravidez de alto risco "aquela na = qual a=20

vida ou sa=FAde da m=E3e e/ou do feto e/ou do = rec=E9m-nascido,=20 t=EAm maiores chances de serem atingidas que as da m=E9dia da = popula=E7=E3o=20 considerada" (Caldeyro-Barcia, 1973).

O interesse pela gesta=E7=E3o de alto risco data = da d=E9cada de=20 sessenta e, como seria de se esperar, despertou a aten=E7=E3o de = in=FAmeros=20 estudiosos, no mundo inteiro. Para a generaliza=E7=E3o dos = conhecimentos, o=20 primeiro passo era a identifica=E7=E3o, em determinada = popula=E7=E3o, daquelas que=20 tivessem fatores de risco. Assim, surgiram in=FAmeras tabelas e = escores na=20 literatura mundial, diferentes entre si, por relatarem realidades = de=20 pa=EDses, ou mesmo regi=F5es diferentes.

No Brasil, por suas grandes dimens=F5es e, = principalmente=20 pelas

diferen=E7as s=F3cio-econ=F4mico-culturais, = evidenciam-se fatores=20

de risco diversos para as v=E1rias regi=F5es. = Partindo-se desta=20

constata=E7=E3o, parece ser de maior interesse = listarem-se os=20 fatores

mais comuns na popula=E7=E3o em geral. Assim, os = fatores

geradores de risco podem ser agrupados em quatro = grandes=20

grupos, que s=E3o:

1. Caracter=EDsticas individuais e condi=E7=F5es=20 s=F3cio-demogr=E1ficas

desfavor=E1veis;

2. Hist=F3ria reprodutiva anterior =E0 = gesta=E7=E3o atual;

3. Doen=E7as obst=E9tricas na gesta=E7=E3o atual; =

4. Intercorr=EAncias cl=EDnicas.

As situa=E7=F5es listadas no Quadro 1, embora de = risco, devem=20

ser abordadas, quanto ao atendimento = especializado, na

depend=EAncia da estrutura=E7=E3o dos servi=E7os = locais. De maneira=20

geral, s=E3o inicialmente atendidas no n=EDvel = prim=E1rio, e=20 referenciadas posteriormente, se necess=E1rio, para n=EDveis mais = complexos de=20

aten=E7=E3o. Na aten=E7=E3o =E0s gestantes ditas = de "baixo risco",=20

deve-se atentar para o aparecimento ou agravamento = dos

referidos fatores. A aus=EAncia de controle = pr=E9-natal, por si=20 mesma, =E9 um fator de risco para a gestante e o rec=E9m-nascido. =

13

Quadro 1. Fatores de risco na gravidez = (Tedesco,=20 1999, modificado)

1. Caracter=EDsticas individuais e = condi=E7=F5es=20 s=F3cio-demogr=E1ficas

desfavor=E1veis

_ Idade menor que 17 e maior que 35 anos

_ Ocupa=E7=E3o: esfor=E7o f=EDsico, carga = hor=E1ria, rotatividade de=20

hor=E1rio, exposi=E7=E3o a agentes f=EDsicos, = qu=EDmicos e biol=F3gicos=20

nocivos, estresse.

_ Situa=E7=E3o conjugal insegura

_ Baixa escolaridade

_ Condi=E7=F5es ambientais desfavor=E1veis

_ Altura menor que 1,45 m

_ Peso menor que 45 kg e maior que 75 kg

_ Depend=EAncia de drogas l=EDcitas ou il=EDcitas =

2. Hist=F3ria reprodutiva anterior

_ Morte perinatal explicada e inexplicada

_ Rec=E9m-nascido com crescimento retardado, = pr=E9-termo ou

malformado

_ Abortamento habitual

_ Esterilidade/infertilidade

_ Intervalo interpartal menor que 2 anos ou maior = que 5 anos=20

_ Nuliparidade e Multiparidade

_ S=EDndrome hemorr=E1gica ou hipertensiva

_ Cirurgia uterina anterior

3. Doen=E7a obst=E9trica na gravidez atual =

_ Desvio quanto ao crescimento uterino, n=FAmero = de fetos e=20

volume de l=EDquido amni=F3tico

_ Trabalho de parto prematuro e gravidez = prolongada

_ Ganho ponderal inadequado

_ Pr=E9-ecl=E2mpsia e ecl=E2mpsia

_ Diabetes gestacional

_ Amniorrexe prematura

_ Hemorragias da gesta=E7=E3o

_ Aloimuniza=E7=E3o

_ =D3bito fetal

4. Intercorr=EAncias cl=EDnicas

_ Hipertens=E3o arterial

_ Cardiopatias

_ Pneumopatias

_ Nefropatias

_ Endrocrinopatias

_ Hemopatias

_ Epilepsia

_ Doen=E7as infecciosas

_ Doen=E7as autoimunes

_ Ginecopatias

14

No seguimento das gesta=E7=F5es de alto risco = levam-se em=20 considera=E7=E3o:

a) Repercuss=F5es m=FAtuas entre a doen=E7a e a = gravidez. =C9=20 de suma import=E2ncia o conhecimento das repercuss=F5es da = gravidez sobre a=20 doen=E7a. Para tanto, o obstetra deve ter conhecimento fundamental = sobre a=20 fisiologia da gravidez. Desconhecendo as adapta=E7=F5es pelas = quais passa o=20 organismo materno e, como consequ=EAncia, o seu funcionamento, = n=E3o h=E1 como=20 avaliar as repercuss=F5es sobre a doen=E7a. Por outro lado, se = n=E3o se conhecem=20 os mecanismos fisiopatol=F3gicos das doen=E7as, como integr=E1-los = ao organismo=20 da gr=E1vida? Portanto, o conhecimento de cl=EDnica m=E9dica =E9 = outro=20 pr=E9-requisito b=E1sico de quem se disp=F5e a atender a gestante = de alto risco.=20

b) Avalia=E7=E3o cl=EDnica. Este = conhecimento permite ao=20 obstetra o adequado estabelecimento das condi=E7=F5es cl=EDnicas = maternas e a=20 correta valoriza=E7=E3o da evolu=E7=E3o da doen=E7a pela = avalia=E7=E3o de par=E2metros=20 cl=EDnicos e laboratoriais. =C9 evidente que para o fornecimento = do melhor=20 acompanhamento da gestante de alto risco, h=E1 necessidade de = equipe=20 multidisciplinar, constitu=EDda por especialistas de outra = =E1reas,=20 enfermagem, psicologia e servi=E7o social.

c) Avalia=E7=E3o obst=E9trica. O = estabelecimento da idade=20 gestacional =E9 o passo b=E1sico, como tamb=E9m o =E9 o correto = acompanhamento da=20 evolu=E7=E3o da gravidez, mediante an=E1lise e adequada = interpreta=E7=E3o dos=20 par=E2metros obst=E9tricos (ganho ponderal, press=E3o arterial e = crescimento=20 uterino). O feto tamb=E9m =E9, obrigatoriamente, avaliado, = considerando-se o=20 seu crescimento e as suas condi=E7=F5es de vitalidade e = maturidade.

d) Parto. A antecipa=E7=E3o do parto, = evento freq=FCente no=20 atendimento =E0 gesta=E7=E3o de alto risco, talvez represente o = maior dilema=20 vivido atualmente pelo obstetra, em rela=E7=E3o ao feto: "morrer = no =FAtero ou=20 morrer no ber=E7=E1rio". Al=E9m disso, s=E3o de sua inteira = responsabilidade a=20 indica=E7=E3o da via de parto e o acompanhamento do trabalho de = parto.

Aspecto quase esquecido, por receio ou = desconhecimento, =E9 o=20 componente emocional no seguimento da gesta=E7=E3o de alto risco. = Assim como,=20 organicamente, a gravidez representa desafio para condi=E7=F5es = maternas,=20 tamb=E9m do ponto de vista emocional, surge como desafio = adaptativo.

No conte=FAdo emocional da mulher gr=E1vida entram = em jogo=20 fatores ps=EDquicos preexistentes e atuais, e, entre os =FAltimos, = os=20 componentes da gravidez e ambientais. Este conte=FAdo manifesta-se = atrav=E9s=20 da

15

ansiedade, mecanismo emocional basal que se = estende durante=20 toda a gravidez, de forma crescente, at=E9 o termo.

A ansiedade tem causas v=E1rias identific=E1veis = para cada=20 trimestre, mas que se intercambiam psicodinamicamente. Listam-se, = entre=20 elas, ambival=EAncia, nega=E7=E3o, regress=E3o, introspec=E7=E3o, = medo, etc. Na=20 gesta=E7=E3o de alto risco, as dificuldades de adapta=E7=E3o = emocional s=E3o=20 maiores, a come=E7ar pelo r=F3tulo que se lhes d=E1, "de alto = risco", portanto=20 "diferente" das demais, "normais". Some-se a isto, o pr=F3prio = fator de=20 risco, como componente estressante e dois modelos cl=EDnicos podem = ser ent=E3o=20 identificados.

Quando a condi=E7=E3o cl=EDnica preexiste =E0 = gesta=E7=E3o, pode, por um=20 lado, ser tomada como nova chance de vida, o triunfo sobre a = doen=E7a. No=20 entanto, por outro lado, h=E1 rotura do equil=EDbrio emocional = anteriormente=20 adquirido, com freq=FCente deteriora=E7=E3o ou perda da = auto-estima e surgimento=20 de sentimento de incompet=EAncia; a partir da=ED, estabelece-se = dificuldade de=20 vincula=E7=E3o.

No segundo modelo, a condi=E7=E3o de risco =E9 = diagnosticada=20 durante a gesta=E7=E3o e a gr=E1vida experimenta, ent=E3o, toda as = rea=E7=F5es=20 pr=F3prias do vivenciamento do luto, pela "morte da gravidez = idealizada".=20 Surgem sentimentos de culpa, raiva, censura.

A hospitaliza=E7=E3o, t=E3o comum quanto por vezes = necess=E1ria no=20 seguimento da gravidez de alto risco, deve ser considerada como =

outro fator estressante adicional. Conscientiza-se = a gr=E1vida=20 da sua doen=E7a; =E9 afastada do suporte familiar; vive conflito = entre a=20 depend=EAncia imposta e a perda de autonomia (perda do controle =

sobre si e sobre a gravidez).

Devem ser levadas em conta ainda neste contexto = emocional,=20 as rea=E7=F5es da fam=EDlia, em tudo semelhantes =E0s da gr=E1vida = (ambival=EAncia,=20 culpa, raiva, luto, etc.). No grupo familiar, o parceiro = desempenha papel=20 importante, por rea=E7=F5es que podem se manifestar atrav=E9s de = sentimentos de=20 exclus=E3o, ressentimento, agressividade, culpa, etc.

Considere-se, neste ambiente emocional, o papel da = equipe=20 assistencial sob a =F3tica da paciente: a equipe =E9 inominada, = onipotente,=20 autorit=E1ria, distante, fria, mal-humorada, "de falar dif=EDcil", = e pouco=20 comunicativa. Por outro lado, o m=E9dico tamb=E9m =E9 visto pela = gr=E1vida como=20 super-homem ou deidade, capaz de salvar a vida dela e de seu = filho.

Mas tamb=E9m =E9 importante a vis=E3o que a equipe = tem de si=20 mesma, pois os sentimentos e emo=E7=F5es s=E3o intercambi=E1veis = com os da=20 paciente. A equipe trabalha entre dificuldades diagn=F3sticas e=20 terap=EAuticas; com cobran=E7as por parte da paciente, da = fam=EDlia ou da=20 institui=E7=E3o,

16

obrigando-se, muitas vezes, =E0 "pol=EDtica de = resultados";=20 conta-se, ainda, o estresse profissional, podendo viver = emo=E7=F5es tipo=20 "montanha russa".

Desta forma, h=E1 a equipe de sa=FAde que ter = conhecimento e=20 sensibilidade para identificar e entender o processo emocional que = rodeia=20 o acompanhamento da gesta=E7=E3o de alto risco.

17

P A R T E I :=20

D O E N =C7 A S=20

O B S T =C9 T R I C = A=20 S

S =CD N D R O M E S H I P = E R T E N S I=20 V A S D A G R A V I D E Z

1

CLASSIFICA=C7=C3O = CL=CDNICA DAS S=CDNDROMES=20 HIPERTENSIVAS DA GRAVIDEZ (adotada pela OMS em 1987). =

A _ HIPERTENS=C3O E/OU PROTEIN=DARIA = GESTACIONAL

1. Hipertens=E3o gestacional (sem protein=FAria) =

2. Protein=FAria gestacional (sem hipertens=E3o) =

3. Hipertens=E3o e protein=FAria = (pr=E9-ecl=E2mpsia)

B _ HIPERTENS=C3O CR=D4NICA E DOEN=C7A RENAL = CR=D4NICA

1. Hipertens=E3o arterial cr=F4nica (sem = protein=FAria)

2. Doen=E7a renal cr=F4nica (protein=FAria e = hipertens=E3o)

3. Hipertens=E3o cr=F4nica com pr=E9-ecl=E2mpsia = superajuntada

C _ HIPERTENS=C3O E/OU PROTEIN=DARIA N=C3O = CLASSIFICADAS=20

D _ ECL=C2MPSIA

Desenvolvimento da = classifica=E7=E3o=20 cl=EDnica e diagn=F3stico diferencial entre as s=EDndromes = hipertensivas da=20 gravidez

A1 _ Hipertens=E3o gestacional

A express=E3o refere-se ao aparecimento da = hipertens=E3o em=20 conseq=FC=EAncia da gravidez, e que acontece ap=F3s 20 semanas de = gesta=E7=E3o.

=95 presen=E7a de press=E3o arterial diast=F3lica = > 90=20 mmHg

=95 aumento da press=E3o diast=F3lica acima de 15 = mmHg do valor=20 conhecido previamente

=95 aus=EAncia de protein=FAria

=95 mulheres previamente normotensas e sem = protein=FAria

=95 normaliza=E7=E3o no puerp=E9rio remoto ap=F3s = seis semanas

Possibilidade de evolu=E7=E3o cl=EDnica:

1. Pr=E9-ecl=E2mpsia quando a hipertens=E3o = associa-se =E0=20 protein=FAria

2. Hipertens=E3o arterial latente ou transit=F3ria = (principalmente em mult=EDparas)

A2 _ Protein=FAria gestacional

_ protein=FAria sem hipertens=E3o

21

_ mulheres previamente normotensas e sem = protein=FAria, com=20 diagn=F3stico ap=F3s a 20=AA semana de gesta=E7=E3o

_ normaliza=E7=E3o no puerp=E9rio remoto

Possibilidades de evolu=E7=E3o cl=EDnica:

1. protein=FAria postural (ortost=E1tica)

2. infec=E7=E3o urin=E1ria

3. pr=E9-ecl=E2mpsia (protein=FAria que precede a = hipertens=E3o)=20

4. doen=E7a renal cr=F4nica n=E3o diagnosticada = previamente

5. doen=E7a renal aguda

A3 _ Pr=E9-ecl=E2mpsia (hipertens=E3o e = protein=FAria), nas=20 formas leve ou

grave:

=95 ap=F3s a 20=AA semana de gesta=E7=E3o em = mulheres previamente=20 normotensas e sem protein=FAria

=95 normaliza=E7=E3o no puerp=E9rio remoto

=95 aumento da press=E3o arterial diast=F3lica a = 90 mmHg ou mais=20

=95 aumento da press=E3o diast=F3lica acima de 15 = mmHg do valor=20 conhecido previamente

=95 presen=E7a de 300 mg ou mais de prote=EDnas em = urina de 24=20 horas ou labistix (1+) ou mais

B1 _ Hipertens=E3o arterial cr=F4nica

Causas:

_ essencial (prim=E1ria)

_ vascular: vasculite, coarcta=E7=E3o de aorta =

_ end=F3crina: supra-renal (feocromocitoma)

_ induzida por droga

_ de origem renal

Diagn=F3stico cl=EDnico:

1. hipertens=E3o antes de 20 semanas de gravidez =

2. hipertens=E3o cr=F4nica comprovada em qualquer = idade=20 gestacional

3. hipertens=E3o que persiste ap=F3s seis semanas = de puerp=E9rio=20

B2 _ Doen=E7a renal cr=F4nica

_ glomerulonefrite (secund=E1ria ou idiop=E1tica) =

_ t=FAbulo intersticial (infecciosa, t=F3xica ou = metab=F3lica)=20

Achados cl=EDnicos:

=95 protein=FAria pr=E9via =E0 20=AA semana de = gravidez

=95 protein=FAria na presen=E7a de doen=E7a renal = previamente=20 conhecida em qualquer idade gestacional

=95 protein=FAria persistente no puerp=E9rio = remoto

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B3 _ Hipertens=E3o cr=F4nica com = pr=E9-ecl=E2mpsia=20 superajuntada

Diagn=F3stico cl=EDnico:

1. piora da hipertens=E3o arterial, com aumento de = pelo menos=20 15 mmHg da press=E3o arterial diast=F3lica sobre os n=EDveis = pr=E9vios

2. desenvolvimento de protein=FAria

3. fundo de olho com exsudato, edema e/ou = hemorragia=20 retiniana

Diagn=F3stico espec=EDfico:

_ bi=F3psia renal com simultaneidade de les=F5es = renais e de=20 endoteliose capilar glomerular

C _ Hipertens=E3o e/ou protein=FAria n=E3o = classificadas=20

Esta categoria =E9 muito =FAtil na pr=E1tica = cl=EDnica, por permitir=20 que o diagn=F3stico cl=EDnico do quadro hipertensivo gestacional = seja revisto=20 no puerp=E9rio.

_ primeira consulta de pr=E9-natal ap=F3s 20 = semanas

_ idade gestacional duvidosa ou ignorada, mas = clinicamente=20 superior a 20 semanas

_ hist=F3ria cl=EDnica com informa=E7=F5es = inconclusivas para o=20 diagn=F3stico de hipertens=E3o arterial cr=F4nica

Reclassifica=E7=E3o no puerp=E9rio, ap=F3s seis = semanas:

1. hipertens=E3o e/ou protein=FAria = gestacional:=20 desaparecem a hipertens=E3o e/ou a protein=FAria

2. hipertens=E3o cr=F4nica ou doen=E7a renal = cr=F4nica: persistem a=20 hipertens=E3o ou a protein=FAria, ou ambas

3. hipertens=E3o arterial cr=F4nica com = pr=E9-ecl=E2mpsia=20 superajuntada: persiste a hipertens=E3o e desaparece a = protein=FAria

D _ Ecl=E2mpsia

=C9 a presen=E7a de convuls=F5es = t=F4nico-cl=F4nicas generalizadas em=20 mulher com quaisquer dos quadros hipertensivos descritos, n=E3o = causadas por=20 epilepsia ou qualquer outra patologia convulsiva, e que pode = ocorrer na=20 gravidez, parto ou at=E9 dez dias de puerp=E9rio.

1.1. = Pr=E9-ecl=E2mpsia

Conceitua-se como pr=E9-ecl=E2mpsia (PE) o = aparecimento de=20 hipertens=E3o arterial acompanhada de protein=FAria em = gesta=E7=E3o acima de 20=20 semanas, podendo haver ou n=E3o edema. Anteriormente a este = per=EDodo, pode=20 surgir acompanhando doen=E7a trofobl=E1stica gestacional.

Assim, considera-se hipertens=E3o o aumento dos = n=EDveis=20 tensionais de 140 x 90 mmHg, confirmado ap=F3s per=EDodo de = repouso. A press=E3o=20 arterial deve ser aferida com a paciente sentada, anotando-se o = 1=BA e 4=BA=20 ru=EDdos (aparecimento e abafamento das bulhas) como indicadores = das=20 press=F5es sist=F3lica e diast=F3lica.

23

Como protein=FAria significativa, consideram-se os = valores=20 maiores ou iguais a 300 mg em 24 horas ou Labstix de (+) ou mais = em=20 amostra casual.

O edema, quando existente, pode ser localizado ou=20 generalizado. Deve ser real=E7ado o chamado "edema oculto", = explicitado pelo=20 ganho ponderal excessivo e que somente =E9 creditado quando = associado a=20 quadro hipertensivo.

Consideram-se fatores de risco para a = pr=E9-ecl=E2mpsia:

_ primigestas

_ antecedentes familiares de = pr=E9-ecl=E2mpsia/ecl=E2mpsia

_ antecedente pessoal de = pr=E9-ecl=E2mpsia/ecl=E2mpsia

_ gesta=E7=E3o gemelar

_ hipertens=E3o arterial cr=F4nica, nefropatia, = lupus, diabetes=20

_ mudan=E7a de parceiro

A pr=E9-eclampsia =E9 classificada em leve ou = grave, de acordo=20 com o grau de comprometimento. Considera-se grave quando = presente=20 um ou mais dos seguintes crit=E9rios:

_ press=E3o arterial diast=F3lica igual/maior que = 110 mmHg;

_ protein=FAria igual/maior que 2,0 g/l em 24 = horas;

_ olig=FAria (menor que 500 ml/dia, ou 15 = ml/hora);

_ n=EDveis s=E9ricos de creatinina maiores que 1,2 = mg/dl;

_ sinais de encefalopatia hipertensiva;

_ sinais de insufici=EAncia card=EDaca;

_ dor epig=E1strica ou no hipoc=F4ndrio direito; =

_ plaquetopenia (< 100.000 / mm3); =

_ aumento de enzimas hep=E1ticas (AST ou TGO, ALT = ou TGP, DHL=20 desidrogenase l=E1ctica) e de bilirrubinas;

_ presen=E7a de esquiz=F3citos em esfrega=E7o de = sangue=20 perif=E9rico;

_ presen=E7a de RCIU e/ou oligo=E2mnio;

_ evid=EAncia cl=EDnica e/ou laboratorial de = coagulopatia

DIAGN=D3STICO

O diagn=F3stico =E9 essencialmente cl=EDnico e = dado pela pr=F3pria=20 conceitua=E7=E3o. Al=E9m da protein=FAria, n=E3o h=E1 nenhum dado = laboratorial que=20 possa ser tomado como indicador seguro da doen=E7a.

CONDUTA

O estabelecimento de conduta frente =E0 PE deve = levar em=20 considera=E7=E3o duas vari=E1veis; idade gestacional e gravidade = do quadro.

Desta forma, tr=EAs eventualidades devem ser = analisadas:

a) Pr=E9-ecl=E2mpsia leve no pr=E9-termo (Esquema = 1)

b) Pr=E9-ecl=E2mpsia leve no termo (Esquema 2) =

c) Pr=E9-ecl=E2mpsia grave no pr=E9-termo e termo = (Esquema 3)

24

PR=C9-ECL=C2MPSIA LEVE PR=C9-TERMO (Esquema = 1)

_ Tratamento ambulatorial: consultar a cada 7 _ 15 = dias

_ Repouso

_ Dieta normoss=F3dica

(*) Via de parto: indica=E7=E3o obst=E9trica _ = n=E3o ultrapassar 40=20 semanas

(**) Cortic=F3ides: usar entre 28=AA /34=AA sem. =

(***) Hipotensores: 1. a metildopa _ 750 mg a 2,0 = g

2. Hidralazina _ 50 a 200 mg/dia

3. b-bloqueadores _ 10 a 30 mg/dia

4. Nifedipina _ 20 a 60 mg/dia

Obs.: N=C3O USAR DIUR=C9TICOS: reduzem o = volume=20 intravascular e a perfus=E3o placent=E1ria j=E1 reduzidos na = pr=E9-ecl=E2mpsia.=20

25

PR=C9-ECL=C2MPSIA LEVE TERMO (Esquema 2) =

26

PR=C9-ECL=C2MPSIA GRAVE PR=C9-TERMO E TERMO = (Esquema 3)=20

(*) Via de parto: indica=E7=E3o obst=E9trica

(**) Cortic=F3ides: usar entre 28 e 34 sem.

(***) Hipotensores: 1. Sulfato de magn=E9sio

2. Hidralazina _ 50 a 200 mg/dia

3. b-Bloqueadores _ 10 a 30 mg/dia

4. Nifedipina _ 20 a 60 mg/dia

27

1.2. Imin=EAncia de=20 ecl=E2mpsia/ecl=E2mpsia

Imin=EAncia de ecl=E2mpsia corresponde ao = quadro de=20 pr=E9-ecl=E2mpsia grave, caracterizado clinicamente por sinais de=20 encefalopatia hipertensiva, dor no epig=E1strio e hipoc=F4ndrio = direito.=20

Ecl=E2mpsia =E9 o aparecimento de convuls=F5es = seguidas ou n=E3o=20 de coma, n=E3o atribu=EDveis a outras causas, em paciente com=20 pr=E9-ecl=E2mpsia.

Assim, fica claro que n=E3o existe ecl=E2mpsia sem = pr=E9-ecl=E2mpsia; ela =E9 fase mais grave da mesma doen=E7a.

CONDUTA

A conduta cl=EDnica na ecl=E2mpsia visa ao = tratamento das=20 convuls=F5es, da hipertens=E3o, dos dist=FArbios metab=F3licos e = cuidados e=20 controles gerais.

a) Tratamento Anticonvulsivante e = Hipotensor

Feito atrav=E9s do Sulfato de Magn=E9sio = (MgSO4). Um=20 dos seguintes esquemas =E9 utilizado na imin=EAncia de ecl=E2mpsia = ou na crise=20 convulsiva:

=95 Aplicar a dose inicial de 4g a 10% por via = intravenosa,=20 associada a 10g, aplicadas em via intramuscular, na = concentra=E7=E3o de 50%,=20 aplicadas (5g em cada gl=FAteo). A manuten=E7=E3o =E9 feita = atrav=E9s da=20 administra=E7=E3o de 5g, a cada 4 horas, tamb=E9m por via = intramuscular.=20 (Esquema de Pritchard) ou

=95 Aplicar inicialmente a dose de ataque de 4g a = 10% por via=20 intravenosa, seguida da dose de manuten=E7=E3o tamb=E9m por via = intravenosa de=20 cerca de 1g/h (obtida com uma solu=E7=E3o de SG 5% 400 ml e 10 = ampolas de=20 sulfato de magn=E9sio a 10%, velocidade de infus=E3o de 16 = gotas/minuto).=20 (Esquema de Zuspan).

Os seguintes cuidados devem ser sempre observados: =

=95 A aplica=E7=E3o da dose intravenosa deve ser = efetuada=20 lentamente (15 a 20 minutos).

=95 Na aplica=E7=E3o intramuscular deve-se, = primeiramente,=20 proceder rigorosa antissepsia. A solu=E7=E3o n=E3o deve ser = totalmente aplicada=20 no mesmo ponto: a agulha deve ser mobilizada de modo a espalhar o = l=EDquido=20 em "leque". A aplica=E7=E3o deve ser profunda e pode-se associar = lidoca=EDna=20 para diminuir a dor.

=95 A administra=E7=E3o da manuten=E7=E3o dever=E1 = ser suspensa caso a=20 freq=FC=EAncia respirat=F3ria tenha menos de 16 incurs=F5es por = minuto, os=20 reflexos patelares estejam completamente abolidos ou a diurese = seja=20 inferior a 100 ml durante as 4 horas precedentes.

28

=95 O gluconato de c=E1lcio a 10% atua como = ant=EDdoto. =C9=20 indispens=E1vel manter sempre =E0 m=E3o uma ampola de 10 ml, para = aplica=E7=E3o=20 imediata no caso de eventual parada respirat=F3ria, apesar de = raramente=20 ocorrer quando devidamente observadas as normas de aplica=E7=E3o e = vigil=E2ncia=20 do sulfato de magn=E9sio.

=95 Na recorr=EAncia de convuls=F5es, utilizam-se = mais 2g IV e=20 aumenta-se a velocidade de infus=E3o do sulfato de magn=E9sio. Na = persist=EAncia=20 delas, com crises subentrantes, pode-se optar pela = fenil-hidanto=EDna,=20 segundo o esquema:

-> ataque: 250 mg + SG 5% 250 ml IV em = gotejamento at=E9=20 completar a dose total de 750 mg.

-> manuten=E7=E3o: 100 mg 8/8 hs IV e, a = seguir, 100 mg=20 8/8 hs VO, at=E9 a alta

Deve-se estar atento para as diferentes = concentra=E7=F5es das=20

apresenta=E7=F5es existentes no mercado: =

=95 MgSO4.7H2O a 50%: 1 = amp =3D 10ml =3D=20 5g

=95 MgSO4.7H2O a 20%: 1 = amp =3D 10ml =3D=20 2 g

=95 MgSO4.7H2O a 10%: 1 = amp =3D 10ml =3D=20 1g

_ Dilui=E7=E3o 4g a 20%: 8 ml de=20 MgSO4.7H2O + 12 ml de soro

fisiol=F3gico a 0,9% =3D 4g =3D 20ml a 20% = (20ml, correr 1ml=20 por minuto).

b) Tratamento Hipotensor

V=E1rios medicamentos s=E3o propostos, sendo o = mais aceito a=20

hidralazina.

=95 Hidralazina, em dose de 5 a 20 mg IV em = "bolus",=20 intermitente em

intervalos de 20 minutos (1 ampola =3D 20 mg; = diluir em 9=20 ml de SF 0,9% e

aplicar 2,5 ml ou 5 mg). Repetir medida de PA = ap=F3s 20=20 min. Frente ao

controle inadequado da PA, deve-se repetir a = dose de 5 a=20 10 mg at=E9 o

m=E1ximo de 20 mg. Como alternativa, = administra-se em=20 infus=E3o cont=EDnua

venosa (20 mg de hidralazina dilu=EDdos em 500 = ml de soro=20 glicosado a 5%,

na velocidade que permita administra=E7=E3o de = 5 a 10 mg/h).=20

Outros hipotensores dispon=EDveis:

1) verapamil - (50 mg em SG 5%) IV

2) beta-bloqueadores

3) nifedipina _ 3 a 5 gotas SL (sublingual) a cada = 40=20 minutos

c) Tratamento dos Dist=FArbios = Metab=F3licos

Visa ao restabelecimento do equil=EDbrio = =E1cido-base, do=20 equil=EDbrio hidro-eletrol=EDtico, das condi=E7=F5es = respirat=F3rias, etc.

d) Cuidados Gerais

_ Manter o ambiente tranq=FCilo, o mais silencioso = poss=EDvel=20

_ Dec=FAbito elevado a 30=BA e face = lateralizada

_ Cateter nasal com oxig=EAnio (5l/min)

_ Pun=E7=E3o de veia central ou calibrosa

_ Sonda vesical cont=EDnua

29

_ A conduta obst=E9trica visa =E0 = estabiliza=E7=E3o do quadro=20 materno, =E0 avalia=E7=E3o das condi=E7=F5es de bem-estar fetal e = a antecipa=E7=E3o do=20 parto, em qualquer idade gestacional. Tentar transferir a gestante = para um=20 centro terci=E1rio de aten=E7=E3o, sobretudo em situa=E7=F5es de = prematuridade.

_ O parto pode ser por via vaginal, desde que = existam=20 condi=E7=F5es favor=E1veis de colo uterino, vitalidade fetal, = condi=E7=F5es maternas=20 e hospital com recursos materiais e humanos adequados para o = controle=20 desse tipo de gestante.

Na eventualidade de ser necess=E1ria uma = cesariana, a=20 anestesia recomendada =E9 a geral, observando-se tempo de 8 a 10 = minutos=20 para a retirada fetal (ver Manual T=E9cnico de Urg=EAncias e = Emerg=EAncias=20 Maternas).

No puerp=E9rio, h=E1 que se manter o controle = metab=F3lico, o=20 controle das condi=E7=F5es respirat=F3rias, de diurese e de = coagula=E7=E3o.

1.3 - S=EDndrome = Hellp

=C9 quadro cl=EDnico caracterizado por = hem=F3lise (H =3D=20 "hemolysis") eleva=E7=E3o de enzimas hep=E1ticas (EL =3D "elevated = liver functions=20 tests") e plaquetopenia (LP =3D low platelets count"). Embora = acompanhe=20 outras doen=E7as, em Obstetr=EDcia =E9 considerada como = agravamento do quadro de=20 pr=E9-ecl=E2mpsia.

A tr=EDade conceitual quando completa =E9 dita = HELLP=20 completa; no entanto, quando isolados os indicadores, = necessitam o=20 mesmo

tipo de aten=E7=E3o e cuidados e a condi=E7=E3o = =E9, ent=E3o, chamada de=20

HELLP parcial.

DIAGN=D3STICO

O diagn=F3stico =E9 feito pelo aparecimento da = tr=EDade em gr=E1vida=20 com pr=E9-ecl=E2mpsia. A hem=F3lise =E9 caracterizada pela = eleva=E7=E3o de=20 bilirrubinas e da desidrogenase l=E1tica, e facilmente detectada = no=20 esfrega=E7o de sangue perif=E9rico, pelo encontro de = esquiz=F3citos. As=20 transaminases hep=E1ticas s=E9ricas encontram-se com valores = maiores que 70=20 UI/litro e a trombocitopenia =E9 grave e em n=EDveis menores que = 100.000=20 plaquetas/mm3.

A s=EDndrome HELLP associa-se freq=FCentemente com = outras

complica=E7=F5es, como insufici=EAncia renal = aguda, edema agudo de=20 pulm=E3o, coagula=E7=E3o intravascular disseminada (CIVD), rotura = hep=E1tica e=20 morte materna.

A CIVD =E9 pesquisada clinicamente pela presen=E7a = de=20 sangramentos em locais de pun=E7=E3o, pet=E9quias, equimoses e = atrav=E9s de=20 dosagem de

30

fibrinog=EAnio, produtos de degrada=E7=E3o da = fibrina, contagem de=20 plaquetas e tempo de protombina. Outros exames incluem: hemograma, = esfrega=E7o de sangue perif=E9rico, antitrombina III, fun=E7=E3o = renal (ur=E9ia,=20 =E1cido =FArico, creatinina), fun=E7=E3o hep=E1tica = (transaminases, LDH),=20 protein=FAria de 24 horas, oftalmoscopia, ECG, exame = ultra-sonogr=E1fico=20 abdominal e obst=E9trico.

CONDUTA

A conduta cl=EDnica implica corre=E7=E3o e/ou = manuten=E7=E3o das=20 condi=E7=F5es maternas. Para tanto utilizam-se:

Cuidados gerais

_ pun=E7=E3o da veia calibrosa

_ instala=E7=E3o da press=E3o venosa central

_ sonda vesical de demora

_ monitoriza=E7=E3o dos sinais vitais

Corre=E7=E3o da CIVD

_ utiliza=E7=E3o de plasma fresco congelado

_ criopreciptado

_ concentrado de plaquetas

_ concentrado de hem=E1cias

A conduta obst=E9trica =E9 a antecipa=E7=E3o do = parto, cuja via =E9 de=20 indica=E7=E3o obst=E9trica, independentemente da idade gestacional = e uma vez=20 avaliadas as condi=E7=F5es maternas.

No caso de parto cir=FArgico, para a sindrome = HELLP=20 recomenda-se a incis=E3o infra-umbilical mediana (ver Manual = T=E9cnico de=20 Urg=EAncias e Emerg=EAncias Maternas).

31

S =CD N D R O M E S H E M = O R R =C1 G I C=20 A S

2

Entre 10% a 15% das gesta=E7=F5es apresentam = hemorragias. Pode=20 representar complica=E7=E3o gestacional ou agravos ginecol=F3gicos = concomitantes=20 com o per=EDodo grav=EDdico.

Classifica=E7=E3o: as mais importantes = situa=E7=F5es=20 hemorr=E1gicas gestacionais s=E3o:

Primeira metade:

_ Abortamento

_ Abortamento habitual

_ Gravidez ect=F3pica

_ Neoplasia trofobl=E1stica gestacional benigna =

_ Descolamento c=F3rio-amni=F3tico

Segunda metade:

_ Placenta pr=E9via

_ Descolamento prematuro da placenta

_ Rotura uterina

2.1. Hemorragias da = primeira metade=20 da gravidez

2.1.1. Abortamento =

Conceitua-se como abortamento a morte = ovular=20 ocorrida antes da 22=AA semana de gesta=E7=E3o, e o processo de = elimina=E7=E3o deste=20 produto conceptual =E9 chamado aborto. O abortamento =E9 = dito=20 precoce, quando ocorre at=E9 a 13=AA semana e tardio, = quando=20 entre 13=AA e 22=AA semanas.

DIAGN=D3STICO

O diagn=F3stico =E9 feito clinicamente e atrav=E9s = da=20 ultra-sonografia. O atraso menstrual, a perda sangu=EDnea uterina = e a=20 presen=E7a de c=F3licas no hipog=E1strio s=E3o dados cl=EDnicos a = serem=20 considerados.

O exame genital =E9 de grande import=E2ncia. O = exame especular=20 permite a visualiza=E7=E3o do colo uterino, constatando-se a = origem=20 intra-uterina do sangramento. Eventualmente, detectam-se = fragmentos=20 placent=E1rios no canal cervical e vagina. Pelo toque =E9 = poss=EDvel a avalia=E7=E3o=20 da

33

permeabilidade do colo, e a escuta dos batimentos = card=EDacos=20 fetais, com sonar Doppler a partir da 13=AA semana, informa sobre = as=20 condi=E7=F5es de vitalidade ovular.

O exame ultra-sonogr=E1fico =E9 definitivo para a = avalia=E7=E3o da=20

vitalidade do concepto, presen=E7a de restos = ovulares e da=20 idade gestacional.

CONDUTA NO ABORTAMENTO PRECOCE

CONDUTA NO ABORTAMENTO TARDIO

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2.1.2. Abortamento = habitual=20

=C9 a perda espont=E2nea e sucessiva de tr=EAs = ou mais=20 gesta=E7=F5es antes da 22=AA semana. Ocorre em cerca de 0,5% = de todas as=20 gesta=E7=F5es.

Citam-se, entre outras, as seguintes condi=E7=F5es = como=20 poss=EDveis fatores causais:

_ Anomalias do desenvolvimento uterino (=FAtero = bicorno ou=20

septado).

_ Leiomiomas _ principalmente os submucosos

_ Incompet=EAncia istmocervical

_ Sin=E9quias uterinas

_ Causas end=F3crinas (diabete melito, = disfun=E7=E3o da tire=F3ide)=20

_ Causa hormonal (insufici=EAncia l=FAtea)

_ Fatores imunol=F3gicos

_ Fatores infecciosos

DIAGN=D3STICO

Durante a gesta=E7=E3o, =E9 feito por:

_ Anamnese (antecedentes ginecol=F3gicos e = obst=E9tricos)

_ Exame ginecol=F3gico

_ Ultra-sonografia obst=E9trica: rastreamento de = malforma=E7=E3o=20 uterina e da incompet=EAncia istmocervical (medida do canal = cervical e do=20 orif=EDcio interno do colo)

_ Avalia=E7=E3o end=F3crina: TSH, T3, T4, glicemia = de jejum e=20 teste oral de toler=E2ncia =E0 glicose (TOTG)

_ Pesquisa de infec=E7=F5es (rub=E9ola, = toxoplasmose, clam=EDdia,=20 micoplasma e citomegalovirus)

_ Avalia=E7=E3o imunol=F3gica (anticorpos = antifosfol=EDpides,=20 anticardiolipina e anticoagulante l=FApico, anticorpos = antinucleares)

No per=EDodo intergestacional o diagn=F3stico =E9 = complementado=20 pela histerosalpingografia e prova de velas de Hegar.

CONDUTA

Recomenda-se o acompanhamento quinzenal atrav=E9s = das

consultas de pr=E9-natal. O tratamento depende da = etiologia.=20

A corre=E7=E3o do fator causal ser=E1 institu=EDda = quando poss=EDvel.=20

No caso da insufici=EAncia l=FAtea, utiliza-se = progesterona=20 natural

(suposit=F3rios de 25 _ 50 mg) por via vaginal, 2 = a 3 vezes=20 por dia, at=E9 a

14=AA semana.

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2.1.3. Gravidez = ect=F3pica=20

A gravidez ect=F3pica corresponde =E0 = nida=E7=E3o do ovo fora da=20 cavidade uterina.

DIAGN=D3STICO

Para o diagn=F3stico utilizam-se dados cl=EDnicos = e a=20 ultra-sonografia.

Na avalia=E7=E3o cl=EDnica, s=E3o = importantes a anamnese=20 (hist=F3ria de atraso menstrual, teste positivo para gravidez, = perda=20 sangu=EDnea uterina, dores no baixo-ventre) e o exame f=EDsico = (avalia=E7=E3o das=20 condi=E7=F5es gerais, sinais de irrita=E7=E3o peritonial, etc). O = exame especular=20 pode mostrar a presen=E7a do sangramento. Pelo toque verifica-se o = amolecimento do colo, o aumento uterino e a palpa=E7=E3o das zonas = anexiais,=20 que, al=E9m de provocar dor, pode demonstrar presen=E7a de tumor. =

Com a ultra-sonografia verifica-se a = presen=E7a de=20 tumor anexial (=E0s vezes, com batimentos card=EDacos) e de = l=EDquido livre no=20 fundo do saco posterior.

Na aus=EAncia do recurso ultra-sonogr=E1fico, = pode-se usar a=20 pun=E7=E3o do fundo de saco vaginal posterior, =E0 procura de = sangue na cavidade=20 abdominal.

CONDUTA

A conduta geralmente =E9 cir=FArgica: = laparotomia ou=20 laparoscopia.

Para a gravidez tub=E1ria rota, indica-se a = salpingectomia.=20 Para a =EDntegra, a conduta depender=E1 da mulher ter ou n=E3o = prole constitu=EDda=20 ou desejar nova gesta=E7=E3o. Se n=E3o houver desejo de nova = gravidez,=20 pratica-se a salpingectomia. Caso contr=E1rio, est=E1 indicada a = cirurgia=20 conservadora (salpingostomia ou a ressec=E7=E3o segmentar).

Alguns estudos sugerem uso de metotrexato: = para o=20 saco gestacional =EDntegro, emprega-se dose de 1 mg/kg de peso e, = quando h=E1=20 massa s=F3lida ou complexa, as doses passam a ser 50 = mg/m2 e=20 administradas por via intramuscular.

2.1.4. Mola = hidatiforme=20

A frequ=EAncia =E9 de 1 caso para cada 2.000 = gesta=E7=F5es.

Na suspeita de mola hidatiforme, os casos devem = ser=20 encaminhados a Centros de Refer=EAncia que cuidam especificamente = desse=20 problema, segundo protocolo nacional coordenado pela FEBRASGO, = conforme=20

proposto a seguir:

36

(*) Preferentemente por v=E1cuo-aspira=E7=E3o e = com controle=20 ultra-sonogr=E1fico. Admite-se a histerectomia total, ap=F3s = curetagem ou=20 aspira=E7=E3o, como procedimento de exce=E7=E3o. Tem indica=E7=E3o = em pacientes com=20 mais de 35 anos de idade e com dificuldade de seguimento.

(**) a) Dosagem de gonadotrofina cori=F4nica (b _ = HCG) com=20 intervalos semanais ap=F3s esvaziamento uterino, at=E9 = obten=E7=E3o de tr=EAs=20 dosagens consecutivamente negativas. Prosseguir com intervalos = quinzenais=20 (uma dosagem) e, ent=E3o, mensal at=E9 completar seis meses ap=F3s = o primeiro=20 resultado negativo, quando houver remiss=E3o espont=E2nea, e um = ano quando a=20 paciente foi submetida a quimioterapia

b) Radiografia dos campos pleuropulmonares com = intervalos=20 quinzenais at=E9 alcan=E7ar remiss=E3o. Da=ED em diante, = estabelecer controle=20 radiol=F3gico.

c) Anticoncep=E7=E3o: deve ser iniciada = imediatamente ap=F3s o=20 esvaziamento uterino. Apesar de question=E1vel, deve se dar = prefer=EAncia aos=20 contraceptivos hormonais orais de baixa dosagem, com 30 mcg de = estrog=EAnio.=20

d) Crit=E9rio de alta, quando: os n=EDveis de = gonadotrofina=20 decrescerem progressivamente e negativarem ao fim de oito ou mais = semanas;=20 houver r=E1pida melhora do estado geral; involu=E7=E3o uterina e = imediata=20 cessa=E7=E3o das hemorragias; aus=EAncia de infiltra=E7=F5es ou de = met=E1stases.=20

37

2.1.5. Descolamento=20 c=F3rio-amni=F3tico

Caracteriza-se por sangramento genital de = pequena=20 intensidade e diagnosticado por exame ecogr=E1fico. A = evolu=E7=E3o =E9 boa,=20 n=E3o representando quadro grave de risco materno e/ou ovular. =

A conduta =E9 conservadora e, basicamente, = consiste no=20 esclarecimento =E0 gestante.

2.2. Hemorragia da = segunda metade da=20 gravidez

2.2.1. Placenta = pr=E9via=20

Por placenta pr=E9via entende-se a = implanta=E7=E3o da placenta,=20 inteira ou parcialmente, no segmento inferior do =FAtero, a partir = da=20 22=AA semana. A freq=FC=EAncia tem aumentado, pela = alta=20 incid=EAncia de cicatrizes de ces=E1reas.

Descrevem-se tr=EAs tipos de placenta pr=E9via, de = acordo com a=20 localiza=E7=E3o placent=E1ria, em rela=E7=E3o ao orif=EDcio = interno do colo:

=95 total, quando recobre toda a =E1rea do = orif=EDcio=20 interno;

=95 parcial, quando o faz parcialmente; =

=95 marginal, quando a margem placent=E1ria = atinge a=20 borda do orif=EDcio interno, sem ultrapass=E1-lo.

DIAGN=D3STICO

O diagn=F3stico =E9 cl=EDnico e = ultra-sonogr=E1fico. Clinicamente,=20 pela anamnese, =E9 relatada perda sangu=EDnea por via vaginal, = indolor,=20 s=FAbita, de cor vermelho-viva, em geral de pequena quantidade, = n=E3o=20 acompanhada de dor. =C9 epis=F3dica, recorrente e progressiva. O = exame=20 obst=E9trico revela volume e tono uterinos normais. Habitualmente, = os=20 batimentos card=EDacos fetais est=E3o mantidos. A ultra-sonografia = confirma o=20 diagn=F3stico e a localiza=E7=E3o placent=E1ria. Quando o exame = ultra-sonogr=E1fico=20 n=E3o =E9 poss=EDvel, o toque deve ser feito de forma cuidadosa = (precavendo-se=20 contra eventual, por=E9m poss=EDvel, perda sangu=EDnea = placent=E1ria maci=E7a) e, de=20 prefer=EAncia, em ambiente com recursos cir=FArgicos.

CONDUTA

A conduta depende dos seguintes par=E2metros: = tipo de=20 localiza=E7=E3o placent=E1ria, volume de sangramento, idade = gestacional e=20 condi=E7=F5es de vitalidade fetal.

Toda paciente com diagn=F3stico placenta pr=E9via = em epis=F3dios=20 hemorr=E1gicos deve ser internada. A conduta conservadora =E9, em = geral,=20 adotada, com recomenda=E7=E3o de repouso e reposi=E7=E3o das = perdas maternas. O=20 objetivo =E9 atingir o termo ou o mais pr=F3ximo poss=EDvel; o uso = de=20 medicamentos uterol=EDticos =E9 discut=EDvel e na presen=E7a de = hemorragias=20

38

maiores deve ser evitado. Entre 28=AA e 34=AA = semanas indica-se=20 o uso de cortic=F3ides.

A conduta intervencionista, com antecipa=E7=E3o do = parto, fica=20 na depend=EAncia da intensidade do sangramento materno, da idade = gestacional=20 e condi=E7=F5es de vitalidade fetal.

A via de parto depender=E1, al=E9m das = condi=E7=F5es maternas, do=20 tipo de placenta pr=E9via. Nas marginais, a via preferencial =E9 a = vaginal.=20 Para as totais =E9 absoluta a indica=E7=E3o de ces=E1rea, com feto = vivo ou morto.=20 Para as parciais, h=E1 indica=E7=E3o de ces=E1rea.

2.2.2. Descolamento = prematuro de=20 placenta

Conceitua-se descolamento prematuro de placenta = (DPP)=20 como a separa=E7=E3o abrupta da placenta antes do nascimento do = feto, em=20 gesta=E7=E3o de 22 ou mais semanas. Ocorre em cerca de 0,5%_1% = de todas as=20 gesta=E7=F5es, sendo respons=E1vel por altos =EDndices de = mortalidade perinatal e=20 materna.

N=E3o se conhece a causa da doen=E7a obst=E9trica, = por=E9m=20 associa-se, em muitos casos, =E0 hipertens=E3o arterial, anemia, = desnutri=E7=E3o,=20 fatores mec=E2nicos (traumatismos, brevidade do cord=E3o, = tor=E7=E3o do =FAtero

grav=EDdico, etc.), fatores placent=E1rios = (placenta=20 circunvalada, infartos, etc.). Atualmente, constata-se = associa=E7=E3o entre=20 DPP e uso de drogas il=EDcitas.

DIAGN=D3STICO

O diagn=F3stico =E9 cl=EDnico e feito pela = dor abdominal=20 s=FAbita, de intensidade vari=E1vel, perda sangu=EDnea de cor = vermelho-escura e=20 em quantidade pequena, incompat=EDvel com o quadro materno de = hipotens=E3o, ou=20 de choque. Em parte dos casos o sangramento =E9 oculto.

Ao exame cl=EDnico, o =FAtero =E9 hipert=F4nico, = doloroso, sens=EDvel=20 =E0s manobras palpat=F3rias; os batimentos card=EDacos fetais = habitualmente n=E3o=20 s=E3o mais aud=EDveis. H=E1 comprometimento vari=E1vel das = condi=E7=F5es gerais=20 maternas, desde palidez de pele e mucosas, at=E9 choque grave e = dist=FArbios=20 da coagula=E7=E3o sangu=EDnea.

Quando realizado o exame ultra-sonogr=E1fico, o = achado de

=E1rea retroplacent=E1ria hipoecog=EAnica = corresponde ao hematoma=20

retroplacent=E1rio, cujas medidas correlacionam-se = diretamente=20

com a gravidade do quadro e com as condi=E7=F5es = de vitalidade=20

fetal.

Importante =E9 o diagn=F3stico de = coagulopatia=20 causada pelo hiperconsumo local de fatores e pela passagem de=20 tromboplastina para a circula=E7=E3o materna, o que ativa o = sistema=20 extr=EDnseco, levando finalmente a um quadro de coagula=E7=E3o = intravascular=20 disseminada. Para tanto, utilizam-se os dados fornecidos pelo=20 coagulograma, fundamentando-se o diagn=F3stico na tombocitopenia = (menos que=20

39

100.000/mm3), na hipofibrinogenemia = (menos que=20 100 mg/dl), na presen=E7a de produtos de degrada=E7=E3o da fibrina = (maior que 20=20 ug/ml) e na eleva=E7=E3o do tempo de tromboplastina parcial (TTP). =

CONDUTA

A conduta cl=EDnica objetiva:

a) reposi=E7=E3o de volume, = princ=EDpio b=E1sico para=20 evitar complica=E7=F5es

como a coagulopatia. Esta reposi=E7=E3o =E9 feita = =E0 base de=20 concentrado de hem=E1cias associado ao soro fisiol=F3gico (evitar = o uso de=20 solutos glicosados). Em situa=E7=F5es excepcionais, na aus=EAncia = absoluta de=20 sangue e derivados, pode-se utilizar solu=E7=F5es expansoras do = plasma.

b) corre=E7=E3o de coagulopatia, = atrav=E9s da=20 transfus=E3o de plasma fresco congelado (cont=E9m praticamente = todos os=20 componentes de coagula=E7=E3o), de crioprecipitado (cont=E9m = tamb=E9m fator VIII e=20 fibrinog=EAnio) e de concentrado de plaquetas. O uso de sangue = fresco total=20 fica restrito =E0 dificuldade do uso de outros hemoderivados.

c) medidas gerais como = cateteriza=E7=E3o de veia=20 calibrosa, sondagem vesical, controles gerais de press=E3o = arterial, pulso,=20 freq=FC=EAncia card=EDaca, freq=FC=EAncia respirat=F3ria, etc., = s=E3o indicadores=20 importantes do choque hipovol=EAmico.

Concomitantemente, procede-se avalia=E7=E3o = laboratorial atrav=E9s=20 do hemograma (hemoglobina e hemat=F3crito); de indicadores da = fun=E7=E3o renal;=20 da gasometria arterial e da instala=E7=E3o de coagulopatia.

A conduta obst=E9trica =E9 sempre a resolu=E7=E3o = do parto. A=20 escolha da via de parto depende das condi=E7=F5es de vitalidade = fetal e=20 condi=E7=F5es maternas. Na situa=E7=E3o de feto vivo, o parto = vaginal s=F3 =E9=20 admitido se for iminente. Caso contr=E1rio, deve se sempre fazer = ces=E1rea. Em=20 casos de feto morto, com boas condi=E7=F5es maternas, o parto = vaginal =E9 uma=20 op=E7=E3o a ser considerada, desde que a evolu=E7=E3o das = condi=E7=F5es cervicais=20 indiquem uma evolu=E7=E3o favor=E1vel.

2.2.3. Rotura = uterina

Trata-se da rotura completa ou incompleta da = parede=20 uterina, que ocorre sobretudo al=E9m da 28a semana=20 gestacional e durante o trabalho de parto, precedida, em sua = maioria, por=20 quadro cl=EDnico de imin=EAncia de rotura uterina, o que = facilita sua=20 preven=E7=E3o. Por essa raz=E3o, a sua freq=FC=EAncia = representa um indicador=20 da qualidade da assist=EAncia obst=E9trica prestada nos servi=E7os = em que=20 ocorre.

40

CAUSAS MAIS FREQ=DCENTES

1. Hipercontratilidade uterina (inclusive = iatrog=EAnica, por=20 estimula=E7=E3o ocit=F3cica ou com misoprostol) em pacientes com = cirurgias=20 uterinas anteriores (sobretudo cesariana corporal e miomectomias). =

2. Cicatrizes de ces=E1rea corporal anterior.

3. Insist=EAncia do parto por via baixa em casos = de=20 despropor=E7=E3o feto-p=E9lvica n=E3o diagnosticada (parto = obstru=EDdo somado ao=20 n=E3o-uso de partograma).

4. Traumas externos.

5. Manobras de vers=E3o interna/externa feitas=20 intempestivamente.

DIAGN=D3STICO

SINAIS DE IMIN=CANCIA DE ROTURA UTERINA =

1. Pacientes com contra=E7=F5es subentrantes = intensas e=20 excessivamente dolorosas.

2. S=EDndrome de distens=E3o segmentar = (Bandl-Frommel)

_ Sinal de Bandl (anel pr=F3ximo ou cont=EDguo =E0 = cicatriz=20 umbilical que separa o corpo do segmento inferior do =FAtero). =

_ Sinal de Frommel (ligamentos redondos retesados = e=20 desviados para frente).

ROTURA UTERINA INSTALADA

1. Dor abrupta e lancinante no = hipog=E1strio,=20 seguida de acalmia dolorosa transit=F3ria.

2. Paralisa=E7=E3o do trabalho de parto. =

3. Hemorragia (interna e/ou externa) cuja = intensidade=20 depender=E1 da extens=E3o da rotura e dos vasos atingidos.

4. Choque diretamente relacionado ao volume = da=20 hemorragia.

5. Sinais de irrita=E7=E3o peritonial.

6. Deformidades abdominais (=FAtero vazio e = feto fora=20 da cavidade _ rotura completa), feto "superficial" e com=20 ausculta em geral negativa.

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CONDUTA

=95 tratamento =E9 cir=FArgico, variando desde a = sutura uterina =E0=20 histerectomia, podendo a paciente necessitar de suporte vital. = Algumas=20 roturas provocam grandes hematomas de ligamento largo, podendo = estender-se=20 ao retroperit=F4nio. A abordagem cir=FArgica desses casos =E9 mais = complexa. O=20 hematoma de ligamento largo deve ser drenado, mas hematomas=20 retroperitoniais, em princ=EDpio, n=E3o devem ser manipulados. =

=95 em casos de parto vaginal com roturas sem = manifesta=E7=E3o=20 cl=EDnica, mais encontrados em rotura de cicatriz segmentar = transversa=20 (muitas vezes deisc=EAncia e n=E3o rotura), detectadas na = revis=E3o de segmento=20 uterino ap=F3s a dequita=E7=E3o, a conduta depender=E1 da = estabilidade=20 hemodin=E2mica da paciente e da hemorragia vis=EDvel. Em alguns = casos pode ser=20 adotada conduta expectante, desde que a paciente fique sob = rigorosa=20 observa=E7=E3o e com ocit=F3cicos em grandes doses. Em grandes = roturas=20 detectadas ao toque, =E9 mais aconselh=E1vel proceder-se =E0 = laparotomia com=20 sutura da =E1rea lesada, podendo ou n=E3o ser feita laqueadura = tub=E1rea,=20 conforme o desejo da paciente e sua condi=E7=E3o obst=E9trica. =

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D E S V I O S D O C R E S = C I M E N T=20 O F E T A L

3

3.1. Retardo de = crescimento=20 intra-uterino

Considera-se retardo do crescimento = intra-uterino (RCIU)=20 quando o peso ao nascer estiver abaixo do percentil 10 (p10) da = curva de=20 peso neonatal para idade gestacional. Sua freq=FC=EAncia =E9 = estimada entre=20 10% a 15% de todas as gesta=E7=F5es.

Tabela de Peso do Rec=E9m-Nascido Normal (em g) = Segundo=20 Percentis para Cada Semana de Gesta=E7=E3o

PERCENTIS

SEMANAS 10 50 90

26 564 821 1155

27 617 957 1346

28 703 1113 1552

29 843 1276 1800

30 1004 1460 1999

31 1161 1642 2196

32 1304 1842 2373

33 1507 2066 2592

34 1772 2322 2901

35 2055 2611 3206

36 2324 2888 3513

37 2529 3090 3690

38 2696 3230 3826

39 2816 3333 3906

40 2916 3430 4003 =

No crescimento fetal s=E3o considerados, al=E9m = dos gen=E9ticos,=20 outros fatores fetais ditos restritivos e facilitadores. Entre os=20 primeiros, destacam-se a desnutri=E7=E3o materna, n=EDvel=20 s=F3cio-econ=F4mico-cultural, uso de drogas l=EDcitas e = il=EDcitas, doen=E7as=20 maternas obst=E9tricas e intercorrentes, medicamentos, = radia=E7=F5es,=20 gemelaridade. Listam-se tamb=E9m como atuantes os fatores = placent=E1rios=20 (placenta circunvalada, tumores, art=E9ria umbilical =FAnica e = anomalias de=20 implanta=E7=E3o). Entre os facilitadores, destacam-se a insulina,=20 somatomedinas e fatores espec=EDficos do crescimento. O RCIU = representa a=20 conseq=FC=EAncia de um desequil=EDbrio desses fatores.

No entanto, em cerca de 40% dos casos n=E3o se = consegue=20 detectar o determinante causal. Nesse contingente incluem-se os=20 emocionais, embora sejam raramente cogitados e pobremente = investigados. A=20 longo prazo, o retardo de crescimento fetal pode associar-se a = doen=E7as=20 futuras (cardiovasculares, diabete melito, etc.).

43

Descrevem-se dois tipos de RCIU. O tipo = sim=E9trico,=20 causado por agente atuante desde fases precoces da = gesta=E7=E3o e o tipo=20 assim=E9trico, cujo fator causal =E9 tardio.

DIAGN=D3STICO

Para o diagn=F3stico =E9 fundamental o = correto=20 estabelecimento da idade gestacional. Utilizam-se par=E2metros = cl=EDnicos e=20 ultra-sonogr=E1ficos. Entre os cl=EDnicos citam-se o antecedente = obst=E9trico de=20 retardo de crescimento fetal em gesta=E7=E3o anterior, a medida de = altura=20 uterina (curva de altura uterina para a idade gestacional. Ver = Assist=EAncia=20 Pr=E9-Natal _ manuais t=E9cnicos do MS) e o ganho ponderal materno = inadequado.=20 Entre os ultra-sonogr=E1ficos: biometria fetal, peso fetal, = altera=E7=F5es=20 placent=E1rias e avalia=E7=E3o do l=EDquido amni=F3tico (ver Parte = 3 deste manual).=20

CONDUTA

N=E3o existe tratamento espec=EDfico. O = estabelecimento da=20 conduta fica na depend=EAncia da idade gestacional, das = condi=E7=F5es de=20 vitalidade fetal, da evolu=E7=E3o cl=EDnica e do fator causal. = Prop=F5em-se=20 medidas como repouso materno e a corre=E7=E3o dos fatores causais=20 identificados.

(*) Via de parto segundo indica=E7=E3o = obst=E9trica

44

=

3.2. Macrossomia = fetal=20

Conceitua-se macrossoma quando o peso fetal ao = nascer for=20 igual ou superior a 4 Kg.

O diabete gestacional constitui a principal causa. = Pode=20 associar-se tamb=E9m =E0 multiparidade, obesidade, gesta=E7=F5es = prolongadas,=20 hidropsia fetal (imune e n=E3o imune).

A macrossomia fetal poder=E1 provocar = complica=E7=F5es maternas=20 (despropor=E7=E3o fetop=E9lvica, sobredistens=E3o uterina, edema = suprap=FAbico,=20 parto prolongado, dispn=E9ia) e fetais (tocotraumatismos, distocia = de ombro,=20 hipoxia perinatal).

DIAGN=D3STICO

Utilizam-se dados cl=EDnicos e = ultra-sonogr=E1ficos:

Cl=EDnicos:

=95 anamnese (hist=F3ria pregressa de fetos = macross=F4micos,=20 diabetes, multiparidade, gesta=E7=F5es prolongadas).

=95 Estabelecimento da idade gestacional

=95 Avalia=E7=E3o da altura uterina

Ultra-sonogr=E1ficos:

=95 biometria fetal

=95 peso fetal

=95 avalia=E7=E3o placent=E1ria

CONDUTA

Clinicamente a corre=E7=E3o do fator causal =E9 = importante. Na=20 conduta obst=E9trica a avalia=E7=E3o das condi=E7=F5es de = vitalidade fetal deve ser=20 feita regularmente. Se preservada, aguarda-se o termo da = gesta=E7=E3o; se=20 comprometida, antecipa-se o parto.

A via vaginal =E9 preferencial, avaliando-se = criteriosamente=20 os riscos de tocotraumatismo e hip=F3xia fetal. A epsiotomia pode = ser=20 indicada, restingindo-se a indica=E7=E3o de ces=E1rea =E0 = impossibilidade do parto=20 por via baixa.

45

A L T E R A =C7 =D5 E S D = A D U R A =C7 =C3 O=20 D A G R A V I D E Z

4

4.1. Incompet=EAncia=20 istmo-cervical

=C9 a causa mais importante e freq=FCente de = abortamento=20 habitual, e se caracteriza pela incompet=EAncia do sistema = oclusivo do =FAtero=20 gr=E1vido, com a abertura do orif=EDcio interno.

DIAGN=D3STICO

_ Anamnese (antecedentes obst=E9tricos: manobras = traum=E1ticas=20 de dilata=E7=E3o cervical, perdas fetais precoces anteriores, = partos vaginais=20 traum=E1ticos ou instrumentados, cirurgia cervical pr=E9via, = etc.).

_ Exame p=E9lvico (especular e toque vaginal). =

_ Ultra-sonografia obst=E9trica (avaliar o = comprimento do colo=20 e determina=E7=E3o de seu di=E2metro antero-posterior ao n=EDvel = do orif=EDcio=20 interno do colo).

CONDUTA

=C9 cir=FArgica, sendo realizada durante a = gesta=E7=E3o, idealmente=20 entre a

12=AA e 16=AA semanas, podendo estender-se at=E9 a = 20=AA=20 semana.

Condi=E7=F5es para realiza=E7=E3o:

_ Dilata=E7=E3o cervical menor que 4 cm.

_ Apagamento cervical inferior a 60%.

_ Aus=EAncia de protrus=E3o avan=E7ada da bolsa = das =E1guas.

_ Bolsa =EDntegra.

_ Tratamento de infec=E7=F5es vaginais.

T=E9cnica cir=FArgica: circlagem cervical

RECOMENDA=C7=D5ES:

_ Restri=E7=E3o relativa a esfor=E7os f=EDsicos =

_ Uso de uteroinibidores e de antibioticoterapia = profil=E1tica=20 n=E3o traz benef=EDcios ao tratamento.

47

4.2. Trabalho de parto = prematuro=20 (TPP)

Conceitua-se gravidez pr=E9-termo aquela cuja = idade=20 gestacional encontra-se entre 22 (ou 154 dias) e 37 (ou 259 dias) = semanas.=20

Nesse per=EDodo, o trabalho de parto =E9 = caracterizado pela=20 presen=E7a de contra=E7=F5es freq=FCentes (uma a cada 5 a 8 = minutos) acompanhadas=20 de modifica=E7=F5es cervicais caracterizadas por dilata=E7=E3o = maior que 2,0 cm=20 e/ou esvaecimento maior que 50%.

Na etiologia do trabalho de parto pr=E9-termo = incluem-se=20 fatores maternos, como complica=E7=F5es m=E9dicas ou = obst=E9tricas=20 (partos prematuros anteriores, placenta pr=E9via, amniorrexe = prematura,=20 polidr=E2mnio, infec=E7=F5es do trato urin=E1rio, corioamnionite, = infec=E7=F5es=20 vaginais, incompet=EAncia istmo-cervical, malforma=E7=F5es = uterinas, cirurgias=20 na gesta=E7=E3o atual, amputa=E7=F5es de colo, etc.), = comportamentais=20 (tabagismo, alcoolismo, h=E1bitos alimentares = inadequados,=20 traumatismos, uso de drogas il=EDcitas, esfor=E7o f=EDsico = intenso), altera=E7=F5es=20 fetais e placent=E1rias, e condi=E7=F5es = s=F3cio-econ=F4micas=20 adversas.

Atualmente, d=E1-se muita import=E2ncia =E0 = corioamnionte e =E0=20 infec=E7=E3o vaginal pela Gardnerella vaginalis.

No entanto, em cerca de 30% dos casos n=E3o =E9 = poss=EDvel a=20 identifica=E7=E3o de fator causal e, seguramente, neste grupo = incluem-se os=20 fatores emocionais, pouco lembrados, e sequer abordados.

DIAGN=D3STICO

O diagn=F3stico =E9 feito atrav=E9s da = confirma=E7=E3o das=20 caracter=EDsticas conceituais do TPP.

CONDUTA

Importantes s=E3o a predi=E7=E3o e = preven=E7=E3o do trabalho de=20 parto pr=E9-termo.

Entre os elementos preditivos listam-se a=20 epidemiologia, com os fatores de risco citados, e os marcadores, = que podem=20 ser cl=EDnicos, ultra-sonogr=E1ficos e bioqu=EDmicos. Entre os = cl=EDnicos, o=20 encontro de dilata=E7=E3o e esvaecimento do colo, a contratilidade = uterina=20 ("=FAtero sens=EDvel"), sangramento genital, corrimentos vaginais, = etc.

No exame do colo uterino pela ultra-sonografia = transvaginal=20 o

comprimento do colo uterino menor que 3,9 cm = corresponde=20 significativamente =E0 chance de parto pr=E9-termo e detecta perto =

de 80% dos casos. Tamb=E9m a dilata=E7=E3o do = orif=EDcio interno=20 maior que

48

1,0 cm no segundo trimestre, detecta cerca de 25% = de partos=20 prematuros.

Entre os elementos utilizados para = preven=E7=E3o=20 encontram-se medidas como repouso relativo (diminui=E7=E3o de = atividades=20 f=EDsicas e sexuais), orienta=E7=E3o quanto =E0 preven=E7=E3o de = infec=E7=F5es urin=E1rias e=20 genitais, adequa=E7=E3o de aportes nutricional e psicol=F3gico. =

As consultas de pr=E9-natal devem ser amiudadas, e = aos exames=20 rotineiros acrescentam-se outros. Assim, o primeiro exame=20 ultra-sonogr=E1fico deve ser realizado o mais precoce poss=EDvel e = repetido a=20 cada 4 a 6 semanas.

O exame bacteriosc=F3pico e cultura do conte=FAdo = vaginal

devem ser feitos (e repetidos no terceiro = trimestre),

erradicando-se os germes relacionados ao parto = prematuro.=20

A inibi=E7=E3o do trabalho de parto pode ser = obtida atrav=E9s de=20 algumas medidas, como repouso, hidrata=E7=E3o e uso de agentes = medicamentosos=20 como os beta-adren=E9rgicos (salbutamol, terbutalina e ritodrina) = e=20 inibidores da protaglandina (indometacina).

a) A hidrata=E7=E3o intravenosa, em gestantes = hipovol=EAmicas ou=20 desidratadas, pode ser feita com solu=E7=E3o fisiol=F3gica a 0.9% = ou Ringer=20 simples, em volume1.000 ml cada 6 a 8 horas. A hidrata=E7=E3o deve = ser=20 utilizada como recurso inicial, devendo-se introduzir os = uterol=EDticos t=E3o=20 logo que poss=EDvel.

b) Uterol=EDticos, os esquemas mais utilizados = s=E3o:

Salbutamol

Apresenta=E7=E3o: injet=E1vel - 0,5 mg (ampolas de = 1 ml)

Ataque:

Via intravenosa

Dose inicial _ 10 mg/min _ (20 gotas/min)

Preparo: 0.5 mg (1 amp.)/500 ml SG 5% (0,01 mg/ml = at=E9 10=20 mg/min)

Aumentar 10 mg/20 min at=E9 inibi=E7=E3o das = contra=E7=F5es

Manter por 60 minutos

Diminuir 10 mg/30 min at=E9 menor dosagem

Manter por 12 horas

49

Terbutalina

Apresenta=E7=E3o: injet=E1vel - 0,5 mg (ampolas de = 1 ml)

Ataque:

Via intravenosa

Dose inicial _ 10 mg/min _ (20 gotas/min)

Preparo: 5,0 mg (10 amp.)/500 ml SG 5% (0,01 mg/ml = at=E9 10=20 mg/

min)

Aumentar 10 mg/20 min at=E9 inibi=E7=E3o das = contra=E7=F5es

Manter por 60 minutos

Diminuir 10 mg/30 min at=E9 menor dosagem

Manter por 12 horas

Ritodrina

Apresenta=E7=E3o: injet=E1vel - 10,0 mg (ampolas = de 5 ml)

Ataque:

Via intravenosa

Dose inicial _ 50 mg/min _ (10 gotas/min)

Preparo: 50 mg (5 amp.)/500 ml SG 5% (0,1 mg/ml = at=E9 100=20 mg/min)

Aumentar 50 mg/20 min at=E9 inibi=E7=E3o das = contra=E7=F5es

Manter por 60 minutos

Diminuir 50 mg/30 min at=E9 menor dosagem

Manter por 12 horas

Indometacina

Apresenta=E7=E3o: via oral - comprimidos de 25 e = 50 mg

via retal - suposit=F3rio de 100 mg

Ataque:

Dose inicial _ 50 mg VO (ou 100 mg/via retal)

Manuten=E7=E3o:

25 mg/VO (1 compr.) cada 4 a 6 horas

* A Indometacina n=E3o deve ser usada ap=F3s a = 34=AA semana=20 (para evitar complica=E7=F5es, como o fechamento precoce do duto = arterioso).=20

50

Cortic=F3ide

=C9 consenso usar cortic=F3ide, entre 28 _ 34 = semanas.=20 Betametasona - 12 mg/dia/2 dias/IM ou Dexametasona - 12 mg/dia/2 = dias/IM.=20 Esquema de uso:

N=E3o h=E1, ainda, consenso sobre:

=95 repeti=E7=E3o semanal do cortic=F3ide

=95 uso de outras drogas que n=E3o as anteriores =

=95 dosagem inferior =E0s recomendadas abaixo

4.3. Gesta=E7=E3o = prolongada=20

Conceitua-se gesta=E7=E3o prolongada, tamb=E9m = referida como=20 p=F3s-datismo, aquela cuja idade encontra-se entre 40 e 42 = semanas. Gravidez=20 p=F3s-termo =E9 aquela que ultrapassa 42 semanas.

A incid=EAncia de p=F3s-datismo =E9 ao redor de 5% = e est=E1=20 associada a fatores fetais (anencefalia), placent=E1rios = (atividade=20 end=F3crina excessiva, defici=EAncia de produ=E7=E3o da sulfatase = placent=E1ria),=20 uterinos (atividade intr=EDnseca do miom=E9trio, altera=E7=F5es = cervicais) e=20 emocionais. A idade da mulher e a paridade n=E3o t=EAm = influ=EAncia.

DIAGN=D3STICO

O diagn=F3stico de certeza somente pode ser feito = com o=20 estabelecimento precoce da idade gestacional. Falseando o = diagn=F3stico,=20 listam-se as irregularidades menstruais, uso de anticoncepcionais=20 hormonais, lacta=E7=E3o, etc. Nesses casos, o exame = ultra-sonogr=E1fico precoce=20 durante a gravidez =E9 recurso eficaz no correto estabelecimento = da idade=20 gestacional.

CONDUTA

A conduta deve objetivar a avalia=E7=E3o da = vitalidade fetal=20 atrav=E9s do registro da movimenta=E7=E3o fetal, cardiotocografia, = dopplervelocimetria, amnioscopia observando a presen=E7a de = mec=F4nio e=20 ultra-sonografia, onde indicador importante =E9 oligo=E2mnio (ver = esquema a=20 seguir).

51

(*) Ver a Parte 3, item 2.1.1.Lembrar que a = determina=E7=E3o da=20 idade gestacional pela ecografia precoce tem menos erro. Portanto, = em=20 gestantes com d=FAvidas na idade gestacional, solicitar a sua = determina=E7=E3o=20 ecogr=E1fica, o mais cedo poss=EDvel, e n=E3o no final da = gesta=E7=E3o.

(**) Significa interrup=E7=E3o da gesta=E7=E3o. A = via do parto ser=E1=20 determinada por indica=E7=E3o obst=E9trica, podendo ser realizada = a indu=E7=E3o do=20 trabalho de parto, quando n=E3o h=E1 contra-indica=E7=E3o absoluta = para esta=20 conduta.

(***) Como a insufici=EAncia placent=E1ria pode = ocorrer antes de=20 42 semanas, a pesquisa da vitalidade deve ser iniciada ao se = completar 40=20 semanas. A avalia=E7=E3o da vitalidade fetal utiliza recusos como: = registro=20 di=E1rio da movimenta=E7=E3o fetal, amnioscopia, cardiotocografia = (vide Parte=20 3). A presen=E7a de mec=F4nio =E0 amnioscopia ou amniocentese = indica interrup=E7=E3o=20 da gesta=E7=E3o.

52

A L T E R A =C7 =D5 E S D = O V O L U M E D=20 E

L =CD Q U I D O A M N I = =D3 T I C=20 O

5

5.1. Oligo=E2mNIO =

A redu=E7=E3o patol=F3gica do volume do = l=EDquido amni=F3tico,=20 ou oligo=E2mnio, incide em 3% a 5% das gesta=E7=F5es no = terceiro trimestre e=20 em cerca de 0,2% no segundo trimestre. S=E3o m=FAltiplas as causas = de=20 oligo=E2mnio. Quando =E9 diagnosticado precocemente, no segundo = trimestre da=20 gesta=E7=E3o, geralmente est=E1 relacionado com malforma=E7=E3o = fetal, sendo as mais=20 comuns as altera=E7=F5es renais fetais, principalmente as = patologias=20 obstrutivas. Outra importante causa de oligo=E2mnio =E9 o retardo = de=20 crescimento intra-uterino (RCIU), decorrente de altera=E7=F5es da = perfus=E3o=20 renal fetal secund=E1rias =E0s altera=E7=F5es placent=E1rias.

Contudo, a mais importante causa de oligo=E2mnio = =E9=20 representada pela rotura prematura de membranas (RPM), = respons=E1vel por=20 cerca de um quarto de todos os casos de oligo=E2mnio. Entretanto, = em algumas=20 situa=E7=F5es, a etiologia n=E3o consegue ser bem esclarecida, = sendo portanto, o=20 olig=E2mnio, considerado idiop=E1tico.

Associa-se a v=E1rias complica=E7=F5es perinatais. = Al=E9m da maior=20 mortalidade perinatal, quanto mais precocemente ocorre, maior a=20 possibilidade de deformidades esquel=E9ticas fetais e hipoplasia = pulmonar.=20 Quanto maior a intensidade do oligo=E2mnio, pior a evolu=E7=E3o da = gesta=E7=E3o. O=20 oligo=E2mnio associa-se a sofrimento fetal, asfixia neonatal e = morte=20 perinatal. Quando decorre de rotura prematura de membranas, = associa-se,=20 ainda, a infec=E7=E3o materna e perinatal.

Com a redu=E7=E3o do volume do l=EDquido = amni=F3tico, h=E1 maior=20 possibilidade de compress=E3o do cord=E3o umbilical, com = conseq=FCente=20 desacelera=E7=E3o da freq=FC=EAncia card=EDaca fetal e o = aparecimento de sinais de=20 sofrimento fetal, com maior risco de morte intra-uterina.

DIAGN=D3STICO

Tradicionalmente, o diagn=F3stico cl=EDnico =E9 = realizado pela=20 medida

da altura do fundo uterino menor que a esperada = para a idade=20 gestacional, associada =E0 sensa=E7=E3o de desconforto materno =E0 = movimenta=E7=E3o=20 fetal, facilidade de palpa=E7=E3o de pequenas

partes fetais e a avalia=E7=E3o subjetiva do = examinador=20 experiente

sobre a redu=E7=E3o do l=EDquido amni=F3tico. Mais = recentemente, o=20

diagn=F3stico tem sido quase sempre confirmado por = exame

ultra-sonogr=E1fico, com o desenvolvimento de = =EDndices=20 objetivos para a mensura=E7=E3o do volume do l=EDquido.

53

O =EDndice de l=EDquido amni=F3tico (ILA), cujo = valor varia de=20 acordo com a idade gestacional, =E9 estimado pela soma do = di=E2metro do maior=20 bols=E3o de l=EDquido medido em cada um dos quadrantes da = proje=E7=E3o do =FAtero=20 grav=EDdico sobre a superf=EDcie abdominal materna.

CONDUTA

O tratamento do oligo=E2mnio visa restaurar o = volume de=20 l=EDquido amni=F3tico e ir=E1 depender de sua etiologia. Quando = for decorrente=20 de anomalias renais fetais, s=F3 poder=E1 ser tratado nas = patologias=20 obstrutivas, atrav=E9s da coloca=E7=E3o de cateter de = deriva=E7=E3o para a cavidade=20 amni=F3tica, procedimento reservado aos centros de refer=EAncia em = Medicina=20 Fetal, para onde os casos devem ser encaminhados. Nos casos de = altera=E7=F5es=20 renais com aus=EAncia de fun=E7=E3o (displasias renais), e na = aus=EAncia de rins=20 (agenesia), n=E3o existe terap=EAutica. Nos caso de altera=E7=E3o = da perfus=E3o=20 placent=E1ria (como na hipertens=E3o arterial), medidas = cl=EDnicas, como o=20 repouso, podem ter alguma valia. Contudo, na amniorrexe prematura, = o=20 tratamento vem sendo mais pesquisado. Os procedimentos para este = fim=20 incluem a amnioinfus=E3o e a hiperhidrata=E7=E3o.

A amnioinfus=E3o consiste na infus=E3o de = l=EDquidos,=20 principalmente solu=E7=E3o salina, na cavidade amni=F3tica. Embora = ainda n=E3o=20 utilizada sistematicamente no pa=EDs, tem demonstrado ser uma = t=E9cnica=20 relativamente simples, e eficaz. Sua utiliza=E7=E3o, entretanto, = ainda n=E3o =E9=20 recomendada rotineiramente, estando restrita aos Centros de = Refer=EAncia.=20

A hidrata=E7=E3o materna tem mostrado sua = efic=E1cia em aumentar o=20 volume do l=EDquido amni=F3tico residual, desde que n=E3o haja = contra-indica=E7=E3o=20 para uma sobrecarga circulat=F3ria. Al=E9m da hidrata=E7=E3o oral, = pode-se=20 complementar por via endovenosa, recomendando-se um aporte total = de 3 a 4=20 litros de l=EDquidos por dia.

Entende-se, ainda, que, pela maior possibilidade = de=20 compress=E3o

de cord=E3o e associa=E7=E3o com progn=F3stico = perinatal=20 desfavor=E1vel,

o oligo=E2mnio constitui uma situa=E7=E3o = obst=E9trica que indica a=20 vigil=E2ncia fetal, com acompanhamento atrav=E9s de = ultra-sonografia e provas=20 de vitalidade fetal. A conduta seq=FCencial depender=E1 dos = resultados dessas=20 provas e da condi=E7=E3o cl=EDnica materna associada ao = oligo=E2mnio.

5.2. Polidr=E2mnio =

=C9 o aumento excessivo do volume do l=EDquido = amni=F3tico,=20 classicamente considerado quando superior a 2.000 ml. Sua = freq=FC=EAncia =E9=20 ao redor de 1% e sua import=E2ncia se deve ao aumento da morbidade = e=20 mortalidade perinatais.

54

Mais freq=FCentemente, associa-se a altera=E7=F5es = fetais como=20 malforma=E7=F5es, infec=E7=F5es, hidropisia imune e n=E3o imune, = tumores, etc.=20 Relaciona-se ainda a altera=E7=F5es placent=E1rias (tumores, = placenta=20 circunvalada) e maternas, cujos mais importantes fatores s=E3o = representados=20 por diabetes e aloimuniza=E7=E3o Rh. Existem ainda causas = idiop=E1ticas.

DIAGN=D3STICO

O diagn=F3stico da polidramnia =E9 suspeitado = clinicamente pelo=20 aumento da altura uterina em rela=E7=E3o =E0 idade gestacional; = aumento do ganho=20 ponderal materno; sobredistens=E3o uterina e dificuldade de = palpa=E7=E3o das=20 partes fetais e de ausculta dos BCF. Sistematicamente, devem ser=20 pesquisados o diabete melito e a presen=E7a de malforma=E7=F5es = fetais.

De certeza, o diagn=F3stico =E9 = ultra-sonogr=E1fico, dado pelo=20 achado do ILA maior que o percentil 95 para a idade gestacional=20 considerada.

CONDUTA

A conduta =E9 o esvaziamento quando surgirem = sinais de=20 desconforto materno. O esvaziamento =E9 feito pela amniocentese e = atrav=E9s de=20 agulha calibrosa e inser=E7=E3o de cateter ligado a frasco a = v=E1cuo.=20 Recomenda-se a retirada lenta e gradual do l=EDquido amni=F3tico, = para evitar=20 a descompress=E3o brusca, podendo levar a riscos maternos e fetais = (descolamento prematuro da placenta, choque materno, =F3bito = fetal, etc.).=20 Sugere-se a retirada de cerca de 200 ml/hora (ou cerca de 3 = ml/minuto) at=E9=20 a melhora da sintomatologia respirat=F3ria materna ou at=E9 = atingir um total=20 m=E1ximo de 500 a 1000 ml. O polidr=E2mnio volta a se formar e=20 excepcionalmente nova pun=E7=E3o pode ser realizada.

No sentido de diminuir a forma=E7=E3o de l=EDquido = amni=F3tico=20 pode-se empregar a indometacina, cuja fun=E7=E3o =E9 diminuir a = fun=E7=E3o renal=20 fetal. Recomenda-se dosagem de 25 mg VO a cada 6 horas, por at=E9 = 3 dias,=20 n=E3o devendo ultrapassar a 34=AA semana. Tais cuidados = s=E3o=20 necess=E1rios para evitar uma das complica=E7=F5es temidas do uso = da=20 indometacina na gesta=E7=E3o, que =E9 o fechamento precoce do duto = arterioso.=20

Para o parto =E9 recomend=E1vel o pr=E9vio = esvaziamento. Muitas=20 vezes surge quadro de hipossistolia, o que pode ser corrigido com=20 ocit=F3cicos. A via de parto =E9 escolhida de acordo com a = indica=E7=E3o=20 obst=E9trica.

55

=CA M E S E E H I P E R = =CA M E S=20 E

6

=C9 a exacerba=E7=E3o da emese grav=EDdica, = comum no primeiro=20 trimestre da gesta=E7=E3o e caracterizada por na=FAseas e = v=F4mitos. Rara nos=20 dias de hoje, estima-se que seu aparecimento ocorra em cerca de 2 = a cada=20 1.000 gesta=E7=F5es.

Mais freq=FCente em primigestas, v=E1rios fatores = s=E3o apontados=20 como seus causadores, sendo os mais aceitos os aspectos emocionais = e as=20 adapta=E7=F5es hormonais pr=F3prias do in=EDcio da gesta=E7=E3o. =

Algumas doen=E7as poder=E3o estar associadas =E0 = hiperemese, como=20 pr=E9-ecl=E2mpsia, gemelaridade, mola hidatiforme, diabetes e = isoimuniza=E7=E3o.=20

DIAGN=D3STICO

Outras causas de n=E1useas e v=F4mitos intensos = devem ser=20 afastadas, como =FAlcera g=E1strica, cisto de ov=E1rio torcido, = prenhez=20 ect=F3pica, insufici=EAncia renal, infec=E7=F5es intestinais. Os = v=F4mitos tardios=20 da gravidez n=E3o devem ser confundidos com hiperemese = grav=EDdica.

Os v=F4mitos incoerc=EDveis e n=E1useas acarretam = um quadro que=20 vai desde a desidrata=E7=E3o e olig=FAria =E0 perda de peso, = alcalose (pela perda=20 maior de cloro, atrav=E9s do suco g=E1strico _ hipocloremia), = perda de=20 pot=E1ssio nos casos mais prolongados e altera=E7=F5es no = metabolismo de=20 gorduras e glicose, podendo chegar =E0 insufici=EAncia hep=E1tica, = renal e=20 neurol=F3gica, nos casos graves.

CONDUTA

O apoio psicol=F3gico e educativo desde o in=EDcio = da gesta=E7=E3o=20 assim como o tratamento precoce da emese grav=EDdica, com = reorienta=E7=E3o=20 alimentar e antiem=E9ticos, s=E3o as melhores maneiras de evitar = os casos de=20 hiperemese.

Antiem=E9ticos orais:

metoclopramida _ 10 mg de 4/4 horas

dimenitrato _ 50 mg de 6/6 horas

Antiem=E9ticos injet=E1veis:

metoclopramida _ 10 mg (1 ampola _ 2 ml) de 4/4 = horas

dimenitrato _ 50 mg (1 ampola _ 1 ml)

Mesmo na emese grav=EDdica, havendo persist=EAncia = dos sintomas,=20 pode ser necess=E1ria seda=E7=E3o e diminui=E7=E3o dos n=EDveis de = ansiedade da=20 gestante,

57

com apoio psicol=F3gico, al=E9m de hidrata=E7=E3o = endovenosa, quando=20 a desidrata=E7=E3o existir.

Todavia, instalado o quadro de hiperemese, a = interna=E7=E3o se=20 faz necess=E1ria, com jejum, reposi=E7=E3o das perdas com soro = glicofisiol=F3gico,=20 manuten=E7=E3o do equil=EDbrio hidroeletrol=EDtico e de = =E1cido-base, al=E9m do uso de=20 antiem=E9ticos injet=E1veis.

A reintrodu=E7=E3o de dieta leve e sua progressiva = normaliza=E7=E3o=20 devem ser feitos na medida da aceita=E7=E3o da gestante, seu = apetite e=20 aus=EAncia de na=FAseas. Nos casos de acentuada perda de peso e = dificuldade de=20 reintrodu=E7=E3o da dieta, a alimenta=E7=E3o parenteral pode ser = necess=E1ria,=20 enquanto persistirem os sintomas.

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G E S T A =C7 =C3 O M =DA = L T I P L=20 A

7

=C9 a gravidez que ocorre com presen=E7a de = dois ou mais=20 fetos.

A mortalidade perinatal =E9 maior que a habitual e = aumenta em=20 propor=E7=E3o direta ao n=FAmero de fetos. =C9 devida, = principalmente, =E0=20 prematuridade e ao retardo de crescimento fetal e, = secundariamente, =E0=20 presen=E7a de malforma=E7=F5es fetais, altera=E7=F5es = placent=E1rias e de cord=E3o,=20 aumento de incid=EAncia de doen=E7as como pr=E9-ecl=E2mpsia, etc. = Est=E1 tamb=E9m=20 aumentado o risco materno pelo aparecimento mais freq=FCente das = s=EDndromes=20 hipertensivas, de anemia, de quadros hemorr=E1gicos no parto, = polidr=E2mnio,=20 apresenta=E7=F5es an=F4malas, etc.

A gravidez m=FAltipla relaciona-se com faixas = et=E1rias maternas=20 maiores, com a ra=E7a negra, com o aumento da paridade, com = hist=F3ria=20 familiar (pelo lado materno), com freq=FC=EAncia maior de = rela=E7=F5es sexuais, e,=20 em dias atuais, com as t=E9cnicas de indu=E7=E3o da ovula=E7=E3o = ou de fertiliza=E7=E3o=20 assistida.

Identificam-se dois tipos de gravidez gemelar;=20 monozig=F3tica, resultado da divis=E3o, em fases muito = precoces do ovo=20 formado pela fecunda=E7=E3o de um =F3vulo, e dizig=F3tica, = resultante da=20 fecunda=E7=E3o de dois =F3vulos por dois espermatoz=F3ides.

DIAGN=D3STICO

O diagn=F3stico, de suspei=E7=E3o, =E9 feito = atrav=E9s de dados=20 cl=EDnicos: aumento da altura uterina, palpa=E7=E3o de dois = p=F3los cef=E1licos,=20 sobredistens=E3o uterina e presen=E7a de dois focos, separados a = mais que 10=20 cm e com batimentos diferentes entre si.

Dados confirmat=F3rios s=E3o dados pelo exame = ultra-sonogr=E1fico.=20 Apesar de se constatarem dois sacos gestacionais e respectivos = embri=F5es em=20 fases iniciais, com a evolu=E7=E3o pode haver "desaparecimento", = por morte de=20 um deles.

Importante =E9 o diagn=F3stico do tipo de gravidez = m=FAltipla=20 (mono ou dizig=F3tica), identificando-se, pela ultra-sonografia, o = septo que=20 separa as duas cavidades amni=F3ticas, com a finalidade de = diagnosticar a=20 s=EDndrome de transfus=E3o feto-fetal.

CONDUTA

As consultas devem ser mais freq=FCentes, no = m=E1ximo a cada=20 tr=EAs semanas. Al=E9m dos exames rotineiros, sugere-se a = ultra-sonografia=20 mensal para avalia=E7=E3o do crescimento dos fetos.

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A vitalidade fetal passa a ser pesquisada a partir = de 28-30=20 semanas (ver Parte 3). Recomenda-se o uso de cortic=F3ides entre = 28 e 34=20 semanas.

Como via de parto, indica-se para:

Cef=E1lico/Cef=E1lico =95 Parto vaginal

Cef=E1lico/P=E9lvico =95 Se o 2=BA feto tiver peso = estimado

< 1.500 g, parto ces=E1reo; se

> 1.500 g, parto vaginal

Cef=E1lico/Transverso =95 Se o 2=BA feto tiver = peso estimado

< 1.500 g, parto ces=E1reo; se

> 1.500 g, vers=E3o e extra=E7=E3o

1=BA P=E9lvico ou Transverso =95 Parto Ces=E1reo. =

Quando existem mais =95 Ces=E1rea

de dois fetos

O intervalo entre os dois partos deve ser ao redor = de 15=20 minutos. Se maior que 30 minutos, indica-se a via alta para o = segundo=20 gemelar, o que deve ser visto como procedimento de exce=E7=E3o. =

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I S O I M U N I Z A =C7 = =C3 O M A T E R N=20 O - F E T A L

8

Cerca de 10% das gesta=E7=F5es t=EAm = incompatibilidade=20 materno-fetal para o fator Rh. Destas, 5% apresentam = aloimuniza=E7=E3o.=20 Cerca de 98% dos casos de aloimuniza=E7=E3o materna por = ant=EDgenos=20 eritrocit=E1rios (doen=E7a hemol=EDtica perinatal _ DHPN) s=E3o = devidos ao fator=20 Rh; os restantes 2% a ant=EDgenos at=EDpicos como os fatores Kell, = E ou c.=20

A aloimuniza=E7=E3o Rh, al=E9m de mais = freq=FCente, =E9 a de maior=20 gravidade para o feto, levando, em alguns casos, =E0 hidropisia e = ao =F3bito.=20

A causa principal =E9 o desenvolvimento de = anticorpos anti-Rh=20 positivo em m=E3es Rh negativo, com feto Rh positivo. =C9 hoje = evento raro,=20 praticamente inexistente, em pa=EDses desenvolvidos. No Brasil, no = entanto,=20 ainda existem casos, mesmo nos centros mais providos de recursos, = pelo=20 n=E3o-uso de imunoglobulina anti-D.

O mesmo pode ser dito para a DHPN causada por = transfus=E3o de=20 sangue incompat=EDvel, por abortamento e amniocentese, e, em dias = atuais,=20 merece destaque o uso de drogas il=EDcitas injet=E1veis.

DIAGN=D3STICO

O diagn=F3stico =E9 feito pela pesquisa = quantitativa de=20 anticorpos irregulares em toda gestante Rh negativo, com parceiro = Rh=20 positivo ou desconhecido. Lembrar que o teste de Coombs indireto = n=E3o =E9=20 espec=EDfico para o ant=EDgeno Rh.

Consideram-se positivos t=EDtulos anti-D iguais ou = maiores que=20 1/16.

CONDUTA

A partir desse resultado, inicia-se a pesquisa das = condi=E7=F5es=20 fetais, pela espectrofotometria do l=EDquido amni=F3tico, conforme = esquema=20 gr=E1fico de Liley. A espectrofotometria fornece, no comprimento = de onda de=20 450 mile micra, a diferen=E7a de densidade =F3ptica entre a = concentra=E7=E3o de=20 bilirrubina indireta fetal e o padr=E3o. O resultado obtido =E9 = levado ao=20 gr=E1fico que estabelece rela=E7=E3o entre a diferen=E7a de = densidade =F3ptica=20 obtida e a idade gestacional, permitindo-se ent=E3o tra=E7ar = conduta=20 espec=EDfica para cada caso.

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Preven=E7=E3o da sensibiliza=E7=E3o pelo fator = Rh:

a) Evitar amniocentese nas gestantes Rh (-) n=E3o=20 sensibilizadas.

b) Administrar imunoglobina humana anti-D dentro = das=20 primeiras 72 horas em:

_ m=E3es Rh (-) n=E3o sensibilizadas (Coombs = indireto negativo)=20 com

partos de rec=E9m-nascido Rh (+) e Coombs direto = negativo;=20

_ p=F3s-abortamento, gravidez ect=F3pica ou mola; =

_ p=F3s-amniocentese, cordocentese ou bi=F3psia de = vilosidade=20

corial;

_ depois de sangramento durante a gesta=E7=E3o. =

c) Administrar imunoglobina humana anti-D durante = gesta=E7=E3o=20 de mulheres Rh (-) e com Coombs indireto negativo com marido Rh = (+) entre=20 28=AA e 34=AA semanas.

Esquema Progn=F3stico de Liley

Mais recentemente, nos centros providos com = recursos=20 humanos e t=E9cnicos mais espec=EDficos para procedimentos de = medicina fetal,=20 tanto a proped=EAutica (dosagem de Hb, teste de Coombs direto) = como a=20 terap=EAutica (transfus=E3o fetal) tendem a ser realizados = atrav=E9s de=20 cordocentese sob vis=E3o ecogr=E1fica direta.

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A M N I O R R E X E P R E = M A T U R=20 A

9

Conceitua-se amniorrexe prematura quando a = rotura da=20 bolsa amni=F3tica se d=E1 antes de instalado o trabalho de parto.=20 Constitui causa importante de partos pr=E9-termo (cerca de 1/3 = dos=20 casos) o que contribui para aumento da mortalidade perinatal. A=20 mortalidade materna tamb=E9m =E9 agravada pelos riscos de = infec=E7=E3o.

DIAGN=D3STICO

O diagn=F3stico =E9 basicamente cl=EDnico. A = anamnese informa=20 sobre perda l=EDquida, em quantidade grande ("molha roupas"), = s=FAbita e=20 habitualmente indolor.

O exame f=EDsico est=E1 dentro dos padr=F5es de = normalidade e o=20 exame obst=E9trico mostra volume uterino adequado para a idade = gestacional=20 referida, =FAtero normot=F4nico, partes fetais palp=E1veis mais = facilmente e=20 batimentos card=EDacos fetais presentes.

A visualiza=E7=E3o de sa=EDda de l=EDquido = amni=F3tico pelo orif=EDcio=20 do

colo =E9 indicador absoluto para o diagn=F3stico. = Como,=20 entretanto,

nem sempre este dado =E9 obtido, utilizam-se = m=E9todos=20 laboratoriais.

Bons resultados s=E3o obtidos pelo teste descrito = por Ianetta=20 (1984), que

consiste na mudan=E7a de colora=E7=E3o (incolor = para marrom) de=20

esfrega=E7o de amostra de l=EDquido amni=F3tico em = l=E2mina,=20 aquecida durante um minuto.

A ultra-sonografia =E9 m=E9todo auxiliar = importante, n=E3o=20 definitivo. =C0 redu=E7=E3o do volume do l=EDquido amni=F3tico, = soma-se avalia=E7=E3o da=20 idade gestacional, par=E2metro b=E1sico na tomada de conduta.

CONDUTA

A conduta cl=EDnica conservadora implica = vigil=E2ncia de=20 par=E2metros indicadores de infec=E7=E3o.

A conduta obst=E9trica segue esquema:

63

AMNIORREXE PREMATURA

Conduta Expectante (*)

_ Na conduta conservadora =E9 imprescind=EDvel = observar as=20 seguintes medidas gerais:

=95 repouso hospitalar

=95 controle de pulso e temperatura, de 6 em 6 = horas

=95 avaliar vitalidade fetal

=95 avaliar a idade gestacional

=95 abstin=EAncia sexual

=95 realizar leucograma duas vezes por semana

=95 evitar o toque vaginal

64

=95 cortic=F3ides _ sugere-se o uso de = cortic=F3ides por diminuir=20 os riscos de s=EDndrome de desconforto respirat=F3rio e de = hemorragia=20 intracraniana no rec=E9m-nascido.

=95 antibi=F3ticos _ devem ser utilizados quando = indicada a=20 antecipa=E7=E3o do parto.

=95 uterol=EDticos _ contra-indicado

_ Hiper-hidrata=E7=E3o: Utilizada quando associada = a oligo=E2mnio=20 importante (ILA < 5 cm), descartando-se, necessariamente, = cardiopatias=20 e corioamnionite.

Esquema:

_ Solu=E7=E3o de Ringer Simples ou Soro = Fisiol=F3gico _ 4.000 ml/=20 IV

_ Considera-se satisfat=F3ria quando ILA > 6 = cm.

_ Passa-se, ent=E3o, =E0 hiper-hidrata=E7=E3o oral = _ 3.000 a 4.000=20 ml/24h.

Indica-se a repeti=E7=E3o do esquema IV se ILA = novamente < 5=20 cm.

9.1. = Corioamnionite

O diagn=F3stico de corioamnionite pode ser = cl=EDnico ou=20 laboratorial

Cl=EDnico:

_ Hipertemia

_ Taquisfigmia

_ Secre=E7=E3o vaginal com odor f=E9tido

_ Taquicardia materna fetal

_ Sensibiliddade aumentada do =FAtero

Laboratorial:

Leucocitose - aumento > ou igual 20%, com = desvio =E0=20 esquerda.

A conduta no diagn=F3stico de = corioamnionite =E9 a=20 interrup=E7=E3o da gesta=E7=E3o.

65

=D3 B I T O F E T A = L=20

10

O =F3bito fetal =E9 definido como a morte do = feto que ocorre=20 antes da completa expuls=E3o ou extra=E7=E3o do produto conceptual = a partir de=20 22 semanas completas de gesta=E7=E3o.

A morte fetal n=E3o =E9 um evento raro e, em = pa=EDses em=20 desenvolvimento, suas causas mais prevalentes continuam sendo = pass=EDveis de=20 controle e/ou tratamento. A ocorr=EAncia de =F3bito fetal varia de = 0,6% a=20 1,2%. Em pa=EDses em desenvolvimento, a taxa de mortalidade fetal = chega a=20 30/1.000 nascimentos, cerca de quatro a cinco vezes maior que nos = pa=EDses=20 desenvolvidos.

=C9 importante que se classifique o =F3bito fetal = de acordo com=20 a =E9poca de acontecimento, em anteparto ou intraparto, j=E1 que = existem=20 grandes diferen=E7as no que diz respeito =E0 etiologia, = complica=E7=F5es maternas=20 e assist=EAncia obst=E9trica.

As principais causas identificadas de morte fetal = no per=EDodo=20 anteparto s=E3o divididas em maternas e feto-anexiais.

=95 Causas maternas: s=EDndromes = hipertensivas,=20 isoimuniza=E7=E3o Rh, endocrinopatias, anemias, infec=E7=F5es, = presen=E7a no soro=20 materno de anticorpos antifosfol=EDpides, desnutri=E7=E3o, uso de = drogas l=EDcitas=20 ou il=EDcitas, intoxica=E7=F5es por metais pesados, altera=E7=F5es = uterinas, etc.=20

=95 Causas feto-anexiais: malforma=E7=F5es = cong=EAnitas,=20 anormalidades cromoss=F4micas, hemorragias do terceiro trimestre = da=20 gesta=E7=E3o, funiculopatias, transfus=E3o na prenhez gemelar = monozig=F3tica.

DIAGN=D3STICO

Cl=EDnico: parada de movimenta=E7=E3o = fetal, diminui=E7=E3o do=20 peso corporal materno, interrup=E7=E3o do crescimento uterino, = redu=E7=E3o da=20 quantidade do l=EDquido amni=F3tico =E0 palpa=E7=E3o, aus=EAncia = dos batimentos=20 card=EDacos fetais. No =F3bito antigo, pode-se perceber o sinal de = Boero, que=20 corresponde =E0 ausculta n=EDtida da pulsa=E7=E3o da aorta = abdominal materna com o=20 estetosc=F3pio de Pinard.

Ultra-sonogr=E1fico: a aus=EAncia de = pulsa=E7=E3o card=EDaca e=20 de movimenta=E7=E3o fetal confirma o diagn=F3stico na totalidade = dos casos. Na=20 depend=EAncia do tempo do =F3bito, podem ainda estar presentes = altera=E7=F5es=20 indicativas de redu=E7=E3o do l=EDquido amni=F3tico e = altera=E7=F5es estruturais=20 fetais.

Etiol=F3gico: para diagnosticar a causa do = =F3bito =E9=20 necess=E1rio o estabelecimento de um extenso protocolo, de acordo = com a=20 disponibilidade do servi=E7o:

Exames laboratoriais: sorologias, glicemia, = hemograma, etc.=20

Exame radiol=F3gico de todo esqueleto do natimorto =

Necropsia

Histopatol=F3gico da placenta

Dosagem de anticorpos antifosfol=EDpides

Bacterioscopia e cultura de: colo uterino, = membranas=20 placent=E1rias e orofaringe do natimorto

Estudo citogen=E9tico do natimorto (atrav=E9s de = fragmento de=20 placenta e/ou de pele)

CONDUTA

Por muito tempo a conduta foi esperar pelo = desencadeamento=20 espont=E2neo do trabalho de parto. Na atualidade, h=E1 tend=EAncia = de conduta=20 ativa, em raz=E3o da ansiedade materna e tamb=E9m pela = possibilidade da=20 ocorr=EAncia de coagulopatias causada pela libera=E7=E3o de = subst=E2ncias=20 trombopl=E1sticas, pela reten=E7=E3o do feto morto por per=EDodo = superior a quatro=20 semanas.

Os m=E9todos de indu=E7=E3o mais utilizados s=E3o: = ocitocina e=20 prostaglandinas, uso extra-amni=F3tico de sondas ou lamin=E1rias. = A ocitocina=20 =E9 prioritariamente utilizada em casos de gesta=E7=F5es com idade = igual ou=20 superior a 28 semanas, com colo uterino favor=E1vel, e as = prostaglandinas=20 nos casos de morte fetal anteparto com colo uterino desfavor=E1vel = e com=20 idade gestacional mais precoce, seja para amadurecimento do colo = ou=20 indu=E7=E3o do trabalho de parto propriamente dito (ver Parte 4). =

O =F3bito fetal n=E3o constitui uma = indica=E7=E3o de ces=E1rea,=20 excetuando-se raras situa=E7=F5es, como: placenta pr=E9via = centro-total,=20 ces=E1reas de repeti=E7=E3o, descolamento prematuro de placenta = com=20 coagulopatia.

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C E S =C1 R E A A N T E R = I O=20 R

11

A presen=E7a de antecedente de uma ces=E1rea = anterior n=E3o=20 contra-indica a ocorr=EAncia de trabalho de parto na gesta=E7=E3o = subseq=FCente.=20 O incentivo =E0 realiza=E7=E3o de prova de trabalho de parto = nessas mulheres=20 =E9 uma das medidas mais importantes para a redu=E7=E3o das taxas = de ces=E1reas no=20 Brasil.

O risco de complica=E7=F5es maternas (rotura = uterina, deisc=EAncia=20 de cicatriz, etc.), assim como de complica=E7=F5es fetais = (sofrimento), =E9=20 muito baixo, desde que haja adequada vigil=E2ncia do trabalho de = parto e da=20 vitalidade fetal.

N=E3o existem limites de intervalo interpartal que = contra-indiquem o trabalho de parto em uma gestante com ces=E1rea = anterior,=20 desde que a incis=E3o da primeira ces=E1rea tenha sido segmentar. =

O =EDndice de sucesso para parto vaginal as = mulheres=20 submetidas a uma prova de trabalho de parto (PVAC _ parto vaginal = ap=F3s=20 ces=E1rea) =E9 de, no m=EDnimo, 50%; alguns trabalhos mostram = cifras de 70% a=20 80%.

69

P A R T E I I :=20

I N T E R C O R R = =CA N C I A S=20

C L =CD N I C A = S=20

I N F E C =C7 =D5 E S =

1

1.1. Infec=E7=E3o = urin=E1ria=20

Este =E9 o problema urin=E1rio mais comum durante = a gesta=E7=E3o.=20 O quadro cl=EDnico varia de bacteri=FAria assintom=E1tica (mais = de 100.000=20 col=F4nias/ml de urina), que acomete de 2% a 10% das = gestantes, at=E9 o=20 quadro de pielonefrite. Em 80% dos casos de bacteri=FAria=20 assintom=E1tica, a Escherichia coli =E9 o agente = etiol=F3gico=20 identificado.

DIAGN=D3STICO

Os casos mais leves caracterizam-se por dis=FAria, = polaci=FAria=20 e urg=EAncia miccional. Nas infec=E7=F5es mais graves aparecem = sintomas de queda=20 do estado geral, como: febre, calafrios, cafal=E9ia, n=E1useas, = v=F4mitos e=20 hipersensibilidade do =E2ngulo costo-vertebral, sugestivos de = pielonefrite=20 aguda. Associados a ela est=E3o a desidrata=E7=E3o, o = comprometimento da fun=E7=E3o=20 renal, a hem=F3lise, a anemia, o choque s=E9ptico, a prematuridade = e a=20 infec=E7=E3o feto-anexial e puerperal.

O diagn=F3stico laboratorial =E9 dado pelo exame = do sedimento=20 urin=E1rio e pela cultura.

CONDUTA

Nos casos leves, o tratamento =E9 ambulatorial e a = antibioticoterapia =E9 feita por via oral durante 7 a 10 dias. Os=20 antibi=F3ticos mais utilizados s=E3o a ampicilina (2 g/dia), a = cefalosporina=20 de 1=AA gera=E7=E3o (2 g/dia) e a nitrofuranto=EDana (300 mg/dia), = esta =FAtima=20 indicada para os germes gram negativos (E. coli). Iniciar a=20 antibioticoterapia frente ao diagn=F3stico cl=EDnico declarado, = n=E3o sendo=20 recomendado aguardar-se a realiza=E7=E3o dos exames laboratoriais = nesses=20 casos, que devem ser feitos 7 a 15 dias ap=F3s o t=E9rmino do = tratamento.

A bacteri=FAria assintom=E1tica requer o mesmo = tratamento dos=20 casos leves.

Os casos graves requerem interna=E7=E3o com = controle dos sinais=20 vitais, hidrata=E7=E3o e antibioticoterapia. O antibi=F3tico mais = usado =E9 a=20 cefalosporina de 1=AA gera=E7=E3o, administrada intravenosamente = na dosagem de 1=20 a 2g de 6 em 6 horas. A efic=E1cia do tratamento =E9 avaliada a = cada 24 horas.=20 Ap=F3s a resolu=E7=E3o do quadro agudo,

passa-se ao antibi=F3tico via oral, cefalosporina = de 2g/dia,=20 durante,

73

no m=EDnimo, 10 dias. No caso de recidivas, = deve-se=20 administrar, como

dose de manuten=E7=E3o, 100mg de = nitrofuranto=EDna, =E0 noite, at=E9 o=20 final da gesta=E7=E3o.

1.2. = Toxoplasmose

A toxoplasmose =E9 causada pelo Toxoplasma gondii = (TG) e=20 adquire especial relev=E2ncia quando atinge a gestante, visto o = elevado=20 risco de acometimento fetal. Entre os agravos anat=F4micos e = funcionais=20 decorrentes dessa afec=E7=E3o podem ser observados retardo de = crescimento=20 intra-uterino, morte fetal, prematuridade e/ou toxoplasmose = cong=EAnita=20 (microftalmia, microcefalia, com ou sem hidrocefalia, retardo = mental,=20 pneumonite, hepatoesplenomegalia, erup=E7=E3o cut=E2nea e = calcifica=E7=F5es=20 cerebrais).

DIAGN=D3STICO:

Cl=EDnico

A anamnese =E9 pouco fidedigna em determinar o = passado de=20 toxoplasmose. Por isto, a hip=F3tese dessa doen=E7a deve ser = lembrada em todos=20 os processos febris ou adenomeg=E1licos que acometem a gestante.=20 Linfoadenomegalia, febre e mal-estar, juntos =E0 hist=F3ria de = contato com=20 felinos, manuseio de terra ou carne crua (sem prote=E7=E3o com = luvas), s=E3o=20 altera=E7=F5es sugestivas de contamina=E7=E3o pelo TG.

O exame f=EDsico pode confirmar os dados da = anamnese, mas,=20 pela baixa especificidade desses dados, o exame sorol=F3gico =E9 = necess=E1rio=20 para fechar o diagn=F3stico.

Laboratorial

A imunofluoresc=EAncia (Elisa) e = hemoglutina=E7=E3o s=E3o os testes=20 utilizados para diagn=F3stico. O Elisa =E9 t=E9cnica de = elei=E7=E3o para diagn=F3stico=20 tanto de fase aguda como da cr=F4nica.

Em locais onde n=E3o seja poss=EDvel a sua = realiza=E7=E3o,=20 indicam-se a imunofluoresc=EAncia indireta e a = hemaglutina=E7=E3o. A=20 combina=E7=E3o dos resultados desses dois exames permite tra=E7ar = o perfil=20 sorol=F3gico, diferenciando fase aguda de cr=F4nica

Desta forma, tem-se:

=95 Toxoplasmose aguda:

Presen=E7a de anticorpos IgM (n=E3o considerar = t=EDtulo) e=20 anticorpos

IgG em r=E1pida ascens=E3o e presen=E7a de = anticorpos IgG de baixa=20

avidez (detectados por Elisa).

Hemaglutina=E7=E3o: apresenta t=EDtulos baixos. =

74

=95 Perfil sorol=F3gico de = transi=E7=E3o:

Imunofluoresc=EAncia: IgG alto, tendendo a = diminuir.

IgM negativo.

Hemaglutina=E7=E3o: t=EDtulos altos (1/4.000, = 1/8.000 etc.).

=95 Toxoplasmose latente ou = cr=F4nica:

Imunofluoresc=EAncia: IgG negativo, com = t=EDtulos menores que=20 anteriormente.

IgM negativo.

Hemaglutina=E7=E3o: t=EDtulos baixos.

CONDUTA

Gestante com infec=E7=E3o aguda: =

Ap=F3s o diagn=F3stico da infec=E7=E3o aguda = materna,=20 independentemente da idade gestacional, iniciar espiramicina (500 = mg) 3,0=20 g/dia, via oral, divididos em 3 tomadas. Ap=F3s informar sobre os = riscos da=20 infec=E7=E3o para o feto/rec=E9m-nascido, propor o diagn=F3stico = da infec=E7=E3o=20 fetal. Lembrar que a discuss=E3o sobre a conduta futura deve ser = abordada,=20 antes de iniciado o diagn=F3stico da infec=E7=E3o fetal. Os pais = devem estar=20 conscientes e concordar com esse tipo de diagn=F3stico.

Diagn=F3stico da infec=E7=E3o fetal: =

Pode ser feito atrav=E9s da pesquisa do = microorganismo ou de=20 anticorpos contra ele no l=EDquido amni=F3tico e no sangue do = cord=E3o=20 umbilical. As possibilidades diagn=F3sticas da infec=E7=E3o fetal = pelo TG=20 dependem dos recursos financeiros e tecnol=F3gicos dispon=EDveis. = O melhor=20 exame isolado para esse diagn=F3stico =E9 a rea=E7=E3o em cadeia = da polimerase=20 (PCR) no l=EDquido amni=F3tico, que pode ser obtido a partir da = 12=AA semana de=20 gesta=E7=E3o. A pesquisa da infec=E7=E3o utilizando o sangue fetal = obtido por=20 cordocentese, ap=F3s 16=AA semana, tamb=E9m aumenta a = probabilidade diagn=F3stica,=20 mas deve ser avaliado o risco do procedimento. No sangue fetal, o = exame=20 que fornece os melhores resultados =E9 a PCR, podendo ser = complementado com=20 a pesquisa de IgM, hemograma fetal (plaquetopenia) e = inocula=E7=E3o em cobaia.=20

O exame ecogr=E1fico s=F3 diagnostica as = complica=E7=F5es tardias=20 dessa afec=E7=E3o, lideradas por microcefalia com hidrocefalia, = calcifica=E7=F5es=20 cerebrais, ascite fetal e altera=E7=F5es de ecotextura hep=E1tica = e espl=EAnica.=20

Conduta ap=F3s os Procedimentos para = Diagn=F3stico da=20 Infec=E7=E3o Fetal pelo TG:

Nos casos em que a pesquisa para identificar a = infec=E7=E3o=20 fetal pelo TG

=E9 negativa, questiona-se a validade de repeti-la = ap=F3s 4=20 semanas.

No entanto, considerando que a morbidade da = amniocentese =E9=20

75

relativamente baixa e que a especificidade da PCR = neste=20 fluido =E9 elevada, teoricamente, justifica-se repetir essa = pesquisa. Manter=20 a espiramicina nas doses recomendadas anteriormente at=E9 que se = tenha o=20 diagn=F3stico definitivo.

Se o feto est=E1 acometido, instituir o tratamento = tr=EDplice=20 materno (pirimetamina, 25 mg de 12/12 horas por via oral; = sulfadiazina, 3=20 g/dia,

via oral, divididas em duas tomadas e =E1cido = fol=EDnico, 10=20 mg/dia).

O tratamento tr=EDplice alterna com espiramicina = por um=20 per=EDodo de

3 semanas, at=E9 o termo. Interromper o uso de = sulfadiazina 2=20 semanas antes do parto.

1.3. Mal=E1ria =

A ocorr=EAncia da mal=E1ria na gesta=E7=E3o n=E3o = consta nas=20 estatisticas, mas =E9 comum nas =E1reas end=EAmicas, nos estados = de Rond=F4nia,=20 Par=E1 e Mato Grosso.

A mal=E1ria na gravidez pode levar a aborto, = prematuridade,=20 baixo peso, anemia megalobl=E1stica, mortalidade perinatal e = materna. As=20 complica=E7=F5es s=E3o mais importantes em primigestas; casos com = sintomas=20 cl=EDnicos exacerbados e parasitemia elevada.

Na gesta=E7=E3o, tem sido encontrada uma = depress=E3o imunit=E1ria do=20 componente humoral, contribuindo para o aumento das = manifesta=E7=F5es cl=EDnicas=20 e gravidade da doen=E7a.

S=E3o comuns as les=F5es placent=E1rias com a = presen=E7a de=20 parasitos e pigmento mal=E1ricos, mas a infec=E7=E3o cong=EAnita = ocorre em 0,3%=20 dos casos de regi=F5es n=E3o-end=EAmicas, ou at=E9 1% a 4% dos = casos de regi=F5es=20 end=EAmicas.

DIAGN=D3STICO

Anamnese:

_ proced=EAncia da paciente (zona end=EAmica ou = n=E3o);

_ per=EDodo de incuba=E7=E3o da doen=E7a (em = m=E9dia 12 _ 14 dias);=20

_ modo de transmiss=E3o (exposi=E7=E3o =E0 picada = de mosquitos,=20 hemotransfus=E3o, uso de seringas comunit=E1rias);

_ febre de car=E1ter intermitente ou parox=EDstica = (a cada 48 ou=20 72 horas).

76

Formas Cl=EDnicas:

Forma

Leve

Febre baixa

Cefal=E9ia

N=E1useas

Mal-estar geral

Parasitemia baixa

Anemia leve

Forma

Moderada

Febre alta a cada 48/72 horas

Calafrios (15 a 60 minutos)

Calor (2 a 6 horas)

Sudorese profusa

Cansa=E7o, cefal=E9ia

N=E1useas e v=F4mitos

Parasitemia (0,1 a 0,5% das Hem=E1ceas)

Anemia moderada

Hepatoesplenomegalia

Forma

Grave

Febre persistente, n=E3o muito elevada

N=E3o h=E1 calafrios

N=E3o h=E1 sudorese

Cefal=E9ia intensa

V=F4mitos freq=FCentes

Pode ter del=EDrio

Dor generalizada por

todo corpo

Parasitemia de 2% das hem=E1ceas

Anemia grave

Hepatoesplenomegalia

Forma de

Urg=EAncia

Febre alta

Cefal=E9ia intensa

V=F4mitos persistentes

Olig=FAria/an=FAria

Icter=EDcia

Hepatoesplenomegalia

Obnubila=E7=E3o

Taquipn=E9ia

Anemia Intensa (50% da

taxa de hemoglobina)

Parasitemia (maior que 2%

e pode alcan=E7ar 30%

das hem=E1cias)

Associa=E7=E3o a complica=E7=F5es

Diagn=F3stico Diferencial

Febre Tif=F3ide Esquistossomose Mans=F4nica

Febre Amarela Abscesso Amebiano Hep=E1tico

Hepatite Infecciosa Leptospirose

Calazar Tuberculose Miliar

Leucoses Salmonelose Septicemia

Meningites Septicemia

Dengue Encefalite Viral

Infec=E7=E3o Puerperal Infec=E7=E3o Urin=E1ria = Alta

Aborto Infectado

Laboratorial

=C9 realizado atrav=E9s do exame espec=EDfico = (gota espessa e=20 esfrega=E7o corado por Giemsa), que al=E9m de requerer pessoal = t=E9cnico bem=20 treinado na identifica=E7=E3o e diferencia=E7=E3o das esp=E9cies = do parasita,=20 oferece baixa sensibilidade, mesmo nos casos sintom=E1ticos _ = 51,7%. Nos=20 casos assintom=E1ticos ou em tratamento a sensibilidade =E9 muito = baixa. Em=20 alguns servi=E7os pode ser encontrado o exame direto com pr=E9via=20 centrifuga=E7=E3o QBC (quantidade buffly coat), que tem = sensibilidade de=20 73,7%. Entre os testes sorol=F3gicos, o mais sens=EDvel =E9 o de=20 imunofluoresc=EAncia indireta, com sensibilidade de 75,3%. =

77

Tratamento Antimal=E1rico na Gesta=E7=E3o

Mal=E1ria Vivax

Droga Dose Via* Dura=E7=E3o Efeitos = Manuten=E7=E3o

Colaterais (evitar reca=EDdas)

Cloroquina 10 mg kg Infus=E3o Dose N=E1useas 300 = mg/sem

Base no 1=BA dia Venosa =DAnica V=F4mitos Em dose = =FAnica

Lenta Di=E1ria Cefal=E9ia V.O., at=E9 final

5 mg/kg no ou por Vis=E3o turva da gesta=E7=E3o =

2=BA e 3=BA dias Sonda Hipertens=E3o

Nasog=E1s- Prurido

trica Desconforto

*Os casos leves s=E3o tratados por VIA ORAL (mesma = dosagem).=20

Obs.: Intoxica=E7=E3o aguda por Cloroquina = _ Coma,=20 convuls=F5es, arritmias e hipotens=E3o.

Mal=E1ria Falciparum _ N=E3o Grave

Droga Dose Via Dura=E7=E3o Efeitos

Colaterais

Sulfato de 8 - 10mg/kg por Via Oral 7 dias = Cinchonismo

Quinino dose, de 8/8 horas N=E1useas

(Qualquer Zumbidos

IG) 10mg/kg por Via Oral 3 dias Cefal=E9ia

+ dose, de 8/8 horas Vis=E3o turva

Clindamicina Perda da

(Qualquer Audi=E7=E3o

IG) Intranq=FCilidade

Hipoglicemia

Diarr=E9ia (colite

pseudomem-

branosa)

Meofloquina 15mg / kg Via Oral Dose N=E1useas

Base =DAnica Dor abdominal

(ap=F3s o Vertigem

1=BA trimestre Cefal=E9ia

da gesta=E7=E3o) Vis=E3o turva

Hipotens=E3o

Diarr=E9ia

Arritmia

Sinusal assimet.

Bradicardia

Sinusal

Obs.:

=95 1 comprimido de Quinino =3D 500 mg

=95 1 comprimido de Clindamicina =3D 150 mg

=95 A Mefloquina tem sido usada para tratamento de = todos os=20 tipos de mal=E1ria, mas s=F3 est=E1 dispon=EDvel em comprimidos. =

Intoxica=E7=E3o = por Mefloquina=20 _ Psicose aguda, encefalopatia transit=F3ria com convuls=F5es. =

78

Tratamento Antimal=E1rico na Gesta=E7=E3o

Mal=E1ria Falciparum _ Grave

Droga Dose Via Dura=E7=E3o Efeitos

Colaterais

Artesunato 1mg/kg EV 4 doses: Praticamente

(Qualquer por dose 1=AA dose, sem efeitos

idade seguida colaterais

gestacional) 10 mg/kg EV de outras (purido, dist. =

+ por dose, ap=F3s 4 horas, gastrointes-

Clindamicina de 8/8 horas 24 e 48 horas tinais e =

(Qualquer hipotens=E3o)

idade 7 dias Diarr=E9ia

gestacional)

Obs.:

=95 N=E3o se disp=F5e de estudos suficientes sobre = a inocuidade do=20 uso de derivados da artemisina em gestantes, mas alguns trabalhos = mostram=20 aus=EAncia de efeitos colaterais para o feto e RN.

=95 O artesunato E.V. deve ser dilu=EDdo em 20 a = 50 ml de=20 solu=E7=E3o glicosada, por dose e pode ser substitu=EDda por = ARTEMETHER I.M (1,6=20 mg / kg, por dose) =E0 0, 12, 24, 48, 72 e 96 horas.

=95 Pode-se usar o Sulfato de Quinino (dilu=EDdo = em soro=20 glicosado na propor=E7=E3o de 1:1 e infundido em 4 horas) durante = tr=EAs dias,=20 associado a clindamicina (7 dias) por via endovenosa, nos casos = graves de=20 M. falciparum.

Conduta Obst=E9trica: a via de parto deve = obedecer=20

indica=E7=E3o obst=E9trica.

Recomenda=E7=F5es

_ A primaquina (8 _ aminoquinole=EDna) est=E1 = contra-indicada=20 por levar =E0 hem=F3lise fetal.

_ A pesquisa de hematozo=E1rios deve ser di=E1ria = at=E9 a=20 negativa=E7=E3o no sangue perif=E9rico.

_ Ocorrendo resist=EAncia medicamentosa, = recomenda-se o=20 tratamento com clindamicina 300 mg/12/12 horas por 5 dias.

_ O =E1cido f=F3lico deve ser administrado = simultaneamente em=20 qualquer tipo de tratamento antimal=E1rico e a paciente informada = dos riscos=20 potenciais.

_ =C9 comum o abandono do tratamento = medicamentoso, ap=F3s o=20 cessar dos sintomas depois do 3=BA dia de medica=E7=E3o. = Entretanto, a paciente=20 deve ser orientada da import=E2ncia da resist=EAncia medicamentosa = e poss=EDveis=20 recidivas.

_ O controle do = tratamento da=20 mal=E1ria na gravidez dever=E1 ser realizado no 15=BA e = 30=BA dia ap=F3s a alta.

79

1.4. Hansen=EDase =

A hansen=EDase =E9 uma doen=E7a cr=F4nica = causada pelo=20 Mycobacterium leprae, parasita intracelular obrigat=F3rio que = apresenta=20 afinidade por c=E9lulas cut=E2neas e por c=E9lulas dos nervos = perif=E9ricos.=20 Esse bacilo tem capacidade de infectar grande n=FAmero de = indiv=EDduos,=20 por=E9m poucos adoecem dada a sua baixa patogenicidade. Apesar = disso, o=20 poder imunog=EAnico do Mycobacterium leprae =E9 respons=E1vel pelo = alto=20 potencial incapacitante de hansen=EDase, o que permite afirmar que = o bacilo=20 =E9 de alta infectividade. O domic=EDlio =E9 apontado como = importante espa=E7o de=20 transmiss=E3o da doen=E7a.

A principal via de elimina=E7=E3o dos bacilos = s=E3o as vias a=E9reas=20 superiores, sendo o trato respirat=F3rio a mais prov=E1vel porta = de entrada do=20 Mycobacterium leprae no corpo. O trato respirat=F3rio superior dos = pacientes=20 multibacilares (virchowianos e dimorfos), =E9 a principal fonte do = agente=20 encontrado no meio ambiente. N=E3o se pode deixar de mencionar a=20 possibilidade de penetra=E7=E3o do bacilo pela pele com = solu=E7=E3o de=20 continuidade.

A hansen=EDase apresenta longo per=EDodo de = incuba=E7=E3o: de dois a=20 sete anos. H=E1 refer=EAncia a per=EDodos mais curtos, de sete = meses como,=20 tamb=E9m, de mais de dez anos.

=C9 freq=FCente os primeiros sinais da = hansen=EDase=20 manifestaram-se na gesta=E7=E3o, como tamb=E9m recidivas e = rea=E7=F5es. As=20 altera=E7=F5es hormonais de gravidez causam deple=E7=E3o da = imunidade celular,=20 fundamental na defesa contra o bacilo.

A gesta=E7=E3o nas mulheres portadoras de = hansen=EDase tende a=20 apresentar poucas complica=E7=F5es, exceto a anemia, comum em = doen=E7as=20 cr=F4nicas. H=E1 na literatura, registros de associa=E7=E3o entre = baixo peso e=20 hansen=EDase.

DIAGN=D3STICO

O diagn=F3stico e tratamento imp=F5em a ado=E7=E3o = da classifica=E7=E3o=20 operacional, baseada no n=FAmero de les=F5es:

ALTERA=C7=C3O ESPESSAMENTO N=BA DE BACILOSCOPIA = CLASSIFICA=C7=C3O=20

NA PELE DOS NERVOS LES=D5ES

=95 Diminui=E7=E3o ou Aus=EAncia ou At=E9 5 = Negativa Paucibacilar=20 (formas

aus=EAncia de 1 tronco nervoso indeterminada e =

sensibilidade espessado tubercul=F3ide)

=95 Mancha

=95 Placa

=95 Diminui=E7=E3o ou Mais de 1 tronco Mais de 5 = Positiva=20 Multibacilar (formas

aus=EAncia de nervoso espessado dimorfia e

sensibilidade virchowiana)

=95 Mancha

=95 Placa

=95 Tub=E9rculo ou

n=F3dulo

=95 Infiltra=E7=E3o =

80

CONDUTA

A gravidez e/ou aleitamento materno n=E3o = contra-indicam a=20 administra=E7=E3o dos esquemas de tratamento da hansen=EDase=20 (poliquimioterapia). Algumas drogas s=E3o excretadas pelo leite, = por=E9m sem=20 efeitos adversos, exceto a hiperpigmenta=E7=E3o da crian=E7a pela = clofazimina,=20 com regress=E3o gradual ap=F3s um ano. A paciente ser=E1 = encaminhada ao Programa=20 de Hansen=EDase.

Os esquemas de poliquimioterapia s=E3o seguros, = tanto para a=20 m=E3e como para a crian=E7a.

Esquema Poliquimioterapia (PQT/OMS) =

PAUCIBACILAR MULTIBACILAR

DROGA

PQT/PB - 6 ROM PQT/MG - 24 PQT/MB - 12

DOSES DOSES DOSES =

600 mg dose =FAnica supervi-sionada

RIFAMPICINA

(RFM)

DAPSONA

(DDS)

CLOFAZIMINA

(CGZ)

MINOCICLINA

(MINO)

OFLOXACINA

(OFLO)

Seguimento

dos

casos

600 mg uma vez por m=EAs supervisionada uma vez = por m=EAs num=20 total de 12 doses em at=E9 18 meses.

100 mg uma

vez ao dia,

auto-dministrada.

300 mg uma vez por m=EAs supervisionada num total = de 12 doses=20 em at=E9 18 meses + 100 mg em dias alternados ou 50 mg di=E1rios=20 auto-administrada.

Comparecimentos mensais para a medica=E7=E3o = su-pervisionada num=20 total de 12 doses mensais.

Revis=E3o dermato-neurol=F3gica na 6=AA e 12=AA = doses.

Para alta, aplicar os crit=E9rios de cura. =

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600 mg uma vez por m=EAs supervisionada num todal = de 6 doses=20 em at=E9 9 meses.

100 mg uma vez ao dia, auto-administrada

Comparecimentos mensais para a medica=E7=E3o = super-visionada num=20 total de 6 doses.

Revis=E3o derma-toneurol=F3gica na 6=AA dose.

Para alta, aplicar os crit=E9rios de cura. =

600 mg uma vez por m=EAs supervisionada uma vez = por m=EAs num=20 total de 24 doses em at=E9 36 meses.

100 mg uma vez ao dia, auto-administrada

300 mg uma vez por m=EAs supervisionada num total = de 24 doses=20 em at=E9 36 meses + 100 mg em dias alternados ou 50 mg di=E1rios=20 auto-administrada.

100 mg administrada em dose =FAnica supervisionada =

400 mg administrada em dose =FAnica supervisionada =

Comparecimentos mensais para a medica=E7=E3o = supervisionada num=20 total de 24 doses mensais.

Revis=E3o dermatoneurol=F3gica nas 12=AA e 24=AA = doses.

Para alta, aplicar os crit=E9rios de cura. =

Crit=E9rio de Cura

A paciente obt=E9m alta por cura ao completar as = doses=20 preconizadas, n=E3o necessitando ficar sob vigil=E2ncia do = servi=E7o de sa=FAde.=20 Pacientes da forma paucibacilar far=E3o 6 doses de PQT/OMS em = at=E9 9 meses de=20 tratamento e aqueles tratados com esquema ROM far=E3o dose = =FAnica. Pacientes=20 da forma multibacilar far=E3o 24 doses de PQT/OMS em at=E9 36 = meses, ou 12=20 doses em at=E9 18 meses no caso do esquema de curta dura=E7=E3o. =

Rea=E7=F5es Hansen=EDacas

Rea=E7=F5es hansen=EDacas s=E3o intercorr=EAncias = agudas que podem=20 ocorrer na hansen=EDase, por manifesta=E7=F5es do sistema = imunol=F3gico. Aparecem=20 no in=EDcio da doen=E7a, durante o tratamento e ap=F3s a alta por = cura, n=E3o=20 sendo recomendada a suspens=E3o ou rein=EDcio do tratamento = espec=EDfico de=20 hansen=EDase.

Pode ocorrer tanto nos casos paucibacilares como = nos=20 multibacilares. A paciente pode acrescentar novas les=F5es = (manchas ou=20 placas), dor e espessamento dos nervos/neurites, altera=E7=F5es de = cor e edema=20 das les=F5es antigas.

O tratamento das rea=E7=F5es =E9 feito com os=20 antiinflamat=F3rios,

corticoster=F3ides e talidomida. A talidomida = =E9 totalmente=20 proibida

para mulheres gestantes por seus efeitos = teratog=EAnicos.=20

1.5. Rub=E9ola =

O v=EDrus da rub=E9ola apresenta elevada = toxicidade para tecidos=20 embrion=E1rios, notadamente no in=EDcio da embriog=EAnese,

causando a s=EDndrome da rub=E9ola cong=EAnita = (microftalmia,

cardiopatia, altera=E7=F5es auditivas e retardo = mental).=20 Entretanto,

existe a possibilidade tanto de acomentimento = isolado de=20 =F3rg=E3os

(n=E3o configurando a s=EDndrome completa) como a = s=EDndrome

de rub=E9ola cong=EAnita ampliada (entre outras = altera=E7=F5es,

miocardite, hepatite, p=FArpura, altera=E7=F5es = =F3sseas, retardo de=20

crescimento intra-uterino e =F3bito). Na tabela a = seguir est=E3o=20 representados

os percentuais m=E9dios das complica=E7=F5es = estruturais graves da=20

rub=E9ola cong=EAnita de acordo com o per=EDodo = gestacional em que=20 ocorreu a infec=E7=E3o prim=E1ria materna.

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Infec=E7=E3o

Materna Percentuais M=E9dios de Acometimento = Fetal Grave=20

(m=EAs)

1=BA 10 _ 40%

2=BA 20 _ 25%

3=BA 10 _ 20%

4=BA 6 _ 7%

5=BA 0,5 _ 1%

DIAGN=D3STICO

Cl=EDnico

Nas pacientes que exibem manifesta=E7=F5es = cl=EDnicas, essas s=E3o=20 lideradas por exantema maculopapular centr=EDfugo, que surge 2 a 3 = semanas=20 ap=F3s a contamina=E7=E3o, durando at=E9 5 dias. Nesse per=EDodo = pode haver=20 febr=EDcula e adenomegalia, principalmente na regi=E3o cervical. = Artralgias=20 est=E3o presentes em 30% _ 40% dos casos. O per=EDodo prodr=F4mico = =E9 marcado=20 pela presen=E7a de mal-estar, febr=EDcula, cefal=E9ia e ardor = conjuntival. Deve=20 ser lembrado que uma semana antes da fase exantem=E1tica o v=EDrus = j=E1 est=E1=20 sendo eliminado na orofaringe.

Laboratorial

A dosagem da IgM antiv=EDrus da rub=E9ola, aferida = pelo m=E9todo=20 Elisa confirma o diagn=F3stico da fase aguda da rub=E9ola. Passa a = ser=20 detect=E1vel por tempo vari=E1vel, no soro materno, mas o seu pico = =E9 em torno=20 de 1 a 2 semanas ap=F3s o exantema. A presen=E7a de IgG nessas = condi=E7=F5es, n=E3o=20 ajuda no diagn=F3stico.

Caso a primeira dosagem de IgM seja negativa, nos = casos=20 suspeitos deve ser repetida 15 dias ap=F3s.

O hemograma ajuda no diagn=F3stico diferencial da = rub=E9ola com=20 infec=E7=E3o bacteriana, pois como toda infec=E7=E3o viral, o = aumento de gl=F3bulos=20 brancos se faz =E0 custa de linf=F3citos.

CONDUTA

Gestante IgG (+)

A gestante com IgG antiv=EDrus da rub=E9ola = positiva significa=20 contato

pr=E9vio com esse v=EDrus. Nessa situa=E7=E3o, o = risco de=20 transmiss=E3o vertical

=E9 m=EDnimo.

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Gestante IgG (-)

Sorologia IgG negativa para rub=E9ola indica = gestante=20 suscept=EDvel. A conduta para essas mulheres =E9 de aten=E7=E3o = diferenciada=20 quanto a evitar o contato com pessoas contaminadas pelo v=EDrus da = rub=E9ola.=20 No puerp=E9rio essas pacientes devem ser orientadas para = vacina=E7=E3o.

Gestante com Infec=E7=E3o Aguda

Aferir corretamente o per=EDodo de viremia em = rela=E7=E3o =E0 idade=20 gestacional desse evento cl=EDnico e informar aos familiares sobre = o=20 progn=F3stico perinatal baseado nos percentuais de acometimento = fetal=20 contidos na tabela anterior; encaminhar a paciente para = diagn=F3stico da=20 infec=E7=E3o fetal em local apropriado de refer=EAncia.

Diagn=F3stico da Infec=E7=E3o Fetal =

O diagn=F3stico da infec=E7=E3o fetal pelo v=EDrus = da rub=E9ola pode=20 ser feito utilizando a pesquisa direta do microorganismo (ou de = seus=20 fragmentos) e/ou de anticorpos contra ele. A PCR (Rea=E7=E3o em = Cadeia da=20 Polimerase) pode ser usada nas amostras de vilo corial = (bi=F3psia), l=EDquido=20 amni=F3tico (amniocentese) e sangue fetal (cordocentese). No = sangue fetal,=20 al=E9m da PCR, podem ser pesquisados IgM (ap=F3s 16 semanas de = gesta=E7=E3o) e=20 hemograma fetal.

Ap=F3s os Procedimentos Diagn=F3sticos Invasivos = da Infec=E7=E3o=20 Fetal

em pacientes que apresentam o fator Rh negativo, = deve-se=20 administrar a imunoglobulina anti-Rh. Se os exames confirmam o = diagn=F3stico=20 da infec=E7=E3o fetal, a situa=E7=E3o deve ser discutida com os = pais com base no=20 per=EDodo gestacional em que o diagn=F3stico =E9 realizado.

1.6. = Citomegalia

Tamb=E9m chamada doen=E7a de inclus=E3o = citomeg=E1lica, =E9=20 causada por um herpev=EDrus, cuja replica=E7=E3o se faz no = interior do n=FAcleo=20 na forma de inclus=E3o. Surge, como conseq=FC=EAncia, = gigantismo do=20 n=FAcleo e citoplasma, originando-se da=ED o nome da doen=E7a. = A preval=EAncia=20 =E9 maior em pa=EDses subdesenvolvidos.

A citomegalia transmite-se a partir do contato com = fluidos=20 biol=F3gicos infectados. A transmiss=E3o vertical =E9 freq=FCente = (0,5% a 2%),=20 podendo tamb=E9m ocorrer atrav=E9s do canal de parto ou, ao = rec=E9m-nascido,=20 pelo leite materno.

A infec=E7=E3o prim=E1ria atinge o feto em cerca = de 35% de todos=20

os casos, nos quais podem ocorrer malforma=E7=F5es = (microcefal=E9ia, calcifica=E7=E3o, hepato-esplenomegalia, = hidropisia, retardo=20 psicomotor, trombocitopenia). Abortamentos, partos prematuros e = retardo de=20 crescimento fetal s=E3o de ocorr=EAncia freq=FCente, e a = mortalidade

perinatal =E9 alta, em torno de 50%. Podem surgir = complica=E7=F5es=20 tardias,

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como d=E9ficit mental e motor, surdez, atrofia = =F3ptica e=20 cegueira, espasticidade motora, etc.

Ap=F3s o quadro prim=E1rio, o v=EDrus permance = inativo no=20 organismo, podendo ser reativado em situa=E7=F5es de exce=E7=E3o = (imunodepress=E3o,=20 por exemplo).

DIAGN=D3STICO

Materno

O quadro cl=EDnico (por vezes semelhante ao da = mononucleose) e=20 a exposi=E7=E3o da gestante casual ou por profiss=E3o (sa=FAde, = professoras, etc.)=20 leva =E0 suspei=E7=E3o da doen=E7a.

Laboratorialmente s=E3o realizados os testes Elisa = e de=20 imunofluoresc=EAncia, com pesquisa de anticorpos da classe IgM = para=20 diagn=F3stico de infec=E7=E3o aguda. No entanto, deve ser lembrado = que, embora a=20 maioria dos rec=E9m-nascidos com manifesta=E7=E3o de infec=E7=E3o = cong=EAnita ao=20 nascimento nas=E7a de m=E3es com infec=E7=E3o aguda, pode ocorrer = infec=E7=E3o fetal=20 mesmo quando as m=E3es j=E1 apresentavam evid=EAncias = sorol=F3gicas de infec=E7=E3o=20 pr=E9via.

Fetal

A ultra-sonografia e proped=EAutica invasiva = (amniocentese e=20 cordocentese) s=E3o os m=E9todos utilizados para diagn=F3stico = fetal, embora n=E3o=20 exista uma padroniza=E7=E3o de consenso sobre o diagn=F3stico = fetal de=20 citomegalovirose.

CONDUTA

Os antivirais para infec=E7=E3o por = citomegalov=EDrus n=E3o devem=20 ser utilizados pela gr=E1vida, pela aus=EAncia de comprova=E7=E3o = dos riscos=20 fetais.

1.7. Doen=E7as = sexualmente=20 transmiss=EDveis

Considerando a exist=EAncia de normas = espec=EDficas (Manual de=20 Controle das Doen=E7as Sexualmente Transmiss=EDveis _ DST, do = Minist=E9rio da=20 Sa=FAde (CN-DST/AIDS _ 3=AA edi=E7=E3o, 1999), ser=E3o abordadas = apenas as mais=20 relevantes na gravidez.

1.7.1. S=EDfilis =

A s=EDfilis cong=EAnita =E9 considerada = verdadeiro evento=20 marcador da qualidade de assist=EAncia =E0 sa=FAde materno-fetal, = pela=20 simplicidade diagn=F3stica e f=E1cil manejo = cl=EDnico/terap=EAutico.

Apesar da subnotifica=E7=E3o, a taxa conhecida de = mortalidade=20 por s=EDfilis cong=EAnita no Brasil variou de 70 a 100 por = milh=E3o de nascidos=20 vivos, no per=EDodo de 1979 a 1990, e estima-se em 40% a = mortalidade=20 perinatal.

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A infec=E7=E3o do feto estaria na depend=EAncia do = estado da=20 doen=E7a na gestante; ou seja, quanto mais recente a infec=E7=E3o = materna, mais=20 treponemas est=E3o circulantes e, portanto, mais grave ser=E1 o=20 comprometimento fetal. O risco de acometimento fetal varia de 70% = a 100%,=20 dependendo da fase de infec=E7=E3o na gestante e do trimestre da = gesta=E7=E3o.=20 Essas considera=E7=F5es justificam a necessidade de testar, = sistematicamente,=20 no m=EDnimo duas vezes na gesta=E7=E3o (in=EDcio do pr=E9-natal e = 30=AA semana), e no=20 momento de sua interna=E7=E3o hospitalar (seja para o parto ou = para curetagem=20 uterina por aborto). A realiza=E7=E3o do teste para s=EDfilis = (VDRL, RPR) no=20 in=EDcio do 3=BA trimestre (28=AA - 30=AA semanas) permite o = tratamento materno=20 at=E9 30 dias antes do parto, intervalo m=EDnimo necess=E1rio para = que o=20 rec=E9m-nascido seja considerado tratado intra-=FAtero.

Classifica-se em:

_ S=EDfilis adquirida recente (com menos de um ano = de=20 evolu=E7=E3o): prim=E1ria, secund=E1ria e latente recente;

_ S=EDfilis adquirida tardia (com mais de um ano = de evolu=E7=E3o:=20 latente

tardia e terci=E1ria);

_ S=EDfilis cong=EAnita (consultar a norma = t=E9cnica de s=EDfilis=20 cong=EAnita do MS)

DIAGN=D3STICO

O diagn=F3stico na fase prim=E1ria =E9 cl=EDnico e = dado pela=20 identifica=E7=E3o do cancro duro. Esse sinal, quando localizado = internamente=20 (vagina, colo do =FAtero), pode passar desapercebido na mulher. Na = fase=20 secund=E1ria, o

diagn=F3stico cl=EDnico =E9 dado por = erup=E7=F5es cut=E2neas=20 generalizadas (ros=E9olas sifil=EDticas) e pelo condiloma plano = (les=F5es=20 elevadas, papulosas e circulares

altamente contagiosas, localizadas nos genitais = e regi=E3o=20 perianal).

Na fase terci=E1ria, a les=E3o =E9 a goma = sifil=EDtica.

Na gesta=E7=E3o, alguns dados cl=EDnicos sugerem a = possibilidade=20 de s=EDfilis: abortamento tardio (a partir do 4=BA = m=EAs),=20 natimortos, hidropsia fetal e parto prematuro.

O diagn=F3stico laboratorial =E9 realizado pelo = VDRL (Venereal=20 Disease Research Laboratory), RPR (Rapid Plasm Reagin) e o FTA-Abs = (Fluorescent Treponema Antigen Absorbent).

O VDRL, teste de diagn=F3stico mais utilizado, = torna-se=20 reativo a partir da segunda semana depois do aparecimento do = cancro=20 (s=EDfilis prim=E1ria) e, em geral, est=E1 mais elevado na fase = secund=E1ria da=20 doen=E7a. Os t=EDtulos tendem =E0 redu=E7=E3o a partir do primeiro = ano de evolu=E7=E3o=20 da doen=E7a, podendo permanecer baixos por longos per=EDodos ou = at=E9 por toda a=20 vida; =E9 o que se denomina "mem=F3ria" ou "cicatriz" = sorol=F3gica. Assim,=20 t=EDtulos baixos podem representar doen=E7a muito recente ou muito = antiga,=20 tratada ou n=E3o. Essa d=FAvida =E9 esclarecida pela anamnese, = exame f=EDsico e=20 realiza=E7=E3o de provas de sorologia trepon=EAmica espec=EDfica, = FTA-Abs.

86

A imunofluoresc=EAncia com o FTA-Abs, sendo um = exame=20 qualitativo, =E9 importante para a confirma=E7=E3o da = infec=E7=E3o, n=E3o se prestando=20 para seu acompanhamento.

CONDUTA

_ S=EDfilis prim=E1ria: Penicilina Benzatina 2.4 = milh=F5es U.I.,=20 via intramuscular, em dose =FAnica (1.2 milh=E3o V.I. em cada = gl=FAteo).

_ S=EDfilis recente secund=E1ria e latente: = Penicilina Benzatina=20 2.4 milh=F5es U.I., via intramuscular, repetida ap=F3s 1 semana. = Dose total de=20 4.8 milh=F5es U.I.

_ S=EDfilis tardia (latente e terci=E1ria): = Penicilina Benzatina=20 2.4 milh=F5es U.I., intramuscular, semanal, por 3 semanas. Dose = total de 7.2=20 milh=F5es U.I.

Ap=F3s a dose terap=EAutica inicial, em alguns = casos, poder=E1=20 surgir a rea=E7=E3o febril de Jarisch _ Herxheimer, com = exacerba=E7=E3o das les=F5es=20 cut=E2neas, geralmente exigindo apenas cuidados sintom=E1ticos; = ocorre=20 involu=E7=E3o espont=E2nea em 12 a 48 horas. N=E3o se justifica a = interrup=E7=E3o do=20 esquema terap=EAutico.

RECOMENDA=C7=D5ES

_ O parceiro deve sempre ser testado e tratado. =

_ As gestantes tratadas requerem seguimento = sorol=F3gico=20 quantitativo mensal durante a gesta=E7=E3o, devendo ser novamente = tratadas,=20 mesmo na aus=EAncia de sintomas, se n=E3o houver resposta ou se = houver aumento=20 de, pelo menos, duas dilui=E7=F5es na titula=E7=E3o do =FAltimo = t=EDtulo do VDRL (ex.:=20 de 1/2 para 1/8).

_ As gestantes com hist=F3ria comprovada de = alergia =E0=20 penicilina (evento raro no caso da penicilina benzatina) devem ser = tratadas com eritromicina na forma de estearato, 500 mg. V.O, de = 6/6=20 horas, por 15 dias para a s=EDfilis recente, e por 30 dias para a = s=EDfilis=20 tardia. O uso dessa droga exige estreita vigil=E2ncia, pela menor = efic=E1cia,=20 e o feto n=E3o deve ser considerado tratado.

_ Para fins operacionais, recomenda-se que os = casos de=20 s=EDfilis latente, com per=EDodo de evolu=E7=E3o desconhecido, e = as portadoras do=20 HIV sejam tratados como s=EDfilis latente tardia.

_ Portadoras do HIV podem ter a hist=F3ria natural = da s=EDfilis=20 modificada, desenvolvendo neuross=EDfilis mais precoce e = facilmente; nesses=20 casos, =E9 indicada a pun=E7=E3o lombar para que se possa definir = o esquema=20 terap=EAutico mais apropriado.

_ As pacientes com manifesta=E7=F5es = neurol=F3gicas e=20 cardiovasculares devem ser hospitalizadas e receber esquemas = especiais de=20 penicilinoterapia.

_ Notifica=E7=E3o da s=EDfilis materna pelo SINAN. =

_ Considerar a associa=E7=E3o entre as DST e a = infec=E7=E3o pelo=20 HIV. Fazer o aconselhamento pr=E9-teste e oferecer a = realiza=E7=E3o de sorologia=20

anti-HIV.

87

_ Orientar a absten=E7=E3o das rela=E7=F5es = sexuais at=E9 a conclus=E3o=20 do tratamento e o desaparecimento dos sintomas (quando presentes); = n=E3o=20 sendo poss=EDvel, orientar o uso do preservativo, que deve ser = mantido ap=F3s=20 o tratamento, em todas as rela=E7=F5es sexuais.

1.7.2. Hepatites B e = C=20

Do ponto de vista epidemiol=F3gico, a = transmiss=E3o sexual de=20 agentes infecciosos causadores de hepatite ocorre mais = freq=FCentemente

com os v=EDrus das hepatites tipo A, B, C e Delta. = Os tipos B=20 (v=EDrus da hepatite B _ HBV) e C (v=EDrus da hepatite C _ HCV) = podem evoluir=20

para doen=E7a hep=E1tica cr=F4nica, e associam-se = com carcinoma=20 hepatocelular prim=E1rio.

Embora os m=E9todos empregados para preven=E7=E3o = de outras DST=20

tamb=E9m sirvam para a infec=E7=E3o pelo HBV, a = vacina=E7=E3o ainda=20

=E9 o m=E9todo mais eficaz de preven=E7=E3o dessa = infec=E7=E3o. A=20 gravidez

e a lacta=E7=E3o n=E3o s=E3o contra-indica=E7=E3o = para a utiliza=E7=E3o de=20 vacina.

N=E3o sendo poss=EDvel pesquisa rotineira no = pr=E9-natal, a=20 sorologia

pode ser solicitada para as gestantes consideradas = de risco.=20

Nas gestantes com sorologia positiva, a ces=E1rea = parece n=E3o=20

reduzir a transmiss=E3o vertical do HBV. No caso = de parto=20 vaginal,

deve-se evitar, tanto quanto poss=EDvel, o contato = do sangue=20 materno

com a crian=E7a, procedendo-se clampeamento = precoce do cord=E3o=20 umbilical e aspira=E7=E3o das vias =E1reas superiores do = rec=E9m-nascido.

Para a profilaxia da infec=E7=E3o do = rec=E9m-nascido, este deve=20 receber a primeira dose da vacina, e tamb=E9m a gamaglobulina = hiperimune,=20 logo ap=F3s o nascimento, preferencialmente nas primeiras 12 horas = de vida.=20 (Para mais informa=E7=F5es, consultar o Manual de Controle das =

Doen=E7as Sexualmente Transmiss=EDveis _ DST, do = Minist=E9rio da=20

Sa=FAde _ 3=AA edi=E7=E3o, 1999, p. 104-109).

1.7.3. Infec=E7=E3o pelo = HIV=20

No Brasil, a soropreval=EAncia da infec=E7=E3o = pelo HIV, entre as=20 gestantes testadas, foi de 0,9%, em outubro de 1998.

Estima-se que sem qualquer interven=E7=E3o 15% a = 30% das=20 crian=E7as nascidas de m=E3es soropositivas para o HIV adquirem o = v=EDrus na=20 gesta=E7=E3o ou durante o trabalho de parto ou parto, ou atrav=E9s = da=20 amamenta=E7=E3o. H=E1 evid=EAncias de que a maioria dos casos de = transmiss=E3o=20 vertical do HIV ocorre mais tardiamente na gesta=E7=E3o, durante o = trabalho de=20

parto e no parto.

Um dos maiores avan=E7os na preven=E7=E3o da = transmiss=E3o vertical=20 do HIV foi demonstrado no estudo multic=EAntrico realizado nos = Estados=20 Unidos e na Fran=E7a, em gestantes que n=E3o amamentaram, o qual = mostrou a=20 redu=E7=E3o de aproximadamente 70% com o uso do AZT na = gesta=E7=E3o, parto e no=20 rec=E9m-nascido (Protocolo ACTG 076).

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DIAGN=D3STICO

_ O diagn=F3stico do HIV na gesta=E7=E3o = possibilita os melhores=20 resultados em rela=E7=E3o =E0 transmiss=E3o vertical, = constituindo-se na=20 interven=E7=E3o mais eficaz, visando garantir a erradica=E7=E3o do = HIV neonatal.=20 Para tanto, =E9 fundamental uma maior ades=E3o _ dos profissionais = de sa=FAde e=20 das usu=E1rias _ na detec=E7=E3o, aumentando o n=FAmero de = gestantes testadas.=20 A identifica=E7=E3o de gestantes soropositivas para o HIV =E9 = fundamental=20 para um acompanhamento adequado no ciclo grav=EDdico-puerperal e = no per=EDodo=20 neonatal.

_ Oferecer o teste anti-HIV a toda gestante, com=20 aconselhamento pr=E9 e p=F3s-teste, independentemente da = situa=E7=E3o de risco da=20 mulher para a infec=E7=E3o pelo HIV. O teste deve ser sempre = volunt=E1rio e=20 confidencial.

FLUXOGRAMA PARA DETEC=C7=C3O DE ANTICORPOS = ANTI-HIV EM=20

INDIV=CDDUOS COM IDADE ACIMA DE 2 ANOS =

(Portaria n=BA 488, de 17/06/98, Minist=E9rio da = Sa=FAde/

Secretaria de Vigil=E2ncia Sanit=E1ria, D.O. da = Uni=E3o, Se=E7=E3o=20 1, p. 3).

89

Obs.: para mais detalhes, consultar Anexo 3. =

CONDUTA

Cl=EDnica

a) Esquema Posol=F3gico AZT

Na gestante

AZT _ c=E1psulas de 100 mg via oral

A partir da 14=AA semana at=E9 o parto.

Dose di=E1ria:

_ 500 mg divididos em 5 doses di=E1rias de 100 mg = ou

_ 600 mg divididos em 3 doses di=E1rias de 200 mg = ou

_ 600 mg divididos em 2 doses di=E1rias de 300 mg = (este=20 esquema facilita a ades=E3o ao tratamento).

Na parturiente

AZT injet=E1vel _ frasco ampola de 200 mg com = 20 ml (10=20 mg/ml)

_ A parturiente deve receber AZT endovenoso,=20 independentemente do trabalho de parto e do clampeamento do = cord=E3o=20 umbilical

_ Iniciar a infus=E3o, em acesso venoso = individualizado, com 2=20 mg/kg na primeira hora, seguindo infus=E3o cont=EDnua com 1 = mg/kg/hora at=E9 o=20 clampeamento do cord=E3o umbilical. Diluir em soro glicosado a 5% = e gotejar=20 conforme tabela abaixo. A concentra=E7=E3o n=E3o deve exceder a 4 = mg/ml.

PREPARA=C7=C3O DO AZT PARA INFUS=C3O = INTRAVENOSA

EM 100 ML DE SORO GLICOSADO A 5%

Peso da Paciente

40 Kg 50 Kg 60 Kg 70 Kg 80 Kg 90 Kg

ATAQUE (2 mg /Kg) Quantidade 8 ml 10 ml 12 ml 14 = ml 16 ml 18=20 ml

de AZT

Ocorrer na primeira hora N=FAmero 36 37 37 38 39 = 39

gotas/min gotas/ gotas/ gotas/ gotas/ gotas/ = gotas/

min. min. min. min. min. min.

MANUTEN=C7=C3O Quantidade 4 ml 5 ml 6 ml 7 ml 8 ml = 9 ml

(1 mg/Kg) de AZT

Ocorrer a cada hora N=FAmero 35 35 35 36 36 36 =

Gotas/min. gotas/ gotas/ gotas/ gotas/ gotas/ = gotas/

min. min. min. min. min. min.

Observa=E7=E3o:

AZT ORAL _ esquema = alternativo:=20 Recomenda-se para uso em situa=E7=F5es de n=E3o disponibilidade do = AZT injet=E1vel=20 no momento do parto.

90

300 mg no come=E7o do trabalho de parto e, a = partir de ent=E3o,=20 300 mg a cada 3 horas at=E9 clampeamento do cord=E3o umbilical. =

No rec=E9m-nascido

AZT _ solu=E7=E3o oral 10 mg/ml

_ Iniciar at=E9 24 horas ap=F3s o parto = (preferencialmente at=E9 a=20 8=AA hora), na dose de 2 mg/kg a cada 6 horas, durante 6 semanas. =

_ Excepcionalmente, quando o RN n=E3o tiver = condi=E7=F5es de=20 receber o medicamento por via oral, deve ser utilizado o AZT = injet=E1vel, na=20 mesma dose do esquema recomendado acima.

_ A dose de AZT apropriada para RN prematuros = abaixo de 34=20 semanas de gesta=E7=E3o ainda n=E3o est=E1 definida, por=E9m = sugere-se utilizar 1.5=20 ml/kg a cada 12 horas VO ou IV, nas primeiras duas semanas, e 2 = mg/kg a=20 cada 8 horas por mais 4 semanas; nas crian=E7as acima de 34 = semanas, a=20 farmacocin=E9tica do medicamento =E9 semelhante =E0 das crian=E7as = de termo.

b) Recomenda=E7=F5es Cl=EDnicas

_ Estabelecer durante o pr=E9-natal o = acompanhamento conjunto=20 da gestante por infectologista ou cl=EDnico experiente no manejo = de=20 pacientes infectadas pelo HIV.

_ Sempre que poss=EDvel, antes de iniciar o uso do = AZT,=20 submeter a gestante =E0 contagem de linf=F3citos CD4 e medida da = carga viral,=20 para melhor avalia=E7=E3o do esquema terap=EAutico e da = necessidade de=20 quimioprofilaxias para infec=E7=F5es oportunistas

_ O AZT deve fazer parte de qualquer esquema = terap=EAutico que=20 venha a ser adotado para a gestante portadora do HIV, j=E1 que = este=20 medicamento =E9 o =FAnico anti-retroviral com efic=E1cia = comprovada na redu=E7=E3o=20 da transmiss=E3o vertical do HIV, al=E9m de n=E3o apresentar = efeitos adversos no=20 rec=E9m-nascido que contra-indiquem seu uso.

_ Oferecer AZT oral a toda gestante infectada pelo = HIV,=20 independentemente do n=EDvel de CD4, carga viral, estado cl=EDnico = ou uso=20 concomitante de outros anti-retrovirais, devendo o tratamento ser = iniciado=20 a partir da 14=AA semana da gesta=E7=E3o at=E9 o parto, com = reavalia=E7=E3o do=20 tratamento no p=F3s-parto. Quando a oportunidade acima for = perdida, o=20 tratamento com AZT dever=E1 ser iniciado em qualquer idade = gestacional,=20 inclusive no momento do parto.

_ Monitorar a gestante com hemograma e = transaminases no=20 in=EDcio do tratamento com AZT e, a seguir, a cada m=EAs. Frente = =E0 ocorr=EAncia=20 de efeitos adversos (anemia, neutropenia, leucopenia, n=E1useas, = v=F4mitos,=20

91

astenia, mal-estar geral, cefal=E9ia, miopatia, = ins=F4nia,=20 pigmenta=E7=E3o ungueal, altera=E7=E3o das provas hep=E1ticas), = reavaliar a conduta.=20

_ As mulheres que j=E1 vinham recebendo = anti-retroviral=20 previamente =E0 gesta=E7=E3o devem ser informadas sobre os = potenciais=20 riscos/benef=EDcios da manuten=E7=E3o, modifica=E7=E3o ou = suspens=E3o do tratamento no=20 tocante =E0 evolu=E7=E3o da sua pr=F3pria doen=E7a, devendo = tamb=E9m ser considerados=20 os potenciais efeitos adversos da terap=EAutica anti-retroviral = sobre a=20 crian=E7a. As condutas dever=E3o ser decididas caso a caso, em = conjunto com a=20 gestante.

_ Gestantes infectadas pelo HIV, com CD4 menor do = que 500=20 c=E9lulas/mm3, carga viral elevada ou que sejam = sintom=E1ticas,=20 poder=E3o receber terapia anti-retroviral combinada, inclusive = inibidores de=20 protease, a crit=E9rio m=E9dico, de acordo com as = recomenda=E7=F5es para Terapia=20 Anti-Retroviral em adultos e adolescentes contidas no documento de = consenso. (Documento dispon=EDvel nas Coordena=E7=F5es do Programa = Estadual e=20 Municipal de DST/AIDS).

_ Mesmo as mulheres que n=E3o receberam AZT oral = durante a=20 gesta=E7=E3o devem receber AZT injet=E1vel durante o trabalho de = parto e parto,=20 at=E9 o clampeamento precoce do cord=E3o.

_ Oferecer AZT solu=E7=E3o oral ao RN. Essa = terapia deve=20 iniciar-se o mais precoce poss=EDvel nas primeiras 24 horas ap=F3s = o parto, e=20 ser mantida at=E9 a 6=AA semana de vida, mesmo que as m=E3es n=E3o = tenham recebido=20 AZT durante a gesta=E7=E3o e parto.

_ As mulheres infectadas devem ser informadas e = aconselhadas=20 sobre o risco de transmiss=E3o do HIV durante a amamenta=E7=E3o e = orientadas=20 quanto ao uso de substitutos do leite materno, ou, quando = dispon=EDvel, o=20 uso de leite de bancos de leite credenciados pelo Minist=E9rio da = Sa=FAde.=20 Nenhuma crian=E7a deve receber aleitamento cruzado (leite de outra = mulher).=20 (Consulte o folheto informativo do Minist=E9rio da Sa=FAde sobre = as=20 orienta=E7=F5es para a alimenta=E7=E3o das crian=E7as nascidas de = mulheres=20 infectadas pelo HIV).

Obst=E9trica

a) Via de parto

_ Evid=EAncias sugerem que a maioria dos casos de = transmiss=E3o=20 vertical ocorre tardiamente na gravidez, em torno do momento do = parto,=20 sugerindo que o per=EDodo mais apropriado para intervir, reduzindo = o risco=20 da infec=E7=E3o vertical, seja o final da gesta=E7=E3o.

_ Estudos recentes mostram que o parto ces=E1reo, = quando=20 realizado de forma eletiva, ou seja, estando as membranas = =EDntegras e sem=20 ter o trabalho de parto iniciado, contribui para a redu=E7=E3o da = transmiss=E3o=20 vertical do HIV. N=E3o h=E1, entretanto, dados consensuais quanto = a morbidade=20 e mortalidade materna ao se adotar essa conduta.

92

_ Recomenda-se que os servi=E7os tenham por regra, = inicialmente, avaliar conjuntamente com a paciente quanto aos=20 riscos/benef=EDcios do parto cir=FArgico. Uma vez decidido pela = ces=E1rea=20 eletiva, as seguintes considera=E7=F5es devem ser observadas:

_ a confirma=E7=E3o da idade gestacional =E9 = obrigat=F3ria, para=20 prevenir a prematuridade iatrog=EAnica,

_ ces=E1reas eletivas devem sempre ser planejadas = e executadas=20 em condi=E7=F5es adequadas para reduzir os riscos de morbidade = materna e=20 perinatal. Os servi=E7os ambulatoriais de alto risco devem = estabelecer uma=20 rotina, em acordo com as maternidades de refer=EAncia, para a = realiza=E7=E3o do=20 parto em dia e hora previamente estabelecidos pelas equipes. No = hor=E1rio da=20 interna=E7=E3o, deve ser previsto o tempo necess=E1rio para a = administra=E7=E3o=20 pr=E9via do AZT, no m=EDnimo de 4 horas, considerando que a = meia-vida=20 intracelular do medicamento =E9 de 3 horas.

_ Considerar a utiliza=E7=E3o de antibi=F3tico = profilaxia, com=20 cefalosporina de segunda gera=E7=E3o, administrada em dose =FAnica = no momento do=20 clampeamento do cord=E3o umbilical.

b) Recomenda=E7=F5es Obst=E9tricas

_ N=E3o h=E1 necessidade em isolar a paciente = portadora do HIV.=20

_ Evitar que as gestantes portadoras de HIV = permane=E7am com=20 bolsa rota por mais de 4 horas, ou em trabalho de parto = prolongado.

_ Contra indicam-se os procedimentos invasivos = durante a=20 gesta=E7=E3o, trabalho de parto e parto (amniocentese, = amniotomia).

_ No parto vaginal, evitar a episiotomia (pelo = sangramento,=20 biosseguran=E7a).

_ Realizar o clampeamento imediato do cord=E3o = umbilical.

_ Aspirar delicadamente as vias a=E9reas do = rec=E9m-nascido,=20 evitando traumatismos em mucosas.

_ Imediatamente ap=F3s o parto, lavar o = rec=E9m-nascido com =E1gua=20 e sab=E3o.

_ Orientar a gestante quanto ao preparo dos = substitutos do=20 leite materno. A pu=E9rpera dever=E1 ser medicada para suspender a = lacta=E7=E3o=20 logo ap=F3s o parto e ser orientada quanto aos cuidados que = dever=E1 ter com=20 suas mamas. A inibi=E7=E3o da lacta=E7=E3o pode ser conseguida = simplesmente com=20 compress=E3o das mamas com atadura, imediatamente ap=F3s o parto, = sem=20 restringir os movimentos respirat=F3rios e causar desconforto = materno, sem=20 apertar. No entanto, alguns casos requerem a=E7=E3o medicamentosa, = que pode=20 ser conseguida com o Benzo-ginoestril AP (hexadrobenzoato de = estradiol), 2=20 amps. de 5 mg (1 ml); ou o Dopergin (hidrogenomaleato de lisurida) = 0,2 mg,=20 1 comprimido pela manh=E3 e 1 =E0 noite, por 14 dias, ou com o = Parlodel=20

93

(bromocriptina) comprimido de 1,25 mg, na dose = total de =BD=20 comprimido pela manh=E3 e =BD comprimido =E0 noite.

_ Ao receber alta no puerp=E9rio, a mulher deve = ser orientada=20 quanto =E0 import=E2ncia do acompanhamento cl=EDnico dela e da = crian=E7a. O=20 acompanhamento cl=EDnico da mulher deve incluir: o retorno para = avalia=E7=E3o=20 cl=EDnico-obst=E9trica no 8=BA e no 40=BA dia p=F3s parto; = encaminhamento para=20 servi=E7o de infectologia para seguimento cl=EDnico do seu estado = de infec=E7=E3o=20 pelo HIV; reavalia=E7=E3o da necessidade de manuten=E7=E3o ou = n=E3o da terapia=20 anti-retroviral, e encaminhamento a um servi=E7o de planejamento = familiar.=20

_ Orientar gestante/pu=E9rpera quanto ao uso de = preservativo=20 em todas as rela=E7=F5es sexuais.

_ O parceiro deve sempre ser aconselhado e = testado.

(Para mais informa=E7=F5es, consultar = "Recomenda=E7=F5es para=20 preven=E7=E3o da transmiss=E3o vertical do HIV" do Minist=E9rio da = Sa=FAde).

1.7.4. Infec=E7=E3o pelo = PapilomaV=EDrus=20 Humano - HPV

Doen=E7a infecciosa, tamb=E9m conhecida como = condiloma=20 acuminado, verruga genital ou crista-de-galo, tem por agente = causal um=20 DNA-v=EDrus, o Papilomav=EDrus humano (HPV). De transmiss=E3o = freq=FCentemente=20 sexual,

s=E3o atualmente conhecidos mais de 70 tipos, 20 = dos quais=20 podem infectar o trato genital. Est=E3o divididos em tr=EAs = grupos, de acordo=20 com seu potencial de oncogenicidade. Os tipos de alto risco = oncog=EAnico,=20 quando associados a outros co-fatores, t=EAm rela=E7=E3o com o = desenvolvimento=20 das neoplasias intra-epiteliais e do c=E2ncer invasor do colo = uterino.

Na gesta=E7=E3o, as les=F5es condilomatosas = poder=E3o atingir=20 grandes propor=E7=F5es, seja pelo aumento da vasculariza=E7=E3o, = seja pelas=20 altera=E7=F5es hormonais e imunol=F3gicas que ocorrem nesse = per=EDodo. Como as=20 les=F5es durante a gesta=E7=E3o podem proliferar e tornar-se = fri=E1veis, muitos=20 especialistas indicam sua remo=E7=E3o nessa fase. A remo=E7=E3o = das pequenas=20 les=F5es deve ser realizada com a aplica=E7=E3o t=F3pica de = =E1cido tricloro-ac=E9tico=20 (concentra=E7=F5es vari=E1veis de 50% a 90%), protegendo as = =E1reas sadias. Para=20 les=F5es grandes, usa-se a recec=E7=E3o por = eletrocauteriza=E7=E3o, sob analgesia.=20 Est=E1 contra-indicado o uso da Podofilina e 20 _ 5 fluoracil. = =C9=20 obrigat=F3ria a pesquisa de HPV no parceiro.

N=E3o est=E1 estabelecido o valor preventivo da = opera=E7=E3o

cesariana, portanto esta n=E3o deve ser realizada, = baseando-se=20

apenas na preven=E7=E3o da transmiss=E3o do HPV = para o=20 rec=E9m-nascido. Apenas em raros casos, quando as les=F5es est=E3o = causando=20 obstru=E7=E3o

do canal de parto ou quando o parto vaginal possa = ocasionar=20 sangramento excessivo, a opera=E7=E3o cesariana poder=E1 ser = indicada.

94

(Para mais informa=E7=F5es, consultar o Manual de = Controle das=20

Doen=E7as Sexualmente Transmiss=EDveis _ DST, do = Minist=E9rio da=20 Sa=FAde _

3=AA edi=E7=E3o, 1999).

1. 7. 5. Herpes simples = v=EDrus=20 (HSV)

A ocorr=EAncia de herpes na gravidez =E9 comum, = sendo mais=20 importante se for primo-infec=E7=E3o. O risco de contamina=E7=E3o = fetal =E9 pequeno,=20 sendo maior no momento da passagem no canal de parto, mesmo na = forma=20 assintom=E1tica.

O diagn=F3stico =E9 basicamente cl=EDnico. Nos = servi=E7os onde=20 houver disponibilidade, pode ser utilizado o citodiagn=F3stico de = Tzanck.=20

A conduta cl=EDnica, na primo-infec=E7=E3o indica = o uso do=20 Aciclovir 400 mg VO de 8/8 horas por 7 a 10 dias.

A indica=E7=E3o da via de parto =E9 obst=E9trica, = exceto na presen=E7a=20 de les=F5es herp=E9ticas ativas, onde est=E1 indicada via alta. = Essa conduta=20 perde seus benef=EDcios quando a bolsa est=E1 rota h=E1 mais de 4 = horas.

RECOMENDA=C7=C3O

Na paciente HIV positiva =E9 recomendado manter a = medica=E7=E3o=20 at=E9 a resolu=E7=E3o cl=EDnica do quadro em raz=E3o da = infec=E7=E3o ser mais prolongada=20 e grave.

1.7.6. Vaginose = bacteriana=20

A vaginose bacteriana =E9 caracterizada por = desequil=EDbrio da=20 flora vaginal normal pelo aumento exagerado de bact=E9rias = (Gardnerella=20 vaginalis, Bacteroides sp, Mobiluncus sp, micoplasmas,=20 peptoestreptococos). Esse aumento =E9 associado =E0 aus=EAncia ou = diminui=E7=E3o=20 acentuada dos lactobacilos acid=F3filos, que, normalmente, s=E3o = os agentes=20 predominantes da flora vaginal normal. A vaginose bacteriana =E9 = causa=20 freq=FCente de infec=E7=E3o vaginal (10% - 25%),

e mesmo assintom=E1tica tem sido associada a = fen=F4menos=20 adversos

na gravidez e puerp=E9rio. Entre essas = conseq=FC=EAncias,=20 incluem-se a

rotura prematura de membranas, o trabalho de parto = prematuro, o parto prematuro e a infec=E7=E3o puerperal.

DIAGN=D3STICO

Encontram-se, geralmente:

_ Corrimento vaginal com odor f=E9tido, mais = acentuado depois=20 do coito e no per=EDodo menstrual;

_ Corrimento vaginal acinzentado, de aspecto = cremoso,=20 algumas vezes bolhoso;

95

_ Dor =E0s rela=E7=F5es sexuais (pouco = freq=FCente);

_ Embora o corrimento seja o sintoma mais = freq=FCente, quase a=20 metade das mulheres com vaginose bacteriana =E9 completamente = assintom=E1tica.=20

O diagn=F3stico da vaginose bacteriana confirma-se = quando=20 estiverem presentes tr=EAs dos seguintes crit=E9rios, ou apenas os = dois=20 =FAltimos:

_ Corrimento vaginal, conforme descri=E7=E3o = anterior;

_ pH da secre=E7=E3o vaginal, que =E9 sempre maior = que 4,5;

_ Teste das aminas positivo (algumas aminas s=E3o = produzidas=20 pela flora bacteriana vaginal, particularmente pelos germes = anaer=F3bios.=20 Essas aminas podem ser identificadas quando o conte=FAdo vaginal = =E9 misturado=20 com 1 ou 2 gotas de KOH a 10%. Na presen=E7a de vaginose = bacteriana ocorre a=20 libera=E7=E3o de aminas com odor f=E9tido, semelhante ao odor de = peixe=20 decomposto);

_ Presen=E7a de "c=E9lulas chaves" (clue-cells): = c=E9lulas=20 epiteliais do conte=FAdo vaginal, recobertas por bact=E9rias = aderidas =E0 sua=20 superficie.

CONDUTA

O tratamento para gestantes poder=E1 ser feito com = um dos=20 esquemas abaixo:

_ Metronidazol 250 mg, VO, de 8/8 horas por 7 dias = (somente=20 ap=F3s completado o primeiro trimestre); ou

_ Metronidazol 2g, VO, dose =FAnica (somente = ap=F3s completado o=20 primeiro trimestre); ou

_ Clindamicina 300 mg, VO, de 12/12 horas por 7 = dias; ou=20

_ Metronidazol Gel 0,75%, uma aplica=E7=E3o = vaginal =E0 noite ao=20 deitar (10 g), por 7 dias.

Parceiros: na gravidez recomenda-se o tratamento = dos=20 parceiros.

RECOMENDA=C7=D5ES

_ Como medida profil=E1tica da amniorrexe e parto = prematuro,=20 recomenda-se que seja pesquisada em toda gestante, em torno da = 30=AA semana,=20 a presen=E7a de vaginose bacteriana;

_ Durante o tratamento com quaisquer dos = medicamentos=20 sugeridos acima, deve-se recomendar a n=E3o-ingest=E3o de =E1lcool = (efeito=20 antabuse, que =E9 o quadro conseq=FCente =E0 intera=E7=E3o de = derivados imidaz=F3licos=20 com =E1lcool e se caracteriza por mal-estar, n=E1useas, tonturas, = "gosto=20 met=E1lico na boca");

_ Tratamento t=F3pico =E9 indicado nos casos de = alcoolismo.=20

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As doen=E7as de transmiss=E3o sexual como as = referidas a seguir,=20 entre outras, poder=E3o ser consultadas no Manual de Controle das = Doen=E7as=20 Sexualmente Transmiss=EDveis _ DST, do Minist=E9rio da Sa=FAde = (CN-DST/AIDS _ 3=AA=20 edi=E7=E3o, 1998):

_ Infec=E7=E3o Gonoc=F3cia;

_ Infec=E7=E3o por Clam=EDdia;

_ Trichomon=EDase;

_ Candid=EDase;

_ Hepatite C.

97

H I P E R T E N S =C3 O A = R T E R I A L=20 C R =D4 N I C A ( H A C )

2

Considera-se hipertens=E3o arterial cr=F4nica a = presen=E7a de=20 n=EDveis tensionais iguais ou acima de 140 X 90 mmHg, = diagnosticada antes da=20 20=AA semana ou previamente =E0 gesta=E7=E3o.

A hipertens=E3o diagnosticada ap=F3s a 20=AA = semana merece=20 diagn=F3stico diferencial com pr=E9-ecl=E2mpsia.

Concomitante com a gravidez, associa-se com = aumento da=20 morbidade e mortalidade materna e perinatal. No Brasil associa-se = =E0=20 pr=E9-ecl=E2mpsia e ecl=E2mpsia para constitu=EDrem-se na causa = mais freq=FCente de=20 morte materna. Sua freq=FC=EAncia na gesta=E7=E3o =E9 alta, = refletindo os dados da=20 popula=E7=E3o em geral. Tamb=E9m =E9 a mais freq=FCente entre as = s=EDndromes=20 hipertensivas da gesta=E7=E3o. A hipertens=E3o arterial leva a = retardo de=20 crescimento fetal, hip=F3xia fetal e aumento da mortalidade = perinatal. Por=20 sua vez, a gravidez tende a agravar os n=EDveis tensionais, o que = pode gerar=20 complica=E7=F5es graves para a m=E3e.

DIAGN=D3STICO

O diagn=F3stico =E9 eminentemente cl=EDnico e =E9 = dado pelo achado=20 da eleva=E7=E3o dos n=EDveis tensionais.

Classifica-se como forma leve quando os valores da = press=E3o=20 diast=F3lica est=E3o abaixo de 110 mmHg, e acima deste limite = caracteriza a=20 forma grave.

Para o diagn=F3stico diferencial com = pr=E9-eclampsia pura ou=20 sobreposta, s=E3o =FAteis os dados mostrados no seguinte quadro: =

99

100

QUADRO DIFERENCIAL ENTRE AS S=CDNDROMES = HIPERTENSIVAS DA=20 GRAVIDEZ

Caracter=EDsticas HAC Pr=E9 _Ecl=E2mpsia (PE) = PE + HAC

Paridade Mult=EDpara Primigesta Mult=EDpara =

Idade Vari=E1vel Extremos da vida reprodutiva = Vari=E1vel

In=EDcio Vari=E1vel Ap=F3s 20=AA semana Ap=F3s a = 20=AA semana

(habitualmente 3=BA trimestre) (habitualmente 2=BA = trimestre)=20

Reatividade vascular Normal Aumentada Aumentada =

Hist=F3ria familiar de PE N=E3o Sim Sim

Hist=F3ria Pr=E9via HAC Sim N=E3o Sim

Aumento do =E1cido =FArico s=E9rico seriado N=E3o = Sim Sim

Protein=FAria Sim/N=E3o Sim Sim

ECG Normal/Sobrecarga VE Normal Normal/Sobrecarga = VE

Atividade antitrombina III N=E3o Diminui=E7=E3o = Diminu=EDda

Fundoscopia Vari=E1vel Vasoespasmo Vari=E1vel

PA Diast=F3lica Vari=E1vel Vari=E1vel > 110 = mmHg

Ritmo circadiano Mantido Mantido Alterado =

CONDUTA

A conduta na HAC durante a gravidez deve ser=20 individualizada,

baseada em duas vari=E1veis: gravidade da doen=E7a = e idade=20 gestacional.

No atendimento pr=E9-natal recomendam-se:

_ Repouso relativo

_ Dieta: normoss=F3dica

_ Corre=E7=E3o dos desvios nutricionais: = (obesidade e=20 desnutri=E7=E3o)

_ Acompanhamento psicol=F3gico

_ Exames laboratoriais rotineiros, mais os = espec=EDficos para=20 a doen=E7a: fun=E7=E3o renal; protein=FAria 24 h; urocultura; = oftalmoscopia; ECG=20 etc.

_ Avalia=E7=E3o da vitalidade fetal a partir de = 34=AA semanas, ou=20 antes, se houver necessidade.

_ V=E1rias drogas podem ser usadas e recomendam-se = as=20 seguintes dosagens:

DOSAGEM

DROGAS M=CDNIMA M=C1XIMA

Alfa-metildopa 750 mg 2,0 g

Pindolol 10 mg 30 mg

Hidralazina 30 mg 300 mg

Nifedipina 20 mg 60 mg

Obs.: est=E3o contra-indicados os hipotensores do = tipo enzima=20 de convers=E3o da angiotensina (ECA).

Recomenda-se tamb=E9m manter a mesma droga j=E1 = utilizada antes=20 da gravidez, se a press=E3o arterial est=E1 controlada. Deve-se = iniciar a=20 medica=E7=E3o hipotensora quando os n=EDveis tensionais = diast=F3licos forem iguais=20 ou maiores que 100 mmHg.

Nos casos de HAC grave, consultar o Manual = T=E9cnico de=20 Urg=EAncias e Emerg=EAncias Maternas.

Conduta Obst=E9trica:

Se as avalia=E7=F5es = das condi=E7=F5es=20 materno-fetais forem mantidas, deve-se aguardar o termo com parto=20 espont=E2neo ou obedecendo =E0 indica=E7=E3o obst=E9trica.

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HIPERTENS=C3O ARTERIAL CR=D4NICA LEVE (PA = dias=F3lica=20 < 100 mmgHg)

(*) Hipotensor: utilizar quando PA diast. > 100 = mmgHg=20

1 _ a metildopa

2 _ Bloqueadores

3 _ Hidralazina

4 _ Nifedipina

(**) n=E3o ultrapassar 40 semanas

(**) via de parto: indica=E7=E3o obst=E9trica =

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HIPERTENS=C3O ARTERIAL CR=D4NICA GRAVE (PA = dias=F3lica=20 > 100 mmgHg)

INTERNA=C7=C3O

* na presen=E7a de estresse emocional pode-se usar = Benzodiapin=EDcos (5 mg/dia).

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A N E M I A S =

3

Conceitua-se anemia na gravidez quando os = valores de=20 hemoglobina s=E3o iguais ou menores que 11,0 g/dl (OMS, 1974). =

No entanto, os valores de hemoglobina assim como = os do=20 hemat=F3crito e do n=FAmero total de gl=F3bulos vermelhos ficam na = depend=EAncia=20 do aumento da massa eritrocit=E1ria, ambos vari=E1veis entre as = gestantes.=20

Desta forma, =E9 interessante adotarem-se outros = crit=E9rios=20 para a conceitua=E7=E3o e para o diagn=F3stico de anemia. Os = =EDndices=20 corpusculares, principalmente o volume corpuscular m=E9dio (VCM = =3D 81 _ 95=20 dl) n=E3o sofrem varia=E7=F5es em rela=E7=E3o ao volume = plasm=E1tico e podem, ent=E3o,=20 ser tomados com tal finalidade. Para fins pr=E1ticos, tomando-se o = VCM como=20 indicador, identificam-se tr=EAs tipos de anemias: microc=EDticas = (VCM menor=20 que 85 dl), normoc=EDticas (VCM entre 81 e 95 dl) e macroc=EDticas = (VCM maior=20 que 95 dl).

O diagn=F3stico dos tipos de anemia pode ser feito = tomando-se=20 os valores de hemoglobina (Hb) < que 8,0 g/dl e do = volume=20 corpuscular m=E9dio (VCM), conforme esquema na p=E1gina 107).

3.1. AnemIa = ferropriva=20

As anemias carenciais s=E3o, de longe, as mais = freq=FCentes em=20 nosso meio, principalmente as ferroprivas, caracterizando anemia=20 microc=EDtica.

O diagn=F3stico =E9 feito basicamente pela dosagem = de=20 hemoglobina

(< 11mg/dl) e pelo valor do volume corpuscular = m=E9dio=20 (VCM) diminuido (Microc=EDtica).

A conduta visa =E0 corre=E7=E3o dos d=E9ficits, o = que se consegue=20 por meio da orienta=E7=E3o alimentar e suplementa=E7=E3o de ferro. = Lembrar que=20 interessa a quantidade de ferro elementar contida no produto e = que, para=20 fins pr=E1ticos, =E9 calculada em aproximadamente 20% do total de = ferro=20 contido no sal.

3.2. Anemia = megalobl=E1stica=20

A anemia megalobl=E1stica =E9 conseq=FC=EAncia de = altera=E7=F5es na=20 s=EDntese de nucleoprote=EDnas e causadas pela aus=EAncia ou = car=EAncia de =E1cido=20 f=F3lico.

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O diagn=F3stico da anemia megalobl=E1stica tem = como=20 caracter=EDstica a diminui=E7=E3o dos valores de hemoglobina e o = aumento do VCM.=20

O tratamento consiste na orienta=E7=E3o alimentar = (ingest=E3o de=20 vegetais folhosos) e na administra=E7=E3o de cerca de 1.0 a 5.0 = mg/dia de=20 =E1cido f=F3lico. A resposta =E9 r=E1pida e a normaliza=E7=E3o dos = valores de=20 hemoglobina e da segmenta=E7=E3o de neutr=F3filos s=E3o = par=E2metros de controle.=20

3.3. Anemia = falciforme=20

A doen=E7a falciforme =E9 hemoglobinopatia = (altera=E7=F5es na cadeia=20 beta), geneticamente transmitida e caracterizada pela presen=E7a = de=20 variedade de hemoglobinas S,C. Podem ser homozigotas (SS,CC) e=20 heterozigotas (Sc, As, AC).

Os portadores de anemia falciforme frente a = fatores=20 estressantes (hipoxia, gravidez, outras doen=E7as) desencadeiam = crises=20 hemol=EDticas caracterizadas por dores abdominais, articulares, = etc.=20 causadas por microenfartos em diversos =F3rg=E3os. Surge anemia e, = eventualmente, icter=EDcia.

O diagn=F3stico =E9 feito pelo quadro cl=EDnico = (se presente) e=20 por valores de hemoglobina menores que 11 g/dl, e do volume = corpuscular=20 m=E9dio dentro da normalidade. A prova de falciza=E7=E3o informa = sobre a=20 atividade da doen=E7a.

O tratamento =E9 sintom=E1tico com analg=E9sicos; = raramente=20 necessita-se transfus=E3o de concentrado de hem=E1cias.

3.4. = Talassemias

S=E3o hemoglobinopatias que afetam as cadeias alfa = ou beta,=20 caracterizando as s=EDndromes talass=EAmicas a e b. As talassemias = alfa e beta=20 podem ser homozigotas e heterozigotas.

A talassemia alfa heterozig=F3tica pode ser = assintom=E1tica ou=20 ter quadro cl=EDnico discreto de anemia; a homozig=F3tica =E9 = grave,=20 praticamente incompat=EDvel com a vida, culminando com =F3bito = intra-uterino.=20

A talassemia beta na forma heterozig=F3tica = tamb=E9m =E9=20 assintom=E1tica e a forma homozig=F3tica, tamb=E9m dita "anemia de = Cooley", tem=20 evolu=E7=E3o grave.

O diagn=F3stico utilizando-se como par=E2metros os = valores de=20 hemoglobina

(< 11,0 g/dl) e do VCM diminu=EDdo, o = diagn=F3stico=20 diferencial com

anemia ferropriva =E9 dado pelos valores normais = do perfil de=20 ferro,

nas talassemias.

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O tratamento das s=EDndromes talass=EAmicas =E9 a = reposi=E7=E3o=20 atrav=E9s de transfus=E3o, quando necess=E1ria.

3.5. Anemia=20 microangiop=E1tica

A anemia microangiop=E1tica na gravidez =E9 = causada por=20 pr=E9-ecl=E2mpsia grave, ecl=E2mpsia, s=EDndrome HELLP, p=FArpura = trombocitop=EAnica=20 tromb=F3tica e s=EDndrome hemol=EDtico ur=EAmica.

O tratamento =E9 o do fator causal.

Diagn=F3stico e conduta nas anemias =

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E N D O C R I N O P A T I = A=20 S

4

4.1. Diabete = melito

O diabetes mellitus =E9 doen=E7a metab=F3lica = cr=F4nica,=20 caracterizada por hiperglicemia. =C9 respons=E1vel por = =EDndices elevados de=20 morbimortalidade perinatal, especialmente macrossomia fetal e = malforma=E7=F5es=20 fetais.

O diabetes mellitus associado =E0 gravidez pode = ser=20 classificado como:

Diabetes pr=E9-gestacional (inclui o diabetes = pr=E9vio =E0=20 gravidez: tipo 1, tipo 2 ou outros).

Diabetes gestacional (diagnosticado durante a = gravidez).=20

O diabetes pr=E9-gestacional requer tratamento = especializado=20 por equipe multiprofissional, visando prevenir as malforma=E7=F5es = fetais=20 associadas =E0 hiperglicemia periconcepcional e as demais

complica=E7=F5es maternas e fetais associadas =E0 = gravidez. Assim,=20

mulheres com diabetes que planejam engravidar = devem ser=20 encaminhadas para centros de aten=E7=E3o secund=E1ria ou = terci=E1ria, visando:=20 compensa=E7=E3o metab=F3lica pr=E9-concep=E7=E3o; avalia=E7=E3o da = presen=E7a de=20 complica=E7=F5es cr=F4nicas da doen=E7a; e orienta=E7=E3o = especializada para a=20 preven=E7=E3o de malforma=E7=F5es fetais, incluindo o uso = rotineiro de =E1cido=20 f=F3lico. Mulheres com diabetes que engravidaram sem esse = planejamento=20 tamb=E9m devem ser encaminhadas a servi=E7o especializado = prontamente.

Diabetes gestacional

O diabetes gestacional =E9 definido como a = "intoler=E2ncia=20 aos carboidratos, de graus variados de intensidade, diagnosticada = pela=20 primeira vez durante a gesta=E7=E3o, podendo ou n=E3o persistir = ap=F3s o parto".=20 No Brasil, a preval=EAncia do diabetes gestacional em mulheres = com mais=20 de 20 anos, atendidas no Sistema =DAnico de Sa=FAde, =E9 de 7,6% = (IC95% 6,9-8,4,=20 crit=E9rio da Organiza=E7=E3o Mundial da Sa=FAde), 94% dos casos = apresentando=20 apenas toler=E2ncia diminu=EDda =E0 glicose e 6%, hiperglicemia no = n=EDvel de=20 diabetes fora da gravidez.

DIAGN=D3STICO

Deve-se iniciar pelo rastreamento dos fatores de = risco,=20 conforme esquema a seguir:

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Esquema Recomendado para a Detec=E7=E3o de = Diabetes Mellitus=20 Gestacional

ANAMNESE:

_ Idade superior a 25 anos

_ Hist=F3ria pessoal

_ Antecedentes familiares (diabetes em parentes de = 1=BA grau)=20

_ Antecedentes obst=E9tricos:

_ Macrossomia

_ Polidr=E2mnio

_ Morte fetal (inexplicada principalmente) ou = Neonatal

_ Malforma=E7=F5es

_ Retardo do crescimento fetal

_ Exame obst=E9trico atual

_ Ganho de peso excessivo

_ Altura uterina > que a esperada

_ Crescimento fetal excessivo

_ Polidr=E2mnio

_ Exame f=EDsico:

_ Baixa estatura

_ Hipertens=E3o arterial

_ Disposi=E7=E3o central excessiva de gordura = corporal

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Gestantes que n=E3o apresentam quaisquer dos = fatores de risco=20 enumerados, s=E3o consideradas de baixo risco, n=E3o requerendo = procedimentos=20 de rastreamento do diabete gestacional.

CONDUTA

Mulheres que apresentam diabetes gestacional devem = ser=20 encaminhadas para centros de aten=E7=E3o secund=E1ria. Na = impossibilidade desse=20 encaminhamento, podem ser adotadas algumas das recomenda=E7=F5es = de entidades=20 oficiais, descritas a seguir:

a) Dieta

O tratamento inicial consiste na prescri=E7=E3o de = dieta para=20 diabetes que permita ganho adequado de peso de acordo com o estado = nutricional da gestante, avaliado pelo =EDndice de massa corporal=20 (peso/altura2) pr=E9-grav=EDdico (Tabela 1).

Tabela 1 - Ganho de peso recomendado de = acordo com o=20 =EDndice de massa pr=E9-grav=EDdico

IMC pr=E9-grav=EDdico Ganho de peso recomendado = (kg)

(kg/m2) Total Semanal*

Baixo (<19,8) 12,5 - 18 0,5

Normal (19,8 - 26) 11,5 - 16 0,4

Sobrepeso (26 - 29) 7 - 11,5 0,3

Obesidade (>29) >6,8 **

* 2o e 3o trimestres da = gravidez

** c=E1lculo deve ser individualizado

=95 Quando o =EDndice for normal, a ingest=E3o = cal=F3rica di=E1ria=20 pode ser estimada por aquela usual pr=E9-grav=EDdica, = acrescentando, a partir=20 do segundo trimestre, 300 kcal/dia.

=95 Em gestantes com sobrepeso ou obesas, pequenas = redu=E7=F5es de=20 ingest=E3o cal=F3rica podem ser recomendadas (dietas com at=E9 =

1.800 kcal/d n=E3o parecem induzir efeitos = adversos ao feto).=20

=95 Gestantes magras requerem ingest=E3o = cal=F3rica capaz de=20 prover ganho adequado de peso. A dieta deve ser fracionada em = cinco a seis=20 refei=E7=F5es di=E1rias.

=95 Carboidratos de = absor=E7=E3o=20 r=E1pida, como o a=E7=FAcar comum, quando permitidos moderadamente = a gestantes=20 com bom controle metab=F3lico, devem entrar no c=E1lculo do valor = cal=F3rico=20 total da dieta. Os ado=E7antes artificiais n=E3o cal=F3ricos podem = ser=20 utilizados, evitando-se aqueles =E0 base de sacarina.

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b) Atividade f=EDsica

A atividade f=EDsica pode fazer parte da = estrat=E9gia de=20 tratamento do diabetes gestacional. Pacientes sedent=E1rias podem = ser=20 orientadas a iniciar um programa de caminhadas regulares e/ou de=20 exerc=EDcios de flex=E3o dos bra=E7os. Gestantes que j=E1 = praticavam exerc=EDcios=20 regularmente podem mant=EA-los, evitando os de alto impacto.

c) Controle glic=EAmico

O controle glic=EAmico =E9 feito, sempre que = poss=EDvel, com=20 glicemias de jejum e p=F3s-prandiais semanais; a medida da = glicos=FAria n=E3o=20 =E9 =FAtil na monitoriza=E7=E3o do controle metab=F3lico na = gravidez. Tratamento=20 com insulina deve ser indicado se ap=F3s duas semanas de dieta os = n=EDveis=20 glic=EAmicos permanecerem elevados, jejum maior ou igual a 105 = mg/dl e 2=20 horas p=F3s-prandiais maior ou igual a 120 mg/dl. Meta de glicemia = de jejum=20 ainda mais baixa (95 mg/dl) foi recentemente recomendada pela = American=20 Diabetes Association.

O crescimento fetal exagerado (circunfer=EAncia = abdominal=20 fetal maior ou igual ao percentil 75 em ecografia obst=E9trica = realizada=20 entre 29 e 33 semanas de gesta=E7=E3o) tamb=E9m =E9 crit=E9rio = para o uso de=20 insulina.

A dose inicial de insulina deve ser em torno de = 0,3 a 0,5=20 U/kg, preferencialmente em mais de uma dose di=E1ria. Esquemas com = doses=20 m=FAltiplas de insulina e associa=E7=E3o de insulinas de a=E7=E3o = intermedi=E1ria e=20 r=E1pida s=E3o descritos em v=E1rias publica=E7=F5es e devem ser = adaptados=20 individualmente; o uso de insulinas humanas =E9 recomendado.

A monitoriza=E7=E3o domiciliar das glicemias = capilares deve ser=20 estimulada nas gestantes que usam insulina, com medidas tr=EAs a = cinco vezes=20 por dia (antes do caf=E9 da manh=E3, antes do jantar e uma ou duas = horas=20 p=F3s-prandiais). As necessidades insul=EDnicas tendem a aumentar=20 progressivamente durante a gravidez. O emprego de = antidiab=E9ticos orais=20 na gravidez =E9 contra-indicado.

d) Conduta obst=E9trica

O controle obst=E9trico =E9 o de uma gesta=E7=E3o = de risco: exame=20 obst=E9trico semanal ou a cada duas semanas, conforme a = evolu=E7=E3o cl=EDnica;=20 deve ser ao menos semanal a partir das 36 semanas. O aumento na = incid=EAncia=20 de altera=E7=F5es hipertensivas na gesta=E7=E3o com diabetes deve = promover=20 cuidados espec=EDficos para sua identifica=E7=E3o e manejo.

A avalia=E7=E3o de bem-estar fetal pode ser adiada = at=E9 as 40=20 semanas,

em gestantes tratadas apenas com dieta e que n=E3o = apresentam=20

outras intercorr=EAncias. Em gestantes que usam = insulina,=20 indicar a realiza=E7=E3o de ultra-som e cardiotocografia anteparto = a partir de=20

32-34 semanas.

e) Parto

As gestantes com =F3timo controle metab=F3lico e = sem=20 intercorr=EAncias da

112

gravidez podem aguardar a evolu=E7=E3o = espont=E2nea para o parto.=20 As gestantes tratadas apenas com dieta seguem a orienta=E7=E3o = obst=E9trica=20 habitual.

A via do parto =E9 uma decis=E3o obst=E9trica, = sendo=20 necess=E1rio estimar o peso fetal por avalia=E7=E3o cl=EDnica e = ultra-sonogr=E1fica.=20 Em trabalhos de parto com evolu=E7=E3o arrastada, reavalia=E7=E3o = das propor=E7=F5es=20 feto-p=E9lvicas deve ser feita para minimizar a ocorr=EAncia de = dist=F3cia de=20 ombro.

Gestantes em uso de insulina requerem aten=E7=E3o = especial:

1. se for programada a interrup=E7=E3o da = gesta=E7=E3o antes de 39=20 semanas, =E9 necess=E1rio realizar amniocentese para avalia=E7=E3o = da maturidade=20 pulmonar: dosagem de fosfatidilglicerol e avalia=E7=E3o da = rela=E7=E3o entre=20 lecitina e esfingomielina;

2. gestantes cujo parto =E9 programado devem = permanecer em=20 jejum e n=E3o receber a dose di=E1ria de insulina;

3. o controle da glicemia capilar deve ser feito = com=20 intervalos de hora em hora; se o controle metab=F3lico estiver bem = e=20 est=E1vel, a monitoriza=E7=E3o glic=EAmica pode ser realizada com = intervalos de 2=20 a 4 horas;

4. a infus=E3o de solu=E7=E3o de glicose a 5% =E9 = iniciada assim que=20 se estabele=E7a a fase ativa do trabalho de parto;

5. se a dose di=E1ria de insulina j=E1 tiver sido = administrada,=20 manter acesso venoso com infus=E3o cont=EDnua de solu=E7=E3o de = glicose, e=20 monitoriza=E7=E3o mais freq=FCente da glicemia capilar;

6. durante o trabalho de parto, os n=EDveis de = glicemia=20 capilar devem ser mantidos entre 70 e 110 mg/dl; para alcan=E7ar = essa meta,=20 insulina regular deve ser administrada de acordo com protocolos = vigentes;=20

7. monitoriza=E7=E3o fetal intraparto =E9 = recomendada, bem como a=20 presen=E7a de neonatologista.

f) P=F3s-parto

O aleitamento natural deve ser estimulado.

Observar os n=EDveis de glicemia nos primeiros = dias ap=F3s o=20 parto, pois a maior parte das mulheres n=E3o mais requer o uso de = insulina.=20 Seu uso estar=E1 indicado caso ocorra hiperglicemia no per=EDodo = de=20 amamenta=E7=E3o.

O estado de regula=E7=E3o da glicose dever=E1 ser = reavaliado a=20 partir de seis semanas ap=F3s o parto, empregando-se a glicemia de = jejum ou=20 o teste oral de toler=E2ncia com 75 g de glicose. A = classifica=E7=E3o do estado=20 de regula=E7=E3o da glicose =E9 feita de acordo com as categorias = diagn=F3sticas=20 vigentes.

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4.2. = Tireoidopatias

A ocorr=EAncia na gravidez =E9 de aproximadamente = 0,2%. A=20 tire=F3ide sofre adapta=E7=F5es fisiol=F3gicas durante a = gesta=E7=E3o, al=E9m do aumento=20 do volume da gl=E2ndula, ocorrendo diminui=E7=E3o do TSH no = primeiro trimestre=20 em conseq=FC=EAncia do aumento da secre=E7=E3o do HCG, e assim uma = eleva=E7=E3o=20 transit=F3ria do T4 livre. Progredindo a gesta=E7=E3o, = ocorre um=20 aumento progressivo do TSH e diminui=E7=E3o do T3 e = T4.=20

4.2.1. = Hipotireoidismo=20

A gravidez associa-se aos casos leves ou aos casos = graves=20 tratados, pois os casos graves n=E3o tratados relacionam-se =E0 = anovula=E7=E3o e=20 conseq=FCente diminui=E7=E3o da fecundidade. O hipotireoidismo = tende a=20 agravar-se durante a gesta=E7=E3o pelo aumento da tireotrofina. =

DIAGN=D3STICO

O diagn=F3stico cl=EDnico =E9 muitas vezes de = dif=EDcil realiza=E7=E3o,=20 pela superposi=E7=E3o dos sinais e sintomas da gravidez. Assim, = uma vez mais,=20 este =E9 feito com as dosagens s=E9ricas laboratoriais do T4 = livre=20 ou =EDndice de tiroxina livre associados ao TSH.

CONDUTA

O tratamento =E9 feito com tiroxina livre at=E9 a = normaliza=E7=E3o=20 dos n=EDveis do TSH. Nas mulheres j=E1 em tratamento, as = necessidades de=20 tiroxina livre aumentam em 30% a 50% durante a gravidez. O TSH = basal deve=20 estar em torno de 0,5-2,0 UI/I, e o T4 livre nos = padr=F5es da=20 normalidade ou levemente aumentado.

O hipotireoidismo n=E3o tratado pode associar-se = =E0 hipertens=E3o=20 gestacional, abortamento, anemia, baixo peso ao nascer e =F3bito = fetal

4.2.2. = Hipertireoidismo=20

A enfermidade mais associada ao hipertireoidismo = na gravidez=20 =E9 a doen=E7a de Basedow-Graves. Outras patologias s=E3o o = adenoma t=F3xico e a=20 disfun=E7=E3o tireoideana associada =E0 doen=E7a trofobl=E1stica. = Na doen=E7a=20 descompensada observa-se um aumento na incid=EAncia de abortamento = (15%),=20 parto prematuro (70%), CIUR, anomalias cong=EAnitas (10%-15%), = DHEG e=20 mortalidade perinatal (3%-15%).

DIAGN=D3STICO

O diagn=F3stico cl=EDnico =E9 dif=EDcil, exceto na = presen=E7a de um=20 quadro descompensado com f=E1cies caracter=EDsticas. Assim, o = diagn=F3stico =E9=20 laboratorial, atrav=E9s da dosagem de T4 livre ou do = =EDndice de=20 tiroxina livre.

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Os sinais de hipertireoidismo s=E3o taquicardia, = fraqueza,=20 intoler=E2ncia ao calor, diarr=E9ia e tremores, associados =E0 = ocorr=EAncia de=20 exoftalmia e b=F3cio. Esses sinais e a presen=E7a de anticorpos = org=E2nicos=20 confirmam a origem da doen=E7a de Graves, que =E9 um processo = auto-imune=20 espec=EDfico, com forma=E7=E3o de anticorpos estimuladores da = tire=F3ide. Esses=20 anticorpos tendem a diminuir durante a gravidez e aumentar = novamente no=20 per=EDodo puerperal, o que est=E1 associado ao curso mais benigno = da doen=E7a=20 durante a gesta=E7=E3o. Os anticorpos maternos podem atravessar a = placenta e=20 causar tireotoxicidade fetal ou neonatal.

conduta

O tratamento baseia-se no uso dos antitireoideanos = de=20 s=EDntese (o propiltiluracil _ PTU _ =E9 o mais usado, por sua = menor passagem=20 transplacent=E1ria e porque inibe a convers=E3o do T4 para T3). A = dose inicial=20 pode ser de 100 a 600 mg/dia (200-300 mg/dia em m=E9dia). A dose = utilizada=20 deve tentar chegar a um padr=E3o eutireoideano (o controle = laboratorial deve=20 ser realizado a cada 2 a 4 semanas) e, ap=F3s se atingir esse = padr=E3o, a=20 droga dever=E1 ser reduzida ao m=EDnimo para diminuir as = conseq=FC=EAncias para o=20 feto. Nos casos graves, deve-se associar betabloqueador para o = controle=20 dos sintomas cardiovasculares, que deve ser reduzido ou retirado = ap=F3s o=20 ajuste adequado do PTU. A tireoidectomia parcial s=F3 =E9 indicada = em casos=20 extremos.

O uso de antitireoideanos maternos pode levar a=20 hipotireoidismo cong=EAnito neonatal e, portanto, os filhos de = m=E3es=20 hipertireoideas devem ser acompanhados nesse per=EDodo. Leucopenia = transit=F3ria foi observada em usu=E1rias de PTU, por=E9m o = tratamento n=E3o deve=20 ser interrompido. Agranulocitose pode ocorrer em 0,2% das = usu=E1rias, sendo=20 indica=E7=E3o de suspens=E3o da droga.

Perda fetal =E9 descrita em 8%-12% das pacientes = n=E3o=20 controladas, bem como alta incid=EAncia de pr=E9-ecl=E2mpsia e = fal=EAncia=20 card=EDaca.

4.2.3. Crise = tireot=F3xica=20

A crise tireot=F3xica =E9 um aumento fulminante = dos sinais e=20 sintomas do hipertireoidismo descompensado, ocorrendo por falta do = diagn=F3stico ou neglig=EAncia no tratamento. Afastados os fatores = desencadeantes, concomitantemente institui-se o tratamento com: =

_ Iodeto de s=F3dio EV, 1-2 mg/dia;

_ Propranolol EV, 1-2 mg ou 40 mg VO, 6/6 horas; =

_ Propiltiouracil VO, 600-1.000 mg/dia ou = metimazol, 60-100=20 mg/dia;

_ Cuidados gerais;

A mortalidade materna nesses quadros atinge = =EDndices de 25%.=20

(Para mais detalhes, ver Manual T=E9cnico de = Urg=EAncia e=20 Emerg=EAncia.)

115

4.2.4. Carcinoma de=20 tire=F3ide

A gravidez n=E3o altera a evolu=E7=E3o do = carcinoma e nem este o=20 da gesta=E7=E3o. O tratamento cir=FArgico est=E1 indicado, n=E3o = se esquecendo da=20 substitui=E7=E3o hormonal e da contra-indica=E7=E3o formal da = terap=EAutica=20 radioativa para abla=E7=E3o da tire=F3ide.

116

C A R D I O P A T I A = S=20

5

As doen=E7as card=EDacas ocorrem em = aproximadamente 1% das=20 gesta=E7=F5es, das quais 90% s=E3o conseq=FC=EAncias de les=F5es = reum=E1ticas. Outras=20 etiologias s=E3o as cardiopatias cong=EAnitas e hipertensivas, = al=E9m das=20 arritmias, prolapso da v=E1lvula mitral, endocardites e = miocardiopatia=20 periparto. Representam, ainda hoje, uma das causas mais = freq=FCentes de=20 mortalidade materna.

Alguns dos sintomas de doen=E7a card=EDaca s=E3o: = dispn=E9ia grave=20 ou progressiva, ortopn=E9ia, dispn=E9ia parox=EDstica noturna, = hemoptise,=20 s=EDncope, dor precordial. Entre os sinais,

destacam-se: cianose, baqueteamento dos dedos, = sopros,=20 murm=FArio diast=F3lico, cardiomegalia, arritmia, desdobramento = persistente da=20 segunda bulha, hipertens=E3o pulmonar.

Classifica=E7=E3o (funcional):

_ Classe I: assintom=E1tica, sem limita=E7=E3o da = atividade=20 f=EDsica.

_ Classe II: levemente sintom=E1tica, = limita=E7=E3o aos grandes=20 esfor=E7os.

_ Classe III: moderadamente sintom=E1tica, com = limita=E7=E3o aos=20 pequenos esfor=E7os.

_ Classe IV: severamente comprometida, = sintomatologia ao=20 repouso.

Nas classes I e II, o risco de complica=E7=F5es = =E9 pequeno, podem=20 ser precipitadas por infec=E7=F5es, tabagismo e uso de coca=EDna = (tanto pelos=20 efeitos cardiovasculares como pelo risco de endocardite).

Nas classes III e IV, a mortalidade materna =E9 de = 4% a 7%. Em=20 alguns casos mais graves, pode-se considerar a possibilidade de=20 interrup=E7=E3o da gesta=E7=E3o por risco de vida materna. Se a = gesta=E7=E3o=20 prosseguir, a gestante necessitar=E1 de interna=E7=F5es = prolongadas e=20 atendimento multidisciplinar em centro de refer=EAncia.

O risco de mortalidade materna depende da = patologia de base,=20 al=E9m de sua classe funcional. Nas pacientes com hipertens=E3o = pulmonar,=20 coarcta=E7=E3o da aorta com acometimento valvar e S=EDndrome de = Marfan com=20 acometimento da aorta, a mortalidade materna pode ser de 25% a = 50%.

DIAGN=D3STICO

O diagn=F3stico, al=E9m da cl=EDnica, deve se = basear no=20 eletrocardiograma, raios-X de t=F3rax e ecocardiografia.

A descompensa=E7=E3o ocorre de maneira progressiva = e inclui o=20 aparecimento de estertores persistentes, edema progressivo, = taquicardia=20

117

e limita=E7=E3o aos esfor=E7os f=EDsicos. = Portanto, para que seja=20 diagnosticada, a gestante deve ter retornos quinzenais, se tudo = estiver=20 bem, e semanais, se houver suspeita de descompensa=E7=E3o. = Dever=E1 ser=20 internada sempre que apresentar sintomatologia exacerbada.

Com rela=E7=E3o ao feto, seu crescimento e = vitalidade devem ser=20 monitorizados, e a maturidade pulmonar estimulada com = cortic=F3ides, sempre=20 que houver necessidade de antecipa=E7=E3o prematura do parto.

CONDUTA

Cl=EDnica

No tratamento cl=EDnico, deve-se levar em conta a = rela=E7=E3o=20 risco/benef=EDcio para cada droga a ser administrada. Os = cardiot=F4nicos,=20 anti-hipertensivos e heparina podem ser utilizados sem = restri=E7=F5es, quando=20 necess=E1rio. S=E3o contra-indicados os anticoagulantes orais, = amiodarona e o=20 nitroprussiato de s=F3dio, por seus efeitos sobre o feto.

A valvuloplastia, quando indicada, tem sido = op=E7=E3o para casos=20 de estenose, com bons resultados. A troca de v=E1lvula tamb=E9m = poder=E1 ser=20 realizada para garantir a sobrevida materna.

Quando houver repouso prolongado, devem ser = prevenidas as=20 complica=E7=F5es tromboemb=F3licas, pela mobiliza=E7=E3o dos = membros e pelo uso de=20 meias el=E1sticas. O esquema de digitaliza=E7=E3o =E9 o mesmo para = as mulheres=20 n=E3o-gr=E1vidas. O uso de diur=E9ticos deve ser feito com = modera=E7=E3o, pelos=20 riscos de redu=E7=E3o excessiva do volume plasm=E1tico e = conseq=FCente d=E9ficit de=20 fluxo placent=E1rio.

Obst=E9trica

O parto pode e deve ocorrer por via vaginal, pois = a=20 morbidade materna =E9 menor. Com rela=E7=E3o =E0 analgesia de = condu=E7=E3o, o risco =E9=20 decorr=EAncia da hipotens=E3o. Em valvulopatas, deve ser realizada = profilaxia=20 da endocardite periparto.

A conduta obst=E9trica visa ao parto vaginal, = evitando-se o=20 esfor=E7o expulsivo. A cesariana s=F3 por indica=E7=E3o = obst=E9trica e deve ser=20 absoluta nas cardiopatias com hipertens=E3o pulmonar. Lembrar que = o=20 esvaziamento uterino r=E1pido na ces=E1rea pode levar =E0 = descompensa=E7=E3o=20 materna.

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P N E U M O P A T I A S=20

6

A gesta=E7=E3o associa-se a mudan=E7as mec=E2nicas = e bioqu=EDmicas que=20 podem afetar a fun=E7=E3o respirat=F3ria. Desse modo, a dispn=E9ia = na gravidez=20 pode resultar dessas altera=E7=F5es, mesmo sem pneumopatia, = estando presente=20 em 60% a 70% das gestantes. A teoria mais aceita =E9 a da = hiperventila=E7=E3o=20 com pCO2 diminu=EDda e resposta ventilat=F3ria = aumentada.

6.1. Asma

=C9 a forma mais comum de doen=E7a pulmonar = encontrada na=20 gravidez. =C9 discut=EDvel se a intensidade da asma =E9 um fator = importante para=20 prever a possibilidade da ocorr=EAncia/agravamento na = gesta=E7=E3o. Em geral,=20 n=E3o existem efeitos previs=EDveis da gravidez sobre a asma. O = controle=20 adequado da asma grave tem reduzido a mortalidade perinatal, = embora exista=20 uma correla=E7=E3o positiva entre a gravidade da doen=E7a e a = prematuridade, e o=20 baixo peso ao nascer.

CONDUTA

* prn =3D pro re nata (quando surgir a ocasi=E3o) =

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Categoria

Broncodilatadores

b-agonistas

Inalados

Subcut=E2neos

Orais

Xantinas

Agentes antiinflamat=F3rios e Corticoster=F3ides = Inalados

Orais

Cromoglicatos

Exemplos

espec=EDficos

Metaproterenol

Albuterol

Terbutalina

Pirbuterol

Adrenalina

Terbutalina

Albuterol

Terbutalina

Teofilina

(libera=E7=E3o lenta)

Beclometasona

Triacinolona

Flunisolida

Prednisona

Cromolina

Dosagem

2 baforadas 4 _ 6h prn*

0,3mL 1:1.000 s.c.

0,25mg s.c.

2 _ 4mg VO/dia

2,5 _ 5 mg VO/dia

Vari=E1vel (200 _ 500 mg/dia)

8 _ 24 baforadas/dia

Vari=E1vel (diminuir a partir da dose inicial de = 40 _ 60 mg)=20

2 baforadas dia

Coment=E1rios

Forma preferida de administra=E7=E3o de

b-agonistas

Alternativa para a administra=E7=E3o inalada para = o tratamento=20 agudo; a adrenalina =E9 idealmente evitada durante a gravidez

Raramente utilizado por causa dos efeitos = colaterais=20 sist=EAmicos

Dose ajustada para manter n=EDvel s=E9rico de

5 _ 15 mg/ml

Fazer gargarejar depois do uso para diminuir o = risco de=20 cand=EDase oral

6.2. = Pneumonias

A freq=FC=EAncia da pneumonia na gesta=E7=E3o = varia de 1 para 400=20 at=E9 1200 casos. Os fatores de risco mais significativos s=E3o: = infec=E7=E3o por=20 HIV, uso da coca=EDna, doen=E7as cl=EDnicas provocadas por fumo. =

A gravidez parece n=E3o afetar a resposta = terap=EAutica, mas a=20 escolha do antibi=F3tico deve levar em conta os efeitos adversos = no feto.=20

A pneumonia bacteriana =E9 a mais freq=FCente, em = geral por=20 causa do estreptococo pneumoniae (pneumonia pneumoc=F3cica). S=E3o = comuns a=20 febre s=FAbita com calafrios, dor tor=E1cica e tosse produtiva, = com dispn=E9ia e=20 taquipn=E9ia.

Na ausculta, encontra-se, em geral, os sinais de=20 consolida=E7=E3o localizada (estertores e macicez). Recorre-se =E0 = radiografia=20 tor=E1cica e =E0 colora=E7=E3o pelo Gram. A cultura do escarro = pode ser negativa.=20

A conduta terap=EAutica mais utilizada =E9:

=95 Penicilina 250 a 500 mg 6/6 horas ou

=95 Penicilina 1.2 a 2.4 milh=F5es EV (de 7 a 14 = dias de=20 tratamento)

Em pacientes al=E9rgicas, usar a eritromicina. =

6.3. = Tuberculose

O tratamento adequado da tuberculose ativa em = gestantes=20 confirma o mesmo bom progn=F3stico que o realizado em mulheres = n=E3o-gr=E1vidas.=20 Em mulheres com tuberculose inativa, a profilaxia com isoniazida, = em=20 geral, garante uma evolu=E7=E3o est=E1vel na gesta=E7=E3o e no = p=F3s-parto.

Entretanto, estudos indicam maior ocorr=EAncia de = aborto,=20 complica=E7=F5es gestacionais (pr=E9-ecl=E2mpsia) e trabalho de = parto dif=EDcil.=20

No diagn=F3stico, recomenda-se a prova cut=E2nea = de tuberculina.=20 Se positiva, a radiografia tor=E1cica pode ser indicada com a = devida=20 prote=E7=E3o abdominal. Como diagn=F3stico definitivo, recorre-se = =E0 prova do=20 escarro (baciloscopia).

A conduta terap=EAutica mais utilizada =E9:

=95 Isoniazida (INH) 300 mg/dia _ 9 meses

=95 Rifampicina 600 mg/dia _ 9 meses

A piridoxina deve ser acrescentada, em raz=E3o das = necessidades crescentes na gesta=E7=E3o. Em caso de suspeita de = resist=EAncia=20 medicamentosa, o etambutol (15 a 25 mg/kg/dia) deve ser = adicionado.=20

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L U P U S E R I T E M A T = O S O S I S=20 T =CA M I C O ( L E S )

7

=C9 uma doen=E7a auto-imune que pode = acometer v=E1rios=20 =F3rg=E3os e, por isso, tem as mais variadas manifesta=E7=F5es = cl=EDnicas. =C9 a mais=20 comum das doen=E7as do col=E1geno, associada =E0 gesta=E7=E3o, por = sua predomin=E2ncia=20 em mulheres na idade reprodutiva.

O LES pode passar por fase de agudiza=E7=E3o e = remiss=E3o e a sua=20 repercuss=E3o sobre a gravidez provavelmente est=E1 relacionada = com o estado=20 imunol=F3gico da mulher no per=EDodo periconcepcional. As = pacientes com doen=E7a=20 em remiss=E3o por dois anos antes da gesta=E7=E3o geralmente t=EAm = uma gravidez=20 com boa evolu=E7=E3o, enquanto as que engravidam com doen=E7a = ativa ou t=EAm a=20 doen=E7a diagnosticada durante a gesta=E7=E3o, apresentam os = piores resultados=20 gestacionais.

A possibilidade de crises de atividades nas = pacientes=20 gr=E1vidas =E9 a

mesma de pacientes n=E3o-gr=E1vidas. O risco de = ter uma crise=20 aumenta no

p=F3s-parto imediato (oito semanas ap=F3s o = parto), quando o=20 m=E9dico e a paciente devem estar atentos. A paciente pode ter um = curso=20 normal da gravidez ou pode ter partos prematuros.

N=E3o s=F3 a atividade da doen=E7a influi sobre o = resultado da=20 gesta=E7=E3o. Pacientes com acometimento renal (nefrite l=FApica) = apresentam=20 maior freq=FC=EAncia de complica=E7=F5es maternas e fetais = (pr=E9-ecl=E2mpsia,=20 ecl=E2mpsia, RCIU, sofrimento fetal cr=F4nico). Outra = complica=E7=E3o importante,=20 =E9 a associa=E7=E3o do LES com a presen=E7a de anticorpos = antifosfol=EDpides e=20 anticoagulante l=FApico, que aumentam muito a ocorr=EAncia de = perdas=20 gestacionais e fen=F4menos tromboemb=F3licos.

DIAGN=D3STICO

O diagn=F3stico =E9 baseado em crit=E9rios = cl=EDnico-laboratoriais.=20 Entre os crit=E9rios cl=EDnicos, observa-se: rush malar, lupus, = disc=F3ide,=20 fotossensibilidade, =FAlceras orais, artrite, serosite, nefrite, = altera=E7=F5es=20 neurol=F3gicas. S=E3o crit=E9rios laboratoriais, altera=E7=F5es = hematol=F3gicas,=20 imunol=F3gicas e anticorpo antinuclear. Para o diagn=F3stico de = certeza, devem=20 estar presentes quatro desses crit=E9rios.

Al=E9m disso, nas gestantes deve-se sempre estar = atento para a=20 S=EDndrome do L=FApus Neonatal, que =E9 uma s=EDndrome rara = caracterizada por=20 bloqueio card=EDaco cong=EAnito e/ou les=F5es cut=E2neas = transit=F3rias,=20 estritamente relacionadas com a passagem transplacent=E1ria de=20 auto-anticorpos maternos, particularmente antiRo/ssa e antiLa/ssb. =

121

N=E3o existem medidas preventivas para a = s=EDndrome, sendo=20 recomendado que a gesta=E7=E3o de m=E3es com auto-anticorpos = antiRo e antiLa,=20 tenham acompanhamento de freq=FC=EAncia card=EDaca fetal rigorosa. =

CONDUTA

As drogas imunossupressoras devem ser utilizadas, = pois a=20 doen=E7a em atividade =E9 mais grave que os efeitos colaterais das = drogas. A=20 prednisona =E9 a mais utilizada, podendo chegar =E0 dose de 1 a 2 = mg/kg/dia.=20 Pulsoterapia de corticoster=F3ide pode ser utilizada em casos = graves. Dos=20 imunossupressores, a droga escolhida =E9 a azatioprina, que pode = causar o=20 retardo do crescimento fetal. A ciclofosfamida deve ser evitada, = por ser=20 considerada teratog=EAnica. A cloroquina n=E3o pode ser usada, = pois est=E1=20 relacionada a malforma=E7=F5es fetais. Os antiinflamat=F3rios = n=E3o-ester=F3ides=20 podem ser utilizados em pacientes com artralgia.

Quando se associa =E0 s=EDndrome = antifosfol=EDpide, apesar de=20 ainda n=E3o haver um consenso quanto =E0 melhor terapia, o uso de = baixas doses=20 de aspirina (100 mg/d) e heparina profil=E1tica (5.000 UI 2 x/d) = associam-se=20 com melhores resultados gestacionais.

Aborto, =F3bito fetal, prematuridade, RCIU e = sofrimento fetal=20 s=E3o muito mais freq=FCentes nas gestantes portadoras de LES que = na popula=E7=E3o=20 geral. Por isso, a vitalidade fetal deve ser vigiada, e a = maturidade=20 estimulada com corticoterapia espec=EDfica. Al=E9m do bloqueio = card=EDaco, lupus=20 neonatal, anemia hemol=EDtica e trombocitopenia podem ocorrer nos = neonatos.=20

ARTRITE REUMAT=D3IDE (AR):

Tende a ocorrer melhora da patologia durante a = gesta=E7=E3o.=20 Alguns autores relatam maior ocorr=EAncia de abortos e partos = prematuro em=20 mulheres com AR, entretanto isso n=E3o =E9 um consenso.

122

S =CD N D R O M E A N T I = F O S F O L =CD=20 P I D E

8

A s=EDndrome de anticorpo antifosfol=EDpide = caracteriza-se pela=20 presen=E7a de anticorpos antifosfol=EDpides no soro de = indiv=EDduos com trombose=20 arterial

ou venosa, =F3bito fetal, abortos recorrentes ou=20 trombocitopenia. =C9 uma causa bem conhecida de = hipercoagulabilidade e tem=20 m=FAltiplas manifesta=E7=F5es, podendo ou n=E3o ser secund=E1rio a = uma doen=E7a

auto-imune.

Em obstetr=EDcia, a s=EDndrome associa-se a perdas = fetais=20 recorrentes (abortamentos ou =F3bitos fetais), com preval=EAncia = de 5% a 15%,=20 patologias placent=E1rias (vilites, vilosites, tromboses, = intervilosites),=20 doen=E7a inflamat=F3ria p=E9lvica, endometriose, antecedente de = infertilidade,=20 insucesso em tratamento de esterilidade e outras condi=E7=F5es. =

Inicialmente, a s=EDndrome foi descrita em = pacientes com=20 diagn=F3stico de lupus eritematoso sist=EAmico. No entanto, hoje = se sabe que =E9=20 mais encontrada em indiv=EDduos sem qualquer outra altera=E7=E3o = auto-imune=20 (s=EDndrome prim=E1ria). Na pr=E1tica, esta possibilidade surge = secundariamente,=20 ap=F3s a investiga=E7=E3o das causas mais comuns das = manifesta=E7=F5es apresentadas.=20 N=E3o raro, associa-se ainda a quadro at=EDpico de hipertens=E3o = arterial.

DIAGN=D3STICO

O diagn=F3stico =E9 definitivo na presen=E7a de = altos t=EDtulos de=20 anticorpos anticardiolipina, ou demais anticorpos = antifosfol=EDpides,=20 associados a duas ou mais das seguintes manifesta=E7=F5es = cl=EDnicas: perdas=20 embrion=E1rias e/ou fetais recorrentes, trombose venosa, oclus=E3o = arterial,=20 =FAlcera de membro inferior, livedo reticularis, anemia = hemol=EDtica e=20 trombocitopenia.

O diagn=F3stico laboratorial da s=EDndrome =E9 = poss=EDvel pela=20 detec=E7=E3o de anticorpos que se ligam a fosfol=EDpides ou ao = complexo=20 fosfolip=EDdeo - prote=EDna. Desses anticorpos, os mais = pesquisados na pr=E1tica=20 s=E3o a anticardiolipina e o antil=FApico dos tipos IgG e IgM, = embora existam=20 outros cuja detec=E7=E3o, no sangue ou em tecido placent=E1rio, = =E9 de mais=20 dif=EDcil realiza=E7=E3o (fosfatidil serina, fosfatidil = etanolamina, fosfatidil=20 inositol, fosfatidil glicerol e =E1cido fosfat=EDdico), ainda = n=E3o dispon=EDveis=20 na pr=E1tica cl=EDnica no Brasil.

A interpreta=E7=E3o =E9 dif=EDcil porque pode ser = positivo em=20 situa=E7=E3o de infec=E7=F5es, doen=E7as inflamat=F3rias, malignas = e induzidas por=20 drogas.

O diagn=F3stico laboratorial da s=EDndrome = antifosfol=EDpide =E9=20 mais prov=E1vel

na presen=E7a de t=EDtulos moderados e altos = (acima de 20 U) de=20 IgG

123

ou IgM anticardiolipina, expressos em unidades GPL = e MPL,=20 respectivamente.

CONDUTA

A import=E2ncia do reconhecimento dessa s=EDndrome = pelos=20 obstetras est=E1 na necessidade de tratamento durante a = gesta=E7=E3o com=20 aspirina em baixas doses (50 mg VO por dia) e heparina = subcut=E2nea,=20 procedimentos que previnem o retardo do crescimento intra-uterino = e a=20 morte fetal. Existem ainda novas propostas utilizando cortic=F3ide = e=20 imunoglobulinas, ainda n=E3o incorporadas =E0 pr=E1tica cl=EDnica = e carentes de=20 uma completa avalia=E7=E3o de efic=E1cia.

124

T R O M B O E M B O L I S = M=20 O

9

=C9 a oclus=E3o total ou parcial de uma veia = por um trombo,=20 com rea=E7=E3o inflamat=F3ria prim=E1ria ou secund=E1ria de sua = parede, sendo mais=20 freq=FCentes em membros inferiores.

Formas cl=EDnicas e incid=EAncias

_ Tromboflebite superficial: 2 - 10 / 1.000 = gesta=E7=F5es.

_ Trombose venosa profunda: 0,2 - 2 / 1.000 = gesta=E7=F5es (3 a 5=20 vezes maior no puerp=E9rio, e 3 a 16 vezes maior ap=F3s = ces=E1rea).

_ Tromboflebite p=E9lvica: 1 - 3 / 1.000 = gesta=E7=F5es (mais=20 freq=FCentes em casos de endometrite p=F3s-ces=E1rea).

A embolia pulmonar surge como complica=E7=E3o do = tromboembolismo=20 em 5/10.000 gesta=E7=F5es.

Fatores de risco:

Doen=E7a varicosa pr=E9via, idade materna = avan=E7ada, obesidade,=20 imobiliza=E7=E3o no leito e compress=E3o da musculatura da = panturrilha.

DIAGN=D3STICO

_ Anamnese

_ Exame f=EDsico: dor na panturrilha ou coxa, = aumento da=20 temperatura local, edema, deambula=E7=E3o dif=EDcil, dor =E0 = dorsiflex=E3o do p=E9=20 (sinal de Homans).

_ Ultra-sonografia Doppler: avalia a imagem da = veia, e a=20 dopplerfluxometria, as altera=E7=F5es do fluxo venoso.

CONDUTA

_ Anticoagulante: heparina =E9 o anticoagulante de = escolha na=20 gravidez. N=E3o atravessa a membrana placent=E1ria, por seu alto = peso=20 molecular.

_ Via endovenosa: cont=EDnua ou intermitente. A = administra=E7=E3o=20 cont=EDnua =E9 a prefer=EDvel (5.000 UI/IV inicialmente e, a = seguir, 1.000=20 UI/hora).

_ Via subcut=E2nea: =E9 prefer=EDvel quando se faz = necess=E1rio o=20 uso a longo prazo. Inicia-se com a dose de ataque 10.000 _ 20.000=20 unidades. Manuten=E7=E3o de 5.000 UI a cada 8 _ 12 horas. =

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_ Heparina de baixo peso molecular: cursa com = menor=20 incid=EAncia de complica=E7=F5es hemorr=E1gicas, n=E3o requerendo = monitoramento t=E3o=20 intensivo. =C9 de custo mais elevado.

_ Monitoramento: tempo de coagula=E7=E3o (TC), = tempo de=20 tromboplastina parcial ativada (TTPA), tempo de tromboplastina = parcial=20 (TTP) e contagem de plaquetas.

_ Antagonista: sulfato de protamina (cada 1 mg = antagoniza=20 100 UI de heparina circulante). O uso de anticoagulante pode ser = mantido=20 at=E9 o parto.

Derivados cumar=EDnicos: Warfarin - s=E3o = contra-indicados na=20 gesta=E7=E3o.

Atravessam a membrana placent=E1ria no primeiro = trimestre,=20 provocam malforma=E7=F5es (hipoplasia nasal, condrodisplasia e = retardo=20 mental); no segundo e no terceiro trimestres, os efeitos s=E3o = decorrentes=20 de fen=F4menos hemorr=E1gicos no feto.

Deve-se evitar o uso concomitante de aspirina,=20 antiinflamat=F3rios e antibi=F3ticos, que podem potencializar o = efeito=20 anticoagulante.

Os rec=E9m-nascidos de m=E3es que amamentam em uso = de=20 anticoagulantes orais, devem receber reposi=E7=E3o de vitamina K 1 = - 2 mg por=20 semana.

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E P I L E P S I = A

10

=C9 afec=E7=E3o neurol=F3gica mais freq=FCente na = gesta=E7=E3o,=20 calculando-se a preval=EAncia entre 0,3% a 0,5% das gr=E1vidas. =

As repercuss=F5es da gravidez sobre a epilepsia = s=E3o=20 contradit=F3rias;

alguns admitem aumento e outros, diminui=E7=E3o da = freq=FC=EAncia=20

das crises. Argumentam aqueles que relatam = aumento, que tal=20

fato se deve a fatores como insuficiente = concentra=E7=E3o=20 sangu=EDnea

do anticonvulsivante, seja por diminui=E7=E3o da = dosagem por=20

prescri=E7=E3o m=E9dica, seja pela eleva=E7=E3o do = volume plasm=E1tico,=20 provocando dilui=E7=E3o na concentra=E7=E3o circulante. Os que =

defendem a melhora do quadro convulsivo apoiam-se = na

possibilidade de maior ades=E3o ao tratamento e = maior

regularidade nas tomadas por parte das pr=F3prias = mulheres.=20

A epilepsia, em si mesma, n=E3o tem efetio = prejudicial =E0=20 gravidez. Prefere-se atribuir a poss=EDvel repercuss=E3o negativa = aos efeitos=20 dos medicamentos anticonvulsivantes, estes, sim, capazes de = provocar=20 malforma=E7=F5es, retardo de crescimento intra-uterino e partos = pr=E9-termo.=20

DIAGN=D3STICO

=C9 feito pelo quadro cl=EDnico e atrav=E9s da = anamnese na qual=20

deve-se detalhar, o melhor poss=EDvel, as = caracter=EDsticas das=20 crises

quanto ao tipo, =E9poca de in=EDcio, = freq=FC=EAncia, dura=E7=E3o, estado=20

p=F3s-convulsivo, etc.

Diante de uma crise convulsiva em gr=E1vidas, no = terceiro=20 trimestre, =E9 importante diferenci=E1-la da convuls=E3o = ecl=E2mptica.

O exame neurol=F3gico e exames complementares = (EEG)=20 pertinentes completam o diagn=F3stico.

CONDUTA

O tratamento cl=EDnico =E9 feito =E0 base de = drogas=20 anticonvulsivantes. Praticamente todos os anticonvulsivantes foram = associados

a malforma=E7=F5es. A despeito disso, os = barbit=FAricos e a

carbamazepina s=E3o os mais utilizados, e alguns=20 consideram-nos

como n=E3o-teratog=EAnicos.

A dosagem ser=E1 sempre individualizada, na = depend=EAncia da=20 freq=FC=EAncia das crises. A difenil-hidanto=EDna tem maior = risco e, por=20 isso, =E9 contra-

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indicada. Com o =E1cido valpr=F3ico e = derivados, ainda n=E3o se=20 tem experi=EAncia necess=E1ria para utiliz=E1-los com = seguran=E7a. Deve-se=20 lembrar que a monoterapia =E9 preferencial, e que a hipervolemia = da gravidez=20 pode tornar necess=E1rio o aumento da dose. A medica=E7=E3o = anticonvulsivante=20 n=E3o pode ser suspensa.

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P A R T E I I I :=20

A V A L I A =C7 =C3 = O=20

F E T A = L

A V A L I A =C7 =C3 O D A = V I T A L I D A=20 D E

1

1.1. M=E9todos cl=EDnicoS =

1.1.1. Registro di=E1rio = da=20 movimenta=E7=E3o fetal (RDMF)

A diminui=E7=E3o do movimento fetal =E9 prova = indireta de=20 insufici=EAncia placent=E1ria e interpretada como adapta=E7=E3o = fetal =E0s condi=E7=F5es=20 de balan=E7o negativo.

Assim, o registro di=E1rio de movimento fetal =E9 = o teste=20 cl=EDnico mais simples para avalia=E7=E3o das condi=E7=F5es de = vitalidade fetal.=20

METODOLOGIA

V=E1rias maneiras s=E3o propostas para a = execu=E7=E3o do RDMF.=20 Quatro s=E3o mais conhecidas:

1) Os registros s=E3o tomados em tr=EAs intervalos = de uma hora=20 de dura=E7=E3o, distribu=EDdos pelos tr=EAs per=EDodos do dia, com = a m=E3e repousando=20 em dec=FAbito lateral.

Os valores obtidos em cada um dos tr=EAs = intervalos s=E3o=20 somados, e o resultado multiplicado por quatro corresponde =E0 = atividade=20 motora fetal em 12 horas.

Diminui=E7=E3o acentuada e brusca ou = cessa=E7=E3o da movimenta=E7=E3o=20 fetal, descritas como "sinal de alarme", associam-se com = sofrimento fetal=20 e precedem de 12 a 24 horas o =F3bito fetal.

2) Contagem da movimenta=E7=E3o fetal at=E9 = complementarem-se 10=20 movimentos, valor considerado como limite m=EDnimo di=E1rio para = fins=20 cl=EDnicos.

O registro da movimenta=E7=E3o pode ser feito com = a gestante em=20 repouso, ou exercendo atividade leve, em qualquer per=EDodo do = dia.

Valores menores que 10 movimentos em 12 horas = representam=20 hip=F3xia fetal. Tamb=E9m neste caso, diminui=E7=E3o abrupta ou = cessa=E7=E3o da=20 movimenta=E7=E3o s=E3o tomadas como sinal de alarme para =F3bito = fetal=20 iminente.

3) Registro dos movimentos fetais por per=EDodo de = uma hora em=20 posi=E7=E3o sentada.

Valores maiores que seis movimentos/hora = correspondem a=20 fetos em boas condi=E7=F5es.

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4) Contagem de movimentos fetais percebidos pela = m=E3e em 2=20 horas. O registro dos movimentos devem ser feitos com a m=E3e em = repouso=20 somando 4 per=EDodos de 30 minutos em 24 horas.

Valor m=EDnimo normal entre 30 - 40 semanas =3D = 10 movimentos=20 em 24 horas.

RECOMENDA=C7=D5ES:

Alguns elementos devem ser tomados em conta para = as=20 adequadas execu=E7=E3o e interpreta=E7=E3o do registro di=E1rio da = movimenta=E7=E3o=20 fetal.

_ A m=E3e decide por si mesma o que =E9 movimento = fetal, tal=20 como ela esteja habituada a sentir.

_ Excluem-se movimentos tipos "solu=E7os", de alta = freq=FC=EAncia=20 e baixa intensidade.

_ Varia=E7=E3o nict=EAmera _ (h=E1 maior = movimenta=E7=E3o fetal nas=20 primeiras horas da noite).

_ Maior movimenta=E7=E3o nos per=EDodos = p=F3s-prandiais e com a m=E3e=20 em repouso. Recomenda-se o exame ap=F3s alimenta=E7=E3o.

_ Uso de medicamentos (sedativos, tranquilizantes) = e de=20 cigarro altera a movimenta=E7=E3o fetal.

_ Sons e ru=EDdos de intensidade elevada = interferem na=20 atividade motora do feto.

O teste, apesar de bons resultados n=E3o deve ser = considerado=20 definitivo na avalia=E7=E3o da vitalidade fetal. T=EAm excelente = indica=E7=E3o para=20 acompanhamento da vitalidade fetal, os exames cardiotocogr=E1ficos = sucessivos. Entretanto, na aus=EAncia de outros m=E9todos, = torna-se decis=F3rio=20 para conduta.

1.1.2. Prova de = acelera=E7=E3o card=EDaca=20 fetal

Consiste na verifica=E7=E3o de acelera=E7=E3o de = batimentos=20 card=EDacos fetais com sonar estetosc=F3pio de Pinard, frente =E0 = movimenta=E7=E3o=20 fetal, est=EDmulos mec=E2nicos ou auditivos.

Consiste em:

1) Determina=E7=E3o de freq=FC=EAncia card=EDaca = fetal de repouso;=20

2) Verifica=E7=E3o da freq=FC=EAncia card=EDaca = fetal (FCF) pela=20 movimenta=E7=E3o espont=E2nea fetal;

3) Na aus=EAncia de respostas (ou de = movimenta=E7=E3o fetal),=20 estimula-se mecanicamente o feto, enquanto se escutam os = batimentos=20 card=EDacos fetais (BCF);

4) Na aus=EAncia de resposta, faz-se a = estimula=E7=E3o=20 vibro-ac=FAstica (buzina de bicicleta).

Boas reservas fetais garantem a eleva=E7=E3o da = (FCF).

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1.2. M=E9todos = biof=EDsicos=20

1.2.1. Cardiotocografia = anteparto de=20 repouso

A an=E1lise cardiotocogr=E1fica possibilita a = avalia=E7=E3o da=20 integridade dos mecanismos do sistema nervoso central envolvidos = no=20 controle da freq=FC=EAncia card=EDaca e da cin=E9tica fetal.

O feto h=EDgido, pr=F3ximo do termo, apresenta = freq=FC=EAncia=20 card=EDaca est=E1vel entre 120 e 160 batimentos por minuto (bpm) e = variabilidade entre 10 e 25 bpm. Al=E9m dessas = caracter=EDsticas,=20 ocorrendo movimenta=E7=E3o, o feto exibe acelera=E7=E3o = transit=F3ria de amplitude=20 igual ou superior a 15 bpm e dura=E7=E3o superior a 15 segundos. =

Algumas situa=E7=F5es como a hip=F3xia fetal, = prematuridade, sono=20 fetal, uso de drogas sedativas, tranquilizantes e = anti-hipertensivos, al=E9m=20 de situa=E7=F5es como febre, hipoglicemia e tabagismo, modificam o = padr=E3o=20 fisiol=F3gico acima descrito.

O exame consiste no registro simult=E2neo da = freq=FC=EAncia=20 card=EDaca e dos movimentos fetais espont=E2neos, pelo menos por = 20 minutos.=20 Quando, nesse per=EDodo inicial, n=E3o se constatem, ao menos, = duas=20 acelera=E7=F5es transit=F3rias ou variabilidade diminu=EDda, ou = ainda=20 desacelera=E7=F5es, o exame deve ser prolongado por mais 20 = minutos, ap=F3s=20 estimula=E7=E3o mec=E2nica, e, se necess=E1rio, vibro-ac=FAstica, = com buzina tipo=20 KOBO sobre o p=F3lo cef=E1lico fetal, por 3 a 5 segundos.

Considera-se acelera=E7=E3o transit=F3ria o = aumento da freq=FC=EAncia=20 card=EDaca fetal (FCF) acima de 15 bpm com 15 ou mais segundos de = dura=E7=E3o.=20

Outros elementos a serem considerados s=E3o o = n=EDvel da linha=20 de base (bradic=E1rdico ou taquic=E1rdico), a variabilidade = (reduzida, menor=20 que 10 bpm ou lisa) e presen=E7a de desacelera=E7=E3o tardia. A = presen=E7a de=20 desacelera=E7=F5es tardias que se iniciam 20 segundos ap=F3s as = contra=E7=F5es=20 uterinas s=E3o indica=E7=E3o de gravidade, assim como as = desacelera=E7=F5es=20 profundas e prolongadas com retorno abrupto.

Os fetos n=E3o-reativos com padr=E3o de linha de = base lisa=20 (aus=EAncia de variabilidade da linha de base), s=E3o considerados = terminais,=20 com risco de =F3bito iminente.

a) FETO ATIVO: _ linha de base entre 120 _ = 160 bpm=20

_ variabilidade 10 a 25 bpm

_ duas ou mais acelera=E7=F5es ap=F3s

movimentos fetais espont=E2neos ou

ap=F3s contra=E7=F5es de Braxton-Hicks.

b) FETO REATIVO: _ linha de base entre 120 = _ 160 bpm=20

_ variabilidade 10 a 25 bpm

_ resposta reativa com acelera=E7=E3o

da FCF de 15 bpm por 3 minutos

e movimenta=E7=E3o fetal ap=F3s est=EDmulo

vibro-ac=FAstico.

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c) FETO N=C3O-REATIVO: _ linha de base = entre 120 - 160=20 bpm

_ variabilidade geralmente est=E1

comprimida ou lisa

_ e n=E3o responde a est=EDmulo.

Recomenda-se:

_ Orientar a gestante sobre o exame = (indica=E7=F5es, t=E9cnica,=20 inocuidade, etc).

_ Iniciar somente ap=F3s a 28=AA semana.

_ A validade do exame =E9 de 7 dias. Portanto, = repetir, no=20 m=E1ximo, dentro desse per=EDodo.

_ Realizar o exame com a mulher:

=95 em posi=E7=E3o semi-sentada (semi-Fowler)

=95 ap=F3s per=EDodo de repouso

=95 alimentada

=95 sem ter fumado ou tomado medica=E7=E3o at=E9 = uma hora antes do=20 exame.

_ Se necess=E1rios est=EDmulos, iniciar sempre = pelo mec=E2nico=20

1.2.2. Perfil biof=EDsico = fetal=20 (PBF)

=C9 prova de vitalidade fetal que se baseia = fundamentalmente=20

em par=E2metros ultra-sonogr=E1ficos, associados = =E0

cardiotocografia. Consiste na avalia=E7=E3o = integrada dos

seguintes par=E2metros: FCF (pela = cardiotocografia), volume do=20

l=EDquido amni=F3tico (avaliado pela medida do = bols=E3o maior),=20 t=F4nus

fetal, movimenta=E7=E3o fetal e movimentos = respirat=F3rios. A cada=20 um

desses par=E2metros atribui-se a pontua=E7=E3o de = 0 (anormal) ou=20

2 (normal). A interpreta=E7=E3o e conduta dependem = do escore=20 obtido

pela somat=F3ria das pontua=E7=F5es (ver quadro na = p=E1gina=20 seguinte).

Esse perfil deve ser pesquisado utilizando-se = monitoramento=20 eletr=F4nico e

ecografia de tempo real.

O PBF =E9 prova capaz de identificar os fetos com = risco, em=20 centros de refer=EAncia, nos casos em que o risco fetal j=E1 foi = previamente=20 triado por provas mais simples. =C9 m=E9todo que apresenta = =EDndice de=20 falso-negativos extremamente elevado, necessitando equipamento e = pessoal=20 especializado para sua realiza=E7=E3o. N=E3o deve substituir, = contudo, as=20 provas de vitalidade fetal mais simples, nem ser aplicado =E0 = popula=E7=E3o de=20 gestantes sem triagem pr=E9via.

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Interpreta=E7=E3o e conduta obst=E9trica da = pontua=E7=E3o do Perfil=20 Biof=EDsico Fetal

Pontua=E7=E3o Interpreta=E7=E3o Conduta = obst=E9trica

8 _ 10 Rec=E9m-nascido normal Repetir semanalmente = e 2 vezes=20

Baixo risco de asfixia por semana em gestantes =

cr=F4nica portadoras de diabetes e com

IG > 42 semanas. Se oligo=E2mnio,

induzir o parto

6 Suspeita de asfixia cr=F4nica Se IG > 36 = semanas, induzir=20 o parto.

Se < 36 semanas e rela=E7=E3o L/E < 2,

repetir a prova em 4 _ 6 horas.

Se oligo=E2mnio, induzir o parto

4 Suspeita de asfixia cr=F4nica Se IG > 32 = semanas, induzir=20 o parto.

Se < 32 semanas, repetir a prova

0 _ 2 Forte suspeita de asfixia Estender o tempo = da prova.=20

cr=F4nica Se persistir < 4, induzir o parto =

1.2.3. = Dopplervelocimetria=20

Consiste na medida da velocidade do fluxo = sangu=EDneo.=20 Durante a gravidez, essa medida pode ser realizada em tr=EAs = leitos=20 vasculares principais: materno (vasos uterinos), = placent=E1rio-umbilical=20 (vasos umbilicais) e fetal (aorta, vasos carot=EDdeos e = cerebrais). Alguns=20 =EDndices s=E3o utilizados para descrever a forma de onda do fluxo = sangu=EDneo,=20 na rela=E7=E3o tempo/velocidade, como tentativa de se medir a = din=E2mica da=20 circula=E7=E3o feto-placent=E1ria, bem compo a resist=EAncia ao = fluxo.

1. =CDndice de pulsatilidade =3D S=EDstole (S) = menos Di=E1stole (D)/=20 Velocidade m=E9dia (VM)

2. =CDndice de Resist=EAncia =3D (S-D/S)

3. Rela=E7=E3o S=EDstole/Di=E1stole (S/D)

A principal = indica=E7=E3o para sua=20 utiliza=E7=E3o =E9 na avalia=E7=E3o da gesta=E7=E3o de alto risco. = =C9 tamb=E9m uma prova=20 sofisticada e deve ser reservada para investiga=E7=E3o da = vitalidade fetal em=20 centros de refer=EAncias mais complexos, realizada por pessoal = treinado e=20 apenas em gestantes previamente selecionadas por outros m=E9todos = de=20 avalia=E7=E3o fetal, tendo sua indica=E7=E3o a partir do terceiro = trimestre.=20 Isoladamente, o resultado alterado da dopplervelocimetria n=E3o = tem poder=20 decis=F3rio final. Ele indica altera=E7=F5es vasculares que = est=E3o nos mecanismos=20 que culminam com o aparecimento de sofrimento fetal. Indica, = portanto, a=20 necessidade de

135

vigil=E2ncia de vitalidade fetal cont=EDnua. Em = locais onde n=E3o=20 esteja ainda dispon=EDvel, =E9 poss=EDvel fazer-se uma boa = avalia=E7=E3o de=20 vitalidade sem essa prova.

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A V A L I A =C7 =C3 O D A = M A T U R I D A=20 D E F E T A L

2

2.1. M=E9todos Cl=EDnicos =

2.1.1. Estabelecimento da = idade=20 gestacional

Baseia-se na data da =FAltima menstrua=E7=E3o = (DUM), na altura=20 do =FAtero (AU), no in=EDcio dos movimentos ativos do feto, na = insinua=E7=E3o e na=20 biometria fetal pela ultra-sonografia.

Cumpre lembrar que a dura=E7=E3o da gesta=E7=E3o = =E9 de 280 dias, em=20 m=E9dia, isto =E9, 40 semanas. Assim, calcula-se, pela regra de = Naegele, a=20 data prov=E1vel do parto, somando-se =E0 DUM 7 dias e = diminuindo-se tr=EAs=20 meses. A seguir, calcula-se quantos dias faltam para a data do = parto. Esse=20 n=FAmero de dias, dividido por 7 d=E1 o n=FAmero de semanas que = faltam para o=20 parto. O n=FAmero de semanas que faltam deve ser subtra=EDdo de 40 = semanas,=20 total da gesta=E7=E3o, obtendo-se assim a idade gesta=E7=E3o em = semanas.

Quanto aos movimentos fetais, se bem que existam=20 precocemente, s=F3 s=E3o percebidos pela gr=E1vida do 4=BA m=EAs = em diante.

Nas duas =FAltimas semanas de gesta=E7=E3o, nas = prim=EDparas pode=20 ocorrer a queda do ventre pela insinua=E7=E3o do p=F3lo cef=E1lico = (com o al=EDvio=20 respirat=F3rio para a gestante).

A ultra-sonografia oferece a oportunidade de = calcular a=20 idade

da gesta=E7=E3o, pela biometria fetal. No in=EDcio = da gesta=E7=E3o, o=20 c=E1lculo

=E9 feito pelo tamanho do saco gestacional, sendo, = entretanto,=20 pouco preciso. Da 8=AA =E0 14=AA semana, mede-se a dist=E2ncia = cabe=E7a-n=E1degas

do feto, o que =E9 um par=E2metro excelente. Na = 2=AA metade da=20 gesta=E7=E3o,

o c=E1lculo da idade gestacional =E9 feito pela = medida do=20 di=E2metro biparietal, do comprimento do f=EAmur, bem como da = presen=E7a e=20 tamanho dos pontos de ossifica=E7=E3o secund=E1ria do f=EAmur, = elementos que=20 constituem um m=E9todo muito bom para a determina=E7=E3o

da idade fetal.

Quando houver d=FAvidas em rela=E7=E3o =E0 idade = gestacional, seja=20 por aus=EAncia de informa=E7=E3o, incerteza quanto =E0 data da = =FAltima menstrua=E7=E3o=20 ou ainda incoer=EAncia entre os achados cl=EDnicos e a = informa=E7=E3o obtida, a=20 gestante dever=E1 ser atendida em n=EDvel secund=E1rio at=E9 que = seja devidamente=20 esclarecida a idade gestacional, somente ent=E3o retornar=E1 ao = n=EDvel=20 prim=E1rio.

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Para esclarecer tais situa=E7=F5es de d=FAvidas, = os seguintes=20 procedimentos devem ser utilizados:

_ a pesquisa da data da =FAltima menstrua=E7=E3o = deve ser=20 exaustivamente verificada, relacionada ao aparecimento dos = primeiros=20 sintomas de gesta=E7=E3o e as datas marcantes (Natal, carnaval, = anivers=E1rios,=20 entre outras).

_ pesquisa de batimentos cardiofetais pelo sonar = Doppler,=20 durante o terceiro m=EAs, anotando as datas e resultados.

_ Exame ecogr=E1fico: deve ser realizado o mais = precoce=20 poss=EDvel, para pesquisar o comprimento cabe=E7a-n=E1dega (CCN), = entre a 8=AA e=20 13=AA semanas. O di=E2metro biparietal (DBP) pode ser medido entre = a 12=AA e 39=AA=20 semanas, entretanto deve ser novamente medido ap=F3s = aproximadamente 2 ou 4=20 semanas, para verificar se o crescimento foi normal. Caso houver = coer=EAncia=20 entre as duas medidas, a margem de varia=E7=E3o fica diminu=EDda. =

2.1.2. Exame do l=EDquido = amni=F3tico

_ = Amnioscopia

=C9 uma endoscopia cervical, com o objetivo de = visualizar o=20 p=F3lo inferior do ovo, isto =E9, as membranas, o l=EDquido = =E2mni=F3tico e a=20 apresenta=E7=E3o.

O amniosc=F3pio =E9 constitu=EDdo por um tubo oco = met=E1lico ou=20 mesmo compacto de acr=EDlico que =E9 introduzido atrav=E9s do = orif=EDcio cervical.=20

Al=E9m do tubo, deve haver uma fonte luminosa. =C9 = necess=E1ria=20 uma cervicodilata=E7=E3o de 1,5 cm ou mais.

A amnioscopia tem como desvantagem a necessidade = de colo=20 perme=E1vel. Apresenta riscos, apesar de pouco freq=FCentes, como = ruptura das=20 membranas ovulares, pequenas hemorragias, traumas e infec=E7=E3o. =

=95 Avaliam-se a cor e a transpar=EAncia do = l=EDquido amni=F3tico=20 e a eventual presen=E7a de grumos. Assim, o l=EDquido pode ser: =

Claro: boa vitalidade

Claro com grumos: boa vitalidade e boa = maturidade=20

Meconial: sofrimento fetal recente

Vermelho: hemorragia

Amarelo: presen=E7a de bilirrubina = (isoimuniza=E7=E3o Rh)=20

Achocolatado: sofrimento antigo ou =F3bito = fetal.=20

138

=95 O resultado =E9 confi=E1vel em 90% dos = casos, havendo=20 falso-positivos e falso-negativos em 10%.

S=E3o contra-indica=E7=F5es utilizar em = mulheres com placenta=20 pr=E9via e processos infecciosos c=E9rvico-vaginais.

_ = Amniocentese

=C9 coleta do l=EDquido amni=F3tico por via = abdominal, hoje=20 orientada pela ultra-sonografia. H=E1 dois tipos fundamentais de=20 amniocentese: precoce, realizada na 1=AA metade da = gravidez (mais=20 particularmente entre 12=AA e 14=AA semanas), e tardia, realizada = na=20 2=AA metade da gravidez (de prefer=EAncia ap=F3s 28=BA = semanas).

Pode ser feita em ambulat=F3rio, com = orienta=E7=E3o=20 ultra-sonogr=E1fica. A agulha usada =E9 a de raquianestesia, = preferencialmente=20 n=FAmero 12 por 20. Retirar 10 a 20 ml de l=EDquido.

Indica=E7=F5es da Amniocentese = Precoce:

a) Cari=F3tipo fetal, principalmente para afastar = a trissomia=20 21 (S=EDndrome de Down).

b) Erros inatos de metabolismo

c) Dosagem de alfa feto prote=EDna (AFP)

d) Determina=E7=E3o do sexo fetal

Indica=E7=F5es da Amniocentese = Tardia:

a) Estudo da vitalidade e maturidade fetal

b) Diagn=F3stico de corioamnionite

c) Esvaziamento, nos casos de polidr=E2mnio agudo =

d) Introdu=E7=E3o de medicamentos

e) Diagn=F3stico, progn=F3stico, tratamento e = preven=E7=E3o da=20 doen=E7a hemol=EDtica

f) Determina=E7=E3o do grupo sangu=EDneo fetal =

Riscos da amniocentese:

Precoce: infec=E7=E3o, abortamento

Tardia: les=E3o fetal anexial, trabalho de = parto=20 prematuro, amniorrexe

2.2. M=E9todos = LaboratOriais=20

2.2.1. Exame do l=EDquido = amni=F3tico

O exame do l=EDquido obtido por amniocentese ou = colhido ap=F3s a=20 rotura da bolsa, pode ser macrosc=F3pico e microsc=F3pico. =

139

Macroscopia. Deve-se fazer uma = descri=E7=E3o do l=EDquido,=20 que =E9 colocado em tubo de ensaio e examinado contra um fundo = branco,=20 atendendo =E0s seguintes caracter=EDsticas: cor e transpar=EAncia. = O l=EDquido=20 normalmente =E9 claro e transparente (=E1gua de rocha) e, ap=F3s = 36 semanas,=20 pode se ver a presen=E7a de grumos (v=E9rnix caseoso), que, em = grande=20 quantidade, tornam o l=EDquido opalescente. Entende-se que o = l=EDquido,=20 apresentando outros aspectos, =E9 patol=F3gico: verde (mec=F4nio = recente),=20 amarelo (presen=E7a de bilirrubina), vermelho (hemorragia) e = achocolatado=20 (sofrimento antigo ou =F3bito fetal). Esses dados avaliam a = vitalidade e a=20 maturidade fetal.

Microscopia. H=E1 provas que s=E3o = realizadas para=20 verificar a maturidade fetal atrav=E9s de:

_ Surfactantes. Nos pulm=F5es existem = subst=E2ncias=20 surfactantes destinadas a proporcionar estabilidade ao alv=E9olo, = evitando=20 atelectasia. Produzidas no pneum=F3cito tipo II, s=E3o = lipoprote=EDnas complexas=20 com estrutura do glicerol. Entre os surfactantes, destacam-se:=20 fosfatidilcolina (lecitina), fosfatidilglicerol, inositol, serina, = etanolamina e esfingomielina.

A lecitina =E9 o mais importante dos surfactantes = e aumenta=20 com o evoluir da gravidez (agente tensoativo). A esfingomielina, = de menor=20 import=E2ncia, decresce no final da gravidez.

Rela=E7=E3o lecitina/esfingomielina (L/E):

rela=E7=E3o L/E inferior a 1,5 significa = imaturidade fetal.

rela=E7=E3o L/E entre 1,5 e 1,9 significa = imaturidade duvidosa.=20

rela=E7=E3o L/E superior a 2,0 significa = maturidade fetal.

OBSERVA=C7=C3O: Os rec=E9m-nascidos de m=E3es = diab=E9ticas podem=20 apresentar membrana hialina mesmo tendo rela=E7=E3o L/E superior a = 2,0. Nesses=20 casos, a pesquisa de fosfatidilglicerol confirma a maturidade

fetal.

A determina=E7=E3o da rela=E7=E3o L/E e a pesquisa = de=20 fosfatidilglicerol s=E3o exames laboratoriais dispon=EDveis em = poucos locais.=20

_ Teste de Clements: pesquisa a maturidade = atrav=E9s da=20 tens=E3o superficial do l=EDquido amni=F3tico, avaliada pela = estabilidade das=20 bolhas (espuma), ap=F3s agita=E7=E3o vigorosa do mesmo em = dilui=E7=E3o =B3 a 1/2. A=20 maturidade est=E1 sempre presente nos resultados positivos (halo = completo de=20 bolhas), por=E9m o teste apresenta significativa propor=E7=E3o de = resultados=20 falso-negativos.

2.2.2. Exame=20 ultra-sonogr=E1fico

A ultra-sonografia n=E3o tem elementos definitivos = para=20 indicar maturidade fetal. Alguns autores mostraram que o = di=E2metro do=20 bi-parietal acima de 87 mm, em grande porcentagem dos casos, =E9 = indicativo=20 de maturidade

140

fetal, para outros autores seria acima de 92 mm. = Grannum et=20 al., 1979, verificaram que placentas com cotil=E9dones vis=EDveis = e com=20 calcifica=E7=F5es tamb=E9m correspondem quase sempre a fetos = maduros.

141

P A R T E I V :=20

A N T E C I P A =C7 = =C3 O=20

E L E T I V A D O=20

P A R T = O

A N T E C I P A =C7 =C3 O = E L E T I V A D=20 O P A R T O

1

A atitude inicial na assist=EAncia =E0 gestante = que apresenta=20 algum tipo de problema deve refletir o objetivo ideal de = diagn=F3stico=20 precoce e tratamento do dist=FArbio identificado. Na pr=E1tica = cl=EDnica, no=20 entanto, apesar das medidas tomadas, permanece uma propor=E7=E3o = de casos com=20 algum grau de disfun=E7=E3o que implica risco elevado para a = gestante ou feto.=20 Em certas situa=E7=F5es, o risco materno =E9 inaceit=E1vel. Em = outras, o risco=20 fetal torna-se maior que o risco neonatal. Nesses casos, a = antecipa=E7=E3o=20 eletiva do parto =E9 medida preventiva conveniente e = insubstitu=EDvel. Por=E9m,=20 o que =E0s vezes representa uma decis=E3o =F3bvia e simples, = constitui-se,=20 outras vezes, numa medida que exige conhecimentos, experi=EAncia e = equipamentos sofisticados.

O risco materno =E9 avaliado a partir das = probabilidades de=20 repercuss=F5es irrevers=EDveis que o organismo da mulher possa ter = em=20 conseq=FC=EAncia das condi=E7=F5es identificadas. J=E1 o risco = fetal =E9 avaliado a=20 partir das condi=E7=F5es maternas e da pesquisa de vitalidade e = crescimento=20 fetal. O risco neonatal depende do peso e da maturidade no momento = do=20 parto, das condi=E7=F5es fetais e dos recursos dispon=EDveis para = a aten=E7=E3o ao=20 rec=E9m-nascido.

Esse momento de decis=E3o =E9, com certeza, o mais = dif=EDcil=20 vivido pelo obstetra. Manter a gesta=E7=E3o pode significar a = m=E3e ou o feto=20 morrerem; se antecipar o parto, o =F3bito pode se dar no = ber=E7=E1rio. Decidir=20 s=F3 pelos conhecimentos t=E9cnicos =E9 tornar-se juiz da vida = humana, situa=E7=E3o=20 de onipot=EAncia injustificada. =C9 fundamental ouvir a gr=E1vida, = e somente a=20 ela cabe a decis=E3o.

Em que pese o fato de alguns casos necessitarem = decis=E3o=20 individualizada, a maioria delas pode ser enquadrada conforme os=20 fluxogramas apresentados a seguir, com a utiliza=E7=E3o de = t=E9cnicas e=20 equipamentos dispon=EDveis.

145

(*) Indica=E7=F5es do TESS: _ Amniorrexe prematura =

_ Amea=E7a de parto prematuro

_ Gesta=E7=E3o prolongada

_ Eritroblastose fetal

_ Hemorragias

_ Patologias maternas (hipertens=E3o, diabetes, = anemia)

Obs.: As pesquisas de vitalidade fetal n=E3o devem = ser=20 realizadas antes da 28=AA semana.

146

INDICA=C7=C3O DE T=C9RMINO DA GRAVIDEZ = (PR=C9-TERMO, TERMO,=20 P=D3S-TERMO) NA AUS=CANCIA DE TRABALHO DE PARTO

M=C9TODOS

Preparo do colo uterino para indu=E7=E3o do = trabalho de parto:=20 indicado quando o =EDndice de Bishop for menor que 6.

Indice de Bishop (Bishop, 1964)

Condi=E7=F5es do Colo 0 1 2 3

Dilata=E7=E3o (cm) 0 1-2 3-4 5+

Esvaecimento (%) 0-30 40-50 60-70 > 70 =

Consist=EAncia Firme M=E9dio Amolecido

Posi=E7=E3o Posterior Central Anterior

Plano apresenta=E7=E3o -3 -2 -1/0 +1

a) M=E9todos mec=E2nicos (contra-indicados em = casos de=20 amniorrexe):

Sonda Foley com bal=E3o de 30 ml

_ Exame especular

_ Antissepsia do colo com polvidine t=F3pico

_ Passagem de sonda pelo canal cervical

_ Insuflar bal=E3o

_ Fixar sonda na coxa (parte interna)

_ Retirar ap=F3s 12-24 horas

_ Iniciar indu=E7=E3o

Lamin=E1ria (alga desidratada)

_ Mesmo procedimento acima

_ Garantir passagem pelo orif=EDcio interno do = colo

_ Retirar ap=F3s 12 horas

_ Iniciar indu=E7=E3o

b) M=E9todos medicamentosos:

_ Prostaglandinas (evitar em casos com = cicatriz de=20 ces=E1rea)

E2: comercialmente inexistente no = Brasil

E1: (Misoprostol):

_ =D3bito fetal: =BD = a 1 comprimido=20 (200 mcg) em fundo de saco vaginal a cada 8 horas.

147

_ Feto vivo: s=E3o necess=E1rias doses de 12,5 _ = 25 mcg no fundo=20 de saco vaginal a cada 8 horas, com vigil=E2ncia constante da = din=E2mica=20 uterina e freq=FC=EAncia card=EDaca fetal, pela possibilidade de=20 hipercontratilidade uterina.

_ Ocitocina:

_ Esquema proposto: utilizar 5U (1 ampola) de = ocitocina=20 dilu=EDdas em 500 ml de soro glicosado a 5%. In=EDcio da = velocidade de infus=E3o=20 de 4 gotas por minuto (2mU/ml), dobrando-se o gotejamento a cada = 30=20 minutos a 1 hora, de acordo com resposta uterina, at=E9 a = obten=E7=E3o de=20 atividade uterina de trabalho de parto (3 a 4 contra=E7=F5es de = 45" em 10').=20 Dose m=E1xima de 64 gotas/min. (32 mU/ml).

_ Na eventualidade de quadros de = hiperestimula=E7=E3o uterina,=20 interromper o gotejamento da solu=E7=E3o. O emprego de pequenas = doses de=20 uterol=EDticos pode ser considerado se houver comprometimento = fetal.

Contra-indica=E7=F5es =E0 indu=E7=E3o do trabalho = de parto:

_ Sofrimento fetal confirmado

_ Cicatriz uterina corporal

_ Cicatriz segmentar de repeti=E7=E3o (mais que = duas)

_ Apresenta=E7=E3o fetal an=F4mala

_ Obstru=E7=E3o do canal de parto

_ Situa=E7=F5es de urg=EAncia

c) Ces=E1rea eletiva: deve ser o m=E9todo de = elei=E7=E3o nas=20 situa=E7=F5es de iteratividade (duas ou mais cicatrizes de = ces=E1reas=20 anteriores), nas situa=E7=F5es de urg=EAncia para a resolu=E7=E3o = do parto ou na=20 presen=E7a de contra-indica=E7=E3o absoluta.

Excetuando-se os casos de urg=EAncia e de = sofrimento fetal, a=20 presen=E7a de contra=E7=F5es uterinas e o trabalho de parto s=E3o = desej=E1veis,=20 mesmo quando a ces=E1rea =E9 a via de parto mais indicada. =C9 um = importante=20 indicador de =E9poca oportuna para o parto; ajuda na forma=E7=E3o = do segmento=20 inferior do =FAtero, facilitando a cirurgia e diminuindo o = sangramento da=20 histerotomia, e na maturidade pulmonar fetal. Deve-se considerar,=20 entretanto, a facilidade de acesso da mulher ao hospital onde a = ces=E1rea=20 ser=E1 realizada.

148

P A R T E V :=20

A T E N D I M E N T = O=20

=C0 G E S T A N T E=20

C O M R I S C O=20

D E V I D = A=20

A T E N D I M E N T O =C0 = G E S T A N T=20 E C O M

R I S C O D E V I D = A=20

1

Entende-se por risco de vida materna toda = situa=E7=E3o cl=EDnica=20 que ocorre durante o per=EDodo gestacional, quer por doen=E7a = pr=F3pria da=20 gesta=E7=E3o ou doen=E7a preexistente que coloca em risco a vida = da gestante e=20 inviabiliza a continua=E7=E3o da gravidez. Nesses casos, est=E1 = indicada a=20 interrup=E7=E3o da gravidez no sentido de preservar a vida da = mulher.

=C9 indispens=E1vel que, no m=EDnimo, dois = m=E9dicos atestem que a=20 interrup=E7=E3o da gravidez =E9 a =FAnica maneira de salvar a vida = da mulher. Pelo=20 menos um deles deve ser da especialidade que est=E1 determinando o = motivo da=20 interrup=E7=E3o.

N=E3o =E9 necess=E1rio pedir autoriza=E7=E3o =E0 = comiss=E3o de =E9tica do=20 hospital, sugerindo-se apenas a sua notifica=E7=E3o, j=E1 que = trata-se de=20 procedimento eticamente embasado e previsto no C=F3digo Penal = Brasileiro,=20 1940 (Art. 128).

Em face aos avan=E7os tecnol=F3gicos, s=E3o raras = as condi=E7=F5es=20 maternas que indicam interrup=E7=E3o da gravidez. Entretanto, em = pacientes com=20 quadros cl=EDnicos de evolu=E7=E3o desfavor=E1vel, como, por = exemplo, hipertens=E3o=20 aortica ou cardiopatia com hipertens=E3o pulmonar, a gravidade da = doen=E7a=20 justifica a interrup=E7=E3o da gravidez.

Os laudos m=E9dicos (obst=E9trico, cl=EDnico e do = especialista)=20 ser=E3o

analisados e discutidos pela equipe que aprovar=E1 = a=20 interrup=E7=E3o

da gravidez. Embora o c=F3digo penal n=E3o exija = autoriza=E7=E3o=20

formal da mulher, recomenda-se que ela deva ser = informada de=20 sua situa=E7=E3o cl=EDnica e participar da decis=E3o. A = comunica=E7=E3o deve ser=20 estendida ao c=F4njuge ou familiares da paciente, mas o que deve = prevalecer=20 =E9 a decis=E3o da mulher. Nas situa=E7=F5es em que a mulher

n=E3o se encontra em condi=E7=F5es de decidir, = prevalecer=E1 o=20 princ=EDpio

b=E1sico da a=E7=E3o m=E9dica, que =E9 preservar a = vida, amparado pelo=20

c=F3digo de =E9tica.

Procedimento para a interrup=E7=E3o da gravidez = em casos de=20 risco de vida para a m=E3e

A decis=E3o de interromper a gravidez n=E3o = depende da idade=20 gestacional, devendo ser baseada em crit=E9rios cl=EDnicos de = gravidade. No=20 entanto, os procedimentos ser=E3o diferenciados de acordo com a = idade=20 gestacional. Considerando a gravidade das situa=E7=F5es, a tomada = de decis=E3o=20 deve ser =E1gil.

151

Idade gestacional at=E9 12 semanas

Podem ser utilizados, para o esvaziamento da = cavidade=20 uterina, os dois m=E9todos identificados a seguir.

1. Dilata=E7=E3o do colo uterino e = curetagem

Dever=E1 ser realizada em centro cir=FArgico = equipado=20 adequadamente, com todos os cuidados de assepsia e antissepsia, = sob=20 anestesia, devendo-se evitar a anestesia paracervical. A = dilata=E7=E3o do colo=20 uterino dever=E1 ser suficiente para a introdu=E7=E3o de pin=E7a = de Winter, que=20 servir=E1 para a tra=E7=E3o das membranas ovulares. Depois, ser=E1 = procedida a=20 curetagem da cavidade uterina. =C9 recomend=E1vel que se introduza = um=20 comprimido de misoprostol 200 mcg intravaginal, no m=EDnimo 12 = horas antes=20 do procedimento, destinado ao preparo do colo uterino com vistas = ao menor=20 traumatismo durante a dilata=E7=E3o.

2. Aspira=E7=E3o manual intra-uterina = (AMIU)

A aspira=E7=E3o manual compreende um jogo de = c=E2nulas de pl=E1stico=20 flex=EDveis, de tamanhos que variam de 4 a 12 mm de di=E2metro, = al=E9m de um=20 jogo de dilatadores anat=F4micos nos mesmos di=E2metros, seringas = de v=E1cuo com=20 capacidade para 60 ml e um jogo de adaptadores para conectar a = c=E2nula =E0=20 seringa. Preferencialmente, deve ser feita sob anestesia local=20 (paracervical) ou outra anestesia.

A t=E9cnica consiste em dilatar o colo uterino = at=E9 que fique=20 compat=EDvel com a idade gestacional. Introduz-se a c=E2nula = correspondente e=20 se procede =E0 aspira=E7=E3o da cavidade uterina, tomando-se o = cuidado de=20 verificar o momento correto do t=E9rmino do procedimento, = ocasi=E3o esta em=20 que se sente a aspereza das paredes uterinas, a forma=E7=E3o de = sangue=20 espumoso e o enluvamento da c=E2nula pelo =FAtero, e em que as = pacientes sob=20 anestesia paracervical referem-se a c=F3licas.

Idade gestacional entre 13 a 28 semanas =

A interrrup=E7=E3o da gravidez dar-se-=E1 mediante = a indu=E7=E3o=20 pr=E9via com misoprostol, na dose de 100 a 200 mcg no fundo de = saco vaginal,=20 ap=F3s limpeza local com soro fisiol=F3gico, a cada 6 horas. A = crit=E9rio=20 cl=EDnico, poder=E1 ser associado o uso de misoprostol oral ou = ocitocina=20 endovenosa. Ap=F3s a elimina=E7=E3o do concepto, proceder-se-=E1 a = complementa=E7=E3o=20 do esvaziamento uterino, com curetagem, se necess=E1rio. Deve ser=20 considerado que h=E1 um risco de complica=E7=F5es, que variam de = 3% a 5%, nos=20 casos de interrup=E7=E3o da gravidez nesse per=EDodo.

Mais de 28 semanas

Com o feto vi=E1vel, segue-se a conduta = obst=E9trica cl=E1ssica.=20 (P=E1g. 146/148 deste manual)

152

O seguimento com os especialistas deve ser = continuado at=E9 a=20 alta cl=EDnica e em n=EDvel ambulatorial, em que se discutir=E1 = tamb=E9m a=20 anticoncep=E7=E3o a ser adotada. Deve-se considerar a = possibilidade de=20 laqueadura tub=E1ria, por indica=E7=E3o m=E9dica, se esta j=E1 = n=E3o tiver sido=20 realizada por ocasi=E3o de ces=E1rea. O acompanhamento = psicol=F3gico =E9=20 fundamental neste processo, devendo oferecer suporte a todos os=20 procedimentos adotados, servindo como base de apoio =E0 gestante e = familiares.

153

A N E X O = S=20

N O R M A S D E B I O S S = E G U R A N=20 =C7 A E P A R T O

1

=95 Biosseguran=E7a: =E9 o conjunto de = a=E7=F5es voltadas para=20 prevenir ou minimizar os riscos para os profissionais de sa=FAde = que=20 trabalham com materiais biol=F3gicos.

=95 Precau=E7=F5es universais (atualmente = denominadas=20 PRECAU=C7=D5ES B=C1SICAS) s=E3o medidas de preven=E7=E3o que devem = ser tomadas:

=95 com qualquer paciente, = independentemente do=20 diagn=F3stico definido ou presumido de doen=E7as infecciosas = causadas por=20 v=EDrus, bact=E9rias ou protozo=E1rios.

=95 na manipula=E7=E3o de sangue, = secre=E7=F5es, mucosas ou=20 pele n=E3o-=EDntegra.

Essas medidas incluem a utiliza=E7=E3o de = equipamentos de=20 prote=E7=E3o individual (luvas, m=E1scara, =F3culos de = prote=E7=E3o, capotes e=20 aventais), com a finalidade de reduzir a exposi=E7=E3o da pele e = das mucosas=20 ao sangue ou aos fluidos corp=F3reos de qualquer paciente e os = cuidados=20 especiais que os profissionais de sa=FAde devem tomar para se = prevenirem=20 contra acidentes com materiais perfurocortantes. (Consulte o = folheto=20 informativo do Minist=E9rio da Sa=FAde sobre as normas gerais de=20 biosseguran=E7a).

157

C U I D A D O S E S P E C = =CD F I C O S=20 D U R A N T E O P A R T O

=95 Preferir sempre seringas de pl=E1stico (isto = se aplica=20 durante a episiotomia, quando esta n=E3o puder ser evitada).

=95 Preferir sempre o uso de tesouras em = vez de bisturi=20 na manipula=E7=E3o do cord=E3o umbilical.

=95 Nunca utilizar l=E2mina de bisturi = desmontada (fora=20 do cabo).

=95 Preferir fios de sutura agulhados.

=95 Evitar agulhas retas de sutura, pelo = maior risco de=20 acidentes percut=E2neo.

=95 Utilizar sempre pin=E7as auxiliares nas = suturas,=20 evitando manipula=E7=E3o dos tecidos com os dedos durante a sutura = da mucosa=20 vaginal, durante o fechamento por planos na opera=E7=E3o = cesareana, etc.

=95 Evitar sutura por dois cirurgi=F5es, = simultaneamente,=20 no mesmo campo cir=FArgico.

=95 A passagem de materiais = perfurocortantes (bisturi,=20 porta-agulhas com agulhas, etc.) do auxiliar para o cirurgi=E3o = deve ser=20 atrav=E9s de cubas, ap=F3s aviso verbal.

=95 Cuidados especiais na manipula=E7=E3o = da placenta e do=20 cord=E3o umbilical deve ser observado, pois o risco de = exposi=E7=E3o =E9 muito=20 grande.

=95 Nos cuidados imediatos do = rec=E9m-nascido, estar=20 paramentado com equipamentos de prote=E7=E3o individual (luvas, = capotes,=20 avental, m=E1scara e gorro), pela possibilidade de expopsi=E7=E3o = a sangue e=20 l=EDquido amni=F3tico.

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D I A G N =D3 S T I C O S = O R O L =D3 G I=20 C O D A

I N F E C =C7 =C3 O P E L = O H I=20 V

3

A fim de maximizar o grau de confiabilidade na = emiss=E3o dos=20 laudos, bem como minimizar a ocorr=EAncia dos resultados = falso-negativos ou=20 falso-positivos, o Minist=E9rio da Sa=FAde, atrav=E9s da Portaria = n=BA 488,=20 de 17 de junho de 1998, estabelece a obrigatoriedade de um = conjunto de=20 procedimentos seq=FCenciados para os testes que visam detectar = anticorpos=20 anti-HIV em indiv=EDduos com idade acima de 2 (dois) anos (ver = fluxograma=20 adiante).

Ao chegar ao laborat=F3rio, com uma = solicita=E7=E3o de teste=20 anti-HIV, o indiv=EDduo tem sua amostra de sangue coletada. Ap=F3s = a coleta,=20 esta amostra =E9 centrifugada, para a obten=E7=E3o do soro ou = plasma que ser=E1=20 utilizado nos testes.

A amostra de soro ou plasma, deve ser inicialmente = submetida=20 =E0 primeira etapa do conjunto de procedimentos seq=FCenciados = obrigat=F3rios,=20 previstos na Portaria, denominado etapa de triagem sorol=F3gica. =

Nessa etapa, a amostra deve ser submetida a dois = testes=20 distintos, em paralelo. Esses dois testes, denominados teste 1 e = teste 2,=20 devem possuir princ=EDpios metodol=F3gicos e/ou ant=EDgenos = diferentes, e pelo=20 menos um deles deve ser capaz de detectar anticorpos anti-HIV-1 e=20 anti-HIV-2. Al=E9m disso, todos os conjuntos de diagn=F3stico = (kits)=20 utilizados para a realiza=E7=E3o dos testes devem estar = registrados no=20 Minist=E9rio da Sa=FAde.

Ap=F3s a realiza=E7=E3o da etapa de triagem = sorol=F3gica, podemos=20 encontrar tr=EAs situa=E7=F5es:

1. caso a amostra apresente resultados = n=E3o-reagentes nos=20 testes 1 e 2, ter=E1 seu resultado definido como "Amostra = negativa para=20 HIV". Nesse caso, o resultado =E9 liberado para o paciente. =

2. caso a amostra apresente resultados reagentes = nos testes=20 1 e 2, dever=E1 ser submetida =E0 etapa de confirma=E7=E3o = sorol=F3gica prevista na=20 Portaria.

3. caso a amostra apresente resultados = discordantes ou=20 indeterminados nos testes 1 e 2, dever=E1 ser retestada em = duplicata, com os=20 mesmos conjuntos de diagn=F3stico (1 e 2).

Ap=F3s a retestagem, em duplicata, podemos = encontrar duas=20 situa=E7=F5es:

1. caso a amostra apresente resultados = n=E3o-reagentes nos=20 dois testes, ter=E1 seu resultado definido como "Amostra = negativa para=20 HIV". Nesse caso, o resultado =E9 liberado para o paciente. =

161

2. caso a amostra possua resultados reagentes, = discordantes=20 ou indeterminados, nos dois testes, dever=E1 ser submetida =E0 = etapa de=20 confirma=E7=E3o sorol=F3gica.

A seguir, vem a etapa de confirma=E7=E3o = sorol=F3gica. Essa etapa=20 deve ser realizada em amostras de resultados que necessitem de=20 confirma=E7=E3o. Nesse caso, o Minist=E9rio da Sa=FAde preconiza a = realiza=E7=E3o dos=20 testes de Imunofluoresc=EAncia Indireta (IFI) e/ou Western Blot = (WB). =C9=20 importante referir que, na maioria dos casos, amostras que = necessitem ter=20 seu resultado confirmado s=E3o elucidadas atrav=E9s do teste de = IFI. Em alguns=20 outros, al=E9m desse, =E9 necess=E1ria a realiza=E7=E3o do teste = WB.

Recapitulando, ap=F3s a realiza=E7=E3o da etapa de = triagem,=20 podemos ter duas situa=E7=F5es em que h=E1 necessidade de = confirma=E7=E3o do=20 resultado:

1. amostras que possuam resultados reagentes nos = testes 1 e=20 2;

2. amostras que possuam resultados discordantes ou = indeterminados nos testes 1 e 2.

Uma vez realizado o teste de IFI, podemos = encontrar duas=20 situa=E7=F5es distintas:

1. amostra com resultado reagente no teste de IFI = ter=E1 seu=20 resultado definido como "Amostra positiva para HIV-1". = Nesse caso,=20 =E9 obrigat=F3ria a coleta de uma nova amostra para = confirma=E7=E3o da=20 positividade da primeira amostra.

2. amostra com resultado indeterminado ou negativo = no teste=20 de IFI devem ser submetidas ao teste de WB.

Ap=F3s a realiza=E7=E3o do teste de WB, podemos = encontrar as=20 seguintes situa=E7=F5es:

1. amostra reagente no teste de WB ter=E1 seu = resultado=20 definido como "Amostra positiva para HIV-1". Nesse caso, = =E9=20 obrigat=F3ria a coleta de uma nova amostra para confirma=E7=E3o da = positividade=20 da primeira amostra.

2. amostra indeterminada ter=E1 seu resultado = definido como=20 "Amostra indeterminada para HIV-1". Nesse caso, dever=E1 = ser=20 submetida =E0 investiga=E7=E3o de anticorpos anti-HIV2. = Recomenda-se, ainda, a=20 coleta de nova amostra, ap=F3s 30 dias, e a repeti=E7=E3o de todo = o conjunto de=20 procedimentos seq=FCenciados.

3. amostra negativa ao teste WB ter=E1 seu = resultado definido=20 como "Amostra negativa para HIV-1" e dever=E1 ser submetida = =E0=20 investiga=E7=E3o de anticorpos anti-HIV2. Recomenda-se, ainda, a = coleta de=20 nova amostra, ap=F3s 30 dias, e a repeti=E7=E3o de todo o conjunto = de=20 procedimentos seq=FCenciados.

Conv=E9m observar que =E9 obrigat=F3ria a coleta = de uma segunda=20 amostra e a repeti=E7=E3o da etapa de triagem sorol=F3gica (Etapa = 1), sempre que=20 uma amostra apresentar resultado definido como "Amostra = positiva para=20

162

HIV-1". Caso os resultados da testagem da = segunda=20 amostra sejam

n=E3o-reagentes ou indeterminados, dever=E3o ser = cumpridas todas=20 as etapas do conjunto de procedimentos seq=FCenciados.

Sempre que a primeira amostra for positiva ao = teste de IFI,=20 ou ao teste de WB, e a segunda amostra for negativa aos testes de = triagem,=20 =E9 preciso considerar a possibilidade de ter havido troca ou = contamina=E7=E3o=20 de amostras.

Deve-se ressaltar o fato de que todos os conjuntos = de=20 diagn=F3stico apresentam caracter=EDsticas intr=EDnsecas que podem = conduzir a=20 resultados falsos.

Resultados falso-positivos podem ser decorrentes = de=20 problemas t=E9cnicos no procedimento do exame ou de altera=E7=F5es = biol=F3gicas no=20 indiv=EDduo, que determinam reatividade, independentemente da = condi=E7=E3o=20 investigada.

Entre as causas de origem t=E9cnica, podemos = citar:=20 contamina=E7=E3o de ponteiras; contamina=E7=E3o da rea=E7=E3o por = soros vizinhos,=20 fortemente positivos; troca de amostras; ciclos repetidos de = congelamento=20 e descongelamento das amostras; pipetagens de baixa acur=E1cia; = inativa=E7=E3o=20 da amostra a 56oC e transporte ou armazenamento = inadequado das=20 amostras ou dos kits.

Como poss=EDveis causas de resultados = falso-positivos podemos=20 mencionar, entre outras, as semelhan=E7as antig=EAnicas entre = microrganismos;=20 doen=E7as auto-imunes; infec=E7=F5es por outros v=EDrus; uso de = drogas=20 endovenosas; aquisi=E7=E3o passiva de anticorpos anti-HIV (de = m=E3e para o=20 filho).

=C9 importante salientar que nem todos os casos de = rea=E7=F5es=20 falso-positivas t=EAm a sua causa definida ou podem ser evitados. = Al=E9m=20 disso, tais causas podem variar ou n=E3o, de acordo com os = m=E9todos=20 utilizados.

Com rela=E7=E3o aos resultados falso-negativos, = =E9 importante=20 mencionar a sensibilidade do teste como uma das principais causas, = em=20 fun=E7=E3o das diferentes capacidades de detec=E7=E3o dos kits; da = ocorr=EAncia do=20 per=EDodo de janela imunol=F3gica; ou da variabilidade na = constitui=E7=E3o=20 antig=EAnica dos conjuntos de diagn=F3stico.

Entre as causas de ordem t=E9cnica como fatores = que contribuem=20 para o aparecimento de resultados falso-negativos, podemos citar: = a troca=20 da amostra; o uso de reagentes fora do prazo de validade; a = utiliza=E7=E3o de=20 equipamentos desajustados; pipetagem incorreta e o transporte ou=20 armazenamento inadequado das amostras ou dos kits.

Finalmente, =E9 importante enfatizar que mesmo com = processamento adequado das amostras de sangue, e a execu=E7=E3o = t=E9cnica=20 correta de todas as etapas da rea=E7=E3o sorol=F3gica no = laborat=F3rio, =E9=20 fundamental que o processo de aconselhamento, antes e depois do = teste,=20 seja feito de forma cuidadosa, para que o resultado do exame seja=20 corretamente

163

interpretado, tanto pelo profissional de sa=FAde = quanto pelo=20 paciente, gerando atitudes que visem =E0 promo=E7=E3o da sa=FAde = e/ou =E0 preven=E7=E3o=20 da infec=E7=E3o pelo HIV nos indiv=EDduos testados, conforme o = diagn=F3stico=20 obtido a partir da avalia=E7=E3o cl=EDnica e laboratorial do = paciente.



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