silândia amaral da silva freitas brasília, 22 de novembro de 2014 neuroproteção no rn prematuro...
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Silacircndia Amaral da Silva FreitasBrasiacutelia 22 de novembro de 2014
wwwpaulomargottocombr
Neuroproteccedilatildeo no RN prematuro
Sulfato de Magneacutesio e Via de parto
Paralisia cerebral (PC) eacute um grupo heterogecircneo de siacutendromes cliacutenicas permanentes natildeo progressivas caracterizadas por disfunccedilatildeo motora e postural devidas a anormalidades do desenvolvimento do ceacuterebro
Updated Sep 10 2014
3
Eacute multifatorial
Causas conhecidas - pequena proporccedilatildeo
Maioria - fatores preacute-natais
Hipoacutexia isquemia perinatal - algum papel
Prematuridade - associaccedilatildeo comum
4
PREMATURIDADE
ESPONTAcircNEA
INDUZIDA
Nos Estados Unidos 2 partos menos 32 semanas de gestaccedilatildeo Magnesium sulfate for the prevention of cerebral palsy American Journal of Obstetrics amp Gynecology JUNE 2009
Melhor assistecircncia neonatal tem aumentado incidecircncia de prematuros bem como a sobrevida deles
Paralisia cerebral ndash 42 a 49 associados a prematuridade
6
Sobrevida e morbidade em prematuros com menos de 32 semanas de gestaccedilatildeo na regiatildeo central do Brasil Maacutercia Pimentel de Castro1Liacutegia Maria Suppo Souza Rugolo2 Paulo Roberto Margotto3
Estudo prospectivo de coorte no qual todos os RN prematuros com IG entre 25 e 31 semanas e 6 dias sem malformaccedilotildees maiores nascidos vivos na Maternidade do Hospital Regional da Asa Sul (HRAS) em Brasiacutelia e internados na UTI neonatal desse Hospital no periacuteodo de 1ordm de novembro de 2009 a 31 de outubro de 2010 foram incluiacutedos
Os RNs foram estratificados em trecircs faixas de IG constituindo 3 grupos G25 IG entre 25 e 27 semanas e 6 dias G28 28 a 29 semanas e 6 dias G30 30 a 31 semanas e 6 dias
Rev Bras Ginecol Obstet 2012 34(5)235-42
7
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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Paralisia cerebral (PC) eacute um grupo heterogecircneo de siacutendromes cliacutenicas permanentes natildeo progressivas caracterizadas por disfunccedilatildeo motora e postural devidas a anormalidades do desenvolvimento do ceacuterebro
Updated Sep 10 2014
3
Eacute multifatorial
Causas conhecidas - pequena proporccedilatildeo
Maioria - fatores preacute-natais
Hipoacutexia isquemia perinatal - algum papel
Prematuridade - associaccedilatildeo comum
4
PREMATURIDADE
ESPONTAcircNEA
INDUZIDA
Nos Estados Unidos 2 partos menos 32 semanas de gestaccedilatildeo Magnesium sulfate for the prevention of cerebral palsy American Journal of Obstetrics amp Gynecology JUNE 2009
Melhor assistecircncia neonatal tem aumentado incidecircncia de prematuros bem como a sobrevida deles
Paralisia cerebral ndash 42 a 49 associados a prematuridade
6
Sobrevida e morbidade em prematuros com menos de 32 semanas de gestaccedilatildeo na regiatildeo central do Brasil Maacutercia Pimentel de Castro1Liacutegia Maria Suppo Souza Rugolo2 Paulo Roberto Margotto3
Estudo prospectivo de coorte no qual todos os RN prematuros com IG entre 25 e 31 semanas e 6 dias sem malformaccedilotildees maiores nascidos vivos na Maternidade do Hospital Regional da Asa Sul (HRAS) em Brasiacutelia e internados na UTI neonatal desse Hospital no periacuteodo de 1ordm de novembro de 2009 a 31 de outubro de 2010 foram incluiacutedos
Os RNs foram estratificados em trecircs faixas de IG constituindo 3 grupos G25 IG entre 25 e 27 semanas e 6 dias G28 28 a 29 semanas e 6 dias G30 30 a 31 semanas e 6 dias
Rev Bras Ginecol Obstet 2012 34(5)235-42
7
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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3
Eacute multifatorial
Causas conhecidas - pequena proporccedilatildeo
Maioria - fatores preacute-natais
Hipoacutexia isquemia perinatal - algum papel
Prematuridade - associaccedilatildeo comum
4
PREMATURIDADE
ESPONTAcircNEA
INDUZIDA
Nos Estados Unidos 2 partos menos 32 semanas de gestaccedilatildeo Magnesium sulfate for the prevention of cerebral palsy American Journal of Obstetrics amp Gynecology JUNE 2009
Melhor assistecircncia neonatal tem aumentado incidecircncia de prematuros bem como a sobrevida deles
Paralisia cerebral ndash 42 a 49 associados a prematuridade
6
Sobrevida e morbidade em prematuros com menos de 32 semanas de gestaccedilatildeo na regiatildeo central do Brasil Maacutercia Pimentel de Castro1Liacutegia Maria Suppo Souza Rugolo2 Paulo Roberto Margotto3
Estudo prospectivo de coorte no qual todos os RN prematuros com IG entre 25 e 31 semanas e 6 dias sem malformaccedilotildees maiores nascidos vivos na Maternidade do Hospital Regional da Asa Sul (HRAS) em Brasiacutelia e internados na UTI neonatal desse Hospital no periacuteodo de 1ordm de novembro de 2009 a 31 de outubro de 2010 foram incluiacutedos
Os RNs foram estratificados em trecircs faixas de IG constituindo 3 grupos G25 IG entre 25 e 27 semanas e 6 dias G28 28 a 29 semanas e 6 dias G30 30 a 31 semanas e 6 dias
Rev Bras Ginecol Obstet 2012 34(5)235-42
7
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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4
PREMATURIDADE
ESPONTAcircNEA
INDUZIDA
Nos Estados Unidos 2 partos menos 32 semanas de gestaccedilatildeo Magnesium sulfate for the prevention of cerebral palsy American Journal of Obstetrics amp Gynecology JUNE 2009
Melhor assistecircncia neonatal tem aumentado incidecircncia de prematuros bem como a sobrevida deles
Paralisia cerebral ndash 42 a 49 associados a prematuridade
6
Sobrevida e morbidade em prematuros com menos de 32 semanas de gestaccedilatildeo na regiatildeo central do Brasil Maacutercia Pimentel de Castro1Liacutegia Maria Suppo Souza Rugolo2 Paulo Roberto Margotto3
Estudo prospectivo de coorte no qual todos os RN prematuros com IG entre 25 e 31 semanas e 6 dias sem malformaccedilotildees maiores nascidos vivos na Maternidade do Hospital Regional da Asa Sul (HRAS) em Brasiacutelia e internados na UTI neonatal desse Hospital no periacuteodo de 1ordm de novembro de 2009 a 31 de outubro de 2010 foram incluiacutedos
Os RNs foram estratificados em trecircs faixas de IG constituindo 3 grupos G25 IG entre 25 e 27 semanas e 6 dias G28 28 a 29 semanas e 6 dias G30 30 a 31 semanas e 6 dias
Rev Bras Ginecol Obstet 2012 34(5)235-42
7
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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- Slide 54
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- Slide 56
-
Melhor assistecircncia neonatal tem aumentado incidecircncia de prematuros bem como a sobrevida deles
Paralisia cerebral ndash 42 a 49 associados a prematuridade
6
Sobrevida e morbidade em prematuros com menos de 32 semanas de gestaccedilatildeo na regiatildeo central do Brasil Maacutercia Pimentel de Castro1Liacutegia Maria Suppo Souza Rugolo2 Paulo Roberto Margotto3
Estudo prospectivo de coorte no qual todos os RN prematuros com IG entre 25 e 31 semanas e 6 dias sem malformaccedilotildees maiores nascidos vivos na Maternidade do Hospital Regional da Asa Sul (HRAS) em Brasiacutelia e internados na UTI neonatal desse Hospital no periacuteodo de 1ordm de novembro de 2009 a 31 de outubro de 2010 foram incluiacutedos
Os RNs foram estratificados em trecircs faixas de IG constituindo 3 grupos G25 IG entre 25 e 27 semanas e 6 dias G28 28 a 29 semanas e 6 dias G30 30 a 31 semanas e 6 dias
Rev Bras Ginecol Obstet 2012 34(5)235-42
7
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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6
Sobrevida e morbidade em prematuros com menos de 32 semanas de gestaccedilatildeo na regiatildeo central do Brasil Maacutercia Pimentel de Castro1Liacutegia Maria Suppo Souza Rugolo2 Paulo Roberto Margotto3
Estudo prospectivo de coorte no qual todos os RN prematuros com IG entre 25 e 31 semanas e 6 dias sem malformaccedilotildees maiores nascidos vivos na Maternidade do Hospital Regional da Asa Sul (HRAS) em Brasiacutelia e internados na UTI neonatal desse Hospital no periacuteodo de 1ordm de novembro de 2009 a 31 de outubro de 2010 foram incluiacutedos
Os RNs foram estratificados em trecircs faixas de IG constituindo 3 grupos G25 IG entre 25 e 27 semanas e 6 dias G28 28 a 29 semanas e 6 dias G30 30 a 31 semanas e 6 dias
Rev Bras Ginecol Obstet 2012 34(5)235-42
7
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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7
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
DANOS CEREBRAIS NA PREMATURIDADE
Limitado entendimento das causas e desenvolvimento de estrateacutegias para prevenccedilatildeo primaacuteria
8
Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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Risco PC quase 80 vezes maior entre os bebecircs nascidos entre 23 e 27 semanas de gestaccedilatildeo do que entre bebecircs nascidos a termo Updated Sep 30 2014
9
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
Lesatildeo da substacircncia branca
Hemorragia intraventricular
Leucomalaacutecia periventricular
Ecodensidade Intraparenquimatosa
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
Resulta de lesatildeo neuronal ou insulto ao ceacuterebro em desenvolvimento
Inflamaccedilatildeo lesatildeo hipoacutexica excitatoacuteria ou oxidativa
10
DANOS CEREBRAIS NA PREMATURIDADEDANOS CEREBRAIS NA PREMATURIDADE
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
Sulfato de Magneacutesio (MgSO4) na Obstetriacutecia
Dados observacionais (1990) menos morbidades neuroloacutegicas em prematuros expostos ao sulfato de magneacutesio
11
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Estabiliza pressatildeo arterial reduzindo a constriccedilatildeo nas arteacuterias cerebraisRestaura perfusatildeo cerebral
Estabilidade hemodinacircmicabullAntenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
12
Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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Lesatildeo HI fase aguda o oxigecircnio eacute esgotado feto metabolismo anaeroacutebico acuacutemulo intracelular de soacutedio caacutelcio cloreto e aacutegua (edema citotoacutexico) neurotransmissores excitatoacuterios
Prevenccedilatildeo de lesotildees e estabilizaccedilatildeo neuronal excitatoacuteria
13
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
14
Bloquea fluxo de NA
Estabiliza membrana para impedir a sua despolarizaccedilatildeo persistente resultante da falha da bomba NA-K ATP-dependente
Restauraccedilatildeo do permeabilidade da barreira hemato-encefaacutelica depois de uma injuacuteria HI
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Radicais livres de oxigecircnio atacam a membrana celular causando a fragmentaccedilatildeo celular e morte
Propriedades antioxidantesbull Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
15
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
SULFATO DE MAGNEacuteSIO MECANISMOS DE ACcedilAtildeO
Mediadores inflamatoacuterios interleucina-1b e fator de necrose tumoralaumentados 1 a 4 h apoacutes a lesatildeo HI citotoxicidade de lesatildeo HI
MgSO4 diminui essas citocinas proacute-inflamatoacuterias
Propriedades anti-inflamatoacuterias
Antenatal Exposure to Magnesium Sulfate and Neuroprotection in Preterm Infants Obstet Gynecol Clin N Am 38 (2011) 351ndash366
16
17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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17
JUNHO 2009
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
18
19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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19
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA I Effect of magnesium sulfate on cerebral palsy
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
20
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
TABELA II Effect of magnesium sulfate on cerebral palsy and pediatric mortality
Nordm of eventstotal number
Outcome Nordm of trials Magnesium No magnesium Relative risk (95 CI) Isup2 ()
Cerebral palsy 6 1042658 1522699 069 (055-088) 44
Moderatesevere cerebral palsy 3 452169 722218 064 (044-092) 00
Mild cerebral palsy 3 542169 742218 074 (052-104) 00
Total pediatric mortality 6 4012658 4002699 101 (089-114) 389
Fetal mortality 5 172254 222298 078 (042-146) 00
Under 2 y of corrected age mortality 5 2172254 2202298 100 (084-119) 473
Death or cerebral palsy 6 5052658 5512699 092 (083-102) 433
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
21
American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine - marccedilo 2010
ldquoA evidecircncia disponiacutevel sugere que o sulfato de magneacutesio administrado antes do nascimento prematuro reduz o risco de paralisia cerebralrdquo
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
Five trials (6145 babies) were eligible for this review Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (relative risk (RR) 068 95 Confidence interval (CI) 054 to 087 five trials 6145 infants) There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 061 95 CI 044 to 085 four trials 5980 infants) No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 104 95 CI 092 to 117 five trials 6145 infants) or on other neurological impairments or disabilities in the first few years of life Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy although there were significant reductions for the neuroprotective groups RR 085 95 CI 074 to 098 four trials 4446 infants but not for the other intent subgroups There were higher rates of minor maternal side effects in the magnesium groups but no significant effects on major maternal complications
22
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
Authors conclusions
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established
The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95 confidence interval 43 to 155)
23
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
bull Quando estaacute indicado
bull Como prescrever
Magnesium for fetal neuroprotection - American Journal of Obstetrics amp Gynecology MARCH 2011
24
25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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25Algorithm for selection of candidates and administration
of magnesium sulfate for fetal neuroprotection
American Journal of Obstetrics amp Gynecology -JUNE 2009
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
26
27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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27
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
28
29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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29
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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-
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
OBJETIVO
Avaliar a associaccedilatildeo da duraccedilatildeo da infusatildeo de sulfato de magneacutesio com natimorto ou morte paralisia cerebral e resultados adversos maternos e neonatais
34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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34
Association of duration of neuroprotective magnesium sulfate infusion with neonatal and maternal outcomesMcPherson JA1 Rouse DJ Grobman WA Palatnik A Stamilio DMObstet Gynecol 2014 Oct
CONCLUSAtildeO
A duraccedilatildeo da infusatildeo de sulfato de magneacutesio preacute-natal natildeo estaacute associada a risco de morte ou paralisia cerebral A duraccedilatildeo oacutetima do tratamento necessaacuteria para a neuroproteccedilatildeo maacutexima permanece desconhecida
Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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Nenhum estudo randomizado IG lt24 semanas
Cada serviccedilo deve avaliar a viabilidade
Se a famiacutelia optar por intervenccedilotildees neonatais nesta idade gestacional deve-se administrar sulfato de magneacutesio
updated Sep 30 2014
36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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36
37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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37
METHODS
We conducted a cohort study of singleton and twin gestation extremely low birth weight infants (1000 g birth weight) born at Duke University Medical Center (Durham NC USA) and admitted to the Duke Neonatal Intensive Care Unit The following three groups were defined those born before magnesium sulfate for neuroprotection protocol (MgPro) (1 January 2009 to 14 July 2010) during MgPro (15 July 2010 to 30 November 2010) and after MgPro (1 January 2011 to 30 October 2011)
DISCUSSAtildeOAnaacutelise de dados demonstrou uma maior taxa de SIP e morte com MgPro em relaccedilatildeo antes depois do protocolo com uma sugestatildeo que o magneacutesio preacute-natal exerce um efeito quantitativo fortemente influenciado pela idade gestacional ao inveacutes de um efeito geral sobre as crianccedilas de todos os pesos e idades gestacionais de nascimento
FETOS lt 25 SEMANAS ndash REAVALIAR DOSE - CONTROLAR NIacuteVEIS SEacuteRICOS DE Mg
38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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38
The Cochrane Library 2013
Objectives
To assess the effectiveness of magnesium sulphate given to women at term as a neuroprotective agent for the fetus
Authorsrsquo conclusions
There is currently insufficient evidence to assess the efficacy and safety of magnesium sulphate when administered to women for neuroprotection of the term fetus As there has been recent evidence for the use of magnesium sulphate for neuroprotection of the preterm fetus high-quality randomised controlled trials are needed to determine the safety profile and neurological outcomes for the term fetus Strategies to reduce maternal side effects during treatment also require evaluation
SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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SULFATO DE MAGNEacuteSIO PARA NEUROPROTECcedilAtildeO
IG 34 07 a 36 67 ndash sem evidecircncia de benefiacutecio
Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeksrsquo gestation
a systematic review and misanalysis JUNE 2009 American Journal of Obstetrics amp Gynecology
39
40
41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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41
42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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42
Mulheres com alto risco de parto dentro de 24 horas espontacircneo ou indicado entre 24 e 32 semanas de gestaccedilatildeo satildeo candidatas ao sulfato de magneacutesio para neuroproteccedilatildeo
updated Sep 30 2014
43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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43
Efeitos colaterais - sudorese rubor naacuteuseas dor de cabeccedila Toxicidade grave eacute rara mas pode levar a parada cardiacuteaca depressatildeo ou parada respiratoacuteria
Magneacutesio atravessa livremente a placenta
A concentraccedilatildeo no sangue do cordatildeo aproxima da do soro materno
Efeitos toacutexicos ou neuroprotetores fetais dependem da dose
Updated Sep 30 2014
Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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Objetivo
Magneacutesio preacute-natal (anteMg) eacute usado para vaacuterias indicaccedilotildees obsteacutetricas incluindo a neuroproteccedilatildeo fetal Crianccedilas expostas a anteMg pode estar em risco de depressatildeo respiratoacuteria na sala de parto (DR) O objetivo do estudo foi comparar o risco de eventos cardiorrespiratoacuterios agudos entre os prematuros que foram ou natildeo expostos a anteMg
Antenatal magnesium sulfate exposure and acute cardiorespiratory events in preterm infants - July 18 2014
ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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ResultadosForam avaliadas 1544 crianccedilas lt29 semanas de idade semanas gestacional (1091 no grupo anteMg e 453 no grupo natildeo expostos) Matildees do grupo anteMg eram mais propensos a ter ensino superior hipertensatildeo induzida pela gravidez e corticosteroacuteides preacute-natais enquanto seus filhos eram mais jovens na gestaccedilatildeo e pesava menos (P lt005) O desfecho primaacuterio (odds ratio [OR] 12 95 intervalo de confianccedila [IC] 088-165) foi semelhante entre os grupos O tratamento da hipotensatildeo (OR 070 95 CI51-097) e ventilaccedilatildeo mecacircnica invasiva (OR 054 IC 95 041-072) foram significativamente menores no grupo anteMg
conclusatildeoEntre prematuros lt29 semanas de gestaccedilatildeo a exposiccedilatildeo anteMg natildeo foi associada com um aumento de eventos cardiorrespiratoacuterios no periacuteodo neonatal precoce A seguranccedila de anteMg medida pela necessidade de intubaccedilatildeo ou suporte respiratoacuterio no dia 1 de vida era comparaacutevel entre os grupos
46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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46
School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placeboJAMA 2014 Sep 17312(11)1105-13 doi 101001jama201411189
Importance Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood although its effects into school age have not been reported from randomized trialsObjective - To determine the association between exposure to antenatal magnesium sulfate and neurological cognitive academic and behavioral outcomes at school ageDesign Setting and Participants The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand comparing magnesium sulfate with placebo given to pregnant women (nthinsp=thinsp535 magnesium nthinsp=thinsp527 placebo) for whom imminent birth was planned or expected before 30 weeksrsquo gestation Children who survived from the 14 centers who participated in the school-age follow-up (nthinsp=thinsp443 magnesium nthinsp=thinsp424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011
47
Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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Main Outcomes and Measures Mortality cerebral palsy motor function IQ basic academic skills attention and executive function behavior growth and functional outcomes Main analyses were imputed for missing dataResults Of the 1255 fetuses known to be alive at randomization the mortality rate to school age was 14 (88629) in the magnesium sulfate group and 18 (110626) in the placebo group (risk ratio [RR] 080 95 CI 062-103 Pthinsp=thinsp08) Of 867 survivors available for follow-up outcomes at school age (corrected age 6-11 years) were determined for 669 (77) Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23295 [8] and 21314 [7] respectively odds ratio [OR] 126 95 CI 084-191 Pthinsp=thinsp27) or abnormal motor function (80297 [27] and 80300 [27] respectively OR 116 95 CI 088-152 Pthinsp=thinsp28) There was also little difference between groups on any of the cognitive behavioral growth or functional outcomesConclusions and Relevance - Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeksrsquo gestation was not associated with neurological cognitive behavioral growth or functional outcomes in their children at school age although a mortality advantage cannot be excluded The lack of long-term benefit requires confirmation in additional studies
SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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SOGC CLINICAL PRACTICE GUIDELINEacute Magnesium Sulphate for Fetal Neuroprotection - No 258 May 2011
1 Para as mulheres com parto prematuro iminente (le 31 semanas e 6 dias) a administraccedilatildeo de sulfato de magneacutesio deve ser considerada para neuroproteccedilatildeo fetal (I-A)
2 Embora haja controveacutersia sobre a idade gestacional superior sulfato de magneacutesio para neuroproteccedilatildeo fetal deve ser considerado a partir de viabilidade ateacute le 31 + 6 semanas (II-1B)
3 Se o sulfato de magneacutesio preacute-natal foi iniciado para neuroproteccedilatildeo fetal tocoacutelise deve ser interrompida (III-A)
4 O sulfato de magneacutesio deve ser interrompido se o parto natildeo eacute mais iminente ou se administrado por 24 horas (II-2B)
5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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5 Para as mulheres com parto prematuro iminente sulfato de magneacutesio deve ser administrado como uma dose de ataque de 4g IV ao longo de 30 minutos seguido por um 1g h de manutenccedilatildeo ateacute o nascimento (II-2B)
6 Para parto prematuro planejado por indicaccedilotildees maternas e fetais sulfato de magneacutesio deve ser iniciado de preferecircncia dentro de 4 horas antes do nascimento(II-2B)
7 Natildeo haacute evidecircncias suficientes de que um curso de repeticcedilatildeo do sulfato de magneacutesio deve ser administrado (III-G)
8 Parto natildeo deve ser adiado a fim de administrar sulfato de magneacutesio para a neuroproteccedilatildeo fetal se houver indicaccedilatildeo materna e ou fetal para parto de emergecircncia (III-E)
9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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9 Quando o sulfato de magneacutesio eacute dado para a neuroproteccedilatildeo fetal prestadores de cuidados devem usar protocolos existentes para monitorizaccedilatildeo (III-A)
10 Indicaccedilotildees para monitorizaccedilatildeo fetal devem seguir as recomendaccedilotildees de vigilacircncia fetal (III-A)
11 Uma vez que o sulfato de magneacutesio tem o potencial de alterar a avaliaccedilatildeo neuroloacutegica do receacutem-nascido causando hipotonia ou apneacuteia prestadores de cuidados de sauacutede que cuidam de receacutem- nascido devem ter uma maior consciecircncia deste efeito (III-C)
51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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51
Na ausecircncia de indicaccedilatildeo de cesariana fetos com baixo peso devem ser submetidos agrave prova de trabalho de parto
A via de parto natildeo eacute um fator independente importante na mortalidade perinatal ou neurodesenvolvimento
Cesariana eletiva - riscos para a matildee Benefiacutecios para o receacutem-nascido de BPN em apresentaccedilatildeo cefaacutelica satildeo incertas
Updated Oct 27 2014
QUAL A MELHOR VIA DE PARTO
52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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52
Compressatildeo da cabeccedila do feto BPN pelos tecidos moles maternas natildeo eacute um dos principais determinantes do IVH Por esta razatildeo sugerimos evitar episiotomia ou foacuterceps de forma eletiva
Vaacutecuo eacute contra-indicado antes de 34 semanas de gestaccedilatildeo
Analgesia - necessidades maternas
Na cesaacuterea a incisatildeo na pele natildeo devem ser menor que o habitual
Updated Oct 27 2014
53
Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
54
Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
55
Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
56
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Background To compare neonatal mortality andneurodevelopmental outcomes at two years of age in verylow birth weight infants (le1500 g) born by cesarean withthose by vaginal delivery
World J Pediatr 201410(3)227-231
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Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
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Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
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Methods In this retrospective case-control study we evaluated neonatal mortality medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants bornbetween January 2005 and December 2010 Of the 710 infants 351 were born by the cesarean and 359710 by vaginal route
Results There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56351 (159) vs 71359 (198) P=020] VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221351 (630) vs 178359 (496) Plt0001] Therewere no differences in other neonatal morbidities including intraventricular hemorrhage [126351 (359) vs 134359 (373) P=069] bronchopulmonary dysplasia [39351 (11) vs 31359 (86) P=038] andnecrotising enterocolitis [40351 (114) vs 32359 (89) P=032] between the two groups The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105351 (299) vs104359 (290) P=078]
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Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
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Conclusions In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants Moreover the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants The mode ofdelivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate
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