Maurício Barbosa | Albert Einstein College of Medicine (original) (raw)

Papers by Maurício Barbosa

Research paper thumbnail of Interventions to improve fetal heart rate patterns during open myelomeningocele repair

Prenatal Cardiology, 2020

To access fetal heart rate (FHR) after multifactorial changes in the performance of open fetal my... more To access fetal heart rate (FHR) after multifactorial changes in the performance of open fetal myelomeningocele surgery. Material and methods: A study with 37 fetuses submitted to intrauterine myelomeningocele repair between the 24th and 27th week of gestation was performed to evaluate FHR at specific periods: pre-anaesthesia, postanaesthesia, during neurosurgery (early skin manipulation, spinal cord release, and synthesis), and at the end of surgery. Surgery room (SRT) and uterine surface (UST) temperatures were strictly controlled. A plastic cover was used to protect to protect uterine heat loss. We determined the mean ± standard deviation (SD) of FHR of each period, and we used analysis of variance (ANOVA) with repeated measures to assess differences among these periods. Tukey multiple comparation test was used to compare global surgery stages. Results: The mean FHR in the specific time points were: 138.6, 138.4, 132.8, 127.7, 131.4, and 132.7 bpm, respectively (p < 0.001). In the comparisons between times two by two, the neurosurgery stage presents the lower frequencies, especially during release of the spinal cord, but episodes of bradycardia were no longer found. SRT and UST remained stable during the critical stages of the procedure. Conclusions: It is known that many are the factors involved in fetal cardiovascular disorders. Possibly, these changes allowed for better haemodynamic control of the fetus, improving the safety of the procedure.

Research paper thumbnail of Re: Perinatal outcomes after open fetal surgery for myelomeningocele repair: a retrospective cohort study

BJOG : an international journal of obstetrics and gynaecology, Jan 15, 2018

Research paper thumbnail of EP21.02: Intrauterine open fetal surgery for cervical spina bifida correction: case report

Ultrasound in Obstetrics & Gynecology, 2017

Conclusions: Fetal therapy is associated with prenatally improvement in cardiac function in recip... more Conclusions: Fetal therapy is associated with prenatally improvement in cardiac function in recipients and donors. However, at third trimester there is still longitudinal motion abnormality in both fetuses and cardiac remodelling in the recipient. Postnatal cardiovascular evaluation is required to assess the clinical value of these findings.

Research paper thumbnail of 57: Histological evidence of reparative activity of chorioamniotic membrane after open fetal surgery for myelomeningocele

American Journal of Obstetrics and Gynecology, 2016

(53%), and 7 experienced poor outcomes (15%). The unadjusted odds of poor outcome was 0.28 (95% C... more (53%), and 7 experienced poor outcomes (15%). The unadjusted odds of poor outcome was 0.28 (95% CI 0.11-0.71) for women undergoing treatment at stage I versus expectant management. Adjusting for nulliparity and for cervical length, maximum vertical pocket and gestational age at diagnosis had little effect (odds ratio 0.29, 95% CI 0.08-1.00). The median number of days from diagnosis of stage I to a change in status in the expectant management group was 6 days (interquartile range 3-14 days). CONCLUSION: Stage I TTTS was associated with substantial perinatal mortality. Treatment of stage I TTTS was associated with a significantly lower risk of a poor outcome compared to expectant management, independent of multiple maternal factors. Spontaneous resolution was observed, though the majority of expectantly managed patients progressed. Further studies are needed to confirm these findings and to further define risk stratification and surveillance strategies for stage I TTTS.

Research paper thumbnail of Dopplervelocimetria Do Duct O Venoso Na Predi��o D a Acidemia Fet Al

RESUMO OBJETIVOS. Investigar a possibilidade da predição da acidemia no nascimento mediante doppl... more RESUMO OBJETIVOS. Investigar a possibilidade da predição da acidemia no nascimento mediante dopplervelocimetria do ducto venoso e definir qual o melhor parâmetro e seus pontos de corte nessa predição em gestações com insuficiência placentária. MÉTODOS. Trata-se de estudo transversal e prospectivo que analisou 47 gestações únicas com insuficiência placentária e idade gestacional superior a 26 semanas, realizado no Hospital São Paulo (UNIFESP) e na Maternidade-Escola Assis Chateaubriand (UFC). A insuficiência placentária foi diagnosticada quando o índice de pulsatilidade da artéria umbilical encontrava-se acima do percentil 95 para a idade gestacional estimada. Fetos com anomalias estruturais ou cromossômicas foram excluídos. O doppler foi realizado a menos de 24 horas do parto. A amostra de sangue da artéria umbilical foi coletada imediatamente após o nascimento para análise da gasometria. Diagnosticou-se acidemia quando o pH encontrava-se abaixo de 7,20 na ausência de trabalho de parto e abaixo de 7,15 quando parto vaginal. Foram consideradas patológicas as acidemias metabólicas ou mistas. Construiu-se curva ROC para as velocidades S, D e A e para o IPV e as relações S/A e (S-A)/S do DV (variáveis independentes) e acidemia (variável dependente). O teste de MacNemar foi utilizado para comparar os parâmetros entre si. RESULTADOS. As velocidades absolutas S, D e A mostraram ser pobres preditoras da acidemia no nascimento. O IPV mostrou ser bom preditor de acidemia (área sob a curva ROC 0,79, p=0,003). As relações S/A e (S-A)/S também mostraram ser boas preditoras da acidemia (área sob a curva ROC 0,818, p=0,001). Os pontos de corte calculados foram: IPV = 0,76, S/A = 2,67 e (S-A)/S = 0,63. CONCLUSÕES. Os índices ângulo-independentes do doppler do DV mostraram excelente correlação com acidemia no nascimento nesta população. Não houve diferença estatisticamene significativa entre estes parâmetros. UNITERMOS: Dopplervelocimetria. Ducto venoso. Acidemia fetal.

Research paper thumbnail of P10.30: Transverse cerebral sinus Doppler velocimetry in the prediction of birth acidemia

Ultrasound in Obstetrics & Gynecology, 2005

Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocim... more Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocimetry and to determine the best parameter and cutoff values for this prediction in pregnancies complicated with placental insufficiency. Patients and methods: This was a prospective cross-sectional study involving forty-seven patients with placental insufficiency managed in two Brazilian hospitals (Hospital São Paulo and Maternidade-Escola Assis Chateaubriand) who were submitted to DV Dopplervelocimetry in the last 24 hours before delivery. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. Metabolic or mixed acidemia at birth were considered pathological. A ROC curve was calculated for each DV parameter (independent variable) and acidemia (dependent variable). A cutoff value was established and sensibility, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated. The MacNemar test was used to compare the parameters. Results: The DV S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as the S/A and (S-A)/S ratios (ROC curve area 0.818, p = 0.001). The cut off values were PIV = 0.76, S/A = 2.67 and (S-A)/S = 0.63. Conclusions: In this high-risk population angle-independent DV Doppler indexes were good predictors of birth acidemia. PIV, S/A and (S-A)/S ratios were statistically equivalent in this prediction.

Research paper thumbnail of P10.29: Venous‐arterial pulsatility index in the prediction of fetal acidemia in pregnancies with placental insufficiency

Ultrasound in Obstetrics & Gynecology, 2005

Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocim... more Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocimetry and to determine the best parameter and cutoff values for this prediction in pregnancies complicated with placental insufficiency. Patients and methods: This was a prospective cross-sectional study involving forty-seven patients with placental insufficiency managed in two Brazilian hospitals (Hospital São Paulo and Maternidade-Escola Assis Chateaubriand) who were submitted to DV Dopplervelocimetry in the last 24 hours before delivery. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. Metabolic or mixed acidemia at birth were considered pathological. A ROC curve was calculated for each DV parameter (independent variable) and acidemia (dependent variable). A cutoff value was established and sensibility, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated. The MacNemar test was used to compare the parameters. Results: The DV S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as the S/A and (S-A)/S ratios (ROC curve area 0.818, p = 0.001). The cut off values were PIV = 0.76, S/A = 2.67 and (S-A)/S = 0.63. Conclusions: In this high-risk population angle-independent DV Doppler indexes were good predictors of birth acidemia. PIV, S/A and (S-A)/S ratios were statistically equivalent in this prediction.

Research paper thumbnail of P10.28: Ductus venosus velocimetry in the prediction of fetal acidemia: which is the best parameter?

Ultrasound in Obstetrics & Gynecology, 2005

Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocim... more Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocimetry and to determine the best parameter and cutoff values for this prediction in pregnancies complicated with placental insufficiency. Patients and methods: This was a prospective cross-sectional study involving forty-seven patients with placental insufficiency managed in two Brazilian hospitals (Hospital São Paulo and Maternidade-Escola Assis Chateaubriand) who were submitted to DV Dopplervelocimetry in the last 24 hours before delivery. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. Metabolic or mixed acidemia at birth were considered pathological. A ROC curve was calculated for each DV parameter (independent variable) and acidemia (dependent variable). A cutoff value was established and sensibility, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated. The MacNemar test was used to compare the parameters. Results: The DV S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as the S/A and (S-A)/S ratios (ROC curve area 0.818, p = 0.001). The cut off values were PIV = 0.76, S/A = 2.67 and (S-A)/S = 0.63. Conclusions: In this high-risk population angle-independent DV Doppler indexes were good predictors of birth acidemia. PIV, S/A and (S-A)/S ratios were statistically equivalent in this prediction.

Research paper thumbnail of Venous-Arterial Doppler Ratios in the Prediction of Acidemia at Birth in Pregnancies with Placental Insufficiency

Fetal Diagnosis and Therapy, 2006

Objectives: Investigate the prediction of birth acidemia in pregnancies with placental insufficie... more Objectives: Investigate the prediction of birth acidemia in pregnancies with placental insufficiency using two newly created venous-arterial Doppler ratios: pulsatility index (PI) of the ductus venosus (DV) over PI of the middle cerebral artery (MCA) and PI of the DV over PI of the umbilical artery and establish cut-off values for this prediction. Methods: This was a prospective cross-sectional study involving 47 patients with placental insufficiency managed in two Brazilian hospitals. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. A ROC curve was calculated for the venous-arterial ratios (independent variable) and acidemia (dependent variable). Results: The DV/AU PI ratio was not a good predictor of acidemia at birth. The DV/MCA PI ratio was related to fetal acidemia (area under the ROC curve 0.785, p = 0.004). The cut-off value was 0.582, sensibility 66.7%, specificity 77.1% and accuracy 74.5%. Conclusions: The DV/MCA PI ratio ...

Research paper thumbnail of Antenatal management of fetal neurosurgical diseases

Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, Jan 29, 2017

The advance in the imaging tools during the pregnancy (ultrasound and magnetic resonance) allowed... more The advance in the imaging tools during the pregnancy (ultrasound and magnetic resonance) allowed the early diagnose of many fetal diseases, including the neurological conditions. This progress brought the neurosurgeons the possibility to propose treatments even before birth. Myelomeningocele is the most recognized disease that can be treated during pregnancy with a high rate of success. Additionally, this field can be extended to other conditions such as hydrocephalus and encephaloceles. However, each one of these diseases has nuances in the diagnostic evaluation that should fit the requirements to perform the fetal procedure and overbalance the benefits to the patients. In this article, the authors aim to review the neurosurgical aspects of the antenatal management of neurosurgical conditions based on the experience of a pediatric neurosurgery center.

Research paper thumbnail of Functional Motor Skills in Children Who Underwent Fetal Myelomeningocele Repair: Does Anatomic Level Matter?

Research paper thumbnail of Fetal modified left myocardial performance index monitoring during open surgery for myelomeningocele repair

Echocardiography (Mount Kisco, N.Y.), Oct 26, 2018

Fetal hemodynamic changes have already been described during open myelomeningocele repair. This s... more Fetal hemodynamic changes have already been described during open myelomeningocele repair. This study aimed to access fetal myocardial performance index (MPI) during this high-complexity surgery. Open myelomeningocele repair was performed in 37 fetuses between the 24th and 27th week of gestation. MPI was calculated at specific periods: pre-anesthesia, postanesthesia, neurosurgery (early skin manipulation, spinal cord releasing, and sintesis), and end of surgery. Mean ± standard deviation (SD) of MPI and its related times-isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), and ejection time (ET)-was determined for each period. Analysis of variance (ANOVA) with repeated measures was used to assess differences among these periods. Tukey multiple comparison times test compared global surgery stages. The mean of MPI in the specific time points was 0.32, 0.32, 0.34, 0.48, 0.36, and 0.32, respectively (P < .001). In the two-tailed comparison times, neurosurgery st...

Research paper thumbnail of Fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome treatment: initial experience in tertiary reference center in Brazil

Obstetrics & gynecology science, 2018

To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for ... more To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil. This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18-26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ test and Mann-Whitney test were used for the statistical analysis. The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetus...

Research paper thumbnail of Cerebellar herniation demonstrated by the occipitum-dens line: Ultrasonography assessment of normal fetuses, fetuses with myelomeningocele, and fetuses that underwent antenatal myelomeningocele surgery

Prenatal diagnosis, Mar 10, 2018

To establish a method to quantify the position of the cerebellum by ultrasonography in normal fet... more To establish a method to quantify the position of the cerebellum by ultrasonography in normal fetuses, fetuses with myelomeningocele (MMC), and fetuses that underwent in utero MMC repair. Reference points identifiable on ultrasound were established. The basilar portion of the occipital bone and upper portion of the odontoid process were considered as the external and internal limits, respectively, of the level zero of a line that was designated the occipitum-dens line (ODL). Eighty-three normal fetuses were assessed 1 occasion (cross-sectional study) in addition to 25 fetuses with MMC and 25 fetuses that underwent in utero MMC repair. The groups were compared using analysis of variance or the Kruskal-Wallis test. The intraclass correlation coefficient (ICC) was used to determine intra- and interobserver reproducibility. The analysis of ODL indicated that all normal fetuses had the cerebellar tonsil above level zero at a mean distance of 2.8 ± 1.1 mm (P = 0.125). The fetuses with MMC...

Research paper thumbnail of Fetal Heart Rate Monitoring during Intrauterine Open Surgery for Myelomeningocele Repair

Fetal Diagnosis and Therapy, 2015

Objective: The aim of this study was to assess fetal hemodynamics during intrauterine open surger... more Objective: The aim of this study was to assess fetal hemodynamics during intrauterine open surgery for myelomeningocele (MMC) repair by describing fetal heart rate (FHR) monitoring in detail related to each part of the procedure. Methods: A study was performed with 57 fetuses submitted to intrauterine MMC repair between the 24th and 27th week of gestation. Evaluations of FHR were made in specific periods: before anesthesia, after anesthesia, at the beginning of laparotomy, during uterus abdominal withdrawal, hysterotomy, neurosurgery (before incision, during early skin manipulation, spinal cord releasing, and at the end of neurosurgery), abdominal cavity reintroduction, and abdominal closure, and at the end of surgery. Means ± standard deviations of FHR were established for each period, and analysis of variance with repeated measures was used to assess differences between these periods. The mean differences were assessed with 95% confidence intervals and were analyzed by Tukey's...

Research paper thumbnail of Fetal brain tumors: Prenatal diagnosis by ultrasound and magnetic resonance imaging

World journal of radiology, Jan 28, 2015

Congenital central nervous system tumors diagnosed during pregnancy are rare, and often have a po... more Congenital central nervous system tumors diagnosed during pregnancy are rare, and often have a poor prognosis. The most frequent type is the teratoma. Use of ultrasound and magnetic resonance image allows the suspicion of brain tumors during pregnancy. However, the definitive diagnosis is only confirmed after birth by histology. The purpose of this mini-review article is to describe the general clinical aspects of intracranial tumors and describe the main fetal brain tumors.

Research paper thumbnail of Ductus venosus versus cerebral transverse sinus Doppler velocimetry for predicting acidemia at birth in pregnancies complicated by placental insufficiency

Prenatal diagnosis, 2013

The objectives of this study is to compare ductus venosus (DV) and cerebral transverse sinus (CTS... more The objectives of this study is to compare ductus venosus (DV) and cerebral transverse sinus (CTS) Doppler velocimetry for predicting acidemia at birth in pregnancies complicated by placental insufficiency. A prospective cross-sectional study involving 69 cases. Doppler assessment of the DV and CTS was carried out in the last 24 hours prior to delivery. The sensitivity, specificity, positive and negative predictive values, and the accuracy and false-positive and false-negative rates were calculated for those parameters considered to be good predictors of acidemia. The McNemar test was used to compare the various parameters. The DV pulsatility index(PI), S/A, and (S - A)/S ratios as well as the CTS PI and the (S - A)/S ratio were good predictors of acidemia. The comparison between DV and CTS showed that for pulsatility index for veins, the sensitivity was 52.4% versus 66.7%, p = 0.508; the specificity was 81.2% versus 77.1%, p = 0.774; and the accuracy was 72.5% versus 73.9%, p = 1.0...

Research paper thumbnail of Ductus venosus Doppler velocimetry in the prediction of acidemia at birth: which is the best parameter?

Prenatal Diagnosis, 2005

To evaluate the prediction of acidemia at birth using ductus venosus Doppler velocimetry and to d... more To evaluate the prediction of acidemia at birth using ductus venosus Doppler velocimetry and to determine the best parameter and cut-off values for this prediction in pregnancies complicated with placental insufficiency. Prospective cross-sectional study. Forty-seven patients with placental insufficiency managed in two Brazilian hospitals were submitted to ductus venosus Doppler velocimetry in the last 24 h before delivery. All pregnancies were singleton, at least 26 weeks of age and without structural or chromosomal anomalies. A ROC curve was calculated for each ductus venosus parameter (independent variable) and acidemia (dependent variable). A cut-off value was established. The McNemar test was used to compare the various parameters. The ductus venosus S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as S/A and (S - A)/S ratios (ROC curve area 0.818, p = 0.001). The cut-off values were PIV = 0.76, S/A = 2.67 and (S - A)/S = 0.63. In this high-risk population, angle-independent ductus venosus Doppler indexes were good predictors of birth acidemia. The S/A and (S - A)/S ratios and the ductus venosus PIV were statistically equivalent in this prediction.

Research paper thumbnail of Ductus venosus Doppler velocimetry to predict acidemia at birth in pregnancies with placental insufficiency

Revista da Associação …, 2005

OBJETIVOS: Investigar a possibilidade da predição da acidemia no nascimento mediante dopplerveloc... more OBJETIVOS: Investigar a possibilidade da predição da acidemia no nascimento mediante dopplervelocimetria do ducto venoso e definir qual o melhor parâmetro e seus pontos de corte nessa predição em gestações com insuficiência placentária. MÉTODOS: Trata-se de estudo transversal e ...

Research paper thumbnail of Fetal growth restriction: current knowledge to the general Obs/Gyn

Archives of Gynecology and Obstetrics, 2012

Background Fetal growth restriction (FGR) is a condition that affects 5-10 % of gestations, and i... more Background Fetal growth restriction (FGR) is a condition that affects 5-10 % of gestations, and it is the second primary cause of perinatal mortality. In this review the most recent knowledge about FGR is presented focusing on its concept, etiology, classification, diagnosis, management, and prognosis. Methods Searches were conducted in Pubmed, Embase and Lilacs database using the term fetal growth restriction. Results FGR is classified as type I (symmetric), manifested early, in which there is a proportional reduction of all fetal parts, generally associated with chromosome abnormalities; type II (asymmetric), with late onset, in which there is a more accentuated reduction of the abdomen, generally related to placental insufficiency; and type III (mixed), with early manifestation, resulting from infections or exposure to toxic agents. Diagnosis may be clinical, although ultrasound associated with arterial and venous Doppler is essential for diagnosis and follow-up. Currently there is no treatment capable of controlling FGR, and the moment of interruption of pregnancy is of vital importance in order to protect maternal and fetal interests. Conclusion Early diagnosis of FGR is very important, because it permits the etiological identification and adequate monitoring of fetal vitality, minimizing the risks related to prematurity and intrauterine hypoxia. Keywords Fetal growth restriction Á Etiology Á Classification Á Doppler ultrasound Á Management Á Prognosis Fetal growth restriction (FGR) is an event that affects 5-10 % of pregnancies [1], and is the second primary cause of perinatal mortality, accounting for 30 % of stillborns, besides determining a higher frequency of premature births and intrapartum asphyxia. It is also associated with neonatal complications, including meconium aspiration, metabolic and hematological disorders, cognitive dysfunction, and cerebral palsy. Some epidemiological studies also report a higher incidence of coronary diseases, arterial hypertension, and diabetes in adult life [2]. Nonetheless, FGR in several cases is not detected during the prenatal phase [3], making this disorder one of the main challenges of Obstetrics today. Further advances are needed, from a better definition of the concept to the establishment of management protocols to assure better prenatal assistance and neonatal well being. In this review, we cover the concept, etiology, classification, diagnosis, management, and prognosis of FGR, with emphasis on the most recent findings of this condition. Concept The definitions of FGR diverge in literature. Ideally, it is understood as a process capable of modifying the growth

Research paper thumbnail of Interventions to improve fetal heart rate patterns during open myelomeningocele repair

Prenatal Cardiology, 2020

To access fetal heart rate (FHR) after multifactorial changes in the performance of open fetal my... more To access fetal heart rate (FHR) after multifactorial changes in the performance of open fetal myelomeningocele surgery. Material and methods: A study with 37 fetuses submitted to intrauterine myelomeningocele repair between the 24th and 27th week of gestation was performed to evaluate FHR at specific periods: pre-anaesthesia, postanaesthesia, during neurosurgery (early skin manipulation, spinal cord release, and synthesis), and at the end of surgery. Surgery room (SRT) and uterine surface (UST) temperatures were strictly controlled. A plastic cover was used to protect to protect uterine heat loss. We determined the mean ± standard deviation (SD) of FHR of each period, and we used analysis of variance (ANOVA) with repeated measures to assess differences among these periods. Tukey multiple comparation test was used to compare global surgery stages. Results: The mean FHR in the specific time points were: 138.6, 138.4, 132.8, 127.7, 131.4, and 132.7 bpm, respectively (p < 0.001). In the comparisons between times two by two, the neurosurgery stage presents the lower frequencies, especially during release of the spinal cord, but episodes of bradycardia were no longer found. SRT and UST remained stable during the critical stages of the procedure. Conclusions: It is known that many are the factors involved in fetal cardiovascular disorders. Possibly, these changes allowed for better haemodynamic control of the fetus, improving the safety of the procedure.

Research paper thumbnail of Re: Perinatal outcomes after open fetal surgery for myelomeningocele repair: a retrospective cohort study

BJOG : an international journal of obstetrics and gynaecology, Jan 15, 2018

Research paper thumbnail of EP21.02: Intrauterine open fetal surgery for cervical spina bifida correction: case report

Ultrasound in Obstetrics & Gynecology, 2017

Conclusions: Fetal therapy is associated with prenatally improvement in cardiac function in recip... more Conclusions: Fetal therapy is associated with prenatally improvement in cardiac function in recipients and donors. However, at third trimester there is still longitudinal motion abnormality in both fetuses and cardiac remodelling in the recipient. Postnatal cardiovascular evaluation is required to assess the clinical value of these findings.

Research paper thumbnail of 57: Histological evidence of reparative activity of chorioamniotic membrane after open fetal surgery for myelomeningocele

American Journal of Obstetrics and Gynecology, 2016

(53%), and 7 experienced poor outcomes (15%). The unadjusted odds of poor outcome was 0.28 (95% C... more (53%), and 7 experienced poor outcomes (15%). The unadjusted odds of poor outcome was 0.28 (95% CI 0.11-0.71) for women undergoing treatment at stage I versus expectant management. Adjusting for nulliparity and for cervical length, maximum vertical pocket and gestational age at diagnosis had little effect (odds ratio 0.29, 95% CI 0.08-1.00). The median number of days from diagnosis of stage I to a change in status in the expectant management group was 6 days (interquartile range 3-14 days). CONCLUSION: Stage I TTTS was associated with substantial perinatal mortality. Treatment of stage I TTTS was associated with a significantly lower risk of a poor outcome compared to expectant management, independent of multiple maternal factors. Spontaneous resolution was observed, though the majority of expectantly managed patients progressed. Further studies are needed to confirm these findings and to further define risk stratification and surveillance strategies for stage I TTTS.

Research paper thumbnail of Dopplervelocimetria Do Duct O Venoso Na Predi��o D a Acidemia Fet Al

RESUMO OBJETIVOS. Investigar a possibilidade da predição da acidemia no nascimento mediante doppl... more RESUMO OBJETIVOS. Investigar a possibilidade da predição da acidemia no nascimento mediante dopplervelocimetria do ducto venoso e definir qual o melhor parâmetro e seus pontos de corte nessa predição em gestações com insuficiência placentária. MÉTODOS. Trata-se de estudo transversal e prospectivo que analisou 47 gestações únicas com insuficiência placentária e idade gestacional superior a 26 semanas, realizado no Hospital São Paulo (UNIFESP) e na Maternidade-Escola Assis Chateaubriand (UFC). A insuficiência placentária foi diagnosticada quando o índice de pulsatilidade da artéria umbilical encontrava-se acima do percentil 95 para a idade gestacional estimada. Fetos com anomalias estruturais ou cromossômicas foram excluídos. O doppler foi realizado a menos de 24 horas do parto. A amostra de sangue da artéria umbilical foi coletada imediatamente após o nascimento para análise da gasometria. Diagnosticou-se acidemia quando o pH encontrava-se abaixo de 7,20 na ausência de trabalho de parto e abaixo de 7,15 quando parto vaginal. Foram consideradas patológicas as acidemias metabólicas ou mistas. Construiu-se curva ROC para as velocidades S, D e A e para o IPV e as relações S/A e (S-A)/S do DV (variáveis independentes) e acidemia (variável dependente). O teste de MacNemar foi utilizado para comparar os parâmetros entre si. RESULTADOS. As velocidades absolutas S, D e A mostraram ser pobres preditoras da acidemia no nascimento. O IPV mostrou ser bom preditor de acidemia (área sob a curva ROC 0,79, p=0,003). As relações S/A e (S-A)/S também mostraram ser boas preditoras da acidemia (área sob a curva ROC 0,818, p=0,001). Os pontos de corte calculados foram: IPV = 0,76, S/A = 2,67 e (S-A)/S = 0,63. CONCLUSÕES. Os índices ângulo-independentes do doppler do DV mostraram excelente correlação com acidemia no nascimento nesta população. Não houve diferença estatisticamene significativa entre estes parâmetros. UNITERMOS: Dopplervelocimetria. Ducto venoso. Acidemia fetal.

Research paper thumbnail of P10.30: Transverse cerebral sinus Doppler velocimetry in the prediction of birth acidemia

Ultrasound in Obstetrics & Gynecology, 2005

Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocim... more Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocimetry and to determine the best parameter and cutoff values for this prediction in pregnancies complicated with placental insufficiency. Patients and methods: This was a prospective cross-sectional study involving forty-seven patients with placental insufficiency managed in two Brazilian hospitals (Hospital São Paulo and Maternidade-Escola Assis Chateaubriand) who were submitted to DV Dopplervelocimetry in the last 24 hours before delivery. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. Metabolic or mixed acidemia at birth were considered pathological. A ROC curve was calculated for each DV parameter (independent variable) and acidemia (dependent variable). A cutoff value was established and sensibility, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated. The MacNemar test was used to compare the parameters. Results: The DV S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as the S/A and (S-A)/S ratios (ROC curve area 0.818, p = 0.001). The cut off values were PIV = 0.76, S/A = 2.67 and (S-A)/S = 0.63. Conclusions: In this high-risk population angle-independent DV Doppler indexes were good predictors of birth acidemia. PIV, S/A and (S-A)/S ratios were statistically equivalent in this prediction.

Research paper thumbnail of P10.29: Venous‐arterial pulsatility index in the prediction of fetal acidemia in pregnancies with placental insufficiency

Ultrasound in Obstetrics & Gynecology, 2005

Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocim... more Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocimetry and to determine the best parameter and cutoff values for this prediction in pregnancies complicated with placental insufficiency. Patients and methods: This was a prospective cross-sectional study involving forty-seven patients with placental insufficiency managed in two Brazilian hospitals (Hospital São Paulo and Maternidade-Escola Assis Chateaubriand) who were submitted to DV Dopplervelocimetry in the last 24 hours before delivery. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. Metabolic or mixed acidemia at birth were considered pathological. A ROC curve was calculated for each DV parameter (independent variable) and acidemia (dependent variable). A cutoff value was established and sensibility, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated. The MacNemar test was used to compare the parameters. Results: The DV S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as the S/A and (S-A)/S ratios (ROC curve area 0.818, p = 0.001). The cut off values were PIV = 0.76, S/A = 2.67 and (S-A)/S = 0.63. Conclusions: In this high-risk population angle-independent DV Doppler indexes were good predictors of birth acidemia. PIV, S/A and (S-A)/S ratios were statistically equivalent in this prediction.

Research paper thumbnail of P10.28: Ductus venosus velocimetry in the prediction of fetal acidemia: which is the best parameter?

Ultrasound in Obstetrics & Gynecology, 2005

Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocim... more Objectives: To evaluate the prediction of fetal acidemia using ductus venosus (DV) Dopplervelocimetry and to determine the best parameter and cutoff values for this prediction in pregnancies complicated with placental insufficiency. Patients and methods: This was a prospective cross-sectional study involving forty-seven patients with placental insufficiency managed in two Brazilian hospitals (Hospital São Paulo and Maternidade-Escola Assis Chateaubriand) who were submitted to DV Dopplervelocimetry in the last 24 hours before delivery. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. Metabolic or mixed acidemia at birth were considered pathological. A ROC curve was calculated for each DV parameter (independent variable) and acidemia (dependent variable). A cutoff value was established and sensibility, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated. The MacNemar test was used to compare the parameters. Results: The DV S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as the S/A and (S-A)/S ratios (ROC curve area 0.818, p = 0.001). The cut off values were PIV = 0.76, S/A = 2.67 and (S-A)/S = 0.63. Conclusions: In this high-risk population angle-independent DV Doppler indexes were good predictors of birth acidemia. PIV, S/A and (S-A)/S ratios were statistically equivalent in this prediction.

Research paper thumbnail of Venous-Arterial Doppler Ratios in the Prediction of Acidemia at Birth in Pregnancies with Placental Insufficiency

Fetal Diagnosis and Therapy, 2006

Objectives: Investigate the prediction of birth acidemia in pregnancies with placental insufficie... more Objectives: Investigate the prediction of birth acidemia in pregnancies with placental insufficiency using two newly created venous-arterial Doppler ratios: pulsatility index (PI) of the ductus venosus (DV) over PI of the middle cerebral artery (MCA) and PI of the DV over PI of the umbilical artery and establish cut-off values for this prediction. Methods: This was a prospective cross-sectional study involving 47 patients with placental insufficiency managed in two Brazilian hospitals. All pregnancies were singleton, over 26 weeks of age and without structural or chromosome anomalies. A ROC curve was calculated for the venous-arterial ratios (independent variable) and acidemia (dependent variable). Results: The DV/AU PI ratio was not a good predictor of acidemia at birth. The DV/MCA PI ratio was related to fetal acidemia (area under the ROC curve 0.785, p = 0.004). The cut-off value was 0.582, sensibility 66.7%, specificity 77.1% and accuracy 74.5%. Conclusions: The DV/MCA PI ratio ...

Research paper thumbnail of Antenatal management of fetal neurosurgical diseases

Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, Jan 29, 2017

The advance in the imaging tools during the pregnancy (ultrasound and magnetic resonance) allowed... more The advance in the imaging tools during the pregnancy (ultrasound and magnetic resonance) allowed the early diagnose of many fetal diseases, including the neurological conditions. This progress brought the neurosurgeons the possibility to propose treatments even before birth. Myelomeningocele is the most recognized disease that can be treated during pregnancy with a high rate of success. Additionally, this field can be extended to other conditions such as hydrocephalus and encephaloceles. However, each one of these diseases has nuances in the diagnostic evaluation that should fit the requirements to perform the fetal procedure and overbalance the benefits to the patients. In this article, the authors aim to review the neurosurgical aspects of the antenatal management of neurosurgical conditions based on the experience of a pediatric neurosurgery center.

Research paper thumbnail of Functional Motor Skills in Children Who Underwent Fetal Myelomeningocele Repair: Does Anatomic Level Matter?

Research paper thumbnail of Fetal modified left myocardial performance index monitoring during open surgery for myelomeningocele repair

Echocardiography (Mount Kisco, N.Y.), Oct 26, 2018

Fetal hemodynamic changes have already been described during open myelomeningocele repair. This s... more Fetal hemodynamic changes have already been described during open myelomeningocele repair. This study aimed to access fetal myocardial performance index (MPI) during this high-complexity surgery. Open myelomeningocele repair was performed in 37 fetuses between the 24th and 27th week of gestation. MPI was calculated at specific periods: pre-anesthesia, postanesthesia, neurosurgery (early skin manipulation, spinal cord releasing, and sintesis), and end of surgery. Mean ± standard deviation (SD) of MPI and its related times-isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), and ejection time (ET)-was determined for each period. Analysis of variance (ANOVA) with repeated measures was used to assess differences among these periods. Tukey multiple comparison times test compared global surgery stages. The mean of MPI in the specific time points was 0.32, 0.32, 0.34, 0.48, 0.36, and 0.32, respectively (P < .001). In the two-tailed comparison times, neurosurgery st...

Research paper thumbnail of Fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome treatment: initial experience in tertiary reference center in Brazil

Obstetrics & gynecology science, 2018

To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for ... more To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil. This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18-26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ test and Mann-Whitney test were used for the statistical analysis. The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetus...

Research paper thumbnail of Cerebellar herniation demonstrated by the occipitum-dens line: Ultrasonography assessment of normal fetuses, fetuses with myelomeningocele, and fetuses that underwent antenatal myelomeningocele surgery

Prenatal diagnosis, Mar 10, 2018

To establish a method to quantify the position of the cerebellum by ultrasonography in normal fet... more To establish a method to quantify the position of the cerebellum by ultrasonography in normal fetuses, fetuses with myelomeningocele (MMC), and fetuses that underwent in utero MMC repair. Reference points identifiable on ultrasound were established. The basilar portion of the occipital bone and upper portion of the odontoid process were considered as the external and internal limits, respectively, of the level zero of a line that was designated the occipitum-dens line (ODL). Eighty-three normal fetuses were assessed 1 occasion (cross-sectional study) in addition to 25 fetuses with MMC and 25 fetuses that underwent in utero MMC repair. The groups were compared using analysis of variance or the Kruskal-Wallis test. The intraclass correlation coefficient (ICC) was used to determine intra- and interobserver reproducibility. The analysis of ODL indicated that all normal fetuses had the cerebellar tonsil above level zero at a mean distance of 2.8 ± 1.1 mm (P = 0.125). The fetuses with MMC...

Research paper thumbnail of Fetal Heart Rate Monitoring during Intrauterine Open Surgery for Myelomeningocele Repair

Fetal Diagnosis and Therapy, 2015

Objective: The aim of this study was to assess fetal hemodynamics during intrauterine open surger... more Objective: The aim of this study was to assess fetal hemodynamics during intrauterine open surgery for myelomeningocele (MMC) repair by describing fetal heart rate (FHR) monitoring in detail related to each part of the procedure. Methods: A study was performed with 57 fetuses submitted to intrauterine MMC repair between the 24th and 27th week of gestation. Evaluations of FHR were made in specific periods: before anesthesia, after anesthesia, at the beginning of laparotomy, during uterus abdominal withdrawal, hysterotomy, neurosurgery (before incision, during early skin manipulation, spinal cord releasing, and at the end of neurosurgery), abdominal cavity reintroduction, and abdominal closure, and at the end of surgery. Means ± standard deviations of FHR were established for each period, and analysis of variance with repeated measures was used to assess differences between these periods. The mean differences were assessed with 95% confidence intervals and were analyzed by Tukey's...

Research paper thumbnail of Fetal brain tumors: Prenatal diagnosis by ultrasound and magnetic resonance imaging

World journal of radiology, Jan 28, 2015

Congenital central nervous system tumors diagnosed during pregnancy are rare, and often have a po... more Congenital central nervous system tumors diagnosed during pregnancy are rare, and often have a poor prognosis. The most frequent type is the teratoma. Use of ultrasound and magnetic resonance image allows the suspicion of brain tumors during pregnancy. However, the definitive diagnosis is only confirmed after birth by histology. The purpose of this mini-review article is to describe the general clinical aspects of intracranial tumors and describe the main fetal brain tumors.

Research paper thumbnail of Ductus venosus versus cerebral transverse sinus Doppler velocimetry for predicting acidemia at birth in pregnancies complicated by placental insufficiency

Prenatal diagnosis, 2013

The objectives of this study is to compare ductus venosus (DV) and cerebral transverse sinus (CTS... more The objectives of this study is to compare ductus venosus (DV) and cerebral transverse sinus (CTS) Doppler velocimetry for predicting acidemia at birth in pregnancies complicated by placental insufficiency. A prospective cross-sectional study involving 69 cases. Doppler assessment of the DV and CTS was carried out in the last 24 hours prior to delivery. The sensitivity, specificity, positive and negative predictive values, and the accuracy and false-positive and false-negative rates were calculated for those parameters considered to be good predictors of acidemia. The McNemar test was used to compare the various parameters. The DV pulsatility index(PI), S/A, and (S - A)/S ratios as well as the CTS PI and the (S - A)/S ratio were good predictors of acidemia. The comparison between DV and CTS showed that for pulsatility index for veins, the sensitivity was 52.4% versus 66.7%, p = 0.508; the specificity was 81.2% versus 77.1%, p = 0.774; and the accuracy was 72.5% versus 73.9%, p = 1.0...

Research paper thumbnail of Ductus venosus Doppler velocimetry in the prediction of acidemia at birth: which is the best parameter?

Prenatal Diagnosis, 2005

To evaluate the prediction of acidemia at birth using ductus venosus Doppler velocimetry and to d... more To evaluate the prediction of acidemia at birth using ductus venosus Doppler velocimetry and to determine the best parameter and cut-off values for this prediction in pregnancies complicated with placental insufficiency. Prospective cross-sectional study. Forty-seven patients with placental insufficiency managed in two Brazilian hospitals were submitted to ductus venosus Doppler velocimetry in the last 24 h before delivery. All pregnancies were singleton, at least 26 weeks of age and without structural or chromosomal anomalies. A ROC curve was calculated for each ductus venosus parameter (independent variable) and acidemia (dependent variable). A cut-off value was established. The McNemar test was used to compare the various parameters. The ductus venosus S, D and A peak velocities were not good predictors of acidemia at birth. Pulsatility Index for Veins (PIV) was a good predictor of acidemia (ROC curve area 0.79, p = 0.003), as well as S/A and (S - A)/S ratios (ROC curve area 0.818, p = 0.001). The cut-off values were PIV = 0.76, S/A = 2.67 and (S - A)/S = 0.63. In this high-risk population, angle-independent ductus venosus Doppler indexes were good predictors of birth acidemia. The S/A and (S - A)/S ratios and the ductus venosus PIV were statistically equivalent in this prediction.

Research paper thumbnail of Ductus venosus Doppler velocimetry to predict acidemia at birth in pregnancies with placental insufficiency

Revista da Associação …, 2005

OBJETIVOS: Investigar a possibilidade da predição da acidemia no nascimento mediante dopplerveloc... more OBJETIVOS: Investigar a possibilidade da predição da acidemia no nascimento mediante dopplervelocimetria do ducto venoso e definir qual o melhor parâmetro e seus pontos de corte nessa predição em gestações com insuficiência placentária. MÉTODOS: Trata-se de estudo transversal e ...

Research paper thumbnail of Fetal growth restriction: current knowledge to the general Obs/Gyn

Archives of Gynecology and Obstetrics, 2012

Background Fetal growth restriction (FGR) is a condition that affects 5-10 % of gestations, and i... more Background Fetal growth restriction (FGR) is a condition that affects 5-10 % of gestations, and it is the second primary cause of perinatal mortality. In this review the most recent knowledge about FGR is presented focusing on its concept, etiology, classification, diagnosis, management, and prognosis. Methods Searches were conducted in Pubmed, Embase and Lilacs database using the term fetal growth restriction. Results FGR is classified as type I (symmetric), manifested early, in which there is a proportional reduction of all fetal parts, generally associated with chromosome abnormalities; type II (asymmetric), with late onset, in which there is a more accentuated reduction of the abdomen, generally related to placental insufficiency; and type III (mixed), with early manifestation, resulting from infections or exposure to toxic agents. Diagnosis may be clinical, although ultrasound associated with arterial and venous Doppler is essential for diagnosis and follow-up. Currently there is no treatment capable of controlling FGR, and the moment of interruption of pregnancy is of vital importance in order to protect maternal and fetal interests. Conclusion Early diagnosis of FGR is very important, because it permits the etiological identification and adequate monitoring of fetal vitality, minimizing the risks related to prematurity and intrauterine hypoxia. Keywords Fetal growth restriction Á Etiology Á Classification Á Doppler ultrasound Á Management Á Prognosis Fetal growth restriction (FGR) is an event that affects 5-10 % of pregnancies [1], and is the second primary cause of perinatal mortality, accounting for 30 % of stillborns, besides determining a higher frequency of premature births and intrapartum asphyxia. It is also associated with neonatal complications, including meconium aspiration, metabolic and hematological disorders, cognitive dysfunction, and cerebral palsy. Some epidemiological studies also report a higher incidence of coronary diseases, arterial hypertension, and diabetes in adult life [2]. Nonetheless, FGR in several cases is not detected during the prenatal phase [3], making this disorder one of the main challenges of Obstetrics today. Further advances are needed, from a better definition of the concept to the establishment of management protocols to assure better prenatal assistance and neonatal well being. In this review, we cover the concept, etiology, classification, diagnosis, management, and prognosis of FGR, with emphasis on the most recent findings of this condition. Concept The definitions of FGR diverge in literature. Ideally, it is understood as a process capable of modifying the growth