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Volume 58 • Número 6 • Novembro/Dezembro 2012 • ISSN 0104-4230 • ISSN 1806-9282 (On-line)
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ARTIGOS
ARTIGOS ORIGINAIS _____________Qualidade da informação da internet disponível para pacientes em páginas em português ___________________________________________________________645 Acesso a informações de saúde na internet: uma questão de saúde pública? ______650 Maus-tratos contra a criança e o adolescente no Estado de São Paulo, 2009_______659 Obesidade e hipertensão arterial em escolares de Santa Cruz do Sul – RS, Brasil ___666 Bone mineral density in postmenopausal women with and without breast cancer ___673 Prevalence and factors associated with thoracic alterations in infants born prematurely __________________________________________________679 Análise espacial de óbitos por acidentes de trânsito, antes e após a Lei Seca, nas microrregiões do estado de São Paulo ___________________________________685 Sobrevida e complicações em idosos com doenças neurológicas em nutrição enteral ______________________________________________________691 Infliximab reduces cardiac output in rheumatoid arthritis patients without heart failure ______________________________________________________698 Análise dos resultados maternos e fetais dos procedimentos invasivos genéticos fetais: um estudo exploratório em Hospital Universitário _______________703 Frequência dos tipos de cefaleia no centro de atendimento terciário do Hospital das Clínicas da Universidade Federal de Minas Gerais __________________709 ARTIGO DE REVISÃO ______________Influência das variáveis nutricionais e da obesidade sobre a saúde e o metabolismo __714
EDITORIAL
Conclusão: como exibir a cereja do bolo 633
PONTO DE VISTA
Os paradoxos da medicina contemporânea 634
IMAGEM EM MEDICINAObstrução duodenal maligna: tratamento endoscópico paliativo utilizando prótese metálica autoexpansível 636 Gossypiboma 638
DIRETRIZES EM FOCO
Hérnia de disco cervical no adulto: tratamento cirúrgico 639
ACREDITAÇÃOAtualização em perda auditiva: diagnóstico radiológico 644
SEÇÕES ____________________________
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ASSOCIAÇÃO MÉDICA BRASILEIRA
Elective cesarean sections, which are those not required by any clinical or obstetrical indication, are significantly increasing in all countries. The main reason for this increase is the possibility to schedule the birth, which, many times, is deemed convenient for the pregnant women and their doctors. The ethical and medical aspects of elective cesarean sections constitute a controversial and very discussed subject in the medical literature. However, little attention has been paid to the disturbing fact that these elective cesarean sections are been performed at increasingly early gestational ages.
In England, during the year 2000, 49% of elective cesarean
sections were performed before the 39th week of pregnancy.
High rates (36.5%) were also described in the United States in 2002. The practice of elective cesarean sections at gestational
ages between the 37th and 38th weeks is based on the
justification that prematurity is defined as birth before the 37th
week and, therefore, it should be safe to end the pregnancy after this gestational age. Another advantage reported is the reduction in the risk, even after scheduling the birth, of patients going into labor and thus having to reformulate their plans. It must also be considered that when asking women about what gestational age they deem safe for birth, over
50% believed that it is between the 34th and the 36th week of
pregnancy, which justifies the ease with which patients accept the early birth, and even the anxiety observed in pregnant
women during the last weeks of pregnancy.1
Elective cesarean section in the 37th or 38th week of
pregnancy, although frequent in the medical practice, is not supported by the medical literature, which unanimously accepts that elective cesarean sections should be performed
after the 39th week of pregnancy.2,3 This recommendation is
based on the analysis of adverse neonatal outcomes in patients
Editorial
Neonatal adverse outcome of elective caesarean section
before 39 weeks of gestation
Intercorrências neonatais da cesárea eletiva antes de 39 semanas
de gestação
submitted to elective cesarean sections between the 37th and
the 39th week of pregnancy. It can be noted that adverse
neonatal outcomes are more frequent in elective cesarean
sections at the 37th week (10% to 17.8%) than after the 39th
week (1.5% to 4.6%). Among adverse neonatal outcomes, we have found situations ranging from obviously more serious conditions, such as hospitalization in neonatal intensive care unit, sepsis, and cardiorespiratory arrest, to conditions deemed mild, as hypoglycemia during the neonatal period and
hospitalization for more than five days.4,5
However, it is important to consider that we are addressing neonatal complications occurring solely and exclusively as a result of deliberate anticipation of birth, with no obstetrical indication, which will cause these children to face risk situations during their life due to a clearly iatrogenic basis. Healthcare costs (whether public or supplementary), which will add totally unnecessary costs to this procedure, should also be analyzed. It is important to mention that some studies have indicated as more frequent maternal characteristics, in the group of patients submitted to elective cesarean sections before 39 weeks: higher average maternal age, lower body mass index, white skin color, married, and use of supplementary
health plans.5 This fact makes it clear that this subject is not
restricted to lower social classes or to public healthcare, and that it may be even more accentuated in patients with better social and economic situations.
Coupled with these facts, we also have to address the emotional damage to pregnant women and their families of the intensive care unit stay of such an expected child, sometimes with significant respiratory disorders and for a long period.
Elective cesarean sections at term (after 37 weeks), but before
94
REV ASSOC MED BRAS. 2013;59(2):93-94been investing in the awareness of the medical professionals and pregnant women to prevent these procedures from being performed, unnecessarily exposing newborns to complications and to the risk of presenting sequelae over the long term, and they have been able to reduce the rate to less than 5% of
cesarean sections performed between the 37th and 39th week
of pregnancy.
Thus, this is a reflection on how iatrogenic it can be to indicate an elective cesarean section at term (after 37 weeks), but before 39 weeks of pregnancy, and on how we can change this situation with simple attitudes, by informing medical professionals and pregnant women about the risks of early birth.
R E F E R E N C E S
1. Goldenberg RL, McClure EM, Bhattacharya A, Groat TD, Stahl PJ. Women’s perceptions regarding the safety of births at various gestational ages. Obstet Gynecol. 2009 Dec;114(6):1254‑8.
2. ACOG Committee Opinion No. 394, December 2007. Cesarean delivery on maternal request. Obstet Gynecol. 2007 Dec;110(6): 1501.
3. Bick D. Caesarean section. Clinical guideline. National Collaborating Centre for Women’s and Children’s Health: commissioned by the National Institute for Clinical Excellence. Worldviews Evid Based Nurs. 2004;1(3):198‑9.
4. Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meyers JA. Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol. 2009 Feb;200(2):156 e1‑4. 5. Tita AT, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW,
et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009 Jan 8;360(2):111‑20.
Rossana Pulcineli Vieira Francisco*, Marcelo Zugaib Department of Obstetrics and Gynecology, Medical School,
Universidade de São Paulo (USP), São Paulo, SP, Brazil
*Corresponding author at: Rua Passo da Pátria, 855, Bairro 98,
