Sífilis congênita: fatores de risco em gestantes admitidas nas maternidades de Maceió/AL e área Metropolitana e avaliação dos critérios diagnósticos adotados no Brasil

• Main Author: PEDROSA, Linda Délia Carvalho de Oliveira
• Other Authors: XIMENES, Ricardo Arraes de Alencar
• Language: br
• Published: Universidade Federal de Pernambuco 2016
• Subjects: sífilis congênita.; DST; fatores de risco
• Online Access: https://repositorio.ufpe.br/handle/123456789/15486

Submitted by Haroudo Xavier Filho ([e-mail]) on 2016-02-26T17:32:06Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) TESE 09agol2015 (1).pdf: 1340528 bytes, checksum: 52150952d443a0f0d5f1de06dc168fe7 (MD5) === Made available in DSpace on 2016-02-26T17:32:06Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) TESE 09agol2015 (1).pdf: 1340528 bytes, checksum: 52150952d443a0f0d5f1de06dc168fe7 (MD5) Previous issue date: 2010-03-01 === O estudo objetiva avaliar os critérios diagnósticos da sífilis congênita (SC) adotados pelo Ministério da Saúde/Brasil (MS) determinando, entre neonatos considerados positivos pelos critérios do MS, o percentual infectado e fatores de risco associados à transmissão vertical. Entre maio/2007 e setembro/2008, realizou-se um estudo de validação fase III de Sackett, a partir dos casos diagnosticados como SC pelos critérios do MS, avaliando o valor preditivo positivo (VPP) e um estudo caso-controle, a partir de mães VDRL positivo. Incluiu gestantes admitidas em 15 maternidades de Maceió/região metropolitana/AL (09 municípios) e seus conceptos nativivos, natimortos e abortos tardios. No caso-controle, definiu-se CASO: neonato, aborto ou natimorto definido pelos critérios do MS e diagnóstico comprovado por FTA-ABs IgM ou histopatológico do cordão umbilical; CONTROLES: nascimentos subsequentes ao caso, mesmo hospital, aborto, neonato ou natimorto, VDRL negativo, inclusive na gestação. À admissão, as gestantes realizavam VDRL e teste rápido de HIV, e os neonatos de mães VDRL positivas, exames clínicos e complementares, incluindo exames PADRÃO DE REFERÊNCIA para confirmação: histopatológico do cordão umbilical e FTA-ABS-IGM. A amostra para análise, casos selecionados pelos critérios do MS, confirmados pelo padrão-referência, correspondeu a 80 casos SC confirmados, dentre 195 casos presumidos e 696 controles. Foram admitidas (partos/curetagens) 35.156 gestantes, 390 (11,1/1.000 gestantes) VDRL positivo e 195 (5,5/1.000 gestantes) preencheram pelo menos um dos critérios do MS; 83,1% gestantes positivas (162/195) enquadraram-se no critério epidemiológico (critério 1). Investigando neonatos usando evidencias sorológica + evidência clinica ou radiológica ou liquórica (critério 3) detectou-se 81/195 (41,5%) neonatos com SC; 20/195 abortos ou natimortos enquadraram-se no critério 4. O critério 1 apresentou VPP de 47,5% (IC 95% 34,8-60,6). Aumentando para 51,3% (IC 95% 41,9-60,6) ao excluir gestantes FTA-Abs negativo. Para o critério 3, o VPP foi 53,1%, (IC 95% 41,7- 64,1), aumentando para 64,2% (IC95% 51,5-75,3) para as gestantes FTA-Abs positivo. O VPP para o critério 4 foi 73,7% (IC 95% 48,6-89,9). Das 245 gestantes admitidas, com VDRL positivo, 18 (7,3%) excluídas, 02 (0,8%) recusas, 30 (12,2%) receberam alta hospitalar antes do resultado dos exames e não localizadas. Dos 195 (79,6%) casos investigados: 10 (5,1%) abortos, 10 (5,1%) natimortos, 175 (89,8%) nativivos; 81/175 (46,3%) VDRL positivo e alteração clínica e/ou liquórica e/ou radiológica de SC; 50/168 (29,6%) confirmados pelo FTA-ABs IgM, e 50/180 (27,8%) pelo histopatológico do cordão, 80/195 casos (41%) com um destes positivo. Realizou-se analise univariada por blocos de variáveis e análise multivariada. O modelo final da associação entre exposição materna a sífilis e SC no neonato contemplou: perda de neonato (OR 4,18 p=0, 000), perda de filho ao final da gestação (OR 4,15 p=0, 000), uso de drogas pelo parceiro (OR 3,49 p=0, 000), ter mais de um parceiro no último ano (1,96 p=0, 058) solteira/viúva/separada (OR 1,70 p= 0, 047). O baixo VPP desses critérios permite questionar sua utilidade no cenário atual da doença, principalmente em regiões de baixa prevalência. Gestantes com perda de neonatos ou filhos ao final da gestação e com mais de um parceiro no último ano apresentaram maior chance de ter filhos com SC. === This study aimed to evaluate the diagnostic criteria of Congenital Syphilis (CS) adopted by the Ministry of Health/Brazil (MH), by determining the percentage of infected neonates amongst those considered positive by the MH criteria, and to identify the factors associated with vertical transmission. A validation (Phase III) and a case-control design were used to investigate the former and the latter objective, respectively. In the case-control study, a CASE was defined as: neonate, abortion or stillborn who met the MH criteria for CS and had the diagnostic confirmed by FTA-ABs IgM or by the histopathological examination of the umbilical cord. CONTROLS were: neonate, abortion or stillborn of the consecutive birth (in the same hospital) following that of the case, with negative VDRL. In the validation study the Positive predictive value (PPV) of CS diagnosed with the MH criteria was estimated. Data was collected between May/2007 and September/2008. Pregnant women admitted in 15 maternity hospitals in Maceió/Metropolitan area/AL (09 cities) and their living child, abortion or stillborn were included in the study. After admission all pregnant women were tested for VDRL and HIV, and the neonates of mothers VDRL positive underwent physical examination and diagnostic testing including those considered as REFERENCE STANDARD for confirmation of CS: histopathology of the umbilical cord and FTA-ABS-IGM. The sample was composed of 80 confirmed cases of CS (cases selected by the MH criteria and confirmed by the standard reference), out of 195 presumed cases, and 696 controls. A total of 35156 pregnant women were admitted (births/curettage), 390 (11.1/1,000 pregnant women) being VDRL positive and 195 (5.5/1,000 pregnant women) fulfilling at least one of the MH criteria; 83.1% pregnant women with a positive VDRL (162/195) met the epidemiological criterion (criterion 1). Investigating neonates presenting serological evidence + clinical or radiological or cerebral spinal fluid evidence (criterion 3), 81/195 (41.5%) neonates with CS were detected; 20/195 abortion or stillborn met criteria 4. Criteria 1 presented a PPV of 47.5% (95%-CI: 34.8-60.6), increasing to 51.3% (95%-CI: 41.9- 60.6) when excluding pregnant women with negative FTA-Abs. For criterion 3, the PPV was 53.1%, (95%-CI: 41.7-64.1), increasing to 64.2% (95%_CI: 51.5-75.3) when just FTA-Abs positive pregnant women were considered. The PPV for criteria 4 was 73.7% (95%-CI: 48.6- 89.9). Of the 245 pregnant women admitted with positive VDRL, 18 (7.3%) were excluded, 02 (0.8%) refused to participate and 30 (12.2%) were discharged from the hospital before the laboratory tests results and were lost to follow-up. Of 195 (79. 6%) investigated cases there were: 10 (5.1%) abortions, 10 (5.1%) stillborns and 175 (89.8%) neonates; 81/175 (46,3%) neonates had VDRL positive and/or clinical and/or cerebral spinal fluid and/or radiological CS alteration; 50/168 (29,6%) were confirmed by FTA-ABs IgM, and 50/180 (27,8%) by the histopathological exam. A total of 80/195 (41%) conceptus had at least one of these exams positive. In the casecontrol study the following factors related to the mothers were independently associated with CS were: loss of neonate (OR 4,18 p=0, 000), loss of child at the end of pregnancy (OR 4,15 p=0, 000), use of drugs by the partner (OR 3,49 p=0, 000), having more than one partner the year before (1,96 p=0, 058) single/widow/separated (OR 1,70 p= 0, 047). The low PPV of the MH criteria allows questioning its utility at the current scenario of the disease, especially in regions with low prevalence. Pregnant women with loss of neonate or loss of child at the end of the pregnancy, as well as more than one partner during the last year showed a greater risk of having children with CS.