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Circular de cordão. Foto: Ricardo Jones
Qual o principal problema associado com a presença de uma ou mais circulares de cordão?Estamos aqui nos referindo às circulares cervicais, aquelas “voltas” que o cordão pode dar em torno do pescoço fetal, porque até onde eu saiba ninguém está preocupado com outros tipos de circulares, que podem se formar em torno do tórax, do abdome, dos membros fetais. O que permeia o imaginário popular, alimentado, infelizmente, pelo terrorismo que alguns obstetras fazem em torno desse achado, é a fantasia de que circulares em torno do pescoço possam levar ao “enforcamento” do bebê, uma entidade nosológica que definitivamente não existe, nunca foi documentada. Bebês nascem “laçados” há milênios. Aqui no Nordeste, não sei se existe em outras regiões do Brasil, até há uma tradição de se dar o nome de José ou Maria José àqueles bebês que nascem com circular cervical de cordão (1). Para evitar que a criança futuramente morra queimada ou afogada, segundo dizem.
Então, senhores, essa história de circular de cordão é antiga. Só que no passado, somente se descobria que o bebê estava “laçado” ao nascimento. Nas últimas décadas, com o advento e a popularização da ultrassonografia pré-natal é que surgiu a possibilidade de se detectar circular de cordão no momento do exame e, infelizmente, isso tem levado a muitas indicações desnecessárias de cesariana em nosso país. Digo em nosso país porque não tenho conhecimento de que circular de cordão represente “indicação” de cesariana fora do Brasil. Corrijam-me, se estiver enganada.
No entanto, a presença de uma ou mais circulares de cordão ao nascimento representa um achado fisiológico em 20 a 40% dos bebês (2-5). Bebês saudáveis se movimentam dentro do útero e giram para um lado e para o outro, podendo formar e desfazer circulares a qualquer momento. Desta forma, é baixa a acurácia da ultrassonografia, mesmo associada à dopplervelocimetria colorida, para predizer circulares de cordão ao nascimento, uma vez que com a constante movimentação fetal, tanto um bebê com diagnóstico de circular pode nascer sem circular como o contrário, um bebê em que a ultrassonografia não detectou circular pode nascer com uma ou mais circulares de cordão (4).
Sugere-se que a presença de circulares seja um evento randômico com maior frequência na gestação tardia, como parte da vida intrauterina, que raramente se associa com aumento de morbidade e mortalidade perinatal (2,4). Na literatura, a taxa de detecção de circulares cervicais pela ultrassonografia varia de acordo com os diferentes estudos, demonstrando-se uma sensibilidade de ultrassonografia com Doppler colorido entre 38 e 79%. Um elevado percentual de falsos positivos e negativos é descrito quando a circular é detectada antes do trabalho de parto. Aproximadamente 25 a 50% das circulares cervicais formadas durante a gravidez irão se resolver antes do parto, e até 60% dos fetos têm uma circular cervical presente em alguma ocasião durante a gravidez (2,4).
Nenhum ensaio clínico randomizado foi realizado com a finalidade de avaliar via de parto na presença de circular cervical, porque não se considera patológico um achado tão frequente, e não há rationale ou justificativa científica para se investir tempo e dinheiro em um estudo desse tipo. Fora as implicações éticas, já imaginaram ter que operar, realizar a cirurgia de extração fetal, o “talho cesáreo” – como veem, eu também leio o Rezende – em mulheres saudáveis tão somente por conta de um diagnóstico essencialmente pouco acurado de circular de cordão?
Além disso, os estudos observacionais demonstram que a presença de circular de cordão não se associa com piora do prognóstico perinatal (2-6). Em um estudo com 11.748 mulheres, a taxa de circulares ao nascimento foi de 33,7% a termo e 35,1% pós-termo. Desacelerações da frequência cardíaca fetal (FCF) intraparto foram mais frequentes na presença de circular de cordão, e eliminação de mecônio foi aumentada apenas nos casos de gestações pós-termo com múltiplas circulares. Alterações de gasimetria foram mais frequentes em bebês com circular de cordão, porém não houve aumento do risco de escores de Apgar menores que sete nem de admissões em UTI neonatal. Os autores concluem afirmando que a presença de circular de cordão não influencia o manejo clínico nem o prognóstico perinatal, e que não é necessário pesquisar circular de cordão pela ultrassonografia no momento da admissão por trabalho de parto (4).
Em tempo: alterações da FCF ocorrem não porque o bebê esteja se “enforcando” mas porque podem existir circulares apertadas – e isso teoricamente em qualquer circular, não apenas nas circulares cervicais – e daí, durante a contração uterina, reduz-se o fluxo sanguíneo para o bebê e resultam as chamadas desacelerações “umbilicais” ou “variáveis”. Aliás, essas desacelerações variáveis podem ocorrer com ou sem circular, por compressão do cordão, por exemplo, como em casos de oligo-hidrâmnio, ou cordão curto (7).
Eventualmente, na presença de múltiplas circulares ou uma circular apertada com cordão curto, pode haver maior risco de desaceleração da frequência cardíaca fetal (FCF), eliminação de mecônio e escores de Apgar mais baixos (4). Entretanto, outros estudos não descrevem associação entre múltiplas circulares e prognóstico neonatal adverso (6, 8). Na eventualidade de circulares apertadas, uma ausculta fetal cuidadosa, como deve ser feita em todos os casos durante o trabalho de parto, pode detectar precocemente alterações da FCF, sobretudo desacelerações umbilicais (4). O prévio conhecimento de que existe uma circular, no entanto, pode levar à indicação de cesárea nesses casos, podendo sobrelevar as taxas de cesárea sem necessariamente melhorar o prognóstico perinatal. Ultrassonografia antes da indução ou no início do trabalho de parto não é recomendação de rotina com essa finalidade (4).
Desta forma, não se deve modificar a conduta obstétrica em função de um diagnóstico eventual de circular de cordão, e não é necessário pesquisar circular de cordão no exame ultrassonográfico nem anteparto nem no momento da admissão em trabalho de parto (4, 9). A monitorização da FCF deve ser realizada em todas as parturientes, independente do prévio conhecimento de que existe uma circular (10). Assim, em caso de uma ou mais circulares apertadas levando a desacelerações da FCF, uma ausculta fetal cuidadosa pode detectar precocemente essas alterações e a conduta obstétrica nesses casos seguirá as recomendações preconizadas para uma frequência cardíaca fetal não tranquilizadora (10).
Como lidar com uma ou mais circulares de cordão é um assunto que tem sido abordado em diversos artigos. Infelizmente, alguns obstetras têm o hábito de ligar precocemente o cordão e proceder ao desprendimento imediato quando se deparam com uma circular de cervical apertada (11). No entanto, além de desnecessária, porque o cordão não irá enforcar o bebê, a ligadura precoce do cordão pode trazer efeitos adversos, privando o bebê do suprimento sanguíneo e das trocas gasosas que se processam através do cordão (12). Uma circular frouxa não precisa ser desfeita, podendo o nascimento processar-se normalmente.
Para circulares apertadas, recomenda-se a manobra de “somersault” com ligadura tardia do cordão (13).
Manobra de “somersault“
E não, não é preciso checar se existe circular logo depois do desprendimento do polo cefálico (14). Voltaremos a falar sobre esse assunto posteriormente, afinal eu quero que vocês continuem lendo este blog.
Referências
1. Souto Maior, M. Nomes próprios pouco comuns. Contribuição ao estudo da antroponímia brasileira. Fundação Joaquim Nabuco, 1973.
2. Clapp JF 3rd, Stepanchak W, Hashimoto K, Ehrenberg H, Lopez B. The natural history of antenatal nuchal cords. Am J Obstet Gynecol. 2003;189: 488-93.
3. Wang Y, Le Ray C, Audibert F, Wagner MS. Management of nuchal cord with multiple loops. Obstet Gynecol. 2008; 112 : 460-1.
4. Schäffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal cords in term and postterm deliveries–do we need to know? Obstet Gynecol. 2005; 106: 23-8.
5. Shrestha NS, Singh N. Nuchal cords and perinatal outcome. Kathmandu Univ Med J (KUMJ) 2007; 5:360-3.
6. Mastrobattista JM, Hollier LM, Yeomans ER, Ramin SM, Day MC, Sosa A, Gilstrap LC 3rd. Effects of nuchal cord on birthweight and immediate neonatal outcomes. Am J Perinatol 2005; 22:83-5.
7. Westgate JA, Wibbens B, Bennet L, Wassink G, Parer JT, Gunn AJ. The intrapartum deceleration in center stage: a physiologic approach to the interpretation of fetal heart rate changes in labor. Am J Obstet Gynecol. 2007; 197: 235.e1-11.
8. Williams M, O’Brien W. Multiple or tight nuchal cord loops are not associated with significant perinatal morbidity. Am J Obstet Gynecol. 2002;187:S93.
9. Peregrine E, O’Brien P, Jauniaux E. Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol. 2005; 25:160-4.
10. Liston R, Sawchuck D, Young D. Society of Obstetrics and Gynaecologists of Canada, British Columbia Perinatal Health Program. Fetal health surveillance: antepartum and intrapartum consensus guideline. J Obstet Gynaecol Can 2007; 29: S3–56.
11. Sadan O, Fleischfarb Z, Everon S, Golan A, Lurie S. Cord around the neck: should it be severed at delivery? A randomized controlled study. Am J Perinatol. 2007; 24: 61-4.
12. McDonald Susan J, Middleton Philippa. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews. In: The Cochrane Library, Issue 07, 2012. Art. No. CD004074. DOI: 10.1002/14651858.CD004074.pub2
13. Mercer JS, Skovgaard RL, Peareara-Eaves J, Bowman TA. Nuchal cord management and nurse-midwifery practice. J Midwifery Womens Health 2005; 50: 373-9.
14. Reed R. Nuchal cords: think before you check. Pract Midwife. 2007; 10:18-20.
____________
Para escrever este post eu me baseei não apenas em textos que escrevi para a lista Parto Nosso como para as comunidades do Orkut, mas também no artigo que publiquei na revista FEMINA junto com Alex Sandro Rolland de Souza e Ana Maria Feitosa Porto, intitulado “Condições frequentemente associadas com cesariana, sem respaldo científico”. Por sinal, recebemos muitos e-mails raivosos quando publicamos esse artigo, os cesaristas que leem a revista queriam nos matar (risos).
http://www.febrasgo.org.br/arquivos/femina/Femina2010/outubro/Femina_v38n10_505-516.pdf
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