RESUMEN

Introdução: A doença tromboembólica venosa e as complicações obstétricas resultantes do tromboembolismo placentário são as principais causas de morbidade e mortalidade materna e fetal. Pode-se dizer que a gravidez é um fator independente para o desenvolvimento de trombose, já que seu risco é de 5 a 6 vezes maior em mulheres grávidas quando comparadas a não grávidas, sendo mais elevado após o parto. Métodos: Trata-se de uma coorte histórica, onde foram estudadas pacientes atendidas no Serviço de Obstetrícia da Universidade Federal de Juiz de Fora (expostos=n=70 pacientes) e na Faculdade de Medicina de Barbacena (não expostos=n=74 pacientes). As pacientes foram divididas em dois grupos: Grupo 1 = pacientes com alguma trombofilia identificada (expostos) através das dosagens de proteína S, proteína C, homocisteína, antitrombina III, mutação da MTHFR, mutação da protrombina e do fator V de Leiden; e Grupo 2 = pacientes do serviço de baixo risco obstétrico. Resultados: Houve associação entre trombofilia e aborto prévio, bem como trombofilia e morte fetal prévia (p<0,05). O tipo de trombofilia que foi associada a abortamento prévio foi o déficit da proteína S. A mutação da MTHFR foi associada aos antecedentes de HELLP síndrome (p=0,03; x2 =4,2) e de pré-eclâmpsia (p=0,03; X2 =4,5) quando em homozigotia mutante. A homozigotia para a MTHFR foi também associada às médias de homocisteína, de forma que as homozigotas eram aquelas que apresentavam a maior dosagem de homocisteína (p=0,01; X2 =5,8; X= 27,2 ± 41,2 vs. 12,62 ± 19,0). Conclusão: As trombofilias hereditárias podem estar associadas a mau desfecho obstétrico e devem ser valorizadas na clínica obstétrica. (AU)

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Introduction: Venous thromboembolic disease and obstetric complications resulting from placental thromboembolism are the main causes of maternal and fetal morbidity and mortality. Pregnancy is considered an independent factor for the development of thrombosis, as its risk is 5 to 6 times greater in pregnant women when compared to non-pregnant women, being even higher after childbirth. Methods: This historical cohort included patients seen at the Obstetrics Service of Federal University of Juiz de Fora (exposed patients, n = 70) and at the School of Medicine of Barbacena (unexposed patients, n = 74). The patients were divided into two groups: Group 1 consisted of patients with some thrombophilia identified through measurement of protein S, protein C, homocysteine, antithrombin III, MTHFR mutation, prothrombin and factor V Leiden mutations; and Group 2 consisted of patients from the low obstetric risk service. Results: There was an association between thrombophilia and previous abortion, as well as thrombophilia and previous fetal death (p < 0.05). MTHFR mutation was associated with history of HELLP syndrome (p = 0.03; x2 = 4.2) and preeclampsia (p = 0.03; x2 = 4.5) when in homozygous mutation. Homozygous MTHFR was also associated with mean homocysteine levels, so that homozygotes were those with highest homocysteine levels (p = 0.01; x2 = 5.8; x = 27.2 ± 41.2 vs. 12.62 ± 19.0). Conclusions: Hereditary thrombophilias may be associated with poor obstetric outcome and should be valued at clinical obstetrics. (AU)

Asunto(s)

Humanos , Femenino , Embarazo , Adolescente , Adulto , Persona de Mediana Edad , Estudios de Cohortes , Trombofilia , Insuficiencia Placentaria/mortalidad , Brasil/epidemiología , Aborto Espontáneo , Muerte Fetal

RESUMEN

INTRODUCTION: Fetal growth restriction (FGR) affects 5%-10% of all pregnancies, contributing to 30%-50% of stillbirths. Unfortunately, growth restriction often is not detected antenatally. The last weeks of pregnancy are critical for preventing stillbirth among babies with FGR because there is a pronounced increase in stillbirths among growth-restricted fetuses after 37 weeks of pregnancy. Here we present a protocol (V.1, 23 May 2016) for the RATIO37 trial, which evaluates an integrated strategy for accurately selecting at-risk fetuses for delivery at term. The protocol is based on the combination of fetal biometry and cerebroplacental ratio (CPR). The primary objective is to reduce stillbirth rates. The secondary aims are to detect low birth weights and adverse perinatal outcomes. METHODS AND ANALYSIS: The study is designed as multicentre (Spain, Chile, Mexico,Czech Republic and Israel), open-label, randomised trial with parallel groups. Singleton pregnancies will be invited to participate after routine second-trimester ultrasound scan (19+0-22+6 weeks of gestation), and participants will be randomly allocated to receive revealed or concealed CPR evaluation. Then, a routine ultrasound and Doppler scan will be performed at 36+0-37+6 weeks. Sociodemographic and clinical data will be collected at enrolment. Ultrasound and Doppler variables will be recorded at 36+0-37+6 weeks of pregnancy. Perinatal outcomes will be recorded after delivery. Univariate (with estimated effect size and its 95% CI) and multivariate (mixed-effects logistic regression) comparisons between groups will be performed. ETHICS AND DISSEMINATION: The study will be conducted in accordance with the principles of Good Clinical Practice. This study was accepted by the Clinical Research Ethics Committee of Hospital Clinic Barcelona on 23May 2016. Subsequent approval by individual ethical committees and competent authorities was granted. The study results will be published in peer-reviewed journals and disseminated at international conferences. TRIAL REGISTRATION NUMBER: NCT02907242; pre-results.

Asunto(s)

Retardo del Crecimiento Fetal/diagnóstico por imagen , Monitoreo Fetal , Insuficiencia Placentaria/diagnóstico por imagen , Complicaciones del Embarazo/diagnóstico por imagen , Tercer Trimestre del Embarazo , Mortinato/epidemiología , Adulto , Chile , República Checa , Femenino , Retardo del Crecimiento Fetal/mortalidad , Retardo del Crecimiento Fetal/fisiopatología , Humanos , Recién Nacido , Israel , México , Insuficiencia Placentaria/mortalidad , Insuficiencia Placentaria/fisiopatología , Embarazo , Complicaciones del Embarazo/fisiopatología , Resultado del Embarazo , Atención Prenatal/estadística & datos numéricos , España , Ultrasonografía Prenatal/estadística & datos numéricos , Adulto Joven

RESUMEN

Physiological prothrombotic changes during pregnancy and the postpartum period, along with other preexisting maternal risk factors, increase the risk of both venous thromboembolism (VTE) and adverse pregnancy outcomes. Pregnancy complications that develop due to placental insufficiency as a result of inappropriate activation of coagulation are present in more than 5% of pregnancies and can contribute to significant maternal morbidity and mortality. Therefore, anticoagulant prophylaxis in women with congenital and acquired thrombophilic conditions should be actively considered. According to the Guidelines of American College of Chest Physicians, the use of low-molecular-weight heparin is suggested for prophylaxis of VTE and pregnancy complications in high-risk pregnant women. However, personalized refinements of such thromboprophylaxis remains unspecified, despite the necessity of better targeted recommendations for life-threatening conditions. We, therefore, review the possibilities of longitudinal monitoring and comprehensive assessment of changes in hemostasis in the group of high-risk pregnant women, which can then be used for early prediction and individualization of the optimal anticoagulant thromboprophylaxis of pregnancy complications. Simultaneously, we present our single-center experience with such monitoring and our first series of results.

Asunto(s)

Aborto Espontáneo/prevención & control , Anticoagulantes/uso terapéutico , Heparina de Bajo-Peso-Molecular/uso terapéutico , Insuficiencia Placentaria/prevención & control , Tromboembolia/prevención & control , Aborto Espontáneo/diagnóstico , Aborto Espontáneo/mortalidad , Femenino , Humanos , Insuficiencia Placentaria/diagnóstico , Insuficiencia Placentaria/mortalidad , Embarazo , Factores de Riesgo , Tromboembolia/diagnóstico , Tromboembolia/mortalidad

RESUMEN

Chronic placental insufficiency and subsequent intrauterine growth restriction (IUGR) increase the risk of hypoxic-ischemic encephalopathy in the newborn by 40 fold. The latter, in turn, increases the risk of cerebral palsy and developmental disabilities. This study seeks to determine the effectiveness of broccoli sprouts (BrSp), a rich source of the isothiocyanate sulforaphane, as a neuroprotectant in a rat model of chronic placental insufficiency and IUGR. Placental insufficiency and IUGR was induced by bilateral uterine artery ligation (BUAL) on day E20 of gestation. Dams were fed standard chow or chow supplemented with 200mg of dried BrSp from E15 - postnatal day 14 (PD14). Controls received Sham surgery and the same dietary regime. Pups underwent neurologic reflex testing and open field testing, following which they were euthanized and their brains frozen for neuropathologic assessment. Compared to Sham, IUGR pups were delayed in attaining early reflexes and performed worse in the open field, both of which were significantly improved by maternal supplementation of BrSp (p<0.05). Neuropathology revealed diminished white matter, ventricular dilation, astrogliosis and reduction in hippocampal neurons in IUGR animals compared to Sham, whereas broccoli sprout supplementation improved outcome in all histological assessments (p<0.05). Maternal dietary supplementation with BrSp prevented the detrimental neurocognitive and neuropathologic effects of chronic intrauterine ischemia. These findings suggest a novel approach for prevention of cerebral palsy and/or developmental disabilities associated with placental insufficiency.

Asunto(s)

Encefalopatías/prevención & control , Encéfalo/patología , Brassica , Fenómenos Fisiologicos Nutricionales Maternos , Insuficiencia Placentaria/dietoterapia , Plantones , Animales , Animales Recién Nacidos , Encefalopatías/patología , Parálisis Cerebral/patología , Parálisis Cerebral/fisiopatología , Parálisis Cerebral/prevención & control , Discapacidades del Desarrollo/patología , Discapacidades del Desarrollo/fisiopatología , Discapacidades del Desarrollo/prevención & control , Suplementos Dietéticos , Modelos Animales de Enfermedad , Femenino , Masculino , Actividad Motora/fisiología , Insuficiencia Placentaria/mortalidad , Insuficiencia Placentaria/patología , Insuficiencia Placentaria/fisiopatología , Embarazo , Distribución Aleatoria , Ratas Long-Evans , Reflejo/fisiología

RESUMEN

Significant placental insufficiency, indicated by Doppler ultrasound findings of absent or reverse end-diastolic flow velocities (AREDV), is associated with increased morbidity and mortality. Analysis of blood flow in the ductus venosus should assist in early intrauterine recognition of threatened foetuses. 58 high-risk pregnancies with umbilical AREDV were repeatedly examined (n=364). Doppler findings were correlated with neonatal signs of deterioration (ratio of normoblasts to leukocytes, pH, base excess, Apgar score), as well as short-term morbidity [need for intubation, duration of assisted respiration, evidence of respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), necrotising enterocolitis (NEC), intraventricular haemorrhage (IVH grade III+IV)] against the analysis of the blood flow findings (normal or increased pulsitility, absence or reverse end-diastolic flow) in the umbilical arteries (AU), the middle cerebral arteries (ACM) and ductus venosus (DV) relating these to birth weight and the duration of the pregnancy. The median period of observation was 12.8 days, 48% of the foetuses showed an abnormal ductus venosus flow and 26% an absent venous or reverse end-diastolic flow. The median date of delivery was 30 weeks, with a mean birth weight of 816 g. 93% were live births with 12% dying postnatally. Although the criteria for postnatal morbidity (BPD, NEC, IVH III+IV) and mortality did not correlate with changes in arterial and venous Doppler parameters in our group, there was a significant relationship between the normoblast count, known to be a marker of chronic hypoxia. The Apgar 10 minte score, umbilical arterial pH and base excess were correlated with changes in the DV flow curves. Healthy survival started, irrespective of arterial or venous blood flow criteria, from 27+0 weeks of pregnancy. If born between 27.0 and 30+6 weeks, the infants were more likely to be healthy the less the blood flow had been compromised. A birth weight of 590 g (sensitivity 62.5%; specificity 93.5%) and gestational age of 28+5 weeks (sensitivity 87.5%; specificity 90.3%) were shown to be cut-off points between healthy survival and survival with serious neonatal complications.

Asunto(s)

Transfusión Fetomaterna/diagnóstico por imagen , Transfusión Fetomaterna/mortalidad , Insuficiencia Placentaria/diagnóstico por imagen , Insuficiencia Placentaria/mortalidad , Resultado del Embarazo/epidemiología , Ultrasonografía Doppler/estadística & datos numéricos , Femenino , Muerte Fetal , Alemania/epidemiología , Humanos , Recién Nacido , Mortalidad Perinatal , Embarazo , Pronóstico , Reproducibilidad de los Resultados , Medición de Riesgo , Sensibilidad y Especificidad , Volumen Sistólico , Ultrasonografía Prenatal/estadística & datos numéricos , Arterias Umbilicales/diagnóstico por imagen

RESUMEN

AIM: to assess whether the incidence of angiotensin II-receptor type 1 antagonist (AT1-antagonist)­ or ACE-inhibitor induced cases of oligohydramnios sequence (OHS) in 2011 was reduced after intensive alerts as to the causal association between AT1-antagonist /ACE-inhibitor and OHS in the German medical literature. METHOD: 3 sources of information were used: A nationwide active surveillance of OHS in German paediatric hospitals (ESPED); Embryotox, (Berlin Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy) and screening of pubmed (AT1-antagonist/ACE-inhibitor induced OHS). RESULTS: 45 cases of OHS were identified, no case due to maternal AT1-antagonist/ACE-inhibitor treatment. Causes for OHS were: premature rupture of membranes (PPROM) (n = 28), congenital anomalies of fetal kidneys and urinary tract(CAKUT (n = 15), placental insufficiency (n = 1),unknown cause (n = 1). Mortality until discharge was 37.8 % (32.1 % PPROM, 57.1 % CAKUT). Embryotox identified 3 exposures to AT1-antagonists in pregnancy, no case was associated with OHS. The pubmed search did not identify any case of OHS related to AT1-antagonist/ACE-inhibitor in pregnancy in Germany in 2011. CONCLUSION: Treatment of pregnant women with ACE inhibitors or AT1-antagonists still occurs but no cases of AT1-antagonist- or ACE-inhibitor induced OHS were reported in 2011 in Germany most likely due to repeated published alerts underlining the importance of consequent education. OHS remains a serious condition with high mortality despite modern intensive care.

Asunto(s)

Bloqueadores del Receptor Tipo 1 de Angiotensina II/efectos adversos , Oligohidramnios/inducido químicamente , Bloqueadores del Receptor Tipo 1 de Angiotensina II/uso terapéutico , Femenino , Rotura Prematura de Membranas Fetales/diagnóstico , Rotura Prematura de Membranas Fetales/epidemiología , Rotura Prematura de Membranas Fetales/mortalidad , Alemania , Humanos , Incidencia , Recién Nacido , Oligohidramnios/epidemiología , Oligohidramnios/mortalidad , Insuficiencia Placentaria/diagnóstico , Insuficiencia Placentaria/mortalidad , Vigilancia de la Población , Embarazo , Medición de Riesgo , Análisis de Supervivencia , Anomalías Urogenitales , Reflujo Vesicoureteral/diagnóstico , Reflujo Vesicoureteral/mortalidad

RESUMEN

OBJECTIVES: To investigate fetal venous Doppler measurements in monochorionic twin pregnancies complicated by placental insufficiency and the relationship between fetal venous flow and acidemia at birth or intrauterine fetal death. METHODS: This was a prospective study of 18 monochorionic twin pregnancies with placental insufficiency. Inclusion criteria were monochorionic-diamniotic twin pregnancy, abnormal umbilical artery (UA) Doppler indices, intact membranes and absence of fetal congenital abnormalities. Cases of twin-to-twin transfusion syndrome were excluded. The following Doppler measurements were studied: UA pulsatility index (PI), ductus venosus PI, middle cerebral artery PI and peak systolic velocity, intra-abdominal umbilical vein (UV) time-averaged maximum velocity (TAMXV) and left portal vein (LPV) TAMXV. Doppler parameters were transformed into Z-scores (SD values from the mean) or multiples of the median according to normative references. RESULTS: UA pH < 7.20 occurred in nine (25.0%) neonates, pH < 7.15 in four (11.1%) and intrauterine death in four (11.1%) fetuses. The UV-TAMXV and LPV-TAMXV Z-scores were significantly lower in the group with pH < 7.20 or intrauterine fetal death (-1.79 vs -1.22, P = 0.006 and -2.26 vs -1.13, P = 0.04, respectively). In cases with pH < 7.15 or intrauterine fetal death, UV pulsations were more frequent (50.0% vs 10.7%, P = 0.03) and UV-TAMXV Z-score was significantly lower (-1.89 vs -1.26, P = 0.003). Mixed effects logistic regression analysis, accounting for the paired nature of the outcomes for the two twins in each pregnancy, demonstrated that the UV-TAMXV Z-score significantly predicted UA pH at birth < 7.20 or intrauterine fetal death. The Doppler parameter that independently predicted pH < 7.15 or intrauterine fetal death was presence of pulsation in the UV. CONCLUSION: UV Doppler parameters may predict acidemia at birth or intrauterine fetal death in monochorionic twins complicated by placental insufficiency.

Asunto(s)

Acidosis/fisiopatología , Muerte Fetal , Retardo del Crecimiento Fetal/fisiopatología , Feto/irrigación sanguínea , Arteria Cerebral Media/fisiopatología , Insuficiencia Placentaria/fisiopatología , Vena Porta/fisiopatología , Arterias Umbilicales/irrigación sanguínea , Acidosis/diagnóstico por imagen , Acidosis/mortalidad , Velocidad del Flujo Sanguíneo , Femenino , Retardo del Crecimiento Fetal/diagnóstico por imagen , Humanos , Recién Nacido , Masculino , Arteria Cerebral Media/diagnóstico por imagen , Insuficiencia Placentaria/diagnóstico por imagen , Insuficiencia Placentaria/mortalidad , Vena Porta/diagnóstico por imagen , Vena Porta/embriología , Embarazo , Resultado del Embarazo , Embarazo Gemelar , Estudios Prospectivos , Flujo Pulsátil , Sensibilidad y Especificidad , Ultrasonografía Doppler

RESUMEN

OBJETIVO: Estudar a dopplervelocimetria da artéria cerebral média fetal em gestações complicadas pela insuficiência placentária e verificar o seu papel no prognóstico de sobrevida neonatal. MÉTODOS: Trata-se de estudo prospectivo de 93 gestantes com diagnóstico de insuficiência placentária estabelecida antes da 34ª semana. A insuficiência placentária foi caracterizada pelo Doppler de artéria umbilical (AU) alterado (> p95). Foram analisados os seguintes parâmetros: índice de pulsatilidade (IP) da artéria umbilical (AU), IP da artéria cerebral média (ACM), relação cerebroplacentária -RCP(IP-ACM/IP-AU), pico de velocidade sistólicada ACM (PVS-ACM) e IP para veias (IPV) do ducto venoso (DV). Os parâmetros foram analisados pelos valores absolutos, em escores zeta (desvios padrão a partir da média) ou múltiplos da mediana (MoM). O desfecho investigado foi o óbito neonatal no período de internação após o nascimento. RESULTADOS: Nas 93 gestações analisadas, ocorreram 25 (26,9%) óbitos neonatais. No grupo que evoluiu com óbito neonatal, quando comparado com o grupo com sobrevida, houve associação significativa com o diagnóstico de diástole zero ou reversa (88% vs. 23,6%, p < 0,001), com maior mediana do IP da AU (2,9 vs. 1,7, p < 0,001) e seu escore zeta (10,4 vs. 4,9, p < 0,001); maior valor do PVS-ACM MoM (1,4 vs. 1,1, p = 0,012); menor valor da RCP (0,4 vs. 0,7, p < 0,001); maior valor do IPV-DV (1,2 vs. 0,8, p < 0,001) e no escore zeta do DV (3,6 vs.0,6, p<0,001). Na regressão logística, as variáveis independentes para a prediçãodoóbito neonatal foram a idade gestacional no parto (OR = 0,45; IC95% 0,3 a 0,7, p < 0,001) e o escore zeta do IP-AU (OR 1,14, IC95% 1,0 a 1,3, p = 0,046). CONCLUSÃO: Apesar da associação verificada pela análise univariada entre a morte neonatal e os parâmetros da dopplervelocimetria cerebral fetal, a análise multivariada identificou a prematuridadeeograude insuficiência da circulação placentária como fatores independentes relacionados com o óbito neonatal em gestações complicadas por insuficiência placentária.

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OBJECTIVE: To study the Doppler velocimetry of the fetal middle cerebral artery in pregnancies complicated by placental insufficiency, and to verify its role in the prognosis of neonatal survival. METHODS: This was a prospective study of 93 pregnant women with diagnosis of placental insufficiency detected before the 34th week of pregnancy. Placental insufficiency was characterized by abnormal umbilical artery (UA) Doppler (> 95th percentile). The following parameterswere analyzed: umbilical artery (UA) pulsatility index (PI); middle cerebral artery (MCA) PI; brain-placenta ratio - BPR (MCA-PI/UA-PI); MCA peak systolic velocity (MCA-PSV); and PI for veins (PIV) of ductus venosus (DV). The parameters were analyzed in terms of absolute values, z-scores (standard deviations from the mean), or multiples of the median (MoM). The outcome investigatedwas neonatal death during the hospitalization period after birth. RESULTS: Of the 93 pregnancies analyzed, there were 25 (26.9%) neonatal deaths. The group that died, when compared to the survival group, presented a significant association with the diagnosis of absent or reversed end-diastolic flow (88% vs. 23.6%, p < 0.001), with a higher median of UA PI (2.9 vs. 1.7, p < 0.001) and UA PI z-score (10.4 vs. 4.9, p < 0.001); higher MCAPSV MoM (1.4 vs. 1.1, p = 0.012); lower BPR (0.4 vs. 0.7, p < 0.001); higher PIV-DV (1.2 vs. 0.8, p < 0.001) and DV z-score (3.6 vs. 0.6, p < 0.001). In the logistic regression, the independent variables predictive of neonatal death were: gestational age at birth (OR = 0.45; 95% CI: 0.3 to 0.7; p < 0.001) and UA PI z-score (OR = 1.14, 95% CI: 1.0 to 1.3, p = 0.046). CONCLUSION: Despite the association verified by the univariate analysis between neonatal death and the parameters of fetal cerebral Doppler velocimetry, the multivariate analysis identified prematurity and degree of insufficiency of placental circulation as independent factors related to neonatal death in pregnancies complicated by placental insufficiency.

Asunto(s)

Femenino , Humanos , Recién Nacido , Masculino , Embarazo , Arteria Cerebral Media , Insuficiencia Placentaria , Arterias Umbilicales , Análisis de Varianza , Velocidad del Flujo Sanguíneo , Flujometría por Láser-Doppler , Insuficiencia Placentaria/mortalidad , Pronóstico , Estudios Prospectivos , Análisis de Supervivencia , Ultrasonografía Prenatal

RESUMEN

OBJECTIVE: To study the Doppler velocimetry of the fetal middle cerebral artery in pregnancies complicated by placental insufficiency, and to verify its role in the prognosis of neonatal survival. METHODS: This was a prospective study of 93 pregnant women with diagnosis of placental insufficiency detected before the 34(th) week of pregnancy. Placental insufficiency was characterized by abnormal umbilical artery (UA) Doppler (> 95(th) percentile). The following parameters were analyzed: umbilical artery (UA) pulsatility index (PI); middle cerebral artery (MCA) PI; brain-placenta ratio--BPR (MCA-PI/UA-PI); MCA peak systolic velocity (MCA-PSV); and PI for veins (PIV) of ductus venosus (DV). The parameters were analyzed in terms of absolute values, z-scores (standard deviations from the mean), or multiples of the median (MoM). The outcome investigated was neonatal death during the hospitalization period after birth. RESULTS: Of the 93 pregnancies analyzed, there were 25 (26.9%) neonatal deaths. The group that died, when compared to the survival group, presented a significant association with the diagnosis of absent or reversed end-diastolic flow (88% vs. 23.6%, p<0.001), with a higher median of UA PI (2.9 vs. 1.7, p<0.001) and UA PI z-score (10.4 vs. 4.9, p<0.001); higher MCA-PSV MoM (1.4 vs. 1.1, p=0.012); lower BPR (0.4 vs. 0.7, p<0.001); higher PIV-DV (1.2 vs. 0.8, p<0.001) and DV z-score (3.6 vs. 0.6, p<0.001). In the logistic regression, the independent variables predictive of neonatal death were: gestational age at birth (OR=0.45; 95% CI: 0.3 to 0.7; p<0.001) and UA PI z-score (OR=1.14, 95% CI: 1.0 to 1.3, p=0.046). CONCLUSION: Despite the association verified by the univariate analysis between neonatal death and the parameters of fetal cerebral Doppler velocimetry, the multivariate analysis identified prematurity and degree of insufficiency of placental circulation as independent factors related to neonatal death in pregnancies complicated by placental insufficiency.

Asunto(s)

Arteria Cerebral Media/diagnóstico por imagen , Insuficiencia Placentaria/diagnóstico por imagen , Arterias Umbilicales/diagnóstico por imagen , Análisis de Varianza , Velocidad del Flujo Sanguíneo , Femenino , Humanos , Recién Nacido , Flujometría por Láser-Doppler , Masculino , Insuficiencia Placentaria/mortalidad , Embarazo , Pronóstico , Estudios Prospectivos , Análisis de Supervivencia , Ultrasonografía Prenatal

RESUMEN

OBJECTIVE: The objective of the study was to compare neonatal morbidity and long-term neurodevelopmental outcome between very preterm infants with placental underperfusion and very preterm infants with histological chorioamnionitis. STUDY DESIGN: We measured the mental and motor development at age 2 and 7 years in 51 very preterm infants with placental underperfusion and 21 very preterm infants with histological chorioamnionitis. RESULTS: At 2 years, very preterm infants with placental underperfusion had poorer mental development than very preterm infants with histological chorioamnionitis (mean [SD] 90.8 [18.3] vs 104.1 [17.2], adjusted d = 1.12, P = .001). Motor development was not different between both groups (92.8 [17.2] vs 96.8 [8.7], adjusted d = 0.52, P = .12). At 7 years, large, although nonsignificant, effects were found for better mental and motor development and fewer behavioral problems in infants with histological chorioamnionitis. CONCLUSION: Placental pathology contributes to variance in mental development at 2 years and should be taken into account when evaluating neurodevelopmental outcome of very preterm infants.

Asunto(s)

Desarrollo Infantil , Corioamnionitis , Insuficiencia Placentaria , Efectos Tardíos de la Exposición Prenatal/etiología , Desempeño Psicomotor , Niño , Trastornos de la Conducta Infantil/etiología , Preescolar , Corioamnionitis/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/etiología , Modelos Logísticos , Masculino , Insuficiencia Placentaria/mortalidad , Embarazo , Pruebas Psicológicas

RESUMEN

OBJECTIVES: To test the hypothesis that earlier delivery may be warranted to improve neonatal outcome of fetuses with intrauterine growth restriction (IUGR) with abnormal Doppler parameters. METHODS: This was a retrospective cohort study of 110 fetuses with an antenatal diagnosis of IUGR due to placental insufficiency which had a very low birth weight (< 1500 g), delivered at the Department of Fetomaternal Medicine of the Medical University of Vienna, Austria, between January 1999 and July 2009. Doppler results before delivery were classified as follows: Group 1: abnormal umbilical artery (UA) pulsatility index (PI) more than 2 SD above the mean for normal reference data, or absent UA end-diastolic flow, both with normal middle cerebral artery (MCA) PI (mean ± 2 SD); Group 2: abnormal UA-PI > mean + 2 SD, or absent or reversed UA end-diastolic flow, with abnormal MCA-PI (< mean - 2 SD) and normal ductus venosus (DV) PI (mean ± 2 SD); Group 3: absent or reversed UA end-diastolic flow, with abnormal MCA-PI (< mean - 2 SD) and abnormal DV-PI (> mean + 2 SD) and/or absent or reversed end-diastolic DV flow. Pregnancy outcome was analyzed according to Doppler results. RESULTS: Due to very poor prognosis, 19 fetuses underwent expectant management and died in utero. These were excluded from further analyses. Of the remaining 91 cases, 17 were in Doppler Group 1, 44 in Group 2 and 30 in Group 3. Within 4 weeks after delivery, 0/17 (0%) infants in Group 1 died, 2/44 (4.5%) infants in Group 2 died and 7/30 (23.3%) infants in Group 3 died (P = 0.019). None of the 42 Group 2 cases that delivered at or after 28 completed gestational weeks died within 4 weeks after delivery, in contrast to 4/20 (20.0%) Group 3 cases (P = 0.009). In comparison, among infants delivered before 27 completed gestational weeks, 2/2 (100%) Group 2 cases died and 3/10 (30.0%) Group 3 cases died; P = 0.152). CONCLUSIONS: Doppler examinations are highly predictive in assessing the outcome of IUGR fetuses. From 28 completed gestational weeks, early delivery before the onset of fetal cardiac decompensation might be beneficial.

Asunto(s)

Retardo del Crecimiento Fetal/diagnóstico por imagen , Trabajo de Parto Inducido/métodos , Insuficiencia Placentaria/diagnóstico por imagen , Ultrasonografía Doppler de Pulso , Ultrasonografía Prenatal/métodos , Estudios de Cohortes , Femenino , Retardo del Crecimiento Fetal/mortalidad , Edad Gestacional , Humanos , Recién Nacido , Recien Nacido Prematuro , Trabajo de Parto Inducido/mortalidad , Insuficiencia Placentaria/mortalidad , Embarazo , Resultado del Embarazo , Nacimiento Prematuro/mortalidad , Pronóstico , Estudios Retrospectivos

RESUMEN

The modern concepts of placental pathology are considered and analysed in the context of forensic medical practice. The most promising approaches to the application of fundamental knowledge of placental pathology (including morphometric methods) for the purpose of forensic medical expertise are discussed.

Asunto(s)

Patologia Forense , Mortalidad Perinatal , Placenta/patología , Asfixia Neonatal/mortalidad , Asfixia Neonatal/patología , Femenino , Humanos , Recién Nacido , Insuficiencia Placentaria/mortalidad , Insuficiencia Placentaria/patología , Embarazo

RESUMEN

Intrauterine growth restriction (IUGR) secondary to placental insufficiency is a major cause of perinatal morbidity and mortality in the United States. Historically, Doppler changes occurring in IUGR fetuses play an important role in the diagnosis and management of these fetuses, and now, based on these changes, we have proposed a staging system for IUGR fetuses that demonstrates prognostic value. This manuscript also summarizes a practical classification for IUGR fetuses. We believe that future studies should differentiate among the different types of IUGR fetuses.

Asunto(s)

Retardo del Crecimiento Fetal/clasificación , Feto/irrigación sanguínea , Placenta/irrigación sanguínea , Placenta/diagnóstico por imagen , Ultrasonografía Doppler , Ultrasonografía Prenatal , Velocidad del Flujo Sanguíneo , Femenino , Sangre Fetal/diagnóstico por imagen , Retardo del Crecimiento Fetal/sangre , Retardo del Crecimiento Fetal/diagnóstico , Edad Gestacional , Humanos , Insuficiencia Placentaria/diagnóstico por imagen , Insuficiencia Placentaria/mortalidad , Insuficiencia Placentaria/fisiopatología , Embarazo , Pronóstico

RESUMEN

La muerte fetal supone más de la mitad de las muertes perinatales. El grupo con mayor morbimortalidad corresponde a los recién nacidos que asocian prematuridad y bajo peso. Hay una marcada tendencia a repetir el mal resultado de la gestación anterior. Se presentan 2 casos de muerte fetal, y se realiza una revisión de las causas más frecuentes y de su influencia. El estudio de las alteraciones maternas, fetales y placentarias puede, en algunos casos, establecer la etiología de la muerte fetal (AU)

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Fetal death represents more than half of perinatal deaths. Morbidity is highest in newborns who associate prematurity and low birth weight. Adverse pregnancy outcomes show a marked tendency to be repeated. We present two cases of fetal death and review the most frequent causes of this adverse outcome and their influence. Study of maternal, fetal and placental alterations can sometimes establish the etiology of fetal death (AU)

Asunto(s)

Humanos , Femenino , Adulto , Factores de Riesgo , Muerte Fetal/complicaciones , Muerte Fetal/diagnóstico , Muerte Fetal/etiología , Insuficiencia Placentaria/complicaciones , Insuficiencia Placentaria/diagnóstico , Insuficiencia Placentaria/mortalidad , Dilatación y Legrado Uterino/métodos , Insuficiencia Placentaria/etiología , Insuficiencia Placentaria/fisiopatología , Acetaminofén/uso terapéutico , Misoprostol/uso terapéutico , Listeria/aislamiento & purificación , Listeria/patogenicidad

RESUMEN

OBJECTIVES: To evaluate the characteristics and association with perinatal outcome of the aortic isthmus (AoI) circulation as assessed by Doppler imaging in preterm growth-restricted fetuses with placental insufficiency. METHODS: This was a prospective cross-sectional study. Fifty-one fetuses with intrauterine growth restriction (IUGR) and either an umbilical artery (UA) pulsatility index (PI) > 95(th) centile or a cerebroplacental ratio < 5(th) centile were examined at 24-36 weeks' gestation. AoI impedance indices (PI and resistance index) and absolute velocities (peak systolic (PSV), end-diastolic and time-averaged maximum (TAMXV) velocities), were measured in all cases and compared with reference ranges by gestational age. Furthermore, fetuses were stratified into two groups according to the direction of the diastolic blood flow in the AoI: those with antegrade flow (n = 41) and those with retrograde flow (n = 10). Clinical surveillance was based on gestational age and Doppler assessment of the UA, middle cerebral artery and ductus venosus (DV). Adverse perinatal outcome was defined as stillbirth, neonatal death and severe morbidity (respiratory distress syndrome, bronchopulmonary dysplasia, Grade III/IV intraventricular hemorrhage, necrotizing enterocolitis and a neonatal intensive care unit stay > 14 days). RESULTS: Adverse perinatal outcome was significantly associated with an increased AoI-PI (area under the curve 0.77; 95% CI, 0.63-0.92; P < 0.005). A significant correlation (P < 0.001) was found between retrograde blood flow in the AoI and adverse perinatal outcome, the overall perinatal mortality being higher in the retrograde group (70% vs. 4.8%, P < 0.001). In 4/5 (80%) fetuses the reversal of flow in the AoI preceded that in the DV by 24-48 h. AoI-PSV and AoI-TAMXV were < 5(th) centile in 40/51 (78%) and 48/51 (94%) cases, respectively, whereas AoI-PI was > 95(th) centile in 21/51 (41%) cases. CONCLUSIONS: Retrograde flow in the AoI in growth-restricted fetuses correlates strongly with adverse perinatal outcome. Absolute velocities in the AoI are decreased in growth-restricted fetuses. The data suggest a potential role for Doppler imaging of the AoI in the clinical surveillance of fetuses with severe IUGR, which should be confirmed in larger prospective studies.

Asunto(s)

Aorta Torácica/diagnóstico por imagen , Retardo del Crecimiento Fetal/diagnóstico por imagen , Feto/irrigación sanguínea , Insuficiencia Placentaria/diagnóstico por imagen , Nacimiento Prematuro/fisiopatología , Aorta Torácica/embriología , Aorta Torácica/fisiopatología , Velocidad del Flujo Sanguíneo/fisiología , Métodos Epidemiológicos , Femenino , Sangre Fetal/diagnóstico por imagen , Retardo del Crecimiento Fetal/mortalidad , Retardo del Crecimiento Fetal/fisiopatología , Edad Gestacional , Humanos , Placenta/irrigación sanguínea , Placenta/diagnóstico por imagen , Insuficiencia Placentaria/mortalidad , Insuficiencia Placentaria/fisiopatología , Embarazo , Nacimiento Prematuro/diagnóstico por imagen , Nacimiento Prematuro/mortalidad , Ultrasonografía Doppler/métodos

RESUMEN

OBJECTIVE: To identify specific estimates and predictors of neonatal morbidity and mortality in early onset fetal growth restriction due to placental dysfunction. METHODS: Prospective multicenter study of prenatally diagnosed growth-restricted liveborn neonates of less than 33 weeks of gestational age. Relationships between perinatal variables (arterial and venous Dopplers, gestational age, birth weight, acid-base status, and Apgar scores) and major neonatal complications, neonatal death, and intact survival were analyzed by logistic regression. Predictive cutoffs were determined by receiver operating characteristic curves. RESULTS: Major morbidity occurred in 35.9% of 604 neonates: bronchopulmonary dysplasia in 23.2% (n=140), intraventricular hemorrhage in 15.2% (n=92), and necrotizing enterocolitis in 12.4% (n=75). Total mortality was 21.5 % (n=130), and 58.3% survived without complication (n=352). From 24 to 32 weeks, major morbidity declined (56.6% to 10.5%), coinciding with survival that exceeded 50% after 26 weeks. Gestational age was the most significant determinant (P<.005) of total survival until 26(6/7) weeks (r(2)=0.27), and intact survival until 29(2/7) weeks (r(2)=0.42). Beyond these gestational-age cutoffs, and above birth weight of 600 g, ductus venosus Doppler and cord artery pH predicted neonatal mortality (P<.001, r(2)=0.38), and ductus venosus Doppler alone predicted intact survival (P<.001, r(2)=0.34). CONCLUSION: This study provides neonatal outcomes specific for early-onset placenta-based fetal growth restriction quantifying the impact of gestational age, birth weight, and fetal cardiovascular parameters. Early gestational age and birth weight are the primary quantifying parameters. Beyond these thresholds, ductus venosus Doppler parameters emerge as the primary cardiovascular factor in predicting neonatal outcome. LEVEL OF EVIDENCE: II.

Asunto(s)

Retardo del Crecimiento Fetal/mortalidad , Enfermedades del Prematuro/etiología , Enfermedades del Prematuro/mortalidad , Insuficiencia Placentaria/mortalidad , Adolescente , Adulto , Peso al Nacer , Estudios de Cohortes , Femenino , Retardo del Crecimiento Fetal/diagnóstico por imagen , Edad Gestacional , Humanos , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/diagnóstico por imagen , Circulación Placentaria/fisiología , Insuficiencia Placentaria/diagnóstico por imagen , Valor Predictivo de las Pruebas , Embarazo , Ultrasonografía Prenatal , Cordón Umbilical/diagnóstico por imagen , Cordón Umbilical/fisiopatología

RESUMEN

UNLABELLED: BACKGROUND/PATIENTS: A reverse flow in the umbilical artery and/or fetal aorta is associated with a higher perinatal and neonatal mortality. 30 fetuses showed a reverse flow using pulsed wave Doppler sonography (group I). A matched-pair control group including 30 fetuses with the same gestational age as well as a normal Doppler flow pattern in the umbilical artery and/or fetal aorta was taken for comparison (group II). RESULTS: In the group with reverse flow the rates of pregnancies with pre-eclampsia (n = 19/30, p < 0.0001), intrauterine growth retardation (n = 25/30, p < 0.0001), oligohydramnios (n = 21/30, p < 0.0001) and nicotine abuse (n = 15/30, p < 0.01) were significantly higher compared to the control group. Postnatal data showed significantly lower pH values in group I (p < 0.01). 40 % of the fetuses with reverse flow died in utero whereas in 67 % the reverse flow was accompanied by an insufficiency of the placenta (IUGR, oligohydramnios, histopathological abnormalities of the placenta). None of the fetuses in the control group died in utero. The incidence of IUGR (< 5ht percentile) was 83 % in group I but only 3 % in group II. The perinatal and overall mortality (including neonatal mortality 7 - 28 days after birth) amounted to 27 % and 53 % in group I, respectively, compared to 3 % and 0 % in the control group (p < 0.001). In addition cerebral anomalies could be found by ultrasound in 50 % of the neonates who presented a reverse flow prenatally. In 28 % of the surviving newborns an intracerebral hemorrhage (ICH) could be detected. None of the newborns of group II developed an ICH. CONCLUSIONS: Pregnancies with a reverse flow in the umbilical artery and/or fetal aorta have to be considered as a high risk group with a poor prognosis. The reverse flow is mainly caused by chronic placental insufficiency with IUGR. With respect to the further neuromotor development the incidence and severity of cerebral lesions in affected fetuses should be considered when discussing the perinatal situation with the parents.

Asunto(s)

Aorta/diagnóstico por imagen , Feto/irrigación sanguínea , Resultado del Embarazo , Embarazo de Alto Riesgo/fisiología , Ultrasonografía Doppler de Pulso , Ultrasonografía Prenatal , Arterias Umbilicales/diagnóstico por imagen , Adulto , Aorta/embriología , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/mortalidad , Femenino , Muerte Fetal/diagnóstico por imagen , Muerte Fetal/fisiopatología , Retardo del Crecimiento Fetal/diagnóstico por imagen , Retardo del Crecimiento Fetal/mortalidad , Humanos , Recién Nacido , Análisis por Apareamiento , Oligohidramnios/diagnóstico por imagen , Oligohidramnios/mortalidad , Insuficiencia Placentaria/diagnóstico por imagen , Insuficiencia Placentaria/mortalidad , Preeclampsia/diagnóstico por imagen , Preeclampsia/mortalidad , Embarazo , Factores de Riesgo , Análisis de Supervivencia , Tabaquismo/diagnóstico por imagen , Tabaquismo/mortalidad

RESUMEN

Conocer la incidencia de la mortalidad fetal, las características maternas, condiciones obstétricas y factores relacionados. Estudio descriptivo análitico de 421 muertes fetales sucedidas entre 1993-1997. Hospital "Dr. Adolfo Prince Lara", Puerto Cabello, Estado Carabobo, Venezuela. La mortalidad perinatal para el período fue de 45,46 por mil nacidos vivos, y la fetal 22,28. Las muertes predominaron en edades de 24 años y menos (47,27 por ciento), con antecedentes familiares hipertensión arterial y diabetes (52,49 por ciento), antecedentes personales hipertensional arterial y diabetes (24,9 por ciento), la patología de ingreso determinante fue la hipertensión arterial 25,41 por ciento seguida de la hemorrágica placentaria 13,06 por ciento. No realizaron control prenatal el 48,22 por ciento, hubo III-VII gestantes (62,47 por ciento), la edad de gestación menor a 37 semanas 62,9 por ciento. El 77,43 por ciento fueron partos vaginales. Predominó el sexo masculino 50,36 por ciento con peso menor de 2500 g. (65,09 por ciento) y talla menor de 50 cm. (65,32 por ciento). El factor de muerte directo conocido en 265 casos fue la insuficiencia placentaria 45,28 por ciento, desencadenada especialmente por hipertensión arterial, seguida por patología hemorrágica placentaria 38,87 por ciento. Los resultados señalan hacer un mejor manejo de las patalogías hipertensivas, diabetes y hemorrágicas placentaria a fin de disminuir la mortalidad fetal

Asunto(s)

Humanos , Masculino , Femenino , Preescolar , Recién Nacido , Insuficiencia Placentaria/mortalidad , Mortalidad Infantil , Factores de Riesgo , Mortalidad Fetal , Diabetes Mellitus/mortalidad , Hipertensión/diagnóstico , Venezuela

Asunto(s)

Mortalidad Infantil , Tamizaje Masivo , Anomalías Congénitas/mortalidad , Anomalías Congénitas/prevención & control , Femenino , Humanos , Recién Nacido , Masculino , Tamizaje Masivo/métodos , Países Bajos/epidemiología , Insuficiencia Placentaria/mortalidad , Insuficiencia Placentaria/prevención & control , Embarazo , Tasa de Supervivencia

RESUMEN

UNLABELLED: The combination of weight discordance and prematurity implies a high perinatal morbidity and mortality for the affected twins. Several pathomechanisms may be responsible for the weight difference in twins including a different genetic growth potential in dizygotic twins, placenta insufficiency in one twin, and chronic feto-fetal transfusion (CFFT). Little is known about neonatal morbidity and mortality of discordant twins. Therefore, a retrospective, case-controlled study on preterm discordant twins up to 34 weeks gestation was carried out. Twenty-seven (27,3%) of 99 twin pairs born in our clinic had a birth weight difference of more than 20%. The control group consisted of 27 non-discordant twins matched for gestational age. Discordant twins showed a significantly higher mortality (19%) than the control twins (2%). Severe intracranial haemorrhage (ICH) and persistent ductus arteriosus Botalli (PDA) were found more often in discordant twins than in the control group. The increased mortality and morbidity of discordant twins compared with concordant twins matched for gestational age indicates that the increased morbidity and mortality of preterm weight discordant twins is not only due to prematurity, but is also related to the discordance itself. Thirteen (48.1%) of the weight discordant twin pairs fulfilled the criteria for CFFT. Twins with CFFT differed significantly from controls with respect to the incidence of mortality and the rate of severe ICH, PDA, and the necessity of postnatal cardiopulmonary resuscitation. By contrast, no significant differences were found between discordant twins without CFFT and controls. Thus, CFFT appears to be a major contributing factor for increased mortality and morbidity of weight discordant twins. Intra-twin pair analysis revealed a higher rate of postnatal hypoglycaemia in the smaller twins only, probably caused by insufficient glycogen storage due to intra-uterine malnutrition. Mortality was the same for both the larger and the smaller twins. It may be concluded that neonatal outcome of smaller twins who have survived intra-uterine malnutrition is the same as in larger twins. Intra-twin pair analysis in twins with CFFT revealed no significant differences except for a higher rate of ICH grade 2-4 in the larger twins which might be explained by hypervolaemia of the recipient. CONCLUSION: Morbidity and mortality of weight discordant twins are increased. CFFT appears to be a major contributing factor for the increased mortality and morbidity. Postnatal mortality was the same in acceptor and donor; however, the acceptor had a higher postnatal morbidity.

Asunto(s)

Enfermedades en Gemelos , Enfermedades del Prematuro/mortalidad , Peso al Nacer , Causas de Muerte , Hemorragia Cerebral/mortalidad , Conducto Arterioso Permeable/mortalidad , Femenino , Retardo del Crecimiento Fetal/mortalidad , Transfusión Feto-Fetal/mortalidad , Estudios de Seguimiento , Edad Gestacional , Humanos , Recién Nacido , Masculino , Insuficiencia Placentaria/mortalidad , Embarazo , Factores de Riesgo , Tasa de Supervivencia