Síndrome Klippel-Trenaunay en el embarazo. Reporte de un caso / Klippel-Trenaunay syndrome in pregnancy. Case report

Resumen ANTECEDENTES: El síndrome Klippel-Trenaunay es neurocutáneo, con repercusión vascular. La triada característica la integran: nevo vascular cutáneo, venas varicosas e hipertrofia asimétrica de los tejidos blandos y huesos que afectan una o más extremidades. Durante el embarazo estas malformaciones se incrementan, con afectación pélvica e intraabdominal. En la bibliografía internacional están reportados menos de 100 casos de embarazos complicados con este síndrome. CASO CLÍNICO: Paciente de 16 años, primigesta, con síndrome Klippel-Trenaunay diagnosticado a los 15 años, enviada a nuestra unidad, en el tercer trimestre del embarazo, para finalización de éste. Se le practicaron estudios preoperatorios: biometría hemática, pruebas de coagulación, reportados sin alteraciones. El ultrasonograma Doppler del segmento uterino sin incremento en la vasculatura. Se programó para cesárea, que se llevó a cabo sin complicaciones intraoperatorias, con sangrado de 600 cc, incremento de la vascularidad en el colon. Permaneció en vigilancia durante 48 horas, luego de la operación, en cuidados intensivos, sin complicaciones hemorrágicas o isquémicas. Se dio de alta del hospital a las 72 horas, con tromboprofilaxis, analgésico y antibiótico. CONCLUSIÓN: El embarazo en pacientes con síndrome de Klippel-Trenaunay implica una elevada morbilidad y mortalidad, que pueden prevenirse con atención multidisciplinaria que disminuya las potenciales complicaciones.

Abstract BACKGROUND: Klippel-Trenaunay syndrome is a neurocutaneous syndrome with vascular repercussion whose characteristic triad is a cutaneous vascular nevus, varicose veins and asymmetric soft tissue and bone hypertrophy, which affect one or more limbs, during pregnancy these malformations increase, with pelvic and intra-abdominal repercussion. In the world literature, fewer than 100 cases of complicated pregnancies with this syndrome have been reported. OBJECTIVE: The second case of complicated pregnancy with Klippel-Trenaunay syndrome treated in our institution is reported, given its high morbidity, due to the high risk of severe complications such as venous thromboembolism or excessive bleeding in the intrapartum period. CLINICAL CASE: A 16-year-old, with a Klippel-Trenaunay syndrome diagnosed at fifteen, sent to our unit, with a third-trimester pregnancy, for resolution of pregnancy. Preoperative studies were performed blood count, coagulation tests, reported without alterations; as well as Doppler ultrasound of the uterine segment, without an increase in vasculature. It is scheduled for caesarean section, which is performed without intraoperative complications, with total bleeding of 600 cc, with an increase in vascularity at the colon level. She remains in immediate postoperative surveillance for 48 hours in an intensive care unit, without presenting haemorrhagic or ischemic complications. She is discharged at 72 hours, with thromboprophylaxis, analgesic and antibiotic. CONCLUSION: Pregnancy in patients with this syndrome implies high morbidity and mortality, which can be prevented with multidisciplinary management, anticipating potential complications.

Complicaciones obstétricas y perinatales en pacientes con anemia / Obstetric and perinatal complications in anemic patients

Resumen OBJETIVO: Determinar la relación entre complicaciones obstétricas y perinatales con la anemia durante el embarazo. MATERIALES Y MÉTODOS: Estudio ambispectivo, observacional y transversal. Se incluyeron pacientes en trabajo de parto, con embarazo único, atendidas entre marzo y octubre de 2017 en el Hospital General Dr. Salvador Zubirán Anchondo, Chihuahua, Chih. Se excluyeron las pacientes con embarazo complicado por defectos congénitos, que hubieran recibido anticoagulantes, con diagnóstico médico de hemoglobinopatías, hemofilias, preeclampsia, síndrome de HELLP, partos instrumentados y distocias, diabetes gestacional, nefropatías, hepatopatías, tabaquismo y toxicomanías. Complicaciones valoradas: amenaza de aborto, amenaza de parto pretérmino, parto pretérmino, ruptura prematura de membranas, infección de vías urinarias, peso al nacer, valoración de Apgar al minuto y a los 5 minutos, hemorragia obstétrica. Se entrevistó a todas las pacientes para evaluar los antecedentes ginecoobstétricos y se tomó una muestra de sangre venosa para determinar: hemoglobina, hematocrito, cantidad de glóbulos rojos, volumen corpuscular medio, concentración de hemoglobina corpuscular media. Se registraron las mediciones antropométricas, valores de Apgar y complicaciones perinatales del expediente clínico. RESULTADOS: Se estudiaron 1051 pacientes divididas en dos grupos: con anemia (n = 172) y sin anemia (n = 879). Se consideró anemia a la hemoglobina menor de 11 g/dL o hematocrito menor de 33%. Se clasificaron de acuerdo con la OMS como: anemia leve 10-10.9 g/dL, moderada 7-9.9 g/dL y severa menos de 7.0 g/dL. La prevalencia de anemia fue de 16%. La anemia leve se identificó con mayor frecuencia 10% (n = 111), anemia moderada y severa 6% (n = 61). Las complicaciones maternas y neonatales no mostraron asociación con la anemia materna durante el embarazo. La hemotransfusión fue mayor en pacientes con anemia (9 vs 1%). CONCLUSIÓN: Se identificó anemia materna en 16% de los casos y se asoció con necesidad de transfusión de hemoderivados en el posparto o posquirúrgico de cesárea.

Abstract OBJECTIVE: Determinate the association between adverse perinatal outcomes and anemia in pregnant women. MATERIALS AND METHODS: Observational, prospective-retrospective and cross-sectional study. Including women in birth labor attended at Hospital General Dr. Salvador Zubirán Anchondo in Chihuahua City, during March to October 2017. Inclusion criteria considered women with single pregnancy. Exclusion criteria with present conditions: congenital deformities, use of anticoagulants, blood diseases, preeclampsia, HELLP syndrome, instrumental delivery with forceps, dystocia, maternal diabetes, kidney and liver diseases, use of tobacco and other drugs. Adverse perinatal outcomes included were: miscarriage risk, preterm labor, preterm birth, pre labor rupture of membranes, urinary infection, low birth weight, Apgar score at birth and after five minutes, obstetric hemorrhage. Patients were interviewed to evaluate obstetric background; blood venous sample was taken to determine haemoglobin, hematocrit, red blood cells number, medium corpuscular volume, medium corpuscular hemoglobin concentration. Birth data was registered from medical records. RESULTS: Two groups were integrated: with anemia (n=172) and without anemia (n=879). Patients with anemia were those with haemoglobin less than 11 g/dL or hematocrit less than 33% according World Health Organization anemia classification: mild 10-10.9 g/dL, moderate 7-9.9 g/dL and severe less than 7.0 g/dL. Anemia frequency was calculated in 16%, mild anemia frequency was 10% (111 patients), 6% moderate and severe anemia (n = 61). Both groups developed patients with adverse perinatal outcomes. Transfusion of blood products showed higher frequency in anemic patients (9% versus 1% control group). CONCLUSION: Anemia prevalence calculated in 16% associated with transfusion of blood products, during puerperium or after c-section period.

Maternity care system for high risk pregnant women in obstetrically underserved area

The number of maternity care hospitals in underserved areas has been falling since 2004 because of business losses steming from low birth rates, inadequate insurance payments for obstetric services, and the shortage of obstetricians. However, the proportion of pregnant women at high risk in Korea has been increasing for decades because of the delay of marriage and the greater number of older pregnant women. High-risk pregnancies tend to lead to pregnancy complications and are associated with high-risk deliveries. An insufficient maternity care system for highrisk pregnant women in Korea has resulted in an increase in maternal mortality. The Ministry of Health and Welfare has supported the establishment of maternity care centers in underserved areas and regional perinatal centers to reduce maternal mortality. Even though the regional perinatal centers are a good system for reducing maternal mortality, they are limited in scope, in that they are not being established quickly on a nationwide scale to detect high-risk pregnancies earlier. This review briefly describes the current maternity care system for high-risk pregnancies and proposes a direction for the development of a health care delivery system between the regional perinatal centers and the maternity care system in underserved areas.

Arteritis de Takayasu en mujer de edad reproductiva: reporte de un caso / Takayasus’s arteritis in a woman of childbearing age: report of a case

Introducción: La arteritis de Takayasu es una enfermedad vascular inflamatoria crónica e inespecífica, de etiología desconocida, que usualmente afecta las ramas del arco aórtico y se presenta con una alta incidencia en la mujer durante la edad reproductiva. De la vigilancia multidisciplinaria dependerán en gran medida los resultados materno-fetales favorables. Objetivo: Presentar el caso de una gestante de 19 años con diagnóstico de arteritis de Takayasu realizado a las 19 semanas de embarazo. Esta paciente cursó la gestación y el parto (cesárea) sin otra complicación que una HTA que apareció a las 27 semanas, con tratamiento y evolución estable en el servicio de obstetricia del Hospital Provincial Docente Ginecobstétrico Julio R Alfonso Medina. Métodos: Se revisó la literatura sobre el tema y su relación con el embarazo, realizando una breve exposición de las características clínicas, diagnóstico, manejo y pronóstico de la enfermedad.

Introduction: The Takayasus's arteritis is a nonspecific, chronic, vascular, inflammatory disease, of unknown etiology, usually occluding one or more of the large branches of the aortic arch, with a high incidence in women during the childbearing age. The favorable maternal-fetal results will depend in a large extend on the multidisciplinary surveillance. Objective: Presenting the case of a pregnant woman aged 19 diagnosed with Takayasus's arteritis when she was 19 weeks pregnant. This patient went through the pregnancy and labor with no more complication than arterial hypertension at the 27 weeks of pregnancy. Being treated in the obstetric service of the Teaching Gynecoobstetric Hospital Dr. Julio R. Alfonso Medina, she showed a favorable evolution. Methodos: We reviewed the literature on the theme and its relation with pregnancy making a brief exposition of the clinical features, diagnosis, handling and prognosis of the disease.

Arteritis de Takayasu y embarazo / Takayasu arteritis and pregnancy

La arteritis de Takayasu es una enfermedad vascular inflamatoria crónica e inespecífica, de etiología desconocida, que usualmente afecta las ramas del arco aórtico y se presenta con una alta incidencia durante la edad reproductiva. El estado de la enfermedad al comienzo del embarazo es un factor decisivo para establecer el manejo ulterior. De la vigilancia multidisciplinaria dependerán en gran medida los resultados materno-fetales favorables. Presentamos el caso de una gestante de 20 años con diagnóstico de arteritis de Takayasu realizado un año previo a la concepción y que cursó un embarazo y parto sin complicaciones bajo seguimiento, en el servicio de obstetricia del Hospital general docente "Enrique Cabrera". Se revisó la literatura sobre el tema y su relación con el embarazo realizando una breve exposición de las características clínicas, diagnóstico, manejo y pronóstico de la enfermedad

Takayasu's arteritis is a nonspecific, chronic, inflammatory and vascular disease, its etiology is unknown usually occluding one or more of the large branches of the aortic arch, with a high incidence during reproductive age. Disease condition at pregnancy onset is a decisive factor for its further management. From multidisciplinary surveillance will depend in large extent the favorable maternal-fetal result. This is the case of a pregnant aged 20 diagnosed with Takayasu's arteritis during one year prior to conception and with a complications-free pregnancy and labor under follow-up in Obstetrics Service of "Enrique Cabrera" Hospital. Literature on this matter was reviewed and its relation to pregnancy, with a brief exposition of clinical features, diagnosis, management and disease prognosis

Hipertensión portal y embarazo / Portal hypertension related to pregnancy

El embarazo con hipertensión portal asociada representa una compleja situación clínica para el obstetra y el equipo multidisciplinario responsable de su atención. Durante el estado gravídico se produce un incremento del flujo portal como consecuencia del estado hipervolémico que se desarrolla y esto contribuye a una mayor presión portal trasmitida hacia las venas colaterales que incrementa el riesgo de sangramiento de las varices esofágicas en estas pacientes. Presentamos el caso de una gestante de 20 años portadora de una hipertensión portal prehepática que después de su manejo multidisciplinario tuvo un embarazo y parto sin complicaciones. Se revisa la literatura disponible sobre el tema.

Pregnancy with associated portal hypertension is a complex clinical situation for obstetrician, and for the multidisciplinary staff responsible for its care. During the gravidism state there is an increment in portal flow as consequence of the developed hypervolemia state, and it contributes to a greater portal pressure transmitted to collateral veins increasing the bleeding risk of esophageal varices in these patients. We present the case of a pregnant woman aged 20 carrier of pre-hepatic portal hypertension which after its multidisciplinary management had a non-complicated pregnancy and labor. We made a review of literature available on this matter.

Midtrimester Amniotic Fluid Levels and Each Ratio of Activn A, Inhibin A and B in Down's Syndrome and Other Complicated Pregnancies / 대한산부인과학회잡지

OBJECTIVE: To evaluate the amniotic fluid levels and each ratio of activin A, inhin A and B in Down's syndrome and other complicated pregnancies. METHODS: This study was performed in 71 women who had undergone a midtrimester amniocentesis with the clinical indications and whose pregnancy outcome was retrospectively determined. Ten Down's syndrome, 15 complicated pregnancies including, preeclamsia, gestational diabetesis mellitus, preterm labor, intrauterine growth restriction (IUGR), and 46 noncomplicated pregnancies with normal chromosome were included in this study. Amniotic fluid activin A, inhibin A and B were measured using enzyme linked immunosorbent assays (ELISA). Statistical analysis was performed with Mann-Whitney U test and regression analysis. RESULTS: There were significant positive correlation (r=0.277, p=0.011) between the ratio activin A/ inhibin B level and maternal age and significant positive correlation (r=0.261, p=0.015) between maternal age and the ratio inhibin A/inhibin B level. There were also significant positive correlation (r=0.202, p=0.045) between gestational weeks and inhibin A levels and significant positive correlation (r=0.474, p<0.001) between gestational weeks and inhibin B levels. Amniotic fluid inhibin A and inhibin B levels were significantly (p<0.05) decreased in Down's syndrome compared with the normal chromosomal groups but there was no difference in the ratio activin A/inhibin A and in the ratio activin A/inhibin B between these groups. The amniotic fluid levels of activin A, inhibins (A and B), each ratio of complicated pregnancies groups with normal chromosome was not significantly different from those of uncomplicated pregnancies with normal chromosome. CONCLUSION: This study revealed that amniotic inhibin levels were significantly decreased in Down's syndrome. But, activin A and each ratio were unchanged. The results suggest that activin A may be relatively decreased in each case of Down's syndrome.