Poor nutritional status of fifteen-year-old or younger adolescent mothers enhances the risk of small-for-gestational-age newborns

Introduction: To analyze the factors (socio-demographic, clinical, prenatal care, delivery, postpartum data and anthropometric measures) associated with the birth of small for gestational age newborns.Methods: A cross-sectional study was performed with 15 years old or younger postpartum adolescents divided into small-for-gestational-age newborn (SGA) and non-small-for-gestational age newborn groups (NSGA). Socio-demographic, clinical, prenatal care, delivery, postpartum data and anthropometric measures (triceps skinfold (TS), and mid-arm circumference, (MAC)) were collected.Results: 8,153 women gave birth at the obstetric ward and 364 (4.46%) ≤ 15 years old adolescents were enrolled in the study. The proportion of SGA newborns was 34.61%. The SGA group attended fewer prenatal visits (p = 0.037), had a higher prevalence of nutritional status classified as "very low weight" (p < 0.001) and vaginal delivery (p = 0.023), compared to the NSGA group. The nutritional status and vaginal delivery remained significant even after adjustment for confounders. The prevalence risk for SGA birth was 30% higher in the group of mothers with nutritional status classified as "very low weight" (odds ratio 1.30, 95% confidence interval 1.13 to 1.50) (p < 0.001).Conclusions: 15.4% of adolescents ≤ 15 years of age had an arm circumference compatible with the "very low weight" condition, demonstrating the high prevalence of poor maternal nutritional status in this group. The birth of SGA among adolescents ≤ 15 years of age is independently associated with maternal nutritional status classified as "very low weight" by the mid-arm circumference measures (MAC).

La salud gestacional y su relación con la restricción del crecimiento intrauterino / Gestational health and its relationship with intrauterine growth restriction

RESUMEN Introducción: La frecuencia de infantes que durante el desarrollo intrauterino experimentan restricción del crecimiento es alta y su mayor incidencia está en los países en desarrollo, entre los que Latinoamérica y el Caribe alcanzan prevalencia del 10 %. Objetivo: Identificar la relación que existe entre la anemia, las alteraciones de la tensión arterial y la disglicemia, con la restricción del crecimiento fetal. Métodos: Se realizó estudio longitudinal descriptivo y retrospectivo de gestantes captadas en dos áreas de salud del municipio Santa Clara, que terminaron su embarazo entre septiembre del 2013 y octubre del 2018. Los recién nacidos presentaron restricción del crecimiento intrauterino. La muestra se clasificó en: pequeños y adecuados, según condición trófica al nacimiento. En cada grupo se estudió la relación de estas afecciones en los que se sospechó un vínculo con el fenómeno de restricción. Resultados: Los niños que presentaron restricción del crecimiento fetal se clasificaron, según su condición trófica, en adecuados; no se apreciaron relaciones significativas entre la anemia, la diabetes gestacional y la hipertensión arterial con la presencia de restricción del crecimiento intrauterino. Conclusiones: esta afección no estuvo relacionada con la salud de las gestantes portadoras en dos áreas de salud del municipio Santa Clara.

ABSTRACT Introduction: the frequency of infants experiencing growth restriction during intrauterine development is high and its highest incidence is in developing countries, among which Latin America and the Caribbean reach a prevalence of 10%. Objective: to identify the relationship among anemia, blood pressure changes and dysglycemia, with fetal growth restriction. Methods: we conducted a descriptive, retrospective and longitudinal study of pregnant women recruited in two health areas from Santa Clara municipality, who ended their pregnancy between September 2013 and October 2018 and in whom the newborns had intrauterine growth restriction. The sample was classified as small and adequate, according to their trophic condition at birth. The relation of these conditions in which a link with the restriction phenomenon was suspected was studied in each group. Results: children who had fetal growth restriction were classified, according to their trophic condition, as adequate; no significant relationships were found among anemia, gestational diabetes and arterial hypertension with the presence of intrauterine growth restriction. Conclusions: this condition was not related to the health of the pregnant women belonging to these two health areas from Santa Clara municipality.

Doppler de arteria umbilical en fetos con síndrome de Down / Umbilical artery Doppler in fetuses with Down syndrome

INTRODUCCIÓN: La aneuploidía más común entre los recién nacidos vivos es el síndrome de Down (SD). En estos niños el crecimiento está disminuido, con una frecuencia del 25% de restricción del crecimiento intrauterino, pero no se ha establecido el papel de la insuficiencia placentaria. El objetivo es estudiar la resistencia placentaria a través del Doppler de arteria umbilical con índice de pulsatilidad (IP) y el tiempo medio de desaceleración (t/2), y el posible efecto de la insuficiencia placentaria en fetos con SD. MÉTODO: Se realizó Doppler en la arteria umbilical en 78 fetos con SD, se midieron el IP y el t/2, y se compararon los resultados con los pesos de nacimiento. RESULTADOS: Se estudiaron 78 fetos con SD con 214 mediciones Doppler. El t/2 y el IP estaban alterados en el 71,5% y el 65% de las mediciones, respectivamente. La incidencia de t/2 alterado aumenta con la edad gestacional desde un 28,6% a las 15-20 semanas hasta un 89,3% sobre las 36 semanas (p < 0,01); cifras similares se observan para el IP. La clasificación de los pesos fue: 64% adecuados, 12% grandes y 24% pequeños para la edad gestacional. La última medición de t/2 antes del parto era normal en el 17% y estaba alterada en el 83%. En el caso del IP, los valores fueron normales en el 27% y anormales en el 73%. El peso de nacimiento, la edad gestacional y el porcentaje de niños adecuados para la edad gestacional eran significativamente mayores en el grupo con Doppler normal que en el grupo con Doppler alterado. El z-score del t/2 estaba marcadamente alterado (−2.23), pero el del peso de nacimiento solo estaba algo disminuido (−0,39). La mortalidad perinatal fue del 10%, significativamente mayor cuando el flujo diastólico era ausente o reverso. CONCLUSIONES: El estudio demuestra que los fetos con SD tienen una alta incidencia de alteración del Doppler umbilical para el IP y el t/2, lo cual sugiere una insuficiencia placentaria grave. Este deterioro parece iniciarse hacia el final del segundo trimestre y aumenta con la edad gestacional. Sin embargo, en estos fetos, la insuficiencia placentaria produce una ligera caída en el crecimiento fetal. Como hipótesis general pensamos que en los fetos con SD hay datos claros de insuficiencia placentaria, pero habría algún factor que les protegería de una restricción grave del crecimiento.

INTRODUCTION: The most common aneuploidy in live newborns is Down syndrome (DS), in these children growth is decreased, with a frequency of 25-36% of fetal growth restriction (FGR); however, it is not established the role of placental insufficiency. The objective is to study the Doppler of the umbilical artery with pulsatility index (PI) and half peak systolic velocity (hPSV) deceleration time and the possible role of placental insufficiency in fetuses with DS. METHOD: Doppler was performed in fetuses with DS, the umbilical artery and IP and hPSV were measured, and the results were compared with birth weights. RESULTS: 78 fetuses with DS were studied with 214 Doppler measurements. hPSV and the IP were altered in 71.5% and 65% of the measurements; the incidence of abnormal hPSV increases with gestational age from 28.6% between 15 to 20 weeks, to 89.3% over 36 weeks (p < 0.01), similar figures are observed with respect to the PI. The weight classification was: 24% of FGR, 12% of great for age and 64% of adequate for gestational age (AGA). The last measurement of hPSV before delivery was normal in 17% of the fetuses and was abnormal in 83%, in the case of PI the normal and abnormal values were 27 and 73%, respectively. Birth weight, gestational age, and the percentage of AGA children were significantly higher in the normal Doppler group than in the abnormal Doppler group. The hPSV z-score was markedly altered (−2.23), but the birth weight z-score is slightly decreased (−0.39). Perinatal mortality is 10% and is significantly higher when diastolic flow is absent or reverse. CONCLUSIONS: The study shows that DS fetuses have a high incidence of abnormal umbilical Doppler measured with IP and hPSV, which suggests severe placental insufficiency, this deterioration seems to start towards the end of the second trimester and increases with gestational age. However, in these fetuses, placental insufficiency causes a discrete drop in fetal growth. As a general hypothesis, we think that there is clear evidence of placental insufficiency in fetuses with DS, but there would be some factor that would protect these fetuses from severe growth restriction.

Tyrosine phosphorylation of Kv1. 5 is upregulated in intrauterine growth retardation rats with exaggerated pulmonary hypertension

Intrauterine growth retardation (IUGR) is associated with the development of adult-onset diseases, including pulmonary hypertension. However, the underlying mechanism of the early nutritional insult that results in pulmonary vascular dysfunction later in life is not fully understood. Here, we investigated the role of tyrosine phosphorylation of voltage-gated potassium channel 1.5 (Kv1.5) in this prenatal event that results in exaggerated adult vascular dysfunction. A rat model of chronic hypoxia (2 weeks of hypoxia at 12 weeks old) following IUGR was used to investigate the physiological and structural effect of intrauterine malnutrition on the pulmonary artery by evaluating pulmonary artery systolic pressure and vascular diameter in male rats. Kv1.5 expression and tyrosine phosphorylation in pulmonary artery smooth muscle cells (PASMCs) were determined. We found that IUGR increased mean pulmonary artery pressure and resulted in thicker pulmonary artery smooth muscle layer in 14-week-old rats after 2 weeks of hypoxia, while no difference was observed in normoxia groups. In the PASMCs of IUGR-hypoxia rats, Kv1.5 mRNA and protein expression decreased while that of tyrosine-phosphorylated Kv1.5 significantly increased. These results demonstrate that IUGR leads to exaggerated chronic hypoxia pulmonary arterial hypertension (CH-PAH) in association with decreased Kv1.5 expression in PASMCs. This phenomenon may be mediated by increased tyrosine phosphorylation of Kv1.5 in PASMCs and it provides new insight into the prevention and treatment of IUGR-related CH-PAH.

Intrauterine thrombosis of umbilical artery - case report / Trombose intrauterina de artéria umbilical - relato de caso

ABSTRACT: CONTEXT: Umbilical cord thrombosis is related to greater fetal and perinatal morbidity and mortality. It is usually associated with umbilical cord abnormalities that lead to mechanical compression with consequent vascular ectasia. Its correct diagnosis and clinical management remains a challenge that has not yet been resolved. CASE REPORT: This study reports a case of umbilical artery thrombosis that occurred in the second half of a pregnancy. The umbilical cord was long, thin and overly twisted and the fetus presented severe intrauterine growth restriction. The clinical and histopathological findings from this case are described. CONCLUSIONS: This case report emphasizes the difficulty in diagnosing and clinically managing abnormalities of intrauterine life with a high chance of perinatal complications.

RESUMO: CONTEXTO: A trombose do cordão umbilical está relacionada com o aumento da morbimortalidade fetal e perinatal. É geralmente associada a alterações do cordão umbilical que levam à compressão mecânica com consequente ectasia vascular. Seu correto diagnóstico e manejo clínico é um desafio que não está ainda bem esclarecido. RELATO DE CASO: Neste relato se descreve caso de trombose da artéria umbilical de ocorrência na segunda metade da gravidez associada a cordão umbilical longo, fino, excessivamente retorcido, associado a feto com restrição de crescimento intrauterino grave. São descritos seus achados clínicos e histopatológicos correlacionados. CONCLUSÃO: Este relato de caso reforça a dificuldade diagnóstica e de manejo clínico em alteração da vida intrauterina com grande possibilidade de complicações perinatais.

Diagnóstico prenatal de trombohematoma subcoriónico masivo (mola de Breus) / Prenatal diagnosis of massive subchorionic thrombohematoma (Breus mole)

El trombohematoma subcoriónico masivo o Mola de Breus, por ser éste el autor que lo describió por primera vez en abortos, es un hematoma subcorial de al menos 1 cm de grosor que ocupa al menos, el 50% de la superficie fetal. Suele asociar una alta morbimortalidad fetal y perinatal, en forma de abortos, retraso del crecimiento intrauterino, muerte intrauterina, desprendimiento de placenta normalmente inserta y recién nacidos de bajo peso, generalmente pretérminos. Esta entidad debe diferenciarse de otros procesos que pueden asentar bajo la placa corial, hacia la superficie fetal como: corioangioma, depósitos de fibrina y trombosis del espacio intervelloso. Se han intentado postular mecanismos que pudieran causar dicha circunstancia, sin que por el momento podamos definir factores de riesgo médicos que claramente predispongan a padecer esta entidad. El objetivo de describir estos dos casos clínicos diagnosticados en 2013 es resaltar que, gracias a la sospecha ecográfica de un trombohematoma subcoriónico masivo, podemos estudiar la pieza de placenta y membranas tras la finalización de la gestación, con lo que obtendríamos así la confirmación anátomo-patológica, de otra manera esta información podría perderse.

The massive subchorionictrombo hematoma or Breus's Mola, this was the author who first described it in miscarriages, is a subchorionic hematoma at least 1 cm in thickness which occupies at least 50% of the fetal surface. Usually associated with high fetal and perinatal morbidity and mortality, as miscarriages, intrau-terine growth retardation, stillbirth, placental abruption and low birth weight, preterm generally. This entity should be distinguished from other processes that can seat under the chorionic plate to the fetal surface as chorioangioma, fibrin deposition and thrombosis intervillous space. They have tried to apply mechanisms that could cause such a circumstance, but for now we don't define medical risk factors that predispose clearly suffer from this entity. In order to describe these two cases diagnosed in 2013 is to emphasize that thanks to the sonographic suspicion of a massive subchorionic trombohematoma, can study the piece of placenta and membranes after the end of pregnancy, so it would provide pathologic confirmation, otherwise this information could be lost.

Physical activity in pregnancy and adverse birth outcomes / Atividade física em gestantes e desfechos perinatais adversos ao nascimento / Actividad física en gestantes y resultados perinatales adversos al nacimiento

This study focused on the association between physical activity in the second trimester of pregnancy and adverse perinatal outcomes: low birth weight (LBW), preterm birth (PTB), and intrauterine growth restriction (IUGR). The study used a sample from the BRISA cohort, São Luís, Maranhão State, Brazil, which included women with singleton pregnancy, gestational age from 22 to 25 weeks confirmed by obstetric ultrasound performed at < 20 weeks, and re-interviewed in the first 24 hours postpartum (n = 1,380). Level of physical activity was measured by the International Physical Activity Questionnaire (IPAQ), short version, categorized as high, moderate, and low. A directed acyclic graph (DAG) was used to identify minimum adjustment to control confounding. High physical activity was not associated with LBW (RR = 0.94; 95%CI: 0.54-1.63), PTB (RR = 0.86; 95%CI: 0.48-1.54), or IUGR (RR = 0.80; 95%CI: 0.55-1.15). The results support the hypothesis that physical activity during pregnancy does not result in adverse perinatal outcomes.

Investigou-se a associação entre atividade física durante o segundo trimestre gestacional e os desfechos perinatais adversos: baixo peso ao nascer (BPN), nascimento pré-termo (NPT) e restrição de crescimento intrauterino (RCIU). Foi utilizada amostra da coorte BRISA, São Luís, Maranhão, Brasil, que incluiu mulheres com gravidez única, idade gestacional de 22 a 25 semanas confirmada por ultrassonografia obstétrica realizada com < 20 semanas, reentrevistadas nas primeiras 24 horas após o parto (n = 1.380). O nível de atividade física foi medido pelo Questionário Internacional de Atividade Física (IPAQ), versão curta, e categorizado em alto, moderado e baixo. Gráfico acíclico direcionado (DAG) foi utilizado para identificar ajuste mínimo para o controle de confundimento. Nível alto de atividade física não foi associado ao BPN (RR = 0.94; IC95%: 0,54-1,63), NPT (RR = 0,86; IC95%: 0,48-1,54) ou RCIU (RR = 0,80; IC95%: 0,55-1,15). Os resultados fortalecem a hipótese de que a prática de atividade física na gestação não parece resultar em desfechos adversos ao nascimento.

Se investigó la asociación entre actividad física durante el segundo trimestre gestacional y los desenlaces perinatales adversos: bajo peso al nacer (BPN), nacimiento pretérmino (NPT) y restricción de crecimiento intrauterino (RCIU). Se utilizó una muestra de la cohorte BRISA, São Luís, Maranhão, Brasil, que incluyó mujeres con un embarazo único, edad gestacional de 22 a 25 semanas, confirmada por ultrasonografía obstétrica realizada con < 20 semanas, reentrevistadas en las primeras 24 horas tras el parto (n = 1.380). El nivel de actividad física fue medido por el Cuestionario Internacional de Actividad Física (IPAQ), versión corta, y categorizado en alto, moderado y bajo. El gráfo acíclico dirigido (DAG) se utilizó para identificar un ajuste mínimo para el control de confusores. Un nivel alto de actividad física no se asoció al BPN (RR = 0,94; IC95%: 0,54-1,63), NPT (RR = 0,86; IC95%: 0,48-1,54) o RCIU (RR = 0,80; IC95%: 0,55-1,15). Los resultados fortalecen la hipótesis de que la práctica de actividad física en la gestación no parece resultar en desenlaces adversos al nacimiento.

Restricción del crecimiento intrauterino: una aproximación al diagnóstico, seguimiento y manejo / Intrauterine growth restriction: an approach to diagnosis, monitoring and management

ANTECEDENTES: La restricción del crecimiento intrauterino (RCIU) es una entidad de origen multifactorial que puede ser causada por una gran variedad de patologías a nivel materno, fetal o placentario, y que representa altas tasas de morbimortalidad materna y perinatal. Es importante realizar un diagnóstico certero de esta patología con el fin de llevar a cabo un enfoque de seguimiento y de manejo que pueda disminuir todas las complicaciones asociadas a la enfermedad. OBJETIVO: Realizar una revisión detallada y actualizada de la etiopatogenia, criterios diagnósticos, seguimiento con ecografía Doppler y manejo de la restricción del crecimiento intrauterino. MÉTODO: Se realizó una búsqueda de literatura publicada en inglés y español en bases de datos como PubMed/MEDLINE, Ovid, MDconsult utilizando las palabras clave: restricción del crecimiento intrauterino, feto pequeño para la edad gestacional, circulación fetal, ecografía Doppler, además de la búsqueda de estadísticas relacionadas con RCIU, de los resultados obtenidos se seleccionaron 61 artículos. La información obtenida fue clasificada y utilizada como soporte para la realización de esta revisión. RESULTADOS: Se presentan los estudios disponibles, las revisiones y artículos recomendados para la evaluación de pacientes con RCIU, adicionalmente aquellos que brindan nueva información con respecto al diagnóstico, evaluación de circulación fetal, seguimiento y manejo de esta entidad clínica. CONCLUSIÓN: La restricción del crecimiento intrauterino es una patología que presenta altas tasas de morbimortalidad perinatal. La identificación temprana de estos fetos y el seguimiento adecuado mediante la evalución Doppler permiten disminuir los resultados adversos y las secuelas a corto y largo plazo.

BACKGROUND: Intrauterine growth restriction has a multifactorial origin and can be caused by a variety of pathologies in the mother, fetus or placenta, representing high rates of maternal and perinatal morbidity and mortality. Therefore, it is important to accurately diagnose this condition in order to focus in the follow and management, which can reduce the complications associated with the disease. OBJECTIVE: To perform a detailed and up to date review of the etiology, diagnostic criteria, follow up with Doppler ultrasonography and management of intrauterine growth restriction. METHODS: A literature search was done in English and Spanish in databases such us PubMed/MEDLINE, Ovid, MDconsult using the following key words: intrauterine growth restriction, small for gestational age fetus, fetal circulation, Doppler ultrasonography. Also national statistics for intrauterine growth restriction were used, obtaining 61 documents. The information obtained was classified and used in the development of this review. RESULTS: The available studies are presented, and recommended revisions to the evaluation of patients with IUGR, additionally those that provide new information regarding the diagnosis, evaluation of fetal circulation, monitoring and management of this clinical entity. CONCLUSION: Intrauterine growth restriction is a pathology with a frequent diagnosis an represents high rates of perinatal morbidity and mortality. Early identification of these fetuses and adequate monitoring by Doppler evaluation allow reducing adverse outcomes and consequences in the short and long term.

Preterm birth add fetal growth restriction in hiv-infected Brazilian pregnant women / Nascimento pré-termo e restrição de crescimento fetal em gestantes brasileiras infectadas pelo HIV

Introduction: Maternal HIV infection and related co-morbidities may have two outstanding consequences to fetal health: mother-to-child transmission (MTCT) and adverse perinatal outcomes. After Brazilian success in reducing MTCT, the attention must now be diverted to the potentially increased risk for preterm birth (PTB) and intrauterine fetal growth restriction (IUGR). Objective: To determine the prevalence of PTB and IUGR in low income, antiretroviral users, publicly assisted, HIV-infected women and to verify its relation to the HIV infection stage. Patients and Methods: Out of 250 deliveries from HIV-infected mothers that delivered at a tertiary public university hospital in the city of Vitória, state of Espírito Santo, Southeastern Brazil, from November 2001 to May 2012, 74 single pregnancies were selected for study, with ultrasound validated gestational age (GA) and data on birth dimensions: fetal weight (FW), birth length (BL), head and abdominal circumferences (HC, AC). The data were extracted from clinical and pathological records, and the outcomes summarized as proportions of preterm birth (PTB, < 37 weeks), low birth weight (LBW, < 2500g) and small (SGA), adequate (AGA) and large (LGA) for GA, defined as having a value below, between or beyond the ±1.28 z/GA score, the usual clinical cut-off to demarcate the 10th and 90th percentiles. Results: PTB was observed in 17.5%, LBW in 20.2% and SGA FW, BL, HC and AC in 16.2%, 19.1%, 13.8%, and 17.4% respectively. The proportions in HIV-only and AIDS cases were: PTB: 5.9 versus 27.5%, LBW: 14.7% versus 25.0%, SGA BW: 17.6% versus 15.0%, BL: 6.0% versus 30.0%, HC: 9.0% versus 17.9%, and AC: 13.3% versus 21.2%; only SGA BL attained a significant difference. Out of 15 cases of LBW, eight (53.3%) were preterm only, four (26.7%) were SGA only, and three (20.0%) were both PTB and SGA cases. A concomitant presence of, at least, two SGA dimensions in the same fetus was frequent. Conclusions: ...

Introdução: A infecção materna pelo HIV e comorbidades associadas podem ter duas consequências para a saúde fetal, a transmissão vertical e o desfecho perinatal adverso. Após o sucesso em reduzir a transmissão vertical, deve-se dar atenção ao risco potencial de nascimento pretermo (PRT) e de restrição de crescimento fetal (RCF). Objetivo: Determinar a prevalência de PRT e RCF em gestantes de baixa renda, infectadas pelo HIV, usuárias de terapia antirretroviral atendidas em hospital público terciário e verificar sua relação com o estágio da infecção viral. Casuística e métodos: Dentre os 250 partos de gestantes infectadas pelo HIV, ocorridos em um hospital universitário na cidade de Vitória, estado do Espírito Santo, Sudeste do Brasil, entre novembro de 2001 e maio de 2012, foram selecionadas 74 gestações não-gemelares, com idade gestacional confirmada por ultrassonografia e as dimensões neonatais: peso ao nascer (PN), comprimento (CN) e perímetros cefálico (PC) e abdominal (PA). Os dados foram extraídos dos prontuários clínicos e laboratoriais e o desfecho sumarizado como nascimento pretermo (PRT < 37 semanas), baixo peso ao nascer (BPN < 2500g) e como pequeno (PIG), adequado (AIG) e grande (GIG) para a IG, definido como tendo um menor valor, entre e maior que ± 1.28 z/IG escore, o critério clínico usual para demarcar os percentis 10 e 90. Resultados: PRT foi observado em 17,5%, BPN em 20,2% e PN, CN, PC e PA PIG em 16,2%, 19,1%, 13,8% e 17,4%, respectivamente. As respectivas proporções observadas nos casos de HIV e AIDS foram: PRT: 5,9 versus 27,5%, BPN: 14,7% versus 25,0%, PFN PIG: 17,6% versus 15,0%, CN: 6,0% versus 30,0%, PC: 9,0% versus 17,9% e PA: 13,3% versus 21,2%; somente a diferença de CN PIG foi estatisticamente significativa. Dentre 15 neonatos com BPN, oito (53,3%) eram somente PRT, quatro (26,7%) PIG somente e três (20,0%) PRT e PIG. Concomitância no mesmo caso de pelo menos duas dimensões PIG foi observada frequentemente. ...

Down syndrome passed from mother to child / Transmisión de síndrome de Down de madre a hijo

Down syndrome is the leading cause of inherited intellectual disability; it is characterized by mental retardation associated to physical growth delay and certain physical traits or features. It is caused by the presence of a third copy of chromosome 21, being this trisomy the most common chromosomal aneuploidy. Women with Down syndrome are less fertile, and pregnancy in these women is rare, although the information on exact statistics of reproduction in these patients is very limited, and they often have difficulties with miscarriage, premature birth, and difficult labor. We report the case of a preterm newborn with Down syndrome passed from her mother; this pregnancy was a result of sexual assault, which is an event that can and should be prevented in this population.

El síndrome de Down es la principal causa de discapacidad intelectual congénita; se caracteriza por retraso mental asociado a retardo del crecimiento y del desarrollo psicomotor, así como a algunas características físicas típicas. Se debe a la presencia de una tercera copia del cromosoma 21, siendo esta trisomía la aneuploidía cromosómica más común. Las mujeres con síndrome de Down tienden a ser menos fértiles y el embarazo en ellas es poco frecuente, aunque los datos estadísticos de este evento son limitados, y se asocia, además, a dificultades que terminan en aborto, parto prematuro y parto difícil. Se reporta el caso de un recién nacido prematuro con síndrome de Down, hijo de madre con el mismo diagnóstico, producto de un embarazo resultado de violación, evento que debe ser prevenido de forma oportuna en esta población de alto riesgo.

Should fetal growth be a matter of concern in isolated single umbilical artery? / Artéria umbilical única isolada e restrição do crescimento fetal

Objective: To examine birth weight in pregnancies with isolated single umbilical artery (ISUA). Methods: Case control study with retrospective review of 131 singleton pregnancies with isolated single umbilical artery diagnosed before birth. Control group consisted of 730 singleton pregnancies recruited prospectively, that had histological confirmation of a 3 vessels cord. Pregnancies were classified as uncomplicated or high-risk according to the presence of diseases that increase the risk of placental insufficiency during pregnancy. Mean birth weight and frequency of low birth weight (< 2.500 g), very low birth weight (< 1.500 g) and fetal growth restriction below the 5th and 10th centiles were compared between groups. Results: Mean birth weight difference between ISUA (n=131, 2840±701g) and control (n=730, 2.983 ± 671g) pregnancies was 143g (95% CI= 17-269; p=0.04) and birth weight below the 5thcentile was significantly more common in ISUA group [28/131 (21.4%) versus 99/730 (13.6%), p=0.02]. When only uncomplicated pregnancies were considered in both groups, no birth weight differences were observed. Amongst high-risk subgroups, birth weight below the 5th centile remained significantly more common in ISUA compared to control pregnancies [10/35 (28.6%) versus 53/377 (14.1%), p=0.04]. Conclusion: Isolated single umbilical artery does not increase the risk of fetal growth restriction in uncomplicated singleton pregnancies. .

Objetivo: Examinar a frequência de peso ao nascer abaixo dos percentis 5 e 10, em gestações únicas com artéria umbilical única isolada (AUUI), de acordo com a presença de complicações maternas. Métodos: Estudo caso-controle. De acordo com a presença de doenças maternas prévias à gestação, ou ocorrência de complicações obstétricas, as gestações foram classificadas em "não complicadas" ou de "alto risco". As frequências de peso ao nascer abaixo dos percentis 5 e 10 foram comparadas entre os subgrupos. Resultados: O peso ao nascer foi significativamente menor em gestações com AUUI (n=134, 2840 ± 701 g) quando comparado com o grupo controle (n= 730, 2983 ± 671 g, p= 0,04; média da diferença=143 g, IC 95% = 17-269). Em gestações de alto risco, peso ao nascer abaixo do 5º percentil foi significativamente mais frequente no subgrupo com AUUI [10/35 (28,6%) versus 53/377 (14,1%), p= 0,04; razão de chances= 2.45 (IC 95% = 1,11- 5,38)]; não foi observada diferença em relação ao peso abaixo do 10º percentil (p= 0,11). Em gestações não complicadas, não foram observadas diferenças na frequência de peso ao nascer abaixo do 5º e 10º percentis entre os subgrupos com AUUI e cordão com 3 vasos (p= 0,21). Conclusão: Em gestações de alto risco, a frequência de peso ao nascer abaixo do percentil 5 é significativamente aumentada. .

Placental mesenchymal dysplasia and intrauterine fetal growth restriction with doppler velocimetry alterations: a case report

Placental mesenchymal dysplasia (PMD) is a rare placental abnormality. We report a case of PMD associated with intrauterine growth restriction (IUGR), which was diagnosed by an ultrasound scan during the second trimester of pregnancy. A 36-year-old primiparous woman with signs of placental chorioangioma was referred to our hospital at the 23th gestational week. An ultrasonography revealed a small-for-gestational-age fetus with a large multicystic placenta. A serial Doppler sonographic assessment of umbilical and uterine artery blood flow showed a compromised fetus. A female, small-for-gestational-age baby was delivered by c-section at 28 weeks, and PMD was histopathologically confirmed

Successful Pregnancy in a Patient with Autosomal Dominant Polycystic Kidney Disease on Long-Term Hemodialysis

Recent advances in dialysis and a multidisciplinary approach to pregnant patients with advanced chronic kidney disease provide a better outcome. A 38-yr-old female with autosomal dominant polycystic kidney disease (ADPKD) became pregnant. She was undergoing hemodialysis (HD) and her kidneys were massively enlarged, posing a risk of intrauterine fetal growth restriction. By means of intensive HD and optimal management of anemia, pregnancy was successfully maintained until vaginal delivery at 34.5 weeks of gestation. We discuss the special considerations involved in managing our patient with regard to the underlying ADPKD and its influence on pregnancy.

Manejo clínico e obstétrico em gestantes portadoras de hepatite autoimune complicada pela plaquetopenia moderada ou grave / Clinical and obstetrical management of pregnant women with autoimmune hepatitis complicated by moderate or severe thrombocytopenia

OBJETIVO: O presente trabalho tem como objetivo descrever o manejo do pré-natal e do parto em pacientes portadoras de hepatite autoimune associada à plaquetopenia moderada ou grave. MÉTODOS: Este trabalho foi realizado em hospital universitário, de nível terciário. Foram analisadas, retrospectivamente, 13 gestações em dez pacientes com diagnóstico de hepatite autoimune complicadas pela plaquetopenia. Os critérios de inclusão foram: diagnóstico clínico de hepatite autoimune, plaquetopenia moderada ou grave (contagem de plaquetas < 100 x 103/mm3), idade gestacional ao nascimento acima de 22 semanas e pacientes acompanhadas por equipe especializada da instituição. As variáveis estudadas incluíram idade materna, paridade, os regimes de tratamento, contagem de plaquetas, exames para investigação da função hepática, tipo de parto, peso ao nascer e idade gestacional no momento do parto. RESULTADOS: A média da idade materna foi de 24,5 anos (DP = 5,3) e seis (50%) ocorreram em nulíparas. Durante a gravidez, a monoterapia com prednisona foi adotada em 11 (92%) casos. De acordo com o perfil de autoanticorpos, sete (58%) gestações possuíam diagnóstico de hepatite autoimune tipo I, duas (17%) do tipo II e três (25%) eram portadoras de hepatite crônica criptogênica (títulos de autoanticorpos indetectáveis). A hipertensão portal foi caracterizada em 11 (92%) gestações. A idade gestacional média no parto foi de 36,9 semanas (DP = 1,5 semana), com média de peso ao nascer de 2446g (DP = 655g), sendo oito (67%) pequenos para a idade gestacional. No momento do parto, a plaquetopenia grave foi caracterizada em quatro (33%) casos e a cesárea foi realizada em sete (58%). As complicações no parto ocorreram em três casos (25%), uma paciente apresentou atonia uterina e duas, hematoma perineal. Não houve morte materna ou perinatal. CONCLUSÃO: As complicações em pacientes plaquetopênicas com hepatite autoimune são elevadas, no entanto, com os cuidados e atenção necessários, podem ser contornáveis. A associação de duas patologias graves parece aumentar o risco de prematuridade e restrição do crescimento fetal, demandando atenção pré-natal especializada, bem como vigilância do bem-estar do concepto.

OBJECTIVE: To describe the management of prenatal care and delivery in patients bearing autoimmune hepatitis associated with moderate or severe thrombocytopenia. METHODS: This study was performed in a tertiary level university hospital. Thirteen pregnancies in ten patients diagnosed with autoimmune hepatitis, complicated by thrombocytopenia, were retrospectively analyzed. The inclusion criteria were as follows: clinical diagnosis of autoimmune hepatitis, moderate or severe thrombocytopenia (platelet count < 100 x 103/mm3), gestational age at birth over 22 weeks, and patient followed-up by a specialized team at the institution. The variables studied were: maternal age, parity, treatment regimen, platelet count, examinations for investigation of hepatic function, type of delivery, weight at birth, and gestational age at the time of delivery. RESULTS: The average maternal age was 24.5 years (SD = 5.3) and six (50%) occurred in nulliparous women. During pregnancy, monotherapy with prednisone was adopted in 11 cases (92%). According to the autoantibody profiles, seven pregnancies (58%) had the autoimmune hepatitis type I diagnosis, two pregnancies had type II (17%), and three pregnancies (25%) had cryptogenic chronic hepatitis (undetectable titers of autoantibodies). Portal hypertension was featured in 11 pregnancies (92%). The average gestational age at delivery was 36.9 weeks (SD = 1.5 weeks), with an average weight at birth of 2,446 g (SD = 655 g). Eight infants (67%) were small for gestational age. At the time of delivery, severe thrombocytopenia was featured in four cases (33%) and cesarean surgery was performed in seven cases (58%). Complications at delivery occurred in three cases (25%), one patient presented uterine atony, and two patients presented perineal bruising. There was no perinatal or maternal death. CONCLUSION: The complications of thrombocytopenic patients with autoimmune hepatitis are elevated; nevertheless, with appropriate attention and care, they can be resolved. The association between two severe pathologies appears to increase the risk of prematurity and fetal growth restriction, demanding specialized prenatal care, as well as surveillance of newborn well-being.

The role of gut-liver axis in the restriction of intrauterine growth in a model of experimental gastroschisis / O papel do eixo intestino-fígado na restrição de crescimento intra-uterino em um modelo de gastrosquise experimental

PURPOSE: To evaluate the intrauterine growth restriction (IUGR) by the expression of IR-β, IRS-1, IRS-2, IGF-IRβ and Ikappaβ in experimental model of gastroschisis. METHODS: Pregnant rats at 18.5 days of gestation were submitted to surgery to create experimental fetal gastroschisis (term = 22 days) were divided in three groups: gastroschisis (G), control (C) and sham (S). Fetuses were evaluated for body weight (BW), intestinal (IW), liver (LW) and their relations IW/BW and LW/BW. IR-β and IGF-IRβ receptors, IRS-1 and IRS-2 substrates and Ikappaβ protein were analyzed by western blotting. RESULTS: BW was lower in G, the IW and IW / BW were greater than C and S (p<0.05) groups. The liver showed no differences between groups. In fetuses with gastroschisis, compared with control fetuses, the expression of IGF-IRβ (p<0.001) and Ikappaβ (p<0.001) increased in the liver and intestine, as well as IR-β (p<0.001) which decreased in both. In contrast to the intestine, IRS-1 (p<0.001) increased in the liver and IRS-2 decreased (p<0.01). CONCLUSION: The axis of the intestine liver has an important role in inflammation, with consequent changes in the metabolic pathway of glucose can contribute to the IUGR in fetuses with gastroschisis.

OBJETIVO: Avaliar a restrição de crescimento intra-uterino (RCIU) pela expressão de IR-β, IRS-1, IRS-2, IGF-IRβ e a via inflamatória do Ikappaβ no modelo de gastrosquise experimental. MÉTODOS: Ratas grávidas com 18,5 dias de gestação foram submetidas a cirurgia experimental para criar gastrosquise fetal (termo = 22 dias) e os fetos foram divididos em três grupos: gastrosquise (G), controle (C) e sham (S). Os fetos foram avaliados quanto ao peso corporal (BW), intestinal (IW), fígado (LW) e suas relações IW/BW e LW/BW. Os receptores IR-β e IGF-IRβ, os substratos IRS-1 e IRS-2 e a proteína Ikappaβ foram analisados por western blotting. RESULTADOS: O BW de G foi menor, o IW e IW/BW foram superiores a C e S (p < 0.05). O fígado não apresentou diferenças entre os grupos. Nos fetos com gastrosquise, quando comparados com fetos controles, a expressão de IGF-IRβ (p<0.001) e Ikappaβ (p<0.001) aumentou no fígado e intestino, assim como IR-β (p<0.001) que diminuiu em ambos. Inversamente ao intestino, IRS-1 (p<0.001) aumentou no fígado e IRS-2 diminuiu (p<0.01). CONCLUSÃO: O eixo do intestino fígado tem um papel importante na inflamação, com consequentes alterações na via metabólica de glicose que pode contribuir para a RCIU em fetos com gastrosquise.

Restricción del crecimiento intrauterino / Intrauterine growth restriction

Se estima que la prevalencia real de la restricción del crecimiento intrauterino es entre el 3 por ciento y el 10 por ciento de los embarazos, lo que convertiría a esta patología fetal en uno de los problemas obstétricos más frecuentes junto al parto prematuro y la rotura prematura de membranas. La importancia del diagnóstico correcto, que se describe en este artículo, radica en que esta patología tiene riesgos asociados de gravedad.

It is estimated that the true prevalence of intrauterine growth restriction is 3-10 percent of all pregnancies, making this fetal condition one of the most frequent obstetric problems, together with premature labor and premature rupture of membranes. The article stresses the importance of early diagnosis because of the associated risks.

Algunos factores de riesgo relacionados con el bajo peso al nacer / Some risk factors related to the low birth weight

Introducción: el peso al nacer es de gran importancia en el recién nacido (RN). Objetivos: identificar factores de riesgo relacionados con el bajo peso del RN. Métodos: estudio de casos/controles en el policlínico Isidro de Armas municipio Playa, entre el 1ro. de enero de 2003 y 31 de diciembre de 2008. Se analizaron algunas variables: edad materna, antecedentes obstétricos: período intergenésico, RN bajo peso en embarazos anteriores, mortinato anterior, hipertensión arterial, embarazo múltiple, enfermedades asociadas o propias de la gestación. Resultados: las mujeres con edades entre 30-34 años aportaron el mayor número de RN con bajo peso (34,1 por ciento); en el grupo control prevaleció el grupo de edades de 20-24 años. En el grupo estudio predominó la hipertensión arterial crónica (9,8 por ciento), las que tuvieron bajo peso con anterioridad (9,8 por ciento) y el período intergenésico corto (7,3 por ciento); en las patologías asociadas fueron la infección cérvicovaginal, la anemia y el asma. En el grupo control predominaron la infección vaginal y la anemia. En el grupo estudio se encontró el retardo del crecimiento fetal (12,1 por ciento) y rotura prematura de membranas, en el grupo control la mayoría (95,1 por ciento) no presentó afecciones propias de la gestación. La mayoría de los nacimientos ocurrieron entre las 32-36 sem (48,8 por ciento) y el peso del RN osciló entre 2 000-2 499 g (85,4 por ciento). Conclusiones: las principales causas de retardo del crecimiento intrauterino fueron: la hipertensión arterial crónica, el antecedente de bajo peso anterior, el período intergenésico corto, la infección cérvicovaginal y la anemia

Introduction: The birth weight is very important in the newborn (NB). Objectives: To identify the risk factors related to the low birth weight of NB. Methods: A case-control study was conducted in the Isidro de Armas polyclinic, Playa municipality from January 1, 2003 to December 31, 2008. Some variables were analyzed: mother age, obstetric backgrounds, inter-genetics period, and newborn with low birth weight in prior pregnancies, previous stillbirth, high blood pressure, multiple pregnancies, and diseases associated or typical of pregnancy. Results:There was predominance of women aged between 30-34 with newborns with low birth weight (34.1 percent); in control group prevailed the ages of 20-24 years. The study group had predominance of chronic arterial blood pressure (9.8 percent), those with a prior low birth (9.8 percent) and the short inter-genetics period (7.3 percent); in the associated pathologies are included the cervicovaginal infection, anemia and asthma. In control group there was predominance of vaginal infection and anemia. In study group there was a fetal growth delay (12.1 percent) and premature rupture of membrane, in control group most of them (95.1 percent) there were not affections typical of pregnancy. Most of births occurred between 32-36 weeks (48.8 percent) and the newborn weight fluctuated between 2 000 and 2 499 g (85.4 percent). Conclusions: The major causes of intrauterine growth delay were: chronic high blood pressure, a prior history of low weight, short inter-genetics period, cervicovaginal infection and anemia

Factores maternos relacionados con el bajo peso al nacer / Mother's factors related to a low birth weight

El peso al nacer es sin duda uno de los elementos más importantes para que un recién nacido experimente un crecimiento y desarrollo satisfactorio. El bajo peso al nacer es una de las causas más importantes de la morbilidad y mortalidad perinatal e infantil. Se realizó un estudio observacional, descriptivo, de serie de casos con el objetivo de conocer el comportamiento de los factores relacionados con el bajo peso al nacer en el Policlínico René Ávila Reyes, de Holguín, en el periodo de enero 2005 a mayo 2010. El universo se conformó con 86 embarazadas cuyo producto de la concepción tuvo un peso inferior a los 2 500 g y la muestra estuvo integrada por 62 gestantes, según los criterios de inclusión. La información se obtuvo mediante la revisión de las gráficas estadísticas del área y los carnet obstétricos. Se utilizaron los métodos teóricos: histórico lógico, análisis y síntesis e inducción deducción en todo momento de la investigación. El crecimiento intrauterino retardado resultó ser la principal causa de bajo peso influenciado por la desnutrición materna y la ganancia insuficiente de peso durante el embarazo. Los antecedentes obstétricos de mayor predominio fueron el período intergenésico corto y los antecedentes de 2 o más interrupciones de embarazos relacionados con la ocurrencia de recién nacidos con restricción del crecimiento intrauterino (RCIU) y pretérmino respectivamente. Las afecciones relacionadas con los embarazos más frecuentes fueron la enfermedad hipertensiva del embarazo que alcanzó la mayor cifra en los casos con restricción del crecimiento intrauterino y la infección vaginal que trajo consigo el mayor número de pretérmino

The weight birth is without doubt one of the more important elements in order to the newborn has a satisfactory growth and development. The low birth weight is one of the leading causes of the perinatal and infantile morbidity and mortality. A descriptive and observational study was conducted in a series of cases to know the behavior of factors related to the low birth weight in the René Avila Reyes polyclinic of Holguín province from January, 2005 to May, 2010. Universe included 86 pregnants whose fetus had a weight lower than 2 500 g and the sample included 62 pregnants, according the inclusion criteria. Information was gathered by review of statistical charts from the area and obstetric cards. Theoretical methods were used: logical historical, analysis and synthesis and induction-deduction in throughout research. A delayed intrauterine growth was the main cause of low weight influenced by the mother's malnutrition and an insufficient weight gain during pregnancy. The obstetric backgrounds more predominant were the short inter-genesis and those of two or more pregnant interruptions related to occurrence of newborns with a restricted intrauterine growth (RIUG) and preterm, respectively. The more frequent affections related to pregnancy were the hypertensive disease related to pregnancy achieving the great figure in the cases with RIUG and the vaginal infection led to a greater number of preterm births

Lesão vascular da placenta condicionando RCIU e hidropisia fetal não imune em gestação gemelar / Placental vascular lesion as cause of IUGR and nonimmune fetal hydrops in twin pregnanc

As lesões vasculares da placenta constituem um grupo de entidades distintas, mas inter-relacionadas, em que se incluem os corioangiomas e a corangiomatose multifocal difusa. O corioangioma é uma lesão nodular expansiva com incidência de cerca de 1 por cento. A corangiomatose multifocal difusa é rara (0,2 por cento) e predominante em placentas em idade gestacional inferior a 32 semanas. Os autores apresentam um caso de gestação gemelar monocoriônica/biamniótica, no qual um dos fetos, à 26ª semana de gestação, apresentou quadro de restrição de crescimento intrauterino, hidropisia e anemia associado à formação tumoral da placenta com vascularização aumentada verificada pela doplervelocimetria. O estudo anatomopatológico da placenta permitiu o diagnóstico de corangiomatose multifocal difusa. Este raro caso de corioangiomatose multifocal difusa com forma de apresentação pré-natal mimetizando a de um corioangioma comprova que a detecção ultrassonográfica de um tumor da placenta com vascularização aumentada deve suscitar outras hipótese diagnóstica, além do corioangioma.

Placenta vascular lesions are a group of distinct yet related entities that include chorangiomas and diffuse multifocal chorangiomatosis. Chorangioma is an expansive nodular lesion with an incidence of about 1 percent. Diffuse multifocal chorangiomatosis is rare (0.2 percent) and mostly seen in placentas before the 32nd gestational week. The authors present a case of a monochorionic/biamniotic twin pregnancy, in which, at the 26th gestational week, one fetus developed intrauterine growth restriction (IUGR), hydrops, and anemia associated with a tumor of the placenta with increased vascularization in the Doppler study. Pathological examination of the placenta diagnosed diffuse multifocal chorangiomatosis. This rare case report of diffuse multifocal chorangiomatosis with prenatal manifestations resembling those of a chorangioma proves that prenatal ultrasound detection of a placenta tumor, with increased vascularization at Doppler study, must raise other diagnostic possibilities beside chorangioma.