Cirugía bariátrica y embarazo: revisión de la literatura / Bariatric surgery and pregnancy: literature review

La obesidad ha logrado proporciones epidémicas en la actualidad, tanto en Chile como en el mundo. Esta patología se asocia a diversas complicaciones maternas en todas las etapas del ciclo vital y durante el embarazo. El tratamiento médico no ha logrado controlar esta patología, por lo que a pesar de no ser la primera línea, la cirugía bariátrica ha ido en aumento durante los últimos años. Esta revisión de la literatura pretende mostrar los resultados actuales del tratamiento quirúrgico en la mujer antes y durante el embarazo, respecto a la fertilidad, diabetes gestacional, preeclampsia e hipertensión transitoria del embarazo. Además aborda los posibles efectos de esta cirugía en el feto en desarrollo, y su relación con el parto prematuro, macrosomía fetal, bajo peso al nacer y defectos del tubo neural; así como también se refiere a los resultados materno-fetales, principalmente en el ámbito de la nutrición. Finalmente nos permitimos plantear recomendaciones importantes en relación al rol de la anticoncepción, la nutrición y el lapso entre la cirugía y el embarazo, sugeridas de esta revisión.

Obesity has currently reached epidemic proportions, both in Chile and in the world. This condition is associated to a variety of maternal complications in all stages of the vital cycle and during pregnancy. Medical treatment has not proved successful thus resulting in an increase in bariatric surgery in recent years, even when it is not first line treatment. This literature review aims to report updated results of surgical treatment for obesity before and during pregnancy with respect to fertility, gestational diabetes, pre-eclampsia and pregnancy-induced hypertension. It also looks into the possible effects of surgery on fetal development, and its relation to premature delivery, fetal macrosomy, low birth weight and neural tube defects, as well as effects on maternal and fetal outcomes, mainly in nutrition. Lastly, we suggest some recommendations that arise from this review on the role of contraception, nutrition and time between surgery and pregnancy.

Consumo de fumonisinas y daños a la salud humana / Fumonisin intake and human health

Las fumonisinas son una familia de micotoxinas que contaminan al maíz, alteran el metabolismo de los esfingolípidos y del folato, se asocian con defectos del tubo neural y están catalogadas por la Agencia Internacional de Investigación en Cáncer (IARC por sus siglas en inglés) como posibles carcinógenos humanos. Debido a que en México los derivados de maíz constituyen una parte importante de la dieta y existe alta prevalencia de población genéticamente susceptible a la deficiencia de folato, en este ensayo se presentan las evidencias mundiales y nacionales de la exposición a fumonisinas y la relevancia que para México representa la evaluación de esta exposición.

Fumonisins are mycotoxins that contaminate maize, disrupt the folate and sphingolipid metabolism, are associated with neural tube defects, and are considered by the International Agency for Research on Cancer (IARC) as possible human carcinogens. Since maize-based foods are significant components of the Mexican diet and there is a high prevalence of genetic susceptibility for folate deficiency among Mexicans, this essay presents international and national evidence of fumonisin exposure and the relevance that such exposure represents for Mexico.

Folatos y hierro en mujeres en edad fértil de una comunidad en Venezuela afectada por la incidencia de defectos del tubo neural / Folate and iron in fertile age women from a Venezuelan community affected by incidence of neural tube defects

El objetivo de este estudio transversal fue identificar el estado nutricional de folatos y hierro en mujeres en edad fértil del Municipio Jiménez, Estado Lara, Venezuela. El muestreo fue probabilístico por conglomerados del área urbana y rural, seleccionándose 15 conglomerados donde se estudiaron a las mujeres entre 12 y 45 años (269 mujeres). Previa firma del consentimiento informado, se les practicó: Encuesta con datos personales, antecedentes y variables relacionadas con folatos y hierro; datos socioeconómicos (Encuesta Graffar-Méndez Castellano y Necesidades Básicas Insatisfechas); en muestra de sangre se determinó Hemoglobina y Folato Eritrocitario (FE); en suero se determinó Ferritina, y Folato Sérico (FS). 53,53% de la muestra presentó valores bajos de FS, y el 10,78% valores deficientes. 80,7% presentó deficiencia severa según FE y 5,9% deficiencia moderada. En ambas pruebas, la media fue mayor en mujeres tratadas con Acido Fólico ó embarazadas (p=0,000) y la media del FE también resultó mayor en adultas que adolescentes (p=0,001) y en mujeres no pobres (p=0,011); no hubo diferencias significativas según ingesta de café, alcohol, anticonceptivos, procedencia, estrato social. La anemia se determinó en 11,2%, más frecuente en adultas (p=0,029) y en las del medio urbano (p=0,042). Ferritina baja se encontró en 37.3% de la muestra, las diferencias según variables no fueron significativas. En conclusión, la prevalencia de deficiencia de hierro y folatos en mujeres en edad fértil del Municipio Jiménez es alta, ésta podría constituir un factor condicionante de defectos del tubo neural, por lo cual deben ejecutarse estrategias para superar este déficit.

The objective of this transversal study was to determine folate and iron nutritional status of women in fertile age from Municipio Jiménez, Lara State, Venezuela. The sampling was probabilistic by conglomerates from the urban and rural areas, selecting 15 conglomerates from which women between 12 and 45 years (269), were studied. After signing informed consent, participating were interviewed for personal data, antecedents related to folate and iron, socioeconomic data (Graffar-Mendez Castellano method and unsatisfied basic needs). In blood sample was determined Hemoglobin, and Erythrocytic Folate (FE). Serum was obtained to determine Ferritin and Serum Folate (FS). 53,53% of the sample presented low FS levels, 10.78% were FS deficient. Severe FE deficiency was present in 80.7% of the cases, moderate deficiency affected 5,9%. For both tests, median was higher for women in treatment with Acido Fólico or pregnant (p=0,000), median for FE was higher for adults (p=0.001) and in non poor women (p=0.011). There were no significant differences for coffee, alcohol, anticonceptive consumption, urban or rural resident or socioeconomic strata. The prevalence of anemia was 11,2% being significantly more frequent in adults than in adolescents (p= 0,029) and in urban women (p=0,042). Low ferritin were found in 37,3% of the sample, the effect of different variables was not statistically significant. In conclusion, there is a high prevalence of iron and folate deficiencies in women of fertile age from Municipio Jiménez, which could constitute a conditioning factor for the appearance of neural tube defects.

Importancia de fortificar la harina de trigo con ácido fólico para prevenir defectos del tubo neural en Perú / Importance of fortifying wheat flour with folic acid to prevent neural tube defects in Peru

La etiología de los defectos del tubo neural (DTN) es multifactorial: interacción de factores ambientales, nutricionales, genéticos, étnicos o de causa desconocida. Se ha relacionado a los DTN con la deficiencia de folatos, cuyas causas son: a) ingesta inadecuada; b) absorción deficiente; c) aumento del consumo; y d) alteraciones en su utilización. Además de la dieta insuficiente hay otras situaciones que favorecen el déficit de folatos: el alcoholismo, las enfermedades intestinales y las interacciones medicamentosas. Esta revisión presenta un panorama sobre los DTN y resalta la importancia de fortificar la harina de trigo con ácido fólico para prevenirlos y muestra información actualizada sobre investigaciones relacionadas con la ingesta de folatos y los DTN en el Perú.

The aetiology of the DTN is multifactorial: environmental interaction, nutritional, genetic, ethnic factors or unknown cause. DTN has been related to the folate deficiency, with causes are: a) inadequate ingestion; inadequate absorption; c) consumption increase; and d) alterations in its use. Besides the insufficient diet, there are other situations to favor folate deficiency: alcoholism, intestinal diseases and medicical interactions. This review focus on DTN and emphasizes the importance of fortifying wheat flour with folic acid to prevent them and displays current information on ingestion of folates related to DTN in Peru.

Neural tube defects; prevalence in population of Rahim Yar Khan

To know the frequency of NTD among total births in teaching Hospital Rahim Yar Khan and to know the possible causes of neural tube defects in area of Rahim Yar Khan. Prospective study. Department of Obstetrics and Gynaecology Sheikh Zayed Medical College/Hospital Rahim Yar Khan. One year from November 2006 to October 2007. All pregnant mothers were registered in the study but only those were selected who were diagnosed during pregnancy or after delivery as a case on NTD. Out of 6701 live births, a total of 52 cases were diagnosed at NTD. The information was collected by taking history along with ultrasound findings and biochemical tests. The incidence came out is 2-8/1000 live births. The maternal mean age was 28.9 years and more common in primigravida i.e. 33% and 30% were grand multigravida. 75.3% of women belonged to low income group, and were not taking proper balanced diet. 80% lived in Joint family and 96.2% females were house wives. 96% cases of NTD were detected by ultrasound at mean gestation of 21.66 wks. The most common NTD was anencephaly found in 67% of cases, spina bifida 29% and encephalocele was found only in 4% of cases. The male; female ratio was 2:3. 74% of women had Hb level less than 10 mg/dl and in 20 women the type of anaemia was macrocytic-hypochromic. Low socio-economic status, poverty and poor dietary habits may be factors for higher incidence of neural tube defects. Our study provides new data for the health care providers to improve health facilities and their utilization and iron and folic acid supplementation targeted to all women of child bearing age to prevent neural tube defects

case of fetal valproate syndrome with new features expanding the phenotype

Fetal valproate syndrome [FVS] is a well-recognized constellation of dysmorphic features, and neurodevelopmental retardation that results from prenatal exposure to the anticonvulsant valproic acid. In this report, we describe a case with typical features of FVS. A 23-year-old lady with post-traumatic epilepsy controlled by sodium valproate [Depakene] 500 mg twice daily throughout pregnancy as monotherapy, gave birth to a female baby with facial features characteristic of FVS, and severe radial ray reduction. She also had wide-spaced nipples and short neck, features not described before. Sodium valproate, a widely used anticonvulsant and mood regulator, is a well-recognized teratogen that can result in severe limb deformities, craniosynostosis, neural tube defects and neurodevelopmental retardation. Therefore, we recommend that valproic acid must be avoided during pregnancy, as new generation of anticonvulsant drugs have emerged into the market

Prevalência de defeitos de fechamento de tubo neural no Vale do Paraíba, São Paulo / Prevalence of neural tube defects in Vale do Paraíba, São Paulo, Brazil

OBJETIVO: Estimar a prevalência de defeitos de fechamento do tubo neural no Vale do Paraíba paulista e identificar possíveis fatores maternos e neonatais associados a tais defeitos. MÉTODOS: Realizou-se um estudo transversal com dados secundários obtidos na Secretaria Estadual da Saúde referentes aos nascimentos ocorridos em 2004 no Vale do Paraíba paulista, que compreende 35 municípios e conta com população de 2 milhões de habitantes. Anencefalia, encefalocele e espina bífida (mielocele e mielomeningocele) foram considerados defeitos de fechamento do tubo neural. As variáveis maternas foram: idade, escolaridade, cor da pele, número de consultas no pré-natal, número de filhos vivos e relato de óbito fetal prévio. As variáveis relativas ao recém-nascido foram: peso, idade gestacional e escore de Apgar. Realizou-se comparação das médias por meio do teste t de Student e obtiveram-se os valores das razões de chance com intervalos de confiança de 95%. RESULTADOS: Foram analisados 33.653 nascidos vivos. Trinta e oito recém-nascidos com o defeito foram encontrados (1,13/1.000 nascidos vivos), sendo 23 casos de espina bífida. Houve associação com baixo peso ao nascimento, prematuridade e menores escores de Apgar de cinco minutos. CONCLUSÕES: A prevalência desta anomalia foi inferior à de outros estudos nacionais e sua presença esteve associada ao baixo peso, à prematuridade e à baixa vitalidade ao nascer.

OBJECTIVE: To estimate the prevalence of neural tube defects in Vale do Paraíba, São Paulo, Brazil, and to identify possible maternal and neonatal variables associated with these defects. METHODS: This cross-sectional study used secondary records of the Health Department of São Paulo State related live births during 2004 in Vale do Paraíba, São Paulo, Brazil. This region has 35 cities and 2 million inhabitants. Anencephaly, encephalocele and spina bifida (myelocele and myelomeningocele) were considered as neural tube defects. The following maternal variables were analyzed: age, educational level, race, number of born alive and stillborn infants and prenatal visits. Neonatal variables were: birth weight, gestational age and Apgar score. Numerical variables were compared by Student t test, and Odds Ratio values were obtained with the 95%confidence interval. RESULTS: The analysis was performed based on 33,653 records of born alive infants. Twenty-three infants with spina bifida were identified, with an estimated prevalence of 1.13 cases for each 1,000 live births. The presence of neural tube defects was associated to low birth weight, prematurity and low Apgar score. CONCLUSIONS: The estimated prevalence of neural tube defects in this region of São Paulo was lower than others reported in previous Brazilian studies. These defects were associated with low birth weight, prematurity and respiratory depression at birth.

prevalence of neural tube defects among newborns delivered in Azadi hospital in Dohuk city, Kurdistan region, Iraq

The study was performed to highlight the prevalence of neural tube defects [NTDs] among newborns delivered in Azadi teaching hospital in Dohuk. Study lasted over one year period started from 1st of December 2004 to 30th of November 2005. Fifty six newborns [alive and stillbirth], 40 females and 16 males, were found to have different types of NTDs. The prevalence of NTDs was found to be 4.7 per 1000 live births, which was higher than similar rates estimated in other areas in the world. The mothers of the affected newborns were not consuming folic acid before conception, which may, to some extent, explain the high rate in this study. Further similar studies, however, are required in North of Iraq to document the findings of this study. All women should consume 0.4 mg folic acid daily during their reproductive years to protect against this defect

Neural tube defects among infants delivered of mothers with tobacco smoke exposure

To verify the occurrence of congenital neural tube anomalies among the newborns of pregnant women who had experienced exposure to tobacco smoke. A cross sectional study of pregnant women at delivery considering their newborns as a gestational cohort. A systematic random sample of 2300 pregnant women who attended for labour at Maternity and Children hospital in Najaf city were interviewed for history of tobacco smoke exposure during the period 2002-2004. The sample was subdivided into exposed and unexposed women to tobacco smoke. The newborns were clinically examined by a pediatrician for presence of any congenital anomalies especially neural tube defects. The over all newly delivered newborns with congenital anomalies were 3.4% among smoker mothers, and 1.9% among nonsmokers [including small defects]. The most frequent neural tube defects among smoker mothers were anencephaly [1.8%] and spina bifid a [1.2%], versus 0.7% and 0.6% respectively among non smokers or unexposed women [P<0.05]. There was some increase in the risk of such defects among exposed women to tobacco smoke who did not take folic acid in relation to unexposed in spite of no statistically significant difference. Also there was no significant difference in the distribution of neural tube defects between those women who live in urban or rural areas or between different age groups. Smoking is a risk factor for neural tube defects

Prevalence and correlates of neural tube defect in south west Iran

In view of the large number of pregnancies complicated by neural tube defect [NTD] in Khuzestan, south west Iran, this study assesses the prevalence of NTD and its ecological and social factors. This is a retrospective study, based on medical documents using an analytic assessment of NTDs in pregnant women attending the Jundi Shapur University hospitals in Ahvaz from 21 March 2002 to 20 March 2004. The total number of pregnant women was 13, 262 and 56 pregnancies were complicated with NTD. A large number of the infants with NTDs were female [70%] and the most common anomaly was anencephaly. The prevalence was 4.2 in 1, 000 births. The percentage in primigravida was 42.6% and in multigravida 57.4%. The main risk factor for NTD was age of the mother, those between 21 and 30 being the most affected. Consanguinity is the second risk factor with 31% of couples who were close relatives. Other socio-demographic factors were also significant. This retrospective study confirms clinical observation that pregnancies complicated by NTD in Khuzestan are common. There are various ecological and social factors that correlate with the prevalence of NTD

Epidemiologic aspects of neural tube defects in South East Iran

To investigate the rate of neural tube defects [NTDs] and their relation to gender, maternal age, consanguineous marriage, season, and drug consumption in Birjand, Iran. This research was carried out on 16,785 live or stillborn newborns in Birjand, Iran from April 1997 to December 2001. The rate of NTDs was 2.97 per 1000. This rate was 1.97 per 1000 in males, and 3.55 per 1000 in females. The rate of anencephaly was 1.37 per 1000, and spina bifida was 0.88 per 1000. We found that 32% of mothers with affected newborns had taken drugs during the first trimester of pregnancy, 90% of mothers did not consume folate before and during the first trimester, and 54% of parents had consanguineous marriage. We concluded that folate deficiency, usage of drugs during pregnancy, and consanguineous marriage may play a role of predisposition to NTD

Study of bone marrow abnormalities in patients with HIV disease.

AIM: Present work was carried out to study the bone marrow abnormalities in patients with HIV/AIDS and to find their association with peripheral hematological abnormalities. METHODS: Seventy four patients of HIV/AIDS were included in the study. The patients had anemia, leucopenia, thrombocytopenia or pyrexia of unknown origin (PUO) as indications for bone marrow examination. A complete blood count, relevant biochemical investigations, HIV RNA load and CD4 positive lymphocyte counts were done, besides a thorough history and clinical examination. HIV positive patients were classified as those having AIDS and those without AIDS according to NACO criteria. RESULTS: Majority of patients (72.9%) had AIDS. Bone marrow was normocellular in 78.95% of non-AIDS and 74.55% of AIDS, hypocellular in 5.26% of non-AIDS and 7.27% of AIDS, hypercellular in 15.79% of non-AIDS and 18.18 % of AIDS patients. Myelodysplasia was present in 21.05% of non AIDS and 36.46% of AIDS and the most common series affected was granulocytic (15.79% of total in non-AIDS and 30.9% in AIDS). Dysplasia was statistically significantly associated with lower CD4 count (p = 0.031) and anemia (p = 0.013). Myelodysplasia was apparent even before patients developed anemia (16.67%). Increased plasma cells in bone marrow were observed in 57.89% of non-AIDS and 65.45% of AIDS, whereas decreased lymphoid cells were seen in 36.84% of non AIDS and 60.00% of AIDS patients. CONCLUSIONS: Myelodysplasia is found in 32.43% of cases of HIV/AIDS and is more common in AIDS than in non AIDS patients. Granulocytic series is most commonly associated with evidence of dysplasia. Myelodysplasia is more common in patients with CD4 count < 200/microl and in patients with anemia. 54.05% of patients had decreased lymphoid cells in bone marrow and it was more commonly seen in AIDS than in non AIDS.

Neural tube defects: pathogenesis and folate metabolism.

Neural tube defects (NTDs) are a group of congenital malformations with worldwide distribution and complex aetio-pathogenesis. Animal studies indicate that there may be four sites of initiation of neural tube closure (NTC). Selective involvement of these sites may lead to defects varying from anencephaly to spina bifida. The NTC involves formation of medial and dorsolateral hinge points, convergent extension and a zipper release process. Proliferation and migration of neuroectodermal cells and its morphological changes brought about by microfilaments and other cytoskeletal proteins mediate NTC. Genetic, nutritional and teratogenic mechanisms have been implicated in the pathogenesis of NTDs. Folate is an important component in one carbon metabolism that provides active moieties for synthesis of nucleic acids and proteins. Several gene defects affecting enzymes and proteins involved in transport and metabolism of folate have been associated with NTDs. It may be possible in future, to identify individuals at higher risk of NTDs by genetic studies. Epidemiological and clinical studies have shown that dietary supplementation or food fortification with folic acid would reduce the incidence of NTDs. The protective effect of folic acid may be by overcoming these metabolic blocks through unidentified mechanisms. Genetic and biochemical studies on foetal cells may supplement currently available prenatal tests to diagnose NTDs. Antiepileptic drugs (AEDs), particularly valproate and carbamazepine have been shown to increase the risk of NTDs by possibly increasing the oxidative stress and deranging the folate metabolism. Accordingly, it is recommended that all women taking AEDs may use 1-5 mg folic acid daily in the pre conception period and through pregnancy.

Edad materna y defectos del tubo neural: evidencia para un efecto mayor en espina bífida que anencefalia / Influence of maternal age on the risk for neural tube defects, a meta analysis

Background: Recent evidence from birth order data suggest that maternal factors can differently influence anencephaly and spina bifida. Aim: To study the influence of maternal age on the risk for neural tube defects. Material and methods: A meta-analysis of published data on neural tube defects (NTDs) was carried out to determine whether there is an increased risk to have a child with NTDs for younger and older mothers and if this risk differs depending on the type of NTD. All data available with information regarding the frequency of live births and NTDs cases by maternal age (five- or ten-year intervals) were included in the analysis. Effect sizes calculations were performed. Results: The analysis supports the hypothesis that there is an increased risk of having an offspring with NTDs for mothers 40 years of age or older. However, this effect is stronger for spina bifida than for anencephaly. There is also evidence that mothers 19 years old or younger have a higher risk for having a child with spina bifida. Conclusions: Maternal age influences the risk of having an offspring with neural tube defects.

Persistence of parvovirus B19 IgM antibodies and DNA in pure red cell aplasia resulting in myelodysplasia--a case report.

Human erythrovirus B19 (B19), previously known as parvovirus B19, is a small spherical, non-enveloped single stranded DNA virus. It has been shown to cause a wide spectrum of clinical conditons including various hematological disorders. We report here for the first time from Inida a case of pure red cell aplasia in a 45-year-old female for last 7 years due to chronic persistent B19 infection leading to myelodysplasia after 4 years. Her sera were positive for two times 4 months apart for B19 IgM and B19 DNA at the initial stage. Presently the patient is on repeated blood transfusion on every 15-20 days.

Disminución de la incidencia de defectos de cierre del tubo neural en el hospital Universitario de Neiva: posible efecto de la promoción del consumo de ácido fólico / Low incidence of congenital neural tube efects at the Neiva University Hospital: possible effect of folic acid supplementation

Los defectos del tubo neural (DTN) son defectos de nacimiento, del cerebro o la médula espinal, los cuales llevan a la muerte o a la discapacidad. Las causas de los DTN son desconocidas. Se piensa que ocurren por una interacción de factores genéticos y ambientales. En 1997, se observó un significativo aumento en la incidencia de defectos del tubo neural en el Hospital Universitario de Neiva (p=0,035), respecto al año anterior. El primer esfuerzo de control consistió en promover el consumo de ácido fólico siguiendo las recomendaciones universales de suplementación y fortificación (CDC Folic Acid Resource Guide) En este estudio se evaluó la incidencia de los DTN durante 1998, como posible indicador del impacto de las medidas tomadas. Se identificaron los nacidos DTN, los nacidos con síndrome de Down o con labio o paladar hendido, la proporción de abortos y la de nacidos muertos. La tasa de DTN disminuyó en forma significativa (p=0,024) respecto a 1997 y su diferencia con la tasa de Latinomérica no fue significativa (p=0,526). Se concluyó que la incidencia fue menor 1998 y regresó a la tasa esperada para la región. Aunque se desconoce la causa del descenso, es posible que sea el resultado de la divulgación de los beneficios de una buena nutrición materna, la suplementación progestacional con ácido fólico, la fortificación de la harina de trigo, o una sumatoria de todas las medidas. Se recomienda desarrollar un estudio de actitudes y prácticas sobre el uso de ácido fólico en la población de mujeres de Neiva en edad fértil y establecer un protocolo de vigilancia activada de los DTN

Importancia del ácido fólico en la medicina actual / The importance of folic acid in present medicine

Lately, folic acid deficiency is gaining a predominant role in the pathogenesis of congenital malformations and cardiovascular diseases in adults. The planning of individual and population preventive strategies for these diseases must consider this deficiency. This paper reviews the anatomical, biochemical and molecular bases of neural tube defects and cardiovascular diseases in adults. In these two frequent diseases, folic acid supplementation has shown a clear cut protective effect

Prevención primaria de malformaciones congénitas / Primary prevention of congenital malformations

A medida que los países mejoran sus índices de salud, las malformaciones congénitas pasan a ocupar el primer lugar en las causas de mortalidad infantil. El énfasis en el tratamiento de las malformaciones congénitas debe hacerse con buenas estrategias de prevensión primaria. Al respecto, durante los últimos años el uso del ácido fólico ha adquirido un rol preponderante. El uso periconcepcional de ácido fólico ha mostrado un claro efecto protector en relación a algunas malformaciones congénitas frecuentes, especialmente en los defectos de cierre del tubo neural. Considerando la importancia de la prevención primaria en la morbimortalidad a cualquier edad, se ha considerado fundamental planificar estrategias de prevención aplicables en el ámbito individual y poblacional. Se presentan las bases embrionarias, anatómicas, bioquímicas y moleculares de los defectos de cierre del tubo neural y la importancia de iniciar estrategias a nivel poblacional que aseguren una ingesta suficiente de ácido fólico en las poblaciones objetivo