Intervenções psicológicas necessárias: a prática como residente no serviço de medicina fetal / Necessary psychological interventions: the practice as a resident in the fetal medicine service / Intervenciones psicológicas necesarias: la práctica como residente en el servicio de medicina fetal

Com os avanços tecnológicos e o aprimoramento da prática médica via ultrassonografia, já é possível detectar possíveis problemas no feto desde a gestação. O objetivo deste estudo foi analisar a prática do psicólogo no contexto de gestações que envolvem riscos fetais. Trata-se de um estudo qualitativo sob formato de relato de experiência como psicólogo residente no Serviço de Medicina Fetal da Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ). Os registros, feitos por observação participante e diário de campo, foram analisados em dois eixos temáticos: 1) intervenções psicológicas no trabalho em equipe em consulta de pré-natal, exame de ultrassonografia e procedimento de amniocentese; e 2) intervenções psicológicas em casos de bebês incompatíveis com a vida. Os resultados indicaram que o psicólogo nesse serviço é essencial para atuar de forma multiprofissional na assistência pré-natal para gravidezes de alto risco fetal. Ademais, a preceptoria do residente é relevante para sua formação e treinamento para atuação profissional no campo da psicologia perinatal.(AU)

Face to the technological advances and the improvement of medical practice via ultrasound, it is already possible to detect possible problems in the fetus since pregnancy. The objective of this study was to analyze the psychologist's practice in the context of pregnancies which involve fetal risks. It is a qualitative study based on an experience report as a psychologist trainee at the Fetal Medicine Service of the Maternity School of UFRJ. The records, based on the participant observation and field diary, were analyzed in two thematic axes: 1) psychological interventions in the teamwork in the prenatal attendance, ultrasound examination and amniocentesis procedure; and 2) psychological interventions in cases of babies incompatible to the life. The results indicated that the psychologist in this service is essential to work in a multidisciplinary way at the prenatal care for high fetal risk pregnancies. Furthermore, the resident's preceptorship is relevant to their education and training for professional performance in the field of Perinatal Psychology.(AU)

Con los avances tecnológicos y la mejora de la práctica médica a través de la ecografía, ya se puede detectar posibles problemas en el feto desde el embarazo. El objetivo de este estudio fue analizar la práctica del psicólogo en el contexto de embarazos de riesgos fetal. Es un estudio cualitativo basado en un relato de experiencia como residente de psicología en el Servicio de Medicina Fetal de la Escuela de Maternidad de la Universidade Federal do Rio de Janeiro (UFRJ). Los registros, realizados en la observación participante y el diario de campo, se analizaron en dos ejes temáticos: 1) intervenciones psicológicas en el trabajo en equipo, en la consulta prenatal, ecografía y los procedimientos de amniocentesis; y 2) intervenciones psicológicas en casos de bebés incompatibles con la vida. Los resultados señalaron como fundamental la presencia del psicólogo en este servicio trabajando de forma multidisciplinar en la atención prenatal en el contexto de embarazos de alto riesgo fetal. Además, la tutela del residente es relevante para su educación y formación para el desempeño profesional en el campo de la Psicología Perinatal.(AU)

Peripartum Hysterectomy: Is There Any Difference Between Emergency and Planned Surgeries? / Histerectomia periparto: Existe alguma diferença entre as cirurgias de emergência e planejada?

Abstract Objective To compare the outcomes of emergency and planned peripartum hysterectomies. Methods The present retrospective cross-sectional study was conducted in two hospitals. Maternal and neonatal outcomes were compared according to emergency and planned peripartum hysterectomies. Results A total of 34,020 deliveries were evaluated retrospectively, and 66 cases of peripartum hysterectomy were analyzed. Of these, 31 were cases of planned surgery, and 35 were cases of emergency surgery. The patients who underwent planned peripartum hysterectomy had a lower rate of blood transfusion (83.9% versus 100%; p=0.014), and higher postoperative hemoglobin levels (9.9±1.3 versus 8.3±1.3; p<0.001) compared with the emergency hysterectomy group. The birth weight was lower, although the appearance, pulse, grimace, activity, and respiration (Apgar) scores were higher in the planned surgery group compared with the emergency cases. Conclusion Planned peripartum hysterectomy with an experienced team results in less need for transfusion and improved neonatal outcomes compared with emergency peripartum hysterectomy.

Resumo Objetivo Comparar os resultados das histerectomias periparto de emergência e planejada. Métodos Este estudo transversal retrospectivo foi realizado em dois hospitais. Os resultados maternos e neonatais foram comparados de acordo com as histerectomias periparto de emergência e planejada. Resultados Um total de 34.020 partos foram avaliados retrospectivamente, e 66 casos de histerectomia periparto foram analisados. Destes, 31 eram casos de cirurgias planejadas, e 35, cirurgias de emergência. As pacientes que foram submetidas à histerectomia periparto planejada tiveram uma taxa menor de transfusão de sangue (83,9% versus 100%; p=0,014), e níveis mais elevados de hemoglobina pós-operatória (9,9±1,3 versus 8,3±1,3; p<0,001) em comparação com o grupo de histerectomia de emergência. O peso ao nascer foi menor, embora as pontuações na escala de aparência, frequência cardíaca, irritabilidade reflexa, tônus muscular, e respiração (appearance, pulse, grimace, activity, and respiration, Apgar, em inglês) fossem maiores no grupo da cirurgia planejada em comparação com os casos de emergência. Conclusão A histerectomia periparto planejada com uma equipe experiente resulta em menos necessidade de transfusão e melhora os resultados neonatais em relação à histerectomia periparto de emergência.

Prediction Model for Massive Transfusion in Placenta Previa during Cesarean Section

0.05). The area under the receiver operating characteristics curve (AUC) was 0.922 [95% confidence interval (CI) 0.89–0.95]. In external validation, the discrimination was good, with an AUC value of 0.833 (95% CI 0.70–0.92) for this model. Nomogram calibration plots indicated good agreement between the predicted and observed outcomes, exhibiting close approximation between the predicted and observed probability.CONCLUSION: We constructed a scoring model for predicting massive transfusion during cesarean section in women with placenta previa. This model may help in determining the need to prepare an appropriate amount of blood products and the optimal timing of blood transfusion.

Ácido fólico y embarazo, ¿beneficio o riesgo? / Folic acid and pregnancy, benefit or risk?

RESUMEN El consumo de ácido fólico se ha relacionado con la disminución en la incidencia de malformaciones congénitas y deficiencias obstétricas, pero existen criterios de que no siempre su uso tiene los efectos favorables esperados para la madre y su descendencia. Con el objetivo de estructurar los presupuestos teóricos que sustentan el beneficio y el riesgo del consumo de ácido fólico para el embarazo, se realizó una búsqueda sobre el tema consultándose 37 referencias bibliográficas actualizadas. El ácido fólico ostenta dos grandes funciones en el organismo: la síntesis y reparación de los ácidos nucleicos, así como la síntesis del aminoácido metionina a partir de la homocisteina, esta última, al acumularse en el organismo se asocia a defectos congénitos y enfermedades crónicas del adulto. A partir de estos aspectos se corrobora que su consumo antes y durante el embarazo es beneficioso pues previene defectos del tubo neural, algunas cardiopatías congénitas, hendiduras bucofaciales, síndrome de Down, desórdenes del espectro autista, infecciones obstétricas, preeclampsia, hemorragia uterina, desprendimiento abrupto de la placenta, retardo del crecimiento intrauterino y prematuridad. El consumo excesivo de más de 5 mg/día se ha asociado a anemia por deficiencia de vitamina B12, déficit de zinc, crecimiento intrauterino retardado y prematuridad; en modelos animales acelera la transformación maligna de tumores existentes. Se concluye que el ácido fólico contribuye a preservar una embriogénesis y placentación normal y no se han demostrado efectos adversos por su uso, pero debe ser consumido en la dosis adecuada y por prescripción médica.

ABSTRACT Acid folic intake has been related to the decrease in the incidence of congenital malformations and obstetric deficiencies but there are criteria about folic acid not always achieving the expected favorable results for mothers and their descendants. A search on the theme was carried out with the objective of structuring the theoretical assumptions upholding the benefit and risk of folic acid intake for pregnancy. 37 updated bibliographic references were consulted. The folic acid has two main functions in the organism: nucleic acids´ synthesis and repair, and also the synthesis of the methionine amino acid from homocystein; when the last one accumulates in the organism, it is associated to congenital defects and adults´ chronic diseases. Beginning from these aspects, it is stated that the intake before and after pregnancy is beneficial because it prevents defects of the neural tube, some congenital deficiencies, oral facial clefts, Down syndrome, autism spectrum disorders, obstetric infections, preeclampsia, uterine hemorrhage, sudden placental abruption, intrauterine grow retardation and prematurity. The excessive intake of more than 5 mg/d has been associate to anemia due vitamin B12 deficiency, zinc deficiency, intrauterine retarded grow and prematurity; in animal models it speeds up the malignant transformation of existent tumors. The authors arrived to the conclusion that folic acid contributes to preserving a normal embryogenesis and placentation, and that no adverse effects have been demonstrated, nevertheless it should be taken in adequate doses and for medical prescription.

Can the combination of internal iliac temporary occlusion and uterine artery embolization reduce bleeding and the need for intraoperative blood transfusion in cases of invasive placentation?

OBJECTIVES: Women with invasive placentation (IP) are at high risk of life-threatening hemorrhage. In the last two decades, less invasive surgical approaches combined with endovascular procedures have proven to be safe. Most case series describe the use of temporary balloon occlusion and embolization, either combined or not. Concerning hemorrhage rates, each separate interventional approach performs better than surgery alone does, yet it is not clear whether the combination of multiple interventional techniques can be beneficial and promote a lower incidence of intrapartum bleeding. We aim to evaluate whether combining temporary balloon occlusion of the internal iliac artery and uterine artery embolization promotes better hemorrhage control than do other individual interventional approaches reported in the scientific literature in the context of cesarean birth followed by hysterectomy in patients with IP. METHODS: This is a retrospective analysis of patients with confirmed IP who underwent temporary balloon occlusion and embolization of the internal iliac arteries followed by puerperal hysterectomy. We compared patient results to data extracted from a recent systematic review and meta-analysis of the current literature that focused on interventional procedures in patients with IP. RESULTS: A total of 35 patients underwent the procedure during the study period in our institution. The mean volume of packed red blood cells and the estimated blood loss were 487.9 mL and 1193 mL, respectively. Four patients experienced complications that were attributed to the endovascular procedure. CONCLUSION: The combination of temporary balloon occlusion and uterine artery embolization does not seem to promote better hemorrhage control than each procedure performed individually does.

Subplacental development in Galea spixii / Desenvolvimento subplacentário do preá (Galea spixii)

Animal models are essential to understand healthy human placentation. Guinea pig related rodents became on focus for such purposes. In particular, processes of trophoblast invasion are similar. The latter is associated with a specialized area, the subplacenta. Since previous results showed differences between the guinea pig and its close relative Galea spixii, we aimed to study subplacental development with more detail. We investigated 16 pregnant females of 14 to 55 days of gestation by means of histology, morphometrics, immunohistochemistry and electron microscopy. The overlap between the fetomaternal blood systems resulted as intimate, suggesting some exchange processes. Proliferation was revealed by three independent methods, being most active in early and mid-gestation, which was in accordance to former results. Though degeneration of tissues took place, the subplacenta was maintained towards term with access to the fetal vascularization, supporting a hypothesis about the release of substances to the fetal unit in advanced gestation. In contrast to other species, the extraplacental trophoblast showed a shift from syncytial streamers to giant cells during mid-gestation. Views on placentation in caviomorphs were influenced by the guinea pig, but our data supported recent studies that the subplacenta had a much greater placidity. In regard to subplacental grow, degeneration and likely also exchange processes, Galea and other species showed a more basal pattern of caviomorphs than the guinea pig. Such differences should be considered, when choosing most adequate animal models for special purposes in comparison to human placentation.(AU)

Modelos animais são essenciais para entender a placenta humana sadia. Neste sentido os roedores relacionados ao porquinho da índia tornaram-se foco para tal entendimento. Em particular, os processos de invasão trofoblástica são semelhantes. O último está associado a uma área especializada, a subplacenta. Uma vez que os resultados anteriores mostraram diferenças entre o porquinho da índia e seu relativo o preá, buscamos estudar o desenvolvimento subplacentário com mais detalhes. Pesquisamos 16 fêmeas gestantes de 14 a 55 dias de gestação por meio de histologia, morfometria, imuno-histoquímica e microscopia eletrônica. A sobreposição entre os sistemas sanguíneos materno e fetal apresentou-se com íntima relação, sugerindo alguns processos de troca. A proliferação foi revelada por três métodos independentes, sendo mais ativos no início e metade da gestação, o que corroborou com os resultados anteriores. Embora a degeneração dos tecidos tenha ocorrido, a subplacenta foi mantida até o termo gestacional com acesso à vascularização fetal, apoiando uma hipótese sobre a liberação de substâncias para a unidade fetal em gestação avançada. Em contraste com outras espécies, o trofoblasto extraplacentário mostrou uma mudança de flâmulas sinciciais para células gigantes durante a metade da gestação. As visualizações sobre a placentação em caviomorfos foram influenciadas pelo porquinho da índia, mas nossos dados apoiaram estudos recentes de que a subplacenta apresentava uma plasticidade muito maior. Em relação ao crescimento subplacentário, a degeneração e provavelmente também os processos de troca, o preá e outras espécies apresentaram um padrão mais basal de caviomorfos do que o porquinho da índia. Tais diferenças devem ser consideradas, ao escolher os modelos animais mais adequados para fins especiais em comparação com a placentação humana.(AU)

Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding

OBJECTIVE: To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE) before obstetrical procedures with high risk for massive bleeding. MATERIALS AND METHODS: A retrospective review of 29 female patients who underwent prophylactic UAE from June 2009 to February 2014 was performed. Indications for prophylactic UAE were as follows: dilatation and curettage (D&C) associated with ectopic pregnancy (cesarean scar pregnancy, n = 9; cervical pregnancy, n = 6), termination of pregnancy with abnormal placentation (placenta previa, n = 8), D&C for retained placenta with vascularity (n = 5), and D&C for suspected gestational trophoblastic disease (n = 1). Their medical records were reviewed to evaluate the safety and efficacy of UAE. RESULTS: All women received successful bilateral prophylactic UAE followed by D&C with preservation of the uterus. In all patients, UAE followed by obstetrical procedure prevented significant vaginal bleeding on gynecologic examination. There was no major complication related to UAE. Vaginal spotting continued for 3 months in three cases. Although oligomenorrhea continued for six months in one patient, normal menstruation resumed in all patients afterwards. During follow-up, four had subsequent successful natural pregnancies. Spontaneous abortion occurred in one of them during the first trimester. CONCLUSION: Prophylactic UAE before an obstetrical procedure in patients with high risk of bleeding or symptomatic bleeding may be a safe and effective way to manage or prevent serious bleeding, especially for women who wish to preserve their fertility.

Placental Growth Measures in Relation to Birth Weight in a Latin American Population / Medidas de crescimento placentário em relação ao peso de nascimento em uma população latino-americana

Abstract Introduction The placenta, translates how the fetus experiences the maternal environment and is a principal influence on birth weight (BW). Objective To explore the relationship between placental growth measures (PGMs) and BW in a public maternity hospital. Methods Observational retrospective study of 870 singleton live born infants at Hospital Maternidad Sardá, Universidad de Buenos Aires, Argentina, between January 2011 and August 2012 with complete data of PGMs. Details of history, clinical and obstetrical maternal data, labor and delivery and neonatal outcome data, including placental measures derived from the records, were evaluated. The following manual measurements of the placenta according to standard methods were performed: placental weight (PW, g), larger and smaller diameters (cm), eccentricity, width (cm), shape, area (cm2), BW/PW ratio (BPR) and PW/BW ratio (PBR), and efficiency. Associations between BW and PGMs were examined using multiple linear regression. Results Birth weight was correlated with placental weight (R2 =0.49, p < 0.001), whereas gestational age was moderately correlated with placental weight (R2 =0.64, p < 0.001). By gestational age, there was a positive trend for PW and BPR, but an inverse relationship with PBR (p < 0.001). Placental weight alone accounted for 49% of birth weight variability (p < 0,001), whereas all PGMs accounted for 52% (p < 0,001). Combined, PGMs, maternal characteristics (parity, pre-eclampsia, tobacco use), gestational age and gender explained 77.8% of BW variations (p < 0,001). Among preterm births, 59% of BW variances were accounted for by PGMs, compared with 44% at term. All placental measures except BPR were consistently higher in females than in males, which was also not significant. Indices of placental efficiency showed weakly clinical relevance. Conclusions Reliable measures of placental growth estimate 53.6% of BW variances and project this outcome to a greater degree in preterm births than at term. These findings would contribute to the understanding of the maternal-placental programming of chronic diseases.

Resumo Introdução Aplacenta traduz como o feto experimenta o ambientematerno, alémde ser a principal influência sobre o peso ao nascer (PN). Objetivo Explorar a relação entre medidas de crescimento da placenta (MCPs) e PN em uma maternidade pública. Métodos Estudo retrospectivo observacional de 870 recém-nascidos vivos únicos na Maternidade Sardá, Universidade de Buenos Aires, Argentina, entre janeiro de 2011 e agosto de 2012 com os dados completos das MCPs. Foram avaliados dados da história clínica e obstétricamaterna, trabalho de parto e resultados neonatais, incluindomedidas da placenta derivadas dos registrosmédicos. Foramrealizadas as seguintesmediçõesmanuais da placenta: peso da placenta (PP, g), diâmetros maior e menor (cm), excentricidade, espessura (cm), forma, área (cm2), razões PN/PP e PP/PN e eficiência. Associações entre PN e MCPs foram examinadas por meio de regressão linear múltipla. Resultados Peso ao nascer foi correlacionado com peso placentário (R2 = 0,49, p < 0,001), enquanto idade gestacional foi moderadamente correlacionada com peso placentário (R2 = 0,64, p < 0,001). Por idade gestacional, houve uma tendência positiva para a relação PP e PN/PP, mas uma relação inversa com a razão PP/PN (p < 0,001). Somente peso da placenta respondeu por 49% da variabilidade do peso ao nascer (p < 0,001), ao passo que todas as MCPs foram responsáveis por 52% (p < 0,001). Combinados, MCPs, características maternas (paridade, pré-eclâmpsia, fumo), idade gestacional e sexo explicaram 77,8% da variação do peso ao nascer (p < 0,001). Entre nascimentos pré-termo, 59% da variância do PN foi contabilizada pelas MCPs, emcomparação com44% a termo. Todas asmedidas placentárias, exceto a razão PN/PP, foram consistentemente maiores em mulheres do que em homens, mas não significativas. Índices de eficiência placentária mostraram fraca relevância clínica. Conclusões medidas confiáveis de crescimento placentário estimam 53,6% da variância do peso ao nascer, e projetamesse resultado a ummaior grau emnascimentos pré-termo do que a termo. Estes resultados contribuiriam para a compreensão da programação materno-placentária de doenças crónicas.

Ácido acetilsalicílico (AAS) na prevenção da pré-eclâmpsia / Acetylsalicylic acid in the pre-eclampsia prevention

As desordens hipertensivas na gestação, em especial a pré-eclâmpsia (PE), são consideradas, nos países em desenvolvimento, a maior causa de morbimortalidade tanto materna quanto perinatal. Com objetivo de alcançar maior entendimento da fisiopatologia da PE e de evitar as manifestações clínicas desta doença e suas consequências, foram realizadas pesquisas relacionadas à suplementação de substâncias que atuariam na fisiopatologia, em especial examinando o uso do ácido acetilsalicílico (AAS). O uso de AAS em baixas doses em gestantes com alto risco de desenvolver PE quando iniciado na 16ª semana de gestação, ou mesmo antes, pode ser considerado importante avanço devido aos resultados observados em estudos relatando boa eficácia e redução do risco de morte perinatal, de restrição de crescimento intrauterino e de nascimento pré-termo.(AU)

Hypertensive disorders in pregnancy, particularly preeclampsia (PE), are considered a major cause of maternal and perinatal morbidity and mortality in developing countries. With the objetive of improving the knowledge about the pathophysiology of PE, and to avoid the clinical manifestations and consequences of this disease, several studies related with the supplementation of acetylsalicylic acid (AAS) on the PE pathophysiology have been performed. The use of low doses of AAS starting at or before week 16 can be considered an important advance in reducing the risk of perinatal death, intrauterine growth restriction and preterm birth.(AU)

Effect of di-(2-ethylhexyl) phthalate exposure on placental development in pregnant mice / 南方医科大学学报

<p><b>OBJECTIVE</b>To investigate the effect of di-(2-ethylhexyl) phthalate (DEHP) exposure on the growth and development of placenta, uterine natural killer (uNK) cell number and angiogenesis at the maternal-fetal interface in pregnant mice.</p><p><b>METHODS</b>From day 1 of pregnancy, pregnant mice were exposed daily to DEHP by oral gavage at 125, 250, or 500 mg/kg for 13 consecutive days. The uterine and placental tissues were then harvested for HE staining and immunohistochemistry to examine the effect of DEHP exposure on the growth and development of the placenta and angiogenesis and uNK cell number at the maternal-fetal interface.</p><p><b>RESULTS</b>Compared with the control group, the mice exposed to 500 mg/kg DEHP, but not those exposed to 125 and 250 mg/kg, showed significantly reduced number of embryo implantation (P<0.05). DEHP exposure significantly increased the rate of abortion. DEHP exposure at 125, 250, and 500 mg/kg significantly and dose-dependently lowered the placental weight compared with that in the control group (0.0637±0.0133, 0.0587±0.0176, 0.0524±0.0183 g vs 0.0786±0.0143 g, respectively; P<0.01), and significantly reduced the total area of the placenta and area of spongiotrophoblasts. DEHP exposure resulted in a significant reduction in the number of fetal vascular branches, and collapse and atresia of blood vessels. The mice exposed to DEHP at 125, 250, and 500 mg/kg had significantly lowered numbers of uNK cells (83.2±10.3, 60.7±12.4, and 50.4±14.5/HP, respectively) as compared with the control group (105.1±14.2/HP) at the maternal-fetal interface (P<0.01).</p><p><b>CONCLUSION</b>DEHP exposure significantly affects the growth and development of the placenta in mice possibly by suppressing angiogenesis and reducing uNK cell number at the maternal-fetal interface during pregnancy.</p>

Desenlaces materno-fetales de los embarazos atendidos en el Hospital Universitario de Santander, Bucaramanga (Colombia), 2007-2011. Estudio de cohorte / Maternal and foetal outcomes in twin pregnancies seen at Hospital Universitario de Santander, Bucaramanga (Colombia), 2007-2011. A cohort study

Los embarazos gemelares implican mayor riesgo de complicaciones materno-fetales que los embarazos únicos, particularmente en los monocoriales. El objetivo del trabajo fue describir las características clínicas y los desenlaces materno-fetales, por tipo de placenta (monocorial o bicorial), de los embarazos gemelares atendidos en el Hospital Universitario de Santander (HUS), institución de tercer nivel de complejidad localizada en Bucaramanga (Colombia). Materiales y métodos: estudio descriptivo de cohorte, se incluyeron las pacientes que terminaron un embarazo gemelar entre 2007 y 2011 en el HUS, hospital general de referencia de la región centro-oriental del país. Muestreo consecutivo. Se evaluó la edad gestacional en la primera consulta al hospital, los hallazgos clínicos en la evaluación inicial, la terminación del parto y los resultados perinatales. Se hace análisis descriptivo por tipo de corionicidad. Resultados: se incluyeron un total de 248 gestantes con embarazo gemelar en el periodo de estudio. La mediana de la edad gestacional en la primera atención en el hospital en fue de 34 semanas. Al ingreso, 127 (51,2 %) pacientes se diagnosticaron con embarazo monocorial, pero solo en dos terceras partes coincidió el diagnóstico prenatal de corionicidad con el del posparto. Se diagnosticó RCIU con más frecuencia en embarazos monocoriales que en bicoriales (22,3 vs. 7,5 %), y el doppler se encontró alterado con mayor frecuencia en fetos de embarazo monocorial (7,8 vs. 1,1 %). Los neonatos > 24 semanas de edad gestacional de embarazo monocorial pesaron, en promedio, 109 g (IC 95 %: 34-184) menos que los bicoriales. Conclusiones: los resultados de este estudio sugieren un problema de salud pública en este grupo de pacientes, con inicio tardío de control prenatal, de remisión tardía a centros especializados y capacidad insuficiente para definir corionicidad. Se requiere plantear estrategias de atención que incluyan considerar los embarazos gemelares como alto riesgo y garantizar la atención oportuna y adecuada, orientada por una guía de cuidado diferencial para este grupo de gestantes...

Twin pregnancies, especially monochorionic placentations, are associated with a higher rate of maternal and foetal complications when compared to singleton pregnancies. The objective of this work was to describe the clinical characteristics and the maternal and foetal outcomes according to the type of placentation (monochorial or dichorial) of twin pregnancies delivered at Hospital Universitario de Santander (HUS), a level III institution located in Bucaramanga, Colombia. Materials and methods: Descriptive cohort study. The cohort consisted of patients delivered of a twin pregnancy between 2007 and 2011 at the HUS, a general referral hospital for the central-eastern region of the country. The assessment included gestational age at the time of initial presentation to the hospital, clinical findings during the initial assessment, delivery completion, and perinatal results. Descriptive analysis by chorionicity type. Results: A total of 248 women with a twin pregnancy during the study period were included. The mean gestational age on the first visit to the hospital was 34 weeks. On admission, 127 patients (51.2%) were diagnosed with a monochorionic pregnancy, but only in two thirds of the cases was the prenatal chorionicity diagnosis consistent with the post-partum finding. IUGR was diagnosed more frequently in monochorionic than in dichorionic pregnancies (22.3% v. 7.5%) and abnormal Doppler findings were more frequent in monochorionic foetuses (7.8% v. 1.1%). Neonates > 24 of gestational age in monochorionic pregnancies weigh in average 109 gr (IC 95%: 34-184) less than dichorionic twins. Conclusions: The results of this study suggest a public health problem in this group of patients who come late for their prenatal visits and are late referrals to specialized centres, when there is already a limited ability to determine chorionicity. There is a need to develop care strategies in which twin pregnancies are included as a high-risk condition, and to ensure timely and adequate care provision in accordance with differential care guidelines for this group of pregnant women...

Placental efficiency in the equine species: which factors may be related? / Eficiência placentária na espécie equina: quais fatores podem estar relacionados?

This review intends to show the main factors that may affect intrauterine growth and the placentals nutrients supply to the fetus, morphofunctional aspects placental efficiency, correlating them with performance indexes, such as breed, age and pluriparious. This study aims to discuss the interrelationships that determine greater placental efficiency, proposing a comparative parallel between various species in order to understand more about the placental efficiency in the equine species.

Esta revisão de literatura propõe levantar os principais fatores que podem influenciar o crescimento intrauterino e o suprimento de nutrientes placentários para o feto, abordando aspectos morfofuncionais relacionados à eficiência placentária, correlacionando-os com aspectos zootécnicos, como raça, pluriparidade e idade das fêmeas gestantes. O objetivo foi estabelecer as interrelações que determinem maior eficiência placentária, propondo um paralelo comparativo entre espécies a fim de ser entendida a eficiência placentária na espécie equina.

Acute Atherosis of the Uterine Spiral Arteries: Clinicopathologic Implications

Acute atherosis is unique vascular changes of the placenta associated with poor placentation. It is characterized by subendothelial lipid-filled foam cells, fibrinoid necrosis of the arterial wall, perivascular lymphocytic infiltration, and it is histologically similar to early-stage atherosclerosis. Acute atherosis is rare in normal pregnancies, but is frequently observed in non- transformed spiral arteries in abnormal pregnancies, such as preeclampsia, small for gestational age (SGA), fetal death, spontaneous preterm labor and preterm premature rupture of membranes. In preeclampsia, spiral arteries fail to develop physiologic transformation and retain thick walls and a narrow lumen. Failure of physiologic transformation of spiral arteries is believed to be the main cause of uteroplacental ischemia, which can lead to the production of anti-angiogenic factors and induce endothelial dysfunction and eventually predispose the pregnancy to preeclampsia. Acute atherosis is more frequently observed in the spiral arteries of the decidua of the placenta (parietalis or basalis) than in the decidual or myometrial segments of the placental bed. The presence and deeper location of acute atherosis is associated with poorer pregnancy outcomes, more severe disease, earlier onset of preeclampsia, and a greater frequency of SGA neonates in patients with preeclampsia. Moreover, the idea that the presence of acute atherosis in the placenta may increase the risk of future cardiovascular disease in women with a history of preeclampsia is of growing concern. Therefore, placental examination is crucial for retrospective investigation of pregnancy complications and outcomes, and accurate placental pathology based on universal diagnostic criteria in patients with abnormal pregnancies is essential for clinicopathologic correlation.

Fetal hematopoietic stem cells express MFG-E8 during mouse embryogenesis

The milk fat globule-EGF-factor 8 protein (MFG-E8) has been identified in various tissues, where it has an important role in intercellular interactions, cellular migration, and neovascularization. Previous studies showed that MFG-E8 is expressed in different cell types under normal and pathophysiological conditions, but its expression in hematopoietic stem cells (HSCs) during hematopoiesis has not been reported. In the present study, we investigated MFG-E8 expression in multiple hematopoietic tissues at different stages of mouse embryogenesis. Using immunohistochemistry, we showed that MFG-E8 was specifically expressed in CD34+ HSCs at all hematopoietic sites, including the yolk sac, aorta-gonad-mesonephros region, placenta and fetal liver, during embryogenesis. Fluorescence-activated cell sorting and polymerase chain reaction analyses demonstrated that CD34+ cells, purified from the fetal liver, expressed additional HSC markers, c-Kit and Sca-1, and that these CD34+ cells, but not CD34- cells, highly expressed MFG-E8. We also found that MFG-E8 was not expressed in HSCs in adult mouse bone marrow, and that its expression was confined to F4/80+ macrophages. Together, this study demonstrates, for the first time, that MFG-8 is expressed in fetal HSC populations, and that MFG-E8 may have a role in embryonic hematopoiesis.

Galectins: Double Edged Swords in the Cross-roads of Pregnancy Complications and Female Reproductive Tract Inflammation and Neoplasia

Galectins are an evolutionarily ancient and widely expressed family of lectins that have unique glycan-binding characteristics. They are pleiotropic regulators of key biological processes, such as cell growth, proliferation, differentiation, apoptosis, signal transduction, and pre-mRNA splicing, as well as homo- and heterotypic cell-cell and cell-extracellular matrix interactions. Galectins are also pivotal in immune responses since they regulate host-pathogen interactions, innate and adaptive immune responses, acute and chronic inflammation, and immune tolerance. Some galectins are also central to the regulation of angiogenesis, cell migration and invasion. Expression and functional data provide convincing evidence that, due to these functions, galectins play key roles in shared and unique pathways of normal embryonic and placental development as well as oncodevelopmental processes in tumorigenesis. Therefore, galectins may sometimes act as double-edged swords since they have beneficial but also harmful effects for the organism. Recent advances facilitate the use of galectins as biomarkers in obstetrical syndromes and in various malignancies, and their therapeutic applications are also under investigation. This review provides a general overview of galectins and a focused review of this lectin subfamily in the context of inflammation, infection and tumors of the female reproductive tract as well as in normal pregnancies and those complicated by the great obstetrical syndromes.

Endoplasmic reticulum stress in periimplantation embryos / 대한생식의학회지

Stress coping mechanisms are critical to minimize or overcome damage caused by ever changing environmental conditions. They are designed to promote cell survival. The unfolded protein response (UPR) pathway is mobilized in response to the accumulation of unfolded proteins, ultimately in order to regain endoplasmic reticulum (ER) homeostasis. Various elements of coping responses to ER stress including Perk, Ask1, Bip, Chop, Gadd34, Ire1, Atf4, Atf6, and Xbp1 have been identified and were found to be inducible in oocytes and preimplantation embryos, suggesting that, as a normal part of the cellular adaptive mechanism, these coping responses, including the UPR, play a pivotal role in the development of preimplantation embryos. As such, the UPR-associated molecules and pathways may become useful markers for the potential diagnosis of stress conditions for preimplantation embryos. After implantation, ER stress-induced coping responses become physiologically important for a normal decidual response, placentation, and early organogenesis. Attenuation of ER stress coping responses by tauroursodeoxycholate and salubrinal was effective for prevention of cell death of cultured embryos. Further elucidation of new and relevant ER stress coping responses in periimplantation embryos might contribute to a comprehensive understanding of the regulation of normal development of embryonic development and potentiation of embryonic development in vitro.

Maternal Preeclampsia and Bronchopulmonary Dysplasia / 대한주산의학회잡지

Preeclampsia is one of the most common complications of pregnancy that is prevalent worldwide, resulting in substantial maternal and neonatal morbidity and mortality. Although the cause remains unclear, preeclampsia may be initiated by abnormal placentation and reduced placental perfusion, followed by an imbalance of angiogenic and antiangiogenic factors and subsequent systemic endothelial dysfunction. High level of antiangiogenic factors, such as soluble vascular endothelial growth factor (VEGF) receptor 1 (sVEGFR-1, also known as sFlt-1) and soluble endoglin, and low levels of angiogenic factors, such as free maternal VEGF and placental growth factor (PlGF), are associated with preeclampsia. Angiogenic and antiangiogenic factors also play an important role during lung angiogenesis, and an imbalance between the two types of factors triggered by inflammation disrupts angiogenesis in bronchopulmonary dysplasia (BPD). Because preeclampsia represents an antiangiogenic state, preterm infants born to mothers with preeclampsia would be at increased risk of developing BPD due to impaired lung development. Recently, preeclampsia has been shown to be independently associated with a high risk for BPD. I have reviewed recent progress in research concerning the correlation between preeclampsia and BPD in aspect of pathophysiology and epidemiology.

Correlação entre o peso, comprimento e anexos fetais de mocós (Kerodon rupestris Wied, 1820) / Correlation between weight, length and fetal membranes of rock cavies (Kerodon rupestris Wied, 1820)

Foi avaliada a existência de correlação entre diferentes anexos fetais de mocós e determinada a relação entre peso do feto e peso da placenta, a relação entre o peso do feto e comprimento do cordão umbilical e a relação entre o peso do feto e comprimento do feto. Foram utilizados anexos fetais e fetos de três, cinco e seis fêmeas, respectivamente, no terço inicial, médio e final de gestação, obtidas no Centro de Multiplicação de Animais Silvestres (CEMAS-UFERSA). Os dados foram expressos em média ± desvio-padrão, bem como valores mínimos e máximos, avaliados pelo programa estatístico GraphPad Prism Versão 6.0. Após a análise dos pressupostos paramétricos, os dados foram submetidos aos Testes de Kruskal-Wallis e Mann-Whitney, e regressão linear. A relação entre peso do feto e peso da placenta demonstrou expressão y = 33,73 + 16,38x com cálculo do coeficiente de correlação entre o peso do feto e o peso da placenta elevado e positivo, evidenciando dependência entre as variáveis (R2 = 0,7251). A relação entre o peso do feto e comprimento do cordão umbilical demonstrou expressão y = 35,64 + 25,64x e a análise de correlação entre as variáveis, positiva (R2 = 0,7201) indicando elevada dependência entre as variáveis. Quanto à relação entre o peso do feto e comprimento do feto, identificou-se uma relação do tipo y = a + bx, cuja expressão definida foi y = 1,26 + 0,41x, com análise de correlação das variáveis apresentando elevada correlação considerando-se o valor de R2 = 0,7890. As variáveis analisadas demonstram uma influência direta no desenvolvimento embrionário e fetal em mocós confirmando a correlação destes com o tamanho do feto.

We evaluated the correlation between different fetal membranes of rock cavies and determined the relationship between fetal weight and placental weight, the relationship between fetal weight and length of the umbilical cord and the relationship between fetal weight and length of the fetus. The fetuses and fetal membranes of three, five and six females respectively in the first third, middle and late gestation were used, obtained from Multiplication Center for Wild Animals of the Federal University Rural of Semiarid (CEMAS-UFERSA). The data were expressed as mean ± standard deviation, minimum and maximum values, evaluated by the statistical program GraphPad Prism version 6.0. After analysis of parametric assumptions, the data were subjected to Kruskal-Wallis’ test and Mann-Whitney’s test and linear regression. The relationship between fetal weight and placental weight showed the expression y = 33.73 + 16.38x with an estimate of the coefficient of correlation between fetal weight and placental weight high and positive, showing dependence between variables (R2 = 0.7251). The relationship between fetal weight and length of the umbilical cord showed expression y = 35.64 + 25.64x and the correlation analysis between variables, positive (R2 = 0.7201) indicating high dependence between variables. Regarding the relationship between fetal weight and length of the fetus, we identified a relationship of the type y = a + bx, whose expression was defined y = 1.26 + 0.41x, with correlation analysis of the variables showing high correlation considering the value of R2 = 0.7890. The variables analyzed demonstrate a direct influence on embryonic andfetal development in rock cavies confirming the correlation of these with the size of the fetus.

Outcome of pelvic arterial embolization for postpartum hemorrhage: A retrospective review of 117 cases

OBJECTIVE: The aim of this study was to evaluate indications, efficacy, and complications associated with pelvic arterial embolization (PAE) for postpartum hemorrhage (PPH). METHODS: We retrospectively reviewed the medical records of 117 consecutive patients who underwent PAE for PPH between January 2006 and June 2013. RESULTS: In our single-center study, 117 women underwent PAE to control PPH refractory to conservative management including uterine massage, use of uterotonic agents, surgical repair of genital tract lacerations, and removal of retained placental tissues. Among 117 patients, 69 had a vaginal delivery and 48 had a Cesarean section. The major indication for embolization was uterine atony (54.7%). Other causes were low genital tract lacerations (21.4%) and abnormal placentation (14.5%). The procedure showed a clinical success rate of 88.0% with 14 cases of PAE failure; there were 4 hemostatic hysterectomies and 10 re-embolizations. On univariate analysis, PAE failure was associated with overt disseminated intravascular coagulation (P=0.009), transfusion of more than 10 red blood cell units (RBCUs, P=0.002) and embolization of both uterine and ovarian arteries (P=0.003). Multivariate analysis showed that PAE failure was only associated with transfusions of more than 10 RBCUs (odds ratio, 8.011; 95% confidence interval, 1.531-41.912; P=0.014) and embolization of both uterine and ovarian arteries (odds ratio, 20.472; 95% confidence interval, 2.715-154.365; P=0.003), which were not predictive factors, but rather, were the results of longer time for PAE. Three patients showed uterine necrosis and underwent hysterectomy. CONCLUSION: PAE showed high success rates, mostly without procedure-related complications. Thus, it is a safe and effective adjunct or alternative to hemostatic hysterectomy, when primary management fails to control PPH.