Tromboprofilaxis precoz y evolución en embarazadas con COVID-19 / Early thromboprophylaxis and evolution in pregnant women with COVID-19

Introducción: en marzo del año 2020 se declara Pandemia, por la aparición de un nuevo Coronavirus, el SARS-CoV2 (COVID-19). Las mujeres embarazadas presentan un riesgo mayor de presentar procesos tromboembólicos, por lo que se recomienda utilizar de manera profiláctica heparina, para prevención de procesos tromboembólicos durante la infección por SARS-CoV2. Objetivo: Describir la evolución de las embarazadas con infección por SARS-CoV2 con la utilización de heparina de bajo peso molecular, Enoxaparina, ajustada al peso de manera precoz. Metodología: estudio descriptivo prospectivo, observacional, de corte transversal. Resultados: en la evolución de 30 mujeres embarazadas con infección por SARS-CoV2, las edades más frecuentes corresponden a 31 a 35 años, mayor número de infectadas en el segundo trimestre del embarazo, el índice de masa corporal predominante en rango de sobrepeso y obesidad, la dosis de enoxaparina utilizada fue de 40 mg/día, ya que se ajustó al peso de la embarazada, las comorbilidades más frecuentes correspondieron al sobrepeso y obesidad, enfermedad hipertensiva del embarazo y diabetes gestacional, la sintomatología resultó muy variada, debido a las distintas variantes del virus, con más frecuencia la rinorrea, congestión nasal, tos, anosmia, disgeusia, cefalea, fiebre y dificultad respiratoria, y la mayoría de las embarazadas no estaban vacunadas. Conclusiones: ninguna de las 30 embarazadas que recibieron heparina de bajo peso molecular (Enoxapina), ajustada al peso, y de manera precoz, con infección por SARS.CoV2, falleció, ni requirió internación en Unidad de Terapia Intensiva. Una embarazada, fue internada por disnea moderada y saturación de oxígeno menor a 95%. Las restantes embarazadas tuvieron buena evolución en su domicilio, sin ninguna complicación

Introduction: in March 2020, a Pandemic was declared, due to the appearance of a new Coronavirus, SARS-CoV2 (COVID-19). Pregnant women have a higher risk of presenting thromboembolic processes, so it is recommended to use heparin prophylactically, to prevent thromboembolic processes during SARS-CoV2 infection. Objective: to describe the evolution of pregnant women with SARS-CoV2 infection with the early use of Enoxaparin, adjusted to the weight of low molecular weight heparin. Methodology: prospective, observational, cross-sectional descriptive study. Results: in the evolution of 30 pregnant women with SARS-CoV2 infection, the most frequent ages correspond to 31 to 35 years, the highest number of infected in the second trimester of pregnancy, the predominant body mass index in the range of overweight and obesity. , the dose of enoxaparin used was 40 mg/day, since it was adjusted to the weight of the pregnant woman, the most frequent comorbidities were overweight and obesity, hypertensive disease of pregnancy and gestational diabetes, the symptoms were highly varied, due to the different variants of the virus, more frequently rhinorrhea, nasal congestion, cough, anosmia, dysgeusia, headache, fever and respiratory distress, and most of the pregnant women were not vaccinated. Conclusions: none of the 30 pregnant women who received low molecular weight heparin (Enoxapine), adjusted for weight, and early, with SARS.CoV2 infection, died or required admission to the Intensive Care Unit. A pregnant woman was hospitalized due to moderate dyspnea and oxygen saturation less than 95%. The remaining pregnant women had a good evolution at home, without any complications

Síndrome de Evans y embarazo: reporte de un caso / Evans syndrome and pregnancy: a case report

Resumen El síndrome de Evans es una enfermedad conformada por la presencia simultánea o secuencial de trombocitopenia inmunitaria y anemia hemolítica autoinmunitaria, que puede ser primaria o secundaria a otra patología. Es una afección poco frecuente, por lo que es necesario tener una alta sospecha, y descartar otras patologías que cursan con dichas alteraciones hematológicas, para hacer el diagnóstico. Su manejo representa un desafío terapéutico dado su curso crónico y recidivante. La presentación durante el embarazo se asocia a morbilidad materna y fetal. A continuación presentamos el caso de una gestante en quien se pesquisó trombocitopenia severa aislada al ingreso al control prenatal, y que en el curso del embarazo desarrolló AHAI conformando un síndrome de Evans, que se consideró secundario a LES incompleto al realizar el estudio reumatológico. Debido a la pobre respuesta al tratamiento médico con corticoides e inmunosupresores, la mayor parte del embarazo se mantuvo hospitalizada para observación, ajuste y cambio de terapia, siendo necesario recurrir a manejo quirúrgico con esplenectomía.

Abstract Evans syndrome is a rare entity formed by the simultaneous or sequential presence of immune thrombocytopenia and autoimmune hemolytic anemia, which can be primary or secondary to another pathology. The presentation of this disease during pregnancy is associated with maternal and fetal morbidity. The syndrome's diagnosis requires a high suspicion and the ruling out of other pathologies that can happen with the same hematological alterations. The management represents a therapeutic challenge because of its chronic and recurrent course. Below we present the case of a pregnant woman in whom isolated severe thrombocytopenia was detected at admission for prenatal control, and who developed AIHA during the pregnancy, forming Evans syndrome, which was considered secondary to incomplete SLE when performing the rheumatological study. Due to the poor response to medical treatment with corticosteroids and immunosuppressants, the patient was hospitalized for most of her pregnancy for observation, adjustment and change of therapy, and even it was necessary resort to surgical management with splenectomy.

Manejo de la trombastenia de Glanzmann durante el embarazo: reporte de un caso y revisión de la literatura / Management of Glanzmann's thrombasthenia during pregnancy: a case report and literature review

Resumen Objetivo: Reportar el caso de una paciente con trombastenia de Glanzmann que recibe manejo con transfusión de plaquetas con factor VII activado y realizar una revisión de la literatura referente al tratamiento y el pronóstico de esta patología durante la gestación. Método: Se presenta el caso de una paciente de 27 años con trombastenia de Glanzmann y embarazo de 33 semanas, con cesárea al término sin complicaciones. Se realizó una búsqueda en las bases de datos Medline vía PubMed, Lilacs, SciELO y ScienceDirect; se incluyeron reportes de caso, series de casos y revisiones bibliográficas hasta 2021. Resultados: Se encontraron 21 artículos, con 23 casos reportados. Los embarazos se presentaron entre la tercera y la cuarta décadas de la vida, siendo la mayoría pacientes con anticuerpos frente a antígenos plaquetarios (43,4% de los casos). El principal manejo fue con transfusión plaquetaria. Conclusiones: La trombastenia de Glanzmann durante el embarazo es infrecuente y se asocia a eventos hemorrágicos. La presencia de anticuerpos frente a antígenos plaquetarios condiciona el manejo con mayor riesgo de complicaciones perinatales. No tiene un enfoque terapéutico unificado, siendo el de elección la transfusión de plaquetas y como segunda línea el factor VII activado.

Abstract Objective: To report the case of a patient with Glanzmann's thrombasthenia who receives management with platelet transfusion with activated factor VII and a literature review regarding the treatment and prognosis of this pathology during pregnancy. Method: We present the case of a 27 year old patient with Glanzmann's thrombasthenia and a 33-week pregnancy, with a cesarean section at term without complications. Medline databases were searched via PubMed, Lilacs, SciELO and ScienceDirect; case reports, case series and bibliographic reviews were included until 2021. Results: A total of 21 articles were found, with 23 reported cases; the pregnancies occurred between the third and fourth decades of life, the majority being patients with anti-platelet antigen antibodies in 43.4% of the cases. The main management was with platelet transfusion. Conclusions: Glanzmann's thrombasthenia during pregnancy is rare and is associated with hemorrhagic events. The presence of anti-platelet antigen antibodies conditions management with a higher risk of perinatal complications. It does not have a unified therapeutic approach, with platelet transfusion being the management of choice and activated factor VII as second line.

Recambio de Hematíes en gestante con Anemia de Células Falciformes: reporte de un caso en el Hospital Regional de Talca / Red blood cell exchange in pregnant women with Sickle Cell Anemia: report of a case in the Regional Hospital of Talca

Sickle cell anemia or sickle cell disease is an autosomal recessive disease, caused by a mutation in the hemoglobin gene, where glutamic acid is substituted for valine at position 6 of the beta chain of hemoglobin, resulting in hemoglobin S The diagnosis is made with electrophoresis. The clinical manifestations are varied, the most frequent being the vaso-occlusive crisis, which can increase in pregnancy, during which sickle cell disease also increases the risk of maternal-fetal complications, caused by pre-eclampsia infections, intrauterine growth restriction, and premature delivery. and miscarriage. The usual treatment for the management of seizures is hydroxyurea, a drug that is teratogenic, so its use is contraindicated during pregnancy. Other treatment alternatives are red blood cell transfusion and red blood cell exchange. Next, the first case of red blood cell exchange or exchange transfusion in a pregnant patient with sickle cell anemia at the Hospital Regional de Talca is presented.

Oral Iron Supplementation in Pregnancy: Current Recommendations and Evidence-Based Medicine Suplementação oral de ferro na gravidez: recomendações atuais e medicina baseada na evidência

Abstract Objective To review the evidence about universal iron supplementation in pregnancy to prevent maternal anemia. Methods Bibliographic research of randomized and controlled clinical trials, meta-analyses, systematic reviews, and clinical guidelines, published between August 2009 and August 2019, using the MeSH terms: iron; therapeutic use; pregnancy; anemia, prevention and control. Results We included six clinical guidelines, three meta-analyses and one randomized controlled clinical trial. Discussion Most articles point to the improvement of hematological parameters and reduction of maternal anemia risk, with supplementary iron. However, they do not correlate this improvement in pregnant women without previous anemia with the eventual improvement of clinical parameters. Conclusion Universal iron supplementation in pregnancy is controversial, so we attribute a SORT C recommendation strength.

Resumo Objetivo Rever a evidência sobre a necessidade de suplementação universal de ferro na gravidez para prevenção de anemia materna. Métodos Pesquisa bibliográfica de ensaios clínicos aleatorizados e controlados, metanálises, revisões sistemáticas e normas de orientação clínica, publicados entre agosto de 2009 e agosto de 2019, utilizando os termos MeSH: iron, terapêuticas use; pregnancy; anemia, preventivos and control. Resultados Incluímos seis normas de orientação clínica, três metanálises e um ensaio clínico randomizado e controlado. Discussão A maioria dos artigos aponta para a melhoria dos parâmetros hematológicos e redução do risco de anemia materna por meio da suplementação com ferro. Conclusões A suplementação universal com ferro na gravidez é controversa, pelo que atribuímos uma força de recomendação SORT C.

Factores sociales y demográficos asociados a la anemia en mujeres embarazada en Perú / Social and demographic factors associated with anemia in pregnant women in Peru

INTRODUCCIÓN Y OBJETIVOS: La anemia en el embarazo persiste como un problema de salud pública y varía según características propias en cada población. El objetivo del estudio fue determinar los factores sociales y demográficos asociados a la anemia en mujeres embarazadas en Perú. MÉTODO: Estudio analítico transversal de la Encuesta Demográfica y de Salud Familiar (ENDES) de 2019. Se incluyeron las mujeres embarazadas que participaron en la encuesta poblacional. Se analizaron las características sociales y demográficas asociados a la anemia, mediante análisis bivariado y análisis de regresión logística múltiple, procesados en el software estadístico R. RESULTADOS: Se incluyeron datos de 1090 mujeres embarazadas, 28,3% presento anemia. En el análisis bivariado, se evidencio asociación entre anemia y región geográfica, nivel educativo, edad y tener seguro de salud (p<0,05). En el análisis multivariado, se evidencio que la anemia se encuentra asociada al nivel educativo de primaria (OR=1,96; IC: 1,18-3,28), secundaria (OR=2,0; IC95%: 1,42-2,82), edad de 15 a 18 años (OR=2,35; IC95%: 1,33-4,14), edad mayor a 35 años (OR=1,51; IC95%: 1,06-2,16), no tener seguro de salud (OR=1,82; IC95%: 1,19-2,79). CONCLUSIÓN: La prevalencia de anemia en mujeres embarazadas fue del 28,3%. Los factores sociales y demográficos asociados a la anemia en mujeres embarazadas fueron la edad de 15 a 18 años, edad tardía de 35 años a más, tener un bajo nivel educativo y no contar con un seguro de salud. Estos factores evidenciaron asociación con anemia en mujeres embarazadas, estando ajustados por otras características como región geográfica, quintil de riqueza y lugar de residencia. Se requieren de más estudios que permiten analizar los resultados según temporalidad en la población con independencia de otros factores asociados.

INTRODUCTION AND OBJECTIVES: Anemia in pregnancy persists as a public health problem and varies according to specific characteristics in each population. The purpose was to determine the social and demographic factors associated with anemia in pregnant women in Peru. METHOD: Analytical cross-sectional study of the 2019 Demographic and Family Health Survey (ENDES). The study included data on pregnant women. The social and demographic characteristics associated with anemia were analyzed using bivariate analysis and multiple logistic regression analysis, processed in the R statistical software. RESULT: Data from 1 090 women were analyzed; 28.3% had anemia. Bivariate analysis showed an association between anemia and geographical region, educational level, age and health insurance (p<0.05). In the multivariate analysis, anemia was associated with the educational level of primary (OR=1,96; IC: 1,18-3,28), secondary (OR=2,0; IC95%: 1,42-2,82), age from 15 to 18 years (OR=2,35; IC95%: 1,33-4,14), age over 35 years (OR=1,51; IC95%: 1,06-2,16), not having health insurance (OR=1,82; IC95%: 1,19-2,79). CONCLUSION: The prevalence of anemia in pregnant women was 28.3%. The social and demographic factors associated with anemia in pregnant women were age 15-18, late age to 35, low educational level and lack of health insurance; regardless of geographical region, wealth quintile and place of residence. More studies are needed to analyze the results according to temporality in the population, independently of other associated factors.

Resultados obstétricos en gestantes diagnosticadas de síndrome antifosfolípido / Obstetric outcomes in pregnant women diagnosed of antiphospholipid syndrome

INTRODUCCIÓN: El síndrome antifosfolípido (SAF) es una enfermedad autoinmune caracterizada por la aparición de trombosis, complicaciones obstétricas y la presencia de anticuerpos antifosfolípidos. El objetivo de este estudio fue evaluar los resultados obstétricos en gestantes diagnosticadas de síndrome antifosfolípido, así como evaluar las condiciones que podrían influir en estos resultados. MATERIAL Y MÉTODOS: Se realizó un estudio retrospectivo de gestantes con diagnóstico previo de SAF, que fueron atendidas en nuestro centro entre los años 2007 y 2017. RESULTADOS: En el período de estudio se recogieron 35 gestantes con SAF, con un total de 50 gestaciones. Se empleó heparina en el 100% de las gestaciones y ácido acetilsalicílico en el 96%. La aparición de alguna complicación obstétrica ocurrió en el 34% de las gestaciones estudiadas. El perfil de anticuerpos triple positivo se asoció a mayor porcentaje de partos prematuros. La presencia de anticoagulante lúpico de forma aislada no se asoció a peores resultados obstétricos. DISCUSIÓN: La gestación en la mujer con SAF supone un importante reto, que precisa de un manejo multidisciplinar por parte del obstetra y el reumatólogo. Por otro lado, el perfil de anticuerpos antifosfolípidos podría detectar a las pacientes con mayor riesgo con el fin de adecuar el tratamiento y mejorar los resultados obstétricos.

INTRODUCTION: The antiphospholipid syndrome (APS) is an autoinmune disease characterized by the occurence of thrombosis, obstetric morbidity and the presence of antiphospholipid antibodies. The aim of this study was to evaluate the obstetric outcomes in pregnant women diagnosed of antiphospholipid syndrome, as well as examine the conditions which may influence in those results. MATERIALS AND METHODS: A retrospective study was undertaken with pregnant women diagnosed of APS, who were attended in our hospital between 2007 and 2017. RESULTS: During the period of study 35 patients with APS and a sum of 50 pregnancies were gathered. Heparin was used in all pregnancies and acetylsalicylic acid in 96%. Any adverse obstetric outcome occurred in 34% of the pregnancies in the study. The triple positivity of antiphospholipid antibodies was associated to higher percentage of premature deliveries. The lupus anticoagulant alone was not related to worse obstetric outcomes. CONCLUSIONS: Pregnancy in APS patients means a challenge, requiring a multidisciplinary management by Obstetricians and Rheumathologists. On the other hand, the antiphospholipid antibodies profile could help to recognize those patients at risk, in order to adequate treatment and improve obstetric results.

Update on thrombocytopenia in pregnancy / Atualização sobre trombocitopenia na gravidez

Abstract Thrombocytopenia, defined as platelet count < 150,000mm3, is frequently diagnosed by obstetricians since this parameter is included in routine surveillance during pregnancy, with an incidence of between 7 and 12%. Therefore, decisions regarding subsequent examination and management are primordial. While most of the cases are due to physiological changes, as gestational thrombocytopenia, other causes can be related to severe conditions that can lead to fetal or maternal death. Differentiating these conditions might be challenging: they can be pregnancy-specific (pre-eclampsia/ HELLP syndrome [hemolysis, elevated liver enzymes, low platelets]), or not (immune thrombocytopenia purpura, thrombotic thrombocytopenic purpura or hemolytic uremic syndrome). Understanding the mechanisms and recognition of symptoms and signs is essential to decide an adequate line of investigation. The severity of thrombocytopenia, its etiology and gestational age dictates different treatment regimens.

Resumo Trombocitopenia, definida como uma contagem de plaquetária < 150.000mm3, é frequentemente diagnosticada pelos obstetras, uma vez que este parâmetro está incluído na vigilância de rotina durante a gravidez, com uma incidência de entre 7 e 12%. Assim, decisões relativas à avaliação e orientação subsequentes são primordiais. Embora a maioria dos casos ocorra devido a alterações fisiológicas, como a trombocitopenia gestacional, outras causas podem estar relacionadas com condições graves que podem levar à morte fetal ou materna. Distinguir entre estas entidades pode ser desafiante: elas podem ser específicas da gravidez (pré-eclâmpsia/síndrome HELLP [hemolysis, elevated liver enzymes, low platelets]) ou não (púrpura trombocitopênica imune, púrpura trombocitopênica trombótica ou síndrome hemolítico urêmico). Compreender os mecanismos e reconhecer os sinais e sintomas é essencial para decidir uma adequada linha de investigação. A severidade da trombocitopenia, a sua etiologia e a idade gestacional ditam regimes de tratamento diferentes.

Thromboprophylaxis during the pregnancy-puerperal cycle - literature review / Tromboprofilaxia no ciclo gravídico-puerperal - revisão da literatura

Abstract Objective To identify current strategies and recommendations for venous thromboembolism prophylaxis associated with the pregnancy-puerperal cycle, a condition of high morbidity and mortality among women. Methods The literature search was performed between May and October 2019, using the PubMed database, including papers published in Portuguese, English and Spanish. The terms thromboembolism (Mesh) AND pregnancy (Mesh) OR postpartum (Mesh) were used as descriptors, including randomized controlled trials, meta-analyses, systematic reviews and guidelines published from 2009 to 2019, presenting strategies for prevention of thromboembolism during pregnancy and the postpartum. Results Eight articles met the inclusion criteria. Many studies evaluated were excluded because they did not address prevention strategies. We compiled the recommendations from the American Society of Hematologists, the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada, the American College of Chest Physicians and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Conclusion: There are some gaps in the research, and clinical studies with appropriate methodology are needed to support decisions made regarding the risk of thromboembolism in the perigestational period. Thus, the attention of the professionals involved in the care of pregnant and postpartum women is crucial, as it is a condition associated with high morbidity and mortality.

Resumo Objetivo Identificar as estratégias e recomendações atuais para profilaxia de tromboembolismo venoso associado ao ciclo gravídico-puerperal, condição de alta morbimortalidade entre mulheres. Métodos A busca na literatura ocorreu entre maio e outubro de 2019, com pesquisa na base de dados do PubMed, contemplando trabalhos publicados nos idiomas português, inglês e espanhol. Os termos thromboembolism (Mesh) AND pregnancy (Mesh) OR postpartum (Mesh) foram utilizados como descritores, incluindo ensaios clínicos randomizados, metanálises, revisões sistemáticas e diretrizes publicadas entre 2009 a 20019, apresentando estratégias de prevenção de tromboembolismo venoso durante a gravidez e o pós-parto. Resultados Oito artigos abordando estratégias de tromboprofilaxia primária e secundária durante a gestação, parto e puerpério foram selecionados para a presente revisão sistemática. Muitos estudos avaliados foram excluídos por não abordarem estratégias de prevenção. Foram compiladas as recomendações das seguintes sociedades: American Society of Hematologists, American College of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynecologists, Society of Obstetricians and Gynaecologists of Canada, American College of Chest Physicians e Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Conclusão Até o presente momento, há algumas lacunas e estudos clínicos com metodologia adequada se fazem necessários para respaldar a tomada de decisão frente ao risco de tromboembolismo venoso no período perigestacional. Torna-se fundamental a atenção dos profissionais envolvidos no atendimento às gestantes e puérperas, pois trata-se de uma condição associada a alta morbimortalidade.

Hemofilia adquirida / Acquired hemophilia

Resumen La hemofilia adquirida (HA) es un trastorno hemostático autoinmune ocasionado por autoanticuerpos dirigidos contra el factor VIII: C. En 52 % de los casos, la causa se desconoce o no se asocia con otra entidad patológica; en el resto, existen factores concomitantes: lupus, artritis reumatoide, cáncer, embarazo y medicamentos. En México no existe registro ni conciencia de la enfermedad entre el personal de salud. Los grupos de mayor incidencia son las mujeres en edad reproductiva y los individuos mayores de 70 años. Se caracteriza por hemorragia grave, sobre todo posterior a traumatismos y parto o cesárea, y equimosis grandes en tronco y extremidades. La sospecha es simple, basta que concurran hemorragia súbita, grave y un TTPa prolongado que no se corrige con plasma. El tratamiento consiste en lograr la hemostasia y erradicar el anticuerpo; lo primero se logra con el factor VII activado recombinante o concentrado del complejo de protrombínico activado. La ciclofosfamida, prednisona o rituximab sirven para erradicar el anticuerpo. La mayoría de los casos no son diagnosticados y la mortalidad es alta. Ya que los médicos desconocen el problema, no se sospecha, no se diagnostica y no se trata. Este documento revisa los datos más recientes de la HA y abunda en el diagnóstico y tratamiento.

Abstract Acquired hemophilia (AH) is an autoimmune hemostatic disorder mediated by autoantibodies directed against factor VIII: C. In 52% of cases, the cause is unknown or is not associated with other pathological entities; in the rest, there are concomitant factors: lupus, rheumatoid arthritis, cancer, pregnancy, and medications. In Mexico, there is not a registry of AH, and awareness of the disease among health personnel is low. The groups with the highest incidence are women of childbearing age and individuals older than 70 years. It is characterized by severe bleeding, especially after trauma and normal childbirth or cesarean delivery, and large ecchymoses in the trunk and extremities. The suspicion is simple, it just takes for sudden, severe hemorrhage and a prolonged activated partial thromboplastin time that is not corrected with plasma to concur in an individual. Treatment involves achieving hemostasis and eradicating the antibody. The former is achieved with recombinant activated factor VII or activated prothrombin complex concentrate. Cyclophosphamide, prednisone or rituximab are used to eradicate the antibody. Most cases of AH are not diagnosed, which translates into a high mortality rate. Given that awareness about the disease among physicians is low, it is not suspected, neither diagnosed, and nor is it treated. This document reviews the most recent data on AH and expands on its diagnosis and treatment.

Forced international migration for refugee food: a scoping review / Migração internacional forçada e alimentação de refugiados: uma scoping review

Abstract Recent crisis and conflicts in African countries, the Middle East and the Americas have led to forced population migration and rekindled concern about food security. This article aims to map in the scientific literature the implications of forced migration on food and nutrition of refugees. Scoping Review, and database search: databases: PubMed Central, LILACS, SciElo, Science Direct and MEDLINE. Languages used in the survey were: English, Portuguese and Spanish, with publication year from 2013 to 2018. 173 articles were obtained and after removing of duplicates and full reading, 26 articles were selected and submitted to critical reading by two reviewers, resulting in 18 articles selected. From the analysis of the resulting articles, the following categories emerged: Food Inequity; Cultural Adaptation and Nutrition; Emerging Diseases and Strategies for the Promotion of Nutritional Health. Food insecurity is a marked consequence of forced international migration, and constitutes an emerging global public health problem, since concomitant with increasing population displacements also widens the range of chronic and nutritional diseases.

Resumo As recentes crises e conflitos em países Africanos, no Oriente Médio e Américas têm originado migração forçada de populações e reacende a preocupação com os cuidados com a alimentação. O objetivo deste artigo é mapear na literatura científica as implicações da migração forçada sobre a alimentação e nutrição de refugiados. Scoping Review, com buscas nas bases de dados: bases de dados: PubMed Central, LILACS, SciElo, Science Direct e MEDLINE. Os idiomas de pesquisa foram: Inglês, Português e Espanhol, e ano de publicação compreendido entre 2013 e 2018. Obteve-se 173 artigos e após remoção dos duplicados e leitura integral, 26 artigos foram selecionados e submetidos à leitura crítica por dois revisores independentes, resultando em 18 artigos selecionados. Da análise dos resultados dos artigos, emergiram as categorias: Iniquidade Alimentar; Adaptação Cultural e Nutrição; Doenças Emergentes e Estratégias de Promoção da Saúde Nutricional. A insegurança alimentar é consequência marcante da imigração internacional forçada, e se constitui um emergente problema de saúde pública global, pois concomitante aos crescentes deslocamentos populacionais também se ampliam a gama de doenças crônicas e nutricionais.

Manejo de una paciente embarazada con déficit congénito de factor VII leve / Management of a pregnant patient with mild factor VII congenital deficiency

RESUMEN No hay guías específicas para el manejo de pacientes embarazadas con la deficiencia de Factor VII; no hay una correlación entre el nivel de FVII y el riesgo de hemorragia y el nivel del Factor VII aumento durante el embarazo. Presentamos un caso clínico, el manejo y las recomendaciones del consenso.

Evaluation of Thalassaemia Screening Tests in the Antenatal and Non-Antenatal Populations in Singapore

INTRODUCTION@#Haemoglobinopathy testing is performed for carrier screening and evaluation of microcytic anaemia. We evaluated the effectiveness of thalassaemia screening tests at our institution and suggest ways of improving the testing algorithm.@*MATERIALS AND METHODS@#A total of 10,084 non-antenatal and 11,364 antenatal samples with alkaline gel electrophoresis (AGE), capillary electrophoresis (CE), haemoglobin H (HbH) inclusion test, mean corpuscular haemoglobin (MCH) and mean corpuscular volume (MCV) were retrospectively reviewed. A subgroup of 187 samples with genetic testing was correlated with HbH inclusions and MCH/ MCV. The effect of iron deficiency on percentage hemoglobin A2 (HbA2) was studied.@*RESULTS@#HbH inclusion test showed low sensitivity of 21.43% for α-thalassaemia mutations but higher sensitivity of 78.95% for deletion. By receiver operating characteristic (ROC) analysis, MCH ≤28 pg or MCV ≤80 fl for non-antenatal samples and MCH ≤27 pg or MCV ≤81 fl for antenatal samples had >98% sensitivity for HbH inclusions. Above these thresholds, the probability that HbH inclusions would be absent was 99%). MCH ≥28 pg had 100% sensitivity (95% CI 95.63%-100%) for α-thalassaemia mutations and 97.68% calculated NPV in the antenatal population. Detection of haemoglobin variants by CE correlated highly with AGE (99.89% sensitivity, 100% specificity). Severe iron deficiency reduced HbA2 in hemoglobin ( <0.001) and α-thalassaemia ( = 0.0035), but not in β-thalassaemia.@*CONCLUSION@#MCH/MCV thresholds have adequate sensitivity for α-thalassaemia in the antenatal population, and genotyping plays an important role as HbH inclusion test shows low sensitivity. CE without AGE, may be used as initial screening for haemoglobin variants. Our study provides contemporary data to guide thalassaemia screening algorithms in Singapore.

Anemia de células falciformes y embarazo. Reporte de caso / Sickle cell anemia and pregnancy: a clinical case report / Anemia falciforme e gravidez: relato de caso clínico

La anemia de células falciformes (ACF) es una patología con altos índices de complicaciones; además, cuando se presenta durante el embarazo su manejo se convierte en un desafío médico debido al riesgo elevado de morbimortalidad materna y perinatal. A continuación, se hace una breve revisión de la literatura sobre ACF y se describe un reporte de caso presentado en el Hospital Universitario Clíni-ca San Rafael de Bogotá, Colombia, en el año 2018. La paciente era una primigestante en tercer trimestre del embarazo con diagnóstico de ACF que se complicó con una preeclampsia con características de severidad y concluyó en parto pretérmino.El objetivo de publicar este caso es revisar la información respecto a la in-cidencia y la morbimortalidad materna y perinatal de la ACF, teniendo en cuenta que debe ser manejada por un equipo multidisciplinario y que se debe hacer detección temprana de complicaciones con el fin de mejorar el pronóstico del binomio madre-hijo.

Sickle cell anemia (SCA) is a pathology with high rates of com-plications, when presented in pregnancy it is a medical cha-llenge to manage patients due to the high risk of maternal and perinatal morbidity-mortality, case report and review of litera-ture presented at the Hospital Universitario Clínica San Rafael de Bogotá (National Clinic) in 2018, a women in the third tri-mester of pregnancy with diagnosis of sickle cell anemia that is complicated with preeclampsia with characteristics of severity and preterm delivery.The objective of publishing this case is to review the informa-tion regarding the incidence, the maternal and perinatal mor-bidity / mortality of this medical condition, its management by a multidisciplinary team and the early detection of com-plications in order to improve the prognosis of the mother-child binomial.

A anemia falciforme (ACF) é uma patologia com altas taxas de complicações; quando ocorre na gravidez, é um desafio médi-co para gerenciar pacientes devido ao alto risco de morbidade materna e perinatal. Apresenta-se o relato de caso e revisão de literatura apresentada no Hospital Universitário Clínico San Rafael de Bogotá (Clínica Nacional) em 2018, primigestante no terceiro trimestre de gravidez com diagnóstico de anemia fal-ciforme complicada pela pré-eclâmpsia com características de gravidade e parto prematuro.O objetivo da publicação deste caso é revisar as informações referentes à incidência, morbimortalidade materna e perinatal dessa condição médica, levando em consideração que ela de-ve ser gerenciada por uma equipe multidisciplinar e fazer a detecção precoce de complicações, a fim de melhorar o prog-nóstico binomial: mãe-filho.

Refractory severe thrombocytopenia during pregnancy: how to manage / Trombocitopenia grave refratária na gravidez: como abordar

Abstract Thrombocytopenia is the most common hemostatic change in pregnancy, but severe thrombocytopenia is rare. One of the causes, immune thrombocytopenic purpura (ITP), is characterized by increased platelet destruction by immunoglobulin G (IgG) antibodies, presenting a high risk of hemorrhage for the patient, but also for the fetus, since antibodiesmay cross the placenta.We present the case of a 23-year-old pregnant woman with a history of Langerhans cell histiocytosis of the mandible submitted to surgery and chemotherapy when she was 10 years old, with diagnosis of ITP since then. At 28 weeks of gestation, she presented with petechiae, epistaxis, and gingival bleeding, with a platelet count of 3 x 109/L and positive IgG antiplatelet antibodies test. At a multidisciplinary discussion, it was decided to delay a cesarean section, due to the absence of fetal distress and to the high risk of morbidity for the patient. Many therapies were attempted without success. The IgG produced a slight and transient increase in the platelet count. On the 36th week of gestation, an elective cesarean section was performed. The perioperative period transfusions were guided by rotational thromboelastometry (ROTEM) monitoring. The procedure was performed under general anesthesia and videolaryngoscopy-assisted intubation. The patient was hemodynamically stable, without significant bleeding, and was transferred to the intensive care unit. The platelet count eventually decreased and a splenectomy was performed. Regional anesthesia may be contraindicated, and general anesthesia is associated with an increased risk of airway hemorrhage due to traumatic injury during the tracheal intubation and of hemorrhage associated with the surgical procedure. A multidisciplinary approach is essential in high-risk cases.

Resumo A trombocitopenia é a alteração da hemostase mais comum na gravidez. Contudo, a trombocitopenia grave é rara. Uma das suas causas, a púrpura trombocitopênica imunológica (PTI), é caracterizada pelo aumento da destruição plaquetária por anticorpos de imunoglobulina G (IgG), apresentando alto risco de hemorragia para a paciente e também para o feto, uma vez que os anticorpos podem atravessar a placenta. Apresentamos o caso de uma grávida de 23 anos com histórico de histiocitose de células de Langerhans da mandíbula submetida a cirurgia e quimioterapia aos 10 anos de idade, com diagnóstico de PTI desde então. Na 28a semana de gestação, a paciente apresentou um quadro de petéquias, epistaxe e hemorragia gengival, com contagem plaquetária de 3 x 109/L e teste de anticorpos antiplaquetários IgG positivo. Em uma discussão multidisciplinar, decidiu-se adiar a cesariana devido à ausência de sofrimento fetal e ao alto risco de morbidade para a paciente. Muitas terapêuticas foram tentadas sem sucesso. A IgG produziu apenas um ligeiro e transitório aumento na contagem plaquetária. Na 36ª semana de gestação, foi realizada uma cesariana eletiva. As transfusões no período perioperatório foram guiadas por tromboelastometria rotacional (ROTEM). O procedimento foi realizado sob anestesia geral e intubação assistida por videolaringoscopia. A paciente manteve-se hemodinamicamente estável, sem hemorragia significativa. Ela foi transferida para a unidade de terapia intensiva. A contagem plaquetária continuou a diminuir, e a paciente foi submetida a uma esplenectomia. Nestes casos, a anestesia regional pode ser contraindicada, e a anestesia geral está associada a um risco aumentado de hemorragia das via aéreas devido a lesão traumática durante a intubação traqueal e de hemorragia associada ao procedimento cirúrgico. Uma abordagem multidisciplinar é essencial em casos de alto risco.

Aplasia medular adquirida y embarazo. caso clínico / Acquired aplastic anemia during pregnancy. report of one case

Aplastic anemia (AA) or acquired aplastic anemia is an uncommon and potentially fatal disease. It is defined as reduction of at least two peripheral blood series, associated with persistent bone marrow hypocellularity. It's association with pregnancy is even more uncommon, and it may result in high mortality for the mother and the child. We report an adolescent female with aplastic anemia, which worsened during pregnancy. Her hemoglobin was 5.2 g/dl, her leukocytes were 1,833/ul and her platelets were 19,000/ul. She was initially treated with cyclosporine and horse antithymocyte globulin without hematologic improvement. At 36 weeks of pregnancy methylprednisolone and platelet transfusions were used and a cesarean section was performed. Six month later she continues to require red blood cell and platelet transfusions.

Comparison in executive function in Chinese preterm and full-term infants at eight months / 医学前沿

Executive function (EF) is increasingly recognized as being responsible for adverse developmental outcomes in preterm-born infants. Several perinatal factors may lead to poor EF development in infancy, and the deficits in EF can be identified in infants as young as eight months. A prospective cohort study was designed to study the EF in Chinese preterm infants and examine the relationship between EF in preterm infants and maternal factors during perinatal period. A total of 88 preterm infants and 88 full-term infants were followed from birth to eight months (corrected age). Cup Task and Planning Test was applied to assess the EF of infants, and the Bayley Scale of Infant Development (BSID-III) was used to evaluate cognitive (MDI) and motor abilities (PDI) of infants. In comparison with full-term infants, the preterm infants performed more poorly on all measures of EF including working memory, inhibition to prepotent responses, inhibition to distraction, and planning, and the differences remained after controlling the MDI and PDI. Anemia and selenium deficiency in mothers during pregnancy contributed to the differences in EF performance. However, maternal depression, hypertension, and diabetes during pregnancy were not related to the EF deficits in preterm infants. Future research should focus on the prevention of anemia and selenium deficiency during pregnancy and whether supplementing selenium in mothers during pregnancy can prevent further deterioration and the development of adverse outcomes of their offspring.

Interpretation of the Guidance for Immune Thrombocytopenia-Review / 中国实验血液学杂志

Since the American Medical Association published the 2011 guidelines for immune thrombocytopenia, China has been the first to update the guidelines for immune thrombocytopenia based on evidence-based medicine. Recently, there have been many breakthroughs in clinical research published, especially the Chinese medical workers have made a prominent contribution to the treatment of the immune thrombocytopenia. However, the references of systematic drug introduction for children, adults, aged and pregnant women are still insufficient, and the first or second line treatment for some patients were ineffective. Therefore, we tried to combine the references to interpret the guidelines, to explore the advantages and disadvantages of each treatment, to find out the bottleneck of clinical treatment, so as to facilitate the implementation and understanding of the guidelines, then update the next guideline.