El recién nacido expuesto a cocaína antenatal: una propuesta de intervención médica y psicosocial integrada / The newborn exposed to antenatal cocaine: a proposal for integrated medical and psychosocial intervention

Introducción: El consumo de cocaína durante la gestación gatilla isquemia, muerte y licuefacción celular en el cerebro fetal, consolidando en la infancia grados variables de retraso mental. El presente estudio busca identificar mediante test de drogas en orina los recién nacidos (RN) expuestos a cocaína en el embarazo y describir el procedimiento clínico y social a seguir. Metodología: Estudio de cohorte prospectivo enero 2016 y enero 2018 en RN con exposición antenatal a cocaína, Unidad de Neonatología del Hospital Clínico San Borja Arriarán. Resultados: Se estudió a 64 RN con test en orina positivo a cocaína. El 42% fue pequeño para la edad gestacional, 33% tenía microcefalia. Se encontraron malformaciones en sistema nervioso y vías urinarias, trastornos del ritmo cardíaco e hipoacusia. Solo 32,8% de las madres controló su embarazo y 52% rechazó la rehabilitación. Servicio Social interpuso medidas de protección a los RN e instó a las madres a programas de rehabilitación. El 12,5% de los RN no tenía familia de apoyo y debió ser derivado a instituciones gubernamentales. Conclusiones: Las consecuencias de la exposición a cocaína antenatal en el RN son devastadoras. Este trabajo permite orientar la pesquisa, estudio y pasos legales a seguir con los RN afectados y sus madres.

Introduction: The consumption of cocaine during pregnancy triggers events such as ischemia, death and cell liquefaction in the fetal brain, consolidating varying degrees of intellectual disability. This study proposed to identify by urine drug test the newborns (NB) with antenatal exposure to and describe the clinical and social procedure to follow with them and their mothers until neonatal discharge. Methodology: Prospective cohort study, conducted in RN who met criteria for risk of antenatal exposure to cocaine, Neonatology Unit of the San Borja Arriaran Clinical Hospital between January 2016 -2018. Results: Antenatal exposure to cocaine was confirmed on 64 NB. Forty-two percent of them were small for gestational age and 33% had microcephaly. Malformations were found in the nervous system urinary tract, as well as disorders in the rhythm of the heart and loss of hearing. Only 32% of mothers controlled her pregnancy, none of them was derived to the secondary. Social Services implemented all the NB protective measures in place and urged mothers to participate in rehabilitation programs. Fifty-two percent rejected rehabilitation and 12.5% of the NB have not family support and had to be referred to government institutions. Conclusions: The consequences of exposure to antenatal cocaine in the NB are devastating. This work allows orienting the research with the NB and showing the legal steps should be taken with the RN and their mothers.

Efecto de la administración de ácido retinoico sobre el desarrollo del esqueleto axial en embriones de ratón Mus musculus / Effect of administration of retinoic acid on the development of the axial skeleton in mouse embryos Mus musculus

El déficit y exceso de vitamina A provoca malformaciones congénitas que afectan distintos órganos y sistemas. El objetivo de este estudio fue determinar el efecto que causa la administración de ácido retinoico a distintas dosis sobre la morfogénesis ósea del esqueleto axial en embriones de ratón Mus musculus. Mediante aleatorización simple se distribuyeron hembras recién preñadas en 4 categorías: A, B, C y D. El día 8 post fecundación (p.f), se administró 40 mg/kg de peso de ácido retinoico al grupo A, 20 mg/kg de peso de esta solución al grupo B, 1 ml/kg de peso de dimetil sulfóxido al grupo C, y el grupo D es grupo control. El día 17 de la gestación las hembras y sus fetos fueron anestesiadas y eutanasiadas con sobredosis de pentotal sódico intraperitoneal. Los fetos de cada camada fueron procesados mediante diafanización y tinción con azul de Alcian para destacar cartílago hialino y alizarina para observar tejido óseo. Los resultados se expresaron en porcentajes de malformaciones en los siguientes tres segmentos: 1) cráneo-columna cervical, 2) segmento torácico y abdominal y 3) cintura pélvica, considerándose un 100% cuando la totalidad de los elementos óseos se encontraban comprometidos. Se utilizó la prueba de Fisher para la comparación de frecuencias de malformaciones y se consideró estadísticamente significativo cuando p<0,05. En el grupo A se evidenciaron malformaciones mayores como ausencia de huesos frontales y parietales, exencefalia, defectos en el número de vértebras, y fusiones de costillas; y en el grupo B se observaron malformaciones menores como alteraciones numéricas y fusiones de costillas, existiendo diferencias significativas entre ambos grupos. En los grupos C y D no se consignaron malformaciones. El ácido retinoico administrado intraperitonealmente el dìa 8 p.f en dosis de 40 y 20 mg/kg de peso se comporta como un teratógeno en los embriones de ratón, existiendo además diferencias significativas entre las malformaciones generadas por ambas dosis de ácido retinoico. La primera concentración afecta los huesos de los tres segmentos estudiados (cráneo-cervical, toracoabdominal, y pélvico) y la segunda concentración sólo afecta a dos segmentos (cráneo-cervical y toracoabdominal). Ambos tratamientos afectan los segmentos en una gradiente céfalo caudal, independiente del origen embrionario de las estructuras. Esto se debería a que los cambios en las gradientes de ácido retinoico alteran el comportamiento de células de la cresta neural craneal y el orden de la expresión de genes Hox.

The deficit and excess of vitamin A causes birth defects affecting different organ systems. The objectives of this study are to determine the effect caused by the administration of different doses of retinoic acid on bone morphogenesis of the axial skeleton in embryonic mouse Mus musculus. By simple randomization newly pregnant females were distributed into 4 categories: A, B, C and D. On day 8 post fertilization, 40 mg/kg was administered by weight of retinoic acid to the group A, 20 mg/kg body weight of the group B solution 1 ml/kg body weight of dimethyl sulfoxide and group C. Group D is the control group. On day 17 of gestation the females and their fetuses were anesthetized and euthanized with an overdose of intraperitoneal sodium pentothal. Fetuses from each litter were processed using diaphanization and Alcian blue staining to hyaline cartilage and alizarin to observe bone tissue. The results are expressed as percentages of malformations in the following three segments: 1) cranio-cervical spine, 2) thoracic and abdominal segment and 3) pelvic segment, considering 100% when all the bony elements were compromised. Fisher's exact test for comparison of frequencies of malformations was used and considered statistically significant when p<0.05. In group A, major malformations and defects were evident in the indemnity of the cranial vault, exencephaly, defects in the number of vertebrae, and fusion of ribs. In group B minor malformations as numerical alterations and rib fusions were observed. Significant differences were found between both groups. In groups C and D no malformations were recorded. Retinoic acid administered intraperitoneally at doses of 40 and 20 mg/kg acts as a teratogen in mouse embryos. There are significant differences between the defects induced by concentrations of 40 mg/k and 20 mg/k of retinoic acid. Both concentrations affect the bones of the three segments studied (cranio cervical, thoraco-abdominal and pelvic) in a cephalo caudal gradient, independent of the embryonic origin of the structures. Changes in retinoic acid concentration alter the behavior of cranial neural crest and changing the order of the HOX gene expression in the axial skeleton.

Embriopatía por isotretinoína con microtia-anotia y cardiopatía: Presentación de un caso / Isotretinoin embryopathy with microtia-anotia and congenital heart disease: Case report

La isotretinoína es un retinoide derivado de la vitamina A utilizado para el tratamiento del acné noduloquístico y refractario, pero ha sido catalogado como un medicamento teratogénico. Se ha comunicado un espectro de defectos congénitos que incluyen malformaciones craneofaciales, defectos cardíacos y defectos en el sistema nervioso con la exposición prenatal a este medicamento. Se presenta el caso de una recién nacida con antecedente de exposición prenatal a isotretinoína con defectos congénitos craneofaciales que incluyen parálisis facial, anotia derecha y microtia izquierda, y cardiopatía compleja.

Isotretinoin is a retinoid that derivates from vitamin A. It is indicated for recalcitrant nodular acne treatment, but it has been classifed as teratogenic. A wide spectrum of birth defects including craniofacial, heart and nervous system malformations have been described associated to prenatal exposure to this drug. We report the case of a newborn with a history of prenatal exposure to isotretinoin with craniofacial defects, including facial paralysis, right anotia, left microtia and complex heart disease.

Fibular dimelia and mirror polydactyly of the foot in a girl presenting additional features of the VACTERL association / Dimelia fibular e polidactilia em espelho do pé em uma menina apresentando achados adicionais de associação VACTERL

CONTEXT: The association between fibular dimelia and mirror polydactyly of the foot is considered to be a very rare lower-limb abnormality. On the other hand, VACTERL is an acronym for a nonrandom association of congenital anomalies for which the etiology is still poorly understood. CASE REPORT: The patient was a seven-month-old white girl whose mother had used misoprostol in the second month of pregnancy to induce abortion. On clinical evaluation, she was small for her age and presented hypotonia, anteverted nares, long philtrum and carp-like mouth. Her left hand had a reduction defect, with absence of the extremities of the second, third and fifth fingers and camptodactyly of the fourth finger. The ipsilateral lower limb presented significant shortening, especially rhizomelic shortening. Her left foot had a mirror configuration with seven toes and no identifiable hallux. The pelvis was hypoplastic. Esophageal atresia with tracheoesophageal fistula and imperforate anus were detected during the neonatal period. Abdominal ultrasound identified agenesis of the right kidney and left pyelocaliceal duplication. Radiographic evaluation on the left side showed iliac and femoral hypoplasia, absence of the tibia with a duplicated fibula and seven metatarsals and toes with no identifiable hallux on the foot. Echocardiography demonstrated an atrial septal defect. Based on the literature, we believe that the spectrum of malformations presented by our patient may be related to the vascular disruptive effect of the misoprostol. However, we cannot rule out the possibility that this association might simply be a coincidence.

CONTEXTO: A associação entre dimelia fibular e polidactilia em espelho do pé é considerada uma anormalidade de membro inferior bastante rara. Por outro lado, VACTERL é um acrônimo para uma associação não aleatória de anomalias congênitas cuja etiologia ainda é pouco compreendida. RELATO DO CASO: A paciente era uma menina branca de sete meses de idade, cuja mãe utilizou misoprostol no segundo mês de gravidez para indução de aborto. Na avaliação clínica, ela era pequena para a idade e apresentava hipotonia, narinas antevertidas, filtro longo e boca em carpa. A mão esquerda apresentava um defeito de redução com ausência das extremidades do segundo, terceiro e quinto dedos e camptodactilia do quarto. O membro inferior ipsilateral apresentava um importante encurtamento, especialmente rizomélico. O pé possuía uma configuração em espelho com sete dedos e nenhum hálux identificável. A pelve era hipoplásica. Atresia de esôfago com fístula traqueoesofágica e imperfuração anal foram detectadas durante o período neonatal. O ultrassom abdominal identificou agenesia do rim direito e duplicidade pielocalicial à esquerda. A avaliação radiográfica mostrou, no lado esquerdo, hipoplasia do osso ilíaco e do fêmur, ausência da tíbia com duplicação da fíbula, e presença de sete metatarsos e dedos, sem um hálux identificável, no pé. A ecocardiografia identificou um defeito do septo atrial. Acreditamos, com base na literatura, que o espectro de anormalidades apresentado por nossa paciente possa estar relacionado com o efeito disruptivo vascular do misoprostol. Entretanto, não podemos excluir a possibilidade de que essa associação possa ter sido simplesmente uma coincidência.

Pentalogía de Cantrell en un recién nacido expuesto en útero a misoprostol / Pentalogy of Cantrell in a newborn associated with prenatal exposure to misoprostol

El misoprostol es un análogo sintético de la prostaglandina E1 y es usada por sus efectos utero-tónicos como abortivo. En los países donde se utiliza como abortivo sin éxito durante el primer trimestre de gestación, se han informado un espectro de malformaciones congenitas asociadas con la exposición prenatal, que incluyen el síndrome de Moebius, defectos de la pared abdominal, artrogriposis y anomalías por reducción de los miembros, entre otros. La pentalogía de Cantrell (PC), con una prevalencia de 1 en 65.000 nacidos vivos, es un síndrome polimalformativo que consta de 5 anomalías: un defecto de la pared abdominal, defecto esternal inferior, defecto del diafragma anterior, defecto pericárdico diafragmático y anormalidades congenitas del corazón. Se reporta un caso de pentalogía de Cantrell asociado al uso de misoprostol en el primer trimestre de la gestación, siendo este reporte el primer registro de esta asociación.

Misoprostol is a synthetic analogue of prostaglandin E1 and is used for effects such as uterotonic aborti-facient. In countries where abortion is used as unsuccessful in the first trimester of gestation, reported a spectrum of congenital malformations associated with prenatal exposure, which include Moebius syndrome, abdominal wall defects, and anomalies as artrogriposis reduction members, among others. The pentalogy of Cantrell with a prevalence of 1 in 65,000 live births, is a syndrome consisting of 5 abnormalities: a defect in the abdominal wall, lower sternal defect, defect above the diaphragm, diaphragmatic pericardial defect, and congenital abnormalities of the heart. We report a case of Pentalogy of Cantrell associated with the use of misoprostol in the first trimester of pregnancy, this report is the first record of this association.

Embriopatía por isotretinoína: Un daño evitable / Isotretinoin embryophaty: Report of one case

Retinoic acid is a widely used drug in the treatment of cystic acné. It has teratogenic effects that depend on the gestational period in which it is used. We report a seven months of female whose mother was exposed to retinoic acid in both pregestational and gestational periods. She had a retardation of psychomotor development and a brain MRI showed frontal atrophy and a malformation of the posterior fossa. We discuss the mechanisms ofthe teratogenic effeets of retinoic acid.

Teratogenic effect of retinoic acid in swiss mice

PURPOSE: To identify the types of malformations resulting from the administration of retinoic acid (RA) to Swiss mice on different days of pregnancy. METHODS: Twenty-four pregnant Swiss mice were divided into 4 groups of 6 animals each. The experimental groups received a single intraperitoneal injection of RA (70 mg/kg) on gestational days 7, 8 and 9 (D7, D8 and D9), while control animals (C) received only saline solution. RESULTS: Were obtained: exencephaly (C:0; D7:16.1 percent; D8:25.4 percent; D9:0), myelomeningocele (C:0; D7:25.8 percent, D8:30.9 percent, D9:0), spina bifida occulta (C:0, D7:29 percent, D8:41.8 percent, D90), gastroschisis (C:0, D7:6.4 percent D8:5.4 percent, D9:0), omphalocele (C:0, D7:6.4 percent, D8:14.5 percent, D9:0), lower limb alterations (C:0, D7:74.1 percent, D8:80 percent, D9:0), imperforated anus (C:0, D7:100 percent, D8:100 percent, D9:100 percent), and tail agenesis/alteration (C: D7:100 percent, D8:100 percent, D9:100 percent). CONCLUSION: The experimental model using Swiss mice proved to be efficient in the induction of the different types of defects, with the eighth gestational day being the one that most favored the induction of neural tube defect, omphalocele, gastroschisis, lower limb defects, imperforated anus and tail agenesis/alteration. On this basis, this is a useful model for future investigation of neural development and of the formation of the appendicular skeleton.

OBJETIVO: Identificar os tipos de malformação resultantes da administração do ácido retinóico (AR) a camundongos Swiss em diferentes dias gestacionais. MÉTODOS: Foram utilizados 24 camundongos fêmeas, linhagem Swiss, prenhes, divididos em 4 grupos com 6 animais cada. Os grupos experimentais receberam uma única injeção intraperitoneal de AR (70mg/Kg) nos dias gestacionais 7, 8 e 9 (D7, D8 e D9), enquanto que os animais do grupo controle (C) receberam apenas solução salina. RESULTADOS: Foram encontrados: exencefalia (C:0; D7:16.1 por cento; D8:25.4 por cento; D9:0); mielomeningocele (C:0; D7:25.8 por cento; D8:30.9 por cento; D9:0); Espina Bífida Oculta (C:0; D7:29 por cento; D8:41.8 por cento; D90); gastrosquise (C:0; D7:6.4 por cento D8:5.4 por cento; D9:0); onfalocele (C:0; D7:6.4 por cento; D8:14.5 por cento; D9:0); alterações do membro inferior (C:0; D7:74.1 por cento; D8:80 por cento; D9:0); imperfuração anal (C:0; D7:100 por cento; D8:100 por cento; D9:100 por cento) e agenesia/alteração de cauda (C: D7:100 por cento; D8:100 por cento; D9:100 por cento). CONCLUSÕES: O modelo experimental utilizando camundongo Swiss mostrou-se eficiente na indução dos diferentes tipos de defeitos, sendo o oitavo dia gestacional o mais propicio na indução de DFTN, onfalocele, gastrosquise, defeitos de membro inferior, imperfuração anal e agenesia/alteração de cauda, tornando este um modelo útil para futuras investigações do desenvolvimento neural e no processo de formação do esqueleto apendicular.

A case of prenatal diagnosis of fetal hydantoin syndrome by ultrasound

Fetal hydantoin syndrome (FHS) is a set of disruptions occasionally present in fetuses exposed in utero to phenytoin or other anticonvulsants. Administration of phenytoin in early pregnancy may impair proper psychomotor performance expected for children's development. Several combined phenotypic markers delineate the syndrome, but the presence of single clinical signs is more common. There is controversy about the etiology of FHS. Associated disruptions may be related to a deficiency in a detoxifying enzyme (epoxide hydrolase), vascular problems, and/or factors not yet known. Genetic causes are believed to influence susceptibility to the drug. This text reports an unusual pattern of malformations detected in an ultrasound scan (gastroschisis, sacral meningomyelocele, and absence of the right lower limb) and in the anatomopathological study (left-side gastroschisis, sacral meningomyelocele, scoliosis, left clubfoot, absence of the right lower limb, and pectus carinatum) of a fetus whose mother took phenytoin. These defects may have been provoked by exposure to the drug during embryogenesis. In view of similar malformations observed in cases of prenatal exposure to cocaine, a recognized vasoconstrictor, it is suggested that vascular disruptions of hemodynamic origin constituted the event leading to some of the anomalies caused in the developing embryo. A complication of the chorionic villus sampling procedure, used for cytogenetic analysis, is another possibility.

Características oftalmológicas asociadas al síndrome alcohólico fetal / Ophtalmological features associated to the fetal alcohol syndrome

El síndrome alcohólico fetal es una condición dismórfica asociada al alcoholismo gestacional. Los rasgos clínicos se relacionaron con la sensibilidad tisular, dosis y duración de la exposición. Estudios actuales indican la frecuencia de esta entidad de 1 a 2 neonatos por cada 1000 nacimientos vivos. La alteraciones asociadas con la teratogenicidad alcohólica puede ser agrupadas en 4 categorías: disfunción específica del sistema nervioso central, deficiencias en el desarrollo, anormalidades faciales y malformaciones diversas de aparatos y sistemas. Las características oculares asociadas con frecuencia son ptosis uni o bilateral, estrabismo y miopía alta. En el segmento anterior es posible encontrar microcórnea, cámara anterior estrecha, glaucoma congénito, catarata y persistencia de la arteria hialoidea y en el fondo de ojo, hipoplasia de papila e incremento de la toruosidad arteriovenosa retiniana. Esta condición no ha sido documentada en la población mexicana, siendo el objetivo del presente trabajo resumir la experiencia existente de la teratogénesis ocular por alcohol con objeto de ayudar en el reconocimiento temprano de los neonatos afectados y facilitar el consejo familiar de los mismos