Ductus venosus as a marker of fetal growth in first trimester in a population of Colombian pregnant women / Ductus venoso como marcador de crecimiento fetal en primer trimestre en una población de gestantes colombianas

Abstract Objectives: to evaluate the relationship between the ductus venosus (DV) and the variables of fetal growth in the first trimester in a Colombian pregnant population. Methods: a descriptive cross-sectional study was carried out with secondary data obtained from a multicenter study.526 patients were included between weeks 11 and 14 for gestational ultrasound follow-up attended in three health care institutions in Bogotá, Colombia, between May 2014 and October 2018. A bivariate descriptive analysis was carried out where the relationship between the characteristics of the DV in the first trimester and ultrasound findings. Results: the flow wave of the DV in the first trimester was normal in the entire sample, with a pulsatility index of the ductus venosus (DVPI) of 0.96±0.18. In addition, a negative correlation was found between the crown-rump length (CRL) and the DVPI (p<0.05). Conclusion: there is a relationship between the DVPI regarding the CRL, indicating an interest in this early marker in relation to fetal growth alterations; however, more studies are required to determine the usefulness of this variable with respect to fetal growth.

Resumen Objetivos: evaluar la relación entre el ductus venoso (DV) y las variables del crecimiento fetal en primer trimestre en una población de gestantes colombianas. Métodos: se realizó un estudio transversal descriptivo con datos secundarios obtenidos de un estudio multicéntrico. Se incluyeron 526 pacientes entre las semanas 11 a 14 para seguimiento ecográfico gestacional atendidas en tres instituciones prestadoras de salud en Bogotá, Colombia, entre mayo del 2014 y octubre del 2018. Se realizó un análisis descriptivo bivariado donde se evaluó la relación entre las características del DV en primer trimestre y los hallazgos ecográficos. Resultados: la onda de flujo del DV en primer trimestre fue normal en la totalidad de la muestra, con un índice medio de pulsatilidad del ductus venoso (IPDV) de 0,96±0.18. Se encontró una correlación negativa entre la longitud cefalocaudal (LCC) y el IPDV (p<0.05). Conclusión: existe una relación entre el IPDV respecto a la LCC, señalando un interés de este marcador temprano en relación con las alteraciones del crecimiento fetal, sin embargo, se requieren más estudios para determinar la utilidad entre esta variable respecto al crecimiento fetal

Doppler Ultrasound of the Umbilical Artery: Clinical Application / Ultrassonografia Doppler da artéria umbilical: Aplicação clínica

Abstract Objective To provide a survey of relevant literature on umbilical artery Doppler ultrasound use in clinical practice, technical considerations and limitations, and future perspectives. Methods Literature searches were conducted in PubMed and Medline, restricted to articles written in English. Additionally, the references of all analyzed studies were searched to obtain necessary information. Results The use of this technique as a routine surveillance method is only recommended for high-risk pregnancies with impaired placentation. Meta-analyses of randomized trials have established that obstetric management guided by umbilical artery Doppler findings can improve perinatal mortality and morbidity. The values of the indices of Umbilical artery Doppler decrease with advancing gestational age; however, a lack of consensus on reference ranges prevails. Conclusion Important clinical decisions are based on the information obtained with umbilical artery Doppler ultrasound. Future efforts in research are imperative to overcome the current limitations of the technique.

Resumo Objetivo Compilar informação relevante proveniente da literatura atual sobre a ultrassonografia Doppler das artérias umbilicais (AUs) na prática clínica, considerações e limitações técnicas e perspectivas futuras. Métodos A pesquisa bibliográfica foi realizada nos bancos de dados PubMed e Medline e restringiu-se a artigos escritos na língua inglesa. Recorreu-se também à bibliografia dos artigos selecionados, quando necessário, para obter informação relevante. Resultados A utilização desta técnica como método de vigilância de rotina está apenas recomendada emgravidezes de alto risco comdisfunção placentar.Metanálises de estudos randomizados mostraram que o seguimento obstétrico baseado nos achados do Doppler da artéria umbilical pode melhorar a mortalidade e a morbilidade perinatal. É consensual que os valores dos índices Doppler da AU decrescem com o avanço da idade gestacional. No entanto, há ainda muita incerteza quanto aos valores de referência. Conclusão As informações obtidas através da AU Doppler US são a base para muitas decisões clínicas importantes. Trabalhos de investigação nesta área são essenciais para tentar colmatar atuais limitações da técnica.

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

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

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

A história obstétrica de gestantes com trombofilias hereditárias / Obstetric history of pregnant women with hereditary thrombophilias

Introdução: A doença tromboembólica venosa e as complicações obstétricas resultantes do tromboembolismo placentário são as principais causas de morbidade e mortalidade materna e fetal. Pode-se dizer que a gravidez é um fator independente para o desenvolvimento de trombose, já que seu risco é de 5 a 6 vezes maior em mulheres grávidas quando comparadas a não grávidas, sendo mais elevado após o parto. Métodos: Trata-se de uma coorte histórica, onde foram estudadas pacientes atendidas no Serviço de Obstetrícia da Universidade Federal de Juiz de Fora (expostos=n=70 pacientes) e na Faculdade de Medicina de Barbacena (não expostos=n=74 pacientes). As pacientes foram divididas em dois grupos: Grupo 1 = pacientes com alguma trombofilia identificada (expostos) através das dosagens de proteína S, proteína C, homocisteína, antitrombina III, mutação da MTHFR, mutação da protrombina e do fator V de Leiden; e Grupo 2 = pacientes do serviço de baixo risco obstétrico. Resultados: Houve associação entre trombofilia e aborto prévio, bem como trombofilia e morte fetal prévia (p<0,05). O tipo de trombofilia que foi associada a abortamento prévio foi o déficit da proteína S. A mutação da MTHFR foi associada aos antecedentes de HELLP síndrome (p=0,03; x2 =4,2) e de pré-eclâmpsia (p=0,03; X2 =4,5) quando em homozigotia mutante. A homozigotia para a MTHFR foi também associada às médias de homocisteína, de forma que as homozigotas eram aquelas que apresentavam a maior dosagem de homocisteína (p=0,01; X2 =5,8; X= 27,2 ± 41,2 vs. 12,62 ± 19,0). Conclusão: As trombofilias hereditárias podem estar associadas a mau desfecho obstétrico e devem ser valorizadas na clínica obstétrica. (AU)

Introduction: Venous thromboembolic disease and obstetric complications resulting from placental thromboembolism are the main causes of maternal and fetal morbidity and mortality. Pregnancy is considered an independent factor for the development of thrombosis, as its risk is 5 to 6 times greater in pregnant women when compared to non-pregnant women, being even higher after childbirth. Methods: This historical cohort included patients seen at the Obstetrics Service of Federal University of Juiz de Fora (exposed patients, n = 70) and at the School of Medicine of Barbacena (unexposed patients, n = 74). The patients were divided into two groups: Group 1 consisted of patients with some thrombophilia identified through measurement of protein S, protein C, homocysteine, antithrombin III, MTHFR mutation, prothrombin and factor V Leiden mutations; and Group 2 consisted of patients from the low obstetric risk service. Results: There was an association between thrombophilia and previous abortion, as well as thrombophilia and previous fetal death (p < 0.05). MTHFR mutation was associated with history of HELLP syndrome (p = 0.03; x2 = 4.2) and preeclampsia (p = 0.03; x2 = 4.5) when in homozygous mutation. Homozygous MTHFR was also associated with mean homocysteine levels, so that homozygotes were those with highest homocysteine levels (p = 0.01; x2 = 5.8; x = 27.2 ± 41.2 vs. 12.62 ± 19.0). Conclusions: Hereditary thrombophilias may be associated with poor obstetric outcome and should be valued at clinical obstetrics. (AU)

As consequências da restrição de crescimento intrauterino na estrutura e fluxo sanguíneo cerebral: uma revisão da literatura / The consequences of fetal growth restriction on brain structure and blood flow: a review

A Restrição de Crescimento Fetal (RCF) é definida como uma incapacidade do feto em alcançar seu potencial de crescimento, afeta 5-10% das gestações e está associada à alta morbimortalidade fetal e neonatal, principalmente a danos neurológicos. O objetivo dessa revisão foi levantar os estudos sobre a alteração cerebral nos fetos com RCF que possam estar relacionados aos danos neurológicos pós-natais já estabelecidos. Nesses fetos, há um crescimento desigual das estruturas cerebrais e reconhece-se que, na dependência de hipoxemia crônica e privação de nutrientes provocados pela insuficiência placentária, o feto tende a preferenciar o fluxo sanguíneo para o cérebro em detrimento de outros órgãos. Os resultados dessa revisão sugerem que o efeito protetor do aumento da perfusão sanguínea cerebral é diferente em cada estágio de deterioração fetal, propondo uma ordem hierárquica na proteção das diferentes funções/áreas cerebrais, e quanto mais severo esse acometimento, maiores mudanças estruturais cerebrais o feto apresentará.(AU)

Fetal growth restriction is defined as an inability of the fetus to reach its growth potential, affects 5-10% of pregnancies and is associated with high fetal and neonatal morbidity and mortality, mainly neurological damage. The aim of this review was to investigate brain alterations in fetus with fetal growth restriction that may be related to the already established postnatal neurological damage. In these fetus there is an uneven growth of the brain structures and it is recognized that in dependence on chronic hypoxemia and nutrient deprivation caused by placental insufficiency, the fetus tends to prefer the blood flow to the brain in detriment of other organs. The results of this review suggest that the protective effect of increased cerebral blood perfusion is different at each stage of fetal deterioration, proposing a hierarchical order in the protection of the different brain functions / areas and more severe this involvement, bigger structural changes the fetus will present.(AU)

¿Se relaciona la obesidad en el embarazo con muerte fetal por insuficiencia placentaria? / Is obesity in pregnancy related to fetal death due to placental insufficiency?

Se presentan 4 casos de muerte fetal en pacientes obesas con embarazos de término, con hallazgos placentarios variados, que sugieren insuficiencia placentaria, que podrían estar asociados a la obesidad. Esta afirmación se basa en evidencias recientes que demuestran que la obesidad por intermedio de la disminución de los mediadores como apelina, leptina, reguladores del tono vascular placentario y de otros reguladores de la angiogénesis, alteran la función placentaria especialmente en embarazos de término y podrían estar implicados con inadecuado crecimiento fetal y con resultados adversos asociados con la obesidad. Comunicamos un mecanismo inusualmente descrito relacionado posiblemente con la obesidad y con resultado desfavorable del embarazo.

We present 4 cases of fetal death in obese pregnant women with term pregnancies, with several placental findings suggesting placental insufficiency, that could be associated with obesity. According to recent evidence obesity could be associated with inadequate fetal growth and adverse outcomes especially at term pregnancies, through the decrease of mediators such as apelin, leptin, regulators of placental vascular tone and other regulators of angiogenesis altering placental function. We report a rarely described mechanism possibly related to obesity and unfavorable outcome of pregnancy.

The Evaluation and Management of Fetal Growth Restriction

Fetal growth restriction (FGR) occurs due to various reasons and is associated with increased fetal and neonatal mortality and morbidity. FGR has been defined as having birth weight less than the 10th centile. The first clinically relevant step is the detection of true FGR, pathological small fetuses, associated with signs of abnormal placental insufficiency and poorer perinatal outcome. The role of obstetric management is to identify growth restricted fetuses at risk of chronic hypoxia in uterus, to monitor their wellbeing, and to deliver when the adverse outcome is imminent. The purpose of this document is to review the FGR with diagnosis, antenatal surveillance tools, and guidance for management and timing of delivery.

Anesthetic Management for Caesarean Section in a Patient with Impetigo Herpetiformis

Impetigo herpetiformis (IH) is an extremely rare pustular disorder and potentially life-threatening condition for both mother and fetus. Intrauterine growth retardation, fetal abnormalities, and even fetal/neonatal death can occur with worsening maternal disease and are probably related to placental insufficiency. Maternal risk is linked to fluid and electrolyte abnormalities, in particular, hypocalcemia- induced convulsions and sepsis. Therefore, early recognition is crucial to reduce both maternal and fetal morbidities, and a patient with IH may require emergency caesarean delivery. Here, we report a case of a 34-year-old pregnant woman with IH who underwent successful urgent general anesthesia for caesarean section.

Fetal growth according to different reference ranges in twin pregnancies with placental insufficiency

The aim of this study was to compare different fetal growth curves in twin pregnancies with severe placental insufficiency. A retrospective cross-sectional analysis of 47 twin pregnancies with absent or reverse end diastolic flow in the umbilical artery of one fetus was performed. Pregnancies with major fetal abnormalities, twin-twin transfusion or three or more fetuses were not included. The estimated fetal weight zeta-scores were calculated for both fetuses (abnormal Doppler and co-twin) according to the following criteria: Hadlock, Liao and Araújo. The abdominal circumference zeta-scores were calculated according to Hadlock, Liao, Araújo, Ong and Stirrup. The mean estimates of the zeta-score values were calculated using generalized estimating equation regression analysis. The mean gestational age at inclusion was 27.4±4.7 weeks. The fetal sex and the interaction Doppler findings × criteria correlated significantly with the zeta-score values (p <0.001 for both variables). The estimated fetal weight mean zeta-scores (standard error) according to each criteria were as follows: Hadlock - abnormal Doppler: -2.98 (0.18), co-twin: -1.16 (0.15); Liao - abnormal Doppler: -2.89 (0.24), co-twin: -0.58 (0.19); and Araújo - abnormal Doppler: -3.05 (0.29), co-twin: -0.75 (0.18). Values for abdominal circumference were as follows: Hadlock - abnormal Doppler: -3.14 (0.26), co-twin: -1.13 (0.19); Liao - abnormal Doppler: -2.63 (0.27), co-twin: -0.42 (0.19); Araújo - abnormal Doppler: -2.44 (0.22), co-twin: -0.71 (0.14); Ong - abnormal Doppler: -3.36 (0.34), co-twin: -1.48 (0.23); and Stirrup AD -- -2.36 (0.14), co-twin: -1.18 (0.10). Sex- and plurality-specific charts should be used in the evaluation of fetal growth in twin pregnancies with placental insufficiency.

Obstetrical Management of Gestational Diabetes Mellitus / 임상당뇨병

Gestational diabetes mellitus (GDM) is traditionally defined as newly onset or detected carbohydrate intolerance during pregnancy. Unprotected exposure to high glucose levels during pregnancy is related to adverse pregnancy outcomes including fetal demise and intrauterine growth restriction associated with placental insufficiency. The most common complications related to GDM comprise macrosomia, shoulder dystocia, brachial plexus palsy, intrauterine fetal death and preeclampsia, polyhydramnios, preterm delivery, and increased cesarean section rate. Moreover, GDM may increase the chance of GDM recurrence in a subsequent pregnancy, impaired glucose tolerance or type 2 DM, and obesity or impaired glucose tolerance in the offspring. Therefore, proper obstetrical management and glucose control are always challenging and important. The aim of this article is to discern: 1) obstetric complications related to GDM diagnosed after pregnancy, 2) various methods of fetal surveillance, 3) proper timing for delivery and mode of delivery, 4) postpartum management for GDM patients and neonates, and 5) preconceptional counseling prior to a possible subsequent pregnancy.

Flujo diastólico borrado o en reversa de la arteria umbilical fetal y su relación con la morbi-mortalidad perinatal / Diastolic deleted or reverse flow in the umbilical artery fetal and their relationship with perinatal morbidity and mortality

Introducción: El flujo diastólico borrado flujo diastólico reverso en las arterias umbilicales, se asocia con resultados perinatales adversos. Objetivo: Determinar el resultado perinatal, en fetos de madres con preeclampsia severa con flujo diastólico borrado y flujo diastólico reverso en la Maternidad “Concepción Palacios”, Caracas. Métodos: Estudio retrospectivo, descriptivo y correlacional. Se incluyeron 64 fetos, de embarazos entre 24-37 semanas en pacientes con preeclampsia severa La información se obtuvo mediante la revisión de historias médicas, para el análisis se registró la relación de la presencia de flujo diastólico borrado o flujo diastólico reverso y edad de gestación al diagnóstico, intervalo entre el diagnóstico e interrupción del embarazo, vía de interrupción, la edad de gestación al nacimiento, variables de pronóstico perinatal y de sobrevida neonatal. Resultados: Se identificaron 47 casos con flujo diastólico borrado y 17 con flujo diastólico reverso; hubo 46 nacidos vivos (71,8 %), y 18 óbitos (28,12 %). Los casos con flujo diastólico borrado se interrumpieron a las 32,66 semanas y los de flujo diastólico reverso a las 26,87 semanas; el peso al nacer fue de 1 333,3 vs 670,55 g respectivamente. La frecuencia de cesárea fue de 78,12 %, con 98 % de ingreso a terapia neonatal. De los 45 recién nacidos vivos que requirieron ingreso a la unidad de terapia intensiva neonatal. La mortalidad neonatal fue de 45,65 % y la sobrevida fue de 53,33 %. Conclusión: El flujo diastólico borrado o flujo diastólico reverso indica insuficiencia placentaria grave, y alta asociación con morbi-mortalidad perinatal por prematuridad.

Introduction: The deleted diastolic flow or reverse in the umbilical arteries, is associated with adverse perinatal outcome. Objective: To determine the perinatal outcome in fetuses of mothers with severe preeclampsia with deleted diastolic flow and reverse diastolic flow at the Maternidad “Concepcion Palacios, Caracas. Methods: Retrospective, descriptive and correlational study. We included 64 fetuses, of pregnancies among 24-37 weeks in patients with severe preeclampsia. The information was obtained from the review of medical records, for the analysis is record the relationship of the presence of deleted diastolic flow or reverse diastolic flow and age of gestation to the diagnosis, interval between diagnosis and termination of pregnancy, termination via, the age of gestation at birth, variables of forecast perinatal and neonatal survival. Results: Forty seven cases with deleted diastolic flow and 17 cases with reverse diastolic flow were identified. There were 46 births (71.8 %), and 18 deaths (28.12 %). Deleted diastolic flow cases were discontinued at 32.66 weeks and the reverse diastolic flow to the 26.87 weeks the weight at birth was of 1 333.3 vs 670.55 g respectively. The frequency of caesarean section was 78.12 %, with 98 % of admission to neonatal therapy. Of the 45 living newborn infants requiring entering the neinatal intensive care unit. Neonatal mortality was 45.65 % and survival was 53.33 %. Conclusion: The deleted diastolic flow or reverse diastolic flow indicates severe placental insufficiency, and high association with prematurity perinatal morbidity-mortality.

Environment and congenital urinary malformations / 中国当代儿科杂志

The development of the kidneys and other organs of the urinary tract follows the natural rule of gene-environment-lifestyle interaction. Both intrinsic and extrinsic factors may be associated with the etiology of various kinds of urinary malformations, but the environmental factor is an extrinsic factor. Related literatures were reviewed in this paper, which focuses on the association of congenital urinary malformations with possible environmental factors. It is concluded that urinary malformation is associated with low birth weight, maternal disease, placental insufficiency, maternal drug exposure, and maternal exposure to environmental pesticides. Living environment and socioeconomic factors may also influence the incidence of urinary malformation.

Cortical Neuronal Loss after Chronic Prenatal Hypoxia: A Comparative Laboratory Study

OBJECTIVE: The purpose of this study was to investigate the prenatal hypoxic effect on the fetal brain development. METHODS: We used the guinea pig chronic placental insufficiency model to investigate the effect of hypoxia on fetal brain development. We ligated unilateral uterine artery at 30-32 days of gestation (dg : with term defined as -67 dg). At 50 dg, 60 dg, fetuses were sacrificed and assigned to either the growth-restricted (GR) or control (no ligation) group. After fixation, dissection, and sectioning of cerebral tissue from these animals, immunohistochemistry was performed with NeuN antibody, which is a mature neuronal marker in the cerebral cortex. RESULTS: The number of NeuN-immunoreactive (IR) cells in the cerebral cortex did not differ between the GR and control groups at 50 dg. However, the number of NeuN-IR cells was lesser in GR fetuses than in controls at 60 dg (p<0.05). CONCLUSION: These findings show that chronic prenatal hypoxia affect the number of neuron in the cerebral cortex of guinea pig fetus at 60 dg. The approach used in this study is helpful for extending our understanding of neurogenesis in the cerebral cortex, and the findings may be useful for elucidating the brain injury caused by prenatal hypoxia.

Dopplervelocimetria da artéria cerebral média fetal e outros parâmetros de vitalidade fetal na sobrevida neonatal em gestações com insuficiência placentária / Doppler velocimetry of the fetal middle cerebral artery and other parameters of fetal well-being in neonatal survival during pregnancies with placental insufficiency

OBJETIVO: Estudar a dopplervelocimetria da artéria cerebral média fetal em gestações complicadas pela insuficiência placentária e verificar o seu papel no prognóstico de sobrevida neonatal. MÉTODOS: Trata-se de estudo prospectivo de 93 gestantes com diagnóstico de insuficiência placentária estabelecida antes da 34ª semana. A insuficiência placentária foi caracterizada pelo Doppler de artéria umbilical (AU) alterado (> p95). Foram analisados os seguintes parâmetros: índice de pulsatilidade (IP) da artéria umbilical (AU), IP da artéria cerebral média (ACM), relação cerebroplacentária -RCP(IP-ACM/IP-AU), pico de velocidade sistólicada ACM (PVS-ACM) e IP para veias (IPV) do ducto venoso (DV). Os parâmetros foram analisados pelos valores absolutos, em escores zeta (desvios padrão a partir da média) ou múltiplos da mediana (MoM). O desfecho investigado foi o óbito neonatal no período de internação após o nascimento. RESULTADOS: Nas 93 gestações analisadas, ocorreram 25 (26,9%) óbitos neonatais. No grupo que evoluiu com óbito neonatal, quando comparado com o grupo com sobrevida, houve associação significativa com o diagnóstico de diástole zero ou reversa (88% vs. 23,6%, p < 0,001), com maior mediana do IP da AU (2,9 vs. 1,7, p < 0,001) e seu escore zeta (10,4 vs. 4,9, p < 0,001); maior valor do PVS-ACM MoM (1,4 vs. 1,1, p = 0,012); menor valor da RCP (0,4 vs. 0,7, p < 0,001); maior valor do IPV-DV (1,2 vs. 0,8, p < 0,001) e no escore zeta do DV (3,6 vs.0,6, p<0,001). Na regressão logística, as variáveis independentes para a prediçãodoóbito neonatal foram a idade gestacional no parto (OR = 0,45; IC95% 0,3 a 0,7, p < 0,001) e o escore zeta do IP-AU (OR 1,14, IC95% 1,0 a 1,3, p = 0,046). CONCLUSÃO: Apesar da associação verificada pela análise univariada entre a morte neonatal e os parâmetros da dopplervelocimetria cerebral fetal, a análise multivariada identificou a prematuridadeeograude insuficiência da circulação placentária como fatores independentes relacionados com o óbito neonatal em gestações complicadas por insuficiência placentária.

OBJECTIVE: To study the Doppler velocimetry of the fetal middle cerebral artery in pregnancies complicated by placental insufficiency, and to verify its role in the prognosis of neonatal survival. METHODS: This was a prospective study of 93 pregnant women with diagnosis of placental insufficiency detected before the 34th week of pregnancy. Placental insufficiency was characterized by abnormal umbilical artery (UA) Doppler (> 95th percentile). The following parameterswere analyzed: umbilical artery (UA) pulsatility index (PI); middle cerebral artery (MCA) PI; brain-placenta ratio - BPR (MCA-PI/UA-PI); MCA peak systolic velocity (MCA-PSV); and PI for veins (PIV) of ductus venosus (DV). The parameters were analyzed in terms of absolute values, z-scores (standard deviations from the mean), or multiples of the median (MoM). The outcome investigatedwas neonatal death during the hospitalization period after birth. RESULTS: Of the 93 pregnancies analyzed, there were 25 (26.9%) neonatal deaths. The group that died, when compared to the survival group, presented a significant association with the diagnosis of absent or reversed end-diastolic flow (88% vs. 23.6%, p < 0.001), with a higher median of UA PI (2.9 vs. 1.7, p < 0.001) and UA PI z-score (10.4 vs. 4.9, p < 0.001); higher MCAPSV MoM (1.4 vs. 1.1, p = 0.012); lower BPR (0.4 vs. 0.7, p < 0.001); higher PIV-DV (1.2 vs. 0.8, p < 0.001) and DV z-score (3.6 vs. 0.6, p < 0.001). In the logistic regression, the independent variables predictive of neonatal death were: gestational age at birth (OR = 0.45; 95% CI: 0.3 to 0.7; p < 0.001) and UA PI z-score (OR = 1.14, 95% CI: 1.0 to 1.3, p = 0.046). CONCLUSION: Despite the association verified by the univariate analysis between neonatal death and the parameters of fetal cerebral Doppler velocimetry, the multivariate analysis identified prematurity and degree of insufficiency of placental circulation as independent factors related to neonatal death in pregnancies complicated by placental insufficiency.

Dandy-Walker complex: a clinicopathologic study of 9 cases / 中华病理学杂志

<p><b>OBJECTIVE</b>To investigate the etiology, pathogenesis, clinicopathologic characteristics, clinical prognosis and treatment of Dandy-Walker syndrome.</p><p><b>METHODS</b>Nine cases of Dandy-Walker syndrome were included in the study. The autopsy findings and clinical history were evaluated along with review of the literature. The causes, pathogenetic mechanism, pathologic features and prognosis of Dandy-Walker syndrome were analyzed.</p><p><b>RESULTS</b>Among 9 Dandy-Walker syndrome cases, six patients presented with variants of Dandy-Walker complex and 3 cases had classic Dandy-Walker malformation. In addition, 4 patients presented with combined lateral ventricle expansion and multiple malformations were seen in 7 cases. Combined umbilical cord abnormality was noted in 4 patients with variant of Dandy-Walker complex and combined placental abnormality was seen in one classic Dandy-Walker syndrome.</p><p><b>CONCLUSIONS</b>Dandy-Walker syndrome is a rare disease. In addition to complex pathogenesis with possible genetic and environmental antigenic etiologies, placental and umbilical cord abnormality may be also related to its development.</p>

Resposta clínica e metabólica de potros neonatos em relação aos achados histopatológicos da placenta na égua / Clinical and metabolic response of neonatal foals related to histopathology finds in mare placenta

Avaliaram-se as respostas clínica e metabólica de potros neonatos em relação aos achados histopatológicos da placenta na égua. Foram avaliados dois grupos de éguas da raça Puro Sangue Inglês - um grupo-problema (n=25) e um grupo-controle (n=25), de acordo com os achados da placenta. O exame dos potros constou de avaliação clínica geral, hematologia e bioquímica sérica. O exame histopatológico da placenta apresentou resultado compatível com a apresentação clínica do potro, sendo que a presença de lesões inflamatórias resultou na produção de potros debilitados. A presença de lesões degenerativas não comprometeu o estado clínico do neonato, mas pode ser responsável pela manifestação de distúrbios subclínicos, evidenciados pelo aumento das taxas de AST e GGT. A ureia pareceu ser um indicador de dano renal decorrente de insuficiência placentária em potros neonatos.

The placenta represents the major communication between the mare and the fetus during the gestational period, and this suggests that any disturbance in the placenta can be an indicator of gestational damage with risk to the fetus. The aim of this paper was to evaluate the clinical and metabolic responses of the newborn foals related with the findings from the histopathological examination of the placenta. This study was conducted in a farm located in Bagé-RS, Brazil, where were evaluated two groups of Throughbred mares for this case-control study: One Problem Group (N=25) and the Control Group (n=25), based on the placental findings. The foal's evaluation was based on general clinical examination, hematology and serum biochemistry. Results from the placenta histopathological exams were compatible with clinical presentation of the foals, with the presence of inflammatory lesions resulting in the production of debilitated foals. The presence of degenerative lesions in the placenta does not compromise the clinical features of the newborn, but they can be responsible for the manifestation of sub-clinical disturbances, evidenced by increased levels of AST and GGT. Urea seems to be an indicator of renal damage due to placental insufficiency in neonatal foals.

Repercussões da cicatriz uterina resultante de cesariana prévia na dopplervelocimetria das artérias uterinas entre 26 e 32 semanas / Repercussions of previous cesarean uterine scar at uterine arteries Doppler velocimetry between the 26th and 32nd gestational weeks

OBJETIVO: Avaliar as repercussões da cicatriz uterina na dopplervelocimetria das artérias uterinas, entre 26 e 32 semanas, em gestantes primíparas com uma cesariana prévia, considerando quando esta foi realizada fora (cesárea eletiva) ou durante o trabalho de parto. MATERIAIS E MÉTODOS: Estudo prospectivo transversal em 45 gestantes, divididas em três grupos: 17 gestantes com cicatriz prévia resultante de cesariana eletiva (grupo A); 14 gestantes com uma cicatriz prévia oriunda de cesariana executada em trabalho de parto (grupo B); 14 gestantes cujo único parto anterior foi realizado por via vaginal (grupo C). A dopplervelocimetria das artérias uterinas foi realizada pela via abdominal. Foram calculados as médias, medianas e desvios-padrão (DP) para cada grupo em estudo. Em relação ao índice de pulsatilidade, a comparação dos grupos foi conduzida pelo teste não paramétrico de Kruskal-Wallis. RESULTADOS: Os valores médios do índice de pulsatilidade no grupo A variaram de 0,60 a 1,60 (média: 0,90; DP: 0,29), no grupo B, de 0,53 a 1,43 (média: 0,87; DP: 0,24), e no grupo C, de 0,65 a 1,65 (média: 1,01; DP: 0,37); p = 0,6329. CONCLUSÃO: Não houve repercussões da cicatriz de cesariana prévia na dopplervelocimetria das artérias uterinas avaliadas de 26 a 32 semanas de gestação.

OBJECTIVE: To evaluate the possible repercussions of the previous cesarean scar at uterine arteries Doppler velocimetry between the 26th and 32nd gestational weeks. MATERIALS AND METHODS: Prospective cross-sectional study including 45 women between 11 and 14 weeks of gestation, divided into three groups: 17 pregnant women with uterine scar resulting from a previous elective cesarean section (group A); 14 with uterine scar resulting from a previous cesarean section performed during labor (group B); and 14 pregnant women with a single previous vaginal delivery (group C). Uterine arteries Doppler velocimetry was performed with transabdominal approach. Means, medians and standard deviation (SD) were calculated for each group in the study. The groups comparison regarding pulsatility index was performed with the non-parametric Kruskal-Wallis test. RESULTS: In group A, the pulsatility index ranged from 0.60 to 1.60 (mean: 0.90; SD: 0.29), in group B, from 0.53 to 1.43 (mean: 0.87; SD: 0.24), and in group C, from 0.65 to 1.65 (mean: 1.01; SD: 0.37); with p = 0.6329. CONCLUSION: No repercussion of previous cesarean scar was observed at uterine arteries Doppler velocimetry performed in the period between the 26th and 32nd gestational weeks.

Avaliação biofísica complementar da vitalidade fetal / Additional biophysical evaluation of fetal surveillance

O nascimento de um feto saudável sempre constituiu um dos principais objetivos da Obstetrícia. Nos dias atuais, vários procedimentos têm sido utilizados com esta finalidade, porém, apesar da evolução dos métodos diagnósticos e da melhor compreensão da fisiopatologia do sofrimento fetal, ainda existem lacunas no conhecimento sobre o comportamento do feto frente à hipóxia. Outro fator complicador na avaliação do sofrimento fetal é o grande número de doenças maternas com diferentes fisiopatologias que podem interferir no bem-estar fetal. Esta revisão tem como objetivo descrever os principais métodos de avaliação biofísica da vitalidade fetal, com base nas melhores evidências científicas correntemente disponíveis na literatura, e incluindo níveis de evidências e graus de recomendação. Será abordada a avaliação da vitalidade fetal nos casos de insuficiência placentária, não sendo estudadas as situações especiais, como diabetes e gestação múltipla. Evidencia-se uma falta de consenso sobre qual procedimento deve ser utilizado na avaliação da vitalidade fetal, na prática clínica diária. As sociedades internacionais recomendam a realização da doplervelocimetria, da cardiotocografia e do perfil biofísico fetal apenas em gestantes de alto risco, com suspeita de insuficiência placentária ou com restrição de crescimento intrauterino

The birth of a healthy baby has always been an important goal of Obstetrics. Nowadays, many procedures have been used for this purpose, but despite great development in diagnostic methods and better understanding of pathophysiology of fetal distress, there are still gaps in knowledge about fetal behavior in situations of hypoxia. Another complicating factor in the assessment of fetal distress is the large number of maternal diseases with different pathophysiology, which can compromise fetal well-being. This review aims at describing the main methods for fetal assessment, based on the best scientific evidence currently available, including levels of evidence and grades of recommendation. Only fetal evaluation in cases of placental insufficiency will be addressed, and special situations such as diabetes and multiple pregnancies will not be studied. Current evidences show a lack of consensus on what is the best procedure to assess fetal well-being in clinical practice. International societies recommend the performance of Doppler velocimetry, cardiotocography, and fetal biophysical profile only in high-risk pregnancies with suspected placental insufficiency or restricted intrauterine growth

Genetics of Pre-eclampsia

Pre-eclampsia is a major cause of maternal and perinatal mortality and morbidity worldwide, but remains unclear about the underlying disease mechanisms. Pre-eclampsia is currently believed to be a two-stage disease. The first stage involves shallow cytotrophoblast invasion of maternal spiral arteriole, resulting in placental insufficiency. The hypoxic placenta release soluble factors, cytokines, and trophoblastic debris into maternal circulation, which induce systemic endothelial damage and dysfunction. This cause the second stage of the disease: maternal syndrome. Epidemiological research has consistently demonstrated a familial predisposition to pre-eclampsia. Intensive research efforts have been made to discover susceptibility genes that will inform our understanding of the pathophysiology of pre-eclampsia and that may provide direction for therapeutic or preventative strategies. In this review, we summarize the current understanding of the role of genetic factors in the pathophysiology of pre-eclampsia and explain the molecular approach to search for genetic clues in pre-eclampsia.