Parámetros del líquido amniótico para diagnóstico de respuesta inflamatoria en parto pretérmino / Amniotic fluid parameters for the diagnosis of inflammatory response in preterm delivery

OBJETIVO: Evaluar el rendimiento del Gram, la glucosa y los leucocitos en líquido amniótico para el diagnóstico de respuesta inflamatoria fetal y materna en pacientes con parto pretérmino. MÉTODO: Estudio de rendimiento de pruebas diagnósticas. Se incluyeron 63 pacientes a quienes se les realizó amniocentesis por sospecha de infección intraamniótica. Se estudió la placenta y se comparó con el Gram, la glucosa y el recuento de leucocitos en líquido amniótico para ver su relación con la respuesta inflamatoria. Se evaluaron la sensibilidad, la especificidad, las razones de verosimilitud (LR, likelihood ratio), los valores predictivos y el valor de kappa. RESULTADOS: Las pruebas con mejor rendimiento fueron en conjunto la glucosa 50/mm3 en líquido amniótico, con una especificidad del 94,3% (intervalo de confianza del 95% [IC95%]: 84,6-98,1), LR + 8,83 (IC95%: 2,5-31,2) y kappa de 0,48 (IC95%: 0,15-0,82). También se consideró la propuesta de un nuevo punto de corte para el recuento de leucocitos en líquido amniótico en la respuesta inflamatoria fetal. CONCLUSIONES: La combinación del recuento de leucocitos en líquido amniótico y los valores de glucosa mejora el rendimiento para el diagnóstico de respuesta inflamatoria fetal en comparación con la histopatología de la placenta, lo que proporciona información útil para el enfoque de los recién nacidos.

OBJECTIVE: To evaluate the performance of Gram, glucose and leukocytes in amniotic fluid for the diagnosis of fetal and maternal inflammatory response in patients with preterm delivery. METHOD: A diagnostic performance test study was carried out. Sixty-three patients with preterm labor were included who underwent amniocentesis due to suspected intra-amniotic infection. Histopathology of the placenta was studied and compared with the Gram result, glucose and leukocyte count in amniotic fluid, and their relationship with the maternal and fetal inflammatory response. Sensitivity, specificity, likelihood ratios, predictive values, and kappa were evaluated. RESULTS: The tests with the best performance were overall glucose 50/mm3 in amniotic fluid for the diagnosis of the fetal inflammatory response, with a specificity of 94.3% (95% confidence interval [95% CI]: 84.6-98.1%), likelihood positive ratio 8.83 (95% CI: 2.5-31.2) and kappa of 0.48 (95% CI: 0.15-0.82). A new cut-off point for leukocyte count in amniotic fluid to diagnose fetal inflammatory response was proposed. CONCLUSIONS: The combination of amniotic fluid leukocyte count and amniotic fluid glucose values improves performance for the diagnosis of inflammatory response compared with placental histopathology, providing useful information for newborns approach.

Clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for severe MAS in neonates with meconium-stained amniotic fluid / 中国当代儿科杂志

OBJECTIVES@#To study the clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for the development of severe MAS in neonates with meconium-stained amniotic fluid (MSAF).@*METHODS@#A total of 295 neonates who were hospitalized due to Ⅲ° MSAF from January 2018 to December 2019 were enrolled as subjects. The neonates were classified to a non-MAS group (n=199), a mild/moderate MAS group (n=77), and a severe MAS group (n=19). A retrospective analysis was performed for general clinical data, blood gas parameters, infection indicators, and perinatal clinical data of the mother. The respiratory support regimens after birth were compared among the three groups. The receiver operating characteristic (ROC) curve and multivariate logistic regression analysis were used to investigate predicting factors for the development of severe MAS in neonates with MSAF.@*RESULTS@#Among the 295 neonates with MSAF, 32.5% (96/295) experienced MAS, among whom 20% (19/96) had severe MAS. Compared with the mild/moderate MAS group and the non-MAS group, the severe MAS group had a significantly lower 5-minute Apgar score (P<0.05) and a significantly higher blood lactate level in the umbilical artery (P<0.05). Compared with the non-MAS group, the severe MAS group had a significantly higher level of interleukin-6 (IL-6) in peripheral blood at 1 hour after birth (P<0.017). In the severe MAS group, 79% (15/19) of the neonates were born inactive, among whom 13 underwent meconium suctioning, and 100% of the neonates started to receive mechanical ventilation within 24 hours. Peripheral blood IL-6 >39.02 pg/mL and white blood cell count (WBC) >30.345×109/L at 1 hour after birth were early predicting indicators for severe MAS in neonates with MSAF (P<0.05).@*CONCLUSIONS@#Meconium suctioning cannot completely prevent the onset of severe MAS in neonates with MSAF. The neonates with severe MAS may develop severe respiratory distress and require mechanical ventilation early after birth. Close monitoring of blood lactate in the umbilical artery and peripheral blood IL-6 and WBC at 1 hour after birth may help with early prediction of the development and severity of MAS.

Uromodulin: a new biomarker of fetal renal function? / Uromodulina: um novo biomarcador de função renal fetal?

Abstract Introduction: Obstructive uropathies are main diseases affecting the fetus. Early diagnosis allows to establish the appropriate therapy to minimize the risk of damage to kidney function at birth. Biochemical markers have been used to predict the prognosis of renal function in fetuses. Uromodulin, also known by Tamm-Horsfall protein (THP) is exclusively produced in the kidneys and in normal conditions is the protein excreted in larger amounts in human urine. It plays important roles in kidneys and urinary tract. Also it participates in ion transport processes, interact with various components of the immune system and has a role in defense against urinary tract infections. Moreover, this protein was proved to be a good marker of renal function in adult patients with several renal diseases. Objective: To evaluate if uromodulin is produced and eliminated by the kidneys during fetal life by analyzing fetal urine and amniotic fluid and to establish correlation with biochemical parameter of renal function already used in Fetal Medicine Center at the Clinic Hospital of UFMG (CEMEFE/HC). Methods: Between 2013 and 2015, were selected 29 fetuses with indication of invasive tests for fetal diagnosis in monitoring at the CEMEFE/HC. Results: The determination of uromodulin was possible and measurable in all samples and showed statistically significant correlation with the osmolarity. Conclusion: There was a tendency of lower levels of Uromodulin values in fetuses with severe renal impairment prenatally. Thus, high levels of this protein in fetal amniotic fluid or fetal urine dosages possibly mean kidney function preserved.

Resumo Introdução: Uropatias obstrutivas estão entre as principais doenças que acometem o feto. O diagnóstico precoce destas doenças permite estabelecer a terapêutica adequada, visando minimizar os riscos de danos à função renal no nascimento. Os marcadores bioquímicos têm sido utilizados na predição do prognóstico da função renal em fetos. A uromodulina, também chamada de proteína de Tamm-Horsfall (THP), é produzida exclusivamente nos rins, e em condições normais, é a proteína excretada em maior volume na urina humana. Ela desempenha importantes funções nos rins e trato urinário. Participa dos processos de transporte de íons, interage com vários componentes do sistema imunológico e possui papel na defesa contra infecções do trato urinário. Além disso, se mostrou um bom biomarcador de função renal em adultos portadores de diversas doenças renais. Objetivos: Avaliar se a uromodulina é produzida e eliminada pelos rins durante a vida fetal através da análise de urina fetal e líquido amniótico, além de estabelecer correlação com o parâmetro bioquímico de função renal já utilizado no Centro de Medicina Fetal do Hospital das Clínicas da UFMG (CEMEFE/HC). Métodos: Entre 2013 e 2015, foram selecionados 29 fetos com indicação de exames invasivos para diagnóstico fetal em acompanhamento no CEMEFE/HC. Resultados: A dosagem da uromodulina foi possível e quantificável em todas as amostras e mostrou correlação significativa com a osmolaridade. Conclusão: A uromodulina mostrou uma tendência em apresentar valores reduzidos em fetos com grave comprometimento renal no pré-natal. Assim, valores elevados desta proteína em dosagens de urina fetal ou líquido amniótico podem significar uma função renal preservada.

Comparação da composição bioquímica do líquido amniótico equino colhido em diferentes estágios gestacionais e no momento do parto / Comparison of the biochemical composition of equine amniotic fluid collected in different gestational phases and at delivery

A viabilidade e maturidade fetais podem ser estimadas através da avaliação dos fluídos fetais em muitas espécies, no entanto a composição bioquímica do líquido amniótico durante a gestação ainda não está bem definida para a espécie equina. O objetivo deste estudo foi estabelecer e comparar o perfil bioquímico do liquido amniótico em diferentes momentos da gestação e no momento do parto para um melhor entendimento da fisiologia da gestação de equinos. Foram avaliados valores encontrados para pH, osmolaridade, glicose, uréia, creatinina, gamma-GT, sódio, potássio, cloretos e proteína total no liquido amniótico colhido de 122 éguas comparando-se os resultados encontrados entre as colheitas em terço inicial (TI), médio (TM) e final (TF) da gestação e no momento do parto (MP). [...] Valores para gamma GT diferiram apenas entre os grupos TF e MP e mais estudos devem ser conduzidos sobre sua função no liquido amniótico das espécies domésticas. Os valores de sódio e cloretos não diferiram significativamente entre os grupos estudados e as concentrações de potássio diferiram apenas entre os grupos TF e MP refletindo a manutenção do equilíbrio eletrolítico do líquido amniótico equino durante a gestação. As concentrações de proteínas totais variaram de maneira heterogênea entre os grupos, porém todos estes demonstraram baixas concentrações. Concluímos que a composição bioquímica do liquido amniótico equino varia de acordo com o desenvolvimento fetal e pode ser utilizada como mensuração da viabilidade e maturidade do feto no futuro, no entanto devido ao pequeno número de estudos conduzidos e diferenças encontradas em seus resultados, outros estudos devem ser realizados para a melhor definição do perfil bioquímico do líquido amniótico equino durante as fases gestacionais e no momento do parto.

The viability and fetal maturity can be estimated by biochemical evaluation of the fetal fluids of several species; however the biochemical composition of amniotic fluid during pregnancy is not fully defined for equine. The aim of this study was to establish and compare the biochemical profile of amniotic fluid in different moments of pregnancy and at delivery, in order to better explain the peculiarities of the physiology of pregnancy in mares. The values founded for pH, osmolarity, glucose, urea, creatinine, gamma-GT, Sodium, potassium, chloride and total protein were evaluated in amniotic fluid collected from 122 mares comparing the results between the initial-third (IT), mid-third (MT) and latter-third (FT) of gestation and at delivery (D). [...] Concentrations of urea tended to be statistically different in at least one of the groups. A significant increase in creatinine concentrations was observed during the initial-third, medium-third and the final-third of pregnancy and the value found at delivery remained equal to final-third. Values for Gamma GT differed only between FT and D groups and more studies should be conducted about its role in the amniotic fluid of domestic species. For the sodium and chloride ions, they were not significantly different between the studied stages, and the potassium ion was significantly different only between FT and D reflecting the maintenance of electrolyte balance of the amniotic fluid during equine pregnancy. Total protein concentrations were different between groups, but all the groups showed low concentrations. We conclude that the values of the parameters studied varied according with the fetal development and can be used for the evaluation of fetal viability and maturity in the future, but the scarce number of studies in this area and the difference between the results found in literature demonstrate the need of more works to establish the biochemical profile of equine amniotic fluid during pregnancy and at delivery.

Gonadotropina coriónica en flujo vaginal para el diagnóstico de rotura prematura de membranas / Chorionic gonadotrophin in vaginal discharge for diagnosis of premature rupture of membranes

Objetivo: Establecer la eficacia diagnóstica de la determinación de gonadotropina coriónica en flujo vaginal para el diagnóstico de la rotura prematura de membranas. Método: Investigación de tipo prospectiva en muestra de 270 embarazadas que asistieron al Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Los grupos consistieron en pacientes con rotura prematura de membranas (grupo A; n = 135) y embarazadas con membranas integras (grupo B; n = 135), consideradas como controles. Se evaluaron las características generales, valores de gonadotropina coriónica en flujo vaginal y efectividad diagnóstica. Resultados: La edad gestacional al momento de la determinación de las concentraciones de gonadotropina coriónica en flujo vaginal fue de 32,9 +/- 1,6 semanas para el grupo A y 33,1 +/- 1,9 semanas para el grupo B (p = ns). No se encontraron diferencias estadísticamente significativas en la edad materna y la frecuencia de paridad entre ambos grupos de tratamiento (p = ns). Las pacientes del grupo A presentaron concentraciones significativamente más altas de gonadotropina coriónica en flujo vaginal (697,4 +/- 382,4 mUI/mL) comparado con las embarazadas del grupo B (91,4 +/- 47,1 mUI/mL; p < 0,0001). Un valor de corte de 100 mUI/mL presentó un valor por debajo de la curva de 0,96 con una sensibilidad del 97,0 por ciento, especificidad del 51,1 por ciento, valor predictivo positivo del 66,5 por ciento y valor predictivo negativo del 94,5 por ciento. Conclusión: La determinación de las concentraciones de gonadotropina coriónica en el flujo vaginal es una técnica diagnóstica útil para la rotura prematura de membranas.

Objective: To establish the diagnostical efficacy of chorionic gonadotropin in vaginal fluid determination for diagnosis of premature rupture of membranes. Method: A prospective research type was done with a sample of 270 pregnant women who assisted to obstetrics emergency at Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Groups consisted in patients with premature rupture of membranes (group A; n = 135) and pregnant women with intact membranes (group B; n = 135), considered as controls. General characteristics, values of chorionic gonadotropin in vaginal fluid and diagnostic efficacy were evaluated. Results: Gestational age at the moment of determination chorionic gonadotropin in vaginal fluid was 32.9 +/- 1.6 weeks in group A and 33.1 +/- 1.9 weeks in group B (p = ns). There were no significant differences in maternal age and frequency of parity between groups (p = ns). Patients in group A showed significant higher concentrations of chorionic gonadotropin in vaginal fluid (697.4 +/- 382.4 mUI/mL) compared with pregnant women in group B (91.4 +/- 47.1 mUI/mL; p < 0.0001). A cut-off point of 100 mUI/mL showed a under the curve value of 0.96 with a sensitivity of 97.0 percent, specificity of 51.1 percent, positive predictive value of 66.5 percent and negative predictive value of 94.5 percent. Conclusions: Determination of chorionic gonadotropin concentrations in vaginal fluid is a useful diagnosis tool for premature rupture of membranes.

The performance of four molecular methods for the laboratory diagnosis of congenital toxoplasmosis in amniotic fluid samples

Introduction Toxoplasmosis may be life-threatening in fetuses and in immune-deficient patients. Conventional laboratory diagnosis of toxoplasmosis is based on the presence of IgM and IgG anti-Toxoplasma gondii antibodies; however, molecular techniques have emerged as alternative tools due to their increased sensitivity. The aim of this study was to compare the performance of 4 PCR-based methods for the laboratory diagnosis of toxoplasmosis. One hundred pregnant women who seroconverted during pregnancy were included in the study. The definition of cases was based on a 12-month follow-up of the infants. Methods Amniotic fluid samples were submitted to DNA extraction and amplification by the following 4 Toxoplasma techniques performed with parasite B1 gene primers: conventional PCR, nested-PCR, multiplex-nested-PCR, and real-time PCR. Seven parameters were analyzed, sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR) and efficiency (Ef). Results Fifty-nine of the 100 infants had toxoplasmosis; 42 (71.2%) had IgM antibodies at birth but were asymptomatic, and the remaining 17 cases had non-detectable IgM antibodies but high IgG antibody titers that were associated with retinochoroiditis in 8 (13.5%) cases, abnormal cranial ultrasound in 5 (8.5%) cases, and signs/symptoms suggestive of infection in 4 (6.8%) cases. The conventional PCR assay detected 50 cases (9 false-negatives), nested-PCR detected 58 cases (1 false-negative and 4 false-positives), multiplex-nested-PCR detected 57 cases (2 false-negatives), and real-time-PCR detected 58 cases (1 false-negative). Conclusions The real-time PCR assay was the best-performing technique based on the parameters of Se (98.3%), Sp (100%), PPV (100%), NPV (97.6%), PLR (∞), NLR (0.017), and Ef (99%). .

A ausência do eco glandular endocervical e a presença de sludge no líquido amniótico podem ser consideradas imagens ultrassonográficas preditivas de parto prematuro? / Absent cervical gland area and amniotic fluid sludge may be considered predictive ultrasound images of preterm birth?

A prematuridade ainda é um grande desafio para a Obstetrícia, sendo considerada a principal causa de morbidade e mortalidade neonatal, com repercussões importantes na infância. Apesar dos avanços da medicina, ainda falhamos muitas vezes em predizer e prevenir o parto prematuro. Novos marcadores surgem a cada dia na tentativa de melhorar o arsenal médico para a predição da prematuridade, entre eles a ausência do eco glandular endocervical e o sludge no líquido amniótico, vistos em avaliações ultrassonográficas transvaginais. Para avaliar os estudos disponíveis sobre esses novos métodos, este estudo de revisão da literatura pesquisou nas bases de dados MEDLINE, PubMed, SciELO, LILACS e Biblioteca Cochrane os descritores "cervical gland area", "amniotic fluid sludge", "sludge", "preterm", "preterm labor" e "preterm birth" e selecionou 12 artigos com base em sua relevância e metodologia. Apesar de vários estudos publicados sugerirem a aplicação desses marcadores, é difícil comparar os resultados apresentados, pois as populações avaliadas são muito diferentes, a casuística ainda é pequena e faltam avaliações com melhor nível de evidência. Até que se consiga realmente comprovar o benefício do uso isolado desses marcadores, podemos associar os métodos propostos com os já utilizados, como fibronectina fetal e comprimento cervical, para tentar diminuir o número de partos prematuros em nossa prática médica. (AU)

Prematurity is still a challenge for Obstetrics, considered the leading cause of neonatal and childhood deaths worldwide, with serious repercussions in childhood. Despite advances in medicine, yet we often fail to predict and prevent preterm birth. New markers appear every day in an attempt to improve the medical arsenal for predicting prematurity, including two sonographic markers: the absence of cervical gland area and amniotic fluid sludge, seen in transvaginal sonographic evaluations. To evaluate the available studies on these new methods, this literature review study searched the databases MEDLINE, PubMed, SciELO, LILACS and the Cochrane Library the following descriptors: "cervical gland area", "amniotic fluid sludge", "sludge", "preterm", "preterm labor" e "preterm birth" and selected 12 articles based on their relevance and methodology. Despite all the published studies suggest the application of these markers, it is difficult to compare the results because the populations evaluated are very different, the sample is still small and we still lack reviews with best level of evidence. Until we can actually prove the benefit of using these markers separately, we can associate the proposed methods with the ones already used, such as fetal fibronectin and cervical length, in an attempt to reduce the number of premature births in our practice.(AU)

Isolamento, caracterização e diferenciação de células-tronco mesenquimais do líquido amniótico equino obtido em diferentes idades gestacionais / Isolation, characterization and differentiation of mesenchymal stem cells derived from equine amniotic fluid obtained from different gestacional ages

O interesse nas pesquisas com células-tronco derivadas de anexos fetais de diversas espécies cresceu exponencialmente nas últimas décadas em virtude de serem fontes de células-tronco adultas com potencial de diferenciação em diversas linhagens celulares que apresentam pouca ou nenhuma imunogenicidade, apresentando-se assim como alternativa de grande importância para a formação de bancos celulares. Apesar do crescente interesse, os estudos para espécie equina ainda são escassos. O objetivo deste trabalho foi isolar, caracterizar e diferenciar células-tronco mesenquimais (CTMs) derivadas do líquido amniótico equino obtidas do terço inicial, médio e final da gestação (LA-CTMs), comparando suas características. Foram colhidas 23 amostras de líquido amniótico as quais foram submetidas às análises morfológica, imunocitoquímica, imunofenotípica por citometria de fluxo e às diferenciações osteogênica, adipogênica e condrogênica in vitro. Todas as amostras demonstraram adesão ao plástico e morfologia fibroblastóide. No ensaio imunocitoquímico as células de todos os grupos foram imunomarcadas para CD44, PCNA e vimentina com ausência de marcação para citoqueratina e Oct-4. Na citometria de fluxo observou-se a expressão de CD44 e CD90 e ausência de expressão de CD34, sendo que os marcadores CD44 e CD90 mostraram padrão de expressão decrescente em relação ao desenvolvimento gestacional. As amostras obtidas de todas as fases da gestação foram capazes de diferenciação nas linhagens osteogênica, condrogênica e adipogênica. Portanto, as células obtidas do líquido amniótico apresentaram características morfológicas, imunofenotípicas e potencial de diferenciação típicos das CTMs, demonstrando que a colheita pode ser realizada em qualquer fase gestacional. No entanto, mais pesquisas devem ser realizadas principalmente quanto à expressão de marcadores de pluripotencialidade (como o Oct-4) e ao seu potencial de diferenciação em linhagens extra mesodermais já relatados na literatura.

The interest in stem cells derived from fetal annexes of many species has exponentially increased during the last decades, because they are adult stem cell sources with potential of differentiation in several cell lineages; which present little or no immunogenicity and are an alternative with great importance for storage cell banks. Despite the rising interest, studies for the equine species are still rare. The aim of this study was to isolate, characterize and differentiate mesenchymal stem cells derived from equine amniotic fluid obtained from initial, middle and late third of gestation (AF-MSCs), and compare their results. Twenty three samples from equine amniotic fluid were evaluated by morphological, immunocytochemical and immunophenotypical (Flow cytometer) assays and osteogenic, adipogenic and chondrogenic in vitro differentiation. All samples demonstrated plastic adhesion and fibroblastoid morphology. The immunocytochemical assay demonstrated cells from all the studied groups were positive for CD44, PCNA and vimentin and negative for cytokeratin and Oct-4. Flow cytometry demonstrated expression of CD44 and CD90 and no expression of CD34, where CD44 and CD90 markers presented decreasing pattern of expression in relation to the gestational development. All samples collected from all gestational phases were capable to differentiate in osteogenic, chondrogenic and adipogenic lineages. Thus, cells obtained from equine amniotic fluid presented morphological and immunophenotypical characteristics and potential of differentiation typical of MSCs showing that the collection can be performed at any stage of pregnancy. However, more studies should be performed about the expression of pluripotent markers as Oct-4 and the differentiation potential for extra mesodermal lineages prior demonstrated in the literature.

Amniotic fluid amino acid levels in non-immune hydrops fetalis: a case-control study

In a prospective case-control study, we compared the amniotic fluid amino acid levels in non-immune hydrops fetalis (NIHF) and normal fetuses. Eighty fetuses underwent amniocentesis for different reasons at the prenatal diagnosis unit of the Department of Obstetrics and Gynecology, Faculty of Medicine, Dicle University. Forty of these fetuses were diagnosed with NIHF. The study included 40 women each in the NIHF (mean age: 27.69 ± 4.56 years) and control (27.52 ± 5.49 years) groups, who had abnormal double- or triple-screening test values with normal fetuses with gestational ages of 23.26 ± 1.98 and 23.68 ± 1.49 weeks at the time of sample collection, respectively. Amniotic fluid amino acid concentrations (intra-assay variation: 2.26-7.85 percent; interassay variation: 3.45-8.22 percent) were measured using EZ:faast kits (EZ:faast GC/FID free (physiological) amino acid kit; Phenomenex, USA) by gas chromatography. The standard for quantitation was a mixture of free amino acids from Phenomenex. The levels of 21 amino acids were measured. The mean phosphoserine and serine levels were significantly lower in the NIHF group, while the taurine, α-aminoadipic acid (aaa), glycine, cysteine, NH4, and arginine (Arg) levels were significantly higher compared to control. Significant risk variables for the NIHF group and odds coefficients were obtained using a binary logistic regression method. The respective odds ratios and 95 percent confidence intervals for the risk variables phosphoserine, taurine, aaa, Arg, and NH4 were 3.31 (1.84-5.97), 2.45 (1.56-3.86), 1.78 (1.18-2.68), 2.18 (1.56-3.04), and 2.41 (1.66-3.49), respectively. The significant difference between NIHF and control fetuses suggests that the amniotic fluid levels of some amino acids may be useful for the diagnosis of NIHF.

Enfermedad hemolítica perinatal: manejo de la embarazada RhD negativo / Perinatal hemolytic disease: management of RhD immunization in pregnancy

En solo 50 años la enfermedad hemolítica perinatal por isoinmunización anti D pasó de ser una enfermedad sin etiología conocida, incurable y no prevenible, a la situación actual en que por las técnicas de prevención, diagnóstico oportuno y tratamiento especializado tiene baja incidencia y altas expectativas de sobrevida, incluso en los casos más severos. Se describe la historia, las técnicas de prevención, diagnóstico, manejo y tratamiento de la enfermedad.

In just 50 years the perinatal hemolytic disease due to RhD isoimmunization went from being a disease without known etiology, untreatable and not preventable to the current situation in which the prevention techniques, opportune diagnosis and specialized treatment has low its incidence and has an expected high survival even in the more severe cases. This article describes the history, prevention techniques, diagnosis, management and treatment of the disease.

Indomethacin-induced colon perforation in Bartter's syndrome.

Bartter's syndrome (BS) is an inherited renal tubular disorder characterized by hypokalemia, hypochloremic metabolic alkalosis, and hyperaldosteronism with normal blood pressure. A 22-year-old woman was referred at 23 week of gestation. Polyhydramnios was detected and the chloride level of the amniotic fluid was high. The mother was treated with indomethacin from 26 to 31 week of gestation. The newborn was delivered at 34 week of gestation. At 8th day of life, indomethacin was also started for the baby. After three days, a colonic perforation developed. Indomethacin-induced colon perforation is uncommon in antenatal Bartter's syndrome. This patient indicates that administration of indomethacin in both antenatal and/or early postnatal period may be associated with colonic perforation.

Líquido amniótico tópico: uma potencial nova alternativa para doenças da superfície ocular: [revisão] / Topical amniotic fluid: a potential new alternative for ocular surface diseases: [review]

O líquido amniótico banha o feto durante a vida intra-uterina e está em contato permanente com a superfície ocular durante este importante período do desenvolvimento. Ele contém uma série de fatores de crescimento que podem ter diversos efeitos sobre o processo cicatricial. Estes fatores aceleram a recuperação da sensibilidade corneana e regeneração nervosa após procedimentos cerato-refrativos, além de controlar a formação de cicatriz e o equilíbrio da superfície ocular após sua aplicação tópica. Centenas de diferentes proteínas têm sido identificadas no líquido amniótico humano e o papel de cada uma continua desconhecido. Os resultados obtidos até o momento sobre a aplicação de líquido amniótico em doenças de superfície ocular sugerem uma terapia promissora. Pesquisas estão sendo realizadas para identificar os efeitos dos fatores específicos do líquido amniótico sobre a inflamação ocular. O objetivo desta revisão é relatar as propriedades e utilizações atuais do líquido amniótico, bem como apresentar os recentes estudos relacionados ao uso deste líquido e doenças da superfície ocular.

Amniotic fluid bathes the fetus during intrauterine life and is in permanent contact with the fetal ocular surface in this important period of development. It contains a series of growth factors that may have multiple effects on the wound healing process. These factors are thought to accelerate the recovery of corneal sensitivity and nerve regeneration after keratorefractive procedures, and also may control scar formation and balance the ocular surface after topical application. Hundreds of different proteins have been identified in the human amniotic fluid, and the role of each still not quite understood. The outcomes obtained so far with amniotic fluid application to ocular surface diseases suggest a promising therapy. Research is underway to identify the effects of specific factors of the amniotic fluid in ocular inflammation. The purpose of this review is to report the properties and current utilizations of amniotic fluid as well as to summarize the recent studies related to the use of this fluid for ocular surface diseases.

Eosinophilic gastroenteritis with ascities: a case report

Eosinophilic gastroenteritis is a rare pathology, of undetermined etiology which incidence is in increase. It is characterized by eosinophilie infiltration of the wall of the gastrointestinal tract. Clinical manifestations are very variable and the severity of the clinical picture depends on the site involved and the wall layers infiltrated we point out the clinical, evolutionary and therapeutic characteristics of this rare affection. We report the case of a 65 years old man, with the history of allergic asthma. He was admitted for diarrhea associated to vomiting and slimming quantified to 3kg in 3 weeks. Physical examination noted an edematous-ascitic syndrome. Biology showed the presence of high peripheral eosinophilia. Paracentesis disclosed exudative effusion with high level of eosinophil. The morphological assessment highlighted a segmental parietal thickening of the small intestine and a dense eosinophilie infiltration of the mucosal duodenal layer. The patient was treated by corticotherapy with a favorable evolution. despite its rarity, the diagnosis of gastroenteritis with ascitis should be evoked even when the etiologic assessment is negative

Elevated amniotic fluid amino acid levels in fetuses with gastroschisis

Our objective was to measure maternal plasma and amniotic fluid amino acid concentrations in pregnant women diagnosed as having fetuses with gastroschisis in the second trimester of pregnancy. Twenty-one pregnant women who had fetuses with gastroschisis detected by ultrasonography (gastroschisis group) in the second trimester and 32 women who had abnormal triple screenings indicating an increased risk for Down syndrome but had healthy fetuses (control group) were enrolled in the study. Amniotic fluid was obtained by amniocentesis, and maternal plasma samples were taken simultaneously. The chromosomal analysis of the study and control groups was normal. Levels of free amino acids and non-essential amino acids were measured in plasma and amniotic fluid samples using EZ:fast kits (EZ:fast GC/FID free (physiological) amino acid kit) by gas chromatography (Focus GC AI 3000 Thermo Finnigan analyzer). The mean levels of essential amino acids (histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine) and non-essential amino acids (alanine, glycine, proline, and tyrosine) in amniotic fluid were found to be significantly higher in fetuses with gastroschisis than in the control group (P < 0.05). A significant positive correlation between maternal plasma and amniotic fluid concentrations of essential and nonessential amino acids was found only in the gastroschisis group (P < 0.05). The detection of significantly higher amino acid concentrations in the amniotic fluid of fetuses with a gastroschisis defect than in healthy fetuses suggests the occurrence of amino acid malabsorption or of amino acid leakage from the fetus into amniotic fluid.

Hormona del crecimiento y prolactina en líquido amniótico y plasma materno durante el embarazo normal / Growth hormone and prolactin in maternal plasma and amniotic fluid during normal gestation

Objective. To measure the concentration of human growth hormone (GH) and prolactin (PRL) In maternal plasma (MP) and amniotic fluid (AF) during gestation and to evaluate their correlation. Methods. HC and PRL were measured by radioimmunoassay in 60 healthy women with uncomplicated singleton pregnancies at 16-36 weeks of gestation (WG). Trends of both hormones were estimated throughout pregnancy. The correlation of either hormone measured in different fluids was also estimated. Results. GH in AF (AF-GH) decreased significantly throughout pregnancy; (AF-GH = 21.32 - 0.54 X WG, r = -0.72 [95% confidence intervals (95% CI) -0.57-0.82], p = 0.001), and increased in MP (MP-GH); (MP-GH = 2.73 +0.11 X WG, r = 0.45 [95% CI, 0.21-0.63]p = 0.05). The correlation between MP-GH and AF-GH was, (AF-GH = 16.28 - 1.54 x - M-PGH, r = -0.47 [95% CI, -0.64 --0.21]; p = 0.01). PRL values did not show significant differences neither in AF (AF-PRL / WG, r = 0.06, p = 0.6) nor in MP (MP-PRL / WG, r = 0.25, p = 0.14) during pregnancy, being AF-PRL (mean 151.3 ng/mL, SD 34.2 ng/mL) significantly higher than MP-PRL (mean 119.3 ng/mL, SD 55.4 ng/mL) (p = 0.006) in all the studied period. Conclusion. AF-GH and MP-GH showed a significant negative correlation during pregnancy. PRL measured in AF and PM did not show changes throughout gestation being AF-PRL significantly higher than MP-PRL.

Objetivo. Medir los valores de hormona del crecimiento (HC) y prolactina (PRL) en el líquido amniótico (LA) y en el plasma materno (PM) durante el embarazo normal y analizar sus asociaciones. Métodos. HC y PRL fueron medidas en el LA y en el PM por medio de radioinmunoanálisis en 60 mujeres con embarazo único y sin complicaciones entre 16 y 36 semanas de gestación (SG). Se evaluaron las tendencias de ambas hormonas a lo largo del embarazo y la correlación entre los valores obtenidos en ambos compartimentos. Resultados. La HC en LA (HCLA) disminuyó en forma significativa durante el embarazo (HCLA = 21.32 - 0.54 X SG, r = -0.72 [intervalos de confianza al 95% (IC 95%) -0.57-0.82], p = 0.001) y en PM (HCPM) aumentó (HCPM = 2.73 + 0.11 X SG, r = 0.45 [IC 95%, 0.21-0.63] p = 0.05). La correlación entre los valores de HC en LA y en PM fue: (HCLA = 16.28-1.54 x -HCPM, r = -0.47 [IC 95% -0.64 -0 -0.21]; p = 0.01). La concentración de PRL a lo largo del embarazo tanto en LA (PRL-LA/SG, r = 0.06, p = 0.6) como en PM (PRL-PM/SG r = 0.25, p = 0.14) no cambió y fue significativamente más alta en LA que en PM (LA; media 151.3 ng/mL, DE 34.2 ng/ inL, PM; media 119.3 ng/mL, DE 55.4 ng/mL, respectivamente, p = 0.006). Conclusiones. HC en PM y HC en LA presentan una correlación inversa a lo largo del embarazo, en tanto que los valores de PRL en ambos compartimentos no cambian, siendo significativamente más elevados en el LA.

Rapid Prenatal Diagnosis of Trisomy 21 by Real-time Quantitative Polymerase Chain Reaction with Amplification of Small Tandem Repeats and S100B in Chromosome 21

Trisomy 21 (Down syndrome) is the most common congenital anomaly, and it occurs in one out of 700-1000 births. Current techniques such as amniocentesis and chorionic villi sampling (CVS) require lengthy laboratory culture procedures and high costs. This study was undertaken to establish a rapid prenatal diagnosis of trisomy 21 using real-time quantitative polymerase chain reaction (PCR) of fetal DNA from amniotic fluid. Real-time quantitative PCR was performed with DNA templates obtained from 14 normal blood samples, 10 normal amniotic fluid samples, 14 Down syndrome blood samples, and 7 Down syndrome amniotic fluid samples. Primers for D21S167 and S100B of chromosome 21 were used. Primers that direct the amplification of the 165-bp fragment of the insulin-like growth factor (IGF) -1 gene on chromosome 12 using a PCR primer were included to generate an internal standard for quantitation. The relative levels of D21S167 and S100B were 2.6 and 2.4 times higher in the blood of Down syndrome patients than those in the control group. The differences between these two groups were statistically significant (p-values were 0.0012 and 0.0016, respectively). The relative levels of D21S167 and S100B were 2.1 and 2.7 times higher in the amniotic fluid of Down syndrome fetuses than those in the control group. The difference between these two groups was statistically significant (p-values were 0.0379 and 0.0379, respectively). Prenatal diagnosis of trisomy 21 by real-time quantitative PCR using STR (small tandem repeats) amplification of D21S167 and S100B is a useful, accurate and rapid diagnostic method. Furthermore, it may also be useful for prenatal diagnosis with fetal DNA from maternal blood, and for preimplantation genetic diagnosis and prenatal counseling.

Methylmalonic acid in amniotic fluid and maternal urine as a marker for neural tube defects / 华中科技大学学报（医学）（英德文版）

To evaluate the implication of methymalonic acid (MMA) in the early diagnosis of neural tube defects (NTD), a quantitative assay for MMA was established by using gas chromatography-mass spectrometry with stable isotope of MMA as an internal standard. Amniotic fluid and maternal urine MMA concentration, maternal serum folate, red blood cell folate and vitamin B12 levels were measured in the middle term of NTD-affected and normal pregnancies. Amniotic fluid and maternal urine MMA concentrations in the middle term of NTD affected pregnancies (1.4 +/- 0.9 micromol/L, and 22.1 +/- 12.6 nmol/micromol creatinine) were significantly higher than that of normal pregnancies (1.0 +/- 0. 4 micromol/L, and 2.5 +/- 1.1 nmol/micromol creatinine). There was no significant difference between normal and NTD pregnancies for serum folate, red blood cell folate and vitamin B12 levels. The results suggested that MMAs in amniotic fluid and maternal urine are sensitive markers for early diagnosis of NTD. Vitamin B12 is an active cofactor involved in the remethylation of homocycteine and its deficiency is an independent risk factor for NTD. MMA is a specific and sensitive marker for intracellular vitamin B12 deficiency. This study suggests that it is necessary to monitor the vitamin B12 deficiency and advocates vitamin B12 supplementation with folate prevention program.

Diagnóstico prenatal y manejo perinatal de defectos nefrourológicos / Prenatal diagnosis and perinatal management of nephrourologic abnormalities

Los defectos nefrourológicos tienen una alta frecuencia en el examen ultrasonográfico prenatal. Los defectos mayores de riñones o vejiga son vistos en aproximadamente 2 a 3 por 1000 embarazos, sobre 2 por ciento de los fetos tiene un diagnóstico menos grave. Los defectos nefrourológicos pueden ser únicos o formar parte de un síndrome genético. El objetivo de este trabajo es presentar la experiencia recopilada durante cinco años en diagnóstico prenatal y manejo perinatal de defectos nefrourológicos. Nuestro servicio cuenta con un equipo de ultrasonografistas que realizan exámenes a pacientes del área del Servicio de Salud Metropolitano Occidente; se cuenta además con la participación de un grupo multidisciplinario de médicos compuesto por neonatólogos, genetistas y cirujanos infantiles con los cuales se revisan los casos y se discute él diagnóstico, pronóstico y tratamiento perinatal de nuestras pacientes

Patologías del líquido amniótico: I: Polihidramnios: incidencia y repercusión perinatal / Pathologics of the amniotic fluid: I: Polyhydramnios perinatal repercussion and incidence

Conocer la incidencia del polihidramnios por ultrasonido y su repercusión perinatal. Se realizó un estudio descriptivo en 4.155 pacientes durante 1988-1998 diagnosticándose 161 casos. Se empleó el índice del líquido amniótico para diagnóstico. Servicio de Perinatología, Hospital "Dr. Adolfo Prince Lara", Puerto Cabello, Estado Carabobo, Venezuela. La incidencia fue de 3,87 por ciento. Las principales patologías relacionadas fueron: la diabetes 48 por ciento (48 casos), macrosonomía fetal 25 por ciento (25 casos), incompatibilidad Rh-9 por ciento (9 casos), malformación fetal 6 por ciento (6 casos). Se atendieron en el hospital 86 pacientes, 67,44 por ciento fueron cesáreas (58 casos) y parto vaginal 32,56 por ciento (28 pacientes). Hubo tratamiento médico en 22,09 por ciento (19 casos), amniocentesis descompresiva 1,16 por ciento (1 caso). La principal morbilidad materna fue el parto pretérmino 10,47 por ciento (9 pacientes) y rotura prematura de membranas 3,49 por ciento (3 pacientes). La morbilidad perinatal global 70, 93 por ciento (61 casos) dado por la macrosomía neonatal 27,91 por ciento (24 recien nacidos), prematurez 10,47 por ciento (9 casos) y malformaciones 8,14 por ciento (7 casos); con una mortalidad perinatal de 17,44 por ciento (15 casos), fetal 5,81 por ciento (5 casos) y neonatal 11,63 por ciento (10 casos). La identificación ecográfica de polihidramnios nos obliga a una exhaustiva pesquisa de las patologías relacionadas para abatir la elevada morbi mortalidad perinatal

Elevated amniotic fluid angiogenin levels are associated with fetoplacental ischemia in pregnancies with high midtrimester maternal serum alpha-fetoprotein

In this study, angiogenin [a potent inducer of neovascularization] was tested in mid trimester amniotic fluid of patients with elevated maternal serum alpha-fetoprotein values to determine whether alpha- fetoprotein elevation is due to ischemia with subsequent stimulation of angiogenesis. Nine patients with elevated maternal serum alpha- fetoprotein levels at triple screen were matched with two controls regarding the year of amniocentesis and maternal age, race and parity. It was concluded that mid trimester amniotic fluid angiogenin levels were significantly elevated in patients with elevated mid trimester maternal serum alpha-fetoprotein levels. The elevation of maternal serum alpha-fetoprotein levels at triple screen was due to placental ischemia