Glycemic control and maternal and fetal outcomes in pregnant women with type 1 diabetes according to the type of basal insulin.

OBJECTIVE: To examine the potential role of the type of basal insulin on glycemic control and maternal and foetal outcomes in pregnant women with type 1 diabetes (T1DM). STUDY DESIGN: Retrospective cohort study of pregnancies attended at 18 Spanish tertiary hospitals. INCLUSION CRITERIA: T1DM, singleton pregnancies, delivery between 2002-2010, and use of the same basal and prandial insulin from before pregnancy until delivery. RESULTS: A total of 1534 pregnancies were included. The basal insulin most commonly used was Neutral Protamine Hagedorn (NPH) (51.7%), followed by glargine (23.2%) and continuous subcutaneous insulin infusion (CSII) (21.1%). CSII users had longer diabetes duration. Multiple logistic regression analysis showed that CSII was independently associated with lower doses of insulin, higher glycated haemoglobin (HbA1c) in all trimesters, and higher rates of miscarriage, preterm birth and neonatal hypoglycemia. Glargine was related to a higher risk of preterm birth and a small-for-gestational age infant (SGA). The odds ratios (OR) of the associations between insulin type and clinical outcomes (from 0.642 to 4.894) have a relevant magnitude. CONCLUSIONS: In this observational study of pregnant women with T1DM, the type of basal insulin was independently associated with metabolic variables and foetal outcomes.

Embarazo ectópico sobre cicatriz de cesárea anterior / Ectopic pregnancy in a previous cesarean section scar

El embarazo implantado sobre la cicatriz de una cesárea anterior constituye la localización más infrecuente de los embarazos ectópicos y, posiblemente, es una de las más peligrosas por el riesgo de rotura uterina y hemorragia que comporta. Se trata de una entidad rara, con pocos casos publicados en la bibliografía mundial y en la que el diagnóstico diferencial puede llegar a ser muy dificultoso. La incertidumbre en los criterios diagnósticos y en su pronóstico hace que no exista hoy un consenso aceptado sobre cuál es la mejor opción terapéutica (AU)

Síndrome de transfusión feto-fetal / Twin-twin transfusion syndrome

El síndrome de transfusión feto-fetal (STFF) es una complicación que se presenta en un 10-15 per cent de las gestaciones gemelares monocoriales biamnióticas. Es una afección exclusiva de este tipo de gemelaridad y se caracteriza por la presencia de anastomosis arteriovenosas cuyo flujo unidireccional no está equilibrado por otras conexiones vasculares y, por consiguiente, se produce la secuencia oligoamnios-hidramnios. La afección fetal es debida a una hipovolemia del gemelo donante y a una hipervolemia del gemelo receptor. Presentamos nuestra experiencia en este tipo de enfermedad. En los casos presentados, diagnosticados al final del segundo trimestre, se llevaron a cabo como medida terapéutica amniodrenajes seriados, los cuales permitieron prolongar la gestación para la maduración pulmonar fetal, aunque no solucionaron el STFF. Realizamos, asimismo, una revisión en cuanto a las diferentes opciones de tratamiento actual que van desde la conducta expectante, con una mortalidad cercana al 100 per cent, hasta los tratamientos etiológicos basados en la ablación selectiva con láser de los vasos comunicantes con una supervivencia de al menos un gemelo del 70 per cent, con una tasa de handicap neurológico menor al 5 per cent. (AU)

Tissue factor levels and high ratio of fibrinopeptide A:D-dimer as a measure of endothelial procoagulant disorder in pre-eclampsia.

To assess coagulation activation and endothelial cell injury in normotensive and pre-eclamptic pregnant women, a comparison was made of plasma levels of tissue factor, fibronectin, fibrinopeptide A and D-dimer. Samples were taken from 50 nonpregnant women, 40 normotensive pregnant women in the third trimester and 27 women with pre-eclampsia after diagnosis and before treatment. High levels of fibrinopeptide A and D-dimer were found in pre-eclamptic women. Moreover, the ratio fibrinopeptide A:D-dimer was much greater in the pre-eclampsia group than in normotensive pregnant women. The levels of fibronectin and tissue factor were also higher in the pre-eclampsia group. The increase of tissue factor levels suggests an alteration of the extrinsic coagulation pathway in pre-eclampsia. The increase of fibrinopeptide A:D-dimer ratio shows that the activation of coagulation is associated with a relative hypofibrinolysis in pre-eclampsia.

Endothelial cell lesion in preeclampsia. Morphofunctional study using umbilical endothelial cells.

Morphofunctional study of umbilical cords from pregnancies complicated by preeclampsia shows both activation and lesion of endothelium. The cellular findings in umbilical cords from pregnancies complicated by preeclampsia can be summarized as: (i) higher number of cells with secretion bladders and increase in the number and size of both secretion bladders and microvilli-like protrusions; (ii) increase in collagen, fibrin, fibronectin and lipidic vesicles in the vessel wall; (iii) vacuolization of endothelial cells; (iv) presence of lipidic vacuoles and lipophages in the vessel wall; (v) erosion and disorganisation of the endothelium that exposes extracellular proteins to the blood flow. Endothelial cell cultures from preeclamptic pregnancies show kinetic disorders and cell detachment. The results confirm that an endothelial cell lesion occurs in preeclampsia and this cellular disorder can be reproduced in vitro.

Coagulation and fibrinolysis parameters in normal pregnancy and in gestational diabetes.

The changes in coagulation and fibrinolysis parameters during pregnancy, delivery and 3 days after delivery were evaluated in normotensive and gestational diabetes pregnant women. Normal pregnant women (n = 60) and pregnant women with gestational diabetes (n = 15) formed the study population. Coagulation and fibrinolysis parameters were estimated using commercial tests. Antithrombin III, thrombin-antithrombin III complexes, heparin cofactor II, protein C, protein S, tissue plasminogen activator, (t-PA) D-dimer and plasminogen activator inhibitor (PAI-1 and PAI-2) activities in normal and gestational diabetes pregnancies were determined. Thrombin-antithrombin III complexes increased and coagulation inhibitors decreased in gestational diabetes. Plasminogen activator inhibitors remained unchanged and t-PA levels increased in gestational diabetes.

Endothelial cell markers and fibrinopeptide A to D-dimer ratio as a measure of coagulation and fibrinolysis balance in normal pregnancy.

OBJECTIVE: Changes in hemostatic system were evaluated in healthy pregnant women. METHODS: Blood was sampled in the 1st, 2nd and 3rd trimesters of gestation, during delivery and 3 days postpartum and plasma factors were measured using commercial tests. RESULTS: Thrombin-antithrombin III complexes, fibrinopeptide A and D-dimer were higher during pregnancy. The endothelial cell markers, fibronectin and tissue factor, remained within the normal reference values in the healthy nonpregnant population. This result suggests no endothelial injury and shows no activation of extrinsic coagulation pathway during pregnancy. The balance coagulation/fibrinolysy is maintained during pregnancy and delivery, as shown by the ratio fibrinopeptide A/D-dimer, however, a tendency towards coagulation process is developed in the early puerperium.

Diagnosis and treatment in utero of goiter with hypothyroidism caused by iodide overload.

A fetal goiter was detected by ultrasonography in a woman receiving potassium iodide. After this medication was discontinued at 29 weeks, a fetal hypothyroidism was confirmed by cordocentesis, and two doses of levothyroxine were administered by amniocentesis. At 34 weeks repeated cordocentesis showed fetal euthyroidism and ultrasonography shrinkage of the goiter. Growth and development normal at 1 year.

Heparin cofactor II: a new marker for pre-eclampsia.

The plasma levels of heparin cofactor II were determined in pregnant women who were either normotensive, or had essential hypertension, gestational hypertension or pre-eclampsia during the third trimester and 72 h after delivery. Heparin cofactor II levels in the pre-eclampsia group were depressed. The clinical relevance of this finding is the potential utility of heparin cofactor II plasma levels in the differential diagnostic between non-proteinuric hypertension and pre-eclampsia.

Coagulation and fibrinolytic parameters in normal pregnancy and in pregnancy complicated by intrauterine growth retardation.

The objective of this article is to evaluate the plasma levels of coagulation and fibrinolysis parameters in the third trimester of gestation and 72 hr postdelivery. Antithrombin III (ATIII), thrombin-antithrombin III complexes (TAT), heparin cofactor II (HCII), protein C (PC), protein S (PS), tissue plasminogen activator (t-PA), D-dimer, and plasminogen activator inhibitors (PAI-1 and PAI-2) levels in uncomplicated pregnancies and in pregnancies complicated by intrauterine growth retardation (IUGR) have been determined. Normal pregnant women (n = 63) and women whose was complicated by IUGR (n = 10) formed the study population. Coagulation and fibrinolysis parameters were estimated using commercial tests. There were no differences in ATIII, HCII, and PS levels between normal and IUGR pregnancies. TAT, t-PA, and D-dimer levels were higher in IUGR pregnancy than in the uncomplicated pregnancy group. PAI-1 and PAI-2 were found depressed in IUGR pregnancy when compared with normal pregnancy. Changes in coagulation and fibrinolytic systems occur in plasma of women with pregnancies complicated by IUGR. The results suggest an activation of the coagulation system in pregnancies complicated by IUGR. Reduced PAI-2 and high TAT levels correlate with birth weight. In IUGR pregnancies a hypercoagulative state with hyperfibrinolytic compensatory mechanisms is suggested.

Fibrinolysis changes in normal pregnancy.

The aim of this study was to evaluate the changes in fibrinolysis parameters during pregnancy. Normal pregnant women (n = 60) formed the study population. Blood samples were taken in the first, second and third trimester, during delivery and three days after delivery. Fibrinolysis parameters were estimated using commercial tests. Tissue plasminogen activator, D-dimer and plasminogen activator inhibitors (PAI-1 and PAI-2) were determined. Tissue plasminogen activator and D-dimer increased after the first trimester and reached maximum levels during delivery. Plasminogen activator inhibitors type 1 and type 2 were also higher, in particular PAI-2, and reached maximum levels in the third trimester. On the third day after delivery, fibrinolysis activity recovered, but D-dimer and PAI-2 levels remained above the normal non-pregnant range.

[Validation of perinatal causes of death in death certificates]. / Validación de las causas de muerte perinatal de los boletines estadísticos de defunción.

OBJECTIVE: The objective of this study was to assess the validity of perinatal causes of death in death certificates and the influence of some variables related to perinatal mortality. PATIENTS AND METHODS: All perinatal deaths having occurred in Barcelona in 1994 and reported in death certificates were included. Additional sources of information were certificates of abortions and also other documents such as autopsy reports and medical records, that served as references to determine the most reliable or standard cause of death (SBC) The SBC was determined by a group of experts. The validity was assessed by comparing the cause of death as stated in the death certificate (BC) and the SBC, calculating the general agreement, the detection rate (DR) or sensitivity and the confirmation rate (CR) or positive predictive value. The chi-square test was used to compare proportions. RESULTS: In 166 (91.2%) of the 182 cases, the BC and SBC were assigned to the same group of the International Classification of Diseases. For congenital defects, the DR was 85.7 (95% CI: 75.1-96.3) and the CR was 81.8 (95% CI: 70.4-93.2). For problems in the perinatal period the DR was 95.6 (95% CI: 92.1-99.1) and the CR was 94.9 (95% CI: 91.2-98.6). Both were considered reliable causes. These rates were similar for the different categories of other variables (birth weight, gestational age, vital status, sex, hospital of birth, autopsy and mother's age). Nevertheless, in the study of detailed causes (3 digits of the International Classification of Diseases) the general agreement was much lower (40.1%). Except for the congenital defects of the nervous system, the remaining causes of death had a low validity. CONCLUSIONS: This study shows the low validity of detailed causes of perinatal death reported in death certificates. It is necessary to improve the completion and coding of death certificates following the WHO recommendations.

[Markers of hypercoagulability during pregnancy: thrombin-antithrombin-III complexes and D dimer]. / Marcadores de hipercoagulabilidad durante el embarazo: complejos trombina-antitrombina-III y dímero D.

Pregnancy can be regarded as a secondary hyper-coagulability state. The development of thrombin-anti-thrombin complexes (TATC), D dimer and anti-thrombin III (AT III) was analysed in the present work on 33 pregnant women. A significant increase of the TATC records was found between the first and third trimesters and between the second and third trimesters (p = 0.005 and p = 0.02, respectively). The AT III values were within the normal range. The values of the D dimer increased progressively during pregnancy, but only the figures achieved in the third trimester were statistically significant with respect to the control group (p = 0.14). The increase of TATC and D dimer during pregnancy are considered as hypercoagulability.

Conservative treatment of intrapartum fetal acidosis with a betamimetic agent.

553 cases of intrapartum fetal acidosis (pH less than 7.25) were treated with a betamimetic agent (ritodrine 250-300 micrograms/min). In 403 cases (72.8%), an improvement of fetal pH greater than 0.05 pH U was observed. Improvement was comparable in cases where the cause of fetal distress was abnormal uterine activity and in those where this was not the cause. Indeed, the recovery rate was the same, independent of the percentage of uterine activity inhibition. The neonatal condition was better in the pH recovered versus not recovered group. We suggest that conservative treatment of fetal distress with betamimetic drugs is a reasonable measure for improvement of fetal and neonatal condition.

Long-term hospitalization and beta-mimetic therapy in the treatment of intrauterine growth retardation of unknown etiology.

A group of 98 third trimester pregnant women whose ultrasonographic studies raised the suspicion of intrauterine fetal growth retardation was studied. The patients were randomly assigned to two groups: Group A (Treatment group: 44 patients) and Group B (Control group: 54 patients). All patients were admitted to the hospital upon diagnosis for baseline evaluation. Those in Group A remained in the hospital until delivery (mean stay 15 +/- 5 days) and received treatment with 10 mg/t.i.d. of p.o. ritodrine. Group B patients were discharged after an average stay of 7 +/- 3 days. This group was not treated with ritodrine, and they were seen weekly in an outpatient setting. The prevalence of low-birth-weight infants for their gestational age was 47.73% in the treatment group and 40.74% in the control group. Of the deliveries in the treatment group, 40.9% were induced (half for fetal indications). In the control group 35.18% of the induced labors was (47.35% for fetal indications). Of the cases in the treatment group 18.18% were delivered by cesarean section, of which 62.5% were performed for fetal distress. The control group showed similar figures: 16.66% cesarean sections with 77.7% of them done for fetal distress. We observed an incidence of 20.45% of acute fetal distress in the study group against 12.96% in the control group. Such a difference is not statistically significant. The group under study demonstrated a rate of 6.82% pathological pH value in the umbilical artery, while the rate of abnormal values in the control group was 18.52%. In both groups, the greatest percentage of acidotic pH was observed in patients with IGR.(ABSTRACT TRUNCATED AT 250 WORDS)