Early life corticosteroid overexposure: Epigenetic and fetal origins of adult diseases.

The relationship between events occurring during intrauterine development and later-life predisposition to long-term disease, has been described. The fetus responds to excess intrauterine exposure to high levels of corticosteroids, modifying their physiological development and stopping their growth. Fetal exposure to elevated levels of either endogenous (alterations in fetal hypothalamic-pituitary-adrenal axis) or synthetic corticosteroids, is one model of early-life adversity; to developing adult disease. At the molecular level, there are transcriptional changes in metabolic and growth pathways. Epigenetic mechanisms participate in transgenerational inheritance, not genomic. Exposures that change 11ß-hydroxysteroid dehydrogenase type 2 enzyme methylation status in the placenta can result in transcriptional repression of the gene, causing the fetus to be exposed to higher levels of cortisol. More precise diagnosis and management of antenatal corticosteroids for preterm birth, would potentially decrease the risk of long-term adverse outcomes. More studies are needed to understand the potential roles of factors to alter fetal corticosteroid exposure. Long-term infant follow-up is required to determine whether methylation changes in placenta may represent useful biomarkers of later disease risk. This review, summarize recent advances in the programming of fetal effects of corticosteroid exposure, the role of corticosteroids in epigenetic gene regulation of placental 11ß-hydroxysteroid dehydrogenase type 2 enzyme expression and transgenerational effects.

Histerectomía obstétrica: análisis de 15 años / Obstetric hysterectomy: analysis of 15 years

Determinar la incidencia, factores asociados y repercusiones de la histerectomía obstétrica. Estudio retrospectivo, descriptivo, analítico y transversal que incluyó 50 pacientes sometidas a histerectomía obstétrica en 64293 casos obstétricos, durante un período de 15 años (del 01 de agosto de 1993 al 31 de julio de 2008). Departamento de Obstetricia y Ginecología. Hospital Nuestra Señora de Chiquinquirá. Maracaibo, Venezuela. La incidencia de histerectomía obstétrica fue 0,07 por ciento (1 HO por 1 285 casos obstétricos). Fue más frecuente en mujeres entre 25-29 años (26 por ciento), IV gestas (34 por ciento), para 3 (26 por ciento), con control prenatal (63,33 por ciento), embarazos de 37-41semanas (56 por ciento), poscesárea (46 por ciento), histerectomía tipo total (86 por ciento), indicadas por atonía uterina (38 por ciento), complicadas con anemia (88 por ciento), ameritaron transfusión sanguínea (84 por ciento) y duraron <7 días de hospitalización (56 por ciento). Hubo 8 muertes maternas (16 por ciento) y la tasa de mortalidad materna ajustada fue 792 por 10000 nacidos vivos. Hubo 9 abortos (18 por ciento), 15 muertes fetales (30 por ciento) y la tasa de mortalidad perinatal fue 129 por 1000 nacidos vivos. En la población estudiada, la histerectomía obstétrica fue poco frecuente, más comúnmente indicada por trastornos hemorrágicos y tuvo cifras de morbilidad y mortalidad materna elevadas

To determine the incidence, associated factors and repercussions of obstetric hysterectomy. Retrospective, descriptive, analytic and transversal study that included 50 obstetric hysterectomies (OH) in 64293 obstetrics cases, during fifteen years (from August 1st, 1993 to July 31th, 2008). Department of Obstetrics and Gynecology. Our Lady of Chiquinquira Hospital. Maracaibo, Venezuela. The incidence of OH was 0.07 percent (1 OH by 1285 obstetric cases). It was more frequent in women between 25-29 years (26 percent), IV gestations (34 percent), para 3 (26 percent), prenatal care (63,33 percent), pregnancies 37-41 weeks (56 percent), after cesarean section (46 percent), total hysterectomy (86 percent), uterine atony as mean indication (38 percent), complicated with anemia (88 percent), blood transfusion (84 percent) and discharged home <7 days length of stay (56 percent). There were 8 maternal deaths (16 percent) and adjusted maternal mortality rate was 792 by 10000 live births. There were 9 abortions (18 percent), 15 fetal deaths (30 percent) and adjusted perinatal mortality rate was 129 by 1000 live births. Obstetric hysterectomy in the studied population, was not frequent, commonest indicated by hemorrhagic disorders and there were high maternal morbidity and mortality

Prediction and prevention of preeclampsia.

Preeclampsia increases maternal and perinatal morbidity and mortality rates. Much research has been done to identify unique screening tests that would predict the risk of developing preeclampsia before the classic symptoms appear. The possible use of a screening test with high predictive accuracy in patients with high-risk or low-risk of preeclampsia remains to be investigated. At present, the search for additional tests continues. There is growing interest in the use of combinations of tests. Effective primary prevention is not possible because the causes are still unknown, but to identify and to modify susceptible risk factors might decrease the frequency of preeclampsia. A community guideline improves the screening and early detection of preeclampsia, and uniforms the referral thresholds and assessment procedures. Secondary prevention with calcium supplementation and aspirin administration during pregnancy are beneficial in low calcium intake women and in the patient at a very high risk of developing severe early onset disease. Lifestyle choices, dietary nutritional measures (antioxidant as vitamin C, vitamin E, lycopene, selenium, zinc, magnesium and the mitochondrial antioxidants nicotine, coenzyme Q(10) and melatonin; and other dietary nutritional measures as low dietary salt, omega 3 fatty acids, folic acid, garlic, nutritional advice, protein and energy supplementation, isocaloric balanced protein and protein and energy restriction for obese women) and others drugs; have not shown benefits or there is insufficient evidence to recommend clinical use. Proper antenatal care and timed delivery are of utmost importance in tertiary prevention.

[Evidence-based obstetric conduct. Severe preeclampsia: aggressive or expectant management?]. / Conducta obstétrica basada en evidencias. Preeclampsia severa: tratamiento agresivo o expectante?

In severe preeclampsia, delivery is assisted immediately without thinking in fetal conditions. Some decades ago, there is agreement to hospitalize, but there is no agreement between expectant or aggressive management. Here are revised these two management evidence based medicine. Fifteen non randomized non controlled trials in English and 4 in Latin American literature highlight 10-14 days pregnancy prolongation without increase maternal morbidity with conservative management; but there were criticized by non random patient selection and non controlled. Two randomized controlled trials showed improvement in neonatal results with no change in maternal, with expectant management. One systematic review of these two trials concluded there is not sufficient data to any reliable recommendation and proposes longer trials are necessary. In United States, National Working Group in the High Blood Pressure Educational Program believes expectant management is only possible in selective women group between 23-32 weeks. The American College of Obstetricians and Gynecologist recommends this management in a tertiary care setting or in consultation with an obstetrician-gynecologist with training in high risk pregnancies. Expectant management present proposal in severe preeclampsia remote from term is summarized.

[Thyroid dysfunctions and pregnancy]. / Disfunciones tiroideas y embarazo.

OBJECTIVE: To study thyroid dysfunctions during pregnancy. PATIENTS AND METHOD: Descriptive, transversal and retrospective study of 61 thyroid dysfunctions during pregnancy, from January 1982 to December 2002. RESULTS: There were 44 hyperthyroidism (1 in 1,908 deliveries: 0.05%) and 17 hypothyroidism (1 in 4,939: 0.02%). Main findings in hyperthyroid patients were: 30-34 years and 2 gestations (34.11%), arterial hypertension (15.90%), abortions (9.09%), preterm delivery (9.09%), term delivery (56.82%), cesarean section (25%), medical treated (97.78%), fetal weighs 3,000-3,499 g (25.61%), 1 and 5 minutes Apgar 8-10 points (60.54 and 81.59%), perinatal mortality rate 0.07 per 1,000 and there was no maternal mortality. And in hypothyroid women: 25-29 years (64.72%), one gestation (29.44%), abortions (17.64%), premature rupture of membranes and oligoamnios (17.64%), term delivery (35.28%), medical treated (100%), fetal weighs 2,500-2,999 g (56.25%), 1 and 5 minutes Apgar 8-10 points (78.58% and 78.58%) and there was no preterm delivery and perinatal or maternal mortality. CONCLUSIONS: Thyroid dysfunctions are infrequent in pregnancy and have little repercussions in perinatal morbidity and mortality.

[Vaginal leiomyoma]. / Leiomioma vaginal.

Vaginal leiomyomas are rare benign tumors. This is a case report with menstrual and urinary difficulties and vaginal mass with inner urethral meatus and hymen displacement. Miccional cystourethrography showed a posterior displaced, comprised and elongated urethra. Excretory urography and pelvic sonogram were normal. Preurethral enucleation extirpation with no complications was practiced. Current literature is reviewed.

[Obstetric behavior based on evidences. Mild preeclampsia: expectant management, inpatient or outpatient?]. / Conducta obstétrica basada en evidencias. Preeclampsia leve: manejo expectante, hospitalario o ambulatorio?

Preeclampsia is a multifactorial disease of unknown ethiology and definitive treatment is delivery. Before, the tendency was to avoid maternal complications, for what the pregnancy was interrupted without caring the fetal conditions. For some decades, the expectant handling has been preferred with the purpose of prolonging the pregnancy so that it matures the fetus and diminish the consequences on the perinatal morbility and mortality. There are divergent opinions on carrying out it in an ambulatory or hospital way. Here these two behaviors are revised with base in the medical discoveries. Initially, the hospital handling was based more in the clinical experience (observational evidence) that in controlled and aleatory studies. Three studies are shown carried out in the United States. In three controlled and randomized tests published in the United Kingdom this behavior was objected and it was intended the monitored ambulatory handling. In other two controlled and randomized trials and in two comparative trials, made also in the United Kingdom, it was suggested that the handling should be carried out in the units of care and fetal surveillance. In four observational studies it was intended the ambulatory handling, and the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy and American College of Obstetricians and Gynecologist considered it an option in selected women. The current proposal is summarized for the ambulatory handling of women with early mild preeclampsia.

Placenta percreta con ruptura uterina espontánea temprana / Placenta percreta with early spontaneous uterine rupture

La placenta percreta es la variedad menos común de acretismo placentario. El diagnóstico durante el embarazo es difícil, especialmente de manera temprana. Las complicaciones inciden en la elevada mortalidad perinatal y materna. La ruptura uterina posterior es menos frecuente, más difícil de diagnosticar y presenta más complicaciones que la anterior. Hasta el 2002, en Venezuela, se han publicado 7 casos de placenta percreta. Se presenta un caso más de placenta percreta con ruptura uterina posterior, complicada con hemoperitoneo, shock hipovolémico, coagulación intravascular diseminada, anemia e hipoxia severa y muerte fetal y materna

Morbimortalidad fetal y neonatal en embarazo gemelar: Hospital Chiquinquirá de Maracaibo: 1991-2000 / Fetal and neonatal morbi-mortality in twin pregnancy: Chiquinquirá Hospital Maracaibo: 1991-2000

Estudiar la morbilidad y mortalidad fetal neonatal en el embarazo gemelar: estudio descriptivo, transversal y retrospectivo de 335 embarazos gemelares entre enero 1991 - diciembre 2000. Departamento de Ginecología y Obstetricia. Hospital Chiquinquirá. Maracaibo, Venezuela. Las principales complicaciones feto-neonatales fueron: bajo peso al nacer (52,72 por ciento), nacimiento pretérmino (46,26 por ciento), trastornos respiratorios (22,21 por ciento) y restricción del crecimiento intrauterino (19,10 por ciento). Se encontró discordancia de peso entre gemelos al nacer > 10 por ciento, en 49,85 por ciento. La muerte ocurrió en 18,35 por ciento. La mortalidad fetal intermedia y neonatal temprana fueron 26,56 y 48,71 por ciento, respectivamente. Las causas más frecuentes: síndrome de dificultad respiratoria (59,16 por ciento), y asfixia (13,05 por ciento). La tasa de mortalidad perinatal fue 2,07 por 1000 nacidos vivos y fue ajustada a 140,7 por 1000 gemelos vivos. Se encontraron más muertes en los de más bajo peso, mayor vivos y fue ajustada a 140,7 por 1000 gemelos vivos. Se encontraron más muertes en los de más bajo peso, mayor discordancia de peso y parto vaginal. El orden de los gemelos no influyó

Gran mioma uterino y embarazo: reporte de un caso / Big uterine myoma and pregnancy: case report

Los grandes miomas uterinos son raros durante la gestación. Este es el reporte de un caso cuyo mioma pesó 2880 g que se resolvió por cesárea y miomectomía, sin complicaciones maternas perinatales

Embarazo gemelar en el Hopsital Chiquinquirá de Maracaibo 1991-2000 / Twin pregnancy an the Chiquinquira Hospital of Maracaibo 1991-2000

El objetivo de este trabajo es analizar el embarazo gemelar durante un decenio. Estudio descriptivo retrospectivo y transversal, de 348 embarazos gemelares atendidos entre enero 1991 y diciembre 2000 en el Departamento de Ginecología y Obstetricia. Hospital Chiquinquirá Maracaibo Estado Zulia. Hubo 1 embarazo gemelar por cada 106,49 nacimientos (0,93 por ciento). Las principales complicaciones maternas fueron: anemia (62,06 por ciento), parto prematuro (39,08 por ciento) y estados hipertensivos (21,55 por ciento). No hubo muertes maternas. El 52,57 por ciento de los neonatos pesó < 2500 g al nacer. El intervalo de nacimiento entre los gemelos fue < 20 minutos en 71,92 por ciento. El 54,96 por ciento fueron dicoriónicos. En la población estudiada, no usuaria de técnicas de reproducción asistida, el embarazo gemelar ha mantenido su incidencia. Se encontró elevado índice de complicaciones maternas y fetales. Se actualizan las cifras y se aportan datos originales

Placenta percreta / Placenta percreta

La placenta adherida al miometrio es muy rara. Varía entre 1:500 y 1:93 000 partos. La placenta percreta es el tipo menos común. Es importante porque las complicaciones pueden ser mortales. La ruptura uterina anterior es más frecuente que la posterior. En la literatura inglesa, entre 1899 y 1999, sólo se reportaron menos de 50 casos con hemoperitoneo. En Venezuela se han descrito 6 placentas percretas. En esta nota clínica se reporta un caso de placenta percreta con rotura uterina posterior, hemoperitoneo e invasión a epiplón.

Embarazo ístmico-cervical con invasión a región vésico-uterina / Isthmic cervical ectopic pregnancy with vesical uterine invasion

El embarazo ectópico cervical es muy raro. Entre 1978 y 1994, sólo se reportaron 120 casos en la literatura inglesa. En Venezuela se han descrito 4. En esta nota clínica se reporta un caso de embarazo ísmico-cervical con invasión a región vésico-uterina