Mouth opening limitation and influence of age and surgical location for static fully guided dental implant placement: an observational, cross-sectional clinical study.

The influence of age and region of the mouth was assessed in regard to mouth opening in fully guided implant placement. Ninety patients were included in this study, 30 in each of three age groups (20-34, 35-55, and >55 years). Maximum passive mouth opening was recorded in three locations: incisal, canine, and molar. The minimum distance required to allow the bone drilling sequence through a static fully guided approach was analysed for four implant systems: Straumann, MIS Dentsply, Astra Tech Dentsply, and Dentium. The mean ± standard deviation maximum mouth opening (all 90 patients) was 46.34 ± 7.70 mm, 36.82 ± 5.92 mm, and 30.99 ± 5.40 mm in the incisal, premolar, and molar region, respectively. No significant difference in mouth opening at any of the three locations was found between the age groups (all P > 0.05). However, a correlation was found between increasing age and decreasing average mouth opening in all three mouth regions; each additional 1 year resulted in a mean reduction of 0.13 mm, 0.09 mm, and 0.08 mm in the incisal, premolar, and molar region, respectively. The minimum required mouth opening was most likely to be met for implant placement in the incisal region (98.9% of all patients) and least likely to be met for placement in the molar region, particularly for older patients (as low as 30% of patients). Mouth opening remains a major limitation in fully guided implant surgery, especially in posterior areas and in older patients. The use of some implant systems in the posterior area may be limited to only one in three patients.

Short implants (<8mm) versus longer implants (≥8mm) with lateral sinus floor augmentation in posterior atrophic maxilla: A meta-analysis of RCT`s in humans.

BACKGROUND: One of the greatest challenges that dentists face today is to rehabilitate severe atrophied alveolar ridges in partially and completely edentulous patients with implants. Despite the high survival rate of implants placed next to sinus elevation, this technique presents complications that can be avoided by placing short implants, an option that also presents high survival rates. For this reason, the aim of this study is to compare the survival rate, marginal bone loss and complications associated with short implants (<8 mm) versus longer implants (≥8mm) placed with lateral sinus floor elevation in posterior atrophic maxillae. MATERIAL AND METHODS: A literature search was conducted by two independent reviewers in the PubMed/Medline (National Library of Medicine, Washington, DC) electronic database for articles published from January 2007 to July 2018. Seven qualified articles were selected for the meta-analysis. RESULTS: The test for overall effect did not find statistical significance in the survival rates, overall complications, intra-operative complications, post-operative complications and prosthetic complications. However, the test showed statistically significant differences in biological complications in favor of standard implants, and marginal bone loss between control and test groups in favor of short implants (<8mm) was found. CONCLUSIONS: Within the limitations of the present study, prosthetic rehabilitations with short implants (<8mm) in posterior maxilla is a reliable treatment option as an alternative to lateral wall sinus floor augmentation.

Osseoinductive elements around immediate implants for better osteointegration: a pilot study in foxhound dogs.

OBJECTIVE: The aim of this study was to evaluate the effects on osseointegration of topical applications of melatonin vs. vitamin D over surfaces of immediate implants. MATERIALS AND METHODS: Mandibular premolar distal roots (P2 , P3 , P4 ) were extracted bilaterally from six American Foxhound dogs. Three conical immediate implants were randomly placed bilaterally in each mandible. Three randomized groups were created: melatonin 5% test group (MI), vitamin D 10% test group (DI), and Control group implants (CI). Block sections were obtained after 12 weeks and processed for mineralized ground sectioning. Bone-to-implant contact (total BIC), new bone formation (NBF), inter-thread bone (ITB), and histological linear measurements (HLM) were assessed. RESULTS: At 12 weeks, all implants were clinically stable and histologically osseointegrated. Total BIC values were 49.20 ± 3.26 for the MI group, 49.86 ± 1.89 for DI group and 45.78 ± 4.21 for the CI group (P < 0.018) with statistically significant difference between the three groups. BIC percentage were 42.44 ± 2.18 for MI, 44.56 ± 1.08 for DI, and 41.95 ± 3.34 for CI groups respectively (P > 0.05). Inter-thread bone formation values were MI 17.56 ± 2.01, for DI 19.87 ± 0.92, and CI 14.56 ± 1.24 (P > 0.05). Statistically significant differences in peri-implant new bone formation were found between the three groups: MI 28.76 ± 1.98, DI 32.56 ± 1.11 and CI 25.43 ± 4.67, respectively (P < 0.045). Linear measurements showed that the MI group showed significantly less lingual crestal bone loss (CBL) (MI 0.59 ± 0.71), compared to DI (0.91 ± 1.21) and CI (0.93 ± 1.21) (P < 0.042), and less lingual peri-implant mucosa (PIM) (MI 3.11 ± 1.34),(DI 3.25 ± 0.18 compared with CI 3.54 ± 1.81 (P = 0.429). Linear measurements of buccal CBL showed significantly less buccal bone loss in test DI (0.36 ± 0.12) than CI (1.34 ± 1.23) and MI (1.11 ± 1.38) (P = 0.078). CONCLUSIONS: Within the limitations of this animal study, topical applications of 5% Melatonin or 10% vitamin D improved bone formation around implants placed immediately after extraction and helped to reduce CBL after 12 weeks osseointegration.

Do topical applications of bisphosphonates improve bone formation in oral implantology? A systematic review.

BACKGROUND: The aim of this systematic literature review was to evaluate the feasibility of topical bisphosphonate application for preserving/enhancing alveolar bone in oral implantology. MATERIAL AND METHODS: An electronic search was conducted in the PubMed/Medline, EMBASE, Scopus, Web of knowledge, and Google-Scholar databases for articles dated from January 2000 to December 2016. Two reviewers assessed the quality of the studies independently. RESULTS: A total of 154 abstracts were identified, of which 18 potentially relevant articles were selected; a final total of nine papers were included for analysis. Comparison of the findings of the selected studies was made difficult by the heterogeneity of the articles, all of them animal research papers that showed heterogeneity in the methodologies used and a high or moderate risk of bias. CONCLUSIONS: The topical application of bisphosphonate solution would appear to favor new bone formation in alveolar defects, and boosts the regenerative capacities of biomaterials resulting in increased bone density.

Osseoinductive elements for promoting osseointegration around immediate implants: a pilot study in the foxhound dog.

OBJECTIVE: The aim of this study was to evaluate the effects of topical applications of melatonin over implant surfaces placed immediately after extraction by means of histological and histomorphometric analysis of peri-implant tissues. MATERIAL AND METHODS: Six American foxhound dogs were used in the study; mandibular premolar distal roots were extracted. Thirty-six immediate conical implants were randomly assigned to the distal site on each site of the mandible in three groups: (Group CI) 12 titanium implants alone; (Group MI) 12 titanium implants supplemented with melatonin; and (Group DI) 12 titanium implants supplemented with vitamin D (DI). Prior to implanting test, implants (MI) were submerged in melatonin 5% solution, and implants from (DI) group were submerged in vitamin D 10% solution. No treatment was applied at control implants. After 12 weeks, animals were sacrificed. Block sections were obtained and processed for mineralized ground sectioning. Bone-to-implant contact (total BIC), new bone formation (NBF), inter-thread bone (ITB) and histological linear measurements (HLM) were analyzed. RESULTS: At 12 weeks, all implants were clinically stable and histologically osseointegrated. Total BIC values were 48.36 ± 7.45* for the MI group and 44.82 ± 10.98 for the CI group (P = 0.035) with statistically significant difference between groups. BIC% were 41.36 ± 3.93 for MI and 41.34 ± 9.26 for CI (P > 0.05). Inter-thread bone formation values were MI 15.99 ± 2.43* and CI 14.79 ± 3.62 (P = 0.03), MI showing significantly better results. No statistically significant differences in peri-implant new bone formation could be found between the two groups: MI 25.37 ± 2.32, CI 26.55 ± 7.75 (P > 0.05). Linear measurements showed that the MI group showed significantly less lingual crestal bone loss (CBL) (MI 0.52 ± 0.74*, CI 0.92 ± 1.98) (P = 0.045) and less lingual peri-implant mucosa (PIM) (MI 3.13 ± 1.41*, CI 3.71 ± 1.81) (P = 0.042). No significant differences were observed in the buccal aspect. CONCLUSIONS: Within the limitations of this animal study, the topical application of melatonin improved bone formation around immediate implants and reduced lingual bone and lingual peri-implant mucosa, after 12 weeks of osseointegration.

Doppler assessment of the aortic isthmus and perinatal outcome in preterm fetuses with severe intrauterine growth restriction.

OBJECTIVES: To evaluate the characteristics and association with perinatal outcome of the aortic isthmus (AoI) circulation as assessed by Doppler imaging in preterm growth-restricted fetuses with placental insufficiency. METHODS: This was a prospective cross-sectional study. Fifty-one fetuses with intrauterine growth restriction (IUGR) and either an umbilical artery (UA) pulsatility index (PI) > 95(th) centile or a cerebroplacental ratio < 5(th) centile were examined at 24-36 weeks' gestation. AoI impedance indices (PI and resistance index) and absolute velocities (peak systolic (PSV), end-diastolic and time-averaged maximum (TAMXV) velocities), were measured in all cases and compared with reference ranges by gestational age. Furthermore, fetuses were stratified into two groups according to the direction of the diastolic blood flow in the AoI: those with antegrade flow (n = 41) and those with retrograde flow (n = 10). Clinical surveillance was based on gestational age and Doppler assessment of the UA, middle cerebral artery and ductus venosus (DV). Adverse perinatal outcome was defined as stillbirth, neonatal death and severe morbidity (respiratory distress syndrome, bronchopulmonary dysplasia, Grade III/IV intraventricular hemorrhage, necrotizing enterocolitis and a neonatal intensive care unit stay > 14 days). RESULTS: Adverse perinatal outcome was significantly associated with an increased AoI-PI (area under the curve 0.77; 95% CI, 0.63-0.92; P < 0.005). A significant correlation (P < 0.001) was found between retrograde blood flow in the AoI and adverse perinatal outcome, the overall perinatal mortality being higher in the retrograde group (70% vs. 4.8%, P < 0.001). In 4/5 (80%) fetuses the reversal of flow in the AoI preceded that in the DV by 24-48 h. AoI-PSV and AoI-TAMXV were < 5(th) centile in 40/51 (78%) and 48/51 (94%) cases, respectively, whereas AoI-PI was > 95(th) centile in 21/51 (41%) cases. CONCLUSIONS: Retrograde flow in the AoI in growth-restricted fetuses correlates strongly with adverse perinatal outcome. Absolute velocities in the AoI are decreased in growth-restricted fetuses. The data suggest a potential role for Doppler imaging of the AoI in the clinical surveillance of fetuses with severe IUGR, which should be confirmed in larger prospective studies.

Customized birthweight standards for a Spanish population.

OBJECTIVE: To analyse the biological factors affecting birthweight and to derive customized birthweight standards for a Spanish population. METHODS: A retrospective cohort was created with all the singleton pregnancies delivered at term and free of pathology in our Institution. Birthweight was modeled by multiple linear regression from maternal (ethnic origin, maternal height, booking weight, smoking, and parity), and fetal (gender, gestational age) characteristics. RESULTS: In addition to gestational age and sex, height, booking weight, ethnic origin, parity, and smoking all have significant and independent effects on birthweight. Women from East-Asia, Morocco and South-America had newborns on average 83 g, 74 g and 95 g heavier than White-European Spanish women. The effect of smoking was found to be dose-related. CONCLUSION: We found the relative effect of the maternal and fetal characteristics to be very similar to that reported in previous studies. We report coefficients for ethnic groups that account for a sizeable proportion of the population composition of several European countries.

Association of smoking during pregnancy and fetal growth restriction: subgroups of higher susceptibility.

OBJECTIVE: To analyze the association between maternal smoking and fetal growth restriction, defined as a failure to achieve the growth potential, and to define subgroups of higher susceptibility for this association. STUDY DESIGN: A definition of growth restriction by customized birthweight standards applied to 13,661 non-malformed singleton deliveries. Customization was performed by maternal ethnic origin, height, booking weight, parity, gestational age at delivery and fetal gender. The adjusted risk of smoking for customized smallness-for-gestational age and the identification of subgroups with higher susceptibility were assessed by logistic regression. RESULTS: Overall, the adjusted odds ratio of smoking (all levels of exposure grouped) for the occurrence of growth restriction was 1.9 (95% confidence interval: 1.69-2.13). Smoking was etiologically responsible for 13.9% (95% confidence interval: 11.2-16.5) of the cases of growth restriction occurring in the population. Smoking resulted in an increasingly greater risk of growth restriction with progressive levels of cigarette consumption. The risk of smoking for fetal growth restriction was significantly greater in older women and those with a previous history of spontaneous preterm delivery. CONCLUSIONS: Smoking is associated with a higher risk for growth restriction. In addition, older pregnant women and those with a previous history of preterm delivery have an increased susceptibility.

Fertility assessment in non-infertile HIV-infected women and their partners.

The objective of the study was to assess the fertility of non-infertile couples seeking pregnancy in whom the woman was HIV infected. Therefore, a cross-sectional study was conducted between January 1998 and March 2005. A standardized fertility assessment was performed in all the included couples. A total of 130 women and 121 men were evaluated. Their median age was 34 years (range 22-43). Only 7.2% of the women were severely immunocompromised. The majority of women had regular cycles. Only one woman had an active sexually transmitted disease at the time of evaluation. A tubal occlusion on hysterosalpingogram was present in 27.8% of the women with no proven fertility. In 50.5% of the women, hepatitis C virus co-infection was present. One-third of the male partners (38/121) was infected with HIV. Abnormal semen parameters were observed in 83.4% of HIV-infected and 41.7% of HIV-uninfected partners (OR = 7; 95% CI = 2.1-23). It is concluded that the great majority of the HIV-infected women seeking pregnancy had a good infection status. Because in many of the couples, the women presented unexplained tubal occlusions and the men presented semen alterations, a hysterosalpingography and semen analysis should be part of the preconceptional investigations.

The use of a variable cut-off value of cervical length in women admitted for preterm labor before and after 32 weeks.

OBJECTIVE: To determine whether the optimal cut-off value to predict low risk of preterm delivery in women admitted for preterm labor should be adjusted for gestational age. METHODS: A cohort of 333 women with singleton pregnancies admitted with preterm labor and intact membranes between 24 and < 36 weeks' gestation was studied. The women were categorized according to prematurity into one of two groups: those admitted at < 32 weeks (Group 1, very preterm) and those admitted at >or= 32 weeks (Group 2, preterm). Transvaginal ultrasound was performed 24-48 h after admission and cervical length measured. The predictive value of different cut-off points was explored. Outcome variables were spontaneous preterm delivery within 7 days of admission and delivery at < 34 weeks. RESULTS: The mean ( +/- SD) gestational ages at admission and delivery were 31.9 ( +/- 2.6) and 37.5 ( +/- 2.2) weeks, respectively, and the mean ( +/- SD) cervical length was 30.4 ( +/- 8.9) mm. The rates of spontaneous delivery within 7 days and at < 34 weeks were 6.3 and 7.0%, respectively. The cut-off value of 15-mm cervical length showed a sensitivity, negative predictive value and false positive rate for delivery within 7 days of 0, 96.5 and 2.7% in the very preterm group, and 35.3, 94.6 and 4% in the preterm group, respectively. For a cut-off point of 25 mm, these values were 75, 99 and 14.3%, and 70.6, 96.8 and 24.5%. CONCLUSIONS: The predictive value of different cut-off points of cervical length is similar at different gestational ages. However, the higher false positive rate after 32 weeks' gestation might justify the adoption of gestational-age related cut-off values in clinical protocols. In women admitted at < 32 weeks' gestation, a cut-off point of 25 mm may be used to predict a low risk of preterm delivery, whereas in women admitted at 32 weeks or later, 15 mm might be more appropriate. Published by John Wiley & Sons, Ltd.

Sequential changes in uterine artery blood flow pattern between the first and second trimesters of gestation in relation to pregnancy outcome.

OBJECTIVE: To describe sequential changes in uterine artery waveform between the first and second trimesters of gestation and to analyze their association with the subsequent risk of hypertensive disorders and fetal growth restriction (IUGR). METHODS: Sequential uterine artery Doppler recordings were obtained in a final cohort of 870 singleton pregnancies over two gestational age intervals: 11-14 weeks and 19-22 weeks. The left and right uterine arteries were examined by color and pulsed Doppler and the mean pulsatility index (PI) as well as the presence of a bilateral protodiastolic notch were recorded during both intervals. Pregnancies were followed for occurrence of hypertensive disorders and IUGR. RESULTS: Mean uterine artery PI showed a significant linear decrease within each of the two intervals considered, while the prevalence of a bilateral notch showed decreasing values only throughout 11-14 weeks of gestation. Sixty-four (7.3%) pregnancies developed a hypertensive disorder and/or IUGR, including three (0.34%) cases of gestational hypertension, 24 cases of pre-eclampsia (2.75%) and 37 (4.25%) of IUGR. Compared with pregnancies with a normal outcome, complicated pregnancies showed a significantly higher prevalence of a bilateral notch and a higher mean PI in each of the two intervals studied. Compared with normal pregnancies, complicated pregnancies had a significantly higher persistence of a bilateral notch (30% vs. 8%), a higher proportion of women with an abnormal first-trimester uterine artery PI shifting to normal in the second trimester (14% vs. 4%) and a higher incidence of a normal first-trimester mean PI that shifted to abnormal in the second trimester (13% vs. 4%). Persistence of an abnormal mean PI from the first to the second trimester identified the group with the greatest risk for adverse perinatal outcome (OR, 10.7; 95% CI, 3.7-30.9). In addition, women in whom the uterine artery mean PI shifted from abnormal to normal between the two trimesters and women in whom the reverse shift occurred showed a similar intermediate risk (OR, 5; 95% CI, 2.1-10.6), comparable to that in women with persistence of a bilateral notch (OR, 5.6; 95% CI, 2.9-10.7). CONCLUSIONS: The sequence of changes in uterine flow between the first and second trimesters correlates with the subsequent development of hypertensive disorders and IUGR. Women with a persistent abnormal mean PI represent the group with the greatest risk for adverse perinatal outcome.

Reference ranges for Doppler parameters of the fetal aortic isthmus during the second half of pregnancy.

OBJECTIVE: To establish reference ranges for blood flow velocity waveforms (FVW) of the fetal aortic isthmus (AoI) during the second and third trimesters of pregnancy. METHODS: This was a prospective cross-sectional observational study involving 458 uncomplicated singleton pregnancies between 19 and 37 weeks of gestation. Fetal AoI Doppler parameters were assessed in either the longitudinal aortic arch view or the three vessels and trachea view. Regression analysis was used to determine gestational-age-specific reference ranges and to construct nomograms for the following Doppler parameters: pulsatility index (PI), resistance index (RI) and peak systolic (PSV), end-diastolic (EDV) and time-averaged maximum (TAMXV) velocities. Intra- and interobserver reproducibility were evaluated by calculating intraclass correlation coefficients (ICCs) and limits of agreement. RESULTS: Reliable FVW in the AoI were obtained in all cases. Acceptable intra- and interobserver reproducibility was obtained. With advancing gestation, there was a significant increase in PSV, TAMXV and PI, whereas RI and EDV remained constant during the second half of pregnancy. No cases of absent or reversed flow during diastole were detected. CONCLUSION: Normal data of the fetal AoI blood FVW throughout the second and third trimesters of pregnancy are provided. The reported Doppler profiles may be of clinical use in the assessment of hemodynamically compromised growth-restricted fetuses.

Comparison between a GnRH antagonist and a GnRH agonist flare-up protocol in oocyte donors: a randomized clinical trial.

BACKGROUND: Little information is available on the outcome of controlled ovarian hyperstimulation (COH) using GnRH antagonist in oocyte donation cycles especially in comparison with the short GnRH agonist protocol. This study was aimed at comparing the two stimulation protocols in oocyte donation (OD) cycles. METHODS: A total of 113 donors randomly received COH using either GnRH antagonist or GnRH agonist. The primary endpoint was the mean number of mature oocytes retrieved per started donor cycle. Secondary endpoints were the mean number of cumulus-oocyte-complexes (COCs) retrieved, the mean proportion of mature oocytes, pregnancy and implantation rates in recipients. RESULTS: Oocytes were distributed to 166 recipients. The mean number (+/- SD) of COC (11.6 +/- 5.8 versus 12.1 +/- 6.7), mature oocytes (8.4 +/- 4.4 versus 8.9 +/- 5.3) and the proportion of mature oocytes (70.8 versus 75.7%) retrieved per started donor cycle were similar in the antagonist and agonist groups, respectively. The implantation rate (26.1 versus 30.1%), clinical (40.2 versus 45.6%) and ongoing pregnancy rate per recipient cycle (32.2 versus 37.9%) were comparable in antagonist and agonist protocols, respectively. CONCLUSIONS: Similar mean number of mature oocytes and comparable pregnancy rates are achieved after OD in which donors received COH using GnRH antagonist or short GnRH agonist protocols.

Oocyte donation in patients with Turner's syndrome: a successful technique but with an accompanying high risk of hypertensive disorders during pregnancy.

BACKGROUND: Few data are available on pregnancy rate and obstetrical outcome after oocyte donation in Turner's syndrome patients. We conducted a retrospective analysis on the outcome of this subgroup. METHODS: Thirty oocyte donation cycles with fresh embryo transfer were performed in 21 patients between 2001 and 2004. RESULTS: The mean (+/-SD) age of the recipients was 33.1+/-1.8 years. The median (range) number of transferred embryos per cycle was two (1-4). Seventeen pregnancies were obtained (57%), of which 12 were clinical (40%). The implantation rate and the ongoing pregnancy rate were 22% (15 out of 68) and 30% (nine out of 30), respectively. Premature delivery was observed in 50% (four out of eight) of the pregnancies and intrauterine growth retardation in 55.5% (five out of nine) of the fetuses. Hypertensive disorders occurred in five out of eight pregnancies (three pre-eclampsias). CONCLUSIONS: Turner's syndrome patients achieve acceptable pregnancy rates after oocyte donation. A high rate of pregnancy-associated hypertensive disorders was observed which have led to a high rate of prematurity and intrauterine growth restriction. Although the number of cases in this study is limited, these results call for the need for intensive surveillance of such pregnancies. In order to reduce the risk of hypertensive disorders induced by multiple pregnancies, single embryo transfer should be proposed.

Versión externa a término: experiencia acumulada / External cephalic version at term: accumulated experience

Objetivo: Evaluar la eficacia y seguridad del intento de versión externa a término. Material y métodos: Entre enero de 2001 y marzo de 2004 se han recogido los resultados perinatales de las gestantes remitidas a la unidad de bienestar fetal para versión externa, procedentes del dispensario de obstetricia. Los criterios de inclusión para el intento de versión externa fueron: a) presentación no cefálica; b) edad gestacional entre las 36 y 38 semanas; c) índice de líquido amniótico >= 8 cm; d) índice cerebroplacentario superior al percentil 5; e) patrón cardiotocográfico reactivo, y f) ausencia de contraindicaciones para el parto vaginal. Como grupo control se ha incluido a las gestantes remitidas para intento de versión que en el momento de la inclusión tenían una presentación cefálica. Resultados: Se remitió a 246 gestantes, de las que un 72% (178/246) cumplía los criterios de inclusión y eran elegibles, de las cuales 5 no aceptaron el procedimiento, finalmente se incluyeron 173 casos. De los casos incluidos, un 56% (97/173) fueron versionadas a cefálica con éxito, mientras que en un 44% (76/173) no se consiguió la versión. La tasa de cesárea en las 173 gestantes incluidas fue del 42% (73/173): un 8,2% (8/97) en las versionadas y un 85,5% (65/76) en las que no se consiguió versionar. En el grupo control la tasa de cesárea fue del 11,5% (6/52). No se observaron diferencias significativas en la puntuación de Apgar al minuto (8,5 frente a 8,7), a los 5 min (9,8 frente a 9,9) ni en el pH arterial al nacimiento (7,24 frente a 7,21) entre las gestantes aceptadas para intento de versión y el grupo control de versiones espontáneas. Conclusiones: El intento de versión externa a término parece ser una técnica eficaz y segura

Objective: To evaluate the safety and effectiveness of the external cephalic version at term. Material and methods: From January 2001 to March 2004, the perinatal results of pregnant women referred to the Fetal Wellbeing Unit of our institution for external cephalic version were collected. Inclusion criteria were the following: a) non-cephalic position; b) gestational age between 36 and 38 weeks; c) amniotic fluid index equal to or above 8; d) cerebroplacental ratio above the 5th percentile; e) reactive cardiotocography; and f) absence of contraindications for a vaginal delivery. Pregnant women referred for external cephalic version with a cephalic position at examination were included as a control group. Results: A total of 246 women were referred to our unit for external cephalic version. Of these, 72% (178/246) met the inclusion criteria. Of the 178 eligible women, five refused to undergo the procedure and 173 women were finally included. Of these, the cephalic version was successfully performed in 56% (97/173) and was unsuccessful in 44% (76/173). The cesarean section rate among included women was 42% (73/173): 8.2% (8/97) in the group with successful cephalic version and 85.5% (65/76) in the group with unsuccessful cephalic version. In the control group, the cesarean section rate was 11.5% (6/52). There were no significant differences in the 1 minute (8.5 vs 8.7) and 5 minute Apgar scores (9.8 vs 9.9), or in umbilical artery pH at birth (7.24 vs 7.21) between included women and the control group. Conclusions: The external cephalic version seems a safe and effective procedure at term

Rotura prematura de membranas en edad gestacional previable / Preterm premature rupture of membranes before 24 weeks of gestation

Objetivo: Describir los resultados perinatales de las gestaciones con rotura prematura de membranas (RPM) antes de la semana 24 de gestación. Pacientes y métodos: Se incluyó a 50 pacientes consecutivas con RPM antes de las 24 semanas de gestación. Después de 1 semana de ingreso, se ofreció la realización de amniopatch a las pacientes con columna máxima de líquido amniótico (Cmáx) < 1 cm y conducta expectante al resto de las pacientes. Se evaluaron los resultados perinatales de dichas gestaciones. Resultados: La edad gestacional (EG) media +/- desviación estandar (DE) en el momento de la amniorrexis fue de 18,2 +/- 3,6 semanas. En 13 (26%) ocasiones se realizó un amniopatch. De los 50 casos, 15 pacientes optaron finalmente por una interrupción legal del embarazo (ILE) y en 35 casos se adoptó finalmente una conducta expectante. De los 35 casos que decidieron continuar la gestación, 12 (34,3%) pacientes presentaron un fallecimiento intraútero o un parto previo a la viabilidad (antes de la semana 24); en 4 (11,4%) casos hubo una muerte anteparto después de la semana 24 y 4 (11,4%) presentaron una muerte posparto. El lapso de tiempo entre la RPM y el parto mostró una relación inversa y significativa con la EG de la amniorrexis. Presentaron hipoplasia pulmonar 4 (11,4%) neonatos y en 8 (22,9%) casos hubo una corioamnionitis clínica. Un neonato (2,9%) presentó una luxación congénita de rodilla. Conclusiones: Las gestaciones complicadas con RPM antes de las 24 semanas de gestación presentan un 42,9% de supervivencia con una mortalidad neonatal del 57,1%. Sin embargo, para las gestaciones que superan las 24 semanas de gestación, la supervivencia mejora notablemente y en nuestra serie se sitúa en un 65,2%

Objective: To describe neonatal outcomes in preterm premature rupture of membranes (PPROM) before 24 weeks of gestation. Patients and methods: Fifty consecutive patients with PPROM before 24 weeks' gestation were included. If deepest pool of amniotic fluid (DPAF) was = 1.0 cm, expectant management was followed. Perinatal and maternal outcomes were evaluated. Results: The mean gestational age at PPROM was 18.2 weeks (SD +/- 3.6). Amniopatch was performed in 13 patients (26%). Of the 50 patients, 15 chose pregnancy termination and 35 were managed expectantly. In these 35 patients, there were 12 (34.3%) fetal demises or non-viable deliveries before 24 weeks, four (11.4%) fetal demises after 24 weeks and four (11.4%) neonatal deaths. A significant inverse relationship was observed between latency period and gestational age at PPROM. Pulmonary hypoplasia occurred in four neonates (11.4%) and chorioamnionitis in eight neonates (22.9%). There was only one case (2.9%) of congenital luxation of the knee. Conclusions: The overall perinatal survival rate in pregnancies with rupture of membranes before 24 weeks was 42.9% with a neonatal mortality of 57.1%. However, survival markedly improves when pregnancy is prolonged to over 24 weeks and in our series it increased to 65.2%

Infección congénita por citomegalovirus con una afección ecográfica progresiva y grave / Congenital cytomegalovirus infection with severe, progressive fetal involvement detected by ultrasound

El citomegalovirus (CMV) produce la infección congénita más frecuente (alrededor del 1% de las gestaciones) con una significativa afección y secuelas fetales. En ausencia de cribado serológico sistemático, el diagnóstico de infección fetal suele hacerse a partir de una ecografía habitual, que revela anomalías ecográficas indicativas de tal afección. En el caso que se presenta las anomalías aparecieron de forma progresiva, inicialmente una hiperecogenicidad intestinal con oligoamnios en la semana 17 y, posteriormente, ventriculomegalia, hepatomegalia y ascitis en la semana 21, cuando se realizó el diagnóstico de la infección mediante estudio de la reacción en cadena de la polimerasa (PCR) en el líquido amniótico

Cytomegalovirus is the most frequent congenital infection with an incidence of approximately 1% and a high rate of fetal involvement and sequelae. In the absence of universal screening, diagnosis of this infection is usually based on abnormal findings during routine ultrasound scan. We present a case showing progressive abnormalities on ultrasound. Initial abnormal findings consisted of hyperechogenic bowel and oligohydramnios at 17 weeks and subsequent abnormalities consisted of marked ventriculomegaly, hepatomegaly and ascites at 21 weeks when cytomegalovirus was detected in the amniotic fluid by polymerase chain reaction

Altura uterina: curvas de normalidad y valor diagnóstico para un bajo peso neonatal / Uterine height: normality curves and diagnostic value for low birth weight

Objetivo: El objetivo del presente estudio es construir unas curvas de normalidad de la altura uterina (AU) con criterios metodológicos estrictos y evaluar la eficacia diagnóstica de su uso en la práctica clínica. Sujetos y métodos: Entre julio de 2003 y enero de 2004, se seleccionaron de manera aleatoria 16 gestantes para cada semana de edad gestacional (EG) entre las 24 y 42 semanas (un total de 304 gestaciones), en las que se midió la AU de forma estandarizada. Se modeló la media de la medida de la AU para la EG y se construyeron los intervalos de normalidad. Para estudiar el valor diagnóstico de la medida de la AU se diseñó un estudio retrospectivo de casos y controles. Se consideró caso a todos los fetos nacidos en nuestro centro en el año 2002, con un peso neonatal inferior al percentil 10 para su EG. Como control se eligió el parto inmediatamente posterior a cada caso con un peso neonatal dentro de los límites de normalidad. Mediante un análisis de curvas ROC se seleccionó el percentil de corte que optimizaba la sensibilidad y especificidad para la detección de peso neonatal inferior al percentil 10. Resultados: El modelo matemático seleccionado para ajustar la relación entre la EG y la AU fue lineal (8,96 + 0,68 EG), con un coeficiente de determinación (R2) de 0,67, es decir, el modelo explica un 67% de la variabilidad de la AU. Para el estudio de casos y controles se identificaron 135 gestaciones con peso neonatal inferior al percentil 10 de normalidad. El análisis mediante curvas ROC de la variable estandarizada AU para la detección de un peso neonatal inferior al percentil 10 mostró cómo el punto de corte que optimizaba la sensibilidad y la especificidad fue el percentil 10 (el 29 y el 96%, respectivamente). Conclusión: El uso clínico de curvas de normalidad de la AU de la población propia puede mejorar la detección prenatal de fetos pequeños para su EG y podría permitir mejorar los resultados perinatales

Objective: To construct normality curves for uterine height using strict methodological criteria and to evaluate the diagnostic efficacy of the use of these curves in clinical practice. Subjects and methods: Between July 2003 and January 2004, 16 pregnant women for each week of gestational age between 24 and 42 weeks (a total of 304 pregnant women) were randomly selected. Uterine height was measured in a standardized manner. The mean uterine height for gestational age was calculated and intervals of normality were determined. To study the diagnostic value of uterine height measurement, a retrospective case-control study was designed. All neonates born in our center in 2002 with a birth weight below the 10th percentile for gestational age were included. As controls, infants born immediately after each case with a birth weight within the normal range were chosen. Using ROC curve analysis, the cut-off percentile that optimized sensitivity and specificity for detection of birth weight below the 10th percentile was selected. Results: The mathematical model selected to adjust the relationship between gestational age and uterine height was linear (UH = 8.96 + 0.68.GA). With a coefficient of determination (R2) of 0.67, the model explained 67% of variability in the variable of uterine height. For the case-control study, 135 pregnancies with birth weight lower than the 10th percentile were identified. ROC curve analysis of the variable of standardized uterine height to detect birth weight lower than the 10th percentile showed that the cut-off point that optimized sensitivity and specificity was the 10th percentile (sensitivity 29%, specificity 96%). Conclusion: The use of normality curves for uterine height in a specific population can improve detection of small for gestational age fetuses and could improve perinatal outcomes

Uterine artery Doppler at 11-14 weeks of gestation to screen for hypertensive disorders and associated complications in an unselected population.

OBJECTIVES: To establish reference values for the first-trimester uterine artery (UtA) pulsatility index (PI) and to investigate the role of UtA Doppler in the early prediction of hypertensive disorders and their associated complications in an unselected Mediterranean population. METHODS: A prospective study including 1091 consecutive singleton pregnancies undergoing routine early ultrasound screening at 11-14 weeks of gestation was performed. The left and right UtA were examined by color and pulsed Doppler transvaginally. The mean PI and the presence of bilateral protodiastolic notching were cross-sectionally recorded. Reference ranges were calculated and the pregnancies were followed for occurrence of pre-eclampsia, gestational hypertension, intrauterine growth restriction, placental abruption and stillbirth. The sensitivity and predictive values of a mean UtA-PI>95th percentile and the presence of bilateral notching in the prediction of these pregnancy complications were calculated. RESULTS: A total of 999 women were finally included. Both the mean UtA-PI and the prevalence of bilateral notches showed a significant linear decrease between 11 and 14 weeks' gestation. Sixty-seven (6.7%) pregnancies developed at least one of the formerly described complications, including 22 (2.2%) cases of pre-eclampsia and 37 (3.7%) cases with intrauterine growth restriction. Compared with women with a normal outcome, complicated pregnancies showed a significantly higher mean PI (2.04 vs. 1.75; P<0.05, t-test) and a higher prevalence of bilateral notching (58% vs. 41%; P<0.05, Chi-square test). Using the 95th percentile in mean UtA-PI as a cut-off, 23.9% (95% CI, 13.7-34.1) of complicated pregnancies and 30.8% (95% CI, 5.68-55.85) of severe cases were identified. CONCLUSIONS: Our results suggest that pregnancies with an increased risk of developing hypertensive disorders and related complications already have an abnormally increased UtA-PI in early pregnancy. However, the use of a single uterine Doppler measurement for screening purposes in unselected early pregnancy populations has limited clinical value. The use of UtA-PI combined with other screening tests needs to be determined by further investigation.

Doppler assessment of fetal aortic isthmus blood flow in two different sonographic planes during the second half of gestation.

OBJECTIVE: To compare the reliability of Doppler blood flow measurements of the fetal aortic isthmus (AoI) according to whether the sampling plane is obtained from the traditional longitudinal aortic arch (LAA) view or the more recently described three vessels and trachea (3VT) view of the fetal upper mediastinum. METHODS: Doppler blood flow measurements of pulsatility index (PI), resistance index (RI), peak systolic (PSV), end-diastolic (EDV) and time-averaged maximum (TAMXV) velocities were performed in the AoI of 40 fetuses between 24 and 36 weeks of gestation. All measurements were sampled in two different sonographic planes of the AoI: the LAA view, at a few millimeters beyond the origin of the left subclavian artery, and the 3VT view, just before the V-shaped junction of the aortic and ductal arches. All scans were performed by the same observer. The reliability of Doppler blood flow measurements was assessed by calculating intraclass correlation coefficients (ICCs) and limits of agreement between the two different sonographic sites evaluating the AoI. RESULTS: Mean values of PI, RI, PSV, EDV and TAMXV were similar in the LAA and 3VT views. The PI and vascular velocities were reliably measured from both sonographic sites. ICCs for variability of measurements were 0.78, 0.63, 0.63, 0.60 and 0.55 for PI, RI, PSV, EDV and TAMXV, respectively. Limits of agreement revealed minimal disagreement between the two sites of evaluation of the AoI for all measurements. CONCLUSIONS: On the basis of our observations, Doppler blood flow measurements across the fetal AoI can be reliably obtained from both the 3VT and the traditional LAA sonographic views. Since the transverse upper thoracic 3VT plane is achievable in most fetal positions, Doppler study of the AoI appears to be easier than expected.