Iatrogenia por variantes del sistema médico. Institucional o privado / Iatrogeny for variants of the medical institutional or private system

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Ética y desarrollo tecnológico / No disponible

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[Influence of intrafollicular factors at ovarian level during oocyte/embryo development]. / Influencia de los factores intrafoliculares a nivel ovárico durante el desarrollo óvulo/embrionario.

There is series of factors associated to fertilization and embryo development events. Each factor has a role in the inter-relationship between various molecular events related to oocyte/embryo quality. Dynamic features associated to endocrine-paracrine environment are determinant to the role of each factor in ovaric follicullar development. Growth factors, vascular-endothelial growth factor, nitric oxide, leptin and others correlate in ovular maturity process. That is why growth factors, vascular-endothelial growth factor, nitric oxide, leptin and others can be expressed as embryo viability and implantation biomarkers.

[Assessment of the penetration of culture media in uterine cavity as an effect of cervical lavage before embryo transfer: prospective and observational study of samples obtained in hysterectomy]. / Evaluación de la penetración del medio de cultivo a la cavidad uterina como efecto del lavado cervical previo a la transferencia embrionaria: estudio prospectivo y observacional en piezas obtenidas por histerectomía.

Cervical lavage used to remove and cleaning some of the scale elements as well as cervical mucous during embryo transfer has been a regular practice in many reproductive centers worldwide. However, the microenvironment influence using these techniques will or not be detrimental in the embryo development. Under this issue, a prospective study was doing in 16 patients (underwent hysterectomy). A cervical lavage was performed previous to the procedure similar to the embryo's transfer step, subsequently cervical invasion was checking. The age was 36.4 +/- 8.6 years, preoperatory diagnosis was abnormal uterine bleeding (n = 4), myomata (n = 4), adenomiosis (n = 4), endometrial polyp (n = 3) and chronic pelvic pain (n = 1). Uterine weight was 127.5 +/- 55.4 g with a surgical time of 48.8 +/- 12.5 minutes. Medium in the uterine cavity was founded in only one case. We believe that cervical lavage is a secure technique in embryo transfer.

[A prospective randomized trial of the impact of misoprostol (PgE1) on pregnancy rate after intrauterine insemination (IUI) therapy: a preliminary report]. / Estudio prospectivo y aleatorio del impacto de misoprostol (PgE1) en las tasas de embarazo con inseminación intrauterina (IIU): informe preliminar.

Although the use of prostaglandin plays an important role in the reproductive human physiology, it is still controversial in the reproductive field. Ovarian stimulation as well as intrauterine insemination increased the reproductive goals in certain group of patients. The objective of the present study was to evaluate the prostaglandin effect (misoprostol) in patients under ovarian stimulation and intrauterine insemination and their final outcome in the clinical pregnancy rate. There were a total of 59 ovarian stimulated cycles, the study group (n = 29) received 200 micrograms of prostaglandin E1 (misoprostol) intravaginal after IUI, compared with the control group (n = 30). Demographic characteristics were similar in both groups. There were no differences in age, FSH. LH and E2, hCG day and number of ampoules between groups. However, a significant pregnancy rate was observed between groups (31% study group vs. 20% control group). We concluded that prostaglandin application in stimulated cycles under intrauterine insemination remain a beneficial effect showing in the pregnancy outcome.

[Diagnosis and treatment of the male factor in the age of intracytoplasmic sperm injection]. / El diagnóstico y tratamiento del factor masculino en la era del ICSI.

Currently, we are witnesses of the Assisted Reproductive techniques; advances reproductive goals have been reached with the Intracytoplasmic Sperm Injection (ICSI) in patients with male factor. However, micromanipulation techniques allowed the reproductive solution without an etiologic and/or physiopathologic diagnosis. The andrologic workup of the dynamic and functional sperm characteristics with the endocrine and urologic evaluation should be performed into the infertility management.

[Response of fetal macrophages in the placenta of pregnant HIV-positive patients with and without antiretroviral treatment]. / Respuesta de los macrófagos fetales en placentas de pacientes embarazadas VIH-1 positivas con tratamiento y sin tratamiento antiretroviral.

We studied the cellular answer of placentary macrophages in pregnant women seropositive to the virus of human immunodefficiency (VIH-1) treated with zidovudina (AZT) and didanosine (ddl). Twenty eight pregnant women were studies; there were four groups of seven patients each: The control group; the group with seropositive women without treatment; the group given AZT, and the group that recieved AZT and ddl. Placentary specimens were obtained immediately after delivery. One hundred and fifty chorionic vellosities of cells. The control group showed an average of 26 Hofbauer cells; the seropositive women without antiretroviral treatment, was 115; the patients who received only AZT, the average was 65; and the ones who received a combine therapy AZT and ddl, cellular average was 44. There were no differences in the weight of the products in all the groups, nor congenital malformations in the newborns. The use of medication antiretroviral suppress viral replication, and so, there is a significant answer in the amount and size of Hofbauer cells. The administration of two medicaments is more effective in the cellular immune answer.

Class II major histocompatibility complex typing across the ethnic barrier in pemphigoid gestationis. A study in Mexicans.

BACKGROUND: Pemphigoid gestationis (PG), also called herpes gestationis, is a rare autoimmune disease of pregnancy or puerperium (estimated 1 out of 50,000 pregnancies among Caucasians). A previous series has demonstrated an association of PG with human leukocyte antigen (HLA)-DR3 or HLA-DR4 haplotypes. While these haplotypes are most commonly found in individuals of European ancestry, they have also been found in African-American patients affected with PG. PG has rarely been reported in other ethnic groups, and the HLA association in non-Europeans has not been examined. METHODS: We have characterized eight patients of Mexican ancestry who have PG by clinical, histologic, and immunofluorescence criteria. Class I and class II major histocompatibility complex (MHC) antigens were studied by standard microlymphocytotoxicity assays. Class II MHC antigens were further studied by polymerase chain reaction (PCR) amplification of HLA-DRB1, DQA, and DQB genes and allele-specific oligonucleotide hybridization. For comparison purposes, we used results obtained from a group of 100 ethnically matched healthy individuals. RESULTS: We found that all eight patients had the HLA-DR3/DR4 phenotype; all HLA-DR3 haplotypes were HLA-DRB1*0301, DQA1*0501, and DQB1*0201, whereas half of the HLA-DR4 haplotypes were from the DRB1*0401 subtype and the other half were DRB1 *0407. CONCLUSIONS: These results suggest that, in Mexicans, the genetic susceptibility for the development of PG is strongly influenced by the genetic admixture of Caucasian origin, and the role of class II MHC antigens in the pathophysiology of this disease is confirmed.

Secular trend in blood lead levels in a cohort of Mexico City children.

We determined the secular trend in blood lead levels in a cohort of 104 children born in Mexico City between 1987 and 1993. We grouped children by the calendar year in which they reached 6 mo of age and measured blood lead levels every 6 mo until they attained 36 mo of age. The overall geometric mean blood lead level was 9.6 microg/dl (range = 1.5-59.5 microg/dl). A repeated measures analysis of variance revealed a highly significant linear trend in blood lead level with year (p < .001); there was a maximum decrease of 7.6 microg/dl between 1989 and 1993. There was a highly significant quadratic age effect (p < .001); blood lead levels rose between 6 and 18 mo of age and decreased thereafter. There was a marginally significant interaction between age of the child and year. Family use of lead-glazed pottery significantly elevated blood lead levels (p = .028). The downward trend in blood lead levels during the time period of study corresponded to the reduction in various sources of lead exposure.

[Radiologic, densitometric, morphologic and electron microscopic study of osteoporosis and osteopenia in the third lumbar vertebra in men and women in the city of Mexico]. / Estudio de la osteoporosis y osteopenia por medio de radiología, densitometría, morfometría y microscopia de barrido en la tercera vértebra lumbar en una muestra de hombres y mujeres en la ciudad de México.

OBJECTIVE: To determine bone density in the third lumbar vertebra in a group of men and women from the Mexico City correlating the morphometric characteristics of vertebral body by specific techniques and to detect groups with alterations like osteoporosis or osteopenia. METHODOLOGY: The study was made in third lumbar vertebra from 23 patients dead of the Medical Service Forense-México, 8 women between 31 to 72 years old and 15 men between 25 yo 62 years old. The studies were: Radiological, bone densitometry and by image in which was determined density of vertical and horizontal trabeculaes. With x-ray technique in scanning electron microscopy was determined in form semiquantitative the presence of Ca, P, Mg and Na, and Ca distribution by technique of x-ray energy dispersed. RESULTS: In the radiological trail all vertebras of the female group were abnormal, the major finding was degenerative feature; 5 Showed trabeculation increased 3 fractured; in the males group 7 patients were normal, degenerative fracture in 8; of these six had densitometry with DEXA; in the females group only one was normal, 3 osteopenia, 5 osteoporosis; in the male group: 5 osteopenia and 5 osteoporosis. Scanning electron microscopy examination exhibit a homogeneous and dense expression pattern, wherever SEM demonstrated the absence or decrease of deposit calcium in osteoporosis. A morphometric examination of the trabecular thickness demonstrates a difference between the two sexes. The normal median was 222.1 microns, the osteoporosis range was 126.3 to 156.2 microns in the female osteoporosis, in male group was found two normal values with a trabecular density mean of 249.7 microns, in the last two cases one with osteopenia and the other with osteoporosis, the mean value was 186.4 microns. CONCLUSIONS: In the present study, was demonstrated that the degenerative alterations in osteoporosis and osteopenia in young people are more frequent to respect other reports. The following observations require special emphasis either because they provide clues to the mechanism of altered expression of calcium: Genetic, ethnic, consume, sedentary and others.

[Advanced maternal age and pregnancy: how much is too much?]. / Edad materna avanzada y embarazo: qué tanto es tanto?

Perinatal evolution was compared and two study groups in women with advanced maternal age and pregnancy. 626 were included from a total of 778 with age 35 years, who resolved their pregnancy during 1995. They were classified, according to age, in two groups: 1) maternal age of 35-39 year; they were considered primigestas and multigestas. Perinatal complications were classified in personal antecedent, antepartum and intrapartum complications. To analyze the association between maternal age and parity with perinatal complications, X2 or exact test of Fisher, was used. Percentage of women with advanced age and pregnancy was 13.6%. Main perinatal complications were: preeclapmsia, gestational diabetes, preterm delivery threat, and membranes rupture. There were no significant differences as to complications by age and parity. There were 90% of children with 2500 g, and Apgar of 97%. Perinatal death was 0.4%, and fetal malformation 0.6%. Cesarean frequency, was over 90% in primigestas and in more of 60% in multigestas. Perinatal evolution in advanced age and pregnancy is adequate, if she starts prenatal control early enough.

Ultrastructural characteristics of Gardnerella vaginalis infection in the heterosexual couple.

Adhesion and penetration of Gardnerella vaginalis into the male urethral and female vaginal epithelial cells were evaluated in a prospective cohort study of infected females and their sexual partners. Vaginal secretions of 10 women with culture proven G. vaginalis infection and semen samples of their asymptomatic husbands were analyzed with conventional optical and electron microscopy. G. vaginalis was isolated in 50% of the male sexual partners of women harboring the microorganism. G. vaginalis adheres to the plasmatic membrane and penetrates into the cytoplasm of both vaginal and urethral epithelial cells. The ability of G. vaginalis to colonize the male lower genital tract may have clinical relevance with respect to the role of the male partner in the reinfection of women.

[Perinatal perspective in heart disease and pregnancy. Review of 1169 cases of pregnancy]. / Perspectiva perinatal de la cardiopatía y embarazo. Revisión de 1169 embarazos.

OBJECTIVE: To determinate the effect of maternal heart disease on pregnancy outcome. METHODS: We reviewed retrospectively 1169 pregnancies in 1093 women with heart disease. 53 women were assisted during 2 pregnancies, ten during 3 and one during 4 pregnancies. All the pregnancies were prenatal and labor assisted at the National Institute of Perinatology, México, D.F. RESULTS: In 705 (60.30%) the heart disease was of rheumatic origin, in 387 (33.10%) congenital and the remaining were a miscellaneous group. Mitral stenosis and mitral regurgitation (42.13%) was the commonest rheumatic cardiac lesion associated with pregnancy. Ventricular septal defect was seen in the 32.81%. 124 women had a heart valve prosthesis (87 mechanical and 40 bioprosthesis [3 women with double heart valve prosthesis]). Intrauterine fetal growth retardation was the commonest complication. (7.52%) in 29 cases were present complications of heart disease in pregnancy. The abortion was present in 30 cases and intrauterine fetal death in 7 cases. There were 977 term pregnancies. The caesarean section rate was 32.5 per cent, most of them were performed for obstetric or fetal indications. The neonatal weight had a average of 2864.4 +/- 526.9 grams. There were eight maternal deaths in this series (five with congenital origin and 3 rheumatic). The incidence of low birth weight was 8.46 per cent. There were two babies born with cardiac congenital malformations.

Umbilical cord beta-endorphin and early childhood motor development.

Stress during delivery has been associated with elevated umbilical cord plasma beta-endorphin levels. Published research suggests that much cord beta-endorphin originates from fetal pituitary. Intact pituitary function is required for normal growth and development. Relationships between cord beta-endorphin and child development have not been previously reported. We measured paired maternal and cord plasma beta-endorphin concentration in a set of 106 low risk deliveries by solid phase two-site immunoradiometric assay. Geometric mean maternal and cord beta-endorphin concentrations were 128 pg/ml and 196 pg/ml, respectively, with corresponding ranges of 33-533 pg/ml and 70-579 pg/ml. Cord beta-endorphin concentration was significantly higher than maternal, regardless of delivery mode, and the two were significantly correlated (r = 0.231; P = 0.017). Multiple regression modeling showed that forceps delivery, maternal beta-endorphin concentration, bradycardia, vaginal delivery, and birth weight each made independent contributions to elevated cord beta-endorphin. Depressed cord beta-endorphin predicted more day 2 neurological soft signs, lower 6-month mental development, and lower 36-month motor score on psychometric tests of the children. Poorer fine motor control and coordination were predominantly associated with lower beta-endorphin. Level of cord beta-endorphin independent of delivery stress exerted the primary influence upon child motor development. Higher levels of stress-independent beta-endorphin may play a direct role in motor development.

[Systemic lupus erythematosus and pregnancy (analysis of 84 cases)]. / Lupus eritematoso sistémico y embarazo (análisis de 84 casos).

We present 84 pregnancies (3 twin pregnancies) of 80 women with Systemic Lupus Erythematosus. Although there was a multidisciplinary prenatal control, in 83% of the cases there were one or more complications during pregnancy, most of them being preterm labor, premature rupture of membranes and preeclampsia-eclampsia. There were flares up in 15 of 84 cases, (17.85%). Worsening of renal function was the most common finding. There were 9 abortions, 3 stillbirths, 1 neonatal death and two newborns with congenital heart block. No maternal deaths were present.

[Ultrastructural analysis of placentas with villitis. Retrospective study]. / Análisis ultraestructural de placentas con villitis. Estudio retrospectivo.

A villitis is a focal or multifocal inflammatory reaction of chorionic villi with infiltration of mononuclear cells and usually is associated with fibrinoid necrosis. The aetiology of villitis could be a transplacental infection of the fetus, especially with virus (VIV), in normal placentae however, the presence of villitis is referred as villitis of unknown ethiology (VED). This study was designed to characterize villitis lesions of 11 placentae, four VIV and seven VED, ultrastructural descriptive comparisons of both types of villitis are discussed. Biopsies were processed with the conventional optic and electronic microscopy techniques. Our ultrastructural observations confirmed the presence of virus in four placentae whereas no virus or bacteria were found in seven placentae. Microvilli were absent or markedly diminished, this finding was associated to the presence of fibrinoid necrosis in the stroma and clinically to intrauterine growth retardation, 4 preterm pregnancies and one obitus. Trophoblast alterations were found in both types of villitis, basal membrane thickness, is some cases associated to electrodense material similar to calcium deposites, vascuolization and the presence of edema in the stroma was observed. In some cases we noted the presence of focal fibrin deposits associated to necrosis zones in the stroma, calcium precipitates and mielinic bodies. Fetal vessels obliteration and intravascular thrombi were found in the syncitiotrophoblast placentae with viral particles CMV or rubivirus associated to an increment in Hofbauer cells and basal membrane calcifications. From our ultrastructural observations, we conclude that both types of villitis are associated to a typic immunologic reaction that induce lose of trophoblast microvilli, mononuclear infiltration and edema. This placental alterations reduce dramatically the maternofetal exchange of gases, nutrients and other active peptides and could be the cause of fetal growth retardation, inmadurity or death.

Maternal influences on cord blood lead levels.

We constructed models of umbilical cord blood lead (PbB), with and without the addition of maternal PbB at delivery and earlier in pregnancy, to determine which factors explaining cord PbB depended upon maternal PbB and which did not. We prospectively studied women of low-to-middle socioeconomic status who lived in the Valley of Mexico from 12 weeks of pregnancy to delivery. We measured maternal venous PbB during pregnancy and at delivery, and umbilical cord PbB (1-38 micrograms/dl, 0.05-1.83 mumol/l). We used multiple regression analyses to model cord PbB and a logit analysis to model the maternal-cord PbB relationship. Older mothers using lead-glazed pottery and canned foods delivered babies with increased cord PbB, while those with occasional alcohol use during pregnancy, high milk intake, and more spontaneous abortions delivered babies with lower cord PbB. Maternal PbB at 36 weeks of pregnancy and at delivery independently explained additional variance in cord PbB, but maternal PbB earlier in pregnancy did not. Some of the effects of lead-glazed pottery, maternal abortions, alcohol use, and canned food use on cord PbB were mediated through maternal PbB. The effects of maternal age and milk intake on cord PbB were independent of their influence on maternal PbB near delivery. Cord PbBs were higher than maternal PbBs at delivery in 33% of the cases, and were predominant in mothers over 30 and those drinking milk less than once per day. Measurable influence of maternal PbB on delivery cord PbB is limited to the four to eight weeks prior to delivery. Many factors suspected of influencing bone lead also control cord PbB, some of them independently of their effect on maternal delivery PbB. Minimizing fetal exposure near the end of pregnancy may require long-term control of maternal lead exposure and good management of pregnancy and diet.

[Magnitude and causes of maternal mortality in the Federal District (1988-1989)]. / La magnitud y las causas de la mortalidad materna en el Distrito Federal (1988-1989).

Despite the availability of health resources to provide prenatal and delivery care for all pregnant women in the Federal District, the maternal mortality ratio is extremely high. Based on the study of all the maternal deaths which occurred in the Federal District during 1988 and the first semester of 1989 (n = 433), a ratio of 11.4 deaths per 10,000 registered live births was estimated. This is almost twice as high as the ratio reported through vital statistics. The maternal mortality ratio is higher among women delivered in public assistance hospitals as compared with those delivered in social security hospitals. This is due to the high percentage of women arriving with severe complications and to the lower standards of obstetric care in the former. About 75% of the deaths were due to one of the following causes: hypertensive disease of pregnancy, hemorrhage and infection. A detailed study of hospital records undertaken by a maternal mortality committee revealed that 85% of the deaths were preventable with the technology and resources available. The committee identified errors in medical judgment as the main factor involved in the chain of causation leading to potential preventable deaths.

[Recurrent abdominal pregnancy. A case report]. / Embarazo abdominal recurrente. Presentación de un caso.

It's a report fo a case of recurrent abdominal pregnancy attended at the Instituto Nacional de Perinatologia of México City, the clinical manifestations, diagnosis, and management are described. A review of the literature is presented.