Orientaciones para reducir las demandas judiciales en diagnóstico prenatal / Guidelines for reducing lawsuits in prenatal diagnosis

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Fetal pyelectasis: is it always "physiologic"?

OBJECTIVE: Our purpose was to determine the degree of fetal pyelectasis predictive of neonatal renal pathologic processes. STUDY DESIGN: Eighty-four cases of pyelectasis were identified during the study period (1989 through 1993). Fetuses with anteroposterior diameter of the renal pelvis > or = 4 mm before 33 weeks or > or = 7 mm after 33 weeks without caliectasis were included. Fetuses with an anteroposterior diameter of > 10 mm were excluded. Postnatal evaluation included renal sonogram, voiding cystourethrogram, and renal flow and function studies. RESULTS: Sixteen cases were excluded because of incomplete postnatal workup. Renal pathologic processes were found in 30 of 68 (44%) at birth; the most common were ureteropelvic junction obstruction (37%) and vesicoureteral reflux (33%). Only four cases required surgical intervention (13%), and the remaining 87% were managed conservatively. A normal urinary tract was found in 25% of the infants and the remaining 21 of 68 (31%) had regression of pyelectasis before birth. Fetuses with a dilated anteroposterior diameter > or = 8 mm after 28 weeks' gestation were found to have renal pathologic features in two of three of the cases, with sensitivity, specificity, and positive and negative predictive values of 87%, 41%, 66.7% and 70%, respectively. CONCLUSION: Fetuses with an anteroposterior diameter of the renal pelvis > or = 8 mm after 28 weeks' gestation require appropriate urologic evaluation after birth.

Prenatal diagnosis and therapy for a fetal hepatic vascular malformation.

BACKGROUND: Congenital hepatic arteriovenous malformations complicated by high-output heart failure and hematologic derangements are associated with up to 90% mortality. Prenatal diagnosis alerts the pediatrician to the need for early neonatal intervention. CASE: A fetal hepatic arteriovenous malformation with associated high-output cardiac failure was diagnosed at 29 weeks' gestation using real-time and color flow Doppler sonography. Hydrocortisone injected directly into the umbilical vein and the amniotic sac resulted in appreciable improvement in hemodynamic and hematologic indices. The pregnancy ended in a preterm delivery at 31 weeks with no evidence of heart failure at birth. CONCLUSION: The compromised preterm fetus with a hepatic arteriovenous malformation can be treated in utero, avoiding early emergency delivery.

Prenatal sonographic diagnosis of a third ventricle choroid plexus papilloma.

We report a case of fetal hydrocephalus secondary to a third ventricle choroid plexus papilloma detected by ultrasound at 33 weeks' gestation. The prenatal sonographic and colour flow Doppler findings of this rare fetal intracranial tumour are discussed.

Caudal regression syndrome: etiopathogenesis, prenatal diagnosis, and perinatal management.

Caudal regression syndrome represents a continuum of congenital malformations ranging from agenesis of the lumbosacral spine to the most severe cases of sirenomelia with lower extremities fusion and major visceral anomalies. The etiology of this syndrome is not well known. Maternal diabetes, genetic predisposition, and vascular hypoperfusion have been suggested as possible causative factors. The degree of associated anomalies usually parallels the severity of the primary defect. Ultrasonography is the diagnostic tool of choice revealing the absent distal vertebrae of the fetal spine. Amnioinfusion and magnetic resonance imaging (MRI) are of help in better evaluation of the fetal anatomy in cases with oligohydramnios. Perinatal management depends mainly on gestational age at diagnosis and severity of the lesion. It should include genetic counseling and serial sonography to assess interval growth and amniotic fluid volume. Surviving infants have usually a normal mental function and they require extensive urologic and orthopedic assistance. Their long-term morbidity consists mostly of neurogenic bladder dysfunction resulting in progressive renal damage and disabling neuromuscular deficits of the lower extremities. Neurosurgical and orthopedic intervention with physical rehabilitation is indicated to improve the quality of their lives.

Amnioinfusion: an aid in the ultrasonographic evaluation of severe oligohydramnios in pregnancy.

OBJECTIVE: Amnioinfusion was used in pregnancy complicated by severe oligohydramnios to enable a more comprehensive ultrasonographic evaluation of the pregnancy. STUDY DESIGN: Thirteen patients were referred to the Division of Obstetrical and Gynecological Ultrasound at the University of Miami because of severe oligohydramnios in which a definitive diagnosis could not be made. Nine patients were in the second trimester and four were in the early third trimester. All patients underwent amnioinfusion with warm physiologic saline solution and instillation of indigo carmine. Genetic amniocentesis was performed in 11 patients. RESULTS: After amnioinfusion a satisfactory comprehensive ultrasonographic examination could be performed on all patients. In most cases we were able to achieve a definitive diagnosis. CONCLUSION: Amnioinfusion with the addition of indigo carmine was a satisfactory technique to enable a more comprehensive ultrasonographic evaluation of pregnancy complicated by severe oligohydramnios.