Consenso SOCHOG/SOCHUMB: utilizar en Chile la curva estándar OMS ultrasonográfica de crecimiento fetal / SOCHOG/SOCHUMB consensus: OMS fetal ultrasound curve is the standard curve for ultrasound growth assessment to use in Chile

La Sociedad Chilena de Obstetricia y Ginecología (SOCHOG) y la Sociedad Chilena de Ultrasonido en Medicina y Biología (SOCHUMB) convocaron a un comité de expertos en el tema de ultrasonido y crecimiento fetal con el fin de proponer utilizar la curva fetal que mejor se adapte a la población chilena. Luego de la discusión, al no contar con curvas chilenas de crecimiento fetal, se concluye proponer que la curva estándar de la Organización Mundial de la Salud (OMS) sería la indicada dada la calidad de su metodología y por ser multicéntrica.

The Chilean Society of Obstetrics and Gynecology (SOCHOG) and the Chilean Society of Ultrasound in Medicine and Biology (SOCHUMB) have convened a committee of experts on the subject of ultrasound and fetal growth in order to propose using the fetal curve that best adapts to the Chilean population. After the discussion, since there are no Chilean fetal growth curves, it is concluded that the World Health Organization (WHO) standard curve would be the one to use given the quality of its methodology and the fact that it is multicentric.

Alfa talasemia e hidrops fetal no inmune a propósito de un caso diagnosticado en la Unidad de Ultrasonografía del Hospital Clínico San Borja Arriarán / Non-immune hydrops fetalis and alfa thalassemia

We report the unique case of a patient of asiatic origin (chinese), who was evaluated, followed and treated at the Sonography Unit of the Maternity Ward, Clinical Hospital San Borja Arriarán (HCSBA), with the collaboration of the Fetal Medicine Unit, Clinical Hospital of the University of Chile. The patient presented a 30 weeks gestation, which at the moment of evaluation showed a fetus with noninmune Hydrops (mother RH(+), Du (-)). Perinatal evaluation discarded cardiopathy, aneuploidiesmarkers and other malformations accounting for this condition. Fetal ultrasonographic evaluation showed severe cardiac insufficiency, middle cerebral artery Doppler (MCA) suggestive of severe anemia and severe oligoamnios with normal kidneys. Dueto these fi ndings and to the asiatic origin of the patient, the ethiological possibilities of viral infection, B19 parvovirus or anemia of genetic origin such as alfa thalassemia were suggested. Cordocentesis shows hematocrite of 39 percent, discordant with the value estimated by MCA Doppler, which reduced the possibility of a viral origin. We sent a fetal blood sample for Hb electrophoresis. Given the critical hemodynamic conditions and having completed the profilaxis of the hyaline membrane, gestation is interrupted by cesarean section, getting a male NB weighing 2.400 gr, in poor condition, who dies at 10 hours from birth. Electrophoresis reported postcesarean section confirms the diagnosis.

Se reporta el caso inédito, de una paciente de origen asiático (China), evaluada, seguida y tratada en la Unidad de Ultrasonografía de la Maternidad del Hospital Clínico San Borja Arriarán (HCSBA), con la colaboración de la Unidad de Medicina Fetal del Hospital Clínico de la Universidad de Chile. La paciente cursaba un embarazo de 30 semanas al momento de ser evaluada en nuestra unidad donde se diagnosticó una gestación única con un feto que presentaba un hidrops no inmune (madre Rh(+), Du (-)). La evaluación perinatal descartó cardiopatía, marcadores de aneuploidía y otras malformaciones que explicaran dicha condición. La evaluación ultrasonográfica fetal mostraba insuficiencia cardiaca severa, Doppler de arteria cerebral media (ACM) sugerente de anemia severa, oligoamnios severo con riñones normales. Debido a estos hallazgos y al origen asiático de la paciente se plantea la posibilidad etiológica de una anemia por infección viral, (parvovirus B19), o una anemia de origen genético, como la alfa talasemia. La cordocentesis muestra un hematocrito de 39 por ciento, discordante con el valor estimado por Doppler de ACM, lo que alejaba la posibilidad de un origen viral y se envía muestra de sangre fetal para electroforesis de hemoglobina(Hb) fetales. Dada las condiciones hemodinámicas críticas y haber completado profilaxis de membrana hialina se interrumpe el embarazo mediante una cesárea obteniéndose un RN de sexo masculino de 2.400 g, hidrópico, en malas condiciones que fallece a las 10 horas de vida. La electroforesis de proteína de sangre fetal, informada post cesárea, confirma el diagnóstico de alfa talasemia.

Progesterone and the risk of preterm birth among women with a short cervix.

BACKGROUND: Previous randomized trials have shown that progesterone administration in women who previously delivered prematurely reduces the risk of recurrent premature delivery. Asymptomatic women found at midgestation to have a short cervix are at greatly increased risk for spontaneous early preterm delivery, and it is unknown whether progesterone reduces this risk in such women. METHODS: Cervical length was measured by transvaginal ultrasonography at a median of 22 weeks of gestation (range, 20 to 25) in 24,620 pregnant women seen for routine prenatal care. Cervical length was 15 mm or less in 413 of the women (1.7%), and 250 (60.5%) of these 413 women were randomly assigned to receive vaginal progesterone (200 mg each night) or placebo from 24 to 34 weeks of gestation. The primary outcome was spontaneous delivery before 34 weeks. RESULTS: Spontaneous delivery before 34 weeks of gestation was less frequent in the progesterone group than in the placebo group (19.2% vs. 34.4%; relative risk, 0.56; 95% confidence interval [CI], 0.36 to 0.86). Progesterone was associated with a nonsignificant reduction in neonatal morbidity (8.1% vs. 13.8%; relative risk, 0.59; 95% CI, 0.26 to 1.25; P=0.17). There were no serious adverse events associated with the use of progesterone. CONCLUSIONS: In women with a short cervix, treatment with progesterone reduces the rate of spontaneous early preterm delivery. (ClinicalTrials.gov number, NCT00422526 [ClinicalTrials.gov].).

Screening test for preeclampsia through assessment of uteroplacental blood flow and biochemical markers of oxidative stress and endothelial dysfunction.

OBJECTIVE: This study was undertaken to evaluate whether screening through a uterine artery (UtA) Doppler and biochemical markers of oxidative stress and endothelial dysfunction predict preeclampsia. STUDY DESIGN: UtA Doppler was performed at 11 to 14 and 22 to 25 weeks on 1447 asymptomatic pregnant women. Oxidative stress, endothelial dysfunction, and antiangiogenic state were assessed in women who later developed preeclampsia and normotensive controls. RESULTS: There was a significantly increased of UtA pulsatility index (PI), plasma levels of soluble fms-like tyrosine kinase 1 (sFlt1), PAI-1/PAI-2 ratio, and F-2 isoprostane in women who subsequently developed preeclampsia compared with control pregnancies. Multivariate logistic regression showed that increased UtA PI performed at 23 weeks was the best predictor for preeclampsia. CONCLUSION: This study demonstrates early changes in markers of impaired placentation, antiangiogenic state, oxidative stress, and endothelial dysfunction suggesting that these derangements may play a role in the pathogenesis of preeclampsia. Our data point to UtA as the best test to predict preeclampsia at 23 weeks of gestation.

[Free protein S (PS) in normal pregnancy: a comparison between two analytical methods]. / Proteína S libre en embarazadas normales: comparación entre dos métodos.

BACKGROUND: Pregnancy is a physiological hypercoagulable state with an increased incidence of thromboembolic phenomena. There is an increase in the concentrations of most clotting factors, a decrease in concentration of some of the natural anticoagulants and reduced fibrinolytic activity. Changes in PS levels have also been reported. AIM: To establish referral range values of functional PS and free PS antigen, during the second (2nd T) and third trimester (3rd T) of normal gestation. PATIENTS AND METHODS: Forty one normal pregnant women were included in our study, 20 during the 2nd T (22-24 weeks) and 21 during the 3rd T (29-38 weeks). Functional PS was measured by a clot based test and free PS antigen by ELISA. RESULTS: Free PS Antigen was 65.8+/-18.3% during the 2nd T and 62.3+/-16.5% during the 3rd T. The figures for normal controls were 106+/-6.5%. Functional PS was 43.8+/-13.3 and 25.9+/-14.6% during the 2nd T and 3rd T, respectively. The figures for normal controls were 97+/-24% (p <0.001 compared with pregnant women). Free PS antigen did not change from the 2nd to the 3rd T (p=NS), however functional PS fell significantly from the 2nd to the 3rd T (p <0.001) and was significantly lower than free PS antigen in both trimesters (p <0.001). CONCLUSIONS: Pregnancy is associated to a decrease in PS. This abnormality is more pronounced for functional PS than free PS antigen and functional PS falls progressively during pregnancy. These assays should not be used to screen for PS deficiency during pregnancy because they could lead to a misdiagnosis.

Pathophysiological basis for the prophylaxis of preeclampsia through early supplementation with antioxidant vitamins.

Preeclampsia (PE) is a multisystem disorder that remains a major cause of maternal and foetal morbidity and death. To date, no treatment has been found that prevents the development of the disease. Endothelial dysfunction is considered to underlie its clinical manifestations, such as maternal hypertension, proteinuria, and edema; however, the precise biochemical pathways involved remain unclear. A current hypothesis invokes the occurrence of oxidative stress as pathogenically important, as suggested by the fact that in PE, the placental and circulating levels of lipid peroxidation products (F2-isoprostanes and malondialdehyde [MDA]) are increased and endothelial cells are activated. A potential mechanism for endothelial dysfunction may occur via nuclear transcription factor kappa B (NF-kappaB) activation by oxidative stress. Alternatively, the idea that the antiangiogenic placental soluble fms-like tyrosine kinase 1 factor (sFlt1) is involved in the pathogenesis of this disease is just emerging; however, other pathophysiological events seem to precede its increased production. This review is focused on evidence providing a pathophysiological basis for the beneficial effect of early antioxidant therapy in the prevention of PE, mainly supported by the biological effects of vitamins C and E.

Beare-Stevenson syndrome: Two South American patients with FGFR2 analysis.

We report two patients with Beare-Stevenson syndrome. This syndrome presents craniosynostosis with or without clover-leaf skull, craniofacial anomalies, cutis gyrata, acanthosis nigricans, prominent umbilical stump, furrowed palms and soles, genital and anal anomalies. Both female newborn patients presented at birth with craniofacial anomalies, variable cutis gyrata in forehead and preauricular regions, prominent umbilical stump and anogenital anomalies. Furrowed palms and soles were also observed. The radiologic examination showed a cloverleaf-form craniosynostosis. Chromosomes were normal. They were born with respiratory distress and were connected to mechanical ventilation for ventilatory support. Both of them died in 50 days after birth due to secondary complications. The molecular analysis of these patients identified the mutation Tyr375Cys in the FGFR2 gene.

Levels of C-reactive protein in pregnant women who subsequently develop pre-eclampsia.

OBJECTIVE: To investigate whether a maternal inflammatory response precedes the development of preeclampsia. DESIGN: Cross-sectional study. SETTING: Antenatal clinic in an inner city teaching hospital. POPULATION: Two groups of women were examined at 23-25 weeks of gestation. The first group (45 women) had normal uterine artery Doppler waveforms and subsequently had a normal pregnancy outcome. The second group (45 women) had Doppler evidence of impaired placental perfusion and 21 (47%) of them had normal outcome, 14 (31%) developed intrauterine growth restriction and 10 (22%) developed pre-eclampsia, with or without intrauterine growth restriction. METHODS: C-reactive protein, an acute-phase reactant, was measured in maternal serum using a highly sensitive method with a detection limit of 0.05 mg/L. MAIN OUTCOME MEASURES: Development of pre-eclampsia, as defined by the International Society for the Study of Hypertension in Pregnancy. Intrauterine growth restriction was defined as birthweight <5th centile for gestation and sex of the neonate. RESULTS: The serum C-reactive protein concentration in women who subsequently developed pre-eclampsia (median 1.56, range 0.55-3.12 mg/L) or delivered a baby with birthweight <5th centile (median 0.74, range 0.64-1.58 mg/L) was not significantly different from that in women with uncomplicated pregnancies (median 1.28, range 0.75-2.08 mg/L; P = 0.95 and P = 0.62, respectively). CONCLUSION: These findings suggest that the onset of clinical signs of pre-eclampsia may not be preceded by a maternal inflammatory response, as assessed by measurement of C-reactive protein.

Frecuencia cardíaca embrionaria y riesgo de perdida reproductiva / Embryonic cardiac frequency and lost risk of reproductive

La pérdida reproductiva es un fenómeno frecuente. El objetivo de este trabajo fue determinar la frecuencia cardíaca embrionaria normal durante el primer trimestre, la frecuencia de pérdida reproductiva de acuerdo a la edad gestacional. la asociación entre frecuencia cardíaca y pérdida reproductiva y determinar el riesgo de aborto de acuerdo a la frecuencia cardíaca embrionaria. Diseñamos un estudio retrospectivo, 1.718 pacientes con embriones entre 2 y 84 mm y seguimiento clínico fueron evaluados por ultrasonido. La frecuencia cardíaca aumentó progresivamente desde 12o Ipm a las seis semanas hasta alcanzar un máximo de 182 Ipm a las 8 semanas de gestación (p<0,01), luego se mantuvo estable entre las 8 y 10 semanas (p> 0,05), para luego disminuir progresivamente hasta las 14 semanas de embarazo (p<0,01). Ciento doce pacientes abortaron (6,5 por ciento) fue más frecuente a mayor edad materna, a menor edad gestacional, y a menor frecuencia embrionaria (110,7 Ipm vs 150,4 Ipm, p< 0,0001). La pérdida reproductiva tuvo una disminución significativa desde 16 por ciento a 3 por ciento entre las 6 y 8 semanas para luego de las 9 semanas permanecer en 1 por ciento aproximadamente. La frecuencia cardíaca embrionaria fue significativamente menor en los embriones que abortan a las seis y siete semanas de gestación (6 semanas 93 vs 118 Ipm, p< 0.001; siete semanas 133 vs 146 Ipm, p< 0,001). El riesgo de pérdida reproductiva a las seis y siete semanas de gestación aumenta 19 veces cuando la frecuencia cardíaca embrionaria es menor de 90 pm (RR 19,9 IC 15,5-25,6) y siete veces cuando esta entre 90 y 100 Ipm (RR 7,1, IC 4,1-12,5)

Absorçäo de metais pesados do lodo de esgoto pelo feijoeiro (Phaseolus vulgaris L.) / Heavy metal uptake of the sewage sludge by bean plants (Phaseolus vulgaris L.)

Toxicity and uptake of heavy metals of sewage sludge by beans (Phaseolus vulgaris L.) were evaluated in green house experiments. Treatments consisted of 1,0; 2,0 and 5,0 per cent (m/m) of dry sewage sludge, collected from Londrina (Bom Retiro and ETE-Sul) and Curitiba (ETE-Belém and RALF). Bean (variety IAPAR 57) was sown three times at 0, 120 and 240 days after the treatment have been applied. Contents of Cd, Cr, Co, Cu, Ni, and Pb in bean tissues cultivated with 5,0 per cent (m/m) of all sewage sludge were similar to the control and Ba contents were reduced by increasing the quantity of sewage sludge in the soil. The Zn content in tissue bean increased from 86 mg kg -1 of contrrol to 462 mg kg-1 by applying 5 per cent (m/m) of sewage sludge in soil, but plant beans did not show toxicity symptons. The addition of 5 per cent (m/m) of sewage sludge increased Mn content in plants, from 193 mg kg-1 of control to 1.960 mg kg -1, showing toxity in bean leaves when the contents were more than 500 mg kg-1. The addition of sewage sludges in soils increased only avaiable Zn carbonate and Cu organic species

Ecocardiografía fetal I: técnica y fundamentos / Fetal echocardiography I: technics and foundations

Se describe la metodología y fundamentos de la ecocardiografía fetal; se analiza la técnica del examen destacando la utilidad de los modos bidimensional, modo M y doppler de ultrasonido en el diagnóstico de cardiopatías congénitas fetales. Se destaca la importancia del diagnóstico precoz de las alteraciones estructurales y del ritmo del corazón fetal

Ecocardiografía fetal II: biometría del corazón fetal normal / Fetal echocardiography II: biometry of the normal fetal heart

Se analiza biometría del corazón fetal normal por ecocardiografía. Se realizan 80 exámenes en 80 fetos entre las 20 y 40 semanas de gestación. Se realiza medición de ventrículos izquierdo y derecho, septum interventricular y raíz de aorta. Todos los parámetros evaluados progresan sus dimensiones a medida que progresa la edad gestacional

Ecocardiografía fetal III: diagnóstico antenatal de alteraciones estructurales y del ritmo / Fetal echocardiography III: prenatal diagnosis of structural and rhythm abnormalities

Se presenta la experiencia del Hospital Clínico de la Universidad de Chile en ecocardiografía fetal. Se realizaron 119 exámenes en 90 fetos de riesgo con edades gestacionales de 20 a 40 semanas. Se encontraron 18 fetos con alteraciones (20%). Seis de ellos con alteraciones estructurales (6,6%) y catorce con alteraciones del ritmo (15,5%). La concordancia diagnóstica en alteraciones estructurales fue de una sensibilidad de 83,3% y una especificidad de 100%. En las alteraciones del ritmo la sensibilidad y específicidad fue de 100%. Se destaca la importancia del diagnóstico antenatal en malformaciones cardíacas congénitas y alteraciones del ritmo