Duplicidad intestinal y diagnóstico diferencial prenatal de lesiones quísticas intraabdominales / Intestinal duplication and prenatal differential diagnosis of intra-abdominal cysts

Resumen ANTECEDENTES: Las duplicaciones del aparato digestivo son una variante poco frecuente de malformación congénita. Si bien la mejora de los equipos de ecografía ha aumentado la tasa diagnóstica, solo el 30% se diagnostican antes del nacimiento. El diagnóstico diferencial de lesiones quísticas intraabdominales es amplio e incluye, por ejemplo, a los quistes de ovario, colédoco, mesenterio o pseudoquistes de meconio. El tratamiento es quirúrgico mediante la resección y restauración de la continuidad intestinal. CASO CLÍNICO: Paciente de 32 años, con un embarazo previo y en el segundo trimestre del actual, con sospecha de un quiste de duplicación intestinal. El estudio genético no evidenció anomalía alguna. La lesión, de morfología quística tubular, fue aumentando progresivamente de tamaño conforme avanzaban las semanas de embarazo. En la semana 39 se indicó, por diabetes gestacional insulinodependiente, la inducción del parto. Nació un varón, asintomático, mediante parto eutócico, sin complicaciones. La ecografía abdominal, resonancia magnética nuclear y estudio del tránsito intestinal del periodo neonatal temprano confirmó el diagnóstico prenatal de sospecha. Mediante una laparoscopia exploradora, a las dos semanas de vida se practicó la resección del defecto que se reportó como: duplicación intestinal ileal, sin comunicación con la luz intestinal. El curso posoperatorio fue favorable. CONCLUSIONES: El diagnóstico prenatal de quistes de duplicación en el aparato digestivo está en aumento debido a la mejoría en las técnicas de diagnóstico prenatal. La valoración multidisciplinaria es decisiva para procurar una adecuada vigilancia médica del embarazo y del recién nacido.

Abstract BACKGROUND: Duplications of the digestive tract are a rare variant of congenital malformation that can occur anywhere in the digestive tract. Although improved ultrasound equipment has increased the diagnostic rate, only 30% are diagnosed before birth. The differential diagnosis of intra-abdominal cystic lesions is broad and includes, for example, cysts of the ovary, common bile duct, mesentery or meconium pseudocysts. Treatment is surgical by resection and restoration of intestinal continuity. CLINICAL CASE: 32-year-old patient, with a previous pregnancy and in the second trimester of the current pregnancy, with suspicion of an intestinal duplication cyst. The genetic study did not reveal any abnormality. The lesion, of tubular cystic morphology, progressively increased in size as the weeks of pregnancy progressed. Induction of labour was indicated in week 39 due to insulin-dependent gestational diabetes. An asymptomatic male was born by euthecological delivery, without complications. Abdominal ultrasound, nuclear magnetic resonance imaging and intestinal transit study of the early neonatal period confirmed the suspected prenatal diagnosis. By means of exploratory laparoscopy, at two weeks of life, resection of the defect was performed, which was reported as: ileal intestinal duplication, without communication with the intestinal lumen. The postoperative course was favourable. CONCLUSIONS: Prenatal diagnosis of duplication cysts in the digestive tract is increasing due to improved prenatal diagnostic techniques. Multidisciplinary assessment is crucial to ensure adequate medical surveillance of the pregnancy and the newborn.

Sulfato de magnesio antenatal y eliminación tardía de meconio: Estudio multicéntrico / Antenatal magnesium sulphate and delayed passage of meconium: A multicentre study

Introducción: La relación entre sulfato de magnesio (MgSO4) y el retraso en la evacuación de meconio presenta resultados controvertidos en la literatura. Objetivos: Determinar si existe relación entre la administración de MgSO4 a la madre y la eliminación tardía de meconio (ETM) en el neonato y conocer los niveles de magnesio en sangre en estos, con respecto a la dosis acumulada de MgSO4 administrada a la madre. Población y métodos: Estudio descriptivo-analítico, en pacientes ≤ 32 semanas de edad gestacional, con diseño retrospectivo-prospectivo, llevado a cabo en dos hospitales de tercer nivel asistencial. Se definió la ETM como retraso en la evacuación meconial ≥ 48 horas y/o necesidad de estimulación rectal en ≥ 2 ocasiones para realizar deposición y/o retraso ≥ 48 horas entre la primera y segunda deposición. Resultados: Se reclutaron 283 pacientes (204 retrospectiva y 79 prospectivamente), de los cuales 152 (53,7%) presentó ETM. No se encontró relación entre la administración de MgSO4 a la madre, ni la dosis acumulada de MgSO4 en esta, ni los niveles de magnesio en sangre del neonato con la presencia de ETM. La mayor edad gestacional (OR 0,8, IC 0,69-0,93, p = 0,003) resultó factor protector independiente de la ETM y la necesidad de reanimación avanzada (OR 2,24, IC 1,04-4,86, p = 0,04) factor de riesgo. Conclusiones: Los niveles alcanzados de magnesio en sangre del neonato con las dosis de MgSO4 administradas a las madres, no se relacionan con la ETM. La menor edad gestacional y la necesidad de reanimación avanzada predicen mayor riesgo de ETM. (AU)

Introduction: The published evidence on the association between magnesium sulphate (MgSO4) and delayed passage of meconium (DPM) is contradictory. Objectives: To determine whether there is an association between the administration of MgSO4 to the mother and DPM in the neonate, and to analyse serum magnesium levels in neonates in relation to the cumulative dose of MgSO4 administered to the mother. Population and methods: Retrospective and prospective descriptive and analytical study conducted in patients delivered at or before 32 weeks of gestation in 2 tertiary care hospitals. Delayed passage of meconium was defined as failure to pass meconium within 48 hours of birth and/or need for rectal stimulation on 2 or more occasions to pass stool and/or interval of at least 48 hours between the first and second bowel movements. Results: The study included 283 patients (204 retrospectively and 79 prospectively), of who 152 (53.7%) experienced DPM. Delayed passage of meconium was not associated with antenatal MgSO4 administration, the cumulative maternal MgSO4 dose or neonatal serum magnesium levels. Older gestational age (OR, 0.8; confidence interval [CI], 0.69–0.93; P = .003) was an independent protective factor against DPM, while the need for advanced resuscitation (OR, 2.24; CI 1.04–4.86; P = .04) was a risk factor for DPM. Conclusion: The neonatal serum levels of magnesium reached with the doses of MgSO4 administered to mothers were not associated with DPM. Lower gestational age and the need for advanced resuscitation were predictors associated with an increased risk of DPM. (AU)

Antenatal magnesium sulphate and delayed passage of meconium: A multicentre study.

INTRODUCTION: The published evidence on the association between magnesium sulphate (MgSO4) and delayed passage of meconium (DPM) is contradictory. OBJECTIVES: To determine whether there is an association between the administration of MgSO4 to the mother and DPM in the neonate, and to analyse serum magnesium levels in neonates in relation to the cumulative dose of MgSO4 administered to the mother. POPULATION AND METHODS: Retrospective and prospective descriptive and analytical study conducted in patients delivered at or before 32 weeks of gestation in 2 tertiary care hospitals. Delayed passage of meconium was defined as failure to pass meconium within 48 h of birth and/or need for rectal stimulation on 2 or more occasions to pass stool and/or interval of at least 48 h between the first and second bowel movements. RESULTS: The study included 283 patients (204 retrospectively and 79 prospectively), of who 152 (53.7%) experienced DPM. Delayed passage of meconium was not associated with antenatal MgSO4 administration, the cumulative maternal MgSO4 dose or neonatal serum magnesium levels. Older gestational age (OR, 0.8; confidence interval [CI], 0.69-0.93; P = 0.003) was an independent protective factor against DPM, while the need for advanced resuscitation (OR, 2.24; CI 1.04-4.86; P = 0.04) was a risk factor for DPM. CONCLUSION: The neonatal serum levels of magnesium reached with the doses of MgSO4 administered to mothers were not associated with DPM. Lower gestational age and the need for advanced resuscitation were predictors associated with an increased risk of DPM.

Síndrome de aspiración meconial: revisión de la fisiopatología y estrategias de manejo / Meconium aspiration syndrome: review of the pathophysiology and management strategies

El síndrome de aspiración meconial, es una condición clínica caracterizada por insuficiencia respiratoria que ocurre en neonatos nacidos a través de líquido amniótico teñido de meconio, y que puede presentarse como una enfermedad grave con riesgo vital. Su incidencia ha disminuido gracias a mejores prácticas obstétricas y atención perinatal y se ha observado una mejoría en la sobrevida, gracias a mejores prácticas en la UCI neonatal. Sin embargo, el abordaje más adecuado sigue siendo un tema de debate, dado que hasta el momento se basa sólo en medidas de soporte, sin que existan medidas que actúen sobre los mecanismos de daño. Por otro lado, la morbilidad a largo plazo entre los sobrevivientes sigue siendo una preocupación importante. Esta revisión ofrece una visión general actualizada de la epidemiología, la fisiopatología, el diagnóstico, el manejo terapéutico, la prevención y el pronóstico de los pacientes que presentan este cuadro.

Meconium aspiration syndrome is a clinical condition characterized by respiratory failure that occurs in neonates born through meconium-stained amniotic fluid and can present as a serious life-threatening disease. Its incidence has decreased thanks to better obstetric practices and perinatal care, and an improvement in survival has been observed, thanks to better practices in the neonatal ICU. However, the most appropriate approach is still a matter of debate, given that so far it is based only on support measures, without any measures that act on the damage mechanisms. On the other hand, long-term morbidity among survivors remains a major concern. This review offers an updated overview of the epidemiology, pathophysiology, diagnosis, therapeutic management, prevention, and prognosis of patients with this condition.

Características clínicas y factores de riesgo asociados a la exposición prenatal a drogas de abuso / Clinical features and risk factors associated with prenatal exposure to drugs of abuse

Introducción: La identificación temprana de los neonatos expuestos a drogas de abuso permite realizar un manejo clínico más preciso.Objetivos: Describir las características clínicas e identificar factores de riesgo asociados a la detección precoz de neonatos expuestos a drogas de abuso en una Unidad de Cuidados Intensivos e Intermedios Neonatales.Métodos: Estudio observacional prospectivo de neonatos con y sin sospecha clínica de exposición prenatal a drogas de abuso. Se analizó meconio empleando técnicas cromatográficas estandarizadas. Se realizaron análisis estadísticos univariante y multivariante.Resultados: Se incluyeron 372 neonatos. En 49 (13,2%) casos se detectó exposición a alguna droga de abuso; en 41 (83,7%) a una, y en ocho (16,3%) a más de una. La somatometría al nacimiento objetivó: a) menor percentil de longitud en expuestos a alguna droga, a más de una y a cannabis; b) menor percentil de peso en expuestos a cannabis, y de éstos en comparación con los expuestos a alcohol. En mayores de 34 semanas de gestación (SG): a) menor percentil de longitud en expuestos a alguna droga; b) menor percentil de longitud y peso en expuestos a más de una. Los factores de riesgo independientes clínicamente útiles para detectar casos de exposición prenatal a drogas de abuso fueron (odds ratio [IC 95%]): motivo de ingreso distinto a prematuridad (5,52 [2,55-1,93]), percentil de longitud menor a 33 (1,95 [1,05-3,60]) y (2,14 [1,04-3,40]) en mayores de 34 SG y distocia social/embarazo no controlado en mayores a 34SG (4,47 [1,03-19,29]).Conclusiones: Existen alteraciones somatométricas y factores de riesgo que pueden ayudar a detectar precozmente a los neonatos expuestos a drogas de abuso. Las alteraciones somatométricas identificadas pueden servir para ampliar su diagnóstico diferencial y el estudio de sus causas. (AU)

Introduction: Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management.Objectives: To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit.Methods: Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed.Results: 372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)).Conclusions: There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

Clinical features and risk factors associated with prenatal exposure to drugs of abuse.

INTRODUCTION: Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management. OBJECTIVES: To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit. METHODS: Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed. RESULTS: 372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)). CONCLUSIONS: There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

Diagnóstico prenatal de peritonitis meconial fetal: Reporte de caso y revisión de la literatura Prenatal

Se comunica el diagnóstico ultrasonográfico prenatal de un caso de peritonitis meconial en un feto de 33 semanas, quien nació de parto pretérmino y se confirmó el diagnóstico con ultrasonografía, radiografía y cirugía. El neonato fue sometido a laparotomía exploratoria, en la cual se desbridó un pseudoquiste meconial, resecándose el área intestinal perforada, y se realizó anastomosis términoterminal. La evolución inicial fue tórpida, pero finalmente fue dado de alta con buen funcionamiento intestinal.

We report the prenatal ultrasonographic diagnosis of a case of meconium peritonitis in a 33-week fetus, who was born preterm and the diagnosis was confirmed with ultrasound, radiography and postnatal surgery. The neonate underwent exploratory laparotomy, in which a meconium pseudocyst was debrided, the perforated intestinal area was resected and end-to-end anastomosis was performed. The initial evolution was torpid, but he was finally discharged with good intestinal function.

Desenlaces perinatales, en un centro de tercer nivel de México de pacientes con colestasis intrahepática del embarazo / Perinatal outcomes of patients with intrahepatic cholestasis of pregnancy in a third level center in Mexico

Resumen OBJETIVO: Describir la atención, tratamiento, desenlaces perinatales y complicaciones asociadas con la colestasis intrahepática del embarazo. MATERIALES Y MÉTODOS: Estudio de serie de casos, retrospectivo y observacional de pacientes embarazadas, con diagnóstico de colestasis intrahepática atendidas en el Instituto Nacional de Perinatología entre los meses de enero de 2016 a diciembre de 2020. Se evaluaron las características obstétricas, los datos demográficos, clínicos, bioquímicos y de tratamiento, la finalización del embarazo y los desenlaces perinatales. RESULTADOS: Se analizaron 67 casos de colestasis intrahepática que arrojaron una incidencia de 0.57%. La edad promedio de las pacientes fue 29.0 ± 6.8 años, 30 de 67 eran primigestas, 12 tuvieron el antecedente de colestasis intrahepática en el embarazo previo y 7 de óbito. El inicio de la enfermedad fue en el tercer trimestre en 41 de 67 pacientes. En los estudios de bioquímica 32 de 67 tuvieron valores de ácidos biliares entre 10 y 39 μM/L; 12 de las 67: 40-99 μM/L y 23 más de 100 (μM/L). Se administró tratamiento con ácido ursodesoxicólico a 63 de 67 y ante la falta de respuesta se agregó rifampicina. El promedio de semanas de gestación fue 35.6 ± 2.0 semanas con peso promedio de 2397 ± 572 g. Se encontró líquido amniótico con meconio en 10 neonatos y restricción del crecimiento en 20 de 67; se registraron 2 óbitos. CONCLUSIONES: Este es el primer estudio efectuado en México que describe la incidencia de la enfermedad y se utiliza la determinación de los ácidos biliares para establecer el diagnóstico. Los desenlaces perinatales coinciden con lo reportado en la bibliografía.

Abstract OBJECTIVE: To describe the care, treatment, perinatal outcomes and complications associated with intrahepatic cholestasis of pregnancy. MATERIALS AND METHODS: A retrospective and observational case series study of pregnant patients with a diagnosis of intrahepatic cholestasis seen at the National Institute of Perinatology between January 2016 and December 2020. Obstetric characteristics, demographic, clinical, biochemical and treatment data, pregnancy termination and perinatal outcomes were evaluated. RESULTS: Sixty-seven cases of intrahepatic cholestasis were analyzed, yielding an incidence of 0.57%. The mean age of the patients was 29.0 ± 6.8 years, 30 of 67 were primigravidases, 12 had a history of intrahepatic cholestasis in the previous pregnancy and 7 had an abortion. The onset of the disease was in the third trimester in 41 of 67 patients. In biochemistry studies 32 of 67 had bile acid values between 10 and 39 μM/L; 12 of 67: 40-99 μM/L and 23 more than 100 (μM/L). Treatment with ursodeoxycholic acid was administered to 63 of 67 and rifampicin to 4 patients. The mean number of weeks of gestation was 35.6 ± 2.0 weeks with a mean weight of 2397 ± 572 g. Amniotic fluid with meconium was found in 10 neonates and growth restriction in 20 of 67; there were 2 recorded abortions. CONCLUSIONS: This is the first study carried out in Mexico in which the incidence of the disease is described, and the determination of bile acids is used to establish the diagnosis. Perinatal outcomes coincide with those reported in the literature.

[Clinical features and risk factors associated with prenatal exposure to drugs of abuse]. / Características clínicas y factores de riesgo asociados a la exposición prenatal a drogas de abuso.

INTRODUCTION: Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management. OBJECTIVES: To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit. METHODS: Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed. RESULTS: 372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)). CONCLUSIONS: There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.

Líquido meconial su asociación con las alteraciones del test de Apgar, hospital Ben Nacer Bachir / Association of meconium fluid with alterations of the APGAR test in the Bennacer Bachir hospital

RESUMEN Introducción: el líquido amniótico meconial constituye un indicador más de la evolución fetal intraparto y un indicador tradicional de asfixia perinatal. Sin embargo, este indicador muestra importantes limitaciones operativas; no se correlaciona bien entre sí, tiene un alto porcentaje de falsos positivos y, en consecuencia, es pobre predictor de morbilidad neurológica precoz o tardía del mal llamado sufrimiento fetal agudo, actualmente estado fetal no tranquilizador. Objetivo: evaluar la asociación del líquido amniótico meconial con las alteraciones del puntaje del Apgar, en el Hospital Ben Nacer Bachir. El Oued. Argelia. Métodos: se realizó una investigación descriptiva longitudinal prospectiva de 628 nacimientos, 39 gestantes que presentaron líquido meconial escogidas de forma aleatoria simple a las cuales se le aplico el test de Apgar. Resultados: el mayor número de pacientes atendidas, fue entre 25 y 29 años. El 76,92 % nulípara, 6,2 % de los nacimientos presentaron líquido meconial, el 48,72 % fue meconio moderado e intenso el 41 %, el 89,74 % presento Apgar normal, sexo predominante fue femenino y el 64,1 % terminó en cesárea. Conclusiones: a pesar del grado de intensificación del líquido meconial, no hubo relación con el Apgar bajo en el mayor porciento de gestantes.

ABSTRACT Introduction: mixture of meconium and amniotic fluid is another indicator of intra-partum fetal development and a traditional indicator of perinatal asphyxia. However, this indicator shows important operational limitations; it does not correlate well with each other, having a high percentage of false positives and, consequently, is a poor predictor of early or late neurological morbidity of the known Acute Fetal Distress (AFD). Objective: to assess the association of meconium and amniotic fluid with Apgar score alterations at the Bennacer Bachir Hospital, El Oued, Algeria. Methods: a prospective, descriptive, longitudinal study of 628 births was conducted, 39 pregnant women who presented meconium fluid were chosen in a simple randomized sample, applying the Apgar test. Results: the greatest number of patients attended was between 25 and 29 years old. Seventy-six percent were nulliparous, 6,2 % of births presented meconium fluid, 48,72 % presented moderate and intense meconium 41 %, normal Apgar score (89,74 %), female sex predominated, and 64,1 % underwent cesarean section. Conclusions: despite the degree of intensification of meconium fluid, there was no relationship with low Apgar score in the highest percentage of pregnant women.

Prevention of meconium obstruction in very low birth weight preterm infants. / Prevención de la obstrucción meconial en recién nacidos prematuros de muy bajo peso.

INTRODUCTION: Delayed meconium expulsion is a cause of bowel obstruction in the extremely premature newborn (<28 WGE) weighing less than 1500g at birth. OBJECTIVE: To evaluate the efficacy of conservative treatment in the prevention of meconium obstruction in very-low-birt- weight preterm infants. METHOD: Descriptive and retrospective study performed at the Neonatal Intensive Care Unit of a tertiary level hospital. All very-low-birth-weight preterm infants who were born during the study period, from August 2016 to January 2017, and who had meconium obstruction were included. RESULTS: A sample of 42 newborn infants was obtained. Regarding the expulsion of meconium, 57.1% of the sample spontaneously ejected meconium, while 42.9% received different treatments. Of these, 72.2% were treated with saline enemas, 16% with acetylcysteine enemas, 16% with Gastrografin® and none required surgical treatment. CONCLUSION: Conservative treatment seems to be an effective therapeutic measure for the prevention of meconium obstruction in very-low-birth-weight preterm infants since it achieved the expulsion of meconium without having to apply surgical treatment.

Perfil clínico ­ epidemiológico de la asfixia perinatal en recién nacidos de la Unidad de Neonatología del Hospital Nacional de Niños Benjamín Bloom de enero de 2013 a diciembre de 2016 / Clinical-epidemiological profile of perinatal asphyxia in newborns of the Neonatology Unit of the Benjamin Bloom National Children's Hospital from January 2013 to December 2016

La asfixia perinatal es un factor importante que contribuye a la mortalidad infantil que es un indicador de los estándares sociales, educativos y económicos de un país. Uno de los objetivos del desarrollo sostenible es para 2030 poner fin a las muertes evitables de recién nacidos y de niños menores de 5 años, logrando que todos los países intenten reducir la mortalidad neonatal al menos hasta 12 por cada 1.000 nacidos vivos. A pesar de la reducción en la morbimortalidad neonatal en los últimos años, la asfixia perinatal sigue siendo una causa importante de muerte y discapacidad motora y cognitiva a nivel mundial. Se ha estimado que la incidencia de asfixia perinatal es de 1/1,000 nacidos vivos en países desarrollados, llegando a 5-10/1,000 nacidos vivos en países en vías de desarrollo. En el Hospital Nacional de Niños Benjamín Bloom la asfixia perinatal es una causa importante de referencia y de admisión en la Unidad de Neonatología. Se realizó un estudio descriptivo de corte transversal, retrospectivo. Según los datos obtenidos por medio del Sistema de Morbimortalidad en la Web (SIMMOW) del Ministerio de Salud entre el período comprendido 2013 ­ 2016 se registraron 180 casos de los cuales 114 fueron incluidos en nuestro estudio. La asfixia perinatal es un problema de salud relevante, en la Unidad de Neonatología del Hospital Nacional de Niños Benjamín Bloom es predominante en el sexo masculino, hijos de madres jóvenes entre 19 ­ 25 años sanas, primigestas que provienen del área rural del país, los manifestaciones clínicas más importantes son hipotensión que requiere uso de aminas vasoactivas y la falla renal aguda evidenciada por el aumento de creatinina en el 43% y 39% de casos respectivamente. La complicación más frecuente es la hipertensión pulmonar persistente se presentó en el 20% de casos, la mortalidad en nuestro estudio fue del 25%. Es necesario continuar con medidas de prevención orientadas a mejorar la atención en el primer y segundo nivel de salud con el fin de impactar en factores de riesgo y disminuir los casos de asfixia perinatal. La principal complicación de la asfixia perinatal es la hipertensión pulmonar persistente por lo tanto se debe mejorar el manejo de esta. Se deben realizar otras investigaciones que completen el perfil clínico de la asfixia perinatal pero enfocada a la búsqueda de secuelas a largo plazo y el impacto de estas en la calidad de vida de los pacientes

Tinción del líquido amniótico por meconio y resultante neonatal en embarazos de bajo riesgo / Amniotic fluid staining by meconium and neonatal outcome in low risk pregnancies

El propósito del estudio fue establecer la asociación entre la tinción del líquido amniótico por meconio y la resultante neonatal en embarazos de bajo riesgo. Se realizó un estudio prospectivo de cohortes complementado por revisión retrospectiva en el Hospital Central Dr. Urquinaona, Maracaibo, Venezuela. Se evaluaron las variables de atención hospitalaria neonatal, puntaje de Apgar y tasa de hospitalización luego de 30 días del nacimiento. Se incluyeron 389 casos de líquido amniótico con meconio espeso (grupo A), 276 casos de líquido amniótico con meconio claro (grupo B) y 103 casos con líquido amniótico con meconio terminal. El grupo de control estaba compuesto por 621 neonatos con líquido amniótico claro (grupo D). Los neonatos de los tres grupos de estudio presentaron puntajes de Apgar al minuto y a los 5 minutos significativamente menores comparado con el grupo D (p < 0,001). La atención pediátrica en la sala de parto fue en forma significativamente más frecuente en el grupo A (p < 0,001). La tasa de consulta pediátrica luego del parto fue del 18,2 % en los neonatos del grupo A comparado con 9,3 % en los neonatos del grupo D (p < 0.001). Se concluye que la presencia y tipo de líquido amniótico teñido de meconio puede predecir el aumento proporcional del uso de recursos hospitalarios, expresados en forma de asistencia pediátrica y medidas de resucitación empleada.

The purpose of the study was to establish the association between amniotic fluid staining by meconium and neonatal outcome in low risk pregnancies. A prospective cohort study was carried out, complemented by a retrospective review at Hospital Central Dr. Urquinaona, Maracaibo, Venezuela. Neonatal hospital care, Apgar score and hospitalization rate after 30 days of birth were evaluated. We included 389 cases of amniotic fluid with thick meconium (group A), 276 cases of amniotic fluid with clear meconium (group B) and 103 cases with amniotic fluid with terminal meconium. The control group consisted of 621 neonates with clear amniotic fluid (group D). The neonates of the three study groups presented Apgar scores at minute and 5 minutes significantly lower compared to group D (p <0.001). Pediatric care in the delivery room was significantly more frequent in group A (p <0.001). The pediatric consultation rate after delivery was 18,2 % in the neonates of group A compared with 9,3 % in the neonates of group D (p <0.001). It is concluded that the presence and type of amniotic fluid stained with meconium can predict the proportional increase in the use of hospital resources, expressed in the form of pediatric care and resuscitation measures used.

Ascitis fetal como manifestación de peritonitis meconial; presentación de un caso y revisión de literature / Fetal ascites as a manifestation of meconium peritonitis; presentation of a case and literature review

RESUMEN Introducción: La peritonitis meconial (PM) corresponde a una inflamación del peritoneo por una reacción química estéril producida por la presencia de meconio, secundaria a una perforación intestinal in útero. Se expone un caso real de PM cuya relevancia está dada por la baja incidencia de esta enfermedad, siendo de aproximadamente 1 caso por cada 30.000 nacidos vivos. El presente trabajo tiene como objetivo dar a conocer la presentación clásica de la PM mediante una revisión actualizada de la literatura. Caso clínico: Paciente de 21 años, primigesta, cursando embarazo de 33 + 5 semanas, con antecedentes de hipotiroidismo gestacional, es derivada al servicio de urgencia maternal por hallazgo en ecografía realizada ese mismo día: Ascitis fetal, intestino hiperecogénico, sin alteraciones en eco-Doppler fetal, hospitalizándose a paciente para estudio. Los exámenes de laboratorio, incluidos VIH y VDRL, resultaron negativos y no esclarecían una etiología. Dado hallazgos ecográficos posteriores se logra orientar el diagnóstico hacia una PM, la cual se objetivó una vez interrumpido el embarazo a la semana 38+5. Discusión: La PM representa un desafío para el médico tanto en su diagnóstico como tratamiento, lo cual está dado en parte por su baja incidencia. El caso expone la presentación más clásica de la PM, en la cual se logró establecer la importancia del diagnóstico prenatal y como este influye en el pronóstico y manejo posterior. Existe acuerdo en adoptar una conducta expectante frente a la PM e incluso esperar el inicio del parto espontaneo, si no existen otras contraindicaciones.

ABSTRACT Introduction: Meconial peritonitis (MP) corresponds to an inflammation of the peritoneum due to a sterile chemical reaction produced by the presence of meconium, secondary to a intestinal perforation in utero. We present a real case of MP whose relevance is given by the low incidence of this disease, being approximately 1 case per 30,000 live births. The present work has as objective to present the classic presentation of the MP through an updated literature review. Clinical case: A 21-year-old woman, primigravous, with a pregnancy of 33 + 5 weeks, and a history of gestational hypothyroidism, is referred to the maternal emergency service due to the following finding on ultrasound performed that same day: Fetal ascites, hyperechogenic bowel, without alterations in fetal echo-Doppler. Patient is hospitalized for study. Laboratory tests, including HIV and VDRL, were negative and did not clarify an etiology. Given later sonographic findings, the diagnosis is oriented towards MP, which was observed once the pregnancy was interrupted at week 38 + 5. Discussion: MP represents a challenge for the physician both in diagnosis and treatment, which is partly due to its low incidence. The case presents the most classic presentation of the MP, in which it was possible to establish the importance of prenatal diagnosis and how it influences the prognosis and subsequent management. There is agreement to adopt an expectant behavior towards MP and even wait for the start of spontaneous birth, if there are no other contraindications.

Early neonatal deaths associated with perinatal asphyxia in infants ≥2500g in Brazil / Óbitos neonatais precoces associados à asfixia perinatal em neonatos ≥2500g no Brasil

Abstract Objective: To assess the annual burden of early neonatal deaths associated with perinatal asphyxia in infants weighing ≥2500 g in Brazil from 2005 to 2010. Methods: The population study enrolled all live births of infants with birth weight ≥2500 g and without malformations who died up to six days after birth with perinatal asphyxia, defined as intrauterine hypoxia, asphyxia at birth, or meconium aspiration syndrome. The cause of death was written in any field of the death certificate, according to International Classification of Diseases,10th Revision (P20.0, P21.0, and P24.0). An active search was performed in 27 Brazilian federative units. The chi-squared test for trend was applied to analyze early neonatal mortality ratios associated with perinatal asphyxia by study year. Results: A total of 10,675 infants weighing ≥2500 g without malformations died within six days after birth with perinatal asphyxia. Deaths occurred in the first 24 h after birth in 71% of the infants. Meconium aspiration syndrome was reported in 4076 (38%) of these deaths. The asphyxia-specific early neonatal mortality ratio decreased from 0.81 in 2005 to 0.65 per 1000 live births in 2010 in Brazil (p < 0.001); the meconium aspiration syndrome-specific early neonatal mortality ratio remained between 0.20 and 0.29 per 1000 live births during the study period. Conclusions: Despite the decreasing rates in Brazil from 2005 to 2010, early neonatal mortality rates associated with perinatal asphyxia in infants in the better spectrum of birth weight and without congenital malformations are still high, and meconium aspiration syndrome plays a major role.

Resumo Objetivo: Avaliar a taxa anual de óbitos neonatais precoces associados à asfixia perinatal em neonatos de peso ≥ 2.500 g no Brasil de 2005 a 2010. Métodos: A população do estudo envolveu todos os nascidos vivos de neonatos com peso ao nascer ≥ 2.500 g e sem malformações que morreram até seis dias após o nascimento por asfixia perinatal, definida como hipóxia intrauterina, asfixia no nascimento ou síndrome de aspiração de mecônio. A causa do óbito foi escrita em qualquer linha do atestado de óbito, de acordo com a Classificação Internacional de Doenças, 10a Revisão (P20.0, P21.0 e P24.0). Foi feita uma pesquisa ativa em 27 unidades federativas brasileiras. O teste qui-quadrado de tendência foi aplicado para analisar os índices de mortalidade neonatal associados a asfixia perinatal até o ano do estudo. Resultados: Morreram 10.675 neonatos com peso ≥ 2.500 g sem malformações até 0-6 dias após o nascimento por asfixia perinatal. Os óbitos ocorreram nas primeiras 24 horas após o nascimento em 71% dos neonatos. A síndrome de aspiração de mecônio foi relatada em 4.076 (38%) dos óbitos. O índice de mortalidade neonatal precoce relacionada à asfixia caiu de 0,81 em 2005 para 0,65 por 1.000 nascidos vivos em 2010 no Brasil (p < 0,001); o índice de mortalidade neonatal precoce relacionada a síndrome de aspiração de mecônio permaneceu entre 0,20-0,29 por 1.000 nascidos vivos durante o período do estudo. Conclusões: Apesar da redução nas taxas no Brasil de 2005 a 2010, as taxas de mortalidade neonatal precoce associadas à asfixia perinatal em neonatos no melhor espectro de peso ao nascer e sem malformações congênitas ainda são altas e a síndrome de aspiração de mecônio desempenha um importante papel.

Early neonatal deaths associated with perinatal asphyxia in infants ≥2500g in Brazil.

OBJECTIVE: To assess the annual burden of early neonatal deaths associated with perinatal asphyxia in infants weighing ≥2500g in Brazil from 2005 to 2010. METHODS: The population study enrolled all live births of infants with birth weight ≥2500g and without malformations who died up to six days after birth with perinatal asphyxia, defined as intrauterine hypoxia, asphyxia at birth, or meconium aspiration syndrome. The cause of death was written in any field of the death certificate, according to International Classification of Diseases, 10th Revision (P20.0, P21.0, and P24.0). An active search was performed in 27 Brazilian federative units. The chi-squared test for trend was applied to analyze early neonatal mortality ratios associated with perinatal asphyxia by study year. RESULTS: A total of 10,675 infants weighing ≥2500g without malformations died within six days after birth with perinatal asphyxia. Deaths occurred in the first 24h after birth in 71% of the infants. Meconium aspiration syndrome was reported in 4076 (38%) of these deaths. The asphyxia-specific early neonatal mortality ratio decreased from 0.81 in 2005 to 0.65 per 1000 live births in 2010 in Brazil (p<0.001); the meconium aspiration syndrome-specific early neonatal mortality ratio remained between 0.20 and 0.29 per 1000 live births during the study period. CONCLUSIONS: Despite the decreasing rates in Brazil from 2005 to 2010, early neonatal mortality rates associated with perinatal asphyxia in infants in the better spectrum of birth weight and without congenital malformations are still high, and meconium aspiration syndrome plays a major role.

Trastornos del espectro alcohólico fetal: biomarcadores del consumo de etanol durante la gestación / Fetal alcohol spectrum disorders: biomarkers of ethanol consumption during pregnancy / Perturbações do espectro do alcoolismo fetal: biomarcadores de consumo de etanol durante a gravidez

El consumo de alcohol durante la gestación está asociado con un amplio espectro de efectos adversos conocidos como trastornos del espectro alcohólico fetal (TEAF). Así es como a través del dosaje de los esteres etílicos de ácidos grasos (FAEEs) en meconio, como biomarcadores de exposición prenatal al consumo de etanol, nos brinda una herramienta importantísima en el screening de los recién nacidos, facilitando la confi rmación del diagnóstico y la intervención clínica adecuada en los individuos afectados por esta problemática con una mejora en las expectativas y calidad de vida. El síndrome alcohólico fetal (SAF) representa el clásico síndrome y la manifestación más grave inducido por el alcohol de forma repetida durante el embarazo. Dado el carácter heterogéneo de las alteraciones clínicas presentes en los recién nacidos expuestos a etanol, la mayoría de los cuales no son específi cos, conlleva a un diagnóstico del TEAF extremadamente difícil.

Alcohol consumption during pregnancy is associated with a wide range of adverse effects known as fetal alcohol spectrum disorders (FASDs). Through the measurement of Fatty Acid Ethyl Esters (FAEEs) in meconium, as biomarkers of prenatal alcohol exposure, we have a very important tool in the screening of newborns, facilitating the confi rmation of diagnosis and adequate clinical intervention in individuals affected by this problem with improvements in life quality and expectancy. Fetal Alcohol Syndrome (FAS) represents the classic syndrome and the most serious condition is caused by repetitive alcohol consumption during pregnancy. Due to the heterogeneous characteristics of clinical alterations of newborns exposed to ethanol, most of which are not specifi c, diagnosis of FASDs is extremely diffi cult.

O consumo de álcool durante a gravidez é associado a um amplo espectro de efeitos adversos conhecidos, tais como transtornos do espectro do alcoolismo fetal (TEAF). É assim como através da dosagem dos ésteres etílicos de ácidos graxos (FAEEs) em mecô- nio, como biomarcadores de exposição pré-natal ao consumo de etanol, fornece uma ferramenta importantíssima na triagem de recém-nascidos, aprimorando a confi rmação do diagnóstico e a intervenção clínica adequada em indivíduos afectados por este problema com uma melhoria das expectativas e qualidade de vida. Síndrome alcoólica fetal (FAS) representa a síndrome clássica e a mais grave manifestação induzida frequentemente pelo álcool durante a gravidez. Dada a heterogeneidade das alterações clínicas em recémnascidos expostos ao etanol, a maioria das quais são não-específi cas, esta situação gera um diagnóstico de TEAF extremamente difícil.

Idiopathic meconium peritonitis as a surgical emergency: A case report in a newborn / Peritonitis meconial idiopática como urgencia quirúrgica. Reporte de caso en una recién nacida

Meconium peritonitis is a rarely described condition that is typically found in fetal and perinatal patients. It manifests in different ways and requires an early diagnosis. In this case report, a clinical suspicion of the disease was made at the antenatal period through an obstetric ultrasound scan showing an abdominal mass in both the bottom and top right quadrants. The patient initial symptoms were those of acute intestinal obstruction. Nevertheless, these symptoms improved after surgical approach was timely performed. Based on this outcome, it can be concluded that a favorable outcome to this pathology depends on its early diagnosis, since an early diagnosis decreases morbidity and mortality chances.

La peritonitis meconial es una entidad poco descrita, propia de la edad fetal y perinatal, que se presenta de diversas formas y requiere un diagnóstico temprano. En el presente caso se realiza sospecha clínica desde el periodo antenatal, por medio de una ecografía obstétrica que muestra una masa abdominal ocupando el cuadrante derecho inferior y superior. La paciente inicia con síntomas agudos de obstrucción intestinal que mejoran luego de un abordaje quirúrgico oportuno. De acuerdo a lo anterior, se concluye que un desenlace favorable en esta patología depende de un diagnóstico temprano, pues a través del mismo se disminuyen las probabilidades de morbilidad y mortalidad

Evacuación del meconio intestinal para mejorar tolerancia alimentaria en prematuro de muy bajo peso (protocolo Emita) / Meconium evacuation to improve feeding tolerance in very low birth weight preterm infants (Emita Protocol)

Introducción: Se ha descrito que la tolerancia alimentaria en el extremo prematuro se asocia a una precoz eliminación de meconio. Estudios prospectivos, randomizados o con controles históricos de estimulación de evacuación de meconio reportan diferentes resultados. El objetivo de este estudio fue evaluar el uso sistemático de enemas que aceleren la evacuación de meconio, y por ende la tolerancia alimentaria. Pacientes y Método: Estudio controlado, aleatorizado y multicéntrico que evaluó el uso de enemas de solución fisiológica con glicerina (0,8 ml de glicerina + 3 ml de solución fisiológica o 1 ml de glicerina + 5 ml de solución fisiológica según peso al nacer menor o mayor de 800 g, respectivamente) versus simulación, iniciado en las primeras 96 h de vida, en prematuros con peso al nacimiento entre 500 y 1.250 g. Se registraron antecedentes maternos (parto prematuro, infección ovular, síndrome hipertensivo del embarazo, administración de sulfato de magnesio, y corticoides prenatales, doppler fetal alterado, tipo de parto, sexo, peso y edad gestacional, evaluación de apgar y necesidad de ventilación asistida y oxígenoterapia) y nutricionales (edad al alcanzar volúmenes de alimentación de 100 ml//kg/día y alimentación enteral completa, edad para eliminar meconio, número de días en nutrición parenteral, peso a los 28 días, volúmenes semanales de leche materna y fórmula de prematuros). Resultados: En 101 sujetos incluidos en el estudio, no se obtienen diferencias significativas en la variable principal de edad para alcanzar el aporte enteral total o los 100 ml por kg por día. Tampoco se observan diferencias en las variables secundarias: número de episodios de sepsis tardías con o sin hemocultivo positivo, hiperbilirrubinemia, enterocolitis necrotizante o hemorragia intracraneana. Conclusiones: El uso sistemático de enemas de solución fisiológica y glicerina, en la forma utilizada en este estudio, no modifica la tolerancia alimentaria enteral de prematuros de muy bajo peso al nacer.

Introduction: it has been reported that feeding tolerance in preterm infants is associated with an early passage of meconium. prospective, randomized or historical control studies that stimulate meconium evacuation have reported varied results. this study was intented to evaluate the use of enemas to speed up meconium evacuation, facilitating feeding tolerance. Patients and Method: a controlled multicenter randomized trial that evaluated the use of physiological saline enemas with glycerol (0.8 ml glycerol + 3 ml saline or 1 ml glycerol + 5 ml saline depending on babies weighing less or more than 800 g at birth, respectively) versus simulation. This procedure was performed in the first 96 hours of life in infants with birth weight between 500 and 1,250 g. Maternal (preterm delivery, clinical chorioamnionitis, gestational hypertension, administration of magnesium sulfate and prenatal corticosteroids, fetal doppler altered, type of delivery, gender, weight and gestational age, assessment of apgar and need for assisted ventilation and oxygenotherapy) and nutritional history (age when feeding volumes of 100 ml/kg/day and full enteral feeding were reached, age to remove meconium, number of days on parenteral nutrition, weight at 28 days, weekly volumes of breast milk and preterm formula) were described. Results: No significant differences were obtained regarding the age to reach full enteral intake or 100 ml/kg/day were found among the 101 patients in the study. also, no differences in the following secondary variables are observed: number of episodes of late sepsis with or without positive blood culture, hyperbilirubine mia, necrotizing enterocolitis and intraventricular hemorrhage. Conclusions: the routine use of saline enemas and glycerin in this study does not alter the enteral feeding tolerance in very low birth weight preterm infants.

Síndrome da aspiração meconial: identificando situações de risco obstétricos e neonatais / Síndrome de aspiración de meconio: identificando situaciones de riesgo obstétrico y neonatal / Meconium aspiration syndrome: identifying obstetric and neonatal risk situations

Objective: To identify situations of obstetric and neonatal risk that favored meconium aspiration syndrome as well as complications in clinical evolution presented by these neonates. Method: It is a quantitative, retrospective study and documentary analysis, conducted from January 2009 to December2010. Data from 40 medical records were recorded in a database and analyzed using descriptive statistical analysis software. Results: 67.5 % of mothers had fewer than six prenatal consultations and 42.5% had complications during pregnancy. Cesarean section predominated with 75%, indicated by fetal distress. There were 90% of neonates had an average gestational age of 37 weeks or more, 82.5 % had an Apgar score below 7, requiring resuscitation at birth and ventilatory support. Conclusion: Proper monitoring of pregnant women through out pregnancy cycle and in labor as well as the need to care for neonates in the delivery room can reduce the incidence of the syndrome.

Objetivo: Identificar as situações de risco obstétricas e neonatais que favorecem a síndrome da aspiração meconial, bem como as complicações na evolução clínica apresentadas por esses neonatos. Método: Estudo quantitativo, retrospectivo e de análise documental, realizado entre janeiro de 2009 a dezembro de 2010. Os dados dos 40 prontuários consultados foram registrados em banco de dados e analisados por meio de software para análise estatística descritiva. Resultados: Quanto às genitoras, 67,5% tiveram menos que seis consultas de pré-natal e 42,5% intercorrências na gestação. Predominou o parto cesáreo em 75%, indicados por sofrimento fetal. Dos neonatos, 90% apresentaram idade gestacional de 37 semanas ou mais; 82,5% tiveram Apgar abaixo de 7, necessitando de reanimação ao nascer e suporte ventilatório. Conclusão: O acompanhamento adequado da gestante em todo ciclo grávido e no trabalho de parto, bem como o atendimento preciso do neonato na sala de parto podem reduzir a incidência da síndrome.

Objetivo: Identificar las situaciones de riesgo obstétrico y neonatal que favoreció el síndrome de aspiración de meconio y complicaciones en la evolución clínica que presentan estos neonatos. Método: Estudio cuantitativo, retrospectivo y de análisis documental, realizado a partir de enero 2009 a diciembre2010. Los datos de 40 historias clínicas se registraron en una base de datos y se analizaron con el software de análisis estadístico descriptivo. Resultados: En cuanto a las madres, el 67,5 % tenían menos de seis consultas prenatales y un 42,5 % de complicaciones durante el embarazo. Cesárea predominó en el 75%, indicado por sufrimiento fetal. De los recién nacidos, el 90% tenían una media de edad gestacional de 37 semanas o más, el 82,5% tenía una puntuación de Apgar por debajo de 7, necesitando reanimación al nacery el apoyo ventilatorio. Conclusión: El control adecuado de la mujer embarazada durante el ciclo de embarazo y en el parto, así como la necesidad de cuidar a los recién nacidos en la sala de parto puede reducir la incidencia del síndrome.