[Preterm delivery: detection of risks and preventive treatment]. / El parto pretérmino: detección de riesgos y tratamientos preventivos.

Every year around the world some 13 million premature children are born. Most of these children are born in developing countries, and they account for the largest share of perinatal morbidity and mortality. This review study analyzed scientifically validated data on interventions to prevent at least some portion of these preterm deliveries and to lessen their impact on neonatal health. The Cochrane and MEDLINE bibliographic databases were consulted. Fifty review pieces and research articles were studied, relating to the following aspects of preterm delivery: risk factors and early detection of the risk of preterm delivery; preventing the risk of preterm delivery; treating preterm delivery once it has begun; and preventing neonatal respiratory distress syndrome. There were few successful approaches to the prediction, prevention, or early detection of the threat of preterm delivery. The only measures that can be recommended for all pregnant women are screening for and treating asymptomatic bacteriuria as a part of prenatal check-ups. Screening for bacterial vaginosis and treating it reduce the incidence of preterm births in pregnant women with a history of premature delivery. In addition, prophylactic cerclage decreases the incidence of premature births in pregnant women who have had more than three preterm births. To treat a delivery that starts early, with or without premature membrane rupture, the interventions that have proved to be effective are administering betamimetics to the parturient woman in order to delay delivery for 48 hours, and using indomethacin for the same purpose, as the second-choice drug. The prenatal administration of corticosteroids to the pregnant woman can induce lung maturation in the fetus and reduce respiratory distress syndrome and ventricular hemorrhage, thus decreasing neonatal mortality. There is a need to continue and support basic and epidemiological research in order to develop new knowledge on the causes and mechanisms of preterm delivery and on preventing the morbidity and mortality that preterm delivery produces.

A new tool for measuring the suckling stimulus during breastfeeding in humans: the orokinetogram and the Fourier series.

The Fourier series was used to analyse the oral movements recorded by the orokinetogram during breastfeeding in human babies. This is a new method that allows recording of oral movements without introducing any extrinsic element between the nipple and the mouth of the baby. The advantage of displaying suckling activity after fast Fourier transform (FFT) is that this algorithm allows storage, quantification and frequency analysis of the oral movements throughout a suckling bout, which enables the total oral activity to be measured. Two types of oral movements are found: slow high amplitude (SHA) and fast low amplitude (FLA). FLA movements may be derived from peristaltic movements of the tongue that result in tickling stimuli to the mechanoreceptors of the nipple and milk expression. The frequency bandwidth of oral movements is wider (0-8 Hz) than has been described previously (0-3 Hz) and this is due to the presence of the FLA oral movements. An indirect measurement of the energy of oral movements during suckling is obtained by the pattern of energy distribution used in each individual frequency band by oral movements. This pattern changes in relation to the periods of continuous and intermittent suckling activity. SHA and FLA oral movements are more intense during continuous suckling. Statistical analysis showed a correlation between the energy of SHA and FLA waves throughout the suckling bout, and also that the highest level of energy during suckling activity is displayed during the first 2 min. The novel tools described in this paper allow investigation of the role of suckling stimulus in reflex hormone release and other mother-infant interactions.

[Intensified insulin therapy in the management of gestational diabetes]. / Insulinoterapia intensificada en el manejo de la diabetes pregestacional.

A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDP's (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop out's (4 pregnancies) belonged to the CMII group. No drop out's were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65%) of "fair" glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering "false satisfactory" MBG's and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDP's who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDP's who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)

Insulinoterapia intensificada en el manejo de la diabetes pregestacional. / [Intensified insulin therapy in the management of gestational diabetes]

A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDPs (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop outs (4 pregnancies) belonged to the CMII group. No drop outs were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65

) of [quot ]fair[quot ] glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering [quot ]false satisfactory[quot ] MBGs and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDPs who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDPs who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)

Insulinoterapia intensificada en el manejo de la diabetes pregestacional. / [Intensified insulin therapy in the management of gestational diabetes]

A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDPs (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop outs (4 pregnancies) belonged to the CMII group. No drop outs were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65

) of [quot ]fair[quot ] glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering [quot ]false satisfactory[quot ] MBGs and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDPs who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDPs who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)

Chronic villitis of unknown aetiology in recurrent intrauterine fetal growth retardation.

Although recurrent chronic villitis of unknown aetiology (CVUA) has been documented in a few instances, placental lesions in recurrent intrauterine growth retardation have not, to the best of our knowledge, been reported. In the present study ten cases of recurrent intrauterine growth retardation have been described; a high incidence of severe CVUA was found in both first and successive pregnancies. If, as has been proposed, CVUA is due to a maternal immune response to placental antigens, subsequent pregnancies with the same father might be similarly affected.

Placental lesions in maternal autoimmune diseases.

We have investigated the presence and clinical implications of maternal vascular lesions and chronic villitis of unknown etiology (CVUE) in 18 placentas of 15 mothers with several autoimmune diseases (AD), including, for the first time, idiopathic thrombocytopenic purpura, autoimmune thyroid diseases, and multiple sclerosis. The group with AD had significantly more maternal vascular lesions and CVUE than the control group. We did not find lesions that could be attributed to any of the diseases in particular. The histopathologic picture was similar in these diseases, although there appears to be a spectrum in severity. Placental vascular damage with deposits of IgM, C3, and C1q was more prominent in systemic lupus erythematosus and in a patient with systemic sclerosis. In both of these diseases but not in the other conditions, these lesions were related to poor fetal outcome. Although the precise role of each of these autoimmune diseases in pregnancy and fetal outcome remains to be established, there appears to be at least one link between them represented by the presence of severe acute atherosis and heavy granular vascular deposits of IgM, C3, and C1q associated in some with poor fetal outcome. The role of CVUE remains speculative.

Intrauterine growth retardation of unknown etiology: II. Serum complement and circulating immune complexes in maternal sera and their relationship with parity and chronic villitis.

Significantly lower CH50 levels were found in women with small for gestational age (SGA) infants. The lowest values corresponded to nulliparous with placental chronic villitis (124.0 +/- 10.6). Three out of five mothers with circulating immune complexes from SGA group were nulliparous, having placental chronic villitis. An immunological derangement in women with SGA infants is proposed for the development of placental lesions, mainly in nulliparous mothers with a lower previous exposure to fetal antigens.

Primary chronic abortion, preeclampsia, idiopathic intrauterine growth retardation, hydatidiform mole, and choriocarcinoma: a unifying concept.

Different degrees of maternal hyporesponse, as far as blocking activity is concerned, are proposed for primary chronic abortion, preeclampsia, and idiopathic intrauterine growth retardation. On the other hand, a maternal hyperresponse to fetal antigens with a higher production of blocking antibodies may be related to an unusual proliferation of the trophoblast in cases of hydatidiform mole and choriocarcinoma.

Chronic villitis of unknown aetiology and decidual maternal vasculopathies in sustained chronic hypertension.

Ninety-six full-term placentae were examined in the study. Of the 96 pregnancies, 72 were normotensive and 24 were complicated by hypertension. Of the 24 hypertensive pregnancies, 19 patients had chronic hypertension only, and 5 had chronic hypertension with superimposed preeclampsia. The birth weights of babies were over the 25th centile of our ponderal curve in all cases. Chronic villitis of unknown aetiology (CVUE) was found in 25% of control placentae and in 26% of placentae from chronic hypertension without preeclampsia. Eighty percent of placentae of chronic hypertension with superimposed preeclampsia presented the lesion. The incidence of CVUE was significantly higher in the latter than in the other groups. The same was observed about the proportion of inflamed villi. A higher frequency of maternal vascular lesions was observed in placentae of chronic hypertension with superimposed preeclampsia. Similar incidence and severity of the above-mentioned placental lesions have been recently described in preeclamptic pregnancies. These results suggest that these lesions (CVUE and maternal vasculopathies) are related to preeclampsia and not only to maternal hypertension.

Deficiency of blocking factors in intrauterine growth retardation and its relationship with chronic villitis.

We tested sera from 22 women and their singleton full-term infants for inhibition in one-way mother/father mixed lymphocyte culture (MLC). Ten of these infants were small for gestational age (SGA) and 12 of them adequate for gestational age (AGA). Twenty placentas from these cases (ten from SGA infants and ten from AGA infants) were histologically studied. The results show evidence that blocking factors capable of inhibiting responses of wife's lymphocytes to husband's cells in MLC are present in sera from women with normal pregnancies but not in women with SGA infants. Sera from AGA infants showed a blocking activity on responses of husband's lymphocytes to wife's cells and this was not observed in sera from SGA infants. Lesions of chronic villitis were found in six placentas from SGA infants and in none from AGA infants. A deficit of blocking protective factors and its relationship with placental lesions is in favor of an immunological mechanism for intrauterine growth retardation.

Absence of Wharton's jelly around the umbilical arteries: an unusual cause of perinatal mortality.

Three cases are described in which Wharton's jelly was completely absent around the umbilical cord arteries but was present around the umbilical vein. All three instances of this anomaly were associated with perinatal death.

Chronic villitis of unknown etiology and maternal arterial lesions in preeclamptic pregnancies.

Placental lesions from 361 singleton full-term pregnancies were studied. These placentas were divided into two major groups: the study group consisting of 146 placentas from mothers with pregnancy-induced hypertension and a normotensive control group, which included 215 placentas from mothers with normal pregnancies. Each group was divided into three subgroups according to the allocation of infant's birthweight in the normal ponderal curve. A statistically significant higher incidence and severity of villous lesions was observed in placentas of mothers with pregnancy-induced hypertension when infants were over the 25th centile of the ponderal curve. Vascular lesions, i.e., absence of physiological changes in spiral arteries of the placental bed, acute atherosis and chronic vasculitis-like lesions were also more frequently observed in the hypertensive group than in controls. These placental lesions have been described in placentas of small for gestational age infants with or without maternal hypertension and in those of preeclamptic women with appropriate for gestational age infants. Since acute atherosis-like lesions have been reported in placentas of pregnant women with systemic lupus erythematosus and in rejected renal transplants, a possible maternal immunological reaction against fetal tissues could be responsible for the pathogenesis of these entities.

Intrauterine growth retardation of unknown etiology. I. Serum complement and circulating immune complexes in mothers and infants.

Complement (C) and circulating immune complexes (CIC) levels were measured in 22 full-term pregnant women and 15 of their small-for-gestational-age (SGA) offspring in order to seek evidence supporting an immunological etiology for placental lesions related to idiopathic intrauterine growth retardation. We used 19 normal full-term pregnant women and 18 of their infants with birthweight above the 25th centile of the ponderal curve as a control population for this study. C levels were significantly lower in mothers of SGA infants than in controls (146.6 +/- 46.6 and 183.6 +/- 36.6 respectively, p less than 0.01). CIC were present in the sera of 5 out of 22 mothers of the SGA group and in 3 out of the 15 infants sera. No CIC were found in the sera of mothers or infants from the control group. Placental lesions were observed in 14 out of the 22 (64%) cases studied in the SGA group and in 1 of 11 (9%) of the controls. Two placentas from SGA infants showed acute atherosclerosis, and deposits of IgM and C3 were found in their vessel walls. These data are in favor of an immunological mechanism for intrauterine growth retardation of unknown etiology.

Chronic villitis of unknown aetiology and intrauterine growth-retarded infants of normal and low ponderal index.

Placentae from 211 term pregnancies were studied. The placentae were divided into three groups: group I, 57 placentae from neonates with birthweight over the 25th centile of the normal birthweight curve; group II, 49 placentae from neonates whose birthweight fell between the 10th and 25th centiles of this curve, and group III, 105 placentae from neonates whose birthweights were below the 10th centile of the curve. Each of the studied groups were divided into two subgroups, one comprising those infants with a normal Ponderal Index (PI) and the other comprising those with a low PI. A higher incidence of chronic villitis and of inflamed villi was observed as the average birthweight decreased in cases with normal PI as well as in cases with low PI, the highest incidence being found in placentae from infants with harmonic intrauterine growth retardation (normal PI). The same was observed with respect to the presence of maternal vascular lesions in all groups studied. It is suggested that an infant's birthweight and crown-heel length may be affected as a consequence of the extension and severity of the placental lesions and the timing of their appearance in gestation.