[Presence of fetal fibronectin in cervico-vaginal secretion as predictor of premature labor]. / Presencia de fibronectina fetal en secreción cérvico-vaginal como predictor de parto pretérmino.

The objective of this article is to correlate a new biochemical method called fetal fibronectin (fFN) found in cervico-vaginal secretions (CVS) in pregnant woman with the presence or not of preterm labor. In this paper the patients studied had pregnancies of 24 up to 37 weeks of pregnancy. The were free of symptoms and without risk factors for preterm labor. The cervico-vaginal specimen was taken with special equipment designed for this purpose (Adeza Biomedical Collection Kit). The laboratory processed this for immunoassay. A positive fFN was considered above 0.05 microgram/dl. There were 263 patients enrolled for this study. Of these 232 had fFN negative (89%) and 31 were positive (12%). The weeks of gestation at birth were 38.6 for the negative group and 34.4 for the positive group (p < 0.0001). Only 5 neonates from the negative group were born before 37 weeks of gestation (2.2%) and in the positive fFN group this occurred in 22 case (71%) (p < 0.0001). The average weight at birth for the negative fibronectin group was 3152 g. for the positive group (p < 0.0001). The neonatal morbidity was more frequent and respiratory distress syndrome was more severe in the positive fibronectin group in comparison with the negative fFN with a significant p. The same tendency was observe with the Apgar score < 7 at 1 and 5 minutes (more frequent in the positive group) (p < 0.0001). The was one neonatal death in the negative group (0.43%) and 5 in the positive group (16%) p = 0.0001. The sensibility and positive predicitive value of positive fFN for the prediction of preterm labor was 81.4 and 71 respectively and the specificity and negative predictive value for negative fFN was 96.1 and 97.8. Finally the RR for prematurity when the fFN was positive on SCV was 32.9. The presence fFN in cervical-vaginal secretion between 24 and 37 weeks of gestation seems to be a good indicator of preterm labor. In this study positive results correlate with less weeks of pregnancy and lees weight at birth. Also with higher with more morbidity and mortality. These findings give the obstetrician a better chance of an opportune diagnosis with adequate treatment and improve perinatal results.

[Maternal and perinatal morbidity-mortality in pregnant women with renal transplant]. / "Morbimortalidad materna y perinatal en pacientes embarazadas con trasplante renal".

The outcome of 32 pregnancies in renal allograft recipients is reported. The mean age at the time of conception was 27.3 years (range, 20 to 37) with an average interval of 47 months from the time of transplantation to conception (range, 2 to 163). Twenty-nine patients received the graft from a living related donor, one from a living no related donor an 2 from cadaver donors. All patients continued their immunosuppressive regimen during pregnancy and only 6 patients were taking cyclosporine A. Hypertension during pregnancy was observed in 10 patients (31%), superimposed preeclampsia in 4 (14%), preterm labor in 4 (14%) and premature rupture of membranes in 2 (7%). Twenty-eight pregnancies resulted in 28 liveborn infants and there were 4 miscarriages. Cesarean section was performed in 17 cases and 11 had vaginal delivery. Intrauterine growth retardation was observed in 4 cases (14%), fetal distress in 2 (7%) and one neonatal death due to multiple malformations. There was not significative impairment of renal function in this group.

[Management of refractory autoimmune thrombocytopenic purpura during pregnancy, Review of the literature and report of three cases]. / Manejo de la púrpura trombocotopénica autoinmune refractaria durante el embarazo. Revisión de la literatura e informe de tres casos.

The immune thrombocytopenic purpura (ITP) is an immunological disease associated with pregnancy; it is difficult to control when there is not an adequate response to the treatment mainly with prednisone (refractory). When this problem occurs there are other ways to treat it: monthly pulses of dexamethasone (oral or intravenously), administration of gamma globulin or anti D and occasionally to perform a splenectomy. Three cases of refractory ITP and pregnancy are presented using different treatment in each case: Case 1 hyperimmune gammaglobulin; case 2 platelets by transfusion and in case number 3 monthly dexamethasone oral pulses. In the case treated with hyperimmune gammaglobulin the maternal response was acceptable but neonatal demise occurred due to hemorrhage; in the treated with platelets transfusion, there were maternal and fetal deaths; the best results were obtained with the administration of dexamethasone monthly, in this way we were able to reach the term of the pregnancy with good results for mother and neonate. The importance of early diagnosis is imperative and initiating the adequate treatment that according to our results would be dexamethasone pulses; the use of hyperimmune gammaglobulin in restricted due to high cost, and the platelets transfusion would be indicated only in cases of severe thrombocythopenia, imminence of hemorrhage or if a surgical procedure has to be done. An extensive review of the literature is done.

[Determination by ultrasound of chorionicity in twin pregnancy]. / Determinación de corionicidad por ultrasonido en embarazo gemelar.

Twins, specially those of monochorionic and monoamniotic pregnancies, are exposed to many perinatal risks and complications. The objective of this study was to evaluate the usefulness of ultrasonographic determination of the chorionicity of human placental by counting the number of layers in amniotic membranes. Thirty-eight patients with twin pregnancies were studied prospectively. The ultrasonographic evaluation of membranes layers was made only once, between the weeks and 16 and 30 of pregnancy. When two layers were identified, the placentation was determined as monochorionic, and when four layers were seen, the diagnosis of bichorionic placentation was made. The type of chorionicity was confirmed by histologic study of the placenta. With ultrasound, the chorionicity was correctly determined in 36 out of 38 cases, for a total predictive value of 94.6%. The capacity for diagnosing bichorionic (4 layers) placentation was 100% (22/22) and 87.6% (14/16) for monochorionic (2 layers) placentation. The ultrasonographic evaluation of the amniotic membranes number is an efficient method to recognize the chorionicity of placenta and constitutes an useful and simple method giving important information in perinatal prognosis.

[Predictive value of fetal pulmonary maturity tests in pregnancy of diabetic mothers]. / Valor predictivo de las pruebas de madurez pulmonar fetal en la paciente diabética embarazada.

Respiratory distress syndrome is a common morbidity in a infants of diabetic mother however there is a controversy in the literature about apparition of lung maturity in this infants. However this reports have not got a control group. Lung maturity tests were prospectively studied, obtained by amniocentesis at 37 weeks of gestation, in 47 patients: twenty diabetics (studied group) and 27 healthy pregnant women (control group). All the pregnancies were solved by cesarean section. The values of lung maturity tests were related to presence of respiratory morbidity in neonates (respiratory distress syndrome: RDS). Five of 49 infants had some kind of respiratory morbidity. The incidence of RDS was 10.2%. Four of 5 infants with RDS belonged to the diabetic group, which gives us an incidence of 20% versus only one of the 29 healthy infants (3.7%). This difference is statistically significant, p < 0.0001. Four infants had false positive lung maturity tests (Od, L/S), three of them (two with severe metabolic meladjustment) occurred in the study group, with alteration of L/S ratio (3/20 = 15%). There was no false positive in PG (specificity 100%) in both group. The 3 lung maturity tests had a specificity of a hundred per cent in the control group). This study shows that the presence of PG in amniotic fluid of diabetic pregnant women confirms maturity with a very low risk to develop RDS. Finally, when the metabolic control of the diabetic is not appropriate, the L/S ratio may give false positive results in 15% of cases, which is quite important.

Elevation of activity of creatine phosphokinase (CK) and its isoenzymes in the newborn is associated with fetal asphyxia and risk at birth.

OBJECTIVE: To investigate the relationship of creatine phosphokinase and its isoenzymes with fetal asphyxia and risk at birth. METHODS: Thirty-five pregnant women with high-risk pregnancy were studied. RESULTS: In 21 patients, fetal distress was diagnosed by interpretation of the fetal heart rate tracing (FHR). The remaining 14 women, having normal fetal cardiotocography, were considered as the control group. Total CK and its isoenzymes activity was measured in cord sera and 24 h after birth in peripheral blood. Abnormal FHR patterns correlate well with elevated enzyme activities. Total CK and its isoenzymes (CK-MM, CK-MB, and CK-BB) exhibited higher values in asphyxiated infants as compared to normal neonates. Electrocardiographic ischemia occurred in seven newborns who had elevated CK-MB and CK-BB levels, both at birth and within 24 h postpartum. Chromatographic study showed in normal neonates that the predominant isoenzyme was CK-MM, whereas CK-BB activity was negligible. In the newborns with abnormal FHR, CK-MB and CK-BB were increased with predominance of CK-MB. CONCLUSIONS: Antepartum fetal distress is associated with release of CK-BB, and particularly CK-MB; therefore, these biochemical markers may indicate either brain or myocardial damage.

[Value of the amniotic fluid rate in premature membrane rupture: prognosis of infection]. / Utilidad del índice del líquido amniótico en la ruptura prematura de membranas: Pronóstico de infección.

The presence of oligohydramnios evaluated by accumulation or major pool technique in pre-term PMR is strongly correlated with maternal and perinatal infection. The objective of this study is to evaluate the usefulness of amniotic fluid volume rate (AFVR) in prediction of maternal and fetal-neonatal infection in patients with PMR before 37 weeks. Thirty patients with PMR were prospectively studied. AFVR was done in all the patients at the time of arrival and they were managed conservatively. None of them had utero-inhibitors and only antibiotics were used after chord clamping. In absence of intrauterine infection corticotherapy was allowed. The results of AFVR were correlated with maternal infection (chorioamnioitis) and perinatal (possible neonatal sepsis or neonatal sepsis). Twenty three out of 30 patients (76.6%) had a AFVR less than or equal to 5.0 cm. (Oligohydramnios) and seven (30.4%) showed a greater rate than 5.0 cm. The earliest pregnancy was 26.5 weeks and the greatest 34.4 weeks. Out of the total of patients 13 (43.3%) had chorioamnioitis and all correspond to the group with AFVI smaller or equal to 5.0 cm. In the group with oligohydramnios were 15 neonates (65.2%) with neonatal infection (six possible sepsis and nine neonatal sepsis). All neonates with positive cultures also corresponded to the group with smaller AFVR; the comparison among the cases with oligohydramnios with infection and the ones that had normal AFVR without infection has statistical significance (p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Preeclampsia in pregnancy. Importance of reclassification]. / Preeclampsia en el embarazo. Importancia de la reclasificación.

It is difficult to determine the etiology of hypertension during pregnancy on the basis of clinical criteria alone. The purpose of the present study is to emphasize the impact of the postpartum reclassification of the hypertensive disorders in gestation. One hundred and fifty eight patients with an initial diagnosis of preeclampsia were prospectively studied. The follow-up included a reclassification of their hypertensive disorder at 4, 8 and 12 weeks postpartum. Such reclassification was based on renal function test and values of blood pressure. Among 158 patients, 118 had an initial diagnosis of preeclampsia during pregnancy, and only in 39 cases (33%) such diagnosis was confirmed postpartum. At the time of reclassification the rest of the patients belonged to the following conditions: gestational hypertension without proteinuria 35%, chronic hypertension 16%, nephropathy (7 with renal biopsy) 11%, and 4% with chronic hypertension and superimposed preeclampsia. There was no significative difference in perinatal morbidity between patients with chronic and gestational hypertension. A total of 10% of perinatal mortality rate was found. We concluded that the reclassification postpartum of the hypertensive disorders in pregnancy is essential to avoid errors in diagnosis and to establish adequate maternal and perinatal outcomes in future pregnancies.

[Correlation of creatine phosphokinase blood level with prenatal fetal heart rate as a prognostic factor in tissue hypoxia]. / Correlación del nivel sanguíneo de creatin fosfoquinasa con los registros de la frecuencia cardiaca fetal anteparto, como un predictor clínico de hipoxia tisular.

The presence of a high serum activity of the creatinine phosphokinase enzyme (CPK) could be the result of an hypoxic tissue event. The existence of an ominous fetal heart rate tracing is a reliable method which indicates the presence of an hypoxic state in variable degrees. Thirty-five pregnancies between 34 and 41 weeks of gestation were prospectively studied to correlate both, CPK activity and cardiotocography, with perinatal morbidity and mortality. All the patients had antepartum fetal heart rate testing and pregnancy was terminated by cesarean section within seven days to the last fetal heart tracing. As soon as the baby was born, we took an umbilical cord sample to measure CPK activity and a second sample was also taken at 36 hours of life. All the neonates had pediatric, neurologic, electrocardiographic and sonographic evaluation within their 48 hours of extrauterine life. Two groups were created: Group A included 14 neonates with normal cardiotocographic tracings (control group) and Group B had 21 infants with abnormal tracings (study group). We found an elevated serum CPK activity with statistic significance in the next three conditions: a) In the sample at 36 hours of life when compared to the cord sample in the control group, p less than 0.001; b) In the neonatal sample at 36 hours of age when compared to the cord sample in the study group, p less than 0.001; c) In the neonates of the study group compared to the neonates of the control group at 36 hours of extrauterine life, p less than 0.05.(ABSTRACT TRUNCATED AT 250 WORDS)

[Biophysical profile in prolonged pregnancy. Another alternative to fetal monitoring]. / Perfil biofísico en el embarazo prolongado. Otra alternativa de vigilancia fetal.

The value of the biophysical profile scoring to predict accurate perinatal outcome in prolonged pregnancy, was assessed. 60 patients with the diagnosis of prolonged pregnancy were included in this prospective clinical trial. A fetal biophysical profile score, described by Manning and modified by Johnson, was recorded in all these patients. There were 40 cases (66%) with normal profile scoring 3 of which had a feature considered as perinatal morbidity (specificity 94.8%). In contrast, from 20 cases with abnormal profile scores, 18 (90%) had abnormal perinatal findings (sensitivity 85.7%). The false positive and negative rates were low, 10 and 7.5% respectively, and the global predictive value of this test was 90%. In our study the amniotic fluid volume was the profile variable most able to identify a compromised fetus and the second with the highest specificity. Although we had a high cesarean section rate, (71%), we suggest that with normal profile scores (greater than or equal to 8) and normal amniotic fluid volume, the fetal biophysical profile may be an accurate test in the evaluation of the fetal condition in this obstetric complication.

[Biophysical profile in prolonged pregnancy. Another alternative of fetal surveillance]. / Perfil biofísico en el embarazo prolongado. Otra alternativa de vigilancia fetal.

The value of the biophysical profile scoring to predict occur-rate perinatal outcome in prolonged pregnancy, was assessed. 60 patients with the diagnosis of prolonged pregnancy were included in this prospective clinical trial. A fetal biophysical profile score, described by Manning and modified by Johnson, was recorded in all these patients. There were 40 cases (66%) with normal profile scoring 3 of which had a feature considered as perinatal morbidity (specificity 94.8%). In contrast, from 20 cases with abnormal profile scores, 18 (90%) had abnormal perinatal findings (sensitivity 85.7%). The false positive and negative rates were low, 10 and 7.5% respectively, and the global predictive value of this test was 90%. In our study the amniotic fluid volume was the profile variable most able to identify a compromised fetus and the second with the highest specificity. Although we had a high cesarean section rate, (71%), we suggest that with normal profile scores (greater than or equal to 8) and normal amniotic fluid volume, the fetal biophysical profile may be an accurate test in the evaluation of the fetal condition in this obstetric complication.

[Cardiotocography in intrauterine growth retardation]. / Cardiotocografía en retardo en el crecimiento intrauterino.

Fifty seven cases of intrauterine growth retardation were analyzed at the Department of Perinatal Medicine, "Luis Castelazo Ayala" Hospital, IMSS. The main purpose of the study was to establish the usefulness of cardiotocography in the decision of pregnancy interruption. The patients were divided in three groups in relation to the last non stress test made before delivery (reactive, non reactive, non reactive, non reactive with declarations). It is concluded that cardiotocography is a useful procedure for the surveillance of these fetuses and it was found a good correlation between progressively ominous traces and fetal condition at birth.

PIP: Early diagnosis, adequate follow-up, and determination of the ideal moment for delivery are fundamental aspects of management of intrauterine growth retardation. This study evaluates the usefulness of cardiotocography in follow-up such cases and in the identification of the best moment for delivery. 57 cases of intrauterine growth retardation were studied at the Department of Perinatal Medicine of a Mexican Institute of Social Security hospital in Mexico City between July 1986-June 1987. The 57 cases were divided into 3 groups based on the results of the most recent nonstress test made 72 hours or less before delivery. Group 1 consisted of 15 cases with reactive tests, group 2 of 17 cases with nonreactive tests, and group 3 of 25 cases of nonreactive tests with decelerations. In group 1 there were no histories of previous complicated pregnancies. In group 2 there were 3 cases of low birth weight and 7 of preterm birth in previous pregnancies. In group 3 there were 3 cases of low birth weight, 2 of preterm birth in previous pregnancies. In group 3 there were 3 cases of low birth weight, 1 of preterm birth, 5 of stillbirth and 1 neonatal death. 77.1% of the 57 mothers were hypertensive, 5.2% had cardiopathies, and 1.7% each had lupus erythematosus, prolonged pregnancy, and hyperparathyroidism. There was no associated pathology in 12.2% of cases. There were 13 caesareans and 2 vaginal deliveries in group 1, with a fetal indication for cesarean in 3 cases. In group 2 there were 13 caesareans and 4 vaginal deliveries, with 9 maternal and 4 fetal indications for cesarean. 24 of 25 deliveries in group 3 were cesarean, with fetal indications in 22 cases and both fetal and maternal indications in 2 cases. The nonstress test was the basic criterion for the indication in group 3. The average birth weight and gestational age respectively were 1798 g and 37.2 weeks for group 1, 1681 g and 36.5 weeks for group 2, and 1551 g and 37 weeks for group 3. The average Apgar score at the minute of birth was 6.8 for group 1, 6.6 for group 2l, and 5.1 for group 3. There were 3 fetal deaths, 2 in group 2 including 1 case of anencephaly and 1 which occurred 48 hours after a recommendation for cesarean following a deterioration in the nonstress test. 1 death in group 3 followed a misinterpreted nonstress test. 4 neonatal deaths included 1 in group 1 from septicemia probably acquired in the nursery and 3 in group 3 attributed to cerebral hemorrhage. The results indicate that the presence of spontaneous decelerations in the fetal heart beat strongly suggest fetal compromise, and are an alarm signal in case of intrauterine growth retardation. The nonstress test is a useful tool in such cases.