Double Myelomeningocele Repair by Fetal Surgery with a Single Micro-Hysterotomy.

INTRODUCTION: Open spina bifida (OSB) is the most common congenital anomaly of the central nervous system. It is associated with severe neurodevelopmental delay, motor impairment, hydrocephalus, and bowel and bladder dysfunction. In selected cases, intrauterine spina bifida repair has been shown to improve neonatal outcomes. Rarely, the spine can have a double defect compromising two different segments and there is a lack of evidence on the feasibility and benefits of intrauterine repair in these cases. CASE PRESENTATION: We present a case with both cervicothoracic and lumbosacral myelomeningocele, Arnold-Chiari malformation type II and bilateral ventriculomegaly, that was treated successfully at 25 weeks with open micro-neurosurgery. Double myelomeningocele was successfully treated through a single 2-cm micro-hysterotomy, by performing external versions to sequentially expose and repair both defects. Weekly postoperative follow-up showed no progression of ventriculomegaly or complications attributable to the procedure. Preterm rupture of membranes prompted a conventional cesarean delivery at 32 weeks of gestation. Neurodevelopmental outcome at 20 months was within normal ranges, having achieved ambulation without orthopedic support and with no need for ventriculoperitoneal shunting. CONCLUSION: This report demonstrates for the first time the feasibility of double OSB repair through a single 2-cm micro-hysterotomy, suggesting that selected isolated cases of double myelomeningocele could be candidates for fetal intervention. Further prospective studies should be carried out to assess the potential benefit of double OSB intrauterine open repair.

Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management.

INTRODUCTION: A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD). METHODS: Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth. RESULTS: Among the study population, 46 TTTS cases were treated by fetoscopy at 27+6 (26+0-31+0) weeks+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32+3 vs. 29+1 weeks+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively). CONCLUSION: MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.

Universal prenatal screening: a initiative from Guanajuato, Mexico to improve equity in perinatal healthcare.

The prenatal approach from a preventive perspective is necessary to reduce perinatal complications. A perinatal care model with a holistic and horizontal approach is required. Mexico is currently considered an emerging market economy with inequality and an economic gap that impacts the accessibility and distribution of healthcare services. Guanajuato is one of the 32 states of Mexico and represents 1.6% of the country's surface. Strategies during the prenatal approach allow prediction, diagnosis, and anticipation of the principal causes of morbidity and mortality. Combining data from maternal characteristics and history with findings of biophysical and biochemical tests at 11 to 13 weeks of gestation can define the patient-specific risk for a large spectrum of complications that include miscarriage and fetal death, preterm delivery, preeclampsia, congenital disorders, and fetal growth abnormalities. We aim to describe the care model designed and implemented in the State Center for Timely Prenatal Screening of the Maternal and Child Hospital of Leon, Guanajuato, Mexico. Previous research showed there is a lack of information for low and middle-income countries regarding how to integrate prenatal screening strategies in the absence of resources to perform cell-free fetal DNA or biochemical serum markers in countries with emergent economies. This care model is carried out through horizontal processes where the screening is provided by trained and certified general practitioners who identify the population at risk in a timely manner for specialized care, and could help guide other Mexican states, and other countries with emergent economies with limited financial, professional, and infrastructural resources to improve prenatal care with a sense of equity, equality, and social inclusion as well as the timely evaluation of specialized perinatal care of high-risk patients.

Intrauterine transfusion of a hydropic fetus with anemia due to a giant chorioangioma: A case report.

Giant chorioangiomas are a potentially life-threatening condition that may require intrauterine therapy. We describe a case of a large chorioangioma (>4cm) diagnosed at 30 weeks of gestation causing severe fetal anemia and hydrops. An intrauterine blood transfusion was performed at 31 weeks with reversal of the anemia and hydrops. The neonate was born at 37 weeks showing respiratory distress syndrome that required neonatal intensive care unit admission but was discharged at 30 days of life. Further evaluation at two months of age showed no signs of abnormal neurodevelopment. When timely indicated, intrauterine transfusion of a hydropic fetus with anemia due to a giant chorioangioma is a potentially life-saving therapy that shows good neurodevelopment of the surviving fetus.

Maternal Death by COVID-19 Associated with Elevated Troponin T Levels.

Cardiomyocyte injury and troponin T elevation has been reported within COVID-19 patients and are associated with a worse prognosis. Limited data report this association among COVID-19 pregnant patients. OBJECTIVE: We aimed to analyze the association between troponin T levels in severe COVID-19 pregnant women and risk of viral sepsis, intensive care unit (ICU) admission, or maternal death. METHODS: We performed a prospective cohort of all obstetrics emergency admissions from a Mexican National Institute. All pregnant women diagnosed by reverse transcription-polymerase chain reaction (RT-qPCR) for SARS-CoV-2 infection between October 2020 and May 2021 were included. Clinical data were collected, and routine blood samples were obtained at hospital admission. Seric troponin T was measured at admission. RESULTS: From 87 included patients, 31 (35.63%) had severe COVID-19 pneumonia, and 6 (6.89%) maternal deaths. ROC showed a significant relationship between troponin T and maternal death (AUC 0.979, CI 0.500-1.000). At a cutoff point of 7 ng/mL the detection rate for severe pneumonia was 83.3% (95%CI: 0.500-0.100) at 10% false-positive rate. CONCLUSION: COVID-19 pregnant women with elevated levels of troponin T present a higher risk of death and severe pneumonia.

The impact of the COVID-19 pandemic on depression and stress levels in pregnant women: a national survey during the COVID-19 pandemic in Mexico.

BACKGROUND: COVID-19 outbreak has been associated with a wide variety of psychiatric manifestations such as panic, anxiety, and depression. We aim to assess the impact of the COVID - 19 pandemic on the levels of stress and depression of pregnant women in Mexico. METHODS: A cross-sectional web survey was carried out in pregnant women in 10 states of the Mexican Republic during the COVID-19 pandemic among public and private hospitals. The perception of stress was assessed using the Perceived Stress Scale, while depressive symptoms were evaluated using the Edinburgh Postnatal Depression Scale. RESULTS: A total of 549 surveys were applied, of which 96.1% (n = 503) were included in the data analysis. The mean participant's age was 28.1 years old. The mean perceived stress scale score was 24. 33.2% (n = 167) of participants had a score equal to 27 points or more and were considered highly stressed. The mean depression score was 9. A total of 17.5% (n = 88) participants had more than 14 points on the Edinburgh's depression scale, and were considered depressed. Stress levels were higher at later gestational ages (p = .008). CONCLUSIONS: COVID-19 pandemic has caused mental health issues in pregnant women reflected by high perceived stress levels and depression.

Recomendaciones para el monitoreo continuo de la glucosa en pacientes embarazadas con diabetes mellitus tipos 1, 2 y gestacional / Recommendations for continuous glucose monitoring in pregnant patients with type 1, 2 and gestational diabetes mellitus

Resumen OBJETIVO: Emitir recomendaciones para la vigilancia y seguimiento de pacientes embarazadas con diabetes mellitus tipos 1, 2 y gestacional con base en la experiencia de un grupo de especialistas y en lo reportado en la bibliografía, desde la perspectiva del sistema de salud mexicano. MATERIALES Y MÉTODOS: Se utilizó la metodología del panel Delphi modificado, mediante la unanimidad de criterios de un grupo de especialistas en Ginecoobstetricia, Biología de la Reproducción y Medicina Materno Fetal mexicanos, tomando en cuenta un nivel de unanimidad del 80% de los participantes. RESULTADOS: Con base en un ejercicio de consenso se recomienda el monitoreo continuo de la glucosa en todas las pacientes embarazadas con diabetes mellitus tipos 1 y 2 a partir del primer trimestre de la gestación. En pacientes con diabetes gestacional considerar, a partir del segundo o tercer trimestre, el monitoreo continuo de la glucosa en usuarias de insulina o en descontrol glucémico, dependiendo del momento en que se diagnostique la diabetes gestacional, del descontrol glucémico y de la necesidad de insulina. La hemoglobina glucosilada y el tiempo en las concentraciones límite también son métricas de control glucémico. CONCLUSIONES: El monitoreo continuo de la glucosa tiene ventajas en: menos complicaciones perinatales, detección oportuna y reducción de eventos de hiper o hipoglucemia, menor descontrol, ajuste de dosis respecto del tratamiento con insulina y mejora en los hábitos para controlar las concentraciones de glucosa.

Abstract OBJECTIVE: To issue recommendations for the surveillance and follow-up of pregnant patients with types 1, 2 and gestational diabetes mellitus based on the experience of a group of experts and on what is reported in the literature, from the perspective of the Mexican health system. MATERIALS AND METHODS: A modified Delphi Panel methodology was performed, through consensus among gynecology, reproductive biologist, and fetal-maternal specialists, and an 80% consensus of all participants. RESULTS: Based on the consensus exercise, we recommend continuous glucose monitoring in all pregnant patients with type I and II diabetes starting on the first trimester; meanwhile in patients with gestational diabetes, continuous monitoring should be considered in patients treated with insulin or uncontrolled glycemia, starting in the second or third trimester, depending on the moment of diagnosis, glycemic levels and insulin requirements, taking into account HbA1c levels and time in range as well as glycemic control metrics. CONCLUSIONS: Continuous glucose monitoring has advantages including the reduction of perinatal complications, timely detection, reduction in the number of hyper/hypoglycemia events, fewer uncontrolled patients, and the capacity for insulin dosage adjustments and improvement of habits for glucose control.

Correlación de los valores de sFlt-1, PlGF y su cociente en preeclampsia con criterios de severidad en una Unidad de Cuidados Intensivos / Correlation of the values of sFlt-1, PlGF and its precilampsy court with severity criteria in an Intensive Care Unit / Correlação dos valores de sFlt-1, PlGF e seu coeficiente em preeclampsia com critérios de gravidade em uma Unidade de Terapia Intensiva

Resumen: Introducción: La detección del desequilibrio entre los factores proangiogénicos/antiangiogénico (sFlt-1, PlGF, cociente sFlt-1/PlGF) en la sangre materna son herramientas de pronóstico y diagnóstico en preeclampsia. Objetivo: Determinar la correlación entre los valores sanguíneos de sFlt-1, PlGF, cociente sFlt-1/PlGF y las complicaciones en mujeres con preeclampsia severa. Material y métodos: Se estudiaron a mujeres que ingresaron a la UCI con diagnóstico de preeclampsia con criterios de severidad y se determinaron las variables clínicas y de laboratorio. Las concentraciones séricas de sFlt-1 y PlGF se realizaron con un equipo automático KRYPTOR compact Plus. Resultados: Encontramos que 33.3% fue preeclampsia temprana y 66.7% tardía. Los criterios de severidad fueron: 66.7% crisis hipertensiva y 33.3% encefalopatía hipertensiva. Existió una correlación negativa entre los valores de sFlt-1 y urea, creatinina, proteínas de orina en 24 horas, presión sistólica (TAS) y presión diastólica (TAD). La correlación fue pobre y no fue estadísticamente significativa. Existió una correlación positiva y estadísticamente significativa para ácido úrico. Existió una correlación negativa entre los valores de PlGF en TAS, TAD. No existió correlación entre los valores cociente sFlt-1/PlGF y las variables medidas como TAS, TAD. Conclusiones: Este estudio confirma que es posible identificar un desbalance angiogénico en mujeres con preeclampsia severa. Sin embargo, los marcadores angiogénicos no presentaron una correlación estadísticamente significativa con respecto a las variables clínicas y bioquímicas de preeclampsia en la Unidad de Cuidados Intensivos.

Abstract: Introduction: The detection of the imbalance between proangiogenic/antiangiogenic factors (sFlt-1, PlGF, sFlt-1/PlGF ratio), in maternal blood are prognostic and diagnostic tools in preeclampsia. Objective: To determine the correlation between blood values of (sFlt-1, PlGF, sFlt-1/PlGF ratio) and complications in women with severe preeclampsia. Material and methods: Women who were admitted to the ICU with a diagnosis of preeclampsia with severity criteria were studied, clinical and laboratory variables were determined. Serum concentrations of sFlt-1, PLGF were performed with a KRYPTOR compact Plus automatic equipment. Results: 33.3% were early preeclampsia and 66.7% late. The severity criteria occurred with 66.7% with hypertensive crisis and 33.3% with hypertensive encephalopathy. There was a negative correlation between the values of sFlt-1 and urea, creatinine, urine proteins in 24 hours, systolic pressure (ASD), diastolic pressure (ADT). The correlation was poor and not statistically significant. There was a positive and statistically significant correlation for uric acid. There was a negative correlation between PlGF values in TAS, TAD. There was no correlation between the sFlt-1/PlGF quotient values and the variables measured as TAS, TAD. Conclusions: This study confirms that it is possible to identify an angiogenic imbalance in women with severe preeclampsia. However, the angiogenic markers did not show a statistically significant correlation, with respect to the clinical and biochemical variables of preeclampsia in the Intensive Care Unit.

Resumo: Introdução: A detecção de desequilíbrio entre fatores pró-angiogênicos/antiangiogênicos (sFlt-1, PlGF, coeficiente sFlt-1/PlGF) no sangue materno são ferramentas de prognóstico e diagnóstico na pré-eclâmpsia. Objetivo: Determinar a correlação entre os valores sanguíneos de (sFlt-1, PlGF, coeficiente sFlt-1/PlGF) e complicações em mulheres com pré-eclâmpsia grave. Material e métodos: Foram estudadas mulheres admitidas na UTI com diagnóstico de pré-eclâmpsia com critérios de gravidade, determinou-se variáveis clínicas e laboratoriais. As concentrações séricas de sFlt-1, PLGF foram realizadas com um equipamento automático KRYPTOR compact Plus. Resultados: 33.3% eram pré-eclâmpsia precoce e 66.7% tardia. Os critérios de gravidade ocorreram com 66.7% com crise hipertensiva e 33.3% com encefalopatia hipertensiva. Houve correlação negativa entre os valores de sFlt-1 e uréia, creatinina, proteínas da urina em 24 horas, pressão sistólica (PAS) e pressão diastólica (PAD). A correlação foi ruim e estatisticamente não significante. Houve uma correlação positiva e estatisticamente significante para o ácido úrico. Encontrou-se uma correlação negativa entre os valores de PLGF no TAS, TAD. Não houve correlação entre os valores do quociente sFlt-1/PlGF e as variáveis medidas como PAS e PAD. Conclusões: Este estudo confirma que é possível identificar um desequilíbrio angiogênico em mulheres com pré-eclâmpsia grave. No entanto, os marcadores angiogênicos não apresentaram correlação estatisticamente significante com relação às variáveis clínicas e bioquímicas da pré-eclâmpsia na unidade de terapia intensiva.