Serie guías clínicas: parto prematuro / Clinical guidelines series: preterm labor

Determinar factores de riesgo de parto prematuro espontáneo < 34 semanas.Determinar las medidas de prevención de parto prematuro espontáneo < 34 semanas.Conocer la alta tasa de falsos positivos del diagnóstico clínico de parto prematuro y el papel de la evaluación ecográfica del cérvix.Conocer el concepto del uso de tocolisis en parto prematuro.Valorar el papel de los corticoides y sulfato de magnesio en la reducción de morbi-mortalidad perinatal en el parto prematuro.Evaluar el papel de los antibióticos en el parto prematuro con membranas íntegras.

Serie guías clínicas: manejo del embarazo gemelar / Clinical guidelines series: management of pregnancy twin

Explicar el diagnóstico y clasificación de los embarazos gemelares.Explicar el modelo de control prenatal de los embarazos gemelares que se aplica en el Hospital Clínico Universidad de Chile. Definir el momento y la vía de interrupción de los distintos tipos de embarazos gemelares nocomplicados. Referirse al parto prematuro en el embarazo gemelar.

[Sex-hormone binding globulin (SHBG) levels during pregnancy as predictors for pre-eclampsia and fetal growth restriction]. / Evaluación de la globulina transportadora de hormonas esteroidales (SHBG) durante el embarazo como factor predictor de pre-eclampsia y restricción del crecimiento intrauterino.

BACKGROUND: Sex-Hormone Binding Globulin (SHBG) may be associated to Pre-eclampsia (PE) and Fetal Growth Restriction (RCIU). AIM: To determine if maternal serum SHBG concentrations during the first and second trimesters are predictive biomarkers of Pre-eclampsia and RCIU. PATIENTS AND METHODS: Prospective cohort study carried out in the Fetal Medicine Unit, Universidad de Chile Clinical Hospital between January, 2005 and December, 2006. Blood samples were obtained from unselected pregnant women during routine 11-14 week and 22-25 week ultrasound examinations, conforming two different study groups. Posteriorly, serum SHBG concentrations were determined in women who developed Pre-eclampsia, RCIU and their respective controls. RESULTS: Fifty five patients were included in the 11-14 weeks group. Nine women that developed PE, 10 that developed RCIU and 36 controls were selected from this group. There were no significant differences in SHBG levels between patients with PE, RCIU or controls (324.7 (26.6), 336.8 (33.9) and 377.5 (24.3) nmol/L, respectively). Fifty four women were included in the 22-25 weeks group. Eight women who developed Pre-eclampsia, 15 who developed RCIU and 31 controls were selected. Again, there were no significant differences in SHBG levels between patients with PE, RCIU or controls (345.5 (151.1), 383.8 (143.4) and 345.5 nmol/l (151.1), respectively). CONCLUSIONS: Maternal SHBG serum levels did not predict subsequent development of Pre-eclampsia and RCIU.

Evaluación de la globulina transportadora de hormonas esteroidales (SHBG) durante el embarazo como factor predictor de pre-eclampsia y restricción del crecimiento intrauterino / Sex-hormone binding globulin (SHBG) levels during pregnancy as predictors for pre-eclampsia and fetal growth restriction

Background: Sex-Hormone Binding Globulin (SHBG) may be associated to Pre-eclampsia (PE) and Fetal Growth Restriction (RCIU). Aim: To determine if maternal serum SHBG concentrations during the first and second trimesters are predictive biomarkers of Pre-eclampsia and RCIU. Patients and Methods: Prospective cohort study carried out in the Fetal Medicine Unit, Universidad de Chile Clinical Hospital between January, 2005 and December, 2006. Blood samples were obtained from unselectedpregnant women during routine 11-14 week and 22-25 week ultrasound examinations, conforming two different study groups. Posteriorly, serum SHBG concentrations were determined in women who developed Pre-eclampsia, RCIU and their respective controls. Results: Fifty five patients were included in the 11-14 weeks group. Nine women that developed PE, 10 that developed RCIU and 36 controls were selected from this group. There were no significant differences in SHBG levels between patients with PE, RCIU or controls (324.7 (26.6), 336.8 (33.9) and 377.5 (24.3) nmol/L, respectively). Fifty four women were included in the 22-25 weeks group. Eight women who developed Pre-eclampsia, 15 who developed RCIU and 31 controls were selected. Again, there were no significant differences in SHBG levels between patients with PE, RCIU or controls (345.5 (151.1), 383.8 (143.4) and 345.5 nmol/l (151.1), respectively). Conclusions: Maternal SHBG serum levels did not predict subsequent development of Pre-eclampsia and RCIU.

Morbilidad neonatal de los prematuros tardíos en embarazos únicos: estudio de caso-control / Neonatal morbidity of late preterm: a case-control study

Objetivo: Comparar los riesgos de morbilidad neonatal entre los prematuros tardíos (PT) y neonatos de término. Método: Estudio de caso control. Se revisan fichas clínicas de partos durante el año 2007. Se excluyen neonatos con malformaciones congénitas mayores, alteración neuromuscular, embarazos múltiples y aneuploidias. Los casos corresponden a todo PT nacido durante el periodo estudiado y los controles a nacidos de término en el mismo periodo. Los resultados neonatales fueron obtenidos y los riesgos calculados usando pruebas de Chi cuadrado y exacto de Fisher. Resultados: Se identifican 1536 partos, con una tasa de PT de 7,1 por ciento (109 casos), 62 cumplieron con criterios de inclusión. El grupo control consistió en 124 partos de término. PT presentaron 2 veces más riesgo de cesárea (p=0,0094) que los de término. El riesgo de ser admitido en UCIN fue de 88 (p=0,000). Los riesgos de morbilidad neonatal fueron: SDR (OR 23; p=0,000), hipoglicemia (OR 6; p=0,014), hipocalcemia (OR 6; p=0,014), hiperbilirrubinemia (OR 28; p=0,000) y necesidad de fototerapia (OR 23; p=0,000). No hubo diferencias en la presentación de enterocolitis necrotizante (p=0,478) ni sepsis neonatal (p=0,615). La mortalidad neonatal fue significativamente superior en los PT (p=0,044). Conclusión: Los PT deben ser considerados de alto riesgo en el período neonatal. Nuestros resultados son importantes para tomar decisiones clinicas respecto al mejor momento de finalizar un embarazo con riesgo inminente de prematurez.

Objective: To compare neonatal morbidity risks between late preterm (LP) and term deliveries. Methods: Case control study. Medical records in 2007 were reviewed. Major congenital malformations, neuromuscular handicap, twin pregnancies and aneuploidies were excluded. The Study group corresponds to all LP births during that period and the control group to term deliveries in the same period. Neonatal outcomes were collected and different risks were calculated using Chi square test and Fisher exact tests. Results: 1536 deliveries with a LP rate of 7.1 percent (109 cases) were observed, 62 cases met inclusion criteria. The control group consisted in 124 single term deliveries. LP had 2 times more risk of cesarean section (p=0.0094) than term deliveries. The risk of NICU admission was 88 (p=0.000). Neonatal morbidity risks were: RDS (OR 23, p=0.000), hypoglycemia (OR 6, p=0.014), hypocalcaemia (OR 6, p=0.014), hyperbillirrubinemia (OR 28, p=0.000) and phototherapy (OR 23, p=0.000). There were no differences in necrotizing enterocolitis (p=0.478) and risk of neonatal sepsis (p=0.615). Neonatal mortality was significantly higher in LP babies (p=0.044). Conclusion: LP newborn must be considered as high risk in the neonatal period. These results are important in making clinical decisions about the better time to end pregnancy.

VIH/SIDA: comportamiento epidemiológico de la transmisión vertical en el contexto general de la infección en Chile / HIV/AIDS: epidemiological behavior of vertical transmission in the general context of infection in Chile

ANTECEDENTES: En embarazadas seropositivas sin profilaxis antirretroviral la transmisión vertical (TV) del VIH es de 30%, cifra que disminuye bajo al 2% con un manejo integral de prevención. OBJETIVO: Conocer el comportamiento epidemiológico de la TV en Chile desde la creación del programa nacional de prevención. MÉTODO: Datos aportados por el Departamento de Epidemiología del MINSAL y CONASIDA (1984-2006). Estudió de situación VIH/SIDA por año, regiones, grupo etario y sexo, con especial énfasis en TV. RESULTADOS: Se notificaron 9.317 casos de VIH y 7.886 casos de SIDA (1984-2006), prevalencia en aumento hasta el 2003 con tendencia descendente posteriormente. La razón actual de VIH entre hombres y mujeres es de 4:1, con clara tendencia al aumento de notificación en mujeres. La principal vía de exposición sigue siendo la vía sexual (93,4%). El grupo más afectado está entre los 20-39 años (73,1% para VIH y 63,1% para SIDA), cabe destacar que entre 0-9 años se encuentra el 1,1% de los afectados por VIH y el 1,4% por SIDA, todos infectados por TV. CONCLUSIONES: La transmisión vertical de VIH en Chile es responsable de un bajo porcentaje de las personas notificadas de VIH/SIDA, pero es la causa de la totalidad de los niños afectados por la infección en nuestro país. Se observa una importante reducción de la TV, llegando a niveles muy cercanos a los objetivos ministeriales.

BACKGROUND: The risk of transmitting HIV from mother to unborn child, without any antiretroviral prophylaxis, reaches 30%. It can be reduced to less than 2% by implementing integral preventive strategies. OBJECTIVE: To assess the epidemiological profile of HIV vertical transmission in Chile since the implementation of the national AIDS transmission prevention program. METHOD: Data from the Epidemiology Department of the Health Ministry and the National Commission for AIDS grouped by year, location, ageandgender. Withspecial emphasis on vertical transmission. RESULTS: 9317 cases of HIV infection and 7886 cases of AIDS have been reported in Chile (1984-2006), with a decreasing tendency since 2003. Sexual exposure continues to be the primary route with 93.4% of the cases. The male/female ratio for case notif¡cation is 4:1, with a rising tendency among women. The most affected is between 20-39 years old (73% HIV notification and 63.1% for AIDS). Among children between 0-9 years of age is 1.1% of the HIV and 1.4% of AIDS notifications, all of them for vertical transmission. CONCLUSIONS: HIV vertical transmission in Chile is responsible for a small percentage of HIV/AIDS notifications, but it accounts for all of the infected children. There's been an important reduction in this transmission route, reaching prevalence close to the aimed rates, which can explained by the expanding prevention programs of the health policies implemented by the Health Ministry.

Hepatitis aguda viral durante el embarazo / Acute viral hepatitis during pregnancy

Acute hepatitis has a very low incidence disease during pregnancy. However, it may be an important cause of jaundice during gestation which in cases of viral etiology can have a very high morbidity and mortality risk to the mother and the fetus. The purpose of this review is to update the available knowledge regarding viral hepatitis during pregnancy including description of the main etiologies, transmission route, maternal-fetal risk and possible management.

La hepatitis aguda es una enfermedad de baja incidencia durante el embarazo; sin embargo, es una causa importante de ictericia durante el desarrollo de éste y en algunos casos presenta un alto riesgo de morbi-mortalidad materno-fetal, siendo la etiología principalmente viral. El propósito de este artículo es actualizar los conocimientos disponibles en la literatura médica respecto a hepatitis viral durante el embarazo, conocer cuáles son los agentes más prevalentes, vía de transmisión, riesgo para el binomio madre- hijo y eventual manejo.

[Acute viral hepatitis during pregnancy]. / Hepatitis aguda viral durante el embarazo.

Acute hepatitis has a very low incidence disease during pregnancy. However, it may be an important cause of jaundice during gestation which in cases of viral etiology can have a very high morbidity and mortality risk to the mother and the fetus. The purpose of this review is to update the available knowledge regarding viral hepatitis during pregnancy including description of the main etiologies, transmission route, maternal-fetal risk and possible management.

[Scientific and ethical perspectives of perinatal and fetal medicine]. / Consideraciones científicas y éticas en las perspectivas diagnósticas y terapéuticas en medicina fetal.

This review emphasizes the importance of recent developments and knowledge on cell biology and human genetics than have integrated, through a basic-clinical concept to an emerging branch of medicine, called Perinatal and Fetal Medicine. We discuss the possible role of fetal cells and DNA in the diagnosis and treatment of diseases in the intrauterine environment The associated bioethical issues associated to these medical actions are discussed, considering the imminent use of these agents in the human species.

[Effectiveness of oral hypoglycemic drugs in the metabolic control of patients with gestational diabetes]. / Eficacia de los hipoglicemiantes orales en el control metabólico de pacientes con diabetes mellitus gestacional.

Gestational Diabetes is characterized by different degrees of glucose intolerance that produce a series of fetal and perinatal alterations. During many years, in those cases of gestational diabetes that did not respond to nutritional interventions, the use of insulin was a proven treatment to achieve metabolic control and thus a better perinatal outcome. At present, some new oral hypoglycemic drugs, from the family of sulfonylureas and biguanides, have been shown to be safe, of low cost, and apparently effective in the metabolic control of this disease. We review the publications that propose the use of oral hypoglycemic drugs for the metabolic control of gestational diabetes that does not respond to nutritional measures.

[Transient renal failure in a newborn due angiotensin receptor II antagonist use during pregnancy: report of a case]. / Efectos sobre la función renal fetal y neonatal del tratamiento con antagonista del receptor de angiotensina II en el embarazo: Caso clínico.

Fetal renal structure and function can be altered by medications prescribed to pregnant women. We report a chronic hypertensive pregnant woman treated with losartan before and throughout pregnancy. At 30 weeks the patient was referred to our Fetal Medicine Unit due to absent amniotic fluid with normal uterine artery Doppler and fetal growth. During her hospitalization a new scan was performed showing that both fetal kidneys were enlarged and slightly hyperechogenic and placental and fetal artery Doppler showed signs of hypovolemia or increased resistance to feto-placental blood flow. Ductus venosous was normal. The fetus was delivered after three days by caesarean section at 30+4 weeks of gestation due to abnormal fetal heart rate tracing. Following delivery, the preterm newborn was treated for a transient renal failure characterized by anuria-oliguria and high plasma creatinine levels (from 3.8 mg/dL at day 5 to 0.8 mg/dL at 16 days). At 30 days of age, ultrasound showed kidneys of normal form and size. The adverse effects of Angiotensin II receptor antagonists in fetal nephrogenesis and function are discussed.

Consideraciones científicas y éticas en las perspectivas diagnósticas y terapéuticas en medicina fetal / Scientific and ethical perspectives of perinatal and fetal medicine

This review emphasizes the importance of recent developments and knowledge on cell biology and human genetics than have integrated, through a basic-clinical concept to an emerging branch of medicine, called Perinatal and Fetal Medicine. We discuss the possible role of fetal cells and DNA in the diagnosis and treatment of diseases in the intrauterine environment. The associated bioethical issues associated to these medical actions are discussed, considering the imminent use ofthese agents in the human species.

Eficacia de los hipoglicemiantes orales en el control metabólico de pacientes con diabetes mellitus gestacional / Effectiveness of oral hypoglycemic drugs in the metabolic control of patients with gestational diabetes

Gestational Diabetes is characterized by different degrees of glucose intolerance that produce a series of fetal and perinatal alterations. During many years, in those cases of gestational diabetes that did not respond to nutritional interventions, the use of insulin was a proven treatment to achieve metabolic control and thus a better perinatal outcome. At present, some new oral hypoglycemic drugs, from the family of sulfonylureas and biguanides, have been shown to be safe, of low cost, and apparently effective in the metabolic control of this disease. We review the publications that propose the use of oral hypoglycemic drugs for the metabolic control of gestational diabetes that does not respond to nutritional measures.

Efectos sobre la función renal fetal y neonatal del tratamiento con antagonista del receptor de angiotensina II en el embarazo: Caso clínico / Transient renal failure in a newborn due angiotensin receptor II antagonist use during pregnancy: Report of one case

Fetal renal structure and function can be altered by medications prescribed to pregnant women. We report a chronic hypertensive pregnant woman treated with ¡osarían before and throughout pregnancy. At 30 weeks the patient was referred to our Fetal Medicine Unit due to absent amniotic fluid with normal uterine artery Doppler and fetal growth. During her hospitalization a new scan was performed showing that both fetal kidneys were enlarged and slightly hyperechogenic and placental and fetal artery Doppler showed signs of hypovolemia or increased resistance to feto-placental blood flow. Ductus venosous was normal. The fetus was delivered after three days by caesarean section at 30+4 weeks of gestation due to abnormal fetal heart rate tracing. Following delivery, the preterm newborn was treated for a transient renal failure characterized by anuria-oliguria and high plasma creatinine levels (from 3.8 mg/dL at day 5 to 0.8 mg/dL at 16 days). At 30 days of age, ultrasound showed kidneys of normal form and size. The adverse effects of Angiotensin II receptor antagonists in fetal nephrogenesis and function are discussed