Asistencia a la gestante con VIH-sida en el período 1996-2006 en el Hospital de León / HIV-AIDS pregnancy management from 1996 to 2006 at the Hospital de León (Spain)

Objetivo. Valoración del tratamiento y seguimiento de la gestante con VIH-sida en el Hospital de León en el período 1996-2006. Material y método. Estudio observacional, descriptivo y retrospectivo. Se analizaron 21.780 nacimientos, 18 gestantes con VIH-sida con 21 partos. Especial hincapié en las variables relativas al momento del parto. Resultados. Prevalencia del VIH-sida del 1‰, tratamiento TARGA el 47%, embarazos a término el 95%, cesáreas el 71,5%. Una única malformación congénita menor. Transmisión vertical en gestantes diagnosticadas antes del parto del 4,7%. Conclusiones. La asistencia fue adecuada y acorde con los protocolos de la SEGO. No se observó alta incidencia de efectos adversos ni patología obstétrica (AU)

Objective. To evaluate the treatment and follow-up of pregnant women with HIV-AIDS at the Hospital de León from 1996 to 2006. Material and method. We performed an observational, descriptive, retrospective study. A total of 21,780 births and 18 pregnant women with HIV-AIDS with 21 labors were analyzed. Special emphasis was placed on labor-related variables. Results. The prevalence of HIV infection was 1%. Highly active antiretroviral therapy was used by 47%. Full term pregnancies were achieved in 95%. Cesarean sections were performed in 71.5%. There was one minor congenital malformation. Vertical transmission in pregnant women diagnosed before delivery occurred in 4.7%. Conclusions. The treatment and follow-up provided to pregnant women with HIV-AIDS was adequate and in accordance with the protocols of the Spanish Society of Obstetrics and Gynecology. The incidence of adverse effects and obstetric pathology was not high (AU)

Análisis de la mortalidad fetal en el Hospital Universitario La Fe: estudio comparativo 1996-2000 frente a 2001-2005 / Analysis of fetal mortality in the Hospital Universitario La Fe: comparison between 1996-2000 vs 2001-2005

Objective: To evaluate fetal deaths in the last 10 years by comparing two time periods and to analyze possible causes and variations of fetal mortality. Material and methods: We examined the fetal death rate between 1996 and 2005. Two groups were compared: group A included fetal deaths occurring in the period 1996-2000 and group B comprised those occurring in the period 2001-2005. Maternal, delivery and fetal characteristics were analyzed. Results: The fetal death rate at our hospital was 6.25 per 1000 births. Fetal death mainly occurred in Spanish mothers aged between 20 and 35 years old. Birth weight was between 500 and 1000 g in 53.4% of deaths and gestational age was less than 28 weeks in 32.5%. Mortality was higher in multiple pregnancies than in single pregnancies. Comparison of the two groups showed no significant differences in fetal death rate but a statistically significant increase (p <0.05) was found in patients aged less than 20 years old (1.2% vs. 6.9%) and foreigners (4.7% vs. 15.5%). There was a nonsignificant increase in fetal mortality in assisted reproductive pregnancies (5.8% vs. 9.2%). The cause of death was unexplained in 20.3% of fetal deaths. The most frequent causes registered were funicular abnormalities (13.3%), chorioamnionitis (8.7%), premature rupture of fetal membranes (8.4%), and abruptio (6.7%). Conclusion: The fetal death rate did not decrease during the periods studied and increased among young women and foreigners (AU)

Objetivo: Evaluar la mortalidad fetal en los últimos 10 años dividiéndola en 2 períodos, y analizar las posibles causas y variaciones de ésta. Material y métodos: Se estudia la tasa de mortalidad fetal (TMF) entre los años 1996 y 2005. Se comparan 2 grupos, el Grupo A con las muertes fetales entre 1996-2000 y el grupo B con los casos entre 2001-2005. Se estudian variables maternas, relacionadas con el parto, y fetales. Resultados: La TMF en nuestro medio fue del 6,25‰ recién nacidos. Principalmente se dio en madres españolas de entre 20 y 35 años. El peso fetal fue, en el 53,4% de los casos, de entre 500-1.500 g y el 32,5% era de edad gestacional < 28 semanas. La mortalidad está incrementada en las gestaciones múltiples respecto a las únicas. Al comparar los 2 grupos no ha habido diferencias significativas en la TMF, pero sí se evidencia un aumento estadísticamente significativo (p < 0,05) de pacientes < 20 años (el 1,2 frente al 6,9%) y extranjeras (el 4,7 frente al 15,5%). Sin embargo, aumenta la mortalidad en gestaciones de reproducción asistida (el 5,8 frente al 9,2%), sin alcanzar significación estadística. La causa de muerte fue, en el 20,3% de los casos, desconocida destacan como causas registradas la patología funicular (13,3%), la corioamnionitis (8,7%), la rotura prematura de membranas pretérmino (8,4%) y el desprendimiento prematuro de la placenta normoinserta (6,7%). Conclusión: No ha disminuido la TMF en los últimos años, aumentando entre gestantes extranjeras y jóvenes (AU)

Rotura uterina asociada a desprendimiento prematuro de placenta normalmente inserta en gestante de 25 semanas / Uterine rupture associated with premature separation of a normally inserted placenta at 25 weeks’ gestation

Se presenta un caso de rotura uterina en paciente secundípara de 25 semanas que ingresó en nuestro centro por rotura prematura de membranas. Se practicó una cesárea de urgencia ante la sospecha de desprendimiento prematuro de placenta normalmente inserta y se objetivó rotura de la cicatriz de la cesárea anterior (AU)

We report a case of uterine rupture in a secundipara at 25 weeks’ gestation who was admitted to our center for premature rupture of membranes. Emergency cesarean section was performed due to suspicion of premature separation of a normally inserted placenta. Rupture of a previous cesarean section scar was observed (AU)

Abruptio placentae 2001-2003 / Placental abruption 2001-2003

El desprendimiento de placenta normalmente inserta (DPPNI) se considera a partir de las 20 semanas de gestación; es responsable de un tercio de las hemorragias en el segundo y el tercer trimestre del embarazo, y es una de las causas más importantes de morbimortalidad maternofetal. En nuestro servicio se ha estudiado a 22 pacientes entre los años 2001 y 2003: gestantes que presentaron desprendimiento de placenta. Esto representa una incidencia del 0,56%. El factor principal de riesgo que se ha encontrado asociado a esta enfermedad es la enfermedad hipertensiva del embarazo (HIE), con 3 casos (13,6%). Ninguno de los casos se ha relacionado con el hábito tabáquico ni con el consumo de cocaína; ambos factores favorecen la vasoconstricción. Igualmente, a lo largo del embarazo en 4 de estas pacientes se diagnosticaron cuadros sugestivos de cólicos nefríticos, a los que en ninguna revisión bibliográfica se hace referencia como causa de DPPNI. Puede ser una coincidencia, dada la alta frecuencia de los cólicos nefríticos en la gestación. La presencia de hemorragia en el tercer trimestre fue del 100%, y hubo antecedentes de desprendimiento placentario y de cesárea anterior en 3 (13,6%) y tan sólo 6 (27,2%) casos, respectivamente. El diagnóstico se realizó anteparto, de forma temprana, ante la evidencia de la clínica en el 100% de los casos. Clínicamente, basándonos en la tríada sintomatológica, el signo más frecuente fue la hemorragia, por lo que las gestaciones terminaron por cesárea en el 100% de los casos, dado el compromiso y el riesgo de morbimortalidad maternofetal. Las complicaciones maternas observadas con más frecuencia fueron la anemia de moderada a grave, que requirió transfusión sanguínea en 8 (36,3%) pacientes, sin evidenciarse otra afección; en estos casos se descartó una alteración de la coagulación intravascular diseminada. La morbilidad perinatal fue considerable, y destaca la prematuridad, en 11 casos (50%) sin evidenciarse mortalidad alguna, posiblemente, a causa del diagnóstico temprano obstétrico realizado en nuestro servicio. Todos los casos se trataron de forma expectante y con excelentes resultados perinatales (AU)

Placental abruption (DPNNI) is usually considered from the 20th week of pregnancy, and it is responsible for a third of the haemorrhages in the second and third trimesters of pregnancy. It is one of the most important causes of maternal and foetal morbidity and mortality. In our Department 22 patients have been studied during the years 2001-2003, that represent an incidence of placental abruption of 0.56%. The main risk factor found was associated with HIE pathology, hypertensive diseases in pregnancy, 3cases (13.6%). None of the cases were related to smoking or using cocaine, both of which cause vasoconstriction. Equally, four patients were diagnosed with nephritic colic type diseases throughout pregnancy, which does is not referred to in any literature review as a cause of DPNNI. I t may be only a coincidence, given the high frequency of nephritic colic during pregnancy. Haemorrhage in the third trimester was present in100% of the cases, and there were antecedents of placental abruption and previous caesarean section in 3 cases (13.6%) and 6 cases (27.2%) respectively All cases were diagnosed before labour, due to clinical signs in 100% of the cases. Clinically based on a triad of symptoms; the most frequent sign was haemorrhage and all pregnancies were terminated with caesarean section given the risk of maternal and foetal morbidity and mortality. The most frequent maternal complications were moderate to severe anaemia in 8 patients that required blood transfusion (36.3%), no other pathology was encountered or disseminated intravascular coagulation disease. Perinatal morbidity was high, mainly prematurity in 11 cases (50%) with no mortality, possibly due to early obstetric diagnosis in this department. All cases were monitored closely, with excellent perinatal results (AU)

Pregnancy outcome following recurrent spontaneous abortions.

OBJECTIVE: The purpose of the present study was to examine the association between spontaneous consecutive recurrent abortions and pregnancy complications such as hypertensive disorders, abruptio placenta, intrauterine growth restriction and cesarean section (CS) in the subsequent pregnancy. METHODS: A population-based study comparing all singleton pregnancies in women with and without two or more consecutive recurrent abortions was conducted. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 154,294 singleton deliveries occurred, with 4.9% in patients with history of recurrent consecutive abortions. Using a multivariate analysis, with backward elimination, the following complications were significantly associated with recurrent abortions-advanced maternal age, cervical incompetence, previous CS, diabetes mellitus, hypertensive disorders, placenta previa and abruptio placenta, mal-presentations and PROM. A higher rate of CS was found among patients with previous spontaneous consecutive recurrent abortions (15.9% versus 10.9%; OR = 1.6; 95% CI, 1.5-1.7; P < 0.001). Another multivariate analysis was performed, with CS as the outcome variable, controlling for confounders such as placenta previa, abruptio placenta, diabetes mellitus, hypertensive disorders, previous CS, mal-presentations, fertility treatments and PROM. A history of recurrent abortion was found as an independent risk factor for CS (OR = 1.2; 95% CI, 1.1-1.3; P < 0.001). About 58 cases of inherited thrombophilia were found between the years 2000-2002. These cases were significantly more common in the recurrent abortion as compared to the comparison group (1.2% versus 0.1%; OR = 11.1; 95% CI, 6.5-18.9; P < 0.001). CONCLUSION: A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions. Careful surveillance is required in pregnancies following recurrent abortions, for early detection of possible complications.

[Diagnostic image (213). A pregnant woman with premature contractions and vaginal blood loss]. / Diagnose in beeld (213). Een zwangere met premature contracties en vaginaal bloedverlies.

Emergency caesarean section was performed in a 40-year-old woman with solutio placentae. A Couvelaire uterus was diagnosed, showing typical blue-purple discolorations of the uterine wall, which are in fact haemorrhages caused by disseminated intravascular coagulation.

Risk factors in term children for visual impairment without a known prenatal or postnatal cause.

Risk factors were studied for visual impairment in children without known pre- or postnatal cause, for a decrease of visual acuity. Children born at term 1979-98 and with a visual impairment were identified from the Swedish Register of Visually Impaired Children and data were linked with the Swedish Medical Birth Registry. Maternal characteristics such as maternal age, parity, maternal smoking habits in early pregnancy, maternal education, nationality, and subfertility were studied as well as maternal diagnoses such as pre-eclampsia, prolonged second stage of labour, abruptio placentae, and placenta praevia. Mode of delivery was analysed as well as birthweight, and birthweight in relation to gestational age. Abruptio placentae turned out to be the strongest risk factor (OR = 8.24 [95% CI 5.01, 13.51]). Smoking did not give a statistically significant increased risk. There is an increased risk with breech delivery (OR = 2.01 [95% CI 1.28, 3.17]). Pre-eclampsia was associated with an increased risk (OR = 2.22 [95% CI 1.46, 3.38]). There is also an increase in risk at low birthweight and small-for-gestational-age as well as birthweight > 4 kg and large-for-gestational-age. In this study we found that risk factors particularly worth noticing in term children with a presumed perinatal cause of visual impairment are abruptio placentae, pre-eclampsia, excessively low as well as excessively high birthweight, and breech delivery, a fact worth noticing in current discussion on risks, advantages or excessive exploitation of caesarean section.

Diagnosis of an unsuspected maternal hemorrhage via fetal heart rate tracing.

Early detection of placental abruption often relies on the observation of vaginal bleeding; however, overt bleeding does not always occur. We report the case of an unsuspected placental abruption diagnosis that was prompted by an internal fetal scalp electrode tracing. The presence of a "normal" fetal heart rate (FHR) of approximately 150 beats per minute with poor variability, which matched the maternal heart rate (MHR), suggested that the tracing was not of fetal origin. An urgent ultrasound examination revealed a fetal demise with a possible concealed abruption, proving that the scalp electrode tracing was actually maternal in origin. Though reports of transmission of MHR via a deceased fetus are not new, it is uncommon for MHR to mimic a normal, reassuring FHR. This report reinforces the need for anesthesiologists to be adept at interpreting and integrating FHR monitors with maternal monitors prior to initiation of epidural analgesia.

First pregnancy characteristics and subsequent breast cancer risk among young women.

There is growing evidence that perinatal factors associated with altered gestational hormones may influence subsequent breast cancer risk in the mother. Events occurring during the first pregnancy may be particularly important. In this matched case-control study, we investigated the relation between characteristics of a woman's first pregnancy and her later breast cancer risk using linked records from the New York State birth and tumor registries. Cases were 2,522 women aged 22 to 55 diagnosed with breast cancer between 1978 and 1995 and who had also completed a first pregnancy in New York State (NY) at least 1 year prior to diagnosis. Controls were 10,052 primiparous women not diagnosed with breast or endometrial cancer in NY and matched to cases on county of residence and date of delivery. Information on factors characterizing the woman's first pregnancy was obtained from the pregnancy record of each subject. The association of these factors to breast cancer risk was assessed using conditional logistic regression. Extreme prematurity (< 32 weeks gestational age) was associated with elevated maternal breast cancer risk [adjusted odds ratio (OR)=2.1, 95% confidence interval (CI) 1.2,3.9], as were abruptio placentae (OR = 1.8, CI 1.1,3.0) and multifetal gestation (OR=1.8, CI 1.1,3.0). Preeclampsia was associated with a marked reduction in breast cancer risk among women who bore their first child after age 30 (OR=0.3, CI 0.2,0.7) and in the first 3 years after delivery (OR=0.2 (0.1-0.9). These findings suggest that certain perinatal factors influence maternal breast cancer risk and offer indirect support for a role of gestational hormones, and particularly gestational estrogens, in the etiology of breast cancer.

A life-threatening second trimester disseminated intravascular coagulopathy with protein s deficiency.

Disseminated intravascular coagulopathy (DIC) is an uncommon but serious complication of pregnancy. Placental abruption is the most common associated condition among the causes of acute obstetrical DIC. We present a case of life-threatening DIC complicating placental abruption in the second trimester of pregnancy with protein S deficiency as a triggering factor, which necessitated urgent termination of pregnancy.

Large volume polymerized haemoglobin solution in a Jehovah's Witness following abruptio placentae.

Severe anaemia, with haemoglobin (Hb) levels < or =3 g dL(-1), is associated with mortality rates of 50-95%. Although accepted transfusion targets have been debated in the literature (Carson et al., 2002; Practice guidelines for blood component therapy. 1996; Consensus Conference. 1988; Hebert et al., 1999), few would argue the risks associated with Hb levels less than 5 g dL(-1) in critically ill patients. In patients who are unable to receive red blood cell transfusions, the utility of Hb solutions is an attractive solution. We describe a Jehovah's Witness patient who exemplifies the marked physiologic derangements of severe anaemia and subsequent clinical resolution with large volume polymerized human Hb transfusion. The Hb-based oxygen carrier, PolyHeme, provided adequate oxygen transport, acting as a bridge until endogenous production could compensate for red cell loss. Practicing physicians need to be aware of current therapeutic options for use in these complicated patients.

Successful outcome following preterm abruption complicated by pancytopenia secondary to folate deficiency: important learning points.

Pancytopenia in pregnancy secondary to folate deficiency is rare, but can still occur in the UK despite improved socioeconomic status, food fortification and modern obstetric surveillance. Currently, there is considerable interest in the role of folate-homocysteine metabolism in the etiology of pregnancy disorders, and this case adds to this debate.

Maternal mortality in Italy, 1980-1996.

OBJECTIVE: To establish the extent of maternal mortality in Italy in between 1980 and 1996 in order to compare it with the international data. STUDY DESIGN: We conducted a retrospective study on maternal deaths in Italy from 1980 to 1996. Data have been collected by Italian Statistic Institute (ISTAT). We calculated both the maternal mortality rates and the percentages of causes of death in the whole period, according to WHO definitions. RESULTS: The data confirmed the trends of the previous decade: maternal mortality rates have decreased from 13.25 (1980) to 3.78 (1996) for 100000 live births. Haemorrhage and hypertension have been the main causes of maternal death, while pulmonary embolism has had a minor affect on maternal mortality rates compared to other countries, particularly in Europe. CONCLUSION: Italian data appear reassuring and encourage further investigations on detailed welfare problems.

The effect of placental abruption on the short-term outcome of premature infants.

The purpose of this study was to analyze the effect of abruption on the outcome of preterm infants. Live-born infants of 23 to 32 weeks gestation born at Beaumont Hospital between 1995 and 1999 who suffered abruption constitute the study group. Controls were matched to cases by sex, gestational age, and birth weight. Medical records were retrospectively reviewed for confirmation of abruption, determination of abruption grade, and subsequent neonatal outcome. Univariate analysis of the grade 2 abruption group revealed statistically significant differences in time from diagnosis to delivery (p = 0.04), Apgar scores at 5 minutes (p = 0.04), and acidotic cord blood (p = 0.04) between cases and controls. However, no differences in short-term outcome were appreciated. In addition, no differences in mortality or morbidity were noted between grade 1 abruption case and control infants. We conclude that abruption is not an independent risk factor for poor outcome among infants born between 23 and 32 weeks gestation, but instead induces the preterm delivery that is the main determinant of outcome.

Mortalidad perinatal. Distribución según la edad gestacional y el peso al nacimiento. Causas más frecuentes. Revisión epidemiológica de 10 años / Perinatal mortality. Birth weight and gestational age distribution. Most frequent causes of death. A ten year epidemiological review

Objetivos: Evaluar la mortalidad perinatal (MP) de los últimos 10 años (1994-2003) habida en el Servicio de Obstetricia del Hospital Miguel Servet de Zaragoza. Se distribuye según la edad gestacional y el peso al nacimiento. Se analizan las posibles causas tanto maternas como fetales que pudieran estar implicadas. Material y métodos: Sobre un total de 37.665 recién nacidos (RN) de más de 500 g de peso, hubo 368 nacidos muertos o que fallecieron antes de los 28 días completos de vida. El Hospital Materno-infantil es un centro de referencia (nivel terciario) para las comunidades de Aragón y La Rioja, para la provincia de Soria y para los RN o sus madres con problemas procedentes de la actividad privada local. Resultados: La MP global es del 9,770/00. Para las comparaciones internacionales, la MP I (> 28 semanas y hasta 7 días de vida) es del 5,620/00. Según la edad gestacional, un 72,28 por ciento son RN pretérmino, la mitad (50 por ciento) con menos de 32 semanas de gestación. Por pesos al nacimiento, la MP está gravada por la gran inmadurez: un 36,68 por ciento de los RN con un peso < 1.000 g y un 51,90 por ciento < 1.500 g, 70 RN proceden de partos múltiples y todos ellos son pretérmino. La MP de los partos múltiples es globalmente del 46,510/00 (el 42,790/00 en gemelos). Las causas fetales más frecuentes son la asfixia y la anoxia antes del inicio del trabajo de parto (26,84 por ciento), la inmadurez extrema, tener un peso < 1.000 g (16,30 por ciento) y la patología respiratoria (12,22 por ciento). Las causas maternas más frecuentes son las gestaciones múltiples (19,02 por ciento), la rotura prematura de las membranas (12,22 por ciento) y el desprendimiento prematuro de la placenta y la hemorragia placentaria (10,05 por ciento) (AU)

Cardiac failure caused by severe pre-eclampsia with placental abruption, and its treatment with anti-hypertensive drugs.

Pre-eclampsia is the abnormality of blood circulation in late pregnancy, often caused by renal failure, hemolysis, elevated liver enzyme, low platelet syndrome, and eclampsia. We present a case of severe pre-eclampsia with placental abruption in a 24-year-old woman, pregnant for the first time. The patient was diagnosed with congestive heart failure, which came as a result of pre-eclampsia. Anti-hypertensive drugs were used for its treatment.

Successful term pregnancy after bilateral uterine artery embolization for postpartum hemorrhage.

BACKGROUND: Selective bilateral uterine artery embolization has been used since the 1970s for the conservative treatment of postpartum hemorrhage. The fertility rate after the embolization procedure is yet to be determined. CASE: A 30-year-old woman presented with placental abruption and subsequently delivered preterm at 29 weeks' gestation. Her delivery was complicated by postpartum hemorrhage, for which selective bilateral uterine artery embolization was performed with successful cessation of the hemorrhage. Three months later, the patient presented with a spontaneous pregnancy. Her pregnancy resulted in an appropriately grown fetus delivered at 39 weeks' gestation. CONCLUSION: This is one of the earliest reported successful pregnancies after a bilateral uterine artery embolization procedure performed for postpartum hemorrhage. This case adds to a growing literature demonstrating that pregnancy after embolization is possible, and can occur soon after the procedure.