Resultados perinatales de un protocolo de atención para gestantes con riesgo de prematuridad extrema

Introduction

Gestational age and birthweight are the most important variables that influence perinatal outcomes and future quality of life.

Method

An intervention project was applied following a protocol for the perinatal care of women admitted to the Mariana Grajales Perinatal Care Unit in Santa Clara at risk of extremely preterm delivery (26 to 32 weeks).

Objective

To evaluate perinatal results and neonatal survival in this high-risk group.

Results

The causes of extreme prematurity were, in order of frequency, aggravated preeclampsia, premature rupture of membranes, spontaneous delivery, and gastorrhagia in the second half of pregnancy. The most common route of delivery was cesarean section. Birthweight was less than 1 500 g in 52% of the neonates, mainly due to preeclampsia and preterm delivery. Low Apgar scores of 4-6 were found in 12.3% of the neonates with 100% recovery at 5 minutes. Delivery occurred at less than 30 weeks in 30.1%. Pregnancy was prolonged by 8.6 days in preeclampsia, by 6 days in premature rupture of membranes and by 322 days in preterm delivery. The most frequent complications were hyaline membrane disease (15%) and sepsis (36.9%), which provoked one death.

Conclusions

Survival in this group of high-risk neonates was high, decisively influencing the low infant mortality rate in this unit in 2009-2010.     

Role of amnioinfusion in the management of premature rupture of the membranes at <26 weeks' gestation

OBJECTIVE: We sought to evaluate whether serial amnioinfusions for persistent oligohydramnios can affect the perinatal and long-term outcomes in extreme cases of preterm premature rupture of membranes. STUDY DESIGN: All singleton pregnancies with preterm premature rupture of membranes at <26 weeks' gestation and lasting >4 days between January 1991 and June 1998 were included. Amniotic fluid volume was assessed as the maximum cord-free pocket with serial ultrasonographic examinations. Consenting women with persistent (>4 days) oligohydramnios (amniotic fluid 2 cm. The pregnancy, neonatal, and long-term neurologic outcomes of the cases that spontaneously maintained a median amniotic fluid pocket >2 cm (amnioinfusion-not-necessary group) were compared with those of women with oligohydramnios who underwent amnioinfusion but continued to have a median amniotic fluid pocket after preterm premature rupture of membranes 2 cm for >/=48 hours in 11 (30%) patients. This successful amnioinfusion group was comparable with the persistent oligohydramnios group (n = 25) in gestational age at first amnioinfusion (median, 20.2 weeks; range, 16-25.6 weeks; vs median, 20.3 weeks; range, 16.5-24.2 weeks; P =.4), number of amnioinfusions (median, 3; range, 1-9; vs median, 3; range, 1-5; P =.4), and interval between amnioinfusions (median, 6 days; range, 4-14 days; vs median, 8 days; range, 6-43 days; P =. 1). However, patients in the persistent oligohydramnios group had a significantly shorter interval to delivery, lower neonatal survival (20%), and higher rates of pulmonary hypoplasia (62%) and abnormal neurologic outcomes (60%) than the patients in the groups in which amnioinfusion was not necessary or was successful (all P 相似文献   

Impacto de la edad materna avanzada en las complicaciones obstétricas y perinatales de las gestaciones gemelares

Objective

To evaluate the pregnancy and perinatal outcomes of twin gestations in women aged 35 or older.

Material and methods

We designed a retrospective cohort study. Maternal complications, mode of delivery and perinatal outcomes were compared in 229 women who delivered at age 35 or older and in 374 women who delivered at age less than 35 years. The computerized database and medical records of pregnant women attending the Miguel Servet University Hospital from January 2001 to December 2007 were retrospectively reviewed.

Results

Older women had an increased risk of conceptions after assisted reproductive techniques (p > 0.001), dichorionic pregnancies (p > 0.001) and gestational diabetes (p = 0.007; 95% CI: 1.119-3.19). There was no significant association between older maternal age and an increased incidence of preterm labor, premature rupture of membranes, fetal growth restriction, cesarean delivery or perinatal mortality.

Conclusion

Based on our data and previous studies, advanced maternal age in twin pregnancies does not seem to significantly increase obstetric complications or adverse perinatal results.     

Abordaje laparoscópico del dolor abdominal agudo en mujeres en edad fértil

Objectives

To assess the effectiveness of the laparoscopic approach in acute abdominal pain in women of reproductive age presenting to the Emergency Department.

Material and methods

We performed an observational, prospective study of acute abdominal pain treated by gynecological laparoscopic procedures. The main variables evaluated were the cause of pain, type of surgery, complications, and conversions to open surgery.

Results

Between January 2009 and December 2011, we performed 110 urgent laparoscopic interventions. The reasons for surgery were rupture of an ovarian cyst in 40 interventions (36.7%), an ectopic pregnancy in 24 (21.8%), a pelvic inflammatory disease in 23 (20.9%), adnexal torsion in 12 (10.9%), and other reasons in 11 (10%). In these 110 interventions, there was one case of postoperative bleeding requiring reintervention and one case of conversion.

Conclusions

The laparoscopic approach is safe and effective in urgent gynecological surgery.     

Factores de riesgo del parto pretérmino

Objective

To determine the risk factors for preterm births occurring spontaneously or due to premature rupture of membranes in our environment.

Patients and method

We performed a retrospective case-control study at the Complejo Hospitalario Universitario de Albacete (Spain) that compared 315 pregnant women with preterm labor occurring spontaneously or due to premature rupture of membranes with 315 women selected as controls who delivered at term. The variables were grouped into sociobiological parameters, obstetric history, and characteristics of the current pregnancy.

Results

Previous preterm birth (OR = 3.4; 95% CI, 1.7-6.7), prior abortions (p = 0.002), multiple gestation (OR = 28.1; 95% CI, 6.7-116.8), assisted reproductive technology (ART) (OR = 5.8; 95% CI, 2.3-14.1), hospitalization and tocolytic therapy (OR = 10.8; 95% CI, 4.2-27.7), and cerclage (OR = 5.6; 95% CI, 1.2-25.7) were more frequent in cases. However, when OR were adjusted (aOR) by other variables, the risk for cerclage disappeared (aOR = 2.8; 95% CI, 0.5-14).

Conclusions

Risk factors for preterm birth in our population were a history of preterm birth and abortions, multiple gestation, ART, and hospitalization with tocolytic therapy.     

Resucitación fetal intrauterina

Introduction

Intrauterine fetal resuscitation includes a series of procedures performed in the mother to improve fetal oxygenation by correcting the cause of fetal compromise manifested by non-reassuring fetal heart rate.

Material and Methods

A literature review was performed with evaluation of the scientific evidence for the techniques traditionally used for this purpose (maternal position, intravenous fluids, oxygen, intrapartum tocolysis and amnioinfusion).

Results

Although the evidence could be more robust, there are sufficient data to suggest that these techniques benefit the fetus, and the risk of harm is minimal when used with common sense. These procedures do not reverse the state of fetal hypoxia but can help to improve fetal oxygenation during the process of preparing for delivery.

Conclusion

Until more data are available, it seems reasonable to err on the side of fetal safety by using these techniques when appropriate, based on the specific fetal heart rate pattern or any other intrapartum fetal surveillance test.     

Pronóstico perinatal y materno de la gestación múltiple en función del protocolo intraparto

Objectives

To evaluate maternal and fetal outcomes of multiple pregnancy according to route of delivery.

Material and methods

We performed a retrospective study of all twin deliveries in the previous 5 years and evaluated the route of delivery, especially in the final year. The information was recorded with Microsoft EXCEL and was analyzed with the statistical program SPSS 12.0 for Windows.

Results

The mean gestational age was 35.3 weeks. Route of delivery was through cesarean section in 59.8%. The mean interval between twins was 7.82 minutes when the first twin was delivered vaginally. Neonatal morbidity was found in 49%, and was higher in the second twin and in preterm deliveries.

Conclusions

Multiple pregnancies are associated with a large number of maternal and perinatal complications, as well as with a greater number of cesarean sections. Consequently, correct intrapartum management is required to reduce neonatal morbility as far as possible.     

Extracción de DIU mediante histeroscopia en la gestación precoz: nuestra experiencia en 4 casos

Objectives

To evaluate the utility and effectiveness of hysteroscopic retrieval of intrauterine devices (IUDs) in early pregnancy.

Subjects and methods

We followed-up four pregnant women with IUDs with retracted tails removed by hysteroscopy before 10 weeks of pregnancy from 2003 to 2005.

Results

After hysteroscopy, pregnancy course was successful in three women, without complications that could be attributed to the procedure. There was one abortion due to rupture of fetal membranes at 15 weeks’ gestation.

Conclusions

The application of hysteroscopy in pregnancy has always been limited. In all patients, a possible optic nerve lesion in the fetus should be evaluated. This technique should not be performed after the 10th week of pregnancy. In most patients, pregnancy continues without complications after IDU removal.     

Embarazo ectópico: de la cirugía de urgencia al tratamiento médico. Evolución de la terapéutica en nuestro centro

Objective

To analyze changing trends in the management of ectopic pregnancy in the previous 9 years.

Material and methods

We performed a retrospective study of 355 patients with ectopic pregnancy treated at the Virgen de las Nieves University Hospital from 1998 to 2006. We reviewed and analyzed changes in treatment trends over this 9-year period.

Results

Medical treatment was initiated in 139 patients (39.15%), with a failure rate of 10.07%. Surgery was performed in 230 women (60.85%). Of these, laparoscopy was performed in 121 and laparotomy in 109.

Conclusions

Laparoscopic surgery is currently the first-line therapeutic option in the management of tubal ectopic pregnancy. However, in the last few years, medical treatment has been shown to be safe and effective, allowing a less invasive approach.     

Hemopatías malignas en el embarazo

Objective

To analyze the incidence of hematological malignancies, their obstetric and medical management, and maternal and perinatal outcomes in pregnant women.

Subjects and methods

Medical histories were reviewed, and all cases of women diagnosed with hematologic malignancies during pregnancy from 2000 to 2005 were analyzed.

Results

We found five cases (two leukemias and three lymphomas, two of which were Hodgkin's disease), in distinct trimesters of pregnancy. The women consulted mainly because of B symptoms. Blood tests and histological data were highly variable. In all patients, complete remission was achieved after proper staging and treatment.

Conclusions

Pregnancy does not alter the development of hematological malignancies. Long-term disease-free survival is similar in both pregnant and non-pregnant women with the same disease.     

Anticoagulación en gestantes portadoras de prótesis mecánicas

Objective

To study distinct anticoagulation regimens in pregnant women with prosthetic heart valves.

Subjects and methods

We performed a systematic review of the literature to determine the required levels of anticoagulation prophylaxis, timing of the introduction of oral anticoagulation and its substitution by heparins, and the maternal and fetal risks associated with different anticoagulation regimens.

Results

A target international normalized ratio (INR) of 2.5-3.5 should be achieved. Although consensus on the heparin of choice is lacking, heparin dose requirements should be based on anti-factor Xa levels (around 1.0 U/mL) or activated partial thromboplastin time (aPTT) (2-3 times control value). The risk of thrombosis in heparin-treated patients is approximately 7%, while the incidence of heparin embryopathy ranges from 1.6-7.4%. The switch from oral anticoagulation to heparin should be made no later than at weeks 35-36 of pregnancy.

Conclusions

The nticoagulation therapy of choice in the first trimester of pregnancy cannot currently be established. Prospective and randomized studies are required to determine the advisability of one treatment over the other     

Prevención del aborto

Objectives

To assess various social factors related to therapeutic abortion (voluntary pregnancy interruption [VPI], since the term therapeutic was traditionally used for abortions due to medical indication) with the aim of obtaining information in the context of the couple, the family and society.

Subjects and methods

Data were gathered through a personal interview performed in 1,600 patients who underwent VPI.

Results

A total of 26.9% of the patients were visiting a gynecologist for the first time. Most of the patients (84.3%) had said nothing to their parents and 12.9% had said nothing to their partners either. Three-quarters (76%) agreed with the possibility of having a VPI and with its legality; 18.3% were against.

Conclusions

Reducing the number and rate of abortions requires a more open understanding of both sex and sexuality, promoting a dialogue within the family and at school, as well as the design of complete education programs.     

Sífilis y embarazo: incidencia y evolución histórica en el área sur de Granada

Objective

To evaluate the prevalence of syphilis infection in pregnancy and the results of the management of this disease.

Material and methods

We performed a retrospective study of all cases of syphilis infection in pregnancy diagnosed and treated between January 1996 and December 2006 in the San Cecilio University Hospital in Granada.

Results

During the 11-year period studied, the overall incidence of syphilis infection in pregnancy was 2.42 × 10⁻⁰⁴ (seven cases), with three cases occurring in the final year.

Conclusions

In our area, the incidence of syphilis in pregnancy was higher than the average reported in other countries of a similar socioeconomic level (e.g. the USA with 1.1 × 100,000 pregnancies), possibly due to the increase in the immigrant population     

Disección aórtica aguda tipo A,una enfermedad catastrófica asociada al embarazo

Objective

To describe two fatal cases of type A acute aortic dissection associated with pregnancy.

Methods

We reviewed the medical records and autopsies of patients, and then identified some mechanisms linking this entity to pregnancy.

Results

Both deaths occurred in women aged less than 35 years at the end of gestation. One patient had aortic coarctation and bicuspid aortic valve, while the other had no risk factors.

Conclusion

Hemodynamic changes in the third trimester of pregnancy may be involved in the onset of this entity. Rapid diagnosis is essential to prevent its high associated mortality.     

Ensayo clínico controlado de la influencia del entrenamiento aeróbico en la tolerancia al ejercicio y los síntomas depresivos en primigestantes colombianas

Introduction

Depression in pregnancy affects almost 60% of pregnant women and several studies have shown that aerobic exercise can reduce depressive symptoms by increasing physical capacity. However, this effect has not been determined in pregnancy.

Objective

To evaluate the influence of aerobic training on exercise tolerance and depressive symptoms in Colombian nulliparous pregnant women.

Materiales and methods

We carried out a simple controlled trial in 80 nulliparous pregnant women, between 16 and 20 weeks of pregnancy, randomized to two groups. 1) The control group continued their usual activities, with no specific exercise regime. 2) The intervention group performed aerobic training between 50% and 65% of their maximal heart rate for 50 minutes, three times a week for 12 weeks. Exercise tolerance was assessed using the 6-minute walk test and symptoms of depression were assessed by the Center for Epidemiological Studies Depression Scale (CES-D) at baseline and immediately after the 3-month intervention.

Results

The mean age was 21 ± 3 years and gestational age was 18 ± 2 weeks. Seventy-four women completed the study. After the intervention, participants who exercised had a higher exercise tolerance, measured by the 6-minute walk test, and a greater reduction in depressive symptoms than the control group, as measured by the CES-D scale, P<.05.

Conclusions

A supervised 3-month program of primarily aerobic exercise during pregnancy reduces depressive symptoms and improves exercise tolerance. These results provide new evidence of the benefits of exercise in preventing maternal depression.     

Pronóstico y resultados en pacientes diagnosticadas de endometriosis a las que se les ha realizado por primera vez una cirugía conservadora por dolor o esterilidad

Objective

To analyze clinical outcomes in patients with suspected endometriosis undergoing conservative surgery. Pain reduction, pregnancy rates, and reinterventions were analyzed.

Material and methods

Patients with suspected endometriosis and symptoms of pain or infertility undergoing conservative surgery for the first time were included (n = 128). Exclusion criteria consisted of incomplete medical histories and interventions indicated for reasons other than pain or infertility.

Results

Surgery was indicated for pain in 70.3% and for infertility in 29.7%. A total of 32.5% of the patients had pain at the first postsurgical visit, 42.5% at 6 months and 58.3% at 1 year. Reintervention was performed in 11.29%. Among reinterventions for pain, there was a higher percentage of intestinal symptoms before surgery (P=.07), as well as episodes of abdominal pain requiring hospital care (P=.08); a higher proportion of these patients had pain in the first visit (P=.05) and at 1 year (P=.03) than patients not undergoing reintervention. Postsurgical medical treatment was less frequent in patients undergoing reintervention (P=.11). Among patients undergoing surgery for infertility, pregnancy was achieved in 65.8%.

Conclusions

Pain was less frequent in the first postsurgical visit than in subsequent visits. Among patients undergoing reintervention for pain, there was a higher percentage of intestinal symptoms and episodes of abdominal pain requiring hospital care prior to the intervention. Pain at the first visit and at 1 year are factors of poor prognosis for reintervention. Patients undergoing reintervention for pain less frequently required postsurgical medical treatment. More than half of patients with interfertility and endometriosis achieved spontaneous pregnancy after surgery.     

Pronóstico perinatal y materno de las gestaciones gemelares concebidas mediante fecundación in vitro,en relación con las obtenidas espontáneamente

Objective

To determine the outcomes of twin pregnancies resulting from in vitro fertilization (IVF) compared with those resulting from spontaneous conception.

Material and methods

We performed a historical cohort study comparing neonatal outcomes of twin pregnancies resulting from IVF (n = 44) with those resulting from spontaneous conception (n = 109) in the Complejo Hospitalario Universitario de Albacete (Spain) in 2001, 2001 and 2003. The primary variable was perinatal mortality. Secondary variables were fetal morbidity (neonatal abnormalities, Apgar < 7, acidotic arterial pH, admission to the neonatal unit), preterm delivery, maternal complications, and type of delivery.

Results

No differences in perinatal mortality and morbidity were found between spontaneous twin pregnancies and twins resulting from assisted reproductive techniques. The rate of preterm labor was significantly higher in spontaneous twin pregnancies (75.2 versus 52%; p = 0.006). The incidence of gestational diabetes was significantly higher in twin pregnancies resulting from IVF than in spontaneous twin pregnancies (25.5 versus 9.7%;p = 0.01).

Conclusions

Perinatal and maternal outcomes in twin pregnancies resulting from IVF are similar to those of spontaneous twin pregnancies.     

Factores etiopatogénicos de la prematuridad en el hospital universitario Sant Joan de Déu de Barcelona

Objective

To determine the rate of preterm births in 2010 at the Sant Joan de Déu University Hospital in Barcelona, and classify them according to the main cause by using a mapping algorithm to establish the main etiological causes of preterm birth.

Subjects and methods

All preterm births at less than 37 weeks’ gestation occurring in the Sant Joan de Déu University Hospital in 2010 (n = 396) were reviewed and assigned to a group according to their primary etiology.

Results

The preterm birth rate was 9.8%. Inflammatory causes accounted for 36% of all preterm births followed by idiopathic causes (29%). In preterm deliveries of multiple gestations, inflammatory causes accounted for 44%.

Conclusions

Inflammatory causes are the main etiology of preterm births and are more common in multiple gestations.     

Éxito del tratamiento de las infecciones urinarias en gestantes tratadas con cefditoren pivoxilo vs. amoxicilina

Objectives

To compare the efficacy of cefditoren pivoxil versus amoxicillin in the treatment of urinary tract infections (UTI) and to evaluate the rate of reinfection and of maternal-fetal complications in both groups.

Material and methods

We performed a cohort study in pregnant women with a diagnosis of UTI in the Vall d’Hebron Hospital from January, 2010 to June, 2010. Diagnosis, follow-up and subsequent evaluation of the mother and infant were performed in both groups.

Results

We included 300 pregnant women diagnosed with a UTI: 150 patients received oral cefditoren pivoxil (400 mg/12 hours for 5 days) and 150 women received amoxicillin. No demographic differences were observed between the two groups. Disappearance of the infection was confirmed in 150 patients in the cefditoren pivoxil group versus 67% of those in the amoxicillin group (P=.03). Both the reinfection rate and the frequency of pyelonephritis were higher in the amoxicillin group [17.3% versus 4.6% (P=.02) and 40.6% vs 2.6% (P=.01) respectively]. There were no differences in hospital stay (2.4 days vs 2.5 days). Adverse effects were observed in 1.33% (two patients) in the cefditoren pivoxil group versus 0% in the amoxicillin group.

Conclusions

In this study, cefditoren pivoxil produced a higher cure rate and a lower reinfection and pyelonephritis rate than did amoxicillin. Cefditoren pivoxil might be a therapeutic alternative in pregnant women with UTI. Further studies are needed to confirm these results.