Rotura prematura de membranas pretérmino: consideraciones y controversias

We report a case of preterm premature rupture of membranes in a diamniotic dichorionic twin pregnancy at the limit of fetal viability. Expectant management was adopted. After 3 weeks of latency the pregnancy ended in chorioamnionitis. The patient delivered two girls whose neurodevelopment seems to be satisfactory at 1 year of follow-up. There are several unresolved controversies about the optimal management of these cases, especially when rupture of membranes occurs at the limit of fetal viability. There is no agreement about the right time to end pregnancy. This case also highlights the complexity of the follow-up of this complication in multiple pregnancies and the need for specific protocols to be developed.     

Amnioinfusión en rotura prematura de membranas en gestaciones pretérmino

Objective

To study the possibility of prenatal amnioinfusion as a therapeutic measure in premature rupture of membranes in preterm pregnancies.

Material and methods

We performed serialized transabdominal amnioinfusions in two patients with premature rupture of membranes in preterm pregnancy. Ringer's solution was instilled by abdominal puncture.

Results

We performed serialized transabdominal amnioinfusions until the 23rd week of pregnancy, after which time both patients showed normal amniotic fluid.

Conclusions

Transabdominal amnioinfusion is a valid therapeutic option in premature rupture of membranes in preterm pregnancy.     

Cribado de parto pretérmino en el primer trimestre de la gestación

First-trimester combined screening for preterm delivery and the early initiation of preventive strategies in high-risk patients can effectively reduce preterm delivery rates.     

Rotura uterina espontánea durante el segundo trimestre asociado a placenta pércreta. Caso clínico y revisión de la literatura

We report a case of histologically-confirmed uterine rupture due to placenta percreta at 20 weeks of gestation. We provide a review of case reports of this event occurring at less than 28 weeks of pregnancy.     

Desarrollo evolutivo infantil,patología obstétrica y repercusión sociofamiliar en nacidos antes de la semana 29

Objectives

To determine the outcomes of infants born at less than 29 weeks’ gestation, obstetric abnormalities, and the social and familial repercussions of this prematurity.

Material and methods

We retrospectively studied 28 infants, born at less than 29 weeks’ gestation, referred to the Early Healthcare Program of the Cantabrian Government between January 2002 and June 2006.

Results

The main causes of prematurity in this group were chorioamnionitis, placental abruption, and preterm labor. Of the infants studied, 28.57% had a disability. Severe mental retardation and cerebral palsy was found in 37% and moderate mental retardation in 24%. Bilateral hypacusis, respiratory alterations and mild mental retardation were found in the remainder. The main social repercussions were a change in family roles, negative economic effects, and heavy emotional burden.

Conclusions

A total of 28.57% of the infants studied had a recognized disability. No predominant obstetric abnormality was identified. However, the social and familial repercussions were substantial.     

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.     

Utilidad de la prueba de la fibronectina fetal y de la longitud del cérvix en la predicción del parto prematuro en gestantes sintomáticas

Objective

To evaluate the usefulness of fetal fibronectin and cervical length in predicting preterm birth in women with preterm uterine contractions.

Material and methods

A prospective study was conducted at the Virgen Macarena Hospital in Seville that included 153 pregnant women with suspected preterm labor and intact membranes. Cervical length was measured by transvaginal sonography and a rapid qualitative fibronectin test was performed in the emergency consultation. Women with a negative fibronectin test and cervical length ≥ 30 mm were not hospitalized or treated with tocolytics or corticosteroids.

Results

The mean gestational age at diagnosis was 223,02 ± 19,98 days, and 267,52 ± 14,15 days at delivery. Preterm birth < 37 weeks rate was 23% and 7,4% for deliveries < 35 weeks. There is an association between cervical length < 30 mm and birth < 37 weeks (OR, 3,68; 95% CI, 1,53-8,84), and with delivery in the following 14 days (OR, 3,35; 95% CI, 1,30-21,95). With the association of both tests we gain specificity in predicting preterm birth.

Conclusion

Cervical length is the test with higher specificity (E) and negative predictive value (VPN) for the prediction of preterm birth in women with symptomatic contractions.     

Translucencia nucal y ductus venoso: valores de referencia en el primer trimestre de la gestación

Objective

To establish the reference ranges for nuchal translucency (NT) and ductus venosus (DV) pulsatility index for veins (PIV) in our population.

Methods

During a 4-year period, pregnancies originated from the general population undergoing 11.1-14.0 weeks ultrasound examination were studied. Reference intervals were constructed following the methodology described by the National Committee for Clinical and Laboratory Standards. According to the conclusion of the partition test, gestational age-related reference intervals were estimated using linear regression models for the NT. Deviances from linearity in the estimated models were evaluated using fractional polynomials of 1st or 2nd degree.

Results

2,612 pregnancies were studied. No significant differences were found for DV PIV between gestational age groups. There was a significant difference of the NT values between age groups (p < 0.001) and the gestational age-related estimation of reference intervals showed a no-linear increase.

Conclusion

A significant increase was found for NT with gestational age, whereas the DV PIV remained constant.     

Rotura de cuerno uterino rudimentario en gestación de 22 semanas. A propósito de un caso y revisión de la literatura

Unicornuate uterus with rudimentary horn is a rare Müllerian anomaly with a high incidence of obstetric complications, affecting 4.5% of women. Pregnancy located in the rudimentary horn occurs in 1 in 76,000 pregnancies with a risk of uterine rupture of 50-80%. Rupture usually occurs at the end of the second trimester of pregnancy. Early diagnosis reduces morbidity and mortality, but ultrasound diagnosis has a sensitivity of only 30%, due to the low prevalence of this entity.     

Neonatos pretérmino tardíos y a término precoces: una población de riesgo

Recently the number of premature newborns (< 37 weeks) has substantially increased worldwide. The prognosis of these neonates has been greatly improved by prenatal (corticosteroids) and postnatal (pulmonary surfactant) therapies. Consequently, almost unconsciously, obstetricians have moved the cut-off for prematurity to the 34^th week, thus promoting an increase in iatrogenic prematurity.     

Cribado de aneuploidía en gestación gemelar: resultados de la aplicación del test combinado

Objective

To evaluate the effectiveness of the Combined Test for trisomy 21 screening in twin pregnancies. To assess the performance of biochemical markers and nuchal translucency (NT) measurement in pregnancies with euploid fetuses and in twin pregnancies with one or two affected fetuses. To compare the value of markers according to chorionicity and the mode of conception.

Material and methods

Retrospective study including 161 twin pregnancies. Maternal serum fß-hCG and PAPP-A were determined at 8 to 12 weeks and fetal NT was measured at 11 to 14 weeks. The individual risk of trisomy 21 was calculated in each fetus using the Combined Test. In monochorionic pregnancies, the single risk for the pregnancy was obtained with the largest NT. An invasive diagnostic procedure was offered when the risk was 1:250 or more in one or both of the fetuses.

Results

All trisomy 21 pregnancies were identified (three pregnancies and four fetuses) by the combined testfor a false-positive rate of 6.4% of pregnancies and 3.5% of fetuses. The median fß-hCG level, expressed in MoM, was 1.72 and the median PAPP-A level was 2.01. The median NT was 1.05 MoM. Both fß-hCG and PAPP-A levels were significantly decreased in monochorionic pregnancies and PAPP-A was significantly decreased in pregnancies resulting from assisted reproduction. No significant differences were observed in NT measurement between monochorionic and dichorionic fetuses or between those conceived naturally or by assisted reproduction.

Conclusions

The combined test shows high sensitivity and specificity in screening for trisomy 21 in twin pregnancies. The differences obtained in the biochemical markers according to chorionicity or the mode of conception require confirmation in further studies with a larger number or cases.     

Inicio de un síndrome de Guillain-Barré durante la gestación

We present the case of a pregnant woman who developed severe Guillain-Barré syndrome in the third trimester and who required admission to the intensive care unit of the referral hospital for suspected disease progression. No clinical improvement was observed. Because the onset of diaphragm paralysis was suspected and the fetus was in the podalic position, emergency cesarean was performed. Given the rarity of onset of Guillain-Barré syndrome in pregnancy, we review this entity to improve knowledge of maternal and fetal management.     

Manejo conservador y seguimiento ecográfico de hematoma en el área Retzius y la fosa isquiopubiana tras malla vía transobturadora

Complications after surgery to correct incontinence by using transobturator vaginal tape are highly uncommon and consequently there are no established protocols for their management and monitoring. We report a case of a large hematoma after placement of TVT-O, in which we chose conservative management using conventional and 3-dimensional ultrasound to monitor this complication, with highly satisfactory results.     

Análisis comparativo de dos protocolos de misoprostol en abortos de segundo trimestre de la gestación

Objective

To compare the mean induction-expulsion times in two regimens of vaginal misoprostol for second-trimester pregnancy termination.

Material and methods

We performed a retrospective study of 281 pregnancies between January 2000 and December 2005 (regimen A: 800 μg /24 h) and between June 2007 and December 2008 (regimen B: 400 μg /4 h). Induction-expulsion time was taken as the main outcome.

Results

The mean expulsion time was similar in both regimens (19.7 h for A and 17.7 h for B). No significant differences were found in the expulsion rate at 12, 24 and 48 h. The most commonly observed adverse effect was fever, which was more frequent in regimen B. No major adverse effects such as uterine rupture or severe hemorrhage were observed.

Conclusions

No significant differences were found between regimens A and B in the mean fetal expulsion time, although fever was more common in regimen B.     

Hiperplasia ductal atípica de mama: correlación de la biopsia percutánea y los resultados de la biopsia quirúrgica

Objetive

The purpose was to evaluate the prevalence of carcinoma found at surgical biopsy of llesions identified as atypical ductal hyperplasia by percutaneous breast biopsy.

Methods

We performed a retrospective study of all asymptomatic patients with a result of atypical ductal hyperplasia on percutaneous breast biopsy and who underwent surgical excision from January 2002 to December 2010.

Results

Sixty-eight patients were found to have atypical ductal hyperplasia at percutaneous breast biopsy and were evaluated with surgical biopsy. Seventeen patients (25%) had carcinoma at surgical excision, 10 had ductal carcinoma in situ, and 7 patients had invasive carcinoma. The mammographic characteristics associated with malignancy were analyzed.

Conclusions

A finding of atypical ductal hyperplasia at percutaneous breast biopsy frequently corresponds to cancer and is therefore an indication for surgical excision.     

Diagnóstico ecográfico de quistes del cordón umbilical en el primer trimestre de la gestación

Although umbilical cord cysts are a relatively frequent entity they cannot be considered a nonpathological sonographic finding. In the first trimester pregnancies the prevalence of umbilical cord cysts has been reported about 3%. Sometimes are associated to other chromosomal and/or structural abnormalities. If they are persistent and progressive in the size, could restrict the fetal sanguineous flow.     

Constricción prematura del ductus arterioso: consecuencias del consumo excesivo de té negro y de hierbas

Intrauterine constriction of ductus arteriosus is a rare event which often results in severe fetal/neonatal morbidity and mortality. Fetal ductus constriction is usually associated with maternal exposure to non-steroidal anti-inflammatory drugs or structural cardiac lesions. The prognosis depends on the degree and interval of ductal flow obstruction. Detailed history taking is generally required to identify the cause of this diagnosis.     

Influencia de la edad y de las técnicas de reproducción asistida en nuestros resultados obstétricos y perinatales

Objective

To evaluate the influence of age ≥ 40 years and ART in our obstetric and perinatal outcomes.

Material and methods

Retrospective study of 14805 singleton pregnancies in our Institute from January 1, 2000 to December 31, 2006. We compared obstetric and perinatal outcome between: Age group: women ≥ 40 years (N = 557) vs. group of women < 40 years (N = 14248); ART group < 40 years: ART pregnancies (N = 1150) vs. spontaneous pregnancies (N = 13098); ART group ≥ 40 years: ART pregnancies (N = 126) vs. spontaneous pregnancies (N = 431).Results: Age ≥ 40 years is significantly associated with preterm birth under 34 weeks (odds ratio [OR] = 2.148 [1.237-3.730]), gestational diabetes (OR = 2.25 [1.799-2.815]), placenta previa (OR = 3.346 [1.516-7.386]), caesarean delivery (OR = 1.831 [1.539-2.177]), and peripartum hysterectomy (OR = 6.414 [1.359-2.177]). In the ART group < 40 years assisted conception (ART) is significantly associated with preterm birth under 37 (OR = 1.67 [1.337-2.088]) and 34 weeks (OR = 1.8 [1.162-2.822]), with gestational diabetes (OR = 1.5 [1.273-1.844]), pre-eclampsia (OR = 2.1 [1.456-3.164]), placenta previa (OR = 5.29 [2.973-9.437]), choriamniotic infection (OR = 3.8 [1.029-14.072]), caesarean delivery (OR = 1.5 [1.346-1.737]) and low birth weight ≤ 2500 g. (OR = 1.67 [1.329-2.114]) and ≤ 1500 g. (OR = 2.44 [1.442-4.135]). In the ART group ≥ 40 years we only find a significantly increased rate of caesarean delivery (OR = 1.76 [1.183-2.635]) in ART group vs. spontaneous pregnancy group.

Conclusions

Age ≥ 40 years increases the risk of adverse obstetric outcome. ART increase the risk of adverse obstetric and perinatal outcome in the group < 40 years, but not in the group of women aged 40 years and older, probably due to the small size of the sample.     

Hemocromatosis neonatal: resultado satisfactorio de la terapia con inmunoglobulina por vía intravenosa a partir de la semana 14 de gestación

Neonatal hemochromatosis is a rare congenital disease that causes severe liver failure, leading to a high mortality rate (80-90%). The cause remains unknown but the alloimmune hypothesis is gaining ground. Intravenous immunoglobulin therapy has been proven to be effective in ameliorating the consequences of this entity.     

Linfoma primario de cérvix: gestación tras tratamiento conservador

The cervix is a rare localization of lymphomas, with an incidence of 0.41- 0.6% of extranodal lymphomas. The initial symptom is usually vaginal bleeding. Diagnosis is made by biopsy. There is no standard treatment due to the low incidence of this tumor. Surgery causes irreversible loss of reproductive capacity.