Anomalías congénitas disruptivas asociadas con misoprostol. Reporte de un caso / Disruptive congenital anomalies associated with misoprostol. Case report

Resumen ANTECEDENTES: La exposición prenatal al misoprostol puede asociarse con un espectro de defectos congénitos que varían desde anomalías del sistema nervioso central, secuencia de Moebius, defectos en la pared abdominal, defectos transversales en las extremidades hasta alteraciones fetales. Esos defectos se observan más comúnmente con esquemas de solo misoprostol para inducción del aborto. Por esos antecedentes es importante que la historia clínica de toda paciente obstétrica sea exhaustiva para permitir identificar el antecedente de la exposición prenatal luego de un aborto fallido. CASO CLINICO: Paciente de 21 años, con 32 semanas de embarazo, con diagnóstico de feto con ventriculomegalia. En la evaluación ecográfica destacó la ventriculomegalia triventricular severa, simétrica y la angulación de ambas extremidades inferiores en varo. La resonancia magnética reportó: ventriculomegalia no comunicante severa, bilateral, simétrica, por probable estenosis del acueducto de Silvio. Cariotipo 46,XY y perfil TORCH negativo. El embarazo finalizó mediante cesárea, por indicación fetal a las 35 semanas. La evaluación al nacimiento reportó: parálisis facial bilateral, macrocefalia y pie equino varo bilateral. Al volver a interrogar a la paciente refirió haber sido tratada con misoprostol en el primer trimestre del embarazo, con fines abortivos. Al descartar las alteraciones cromosómicas e infecciosas se estableció el diagnóstico de secuencia Moebius. CONCLUSIONES: La exposición prenatal al misoprostol está relacionada con la aparición de defectos vasculares en algunos fetos expuestos. Aún no se ha determinado el espectro preciso ni la estimación potencial de teratogenicidad. La historia clínica es el pilar para la asociación en estos casos.

Abstract BACKGROUND: Prenatal misoprostol exposure can be associated with a spectrum of birth defects, ranging from central nervous system abnormalities, Moebius sequence, abdominal wall defects, as well as transverse limb defects, fetal abnormalities are more commonly seen with the use of the misoprostol-only regimen for induction of abortion, such that a thorough medical history is essential to detect a history of prenatal exposure after a failed abortion. CLINICAL CASE: A 21-year-old patient, with a 32-week pregnancy, who attended the institute with a diagnosis of a fetus with ventriculomegaly, the ultrasound evaluation highlighted severe symmetric triventricular ventriculomegaly and angulation of both lower extremities in varus, magnetic resonance imaging reported severe non-communicating ventriculomegaly Symmetric bilateral, due to probable stenosis of the aqueduct of Silvio, the karyotype reported 46, XY, as well as a negative TORCH profile, however, a cesarean section was performed for fetal indication at 35 weeks, the evaluation at birth showed bilateral facial paralysis, macrocephaly and foot Bilateral equinus varus, upon re-examination the patient referred the use of misoprostol in the first trimester of pregnancy for abortive purposes, so as there were no chromosomal or infectious alterations, a Moebius sequence was suggested. CONCLUSIONS : Prenatal exposure to misoprostol is related to the appearance of vascular disruption defects in some exposed fetuses, the precise spectrum and potential estimation of teratogenicity have not yet been determined, the clinical history is the mainstay for the association in these cases.

Use of a screening questionnaire for systemic lupus erythematosus among pregnant women in a Mexican population.

OBJECTIVE: To conduct a diagnostic assessment of pregnant women using a screening questionnaire for SLE. MATERIALS AND METHODS: This was an analytical cross-sectional study carried out at the National Institute of Perinatology between 1 November 2019 and 28 February 2020, using a screening questionnaire for SLE. Antinuclear antibody and anti-double stranded DNA antibody tests and a clinical assessment by a rheumatologist were conducted for participants who obtained ≥4 positive responses on the questionnaire. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the screening questionnaire for SLE were calculated. RESULTS: The questionnaire survey was conducted with 540 pregnant patients, 22 of whom (4.1%) had ≥4 positive responses. An antinuclear antibody test was conducted in all aforementioned 22 patients; 17 (77.3%) showed titres of ≥1:80. Of the 22 patients, 19 (86.4%) underwent clinical assessment by a rheumatologist. The patients were classified according to the SLE classification criteria: 7/19 (36.9%) met the revised 1997 American College Rheumatology (ACR) criteria, 8/19 (42.1%) met the Systemic Lupus International Collaborating Clinics criteria and 7/19 (36.9%) met the 2019 ACR/EULAR criteria (sensitivity=0.86, specificity=0.97, PPV=0.77 and NPV=1 for antinuclear antibody titre of ≥1:80; sensitivity=0.88, specificity=0.98, PPV=0.37 and NPV=1 for SLE according to the 2019 ACR/EULAR criteria). CONCLUSIONS: The questionnaire showed high sensitivity and specificity in the diagnosis of SLE. Given its usability and cost:benefit ratio, this strategy should be used for all patients coming in for their first visit to determine who requires antinuclear antibody testing and who needs to be referred to a rheumatologist.

Transcervical chorionic villus sampling in a low-cost simulation model: Learning curve of maternal-fetal medicine fellows in Mexico.

The implementation of a low­cost simulation model and cumulative sum analysis enables training and monitoring of individual learning curves for transcervical chorionic villus sampling.

Acute kidney injury in pregnancy and the role of underlying CKD: a point of view from México.

The incidence of acute kidney injury in pregnancy (P-AKI) in developed countries is significantly lower than in developing ones, where it is estimated to range between 4 and 26%. Mortality in cases of P-AKI requiring dialysis is high, varying from 20 to 80%. In developing countries, clinical decisions are often based on the availability of services and not on needs. Prenatal surveillance in Mexico does not include serum creatinine, limiting the potential for early diagnosis of AKI and CKD and their differential diagnosis. There are few specialized centers for the care of a pregnancy complicated with kidney disease in Mexico. P-AKI superimposed on preexistent, and usually undiagnosed CKD, is common: in Guadalajara 10 out of the 27 patients with Stage 3-5 CKD or nephrotic proteinuria, that were followed in 2013-2015, required renal replacement therapy (RRT) in pregnancy; in the same period in Mexico City out of 18 patients with P-AKI requiring dialysis, 5 remained dialysis dependent, 3 started dialysis in the following year after their pregnancy and only 1 fully recovered renal function. The grim prognosis is exacerbated by the fact that 70% of Mexicans are not reimbursed for dialysis, and pregnancy-related coverage lasts for only 42 days after delivery. Perinatal results are no less troubling, as most patients with P-AKI give birth preterm to small or very small babies. While our data do not allow us to evaluate needs, they do make it possible to define the complexity of the problems faced in the care of P-AKI in Mexico. Early diagnosis of P-AKI and chronic kidney disease (CKD) is needed to protect mothers and children and the country urgently needs programs to enable it to fulfil the World Health Organization's imperative that we "make every mother and child count".

Controversies concerning the antiphospholipid syndrome in obstetrics. / Controversias del síndrome de anticuerpos antifosfolipídicos en obstetricia.

Antiphospholipid antibody syndrome is a non-inflammatory autoimmune disease characterized by recurrent thrombotic events and/or obstetric complications associated with the presence of circulating antiphospholipid antibodies (anticardiolipin antibodies, anti-ß2 glycoprotein-i antibodies, and/or lupus anticoagulant. Antiphospholipid antibodies are a heterogeneous group of autoantibodies associated with recurrent miscarriage, stillbirth, fetal growth restriction and premature birth. The diversity of the features of the proposed placental antiphospholipid antibodies fingerprint suggests that several disease processes may occur in the placentae of women with antiphospholipid antibody syndrome in the form of immune responses: inflammatory events, complement activation, angiogenic imbalance and, less commonly, thrombosis and infarction. Because of the disparity between clinical and laboratory criteria, and the impact on perinatal outcome in patients starting treatment, we reviewed the aspects of antiphospholipid antibody syndrome related to obstetric complications and seronegative antiphospholipid antibody syndrome, and their treatment in obstetrics.

Amniotic band sequence: prenatal diagnosis, phenotype descriptions, and a proposal of a new classification based on morphologic findings.

OBJECTIVE: The aim of this study is to describe the phenotype of fetuses affected by amniotic band sequence (ABS) that were diagnosed at the Instituto Nacional de Perinatología Isidro Espinosa de los Reyes and to propose a new classification based on morphologic findings. MATERIAL AND METHODS: Cases with a final diagnosis of amniotic band sequence, diagnosed between January 1993 and July 2010 in the Department of Maternal Fetal Medicine, were reviewed. Demographic, clinical, and periconceptional data were collected, and the defects were described and classified. The association frequencies of the defects were also determined. RESULTS: We included 50 cases with prenatal diagnosis of amniotic band sequence. The mean maternal age was 25.7 ± 6.9 years. Of these patients, 54% (27/50) were primiparous compared to 22% (11/50) who had three or more previous pregnancies. Craniofacial defects were seen in 78% (39/50) of the cases, followed by defects of the extremities 70% (35/50), abdominal wall, spine, and/or thorax 52% (26/50). The most frequent defects were the following: a) Encephalocele and facial clefts in the craniofacial group. b) Shortening at any level in the limb defects group, and c) Alterations of the spinal column curvature in the group of "other" defects. CONCLUSIONS: The amniotic band sequence shows a tendency to affect women who are in their earlier years of reproduction. We observed an inverse relationship between the number of pregnancies and the frequency of presentation of this pathology. The majority of affected fetuses showed a phenotype that fit into one of many groups. Therefore, we propose classifying the amniotic band sequence phenotypes into the following groups: I. Craniofacial defect + limb defect. II. Craniofacial defect + limb defect + abdominal wall, spinal column, and/or thoracic defects. III. Limb defect + abdominal wall, spinal column, and/or thoracic defects; and IV. Isolated defect (craniofacial, limb, or thoraco-abdominal wall). This classification system will be helpful in diagnosing amniotic band sequence. Based on future research studies, we hope that we can use this classification system as a prognosis fetal factor to establish a more accurate fetal prognosis and recurrence probability. Finally, we created a flowchart describing all of the steps that were followed by our Department from the moment an amniotic band was found by ultrasound until the definitive diagnosis was made and the follow up according to the fetal findings.

Major craniofacial defects: case series and prenatal diagnosis at the Instituto Nacional de Perinatología, Mexico.

OBJECTIVE: To describe the prenatal diagnosis, characteristics, development, perinatal outcome, and final diagnosis of pregnancies complicated by fetuses with major craniofacial defects, at the Instituto Nacional de Perinatologia, México, 1997-2008. MATERIAL AND METHODS: A retrospective, descriptive study from January of 1997 to January 2008, analyzed 152 pregnancies complicated by fetuses with major craniofacial defects, diagnosed at the Department of Fetal Medicine of the National Institute of Perinatology. Data were obtained from patients clinical records. RESULTS: . The mean age was 28 +/- 8 years, with the largest number of cases between 20 and 24. The mean gestational age at diagnosis was 27.5 +/- 6.4 gestational weeks. The average termination of pregnancy was at 35 +/- 5 gestational weeks. In 43.4% of cases there were no major structural defects associated with the facial defect. The most commonly associated structural alterations were cerebral, cardiac, and limb abnormalities. Karyotyping was performed in only 57 cases, and was abnormal in 25. CONCLUSIONS: Structural ultrasound should be performed on all pregnant women between weeks 18 and 24 for detection of major craniofacial defects. Where defects are found, a thorough review of other structures should be carried out to determine whether the defects are syndromic. A systematic and multidisciplinary approach is essential to providing the best care and appropriate advice to parents.

[Diffuse cavernous hemangioma of the uterus diagnosed during pregnancy. Case report]. / Hemangioma cavernoso difuso del utero diagnosticado durante el embarazo. Reporte de un caso.

We report the case of a pregnancy of 16 weeks with anemia and a presumptive diagnosis of partial mole. In secondary care this diagnosis was ruled out through ultrasonography and diffuse cysts were found in the myometrium. Spectral Doppler ultrasound showed no flow, but it could be observed with power angiography. Cesarean section was performed at 38 weeks and hysterectomy 24 hours after because of intra-abdominal hemorrhage. Power angiography, spectral Doppler and serum human chorionic gonadotropin are the most useful diagnostic tools in the differential diagnosis of diffuse cavernous hemangioma of the uterus. Postpartum hemorrhage is a likely complication.

[Application of a technique to establish criteria for uterine length measurement]. / Aplicación de un método para establecer los criterios de la medición del fondo uterino.

BACKGROUND: The uterine length measurement is a routine practice in the prenatal care of pregnant women. It has been attributed a sensibility of 86% to detect fetal grown restriction. The technique is easy to perform and reproducible between observers, although we have found variation between intra- and inter-observers measurements. OBJECTIVE: To evaluate the useful of a maneuver to improve the reliability of the uterine length measurement in a group of obstetrics residents. MATERIAL AND METHODS: The measurement was performed on pregnant women. The results were analyzed by intraclass correlation coefficient to evaluate the concordance between observers based in a variance analysis model (ANOVA) of repeated measurements. RESULTS: There were not differences between groups about demographic variables. All residents improve the reliability in their measurements. The intra-class correlation coefficient was 0.77 (confidence interval 0.63-0.88) before the maneuver, and after this one the intra-class correlation coefficient improved to 0.96 (confidence interval 0.92-0.98). CONCLUSION: The uterine measurement following detailed indications improve the interobserver concordance. We think it is advisable to evaluate the use of this maneuver in a routine way in our institute and in other places that bring prenatal care.

[Perinatal results of the patients assessed by fetal hypomotility]. / Resultado perinatal de las pacientes evaluadas por hipomotilidad fetal.

OBJECTIVE: To describe the perinatal outcome of those patients that come to emergency room because of diminished fetal movements. PATIENTS AND METHOD: This is a case series in which we evaluated the patients who were attended at the Maternal Fetal Medicine Department from January 2002 to December 2003. All patients with prenatal control in the institution whatever the basic pathology were enrolled in the study. They were evaluated following the institution protocol. All data was obtained from maternal and neonatal files. RESULTS: A total of 240 patients with mean age of 27 +/- 7 (SD) years were evaluated in the study. Ninety of them (37%) were primiparous, 66 (27%) secundiparous, and 44 (18%) coursed the third pregnancy. Mean gestational age when they were evaluated for diminished fetal movements was 37.1 +/- 2.5 (SD) weeks. After the evaluation, 195 (81%) patients resulted with a reactive non-stress test, 42 (17%) had a non-reactive stress test with a positive vibroacoustic stimulation test, no patients were found with a non-reactive non-stress test and a negative vibroacoustic stimulation test. In two patients (< 1%) the register showed ominous pattern. In these two preterm cases pregnancy was interrupted. Mean gestational age at birth was 39.1 (+/- 1.7) weeks, and 223 (92.91%) born at term. From the two intervened cases, one had intrauterine growth restriction and the other asphyxia with intraventricular hemorrhage as a consequence. CONCLUSIONS: Hypomotility is one manifestation of the loss of fetal well-being and cannot be ignored because there are some cases in which intervention is needed. A great number of patients without a real risk of asphyxia and with a good perinatal outcome must be evaluated, so we have to look for another mechanism of evaluation for these patients. A clinimetric method could be an intermediary step between clinic and electronic surveillance.

[Thoracoamniotic shunts and thoracocentesis in fetal therapy]. / Derivaciones toracoamnióticas y toracocentesis en el tratamiento fetal.

BACKGROUND: The not heart thoracic anomalies are caused by different abnormalities in the embryonic period with similar physiopathologic mechanisms. The prenatal treatment by means of decompression can improve substantially the clinical results in these patients. OBJECTIVE: To evaluate, in a qualitative way, the effect of the thoracoamniotic shunts and thoracocentesis in the perinatal outcome in fetuses with not heart thoracic anomalies. METHODS: Twenty-two articles were revised describing 308 cases of fetuses with congenital cystic adenomatoid malformation (CCAM), 25 cases of hydrothorax and 55 cases of broncopulmonary sequestration (BPS). We analyzed the adverse prognostic factors that indicated the treatment election in uterus as well as complications and perinatal outcome. RESULTS: Of the 388 cases of not heart thoracic anomalies, 250 fetuses were managed conservatively, and in 102 fetuses handling in uterus was started. Hydrops was identified as the worst prognostic factor to these fetuses, with a survival rate of 55.7%. The global survival was of 56.5% (155 cases) in the fetuses with CCAM, 98.1% (52 cases) in the fetuses with BPS and of 80% (20 cases) in the fetuses with hydrothorax. CONCLUSIONS: When having a fetus with some of these pathologies, it should be evaluated in an individual and integral way; according to the gestational age when diagnosed, as well as the type of lesion and the presence or absence of fetal dropsy to decide between fetal therapy or expectant handling.

[Doppler ultrasound to detect Rh: a systematic review]. / Ultrasonido doppler para detección rh: una revisión sistemática.

BACKGROUND: Red cell alloimmunization is an important cause of perinatal morbidlity and mortality. Invasive procedures used to diagnose fetal anemia are associated with serious fetal and maternal complications. The development of noninvasive techniques as Doppler ultrasound can help us in the fetal anemia diagnosis. OBJECTIVES: To evaluate the effect of the Doppler ultrasound in prediction of fetal anemia caused by red cell alloimmunization. Strategy search: Relevant studies were identified by reviewing the registry of COCHRANE, and OVID, PROQUEST, MEDLINE and EMBASE data bases from 1966 to 2004. SELECTION CRITERIA: All prospective studies with clinically relevant results with comparison of Doppler ultrasound in fetal umbilical artery, fetal descendent aorta, middle cerebral fetal artery or esplecnic fetal artery with hemoglobin or fetal hematocrit. DATA COLLECTION AND ANALYSIS: Data were extracted from each report. The quality revision of the studies and the data compilation were made by the reviewers. MAIN RESULTS: Eighteen articles were included. Two studies reached the level of evidence 1 for diagnostic tests. The diagnostic tests had variations depending on the different cut-off of each study. Studies with level 1 of evidence reported detection of 100% for moderate to severe fetal anemia. CONCLUSIONS: Implementation of Doppler ultrasound for prediction of fetal anemia in complicated pregnancies with alloimmunization could reduce the number of invasive procedures and therefore its complications. The level of present evidence reveals to us that the studies do not fulfill the criteria of methodological quality.

[Perinatal mortality: a proposed analysis]. / Mortalidad perinatal: una propuesta de análisis.

Perinatal mortality is an epidemiologic indicator that evaluates materno-infantil quality care indirectly. Obtaining rates of perinatal mortality from continuous and confident information systems allow us a more precise evaluation of quality care in developed countries. In developing countries as Mexico, there aren't yet evaluating health programs that let us to know the actual situation of our medical care. Being the main mistake subregister problems in regional and national perinatal mortality case. All this let us to a not optimum use of the limited resources given for health. The aim of this paper is to propose an analysis way into this matter for knowing our institutional and national situation. This would permit us to suggest effective strategies in the prevention of obstetric complications as in the preterm birth case. The main objective is to prevent death in the perinatal period.

Estudio de las anomalías congénitas: utilidad de la amnioinfusión en la evaluación del embarazo con oligohidramnios severo-anhidramnios / Usefulness of amnioinfusion in server oligohydramnios-amnioinfusion

La infusión intra-amniótica de solución salina ha sido propuesta en los embarazos con oligohidramnios severo o anhidramnios para mejorar el diagnóstico ultrasonográfico en caso de anomalías estructurales; confirmar o exlcuir la ruptura de membranas; y determinar el cariotipo fetal. Se presenta la experiencia con 76 amnioinfusiones prenatales, realizadas en 65 embarazadas con diagnóstico de oligohidramnios severo o anhidramnios con edad gestacional media de 24.4 semanas; se describen los diagnósticos previos y posteriores a las amnioinfusiones. El procedimiento fue exitoso en 71 casos (93.4 por ciento) con la infusión de un volumen medio de 187.3 ml. de solución salina. Antes de la amnioinfusión se realizaron 87 diagnósticos de sospecha de los cuales 77 fueron confirmados post-amnioinfusión (88.5 por ciento), los hallazgos incluyeron: 65 alteraciones estructurales, 8 retardos en el crecimiento y 4 rupturas de membranas. Los diagnósticos excluidos correspondieron a 6 rupturas de membranas y 4 anomalías estructurales. El grupo de anomalías no sospechadas previamente y diagnosticadas post-amnioinfusión incluyó 25 estructurales y 7 cromosómicas. Dentro de las complicaciones se presentaron 7 casos de ruptura prematura de membranas. Se discuten las contribuciones de la amnioinfusión en el diagnóstico prenatal, enfatizando su utilidad para determinar un pronóstico y decidir la conducta más apropiada. Se concluye señalando el papel importante de este procedimiento en la evalución del embarazo con oligohidramnios severo o anhidramnios. Finalmente, se recomienda hacer esfuerzos en futuras investigaciones para establecer una evaluación adecuada y completa acerca de los beneficios y riesgos de este procedimiento diagnóstico, antes de su incorporación a la práctica clínica