Amniotic fluid lactic acid and matrix metalloproteinase-8 levels at the time of fetal surgery for a spine defect: association with subsequent preterm prelabour rupture of membranes.

OBJECTIVE: In utero fetal surgery to correct incomplete closure of the spinal cord lessens the extent of permanent damage but is associated with preterm prelabour rupture of membranes (PPROM). We determined whether compounds in amniotic fluid collected at the time of surgery predicted subsequent development of PPROM. DESIGN: Prospective study. SETTING: Hospitals in Sao Paulo, Brazil. POPULATION: Twenty-four consecutive pregnant women at 24-26 weeks of gestation seen between February and October 2017 with a singleton pregnancy underwent in utero surgery to correct an open spinal defect in their fetus. METHODS: Amniotic fluid was tested for lactic acid, matrix metalloproteinase 2 (MMP-2), MMP-8, MMP-9 and interleukin-6 (IL-6) by enzyme-linked immunosorbent assay. Clinical data were collected after completion of all laboratory studies. MAIN OUTCOME MEASURE: Amniotic fluid concentration of compounds in women with or without PPROM. RESULTS: Preterm prelabour rupture of membranes occurred in seven (29.2%) women. There were no differences in maternal age, gravidity, parity, race, history of caesarean sections or fetal gender between women with or without PPROM. Length of surgery, days of wound healing and length of hospital stay were also indistinguishable. The median concentrations of MMP-8 (1.7 versus 0.6 ng/ml; P = 0.0041) and lactic acid (7.1 versus 5.9 mm; P = 0.0181) were higher in women with PPROM. The amniotic fluid MMP-8 level was also negatively correlated with gestational age at delivery (Spearman r = -0.4217, P = 0.0319). CONCLUSION: Differences in susceptibility to develop PPROM are present before fetal surgery. An increase in anaerobic glycolysis, evidenced by the intra-amniotic lactic acid level, may enhance MMP-8 production and weaken maternal and fetal membranes. TWEETABLE ABSTRACT: Matrix metalloproteinase-8 and lactic acid in amniotic fluid predict preterm prelabour rupture of membranes.

Perinatal outcomes after open fetal surgery for myelomeningocele repair: a retrospective cohort study.

OBJECTIVE: Describe outcomes of open fetal surgery for myelomeningocele (MMC) repair in two Brazilian hospitals and the impact of surgical experience on outcome. DESIGN: Retrospective cohort study. SETTING: Sao Paulo, Brazil. POPULATION: 237 pregnant women carrying a fetus with an open spinal defect. METHODS: Surgical details, and maternal and fetal outcomes collected from all patients. MAIN OUTCOME MEASURES: Analysis of surgical and perinatal outcome parameters. RESULTS: Total surgical time was 119 ± 7.6 minutes. Preterm labour occurred in 24.2%, premature rupture of membranes in 26.7%, placental abruption in 0.8%, need for a blood transfusion at delivery in 2.1%, and dehiscence at the repair site in 2.5%. Reversal of hindbrain herniation at birth occurred in 71.4%. There were no maternal deaths or severe maternal morbidities. The failure rate with the patient anaesthetised was 0.42% and perinatal mortality was 2.1% (three intrauterine demises and two neonatal deaths). Comparing results from our study in the first 3 years with the last 3 years demonstrated improvement in the total surgical time (121.2 ± 6.4 versus 118.5 ± 8.2 minutes, P = 0.005) and an increase in reversal of hindbrain herniation at birth (64.0 versus 77.1%, P = 0.042). CONCLUSION: Our open fetal surgical approach for MMC was effective and results were comparable to past studies. Improvements in surgical performance and perinatal outcome increased as the surgical team became more familiar with the procedure. FUNDING: The study was funded solely by institutional funds. TWEETABLE ABSTRACT: Brazilian experience of in utero open surgery for myelomeningocele repair.

Tuberculosis in pregnancy:a challenging differential diagnosisfor inflammatory bowel disease.

OBJECTIVE: To describe a case of tuberculosis with intestinal variant in a pregnant woman in the 17th week of pregnancy. DESIGN: Case report. SETTING: Department of Obstetrics, Federal University of São Paulo (UNIFESP), São Paulo-SP, Brazil. CONCLUSION: Tuberculosis is a public health problem that concerns many countries in the world. It was declareda public emergency by the World Health Organization in 2005. Its presence during pregnancy brings maternal risk and fetal impairment if not treated quickly and properly. The intestinal variant is not the most common form of the disease and may be confused with inflammatory bowel diseases, especially Crohns disease. Knowledge of the specific characteristics, combined with a detailed medical history and appropriate diagnostic methods can make all the difference in gestational prognosis. We report the case of a pregnant woman who wrongly underwent treatment for inflammatory bowel disease at another service. After admission to our university hospital, fruitful diagnostic clarification was achieved and the patient was diagnosed and treated for tuberculosis. We describe the details of the investigation and, in particular, review the main characteristics in the literature for differentiating the two diseases.