Protocolo clínico para inducción del trabajo de parto: propuesta de consenso / Clinical protocol for labor induction: consensus proposal

Resumen: ANTECEDENTES: la inducción del trabajo de parto es un procedimiento que se indica cuando existe riesgo de continuar el embarazo, en lugar de interrumpirlo. Esta maniobra enfrenta nuevas presiones, por lo que es necesario mantener actualizado el conocimiento sobre su indicación. En los últimos años se han desarrollado protocolos clínicos de mayor eficacia y seguridad, que han hecho más accesible este procedimiento. OBJETIVO: emitir un consenso actualizado y analizar los diferentes aspectos de la práctica cotidiana relacionada con la inducción del trabajo de parto. MATERIALES Y MÉTODOS: se integró un grupo de especialistas de trece instituciones nacionales para analizar diferentes aspectos de la práctica cotidiana de la inducción del trabajo de parto. Se siguió una metodología tipo Delphi de cuatro etapas, con bibliografía de normas clínicas internacionales de apoyo. CONCLUSIONES: la inducción del trabajo de parto considera los siguientes criterios: establecer con certeza que el procedimiento ofrece el mejor desenlace para la madre y el feto, confirmar la edad gestacional, realizar la evaluación obstétrica completa y contar con infraestructura para enfrentar las posibles complicaciones. Existen diferentes opciones para la inducción del trabajo de parto; sin embargo, en los últimos años se ha generalizado la prescripción de análogos de prostaglandinas (misoprostol) en todo el mundo. El especialista debe efectuar la evaluación individualizada de la paciente y el feto, con la finalidad de descartar situaciones que comprometan la salud de ambos. La complicación más común de la inducción del trabajo de parto es la taquisistolia, que puede asociarse con desprendimiento prematuro de placenta, rotura uterina y sufrimiento fetal agudo. Los óvulos vaginales de liberación controlada representan la única opción para retirar el estímulo con dinoprostona o misoprostol ante efectos adversos.

Abstract: BACKGROUND: Induction of labor is a maneuver indicated when there is a greater risk of continuing the pregnancy, than interrupting it. The induction of labor faces new pressures that make it necessary for the doctor to be permanently updated. In recent years, clinical protocols of greater efficiency and safety have been developed, which have made this procedure more accessible. OBJECTIVE: To present an updated consensus and to analyze the different aspects related to the labor induction. MATERIAL AND METHODS: A Delphi-type of consensus was conducted with participation of active obstetricians and gynecologists specialists from thirteen national institutions. Major clinical-oriented topics of induction of labor were addressed. CONCLUSIONS: To induce labor, it is necessary that at least the following situations coexist: to establish with certainty that the procedure offers the best outcome for the mother and her child, to confirm the gestational age, to make a complete obstetric evaluation and to have the infrastructure Necessary to deal with possible complications. There are several options to induce labor, although in recent years the indication of prostaglandin analogues (misoprostol) has become the most common option worldwide. The specialist must make an individualized evaluation of the patient and the fetus, in order to rule out situations that may endanger the health of any of them. The most common complication of labor induction is tachysystole, which can be complicated by premature placental abruption, uterine rupture and acute fetal distress, requiring urgent attention. Controlled-release vaginal ovules are the only option available to withdraw the stimulus with dinoprostone or misoprostol in the presence of adverse effects.

[Pilot tests using molecular diagnostic assay cervicovaginal infection during pregnancy]. / Ensayo piloto del uso de pruebas moleculares para el diagnóstico de infecciones cervicovaginales en pacientes embarazadas.

Background: The prevalence of cervicovaginal infections during pregnancy has been associated with adverse perinatal outcomes however, the actual approach used for diagnosis is not effective. The aim of this study was to compare the diagnosis of vaginal infections in pregnant women using clinical, molecular diagnostic and traditional microbiological culture in a pilot study, to determine the prevalence and association with the development of preterm labor. Materials and methods: We performed a nested cross-sectional study composed by 54 women in a cohort of pregnant women in Mexico City. Cervicovaginal infections were evaluated by clinical methods, microbiology culture and a commercially available molecular biology test. Results: Prevalence of cervicovaginal infections during pregnancy was estimated between 28% and 50% according to methodologies. Considering the clinical diagnosis of preterm labor as the gold standard, all diagnostic tests were poor as predictors of preterm labor. Conclusion: Traditional approaches to establish the significance of cervicovaginal infection in pregnancy are exhausted, so be sought new ways to understand this complex relationship. Meanwhile it is recommended to continue to use traditional methods to identify infections during pregnancy in both knowledge of new methods aimed at understanding these relationships are sophisticated.

A randomized, clinical trial of ketorolac tromethamine vs ketorolac trometamine plus complex B vitamins for cesarean delivery analgesia.

BACKGROUND: Ketorolac is widely used for postoperative analgesia in patients who undergo cesarean delivery. In countries where the use of opioids is considerably restricted, alternatives to narcotics are required. AIM: We hypothesize that the addition of complex B synergize the analgesic effect of ketorolac in postoperative cesarean patients, thus requiring a smaller dose of the anti-inflammatory agent, and therefore decreasing the potential side effects of ketorolac. METHODS: A randomized clinical trial with 100 patients undergoing a primary elective cesarean delivery enrolled in the study. Pain was assessed in the recovery room and then they were randomized to receive ketorolac 30 mg intramuscular (i.m.) or 15 mg of ketorolac plus complex B vitamin (CBV). The pain score with an analog scale was assessed 1, 2, 6, 12, 18, and 24 h after the baseline. The student's t test was performed to compare the demographic differences between the 2 means. RESULTS: 100 patients were included in the study, showing no statistical differences in the demographics. The patient's pain score at 1, 2, 6, 12, 18 and 24 hours showed no statistical differences between the control group (ketorolac 30mg) compared to the group of ketorolac 15mg and complex B vitamins. No changes in the coagulation studies were found in both groups. CONCLUSION: The present study demonstrates that ketorolac 30 mg and ketorolac 15 mg plus complex B vitamins can provide acceptable analgesia in many patients with severe pain.

[Induction of nitric oxide synthesis in mononuclear cells in culture using peritoneal fluid from women with endometriosis, in relation to the percentage of T lymphocytes and NK cells identified in an such environment]. / Inducción de la síntesis de óxido nítrico en células mononucleares en cultivo utilizando líquido peritoneal de mujeres con endometriosis, en relación al porcentaje de linfocitos T y células NK identificado en dicho ambiente.

UNLABELLED: Even though endometriosis represents a reproductive health problem of the greatest importance due to the fact that it is one of the most common benign gynecological conditions, its aetiology is still unknown. The most accepted hypothesis is the one proposed by John Sampson, suggesting that the endometrial cells and tissues derived from menstrual flow during uterine scaling reach the peritoneum through the tubes by reversed flow and, under the specific conditions of the peritoneal microenvironment, they are able to implant and proliferate in an ectopic manner. Some evidence shows that the number and activation of macrophages are increased in the peritoneal medium of women with endometriosis. It is known that the activation of this cell group leads to a greater synthesis of diverse molecules associated with this condition. OBJECTIVE: Evaluating the association between the nitric oxide (NO) synthesis induction capacity of the peritoneal fluid, the percentage of cooperative T lymphocytes and NK cells present in the peritoneal medium of women with different stages of endometriosis, as compared to fertile and healthy women. We also tried to find the correlation between the concentration of TNF-alpha identified in the peritoneal fluid of both groups with the NO synthesis induction that was carried out. Material and methods. The study group was formed by women with endometriosis (WEN) from the National Institute of Perinatology, and the control group was formed by patients attending the Family Planning Clinic of the Northeast Regional Unit (Culiacán, Sin.) (HFW). A NO synthesis induction was performed using lymphocytes stimulated with peritoneal fluid from WEN and HFW in order to measure the concentration of cooperative T lymphocytes and NK cells, the TNF-alpha of the peritoneal fluid was also measured. RESULTS: The NO synthesis induction capacity of peritoneal fluid observed with lymphocytes from a culture was greater than the one presented by healthy women. CONCLUSION: Nitric oxide was recently described as a potent inhibitor of effector cytotoxic activity associated to the immunological response of cooperative T lymphocytes of the TH-1 type promoting cytotoxic activity on different cell strains. Evidence suggests that NO inhibits INF-alpha synthesis, the later being a potent proliferation and cytotoxic activity inducer in NK cells, cytotoxic T lymphocytes, and cooperative T lymphocytes. A role of NO as a regulator of NK cell activity has also been described.

[Tumor necrosis factor-alpha and interleukin-1 beta in maternal, fetal and retroplacental intravascular compartments at term and preterm labor]. / Factor de necrosis tumoral-alpha e interleucina-1 beta en los compartimentos intravascular materno, fetal y retroplacentario en parto a término y pretérmino.

Neonato preterm birth (before 37 pregnancy weeks) account more than 80% perinatal deaths not attributable to congenital malformations. Preterm and term labor full mechanisms are unknown at present. Proinflammatory cytokinesis direct participation have been involved in the phenomena by several experimental evidence. The study's aim was to determine TNF-alpha and IL-1 beta concentration at maternal, fetal and fetal-maternal vascular compartments in women with term and preterm delivery and in women at term childbirth without labor. TNF-alpha and IL-1 beta concentration were determinated by commercial immunoassay. TNF-alpha concentration showed a tendency to be in more proportion at fetal and fetal-maternal compartments in preterm and term childbirth groups versus TNF-alpha concentration in term group without labor at same places. IL-1 beta concentration showed same tendency of increase than TNF-alpha in preterm and term childbirth groups, but alone at fetal-maternal compartment. Statistical difference were not documented at any compartment or group compared. Data allow to identify fetal-maternal compartments as target places where TNF-alpha and IL-1 beta were synthesized. Gradient concentration synthesis of cytokinesis allows to intend fetus as TNF-alpha initial producer.

[Apoptosis in trophoblast of patients with recurrent spontaneous abortion of unidentified cause]. / Apoptosis en trofoblasto de pacientes con aborto espontáneo recurrente de causa no identificada.

Recurrent spontaneous abortion of unidentified cause or idiopatic is an important problem of reproduction health. In this study, the study has been started of one of the mechanisms that could act in the pathology of human pregnancy. The general hypothesis proposed, is that in the case of patients with recurrent spontaneous abortion of non identified cause (RSA) there are phenomenons in the materno/fetal/placentary means that manifest themselves in harm to the functionality and/or vitality of placentary tissue. The hypothesis was consistent with the finding of massive activation of cellular death in all the cases with RSA studied in this work.

[Apoptosis and extracellular matrix degradation in chorio-amnion during labor and premature membrane rupture]. / Apoptosis y degradación de matriz extracelular en corioamnios durante el trabajo de parto y en la ruptura prematura de membranas.

BACKGROUND: The molecular mechanisms of chorioamniotics membranes rupture during labor are relationated with a group of enzymes named metalloproteinases of extracellular matrix (MMP), the production of these enzymes are elevated in premature rupture of membranes. The collagenase IV (molecular weight 92 kDa) is induced in specific form during both events. We unknown the regulatory mechanisms to these enzymes in the chorioamnios. OBJECTIVE: To determine the presence of apoptosis and expression of (MMP-) in human chorioamnios during the labor and premature of the fetal membranes. MATERIAL AND METHODS: The gel lysis using zimography was determined in membranes of 1) Labor, 2) Cesarean section, 3) PRM. The analysis of DNA fragmentation in situ and DNA of the membranes was studied. Using immunohistochemistry techniques was identified MMP-9. RESULTS: It was observed increase of gel lysis in stracts with PRM and labor in comparation with cesarean section. In all the specimens were found apoptotics cells, however, they were scareces, abundance or very abundance in cesarean section specimens, labor or PRM respectively. The fragmentation in situ was confirmed in specimens of DNA. The immunohistochemistry showed positively to MMP-9 in labor and PRM specimens, and not in cesarean section specimens. The MMP-9 immunorreactivity was extensive in PRM and only was found apoptosis. CONCLUSIONS: The results demonstrate that apoptosis and expression-activity of MMP-9 can be associated to membranes rupture during labor and lysis, the same explanation may be true for the increased expression of MMP-9 in PRM both phenomena seems to have a sequence.

[Identification of molecular nexus between infection and premature rupture of membranes]. / Identificación de nexos moleculares entre infección y ruptura prematura de membranas.

The tumoral necrosis factor alfa (TNF-alpha) has been characterized as a signal contained in chorioamniotic membrane with premature rupture of membrane complicated with infection, inducing enzymes that degrade extracellular matrix components in fetal membranes. This cytocine is normally produced of immune system cells as a response to contact with infectious agents, and its identification is a direct molecular nexus between inflammatory response and development of premature rupture of membranes.

[Dietetic factors and premature rupture of fetal membranes. Effect of vitamin C on collagen degradation in the chorioamnion]. / Factores dietéticos y ruptura prematura de membranas. Efecto de la vitamina C en la degradación de colágena en el corioamnios.

Some studies have shown an association between vitamin C disposability (Vit C), and the development of premature rupture of membranes (RPM). However, vitamin C role in the metabolism of collagen upon chorioamnion tissue, has not been analyzed. In this study the effect of modulation with different vit C concentrations in culture cells derived from human amnion, was analyzed. Vit C concentrations were used in order to cover physiological range (29.0 micrograms/ml). After stimulation the cells media were analyzed for enzymatic activity of metalloproteinases with extracellular matrix (MMP), and relative quantity of MMP-1, MMP-2 and MMP-9, was quantified, by immune transference, using monospecific polyclonal antibodies. The activity, as well as protein decreased in amniotic cells media, in a direct way as to vit C concentration, so, at the highest used concentrations (100 micrograms/ml), the least MMP activity/quantity, was obtained. These results show a finding not described until now, which permits to establish a direct connection between vit C availability and increase in collagen degradation. According to results, the less availability of vit C, the greater degradation of collagen, which should lead to a mechanical support loss and eventual fetal membranes rupture.

[Transition from the latent to the active enzymatic form as a model of regulation of extracellular matrix degradation in the chorioamnion during human labor]. / Transición de la forma enzimática latente a activa como un modelo de regulación de la degradación de matriz extracelular en el corioamnios durante el trabajo de parto humano.

Matrix metallo proteinases (MMP) are the physiological mediators of collagen degradation and its participation in physiopathogenesis of premature rupture of membranes has been suggested by our group. With the idea of defining if some MMP become active active in a coordinated way with labor in fetal membranes, we analyzed enzymatic activity and immunoreactive protein present in extracts of amnion and chorion. It was possible to identify the presence of MMP-9 in extracts of membranes obtained during cesarean sections, without labor, although its activity/quantity was faintly detectable. Instead, extracts of fetal membranes obtained during active labor showed large activity/quantity of this MMP. With a monoclonal antibody, it was possible to show that the active form of MMP-9 could only be found in samples with labor. MMP-9 and its messenger RNA, were localized by immunohistochemistry and in situ hybridization in amniotic epithelium, in some fibroblasts of the compact layer and in trophoblast-like cells in chorion. It is concluded that: 1. Activity and quantity of MMP-9 increase selectively associated to labor; and 2. That this enzyme is expressed by different cellular populations of fetal membranes.

[Role of metalloproteases of extracellular matrix in the premature rupture of fetal membranes: a novel physiopathogenic model]. / Participación de las metaloproteasas de matriz extracelular en la ruptura prematura de membranas fetales: un modelo fisiopatogénico novedoso.

Experimental proofs are presented, that involve the participation of the metalloproteinases family, of extracellular matrix in the genesis of premature rupture of membranes. The expression of this group of enzymes, which presents in normal conditions of labor appears in the RPM without relation with gestational age. This phenomenon is not presented as an isolated example of participation of metalloproteinases in events related to labor and delivery, as is very well known its participation in maturation of uterine cervix preceding product expulsion, and that consists in similar mechanisms to the ones now chosen for the maturation of fetal membranes. The working hypothesis in pathologic conditions, implies, then, the activation of a normal system in an inadequate moment that results in premature rupture of membranes.