Actualización del diagnóstico prenatal y cirugía fetal del mielomeningocele / Update on prenatal diagnosis and fetal surgery for myelomeningocele

A partir del estudio seminal Management of Myelomeningocele Study en el año 2011, el cual demostró que la reparación prenatal del defecto del mielomeningocele antes de la semana 26 mejoraba los resultados neurológicos, la cirugía fetal fue incorporada dentro de las opciones de estándar de cuidado. Así, el diagnóstico prenatal del mielomeningocele dentro de la ventana terapéutica se convirtió en un objetivo obligatorio y, por ello, se intensificó la investigación de estrategias de tamizaje, sobre todo, en el primer trimestre. Además, se desarrollaron distintas técnicas de cirugía fetal para mejorar los resultados neurológicos y disminuir los riesgos maternos. El objetivo de la siguiente revisión es actualizar los avances en tamizaje y diagnóstico prenatal en el primer y segundo trimestre, y en cirugía fetal abierta y fetoscópica del mielomeningocel

A seminal study titled Management of Myelomeningocele Study, from 2011, demonstrated that prenatal myelomeningocele defect repaired before 26 weeks of gestation improved neurological outcomes; based on this study, fetal surgery was introduced as a standard of care alternative. Thus, prenatal myelomeningocele diagnosis within the therapeutic window became a mandatory goal; therefore, research efforts on screening strategies were intensified, especially in the first trimester. In addition, different fetal surgery techniques were developed to improve neurological outcomes and reduce maternal risks. The objective of this review is to provide an update on the advances in prenatal screening and diagnosis during the first and second trimesters, and in open and fetoscopic fetal surgery for myelomeningocele

Update on prenatal diagnosis and fetal surgery for myelomeningocele. / Actualización del diagnóstico prenatal y cirugía fetal del mielomeningocele.

A seminal study titled Management of Myelomeningocele Study, from 2011, demonstrated that prenatal myelomeningocele defect repaired before 26 weeks of gestation improved neurological outcomes; based on this study, fetal surgery was introduced as a standard of care alternative. Thus, prenatal myelomeningocele diagnosis within the therapeutic window became a mandatory goal; therefore, research efforts on screening strategies were intensified, especially in the first trimester. In addition, different fetal surgery techniques were developed to improve neurological outcomes and reduce maternal risks. The objective of this review is to provide an update on the advances in prenatal screening and diagnosis during the first and second trimesters, and in open and fetoscopic fetal surgery for myelomeningocele.

A partir del estudio seminal Management of Myelomeningocele Study en el año 2011, el cual demostró que la reparación prenatal del defecto del mielomeningocele antes de la semana 26 mejoraba los resultados neurológicos, la cirugía fetal fue incorporada dentro de las opciones de estándar de cuidado. Así, el diagnóstico prenatal del mielomeningocele dentro de la ventana terapéutica se convirtió en un objetivo obligatorio y, por ello, se intensificó la investigación de estrategias de tamizaje, sobre todo, en el primer trimestre. Además, se desarrollaron distintas técnicas de cirugía fetal para mejorar los resultados neurológicos y disminuir los riesgos maternos. El objetivo de la siguiente revisión es actualizar los avances en tamizaje y diagnóstico prenatal en el primer y segundo trimestre, y en cirugía fetal abierta y fetoscópica del mielomeningocele.

Decidual factors and vasoactive intestinal peptide guide monocytes to higher migration, efferocytosis and wound healing in term human pregnancy.

AIM: To explore the functional profile of circulating monocytes and decidual macrophages at term human pregnancy and their contribution to tissue repair upon stimulation ex vivo with decidual factors and the vasoactive intestinal peptide (VIP). METHODS: Peripheral blood monocytes were isolated from pregnant and non-pregnant volunteers and tested in vitro with decidual explants from term placenta and VIP. The effect of VIP on decidual explants and the effect of its conditioned media on monocytes or decidual macrophages isolated by magnetic beads was carried out by RT-qPCR and ELISA for cytokines expression and release. Migration assays were performed in transwell systems. Efferocytosis was assessed in monocytes or decidual macrophages with CFSE-labelled autologous apoptotic neutrophils and quantified by flow cytometry. Monocyte and decidual macrophages wound healing capacity was evaluated using human endometrial stromal cell monolayers. Immunohistochemistry was performed in serial tissue sections of different placentas. RESULTS: VIP is expressed in the villi as well as in trophoblast giant cells distributed within the decidua of term placenta. VIP induced the expression of antiinflmammatory markers and monocyte chemoattractant CCL2 and CCL3 in decidual tissues. Monocytes presented higher migration towards decidual explants than CD4 and CD8 cells. VIP-conditioned monocytes displayed an enhanced efferocytosis and wound healing capacity comparable to that of decidual macrophages. Moreover limited efferocytosis of pregnant women monocytes was restored by VIP-induced decidual factors. CONCLUSION: Results show the conditioning of monocytes by decidual factors and VIP to sustain processes required for tissue repair and homeostasis maintenance in term placenta.

Impact of the 21-Gene Recurrence Score (Oncotype DX®) on adjuvant therapy decision-making: a collaborative multicenter cohort study from Argentina

Introduction: At present, more than half of patients diagnosed with early-stage breast cancer (BC) and express hormonal receptors will receive some adjuvant chemotherapy scheme, but only a few of them would benefit in terms of survival. Genomic platforms allow a better understanding of the heterogeneity of different types of hormonal receptor-positive and HER2-negative BC. They have proven their validity as tools to identify those patients who will obtain a clear benefit with the indication of chemotherapy treatment. The aim of this study is to analyze the use of the genomic platform, namely, Oncotype Dx® and its impact on the indication of adjuvant treatment, evaluated mainly as the change in treatment indication. Methods: Multicenter observational cohort study was performed in different Mastology units in Argentina. Patients underwent the Oncotype Dx to clarify the adjuvant treatment. Treatment decisions were settled before and after performing Oncotype Dx. Results: From January 2013 to December 2018, 211 patients with luminal A or B and HER2-negative breast carcinomas, who underwent the Oncotype Dx, were included. Based on our records, 40% of the patients change the indication of adjuvant treatment after the performance of the Oncotype Dx. Of these, 24% of patients who underwent initial endocrine therapy only adjusted their treatment with the addition of chemotherapy. Among patients with an initial CTH recommendation, 49% were able to receive endocrine therapy only when, due to traditional prognostic factors, they would have received chemotherapy. Conclusions: In our population, the use of the Recurrence Score was clinically significant in relation to the change of the established treatments. Consequently, it is a very important tool and a decisive factor in the adjuvant indication in patients with positive hormonal receptors and HER2neu-negative early BC.

Non-conservative Management of Placenta Accreta Spectrum in the Hybrid Operating Room: A Retrospective Cohort Study.

INTRODUCTION: Hysterectomy is the standard of care in placenta accreta spectrum (PAS). To reduce the risks of obstetric hemorrhage during surgery, endovascular interventions have been proposed. Our aim is to evaluate the feasibility and safety of the overall non-conservative management of PAS in the hybrid operating room (OR) to replace the classic two-step procedure (catheterization in the interventional radiology suite and transfer to conventional OR). MATERIALS AND METHODS: This is a retrospective study of series of patients with histopathologic confirmation of PAS treated in the hybrid OR at the same university hospital. We used for comparison our historical cohort managed with the standard two-step procedure. RESULTS: We included 110 patients, 80 in the conventional OR and 30 in the hybrid OR. There were no cases of major complications attributable to the endovascular procedures. In the two-step procedure, there were 10 (12.5%) intra-arterial catheter displacements that required repositioning in the conventional OR under mobile C-arm fluoroscopy and no cases in the hybrid OR (p = 0.04). The mean operative time was 380 + 42 min in the conventional OR and 296 + 66 min in the hybrid OR (p = .00001). There were no differences in the gestational age at delivery, postoperative length of stay, or large-volume blood transfusion. There were no maternal deaths. CONCLUSIONS: The overall non-conservative management of PAS in the hybrid OR has shown to be feasible and safe in our series, offering potential advantages to replace the classic two-step procedure. More studies are needed to evaluate whether this strategy is cost-effective and whether it may improve maternal and perinatal outcomes.

Validación de un modelo de predicción de necesidad de cirugía cardiovascular o cateterismo terapéutico neonatal en fetos con cardiopatías congénitas / Validation of a prediction model for need of neonatal cardiac surgery or catheter-based therapy in fetuses with congenital heart defects

INTRODUCCIÓN: el diagnóstico prenatal de las cardiopatías congénitas, con nacimiento en centros especializados, permite disminuir la morbimortalidad. Se ha desarrollado un modelo predictivo de necesidad de tratamiento cardíaco intervencionistaneonatal (TCIN) (cirugía cardiovascular y/o cateterismo cardíacoterapéutico) a partir de hallazgos en vistas ecográficas de pesquisa del corazón fetal. Con este modelo sería posible seleccionar a quienes requieren derivación prenatal. OBJETIVOS: Validar dicho modelo predictivo. MÉTODOS: Se llevó a cabo un estudio de cohorte de validación, prospectivo y multicéntrico. Se realizó análisis de regresión logística univariado y multivariado, valoración de calibración del modelo mediante test de Hosmer-Lemeshow, y de discriminaciónmediante valoración de área bajo la curva ROC (Receiver OperatingCharacteristic). RESULTADOS: En 58 (51,8%) de 112 pacientes incluidos se requirió TCIN. La adecuación del ajuste del modelo no resultó estadísticamente significativa (p 0,232), y la discriminación fue buena (área bajo la curva ROC 0,833; IC95%: 0,757-0,909). Para un punto de corte de 0,3 (a partir del cual el riesgo de necesidad de TCIN resultó significativo en el modelo original), hubo sensibilidad de 96,6%, especificidad de 55,6%, valor predictivo positivo de 70% y negativo de 93,8%. CONCLUSIONES: La aplicación del modelo estudiado en fetos con cardiopatías congénitas es factible, presenta una capacidad diagnóstica satisfactoria y constituye una herramienta útil para el manejo perinatal.

INTRODUCTION: prenatal diagnosis of congenital heart diseases allows timely in-utero referral to specialized centersand reduces the risk of morbidity and mortality. A model was developed to predict the need of neonatal cardiac surgery or catheter-based therapy in fetuses with congenital heart defects.With this model, based on fetal cardiac ultrasonographic findings, it would be possible to select patients in need of prenatal referral. OBJECTIVES: To validate such predictive model. METHODS: A prospective multicenter cohort validation study was conducted.Univariate and multivariate logistic regression analysis was performed, evaluating calibration by Hosmer-Lemeshow test and discrimination by area under the curve (AUC) of the receiver operating characteristic (ROC). RESULTS: In 58 (51.8%) of the 112 patients, neonatal cardiac surgery or catheter-based therapy was needed. There was no significant difference between observed and predicted event rates (p 0.232), and discrimination wassatisfactory (AUC of the ROC 0.833; CI95%: 0.757-0.909). For a cut-off probability of 0.3 (that showed significant risk of need for neonatal cardiac invasive therapy in the original model), sensitivity was 96.6%, specificity 55.6%, positive predictive value 70% and negative predictive value 93.8%. CONCLUSIONS: Theapplication of this predictive model in fetuses with congenital heart defects is feasible, shows a good diagnostic ability and can be a useful tool for perinatal management.

Prenatal diagnosis of CHDs: a simple ultrasound prediction model to estimate the probability of the need for neonatal cardiac invasive therapy.

OBJECTIVES: To develop a prediction model based on echocardiographic findings to estimate the probability of the need for neonatal cardiac invasive therapy, including cardiac surgery or catheter-based therapy, in foetuses with CHD. METHODS: Retrospective cohort study: a prediction model was developed based on echocardiographic findings on the examination of the four-chamber, the three-vessel, and the three-vessel and tracheal views. We assessed performance using the area under the curve of the receiver operating characteristic. RESULTS: Among 291 patients with prenatal diagnosis of CHD and complete follow-up, 175 (60.1%) required neonatal cardiac invasive therapy. The variables "functionally single ventricle", "great artery reverse flow", and "congenital heart block" had a discrimination value of 100% and were excluded from the model. In univariate and multivariate analysis, "non-visualisation of a great vessel", "asymmetry of the great vessels", "visualisation of one atrioventricular valve", and "ventricular asymmetry" were significantly associated with the need for neonatal cardiac invasive therapy. The area under the receiver operating characteristic curve was 0.9324 (95% CI 0.92-0.97). CONCLUSIONS: A prediction model based on echocardiographic findings in foetuses with CHD, even without a definite diagnosis, allows an accurate estimation of the probability of requiring neonatal cardiac invasive therapy. This can modify patient care, especially in regions where a Foetal Medicine Specialist or a Paediatric Cardiologist is not available and referral may be extremely difficult due to social and economic barriers.

Feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta.

PURPOSE: To evaluate the feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta (PA). MATERIALS AND METHODS: Retrospective chart review was performed of 95 consecutive patients with prenatal suspicion of PA managed in a 10-year period with a strategy that included prophylactic bilateral uterine artery catheterization, delivery of the baby, uterine artery embolization if indicated, and subsequent surgery. Feasibility was defined as catheterization being possible to perform, technical success as embolization being possible when indicated and complete stasis of the vessels achieved, and clinical success as no maternal death or major blood loss. Median gestational age at delivery was 36 weeks (interquartile range, 24-39 wk). RESULTS: PA was confirmed in 79 patients (83%). Feasibility was 97% (92 of 95); in three cases (3%), acute early massive hemorrhage forced emergency delivery without catheterization. Embolization was performed in 83 of 92 patients (87%) to the extent of complete stasis; in the remaining nine, it was unnecessary because spontaneous placental detachment was visualized after fetal delivery (technical success rate, 100%). There were several complications, including bleeding requiring blood transfusion (49%) and bladder surgery (37%), but there were no major complications attributable to the endovascular procedures. There was one minor complication presumably related to embolization (transient paresthesia and decreased temperature of lower limb), with uneventful follow-up. Clinical success rate was 86%, with no maternal deaths, but 14% of patients received large-volume blood transfusion. CONCLUSIONS: Prophylactic uterine artery catheterization and embolization in the management of PA appeared to be feasible and safe in this consecutive series of patients.

Determinación de valores de referencia en dimensiones cardíacasfetales en el tercer trimestre de gestación / Determination of reference values for fetal cardiac dimensions in the third trimester of pregnancy

INTRODUCCION: El pronóstico de las cardiopatías congénitas mejora con su detección prenatal. Las alteraciones enlas dimensiones cardíacas fetales son un hallazgo frecuente en presencia de anomalías cardíacas. OBJETIVO: Determinar valores de referencia para cavidades ventriculares y diámetro de grandes arterias en el tercer trimestre de la gestación, en vistas utilizadasen ecografía obstétrica. METODOS: Se realizó un estudio descriptivo de corte transversal. Se determinó la distribución de valores de referencia de dimensiones cardíacas fetales a partir de medicionesrealizadas en fetos de embarazadas de entre 25 y 41 semanas, controladas en dos hospitales privados de la Ciudad Autónoma de Buenos Aires y en un centro de diagnóstico privado de la provincia de Buenos Aires a lo largo de un año. RESULTADOS: Se obtuvierony analizaron los datos clínicos y las mediciones cardíacas fetales de 577 pacientes. Se determinaron valores de referencia en términos de media, desvío estándar y curvas de percentiles de anchos ventriculares, diámetros de grandes arterias y relaciones entre dichas estructuras (entre ventrículos y entre arterias). CONCLUSIONES: Sepresentan valores de referencia de dimensiones cardíacas fetalesobtenidos en cortes ecográficos de pesquisa en el tercer trimestrede la gestación.

INTRODUCTION: The prognosis of congenital heart diseases improves with prenatal detection. Alterations in fetal cardiac dimensions are a common finding in the presence of cardiac abnormalities. OBJECTIVE:To determine reference values for ventricular cavities and diameter of great arteries during the third trimesterof pregnancy, in views used in obstetric ultrasound. METHODS: A descriptive cross-sectional study was conducted,determining the distribution of reference values for fetal cardiac dimensions. It took into account sonographicmeasurements in fetuses between 25 and 41 weeks of pregnant women treated during one year in two privatehospitals from Buenos Aires city and one private diagnostic center in Buenos Aires province. RESULTS: Clinical dataand fetal cardiac measurements of 577 patients were collected and analyzed. Reference values were determined interms of mean, standard deviation and percentile curves of ventricular widths, diameters of great arteries, andrelationships between these structures (between ventricles and between arteries). CONCLUSIONS: Reference values for fetal heart measurements obtained in sonographic heart views used in obstetric scanning are presented for third trimester fetuses.

Foetal aortic valvuloplasty: experience of five cases.

OBJECTIVES: Foetal aortic valvuloplasty has been proposed as a strategy to improve left heart growth and function in foetuses with severe aortic stenosis at risk of progression to hypoplastic left heart syndrome. We report our experience with this intervention. METHODS AND RESULTS: Between 2005 and 2010, five foetuses with aortic stenosis and at risk of progression to hypoplastic left heart syndrome underwent ultrasound-guided percutaneous foetal aortic valvuloplasty. There were no associated maternal complications or foetal demise. In one case, the pregnancy was terminated a couple of weeks after the intervention, one foetus evolved to hypoplastic left heart syndrome, and three did not. CONCLUSIONS: Foetal aortic valvuloplasty seems to be a safe and feasible procedure. It has been reported that it has the potential to prevent progression to hypoplastic left heart syndrome in selected foetuses with severe aortic stenosis. Further investigation regarding physiological and clinical aspects of this disease both prenatally and postnatally will probably allow to improve therapeutic strategies and clinical outcome.

Las preguntas de la embarazada

Contenido: Antes del embarazo. Inicio del embarazo. Control prenatal durante el embarazo. Hábitos durante el embarazo. Cambios físicos y molestias durante el embarazo. Complicaciones durante el embarazo. Parto. Puerperio. Lactancia

Diagnóstico genético prenatal no invasivo de factor Rh y sexo fetal a través del análisis de ADN fetal libre en plasma materno / Non invasive prenatal genetic diagnosis of fetal RhD and sex through the analysis of free fetal DNA in maternal plasma

Introducción. El análisis de ADN fetal libre en plasma materno permite estudiar material genético del feto sin realizar procedimientos invasivos sobre el embarazo. Objetivo. Evaluar la factibilidad y desempeño diagnóstico de la determinación del genotipo RhD y del sexo fetal a través del análisis molecularde ADN fetal libre en plasma de embarazadas mediante reactivos de uso general en biología molecular. Material y métodos. Se extrajeron 109 muestras de sangre de embarazadas. Se amplificó por PCR en tiempo real una porción del gen RhD para el diagnóstico de Rh fetal en mujeres Rh-negativas y una región del cromosoma Y para la determinación del sexo fetal. Ambos datos se compararon con los resultados neonatales. Resultados. Respecto de las 109 muestras, 26 embarazos están en curso, 4 tuvieron abortos espontáneos y en 3 se perdió el seguimiento. De las 76 restantes con resultado neonatal, en 65 mujeres Rh-negativas se efectuó el análisis del gen RhD para la determinación del Rh fetal y en 66 muestras se realizó la determinación del sexo fetal. Quince muestras fueron no concluyentes y se excluyeron del análisis. El valor predictivo para RhD-positivo y RhD-negativo fue 85 por ciento y 90%, respectivamente, mientras que la predicción de sexo masculino fue 94,3 por ciento y la del femenino 95 por ciento. Conclusiones. La determinación no invasiva del RhD y sexo fetal en plasma materno mediante reactivos de uso general en biología molecular fue factible en la mayoría de los casos, con un desempeño diagnóstico similar al descripto en la bibliografía.

Introduction. The analysis of free fetal DNA in maternal plasma allows the assessment of fetal genetic material avoiding the necessity of invasive procedures during pregnancy. Objective. To evaluate the feasibility and the diagnostic performance of fetal sex and fetal RhD detection through the analysis of free fetal DNA in maternal plasma using standard reagents in molecular biology. Material and methods. A hundred and nine blood samples of pregnant women were obtained obtained. Amplification by real time PCR a sequence from the RhD gene in Rh negative patients and a Y-chromosome sequence, for the diagnosis of fetal Rh and sex respectively, were performed. Results were compared with neonatal outcomes. Results. From the 109 samples, 26 are still ongoing, 4 ended in spontaneous abortions and in 3 were lost to follow up. From the remaining 76 samples with neonatal result, the determination of fetal Rh from the RhD gene was performed in 65 Rh negative women, whereas in 66 samples the fetal sex analysis was evaluated. Overall, 15 samples had not conclusive results and were excluded from the study. The predictive values for RhD positive and negative were 85 percent and 90 percent, respectively, while the prediction for male sex was 94.3 percent and for female sex 95 percent. Conclusion. The non invasive determination of fetal RhD and sex in maternal plasma using standard reagents in molecular biology was feasible in the majority of the samples, with a diagnostic performance similar to the reported in the literature.

Evaluación de la efectividad de un programa de cuidado intensivo neonatal. Impacto de la incorporación de surfactante / Effectiveness assessment of a neonatal intensive care program for very low birth weight infants. Impact of surfactant administration

Introducción. La implementación de medidas terapéuticas en la Unidades de Cuidado Intensivo Neonatal (UCIN) se ha estudiado mediante medidas de eficacia (estudios aleatorizados), pero se han realizado pocas evaluaciones sobre su impacto en la práctica diaria, es decir, medición de la efectividad. Objetivo. Determinar si ha variado la efectividad en una UCIN durante un período de 14 años, comparando el efecto del cambio de actitud en la reanimación antes del uso masivo de surfactante y después de él en la calidad de la supervivencia neonatal en un hospital general. Métodos. Se incluyeron todos los pacientes ingresados en UCIN con un peso al nacer (PN) ≤1.500 g,durante un período de 14 años: 1989-1992 (n= 145), 1993-2002 (n= 342). Los sobrevivientes fueron seguidos hasta los 2 años de edad. Las tasas de seguimiento fueron de 80 por ciento y 85 por ciento en los períodos estudiados. Para el estudio se dividieron los pacientes en 4 grupos a intervalos de 250 g, entre 500 y 1.500 g. Medida de resultados. Supervivencia y calidad ajustada de supervivencia. Para estimar la calidad de la supervivencia se empleó el cálculo de los años de vida ganados (AVG). Se crearon categorías para cuantificar la pérdida de AVG por discapacidad. El tiempo de internación se analizó según las categorías de peso y la variación de la mortalidad durante los dos períodos. Resultados. La tasa de supervivencia tuvo un incremento absoluto del 23 por ciento entre los 2 períodos observados 52 por ciento contra 75 por ciento). Se calculó la supervivencia actuarial en los cuatro grupos con un incremento significativo en los 4 grupos (p menos 0,001) más marcado entre 500-749 g (4 por ciento contra 33 por ciento). Los AVG presentaron diferencias significativas en los grupos con PN menor750 g (p menor 0,002, 3,6 contra 23,4) y 750-999 g (p menor 0,001; 22,3 contra 48) no observándose diferencias en los otros dos grupos de PN.

Disfunciones miccionales luego de la modificación en la técnica de inserción del sling transobturador de acceso externo / Mictional dysfunctions after modifying the insertion of external access transobturator sling

Objetivo: Evaluar la curación de la incontinencia urinaria de estrés y las disfunciones miccionales postoperatorias observadas mediante una modificacion en la técnica de inserción del sling transobdurtriz. Material y métodos: Estudio prospectivo exploratorio con asignación alternada, comparando la técnica clásica con la comparada. La modificación consistió en realizar una incisión vaginal en U invertida en lugar de clásica vertical. Las pacientes fueron evaluadas clínicamente con interrogatorio examen urogenital, ecografía transvaginal y RMN dinámica. Resultados: Se incluyeron 17 pacientes. Ambos fueron de características similares. Edad promedio 59,5 años. Seguimiento entre 3 y 15 meses. Los resultados de curación y posicionamiento del sling fueron similares. La tasa de disfunciones de la micción fue significativamente menor en el grupo de cirugía modificad (12 por ciento vs 72 por ciento p<0.0001). Conclusiones: La modificación propuesta impresiona como una alternativa para disminuir las funciones postoperatorias, constituyéndose en un interesante punto de partida para futuras investigaciones...

Manejo interdisciplinario de un quilotórax congénito complicado con hidropesía fetal / Interdisciplinary management of a congenital chylotorax complicated with hydrops fetalis

La evolución natural del quilotórax congénito complicadocon hidropesía fetal se asocia con alta mortalidadperinatal. El objetivo de la presente comunicaciónes describir una potencial alternativa terapéuticaintrauterina en el manejo perinatal de estapatología fetal grave. Se describe el caso de unembarazo de 27 semanas con una hidropesía fetalpor quilotórax congénito diagnosticado a travésdel análisis del líquido pleural fetal. Ante la progresióndel cuadro se insertó a las 29 semanas deembarazo un catéter de derivación pleuroamnióticacon guía ecográfica, con reversión de la hidropesíafetal y del hidrotórax. A las 32 semanas se constatóla expulsión del catéter a la cavidad amniótica y,ante la recurrencia del hidrotórax, se finalizó elembarazo. Se realizó una toracocentesis fetal inmediatamenteantes de la cesárea. Se extrajo un reciénnacido de sexo femenino de 2.160 gramos, se efectuóintubación endotraqueal electiva en sala departos. Se colocaron tubos de drenaje pleural. Elcuadro era compatible con hipoplasia pulmonar,recibió surfactante, asistencia respiratoria mecánicapor 3 semanas y alimentación parenteral y luegoenteral con leche adecuada por su enfermedad debase. La evolución fue favorable, con alta al mes devida y control normal al año. El manejo interdisciplinariode una patología fetal y neonatal grave apartir del diagnóstico prenatal, como el hidrotóraxfetal primario complicado con hidropesía fetal, permitiríaoptimizar los resultados perinatales a travésde estrategias terapéuticas prenatales, perinatales,y neonatales.Palabras clave: quilotórax; hidrotórax fetal, derivaciónpleuroamniótica, hidropesía fetal.

Estudio aleatorizado y controlado de realimentaci¨®n temprana post ces¨¢rea / Early feeding after cesarean section: a randomized controlled trial

Introducci¨®n: La realimentaci¨®n progresiva no parece ser mejor tolerada que la realimentaci¨®n temprana y suele generar insatisfacci¨®n en las madres.Objetivo: Primario: Evaluar el nivel de satisfacci¨®n postoperatoria en pacientes sometidas a una operaci¨®n ces¨¢rea aquienes se les ofrece realimentaci¨®n temprana o realimentaci¨®n tradicional. Objetivos secundarios: evaluar la incidencia de s¨ªntomas de ¨ªleo, tiempo de retorno de ruidos hidro-a¨¦reos y de eliminaci¨®n de gases y dolor postoperatorio. Material y m¨¦todos: Ensayo cl¨ªnico aleatorizado. Se incluyeron todas las mujeres embarazadas cuyo parto fuese porces¨¢rea. Se excluyeron aquellas mujeres que presentaron: embarazos menores de 37 semanas, embarazo m¨²ltiple, uso de anestesia general, antecedentes de cirug¨ªa de intestino o lesi¨®n intestinal durante la ces¨¢rea, adherencias intra-abdominales,histerectom¨ªa puerperal, administraci¨®n de sulfato de magnesio o bloqueantes c¨¢lcicos, alguna condici¨®n m¨¦dica y/o quir¨²rgica que imposibilite la alimentaci¨®n temprana (diabetes). La intervenci¨®n consisti¨® en: Alimentaci¨®n temprana (AT): dieta general dentro de las primeras 8 h postoperatorias (m¨ªnimo de 400 Kcal). Alimentaci¨®n progresiva (AP): nada por boca en las primeras 0-4 h postoperatorias, dieta l¨ªquida 4-24 h y dieta general a partir de las 24 h postoperatorias hasta el alta hospitalaria. Dado que es un estudio de equivalencia, el an¨¢lisis se realiz¨® por tratamiento recibido. Resultados: Ciento tres mujeres fueron asignadas al grupo AP y 97 al grupo AT, en tanto 110 recibieron efectivamente AP y 90 AT. No hubo diferencias en las caracter¨ªsticas basales de los grupos. La media de satisfacci¨®n fue de 73,3 mm (IC95% 70,2-76,4) en la EAV (escala visual anal¨®gica) en el grupo AT (DS 16,5), y de 76,8 mm (IC 95% 74,0- 79,7) en el grupo AP (DS 13,6), con una diferencia entre grupos de -3,51 (IC 95% -7,80 0,77)...

Objective: To determine the equivalence of different patterns of postoperative feeding on the overall patient satisfaction or dissatisfaction with the process of care during postpartum hospital stay. Methods: A randomized, controlled study of equivalence was performed in which 97 patients were offered traditional feeding after c-section (nothing by mouth between 0 and 4 postoperative hours, then advanced to liquid diet between 5and 24 hours after surgery, and then fed with usual diet until discharge) and 103 patients were offered early feeding (solid food within 8 hours of surgery, with a minimum of 400 kcal) between December 15, 2003, and April 12, 2004, previous acceptation of a written informed consent. Both treatments were considered equivalent if the 95% confidence interval (CI) of difference between the means, was within the limits of -10 to +10 and contained the bound zero in both analyses, the as-treated as well as in the conservative intention-to-treat. The randomization occurred at the end of the surgery. Women were eligible for trial entry if they had a term pregnancy, irrespective of whether they had scheduled or intrapartum cesarean section performed under regional anthestesia. Women were excluded if they had any condition that precluded adherence to the planned intervention, if they received tocolytic drugs (magnesium sulfate, ¦Â2 agonists, calcium channel blockers), or general anesthesia. History of bowel surgery or intraoperative intestinal complications was also an exclusion criteria. Result: The preoperative and intraoperative base-line characteristics of these patients according to the assigned treatment were similar. Mean satisfaction was 73,3 mm (CI 95% 70,2-76,4) in the visual adjectival scale (VAS) in the traditional group (S.D. 16,5), and 76,8 mm (CI 95% 74,0-79,7) in the early feeding group (S.D. 13,6), with a difference betweengroups of -3,51 (CI 95% -7,80 0,77)...