Evaluation of perinatal outcomes in pregnant women with preterm premature rupture of membranes / Avaliação dos resultados perinatais em gestantes com rotura prematura das membranas pré-termo

SUMMARY Objective: To determine the association between amniotic fluid index (AFI) and perinatal outcomes in preterm premature rupture of membranes (PPROM). Method: A retrospective cohort study was conducted between 2008 and 2012. 86 pregnant women were included, with a diagnosis of PPROM and gestational age from 24 to 35 weeks. Women who presented hypertensive disorders, diabetes, fetuses with birth defects and infection at admission were excluded. To determine the association between AFI and perinatal outcomes, chi-square and Fisher’s exact test were used if necessary, as well as risk ratio (RR) and 95% confidence intervals (95CI). Correlation between AFI and perinatal outcomes was determined by using simple linear regression, and AFI progression during pregnancy was analyzed by Z-test. Results: When comparing newborns presenting ultrasound with AFI<5cm and AFI>5cm, there was a higher frequency of perinatal mortality when the AFI was lower than 5 cm. However, when the oligohydramnios was diagnosed as severe (AFI<3cm), there was a higher frequency of Apgar scores less than seven at 1 minute, neonatal sepsis and early neonatal mortality compared to those presenting AFI>3cm. There was a positive correlation between AFI and gestational age at delivery, birth weight and Apgar scores at minutes 1 and 5. There was also a decrease in amniotic fluid volume with increased gestational age. Conclusion: The presence of severe oligohydramnios after PPROM contributed to a higher frequency of perinatal complications and death.

RESUMO Objetivo: determinar a associação do índice de líquido amniótico (ILA) com os resultados perinatais na rotura prematura das membranas pré-termo (RPMPT). Método: realizou-se um estudo de coorte retrospectivo, de 2008 a 2012. Foram incluídas 86 gestantes, com diagnóstico de RPMPT e idade gestacional entre a 24ª e 35ª semanas. Foram excluídas gestantes que apresentavam síndromes hipertensivas, diabetes, fetos com malformações fetais e infecção na admissão. Para determinar a associação entre ILA e desfechos perinatais, foram utilizados os testes qui-quadrado e exato de Fisher, quando pertinentes, além da razão de risco (RR) e seu intervalo de confiança a 95% (IC95%). A correlação entre ILA e desfechos perinatais foi determinada por regressão linear simples, e a evolução do ILA durante a gestação foi analisada pelo teste Z. Resultados: quando comparados os recém-nascidos que apresentavam ultrassonografia com ILA<5 cm e ILA>5 cm, observou-se maior frequência de mortalidade perinatal nos casos de ILA<5 cm. Quando o oligo-hidrâmnio, porém, era diagnosticado como grave (ILA<3 cm), observava-se maior frequência de escore de Apgar <7 no 1º minuto, sepse neonatal e mortalidade neonatal precoce em relação aos que apresentavam ILA>3 cm. Observou-se uma correlação positiva entre ILA e idade gestacional no parto, peso ao nascer e escore de Apgar no 1º e 5º minutos, além de diminuição do volume do líquido amniótico com o avançar da idade gestacional. Conclusão: a presença de oligo-hidrâmnio grave após a RPMPT contribuiu para uma maior frequência de complicações e mortalidade perinatal.

Amniotic fluid exerts a neurotrophic influence on fetal neurodevelopment via the ERK/GSK-3 pathway

BACKGROUND: The fetus is surrounded by the amniotic fluid (AF) contained by the amniotic sac of the pregnant female. The AF is directly conveyed to the fetus during pregnancy. Although AF has recently been reported as an untapped resource containing various substances, it remains unclear whether the AF could influence fetal neurodevelopment. RESULTS: We used AF that was extracted from embryos at 16 days in pregnant SD rat and exposed the AF to the neural cells derived from the embryos of same rat. We found that the treatment of AF to cortical neurons increased the phosphorylation in ERK1/2 that is necessary for fetal neurodevelopment, which was inhibited by the treatment of MEK inhibitors. Moreover, we found the subsequent inhibition of glycogen synthase kinase-3 (GSK-3), which is an important determinant of cell fate in neural cells. Indeed, AF increased the neural clustering of cortical neurons, which revealed that the clustered cells were proliferating neural progenitor cells. Accordingly, we confirmed the ability of AF to increase the neural progenitor cells through neurosphere formation. Furthermore, we showed that the ERK/GSK-3 pathway was involved in AF-mediated neurosphere enlargement. CONCLUSIONS: Although the placenta mainly supplies oxygenated blood, nutrient substances for fetal development, these findings further suggest that circulating-AF into the fetus could affect fetal neurodevelopment via MAP kinases-derived GSK-3 pathway during pregnancy. Moreover, we suggest that AF could be utilized as a valuable resource in the field of regenerative medicine.

Effect of maternal hydration on the increase of amniotic fluid index

The objective of this study was to determine the effect of maternal hydration with oral isotonic solution and water on the amniotic fluid (AF) index of women with normohydramnios. Women with a normal AF index and gestational age between 33 and 36 weeks without maternal complications were randomized into three groups [isotonic solution (Gatorade®), water, control]. The isotonic solution and water groups were instructed to drink 1.5 L of the respective solution and the control group was instructed to drink 200 mL water over a period of 2 to 4 h. AF index was measured before and after hydration by Doppler ultrasonography. The investigator performing the AF index measurement was blind to the subject’s group. Ninety-nine women completed the study without any adverse maternal effects. The median increase in AF index after hydration was significantly greater for the isotonic solution and water groups than for the control group. There was no significant difference between the isotonic solution and water groups. Hydration with isotonic solution and water caused a 10-fold (95 percentCI: 2.09-49.89) and 6-fold (95 percentCI: 1.16-30.95) increase in the chance of a 20 percent increase of AF index, respectively. Maternal hydration with isotonic solution or water increased the AF index in women with normohydramnios.

Síndrome de dificultad respiratoria asociado a líquido amniótico meconial en recién nacidos de término y postérmino: incidencia, factores de riesgos y morbimortalidad / Respiratory distress syndrome associated to meconial amniotic fluid in posterm and term newborns: incidence, risk factors and morbimortality

Introducción. El líquido amniótico meconial (LAM) se presenta en 5 a 30 por ciento en recién nacidos de término y postérmino, entre el 2 al 10 por ciento desarrollan síndrome de aspiración de líquido amniótico meconial (SALAM). La mortalidad asociada es del 4 al 40 por ciento. Los factores de riesgo para la aparición de SALAM son: el aumento en la consistencia del LAM, alteraciones en el monitoreo fetal, las cesáreas, menos de 5 controles prenatales, el sexo masculino, score de Apgar menor a 7 y el oligoamnios. El LAM aumenta el riesgo de síndrome de dificultad respiratoria (SDR) en recién nacidos de término y postérmino. Objetivos. Estimar la incidencia de LAM y SALAM en RN de término o postérmino. Comparar el riesgo de SDR en RN con LAM con aquellos RN con líquido amniótico claro (LAC). Analizar los factores de riesgos asociados a SALAM. Población y muestra. Criterios de inclusión: Casos: 1.150 RN >37 semanas de EG con LAM. Controles: 2.300 RN >37 semanas de EG con LAC. Criterios de exclusión: RN <37 semanas de EG, hijo de madre diabética o hipertensa, RN con malformaciones, madre con corioamnionitis, recién nacido pequeño para edad gestacional. Resultados. Sobre un total de 10.332 RN vivos durante el período de estudio en la Maternidad Sardá, 1.150 presentaron líquido amniótico meconial, que corresponde a una incidencia del 11,1%. Se observó una mayor asociación de SALAM a mayor edad gestacional. La incidencia de SALAM fue del 3,9 por ciento y la presencia de SDR en RN con líquido amniótico claro fue del 1,3 por ciento (RR: 2,5 [IC 95 por ciento 1,3-3,7]). En presencia de LAM se evidenció SDR con más severidad, más presencia de escapes de aire, menor puntaje de Apgar y mayor mortalidad. En el análisis del subgrupo con SDR encontramos un menor control prenatal, menor puntaje de Apgar al 5to minuto, prevalencia del sexo masculino, mayores complicaciones y mortalidad en el grupo con líquido amniótico meconial...

Polyhydramnios; study of causes and fetal outcome

Polyhydramnios is though an uncommon problem but very distressing for patient. To locate the causative factors and neonatal outcome in polyhydramnios. Case series. Department of Obstetrics and Gynaecology unit 1, Lahore General Hospital, Lahore. From January 2004- December 2005. Total 82 diagnosed cases of polyhydramnios in 3[rd] trimester were included in this study. According to the results of this study polyhydramnios can occur in primigravida as well as multigravida. Causative factor are mainly idiopathic after which the most important is fetal defects. Diabetes is also associated finding with polyhydramnios in 26.8% cases. The impact of polyhydramnios on neonatal outcome is that most of the babies were born without any significant effect. There were only 26 babies [31.5%] in which anomalies were present and neural tube defects were common. Idiopathic polyhydramnio being the most common type. Improved prenatal and antenatal screening and early detection of congenital anomalies may help to minimize the morbidity of the patient

Decreased amniotic fluid index and adverse pregnancy outcome at term

To find out the effect of decreased amniotic fluid index [AFI] on adverse pregnancy outcome at term. This experimental study was conducted at Gynae [B] unit Lady Reading Hospital Peshawar from September 2004 to August 2005. A total of 100 pregnant women admitted in labour ward were included in the study. Fifty cases with an amniotic fluid index of <5cm comprised the patient group. Fifty controls having AFI>5cm were matched with the cases regarding age [ +/- 3years], parity and antenatal complication [hypertension, diabetes]. Apart from demographic details, maternal outcome measures such as induction of labour; mode of delivery; meconium stained liquor; and fetal outcome measures such as Apgar score and admission to neonatal intensive care unit were recorded on a semi structured proforma for both the groups and analyzed by Chi square test using SPSS v.ll. Labour induction was significantly higher in patients having AFI<5cm as compared to the control group [p-value=0.009]. Meconium stained liquor [p-value=0.023] and cesarean section rate for fetal distress [p-value=0.000] were higher in patients having AFI<5cm. Neonatal complications were found to be more frequent in the patients having AFI<5cm and these include, low Apgar score <7 [p<0.00l] and neonatal intensive care unit admission [p=0.078]. There was no perinatal mortality in both the groups. Amniotic fluid index of <5cm was associated with adverse pregnancy outcomes in the form of meconium stained liquor, induction of labour, cesarean section for fetal distress, low Apgar score and neonatal intensive care unit admission

Valoración ultrasonográfica simplificada del líquido amniótico y su asociación con el crecimiento fetal / Single ultrasonographic assessment of amniotic fluid and fetal growth

La valoración del líquido amniótico, durante la gestación ha demostrado ser un parámetro útil para tamizaje, porque orienta sobre algún trastorno de base en el binomio feto-materno. El examen sonográfico es el método no invasivo más utilizado. Realizándose habitualmente, mediante valoración cualitativa del líquido, reservando los métodos semi-cuantitativos: como son el índice de líquido amniótico y la medición única del bolsillo vertical mayor, sólo para aquellos casos considerados anormales. En la maternidad del Hospital Regional de Temuco se estableció con técnica semi-cuantitativa de medición única del bolsillo vertical mayor de líquido amniótico, la curva de distribución del líquido durante la gestación (14 a 41 semana) obteniendo como puntos de corte, valores más centralizado que lo reportado en el criterio clásico de medición única propuesto por Chamberlain y Manning. Posteriormente se correlacionó nuestros percentiles observados con el grado de crecimiento fetal evaluado al parto como: pequeño, adecuado o grande para la edad de gestación, encontrando diferencias estadísticamente significativas entre variaciones menores del líquido amniótico con alteraciones del crecimiento fetal; oligohidroamnios (bolsillo < 35 mm) con recién nacido para la edad de gestación y polihidroamnios (bolsillo > 75 mm) con recién nacido grande para la edad gestacional.

Assessment of amniotic fluid throughout pregnancy has proved to be a useful parameter for screening. It constitutes a technique for suspecting any baseline disorder in the fetal-maternal unit. Ultrasound is currently the most frequently used non-invasive method, such as amniotic fluid index and measurement of the single largest pocket, for those cases considered as abnormal. By appling the semi-quantitative technique of measurement of the single largest vertical pocket, the amniotic fluid distribution curve during gestation (14-41 week’s gestation) was determined in patients attending the Maternity Department, Regional Hospital, Temuco, Chile. More centralizad values than those reported according to the classical criterium of single assessment proponed by Chamberlain and Manning were obtained as cutting points. Subsequently, our percentiles were correlated with the fetal growth at delivery: small, adequate or large for gestacional age. Statistical significant defferences between minor variations of amniotic fluid and fetal growth alterations were found. Oligohydramnios (pocket <35 mm) with small-for gestacional age infants. Polihydramnios (pocket >75 mm) with large for gestacional age newborns.

Adriamycin-induced fetal hydronephrosis

INTRODUCTION: At the end of pregnancy, the amniotic fluid (AF) depends basically on renal function, corresponding to fetal urine. Changes in AF, especially oligohydramnios, are reported in association with fetal hydronephrosis (FH). The experimental model using adriamycin in pregnant female rats has a teratogenic effect and has been classically employed to study esophageal atresia. Nevertheless, adriamycin promotes FH with high frequency as well. In the present study, using this animal model, we tried to identify the incidence and microscopic changes of FH, as well as its correlation with AF weight. MATERIALS AND METHODS: Eight Spreague-Dawley pregnant female rats received adriamycin 2.2 mg/kg on the 8th and 9th gestational days (considering term gestation = 22 days). Those fetuses that received adriamycin (Adriamycin Group) were compared with fetuses from 2 female rats (Control Group), which received 0.9 percent saline solution. On the 21.5 gestational day, the fetuses were collected by cesarean incision, sacrificed, and examined for macro and microscopic changes in kidneys and ureters. Fetuses with bilateral hydronephrosis formed the Hydronephrosis Group. AF weight was determined as well. RESULTS: Hydronephrosis occurred in 70 (95 percent) of the 74 fetuses in the adriamycin group against none of the 21 fetuses from the control group. The amniotic fluid weight was increased in the adriamycin group in relation to the control group (p < 0.001). The histomorphometric study revealed dilation of the renal pelvis and reduction of renal parenchyma in the hydronephrosis group in relation to the control group. Severe cortical atrophy, cortical tubular atrophy and medullar atrophy were observed in the hydronephrosis group. CONCLUSIONS: Slight renal lesions were in agreement with changes in AF weight, since they suggest that there was production of urine with the maintenance of AF.

Análise bioquímica dos líquidos fetais e citologia do fluido amniótico da fêmea de Mocó (Kerodon rupestris) / Biochemical analysis of fetal fluids and cytology of the amniotic fluid of female Mocó (Kerodon rupestris)

Foram utilizados 10 sistemas genitais femininos de mocós (Kerodon rupestris) para estabelecer parâmetros de referência relativos à osmolaridade, pH, cálcio, fósforo, uréia, creatinina, glicose e proteínas totais. Os animais foram criados em cativeiro no CEMAS (Centro de Criação de Animais Silvestres), Mossoró - RN. As fêmeas estavam da metade (30-45 dias) para o final da gestação (65-70 dias). As bolsas amnióticas e alantoideanas foram puncionadas individualmente para colheita dos líquidos fetais, que foram centrifugados e analisados posteriormente. Para o líquido amniótico, as concentrações médias em mg/dl foram: glicose = 45,87 ± 22,38; cálcio = 6,31 ± 1,24; fósforo = 1,64 ± 0,72; creatinina = 0,45 ± 0,12; uréia = 34,03 ± 5,96; proteínas totais = 31,24 ± 16,67. Para o líquido alantoideano, as concentrações médias em mg/dl foram: glicose = 59,17 ± 10,85; cálcio = 5,58 ± 0,59; fósforo = 1,27 ± 0,73; creatinina = 0,38 ± 0,38; uréia = 31,49 ± 2,28; proteínas totais = 30,70 ± 18,39. Foram observadas pequenas oscilações entre as concentrações dos parâmetros bioquímicos do fluido amniótico e alantoideano. Estas concentrações são determinadas, provavelmente, pela atividade metabólica materno-fetal. A análise das células do fluido amniótico revelou quatro tipos celulares.

Effect of Ramadan fasting on amniotic fluid volume.

This cross-sectional study was carried out to assess the influence of Ramadan fasting on amniotic fluid volume. For this purpose 2 groups of fasting [n=28] and non-fasting [n=25] pregnant women were investigated for amniotic fluid index [AFI] and deepest vertical pocket of amniotic fluid in November [Ramadan month] of 2001-2002 in Kerman Prenatal Clinics in Kerman, Iran. Mean of gestational age based on the last menstrual period and ultrasound reports were 29.6 +/- 5.8 week and 29.5 +/- 4.2 week in fasting and non-fasting groups. There was no significant difference between the 2 groups in age, gestational age, gravidity, parity and systolic/diastolic blood pressures. The mean deepest vertical pocket in fasting and non-fasting groups were 65.9 +/- 12.9 mm and 62.7 +/- 6.5 mm and there was no significant difference between the 2 groups in this regard. Mean AFI in fasting group [189.9 +/- 35.9 mm] and in non-fasting group [166.8 +/- 25.3 mm] showed a significant difference [p value aof less than 0.05]. Based on the results of the present study fasting in Ramadan has no significant effect on the decrease of AFI, deepest vertical pocket and amniotic fluid volume

Diagnóstico laboratorial do líquido amniótico / Laboratory diagnosis of amniotic fluid

O presente trabalho tem como objetivos a definiçäo e a fisiologia do líquido amniótico, ressaltando aspectos citológicos e principais técnicas para diagnóstico laboratorial das patologias mais freqüentes. A metodologia utilizada foi a revisäo bibliográfica atualizada relacionando os aspectos citológicos com a idade gestacional e técnicas laboratoriais para diagnóstico das principais patologias em que säo observadas alterações do líquido amniótico, concluindo-se que este é um importante componente do ambiente intra-uterino. Sua produçäo e absorçäo dependem de uma série de mecanismos interdependentes entre o feto, a placenta, as membranas e o organismo materno. Atualmente este fluido pode fornecer inúmeras informações sobre a saúde fetal, realizando-se diversas técnicas, entre elas a amniocentese e a dosagem de alfafetoproteína, que pode detectar defeitos do tubo neural e trissomia do cromossomo 21. A análise do líquido amniótico reforça a importância da realizaçäo adequada de um pré-natal, sendo importante relacionar os resultados laboratoriais com a clínica

Síndrome de aspiraçäo do mecônio: análise de resultados obstétricos e perinatais / Meconium aspiration syndrome: obstetric and perinatal outcome analysis

Objetivos: analisar os resultados obstétricos e perinatais de 26 casos de síndrome de aspiraçäo de mecônio (SAM). Métodos: realizou-se uma revisäo dos prontuários de 26 recém-nascidos (RN) com diagnóstico de SAM. Os casos foram estudados em funçäo da média de permanência do RN na UTIN e das principais complicações maternas e neonatais, correlacionando-as entre si. Resultados: dezoito conceptos nasceram no HG-FUCS e 8 fora; no período citado, ocorreram 3.976 nascimentos no HG-FUCS, incidência de SAM de 0,45 por cento. Dos 18 casos estudados, 9 nasceram pela via vaginal; o peso ao nascimento foi 2.500 g em dezesseis casos. Mecônio leve ocorreu em 50 por cento, semelhante ao espesso. O Apgar no 1º minuto foi 7 em 3 casos (16,7 por cento), entre 4 e 6, em 7 casos (38,9 por cento), e entre 0 e 3, em 8 casos (44,4 por cento). No 5º minuto, sete RN permaneceram deprimidos. A principal complicaçäo neonatal foi anoxia (36 por cento dos casos). A taxa de óbito neonatal foi de 7,7 por cento. A internaçäo média na UTIN foi de 19,9 dias. Conclusäo: a SAM constitui-se em grave entidade clínica neonatal, relacionando-se com altas taxas de mortalidade neonatal, mecônio espesso em pelo menos a metade dos casos e nascimento de fetos deprimidos na sua maioria

Fisiología renal del feto y del recién nacido / Renal physiology in fetuses and newborns

La placenta regula la hemeostasis orgánica durante la vida fetal. Sin embargo, la función renal del feto es importante desde el punto de vista de producción de orina y regulación del volumen del líquido amniótico. La nefrogénesis incluye el desarrollo del pronefros, mesonefros y metanefros durante el período embrionario. La producción de orina aparece entre la quinta y séptima semana de gestación y la nefrogénesis continúa hasta la semana 35 de edad conceptual, independientemente que el bebé haya nacido o aún se encuentre en útero. Al momento del nacimiento ocurren cambios hemodinámicos importantes que repercuten en la fisiología renal. Se reduce la resistencia vascular renal y en los días siguientes aumentan el flujo plasmático renal, la velocidad de filtración glomerular, así como la producción de algunas hormonas, como la antidiurética o vasopresina y el factor natriutético auricular. Se discute el concepto de inmadurez funcional renal del neonato a término, ya que en condiciones fisiológicas la función renal logra la regulación de la hemeostasis orgánica en este grupo etario. Sin embargo, se advierte que esta situación no es aplicable al prematuro. En el presente trabajo se revisan aspectos fisiológicos y patológicos que intervienen en la regulación del volumen de los diferentes espacios líquidos corporales en el feto y en el recién nacido, así como aspectos hemidínamicos y modificaciones de la fisiología renal en estas etapas difíciles de la vida. También se discuten los mecanismos de regulación del metabolismo ácido-base y criterios de valoración de la función renal y se establece la comparación con niños de mayor edad y con los adultos

Antenatal fetal assessment using biophysical profile score.

This prospective cross sectional study was conducted in a tertiary hospital in Northern India. The objective of the study was to investigate the utility of recording certain fetal biophysical variables at or near term in high risk pregnancy for predicting the fetal outcome. A fetal biophysical profile score was used for predicting the outcome. The scoring system utilized following variables: non stress test, fetal breathing movement, fetal movement, fetal tone and amniotic fluid volume. One hundred and fifty four pregnant women attending a high risk pregnancy clinic were consecutively included in the study. At a cut off score < or = 4, sensitivity of the scoring system was 12.5% and specificity 99.23%. At score < or = 8, corresponding figures were 70.83% and 91.53%. As compared to each individual variable, the positive predictive value for abnormal perinatal outcome improved considerably after combining all the variables. The negative predictive value for normal perinatal outcome did not improve. Though biophysical profile scoring is used as a valuable adjunct in caring high risk fetuses, a simple and more practical screening test should be sought for. The cost-benefit analysis of such tests should also be performed.