Monochorionic triplet pregnancy complicated by conjoined twins and early twin-twin transfusion syndrome.

BACKGROUND: The condition of monozygotic, monochorionic triplet fetuses with a pair of conjoined twins is extremely rare (close to one in a million births), presents challenges in its management, and with poor prognosis. CASE REPORT: We report a case of monochorionic diamniotic triplet pregnancy, ultrasound at 14 weeks shows a pair of conjoined thoracopagus fetuses, sharing heart, liver, and umbilical cord, in addition to omphalocele. The third fetus, without malformations, presents signs of early heart failure compatible with twin-to-twin transfusion syndrome. It was decided to carry out expectant management where at 18 weeks, intrauterine death of the three fetuses occurs. An abortion is performed by hysterotomy. CONCLUSIONS: The treatment in these cases is discussed, three management options have been proposed: expectant management, selective reduction of the conjoined fetuses, or termination of the pregnancy. A review of the literature found only 12 cases with this combination of pathologies, in which only 3 normal fetuses (25%) survived and none of the conjoined twins survived. To our knowledge, this case is the first of a monochorionic triplet pregnancy with conjoined fetuses complicated with early twin-to-twin transfusion.

Umbilical artery pulsatility index and half-peak systolic velocity in second- and third-trimester fetuses with trisomy 18 and 13.

OBJECTIVES: To analyze umbilical artery (UA) Doppler velocimetry and its possible role in placenta-mediated fetal growth restriction (FGR) in second- and third-trimester fetuses with trisomy 18 and 13. METHODS: UA pulsatility index (PI) and half-peak systolic velocity deceleration time (hPSV-DT) were measured in fetuses with trisomy 18 and 13. Correlation with gestational age, birthweight, and perinatal outcome was analyzed. RESULTS: A total of 80 measurements were taken from 33 fetuses with trisomy 18 and 19 with trisomy 13. Overall, there was a high prevalence of abnormal UA Doppler velocimetry. In fetuses with trisomy 18, 54% (27/50) of the UA PI values and 58% (29/50) of the UA hPSV-DT values were abnormal. In fetuses with trisomy 13, 80% (24/30) of the UA PI values and 87% (26/30) of the UA hPSV-DT values were abnormal. The prevalence of abnormal UA Doppler velocimetry increased with gestational age in both types of aneuploidy. However, this trend was only significant for trisomy 13 (p<0.05). All fetuses with trisomy 18 and 86% of fetuses with trisomy 13 were classified at birth as FGR. There were no perinatal survivors in this series. CONCLUSIONS: A high prevalence of abnormal UA Doppler velocimetry was found in second- and third-trimester fetuses with trisomy 18 and 13, which further increased with gestational age. These results may well correlate with alterations described previously in the placenta, suggesting placental insufficiency has an important role in the development of FGR in these autosomal aneuploid fetuses.

Umbilical artery pulsatility index and half-peak systolic velocity deceleration time in fetuses with trisomy 21.

Objective: To analyze placental vascular resistance and the role of placental insufficiency in the etiology of reduced fetal growth in fetuses with trisomy 21 as determined by umbilical artery (UA) Doppler velocimetry.Methods: Second- and third-trimester UA Doppler ultrasound studies were performed in fetuses with trisomy 21 at the time of clinically indicated obstetric ultrasound assessment. The UA pulsatility index (PI) and half-peak systolic velocity deceleration time (hPSV-DT) were measured and recorded. Perinatal outcome was reviewed and the results from UA Doppler velocimetry were compared with birthweight according to gestational age at the time of the delivery.Results: A total of 60 fetuses with trisomy 21 were studied and information from 147 UA Doppler studies was analyzed. Overall, at least one of the UA PI and hPSV-DT values was abnormal in 82% (n = 49) and 90% (n = 54) of the cases, respectively. The incidence of abnormal UA PI values increased with gestational age from 39% (7/18) before 21 weeks to 78% (18/23) after 35 weeks (p < .05). The increase was even more evident for UA hPSV-DT values from 28% (5/18) before 20 weeks to 91% (21/23) after 35 weeks (p < .01). After exclusion of four fetuses with hydrops or isolated hydrothorax/ascites, 16 (29%) were classified at birth as small for gestational age (SGA), 34 (61%) as adequate for gestational age, and six (11%) as large for gestational age, with a mean birthweight z-score of -0.36. When only considering the last Doppler ultrasound assessment prior to delivery, UA PI and hPSV-DT values were abnormal in 73% (41/56, mean z-score = +1.72) and 82% (46/56; mean z-score = -2.18) of the cases, respectively. Mean gestational age at delivery and birth weight were significantly lower in the group with abnormal compared to normal UA PI and hPSV-DT values. Similarly, the incidence of SGA fetuses was significantly higher in the group with abnormal compared to normal UA PI and hPSV-DT values, with 94 (n = 15) and 100% of the 16 SGA newborn infants having abnormal UA PI and hPSV-DT values prior to delivery, respectively.Conclusions: Trisomy 21 fetuses have a progressively higher incidence of abnormal UA impedance indices throughout pregnancy, which suggests developing placental vascular resistance as the pregnancy progresses. This alteration likely begins around the mid second trimester and increases with gestational age; however, increasing placental vascular resistance seems to produce a discrete decrease in fetal growth, despite severe alteration of the UA Doppler impedance indices. As a general hypothesis, we postulate that trisomy 21 fetuses have increasing placental vascular resistance but there may be some factors that protect these fetuses from severe fetal growth restriction.

Umbilical Artery Half-Peak Systolic Velocity Deceleration Time in Fetal Growth Restriction.

OBJECTIVE: To study the umbilical artery (UA) half-peak systolic velocity deceleration time (hPSV-DT) in pregnancies complicated by fetal growth restriction (FGR). METHODS: The study included 266 singleton, high-risk pregnancies with an estimated fetal weight <10th percentile, which were examined between 24 and 40 weeks' gestation and delivered within a week from the last ultrasound evaluation. UA hPSV-DT was measured with Doppler ultrasound in the same wave used to measure the pulsatility index. UA hPSV-DT values were correlated with perinatal outcome. RESULTS: UA hPSV-DT <5th percentile was found in 87 and 98% of fetuses with moderate and severe FGR, respectively. 94% of fetuses with a UA hPSV-DT <90 ms had poor perinatal outcome including perinatal death or prolonged admission to the neonatal intensive care unit. None of the fetuses had a UA hPSV-DT <70 ms. Perinatal death occurred in 39 fetuses; UA hPSV-DT was abnormal in all of them, with 95% of these fetuses having values of ≤120 ms. In the group of fetuses with absent/reverse end-diastolic velocity in the UA, the perinatal mortality rate was 51% for those with a UA hPSV-DT ≤90 ms and only 23% for those having a UA hPSV-DT >90 ms (p < 0.01). CONCLUSIONS: UA hPSV-DT seems to be a useful technique in the evaluation of pregnancies at risk for FGR and perinatal death. Additionally, hPSV-DT was shown to be a good predictor of perinatal death, with values of <90 ms corresponding to imminent risk of intrauterine demise and values of <70 ms being likely to be incompatible with intrauterine life.

Arteria umbilical única: reporte de tres casos / Single umbilical artery: report of three cases

La arteria umbilical única es la malformación más frecuente del cordón umbilical y se asocia a un aumento de las complicaciones del embarazo y del recién nacido, pesquisándose hasta un 68 por ciento de malformaciones congénitas entre las que destacan las cardiopatías. El ultrasonido con estudio de flujo doppler es un método diagnóstico sensible para el diagnóstico de arteria umbilical única. Se presentan tres casos clínicos de arteria umbilical única diagnosticados en el Servicio de Gineco-Obstetricia del Hospital San Juan de Dios, a los cuales se les realizó seguimiento desde el diagnóstico hasta el fin del embarazo. Este trabajo analiza el curso clínico de los tres casos de arteria umbilical única, revisando sus complicaciones y el resultado perinatal, además de destacar la importancia del doppler en el diagnóstico de esta patología.

Síndrome HELLP: a propósito de un caso / HELLP syndrome: apropos of a case

Se presenta un caso clínico de síndrome HELLP y se realiza una revisión de la literatura. El síndrome es una variedad de la peeclampsia consistente en hemólisis microangiopática, trombocitopenia y falla hepatocelular: se debería a un desequilibrio en la sínteses de prostaglandinas, con aumento de tromboxano y disminución de prostaciclina. El pronóstico es malo, con mortalidad perinatal de 8-36% y materna de l,8-3,5%. Como conclusión, el síndrome HELLP es un índice de severidad de la pre-eclampsia, y su manejo debe ser agresivo, con interrupción inmediata del embarazo

El embarazo en la quinta década de la vida / Pregnancy in the fifth decade of life

Se analizan los resultados de 163 embarazos en pacientes de 40 años o más, comparado con un grupo control. Se demuestra que las embarazadas mayores de 40 años tienen mayor incidencia de patología previa a la gestación (24%), diabetes y gestación, miomatosis e hipertensión arterial crónica. Durante el parto son más frecuentes el sufrimiento fetal agudo y la césarea (41%). En los recién nacidos se demostró mayor frecuencia de asfixia neonatal, bajo peso de nacimiento y síndrome de Down (3,6%). La mortalidad perinatal es de 36,8% nacidos vivos, sin diferencia estadística respecto al grupo control (p = 0,054), pero se eleva al 75% en los hijos de pacientes con patología previa al embarazo. Como conclusión, el embarazo sobre los 40 años condiciona un riesgo, principalmente por la patología asociada. El 93% (con limites de confianza de 90-96%), logra un niño vivo, sano y sin malformaciones, y esta cifra mejora en las pacientes sin patología previa

Primaridad tardía / Delayed primiparity

Se analizan las fichas clínicas de 167 primíparas tardías (P.T.), e igual número de pacientes controles, que resolvieron su parto en la maternidad del Hospital Clínico de la Universidad Católica, entre los años 1978 y 1983. Se demuestra que las P.T. tenían entre sus antecedentes mayor incidencia de infertilidad, abortos previos, hipertensión arterial crónica y mioma uterino. Durante el embarazo estas pacientes presentaron, con mayor frecuencia, síndrome hipertensivo del embarazo, diabetes gravídica, meconio y distocias de presentación al término. 55% de ellas cursó un embarazo fisiológico. La vía de parto en P.T. fue cesárea electiva en 40,7% de los casos; de las pacientes que tuvieron trabajo de parto, 69% logró parto vaginal (40% del total de P.T.). No hubo diferencias en el puerperio, salvo una disminución de la lactancia exclusiva. En cuanto al RN, no se demostraron diferencias en el índice de Apgar, morbilidad, prematurez y mortalidad perinatal. Existió mayor incidencia de bajo peso de nacimiento y de malformaciones congénitas, así como menor peso promedio en los RN de las P.T.. Se concluye que una buena parte de las P.T. tiene embarazo normal, y que con un buen control antenatal y un manejo juicioso de la cesárea y el trabajo de parto condicionan un pronóstico materno y perinatal semejante a primigestas más jóvenes