Análisis de la tasa de cesáreas por grupos de Robson en Clínica Universidad de los Andes

Introducción: La tasa de cesáreas es importante para cualquier centro de atención hospitalaria. Es un indicador de calidad utilizado en muchas publicaciones y, aunque no es una estadística vital, se ha reconocido como un indicador de la calidad de atención. Objetivo: Conocer la tasa de cesáreas en una institución utilizando los grupos de Robson. Métodos: Estudio retrospectivo de bases de datos de la maternidad. Se consideraron las variables de paridad, cesárea anterior, trabajo de parto, inducción, para poder clasificar la población según los grupos de Robson. El análisis consideró los nacimientos desde octubre del 2014 hasta junio del 2021. Resultados: Se observó una tasa de 27,9% en el periodo de estudio. El grupo 5 de Robson, que considera pacientes con una o más tasa de cesáreas, mostró una elevada tasa (68%), contribuyó con el 36% de todas las cesáreas, siendo solamente el 15% de la población. El grupo 3, de multíparas con trabajo de parto espontáneo, tuvo una tasa del 1,8%, contribuyó al 0,4% de las cesáreas, siendo el 20% de la población de estudio. Se encontró una correlación significativa entre uso de parto instrumental y menor tasa de cesáreas, al realizar análisis por operador (Spearman rho: -0,45; IC95%: -0,788 a -0,0190; p = 0,043). Conclusión: La tasa de cesáreas observada fue 27,9%, y las pacientes con cesárea anterior son un grupo donde pueden concentrarse mayores esfuerzos para bajar la tasa global. Entre los operadores, los usuarios de parto instrumental tuvieron menor proporción cesáreas.

Introduction: The cesarean section rate is important for any hospital care center. It is a quality indicator used in many publications, and although not a vital statistic, it has been recognized as an indicator of the quality of care. Objective:: To know the cesarean section rate in an institution using Robson groups. Methods: Retrospective study of maternity databases. The variables of parity, previous cesarean section, labor, induction was considered in order to classify the population according to Robson groups. The analysis considered births from October 2014 to June 2021. Results: A rate of 27.9% was observed in the study period. Robson's group 5, which considers patients with one or more rate of cesarean sections, showed a high rate (68%), contributing to 36% of all cesarean sections, being only 15% of the population. Group 3, multiparas with spontaneous labor, had a rate of 1.8%, contributing to 0.4% of cesarean sections, making up 20% of the study population. A significant correlation was found between the use of instrumental delivery and a lower rate of cesarean sections, when analyzing by operator (Spearman rho: -0.45; IC95%: -0.788 to -0.0190; p = 0.043). Conclusion: The observed cesarean section rate was 27.9%, and patients with a previous cesarean section are a group where greater efforts can be concentrated to lower the overall rate. Among the operators, users of instrumental delivery had a lower proportion of cesarean sections.

COVID-19 grave y embarazo: a propósito de dos casos alrededor de la viabilidad fetal / Severe COVID-19 and pregnancy: on purpose of 2 cases around fetal viability

Resumen El presente trabajo describe la evolución de dos casos clínicos graves de COVID-19 en pacientes embarazadas con 27 y 24 semanas de amenorrea. A partir de estos casos se resume la evidencia disponible en la literatura en relación con el curso grave de la enfermedad durante el embarazo y se sugieren guías para considerar en la reflexión multidisciplinaria que permite manejar y resolver casos similares.

Abstract The present article describes the evolution of two clinical cases of severe COVID-19 in pregnant patients with 27 and 24 weeks of gestational weeks. The available up-to-date evidence about severe course of the disease during pregnancy is resumed. Management guides are suggested for the multidisciplinary approach of similar cases.

En mujeres embarazadas con rotura prematura de membranas y edad gestacional entre 34 y 37 semanas: ¿Es la interrupción del embarazo (manejo activo) mejor que el manejo expectante para reducir la sepsis neonatal? / In pregnant women with premature rupture of membranes and gestational age between 34 and 37 weeks: Is termination of pregnancy (active management) better than expectant management to reduce neonatal sepsis?

INTRODUCCIÓN: La rotura prematura de membranas (RPM) ocurre en un 8 a 10% de las embarazadas, y de ellas, un 20% corresponde a embarazos de pretérmino. El mayor riesgo para el feto luego de una RPM pretérmino son las complicaciones propias de la prematurez. Por debajo de las 34 semanas se favorece el manejo expectante, y el uso de antibióticos y corticoides. Entre las 34 y 37 semanas, sin embargo, las prácticas varían, no habiendo un consenso claro sobre la conducta óptima. OBJETIVO: El objetivo de esta revisión es explorar la evidencia actualmente disponible respecto de la conducta activa versus la expectante en embarazos con RPM entre las 34 y 37 semanas (36 semanas más 6 días). METODOLOGÍA: Se realizó una búsqueda de literatura médica en distintas bases de datos, dentro de las cuales se incluye "PubMed" y "Cochrane", usando los siguientes términos: "Fetal Membranes, Premature Rupture", "Premature Birth", "34 and 37 weeks" y "Clinical Trial". Se limitó la búsqueda a artículos que fueran ensayos clínicos aleatorizados. De un total de 31 trabajos, se seleccionaron 3, a los cuales se les aplicó la pauta de análisis crítico para evaluación de estudios de terapia. RESULTADOS: Se incluyeron 3 estudios que respondían a la pregunta planteada. En el primer estudio se concluyó que en pacientes en que hay interrupción inmediata la incidencia de sepsis neonatal es baja y no es posible demostrar que esta conducta mejore los resultados en comparación con el manejo expectante (2.6% vs. 4.1%). El manejo activo en este estudio se asoció a mayor incidencia de hiperbilirrubinemia, hipoglicemia, y mayor estadía hospitalaria neonatal. En el segundo artículo se planteó que la incidencia de sepsis neonatal sigue siendo baja, lo cual no disminuyó con la inducción del trabajo de parto. Esta tampoco disminuyó el riesgo de otros resultados neonatales o maternos. Finalmente, el tercer estudio concluyó que la interrupción inmediata aumenta las complicaciones neonatales sin disminución de la sepsis neonatal, pero a expensas de mayor frecuencia de fiebre materna y de hemorragia intraparto. CONCLUSIONES: El manejo expectante no es inferior al manejo activo en el contexto de RPM entre las semanas 34 a 37 de edad gestacional.

INTRODUCTION: Premature rupture of membranes (PROM) occur in eight to ten percent of pregnancies, and 20 percent of them occur in preterm pregnancies. Biggest fetal risks after preterm PROM are complications due to prematurity. Before 34 weeks of gestation it is preferred an expectant management, and the use of antibiotics and steroids. Between 34 and 37 weeks, however, practices are variable without a clear consensus about the best management. OBJECTIVE: The objective of this review is to explore the available evidence about active versus expectant management in pregnancies with PROM between 34 and 37 weeks (36 weeks plus 6 days). METHODS: Different databases were searched for medical literature, including 'PubMed' and 'Cochrane', using the following terms: 'Fetal Membranes, Premature Rupture', 'Premature Birth', '34 and 37 weeks' and 'Clinical Trial'. The search was limited to clinical randomized trials. From a total of 31 studies, three were selected, in which critical analysis guidelines for evaluation of therapy studies were applied. RESULTS: Three clinical trials which answered our question were included in this review. The first study concluded that in patients whose pregnancies were interrupted immediately, the incidence of neonatal sepsis was low but is was not able to demonstrate that this action improved outcomes compared to expectant management (2.6% vs 4.1%). Active management in this study was associated to greater incidences of hyperbilirubinemia, hypoglycemia and longer neonatal hospital stay. In the second article the incidence of neonatal sepsis was low and didn't decrease with induction of labor. It also didn't reduce the risk of other maternal nor neonatal outcomes. Finally, the third study concluded that induction of labor increased neonatal complications without reducing neonatal sepsis, but at the expense of increased frequency of intrapartum hemorrhage and maternal fever. CONCLUSION: After analyzing the selected articles, it is possible to conclude that there is enough evidence to say that expectant management is not inferior to active management in relation to PROM between 34 and 37 weeks of gestational age.

Oxidative damage and nitric oxide synthase induction by surgical uteroplacental circulation restriction in the rabbit fetal heart.

OBJECTIVE: This study investigated the role of oxidative damage and nitric oxide (NO) synthases in the fetal heart using a model of intrauterine growth restriction induced by uteroplacental circulation restriction (UCR). METHODS: New Zealand white rabbits kept under 12-h light cycles, with food and water provided ad libitum, were subjected at day 25 of pregnancy to 40-50% uteroplacental artery ligation. We analyzed the gene expression of enzymes linked to nitric oxide synthesis (iNOS, eNOS, HO-1, and ARG-2), hypoxia inducible factor 1 alpha (HIF-1α), and the state of oxidative stress (protein carbonyl levels) in fetal heart homogenates. Additionally, we studied the histological morphology of the fetal heart. RESULTS: We found that fetal growth restriction was associated with a significant reduction in heart weight but a normal heart/body weight ratio in UCR animals. Hematoxylin and eosin staining showed normal left and right ventricular thickness but increased vessel dilatation with hyperemia in the hearts of the UCR group. We observed HIF-1α, eNOS, p-eNOS, and iNOS induction concomitant with intensified protein carbonyl levels but observed no changes in HO-1 or ARG-2 expression, suggesting increased NO and oxidative stress in the hearts of UCR animals. CONCLUSION: Uteroplacental circulation restriction increased NO-linked enzymes, oxidative damage, and dilated coronary vessels in fetal hearts. © 2017 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

Nitric oxide synthase and changes in oxidative stress levels in embryonic kidney observed in a rabbit model of intrauterine growth restriction.

OBJECTIVE: This work aimed to study the effect of uteroplacental circulation restriction on endothelial kidney damage in a fetal rabbit model. METHODS: New Zealand rabbits were subjected to 40% to 50% of uteroplacental artery ligation at day 25 of pregnancy. After 5 days, surviving fetuses were harvested by cesarean section. The gene and protein expressions of selected enzymes associated with nitric oxide production and oxidative stress were analyzed in fetal kidney homogenates. RESULTS: The placenta weight (6.06 ± 0.27, p < 0.0319) and fetal body (19.90 ± 1.03, p < 0.0001) were significantly reduced in the uteroplacental circulation restriction group. The kidneys from restricted fetuses presented a mild vascular congestion and glomerular capillary congestion, without inflammation or hypertrophy. We found endothelial nitric oxide synthase phosphorylation inhibition (0.23 ± 0.13, p < 0.012) and arginase-2 (0.29 ± 0.14, p < 0.023) protein induction in fetal kidneys of the circulation restriction group. Finally, the kidneys from circulation-restricted fetuses showed increased inducible nitric oxide synthase messenger RNA (mRNA) (2.68 ± 0.24, p < 0.01) and reduced heme oxygenase-1 mRNA (23 ± 1.3, p < 0.003), with increased reactive oxygen species (1.69 ± 0.09, p < 0.001) and nitrotyrosine protein (1.74 ± 0.28, p < 0.003) levels, without changes in Nox mRNA. CONCLUSION: We describe significant deregulation of vascular activity and oxidative damage in kidneys of fetal rabbits that have been exposed to restriction of the uterine circulation. © 2016 John Wiley & Sons, Ltd.

Intrauterine growth restriction modifies the normal gene expression in kidney from rabbit fetuses.

The aim of this work was to study the effect of intrauterine growth restriction (IUGR) on fetal kidneys. The IUGR was induced by uteroplacental vessels ligature in a model of pregnant rabbit. We centralized the study in the gene expression of essential proteins for fetal kidney development and kidney protection against hypoxia, osmotic stress, and kidney injury. The gene expression of HIF-1α, NFAT5, IL-1ß, NGAL, and ATM were studied by qRT-PCR and Western blot in kidneys from control and IUGR fetuses. Experimental IUGR fetuses were significantly smaller than the control animals (39 vs. 48 g, p<0.05). The number of glomeruli was decreased in IUGR kidneys, without morphological alterations. IUGR increased the gene expression of HIF-1α, NFAT5, IL-1ß, NGAL, and ATM (p<0.05) in kidneys of fetuses undergoing IUGR, suggesting that fetal blood flow restriction produce alterations in gene expression in fetal kidneys.

Fetal evaluation of the modified-myocardial performance index in pregnancies complicated by diabetes.

OBJECTIVE: To evaluate the fetal cardiac function by modified myocardial performance index (Mod-MPI) in pregnant diabetic patients. METHODS: Modified myocardial performance index was measured in fetuses of patients with diabetes (DM) between 30 and 40 weeks of gestation. The isovolumetric contraction time, isovolumetric relaxation time and ejection time were measured. Mod-MPI was calculated as (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. Results were analyzed by using one-way analysis of variance (post hoc Bonferroni correction), Chi-square and Student's test. RESULTS: Modified myocardial performance index values of fetuses from DM mothers were significantly higher than controls (0.43 vs 0.37, P < 0.0001), and it was not different between gestational versus pregestational DM (0.42 vs 0.45, P = 0.18). Mod-MPI was also higher in the presence of polyhydramnios (0.49 vs 0.41, P < 0.0001), insulin use (0.46 vs 0.40, P < 0.05), and large for gestational age fetuses (0.49 vs 0.40, P < 0.0001). There were no significant differences in Mod-MPI between newborns with versus without neonatal complications such as hypoglycemia or polycythemia. CONCLUSIONS: In fetuses of DM mothers, evaluation of the Mod-MPI identifies those with worse maternal disease and large fetal size.

Cervicovaginal fluid changes to detect ovulation accurately.

OBJECTIVE: The purpose of this study was to evaluate changes in cervicovaginal fluid characteristics to identify ovulation. STUDY DESIGN: Several ovulation indicators were studied in a university-based natural family planning center. Fifteen parous women during 29 ovulatory cycles detected cervicovaginal fluid at the vulva. They self-aspirated their upper vaginal fluid, described it, and kept it for later checking. They also took basal body temperature, collected timed first morning urine samples for estrone and pregnanediol glucuronide enzyme immunoassays, and submitted to serial ovarian transvaginal ultrasound scans. RESULTS: Considering a +/-1-day period since ultrasound ovulation detection or allowing an extra day (-1 to +2), women perceived ovulation from cervicovaginal fluid at the vulva in 76% or 97% of cycles, on the basis of their visual description of vaginally extracted fluid in 76% or 90%, which rose to 90% or 97% for the instructor's description, and in 76% or 86% with a rapid drop in glucuronide ratio. Basal body temperature was less precise (71% or 79%). CONCLUSION: Evaluation of cervicovaginal fluid changes is an accurate ovulation indicator.

Hantavirus y embarazo: aspectos hemodinámicos y respiratorios / Hanta virus and pregnancy: hemodynamic and respiratory aspects

The disease by Hanta virus has a recent diagnose in our country. 218 cases have been reported to date and given its high mortality of 44 percent, a great epidemiological campaign has been implemented, for its isolation and control. The most severe form of this disease, Hanta virus, is the cardio pulmonary syndrome which present characterics that difference it from other similar disorders. The more frequent hemodynamics patrons to find are low cardiac indexes (CI) with pulmonary vascular resistences and elevated (RVS) systemic. On the other hand, the respiratory disorders correspond to a pulmonary edema non cardiogenic, similar to acute respiratory distress syndrome (SDRA). There are few reports of Hanta in pregnant patients described in literature and case present a high rate of fetal and maternal mortality and there is not a clear description of the hemodynamic compromise, or certitude if there is vertical transmission of the virus from the infected mother to the fetus. We described the clinical case of a 12 weeks pregnant patient with cardio pulmonary syndrome due to Hanta virus (SCPH) which shws a different hemodynamics patron than which has been published and who survives both she as well as her child and do not present virus transmission to the fetus