Expectant management in pregnant women with early and severe preeclampsia and concomitant risk factors.

AIM: The aim of this study was to demonstrate that women with severe early-onset preeclampsia and concomitant risk factors benefit from expectant management. METHODS: This retrospective study was conducted between January 2009 and December 2010. Stable women with severe preeclampsia between 23+6 and 33+6weeks of gestation were admitted to the IOCU for conservative management. They were classified into two groups: those with concomitant risk factors, i.e. associated medical conditions, HELLP syndrome, severe oligohydramnios, fetal growth restriction and multiple pregnancies (group A) and those without (group B). P values lesser than 0.05 were considered statistically significant. RESULTS: No significant differences were found in maternal and perinatal outcomes between groups. Neither were differences observed in pregnancy prolongation (mean: 8.42days (SD±7.462) in group A and 10.5days (SD±8.235) in group B (p=0.391)). At the start of expectant management, 31.8% of fetuses had an abnormal middle cerebral artery Doppler; prior to delivery, this percentage was 77.4%. CONCLUSION: Pregnant women with severe early-onset preeclampsia and associated risk factors benefited from expectant management. During expectant management using a continuous magnesium sulfate regimen, the majority of fetuses showed cerebral vasodilatation. The exact clinical value of this finding should be clarified in further studies.

Sonographic cervical length measurement in pregnant women with a cervical pessary.

OBJECTIVES: The aims of this study were to describe and assess the feasibility of measuring cervical length by standard transvaginal sonography (TVS) and transperineal sonography (TPS) in women with a cervical pessary and compare these measurements with those obtained with a new transvaginal technique. METHODS: Measurement of cervical length by TPS was attempted immediately before measurement using TVS in 48 women with a cervical pessary at between 22 and 23 weeks' gestation. The TVS procedure consisted of two types of measurement: in the first, the probe was placed on the anterior fornix (standard technique) and in the second, the probe was inserted into the pessary to touch the anterior cervical lip (new technique). Two physicians consecutively performed these procedures and compared the measurements obtained. Intraclass correlation coefficients (ICCs) with 95% CI were used to evaluate interobserver reliability, and Bland-Altman analysis was used to assess interobserver agreement. RESULTS: In total, 258 measurements (obtained from 43 women) were analyzed. Interobserver ICCs of the measurements obtained were 0.58 (95% CI, 0.34-0.75) for TPS, 0.65 (95% CI, 0.44-0.79) for the standard TVS technique and 0.97 (95% CI, 0.95-0.98) for the new TVS technique. Bland-Altman analysis showed small mean differences between measurements obtained by two physicians for the three methods, but with narrower limits of agreements (LOA) for the new TVS technique: TPS mean difference - 0.99 mm (95% LOA, - 13.23 to 11.25 mm), standard TVS technique mean difference - 0.23 mm (95% LOA, - 10.90 to 10.44 mm) and new TVS technique mean difference - 0.01 mm (95% LOA, - 2.57 to 2.55 mm). It was apparent from the images obtained that the external os was not visible in 89% of cases when either the TPS or standard TVS technique was used. However, the external os was visible in all cases when the new TVS method was used. CONCLUSIONS: We propose a new technique for measuring and monitoring cervical length in women with a cervical pessary that provides improved visualization of the cervix and increased reliability in comparison to established techniques.

Flujo diastólico umbilical intermitente en gestación gemelar monocorial: descripción de un nuevo signo en la exploración Doppler y asociación con mal pronóstico perinatal / Intermittent diastolic flow in monochorionic twin pregnancies. Description of a new Doppler sign and association with poor perinatal outcome

Objetivo: Evaluar la incidencia y la relevancia clínica del flujo diastólico intermitente en el Doppler de arteria umbilical en la gestación monocorial. Métodos: Estudio prospectivo que incluyó 3 grupos de gemelos monocoriales: grupo I, una cohorte de gemelos monocoriales controlados con ecografía cada 15 días desde el primer trimestre (n = 80); grupo II, retardo de crecimiento intrauterino selectivo (n = 40), y grupo III, síndrome de transfusión fetofetal grave (n = 50). Se registró la presencia y persistencia en el tiempo de flujo diastólico ausente y/o revertido intermitente en el Doppler de arteria umbilical. Se examinaron las placentas, se registró la presencia de anastomosis arterioarteriales grandes (> 2 mm) y se calculó el reparto placentario. Los resultados perinatales se obtuvieron en todos los casos. Resultados: Se observó flujo diastólico intermitente en el 5% (4/80) de los casos del grupo I, en el 45% (18/40) del grupo II y en el 2% (1/50) del grupo III (p < 0,0001, grupo II frente a I y III). Se identificaron anastomosis arterioarteriales grandes en todos los casos examinados con flujo intermitente (18/18) y en el 3,6% (4/112) de los casos sin él. No hubo mortalidad fetal intraútero en el grupo I y en los fetos del grupo II sin flujo intermitente. En los casos del grupo II con flujo diastólico intermitente, la mortalidad intraútero global fue de 19,4%. Conclusiones: El flujo diastólico intermitente debe considerarse como un signo característico de los gemelos monocoriales, y parece ser la expresión de la existencia de anastomosis arterioarteriales grandes. Su incidencia está significativamente aumentada en el contexto del retraso de crecimiento intrauterino selectivo, e indica un mal pronóstico perinatal en esos casos

Objective: To evaluate the incidence and clinical relevance of intermittent diastolic flow on umbilical artery Doppler in monochorionic twin pregnancies. Methods: We performed a prospective study that included 3 groups of monochorionic pregnancies: group I: a cohort of monochorionic pregnancies with ultrasonographic follow-up every 15 days from the first trimester (n = 80); group II: monochorionic twins with selective intrauterine growth retardation (n = 40), and group III: severe twin-twin transfusion syndrome (n = 50). The presence and persistence over time of intermittent absent and/or reverse diastolic flow on umbilical artery Doppler was recorded. Placentas were examined and placental sharing and the presence of large arterio-arterial anastomoses (> 2 mm) were assessed. Perinatal outcome was recorded in all cases.Results: Intermittent diastolic flow was present in 5% (4/80) of pregnancies in group I, 45% (18/40) in group II and 2% (1/50) in group III (p < 0.0001, group II versus groups I and III). Large arterio-arterial anastomoses were identified in all examined pregnancies with intermittent flow (18/18) and in 3.6% (4/112) of those without. The in utero mortality rate was 0% in group I and in group II fetuses without intermittent flow. However, intrauterine mortality was 19.4% in fetuses in group II with intermittent diastolic flow. Conclusions: Intermittent diastolic flow should be considered a characteristic sign of monochorionic pregnancy. This sign seems to result from the presence of large arterio-arterial anastomoses. The incidence of intermittent diastolic flow is significantly increased in the context of selective intrauterine growth retardation, indicating a poor perinatal outcome in these casesAim: To analyze knowledge, sexual behavior and the contraceptive methods used by the young Spanish population. Subjects and method: The study population consisted of teenagers and young adults aged 15-24 years. The method was based on a questionnaire carried out from 15th May until 5th June in a representative sample (n = 1,826). Results: A total of 16.3% of young men and 11.9% of young women did not receive information about sex or contraception during their school years. Among those that had received information, 19% considered it insufficient. The mean age of the first encounter was 17 years. Forty percent of young women did not use any contraceptive method. The most commonly used methods were the condom (36.3%), followed by the pill (17.9%). The condom was incorrectly used by 32.7% of young men and by 30.5% of young women. Eighteen percent of the women reported they had used emergency contraception. Conclusions: Inadequacies in the information received and incorrect use of contraceptive methods probably contribute to teenage pregnancies

Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow.

OBJECTIVE: To assess the incidence of parenchymal lesions on early and late neonatal brain scans and its association with the presence or absence of intermittent absent or reversed end-diastolic umbilical artery flow velocity (A/REDV) in monochorionic twins complicated by selective intrauterine growth restriction (IUGR), as compared to dichorionic twins and monochorionic twins without selective IUGR. METHODS: This was a prospective cohort study involving 42 monochorionic twins diagnosed with selective IUGR and managed expectantly. The presence or absence of intermittent A/REDV was recorded in all cases. This study group was compared to dichorionic twins (n = 29) and monochorionic twins without selective IUGR (n = 32) delivered at 26-34 weeks during the study period. All infants underwent an early neonatal brain scan (at or before the fourth day of postnatal life) and at least one follow-up scan during the first 28 days of postnatal life. Perinatal outcome and the incidence of neurological damage were compared between the study groups. RESULTS: The incidence of intrauterine fetal death (IUD) and periventricular leukomalacia was significantly increased in monochorionic twins complicated with selective IUGR, as compared with the other study groups. Intermittent A/REDV was observed in 22/42 (52.4%) twin pairs, and was always present in the growth-restricted twin. The incidence of IUD (overall 9/44 (20.5%) vs. 0/40, P < 0.001; smaller twin 6/22 (27.3%) vs. 0/20, P < 0.05) and parenchymal brain damage (overall 7/35 (20.0%) vs. 2/40 (5.0%), P = 0.07; larger twin 7/19 (36.8%) vs. 1/20 (5.0%), P < 0.05) was significantly higher in pregnancies with intermittent A/REDV than in those without intermittent A/REDV. Brain damage usually occurred in the larger twin, irrespective of whether the smaller twin was liveborn or not. CONCLUSIONS: The presence of intermittent A/REDV in monochorionic twins with selective IUGR identifies a subgroup with an elevated risk of intrauterine demise of the smaller twin and neurological damage in the larger twin; this latter finding is not restricted to cases with IUD of the cotwin.

Curvas de normalidad de la longitud cervical ecográfica según edad gestacional en población española / Gestational age-dependent normal values of ultrasonographic measurement of cervical length in the Spanish population

Objetivo: Obtener curvas de normalidad de la longitud cervical uterina en población española, en gestación única y gemelar. Sujetos y métodos: Gestantes derivadas a nuestro centro para control ecográfico rutinario entre las 12 y 36 semanas. Se realizaron 285 ecografías transvaginales en gestaciones únicas y 281 en múltiples. Se calculó la media y los percentiles 5 y 95 de la longitud cervical para cada semana de gestación, y se obtuvieron las curvas de normalidad. Resultados: La longitud cervical media disminuyó de forma progresiva durante el embarazo. Tanto en gestaciones únicas como múltiples, el percentil 5 al inicio del segundo trimestre se situó en 25 mm. Sin embargo, en el tercer trimestre se observó una disminución muy marcada especialmente en gestaciones múltiples, que llegó a ser de 15 mm en gestaciones únicas e inferior a 10 mm en múltiples. Conclusiones: Nuestros resultados aportan puntos de corte para la evaluación de la utilización clínica o en investigación de la longitud cervical ecográfica. Las diferencias observadas en gestación única y múltiple justifican la utilización de curvas diferenciadas (AU)

Incidence and characteristics of umbilical artery intermittent absent and/or reversed end-diastolic flow in complicated and uncomplicated monochorionic twin pregnancies.

OBJECTIVE: To evaluate the incidence and clinical relevance of intermittent absent and/or reversed diastolic flow on umbilical artery Doppler in different groups of monochorionic twin pregnancies. METHODS: This was a prospective study involving three groups of monochorionic pregnancies: Group 1: controls followed fortnightly from the first trimester (n = 80); Group 2: cases with selective intrauterine growth restriction (n = 40); and Group 3: cases with severe twin-twin transfusion syndrome (n = 50). The presence and persistence over time of intermittent absent and/or reversed end-diastolic flow on umbilical artery Doppler was recorded. Placentas were examined and placental sharing and the presence of large arterioarterial anastomoses (AAA) was assessed. Perinatal outcome was recorded in all cases. RESULTS: Intermittent absent and/or reversed diastolic flow was present in 5% (4/80) of cases in Group 1, 45% (18/40) in Group 2 and 2% (1/50) in Group 3 (P < 0.0001, Group 2 vs. 1 and 3). Placental examination was performed in 76.4% (130/170) of cases and sharing was 58% for Group 1, 81% for Group 2 and 73% for Group 3 (P < 0.0001, Groups 2 and 3 vs. 1). Large AAA were identified in all examined cases with intermittent flow (18/18) and in 3.6% (4/112) of those without. The in-utero mortality rate was 0% in Group 1 and in Group 2 fetuses without intermittent flow. However, it was 19.4% in Group 2 cases with intermittent diastolic flow. CONCLUSIONS: Intermittent absent and/or reversed end-diastolic flow may be considered to be a characteristic sign of monochorionic pregnancy, and seems to result from the existence of large AAA. Its incidence is significantly increased in the context of selective intrauterine growth restriction, indicating a high risk for poor pregnancy outcome in these cases.

Fetoscopia y coagulación láser en transfusión fetofetal: resultados y evolución neonatal / Fetoscopic laser coagulation in twin-twin transfusion syndrome: results and neonatal outcome

Objetivos: Evaluar los resultados perinatales en los primeros 50 casos de transfusión feto-fetal (TFF) tratados en España con coagulación fetoscópica láser de anastomosis placentarias. Sujetos y métodos: Estudio prospectivo con 50 casos de TFF grave tratadas con láser. Se evaluó la supervivencia y la evolución neonatales, las complicaciones obstétricas, y la tasa de lesión neurológica neonatal (28 días). Resultados: La edad gestacional media de tratamiento fue de 19,8 semanas (rango: 16,6-25,8). La supervivencia neonatal global fue del 72 por ciento (72/100), con un 86 por ciento (43/50) de casos con, al menos, un superviviente. Ocurrió rotura prematura de membranas en 9 pacientes (18 por ciento), tres de ellas (6 por ciento) precoces (menos de 32 semanas). La edad gestacional media de parto fue de 31,8 semanas (rango: 26,0-38,2), con un 94 por ciento (47/50) por encima de las 28 semanas. El peso medio fue de 1.840 g (rango: 640-3.390) para receptores y 1.415 g (rango: 390-2.250) en donantes. Se observó algún grado de lesión neurológica en el 5,5 por ciento (4/72) de los supervivientes. Conclusión: Los resultados presentados se sitúan en el rango alto de lo previamente reportado por otros grupos. La coagulación fetoscópica láser permite ofrecer una alternativa terapéutica a una proporción importante de casos de TFF grave (AU)

Oclusión fetoscópica del cordón umbilical en gestación gemelar monocorial / Fetoscopic cord occlusion in discordant monochorionic pregnancies

Objetivos: La enfermedad o muerte de un feto amenaza gravemente a su gemelo en la gestación gemelar monocorial. En estos casos la cirugía endoscópica intrauterina, mediante la oclusión de cordón, puede ser la única solución para mejorar el pronóstico. Este estudio evalúa la experiencia y los resultados perinatales con la oclusión fetoscópica de cordón umbilical en gestación monocorial discordante en los primeros 14 casos realizados en nuestro centro. Material y métodos: Catorce casos de gestación monocorial biamniótica con indicación de oclusión de cordón tratados mediante oclusión fetoscópica con láser (n = 2), coagulación bipolar (n = 6) o una combinación de los dos (n = 6). Se analizan los resultados perinatales y la presencia de alteraciones en ecografía cerebral al mes de vida. Resultados: El procedimiento se pudo completar en todos los casos. No hubo complicaciones intraoperatorias remarcables. Se produjo muerte intrauterina del feto normal en dos casos (14 per cent). La incidencia global de rotura prematura de membranas fue del 14 per cent (2/14), a las 28 y 36 semanas. La edad gestacional media de parto fue 34,7 (límites, 28-40) semanas, y el peso medio fetal de 2.335 g (límites, 890-3.300 g). La supervivencia neonatal del feto normal fue del 86 per cent (12/14). Un feto nacido a las 28 semanas desarrolló un cuadro de leucomalacia de grado II. En el resto de casos no hubo complicaciones neonatales graves y la ecografía neonatal fue normal. Conclusión: La oclusión fetoscópica de cordón umbilical puede mejorar significativamente el pronóstico del feto normal en la gestación monocorial discordante, y es una técnica consolidada dentro del arsenal terapéutico de la cirugía endoscópica intrauterina. Los resultados presentados en esta serie son comparables a los reportados en series previas, y se sitúan en el rango alto de supervivencia descrito (AU)

Diagnóstico prenatal ecográfico de las alteraciones esqueléticas fetales / Fetal skeletal anomalies. Ultrasound prenatal diagnosis

El diagnóstico prenatal de las alteraciones esqueléticas supone una gran dificultad, sobre todo en los dos primeros tercios del embarazo, comprometiendo por este motivo las tomas de decisiones antes de la 22 semana. A ello se une la extensa relación de las diversas patologías esqueléticas. En el presente capítulo se expone la sistemática exploradora de la anatomía ósea fetal, la clasificación de las patologías más comunes, así como los signos ecográficos más significativos de esta difícil y comprometida patología prenatal (AU)