First trimester examination of fetal anatomy: clinical practice guideline by the World Association of Perinatal Medicine (WAPM) and the Perinatal Medicine Foundation (PMF).

This recommendation document follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation. We aim to bring together groups and individuals throughout the world for precise standardization to implement the ultrasound evaluation of the fetus in the first trimester of pregnancy and improve the early detection of anomalies and the clinical management of the pregnancy. The aim is to present a document that includes statements and recommendations on the standard evaluation of the fetal anatomy in the first trimester, based on quality evidence in the peer-reviewed literature as well as the experience of perinatal experts around the world.

The use of antenatal corticosteroids for fetal maturation: clinical practice guideline by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine foundation.

This practice guideline follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world, with the goal of improving the use of antenatal corticosteroids (ACS) for fetal maturation. In fact, this document provides further guidance for healthcare practitioners on the appropriate use of ACS with the aim to increase the timely administration and avoid unnecessary or excessive use. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world and serves as a guideline for use in clinical practice.

Manejo prenatal del teratoma sacroccocígeo, a propósito del primer caso sometido a transfusión sanguínea intrauterina en el Perú / Prenatal management of sacroccocygeal teratoma, a propos of the first case subjected to intrauterine blood transfusion in Peru

El teratoma sacrococcígeo es una enfermedad rara en el feto, pero con alta mortalidad perinatal debido al secuestro de flujo sanguíneo y consiguiente desarrollo de anemia fetal severa. Presentamos el caso de una gestante de 27 semanas referida a nuestro servicio para manejo prenatal de un feto con teratoma sacrococcígeo gigante, que desarrolló anemia fetal severa y fue sometido a una transfusión intrauterina intravascular, la cual pudo prolongar el embarazo y mejorar los resultados perinatales.

Sacrococcygeal teratoma is a rare fetal disease but with high perinatal mortality due to sequestration of blood flow and consequent development of severe fetal anemia. We present the case of a 27 weeks pregnant woman referred to our service for prenatal management of a fetus with giant sacrococcygeal teratoma and severe anemia and who was subjected to intrauterine intravascular transfusion that could permit prolongation of the pregnancy and improve perinatal results.

Incidence of eclampsia with HELLP syndrome and associated mortality in Latin America.

OBJECTIVE: To describe the maternal outcome among women with eclampsia with and without HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). METHODS: A cross-sectional study of women with eclampsia was undertaken in 14 maternity units in Latin America between January 1 and December 31, 2012. Outcomes were compared between women with and without concomitant HELLP syndrome. Logistic regression analysis was performed to identify independent risk factors of maternal mortality. RESULTS: There were 196 eclampsia cases among 115 038 deliveries; 142 (72.4%) women had eclampsia alone and 54 (27.6%) women had concomitant HELLP syndrome. Severe systolic hypertension (≥160 mm Hg), severe diastolic hypertension (≥110 mm Hg), and hypertensive encephalopathy were significantly more common among women with HELLP than among those with eclampsia alone (P=0.01 for all). There were 8 (4.1%) maternal deaths, all in the group with HELLP syndrome, and 18 (9.1%) perinatal deaths. In a multivariate regression model, maternal mortality was significantly associated with low platelet count and severe systolic hypertension (P<0.05). CONCLUSION: Eclampsia with HELLP syndrome is a dangerous complication associated with pregnancy. Low platelet count secondary to HELLP syndrome and severe systolic hypertension were independently associated with maternal mortality from eclampsia.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth.

BACKGROUND: When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean (VBAC), current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution. OBJECTIVES: To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned VBAC for women with a previous caesarean birth. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: Two randomised trials involving 320 women and their infants were included. However, data for maternal and infant clinical outcomes were available from one trial with very low event rates, involving 22 women only.For the primary outcomes maternal death or serious morbidity (one study; 22 women; risk ratio (RR) not estimable), and infant death or serious morbidity (one study; 22 women; RR not estimable), there were no statistically significant differences between planned caesarean birth and planned vaginal birth identified. AUTHORS' CONCLUSIONS: Planned elective repeat caesarean section and planned VBAC for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is largely drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

Valor predictivo del índice de pulsatilidad promedio de las arterias uterinas en la predicción de preeclampsia en las gestantes entre 11 y 14 semanas, Instituto Nacional Materno Perinatal / Predictive value of mean pulsatility index of uterine arteries in the prediction of preeclampsia in pregnant women between 11 and 14 weeks, National Maternal Perinatal Institute

Los trastornos hipertensivos son una de las complicaciones más frecuentes del embarazo, constituyendo un problema de salud pública mundial. En el Perú se registra entre un 10% y 14%, y constituye una de las tres primeras causas de mortalidad materna y de retardo del crecimiento intrauterino. En los últimos años se ha demostrado que un patrón anormal en las ondas velocidad de flujo de las arterias uterinas durante el primer trimestre del embarazo está relacionado con un mayor riesgo de desarrollar preeclampsia. Objetivo: Determinar el índice de pulsatilidad (IP) promedio de las arterias uterinas y calcular el valor predictivo del percentil mayor o igual que 95 (p95) en la predicción de preeclampsia en las gestantes entre 11 y 14 semanas de gestación. Métodos: Estudio longitudinal llevado a cabo en la Unidad de Medicina Fetal del Instituto Nacional Materno Perinatal, hospital docente de la ciudad de Lima, en el periodo mayo de 2009 a marzo de 2010. Las participantes fueron gestantes entre 11 y 14 semanas. Se realizó una evaluación Doppler de las arterias uterinas en las gestantes que acudían a su control prenatal. Mediante Doppler color se identificaron las arterias uterinas derecha e izquierda y luego con el Doppler pulsado se obtuvieron las ondas de velocidad de flujo. Se realizó la determinación del índice de pulsatilidad (IP) promedio de las arterias uterinas, identificación del p95, determinación de la sensibilidad, especificidad, valor predictivo positivo (VPP) y negativo (VPN). Resultados: De las 120 pacientes estudiadas, 24 presentaron hipertensión gestacional (20%), seis preeclampsia leve (5%) y cuatro preeclampsia severa (3.3%). El valor del IP promedio para el p95 fue 2.66. La capacidad predictiva del IP anormal (IP 2.66) se estableció estimando una sensibilidad de 20% (IC95%: 0.0% a 49.8%), especificidad de 96.4% (IC95%: 92.4% a 100%), VPP de 33.3% (IC95%: 0.0% a 79.4%), VPN de 93.0% (IC95%: 87.9% a 98.1%)...

Hypertensive disorders are one of the most common complications during pregnancy, constituting a public health problem worldwide. It has been reported between 10% and 14% of pregnancy, in Peru, and it is one of the three leading causes of maternal mortality and intrauterine growth retardation. In recent years it has been shown that an abnormal pattern on the flow rate of the uterine arteries during the first trimester of pregnancy is associated with an increased risk of developing preeclampsia. Objective: To determine the pulsatility index (PI) average of the uterine arteries and calculate the predictive value of percentile more or equal than 95 (p95) in the prediction of preeclampsia in pregnant women between 11 and 14 weeks of gestation. Methods: A longitudinal study conducted in the Fetal Medicine Unit of the National Maternal Perinatal Institute, a teaching hospital in the city of Lima, in the period May 2009 to March 2010. Participants were pregnant women between 11 and 14 weeks. An assessment of uterine artery Doppler in pregnant women attending prenatal care was performed. Color Doppler identified the right and left uterine arteries and then obtained Doppler waves velocity. We performed the determination of the pulsatility index average of the uterine arteries, identification of p95, determination of sensitivity, specificity, positive and negative predictive value (PPV and NPV). Results: Of the 120 patients studied, 24 had gestational hypertension (20%), six mild pre-eclampsia (5%) and four severe pre-eclampsia (3.3%). The average value of IP for p95 was 2.66. The predictive ability of abnormal IP (IP 2.66) was established by estimating a sensitivity of 20% (95%CI 0.0% to 49.8%), specificity of 96.4% (95%CI 92.4% to 100%), PPV of 33.3% (95%CI 0.0% to 79.4%), NPV of 93.0% (95%CI 87.9% to 98.1%) and validity index of 90.0% (95%CI 84.2% to 95.8%). The estimated relative risk was 4.75 (95%CI: 1.28 to 17.68)...

Perinatal outcomes after sonographic detection of isolated short femur in the second trimester.

PURPOSE: To determine the association of fetal isolated short femur in the second-trimester ultrasound (US) examination with perinatal outcomes such as small-for-gestational age (SGA) and low-birth weight (LBW) neonates. METHODS: This is a retrospective cohort study in fetuses routinely assessed by US examination at 18 to 24 weeks during 2006-2009. A fetal isolated short femur was defined as femur length below the 5th percentile and with no chromosomal or structural abnormalities. Fetuses with abdominal circumference below the 5th percentile at the time of US examination were excluded. Each case of short femur was matched with three controls according to gestational age at the time of the US examination. RESULTS: Sixty-one fetuses met the inclusion criteria. Both the group of women carrying a fetus with isolated short femur and that of women carrying a fetus with normal femur length had similar general and obstetric characteristics. Women carrying a fetus with isolated short femur were significantly more likely to deliver a SGA neonate (19.7% versus 8.7%, p < 0.05) and a LBW neonate (19.7% versus 7.1%, p < 0.05) than women carrying a fetus with normal femur length. Logistic regression analysis found odds ratios for SGA and LBW of 2.6 (95% confidence interval, 1.1-5.9) and 2.9 (95% confidence interval, 1.2-7.1), respectively. CONCLUSIONS: Isolated short femur in the second-trimester US examination is associated with a subsequent delivery of SGA and LBW neonates.

Risk of impending preterm delivery associated with the presence of amniotic fluid sludge in women in preterm labor with intact membranes.

OBJECTIVE: To determine the association of amniotic fluid sludge with impending preterm delivery in women in preterm labor with intact membranes. METHODS: This was a retrospective cohort study in women at 22-34 weeks' gestation in preterm labor with intact fetal membranes between February 2008 and May 2009. 16 women with amniotic sludge were identified. Each case of amniotic sludge was matched with 3 randomly selected controls. The primary outcome was delivery within 48 h of examination. RESULTS: Mean cervical length was shorter in women with sludge than women without sludge (20.5 ± 9.0 vs. 27.9 ± 6.9 mm, p = 0.0016). There was a significant difference in the mean ultrasound-to-delivery interval in women with and without sludge (21.7 vs. 49.4 days, p = 0.006). Logistic regression analyses demonstrated that amniotic fluid sludge is a strong independent predictor of impending preterm delivery within 48 h (OR 11.2, 95% CI 1.2-125.9), 7 days (OR 3.8, 95% CI 1.2-17.3) and 14 days (OR 7.5, 95% CI 1.8-30.4). CONCLUSIONS: Amniotic fluid sludge on ultrasound scan is associated with impending preterm delivery in women in preterm labor with intact membranes.

Prenatal sonographic diagnosis of duplicated middle cerebral artery.

We report a fetus scanned by color Doppler ultrasound at 37 weeks for suspicion of growth restriction with an extremely rare variation of duplicated middle cerebral artery. Three-dimensional color power Doppler and tomographic ultrasound imaging enhanced our incidental finding.

Síndrome de costillas cortas y polidactilia: displasia esquelética fetal incompatible con la vida / Short rib polydactyly syndrome: lethal skeletal dysplasia

El síndrome costillas cortas polidactilia es una categoría descriptiva para un grupo de displasias esqueléticas incompatibles con la vida, caracterizadas por tórax estrecho, costillas extremadamente pequeñas, micromelia, polidactilia y anomalías viscerales. Las 4 variantes establecidas son SRPS I (tipo Saldino-Noonan), SRPS II (tipo Majewski), SRPS III (tipo Verma-Naumoff) y SRPS IV (tipo Beemer-Langer). Se piensa que todas las variantes son heredadas en forma autosómica recesiva. Debido a la frecuente superposición fenotípica, existe controversia si las variantes son debidas a expresión variable o a heterogeneidad genética. Presentamos un caso de un feto masculino, con signos ecográficos característicos de displasia esquelética, tales como micromelia, tórax estrecho en forma de campana, hipertelorismo, implantación baja de las orejas y polidactilia, que nació de parto vaginal y falleció a los 2 días de vida, producto de insuficiencia respiratoria, la cual presentó desde el nacimiento.

Short rib-polydactyly syndrome is a descriptive category for a group of lethal skeletal dysplasias characterized by hypoplastic thorax, short ribs, short limbs, polydactyly, and visceral abnormalities. The 4 established variants are SRPS I (Saldino-Noonan type), SRPS II (Majewski type; 263520), SRPS III (Verma-Naumoff type; 263510), and SRPS IV (Beemer-Langer type; 269860). All variants are thought to be inherited in autosomal recessive pattern. Because of the frequent phenotype overlap there is controversy as to whether the variants are due to variable expression or to genetic heterogeneity. We present a case of a male fetus, with typical ultrasound markers of skeletal dysplasia such as micromelia, bell shaped narrow thorax, hypertelorism, low implantation ears and polidactily who was born by vaginal delivery and died two days later due to respiratory insufficiency present since birth.

Displasia mesenquimal placentaria / Placental mesenchymal dysplasia

La displasia mesenquimal placentaria es una rara condición de placentomegalia y vellosidades coriales anormales, con frecuencia confundida clínicamente como mola hidatidiforme parcial. Sin embargo, es clínica y patológicamente distinta, con alta incidencia de restricción de crecimiento intrauterino y muerte fetal. Se presenta la evolución clínica de una gestante portadora de una displasia mesenquimal placentaria, el primer caso diagnosticado en el Instituto Nacional Materno Perinatal. Se describe el problema, para sospechar el diagnóstico y el manejo de la gestación. Hubo necesidad de realizar cesárea a las 27 semanas de gestación, obteniéndose una recién nacida mujer de 1 048 gramos, con Ápgar 8 al minuto y 9 a los 5 minutos, líquido amniótico sanguinolento en regular cantidad y placentomegalia. La paciente evolucionó satisfactoriamente y salió de alta al tercer día. En el neonato se confirmó una tumoración abdominal hepática y tuvo que ser intervenido quirúrgicamente, previa ganancia ponderal, determinándose el diagnóstico anatomopatológicode hamartoma mesenquimal de hígado.

Placental mesenchymal dysplasia is a rare condition of placentomegaly and abnormal chorionic villous, often clinically confused as partial hydatidiform mole. However, it is different clinically and pathologically, with high incidence of intrauterine growth restriction and still birth. We present the clinical course of a pregnant woman carrying placental mesenchymal dysplasia, the first case diagnosed at the Maternal Perinatal National Institute, how to suspect diagnosis and gestational care. There was need for caesarean section at 27 weeks gestation, obtaining a 1 048 g newborn girl, with Apgar 8 at the first minute and 9 at the fifth minute, bloody amniotic fluid in regular quantity and placentomegaly. Patient evolved satisfactorily and was discharged on the third hospitalization day. An abdominal liver tumor was confirmed in the newborn and surgical pathology report was liver mesenchymal hamartoma.

Discordancia entre cultivos de vellosidades coriónicas, de corto y largo plazo. Presentación de un caso y revisión del tema / Short and long term chorion villi culture discordance. Presentation of a case and theme review

Presentamos un caso de diagnóstico prenatal en el que se halló un resultado falso negativo en un cultivo a largo plazo de vellosidades coriónicas, discordante con los resultados del cultivo a corto plazo, que mostraba trisomía 21. Se discute las posibles causas de discrepancia en éste y otros casos similares, y la mejor manera de proceder para asegurar el diagnóstico correcto.

We present a prenatal diagnosis case with false negative result in long term villi culture discordant with short term villi culture showing trisomy 21. We discuss possible causes of discordance in this and similar cases and the best way to proceed to ensure correct diagnosis.