Manejo de la embarazada con isoinmunización por anticuerpos irregulares / Pregnant management by isoimmunized irregular antibodies

La isoinmunización eritrocitaria feto-materna se define como la presencia de anticuerpos maternos dirigidos contra antígenos presentes en los glóbulos rojos fetales. Los anticuerpos maternos pueden atravesar la barrera placentaria y provocar hemólisis de los glóbulos rojos fetales produciendo anemia hemolítica e hiperbilirrubinemia, características de la enfermedad hemolítica perinatal (EHP). La principal causa de EHP es la incompatibilidad ABO, seguida de la isoinmunización por RhD; esta última ha disminuido su incidencia dado el amplio uso de inmunoglobulina anti D. Sin embargo, el glóbulo rojo tiene más de 400 antígenos, muchos de ellos (>50) capaces de producir isoinmunización y EHP. En este artículo, revisamos la evidencia y proponemos un algoritmo de manejo y seguimiento de las embarazadas con isoinmunización por anticuerpos irregulares. En la isoinmunización por anticuerpos irregulares, los títulos de anticuerpos maternos no se correlacionan con la gravedad de la enfermedad. La anemia en la EHP por anticuerpos anti-Kell es secundaria a una supresión de la eritroblastosis fetal a diferencia del resto de los sistemas que producen anemia hemolítica. Recomendamos efectuar tamizaje de todas las pacientes en el control prenatal, solicitando grupo sanguíneo, Rh y test de Coombs indirecto. En las pacientes Rh (+) con test de Coombs indirecto positivo es necesario identificar los anticuerpos irregulares. En caso de tener isoinmunización por anticuerpos irregulares con riesgo de EHP, derivar a una unidad de alto riesgo obstétrico para realizar seguimiento de la aparición de anemia fetal midiendo de modo seriado el peak sistólico de la arteria cerebral media. Si se detecta anemia fetal, debemos planificar una cordocentesis para confirmar el diagnóstico y tratar la anemia.

The fetomaternal erythrocyte isoimmunization is defined as the presence of maternal antibodies directed against antigens present in fetal red blood cells. Maternal antibodies can cross the placenta and cause hemolysis of fetal red blood cells causing hyperbilirubinemia and hemolytic anemia, known as perinatal hemolytic disease (PHD). The main cause of PHD is ABO incompatibility, followed by RhD isoimmunization. The latter has decreased its incidence since the widespread use of anti-D immunoglobulin. However, the red cell has more than 400 antigens; many of them (>50) can lead to isoimmunization and PHD. In this article, we review the evidence and propose an algorithm for the management and monitoring of pregnant women with irregular antibodies isoimmunization. In the isoimmunization by irregular antibodies, maternal antibody titers do not correlate with the severity of the disease. Anemia in PHD by anti-Kell is secondary to suppression of fetal erythroblastosis unlike other systems that produce hemolytic anemia. We suggest the screening of all patients in the prenatal control with blood group, Rh and indirect Coombs test. In the Rh (+) patients with positive indirect Coombs test, irregular antibodies should be identified. In case of immunization by irregular antibodies in risk of PHD, the women should be referred to a high-risk obstetrics where the appearance of fetal anemia should be seek by measuring systolic peak of middle cerebral artery. If anemia is detected full confirmation of diagnosis and treatment should be effected by cordocentesis.

Mantención de cerclaje luego de rotura prematura pretérmino de membranas antes de las 34 semanas se asocia a un aumento de corioamnionitis materna y mortalidad neonatal por sepsis / Retained cerclage after preterm premature rupture of membranes before 34 weeks is associated with increased maternal chorioamnionitis and neonatal sepsis mortality

El cerclaje es un factor de riesgo de rotura prematura pretérmino de membranas (RPPM). La RPPM ocurre en aproximadamente un 38-65 por ciento de los embarazos con cerclaje y no existe consenso aún sobre cuál es el manejo más adecuado: retirar o mantener el cerclaje. En esta revisión presentamos la evidencia disponible en relación al retiro versus mantención del cerclaje y su directa influencia sobre el resultado materno-perinatal, con el objetivo de proponer una pauta de manejo. La mantención del cerclaje se asoció a un aumento de la latencia al parto mayor a 48 horas, a un aumento en la incidencia de corioamnionitis clínica, y aumento en la incidencia de mortalidad neonatal por sepsis. Conclusión: en pacientes embarazadas con cerclaje que presentan RPPM antes de las 34 semanas proponemos como la conducta más adecuada la mantención del cerclaje sólo hasta completar la inducción de madurez pulmonar con corticoides, luego retirar el cerclaje y proceder al manejo habitual de un embarazo con RPPM antes de las 34 semanas.

Cervical cerclage is a risk factor for preterm premature rupture of membranes (PPROM). PPROM occurs in about 38-65 percent of pregnancies with cerclage. There is no consensus on whether to remove or retain the cerclage after PPROM. Here we review the evidence about clinical management of PPROM in women with cerclage and its influence on maternal and neonatal outcome. Retained cerclage was found to be associated to a prolongation of pregnancy by more than 48 hours, to a higher incidence of maternal chorioamnionitis and to a higher incidence of neonatal mortality from sepsis. In pregnancies with cerclage complicated with PPROM before 34 weeks we propose to retain the cerclage just enough time to complete fetal lung maturation with corticosteroid therapy, then remove the cerclage and manage pregnancy as any PPROM before 34 weeks.

El cambio del perfil epidemiológico de la mortalidad materna en Chile dificultará el cumplimiento del 5° objetivo del Milenio / The change in the epidemiological profile of maternal mortality in Chile will hinder the fulfillment of the Millennium 5th goal

Background: The death of women during pregnancy, childbirth or puerperium, remains a serious public health problem worldwide. Chile is committed to comply with the Millennium 5th Goal of reducing maternal mortality to 9.9/100,000 live births in 2015. Aim: To analyze trends in maternal mortality in Chile during 2000-2009. Material and Methods: A descriptive population analysis using raw data obtained from the yearbooks of the National Institute of Statistics of Chile. Maternal mortality, causes of death and age of the dead mothers were evaluated. The causes of maternal death were classified according to the tenth revision of International Classification of Diseases. Trend studies were performed using Pearson correlation analysis. Results: In the studied period there were no significant changes in maternal mortality and fertility. The five major causes of maternal death were concurrent diseases, hypertension, abortion, obstetric embolism and postpartum hemorrhage. Mortality associated with concurrent illness showed a significant upward trend (r = 0.656, p = 0.035). Abortion associated mortality had a significant downward trend (r = -0.712, p = 0.023). The group of women 40 years and older significantly increased its birth rate (r = 0.930, p < 0.001), this group showed the highest maternal mortality, especially in association with concurrent diseases. Conclusions: The increased birth rate occurring in women over 40 years old and its larger maternal mortality rate, probably will hinder the fulfillment of the Millennium 5th goal in Chile.

El aborto eugenésico podría explicar la menor mortalidad infantil existente en Cuba comparada con la de Chile / Eugenic abortion could explain the lower infant mortality in Cuba compared to that in Chile

Background: Cuba and Chile have the lower infant mortality rates of Latin America. Infant mortality rate in Cuba is similar to that of developed countries. Chilean infant mortality rate is slightly higher than that of Cuba. Aim: To investigate if the lower infant mortality rate in Cuba, compared to Chile, could be explained by eugenic abortion, considering that abortion is legal in Cuba but not in Chile. Material and Methods: We compared total and congenital abnormalities related infant mortality in Cuba and Chile during 2008, based on vital statistics of both countries. Results: In 2008, infant mortality rates in Chile were significantly higher than those of Cuba (7.8 vs. 4.7per 1,000 live born respectively, odds ratio (OR) 1.67; 95% confidence intervals (Cl) 1.52-1.83). Congenital abnormalities accounted for 33.8 and 19.2% of infant deaths in Chile and Cuba, respectively. Discarding infant deaths related to congenital abnormalities, infant mortality rate continued to be higher in Chile than in Cuba (5.19 vs. 3.82 per 1000 live born respectively, OR 1.36; 95%CI 1.221.52). Conclusions: Considering that antenatal diagnosis is widely available in both countries, but abortion is legal in Cuba but not in Chile, we conclude that eugenic abortion may partially explain the lower infant mortality rate observed in Cuba compared to that observed in Chile.

[The change in the epidemiological profile of maternal mortality in Chile will hinder the fulfillment of the Millennium 5th goal]. / El cambio del perfil epidemiológico de la mortalidad materna en Chile dificultará el cumplimiento del 5° objetivo del Milenio.

BACKGROUND: The death of women during pregnancy, childbirth or puerperium, remains a serious public health problem worldwide. Chile is committed to comply with the Millennium 5th Goal of reducing maternal mortality to 9.9/100,000 live births in 2015. AIM: To analyze trends in maternal mortality in Chile during 2000-2009. MATERIAL AND METHODS: A descriptive population analysis using raw data obtained from the yearbooks of the National Institute of Statistics of Chile. Maternal mortality, causes of death and age of the dead mothers were evaluated. The causes of maternal death were classified according to the tenth revision of International Classification of Diseases. Trend studies were performed using Pearson correlation analysis. RESULTS: In the studied period there were no significant changes in maternal mortality and fertility. The five major causes of maternal death were concurrent diseases, hypertension, abortion, obstetric embolism and postpartum hemorrhage. Mortality associated with concurrent illness showed a significant upward trend (r = 0.656, p = 0.035). Abortion associated mortality had a significant downward trend (r = -0.712, p = 0.023). The group of women 40 years and older significantly increased its birth rate (r = 0.930, p < 0.001), this group showed the highest maternal mortality, especially in association with concurrent diseases. CONCLUSIONS: The increased birth rate occurring in women over 40 years old and its larger maternal mortality rate, probably will hinder the fulfillment of the Millennium 5th goal in Chile.

[Eugenic abortion could explain the lower infant mortality in Cuba compared to that in Chile]. / El aborto eugenésico podría explicar la menor mortalidad infantil existente en Cuba comparada con la de Chile.

BACKGROUND: Cuba and Chile have the lower infant mortality rates of Latin America. Infant mortality rate in Cuba is similar to that of developed countries. Chilean infant mortality rate is slightly higher than that of Cuba. AIM: To investigate if the lower infant mortality rate in Cuba, compared to Chile, could be explained by eugenic abortion, considering that abortion is legal in Cuba but not in Chile. MATERIAL AND METHODS: We compared total and congenital abnormalities related infant mortality in Cuba and Chile during 2008, based on vital statistics of both countries. RESULTS: In 2008, infant mortality rates in Chile were significantly higher than those of Cuba (7.8 vs. 4.7 per 1,000 live born respectively, odds ratio (OR) 1.67; 95% confidence intervals (Cl) 1.52-1.83). Congenital abnormalities accounted for 33.8 and 19.2% of infant deaths in Chile and Cuba, respectively. Discarding infant deaths related to congenital abnormalities, infant mortality rate continued to be higher in Chile than in Cuba (5.19 vs. 3.82 per 1000 live born respectively, OR 1.36; 95%CI 1.221.52). CONCLUSIONS: Considering that antenatal diagnosis is widely available in both countries, but abortion is legal in Cuba but not in Chile, we conclude that eugenic abortion may partially explain the lower infant mortality rate observed in Cuba compared to that observed in Chile.

Analisis critico del manejo de la incompetencia cervical

La incompetencia cervical se caracteriza por la dilatación progresiva del cuello uterino en ausencia de contracciones uterinas. Esta condición es causa de aborto de segundo trimestre y parto prematuro. Clásicamente el tratamiento ha sido el cerclaje cervical, cuya utilidad, sin embargo, no ha sido demostrada. La evidencia disponible, y el uso clínico habitual sugiere que el grupo de pacientes con historia clínica característica de incompetencia cervical (abortos repetidos de segundo trimestre secundarios a dilatación cervical pasiva), se beneficiarían del cerclaje cervical en forma electiva entre las 12-14 semanas. Sin embargo, la evidencia no es concluyente respecto de cuál es la mejor opción terapéutica para las pacientes sin historia característica, pero en riesgo de incompetencia cervical (acortamiento cervical ecográfico o antecedente de parto prematuro). Se requiere de estudios randomizados de buen diseño para resolver la pregunta en cada grupo.

Comparación del índice lecitina/esfingomielina versus fosfatidilglicerol en la evaluación de la madurez pulmonar fetal / Comparison of the lecitina/esfingomielina index versus fosfatidilglicerol in the evaluation of pulmonary fetal maturity

Reportamos el manejo y evolución de tres embarazadas cuyo estudio de índice de madurez pulmonar en el líquido amniótico mostró lecitina/esfingomielina (L/E) inmaduro (<2) con fosfatidilglicerol presente. Agregamos una revisión respecto de la capacidad de ambos test de predecir madurez pulmonar. Se ha descrito que cuando el fosfatidilglicerol está presente, aquellas paciente con un índice de L/E > 2 tiene una probabilidad cercana a cero de presentar enfermedad de membrana hialina neonatal. Por el contrario aquellos casos en los que el índice L/E presenta entre 1,5 y 1,9 la probabilidad de desarrollar la enfermedad es de un 3,4 por ciento. Para este último grupo recomendamos que, si la condición fetal y materna lo permite, la interrupción del embarazo sea diferida en una semana

Embarazo en una paciente usuaria de diálisis peritoneal / Pregnancy in a peritoneal dialysis patient

El embarazo en pacientes con insuficiencia renal terminal es un evento infrecuente que se asocia a perdida fetal, prematurez y restricción de crecimiento intrauterino, además de exacerbación o aparición de patología maternal como hipertensión arterial. A continuación se presenta el caso clínico de una paciente en diálisis peritoneal ambulatoria continua que cursa un embarazo en el cual se obtiene excelentes resultados materno-perinatales. Existió un adecuado control metabólico y manejo de las cifras tensionales en la madre. Las complicaciones fetales fueron el desarrollo de polihidroamnios y prematurez (36 semanas de edad gestacional) El producto fue un recién nacido sano adecuado para la edad gestacional, sin complicaciones neonatales. De esta manera sugerimos la diálisis peritoneal como una opción válida en el manejo de pacientes embarazadas en falla renal terminal

Restricción de crecimiento fetal: un hallazgo frecuente entre los recién nacidos prematuros / Premature fetal growth restriction: an finding frequently observed in premature newborns

Clínicamente los partos prematuros se clasifican en: Parto Prematuro Idiopático (PP). Parto Prematuro secundario a Rotura Prematura de Membranas (RPPM) y Parto Prematuro como consecuencia de Indicación Médica (IM). Evaluamos retrospectivamente los antecedentes clínicos maternos y de los recién nacidos prematuros de nuestra maternidad por un período de 4 años (693 RN prematuros) y comparamos el resultado perinatal con el de un grupo control de término. Los partos prematuros se dividen aproximadamente en tercios en los tres grupos clínicos mencionados (28 por ciento RPPM, 39 por ciento PPI y 33 por ciento IM). Evidenciamos que la frecuencia de restricción de crecimiento fetal fue significativamente mayor en el grupo PPI (p< 0.05 OR 1.49, IC 95 por ciento 1.01-2,24) o RPPM (p< 0.05, OR 1.59, IC 95 por ciento 1.01-2.49) comparados con el grupo control. Esta diferencia apoya nuestra hipótesis de que la isquemia útero-placentaria juega un rol etiológico en la génesis del parto prematuro