Intended delivery mode and neonatal outcomes in pregnancies with fetal growth restriction.

Objective: To compare neonatal outcomes in pregnancies with fetal growth restriction (FGR) by intended delivery mode.Methods: This is a retrospective cohort study of singleton pregnancies with FGR that were delivered ≥34.0 weeks gestation. Neonatal outcomes were compared according to the intended delivery mode, which the attending obstetrician determined. Of note, none of the subjects had a contraindication to labor. Crude and adjusted odds ratios (ORs) and corresponding confidence intervals (CIs) were calculated via logistic regression models to assess the potential association between intended delivery mode and neonatal morbidity defined as a composite outcome (i.e. umbilical artery pH ≤7.1, 5-min Apgar score ≤7, admission to the neonatal intensive care unit, hypoglycemia, intrapartum fetal distress requiring expedited delivery, and perinatal death). A sensitivity analysis excluded intrapartum fetal distress requiring emergency cesarean delivery from the composite outcome since only patients with spontaneous labor or labor induction could meet this criterion. Potential confounders in the adjusted effects models included maternal age, body mass index, hypertensive disorders, diabetes, FGR type (i.e. early or late), and oligohydramnios.Results: Seventy-two (34%) patients had an elective cesarean delivery, 73 (34%) had spontaneous labor and were expected to deliver vaginally, and 67 (32%) underwent labor induction. The composite outcome was observed in 65.3%, 89%, and 88.1% of the groups mentioned above, respectively (p < 0.001). Among patients with spontaneous labor and those scheduled for labor induction, 63% and 47.8% required an emergency cesarean delivery for intrapartum fetal distress. Compared to elective cesarean delivery, spontaneous labor (OR 4.32 [95% CI 1.79, 10.42], p = 0.001; aOR 4.85 [95% CI 1.85, 12.66], p = 0.001), and labor induction (OR 3.92 [95% CI 1.62, 9.49] p = 0.002; aOR 5.29 [95% CI 2.01, 13.87], p = 0.001) had higher odds of adverse neonatal outcomes.Conclusion: In this cohort of FGR, delivering at ≥34 weeks of gestation, pregnancies with spontaneous labor, and those that underwent labor induction had higher odds of neonatal morbidity than elective cesarean delivery.

Anomalías congénitas disruptivas asociadas con misoprostol. Reporte de un caso / Disruptive congenital anomalies associated with misoprostol. Case report

Resumen ANTECEDENTES: La exposición prenatal al misoprostol puede asociarse con un espectro de defectos congénitos que varían desde anomalías del sistema nervioso central, secuencia de Moebius, defectos en la pared abdominal, defectos transversales en las extremidades hasta alteraciones fetales. Esos defectos se observan más comúnmente con esquemas de solo misoprostol para inducción del aborto. Por esos antecedentes es importante que la historia clínica de toda paciente obstétrica sea exhaustiva para permitir identificar el antecedente de la exposición prenatal luego de un aborto fallido. CASO CLINICO: Paciente de 21 años, con 32 semanas de embarazo, con diagnóstico de feto con ventriculomegalia. En la evaluación ecográfica destacó la ventriculomegalia triventricular severa, simétrica y la angulación de ambas extremidades inferiores en varo. La resonancia magnética reportó: ventriculomegalia no comunicante severa, bilateral, simétrica, por probable estenosis del acueducto de Silvio. Cariotipo 46,XY y perfil TORCH negativo. El embarazo finalizó mediante cesárea, por indicación fetal a las 35 semanas. La evaluación al nacimiento reportó: parálisis facial bilateral, macrocefalia y pie equino varo bilateral. Al volver a interrogar a la paciente refirió haber sido tratada con misoprostol en el primer trimestre del embarazo, con fines abortivos. Al descartar las alteraciones cromosómicas e infecciosas se estableció el diagnóstico de secuencia Moebius. CONCLUSIONES: La exposición prenatal al misoprostol está relacionada con la aparición de defectos vasculares en algunos fetos expuestos. Aún no se ha determinado el espectro preciso ni la estimación potencial de teratogenicidad. La historia clínica es el pilar para la asociación en estos casos.

Abstract BACKGROUND: Prenatal misoprostol exposure can be associated with a spectrum of birth defects, ranging from central nervous system abnormalities, Moebius sequence, abdominal wall defects, as well as transverse limb defects, fetal abnormalities are more commonly seen with the use of the misoprostol-only regimen for induction of abortion, such that a thorough medical history is essential to detect a history of prenatal exposure after a failed abortion. CLINICAL CASE: A 21-year-old patient, with a 32-week pregnancy, who attended the institute with a diagnosis of a fetus with ventriculomegaly, the ultrasound evaluation highlighted severe symmetric triventricular ventriculomegaly and angulation of both lower extremities in varus, magnetic resonance imaging reported severe non-communicating ventriculomegaly Symmetric bilateral, due to probable stenosis of the aqueduct of Silvio, the karyotype reported 46, XY, as well as a negative TORCH profile, however, a cesarean section was performed for fetal indication at 35 weeks, the evaluation at birth showed bilateral facial paralysis, macrocephaly and foot Bilateral equinus varus, upon re-examination the patient referred the use of misoprostol in the first trimester of pregnancy for abortive purposes, so as there were no chromosomal or infectious alterations, a Moebius sequence was suggested. CONCLUSIONS : Prenatal exposure to misoprostol is related to the appearance of vascular disruption defects in some exposed fetuses, the precise spectrum and potential estimation of teratogenicity have not yet been determined, the clinical history is the mainstay for the association in these cases.

Use of a screening questionnaire for systemic lupus erythematosus among pregnant women in a Mexican population.

OBJECTIVE: To conduct a diagnostic assessment of pregnant women using a screening questionnaire for SLE. MATERIALS AND METHODS: This was an analytical cross-sectional study carried out at the National Institute of Perinatology between 1 November 2019 and 28 February 2020, using a screening questionnaire for SLE. Antinuclear antibody and anti-double stranded DNA antibody tests and a clinical assessment by a rheumatologist were conducted for participants who obtained ≥4 positive responses on the questionnaire. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the screening questionnaire for SLE were calculated. RESULTS: The questionnaire survey was conducted with 540 pregnant patients, 22 of whom (4.1%) had ≥4 positive responses. An antinuclear antibody test was conducted in all aforementioned 22 patients; 17 (77.3%) showed titres of ≥1:80. Of the 22 patients, 19 (86.4%) underwent clinical assessment by a rheumatologist. The patients were classified according to the SLE classification criteria: 7/19 (36.9%) met the revised 1997 American College Rheumatology (ACR) criteria, 8/19 (42.1%) met the Systemic Lupus International Collaborating Clinics criteria and 7/19 (36.9%) met the 2019 ACR/EULAR criteria (sensitivity=0.86, specificity=0.97, PPV=0.77 and NPV=1 for antinuclear antibody titre of ≥1:80; sensitivity=0.88, specificity=0.98, PPV=0.37 and NPV=1 for SLE according to the 2019 ACR/EULAR criteria). CONCLUSIONS: The questionnaire showed high sensitivity and specificity in the diagnosis of SLE. Given its usability and cost:benefit ratio, this strategy should be used for all patients coming in for their first visit to determine who requires antinuclear antibody testing and who needs to be referred to a rheumatologist.

Amniocentesis learning curve using a low-cost simulation model to teach maternal-fetal medicine fellows.

OBJECTIVE: To describe the learning curve for amniocentesis among Maternal-Fetal Medicine (MFM) fellows using a low-cost simulation model in Mexico. METHODS: Fourteen first- and second-year MFM fellows with no previous experience in amniocentesis participated in this single-center prospective study from March to June of 2019. The study was approved by the Institutional Review Board at the Instituto Nacional de Perinatologia and written informed consent was obtained from all participants. After an introductory course based on a standardized technique for amniocentesis, each fellow performed this procedure using a low-cost simulation model; experienced operators supervised the procedures. Learning curves were then created using cumulative sum analysis. Thresholds for acceptable and unacceptable failure rates were defined as 10% and 25%, respectively. RESULTS: Experienced MFM specialists evaluated 3675 procedures. On average, MFM fellows performed 263 ± 53 procedures. The mean number to achieve competence was 255 ± 53. The overall failure rate among the trainees was 16%. CONCLUSION: We describe individual learning curves for amniocentesis among MFM fellows using a low-cost simulation model. This approach allows direct assessment of proficiency in amniocentesis before clinical practice.

Transcervical chorionic villus sampling in a low-cost simulation model: Learning curve of maternal-fetal medicine fellows in Mexico.

The implementation of a low­cost simulation model and cumulative sum analysis enables training and monitoring of individual learning curves for transcervical chorionic villus sampling.

Controversias del síndrome de anticuerpos antifosfolipídicos en obstetricia / Controversies concerning the antiphospholipid syndrome in obstetrics

El síndrome de anticuerpos antifosfolipídicos es una enfermedad autoinmune no inflamatoria, caracterizada por eventos trombóticos recurrentes y/o complicaciones obstétricas, asociados a la presencia de anticuerpos antifosfolipídicos circulantes: anticuerpos anticardiolipina, anti-β2 glucoproteína-i y/o anticoagulante lúpico. Los anticuerpos antifosfolipídicos son un grupo heterogéneo de autoanticuerpos asociados con morbilidad obstétrica, como pérdida gestacional recurrente, muerte fetal, parto pretérmino asociado a insuficiencia placentaria como enfermedad hipertensiva del embarazo y/o restricción del crecimiento intrauterino. Los procesos fisiopatológicos relacionados con la morbilidad obstétrica no se han comprendido del todo, involucrándose múltiples eventos inmunológicos, entre ellos los inflamatorios, la activación del complemento, el desbalance de los factores angiogénicos y, en alguna proporción de los casos, se ha demostrado trombosis e infarto. Debido a la controversia en los criterios clínicos y de laboratorio, así como a la repercusión en la mejora de los resultados perinatales en pacientes que inician tratamiento, decidimos llevar a cabo esta revisión sobre los conceptos de síndrome de anticuerpos antifosfolipídico relacionado con complicaciones obstétricas y síndrome de anticuerpos antifosfolipídico seronegativo, así como su manejo en obstetricia (AU)

Antiphospholipid antibody syndrome is a non-inflammatory autoimmune disease characterized by recurrent thrombotic events and/or obstetric complications associated with the presence of circulating antiphospholipid antibodies (anticardiolipin antibodies, anti-β2 glycoprotein-i antibodies, and/or lupus anticoagulant. Antiphospholipid antibodies are a heterogeneous group of autoantibodies associated with recurrent miscarriage, stillbirth, fetal growth restriction and premature birth. The diversity of the features of the proposed placental antiphospholipid antibodies fingerprint suggests that several disease processes may occur in the placentae of women with antiphospholipid antibody syndrome in the form of immune responses: inflammatory events, complement activation, angiogenic imbalance and, less commonly, thrombosis and infarction. Because of the disparity between clinical and laboratory criteria, and the impact on perinatal outcome in patients starting treatment, we reviewed the aspects of antiphospholipid antibody syndrome related to obstetric complications and seronegative antiphospholipid antibody syndrome, and their treatment in obstetrics (AU)

Controversies concerning the antiphospholipid syndrome in obstetrics. / Controversias del síndrome de anticuerpos antifosfolipídicos en obstetricia.

Antiphospholipid antibody syndrome is a non-inflammatory autoimmune disease characterized by recurrent thrombotic events and/or obstetric complications associated with the presence of circulating antiphospholipid antibodies (anticardiolipin antibodies, anti-ß2 glycoprotein-i antibodies, and/or lupus anticoagulant. Antiphospholipid antibodies are a heterogeneous group of autoantibodies associated with recurrent miscarriage, stillbirth, fetal growth restriction and premature birth. The diversity of the features of the proposed placental antiphospholipid antibodies fingerprint suggests that several disease processes may occur in the placentae of women with antiphospholipid antibody syndrome in the form of immune responses: inflammatory events, complement activation, angiogenic imbalance and, less commonly, thrombosis and infarction. Because of the disparity between clinical and laboratory criteria, and the impact on perinatal outcome in patients starting treatment, we reviewed the aspects of antiphospholipid antibody syndrome related to obstetric complications and seronegative antiphospholipid antibody syndrome, and their treatment in obstetrics.

Amniotic band sequence: prenatal diagnosis, phenotype descriptions, and a proposal of a new classification based on morphologic findings.

OBJECTIVE: The aim of this study is to describe the phenotype of fetuses affected by amniotic band sequence (ABS) that were diagnosed at the Instituto Nacional de Perinatología Isidro Espinosa de los Reyes and to propose a new classification based on morphologic findings. MATERIAL AND METHODS: Cases with a final diagnosis of amniotic band sequence, diagnosed between January 1993 and July 2010 in the Department of Maternal Fetal Medicine, were reviewed. Demographic, clinical, and periconceptional data were collected, and the defects were described and classified. The association frequencies of the defects were also determined. RESULTS: We included 50 cases with prenatal diagnosis of amniotic band sequence. The mean maternal age was 25.7 ± 6.9 years. Of these patients, 54% (27/50) were primiparous compared to 22% (11/50) who had three or more previous pregnancies. Craniofacial defects were seen in 78% (39/50) of the cases, followed by defects of the extremities 70% (35/50), abdominal wall, spine, and/or thorax 52% (26/50). The most frequent defects were the following: a) Encephalocele and facial clefts in the craniofacial group. b) Shortening at any level in the limb defects group, and c) Alterations of the spinal column curvature in the group of "other" defects. CONCLUSIONS: The amniotic band sequence shows a tendency to affect women who are in their earlier years of reproduction. We observed an inverse relationship between the number of pregnancies and the frequency of presentation of this pathology. The majority of affected fetuses showed a phenotype that fit into one of many groups. Therefore, we propose classifying the amniotic band sequence phenotypes into the following groups: I. Craniofacial defect + limb defect. II. Craniofacial defect + limb defect + abdominal wall, spinal column, and/or thoracic defects. III. Limb defect + abdominal wall, spinal column, and/or thoracic defects; and IV. Isolated defect (craniofacial, limb, or thoraco-abdominal wall). This classification system will be helpful in diagnosing amniotic band sequence. Based on future research studies, we hope that we can use this classification system as a prognosis fetal factor to establish a more accurate fetal prognosis and recurrence probability. Finally, we created a flowchart describing all of the steps that were followed by our Department from the moment an amniotic band was found by ultrasound until the definitive diagnosis was made and the follow up according to the fetal findings.

Association between selected structural defects and chromosomal abnormalities.

OBJECTIVE: To determine the association between some major structural abnormalities detected prenatally by ultrasound and chromosomal abnormalities. MATERIAL AND METHODS: The present study was a retrolective, transversal study. We analyzed case records of patients during the fetal follow-up at the Department of Maternal Fetal Medicine from January 1994 to May 2010 to identify fetal patients with a diagnosis of holoprosencephaly, diaphragmatic hernia, omphalocele, cystic hygroma, hydrops and cardiac defects. We analyzed patients who had a prenatal invasive diagnosis procedure to obtain the odds ratio (OR) for some major isolated anomalies and their different combinations with respect to chromosomal abnormalities. RESULTS: We examined 280 patients with ultrasonographic markers for chromosomal alteration, 197 met inclusion criteria, from which 88 had chromosomal abnormalities. The most frequent diagnosis was trisomy 18 (31.8%), which was followed by trisomy 21 (21.6%), trisomy 13 (21.6%), Turner syndrome (monosomy X) (14.8%) and other chromosomal abnormalities (10.2%). Among the fetuses with nonisolated holoprosencephaly, we obtained an OR of 4.9 95% CI (0.99-24.2) for aneuploidy. Associated omphalocele had an OR of 7.63 95% CI (2.07-46.75), p < 0.01. Interestingly, 62% of aneuploidy cases had associated cardiac defects [OR = 7.7 95% CI (1.4-41.7)]. In addition, associated cystic hygroma had an OR of 2.5 95% CI (0.59-10.91). Heart defects were the most common defects in fetuses with trisomy 18 (57.1%), when they were associated with facial cleft, we had an OR of 11.08 95% CI (2.99-41.11), p < 0.0001. Statistical potency was calculated for each analyzed defect and it was over 80% for all of them but diaphragmatic hernia. CONCLUSIONS: The association of 2 or more structural defects increased the probability of a fetus to be a carrier of a chromosomal disorder; however this was not statistically significative except for associated omphalocele. Heart defects showed the greatest association with all chromosomal abnormalities. The most important association was among heart defect, facial cleft and trisomy 13.

Prenatal prevalence of skeletal dysplasias and a proposal ultrasonographic diagnosis approach.

OBJECTIVE: To determine the prevalence of fetal bone dysplasias diagnosed at the Department of Maternal Fetal Medicine (UNIMEF) of the Instituto Nacional de Perinatologia (INPer); and to describe the most frequent skeletal dysplasias and to propose a diagnostic flow chart. MATERIALS AND METHODS: This is a case series study including skeletal dysplasias cases from January 1995 until December 2009 at the UNIMEF Statistical analysis was performed using SPSS 12 statistical software. RESULTS: A total of 81,892 births were registered at the institution during the study period. The prevalence of bone dysplasia was 8.1 per 10,000 births. We used a diagnostic flow chart that was developed at our institution to diagnose skeletal dysplasias. Micromelia (n = 40, 59.7%) and both rhizomelia and mesomelia (n = 17, 25.3%) were highly prevalent. We found other structural anomalies in 40 cases (61.1%), which were associated with different skeletal dysplasias; these other anomalies were mainly congenital heart diseases (12 cases) with a predominance of ventricular septal defects. There was polyhydramnios in 43.2% of cases. The mean of the gestational age at diagnosis was 24.5 weeks (SD 5.66). The karyotype was obtained in 11.9% (8/67) of cases. A total of 7 stillbirths and 11 neonatal deaths were registered, of which only 10 cases received a necropsy. Births occurred in the third trimester for 88% of cases, of which 85% were born via Cesarean section, whereas in the second trimester, the vaginal approach was chosen in 100% of cases. CONCLUSIONS: The prenatal diagnosis of bone dysplasias is challenging due to the late development of the diagnostic features. Nevertheless, using ultrasonography in a systematic approach, in conjunction with a multidisciplinary approach, is a key factor in the diagnosis of this disease during the fetal period.

Major craniofacial defects: case series and prenatal diagnosis at the Instituto Nacional de Perinatología, Mexico.

OBJECTIVE: To describe the prenatal diagnosis, characteristics, development, perinatal outcome, and final diagnosis of pregnancies complicated by fetuses with major craniofacial defects, at the Instituto Nacional de Perinatologia, México, 1997-2008. MATERIAL AND METHODS: A retrospective, descriptive study from January of 1997 to January 2008, analyzed 152 pregnancies complicated by fetuses with major craniofacial defects, diagnosed at the Department of Fetal Medicine of the National Institute of Perinatology. Data were obtained from patients clinical records. RESULTS: . The mean age was 28 +/- 8 years, with the largest number of cases between 20 and 24. The mean gestational age at diagnosis was 27.5 +/- 6.4 gestational weeks. The average termination of pregnancy was at 35 +/- 5 gestational weeks. In 43.4% of cases there were no major structural defects associated with the facial defect. The most commonly associated structural alterations were cerebral, cardiac, and limb abnormalities. Karyotyping was performed in only 57 cases, and was abnormal in 25. CONCLUSIONS: Structural ultrasound should be performed on all pregnant women between weeks 18 and 24 for detection of major craniofacial defects. Where defects are found, a thorough review of other structures should be carried out to determine whether the defects are syndromic. A systematic and multidisciplinary approach is essential to providing the best care and appropriate advice to parents.

[Diffuse cavernous hemangioma of the uterus diagnosed during pregnancy. Case report]. / Hemangioma cavernoso difuso del utero diagnosticado durante el embarazo. Reporte de un caso.

We report the case of a pregnancy of 16 weeks with anemia and a presumptive diagnosis of partial mole. In secondary care this diagnosis was ruled out through ultrasonography and diffuse cysts were found in the myometrium. Spectral Doppler ultrasound showed no flow, but it could be observed with power angiography. Cesarean section was performed at 38 weeks and hysterectomy 24 hours after because of intra-abdominal hemorrhage. Power angiography, spectral Doppler and serum human chorionic gonadotropin are the most useful diagnostic tools in the differential diagnosis of diffuse cavernous hemangioma of the uterus. Postpartum hemorrhage is a likely complication.

Accuracy of different equations for estimating fetal weight.

OBJECTIVE: To evaluate the accuracy of ten equations based on ultrasound parameters for estimating fetal weight (FW). STUDY DESIGN: A cross-sectional study was performed in 250 healthy women with normal singleton pregnancies between 34 and 41 weeks of gestation. FW estimations calculated according to ten different equations were compared against birth weight (BW) which was determined within 72 h after FW estimation. Estimated error rate, intraclass correlation coefficient, and agreement between BW and FW calculated by each formula were analyzed. RESULTS: Most of the formulas were inaccurate in predicting BW, only 2 formulas showed less than 10% of the measurements lying within the 10% of estimated error. Four formulas tended to overestimate, while six tended to underestimate FW. CONCLUSIONS: Appropriate equations for estimating FW in all populations should be developed. However, where there are no local growth curves, the accuracy of the available fetal growth equations should be tested.

[Application of a technique to establish criteria for uterine length measurement]. / Aplicación de un método para establecer los criterios de la medición del fondo uterino.

BACKGROUND: The uterine length measurement is a routine practice in the prenatal care of pregnant women. It has been attributed a sensibility of 86% to detect fetal grown restriction. The technique is easy to perform and reproducible between observers, although we have found variation between intra- and inter-observers measurements. OBJECTIVE: To evaluate the useful of a maneuver to improve the reliability of the uterine length measurement in a group of obstetrics residents. MATERIAL AND METHODS: The measurement was performed on pregnant women. The results were analyzed by intraclass correlation coefficient to evaluate the concordance between observers based in a variance analysis model (ANOVA) of repeated measurements. RESULTS: There were not differences between groups about demographic variables. All residents improve the reliability in their measurements. The intra-class correlation coefficient was 0.77 (confidence interval 0.63-0.88) before the maneuver, and after this one the intra-class correlation coefficient improved to 0.96 (confidence interval 0.92-0.98). CONCLUSION: The uterine measurement following detailed indications improve the interobserver concordance. We think it is advisable to evaluate the use of this maneuver in a routine way in our institute and in other places that bring prenatal care.

[Thoracoamniotic shunts and thoracocentesis in fetal therapy]. / Derivaciones toracoamnióticas y toracocentesis en el tratamiento fetal.

BACKGROUND: The not heart thoracic anomalies are caused by different abnormalities in the embryonic period with similar physiopathologic mechanisms. The prenatal treatment by means of decompression can improve substantially the clinical results in these patients. OBJECTIVE: To evaluate, in a qualitative way, the effect of the thoracoamniotic shunts and thoracocentesis in the perinatal outcome in fetuses with not heart thoracic anomalies. METHODS: Twenty-two articles were revised describing 308 cases of fetuses with congenital cystic adenomatoid malformation (CCAM), 25 cases of hydrothorax and 55 cases of broncopulmonary sequestration (BPS). We analyzed the adverse prognostic factors that indicated the treatment election in uterus as well as complications and perinatal outcome. RESULTS: Of the 388 cases of not heart thoracic anomalies, 250 fetuses were managed conservatively, and in 102 fetuses handling in uterus was started. Hydrops was identified as the worst prognostic factor to these fetuses, with a survival rate of 55.7%. The global survival was of 56.5% (155 cases) in the fetuses with CCAM, 98.1% (52 cases) in the fetuses with BPS and of 80% (20 cases) in the fetuses with hydrothorax. CONCLUSIONS: When having a fetus with some of these pathologies, it should be evaluated in an individual and integral way; according to the gestational age when diagnosed, as well as the type of lesion and the presence or absence of fetal dropsy to decide between fetal therapy or expectant handling.