Resultados obstétricos asociados al incremento del índice de masa corporal durante el embarazo en el Hospital Clínico de la Universidad de Chile / No disponible

Introducción: Estudios previos muestran que el incremento en la categoría del índice de masa corporal (IMC) se asocia a un mayor riesgo de complicaciones obstétricas. Objetivo: Investigar el impacto que tiene el incremento del IMC durante el embarazo en los resultados obstétricos en el Hospital Clínico de la Universidad de Chile. Material y métodos: Estudio retrospectivo que incluye a embarazadas atendidas en el hospital entre el año 2001 y 2006. Las mujeres con embarazos únicos fueron clasificadas en las distintas categorías de IMC. El incremento del IMC se calculó como la diferencia entre el IMC del inicio y el del final de la gestación. Para comparar las variables categóricas se usó el test exacto de Fisher y para las variables continuas el test de la t para comparación de 2 medias. Resultados: El estudio incluyó a 5.478 mujeres: 568(10,48%) no incrementaron su categoría de IMC y4.910 (89,51%) aumentaron su IMC en 1 o más categorías. El incremento del IMC se asoció a mayor riesgo de preeclampsia (p = 0,004) y operación cesárea (p =0,009) en las pacientes con sobrepeso, no así en las pacientes con normopeso al inicio del embarazo. Las pacientes obesas presentan mayor riesgo de preeclampsia(p = 0,008), diabetes gestacional (p < 0,001), operación cesárea (p < 0,001) e infección posparto (p = 0,009).Conclusión: El incremento en la categoría de IMC se asocia a un aumento del riesgo de complicaciones obstétricas (AU)

Background: Previous studies have shown that an increase in body mass index (BMI) is associated with a greater risk of obstetric complications. Aim: To investigate the effect of an increase in BMI category on obstetric outcomes in Hospital Clínic of the University of Chile. Material and methods: A retrospective study was conducted of women followed-up in the hospital from2001 to 2006. Women with singleton pregnancies were placed in standard BMI categories. Increases in BMI were calculated as the difference between initial BMI and that at delivery. Fisher’s exact test was used to compare categorical variables and the t test between two means was used for continuous variables. Results: This study included 5,478 women: 568(10.48%) had no change in BMI category and 4.910(89.51%) increased their BMI by >= 1 category. An increase in BMI category was associated with higher rates of preeclampsia (p = 0.004) and cesarean delivery(p = 0.009) in overweight women but not in women with a healthy weight at the beginning of pregnancy. Obese women had a higher risk of preeclampsia (p =0.008), gestational diabetes (p < 0.001), cesarean delivery(p < 0.001), and postpartum infection (p = 0.009).Conclusions: An increase in BMI category is associated with a greater risk of obstetric complications (AU)

Zinc supplementation in infants with asymmetric intra uterine growth retardation; effect on growth, nutritional status and leptin secretion / Suplementación con zinc en niños con retraso de crecimiento intra-uterino asimétrico; efecto en el crecimiento, estado nutricional y secreción de leptina

Objetivos: Valorar el efecto de la suplementación con cinc en el crecimiento y estado nutricional de un grupo homogéneo de recién nacidos con retraso de crecimiento intra-uterino asimétrico. También se analizó el efecto delos cambios en el status del cinc en el crecimiento y las concentraciones séricas de leptina. Población y método: Se diseñó un ensayo clínico randomizado y doble ciego, con el fin de detectar diferencias en el crecimiento entre los grupos recibiendo cinc o placebo, durante los seis primeros meses de vida. 31 niños fueron incluidos en el grupo cinc (n = 14) (38,8 ± 1,4 semanas edad gestacional, 2.171 ± 253 g peso) o grupo placebo (n = 17) (38,9 ± 1.1 semanas edad gestacional, 2.249 ± 220 g peso). El grupo cinc recibió un suplemento de 3 mg de cinc elemental por día (en forma de sulfato de cinc).Resultados: No hubo diferencias significativas entre ambos grupos en cuanto a las medidas antropométricas a lo largo del período de estudio. Se observó un efecto significativo del grupo de estudio, en las concentraciones de cinc en el pelo, pero no en las concentraciones séricas de cinc; las comparaciones post-hoc para el cinc del pelo pusieron de manifiesto que había diferencias significativas entre los grupos, en los meses 1, 2 y 6 de edad. Los cambios en las concentraciones de cinc en el suero y en el pelo, desde el inicio del estudio hasta los 6 meses, mostraron correlaciones estadísticamente significativas con los cambios en peso/edad y longitud/edad (puntuación típica), en el grupo que recibió el suplemento de cinc. Los cambios en las concentraciones séricas de leptina durante el seguimiento, mostraron correlaciones estadísticamente significativas para la suma de 4 pliegues y para peso/edad (puntuación típica), en el grupo placebo. Los cambios en las concentraciones de cinc en el pelo mostraron correlaciones estadísticamente significativas con los cambios en las concentraciones séricas de leptina, desde el inicio del estudio hasta los 6 meses de seguimiento. Conclusiones: En un grupo homogéneo de niños con retraso de crecimiento intra-uterino asimétrico, el suplemento de cinc a una dosis de 3 mg/día, no origina mejora significativa en el crecimiento en peso y longitud. Los cambios en el status de cinc se relacionaron con los cambios en peso y longitud durante los 6 primeros meses de vida. Los cambios en las concentraciones séricas de leptina se relacionaron con los cambios en los índices antropométricos de acúmulo de grasa corporal

Objectives: To analyse the effect of zinc supplementation in growth and nutritional status of a homogeneous group of newborns with intra uterine growth retardation and asymmetric growth. The effect of changes of zinc status on growth and leptin serum concentrations was also analysed. Population and methods: A double blind, randomised clinical trial was designed in order to detect differences in growth between zinc and placebo groups during the first 6 months of life. 31 infants were included either to the zinc group (n = 14) (38.8 ± 1.4 weeks GA, 2,171 ± 253 g body weight) or the placebo group (n = 17) (38.9 ± 1.1 weeks GA, 2,249 ± 220 g body weight). The zinc group received a supplement of 3 mg elemental zinc per day (as zinc sulphate).Results: There were not significant differences between groups for anthropometric measurements through the study period. We found a significant effect of the study group, in hair zinc concentrations, but not in serum zinc concentrations; post-hoc comparisons for hair zinc revealed that there were significant differences between groups at 1, 2, and 6 months of age. Changes in serum and hair zinc concentrations from baseline to 6 months, showed significant correlations with changes in weight/age and length/age z-scores, in the supplement group. Changes in leptin serum concentrations during follow-up, showed significant correlations with changes in sum of 4 skinfolds and weight/age z-score, in the placebo group. Changes in hair zinc concentration through the study period showed significant correlations with changes in leptin serum concentrations from baseline to 6 months of follow-up. Conclusions: In a homogeneous group of intra uterine growth retardation infants with asymmetric growth, 3mg/day zinc supplementation do not show significant improvements in weight and length growth. Changes in zinc status were related with changes in weight and length during the first 6 months of life. Changes in leptin serum concentrations were related with changes in the anthropometric indices of body fat accretion

Mosaicismo de trisomía 9: caso de larga supervivencia / Mosaic trisomy 9: report of a new case with a long-term survival

Introducción: La trisomía 9 es una aneuploidía infrecuente y, por tanto, difícil de sospechar. Objetivo: Comunicar un nuevo caso de mosaicismo de trisomía 9, de larga supervivencia, para contribuir al mejor conocimiento de sus características clínicas y pronóstico. Caso clínico: Primera hija de padres sanos. Retraso de crecimiento intrauterino asimétrico y oligohidramnios. Nace a las 34 semanas con 1.478 g de peso, depresión respiratoria y fenotipo anómalo: dolicocefalia; hipotelorismo, microftalmia, hendiduras palpebrales pequeñas; nariz de base ancha y punta en bulbo; micrognatia; orejas de implantación baja, y anomalías en las manos y los pies. Ausencia de malformaciones en los órganos internos. Cariotipo: normal (46,XX). A los 17 meses, ante el retraso psicomotor evidente y las alteraciones descritas se realiza un segundo cariotipo convencional insistiendo en el análisis de un mayor número de células. Se halla un mosaicismo de trisomía 9 (46,XX/47,XX, 1 9). Como dato fenotípico curioso, a los 24 meses aparece un incisivo único superior medial, no descrito antes en otros casos de trisomía 9. Actualmente, tiene 4 años, un retraso mental profundo y ninguna otra complicación. Comentarios: Destaca la mayor dificultad diagnóstica de los mosaicismos; por lo que se debe insistir en el análisis de un número suficiente de células al estudiar el cariotipo. Además, es importante su diagnóstico en sujetos con anomalías fenotípicas, para dar información correcta a los padres en orden a su pronóstico y a la futura descendencia (AU)

Introduction: Trisomy 9 is an uncommon chromosome abnormality that may be seen in a mosaic or non-mosaic state. Objective: To better define the phenotype and prognosis of this disorder we report a new case of mosaic trisomy 9 with a long-term survival. Clinical report: We present the case of a female patient, born from the first pregnancy of a healthy couple. Fetal ultrasounds disclosed intrauterine growth retardation and oligohydramnios. Cesarean section was performed in the 34th week. Birth weight was 1,478 g. Neonatal examination showed: dolichocephaly; hypotelorism, microphthalmia, short palpebral fissures; broad-based nose with bulbous tip; micrognathia; low-set malformed ears; abnormal hands and feet; no other malformations. The initial karyotype determination was normal (46,XX). At 17 months of age, a second karyotype was requested because the patient developed severe psychomotor retardation. Chromosome analysis showed mosaic trisomy 9 (46,XX/47,XX, 1 9). Six months later, a single upper central incisor was noted. To our knowledge, this feature has not been reported previously in the trisomy 9. The patient is now 4 years old. She shows severe psychomotor retardation, but no other complications. Comments: It is important to be aware of the possibility that mosaicism may exist in a patient with normal blood karyotype and abnormal phenotype. We conclude that a great number of cells is needed in order to obtain a correct karyotype diagnosis. Correct diagnosis is essential to define the prognosis and provide accurate genetic counseling (AU)

Síndrome de CHARGE em gestação gemelar: a propósito de um caso clínico / CHARGE syndrome in a twin pregnancy: a case report

O síndrome de CHARGE (SC; #OMIM 214800) é um síndromegenético raro, com uma incidência estimada de1/8.500 a 1/12.000. A designação CHARGE representa o acrónimo das características mais frequentes do síndrome, coloboma, heart disease, atresia choanae, retarded growth and development, genital hypoplasia, and ear abnormalities. O SC é na grande maioria dos casos de natureza esporádica. Embora as evidências sugerissem uma causa genética, a etiologia permaneceu desconhecida até recentemente quando foram identificadas mutações no gene CHD7, localizado no cromossoma 8q12, responsáveis pelo SC em dois terços da população testada. O diagnóstico pré-natal de algumas das malformações presentes no SC é possível. No entanto, o diagnóstico pré-natal ecográfico do SC não é fácil, a não ser que haja um alto índice de suspeita, como feto afectado em gestação anterior e presença de hidrâmnios. A recente descoberta do gene CHD7 terá um importante impacto no diagnóstico, aconselhamento genético e diagnóstico pré-natal. Os autores descrevem uma gravidez gemelar monozigótica, em que os recém-nascidos apresentaram quadro clínico compatível com SC

No disponible

Problemática del embarazo post-trasplante renal / Renal post transplantation pregnancy: problems

El embarazo después del trasplante renal debe considerarse de alto riesgo tanto por las complicaciones maternas como por las fetales que puedan producirse. No obstante, siguiendo una serie de recomendaciones es posible y las complicaciones pueden minimizarse realizando un abordaje multidisciplinar. El embarazo puede considerarse seguro si se da en pacientes con buena micción renal, son proteinuria, sin HTA y sin evidencia de rechazo 2 años después del trasplante renal

Pregnancy after transplantation should be considered a high-risk pregnancy and should be monitored by a multidisciplinar team. Pregnancy could be considered safe about 2 years after transplantation in women with good renal function, without proteinuria, without arterial hypertension and with no evidence of ongoing rejection

Creixement intrauterí retardat i patologia cardiovascular i endocrinològica a l’edat adulta / No disponible

No disponible

Bone ultrasound velocity of infants born small for gestational age.

BACKGROUND: Quantitative ultrasound is increasingly used to assess bone status. Bone speed of sound (SOS), a biophysical property of bone, has been used to predict bone breakability. While decreased bone mineral content and delayed epiphyseal growth have been reported in small for gestational age (SGA) infants, there are no data on bone SOS in this group of infants. OBJECTIVE: To test the hypothesis that SGA infants have lower bone SOS than appropriate for gestational age (AGA) infants. METHODS: Bone SOS was measured within the first 96 hours of life at the right tibial midshaft in 22 singleton SGA infants. We compared these data with data obtained in 73 AGA controls. We used the Omnisense instrument which measures axially transmitted SOS. Infants ranged in gestational age (GA) from 25 to 42 weeks and in birth weight (BW) from 500 to 2,585 g. Statistical analyses included paired t-tests between the actual value obtained in every child and the theoretical, computed average normal value for GA, BW, or knee-sole length (KSL) based on our curves for AGA singletons. A p value < 0.05 was considered significant. RESULTS: Bone SOS measured in SGA infants was higher than the predicted computed average SOS of AGA singletons with significant differences in all of the parameters studied. CONCLUSIONS: Contrary to our hypothesis, SGA infants have higher bone SOS than AGA controls. Since bone mineral density is reported to be low in these infants, we speculate that intrauterine growth restriction may affect bone mineral density and bone protein matrix in opposite directions.

Morbimortalidad por CIUR. Estudio del año 2002 en el Hospital Docente Ginecobstétrico América Arias / Morbimortality due to IUGR, a study from the year 2002 in the America Arias Gynaecology and Obstetric Teaching Hospital

Se realizó un estudio retrospectivo descriptivo de 154 gestantes que tuvieron hijos con crecimiento intrauterino retardado (CIUR) en el Hospital Docente Ginecobstétrico América Arias en el año 2002. Se realiza este estudio ya que sigue siendo en la actualidad un problema para la obstetricia que las madres tengan recién nacidos de bajo peso, sobre todo los catalogados como CIUR, por la alta morbimortalidad que presentan luego del nacimiento, así como su tremendo impacto económico y social. El universo de estudio comprendió a todos los neonatos con diagnóstico de crecimiento intrauterino retardado al nacer en el período comprendido entre enero y diciembre de 2002 en el Hospital Docente Ginecobstétrico América Arias. El estudio tiene como objetivo identificar la morbimortalidad de este grupo al nacer. Para dar cumplimiento a nuestros objetivos se revisaron los registros continuos de parto y las historias clínicas de las madres y los neonatos. Nuestro estudio arrojó que el mayor número de casos correspondió a los CIUR moderados y producto de embarazos a término, que sólo la mitad de éstos fueron diagnosticados antes del término. El mayor porcentaje nació producto de cesáreas y con buen Apgar y aportó como grupo una alta tasa de mortalidad neonatal. Se concluyó que el factor fundamental relacionado con el CIUR es hacer el diagnóstico en el mayor número de casos y 10 más precozmente posible para poder manejarlos de forma más oportuna y mejorar los resultados perinatales (AU)

A retrospective, and descriptive study of 154 mothers who had children with Intrauterine Growth Retardation (IUGR) at birth. The study was conducted at the America Arias Gynaecology and Obstetric Teaching Hospital in 2002, It was aimed at identifying the mortality and morbidity in our cases. The continual delivery registries, as well as the medical history of mothers and neonates, were reviewed. Results: The IURG most frequently found was moderate, and at the end of pregnancy, a only half o these cases were diagnosed before birth. The highest percent of these births were by caesarean section, and the Apgar was normal. It was concluded that the most important aspect in the management of IUGR is its early diagnosis (AU)

[Preterm labor and IUGR rates in patients with cardiac anomalies in the material of the Pregnancy Pathology Unit at the Jagiellonian University OB/GYN Department between 1986-1999]. / Czestosc porodów przedwczesnych i hipotrofii w grupie pacjentek z wadami serca w materiale Oddzialu Patologii Ciazy Katedry Ginekologii i Poloznictwa Collegium Medicum Uniwersytetu Jagiellonskiego w latach 1986-1999.

INTRODUCTION: Advance in medicine in general caused more and more women with cardiac defects reach reproductive age. AIM: Analysis of kind and advance of cardiac disease influence on preterm labour and IUGR rates. MATERIAL AND METHODS: A prospective study on 232 pregnant patients with cardiac malformations, who were hospitalised in Pathology of Pregnancy Unit of OB./ GYN Jagiellonian University Clinic was performed between 1986-1999. Acquired data were compared with results obtained from control group of 424 pregnant patients with physiological course of pregnancy. RESULTS: Results prove of shorter pregnancy duration in patients with higher NYHA classes. Preterm labour rate in patients of NYHA III and IV equals to 31.15% and is 3 times higher than in control group. Patients of NYHA I and II revealed comparable gestational age with control group. CONCLUSIONS: Worse obstetric outcome is characteristic for 3rd and 4th NYHA classes. Intrauterine growth retardation in patients with cardiac malformations occurs after 34 week of pregnancy.

Endocrine and metabolic consequences of intrauterine growth retardation.

Size at birth and early infancy growth rates have been linked to long-term risks for diseases, such as type 2 diabetes and cardiovascular disease. These associations could be explained by permanent programming of metabolic responses and selective survival of those genetically predisposed to such adaptations. These epidemiologic associations may also affect long-term disease risk in short small-for-gestational age children, who are often treated with growth hormone. Study of the mechanisms and genetic factors involved in the association between small size at birth, rapid postnatal weight gain, and adult disease may promote the early identification of subjects with the highest disease risk and new opportunities to develop targeted early interventions.

Feeding growth restricted preterm infants with abnormal antenatal Doppler results.

Absence or reversal of end diastolic flow (AREDF) in the umbilical artery is associated with poor outcome, and elective premature delivery is common. Feeding these infants is a challenge. They often have poor tolerance of enteral feeding, and necrotising enterocolitis may develop. This review explores current practice to see if there is evidence on which to base guidelines. The incidence of necrotising enterocolitis is increased in infants with fetal AREDF, especially when complicated by fetal growth restriction. Abnormalities of splanchnic blood flow persist postnatally, with some recovery during the first week of life, providing justification for a delayed and careful introduction of enteral feeding. Such a policy exposes babies to the risks of parenteral nutrition, with no trials to date showing any benefit of delayed enteral nutrition. Trials are required to determine the optimum timing for introduction of enteral feeds in growth restricted infants with fetal AREDF.

[Triploidy: prompt diagnosis based on typical clinical signs in a live-born extremely low birth-weight infant]. / Triploidie: Rasche Diagnosestellung anhand der typischen klinisch erhobenen Stigmata eines lebend geborenen extrem kleinen Frühgeborenen.

A child with complete triploidy is rarely born alive. However, owing to the advances in perinatal medicine even extremely immature preterm infants receive full support in the delivery room and are admitted to the neonatal ICU. Consequently, the clinician may also have to consider the diagnosis of triploidy when faced with a dysmorphic extremely preterm infant. We report here the smallest described live born girl of 25 + 5 weeks of gestational age with typical clinical findings of complete triploidy phenotype II. The aim of the case report is to make the neonatologist aware of this syndrome using photographs of this case as well as discussing the literature available. Prompt clinical diagnosis confirmed by chromosome analysis helps doctors and parents with the decision whether to continue promising or to limit futile life support measures.

[Foeto-foetal conflict of interests in multiple pregnancies with severe discordant growth; ethical dilemmas]. / Foeto-foetaal belangenconflict bij een meerlingzwangerschap met ernstig discordante groei; ethische afwegingen.

Two pregnant women, 19 and 26 years old, presented at the beginning of the third trimester with one growth-retarded foetus in a multiple pregnancy. Both cases were managed conservatively. In the first woman, one foetus died at 30 weeks of gestation, after the mother developed pre-eclampsia. After the death of the impaired foetus pre-eclampsia resolved and the second child was born healthy at 36 weeks of gestation. The second woman had triplets with one severely growth-retarded foetus. This foetus died at 3I weeks of gestation. At 33 & 317 weeks, caesarean section was performed on both maternal and foetal indications. Two healthy premature neonates were born. In multiple pregnancy with discordant growth, the interests of the foetuses may be in opposition, which creates an ethical dilemma. This may be resolved by carefully addressing the interests of all those involved and keeping in mind the prognosis, duration of pregnancy and the best interests of the healthy foetus, which should not be harmed by intervention. Therefore, active intervention is not always the best option; the least harm it does is increasing the risk ofpreterm birth.

Intrauterine growth restriction-etiology and consequences: what do we know about the human situation and experimental animal models?

Embryonic and fetal growth depend on genetic and environmental factors, and the process is the result of the interaction between these factors. About 7-9% of live-born infants have a birth weight below normal (below the 10th percentile). The rate and extent of intrauterine growth restriction (IUGR) varies by ethnicity and socio-economic status. Some of the suspected causes of IUGR are as follows. (1) Maternal factors such as inadequate or severe malnutrition, chronic maternal diseases, birth order, multiple births, and parental genetic factors. (2) Placental pathology, mainly placental vascular damage that may lead to placental insufficiency. This is often found in maternal diseases such as pre-eclampsia, and Thrombophilia. (3) Intrauterine infections and specific fetal syndromes, including chromosomal aberrations. (4) Non-classified causes such as adolescent's pregnancy, maternal smoking and alcohol drinking, living at high altitudes. Several existing animal models for IUGR, including uterine artery ligation or gene knock out models, although insightful of potential mechanism(s) underlying intrauterine growth restriction, are limited in that they do not reflect human causality. As the ultimate goal is prevention, we seem still to be distant from achieving this goal.

Experimental intrauterine growth retardation in the rat causes a reduction of pancreatic B-cell mass, which persists into adulthood.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the possibility that intrauterine growth retardation (IUGR) causes alterations of glucose tolerance, insulin secretory response to glucose, and pancreatic B-cell growth, and if such changes may persist into adulthood. METHODS: Pregnant rats were operated on day 16 of pregnancy ad modum Wigglesworth to induce IUGR. Operated rats gave birth to viable offspring but litter size was reduced. The mothers nursed their pups, which were subsequently weaned and reared to an age of 3 months in apparent good health. RESULTS: At 1 day of age, IUGR pups were 10% lighter than control newborns whose mothers had been subjected to a sham operation. Pancreatic B-cell mass and insulin content were reduced by 35-40% in newborn IUGR offspring. Postnatal growth did not differ between IUGR and control animals of either sex and the difference in body weight at birth was not apparent from 1 week of age and onwards. Tests performed at 3 months of age could not demonstrate differences in glucose tolerance between IUGR and control animals. In females, but not in males, the peak insulin secretory response to glucose was lower in IUGR animals compared to controls. In the 3-month-old rats, B-cell mass was reduced by 40% in male and by 45% in female IUGR rats compared to controls, a reduction corresponding to a similar decrease in pancreatic insulin content (male reduction 48%, female reduction 45%). CONCLUSIONS: In the rat, IUGR causes a diminution of pancreatic B-cell mass which persists into adulthood. Normal glucose tolerance could be maintained but it is conceivable that increasing demands on insulin secretion may not be met by the reduced B-cell mass and that impaired glucose tolerance and even diabetes would hence develop.

Fetal origins of insulin resistance and obesity.

A number of epidemiological studies worldwide have demonstrated a relationship between poor early growth and an increased susceptibility to insulin resistance, visceral obesity, type 2 diabetes and other features of the metabolic syndrome in adulthood. However, the mechanistic basis of this relationship and the relative roles of genes and the environment remain a subject of debate. The 'thrifty phenotype' hypothesis proposes that poor fetal nutrition leads to programming of metabolism and an adult phenotype that is adapted to poor but not plentiful nutrition. The maternal reduced-protein rat model has been used to examine the importance of the maternal environment in determining susceptibility to adult disease. Pregnant and lactating rat dams are fed a diet containing 80 g protein/kg as compared with 200 g protein/kg, which leads to growth restriction in utero. Offspring of low-protein dams have increased susceptibility to diabetes, insulin resistance and hypertension when fed a palatable high-fat diet that promotes obesity. Administration of leptin during pregnancy and lactation to these protein-restricted dams produces offspring that have increased metabolic rate and do not become obese or insulin resistant when fed on a high-fat diet. Increased glucocorticoid exposure, particularly during late gestation, has been linked with insulin resistance in adulthood. High levels of fetal glucocorticoids may result from a decreased activity of placental 11beta-hydroxysteroid dehydrogenase (11beta-HSD) type 2, which normally protects the fetus from high maternal glucocorticoid levels. Leptin administration to protein-restricted dams inhibits the suppression of 11beta-HSD-2 and may be one mechanism by which the metabolic syndrome is prevented.

Epidural local anesthetics: a novel treatment for fetal growth retardation?

BACKGROUND: Chronically compromised uterine perfusion may lead to placental insufficiency and subsequent intrauterine growth restriction (IUGR). Various therapeutic approaches (e.g. vasodilators, low-dose aspirin, intravenous glucose infusion, and hemodilution) are often of limited efficacy. Local anesthetics have been shown to improve placental blood flow in pre-eclamptic women. We hypothesized that epidural administration of local anesthetics might improve outcome in IUGR independent of the underlying cause. In preparation for a clinical trial to test this hypothesis, we performed a pilot study in 10 patients. METHODS: After approval of the study protocol, 10 pregnant women presenting with oligohydramnios and IUGR were included in the study. In addition to our standard protocol (magnesium, glucose, betamethasone), each patient received an epidural catheter (T10/T12) with continuous infusion of bupivacaine 0.175% at a rate of 5 ml/h. Uteroplacental circulation was monitored by Doppler sonography and the amount of amniotic fluid was estimated daily. RESULTS: Epidural insertion and infusion was performed without complications. Four patients continued to deteriorate rapidly, amniotic fluid volume did not change and uterine artery pulsatility index (PI) tended to increase. In the remaining 6 patients the clinical status stabilized, amniotic fluid volume tended to increase and uterine artery PI tended to decrease during treatment. This improvement was associated with a prolonged interval to cesarean section and increased infant birth weight. CONCLUSION: Our data suggest that, even if the underlying cause of IUGR is not pre-eclampsia, epidural local anesthetic administration might improve placental blood flow and be beneficial in a subgroup of patients. A clinical trial to test this hypothesis appears warranted.