Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study.

Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical (AU) e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Causal Pathways Between the Acute Experience of Violence During Pregnancy and Fetal Intrauterine Growth Restriction: A Cohort Study.

Introduction: Violence during pregnancy (VDP) is a prevalent global issue with dire consequences for the mother and the developing fetus. These consequences include prematurity, low birthweight, and intrauterine growth restriction (IUGR), but its pathways remain elusive. This study investigated the causal pathways between VDP and IUGR using mediation analysis. Methods: A prospective population-based birth cohort was followed from the beginning of the third gestational trimester to the second year of life. IUGR was defined by the Kramer index, and information on VDP was collected using the WHO-Violence Against Women (WHO VAW) questionnaire. Cases were considered positive only when no other life episodes were reported. Ten different mediators were analyzed as possible pathways based on previous research. Path analysis was conducted to evaluate these relationships. Results: The path analysis model included 755 dyads and presented an adequate fit. Violence during pregnancy showed a direct effect (ß = -0.195, p = 0.041) and a total effect (ß = -0.276, p = 0.003) on IUGR. Violence was associated with gestational depression or anxiety, tobacco and alcohol consumption, changes in blood pressure, and the need for emergency care, but these did not constitute mediators of its effect on IUGR. The sum of the indirect effects, however, showed a significant association with IUGR (ß = -0.081, p = 0.011). Conclusion: The acute experience of violence during pregnancy was associated with IUGR, primarily via a direct pathway. An indirect effect was also present but not mediated through the variables analyzed in this study. The robust strength of these associations underscores the negative health consequences of violence against women for the succeeding generation.

Associação entre as condições de nascimento e a densidade mineral óssea de adultos das coortes de nascimentos de 1982 e 1993 de Pelotas, Rio Grande do Sul, Brasil / Association between birth conditions and bone mineral density in adults from the 1982 and 1993 birth cohorts in Pelotas, Rio Grande do Sul State, Brazil / Asociación entre las condiciones de nacimiento y la densidad mineral ósea de adultos de las cohortes de nacimiento de 1982 y 1993 en Pelotas, Rio Grande do Sul, Brasil

Resumo: Este estudo avaliou a associação do peso ao nascer, idade gestacional e crescimento intrauterino com a densidade mineral óssea (DMO) aos 22 e 30 anos, nas coortes de nascimentos de 1982 e 1993 de Pelotas, Rio Grande do Sul, Brasil. A DMO foi medida por absorciometria por raios X com dupla energia (DXA), a associação foi avaliada usando análise de variância e a regressão linear múltipla para o controle de confundimento por: sexo, renda familiar ao nascer, tabagismo materno na gestação, escolaridade materna, cor da pele materna e índice de massa corporal pré-gestacional. Foi testado se a gordura corporal na vida adulta era mediadora da associação analisada, por meio da G-computation Formula. Foram avaliados 6.803 participantes das coortes de 1982 e 1993, aos 30 e 22 anos, respectivamente. O peso ao nascer teve associação com a DMO em todos os sítios, com maior diferença no colo femoral. Os nascidos com menos de 2.000g apresentaram, em média, -0,036g/cm2 (IC95%: -0,064; -0,008) de DMO no colo femoral em comparação àqueles com mais de 3.500g. Aqueles com escore-z de crescimento intrauterino com pelo menos 1,28 desvio padrão abaixo da média apresentaram, em média, -0,013g/cm2 (IC95%: -0,024; -0,002) de DMO na coluna lombar, em relação aos com escore-z acima da média. A análise de mediação mostrou que gordura corporal na idade adulta não mediou a associação. As condições de nascimento foram associadas com a densidade mineral óssea na vida adulta, e a identificação dos fatores precoces relacionados à perda de DMO é essencial devido à inversão demográfica em progresso em países de média e baixa renda.

Abstract: This study assessed the association of birth weight, gestational age, and intrauterine growth with bone mineral density (BMD) at 22 and 30 years of age in the 1982 and 1993 birth cohorts in Pelotas, Rio Grande do Sul State, Brazil. BMD was measured by dual-energy X-ray absorptiometry (DXA) and the association was assessed using analysis of variance. Multiple linear regression was used to control for confounding factors: sex; household income at birth; maternal smoking during pregnancy; maternal schooling; maternal ethnicity/skin color; and pre-pregnancy body mass index. The study tested whether body fat in adulthood was a mediator of the association analyzed, using the G-computation Formula. A total of 6,803 participants from the 1982 and 1993 cohorts were evaluated at 30 and 22 years of age, respectively. Birth weight was associated with BMD at all sites, with a greater difference at the femoral neck. Individuals born weighing less than 2,000g had on average -0.036g/cm2 (95%CI: -0.064; -0.008) of BMD in the femoral neck than individuals weighing more than 3,500g. Individuals with an intrauterine growth z-score at least 1.28 standard deviation below the mean had an average of -0.013g/cm2 (95%CI: -0.024; -0.002) of BMD in the lumbar spine compared with individuals with an above-average z-score. The mediation analysis showed that body fat in adulthood did not mediate the association. Birth conditions have been associated with BMD in adulthood and the identification of early factors related to bone loss is essential due to the demographic inversion that has been taking place in low- and middle-income countries.

Resumen: Este estudio evaluó la asociación del peso al nacer, la edad gestacional y el crecimiento intrauterino con la densidad mineral ósea (DMO) a los 22 y 30 años de edad, en las Cohortes de Nacimiento de 1982 y 1993 de Pelotas, Rio Grande do Sul, Brasil. La DMO se midió mediante absorciometría de rayos X de doble emisión (DXA), y la asociación se evaluó mediante ANOVA y regresión lineal múltiple para controlar la confusión por sexo, ingresos familiares al nacer, tabaquismo materno durante el embarazo, escolaridad materna, color de piel materno e índice de masa corporal antes del embarazo. Se comprobó si la grasa corporal en la edad adulta era un mediador de la asociación analizada, utilizando G-computation Formula. Se evaluaron 6.803 participantes de las cohortes 82 y 93, de 30 y 22 años, respectivamente. El peso al nacer se asoció con la DMO en todos los sitios, con la mayor diferencia en el cuello femoral. Los nacidos con un peso inferior a 2.000g tuvieron una media de -0,036g/cm2 (IC95%: -0,064; -0,008) de DMO en el cuello femoral, que aquellos con más de 3.500g. Aquellos con una puntuación z de crecimiento intrauterino de al menos 1,28 desviaciones estándar por debajo de la media presentaron un promedio de -0,013g/cm2 (IC95%: -0,024; -0,002) de DMO en la columna lumbar, con relación a aquellos con un puntaje z superior a la media. El análisis de mediación mostró que la grasa corporal en la edad adulta no medió la asociación. Las condiciones de nacimiento se asociaron con la DMO en la edad adulta, y la identificación temprana de factores relacionados con la pérdida de DMO es esencial debido a la inversión demográfica que ha estado ocurriendo en los países de ingresos medios y bajos.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study / Efeitos do corticoide antenatal na hemodinâmica fetal: um estudo longitudinal

Abstract Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Resumo Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Mode of delivery according to Robson classification and perinatal outcomes in restricted and small for gestational age fetuses

Abstract Objective To evaluate the mode of delivery according to Robson classification (RC) and the perinatal outcomes in fetal growth restriction (FGR) and small for gestational age (SGA) fetuses. Methods Retrospective cohort study by analyzing medical records of singleton pregnancies from two consecutive years (2018 and 2019). FGR was defined according to Delphi Consensus. The Robson groups were divided into two intervals (1-5.1 and 5.2-10). Results Total of 852 cases were included: FGR (n = 85), SGA (n = 20) and control (n=747). FGR showed higher percentages of newborns < 1,500 grams (p<0.001) and higher overall cesarean section (CS) rates (p<0.001). FGR had the highest rates of neonatal resuscitation and neonatal intensive care unit admission (p<0.001). SGA and control presented higher percentage of patients classified in 1 - 5.1 RC groups, while FGR had higher percentage in 5.2 - 10 RC groups (p<0.001). FGR, SGA and control did not differ in the mode of delivery in the 1-5.1 RC groups as all groups showed a higher percentage of vaginal deliveries (p=0.476). Conclusion Fetuses with FGR had higher CS rates and worse perinatal outcomes than SGA and control fetuses. Most FGR fetuses were delivered by cesarean section and were allocated in 5.2 to 10 RC groups, while most SGA and control fetuses were allocated in 1 to 5.1 RC groups. Vaginal delivery occurred in nearly 60% of FGR allocated in 1-5.1 RC groups without a significant increase in perinatal morbidity. Therefore, the vaginal route should be considered in FGR fetuses.

Resultados perinatales del crecimiento intrauterino restringido. Cienfuegos, 2022

Fundamento: el crecimiento intrauterino restringido necesita un manejo intensivo prenatal para determinar el estado fetal y el tiempo del parto. Objetivo: describir los resultados perinatales del crecimiento intrauterino restringido. Métodos: estudio de serie de casos desarrollado en el Hospital de Cienfuegos, en el 2022. Se estudiaron las variables: tipo de crecimiento intrauterino retardado, resultados del ultrasonido Doppler en vasos maternos y fetales, enfermedades que complicaron el embarazo, tipo de parto, peso y tiempo gestacional al parto, resultados adversos perinatales. Se comparó la distribución de variables de importancia en la clínica con los resultados adversos perinatales. Resultados: el crecimiento restringido afectó al 4,7 % de los partos, el 25 % fue de inicio precoz; el 17,3 % presentó preeclampsia, el 41,3 % tuvo IPM ArUt >95 p. El 14,4 % de los fetos presentó alteraciones en los flujos del Doppler (ICP<5 p con 42 %); el 98 % tuvo crecimiento restringido grado I. El 19 % de las gestantes necesitó interrupción del embarazo en semana 34 o antes. Se realizó cesárea al 44,6 % y el 18,7 % de los recién nacidos vivos necesitó ingreso en UCIN; hubo tres muertes neonatales y dos muertes fetales tardías. Los resultados adversos perinatales fueron más frecuentes en fetos con ICP<5 p, el parto antes de las 34 semanas y el peso al nacer menor de 1500 g (p<0,05). Conclusiones: la alteración del índice cerebro placentario en el feto, nacer antes de las 34 semanas y peso inferior a 1500 g al nacer, eleva el riesgo adverso perinatal en los fetos/neonatos con crecimiento intrauterino restringido.

Foundation: restricted intrauterine growth requires intensive prenatal management to determine fetal status and delivery time. Objective: To describe the perinatal outcomes of restricted intrauterine growth. Methods: case series study developed at the Cienfuegos Hospital in 2022. The studied variables were: type of delayed intrauterine growth, results of Doppler ultrasound in maternal and fetal vessels, diseases that complicated the pregnancy, type of delivery, weight and gestational time to delivery, adverse perinatal outcomes. The distribution of clinically important variables was compared with adverse perinatal outcomes. Results: delayed growth affected 4.7% of births, 25% had early onset; 17.3% had preeclampsia, 41.3% had MPI ArUt >95 p. 14.4% of fetuses presented alterations in Doppler flows (ICP<5 p with 42%); 98% had restricted growth grade I. 19% of pregnant women needed termination of pregnancy at week 34 or before. A cesarean section was performed in 44.6% and 18.7% of live newborns required admission to the NICU; there were three neonatal deaths and two late fetal deaths. Adverse perinatal outcomes were more frequent in fetuses with ICP<5 p, delivery before 34 weeks and birth weight less than 1500 g (p<0.05). Conclusions: the alteration of the cerebroplacental index in the fetus, birth before 34 weeks and weight less than 1500 g at birth, increases the adverse perinatal risk in fetuses/neonates with restricted intrauterine growth.

La suplementación con zinc favorece el crecimiento intrauterino en fetos de ratas diabéticas / Zinc supplementation favours intrauterine growth in diabetic rat fetuses

La deficiencia de zinc puede ser un factor mediador en los trastornos del crecimiento fetal en la descendencia de la gestante diabética. Se persiguió como objetivo determinar la influencia de un suplemento con zinc sobre la morfometría externa corporal y craneofacial en fetos de ratas diabéticas con hiperglucemias moderadas. Durante la gestación, ratas diabéticas y controles fueron suplementadas por vía oral con sulfato de zinc (50 mg/kg-pc) o no recibieron tratamiento. Los fetos descendientes del grupo diabético suplementado presentaron niveles similares a los controles en las variables de crecimiento somático determinadas. La suplementación con zinc a ratas diabéticas favoreció el crecimiento intrauterino en los fetos. Los resultados de esta investigación constituyen aportes para dilucidar los requerimientos de zinc que permitan prevenir los trastornos del crecimiento fetal en la descendencia de gestantes diabéticas.

Zinc deficiency may be a mediating factor in fetal growth disorders in the offspring of diabetic pregnant women. The objective was to determine the influence of a zinc supplement on external body and craniofacial morphometry in diabetic rat fetuses with moderate hyperglycemia. During gestation, diabetic and control rats were orally supplemented with zinc sulphate (50 mg/kg bw) or received no treatment. The fetuses descendants of the supplemented diabetic group had levels similar to the control ones in the determined somatic growth variables. Zinc supplementation to diabetic rats favoured intrauterine growth in fetuses. The results of this research constitute a contribution to elucidate zinc requirements that allow preventing fetal growth disorders in the offspring of diabetic pregnant women.

Maternal, obstetric, and fetal Doppler characteristics in a high-risk population: prediction of adverse perinatal outcomes and of cesarean section due to intrapartum fetal compromise.

Objective: To evaluate the capacity of fetal Doppler, maternal, and obstetric characteristics for the prediction of cesarean section due to intrapartum fetal compromise (IFC), a 5-min Apgar score < 7, and an adverse perinatal outcome (APO), in a high-risk population. Materials and Methods: This was a prospective cohort study involving 613 singleton pregnant women, admitted for labor induction or at the beginning of spontaneous labor, who underwent Doppler ultrasound within the last 72 h before delivery. The outcome measures were cesarean section due to IFC, a 5-min Apgar score < 7, and any APO. Results: We found that maternal characteristics were neither associated with nor predictors of an APO. Abnormal umbilical artery (UA) resistance index (RI) and the need for intrauterine resuscitation were found to be significant risk factors for cesarean section due to IFC (p = 0.03 and p < 0.0001, respectively). A UA RI > the 95th percentile and a cerebroplacental ratio (CPR) < 0.98 were also found to be predictors of cesarean section due to IFC. Gestational age and a UA RI > 0.84 were found to be predictors of a 5-min Apgar score < 7 for newborns at < 29 and ≥ 29 weeks, respectively. The UA RI and CPR presented moderate accuracy in predicting an APO, with areas under the ROC curve of 0.76 and 0.72, respectively. Conclusion: A high UA RI appears to be a significant predictor of an APO. The CPR seems to be predictive of cesarean section due to IFC and of an APO in late preterm and term newborns.

Objetivo: Avaliar a capacidade do Doppler fetal e características materno-obstétricas na predição de cesariana por comprometimento fetal intraparto (CFI), índice de Apgar de 5º min < 7 e desfecho perinatal adverso (DPA) em uma população de alto risco. Materiais e Métodos: Estudo de coorte prospectivo envolvendo 613 parturientes admitidas para indução ou em início de trabalho de parto espontâneo que realizaram ultrassonografia Doppler nas 72 horas anteriores ao parto. Os desfechos foram cesariana por CFI, índice de Apgar de 5º min < 7 e DPA. Resultados: As características maternas não foram associadas nem preditoras de DPA. Índice de resistência (IR) da artéria umbilical (AU) anormal (p = 0,03) e necessidade de medidas de ressuscitação intrauterina (p < 0,0001) permaneceram como fatores de risco significativos para cesariana por CFI. IR AU > 95º e razão cerebroplacentária (RCP) < 0,98 foram preditores de cesariana. Idade gestacional e IR AU > 0,84 foram os preditores de índice de Apgar de 5º min < 7 para recém-nascidos < 29 e ≥ 29 semanas, respectivamente. IR AU e RCP apresentaram acurácia moderada na predição de DPA (área sob a curva ROC de 0,76 e 0,72, respectivamente). Conclusão: IR UA mostrou-se preditor significativo de DPA. RCP revelou-se possível preditora de cesariana por CFI e DPA em recémnascidos prematuros tardios e a termo.

Morfometría en placentas procedentes de embarazos gemelares / Morphometry in placentas from twin pregnancies

Introducción: La disfunción de la placenta puede originar complicaciones fetales, restricción del crecimiento intrauterino y complicaciones maternas, como la preeclampsia. Objetivo: Identificar el patrón morfométrico de las placentas gemelares y su relación con la corionicidad, el peso del recién nacido y las malformaciones plancentarias. Método: Se realizó un estudio descriptivo en una muestra de 16 gestantes con embarazo gemelar, 25 placentas y los 32 recién nacidos. Se estudiaron las variables malformaciones placentarias, tipo de placenta, presencia de calcificaciones, peso del recién nacido, peso de la placenta, volumen placentario, diámetro placentario y espesor placentario; se determinó la asociación del peso del recién nacido, con el tipo de placenta y la presencia de calcificaciones, las malformaciones placentarias, así como espesor, diámetro, volumen y peso, con el tipo de placenta. Resultados: Hubo mayor frecuencia de recién nacidos de placentas monocoriónicas (60 por ciento) sin que la asociación fuera estadísticamente significativa; las malformaciones placentarias se relacionaron de forma significativa con el tipo de placenta, así como el peso del recién nacido y la presencia de calcificaciones placentarias, y el espesor, diámetro, volumen y peso de la placenta, con el tipo de plancenta (p< 0,01). Conclusiones: Son más frecuentes las placentas dicoriónicas y estas tienen menos malformaciones; existe relación entre el bajo peso del recién nacido y la presencia de calcificaciones placentarias, así como entre el espesor, diámetro, volumen y peso de la placenta, con el tipo de placenta(AU)

Introduction: Placental dysfunction can originate fetal complications, intrauterine growth restriction and maternal complications, such as preeclampsia. Objective: To identify the morphometric pattern of twin placentas and its relationship with chorionicity, newborn weight and placental malformations. Methods: A descriptive study was carried out in a sample of 16 pregnant women with twin pregnancy, 25 placentas and 32 newborns. The variables placental malformations, type of placenta, presence of calcifications, newborn weight, placental weight, placental volume, placental diameter and placental thickness were studied; the association of newborn weight with the type of placenta and the presence of calcifications, placental malformations, as well as thickness, diameter, volume and weight, with the type of placenta was determined. Results: There was a higher frequency of newborns with monochorionic placentas (60 percent) without the association being statistically significant; placental malformations were significantly related to placenta type, as well as newborn weight and the presence of placental calcifications, and placental thickness, diameter, volume and weight, with placenta type (p< 0.01). Conclusions: Dichorionic placentas are more frequent and these have fewer malformations; there is a relationship between low newborn weight and the presence of placental calcifications, as well as between placental thickness, diameter, volume and weight, with the type of placenta(AU)

Prediction of Perinatal and Neurodevelopmental Outcomes in Newborns with a Birth Weight below the 3rd Percentile: Performance of Two International Curves - Prospective Cohort from a Brazilian City / Predição de resultados perinatais e de neurodesenvolvimento em recém-nascidos com peso ao nascer abaixo do percentil 3: Desempenho de duas curvas internacionais - coorte prospectiva de uma cidade brasileira

Abstract Objectives To evaluate the performance of Intergrowth-21 st (INT) and Fetal Medicine Foundation (FMF) curves in predicting perinatal and neurodevelopmental outcomes in newborns weighing below the 3rd percentile. Methods Pregnant women with a single fetus aged less than 20 weeks from a general population in non-hospital health units were included. Their children were evaluated at birth and in the second or third years of life. Newborns (NB) had their weight percentiles calculated for both curves. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the ROC curve (ROC-AUC) for perinatal outcomes and neurodevelopmental delay were calculated using birth weight < 3rd percentile as the cutoff. Results A total of 967 children were evaluated. Gestational age at birth was 39.3 (± 3.6) weeks and birth weight was 3,215.0 (± 588.0) g. INT and FMF classified 19 (2.4%) and 49 (5.7%) newborns below the 3rd percentile, respectively. The prevalence of preterm birth, tracheal intubation >24 hours in the first three months of life, 5th minute Apgar <7, admission to a neonatal care unit (NICU admission), cesarean section rate, and the neurodevelopmental delay was 9.3%, 3.3%, 1.3%, 5.9%, 38.9%, and 7.3% respectively. In general, the 3rd percentile of both curves showed low sensitivity and PPV and high specificity and NPV. The 3rd percentile of FMF showed superior sensitivity for preterm birth, NICU admission, and cesarean section rate. INT was more specific for all outcomes and presented a higher PPV for the neurodevelopmental delay. However, except for a slight difference in the prediction of preterm birth in favor of INT, the ROC curves showed no differences in the prediction of perinatal and neurodevelopmental outcomes. Conclusion Birth weight below the 3rd percentile according to INT or FMF alone was insufficient for a good diagnostic performance of perinatal and neurodevelopmental outcomes. The analyzes performed could not show that one curve is better than the other in our population. INT may have an advantage in resource contingency scenarios as it discriminates fewer NB below the 3rd percentile without increasing adverse outcomes.

Resumo Objetivos Avaliar o desempenho das curvas de Intergrowth-21 st (INT) e Fetal Medicine Foundation (FMF) na predição de resultados perinatais e de neurodesenvolvimento de recém-nascidos com peso abaixo do percentil 3. Métodos Foram incluídas gestantes de feto único com idade inferior a 20 semanas de uma população geral em unidades de saúde não hospitalares. Seus filhos foram avaliados ao nascimento e no segundo ou terceiro anos de vida. Os recém-nascidos tiveram seus percentis de peso calculados para ambas as curvas. Sensibilidade, especificidade, valor preditivo positivo (VPP) e negativo (VPN) e área sob a curva ROC (ROC-AUC) foram calculados para desfechos perinatais e atraso de neurodesenvolvimento considerando o peso ao nascimento menor que o percentil 3 como ponto de corte. Resultados Um total de 967 crianças foram avaliadas ao nascimento e no segundo ou terceiro anos de vida. A idade gestacional ao nascer foi de 39,3 (±3,6) semanas e o peso ao nascimento foi de 3.215,0 (±588,0) g. INT e FMF classificaram 19 (2,4%) e49 (5,7%) recém-nascidos abaixo do percentil 3, respectivamente. A prevalência de parto prétermo, intubação traqueal > 24 horas nos primeiros três meses de vida, Apgar de 5° minuto < 7, internação em unidade de terapia intensiva neonatal (internação em UTIN), taxa de cesariana e atraso de neurodesenvolvimento foi 9,3%, 3,3%, 1,3%, 5,9%, 38,9% e 7,3% respectivamente. Em geral, o percentil 3 de ambas as curvas apresentou baixa sensibilidade e VPP e alta especificidade e VPN. O percentil 3 de FMF mostrou sensibilidade superior para parto prematuro, internação em UTIN e taxa de cesariana. INT foi mais específico para todos os desfechos e apresentou maior VPP para o atraso do neurodesenvolvimento. Entretanto, exceto por uma pequena diferença na predição de parto pré-termo em favor de INT, as curvas ROC não mostraram diferenças na predição de resultados perinatais e de desenvolvimento neurológico. Conclusão O peso ao nascer abaixo do percentil 3 segundo INT ou FMF isoladamente foi insuficiente para um bom desempenho diagnóstico de desfechos perinatais e de neurodesenvolvimento. As análises realizadas não puderam mostrar que uma curva é melhor que a outra em nossa população. INT pode ter vantagem em cenários de contingência de recursos, pois discrimina menos recém-nascidos abaixo do percentil 3 sem aumentar os desfechos adversos.

Displasia broncopulmonar y severa restricción del crecimiento intrauterino en neonato de 850 gramos al nacer

Introducción: La displasia broncopulmonar es una enfermedad pulmonar crónica de inicio en edad neonatal. La restricción del crecimiento intrauterino se define como fracaso del feto para alcanzar su potencial de crecimiento genéticamente determinado. Objetivo: Describir el manejo interdisciplinario de la displasia broncopulmonar y revisar la literatura sobre el tema. Caso clínico: Se presenta el caso de un neonato hijo de madre adolescente producto de su primera gestación, la cual llevó un adecuado control prenatal. Presentó restricción del crecimiento intrauterino grado IV caracterizada por alteraciones en el ultrasonido Doppler en relación con insuficiencia placentaria severa y oligohidramnios, motivo por el cual se interrumpe el embarazo por parto distócico por cesárea a las 34+1 semanas, con bolsa rota al nacer, líquido amniótico claro y muy escaso. Nace en buenas condiciones clínicas con 850 gramos de peso. En los primeros días de vida, comenzó con manifestaciones clínicas de sepsis; se diagnosticó enterocolitis necrotizante luego presentó un súbito deterioro clínico debido a la aparición de hemorragia pulmonar. Con 695 gramos de peso, se inició tratamiento con ventilación mecánica invasiva, la cual se prolongó por un período de 30 días. Después del destete de la ventilación mecánica, el niño mantuvo una dependencia del oxígeno durante 71 días más; como manifestación de la displasia broncopulmonar. Se realizaron interconsultas con especialistas en Cardiología, Hematología, Imagenología, Nutrición, Inmunología y Genética; y, en colectivo, se decidió, la terapéutica desarrollada. El neonato evolucionó satisfactoriamente. Conclusiones: Se mostró el manejo interdisciplinario de la displasia broncopulmonar. Se consultó la bibliografía actualizada.

Introduction: Bronchopulmonary dysplasia is a chronic lung disease of neonatal age onset. Intrauterine growth restriction is defined as failure of the fetus to reach its genetically determined growth potential. Objective: To describe the interdisciplinary management of bronchopulmonary dysplasia and review the literature on the subject. Case report: The case of a newborn son of an adolescent mother, product of her first pregnancy, which had an adequate prenatal control, is presented. She presented grade IV intrauterine growth restriction characterized by alterations in the Doppler ultrasound in relation to severe placental insufficiency and oligohydramnios, which is why the pregnancy was terminated due to dystocic delivery by cesarean section at 34+1 weeks, with a ruptured bag at birth, liquid clear and very scanty amniotic. He was born in good clinical condition with a weight of 850 grams. In the first days of life, he began with clinical manifestations of sepsis; necrotizing enterocolitis was diagnosed, then he presented a sudden clinical deterioration due to the appearance of pulmonary hemorrhage. Weighing 695 grams, treatment with invasive mechanical ventilation was started, which lasted for a period of 30 days. After weaning from mechanical ventilation, the child remained oxygen dependent for a further 71 days; as a manifestation of bronchopulmonary dysplasia. Interconsultations were made with specialists in Cardiology, Hematology, Imaging, Nutrition, Immunology and Genetics; and, collectively, it was decided, the therapy developed. The neonate evolved satisfactorily. Conclusions: The interdisciplinary management of bronchopulmonary dysplasia was shown. The updated literature was consulted.

Restricción del crecimiento intrauterino y enfermedades no transmisibles durante las edades pediátricas / Intrauterine Growth Restriction and Noncommunicable Diseases during Pediatric Ages

Introducción: En la aparición de las enfermedades crónicas durante las edades pediátricas y la adolescencia, la restricción del crecimiento intrauterino se considera un factor clave. Objetivo: Determinar la relación entre la restricción del crecimiento intrauterino y las enfermedades no trasmisibles durante las edades pediátricas. Métodos: Se realizó una revisión narrativa con búsqueda bibliográfica en Pubmed, SciELO, LILACS y Google académico en los últimos cinco años sobre el tema que se trata. Se examinaron artículos originales, de revisión y capítulos de libros. Se utilizaron las palabras clave: retardo del crecimiento fetal, factores de riesgo cardiometabólicoy atención integrada a las enfermedades prevalentes de la infancia. Se descartaron aquellos artículos no pertinentes o que tuvieran deficiencias metodológicas notables. Análisis y síntesis de la información: Se expusieron las definiciones de pequeño para la edad gestacional y restricción del crecimiento intrauterino, se mostró la clasificación más actualizada, se mencionaron las enfermedades que aparecen en la infancia en estos recién nacidos de riesgo y se señalaron sus mecanismos. Conclusiones: El antecedente de restricción del crecimiento intrauterino se relaciona con alteraciones del crecimiento pondoestatural, del neurodesarrollo; el síndrome metabólico; las afecciones cardiovasculares; las enfermedades endocrinas, hepáticas, respiratorias, del sistema inmunológico y renales, los trastornos auditivos y de la visión. Estas afecciones se presentan en etapas tempranas de la vida como la infancia y la adolescencia(AU)

Introduction: In the occurrence of chronic diseases during pediatric ages and adolescence, intrauterine growth restriction is considered a key factor. Objective: To determine the relationship between intrauterine growth restriction and noncommunicable diseases during pediatric ages. Methods: A narrative review was performed with a literature search in Pubmed, SciELO, LILACS and Google Scholar in the last five years on the topic under discussion. Original articles, review articles and book chapters were examined. The keywords used were: fetal growth retardation, cardiometabolic risk factors, integrated care for prevalent childhood diseases. Articles that were not relevant or had notable methodological deficiencies were discarded. Analysis and synthesis of the information: The definitions of small for gestational age and intrauterine growth restriction were exposed, the most updated classification was shown, the diseases that appear during infancy in these at-risk newborns were mentioned and their mechanisms were pointed out. Conclusions: The history of intrauterine growth restriction is related to alterations of pondoestatural growth, neurodevelopment, metabolic syndrome, cardiovascular conditions, endocrine, hepatic, respiratory, immune system, renal, hearing and vision disorders. These conditions surface in early stages of life such as infancy and adolescence(AU)

Maternal, obstetric, and fetal Doppler characteristics in a high-risk population: prediction of adverse perinatal outcomes and of cesarean section due to intrapartum fetal compromise / Características maternas, obstétricas e do Doppler fetal em uma população de alto risco: predição de desfechos perinatais adversos e de cesariana por comprometimento fetal intraparto

Abstract Objective: To evaluate the capacity of fetal Doppler, maternal, and obstetric characteristics for the prediction of cesarean section due to intrapartum fetal compromise (IFC), a 5-min Apgar score < 7, and an adverse perinatal outcome (APO), in a high-risk population. Materials and Methods: This was a prospective cohort study involving 613 singleton pregnant women, admitted for labor induction or at the beginning of spontaneous labor, who underwent Doppler ultrasound within the last 72 h before delivery. The outcome measures were cesarean section due to IFC, a 5-min Apgar score < 7, and any APO. Results: We found that maternal characteristics were neither associated with nor predictors of an APO. Abnormal umbilical artery (UA) resistance index (RI) and the need for intrauterine resuscitation were found to be significant risk factors for cesarean section due to IFC (p = 0.03 and p < 0.0001, respectively). A UA RI > the 95th percentile and a cerebroplacental ratio (CPR) < 0.98 were also found to be predictors of cesarean section due to IFC. Gestational age and a UA RI > 0.84 were found to be predictors of a 5-min Apgar score < 7 for newborns at < 29 and ≥ 29 weeks, respectively. The UA RI and CPR presented moderate accuracy in predicting an APO, with areas under the ROC curve of 0.76 and 0.72, respectively. Conclusion: A high UA RI appears to be a significant predictor of an APO. The CPR seems to be predictive of cesarean section due to IFC and of an APO in late preterm and term newborns.

Resumo Objetivo: Avaliar a capacidade do Doppler fetal e características materno-obstétricas na predição de cesariana por comprometimento fetal intraparto (CFI), índice de Apgar de 5º min < 7 e desfecho perinatal adverso (DPA) em uma população de alto risco. Materiais e Métodos: Estudo de coorte prospectivo envolvendo 613 parturientes admitidas para indução ou em início de trabalho de parto espontâneo que realizaram ultrassonografia Doppler nas 72 horas anteriores ao parto. Os desfechos foram cesariana por CFI, índice de Apgar de 5º min < 7 e DPA. Resultados: As características maternas não foram associadas nem preditoras de DPA. Índice de resistência (IR) da artéria umbilical anormal (p = 0,03) e necessidade de medidas de ressuscitação intrauterina (p < 0,0001) permaneceram como fatores de risco significativos para cesariana por CFI. IR AU > 95º e razão cerebroplacentária (RCP) < 0,98 foram preditores de cesariana. Idade gestacional e IR AU > 0,84 foram os preditores de índice de Apgar de 5º min < 7 para recém-nascidos < 29 e ≥ 29 semanas, respectivamente. IR AU e RCP apresentaram acurácia moderada na predição de DPA (área sob a curva ROC de 0,76 e 0,72, respectivamente). Conclusão: IR UA mostrou-se preditor significativo de DPA. RCP revelou-se possível preditora de cesariana por CFI e DPA em recémnascidos prematuros tardios e a termo.

Prognostic factors and perinatal outcomes in early-onset intrauterine growth restriction due to placental insufficiency.

OBJECTIVE: To determine the principal prognostic factors and neonatal outcomes associated with perinatal death in cases of early-onset intrauterine growth restriction (IUGR) due to placental insufficiency and to define the cutoff point for the risk of perinatal death. METHODS: A retrospective cohort study conducted with 198 pregnant women with a diagnosis of early-onset IUGR (as detected before the 32nd week of gestational age). The association between the dependent variable (perinatal death) and the independent variables was investigated using a multivariate logistic regression model. The area under the receiver operating characteristic (ROC) curve was calculated to determine the sensitivity and specificity of the adjusted model. A significance level of 5% was established for the entire statistical analysis. RESULTS: Perinatal deaths occurred in 89 (44.9%) of the 198 fetuses with early-onset IUGR. Birthweight <800 grams (OR: 14.73; 95%CI: 4.13-52.54; p < .001), postnatal need for mechanical ventilation (OR: 24.56; 95%CI: 5.58-108.08; p < .001) and postnatal use of an oxygen hood (OR: 0.09; 95%CI: 0.02-0.39; p = .001) remained significantly associated with neonatal death in the multivariate model. The sensitivity, specificity, positive and negative predictive values for birthweight <800 grams and need for mechanical ventilation as predictors of death were, respectively, 84%, 91%, 88%, 88% and 93%, 71%, 60% and 96%, while the values for use of an oxygen hood were, respectively, 15%, 62%, 15% and 62%. CONCLUSION: The principal determinants of perinatal death in fetuses with early-onset IUGR were birthweight <800 grams, gestational age at delivery <30 weeks and postnatal need for mechanical ventilation as risk factors while postnatal use of an oxygen hood was found to constitute a protective factor.

Hidatidosis esplénica gigante primaria en una gestante: reporte de caso / Primary giant splenic hydatid disease in a pregnant woman: case report

La hidatidosis es considerada en la actualidad como un problema de salud pública en el Perú. Es una infección parasitaria trasmitida por la ingesta de huevos de Echinococcus granulosus y los órganos más comprometidos son el hígado y los pulmones, siendo rara la afectación del bazo. Presentamos el caso de una gestante joven con dolor abdominal y sensación de masa en hipocondrio izquierdo. El estudio ecográfico reveló imagen quística multitabicada en hemiabdomen izquierdo, con feto viable. Se le realizó cesárea, seguido de laparotomía exploratoria y se halló una tumoración gigante de bazo que, según el estudio anatomopatológico corresponde a una hidatidosis esplénica multiquística. Asimismo, como complicación fetal ocurrió restricción del crecimiento intrauterino. La paciente evolucionó favorablemente sin recurrencia de focos hidatídicos, mientras que el neonato mostró un patrón de crecimiento adecuado.

Hydatidosis is currently considered a public health problem in Peru. It is a parasitic infection transmitted by the ingestion of eggs of Echinococcus granulosus. The most involved organs are the liver and lungs, with spleen involvement being rare. We present the case of a young pregnant woman with abdominal pain and a sensation of mass in the left hypochondrium. The ultrasound study revealed a multiloculated cystic image in the left hemiabdomen, and a viable fetus. She underwent cesarean section, followed by exploratory laparotomy, which revealed a giant spleen tumor that, according to the anatomopathological study, corresponded to multicystic splenic hydatid disease. Likewise, intrauterine growth restriction was found as a fetal complication. The patient progressed favorably without recurrence of hydatid foci and the neonate had an adequate growth pattern.

Supresión de la visita de tercer trimestre en embarazo de bajo riesgo en la pandemia de SARS-CoV-2 / Third trimester suppression in low-risk pregnancy in the SARS-CoV-2 pandemic

Resumen Objetivo: La pandemia de SARS-CoV-2 ha obligado a una reorganización de las visitas presenciales, y por ese motivo se han minimizado hasta el punto de reconsiderar la realización de la visita del tercer trimestre. Nuestro centro suprimió dicha visita obstétrica y obtuvo datos propios para comparar los resultados perinatales logrados con dicho manejo. Método: Se realizó un estudio de cohortes retrospectivo, en marzo de 2020, con una cohorte con visita presencial única en la semana 40 de gestación (122 gestantes) frente a una cohorte con seguimiento convencional con visita presencial en la semana 36 de gestación (162 gestantes). Se evaluaron la restricción del crecimiento fetal, la edad gestacional al nacimiento, el peso neonatal y las tasas de inducciones, partos eutócicos y cesáreas urgentes en trabajo de parto. Resultados: Se encontraron diferencias leves en la tasa de nuliparidad (p < 0,04), sin hallarlas en el resto de las variables maternas. No hubo diferencias entre las dos cohortes en los resultados neonatales. Conclusiones: No hay diferencias entre los resultados materno-fetales obtenidos en gestantes con seguimiento gestacional con restricción de la visita del tercer trimestre respecto del seguimiento tradicional, excepto en el diagnóstico de las alteraciones de la estática fetal al término de la gestación.

Abstract Objective: The SARS-CoV-2 pandemic has forced a reorganization of face-to-face visits, for this reason they have been minimized to the point of reconsidering the completion of the third trimester visit. Our center eliminated the performance of this obstetric visit and obtained its own data to compare the perinatal results obtained with such management. Method: A retrospective cohort study was carried out in March 2020, with a cohort with a single face-to-face visit at 40th week of gestation (122 pregnant women), versus a cohort with conventional follow-up with face-to-face visit at 36th week of gestation (162 pregnant women). The following were evaluated fetal growth restriction, gestational age at birth, neonatal weight, rate of inductions, of eutocic deliveries, and of urgent cesarean sections in labor. Results: Slight differences were found in the nulliparity rate (p < 0.04), without finding them in the rest of the maternal variables. There were no differences between the two cohorts in neonatal outcomes. Conclusions: There were no differences between the maternal-fetal results obtained in pregnant women with gestational follow-up with restriction of the third trimester visit compared to traditional follow-up, except in the diagnosis of alterations in fetal statics at the end of pregnancy.

La salud gestacional y su relación con la restricción del crecimiento intrauterino / Gestational health and its relationship with intrauterine growth restriction

RESUMEN Introducción: La frecuencia de infantes que durante el desarrollo intrauterino experimentan restricción del crecimiento es alta y su mayor incidencia está en los países en desarrollo, entre los que Latinoamérica y el Caribe alcanzan prevalencia del 10 %. Objetivo: Identificar la relación que existe entre la anemia, las alteraciones de la tensión arterial y la disglicemia, con la restricción del crecimiento fetal. Métodos: Se realizó estudio longitudinal descriptivo y retrospectivo de gestantes captadas en dos áreas de salud del municipio Santa Clara, que terminaron su embarazo entre septiembre del 2013 y octubre del 2018. Los recién nacidos presentaron restricción del crecimiento intrauterino. La muestra se clasificó en: pequeños y adecuados, según condición trófica al nacimiento. En cada grupo se estudió la relación de estas afecciones en los que se sospechó un vínculo con el fenómeno de restricción. Resultados: Los niños que presentaron restricción del crecimiento fetal se clasificaron, según su condición trófica, en adecuados; no se apreciaron relaciones significativas entre la anemia, la diabetes gestacional y la hipertensión arterial con la presencia de restricción del crecimiento intrauterino. Conclusiones: esta afección no estuvo relacionada con la salud de las gestantes portadoras en dos áreas de salud del municipio Santa Clara.

ABSTRACT Introduction: the frequency of infants experiencing growth restriction during intrauterine development is high and its highest incidence is in developing countries, among which Latin America and the Caribbean reach a prevalence of 10%. Objective: to identify the relationship among anemia, blood pressure changes and dysglycemia, with fetal growth restriction. Methods: we conducted a descriptive, retrospective and longitudinal study of pregnant women recruited in two health areas from Santa Clara municipality, who ended their pregnancy between September 2013 and October 2018 and in whom the newborns had intrauterine growth restriction. The sample was classified as small and adequate, according to their trophic condition at birth. The relation of these conditions in which a link with the restriction phenomenon was suspected was studied in each group. Results: children who had fetal growth restriction were classified, according to their trophic condition, as adequate; no significant relationships were found among anemia, gestational diabetes and arterial hypertension with the presence of intrauterine growth restriction. Conclusions: this condition was not related to the health of the pregnant women belonging to these two health areas from Santa Clara municipality.

Diagnosis of congenital infections in premature, low-birthweight newborns with intrauterine growth restriction caused by cytomegalovirus (CMV), herpes simplex virus (HSV), Parvo-B 19, and Zika virus: a systematic review.

OBJECTIVES: To identify the prevalence of viral congenital infections in newborns classified as premature, low-birthweight, small for gestational age or intrauterine growth restriction. METHODS: The definition considered for selecting papers were: P as newborns younger than 28 days; V as low-birthweight, prematurity and intrauterine growth restriction; O as frequency of congenital infections with Cytomegalovirus, Parvovirus B19, Herpes Simplex, and Zika virus. The research was performed using EMBASE, LILACS, SCOPUS and MEDLINE databases, with no limitations on date and language. RESULTS: Eight studies were included. Manuscripts including Herpes Simplex, Zika virus or Parvovirus B19 did not fulfill the defined criteria. A wide variation in the frequency of CMV congenital infection (0-4.8%) was found, which might be attributed to regional and methodological differences between investigations. CONCLUSIONS: Newborn characteristics associated with CMV congenital infections may direct investigations towards these patients with a higher probability of infection. However, as data are controversial, studies concerning screening of infection are important to define recommendations of diagnosis.

Sildenafil como tratamiento de la restricción de crecimiento intrauterino, revisión sistemática de la literatura / Sildenafil as a treatment for blood restriction fetal growth, systematic review of the literature

INTRODUCCIÓN Y OBJETIVO: La restricción del crecimiento intrauterino (RCIU), expresión insuficiente del potencial genético de crecimiento fetal, complica el 5-8% de los embarazos, con unas altas tasas de morbimortalidad perinatal. De origen multifactorial, puede ser causada por patologías maternas, fetales o placentarias. El tratamiento es limitado, optándose por un seguimiento riguroso con eventual interrupción del embarazo según la evolución. Se han utilizado diferentes estrategias terapéuticas para su prevención y manejo, surgiendo el citrato de sildenafil (CS), inhibidor de la fosfodiesterasa tipo 5, como fármaco que podría mejorar el flujo sanguíneo uteroplacentario y ofrecer mejores resultados perinatales en fetos con RCIU. Se propone realizar una revisión de la literatura disponible en relación al CS como tratamiento del RCIU. MÉTODO: Se realizó una búsqueda de literatura en inglés y español. De 105 artículos seleccionados, se excluyeron 94. La información obtenida fue clasificada y utilizada como soporte para la realización de esta revisión, siguiendo el modelo PRISMA. RESULTADOS: Se encontraron 11 estudios que contrastan el uso de placebo y CS en pacientes con RCIU. Respecto al aumento de peso al nacimiento, solo dos estudios demostraron evidencia significativa. Se reportaron 40 casos de muerte fetal/neonatal asociada al tratamiento con CS. CONCLUSIONES: No se encontró evidencia suficiente que justifique el uso sistemático de CS en casos de RCIU. Aún es necesario realizar estudios con muestras de mayor tamaño y posterior metaanálisis para confirmar el beneficio farmacológico en cuanto al aumento de peso de nacimiento, la prolongación del embarazo y los posibles efectos adversos a largo plazo.

INTRODUCTION AND OBJECTIVE: Intrauterine growth restriction (IUGR) is an insufficient expression of the genetic potential for fetal growth, complicates 5-8% of pregnancies and represents high rates of perinatal morbidity and mortality. Of multifactorial origin, it can be caused by pathologies at the maternal, fetal or placental level. The treatment is limited, opting for a rigorous follow-up with eventual interruption of the pregnancy according to evolution. Different therapeutic strategies have been used for its prevention and management, emerging sildenafil citrate (CS), inhibitor of phosphodiesterase type 5, as a drug that could improve the uteroplacental blood flow and offer better perinatal results in fetuses with IUGR. A review of the available literature on CS as a treatment for IUGR is proposed. METHOD: A search was conducted for literature in English and Spanish. Out of 105 selected articles, 94 were excluded. The information obtained was classified and used as support for this review, following the PRISMA model. RESULTS: We found 11 studies that contrast the use of placebo and CS in patients with IGR. Regarding birth weight gain, only two studies showed significant evidence. Forty cases of fetal/neonatal death associated with CS treatment were reported. CONCLUSIONS: Not enough evidence was found to justify the routine use of CS in IUGR cases. Studies with larger samples and subsequent meta-analysis are still necessary to confirm the benefit of this drug in terms of birth weight gain, prolongation of pregnancy and possible long-term adverse effects.

Adverse pregnancy outcomes and occlusal traits in the primary dentition: A prospective cohort (BRISA).

OBJECTIVES: This study aimed to analyse the relationship between adverse pregnancy outcomes (APO) and occlusal traits in the primary dentition, checking for different mediation paths. SETTING AND SAMPLE POPULATION: Children evaluated at birth (T1), between 12 and 24 months (T2), and between 24 and 36 months (T3) were included. Two hundred and seventeen children who participated in T1 and T2 were randomly selected to perform the occlusion examination. MATERIALS AND METHODS: This is a prospective cohort study (BRISA). The theoretical model was tested by structural equation modelling (SEM), estimating standardized coefficients (Coeff.) (α = 0.05). The primary exposure was APO-a latent variable manifested from three health problems at birth: low birthweight (LBW), pre-term birth (PTB) and intrauterine growth restriction (IUGR), evaluated in T1. The outcomes were four different occlusal traits assessed in T3: overjet, anterior and posterior crossbite, and crowding. Each outcome's direct and indirect effects were tested, mediated by growth, breathing, breastfeeding, and pacifier use. RESULTS: There was no direct association between APO and any of the outcomes: overjet (Coeff. = -0.163, P = .241), anterior crossbite (Coeff. = -0.696, P = .065), posterior crossbite (Coeff. = -0.087, P = .589) and crowding (Coeff. = 0.400, P = .423). The indirect (total and specifics) effects tested also showed no association (P > .05). However, APO was associated with lower child growth in all models; breastfeeding was associated with higher child growth in all models, and pacifier use was associated with overjet (Coeff. = 0.184, P < .001) and posterior crossbite (Coeff. = 0.373, P = .011). CONCLUSION: APO was not a risk factor for overjet, crossbite and crowding in an early stage of the primary dentition by direct and indirect pathways. However, growth has been lower in children with APO and higher in children breastfed. Also, the harmful effects of using a pacifier in dental occlusion are highlighted.