Melatonin treatment in fetal and neonatal diseases.

This literature review aims to address the main scientific findings on oxidative stress activity in different gestational disorders, as well as the function and application of melatonin in the treatment of fetal and neonatal changes. Oxidative stress has been associated with the etiopathogenesis of recurrent miscarriages, preeclampsia, intrauterine growth restriction, and stillbirth. Both, the exacerbated consumption of the antioxidant enzymes superoxide dismutase, catalase and glutathione peroxidase, and the increased synthesis of reactive oxygen species, such as superoxide, peroxynitrite, and hydrogen peroxide, induce phospholipid peroxidation and endothelial dysfunction, impaired invasion and death of trophoblast cells, impaired decidualization, and remodeling of maternal spiral arteries. It has been postulated that melatonin induces specific biochemical responses that regulate cell proliferation in fetuses, and that its antioxidant action promotes bioavailability of nitric oxide and, thus, placental perfusion and also fetal nutrition and oxygenation. Therefore, the therapeutic action of melatonin has been the subject of major studies that aim to minimize or prevent different injuries affecting this pediatric age group, such as intrauterine growth restriction, encephalopathy, chronic lung diseases, retinopathy of prematurity Conclusion: the results antioxidant and indicate that melatonin is an important therapy for the clinical treatment of these diseases.

Mola hidatiforme parcial recorrente evoluindo para neoplasia trofoblástica gestacional / Recurrent partial hydatidiform mole evolving to gestational trophoblastic neoplasia

Mola hidatiforme parcial recorrente é evento em que há repetição da mola hidatiforme parcial. Há cerca de 100 casos relatados na literatura e dúvida se essa entidade pode evolver para neoplasia trofoblástica gestacional pós-molar. Apresenta-se relato de caso de paciente com recorrência de mola hidatiforme parcial em que houve aumento de embriopatia, bem como transformação maligna da mola parcial recorrente. Empregou-se quimioterapia com Methotrexate para induzir cura. Não obstante seja ocorrência rara, a importância deste relato encontra-se na evidência de neoplasia trofoblástica gestacional em recorrência de mola hidatiforme parcial, determinando vigilância hormonal rigorosa para detectar a malignização desses blastomas.

Recurrent partial hydatidiform mole is an event of repetitive partial hydatidiform mole. It has been reported around 100 cases in the literature and it is still unclear if this entity can evolve to postmolar gestational trophoblastic neoplasia. In this report, it is presented a case of recurrent partial hydatidiform mole with an increase in embriologic alterations, as well as malignization of recurrent partial hydatidiform mole. Chemotherapy with Methotrexate regimen was used to induce remission. Although rare, the importance of this report relies on the evidence of gestational trophoblastic neoplasia in recurrent partial hydatidiform mole, demanding straight hormonal surveillance to detect malignization of these tumors.

Miocarditis y bloqueo aurículo-ventricular fetal asociado a lupus eritematoso sistémico materno / Myocarditis and atrioventricular block associated with systemic lupus erythematosus

El lupus eritematoso sistémico (LES) es una de las patologías autoinmunes más frecuentes durante el embarazo, asociándose con distintas complicaciones fetales y neonatales, sobre todo cardíacas, secundario al traspaso de anticuerpos maternos a través de la placenta. Estos anticuerpos se unen a los cardiomioci-tos fetales, desencadenando una respuesta inflamatoria local que determina la aparición de lesiones que pueden ser permanentes y letales. Presentamos el caso de una paciente embarazada con LES, en la cual se observó en el feto la presencia de bloqueo aurículo-ventricular de primer grado y signos sugerentes de miocarditis. Estas complicaciones se caracterizan por un aumento en la morbimortalidad perinatal, por lo que las estrategias actuales están dirigidas a la detección precoz de éstas y también en la prevención de las mismas. Un tratamiento estándar aun es tema de investigación, pese a los reportes que muestran la efectividad de corticoides como la dexametasona. En embarazadas con anticuerpos anti-Ro positivo se recomienda efectuar ecocardiograma fetal seriados cada 1-2 semanas desde la semana 16, para detectar precozmente anomalías cardiacas sobre las cuales pudiese intervenirse.

Systemic lupus erythematosus (SLE) is one of the most common autoimmune disease during pregnancy, associated with various fetal and neonatal complications, especially heart disease, secondary to the transfer of maternal antibodies through the placenta. These antibodies bind to fetal cardiomyocytes, triggering a local inflammatory response that determines the appearance of lesions that may become permanent and deadly. We report a pregnant patient with SLE, in which was observed the presence of atrioventricular block of 1st degree and signs suggestive of myocarditis in the fetus. These complications are characterized by an increase in fetal and neonatal morbidity and mortality, so that current strategies are aimed at early detection of these and also in preventing them. A standard therapy for atrioventricular block is still matter of investigation, although corticosteroids like dexamethasone have been reported to be effective for associated cardiomyo-pathy. Serial echocardiograms and obstetric sonograms, performed at least every 1-2 weeks starting from the 16th week of gestational age, are recommended in anti-Ro/SSA-positive pregnant women to detect early fetal abnormalities that might be a target of preventive therapy.

[Fetal supraventricular tachyarrhythmias refractory to initial therapy]. / Taquiarritmias supraventrículares fetales refractarias al tratamiento inicial.

Fetal arrhythmia is an unusual cause of admission in critical care unit. We report three cases of pregnant patients with gestational age of 27 to 32 weeks, with diagnosis of fetal sustained supraventricular tachyarrhymias; which were resistant to digoxin as first line therapy. Two fetuses had supraventricular tachycardia and were converted with flecainide in association with digoxin. A remaining hydropic fetus suffering atrial flutter with 2:1 auriculo-ventricular conduction, failed to restore sinus rhythm with digoxin alone or in association with flecainide nor amiodarone, and required premature c-section at 30a week of gestation. Due to amiodarone administration the neonate suffered transient neonatal hypothyroidism.

Insulin analogue therapy in pregnancies complicated by diabetes mellitus.

Pregnancies complicated by diabetes mellitus (DM) include pregestational DM and gestational DM, defined as carbohydrate intolerance of variable severity first detected during pregnancy. DM leads to poor pregnancy outcome. The aim of treatment is to control maternal hyperglycaemia and to imitate postprandial insulin release. Rapid-acting insulin analogues are suitable therapeutic candidates, as they are able to reduce postprandial hyperglycaemia (predictive of adverse pregnancy outcome). There is no excess risk of adverse fetal or maternal outcomes when compared with regular insulin. Data suggest that rapid-acting insulin analogues do not transfer to human placenta. Because of the reduced risk of hypoglycaemia and improved postprandial and overall glucose control, insulin analogues could be considered the rapid-acting insulin choice during pregnancy.

[Reduction of HIV mother-to-child transmission in Colombia, two years of experience, 2003-2005]. / Reducción de la transmisión madre hijo del VIH en Colombia: dos años de experiencia nacional, 2003-2005.

INTRODUCTION: A national initiative on reduction of HIV mother-to-child-transmission is being implemented since 2003 in Colombia, including HIV counseled and voluntary testing as part of the routine antenatal care, comprehensive care with ARV treatment to HIV-positive pregnant women and their infected children, caesarian delivery, and replacement of breast milk. OBJECTIVE: To describe the achievements in the implementation of the prevention strategy of mother-to-child HIV transmission, 2003-2005. MATERIALS AND METHODS: The implementation procedures of the Project are described, as well as the coverage percentages achieved, the prevention of vertical transmission and its associated factors, and the six-month prevalence by geographical departments. The probability of transmission adjusted to the ARV treatment offered and the differences by regions are also analyzed. RESULTS: The Project was implemented in 757 municipalities (68%); diagnostic tests were performed to 200,853 pregnant women, 377 of whom were diagnosed as HIV positive (0.19%), with higher prevalences in the Caribbean region, and in the Departments of Quindio and Santander. Complete six-month follow-up after delivery was provided to 285 women and their neonates (12 of whom were HIV-positive). The probability of transmission with the use of ARV schemes during pregnancy (n=170) was 1.78% (IC 95%: 0.37-5.13%). Factors related to probability of transmission were: initial viral load > 10,000/mm3, absence of antenatal care, and late recruitment of pregnant women. No statistical differences were found between the ARV schemes used. In the Caribbean region, antenatal care was lower, and late recruitment of pregnant women was higher. CONCLUSIONS: Reduction of HIV mother-to-child-transmission is an effective preventive intervention, which also strengthens the quality of antenatal care services. Sustainability of this initiative, with nationwide coverage, must be a target for national and regional public health authorities, and for health care providers.

Taquiarritmias supraventrículares fetales refractarias al tratamiento inicial / Fetal supraventricular tachyarrhythmias refractory to initial therapy

Las arritmias fetales representan un motivo infrecuente de ingreso ala unidad de cuidados intensivos. Se presenta tres casos de gestantes entre 27 y 32 semanas, con el diagnóestico de taquiarritmias supraventriculares fetales sostenidas, que exhibían fracaso en el intento inicial de reversión con digoxina. Dos casos con taquicardia sapraventricular respondieron favorablemente cuando se asoció flecainida. Un feto hidrópico con aleteo auricular y bloqueo 2:1 no revirtió con la associón de flecainida ni amiodarona a la digoxina y requirió la interrupsión de la gestación en la 30 ª semana. El neonato presentó disfunción tiroidea transitória atribuída a la administración de amiodarona.

Taquiarritmias supraventrículares fetales refractarias al tratamiento inicial / Fetal supraventricular tachyarrhythmias refractory to initial therapy

Las arritmias fetales representan un motivo infrecuente de ingreso ala unidad de cuidados intensivos. Se presenta tres casos de gestantes entre 27 y 32 semanas, con el diagnóestico de taquiarritmias supraventriculares fetales sostenidas, que exhibían fracaso en el intento inicial de reversión con digoxina. Dos casos con taquicardia sapraventricular respondieron favorablemente cuando se asoció flecainida. Un feto hidrópico con aleteo auricular y bloqueo 2:1 no revirtió con la associón de flecainida ni amiodarona a la digoxina y requirió la interrupsión de la gestación en la 30 ¬ semana. El neonato presentó disfunción tiroidea transitória atribuída a la administración de amiodarona. (AU)

Fetal tachyarrhythmia with 1:1 atrioventricular conduction. Adenosine infusion in the umbilical vein as a diagnostic test.

This is the report of a case of fetal tachyarrhythmia with 1:1 atrioventricular conduction detected by pre-natal echocardiography in a fetus at 25-weeks gestation. Adenosine infusion via cordocentesis was performed as a diagnostic test to differentiate between atrioventricular nodal reentrant supraventricular tachyarrhythmia and atrial flutter. After infusion, transient 2:1 atrioventricular dissociation was obtained and the diagnosis of atrial flutter was made. Transplacental therapy with digoxin and amiodarone was then successfully used.

Clinical utility of adrenal ultrasonography in the diagnosis of congenital adrenal hyperplasia.

Rapid, accurate diagnosis of congenital adrenal hyperplasia (CAH) is essential in the neonate with ambiguous genitalia, life-threatening salt loss, or both. We aimed to determine the accuracy of adrenal ultrasonography in the diagnosis of CAH in a retrospective analysis of 52 children with ambiguous genitalia or salt-losing crises. Adrenal ultrasounds were interpreted as follows: "normal" if the adrenals were normal in size (adrenal limb width <4 mm), had a smooth surface, and a central echogenic stripe with a hypoechoic rim, and "abnormal" if they were increased in size (limb width >4 mm), had a lobulated or cerebriform surface, or showed abnormal echogenicity. Group 1 consisted of 25 neonates and infants with CAH; group 2, 19 children with conditions other than CAH; and group 3, 8 with treated CAH: 7 receiving replacement therapy and 1 whose mother received glucocorticoids during pregnancy. In all children in groups 2 and 3, adrenal ultrasounds were read as normal. In group 1 adrenal ultrasonography was normal in 2 (8%) and abnormal in 23 (92%). Thus adrenal ultrasonography has a sensitivity of 92% and a specificity of 100% for diagnosing CAH. Adrenal ultrasonography is a highly sensitive and specific adjunct in the diagnosis of CAH. The presence of enlarged, lobulated adrenals with stippled echogenicity is invariably associated with CAH.

Tratamiento antenatal de taquicardía supraventricular fetal / Prenatal treatment of fetal supraventricular tachycardia

Se presenta un caso de taquicardia supraventricular fetal, diagnosticado a las 33 semanas de embarazo y tratado en forma exitosa con asociación de drogas antiarrítmicas, logrando un embarazo a término. Se comenta frecuencia de la patología, su diagnóstico y alternativas terapéuticas

Diagnosis and treatment in utero of goiter with hypothyroidism caused by iodide overload.

A fetal goiter was detected by ultrasonography in a woman receiving potassium iodide. After this medication was discontinued at 29 weeks, a fetal hypothyroidism was confirmed by cordocentesis, and two doses of levothyroxine were administered by amniocentesis. At 34 weeks repeated cordocentesis showed fetal euthyroidism and ultrasonography shrinkage of the goiter. Growth and development normal at 1 year.

Taquiarritmias supraventriculares no feto. Experiência de uma unidade de referência em cardiologia fetal / Fetal supraventricular Tachyarrhythmias. Experience of a fetal cardiology reference center

OBJETIVO: Avaliar a forma de apresentaçäo, diagnóstico e tratamento das taquiarritmias supraventriculares fetais, através do relato de uma série de casos acompanhados em um centro terciário de cardiologia fetal. MÉTODOS: Säo descritos 25 casos de taquiarritmia supraventricular diagnosticados intra-útero, no período de janeiro/89 a outubro/97, em uma populaçäo compreendendo 3117 gestantes. RESULTADOS: Foram diagnosticados 17 casos taquiarritmia supraventricular e 8 casos de flutter atrial fetal. As idades gestacionais variam de 26 a 40 semanas. Doze fetos apresentavam hidropisia no momento do diagnóstico (6 com taquicardia supraventricular (TSV) e 6 com flutter atrial). Quatro fetos com TSV apresentavam cardiopatias estruturais (dois casos de anomalia de Ebstein e dois com comunicaçäo interventricular). Todos os fetos foram internados na Unidade de Cardiologia Fetal para monitorizaçäo e tratamento. Entre os 17 fetos com TSV, 12 apresentaram reversäo da arritmia após administraçäo de digoxina, mas esta medida näo foi eficaz em nenhum paciente com flutter. Dois pacientes com TSV e seis com necessitaram interrupçäo da gestaçäo para cardioversäo elétrica pós-natal. A mortalidade foi de 3/17 no grupo da TSV (incluindo dois pacientes com anomalia de Ebstein) e de 0/8 no grupo com flutter. CONCLUSÄO: As taquiarritmias supraventriculares fetais säo enventos raros na populaçäo geral. Entretanto, podem provocar insuficiência cardíaca e óbito intrauterino. Como a resposta ao tratamento é satisfatória, tornam-se de extrema importância o diagnóstico precoce e o tratamento adequado.

Conjugated hyperbilirubinemia in a newborn infant after maternal (transplacental) treatment with flecainide acetate for fetal tachycardia and fetal hydrops.

An infant with intrauterine supraventricular tachycardia and fetal hydrops, successfully treated with administration of flecainide acetate to the mother had conjugated hyperbilirubinemia shortly after birth. An extensive evaluation failed to disclose a known cause. We believe that in utero exposure to flecainide acetate resulted in conjugated hyperbilirubinemia in this infant.

[Use of sympathomimetic agents in fetal atrioventricular heart block]. / Uso de simpaticomimético em bloqueio atrioventricular fetal.

A healthy pregnant was referred at 34 weeks gestation because an obstetrical ultrasound examination had shown fetal bradycardia and nonimmune hydrops. The heart was anatomically normal but complete heart block was present with a ventricular rate of 22bpm and atrial of 101bpm. We injected isoproterenol by cordocentesis direct in the umbilical vein of the fetus and a significant increase into the ventricular and atrial rates were obtained. The direct therapy with sympathomimetic drugs is a simple technique and may save fetuses with complete heart block and hidrops.

Uso de simpaticomimético em bloqueio atrioventricular fetal / Sympathomimetic Drug Therapy in Fetal Complete Heart Block

Gestante de 34 semanas foi encaminhada para ecocardiografia fetal por bradicardia e hidropsia fetal ao ultrassom obstétrico. A anatomia cardíaca mostrou-se normal, porém, foi diagnosticado bloqueio atrioventricular total com freqüência ventricular de 22 bpm e freqüência atrial de 101 bpm. Através de cordocentese, injetou-se na veia umbilical 0,06µg de isoproterenol, elevando-se a freqüência ventricular para 40bpm e a atrial para 171bpm. A utilizaçäo de simpaticomiméticos diretamente na veia umbilical fetal é um procedimento relativamente simples e, em muitos casos, pode evitar a hidropsia e o óbito

Clinical and pharmacologic study of fetal supraventricular tachyarrhythmias.

The purpose of this study was to evaluate the efficacy of maternal digoxin administration in 16 cases of fetal supraventricular tachyarrhythmia diagnosed by fetal echocardiography; cardiac anatomy was normal in all cases. The retrospective analysis included nine mothers who received digoxin orally in most cases, with control of the arrhythmia in two fetuses. The addition of amiodarone (five cases) and propranolol (two cases) yielded two successes with amiodarone. The therapeutic regimen of digoxin was then modified on the basis of poor response to orally administered digoxin. In the prospective study, digoxin was administered intravenously to seven mothers according to a standard protocol; high doses (1 to 2 mg intravenously) were prescribed for the first 24 hours and intravenous digoxin therapy was maintained for at least 5 days, depending on the fetal response. Digoxin pharmacokinetic studies of four mothers showed an increased plasma clearance and reduced elimination half-life. Digoxin controlled the five supraventricular tachycardias (with hydrops in four cases). Maternal flecainide therapy restored sinus rhythm in two cases of atrial flutter. Our prospective study emphasizes the efficacy and safety for the fetus and the mother of intravenously administered digoxin as a first-choice drug in the treatment of supraventricular tachyarrhythmias. Flecainide may be a promising second-choice drug but requires further clinical investigation. Amiodarone and propranolol seem to be ineffective.