Clinical implementation of the sFlt-1/PlGF ratio to identify preeclampsia and fetal growth restriction: A prospective cohort study.

OBJECTIVE: To analyze the usefulness of a clinical protocol for early detection of preeclampsia and/or fetal growth restriction (PE/FGR) using, in previously selected pregnancies, the measurement of the sFlt-1/PlGF ratio at 24-28 weeks of gestation. STUDY DESIGN: Prospective observational cohort study carried out in a single tertiary hospital in Spain. 5601 consecutive singleton pregnancies with complete follow-up were included. High-risk women for PE/FGR were selected by combining data from maternal history and second trimester uterine artery Doppler. Subsequently these patients underwent intensive monitoring, including the measurement of the sFlt-1/PlGF ratio at 24-28 weeks to predict PE/FGR. MAIN OUTCOME MEASURES: Early, intermediate and late PE/FGR (delivery <32 + 0, 32 + 0 - <36 + 0 and ≥36 + 0 weeks, respectively). RESULTS: Overall incidence of early, intermediate and late PE/FGR was 0.3%, 0.7% and 3.2%, respectively, being higher in the 4.3% of women selected for intensive monitoring: 5.8%, 8.7% and 15.4%, respectively (all p < 0.001). The area under the curve (AUC) with 95%CI of the sFlt-1/PlGF ratio for detecting early PE/FGR was 0.98 (0.97-1.00), and the sFlt-1/PlGF ratio >95th centile showed a sensitivity (%) of 100 (95%CI, 78.5-100) and specificity (%) of 80.6 (95%CI, 75.0-85.2). The AUC of the sFlt-1/PlGF ratio for detecting intermediate and late PE/FGR was of 0.87 (95%CI, 0.77-0.97) and 0.68 (95%CI, 0.58-0.79), respectively. CONCLUSION: A contingent strategy of measuring the sFlt-1/PlGF ratio at 24-28 weeks in women previously selected by clinical factors and uterine artery Doppler enables an accurate prediction of PE/FGR. This performance is optimal to predict PE/FGR requiring delivery before 32 weeks.

Listeriosis durante el embarazo: importancia del tratamiento precoz / Listeriosis during pregnancy: Importance of early treatment

La infección por listeria monocytogenes durante la gestación tiene una repercusión grave en la evolución del embarazo.Ante una sospecha clínica, resulta indispensable iniciar un tratamiento precoz con ampicilina y gentamicina para evitar la infección neonatal secundaria a la bacteriemia materna.Describimos tres casos clínicos de listeriosis durante la gestación con distintos desenlaces en función de la precocidad del tratamiento (AU)

Listeria monocytogenes infection in pregnant women may have severe consequences for pregnancy outcome. Early antenatal treatment with ampicillin and gentamicin when there is clinical suspicion is highly recommended to avoid neonatal infection caused by maternal bacteremia. We describe three cases with distinct outcomes due to the different timing of treatment (AU)

Role of uterine artery Doppler in interpreting low PAPP-A values in first-trimester screening for Down syndrome in pregnancies at high risk of impaired placentation.

OBJECTIVES: Low maternal serum levels of pregnancy-associated plasma protein-A (PAPP-A) are associated with both increased risk of aneuploidies and impaired trophoblastic invasion, while high uterine artery (UtA) resistance is associated with impaired trophoblastic invasion but not with an increased risk of aneuploidies. The aim of this study was to determine whether high UtA resistance plays a role in explaining low PAPP-A levels in the absence of aneuploidies. METHODS: This was a prospective study of 116 singleton pregnancies at high risk for impaired placentation (having at least one major risk factor: prior history of pre-eclampsia, pregestational diabetes mellitus, chronic hypertension, chronic kidney disease, body mass index >30, autoimmune disorder, thrombophilia or recurrent pregnancy loss), booked for routine assessment of risk for aneuploidies by means of the first-trimester combined screening test (nuchal translucency thickness (NT) + PAPP-A + beta-human chorionic gonadotropin (beta-hCG)). Measurement of NT and the mean UtA pulsatility index (PI) were carried out at the 11 to 13 + 6-week scan. All values were calculated in multiples of the median (MoM) adjusted for gestational age. A cut-off risk of 1/270 at time of sampling was adopted to differentiate high- from low-risk groups for trisomy 21. RESULTS: There were 108 patients deemed to be at low risk for trisomy 21 and eight at high risk. None had chromosomal defects, giving a false-positive rate for trisomy 21 of 6.9%. The greatest differences between patients at low risk and those at high risk for trisomy 21 were found in their PAPP-A (0.98 vs. 0.38 MoM, P < 0.01) and beta-hCG (1.09 vs. 1.77 MoM, P = 0.04) values. Greater NT thickness (1.02 vs. 0.90 MoM) and higher mean UtA-PI (1.05 vs. 0.96 MoM) were recorded in the high-risk group, although the differences did not reach statistical significance (P = 0.19 and 0.40, respectively). After log-transformation there were no significant correlations between mean UtA-PI and NT and between mean UtA-PI and beta-hCG. There was a significant negative linear correlation between mean UtA-PI and PAPP-A (r = -0.331; P < 0.01). After adjusting the PAPP-A values by UtA-PI, the false-positive rate for trisomy 21 decreased to 2.6%. CONCLUSION: Mean UtA-PI at the 11 to 13 + 6-week scan may be an effect-modifier variable for PAPP-A that should be taken into account in the first-trimester combined screening for aneuploidies, at least in pregnancies at high risk for impaired placentation.

Mujeres inmigrantes: características del control prenatal y del parto / Female immigrants: characteristics of antenatal care and delivery

Objetivos: Comparar las características sociodemográficas, el control de la gestación y el parto en mujeres procedentes de países de escasos recursos económicos (denominadas inmigrantes en el presente trabajo) y en las que no lo son (principalmente españolas).Métodos: Entre diciembre de 2000 y marzo de 2001 se incluyó en el estudio a todas las mujeres inmigrantes y a una muestra representativa (1:2) de las mujeres no inmigrantes que dieron a luz en un hospital de Madrid.Resultados: Durante el período de estudio, 203/1.352 (15 por ciento; intervalo de confianza [IC] del 95 por ciento, 13,2-17,1) de las mujeres que parieron fueron inmigrantes; el 56 por ciento (IC del 95 por ciento, 49-62) procedía de Centro y Sudamérica. La mayoría tuvo un embarazo y un parto sin complicaciones. El número mediano de visitas de control de embarazo fue de 8 (intervalo intercuartil [IQ], 6-9) para las inmigrantes y 9 (IQ, 8-10) para las españolas; la proporción de cesáreas fue, respectivamente, del 17,3 por ciento (IC del 95 por ciento, 12,5-23,3) y el 16,3 por ciento (IC del 95 por ciento, 12,9-20,2).Conclusiones: Las mujeres procedentes de países de escasos recursos económicos que acuden a parir a un hospital de tercer nivel de Madrid tienen un seguimiento de la gestación adecuado y no presentan mayor riesgo de complicaciones durante el embarazo y el parto, contrariamente a lo que suele ser la percepción generalizada. Las diferencias encontradas son principalmente de características sociales. Estos resultados pueden no ser extrapolables a otros centros, ya que la población de mujeres inmigrantes y españolas que se atiende en los distintos centros sanitarios puede ser muy diferente (AU)

Pregnancy in a patient with chronic intestinal pseudo-obstruction on long-term parenteral nutrition.

Parenteral nutrition support is provided in most instances for short intervals during pregnancy in conditions where oral/enteral intake is severely compromised. Few reports describe the use of parenteral nutrition from conception to delivery. We report the case of a 30-year-old woman suffering from a severe form of chronic intestinal pseudo-obstruction on long-term parenteral nutrition because of malabsorption and malnutrition. Pregnancy and delivery developed uneventfully. The fetus grew normally throughout pregnancy. Our patient needed only slight modifications in her parenteral nutrition regimen during lactation. There were no metabolic complications during pregnancy. We conclude that female patients even with severe forms of gastrointestinal diseases, such as chronic intestinal pseudo-obstruction requiring long-term home parenteral nutrition, can conceive and carry successfully a pregnancy to term.