Multidisciplinary Workup for Stillbirth at a Tertiary-Care Hospital in Northeast Mexico: Findings, Challenges and Perspectives.

OBJECTIVES: Stillbirth is an important health problem, and in Mexico, only half of the stillbirths have an explainable cause. The aim of this study was to implement a multidisciplinary workup to identify the etiology and potential risk factors for stillbirth at the Hospital Universitario "Dr. José Eleuterio González". METHODS: This is a prospective, descriptive, observational study that included stillbirths from the Obstetrics Service from October 1st, 2019 to May 25, 2020. Evaluation strategies included a complete maternal medical history, physical examination of the fetus, and a photographic medical record. For every stillbirth either a prenatal ultrasound, a postnatal x-ray, or a fetal autopsy, were needed. Multiplex Ligation Probe Amplification (MLPA) was performed with an umbilical cord sample. RESULTS: Thirty-three stillbirths were reported; 21 were included in the analysis. Eleven women (52.3%) had known risk factors for stillbirth, mainly elevated body mass index and diabetes. On physical examination, external birth defects were found in 8 fetuses (38%). X-ray was performed in 14 cases (66%), alterations were detected as a probable etiologic cause just in one. All cases underwent MLPA, which were reported negative. Three cases had criteria for autopsy. Findings were inconclusive to determine etiology. CONCLUSIONS: The best tools for evaluation of stillbirth were the elaboration of clinical history, physical examination, and prenatal ultrasound. Diabetes and obesity were the most frequent risk factors found in our population. These factors are preventable by implementing strategies that lead to better prenatal care.

Stillbirth is a health problem whose causes are rarely evaluated and explained to the families that go through this situation. To completely explain the causes of stillbirth a complete workup should be performed, where a multidisciplinary participation is needed. Mainly these workups have been performed retrospectively, however we introduce a complete evaluation of stillbirth since the moment of arrival to obstetrics department and performing evaluations for fetal, maternal or combined causes, including genetic testing; detecting key health issues in our population, that can be prevented with an adequate prenatal care.

Frequency of needle stick injuries among healthcare providers during large-scale SARS-CoV-2 vaccination brigades.

The frequency of needle stick-related accidents in large-scale vaccination brigades during the COVID-19 pandemic is unknown. We determined the incidence of needle stick injuries (NIs) from the SARS-CoV-2 vaccination brigades in the Monterrey metropolitan area. We calculated the rate of NI by 100,000 doses administered from a registry of over 4 million doses.

Proteomic profile of preeclampsia in the first trimester of pregnancy.

OBJECTIVE: Preeclampsia (PE) is a leading cause of pregnancy-associated maternal and neonatal morbidity and mortality. Detection of patients at risk before the clinical onset of PE is a priority. Proteomics have become a valuable tool for the discovery of new biomarkers; however, the understanding of the underlying mechanism is necessary. The aim of the study was to determine differences between proteomic serum profiles of PE and normotensive pregnancies using quantitative and qualitative approaches. STUDY DESIGN: Serum samples from pregnant women were taken at 10-12 weeks of gestation with follow-up to determine PE development. Samples were analyzed using nano 2-D liquid chromatography UPLC and qTOF-MS/MS. RESULTS: A total of 136 women were recruited, of which eight (5.9%) developed PE, and eight normotensive were randomly selected as a control group for comparison. A different profile was obtained between groups. Nine proteins showed quantitative differences with fold-change over 1.5: PRRC2C (217.02), HEATR5A (179.46), ATP6 (162.38), PRRC2B (83.09), RBM25 (5.36), NUP205 (3.38), HLA-I (2.27), ZC3H13 (2.15), and SREK1 (1.66); and two under 0.66: Importin-4 (0.55) and Cytochrome b (0.26). Using bilateral Fisher's exact test for the qualitative approach, LRRK1 had statistical significance (p = .044), while PRRC2B (p = .121), PRRC2C (p = .134), and NUP205 (p = .134) showed a tendency to be present in PE. CONCLUSION: The found proteins have plausibility with the early pathophysiological events that have been associated with this pathology. Further studies should be performed to confirm these findings and elucidate their specific roles.

Telangiectasia hemorrágica hereditaria durante el embarazo: Reporte de caso / Hereditary hemorrhagic telangiectasia during pregnancy: Case report

Resumen ANTECEDENTES: La telangiectasia hemorrágica hereditaria, o síndrome de Rendu-Osler-Weber, es una enfermedad vascular, hereditaria y autosómica caracterizada por telangiectasias mucocutáneas y malformaciones arteriovenosas en el pulmón, el cerebro e hígado. La prevalencia estimada es de 1.5 a 2 personas afectadas por cada 10,000 habitantes. El 90% de los casos se debe a una mutación en el gen endoglina y en el de la cinasa 1 similar al receptor de activina (ACVRL1). En la mujer embarazada, la telangiectasia hemorrágica hereditaria es de alto riesgo, sobre todo durante el segundo y tercer trimestre. OBJETIVO: Reportar un caso de telangiectasia hemorrágica hereditaria y exponer las complicaciones que pueden registrarse durante el embarazo. CASO CLÍNICO: Paciente de 23 años, con antecedente heredofamiliar de madre con diagnóstico de telangiectasia hemorrágica hereditaria (síndrome de Osler-Weber-Rendu) que falleció a los 38 años. Antecedente personal patológico de telangiectasia hemorrágica hereditaria, con diagnóstico a los 12 años luego de múltiples episodios de epistaxis. Recibió tratamiento con transfusiones sanguíneas en múltiples ocasiones y 200 mg de sulfato ferroso cada 24 horas. CONCLUSIÓN: La telangiectasia hemorrágica hereditaria condiciona, en la mujer embarazada, la aparición de complicaciones que pueden poner en riesgo la vida de la madre y el feto. Las mujeres con antecedente conocido deben valorarse antes de la concepción con el propósito de conocer el estado de la enfermedad.

Abstract BACKGROUND: Hereditary hemorrhagic telangiectasia, or Rendu-Osler-Weber syndrome, is an autosomal inherited vascular disease characterized by mucocutaneous telangiectasias and arteriovenous malformations in the lung, brain and liver. The estimated prevalence is 1.5 to 2 affected persons per 10,000 population. Ninety percent of cases are due to a mutation in the endoglin gene and in the activin receptor-like kinase 1 gene (ACVRL1). In pregnant women, hereditary hemorrhagic telangiectasia is high risk, especially during the second and third trimester. OBJECTIVE: To report a case of hereditary hemorrhagic telangiectasia and to expose the complications that can occur during pregnancy. CLINICAL CASE: 23-year-old patient, with hereditary family history of mother diagnosed with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) who died at 38 years of age. Personal pathological history of hereditary hemorrhagic telangiectasia, diagnosed at the age of 12 years after multiple episodes of epistaxis. She was treated with multiple blood transfusions and 200 mg of ferrous sulfate every 24 hours. CONCLUSION: Hereditary hemorrhagic telangiectasia conditions, in pregnant women, the appearance of complications that can put the life of the mother and fetus at risk. Women with a known history should be evaluated before conception in order to know the status of the disease.

Asociación entre el hiperparatiroidismo secundario a la deficiencia de vitamina D en el embarazo y la frecuencia de preeclampsia / Association between hyperparathyroidism secondary to vitamin D deficiency in pregnancy and the frequency of preeclampsia

Resumen OBJETIVO: Establecer si existe asociación entre el hiperparatiroidismo secundario a una deficiencia de vitamina D en el embarazo y la frecuencia de preeclampsia. MATERIALES Y MÉTODOS: Estudio de casos y controles, prospectivo y longitudinal efectuado en pacientes con y sin preeclampsia que entre el 1 de enero y el 30 de junio del 2021 acudieron al Hospital Universitario de la Universidad Autónoma de Nuevo León para la atención del parto. Criterios de inclusión: pacientes embarazadas con diagnóstico de preeclampsia en el último trimestre de la gestación con tensión arterial igual o mayor a 140-90 mmHg y proteinuria igual o mayor a 30 mg/dL. Para el grupo control: embarazadas sanas, sin diagnóstico de preeclampsia en el último trimestre de la gestación. Criterios de exclusión: tabaquismo, alcoholismo y drogadicción y quienes no aceptaron entrar al estudio o tuvieran diagnóstico de enfermedades médicas crónicas. RESULTADOS: Se estudiaron 90 pacientes divididas en dos grupos: con preeclampsia (n = 45) y sin ésta (control, n = 45). Se encontró una relación entre la deficiencia de vitamina D, la hipocalcemia y la preeclampsia; no así entre la paratohormona y la preeclampsia en los rangos internacionales de la primera. La preeclampsia se encontró con mayor frecuencia en pacientes de 12 a 15 años. CONCLUSIONES: El hiperparatiroidismo secundario a la deficiencia de vitamina D en el embarazo no se observó en pacientes con preeclampsia, quienes sí la padecieron tuvieron concentraciones de paratohormona en límites normales. Se encontró una relación entre la deficiencia de vitamina D, la hipocalcemia y la preeclampsia.

Abstract OBJECTIVE: To establish whether there is an association between hyperparathyroidism secondary to vitamin D deficiency in pregnancy and the frequency of preeclampsia. MATERIALSAND METHODS: Case-control, prospective, longitudinal study performed in patients with and without preeclampsia who between January 1 and June 30, 2021 attended the Hospital Universitario of the Universidad Autónoma de Nuevo Leon for delivery care. Inclusion criteria: pregnant patients with a diagnosis of preeclampsia in the last trimester of gestation with blood pressure equal to or greater than 140-90 mmHg and proteinuria equal to or greater than 30 mg/dL. For the control group: healthy pregnant women without a diagnosis of preeclampsia in the last trimester of gestation. Exclusion criteria: smoking, alcoholism and drug addiction and those who did not agree to enter the study or had a diagnosis of chronic medical diseases. RESULTS: We studied 90 patients divided into two groups: with preeclampsia (n = 45) and without preeclampsia (control, n = 45). A relationship was found between vitamin D deficiency, hypocalcemia, and preeclampsia; a relationship was not found between parathormone and preeclampsia in the international parathormone ranges. Preeclampsia was found more frequently in patients aged 12 to 15 years. CONCLUSIONS: Hyperparathyroidism secondary to vitamin D deficiency in pregnancy was not observed in patients with preeclampsia; those who had it had parathormone concentrations in normal limits. A relationship was found between vitamin D deficiency, hypocalcemia, and preeclampsia.

Moral Distress: Its Manifestations in Healthy Donors during Peripheral Blood Hematopoietic Stem Cell Harvesting.

Hematopoietic stem cell donors (HSCDs) may have ambivalent feelings about donation. These feelings are related to moral obligation to help a sick relative and/or fear about the donation procedure. This ambivalence can produce moral distress (MD) and anxiety, which are usually unnoticed by the treating physician. The aim of this study was to evaluate the incidence of MD and anxiety in a group of related HSCDs for allogeneic transplantation. In this prospective observational study, to assess MD and anxiety, we applied 3 self-answered questionnaires-a questionnaire developed to assess MD (MDQ), State Trait Anxiety Index (STAI), and Edmonton Symptom Assessment System (ESAS)-before, during, and after hematopoietic stem cell donation. A total of 60 consecutive related HSCDs with a mean age of 38.2 years were included. Thirty-six were male. Hematopoietic stem cell collections were done by apheresis, performed as an outpatient process in all cases. The incidence of MD during the donation process was 56%. The proportion of HSCDs with moderate to high state anxiety decreased significantly from before donation (63%) to after donation (30%). Higher scores for MD correlated with higher scores on the STAI questionnaire (r = 0.448; P < .005). Thirty-seven donors (62%) had at least 1 physical symptom even before the stem cell mobilization process started, mainly anxiety (33%), difficulty sleeping (33%), and fatigue (30%). The number of symptomatic donors increased during donation (100%) and decreased after the procedure (80%). We conclude that MD and anxiety symptoms experienced by HSCDs are very common and can be explained by mixed feelings about the donation process. Providing comprehensive psychological support before starting the donation process and guaranteeing respect for the donor's autonomy are needed to decrease the negative impact of the donation experience.

Early triglyceride and glucose index as a risk marker for gestational diabetes mellitus.

OBJECTIVE: To assess the risk of gestational diabetes mellitus (GDM) according to the triglyceride and glucose (TyG) index values during the first trimester of pregnancy in Latin American women. METHODS: Pregnant women were enrolled at their first prenatal visit at the Obstetric Division in the University Hospital "Dr. José E. González". Triglycerides and fasting plasma glucose (FPG) were collected to determine the TyG index. GDM diagnosis was performed by a single-step 2-hour 75-g oral glucose tolerance test. Generalized linear models were used to determine risk ratios; pregnancy outcomes at delivery were collected from the hospital medical records. RESULTS: A total of 164 pregnant women were included. GDM was present in 29 (17.7%) women. No significant differences in age, first-trimester body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), family history of diabetes, and TyG index were observed between GDM cases and the reference group without GDM. The adjusted analysis showed no association between TyG and GDM (risk ratio [RR] 1.03, 95% confidence interval [CI] 0.57-1.88]). Higher TyG index values between women with and without a diagnosis of GDM in the second trimester were observed. No significant differences were identified in pregnancy outcomes, although a trend was observed for hyperbilirubinemia in women with first-trimester TyG index values greater than 8.7. CONCLUSIONS: Our findings do not support the use of the TyG index for GDM prediction in Latin American women.

Diagnostic accuracy of the triglyceride-glucose index for gestational diabetes screening: a practical approach.

The oral glucose tolerance test (OGTT) remains as the gold standard to diagnose gestational diabetes mellitus (GDM); however, this test may be inconvenient and costly. Hence, other easy to perform and accurate diagnostic alternatives would be valuable for maternal care. The objective of the study was to assess the diagnostic performance of the TyG index to screen for GDM at 24-28 of pregnancy. A total of 140 pregnant women who received the one-step 2 h 75 g OGTT were included. Overall GDM prevalence was 27.1% according to IADSPG criteria. The mean TyG index value in the GDM group was significantly higher than the TyG index for the no GDM group (4.88 ± 0.70 versus 4.68 ± 0.19, p<.001). A sensitivity of 89% [95% CI 0.75-0.97] and a specificity of 50% [95% CI 0.39-0.60)], accompanied by a high negative predictive value of 93% was observed. No differences were found in maternal and neonatal outcomes irrespective of the TyG cutoff value for GDM. According to our results, the TyG index may be a highly sensitive and easy to perform screening test for GDM.

Polymorphic eruption of pregnancy in Mexico.

BACKGROUND: Currently, the exact incidence of Polymorphic Eruption of Pregnancy (PEP) in the Mexican population is unknown. PEP tends to manifest in the abdomen, primarily in the stretch marks caused by distension. It is characterized by severely pruritic urticarial-like papules that converge in plaques, extending to the buttocks and proximal thighs. Our study determined its incidence, along with other common dermatoses in pregnancy. METHODS: Patients between 14 and 45 years of age were evaluated. In each patient, a complete medical history and physical examination was performed with emphasis on skin and adnexa. Patients were followed until the end of their pregnancy. RESULTS: A total of 217 women were included. PEP was identified in three patients (1.38%), all primigravida, with single fetus pregnancy, and all concluded their pregnancy by vaginal delivery. The neonates were 2 females and 1 male. No other gestational pathologies were identified. CONCLUSIONS: We identified a higher incidence of PEP than reported, without association to complications or need for medical management. There may be an association between high maternal weight and the presence of PEP, however a larger sample is needed.

Tratamiento y desenlace obstétrico de una paciente con artrogriposis múltiple congénita / Clinical treatment and outcome of a patient with arthrogryposis multiplex congenita

Resumen ANTECEDENTES: La artrogriposis múltiple congénita es una alteración excepcional, caracterizada por contracturas musculares en diversas partes del cuerpo. Las pacientes embarazadas con esta enfermedad tienen mayor riesgo de complicaciones obstétricas. CASO CLÍNICO: Paciente de 19 años, con artrogriposis múltiple congénita, de ocho semanas de embarazo, quien acudió al servició médico para iniciar el control prenatal. Recibió asesoría de los riesgos cardiovasculares y del sistema respiratorio, secundarios a la enfermedad de base, que pudieran exacerbarse por el embarazo. El ultrasonido efectuado en la semana 22 del embarazo no reportó alteraciones estructurales. La paciente continuó en control prenatal, sin dificultad respiratoria ni alteraciones cardiovasculares. No recibió anticoagulantes profilácticos, ni manifestó signos de trombosis durante el embarazo. Se decidió la interrupción del embarazo por cesárea, debido a la limitación del movimiento de la cadera. Se programó para cirugía en la semana 38.3 del embarazo, con valoración del servicio de Cardiología, quienes reportaron fracción de eyección del ventrículo izquierdo adecuada y sin evidencia de miocardiopatía. Se aplicó anestesia por vía epidural sin complicaciones. El examen físico del neonato no mostró alteraciones. Actualmente, la madre y su hijo permanecen con buen estado de salud. CONCLUSIONES: Las pacientes embarazadas con artrogriposis múltiple congénita deben recibir asesoría de los riesgos inherentes y posibles complicaciones de la enfermedad. Es importante la intervención de un equipo multidisciplinario, para evaluar la función cardiovascular y respiratoria, además de efectuar revisiones seriadas para asegurar el bienestar materno-fetal.

Abstract BACKGROUND: Arthrogryposis multiplex congenita is a rare entity characterized by the appearance of multiple muscle contractures in various parts of the body. Pregnant patients with this condition have a higher risk of complications in obstetric management. CLINICAL CASE: A 19-year-old patient, with arthrogryposis multiplex congenita, eight weeks pregnant, attended in medical service to start prenatal care. Received advice on the cardiovascular and respiratory system risks, secondary to the underlying disease, that could be exacerbated by pregnancy. The ultrasound during the 22nd week of pregnancy did not report any structural alterations. The patient continued in prenatal control, without respiratory difficulty or cardiovascular alterations. Did not receive prophylactic anticoagulants, neither showed signs of thrombosis. We decide finished the pregnancy by caesarean section, due to the limited movement of the hip. Surgery was scheduled at week 38.3 of pregnancy, with assessment by the Cardiology service, who reported adequate left ventricular ejection fraction and no evidence of cardiomyopathy. Epidural anesthesia was applied without complications. The physical examination of the newborn showed no alterations. Currently, the mother and her son remain in good health. CONCLUSIONS: In pregnant patients with arthrogryposis multiplex congenita its important to explain the inherent risks of their condition and their possible complications. Multidisciplinary management should be performed with cardiovascular, respiratory, and serial reviews to ensure the welfare of the maternal-fetal binomial.

Effect on growth and osteoblast mineralization of hydroxyapatite-zirconia (HA-ZrO2) obtained by a new low temperature system.

Ceramics and bioceramics, such as hydroxyapatite and zirconium, are used in bone tissue engineering. Hydroxyapatite has chemical properties similar to bone while zirconium offers suitable mechanical properties. The aim of this article is to evaluate the ability to support cell growth and osteoblastic mineralization of hydroxyapatite-zirconium obtained by a new system based on different low temperatures, such as 873 K (HZ600), 923 K (HZ650) and 973 K (HZ700). Hydroxyapatite-zirconia obtained by this new system was examined in terms of thermogravimetric features and x-ray diffractograms. Furthermore, the ability for supporting osteoblast growth and mineralization were analyzed. By x-ray diffraction analysis, we clearly demonstrated that no high-temperature processing was required. Moreover, it is possible to form tetragonal-zirconium at 923 K. Proliferation assays showed that osteoblast growth was not influenced by any of the composite evaluated. Regarding the osteogenic marker Col1, a 2-fold increase in expression was observed for HZ650 compared to HZ600 and HZ700. Interestingly, osteoblasts grown on HZ650 showed globular accretions covered with collagen bundles and calcium-rich extracellular matrix whereas HZ600 and HZ700 showed no phosphate or calcium deposits. This study demonstrated that at 923 K it is possible to generate stable tetragonal-zirconium and the resulting HZ650 composite is able to promote a suitable osteoblast mineralization process.

Comparative analysis of iron status and other hematological parameters in preeclampsia.

OBJECTIVE: To compare serum ferritin (SF) concentrations and other hematological parameters between patients with preeclampsia (PE) and normal pregnant women of the same gestational period who received supplemental iron during pregnancy. METHODS: Prospective, comparative, observational pilot study that included 31 women with PE and 30 healthy pregnant women, at 20 weeks' of gestation. Ferritin, iron and complete blood cell count were compared between groups. RESULTS: In comparison with controls, preeclamptic patients had a higher weight, body mass index, and arterial pressure. Serum ferritin and serum iron were higher in patients with PE (median: 36.5 µg/l vs. 20.9 µg/l and 103.9 µg/dl vs. 90.8 µg/dl) with a significant difference (P = 0.019 and P = 0.345). SF values >40 µg/l correlated with PE (r = 0.281; P = 0.032). A platelet count less than 100 × 109/l was higher in the PE group than in the control group (13% vs. 3%, P = 0.354). CONCLUSION: Higher SF levels, despite being within normal range, were associated with PE. The incidence of thrombocytopenia was higher in preeclamptic women, however, the remaining hematological parameters were similar in both groups.