Serum biomarkers and Doppler pulsatile index increases likelihood ratio for prediction of preeclampsia in the second trimester of pregnancy.

This study aims to compare the accuracy of risk prediction for preeclampsia (PE) of three calculators during the second trimester of gestation: American College of Obstetricians and Gynaecologists (ACOG), National Institute for Health and Care Excellence (NICE), and Foetal Medicine Foundation (FMF). Complete medical history, mean uterine artery Doppler pulsatile index were performed (PI) and venous blood samples for placental growth factor (PIGF), soluble fms-like tyrosine kinase-1 (sFLT-1), and Endoglin measurements were obtained from 214 women between 20-24 weeks gestation. PE frequency was 8.4% (18/214). Sensitivity and specificity were 94.4% and 37.2% and 44.4% and 74.5% for ACOG and NICE respectively. Sensitivity for FMF was 66.7% and 44.4% at <32 weeks and <36 weeks respectively and specificity was 97.2% and 98.1%. The highest positive likelihood ratio, 22, was obtained for FMF as compared to 1.49 and 1.76 for ACOG and NICE. These findings suggest that the addition of US and serum biomarkers in the FMF calculator increases accuracy for prediction of PE.Impact StatementWhat is already known on this subject? Several strategies have been implemented to evaluate risk for PE. The ACOG and NICE calculators, based on medical and anthropomorphic data, and the FMF calculator, which includes ultrasound and serum biomarkers, have been used for the prediction of PE risk in the first trimester of gestation.What do the results of this study add? Although the identification of markers for the prediction of PE during the first trimester of pregnancy has been of major clinical interest, in many countries women attend their first prenatal visit up until the second trimester of pregnancy. This is the first multicentre study in Latin American population to compare the three risk prediction systems including serum biomarkers during the second trimester of pregnancy.What are the implications of these findings for clinical practice and/or further research? We propose the FMF calculator (including PI and serum biomarkers) as a useful tool for PE risk detection during the second trimester of pregnancy. However, as this study is limited by its small sample size, larger multicenter studies are needed to confirm our findings and assert the usefulness of the FMF calculator.

Prediction of low birth weight with hypoglycemia in glucose tolerance test.

OBJECTIVE: Determine the value of the combination of fasting glucose less than the 10th percentile (FG < p10) during 75 gram oral glucose tolerance test (75g OGTT) with maternal characteristics to predict low birth weight (LBW) established by Intergrowth-21st tables. METHODS: Prospective cohort study of pregnant women who was underwent 75g OGTT between 24 and 28.6 weeks. The 10th percentile fasting glucose of the population was determined at 65 mg/dL and women with risk factors that could modify fetal weight, including those related to intrauterine growth restriction, were excluded. Two groups were formed: group FG < p10 and group with normal fasting glucose. The main finding was the diagnosis of LBW. The association between FG < p10, maternal characteristics and LBW was established by multivariate logistic regression. The predictive performance of the models constructed was evaluated by receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis. RESULTS: 349 women were eligible for study, of whom 66 (18.91%) had FG < p10; neonates in this group had lower birth weights (2947.28 g and 3138.26 g, p = 0.001), higher frequencies of LBW (25% and 6.81%, p < 0.001) and of weights < 2500 g in term births (8.6% and 2.3%, p = 0.034). The basal prediction model consisted of nulliparity by achieving an AUC of 60%, while the addition of FG < p10 resulted in the significant improvement of the previous model (AUC 72%, DeLong: p = 0.005). CONCLUSIONS: In pregnant women without factors that could modify fetal weight, the predictive model created by combining FG < p10 during 75g OGTT with nulliparity was significantly associated with increased risk of LBW. REGISTRATION: ClinicalTrials.gov: NCT04144595.

Prediction of low birth weight with hypoglycemia in glucose tolerance test / Predicción de bajo peso al nacer con hipoglucemia en la prueba de tolerancia a la glucosa

ABSTRACT OBJECTIVE: Determine the value of the combination of fasting glucose less than the 10th percentile (FG < p10) during 75 gram oral glucose tolerance test (75g OGTT) with maternal characteristics to predict low birth weight (LBW) established by Intergrowth-21st tables. METHODS: Prospective cohort study of pregnant women who was underwent 75g OGTT between 24 and 28.6 weeks. The 10th percentile fasting glucose of the population was determined at 65 mg/dL and women with risk factors that could modify fetal weight, including those related to intrauterine growth restriction, were excluded. Two groups were formed: group FG < p10 and group with normal fasting glucose. The main finding was the diagnosis of LBW. The association between FG < p10, maternal characteristics and LBW was established by multivariate logistic regression. The predictive performance of the models constructed was evaluated by receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis. RESULTS: 349 women were eligible for study, of whom 66 (18.91%) had FG < p10; neonates in this group had lower birth weights (2947.28 g and 3138.26 g, p = 0.001), higher frequencies of LBW (25% and 6.81%, p < 0.001) and of weights < 2500 g in term births (8.6% and 2.3%, p = 0.034). The basal prediction model consisted of nulliparity by achieving an AUC of 60%, while the addition of FG < p10 resulted in the significant improvement of the previous model (AUC 72%, DeLong: p = 0.005). CONCLUSIONS: In pregnant women without factors that could modify fetal weight, the predictive model created by combining FG < p10 during 75g OGTT with nulliparity was significantly associated with increased risk of LBW. REGISTRATION: ClinicalTrials.gov: NCT04144595.

RESUMEN OBJETIVO: Determinar el valor de la combinación de la glucosa en ayunas menor que el percentil 10 (GA < p10) durante la prueba de tolerancia oral a la glucosa con 75 gramos (PTG-75g) con características maternas para predecir bajo peso al nacer (BPN) establecido mediante tablas de Intergrowth-21st. MÉTODOS: Estudio de cohorte prospectivo de mujeres embarazadas que se realizaron PTG-75g entre las 24 y 28.6 semanas. Se determinó el percentil 10 de glucosa en ayunas de la población en 65 mg/dL y fueron excluidas aquellas mujeres con factores de riesgo que pudieran modificar el peso fetal incluyendo los relacionados con la restricción del crecimiento intrauterino. Se formaron dos grupos: grupo GA < p10 y grupo con glucosa en ayunas normal. El hallazgo principal fue el diagnóstico de BPN. La asociación entre GA < p10, características maternas y BPN se estableció mediante regresión logística multivariante. El desempeño predictivo de los modelos construidos fue evaluado por el análisis de la curva característica operativa del receptor (ROC) y del área bajo la curva (ABC). RESULTADOS: Fueron elegibles para estudio 349 mujeres, de las cuales 66 (18,91%) tuvieron GA < p10; los neonatos de este grupo tuvieron pesos al nacer más bajos (2947.28 g y 3138.26 g, p = 0,001), frecuencias más altas de BPN (25% y 6,81%, p < 0,001) y de pesos < 2500 g en nacimientos de término (8,6% y 2,3%, p = 0,034). El modelo basal de predicción consistió en nuliparidad al lograr un ABC del 60%, mientras que al añadir la GA < p10 se obtuvo la mejora significativa del modelo previo (ABC 72%, DeLong: p = 0,005). CONCLUSIONES: En mujeres embarazadas sin factores que pudieran modificar el peso fetal, el modelo predictivo creado combinando GA < p10 durante la PTG-75g con nuliparidad estuvo asociado significativamente con riesgo incrementado de BPN. REGISTRO: ClinicalTrials.gov: NCT04144595.

Randomized double-blind placebo-controlled trial of buccal misoprostol to reduce the need for additional uterotonic drugs during cesarean delivery.

OBJECTIVE: To determine whether buccal misoprostol during cesarean delivery in conjunction with active management of the third stage of labor reduces the need for additional uterotonic drugs. METHOD: A double-blind, randomized, placebo-controlled trial was performed in Monterrey, Mexico, between February 2008 and December 2013. Eligible women had risk factors for uterine atony and were to undergo cesarean delivery under epidural block. Using a computer-generated sequence and blocks of six, patients were randomly assigned to receive 400µg misoprostol or 800µg placebo buccally after cord clamping. Both groups received an intravenous oxytocin infusion. The primary outcome was the need for additional uterotonic drugs. Analyses were performed per protocol. Patients, investigators, and data analysts were masked to group assignment. RESULTS: A total of 120 women were included in analyses (60 in each group). At least one additional uterotonic drug was required in 24 (40%) women in the placebo group versus 6 (10%) women in the misoprostol group (relative risk 0.16; 95% confidence interval 0.06-0.44). No adverse effects due to misoprostol were recorded. CONCLUSION: Buccal misoprostol during cesarean delivery reduced the need for additional uterotonic drugs to treat uterine atony. ClinicalTrials.gov:NCT01733329.

[Ambulatory treatment of prolonged pregnancy with prostaglandin E2 gel]. / Embarazo de 41 semanas o mayor. Manejo ambulatorio con gel de prostaglandina E2.

BACKGROUND: the rutinary labor induction with prostaglandin E2 (PGE2) in pregnancy at 41 weeks has showed a fetal benefit without an increase in maternal morbidity or cesarean delivery. OBJECTIVE: to show that the ambulatory management of prolonged pregnancy with PGE2 gel decreases the cesarean delivery and prenatal morbidity rates. METHODS: quasiexperimetal study of patients with an accurate dated pregnancy of 41 weeks and beyond were analyzed. The women were divided in two groups of 196 each one. In the treated group, the endocervical application of PGE2 was followed by cardiotocographic control. If there was no reason to interrupt the pregnancy they were evaluated twice a week. Perinatal outcomes, mode of delivery and indications for cesarean section were assessed in both groups. RESULTS: there was a decrease in rate of cesarean delivery in treated group, 43 % versus 54 % in control group (p < 0.05). Apgar score at 1 and 5 minute showed no difference, but there were two intrauterine deaths in control group. The indications for cesarean surgery were the same in both groups and there was a case of tachysystole in each one. CONCLUSION: we concluded that decrease in the rate of cesarean deliveries without increments of fetal and maternal morbidity in this study, point to a secure management choice with PGE2 in ambulatory patients.

Uso de metformina en el embarazo / Metformin use during pregnancy

La utilización de metformina en pacientes con diabetes gestacional (DG) ha mostrado efectos benéficos al disminuir la resistencia a la insulina y no relacionarse con teratogénesis, pero no ha sido evaluado su efecto sobre la morbilidad perinatal al utilizarlo desde las primeras semanas del embarazo. Objetivo: Demostrar que la administración de metformina desde el inicio del segundo trimestre del embarazo en pacientes obesas con diabetes gestacional (OG) disminuye la macrosomía y morbilidad neonatal. Diseño: Estudio cuasiexperimental. Lugar: Departamento de Medicina Materno-Fetal, Universidad Médica de Alta Especialidad, Instituto Mexicano del Seguro Social. Participantes: Pacientes con diagnóstico de DG. Intervenciones: Se obtuvo del archivo del Hospital los datos de pacientes con diagnóstico de DG, cursando embarazos de 17 o menos semanas de gestación al inicio del tratamiento e índice de masa corporal de 30 o mayor. Se formó 2 grupos: el de casos, con 34 pacientes, a quienes se administró únicamente metformina durante todo el embarazo, debido a que no aceptaron el tratamiento con insulina, y el grupo control, formado por 40 pacientes, quienes utilizaron diversos esquemas de insulina. Principales medidas de resultados: Resultados perinatales, vía de nacimiento, asociación con estados hipertensivos y progresión a diabetes tipo 2 en el puerperio. Resultados: Encontramos disminución de la macrosomía en el grupo tratado con metformina, una (2 por ciento), en relación al de insulina, 6 (15 por ciento), pero no fue estadísticamente significativo (p mayor que 0,05). Se obtuvo resultados similares con la morbilidad neonatal, la asociación con estados hipertensivos y la progresión a diabetes tipo 2. Conclusiones: Aunque clínica, pero no estadísticamente significativos, se obtuvo mejores resultados con el uso de metformina; éste representa una alternativa segura y con fiable en el manejo de pacientes obesas con DG que no aceptan el tratamiento con insulina.

Metformin therapy in gestational diabetes (GD) has beneficial effects on insulin resistance and does not appear to be teratogenic; but the use effect in early pregnancy on perinatal morbidity has not been studied. Objective: To assess that metformin therapy initiated early in pregnancy in obese women with GO reduces macrosomia and neonatal morbidity. Design: Quasiexperimental study. Setting: Department of Maternal Fetal Medicine, high specialty medical university, Social Security Mexican Institute. Participants: Patients with diagnosis of GD. Interventions: We examined the records of women with GD, 17 or less weeks of pregnancy and a body mass index equal or more than 30 when they started therapy. They were divided in two groups: metformin group (women treated only with metformin throughout pregnancy because they did not accept to use insulin, n = 34) and insulin group (women who received only insulin treatment, n = 40). Perinatal outcomes, mode of delivery, development of gestational hypertension and type 2 diabetes were assessed. Main outcome measures: Perinatal results, birth type, association with hypertensive states and progression to type 2 diabetes in the postpartum. Results: There was a decrease in macrosomia in the metformin group, 1 (2 per cent) vs. 6 (15 per cent) in the insulin group, but this difference was not significant (p more than 0/05). Results in neonatal morbidity and gestational hypertension and type 2 diabetes development were similar. Conclusions: Even though results with metformin therapy were not statistically better, it represents a safe management alternative in patients with GD and obesity who do not accept insulin use.

[Sensitivity and predictive value of the Johnson and Toshach method to estimate fetal weight]. / Sensibilidad y valor predictivo del método de Johnson y Toshach para estimar peso fetal.

INTRODUCTION: Several clinical methods have been used to follow up fetal growth, mainly based in uterine enlargement. Ultrasound (US) is nowadays the main tool to evaluate fetal growth; however, is not widely available. Thus, we decided to evaluate the Johnson and Toshach method (JTM) to predict newborns weight on clinical basis. OBJECTIVE: to evaluate the sensitivity and positive predictive value of the JTM. We selected 132 women with single term pregnancies whose gestational age was previously confirmed by US, and followed the method described by JTM. At the end of pregnancies by delivery or cesarean section, we compared our estimations with the newborn infant's weight. In order to avoid bias, only women whose pregnancies ended in the following 72 hours were included. All clinical measurements were done by one observer. The sensitivity, specificity and positive predictive value of the JTM were calculated. RESULTS: We found non-significant difference between the mean of the fetal weight (3,295 g) calculated with the JTM and the mean of the newborn infants weight (3,343 g) (p = NS). The standard deviation was 325 g and the standard error mean was >or=53 g or 16 g/kg (error = 1.6%). In normal weight groups of neonates, the JTM had a sensitivity of 97%, a specificity of 71% and the positive predictive value was 98%. We observed a higher sensitivity in the detection of macrosomy (80%) than of low-weight newborns (33%), but with an inverted specificity of 71.4% vs. 99.2%, respectively. CONCLUSION: The JTM is a useful clinical technique to estimate fetal weight in the third trimester of gestation that may be applied when US is not available, being more sensitive to detect normal weight than macrosomic or low-weight newborns.

[Prenatal diagnosis of pentalogy of Cantrell associated to bilateral cleft lip. A case report]. / Diagnóstico prenatal de la pentalogía de Cantrell concomitante con labio hendido bilateral. Reporte de un caso.

The pentalogy of Cantrell is a rare congenital syndrome characterized by deficiency of the anterior diaphragm and defects of abdominal wall, the pericardium, the lower sternum, as well as congenital intracardiac abnormalities. It has usually a poor prognosis, but most cases have had incomplete variants of this syndrome, so it is important to make a prenatal diagnosis to determine the size of the wall defect and to establish a multidisciplinary management. Less than 90 cases have been reported in the world literature. There are no casuistic or even treatment criteria in Latin America. A case of a newborn in whom was suspected this pentalogy associated to bilateral cleft lip by an ultrasound examination at 25 week of gestation is described. We also comment on diagnostic aspects, as well as anatomopathological, therapeutic, and prognostic characteristics.