Perinatal outcome following renal transplantation.

OBJECTIVE: To assess pregnancy outcomes in a population of renal transplant recipients in Mexico. METHOD: A total of 75 pregnancies in 60 patients managed at the National Institute of Perinatology, Mexico City, Mexico, were reviewed. RESULT: The mean age at conception was 26.97+/-5.42 years and the mean time from transplantation to pregnancy was 5.49+/-3.6 years. Prepregnancy renal function was determined by serum creatinine level (mean, 1.32+/-0.73 mg/dL). Prepregnancy hypertension was noted in 45.3% of the patients. Urinary tract infection was the most common complication, followed by pregnancy-induced hypertension. The pregnancy resulted in abortion in 11 patients and in live birth for the remaining 64 participants. The mean+/-SD gestational age at birth was 37.1+/-3 weeks, and intrauterine growth restriction was noted in 12 newborns. A serum creatinine level of 1.5 mg/dL or higher prior to pregnancy was associated with delivery before the 34th week and low birth weight. CONCLUSION: In this study, pregnancy ended in a live birth in 84% of women with a renal transplant.

[Within the limits of viability: the dilemma of the obstetrician. A 5-year experience at a perinatal care center]. / En los límites de la viabilidad: el dilema del obstetra. Experiencia de cinco años en un Centro de Atención Perinatal.

The study was performed in order to establish the obstetric factors that influence survival of newborns whose birth weight is under 1000 g. All medical records of babies with such birth weight, born alive at the Instituto Nacional de Perinatología in Mexico City during the period from 1991 to 1996 were revised. Babies with congenital malformations, cromomosomopathies or those who after birth were referred to another medical center were excluded. Survival status was used to form two study groups: those who were discharged alive and those who died during their hospital stay. Different obstetric conditions on management were compared between these two groups. Statistical Analysis was performed through t-test, chi square or exact Fisher's test. Two hundred and ninety two cases were included out of 294. Sixty nine (25.4%) survived while 203 (74.6%) died during their hospitalization. Several obstetric conditions were found to have statistical differences between survivors (S) and non survivors (NS): cervical dilatation on admittance to hospital (1.6 cm among S and 2.7 among NS), cervical dilatation prior to resolution (3.3 cm S vs 4.9 cm NS), gestational age (28.3 vs 27 weeks). Newborn conditions also showed significant statistical differences as in birth weight (867.1 vs 795.5 g), 1 minute Apgar (4.1 vs 2.5), and 5 min Apgar (6.9 vs 5). Use of antepartum steroids showed a striking difference between groups while duration of labor, usage of oxitocin and way of delivery showed no statistical differences. Gestational age (over 28 weeks), birth weight (above 867 g) and the use of antepartum steroids are of extreme importance in the survival status of babies born weighting less than 1000 g.

[Transabdominal cerclage in the management of cervical incompetence]. / Cerclaje transabdominal en el manejo de la incompetencia cervical.

The Transabdominal Cerclage in the Cervical Incompetence. The purpose of this study was to assess the transabdominal cerclage indications at the Instituto Nacional de Perinatología. A retrospective study was carried on in order to evaluate fetal outcome in all patients with transabdominal cerclages. Since 1997 seven transabdominal cerclages were performed. The primary indication was unsuccessful previous vaginal cerclage. All seven patients delivered at term. The rate of live births before the procedure was 5.2% compared to 85.8% after the transabdominal cerclage. There was one still birth a the gestational of 37.2 in a woman with preeclampsia. Five newborns were small for gestational age. In our study the transabdominal cerclage, under strict indications, offers a high fetal survival rate with a minimum of complications in patients with a poor obstetric history due to cervical incompetence and unsuccessful vaginal cerclage.

[Repeat cesarean section: a necessary procedure?]. / Cesárea de repetición: Una cesárea necesaria?

The purpose of this study was to identify the clinical indications for the repeated cesarean section (RCS). In order to determine if the indication was an absolute or a relative one and to establish if it was justified. This is a cross sectional study of all patients with a previous cesarean delivery who underwent a RCS from January 1996 to December 1997 at the National Institute of Perinatology. Multiple pregnancies were excluded. According to the indication two groups were identified: those with an absolute indications and those with a relative one. In order to assess the differences between both groups data were analyzed through chi square test or Fisher's Exact test. During the study period there were 5,545 cesarean deliveries, 664 were RSC (11.9%). Only 641 of the RCS complied with the inclusion criteria for the study. Average maternal age was 30 years. More than half the patients under study (57.2%) did not have any pathological condition during pregnancy, and the rest (42.7%) had at least one (preeclampsia, diabetes mellitus/gestational, chronic hypertension). Indications for the previous cesarean section were absolute in 25.9% and relative in 74.1% (p = 0.0006). Indications for the RCS were also predominantly relative (70.7%), with only 29.3%) absolute (p = 0.0001). The main RCS indications were: elective (20.1%) cephalopelvic disproportion (17.8%), preeclampsia (15.4%), fetal distress (8%). Trial for vaginal delivery was undertaken in 65.4% of the absolute indications group and in 36.9% of the relative indications group (p = 0.0001). Low Apgar one minute and five minute scores were more frequent among the absolute indications group (p = 0.03 and p = 0.01 respectively). Newborns having had an absolute cesarean delivery indication entered the National Intensive Care Unit more frequently (53.6%) than those with relative indications (46.4%) (p = 0.001). The main indication for RCS in our hospital were relative, and thus it is possible to reduce the cesarean rate through a thorough assessment of all cases with a previous cesarean section, and by giving a delivery trial of all this patients.

[Acute fatty liver of pregnancy. Report of a case and review of the literature]. / Hígado graso agudo del embarazo. Informe de un caso y revisión de la literatura.

Acute Fatty Liver of Pregnancy. The acute fatty liver of pregnancy (AFLP) is an uncommon entity, potentially fatal, which affects women during the last quarter of pregnancy. It is characterized by a prodromic period of symptoms followed by jaundice, hepatic failure, clotting disorders and fatty infiltration of the liver, evident through hepatic biopsy. The incidence ranks from 1 to 20 thousand births, and it is more frequent among women with multiple pregnancies. We report the case of a 29-year-old patient, with multiple pregnancy 33 to 34 weeks of gestation, blood pressure values of 140/90 mmHg, 160,000/dL platelets, PT 25.6 seconds, TPT 64.7 seconds, blood glucose 52 mL/dL, creatinine 2.1 mg/dL, uric acid 11.9 mg/dL, lactic dihydrogenase 1063 U/l, GPT 220 U/l, AF 1172 U/l, total bilirubin 8.4 mg/dL, proteinuria 30 mg/dL. A cesarean section was practiced after correcting the coagulation disorders. The first twin was a male with birth weight of 2,070 g, APGAR 8-9; the second twin was a female fetal death weighting 2,050 g. Hepatic biopsy confirmed the diagnosis. The cause of AFLP is unknown. The frequency among multiple pregnancies is higher. Almost half of the cases have hypertension and proteinuria. There are also high levels of both transaminases, phosphatase and bilirubins and hypoglycemia. The prothrombin time is enlarged. The differential diagnostic between pre-eclampsia and AFLP is not crucial since the obstetric management is the same. The main treatment is promptly deliverance and general measures. The obstetrician must be aware of this hepatic disease.

[Advanced maternal age and pregnancy: how much is too much?]. / Edad materna avanzada y embarazo: qué tanto es tanto?

Perinatal evolution was compared and two study groups in women with advanced maternal age and pregnancy. 626 were included from a total of 778 with age 35 years, who resolved their pregnancy during 1995. They were classified, according to age, in two groups: 1) maternal age of 35-39 year; they were considered primigestas and multigestas. Perinatal complications were classified in personal antecedent, antepartum and intrapartum complications. To analyze the association between maternal age and parity with perinatal complications, X2 or exact test of Fisher, was used. Percentage of women with advanced age and pregnancy was 13.6%. Main perinatal complications were: preeclapmsia, gestational diabetes, preterm delivery threat, and membranes rupture. There were no significant differences as to complications by age and parity. There were 90% of children with 2500 g, and Apgar of 97%. Perinatal death was 0.4%, and fetal malformation 0.6%. Cesarean frequency, was over 90% in primigestas and in more of 60% in multigestas. Perinatal evolution in advanced age and pregnancy is adequate, if she starts prenatal control early enough.

[Cesarean section: science or anxiety? Eleven years of institutional experience]. / Operación cesárea: ciencia o ansiedad? Once años de experiencia institucional.

The increasing rise of cesarean section rate invites to analyze its indications. The present study was done from 1985 to 1995, which means 11 years of study with 38,407 cases. Frequency and clinical indications were analyzed. As to births, frequency was 40.6%. Main causes were: Iterative section 38.2%; cephalopelvic disproportion 28.1%; pelvic presentation, 23.4%; hypertensive disease in pregnancy 16.3%; and acute fetal suffering, 10.9%. The careful observation of indications in every institution, may produce better reasons for reducing such high indexes.

[Systemic lupus erythematosus and pregnancy (analysis of 84 cases)]. / Lupus eritematoso sistémico y embarazo (análisis de 84 casos).

We present 84 pregnancies (3 twin pregnancies) of 80 women with Systemic Lupus Erythematosus. Although there was a multidisciplinary prenatal control, in 83% of the cases there were one or more complications during pregnancy, most of them being preterm labor, premature rupture of membranes and preeclampsia-eclampsia. There were flares up in 15 of 84 cases, (17.85%). Worsening of renal function was the most common finding. There were 9 abortions, 3 stillbirths, 1 neonatal death and two newborns with congenital heart block. No maternal deaths were present.

[Progressive systemic sclerosis and pregnancy]. / Esclerosis sistémica progresiva y embarazo.

Nine cases with the association of systemic progressive sclerosis and pregnancy at Instituto Nacional de Perinatología, from 1984 to 1994, are presented. All the patients were referred with the confirmed diagnosis by histopatological study. The variety CREST type was seen in three patients. Average age of patients was 29.2 +/- 5.4 years. Acute hypertensive disease of pregnancy; pre-term birth; and retarded intrauterine growth, were the most frequent complications. Most of the pregnancies were resolved by abdominal via, due to maternal and fetal indications. No maternal deaths.

[Gestational trophoblastic disease. A 6-year experience at the Instituto Nacional de Perinatología]. / Enfermedad trofoblástica gestacional. Experiencia de 6 años en el Instituto Nacional de Perinatología.

From January, 1988 to March, 1994, 83 patients with diagnosis of gestational trophoblastic disease, were identified. Incidence was 2.4 per 1000 births. Average age of patients was 28.9 years. Forty four point five per cent of them were multiparae and in 25.3% there was the antecedent of molar pregnancy. Seventy seven point one per cent of the cases are from low socioeconomic stratum. The diagnosis was done by ultrasound in 89.1%. Instrumental uterine curettage was done in 89.1%, with histological confirmation in 100% of the cases. From the 83 cases with molar pregnancy, 74 were classified as complete moles, four, incomplete, four, invasive and one choriocarcinoma. There was follow up in all the patients with beta fraction of chorionic gonadotropin hormone; this was negative in most of the cases for eight weeks after evacuation. Oral contraceptives were indicated in 73.4% of the cases.

[Persistent trophoblastic tumor. Report of 15 cases at the National Institute of Perinatal Medicine]. / Tumor trofoblástico persistente. Informe de 15 casos del Instituto Nacional de Perinatología.

Fifteen (18%) out of 83 patients with gestational trophoblastic disease, developed persistent trophoblastic tumor, from January, 1988 to March, 1994. Average age of patient was 25.5. There was antecedent of molar pregnancy in two cases. Beta fraction of chorionic gonadotrophin hormone at the time of diagnosis was 152,200 m UI/ml, average. During control it was in 80% of anovulatory oral cases. The treatment was based on metotrexate, and folinic acid; there was 100% remission. There was a total of 46.6% of pregnancies, after treatment; and 40% of them were normal.

[Placenta praevia/accreta and previous cesarean section. Experience of five years at the Mexico National Institute of Perinatalogy]. / Placenta previa/acreta y cesárea previa. Experiencia de cinco años enel Instituto Nacional de Perinatología.

Two hundred and ten cases with placenta previa, were reviewed (1989-1994). In 37 (17.6%) placenta accreta was present. From accretism cases in 26 (70.2%) only, there was the antecedent of cesarean section. Average age was 31 years; the highest risk group was 35-39 years with 26% of cases of accretism. Average parity was three, in the group of five gestaes, 33.3% developed placenta accreta. In the group without antecedent of cesarean section, accretism risk was 9.4%; with one section was 21.1%, but with two or more cesarean sections, it was 50%. In the presence of placenta previa advanced maternal age, and two or more cesarean sections, placenta accreta risk is high.

[Placenta praevia. Maternal and perinatal repercussions. Analysis of 170 cases]. / Placenta previa. Repercusiones maternas y perinatales. Análisis de 170 casos.

One hundred and seventy cases with placenta previa, at Instituto Nacional de Perinatología, from 1989 to 1993, were reviewed. Incidence in our population was 0.62%; average maternal age was 31 years; the greater amount of cases was among nulliparae; in 72% of them there was the antecedent of uterine scar. Ultrasound diagnosis was done in 81% of the patients, and most frequent placental insertion type was the low one in 49%, and in 31%, total, central placenta. The first hemorrhagic episode occurred at a gestational age of 34 weeks. Most frequent complication was threatening pre-term delivery, and ethinyl adrianol was used as uterine inhibitor. All pregnancies were interrupted, via abdominal. Placental accretion was a frequent complication. Hemorrhage during the second half of gestation is one of the main causes of perinatal morbidity-mortality. Frequency of this complication is from 3% to 5%, of all pregnancies in an open population; and when it appears, is one of the most serious urgencies; so its early diagnosis and opportune treatment will diminish maternal and perinatal morbidity-mortality. Etiology is unknown, but diminished endometrial vascularization, at fundus and body, may be the causal factor. There are other predisposing causes as age, advanced maternal age, multiparity, tumours, scars and smoking. The objective of this study, was to analyze maternal and perinatal repercussions, of placenta previa, based on the experience at Instituto Nacional de Perinatología.

[Hallermann-Streiff syndrome and pregnancy. Report of a case]. / Síndrome de Hallermann-Streiff y embarazo. Reporte de un caso.

The Hallermann-Streiff syndrome is characterized by dyscephaly (bird like facies), microphthalmia, cataracts, micrognathia, beaked nose, abnormal dentition, hypotrichosis, cutaneous atrophy and proportional small stature. There is no sex predilection. Productive capacity has not been studied in these patients. Successful pregnancy is rare. We present a patient with the classical signs associated with pregnancy, the outcome of which was successful. This is the first reported case of Hallermann-Streiff syndrome associated with pregnancy.