Obesity and Gestational Diabetes in Pregnant Care and Clinical Practice.

Obesity and Gestational Diabetes Mellitus (GDM) are the most frequent pathologies affecting mothers and offspring during pregnancy. Both conditions have shown a sustained increase in their prevalence in recent years, and they worsen the outcome of pregnancy and the long-term health of mothers. Obesity increases the risk of GDM and pre-eclampsia during pregnancy and elevates the risk of developing metabolic syndrome in later life. Offspring of obese mothers have an increased risk of obstetric morbidity and mortality and, consistent with the developmental origins of health and disease, a long term risk of childhood obesity and metabolic dysfunction. On the other hand, GDM also increases the risk of pre-eclampsia, caesarean section, and up to 50% of women will develop type 2 diabetes later in life. From a fetal point of view, it increases the risk of macrosomia, large-for-gestational-age fetuses, shoulder dystocia and birth trauma. The insulin resistance and inflammatory mediators released by a hypoxic trophoblast are mainly responsible for the poor pregnancy outcome in obese or GDM patients. The adequate management of both pathologies includes modifications in the diet and physical activity. Drug therapy should be considered when medical nutrition therapy and moderate physical activity fail to achieve treatment goals. The antenatal prediction of macrosomia is a challenge for physicians. The timing and the route of delivery should consider adequate metabolic control, gestational age, and optimal conditions for a vaginal birth. The best management of these pathologies includes pre-conception planning to reduce the risks during pregnancy and improve the quality of life of these patients.

Evaluación por médicos especialistas de curso de urgencias gineco-obstétricas utilizando metodología de simulación clínica / Evaluation by emergency medical specialists gyneco-obstetricians using clinical simulation methodology

Introducción: La simulación clínica es una herramienta de aprendizaje complementaria a los métodos tradicionales en la práctica clínica. Permite desarrollar habilidades y destrezas en escenarios seguros. La división de ginecología y obstetricia de la Universidad Católica (UC) imparte un curso de emergencias obstétricas para especialistas utilizando esta metodología. Presentamos la evaluación de los especialistas que realizaron el curso en el año 2016. Materiales y métodos: se realizó un curso de simulación de escenarios de emergencia en obstetricia, con un total de 16 horas separadas en 2 días. Con simuladores de alta y mediana complejidad. Tutoriados por instructores acreditados por el Institute of medical simulation de la Universidad de Harvard. Al finalizar el curso los participantes respondieron una encuesta escrita de diversos tópicos del curso. Resultados: participaron 93 especialistas. 76 por ciento de los participantes estuvo completamente de acuerdo y 23 por ciento de acuerdo con que la práctica con modelos simulados mejora la destreza relacionada con la realización de los procedimientos propuestos en el curso. El 100 por ciento de ellos indica que recibió retroalimentación considerada como útil durante las sesiones de entrenamiento y consideran que están completamente de acuerdo o de acuerdo con que esta metodología les permite cometer errores en forma segura. Conclusiones: la implementación de la metodología de simulación clínica en la docencia de emergencias obstétricas es muy bien evaluada por los especialistas, ya que entrega retroalimentación académica útil de cada caso y les permite cometer errores sin riesgos para los pacientes con un alto nivel de realismo.(AU)

Introduction: Clinical simulation is a learning tool complementary to traditional methods in clinical practice. It allows the development of skills and abilities in safe scenarios. The department of obstetrics and gynecology at the Catholic University offers an obstetrics emergency course for specialists using this methodology. Below we present the evaluation of the specialists who completed the course in 2016. Methods and Materials: A simulation course of emergency scenarios in obstetrics was carried out, distributed in clinical stations, with high and medium complexity simulators for a total of 16 hours' duration in 2 days. The tutors where instructors accredited by the Institute of medical simulation of Harvard University. At the end of the course the participants answered a written survey including various topics of the course. Results: Ninety-three specialists participated. 76 percent of the participants were in complete agreement and 23 percent agreed that the practice with simulated models improved the skills related to the clinical procedures proposed in the course. One hundred percent of them considered that the feedback received was useful during the training sessions and completely agreed that this methodology allows them to make mistakes in a safe form. Conclusions: The implementation of the methodology of clinical simulation in the teaching of obstetrical emergencies was very well evaluated by the specialists, since it provides useful academic feedback of each case and allows them to make mistakes without risks for the patients with a high level of realism.(AU)

Utilidad de factores pronósticos antenatales en pacientes con hernia diafragmática congénita aislada / Usefulness of antenatal prognostic factors in patients with hernia congenital diaphragmatic isolated

La Hernia Diafragmática Congénita (HDC) corresponde a una malformación del diafragma por la cual los órganos abdominales protruyen hacia la cavidad torácica durante el desarrollo intrauterino. Los recién nacidos afectados presentan grados variables de insuficiencia respiratoria e hipertensión pulmonar, asociándose a una alta morbilidad y mortalidad. Materiales y métodos: Se revisaron los casos de HDC controlados en los períodos pre y post-natal en el Hospital Clínico UC durante el período 2012-2016. Se analizaron los resultados perinatales según distintos factores pronósticos. Resultados: Fueron analizadas 26 embarazadas con diagnóstico de HDC. La sobrevida global fue de un 77% (20/26). La mortalidad global de las pacientes con herniación hepática fue de un 45% (5/11) versus 7% (1/15) en los fetos con hígado no herniado. La mortalidad neonatal fue de un 14% (3/21) en las pacientes con la relación pulmón cabeza (LHR), (observado/ esperado) o/e ≥ a 45% y 60% (3/5) cuando el LHR o/e es < 45%. De las pacientes con LHR o/e ≥ 45%, la necesidad de ECMO fue de un 33% (8/21) mientras que un LHR o/e < 45% fue de un 20% (1/5). Conclusión: La obtención antenatal de un LHR o/e ≥ 45% y ausencia de herniación hepática, son buenos predictores de sobrevida neonatal. La medición de LHR o/e no es capaz de discriminar que pacientes desarrollarán morbilidad respiratoria grave, por lo que debemos buscar nuevos y mejores modelos que permitan seleccionar que pacientes requerirán nacer en un centro con disponibilidad de terapias de soporte vital avanzado como el ECMO neonatal. (AU)

Congenital Diaphragmatic Hernia (CDH) is a malformation of the diaphragm muscle in which the abdominal organs protrude into the thoracic cavity during intrauterine development. Affected newborns have varying degrees of respiratory failure and pulmonary hypertension, associated with high morbidity and mortality. Materials and methods: Controlled HDC cases were reviewed in the pre and post-natal periods at the Clinical Hospital UC during the period 2012-2016. Perinatal results were analyzed according to different prognostic factors. Results: During the 2012-2016 period, 26 pregnant women with a diagnosis of CDH were monitored. The overall mortality of patients with hepatic herniation was 45% (5/11) versus 7% (1/15) in fetuses with a non-herniated liver. Neonatal mortality was 14% (3/21) in patients with o/e (observed/expected) LHR ≥ 45% and 60% (3/5) when the o/e LHR <45%. Of the patients with o/e LHR ≥ 45%, the need for ECMO was 33% (8/21), while a LHR o/e <45% was 20% (1/5). Conclusion: An o/e LHR ≥ 45% and absence of hepatic herniation are good predictors of neonatal survival. The o/e LHR measurement is not capable of identifying which patients will develop severe respiratory morbidity, so we must explore new and better models that allow us to select patients who need to give birth in centers with available advanced life support therapies, such as neonatal ECMO. (AU)

Gestational diabetes and pre-pregnancy overweight: possible factors involved in newborn macrosomia.

AIM: Good glycemic control in gestational diabetes mellitus (GDM) seems not to be enough to prevent macrosomia (large-for-gestational-age newborns). In GDM pregnancies we studied the effects of glycemic control (as glycosylated hemoglobin [HbA1c]), pre-pregnancy body mass index (PP-BMI) and gestational weight gain per week (GWG-W) on the frequency of macrosomia. METHODS: We studied 251 GDM pregnancies, divided into two groups: PP-BMI<25.0kg/m(2) (the non-overweight group; n=125), and PP-BMI≥25.0kg/m(2) (the overweight group; n=126). A newborn weight Z-score>1.28 was considered large-for-gestational-age. Statistical analysis was carried out using the Student's t-test and χ(2) -test, receiver-operator characteristic curves and linear and binary logistic regressions. RESULTS: Prevalence of macrosomia was 14.9% among GDM (n=202/251, 88.4%) with good glycemic control (mean HbA1c<6.0%), and 28.1% in those with mean HbA1c≥6.0% (n=49/251, P<0.025). Macrosomia rates were 10.4% in the non-overweight group and 24.6% in the overweight group (P=0.00308), notwithstanding both having similar mean HbA1c (5.48±0.065 and 5.65±0.079%, P=0.269), and similar GWG-W (0.292±0.017 and 0.240±0.021kg/week, P=0.077). Binary logistic regressions showed that PP-BMI (P=0.012) and mean HbA1c (P=0.048), but not GWG-W (P=0.477), explained macrosomia. CONCLUSIONS: Good glycemic control in GDM patients was not enough to reduce macrosomia to acceptable limits (<10% of newborns). PP-BMI and mean HbA1c (but not GWG-W) were significant predictors of macrosomia. Thus, without ceasing in our efforts to improve glycemic control during GDM pregnancies, patients with overweight/obesity need to be treated prior to becoming pregnant.

Successful liver transplantation and delivery in a woman with fulminant hepatic failure occurring during the second trimester of pregnancy.

BACKGROUND: Severe liver dysfunction occurring during pregnancy is an unusual but dramatic event that poses special technical and ethical issues because it involves two lives. METHODS AND RESULTS: We report the case of a 35-year-old woman with cryptogenic fulminant hepatic failure who underwent successful orthotopic liver transplantation at 22 weeks of pregnancy. After a relatively uneventful post-operative course she delivered a normal offspring at the 27th week of gestation. There were no obstetrical complications and neonatal outcome was excellent. After a year of follow-up, the patient is doing well,and the newborn has exhibited normal psychomotor and weight/height development. CONCLUSION: This case illustrates the challenge of treating fulminant hepatic failure during pregnancy and demonstrates that liver transplantation is a feasible therapeutic option for treatment of patients with this condition, allowing successful completion of pregnancy.

Demostración a través de técnicas de biología molecular de la transmisión perinatal de streptococcus grupo B: s. agalactie / Demonstration through molecular biology techniques of perinatal transmision of group B streptococcus: s. agalactie

Se presenta un caso de meningitis neonatal de aparición precoz por streptococcus grupo B (S. agalactie), en el cual se demuestra, a través de la técnica de reacción de polimerasa en cadena (PCR), que la fuente de infección fue el canal del parto de la madre colonizada por dicho microorganismo. Este es un ejemplo de las muchas utilidades que tiene la biología molecular en perinatología