Identificación de factores que se asocian a alto riesgo de desarrollar diabetes gestacional / Identification of factors associated with a high risk of developing gestational diabetes

Objetivos: Principal. Determinar la prevalencia de los factores de riesgo reconocidos para diabetes gestacional (DG) en nuestra población. Definir el perfil de las pacientes con mayor riesgo de desarrollar DG. Secundario. Analizar la aceptabilidad por parte de las gestantes de las pruebas de cribado. Material y método: Se trata de un estudio observacional ambispectivo en el que se reclutaron 1448 gestantes en un único centro, entre el 1 de diciembre de 2017 y el 31 de julio de 2019. Los criterios de inclusión fueron: no antecedente de diabetes mellitus pregestacional, no antecedente de DG en gestación previa, no antecedentes de cirugía bariátrica, haber realizado cribado para DG en la actual gestación. Resultados: La prevalencia de DG en nuestra población fue del 6,7%. Los factores de riesgo que se asociaron con el desarrollo de DG en nuestra población fueron: edad≥27,5 años (OR: 3,8; IC95%: 2,01-9,16), IMC≥28,5kg/m2 (OR: 2,3; IC95%:1,47-3,59); antecedente de diabetes mellitus en familiares de primer grado (OR: 2,3; IC95%: 1,5-3,66) y la gestación múltiple (OR: 2,8; IC95%: 0,86-6,36). La prevalencia de la DG se incrementó según lo hacía el número de factores de riesgo encontrados en la gestante: desde el 1,4% en las pacientes sin los factores de riesgo hasta el 25.2% con 3 factores de riesgo presentes. El 26,8% de las pacientes calificaron como desagradable la realización del test de ÓSullivan (50g glucosa) y el 65,4% la prueba de sobrecarga oral con 100g de glucosa. Conclusiones: La edad de la gestante≥27,5, el IMC≥28,5kg/m2, el antecedente de diabetes mellitus en familiares de primer y la gestación múltiple son factores que se asocian con alto riesgo de desarrollar DG; estos factores serían suficientes para identificar a la mayoría de las gestantes que desarrollarán DG. Nuestros resultados pueden aplicarse para mejorar los programas de atención prenatal destinados al diagnóstico y tratamiento precoz de la DG.(au)

Objectives: The main objective is to determine the current prevalence of recognised risk factors for gestational diabetes mellitus (GDM) in our region, and to define the profile of patients at higher risk of developing this condition. We also investigate patient acceptability of the screening tests. Material and methods: This is an ambispective study with 1,448 pregnant women recruited between December 2017 and July 2019 from a single centre. Inclusion criteria were no diabetes mellitus prior to the pregnancy, no history of GDM in any previous pregnancy, no history of bariatric surgery before the pregnancy, and GDM screening tests performed. Results: The prevalence of GDM was 6.7%. Risk factors associated with development of GDM were: age≥27.5 years (OR: 3.8; 95% CI: 2.01-9.16); BMI≥28.5kg/m2 (OR: 2.3; 95% CI: 1.47-3.59); history of diabetes mellitus in first-degree relatives (OR: 2.3; 95% CI: 1.5-3.66); and multiple pregnancy (OR: 2.8; 95% CI: 0.86-6.36); Prevalence of GDM increased with the number of risk factors presented by patients: from 1.4% with no risk factor, to 25.2% with 3. The O'Sullivan test (50g glucose) and oral glucose tolerance test (100g glucose) were perceived as “unpleasant” by 26.8% and 65.4% of patients, respectively. Conclusions: Age≥27.5 years, BMI≥28.5kg/m2, history of diabetes mellitus in first-degree relatives, and multiple pregnancy are factors related to an increased risk of GDM; these factors would be enough to identify most pregnant women developing GDM. Our findings may be used to improve programmes aimed at early diagnosis of gestational diabetes and supporting high-risk mothers in antenatal care.(AU)

Diagnóstico de malformación uterina en una paciente de 10 años con piometra. A propósito de un caso / Diagnosis of uterine malformation in a ten-year-old patient. Case report

Las malformaciones uterinas congénitas son poco frecuentes. El útero bicorporal tiene una prevalencia del 0,4%. Generalmente asintomático, se puede manifestar como dolor pélvico por un hematometra o menstruación retrógrada de un cuerno uterino no comunicante. Se presenta el caso de una niña de 10 años a quien, en el contexto de dolor abdominal y fiebre, se le realizaron pruebas de imagen y en quien se objetivó un útero bicorporal ocupado por lo que parecía un hematometra. Se intervino a la paciente para drenarlo, por vía histeroscópica y laparoscópica, y se comprobó que se trataba de un piometra. Se realizó hemihisterectomía, sin incidencias, con el fin de preservar su fertilidad y resolver el cuadro infeccioso.(AU)

Congenital uterine malformations are rare. The bicorporal uterus has a prevalence of 0.4%. Generally asymptomatic, it can manifest as pelvic pain from a haematometra or retrograde menstruation from a non-communicating uterine horn. The case of a 10-year-old girl is presented who, in the context of abdominal pain and fever, underwent imaging tests revealing a bicornuate uterus occupied by what appeared to be a haematometra. The patient was operated on to drain it, hysteroscopically and laparoscopically, confirming that it was a pyometra. Hemihysterectomy was performed without incident to preserve fertility and resolve the infection.(AU)

OnabotulinumtoxinA in urinary incontinence: Prospective Study of a Case Series. / Onabotulinumtoxin A en la incontinencia urinaria: estudio prospectivo de serie de casos.

OBJECTIVE: To assess the safety and efficacy of a single intravesical injection of onabotulinumtoxinA (OnaBTA) for treating urge urinary incontinence (UUI) in women. METHOD: We performed a prospective case-series study of consecutive patients with refractory UUI treated with an intravesical injection of OnaBTA. The patients were administered 100 units of OnaBTA injected into the bladder wall following 4 weeks of flushing with anticholinergic agents or beta 3 agonists. The urodynamic and clinical endpoints were evaluated before and 6 months after the injection of OnaBTA. The primary study endpoint was the number of episodes of urinary leakage. RESULTS: A total of 204 of the 210 selected patients conducted a valid visit 6 months after the therapeutic application. At 6 months of treatment with OnaBTA, 110 (53.9%) patients remained continent and were considered a success. However, 57 (27.9%) patients experienced one episode of urinary leakage per day, and 37 (18.2%) had 2 or more. In terms of the urodynamic parameters, we observed the following changes: increase in maximum bladder capacity (P<.0001) and reduced maximum pressure of the detrusor (P<.0001). In terms of the safety profile, 8 (3.9%) patients had self-limiting haematuria during the procedure, which resolved spontaneously, and 9 (4.4%) patients had acute urinary retention that required intermittent catheterisation. CONCLUSIONS: This study supports the use of OnabotulinumtoxinA in patients with urge urinary incontinence that does not respond to medical treatment.

sFlt-1/PlGF for prediction of early-onset pre-eclampsia: STEPS (Study of Early Pre-eclampsia in Spain).

OBJECTIVE: A high ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) has been linked to pre-eclampsia (PE). We evaluated the sFlt-1/PlGF ratio as a predictive marker for early-onset PE in women at risk of PE. METHODS: This prospective, Spanish, multicenter study included pregnant women with a risk factor for PE, including intrauterine growth restriction, PE, eclampsia or hemolysis, elevated liver enzymes and low platelet count syndrome in previous pregnancy, pregestational diabetes or abnormal uterine artery Doppler. The primary objective was to show that the sFlt-1/PlGF ratio at 20, 24 and 28 weeks' gestation was predictive of early-onset PE (< 34 + 0 weeks). Serum sFlt-1 and PlGF were measured at 20, 24 and 28 weeks. Multivariate logistic regression was used to develop a predictive model. RESULTS: A total of 819 women were enrolled, of which 729 were suitable for analysis. Of these, 78 (10.7%) women developed PE (24 early onset and 54 late onset). Median sFlt-1/PlGF ratio at 20, 24 and 28 weeks was 6.3 (interquartile range (IQR), 4.1-9.3), 4.0 (IQR, 2.6-6.3) and 3.3 (IQR, 2.0-5.9), respectively, for women who did not develop PE (controls); 14.5 (IQR, 5.5-43.7), 18.4 (IQR, 8.2-57.9) and 51.9 (IQR, 11.5-145.6) for women with early-onset PE; and 6.7 (IQR, 4.6-9.9), 4.7 (IQR, 2.8-7.2) and 6.0 (IQR, 3.8-10.5) for women with late-onset PE. Compared with early-onset PE, the sFlt-1/PlGF ratio was significantly lower in controls (P < 0.001 at each timepoint) and in women with chronic hypertension (P < 0.001 at each timepoint), gestational hypertension (P < 0.001 at each timepoint) and late-onset PE (P < 0.001 at each timepoint). A prediction model for early-onset PE was developed, which included the sFlt-1/PlGF ratio plus mean arterial pressure, being parous and previous PE, with areas under the receiver-operating characteristics curves of 0.86 (95% CI, 0.77-0.95), 0.91 (95% CI, 0.85-0.97) and 0.93 (95% CI, 0.86-0.99) at 20, 24 and 28 weeks, respectively, and was superior to models using the sFlt-1/PlGF ratio alone or uterine artery mean pulsatility index. CONCLUSIONS: The sFlt-1/PlGF ratio can improve prediction of early-onset PE for women at risk of this condition. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Do knowledge of uterine artery resistance in the second trimester and targeted surveillance improve maternal and perinatal outcome? UTOPIA study: a randomized controlled trial.

OBJECTIVES: To ascertain whether screening for pre-eclampsia (PE) and intrauterine growth restriction (IUGR) by uterine artery (UtA) Doppler in the second trimester of pregnancy and targeted surveillance improve maternal and perinatal outcomes in an unselected population. METHODS: This was a multicenter randomized open-label controlled trial. At the routine second-trimester anomaly scan, women were assigned randomly to UtA Doppler or non-Doppler groups. Women with abnormal UtA Doppler were offered intensive surveillance at high-risk clinics of the participating centers with visits every 4 weeks that included measurement of maternal blood pressure, dipstick proteinuria, fetal growth and Doppler examination. The primary outcome was a composite score for perinatal complications, defined as the presence of any of the following: PE, IUGR, spontaneous labor < 37 weeks' gestation, placental abruption, stillbirth, gestational hypertension, admission to neonatal intensive care unit and neonatal complications. Secondary outcomes were a composite score for maternal complications (disseminated intravascular coagulation, maternal mortality, postpartum hemorrhage, pulmonary edema, pulmonary embolism, sepsis), and medical interventions (for example, corticosteroid administration and induction of labor) in patients developing placenta-related complications. RESULTS: In total, 11 667 women were included in the study. Overall, PE occurred in 348 (3.0%) cases, early-onset PE in 48 (0.4%), IUGR in 722 (6.2%), early-onset IUGR in 93 (0.8%) and early-onset PE with IUGR in 32 (0.3%). UtA mean pulsatility index > 90(th) percentile was able to detect 59% of early-onset PE and 60% of early-onset IUGR with a false-positive rate of 11.1%. When perinatal and maternal data according to assigned group (UtA Doppler vs non-Doppler) were compared, no differences were found in perinatal or maternal complications. However, screened patients had more medical interventions, such as corticosteroid administration (relative risk (RR), 1.79 (95% CI, 1.4-2.3)) and induction of labor for IUGR (RR, 1.36 (95% CI, 1.07-1.72)). In women developing PE or IUGR, there was a trend towards fewer maternal complications (RR, 0.46 (95% CI, 0.19-1.11)). CONCLUSIONS: Routine second-trimester UtA Doppler ultrasound in an unselected population identifies approximately 60% of women at risk for placental complications; however, application of this screening test failed to improve short-term maternal and neonatal morbidity and mortality. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

[Morbidity and mortality in newborns at the limit of viability in Spain: a population-based study]. / Morbimortalidad en recién nacidos al límite de la viabilidad en España: estudio de base poblacional.

INTRODUCTION: Perinatal care in extremely immature newborns is a clinical and ethical problem of great importance for professionals and families, and requires that the available information on the chances of child survival is of the highest quality. The aim of this study was to determine the specific rates of survival at hospital discharge, and survival without major morbidity in newborns with a gestation age (GA) ≤ 26 weeks in Spain. PATIENTS AND METHODS: We included live newborns ≤ 26 weeks admitted to the collaborating centers of the SEN1500 network (2004-2010). Out born patients, infants who died in delivery room, and those with congenital anomalies incompatible with life were excluded. RESULTS: A total of 3,236 patients were included. GA specific survival was 12.5, 13.1, 36.9, 55.7, and 71.9% at 22, 23, 24, 25, and 26 weeks of GA, respectively. Survival without severe intracranial hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, and/or retinopathy of prematurity was 1.5, 9.5, 19.0, and 29.9% at 23, 24, 25 and 26 weeks GA, respectively. CONCLUSIONS: Survival without major morbidity in infants less than 23 weeks GA is exceptional, and scarce in newborns with 23 and 24 weeks GA. Infants ≥ 25 weeks GA have reasonable chances of survival and, in the absence of major malformations or other relevant complications, should be offered active resuscitation and intensive care. The continuous updating of the results of individual centers is of utmost importance, as well as their comparison with the reference population-based results.

[Construction of model for calculating and recording neonatal weight percentiles]. / Construcción de un modelo de cálculo y registro del percentil de peso neonatal.

OBJECTIVES: To construct a model for calculating optimal foetal and neonatal weight curves with a method that allows automatic calculation of the percentile and sequential recording of results. MATERIAL AND METHODS: A model was constructed for calculating optimal weight and the corresponding percentiles for gestational age and sex from a sample of 23,578 newborns, after excluding cases with diseases. Birth weight was modelled using stepwise multiple regression analysis. Newborns were classified as small or large for gestational age (SGA or LGA) using the proposed model. The resulting classification was compared with those derived from other models designed for Spanish children. RESULTS: Optimal weight model: 3,311.062+68.074 *sex+143.267 *GE40 -13.481 *GE40(2) - 0.797 *GE40(3)+sex* (5.528 *GE40 - 0.674 *GE40(2) - 0.064 *GE40(3)). (GE, gestational age). Weight percentiles were obtained from standardized data using the coefficient of variation of the optimal weight. The degree of agreement between our model classification and those of the Carrascosa model and Ramos model, with empirical and smooth percentiles, was "almost perfect" (κ=0.866, κ=0.872, and κ=0.876 (P<.001), respectively), and between our model and that proposed by Figueras it was "substantial" (κ=0.720, P<.001). CONCLUSIONS: The new model is comparable to those used for Spanish children and allows accurate, updated automatic percentile calculation for gestational age and sex. The results can be digitally stored to track longitudinal foetal growth. Free access to the model is offered, together with the possibility of automatic calculation of foetal and neonatal weight percentiles.

[Influence of gestational age, type of delivery, and resuscitation, on the incidence of pneumothorax in term neonates]. / Influencia de la edad gestacional, el tipo de parto y la reanimación en el riesgo de neumotórax en neonatos mayores de 37 semanas.

BACKGROUND: Elective caesarean section before 39 weeks gestational age (GA) has been associated with a higher incidence of iatrogenic respiratory distress and pneumothorax in term newborn babies, probably because of a higher respiratory morbidity and the need for resuscitation. These factors have not been systematically evaluated in our patients. OBJECTIVE: To determine whether the gestational age, type of delivery, and intensity of resuscitation, are associated with an increase in the incidence of pneumothorax in term neonates. PATIENTS AND METHODS: Full term neonates (≥ 37 weeks GA) born in our maternity unit from January 2006 to December 2010 were studied, along with the type of delivery (vaginal, forceps or caesarean section). Advanced cardiopulmonary resuscitation (CPR) was defined as the need of bag and mask intermittent ventilation, intubation, chest compression, and/or administration of medication. The diagnosis of pneumothorax was clinical and radiological in all cases. RESULTS: A total of 32,238 full term newborns were included. Type of delivery: vaginal 76.1%, C-section 12.4%, and forceps 11.5%. The incidence of pneumothorax was 0.316%. It was significantly higher in C-section (0.85%), than in forceps (0.59%), or non-instrumental vaginal deliveries (0.19%) (P<.001), and in infants ≥ 40 weeks GA (0.37%) compared to ≤ 39 weeks GA (0.24%) (P=.033), and in advanced CPR (4.29%) compared to basic CPR (0.18%) (P<.001). CONCLUSIONS: A GA ≥ 40 weeks, C-section, or forceps delivery, and advanced CPR immediately after birth were significantly associated with a higher incidence of pneumothorax in full term newborn babies. In our population, we did not observe an increase in pneumothorax among neonates born by elective C-section before 39 weeks of gestation.

Saturación cerebral de oxígeno como marcador hemodinámico en la cirugía cardíaca / Regional cerebral oxygen saturation as a marker of hemodynamic state following cardiac surgery

Introducción: La saturación cerebral de oxígeno (SrcO2) es una medida del estado de perfusión y oxigenación. El objetivo ha sido analizar la relación entre la SrcO2 y varios parámetros hemodinámicos y respiratorios. Pacientes y métodos Entre octubre del 2011 y julio del 2012, se intervino a 43 niños que fueron incluidos en un estudio prospectivo, observacional y descriptivo. Se midieron la SrcO2 y la presión arterial media (PAM), y se realizaron gasometrías en sangre arterial y venosa. Se determinaron la saturación arterial (SaO2), la saturación venosa (SvcO2), la presión arterial de oxígeno (paO2) y anhídrido carbónico (paCO2), y el lactato, y se calcularon la paO2/FiO2, el índice de oxigenación (IO) y la extracción tisular de oxígeno (ETO2). Estas medidas fueron correlacionadas con la SrcO2, determinándose además la concordancia (índice Kappa) entre esta variable y las que resultaron significativas en el análisis de correlación. Resultados: La edad y el peso fueron de 27,3 meses y 9,2 kg. Se encontraron una correlación positiva de la SrcO2 con la SvcO2 (r = 0,73, p < 0,01) y con la PAM (r = 0,59, p < 0,01), y una correlación negativa con la ETO2 (r = −0,7, p < 0,01). La SrcO2 no se correlacionó con las variables respiratorias. El análisis de concordancia estableció un índice Kappa aceptable (> 0,4) entre la SrcO2 y la SvcO2, y entre la SrcO2 y la ETO2. Conclusiones: La SrcO2 se relaciona estadísticamente con variables hemodinámicas como la PAM, la SvcO2 y la ETO2, pero no con variables respiratorias (AU)

Introduction: Regional cerebral oxygen saturation (rSO2) is a measure of the general state of perfusion and oxygenation. We aim to analyze the relationship between this and various hemodynamic and respiratory parameters. Patients and methods: Forty-three patients, operated on between October 2011 and July 2012, were included in this prospective observational descriptive study. The following parameters were measured: mean arterial pressure, both arterial and central venous oxygen saturation and partial pressures of oxygen and carbon dioxide, and lactate levels. From these parameters, the oxygenation index and the oxygen extraction ratio were calculated. These measurements were studied to evaluate whether rSO2 correlated significantly with the other parameters. Results: The average age and weight of the patients were 27.3 months and 9.2 kg, respectively. The rSO2 correlated positively with both central venous oxygen saturation (r = 0.73, P<0.01) and mean arterial pressure (r = 0.59, P<0.01), and negatively with the oxygen extraction ratio (r =−0.7, P<0.01). No correlation was found with the respiratory parameters. Concordance analysis established an acceptable Kappa index (> 0.4) between the rSO2 and central venous oxygen saturation, and between the rSO2 and oxygen extraction ratio. Conclusions: Regional cerebral oxygen saturation correlates well with hemodynamic parameters- mean arterial pressure, venous saturation, and the tissue oxygen extraction. However, it does not correlate with respiratory parameters (AU)

[Regional cerebral oxygen saturation as a marker of hemodynamic state following cardiac surgery]. / Saturación cerebral de oxígeno como marcador hemodinámico en la cirugía cardíaca.

INTRODUCTION: Regional cerebral oxygen saturation (rSO2) is a measure of the general state of perfusion and oxygenation. We aim to analyze the relationship between this and various hemodynamic and respiratory parameters. PATIENTS AND METHODS: Forty-three patients, operated on between October 2011 and July 2012, were included in this prospective observational descriptive study. The following parameters were measured: mean arterial pressure, both arterial and central venous oxygen saturation and partial pressures of oxygen and carbon dioxide, and lactate levels. From these parameters, the oxygenation index and the oxygen extraction ratio were calculated. These measurements were studied to evaluate whether rSO2 correlated significantly with the other parameters. RESULTS: The average age and weight of the patients were 27.3 months and 9.2 kg, respectively. The rSO2 correlated positively with both central venous oxygen saturation (r=0.73, P<.01) and mean arterial pressure (r=0.59, P<.01), and negatively with the oxygen extraction ratio (r=-0.7, P<.01). No correlation was found with the respiratory parameters. Concordance analysis established an acceptable Kappa index (> 0.4) between the rSO2 and central venous oxygen saturation, and between the rSO2 and oxygen extraction ratio. CONCLUSIONS: Regional cerebral oxygen saturation correlates well with hemodynamic parameters - mean arterial pressure, venous saturation, and the tissue oxygen extraction. However, it does not correlate with respiratory parameters.

[Oxygen extraction as a predictor of mortality in patients on high frequency ventilation]. / Extracción de oxígeno como predictor de mortalidad en pacientes con ventilación de alta frecuencia.

INTRODUCTION: The high frequency oscillatory ventilation (HFOV) may reduce cardiac output. The haemodynamics were analysed and predictors of mortality identified. PATIENTS AND METHODS: A total of 48 children with respiratory failure undergoing HFOV between January 2003 and December 2010 were included. The study design was prospective, observational, and descriptive. Inclusion criteria were based on the existence of hypoxemia. The variables studied were: arterial and central venous pressure, arterial pH, venous saturation and oxygen extraction ratio, with determinations performed prior to HFOV, during, and before turning to conventional ventilation. Prognostic factors were identified by bivariate analysis and a predictive model of mortality was developed. RESULTS: The mean age was 21 [4 to 72] months. On admission, PRISM scales and Murray were 33 and 2.8, PaO(2)/FiO(2) of 61 and oxygenation index of 35. After HFOV an increase in pH (P<.001), mean arterial pressure (P<.001) and venous saturation, and decreased venous pressure and O(2) extraction (P<.001), was obtained. The prognostic factors of mortality at 24 hours after starting HFOV were: FiO(2), PaO(2)/FiO(2), oxygenation index, shunt, pH, central venous pressure and mean arterial pressure, venous saturation, and O(2) extraction. The model developed at 12 hours, consisting of EtO(2) and SvcO(2) was able to predict death with a probability of 92.3%. CONCLUSIONS: HFOV improves haemodynamics. The model at 12 hours is the best predictor of death.

Use of a specific anti-stretch mark cream for preventing or reducing the severity of striae gravidarum. Randomized, double-blind, controlled trial.

Few studies have tested the efficacy of commercially available cosmetic products for preventing striae gravidarum. Therefore, the objective of this study was to evaluate efficacy on prevention of striae gravidarum using a specific anti-stretch mark cream containing hydroxyprolisilane-C, rosehip oil, Centella asiatica triterpenes and vitamin E. A randomized, double-blind, placebo-controlled trial was conducted between November 2009 and April 2011. Pregnant women were included and classified as treated group (emollient and moisturizer containing hydroxyprolisilane C, rosehip oil, Centella asiatica triterpenes and vitamin E) and control group (cream without the active ingredients). Overall incidence of stretch marks during pregnancy was 33.3% for the control group and 37.6% for the treated group (n.s.). Severity of previous stretch marks significantly increased in the control group during the study (17.8%, P = 0.001), but not in the treated group (6.3%, ns). In women who developed new stretch marks during the study, there was a significantly greater 'difference in severity' (between baseline and maximum severity) in control group vs. treated group (0.47 [0.57] vs. 0.14 [0.60], P = 0.031). In women without previous striae, incidence of these marks was significantly lower for the treated group patients compared with control group (5.6% vs. 35%, P = 0.031, OR: 9.2 [95% CI: 1.0-83.3]). The use of the anti-stretch mark product is proved to be effective in reducing severity of the striae during pregnancy, prevents the appearance of new striae and halts progression of those already present. In women who had no striae at baseline, use of the anti-stretch mark cream was more effective than placebo in preventing new stretch marks.

Cervical length vs VOCAL cervical volume for predicting pre-term delivery in asymptomatic women at 20-22 weeks' pregnancy.

We conducted a prospective observational study of 306 asymptomatic women at 20-22 weeks of pregnancy to compare 3-dimensional ultrasound measurements of cervical volume with 2-dimensional ultrasound measurements of cervical length to evaluate the performance of cervical volume as a predictor of pre-term delivery, compared with the current standard, cervical length. Participants underwent transvaginal ultrasound measurements of cervical length (mm) and cervical volume (cm(3)). Cervical volume as measured by 3-dimensional ultrasound was found to be a useful tool for predicting pre-term delivery; however, due to the high correlation between cervical length and cervical volume and the lack of differences in the sensitivity, specificity, positive predictive value, negative predictive value and relative risk between the two methods, replacing cervical length measurements with cervical volume calculations does not seem to be justified for this purpose, because of increased difficulty in volume acquisition.

[Prognostic markers of mortality after congenital heart defect surgery]. / Marcadores pronósticos de mortalidad en el postoperatorio de las cardiopatías congénitas.

INTRODUCTION: Our aim is to identify risk factors for mortality after surgery for congenital heart disease in children, in order to establish indications for extracorporeal membrane oxygenation (ECMO). PATIENTS AND METHODS: One hundred and eighty six children underwent cardiac surgery with extracorporeal circulation from April 2007 to June 2009. The following parameters were measured serially during their stay in Paediatric Intensive Care (PICU): Arterial and venous blood pH, pCO2, base excess, oxygen saturation, arterio-venous oxygen saturation difference, oxygen extraction ratio, ventilatory dead space and intrapulmonary shunting. RESULTS: Hospital mortality was 13,4%. The following risk factors for mortality were identified: age, bypass time, inotropic score, lactate level upon arrival in PICU including its peak value and its rate of variation, mixed venous saturation, base excess, ventilatory dead space, oxygen extraction ratio, and intrapulmonary shunting. However, the strongest predictors of mortality were bypass time, lactate levels upon admission on PICU, and the peak lactate level. Multivariate analysis showed a lactate level of 6.3mmol/l and a high blood lactate for 24hours to be independent predictors of mortality. CONCLUSIONS: The peak lactate level is a strong predictor of mortality. As such, it would be a useful indicator of the need for ECMO support.

First-trimester screening for large-for-gestational-age infants.

OBJECTIVES: To examine the relationship between newborn birth weight and first-trimester uterine artery (UtA) pulsatility index (PI), maternal characteristics, serum pregnancy-associated plasma protein-A (PAPP-A), free ß-human chorionic gonadotropin (ß-hCG) and fetal nuchal translucency (NT) thickness. We also examined the results of screening for large-for-gestational-age (LGA) neonates by an integrated first-trimester approach incorporating these parameters. METHODS: We evaluated maternal characteristics, fetal NT, PAPP-A, free ß-hCG and UtA-PI in 2097 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Linear models based on quasi Akaike's Information Criterion were used to determine the best predictive model for fetal birth weight. The patient-specific risk of delivering an LGA infant was derived from multiple logistic regression analysis and the performance of screening was determined by receiver-operating characteristics curve analysis. RESULTS: The best predictive models for fetal birth weight included UtA-PI, PAPP-A, NT, parity, maternal age, smoking status, weight, height and free ß-hCG. In pregnancies delivering LGA newborns compared with non-LGA pregnancies, PAPP-A and NT thickness were significantly increased (P = 0.016 and 0.001, respectively) and UtA-PI was significantly decreased (P = 0.011). A combination of maternal factors with PAPP-A, fetal NT and UtA-PI identified 34.4% of LGA newborns for a false-positive rate of 10%. CONCLUSIONS: This study showed an association between newborn birth weight and maternal factors, and first-trimester PAPP-A, ß-hCG, fetal NT and UtA-PI. Together, these factors can be used to identify over a third of pregnancies that will deliver LGA infants.

[Prognostic evaluation of arterial switch in the transposition of great arteries]. / Valoración pronóstica del switch arterial en la transposición de grandes arterias.

INTRODUCTION AND OBJECTIVES: The arterial switch is the procedure of choice for transposition of great arteries, with or without ventricular septal defect. The aim of this study was to identify risk factors for hospital mortality. METHODS: The study included 121 children between January 1994 and June 2008. Of these, 80 (66%) were diagnosed with intact ventricular septum, and 41 (34%) with ventricular septal defect. Variables were collected pre-operatively, during surgery, and postoperatively. RESULTS: The mean age was 11 [8 to 16] days and a mean weight of 3.5 [3.0 to 3.7] kg. A ventricular septal defect was closed in 11 children (9.1%). A total of 81.8% had a normal coronary pattern. There was delayed closure of the chest in 38 patients (31.4%). The hospital mortality was 11.6%, decreasing over the past 5 years to 2.1%. The weight, abnormal coronary pattern, time of cardiopulmonary bypass, mean arterial pressure at admission, pulmonary dead space, and delayed closure of the chest, were risk factors of mortality. The model that best predicts death, consists of the mean arterial pressure at admission, and delayed closure of the chest. CONCLUSIONS: The reduction in extracorporeal circulation time and the use of delayed closure of the chest, have helped to reduce mortality. The abnormal coronary pattern remains a risk factor for mortality. In children with delayed closure of the chest, a mean arterial pressure at admission ≥ 47.5 mmHg is a goal to achieve.

Mortalidad materna 1991–2007. Por qué mueren las madres en un hospital de tercer nivel / Maternal mortality 1991–007. Why mothers die in a third level hospital

Objetivos Crear un registro de mortalidad materna en nuestro centro, analizar las causas e introducir medidas correctivas para reducir su frecuencia. Material y método Estudio longitudinal retrospectivo de los casos de muerte materna ocurridos en nuestro centro entre enero de 1991 y diciembre de 2007.Resultados Se registraron un total de 128.262 recién nacidos vivos y 25 muertes maternas en el periodo de estudio. Nuestra tasa de mortalidad materna es de 19,4 por 100.000 recién nacidos vivos. El 88% de las madres tenían más de 20 años. El 64% eran primíparas y el 32% multíparas. El 60% tenían entre 22 y 37 semanas en el momento del parto. El 52% de las muertes fueron obstétricas indirectas y el 48% obstétricas directas. No hubo casos de muerte accidental. Conclusiones La tasa de muerte materna es de 19,4 por 100.000 recién nacidos vivos en nuestro centro. La causa más frecuente de muerte materna es la hemorragia puerperal asociada a shock hipovolémico, seguida del shock séptico y el accidente cerebrovascular (A)

Objectives To create a record of maternal mortality in our center, analyze the causes of mortality, and implement corrective measures to reduce the frequency of maternal death. Material and method We performed a longitudinal retrospective study of maternal deaths recorded in our department between January 1991 and December 2007.ResultsA total of 128,262 live newborns and 25 maternal deaths were recorded in the study period. The maternal mortality rate in our center was 19.4 per 100,000 live newborns. Eighty-eight percent of the mothers were aged over 20 years old. Sixty-four percent were primiparous and 32% were multiparous. Sixty percent were between 22 and 37 weeks of pregnancy at the time of delivery. Fifty-two percent were indirect obstetric deaths and 48% were direct obstetric deaths. There were no accidental deaths. Conclusions The maternal death rate in our hospital is 19.4 per 100,000 live newborns. The most common cause of maternal death was puerperium hemorrhage associated with hypovolemic shock, followed by septic shock and stroke (AU)