Factores de riesgo de la muerte fetal anteparto / Risk factors for antepartum fetal death

La muerte fetal supone más de la mitad de las muertes perinatales. El grupo con mayor morbimortalidad corresponde a los recién nacidos que asocian prematuridad y bajo peso. Hay una marcada tendencia a repetir el mal resultado de la gestación anterior. Se presentan 2 casos de muerte fetal, y se realiza una revisión de las causas más frecuentes y de su influencia. El estudio de las alteraciones maternas, fetales y placentarias puede, en algunos casos, establecer la etiología de la muerte fetal (AU)

Fetal death represents more than half of perinatal deaths. Morbidity is highest in newborns who associate prematurity and low birth weight. Adverse pregnancy outcomes show a marked tendency to be repeated. We present two cases of fetal death and review the most frequent causes of this adverse outcome and their influence. Study of maternal, fetal and placental alterations can sometimes establish the etiology of fetal death (AU)

Feto acardio en aborto gemelar / Acardiac fetus in intrauterine fetal demise in a twin pregnancy

Se trata de una entidad poco frecuente que complica las gestaciones múltiples, en mayor medida las gemelares univitelinas, aunque puede afectar también a las monocoriales dicigóticas, las triples e incluso a embarazos únicos. La presencia del feto acardio supone una sobrecarga para el gemelo donante que tiene que mantener la perfusión propia y la del gemelo parásito. Se presenta el caso clínico de una paciente con gestación gemelar (no controlada) con diagnóstico de muerte fetal intraútero de ambos gemelos, uno de ellos un feto acárido (AU)

Acardiac fetus is a rare entity that complicates multiple pregnancies. Occurrence is more frequent in monozygotic twin pregnancies but monochorionic dizygotic, triple and even singleton pregnancies may also be affected. The acardiac fetus acts as a parasite on the pump twin, which must provide a blood supply for the perfused fetus. We present the case of a patient with a twin pregnancy (without prenatal monitoring) with a diagnosis of intrauterine fetal demise in both twins, one of which was an acardiac fetus (AU)

Hemorragia fetomaterna masiva. Caso clínico / Massive maternofoetal haemorrhage. A clinical case

La hemorragia fetomaterna masiva es un cuadro clínico grave que, en la mayoría de los casos, acontece en gestaciones cercanas al término sin factores de riesgo; es por ello que este diagnóstico se debería considerar en cualquier paciente con disminución de los movimientos fetales, registro cardiotocográfico con un patrón sinusoidal y un incremento de la velocidad de flujo de la arteria cerebral media (AU)

Massive feto-maternal haemorrhage is a grave clinical picture which, in the majority of cases, happens in gestations near to term with no risk factors. It is for this reason that this diagnosis should be considered in any patient with diminished foetal movements, cardiotocogram with a sinusoidal pattern and an increase in the speed of flow of the middle cerebral artery (AU)

Tratamiento quirúrgico de las hemorragias del alumbramiento / Surgical management of haemorrhage in third stage of labour

Las hemorragias del alumbramiento contribuyen de forma importante al aumento de la morbilidad y mortalidad maternas. En esta revisión se repasan las distintas posibilidades del tratamiento quirúrgico de esta complicación. Ha de entenderse que, habitualmente, éste no puede ser aplicado aisladamente sino como parte de un arsenal terapéutico que comprende tanto el empleo de fármacos como medidas de soporte vital. Se señala la gran importancia del trabajo en equipo de las distintas especialidades implicadas y del personal subalterno del hospital

The postpartum haemorraghes are important factors that increase the maternal morbidity and mortality. This rewiew summarizes several surgical options aviable for the management of this complication. It is important to know that the surgical management is only one between different therapeutical options and, usually must be used with other therapies that include pharmacology and vital support actions. It is very important that the medical members of different specialities and other hospital workers

Aplasia cutis congénita y feto papiráceo en embarazo gemelar monocoriónico / Aplasia cutis congenita with fetus papyraceus in a monochorionic twin pregnancy

Presentamos un caso clínico de aplasia cutis congénita en un recién nacido de un embarazo gemelar monocoriónico con feto papiráceo a las 14 semanas. Una revisión de la bibliografía parece soportar la hipótesis de que la existencia del feto papiráceo pueda ser la causa de esta patología en el neonato, consecuencia del “síndrome de embolización gemelar”

We report a case of aplasia cutis congenita in one twin of a monochorionic twin pregnancy with fetus papyraceus at 14 weeks. A review of the literature seems to support the hypothesis that the fetus papyraceus could be the cause of this entity in the neonate as a consequence of “twin embolization syndrome”

Brain damage to the survivor within 30 min of co-twin demise in monochorionic twins.

Single fetal death in a twin pregnancy in the late second or early third trimester is associated with significant morbidity and mortality rate in the surviving co-twin, especially in monochorionic twin pregnancies. The common causes are twin-to-twin transfusion syndrome, chromosomal abnormalities, and congenital anomalies of the fetus or anomalies of the umbilical cord-placenta. Here we report a case of monochorionic twin pregnancy in which one fetus had a single umbilical artery (SUA) while the co-twin had two umbilical arteries. The twin with SUA died in utero at the 30th week of gestation and the other fetus was delivered by cesarean section immediately due to fetal distress diagnosed by cardiotocography. Disseminated intravascular coagulation and multicystic encephalomalacia have been observed in the surviving neonate. This case and review of the literature suggest that neurologic complication rates are also increased in monochorionic twin pregnancies with single fetal demise despite the immediate delivery as in our case.

[Acute renal failure during HELLP syndrome--case report]. / Ostra niewydolnosc nerek w przebiegu zespolu HELLP--opis przypadku.

Case report was presented of a 22 year old pregnant patient with diagnosed intrauterine fetal death, who developed HELLP syndrome and acute renal failure. Immediate hemodialysis treatment was initiated that permitted management of pulmonary edema; subsequent plasmapheresis eliminated not only elevated bilirubin and toxins liberated to circulation from the dead intrauterine fetus but also allowed for patient recovery. The HELLP Syndrome requires careful obstetric supervision and if possible treatment in the Intensive Care Unit.

Management of other complications specific to monochorionic twin pregnancies.

Monochorionic (MC) twins have a 3-10-fold higher perinatal mortality and morbidity than dichorionic twins. This is largely attributable to their common vascular architecture and the high rate of discordant fetal growth, growth restriction and congenital abnormalities. In the event of a single intrauterine death (IUD), intertwin agonal transfusion results in up to a 38% risk of death and a 46% risk of neurological injury to the co-twin. This chapter addresses the management of complications unique to MC twins. The primary aim of management is to prevent single IUD or, if inevitable, prevent agonal transfusion occurring by vascular occlusive selective feticide. Older fetoscopic techniques have been replaced by the simpler ultrasound-guided techniques of interstitial laser and bipolar cord occlusion. Their application in twin reversed-arterial perfusion sequence has been associated with a 50% reduction of perinatal mortality in the pump twin. Moreover, prophylactic interstitial laser therapy in early pregnancy might obviate the technical and clinical difficulties in the presence of fetal decompensation in later pregnancy. Recent strategies to reduce the high perinatal mortality due to cord entanglement in antenatally diagnosed monoamniotic twins including medical amnioreduction and elective caesarean delivery at 32 weeks, are also discussed.

[Case report of 18 weeks delayed delivery of the second twin after the miscarriage of the first fetus at the 17th week of pregnancy]. / Poród odroczony o 18 tygodni po wczesniejszym poronieniu pierwszego z blizniat.

Delayed delivery of the second twin after the miscarriage of the first foetus is very rare. Delayed second-twin delivery gives the opportunity for corticoid and antibiotics administration--procedures that decrease the infant morbidity and mortality. We report a case of the second twin's retention after miscarriage of the first at 17th week of pregnancy. The delay time was of 126 days (18 weeks). Pregnancy like this is at increased risk for all maternal complications, in particular intrauterine infection. Parents consent have to be obtained after informing them about advantages and risk of such procedure. The patient was treated with tocolysis, antibiotics, corticosteroids but not previous cervix cerclage has been performed. On regards of our experience and the data from literature we conclude that when observing fetal status and maternal condition, it is possible to delay the second twin's delivery long time after the miscarriage or birth of the first one thus giving the chance to the second twin to grow more mature. The main problem is imminent infection which defines the prognosis. Cerclage does not seem to be essential for better outcome.

Natural history of twin disruption sequence.

Intrauterine death of one fetus in a monochorionic twin pregnancy is associated with high morbidity and mortality in the surviving co-twin. Thromoboplastic material from the dead twin may pass to the circulation of the living twin via placental anastomoses and cause tissue necrosis by direct embolization or by activating intravascular coagulation. Alternatively, acute blood loss into the dying twin through placental anastomoses may result in hypotension and hypoxic-ischemic damage to cerebral and visceral tissue in the surviving twin. The resulting clinical picture is referred to as twin disruption sequence. Affected twins have rarely been followed beyond the neonatal period and the long-term development of such children is unknown. Here, we present a natural history and neurological assessment of 18 patients with twin disruption sequence, whom we have followed over several months to years.

Management of single fetal demise in a multiple gestation.

Intrauterine fetal demise of 1 twin in a multiple gestation is a complex clinical situation. Chorionicity, gestational age at diagnosis, problems specific to the pregnancy, and the emotional needs of the patient can impact management. Strategies to optimize outcomes may include a multidisciplinary team approach and fetal surveillance. The following article reviews (1) adverse fetal and neonatal outcomes associated with intrauterine fetal demise of 1 twin, (2) the potential maternal impact, and (3) the strategies to possibly prevent poor outcomes. It is important to remember that even the most vigilant care may not avoid adverse sequelae in a portion of at-risk pregnancies.

Neuromorbidity in preterm twins in relation to chorionicity and discordant birth weight.

OBJECTIVE: The purpose of this study was to determine the incidence of neurologic morbidity in preterm monochorionic (MC) and dichorionic (DC) twins. STUDY DESIGN: We collected perinatal, neonatal, and infant follow-up data of 76 MC and 78 DC twins born between 24 and 34 weeks of gestation (295 infants). Risks of neuromorbidity in the surviving infants were evaluated in relation to chorionicity, discordant birth weight (>20%), twin-twin transfusion syndrome (TTTS), and cotwin death. RESULTS: The overall incidence of cerebral palsy and minor neurologic disabilities in surviving twins was 4% and 9%, respectively. MC infants had a higher incidence of cerebral palsy (8% vs 1%, P<.05) and neurologic morbidity (15% vs 3%, P<.05) than DC infants. The risk of impaired neurodevelopment was higher in MC infants with discordant birth weight (42%, P<.01), TTTS (37%, P<.01), and cotwin death (60%, P<.01) than those with concordant birth weight (8%). In MC pregnancies, the cerebral palsy risk was higher in infants with discordant birth weight than those with chronic TTTS (19% vs 4%, P<.05). Similarly, discordant DC infants had higher neuromorbidity than concordant group (5% vs 1%, P<.05). In both MC and DC discordant infants, neurologic morbidity was independent of growth restriction. CONCLUSION: Neurologic morbidity in the preterm MC infants was 7-fold higher than DC infants because of chronic TTTS, discordant birth weight, and cotwin death in utero.

The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin.

OBJECTIVE: The purpose of this study was to assess the value of the fetal middle cerebral artery peak systolic velocity in the prediction of anemia within 24 hours of the death of one monochorionic twin in twin-to-twin-transfusion syndrome and to establish the correlation between middle cerebral artery peak systolic velocity and hemoglobin concentration in fetuses who are at risk for acute anemia. STUDY DESIGN: Doppler examination of the middle cerebral artery peak systolic velocity was performed in 20 monochorionic survivors of pregnancies that were complicated by twin-to-twin-transfusion syndrome that occurred between 20 and 34 weeks of gestation. Doppler examination was performed before cordocentesis and after intrauterine transfusion when appropriate. Both hemoglobin concentration and middle cerebral artery peak systolic velocity were expressed in multiples of the median. Severe anemia was defined as hemoglobin concentration of <0.55 multiples of the median, and we used the cutoff point of 1.50 times the median values at any gestational age to calculate the sensitivity and specificity of middle cerebral artery peak systolic velocity in detecting moderate or severe anemia. RESULTS: Fetal anemia was confirmed in 10 of 20 fetuses. We performed seven intrauterine transfusions. The sensitivity and specificity of middle cerebral artery peak systolic velocity in the prediction of severe fetal anemia were of 90%, with a false-negative rate of 10%. The correlation between peak systolic velocity and hemoglobin concentration both before and after transfusion was evaluated by regression analysis and was strongly significant. CONCLUSION: In fetuses who are at risk of acute anemia, the measurement of middle cerebral artery peak systolic velocity was found to be a reliable noninvasive diagnostic tool and may be helpful in counseling and planning invasive assessment.

The influence of fetal loss on the presence of fetal cell microchimerism: a systematic review.

OBJECTIVE: Fetal cells enter the maternal circulation during most pregnancies. Their persistence for years occurs in only some women and has been associated with several autoimmune diseases such as systemic sclerosis. The objective of this study was to determine whether pregnancy history influences the persistence of fetal microchimeric cells. METHODS: We reviewed all reports of studies on fetal cell microchimerism, defined as male DNA in maternal tissue, that describe individual pregnancy histories, disease diagnoses, and microchimerism status. The total numbers of pregnancies, births, and sons, the history of fetal loss (spontaneous abortion and elective termination), and the presence of a maternal autoimmune disease were tested as factors potentially associated with persistent microchimerism. RESULTS: One hundred twenty-four subjects from 11 studies met the inclusion criteria. Only fetal loss was significantly associated with the presence of microchimerism (odds ratio 2.4, 95% confidence interval 1.2-6.0). CONCLUSION: These results suggest that fetomaternal cell trafficking following fetal loss may be important for the engraftment of microchimeric cells in maternal tissue. This may be due to an increased amount of fetomaternal transfusion or to transfer of a cell type that is more likely to engraft. We recommend that investigators in future studies on microchimerism report detailed pregnancy information, since these data are critical for the understanding of factors that influence the development of fetal cell microchimerism.

Thrombophilia and pregnancy.

Pregnancy is hypercoagulable state. The field of thrombophilia; the tendency to thrombosis, has been developed rapidly and has been linked to many aspects of pregnancy. It is recently that severe pregnancy complications such as severe preeclampsia intrauterine growth retardation abruptio placentae and stillbirth has been shown to be associated with thrombophilia. Recurrent miscarriage and has also been associated with thrombophilia. Finally, thromboembolism in pregnancy as in the non-pregnant state is linked to thrombophilia. In this review all aspects of thrombophilia in pregnancy are discussed, and also all prophylactic and therapeutic implications.

Multicystic encephalomalacia.

Antepartum death of a fetus in a multiple gestation can be associated with mortality or major morbidity in the survivor. This article reports a rare case of multicystic encephalomalacia that occurred in the survivor twin with antepartum death of its co-twin. Its pathology and pathogenesis are discussed with review of literature.

Burden of malaria during pregnancy in areas of stable and unstable transmission in Ethiopia during a nonepidemic year.

Little is known about the epidemiology of malaria during pregnancy in areas of unstable (epidemic-prone) transmission (UT) in sub-Saharan Africa. In cross-sectional studies, peripheral malaria parasitemia was identified in 10.4% of women attending antenatal care clinics at 1 stable transmission (ST) site and in 1.8% of women at 3 UT sites; parasitemia was associated with anemia in both ST (relative risk [RR], 2.0; P<.001) and UT (RR, 4.4; P<.001) sites. Placental parasitemia was identified more frequently during deliveries at ST sites (12/185; 6.5%) than at UT sites (21/833; 2.5%; P=.006). Placental parasitemia was associated with low birth weight at the ST site (RR, 3.2; P=.01) and prematurity at ST (RR, 2.7; P=.04) and UT (RR, 3.9; P=.01) sites and with a 7-fold increased risk of stillbirths at UT sites. The effectiveness and efficiency in Ethiopia of standard preventive strategies used in high-transmission regions (such as intermittent preventive treatment) may require further evaluation; approaches such as insecticide-treated bednets and epidemic preparedness may be needed to prevent adverse pregnancy outcomes.

Long-term neurodevelopmental outcome after intrauterine laser treatment for severe twin-twin transfusion syndrome.

OBJECTIVE: The purpose of this study was to investigate long-term neurodevelopmental outcome after intrauterine laser treatment for twin-twin transfusion syndrome. STUDY DESIGN: All 89 surviving infants who were treated between January 1995 and May 1997 were investigated in a single center. Seventy-five children were tested with the Griffiths' Developmental Test Scales at a median age of 21 months; 14 children (median age, 34 months) were tested with the Snijders-Oomen-Non-Verbal-Intelligence Test. All children underwent a detailed standardized physical and neurologic examination. RESULTS: Sixty-nine infants (78%) showed a normal development (group I), 10 infants (11%) had minor neurologic deficiencies (group II), and 10 infants (11%) had major neurologic deficiencies (group III). No difference between recipient and donor status was observed (P =.93). There was a trend toward a more favorable outcome for those infants who were born as twins (53 infants [81%] in group I and 5 infants [8%] in group III) compared with singleton survivors after intrauterine death of the cotwin (16 infants [67%] in group I and 5 infants [21%] in group III); however, the difference was not significant (P =.12). CONCLUSION: After intrauterine laser treatment for twin-twin transfusion syndrome, 78% of the children had a normal neurodevelopmental status, 11% of the children had minor neurologic deficiencies, and 11% of the children had major neurologic deficiencies, at a median age of 22 months.

Anti-shock garment provides resuscitation and haemostasis for obstetric haemorrhage.

OBJECTIVE: To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock. DESIGN: During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, Pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review. SETTING: Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day. POPULATION: During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms. METHODS: As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. Vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion. MAIN OUTCOME MEASURES: Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. Morbidity included any complications noted in the medical chart. RESULTS: Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. Patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output. CONCLUSIONS: The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.

Acquired and inherited thrombophilia in women with unexplained fetal losses.

OBJECTIVE: The purpose of this study was to investigate the possible role of inherited and acquired thrombophilia in women with unexplained abortions and intrauterine fetal death. STUDY DESIGN: We included 75 women with >/=1 unexplained fetal loss, and 75 control subjects with at least 1 healthy term infant and without gestational complications. All of these women were tested for mutations of factor V Leiden, methylenetetrahydrofolate reductase, and prothrombin gene; deficiencies of antithrombin-III, protein C, and protein S; and the presence of antiphospholipid antibodies and fasting homocysteine concentration. A placental histologic study was also carried out. RESULTS: Thirty-five percent of the 75 patients had thrombophilia (control subjects, 16%; P =.008; odds ratio, 2.78). This prevalence was more prominent in second and third trimesters (P =.0002; odds ratio, 6.3), and the presence of combined genetic defects was associated with intrauterine fetal death (P =.04; odds ratio, 12; 95% CI, 1.44-102). When we analyzed the overall gestations of the patients, we observed an increase of intrauterine fetal death in patients with thrombophilia (P =.01) and early pregnancy loss in patients without thrombophilia (P =.02). The analysis of the correlation between extensive placental infarctions and thrombophilic defects rendered values in the boundaries of significance (P =.05). CONCLUSION: The significant high prevalence of biologic causes in patients with late fetal loss suggests that a study of thrombophilia should be carried out, together with an assessment of a preventive treatment.