[Criteria for birth delivery in women with severe preeclampsia in expectant management]. / Criterios de inducción del nacimiento en mujeres con preeclampsia severa en tratamiento expectante.

BACKGROUND: Preeclampsia complicates pregnancy in 3% to 8%, in Mexico it occurs in 5% to 10% of all pregnancies. The world incidence of the severe form all is unknown; however, in United States an incidence of 1% has been reported. Among the causes precipitating birth induction are intrauterine growth restriction, fetal distress and placenta abruption. OBJECTIVES: To determine maternal and fetal complications in women with severe preeclampsia who were admitted to the National Institute of Perinatology, and to establish the indications for birth induction in these women undergoing expectant management between 25 to 32 weeks of gestation. PATIENTS AND METHOD: A retrospective cohort study in which we reviewed the records of all patients diagnosed with severe preeclampsia between 2005 and 2009, and we used those records of women who had a diagnosis of severe preeclampsia at admission and who met criteria for expectant management, the data were collected in a database of art, and then analyzed the different variables in Statistical Package for the Social Sciences (SPSS). RESULTS: Of the 27 patients studied, the average weeks of gestation on admission was 29.2, 41% were nulliparous as main risk factor, 100% completed lung maturity; the average time of days of expectant management was 3.1 +/- 1.3 days (interval: one to seven days). The average gestational age at the birth induction was of 30.1 weeks (interval: 25.2 to 32.5 weeks of gestation). The main criteria for birth induction were: hypertensive crisis (44%), intrauterine growth restriction (30%), hypertensive encephalopathy and epigastric pain (19% each), elevation of transaminases and thrombocytopenia (11%), and oliguria (7%). The way of birth was 96% by caesarean and 4% by vaginal birth. CONCLUSION: The main criteria for birth induction in our sample were the uncontrolled blood pressure and intrauterine growth restriction. The time for the extension of the pregnancy was not significant compared with other studies; however, fetal lung maturity was completed.

sFlt-1 Is an Independent Predictor of Adverse Maternal Outcomes in Women With SARS-CoV-2 Infection and Hypertensive Disorders of Pregnancy.

Background: Preeclampsia (PE) and COVID-19 share a common vascular-endothelial physiopathological pathway that may aggravate or worsen women's outcomes when both coexist. This study aims to evaluate the association of sFlt-1 levels and adverse maternal outcomes among positive SARS-CoV-2 pregnant women with and without hypertensive disorders of pregnancy (HDP). Methods: We performed a multicenter retrospective cohort study of pregnant women with confirmed SARS-CoV-2 infection that required hospital admission. The exposed cohort comprised women with a diagnosis of an HDP. The primary outcome was a composite definition of adverse maternal outcome. The association between predictors and the main and secondary outcomes was assessed using an elastic-net regression which comprised a Lasso and Ridge regression method for automatic variable selection and penalization of non-statistically significant coefficients using a 10-fold cross-validation where the best model if automatically chosen by the lowest Akaike information criterion (AIC) and Bayesian information criteria (BIC). Results: Among 148 pregnant women with COVID-19, the best predictive model comprised sFlt-1 MoMs [odds ratio (OR): 5.13; 95% CI: 2.19-12.05], and HDP (OR: 32.76; 95% CI: 5.24-205). sFlt-1 MoMs were independently associated with an increased probability of an adverse maternal outcome despite adjusting for HDP. Conclusions: Our study shows that sFlt-1 is an independent predictor of adverse outcomes in women with SARS-CoV-2 despite hypertension status.

Maternal Death by COVID-19 Associated with Elevated Troponin T Levels.

Cardiomyocyte injury and troponin T elevation has been reported within COVID-19 patients and are associated with a worse prognosis. Limited data report this association among COVID-19 pregnant patients. OBJECTIVE: We aimed to analyze the association between troponin T levels in severe COVID-19 pregnant women and risk of viral sepsis, intensive care unit (ICU) admission, or maternal death. METHODS: We performed a prospective cohort of all obstetrics emergency admissions from a Mexican National Institute. All pregnant women diagnosed by reverse transcription-polymerase chain reaction (RT-qPCR) for SARS-CoV-2 infection between October 2020 and May 2021 were included. Clinical data were collected, and routine blood samples were obtained at hospital admission. Seric troponin T was measured at admission. RESULTS: From 87 included patients, 31 (35.63%) had severe COVID-19 pneumonia, and 6 (6.89%) maternal deaths. ROC showed a significant relationship between troponin T and maternal death (AUC 0.979, CI 0.500-1.000). At a cutoff point of 7 ng/mL the detection rate for severe pneumonia was 83.3% (95%CI: 0.500-0.100) at 10% false-positive rate. CONCLUSION: COVID-19 pregnant women with elevated levels of troponin T present a higher risk of death and severe pneumonia.

[Takayasu's arteritis in pregnancy: report seven cases]. / Arteritis de Takayasu en el embarazo: reporte de siete casos.

Takayasu's arteritis is a chronic and non-specific disease of young women in reproductive age that primarily affects the aorta, its branches and the pulmonary artery. Ramirez Cueto G. and Fernandez Del Castillo C. et al. published a case of pregnancy in Mexico and Takayasu's arteritis in 1968. There are no reports of this disease in pregnancy since. The purpose of this study is to describe the clinical course and perinatal outcome of seven pregnant patients with known diagnosis of Takayasu arteritis. The clinical course, laboratory findings, angiographic findings and perinatal outcomes were assessed in retrospect in seven pregnant patients with diagnosis of Takayasu's arteritis seen at the National Institute of Perinatology Isidro Espinosa Reyes (Mexico) during the period 2002-2010. The results of the conducted follow-up of 7 patients pregnant with Takayasu's arteritis were: 3 patients were complicated with pre-eclampsia and 2 newborn presented intrauterine growth restriction. Disease activity wasn't observed during pregnancy. No cases of congestive heart failure, brain ischemia or maternal deaths were presented. There were no fetal deaths. We didn't observed induced activity during pregnancy in the cases presented. The most common mother complication was type renovascular hypertension with added severe preeclampsia, which determined the presence of intrauterine growth restriction. There were no maternal or perinatal deaths.

[Acute toxicity by methotrexate used for abortion purpose. Case report]. / Intoxicación aguda por metotrexato utilizado con fines abortivos. Reporte de caso.

We report the case of a 16 years old female patient, with a pregnancy history of 11.4 weeks by ultrasound and intrauterine fetal death. In a private clinic were prescribed methotrexate 500 mg intramuscular single dose, and vaginal misoprostol. She had a clinical feature of five days of evolution characterized by fever of 39 degrees C, nausea, general attack and vomiting. The initial diagnosis was severe sepsis secondary to septic abortion, oral candidiasis and acute poisoning by methotrexate. After that, she was referred to the Instituto Nacional de Perinatologia, where stayed with fever for four days, and was managed with hydration, antibiotics, folinic acid and alkalizing. Her recovery was gradual. She was discharged after 12 days with significant clinical improvement. The literature review describes that the use of methotrexate for abortion purpose with therapeutic-dose presents a similar adverse effects to those found in our patient, however there are no case reports that describe the use of this drug in macrodosis for the same purpose, and their cytotoxic effects. We present this case because the patient used a macrodosis of this antimetabolite and due to the premature and empirical management with folinic acid, joined with alkalinization of urine, is the ideal treatment and as it is illustrated in our case.

Novel Ratio Soluble Fms-like Tyrosine Kinase-1/Angiotensin-II (sFlt-1/ANG-II) in Pregnant Women Is Associated with Critical Illness in COVID-19.

BACKGROUND: In healthy pregnancies, components of the Renin-Angiotensin system (RAS) are present in the placental villi and contribute to invasion, migration, and angiogenesis. At the same time, soluble fms-like tyrosine kinase 1 (sFlt-1) production is induced after binding of ANG-II to its receptor (AT-1R) in response to hypoxia. As RAS plays an essential role in the pathogenesis of COVID-19, we hypothesized that angiogenic marker (sFlt-1) and RAS components (ANG-II and ACE-2) may be related to adverse outcomes in pregnant women with COVID-19; Methods: Prospective cohort study. Primary outcome was severe pneumonia. Secondary outcomes were ICU admission, intubation, sepsis, and death. Spearman's Rho test was used to analyze the correlation between sFlt-1 and ANG-II levels. The sFlt-1/ANG-II ratio was determined and the association with each adverse outcome was explored by logistic regression analysis and the prediction was assessed using receiver-operating-curve (ROC); Results: Among 80 pregnant women with COVID-19, the sFlt-1/ANG-II ratio was associated with an increased probability of severe pneumonia (odds ratio [OR]: 1.31; p = 0.003), ICU admission (OR: 1.05; p = 0.007); intubation (OR: 1.09; p = 0.008); sepsis (OR: 1.04; p = 0.008); and death (OR: 1.04; p = 0.018); Conclusion: sFlt-1/ANG-II ratio is a good predictor of adverse events such as pneumonia, ICU admission, intubation, sepsis, and death in pregnant women with COVID-19.

The sFlt-1/PlGF ratio as a triage tool to identify superimposed preeclampsia in women with chronic hypertension in emergency rooms.

OBJECTIVES: Assess the usefulness of the sFlt-1/PlGF ratio for the differential diagnosis of uncontrolled chronic hypertension vs. superimposed preeclampsia. STUDY DESIGN: We performed a cross-sectional study from 2015 to 2017 and 42 women with initial diagnosis of superimposed preeclampsia were enrolled in the emergency room. After a 12 week follow up patients were grouped as superimposed preeclampsia (Group A) and uncontrolled chronic hypertension (Group B) according to the American College of Obstetricians and Gynecologist criteria. A group of 33 healthy women paired by gestational age were included as controls (Group C). Maternal serum levels of sFlt-1 and PlGF were measured at enrollment, and the ratios of the groups were compared. MAIN OUTCOME MEASURES: Superimposed preeclampsia vs. uncontrolled chronic hypertension. RESULTS: After follow-up, group distribution was 30 women in Group A, 12 women in Group B, and 25 women in Group C. The sFlt-1/PlGF ratio was higher in women with superimposed preeclampsia than in women with uncontrolled chronic hypertension (215.5 vs. 9.65, p < 0.001). The control group displayed lower ratio values (3.66, p < 0.001). The sFlt-1 concentration was higher in Group A than in Group B (7564 vs. 1281 pg/mL, p < 0.001) and the PlGF level was lower in Group A (34.39 vs. 169 pg/mL, p < 0.001). CONCLUSIONS: The sFlt-1/PlGF ratio exhibits good performance for the differential diagnosis of superimposed preeclampsia vs. uncontrolled chronic hypertension.

[Hypokalemic paralysis during pregnancy: a report of two cases]. / Parálisis hipocalémica en el embarazo: reporte de dos casos.

The hypokalemic paralysis is a disease characterized by the development of acute muscular weakness, associated to low levels of blood potassium (< 3.5 meq/L). Here we present two cases: in the first one, a 23 years old woman, with 15.5 weeks of gestation has a cuadriplegia associated to blood potassium level of 1.4 meq/L, diagnosed with distal tubular acidosis; she required mechanical ventilation for respiratory paralysis. The medical profile remits with potassium intravenous replacement and the pregnancy ends with a spontaneous abortion. The second case is a 15 years old woman with 26.5 weeks of pregnancy, who suffers a generalized paralysis with blood potassium of 2.7 meq/L, requiring also mechanical ventilation for respiratory paralysis; the final diagnosis was Barterr syndrome, and the medical profile remited after potassium supplement. Her pregnancy got complicated with a severe preeclampsia, enough reason for interrumpting the pregnancy at 29.1 weeks of gestation. In both cases Guilliain-Barre syndrome was ruled out.

[Gestational malaria: HELLP syndrome mistaken diagnosis]. / Paludismo gestacional: confusión del diagnóstico con síndrome HELLP.

Malaria is one of the most important parasitic infections in Mexico and Latin America. Here we report a case of a 21 year-old female with 38.4 weeks of pregnancy and previous hospitalization due to malaria. Showing a thick drop negative test she was referred to Mexico City Hospital de la Mujer with presumptive diagnosis of preeclampsia and HELLP syndrome. During her stay in ICU she developed malarial paroxysm and Plasmodium vivax was identified, conducting to specific therapy.

Reanimación cardiopulmonar y cerebral durante el embarazo. Revisión narrativa / Cardiopulmonary and brain resuscitation during pregnancy. Narrative review

Resumen ANTECEDENTES: La reanimación cardiopulmonar representa el 1 a 2% de los ingresos a las unidades de cuidados intensivos. En 2018, 17.4 por cada 1000 pacientes embarazadas de Estados Unidos requirieron reanimación cardiopulmonar e ingreso a unidades de cuidados intensivos, con mortalidad del 52% posterior al primer día de puerperio. OBJETIVO: Aportar conceptos indispensables de reanimación cardiopulmonar, causas de paro cardiaco materno y difundir algoritmos de atención y respuesta luego de la activación de un código para probable cesárea de urgencia en los cuatro minutos posteriores al paro cardiorrespiratorio, en casos sin retorno a la circulación espontánea. Esto con la finalidad de aumentar la calidad de atención de salud y disminuir los índices de mortalidad materna. METODOLOGÍA: Primera etapa: búsqueda en PubMed de artículos con antigüedad no mayor a cinco años, publicados en inglés o español, Guías de Práctica Clínica de Perinatología Clínica, revisiones sistemáticas y metanálisis. Segunda etapa: algoritmo de búsqueda ("cardiopulmonary resuscitation "[MeSH-Terms] AND "pregnancy" [MeSH-Terms]) AND ((y_5[Filter]) AND (systemati creview[Filter]) AND (english [Filter]) OR spanish [Filter])). RESULTADOS: Se reunieron 35 artículos o páginas web de los que se seleccionaron 19, incluidos 3 libros de texto relacionados con el tema y 3 páginas web gubernamentales. Además, se analizaron otros artículos para complementar el conocimiento del tema. CONCLUSIONES: El reconocimiento del colapso materno y la oportuna respuesta del personal de salud permitirán una reanimación cardiopulmonar de alta calidad; por esto debe fomentarse la capacitación al personal de salud.

Abstract BACKGROUND: Cardiopulmonary resuscitation accounts for 1% to 2% of intensive care unit admissions. In 2018, 17.4 per 1000 US pregnant patients requiring cardiopulmonary resuscitation were admitted to intensive care units, with mortality of 52% after the first postpartum day. OBJECTIVE: To provide essential concepts of cardiopulmonary resuscitation, causes of maternal cardiac arrest and to disseminate algorithms of care and response after activation of a code for probable emergency cesarean section within four minutes after cardiorespiratory arrest, in case of failure to return to spontaneous circulation. The aim is to increase the quality of health care and reduce maternal mortality rates. METHODOLOGY: First stage: search in PubMed of articles not older than five years, published in English or Spanish, Clinical Practice Guidelines of Clinical Perinatology, systematic reviews, and meta-analyses. Second stage: search algorithm ("cardiopulmonary resuscitation "[MeSH-Terms] AND "pregnancy" [MeSH-Terms]) AND ((y_5[Filter]) AND (systematic creview[Filter]) AND (english [Filter]) OR spanish [Filter])). RESULTS: Thirty-five articles or web pages were collected from which 19 were selected, including 3 textbooks related to the topic and 3 governmental web pages. In addition, other articles were analyzed to complement knowledge of the topic. CONCLUSIONS: Recognition of maternal collapse and timely response by health care personnel will enable high-quality cardiopulmonary resuscitation; therefore, training of health care personnel should be encouraged.

Variables ecocardiográficas de disfunción sistólica y diastólica en pacientes con preeclampsia con criterios de severidad / Echocardiographic variables of systolic and diastolic dysfunction in women with preeclampsia with severity criteria

Resumen OBJETIVO: Describir los valores ecocardiográficos en pacientes con diagnóstico de preeclampsia con criterios de severidad. MATERIALES Y MÉTODOS: Estudio prospectivo, transversal y descriptivo efectuado en pacientes con diagnóstico de preeclampsia con criterios de severidad. Criterios de inclusión: pacientes mayores de 18 años, con diagnóstico de preeclampsia, hospitalizadas en terapia intensiva entre los meses de junio a septiembre del 2022. Criterios de exclusión: pacientes cardiópatas o con procesos sépticos. A todas las pacientes se les practicó un ecocardiograma. Se describieron las variables relacionadas con la función sistólica y diastólica. RESULTADOS: Se estudiaron 20 pacientes; 6 de ellas requirieron ingreso a cuidados intensivos debido a cifras tensionales superiores a 160-90 mmHg. Se encontraron 6 pacientes con lesión renal (creatinina sérica superior a 1.1 mg/dL) y 4 con síndrome de HELLP. En 6 pacientes se estableció el diagnóstico de disfunción sistólica, 4 de ellas con preeclampsia temprana que cumplieron los criterios de severidad y 2 con preeclampsia tardía y misma característica de disfunción sistólica. De las pacientes con preeclampsia con criterios de severidad 10 tuvieron disfunción diastólica; 7 preeclampsia temprana y 3 preeclampsia tardía. CONCLUSIÓN: A pesar de lo pequeño de la muestra se proporciona una visión detallada de la función sistólica y diastólica de pacientes con preeclampsia con criterios de severidad. Queda claro que la valoración sonográfica cardiaca puede tener implicaciones significativas en el pronóstico y en la atención médica personalizada de cada paciente.

Abstract OBJECTIVE: To describe echocardiographic values in patients with a diagnosis of pre-eclampsia with severity criteria. MATERIALS AND METHODS: Prospective, cross-sectional, descriptive study performed in patients with a diagnosis of pre-eclampsia with severity criteria. Inclusion criteria: patients older than 18 years, with a diagnosis of pre-eclampsia, hospitalized in the intensive care unit between June and September 2022. Exclusion criteria: patients with heart disease or septic processes. All patients underwent echocardiography. Variables related to systolic and diastolic function were described. RESULTS: 20 patients were studied; 6 of them required admission to intensive care due to blood pressure higher than 160-90 mmHg. Six patients were found to have renal damage (serum creatinine greater than 1.1 mg/dL) and 4 with HELLP syndrome. Systolic dysfunction was diagnosed in 6 patients, 4 with early preeclampsia meeting the severity criteria and 2 with late preeclampsia and the same feature of systolic dysfunction. Among patients with pre-eclampsia meeting the severity criteria, 10 had diastolic dysfunction; 7 with early pre-eclampsia and 3 with late pre-eclampsia. CONCLUSION: Despite the small sample size, a detailed view of systolic and diastolic function in patients with pre-eclampsia with severity criteria is provided. It shows that cardiac sonographic assessment may have significant implications for prognosis and personalized medical care for each patient.

Cardiomiopatía por estrés con membrana de oxigenación extracorpórea V-A durante el puerperio. Reporte de un caso y revisión de la literatura / Stress cardiomyopathy with extracorporeal oxygenation membrane V-A during the puerperium. Case report and literature review / Cardiomiopatia de estresse com oxigenação por membrana extracorpórea V-A durante o puerpério. Relato de caso e análise literária

Resumen: Se presenta un caso de una mujer de 28 años, primera gesta, embarazo normoevolutivo, quien acudió a atención de parto, se realizó cesárea por falta de progresión. Durante el perioperatorio desarrolló atonía uterina y sangrado (2,000 mL), por lo que se le realizó histerectomía subtotal abdominal, embolización selectiva de vasos pélvicos, transfusión masiva y empaquetamiento pélvico. Evolucionó con vasoplejía y perfil hemodinámico compatible con choque cardiogénico, ecocardiograma transtorácico con disfunción sistólica severa, fracción de eyección de ventrículo izquierdo (FEVI) 18%, contractilidad normal en los tercios basales de la pared lateral. El resto de los segmentos con hipocinesia severa, NT-pro BNP 9,226 pg/mL, troponina de alta sensibilidad 490 pg/mL, electrocardiograma con taquicardia sinusal sin datos de lesión. Se estableció el diagnóstico de Takotsubo (miocardiopatía por estrés). Se colocó membrana de oxigenación extracorpórea (ECMO) V-A y balón de contrapulsación intraaórtica. Desarrolló lesión renal aguda y sobrecarga hídrica, por lo que se inició terapia de sustitución renal. La terapia ECMO se mantuvo durante nueve días, y se egresó a domicilio a los 18 días. El ECMO es una estrategia terapéutica para el soporte hemodinámico del choque cardiogénico incluyendo la cardiomiopatía por estrés; este caso ilustra su utilidad en el puerperio.

Abstract: We present a case of a 28-year-old woman currently in her first pregnancy, normal evolution, who attended delivery care, a cesarean section was performed due to lack of progression. During the perioperative period, she developed uterine atony and bleeding of 2,000 mL, for which she underwent a subtotal abdominal hysterectomy, selective embolization of the pelvic vessels, massive transfusion, and pelvic packing. She evolved with vasoplegia and hemodynamic profile compatible with cardiogenic shock, transthoracic echocardiogram exposes severe systolic dysfunction, LVEF 18%, normal contractility in the basal thirds of the lateral wall, the rest of the segments with severe hypokinesia, NT-pro BNP 9,226 pg/mL, high-sensitivity troponin 490 pg/mL, electrocardiogram whit sinus tachycardia with no evidence of injury, the diagnosis of Takotsubo (stress cardiomyopathy) was established. Extracorporeal membrane oxygenation (ECMO) V-A and intra-aortic balloon counterpulsation were placed. Acute kidney injury developed, and fluid overload, for which renal replacement therapy was started. ECMO therapy was maintained for nine days, and she was discharged home after 18 days. ECMO is an innovative therapeutic strategy for hemodynamic support of cardiogenic shock, including stress cardiomyopathy, and this case illustrates its potential utility in the postpartum period.

Resumo: Apresenta-se o caso de uma mulher de 28 anos, primigesta, gravidez evolução normal, que assistiu ao parto, tendo sido submetida a cesariana por falta de evolução. No período perioperatório, apresentou atonia uterina e sangramento (2,000 mL), sendo submetida a histerectomia abdominal subtotal, embolização seletiva de vasos pélvicos, transfusão maciça e tamponamento pélvico. Evoluiu com vasoplegia e quadro hemodinâmico compatível com choque cardiogênico, ecocardiograma transtorácico com disfunção sistólica grave, FEVE 18%, contratilidade normal nos terços basais da parede lateral, restante dos segmentos com hipocinesia grave, NT-pro BNP 9,226 pg/mL, troponina de alta sensibilidade 490 pg/mL, eletrocardiograma com taquicardia sinusal sem evidência de lesão, foi estabelecido o diagnóstico de Takotsubo (cardiomiopatia de estresse). Colocou-se uma oxigenação por membrana extracorpórea (ECMO) V-A e um balão de contrapulsação intra-aórtico. Evoluiu com lesão renal aguda e sobrecarga hídrica, sendo iniciada terapia renal substitutiva. A terapia com ECMO foi mantida por 9 dias e ele recebeu alta após 18 dias. A ECMO é uma estratégia terapêutica para suporte hemodinâmico do choque cardiogênico, incluindo a cardiomiopatia de estresse, e este caso ilustra sua utilidade no puerpério.

Diferencias en la gravedad del choque hemorrágico en mujeres con placenta previa y acretismo placentario antes y durante la pandemia de COVID-19 / Differences in the degree of hemorrhagic shock in women with placental insertion anomalies before and during the COVID-19 pandemic / Diferenças na gravidade do choque hemorrágico em mulheres com placenta previa e acretismo placentário antes e durante a pandemia de COVID-19

Resumen: Introducción: estudios previos han mostrado una mayor incidencia de todas las causas de hemorragia postparto durante la pandemia de COVID-19. El acretismo placentario es una causa frecuente de hemorragia postparto. Objetivo: determinar las diferencias en la severidad del choque hemorrágico y la cantidad de sangrado en mujeres con diagnóstico del espectro placenta previa-acretismo, antes de la pandemia y durante la pandemia por COVID-19. Material y métodos: en un estudio con cohortes comparativas de mujeres con placenta previa-acretismo, atendidas en el Instituto Nacional de Perinatología, durante el periodo de enero de 2017 a diciembre de 2019, grupo I (prepandemia), y de enero de 2020 a marzo de 2022, grupo II (pandemia), se comparó entre los grupos la cantidad de hemorragia y la clase del choque hemorrágico de acuerdo a ATLS. Resultados: se estudió a 277 mujeres, 211 fueron del grupo I (pre-COVID-19) y 66 del grupo II (COVID-19), se observó una mayor cantidad de sangrado durante la pandemia de COVID versus la fase pre-COVID (2,150.56 ± 1,910.08 mL versus 1,246.34 ± 1,494.1 mL) p = 0.001, existieron diferencias en las proporciones de la gravedad del choque hemorrágico en la fase de pandemia para las clases III y IV. Conclusión: se encontró un incremento en la cantidad de sangrado y gravedad del choque durante la pandemia de COVID-19.

Abstract: Introduction: previous studies have shown an increased incidence of all-cause postpartum hemorrhage during the COVID-19 pandemic. Placental accreta is a frequent cause of hemorrhagic shock. Objective: determine the severity of shock and the amount of bleeding during the COVID-19 pandemic in women diagnosed with placenta previa and placental accreta. Material and methods: in a comparative cohort study of women with placenta previa and accreta treated at the National Institute of Perinatology during the period from January 2017 to December 2019 group I (pre-pandemic) and from January 2020 to March 2022 group II (pandemic) the amount of hemorrhage and the class of hemorrhagic shock according to ATLS were compared between the groups. Results: 277 women were studied, 211 were from group I (pre COVID-19) and 66 from group II (COVID-19). A greater amount of bleeding was observed during the COVID pandemic versus the pre COVID phase (2,150.56 ± 1,910.08 mL vs 1,246.34 ± 1,494.1 mL) p = 0.001, there were differences in the proportions of severity of hemorrhagic shock in the pandemic phase for classes III and IV. Conclusion: an increase in the amount of bleeding and severity of shock was found during the COVID-19 pandemic.

Resumo: Introdução: estudos anteriores mostraram uma maior incidência de hemorragia pós-parto de todas as causas durante a pandemia de COVID-19. O acretismo placentário é uma causa frequente de hemorragia pós-parto. Objetivo: determinar as diferenças na gravidade do choque hemorrágico e na quantidade de sangramento em mulheres diagnosticadas com o espectro de placenta prévia-acretismo antes da pandemia e durante a pandemia de COVID-19. Material e métodos: em um estudo de coorte comparativo de mulheres com placenta prévia e acreta tratadas no Instituto Nacional de Perinatologia durante o período de janeiro de 2017 a dezembro de 2019, grupo I (pré-pandemia) e de janeiro de 2020 a março de 2022, grupo I II (pandemia) a quantidade de sangramento e a classe de choque hemorrágico de acordo com o ATLS foram comparadas entre os grupos. Resultados: foram estudadas 277 mulheres, 211 eram do grupo I (pré-COVID-19) e 66 do grupo II (COVID-19). Observou-se uma maior quantidade de sangramento durante a pandemia de COVID versus a fase pré-COVID (2,150.56 ± 1,910.08 mL vs 1,246.34 ± 1,494.1 ml) p = 0.001, houve diferenças nas proporções da gravidade do choque hemorrágico na fase pandêmica para as classes III e IV. Conclusão: um aumento na quantidade de sangramento e gravidade do choque foi encontrado durante a pandemia de COVID-19.

Lesión traqueal, neumotórax a tensión y neumomediastino, posterior a traqueostomía percutánea en COVID-19: reporte de un caso / Tracheal injury, tension pneumothorax and pneumomediastinum, after percutaneous tracheostomy in COVID-19: report of a case / Lesão traqueal, pneumotórax hipertensivo e pneumomediastino após traqueostomia percutânea em COVID-19: relato de um caso

Resumen: La traqueostomía percutánea es un procedimiento generalmente seguro, aunque no exento de complicaciones, se considera el procedimiento de elección en el paciente crítico con ventilación mecánica prolongada. Se presenta el caso de una mujer con síndrome de insuficiencia respiratoria aguda secundario a neumonía COVID-19 que requirió traqueostomía percutánea por ventilación prolongada. La paciente desarrolló complicaciones que requirieron intervención quirúrgica.

Abstract: Percutaneous tracheostomy is a generally safe procedure, although not without risk of complications, it is considered the procedure of choice in critically ill patients with prolonged mechanical ventilation. We present the case of a woman with acute respiratory failure syndrome secondary to COVID-19 pneumonia who required percutaneous tracheostomy due to prolonged ventilation. The patient developed significant complications that required surgical intervention.

Resumo: A traqueostomia percutânea é um procedimento geralmente seguro, sem ser isenta de complicações, é o procedimento de escolha em pacientes críticos com ventilação mecânica prolongada. Apresentamos o caso de uma mulher com síndrome de insuficiência respiratória aguda por pneumonia por COVID-19 que necessitou de traqueostomia percutânea devido à ventilação prolongada, evoluindo com complicações, resolvidas com intervenção cirúrgica. A adequação dos métodos guiados por ultrassom para evitar a emissão e exposição a aerossóis é analisada.

Estudios de imagen cerebral en el diagnóstico diferencial de enfermedades hipertensivas del embarazo y convulsiones. Reporte de dos casos / Brain imaging studies in the differential diagnosis of patients with hypertensive diseases of pregnancy and seizures. Report of two cases

Resumen ANTECEDENTES: Las crisis convulsivas durante el embarazo son la complicación neurológica más frecuente. Casi todas ocurren en pacientes con epilepsia; cuando aparece la primera durante el embarazo debe establecerse su causa. PRIMER CASO: Paciente de 28 años, con antecedente de hipertensión arterial. Cursaba el puerperio posquirúrgico tardío con preeclampsia sobreagregada cuando tuvo tres crisis convulsivas. Acudió a urgencias y la trataron con sulfato de magnesio: evolucionó a estatus epiléptico. Los estudios de neuroimagen reportaron trombosis de la vena cortical frontal izquierda. Se aplicaron medidas de neuroprotección con adecuada evolución clínica y fue dada de alta del hospital sin déficit motor, sensitivo y cognoscitivo. SEGUNDO CASO: Paciente de 22 años, con antecedente de citopatía mitocondrial del fenotipo oftalmoplejía externa progresiva crónica. Cursaba su primer embarazo sin control prenatal. A la semana 28 sufrió cefalea y una crisis convulsiva. Acudió a urgencias debido a la hipertensión arterial; le prescribieron un antihipertensivo y sulfato de magnesio. Los estudios de neuroimagen reportaron: síndrome de encefalopatía reversible posterior, secundario a eclampsia. Se interrumpió el embarazo y la paciente evolucionó favorablemente. CONCLUSIÓN: Las convulsiones en el embarazo y puerperio en mujeres con enfermedades hipertensivas pueden tener un comportamiento benigno o ser potencialmente mortales. Se propone un algoritmo diagnóstico para tratar a estas pacientes, resalta la sospecha clínica de otras causas de convulsiones como la principal indicación de estudios de imagen.

Abstract BACKGROUND: Seizures during pregnancy are the most frequent neurological complication. Most occur in patients with epilepsy. When the first crisis appears during pregnancy, the cause must be determined. FIRST CASE: A 28-year-old patient with a history of high blood pressure. She was in the late puerperium with over-added preeclampsia when she presented three seizures. She went to the emergency room and started magnesium sulfate, evolving to epileptic status. Neuroimaging studies were performed and reported thrombosis of the left frontal cortical vein. Neuroprotection measures were applied with adequate clinical evolution. She was discharge without motor, sensory and cognitive deficits. SECOND CASE: A 22-year-old patient with a history of a chronic progressive external ophthalmoplegia mitochondrial cytopathy. She was in her first pregnancy without prenatal control. At the 28 week she began with headache and had a seizure. She went to the emergency department with high blood pressure, so she was given antihypertensive therapy and magnesium sulfate. Neuroimaging studies reported a posterior reversible encephalopathy syndrome secondary to eclampsia. The pregnancy was interrupted, and she evolved favorably. CONCLUSION: Seizures in pregnancy and puerperium in women with hypertensive diseases of pregnancy may have benign behavior or may be life-threatening. We propose a diagnostic algorithm for the approach of these patients, highlighting the clinical suspicion of other causes of seizures as the main indication of imaging studies.

Correlación de los valores de sFlt-1, PlGF y su cociente en preeclampsia con criterios de severidad en una Unidad de Cuidados Intensivos / Correlation of the values of sFlt-1, PlGF and its precilampsy court with severity criteria in an Intensive Care Unit / Correlação dos valores de sFlt-1, PlGF e seu coeficiente em preeclampsia com critérios de gravidade em uma Unidade de Terapia Intensiva

Resumen: Introducción: La detección del desequilibrio entre los factores proangiogénicos/antiangiogénico (sFlt-1, PlGF, cociente sFlt-1/PlGF) en la sangre materna son herramientas de pronóstico y diagnóstico en preeclampsia. Objetivo: Determinar la correlación entre los valores sanguíneos de sFlt-1, PlGF, cociente sFlt-1/PlGF y las complicaciones en mujeres con preeclampsia severa. Material y métodos: Se estudiaron a mujeres que ingresaron a la UCI con diagnóstico de preeclampsia con criterios de severidad y se determinaron las variables clínicas y de laboratorio. Las concentraciones séricas de sFlt-1 y PlGF se realizaron con un equipo automático KRYPTOR compact Plus. Resultados: Encontramos que 33.3% fue preeclampsia temprana y 66.7% tardía. Los criterios de severidad fueron: 66.7% crisis hipertensiva y 33.3% encefalopatía hipertensiva. Existió una correlación negativa entre los valores de sFlt-1 y urea, creatinina, proteínas de orina en 24 horas, presión sistólica (TAS) y presión diastólica (TAD). La correlación fue pobre y no fue estadísticamente significativa. Existió una correlación positiva y estadísticamente significativa para ácido úrico. Existió una correlación negativa entre los valores de PlGF en TAS, TAD. No existió correlación entre los valores cociente sFlt-1/PlGF y las variables medidas como TAS, TAD. Conclusiones: Este estudio confirma que es posible identificar un desbalance angiogénico en mujeres con preeclampsia severa. Sin embargo, los marcadores angiogénicos no presentaron una correlación estadísticamente significativa con respecto a las variables clínicas y bioquímicas de preeclampsia en la Unidad de Cuidados Intensivos.

Abstract: Introduction: The detection of the imbalance between proangiogenic/antiangiogenic factors (sFlt-1, PlGF, sFlt-1/PlGF ratio), in maternal blood are prognostic and diagnostic tools in preeclampsia. Objective: To determine the correlation between blood values of (sFlt-1, PlGF, sFlt-1/PlGF ratio) and complications in women with severe preeclampsia. Material and methods: Women who were admitted to the ICU with a diagnosis of preeclampsia with severity criteria were studied, clinical and laboratory variables were determined. Serum concentrations of sFlt-1, PLGF were performed with a KRYPTOR compact Plus automatic equipment. Results: 33.3% were early preeclampsia and 66.7% late. The severity criteria occurred with 66.7% with hypertensive crisis and 33.3% with hypertensive encephalopathy. There was a negative correlation between the values of sFlt-1 and urea, creatinine, urine proteins in 24 hours, systolic pressure (ASD), diastolic pressure (ADT). The correlation was poor and not statistically significant. There was a positive and statistically significant correlation for uric acid. There was a negative correlation between PlGF values in TAS, TAD. There was no correlation between the sFlt-1/PlGF quotient values and the variables measured as TAS, TAD. Conclusions: This study confirms that it is possible to identify an angiogenic imbalance in women with severe preeclampsia. However, the angiogenic markers did not show a statistically significant correlation, with respect to the clinical and biochemical variables of preeclampsia in the Intensive Care Unit.

Resumo: Introdução: A detecção de desequilíbrio entre fatores pró-angiogênicos/antiangiogênicos (sFlt-1, PlGF, coeficiente sFlt-1/PlGF) no sangue materno são ferramentas de prognóstico e diagnóstico na pré-eclâmpsia. Objetivo: Determinar a correlação entre os valores sanguíneos de (sFlt-1, PlGF, coeficiente sFlt-1/PlGF) e complicações em mulheres com pré-eclâmpsia grave. Material e métodos: Foram estudadas mulheres admitidas na UTI com diagnóstico de pré-eclâmpsia com critérios de gravidade, determinou-se variáveis clínicas e laboratoriais. As concentrações séricas de sFlt-1, PLGF foram realizadas com um equipamento automático KRYPTOR compact Plus. Resultados: 33.3% eram pré-eclâmpsia precoce e 66.7% tardia. Os critérios de gravidade ocorreram com 66.7% com crise hipertensiva e 33.3% com encefalopatia hipertensiva. Houve correlação negativa entre os valores de sFlt-1 e uréia, creatinina, proteínas da urina em 24 horas, pressão sistólica (PAS) e pressão diastólica (PAD). A correlação foi ruim e estatisticamente não significante. Houve uma correlação positiva e estatisticamente significante para o ácido úrico. Encontrou-se uma correlação negativa entre os valores de PLGF no TAS, TAD. Não houve correlação entre os valores do quociente sFlt-1/PlGF e as variáveis medidas como PAS e PAD. Conclusões: Este estudo confirma que é possível identificar um desequilíbrio angiogênico em mulheres com pré-eclâmpsia grave. No entanto, os marcadores angiogênicos não apresentaram correlação estatisticamente significante com relação às variáveis clínicas e bioquímicas da pré-eclâmpsia na unidade de terapia intensiva.

Instrumento de una Guía de Práctica Clínica INPer: Protocolo de diagnóstico y tratamiento en reanimación cardiopulmonar durante el embarazo / Instrumentation of a Clinical Practice Guideline at the Instituto Nacional de Perinatología: Diagnosis and treatment protocol in Cardiopulmonary resuscitation during pregnancy

La reanimación cardiopulmonar (RCP) es la estrategia de tratamiento del paro cardiorrespiratorio, la cual tiene una incidencia durante el embarazo de 1:20,000. Existen cambios sustanciales en la rutina de la reanimación cardiopulmonar durante el embarazo. Justificación: Proporcionar al personal un instrumento para el abordaje médico de las pacientes embarazadas en paro cardiorrespiratorio. Objetivo: Simplificar el manejo en forma de guía, adaptada al Instituto Nacional de Perinatología (INPer), para las pacientes embarazadas que se encuentren en paro cardiorrespiratorio. Esta guía pone a disposición del personal las recomendaciones basadas en la mejor evidencia disponible con la intención de estandarizar el manejo de estas pacientes. La guía presenta un cuadro con intervenciones básicas para la prevención de un paro cardiorrespiratorio, así como un algoritmo intrahospitalario de soporte de vida cardiopulmonar inicial y avanzado en el embarazo.

The cardiopulmonary resuscitation (CPR) is the treatment for the cardiopulmonary arrest. During pregnancy the incidence of the cardiopulmonary arrest is 1:20,000. There are many differences between the routine cardiopulmonary resuscitation procedure and the cardiopulmonary resuscitation in pregnant women. Justification: Provide to the medical and paramedical personal the better tools for the primary and advanced medical treatment for the cardiopulmonary arrest during pregnancy. The majority of the patients at the National Institute of Perinatology (INPer) are pregnant women, so is very important that all the medical personal knows how to implement correctly the cardiopulmonary resuscitation procedure. Objective: To simplify the treatment of the cardiopulmonary arrest using a guideline, that was designed accord with the characteristics of the patients attended at the INPer. This guideline is a practical clinical tool for easy application. The recommendations of the guideline represent the better clinical evidence identified at the medical literature, with the objective of standardize the treatment of pregnant women in cardiopulmonary arrest.

Enfermedad renal crónica durante el embarazo: curso clínico y resultados perinatales en el Instituto Nacional de Perinatología Isidro Espinosa de los Reyes / Chronic renal disease during pregnancy: clinical course and perinatal outcomes at the Instituto Nacional de Perinatología Isidro Espinosa de los Reyes

Objetivo: Describir las características clínicas y demográficas de las pacientes que ingresaron al Instituto Nacional de Perinatología con enfermedad renal crónica y embarazo, así como también describir el curso clínico del embarazo, de la enfermedad renal y los resultados perinatales obtenidos. Diseño del estudio: Estudio de cohorte simple donde se revisaron los expedientes de todas las pacientes con diagnóstico de enfermedad renal crónica y embarazo admitidas al Instituto Nacional de Perinatología durante el periodo de enero de 2004 a diciembre de 2007; para el análisis estadístico se obtuvieron media y desviación estándar para las variables numéricas y proporciones para las variables nominales y categóricas. Resultados: Se estudiaron 47 pacientes de las cuales el promedio de edad fue de 25.8 ± 5.6 años, el promedio de edad gestacional de inicio del control prenatal fue de 17.6 ± 6.2 semanas y la incidencia de enfermedad renal crónica y embarazo de nuestro estudio fue de 0.33%. La etiología de la enfermedad renal crónica más frecuente fue la hipertensión arterial sistémica crónica en el 38.3% de los casos. El estadio de la enfermedad renal crónica al momento del ingreso fue: leve en el 31.9% de las pacientes, moderada en el 29.8% y severa en el 38.3%. El promedio de creatinina sérica al ingreso fue de 2.7 (± 1.90) mg/dL y posterior a la resolución fue de 4.4 (± 2.80) mg/dL. La depuración de creatinina al ingreso fue en promedio de 33.8 (± 20.58) mL/min y posterior a la resolución fue de 24.1 (± 15.69) mL/min. Se presentó anemia en el 57.4% de estas pacientes. El 46.8% de las embarazadas presentó deterioro en la función renal y el 27.6% desarrollaron preeclampsia. Se requirió de diálisis en nueve casos (19.1%). La vía de resolución más frecuente fue por cesárea en el 76.6% de los casos. Las indicaciones maternas para la interrupción del embarazo más frecuentes fueron preeclampsia (27.7%) y deterioro de la función renal (14.9%). Las indicaciones fetales correspondieron al 23.4% siendo las más frecuentes la restricción del crecimiento intrauterino (10.6%) y el estado fetal no confiable (6.4%). El destino fetal posterior a la resolución más frecuente fue la terapia neonatal en el 59.6% de los casos, con una supervivencia global del 83%. Conclusión: Las complicaciones perinatales más frecuentes fueron preeclampsia, deterioro de la función renal, anemia, prematurez y restricción del crecimiento intrauterino.

Objective: To describe the clinical and demographic characteristics of patients admitted to the Instituto Nacional de Perinatología with chronic kidney disease and pregnancy, as well as to describe the clinical course of pregnancy, kidney disease and perinatal outcomes achieved. Study design: Simple cohort study in which records were reviewed of all patients diagnosed with chronic kidney disease and pregnancy admitted to the Instituto Nacional de Perinatología, during the period of January 2004 to December 2007; statistical analysis we obtained mean and standard deviation for numeric variables and proportions for nominal and categorical variables. Results: Evaluate a total of 47 patients in which the average age was 25.8 ± 5.6 years, mean gestational age of initiation of prenatal care was 17.6 ± 6.2 weeks. The incidence of chronic kidney disease and pregnancy of our study was 0.33%. The most common etiology of chronic kidney disease was sistemic chronic hypertension in 38.3% of cases. The stage of chronic kidney disease at the time of admission was: mild in 31.9% of patients, moderate in 29.8% and severe in 38.3%. The mean serum creatinine at admission was 2.7 (± 1.90) mg / dL and after delivery 4.4 (± 2.80) mg / dL. The creatinine clearance average at admission was 33.8 (± 20.58) mL / min and after the resolution of pregnancy was 24.1 (± 15.69) mL / min. Anemia was present in 57.4% of these patients. 46.8% of pregnant women showed deterioration in renal function and 27.6% developed preeclampsia. Dialysis was required in nine cases (19.1%). The most common way to conclude pregnancy was by cesarean section in 76.6% of cases, and the maternal preeclampsia, was the indication more frequent in (27.7%) and then renal function impairment (14.9%). Fetal indications were 23.4% and the most common was intrauterine growth restriction (10.6%) then fetal unreliable stage (6.4%). The most common destination after birth was the neonatal therapy in 59.6% of cases, and the overall survival of 83%. Conclusion: The most common perinatal complications were preeclampsia, impaired renal function, anemia, prematurity and intrauterine growth restriction.

Evaluación inicial de las cardiopatías congénitas con cortocircuito en el embarazo / Initial evaluation of congenital heart with short-circuit in pregnancy

Existe en la actualidad un gran número de mujeres con cardiopatía congénita, las cuales alcanzan la edad reproductiva gracias a las correcciones quirúrgicas que se realizan en edades pediátricas. Las mujeres que llegan al embarazo luego de haber recibido tratamiento quirúrgico correctivo o paliativo generalmente tienen un buen resultado perinatal y con pocos riesgos maternos. En otras pacientes, el diagnóstico primario de cardiopatías congénitas se realiza en una consulta de rutina durante el embarazo y la gran mayoría de éstas requieren un manejo especializado; de igual forma existe un tercer grupo con diagnóstico previo, pero que nunca ha recibido tratamiento quirúrgico. La gran mayoría de estas pacientes requieren de un manejo especializado durante el embarazo, el trabajo de parto y el puerperio por un equipo médico interdisciplinario que debe incluir cardiólogos, internistas e intensivistas que comprendan los cambios fisiológicos asociados al embarazo, obstetras con conocimiento de la fisiopatología de la malformación cardiaca y anestesiólogos con un enfoque de la paciente obstétrica en el marco de su enfermedad cardiovascular. El objetivo de esta revisión es mostrar las características clínicas y hemodinámicas de pacientes embarazadas con las cardiopatías congénitas con cortocircuito intracardiaco; se mencionan los mecanismos de diagnóstico y los parámetros a evaluar para determinar el pronóstico durante el embarazo.

There is now a large number of women with congenital heart disease, which reach reproductive age due to surgical corrections done during childhood. Women who become pregnant after receiving corrective or palliative surgery generally have a good perinatal outcome and few maternal risks. In other patients the primary diagnosis of congenital heart disease is performed, in a routinely query during pregnancy, there is a third group with previous diagnosis but who have never undergone surgery, and the vast majority of these require specialized handling during pregnancy, labor and the postpartum period by a multidisciplinary medical team, which should include cardiologists, internists, and intensivists who understand the physiological changes associated with pregnancy, and obstetricians with knowledge of the pathophysiology of cardiac malformations. Finally a group anesthesiologists with training on the obstetric patients in the context of cardiovascular disease.The aim of this review is to show the clinical and hemodynamic characteristics of pregnant patients with congenital heart disease with intracardiac short-circuit,the diagnostic mechanisms and parameters to be evaluated to determine the prognosis for pregnancy.

Lupus eritematoso sistémico activo durante el embarazo. Curso clínico y pronóstico en una Unidad de Cuidados Intensivos / Active systemic lupus erythematosus during pregnancy. Clinical course and prognosis in an Intensive Care Unit

Introducción: El lupus eritematoso sistémico complica aproximadamente uno de cada 1,000 embarazos de la población latinoamericana. De 10 a 25% de pacientes con enfermedad reumática sistémica acuden a los servicios de urgencias y requieren ser hospitalizados y un 30% de éstos requieren de cuidados intensivos. La incidencia de muerte en pacientes con lupus eritematoso sistémico en unidades de cuidados intensivos puede ser de hasta 79%. Objetivo: Describir el curso clínico y el pronóstico de mujeres embarazadas con diagnóstico de lupus eritematoso sistémico activo, que ingresaron a una Unidad de Cuidados Intensivos. Material y métodos: Durante el periodo de enero 2005 a diciembre de 2009 se estudió a 23 pacientes embarazadas con diagnóstico de lupus eritematoso sistémico activo, atendidas en la Unidad de Cuidados Intensivos del Instituto Nacional de Perinatología, para describir su curso clínico y pronóstico. Resultados: Se utilizó estadística descriptiva a través de frecuencias y porcentajes y medidas de tendencia central, con los siguientes hallazgos: restricción de crecimiento intrauterino en nueve casos (39.1%), parto pretérmino en 18 pacientes (78.2%), preeclampsia severa en siete casos (30.4%) y muerte materna en cuatro (17.4%). Se encontraron diferencias significativas de medias, en las cifras de proteinuria y ácido úrico entre las pacientes con parto pretérmino, RCIU y muerte fetal y aquellas que no los presentaron. Conclusiones: El lupus eritematoso sistémico activo es un padecimiento que puede producir desenlaces perinatales adversos en forma importante, como lo es el parto pretérmino y la preeclampsia severa; por tal motivo, consideramos imperativo que la vigilancia y tratamiento de estas pacientes se lleve a cabo por un equipo interdisciplinario en el momento y sitio adecuados con la finalidad de disminuir estas complicaciones.

Introduction: Systemic lupus erythematosus (SLE) complicates one of every 1,000 pregnancies in Latin American population, 10 to 25% of, patients with systemic rheumatic disease, require hospitalization while attend to emergency room, and 30% of these require intensive care treatment. The death incidence in SLE patients in intensive care units can be up to 79%. Objective: Describe the clinical course and prognosis of pregnant women who were diagnosed with active systemic lupus erythematosus (ASLE), admitted to an intensive care unit. Material and methods: Between January 2005 and December 2009 at the intensive care unit of the Instituto Nacional de Perinatología (INPer), 23 pregnant patients diagnosed and treated with ASLE, were studied to determine, the clinical course and prognosis. Results: High frequencies in intrauterine growth restriction (39%), preterm delivery (80%), fetal death (13%), severe preeclampsia (30.4%) and maternal death (17%) were seen. Also found significant differences in proteinuria, uric acid, IUGR and fetal death in those patients who had preterm birth and those who had not. Conclusions: Active systemic lupus erythematosus associated with pregnancy, has high frequency of adverse perinatal outcomes, like premature delivery and severe preeclampsia. So it has to be considered, that this type of patients must be controlled and treated in the appropriate facility by an interdisciplinary professional team, with the aim of consider diminishing those complications.