Pathologic ventricular hypertrophy in the offspring of diabetic mothers: a retrospective study.

AIMS: Diabetes in pregnant women is increasing and with that the complications in their offspring. We studied our population of diabetic mothers (2003-2005) for pathologic ventricular hypertrophy (PVH). METHODS AND RESULTS: In our retrospective study of all 87 diabetic pregnancies (92 neonates), 16 were type 1, 17 were type 2, and 54 were gestational diabetes (GD). Haemoglobin glycated (HbA1c) median was 5.8% (5.3-6.5): 17 with HbA1c above normal 2 with congenital heart disease (CHD) and six with PVH. A total of 75 neonates were normal, five had CHD, and 12 had PVH (1/12 died post-natally, 1/12 stillborn, 2/12 required premature delivery, 8/12 normal). The 16 type 1 pregnancies resulted in three neonates with CHD and in 50% PVH, including one death, one premature Cesarean section because of PVH. The 17 neonates of type 2 pregnancies showed in one CHD and in 25% PVH. Of the 54 GD pregnancies, one had CHD and one had PVH. CONCLUSION: Pregnancies of both type 1 and 2 diabetes carry an increased risk for foetal development of PVH compared with those with GD. The insufficient effect of preventive glycaemia controls leads to conclude that although no definite predictive parameters for malignant outcome can be presented, close monitoring of these pregnancies may prevent perinatal catastrophes.

Influence of Assisted Reproductive Techniques in the occurrence of weight discordance in twin gestations

Background:There is no actual evidence that the ART are directly related to the occurrence of weight discordance. In some studies, ART-­‐conceived twin pregnancies are at greater risk than non-­‐ART-­‐conceived ones for pregnancy complications and adverse perinatal outcome: the incidences of pregnancy-­‐induced hypertension, uterine bleeding, premature contractions, IUGR, fetal death, discordance, and cesarean section were significantly higher. Discordance rate was elevated (25.3% vs.17.0%) among ART twins, which can increase perinatal risk (increased incidence of SGA and NICU admission). Other studies say that perinatal and neonatal morbidity, gestational age at delivery, and birth weight are not affected by ART. Regarding the first trimester ultrasound, some studies didn’t notice significant differences in CRL disparity or birth weight discordance between spontaneous and ART-­‐ conceived dichorionic twin pregnancies. In ART-­‐conceived dichorionic twin pregnancies, CRL disparity may be associated with birth weight discordance. In some studies, CRL discordance in twin pregnancies in the first trimester was a frequent finding. Objectives: To analyze the association of the ART in the occurrence of weight discordance in the pregnancies between 2010 and 2013 in the Hospital Universitari de Girona Doctor Josep Trueta, and to describe the proportion of diagnosis of growth discordance in the first trimester by the ultrasonography technology. Methods: A retrospective cohort study will be performed in those patients with twin pregnancies between 2010 and 2013, within the Hospital Universitari de Girona Doctor Josep Trueta (HUJT). A retrospective and descriptive study will be done in those cases with discordance weight in the moment of the birth, in which the CRL will be studied in the first trimester ultrasound, describing the percentage of discordance detected in that moment. The general characteristics of the sample are going to be analyzed by Logistic RegressionInfluenceof

Influence of Assisted Reproductive Techniques in the occurrence of weight discordance in twin gestations

Background:There is no actual evidence that the ART are directly related to the occurrence of weight discordance. In some studies, ART-­‐conceived twin pregnancies are at greater risk than non-­‐ART-­‐conceived ones for pregnancy complications and adverse perinatal outcome: the incidences of pregnancy-­‐induced hypertension, uterine bleeding, premature contractions, IUGR, fetal death, discordance, and cesarean section were significantly higher. Discordance rate was elevated (25.3% vs.17.0%) among ART twins, which can increase perinatal risk (increased incidence of SGA and NICU admission). Other studies say that perinatal and neonatal morbidity, gestational age at delivery, and birth weight are not affected by ART. Regarding the first trimester ultrasound, some studies didn’t notice significant differences in CRL disparity or birth weight discordance between spontaneous and ART-­‐ conceived dichorionic twin pregnancies. In ART-­‐conceived dichorionic twin pregnancies, CRL disparity may be associated with birth weight discordance. In some studies, CRL discordance in twin pregnancies in the first trimester was a frequent finding. Objectives: To analyze the association of the ART in the occurrence of weight discordance in the pregnancies between 2010 and 2013 in the Hospital Universitari de Girona Doctor Josep Trueta, and to describe the proportion of diagnosis of growth discordance in the first trimester by the ultrasonography technology. Methods: A retrospective cohort study will be performed in those patients with twin pregnancies between 2010 and 2013, within the Hospital Universitari de Girona Doctor Josep Trueta (HUJT). A retrospective and descriptive study will be done in those cases with discordance weight in the moment of the birth, in which the CRL will be studied in the first trimester ultrasound, describing the percentage of discordance detected in that moment. The general characteristics of the sample are going to be analyzed by Logistic RegressionInfluenceof

Influence of Assisted Reproductive Techniques in the occurrence of weight discordance in twin gestations

Background:There is no actual evidence that the ART are directly related to the occurrence of weight discordance. In some studies, ART-­‐conceived twin pregnancies are at greater risk than non-­‐ART-­‐conceived ones for pregnancy complications and adverse perinatal outcome: the incidences of pregnancy-­‐induced hypertension, uterine bleeding, premature contractions, IUGR, fetal death, discordance, and cesarean section were significantly higher. Discordance rate was elevated (25.3% vs.17.0%) among ART twins, which can increase perinatal risk (increased incidence of SGA and NICU admission). Other studies say that perinatal and neonatal morbidity, gestational age at delivery, and birth weight are not affected by ART. Regarding the first trimester ultrasound, some studies didn’t notice significant differences in CRL disparity or birth weight discordance between spontaneous and ART-­‐ conceived dichorionic twin pregnancies. In ART-­‐conceived dichorionic twin pregnancies, CRL disparity may be associated with birth weight discordance. In some studies, CRL discordance in twin pregnancies in the first trimester was a frequent finding. Objectives: To analyze the association of the ART in the occurrence of weight discordance in the pregnancies between 2010 and 2013 in the Hospital Universitari de Girona Doctor Josep Trueta, and to describe the proportion of diagnosis of growth discordance in the first trimester by the ultrasonography technology. Methods: A retrospective cohort study will be performed in those patients with twin pregnancies between 2010 and 2013, within the Hospital Universitari de Girona Doctor Josep Trueta (HUJT). A retrospective and descriptive study will be done in those cases with discordance weight in the moment of the birth, in which the CRL will be studied in the first trimester ultrasound, describing the percentage of discordance detected in that moment. The general characteristics of the sample are going to be analyzed by Logistic RegressionInfluenceof

Neonatal lupus erythematosus with congenital heart block and severe heart failure due to myocarditis and endocardititis of the mitral valve.

We report a case of neonatal lupus erythematosus (NLE) with congenital heart block and severe myocardial failure, which was followed from the 25th week of gestation because of fetal bradycardia. The child was delivered at the 37th week of gestation by elective cesarean section because of echocardiographically documented heart enlargement, pericardial effusion and moderate insufficiency of the mitral and tricuspid valves. In spite of immediate pacing, intubation and supportive treatment, the newborn developed progressive heart failure. Echocardiography showed endocarditis of the mitral valve and diffuse myocarditis. The heart failure resolved under steroid treatment. Our experience supports the early use of steroids in treating myocarditis due to NLE. Intrauterine steroid treatment in the presence of fetal hydrops and congenital heart block is discussed.

Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil

PURPOSE: To evaluate changes to the pelvic floor of primiparous women with different delivery modes, using three-dimensional ultrasound. METHODS: A prospective cross-sectional study on 35 primiparae divided into groups according to the delivery mode: elective cesarean delivery (n=10), vaginal delivery (n=16), and forceps delivery (n=9). Three-dimensional ultrasound on the pelvic floor was performed on the second postpartum day with the patient in a resting position. A convex volumetric transducer (RAB4-8L) was used, in contact with the large labia, with the patient in the gynecological position. Biometric measurements of the urogenital hiatus were taken in the axial plane on images in the rendering mode, in order to assess the area, anteroposterior and transverse diameters, average thickness, and avulsion of the levator ani muscle. Differences between groups were evaluated by determining the mean differences and their respective 95% confidence intervals. The proportions of levator ani muscle avulsion were compared between elective cesarean section and vaginal birth using Fisher's exact test. RESULTS: The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm², respectively, versus 12.4 cm² in the Control Group (elective cesarean). Avulsion of the levator ani muscle was observed in women who underwent vaginal delivery (3/25), however there was no statistically significant difference between cesarean section and vaginal delivery groups (p=0.5). CONCLUSION: Transperineal three-dimensional ultrasound was useful for assessing the pelvic floor of primiparous women, by allowing pelvic morphological changes to be differentiated according to the delivery mode.

Obstetric outcomes in the second birth of women with a previous caesarean delivery: a retrospective cohort study from Peru

PURPOSE: To examine obstetric outcomes in the second birth of women who had undergone a previous cesarean delivery. METHODS: This was a large hospital-based retrospective cohort study. We included pregnant women who had a previous delivery (vaginal or cesarean) attending their second birth from 2001 to 2009. Main inclusion criteria were singleton pregnancies and delivery between a gestation of 24 and 41 weeks. Two cohorts were selected, being women with a previous cesarean delivery (n=7,215) and those with a vaginal one (n=23,720). Both groups were compared and logistic regression was performed to adjust for confounding variables. The obstetric outcomes included uterine rupture, placenta previa, and placental-related complications such as placental abruption, preeclampsia, and spontaneous preterm delivery. RESULTS: Women with previous cesarean delivery were more likely to have adverse outcomes such as uterine rupture (OR=12.4, 95%CI 6.8-22.3), placental abruption (OR=1.4, 95%CI 1.1-2.1), preeclampsia (OR=1.4, 95%CI 1.2-1.6), and spontaneous preterm delivery (OR=1.4, 95%CI 1.1-1.7). CONCLUSIONS: Individuals with previous cesarean section have adverse obstetric outcomes in the subsequent pregnancy, including uterine rupture, and placental-related disorders such as preeclampsia, spontaneous preterm delivery, and placental abruption.

Spontaneous rupture of renal angiomyolipoma during pregnancy

Renal angiomyolipoma is a benign tumor, composed of adipocytes, smooth muscle cells and blood vessels. The association with pregnancy is rare and related with an increased risk of complications, including rupture with massive retroperitoneal hemorrhage. The follow-up is controversial because of the lack of known cases, but the priorities are: timely diagnosis in urgent cases and a conservative treatment when possible. The mode of delivery is not consensual and should be individualized to each case. We report a case of a pregnant woman with 18 weeks of gestation admitted in the emergency room with an acute right low back pain with no other symptoms. The diagnosis of rupture of renal angiomyolipoma was established by ultrasound and, due to hemodinamically stability, conservative treatment with imaging and clinical monitoring was chosen. At 35 weeks of gestation, it was performed elective cesarean section without complications for both mother and fetus.

Pregnancy in women undergoing hemodialysis: case series in a Southeast Brazilian reference center

PURPOSE: To describe maternal and neonatal outcomes in pregnant women undergoing hemodialysis in a referral center in Brazilian Southeast side.METHODS: Retrospective and descriptive study, with chart review of all pregnancies undergoing hemodialysis that were followed-up at an outpatient clinic of high- risk prenatal care in Southeast Brazil.RESULTS: Among the 16 women identified, 2 were excluded due to follow-up loss. In 14 women described, hypertension was the most frequent cause of chronic renal failure (half of cases). The majority (71.4%) had performed hemodialysis treatment for more than one year and all of them underwent 5 to 6 hemodialysis sessions per week. Eleven participants had chronic hypertension, 1 of which was also diabetic, and 6 of them were smokers. Regarding pregnancy complications, 1 of the hypertensive women developed malignant hypertension (with fetal growth restriction and preterm delivery at 29 weeks), 2 had acute pulmonary edema and 2 had abruption placenta. The mode of delivery was cesarean section in 9 women (64.3%). All neonates had Apgar score at five minutes above 7.CONCLUSIONS: To improve perinatal and maternal outcomes of women undergoing hemodialysis, it is important to ensure multidisciplinary approach in referral center, strict control of serum urea, hemoglobin and maternal blood pressure, as well as close monitoring of fetal well-being and maternal morbidities. Another important strategy is suitable guidance for contraception in these women.

Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal

PURPOSE: It was to analyse the most critical areas in Obstetrics and to suggest measures to reduce or avoid the situations most often involved in these disputes. METHODS: Obstetrics cases submitted to the Medico-legal Council since the creation of the National Institute of Legal Medicine and Forensic Sciences in 2001 until 2011 were evaluated. A comprehensive characterization, determination of absolute/relative frequencies, hypothesis of a linear trend over the years and the association between each parameter was done. RESULTS: The analysis has shown no significantly linear trend. The most common reasons for disputes were perinatal asphyxia (50%), traumatic injuries of the newborn (24%), maternal sequelae (19%) and issues related to prenatal diagnosis and/or obstetric ultrasound (5.4%). Perinatal asphyxia showed no significantly linear trend (p=0.58) and was usually related to perinatal deaths or permanent neurologic sequelae in newborn children. Traumatic injuries of the newborn, mostly related to instrumented deliveries, shoulder dystocia or vaginal delivery in breech presentation, has shown a significantly increased linear trend (p<0.001), especially related to instrumented deliveries. The delay/absence of cesarean section was the clinical procedure questioned in a significantly higher number of cases of perinatal asphyxia (68.7%) and of traumatic lesions of the newborn due to instrumented deliveries (20.5%). CONCLUSION: It is important to improve and correct theoretical/practical daily clinical performance in these highlighted areas, in order to reduce or even avoid situations that could end up in medico-legal litigations.

Estimation of Fetal Weight during Labor: Still a Challenge

Objective To evaluate the accuracy of fetal weight prediction by ultrasonography labor employing a formula including the linear measurements of femur length (FL) and mid-thigh soft-tissue thickness (STT). Methods We conducted a prospective study involving singleton uncomplicated term pregnancies within 48 hours of delivery. Only pregnancies with a cephalic fetus admitted in the labor ward for elective cesarean section, induction of labor or spontaneous labor were included. We excluded all non-Caucasian women, the ones previously diagnosed with gestational diabetes and the ones with evidence of ruptured membranes. Fetal weight estimates were calculated using a previously proposed formula [estimated fetal weight = [1] 1687.47 + (54.1 x FL) + (76.68 x STT). The relationship between actual birth weight and estimated fetal weight was analyzed using Pearson's correlation. The formula's performance was assessed by calculating the signed and absolute errors. Mean weight difference and signed percentage error were calculated for birth weight divided into three subgroups: < 3000 g; 3000-4000g; and > 4000 g. Results We included for analysis 145 cases and found a significant, yet low, linear relationship between birth weight and estimated fetal weight (p < 0.001; R2 = 0.197) with an absolute mean error of 10.6%. The lowest mean percentage error (0.3%) corresponded to the subgroup with birth weight between 3000 g and 4000 g. Conclusions This study demonstrates a poor correlation between actual birth weight and the estimated fetal weight using a formula based on femur length and mid-thigh soft-tissue thickness, both linear parameters. Although avoidance of circumferential ultrasound measurements might prove to be beneficial, it is still yet to be found a fetal estimation formula that can be both accurate and simple to perform.

Risk factors for excess weight loss and hypernatremia in exclusively breast-fed infants

Data were prospectively obtained from exclusively breast-fed healthy term neonates at birth and from healthy mothers with no obstetric complication to determine risk factors for excess weight loss and hypernatremia in exclusively breast-fed infants. Thirty-four neonates with a weight loss > or = 10% were diagnosed between April 2001 and January 2005. Six of 18 infants who were eligible for the study had hypernatremia. Breast conditions associated with breast-feeding difficulties (P < 0.05), primiparity (P < 0.005), less than four stools (P < 0.001), pink diaper (P < 0.001), delay at initiation of first breast giving (P < 0.01), birth by cesarean section (P < 0.05), extra heater usage (P < 0.005), extra heater usage among mothers who had appropriate conditions associated with breast-feeding (P < 0.001), mean weight loss in neonates with pink diaper (P < 0.05), mean uric acid concentration in neonates with pink diaper (P < 0.0001), fever in hypernatremic neonates (P < 0.02), and the correlation of weight loss with both serum sodium and uric acid concentrations (P < 0.02) were determined. Excessive weight loss occurs in exclusively breast-fed infants and can be complicated by hypernatremia and other morbidities. Prompt initiation of breast-feeding after delivery and prompt intervention if problems occur with breast-feeding, in particular poor breast attachment, breast engorgement, delayed breast milk "coming in", and nipple problems will help promote successful breast-feeding. Careful follow-up of breast-feeding dyads after discharge from hospital, especially regarding infant weight, is important to help detect inadequate breast-feeding. Environmental factors such as heaters may exacerbate infant dehydration.

Racial inequalities and perinatal health in the southeast region of Brazil

Few studies are available about racial inequalities in perinatal health in Brazil and little is known about whether the existing inequality is due to socioeconomic factors or to racial discrimination per se. Data regarding the Ribeirão Preto birth cohort, Brazil, whose mothers were interviewed from June 1, 1978 to May 31, 1979 were used to answer these questions. The perinatal factors were obtained from the birth questionnaire and the ethnic data were obtained from 2063 participants asked about self-reported skin color at early adulthood (23-25 years of age) in 2002/2004. Mothers of mulatto and black children had higher rates of low schooling (£4 years, 27.2 and 38.0%) and lower family income (£1 minimum wage, 28.6 and 30.4%). Mothers aged less than 20 years old predominated among mulattos (17.0%) and blacks (14.0%). Higher rates of low birth weight and smoking during pregnancy were observed among mulatto individuals (9.6 and 28.8%). Preterm birth rate was higher among mulattos (9.5%) and blacks (9.7%) than whites (5.5%). White individuals had higher rates of cesarean delivery (34.9%). Skin color remained as an independent risk factor for low birth weight (P < 0.001), preterm birth (P = 0.01), small for gestational age (P = 0.01), and lack of prenatal care (P = 0.02) after adjustment for family income and maternal schooling, suggesting that the racial inequalities regarding these indicators are explained by the socioeconomic disadvantage experienced by mulattos and blacks but are also influenced by other factors, possibly by racial discrimination and/or genetics.