Enrique Valdés R

ESPECTRO CLÍNICO DE LA PREECLAMPSIA: ESTUDIO COMPARATIVO DE SUS DIVERSOS GRADOS DE SEVERIDAD

RESUMENObjetivo: Comparar los resultados maternos y perinatales en embarazadas que cursaron conpreeclampsia (PE) en sus diversas presentaciones en el periodo 2001 -2005. Material y Metodo: Estudioretrospectivo de 7.205 partos asistidos en la maternidad del Hospital Clinico de la Universidad de Chile. 204mujeres presentaron PE/eclampsia, dividiendose en 3 grupos: PE modera, severa y sindrome de HELLP.Se analizaron las variables clinicas y de laboratorio de la embarazada y del recien nacido. Se compararonestos resultados en los 3 grupos de estudio. Para variables continuas de distribucion normal se empleo elanalisis de varianza (ANOVA). Para variables categoricas se empleo la tabla de contingencia de Chi2 o laprueba exacta de Fisher. Resultados: 80 mujeres presentaron PE moderada (39,2%), 114 PE severa(55,8%) y 10 HELLP (4,9%). Se observaron diferencias significativas en la via de parto, edad gestacional,peso del recien nacido, percentil, morbi-mortalidad neonatal, complicaciones maternas medico-quirurgicasen los grupos de PE severa y HELLP comparados con las PE moderadas. La PE severa tuvo una mayorproteinuria que los otros dos grupos. Asi mismo, se observaron tambien diferencias significativas en elgrupo de sindrome de HELLP en los niveles de enzimas hepaticas, LDH y recuento plaquetario encomparacion con el grupo de las PE moderadas y severas. Conclusion: La PE es una entidad clinica quepuede presentarse en diversos grados de severidad, por lo que su correcta clasificacion de acuerdo acriterios clinicos y de laboratorio, es clave para el tratamiento y pronostico de las pacientes.PALABRAS CLAVES: Preeclampsia, sindrome de HELLP, morbi-mortalidad maternal y neonatalSUMMARYObjective: The aim of this study was to compare maternal and perinatal outcome in pregnant women withthe different spectrum of severity of pre-eclampsia (PE). Methods: A retrospective study in 7205 pregnanciesdelivered at the University of Chile Hospital. 204 pregnant women were diagnosed preeclampsia, whichwere divided in three groups: moderate PE, severe PE, and HELLP syndrome, according to standarddefinitions. The maternal and perinatal outcomes were analyzed between groups and statisticallydifferences were considered when p<0.05. Analyses of variance (ANOVA) and Chi2 or Fisher`s exact testswere used for continuous or categorical variables, respectively. Results: 80 women were moderate PE(39.2%), 114 severe PE (55.8%), and 10 HELLP (4.9%). Rate of cesarean section, birthweight, gestationalage, fetal percentile, neonatal mortality and morbidity and medical and surgical maternal morbidity were

Efectos sobre la función renal fetal y neonatal del tratamiento con antagonista del receptor de angiotensina II en el embarazo: Caso clínico

Fetal renal structure and function can be altered by medications prescribed to pregnant women. We report a chronic hypertensive pregnant woman treated with losartan before and throughout pregnancy. At 30 weeks the patient was referred to our Fetal Medicine Unit due to absent amniotic fluid with normal uterine artery Doppler and fetal growth. During her hospitalization a new scan was performed showing that both fetal kidneys were enlarged and slightly hyperechogenic and placental and fetal artery Doppler showed signs of hypovolemia or increased resistance to feto-placental blood flow. Ductus venosous was normal. The fetus was delivered after three days by caesarean section at 30+4 weeks of gestation due to abnormal fetal heart rate tracing. Following delivery, the preterm newborn was treated for a transient renal failure characterized by anuria-oliguria and high plasma creatinine levels (from 3.8 mg/dL at day 5 to 0.8 mg/dL at 16 days). At 30 days of age, ultrasound showed kidneys of normal form and size. The adverse effects of Angiotensin II receptor antagonists in fetal nephrogenesis and function are discussed.

VIH-SIDA Y EMBARAZO: ACTUALIZACION Y REALIDAD EN CHILE

INTRODUCCIONEl virus de la inmunodeficiencia humana (VIH)es un lentivirus de la familia retrovirus, del cual sehan identificado dos tipos: VIH-1, el mas frecuente,que conduce al sindrome de inmunodeficienciaadquirida y a la muerte; VIH-2, principalmente enhabitantes o visitantes del Africa Occidental, trans-mitido con menor eficacia, mas indolente, pero quetambien termina en SIDA y muerte. Ambos tiposson de estructura viral y genomica muy similar.El virion de VIH consta de cuatro capas basicas:– Un nucleo cilindrico con dos bandas identicasde RNA unidas por la proteina p9, copias de laenzima transcriptasa reversa y proteinas nucleares.– Capa de proteinas de la capside constituidopor el antigeno p24.– Capa de la matriz compuesta por el antigenop17, que sirve como revestimiento interno de laenvoltura viral externa.– Doble capa de lipidos de la envoltura, deriva-da de la membrana plasmatica de la celula hues-ped. Embebida en ella se encuentra la proteinatransmembrana gp41, donde se ancla la glicopro-teina de superficie Gp120, que sirve como sitio deinsercion primaria de las particulas de VIH a lasmoleculas de superficie en las celulas huespedes.Mecanismo de replicacion viralEl genoma de VIH-1 es relativamente pequeno,constituido por genes que codifican proteinas es-tructurales, reguladoras y accesorias. La particulaviral se une a las celulas huesped susceptible, queincluyen linfocitos T, monocitos, macrofagos, celu-las dendriticas foliculares y celulas de microglia. Seproduce un enlace de alta afinidad entre la gp 120de la superficie viral y la molecula receptora CD4 dela celula huesped. Las membranas celulares sefusionan y el virus se introduce, quedando al des-cubierto su RNA. Se postula que despues de lainfeccion ocurre una regulacion descendente de laexpresion de CD4 de la superficie de la celula infec-tada, lo que impide una superinfeccion, permite unareplicacion eficaz del virus y aminora las posibilida-des de muerte celular temprana o apoptosis. Enuna etapa temprana, se activa la transcriptas re-versa viral y otros factores, formandose copiascompletas de DNA de doble hebra a partir del RNAviral. Esta copia de DNA se transporta al nucleocelular y se une al DNA de la celula huesped me-diante la integrasa viral conformando el llamadoprovirus. Este puede permanecer latente duranteun periodo, no conociendose bien los factores delhuesped que determinan el periodo de latencia. Encelulas activadas, la transcripcion proviral generaRNA genomico para su incorporacion a nuevosviriones y RNA mensajero cuya traduccion generaproteinas estructurales y varias proteinas regula-doras y accesorias que facilitan la replicacion, en-samblaje y liberacion viral.El sistema inmunitario del adulto tiene varioscomponentes criticos para la infeccion por VIHcomo son los linfocitos B y T, celulas presentadorasde antigenos, antigenos de histocompatibilidadmayor (tipo I y II), celulas natural killer, citoquinas ycomplemento. Siempre antes de una infeccion oestimulacion antigenica, los linfocitos B se encuen-tran como celulas “ingenuas”. Despues de suestimulacion, forman dos subgrupos especificos

Impétigo herpetiforme recurrente: manejo exitoso con ciclosporina

Impetigo Herpetiformis is a high-risk gestational skin disease that represents a risk for both the mother and offspring. Its management is based on multisystemic support and maternal steroid therapy. When these measures are insufficient to control the disease, the association of ciclosporine to the treatment has been proposed. We report a 24 yearold woman with a 16 weeks pregnancy, that presented with Impetigo Herpetiformis. The disease was refractory to the use of steroids, the patient had a metabolic decompensation and a dehydration with electrolyte imbalance. Therefore, treatment with ciclosporine was initiated and a rapid regression of the lesions was observed. Gestation was maintained, with a good perinatal outcome (Rev Med Chile 2005; 133: 1071-74). (Key Words: Adrenal cortex hormones; Cyclosporine; Impetigo)

PREVALENCIA DE COLONIZACIÓN POR STREPTOCOCCUS AGALACTIAE (GRUPO B) DURANTE EL EMBARAZO PESQUISADO EN MEDIO DE CULTIVO SELECTIVO

RESUMENStreptococcus agalactiae es el principal agente bacteriano responsable de la sepsis neonatal. Paraevitar la infeccion perinatal se recomienda su pesquisa en la region vagino-anal durante el tercertrimestre, y tratamiento antibiotico durante el trabajo de parto en las gestantes colonizadas. El objetivode este estudio es conocer la prevalencia de colonizacion del Streptococcus agalactie en la poblacion deembarazadas controladas en la maternidad del Hospital Clinico de la Universidad de Chile, en el periodocomprendido entre el 1 de marzo y el 31 de mayo de 2003. Se tomo cultivo selectivo de Todd Hewitt,entre las 35 y 37 semanas de gestacion a 185 embarazadas. Se determino una prevalencia decolonizacion vagino-anal de 14,0%.PALABRAS CLAVE: Streptococcus agalactiae, sepsis neonatalSUMMARYStreptococcus agalactiae is the main bacterial agent in neonatal sepsis. To avoid the perinatalinfection, a vaginal and anal culture in the third trimester is recommended and then treated withantibiotics during labour. The aim of the study was to study the prevalence of Streptococcus agalactiaein pregnant patients in University of Chile Hospital in Santiago. The study period was from March 1 toMay 31 of 2003. Vaginal and anal samples were taken at 35-37 weeks using selective medium (ToddHewitt broth). A total of 185 patients were studied and the prevalence of streptococcus was 14,0%.KEY WORDS: Streptococcus agalactiae, neonatal sepsis

Eficacia de los hipoglicemiantes orales en el control metabólico de pacientes con diabetes mellitus gestacional

Gestational Diabetes is characterized by different degrees of glucose intolerance that produce a series of fetal and perinatal alterations. During many years, in those cases of gestational diabetes that did not respond to nutritional interventions, the use of insulin was a proven treatment to achieve metabolic control and thus a better perinatal outcome. At present, some new oral hypoglycemic drugs, from the family of sulfonylureas and biguanides, have been shown to be safe, of low cost, and apparently effective in the metabolic control of this disease. We review the publications that propose the use of oral hypoglycemic drugs for the metabolic control of gestational diabetes that does not respond to nutritional measures (Rev Med Chile 2008; 136: 915-20). (Key words: Diabetes, gestational; Hypoglycemic agents; Insulin)

Hepatitis aguda viral durante el embarazo

La hepatitis aguda es una enfermedad de baja incidencia durante el embarazo; sin embargo, es una causa importante de ictericia durante el desarrollo de este y en algunos casos presenta un alto riesgo de morbi-mortalidad materno-fetal, siendo la etiologia principalmente viral. El proposito de este articulo es actualizar los conocimientos disponibles en la literatura medica respecto a hepatitis viral durante el embarazo, conocer cuales son los agentes mas prevalentes, via de transmision, riesgo para el binomio madre- hijo y eventual manejo.

Intoxicación aguda con metotrexato usado con fines abortivos: descripción de 2 casos

Acute intoxication with methotrexate, used as an abortive, has not been described in Chile. We report two female patients, aged 15 and 24 years old, who presented with mucositis, erythrodermia, pancytopenia, and elevation of hepatic enzymes. Plasma methotrexate levels confirmed the clinical diagnosis and both patients were treated with high leucovorin doses and management of associated complications. In one patient, pregnancy continued, giving birth to a newborn with cranial, face and limb malformations. The second patient had a late rescue with leucovorin and was discharged with a persistent sensory motor neuropathy. Considering the severity of complications and that patients may deny its use, when there is reasonable clinical suspicion of methotrexate intoxication, leucovorin treatment should be started.

Morbilidad neonatal de los prematuros tardíos en embarazos únicos: estudio de caso-control

Objetivo: Comparar los riesgos de morbilidad neonatal entre los prematuros tardios (PT) y neonatos de termino. Metodo: Estudio de caso control. Se revisan fichas clinicas de partos durante el ano 2007. Se excluyen neonatos con malformaciones congenitas mayores, alteracion neuromuscular, embarazos multiples y aneuploidias. Los casos corresponden a todo PT nacido durante el periodo estudiado y los controles a nacidos de termino en el mismo periodo. Los resultados neonatales fueron obtenidos y los riesgos calculados usando pruebas de Chi cuadrado y exacto de Fisher. Resultados: Se identifican 1536 partos, con una tasa de PT de 7,1% (109 casos), 62 cumplieron con criterios de inclusion. El grupo control consistio en 124 partos de termino. PT presentaron 2 veces mas riesgo de cesarea (p=0,0094) que los de termino. El riesgo de ser admitido en UCIN fue de 88 (p=0,000). Los riesgos de morbilidad neonatal fueron: SDR (OR 23; p=0,000), hipoglicemia (OR 6; p=0,014), hipocalcemia (OR 6; p=0,014), hiperbilirrubinemia (OR 28; p=0,000) y necesidad de fototerapia (OR 23; p=0,000). No hubo diferencias en la presentacion de enterocolitis necrotizante (p=0,478) ni sepsis neonatal (p=0,615). La mortalidad neonatal fue significativamente superior en los PT (p=0,044). Conclusion: Los PT deben ser considerados de alto riesgo en el periodo neonatal. Nuestros resultados son importantes para tomar decisiones clinicas respecto al mejor momento de finalizar un embarazo con riesgo inminente de prematurez.

Evaluación de la Globulina transportadora de Hormonas Esteroidales (SHBG) durante el embarazo como factor predictor de pre-eclampsia y restricción del crecimiento intrauterino.

BACKGROUND Sex-Hormone Binding Globulin (SHBG) may be associated to Pre-eclampsia (PE) and Fetal Growth Restriction (RCIU). AIM To determine if maternal serum SHBG concentrations during the first and second trimesters are predictive biomarkers of Pre-eclampsia and RCIU. PATIENTS AND METHODS Prospective cohort study carried out in the Fetal Medicine Unit, Universidad de Chile Clinical Hospital between January, 2005 and December, 2006. Blood samples were obtained from unselected pregnant women during routine 11-14 week and 22-25 week ultrasound examinations, conforming two different study groups. Posteriorly, serum SHBG concentrations were determined in women who developed Pre-eclampsia, RCIU and their respective controls. RESULTS Fifty five patients were included in the 11-14 weeks group. Nine women that developed PE, 10 that developed RCIU and 36 controls were selected from this group. There were no significant differences in SHBG levels between patients with PE, RCIU or controls (324.7 (26.6), 336.8 (33.9) and 377.5 (24.3) nmol/L, respectively). Fifty four women were included in the 22-25 weeks group. Eight women who developed Pre-eclampsia, 15 who developed RCIU and 31 controls were selected. Again, there were no significant differences in SHBG levels between patients with PE, RCIU or controls (345.5 (151.1), 383.8 (143.4) and 345.5 nmol/l (151.1), respectively). CONCLUSIONS Maternal SHBG serum levels did not predict subsequent development of Pre-eclampsia and RCIU.Background: Sex-Hormone Binding Globulin (SHBG) may be associated to Pre-eclampsia (PE) and Fetal Growth Restriction (RCIU). Aim: To determine if maternal serum SHBG concentrations during the first and second trimesters are predictive biomarkers of Pre-eclampsia and RCIU. Patients and Methods: Prospective cohort study carried out in the Fetal Medicine Unit, Universidad de Chile Clinical Hospital between January, 2005 and December, 2006. Blood samples were obtained from unselectedpregnant women during routine 11-14 week and 22-25 week ultrasound examinations, conforming two different study groups. Posteriorly, serum SHBG concentrations were determined in women who developed Pre-eclampsia, RCIU and their respective controls. Results: Fifty five patients were included in the 11-14 weeks group. Nine women that developed PE, 10 that developed RCIU and 36 controls were selected from this group. There were no significant differences in SHBG levels between patients with PE, RCIU or controls (324.7 (26.6), 336.8 (33.9) and 377.5 (24.3) nmol/L, respectively). Fifty four women were included in the 22-25 weeks group. Eight women who developed Pre-eclampsia, 15 who developed RCIU and 31 controls were selected. Again, there were no significant differences in SHBG levels between patients with PE, RCIU or controls (345.5 (151.1), 383.8 (143.4) and 345.5 nmol/l (151.1), respectively). Conclusions: Maternal SHBG serum levels did not predict subsequent development of Pre-eclampsia and RCIU.