Erika Padrón

Control de gestación en inmigrantes

El fenomeno de la inmigracion ha supuesto un impacto en la atencion a la salud de la poblacion. En Espana la poblacion inmigrante representa hoy en dia, aproximadamente el 8% de su poblacion total. Esta poblacion en su mayoria procede de paises de baja renta, y su procedencia y distribucion es diversa. La poblacion inmigrada se caracteriza por ser joven, sana, y con capacidad de adaptacion a los cambios, pero sus condiciones sociales, economicas y laborales, con frecuencia son precarias y favorecen la vulnaribilidad a la enfermedad. A pesar de que el numero de inmigrantes de sexo varon es globalmente superior al de mujeres, el porcentaje de inmigrantes de sexo femenino es cada vez mayor. Este incremento de poblacion inmigrante femenina trae como consecuencia la aparicion de necesidades especificas en atencion sanitaria, sobre todo en lo que a su salud sexual y reproductiva se refiere. A esto debemos anadir un incremento sustancial de patologias, prevalentes en los paises de origen como la anemia, tuberculosis, desnutricion, hemoglobinopatias, co-sanguinidad, hipocalcemia, hepatitis B y/o C, infecciones de transmision sexual, enfermedades infecciosas transmitidas por artropodos como enfermedad de Chagas y otras parasitosis, asi como mutilaciones genitales. El objetivo de este capitulo es analizar los factores que dificultan el control de la gestacion en la poblacion inmigrante, asi como establecer pautas de actuacion en la consulta de control de gestacion, insistiendo en la educacion sanitaria y la prevencion durante el embarazo, considerando la aparicion de enfermedades poco comunes, relacionadas con algunos de estos colectivos.

Obstetric and perinatal outcome in women with twin pregnancy and gestational diabetes

Objective: The aim of this study was to evaluate pregnancy complications and obstetric and perinatal outcomes in women with twin pregnancy and GDM. Study Design: An observational multicentre retrospective study was performed and 534 pregnant woman and 1068 twins infants allocated into two groups, 257 with GDM and 277 controls, were studied. Main Outcome Measures: Pregnant women characteristics, hypertensive complications, preterm delivery rate, mode of delivery and birthweight were analysed. Results: Pregnant women with GDM were older (p < 0.001) and had higher body mass index (p < 0.001) than controls. GDM was associated with higher risk of prematurity in twin pregnancy (odds ratio 1.64, 95% confidence interval [1.14–2.32], p = 0.005). This association was based on the association with other pregnancy complications. Birthweight Z-scores were significantly higher in the GDM group (p = 0.02). The rate of macrosomia was higher in the GDM group (p = 0.002) and small for gestational age (SGA) babies were significantly less frequent (p = 0.03). GDM was an independent predictor of macrosomia (p = 0.006). Conclusion: The presence of GDM in twin pregnancy was associated with a higher risk of hypertensive complications, prematurity and macrosomia, but significantly reduces the risk of SGA infants. Prematurity was related to the presence of other associated pregnancy complications.

Effect of pregestational diabetes mellitus on first trimester placental characteristics: Three-dimensional placental volume and power Doppler indices

OBJECTIVE To investigate whether pregestational diabetes mellitus (DM) induces changes in vascular placental development detectable at first trimester. METHODS This was a prospective case-control study in 69 women with pregestational DM and 94 controls undergoing first-trimester combined screening for aneuploidies. Maternal characteristics, fetal nuchal translucency thickness, maternal serum pregnancy-associated plasma protein A (PAPP-A) and free β human chorionic gonadotrophin (β-hCG) were evaluated. Three-dimensional ultrasound was used to measure placental volume and three dimensional power Doppler (3D-PD) placental vascular indices including: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). Pregnancy-associated hypertensive complications (PAHC) and perinatal outcomes were analyzed. The total group of diabetic women and the group of diabetic women without PAHC were compared separately with the control group. RESULTS 3D-PD placental vascular indexes were significantly lower in women with DM than in controls (VI p = 0.007, FI p = 0.003 and VFI p = 0.04). These differences remained on excluding cases with PAHC in the DM group. No differences were found in placental volumes between the DM group and controls. Serum PAPP-A levels were also lower in diabetic women (p < 0.02) and negatively correlated with the degree of maternal metabolic control at first trimester. CONCLUSIONS Pregestational DM induces demonstrable alterations in first trimester placental development, with significantly reduced placental vascularization indices and PAPP-A values. This effect is independent of the later development of PAHC.

First trimester placental volume and vascular indices in pregnancies complicated by preeclampsia

To analyze placental volume and vascularization at first trimester in women with pre‐eclampsia, and secondarily, the effect of maternal characteristics on placental development and perinatal outcomes.

The effect of customized growth charts on the identification of large for gestational age newborns

Objective: To determine the effect of using customized vs. standard population birthweight curves to define large for gestational age (LGA) infants. Methods: We analyzed data obtained from 2,097 singleton pregnancies using three different methods of classifying newborn birthweight: standard population curves, British or Spanish customized curves. We recorded maternal characteristics, proportion of LGA newborns when using each method, percentage of LGA according to one method but not for the others, and concordance between the different methods. Results: The proportion of LGA newborns according to Spanish customized curves was significantly lower than that calculated using either standard general population birthweight curves or British curves (p < 0.001). A third (33.9%) of the infants classified as LGA according to the general population method were adequate for gestational age (AGA) when the Spanish customized curves were used, and 18.5% of non-LGA were LGA according to customized curves (p < 0.001). Concordance between the different models high, but on excluding AGA the concordance coefficient was low (Cohen’s κ <0.4). Conclusions: The use of customized curves allows differentiation between constitutional LGA and cases of fetal overgrowth, leading to a decrease in the rate of both false-positives and negatives as well as the overall proportion of LGA babies.

Application of Customized Birth Weight Curves in the Assessment of Perinatal Outcomes in Infants of Diabetic Mothers

Objective: To determine whether the use of customized curves (CC) allows better detection of large- (LGA) or small-for-gestational age (SGA) infants at risk of adverse perinatal morbidity than non-CC in women with diabetes mellitus (DM). Material and Methods: A model of CC was applied to all infants of diabetic mothers (IDM) who attended the Hospital Universitario Materno Infantil de Canarias between 2008 and 2011. We compared perinatal outcomes of IDM classified as LGA or SGA by non-CC versus CC. Results: One of 4 LGA was appropriate for gestational age (AGA) by CC (false-positive rate: 25%) and 30% of SGA by CC were not identified by non-CC (false-negative rate). False-positive LGA and SGA showed similar perinatal outcomes to AGA infants. The rates of cesarean section, cephalopelvic disproportion, total fetal distress and shoulder dystocia were significantly higher in false-negative LGA than in AGA by CC (p < 0.004, p < 0.02, p < 0.04 and p < 0.04, respectively). Fetal distress was higher in false-negative SGA than in AGA by CC (p < 0.03). Discussion: In pregnancies complicated by DM, the use of CC allowed more accurate identification of LGA and SGA infants at high risk of perinatal morbidity than non-CC.

Customized weight curves for Spanish fetuses and newborns

Abstract Objectives: To construct a model of customized birthweight curves for use in a Spanish population. Materials and methods: Data of 20 331 newborns were used to construct a customized birthweight model. Multiple regression analysis was performed with newborn weight as the dependent variable and gestational age (GA), sex and maternal (M) weight, height, parity and ethnic origin as the independent variables. Using the new model, 27 507 newborns were classified as adequate for GA (AGA), large for GA (LGA) or small for GA (SGA). The results were compared with those of other customized and non-customized models. Results: The resulting formula for the calculation of optimal neonatal weight was: Optimum weight (g) = 3289.681 + 135.413*GA40–14.063*GA402–0.838*GA403 + 113.889 (if multiparous) + 165.560 (if origin = Asia) + 161.550 (South America) + 67.927 (rest of Europe) +109.265 (North Africa) + 9.392*Maternal-Height + 4.856*Maternal-Weight–0.098*Maternal-Weight2 + 0.001*Maternal-Weight3 + 67.188*Sex + GA40*(6.890*Sex + 9.032 (If multiparous) +0.006*Maternal-Height3 + 0.260*Maternal-Weight) + GA402 (−0.378*Maternal-Height – 0.008*Maternal-Height2) + GA403 (−0.032*Maternal-Height). Weight percentiles were obtained from standard data using optimum weight variation coefficient. Agreement between our customized model and other Spanish models was “good” (κ = 0.717 and κ = 0.736; p < 0.001). Conclusions: Our model is comparable to other Spanish models, but offers the advantage of being customized, updated and freely available on the web. The 30.6% of infants classified as SGA using our model would be considered as AGA following a non-customized model.

First and second trimester screening for large for gestational age infants.

Abstract Objectives: To find the best early predictor model for fetal growth and large for gestational age (LGA) infants considering clinical, ultrasonographic and biochemical variables. Method: In 2097 singleton pregnancies at first trimester, we evaluated maternal characteristics, PAPP-A and ß-HCG proteins, fetal nuchal translucency thickness and uterine artery pulsatility index (UtA-PI). At second trimester fetal ultrasound biometry and UtA-PI were then measured. The relationships between birth weight and LGA and maternal characteristics, first and second trimester variables, and all variables combined, were studied. The performance of screening was determined by receiver operating characteristic curves analysis. Results: Stepwise regression analysis showed that in the prediction of birthweight percentile there were significant contributions from all maternal factors, PAPP-A and Ut-A PI in the first trimester, and fetal biometric variables in the second trimester. Maternal charateristics combined with PAPP-A, β-hCG, fetal NT and uterine artery PI identified 30.2 % LGA (FPR 10%). The combined model reached a sensitivity of 41.2% (FPR 10%) and 56.2% (FPR 20%). Conclusions: Sensitivity of the screening for LGA improves significantly after addition of second trimester ultrasound measurements to first trimester variables and maternal characteristics.

Value of Placental Volume and Vascular Flow Indices as Predictors of Early and Late Preeclampsia at First Trimester

Introduction: We evaluated the utility of placental volume and three-dimensional (3D) vascular flow indices to predict early and late preeclampsia. Material and Methods: In 1,004 pregnancies attending routine care, we recorded first-trimester screening program for aneuploidy (FTSA) parameter and measured uterine artery pulsatility index (uterine-a PI). Placental volume and vascular flow indices were obtained using 3D power Doppler and VOCAL techniques. Results: Placental volume was lower and uterine-a PI was higher in both early and late preeclampsia groups versus nonaffected pregnancies. The prediction rate of placental volume in late preeclampsia was higher than that of uterine-a PI (AUROC 0.707 vs. 0.581, p < 0.011). The inclusion of placental volume improved significantly the prediction rate of total and late preeclampsia in the models constructed with maternal characteristics, FTSA, and uterine-a PI (AUROC 0.745 vs. 0.818, p < 0.004, and 0.740 vs. 0.812, p < 0.012, respectively). The inclusion of vascular indices did not improve the predictive value of these models. Discussion: Placental volume was an independent predictor of total, early, and late preeclampsia and its inclusion in combined predictive models significantly improved prediction rates. Reduced placental volume observed at first trimester in women with early and late preeclampsia suggests that these entities are the clinical expression of a similar pathophysiological process.

Value of placental volume and vascular flow indices as predictors of intrauterine growth retardation

OBJECTIVE To evaluate the utility of first-trimester placental volume and vascular flow indices to predict intrauterine growth retardation (IUGR). STUDY DESIGN In 1004 singleton pregnancies attending routine care we recorded maternal characteristics, biophysical and biochemical factors included in the first trimester screening for aneuploidy (FTSA) and uterine artery pulsatility index (PI). Placental volume, Vascularization Index, Flow Index and Vascularization Flow Index were obtained. Customized curves were used to define IUGR. We compared pregnancies with and without IUGR. The performance of different predictive models was described by the areas under the receiver operator characteristic (AUROC) curve. Predictive models of IUGR were compared using a two by two approach and subset analysis was performed. RESULTS Placental volume and all vascular indices were significantly lower (p<0.001, p≤0.01), and uterine artery PI higher (p<0.001), in pregnancies with IUGR, with and without associated pre-eclampsia. RESULTS obtained in the analysis of homogeneous subsets showed that the effectiveness of combined predictive models for IUGR improved significantly after adding vascular indices or placental volume to maternal characteristics, FTSA variables and uterine artery PI (AUROC curve value 0.703 (95% CI 0.663-0.744) versus 0.720 (95% CI 0.681-0.759) and 0.735 (95% CI 0.696-0.733), respectively). The most effective model at first trimester was that which included only maternal characteristics, uterine a-PI and placental volume, similar to that of the most complex model built with all the factors analyzed in this study AUROC curve value 0.735 (95% CI 0.696-0.773). CONCLUSIONS Placental volume and vascular indices were predictors factors of IUGR at first trimester. The effectiveness of combined predictive models for IUGR increased significantly after adding these factors, but the sensitivity of these models was too low for them to be considered useful in clinical practice.