Jorge arvajal C

Effectiveness of antenatal corticosteroids in reducing respiratory disorders in late preterm infants: randomised clinical trial

Objetivos: Determinar la efectividad de los corticosteroides en reducir los trastornos respiratorios en recién nacidos entre las 34-36 semanas de gestación. Diseño: Investigación clínica aleatorizada triple ciego. Escenario: Hospital terciario docente del noreste de Brasil. Participantes: Mujeres entre las 34-36 semanas de embarazo, en riesgo inminente de parto prematuro. Intervenciones: Betametasona 12 mg o placebo intramuscular por dos días consecutivos. Principales medidas de resultado: El resultado primario fue la incidencia de trastornos respiratorios (síndrome de distrés respiratorio y taquipnea transitoria del recién nacido). Los resultados secundarios incluyen la necesidad de apoyo ventilatorio, morbilidad neonatal y duración de la estadía en el hospital. Resultados: 320 mujeres fueron aleatorizadas, 163 de las cuales fueron asignadas al grupo tratamiento y 157 a los controles. El análisis final incluye 143 y 130 infantes, respectivamente. La tasa de síndrome de distrés respiratorio fue baja (dos [1,4%] en el grupo corticosteroide; uno [0,8%] en el grupo placebo; p=0,54), mientras la tasa de taquipnea transitoria fue alta en ambos grupos (34 [24%] vs 29 [22%]; p=0,77). No hubo reducción en el riesgo de morbilidad respiratoria con uso corticosteroides, incluso después de ajuste por subgrupos de edad gestacional (34-34+6 semanas, 35-35+6 semanas y ≥36 semanas). El riesgo ajustado de morbilidad respiratoria fue 1,12 (IC 95% 0,74-1,70). La necesidad de apoyo ventilatorio fue cercana a 20% en ambos grupos. No hubo diferencia en morbilidad neonatal (88 [62%] vs 93 [72%]; p=0,08) o en duración de la estadía en el hospital entre los dos grupos (5,12 vs 5,22 días; p=0,87). La fototerapia debido a ictericia fue requerida con menor frecuencia en los bebés cuyas madres recibieron corticosteroides (RR 0,63; IC 95% 0,440,91). Conclusiones: El tratamiento antenatal con corticosteroides a las 34-36 semanas de embarazo, no reduce la incidencia de trastornos respiratorios en los recién nacidos. Registro del Estudio: Clinical Trials NCT00675246

The change in the epidemiological profile of maternal mortality in Chile will hinder the fulfillment of the Millennium 5th goal

BACKGROUND: The death of women during pregnancy childbirth or puerperium remains a serious public health problem worldwide. Chile is committed to comply with the Millennium 5th Goal of reducing maternal mortality to 9.9/100000 live births in 2015. AIM: To analyze trends in maternal mortality in Chile during 2000-2009. MATERIAL AND METHODS: A descriptive population analysis using raw data obtained from the yearbooks of the National Institute of Statistics of Chile. Maternal mortality causes of death and age of the dead mothers were evaluated. The causes of maternal death were classified according to the tenth revision of International Classification of Diseases. Trend studies were performed using Pearson correlation analysis. RESULTS: In the studied period there were no significant changes in maternal mortality and fertility. The five major causes of maternal death were concurrent diseases hypertension abortion obstetric embolism and postpartum hemorrhage. Mortality associated with concurrent illness showed a significant upward trend (r = 0.656 p = 0.035). Abortion associated mortality had a significant downward trend (r = -0.712 p = 0.023). The group of women 40 years and older significantly increased its birth rate (r = 0.930 p < 0.001) this group showed the highest maternal mortality especially in association with concurrent diseases. CONCLUSIONS: The increased birth rate occurring in women over 40 years old and its larger maternal mortality rate probably will hinder the fulfillment of the Millennium 5th goal in Chile.BACKGROUND The death of women during pregnancy, childbirth or puerperium, remains a serious public health problem worldwide. Chile is committed to comply with the Millennium 5th Goal of reducing maternal mortality to 9.9/100,000 live births in 2015. AIM To analyze trends in maternal mortality in Chile during 2000-2009. MATERIAL AND METHODS A descriptive population analysis using raw data obtained from the yearbooks of the National Institute of Statistics of Chile. Maternal mortality, causes of death and age of the dead mothers were evaluated. The causes of maternal death were classified according to the tenth revision of International Classification of Diseases. Trend studies were performed using Pearson correlation analysis. RESULTS In the studied period there were no significant changes in maternal mortality and fertility. The five major causes of maternal death were concurrent diseases, hypertension, abortion, obstetric embolism and postpartum hemorrhage. Mortality associated with concurrent illness showed a significant upward trend (r = 0.656, p = 0.035). Abortion associated mortality had a significant downward trend (r = -0.712, p = 0.023). The group of women 40 years and older significantly increased its birth rate (r = 0.930, p < 0.001), this group showed the highest maternal mortality, especially in association with concurrent diseases. CONCLUSIONS The increased birth rate occurring in women over 40 years old and its larger maternal mortality rate, probably will hinder the fulfillment of the Millennium 5th goal in Chile.

GUÍA PARA EL ANÁLISIS CRÍTICO DE ESTUDIOS QUE EVALÚN EXÁMENES DIAGNÓSTICOS

SUMMARY The critical analysis of articles on diagnostic test allows to recognize their clinical utility analyzing their validity, results and applicability. This document present the methodology to obtain the objective.

Reducción de la fecundidad y envejecimiento de la población de mujeres chilenas en edad fértil: 1990-2004

BACKGROUND Chile is in the advanced stage of demographic transition with a low natural growth and a progressively aging population. AIM To analyze births by range of maternal age and to establish if population aging is expressed in the womens fertile age range. MATERIAL AND METHODS Trend analysis of births and age-specific birth rates in the period 1990-2004, in the Chilean women population of reproductive age. Raw data were obtained from the Vital Statistics Yearbooks of the National Institute of Statistics. Trends were studied by linear regression and Generalized Estimating Equation (GEE). RESULTS The general trend of births descended significantly from 1999 to 2004 (r: -0.996; p <0.001). Births significantly decreased in the range of ages from 20 to 34 years. There was an increase in the range of ages from 35 to 44 and from 10 to 14 years. The age-specific birth rate declined in all ranges, with the exception of women aged 10 to 14 years. The number of women increased significantly at all age ranges, except for the 20-24 year-old range where no significant change was observed and the 25-29 year-old range that experienced a significant reduction. CONCLUSIONS In the period from 1990 to 2004, there was a significant reduction of births and age-specific birth rates in Chile. There was also an increased birth rate among women aged 35 to 44 years and an aging of the fertile women population.

PAUTAS DE MANEJO CLÍNICO DE EMBARAZOS GEMELARES

SUMMARY Multiple pregnancy has high risk of perinatal morbidity and mortality. Since antenatal care has been demonstrated as a useful tool in reducing perinatal risk, we decided to elaborate evidence based clinical guidelines, to facilitate antenatal care of women carrying multiple pregnancies. We reviewed recent publications, clinical guidelines and text books to obtain necessary information. Here we present a list of recommendations, and the quality of supporting evidence, about six items: a. Assisted reproduction; b. Diagnosis of multiple pregnancy; c. General care of multiple pregnancy; d. Preterm Labor; e. Specific complications of multiple pregnancy; f. Timing of delivery and labor management.

EVALUACIÓN FETAL INTRAPARTO: ANÁLISIS CRÍTICO DE LA EVIDENCIA

SUMMARY Fetal intrapartum surveillance is one of the greatest obstetrics’ challenges. To improve the limited diagnostic accuracy of intrapartum fetal heart rate monitoring, complementary intrapartum fetal surveillance tests have been developed. Here we present a critical appraisal of those complementary intrapartum fetal surveillance tests, regarding diagnostic accuracy and clinical usefulness, to recommend any of them as a gold standard in current clinical practice.

EL DIAGNÓSTICO PRENATAL DE CARDIOPATÍAS CONGÉNITAS MEJORA EL PRONÓSTICO NEONATAL

SUMMARY Congenital malformations are the main cause of neonatal death; in most of the cases they correspond to major congenital heart defects. Congenital heart defects have an incidence of 8/1,000 live newborns, corresponding half of them to major congenital heart defects. To reduce the mortality of this group of children routine evaluation of fetal heart anatomy by ultrasound is recommended, allowing neonatal care, of those fetuses with congenital heart defects, at the appropriate time and place. Here we attempt to verify if prenatal diagnosis of a congenital heart defect improves the perinatal outcome compare to postnatal diagnosis. We observed that the prenatal diagnosis of congenital heart defects, does not improve the neonatal outcome, except in certain congenital ductus dependent heart defects (transposition of great vessels, hypoplastic left heart syndrome and aortic coarctation), where a better outcome has been shown for those new born with prenatal diagnosis. We recommend routine evaluation of the fetal heart during prenatal ultrasound, and to carry out fetal echocardiography in high risk groups or when a defect is suspected.

Tamizaje y prevención de pre-eclampsia guiado por Doppler de arterias uterinas: revisión sistemática de la literatura

Antecedentes: La pre-eclampsia (PE) es una enfermedad grave asociada al embarazo con una prevalencia de ~3%. La identificacion de las mujeres en riesgo podria mejorar el resultado materno y perinatal. La estimacion de riesgo individual de PE permitiria ofrecer un tratamiento preventivo para esta [ej: aspirina (AAS)]. Se ha descrito el Doppler de arterias uterinas (DAUt) en primer y segundo trimestre como un metodo de tamizaje de PE. Objetivo: Recopilar la evidencia disponible sobre el uso del DAUt para predecir PE y los potenciales beneficios de la profilaxis con AAS. Metodo: Se realizo una busqueda en Pubmed, revisandose 32 trabajos originales, 5 revisiones y 1 meta-analisis. La calidad de los estudios se analizo segun guias de analisis critico de publicaciones cientificas y de estudios que evaluan examenes diagnosticos. Resultados: Luego de analizar todos los trabajos y resultados, se encuentra que la mejor capacidad diagnostica del DAUt es la medicion del indice de pulsatilidad promedio por via transvaginal entre las 20 y 24 semanas en poblacion de alto riesgo para predecir PE de inicio precoz. Utilizando el p95 como valor de corte se logra sensibilidad: 85%, especificidad: 95%, valor predictivo positivo: 18%. AAS se ha mostrado efectiva en la prevencion de PE en poblacion de riesgo, con disminuciones marginales (~17%) en su incidencia y sin disminuir la morbimortalidad materna ni perinatal. Conclusion: El DAUt es un metodo util para el tamizaje de PE precoz en pacientes embarazadas seleccionadas por factores de riesgo, pero se necesitan mas estudios evaluando la utilidad del AAS como profilaxis de PE en dicha poblacion.

EPIGNATHUS: REPORTE DE UN CASO Y REVISIÓN DE LA LITERATURA

SUMMARY Epignahtus is an uncommon form of teratoma, located in the oropharynge, which protrudes through the mouth and that is associated with a high mortality during the neonatal period. The key to a successful outcome in managing of the airway obstruction is early prenatal diagnosis and the controlled execution of the EXIT (ex-utero intrapartum treatment) to secure the fetal airway. We report a case of a giant epignathus and the application of EXIT procedure, in which time to secure an airway is provided while preserving uteroplacental gas exchange.

EMBARAZO GEMELAR CON UN ÓBITO: RESCATE MEDIANTE TRANSFUSIÓN INTRAVASCULAR INTRAUTERINA

RESUMENSe presenta el caso de un embarazo gemelar monocorial con un gemelo muerto a las 24 semanasde embarazo, manejado en forma expectante luego de efectuada una transfusion intrauterina de rescate.La paciente evoluciono con analisis de coagulacion dentro de limites normales y pruebas de bienestarfetal satisfactorias. A las 35 semanas de embarazo se asistio un parto vaginal eutocico; el recien nacido,tuvo un examen fisico y una ultrasonografia cerebral sin hallazgos patologicos al tercer dia de vida.PALABRAS CLAVE: Embarazo gemelar monocorial, trasfusion intrauterina de rescateSUMMARYWe report a monochorionic twin pregnancy with a single intrauterine demise at 24 weeks, whorequired a rescue intrauterine trasfusion. At 35 weeks of pregnancy occurs an spontaneus vaginaldelivery, the baby was healthy with a normal cerebral ultrasound scan.KEY WORDS: Monochorial twin pregnancy, rescue intrauterine transfusion Caso Clinico *Trabajo leido en la sesion del martes 20 de julio de 2004 de la Sociedad Chilena de Obstetricia y Ginecologia.