Lluis Cabero Roura

Facing the noncommunicable disease (NCD) global epidemic – The battle of prevention starts in utero – The FIGO challenge

Noncommunicable diseases (NCDs) are responsible for 36 million deaths every year. Of this death toll, nearly 80% (29 million) occur in low- and median-income countries. More than 9 million deaths attributed to NCDs occur in people under 60 years of age. National economies are suffering considerable losses due to premature death or disability to work resulting from heart disease, stroke, and diabetes. The knowledge that in utero and in early childhood certain processes can affect the risk of developing NCDs provides an opportunity to enforce interventions during this critical time, when they may have the greatest effect. Using appropriate protocols, the health-care provider can educate mothers about the risks of certain nutritional and environmental exposures and integrate health promotion on the agenda, as part of the social and economic development. All this could motivate a substantial reduction in the risk of NCDs. Current and future health challenges demand new and changing competencies that should form the basis for education, training, and workforce planning. The International Federation of Gynaecology and Obstetrics (FIGO) is aware of that responsibility and has joined hands with other agencies and organizations that make a considerable effort in providing appropriate prenatal care programs to prevent and treat most of the common preconditioning factors, especially in low-income countries.

Vacunación antigripal en gestantes. Cobertura vacunal y conocimientos y prácticas de los obstetras

BACKGROUND AND OBJECTIVES Women who are pregnant during influenza season have an increased risk of infection and severe clinical disease. Several national and international organizations currently recommend vaccination for pregnant women. We intended to estimate the influenza vaccination rate in a population of postpartum women attended in a tertiary hospital in Barcelona. Moreover, we assessed the knowledge and practice of obstetricians about influenza vaccination during pregnancy. METHODS Two cross-sectional surveys were performed. Postpartum women who delivered from December 2007 to February 2008 were included. The sample of obstetricians was constituted by those who were working in hospital or primary care reference areas. RESULTS Influenza vaccination rate was 4.1%. Healthy women represented 80.5% of our population. The vaccination rate in the group with comorbidities was 3.3%. The providers who recommended the vaccine more frequently were the midwife in 28.9% and the nurse in 18.4%. Among the obstetricians, 20.9% responded that the influenza vaccine was recommended in the first trimester of pregnancy and 65.1% said that it was recommended in the second or third trimester. In relation to practice, only 7% offered the vaccine in the first trimester and 20,9% in the second or third trimester. CONCLUSIONS The influenza vaccination rate in pregnant women in our study is very low. Obstetricians showed a low level of knowledge about the current influenza vaccination recommendations, mainly in the case of first trimester of pregnancy and only few offered the vaccine in their practice.

The prevalence of congenital varicella syndrome after a maternal infection, but before 20 weeks of pregnancy: a prospective cohort study

Objective. To describe the prevalence of congenital varicella syndrome (CVS) within the population of presumably infected pregnant women. Methods. From 1993 to 2006, all women who presented vesicular rash or a suspicious contact were referred and evaluated in a special unit at our center. Those with residual immunity or were serologically negative were precluded from this study. Positive IgM cases underwent monthly ultrasound scans (US), fetal blood (FB) sampling (including IgM anti VZV and virus culture). Amniotic fluid sample for PCR was added to the diagnosis of positive IgM cases after 1997. Results. A total of 276, of the 566 consulted women, tested positive for IgM anti VZV. Seventeen (6%) were excluded because of an unadvised termination of pregnancy and seven (2.55%) miscarried. Only seven (2.7%) were considered highly likely to have a VZV fetal infection. One case showed positive IgM in FB but developed normally. Another fetus showed positive PCR and infection was confirmed post TOP. Four cases that underwent TOP and histochemistry confirmed no more cases. Complete post-natal follow-up was carried out. The asymptomatic infected child grew healthy until the completion of screening tests when it reached 5 years old. Conclusion. The fetal infection rate in this cohort was 0.8%, but the best expected prevalence of CVS, according to our findings, should be 0.39% among infected women. This data should be considered and used during parental counselling.

Use of 3-Dimensional Sonography for Prenatal Evaluation and Follow-up of Fetal Goitrous Hypothyroidism

Objective. Fetal goitrous hypothyroidism is a rare and potentially lethal condition. Consequently, its early diagnosis and treatment improve prognosis. Thyroid hormone measurement in either fetal serum or amniotic fluid implies important risks. Here we present a fetal goiter and the follow‐up procedure, both done by the traditional method and by using 3‐dimensional power Doppler (3DPD) imaging and virtual organ computer‐aided analysis (VOCAL). Methods. A single well‐documented case of fetal goiter was followed weekly from 22 weeks until delivery. Amniocentesis for thyrotropin (TSH) and free thyroxine (T4) measurement as well as levothyroxine injections were performed at every control. In addition to amniocentesis, every control involved a sonographic evaluation, which included standard measurements of the gland and the capture of volume image sets in gray scale and 3DPD. Volume calculation of the gland was done using VOCAL software. Vascularization of the gland was evaluated by the vascularization index (VI) included in the software. Results. With treatment, TSH levels decreased progressively until normalization. Free T4 levels increased toward the end of gestation. Sonographic measurements of the gland volume to estimated fetal weight ratio decreased across treatment as levels of TSH did. The VI clearly depicted the vascular regression of the goiter, decreasing throughout treatment in a consistent way until 24 hours before delivery. Conclusions. Gray scale and 3DPD evaluations of the thyroid gland have been validated under similar circumstances and might be reliable complements to the invasive methods used in the management of this fetal condition.

The role of placental alpha microglobulin-1 amnisure in determining the status of the fetal membranes; its association with preterm birth. Traditions … traditions …

Abstract The integrity of the fetal amnion-chorion is an imperative for the preservation of a normal pregnancy in the human. The diagnosis of the status of the fetal membranes has traditionally been reduced to either intact or ruptured. In the last decades, evidence has accumulated demonstrating that this clinical approach may well be an over simplification. Practically, all maternal organs experienced physiologic or eventually pathologic changes during the length of the gestational period. We propose that the fetal membranes are also significantly impacted by those changes. The accurate, specific, simplified and low-cost diagnosis of the status of the fetal membranes is of critical importance for the assessment of risk to the pregnancy followed by efficient and prompt treatment. The presence of placental alpha macroglobulin-1 in the vagina specifically indicates a disruption in the integrity of the fetal membranes and may indirectly mean increased risk for preterm birth. Further research to properly characterize this marker and its importance in the care of pregnant woman at risk for preterm birth is strongly recommended.

Complicaciones maternas a corto plazo en pacientes con cesárea

Resumen Objetivo Determinar si las pacientes con cesarea tienen un mayor numero de complicaciones que las de parto y describir el tipo de complicaciones observadas. Sujetos y metodos Se revisaron los expedientes de 1.017 pacientes que finalizaron su gestacion en el Hospital Materno-Infantil Vall d’Hebron durante el primer trimestre de 2007. Resultados Para una tasa de cesareas del 22%, la incidencia de complicaciones maternas fue del 18% y del 6% en los partos (riesgo relativo = [RR] 3,1; intervalo de confianza [IC] del 95%, 2,4-15.1). Las complicaciones mas frecuentes fueron la infeccion de herida (7,5%), la transfusion de sangre (5,3%) y la hemorragia (3,1%); la endomiometritis fue mas comun en el grupo de pacientes de parto (el 1,6 frente al 1,3%). Conclusiones La cesarea tiene un riesgo de complicaciones tempranas 3 veces mayor que el parto. La menor incidencia de endomiometritis poscesarea quiza es consecuencia de la profilaxis antibiotica, pero se requieren mas estudios para llegar a una conclusion al respecto.

Directrices para el manejo del parto prematuro espontáneo

Vale la pena señalar que la incidencia de nacimiento prematuro espontáneo (NPE) no ha experimentado cambios debido al mayor número de neonatos en edad gestacional muy temprana, con peso extremadamente bajo al nacer y en los límites de viabilidad que actualmente estamos incluyendo en nuestras estadísticas, situación que no se había producido nunca en las estadísticas previas. La mejora de los cuidados intensivos neonatales está incrementando también la tendencia hacia el parto prematuro electivo e indicar, por último, que el parto a término no constituye per se un buen indicador del resultado final si tenemos en cuenta que cada día de retraso entre las semanas 22 y 28 de gestación aumenta la supervivencia en un 3%, sin necesidad de llegar a término. Por otra parte, el mito de que los tocolíticos funcionan únicamente 48 h surge de la interpretación errónea de un metaanálisis de fármacos betaagonistas, según el cual el período de 48 h fue el único hallazgo sistemático encontrado en los 16 artículos examinados a efectos comparativos. Sin embargo, son muchos los tocolíticos que han demostrado ejercer sus efectos más allá de las 48 h. Respecto al argumento de que ningún tocolítico ha conseguido disminuir la incidencia de morbimortalidad perinatal, hay que señalar que ninguno de los estudios realizados hasta ahora con tocolíticos estuvieron dotados de la potencia estadística (tamaño muestral) suficiente para poder demostrar ese beneficio.