La Fundación Medicina Fetal Barcelona publica en esta web los protocolos de medicina maternofetal del Centro de Medicina Maternofetal y Neonatal de Barcelona (BCNatal): Hospital Clínic - Hospital de Sant Joan de Déu con el fin de facilitar su acceso a la comunidad de especialistas en medicina maternofetal.
A classification system based on umbilical artery (UA) Doppler flow of the smaller twin was proposed by Gratacós et al. 1: in type I, there is positive end-diastolic flow in the UA (pEDFUA); in type II, there is persistent absent/reversed (ar) EDFUA; and in type III, there is intermittent absent/reversed (iar) EDFUA 3. Type I cases have a good prognosis and can be managed expectantly 6,7. Type II and III cases carry a high risk of fetal/perinatal mortality and postnatal handicap for both twins when managed expectantly. In these cases, laser ablation of placental vessels (LAPV) and cord occlusion of the smaller twin have been proposed as management options 1,8-11. Cord occlusion is an option when selective reduction of the smaller twin is approved by the parents and allowed by local regulations. Otherwise, LAPV is available when cord occlusion is not possible for any reason, but there is a paucity of information about whether compared to expectant management, it improves perinatal outcomes.
The inclusion criteria were as follows: MCDA twin pregnancy with type II or III sFGR diagnosed before 26 weeks of gestation, diagnosis and antenatal management at one of the participating centers, no fetal or neonatal malformations, and a cervical length of at least 15 mm (the 5th percentile according to To et al. 12) before the LAPV procedure. Patients with twin oligo-polyhydramnios sequences (TOPS) or twin anemia-polycythemia sequences (TAPS) were not included.
Ultrasound and Doppler examinations were performed transabdominally with a 3.5-5.0 MHz curvilinear-array transducer (Envisor-Phillips; Voluson Expert E8, General Electric Healthcare; UGEO WS80a, Samsung; Accuvix XG, Samsung) by operators with considerable experience in examining twins. Doppler waveforms of the UA were assessed with a minimum of three measurements on a free loop, avoiding maternal and fetal breathing and movement.
Perinatal outcomes according to management strategy are presented in Table 2. The overall fetal death rate was 25.4% (34/134), with a rate of 30.6% (22/72) for type II sFGR cases and 19.4% (12/62) for type III sFGR cases.
One potential limitation is the number of cases of each management strategy based on sFGR type, with fewer expectant management cases in the type II sFGR group and fewer LAPV cases in the type III sFGR group. It is possible that selection bias occurred, considering that all expectant management cases came from the National Health System (NHS), and first trimester scans are not routinely performed for these patients. The few type II sFGR cases that were referred to USP Medical School Hospital consisted of patients who had the chance to undergo an early scan and probably presented with a less severe fetal compromise. The patients who underwent LAPV predominantly had insurance or were receiving private care and thus were followed beginning in the first trimester with an adequate ultrasound schedule for twins. Additionally, as demonstrated by others, type II sFGR is the most severe, with a shorter latency from diagnosis to fetal death or delivery compared to type III sFGR 1. It is possible that several patients under NHS care suffered a miscarriage before referral to USP Medical School Hospital. The number of type III sFGR cases that underwent LAPV was limited because this procedure was only indicated upon identification of arAWDV, and the latency to fetal deterioration is longer compared to that for cases of type II sFGR 1,3. This limitation also explains why only two patients underwent LAPV at the USP Medical School Hospital during the study period. These two cases were not included in the present analysis because LAPV was performed by a different operator. It was not the purpose of the present study to compare the perinatal outcomes of type II and type III UA Doppler patterns. Nevertheless, the perinatal outcomes for both Doppler patterns were similar to those of previous studies, with a worse prognosis for type II cases 1,6,8,14,17. Specific comparisons between studies 1,6,8,14,17 are difficult due to heterogeneity in data presentation, laser indication and type of intervention performed (laser or cord occlusion). Moreover, due to the scarcity of these cases and the difficulties in performing randomized studies, a meta-analysis of individual patient data is a reasonable option to obtain sound evidence.
La mitad del libro describe la técnica correcta para la exploración de la gran mayoría de vasos en medicina maternofetal. La segunda mitad se dedica a las aplicaciones clínicas, con un énfasis marcado en la información útil para la práctica clínica.
Revista Médica de Clínica Las Condes (RMCLC) es el órgano de difusión científica de Clínica Las Condes, hospital privado chileno de alta complejidad y acreditado por la Joint Commission International. Esta revista, de edición bimestral, publica revisiones bibliográficas de la literatura biomédica, actualizaciones, experiencias clínicas derivadas de la práctica médica, artículos originales y casos clínicos, en todas las especialidades de la salud. Cada número se estructura en torno a un tema central, el cual es organizado por un editor invitado especialista en ese ámbito de la medicina. Los artículos desarrollan este tema central en detalle, considerando sus diferentes perspectivas y son escritos por autores altamente calificados, provenientes de diferentes instituciones de salud, tanto chilenas como extranjeras. Todos los artículos son sometidos a un proceso de revisión por pares. El objetivo de RMCLC es ofrecer una instancia de actualización de primer nivel para los profesionales de la salud, además de constituir una herramienta de apoyo para la docencia y de servir como material de estudio para los alumnos de medicina de pre- y postgrado y de todas las carreras de la salud.
To investigate whether there is a differential association between heavy metals exposure and fetal smallness subclassification into intrauterine growth restriction (IUGR) and small-for-gestational age (SGA).
Citation: Sabra S, Malmqvist E, Saborit A, Gratacós E, Gomez Roig MD (2017) Heavy metals exposure levels and their correlation with different clinical forms of fetal growth restriction. PLoS ONE 12(10): e0185645.
One of the investigated causes behind reduced birth weight is heavy metal exposure; including Cadmium (Cd), mercury (Hg), lead (Pb), arsenic (As), and zinc (Zn). These metals are of great interest to the maternal reproductive health and fetal wellbeing due to their ability to cross the placenta causing fetal toxicity [10, 11, 12]. These metals are used in various medical, technological, agricultural and domestic fields, which lead to their increased exposure . Smoking and ingestion of foods grown in contaminated soil with Cd are considered the main sources of Cd exposure . Hg exposure is mainly through consumption of contaminated fish, which predominantly accumulates in the fetal central nervous system . The use of lead-based paints, glazed food containers are common sources of Pb exposure. The latter leads to fetal neurotoxic effects and neurodevelopmental disorders . Exposure to As occurs mainly through the consumption of contaminated water and pesticide manufacturing [17, 18]. In contrary, Zn is a trace element that occurs naturally in the earth, air, and food.
Therefore, lately, there has been increased attention regarding evaluating fetal exposure to the above-mentioned heavy metals and their influences on birth weight. For example, Lafuente et al. showed that Cd exposure influenced the hormonal release of the pituitary hormones, which play an essential role in the reproductive health, fetal growth and development . In addition, Kippler found that Cd concentration in the placenta was inversely associated with birth weight . Another study in Norway, detected that women with high Hg exposure delivered offsprings with reduced birth weights . Xie et al documented that increased maternal blood lead level was negatively related to birth weight among his cohort of Chinese women . Other studies proved that As easily crossed the placenta causing abortions, infant mortality and reduced birth weight [23, 24, 25]. However, Zn deficiency was reported to be associated with infertility, increased rates of fetal death, teratogenesis and reduced birth weight [26, 27]. Nevertheless, the influence of heavy metals on neonatal birth weight has been disputed in the literature. Recent data have also suggest that there is no change in birth weight from heavy metals exposure [28, 29, 30, 31, 32, 33, 34, 35, 36].
Therefore, a prospective case-control study was used to evaluate maternal and fetal exposure to Cd, Hg, Pb, As and Zn assessed by the levels of these heavy metals in the three compartments; maternal and fetal serum and in the placenta of appropriate for gestational age (AGA) and of the two clinical forms of fetal smallness; IUGR and SGA. In addition, this study investigated the degree of mother-to-fetus trans-placental passage of these heavy metals detected levels in the maternal and fetal serum in the form of ratios; fetal to maternal (F/M), fetal to placental (F/P) and maternal to placental (M/P) in the three groups. The study, also, explored whether there was any differential correlation between the levels of these heavy metals with IUGR and SGA groups.
The detected levels of Cd, Hg, Pb, As and Zn in the maternal, and fetal serum (μg/dL) and in the placenta (mg/kg) of the three groups (AGA, IUGR and SGA) are shown in Table 2A, 2B & 2C. The levels of Cd, Hg, Pb and As in the maternal, and fetal serum and in the placenta are represented as medians and interquartile range (IQR) while the detected levels of Zn in the three compartments are presented as mean and standard deviations (SD). 2b1af7f3a8