Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Doppler
Doppler
OBSTETRICIA
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20
24
28
32
Edad gestacional (sem)
36
40
2. ARTERIA UMBILICAL
1.5
1.0
0.5
0.0
22
24
26
28
30
32
34
36
38
40
24
26
28
30
32
34
36
38
40
media
10
VCI
Aorta
11
4. DUCTUS VENOSO
El ductus venoso comunica la vena umbilical intra-abdominal con la
vena cava inferior, y desde all, la sangre oxigenada pasa rpidamente a
la aurcula izquierda y preferencialmente al cerebro y coronarias. Este
vaso es una conexin estrecha, tipo embudo, que acelera el flujo
sanguneo venoso desde la vena umbilical (normalmente 10 cm/seg) al
menos 5 a 6 veces.
12
13
14
15
17
18
19
DISFUNCION ENDOTELIAL
La extraordinaria variabilidad de este sndrome clnico se debera al
gran disturbio circulatorio mediado por la disfuncin de las clulas
endoteliales maternas. Cuando se propuso por primera vez la hiptesis
de que la PE se caracterizaba esencialmente por una disfuncin
endotelial fue considerado un gran avance en el conocimiento de la
gnesis de este sndrome clnico.45 Sin embargo, en la actualidad ha
surgido el concepto de que en la mujer embarazada con este sndrome
clnico existira una susceptibilidad especial o disfuncin endotelial preexistente (enfermedades crnicas). Esto podra explicar las diferentes
manifestaciones clnicas asociados a este sndrome.
Evidencias de la disfuncin endotelial son la demostracin de un
aumento de la concentracin plasmtica de marcadores dao endotelial.
Entre ellos es importante destacar al factor de von Willebrand, al
activador del plasmingeno tisular y a los inhibidores del activador del
plasmingeno endotelial y placentario (PAI-1 y 2)46;47 que preceden al
establecimiento clnico de estas enfermedades. Chappel y col.48
emplearon marcadores del dao endotelial y funcin placentaria con la
intencin de evaluar el efecto de los antioxidantes en la prevencin de
PE en pacientes con alto riesgo de presentar esta patologa. El dao
endotelial y la funcin placentaria fueron evaluado por medio de la
relacin entre el inhibidor del activador del plasmingeno 1 (PAI-1),
sintetizado predominantemente por el endotelio, y el PAI-2, sintetizado
por la placenta. Se observ que los niveles plasmticos de PAI-1
aumentan progresivamente durante la gestacin normal y ms an en
las pacientes con PE.47 Por otro lado, los niveles de PAI-2 aumentan
progresivamente durante la gestacin normal, pero disminuyen cuando
existe una alteracin de la funcin placentaria.47 La relacin de PAI1/PAI-2 disminuye en el embarazo normal debido al aumento de la
masa placentaria, sin embargo esta relacin aumenta en PE debido a la
activacin celular e insuficiencia placentaria 49.
El dficit de xido ntrico (NO) ha sido involucrado en la gnesis de
50
PE y en especial en este ltimo tiempo el aumento de la dimetilarginina asimtrica (ADMA), inhibidor competitivo de la xido ntrico
sintetiza (eNOS)51, el cual se ha asociado tambin al aumento del estrs
oxidativo mediado por la inactivacin de su enzima metabolizadora
dimetil-aminotransferasa (DDAH 1 y II)52.
Otras evidencias de la alteracin de la funcin endotelial se han
descrito en arterias aisladas provenientes de pacientes con PE. McCarthy
y col53, empleando arterias obtenidas de la piel de mujeres PE, mostr
una alteracin de la respuesta vasodilatadora a la acetilcolina (Ach), la
cual fue dependiente de endotelio. Posteriormente, Knock y col.54
evaluaron la respuesta a bradiquinina (BK) en los mismos vasos, y
encontraron, al igual que con Ach, una alteracin de la relajacin a BK
20
21
22
23
24
Presin arterial:
cido rico:
25
Marcadores bioqumicos:
26
27
E.
DOPPLER
DE
LAS
ARTERIAS
PREDICTORES
DE
PREECLAMPSIA
Y
CRECIMIENTO FETAL
UTERINAS
COMO
RESTRICCIN
DE
28
29
30
31
33
34
35
36
37
149
A. Antecedentes
isoinmunizacin Rh
de
embarazo
previo
afectado
por
39
40
41
r=0.62 p<0,006
2.40
MOM VM-ACM
2.00
1.60
1.20
0.80
0.40
0.00
0.00
0.20
0.40
0.60
0.80
1.00
MOM Hb fetal
MOM VM-ACM
1.60
1.20
0.80
0.40
0.00
0.60
0.70
0.80
0.90
1.00
1.10
1.20
MOM Hb fetal
42
43
I. INTRODUCCION
44
45
B. Vasos venosos
En un estudio realizado en embarazos gemelares con TFF para
determinar el patrn circulatorio del donante y receptor, Hecher y cols
164
determin que exista un aumento de los ndices de pulsatilidad
venoso en ambos gemelos. El gemelo donante se caracterizaba por un
aumento del IPV del ductus venoso secundario a hipovolemia, con la
consecuente disminucin de la precarga, y aumento de la postcarga
debido al aumento de la resistencia placentaria. Mientras que el gemelo
receptor muestra evidencias de flujo hiperdinmico, caracterizado por
un aumento del IPV del ductus venoso. (Figura)
46
V. DOPPLER Y ANEUPLOIDIA
Ductus venoso
El ductus venoso es una comunicacin nica que dirige la sangre
oxigenada desde la vena umbilical directamente hacia la circulacin
cerebral y coronaria, la cual es dirigida por un flujo preferencial de alta
velocidad que lo lleva a travs del foramen oval y aurcula izquierda. El
flujo del ductus venoso, a diferencia de otros flujos venosos, se
caracteriza por tener simpre flujos anterogrados, incluso durante la
contraccin auricular (onda A). La alteracin del ductus venoso,
caracterizada por un aumento del ndice de pulsatilidad venoso (IPV) o
ausencia de onda A, se observa habitualmente en el segundo y tercer
trimestre secundario a una descompensacin cardaca (insuficiencia
cardaca) de una hipoxia fetal.164
Por otro lado, la alteracin del ductus venoso en el primer trimestre
(ver figura con imagen normal de onda del ductus venoso) se ha
asociado a alteraciones cromosmicas, defectos cardacos, y mal
resultado perinatal. En un meta-anlisis de 6 estudios en fetos con
ductus venoso anormal, se encontr una asociacin de 83% con
Sndrome de Down y 74% con otras alteraciones cromosmicas con 5%
de falsos positivos.169 En este meta-anlisis se inform que en los
distintos estudios se encontr ya sea una ausencia o una debil
asociacin con aumento de la translucidez nucal. Nuestro grupo
present recientemente en el Congreso Mundial de Obstetricia y
Ginecologa nuestra experiencia con alrededor de 200 mediciones entre
11-14 semanas de gestacin.170 En este estudio mostramos un relacin
directamente proporcional con el aumento de la translucidez nucal
(r=0,72,p<0,001) y consecuentemente su asociacin con mal pronstico
perinatal (60% de malformaciones cardacas, siendo la mayora asociada
a aumento de TN y aneuploida) (Figura y Tabla).
47
4
3.5
IPV DV
3
2.5
2
1.5
1
0.5
0
0
10
15
20
25
TN (mm)
IPV
TN
MF
(mm)
cardaca
Sd Apert
2,48
13
Sd
Edwards
2,17
13
RCF
2,02
1,4
CIV
Ventrculo
nico
No
48
Sd Down
Aborto
(15 sem)
1,88
4,0
Canal AV
1,61
7,2
49
Arteria umbilical
Existen evidencias contradictorias de la asociacin entre el aumento
de la impedancia de la arteria umbilical en el primer trimestre y
alteraciones cromosmicas. Uno de estos estudios mostr en el grupo
con arteria umbilical sobre el percentil 95 un 55% de fetos/neonatos con
alteraciones cromosmicas, mientras que otros dos estudios no
mostraron diferencias significativas con los controles normales, slo 7%
de fetos con alteraciones cromosmicas en el grupo con arteria umbilical
alterada.175,176
Otro estudio, mostr que la ausencia o flujo reverso en distole
la arteria umbilical entre 11-14 semanas se asoci con un 80%
aneuploida, pero todos ellos tenan tambin un aumento de
translucidez nucal.177 Estos antecedentes ayudan a sealar que
arteria umbilical no es un buen examen de cribado de aneuploidas.
de
de
la
la
Vena Umbilical
Las pulsaciones venosas en el segundo y tercer trimestre del
embarazo son un signo ominoso de compromiso fetal.178 En un estudio
realizado en el primer trimestre mostr en primer lugar que un 25% de
los fetos normales presentan pulsaciones en la vena umbilical y en el
90% de los fetos con sndrome de Edwards o Pateau. Sin embargo, en
los fetos con sndrome de Down no hubo diferencias significativas con
los controles.179
50
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