Tania T Herrera R

Introduction Pregnancy loss, including miscarriage and stillbirth, remains a significant public health concern, particularly in low‐ and middle‐income countries. Reliable national‐level data are essential to monitor trends and guide interventions. This study aims to describe temporal trends in pregnancy losses in Panama over the past 2 decades, using national vital statistics. Methods We conducted a population‐based, retrospective analysis of pregnancy outcomes in the Republic of Panama between 2002 and 2024. Data were obtained from the Panama National Institute of Statistics and Census, which compiles vital statistics from health facilities nationwide. The dataset included all registered pregnancies resulting in live birth, miscarriage, or stillbirths. Causes for miscarriage and stillbirth were classified using ICD‐10 coding categories. All analyses were conducted using IBM SPSS Statistics Version 29 and Joinpoint Regression Program version 6.0. Results This study registered 190,764 miscarriages, 15,904 stillbirths, and 1,582,352 live births, which represented an average raw pregnancy loss rate of 115.6 (95% CI 110.7–120.4) per 1000 total registered pregnancies in Panama from 2002 to 2024. While the average miscarriage rate was 106.6 (95% CI 101.9–111.4) per 1000 total registered pregnancies, the average stillbirth rate was 10.0 (95% CI 9.6–10.4) per 1000 total births. In general, 11.6% of all registered pregnancies in Panama ended in pregnancy loss. Rates of pregnancy loss were highest among women aged ≥ 40 years and single women. Joinpoint regression analysis identified significant declines in miscarriage rates (2008–2021) and stillbirth rates (2002–2017), but neither was sustained through 2024. All miscarriage cases were coded exclusively as P01, reflecting a complete absence of diagnostic diversity. Among stillbirths, P95 (unspecified fetal death; 53.4%), P02 (placenta, cord, and membranes; 21%), and P20 (intrauterine hypoxia; 7.4%) together accounted for over 80% of cases. Conclusion Pregnancy loss rates in Panama have remained stagnant over the past 2 decades, despite the establishment of national surveillance policies and reporting mechanisms. Miscarriage and stillbirth trends showed limited and unsustainable improvements. The overwhelming reliance on a narrow set of ICD‐10 codes highlights systemic weaknesses in perinatal cause of death classification that limits opportunities for prevention. Strengthening perinatal pathology capacity, coder training and equitable care access must be strengthened.

Background: Chromosomal microarray analysis (CMA) is the recommended genetic test for fetuses with increased nuchal translucency (NT); however, its use in Latin America remains limited. The objective of this study was to determine the prevalence of genetic testing in fetuses with increased NT in Panama and across Latin America. Methods: We conducted a retrospective cohort study of 1512 women who underwent first-trimester screening in Panama, along with a systematic review and meta-analysis of studies reporting genetic testing in Latin America. A comprehensive literature search was conducted across MEDLINE (via PubMed), Epistemonikos, LILACS, BRISA, SciELO, and Google Scholar, covering studies from inception to June 2023 was updated to December 2023. The extracted data included population, setting, timing, and genetic testing methods. The Joanna Briggs Tool was used to assess the risk of bias. Pooled prevalence estimates were calculated using random-effects models. Results: Among 1236 fetuses in the Panamanian cohort, 77 (6.23%) had NT ≥95th percentile. The systematic review included 11 studies encompassing 842 fetuses diagnosed with increased NT. The overall proportion of fetuses undergoing invasive testing was 0.31 (95% confidence interval [CI]: 0.28–0.33). Anomalies were found in 63% of cases with increased NT. CMA was not reported in any of the studies. Conclusions: Most patients in Latin America do not undergo invasive testing, and conventional karyotyping remains the most frequently performed method. To date, no studies have reported the use of CMA in this context. Therefore, the findings of this study highlight significant gaps in access to genetic testing, emphasizing the need for strategic initiatives to improve test availability and build capacity for implementing microarray analysis in the region. Registration: The study has been registered on https://www.crd.york.ac.uk/prospero/ (registration number: CRD42023398899; registration link: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023398899).

Introduction: Postpartum depression is one of the most common medicalcomplications associated with adverse short- and long-term perinatal outcome inthe mother, infant, and family. Objective: To describe various diagnostic methodsand therapies used for the management of postpartum depression and toanalyze the recommendations generated by different scientific groups (maternalfetalmedicine, American College of Obstetrics and Gynecology, NICE guidelines,psychiatry, pediatrics). Methodology: Different search strategies were used in thedatabases Medline (via Pubmed), Scopus, Web of Science, Embase, Cochrane, OVIDPsycho, from January 01, 2020 to February 01, 2023, using the keywords "postpartumdepression", "antidepressants", "cognitive behavioral therapy", "interpersonaltherapy", "mindfulness", controlled vocabulary. Two investigators independentlyreviewed study titles and abstracts. Results: About 14% of pregnant women developpostpartum depression. The most relevant risk factors are a history of anxiety,depression, history of psychiatric treatment, history of physical abuse, postpartummedical complications. Conclusions: One in seven patients (14%) develop perinataldepression. Tools such as the Edinburgh Scale should be applied to all pregnantwomen at their first prenatal check-up appointment, during the third trimester andin the postpartum period. There are several safe therapies that have demonstratedsymptom reduction and decreased levels of relapse, with few side effects.

Objective: To examine maternal mortality in Panama, analyzing its direct obstetric deaths, indirect obstetric deaths, and contributory conditions. Methods: was performed to analyze the data. Results: = 0.1 (y = -0.5147x + 1094.7), which is not statistically significant but meets the 2030 Sustainable Development Goals. The specific primary causes of direct obstetric deaths were: 12.9% due to postpartum hemorrhage (ICD O72); 9.2%, eclampsia (ICD O15); 6.7%, puerperal sepsis (ICD O85); and 6.3%, pre-eclampsia (ICD O14). For indirect obstetric deaths, the primary causes were: 14.9% due to other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium (ICD O99); and 7.3%, maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium (ICD O98). Conclusions: = 0.1), the MMR satisfies requirements for the 2030 Sustainable Development Goals. Future studies should consider factors related to indirect obstetrics and contributory causes of deaths, health care access, COVID-19, cesarean section and natural birth, age, economic income, prenatal and postpartum care, as well as the quality of private and public health facilities in the Americas.

Introduction: Postpartum depression is one of the most common medicalcomplications associated with adverse short- and long-term perinatal outcome inthe mother, infant, and family. Objective: To describe various diagnostic methodsand therapies used for the management of postpartum depression and toanalyze the recommendations generated by different scientific groups (maternalfetalmedicine, American College of Obstetrics and Gynecology, NICE guidelines,psychiatry, pediatrics). Methodology: Different search strategies were used in thedatabases Medline (via Pubmed), Scopus, Web of Science, Embase, Cochrane, OVIDPsycho, from January 01, 2020 to February 01, 2023, using the keywords "postpartumdepression", "antidepressants", "cognitive behavioral therapy", "interpersonaltherapy", "mindfulness", controlled vocabulary. Two investigators independentlyreviewed study titles and abstracts. Results: About 14% of pregnant women developpostpartum depression. The most relevant risk factors are a history of anxiety,depression, history of psychiatric treatment, history of physical abuse, postpartummedical complications. Conclusions: One in seven patients (14%) develop perinataldepression. Tools such as the Edinburgh Scale should be applied to all pregnantwomen at their first prenatal check-up appointment, during the third trimester andin the postpartum period. There are several safe therapies that have demonstratedsymptom reduction and decreased levels of relapse, with few side effects.

In recent decades, prenatal medicine has progressively incorporated different diagnostic technologies that have been able to complement existing methods. Cytogenetic techniques such as karyotyping have been complemented with novel high-resolution molecular techniques, allowing the identification of genomic changes with single nucleotide resolution. Some of these techniques incorporated into the evaluation of prenatal cases are QF-PCR, comparative genomic hybridization (CGH array), different methods of massively parallel sequencing, among others. Currently these molecular technologies for prenatal diagnosis are being implemented in our region since the last decade. Every implementation process brings with it advantages and challenges intrinsic to each technology, and the multidisciplinary team must clearly manage the indications for its use and the implications after the generation of results. In this paper we present some of the considerations by the American College of Genetic and Genomic Medicine and the International Society for Prenatal Diagnosis regarding the indications for these molecular tests and post-test counseling. This will allow the health personnel involved in these tests to implement them effectively, and to obtain a greater benefit for the patient.

Introducción: El síndrome de insensibilidad androgénica es un desorden genético y un tipo de trastorno del desarrollo sexual. Es la feminización de los genitales externos evaluados al nacimiento cuando el genotipo es 46, XY. Objetivo: Presentar la clínica, estudios moleculares, ultrasonidos durante el embarazo y del recién nacido con trastorno de diferenciación sexual. Caso Clínico: Femenina de 35 años con tercer embarazo, feto único, con resultado de cribado genético prenatal no invasivo ampliado de aneuploidías cromosómicas y determinación del sexo fetal a la semana 11 de gestación con sexo genético masculino, ultrasonido con ángulo del tubérculo genital de menos de 30° indicativo de sexo fenotípico femenino y ecografía postnatal con sexo gonadal masculino. Panel molecular genético con una variante patogénica para el Gen AR, en hemicigosis, asociado a Síndrome de Insensibilidad Androgénica. Conclusión: La discordancia sexual fenotipo-genotipo puede indicar una condición genética, cromosómica o bioquímica subyacente. El manejo conjunto interdisciplinario y el consejo genético permite el diagnóstico molecular neonatal temprano de la condición.

BACKGROUND: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

Objective The aim of this study was to assess the accuracy of prenatal imaging for the diagnosis of congenital Zika syndrome. Data sources Medline (via Pubmed), PubMed, Scopus, Web of Science, and Google Scholar from inception to March 2022. Two researchers independently screened study titles and abstracts for eligibility. Study eligibility criteria Observational studies with Zika virus-infected pregnant women were included. The index tests included ultrasound and/or magnetic resonance imaging. The reference standard included (1) Zika infection-related perinatal death, stillbirth, and neonatal death within the first 48 h of birth, (2) neonatal intensive care unit admission, and (3) clinically defined adverse perinatal outcomes. Synthesis methods We extracted 2 × 2 contingency tables. Pooled sensitivity and specificity were estimated using the random-effects bivariate model and assessed the summary receiver operating characteristic (ROC) curve. Risk of bias was assessed using QUADAS 2 tool. The certainty of the evidence was evaluated with grading of recommendations. Results We screened 1,459 references and included 18 studies (2359 pregnant women, 347 fetuses with confirmed Zika virus infection). Twelve studies (67%) were prospective cohorts/case series, and six (37%) were retrospective cohort/case series investigations. Fourteen studies (78%) were performed in endemic regions. Ten studies (56%) used prenatal ultrasound only, six (33%) employed ultrasound and fetal MRI, and two studies (11%) used prenatal ultrasound and postnatal fetal MRI. A total of six studies (ultrasound only) encompassing 780 pregnant women (122 fetuses with confirmed Zika virus infection) reported relevant data for meta-analysis (gestation age at which ultrasound imagining was captured ranged from 16 to 34 weeks). There was large heterogeneity across studies regarding sensitivity (range: 12 to 100%) and specificity (range: 50 to 100%). Under a random-effects model, the summary sensitivity of ultrasound was 82% (95% CI, 19 to 99%), and the summary specificity was 97% (71 to 100%). The area under the ROC curve was 97% (95% CI, 72 to 100%), and the summary diagnostic odds ratio was 140 (95% CI, 3 to 7564, P < 0.001). The overall certainty of the evidence was “very low”. Conclusion Ultrasound may be useful in improving the diagnostic accuracy of Zika virus infection in pregnancy. However, the evidence is still substantially uncertain due to the methodological limitations of the available studies. Larger, properly conducted diagnostic accuracy studies of prenatal imaging for the diagnosis of congenital Zika syndrome are warranted. Systematic review registration Identifier [CRD42020162914].

Abstract Introduction: We aim to synthesize the best available evidence on the accuracy of prenatal imaging for the diagnosis of congenital Zika syndrome due to maternal Zika virus (ZIKV) infection. Specifically, we explored the factors that may influence diagnosis accuracy, such as geographic area, endemicity of ZIKA, operator, gestational age, and type of reference standard used. Methods and analysis Study selection criteria: All types of observational studies were included, that examined pregnant women with ZIKV infection (positive real time polymerase chain reaction or immunoglobulin M (IgM) serological tests and plaque neutralization reduction test). The index tests included prenatal imaging studies (ultrasound and/or magnetic resonance imaging). The reference standard was defined as follows: 1) perinatal death, including stillbirth and neonatal death within the first 48 h of birth, 2) neonatal intensive care unit admission, and 3) composite adverse perinatal outcomes. Case reports will be excluded if they only included fewer than five case. Sources of information: PubMed, Scopus, ISI Web of Science, and Google Scholar will be search from inception to March 2021. Two researchers will independently screen study titles and abstracts for eligibility, followed by full-text assessment. Data extraction will include population, settings, timing, and use of the index test and reference standard used. We will assess the methodological quality of the included studies and a meta-analysis will be performed to estimate summary statistics. Bivariate and hierarchical summary receiver operating characteristic modeling will be used to evaluate the diagnostic performance. The quality of evidence will be assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) metholody. Sources: This systematic review is funded by Secretaria Nacional de Ciencia y Tecnología-Panama. Ethics and dissemination: Ethical approval will not be necessary. Results will be published in a peer review scientific journal. Systematic review registration number in Prospero: CRD42020162914

BACKGROUND: Twin reversed arterial perfusion sequence is a rare and potentially lethal condition affecting approximately 1% of monochorionic twin pregnancies and 1 in 35,000 pregnancies overall. An apparently normal (pump) twin perfuses its severely malformed cotwin with deoxygenated blood via retrograde flow in direct arterioarterial anastomoses between the umbilical arteries of each twin. Fetal intestinal volvulus is a rare condition usually manifesting after birth. We report a unique case of twin reversed arterial perfusion sequence in association with intestinal volvulus in the surviving pump twin. CASE PRESENTATION: A 32-year-old Hispanic primigravida was referred to our clinic after a fetoscopy procedure of laser photocoagulation of anastomoses at 18 weeks of gestation. Follow up scans in the ex-pump twin revealed dilated bowel loops and a typical "whirlpool sign" at 26 weeks of gestation, and intrauterine intestinal volvulus was suspected. At 29 weeks of gestation, preterm premature rupture of membranes occurred, and an emergency cesarean section was performed. The newborn was diagnosed in the early neonatal period with intestinal perforation. The diagnosis was postnatally confirmed by surgery and histopathology. CONCLUSIONS: The type of fetal intervention and late gestational age of the procedure increase the risk of complications. This case alerts health providers to be vigilant in the follow-up of patients with complicated monochorionic pregnancies.

We read with interest the article by Pomar et al. This observational study raises some issues that we feel should be brought to the readers' attention.

OBJECTIVE: Increasing maternal weight has been shown to predict adverse perinatal outcome, including increases in the relative risk of fetal death, stillbirth, neonatal death, perinatal death and infant death. In order to better understand the pathophysiological factors associated with obesity during pregnancy, the role of biomarkers associated with adverse outcomes in obese pregnant women is under investigation. The purpose of this review study was to examine potential biomarkers that could serve as effective screening strategies in obese pregnant women to reduce fetal and neonatal morbidity, as well as maternal morbidity. METHODS: Electronic databases (Pubmed, Embase) were searched for previously published research studies that investigated biomarkers associated with perinatal outcomes in obese pregnant women and the putative mechanisms underlying biomarker effects on pregnancy outcomes. RESULTS: It is evident that while several biomarkers predict perinatal complications in obese pregnant women, none fulfilled the criteria to be considered clinically useful. CONCLUSION: There is a critical need for reliable blood-based biomarkers associated with an increased risk of adverse perinatal outcomes in obese pregnant women.