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ResumenLa mujer en edad reproductiva y especialmente la embarazada muestra cifras alarmantes de mal nutrición por exceso. El año 2009 el sobrepeso alcanzaba 32,0% y la obesidad 20,9% en embarazadas, según cifras del INE. La retención de peso a los seis meses post parto mostraba valores de 33,4% y 22,2% de sobrepeso y obesidad, respectivamente. En estas mujeres se observa mayor incidencia de aborto, mayor tasa de fracaso en técnicas de fertilidad y mayor incidencia de parto prematuro, preeclampsia, diabetes gestacional, tasa de cesáreas y macrosomía fetal. Por otra parte, los hijos de mujeres obesas tienen mayor riesgo de desarrollar obesidad y secuelas metabólicas. Variadas estrategias se han diseñado a objeto de regular el incremento de peso durante el embarazo, así como requerimientos específicos en el control prenatal, tendientes a un cuidado de las gestantes obesas. La cirugía bariátrica se presenta como una auspiciosa alternativa.SummaryWomen of childbearing age and pregnant women especially alarming figures show excess malnutrition. 2009 the figures reached overweight and obesity 32.0% 20.9% in pregnant women, according to figures from INE. and weight retention at six months postpartum showed values of 33.4% and 22.2% of overweight and obesity respectively. In these women have the largest incidence of abortion, higher technical failure rate of infertility and increased incidence of preterm delivery, preeclampsia, gestational diabetes, cesarean rate and fetal macrosomia Moreover, children of obese women at higher risk of developing obesity and metabolic consequences. Various strategies have been designed to regulate weight gain during pregnancy, as well as specific requirements for antenatal care. Bariatric surgery is presented as an auspicious choice.

Contexto: Chile presenta una tendencia secular hacia una sostenida mejoría en los principales indicadores materno-infantiles. Su situación constituye una experiencia positiva a nivel de la región de Latino-América y el Caribe. Sin embargo, esta tendencia se ha estancado en los últimos diez años lo que produce una situación inestable y preocupante desde el punto de vista de la salud pública materna. Esto motiva una reunión de expertos a nivel nacional e internacional para proponer estrategias para el alto nivel político orientadas a alcanzar los Objetivos 4 y 5 del Milenio. Conclusión: Este documento de consenso sobre mortalidad materna, sugiere un enfrentamiento en dos ejes: primero, enfrentar la nueva realidad epidemiológica desde la etapa pre-concepcional, esto incluye considerar la alta prevalencia de obesidad, hipertensión arterial, diabetes, hiperlipidemias e hipotiroidismo en la población, y por otro lado reforzar la seguridad de la asistencia del embarazo, parto y puerperio en los lugares más alejados y más vulnerables del país. Es necesario focalizar las intervenciones en los grupos de mayor riesgo vital (edades extremas de la vida fértil y portadoras de enfermedades médico-quirúrgicas severas, que se reflejan en el aumento proporcional de las causas indirectas de muerte materna), reforzar las actividades de auditorías de mortalidad/near miss, así como controlar el aumento alarmante de la tasa de partos por cesáreas. Background: Chile represents a positive evolution in terms of maternal and infant health in last fifty years. This trend in last ten years has remains stable. According to this situation a National and Regional Consensus meeting about Maternal Mortality has been organized. Conclusion: Propositions have been released about how to improve maternal and child health in Chile. Main focus might be to confront the new epidemiological reality including maternal overweight/obesity, hypertension, diabetes, hyperlipidemia and hypothyroidism. Effort must be done focusing in the day around the birth, mainly in rural and poorest areas of the country. Indirect causes of maternal mortality have become the main problems in maternal care; this fact must be reflected in protocols, audits (including near miss) and public policies. High rate of cesarean section also remains a challenged.

Based on two patients, we discuss the difficulties in diagnosing and managing primary aldosteronism in pregnancy, which derive from changes of the renin-angiotensin-aldosterone axis, from the uncertainty regarding blood pressure control along gestation and postpartum, and from the contraindication to the use of spironolactone. The first case is a 27 years old woman with a long standing refractory hypertension, a hemorrhagic stroke with left brachial hemiplegia and crural hemiparesia, two miscarriages, one stillbirth and one offspring with intrauterine growth retardation. Due to hypokalemia, a plasma aldosterone/renin activity ratio of 91, and a negative genetic screening for glucocorticoid remediable aldosteronism (GRA), a primary hyperaldosteronism with normal adrenals in CT scan was diagnosed, and good blood pressure control was attained with spironolactone. After two and a half years of normotension, a fifth pregnancy, managed with methyldopa evolved with satisfactory blood pressures, plasma potassium, fetal growth, uterine and umbilical arterial resistance indexes, and maternal endothelial function. At 37 1/2 weeks of pregnancy the patient delivered a healthy newborn weighing 2,960 g. Blood pressure rose during the 48 hours of postpartum in the absence of proteinuria and required iv hydralazine. The second patient is a 37 years old woman, with known refractory hypertension for 7 years, hypokalemia, plasma aldosterone/renin activity ratio greater than 40, normal adrenals in the CAT scan, and a negative genetic screening for GRA. She had normotensive pregnancies 5 and 3 years prior to the detection of hypertension, with hypertensive crisis in both postpartum periods, retrospectively considered as expressions of primary hyperaldosteronism (Rev Méd Chile 2002; 130: 1399-1405)

Endothelium controls vascular smooth muscle tone by secreting relaxing and contracting factors. There is a constant release of endothelium derived relaxing factors, mainly nitric oxide, a potent vasodilator, inhibitor of platelet aggregation, monocyte adhesion and smooth muscle proliferation. In addition, the endothelium may increase the release of NO in response to humoral stimulation by vasoactive substances such as acetylcholine, bradikinin or substance P. Although the endothelium releases a number of products, no single blood test has yet proved useful to determine normal endothelial function or as early abnormalities. The most useful test of endothelial function relies on the meassurement of endothelium-dependent dilatation in response to pharmacological or physiologic stimuli. The alteration of this response is known as endothelial dysfunction and has been observed in a variety of circumstances related to cardiovascular risk. This review summarizes the evidence that sustains this association and emphasizes the clinical utility of assessing endothelial function presenting two clinical cases of hypercholesterolemia in which a high-resolution vascular ultrasound in the braquial artery was used. (Rev Méd Chile 2000; 128: 659-70).