Complicaciones perinatales de la hiperdatia gestacional

Objective

The aim of this study was to evaluate the perinatal morbidity and mortality associated with pregnancies ending at 41 weeks.

Subjects and methods

We designed a retrospective cohort study. The perinatal outcomes of 230 pregnancies ending at 41 weeks’ gestation were compared with those of 234 pregnancies ending at between 37 and 40 weeks’ gestation at the Miguel Servet University Hospital in 2005.

Results

The rates of oligohydramnios, meconium-stained amniotic fluid, macrosomia, 5-minute Apgar score < 7 and low umbilical artery pH were all increased at 41 weeks’ gestation compared with pregnancies ending at between 37 and 40 weeks’ gestation (P < .05).

Conclusions

We found that the rates of perinatal complications increased as pregnancy was prolonged to 41 weeks. Accurate investigation of these rates is important to determine the gestational age at which the risk of continuing the pregnancy outweighs the risk of labor induction.     

Análisis comparativo de dos protocolos de misoprostol en abortos de segundo trimestre de la gestación

Objective

To compare the mean induction-expulsion times in two regimens of vaginal misoprostol for second-trimester pregnancy termination.

Material and methods

We performed a retrospective study of 281 pregnancies between January 2000 and December 2005 (regimen A: 800 μg /24 h) and between June 2007 and December 2008 (regimen B: 400 μg /4 h). Induction-expulsion time was taken as the main outcome.

Results

The mean expulsion time was similar in both regimens (19.7 h for A and 17.7 h for B). No significant differences were found in the expulsion rate at 12, 24 and 48 h. The most commonly observed adverse effect was fever, which was more frequent in regimen B. No major adverse effects such as uterine rupture or severe hemorrhage were observed.

Conclusions

No significant differences were found between regimens A and B in the mean fetal expulsion time, although fever was more common in regimen B.     

Análisis de los factores que influyen en la aparición de efectos adversos en la versión cefálica externa

Objectives

To identify the association between the adverse effects of the external cephalic version (ECV) and several variables related to the technique.

Material and method

We performed a prospective study in 180 pregnant women who delivered through the ECV. We analyzed fetal and maternal adverse effects and their association with the final result of the version, the experience of the obstetrician, the time used in the maneuver, the number of attempts performed in the same session, and the drug used as a uterine relaxant.

Results

The ECV was successfully performed in 32.6% of primiparas and 79.19% of multiparas. The overall rate of adverse effects was 28.33%, and was higher in versions that failed, those with a greater number of failed attempts, those with longer duration and those in which ritodrine was used as a uterine relaxant.

Conclusions

The factors increasing the probability of success and reducing the rate of adverse effects in ECV are a single attempt at the maneuver, total duration of the maneuver of less than 5 minutes, and use of salbutamol as a uterine relaxant.     

Anticoncepción posparto en mujeres con riesgo de exclusión social

Objective

Improve birth control rates in women from vulnerable populations, space time out between pregnancies and reduce the rate of abortions.

Material and methods

We gave 90 pregnant women at risk of social exclusion an appointment for a postpartum check- up a month and a half after their expected due date, with a SMS reminder 48 hours before the appointment and a phone number in case they failed to make the appointment. We strive to implement long-term methods on the day of appointment.

Results

92% attended the postnatal visit. The overall rate of contraception was 86%, 68% were long-term methods: subdermal implants and IUDs.

Conclusion

Consultation with postpartum women from disadvantaged social groups can be very useful to facilitate contraceptive methods which are safe, effective and long-lasting. Flexibility and agility in the implementation of the methods are essential.     

Carbetocina vs. oxitocina para la prevención de hemorragia posparto en pacientes grandes multíparas: estudio aleatorizado controlado

Objective

Carbetocin is a long-acting oxytocin analogue that can be used as a uterotonic agent in the management of postpartum hemorrhage. The purpose of this study was to compare the effectiveness of carbetocin (100 μg IV) with that of oxytocin (20 U IV) in the prevention of postpartum bleeding in grand multiparous patients (five or more pregnancies).

Design

Prospective, randomized controlled trial.

Population

Patients with vaginal deliveries of singleton pregnancies (≥28 weeks).

Methods

A total of 135 patients were selected to receive 100 μg of carbetocin in a single IV dose or 400 mU oxytocin/min (LR 1000 cc+20 U oxytocin, 100 cc/h) at the end of the third stage of labor.Main outcome measures: Postpartum hemorrhage despite the medication used, requiring the use of alternative measures.

Results

There were no statistically significant differences in the frequency of therapeutic failures or the need to transfuse blood products. The use of carbetocin was associated with a lesser need to manually explore the uterus (RR: 0.12; 95% CL 0.03-0.48). The incidence of adverse effects was similar in both groups. There were no differences in the effects of drugs on breastfeeding.

Conclusions

The use of a single IV dose of carbetocin is as effective as 20 IV units of oxytocin in the prevention of postpartum hemorrhage in grand multiparous women after vaginal delivery. The incidence of adverse effects and complications was similar in the two groups. Carbetocin should be considered a useful alternative to conventional uterotonics in the prevention of postpartum bleeding in grand multiparous patients.     

Cribado cromosómico del primer trimestre. Resultados en gestaciones tras reproducción asistida

Objective

To determine the effectiveness of the combined test for aneuploidies in the first trimester of spontaneous pregnancies in comparison with pregnancies following assisted reproductive technology (ART).

Materials and methods

We performed a retrospective study of 1675 triple tests performed in the first trimester in our center, including pregnancy-associated plasma-A (PAPP-A) and the free fraction of the β subunit of human chorionic gonadotropin (free β-hCG), maternal age and nuchal scan. Of these, 1299 (77.5%) were spontaneous pregnancies and 376 (22.5%) were pregnancies following ART. The cut-off point for recommending an invasive test was 1/270.

Results

The combined test was carried out in 74 twin pregnancies, with two false-positive results. Among single pregnancies, 70 positive triple tests were obtained, 3.79% of spontaneous pregnancies and 6.84% of ART pregnancies. Eleven chromosomal abnormalities were found, nine in spontaneous pregnancies and two in ART pregnancies. The sensitivity of the test was 89% in spontaneous pregnancies and 100% in ART pregnancies. The specificity was 96% and 93.77%, respectively.

Conclusions

The first trimester triple test has high sensitivity and specificity in single pregnancies, whether spontaneous or following ART. The rate of positive triple tests is higher in pregnancies following ART.     

Conizacion con asas diatermias en lesiones premalignas de cuello uterino

Objective

To compare the effectiveness of uterine conization in high-grade cervical squamous intraepithelial lesions (HSIL) by means of surgical electrical excision with Trucone loop or Leep loop.

Subjects and methods

We performed a comparative study that included 150 patients, aged between 20 and 45 years, with a diagnosis of HSIL. All patients underwent uterine conization with diathermy loop. The patients were separated into two groups according to the type of loop used.

Results

Both loops were effective in the management of HSIL but significant differences were found in favor of the Trucone loop in surgical time (X: 3.7 ± 0.52, p < 0.01), lesser margin involvement (100% free margins, p < 0.05) and a lower frequency of residual lesions (94.7%, p > 0.01).

Conclusions

Both diathermy loops were effective in the treatment of HSIL but the frequency of complications and residual lesions was lower with the Trucone loop.     

Pronóstico perinatal y materno de las gestaciones gemelares concebidas mediante fecundación in vitro,en relación con las obtenidas espontáneamente

Objective

To determine the outcomes of twin pregnancies resulting from in vitro fertilization (IVF) compared with those resulting from spontaneous conception.

Material and methods

We performed a historical cohort study comparing neonatal outcomes of twin pregnancies resulting from IVF (n = 44) with those resulting from spontaneous conception (n = 109) in the Complejo Hospitalario Universitario de Albacete (Spain) in 2001, 2001 and 2003. The primary variable was perinatal mortality. Secondary variables were fetal morbidity (neonatal abnormalities, Apgar < 7, acidotic arterial pH, admission to the neonatal unit), preterm delivery, maternal complications, and type of delivery.

Results

No differences in perinatal mortality and morbidity were found between spontaneous twin pregnancies and twins resulting from assisted reproductive techniques. The rate of preterm labor was significantly higher in spontaneous twin pregnancies (75.2 versus 52%; p = 0.006). The incidence of gestational diabetes was significantly higher in twin pregnancies resulting from IVF than in spontaneous twin pregnancies (25.5 versus 9.7%;p = 0.01).

Conclusions

Perinatal and maternal outcomes in twin pregnancies resulting from IVF are similar to those of spontaneous twin pregnancies.     

Influencia de la edad y de las técnicas de reproducción asistida en nuestros resultados obstétricos y perinatales

Objective

To evaluate the influence of age ≥ 40 years and ART in our obstetric and perinatal outcomes.

Material and methods

Retrospective study of 14805 singleton pregnancies in our Institute from January 1, 2000 to December 31, 2006. We compared obstetric and perinatal outcome between: Age group: women ≥ 40 years (N = 557) vs. group of women < 40 years (N = 14248); ART group < 40 years: ART pregnancies (N = 1150) vs. spontaneous pregnancies (N = 13098); ART group ≥ 40 years: ART pregnancies (N = 126) vs. spontaneous pregnancies (N = 431).Results: Age ≥ 40 years is significantly associated with preterm birth under 34 weeks (odds ratio [OR] = 2.148 [1.237-3.730]), gestational diabetes (OR = 2.25 [1.799-2.815]), placenta previa (OR = 3.346 [1.516-7.386]), caesarean delivery (OR = 1.831 [1.539-2.177]), and peripartum hysterectomy (OR = 6.414 [1.359-2.177]). In the ART group < 40 years assisted conception (ART) is significantly associated with preterm birth under 37 (OR = 1.67 [1.337-2.088]) and 34 weeks (OR = 1.8 [1.162-2.822]), with gestational diabetes (OR = 1.5 [1.273-1.844]), pre-eclampsia (OR = 2.1 [1.456-3.164]), placenta previa (OR = 5.29 [2.973-9.437]), choriamniotic infection (OR = 3.8 [1.029-14.072]), caesarean delivery (OR = 1.5 [1.346-1.737]) and low birth weight ≤ 2500 g. (OR = 1.67 [1.329-2.114]) and ≤ 1500 g. (OR = 2.44 [1.442-4.135]). In the ART group ≥ 40 years we only find a significantly increased rate of caesarean delivery (OR = 1.76 [1.183-2.635]) in ART group vs. spontaneous pregnancy group.

Conclusions

Age ≥ 40 years increases the risk of adverse obstetric outcome. ART increase the risk of adverse obstetric and perinatal outcome in the group < 40 years, but not in the group of women aged 40 years and older, probably due to the small size of the sample.     

Recuperación del parto vaginal de nalgas y versión cefálica externa

Objective

To review the obstetric and neonatal outcomes of the application of an updated vaginal breech delivery protocol 10 years after this practice had been discontinued.

Methods

Breech presentations were referred to a dedicated breech unit at 36 weeks where the external cephalic version was offered. If breech presentation persisted, the patients were selected to undergo attempted vaginal delivery if the following criteria were met: a) estimated fetal weight of 2.500-3.600 g; b) frank or complete breech presentation; c) absence of hyperextension of the fetal head; and d) a clinically adequate pelvis. Intrapartum criteria included: a) progression of labor of ≥ 1 cm/hour in the first hour; b) In the second stage, 90 minutes were allowed for adequate descent of the breech, and 1 hour of active pushing, and c) the availability of an on-call expert.

Results

A total of 93 patients showed single live pregnancies in breech presentation after external cephalic version. Sixty-nine patients (73.4%) underwent elective prelabor cesarean delivery, and 24 (26.6%) progressed to attempted vaginal breech delivery, which was successful in 19 (20.1%). Cesarean indications for breech presentation were reduced from 5.7% in 2009 to 2.02% after the application of external cephalic version and vaginal breech delivery (P<.001). We observed no fetal deaths, no Apgar test at 5 minutes of less than 7, no umbilical artery pH of less than 7, and no fetal injuries.

Conclusions

. When antepartum and intrapartum criteria are met, vaginal breech delivery is safe. The availability of an on-call expert allows vaginal breech delivery to be safely performed. The combination of external cephalic version and vaginal breech delivery decreases the cesarean rate for breech presentation.     

Influencia de la visita puerperal temprana en la detección y evolución de la depresión posparto

Objectives

The aim of this study was to determine the influence of early postpartum home visits in reducing the incidence of puerperal depression in our environment.

Material and methods

A total of 430 patients with uncomplicated pregnancy and delivery were randomized to two homogeneous groups (one group receiving an early postpartum home visit and a control group). The hospital anxiety and depression scale was used to assess puerperal depression at 7 and 30 days.

Results

At 7 days, 10.2% of the patients had a positive score for puerperal depression. At 30 days, the incidence of puerperal depression was lower in the group receiving an early home visit (0.9%) than in the control group (3.7%).

Conclusion

The incidence of postpartum depression in our setting was similar to the expected incidence. Early postpartum home visits seem to be useful in detecting this disorder and in reducing symptoms.     

Implantación de una política de episiotomía selectiva en el Hospital de Baza. Resultados materno-fetales

Objective

To evaluate maternal and fetal outcomes associated with the selective use of episiotomy.

Methods

A retrospective analytical study of births attended in the Hospital of Baza (Granada, Spain).

Results

Episiotomy rates fell from 69% (89% of nulliparas and 51.75% of multiparas) to 20% (35.7% of nulliparas and 8.43% of multiparas). Association tests showed that episiotomy was associated with nulliparity, maternal age in nulliparas, epidural analgesia, instrumental delivery and lithotomy position. Selective episiotomy did not affect neonatal Apgar scores. Different lithotomy positions reduced the performance of episiotomy and protected against severe lacerations. A selective episiotomy policy helped to preserve the perineum intact but also increased grade I and II perineal tears.

Conclusions

The implementation of a selective episiotomy policy favors humanized birth and helps to preserve the perineum intact, without worsening maternal and fetal outcomes.     

Análisis de la relación entre riesgo gestacional y ansiedad materna

Objective

To evaluate levels of maternal anxiety in third trimester pregnancies according to pregnancy risk, classified as low, medium and high-risk/very high-risk.

Patients and methods

We performed an observational, analytical and cross-sectional study of anxiety levels in 174 pregnant women followed-up in our hospital. Levels of both state anxiety and trait anxiety were evaluated in the three groups of pregnant women.

Results

Of the 174 participants in the study, 98 (56.3%) had low risk pregnancies, 40 showed medium risk (23%) and 36 (20.7%) had high risk or very high risk pregnancies. We obtained a mean of 32.8 points for state anxiety and of 27.3 points for trait anxiety. Mean anxiety levels scores were 44.1 points in the high/very high risk group, 33 points in the medium risk group, and 28.5 points in the low risk group, with statistically significant differences (P = .0001 for the high risk group and P = .038 for the medium risk pregnancies). A significant correlation was found between trait anxiety and state anxiety (P = .0001). Statistically significant differences were observed in anxiety related to the number of children (P = .0001).

Conclusions

In pregnant women, anxiety levels were higher than average levels in the general population. Anxiety levels increased in accordance with greater risk in the pregnancy. The greater the number of children the mother already had the lower her anxiety level.     

Influencia de la educación maternal sobre hábitos tóxicos y uso del servicio de urgencias obstétricas

Objectives

To determine the influence of the women's exposure to maternal education on smoking and the use of obstetric emergency services.

Method

A multicenter observational study was conducted on women whose childbirth was the first in four hospitals in Andalusia (Spain) in 2011. The data were collected through an interview and medical history. The analysis estimated odds ratios and both raw and adjusted averages.

Results

A total of 520 women were studied. Participation in the maternal education program seemed to have no influence on the use of obstetric emergency services (ORa = 0.70, 95% CI = 0.47-1.04) or on changing smoking habits (ORa = 0.84, 95% CI = -0.43-1.68).

Conclusions

Attendance at a maternal education program did not modify smoking. We found no conclusive evidence of the impact of maternal education on the use of emergency obstetric services.     

Ayuno vs. dieta líquida. Estudio aleatorizado controlado para evaluar la duración de la labor de parto,tasa de cesáreas y satisfacción con la labor

Aim

To evaluate the benefits of allowing oral intake of clear liquids in terms of labor duration, the cesarean section rate, and personal satisfaction.

Methods

A randomized controlled trial was carried out to assess the effects of a clear liquid diet in a low risk population. The primary outcome was labor duration. The secondary outcome was the incidence of cesarean section. A satisfaction survey was performed within the first 2 h after delivery to evaluate the patient's perception of labor.

Results

A total of 348 patients were randomized. The mean duration of labor was 257.75 min in the liquid diet group and 288.40 min in the fasting group (p = NS). There was no statistically significant difference (per-protocol analysis and intention-to-treat analysis) in the cesarean section rate.Patients reported greater satisfaction when allowed to drink during labor than when fasting.

Conclusion

A clear liquid diet during labor did not alter the duration of labor or the cesarean section rate. Allowing a liquid diet during labor was associated with a better perception of the birth process and a higher degree of satisfaction.     

Índice de masa corporal y aumento de peso en el embarazo. Resultado obstétrico de la inducción de parto

Objective

To determine the obstetric results of labor induction in relation to body mass index (BMI) and gestational weight gain at the Leon Hospital between January and March, 2008.

Material and method

We conducted a prospective cohort study of 127 labor inductions. The variables included were the medical reason for induction, the procedures employed for cervical ripening and induction, maternal age at the end of pregnancy, type of labor, parity, initial Bishop's score, BMI, weight, height, gestational weight gain, neonatal weight and Apgar test at 1 and 5 minutes.

Results

Inductions were performed in 21.3% of births, while vaginal delivery was achieved in 81.1%. A total of 36.2% of the patients were overweight, 21.2% were obese and 4.7% were morbidly obese.

Conclusions

A non-statistically significant association was observed between failure of vaginal delivery and BMI (P = .08) and body weight gain (P = .07). These two variables seem to increase the chances of failure of cervical ripening and induction of labor, increasing the percentage of cesarean sections.     

Resultados perinatales en 492 presentaciones podálicas: cesárea vs. parto vaginal

Objective

To analyze the perinatal results in our hospital comparing vaginal delivery and cesarean section in breech presentation singleton pregnancies at term.

Material and Methods

All live ante-partum singleton fetuses in breech presentation, at 37 to 41+6 weeks and days who delivered between July 2006 and August 2010 were included in the study. We compared perinatal results between cesarean section and vaginal delivery.

Results

There were no differences in Apgar score at 5 minutes < 7, pH umbilical cord < 7, base deficits and lactate, neonatal intensive care unit admission or perinatal mortality.

Conclusions

With appropriate maternal and fetal conditions and a qualified medical team, a breech vaginal delivery could be propose obtaining good perinatal outcomes.     

Cáncer de cérvix metastásico y gestación: una situación poco frecuente que invita a la reflexión

Background

Coexistence of pregnancy and metastasic cervical cancer in an exceptional situation that will mark, in the presented case, the evolution of the pregnancy.

Case

A 34-year-old woman, gravida 2 para 1, at 13 weeks’ gestation was taken to our emergency service with menorragia, and was admitted under the suspicion of invasive cervical cancer. Patient?s evolution was complicated by the detection of supraclavicular metastasis and massive pulmonary tromboembolism. The patient decides voluntary interruption of pregnancy in the 17^th week.

Conclusions

This is a very unusual case, not as much the presence of an early stage cervical cancer in a pregnant woman. It reminds us of the need to carry out the mandatory gynecological exploration and smear in the first visit of prenatal care, often omitted in our dayly practice.     

Histerectomía total laparoscópica. Evolución de la técnica y comparación de resultados en 2 períodos

Objective

To analyze the influence of the learning curve and surgical technique on the results of total laparoscopic hysterectomies (TLH) for benign conditions in two study periods.

Material and methods

A total of 500 patients underwent surgery between 2000 and 2008, divided in two periods as different surgical techniques were used. Epidemiological data, surgical indications, operative results and complication rates were compared between the two groups.

Results

The epidemiological characteristics and surgical indications were similar between the two groups. There were no significant differences in operating time. Hospital stay was significantly lower (2.7 vs 2.4 days; P < .01), and there was a lower drop in hemoglobin levels (1.9 g/dl vs 1.7 g/dl; P < .05) from 2005-2008 compared with 2000-2005. In the second period, uterine weight was significantly higher (288 g vs 203 g; P < .01) and both the overall complications rate (8.5% vs 3.6%; P < .05) and major complications rate (5.4% vs 1.8%; P < .05) were lower.

Conclusions

TLH is a safe, feasible and reproducible technique, after an appropriate learning curve. Greater experience of the surgical team and modifications in the surgical technique significantly reduced the complications rate, with acceptable operating times even for bulky uterus.