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.     

Análisis de la finalización de la gestación y morbilidad materna en las gestaciones de 41 semanas

Objective

To evaluate the mode of delivery and maternal morbidity associated with pregnancies ending at 41 weeks.

Material and methods

We designed a retrospective cohort study. The mode of delivery and maternal complications of 230 pregnancies ending at 41 weeks were compared with those in 234 pregnancies ending between 37 and 40 weeks at the Miguel Servet University Hospital in 2005.

Results

Women delivering at 41 weeks had an increased risk of membrane sweep, unfavorable Bishop score at admission, induction and longer duration of labor. These increases were also seen in the rates of operative vaginal delivery (25.6 vs 17.6%, p < 0.001) and cesarean section (21.7 vs 8.5%, p < 0.001).

Conclusions

The rates of maternal peripartum complications increase as pregnancy reaches 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.     

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.     

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.     

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.     

Papel de p16 en lesiones preinvasivas e invasivas de cáncer de cuello uterino. Aplicación de la técnica a citología convencional

Introduction

Detection of p16 expression by immunohistochemistry and immunocytochemistry is a good standard for the identification of high-grade cervical epithelial lesions and low-grade lesions with DNA HPV viral integration (with a tendency for progression).

Material and methods

We evaluated p16 expression in 58 HPV-positive cervical biopsies and 53 conventional cytological samples that tested HPV-positive with immunohistochemical and immunocytochemical techniques.

Results

All high-grade lesions were positive for p16 while only some of the low-grade lesions were positive. The results obtained in histological samples could be extrapolated to cytological samples from the same patients.

Conclusions

p16 expression in conventional cytology provides similar results to those in histological samples.     

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.     

Ensayo clínico controlado de la influencia del entrenamiento aeróbico en la tolerancia al ejercicio y los síntomas depresivos en primigestantes colombianas

Introduction

Depression in pregnancy affects almost 60% of pregnant women and several studies have shown that aerobic exercise can reduce depressive symptoms by increasing physical capacity. However, this effect has not been determined in pregnancy.

Objective

To evaluate the influence of aerobic training on exercise tolerance and depressive symptoms in Colombian nulliparous pregnant women.

Materiales and methods

We carried out a simple controlled trial in 80 nulliparous pregnant women, between 16 and 20 weeks of pregnancy, randomized to two groups. 1) The control group continued their usual activities, with no specific exercise regime. 2) The intervention group performed aerobic training between 50% and 65% of their maximal heart rate for 50 minutes, three times a week for 12 weeks. Exercise tolerance was assessed using the 6-minute walk test and symptoms of depression were assessed by the Center for Epidemiological Studies Depression Scale (CES-D) at baseline and immediately after the 3-month intervention.

Results

The mean age was 21 ± 3 years and gestational age was 18 ± 2 weeks. Seventy-four women completed the study. After the intervention, participants who exercised had a higher exercise tolerance, measured by the 6-minute walk test, and a greater reduction in depressive symptoms than the control group, as measured by the CES-D scale, P<.05.

Conclusions

A supervised 3-month program of primarily aerobic exercise during pregnancy reduces depressive symptoms and improves exercise tolerance. These results provide new evidence of the benefits of exercise in preventing maternal depression.     

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.     

Torsión anexial: experiencia en el Complejo Hospitalario Universitario de Albacete

Objective

To evaluate the management of adnexal torsion in our center during a 10-year period.

Patients and methods

We studied cases of adnexal torsion in patients of reproductive age treated surgically between 1997 and 2007. The clinical, ultrasonographic, surgical and histological findings, as well as the treatment and follow-up of these patients, were retrospectively analyzed.

Results

We identified 25 cases of adnexal torsion in 24 patients. Abdominal pain was present in 92%, nausea and/or vomiting in 32%, fever in 4% and leucocytosis in 54.2%. The most frequent echographic findings were complex tumors (52.2%). Torsion was suspected in the first evaluation in only 8% of the cases and before surgery in 36%. Most (72%) of the torsions involved the right adnexa and 52% a tumoral adnexa. Suspicion of necrosis was confirmed in 66.6% and the most frequent histopathological diagnosis was teratoma (28.6%). Conservative treatment was performed through detorsion and/or cystectomy in 40% and in patients whose subsequent clinical course was normal.

Conclusions

When an adnexal torsion is present, the most frequent symptom is abdominal pain. Clinical suspicion in the first evaluation is infrequent, and diagnosis is usually made during surgery. When a tumoral adnexa is torsioned, a teratoma is usually present. Conservative treatment is often performed with good results.     

Evaluación del índice proteína-creatinina en orina aislada para la predicción de proteinuria significativa durante la gestación

Introduction

Diagnosis and follow-up of preeclampsia requires measurement of proteinuria and the gold standard for this evaluation is the 24-hour collection. However, this collection is cumbersome, time consuming and delays clinical diagnosis. The purpose of this study is assess the diagnostic performance of the spot urine protein/creatinine (P/C) ratio to predict the absence or presence of significant proteinuria (≥ 300 mg per 24 hours) among outpatient pregnant women with suspected or previous diagnosis of preeclampsia.

Material and methods

The P/C ratio was calculated in 106 single voided urine samples, obtained after the completion of the 24-hour collection, from 66 outpatient pregnant women admitted to the Maternal Fetal Care Unit at our Hospital to follow-up of hypertension gestational. Correlation between the spot urine P/C ratio with the 24-hour urine protein excretion was calculated. Receiver operator characteristic (ROC) curves analysis was used to evaluate the diagnostic performance and to determinate the best cutoff to predict the absence or presence of significant proteinuria.

Results

Significant proteinuria on 24 hour collection urine was identified in 31 urines from 22 pregnant women. There was a significant correlation between the spot urine P/C and 24-hour urine protein excretion (r_Spearman = 0,658, p = 0,01). ROC curves analysis revealed an area under the curve for spot P/C ratio of 0,838, greater than urine dipstick (0,629). No single P/C ratio cutoff was appropriate to rule-out or predict significant proteinuria; however, use of dipstick and spot urine P/C ratio, with two cutoffs, 120 mg/g to predict the absence of significant proteinuria and 240 mg/g to confirm it, clasiffied correctly 44,3% of urines and avoided the collection of 24 hours urine in 51% of the cases.

Conclusions

Spot urine P/C ratio, in conjunction with dipstick urianalysis, is a useful test in the initial screen for rule-out and predict significant proteinuria in outpatient pregnant women with hypertensive pregnancy or preeclampsia, but it should not be used as an alternative to 24-hour total protein evaluation in midrange P/C ratio, requiring a full 24-hour urine for accurate results.     

Descenso de la edad al diagnóstico en el cáncer de mama

Introduction

Increasingly younger women are apparently diagnosed with breast cancer. The aim of this study was to determine whether age at diagnosis of this disease is declining.

Material and methods

We calculated incidence rates for breast cancer in Zaragoza (Spain) by age groups. The median age at diagnosis over a 20-year period was calculated. A Joinpoint regression was subsequently performed to determine the trend.

Results

The median showed a downward trend with an annual percentage change of -0.3% (95% CI -0.6, -0.1) over the 20-year period. The crude incidence rates for age groups showed that the positive trend was highest among women aged more than 85 years, PAC = 14% (95% CI 4.03; 25.9), followed by the group aged 40-44 years with a PAC of 10% (95% CI 3.4, 17.1).

Conclusions

The median age at diagnosis of breast cancer has declined over the past 20 years.     

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.     

Aportación del Doppler de la arteria cerebral media y del genotipado RHD fetal en el manejo de la isoinmunización

Objective

To assess the clinical application of non-invasive methods in the management of alloimmunization from 2006 to 2010.

Subjects and methods

Seventy pregnancies with risk of fetal anemia were studied by fetal middle cerebral artery peak systolic velocity (MCA-PSV). The efficacy of MCA-PSV was compared between the first, second and third transfusions. Prenatal testing of fetal RHD blood group using maternal blood was performed in pregnancies followed-up in our center.

Results

Fetal blood sampling was performed in 22 pregnancies; of these, fetal transfusion was carried out in 20. Detection rates and the false-positive rate of MCA-PSV in the prediction of severe or moderate fetal anemia were 89% and 15% in pregnancies with no previous transfusions, 100% and 41% in patients with one previous transfusion, and 40% and 24% when more than one transfusion was performed.

Conclusion

MCA-PSV has high sensitivity when there is one previous fetal transfusion but its specificity is lower.     

Sensibilidad de la ecografía transvaginal en el diagnóstico de la mola hidatiforme de primer trimestre

Objective

To assess the accuracy of first trimester ultrasound to diagnose complete or partial hydatidiform moles.

Patients and methods

All cases of sonographically suspected and/or histologically proven complete or partial hydatidiform mole diagnosed in our center from January 1998 to December 2010 were analyzed. The sensitivity and positive predictive value of ultrasound in the detection of molar pregnancies were calculated.

Results

The study group included 59 patients. Of these, 49 were suspected of having hydatidiform mole by ultrasound, 39 of which were histologically confirmed (27 partial and 12 complete). In the remaining 10 cases, the histological diagnosis was pregnancy loss. During the same period, histopathology demonstrated molar pregnancy in a further 10 patients (nine partial and one complete) previously diagnosed as pregnancy loss by ultrasound. Therefore, the study included a total of 49 cases with a final diagnosis of hydatidiform mole (36 partial, 13 complete). The sensitivity and positive predictive value of ultrasound in first-trimester hydatidiform mole was 79.6% (39/49) and 79.6% (39/49) respectively. Of the 49 molar pregnancies, 10 (20.4%) were not identified correctly. The detection rate for complete mole (12/13, 92.3%) was slightly better than that for partial mole (27/36, 75%) but this difference was not significant (p=0.18).

Conclusion

The accuracy of first-trimester ultrasound in the diagnosis of hydatidiform mole is high. No significant differences were found between the diagnosis of partial and complete hydatidiform mole. In view of the significant number of molar pregnancies not diagnosed by ultrasound, we recommend histopathological evaluation of all cases of pregnancy loss.     

Eficacia y seguridad de la utilización del óxido nitroso al 50% como analgesia en el parto

Objectives

To evaluate the safety and efficacy of 50% nitrous oxide with oxygen as an inhaled analgesic during delivery.

Material and methods

We performed a systematic review of the literature through a literature search (2010) of electronic databases. Studies comparing administration of inhaled nitrous oxide at 50% with another intervention in adult women during labor and reporting results on efficacy and safety were included.

Results

A total of 230 references were obtained and 24 studies that met the inclusion criteria were selected. After analysis of the texts, one systematic review and three clinical trials were selected. The quality of the trials included was moderate-high. Nitrous oxide as an analgesic technique produced acceptable results when compared with placebo but the results were less satisfactory when nitrous oxide was compared with other analgesics. Safety results were similar to those found with other analgesic treatments.

Conclusions

Administration of inhaled 50% nitrous oxide in women during labor could be an alternative to routinely used techniques.