Decidualización peritoneal y embolización de arterias uterinas en la hemorragia puerperal tras cesárea

Deciduosis peritonei consists of the presence of decidua in the peritoneal surface and develops during pregnancy due to the effect of progesterone. The typical lesions are highly vascularized and immunohistochemical studies are required to exclude a diagnosis of malignancy. Selective arterial embolization is a conservative procedure to treat postpartum hemorrhages with minimal side effects and allows fertility to be preserved. We present a case of severe deciduosis peritonei identified during a cesarean section in a patient who subsequently required embolization of the uterine arteries due to a postpartum hemorrhage.     

Crecimiento paradójico y complicaciones de la embolización arterial de miomas uterinos. Presentación de 2 casos

Uterine myoma is the most common nonmalignant pelvic tumor in women, occurring in 30%. Menorrhagia, pelvic pain, hypogastric distress, infertility and rapid growth are indications for hysterectomy. Uterine artery embolization has been proposed as a therapeutic alternative for menorrhagia caused by uterine myoma.     

Embolización de las arterias uterinas como alternativa de tratamiento para miomas uterinos. Experiencia en 60 pacientes

Introduction

Uterine fibroids are the most common benign solid tumors of the female genital tract. Uterine artery embolization (UAE) is presented as an alternative to surgical treatment.

Objective

To evaluate the efficacy of UAE in the management of symptomatic fibroids, establish the success rate, and evaluate the safety of the technique by detecting complications during the procedure.

Material and methods

A retrospective dual-center study was performed in 60 patients undergoing UAE from 2000 to 2011 in Albacete and the Puerta de Hierro General Hospital in Madrid.

Results

The clinical success of the technique was demonstrated in 41 of the 60 patients (overall success rate of 68% at 4 years of follow-up) Complications occurred in 7 of the 60 patients (11.6%), consisting of embolization syndrome and transient ischemic pain in the first and second, which resolved with medical treatment and without further complications.

Conclusion

UAE is an effective treatment for women with symptomatic fibroids, showing high reliability and a low rate of minor complications.     

Embolización de las arterias uterinas en hematoma disecante de la episiotomía

Background

Postpartum hemorrhage is a potentially serious complication and includes bruising of the birth canal. It is vitally important that the diagnosis and treatment take place at an early stage.

Case

We report a serious case of bruising of the birth canal that required selective embolization after unsuccessful local surgical treatment, with hypovolemic shock and disseminated intravascular coagulation.

Conclusion

Embolization requires an infrastructure and technology that are available in tertiary care hospitals. Early diagnosis allows embolization to be performed in hemodynamically stable patients. Uterine artery embolization in expert hands enables future fertility to be preserved with few complications.     

Embolización de las arterias uterinas en el tratamiento del mioma uterino sintomático. Resultados en 90 pacientes a los 2 años

Objective

To evaluate the mid-term outcomes and patient satisfaction following UAE in women with symptomatic leiomyomata, as well as to assess safety treatment.

Material and methods

Prospective study of 90 patients from Sabadell Hospital between December 2002 and October 2006.Data were collected using a questionnaire and was later introduced in a specific database. Statistical analysis of data was carried out using SPSS 15.0.All patients went on a 2-year follow-up after UAE, including clinical, laboratory and diagnostic imaging examinations.Symptoms were scored as successful, improvement, unchanged or worsened. Adverse events were noted following the Society of Interventional Radiology's classification. Patients were also asked about their satisfaction.The need of an eventual hysterectomy or the persistence of symptoms was considered to be a treatment failure.

Results

The improvement of symptoms occurred in 90,7% of all the embolized women. We had to perform a second embolization in 4 cases, and a hysterectomy in 6 cases.6 months later, null vascularisation or hypovascularisation of the myoma was observed in 92.8% of women. Over two years, the average volume reduction of the dominant myoma was 76.3%.The rate of major complications was 12.7%. Patient satisfaction for the procedure was 90.2%.

Conclusions

Uterine artery embolization is an effective treatment for women with symptomatic uterine leiomyomata, being well accepted by the patients in the mid-term follow-up.     

Retención intraabdominal de feto posterior a legrado uterino. Comunicación de un caso

Uterine perforation during the first trimester after uterine curettage is a rare complication that occurs in 0.02% to 0.4% of all procedures. The presence of fetus or any of its parts is even less common. We report the case of a 19-year-old patient, gravida I, abortion I, who presented with abdominal pain 1 week after a curettage. Exploratory laparotomy was performed, revealing a perforation in the posterior portion of the right uterine horn with the presence of a fetus in the pouch of Douglas.     

Utilidad de la determinación del virus del papiloma humano en el primer control tras una conización

Objective

To estimate the negative predictive value of human papilloma virus (HPV) status in the first visit at 3 months after conization.

Material and methods

We evaluated the first follow-up visit in 208 patients who underwent conization in Hospital Donostia between January 1, 2003 and December 31, 2006.

Results

The negative predictive value of HPV status at 3 months after conization was 97.99% (95% CI 95.40-100), the positive predictive value was 47.92% (95% CI 32.74-63.09), sensitivity was 88.46% (95% CI 74.26-100) and specificity was 85.38% (95% CI 79.79-90.97).

Conclusions

Negative HPV status 3 months after conization is useful to evaluate cervical disease and could reduce the number of cytological examinations.     

Embarazo ectópico cervical: a propósito de 3 casos. Revisión de la práctica clínica

Three cases of cervical ectopic pregnancy treated medically are described. The first case with selective uterine artery embolization and methotrexate dose single, the second case with selective uterine artery embolization and methotrexate dose multiple, and the third case intraamniotic puncture and instillation of KCl due to persistent embryonic heartbeat was necesary, before selective uterine artery and methotrexate dose unique. A spontaneous evacuation of the cervical pregnancy occurred in all patients treated conservatively. We postulate that the preventive use of uterine artery embolization in combination with standard MTX treatment could contribute to reduce the risk of excessive bleeding and facilitate spontaneous expulsion. The diagnostic and therapeutic methods are discussed and the literature is reviewed.     

Influencia de la gestación de bajo riesgo en la calidad de vida relacionada con la salud percibida por las gestantes

Objectives

The aims of the present study were four-fold: to assess health-related quality of life (QoL) perceived by women with low-risk pregnancies in comparison with reference population values for women in the same age group; to determine whether low risk pregnancy by itself can modify perceived QoL; to determine the association between the physiological changes of pregnancy and perceived loss of QoL; to obtain reference values for QoL from the questionnaire Medical Outcomes Study (MOS) 36-Item Short Form (SF-36) for expectant mothers in their first or third trimester, given that to date we have found no Spanish publications on the topic.

Material and methods

We performed a cross-sectional survey of prevalence, with comparison of two independent groups. Measuring instrument: SF-36.

Conclusions

The expectant mothers showed a statistically significant loss in physical dimensions in comparison with the reference population values for women in the same age group; this loss was more significant as the pregnancy progressed, that is, the chronological progression of a normal pregnancy is, by itself, able to alter the quality of life perceived by the pregnant women, especially in the physical domain. No changes in the dimensions related to social or emotional functions were observed.The typical symptoms of pregnancy such as nausea and vomiting are able to alter physical and emotional functions.     

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.     

Conocimiento de los mecanismos de acción de los métodos de planificación familiar

Objective

To investigate women's knowledge of the mechanisms of action of birth control methods, especially those that act after fertilization, and to identify whether women want more information on this issue.

Methods

We performed a cross sectional study in a sample of 725 fertile women from primary care health centers in Pamplona (Spain) through a self-administered, anonymous, 30-item questionnaire on family planning. Univariate and multivariate logistic regression analyses were performed.

Results

Less than 5% knew all the mechanisms of action of oral contraceptives and the intrauterine device and only 7% knew those of the emergency contraception pill. Regardless of their beliefs, most women (91%) believed that they should be informed of any postfertilization effects.

Conclusions

To ensure their right to free choice,women should be informed of all the mechanisms of action of birth control methods.     

Revisión de la evidencia sobre la eficacia de los probióticos en la prevención de las infecciones del tracto urinario inferior y las infecciones vaginales

Objectives

To identify, critically evaluate and describe the available scientific evidence on the efficacy and safety of oral or vaginal administration of probiotics in preventing recurrent urinary tract infections and microbial or fungal vaginal infections.

Methods

An electronic search was performed in PubMed Central, the Cochrane Library and the meta-searcher TRIP databases using the terms: “Lactobacillus”, “probiotics”, “female urogenital diseases”, “urinary tract infections” and “genitourinary infections”.

Results

Of 20 studies that met the selection criteria for this review, a tendency to favor the use of probiotics was observed, especially in the population at high risk of bacterial vaginosis and fungal vulvovaginitis.

Conclusions

Probiotics are a promising option in the prevention of recurrences of lower urinary tract infections. Their use can be recommended as a safe and cost effective option especially in high risk subgroups.     

Éxito en el manejo conservador del acretismo placentario mediante embolización y metotrexato

Introduction

The incidence of placenta accreta has risen and this entity can cause postpartum hemorrhage, often requiring obstetric hysterectomy. There are, however, alternative conservative treatments to surgery.

Case report

A 38-year-old woman in her first pregnancy underwent manual removal of the placenta, with moderate hemorrhaging and subsequent curettage. The diagnosis was confirmed by ultrasound scan and magnetic resonance imaging. Selective embolization of the nutritional vessel was performed and methotrexate was administered. Three days after the embolization, the placental mass was expelled.

Conclusions

Selective embolization of a nutritional vessel and adjuvant treatment with methotrexate are conservative techniques that allow preservation of both the uterus and fertility. According to previous reports in the literature, the time interval between delivery and definitive placental expulsion was lower in our case than in other conservatively managed cases.     

Implantación de un sistema de gestión de riesgos en obstetricia: aprendiendo de los errores

Objective

To describe the implementation of a patient safety program in an obstetrics department and the results obtained.

Material and methods

The program was applied in all women admitted to the labor and delivery unit. To detect adverse events, a patient safety indicator system that allows monitoring over time was designed and an anonymous event reporting tool was activated.

Results

An adverse event occurred in 9.26% of hospitalized patients. Adverse events were more common in the puerperium (6.61%) and after cesarean delivery (16.04%) than in instrumental (10.63%) and vaginal delivery (7.40%). Most of the notifications concerned potential adverse events (near misses) and 72% led to improvements.

Conclusions

Our program detects adverse events and allows improvement measures to be designed. In obstetrics, safety is of great importance because of the potential effects to mother and child. Furthermore, childbirth is a frequent cause of hospitalization and litigation in obstetrics is common.     

Inversión uterina no puerperal: a propósito de un caso

Non-puerperal uterine inversion is a very infrequent event. The cause is often the presence of a fundal submucous leiomyoma, but diagnosis is difficult and requires a high index of suspicion.     

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.     

Recurrencia del tumor ovárico de las células de la granulosa

We present the case of a 79-year-old woman who was misdiagnosed with an ovarian fibroma 5 years previously. The patient presented with pain in the right iliac fossa with leukocytosis and was diagnosed with diverticulitis. A mass was incidentally found in the anterior abdominal wall, which was later confirmed as metastasis from a granulosa cell tumor of the ovary.We provide a literature review, focussing on the clinical findings and treatment of this tumor. Few reports have been published of this uncommon entity, characterized by a long natural history and tendency to recur years after the initial diagnosis.     

Teratoma inmaduro de ovario en la gestación

Ovarian tumors are estimated to occur in about 1 in 1000 pregnancies; of these, 3% are malignant. Most patients are clinically asymptomatic and the masses are usually detected in a routine abdominal examination during the second trimester of pregnancy. The management of these ovarian masses depends on their etiology and clinical findings. Surgical intervention is required when malignancy is suspected. Neoadjuvant chemotherapy is also indicated. Fertility conserving surgery should be attempted.