Vasa previa: diagnóstico prenatal ecográfico y conducta obstétrica

Vasa previa is an uncommon obstetric complication in which aberrant vessels coming from the placenta or the umbilical cord cross over the internal cervical os, thus appearing immediately before the foetal presentation. If it is not diagnosed before the onset of labour or rupture of membranes, the perinatal outcome is general very poor. We report a case of vasa previa which was prenatally diagnosed by ultrasound in a woman presenting with antepartum bleeding and a low-lying bilobular placenta in the third trimester. The aetiology and clinical management of this condition are discussed.     

Histerectomía obstétrica por sepsis en el puerperio

Bleeding of obstetric origin and severe pelvic infections are the main causes of hysterectomy in the puerperium. Timely diagnosis and hysterectomy influence the outcome of these patients.     

Desarrollo evolutivo infantil,patología obstétrica y repercusión sociofamiliar en nacidos antes de la semana 29

Objectives

To determine the outcomes of infants born at less than 29 weeks’ gestation, obstetric abnormalities, and the social and familial repercussions of this prematurity.

Material and methods

We retrospectively studied 28 infants, born at less than 29 weeks’ gestation, referred to the Early Healthcare Program of the Cantabrian Government between January 2002 and June 2006.

Results

The main causes of prematurity in this group were chorioamnionitis, placental abruption, and preterm labor. Of the infants studied, 28.57% had a disability. Severe mental retardation and cerebral palsy was found in 37% and moderate mental retardation in 24%. Bilateral hypacusis, respiratory alterations and mild mental retardation were found in the remainder. The main social repercussions were a change in family roles, negative economic effects, and heavy emotional burden.

Conclusions

A total of 28.57% of the infants studied had a recognized disability. No predominant obstetric abnormality was identified. However, the social and familial repercussions were substantial.     

Rotura uterina anteparto: importancia diagnóstica de la ecografía obstétrica

Uterine rupture is an uncommon event but can cause serious damage to both the mother and fetus. We report a case of spontaneous uterine rupture in a 37-week pregnant woman that occurred before the onset of labor. Obstetric ultrasound was the key to diagnosis, providing information not given by abdominal ultrasound or magnetic resonance imaging. Early laparotomy allowed a healthy newborn to be delivered and the uterine defect to be corrected. Subsequently, an exhaustive history was taken, revealing the antecedent of two curettages performed in two previous pregnancies as the only risk factor for this complication.     

Desgarro rectovaginal con esfínter anal íntegro: una complicación obstétrica infrecuente

The incidence of isolated rectovaginal tear is low in obstetrics and the scarcity of publications on the subject contributes to the lack of consensus on its management. The present article describes the occurrence of two such injuries in our hospital (1800 births / year) over the course of 10 years. Through a literature review, we discuss the risk factors and principles of treatment. Early detection of the injury is essential, as well as meticulous surgical repair. Forceps seems to be the main causative factor and therefore choice of less harmful instruments is advisable, especially in the elderly, primiparous patients, and macrosomic fetuses.     

Análisis de la variabilidad interobservador en la interpretación de la radiopelvimetría y su utilidad en la práctica obstétrica actual

Introduction

X-ray pelvimetry has been directly associated with an increase in the rate of cesarean sections and consequently this technique has fallen into disuse.

Objectives

To analyze the impact of evaluator subjectivity in the interpretation and evaluation of X-ray pelvimetry in order to determine the usefulness of this technique as an objective complementary test.

Materials and methods

We carried out a prospective study of X-ray pelvimetry in 113 primiparous pregnant women prior to labor induction. The scans were measured and interpreted independently and blindly by three researchers with wide experience in obstetrics.

Results

There were discrepancies between the first two researchers on 60 occasions (45.11%) and assessment by the third researcher was required on 49 occasions (36.84%).

Conclusions

X-ray pelvimetry lacks value in predicting delivery route since there is wide interobserver variability in the measurement and interpretation of scans.     

Tasa de partos instrumentales en España

The Spanish Society of Gynaecology and Obstetric and several National and International Health bodies currently advocate a more physiological care instead of a more medicalised care. However, the incidence of instrumental deliveries is high in Spain (23%) compared with other Western Countries (10% rate), and the reason for some is not well justified, as 40% of these is done to prevent problems or teaching. Also, the use of forceps (52%) compared to the total number of instrumental deliveries is high (20% incidence). Instrumental delivery, particularly forceps, is a very important risk factor for grade III and IV tears, which in turn increase the risk of faecal and air incontinence in women. Thus, in this country it is vital to optimise the system to review the rate of instrumental deliveries and the use of forceps in the total.     

Evolución del porcentaje de episiotomía en un hospital comarcal entre los años 2003–2009. Factores de riesgo de los desgarros graves de periné

Objective

The primary objective of this paper is to present the evolution of the episiotomy rate between the years 2003-2009, following a policy of restrictive use and its possible influence on the rate of severe lacerations and perinatal morbidity in the short term.

Methods

This is a retrospective study based on a cohort made up of women who gave birth in our hospital (9023 women). The valued parameters are: changes in the episiotomy rate, percentage of severe perineal tears according to the use of episiotomy or not. Normal vaginal deliveries versus instrumental ones and the type of instrumental delivery. Apgar score below 7 at five minutes. A multivariable logistic regression was performed in order to assess the relationship between risk factors and the incidence of severe tears.

Results

The episiotomy rate ranged between 40.37% in 2003 and 8% in 2009, the downward trend was statistically significant. The rate of severe tears remained between 0.49% and 1.04% that change was not statistically significant. There was no significant variation in the rate of Apgar score less than 7 at 5 minutes. The odds ratio (OR) of having a serious perineal tear is 2.99 (95% CI 1.47 to 6.05) in women who had an episiotomy compared with those that did not have it, the 2.40 (95% CI 1.16 to 4.99) in the instrumental delivery versus eutocic delivery and the 6.43 (95% CI 1.50 to 27.49) in forceps deliveries compared with vacuum deliveries.

Conclusions

Over a period of 7 years the episiotomy rate was reduced by 80% without modifying the rate of serious perineal tears, and the short-term perinatal morbidity remained constant.     

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.     

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.     

Embarazo ectópico cervical: diagnóstico y tratamiento

We report a case of cervical ectopic pregnancy treated with methotrexate and abdominal hysterectomy.     

Teratoma sacrococcígeo: diagnóstico y seguimiento

We report a case of sacrococcygeal teratoma diagnosed in routine morphologic evaluation using ultrasonography at 21 weeks. At diagnosis, measurements were 38 × 38 × 42 mm, and there were no associated alterations. After serial ultrasound scans, rapid tumoral growth was found, as well as other alterations induced by compression of the mass and high vascularity, ending in fetal death at 28 + 2 weeks. At this time, tumoral size was 353 mm. Vaginal labor was provoked, with extraction of a hydropic male fetus weighing 2170 g.     

Correlación entre la medición ecográfica del cordón umbilical y la edad gestacional,su relación con la biometría fetal y los resultados perinatales

Aim

(a) To evaluate the umbilical cord in normal pregnancies using ultrasonography in the third trimester with a view to obtaining gestational age values according to reference tables. (b) To compare umbilical cord measurements with fetal biometry, length, weight and perinatal outcomes to determine whether this type of correlation exists in our population and whether it could be used to establish values of normality that would help to diagnose abnormalities.

Material and methods

From Juny 2001 to June 2002 we studied 48 pregnat women that have been controlled by ultrasound from week 28 to 38 of gestation. We just included patients with normal and controlled pregnancies, without any associated pathology. We obtain biparietal diameter, abdominal circumference, femoral long measurement, and umbilical cord diameter through a transversal cut of the umbilical area. Gestational age was obtain by last menstruation and by ultrasound according with biometry. measurement of the umbilical cord was compared with a nomogram of the gestational age (GA) performed by the Obstetric and Gynaecology Department of the Insubria University in Italy.We registered the type of birth the GA at birth, APGAR score length, weight, cephalic diameter, and eventually complications. For calculate the normal umbilical cord area according to the gestational age by last menstruation we use the Raio et al equations to construct the corresponding nomogram. It was apply statistics methods with an alfa of 5%.

Results

LMP-based gestational age was highly correlated with ultrasound measurements. Theoretical UCA was not correlated with observed UCA. Only 54.2% of UCAs were found to be within the 5th and 95th percentiles (P =0.001), and consequently only two-thirds of the patients were within the parameters of normality. No correlation was found between UCA and gestational age, when attempting to construct a nomogram for our population (P=.99). No association was found between UCA and fetal biometry parameters. No significant correlation was found with weight, length, head circumference or gestational age at delivery. Apgar score was favorable and stable in all neonates; Apgar score was thus considered a constant and was not correlated with UCA. UCA was significantly lower in women who underwent cesarean section than in those with normal deliveries (P<.05).

Conclusion

UCA was not correlated with gestational age, fetal biometry or perinatal outcomes. Values in our population cannot be extrapolated to existing nomograms.     

Utilidad de la determinación del pH vaginal para el diagnóstico de las vulvovaginitis y su relación con la patología obstétrica

Objective

To assess the usefulness of vaginal pH determination in the first prenatal visit in the diagnosis of vulvovaginitis and its association with obstetric abnormalities.

Material and methods

We determined vaginal pH in the first prenatal visit in 200 low-risk pregnancies. In 103 women, vaginal secretions were cultured, independently of their symptoms. In the remaining 97 women, culture was performed only if symptoms were present and/or pH was >4.5. Treatment was prescribed in symptomatic women only. The pregnancies were followed up to evaluate obstetric abnormalities and data on deliveries.

Results

The mean pH in the study sample was 4.41 (4.04–4.78). We found a statistically significant association (P<.000) between an increase in vaginal pH over 4.5 and isolation through culture of Gardnerella vaginalis (G. vaginalis), with an OR of 35.15 (4.67–730.39). Most cultures were normal. In order of frequency, the identified microorganisms were Candida albicans (C. albicans) (17.5%), G. vaginalis (7.8%) and Streptococcus agalactiae (7.8%). More than 85% of the carriers were asymptomatic. Obstetric pathology in our sample consisted of preterm labor (2%), premature rupture of membranes (2%), preterm delivery (4.5%) and miscarriage (6%).

Conclusions

Vaginal pH determination might be an effective screening test for the diagnosis of bacterial vaginosis. The most prevalent microorganism in our sample was C. albicans and most carriers were asymptomatic. We found no relationship between obstetric pathology and the microorganisms isolated in cultures of vaginal secretions.     

Leiomioma perineal grande en gestante de 9 semanas

Perineal leiomyoma are rare mesenchymal tumours classified as somatic or retroperitoneal. The retroperitoneal variety are mainly related to women during the peri-menopausal phase. Diagnosis is directed at differentiating them from leiomyosarcomas and gastrointestinal stromal tumours. We report on a case of a 30-year-old and 9-week pregnant woman. She consulted due to a progressive growing mass in the right ischiorrectal fossa coinciding with pregnancy, but with sparse symptoms. Surgery was performed through a perineal access with a complete resection of a 9 cm tumour.     

Leucorreas líquidas y cremosas: diferencias clínicas y microbiológicas (estudio prospectivo de 1 año)

Objective

We performed a prospective 1-year study to identify the clinical and microbiological characteristics of liquid and creamy leukorrheas.

Design and method

We classified leukorrheas into liquid and creamy, according to their appearance and characteristics in vaginal examination with a speculum. Samples were taken for cervicovaginal cytology. A further sample was taken with a cotton-swab for transfer to a medium for microbiological culture.

Results

The mean age of the women was 30 years (range, 16-62 years). Fifty percent were nulligravidas. The leukorrheas were found in the second phase of the menstrual cycle in 60% of the women and were more frequent in spring (March and April). The leukorrheas were white in 50% and yellow in 25%. Pruritus was found in 25%. The vulvas were depilated in 25%. Sixty percent of the women used no contraception. Twenty-three percent were foreigners. Cytology was positive in 35%. The most frequent diagnosis was bacterial vaginosis in 17%. Culture was negative in 88%. In positive cultures, the most frequent organisms were Gardnerella vaginalis in 37% and Candida albicans in 31%.

Conclusions

Liquid leukorrheas were more physiologic as cultures were negative in 50%. The most frequent organisms were G. vaginalis and C. albicans, each being found in 17.30% of patients. Creamy leukorrheas were more pathologic, with positive culture in 61.42%. The most frequent organisms were G. vaginalis in 22.85%, Candida spp in 21.25%, and C. albicans in 14.28%.     

Miomas y función sexual. Estudio prospectivo de un año

Objective

To prospectively study sexual function in women with myomas over a 1-year period. Absence of sexual desire, absence of arousal, anorgasmia, dyspareunia and pelvic pain were compared in women with myomas versus controls.

Design and method

A total of 172 women with myomas (largest diameter: 3-5 cm) and 80 women (largest diameter > 5 cm) were examined in the author's consulting rooms in 2009. Both groups were compared with control groups paired by age. The two myoma groups were also compared between each other. Sexual data were gathered through personal interviews.

Results

The most statistically significant differences were the following: in the group of women with myomas measuring 3-5 cm, differences were found in medical history (P < .001), absence of sexual desire (P < .01), vaginal dryness (P < .05), subserosal myomas (P < .001) and in equal size of the myoma at 1 year (P < 0,001); in the group of myomas measuring > 5 cm, differences were found in the absence of sexual relations (P = .02), intramural myomas (P < .001), increased size of the myoma at 1 year (P < .001), and in pain (P = .02). No significant differences were found in sexual parameters (sexual desire, arousal, orgasm, dyspareunia, and vaginal dryness) between each group or their controls.

Conclusions

1) In women with myomas measuring 3-5 cm, statistically significant differences were found in the absence of sexual desire (P < .01) and in vaginal dryness (P < .05). 2) In myomas measuring > 5 cm, statistically significant differences were found in the absence of sexual intercourse (P = .02), in increased size of the myoma at 1 year (P < .001) and in chronic pelvic pain (P = .02).     

Evaluación del protocolo de actuación clínica en el legrado obstétrico por aspiración

Objectives

To assess a clinical intervention protocol for aspiration curettage based on a nonstandard procedure for presurgical evaluation, continuous ultrasonographic monitoring, and performance of the process in an outpatient room.

Subjects and methods

We reviewed 1,600 surgical procedures carried out in our hospital according to our protocol. Surgical times, the complication rate and patient satisfaction were analyzed.

Results

The mean surgical time was 6.88 minutes. There were five surgical complications (0.3%). Medical complications occurred in 39 patients (2.4%). Dilatation was easy in 97.8%, difficult in 1.7% and very difficult in 0.6%. Tolerance to the technique was considered as excellent or good by 96.8% of the patients.

Conclusions

Assessment of the clinical intervention protocol in obstetric aspiration curettage is safe, effective and quick.