Síndrome de bridas amnióticas: caso clínico y revisión del tema

Amniotic band syndrome is a set of congenital birth defects consisting of constriction rings and limb or digit amputations, associated with the presence of amniotic bands. The incidence of this complication is low and its occurrence is sporadic. This syndrome usually causes constriction rings in the distal end of limbs or digits, which, in severe cases, can lead to complete amputation of the limbs or other malformations. Only 29-50% of cases are diagnosed prenatally. We report the case of a patient with an ultrasonographic diagnosis of amniotic band syndrome in week 12 of pregnancy.     

Embolismo del líquido amniótico: caso clínico y revisión de la literatura

Amniotic fluid embolism (AFE) is a rare but fatal syndrome occurring mostly during delivery or immediately postpartum. We report the case of a 33-year-old patient with no significant medical history. Coinciding with the rupture of the amniotic sac, the patient experienced dizziness that improved in the left lateral position with fluid therapy. Cardiac arrest occurred after delivery. After 45 min of cardiopulmonary resuscitation, the patient recovered but developed an atonic postpartum hemorrhage reversible with methylergometrine and misoprostol and the placement of a Bakri balloon. Disseminated intravascular coagulation was suspected and the patient was transfused with eight packs of red blood cells, three plasma concentrates and 2000 IU of Octaplex. The patient was then transferred to our hospital and admitted to the intensive care unit with a suspected diagnosis of AFE. On admission, she showed active metrorrhagia and hematuric urine, hemoglobin levels of 7.9, thrombocytopenia and coagulopathy, requiring transfusion of packed red blood cells, 1 platelet pool, 750 ml of plasma, fibrinogen and clotting factor VII. After correction of the coagulopathy, the bleeding stopped and the patient was discharged 6 days later.     

Valoración de la invasión miometrial en el carcinoma de endometrio mediante resonancia magnética

Objective

Evaluation of feability of magnetic resonance (MRI) in the assessment of the grade of myometrial invasion in endometrial carcinoma in our service.

Material and method

Retrospective study about pelvic MRI (dynamic, intravenous contrast media with gadolinium) sistematically made in the presurgical study of endometrial carcinoma in our service. 123 MRI were made in many other patients diagnosed of endometrial carcinoma between the year 2000-2004, both included. Afterwards, the results were contrasted with the histologic studies of the surgical piece.

Results

In 112 of the 123 neoplasms studied there was myometrial invasion valorated in the anatomopathologic study (paraffin sections). The MRI presented concordance with the histology in 101 cases, the positive predictive value (PPV) was 97% and although the negative predictive value (NPV) was 38.8%, the corrected negative predictive value (cNPV) was 87.5%.

Conclusions

Pelvic magnetic resonance with intravenous contrast media is a good technique to leave out deep myometrial invasion in endometrial carcinoma (cNPV: 87.5%), but its value is lower when pretending to asses superficial myometrial invasion (NPV 38,8%).When the uterine miomas are associated to endometrial carcinoma the specificity (25%) and the cNPV (14%) endure a great descent.     

Embolia de líquido amniótico

Amniotic fluid embolism is undoubtedly one of the most dangerous conditions of pregnancy and treatment is mainly supportive. We report the case of a patient with an amniotic fluid embolism at 41 weeks of pregnancy with a sudden episode of thoracic pain accompanied by dyspnea. The clinical presentation consisted of hypotension, hypoxia and coagulopathy, causing maternal and fetal death.     

Embolia no letal de líquido amniótico posterior a parto instrumentado

Amniotic fluid embolism is an uncommon and serious clinical syndrome that leads to high mortality. Its complex pathophysiology produces dyspnea, confusion, progressive heart failure and disseminated intravascular coagulation leading to death or severe neurologic sequelae. We report the case of a 39-year-old woman at 40 weeks of pregnancy who was admitted to hospital during labor. After 40 minutes of instrumental delivery, the patient developed sudden, abundant genital bleeding, hypotension, progressive loss of consciousness and “shock”. Early suspicion, immediate resuscitation, and multidisciplinary management of this complex clinical situation modified the outcome of this case.     

Rotura de cuerno uterino rudimentario en gestación de 22 semanas. A propósito de un caso y revisión de la literatura

Unicornuate uterus with rudimentary horn is a rare Müllerian anomaly with a high incidence of obstetric complications, affecting 4.5% of women. Pregnancy located in the rudimentary horn occurs in 1 in 76,000 pregnancies with a risk of uterine rupture of 50-80%. Rupture usually occurs at the end of the second trimester of pregnancy. Early diagnosis reduces morbidity and mortality, but ultrasound diagnosis has a sensitivity of only 30%, due to the low prevalence of this entity.     

Manifestación de leucemia promielocítica aguda en el embarazo

Acute promyelocytic leukemia, also known as M3 in the French-American-British classification, presents as severe hemorrhagic syndrome in 80% of affected pregnant women, posing a lethal threat to both mother and fetus. The results of multicenter studies suggest that the most effective treatment consists of the concomitant use of all-trans retinoic acid plus idarubicin. We present the case of a 32-year-old woman at 33 weeks of pregnancy with severe coagulation abnormalities due to acute promyelocytic leukemia, who was admitted to the intensive care unit for respiratory insufficiency due to an acute pulmonary lesion. The interest of this case lies in its infrequency. We describe the therapeutic management and initial course of the disease, as well as the prognostic implications of treatment during pregnancy.     

Agenesia lumbosacra. Expresión del síndrome de regresión caudal

Lumbosacral agenesis is an uncommon condition which is part of the caudal regression syndrome.     

Obesidad como factor pronóstico reproductivo en ciclos de fecundación in vitro-inyección espermática intracitoplasmática

Objective

To compare reproductive outcomes in our in vitro fertilization (IVF) program according to women's body mass index (BMI).

Subjects and methods

We included a total of 863 IVF-intracytoplasmic sperm injection (ICSI) cycles with controlled ovarian stimulation with GnRH antagonists.

Results

Patient age differed among the BMI groups but this difference was not clinically relevant (± 1 year). No significant differences were found among BMI groups in the duration of ovarian stimulation or in the total follicle-stimulating hormone dose used. However, there were significantly fewer selected follicles, retrieved oocytes, mature oocytes and transferred embryos at higher BMIs. Rates of pregnancy and live births were progressively and significantly reduced as BMI increased (group i: 41.4%, group i: 32.5%, group iii: 29.6%; P<.05).

Conclusions

Female overweight and obesity impair IVF outcomes. Pregnancy and live birth rates were progressively reduced as BMI increased.     

Embolia de líquido amniótico que debuta como asistolia durante el trabajo de parto

Amniotic fluid embolism (AFE) is infrequent in pregnancy or the postpartum, but the consequences can be devastating for both the mother and the fetus. We report the case of a 35-year-old primipara with sudden cardiac arrest during labor. Advanced cardiopulmonary resuscitation and peri-mortem cesarean section were performed. The clinical course was poor with multiple cardiovascular complications and severe coagulopathy, requiring hysterectomy. The patient died at 8 days and the neonate at 5 days. According to the most recent broad population-based studies, the incidence of AFE is between 1/15000 and 1/50000 childbirths, with mortality that is classically around 60-80%. Treatment is largely based on support measures and symptomatic treatment. The principal complications are hemorrhagic, cardiovascular and respiratory. Advanced life support measures should be started as soon as possible, aiming to maintain oxygen supply and circulation and arrest coagulopathy.     

Lesión quística en la pelvis: un caso de útero doble con hemivagina ciega

We report a case of uterine duplicity with blind hemivagina, hematocolpos and ipsilateral renal agenesis that manifested in adulthood with a cystic lesion in the pelvis. Uterine duplicity is a mesonephric or Wolffian anomaly inducing alterations in the fusion and resorption of the Müllerian duct during embryonic development, resulting in the presence of blind hemivagina and ipsilateral renal agenesis.     

Entrecruzamiento de cordones en la gestación gemelar monocorial monoamniótica

Monochorial monoamniotic twins are at high risk of fetal death due to the general complications seen in multiple gestations, as well as those specific to this type of pregnancy. The most severe complication in these pregnancies is fetal death due to cord entanglement, which occurs in almost all cases.Early ultrasonographic diagnosis and intensive prenatal surveillance are essential for the early detection of cord entanglement and the prevention of fetal death.The need for in-hospital management and the exact gestational age for delivery continue to generate controversy in the literature.     

Evisceración vaginal. Abordaje abdominal y reparación con malla sintética

Spontaneous vaginal evisceration is a rare phenomenon in daily clinical practice. Since McGregor reported the first case at the beginning of the past century, more than 70 cases have been reported to date. Spontaneous vaginal evisceration usually occurs in patients with postmenopausal hypoestrogenism associated with previous gynecologic surgery. This entity has recently been described in non-gynecological conditions after perineal proctectomy. We present a new case of spontaneous vaginal evisceration in a postmenopausal woman with previous gynecological surgery. Surgical mesh repair was performed through conventional laparotomy.     

Sludge amniótico como marcador ecográfico en una gestación gemelar con parto diferido del segundo gemelo

The presence of amniotic fluid sludge is a marker of poor obstetric prognosis because of its association with preterm delivery, which carries greater perinatal morbidity and mortality. The prevalence of multiple pregnancies has increased in the last few years. These pregnancies are at risk of preterm delivery, which sometimes occurs at very preterm gestational ages. Delivery of the first twin is usually soon followed by that of the second twin and an interval of days or even weeks is unusual. We present the case of a twin pregnancy with delayed interval delivery of the second twin and a finding of amniotic sludge in the ultrasound assessment.     

Secreción por ambas axilas sin presencia de pezón supernumerario

We report the case of a patient who developed bilateral axillary secretion on the eighth day of lactation. On examination, there were no supernumerary nipples and secretion was through the skin pores. Ultrasound study revealed ectopic breast tissue.     

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.     

Manifestación atípica de hígado graso agudo del embarazo

Acute fatty liver of pregnancy is an uncommon but highly serious entity. The classical features are abdominal pain, nausea, vomiting, and elevated liver enzymes. Acute fatty liver of pregnancy can also present with atypical features with insidious onset and other clinical manifestations that are infrequent in this entity.     

Inserción velamentosa extrema de cordón umbilical, sin rotura de vasa previa

Velamentous insertion of the umbilical cord appears in one out of every 100 pregnancies and can prove life-threatening for the fetus. Consequently, prenatal diagnosis through ultrasound scanning is required, at least in women with a risk of vasa previa, such as those with multiple pregnancies, in vitro fertilization, or placenta previa, who will require an elective cesarean section.We present an extreme case of velamentous insertion of the umbilical cord, in which the vascular distribution was reminiscent of a bird's cage. Surprisingly, there was no vascular injury.     

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.     

Adecuación de la profilaxis antibiótica en el parto por cesárea

Objective

To evaluate compliance with a protocol for antibiotic prophylaxis in cesarean sections and its influence on the incidence of surgical wound infection.

Patients and methods

A prospective cohort study was carried out to assess compliance with our antibiotic prophylaxis protocol. Percentages of compliance and the cumulative incidence of infection were calculated. The effect of compliance with the protocol for antibiotic prophylaxis on surgical wound infection was estimated with the relative risk.

Results

We included 680 patients. Overall compliance with the protocol was 95.7%. The most frequent cause of lack of compliance was the time of administration (96.6%). The cumulative incidence of infection was 2.5% and there was no association between compliance with the protocol and the infection rate (RR = 4.5; 95% CI: 0.55-38.4; P>.05).

Conclusions

Compliance with the protocol for antibiotic prophylaxis was high. The cumulative incidence of surgical wound infection was low and was unrelated to antibiotic prophylaxis.