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.     

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.     

Gestación heterotópica en inseminación artificial

We report a case of heterotopic pregnancy, which is of interest due to its low incidence and the serious complications that can ensue when diagnosis is delayed. Most of the heterotopic pregnancies described occurred after in vitro fertilization techniques. These pregnancies are less frequent after artificial insemination and are exceptional in spontaneous pregnancies. Our objective is to emphasize the increase in this type of pregnancy in the last few years due to assisted reproduction techniques and to highlight the importance of early diagnosis.     

Malformación arteriovenosa uterina como causa de hemorragia puerperal tardía

Arteriovenous malformation (AVM) of the uterus should be included in the differential diagnosis of patients with postpartum hemorrhage that does not yield to routine measures and may even worsen after curettage. Color Doppler sonography can aid in the diagnosis and clinical management of this entity. Although the classical treatment has been hysterectomy, conservative treatment with uterine artery embolization should currently be considered the first therapeutic option for these lesions because of its safety and effectiveness. We report the case of a patient with delayed postpartum hemorrhage and AVM successfully resolved with selective embolization of the left uterine artery.     

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.     

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.     

Gestación heterotópica triple: gestación gemelar intrauterina

Heterotopic pregnancy is increasingly common in Spain mainly due to the greater use of in vitro fertilization techniques. We report a case of heterotopic pregnancy after artificial insemination in a patient who consulted for mild metrorrhagia. Ultrasound examination showed a diamniotic dichorionic twin pregnancy and a singleton intrauterine gestation in the right tube. The case was resolved by laparoscopic unilateral salpingectomy. The symptoms of these rare pregnancies are nonspecific. Moreover, they are usually underdiagnosed, because the adnexa are not usually examined when an intrauterine gestational sac is found. Due to the severity of maternal and fetal compications, early diagnosis is essential.     

Resultados obstétricos y perinatales de la implementación de un programa de versión externa cefálica

Objectives

To evaluate the effectiveness of the external cephalic version, the time required for its completion, the safety of the technique, its effectiveness in reducing the rate of caesarean sections and the perinatal outcomes.

Methods

The study included 180 pregnant women with pelvic presentation at term. Routine cardiotocographic monitoring and an ultrasound were used pre-and post-release version for foetal welfare and presentation.

Results

Success was achieved in 30% of the external cephalic version (ECV) cases during the first year, while 61.90% was successfully achieved during the fourth year. Vaginal births accounted for 61 out of the 93 successful versions, the spontaneous reversal rate was 5.37% and the spontaneous version rate following failed external version, was 3.44%. In 45 cases (25%) some kind of minor adverse effect was found and in 18 cases it was due to the use of uterine relaxants.

Conclusions

The ECV is safe and useful for reducing caesarean rates. The experience of the obstetrician who performed the technique plays a key role in ensuring success.     

Análisis del dolor en la versión cefálica externa

Objective

To analyze the maternal perception of pain during external cephalic version.

Material and methods

A prospective study was carried out on 71 patients at the Hospital de Cruces between April 2005 and April 2006, based on personal surveys conducted after the version. These surveys included a «numeric pain intensity rating scale» as well as a series of questions regarding the procedure. Results were analyzed in terms of success or failure of the procedure.

Results

The overall success rate was 50.7%. The procedure was well tolerated by all pregnant women, with no complications being observed. The overall median pain stood at 7; 5 in successful versions, as opposed to 8 in unsuccessful versions (P<.01). A total of 83.1% of patients stated that they would be willing to undergo the procedure again in the future, more than 50% of them basing their decision on the benefits of cephalic delivery.

Conclusions

The fact that external cephalic version is a well tolerated procedure is probably due to its brevity, although it must be noted that it is not a pain-free maneuver.     

Resucitación fetal intrauterina

Introduction

Intrauterine fetal resuscitation includes a series of procedures performed in the mother to improve fetal oxygenation by correcting the cause of fetal compromise manifested by non-reassuring fetal heart rate.

Material and Methods

A literature review was performed with evaluation of the scientific evidence for the techniques traditionally used for this purpose (maternal position, intravenous fluids, oxygen, intrapartum tocolysis and amnioinfusion).

Results

Although the evidence could be more robust, there are sufficient data to suggest that these techniques benefit the fetus, and the risk of harm is minimal when used with common sense. These procedures do not reverse the state of fetal hypoxia but can help to improve fetal oxygenation during the process of preparing for delivery.

Conclusion

Until more data are available, it seems reasonable to err on the side of fetal safety by using these techniques when appropriate, based on the specific fetal heart rate pattern or any other intrapartum fetal surveillance test.     

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.     

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.     

Inversión uterina puerperal

Introduction

Uterine inversion is a rare obstetric emergency that occurs during the third stage of labor

Objective

To describe the clinical, diagnostic and therapeutic characteristics and outcomes in patients with uterine inversion.

Material and methods

We performed a retrospective study of six patients with uterine inversion during the puerperium in the Hospital de Leon (Spain) in 2005.

Results

All inversions occurred in primiparous women with epidural anesthesia and instrumental delivery at term. Oxytocin was used in 83% during dilatation; the average duration of which was 6.5 hours. Diagnosis was mainly clinical except in one grade II inversion, which required ultrasonography and was resolved surgically. The remaining cases were resolved through manual reduction (83%). After the episode, hemoglobin levels were reduced by an average of 2.7 g/dl from prepartum levels, and only two patients required blood transfusion.

Conclusions

Factors predisposing to uterine inversion were hypotonic uterus, fundal implantation of the placenta, and placenta accreta. Sixty percent of all cases were caused by precipitous maneuvers including traction on the cord or improper fundal pressure. Diagnosis is essentially clinical. Although uncommon, uterine inversion will result in severe hemorrhage and shock if left unrecognized, leading to maternal death. Once a diagnosis is made, immediate measures must be taken to stabilize the mother. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as ritrodine, magnesium sulphate and terbutaline, or halogenated anesthetics may be administered to relax the uterus and aid its reversal. Intravenous nitroglycerin is an alternative to tocolytics. Failure of reversion or recurrence requires surgical treatment.     

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.     

Papel de la inseminación intrauterina en la era de la fertilización in vitro

Intrauterine insemination is a low-complexity assisted reproduction technology in which previously washed sperm are deposited in the uterine cavity with ovarian stimulation. This invasive technique is well accepted by patients and achieves cumulative pregnancy rates similar to those obtained in a single cycle of more complex assisted reproduction techniques. We compared two methods of assisted reproduction: in vitro fertilization and intrauterine insemination in relation to their effectiveness and cost. We conclude that intrauterine insemination is the first-line treatment in male factor infertility without severe disruption or unexplained infertility; pregnancy can be achieved with 3 to 6 cycles in a high percentage of these cases at lower cost and with lower risk of multiple pregnancy than with in vitro insemination. We did not consider other techniques, such as intracytoplasmic sperm injection, which is also indicated for the treatment of male factor infertility, since this technique requires greater technical and human resources, thus precluding comparison.     

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.     

Gestación tras embolización bilateral de arterias uterinas por hemorragia obstétrica

We report a case of normal pregnancy and delivery after bilateral embolization of uterine arteries due to postpartum hemorrhage in a previous pregnancy.The introduction of pelvic arterial embolization in the management of postpartum hemorrhage refractory to medical treatment avoids emergency obstetric hysterectomy, which used to be required in most cases, with the possibility of preserving fertility. Nevertheless, there are still only a few published cases of pregnancies after embolization of both uterine arteries for an obstetric cause.     

Vaginoplastia mediante interposición de membrana amniótica

Objective

To study the results and complications of the technique performed by Dr. G. Sancho Leza for the creation of a neovagina using amnion in patients with vaginal agenesis.

Material and method

A retrospective study of 16 women who were diagnosed with vaginal agenesis in our service from 1989 to 2005 was performed.

Results

The neovagina created with this procedure allowed sexual activity in all women. Two women required reintervention due to stenosis. There were no graft rejections or serious postoperative complications.

Conclusions

Vaginoplasty using amnion produces good results and fewer complications than other procedures using different materials.     

Expulsión vaginal de los miomas tras la embolización de las arterias uterinas

We present 2 cases of spontaneous transcervical expulsion of myoma after uterine artery embolization as a primary treatment of leiomyomata, which produced symptom improvement. Subsequent follow-up was performed with hysteroscopy and magnetic resonance imaging.