Embarazo ectópico primario en epiplón. Reporte de caso

Abdominal pregnancy occurs in one out of 10,000 deliveries. Omental ectopic pregnancy is the least common of these pregnancies and diagnosis is generally made during laparotomy. We report the case of a 28-year-old woman, secundigesta, secundípara, who presented with menstrual delay, cutaneous-mucosal pallor, and severe abdominal pain. During laparotomy, the presence of omentum was observed in the pelvis and uterus. Both adnexa were normal. A tumor was found on the inferior border of the omentum. The tumor was removed and partial omentectomy was performed. A primary omental ectopic pregnancy was diagnosed.     

Resultados perinatales en 492 presentaciones podálicas: cesárea vs. parto vaginal

Objective

To analyze the perinatal results in our hospital comparing vaginal delivery and cesarean section in breech presentation singleton pregnancies at term.

Material and Methods

All live ante-partum singleton fetuses in breech presentation, at 37 to 41+6 weeks and days who delivered between July 2006 and August 2010 were included in the study. We compared perinatal results between cesarean section and vaginal delivery.

Results

There were no differences in Apgar score at 5 minutes < 7, pH umbilical cord < 7, base deficits and lactate, neonatal intensive care unit admission or perinatal mortality.

Conclusions

With appropriate maternal and fetal conditions and a qualified medical team, a breech vaginal delivery could be propose obtaining good perinatal outcomes.     

Éxito del tratamiento de las infecciones urinarias en gestantes tratadas con cefditoren pivoxilo vs. amoxicilina

Objectives

To compare the efficacy of cefditoren pivoxil versus amoxicillin in the treatment of urinary tract infections (UTI) and to evaluate the rate of reinfection and of maternal-fetal complications in both groups.

Material and methods

We performed a cohort study in pregnant women with a diagnosis of UTI in the Vall d’Hebron Hospital from January, 2010 to June, 2010. Diagnosis, follow-up and subsequent evaluation of the mother and infant were performed in both groups.

Results

We included 300 pregnant women diagnosed with a UTI: 150 patients received oral cefditoren pivoxil (400 mg/12 hours for 5 days) and 150 women received amoxicillin. No demographic differences were observed between the two groups. Disappearance of the infection was confirmed in 150 patients in the cefditoren pivoxil group versus 67% of those in the amoxicillin group (P=.03). Both the reinfection rate and the frequency of pyelonephritis were higher in the amoxicillin group [17.3% versus 4.6% (P=.02) and 40.6% vs 2.6% (P=.01) respectively]. There were no differences in hospital stay (2.4 days vs 2.5 days). Adverse effects were observed in 1.33% (two patients) in the cefditoren pivoxil group versus 0% in the amoxicillin group.

Conclusions

In this study, cefditoren pivoxil produced a higher cure rate and a lower reinfection and pyelonephritis rate than did amoxicillin. Cefditoren pivoxil might be a therapeutic alternative in pregnant women with UTI. Further studies are needed to confirm these results.     

Análisis de los factores de influencia sobre el resultado de 500 ciclos de inseminación intrauterina homóloga

Objective

To evaluate the results and analyse different factors influencing pregnancy rate using homologous intrauterine insemination.

Subjects and methods

Retrospective analysis of 500 homologous intrauterine insemination cycles in 183 infertile couples. Only one insemination per stimulated ovarian cycle was performed in patients with: mild endometriosis, ovulatory factor, male subfertility or unexplained infertility. We studied female age, duration of infertility, stimulation protocol, number of cycle, number of preovulatory follicles, motile sperm count and endometrial thickness related to pregnancy rate.

Results

Pregnancy rate per couple was 24% and per intrauterine insemination 9%, 11% was multiple pregnancies. Best outcome has been got in women younger than 37 years (P=.048) and in cycles with more than one preovulatory follicle. Other studied factors did not have influence in homologous intrauterine insemination outcome.

Conclusions

Female age is a prognostic factor for homologous intrauterine insemination with poor outcome in women older than 38 years. Cycles with more than one preovolatory follicle have better outcome. No differences in pregnancy rate have been achieved with motile sperm count over 1.5 millions/0.3 ml.     

Pronóstico perinatal y materno de las gestaciones gemelares concebidas mediante fecundación in vitro,en relación con las obtenidas espontáneamente

Objective

To determine the outcomes of twin pregnancies resulting from in vitro fertilization (IVF) compared with those resulting from spontaneous conception.

Material and methods

We performed a historical cohort study comparing neonatal outcomes of twin pregnancies resulting from IVF (n = 44) with those resulting from spontaneous conception (n = 109) in the Complejo Hospitalario Universitario de Albacete (Spain) in 2001, 2001 and 2003. The primary variable was perinatal mortality. Secondary variables were fetal morbidity (neonatal abnormalities, Apgar < 7, acidotic arterial pH, admission to the neonatal unit), preterm delivery, maternal complications, and type of delivery.

Results

No differences in perinatal mortality and morbidity were found between spontaneous twin pregnancies and twins resulting from assisted reproductive techniques. The rate of preterm labor was significantly higher in spontaneous twin pregnancies (75.2 versus 52%; p = 0.006). The incidence of gestational diabetes was significantly higher in twin pregnancies resulting from IVF than in spontaneous twin pregnancies (25.5 versus 9.7%;p = 0.01).

Conclusions

Perinatal and maternal outcomes in twin pregnancies resulting from IVF are similar to those of spontaneous twin pregnancies.     

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.     

Factores psicológicos en mujeres que padecen pelvialgia crónica grave operadas por laparoscopia o laparotomía

Purpose

To analyze the importance of psychological factors, understood as levels of anxiety and depression, among women with chronic pelvic pain and to evaluate the possibility of a relationship between these psychological factors and the persistence of pain after surgery.

Material and methods

We studied 41 women with chronic pelvic pain for more than 6 months who had undergone laparoscopy or laparotomy as a diagnostic-therapeutic method. The results in these women were compared with those in a control group of 86 women attending the clinic for bilateral tubal ligation. These patients were interviewed before surgery to evaluate their depression and anxiety levels using the Beck test and the STAI scale. The persistence of pain after surgery was assessed through a telephone survey.

Results

Levels of depression and anxiety were higher in the chronic pelvic pain group than in the control group but no differences were found in the trait anxiety variable. When interviews were carried out 3 months after surgery, the percentage of patients who continued to have postoperative pain was significantly higher in the chronic pelvic pain group than in the control group.

Conclusion

Quality of life is impaired in women experiencing pelvic pain for more than 6 months, due to increased levels of depression and state anxiety. Persistence of pain 3 months after surgery, despite elimination of its apparent gynecological cause, could be influenced by anxiety and depression.     

Abordaje conservador del embarazo ectópico cervical

Cervical pregnancy is a rare form of ectopic pregnancy with a high risk of hemorrhage. Early diagnosis is an important prognostic factor for survival and preserved fertility in these patients. We present the case of a patient diagnosed with cervical ectopic pregnancy in her seventh week of gestation. The therapeutic management was conservative and involved the combination of systemic and intra-amniotic methotrexate Because of the lower associated morbidity and mortality and the possibility of maintaining the patient’s fertility, conservative treatment is a viable therapeutic approach in cases such as that presented herein.     

Pronóstico y resultados en pacientes diagnosticadas de endometriosis a las que se les ha realizado por primera vez una cirugía conservadora por dolor o esterilidad

Objective

To analyze clinical outcomes in patients with suspected endometriosis undergoing conservative surgery. Pain reduction, pregnancy rates, and reinterventions were analyzed.

Material and methods

Patients with suspected endometriosis and symptoms of pain or infertility undergoing conservative surgery for the first time were included (n = 128). Exclusion criteria consisted of incomplete medical histories and interventions indicated for reasons other than pain or infertility.

Results

Surgery was indicated for pain in 70.3% and for infertility in 29.7%. A total of 32.5% of the patients had pain at the first postsurgical visit, 42.5% at 6 months and 58.3% at 1 year. Reintervention was performed in 11.29%. Among reinterventions for pain, there was a higher percentage of intestinal symptoms before surgery (P=.07), as well as episodes of abdominal pain requiring hospital care (P=.08); a higher proportion of these patients had pain in the first visit (P=.05) and at 1 year (P=.03) than patients not undergoing reintervention. Postsurgical medical treatment was less frequent in patients undergoing reintervention (P=.11). Among patients undergoing surgery for infertility, pregnancy was achieved in 65.8%.

Conclusions

Pain was less frequent in the first postsurgical visit than in subsequent visits. Among patients undergoing reintervention for pain, there was a higher percentage of intestinal symptoms and episodes of abdominal pain requiring hospital care prior to the intervention. Pain at the first visit and at 1 year are factors of poor prognosis for reintervention. Patients undergoing reintervention for pain less frequently required postsurgical medical treatment. More than half of patients with interfertility and endometriosis achieved spontaneous pregnancy after surgery.     

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.     

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.     

Lesiones del tracto urinario en cirugía ginecológica

We retrospectively analyzed 27 patients with urinary tract injuries who underwent gynecologic surgery from January 1, 2001 to December 31, 2009. The type and timing of injury, diagnostic methods and management of urinary fistulas were evaluated.Twenty-seven urological injuries were incurred during 6,276 gynecologic surgical procedures, representing an incidence of 0.43%. There were 12 urethral injuries and 15 bladder injuries, with an incidence of 0.19% and 0.24%, respectively. Urinary tract injury was diagnosed intraoperatively in 15 patients (55.5%) and postoperatively in 12 (44.5%). Urinary fistulas occurred in nine patients (33%).Most of the urinary tract injuries occurring in gynecologic surgery had optimal results when diagnosed early and managed correctly.     

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.     

Manejo del embarazo prolongado no complicado: ¿inducción o espera?

Objective

To assess our protocol of performance at the post-term pregnancies, determining if the induction of labour at 42 weeks’ gestation entails more mother-foetal benefits than the later ending of it.

Methods

64 uncomplicated post-term pregnancies that decided to finish her pregnancy at 42 weeks were compared with 173 women who decided to continue her pregnancy beyond the above mentioned date of gestation.

Results

There was a greater rate of caesarean section and poor perinatals results in the group of women that decided not to induce the labour at 42 weeks’ gestation. Most of these women finishes her gestation inducing it slightly later on.

Conclusions

In uncomplicated post-term pregnancies, the induction of the labour at 42 weeks’ gestation entails better mother-foetal results and is more efficient than to continue with mother-foetal controls during more time.     

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.     

Degeneración cerebelosa paraneoplásica en cáncer ginecológico: descripción de 3 casos

Background and objective

Paraneoplastic cerebellar degeneration (PCD) is a rare neurological complication that develops in patients with cancer and is associated with different antibodies. PCD associated with anti-Yo antibodies usually occurs in patients with gynecological cancer. There is no diagnostic method that would allow early detection and appropriate treatment.

Methods

We describe three patients who presented with subacute cerebellar dysfunction and positive anti-Yo antibodies. After diagnosis and treatment, the patients were monitored to evaluate persistence of the neurological syndrome.

Results

Imaging studies were performed when gynecologic cancer was suspected. In all patients, fluorodeoxyglucose-positron emission tomography/tomography computerized (FDG-PET/TC) was the only imaging test that led to suspicion of the primary lesion. Histological examination confirmed the diagnosis of ovarian carcinoma in two patients and carcinoma of the horn in the third patient. All patients underwent radical surgery and subsequent chemotherapy. Corticosteroids were administered with no improvement of the neurological syndrome in any of the patients.

Conclusion

Oncologic treatment does not improve neurological symptoms. FDG-PET/TC with fluorodeoxyglucose could be useful in cases of PCD in which conventional imaging tests do not identify the underlying malignancy.     

Resultados de 1.000 cirugías ginecológicas laparoscópicas sucesivas

Objectives

To review the indications and outcomes of 1,000 consecutive laparoscopic surgeries.

Material and methods

We carried out an observational, retrospective study of the first 1,000 gynecological laparoscopic procedures performed in our hospital. Data on complications and conversions were recorded.

Results

Between January 2005 and November 2011, we performed 1000 laparoscopic surgeries: 452 (45.2%) ovarian procedures, 200 (20%) hysterectomies for benign causes, 105 (10.5%) gynecological neoplasms, 88 (8.8%) tubal ligations, 75 (7.5%) diagnostic laparoscopies, 56 (5.6%) myomectomies, 19 (1.9%) sacropexies and 5 (0.5%) appendectomies. There were 22 major complications (2.2%) and 32 conversions to open surgery (3.2%).

Conclusion

The laparoscopic approach to gynecological surgery is safe and effective.     

Disección aórtica aguda tipo A,una enfermedad catastrófica asociada al embarazo

Objective

To describe two fatal cases of type A acute aortic dissection associated with pregnancy.

Methods

We reviewed the medical records and autopsies of patients, and then identified some mechanisms linking this entity to pregnancy.

Results

Both deaths occurred in women aged less than 35 years at the end of gestation. One patient had aortic coarctation and bicuspid aortic valve, while the other had no risk factors.

Conclusion

Hemodynamic changes in the third trimester of pregnancy may be involved in the onset of this entity. Rapid diagnosis is essential to prevent its high associated mortality.     

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.