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 de los factores que influyen en la aparición de efectos adversos en la versión cefálica externa

Objectives

To identify the association between the adverse effects of the external cephalic version (ECV) and several variables related to the technique.

Material and method

We performed a prospective study in 180 pregnant women who delivered through the ECV. We analyzed fetal and maternal adverse effects and their association with the final result of the version, the experience of the obstetrician, the time used in the maneuver, the number of attempts performed in the same session, and the drug used as a uterine relaxant.

Results

The ECV was successfully performed in 32.6% of primiparas and 79.19% of multiparas. The overall rate of adverse effects was 28.33%, and was higher in versions that failed, those with a greater number of failed attempts, those with longer duration and those in which ritodrine was used as a uterine relaxant.

Conclusions

The factors increasing the probability of success and reducing the rate of adverse effects in ECV are a single attempt at the maneuver, total duration of the maneuver of less than 5 minutes, and use of salbutamol as a uterine relaxant.     

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.     

Método Essure: contracepción definitiva por vía histeroscópica

Aim

To describe hysteroscopic permanent contraception through the Essure procedure and to compare this procedure with other already available methods.

Subjects and methods

We analyzed multicenter studies published before approval of the Essure method as well as the experience reported in subsequent studies by groups with expertise in hysteroscopy.

Results

Data from two multicenter, international, prospective, randomized studies published in 2003 demonstrate that the Essure procedure provides high contraceptive efficacy (greater than 99%), with a minor complications rate of less than 3%.

Conclusions

Permanent contraception with the Essure procedure, when performed after an adequate learning curve and by practitioners with extensive experience in diagnostic hysteroscopy, can be carried out as an outpatient technique with a 95% success rate.     

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.     

Clasificación de cesáreas por Grupos de Robson en dos periodos comparativos en el Hospital de Manacor

Objective

To identify groups of women with changes in cesarean rates in two different periods.

Subjects and methods

Deliveries in the Manacor Hospital in 2000-2001 and 2005-2006, were analyzed through a retrospective review of clinical records and were grouped using Robsońs classification.

Results

The cesarean rate increased from 14 to 18.6% with a statistically significant increase among women with a single cephalic pregnancy at term who underwent labor induction or elective cesarean section. These two groups were the major contributors to the cesarean rate at our hospital.

Conclusion

A trend towards an increase in the rates of cesarean section was found during the study period. Robson's Classification allowed us to identify the groups of women contributing to this increase.     

Situación de la conización del cuello uterino en el País Vasco

Objective

The main objective of this study was to evaluate the conization technique used in Basque Country hospitals and to determinate the most appropriate place to perform this procedure (outpatient clinic or operating room) by evaluating pain, early and late complications and histological results.

Materials and methods

We selected 232 patients with a cytologic and colposcopic diagnosis of cervical dysplasia requiring surgical cervical conization between September 2006 and July 2007 in eight public hospitals of the Basque Country.

Results

A total of 94.8% of conizations were performed with long loop excision of transformation zone (LLETZ) and, exceptionally, with cold knife conization. Local anesthesia was used in tertiary hospitals and regional anesthesia in county hospitals. Pain tolerance in outpatient conization with LLETZ under local anesthesia was excellent. In Hospital Donostia, pain was scored on a visual analogue scale and low scores were achieved, in accordance with the high degree of satisfaction obtained with the procedure. Conization margins depended on the grade of dysplasia rather than on the technique. There were few early complications and even fewer late complications.

Conclusion

The LLETZ method performed under local anesthesia in the outpatient clinic is very well tolerated by patients and has few complications. Consequently, this option is a valid alternative to conization under general or regional anesthesia. The LLETZ technique provides multiple advantages for the patient and health service due to its lower cost, without medical disadvantages, and satisfactory tolerance.     

Cesárea a petición de la embarazada

Objetive

: To know Spanish Obstetrics and Gynaecology Society (SEGO) members about cesarean section on request.

Method

Three questions appeared on SEGO web: 1) If a normal primigravid with a term, cephalic presentation foetus ask you for a caesarean section, would you do it?; 2) If a normal primigravid with a term, breach presentation foetus ask you for a caesarean section, would you do it?; 3) If a woman on her normal third pregnancy with two previous vaginal and with a term, breach presentation foetus ask you for a caesarean section, would you do it? Questions were asked in May 2006 and answers were collected 19^th October 2006. Data analysis was processed with web page statistic method.

Results

Among the 5300 members of SEGO, 1222 contacted the web page (23%). To question n° 1, 57.8% answered no, 24.8% yes and 17.4% had no answer. To question n° 2, 6.1% answered no, 93.8% yes and there were no abstention. To n° 3 question, 16.7% said no, 74.5% said yes and 8.8% has no opinion.Results are commented, advantages and disadvantages of caesarean are discussed as well as sanitary consequences of such an indication.     

Idoneidad de las indicaciones de cesárea. Una aplicación en la gestión de la práctica clínica

Objectives

To describe the quality management system applied by the Obstetrics and Gynecology Service of the Manacor Hospital, Majorca (Spain) to the process of cesarean section, and to assess the appropriateness of caesarean sections performed in this service between 2004 and 2005.

Subjects and methods

Consensus was reached on evidence-based indications for emergency and elective cesarean sections and on their quality criteria. All clinical records were reviewed to assess the appropriateness of cesarean sections performed from 2004-2005 according to previously established standards.

Results

In all two-monthly periods, appropriateness was achieved according to previously established standards (100% of elective interventions and > 90% of emergency cesarean sections), except in July-August, 2004 and May-June 2005 (appropriateness of elective cesarean sections = 92%), and in July-August 2004 (appropriateness of emergency interventions = 84%).

Conclusions

To reduce unjustified variability in clinical practice, cesarean section indications must be standardized, based on scientific evidence, and regularly assessed.     

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.     

Versión cefálica externa en presentación de nalgas: una técnica ancestral muy actual

Breech presentation occurs in 3-4% of pregnancies and is a routine indication for cesarean section. The external version is a maneuver that has been performed since Hippocrates’ time. Nevertheless, despite decreasing the cesarean section rate, this technique is only offered to a small percentage of patients due to lack of awareness and the shortage of experienced obstetricians. The success rate ranges from 40-74%. Factors that can influence the success of the maneuver are gestational age, the amniotic fluid index, presentation, and the location of the placenta. The use of tocolytics and effective analgesia can facilitate the maneuver and improve the success rate. When a standardized protocol is followed and the technique is performed by an experienced gynecologist, the external cephalic version has an excellent safety profile and is an effective option that avoids surgery.     

Evolución del cáncer de mama en Aragón (España). Proyecciones a 15 años

Objective

The aim of this study was to determine the trend in breast cancer in Aragon by projecting the incidence rates, prevalence and mortality over a 15-year period from 2008 to 2022.

Material and methods

Data were obtained from the National Institute of Statistics and the program used was the MIAMOD.

Results

We estimated that from 2008 to 2022, the incidence rate of breast cancer in Aragon will decrease from 53.06 to 45.56 (adjusted from 31.66 to 25.22). Mortality will decline gradually from 15.6 in 2008 to 12.9 (adjusted from 8.13 to 6.37) and the prevalence will decrease from 568.33 to 522.17 (adjusted from 322.15 to 271.32).

Conclusions

These projections indicate that the incidence, mortality and prevalence of breast cancer in Aragon will decrease, although only the reduction in the incidence rate will be statistically significant.     

Utilidad de la resonancia magnética en la estadificación prequirúrgica del cáncer de endometrio

Objective

To evaluate the usefulness of magnetic resonance imaging (MRI) for preoperative staging of endometrial carcinoma.

Materials and methods

We performed a retrospective study of 71 endometrial neoplasms diagnosed in Hospital Sant Joan de Déu. The results of preoperative MRI scans were compared with those of the definitive histological examination.

Results

The preoperative stage obtained by MRI and the final stage were concordant in 69% of cases.

Conclusion

MRI is the most useful diagnostic method for preoperative staging of endometrial carcinoma     

Márgenes histológicos de los carcinomas de mama diagnosticados mediante biopsia con arpón

Objectives

We analyzed the characteristics of carcinomas that could influence margin status and the existence of residual tumor in reexcisons.

Material and methods

We retrospectively studied the characteristics of 133 breast carcinomas diagnosed by mammographic wire-guided biopsy.

Results

In 37.59% biopsy was the only surgery in the breast. A total of 31.6% of margins were clear (more than 3 mm.), 20.3% were close (equal to or less than 3 mm) and 48.1% showed tumoral involvement. The mean tumor size of carcinomas with clear margins was statistically smaller than those with involved margins. Histological grade was related to margin status in ductal carcinomas in situ (DCIS) and to higher positive reexcision rates (grades II and III) in infiltrating ductal carcinomas (IDC). The overall residual tumor rate was 50%, but this percentage was higher in reexcisions of infiltrating lobular carcinomas (ILC) (85.71%), DCIS (70.53%), and in carcinomas with axillary lymph node involvement. A second reexcision was required in 13.79% of DCIS.

Conclusions

Reexcision is recommended in patients with ILC, DCIS and IDC (especially histological grades II and III in both cases) in which margins of more than 3 mm have not been achieved, regardless other characteristics. Clear margins are sometimes difficult to obtain in DCIS.     

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.     

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.     

Clasificación morfológico-histeroscópica del cancer endometrial

Objective

To assess the morphological-hysteroscopic nomenclature for endometrial cancer used by our group by evaluating the differences between distinct patterns, both morphological and those related to histological grade and stage at diagnosis.

Material and methods

We analyzed 272 patients with hysteroscopically-diagnosed endometrial cancer. Using our classification, we grouped the tumors into three patterns (pseudohyperplasial,nodular, and malignant transformation of polyps) and one subpattern (advanced). We next compared these patterns with the surgical stage and the final histological grades.

Results

When advanced signs were lacking, the patterns of pseudohyperplasia and malignant transformation of polyps were related to earlier stages and differentiated histological grades.Nodular patterns were related to scarcely differentiated histological grades. Finally, advanced subpatterns, irrespective of the basic pattern to which they belonged, were diagnosed at later stages.

Conclusions

Currently, the value of hysteroscopy in the diagnosis of endometrial cancer and intracavity involvement is widely accepted. This study demonstrates the utility and validity of our morphological-hysteroscopic classification; the nomenclature described can be used to give a name to the malignancies diagnosed and even to hazard a prognosis related to their stage and grade of histological differentiation.     

Influencia de la educación maternal sobre hábitos tóxicos y uso del servicio de urgencias obstétricas

Objectives

To determine the influence of the women's exposure to maternal education on smoking and the use of obstetric emergency services.

Method

A multicenter observational study was conducted on women whose childbirth was the first in four hospitals in Andalusia (Spain) in 2011. The data were collected through an interview and medical history. The analysis estimated odds ratios and both raw and adjusted averages.

Results

A total of 520 women were studied. Participation in the maternal education program seemed to have no influence on the use of obstetric emergency services (ORa = 0.70, 95% CI = 0.47-1.04) or on changing smoking habits (ORa = 0.84, 95% CI = -0.43-1.68).

Conclusions

Attendance at a maternal education program did not modify smoking. We found no conclusive evidence of the impact of maternal education on the use of emergency obstetric services.