The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders).

PURPOSE: Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology. METHODS: A systematic review, adhering to the PRISMA methodology, was conducted. RESULTS: Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging. CONCLUSIONS: Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.

Substance use, mental health and dual disorders on pregnancy: Results of prevalence and treatment rates in a developed country. / Salud mental, abuso de sustancias y trastornos duales en el embarazo: Tasas de prevalencia y tratamiento en un país desarrollado.

Smoking and substance use during pregnancy are major preventable causes of mortality and morbidity, having a bidirectional and deleterious relationship with the mental health of the mother and child. As part of the WOMAP (Woman Mental Health and Addictions on Pregnancy) initiative, our study aimed to describe the prevalence of co-occurring mental illness and substance use problems, diagnoses and severity of those considered at risk and rates of treatment.A screening of 2,014 pregnant women was done using the AC-OK scale and they were asked about their smoking habits and services use for mental health/substance abuse. Of these, 170 women were considered at risk of co-occurring mental illness and substance use problems (≥ 2 positive responses to the AC-OK-Mental Health subscale, ≥ 1 positive response to the AC-OK-Substance Abuse subscale and/or smoking more than once a month and no use of specialized services) and were assessed with a more extensive battery of measures (Patient Health Questionnaire [PHQ-9], General Anxiety Disorder [GAD-7], Posttraumatic stress disorder [PTSD] Checklist for DSM-5 [PCL-5], Alcohol Use Disorders Identification Test [AUDIT], Drug Abuse Screening Test [DAST] and Fagerström).In the last year, 614 women (30.5%) smoked tobacco (42.5% daily) and 9.8% were positive for both substance use and mental illness per the AC-OK. Only 11.1% of them received specific treatment in the previous three months while another 13.6% were scheduled to attend services in the following month. From the subsample assessed in depth, 62(36.5%) endorsed at least moderate depression, 35(20.6%) endorsed at least moderate anxiety, 32(18.8%) endorsed PTSD on the PCL, and 37 out of 88 alcohol users scored above the threshold in AUDIT (≥ 3). In conclusion, high prevalence and low treatment rates suggest that effective detection mechanisms should be integrated into usual care, allowing for early interventions.

El tabaquismo y el consumo de sustancias durante el embarazo son importantes causas prevenibles de morbimortalidad, teniendo una relación bidireccional y deletérea con la salud mental de la madre y el niño. Como parte de la iniciativa WOMAP (Woman Mental Health and Addictions on Pregnancy), se estudiaron 2.014 embarazadas buscando describir la prevalencia de trastornos mentales y por uso de sustancias concurrentes, las tasas de tratamiento y los diagnósticos y la gravedad. Las participantes fueron evaluadas con la escala AC-OK y se les preguntó sobre sus hábitos tabáquicos y uso de servicios de salud mental/sustancias. De las participantes, 170 mujeres resultaron positivas para un trastorno mental y por uso de sustancias concurrentes (≥ 2 positivos a la subescala AC-OK-Salud Mental, ≥ 1 positivos a la subescala AC-OK-Sustancias y/o fumar más de una vez al mes y no estar en tratamiento) y fueron evaluadas en profundidad mediante una batería de escalas (Patient Health Questionnaire [PHQ-9], General Anxiety Disorder [GAD-7], Post-traumatic stress disorder Checklist [PCL-5], Alcohol Use Disorders Identification Test [AUDIT], Drug Abuse Screening Test [DAST] y Fagerström).En el último año, 614 mujeres (30,5%) fumaron tabaco (42,5% diariamente) y el 9,8% fueron positivas para problemas por uso de sustancias y salud mental según la AC-OK. Solo el 11,1% había recibido tratamiento en los tres meses previos y solo un 13,6% tenía una cita en el siguiente mes. De las 170 pacientes evaluadas secundariamente, 62(36,5%) presentaron al menos depresión moderada, 35(20,6%) al menos ansiedad moderada, 32(18,8%) fueron positivas a la PCL-5, y 37 de las 88 que reconocieron uso de alcohol puntuaron por encima del umbral en AUDIT (≥ 3). En conclusión, la combinación de una prevalencia significativa junto con bajas tasas de tratamiento, remarcan la necesidad de mecanismos de detección efectivos en la atención habitual, permitiendo una intervención temprana.

Tumor ovárico benigno proliferante mucinoso de tipo endocervical con hiperplasia microglandular / Benign mucinous endocervical type ovarian tumor with microglandular hyperplasia

Resumen Antecedentes La aparición más común de la hiperplasia micro-glandular es en el endocérvix, luego en sitios con epitelio glandular mucinoso; en el ovario es excepcional. Se ha descrito posterior a la exposición a la progesterona como anticonceptivo, sin antecedente de exposición hormonal y en mujeres posmenopáusicas. En 2014 la OMS clasificó los tumores mucinosos de ovario como: mucinosos fronterizos (borderline), seromucinosos fronterizos (tumores mucinosos de tipo endocervical-mülleriano) y carcinoma mucinoso. Objetivo Exponer el diagnóstico de una tumoración ovárica benigna infrecuente, en una paciente que recibió estimulación hormonal con fines reproductivos. Caso clínico Paciente de 38 años, con hallazgo ecográfico de formación quística de 25 x 33 mm de pared gruesa e irregular, con papila de 6 mm vascularizada y el resto de contenido quístico heterogéneo. La paciente había recibido hiperestimulación ovárica controlada en cuatro ocasiones, la última seis meses previos al hallazgo, momento en que recibía anticoncepción combinada, previa a un nuevo ciclo. Se le practicó anexectomía derecha y lavado peritoneal. El diagnóstico anatomopatológico fue de tumor mucinoso proliferante, de tipo endocervical, con hiperplasia microglandular y citología del líquido aspirado, inflamatoria. El perfil inmunohistoquímico fue: citoqueratina7 positiva y citoqueratina 20, CDX2 (proteína homeobox) y antígeno carcinoembrionario negativos. El anticuerpo monoclonal Ki-67 fue menor de 10%. Los receptores de estrógenos fueron focalmente positivos y los de progesterona positivos de forma difusa e intensa. La paciente evolucionó favorablemente después del tratamiento. Conclusiones La hiperplasia microglandular puede aparecer en tumores mucinosos benignos de ovario y hay que considerar su posible implicación hormonal.

Abstract Background Microglandular hyperplasia is most commonly located in the endocervix, but may appear in any location with mucinous glandular epithelium. Ovarian presentation is exceptional. It has been described in women after exposure to progesterone as contraceptive, without history of hormonal exposure and in postmenopausal. In 2014, WHO classified mucinous ovarian tumors as borderline mucinous, borderline seromucinous (mucinous tumors of the endocervical/mül-lerian type) and mucinous carcinoma. Objective To describe the diagnosis of an uncommon benign ovarian tumor in a patient who underwent hormonal stimulation for reproductive purposes. Clinical case 38-year-old patient with an ultrasound finding of a 25 x 33mm cystic formation with a thick and irregular wall, a 6mm vascularized papilla and a heterogeneous cystic content. The patient had undergone controlled ovarian hyperstimulation on four occasions, the last one 6 months prior to the finding, when she was on combined contraception prior to a new cycle. Right adnexectomy and peritoneal lavage were performed. The anatomopathological diagnosis was an endocervical mucinous proliferative tumor with microglan-dular hyperplasia and inflammatory cytology of the aspirated fluid. The immunohistochemical profile was: cytokeratin 7 positive and cytokeratin 20, CDX2 (homeobox protein) and CEA (carcinoembry-onic antigen) negative. The monoclonal antibody Ki-67 was < 10%. Estrogen receptors were focally positive and progesterone receptors positive in a diffuse and intense form. After treatment, the patient had a favorable evolution. Conclusions Microglandular hyperplasia may be present in ovarian mucinous benign tumors. A hormonal involvement should be considered.

[Great vesicovaginal fistula after normal vaginal delivery in a developed country]. / Gran fístula vesicovaginal después de un parto eutócico. Reporte de un caso.

BACKGROUND: Obstetric fistulas in developed countries are infrequent and have been associated with instrumental vaginal delivery, manual removal of placenta and surgical complications during caesarean section. We present the diagnosis and treatment of an obstetric fistula of patient without clear risk factors in a developed country. CASE REPORT: The case presented is of a 37 weeks pregnant with history of previous cesarean section. A male of 2,600 g was born after a not prolonged vaginal delivery. In the immediate postpartum period, appeared evident hematuria and in the exploration a defect was detected in the vaginal anterior face at 3 cm from the urethral meatus. Cystoscopy showed a torn in bladder of 8 cm at the bottom. Reparation of vesicovaginal fistula was carried out with omentoplasty. Postoperative course was uneventful. CONCLUSION: A vesicovaginal fistula must be considered in any patient with hematuria. Early repair is essential for a favorable outcome.

[Symptomatic exaggerated placental site after first trimester abortion]. / Lecho placentario amplio sintomático tras aborto del primer trimestre.

Exaggerated placental site, a trophoblastic benign lesion, is characterized by an extensive infiltration of the endometrium, myometrium and arterial walls by intermediate trophoblast cells. Trophoblastic benign lesions are often an incidental finding in the anatomopathological study, but may be associated with severe bleeding especially in relation to trauma. Case report: Multigravida 39 years old with excessive uterine bleeding after medical treatment of abortion. Once expelled gestational vesicle is seen sonographically a uterine cavity occupied by a heterogeneous endometrium with maximum anteroposterior diameter of 21 mm, plenty of color map, reaching myometrium. B-HCG serum is 164 mlU/ml. During hysteroscopy a massive bleeding happens and its necesary to use an intrauterine catheter to stop it. Computed tomography angiography shows suggestive findings of uterine vascular malformation. A hysterectomy as a diagnostic and definitive treatment is made and pathology reports an exaggerated placental site.

[Co-expression of estrogen receptors and Her2/neu in breast cancer. Neoadjuvant chemotherapy sentinel lymph node and hormonotherapy]. / Cancer de mama con Her-2-neu y receptores hormonales positivos. Quimioterapia neoadyuvante, biopsia de ganglio centinela y tratamiento hormonal.

Neoadjuvant chemotherapy is an interesting option in the therapy of some breast cancer cases. Cases in which the timing for sentinel lymph node biopsy is controversial. Co-expression of estrogen receptors and Her2/neu (c-erbB-2) in breast cancer may imply hormone resistance, especially to tamoxifen. We present a clinic case with co-expression of estrogen receptors and Her2/neu that was treated with neoadjuvant chemotherapy and previous sentinel lymph node biopsy followed by breasttumorectomy with axillar lymphadenectomy, radiotherapy and hormonotherapy with letrozol, geserelina and trastuzumab. A good treatment response was found.

[Symptomatic recurrence of endometriomas after ultrasound and laparoscopic surgery]. / Recurrencia sintomática y ecográfica de endometriomas tras cirugía laparoscópica.

BACKGROUND: Endometriosis affects to 5-12% women. Laparoscopic surgery is the treatment of choice, but the high rate of recurrence is alarming. OBJECTIVE: Analyse the influence of various variables in the recurrence after ovarian endometrioma laparoscopic excision. MATERIAL AND METHODS: Retrospective study of 214 cases with laparoscopic treatment in 2005 and 2006 in the Hospital La Paz. A 5 years follow-up was made. Choosen recurrence criteria were pain and suggestive ultrasound finding. Variables studied were: age, pain (0-10), Ca 125 levels, myoma, adenomyosis, number, size and laterality of cyst, medical treatment before and after laparoscopic surgery, infertility, kind of surgery and characteristics, progression and treatment of recurrences. RESULTS: 30,8% (66/214) of patients presented pain recurrence, 28% (60/214) ultrasound recurrence. Patients with symptomatic recurrence had a bigger degree of dysmenorrhea and dyspareunia before surgery (6.8 +/- 2.5 and 1.3 +/- 2.5 against 3.8 +/- 3.4 and 0.2 +/- 1.0 in no recurrence ones (p = 0.0001; p = 0.0001). Previous dysmenorrheal and dyspareunia punctuation was also greater in ultrasound recurrences (5.9 +/- 3.3 and 1.2 +/- 2.5 against 4.3 +/- 3.4 and 0.2 +/- 1.1 of those with no recurrence) (p = 0.003; p = 0.002). Dysmenorrhea recurrence was greater in young (31.3 +/- 5.4 years old versus 34.3 +/- 7.8; p = 0.02), with cystectomy (35% versus 16,7% in adnexectomy; p = 0.02), adhesiolysis (46.4% versus 23.4%; p = 0.001) and with medical treatment after surgery (41.5% against 22.5%; p = 0.004). The mean time of no symptomatic recurrence was 44 months (CI 95%: 41-47) and the no ultrasound recurrence was 47 months (CI 95%: 45-50). CONCLUSION: Dysmenorrhea and dyspareunia degree before surgery was the most clearly associated factor with recurrence.

[Postpartum urinary and fecal incontinence in gemelar pregnancy according to route and mode of delivery]. / Incontinencia urinaria y fecal postparto en gestación gemelar según vla y tipo de parto.

BACKGROUND: The incidence of multiple pregnancies increased in the last two decades. Several studies seeking the incidence of pelvic floor pathology, particularly urinary incontinence and its risk factors, conclude that a previous cesarean and vaginal delivery even more, carry an increased risk for developing urinary and fecal incontinence, compared with patients nulligravida. OBJECTIVE: To determine the different risk factors for urinary incontinence after a twin pregnancy. PATIENTS AND METHODS: 331 women from 20 to 50 years of age without symptoms prior to pregnancy were interviewed, attending antenatal care of twin pregnancy in the Hospital La Paz, Madrid. The interview included the ICIQ-SF (International Consultation on Incontinence Questionnaire-Short Form). We recorded maternal age, gestational age, parity, episiotomy, weights of both newborns, the need for urinary protectors and fecal or gas incontinence. RESULTS: The prevalence of urinary incontinence postpartum according ICIQ-SF >0 was 23%; 20.4% in the caesarean group, 25.3% in the eutocic delivery group and 35.5% in the instrumental delivery group (p = 0.033). The prevalence of moderate to severe incontinence (ICIQ-SF >6) was 14.8%; 12.3% in caesarean group, 14.5% in the eutocic delivery group and 32.3% in the instrumental delivery group (p = 0.005). The prevalence of fecal incontinence was 3.4%; 4.8% in eutocic delivery group, 1.9% in the caesarean group and 9.7% in the instrumental delivery group (p = 0.058). CONCLUSIONS: The risk of urinary incontinence after a twin pregnancy was higher among patients who had an instrumental delivery when compared with patients with eutocic delivery or cesarean section. The total fetal weight and maternal age did not appear as risk factors in our study. Any woman who had an instrumental delivery for twins should be followed up by a pelvic floor specialist.

[Role of middle cerebral artery Doppler in the management of Rhesus alloimmunization cases]. / Papel del Doppler en la arteria cerebral media en la atención de pacientes con isoinmunización Rhesus.

BACKGROUND: The most common cause of anemia remains fetal red cell alloimmunization. Although after the systematization of prophylactic anti-D gamma globulin decreased the number of cases, has not eliminated the problem. OBJECTIVES: To evaluate the role of the fetal middle cerebral artery peak systolic velocity in the management of fetus at risk for anemia due to Rh alloimmunization and analyze the effect in perinatal outcomes. MATERIAL AND METHOD: 68 pregnancies complicated by Rh alloimmunization, in La Paz Hospital (Madrid, Spain) since February 2006 until August 2009, with maternal antibody titers > or = 1:32, affected in previous pregnancies and/or anti-Kell isoimmunization. In every case it was measured the middle cerebral artery peak systolic velocity and the fetal hemoglobin concentration in blood obtained either by cordocentesis or at delivery. RESULTS: For the detection of moderate-severe fetal anemia, Doppler ultrasonography of the middle cerebral artery had a sensitivity of 80% (95% confidence interval: 59.8 to 100%), a specificity and positive predictive value of 100%, and a negative predictive value of 85.7% (95% confidence interval: 70.7 to 100%). The Pearson correlation coefficient between estimated hemoglobin and real hemoglobin was 0.71. The 22% (15/68) of the fetuses required at least one intrauterine transfusion making a total of 26. In 23% (6/26) of them appeared complications. The last middle cerebral artery peak systolic velocity measurement is associated with neonatal anemia and/or icterus (p < 0.01), anemia during the hospitalization (p < 0.05) and neonatal transfusion (p < 0.05). CONCLUSION: The measurement of the middle cerebral artery peak systolic velocity predicts moderate-severe fetal anemia cases, which are the most important in the clinical management because of the need of active treatment with intrauterine transfusion or induction labor.