Acute renal disease in patients with ovarian peritoneal carcinomatosis treated with cytoreduction and HIPEC: the influence of surgery and the cytostatic agent used.

BACKGROUND: The main objective of this study was to evaluate the differences between cisplatin and paclitaxel in the development of postoperative renal toxicity, using as a reference the RIFLE (Risk, Injury, Insufficiency, Loss, and End-stage renal function) and AKIN (Acute Kidney Injury Network) criteria in patients with primary or recurrent ovarian cancer with peritoneal dissemination treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: One hundred fifty-two patients who were treated between December 2007 and June 2017 were analyzed. RESULTS: Patients who received previous platinum-based chemotherapy had higher baseline creatinine levels than those who had not (p = 0.05). A total of 11 (7.2%) and 4 (2.6%) patients developed an acute renal dysfunction (ARD) during the postoperative period of cytoreduction and HIPEC according to the RIFLE and AKI criteria respectively. RIFLE detects a higher rate of ARD due to different parameters such as GFR (7.2% versus 2.6%, p = 0.016). Performing ostomy (p = 0.007; OR: 39.320; 95% CI = 2.74-56.13) and using of cisplatin during HIPEC treatment (p = 0.017; OR = 13.619; 95% IC = 1.600-25.95) were factors independently related to a higher rate of ARD. CONCLUSION: ARD has a multifactorial origin. Cisplatin was associated with the development of a higher rate of ARD than paclitaxel. Diagnosis of ARD did not correlate with worse survival figures.

Phospholipids in lipoproteins: compositional differences across VLDL, LDL, and HDL in pregnant women.

OBJECTIVE: The aim of this study was to analyse the differences in the phospholipid composition of very low density (VLDL), low density (LDL) and high density lipoprotein (HDL) monolayers in pregnant lean and obese women. METHODS: LDL, HDL, and VLDL were isolated from plasma samples of 10 lean and 10 obese pregnant women, and their species composition of phosphatidylcholines (PC) and sphingomyelins (SM) was analysed by liquid-chromatography tandem mass-spectrometry. Wilcoxon-Mann-Whitney U test and principal component analysis (PCA) were used to investigate if metabolite profiles differed between the lean/obese group and between lipoprotein species. RESULTS: No significant differences have been found in the metabolite levels between obese and non-obese pregnant women. The PCA components 1 and 2 separated between LDL, HDL, and VLDL but not between normal weight and obese women. Twelve SM and one PCae were more abundant in LDL than in VLDL. In contrast, four acyl-alkyl-PC and two diacyl-PC were significantly higher in HDL compared to LDL. VLDL and HDL differed in three SM, seven acyl-alkyl-PC and one diacyl-PC (higher values in HDL) and 13 SM (higher in VLDL). We also found associations of some phospholipid species with HDL and LDL cholesterol. CONCLUSION: In pregnant women phospholipid composition differs significantly in HDL, LDL and VLDL, similar to previous findings in men and non-pregnant women. Obese and lean pregnant women showed no significant differences in their lipoprotein associated metabolite profile.

Assessment of anogenital distance as a diagnostic tool in polycystic ovary syndrome.

RESEARCH QUESTION: Is anogenital distance (AGD) a useful clinical tool for predicting polycystic ovarian syndrome (PCOS) and its main National Institutes of Health (NIH) phenotypes? DESIGN: Case-control study conducted between September 2014 and May 2016 at the Department of Obstetrics and Gynecology of the University Clinical Hospital 'Virgen de la Arrixaca' in the Murcia region (south-eastern Spain). One hundred and twenty-six cases of PCOS and 159 controls without PCOS were included. AGD measurements were taken from the anterior clitoral surface to the upper verge of the anus (AGDAC), and from the posterior fourchette to the upper verge of the anus (AGDAF). Parametric and non-parametric tests and receiver operating characteristic (ROC) curves were used to assess associations between AGD and the presence of PCOS and its phenotypes. RESULTS: AGDAC, but not AGDAF, was associated with PCOS and all its phenotypes (P-values < 0.001 to 0.048). The highest area under the curve (0.62; 95% confidence interval 0.55 to 0.71) was obtained for all PCOS with AGDAC with a sensitivity and specificity of 50.0% and 73.0%, and positive and negative predictive value of 59.0% and 64.4%, respectively. CONCLUSIONS: AGDAC could moderately discriminate the presence of PCOS and may be a useful clinical tool.

Presence of polycystic ovary syndrome is associated with longer anogenital distance in adult Mediterranean women.

STUDY QUESTION: Is polycystic ovary syndrome (PCOS) associated with anogenital distance (AGD), a biomarker of fetal androgen exposure, in adult Mediterranean women? SUMMARY ANSWER: Longer AGD is associated with PCOS in adult Mediterranean women. WHAT IS KNOWN ALREADY: AGD is a biomarker of prenatal androgen milieu. Human observational studies have reported that associations between AGD and reproductive parameters in both sexes. Exposure of the female fetus to intrauterine androgens may be a risk factor for PCOS in adulthood. STUDY DESIGN, SIZE, DURATION: This was a case-control study of 126 women with PCOS and 159 controls between September 2014 and May 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: Cases were attending the gynecology unit of the 'Virgen de la Arrixaca' University Clinical Hospital (Murcia, Spain), and were diagnosed following the Rotterdam criteria. Phenotypic subtypes of PCOS were also assessed. Both prevalent and incident (newly diagnosed) cases were included. Controls were women without PCOS attending the gynecological outpatient clinic for routine gynecological exams. All women completed health questionnaires, and underwent physical and gynecological examinations, including transvaginal ultrasound and blood draw. We obtained measures from the anterior clitoral surface to the upper verge of the anus (AGDAC), and from the posterior fourchette to the upper verge of the anus (AGDAF). Gynecologists performing the AGD measures were blind to the status of the patients. We used unconditional multiple logistic regression to evaluate the association between AGD measurements and PCOS while accounting for relevant covariates and confounders, such as BMI, age and episiotomy. MAIN RESULTS AND THE ROLE OF CHANCE: Cases showed significantly longer AGDAF and AGDAC compared to controls in bivariate analyses (P-values < 0.05). In the final adjusted models, AGDAC, but not AGDAF, was associated with the presence of PCOS (P-values = 0.002-0.008). Women with AGDAC in the upper compared to the lowest tertile were 2.9-times (95% CI 1.4-5.9; P-trend = 0.008) more likely to have PCOS. AGDAC measures were also significantly associated with all of the different phenotypic subtypes of PCOS (ORs = 3.1-5.1; P-values < 0.05). LIMITATIONS REASONS FOR CAUTION: We took into account known and suspected covariates and confounders, but the possibility of chance findings or residual confounding should be noted. As with all observational studies, causal inference is limited, and study selection and information bias should not be ruled out. WIDER IMPLICATIONS OF THE FINDINGS: Our results support the hypothesis that PCOS has an intrauterine origin, and that the hormonal environment in which the fetus develops may be highly relevant. STUDY FUNDING/COMPETING INTEREST: This work was supported by the Ministry of Economy and Competitiveness, Instituto de Salud Carlos III (ISCIII) (AES, Acción Estratégica en Salud), grant No. PI13/01237, and The Seneca Foundation, Murcia Regional Agency of Science and Technology, grant No. 19443/PI/14. There are no competing interests. TRIAL REGISTRATION NUMBER: Not applicable.

Investigation of anogenital distance as a diagnostic tool in endometriosis.

An association between anogenital distance (AGD) and endometriosis has been reported, suggesting that AGD may be a useful clinical tool in endometriosis. The predictive ability of AGD of women in discriminating presence and type of endometriosis was examined. A case-control study was conducted at the University Hospital 'Virgen de la Arrixaca', Murcia, Spain, between 2014 and 2015. A total of 114 participants diagnosed with endometriosis using ultrasound findings and 105 controls were recruited. Two AGD measurements were obtained: one from the anterior clitoral surface to the upper verge of the anus (AGDAC), and another one from the posterior fourchette to the upper verge of the anus (AGDAF). Parametric and non-parametric tests andreceiver operator characterstic analyses were used to determine relationships between AGD and presence of endometriosis and subgroups (ovarian endometriomas or deep infiltrating endometriosis [DIE]). The AGDAF, but not AGDAC, was associated with presence of endometriomas, DIE (P-values, <0.001-0.02), or both. The highest area under curve (0.91; 95% CI 0.84 to 0.97) was obtained for the DIE subgroup with the AGDAF measurement, with a sensitivity and specificity of 84.4% and 91.4%, respectively. AGDAF can therefore efficiently discriminate the presence of DIE and may be a useful clinical tool.

Endometriomas and deep infiltrating endometriosis in adulthood are strongly associated with anogenital distance, a biomarker for prenatal hormonal environment.

STUDY QUESTION: Is the length of the anogenital distance (AGD), a biomarker of the in-utero prenatal hormonal environment, associated with the presence of endometriomas and deep infiltrating endometriosis (DIE)? SUMMARY ANSWER: Shorter AGD is associated with presence of endometriomas and DIE. WHAT IS KNOWN ALREADY: It is debated whether hormonal exposure to estrogens in utero may be a risk factor for endometriosis in adulthood. AGD is a biomarker of prenatal hormonal environment and observational studies have shown an association between AGD and reproductive parameters in both sexes. STUDY DESIGN, SIZE, DURATION: This case-control study of 114 women with endometriosis (endometriomas and/or DIE) and 105 controls was conducted between September 2014 and May 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS: Cases were attending the Endometriosis Unit of the Hospital. Prevalent as well as incident cases, diagnosed by transvaginal ultrasound (TVUS), were included. Controls were women without endometriosis attending the gynecological outpatient clinic for routine gynecological exams. Participants completed health questionnaires, followed physical and gynecological examinations, including TVUS. Measurements from the anterior clitoral surface to the upper verge of the anus (AGDAC), and from the posterior fourchette to the upper verge of the anus (AGDAF) were obtained in all subjects. Unconditional multiple logistic regression was used to estimate the association between AGD measurements and presence of endometriomas and/or DIE while accounting for important confounders and covariates, including age, body mass index, vaginal delivery or episiotomy. MAIN RESULTS AND THE ROLE OF CHANCE: AGDAF was related to presence of endometriomas and/or DIE. For all cases of endometriosis (endometriomas and DIE), women in the lowest tertile of the AGDAF distribution, compared with the upper tertile, were 7.6-times (95% CI 2.8-21.0; P-trend < 0.001) more likely to have endometriosis. With regard to DIE, women with AGDAF below the median, compared with those with AGDAF above the median, were 41.6-times (95% CI 3.9-438; P-value = 0.002) more likely to have endometriosis. LIMITATIONS, REASONS FOR CAUTION: In case-control studies, information and selection bias has to be ruled out. Physicians conducting the measurement were blind to the status of the patients. Controls came from the same population as the cases. We adjusted for known and suspected confounders and covariates, but the possibility of residual confounding or chance findings should always be considered. As with all observational studies, causal inference is limited. WIDER IMPLICATIONS OF THE FINDINGS: This study suggests that endometriosis, especially the DIE, might have a prenatal origin that may be traced back to the hormonal milieu in which the fetus develops. STUDY FUNDING/COMPETING INTEREST: This work was supported by the Ministry of Economy and Competitiveness, ISCIII (AES), grant no. PI13/01237 and the Seneca Foundation, Murcia Regional Agency of Science and Technology, grant no. 19443/PI/14. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Uterine and umbilical artery Doppler at 28 weeks for predicting adverse pregnancy outcomes in women with abnormal uterine artery Doppler findings in the early second trimester.

OBJECTIVE: The objective of this study was to determine the contribution of uterine (UtA) and umbilical arteries (UA) Doppler examination at 28 weeks to predict adverse pregnancy outcomes in women who had increased resistance in UtA in the early second trimester. METHODS: Women with UtA mean pulsatility index (PI) above the 95th centile at 19-22 weeks of gestation were offered a growth scan including Doppler examination of UtA and UA at 28 weeks. Adverse pregnancy outcomes included small for gestational age (SGA), defined as birth weight below the tenth centile, preeclampsia (PE) and early-onset PE (PE before 34 weeks). RESULTS: We studied 266 pregnant women with elevated PI in the UtAs in the second trimester and ultrasound reassessment at 28 weeks. UtA PI >95th centile at 28 weeks was associated with subsequent PE [odds ratio (OR): 10.0, 95% CI: 2.3-43.5], early-onset PE (OR: 57.7, 95% CI: 3.8-87.6) and SGA less than the tenth centile (OR: 5.5, 2.2-13.9). UA PI >95th centile at 28 weeks was not significantly associated with any adverse outcome. CONCLUSIONS: In women with abnormal UtA Doppler in the early second trimester scan, persistence of elevated UtA PI, but not abnormal UA PI, is associated with adverse pregnancy outcomes including PE, early-onset PE and SGA. © 2014 John Wiley & Sons, Ltd.

Umbilical artery Doppler at 19 to 22 weeks of gestation in the prediction of adverse pregnancy outcomes.

OBJECTIVE: The aim of this study was to determine the clinical utility of Doppler assessment of the umbilical artery in the second trimester scan for predicting adverse pregnancy outcomes. METHODS: Singleton pregnancies that had undergone routine anomaly scan at 19 to 22 weeks of gestation with umbilical and uterine artery Doppler measurements. Receiver operating characteristic curves were constructed to evaluate the ability of umbilical artery pulsatility index (PI) to predict small for gestational age and preeclampsia. RESULTS: The final study population comprised 4565 singleton pregnancies. Multiple regression analysis showed significant independent contribution of umbilical artery PI in predicting SGA <10th and SGA <5th centiles (adjusted odds ratios of 2.51 and 3.51, respectively). By using a cutoff of umbilical artery PI >90th centile, the likelihood ratio of SGA <5th centile is 2.3 (95% CI: 1.7-3.0). CONCLUSIONS: Umbilical artery PI at 19 to 22 weeks of gestation is significantly associated with SGA below the tenth and fifth centiles. A multivariate model combining umbilical and uterine artery Doppler measurements with additional maternal and sonographic characteristics may help predict small for gestational age, particularly those below the fifth centile.

Misoprostol to reduce intraoperative and postoperative hemorrhage during cesarean delivery: a systematic review and metaanalysis.

OBJECTIVE: To evaluate the efficacy and safety of prophylactic misoprostol use at cesarean delivery for reducing intraoperative and postoperative hemorrhage. STUDY DESIGN: Systematic review and metaanalysis of randomized controlled trials. RESULTS: Seventeen studies (3174 women) were included of which 7 evaluated misoprostol vs oxytocin and 8 evaluated misoprostol plus oxytocin vs oxytocin alone. Overall, there were no significant differences in intraoperative and postoperative hemorrhage between sublingual or oral misoprostol and oxytocin. Rectal misoprostol, compared with oxytocin, was associated with a significant reduction in intraoperative and postoperative hemorrhage. The combined use of sublingual misoprostol and oxytocin, compared with the use of oxytocin alone, was associated with a significant reduction in the mean decrease in hematocrit (mean difference, -2.1%; 95% confidence interval, -3.4 to -0.8) and use of additional uterotonic agents (relative risk, 0.33; 95% confidence interval, 0.18-0.62). Compared with oxytocin alone, buccal misoprostol plus oxytocin reduced the use of additional uterotonic agents; rectal misoprostol plus oxytocin decreased intraoperative and postoperative blood loss, mean fall in hematocrit, and use of additional uterotonic agents; and intrauterine misoprostol plus oxytocin reduced the mean fall in hemoglobin and hematocrit. Women receiving misoprostol, alone or combined with oxytocin, had a higher risk of shivering and pyrexia. CONCLUSION: Misoprostol combined with oxytocin appears to be more effective than oxytocin alone in reducing intraoperative and postoperative hemorrhage during cesarean section. There were no significant differences in intraoperative and postoperative hemorrhage when misoprostol was compared to oxytocin. However, these findings were based on a few trials with methodological limitations.

Eligibility criteria for Menopausal Hormone Therapy (MHT): a position statement from a consortium of scientific societies for the use of MHT in women with medical conditions. MHT Eligibility Criteria Group.

This project aims to develop eligibility criteria for menopausal hormone therapy (MHT). The tool should be similar to those already established for contraception A consortium of scientific societies coordinated by the Spanish Menopause Society met to formulate recommendations for the use of MHT by women with medical conditions based on the best available evidence. The project was developed in two phases. As a first step, we conducted 14 systematic reviews and 32 metanalyses on the safety of MHT (in nine areas: age, time of menopause onset, treatment duration, women with thrombotic risk, women with a personal history of cardiovascular disease, women with metabolic syndrome, women with gastrointestinal diseases, survivors of breast cancer or of other cancers, and women who smoke) and on the most relevant pharmacological interactions with MHT. These systematic reviews and metanalyses helped inform a structured process in which a panel of experts defined the eligibility criteria according to a specific framework, which facilitated the discussion and development process. To unify the proposal, the following eligibility criteria have been defined in accordance with the WHO international nomenclature for the different alternatives for MHT (category 1, no restriction on the use of MHT; category 2, the benefits outweigh the risks; category 3, the risks generally outweigh the benefits; category 4, MHT should not be used). Quality was classified as high, moderate, low or very low, based on several factors (including risk of bias, inaccuracy, inconsistency, lack of directionality and publication bias). When no direct evidence was identified, but plausibility, clinical experience or indirect evidence were available, "Expert opinion" was categorized. For the first time, a set of eligibility criteria, based on clinical evidence and developed according to the most rigorous methodological tools, has been defined. This will provide health professionals with a powerful decision-making tool that can be used to manage menopausal symptoms.

Peritoneal Surface Disease Severity Score (PSDSS), AGO-score and TIAN model in patients with platinum-sensitive recurrent ovarian cancer treated by cytoreductive surgery plus HIPEC.

In patients with platinum sensitive recurrent ovarian cancer selected for a secondary cytoreduction, the use of prognostic scores allows predicting the possibilities of a new complete cytoreduction. The aim of this work is to evaluate the usefulness of PSDSSov, the AGO-score and the TIAN-model as prognostic tools in these patients. Sixty four patients with recurrent platinum sensitive ovarian cancer treated by cytoreduction and HIPEC were analyzed between January 2008 and December 2016. Since 2012, the data needed to calculate the PSDSS, AGO-score and TIAN model were collected prospectively. Fifty patients (78%) received systemic chemotherapy before cytoreduction and HIPEC. In 57 patients (89%) a CC-0 was achieved. Patients with PSDSSov I-II and TIAN model of "low risk" had a DFS at 1 and 5 years of 71% and 57%, respectively, without reaching the median of DFS. PSDSSov is a useful prognostic tool and can be used in decision making in patients with peritoneal carcinomatosis due to recurrent platinum-sensitive ovarian cancer. Its combination with the Tian model makes it possible to identify patients with an especially favorable prognosis.

Accuracy of anogenital distance and anti-Müllerian hormone in the diagnosis of endometriosis without surgery.

OBJECTIVE: To assess the predictive ability of a combination of anogenital distance (AGD) and anti-Müllerian hormone (AMH) to diagnosis the presence of endometriosis without surgery. METHODS: The present study included women diagnosed with endometriosis and a control group who attended the "Virgen de la Arrixaca" University Hospital, Murcia, Spain, between September 1, 2014, and May 31, 2015. Serum concentrations of AMH were measured, and two AGD measurements were obtained: from the anterior clitoral surface to the upper verge of the anus (AGDAC ), and from the posterior fourchette to the upper verge of the anus (AGDAF ). Data were assessed by receiver operator characteristic (ROC) curves. RESULTS: Women in the endometriosis group (n=57) had significantly shorter AGDAF (22.8 ± 4.6 vs 27.2 ± 5.7 mm; P<0.001) and lower AMH (2.2 ± 2.5 vs 3.3 ± 1.9 ng/mL; P<0.003) compared with the control group (n=93). Women with serum AMH below the clinical cut-off (1 ng/mL) were 17.40-times more likely to have endometriosis (95% confidence interval [CI] 5.64-53.82). The area under the ROC curve of combined AMH and AGDAF was 0.77 (95% CI 0.70-0.85). CONCLUSION: The model for predicting endometriosis on the basis of AMH and AGD could be useful for clinicians and epidemiologists to improve diagnosis and prognosis of this condition.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System.

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.

Ultrasonography in Experimental Reproductive Investigations on Rats.

With the development of assisted reproductive technology and the ethical limitations of research on humans, rat animal models have been widely used in reproductive medicine. In the past, the study of reproductive system development in rodents has been based on one-time histological examination of excised tissues. Recently, with the development of high-resolution transabdominal ultrasound, high-quality sonography can now be performed to evaluate the reproductive organs of rats, allowing a new method for studying the reproductive system. Images were obtained using a high-resolution ultrasonographic system. Gynecological ultrasonography was performed on 28 eight-week-old non-pregnant rats and 5 pregnant Sprague-Dawley rats. We describe how to recognize organs of the reproductive system and associated structures in typical views during different phases of the estrus cycle. Color flow Doppler was used to measure uterine artery blood flow and evaluate uterine blood flow pattern changes during different stages of pregnancy. We have demonstrated that ultrasound exploration is a useful method for evaluating changes in internal reproductive organs. Its use raises the possibility of conducting additional experiments, including medical or surgical procedures, and provides the ability to monitor sonographic changes to internal organs without sacrificing animals.

Effects of delayed cord clamping on the third stage of labour, maternal haematological parameters and acid-base status in fetuses at term.

OBJECTIVE: To compare the time in the third stage of labour, differences in maternal hematologic parameters 48h after birth and acid-base status in the umbilical cord between the early cord clamping (ECC) and delayed cord clamping (DCC). STUDY DESIGN: 97 healthy pregnancies at term and a spontaneous vertex delivery at Clinic University Hospital "Virgen de la Arrixaca" (Murcia, Spain), were randomized to ECC group (<10s post-delivery) or to DCC group (2min post-delivery). Duration of the third stage of labour was measured. Samples for acid-base status were taken both from the umbilical artery and vein. Blood samples were taken from the mothers 48h after birth. RESULTS: No statistical differences were found in the time of the third stage of labour (p=0.35). No statiscally significant differences were found between the number of red cells (p=0.25), hemoglobin (p=0.08) or hematocrit (p=0.15) in mothers. Umbilical acid-base status or gas analysis did not show any differences between the two groups CONCLUSIONS: Delayed cord clamping does not affect significantly the time of the third stage of labour. It does not show either any effect on the hematological parameters in the mother 48h after birth.

Spanish consensus on vulvar disorders in postmenopausal women.

INTRODUCTION: The consequences of vulvar disorders in terms of health, sexuality, and quality of life are usually undervalued, with disparities in the conceptual, diagnosis and treatment criteria. AIM: The objective of this guide will be to analyse the factors associated with the diagnosis and treatment of vulvar disorders and to provide recommendations for the most appropriate diagnostic and therapeutic measures. METHODOLOGY: A panel of experts from various Spanish scientific societies related to sexual health (Spanish Menopause Society [SMS] and the Asociación Española de Patología Cervical y Colposcopia [AEPCC]) met to reach a consensus on these issues and to decide the optimal timing and methods based on the best evidence available. RESULTS: We recommend a biopsy of all vulvar lesions with an uncertain diagnosis, especially with asymmetry, irregular borders, variegated and irregular colour and diameter >6mm. For vulvodynia, we recommend the use of lubricants or topical treatments with lidocaine or bupivacaine, amitriptyline, baclofen or triamcinolone. For vulvar epithelial disorders, we recommend beginning with topical corticosteroids of moderate to high potency. For sexual dysfunction, a multidisciplinary approach is the best management strategy in these patients.

Porfiria y gestación: a propósito de un caso / Porphyria and pregnancy: case report

The porphyrias are a group of diseases caused by a deficiency of enzymes responsible for the synthesis of heme, that can lead to severe disease that requires early diagnosis to avoid complications. The frequency of the disease is low and its association with pregnancy unusual, but it is a good time for patients carrying develop the disease or suffer an exacerbation of the same, hence the vital importance of prophylaxis of the factors risk.

Las porfirias son un grupo de enfermedades producidas por un déficit de las enzimas encargadas de la síntesis del hemo, que pueden dar lugar a un cuadro clínico grave que requiere un diagnóstico precoz para evitar complicaciones. La frecuencia de la enfermedad es baja y su asociación con el embarazo inusual, pero es un buen momento para que las pacientes portadoras desarrollen la enfermedad o sufran una exacerbación de la misma, de ahí la importancia vital de la profilaxis de los factores de riesgo.

Relationship between selected hormonal and metabolic parameters at birth and blood pressure during pre-adolescence / Relación entre parámetros endocrino-metabólicos al nacimiento y la presión arterial durante la pre-adolescencia

Objective: The aim of the present study was to evaluate the relationship between selected hormonal parameters (at birth and at age 8 years) and blood pressure levels at pre-adolescence in a cohort of intrauterine growth retarded (IUGR) and normal birth weight infants (NBW). Methods: A cohort study from early pregnancy to childhood was performed. Seventy-six fetuses/children were evaluated between 1995 and 2004. Cord blood samples were taken at birth and several hormonal and metabolic parameters evaluated. Sixty-four children of the original cohort were available for blood sampling, blood pressure and anthropometric measures at a mean age of 8 years. 27 (42.2%) were IUGR and 37 (57.8%) were NBW. Multiple regression analyses were conducted with cord blood levels of hormonal and metabolic parameters at birth and at 8 years as independent variables and children’s blood pressure as dependent variable adjusted by IUGR status, gender, Body Mass Index and age of the child at the time of blood pressure evaluation. Results: The maternal age (26.6±5.8 vs 26.9±5.8 years old) and the gestational age at birth (39.1±1.4 vs 39.6±1.3 weeks) were similar between the groups. IUGR children were shorter (1.28± 0.09 m vs 1.33± 0.09 m, p=0.04). Growth hormone levels (GH) at birth were negatively associated with systolic blood pressure at 8 years of age (regression coefficients for umbilical cord blood levels: -0.9, 95% CI -2.03 to 0.04 mg/ml, p= 0.04). Conclusion: The alterations on blood pressure can begin in fetal life were levels of GH could have an important role.

Objetivo: Evaluar la relación entre parámetros hormonales seleccionados (al nacimiento y a los 8 años de edad) y los niveles de presión arterial a los 8 años de edad en una cohorte de niños con restricción en el crecimiento intrauterino (RCIU) y con peso normal al nacimiento (PNN). Material y métodos: Se realizó un estudio de cohortes desde el inicio del embarazo hasta la infancia (1995-2004). Se tomaron muestras de sangre de cordón umbilical al nacimiento y a los 8 años para evaluar parámetros endocrino-metabólicos seleccionados (variable independiente) y la presión arterial a los 8 años de edad (variable dependiente). Se evaluaron 64 niños de la cohorte original; 27 (42.2%) casos pertenecían al grupo de RCIU y 37 (57.8%) al grupo con PNN. El análisis multivariado se ajustó por RCIU, género, índice de masa corporal y edad del niño en el momento de medir la presión arterial. Resultados: La edad de las madres (26.6±5.8 vs 26.9±5.8 años) y la edad gestacional al parto (39.1±1.4 vs 39.6±1.3 semanas) fueron similares entre los grupos. Los niños de 8 años que nacieron con RCIU fueron más bajos (1.28± 0.09 m vs 1.33± 0.09 m, p=0.04). Los niveles de hormona de crecimiento (GH) al nacimiento fueron asociados negativamente con la presión arterial sistólica del niño (coeficiente de regresión: -0.9, 95% CI -2.03 a 0.04 mg/ml, p=0.04). Conclusión: Las alteraciones de la presión arterial pueden comenzar desde la vida fetal y los niveles de GH fetal pueden jugar un papel importante.

Association between calcium intake, parathormone levels and blood pressure during pregnancy / Asociación entre consumo de calcio, niveles de parathormona y presión arterial en el embarazo

Purpose: To evaluate the association between calcium intake from diet, calciotropic hormones (PTH, PTH-rp), vasoactive regulators (endothelin, nitric oxide) and blood pressure levels during pregnancy, birth and puerperium. Method: In a prospective study 149 healthy normotensive primigravidas were followed-up from 15 weeks of gestation to puerperium. Daily calcium intake, calciuria, PTH, PTH-rp, endothelin, nitrite-nitrate, and Holter Test were assessed. Linear regression models were performed to evaluate the association between calcium intake, blood pressure levels and the laboratory tests. Multivariate regression models were performed to control potential confounders. Results: A significant increase of calcium intake during pregnancy was observed (931±301 mg/day to 1,195±467 mg/day, p<0.001). Plasma PTH-rp, endothelin, and nitrite-nitrate levels did not change during pregnancy. Among the women 38 (25.4%) had low calcium intake (<800 mg/day) with a larger increase of systolic and diastolic blood pressure during pregnancy (p=0.04) birth (p=0.006) and puerperium (p=0.01). After adjusting for other factors the multivariate analyses showed statistical association between low calcium intake, high parathormone levels and high systolic blood pressure levels during pregnancy (p=0.002). Conclusion: Low calcium intake during pregnancy is associated with a larger increase of systolic blood pressure and high parathormone levels.

Objetivo: Evaluar la asociación entre la ingesta de calcio en el embarazo, los niveles de presión arterial, las hormonas calciotrópicas (PTH, PTH-rp) y sustancias vasorreguladoras (endotelina, óxido nítrico). Métodos: Se realizó un estudio prospectivo con 149 primigrávidas normotensas que fueron incluidas en la semana 15 de gestación con seguimiento y evaluación hasta el puerperio. Se evaluó la ingesta diaria de calcio, la monitoría Holter de 24 horas, la calciuria, PTH, PTH-rp, la endotelina, nitritos y nitratos. Se siguieron modelos de regresión lineal para evaluar la asociación entre la ingesta de calcio, la presión arterial, las hormonas calciotrópicas y los vasorreguladores. Para controlar las variables de confusión se hicieron modelos de regresión múltiple. Resultados: Durante el embarazo la ingesta de calcio aumentó significativamente (931±301 mg/día a 1,195±467 mg/día, p<0.001). Entre las embarazadas 38 (25.4%) tuvieron una baja ingesta de calcio (<800 mg/día) asociada con mayores niveles de presión arterial sistólica y diastólica durante el embarazo (p=0.04), en el parto (p=0.006) y en el puerperio (p=0.01). Los mayores niveles de presión arterial sistólica durante el embarazo se asociaron con mayores niveles de paratormona y con menores niveles de ingesta de calcio (p=0.002). Los niveles plasmáticos de PTH-rp, endotelina, nitritos y nitratos no mostraron cambios durante el embarazo. Conclusión: La baja ingesta de calcio en el embarazo se asoció con mayores niveles de paratormona y de presión arterial sistólica durante el embarazo.