Efectos de la aspirina en fetos de rata con reducción de la presión de la perfusión uterina / Effects of aspirin on rat fetuses with reduction of uterine perfusion pressure

La preeclampsia (PE) es un trastorno hipertensivo inducido por el embarazo donde se reduce la presión de la perfusión uterina. Investigaciones avalan el uso de dosis baja de aspirina (DBAAS) y su utilidad en la prevención de PE en gestantes con factores de riesgo. Sus beneficios en modelos animales sometidos a esta reduccción no están determinados. El objetivo de la investigación fue analizar la presión arterial sistémica y los hallazgos morfológicos a nivel renal en fetos de ratas con reducción de la presión de perfusión uterina (RPPU) expuestas a DBAAS en comparación a las no expuestas. Se conformaron cuatro grupos de ratas hembras preñadas Sprague Dawley (n=5). A los 14,5 días post-concepción (dpc), vía quirúrgica se indujo RPPU, ligando arterias uterinas, conformándose el grupo RPPU y el grupo RPPU+DBAAS al que se le administró 5 mg/kg/día de aspirina vía oral. El grupo control lo conformaron las no operadas y el grupo DBAAS se le administró aspirina en igual dosis desde el 14,5 dpc. A los 18,5 dpc, previo a la eutansia se midió la presión arterial sistémica con pletismógrafo caudal Insight v2.11 y se extrajeron los fetos. Se midió la longitud céfalo-caudal (LCC), se procesaron y tiñeron con hematoxilina-eosina, describiéndose cortes histológicos transversales a nivel renal. Se determinó que en la presión arterial media, hubo diferencias significativas entre el grupo RPPU y RPPU+DBAAS (p<0,05). El tamaño de los fetos fue menor en el grupo RPPU (p<0,0001), donde 1 feto presentó hernia umbilical congénita. La cuantificación de vesículas renales también fue menor (p<0,005). En conclusión, la administración de DBAAS disminuye los efectos inducidos por la RPPU en cuanto al tamaño fetal, morfología renal y malformaciones congénitas como hernia umbilical. En cuanto a la presión arterial sistémica, tendría efectos sólo en presión arterial media.

Preeclampsia (PE) is a hypertensive disorder induced by pregnancy where there is a reduction in the uterine perfusion pressure. Research supports the use of low dose aspirin (LDAAS) and its usefulness in the prevention of PE in pregnant women with risk factors. Their benefits in animal models subject to RUPP are not determined. The objective of the investigation was to analyze the systemic blood pressure and the morphological findings at renal level in fetuses of rats with reduction of uterine perfusion pressure (RUPP) exposed to LDAAS compared to those not exposed. Four groups of pregnant female rats Sprague Dawley (n=5) were formed. At 14.5 days post-conception (dpc), surgical RUPP was induced, ligating uterine arteries, with the RUPP group and RUPP+LDAAS group being given 5 mg/kg/day of aspirin orally. The control group was made up of those not operated and the LDAAS group was administered aspirin in the same dose from 14.5 dpc. A 18.5 dpc, prior to euthanasia systemic blood pressure was measured with flow plethysmograph Insight v2.11 and fetuses were extracted. The cephalo-caudal length (CCL) was measured, processed and stained with hematoxylin-eosin, describing transverse histological sections at the kidney level. It was determined that in the mean arterial pressure, there were significant differences between the group RUPP and RUPP+LDAAS (p <0.05). The size of the fetuses was lower in the RUPP group (p <0.0001), where one fetus presented congenital umbilical hernia. The quantification of renal vesicles was also lower (p <0.005). In conclusion, the administration of LDAAS decreases the effects induced by RUPP in terms of fetal size, renal morphology and congenital malformations such as umbilical hernia. Regarding the systemic blood pressure, effects would only mean arterial pressure.

Can the combination of internal iliac temporary occlusion and uterine artery embolization reduce bleeding and the need for intraoperative blood transfusion in cases of invasive placentation?

OBJECTIVES: Women with invasive placentation (IP) are at high risk of life-threatening hemorrhage. In the last two decades, less invasive surgical approaches combined with endovascular procedures have proven to be safe. Most case series describe the use of temporary balloon occlusion and embolization, either combined or not. Concerning hemorrhage rates, each separate interventional approach performs better than surgery alone does, yet it is not clear whether the combination of multiple interventional techniques can be beneficial and promote a lower incidence of intrapartum bleeding. We aim to evaluate whether combining temporary balloon occlusion of the internal iliac artery and uterine artery embolization promotes better hemorrhage control than do other individual interventional approaches reported in the scientific literature in the context of cesarean birth followed by hysterectomy in patients with IP. METHODS: This is a retrospective analysis of patients with confirmed IP who underwent temporary balloon occlusion and embolization of the internal iliac arteries followed by puerperal hysterectomy. We compared patient results to data extracted from a recent systematic review and meta-analysis of the current literature that focused on interventional procedures in patients with IP. RESULTS: A total of 35 patients underwent the procedure during the study period in our institution. The mean volume of packed red blood cells and the estimated blood loss were 487.9 mL and 1193 mL, respectively. Four patients experienced complications that were attributed to the endovascular procedure. CONCLUSION: The combination of temporary balloon occlusion and uterine artery embolization does not seem to promote better hemorrhage control than each procedure performed individually does.

Vascularização uterina de éguas prenhes de jumento e de garanhão monitoradas por ultrassonografia Doppler / Uterine vasculature of pregnant mares of donkey and stallion through the Doppler ultrasonography spectral mode

Este estudo teve como objetivo analisar e descrever os achados ultrassonográficos do útero de éguas gestantes de diferentes idades, de jumento e garanhão, utilizando a técnica de ultrassonografia Doppler Espectral, visando caracterizar os índices de resistência (RI) e pulsatilidade (PI) até 154 dias de gestação. Foram utilizadas 20 éguas em idade reprodutiva, sem raça definida. As avaliações foram realizadas nas artérias uterinas. Não foi constatada interação entre os valores de RI e PI obtidos nos cornos uterinos (que iniciaram ou não a gestação) com o tempo da gestação (P>0,05), desta forma os dados foram discutidos separadamente. Não foram encontradas diferenças entre as avaliações de RI e PI quando comparado os cornos que iniciaram ou não a gestação (P>0,05). Verificou-se efeito de tempo (P<0,05) sobre o PI, onde no D70 foi constatada a menor média quando comparado aos tempos D0, D7, D14 e D21. Não f oi encontrado efeito de tempo sobre o RI (P>0,05). As éguas gestantes de jumento apresentaram maior vascularização uterina no corno não gestante, que as éguas gestantes do garanhão. Com exceção do RI no lado não gravídico, foi verificado efeito de idade da fêmea sobre o lado da gestação (P<0,05), onde as éguas idosas, tanto no corno que iniciou a gestação e o contralateral, tiveram PI e RI mais altos, ou seja, menos vascularizados. Concluiu-se que a vascularização uterina não apresentou diferença entre os cornos uterinos. Há um aumento da vascularização uterina no 70º dia de gestação. Éguas gestantes de jumentos apresentaram maior vascularização uterina, quando comparada às éguas gestantes de garanhões. Éguas com idade acima de 15 anos apresentaram menor vascularização uterina, quando comparadas com idade inferior a 15 anos.(AU)

This study aimed to evaluate and describe the ultrasonographic findings of uterus of pregnant mares of different ages, mated by either ass or stallion, using the spectral Doppler ultrasonography, aiming to characterize the resistance (RI) and pulsatility (PI) Doppler indices up to 154 days of pregnancy. A total of 20 mares in reproductive age of non-defined breed were used. The evaluations were performed in uterine arteries. There was no interaction between RI and PI values obtained in uterine horns (that initiated or not the pregnancy) with time of pregnancy (P>0.05), thus, data were discussed separately. There were no differences between RI and PI evaluations when compared to the uterine horns that initiated or not the pregnancy (P>0.05). A time effect was observed (P<0.05) on PI, when D70 presented lower averages than D0, D7, D14 and D21. There was no time effect (P>0.05) on RI. Pregnant mares mated by asses presented higher uterine vascularization in non-pregnant horn than pregnant mares mated by stallions. With the exception of RI in non-pregnant horn, there was a female age effect on the side of pregnancy (P<0.05), where aged mares in both - pregnant and non-pregnant horns - showed higher PI and RI, so less vascularized. It is possible to conclude that the uterine vascularization did not present any difference between uterine horns. There is an increase in the uterine vascularization on the 70th day of pregnancy. Pregnant mares mated by assess presented higher uterine vascularization when compared to those mated by stallions. Mares aging over 15 years old presented lower uterine vascularization, when compared to those younger.(AU)

Uterine artery Doppler flow velocimetry parameters for predicting gestational trophoblastic neoplasia after complete hydatidiform mole, a prospective cohort study

OBJECTIVES: Doppler ultrasonography can be used to assess neoangiogenesis, a characteristic feature of postmolar gestational trophoblastic neoplasia. However, there is limited information on whether uterine artery Doppler flow velocimetry parameters can predict gestational trophoblastic neoplasia following a complete hydatidiform mole. The purpose of this study was as follows: 1) to compare uterine blood flow before and after complete mole evacuation between women who developed postmolar gestational trophoblastic neoplasia and those who achieved spontaneous remission, 2) to assess the usefulness of uterine Doppler parameters as predictors of postmolar gestational trophoblastic neoplasia and to determine the best parameters and cutoff values for predicting postmolar gestational trophoblastic neoplasia. METHODS: This prospective cohort study included 246 patients with a complete mole who were treated at three different trophoblastic diseases centers between 2013 and 2014. The pulsatility index, resistivity index, and systolic/diastolic ratio were measured by Doppler flow velocimetry before and 4-6 weeks after molar evacuation. Statistical analysis was performed using Wilcoxon’s test, logistic regression, and ROC analysis. RESULTS: No differences in pre- and post-evacuation Doppler measurements were observed in patients who developed postmolar gestational trophoblastic neoplasia. In those with spontaneous remission, the pulsatility index and systolic/diastolic ratio were increased after evacuation. The pre- and post-evacuation pulsatility indices were significantly lower in patients with gestational trophoblastic neoplasia (odds ratio of 13.9-30.5). A pre-evacuation pulsatility index ≤1.38 (77% sensitivity and 82% specificity) and post-evacuation pulsatility index ≤1.77 (79% sensitivity and 86% specificity) were significantly predictive of gestational trophoblastic neoplasia. CONCLUSIONS: Uterine Doppler flow velocimetry measurements, particularly pre- and post-molar evacuation pulsatility indices, can be useful for predicting postmolar gestational trophoblastic neoplasia.

Sheep Model for Uterine Transplantation: The Best Option Before Starting a Human Program

OBJECTIVE: This study reports the first four cases of a uterine transplant procedure conducted in sheep in Latin America. The aim of this study was to evaluate the success of uterine transplantation in sheep. METHOD: The study was conducted at Laboratory of Medical Investigation 37 (LIM 37) at the University of São Paulo School of Medicine. Four healthy mature ewes weighing 40-60 kg were used as both the donor and recipient for a transplant within the same animal (auto-transplant). Institutional guidelines for the care of experimental animals were followed. RESULTS: The first two cases of auto-transplant were performed to standardize the technique. After complete uterine mobilization and isolation of the blood supply, the unilateral vascular pedicle was sectioned and anastomosed on the external iliac vessels. After standardization, the protocol was implemented. Procurement surgery was performed without complications or bleeding. After isolation of uterine arteries and veins as well as full mobilization of the uterus, ligation of the distal portion of the internal iliac vessels was performed with subsequent division and end-to-side anastomosis of the external iliac vessels. After vaginal anastomosis, the final case presented with arterial thrombosis in the left uterine artery. The left uterine artery anastomosis was re-opened and flushed with saline solution to remove the clot from the artery lumen. Anastomosis was repeated with restoration of blood flow for a few minutes before another uterine artery thrombosis appeared on the same side. All four animals were alive after the surgical procedure and were euthanized after the experimental period. CONCLUSION: We describe the success of four uterine auto-transplants in sheep models.

Evaluation of embolization for periuterine varices involving chronic pelvic pain secondary to pelvic congestion syndrome

OBJECTIVES: To evaluate the clinical response and success rate after periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome and to report the safety of endovascular treatment and its rate of complications. METHODS: Retrospective cohort of patients undergoing endovascular treatment of pelvic congestion syndrome in our department from January 2012 to November 2015. Data were analyzed based on patient background, imaging findings, embolized veins, rate of complications, and clinical response as indicated by the visual analog pain scale. RESULTS: We performed periuterine varices embolization in 22 patients during the study, four of which required a second embolization. Seventeen patients reported a reduction in pelvic pain after the first embolization and three patients reported a reduction in pelvic pain after the second embolization. Minor complications were observed in our patients, such as postural hypotension, postoperative pain, and venous perforation during the procedure, without clinical repercussion. CONCLUSION: Periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome appears to be an effective and safe technique.

Effect of maternal exercises on biophysical fetal and maternal parameters: a transversal study / Efeito do exercício materno em parâmetros biofísicos maternofetais: um estudo transversal

ABSTRACT Objective To evaluate the acute effects of maternal and fetal hemodynamic responses in pregnant women submitted to fetal Doppler and an aerobic physical exercise test according to the degree of effort during the activity and the impact on the well-being. Methods Transversal study with low risk pregnant women, obtained by convenience sample with gestational age between 26 to 34 weeks. The participants carry out a progressive exercise test. Results After the exercise session, reduced resistance (p=0.02) and pulsatility indices (p=0.01) were identified in the umbilical artery; however, other Doppler parameters analyzed, in addition to cardiotocography and fetal biophysical profile did not achieve significant change. Maternal parameters obtained linear growth with activity, but it was not possible to establish a standard with the Borg scale, and oxygen saturation remained stable. Conclusion A short submaximal exercise had little effect on placental blood flow after exercise in pregnancies without complications, corroborating that healthy fetus maintains homeostasis even in situations that alter maternal hemodynamics.

RESUMO Objetivo Avaliar os efeitos agudos de respostas hemodinâmicas maternas e fetais em gestantes submetidas a Doppler fetal e a um teste de exercício físico aeróbio, de acordo com o grau de esforço durante a atividade e o impacto sobre o bem-estar. Métodos Estudo transversal desenvolvido com gestantes de baixo risco, por amostra de conveniência com idade gestacional entre 26 e 34 semanas. As participantes realizam um teste de esforço progressivo. Resultados Na artéria umbilical, após sessão de exercício físico, identificou-se a redução do índice de resistência (p=0,02) e do índice de pulsatilidade (p=0,01), mas os demais parâmetros Doppler analisados, além da cardiotocografia e do perfil biofísico fetal, não obtiveram alteração significativa. Os parâmetros maternos obtiveram crescimento linear com a atividade, mas não foi possível estabelecer padrão com a escala de Borg, e a saturação de oxigênio se manteve estável. Conclusão O esforço submáximo curto teve pouco efeito sobre o fluxo de sangue da placenta após o exercício em gestações sem complicações, corroborando que o feto hígido mantém a homeostase mesmo em situações que alterem a hemodinâmica materna.

Pelvic Intravenous Leiomyomatosis - Case Report / Leiomiomatose intravenosa pélvica - caso clínico

Abstract Introduction Intravenous leiomyomatosis is a benign and rare condition that can result in cardiac events with fatal outcomes when left untreated. Intravenous leiomyomatosis is probably underestimated because the diagnosis is easily missed. We present a case of an intravenous leiomyomatosis without extra-pelvic involvement, with a brief review of this pathology. Case Report 46-year-old woman submitted to hysterectomy and bilateral adnexectomy because of a pelvic mass detected in ultrasound. During the surgery, intravenous leiomyomatosis diagnosis was suspected. Pathological analysis confirmed this suspicion. Further imaging exams were performed without detecting any anomalies related to this condition. The patient remained with no evidence of disease after one year of follow-up. Conclusion Intravenous leiomyomatosis is a rare condition that can lead to serious complications. Early diagnosis followed by an appropriate treatment is very important to patient outcome, and underdiagnoses can be counteracted if the gynecologist is aware of this entity.

Resumo Introdução A leiomiomatose intravenosa é uma condição benigna, rara, que pode resultar em eventos cardíacos, podendo ser fatal quando não tratada. Esta patologia está provavelmente subestimada, uma vez que facilmente não é diagnosticada. Neste artigo, apresentamos um caso de leiomiomatose intravenosa sem envolvimento extrapélvico, com uma breve revisão da patologia. Relato de Caso Mulher de 46 anos de idade, submetida a histerectomia e anexectomia bilateral após detecção ecográfica de massa pélvica. Durante a cirurgia, houve a suspeita de leiomiomatose intravenosa, e o exame anátomo-patológico confirmou o diagnóstico. A paciente foi submetida a outros exames de imagem, não sendo detectada qualquer anomalia relacionada com a patologia. Após um ano de followup, a paciente manteve-se sem evidência de doença. Conclusão A leiomiomatose intravenosa é uma condição rara que pode levar a complicações graves. O diagnóstico precoce e o tratamento adequado são muito importantes para o prognóstico da paciente, e os subdiagnósticos podem ser evitados se o ginecologista estiver ciente dessa entidade.

Malformación arteriovenosa uterina: a propósito de un caso / Arteriovenous uterine malformation: a case report

Paciente de 37 años que acudió a urgencias por metrorragia, G3P1A2, el último de ellos un aborto tardío en gestación gemelar monocorial biamniótica de 20 semanas hacía dos meses. En la ecografía destaca en zona miometrial un área de marcada vascularización de 67 x 45 mm. Tras descartar proceso residual gestacional y ante la sospecha de malformación arteriovenosa uterina se solicitó resonancia magnética nuclear y angiotac, tras confirmar la malformación vascular se programó para embolización de ambas arterias uterinas con el fin de preservar la fertilidad.

A 37-year-old patient came to the emergency due to metrorrhagia, G3P1A2, the last of them a late abortion in a 20 weeks monochorionic diamniotic twin pregnancy two months ago. Ultrasound revealed an intramiometrial area of 67 x 45 mm with increased vascularization area. A diagnosis of an arteriovenous malformation was considered. In order to confirm the diagnosis pelvic magnetic resonance and angiogram was performed. Once the vascular malformation was confirmed the patient was scheduled for transcatheter arterial embolization in order to preserve fertility.

Remifentanil protects uterus against ischemia-reperfusion injury in rats

PURPOSE: To investigate the effects of remifentanil as an antioxidant and analyze the histopathologic, biochemical changes in experimental ischemia-reperfusion (I/R) exposed rat uteri. METHODS: Wistar albino rats were assigned to three groups (n = 7). 2h period of ischemia was followed by 1h of reperfusion in the I/R and the I/R-remifentanil groups. After ischemia, no drug was administered in the sham and I/R groups. In the I/R-remifentanil group, remifentanil infusion (2 μg/kg/min) was started in the ischemia period, and continued until the end of reperfusion. After the ischemic and reperfusion period, the ischemic uterine horns were removed surgically for biochemical and histopathologic examination. Tissue damage scores (endometrial epithelial glandular leukocytosis, degeneration, and endometrial stromal changes) were examined. Malondialdehyde levels and catalase, superoxide dismutase enzyme activities in tissue were measured. RESULTS: We found significantly lower epithelial leukocytosis and cell degeneration in the I/R-remifentanil group (p<0.05). Remifentanil administration significantly decreased concentrations of malondialdehyde, and increased catalase and superoxide dismutase enzyme activities (p<0.05). CONCLUSION: Remifentanil appears to protect the uterine tissue against ischemia-reperfusion and can be used safely in uterus transplantation.

Malformación arterio-venosa uterina y hemorragia obstétrica: diagnóstico y manejo en tres casos clínicos / Uterine arteriovenous malformation and obstetric hemorrhage: diagnosis and management in three cases

Las malformaciones vasculares uterinas son muy infrecuentes y se presentan asociadas a metrorragia con riesgo vital. Su incidencia no es conocida porque las series son de pocos casos. Presentamos tres pacientes con hemorragia obstétrica cuyo estudio diagnóstico con ultrasonido y angiografía, demostró malformación arteriovenosa uterina. En un caso, dada la extensión de la lesión, el tratamiento fue con embolización bilateral de arterias uterinas seguida de histerectomía. Otras dos pacientes, por preservación de fertilidad, fueron sometidas solo a embolización. La evolución clínica y las imágenes confirmaron que los procedimientos fueron exitosos. Se discute la importancia de la interpretación correcta de las imágenes para el diagnóstico, la adaptación de los métodos terapéuticos al caso individual y el manejo multidisciplinario.

The uterine vascular malformations are very infrequent and associated to maternal hemorrhage with vital risk. The incidence is unknown because the published series are little with few cases. We described three cases with obstetrical hemorrhage and the image study with ultrasound and angiography showed an arteriovenous malformation. One patient, for the extensive lesion, was treated with bilateral embolization of uterine arteries and then, histerectomy. The others patients, for preservation her fertility, were treated with embolization only. The clinical evolution and the vascular images study confirm the success of the procedures. We discuss the importance of images analysis for the diagnosis, the individual application of therapeutic methods and a multidisciplinary approach for this scope.

Regulación del flujo sanguíneo uterino: II. funciones de estrógeno y receptores estrogénicos alfa/beta en acciones genómicas y no-genómicas del endotelio uterino / Regulation of uterine blood flow: II. functions of estrogen and estrogen receptor alpha/beta in genomic and non- genomic actions of the uterine endothelium

El embarazo está marcado por cambios y adaptaciones cardiovasculares que son importantes para el crecimiento y mantenimiento de la placenta y el feto. Durante este periodo, las adaptaciones vasculares uterinas manifiestan cambios clasificados como de corto o largo plazo los cuales están relacionados con adaptaciones vasodilatadoras, angiogénicas o de remodelación. El estrógeno y los receptores estrogénicos clásicos (REs), RE-alfa y RE-beta, han demostrado ser parcialmente responsables por facilitar el incremento dramático en el fluido sanguíneo uterino necesario durante el embarazo. En ésta revisión bibliográfica se discuten la base estructural para la diversidad y selectividad funcional de los REs por el estrógeno, el papel de los REs sobre los efectos genómicos y no-genómicos en células endoteliales de arterias uterinas (CEAU). Estos temas integran el conocimiento científico sobre la regulación molecular de CEAU para mantener el incremento fisiológico en la perfusión útero-placentaria observada durante un embarazo normal.

Pregnancy is marked by changes and cardiovascular adaptations that are important for the maintenance and growth of the placenta and fetus. During this period, the uterine vascular adaptations manifest changes that can be classified as short or long term and they related to adaptations for vasodilation, angiogenic or remodeling. Estrogen and the classical estrogen receptors (ERs), ER-alpha and ER-beta, have been shown to be partially responsible for facilitating this dramatic increase in uterine blood flow needed during pregnancy. This literature review discusses the basis for structural diversity and functional selectivity of ERs by estrogen, the role of ERs on the genomic and non-genomic effects in endothelial cells of uterine arteries (UAEC). These themes integrate scientific knowledge about the molecular regulation of UAEC to maintain the physiological increase in uteroplacental perfusion observed during normal pregnancy.

Predictive factors for pelvic magnetic resonance in response to arterial embolization of a uterine leiomyoma

OBJECTIVE: Minimally invasive methods are used as alternatives to treat leiomyomas and include uterine artery embolization, which has emerged as a safe, effective method. This study aims to evaluate the magnetic resonance imaging predictors for a reduction in leiomyoma volume in patients undergoing uterine artery embolization. METHODS: This prospective longitudinal study was performed at a university hospital. We followed 50 symptomatic premenopausal women with uterine leiomyomas who underwent uterine artery embolization. We examined 179 leiomyomas among these patients. Magnetic resonance imaging was performed one month before and six months after uterine artery embolization. Two radiologists who specialized in abdominal imaging independently interpreted the images. Main Outcome Measures: The magnetic resonance imaging parameters were the uterus and leiomyomas volumes, their localizations, contrast perfusion pattern and node-to-muscle ratio. RESULTS: Six months after treatment, the average uterine volume reduction was 38.91%, and the leiomyomas were reduced by 55.23%. When the leiomyomas were submucosal and/or had a higher node-to-muscle ratio in the T2 images, the volume reduction was even greater (greater than 50%). Other parameters showed no association. CONCLUSIONS: We conclude that symptomatic uterine leiomyomas in patients undergoing uterine artery embolization exhibit volume reductions greater than 50% by magnetic resonance imaging when the leiomyomas are submucosal and/or had a high node-to-muscle ratio in the T2 images. .

Post-Operative Hemorrhage after Myomectomy: Safety and Efficacy of Transcatheter Uterine Artery Embolization

OBJECTIVE: To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage. MATERIALS AND METHODS: We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted. RESULTS: The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients. CONCLUSION: Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.

Regulación del flujo sanguíneo uterino: I. funciones de estrógeno y receptores estrogénicos alfa/beta en el endotelio vascular uterino durante el embarazo / Regulation of uterine blood flow: I. functions of estrogen and estrogen receptor alpha/beta in the uterine vascular endothelium during pregnancy", "_i": "en

El estrógeno y los receptores estrogénicos clásicos (REs), RE- alfa y RE-beta, han demostrado ser parcialmente responsable por las adaptaciones endoteliales uterinas durante el embarazo al corto y largo plazo. Las diferencias moleculares y estructurales, junto con los diferentes efectos causados por estos receptores en las células y los tejidos, sugieren que su función varía dependiendo de la manera en la cual el estrógeno se comunica con sus receptores. En ésta revisión bibliográfica se discuten la función del estrógeno y sus receptores clásicos en las adaptaciones cardiovasculares durante el embarazo y la expresión de los Res in vivo e in vitro en el endotelio de la arteria uterina durante el ciclo ovárico y el embarazo, a la vez comparado con la expresión en endotelio arterial de tejidos reproductivos y no reproductivos. Estos temas integran el conocimiento actual de este amplio campo científico con interpretaciones e hipótesis diversas relacionadas con los efectos estrogénicos mediados bien sea por uno o los dos REs. Esta revisión también incluye la relación con las adaptaciones vasodilatadoras y angiogénicas requeridas para modular el dramático incremento fisiológico en la perfusión útero-placentaria observada durante un embarazo normal.

Estrogen and classical estrogen receptors (ERs), ER- alpha and ER- beta, have been shown to be partially responsible for short and long term uterine endothelial adaptations during pregnancy. The molecular and structural differences, together with the various effects caused by these receptors in cells and tissues, suggest that their function varies depending upon estrogen and estrogen receptor signaling. In this review, we discuss the role of estrogen and its classic receptors in the cardiovascular adaptations during pregnancy and the expression of ERs in vivo and in vitro in the uterine artery endothelium during the ovarian cycle and pregnancy, while comparing their expression in arterial endothelium from reproductive and non-reproductive tissues. These themes integrate current knowledge of this broad scientific field with various interpretations and hypothesis that related estrogenic effects by either one or both ERs. This review also includes the relationship with vasodilator and angiogenic adaptations required to modulate the dramatic physiological increase to the uteroplacental perfusion observed during normal pregnancy.

Transrectal Doppler sonography of uterine blood flow during the first two weeks after parturition in Simmenthal heifers

Transrectal Doppler sonography was used to evaluate uterine blood flow during the first two weeks after parturition in six primiparous Simmental cows. The uterine blood flow was evaluated on the day of parturition (Day 0), once daily from Days 1 to 8 and then every other day until Day 14. Blood flow was quantified by determining the diameter (D), the time-averaged maximum velocity (TAMV), the pulsatility index (PI) and the blood flow volume (BFV) of the uterine arteries ipsilateral and contralateral to the formerly pregnant uterine horn. During the first four days after calving D, TAMV and BFV declined (ipsilateral: TAMV 70%, BFV 87%, contralateral: D 47%, BFV 84%; p +/-0.75, p < 0.05), with negative correlations with PI and positive correlations with all other investigated factors. Overall, this study revealed characteristic changes in uterine perfusion during the first two weeks after parturition in cows that were pronounced during the first four days postpartum.

Função endotelial, perfusão uterina e fluxo central em gestações complicadas por Pré-Eclampsia / Endothelial function, uterine perfusion and central Flow in pregnancies complicated by Preeclampsia

FUNDAMENTO: A fisiopatologia da Pré-Eclampsia (PE) é caracterizada por deficiência no processo de placentação, disfunção endotelial sistêmica e hiperfluxo do Sistema Nervoso Central (SNC). Do ponto de vista clínico, seria interessante determinar a ocorrência desses fenômenos antes do aparecimento das manifestações clínicas da doença, levantando a possibilidade de novos métodos de predição da PE. OBJETIVO: Comparar o processo de placentação, a função endotelial e o hiperfluxo do SNC em gestantes de alto risco para desenvolvimento de PE que posteriormente desenvolveram ou não a síndrome. MÉTODOS: Um total de 74 gestantes foi submetido ao exame de Dilatação Fluxo-Mediada (DFM) da artéria braquial, dopplerfluxometria de artérias uterinas e oftálmica para avaliação da função endotelial, processo de placentação e hiperfluxo central, respectivamente. Os exames foram realizados entre 24 e 28 semanas de gestação e as pacientes foram acompanhadas até o puerpério para coleta de dados. RESULTADOS: Quinze pacientes tiveram a gestação complicada pela PE e 59 se mantiveram normotensas até o puerpério. Pacientes que subsequentemente desenvolveram PE apresentaram entre 24 e 28 semanas de gestação, maiores valores no índice de pulsatilidade das artérias uterinas e menores valores de DFM (p < 0,001 e p = 0,001, respectivamente). Entretanto, não houve diferença nos valores obtidos no índice de resistência da artéria oftálmica (p = 0,08). CONCLUSÃO: Os dados obtidos sugerem que a deficiência no processo de placentação e a disfunção endotelial precedem cronologicamente as manifestações clínicas da PE, o que não ocorre com o hiperfluxo do SNC.

BACKGROUND: The physiopathology of Preeclampsia (PE) is characterized by a deficiency in the process of placentation, systemic endothelial dysfunction and Central Nervous System (CNS) hyperflow. From a clinical point of view, it would be interesting to determine the occurrence of these phenomena before the onset of clinical manifestations of the disease, raising the possibility of new methods for predicting PE. OBJECTIVE:Compare the process of placentation, endothelial function and CNS hyperflow in pregnant women at high risk for the development of PE who subsequently developed or not the syndrome. METHODS: A total of 74 pregnant women underwent the Flow-Mediated Dilation (FMD) of the brachial artery, Doppler study of uterine and ophthalmic arteries for the assessment of endothelial function, process of placentation and central hyperflow, respectively. The examinations were performed between 24 and 28 weeks of gestation and were followed until the postpartum period for data collection. RESULTS: Fifteen patients had PE and 59 remained normotensive until the puerperium. Patients who subsequently developed PE had between 24 and 28 weeks of gestation, higher pulsatility index of uterine arteries and lower values of FMD (p < 0.001 and p = 0.001, respectively). However, there was no difference in the values obtained in the resistive index in the ophthalmic artery (p = 0.08). CONCLUSION: The data obtained suggest that the deficiency in the process of placentation and endothelial dysfunction chronologically precede the clinical manifestations of PE, which does not occur with CNS hyperflow.

Pregnancy at an unusual location: a case report with review of literature

Implantation of the embryo at the site of a previous Caesarean scar is the rarest form of ectopic pregnancy, with a high risk of maternal complications. The incidence of CSP [caesarean scar Pregnancy] is estimated in a recent series as 1:2226 of all pregnancies. A delay in establishing a diagnosis and in starting treatment can result in uterine rupture, massive hemorrhage and serious maternal morbidity, and may require hysterectomy. Several options are available to treat CSP if diagnosed early, although there are no evidence-based guidelines recommended due to its rarity. The management should be tailored to the individual situations. Little is known about the future pregnancies, outcomes and recurrences after fertility-preserving treatments following CSP. We report a case of suspected CSP in a 28 year old Gravida 2, Para one, who was referred to us for the management of incomplete miscarriage. Her previous delivery was six years back and was by Cesarean section. Ultrasound examination revealed that the patient had a large anterior lower uterine segment vascular mass of 9.3x8.2x9cms, suspected to be a persistent trophoblastic tissue invading the anterior uterine wall, though a degenerating fibroid could not be ruled out. The patient underwent dilatation and curettage as she had been bleeding for more than a month and still 3HCG being positive. The procedure was also used to establish a histopathological diagnosis. A follow up MRI and Ultrasound revealed a heterogenous mass. With a strong clinical suspicion based on history and early ultrasound reports, the diagnosis of an anterior uterine wall mass probably due to penetrating trophoblastic tissue on previous caesarean scar was made. The patient has been referred for either uterine artery embolisation or a laparoscopic removal in order to preserve her fertility

Impacto da embolização arterial do leiomioma uterino no volume uterino, diâmetro do mioma dominante e na função ovariana / Impact of the myoma arterial embolization by uterine volume, diameter myoma greater and in the ovarian function

RESUMO OBJETIVO: Avaliar o impacto da embolização arterial de miomas (EAM) sobre o volume uterino (VU), na função ovariana. MÉTODOS: Trinta pacientes com leiomioma se submeteram à EAM. Foram realizados exames de USPTV e FSH antes e três meses após a EAM. Foram analisados o VU em cm³, o diâmetro do mioma dominante (DMD) em cm e o FSH em UI/mL, expressos por média desvio padrão (DP) e submetidos a análise estatística pelo teste não paramétrico de Mann-Whitney. RESULTADOS: Foram incluidos na análise 29 casos. A média do VU pré-EAM foi 402,4 165,9 cm³, DMD pré-EAM 5,9 2,1 cm. O VU pós-EAM foi 258,9 118,6 cm³, DMD pós-EAM foi 4,6 1,8 cm. A média da dosagem de FSH pré-EAM foi 4,9 3,5 UI/mL e pós-EAM foi 5,5 4,7 UI/mL com p=0,5. Houve redução de 35 por cento do VU, de 22 por cento no DMD e a EAM não alterou significativamente os valores de FSH após três meses. CONCLUSÃO: O procedimento diminui significativamente o VU e DMD e, não há aumento significativo dos níveis séricos de FSH, não havendo, portanto, alterações na função ovariana.

PURPOSE: To evaluate the impact of uterine artery embolization (UAE) on uterine volume (UV), greater myoma diameter (GMD) and ovarian function three months after the procedure, by transvaginal pelvic ultrasonography (TVPUS) and by the determination of follicle-stimulating hormone (FSH). METHODS: Thirty patients with leiomyomas were submitted to UAE. TVPUS and FSH determination were performed before and three months after UAE. UV was determined in cm³, GMD in cm and FSH in IU/mL. Data are reported as as mean standard deviation (SD) and were analyzed statistically by the nonparametric Mann-Whitney test. RESULTS: Twenty-nine patients were analyzed. Before UAE, mean UV was 402.4 165.9 cm³ and GMD was 5.9 2.1 cm. After UAE, mean UV was 258.9 118.6 cm³ and GMD was 4.6 1.8 cm. Mean FSH concentration was 4.9 3.5 IU/mL before UAE and 5.5 4.7 IU/mL after UAE, with p=0.5. There was a 35 percent reduction of UV and a 22 percent reduction of GMD, with no changes in FSH values after three months. CONCLUSION: The procedure significantly reduced UV and GMD but did not cause a significant increase in FSH levels, thus causing no changes in ovarian function.

Ligadura vaginal de arterias uterinas en hemorragia postparto: técnica simple, rápida y efectiva / Vaginal ligature of uterine arteries in patients with postpartum hemorrhage

La metrorragia posparto es una de las complicaciones más graves de la obstetricia con importante morbi-mortalidad materna. La ligadura de las arterias uterinas forma parte de la cadena de procedimientos terapéuticos. Esta comunicación muestra una paciente con hemorragia posparto tratada con ligadura vaginal de arterias uterinas, con cese del sangrado y recuperación de la paciente sin complicaciones.

Postpartum hemorrhage is one of the most serious obstetrics complications with significant maternal morbidity and mortality. Uterine arteries ligature is part of the chain of therapeutic procedures. This communication presents a patient with postpartum hemorrhage treated with vaginal uterine arteries ligature with cessation of bleeding after the intervention and recovery without complications.