Diagnóstico de leucemia mieloide aguda en gestante / Diagnosis of acute myeloid leukemia in pregnant

Objetivo: manifestar la importancia del control analítico durante el embarazo y hacer un buen diagnóstico diferencial ante una anemia, ya que nos lleva a diagnósticos como el de Leucemia. También muestra la importancia de un diagnóstico temprano y manejo multidisciplinar para obtener el mejor pronóstico y fetal. Descripción del caso: paciente de 38 años, gestante de 33 semanas, en seguimiento por anemia macrocítica y trombopenia en analítica del primer trimestre. Tras estudios, se diagnostica de Leucemia Mieloide Aguda, como síntomas, astenia y gingivorragia leve. Se decide administrar ciclo de maduración pulmonar fetal y finalizar gestación para iniciar cuanto antes el tratamiento. Conclusiones: es muy importante el control analítico durante el embarazo y hacer un buen diagnóstico de la anemia para poder hacer un diagnóstico precoz de problemas como la Leucemia, en los que es crucial el tiempo y poder hacer el mejor manejo multifactorial dependiendo de la edad gestacional

Objective: To demonstrate the importance of analytical control during pregnancy and make a good differential diagnosis in the face of anemia, as it leads to diagnoses such as Leukemia. It also shows the importance of an early diagnosis and multidisciplinary management to obtain the best prognosis and fetal. Case description: 38-year-old patient, pregnant woman of 33 weeks, followed by macrocytic anemia and thrombocytopenia in the first trimester. After studies, Acute Myeloid Leukemia is diagnosed as symptoms, asthenia and mild gingivorrhagia. It was decided to administer a fetal lung maturation cycle and finish gestation to start the treatment as soon as possible. Conclusions: It is very important the analytical control during pregnancy and make a good diagnosis of anemia to be able to make an early diagnosis of problems such as Leukemia, in which time is crucial and can make the best multifactorial management depending on gestational age

Influence of age on tolerability, safety and effectiveness of subdermal contraceptive implants.

The use of long-acting contraceptive methods is on the rise. The aim of this study was to describe the main variables (effectiveness, tolerability, menstrual bleeding) associated with the use of subdermal contraceptive implants and to investigate the influence of age on these variables. This was a descriptive, retrospective, observational study of 221 cases of contraceptive implants inserted at a Spanish hospital between 2006 and 2015. The mean age of implant users was 31.2 ± 7.5 years. Effectiveness was 100% and good tolerability was recorded for 86.5%. Infrequent bleeding was the most common bleeding pattern, followed by amenorrhoea. Of the 221 implants inserted, 47.5% were removed. The main reasons were expiration (54.3%) and discomfort due to bleeding alterations and other adverse effects (25.7%). Nulliparity and weight gain were significantly associated with an increased probability of implant removal. This study shows that implants were highly effective, safe and well-tolerated in our population. The age of users had no influence on any of the study variables analysed. Impact Statement What is already known on this subject? Subdermal contraceptive implants are long-acting reversible contraceptives which are both safe and effective. What do the results of this study add? The age of users had no influence on any of the study variables analysed. Nulliparity and weight gain were significantly associated with an increased probability of implant removal. What are the implications of these findings for clinical practice and/or further research? Subdermal contraceptive implants were a safe and effective long-acting progestin contraceptive method for women from all age groups in our series because no significant age-related differences were observed for the tolerability, vaginal bleeding patterns, the effectiveness, the adverse effects or any other variables.

[Spontaneous hemoperitoneum and clear cell tumor of ovary]. / Hemoperitoneo espontáneo y carcinoma ovárico de células claras.

UNLABELLED: Hemoperitoneum is a rare cause of acute abdomen, which is usually due to liver, spleen, hematologic and vascular causes. We should consider gynecological origin in women in reproductive age, being a rare etiology in postmenopausal. CLINICAL CASE: We report the case of a spontaneous hemoperitoneum in a postmenopausal woman as the first manifestation of an ovarian tumor, with exceptional pathological lineage: clear cell carcinoma. Hemoperitoneum is a suspected diagnosis before clinical symptoms of hypovolemic shock and acute abdomen, with decrease in hemoglobin. To treating underlying cause, which in this case was surgical, it's important the clinical suspect and the appropriate hemodynamic support of the patient. Despite the resolution of the acute, it is particularly important the subsequent clinical monitoring of the patient by the peculiarities of this type of tumors.

Muerte fetal anteparto. Duelo perinatal / Antepartum stillbirth. Perinatal bereavement

Introducción. La muerte fetal intrauterina es una de las situaciones más difíciles de enfrentar en la práctica obstétrica diaria. Esta condición es bien caracterizada como un duelo. Especial énfasis debe ser otorgado al apoyo psicológico brindado especialmente a la madre. Sujetos y métodos. Se presenta el caso clínico de una primigesta de 40 semanas diagnosticada de muerte fetal anteparto. Ilustramos las etapas del duelo y su manejo clínico. Conclusiones. Consideramos interesante establecer protocolos y directrices bien planificadas sobre el cuidado de la madre y de la pareja durante la pérdida gestacional (AU)

Introduction. Intrauterine fetal death is one of the most difficult situations to face in daily obstetric practice. This condition is well characterized as a bereavement. Special emphasis should be given to the provision of psychological support, especially to the mother. Subjects and methods. We report the case of a primigravida at 40 weeks of pregnancy who was diagnosed with an antepartum stillbirth. We illustrate the stages of grief and their clinical management. Conclusions. Protocols and guidelines should be designed for the care of the mother and her partner during pregnancy loss (AU)

[Non-surgical management of rectovaginal fistula: a case report]. / Tratamiento no quirúrgico de la fístula rectovaginal. A propósito de un caso.

BACKGROUND: The rectovaginal fistula is a rare disease whose treatment is extremely difficult. OBJECTIVE: To present the expectant management of rectovaginal fistula as an alternative to surgery for those cases in which the surgical risk is not an acceptable option. CLINICAL CASE: We report the case of a rectovaginal fistula in an 85-year-old woman with significant comorbidity that avoided the performance of any surgical technique. CONCLUSION: In patients whose surgical risk does not exceed the benefits, non-surgical management would be an option of treatment of rectovaginal fistula.

[Diagnosis and treatment of hemophilia A acquired during postpartum ]. / Diagnóstico y tratamiento de hemofilia A adquirida durante el posparto.

Acquired hemophilia A is a truly exceptional hemorrhagic diathesis, that consists of the emergence of polyclonal autoantibodies (inhibitor) IgG-type (subclasses 1 and 4, in most cases) against the coagulant function of the circulating factor VIII, which acts in the domains C2, A2 and A3 of the molecule, thus interfering their interaction with the factor IXa, the phospholipids and the Von Willebrand factor. Its morbidity and mortality are high, but nevertheless its low incidence (1-1.5 cases per million population per year) is the most frequent autoimmune disorder. This paper reports the clinical case of two patients; the first one, 36 years old, who the tenth day of postpartum required re-entry due to a diagnosis of hematoma of the abdominal wall that was surgically drained twice. The patient of case 2 was 39 years old and at six days of postpartum went to the emergency room due to bleeding, she was underwent to curettage and therapeutic transfusion of 3 UCH. Because of the persistence of bleeding, which was not possible to control with medical treatment and conservative measures, therapeutic hysterectomy was performed, with blood transfusion later. Due to the hemorrhagic complications of this condition and the serious clinical consequences derived from them, it is important to establish an early diagnosis; it is therefore critical to know the existence of this very rare disease to be able to avoid its consequences.

Embolización de las arterias uterinas como alternativa de tratamiento para miomas uterinos. Experiencia en 60 pacientes / Uterine artery embolization as an alternative treatment for uterine fibroids. Experience in 60 patients

Introducción. Los miomas uterinos son los tumores sólidos benignos más comunes del aparato genital femenino. La embolización de las arterias uterinas (EAU) se presenta como una alternativa al tratamiento quirúrgico. Objetivo. Evaluar la eficacia de EAU en el manejo de los miomas sintomáticos. Establecer la tasa de éxito y evaluar la seguridad de la técnica mediante la detección de complicaciones durante el procedimiento y con posterioridad al mismo. Material y métodos. Estudio retrospectivo bicéntrico de 60 pacientes sometidas a EAU desde el año 2000 hasta el 2011 en H. General de Albacete y H. Puerta de Hierro de Madrid. Resultados. El éxito clínico de la técnica se demostró en 41 de los 60 casos (tasa de éxito global del 68% a los 4 años de seguimiento). En 7 de los 60 casos (11,6%) se presentaron complicaciones como síndrome postembolización, dolor e isquemia transitoria del 1.er y 2.° dedo del pie, que cedieron sin mayor complicación con tratamiento médico. Conclusión. La EAU es un tratamiento eficaz en mujeres con miomas sintomáticos, mostrando una alta seguridad y un bajo índice de posibles complicaciones menores (AU)

Introduction. Uterine fibroids are the most common benign solid tumors of the female genital tract. Uterine artery embolization (UAE) is presented as an alternative to surgical treatment. Objective. To evaluate the efficacy of UAE in the management of symptomatic fibroids, establish the success rate, and evaluate the safety of the technique by detecting complications during the procedure. Material and methods. A retrospective dual-center study was performed in 60 patients undergoing UAE from 2000 to 2011 in Albacete and the Puerta de Hierro General Hospital in Madrid. Results. The clinical success of the technique was demonstrated in 41 of the 60 patients (overall success rate of 68% at 4 years of follow-up) Complications occurred in 7 of the 60 patients (11.6%), consisting of embolization syndrome and transient ischemic pain in the first and second, which resolved with medical treatment and without further complications. Conclusion. UAE is an effective treatment for women with symptomatic fibroids, showing high reliability and a low rate of minor complications (AU)

¿Puede ser el tiempo de tránsito de pulso útil para detectar hipertensión arterial en pacientes remitidos a la unidad de sueño? / Can Pulse Transit Time Be Useful for Detecting Hypertension in Patients in a Sleep Unit?

Introducción: La relación causal entre el síndrome de apneas e hipopneas de sueño (SAHS) y la hipertensión arterial (HTA) es un hecho establecido en la literatura. El tiempo de tránsito de pulso (PTT) representa el tiempo que tarda el pulso en viajar entre 2 puntos arteriales diferentes, y puede ser útil en la estimación de la presión arterial (PA). Con este estudio se pretende valorar la utilidad del PTT en la estimación de la PA, ya que además de ser una técnica no invasiva y exenta de coste adicional, ofrece la ventaja de evitar arousals, como sucede con la monitorización ambulatoria de la PA (MAPA). Métodos: Estudio prospectivo y observacional realizado en una unidad multidisciplinar de sueño con la colaboración del servicio de Nefrología. Se reclutaron 30 pacientes consecutivos que acuden a consulta de sueño por sospecha de SAHS a los que se les realiza una polisomnografía (PSG) basal seguida de MAPA al día siguiente. Se calcula la PA sistólica (PAS) y la diastólica (PAD) media por PTT en la PSG y se compara con los resultados de la MAPA. Se diagnosticaron como pacientes con hipertensión arterial aquellos con cifras medias de MAPA durante la noche iguales o superiores a 120/70 mmHg, siguiendo normativas internacionales. Resultados: Edad media de 60 años (66% varones). El 80% eran SAHS (36% SAHS grave). La validez diagnóstica de HTA del PTT con respecto a la MAPA considerada como técnica de referencia fue: sensibilidad, 85%; especificidad, 88%; valor predictivo positivo, 85%, y valor predictivo negativo, 88%. El coeficiente de correlación lineal (R) entre la PAS media medida por MAPA durante la noche (desde las 24:00 h del día siguiente hasta las 6:00 h) y por PTT fue de 0,88, con un coeficiente de correlación intraclase de 0,88 (intervalo de confianza: 0,76-0,94), observándose una distribución de todos los sujetos entre ± 15 mmHg de diferencia entre las pruebas. Conclusiones: Existe una correlación positiva entre el PTT y la MAPA en la HTA sistólica. El PTT podría ser una alternativa capaz de ofrecer una medición continua y no invasiva de cribado de HTA no conocida o mal controlada

Introduction: Pulse transit time (PTT) is the time that a pulse wave takes to travel between two different arterial points, and may be useful in estimating blood pressure. This noninvasive technique, which does not add any cost to the procedure, offers the advantage of avoiding ‘arousals’ during sleep measurement as it occurs with ambulatory blood pressure monitoring (ABPM). We aim to confirm the usefulness of PTT for the detection of hypertension, and to study the correlation between both the measurements. Methods: Prospective observational study in a multidisciplinary sleep unit. We recruited 30 consecutive patients attending a sleep clinic and ran a baseline polysomnography followed by an ABPM the following day. Average systolic and diastolic blood pressure (SBP, DBP) by PTT were calculated and compared with ABMP results. In accordance with international guidelines, patients with mean nocturnal ABMP≥120/70 mmHg were diagnosed as having arterial hypertension. Results: Mean age was of 60 years; 66% were male, of whom 80% suffered from sleep apnoea (OSAS). Taking the ABPM as the reference technique, we found that the diagnostic sensitivity of PTT is 85% with a specificity of 88% in the case of SBP, with a positive predictive value of 85% and negative predictive value of 88%. By studying the relationship between mean SBP measured by ABPM and PTT, we found a linear correlation coefficient (R) of 0.88, showing a distribution of all subjects with a difference of ±15 mmHg between the tests. There is also a positive correlation between mean DBP measured for the two tests and with a weaker linear correlation. Conclusions: Pulse transit time shows a strong correlation with blood pressure (measured by ABPM). PTT provides continuous, non-invasive, cuffless blood pressure monitoring free of additional cost and could be an alternative for screening hypertension

Can pulse transit time be useful for detecting hypertension in patients in a sleep unit?

INTRODUCTION: Pulse transit time (PTT) is the time that a pulse wave takes to travel between two different arterial points, and may be useful in estimating blood pressure. This noninvasive technique, which does not add any cost to the procedure, offers the advantage of avoiding 'arousals' during sleep measurement as occurs with ambulatory blood pressure monitoring (ABPM). We aim to confirm the usefulness of PTT for the detection of hypertension, and to study the correlation between both measurements. METHODS: Prospective observational study in a multidisciplinary sleep unit. We recruited 30consecutive patients attending a sleep clinic and ran a baseline polysomnography followed by an ABPM the following day. Average systolic and diastolic blood pressure (SBP, DBP) by PTT were calculated and compared with ABMP results. In accordance with international guidelines, patients with mean nocturnal ABMP ≥ 120/70 mmHg were diagnosed as having arterial hypertension. RESULTS: Mean age of 60years; 66% male, 80% suffered from sleep apnoea (OSAS). Taking the ABPM as the reference technique, we found that the diagnostic sensitivity of PTT is 85% with a specificity of 88% in the case of SBP, with a positive predictive value of 85% and negative predictive value of 88%. By studying the relationship between mean SBP measured by ABPM and PTT, we found a linear correlation coefficient (R) of 0.88, showing a distribution of all subjects with a difference of between ±15mmHg between tests. There is also a positive correlation between mean DBP measured for the two tests, with a weaker linear correlation. CONCLUSIONS: Pulse transit time shows a strong correlation with blood pressure (measured by ABPM). PTT provides continuous, non-invasive, cuffless blood pressure monitoring free of additional cost and could be an alternative for screening hypertension.

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy.

OBJECTIVE: To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies. STUDY DESIGN: We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described. RESULTS: The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with ß-HCG levels that decreased and became negative within 14-49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation. CONCLUSION: Methotrexate-mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.