Geographical approach analysis of the impact of air pollution on newborn intrauterine growth and cord blood DNA damage in Mexico City.

BACKGROUND: Few epidemiologic studies have focused on the specific source of ambient air pollution and adverse health effects in early life. Here, we investigated whether air pollutants from different emission sources were associated with decreased birth anthropometry parameters and increased DNA adduct formation in mother-child pairs residing in the Mexico City Metropolitan Area (MCMA). METHODS: This cross-sectional study included 190 pregnant women recruited during their last trimester of pregnancy from two hospitals at MCMA, and a Modeling Emissions Inventory (MEI) to calculate exposure to ambient air pollutants from different emissions sources (area, point, mobile, and natural) for two geographical buffers 250 and 750 m radii around the participants households. RESULTS: Contaminants were positively correlated with umbilical cord blood (UCB) adducts, but not with maternal blood (MB) adducts. PM10 emissions (area and point sources, overall emissions), PM2.5 (point sources), volatile organic compounds (VOC), total organic compounds (TOC) from point sources were positively correlated with UCB adducts. Air pollutants emitted from natural sources were correlated with a decrease in MB and UCB adducts. PM10 and PM2.5 were correlated (p < 0.05) with a decrease in birth weight (BW), birth length (BL) and gestational age at term (GA). In multivariate analyses adjusted for potential confounders, PM10 was associated with an increase in UCB adducts. PM10 and PM2.5 from overall emissions were associated with a decrease in BW, BL and GA at term. IMPACT: Results suggested higher susceptibility of newborns compared to mothers to damage related to ambient air pollution. PMs are associated with birth anthropometry parameters and DNA damage in adjusted models, highlighting the need for more strict regulation of PM emissions.

Índice de Robson: riesgo de cesárea en un centro de primer nivel en México / Robson index, c-section risk in a first level center in Mexico

Resumen OBJETIVO: Determinar, conforme al Índice de Robson, la tasa de cesáreas en pacientes atendidas, en un periodo de nueve meses, en el Centro de Investigación Materno-Infantil del Grupo de Estudios al Nacimiento. MATERIALES Y MÉTODOS: Estudio retrospectivo, transversal, descriptivo y monocéntrico efectuado en pacientes embarazadas atendidas en el Centro de Investigación Materno Infantil del Grupo de Estudios al Nacimiento, (CIMIGen) que finalizaron el embarazo por cesárea y en quienes se utilizó el índice de Robson para su clasificación. Parámetros de estudio: indicaciones de la cesárea, riesgo de pérdida del bienestar fetal, alta de progresión del trabajo de parto, falla en la inducción del trabajo de parto, macrosomía, periodo intergenésico corto (menos de 18 meses). RESULTADOS: Se obtuvieron 569 pacientes de las que 228 finalizaron el embarazo mediante cesárea y 341 por parto, lo que representó una tasa de cesáreas del 39.9%. Al aplicar el método de clasificación de Robson, los grupos con mayor contribución relativa a la tasa global de cesáreas fueron: grupo 1 (17.62%), grupo 2, subdividido en sus dos categorías: 2a con 19.38% y 2b 17.18%; y el grupo 5.1 (22.91%) y grupo 5.2 (3.96%). Las principales indicaciones de cesárea fueron: 1) riesgo de pérdida del bienestar fetal (18.9%), 2) falta de progresión del trabajo de parto (16.7%), 3) falla en la inducción del trabajo de parto (11.1%), 4) macrosomía (7.2%) y 5) periodo intergenésico corto (7.2%). CONCLUSIONES: El índice de Robson señaló a los grupos 1, 2 y 5 como los mayores contribuyentes a la tasa de cesáreas en CIMIGen. Esta tendencia, grupos 1 y 2 con porcentajes elevados, también se observa en otros centros de atención en México, lo que pudiera indicar una práctica de atención obstétrica que debe revisarse. Esto también se ve en otros países, aunque los porcentajes son distintos pero siguen siendo considerables en los grupos 1, 2 y 5.

Abstract OBJECTIVE: To determine, according to the Robson Index, the caesarean section rate in patients attended, over a period of nine months, at the Maternal and Infant Research Centre of the Childbirth Studies Group. MATERIALS AND METHODS: Retrospective, cross-sectional, descriptive, single-centre study carried out in pregnant patients attended at the Maternal and Infant Research Centre of the Childbirth Study Group (CIMIGen) who terminated gestation by caesarean section and in whom the Robson index was used for classification. Study parameters: indications for caesarean section, risk of loss of fetal well-being, high labour progression, failure of labour induction, macrosomia, short inter-gestational period (less than 18 months). RESULTS: We obtained 569 patients of whom 228 terminated pregnancy by caesarean section and 341 by delivery, representing a caesarean section rate of 39.9%. Applying Robson's classification method, the groups with the highest relative contribution to the overall caesarean section rate were: group 1 (17.62%), group 2, subdivided into its two categories: 2a with 19.38% and 2b 17.18%; and group 5.1 (22.91%) and group 5.2 (3.96%). The main indications for caesarean section were 1) risk of loss of fetal well-being (18.9%), 2) failure of labour to progress (16.7%), 3) failure of induction of labour (11.1%), 4) macrosomia (7.2%) and 5) short inter-gestational period (7.2%). CONCLUSIONS: Robson's index pointed to groups 1, 2 and 5 as the largest contributors to the caesarean section rate at CIMIGen. This trend, groups 1 and 2 with high percentages, is also seen in other facilities in Mexico, which may indicate an obstetric care practice that needs to be reviewed. This is also seen in other countries, although the percentages are different but still considerable in groups 1, 2 and 5.

Pregnancy hypothyroidism incidence and complications using the 2011 and 2017 ATA cutoff values. Experience at a maternity hospital in a densely populated area in Mexico City.

OBJECTIVES: Normal thyroid activity has an essential role in fetal development, its deficiency may hamper fetal neurodevelopment and neonatal growth. The quantitation of thyroid hormones although useful, still exposes differences on cut off levels to diagnose thyroid deficit accurately that can elicit under or over diagnosis of thyroid dysfuntion. METHODS: A total of 839 pregnant patients were studied for thyroidal clinical assessment through quantitation of thyroid-stimulating hormone (TSH) and free thyroxine (FT4) circulating levels. Patients evaluated for prenatal and neonatal outcomes. Thyroid function deficiencies were determined with the American Thyroid Association (ATA) 2011 and 2017 values. Statistical analysis searched for associations between variables, odds ratios (OR) and correlations were calculated to evaluate the reliability of the cutoff values recommended by the ATA. RESULTS: Mean age of our cases was 27.5 + 5.83 years at diagnosis, mean gestational age at first consultation was 23.8 + 10.5 weeks. Mean TSH levels detected were: 2.5 + 1.89 mIU/L, total T3: 3.55 + 4.1 ng/dL, FT4: 3.14 + 4.4 ng/dL. The ATA 2011 values yielded 332 hypothyroidism cases vs. 507 euthyroid patients, a total incidence of 39.6% vs. the ATA 2017 values, diagnosing 100 hypothyroidism cases and 739 euthyroid patients, total incidence of 11.9%. Association with complications were not significant. CONCLUSIONS: Using ATA 2017 values showed a decreased population with gestational hypothyroidism, hence preventing overdiagnosis and over-treatment. No significant complications were associated, requiring the determination of new regional values. Education and sensibilization of our population is needed to comply with early prenatal consultation and thyroid function testing.

Prenatal Particulate Matter (PM) Exposure and Natriuretic Peptides in Newborns from Mexico City.

(1) Background: The aim of this study was to assess associations between particulate matter (PM) exposure and natriuretic peptide concentrations in cord blood from newborns. (2) Methods: we conducted a cross-sectional study in Mexico City with 101 pregnant women from CIMIGEN Hospital. Atrial natriuretic peptide (ANP), B-type natriuretic peptide (BNP) and C-type natriuretic peptide (CNP) were measured in plasma from cord blood in 51 newborns by ELISA. We estimated PM exposure (PM2.5 and PM10) at first, second and third trimester of pregnancy. (3) Results: The median and interquartile range for ANP, BNP and CNP plasma concentrations were 66.71 (46.92-80.23), 98.23 (73.64-112.30) and 1129.11 (944.10-1452.02) pg/mL, respectively. PM2.5 and PM10 levels for the whole pregnancy period were 22.2 µg/m3 and 41.63 µg/m3, respectively. Employing multivariable linear regression models adjusted for maternal age, newborn sex, smoking before pregnancy, maternal occupation and newborns' length and height, we observed a 2.47 pg/mL (95%CI: -4.67, -0.27) decrease in BNP associated with PM2.5 exposure during second trimester. Adjusted for the same set of confounders, third trimester PM10 exposure was inversely associated with ANP concentrations (beta estimate: -0.90; 95% CI: -1.80, -0.03). Neither PM10 nor PM2.5 were associated with CNP at any trimester of pregnancy. (4) Conclusions: Prenatal exposure to particulate matter was associated with ANP and BNP decrease in newborns.

Intensive Medical Nutrition Therapy Alone or with Added Metformin to Prevent Gestational Diabetes Mellitus among High-Risk Mexican Women: A Randomized Clinical Trial.

The aim of this study was to examine the efficacy of intensive medical nutrition therapy (MNT) plus metformin in preventing gestational diabetes mellitus (GDM) among high-risk Mexican women. An open-label randomized clinical trial was conducted. Inclusion criteria were pregnant women with three or more GDM risk factors: Latino ethnic group, maternal age >35 years, body mass index >25 kg/m2, insulin resistance, and a history of previous GDM, prediabetes, a macrosomic neonate, polycystic ovarian syndrome, or a first-degree relative with type 2 diabetes. Women before 15 weeks of gestation were assigned to group 1 (n = 45): intensive MNT-plus metformin (850 mg twice/day) or group 2 (n = 45): intensive MNT without metformin. Intensive MNT included individual dietary counseling, with ≤50% of total energy from high carbohydrates. The primary outcome was the GDM incidence according to the International Association of Diabetes Pregnancy Study Groups criteria. There were no significant differences in baseline characteristics and adverse perinatal outcomes between the groups. The GDM incidence was n = 11 (24.4%) in the MNT plus metformin group versus n = 7 (15.5%) in the MNT without metformin group: p = 0.42 (RR: 1.57 [95% CI: 0.67-3.68]). There is no benefit in adding metformin to intensive MNT to prevent GDM among high-risk Mexican women. Clinical trials registration: NCT01675310.

Violence against trainees: urgent ethical challenges for medical educators and academic leaders in perinatal medicine.

Objectives Violence against medical trainees confronts medical educators and academic leaders in perinatal medicine with urgent ethical challenges. Despite their evident importance, these ethical challenges have not received sufficient attention. The purpose of this paper is to provide an ethical framework to respond to these ethical challenges. Methods We used an existing critical appraisal tool to conduct a scholarly review, to identify publications on the ethical challenges of violence against trainees. We conducted web searches to identify reports of violence against trainees in Mexico. Drawing on professional ethics in perinatal medicine, we describe an ethical framework that is unique in the literature on violence against trainees in its appeal to the professional virtue of self-sacrifice and its justified limits. Results Our search identified no previous publications that address the ethical challenges of violence against trainees. We identified reports of violence and their limitations. The ethical framework is based on the professional virtue of self-sacrifice in professional ethics in perinatal medicine. This virtue creates the ethical obligation of trainees to accept reasonable risks of life and health but not unreasonable risks. Society has the ethical obligation to protect trainees from these unreasonable risks. Medical educators should protect personal safety. Academic leaders should develop and implement policies to provide such protection. Institutions of government should provide effective law enforcement and fair trials of those accused of violence against trainees. International societies should promulgate ethics statements that can be applied to violence against trainees. By protecting trainees, medical educators and academic leaders in perinatology will also protect pregnant, fetal, and neonatal patients. Conclusions This paper is the first to provide an ethical framework, based on the professional virtue of self-sacrifice and its justified limits, to guide medical educators and academic leaders in perinatal medicine who confront ethical challenges of violence against their trainees.

Comparison of fetal heart rate variability by symbolic dynamics at the third trimester of pregnancy and low-risk parturition.

Fetal heart rate variability (fHRV) is an essential source of information to monitor fetal well-being during pregnancy. This study aimed to apply a nonlinear approach, known as symbolic dynamics (SD), for comparing human fHRV in the third trimester of pregnancy during active fetal state (TT) and active labor at term (P). We performed a longitudinal, prospective, descriptive, and comparative study composed of 42 longitudinal recordings of 5-minutes of fetal heartbeat interval series. Recordings were collected from 21 low-risk, healthy, pregnant women attending the Maternal and Child Research Center (CIMIGen), Mexico City. We calculated relevant linear parameters of fHRV between TT and P stages, such as the percentage of differences between adjacent RR intervals >5 ms (PRR5, related to vagal modulations) and other SD parameters such as the percentage of no variations between three successive symbols (%0V, reflects sympathetic modulations) and the probability of low variability with a threshold of 4 ms (POLVAR4, associated with a low variability). We identified statistical differences for PRR5 between TT and P (37.13% [28.47-47.60%] vs. 28.84% [19.36-36.76%], p = 0.03), respectively. Also, for 0V% (65.66% [59.01-71.80%] vs. 71.14% [65.94-75.87%], p = 0.03) and for POLVAR4 values (0.06 [0.04-0.11] vs. 0.15 [0.09-0.24], p = 0.002), respectively. Our results indicate that during parturition, the short-term fetal fHRV is decreased, showing a decreased vagal modulations and higher adrenergic response of the heart. These autonomic modifications may result from the fetal response to the stressful inflammatory challenge of labor. We thus confirmed that the analysis of the SD applied to fHRV time series could be a potential clinical biomarker to differentiate the fetal autonomic cardiac condition at different stages of pregnancy.

Metformina: interacciones moleculares, celulares y su repercusión en la Obstetricia. Revisión bibliográfica / Metformin: Cellular and molecular interactions and its' impact in obstetrics. Literature review

Resumen OBJETIVO: Identificar los mecanismos celulares más reconocidos de la metformina y su relación con patologías en Obstetricia y determinar las moléculas y vías involucradas con potencial terapéutico. METODOLOGÍA: Estudio retrospectivo efectuado con base en la búsqueda de artículos registrados en Pubmed y Cochrane publicados en inglés entre los años 2000 a 2019 que contuvieran las palabras clave (MeSH): "Metformin"; "Celular mechanisms"; "AMPK"; "LKB1"; "Gestational diabetes", "Abortion" y "Preeclampsia". RESULTADOS: Se encontraron 1750 artículos que contenían las palabras clave de búsqueda; al final solo se analizaron 57. En estos se concluye que la intervención con este fármaco inhibe el complejo I de la cadena respiratoria mitocondrial, con repercusión en varios procesos celulares. La diabetes gestacional, el aborto y la preeclampsia se consideraron por su incidencia y relevancia obstétrica, y por la indicación de la metformina en su tratamiento. Se identificaron los mecanismos involucrados en el efecto colateral gastrointestinal y la asociación con los mecanismos celulares influidos por la metformina. En los padecimientos obstétricos se identificaron los procesos metabólicos para tratamiento común, la diabetes gestacional fue la más identificada por la experiencia en diabetes mellitus. CONCLUSIONES: Si bien la metformina tiene una indicación clara en pacientes con diabetes gestacional, los resultados son insuficientes para aborto; en preeclampsia los mecanismos intervenidos pueden tener mayor potencial terapéutico y preventivo.

Abstract OBJECTIVE: Identify the most recognized cellular mechanisms and their relations to obstetric pathology, determining molecular pathways for potential therapeutic use. METHODOLOGY: After a bibliographical search done in Pubmed and Cochrane database of MeSH terms: "metformin", "cellular mechanisms", "AMPK", "LKB1", "gestational diabetes", "abortion", "preeclampsia", in the periods comprehending 2000 through 2019, a total of 49 references were selected, on the basis of the criteria established by the objective of this review. RESULTS: With 49 selected references, we found that metformin regulates adenosine monophosphate protein kinase (AMPK) and LKB1, both who which participate in metabolic mechanisms, activating second messengers who stimulate or inhibit processes like gluconeogenesis, steroid and protein synthesis and cellular growth. This drug actually acts by inhibiting complex I of the mitochondrial respiration process, impacting various cell functions. Gestational diabetes, abortion and preeclampsia are three obstetric pathologies selected due to their incidence and relevance, as well as the fact that metformin is being used for their treatment. We also identified the mechanisms for gastrointestinal symptoms where OCT-1, PMAT and 5-HT are involved and may be therapeutic targets. The association of cell mechanisms influenced by metformin are part of various metabolic pathways, being the ones in gestational diabetes the most, well known due to experience with diabetes mellitus. CONCLUSIONS: Although metformin has a clear role in gestational diabetes, results are insufficient to identify its' role in abortion. As for preeclampsia, the mechanisms identified have a greater preventive and therapeutic potential.

Particulate matter-associated micronuclei frequencies in maternal and cord blood lymphocytes.

Studies associate particulate matter (PM) exposure with pulmonary, cardiovascular, and neurologic diseases. Elevated levels of coarse (PM10) and fine (PM2.5) PM have been reported in the Mexico City metropolitan area during the last two decades. There is limited information if these conditions affect newborns. We associated maternal exposure to PM reported by the monitoring stations considering the place of residence of each participant with the presence of genotoxic damage (cytome analysis) in maternal and umbilical cord blood (UCB) lymphocytes. Eighty-four healthy women in their last quarter of pregnancy met the inclusion criteria. Each volunteer exposure was estimated according to the average PM2.5 and PM10 levels during the last month of gestation. The micronuclei (MN) frequencies in UCB lymphocyte cultures ranged between 0 and 9. They also showed lower cell proliferation indexes than their mothers. There was a strong correlation between the maternal and the UCB MN frequency (ρ = 0.3767, P = 0.0002). Multiple regression analysis including PM10 and PM2.5 levels, maternal age, and occupation, showed a significant and positive association between UCB MN frequency and PM2.5. A statistically significant increase in the MN frequency in both maternal and UCB lymphocytes was observed in samples obtained during the dry season (higher PM levels) as compared with the MN frequency in blood samples obtained during the rainy season (lower PM levels). These results suggest that PM, mainly PM2.5 , can cross the placenta causing DNA damage in fetal cells which may increase the potential for diseases during childhood or adult life. Environ. Mol. Mutagen. 60:421-427, 2019. © 2019 Wiley Periodicals, Inc.

[Comparación de síntomas de hiperactividad e inatención en adolescentes con y sin antecedentes de embarazo].

Introduction: Teenage pregnancy has a negative impact both on mother's health and on her offspring quality life and development. In spite of its important social relevance, behavioral factors that can favor its occurrence have not been extensively explored. Objective: To compare symptoms of inattention and hyperactivity between adolescents with and without a history of pregnancy. Method: A sociodemographic record and the attention deficit hyperactivity disorder questionnaire (ADD) of the Neuropsi instrument were applied to 60 adolescents: 30 cases and 30 controls. The ADD was answered by the adolescents themselves, as well as by a close relative (parent or spouse) or by one of their teachers. Results: From the perspective of others (parents and teachers), adolescents with a history of pregnancy showed more symptoms of attention deficit and higher attention deficit and hyperactivity overall score (both p ≤ 0.01). In addition, ADD overall score was found to be associated with adolescent pregnancy (OR = 1.11, 95% CI = 1.01-1.24, p = 0.036). Conclusions: Symptoms of attention deficit and hyperactivity can represent another factor associated with teenage pregnancy.

Introducción: El embarazo adolescente ejerce un impacto negativo tanto en la salud de la madre como en la calidad de vida y desarrollo de sus hijos. Pese a su importante carga social, no se han explorado con detalle los factores conductuales que pueden favorecer su presencia. Objetivo: Comparar los síntomas de inatención e hiperactividad entre adolescentes con y sin antecedente de embarazo. Método: A 60 adolescentes se aplicó una ficha de datos sociodemográficos y el Cuestionario de Trastorno por Déficit de Atención e Hiperactividad (DDA) del Neuropsi, 30 casos y 30 controles. El DDA fue contestado por las propias adolescentes, así como por un familiar cercano (padre o pareja) y/o por un profesor del adolescente. Resultados: Desde la perspectiva de los otros (padres y profesores), las adolescentes con antecedentes de embarazo presentaron más síntomas de déficit de atención y mayor puntuación global de déficit de atención e hiperactividad (ambas con p ≤ 0.01). Asimismo, se encontró que la puntuación global del DDA se asoció con el embarazo adolescente (RM = 1.11, IC 95 % = 1.01-1.24, p = 0.036). Conclusiones: Los síntomas de déficit de atención e hiperactividad pueden representar otro factor asociado con el embarazo adolescente.

Women Serum Concentrations of the IL-10 Family of Cytokines and IFN-γ Decrease from the Third Trimester of Pregnancy to Active Labor.

Labor is regarded as increased myometrial activity with a regular contractility pattern. At this final stage of pregnancy, myometrial quiescence is lost, accompanied by altered immune homeostasis. It is well known that the interleukin (IL)-10 family of cytokines modulates immunological responses mainly in epithelial cells, including the endometrium. To investigate their inflammatory profile during labor, we performed a longitudinal study in a group of healthy pregnant women (n = 20) with uncomplicated pregnancies in the third trimester of pregnancy and during active labor. Blood was sampled from pregnant women in the third trimester (gestational age 32-38 weeks, mean 36 ± 2 weeks) and during active labor (39-41 weeks of gestation, mean 40 ± 1 weeks). Serum levels of several cytokines were measured using multiplex immunoassays for both stages, indicating that the concentrations of IL-10, IL-20, IL-22, IL-28A, and interferon (IFN)-γ were significantly decreased during active labor in comparison with third-trimester levels (p < 0.05). Our analysis did not find significant correlations between IL-10, IL-20, IL-22, IL-28A, and IFN-γ levels and gestational age. However, our data suggest that the systemic downregulation of several members of the IL-10 family of cytokines plays an important role in the activation of myometrial smooth cells associated with uterine contractions during active labor. Downregulation of this IL-10 family of cytokines seems to coincide with the well-reported functional progesterone withdrawal during labor. Likewise, lower plasma IFN-γ concentrations may indicate a role for IFN-γ in active labor.

Complex Laparoscopic Myomectomy with Severe Adhesions Performed with Proper Preventive Measures and Power Morcellation Provides a Safe Choice in Certain Infertility Cases.

Laparoscopic myomectomy offers a real benefit to infertile patients with uterine fibroids and peritoneal adhesions. The procedure requires a skilled surgeon and laparoscopy technique to minimize adhesion formation and other proven benefits. Restrictions arise since this procedure requires power morcellation for fibroid tissue extraction. Two years ago, the Food and Drug Administration in the United States of America (FDA) issued the alert on power morcellation for uterine leiomyomas, addressing the risk of malignant cell spreading within the abdominal cavity (actual risk assessment from 1 in 360 to 1 in 7400 cases). We review a 30-year-old female, without previous gestations, hypermenorrhea, intermenstrual bleeding, and chronic pelvic pain. Transvaginal ultrasound reports multiple fibroids in the right portion of a bicornuate uterus. Relevant history includes open myomectomy 6 years before and a complicated appendectomy, developing peritonitis within a year. Laparoscopy revealed multiple adhesions blocking uterine access, a bicornuate uterus, and myomas in the expected site. Myomectomy was performed utilizing power morcellation with good results. FDA recommendations have diminished this procedure's selection, converting many to open variants. This particular case was technically challenging, requiring morcellation, and safety device deployment was impossible, yet the infertility issue was properly addressed. Patient evaluation, safety measures, and laparoscopy benefits may outweigh the risks in particular cases as this one.

Forceps, Actual Use, and Potential Cesarean Section Prevention: Study in a Selected Mexican Population.

OBJECTIVE: Assessment of the frequency of complications observed with various forceps and operative vaginal delivery (OVD) techniques performed at the ABC Medical Center (Mexico City) to evaluate their safety, bearing in mind the importance of decreasing our country's high cesarean section incidence. METHODS: We reviewed 5,375 deliveries performed between the years 2007 and 2012, only 146 were delivered by OVD. RESULTS: Only 1.0% of the cases had a serious, life-threatening situation (uterine rupture). The Simpson forceps was the most favored instrument (46%) due to its simplicity of use, effectiveness, and familiarity. Prophylactic use was the most common indication (30.8%) and significant complications observed were vaginal lacerations (p = 0.016), relative risk (RR) of 3.4 (95% confidence interval [CI]: 1.15-10.04), and fourth degree perineal tear (p = 0.016), RR of 3.4 (95% CI: 1.15-10.04). CONCLUSIONS: Forceps use and other OVD techniques are a safe alternative to be considered, diminishing C-section incidence and its complications.

[Antenatal diagnosis of placental acretism-percretism]. / Diagnóstico antenatal de acretismo-percretismo placentario.

Placental acretism is an adherencial pathology associated with a high maternal morbidity and mortality rates. Antepartum diagnosis is essential to plan a proper management and reduce serious complications. Risk factors in these patients include prior cesarean sections, uterine scars and placenta previa. Second level ultrasonography may detect placental acretism with high sensitivity and specificity; magnetic resonance imaging may play a complimentary role in the diagnosis of placental acretism when ultrasonographic findings are non-conclusive, specially when determining miometrium invasion in placental acretism (incretism, percretism). This paper reports the case of a patient treated at the ABC Medical Center of Santa Fe, in her second gestation with the diagnosis of an arcuate uterus, previous cesarean section and placenta previa who presented a vaginal bleeding during pregnancy; ultrasound evaluation, in the second trimester, identified a probable placental acretism, in the third trimester, the same technology suggested placenta percreta, complimentary magnetic resonance imaging supported this diagnosis, with probable invasion to bladder, bowel and abdominal wall muscles. Imaging studies were performed at the Hospital Angeles Lomas (Maternal Fetal Clinic). A diagnosis of placenta acreta-percreta, called for a multidisciplinary surgical team, availability of blood products and other resources to face probable complications associated to the obstetrical resolution. Maternal results were optimal since histopathological evaluation reported miometrial incretism, with placental invasion millimeters away from the uterine serosa. Most ultrasonographic studies evaluating the invasion degree of the placenta have small sample sizes, generating a greater degree of false positive or false negative observations. Therefore, we agree with other authors that in all acretism cases (independent of their invasion degree), a multidisciplinary surgical team should be assembled in order to increase patient's safety. Risk factor identification, precise prenatal diagnosis, and multidisciplinary management diminish maternal morbidity and mortality rates during obstetric resolution procedures.

Robotics in Gynecology: Why is this Technology Worth Pursuing?

Robotic laparoscopy in gynecology, which started in 2005 when the Da Vinci Surgical System (Intuitive Surgical Inc) was approved by the US Food and Drug Administration for use in gynecologic procedures, represents today a modern, safe, and precise approach to pathology in this field. Since then, a great deal of experience has accumulated, and it has been shown that there is almost no gynecological surgery that cannot be approached with this technology, namely hysterectomy, myomectomy, sacrocolpopexia, and surgery for the treatment of endometriosis. Albeit no advantages have been observed over conventional laparoscopy and some open surgical procedures, robotics do seem to be advantageous in highly complicated procedures when extensive dissection and proper anatomy reestablishment is required, as in the case of oncologic surgery. There is no doubt that implementation of better logistics in finance, training, design, and application will exert a positive effect upon robotics expansion in gynecological medicine. Contrary to expectations, we estimate that a special impact is to be seen in emerging countries where novel technologies have resulted in benefits in the organization of health care systems.

[Diagnosis of molar pregnancy by hysteroscopy]. / Diagnóstico de embarazo molar por histeroscopia.

BACKGROUND: Gestational trophoblastic disease has a high incidence worldwide. Proper pre-evacuation diagnosis must be performed due to the risk of malignant complications associated with hydatidiform moles. Diagnosis of early molar pregnancies might be elusive due to atypical clinical manifestations and inconclusive ultrasonographic findings. OBJECTIVE: Report on the efficiency and precision by hysteroscopy for the diagnosis of molar pregnancy in one particular case. CLINICAL CASE: Thirty-year old woman, 5.6-week pregnant, suffering from pelvic pain, uterine bleeding and high concentrations of human chorionic gonadotropin beta fraction (beta-hCG). Ultrasonography suggested inconclusively either a hematoma or a gestational sac so that further evaluation by hysteroscopy had to be performed in order to reach a proper diagnosis. RESULTS: Hysteroscopic evaluation provided conclusive diagnostic images of hydropic degeneration of the chorionic villi. Histopathological evaluation confirmed a molar pregnancy. The mole was removed by uterine curettage and beta-hCG tests followed. CONCLUSIONS: Hysteroscopy is a useful tool for diagnostic protocol in case of early atypical molar pregnancy.

[Family planning methods based on fertility awareness]. / Métodos de planificación familiar basados en el conocimiento de la fertilidad.

The desire to limit fertility is recognized both by individuals and by nations. The concept of family planning is based on the right of individuals and couples to regulate their fertility and is based in the area of health, human rights and population. Despite the changes in policies and family planning programs worldwide, there are large geographic areas that have not yet met the minimum requirements in this regard, the reasons are multiple, including economic reasons but also ideological or religious. Knowledge on the physiology of the menstrual cycle, specifically ovulation process has been further enhanced due to the advances in reproductive medicine research. The series of events around ovulation are used to detect the "fertile window", this way women will look for the possibility of postponing their pregnancy or actually start looking for it. The aim of this article is to review the current methods of family planning based on fertility awareness, from the historical methods like the core temperature determination and rhythm, to the most popular ones like the Billings ovulation method, the Sympto-thermal method and current methods like the two days, and the standard days method. There are also mentioned methods that require electronic devices or specifically computer designed ones to detect this "window of fertility". The spread and popularity of these methods is low and their knowledge among physicians, including gynecologists, is also quite scarce. The effectiveness of these methods has been difficult to quantify due to the lack of well designed, randomized studies which are affected by small populations of patients using these methods. The publications mention high effectiveness with their proper use, but not with typical use, what indicates the need for increased awareness among medical practitioners and trainers, obtaining a better use and understanding of methods and reducing these discrepancies.

[Robotics in gynecology. Background, feasibility and applicability]. / La robótica en Ginecología. Antecedentes, viabilidad y conveniencia.

BACKGROUND: Robotic surgery is a technology that emerged from the fusion and improvement of laparoscopy, robotics and telepresence. All these three technologies underwent a long experimentation process in which several applications and innovations were tested until the only system approved for use in humans was developed: the Da Vinci system by Intuitive Surgical Inc. Gynecology, being one of the pioneer branches of Medicine involved in the development of laparoscopy, is one of the fields with the greatest possibilities for robotics, which offers great diversity of applications in hysterectomies, myomectomies, endometriosis, and in the fields of urogynecology and, most importantly, oncology. There are no publications in Mexico with a proper description of the clinical experience with gynecologic robotic surgery, though a great amount of clinical experience has been accumulated in institutions that already have such equipment. A serious evaluation of the cost-benefit ratio is required because of the high cost of this technology. OBJECTIVE: Evaluate and analyze the accumulated experience on this technology of foreign institutions in order to assess the benefits, cost and effectiveness of robotic surgery. CONCLUSION: The key to the optimal use of robotic technology is to diminish costs and speed the learning curve, and this implies the entry of other systems into the market as well as institutions with a high volume of patients and determined to invest in a highly trained and skilled surgical team. In order to recommend its implementation in our country an assessment of the efficiency and advantages of robotic technology considering institutional needs is mandatory.

Resolución laparoscópica de translocación abdominal de dispositivo intrauterino: Reporte de un caso / Laparoscopic removal of an intra-abdominal translocated intrauterine device: Case report

A partir de que Richter R, en 1909, realizó la primera publicación sobre el uso de dispositivos intrauterinos con fines anticonceptivos, la forma, los materiales, las indicaciones, así como las contraindicaciones han evolucionado hasta convertirse en el método de planificación familiar más usado en el mundo. El riesgo de perforación durante la inserción es bajo; sin embargo, ha sido referida. En la literatura se ha descrito el uso de la laparoscopia para la extracción de dispositivos intrauterinos migrados a cavidad abdominal. En la presente publicación se reporta el caso clínico de una mujer de 29 años de edad, con antecedente de colocación de dispositivo intrauterino, dos años previos, por vía vaginal sin complicación aparente; comenta sólo dolor de cólico posterior a la colocación que va cediendo a analgésicos vía oral no especificados, sin sintomatología hasta la fecha. Acude a revisión y realización de citología cervical donde no se encuentran hilos guía del dispositivo intrauterino. Mediante radiografía simple de abdomen y bajo fluoroscopia se determina la localización intraabdominal del testigo radiopaco del dispositivo, es valorada por el Servicio de Cirugía General y se determina a realizar la extracción del mismo por vía laparoscópica sin complicaciones; se encontró el dispositivo con adherencias a omento mayor, sin afección aparente de órganos intraabdominales. La Organización Mundial de la Salud recomienda la extracción inmediata de los dispositivos intrauterinos que han migrado. La migración del dispositivo intrauterino a la cavidad abdominal es una complicación poco frecuente, y la presentación como hallazgo en pacientes asintomáticas es aún menos frecuente; en una revisión sistemática de la literatura, Richdeep S y cols. valoraron 49 artículos en los que encontraron 179 casos de manejo laparoscópico, reportando al omento como el sitio más frecuente de localización (26.7%). La relevancia del presente caso radica en la presentación asintomática dos años posteriores a su inserción, la ruta diagnóstica utilizando radiografías simples y fluoroscopia, así como la extracción sin complicaciones y con excelente resultado, vía laparoscópica.

Since Richter R. in 1909 performed the first publication on the use of intrauterine devices; materials, forms, indications and contraindications of these have evolved to become the method most widely used family planning in the world. Although the risk of perforation during insertion is low, it exists. The literature has described the use of laparoscopy for removal of intrauterine devices migrated to the abdominal cavity. Case report: 29 years old woman who two years before suffers colic pain posterior to application of an intrauterine device with no complications, and diminishes with the use of unspecified analgesics, and stays asymptomatic to date. She attended a review, and underwent to cervical cytology, during the procedure, was impossible to see the strings of the intrauterine device. Plain abdominal radiography and fluoroscopy were done to determine the location of the radiopaque intraabdominal witness. Assessed by the General Surgery Service we determined extraction of the device by laparoscopy and was done without any complication. Findings: strong omentum adhesions to the device, but no apparent damage to other abdominal organs. The World Health Organization recommends the immediate removal of intrauterine devices that have migrated. The migration of the intrauterine devices into the abdominal cavity is a rare complication, and the presentation as an incidental finding in asymptomatic patients is even less common, a systematic review of literature, Richdeep S. et al, evaluated 49 items found 179 cases of laparoscopic management reporting the omentum as the most common site of localization (26.7%). The relevance of this case lies in the asyntomatic presentation two years after insertion, the diagnostic route using radiographs and fluoroscopy, and extraction without complications and with excellent results laparoscopically.

[Comparison of laparoscopic vs. laparotomy treatment in ovarian teratomas]. / Comparación del tratamiento laparoscópico vs laparotomía en teratomas ováricos.

BACKGROUND: Benign cystic teratoma is one of the most common benign tumors of the ovary, according to international series represents between 44 and 62% of all ovarian tumors diagnosed in women younger than 40 years. OBJECTIVES: To evaluate and compare the efficacy and safety between laparoscopy and laparotomy in the management of ovarian teratomas, as well as the recurrence between both techniques. MATERIALS AND METHOD: Retrospective, clinical series study involving 169 cases of ovarian teratomas operated at the Instituto Nacional de Perinatología Isidro Espinosa de los Reyes in the period comprehended between 2000-2008. The cases were divided into the ones solved by laparoscopy, corresponding to group 1 (102 cases) and 67 cases solved by laparotomy, corresponding to group 2. RESULTS: Group 1 (laparoscopic approach) consisted of 102 patients (60.3%), and group 2 (laparotomy approach) had 67 patients (39.7%). Surgical bleeding: 55.7 +/- 21.4 mL vs. 91.6 +/- 29.2 mL (p < 0.0001), hospital stay: 1.6 +/- 0.57 vs. 2.7 +/- 0.42 days (p < 0.0001), surgical time: 110.3 +/- 27.2 vs. 83.6 +/- 26.9 minutes (p < 0.0001), teratoma size: 7.2 +/- 2.3 vs. 11.5 +/- 4.2 cm (p < 0.0001) in groups 1 and 2, respectively. Teratoma rupture had 57.8% incidence (59 cases) in group 1, and 16.4% in group 2 (11 cases). Laparoscopy was a risk factor for broken open for ovarian cyst (OR: 6.9; CI 95%: 3.3-14.8). Not a single case was complicated by chemical peritonitis in any study group. CONCLUSIONS: Laparoscopic approach to teratomas is a safe and efficient procedure, it does not increase complications in comparison to the laparotomy approach; it presents less bleeding and short hospital stay, offering a quick recovery.