The impact of laparoscopic gynecological surgery training on the technicity index of a developing country center

Purpose: To compare laparoscopic gynecological surgery training between a developed country's reference center (host center) and a public reference service in a developing country (home center), and use the technicity index (TI) to compare outcomes and to determine the impact of laparoscopic gynecological surgery fellowship training on the home center's TI. Methods: The impact of training on the home center was assessed by comparing surgical performance before and after training. TI was assessed in 2017 in the host center, and before and after training in the home center. Epidemiological and clinical data, and information on reason for surgery, preoperative images, estimated intraoperative bleeding, operative time, surgical specimen weight, hospital stay length, complication and reintervention rates were collected from both institutions. Home center pre-training data were retrospectively collected between 2010 and 2013, while post-training data were prospectively collected between 2015 and 2017. A two-tail Z-score was used for TI comparison. Results: The analysis included 366 hysterectomies performed at the host center in 2017, and 663 hysterectomies performed at the home center between 2015 and 2017. TI in the host center was 82.5%, while in the home center it was 6% before training and 22% after training. There were no statistical differences in length of hospital stay, preoperative uterine volume, surgical specimen weight and complication rate between centers. However, significantly shorter mean operative time and lower blood loss during surgery were observed in the host center. Conclusions: High-quality laparoscopic training in a world-renowned specialized center allowed standardizing laparoscopic hysterectomy procedures and helped to significantly improve TI in the recipient's center with comparable surgical outcomes.

Intervenções psicológicas necessárias: a prática como residente no serviço de medicina fetal / Necessary psychological interventions: the practice as a resident in the fetal medicine service / Intervenciones psicológicas necesarias: la práctica como residente en el servicio de medicina fetal

Com os avanços tecnológicos e o aprimoramento da prática médica via ultrassonografia, já é possível detectar possíveis problemas no feto desde a gestação. O objetivo deste estudo foi analisar a prática do psicólogo no contexto de gestações que envolvem riscos fetais. Trata-se de um estudo qualitativo sob formato de relato de experiência como psicólogo residente no Serviço de Medicina Fetal da Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ). Os registros, feitos por observação participante e diário de campo, foram analisados em dois eixos temáticos: 1) intervenções psicológicas no trabalho em equipe em consulta de pré-natal, exame de ultrassonografia e procedimento de amniocentese; e 2) intervenções psicológicas em casos de bebês incompatíveis com a vida. Os resultados indicaram que o psicólogo nesse serviço é essencial para atuar de forma multiprofissional na assistência pré-natal para gravidezes de alto risco fetal. Ademais, a preceptoria do residente é relevante para sua formação e treinamento para atuação profissional no campo da psicologia perinatal.(AU)

Face to the technological advances and the improvement of medical practice via ultrasound, it is already possible to detect possible problems in the fetus since pregnancy. The objective of this study was to analyze the psychologist's practice in the context of pregnancies which involve fetal risks. It is a qualitative study based on an experience report as a psychologist trainee at the Fetal Medicine Service of the Maternity School of UFRJ. The records, based on the participant observation and field diary, were analyzed in two thematic axes: 1) psychological interventions in the teamwork in the prenatal attendance, ultrasound examination and amniocentesis procedure; and 2) psychological interventions in cases of babies incompatible to the life. The results indicated that the psychologist in this service is essential to work in a multidisciplinary way at the prenatal care for high fetal risk pregnancies. Furthermore, the resident's preceptorship is relevant to their education and training for professional performance in the field of Perinatal Psychology.(AU)

Con los avances tecnológicos y la mejora de la práctica médica a través de la ecografía, ya se puede detectar posibles problemas en el feto desde el embarazo. El objetivo de este estudio fue analizar la práctica del psicólogo en el contexto de embarazos de riesgos fetal. Es un estudio cualitativo basado en un relato de experiencia como residente de psicología en el Servicio de Medicina Fetal de la Escuela de Maternidad de la Universidade Federal do Rio de Janeiro (UFRJ). Los registros, realizados en la observación participante y el diario de campo, se analizaron en dos ejes temáticos: 1) intervenciones psicológicas en el trabajo en equipo, en la consulta prenatal, ecografía y los procedimientos de amniocentesis; y 2) intervenciones psicológicas en casos de bebés incompatibles con la vida. Los resultados señalaron como fundamental la presencia del psicólogo en este servicio trabajando de forma multidisciplinar en la atención prenatal en el contexto de embarazos de alto riesgo fetal. Además, la tutela del residente es relevante para su educación y formación para el desempeño profesional en el campo de la Psicología Perinatal.(AU)

Competencia obstétrica en la atención prenatal: una mirada desde el trabajo interprofesional / Obstetric competence in prenatal care: a look from inter-professional work

RESUMEN Introducción: las actividades extensionistas en la educación médica tributan a la formación integral del estudiante y a la solución de los principales problemas de salud de la sociedad. Objetivo: describir los saberes de la competencia obstétrica en la atención prenatal, desde una mirada interprofesional en estudiantes de Licenciatura en Enfermería. Materiales y métodos: se realizó una investigación cualitativa con enfoque fenomenológico en 10 estudiantes de la ayudantía en Ginecobstetricia. Se aplicaron entrevistas y guías de observación validadas por expertos. El estudio se diseñó en tres fases: experiencias vividas en la sostenibilidad del Programa de Atención Materno Infantil, necesidades de aprendizaje sobre la atención prenatal y determinación de saberes obstétricos con enfoque interprofesional. Resultados: los estudiantes manifestaron como experiencia vivida la necesidad de superación continua. Se reforzaron valores como el humanismo y la responsabilidad en la práctica profesional. Se identificaron las necesidades de aprendizaje: valoración de exámenes y pruebas diagnósticas, orientación psicofísica y nutricional, sistemas de apoyo a la familia, medidas de seguridad a la gestante, e identificación y toma de conducta ante las complicaciones. Se determinaron los saberes a considerar en la competencia obstétrica a partir de un modelo con enfoque interprofesional. Conclusiones: el modelo propuesto permitirá el adecuado desempeño de los estudiantes de Licenciatura en Enfermería, al integrarse como agentes activos en las diferentes acciones de salud comunitaria, y al apropiarse de los saberes necesarios para un adecuado seguimiento de la embarazada en el nivel primario de salud (AU).

ABSTRACT Introduction: the extension activities in medical education contribute to the integral training of the student and to the solution of the main health problems of the society. Objective: to describe the knowledge of obstetric competence in prenatal care, from an inter-professional perspective in the students of Bachelor's degree in Nursing. Materials and methods: a qualitative research with a phenomenological approach was carried out in 10 students of the assistantship in Gynecobstetrics. Expert-validated interviews and observation guides were applied. The study was designed in three phases: experiences in the sustainability of the Maternal and Child Care Program, learning needs on prenatal care and identification of obstetric knowledge with an inter-professional approach. Results: the students expressed as lived experience the need for continuous improvement. Values such as humanism and responsibility in professional practice were reinforced. Learning needs were identified: assessment of examinations and diagnostic tests, psychophysical and nutritional counseling, family support systems, safety measures for pregnant women, and identification and behavior in the face of complications. The knowledge to be considered in obstetric competence was determined from a model with an inter-professional approach. Conclusions: the proposed model will allow the appropriate performance of the students of Bachelor´s degree in Nursing, while integrating them as active agents in the different community health actions, and by appropriating the necessary knowledge for an adequate follow-up of the pregnant woman at the primary health level (AU).

Métodos de estudio de pacientes con sangrado uterino posmenopáusico: recomendaciones prácticas / Study methods of patients with postmenopausal uterine bleeding: practical recommendations

Resumen El sangrado uterino posmenopáusico se define como aquel sangrado que ocurre después del cese definitivo de la menstruación en la etapa reproductiva de la mujer como consecuencia de la claudicación biológica de los ovarios, o como un sangrado no esperado en mujeres con terapia de reposición hormonal sistémica de la menopausia. Representa el 5% de las consultas ginecológicas y, si bien su origen suele ser por causas benignas, puede requerir una evaluación minuciosa para descartar patologías malignas del endometrio. El objetivo de este trabajo es establecer un flujograma diagnóstico basado en la evidencia para la evaluación de las pacientes con sangrado uterino posmenopáusico.

Abstract Postmenopausal uterine bleeding is defined as the bleeding that occurs after the last menstruation due to loss of ovarian function, or a non-scheduled bleeding in patients with hormonal therapy. It represents 5% of the gynecologic visits, and even though its origin is often benign, it requires a thorough evaluation to discard malignant diseases. The objective of these review is to propose a diagnostic algorithm based on the available evidence for the evaluation of patients with postmenopausal uterine bleeding.

Abdome agudo em ginecologia / Acute abdomen in Gynecology

O abdome agudo ginecológico ou a síndrome do abdome agudo ginecológico é uma manifestação clínica cuja principal característica é a dor abdominal aguda, que requer abordagem imediata, clínica ou cirúrgica. Constitui-se em um dos problemas mais importantes na prática médica em virtude de sua alta incidência, das dificuldades e dúvidas no seu diagnóstico e da necessidade de se adotar uma terapêutica precoce. O abdome agudo cirúrgico é uma situação clínica frequente, responsável por cerca de 7% a 10% das consultas em prontos atendimentos, de apresentação brusca, que se manifesta mediante sintomas e sinais indicativos de uma afecção abdominal aguda potencialmente grave e de caráter evolutivo. Exige decisões terapêuticas rápidas e objetivas, em que se estabelece a necessidade ou não de uma intervenção cirúrgica e se essa deve ser realizada imediatamente ou não.(1,2) Caso essas ações não ocorram em tempo hábil, as consequências podem ser irreparáveis, e estas variam desde a condição de cronificação do processo de dor, com perda de fertilidade, até óbito. A dor aguda no abdome inferior e na pelve é uma queixa comum. Sua definição varia de acordo com a duração, mas, em geral, o desconforto está presente há menos de sete dias.(AU)

Comparative analysis of Insulin-like growth factor binding protein-1, placental alpha-microglobulin-1, phenol and pH for the diagnosis of preterm premature rupture of membranes between 20 and 36 weeks.

AIM: Preterm premature rupture of membranes (PPROM) is responsible for approximately one-third of premature births worldwide, and although the diagnosis is often straightforward, this condition can still present difficulties. The purpose of this research was to compare the accuracy of several PPROM diagnostic tests. METHODS: A total of 94 pregnant women with clinical suspicion of PPROM who were between 20 and 36 weeks of pregnancy were examined by vaginal speculum, and tests were performed for phenol, pH, insulin-like growth factor binding protein-1 (IGFBP-1) and placental alpha-microglobulin-1 (PAMG-1). All patients were followed up until the diagnosis was fully defined, and a diagnosis of PROM was confirmed by a definitive evolution of the clinical symptoms (visualization of vaginal amniotic fluid or persistence of oligohydramnios). RESULTS: After excluding the cases that could not be definitively diagnosed, a good diagnostic performance of the immunochromatographic tests was observed that was superior to that of the clinical tests. Similar accuracies were observed for IGFBP-1 (98.7%) and PAMG-1 (93.9%). However, while the IGFBP-1 test differed from a vaginal pH ≥7 (88.9%) and the phenol test (85.7%), this did not occur for the PAMG-1 test. The performance of the tests was modified only by the presence of bleeding (with lower specificity rates for pH and phenol), without interference of gestational age or maternal morbidities. CONCLUSION: Immunochromatographic tests are good tools but should be used sparingly in resource-poor settings because they are expensive, and there is no significant difference between PAMG-1 and traditional tests.

Accuracy of 2D ultrasound and Doppler ultrasound findings for the diagnosis of placenta accreta in pregnant women with risk factors / Exactitud de los hallazgos ecográficos 2D más ecografía doppler para el diagnóstico de acretismo placentario clínico en gestantes con factores de riesgo

ABSTRACT Objective: To determine the accuracy of 2D ultrasound and Doppler ultrasound for the diagnosis of placenta accreta in pregnant women with risk factors when compared to clinical diagnosis. Materials and methods: Study of diagnostic accuracy for the assessment of placenta accreta in high-risk patients who ended their pregnancy between 2014 and 2016 at Hospital Universitario de Santander. After obtaining their informed consent, 51 pregnant women over 18 years of age, more than 12 weeks of gestational age, low or anterior placenta or a history of uterine surgery were included. The diagnosis of a high probability of placenta accreta based on the presence of at least two ultrasound criteria and one Doppler criterion was compared with the gold standard of the visual finding during the cesarean section and of the surgical specimen in patients taken to hysterectomy, or during the clinical course in women with vaginal delivery. Sociodemographic and clinical variables are described, and the sensitivity and specificity, and positive or negative odds ratios are estimated. Results: The diagnosis of high probability of placenta accreta based on 2D Doppler Ultrasound has a high sensitivity of 88.2% (95% CI: 70.0-100) and specificity of 97.1% (95% CI: 89,9-100), with positive LR of 30.0 (95% CI: 4.3-208.5) and negative LR of 0.12 (95% CI: 0.03-0.45). Conclusions: The diagnosis of high probability of placenta accreta using non-invasive imaging provides valuable information regarding the presence and extent of placenta accreta in patients with known risk factors.

RESUMEN Objetivo: Establecer, en gestantes con factores de riesgo, la exactitud de la ecografía 2D más Doppler para hacer el diagnóstico de acretismo placentario al compararlo con el diagnóstico clínico. Materiales y métodos: Estudio de evaluación de la exactitud diagnóstica en gestantes de alto riesgo de placenta ácreta que terminaron el embarazo entre 2014 y 2016 en el Hospital Universitario de Santander. Previo consentimiento informado se incluyeron 51 gestantes mayores de 18 años, con más de 12 semanas de edad gestacional, con placenta baja o anterior, o antecedentes de cirugía uterina. Se comparó el diagnóstico de alta probabilidad de acretismo placentario dado por la presencia de, al menos, dos criterios en la ecografía 2D y uno en el Doppler, con un patrón de oro dado por el hallazgo visual durante la cesárea y la pieza quirúrgica en las que fueron llevadas a histerectomía, o la evolución clínica en las mujeres con parto vaginal. Se describen las variables sociodemográficas y clínicas, y se calcula la sensibilidad, especificidad y razón de probabilidades positiva y negativa. Resultados: El diagnóstico de alta probabilidad de acretismo placentario dado por ecografía 2D más Doppler tiene una sensibilidad del 88,2 % (IC 95 %: 70,0-100) y especificidad del 97,1 % (IC 95 %: 89,9- 100), LR positivo de 30,0 (IC 95 %: 4,3-208,5) y LR negativo de 0,12 (IC 95 %: 0,03-0,45). Conclusiones: El diagnóstico de alta probabilidad de acretismo placentario por imágenes diagnósticas no invasivas ofrece información valiosa sobre la presencia y extensión del acretismo placentario en pacientes con factores de riesgo conocidos Palabras clave: acretismo placentario, ultrasonografía doppler, técnicas de diagnóstico obstétrico y ginecológico.

Leiomioma parauretral en la postmenopausia reporte de un caso / Paraurethral leiomyoma in the postmenopause report of a case

El leiomioma parauretral es una patología poco frecuente, se trata de un tumor mesenquimatoso no dependiente de uretra y que ocasiona sintomatología uroginecológica en la paciente. Su manejo es principalmente quirúrgico. No se reportan casos de malignización, recidiva, ni metástasis y su diagnóstico diferencial se debe realizar con todas las patologías de masas uretrales y para-uretrales. El presente caso describe la presencia de este tumor en una mujer post-menopaúsica de 60 años, que además de presentar incontinencia urinaria mixta, refería signos obstructivos urinarios, fue diagnosticada y manejada de manera quirúrgica: Resección de tumor y posterior ubicación de cinta suburetral.

The paraurethral leiomyoma is a rare pathology, it is a mesenchymal tumor not dependent of the urethra which causes urogynecological symptoms in the patient. Its management is mainly surgical. No cases of malignancy, recurrence or metastasis are reported and its differential diagnosis must be performed with all pathologies of urethral and para-urethral masses. The present case describes the presence of this tumor in a 60-year-old post-menopausal woman who, in addition to presenting mixed urinary incontinence, referred obstructive urinary signs, was diagnosed and managed surgically: tumor resection and subsequent placement of suburethral tape.

Anemia ferropénica como factor de riesgo en la presencia de emergencias obstétricas / Iron-deficiency anemia as a risk factor in the presence of obstetric emergencies

Introducción:La anemia ferropénica es un trastorno nutricional frecuente en mujeres embarazadas, alrededor del 75% a nivel mundial la padecen debido a inadecuada nutrición, falta de valoración durante la gestación incrementando el riesgo de morbi-mortalidad materno neonatal.Objetivo:Identificar la anemia ferropénica como factor de riesgo de emergencias obstétricas en gestantes atendidas del área de ginecología del Hospital General Teófilo Dávila en el segundo periodo del 2016.Métodos:Se realizó una investigación cuantitativa, no experimental, transversal, analítico correlacional, de 384 historias clínicas únicas de gestantes hospitalizadas en ginecología de julio a diciembre del 2016, bajo criterio de anemia ferropénica Hb < a 11g/L,Hematocrito (HCT) < 33%, Hemoglobina corpuscular media (MCH) < 30pg, Volumen corpuscular medio (VCM) < 79fL; los datos fueron procesados en base de datos elaborada en Excel y Epi Info y analizados mediante test de chi2,con nivel de significación de p<0.05Resultados:Hay asociación entre la anemia ferropénica y emergencia obstétrica (chi2 = 48.3566, p=0). También relación entre edad de las Gestantes y complicaciones (chi2=48.3459, p=0,032); las afectadas fueron de 15 a 24 años; presentando en el segundo trimestre de gestación; preeclampsia, hipertensión gestacional, placenta previa, eclampsia (chi2=14.8374, p=0,0381); tercer trimestre de embarazo; infección de vías urinarias; parto prematuro; abrupto placentario (chi2=, p=0).Conclusiones:La anemia ferropénica predominó en las gestantes como principal factor de riesgo para el desarrollo de emergencias obstétricas, la misma que tiene mayor impacto en adolescentes de 15 a 24 años de edad, asociada a suinadecuado estado nutricional

Introduction:Iron-deficiency anemia is a nutritional disorder in pregnant women; around 75% worldwide suffer from it, due to inadequate nutrition, lack of assessment during pregnancy; increasing the risk of maternal and neonatal morbidity and mortality.Objective:To identify iron-deficiency anemia as a risk factor for obstetric emergencies in pregnant women treated Teófilo Dávila General Hospital gynecology area, 2016.Methods: A quantitative, non-experimental, cross-sectional and analytical-correlational from 384 clinical histories, only of pregnant women hospitalized in gynecology, from July to December 2016. It was considered the criterion of iron-deficiency anemia Hb

Tendo que se submeter ao exame Papanicolau regularmente: uma análise sob a ótica da desmedicalização / aving got to undergo the Pap Smear regularly: an analysis of the demedicalization perspective

Este estudo tem como objeto os significados atribuídos ao exame Papanicolau por mulheres a partir do processo de interação social. Atualmente, a estratégia mais eficaz no controle do câncer de colo de útero é o rastreamento pelo exame Papanicolau. Contudo, acredita-se que a percepção que as mulheres têm acerca deste tipo de exame, bem como os significados que são atribuídos a ele, influencia na realização do mesmo. Os objetivos deste estudo são: identificar os significados do exame Papanicolau para mulheres e analisar o processo de interação social dessas mulheres com o exame, no contexto do câncer do colo do útero, a partir dos significados por elas atribuídos. Trata-se de pesquisa descritiva e explicativa com abordagem qualitativa. A pesquisa foi realizada em locais públicos de grande circulação de pessoas, situados no município do Rio de Janeiro, devido àgrande diversidade de mulheres nesses locais. Contou com a participação de 10 mulheres que transitavam nesses locais, entre 25 a 64 anos e que já tinham iniciado a vida sexual, divididas em 2 grupos amostrais.Foram realizadas entrevistas com roteiro semiestruturado e os dados foram analisados segundo os pressupostos do interacionismo simbólico e da Grounded Theory. Projeto aprovado pelo CEP/UERJ 1.660.721. Os dados foram organizados em duas categorias que explicam o processo de interação social da mulher com o exame preventivo: "Reproduzindo o discurso de que o exame é importante para prevenção" e "Apesar das dificuldades, tendo que se submeter ao exame Papanicolau regularmente". Na primeira categoria, os dados mostram que as mulheres percebem o exame como uma forma de prevenir doenças em geral com a ideia de receio de agravo. Consideram o exame importante para diagnóstico precoce e prevenção de agravos e sustentam a importância da prevenção na perspectiva do diagnóstico para tratamento por convencimento. Na segunda categoria, as mulheres relatam os motivos que funcionam como barreiras para a realização do exame, tais como: vergonha e desconforto, falta de acesso, falta de sintomas e o impeditivo do trabalho, contudo, apesar disso, relatam realizar o exame regularmente. Emergiu no trabalho uma categoria central: "tendo que se submeter ao exame Papanicolau regularmente", em que fica evidenciado que, apesar de todas as dificuldades, a mulher realiza o exame de Papanicolau para prevenção. Desta forma, conclui-se que, mesmo que não seja de forma regular como preconizado pelos protocolos, a mulher se submete ao exame Papanicolau para prevenção de doenças. Ficou evidente, pelos dados, que é necessário promover atividades que vão além de orientações e informações sobre o câncer do colo do útero e a importância deste exame. É importante criar estratégias de promoção da saúde para estimular a autonomia das mulheres e o empoderamento do próprio corpo, para, assim, propiciar maior cobertura do exame através da adesão regular das mulheres.

This study has as its object the meanings attributed to the Pap smear by women from the process of social interaction. Currently, the most effective strategy in the control of cervical cancer is screening by the Pap smear. However, it is believed that the perception that women have about this type of examination, as well as the meanings that are attributed to it, influences itsexecution. The objectives of this study are: to identify the meanings of the Pap smear for women and to analyze the social interaction process of these women with the examination, in the context of cervical cancer, based on the meanings they assign. It is a descriptive and explanatory research with a qualitative approach. The research was carried out in public places of great circulation of people, located in the city of Rio de Janeiro, due to the great diversity of women around these places. It had the participation of 10 women who transited in these places, between 25 to 64 years and that had already begun their sexual life, separated in a 2 groups sample. Semi-structuredinterviews were conducted and the data were analyzed according to the assumptions of Symbolic Interactionism and Grounded Theory. Project was approved by CEP/UERJ 1.660.721. The data wereorganized in two categories that explain the process of social interaction of women with the Paptest: "Reproducing the discourse thatexamination is important for prevention" and "Despite the difficulties, having got to undergo the Pap smear regularly". In the first category, data showedthat women perceive the test as a way to prevent diseases in general with an idea of fear of any disorders. They consider the exam important for early diagnosis and prevention of diseases and they support the importance of prevention from the perspective of diagnosis for a treatment by professional convincing. In the second category, women reportedreasons that act as barriers to the examination, such as: embarrassment and discomfort, lack of access, lack of symptoms, and theirwork as a hampering; however, they report taking the exam regularly. A central category emerged at work: "having to undergo Pap smear regularly", which showed that despite all the difficulties women perform the Pap smear for prevention. Thus, it is concluded that, even if it is not in a regular way as recommended by the protocols, women undergo Pap smear for disease prevention. Data show that it is necessary to promote activities that would go beyond guidance, giving information about cervical cancer and the importance of this examination. It is important to create health promotion strategies to stimulate women's autonomy and body empowerment, so as to provide greater coverage of the examination through the regular adherence of women.

Utilidad y aplicación del ecodoppler en el embarazo de alto riesgo / Utility and application of ecodoppler in high risk pregnancy

Introducción: La detección de alteraciones en la circulación fetal y materna advierte sobre las alteraciones hemodinámicas que comienza a sufrir el feto. Si la edad gestacional garantiza la viabilidad fetal no se requiere prolongar la gestación, evitando complicaciones por hipoxia crónica. Sin embargo, en fetos con inmadurez pulmonar se esperan trastornos más severos por alteraciones en el sistema venoso fetal. En embarazos de alto riesgo, la ecografía fetal con Doppler es el método de elección debido a su alta sensibilidad que, además de ser no invasivo y accesible, permite la identificación de alteraciones que ponen en riesgo la vida del feto, ayudando al diagnóstico y monitoreo de las mismas. Su buen uso reduce el riesgo de muerte fetal en casos de alto riesgo. La evaluación de las arterias uterinas en el tamizaje de patologías del embarazo es de utilidad en preeclampsia, restricción de crecimiento intrauterino, desprendimiento de placenta y muerte fetal. El estudio de la morfología de onda de la arteria umbilical se utiliza ante sospecha de hipoxia, siendo el mejor indicador para interrupción de la gestación ante la presencia de anomalías, mientras que los cambios en la velocimetría de la arteria cerebral media son de utilidad en la evaluación de fetos con insuficiencia placentaria y anemia. El índice cerebro-placentario es el marcador más sensible para diagnosticar la redistribución cerebral como primer fenómeno adaptativo del feto ante la injuria. El estudio del sistema venoso fetal detecta estados más avanzados de hipoxia fetal, acompañados de acidemia e insuficiencia cardíaca. Objetivo: Describir aspectos a evaluar con EcoDoppler fetal para identificar alteraciones sugerentes de patología materno-fetal. Destacar su utilidad en embarazos de alto riesgo. Revisión de bibliografía actualizada. Materiales y Método: Para la localización de la bibliografía se utilizaron varias fuentes documentales, abarcando una búsqueda crítica en internet desde Google Académico, incluyendo artículos publicados a partir del año 2002, utilizando los descriptores: ecografía, ecoDoppler, embarazo, control prenatal, preeclampsia, restricción del crecimiento intrauterino. Se seleccionaron aquellos documentos que informasen sobre los aspectos físicos del ecoDoppler, aplicación del ecoDoppler en embarazos de alto riesgo y metodología del estudio

Introduction: The detection of alterations in the fetal and maternal circulation warns about the hemodynamic alterations that the fetus begins to suffer. If gestational age guarantees fetal viability, it is not necessary to prolong gestation, avoiding complications due to chronic hypoxia. However, in fetuses with pulmonary immaturity more severe disorders are expected due to alterations in the fetal venous system. In high-risk pregnancies, fetal ultrasound with Doppler is the method of choice due to its high sensitivity that, in addition to being non-invasive and accessible, allows the identification of alterations that put the life of the fetus at risk, aiding diagnosis and monitoring from the same. Its good use reduces the risk of fetal death in high-risk cases. The evaluation of the uterine arteries in the screening of pathologies of pregnancy is useful in preeclampsia, intrauterine growth restriction, placental abruption and fetal death. The study of the wave morphology of the umbilical artery is used when hypoxia is suspected, being the best indicator for interruption of gestation in the presence of anomalies, while changes in the velocimetry of the middle cerebral artery are useful in the evaluation of fetuses with placental insufficiency and anemia. The brain-placental index is the most sensitive marker to diagnose cerebral redistribution as the first adaptive phenomenon of the fetus before injury. The study of the fetal venous system detects more advanced stages of fetal hypoxia, accompanied by acidemia and heart failure. Objective: Describe aspects to be evaluated with Fetal EcoDoppler to identify alterations suggestive of maternal-fetal pathology. Highlight its usefulness in high risk pregnancies. Review of updated bibliography. Materials and Method:Several documentary sources were used to locate the bibliography, covering a critical search on the Internet from Google Scholar, including articles published since 2002, using the descriptors: ultrasound, ecoDoppler, pregnancy, prenatal control, preeclampsia, intrauterine growth restriction . We selected those documents that reported on the physical aspects of ecoDoppler, application of ecoDoppler in high-risk pregnancies and study methodology.

Evaluación clínica objetiva y estructurada (ECOE) en la maestría de Enfermería Ginecobstétrica y Perinatal: una sistematización de la experiencia / Objective and structured clinical evaluation (ECOE) in the masters of Gyneco-Obstetrical and Perinatal Nursing: a systematization of experience / Avaliação clínica objetiva e estruturada (ECOE) em Enfermagem gynecobstetric e Perinatal mestre: experiência sistematizar

ResumenEn busca de la excelencia profesional, la maestría en Enfermería Ginecológica, Obstétrica y Perinatal de la Universidad de Costa Rica, se mantiene a la vanguardia respecto de los procesos de enseñanza y aprendizaje. La inclusión de la simulación clínica forma parte de estas innovaciones educativas desde el año 2012; sin embargo esta es la primera vez que se incluye los procesos evaluativos de tipo ECOES los cuales, en experiencias internacionales, han demostrado pertinencia en el cumplimiento de los objetivos de enseñanza. Esta experiencia se sistematiza, según los cinco tiempos que Óscar Jara establece en su libro Para sistematizar experiencias, con el objetivo de definir la pertinencia del ECOE en cuanto a cumplir los objetivos de aprendizaje del curso. La profesora del curso y la autora recopilaron la experiencia en un diario de registro que incluye la elaboración de los escenarios, y la creación de las rubricas de evaluación. Además las estaciones fueron grabadas. La evaluación se llevó a cabo con la totalidad de estudiantes matriculados, en el curso de Enfermería Ginecoobstétrica y Perinatal I. Se estableció tres estaciones que permitirían evaluar aspectos teóricos, habilidades técnicas y sociales en la atención de las personas. Además, se creó rúbricas de evaluación, basadas en guías clínicas procedimentales y en protocolos de atención de la seguridad social costarricense. Se concluye que la experiencia demuestra clara pertinencia de los ECOEs, para evaluar la aplicación de conocimientos teóricos y habilidades psicomotoras, sociales y de comunicación en estudiantes que cursan la maestría y evidencia su preparación para continuar con los niveles más complejos de la carrera.

AbstractIn search of professional excellence, the master's degree in Gynecological, Obstetrical and Perinatal Nursing at the University of Costa Rica remains at the forefront of teaching and learning processes. The inclusion of clinical simulation is part of these educational innovations since 2012. However, this is the first time that includes ECOES evaluation processes which, in international experiences, have demonstrated relevance in the fulfillment of teaching objectives. This experience is systematized, according to the five times that Oscar Jara establishes in his book. To systematize experiences, with the objective of defining the relevance of the ECOE in terms of meeting the learning objectives of the course. The course teacher and the author collected the experience in a log diary that includes the elaboration of the scenarios, and the creation of the evaluation rubrics. In addition, the stations were recorded. The evaluation was carried out with all the enrolled students, in the course of Gyneco-Obstetric and Perinatal Nursing I. Three stations were established that would allow to evaluate theoretical aspects, technical and social skills in the attention of the people. In addition, evaluation rubrics were created, based on procedural clinical guidelines and Costa Rican social security care protocols. It is concluded that the experience shows a clear relevance of the ECOEs, to evaluate the application of theoretical knowledge and psychomotor, social and communication skills in students who are masters and evidence their preparation to continue with the most complex levels of the career.

ResumoProcurando por excelência profissional, especialização em Enfermagem Ginecológica, Obstétrica e Perinatal mestre da Universidade da Costa Rica, continua na vanguarda no que diz respeito ao ensino e aprendizagem. Incluindo simulação clínica faz parte dessas inovações educacionais desde 2012; no entanto esta é a primeira vez que tais processos de avaliação que incluem ECOES em experiências internacionais têm mostrado relevância no cumprimento dos objectivos de ensino. Esta experiência é sistematizado como cinco vezes Óscar Jara afirma em seu livro de sistematizar experiências, com o objetivo de definir a relevância da OSCE na prossecução dos objectivos de aprendizagem do curso. Professor do Curso e autor reuniu experiência em um diário de bordo, que inclui o desenvolvimento de cenários e criando rubricas de avaliação. Além disso estações foram registrados. A avaliação foi realizada com todos os alunos inscritos no curso e Enfermagem Gynecoobstetric Perinatal I três estações que permitem avaliar competências teóricas, técnicas e sociais para lidar com pessoas foi estabelecida. Além disso, as rubricas de avaliação com base em diretrizes clínicas e protocolos processuais atenção da segurança social da Costa Rica foi criado. Concluise que a experiência mostra clara relevância de ECOES para avaliar a aplicação de conhecimentos e psicomotoras competências teóricas, habilidades sociais e de comunicação em estudantes perseguir mestrado e preparar provas para avançar para níveis mais complexos da corrida.

Controversia en el tratamiento de la lesión intraepitelial escamosa de alto grado (NIC II) / Controversy in the treatment of high-grade squamous intraepithelial lesion (CIN II)

Contexto: el cono LLETZ actualmente es el tratamiento de las NIC de alto grado. La resistencia al procedimiento es argumentada por los efectos del sobretratamiento (estenosis e insuficiencia cervical), sobre todo cuando se utilizan métodos ablativos destructivos en lugar de la resección quirúrgica ambulatoria (LLETZ). Objetivo: analizar el diagnóstico y tratamiento del NIC II mediante cono y legrado en pacientes que acuden al servicio de Patología del tracto genital inferior del Hospital Oncológico SOLCA-Quito Ecuador. Sujetos y métodos: en este estudio epidemiológico descriptivo observacional de corte transversal se analizaron expediente clínicos de 820 pacientes con diagnóstico histopatológico por biopsia de NIC II; mujeres entre 17 a 82 años que acudieron al servicio de patología del tracto genital inferior sujetas a control, en estas pacientes se realizó 530 legrados. El estudio fue realizado en el Hospital Oncológico SOLCA de Quito Ecuador, de los años 2004 a 2013. Resultados: la histopatología de los conos libres de neoplasia representa el 98,66% (n=809); existen 11 casos de neoplasias residuales (1,34%). El 53,7% de casos presenta una lesión igual o mayor que en biopsia, lo que justifica el cono. Conclusión: el procedimiento de cono LLETZ tiene gran utilidad diagnóstica, terapéutica y pronóstica en mujeres que presentan NIC II y otras patologías similares. (AU)

Background: the LLETZ cone is currently the treatment of high grade NICs. The resistance to the procedure is argued by the effects of overtreatment (stenosis and cervical insufficiency), especially when destructive ablative methods are used instead of ambulatory surgical resection (LLETZ). Objective: to analyze the diagnosis and treatment of CIN II by means of cone and curettage in patients attending the pathology department of the lower genital tract of the SOLCA-Quito Ecuador Oncology Hospital. Subjects and methods: in this cross-sectional descriptive epidemiological observational study, we analyzed clinical records of 820 patients with histopathological diagnosis by CIN II biopsy; women between 17 and 82 years old who visited the pathology service of the lower genital tract subject to control, in these patients 530 catheters were performed. The study was conducted at the SOLCA Oncology Hospital of Quito, Ecuador, from 2004 to 2013. Results: the histopathology of neoplasm-free cones represents 98.66% (n = 809); there are 11 cases of residual neoplasms (1.34%). 53.7% of cases present a lesion equal to or greater than in biopsy, which justifies the cone.(AU)

Cytobrush: A tool for sequential evaluation of gene expression in bovine endometrium.

Aims were to (i) compare specific transcript abundance between endometrial samples collected by transcervical biopsy and cytobrush and (ii) measure the abundance of endometrial transcripts involved in PGF2α synthesis in samples collected by cytobrush. In Experiment 1, endometrial samples were taken transcervically by cytobrush and biopsy 10 days after ovulation. Compared to biopsy samples, abundance of transcripts for MSTN, AKR1C4 and PGR was similar, VIM, FLT1 and PTGES was lower (p < .05) and KRT18 and CD3D was greater in cytobrush samples (p < .05). Thus, there was an enrichment of epithelial and immune cells in the cytobrush samples. In Experiment 2, endometrial samples were collected by cytobrush on days 10, 13, 16 and 19 after ovulation. Abundance of PGR2 mRNA was maximum on day 10 then decreased (p < .05). Abundance of ESR1 decreased gradually from day 10 to day 16 then increased again on day 19. The greatest abundance of OXTR was noted on day 19. The sequential alterations in abundance of these transcripts are consistent with the release of PGF2α associated with luteolysis. In summary, cytobrush sampling provides representative, physiologically relevant samples of the luminal epithelium in cattle.

Histerectomía laparoscópica / Laparoscopic hysterectomy

Introducción: la incorporación de la cirugía laparoscopia representa un cambio indiscutible en la especialidad de Ginecología, ya que permite la realización de procedimientos diagnósticos y terapéuticos. Objetivo: evaluar los resultados obtenidos con la implementación de la histerectomía laparoscópica como tratamiento definitivo de las enfermedades ginecológicas quirúrgicas. Métodos: se realizó un trabajo de investigación-desarrollo de tipo explicativo, cuasi experimental. Hubo 140 pacientes con indicación de histerectomía que acudieron al servicio de Cirugía General del Hospital General Docente Comandante Pinares desde enero 2013 hasta diciembre 2014. Se controlaron variables como las operaciones y enfermedades ginecológicas previas, las complicaciones transoperatorias y posoperatorias. Así como: tiempo quirúrgico, pérdidas sanguíneas, estadía y costo hospitalario. Resultados: la cesárea fue la intervención anterior más frecuente y el fibroma uterino la principal enfermedad tratada por este método. Las complicaciones posoperatorias fueron las de mayor incidencia. Disminuyeron variables como pérdidas sanguíneas, tiempo quirúrgico y costos hospitalarios. Conclusiones: queda demostrado que la histerectomía laparoscópica tiene mayores ventajas biológicas, sociales y económicas(AU)

Introduction: The laparoscopic surgery's incorporation represents an indisputable change in the specialty of gynecology, since it permits the realization of diagnostic and therapeutic procedures. Objective: To evaluate the outcomes from the implementation of the laparoscopic hysterectomy as definitive treatment for surgical gynecological diseases. Methods: An explanatory and quasiexperimental development investigation was carried out. There were 140 patients with hysterectomy indications who went to the general surgery service at Comandante Pinares General Teaching Hospital from January 2013 to December 2014. Variables were controlled, like operations and previous gynecological diseases, complications during and after operation, as well as surgical time, blood loss, and in-hospital stay and cost. Results: The cesarean was the most frequent previous operation, and the uterine fibroid was the main disease treated through this method. The postoperative complications were the most common. Variables like blood loss, surgical time and in-hospital cost decreased. Conclusions: The laparoscopic hysterectomy has proved to have more social, economic and biological advantages(AU)

Value of the Ultrasound in the Study of Ovarian Reserve for Prediction of Oocyte Recovery.

Purpose To identify which methods used in the assessment of the ovarian reserve are exclusive or complementary to identify the best response to follicle development. Methods Retrospective cohort study, involving patients undergoing assisted reproduction treatment at the Instituto de Medicina Reprodutiva e Fetal, from April 2009 to July 2014. Age, biochemical tests, and ultrasound were assessed. The data were analyzed to predict the follicular development and the relation between them, using, for statistical analysis, Statistical Package for Social Sciences software. Results Out of the 293 couples included, 50.2% presented infertility by ovarian factor. Considering the age as the main variable, a significant negative correlation with the volume of both ovaries was observed (right ovary, r = 0.21; left ovary, r = -0.22; both p < 0.0001), and with the antral follicle count (right ovary, r = -0.38; left ovary, r = -0.47; both p < 0.0001). Considering the antral follicle count as the main variable, a significant positive correlation with the total recruited oocytes was observed. When we correlated the antral follicle count with the recruited follicles larger than 18 mm, we observed that, with a cutoff of 12 antral follicles, there is a positive predictive value of 99%, and an area under the ROC curve of 0.76. Conclusion We concluded from our study that age and antral follicle count are effective predictors of ovarian response in cycles of assisted reproduction. The ovarian volume, as well as the anti-Müllerian hormone dosage, seem to be adequate markers of the ovarian reserve.