Clinical Presentation, Treatment Outcomes, and Resistance-related Factors in South American Women with Low-risk Postmolar Gestational Trophoblastic Neoplasia / Apresentação clínica, resultados do tratamento e fatores relacionados à resistência em mulheres sul-americanas com neoplasia trofoblástica gestacional pós-molar de baixo risco

Abstract Objective There are few multinational studies on gestational trophoblastic neoplasia (GTN) treatment outcomes in South America. The purpose of this study was to assess the clinical presentation, treatment outcomes, and factors associated with chemoresistance in low-risk postmolar GTN treated with first-line single-agent chemotherapy in three South American centers. Methods Multicentric, historical cohort study including women with International Federation of Gynecology and Obstetrics (FIGO)-staged low-risk postmolar GTN attending centers in Argentina, Brazil, and Colombia between 1990 and 2014. Data were obtained on patient characteristics, disease presentation, and treatment response. Logistic regression was used to assess the relationship between clinical factors and resistance to first-line single-agent treatment. A multivariate analysis of the clinical factors significant in univariate analysis was performed. Results A total of 163 women with low-risk GTN were included in the analysis. The overall rate of complete response to first-line chemotherapy was 80% (130/163). The rates of complete response to methotrexate or actinomycin-D as first-line treatment, and actinomycin-D as second-line treatment postmethotrexate failure were 79% (125/157), 83% (⅚), and 70% (23/33), respectively. Switching to second-line treatment due to chemoresistance occurred in 20.2% of cases (33/163). The multivariate analysis demonstrated that patients with a 5 to 6 FIGO risk score were 4.2-fold more likely to develop resistance to first-line single-agent treatment (p= 0.019). Conclusion 1) At presentation, most women showed clinical characteristics favorable to a good outcome, 2) the overall rate of sustained complete remission after first-line single-agent treatment was comparable to that observed in developed countries, 3) a FIGO risk score of 5 or 6 is associated with development of resistance to first-line single-agent chemotherapy.

Resumo Objetivo Existem poucos estudos multinacionais sobre os resultados do tratamento da neoplasia trofoblástica gestacional (NTG) na América do Sul. O objetivo deste estudo foi avaliar a apresentação clínica, os resultados do tratamento e os fatores associados a casos de quimiorresistência em NTG pós-molar de baixo risco tratados com quimioterapia de agente único de primeira linha em três centros sul-americanos. Métodos Estudo multicêntrico de coorte histórica incluindo mulheres com NTG pós-molar de baixo risco com estadiamento International Federation of Gynecology and Obstetrics (FIGO) em centros de atendimento na Argentina, Brasil e Colômbia entre 1990 e 2014. Foram obtidos dados sobre as características do paciente, apresentação da doença e resposta ao tratamento. A regressão logística foi usada para avaliar a relação entre fatores clínicos e resistência ao tratamento de primeira linha com agente único. Foi realizada uma análise multivariada dos fatores clínicos significativos na análise univariada. Resultados Cento e sessenta e três mulheres com NTG de baixo risco foram incluídas na análise. A taxa global de resposta completa à quimioterapia de primeira linha foi de 80% (130/163). As taxas de resposta completa ao metotrexato ou actinomicina-D como tratamento de primeira linha e actinomicina-D como tratamento de segunda linha após falha do metotrexato foram 79% (125/157), 83% (⅚) e 70% (23/33), respectivamente. A mudança para o tratamento de segunda linha por quimiorresistência ocorreu em 20,2% dos casos (33/163). A análise multivariada demonstrou que pacientes com pontuação de risco FIGO de 5 a 6 foram 4,2 vezes mais propensos a desenvolver resistência ao tratamento com agente único de primeira linha (p= 0,019). Conclusão 1) Na apresentação, a maioria das mulheres demonstrou características clínicas favoráveis a um bom resultado, 2) a taxa geral de remissão completa sustentada após o tratamento de primeira linha com agente único foi comparável à de países desenvolvidos, 3) um escore de risco FIGO de 5 ou 6 está associado ao desenvolvimento de resistência à quimioterapia de agente único de primeira linha.

Clinical Presentation, Treatment Outcomes, and Resistance-related Factors in South American Women with Low-risk Postmolar Gestational Trophoblastic Neoplasia.

OBJECTIVE: There are few multinational studies on gestational trophoblastic neoplasia (GTN) treatment outcomes in South America. The purpose of this study was to assess the clinical presentation, treatment outcomes, and factors associated with chemoresistance in low-risk postmolar GTN treated with first-line single-agent chemotherapy in three South American centers. METHODS: Multicentric, historical cohort study including women with International Federation of Gynecology and Obstetrics (FIGO)-staged low-risk postmolar GTN attending centers in Argentina, Brazil, and Colombia between 1990 and 2014. Data were obtained on patient characteristics, disease presentation, and treatment response. Logistic regression was used to assess the relationship between clinical factors and resistance to first-line single-agent treatment. A multivariate analysis of the clinical factors significant in univariate analysis was performed. RESULTS: A total of 163 women with low-risk GTN were included in the analysis. The overall rate of complete response to first-line chemotherapy was 80% (130/163). The rates of complete response to methotrexate or actinomycin-D as first-line treatment, and actinomycin-D as second-line treatment postmethotrexate failure were 79% (125/157), 83% (⅚), and 70% (23/33), respectively. Switching to second-line treatment due to chemoresistance occurred in 20.2% of cases (33/163). The multivariate analysis demonstrated that patients with a 5 to 6 FIGO risk score were 4.2-fold more likely to develop resistance to first-line single-agent treatment (p = 0.019). CONCLUSION: 1) At presentation, most women showed clinical characteristics favorable to a good outcome, 2) the overall rate of sustained complete remission after first-line single-agent treatment was comparable to that observed in developed countries, 3) a FIGO risk score of 5 or 6 is associated with development of resistance to first-line single-agent chemotherapy.

OBJETIVO: Existem poucos estudos multinacionais sobre os resultados do tratamento da neoplasia trofoblástica gestacional (NTG) na América do Sul. O objetivo deste estudo foi avaliar a apresentação clínica, os resultados do tratamento e os fatores associados a casos de quimiorresistência em NTG pós-molar de baixo risco tratados com quimioterapia de agente único de primeira linha em três centros sul-americanos. MéTODOS: Estudo multicêntrico de coorte histórica incluindo mulheres com NTG pós-molar de baixo risco com estadiamento International Federation of Gynecology and Obstetrics (FIGO) em centros de atendimento na Argentina, Brasil e Colômbia entre 1990 e 2014. Foram obtidos dados sobre as características do paciente, apresentação da doença e resposta ao tratamento. A regressão logística foi usada para avaliar a relação entre fatores clínicos e resistência ao tratamento de primeira linha com agente único. Foi realizada uma análise multivariada dos fatores clínicos significativos na análise univariada. RESULTADOS: Cento e sessenta e três mulheres com NTG de baixo risco foram incluídas na análise. A taxa global de resposta completa à quimioterapia de primeira linha foi de 80% (130/163). As taxas de resposta completa ao metotrexato ou actinomicina-D como tratamento de primeira linha e actinomicina-D como tratamento de segunda linha após falha do metotrexato foram 79% (125/157), 83% (⅚) e 70% (23/33), respectivamente. A mudança para o tratamento de segunda linha por quimiorresistência ocorreu em 20,2% dos casos (33/163). A análise multivariada demonstrou que pacientes com pontuação de risco FIGO de 5 a 6 foram 4,2 vezes mais propensos a desenvolver resistência ao tratamento com agente único de primeira linha (p = 0,019). CONCLUSãO: 1) Na apresentação, a maioria das mulheres demonstrou características clínicas favoráveis a um bom resultado, 2) a taxa geral de remissão completa sustentada após o tratamento de primeira linha com agente único foi comparável à de países desenvolvidos, 3) um escore de risco FIGO de 5 ou 6 está associado ao desenvolvimento de resistência à quimioterapia de agente único de primeira linha.

Management practices for placenta accreta spectrum patients: a Latin American hospital survey.

INTRODUCTION: Placenta accreta spectrum (PAS) causes severe morbidity and can result in maternal death. It must be managed in specialized centers with interdisciplinary groups, but few publications have described the usual management within a specific geographic region. We intend to describe the usual approach for PAS in reference centers in Latin America. METHODOLOGY: This was an observational, multicenter, cross-sectional study conducted in Latin American PAS reference centers. A standardized survey was implemented and applied to obstetric service coordinators and leaders of interdisciplinary groups with experience in PAS between September and November 2020. RESULTS: One hundred fifty-four hospitals were included. Most of them (64.3%) handle approximately one case of PAS every two months, and almost all centers (89.6%) believe that their performance could be improved. CONCLUSIONS: Most of the reference centers for PAS in Latin America attend to a small number of cases each year, and almost all of these hospitals identify opportunities to improve the management or approach for PAS in women.

Lack of experience is a main cause of maternal death in placenta accreta spectrum patients.

INTRODUCTION: Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost complete lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems. MATERIAL AND METHODS: This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated. RESULTS: Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases. CONCLUSIONS: Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.

Comparison of 2 Human Chorionic Gonadotropin Immunoassays Commercially Available for Monitoring Patients With Gestational Trophoblastic Disease.

OBJECTIVE: The aim of this study was to compare serum human chorionic gonadotropin (hCG) levels in patients with gestational trophoblastic disease (GTD) using 2 commercially available hCG immunoassays. METHODS: Serum samples were obtained from patients with GTD attending the Botucatu Medical School Trophoblastic Diseases Center of São Paulo State University (UNESP), from November 2014 to October 2015. Serum hCG levels were measured with both Architect i2000SR and Immulite 2000 XPi chemiluminescence assays. Serum hCG levels were compared against the null hypothesis. Agreement in clinical management decisions based on the hCG results was determined by comparing baseline hCG measurements and the hCG curves obtained with both assays. RESULTS: Seventy-three patients with GTD were included in the analysis. Of these, 45 had hydatidiform mole and spontaneous remission, whereas 28 had gestational trophoblastic neoplasia (GTN). There was a perfect (zero difference) agreement in mean hCG levels between Immulite 2000 XPi and Architect i2000 when hCG is less than 100 mIU/mL. For hCG values greater than 100 mIU/mL, there was a significant difference between assays (P < 0.05), with levels measured via Architect i2000SR being higher than those measured by Immulite 2000 XPi in patients with hydatidiform mole/spontaneous remission (R = 90%, P < 0.01) and GTN (R = 98%, P < 0.01). Baseline clinical management decisions showed agreement in 100% (73/37) of cases (κ = 1.0, P < 0.001), whereas decisions based on hCG curve agreed in 98% (71/72) of cases (κ = 0.93, P < 0.001). CONCLUSIONS: Immulite 2000 XPi is the most frequently recommended assay for diagnosing and monitoring patients with GTD. However, our results suggest that because Immulite 2000 XPi and Architect i2000 show very similar performance in measuring hCG levels and in determining clinical management, Architect may be used as an alternative.

Determining the time required to achieve negative human chorionic gonadotropin value after a nonmolar pregnancy: preliminary results.

OBJECTIVE: To determine the time of human chorionic gonadotropin (hCG) regression in nonmolar gestation. STUDY DESIGN: Patients treated at our institution between June 2012 and July 2013 were selected by a deterministic sequential sampling distributed among 2 phases. Distribution of the patients included resolved cases by vaginal delivery and cesarean section in preterm and term pregnancies, ectopic, and abortion. Phase 1: serum hCG values were determined at 4, 5 and 6 weeks of obstetric resolution. Phase 2: hCG serum values were determined immediately at obstetric resolution and at 2, 3 and 4 weeks of the resolution of the cases, too. RESULTS: Phase 1: After the analysis of serum hCG of 63 patients at 4, 5 and 6 weeks postresolution, a negative result was corroborated in 100% of cases, in any period of the sample, with average values of 1.71, 0.55, and 0.18 mIU/mL, respectively. Phase 2 included 398 patients, with serum hCG in the first 72 hours postresolution, showing an average hCG value of 1,483.5 mIU/mL (range, 0.07-10,789), noting that 1% of cases had negative results. We then obtained hCG values at 2, 3 and 4 weeks of resolution, showing the regression in 73.4% of cases in the 2nd week, in 96.7% of patients in the 3rd week, and in all cases in the 4th week. CONCLUSION: The regression of hCG after nonmolar pregnancy does not exceed 3 weeks.

Hydatidiform mole in ectopic pregnancy: clinical, imaging, pathological and immunohistochemical characteristics.

OBJECTIVE: To determine the clinical, pathological, immunohistochemical and imaging characteristics of hydatidiform mole in ectopic pregnancy (HMEP) in all the cases admitted to the Department of Obstetrics and Gynecology, University Hospital of Caracas (HUC), Central University of Venezuela. STUDY DESIGN: Retrospective and comparative study, based on clinical records review of 2 groups: 10 cases with a diagnosis of HMEP and 20 cases with intrauterine hydatidiform mole (IUHM) admitted to the Obstetrics and Gynecology Department of HUC from 1996 to 2010. Clinical, pathological, immunohistochemical and imaging features were analyzed. RESULTS: The prevalence of HMEP in this study was 0.14:1,000 pregnancies; in this group the mean age was 28.8 years, and the mean gestational age at admission was 8.6 weeks. Both groups (HMEP and IUHM) were comparable in these last variables. Abdominal pain and genital bleeding were the most common clinical symptoms in the HMEP group, while it was vaginal bleeding in the IUHM group. Ultrasound findings were similar to those traditionally described in nonmolar ectopic pregnancy. Histology and immunohistochemistry showed that all cases of HMEP were partial mole. CONCLUSION: Although in this study the prevalence of HMEP was high, the size of the sample limits definitive conclusions. This study concludes that all cases of HMEP are partial mole.

Influence of hydatidiform mole follow-up setting on postmolar gestational trophoblastic neoplasia outcomes: a cohort study.

OBJECTIVE: To assess the influence of hydatidiform mole (HM) management setting (reference center versus other institutions) on gestational trophoblastic neoplasia (GTN) outcomes. METHODS: This cohort study included 270 HM patients attending Botucatu Trophoblastic Diseases Center (BTDC, São Paulo State University, Brazil) between January 1990 and December 2009 (204 undergoing evacuation and entire postmolar follow-up at BTDC and 66 from other institutions [OIs]). GTN characteristics and outcomes were analyzed and compared according to HM management setting. The confounding variables assessed included age, gravidity, parity, number of abortions and HM type (complete or partial). Postmolar GTN outcomes were compared using Mann-Whitney's test, chi2 test or Fisher's exact test. RESULTS: Postmolar GTN occurred in 34 (34/204 = 16.7%) BTDC patients and in 27 (27/66 = 40.9%) of those initially treated in other institutions. BTDC patients showed lower metastasis rate (5.8% vs. 48%, p = 0.003) and lower median FIGO (2002) score (2.00 [1.00, 3.00] vs. 4.00 [2.00, 7.00], p = 0.003]. Multiagent chemotherapy to treat postmolar GTN was required in 2 BTDC cases (5.9%) and in 8 OI cases (29.6%) (p = 0.017). Median time interval between molar evacuation and chemotherapy onset was shorter among BTDC patients (7.0 [6.0, 10.0] vs. 10.0 [7.0, 16.0], p = 0.040). CONCLUSION: BTDC patients showed GTN characteristics indicative of better prognosis. This underscores the importance of GTD specialist centers.

Utility of p57 protein(KIP2) in molar disease to determine its androgenetic origin.

OBJECTIVE: To determine, qualitatively and semiquantitatively, the expression of p57 protein in different trophoblastic cell populations of hydatidiform mole and anembryonic pregnancy. STUDY DESIGN: We performed an observational study of the histopathologic and immunohistochemical findings of 48 cases of hydatidiform mole and 2 anembryonic pregnancies. The histologic samples stained with hematoxylin-eosin were reviewed blindly by 3 pathologists to establish a diagnosis and compare it to the previous one. Afterward, immunohistochemical staining was performed using a polyclonal antibody on paraffin-embedded, formalin-fixed tissue sections. The nuclear staining was assessed in 5 cell types: villous mesenchyme, cytotrophoblast, syncytiotrophoblast, intervillous trophoblast and decidua. RESULTS: The degree of agreement between the previous histologic diagnosis and the current one was excellent (kappa = 0.702). The sensitivity was 82.6% for complete and 84% for partial mole. On immunohistochemical analysis, the degree of agreement was low (kappa = 0.2). The sensitivity was 53.9% for complete mole and 59.1% for partial mole. The cell population with the least expression for p57 was the cytotrophoblast. The results for anembryonic pregnancies remained the same. CONCLUSION: Immunohistochemistry with p57 is a useful method to differentiate complete from partial mole, which is important to establish the prognosis of the patient.

Feocromocitoma asociado con embarazo / Pheochromocytoma associated wih pregnancy

Se comunica el caso de gestante de 22 años, controlada en la consulta de alto riesgo por diagnóstico de feocromocitoma, con control adecuado de las cifras de tensión arterial. Se realizó cesárea segmentaria más adrenalectomía a las 35 semanas; durante el acto operatorio presentó crisis hipertensiva de difícil manejo, por lo cual, se difirió la adrenalectomía. En el posoperatorio inmediato presentó atonía uterina que ameritó realizar histerectomía subtotal e inmediatamente adrenalectomía derecha. El estudio histopatológico confirmó el diagnóstico de feocromocitoma. El manejo multidisciplinario permitió una evolución favorable materno-fetal.

The case of a 22 year old patient followed in the high risk pregnancy clinic due to diagnosis of pheocromocytoma, with adecuate control of blood pressure, was reported. At 35 weeks of gestation, a cesarean section with adrenalectomy was indicated; however, during surgery she presented high blood pressure which did not respond to the pharmacological therapy, so adrenalectomy was postponed. After surgery, she presented uterine atony, hence subtotal hysterectomy and right adrenalectomy was performed. The histology confirmed the diagnostic of pheocromocytoma. The multidisciplinary management allowed in this case a satisfactory maternal-fetal outcome.

Metastasis detection with 18 FDG-positron emission tomography/computed tomography in gestational trophoblastic neoplasia: a report of 2 cases.

BACKGROUND: The imaging methods proposed by the International Consensus for the Diagnosis of Metastases in Trophoblastic Neoplasia are sufficient to stage the disease in most cases. However, there are 2 circumstances in which a more accurate imaging method is necessary: condemonstrate tl fusing images in conventional studies and persistent low 18 FDG-PET/CT human chorionic gonadotropin (hCG) values. Eighteen-fluoro-2-deoxyglucose-positron emission tomography/ computed tomography (18 FDG-PET/CT) can be helpful in these cases. CASES: Case 1. A 51-year-old woman was referred to the Hospital Universitario de Caracas from another hospital with a diagnosis of cervical adenosquamous carcinoma. She complained of vaginal bleeding; clinical and sonographic evaluation demonstrated a tumor in the uterus and lower third of the vagina. A new histopathologic study was performed, and choriocarcinoma (CC) was diagnosed and staged as International Federation of Gynecologists and Obstetricians (FIGO) II:12 The im aging studies were confusing, so an 18 FDG-PET/CT was performed, showing multiple nodules in the lungs. Case 2. A 25-year-old woman was admitted with symptoms that mimicked those of ectopic pregnancy; a left salpingectomy was performed, with a histopathologic report of CC. It was classified as FIGO stage 11:4. Treatment consisted of chemotherapy, hysterectomy and 1 pelvic tumor resection. Two years after discontinuing therapy, persistent low hCG values were detected without evident metastatic disease demonstrated by CT. Eighteen FDG-PET/CT showed multiple pulmonary nodules. CONCLUSION: Eighteen FDG-PET/CT seems to reveal metastases that are either confusing or not detected by other imaging techniques currently accepted in most gestational trophoblastic neoplasia protocols.

Gestational trophoblastic neoplasia: clinical trends in 8 years at Hospital Universitario de Caracas.

OBJECTIVE: To analyze the clinical trends of gestational trophoblastic neoplasia (GTN) at the Department of Obstetrics and Gynecology, Hospital Universitario de Caracas (HUC). STUDY DESIGN: A medical record review was performed of epidemiologic, clinical and diagnostic features of 25 cases of GTN at HUC from 1997 to 2004. RESULTS: During the study period, 35,300 deliveries occurred, and 25 patients were diagnosed with GTN; the prevalence was 0.70:1,000 deliveries. The mean age was 29.2 years. Fifty-six percent were posthydatidiform mole (HM), 36% postchoriocarcinoma (CC), 4% postinvasive mole and 4% postabortion with abundant intermediate trophoblast. Vaginal bleeding was the main symptom in patients with CC. Two cases resembled ectopic pregnancy, and another resembled a vaginal endometrioma. Fifty-two percent of cases were at stage Ib; 76% received single-agent chemotherapy. Hysterectomy was performed in 6 cases. Twenty-one patients achieved remission, 2 showed regression and 2 died. CONCLUSION: GTN had a high prevalence because HUC is a reference center. The most common presentation was post-HM GTN. Vaginal bleeding is frequent in CC and can mimic other gynecologic diseases. Chemotherapy is helpful, and hysterectomy can be performed in selected cases at early stages or with severe vaginal bleed-with a good ing. GTN has a good prognosis, and early diagnosis is possible.

Gestational trophoblastic disease in ectopic pregnancy: A case series.

OBJECTIVE: To describe 6 cases of gestational trophoblastic disease (GTD) in ectopic pregnancy admitted to Hospital Universitario de Caracas (HUC). STUDY DESIGN: Medical records of 6 patients admitted to the Obstetrics and Gynecology Department, HUC, from 1996 to 2004 were reviewed. They underwent surgery with a diagnosis of ectopic pregnancy, and histologic analysis revealed GTD. Clinical trends were analyzed. RESULTS: The prevalence of GTD in ectopic pregnancy was 0.16:1,000 deliveries. The mean patient age was 29 years. The preceding gestation was a term delivery in 4 and abortion in 2. The mean gestational age at admission was 8 weeks. All patients complained of abdominal pain, and 3 of them also had vaginal bleeding. Ultrasound revealed an adnexal tumor in 5 cases; this tumor and hemoperitoneum (6 cases) were the most frequent surgical findings. Histopathologic diagnosis was partial mole in 5 and choriocarcinoma in 1. Four patients were lost to follow-up. CONCLUSION: In this series the prevalence of ectopic GTD was high. The condition can mimic the usual symptoms of ectopic pregnancy, especially when a hemoperitoneum is present. It is important to apply strict histologic criteria for GTD when a sample of ectopic pregnancy is analyzed and to monitor those patients with careful human chorionic gonadotropin follow-up.

Histopathologic and immunohistochemical evaluation of blood vessels in complete and partial hydatidiform mole.

OBJECTIVE: To assess 46 cases diagnosed as complete and partial hydatidiform mole in regard to their histopathologic aspects according to current World Health Organization (WHO) criteria and to determine whether their immunohistochemical features are related to the presence of blood vessels. STUDY DESIGN: An observational, descriptive study was done on the histopathologic and immunohistochemical findings of 46 molar pregnancy cases seen at the Gynecological Pathology Department, Anatomopathological Institute, Central University of Venezuela, during 1990-2003. Data were obtained primarily from the tumor registry. These cases were histopathologically and immunohistochemically evaluated with CD34 antibody to detect endothelial cells. RESULTS: Baseline histopathologic diagnoses were partial moles in 25 cases (54%) and complete moles in 21 (46%). Based on the current criteria we demonstrated 25 cases of partial moles, 20 of complete moles and 1 anembryonic pregnancy case. Diagnostic differences in 4 cases from complete to partial mole, 3 cases from partial to complete mole and 1 case from partial mole to anembryonic pregnancy were determined. Blood vessels were identified in 93.8% of complete moles, in which cisterns were predominantly extensive. CONCLUSION: Using CD34 immunostain, blood vessels were found in complete and partial hydatidiform moles, without significant differences between them.

Episiotomía selectiva versus rutinaria en pacientes nulíparas / Routine versus selective episiotomy in nulliparous patients

Comparar la utilización rutinaria de la episiotomía con su uso selectivo en pacientes nulíparas. Se realizó un estudio prospectivo, comparativo, aleatorio y controlado con 100 pacientes nulíparas entre marzo y noviembre de 2002. Cincuenta pacientes fueron asignadas al grupo de episiotomía rutinaria y 50 al de episiotomía selectiva. Hospital Dr. Domíngo Luciani. Caracas. La principal variable en el estudio fue el daño perineal. Los desgarros perineales severos fueron poco frecuentes y no hubo diferencias estadísticamente significativas entre el grupo rutinario y selectivo (4 por ciento vs 0 por ciento, p= 0,495), mientras que los desgarros anteriores y los perineales leves fueron más frecuentes en el segundo grupo selectivo. No hubo diferencias estadísticamente significativas en la duración del período expulsivo, presencia de meconio, puntuación de Apgar, gasto en material de sutura, dolor y complicaciones a las 24 y 48 horas. La mayoría de las pacientes del grupo selectivo (76 por ciento) sólo presentaron desgarros leves o no presentaron desgarros; entre ellas un 30 por ciento no requirieron sutura. Estos resultados no demuestran ninguna ventaja clínicamente significativa con el uso rutinario de la episiotomía, tasas superiores al 30 por ciento no se justifican

Utero doble, hemivagina obstruida y agenesia renal ipsilateral: caso clínico Hospital Universitario de Caracas (HUC) / Double uterus and obstructed hemivagina ipsilateral to the renal agenesia: case clinic Hospital Universitario de Caracas (HUC)

Se ha descrito la coexistencia de alteraciones congénitas del tracto urinario con malformaciones congénitas del aparato genital. En esta publicación se presenta un caso de una asociación fija descrita en un síndrome clínico caracterizado por Agenesia renal, Utero doble y hemivagina obstruida ipsilateral a la agenesia renal; este síndrome ha sido publicado en algunas revistas internacionales no encontrándose referencia alguna en publicaciones nacionales indexadas

Parto instrumental y cesárea en gestantes adolescentes / Instrumental delivery and cesarean in adolescent gestants

Se realizó un estudio prospectivo que incluyo 694 gestantes adolescentes con la finalidad de comparar la incidencia de parto instrumental y cesárea entre las jóvenes de 12 a 15 años (82 casos, grupo No 1) y las de 16 a 19 años (612 casos, grupo No 2). las adolescentes representaron el 22.6 por ciento de los casos obstetricos atendidos en el Hospital Universitario de Caracas en 1994. En el grupo No. 1 encontramos 13.6 por ciento de forceps: 63.6 por ciento por agotamiento materno y 18.2 por ciento: terminaron en cesárea 17.3 por ciento: por desproporción fetopélvica,28.6 por ciento, por sufrimiento fetal 28.6 por ciento y por presentación podálica 21.4 por ciento. En el grupo No. 2 hallamos 12.8 por ciento de forceps: 23.9 por ciento fué profiláctico y 19.7 por ciento debido a sufrimiento fetal: la frecuencia de cesárea fué de 15.5 por ciento por desproporción fetopélvica, 41.9 por ciento y por sufrimiento fetal 24.4 por ciento. No se hallo diferencia estadísticamente significativa en cuanto a la incidencia de parto instrumental y cesárea entre ambos grupos etarios

Correlación entre la evaluación endometrial por ultrasonidos y los hallazgos histopatológicos / Correlation between the endometrial evaluation by ultrasounds, and the find histopathology

Este es un estudio prospectivo que incluyó 67 pacientes divididas en 2 grupos:53 en edad reproductiva y 14 menopáusicas, encontrando que en el grupo de pacientes no menopáusicas hubo poca concordancia entre el diagnóstico presuntivo ecográfico y el histopatológico; en el grupo de pacientes menopáusicas dicha concordancia fue significativa. El criterio ecográfico de más valor lo representó la medición del espesor endometrial, donde un grosor mayor de 6mm se asoció a patología endometrial y endometrio de menor espesor se asoció a atrofia endometrial.