[Ovarian volume as a predictive factor of ovarian reserve in response to exogenous stimulation with gonadotropins and its correlation with ovum/embryo development in FIVTE/ICSI results]. / Estudio del volumen ovárico como factor predictivo de reserva ovular en respuesta a la estimulación exógena con gonadotropinas y su correlación con el desarrollo óvulo/embrionario en los resultados de FIVTE/ICSI.

UNLABELLED: The evaluation of ovarian reserve in regard to the exogenous response elicited by gonadotropines is directly related to the interconnection of diverse intrafollicular factors involved in ovum components, and thus, to a better embryonic development, which will be reflected in the pregnancy ratios of assisted reproduction programs. A series of markers have been proposed in order to dynamically evaluate the ovarian response: hormone determinations (FSH, E2, FSH:LH index), biochemical factors (inhibine-B), intrafolicular (cytokines, leptin), neuromodulators (GNRH test), and so forth. However, none has shown a specific sensitivity in order to accurately determine the best treatment depending on the values they provide. OBJECTIVE: To evaluate the capacity of ovarian response on the basis of ovarian volume determination. Two groups of patients were studied: group 1 (n = 19) with a basal ovarian volume smaller than 3 cm3, and group 2 (n = 21), those with a volume greater than 3 cm3. Patients in group 2 showed a better response to ovarian stimulation, as well as the collection of better quality ovarian, increased fertilization, segmentation and pregnancy ratios and a lower cancellation index as compared to group 1. It can be concluded that patients with an ovarian volume lower than 3 cm3 on the day before the stimulation will present a poor response to exogenous gonadotropins, thus, this variable must be considered as a marker of ovarian follicular response.

[Transabdominal cerclage in the management of cervical incompetence]. / Cerclaje transabdominal en el manejo de la incompetencia cervical.

The Transabdominal Cerclage in the Cervical Incompetence. The purpose of this study was to assess the transabdominal cerclage indications at the Instituto Nacional de Perinatología. A retrospective study was carried on in order to evaluate fetal outcome in all patients with transabdominal cerclages. Since 1997 seven transabdominal cerclages were performed. The primary indication was unsuccessful previous vaginal cerclage. All seven patients delivered at term. The rate of live births before the procedure was 5.2% compared to 85.8% after the transabdominal cerclage. There was one still birth a the gestational of 37.2 in a woman with preeclampsia. Five newborns were small for gestational age. In our study the transabdominal cerclage, under strict indications, offers a high fetal survival rate with a minimum of complications in patients with a poor obstetric history due to cervical incompetence and unsuccessful vaginal cerclage.

[Repeat cesarean section: a necessary procedure?]. / Cesárea de repetición: Una cesárea necesaria?

The purpose of this study was to identify the clinical indications for the repeated cesarean section (RCS). In order to determine if the indication was an absolute or a relative one and to establish if it was justified. This is a cross sectional study of all patients with a previous cesarean delivery who underwent a RCS from January 1996 to December 1997 at the National Institute of Perinatology. Multiple pregnancies were excluded. According to the indication two groups were identified: those with an absolute indications and those with a relative one. In order to assess the differences between both groups data were analyzed through chi square test or Fisher's Exact test. During the study period there were 5,545 cesarean deliveries, 664 were RSC (11.9%). Only 641 of the RCS complied with the inclusion criteria for the study. Average maternal age was 30 years. More than half the patients under study (57.2%) did not have any pathological condition during pregnancy, and the rest (42.7%) had at least one (preeclampsia, diabetes mellitus/gestational, chronic hypertension). Indications for the previous cesarean section were absolute in 25.9% and relative in 74.1% (p = 0.0006). Indications for the RCS were also predominantly relative (70.7%), with only 29.3%) absolute (p = 0.0001). The main RCS indications were: elective (20.1%) cephalopelvic disproportion (17.8%), preeclampsia (15.4%), fetal distress (8%). Trial for vaginal delivery was undertaken in 65.4% of the absolute indications group and in 36.9% of the relative indications group (p = 0.0001). Low Apgar one minute and five minute scores were more frequent among the absolute indications group (p = 0.03 and p = 0.01 respectively). Newborns having had an absolute cesarean delivery indication entered the National Intensive Care Unit more frequently (53.6%) than those with relative indications (46.4%) (p = 0.001). The main indication for RCS in our hospital were relative, and thus it is possible to reduce the cesarean rate through a thorough assessment of all cases with a previous cesarean section, and by giving a delivery trial of all this patients.

[Abdominal pregnancy, institutional experience]. / Embarazo abdominal experiencia institucional.

Abdominal pregnancy is a rare entity, which has been classified as primary or secondary by Studiford criteria. A retrospective study, between January 1989 and December 1994, realized at Instituto Nacional de Perinatología, found 35,080 pregnancies, from which 149 happened to be ectopic, and 6 of them were abdominal. All patients belonged to a low income society class, age between 24 and 35 years, and average of gestations in 2.6. Gestational age varied from 15 weeks to 32.2 weeks having only one delivery at term with satisfactory postnatal evolution. One patient had a recurrent abdominal pregnancy, with genital Tb as a conditional factor. Time of hospitalization varied from 4 to 5 days, and no further patient complications were reported. Fetal loss was estimated in 83.4%. Abdominal pregnancy is often the sequence of a tubarian ectopic pregnancy an when present, it has a very high maternal mortality reported in world literature, not found in this study. The stated frequency of abdominal pregnancy is from 1 of each 3372, up to 1 in every 10,200 deliveries, reporting in the study 1 abdominal pregnancy in 5846 deliveries. The study had two characteristic entities one, the recurrence and two, the delivery at term of one newborn. Abdominal pregnancy accounts for 4% of all ectopic pregnancies. Clinical findings in abdominal pregnancies are pain, transvaginal bleeding and amenorrea, being the cardinal signs of ectopic pregnancy.

[Shock in obstetrics. Institutional experience]. / Choque en obstetricia. Experiencia institucional.

Shock is one of the most difficult problems an obstetrician can face. Hemorrhage is the main reason of shock. A descriptive and retrospective research was conducted at Instituto Nacional de Perinatología, from January 1992 to May 1996, including all patients admitted to the intensive care unit with diagnosis of shock. There were found 90 cases with diagnosis of shock, 82 were hipovolemic, and 8 cases had the septic kind of shock. The average of age was 32.2 years, with a gestational age between 6.2 to 41.4 weeks . There were 71 healthy patients, hypertension was associated to pregnancy in 9 cases, infertility in two, myomatosis in 2, and diabetes in 2 more patients. Other 5 cases reported different pathologies. The most frequent cause for hipovolemic shock resulted to be placenta acreta (40 cases), followed by uterine tone alterations in 37 patients, ectopic pregnancy in 7, uterine rupture or perforation in 4, and vaginal or cervical lacerations in 2. The estimated blood loss varied from 2200 cc to 6500 cc, and the minimal arterial pressure registered during shock was between 40/20 mmHg to 90/60 mmHg. Medical initial assistance consisted in volume reposition with crystalloids, globular packages, and plasma expansors in 73 patients (81.1%). The rest of the patients received in addition coloids, platelets and cryoprecipitates. A total of 76 patients required surgical intervention consisting in total abdominal hysterectomy. In 5 cases the previous surgical procedure was done and ligation of hypogastric vessels was needed. Salpingectomy was performed in 5 patients, and rupture or perforation repair in 3. The average surgery time was 2 hours and 33 minutes. The observed complications were 7 cases with abscess of the cupula, consumption coagulopathy in 2, 1 vesical quirurgical injury, 1 intestinal occlusion, and 11 vesico-vaginal fistula. The average days of hospitalization resulted to be 5. The most frequent kind of shock seen by obstetricians is the hipovolemic type, followed by septic shock, Volume reposition and restoration of adequate tissue oxygenation is the main goal in treatment, and so the rapid and opportune decision for surgery shall prevent the patients decriment and maternal mortality.

[Obstetric hysterectomy. Review of 675 cases at the Instituto Nacional de Perinatología]. / Histerectomía obstétrica. Revisión de 675 casos en el Instituto Nacional de Perinatología.

A retrospective study of 675 patients subject to obstetric hysterectomy from January 1st, 1985 to December 31st, 1995 at the Instituto Nacional de Perinatología was carried out. The incidence of this procedure reached its highest level in patients from 26 to 40 years, which represented 60.5% (409 cases) of the studied population. Patients with one previous cesarean section comprised 34.8% of total obstetric hysterectomies, followed by women with two to three previous cesarean sections (24.5% and 22.2%, respectively). As for gestational age, it reached term in 51.1% (345 cases), pre-term in 38% (257), post-term in 1.4% (10), and less than 20 weeks in 9.3% (63 cases). Main indications for obstetric hysterectomy included placenta accreta in 34.07% (230 cases), uterine atony in 32.4% (219), deciduomyometritis in 6.3% (43 cases), and uterine rupture in 4.5% (31). Most frequent complications included hypovolemia (12.1%), bladder injury (5.4%), and ureteral injury (0.7%). Postoperative complications included anemia (61.6%), febrile syndrome (7.5%), mechanic ileum (7.5%), wall abscess (3.4%), and vesicovaginal fistula (1.6%). A total of eight maternal deaths (1.1%) was reported.

[Ceftriaxone vs. cefazolin in obstetrical surgical prevention]. / Ceftriaxona vs. cefazolina en la profilaxis quirúrgica obstétrica.

The cesarean section is associated with a high incidence of puerperal infections. The antibiotic prophylaxis in obstetric surgery may reduce infectious complications, nevertheless antibiotic prophylaxis only has proved to be effective in women with risk factors for the occurrence of infection. We made a comparative study of the prophylactic efficacy of the ceftriaxone a single dose versus cefazolin three doses, in women with risk factor for infection. There were enrolled 100 patients, 50 in each group. Six percent of the ceftriaxone group patients developed puerperal infections while 12% of the cefazolin group women developed this complication. The statistic analysis don't show difference between the groups. We consider the single dose prophylactic schema is better because its application is easier, administration is safety and reduces the risk of adverse reactions.