Prediction of insulin therapy in women with gestational diabetes: a systematic review and meta-analysis of observational studies.

OBJECTIVES: To identify antenatal risk factors that may predict the need for insulin treatment upon diagnosis of gestational diabetes (GDM), that is, to identify the specific characteristics of women diagnosed with GDM who did not achieve good glycemic control through lifestyle modifications. METHODS: We performed a comprehensive literature search in PubMed, Science Direct, Ebsco, and Scielo for studies evaluating the associations between antenatal factors and the need for insulin treatment published until January 28th, 2021. Random-effects models were used to estimate risk ratios and their 95% confidence interval. The quality of studies was assessed using the Newcastle-Ottawa Scale. Random-effects models were used to estimate outcomes, and effects reported as risk ratio and their 95% confidence interval. The systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews. RESULTS: Eighteen observational studies were selected, reporting 14,951 women with GDM of whom 5,371 received insulin treatment. There were statistically significant associations between the need for insulin treatment and BMI ≥ 30 (RR:2.2; 95%CI: 1.44-3.41), family history of type 2 diabetes mellitus (RR:1.74; 95%CI: 1.56-1.93), prior personal history of GDM (RR:2.10; 95%CI: 1.56-2.82), glycated hemoglobin value at GDM diagnosis (RR:2.12; 95%CI: 1.77-2.54), and basal glycemia obtained in the diagnostic curve (RR: 1.2; 95%CI: 1.12-1.28). Nulliparity and maternal age were not determinants factor. There was moderate-to-high heterogeneity among the included studies. CONCLUSIONS: the strong causal association between BMI ≥ 30, family history of type 2 diabetes mellitus, prior history of GDM and glycosylated hemoglobin with the need for insulin treatment was revealed.

Análisis del cáncer de endometrio en un hospital universitario de Ourense, España / Analysis of endometrial cancer in a university hospital in Ourense, Spain

Resumen OBJETIVO: Describir, de forma retrospectiva, el comportamiento del cáncer de endometrio en pacientes diagnosticadas en el Complexo Hospitalario Universitario de Ourense MATERIALES Y MÉTODOS: Estudio descriptivo, observacional y retrospectivo efectuado en el Complexo Hospitalario Universitario de Ourense entre septiembre de 2014 y enero de 2018. Criterio de inclusión: diagnóstico, tratamiento y seguimiento en nuestro centro. Criterio de exclusión: historia incompleta y diagnóstico o tratamiento en otro centro. Variables de estudio: tipo de tumor y de tratamiento. Se realizó un análisis descriptivo. Las posibles asociaciones se comprobaron mediante χ2, Fisher, t de Student y prueba de Mann-Whitney. RESULTADOS: Se estudiaron 149 pacientes, con edad media al diagnóstico de 69.38 años ± 9.6 años. El 86.6% (n = 129) de las pacientes estaban en la posmenopausia. El 68% (n = 101) eran obesas y el 54.7% (n = 81) hipertensas. El 54.7% (n = 81) se diagnosticaron en estadio IA. El 68.4% de los tumores grado 3 tuvieron infiltración miometrial mayor al 50%, el 28.6% grado 1 (p < 0.001). De las pacientes que recibieron radioterapia o braquiterapia el 46% estaba en estadios avanzados; 76% en estadio IB, 26% en estadio IA (p < 0.001). El 91.3% de los tumores estadio I fueron tipo I, en los estadios avanzados hubo 48.6% de tumores tipo I (p < 0.001). El 87.4% de los tumores grados 1 o 2 se encontraron en estadio I, un 45.2% de los tumores grado 3 en estadio I (p < 0.001). CONCLUSIONES: La mayoría de las pacientes tenía más de 60 años y eran diabéticas, hipertensas y obesas. El cáncer de endometrio suele diagnosticarse en estadios tempranos. La braquiterapia es la coadyuvancia más indicada.

Abstract OBJECTIVE: To retrospectively describe the behavior of endometrial cancer in patients diagnosed at the Complexo Hospitalario Universitario de Ourense. MATERIALS AND METHODS: Descriptive, observational and retrospective study in the Complexo Hospitalario Universitario de Ourense between September 2014 and January 2018. Inclusion criteria: diagnosis, treatment and follow-up in our center. Exclusion criteria: incomplete history and diagnosis or management in another center. Patient, tumor and treatment variables were collected. A descriptive analysis was performed. Possible associations were tested by Chi-square, Fisher, Student's t-test and Mann-Whitney test. RESULTS: 149 patients were studied, with mean age at diagnosis of 69.38 years ± 9.6 years. 86.6% (n = 129) of the patients were postmenopausal. 68% (n = 101) were obese and 54.7% (n = 81) hypertensive. 54.7% (n = 81) were diagnosed at stage IA. 68.4% of grade 3 tumors had myometrial infiltration greater than 50%, 28.6% grade 1 (p < 0.001). Of the patients who received radiotherapy or brachytherapy 46% were advanced stage; 76% stage IB, 26% stage IA (p < 0.001). 91.3% of stage I tumors were type I, in advanced stages there were 48.6% of type I tumors (p < 0.001). 87.4% of grade 1 or 2 tumors were stage I, 45.2% of grade 3 tumors were stage I (p < 0.001). CONCLUSIONS: Most patients were older than 60 years and were diabetic, hypertensive and obese. Endometrial cancer is usually diagnosed at early stages. Brachytherapy is the most indicated adjuvant.

Desenlaces maternos y neonatales relacionados con edad materna avanzada / Maternal and neonatal outcomes in advanced maternal age

Resumen OBJETIVO: Describir los desenlaces maternos y perinatales en embarazadas de edad avanzada. MATERIALES Y MÉTODOS: Estudio de dos cohortes, prospectivo y retrospectivo efectuado con base en la información de expedientes clínicos de pacientes atendidas en el Complexo Hospitalario Universitario de Ourense entre 2017 y 2018. Se establecieron dos cohortes: la cohorte A con edad mayor o igual a 40 años y la cohorte B con edad menor de 40 años. Se realizaron pruebas paramétricas y no paramétricas para determinar la asociación potencial entre las variables de estudio (χ2, t de Student, U de Mann-Whitney). RESULTADOS: Las pacientes de la cohorte A (n = 207) tuvieron significación estadística: índice de masa corporal mayor al inicio del embarazo (p = 0.028), mayor cantidad de embarazos previos (p = 0.001), a expensas de mayor cantidad de abortos (p < 0.001), estados hipertensivos del embarazo (p = 0.03), prematurez (p = 0.009), retraso en el crecimiento intrauterino (p = 0.006), macrosomía fetal (p = 0.04), inducciones (p < 0.001), cesáreas programadas o intraparto y hemorragia posparto (p = 0.001). No se encontraron diferencias en la paridad, amenorrea al parto, diabetes pregestacional-gestacional, peso fetal medio, Apgar, pH de la arteria umbilical y cantidad de recién nacidos con requerimiento de ingreso a la unidad de Neonatología. CONCLUSIONES: La edad materna avanzada es un factor de riesgo importante de morbilidad materna y perinatal. La mayor tasa de complicaciones descritas refleja la importancia del control exhaustivo del embarazo y vigilancia periparto minuciosa.

Abstract OBJECTIVE: To describe the maternal and perinatal results in pregnant women with advanced age. MATERIALS AND METHODS: A cohort study was conducted with prospective follow-up and retrospective data collection of the Clinical History of the University Hospital Complex of Ourense between 2017 and 2018. Two cohorts were established, cohort A with age greater than and equal to 40 years and the cohort B with age under 40 years. Parametric and non-parametric tests were performed to determine the potential association between the study variables (Chi-Square, Student's T, Mann-Whitney U). RESULTS: The cohort A patients (n = 207) presented with statistical significance: body mass index higher at the beginning of pregnancy (p = 0.028), higher number of previous pregnancies (p = 0.001), but at the expense of a higher number of abortions (p <0.001), hypertensive states of pregnancy (p = 0.03), prematurity (p = 0.009), intrauterine growth retardation (p = 0.006), fetal macrosomia (p = 0.04), inductions (p < 0.001), of both scheduled and intrapartum caesarean sections and postpartum hemorrhage (p = 0.001). No differences were found in parity, amenorrhea at delivery, pregestational / gestational diabetes, mean fetal weight, Apgar score, umbilical artery pH and number of newborns who required admission to the Neonatal Unit. CONCLUSIONS: Advanced maternal age is an important risk factor for maternal and perinatal morbidity. The higher rate of complications described reflects the importance of thorough pregnancy control and careful peripartum surveillance.

Eficacia del retiro quirúrgico de Essure para el alivio del dolor pélvico: serie de casos / Surgical removal of the Essure device as a response to pelvic pain: case series

Resumen OBJETIVO: Evaluar la eficacia del retiro quirúrgico del Essure como medida para aliviar el dolor pélvico ocasionado, presuntamente, por este dispositivo. MATERIALES Y MÉTODOS: Estudio descriptivo y retrospectivo de una serie de casos. Se revisaron las historias clínicas de las pacientes atendidas entre el 1 de enero de 2016 y el 15 de agosto de 2018 en el Complexo Hospitalario Universitario de Ourense para la extracción quirúrgica del dispositivo Essure. Parámetros de estudio: datos demográficos, historial médico, información de la inserción, características del dolor, tipo de intervención, hallazgos durante la intervención y posoperatorios. Los datos se analizaron con el programa SPSS, versión 24 para Windows. RESULTADOS: Se intervinieron 11 pacientes y 7 de ellas tuvieron dolor abdominal después de la colocación del dispositivo, con una tardanza media de aparición de 3.75 años. La técnica quirúrgica más practicada fue la salpingectomía bilateral (7 de 11 pacientes). 7 de las 11 pacientes continuaron con dolor luego de la extracción del dispositivo; de ellas, 2 tenían diagnóstico previo de dolor crónico y 3 antecedente de cirugía abdominal. CONCLUSIONES: En esta muestra de pacientes a quienes se extrajo el Essure, el retiro no resultó eficaz para aliviar el dolor en casi dos tercios de ellas. Esto pone de relieve que la extracción no garantiza la eliminación del dolor. Las investigaciones futuras deberán dirimir porqué en algunos casos la cirugía de extracción no resulta efectiva.

Abstract OBJECTIVE: To evaluate the efficacy of the surgical removal of Essure in the elimination of pelvic pain caused, presumably, by this device. MATERIALS AND METHODS: A descriptive study of case series was conducted retrospectively. A review was performed of the medical histories of all the patients (11 in total) who underwent surgical removal of Essure devices at the University Hospital of Ourense (Spain) in the period between 1 January 2016 and 15 August 2018. The following items were collected: demographic data, medical history, data related to the insertion, characteristics of the pain, type of intervention, findings during the intervention and postoperative findings. The total number of patients intervened during that period was 11. The data was analyzed with the statistical software SPSS version 24 for Windows. RESULTS: Eleven patients were operated and 7 of them had abdominal pain after placement of the device, with an average delay of appearance of 3.75 years. The most practiced surgical technique was bilateral salpingectomy (7 of 11 patients). 7 of the 11 patients continued with pain after removal of the device; of them, 2 had previous diagnosis of chronic pain and 3 antecedents of abdominal surgery. CONCLUSIONS: It is evident that surgical removal of the Essure insert was not effective in almost two-thirds of the patients under study, which highlights that its removal does not guarantee the elimination of pain. Future research should determine why in some cases surgical removal is not effective.

Hemorragia posparto secundaria o tardía / Secondary postpartum haemorrhage

Introducción: la hemorragia posparto secundaria puede estar asociada a entidades poco conocidas, pero con capacidad para incrementar la morbimortalidad materna, por lo cual es necesario su conocimiento con el fin de instaurar las medidas terapéuticas oportunas. Objetivo: conocer la incidencia de la hemorragia posparto secundaria (HPS), los factores de riesgo, así como la prevalencia de las principales entidades implicadas en esta patología. Material y métodos: estudio descriptivo, observacional y retrospectivo, mediante el análisis poblacional de las pacientes hospitalizadas con el diagnóstico de HPS, en el Complexo Hospitalario Universitario de Ourense, en el periodo comprendido entre 2004 y el 31 de marzo de 2014. El criterio de selección se realizó de acuerdo con la definición de la OMS de la HPS: 'sangrado uterino excesivo que ocurre entre las 24 horas y las 12 semanas posteriores al parto'. Resultados: la incidencia de HPS fue del 0,29%. Esta enfermedad se asocia con mayor frecuencia al antecedente de parto vaginal en el actual episodio. La causa más prevalente de HPS fue la retención de restos placentarios, la cual representó el 75,51% del total de casos. El tratamiento realizado con mayor frecuencia fue el legrado evacuador (77,55%). Hasta en el 14% de los casos se asocia con anemia severa que requiere transfusión sanguínea. Conclusiones: la principal causa de la HPS es la retención de restos placentarios. Existen otras causas menos frecuentes y menos conocidas, pero con un alto potencial de generar morbimortalidad (AU)

Background: Secondary postpartum hemorrhage may be associated with little known entities but with ability to increase maternal mortality and morbidity by which its knowledge is necessary in order to establish appropriate therapeutic measures. Objective: To determine the incidence of secondary postpartum hemorrhage (HPS), risk factors, and the prevalence of the main entities involved in this pathology. Material and methods: Descriptive and retrospective study using the population analysis of patients hospitalized with the diagnosis of HPS in the University Hospital Complex of Ourense, in the period between 2004 and March 31, 2014. Inclusion criteria was the WHO’s definition for HPS: 'excessive uterine bleeding from 24 hours to 12 weeks after childbirth'. Results: The incidence of HPS was 0.29%. This entity is more strongly associated with previous vaginal deliveries in the current episode. The most prevalent cause of HPS was retained placental remnants, representing 75.51% of all cases. The treatment most frequently performed was evacuator curettage (77.55%). Severe anemia is observed in 14% of the women requiring blood transfusion. Conclusions: The principal cause of the HPS is placental retention. There are other less common and less well-known causes but with a high potential for morbidity and mortality (AU)

[Risk factors of evolution of postpartum hemorrhage towards severe postpartum hemorrhage: A case-control study]. / Factores de riesgo de la evolución de la hemorragia posparto a hemorragia posparto severa: estudio de casos y controles.

OBJECTIVE: To describe the incidence and risk factors for evolution of postpartum haemorrhage towards severe. MATERIAL AND METHODS: Epidemiologic, observational, analytical, case-control study was done from total data of deliveries in Complexo Hospitalario de Ourénse between January 1st 2004 and June 30th 2014. Mann-Whitney U test was used to determine the differences between cases and controls. The statistical analyses were made with the informatic programs Spss 15.0 y Epidat 3.0. We considered statistical significance for p < 0.05. RESULTS: The initial size of the sample was 17,116 deliveries from which we selected 150 patients with the diagnosis of postpartum haemorrhage. The incidence for HPSe form all deliveries was 3.3% reaching 36% of the total of postpartum haemorrhages. 79.63% of HPSe showed symptoms withing the first 24h postpartum, but we found that 20.37% debuted as secondary postpartum haemorrhages. BMI ≥ 35, hypertensive gestational manifestations, labor's second phase ≥ 120 minutes and weight at birth > 4000 g presented statistical significance as risk factor for evolution to severe postpartum haemhorrage. The relative risk for evolution towards HPSe was 2.81 for instrumental delivery and 3.55 for cesarean section. The most prevalent etiology was uterine atony. CONCLUSION: The incidence of HPSe in our hospital is low, as well as secondary maternal mortality. The major risk factor for the appearance of the clinical symptoms is cesarean section, followed, in less proportion by instrumental delivery. It is possible for the HPSe to make its appearance delayed after delivery, usually secondary to infrequent and non well-known clinical presentations.

[Perinatal outcomes of twin pregnancies conceived through in vitro fertilization versus spontaneous]. / Resultados perinatales de las gestaciones gemelares concebidas mediante fecundación in vitro versus espontáneas.

OBJECTIVE: Determine maternal and fetal characteristics of in vitro fertilization twin pregnancies in comparison with spontaneous twin pregnancies. MATERIAL AND METHODS: Retrospective historical cohort study between 2011 and 2013. Statistical analysis was performed with SPSS 15.0 program and Epidat 3.0. A value of p<0.05 was considered statistically significant. RESULTS: 96 twin pregnancies met inclusive criteria with an incidence of 2.01%, of which 54.16% were spontaneous twin pregnancies and 45.83% in vitro fertilization twin pregnancies. Mean maternal age at delivery was higher in vitro fertilization twin pregnancies (p=0.004). The primigravidae were more frequent in vitro fertilization twin pregnancies group (p<0.001). Monochorionic pregnancies percentage was superior in spontaneous pregnancies (p=0.009). Amenorrhea at delivery was not a significant difference between cohorts (p=.9). Preterm rate was superior in spontaneous twin pregnancies group (p=0.003). However, "great preterm deliveries" were higher in in vitro fertilization twin pregnancies (p<0.001). Significant differences were not observed in fetal presentation at delivery, first-born child birth-weight or intrauterine growth retardation between the two groups. Nevertheless, the mean birth-weight of second-born spontaneously conceived twins was higher than second-born twins of the in vitro fertilization conceived group (p=0.027). Gestational pathology presented the same distribution in both cohorts. There was no significant difference in the mode of delivery between the two groups. Total perinatal mortality rate was 20,83%o and comprised 2 first born twins and 2 second born twins. Three of the stillbirths came from the spontaneous pregnancies group and one from the in vitro fertilization group. CONCLUSIONS: Perinatal death was secondary to stillbirths, which we found higher in spontaneously conceived twin pregnancies due to higher number of monochorionic pregnancies.

[Ultrasonography as a method to determine the correct implantation of intratubaric devices]. / La ecografía como método para determinar la correcta implantación de dispositivos intratubáricos.

BACKGROUND: Essure procedure consists in the placement of two coils in the intramural segment of Fallopian tubes by hysteroscopic causing a fibrosis reaction that unleashes a physiological obstruction. Hysterosalpingography, until today, is the gold standard checking the success of this method of sterilization. OBJECTIVE: Determining if a scan at three months postimplantation is sufficient to confirm the correct positioning of the device. MATERIAL AND METHODS: Descriptive study with 61 patients undergoing definitive hysteroscopic sterilization to validate transvaginal ultrasound as a technique to determine the effectiveness of the method. RESULTS: There were placed 120 devices, of which 117 (97'5%) were visible by ultrasound. Comparing ultrasound findings with gold standard, we obtain that in cases of proper bilateral implantation by hysterosalpingography, with ultrasound we diagnosed the 81 '13%; in cases of correct unilateral implantation we detected 75% with ultrasound, except one patient who was considered proper placement of the coil by ultrasound but hysterosalpingography reported that it was misplaced and the Fallopian tube was permeable. DISCUSSION: Transvaginal ultrasound is an appropriate method to confirm the correct position of intratubaric Essure devices, its safety, low cost and reproducibility. However, our study cannot replace the hysterosalpingography as gold standard.

Mesotelioma peritoneal maligno con afectación uterina / Malignant mesothelioma of the peritoneum with uterine involvement

El mesotelioma peritoneal maligno es un tumor de presentación infrecuente, diagnóstico difícil y comportamiento agresivo en la mayoría de los casos. Presentamos el caso de una mujer de 80 años con una formación pélvica que depende de útero con carcinomatosis peritoneal, abundante líquido ascítico e infiltración de recto y vejiga. Se decide realizar un estudio histológico de la masa para después comenzar con quimioterapia paliativa por estado avanzado de la enfermedad. Se indica una minilaparotomía y se realizan múltiples biopsias. La histología y la inmunohistoquímica de la pieza son compatibles con un mesotelioma peritoneal maligno de tipo mixto (epitelial y sarcomatoide). La paciente comienza con evolución desfavorable y se deciden medidas de soporte paliativo. Fallece a los 15 días poscirugía. En mujeres con afectación de órganos genitales es importante hacer el diagnóstico diferencial con los tumores serosos de origen ginecológico puesto que los protocolos de tratamiento quimioterápico son diferentes (AU)

Malignant mesothelioma of the peritoneum is an infrequent tumor that is difficult to diagnose and usually behaves aggressively. We present the case of an 80-year-old woman with a pelvic mass of uterine origin, peritoneal carcinomatosis and abundant ascites. Histologic study of the mass was requested and palliative chemotherapy was started because of the advanced stage of the disease. A minilaparotomy was performed and multiple biopsies were taken. Histologic and immunochemistry studies were compatible with a mixed (epithelial and sarcomatoid) malignant mesothelioma of the peritoneum. Prognosis was poor and palliative care was provided. The patient died 15 days after surgery. In women with involvement of the genital organs, it is important to make a differential diagnosis with serous tumors of gynecologic origin because the chemotherapy protocols differ (AU)

[Complete uterine ruptures]. / Roturas uterinas completas.

BACKGROUND: Uterine rupture is one of the most severe Obstetric complications by high morbidity and maternal and fetal mortality. OBJECTIVES: To review cases of uterine rupture occurred for the last five years. Release the incidence, the risk factors and maternal and fetal complications, both immediate and long term. METHODS: Retrospective cohort study including all patients who completed their gestation in the University Hospital Complex of Ourense (Spain) between 2008 and March 2013. Review all medical records of patients diagnosed with uterine rupture during this period. Statistical analysis was performed using the statistical package Epidat 3.0. RESULTS: We found an overall incidence of uterine rupture of 0.078 %. In patients with a previous cesarean delivery incidence rises to 0.31%. CONCLUSION: Uterine rupture is an uncommon but with high maternal fetal morbidity. The main risk factor is a trial of labor after a previous cesarean delivery.