El estado metabólico y su asociación con la actividad ósea en la mujer posmenopáusica / Metabolic status and its association with bone activity in post-menopausal women

Antecedentes y objetivo: En la posmenopausia se presentan alteraciones en el metabolismo de los lípidos, sensibilidad a la insulina e incremento del tejido adiposo visceral, lo que se asocia a un aumento del riesgo cardiometabólico. La osteocalcina (OCN) es una proteína de remodelación ósea, que recientemente se ha observado que participa en la regulación del metabolismo de la glucosa, lípidos y del tejido adiposo. Son limitados los estudios de OCN en la etapa posmenopáusica. El objetivo de este trabajo fue investigar la relación de la concentración de OCN con la obesidad y el síndrome metabólico (SM) en mujeres pre y posmenopáusicas. Métodos: Estudio transversal que incluyó a 261 participantes de 45 a 60 años, quienes fueron evaluadas clínicamente y se les midió glucosa y perfil de lípidos. La OCN sérica y la insulina se determinaron por quimioluminiscencia. Resultados: De las participantes, 128 fueron premenopáusicas y 133 posmenopáusicas; el 33% de las participantes presentaban SM. En las mujeres posmenopáusicas, la concentración de OCN fue superior en comparación a las premenopáusicas (7,2±4,0 vs. 5,5±6,4 ng/mL, p<0,019). La concentración de OCN en la mujer posmenopáusica con SM fue más elevada en comparación al grupo control (8,4±5,1 vs. 6,3±2,8 ng/mL, p=0,003). Conclusión: En la posmenopausia, el déficit de estrógenos y la resistencia a la insulina se asocian a un incremento de la concentración de OCN

Introduction and objective: Changes in lipid metabolism, insulin sensitivity, and visceral adipose tissue increase cardio-metabolic risk. Recent evidence suggests that osteocalcin (OCN) may play a role in metabolism. However, little is known about the OCN in post-menopausal women. The aim of this study was to investigate the relationship between the concentration of OCN with obesity and metabolic syndrome (MS) in pre-and post-menopausal women. Methods: A cross-sectional study was conducted that included 261 participants who were reviewed clinically and underwent laboratory studies, including the determination of serum OCN and insulin by chemiluminescence. Results: Of the participants, 128 were pre-menopausal, 133 post-menopausal, and 33% had MS. OCN concentration was higher in post-menopausal women than in pre-menopausal (7.7±5.7 vs. 5.3 + 2.6 ng/mL, P<.001). OCN levels in post-menopausal women with MS were greater than those without MS (8.4±5.1 vs 6.3±2.8 ng/mL, P.003). Conclusion: Oestrogen deficiency and insulin resistance are associated with increased OCN during the stage of post-menopausal stage

Correlación de la concentración sérica de ácido úrico en pacientes con preeclampsia severa en la unidad de cuidados intensivos / Correlation of serum uric acid concentration in patients with severe preeclampsia in the intensive care unit

Resumen OBJETIVOS: determinar si las concentraciones séricas de ácido úrico se correlacionan con la preeclampsia severa, exponer la presentación clínica, morbilidad y mortalidad materno y fetal en pacientes hospitalizadas en la unidad de cuidados intensivos. MATERIAL Y MÉTODOS: estudio transversal, retrolectivo y descriptivo al que se incluyeron pacientes con embarazo mayor de 20 semanas de gestación, con reporte de concentraciones séricas de ácido úrico al ingreso al hospital, con diagnóstico establecido de preeclampsia severa e ingresadas a la unidad de cuidados intensivos. Los datos se reunieron en una hoja de Excel 2010 y el análisis estadístico se efectuó en el programa SPSS para Windows, V19.0. RESULTADOS: se consultaron los registros de 72 pacientes; las embarazadas normotensas tuvieron concentraciones significativamente más bajas de ácido úrico: 3.6 ± 0.4 mg/dL que las mujres con preeclmpsia severa: 6.3 ± 1.4 mg/dL (p<0.001). Con respecto a la manifestación clínica, el vasoespasmo y la epigastralgia se relacionaron con la hiperuricemia y los datos de severidad estudiados, como el daño renal agudo con la consecuente correspondencia directa con la mortalidad materna. En el pronóstico fetal se observó una correlación negativa en la calificación APGAR de mayor importancia a los 5 minutos. CONCLUSIONES: se identificó una relación estadísticamente significativa de las concentraciones elevadas de ácido úrico con la preeclampsia severa; esto demuestra que la hiperuricemia en embarazos con hipertensión se relaciona con pobres resultados perinatales y maternos. Por lo tanto, la elevación del ácido úrico puede ser una herramienta pronóstica de fácil determinación que permite identificar a las pacientes con preeclampsia asociada con mayores complicaciones materno-fetales.

Abstract BACKGROUND: Severe preeclampsia as a public health problem is a multifactorial and several events that result in highly lethal episodes of obstetric emergencies. In Mexico according to data reported by the INEGI, preeclampsia had a frequency until 35.6%. Maternal death is an indicator of impact and quality of obstetric care and is associated with failures in the health care and preventable deaths are up 80%. Prevention is most important to prevent complications, as well biochemical markers as risk factors like uric acid to known is modified levels in this obstetric complication. OBJECTIVES: To determine whether serum uric acid levels correlate with the presence of severe preeclampsia, as well as their clinical presentation, and maternal morbidity and fetal mortality in patients hospitalized in the intensive care unit. MATERIALS AND METHODS A cross-sectional study, retrolective, descriptive was carried-out. Were included pregnancies higher than 20 weeks with reports of serum measurement of uric acid at hospitalization, with an established diagnosis of severe preeclampsia were admitted to the service of intensive care unit. Statistical analysis was performed using Microsoft Excel 2010 and the Statistical program SPSS for Windows version 19.0. RESULTS: Were included 72 patients in the present study, pregnant normotensive patients had significantly lower uric acid 3.6±0.4 mg/dL compared with the study group with severe preeclampsia 6.3±1.4 mg/dL (p <0.001). With regard to the clinical manifestation the vasospasm and the epigastralgia were related with the hyperuricemia; as well as the studied data of severity, as the acute renal damage with the consequent direct correspondence in the maternal mortality. In relation to the fetal pronostic a negative correlation is observed in the qualification APGAR with more importance to the 5 minutes. CONCLUSIONS: In this study, a statistically significant relationship between high levels of uric acid in the presence of preeclampsia was identified. With respect to the clinical presentation of data presentation and epigastralgia vasospasm they are related to hyperuricemia, and is associated with poor perinatal and maternal outcomes. Thus, the elevation of uric acid could be a prognostic tool for easy determination that would identify a group of patients with severe preeclampsia associated with higher damage.

Miomatosis uterina: implicaciones en salud reproductiva / Uterine myomatosis: Implications on reproductive health

Resumen OBJETIVO: dar a conocer a los ginecoobstetras un documento donde pueda consultarse, a la luz de los estudios más recientes y con la mejor evidencia en la fisiopatología, prevalencia y significado clínico de los miomas uterinos, así como la mejor evidencia posible acerca de las diversas modalidades de tratamiento. METDOLOGÍA: estudio retrospectivo efectuado por los miembros del Comité de expertos de la Asociación Mexicana de Medicina de la Reproducción, empleando los artículos publicados entre los años 2000 a 2016 en Pubmed y que en el resumen contuvieran los MeSH: leiomyomatosis uterus, leiomyoma, leiomyomatosis uterine, leiomyomatosis uterine in pregnancy. La calidad de la evidencia y la formulación de las recomendaciones se realizaron con la metodología establecida por el sistema GRADE. RESULTADOS: se incluyeron 97 artículos en los que se encontró que la prevalencia en mujeres en edad reproductiva es variable, según la edad (20 a 80%). En la mayoría el diagnóstico se establece entre los 35 y 54 años. Para el tratamiento existen varias opciones con distintos porcentajes de eficacia. CONCLUSIONES: queda de manifiesto la evidencia de la eficacia de varios medicamentos indicados para el control de los síntomas y para mejorar la calidad de vida de las pacientes. En la comparación entre acetato de leuprolide y acetato de ulipristal no se encontraron que originaran síntomas vasomotores, ni disminuyeran la masa ósea. En relación con el último se vislumbra la posibilidad de evitar la cirugía, aunque aún se requiere más investigación a este respecto.

Abstract OBJECTIVE: To make known to the gynecological obstetricians a document where they can be consulted, in the light of the most recent studies and with the best evidence on the pathophysiology, prevalence and clinical significance of uterine fibroids, as well as the best possible evidence about the various treatment modalities. METDOLOGY: A retrospective study carried out by the members of the Committee of experts of the Mexican Association of Reproductive Medicine, using the articles published between 2000 and 2016 in Pubmed and that in the abstract contained MeSH: leiomyomatosis uterus, leiomyoma, Leiomyomatosis uterine, leiomyomatosis uterine in pregnancy. The quality of the evidence and the formulation of the recommendations were made using the methodology established by the GRADE system. RESULTS: 97 articles were included in which the prevalence was found to be variable, according to age (20 to 80%) in women of reproductive age. In most, the diagnosis is established between 35 and 54 years. There are several treatment options with different percentages of effectiveness. CONCLUSIONS: Evidence of the efficacy of several medications indicated for the control of symptoms and to improve the quality of life of the patients is evident. In the comparison between leuprolide acetate and ulipristal acetate, they were not found to cause vasomotor symptoms or to decrease bone mass. Regarding the latter, the possibility of avoiding surgery is envisaged, although more research is still needed in this regard.

[Evaluation of visceral adipose tissue and lipid level in premenopausal and postmenopausal women's]. / Evaluación del tejido adiposo visceral y de la concentración de lípidos en mujeres pre y posmenopáusicas.

BACKGROUND: Postmenopausal women present weight gain and intensification of obesity, especially visceral adipose tissue (VAT) increases in postmenopausal women. But it is still not clear whether abdominal fat increases during this stage independently of body weight. OBJECTIVE: compare the VAT and lipid profile between postmenopausal and premenopausal Mexican women. METHODS: A case control study in postmenopausal women matched for BMI with premenopausal women. Anthropometric and laboratory measurements as well as body composition analysis were performed. RESULTS: VAT was increased in postmenopausal women in contrast with premenopausal women (114.8 ± 39.5 vs 97.3 ± 29.0, p<0.05). Compared with premenopausal women, postmenopausal women showed higher total cholesterol (231 .6 ± 56.1 vs 206.8 ± 29.5 p <0.05), and LDL-cholesterol levels (145.9 ± 48.3 vs 121.7 ± 34.1, p < 0.05), whereas H DL-cholesterol remained unchanged. CONCLUSION: The results of the present study have demonstrated that Mexican postmenopausal women had a significant increment in visceral adipose tissue and in other metabolic risk factors, independent of the body mass index.

Reductions in caloric intake and early postnatal growth prevent glucose intolerance and obesity associated with low birthweight.

AIMS/HYPOTHESIS: Low birthweight (LBW) and rapid postnatal weight gain, or catch-up growth, are independent risk factors for the development of obesity and diabetes during adult life. Individuals who are both small at birth and have postnatal catch-up growth are at the highest risk. We hypothesised that dietary interventions designed to attenuate catch-up growth in LBW subjects may have long-term beneficial consequences. MATERIALS AND METHODS: We used our previously described mouse model of LBW-associated diabetes, created by restricting maternal food intake to 50% during the last week of gestation. Control (C) dams and dams that had been subjected to undernutrition (U) were then provided either chow ad libitum after delivery or 50% food restriction on a per-day basis from delivery until weaning. We designated the resulting four groups control-control (CC), undernutrition-control (UC), control-undernutriton (CU) and undernutrition-undernutrition (UU), indicating the prenatal and postnatal experimental conditions, respectively. Carbohydrate metabolism and adiposity were assessed prospectively in offspring until age 6 months. RESULTS: Males that were small at birth and exhibited early postnatal catch-up growth developed glucose intolerance and obesity by age 6 months. In contrast, LBW mice without catch-up growth (UU) remained smaller than controls (CC), and glucose intolerance and obesity was prevented. Similarly, mice with normal birthweight that had blunted catch-up growth (CU) were leaner and had better tolerance test than CC mice. Catch-up growth during the first week of life correlated better than birthweight with glucose, fat mass and glucose tolerance up to 6 months of age. CONCLUSIONS/INTERPRETATION: Prevention of early catch-up growth reversed the development of glucose intolerance and obesity in our mouse model of LBW-associated diabetes.

Glucose screening during active labour for the detection of undiagnosed hyperglycaemia and newborn malformations in a population without prenatal care.

AIM: This prospective study was undertaken to look at the frequency of hyperglycaemia in pregnant women who were without health benefits and did not receive prenatal specialist care, and to examine the relationship between fetal complications and the prenatal care received. METHODS: The subjects consisted of 304 pregnant women, divided into two groups. Group I included 176 women who had inadequate prenatal care (73 women with irregular care, and 103 women without any specialist care.) with a mean of 1.1 visits to a specialist. Group II included 128 women who had regular prenatal care with a mean of 6.5 consultations per patient. RESULTS: There were no statistical differences between the two groups in relation to maternal age, obstetrical history and gestational weeks. The familial antecedent of diabetes was found in 30.1% of women in group I and 19.5% of women in group II (p < 0.05). Hyperglycaemia was found in 55 (31.2%) patients in group I and 4 (3.1%) patients in group II (p < 0.001) with mean blood glucose levels of 163 and 130 mg/dL respectively. Clinical characteristics of newborns show statistically significant increased abnormalities in 15.9% of babies whose mothers had inadequate prenatal care vs. 3.9% of babies whose mothers had regular prenatal care. The abnormalities seen were myelomeningocele, cleft lip and palate, oesophageal atresia, polydactyly, phocomelia and encephalocele. CONCLUSIONS: The frequency of hyperglycaemia in pregnant women with inadequate prenatal care was higher than in pregnant women with regular prenatal care. Additionally newborn abnormalities and complications occurred more frequently in babies of mothers with inadequate prenatal care. The benefits of prenatal care are evident and it is important to improve and start instituting new programmes and ways of making health information available to women in primary care clinics to educate the general population and stress the importance of regular visits to a prenatal care specialist.

[Fetal weight at weight as predisposing risk factor for type 2 diabetes in adulthood]. / El peso fetal al nacimiento como factor de riesgo predisponente para diabetes tipo 2 en la vida adulta.

When the fetus growth in an unfavorable intrauterine environment, this process has implications in the adult life, that predisposes to suffer metabolic abnormalities as obesity, hypertension and non-insulin dependent diabetes mellitus. The unfavorable intrauterine environment includes the pregnancy with diabetes mellitus, pregnancy with gestational diabetes, and pregnancy with maternal undernutrition. Multiple epidemiological studies developed in North America and Europe appear to broadly confirm the association of the low birth weight in babies borne at term, with the glucose metabolism impairments in the adult life. An implication of metabolic impairments on high birth weight for the gestational age has been founded. This alteration could start when there are changes in nutritional habits in migrate populations, having number and function of the pancreatic islets altered, maybe because during fetal life they were faced to blood fluid decreased, and nutrients also decrease as well as the differentiation of cells was modified, as an important intent for fetal survival. The prevalence of type 2 diabetes has been reported in 13 to 25% for low birth weight. On the other hand, maternal hyperglycemia leads to beta-cell hyperplasia in the fetus, by a constant stimulus over the insulin production which stimulates the use of glucose as nutrients, leading to the increase in fetal weight and determining genetic changes. In overnutrition conditions, the prevalence of type 2 diabetes has been reported of 8 to 18%. Growth of tissues has critical periods at different times and intrauterine environment can be one mechanism for may permanently changes in pancreas structure and hormonal secretion patterns. Thus, the hypothesis that autoprotective fetal changes during the intrauterine life occur, took place, specially during the critical period of development, leaves to permanent changes called "programmed changes", including an endocrine disturbance of pancreatic functions, appearing in adult life. Further molecular studies of pancreatic islets are necessary in order to determine the mechanisms for lifelong changes and insulin metabolism due to intrauterine growth.

Insulin-like growth factor I, epidermal growth factor and transforming growth factor beta expression and their association with intrauterine fetal growth retardation, such as development during human pregnancy.

AIM: Fetal intrauterine growth retardation (IUGR) is one of the most common obstetric problems, with a frequency of 12% in Mexico. In the past, investigations have focused on extrinsic causes of IUGR. More recent studies have examined the intrinsic factors that cause fetal intrauterine growth. Maintenance of fetal growth has been attributed to insulin-like growth factor (IGF), epidermal growth factor (EGF) and transforming growth factor beta (TGF-beta). The objective of this study was to assess the levels of these growth factors during pregnancy and to determine whether or not low concentrations are associated with IUGR. METHODS: Nine women whose pregnancies were complicated by IUGR and a group of nine women whose pregnancies exhibited normal fetal intrauterine growth were studied. IUGR was determined by sonography and confirmed by weight at birth. Venous blood samples were taken from both groups of pregnant women at the end of each trimester. Enzyme-linked immunosorbent assays, immunoradiometric assays and radioimmunoassays were used to process samples, and the results were analysed by anova. RESULTS: IGF-I levels increased in both groups during pregnancy, but the increase was lower (p < 0.001) in the IUGR group throughout pregnancy and at delivery. EGF did not show any significant changes during pregnancy. Blood TGF-beta levels varied only during the first trimester of pregnancy. The differences were not statistically significant. However, TGF-beta concentrations were higher in the pregnancies with IUGR. Women in the IUGR group were smaller than in the control group (p < 0.05), and, using the covariance test (p < 0.05), this was found to be correlated with IGF-I levels but not with EGF or TGF-beta levels. CONCLUSIONS: Changes in fetal weight might be explained by the different concentrations of IGF. The structural homology between IGF-1 and insulin could mean that the presence of higher levels of IGF would result in a increased energetic metabolism that could contribute to fetal growth. EGF levels were not related to IUGR, and TGF-beta levels increased only during the first 3 months in the IUGR group. This observation correlates with the in vitro action of TGF-beta as a negative factor of growth, but as a positive support for sustaining early pregnancy. Our data illustrates that low height represents an increased risk factor for IUGR. These data also correlate with the studies involving extrinsic factors.

[Barrier family planning methods as risk factor which predisposes to preeclampsia]. / Los métodos de planificación familiar de barrera como factor de riesgo que predispone a la presencia de preeclampsia.

Preeclampsia is a pregnancy-specific syndrome, it occurs in approximately 5-10% of all pregnancies and the etiology remains unknown, but the primigravida adolescent as such as multigravid older women whom have conceived with a new sexual partner have a greater risk, this has been associated also with the use of barrier contraceptive methods that prevent exposure to sperm with the endometrial cavity. An immunological factor has been suspected because fetal antigen's could cause antigenic reaction with the maternal immunological apparatus, for first exposure at these antigens, since the fetus is considered like an allotransplantation. This is supported in some studies that report that the use of condoms, spermicides and withdrawal are associated with developing of preeclampsia in subsequent pregnancy, and another hand indicate at cohabitation preceded for long period, practiced oral sex and use of contraceptive methods that permit exposure to sperm viable with uterus decreased the prevalence of preeclampsia. To test this hypothesis, we initially used data from two groups of pregnant women, comparing the contraceptive and reproductive history of 73 pregnant women with preeclampsia and 70 pregnant women without preeclampsia. The odds ratio for preeclampsia indicated a 2.52-fold (with 95% confidence interval, 1.17 to 5.44, p < 0.05), increased risk of preeclampsia for users of barrier contraceptives compared with women using nonbarrier contraceptives methods. Other variables like socio-demographic and obstetrics analysis were not different between both groups. This study suggest that nonbarrier contraceptive methods or the exposure of paternal spermatic antigens is protective against development of preeclampsia. Further immunological studies are necessary to determine the role of contraception methods and preeclampsia.

[Use of modified intrauterine device (IUD) TCu 380 with chromium filaments in the immediate postpartum]. / Uso del DIU Tcu 380 modificado con filamentos de cromo en el posparto inmediato.

Postpartum insertion of the intrauterine device (IUD) can provide an effective and convenient means of contraception. As a result, the use of IUD's has steadily increased, and the Family Planning Program recommends it because it offers many advantages. However, a major risk associated with the use of IUD's is the possibility of its expulsion, which ranges from 4 to 60%. Furthermore, 20% of women who expelled IUD's were unaware that it occurred, thus increasing their susceptibility to unwanted pregnancies. IUD's modified by the addition of biodegradable strands of chromic suture at time of implantation are thought to be less likely to be expelled, as the sutures anchor the IUD more firmly to the endometrium, and it is possible that the use of these sutures may decrease the risk of expulsion. Therefore we determined if the chromic extension to IUD enhance retention and decreased the rate of expulsion. In one year of study, 150 women received a modified IUD (TCu 380) with chromic catgut number 0 (ccO) in the transversal arm within 10 minutes of delivery of the placenta. However, only 84 women completed the follow-up study. To evaluate IUD expulsion, exploratory examinations were conducted during the immediate postpartum, at 7 days postpartum and at 6 weeks after delivery. We determined the presence or expulsion of the IUD in these three periods postpartum. Other parameters such as parity, age and marital status were also considered. A total of 14 modified IUD's (16.6%) were expelled. This represents a similar frequency of expulsion both during the immediate postpartum and the 7 days postpartum period. There was no significant difference in the rate of expulsion between the two periods. Moreover, there was no expulsion at 6 weeks postpartum. The primiparity women had the highest percentage of expulsion (22.8%). Single mothers either living with or without their sexual partner had expulsion rates of 20.6 and 20.5%, respectively. The highest rate of expulsion when we considered age was in women younger than 30 years of age. There was only one case of expulsion where the mother was unaware of its occurrence. The results described here indicate that age, parity and civil status have no direct influence on expulsion of modified IUD's with chrome extensions. In all postpartum periods studied the p-value was greater than 0.05. Six weeks postpartum was the only time at which there was no IUD expulsion. This is most likely a consequence of decreased uterine cavity size and closure cervix. The modified IUD TCu 380 with chrome strands shows a rate of expulsion similar to other modified IUD's as evidenced in the literature. However, there is a lower rate of expulsion than in unmodified IUD's. It is an important to rote that incomplete expulsion of modified IUD's in this study was considered a total expulsion which represent loss of contraceptive effectiveness. On the contrary, if we had considered only completely expelled IUD's in this study, the percentage would have been significantly lower, as only one total expulsion was found. Further studies are necessary to investigate consecutive expulsions of the TCu 380 modified IUD.

[The role of insulin-like growth factor in polycystic ovary syndrome]. / Participación del factor de crecimiento insulinoide (IGF), en el síndrome de ovario poliquístico (SOP).

The partnership the insulin-like growth factor (IGF) in women with polycystic ovary syndrome (PCOS) is characterized by mechanisms underlying alterations in the GH/IGF-1, axis. In the pathogenesis exist a synergism markedly enhanced between IGF-1 and insulin, and IGF-1 with LH to increase androgen production, causing a reduced IGFBPs and SHBG production, the resulting hyperandrogenism, within and outside the ovary, may inhibitor follicular maturation and the biosynthesis of estrogen. At the present, the data suggests up to date paracrine, autocrine as well as endocrine actions in the ovary in normal conditions and the lost of this homeostasis can be followed by neuro-endocrine.

[Insulin resistance in polycystic ovary syndrome]. / Resistencia a la insulina en el síndrome de ovario poliquístico.

Polycystic Ovary Syndrome has been related with hyperinsulinemia and insulin resistant, is a heterogenous disorder biochemistry and clinical, as a consequence androgens and insulin hypersecretion, the exacerbation for the chronic anovulation and obesity, which is caused frequently of hirsutism and sterility, moreover is related with great variety metabolic pathologies, cardiac sickness and oncologies disease in long time. The most important in this present review is to determine a role of the hyperinsulinaemia and insulin resistance in this syndrome.

[Intra-vesical translocation of an intrauterine device, report of a case]. / Dispositivo intrauterino traslocado (intravesical), informe de un caso.

The intra-uterine device TCu 380 (IUD) has a great acceptance among the group of women that take the fertility control in not definitive form and it is being accepted by more women. In spite of the simple technique to insert the IUD, the people in charge of the planning family program in the first level attention section of the centers of health, have not enough knowledge for its insertion. We reported the case of a 21 year old woman that applied the IUD immediately after her baby's birth and she had sudden expulsion the following week. She went to the first level attention section where they inserted the IUD again and four months later she began to have urinary symptoms and abdominal pain, she went for a check, but could not find the filaments of the IUD. The x-ray of her abdomen showed an inverted IUD, they tried to take it off, but without any success. She was sent to the General Hospital where made an ultrasound that showed the IUD in the urinary bladder. A transurethral endoscopy was made and also an ultrasonographic dragging without gerring it. That is why decided to take it off by abdominal and urinary bladder surgery. The IUD was inserted transurethral which the diameter of the applier is thin and lets it go free in thorough the urethra, besides that during the operation did not find any harm in the uterus or the bladder that could make suspect the perforation in order to make the IUD reach the urinary bladder. The above mention demonstrate the ignorance of the technique and the anatomic place for the insertion of the IUD. That is the reason why it is necessary a more detailed preparation it the whole personnel assigned to the family planning programs.

[Janiceps cephalo-thoraco-abdominopagus pregnancy]. / Embarazo Janiceps, cefalotoracoabdominopago.

Cojoined twins was analyzed type cephalothoracoabdominopagus, is especially rare case of dysgenetic abnormalities, in which the heads, necs, thoraces and abdomen are joined. Twins births joined have been said to occur with a frequency of 1 per 100,000 deliveries, but the incidence of this malformations is one in three million conjoined twins. Conjoined twinning may be associated with a more fundamental failure of embryonic migration or may be associated with a more fundamental failure of ambryonic migration or fusion, 95% of conjoined twins are females. The Janiceps type of cephalothoracoabdominopagus derives its name from Janus, in Roman nythology, the god of doors and gateways, his statue with two faces, facing east and west for the beginning and ending of the day. The anatomic features with the Janiceps type of cephalothoracoabdominopagus are describe, and the mechanisms that may have played a role in the abnormal development of these twins are discussed. The mother was a 22-year-old, with last menstrual period January 12, 1997. She came to the other medical center, with an ultrasound study performed at 27 weeks' gestation, and possible multiple fetal anormalies, a second ultrasound examination, confirmed abnormalities, two hearts, as well as polihidramnios. Past history included normal espontaneous vaginal delivery of healthy term infant, who were alive and well, family history was negative for congenital anormalies, and no prior history of twinning. She denied use of drugs, alcohol, or cigarettes; had no fever, vaginal bleeding, or other problems with the pregnancy. The abdomen was gravid to 48 cm, and contractions were palpable, fetal heart tones were 1400 beats per minute. On the one day of admission the patient underwent delivery of conjoined infants, the Apgar scores were zero at 1 minute and at 5 minutes. The infants were joined front-to-front, with two faces, each a compositive of toth twins, each twin han four extremities, in each face resambled a one nose, with structure incomplete in one face, esophagi were fused. Each twin had its own skeletal system extending from the cervical spine downwards. The congenital malformations for each conjoined twin are listed in the autopsy report, abnormalities included absent ovary and uterus in both twin. COnjoined twins develop from a single zygote, the cause is unknown. We proposed, embryonic tissue divides incompletely, likely to result in twinning anomalies from the 15th to 16th day postovulation, during the late part of period six, about the third week.

[The proportion of molecular forms of gonadotropins changes in patients with polycystic ovaries]. / La proporción de formas moleculares de gonadotropinas se altera en pacientes con síndrome de ovarios poliquísticos.

It is known that protein hormones circulate as different molecular forms and the relative proportion of these isoforms changes according to endocrine milieu. In particular gonadotropins, both LH and FSH, isoforms suffer variations related to the estrogen levels; thus sera obstained from menopausal women show a predominance of larger molecular forms which are considered as having lesser biological activity and the administration of estrogen replacement therapy is followed by the appearance of intermediate molecular forms possessing higher biological activity. This chormatographic pattern with predominance of intermediate isoforms is typical at midcycle in sera from normal women at the periovulatory stage. Present study showed that sera obtained from anovulatory women, such as patients with polycystic ovaries a predominance of larger and smaller molecular weight isoforms, exhibiting a chromatographic pattern different from that observed in normal women. It is speculate that there is some imbalance between the ovarian steroid synthesis and gonadotropin production in the stage of tertiary structural conformation.

[Postmenopausal metabolic effects of a synthetic estrogen (tibolone) with a characteristic estrogenic action]. / Efectos metabólicos en la posmenopausia de un esteroide sintético (tibolona) con acción estrogénica característica.

Life expectancy in women has nearly reached 80 yr old, therefore the postmenopausal period is considered very important, particularly regarding the benefits of hormone replacement therapy. At the present there are several therapeutic options in order to protect against the long term complications resulting from chronic hypoestrogenism and avoiding some of the side effects associated with estrogens medication, tibolone is a synthetic steroid possessing mild estrogenic effect and some progestagenic and androgenic actions; moreover this steroid does not require to be converted to estradiol. We studied the effect of administering tibolone 2.5 mg daily orally during six months to 11 postmenopausal women in order to analyze any changes on several biochemical markers. Estradiol concentrations were not modified although FSH, total cholesterol, low density lipoproteins and triglycerides levels decreased. Collaterally there was observed an increment in high density lipoproteins and sexual hormone binding globulin. It is concluded that tibolone exerts its effect directly on specific receptor tissues without being converted to estradiol so that this finding may help to understand some of the clinical effects, particularly upon mammary gland, endometrium and body weight.

[Variations in the molecular forms of LH and FSH during the normal ovarian cycle]. / Variaciones de las formas moleculares de LH y FSH durante el ciclo ovárico normal.

FSH and LH concentrations during the menstrual cycle are well known, showing characteristically a midcycle surge in LH as well as in less degree in FSH. At the present there is an increasing interest in studying variations of the moleculoar forms of both gonadotropins. We have studied the chromatographic profile of FSH and LH in sera obtained from women regularly ovulating and in patients with anovulatory cycles by the use of gel column chromatography. It was observed the predominance of LH 32-34 kDa at midcycle and the heterogeneous FSH profile during the ovarian cycle. In sera from anovulatory patients the chromatographic profile was even more irregular for both LH and FSH. It is concluded that LH 32-34 kDa may be the more biological isoform in turn related with the process of ovulation.