Acretismo placentario focal tratado mediante embolización de arterias uterinas / Focal placenta accreta treated by uterine artery embolisation

El acretismo placentario es causa de hemorragia posparto y es una entidad que incrementa considerablemente la morbimortalidad materna. El diagnóstico anteparto es difícil. La embolización selectiva del vaso nutricio es una técnica conservadora que permite preservar el útero, y por lo tanto conservar la fertilidad. Presentamos el caso de una mujer con hemorragia puerperal, en el que se planteó el diagnóstico diferencial entre acretismo focal y malformación arterio-venosa uterina, que se trató exitosamente mediante embolización de arterias uterinas y posterior legrado, preservando fertilidad y consiguiendo nuevo embarazo posteriormente. Se evalúa la importancia de la interpretación de las imágenes para el diagnóstico, y la adaptación individual de los métodos terapéuticos y el manejo multidisciplinar

Placenta accreta can cause postpartum bleeding and has high maternal morbidity and mortality. Prenatal diagnosis is difficult. Selective embolisation of the uterine artery is a conservative technique that preserves the uterus and fertility. We present the case of a woman with puerperal bleeding, with a postulated differential diagnosis of focal placenta accreta and uterine arteriovenous malformation. Uterine artery embolisation and curettage successfully preserved fertility and the patient subsequently conceived again. We discuss the importance of image interpretation for correct diagnosis, the personalised adaptation of therapeutic methods and a multidisciplinary approach

Penfigoide gestacional / Pemphigoid gestationis

El penfigoide gestacional (PG) o herpes gestationis es una rara enfermedad cutánea autoinmune, que generalmente aparece en el segundo y tercer trimestre, y durante el puerperio, y que puede afectar al curso de la gestación y producir afectación neonatal. Presentamos el caso de una secundigesta con gestación gemelar y pénfigo gestacional. Se describe el proceso de diagnóstico, tratamiento y evolución

The pemphigoid gestationis or herpes gestationis is a rare autoimmune skin disease that occurs during the second or third trimester of pregnancy or in the immediate postpartum and which may affect the course of the pregnancy and cause neonatal pemphigoid gestationis. We present the case of a 40-year-old secudigravida with a twin pregnancy and pemphigoid gestationis. We describe the diagnostic process, treatment, and outcome

Fetal intracranial immature teratoma: presentation of a case and a systematic review of the literature.

OBJECTIVES: To describe a case diagnosed with intracranial teratoma in week 32 of gestation, as well as review of the literature in order to discern the appropriate treatment method and general prognosis of this anomaly. METHODS: A literature search was performed on the prenatal diagnosis of congenital intracranial teratomas in MEDLINE, EMBASE, Cochrane library data bases. Evaluated in this review are parameters such as time of prenatal diagnosis, associated pathology, size of tumors, method of terminating pregnancy, perinatal outcome and histological study of the tumor. RESULTS: A total of 49 cases were found, of which 12 were finished gestation, 28 cesarean section was performed and only nine had vaginal delivery. All died in the neonatal period except in three cases with intrauterine death after diagnosis. CONCLUSION: As the incidence of intracranial immature teratomas is very low and the prognosis is poor, their prenatal diagnosis and obstetric management present a great challenge for the planning of a follow-up and treatment of the disease in accordance with the preferences of the parents.

Complejo agnatia-otocefalia / Agnathia-otocephaly complex

El complejo agnatia-otocefalia es una malformación letaly muy infrecuente que puede ser diagnosticada medianteecografía de alta resolución. Describimos el caso de estaentidad en la que la ecografía reveló polihidramnios, cámara gástrica reducida y malformaciones faciales como agnatia, sinotia y protuberancia de la fusión nasobucal

Agnathia-otocephaly complex is a very unfrequentand lethal malformation that could be diagnosed by realtime ultrasonography. We report a case of prenatal diagnosis of this fetal malformation in which the ultrasound examination revealed polyhhidramnios, small stomach shadow and fetal face malformations like agnathia and a protuberance of the nose-mouth fusion

Prostaglandina E2 intracervical (Prepidil) frente a dispositivo vaginal (Propess) en la maduración cervical e inicio del parto. Estudio comparativo / Comparative study of intracervical prostaglandin E2 (Prepidil) versus vaginal insert (Propress) in labor induction

Objetivo. Comparar la eficacia y seguridad de un gel de prostaglandina E2 (PGE2) intracervical (Prepidil) con la de un dispositivo vaginal de PGE2 (Propress), para la maduración cervical y la inducción de parto. Material y métodos. Un total de 200 gestantes con test de Bishop desfavorable (< 6) y que precisaban inducción de parto fueron seleccionadas en el contexto de un muestreo no probabilístico de casos consecutivos y tratadas con PGE2. Cien gestantes recibieron una dosis de PGE2 intracervical que se repitió a las 24 y 48 h si el cérvix permanecía desfavorable. Si pasadas 48 h de la dosis inicial el parto no se había desencadenado, se procedía a la amniotomía e inducción oxitócica. Del mismo modo, se procedía con otras 100 mujeres a las que se aplicó PGE2 en dispositivo vaginal. Se valoraron las características de las gestantes, el número de aplicaciones, el intervalo entre la aplicación y el comienzo del parto, el tipo de parto, el resultado perinatal y los efectos secundarios. Para la comparación estadística de resultados se utilizó el paquete informático SPSS 10,0, y se consideraron significativos valores de p < 0,05. Resultados. Las características de las pacientes fueron similares, lo que permite que la comparación sea exacta. En el 76% de los casos tratados con gel intracervical, el trabajo activo de parto comenzó tras la primera aplicación, frente al 78% de los casos en que se utilizó el dispositivo vaginal. Ambos procedimientos se mostraron más eficaces en multíparas que en nulíparas. En el 55% de los casos, el intervalo entre la aplicación del gel intracervical y el comienzo del parto fue < 12 h, frente al 40% de los casos en que se aplicó el dispositivo vaginal. No obstante, el intervalo medio entre uno y otro procedimiento apenas mostró diferencias: 17,06 h para el gel y 18,46 h para el dispositivo vaginal. Este intervalo fue menor para ambos procedimientos en las multíparas (10,82 frente a 15,40 h). La tasa de cesáreas fue del 27% para el gel intracervical y del 24% para el dispositivo vaginal. Esta diferencia no fue estadísticamente significativa. En el primer grupo se practicaron un 5% de cesáreas por fracaso de inducción y un 3% en el segundo. Una segunda aplicación se asoció a una mayor tasa de cesáreas, siendo el porcentaje mayor en el grupo tratado con gel intracervical con diferencias estadísticamente significativas (p < 0,005). En los 2 procedimientos utilizados, la cesárea fue más frecuente en nulíparas que en multíparas, con diferencias significativas en el grupo del dispositivo vaginal, si bien estas diferencias no llegaron a ser significativas en el grupo de gel intracervical debido al escaso número de multíparas en este grupo. El resultado perinatal y los efectos secundarios no mostraron diferencias en los 2 grupos estudiados. Conclusión. Ambas formas de PGE2 son seguras y eficaces, si bien la aplicación del dispositivo vaginal se asocia a una menor tasa de cesáreas cuando es necesaria una segunda aplicación, lo que puede estar en relación con una menor tasa de cesáreas por fracaso de inducción con respecto al gel intracervical y la mayor paridad en este grupo. Si a ello se une la facilidad para su colocación y retirada, es evidente que el dispositivo vaginal es una alternativa fiable para la maduración cervical e inducción del parto (AU)

Objective. To compare the efficacy and safety of prostaglandin E2 (PGE2) intracervical gel (Prepidil) with that of PGE2 vaginal insert (Propress) in cervical ripening and labor induction. Material and methods. Two hundred pregnant women with unfavorable Bishop's scores (< 6) requiring induction of labor were selected through nonprobabilistic sampling of consecutive cases. All the women were treated with PGE2. One-hundred pregnant women received an intracervical PGE2 dose, which was repeated 24 and 48 hours later if the cervix remained unfavorable. If labor was not induced 48 hours after the initial dose, amniotomy was performed and oxytocin was administered. The same procedures were performed in another 100 women who were administered PGE2 through a vaginal insert. The characteristics of the pregnant women, the number of applications, the interval between the applications and the beginning of labor, type of delivery, perinatal outcomes, and adverse effects were evaluated. For the statistical comparison of results, the SPSS 10.0 statistical package was used. Values of p < 0.05 were considered significant. Results. The patients' characteristics were similar, allowing exact comparisons. Active labor began after the first application of PGE2 in 76% of the patients treated with intracervical gel compared with 78% of those with the vaginal insert. Both procedures proved to be more effective in multiparas than in nulliparas. The interval between PGE2 application and the beginning of labor was less than 12 hours in 55% of the group with intracervical gel compared with 40% of the group with the vaginal insert. Nevertheless, the mean interval between the two procedures showed minimal differences: 17.06 hours for the gel and 18.46 hours for the vaginal device. With both procedures, this interval was lower in multiparas than in nulliparas (10.82 hours versus 15.40 hours). The rate of caesarean section was 27% in women with intracervical gel and 24% in those with the vaginal device. This difference was not statistically significant. Five percent of cesarean sections were performed for failure of induction in the group with intracervical gel compared with 3% in the group with the vaginal device. A second application was associated with a higher rate of caesarean section; the highest percentage was found in the group treated with intracervical gel, with statistically significant differences (p < 0.005). With both procedures, cesarean section was more frequent in nulliparas than in multiparas, with statistically significant differences in the vaginal insert group; however, in the intracervical gel group these differences did not reach statistical significant due to the small number of multiparas in this group. No significant differences were found between the two groups in perinatal outcomes or adverse effects. Conclusion. Both forms of PGE2 are safe and effective, although the vaginal insert was associated with a lower rate of caesarean section when a second application was required. This finding could be related to the lower rate of cesarean section for failure of induction and to the higher parity in the vaginal insert group. In view of these results and the ease of placement and withdrawal of the vaginal device, this alternative is a valid option for cervical ripening and labor induction (AU)

Trastorno de la coordinación uterina. Inversión del triple gradiente descendente / Uncoordinated uterine activity. Inversion of the triple descending gradient

Se describe el caso de una gestante que en 2 ocasiones y de forma consecutiva presentó, poco antes del término, una actividad uterina descoordinada sin modificaciones cervicales y que fue diagnosticada de distocia dinámica por inversión del “triple gradiente de contracción”. Desde los años cincuenta se conoce su existencia, pero nunca se había podido explicar la causa de este fenómeno. A través de la revisión bibliográfica se analizan las posibles causas y los distintos tratamientos empleados en su resolución

We describe the case of a pregnant woman who, on two consecutive occasions and shortly before term, presented uncoordinated uterine activity without cervical modification and who was diagnosed with dynamic dystocia due to inversion of the “triple contraction gradient”. This phenomenon has been known since the 1950s but its cause has never been explained. We performed a literature review to analyze its possible causes and the various treatments used to resolve it

Plasma beta-endorphin levels in obese and non-obese patients with polycystic ovary disease.

The aim of this study was to determine the influence of body weight on circulating plasma levels of beta-endorphin and insulin in women with polycystic ovary disease (PCOD), as well as the correlation between the plasma levels of beta-endorphin and insulin. One-hundred and sixty-seven consecutive subjects with PCOD were recruited, 117 of whom had normal weight (body mass index (BMI) < 25) while 50 were obese (BMI > 25). A venous blood sample was taken and plasma concentrations of beta-endorphin, insulin, gonadotropins, prolactin, progesterone, 17 beta-estradiol, estrone, androgens, dehydroepiandrosterone sulfate and sex hormone-binding globulin (SHBG) were measured. Mean beta-endorphin and insulin plasma levels were significantly higher (p < 0.05) in obese PCOD women than in non-obese ones. Correlation analysis showed a positive association between insulin and beta-endorphin, beta-endorphin and BMI (and weight), insulin and BMI (and weight), and a negative correlation was found between insulin and SHBG. A weak association was found between beta-endorphin and luteinizing hormone (LH) in peripheral plasma. Stratified and linear regression analysis showed that plasma beta-endorphin concentrations correlate more with BMI than with insulinemia.

Gestación gemelar con feto acardio-acéfalo / Twin gestation with an afacial and acephalic fetus

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Circulating levels of immunoreactive beta-endorphin in polycystic ovary syndrome.

The plasma levels of beta-endorphin were studied in 64 women with polycystic ovarian disease (PCOD), from whom was selected a group of 23 women with normal weight and amenorrhea of < 36 days. On day 21, beta-endorphin levels were: mean 64.92 pg/ml; SD 37.32 pg/ml; 95% CI 48.38-81.47 pg/ml. It was also observed that their levels of opioid peptide were reduced, compared with women who had normal ovulatory cycles, both in the follicular phase (mean 70.93 pg/ml; SD 24.59 pg/ml; 95% CI 76.84-99.77 pg/ml) and luteal phase (mean 88.30 pg/ml; SD 31.80 pg/ml; 95% CI 76.84-99.77 pg/ml). The results were statistically significant (p < 0.05) for levels in PCOD patients compared with those of the luteal phase in women with normal ovulatory cycles. The decreased levels of beta-endorphin were negatively related to luteinizing hormone (LH) levels, which might explain the rise of LH levels in women with PCOD who control their weight and at the time of amenorrhea, although it is not clear if central opioid activity is reflected in the peripheral blood.