Rationalisation of the caesarean section rate in a tertiary referral hospital using the Robson classification.

The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.

Frecuencia de episiotomías en un hospital de tercer nivel / Frequency of episiotomy in a third-level hospital

OBJETIVO: Determinar la frecuencia y correlación de las episiotomías y desgarros en pacientes con parto eutócico. MATERIALES Y MÉTODOS: Estudio observacional y retrospectivo efectuado en el Hospital General Universitario de Alicante en dos periodos: 1) 2008-2012 y 2) 2013-2018. Se incluyen los partos eutócicos de embarazos únicos, a término, en presentación cefálica. Variables de estudio: episiotomía, desgarro, edad, semanas de embarazo, paridad, inducción del parto, cesárea anterior, analgesia regional, peso y sexo del recién nacido. Los resultados se expresan en porcentaje, coeficiente de correlación y las variables implicadas con razón de momios (RM). RESULTADOS: La tasa de episiotomía entre el periodo 1 vs el 2 disminuyó de manera muy importante: de 42.3 a 32.8%; [p < 0.001; RM: 0.81 (0.78-0.84)]. En cambio, el porcentaje de desgarros aumentó: de 42.7 a 50.8%; (p < 0.001; RM: 1.16[1.13-1.20]). El coeficiente de correlación fue de -0.91. Uno de los factores de riesgo asociados con la episiotomía fue la edad menor de 35 años, con RM de 1.25; IC95%: 1.16-1.35; p < 0.001, pero fue un factor protector de desgarros con RM de 0.76; IC95%: 0.71-0.81; p < 0.001. CONCLUSIONES: La tendencia de la episiotomía es decreciente, mientras que la de desgarro es inversamente proporcional. No se encontraron diferencias en la tasa de desgarro de III y IV grado.

Abstract OBJECTIVE: To determine the frequency and correlation of episiotomies and tears of patients with eutocic deliveries. MATERIALS AND METHODS: Observational and retrospective study carried out at the Hospital General de Alicante, Spain, in two periods: 1) 2008-2012 and 2) 2013-2018. Eutocic deliveries of single pregnancies, at term, in cephalic presentation are included. Study variables: episiotomies, tear, age, weeks of pregnancy, parity, labor induction, previous caesarean section, regional analgesia, weight and sex of the newborn. The results are expressed as a percentage, correlation coefficient and the variables involved with odds ratio. RESULTS: The episiotomy rate between period 1 vs. 2 decreased very significantly: 42.3% vs 32.8%; [p <0.001; OR: 0.81 (0.78-0.84)]. In contrast, the percentage of index tears: 42.7% vs 50.8%; (p <0.001; OR: 1.16 [1.13-1.20]). The correlation coefficient was -0.91. Regarding risk factors associated with episiotomy, one of them was the age under 35 years with an OR (95% CI): 1.25 (1.16-1.35; p <0.001), but it was a OR protective factor (95% CI): 0.76 (0.71-0.81; p <0.001) for the appearance of tears. CONCLUSIONS: The tendency in the realization of episiotomies is decreasing, while the tendency of the appearance of tears is inversely proportional. No differences were found in the tear rate of III and IV grade.

Hamartoma perineal congénito con malformación genital y anorrectal, asociado a alteración genética: duplicidad del gen TGIF2LX / Congenital perineal hamartoma with genital and anorectal malformation associated with genetic alteraction: duplicity of the TGIF2LX gene

Se presenta el caso de una gestante de 29 años, en la que en la ecografía de la semana 20 se evidencia un varón con genitales externos ambiguos, sospecha de hipospadias y una masa perineal, con el resto de hallazgos normales. La amniocentesis informa de cariotipo 46 XY normal y microarray CGH con duplicidad del gen TGIF2LX, cuya expresión es testicular y su función parece relacionada con la espermatogénesis, y también duplicidad de su gen homólogo TGIF2LY, cuya significación es desconocida. El seguimiento prenatal es normal, con persistencia de la alteración en genitales externos. Al nacimiento se detecta hipospadias con meato en linea media, escroto bífido y masa de consistencia blanda de 4 cm con apéndice cutáneo, asociado a fístula rectoperineal. Las pruebas de imagen indican que se trata de una masa perineal exófitica de 2,2 x 4 cm, de apariencia grasa con nódulo sólido de 1,4 cm en su interior, que podría corresponder a tumor de estirpe grasa de aspecto benigno. Intervenido para resección de la masa a los 11 días de vida, anorrectoplastia posterior y localización de neoano mediante neuroestimulación. El diagnóstico anatomopatológico es hamartoma perineal congénito, con músculo liso, cartílago maduro y tejido adiposo, sin evidencia de malignidad. El postoperatorio precisa de dilataciones anales hasta conseguir defecación espontánea, pero en general es normoevolutivo. El hamartoma perineal congénito es un tumor raro y casi siempre aparece asociado a alguna malformación genital o anorrectal, pero no hay publicaciones que describan correlación con alteraciones genéticas, como podría ser nuestro caso

We present the case of a 29 years old patient, in which the ultrasound of week 20 shows a male with ambiguous external genitals, suspected hypospadias and a perineal mass, with the rest of normal findings. Amniocentesis reports normal 46 XY karyotype and CGH microarray with duplicity of the TGIF2LX gene, whose expression is testicular and its function seems related to spermatogenesis, and also duplicity of its homologous gene TGIF2LY, whose significance is unknown. The prenatal follow-up is normal, with persistence of the alteration in external genitals. At birth, hypospadias was detected with a midline meatus, bifid scrotum, and a soft consistency mass of 4 cm with cutaneous appendage, associated with rectoperineal fistula. The imaging tests indicate an exophytic perineal mass of 2.2 x 4 cm, with a greasy appearance and a solid nodule measuring 1.4 cm inside, which could correspond to a benign-looking fat line tumor. Intervened for resection of the mass at 11 days of life, posterior anoreplasty and neoano localization by neurostimulation. The anatomopathological diagnosis is congenital perineal hamartoma, with smooth muscle, mature cartilage and adipose tissue, without evidence of malignancy. The postoperative period requires anal dilations until spontaneous defecation, but in general it is normal. The congenital perineal hamartoma is a rare tumor and almost always appears associated with some genital or anorectal malformation, but there are not publications that describe correlation with genetic alterations, how could our case be

Worldwide scientific production in obstetrics: a bibliometric analysis.

BACKGROUND: Randomised clinical trials are considered to be the most reliable study design for assessing the efficacy and safety of health interventions. AIMS: To analyse worldwide obstetrics research carried out through randomised clinical trials, from 2002 to 2013. METHODS: A bibliometric analysis was performed. Publications on obstetrics that were published journals indexed in the MEDLINE database from 2002 to 2013 were analysed. The major medical subject headings used in the search were obstetrics, pregnancy complications and obstetrics surgical procedures. The main study outcome was index of research productivity. RESULTS: Our study search strategy yielded a total of 142,659 articles and 9967 clinical trials. The growth rate of scientific production in obstetrics during this period was 55.43% (n = 5094). The growth rate of production of randomised clinical trials in this specialty, meanwhile, was 97.84% (n = 544). Most of the identified authors (n = 22,622, 71.21%) published only one paper during the study period. Patterns of co-authorship among the 20 most productive authors were identified. After applying Bradford's law, six journals in the nucleus (the most prolific journals) were found. Of all the clinical trials in obstetrics published between 2002 and 2013, 10.3% were published in journals belonging to categories other than Obstetrics and Gynecology. The most common research topic in 2002 and 2013 was the use of analgesia and anesthesia in obstetrics. CONCLUSIONS: Total scientific production rate in obstetrics increased from 2002 to 2013, especially randomised clinical trials. However, randomised clinical trials continue to represent a small proportion of total production.

Estudio de la vascularización placentaria mediante Power Doppler tridimensional en la semana 20 en gestaciones espontáneas y tras técnicas de reproducción asistida / Study of placental vascularization using 3D Power Doppler on week 20 of spontaneous pregnancies and after assisted reproductive techniques

OBJETIVO: Comprobar si hay diferente vascularización placentaria en gestaciones espontáneas comparadas con las conseguidas tras técnicas de reproducción asistida (TRA). MÉTODOS: Se realizó un estudio observacional de casos y controles retrospectivo, de embarazos únicos en semana 20, mediante ecografía transvaginal con Tridimensión y power Doppler. Los volúmenes adquiridos fueron analizados utilizando el programa de imagen VOCAL (Virtual Organ Computer Aided Analysis), para evaluar el Índice de Vascularización (IV), el Índice de Flujo (IF) y el Índice de Vascularización de Flujo (IVF). RESULTADOS: De 130 gestantes incluidas en el estudio, 55 de ellas se habían sometido a tratamientos de esterilidad y 75 eran gestaciones espontáneas. En un análisis comparativo, la vascularización placentaria en el grupo de TRA mostró diferencias estadísticamente significativas, siendo menores, tanto para el IF (p = 0,033) como para el IVF (p = 0,038), acercándose a la significación estadística el IV (p = 0,076). CONCLUSIONES: El estudio de la vascularización placentaria, podría ser de utilidad para comprender algunas diferencias entre gestaciones espontáneas y tras TRA que explicarían algunos resultados perinatales adversos en este tipo de gestaciones

AIM: Check for different placental vascularization in spontaneous pregnancies compared with those obtained after assisted reproduction techniques (ART). METHODS: An observational retrospective study of cases and controls, on singleton pregnancies at week 20, performed by tridimensional transvaginal sonographer and Power Doppler. The volumes acquired were analyzed using the program image VOCAL (Virtual Organ Computer Aided Analysis), to assess the vascularization index (VI), the flow index (FI) and vascularization index Flow (VIF). Outcome: Of 130 pregnant women included in the study, 55 of them had undergone a fertility treatment and 75 were spontaneous pregnancies. In a comparative analysis, placental vascularization in the ART group showed statistically significant differences, being lower for both the FI (p = 0.033) and for VIF (p = 0.038), approaching the VI statistical significance (p = 0.076). CONCLUSIONS: The study of placental vascularization could be useful to understand some differences between spontaneous and after ART pregnancies, to explain some adverse perinatal outcomes in those pregnancies

Anomalías congénitas tras técnicas de reproducción asistida y su correlación con la calidad embrionaria / Congenital anomalies after assisted reproduction techniques and their correlation with embryonic quality

OBJETIVO: Conocer la posible relación entre la calidad de los embriones transferidos en ciclos de Fecundación In Vitro (FIV) y Microinyección Intracitoplásmica de Espermatozoides (ICSI) con la presencia de anomalías fetales. MATERIAL Y MÉTODOS: Análisis retrospectivo incluyendo casos de anomalías congénitas (n=76), comparándolos con un grupo control (n=240) de nacimientos tras técnicas de reproducción asistida (TRA). Según los tipos de embriones obtenidos, se dividieron los casos en transferencia de calidad alta, media y baja. RESULTADOS: La aparición de defectos es similar con embriones de calidad alta (22,5 %) y media (21,8 %) pero se incrementa cuando se emplean los de baja calidad (40,0 %). Es similar en cuanto a la técnica empleada (FIV o ICSI), gestación única o múltiple, cultivo corto o largo. Sí hay influencia según la edad materna. CONCLUSIÓN: La transferencia de embriones de baja calidad, se asocia a la aparición de un mayor número de defectos congénitos

OBJECTIVE: To find out the possible correlation between the quality of embryos transferred in In Vitro Fertilization (IVF) and Intracytoplasmic Sperm Injection (ICSI) cycles and fetal anomalies. MATERIALS AND METHODS: Retrospective study including cases of congenital anomalies (n=76), compared to the control group (n=240) in births after assisted reproductive techniques (ART). Depending on the type of embryos obtained, the cases were divided into cases of high, medium and low quality transfer. RESULTS: The appearance of defects is similar between high (22.5 %) and medium (21.8 %) quality embryos, but increase when low quality embryos are used (40.0 %). This is similar in both techniques (IVF or ICSI), single or multiple pregnancies, long and short cultures. Maternal age does have an influence. CONCLUSION: Transferring low quality embryos is related to the appearance of a higher number of congenital defects

Moderately increased albuminuria unmasked hypertension.

The normal rate of albumin excretion is less than 30 mg/day (20 µg/min); persistent albumin excretion between 30 and 300 mg/day (20-200 µg/min) is called moderately increased albuminuria (formerly called microalbuminuria). In addition to being associated with diabetic nephropathy, moderately increased albuminuria has also been associated with cardiovascular disease in patients with as well as without diabetes. We present a case report of a man with moderately increased albuminuria who developed hypertension only detected by an ambulatory blood pressure monitoring procedure.

Acute genital ulcers.

Acute genital ulcers, also known as acute vulvar ulcers, ulcus vulvae acutum or Lipschütz ulcers, refer to an ulceration of the vulva or lower vagina of non-venereal origin that usually presents in young women, predominantly virgins. Although its incidence is unknown, it seems a rare entity, with few cases reported in the literature. Their aetiology and pathogenesis are still unknown. The disease is characterised by an acute onset of flu-like symptoms with single or multiple painful ulcers on the vulva. Diagnosis is mainly clinical, after exclusion of other causes of vulvar ulcers. The treatment is mainly symptomatic, with spontaneous resolution in 2 weeks and without recurrences in most cases. We present a case report of a 13-year-old girl with two episodes of acute ulcers that fit the clinical criteria for Lipschütz ulcers.

Uterine duplicity without communication between both hemiuteri and cervicovaginal atresia: importance of a thorough diagnosis before treatment.

The study described diagnostic and therapeutic processes for an exceptional congenital female genital anomaly involving a 15-year-old girl with progressive dysmenorrhoea and intense abdominal pain, and analyses pathogenesis of embryological anomalies associated with uterine duplicity (UD). Diagnostic methodology is analysed; treatment is described; and recommendations are provided. For the study of anomalies such as UD, we recommend the use of an ultrasound, vaginoscopy, MRI and laparoscopy imaging. Keeping in mind that hemihysterectomy should only be performed in cases with endometriosis or other unusual circumstances, surgical treatment should be avoided. A complete study based on gynaecological examination and ultrasound should be performed in adolescents with severe and progressive dysmenorrhoea. Based on the findings, imaging tests such as MRI and, if necessary, laparoscopy coinciding with menstruation, should be conducted before opting for surgical treatment.

Prenatal diagnosis of caudal dysplasia sequence associated with undiagnosed type I diabetes.

Caudal regression or caudal dysplasia sequence (CDS) is a rare congenital malformation, which includes a wide spectrum of musculoskeletal abnormalities involving the lumbosacral spine, pelvis and lower limbs. It can be associated to visceral defects in various degrees. Maternal diabetes, genetic predisposition and vascular hypoperfusion have been suggested as possible causative factors. Women with diabetes who are dependent on insulin are 200-400 times more likely to have a child with caudal regression, making CDS the most characteristic fetal abnormality of diabetic embryopathy. Prenatal diagnosis is possible by ultrasonographic examination. The sonographic findings include abrupt interruption of the lumbar spine and 'Buddha or frog position' of the lower limbs. MRI has demonstrated the level of the vertebral anomalies as well as the associated abnormalities and this is crucial because the prognosis of this condition depends on the severity of the lesion and the presence of associated disorders.

Uterine arteriovenous malformation.

Uterine arteriovenous malformation (AVM) is a little known condition of which, to date, very few cases have been described. It has a very diverse symptomatology, even though in most cases, it is diagnosed during a severe and acute haemorrhagic event. Its treatment can vary from expectant management to hysterectomy; however, current evidence suggests that the embolisation of uterine arteries is the most effective approach, especially if fertility is to be preserved. We present a case report classified as AVM, with additional images that show the appearance of this pathology in a short span of time. This case has a number of peculiarities: unusual persistence of human chorionic gonadotropin hormone (ß-HCG), asymptomatic patient, quick establishment of the lesion and its duration with unchanging characteristics and finally its spontaneous resolution without further consequences. This entity shows an aetiopathogenesis, that is, not well established or described. We discuss its physiopathology and aetiopathogenesis.

Wernicke's encephalopathy induced by hyperemesis gravidarum.

Wernicke's encephalopathy (WE) is a reversible neurological emergency caused by thiamine deficiency. Prolonged vomiting in pregnancy results in thiamine depletion. The early recognition of its clinical signs and symptoms is essential to establish the suspected diagnosis and can be confirmed by MRI. Prompt administration of thiamine is important for preventing the occurrence of sequelae in the mother and for improving the fetal prognostic. We report a case of WE induced by hyperemesis gravidarum with a good maternal and fetal outcome.

Diagnóstico ecográfico prenatal de lisencefalia asociada a síndrome de Miller-Dieker / Prenatal ultrasound diagnosis of lissencephaly associated with Miller-Dieker syndrome

La lisencefalia es una malformación cerebral caracterizada por la ausencia (agiria) o reducción (paquigiria) de las circunvoluciones cerebrales, causado por una migración neuronal anómala en el neocórtex. Presentamos un caso de sospecha ecográfíca prenatal de feto afectado de lisencefalia, confirmado mediante resonancia magnética posnatal. El recién nacido presentó una dismorfia facial característica y el cariotipo con estudio FISH una deleción del cromosoma 17p13.3, lo que nos llevó a un diagnóstico definitivo de síndrome de Millar-Dieker (AU)

Lissencephaly is a cerebral malformation characterized by the absence (agyria) or reduced number (pachygyria) of convolutions, caused by a failure of neuron migration in the neocortex. We present the case of a fetus with a suspected diagnosis of lissencephaly based on prenatal ultrasound, which was confirmed by postnatal magnetic resonance imaging. The newborn showed characteristic facial dysmorphism, and cytogenetic analysis with FISH studies showed a deletion of a region at chromosome locus 17p 13.3, leading to a definitive diagnosis of Miller-Dieker syndrome (AU)