Factores asociados con el éxito de una prueba de trabajo de parto después de cesárea (TOLAC) sin antecedente de parto / Factors associated with the success of a trial of labor after cesarean section (TOLAC) without a history of vaginal delivery

Resumen OBJETIVO: Determinar los factores asociados con una prueba de trabajo de parto después de una cesárea exitosa en mujeres sin antecedente de parto previo. MATERIALES Y MÉTODOS: Estudio observacional de casos y controles, longitudinal, retrospectivo y analítico efectuado en pacientes atendidas entre el 2017 y 2020 en el Hospital Ángeles Lomas, con embarazo único de más de 37 semanas, con una prueba de trabajo de parto, con una cesárea previa y sin parto previo. Se compararon las variables independientes entre el grupo que logró una prueba exitosa de trabajo de parto después de cesárea con las del grupo con prueba fallida. Para el análisis estadístico se utilizó el programa SPSS de IBM, versión 21. Todas las variables categóricas se expresan en frecuencias y porcentajes. RESULTADOS: Se incluyeron 135 pacientes con prueba de trabajo de parto después de cesárea de las que 65 (48.1%) tuvieron parto (prueba exitosa) y 70 (51.8%) cesárea (prueba fallida). Hubo una mayor proporción de trabajo de parto espontáneo en el grupo con prueba exitosa en comparación con el grupo con prueba fallida (66.2% en comparación con 37.1%). No hubo diferencias significativas en cuanto a la conducción del trabajo de parto, integridad de membranas amnióticas al ingreso, horas de trabajo de parto y peso al nacer. CONCLUSIONES: Un índice de masa corporal menor, un trabajo de parto espontáneo y una mayor dilatación al ingreso se asociaron, significativamente, con una prueba exitosa de trabajo de parto después de cesárea. La integridad de las membranas, la duración de la prueba y el peso al nacer no tuvieron diferencias significativas entre los grupos.

Abstract OBJECTIVE: To determine the factors associated with a trial of labor after a successful cesarean section in women with no history of previous delivery. MATERIALS AND METHODS: Observational case-control, longitudinal, retrospective, analytical, retrospective study performed in patient attended between 2017 and 2020 at Hospital Ángeles Lomas, with a singleton pregnancy of more than 37 weeks, with a trial of labor, with a previous cesarean section and no history of previous delivery. The independent variables were compared between the group that achieved a successful trial of labor after cesarean section with those of the group with failed trial. For statistical analysis, the IBM SPSS program, version 21, was used. All categorical variables are expressed in frequencies and percentages. RESULTS: We included 135 patients with trial of labor after cesarean section of whom 65 (48.1%) had labor (successful trial) and 70 (51.8%) had cesarean section (failed trial). There was a higher proportion of spontaneous labor in the successful trial group compared to the failed trial group (66.2% compared to 37.1%). There were no significant differences in labor conduction, amniotic membrane integrity on admission, hours of labor, and birth weight. CONCLUSIONS: Lower body mass index, spontaneous labor, and greater dilation on admission were significantly associated with a successful trial of labor after cesarean section. Membrane integrity, length of trial, and birth weight had no significant differences between groups.

Influencia de factores no médicos para el nacimiento por cesárea en un hospital privado / Influence of non-medical factors for cesarean birth in a private hospital

Resumen: OBJETIVO: Encontrar los factores no médicos que intervienen en el criterio del obstetra para elegir que la vía de nacimiento sea por parto o cesárea. MATERIALES Y MÉTODOS: Estudio transversal, retrospectivo, observacional y analítico, efectuado en pacientes atendidas entre 2016 y 2019 en el Hospital Ángeles Lomas, con más de 24 semanas de embarazo y que lo terminaron mediante parto o cesárea. Criterio de exclusión: embarazos múltiples. Variable dependiente: nacimiento por parto o cesárea. Variables independientes: sexo del obstetra, consultorio en el mismo hospital o externo, disponibilidad de asistente médico, mes del año, día de la semana y periodo vacacional. RESULTADOS: Se incluyeron 3906 nacimientos, 1495 cesáreas (38.3%) y 2411 partos (61.7%). Se observó mayor riesgo de cesárea, con significación estadística en: nacimientos atendidos por obstetras externos (OR = 3.81; IC95%: 3.07-4.73), nacimientos atendidos por obstetras del mismo hospital sin asistente médico (OR = 1.75; IC95%: 1.48-2.08), obstetras mujeres (OR = 2.55; IC95%: 2.06-3.16), abril vs diciembre (OR = 1.44; IC95%:1.04-1.98) y miércoles vs domingos (OR = 1.55; IC95%:1.14-2.05). Se registraron más cesáreas en el periodo prevacacional vs vacacional (OR = 1.51; IC95%: 0.94-2.43) sin diferencia estadísticamente significativa. CONCLUSIONES: Existen factores no médicos que aumentan la frecuencia de cesárea. Los relacionados con el obstetra incluyen: no tener el consultorio en el mismo hospital y carecer de asistente médico.

Abstract: OBJECTIVE: To find the non-medical factors that intervene in the obstetrician's criteria for choosing a birth canal or Cesarean section. MATERIALS AND METHODS: Transversal, retrospective, observational and analytical study carried out on patients attended between 2016 and 2019 at Hospital Ángeles Lomas (Mexico City), with more than 24 weeks of pregnancy and who finished it by vaginal delivery or cesarean section. Exclusion criterion: Multiple pregnancies. Dependent variable: birth by delivery or cesarean section. Independent variables: sex of the obstetrician, office in the same hospital or outside, availability of medical assistant, month of the year, day of the week and vacation period. RESULTS: 3906 births, 1495 cesarean sections (38.3%) and 2411 deliveries (61.7%) were included. A higher risk of cesarean section was observed, with statistical significance in: births attended by external obstetricians (OR = 3.81; CI95%: 3.07-4.73), births attended by obstetricians at the same hospital without a physician's assistant (OR = 1. 75; CI95%: 1.48-2.08), female obstetricians (OR = 2.55; CI95%: 2.06-3.16), April vs. December (OR = 1.44; CI95%:1.04-1.98) and Wednesday vs More cesarean sections were recorded in the pre-vacation vs. vacation period (OR = 1.51; IC95%: 0.94-2.43) with no statistically significant difference. CONCLUSIONS: There are non-medical factors that increase the frequency of cesarean section. Those related to the obstetrician included: not having the office in the same hospital and not having a medical assistant.

[Accidents and incidents in gynecologic surgery]. / Accidentes e incidentes en cirugía ginecológica.

Gynecologic surgery often entails meticulous dissection in areas close to the bladder, rectum, ureters and major vessels of the pelvis. The close anatomical relationship between these bodies that frequently makes are affected during pelvic surgery. When a complication occurs, it is vital to recognize and treat appropriately, emphasizing that gynecologists should handle its own complications and when they exceed the capacities of their own specialty, as in the case of unusual or complex lesions, should be sent assistance of a colleague in another specialty to solve the problem. To avoid intraoperative or injury is very important to timely diagnose an adequate knowledge of anatomy, surgical techniques using methodical and meticulous, with delicate sharp dissection and manipulation of tissues with a high index of suspicion constant in addition to routine cystoscopy after surgery to rule out injury. Once diagnosed the injury, repairing it at primary surgery is usually easier, successful and results in less morbidity.

[Azoospermia : In vitro fertilization results, using testicular biopsy and cryopreserved spermatozoa]. / Azoospermia: resultados en reproducción asistida con el uso de biopsia testicular y espermatozoides criopreservados.

Testicular sperm extraction (TESE) by open testicular biopsy, has become, since the introduction of the ICSI in 1992, the corner stone in treatment for azoospermia. This study reports the outcome of patients with open testicular biopsy for ICSI procedure indicated by azoospermia. 16 patients with azoospermia (12 obstructive and 4 non obstructive). The open testicular biopsy was performed prior the controlled ovarian hyperstimulation (COH) protocols of their couples, in two of the 16 patients no sperm were found in the biopsy, and the other 14 patients were admitted to 18 ICSI cycles, and the testicular samples were cryopreserved until oocyte capture. The controlled ovarian hyperstimulation (COH) was individualized in each case in accordance to the characteristics of each patient: 12 patients were used the long luteal phase GnRH agonist protocol, ultrashort protocol (Flare up) in one patient, GnRH antagonist in four, and the last one with endometrial preparation for cryopreserved embryo transfer. The mean of oocytes recovered was 11.71 +/- 7.24 oocytes per patient with a recovery rate of 72.64%. The fertilization rate was 49.35 +/- 29.24 and were transfered an average of 3 embryos per patient with a range between 1 and 5 embryos. In 18 cycles, 7 pregnancies occurred, four singles, one twin, one triple and one biochemical pregnancy. In conclusion the testicular sperm extraction (TESE) by open testicular biopsy is a good option for patients with azoospermia usually it achieves an adequate sample of testicular tissue with high possibilities of sperms recovery, in our study we obtained appropriate sperms in fourteen of sixteen patients for the ICSI procedure with good fertilization and pregnancy rates.

[Maternal morbidity in adolescent pregnancy]. / Morbilidad materna en la adolescente embarazada.

OBJECTIVE: To evaluate the maternal morbidity in < or = 16 year old pregnant teenagers. MATERIAL AND METHODS: A prospective study of the reviewed cases was carried out from June 1998 to May 1999. All pregnant teenagers which attended the Coordination for the Attention of the Teenage Patient and whose pregnancy came to term during the study period were included. The following variables were analyzed: maternal age, preexisting related diseases, number of pregnancies, number of prenatal control medical visits and the time at which these were started, and maternal morbidity secondary to pregnancy. RESULTS: Two hundred and ninety six of 330 case were included. The average maternal age was 15.1 years old (10-16 range); 68.9% had finished middle school; 82.2% were housekeepers, and 61.4% were single. Prenatal control was initiated in the 2nd trimester by 50.7% of them, while 39.5% started it in the 3rd trimester and the remaining 9.8% in the 1st trimester. The most frequent previous pathologies were: bronchial asthma (2.5%), drug addiction (2%), hypothyroidism (2%), cardiopathy (1.5%). The most common complications during pregnancy: urinary system infections (20.4%), anemia (9.8%), threats of premature labour (9.8%), premature membrane rupture (9%), hypertensive disease induced by pregnancy (3.2%), delayed intrauterine growth (2.4%) and fetal malformation (2.4%). About 44.1% of the pregnancies were interrupted by cesarean section, 35.6% by eutochia and 20.3% by instrumented labour. The most frequent complications during the puerperium were: tearing of the canal of the cervix (7%), decidual endometritis (3.3%), dehiscence of surgical wounds (2.7%), and pyelonephritis (1.6%). CONCLUSIONS: The pregnant teenager is a "special" patient form the biopsychosocial point of view, thus, she must be managed by a multidisciplinary team, with special emphasis in the problems analyzed in this study.

[Pelvic surgery as a predictive marker of the follicular response to ovulation inducers]. / La cirugía pélvica como un marcador predictivo de la respuesta folicular a los inductores de ovulación.

OBJECTIVE: Comparing the follicular response in a group of patients with previous pelvic surgery submitted to in vitro fertilization. MATERIAL AND METHODS: Patients who were going to be submitted to controlled ovarian stimulation and in vitro fertilization were included. Two groups were formed: one with those patients who had had a previous pelvic operation and the other with those patients who had not. The characteristics which were analyzed included: age, weight, body mass index, FSH, LH and estradiol levels, as well as total ova numbers, grade of embryonic maturity, and number of transferred embryos. RESULTS: Ninety nine patients were studied: 46 had been submitted to pelvic surgery and 53 had not. Due to the design of the study there were no differences regarding age, weight, size and body mass index; the evaluation of the ovarian reserve was similar in both groups. However, the group of patients previously submitted to pelvic surgery presented a lower quantity of total ova (p = 0.004), less mature ova (p = 0.008) with a significantly lower pregnancy rate. CONCLUSIONS: Surgical procedures, combined with adherence processes, probably have a direct incidence on the characteristics of the perifollicular environment which interfere with adequate development of the ovum. All these can be observed in a decrease of fertilization processes and embryonic development, regardless of the expression of the adequate biochemical markers of the ovarian reserve. Our research shows that the group under study presents a decrease in follicular response affecting the quality of the ovum-embryo expressed in the pregnancy rate.

Choque en obstetricia. Experiencia intitucional / Shock in obstetrics. institucional experience

El estado de choque es uno de los problemas más difíciles a los que se puede enfrentar el ginecoobstetra. Una de las principales causas de choque es la hemorragia, problema que se presenta con cierta frecuencia en la obstetricia. Se realizó una investigación retrospectiva descriptiva en el Instituto Nacional de Perinatología desde el mes de enero de 1992 al mes de mayo de 1996. Se incluyeron todas las pacientes que ingresaron a la terapia intensiva con diagnóstico de choque. Se encontraron 90 casos con diagnóstico de choque, de los cuales 82 correspondieron al tipo hipovolémico y 8 al tipo séptico. El promedio de edad fue 32.2 años y la edad gestacional entre 6.2 a 41.4 semanas. Se encontraron 71 pacientes sin patología de base, 9 con enfermedad hipertensiva asociada, infertilidad o esterilidad en 2, miomatosis uterina en 2, diabetes mellitus en 2 y otras enfermedades en 5 casos. La causa más frecuente de choque hipovolémico fue el acretismo placentario (40 casos), seguido de alteraciones del tono uterino (37 casos), embarazo ectópico en 7 casos, ruptura o perforación uterina en 4 casos y laceraciones del canal del parto en 2 casos. La pérdida hemática estimada varió desde 2200 ml a 6500ml. La presión arterial mínima registrada tuvo un rango de 40/20 mmHg hasta 90/60 mmhg. El tratamiento médico se basó en la utilización de cristaloides, concentrados eritrocitarios y expansores del plasma en 73 casos (81.1 por ciento). Al grupo restante se agregaron además de lo anterior coloides, crioprecipitados y plaquetas. Un total de 76 pacientes requirió histerectomía total abdominal y 5 casos con histerectomía total y ligadura de hipogástricas, salpingectomía en 5 pacientes y reparación de ruptura o de perforación uterina en 3. Se presentó un promedio de tiempo quirúrgico de 2 horas con 33 minutos. Las complicaciones observadas fueron 7 casos con absceso de cúpula, 2 con coagulopatía de consumo, una lesión vesical, una oclusión intestinal y una fístula vesicovaginal. El promedio de estancia fue de 5 días. La causa más frecuente de choque en obstetricia es la hemorragia para el tipo hipovolémico, seguido del choque séptico. En cuanto al manejo de las pacientes en estado de choque, la reposición volumétrica y restitución de la oxigenación son las metas principales, así como la oportuna intervención y rápida decisión de una cirugía radical que evitará el mayor deterioro de la paciente y la mortalidad materna

Histerectomía obstétrica. Revisión de 675 casos en el Instituto Nacional de Perinatología / Obstetric hysterectomy. A review of 675 cases at the Instituto Nacional de Perinatologia

En el Instituto Nacional de Perinatología (INPer), se realizó un estudio retrospectivo de 675 pacientes sometidas a histerectomía obstétrica en el periodo comprendido del 1 de enero de 1985 al 31 de diciembre de 1995. En cuanto a la edad en que se efectuó dicho procedimiento, presentó una mayor incidencia en los tres grupos comprendidos entre los 26 y 40 años, representó una mayor incidencia en los tres grupos compredidos entre los 26 y 40 años, representando el 72.5 por ciento (387 casos). La mayor incidencia correspondió a pacientes que contaban con 2 a 4 gestaciones previas, constituyendo 60.5 por ciento (409 casos) de la población estudiada. El 34.8 por ciento de las histerectomías obstétricas se practicó en pacientes con una cesárea previa, seguidas del grupo de pacientes con tres y dos cesáreas anteriores (24.5 por ciento y 22.2 por ciento, respectivamente). La edad gestacional en 51.1 por ciento (345 casos) fue de término, mientras que 38 por ciento (257 casos) fue de pretérmino, en 1.4 por ciento (10 casos) de postérmino y, finalmente, en 9.3 por ciento (63 casos) fue menor de 20 semanas. Las indicaciones principales para la realización de la histerectomía obstétrica fueron el acretismoplacentario en 34.07 por ciento (230 casos), atonía uterina en 32.4 por ciento (219 casos), deciduomiomeitritis en 6.3 por ciento (43 casos) y ruptura uterina en 4.5 por ciento (31 casos). Las complicaciones más frecuentes durante el procedimiento comprendieron la hipovolemia (12.1 por ciento), lesión vesical (5.4 por ciento) y lesión ureteral (0.7 por ciento). Como complicaciones posoperatorias, se tuvieron anemia (61.6 por ciento), síndrome febril (7.5 por ciento), íleo mecánico (7.5 por ciento), absceso parietal (3.4 por ciento) y fístula vesicovaginal (1.6 por ciento). Se informó en total de 8 muertes maternas (1.1 por ciento)