Valoración de la satisfacción del paciente a medio plazo tras reparación del prolapso urogenital con malla de polipropileno / Evaluation of medium-term patient satisfaction after repair of urogenital prolapse using polypropylene mesh

Objetivo: Evaluar la tasa de satisfacción de las pacientes sometidas a cirugía de corrección del prolapso urogenital con malla de polipropileno. Material y método: Estudio retrospectivo, no aleatorizado, con 106 pacientes que, desde abril de 2005 a enero de 2007, se sometieron a corrección de diferentes tipos de prolapso urogenital mediante malla de polipropileno. El seguimiento se realizó mediante visitas en consulta a los 2 y 6 meses. Posteriormente se realizó un análisis descriptivo de los datos. Resultados: La edad media fue de 64,4 años. El 91,51% era multípara y el 92,45% había pasado la menopausia. La intervención mayoritaria fue la colocación de una malla anterior con banda libre de tensión para la corrección de la incontinencia urinaria asociada, que representó un 34,90% del total. Se obtuvo una tasa global de complicaciones intraoperatorias del 2,83%, inmediatas del 37,73% y tardías del 21,69%. La tasa de éxito del procedimiento a los 6 meses estuvo entre el 80 y el 100%. La tasa de satisfacción de las pacientes a los 2 y 6 meses varió entre el 50 y el 100%, según el procedimiento realizado. Conclusiones: A pesar de la baja tasa de complicaciones intraoperatorias y a medio plazo en las cirugías de reparación del suelo pélvico en los prolapsos urogenitales con la malla de polipropileno, la tasa de satisfacción de las pacientes dependió mucho del procedimiento realizado, que fue menor en las mallas posteriores y cuando se asociaba cirugía de corrección de la incontinencia urinaria (AU)

Objective: To evaluate the satisfaction rate among women who underwent repair of urogenital prolapse using polypropylene meshes. Material and method: We performed a retrospective, non-randomized study in 106 patients who had undergone different kinds of urogenital prolapse repairs using polypropylene meshes between April 2005 and January 2007. Follow-up consisted of 2 visits to the hospital, 2 and 6 months after surgery. Subsequently, the information was analyzed descriptively. Results: The mean age was 64.4 years. The rate of multiparous and postmenopausal women was 91.51% and 92.45%, respectively. The most frequently used surgical technique was anterior mesh placement with a tension-free band (34.90%) to correct associated urinary incontinence. The complications rates were as follows: intraoperative complications (2.83%), immediate complications (37.73%), and late complications (21.69%). The success rate after 6 months was 80%-100%, depending on the technique. The satisfaction rate varied between 50%-100% and also depended on the technique. Conclusions: Despite the low rate of intraoperative and medium-term complications in the reconstructive surgery of pelvic floor for urogenital prolapses using polypropylene meshes, the satisfaction rate depended heavily on the kind of mesh use. The lowest rates were found in posterior meshes and when surgery for urinary incontinence was associated (AU)

Valor pronóstico de la isoforma fosforilada de la proteína transportadora del factor de crecimiento similar a la insulina tipo 1, en el éxito de la inducción del parto / Prognostic value of the phosphorylated isoform of type I insulin-like growth factor binding protein-1 on successful induction of delivery

Objetivo: Analizar la relación entre el éxito de la inducción del parto y la presencia, en la secreción cervical, de la forma altamente fosforilada de la proteína transportadora del factor de crecimiento similar a la insulina tipo I (IGFBP-1). Sujetos y métodos: Se estudió a 102 pacientes ingresadas para inducción del parto entre las semanas 37 y 41 con gestaciones únicas y presentación cefálica. Se realizó una historia obstétrica, examen físico, ecografía transvaginal y determinación de la isoforma altamente fosforilada de la IGFBP-1 (Actim ® PARTUS). El éxito de la inducción se definió como el parto vaginal dentro de las 24 h siguientes al inicio del procedimiento. Se realizó un análisis de regresión logística para identificar las variables que se asociaron de manera independiente con el éxito de la inducción. Resultados: El éxito en la inducción se produjo en 56 (65,1%) casos. El test Actim ® PARTUS resultó positivo en el 67,4% de los casos, y mostró una sensibilidad del 76,8% y una especificidad del 50%. El análisis de regresión logística mostró que la única variable que se asoció de modo independiente con el éxito de la inducción fue la paridad. El resto de covariables analizadas, incluyendo el test Actim ® PARTUS, no mostraron una relación independiente con el éxito de la inducción. Conclusiones: La presencia en la secreción cervical de la forma altamente fosforilada de la IGFBP-1 no se relaciona de modo independiente con el éxito de la inducción

Objective: To evaluate the relationship between successful induction of labor and the presence of the highly phosphorylated isoform of type-I insulin-like growth factor binding protein-1 (IGFBP-1) in the cervical fluid. Subjects and methods: A total of 102 women with singleton vertex pregnancies undergoing induction of labor between 37 and 41 completed weeks of gestation were studied. Obstetric history, physical examination, transvaginal ultrasound and determination of the highly phosphorylated isoform of IGFBP-1 (Actim TM PARTUS) were performed. Successful labor induction was defined as vaginal delivery within 24 hours of the procedure. Logistic regression modeling was performed to identify which variables were independently associated with successful induction. Results: Labor induction was successful in 56 patients (65.1%). An Actim TM PARTUS positive result was observed in 67.4% of the patients, with a sensitivity of 76.8% and a specificity of 50%. On logistic regression, the only variable independently associated with the outcome of labor induction was parity. The other covariates, including the Actim TM PARTUS test, did not show a significant association. Conclusions: The presence of the highly phosphorylated isoform of IGFBP-1 in the cervical fluid is not an independent factor associated with the success of labor induction

Creación de neovagina por laparoscopia en el síndrome de Rokitansky. Análisis de nuestros casos / Laparoscopic construction of a neovagina in Rokitansky syndrome. Analysis of our cases

Objetivo: Utilización de la laparoscopia como medio para la realización de una neovagina en pacientes con síndrome de Rokitansky aplicando los principios de Vecchietti. Pacientes y método: Dieciséis pacientes con síndrome de Rokitansky tratados mediante una modificación de la técnica de Vecchietti por vía laparoscópica. Resultados: Satisfactorio en 15 pacientes al obtener una vagina de al menos 8 cm en la revisión definitiva. Poco satisfactorio en 1 caso al disminuir la vagina de 12 a 6 cm por no seguir el tratamiento de mantenimiento. Conclusiones: La creación de una neovagina con asistencia laparoscópica es un procedimiento fácil, mínimamente invasivo y con pocos riesgos que permite un resultado temprano y satisfactorio para la paciente

Objective: Vecchieti’s principles were applied to laparoscopic construction of a neovagina in patients with Rokitansky syndrome. Patients and method: Sixteen patients with a diagnosis of Rokitansky syndrome were treated with a modified Vecchietti method by laparoscopic approach. Results: A satisfactory result was defined as a neovagina of at least 8 cm long on the final follow-up visit and was found in 15 patients. The result was much less satisfactory in the 16th patient in whom the vagina was discovered to be shortened from 12 cm to 6 cm at 2 years’ follow up as she had not followed the postoperative treatment. Conclusions: Laparoscopic creation of a neovagina is a safe, minimally invasive treatment with few risks and good functional results

Manejo de la hemorragia puerperal masiva por atonía uterina con desvascularización progresiva del útero, B-Lynch modificado y antitrombina III / Management of massive puerperal hemorrhage due to uterine atony with progressive uterine devascularization, modified B-Lynch suture technique and antithrombin III

Presentamos un caso de hemorragia puerperal masiva por atonía uterina tras cesárea urgente, que tuvo lugar en nuestro centro. Ante el fracaso del tratamiento médico, la alternativa quirúrgica a la histerectomía fue la realización de una desvascularización progresiva del útero, seguida de coartación de la cavidad uterina mediante la técnica descrita por B-Lynch. Por otra parte, se añadió al tratamiento el empleo de antitrombina III. Se describe la técnica empleada y comparamos su utilidad frente a otras opciones quirúrgicas. La técnica de B-Lynch modificada es una alternativa eficaz en el tratamiento de la atonía uterina, que permite conservar la fertilidad (AU)

We report a case of massive postpartum hemorrhage secondary to uterine atony after an emergency cesarean delivery in our center. Medical therapy was unsuccessful and progressive uterine devascularization followed by coarctation of the uterine cavity using the B-Lynch suture technique were employed as an alternative to postpartum hysterectomy. Treatment was completed with antithrombin III. We describe the B-lynch technique and compare its utility with that of other surgical options (AU)

Valoración de beta-HCG, estradiol y progesterona en mujeres portadoras de DIU / Evaluation of beta-human chorionic gonadotrophin, estradiol and progesterone in women with intrauterine devices

Objetivo: Se pretende investigar una posible alteración del ciclo ovárico en mujeres portadoras de dispositivo intrauterino (DIU), al mismo tiempo que se intenta averiguar mediante el estudio de la beta-HCG si estos dispositivos son abortivos.Material y método: Se estudian tres grupos. El primero compuesto por 103 mujeres portadoras de DIU, el segundo por 300 mujeres que utilizaban un método de barrera, y el tercero por 300 mujeres que deseaban gestación y no utilizaban método anticonceptivo. En todos ellos se determinaron los valores de progesterona y estradiol en la fase lútea, así como la beta-HCG sérica.Resultados: En el grupo I no se detectó ninguna beta-HCG positiva, frente a un caso en el grupo II y 57 en el grupo III. No se encontraron diferencias significativas respecto a la determinación del estradiol y de la progesterona.Conclusiones: De los hallazgos de nuestro estudio no podemos concluir que la acción anticonceptiva del DIU se produzca durante el ciclo ovárico, no existiendo tampoco fecundación, por lo que se descarta también la acción abortiva. (AU)

Doppler study of arterial and venous intraovarian blood flow in stimulated cycles.

OBJECTIVE: To evaluate arterial and venous intraovarian blood flow in follicle stimulating hormone-stimulated cycles. SUBJECTS AND METHODS: This was a prospective study of 76 follicle stimulating hormone-stimulated cycles carried out in 39 infertile patients who were included in a timed intercourse or intrauterine insemination program in a referral center for assisted reproduction. Transvaginal color and pulsed Doppler measurements of the follicular and luteal phase resistance index, pulsatility index, peak systolic velocity and maximum venous velocity were made and serum progesterone levels during the mid-luteal phase were recorded. Velocimetric parameters were established and then used to classify ovarian function as having a normal ovulatory cycle, or a cycle in which there was either luteal phase deficiency or a luteinized unruptured follicle. RESULTS: In 52 normal ovulatory cycles, the luteal phase peak systolic and maximum venous velocities were significantly higher and resistance and pulsatility indices were significantly lower than those found in the follicular phase. In 15 women with luteal phase deficiency we did not find any differences in arterial velocimetric parameters when compared with normal ovulatory cycles. However, luteal phase maximum venous velocities were lower in the luteal phase deficiency cycles and there was a significant correlation between luteal phase maximum venous velocity and serum progesterone levels (r = 0.36). Luteinized unruptured follicle cycles (n = 9) did not show significant changes during the ovarian cycle and no 'luteal conversion' of the Doppler signal was identified. CONCLUSIONS: Follicle stimulating hormone-stimulated cycles in infertile patients can have a high percentage of abnormal functional responses that can be diagnosed only by sonographic assessment, Doppler and the appropriate hormonal follow-up. Arterial and venous intraovarian blood flow remain unaltered during luteinized unruptured follicle cycles and serum progesterone levels correlated with luteal phase maximum venous velocity, which makes Doppler a potentially useful non-invasive test to assess ovulation and luteal function.

Six thousand office diagnostic-operative hysteroscopies.

OBJECTIVE: To compare CO(2) and normal saline as distention media in office diagnostic hysteroscopy. METHODS: The outcome of more than 6000 office hysteroscopies was analyzed. We used carbon dioxide or saline as distension medium. Minor hysteroscopic techniques were performed when indicated. RESULTS: The major indication was abnormal uterine bleeding (45%). Satisfactory hysteroscopy was achieved in 92. 4% with CO(2) and in 98.3% with saline (P<0.05). Local anesthesia was used in 54 patients (1.5%) with CO(2) and in three patients (0. 1%) with saline (P<0.001). Four hundred and two women (16.3%) underwent hysteroscopic procedures under saline hysteroscopy. Endometrial polyps were removed in 281 patients, 75 IUDs were removed, 14 fibroids were extracted, uterine septa were excised in 11 cases and mild and moderate adhesions were transected in 21 patients. CONCLUSION: Saline office diagnostic hysteroscopy offers at least all the advantages of the CO(2) hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed.

El índice cerebro-placentario como predictor de malos resultados perinatales. Evaluación en una población no seleccionada / The brain-placenta index as a predictor of poor perinatal outcome. Evaluation of an unselected population

Objetivo: Comprobar si existe la posibilidad de utilizar el índice cerebro-placentario como técnica de rutina en el control de las gestaciones normales o si, por el contrario, su empleo debe reservarse sólo a gestaciones de alto riesgo.Sujetos y métodos: Se estudiaron 904 gestantes no seleccionadas controladas desde el primer trimestre en la consulta de obstetricia de nuestra área sanitaria desde noviembre de 1993 hasta febrero de 1996. Los criterios de inclusión fueron una edad gestacional correctamente datada por ecografía y parto asistido en el Hospital Universitario de Getafe. Se excluyeron 32 casos cuyo parto se realizó en otros centros, siendo el grupo de estudio total de 872 gestantes. En 139 casos el estudio Doppler del índice cerobroplacentario se realizó con una semana o menos de antelación respecto al parto. Se registraron los resultados perinatales siguientes: peso en relación con edad gestacional; registro cardiotocográfico anteparto e intraparto; indicación de cesárea por sufrimiento fetal; pH de arteria umbilical < 7,20; apgar a los 5 min < 7 y necesidad de ingreso en neonatos o necesidad de reanimación profunda. Con estas variables se realizaron tablas de contingencia para el cálculo de la sensibilidad, especificidad, valor predictivo positivo y negativo tanto para el grupo de 139 gestantes anteparto como para el resto, con el fin de evaluar el margen de confianza que puede merecernos la prueba.Resultados y conclusiones: A la vista de nuestros resultados, mostrados en la tabla 2, no podemos considerar justificado el empleo del Doppler, en particular del índice cerebro-placentario, en el screening de malos resultados fetales en gestantes sin factores de riesgo (AU)

Assessment with transvaginal ultrasonography of endometrial thickness in women with postmenopausal bleeding.

OBJECTIVE: The aim of this study was to assess the use of transvaginal ultrasonography in measuring endometrial thickness in postmenopausal women with bleeding, thus to determine the least invasive treatment. STUDY DESIGN: We evaluated 168 women with postmenopausal bleeding by transvaginal ultrasonography and histological study of the endometrium. RESULTS: No cancerous or precancerous lesions were found when endometrial thickness was under 10 mm. The mean endometrial thickness in women with cancerous and precancerous lesions was 10.75 +/- 1.63 mm, while in non-pathological lesions it was 1.36 +/- 1.18 mm. CONCLUSIONS: To diagnose endometrial pathology, an endometrial thickness over 6 mm yields a sensitivity of 88.6%, a specificity of 90.6%, a positive predictive value of 92%, with 4.6% of false-positives and 4.6% of false-negatives (six small polyps and one irregular maturation). Although we are waiting for other prospective and multicentric studies, our present experience leads us to believe that Dilatation and Curettage (D&C) can be avoided in postmenopausal bleeding with endometrial thickness under or equal to 6 mm.

Analysis of compliance with oral contraception in Spain.

OBJECTIVE: The study was designed to analyze factors related to compliance in oral hormonal contraception in Spain. METHOD: A review study and a multicenter analysis of experience of compliance by 300 doctors, by means of a questionnaire and discussion about the determinants of contraceptive use. RESULTS: Compliance is a major problem in Spain, being influenced mainly by side-effects, the general perception of the method and personal factors. The different factors involved in non-compliance in Spain were analyzed, with regard to the perspective of the professionals. CONCLUSIONS: Strategies to improve compliance in Spain aim mainly at improving the general perception of the method and the accessibility of family planning centers. Factors associated with compliance are still not well known in our country. Better knowledge of the determinants of non-compliance in Spain is needed. For this purpose, another research group was formed to conduct a national study among women.

The safety and effectiveness of stepwise and low-dose administration of follicle stimulating hormone in WHO group II anovulatory infertile women: evidence from a large multicenter study in Spain.

PURPOSE: Our goal was to investigate the safety, effectiveness, and feasibility for the practicing physician of stepwise and low-dose administration of FSH in WHO group II anovulatory infertile women. METHODS: Infertile female patients (n = 234) suffering from WHO group II anovulation, and who failed to became pregnant with clomiphene citrate, were included in a multicenter, prospective, clinical study of treatment with a protocol of chronic low-dose and small incremental rises with urinary purified or highly purified FSH. Follicular development was monitored with ultrasonographic scans. RESULTS: The 234 patients received a total of 534 cycles of treatment, for a mean number of 2.3 treated cycles per patient. hCG was withheld in 65 (12.2%) cyles because of no response and in 28 (5.2%) cycles because of hyperresponse. Of the remaining 441 cycles, 419 (95%) were ovulatory, and in 198 (47.3%) of these cycles a single dominant follicle developed. There were 93 pregnancies (39.7% per patient), for a cycle fecundity rate of 17.4%. Cumulative conception rate after two treated cycles was 33.5%. There were 14 (15%) pairs of twins and 10 (10.8%) spontaneous miscarriages. The prevalence of complications was low with no cases of severe OHSS. Basal LH/FSH ratio was significantly higher in the pregnant group of patients than in nonpregnant women. CONCLUSIONS: Stepwise and chronic low-dose administration of FSH is a safe and effective method for treatment of WHO group II anovulatory infertility, mainly in those patients having high LH/FSH ratios.

Early ultrasound-guided transvaginal drainage of tubo-ovarian abscesses: a randomized study.

A prospective study of 40 women diagnosed as suffering from tubo-ovarian abscesses was carried out in order to compare the outcome after treating these abscesses with intensive antibiotic therapy alone or in association with early ultrasound-guided vaginal drainage. Patients were assigned to two groups, distributed on a random basis, with a clinical and ultrasound diagnosis of tubo-ovarian abscess of less than 10 cm maximal diameter. Both groups received an antimicrobial combination of clindamycin and gentamicin. In the study group, we performed, in addition, early transvaginal drainage of the abscess. Both short-term (48-72 h) and medium-term (4 weeks) responses to the treatment were evaluated. In the study group we observed a favorable short-term response in 90% of the cases, whereas this was 65% in the control group. In the medium-term follow up, one patient in the study group and three in the control group had an adnexal mass on transvaginal sonography.

Sonographic follow-up of a placenta left in situ after delivery of the fetus in an abdominal pregnancy.

A case of abdominal pregnancy was followed until 34 weeks' gestation, when rupture of the amniotic sac was noted. A live and anatomically normal female weighing 1400 g was delivered by laparotomy and the placenta was left in place. Color Doppler imaging and measurement of serum beta-human chorionic gonadotropin (beta-hCG) were successfully used to follow the placental involution after delivery. A progressive increase in the resistance index in the utero-ovarian and subplacental vessels was observed while beta-hCG disappeared 45 days after laparotomy. The mother and baby left hospital 20 days after delivery and are both doing well.