The utility of fetal heart rate deceleration's descending slope in searching for a non-National Institute of Child Health and Human Development parameter for the detection of fetal acidosis.

OBJECTIVE: To identify new parameters predicting fetal acidemia. METHODS: A retrospective case-control study in a cohort of deliveries from a tertiary referral hospital-based cohort deliveries in Zaragoza, Spain between 2018 and 2021 was performed. To predict fetal acidemia, the NICHD categorizations and non-NICHD parameters were analyzed in the electronic fetal monitoring (EFM). Those included total reperfusion time, total deceleration area and the slope of the descending limb of the fetal heart rate of the last deceleration curve. The accuracy of the parameters was evaluated using the specificity for (80%, 85%, 90%, 95%) sensitivity and the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 10 362 deliveries were reviewed, with 224 cases and 278 controls included in the study. The NICHD categorizations showed reasonable discriminatory ability (AUC = 0.727). The non-NICHD parameters measured during the 30-min fetal monitoring, total deceleration area (AUC = 0.807, 95% CI: 0.770, 0.845) and total reperfusion time (AUC = 0.750, 95% CI: 0.707, 0.792), exhibited higher discriminatory ability. The slope of the descending limb of the fetal heart rate of the last deceleration curve had the best AUC value (0.853, 95% CI: 0.816, 0.889). The combination of total deceleration area or total reperfusion time with the slope demonstrated high discriminatory ability (AUC = 0.908, 95% CI: 0.882, 0.933; specificities of 71.6% and 72.7% for a sensitivity of 90%). CONCLUSIONS: The slope of the descending limb of the fetal heart rate of the last deceleration curve is the strongest predictor of fetal acidosis, but its combination with the total reperfusion time shows better clinical utility.

Personalized Model to Predict Small for Gestational Age at Delivery Using Fetal Biometrics, Maternal Characteristics, and Pregnancy Biomarkers: A Retrospective Cohort Study of Births Assisted at a Spanish Hospital.

Small for gestational age (SGA) is defined as a newborn with a birth weight for gestational age < 10th percentile. Routine third-trimester ultrasound screening for fetal growth assessment has detection rates (DR) from 50 to 80%. For this reason, the addition of other markers is being studied, such as maternal characteristics, biochemical values, and biophysical models, in order to create personalized combinations that can increase the predictive capacity of the ultrasound. With this purpose, this retrospective cohort study of 12,912 cases aims to compare the potential value of third-trimester screening, based on estimated weight percentile (EPW), by universal ultrasound at 35−37 weeks of gestation, with a combined model integrating maternal characteristics and biochemical markers (PAPP-A and ß-HCG) for the prediction of SGA newborns. We observed that DR improved from 58.9% with the EW alone to 63.5% with the predictive model. Moreover, the AUC for the multivariate model was 0.882 (0.873−0.891 95% C.I.), showing a statistically significant difference with EPW alone (AUC 0.864 (95% C.I.: 0.854−0.873)). Although the improvements were modest, contingent detection models appear to be more sensitive than third-trimester ultrasound alone at predicting SGA at delivery.

Bakri Balloon: an easy, useful and effective option for the treatment of postpartum haemorrhage.

We report our postpartum haemorrhage protocol focussing on the use of Bakri Balloon, describing its placement and affixing method, effectiveness rates, risk factors that might contribute to Bakri Balloon's failure and complications associated. We designed a retrospective study including 147 cases where a Bakri Balloon was necessary to control the postpartum uterine bleeding to assess the efficacy and to determine which clinical, obstetric or delivery variables could be associated with successful treatment. Failed treatment was defined when surgery or any other technique was needed after a Bakri Balloon placement in order to control uterine bleeding. For statistical analysis, we developed a descriptive analysis and a univariate logistic regression study.IMPACT STATEMENTWhat is already known on this subject? Postpartum haemorrhage is one of the most severe situations in the immediate postpartum period entailing a major cause of maternal morbimortality if an accurate and quick intervention is not carried out.What do the results of this study add? The use of Bakri Balloon was effective in 94.6% of patients. No statistically significant differences were found in the success rates according to obstetric or delivery characteristics. No major complications occurred due to the placement of a Bakri Balloon. In the failure group, blood loss was significantly higher and all required blood products transfusion.What are the implications of these findings for clinical practice and/or further research? Bakri Balloon is an easy-to-use device that provides an effective therapeutic alternative to more aggressive techniques in postpartum haemorrhages when medical treatment fails. Obstetrics or delivery characteristics should not entail a contraindication in its use. A continuous training system based on an agreed protocol is recommended in order to guarantee the best care possible.

Uterocervical angle as a predictor of spontaneous preterm birth in twin pregnancies.

OBJECTIVE: To assess the ability of uterocervical angle (UCA) compared with cervical length (CL) to predict the risk of spontaneous preterm birth (sPTB) in twin pregnancies and its performance when it was included in a combined predictive model of clinical and ultrasonographic parameters. METHODS: We conducted a retrospective cohort study of twin pregnancies undergoing transvaginal ultrasound between 19+0-21+6 weeks to measure CL during routine second trimester scan from January 2015 through December 2016. Recorded ultrasound images of CL were reassessed to evaluate UCA. Medical and obstetric data were also collected for statistical analysis. A logistic regression model was created for predicting sPTB including UCA and other variables. RESULTS: A total of 177 women were included. The rates of sPTB rate below 28, 32 and 34 weeks of gestation were 4.5%, 6.8% and 12.4%, respectively. ROC curves showed a better area under the curve (AUC) for UCA at all gestational ages compared with CL (AUC for sPTB <28 weeks 0.840 (p = .005) vs 0.627 (p = .388); AUC for sPTB <32 weeks 0.706 (p = .022) vs 0.619 (p = .255); AUC for sPTB <34 weeks 0.674 (p = .008) vs 0.568 (p = .344). UCA >117 degrees was significantly associated with sPTB <28 weeks (p = .002; OR 15.3; CI 1.66-142.37; NPV, 99.2%), <32 weeks (OR 3.84; p = .031) and <34 weeks of gestation (OR 3.10; p = .016). Based on multivariate analyses, the best predictive model included uterocervical angle (p = .032), cervical length (p = .002) and maternal height (p = .001) (Nagelkerke R2 0.944). CONCLUSION: In our study, an UCA > 117 degrees allowed to identify those women with twin pregnancies at risk of sPTB and performed better than CL measurement. Our combined prediction model was able to adequately predict the risk of sPTB in the twin pregnancies of our research.

Total intrapartum fetal reperfusion time (fetal resilience) and neonatal acidemia.

OBJECTIVE: The main objective is to study the predictive capacity of intrapartum total fetal reperfusion (fetal resilience) by itself or in combination with other parameters as a predictor of neonatal acidemia. STUDY DESIGN: A retrospective case-control study was carried out at the Miguel Servet University Hospital (Zaragoza, Spain) on a cohort of 5694 pregnant women between June 2017 and October 2018. Maternal, perinatal, and cardiotocographic records were collected. Two reviewers blindly described the monitors with the American College of Obstetricians and Gynecologists (ACOG) categorizations and parameters and the non-ACOG parameters. Neonatal acidemia was defined as pH <7.10. The parameters analyzed to predict acidemia were evaluated using the sensitivity for specificity 90% value, and the area under the receiver operating characteristic curve. RESULTS: We recorded 192 infants with acidemia, corresponding to a global acidemia rate of 3.4%. Of these, 72 were excluded for lack of criteria, leaving 120 patients with arterial acidemia included in the study and 258 in the control group. The sensitivity (specificity 90%) of detection of acidemia was 42% for the ACOG III categorization (AUC, 0.524: 95% CI, 0.470-0.578), 24% for fetal reperfusion (AUC, 0.704: 95% CI, 0.649-0.759), 27% for total area of decelerations (AUC, 0.717: 95% CI, 0.664-0.771) and 50% for the multivariate model built from total reperfusion time (AUC, 0.826: 95% CI, 0.783-0.869). The total reperfusion time corresponding to a false negative rate of 10% is 23.75 min, with 28% of fetuses above this time. The AUC and sensitivity for a false negative rate of 10% are equivalent for deceleration area and time of reperfusion (p = .504). CONCLUSION: The total reperfusion time (fetal resilience) and total deceleration area are non-ACOG parameters with a good predictive ability for neonatal acidemia, higher than the ACOG III classification and without statistical differences between them. The discrimination ability of total reperfusion time can be improved using a multivariate model. As a cutoff for its use we suggest 23.75 min in 30 min corresponding to an acidemic classification rate of 90%. New parameters in combination with other maternal, obstetrics, or fetal variables, are required for the interpretation of fetal well-being.

Reduced Growth in Non-Small for Gestational Age Fetuses from 35 Weeks of Gestation to Birth and Perinatal Outcomes.

OBJECTIVE: This study aimed to assess reduced fetal growth between 35 weeks of gestation and birth in non-small for gestational age fetuses associated with adverse perinatal outcomes (APOs). MATERIAL AND METHOD: It is a retrospective cohort study of 9,164 non-small for gestational age fetuses estimated by ultrasound at 35 weeks. The difference between the birth weight percentile and the estimated percentile weight (EPW) at 35 weeks of gestation was calculated, and we studied the relationship of this difference with the appearance of APO. APOs were defined as cesarean or instrumental delivery rates for nonreassuring fetal status, 5-min Apgar score <7, arterial cord blood pH <7.10, and stillbirth. Fetuses that exhibited a percentile decrease between both moments were classified into 6 categories according to the amount of percentile decrease (0.01-10.0, 10.01-20.0, 20.01-30.0, 30.01-40.0, 40.01-50.0, and >50.0 percentiles). It was evaluated whether the appearance of APO was related to the amount of this percentile decrease. Relative risk (RR) was calculated in these subgroups to predict APOs in general and for each APO in particular. Receiver operating characteristic and area under curves (AUC) for the difference in the percentile was calculated, used as a continuous parameter in the entire study population. RESULTS: The median gestational age at delivery in uncomplicated pregnancies was 40.0 (39.1-40.7) and in pregnancies with APOs 40.3 (49.4-41.0), p < 0.001. The prevalence of APOs was greater in the group of fetuses with a decrease in percentile (7.6%) compared to those with increased percentile (4.8%) (p < 0.001). The RR was 1.63 (95% CI: 1.365-1.944, p < 0.001). Although the differences were significant in all decreased percentile groups, RRs were significantly higher when decreased growth values were >40 points (RR: 2.036, 95% CI: 1.581-2.623, p < 0.001). The estimated value of the AUC for percentile decrease was 0.58 (0.56-0.61, p < 0.001). CONCLUSION: Fetuses with a decrease in the EPW between the ultrasound at 35 weeks of gestation and birth have a higher risk of APOs, being double in fetuses with a decrease of >40 percentile points.

Uterocervical angle at 20 weeks: A promising predictor of spontaneous preterm birth in twin pregnancies.

OBJECTIVE: To compare the performance of uterocervical angle (UCA) and cervical length (CL) measurement at 20 weeks of pregnancy for prediction of spontaneous preterm birth (sPTB) in twin pregnancies. STUDY DESIGN: We conducted a retrospective cohort study of 424 twin pregnancies who delivered in our center from October 2014 to December 2018 and who underwent transvaginal ultrasound between 19+0-22+0 weeks to measure CL during routine second trimester scan. Recorded ultrasound images of CL were reassessed to evaluate UCA. Medical and obstetric data were also collected for statistical analysis. RESULTS: A total of 424 women were included. The rates of sPTB rate below 28, 32 and 34 weeks of gestation were 2.8 %, 5.4 % and 10.4 %, respectively. ROC curves showed a better area under the curve (AUC) for UCA at all gestational ages compared with CL (AUC for sPTB <28 weeks 0.902 (p < 0.001) vs 0.620 (p 0.175); AUC for sPTB <32 weeks 0.740 (p 0.001) vs 0.620 (p 0.058); AUC for sPTB <34 weeks 0.676 (p 0.001) vs 0.632 (p 0.047). UCA > 120 degrees was significantly associated with sPTB <28 weeks (p < 0.001; OR 39.17; CI 4.81-319.23; NPV, 99.65 %), <32 weeks (OR 4.23; p 0.002) and <34 weeks of gestation (OR 2.66; p 0.01). CONCLUSION: In our study, an UCA > 120 degrees allowed to identify those women with twin pregnancies at risk of sPTB and performed better than CL measurement.

Detection of Adverse Perinatal Outcomes at Term Delivery Using Ultrasound Estimated Percentile Weight at 35 Weeks of Gestation: Comparison of Five Fetal Growth Standards.

OBJECTIVE: To assess the predictive ability of the ultrasound estimated percentile weight (EPW) at 35 weeks of pregnancy to predict adverse perinatal outcomes (APOs) at term delivery according to 5 fetal growth standards, including population, population-customized, and international references. METHODS: This was a retrospective cohort study of 9,585 singleton pregnancies. Maternal clinical characteristics, fetal ultrasound data obtained at 35 weeks and pregnancy and perinatal outcomes were used to calculate EPWs to predict APOs according to: the customized and noncustomized (NC) Miguel Servet University Hospital (MSUH), the customized Figueras, the NC INTERGROWTH-21st, and the NC World Health Organization (WHO) international standards. APOs were defined as the occurrence of cesarean or instrumental delivery for nonreassuring fetal status, 5-min Apgar score < 7, arterial cord blood pH <7.10, or stillbirth. The predictive ability of EPW for APOs was analyzed using the area under the curve (AUC), and sensitivities were calculated for different false-positive rates (FPRs). RESULTS: For a 10% FPR, detection rates for total APOs ranged between 12.7% with the customized MSUH (AUC 0.52; 95% CI 0.50-0.55) and 14.4% with the NC MSUH standard (AUC 0.55; 95% CI 0.53-0.57) for EPW by ultrasound; and from 22.0% with the customized MSUH standard (AUC 0.60; 95% CI 0.58-0.63) to 27.8% with the NC WHO (AUC 0.65; 95% CI 0.63-0.68) for EPW at delivery. CONCLUSIONS: The predictive capacity of the EPW for APOS is limited and similar, by both ultrasound and at delivery, for the 5 growth standards, without significant differences between customized and NC standards.

Hemoperitoneo secundario a la ruptura espontánea de una variz uterina en una paciente con embarazo a término: reporte de un caso y revisión bibliográfica / Hemoperitoneum secondary to spontaneous rupture of a uterine varice in a patient with a full-term pregnancy: A case report and literature review

Resumen: ANTECEDENTES: La ruptura de una variz útero-ovárica durante el embarazo es un evento poco frecuente, pero con importantes implicaciones en la morbilidad y mortalidad materna y neonatal. Puede acontecer en cualquier momento del embarazo, aunque su frecuencia se incrementa en el tercer trimestre y durante el parto. CASO CLÍNICO: Paciente de 32 años, con 39 semanas de embarazo, en control prenatal, sin contratiempos, que acudió al servicio de Urgencias debido a un dolor abdominal generalizado e intenso, de dos horas de evolución. A la exploración física se encontraron: hipotensión, taquicardia y anemia moderada; hemoglobina de 8.9 g/dL y hematócrito de 35%. La evaluación fetal reportó: taquicardia y posterior bradicardia. Se decidió finalizar el embarazo por cesárea urgente, donde se objetivó hemoperitoneo de aproximadamente 1 L y sangrado activo procedente de la ruptura de un vaso en la parte posterior de la pared uterina que se suturó con puntos dobles. El desenlace materno y neonatal fue favorable. CONCLUSIONES: La rotura de las várices útero-ováricas puede originarse por hemoperitoneo masivo y resultar en consecuencias graves para la madre y el feto. La sospecha diagnóstica y la laparotomía de urgencia son decisivas para cohibir el sangrado y lograr un desenlace materno y fetal satisfactorios.

Abstract: BACKGROUND: The rupture of an utero-ovarian varicose vein during pregnancy is an infrequent event but it can have important implications for maternal and neonatal morbidity and mortality. It can occur at any time during pregnancy, although its frequency is increased in the third trimester and during labor. CLINICAL CASE: A single gestation of 39 weeks, with regular monitoring without incidents, who went to the emergency department for intense and generalized abdominal pain of two hours of evolution. The patient presented hypotension and tachycardia and moderate anemia with a hemoglobin of 8.9 g/dL and a hematocrit of 35%. Fetal monitoring showed fetal tachycardia with decreased variability and subsequent bradycardia. It was decided to end the pregnancy by an urgent caesarean section where a hemoperitoneum of approximately 1 liter was observed. As well, and active bleeding resulting from the rupture of a posterior uterine wall vein was noted and controlled with hemostatic sutures. The maternal and neonatal results were favorable. CONCLUSIONS: Spontaneous rupture of utero-ovarian varicose veins can be the cause of massive hemoperitoneum and can maternal and fetal serious consequences. A promptly suspected diagnosis and an urgent laparotomy are vital to restrain bleeding and achieve a good maternal and fetal result.

Early prenatal diagnosis of fetal abdominal cyst. Differential diagnosis of choledochal cyst / Diagnóstico prenatal temprano de quiste abdominal fetal. Diagnóstico diferencial de quiste del conducto colédoco

OBJECTIVE: To improve differential diagnosis of choledochal cyst, a rare pathology but whose prenatal diagnosis improves neonatal prognosis. CASE REPORT: Choledochal cysts are a rare congenital abnormality of biliary ducts that present as an anechoic mass in the right upper quadrant of the abdomen. In sonographic examination, a connection between the cyst and the common bile duct must be observed to confirm this diagnosis. It is more frequently diagnosed in females and in Asian countries. We describe a pregnant woman diagnosed of an intra-abdominal fetal cyst at 17-weeks of gestation. Ultrasound assessment showed a cystic mass separated from the stomach, moving other abdominal organs from its normal location and growing progressively. Postnatal study confirmed a choledochal cyst of 8-centimeters in diameter. Surgical treatment was recommended and post-surgical evolution was favourable. CONCLUSIONS: Prenatal diagnosis of choledochal cyst allowed to intensify controls to check the growth. Early surgical treatment improved neonatal prognosis and reduced the risk of sequelae

OBJETIVO: mejorar el diagnóstico diferencial del quiste de colédoco, una patología rara pero cuyo diagnóstico prenatal mejora el pronóstico neonatal. CASO CLÍNICO: los quistes de colédoco son una anormalidad congénita rara de los conductos biliares que se presentan como anecoicos, una masa en el cuadrante superior derecho del abdomen. En el examen ecográfico hay una conexión entre el quiste y se debe observar el conducto biliar común para confirmar este diagnóstico. Se diagnostica con mayor frecuencia en mujeres y en países asiáticos. Describimos a una mujer embarazada diagnosticada de un quiste fetal intrabdominal a las 17 semanas de gestación. La evaluación por ultrasonido mostró una masa quística separada del estómago, moviendo otros órganos abdominales desde su ubicación normal y creciendo progresivamente. El estudio posnatal confirmó un quiste de colédoco de 8 centímetros de diámetro. Se recomendó tratamiento quirúrgico y la evolución posquirúrgica fue favorable. CONCLUSIONES: el diagnóstico prenatal del quiste de colédoco permitió intensificar los controles para supervisar el crecimiento temprano. El tratamiento quirúrgico mejoró el pronóstico neonatal y redujo el riesgo de secuelas

Sexual assault in gynecology emergency departments: patient profile and associated factors / Agresiones sexuales en Urgencias de Ginecología: perfil de la paciente y factores relacionados

Objective: To study the characteristics of patients attended for sexual assault in the Emergency Department of Miguel Servet Maternity Hospital. Material and methods: Descriptive cross-sectional study of sexual assaults managed between October 2016 and April 2018 at Miguel Servet Maternity Hospital. Results: We attended 52 cases of sexual assault in 50 women. Patients were generally young women with an average age of 28 years (24% were minors), had been assaulted by penetration (57.7%) by a single assailant (80.8%), and had received no observable physical lesions on the genitals (86.5%) or other parts of the body (65.4%). Fifty percent of the assaults took place during the weekend, and 63.5% of the patients came to the emergency department within 24 hours of the incident. In 75% of cases, the women reported the assault to the police. In 48% of cases, the patient did not undergo serology testing after visiting the emergency department; of those who did, 81% did not undergo repeat testing 3 months later. Conclusions: We observed a lack of agreement between the overall rate of sexual assault and the number of patients who came to the Emergency Department for this reason. Patients were mostly young, with no secondary physical lesions, and had been assaulted by penetration by a single assailant. Patients' adherence to medical indications was poor. Appropriate coordination between health workers, the police, and forensic experts is essential for appropriate management of sexual assaults are

Objetivo: estudiar las características de las pacientes atendidas en el Servicio de Urgencias del Hospital Maternal Miguel Servet por agresión sexual. Material y métodos: estudio descriptivo de las agresiones sexuales entre octubre de 2016 hasta abril de 2018 en el Hospital Maternal Miguel Servet. Resultados: se atendieron 52 urgencias de 50 pacientes diferentes. El perfil de la paciente fue: mujer joven, con una edad media de 28 años (el 24% fueron menores de edad), mediante penetración (57,7%), por un agresor único (80,8%) y sin lesiones físicas objetivables en genitales (86,5%) ni otras partes del cuerpo (65,4%). El 50% de agresiones se produjeron durante el fin de semana y el 63,5% acudió al Servicio de Urgencias en las primeras 24 horas tras la agresión. El 75% denunció los hechos a la policía. El 48% de las pacientes no se realizó serologías tras la visita al Servicio de Urgencias, y de las que lo hicieron, el 81% no repitió la determinación a los 3 meses. Conclusiones: existe una discordancia entre la tasa de agresión sexual global y el número de mujeres que acudió a Urgencias por este motivo. Las pacientes fueron en su mayoría jóvenes, sin lesiones físicas secundarias y agredidas mediante penetración por un agresor único. Fue observada una baja adherencia a las indicaciones médicas por parte de las pacientes. Una adecuada coordinación entre profesionales sanitarios, policía y especialistas en Medicina Legal y Forense es fundamental para un correcto manejo de la situación

Is it too late to quit? Premature placental aging and smoking / ¿Demasiado tarde para dejarlo? Envejecimiento placentario prematuro y tabaquismo

Objetive: The aim of this study was to determine the relationship between being smoker, ex-smoker or passive smoker and the risk of developing a placental Grannum-grade- III and the interval of time necessary between stop smoking and becomepregnant. Material and methods: A retrospective case-control analysis was performed for women with singleton pregnancy that had ultrasound in the third trimester, establishing two groups according to the classification of placental aging purposed by Grannum: Grannum grade III and Grannum grade I-II. In both groups,maternal characteristics and perinatal outcomes were studied, and also the risk of placental premature aging in pregnant smokers, ex-smokers and passive smokers. Results: Being smokers (p < 0.01) or suffer from a hypertensive disorder (p = 0.01)is associated with a higher risk of premature placental aging. Smokers who quit during early pregnancy and passive smokers behave like smokers,withno significant differences between them. We have also studied ex-smokers and the period of time between quit and became pregnant and the findings show a decrease of six times risk of to develop a Grannum grade III placenta for women who retires from smoke more than a year beforepregnancy. Conclusions: The main causes of developing a premature aging of the placenta are being a smoker and developing a hypertensive disorder. Smoking cessation should occur before becoming pregnant, ideally more than 18 months earlier, in order to avoid placentalabnormalities

Objetivo: el objetivo de este estudio fue determinar la relación entre ser fumadora, exfumadora o fumadora pasiva y el riesgo de desarrollar una placenta Grannum grado III y el intervalo de tiempo necesario entre dejar de fumar y quedarembarazada. Material y métodos: se realizó un análisis retrospectivo de casos y controles para mujeres con embarazos únicos a las que se realizó una ecografía en el tercer trimestre, estableciendo dos grupos según la clasificación de envejecimiento placentario propuesta por Grannum: Grannum grado III y Grannum grado I-II. En ambos grupos, se estudiaron las características maternas y los resultados perinatales, así como el riesgo de envejecimiento prematuro de placenta en mujeres embarazadas fumadoras, exfumadoras y fumadoraspasivas. Resultados: ser fumador (p < 0,01) o padecer un trastorno hipertensivo (p = 0,01) se asocia con mayor riesgo de envejecimiento prematuro de placenta. Las fumadoras que abandonan el hábito al inicio del embarazo y las fumadoras pasivas se comportan como fumadoras, sin diferencias significativas entre ellas. Asimismo se ha estudiado a las exfumadoras y el período de tiempo entre dejar de fumar y quedar embarazada y los hallazgos muestran un riesgo seis veces menor de desarrollar una placenta de grado III de Grannum en mujeres que abandonaron el hábito más de doce meses antes de quedar gestantes. Conclusiones: las principales causas de desarrollar envejecimiento prematuro de placenta son ser fumadora y desarrollar un trastorno hipertensivo. El abandono del hábito tabáquico debe producirse antes de quedar embarazada, idealmente más de 18 meses antes, para evitar anormalidades placentarias

Uso exitoso del balón de Bakri en un caso de hemorragia postaborto de segundo trimestre y cesárea anterior / Successful use of Bakri balloon in a case of second trimester postabortion hemorrhage and prior caesarean section

Presentamos el caso de una secundigesta de 24 años (19+1 semanas de gestación) con cesárea anterior que presenta un aborto espontáneo y posterior hemorragia tras la evacuación uterina. Durante la exploración se constata una dehiscencia uterina. Ante el fracaso del tratamiento médico se coloca un balón de Bakri, consiguiendo detener el sangrado. Este caso pone de manifiesto la eficacia del taponamiento uterino en otras indicaciones diferentes a la hemorragia postparto. El manejo conservador con el balón de Bakri evitó una histerectomía, con la consiguiente preservación de la fertilidad y reducción de la morbi-mortalidad asociada

This article introduces the case of a 24-year-old gravida 2 (19+1 weeks of gestation) having had performed a previous cesarean, who presents a spontaneous abortion and a hemorrhage after uterine evacuation. Throughout the examination, it is remarkable a cesarean scar dehiscence and placenta accreta is suspected to be present. Having the starting therapies failed to work, a Bakri balloon is set managing to stop the bleeding. This case highlights the efficacy of uterine tamponade in situations different from postpartum hemorrhage. A hysterectomy was avoided with the Bakri balloon, resulting in the subsequent preservation of fertility and associated morbi-mortality reduction

Maternal morbidity after implementation of a postpartum hemorrhage protocol including use of misoprostol.

OBJECTIVE: To compare maternal morbidity before and after implementation of a postpartum hemorrhage (PPH) protocol that included misoprostol. METHODS: A retrospective analysis was performed using data from 34 631 deliveries recorded at a Spanish hospital between January 1, 2007, and December 31, 2014. The PPH protocol was implemented in 2009 and included use of misoprostol and the Bakri balloon. RESULTS: The pre-implementation and post-implementation groups comprised 9394 and 25 237 women, respectively. Women in the pre-implementation group tended to have lower hemoglobin levels than did those in the post-implementation group: 811 (8.6%) versus 1349 (5.3%) for levels less than 90 g/L, and 272 (2.9%) versus 497 (2.0%) for levels less than 80 g/L (both P<0.001). Implementation of the PPH protocol was also associated with a decrease in the frequency of postpartum hysterectomies owing to uterine atony (0.11 cases per 1000 deliveries vs 0.53 cases per 1000 deliveries for the pre-implementation group; P=0.063). Pregnancy length, maternal age, neonatal weight at delivery, multiple pregnancy, previous cesarean delivery, parity, operative vaginal delivery, induced labor, cesarean delivery, and not using the PPH protocol were found to predict postpartum anemia in the multivariate analysis (all P<0.001). CONCLUSION: Implementation of the PPH protocol decreased rates of postpartum anemia and postpartum hysterectomy owing to uterine atony.

Ecografía transvaginal en preinducción de parto: predicción de parto vaginal en gestantes con cesárea anterior / Transvaginal ultrasound in induction of labour: predicting vaginal delivery in patients with a prior cesarean section

Resumen Objetivo: Determinar qué mediciones de la ecografía transvaginal efectuada en el momento de la inducción actúan como predictoras de éxito de parto vaginal en embarazadas con cesárea anterior. La valoración cervical previa a la inducción del parto se lleva a cabo mediante tacto vaginal y estimación del índice de Bishop. Se trata de un diagnóstico subjetivo y sujeto a variabilidad interobservador, por lo que es necesario encontrar un sistema alternativo objetivo y con mínima variabilidad interindividual. Materiales y métodos: Estudio analítico, observacional y prospectivo al que se incluyeron pacientes con antecedente de cesárea, previamente inducidas con sonda de doble balón. Antes de la finalización del embarazo a todas las pacientes se les tomó una ecografía transvaginal para determinar: la longitud cervical, ángulo cervical posterior, grosor y dilatación cervical. Se obtuvieron los informes de la preinducción, parto y puerperio. Resultados: Se estudiaron 35 pacientes y la tasa de parto vaginal fue de 52%. Hubo diferencias significativas en la medición de la longitud cervical entre el grupo de parto vaginal y cesárea, en estas últimas fue más larga (26.8 vs 33.5 mm; p = 0.036). No se encontraron diferencias en el ángulo cervical posterior, dilatación o grosor cervical. Conclusiones: La longitud cervical se perfila como variable predictora de parto vaginal en la preinducción de embarazadas con cesárea anterior; existen diferencias significativas entre el grupo de embarazadas con parto vaginal luego de una cesárea previa (26.8 mm) y el grupo de pacientes con segunda cesárea (33.5 mm).

Abstract Objective: The aim of this study was to determine what circumstances during transvaginal ultrasound predict vaginal delivery in labour induction of patients with a previous caesarean section. Several studies have confirmed that the accuracy of the Bishop's score in predicting the outcome of induction of labour is poor, due to the subjectivity of digital examination, which is also influenced by interobserver variability. That is why it is necesary to find an alternative score which provides objectiveness and minimum interobserver differencies. Materials and methods: An observational prospective and analytic study was designed and 35 patients were included. All of them had a previous caesarean section and underwent cervical induction with a double balloon device. Transvaginal ultrasound was run in all the cases, regarding cervical length, posterior cervical angle, thickness and cervical dilation. Moreover, data from delivery and postpartum were recorded. Results: Vaginal delivery rate was 51.6%. Significative diferencies between cervical lenght in patients who delivered vaginally and those with a second cesarean section were found (26.8mm versus 33.5mm, p = 0.036). No differencies were found between posterior cervical angle measures, nor cervical dilation or cervical thickness. Conclusions: Cervical length is outlined as a predictive variable of vaginal delivery in preinduction of patients with a previous cesarean section. It has been demostrated that this measurement is significatively shorter in patients having a vaginal delivery (26.8mm) than in patients with a second cesaren section (33.5 mm).

Interrupcion de vena cava inferior: diagnostico prenatal de sus variantes / Inferior vena cava interruption: prenatal diagnosis of its variants

La anomalía más frecuente de la vena cava inferior es su interrupción. En estos casos, el drenaje al corazón se realizará por la vena ácigos y menos frecuentemente por la vena hemiácigos. Se considera un marcador ecográfico prenatal de isomerismos y/o cardiopatías por lo que su hallazgo obliga a descartarlos realizando una ecografía detallada del corazón y del situs fetal. Además, probablemente sea de las anomalías venosas que más implicaciones clínicas pueden tener en la edad adulta por su asociación a trombosis venosa profunda y es útil conocer la anatomía para posibles futuros procedimientos quirúrgicos o cateterismos cardiacos. Por lo tanto, es interesante realizar el diagnóstico prenatal, aunque se presente de forma aislada, siendo su diagnóstico ecográfico sencillo si somos sistemáticos en la práctica de la ecografía morfológica. El signo característico ecográfico es el de «doble vaso¼ o «doble burbuja¼ en un corte axial abdominal o torácico. Presentamos los esquemas ecográficos de diagnóstico de los dos tipos de drenaje principales de la interrupción de la vena cava inferior para poder realizar el correcto diagnóstico prenatal. Para ello tomamos de referencia dos casos clínicos que no presentan cardiopatías ni isomerismos asociados.

The most frequent anomaly of the inferior vena cava is its interruption. In these cases, drains into the heart by the azygos vein and less frequently by the hemiazygos vein. It is considered a prenatal ultrasound marker of isomerisms and/or heart disease, therefore, its finding requires to discard them by performing a detailed ultrasound of the fetal heart and situs. Probably it is one of the venous anomalies with more clinical implications in adulthood due to their association with deep venous thrombosis, and it is useful to know the anatomy for possible future surgical or cardiac catheterization procedures. Therefore, it is interesting to perform the prenatal diagnosis, although isolated. In this sense, the ultrasound diagnosis of the interruption is simple if we are systematic in the practice of morphological ultrasound. The characteristic ultrasound sign of the aforementioned interruption is the "double vessel" or "double bubble" in an axial abdominal or thoracic section. We present the ultrasound diagnosis diagrams of the two main types of drainage of the inferior vena cava interruption in order to perform the correct prenatal diagnosis. For these purposes, we refer two cases with no heart diseases or isomerisms associated.

Double-balloon catheter for induction of labour in women with a previous cesarean section, could it be the best choice?

INTRODUCTION: We analysed the efficacy and safety of double-balloon catheter for cervical ripening in women with a previous cesarean section and which were the most important variables associated with an increased risk of repeated cesarean delivery. MATERIALS AND METHODS: We designed an observational retrospective study of 418 women with unfavourable cervices (Bishop Score <5), a prior cesarean delivery, and induction of labour with a double-balloon catheter. Baseline maternal data and perinatal outcomes were recorded for a descriptive, bivariate, and multivariate analysis. A p value <0.05 was considered statistically significant. RESULTS: Most women improved their initial Bishop Score (89.5%) although only a 20.8% of them went into spontaneous active labour. Finally, 51.4% of the women achieved a vaginal delivery. Five cases of intrapartum uterine rupture (1.2%) occurred. After multivariate analysis, main risk factors for repeated cesarean section were dystocia in the previous pregnancy (OR 1.744; CI 95% 1.066-2.846), the absence of previous vaginal delivery (OR 2.590; CI 95% 1.066-6.290), suspected fetal macrosomia (OR 2.410; CI 95% 0.959-6.054), and duration of oxytocin induction period (OR 1.005; CI 95% 1.004-1.006). The area under the curve was 0.789 (p < 0.001). CONCLUSIONS: Double-balloon catheter seems to be safe and effective for cervical ripening in women with a previous cesarean delivery and unfavourable cervix. In our study, most women could have a vaginal delivery in spite of their risk factors for cesarean delivery. A multivariate model based on some clinical variables has moderate predictive value for intrapartum cesarean section.

Deceleration area and fetal acidemia.

AIMS: To compare the predictive ability for neonatal acidemia of individual components of intrapartum cardiotocography (CTG) described by National Institute of Child Health and Human Development (NICHD) system and deceleration area. DESIGN: Case-control study. SETTING: Spanish tertiary obstetrical hospital. POPULATION: CTG patterns of 102 acidemic fetus (umbilical arterial cord gas pH ≤7.10, base deficit (BD) > 8) and 102 nonacidemic controls (umbilical arterial cord gas pH > 7.10). METHODS: Two reviewers blind to clinical and outcome data analyzed the last thirty minutes before delivery of 204 fetal heart rate (FHR) tracings, extracting those features defined by NICHD and certain measures of FHR decelerations, including deceleration area, not considered by this system. OUTCOME MEASURES: The primary outcome was the predictive ability of NICHD features and non-NICHD deceleration measures for fetal acidemia. The secondary outcome was the impact of deceleration area in the last 30 min of labor on gasometry components (pH, BD and lactate). RESULTS: Minimal variability (area under the curve (AUC) 0.74), total number of late (AUC: 0.75) and prolonged decelerations (0.77) were the three NICHD features with the greatest predictive ability for fetal acidemia in the last thirty minutes of labor. Total deceleration area demonstrated the highest discrimination power (AUC: 0.83) of all the analyzed elements. For each cm2 the area increases in the last 30 min of labor, pH decreases 0.08 units, BD increases 0.272 mEq/L and lactate 0.183 mEq/L. CONCLUSIONS: Total deceleration area showed the greatest predictive ability for fetal acidemia and its measure could help to estimate intrapartum fetal acid-base status.

Atypical decelerations: do they matter?

OBJECTIVE: To estimate the association between atypical variable decelerations and neonatal acidemia. METHOD: We conducted a one-year case-control study comparing the last thirty minutes before delivery of fetal heart rate tracings of 102 acidemic neonates (umbilical arterial cord gas pH ≤ 7.10) with 100 non-acidemic controls (umbilical arterial cord gas pH > 7.10). Incidence of atypical features and total number of decelerations, number of atypical decelerations, number of slow return decelerations and number of decelerations with loss of moderate variability during deceleration were extracted. We estimated the association between atypical features, neonatal acidemia and neonatal morbidity. RESULTS: Acidemic neonates showed a larger number of atypical decelerations (4 [0-12] vs. 3 [0-10]), "slow return" decelerations (4 [0-11] vs. 1 [0-10]) and decelerations with non-moderate variability (0[0-12] vs. 0 [0-6]) compared to non-acidemic controls. "Slow return" was significantly associated with an increased risk of acidemia at birth (OR 4.46; CI 95%: 2.18 - 9.15) "Slow return" was the most discriminating feature between groups with an AUC: 0.745. CONCLUSION: Certain atypical features, as "slow return" and loss of moderate variability within decelerations are associated with neonatal acidemia. "Slow return" could help in the gradation of acidemia risk levels, as an indicator of gravity.

pH, base deficit or lactate. Which is better for predicting neonatal morbidity?

OBJECTIVE: To determine which parameter of the umbilical arterial cord gas analysis, pH, base deficit (BD) or lactate has a bigger predictive ability for neonatal morbidity at term. METHOD: We conducted a four-year retrospective cohort study including all non-anomalous, singleton, vertex, term births with neonatal acidemia (umbilical arterial cord gas pH ≤ 7.1). The primary outcomes were a composite neurological morbidity and a composite systemic morbidity. The predictive ability of lactate, BD and pH was compared using receiver operator characteristic (ROC) curves. Optimal cutoff values of lactate, BD and pH were estimated based on their maximal Youden Index. RESULTS: We identified 466 acidemic neonates who had paired and validated cord blood gas data. The ROC curve analysis revealed that pH, BD and lactate had a similar predictive ability for neurological (AUC: 0.81; 0.78; 0.83, respectively) and systemic neonatal morbidity (AUC: 0.77; 0.82; 0.82, respectively). The combination of pH ≤ 7.0 and lactate ≥ 7.0 mmol/L presented similar validity to that of pH ≤ 7.0 and BD ≥ 12 mmol/L, but both were comparable to pH alone. CONCLUSIONS: pH, BD and lactate have similar predictive ability for adverse neonatal outcomes among acidemic neonates. Umbilical arterial lactate could replace BD as a measure of the metabolic component in acidemic neonates. However, neither BD nor lactate demonstrated in this study to improve the predictive ability of pH alone for short-term neonatal outcomes.