Hemoglobina glucosilada en el diagnóstico de diabetes gestacional en mujeres mexicanas durante el tercer trimestre / Glycosylated hemoglobin in the diagnosis of gestational diabetes in Mexican women during the third trimester

Resumen El objetivo del trabajo fue analizar los valores de hemoglobina glucosilada en el tercer trimestre de embarazo como predictores alternativos de la diabetes gestacional en pacientes del Noreste de México. Se trata de un estudio retrospectivo de casos y controles a partir de 121 expedientes de pacientes embarazadas, divididos en dos grupos, pacientes con diabetes gestacional (casos) y gestantes con valores glucémicos normales (controles). Se analizaron los factores de riesgo asociados a la diabetes gestacional y se obtuvo un punto de corte para la hemoglobina glucosilada. Se encontró que la obesidad materna, la edad y el antecedente del padecimiento fueron asociados significativamente con la diabetes gestacional. Valores de hemoglobina glucosilada ≥5% incrementaron el riesgo de padecer diabetes mellitus gestacional 4 veces y, aunado a un factor de riesgo, la probabilidad se incrementó 7 veces. Se concluye que los valores de hemoglobina glucosilada en el tercer trimestre de embarazo podrían emplearse como prueba diagnóstica de la diabetes gestacional en pacientes del Noreste de México. Sin embargo, aunque las diferencias encontradas fueron estadísticamente significativas, los resultados se deben interpretar con cautela y requieren su confirmación con estudios que incluyan una muestra mayor.

Abstract The objective of this study was to analise glycosylated hemoglobin values in the third trimester of pregnancy as an alternative predictor of gestational diabetes in North East Mexican cohort patients. This is a retrospective case-control study based on 121 records of pregnant patients, divided into two groups, patients with gestational diabetes (cases) and pregnant women with normal glycemic values (control). The risk factors associated with gestational diabetes were analised and a cut-off point for glycosylated hemogestaglobin was obtained. It was found that maternal obesity, age and a history of the condition were significantly associated with gestational diabetes. Values of glycosylated hemoglobin ≥5% increased the risk of suffering from gestational diabetes 4 times, and coupled with a risk factor, the risk increased 7 times. It is concluded that glycosylated hemoglobin values in the third trimester of pregnancy could be used as a diagnostic test for gestational diabetes in patients from the North East of Mexico. Although the differences found were statistically significant, our results must be interpreted with caution and require confirmation by studies with a larger sample.

Resumo O objetivo deste estudo foi analisar os valores da hemoglobina glicada no terceiro trimestre de gestação como preditores alternativos do diabetes gestacional em pacientes na região nordeste do México. Trata-se de um estudo retrospectivo de casos e controles utilizando 121 prontuários de gestantes divididas em dois grupos; pacientes com diabetes gestacional (casos) e gestantes com valores de glicemia normais (controles). Foram analisados os fatores de risco associados a diabetes gestacional obtendo-se um ponto de corte para a hemoglobina glicada. Descobriu-se que a obesidade materna, idade e antecedentes da doença foram associados significativamente ao diabetes gestacional. Valores da hemoglobina glicada ≥ 5% aumentaram o risco de padecer diabetes mellitus gestacional 4 vezes, e juntamente a um fator de risco, a probabilidade aumentou 7 vezes. Conclui-se que os valores da hemoglobina glicada no terceiro trimestre de gestação poderiam ser usados como teste diagnóstico do diabetes gestacional em pacientes da região nordeste do México. Embora as diferenças encontradas tenham sido estatisticamente significativas, os resultados devem ser interpretados com cautela e requerem confirmação através de estudos que incluam uma amostra maior.

Evaluación del control de infecciones poscesárea mediante la implementación de un programa preventivo / Evaluation of post-cesarean infection control through the implementation of a preventive program

Resumen OBJETIVO: Estimar la incidencia de infecciones en pacientes que finalizaron el embarazo por cesárea e identificar los factores de riesgo asociados antes y después de la implementación de un programa preventivo. MATERIALES Y MÉTODOS: Estudio cuantitativo, no experimental, de cohorte prospectiva. Se seleccionaron mujeres que finalizaron el embrazo por cesárea en el Hospital Universitario de Saltillo, entre octubre de 2015 a octubre de 2016. Se practicaron tres medidas preventivas para disminuir el riesgo de infecciones poscesárea: administración profiláctica de antibiótico, lavado vaginal preoperatorio con yodopovidona y retiro del catéter urinario al término de la cirugía. Al séptimo día del alta hospitalaria se citó a las pacientes para evaluar la posibilidad de infección de la herida quirúrgica, endometritis o sepsis. Para el análisis estadístico se utilizó el programa SPSS versión 21. Se consideró estadísticamente significativo el valor de p < 0.05. RESULTADOS: Se registraron 103 pacientes. La incidencia de infección de la herida quirúrgica, fue de 1.9% y de dehiscencia 1%; no se registraron casos de endometritis. Al comparar la incidencia de infecciones poscesárea, previo al protocolo (año 2015) y posterior a la implementación de las medidas preventivas, se demostró la disminución de infección de la herida quirúrgica (2.4 a 1.9%) y de endometritis (1.9 a 0%). CONCLUSIÓN: La implementación del programa preventivo de infecciones poscesárea, basado en la administración profiláctica de antibiótico, lavado vaginal con yodopovidona y retiro de la sonda urinaria temprana, disminuye el índice de infecciones puerperales poscesárea.

Abstract OBJECTIVE: An estimates the incidence and risk factors associated with infections in caesarean sections before and after the implementation of the preventive program. MATERIALS AND METHODS: Non-experimental quantitative study of a prospective cohort type. The study population were women they finished the pregnancy by caesarean section during the period of october 2015 to october 2016. Three preventive measures were performed to reduce the risk of postoperative infections: prophylactic antibiotic, preoperative vaginal lavage with iodopovidone and urinary catheter removal at the end of the surgery a follow-up was performed at 7 days identifying patients with infected wound, endometritis and sepsis. The results will be analyzed using the SSPS software versión 21. RESULTS: A total of 103 women were incorporated into the protocol. The incidence of postoperative infections was 1.9% for wound infections, 1.0% dehiscence and 0% endometritis. A comparative analysis was performed of incidences of surgical site infection, endometritis, sepsis and surgical wound dehiscence, prior to the preventive protocol (year 2015) and after the implementation of preventive measures, and we observed a reduction of endometritis from 1.9% to 0% and of the surgical wound infection from 2.4% to 1.9%. CONCLUSION: The preventive program integrated by the use of prophylactic antibiotic, preoperative vaginal lavage with iodopovidone and urinary catheter removal at the end of surgery, reduced the rate of post-cesarean puerperal infections.

Ácido tranexámico: una alternativa terapéutica en pacientes con síndrome de HELLP / Tranexamic acid: A therapeutic alternative in patients with HELLP syndrome

Resumen OBJETIVO Evaluar si la prescripción de ácido tranexámico a pacientes con síndrome de HELLP mejora su curso clínico en forma general. MATERIALES Y MÉTODOS Estudio retrospectivo, analítico y comparativo al que se incluyeron dos grupos de pacientes con diagnóstico de síndrome de HELLP atendidas entre enero de 2015 y diciembre de 2016 en el servicio de Ginecología y Obstetricia del Hospital Universitario de Saltillo. A un grupo se le indicó ácido tranexámico y al control ningún medicamento. RESULTADOS Se incluyeron 18 pacientes, 9 en cada grupo. Parámetros de laboratorio: plaquetas mayores a 105 vs menores a 105 en el grupo control. La deshidrogenasa láctica (DHL) tuvo un decremento de 58 vs 16% en las pacientes tratadas en las primeras 48 horas. La aspartato aminotransferasa (TGO) mejoró 56 vs 43% en el grupo control y la alanina aminotransferasa (TGP) mejoró 31 vs 20% en el grupo control, ambas en las primeras 24 horas. La cuantificación de proteínas en orina en 24 horas reportó 2867 mg versus 3378 mg en el grupo control. La hemoglobina permaneció siempre en cifras superiores a 11 vs 9.92 g/dL del grupo control. Los días de estancia en la unidad de cuidados intensivos fue de 3 vs 4.16 del grupo control. CONCLUSIONES Hacen falta más estudios con asignación al azar, con una muestra más amplia, para valorar las ventajas y efectos del ácido tranexámico en pacientes con síndrome de HELLP. La prescripción de este medicamento representa una alternativa en el tratamiento del síndrome de HELLP, que proporciona un beneficio clínico.

Abstract OBJECTIVE To stablish if the use of tranexamic acid (TXA) in patients with HELLP syndrome improves the clinic curse in general terms. MATERIALS AND METHODS Analytic, comparative and retrospective study where two groups of patients are included, which assisted to the obstetrics and gynecology service in the Hospital Universitario de Saltillo, where the diagnosis of HELLP syndrome was made. Tranexamic acid was given to one of the groups versus the control group without the drug. RESULTS 18 patients were included, 9 in each group. The following was observed respect to the laboratory parameters: platelets greater than 105 vs smaller than 105 in the control group. The lactate dehydrogenase (DHL) had a decrease of 58 vs 16% in the patients without tranexamic acid in the first 48 hours. The aspartate aminotransferase (AST) improved 56 vs 43% in the control group, and the alanine aminotransferase (ALT) improved 31 vs 20% in the control group, both in the first 24 hours. The report of protein quantification in 24 hours was 2867 vs 3378 mg in the control group. The hemoglobin figures remained greater than 11vs 9.92 g/dL of the control group. The days of stay in the intensive care unit (UCI) were 3 vs 4.16 of the control group. CONCLUSIONS: Randomized studies are required with an extended sample, to value the benefits and effects of the tranexamic acid, in this kind of patients. According to the collected data the use of tranexamic acid represents an alternative in the treatment of HELLP syndrome, which provides a clinic benefit.

Miomectomía por laparoscopia con extracción por colpotomía posterior: reporte de tres casos / Laparoscopic myomectomy with extraction by posterior colpotomy: Report of three cases

Resumen ANTECEDENTES La extracción de un mioma, posterior a la resección laparoscópica, puede ser: directa, mediante colpotomía posterior, minilaparotomía, morcelación intraabdominal estándar o eléctrica. La mayor parte de estas opciones suele requerir la colocación de un trocar de 10-12 mm o la ampliación de la incisión en la piel y fascia para extraer el tejido; esto implica desventajas estéticas y clínicas, como el riesgo de hernias incisionales. CASOS CLÍNICOS Se comunican tres casos de pacientes con diagnóstico de miomatosis de grandes elementos (7 cm el menor y 15 cm el mayor) en los que posterior a la miomectomía por laparoscopia se extrae la pieza quirúrgica íntegra mediante colpotomía posterior, con evolución posquirúrgica favorable y sin síntomas concomitantes. CONCLUSIÓN La extracción transvaginal mediante colpotomía posterior es una alternativa segura y efectiva para retirar piezas quirúrgicas porque la elasticidad de la vagina permite extraer de forma segura piezas grandes, y evitar así el uso del morcelador y sus posibles riesgos. Además, se evita ampliar las incisiones abdominales, lo que implica menor dolor posoperatorio, recuperación más rápida y mejores resultados cosméticos. La vía vaginal es segura, con mínimo riesgo de complicaciones y con mejores resultados posquirúrgicos comparada con el resto de las opciones de cirugía laparoscópica.

Abstract BACKGROUND The extraction of the myoma after laparoscopic resection can be done by: direct extraction, standard intra-abdominal morcellation, electric morcellation, extraction by posterior colpotomy or by minilaparotomy. Most of these options generally require placement of a 10-12 mm trocar and / or enlargement of the skin incision and fascia for tissue removal; In addition to the aesthetic disadvantages, it represents clinical implications such as the risk of incisional hernias. CLINICAL CASES We present 3 cases of patients with diagnosis of myomatosis of large elements, the smallest being 7 cm and the largest being 15 cm, in greater diameter, after the laparoscopic myomectomy the extraction of the complete surgical piece is performed through posterior colpotomy, presenting a favorable postoperative recovery, without associated symptoms. CONCLUSIONS The transvaginal extraction through posterior colpotomy represents a safe and effective alternative for the extraction of surgical pieces, the elasticity of the vagina allows the safe extraction of large pieces, avoiding the use of the morcellator and its possible risks; It also avoids expanding the abdominal incisions, associating to less postoperative pain, faster recovery and better cosmetic results. The vaginal route is a safe option with minimal risk of complications, and with better postsurgical results compared to the other options in laparoscopic surgery.

Acretismo placentario con abordaje predictivo y preventivo de hemorragia obstétrica / Placental accreta with predictive and preventive approach to obstetric hemorrhage

Resumen OBJETIVO Exponer el tratamiento médico y quirúrgico indicado en el Hospital Universitario de Saltillo a pacientes con acretismo placentario. MATERIALES Y MÉTODOS Estudio retrospectivo, transversal y analítico efectuado en pacientes tratadas con enfoque predictivo y preventivo de hemorragia obstétrica atendidas entre los años 2015-2017. Se incluyeron todas las pacientes operadas con la técnica descrita. Se analizan las variables maternas y fetales posquirúrgicas que aportan información para evaluar los resultados obstétricos mediante medias y porcentajes. RESULTADOS Se incluyeron 10 pacientes con media de edad de 31 años, 70% con antecedente de cesárea y 50% de legrado. El sangrado transquirúrgico tuvo una media de 1067 cc, con un tiempo quirúrgico promedio de 3.6 h, la media de transfusión de concentrados eritrocitarios fue de 2.3, el Apgar de los recién nacidos se reportó en ≥ 7, no se requirió reinternvención y no se encontraron casos de muerte materna. CONCLUSIONES Si bien el tamaño de la muestra es pequeño continuaremos recabando datos de lo sucedido con otras pacientes. Es indispensable estudiar más casos para tener evidencias de nuestra propuesta de tratamiento con pruebas aún más sólidas. También hace falta un seguimiento prolongado a las pacientes para conocer si hay o no complicaciones tardías.

Abstract OBJECTIVE Expose the medical and surgical treatment indicated in the University Hospital of Saltillo to patients with placental accreta. MATERIAL AND METHODS A retrospective, cross-sectional and analytical study, patients treated with a predictive and preventive approach of obstetric hemorrhage were studied in Hospital Universitario de Saltillo during 2015-2017. RESULTS 10 patients were included, with a mean age of 31 years, 70% had a history of cesarean section and 50% curettage. Transurgical bleeding averaged 1067 cc, an average surgical time of 3.6 hrs, average of transfusion of erythrocyte concentrates was 2.3, Apgar of newborns was reported ≥7, no surgical reoperation was required, no cases were found of maternal death. CONCLUSIONS Although the size of the sample is small, we will continue to collect data on what happened with other patients. It is essential to study more cases to have evidence of our treatment proposal with even more solid evidence. There is also a need for prolonged follow-up of patients to determine whether there are late complications or not.

[Cervical ectopic pregnancy of 16 weeks gestation. Block with preventive hysterectomy surgical technique for massive pelvic hemorrhage. Case report]. / Embarazo ectópico cervical de 16 semanas de gestación. Histerectomía en bloque con técnica quirúrgica preventiva para hemorragia pélvica masiva. Reporte de un caso.

Obstetric hemorrhage remains the leading cause of maternal death, we continue to insist on preventive management of patients at high risk of massive pelvic bleeding, uterine dearterialization selective, significantly reduces the morbidity and mortality of the patient, on this ocassion we report the case of a 33-year-old with a diagnosis of cervical ectopic pregnancy of 13 gestational weeks, treated with selective dearterialization of hypogastric arteries with excellent results, without postoperative complications.

[Hypogastric arteries ligation: an experience in gynecological and obstetric patients at Hospital Universitario de Saltillo]. / Experiencia en la ligadura de arterias hipogástricas a pacientes ginecológicas y obstétricas del Hospital Universitario de Saltillo.

BACKGROUND: Pelvic hemorrhage is a potential complication that occurs performing an obstetric or gynecological surgery, it is essential to know the distribution of pelvic vascular supplement, and implement preventive measures, can significantly reduce morbidity and mortality. OBJECTIVE: To describe the experience of hypogastric artery ligation, as a preventive and therapeutic measure of pelvic hemorrhage, this will give us new prospective lines for future investigation. METHODS: Retrospective observational study, in which all patient who were performed a surgical procedure and report hypogastric artery ligation at the Saltillo University Hospital, from January 2008 to July 2014 was studied. RESULTS: 41 patients were obtained with hypogastric artery ligation, 28 gynecological and 13 obstetric patients. Among gynecological indications, cancer surgery represents 67.85%, benign lesions 25% and pelvic abscess 7.12%. Obstetric indications were uterine hypotonia with 46%, placenta previa with 23.07% and uterine fibroids, broad ligament hematoma and abruptio placenta a total of 30.7%. There was one complication in relation with technique that was a laceration of internal iliac artery without any consequence linked to this. And uterine preserving of 62% was observed in obstetric patients. CONCLUSIONS: This technique is a feasible and safe for preventive and therapeutic management of pelvic surgery, with a low incidence of complications 3.5% in gynecological patients and 0% in obstetric, with a mortality of 0%.

[Anterior pelvic exenteration. Report of a case]. / Exenteración pelvica anterior. Reporte de un caso.

Anterior pelvic exenteration is the last opportunity to control disease in a patient with cervical cancer in an advanced stage with a vesico-vaginal fistula, or in a patient with persistence of the disease and the need of improving the quality of life. In this case we present the cause of a 62 year old patient, with IVa stage cervical cancer, with bladder spread and a vesico-vaginal fistula treated with an anterior pelvic exenteration with Bricker technique and adjuvant treatment with radiotherapy.

[Histologic chorioamnionitis prevalence in patients with premature rupture membranes]. / Frecuencia de corioamnionitis histológica en pacientes con ruptura prematura de membranas.

OBJECTIVE: Search Histologic Chorioamnionitis frequency in patients in week 28 (+/-) and pregnancy with premature rupture of membranes. PATIENTS AND METHOD: Retrospective and observational study in which we studied all patients who came between June 28, 2011 and November 15, 2011 to receive obstetric care in the service of Tocochirurgical of the University Hospital of Saltillo, with greater than or equal 28 weeks of pregnancy. RESULTS: 598 patients were studied, and the frequency of premature rupture of membranes with histologic chorioamnionitis at term patients was, respectively, 1.7 and 5.3% in preterm labor. In the total sample frequency of histologic chorioamnionitis was 0.6% (4 patients) and, of these, 25% were term and 75% with preterm rupture. In patients with premature rupture of membranes the clinical chorioamnionitis was 0% valued by the criteria of Gibbs. CONCLUSIONS: The premature rupture of membranes is a risk factor important for histological chorioamnionitis. To decrease risk factors and possible complications, an established protocol must be taken.