Imaging in fetal genital anomalies.

Genital anomalies are a heterogeneous group of congenital pathologies that have become increasingly relevant since the Chicago Consensus of 2005. Their postnatal diagnosis has developed significantly in the last two decades, while prenatal diagnosis seems to be underdeveloped, with few protocols available, fragmented scientific literature, and low diagnostic rates. This review aims to examine the current status of this subspecialty from the perspective of prenatal imaging. Indications for the evaluation of fetal genitalia can be divided into medical and non-medical reasons. Medical reasons include sex-linked disorders, detection of other anomalies, relevant family history, or multiple pregnancy. Non-medical reasons include parental request for sex disclosure. Disclosure of fetal sex may be associated with ethical, legal, and medical issues. The main imaging technology used is 2D ultrasound, although there are other complementary techniques such as 3D, MRI, or Color Doppler. Regarding working methodology, several authors have drawn attention to the lack of standardized protocols and guidelines. Most guidelines tend to limit their recommendations to study indications and ethical issues. Technical proposals, measurements, or working methods have not yet been standardized. Fetal sex determination is usually divided into early and late gestation. Early gestation is based on the sagittal sign. Late gestation is based on direct visualization. There are several measurements to describe male and female genitalia, such as penile length, bilabial diameter, or scrotal diameter. Prenatal diagnosis of genital pathologies presents some particularities such as the wide spectrum of phenotypes, the high frequency of associated deformities, or the time of diagnosis. Some of the most frequent pathologies are ambiguous genitalia, fetal sex discordance, hypospadias, micropenis, clitoromegaly, ovarian cysts, hydro(metro)colpos, and cloacal anomalies. Higher-quality studies and direction from scientific societies through the implementation of clinical guidelines are needed.

Supresión de la visita de tercer trimestre en embarazo de bajo riesgo en la pandemia de SARS-CoV-2 / Third trimester suppression in low-risk pregnancy in the SARS-CoV-2 pandemic

Resumen Objetivo: La pandemia de SARS-CoV-2 ha obligado a una reorganización de las visitas presenciales, y por ese motivo se han minimizado hasta el punto de reconsiderar la realización de la visita del tercer trimestre. Nuestro centro suprimió dicha visita obstétrica y obtuvo datos propios para comparar los resultados perinatales logrados con dicho manejo. Método: Se realizó un estudio de cohortes retrospectivo, en marzo de 2020, con una cohorte con visita presencial única en la semana 40 de gestación (122 gestantes) frente a una cohorte con seguimiento convencional con visita presencial en la semana 36 de gestación (162 gestantes). Se evaluaron la restricción del crecimiento fetal, la edad gestacional al nacimiento, el peso neonatal y las tasas de inducciones, partos eutócicos y cesáreas urgentes en trabajo de parto. Resultados: Se encontraron diferencias leves en la tasa de nuliparidad (p < 0,04), sin hallarlas en el resto de las variables maternas. No hubo diferencias entre las dos cohortes en los resultados neonatales. Conclusiones: No hay diferencias entre los resultados materno-fetales obtenidos en gestantes con seguimiento gestacional con restricción de la visita del tercer trimestre respecto del seguimiento tradicional, excepto en el diagnóstico de las alteraciones de la estática fetal al término de la gestación.

Abstract Objective: The SARS-CoV-2 pandemic has forced a reorganization of face-to-face visits, for this reason they have been minimized to the point of reconsidering the completion of the third trimester visit. Our center eliminated the performance of this obstetric visit and obtained its own data to compare the perinatal results obtained with such management. Method: A retrospective cohort study was carried out in March 2020, with a cohort with a single face-to-face visit at 40th week of gestation (122 pregnant women), versus a cohort with conventional follow-up with face-to-face visit at 36th week of gestation (162 pregnant women). The following were evaluated fetal growth restriction, gestational age at birth, neonatal weight, rate of inductions, of eutocic deliveries, and of urgent cesarean sections in labor. Results: Slight differences were found in the nulliparity rate (p < 0.04), without finding them in the rest of the maternal variables. There were no differences between the two cohorts in neonatal outcomes. Conclusions: There were no differences between the maternal-fetal results obtained in pregnant women with gestational follow-up with restriction of the third trimester visit compared to traditional follow-up, except in the diagnosis of alterations in fetal statics at the end of pregnancy.

Stretched penile length at birth: a systematic review.

BACKGROUND: Micropenis is an endocrinological condition that is habitually observed at birth. Diagnosis is made by measuring the stretched penile length, a method established 80 years ago. Discrepancies in the normative data from recent studies raise the need for a current revision of the methodology. OBJECTIVES: The aims of this systematic review were to compare the different normative data of SPL at birth, to examine the methodological aspects of the technique and to evaluate the independent variables that may be involved. METHODS: Searches were performed using MEDLINE, EMBASE, Scielo, the Cochrane Library and Web of Science. A combination of the relevant medical terms, keywords and word variants for "stretched penile length", "penile length", "penile size", "newborn" and "birth" were used. Eligibility criteria included normative studies that used the stretched penile length (SPL) measurement on a population of healthy, full-term newborns during the first month of life. The outcomes studied included characteristics of the studies, methodological aspects and independent variables. RESULTS: We identified 49 studies comprising 21,399 children. Significant discrepancies are observed between the different studies. Methodological aspects seem to be consistent and similar. The main independent variables appear to be ethnic group and gestational age. Main limitations were the absence of studies of entire world regions such as Europe or South America, and the heterogeneity of the ethnic background that complicates the analysis. CONCLUSIONS: It seems advisable to suggest the creation of customized reference charts for each specific population instead of resorting to the classic cut-off points.

Open-legs axial plane: A standardized methodology and reference values for fetal genital biometry in mid-trimester ultrasound.

BACKGROUND: Evaluation of the external genitalia is an important part of prenatal ultrasound. However, there is no standardized methodology that includes biometric measurements and normative data to be able to carry out this evaluation. OBJECTIVE: To develop a standardized methodology for fetal genital biometry and obtain reference values for use in mid-trimester ultrasound. STUDY DESIGN: A prospective cross-sectional study was used. 273 male and 253 female fetuses of normal, singleton pregnancies at 18 to 22 weeks were included. Measurements of fetal penis length, penile width and transverse scrotal diameter in male fetuses and bilabial diameter in female fetuses were performed by transabdominal ultrasound. Reference values were calculated for each gestational week. RESULTS: Realization of the open-legs axial plane is described as a working methodology. Normative data for penile length, penile width, transverse scrotal diameter and bilabial diameter are defined, including mean, minimum and maximum values, range, and 5th, 10th, 90th and 95th percentiles. CONCLUSIONS: We have provided a standardized methodology using the open-legs axial plane, which would integrate the main measurements. In addition with the normative data constructed from their use, we hope to be able to improve the external genitalia assessment and diagnosis of genital anomalies in mid-trimester ultrasound.

Third trimester ultrasound. A long-standing debate.

Third trimester ultrasound has long been in obstetrics a topic of debate. This issue is framed in a historical debate on the effectiveness of routine obstetrical ultrasound and two opposing trends originated in America and Europe, respectively. Primary function of this ultrasound has been to detect fetal growth restriction, but no study has shown evidence of improving perinatal outcomes. Other secondary functions are detection of fetal abnormalities or evaluation of fetal presentation, and they have also shown no evidence. Despite the continuous appearance of works in this regard, health policies of both american and european trends have not been modified. Future seems to show a prolongation of the stalemate. Those health systems with a universal third trimester policy should propose an optimization of the test, in order to improve the benefits and obtain data for future studies that could resolve this longstanding debate.

Desgarro perineal con mucosa vaginal íntegra tras primera relación sexual / Perineal tear with intact vaginal mucosa after first sexual intercourse

RESUMEN Las lesiones del tracto genital femenino tras relaciones sexuales son un problema frecuente en las urgencias de ginecología, pero poco estudiado salvo su aspecto médico-legal. Su incidencia es desconocida ya que muchas mujeres no llegan a consultar por miedo o pudor. El reconocimiento precoz de estas lesiones y su correcto tratamiento puede evitar la parición de secuelas que acompañarán a nuestra paciente durante el resto de su vida. Presentamos el caso de una paciente de 18 años con un desgarro perineal con mucosa vaginal íntegra tras su primera relación sexual.

ABSTRACT Injuries to the female genital tract after sexual intercourse are a frequent problem in gynecological emergencies, but little studied except for their medico-legal aspect. Its incidence is unknown since many women do not go to their specialist out of fear or embarrassment. Early recognition of these injuries and their correct treatment may prevent the appearance of sequelae that will accompany our patient for the rest of her life. We present the case of an 18-year-old patient with a perineal tear with intact vaginal mucosa after her first sexual intercourse.

Perinatal and obstetric outcomes in older pregnant women / Gestantes de edad avanzada y resultados obstétricos y perinatales

Introduction: Maternity is being postponed to a more advanced age for sociocultural, occupational, and economic reasons. This phenomenon, which has become more common in the last 2 decades, means that the typical pregnant woman has changed. Pregnancy at the extremes of reproductive life is considered a risk factor owing to the greater likelihood of perinatal conditions. However, literature data on maternal and perinatal adverse events in pregnant women are contradictory. The objective of our study was to determine whether older pregnant women present a higher rate of obstetric and perinatal adverse outcomes than younger pregnant women. Material and methods: We conducted a retrospective cohort study. The study population consisted of patients from Health Area II of the Region of Murcia whose pregnancy and delivery were monitored in 2016 at University Hospital Santa Lucía. We divided patients into 2 groups: a group comprising pregnant women aged 40 to 45 years and a control group comprising pregnant women aged 30 to 35 years, who fulfilled the inclusion criteria and none of the exclusion criteria. We collected data from the predictive variables of the clinical history and data from the variables also resulting from the clinical history and the partograph. The statistical analysis was performed using SPSS. Results: We obtained a sample of 468 patients, with 234 patients in each group. The mean (SD) age of the cases was 41.59 (1.37), and that of the control group 32.81 (1.33). The risk of presenting adverse effects in the older group with respect to the control group was as follows: uterine bleeding (OR, 13.70), gestational diabetes (OR, 2.56), preterm birth (OR, 2.22), and admission to the neonatal ICU, 2.02). The risk of cesarean delivery and intrauterine growth retardation was higher in the older patients, although this association was not statistically significant. One woman died in the older group. No cases of neonatal mortality were recorded in either group. Conclusions: Advanced maternal age is a risk factor for major medical and obstetrical complications such as preterm birth, gestational diabetes, admission of newborn infants to the neonatal ICU, and uterine bleeding during childbirth

Introducción: actualmente la maternidad se está posponiendo a edades más avanzadas debido a motivos socioculturales, laborales y económicos. Este fenómeno, que se aprecia de forma más acentuada en las últimas dos décadas, hace que el prototipo de gestante actual haya variado. El embarazo en los extremos de la vida reproductiva es considerado como factor de riesgo por el aumento de la patología perinatal que se presenta, pero en la bibliografía hay resultados contradictorios sobre los eventos adversos maternos y perinatales en las gestantes de edad avanzada. El objetivo de nuestro estudio es comparar si este grupo de gestantes presenta mayor tasa de resultados adversos obstétricos y perinatales que la población gestante de menor edad. Material y métodos: hemos llevado a cabo un estudio de cohortes retrospectivo. La población de estudio la forman las pacientes del Área II de Salud de la Región de Murcia, que acudieron para control de gestación y parto en el año 2016 en el Hospital Universitario Santa Lucía. Hemos realizado dos grupos: grupo de casos con gestantes de 40 a 45 años, y grupo control con gestantes de 30 a 35 años, que cumplían criterios de inclusión y no de exclusión. Hemos recogido los datos de las variables predictoras de la historia clínica y los datos de las variables resultado también de la historia clínica y del partograma. El análisis estadístico se realizó mediante SPSS. Resultados: se obtuvo una muestra de 468 pacientes, 234 por cada grupo. La edad media de los casos fue 41,59 ± 1,37 y la del grupo control 32,81 ± 1,33. El riesgo de presentar efectos adversos del grupo de gestantes de edad materna avanzada con respecto al control fue de: hemorragias uterinas (OR: 13,70), diabetes gestacional (OR: 2,56), prematuridad (OR: 2,22), ingreso en UCI neonatal (OR: 2,02). Se observó que el riesgo de cesárea y de retraso de crecimiento intrauterino fue mayor en el grupo de las gestantes de edad avanzada, pero esta asociación no resultó estadísticamente significativa. Tuvimos un caso de mortalidad materna en el grupo de edad materna avanzada y ningún caso de mortalidad neonatal en los grupos de estudio. Conclusiones: la edad materna avanzada representa un factor de riesgo para algunas complicaciones médicas y obstétricas importantes como son la prematuridad, la diabetes gestacional, la necesidad de ingreso del recién nacido en UCI neonatal, así como para la aparición de hemorragias uterinas durante el parto

Cutaneous endometriosis: Presentation of 33 cases and literature review.

OBJECTIVE: Cutaneous endometriosis is a rare condition that usually affects the abdominal wall in women with a history of open abdominal surgery. It has a characteristic clinical picture of a mass and pain associated with menstruation. The diagnosis is difficult on being an uncommon and little known condition. Once there is suspicion, a correct anamnesis and examination is usually sufficient. The treatment is normally surgery. STUDY DESIGN: The study included all women identified with a diagnosis of cutaneous endometriosis over a period of 20 years. The variables collected and analysed included, age, surgical history, gynaecology history, symptoms, time period between surgery and consultation, specialist consulted, location, size, tests performed, treatment, and recurrence. RESULTS: A total of 33 women were identified, with a mean age of 35.4 ±â€¯2.33 years. A surgical history was found in 31 (93%) of 33 women. The main symptom was abdominal mass (96%), followed by period pain (51%), and non-period pain (42%). The initial diagnosis was correct in 15 (45%) of 33 women, and after performing further tests it was correct in 23 (69%) of 33 women. The main additional test was fine needle aspiration (FNA) in 24 (72%) of 33 patients. Surgery was performed on 30 (90%) of 33 women, with 8 (24%) women requiring a prosthesis. There was a recurrence of cutaneous endometriosis in 3 (9%) women. CONCLUSION: Although it is a rare disease, its association with gynaecological surgery, and in particular caesarean section, means that there should be more awareness of this condition. Its diagnosis may be complicated due to lack of knowledge, when a proper examination and anamnesis can give us the key.

La importancia del sexo fetal en la ecografía morfológica: genitales ambiguos y disgenesia gonadal mixta / The importance of fetal sex in morphological ultrasound: ambiguous genitalia and mixed gonadal dysgenesis

La identificación del sexo fetal forma parte de la ecografía de segundo trimestre. En ocasiones se presentan anomalías genitales que no permiten definirlo adecuadamente, lo que se conoce como genitales ambiguos. La importancia de los mismos se debe a su asociación con desórdenes del desarrollo sexual, patologías más complejas y graves. En la mayoría de casos el diagnóstico y el manejo es postnatal, estando bien establecido. El diagnóstico prenatal, en cambio, es poco frecuente, limitado y menos conocido. Presentamos el caso de una gestante de 20 años con el hallazgo de genitales ambiguos en semana 29 y posteriormente se diagnosticó de disgenesia gonadal mixta (AU)

Fetal sex identification is a well-established part of the second trimester ultrasound. Sometimes there are genital abnormalities that prevent proper identification, called ambiguous genitalia. Its importance is based on its association with development sex disorders, a far more severe and complex diseases. In most of the cases, diagnosis and management are postnatal and well systematized. Prenatal diagnosis, however, is less frequent and more limited. We present the case of a 20 year old pregnant with a finding of ambiguous genitalia at 29 week and a diagnosis of mixed gonadal dysgenesis (AU)

Octava cesárea en una misma paciente / Eighth cesarean section in the same patient

La tasa de cesáreas está aumentando en todo el mundo desde hace décadas. El deseo en muchas regiones o países de tener un alto número de hijos junto con la falta de medidas contraceptivas efectivas está provocando la aparición de un nuevo tipo de paciente, la gestante con cesárea múltiple repetida. En algunos países suponen ya un 4-6% de todas las embarazadas. Las complicaciones en estas pacientes son frecuentes y la morbilidad está aumentando. Pese a ello, los datos sobre los riesgos y para el manejo de esta paciente son aún muy limitados. Presentamos el caso de una paciente de 39 años que fue sometida a su octava cesárea (AU)

Cesarean rate is increasing worlwide in the last decades. Women's desire of large families and the lack of adequate contraception is producing a new patient's type: pregnant with multiple repeat cesarean section Ir represents 4-6% pregnancies in some countries and regions. Complications are common in this patients and there is a elevated morbidity. Despite this, data about risks and a properly management are very limited. We present the case of a patient who underwent her eight cesareansection (AU)

Obstrucción de vías urinarias bajas (LUTO): expectativas del tratamiento intraútero / Obstruction of low urinary tract (LUTO): expectations of intrauterine treatment

La obstrucción de vías urinarias bajas es una patología fetal infrecuente causada por una persistencia de valvas uretrales o una estenosis/atresia uretral. La ausencia de drenaje va a producir graves daños en el sistema renal y respiratorio, provocando una alta morbimortalidad. Los hallazgos ecográficos característicos son la megavejiga, el signo de la cerradura y la hidronefrosis. Los casos seleccionados son subsidiarios de terapia fetal intraútero, mediante la inserción de un shunt vesicoamniótico o la realización de una cistoscopia-láser, pero los resultados son aún controvertidos. Presentamos una paciente de 29 años con un caso de obstrucción de vías urinarias bajas (AU)

Low urinary tract obstruction is an uncommon fetal disease caused by posterior urethral valves or urethral stenosis/ atresia. Failure of drainage produces severe injury at urinary and respiratory sistem, with a high morbimortality. Sonographic findings are megacystis, keyhole sign and hydronephrosis. It is possible in selected cases the realization of in-uterotherapy, using a vesicoamniotics hunt (VAS) or a fetal cystoscopy. Outcomes and the usefulness of this techniques are still in debate. We present a patient of 29 years with a low urinary tract obstruction case (AU)

Corioangioma gigante placentario / Placental giant chorioangioma

El corioangioma es la tumoración benigna placentaria no trofoblástica más frecuente, aunque su incidencia es menor del 1%. En algunos casos raros superan los 4 cm, denominándose corioangiomas gigantes, y se relacionan con malos resultados perinatales debido al compromiso de flujo fetoplacentario. El diagnóstico de sospecha se realiza mediante ecografía-Doppler, siendo de utilidad la resonancia magnética nuclear. El diagnóstico definitivo es anatomopatológico. Es necesaria una vigilancia estrecha del bienestar fetal y puede precisar técnicas invasivas como la cordocentesis o la fetoscopia. Presentamos el caso de un corioangioma placentario gigante de 11 cm que fue diagnosticado a las 21 semanas de gestación (AU)

Chorioangioma is the most common non-trophoblastic placental benign tumour, although its incidence is less than 1%. Some rare tumours are larger than 4 cm, called giant choriangiomas, and are related to adverse perinatal outcomes because of the arrest of placental blood flow. Initial diagnosis is conducted with ultrasound Doppler, and magnetic resonance imaging can sometimes be useful. The definitive diagnosis is histological. Early suspicion allows more effective vigilance of foetal wellbeing and the possibility of diagnostic-therapeutic tools such as cordocentesis or foetoscopy. We present a case of a giant placental chorioangioma of 11 cm, diagnosed at 21 weeks of pregnancy (AU)

Asociación de nivel bajo de PAPP-A en primer trimestre con resultados obstétricos adversos / Association of low PAPP-A level in the first trimester with adverse obstetric outcomes

ANTECEDENTES: La PAPP-A es una proteína utilizada en obstetricia de forma rutinaria para el cribado de aneuploidías de primer trimestre. En los últimos años se está conociendo más acerca de su papel en la función placentaria. Diversos estudios están mostrando una asociación entre un nivel bajo de PAPP-A y distintos eventos obstétricos. OBJETIVO: Establecer una asociación entre PAPP-A baja y eventos obstétricos adversos. MÉTODO: Estudio retrospectivo de casos y controles anidado en una cohorte. Se han recogido las gestaciones únicas con PAPP-A inferior a percentil 5 en primer trimestre durante 2 años. Se ha recogido de la misma cohorte un grupo control, en proporción 2:1. Se compara mediante análisis estadístico la incidencia de eventos obstétricos adversos de cada grupo. RESULTADOS: Se incluyó un total de 285 pacientes en el grupo de casos y 570 pacientes en el grupo control. Se observó un aumento significativo en el grupo de casos de la incidencia de prematuridad, restricción del crecimiento, hipertensión gestacional y diabetes gestacional. Se ha correlacionado la PAPP-A baja con varios eventos obstétricos adversos, incluyendo prematuridad (OR 4,27), diabetes gestacional (OR 2,40), restricción del crecimiento (OR 2,36) e hipertensión gestacional (OR 2,22). No se observó relación con el resto de eventos obstétricos adversos. CONCLUSIÓN: Un nivel de PAPP-A bajo se asocia con aumentos significativos de prematuridad, diabetes gestacional, restricción del crecimiento e hipertensión gestacional.

BACKGROUND: PAPP-A is a placental protein used in obstetrics as a first trimester marker in aneuploidy screening. In the last few years we are knowing more about its placental function. Some studies are showing a association between low PAPP-A and obstetrical adverse events. AIM: Establish an association between low PAPP-A an obstetrical adverse events. METHOD: This is a retrospective nested case-control study. We identified each singleton pregnancy with a normal phenotype and a low PAPP-A (under percentile 5) in the last 2 years, and match it with a control group of the same population in a 2:1 proportion. It was compared the incidence of each obstetrical adverse outcomes with statistical analysis. RESULTS: We found 285 patients in the case group and match it with 570 patients from control group. It was observed a significative increase in the incidence of prematurity, intrauterine growth restriction, gestational hypertension and gestational diabetes. A low PAPP-A level was correlated with some obstetrical adverse events, like prematurity (OR 4.27), gestational diabetes (OR 2.40), intrauterine growth restriction (OR 2.36) and gestational hypertension (OR 2.22). We observe no correlation with the rest of outcomes. CONCLUSIONS: A low PAPP-A level is related with significative increases of prematurity, gestational diabetes, intrauterine growth restriction and gestational hypertension.

Intervalos de referencia de ácido úrico en suero durante la gestación / Reference intervals for serum uric acid during pregnancy

Introducción. La interpretación de las magnitudes bioquímicas durante la gestación requiere de intervalos de referencia específicos para dicha etapa, dados los cambios fisiológicos que se producen durante el embarazo. El objetivo de este estudio fue obtener el intervalo de referencia de la concentración sérica de ácido úrico, biomarcador asociado a un incremento del riesgo de desarrollo de preeclampsia en gestantes residentes en el Área 2 de Salud de la Región de Murcia (España). Material y métodos. Estudio prospectivo, longitudinal y consecutivo en el que la población de referencia estuvo finalmente formada por 270 gestantes sanas en las que se midió la uricemia durante los tres trimestres de gestación. Las recomendaciones del Clinical and Laboratory Standards Institute se utilizaron para la obtención de los intervalos de referencia. Resultados. La uricemia aumentó de forma significativa durante la gestación, alcanzando una concentración marcadamente superior durante el tercer trimestre. Se definieron los siguientes intervalos de referencia: primer trimestre: 2,0-4,6 mg/dl, segundo trimestre: 2,0-4,7 mg/dl y tercer trimestre: 2,6-5,7 mg/dl. Conclusión. La interpretación de la uricemia durante la gestación requiere de intervalos de referencia específicos para este estado fisiológico, estratificados por trimestres. Los intervalos obtenidos en nuestro estudio son una herramienta útil en la interpretación de la uricemia durante la gestación para la identificación de aquellas gestantes con un riesgo incrementado de preeclampsia (AU)

Introduction. Interpretation of biochemical variables during pregnancy requires reference intervals specific to that state, due to the physiological changes that occur during pregnancy. The objective of this study was to obtain the reference range of serum uric acid, biomarker associated with an increase in the risk of developing preeclampsia, in pregnant women of the Area 2 of the Region of Murcia (Spain). Material and methods. This is a consecutive longitudinal prospective study in which the reference population finally included 270 healthy pregnant women, in which serum uric acid was measured during the three trimesters of pregnancy. Recommendations of the Clinical and Laboratory Standards Institute were used to obtain reference intervals. Results. Serum uric acid levels increased significantly during pregnancy, reaching a concentration notably higher during the third trimester. The following reference intervals were defined: first trimester: 2,0-4,6 mg/dl, second trimester: 2,0-4,7 mg/dl and third trimester: 2,6-5,7 mg/dl. Conclusion. Interpretation of serum uric acid levels during pregnancy requires reference intervals specific to this physiological state, stratified by trimesters. The ranges obtained in our study are a useful tool to identificate those pregnant women with an increased risk of preeclampsia (AU)