Cáncer de ovario avanzado y linfadenectomía / No disponible

No disponible

Cesárea y tocurgia en la obstetricia actual / Cesarean section and tocurgia in current obstetrics

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Análisis prospectivo de LEEP realizados sin anestesia en la consulta de patología cervical / Prospective analyses of outpatient LEEP carried out in cervical pathology clinic without anesthesia

Objetivo: determinar si la técnica Loop Electrosurgical Excision Procedure es un procedimiento efectivo y seguro para realizarlo en consulta ambulatoria de patología cervical. Material y métodos: estudio observacional prospectivo que incluye 156 pacientes que se les realiza Loop Electrosurgical Excision Procedure en consulta ambulatoria, sin anestesia, durante un periodo de seguimiento de 84 meses (7 años). Se excluyen 24 pacientes. Se analizan diferentes variables epidemiológicas, técnica, estado de bordes quirúrgicos, complicaciones y tolerancia al dolor. Resultados: la edad media de las pacientes fue de 35,7 años con inicio de la actividad sexual 17,9 años y 9 parejas sexuales de media. El diámetro mayor de las piezas analizadas fue de 1,7 cm. En el 18 pacientes (13,6%) los bordes quirúrgicos fueron reportados "afectos". Presentamos en 3 casos (2,3%) daño de la mucosa vaginal y un caso (0,8%) hemorragia tardía. La tolerancia al dolor fue satisfactoria en 121 pacientes (91,7%) y solo 1 paciente (0,8%) precisó de anestésico local. Discusión: el Loop Electrosurgical Excision Procedure es un procedimiento que puede ser realizado en consulta bajo imagen colposcopica en forma segura, efectiva y sin anestesia (AU)

Objective: To determine if cervical conization realized by leep procedure is an effective and safe procedure in an outpatient cervical pathology clinic. Material and methods: Prospective cohort study which includes 156 patients, who experienced a Loop Electrosurgical Excision Procedure procedure in an outpatient clinic without anesthesia, in a 84 months follow-up period (7 years). 24 patients are excluded. Different epidemiological variables and techniques were analyzed, as well as excision margins state, complications and pain tolerance. Results: The patients average age were 35.7 years old, with an onset of sexual activity median age of 17.9 years and a average number 9 sexual partners. The largest diameter of the analyzed pieces was 1.7 cm. In 18 patients (13.6%), excision margins were reported as "affected". In 3 cases (2.3%) the vaginal mucosa became damaged and one patient (0.8%) had late bleeding. The pain tolerance was satisfactory in 91.7% cases and local anaesthetic was administered to one patient only (0.8%). Discussion: Loop Electrosurgical Excision Procedure procedure can be carried out in an outpatient clinic under colposcopic vision being a safe, effective and without need of anesthesia procedure (AU)

Methotrexate-treated ectopic pregnancy: beta human chorionic gonadotropin serum changes as a success predictor using a mathematical model validation.

BACKGROUND: Surgical rescue of methotrexate-treated ectopic pregnancy is necessary when tubal rupture or medical therapy failure is detected during post-therapeutic monitoring. It is known that an increased beta human chorionic gonadotropin (ß-hCG) concentration is the most important factor associated with treatment failure. Therefore, we suggested that relative changes in serum ß-hCG could predict a successful result of medical treatment, leading to facilitation of the decision to forgo the prospect of possible surgical rescue. METHODS: A retrospective observational study of 115 patients with an ectopic pregnancy who were treated with a single dosage protocol of 50mg/m2 of methotrexate injected intramuscularly was performed at Puerta de Hierro University Hospital and Gregorio Marañón University General Hospital. Standard statistical tests were applied in order to evaluate the relative changes in ß-hCG concentration between the 1st and the 4th days following methotrexate injection. RESULTS: Methotrexate treatment has a 95% probability to be successful if the relative change of ß-hCG from the 1st to the 4th day of monitoring is within the following interval: [-1.02; 0.15]. Moreover, if the values of ß-hCG-relative change from 1st to 4th day of monitoring are within [0.54; 1.2], it assures a negative result of treatment with 95% probability. Therefore, the value 0.15 (15%) of ß-hCG relative change can be considered a cut-off value for a positive result to treatment. CONCLUSIONS: Our data support that negative ß-hCG relative changes on the 4th day of treatment likely predict a successful result of methotrexate therapy, with a cut-off point of 0.15. Expectant management should be carried out in these cases if no clinical indications of surgery are presented.

¿Qué gestante con PTI requiere un seguimiento más estrecho? / What pregnant woman with PTI requires closer tracking?

Nuestro objetivo es establecer si existe alguna característica que pueda determinar qué gestante con púrpura trobótica idiopática es más sensible que otra, y por tanto necesita un seguimiento médico más estrecho. Los datos se han recogido de forma retrospectiva a partir de pacientes embarazadas en seguimiento entre 1999 y 2014 con diagnóstico confirmado de púrpura trobótica idiopática. Se recogió información de 57 embarazos en 43 mujeres. Dentro de nuestra muestra, 46 mujeres habían sido previamente diagnosticadas (80,7%). A favor de aquellas con púrpura trobótica idiopática crónica, identificamos varios datos que demostraron correlación significativa, tales como los síntomas hemorrágicos. No encontramos, sin embargo, ninguna relación entre la severidad de la trombopenia maternal y los resultados neonatales, además, ninguno de los recién nacidos sufrieron síntomas hemorrágicos. Aquellas pacientes que fueron diagnosticadas de forma aguda requirieron un seguimiento médico más estrecho teniendo en cuenta que tienen un riesgo aumentado de descompensarse (AU)

Our aim was to establish if there were some features that could determine which pregnant woman who suffered from idiopathic thrombocytopenic purpura was more sensitive and therefore needs more accurate medical monitoring than others. Data were collected retrospectively from pregnant patients followed-up from 1999 to 2014 with a clear diagnosis of idiopathic thrombocytopenic purpura, with a total of 57 pregnancies in 43 women. Among our sample 46 women had been previously diagnosed (80.7%). In favor of those with chronic idiopathic thrombocytopenic purpura we identified several data which showed significant correlation as symptoms in the gestation. We did not find any correlation between the severity of maternal platelet counting and the neonatal outcomes, as well as any newborn suffered hemorrhagic symptoms. As we could see in our study, those pregnant women who are diagnosed with idiopathic thrombocytopenic purpura acutely require closer medical monitoring due to they have an increased risk to become unbalanced (AU)

Criterios de indexación de una revista cientifica / Criteria to index a scientific journal

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Diagnóstico prenatal de Pentalogía de Cantrell / Antenatal diagnosis of Cantrell pentalogy

La pentalogía de Cantrell es una anomalía congénita rara que acontece 1 por 100.000 embarazos; los defectos extensos a nivel de la fusión de la línea media craneofacial, torácica y abdominal caracterizan a este cuadro con una elevada morbimortalidad. Presentamos dos casos de pentalogía de Cantrell diagnosticados en nuestro hospital a las 12 semanas de gestación, ambos en gestaciones únicas, con cariotipo 46XX y uno de ellos con el hallazgo de microdelección de cromosoma 22q11 (AU)

Pentalogy of Cantrell is a rare congenital abnormality reported in 1 per 100,000 pregnancies. Large defects in craniofacial midline fusion, as well as thoracic and abdominal defects, are the main features of this syndrome that entails high morbidity and mortality. We present two cases of pentalogy of Cantrell identified in our hospital at 12 weeks of pregnancy. Both were singleton pregnancies, with 46XX karyotype, and one of them with a microdeletion in chromosome 22q11. We describe the clinical maternal characteristics, as well as the most relevant ultrasonographic findings (AU)

"The impact of debulking surgery in patients with node-positive epithelial ovarian cancer: Analysis of prognostic factors related to overall survival and progression-free survival after an extended long-term follow-up period".

OBJECTIVE: to estimate the prognostic factors associated with survival and progression free survival (PFS) in patients with node-positive epithelial ovarian cancer (EOC) after an extended long-term follow-up period. METHODS: Data was provided by the Tumor Registry of the Mayo Clinic, Scottsdale, Arizona on 116 node-positive EOC patients who underwent primary cytoreductive surgery observed over the period 1996-2014. RESULTS: At censoring date, 21 patients were alive (18%), 95 dead (82%), 18 without evidence of disease (NED) (15 alive, 3 dead) and 76 with evidence of disease (ED) (2 alive, 74 dead). Twenty-nine ED patients (38.2%) experienced a recurrence within 2 years, 53 patients (69.7%) before 5 years. No recurrences were recorded after 10 years. The median follow-up in alive patients was 169.8 months (1.20-207.9 months), 34.9 months (0.30-196.2 months) in dead patients, 128.4 months for NED patients (72.8-202.5 months) and 34.6 months (0.1-106.9 months) in ED patients. Multivariate analysis showed an increased risk of dead in patients with age ≥ 60 years (HR: 3.20; p < 0.002), stage IVA/B (compared with stage IIIA1/2, HR: 4.31; p < 0.001 and stage IIIB/C, HR: 5.31; p < 0.010) and incomplete surgery (compared with complete surgery, HR: 3.10; 95% CI, 1.41-6.77; p < 0.003) and a decreased PFS in stage IVA/B (compared with stages IIIB/C; p = 0.003 and stage IIIA; p = 0.000) and residual volume after surgery >0.6 cm (compared with residual disease <0.5 cm; p < 0.023). CONCLUSIONS: prognostic factors for an extended long-term PFS are similar as those for survival, because after 17-year follow-up period, the majority of alive patients are NED patients.

Virus Zika y gestación / Zika virus and pregnancy

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Peritoneal carcinomatosis: A malignant disease with an embryological origin?

INTRODUCTION: In 1931, Simpson et al. coined the term "peritoneal carcinomatosis" to describe the regional spread of ovarian tumors as localized or extended with involvement of the peritoneal serous membrane and neighboring anatomical structures. Research into the origin of peritoneal carcinomatosis is based on two phases in a woman's life: EMBRYO DEVELOPMENT: During week 3, the bilaminar disc becomes a trilaminar disc called the mesoderm. Inside the lateral plate mesoderm, the coelomic cavity is divided into 2 layers: the parietal (somatic) mesoderm, which gives rise to the parietal peritoneum and pleural surfaces; and the visceral (splanchnic) mesoderm, which gives rise to the visceral peritoneum, visceral surface of the pleura, gonadal stroma, and the muscular layer of the hollow viscera and its mesenteries. TUMOR SPREAD: Transcoelomic metastasis and metaplasia of pluripotent stem cells in the peritoneum was involved in the pathogenesis of ovarian cancer. This involvement takes the form of a synchronous malignant transformation at multiple foci and may cause intraperitoneal field cancerization. Pluripotent stem cells play a role both in the development of the embryonic peritoneum and in the spread of transcoelomic tumors. Consequently, knowledge of the origin of these cells (embryonic or current) could be extremely useful. The many markers that act during the embryonic period can affect descendants, that is, cells are already marked before specification and differentiation are activated. Thus, programmed activation could be attributed to genetic and epigenetic changes.

Cardiovascular System Sonographic Evaluation Algorithm: A New Sonographic Algorithm for Evaluation of the Fetal Cardiovascular System in the Second Trimester.

OBJECTIVES: To evaluate the reproducibility and feasibility of the new cardiovascular system sonographic evaluation algorithm for studying the extended fetal cardiovascular system, including the portal, thymic, and supra-aortic areas, in the second trimester of pregnancy (19-22 weeks). METHODS: We performed a cross-sectional study of pregnant women with healthy fetuses (singleton and twin pregnancies) attending our center from March to August 2011. The extended fetal cardiovascular system was evaluated by following the new algorithm, a sequential acquisition of axial views comprising the following (caudal to cranial): I, portal sinus; II, ductus venosus; III, hepatic veins; IV, 4-chamber view; V, left ventricular outflow tract; VI, right ventricular outflow tract; VII, 3-vessel and trachea view; VIII, thy-box; and IX, subclavian arteries. Interobserver agreement on the feasibility and exploration time was estimated in a subgroup of patients. The feasibility and exploration time were determined for the main cohort. Maternal, fetal, and sonographic factors affecting both features were evaluated. RESULTS: Interobserver agreement was excellent for all views except view VIII; the difference in the mean exploration time between observers was 1.5 minutes (95% confidence interval, 0.7-2.1 minutes; P < .05). In 184 fetuses (mean gestational age ± SD, 20 ± 0.6 weeks), the feasibility of all views was close to 99% except view VIII (88.7%). The complete feasibility of the algorithm was 81.5%. The mean exploration time was 5.6 ± 4.2 minutes. Only the occiput anterior fetal position was associated with a lower frequency of visualization and a longer exploration time (P < .05). CONCLUSIONS: The cardiovascular system sonographic evaluation algorithm is a reproducible and feasible approach for exploration of the extended fetal cardiovascular system in a second-trimester scan. It can be used to explore these areas in normal and abnormal conditions and provides an integrated image of extended fetal cardiovascular anatomy.

Reference ranges for the pulsatility index of the fetal aortic isthmus in singleton and twin pregnancies.

OBJECTIVES: The purpose of this study was to estimate reference ranges for the pulsatility index (PI) of the fetal aortic isthmus in uncomplicated singleton and twin pregnancies during the second half of pregnancy. METHODS: We conducted a cross-sectional observational study involving 543 healthy fetuses: 361 singleton pregnancies and 182 twin pregnancies between 19 and 36 weeks' gestation. The aortic isthmus PI was measured in 2 sonographic planes: the longitudinal aortic arch view and the 3-vessel and trachea view. We evaluated the reproducibility of aortic isthmus PI measurements between these planes by calculating intraclass correlation coefficients and limits of agreement. Scans were performed by 2 physicians, and intraobserver agreement was also measured. Regression analysis was used to estimate gestational age reference values for the aortic isthmus PI. RESULTS: The aortic isthmus PI was significantly correlated with gestational age in singletons and twins during the second half of pregnancy (P < .01). We did not find significant differences between reference ranges in singletons and twins or between the sonographic views. CONCLUSIONS: This study offers reference ranges for the aortic isthmus PI during the second half of gestation in singleton and twin pregnancies. Mean aortic isthmus PI values were similar in both types of gestations as well as both sonographic views. The aortic isthmus PI may be reliably obtained from either sonographic view.

International Federation of gynecology and obstetrics staging classification for cancer of the ovary, fallopian tube, and peritoneum: estimation of survival in patients with node-positive epithelial ovarian cancer.

OBJECTIVE: The objective of this study was to determine the survival of patients with node-positive epithelial ovarian cancer according to the 2014 International Federation of Gynecology and Obstetrics (FIGO) staging system. MATERIALS AND METHODS: We performed a retrospective chart review. Data from all consecutive patients with node-positive epithelial ovarian cancer (stages IIIC and IV) who underwent cytoreductive surgery at the Mayo Clinic from 1996 to 2000 were reassessed to evaluate the prognostic significance of the new FIGO stages. Multivariate Cox regression was performed, and Kaplan-Meier survival curves constructed. RESULTS: The distribution of the restaged patients was as follows: IIIA1, 23 patients (IIIA1i, 9 patients; and IIIA1ii, 14 patients); IIIA2, 3 patients; IIIB, 4; IIIC, 67 patients; IVA, 4 patients; and IVB, 15 patients. In the univariate analysis, the relative risk for positive nodes greater than 10 mm on the longer axis was 2.57 and 3.00 for patients with microscopic peritoneal disease, compared with patients with microscopic positive nodes. However, the difference was not statistically significant. Moreover, the univariate analyses revealed statistically significant differences for 2014 FIGO stages (IIIA, IIIB, IIIC, and IVA-B), anatomical sites of peritoneal metastases, and disease staged at IIIC because of the presence of omental metastases. Multivariate analysis showed that survival was higher in patients restaged to IIIA-B than in those restaged to IIIC and IV (hazard ratios, 2.75 and 3.16, respectively; P = 0.002). The hazard ratio for patients with abdominal peritoneal metastases was 2.76 compared with patients with pelvic peritoneal metastases (P = 0.001). CONCLUSIONS: The current 2014 FIGO staging system for ovarian cancer successfully correlates survival, anatomical location of peritoneal metastases, and extra-abdominal lymph node metastases.

[A case study of anaphylaxis in a pregnant woman]. / Choque anafiláctico en una gestante en el tercer trimestre de embarazo.

We report a case of anaphylaxis in a 35+5 week of pregnancy patient who came to the Emergency Room with shortness of breath, hypotension and loss on fetal wellbeing. Due to her medical history and given the clinical picture at that time, an anaphylactic shock was suggested as the most probable diagnose. The administration of dexchlorpheniramine and methylprednisolone resulted in an immediate and positive reaction. Simultaneously, an improvement in the fetus cardiotocographic record was objectified. The patient was hospitalized for 48 hours, after which she was discharged. In case of suspicion of anaphylaxis in a pregnant woman, four aspects should be handled: the severity of the anaphylaxis chart, individual complications regarding a pregnant woman, unfavorable effects of the regularly used treatment during that specific gestation, and the need of fetal extraction based of gestational age.

[Ultrasound scan of the fetal thymus]. / Evaluación ecográfica del timo fetal.

There is an increased interest nowadays on ultrasound analysis of the fetal thymus. Abnormal fetal thymic growth have been associated with DiGeorge syndrome, conotruncal cardiac malformations, chromosomal abnormalities and adverse outcome in different perinatal conditions as intrauterine growth restriction, preterm birth and others. Different methodologies that measure the fetal thymus by ultrasound have been published, however there is not a consensus of which one is the most useful. Our aim is to describe these methodologies and discuss their clinical applications.

Experience in IVIg therapy for selected women with recurrent reproductive failure and NK cell expansion.

PROBLEM: Recurrent reproductive failure (RRF) has been associated with expansion of circulating NK cells, key cells for maternal tolerance, decidual vasculogenesis and embryo growth. This study reports our experience in intravenous immunoglobulin (IVIg) therapy of a large cohort of women with RRF with expanded circulating NK and/or NKT-like cells (blood NKT cells are a heterogeneous subset of T cells that share properties of both T cells and NK cells). METHOD OF STUDY: Observational study of RRF women with NK or NKT-like expansion (>12% or 10% cutoff levels of total lymphocytes, respectively), treated with IVIg for the next gestation. RESULTS: By multivariant logistic regression analysis after adjusting for age, NK cells subsets and other therapies, IVIg significantly improved the live birth rate to 96.3% in women with recurrent miscarriage (RM) compared with 30.6% in case not receiving IVIg (P < 0.0001). In women with recurrent implantation failure (RIF), in comparison with women not receiving IVIg, treatment increased the pregnancy rate from 26.2 to 93.8% (P ≤ 0.0001) and the live birth rate from 17.9 to 80.0% in RIF (P ≤ 0.0001). CONCLUSIONS: Immunomodulation with IVIg in our selected group of RRF patients with immunologic alterations enhanced clinical pregnancy and live birth rates. Our results may facilitate the design of future clinical trials of IVIg in this pathology.

The impact of pelvic retroperitoneal invasion and distant nodal metastases in epithelial ovarian cancer.

BACKGROUND: The absence of disease after debulking surgery is the most important prognostic factor in the treatment of advanced epithelial ovarian cancer (EOC). Occasionally, the presence of extra-abdominal disease complicates the ability to obtain a complete surgery, considering some locations of the metastatic disease as unresectable. The objective of the study was to estimate the survival impact of pelvic retroperitoneal invasion and extrapelvic and aortic distant nodal metastases in EOC patients. The anatomical landmarks of primary cytoreductive surgery will be discussed. MATERIAL AND METHODS: We reviewed data from 116 consecutive Mayo Clinic patients with epithelial ovarian cancer (EOC) stage IIIC and IV, undergoing primary cytoreduction surgery between 1996 and 2000. Univariate and multivariate analysis for patients with positive distant nodes and pelvic retroperitoneal invasion was performed, including 57 patients with no residual disease after surgery. Kaplan-Meier curves were used to estimate the probability of survival. RESULTS: The median patient's age was 65 years (range 24-87 years). The 5 years overall survival was 44.8% (range 30.1-57.9 months) and the median length of survival was 39.9 months (range 0.13-60 months, 95% confidence interval: 30.1-57.9). Pelvic retroperitoneal invasion was present in 22 EOC patients (18.9%) and distant positive nodes were noted in 11 (9.5%): suprarenal/celiac (5.2%), inguinal (4.3%) and supraclavicular (0.9%). Univariate and multivariate Cox regression analysis, identified distant positive lymph nodes and pelvic retroperitoneal invasion as factors statistically associated with overall survival (p = 0.002 and p = 0.025, respectively). CONCLUSIONS: Metastatic distant nodes and pelvic retroperitoneal invasion are independent prognostic factors for survival in patients with advanced EOC.

Chronic perineal pain: analyses of prognostic factors in pudendal neuralgia.

OBJECTIVES: To establish the prognostic factors and outcomes of patients with pudendal neuralgia (PN). MATERIALS AND METHODS: A total of 51 patients with PN treated at the Puerta de Hierro University Hospital of Madrid between January 2011 and June 2012 were included in this study. Patients were compared in relation to pain intensity and response to the first-line treatment of neuropathic pain. Univariate and multivariable Cox regression analyses were used. RESULTS: The median for patients' age, duration, and intensity of pain evaluated by visual analogue scale were 40.9, 3.6, and 7.6 years, respectively. Among 45 patients, there were 19 good responders to first-line treatment for neuropathic pain and 26 nonresponders. The 19 responders measured their improvement at 47%. Tramadol was used for nonresponding patients, 30.8% of whom expressed a 35% improvement. Analysis of 45 patients with PN demonstrated that the pain intensity was associated with dorsal clitoris nerve damage (15.4% vs. 52.2%; P=0.035; odds ratio 4.5; 95% confidence interval [CI], 1.11-18.1) and with sensory deficit at the S2-S4 dermatome map (57.7% vs. 87%; P=0.05; odds ratio 3.7; 95% CI, 0.80-16.8). The pain located at the dorsal clitoris nerve was a significant prognostic factor for having no response to the first-line treatment of neuropathic pain (28% vs. 53%; P=0.033; odds ratio 4.5; 95% CI, 1.06-19.6). DISCUSSION: A mixed analgesic ladder for chronic pain showed improvement in 73% of the patients with PN. Pain restricted to the dorsal clitoris nerve and small fibers in the S2-S4 dermatome were classified as bad prognostic factors. A longer duration of pain was also correlated with a worse prognosis.

Fetal MRI as a complementary technique after prenatal diagnosis of persistent vitelline artery in an otherwise normal fetus.

Prenatal ultrasound is the standard for the diagnosis of fetal anomalies. However, fetal MRI has emerged as a valuable diagnosis tool to complete the study of fetal malformations. Type II single umbilical artery results from the absence of both umbilical arteries and persistence of the vitelline artery. It has been described only in fetuses with sirenomelia or caudal regression syndrome. We report a favorable outcome in a normal fetus in which prenatal ultrasound and MRI showed a single umbilical artery arising from the aorta. The etiology of such a finding and its possible consequences are discussed.

New decision-tree model for defining the risk of reproductive failure.

PROBLEM: Natural killer (NK) cells play a key role in embryo implantation and pregnancy success, whereas blood and uterine NK expansions have been involved in the pathophysiology of reproductive failure (RF). Our main goal was to design in a large observational study a tree-model decision for interpretation of risk factors for RF. METHODS OF STUDY: A hierarchical multivariate decision model based on a classification and regression tree was developed. NK and NKT-like cell subsets were analyzed by flow cytometry. RESULTS: By multivariate analysis, blood NK cells expansion was an independent risk factor for RF (both recurrent miscarriages and implantation failures). We propose a new decision-tree model for the risk interpretation of women with RF based on a combination of main risk factors. CONCLUSIONS: Women with age above 35 years and >13% CD56⁺CD16⁺ NK cells showed the highest risk of further pregnancy loss (100%).