Invasive mole in a perimenopausal woman with lung and vaginal metastases: A case report.

Gestational trophoblastic disease can result in serious complications and disease progression. Therefore, follow-up of such patients is essential for early detection of malignant trophoblastic tumors and to reduce mortality rate. Primary treatment is chemotherapy but hysterectomy should be considered in patients who have uncontrollable hemorrhage and hemodynamic instability.

Retroperitoneal Laparoscopic Para-Aortic Lymphadenectomy in Para-Aortic Staging of Locally Advanced Cervical Cancer.

STUDY OBJECTIVE: To review/learn a surgical technique not very well-known by gynecologic oncologists. DESIGN: Level of evidence III. SETTING: A review of a surgical technique with emphasis on the para-aortic sentinel lymph nodes using indocyanine green. INTERVENTION: The film features the following steps to perform the procedure: 1. Creating a retroperitoneal window. 2. What to do if the peritoneum is torn. 3. Finding the psoas muscle, right ureter, and common iliac artery. Dissecting the right common iliac artery caudally to the bifurcation of the external iliac artery and internal iliac artery and cranially to the inferior mesenteric artery, the ovarian arteries, and the left renal vein. 4. A view of all of the nodes with fluorescence when indocyanine green is injected into the cervix. At present, the sentinel lymph nodes are not the standard of care for locally advanced cervical cancer. If the nodes are metastatic at this stage, all the para-aortic area will undergo radiation therapy. 5. Dissecting the inferior vena cava from the intersection with the right uterer to the right and left renal veins. 6. Performing the lateroaortic, preaortic, and precaval lymphadenectomy. 7. A final view with all of the elements (i.e., bifurcation of the common iliac artery, the left renal vein, and both ureters). 8. In the final part of the video, we open the peritoneal window to decrease the incidence of lymphoceles. CONCLUSION: The real novelty of this video is how the para-aortic area nodes are seen when green indocyanine is injected into the cervix. This video shows a simplified technique of retroperitoneal para-aortic lymphadenectomy using an advanced bipolar sealant. Some tips and tricks to facilitate the procedure are emphasized, especially in cases of accidental peritoneal tears. To decrease the incidence of lymphoceles before completing the surgery, the peritoneal window should be opened. This surgical technique is especially useful in endometrial cancer for staging the para-aortic area in obese patients and in advanced cervical cancer to determine the field of radiotherapy.

Resultados del test molecular GynEC®-DX en aspirados endometriales con dictamen histológico no concluyente / Results of GynEC®-DX molecular test in endometrial aspirates with inconclusive histological assessmen

Objetivo: medir el porcentaje de resultados concluyentes obtenidos mediante el test de diagnóstico molecular GynEC®-DX en un grupo de pacientes con resultado anatomopatológico insuficiente o no concluyente en la biopsia obtenida mediante aspirado endometrial. Material y métodos: estudio multicéntrico prospectivo, en el que se realizó el test de diagnóstico molecular en una nueva toma de aspirado endometrial tras un resultado no concluyente previo en el estudio histológico. Resultados: se obtuvo un resultado concluyente en el 89,4% (n = 84) de las 94 pacientes reclutadas. En este estudio, el test demostró una sensibilidad del 100%, una especificidad del 88,2%, y un valor predictivo negativo del 100%. Conclusiones: el test de diagnóstico molecular consiguió establecer un resultado determinante en el 89,4% de los casos en los que el patólogo no pudo obtener un diagnóstico mediante análisis histológico (AU)

Objective: To estimate the percentage of conclusive result obtained with GynEC®-DX molecular diagnostic test in a group of patients with an insufficient or inconclusive pathological result in the endometrial aspirate biopsy. Material and methods: Prospective multicenter study where the molecular diagnostic test was carried out in a new endometrial aspirate sample. Results: A conclusive result was obtained in 89.4% (n = 84) of the 94 patients recruited. The molecular test had a sensitivity of 100%, a specificity of 88.2% and a negative predictive value of 100%. Conclusions: The molecular diagnostic test was able to establish a determining result in 89.4% of the cases in which the pathologist could not obtain a diagnosis by histological analysis (AU)

Disomía uniparental-duplicación paterna de la región del cromosoma 11p15.5 como causa de displasia mesenquimatosa placentaria / Placental mesenchymal dysplasia due to uniparental disomy/paternal duplication of 11p15.5

Resumen ANTECEDENTES La displasia mesenquimatosa de la placenta es una enfermedad rara que en la ecografía se observa con vesículas en forma de racimo de uvas. Puede provocar complicaciones en el embarazo, como: restricción del crecimiento intrauterino, muerte intrauterina y parto pretérmino. CASO CLÍNICO Paciente de 31 años con displasia mesenquimatosa placentaria diagnosticada en la ecografía del primer trimestre de embarazo. Se apreció una zona con formaciones econegativas de 14 x 20 mm, con escasa captación del doppler color y que terminó de confirmarse en el segundo trimestre, con una biopsia corial. El embarazo trascurrió con normalidad hasta la semana 33, que fue cuando se detectó la restricción del crecimiento intrauterino. Debido a la alta incidencia de complicaciones obstétricas derivadas de éste se decidió la inducción del parto en la semana 37 de la gestación. CONCLUSIONES El diagnóstico de displasia mesenquimatosa placentaria requiere seguimiento estrecho del embarazo e inducir su finalización entre las semanas 37-38 para aminorar las complicaciones perinatales.

Abstract BACKGROUND Placental mesenchymal dysplasia is a rare disease of the placenta which presents with vesicles in the form of a cluster of grapes on ultrasound. It can cause pregnancy complications such as: intrauterine growth restriction, intrauterine death, and preterm birth CLINICAL CASE A 31-year-old patient with placental mesenchymal dysplacia diagnosed on the ultrasound of the first trimester of pregnancy, in which an area with 14 x 20 mm econegative formations was observed with little uptake of the color Doppler and which was confirmed in the second trimester by corial biopsy of that area. The pregnancy was normal until week 33, after which an intrauterine growth restriction was detected. Due to the high incidence of obstetric complications of this entity, an induction of labor was decided at week 37 of gestation. CONCLUSIONS Whenever this type of pathology is diagnosed, it is recommended a close follow-up of pregnancy and an induction of labor around 37-38 weeks of gestation, due to the perinatal complications presents.

Hormona antimülleriana como predictor de respuesta ovárica. Revisión de la literatura y validación del test en nuestra unidad de reproducción asistida / Antimüllerian hormone as a predictor of ovarian response. Review of the literature and validation of the test in our assisted reproduction unit

Objetivo: evaluar la capacidad del test de hormona antimülleriana para predecir la baja o alta respuesta en pacientes usuarias de fecundación in vitro de nuestro centro. Se realiza una revisión bibliográfica sobre el papel del test de hormona antimülleriana en el estudio de la paciente infértil. Material y métodos: se trata de un estudio retrospectivo en 392 mujeres incluidas en nuestro programa de fecundación in vitro entre los años 2014-2015. A cada paciente se le extrajo una muestra de sangre para la determinación de hormona antimülleriana como parte del estudio básico de infertilidad. Tras la estimulación y punción ovárica, se correlacionó la hormona antimülleriana con el número de ovocitos obtenidos. Resultados: el valor de 0,29 ng/ml predijo la baja respuesta con una especificidad del 99%. El valor que mejor se comportó a la hora de predecir la alta respuesta fue 4,38 ng/ml con una sensibilidad del 87% y una especificidad de 84%. Conclusiones: la hormona antimülleriana nos ayuda a predecir la respuesta a la estimulación ovárica controlada en los ciclos de fecundación in vitro. Un valor de 0,29 ng/ml nos permite identificar la baja respuesta con un 99% de especificidad y un valor predictivo positivo del 86% en nuestra población. Nuestros puntos de corte son similares a los publicados en la literatura (AU)

Objective: Evaluate the potential of antimüllerian hormone levels to predict low or high response, in vitro fertilization patients treated by our centre. Perform a literature review of the use of antimüllerian hormone testing in the Investigation of infertile patients. Material and methods: We carried out a retrospective study of 392 women, who started treatment of in vitro fertilization between 2014 and 2015 in our reproductive unit. Each patient provided a blood sample as part of the basic infertility investigations; this was tested for levels of antimüllerian hormone. Following ovarian stimulation and harvest, the level of antimüllerian hormone was correlated with the number of oocytes extracted. Results: A Value of 0.29 ng/ml predicts low response with a specificity of 99%. The antimüllerian hormone level, which best correlated with a high response, was greater than 4.38 ng/ml, with high sensitivity (87%) and specificity (84%). Conclusions: Antimüllerian hormone levels help to predict response to controlled ovarian stimulation in cycles of in vitro fertilization. A Value of 0.29 ng/ml helps us to identify low likelihood of response, with a specificity of 99% and a positive predictive value of 86% in our population. Our cut-off points are similar to those reported in the literatura (AU)

Hematoma de rectos abdominales en el embarazo. Reporte de un caso / Rectus sheath haematoma in pregnancy. A case report

Introducción: aunque el hematoma de los músculos rectos del abdomen es infrecuente durante el embarazo, debe ser considerado en el diagnóstico diferencial de pacientes que presenten abdomen agudo al fi nal del embarazo. Tanto la RM como la ecografía son útiles en el diagnóstico y tratamiento; que, inicialmente, y si el paciente se encuentra hemodinámicamente estable, debe ser conservador Caso clínico: presentamos el caso de una gestante con hematoma de músculos rectos del abdomen que, en un primer momento, se confundió con un desprendimiento prematuro de placenta (AU)

Background: Rectus sheath haematoma is infrequent during pregnancy but must be considered in the differential diagnosis of acute abdominal pain at the end of pregnancy. Both magnetic resonance imaging and ultrasound are useful for its diagnosis and treatment, which should be conservative as long as the patient is haemodynamically stable. Case report: We present the case of a pregnant woman with a rectus sheath haematoma, which was thought to be a placental abruption (AU)

Endometritis tuberculosa sin foco primario y dolor pélvico crónico / Tuberculous endometritis with no primary focus and chronic pelvic pain

Antecedentes: La tuberculosis genital y la endometritis tuberculosa es una forma de tuberculosis que continúa siendo frecuente en los países en desarrollo y habitualmente es secundaria a un foco primario pulmonar. Puede cursar de forma asintomática, o bien, producir síntomas como infertilidad primaria o secundaria, alteraciones menstruales o dolor pélvico crónico, entre otros. Caso clínico: Se presenta el caso de una paciente de 47 años en estudio por ginecología y urología por dolor pélvico crónico y sintomatología urinaria inespecífica de aproximadamente 6 meses de evolución. La ecografía transvaginal muestra contenido intracavitario escaso sugerente de piometra e imágenes trabeculares compatibles con sinequias uterinas. Mediante aspirado endometrial se extrae pus y muestra endometrial que se remite para estudio anatomopatológico. Tras el informe anatomopatológico que diagnostica inflamación crónica granulomatosa necrotizante, se solicita estudio por PCR y cultivo para micobacteriumm tuberculosis, siendo ambos positivos para el microorganismo. De este modo, se diagnosticó como endometritis tuberculosa sin existir afectación de otros órganos tras el estudio completo. Se realizó tratamiento con etambutol hidrocloruro, isoniacida, pirazinamida y rifampicina durante 2 meses y pirazinamida e isonicida durante 7 meses adicionales. Al final del tratamiento, la paciente mostraba clara mejoría de los síntomas y a la ecografía desaparición de la colección intracavitaria uterina.

Background: Genital tuberculosis and endometritis tuberculosa is a form of tuberculosis which remains prevalent in developing countries and is usually secondary to a pulmonary primary focus. It may be asymptomatic, or may produce symptoms such as primary or secondary infertility, menstrual disorders or chronic pelvic pain, among others. Clinical case: We present the case of a patient of 47-year who was studied by ginecology and urology for chronic pelvic pain and unspecific urinary symptoms since about 6 months. In transvaginal ultrasound pyometra and trabecular images compatible with uterine synechiae were observed. Endometrial samples were obtaining and sent for histopathologic examination which was informed of chronic necrotizing granulomatous inflammation. We asked for PCR and culture for tuberculosis micobacteriumm, both being positive for the microorganism. Thus, she was diagnosed of endometritis tuberculosa without involvement of other organs after complete study. She performed a treatment with ethambutol hydrochloride, isoniazid, rifampicin and pyrazinamide for 2 months and pyrazinamide and isoniazid for 7 months. At the end of treatment, the patient showed clear improvement of symptoms and disappearance of uterine intracavitary collection in the ultrasonographic study.

Endometrial adenocarcinoma in one horn of a didelphic uterus with vaginal duplication.

A 59-year-old female patient presented with vaginal bleeding. A didelphic uterus with vaginal duplication was diagnosed on the basis of physical examination and radiology tests. Biopsy revealed an endometrial cancer in the left horn, while the right was atrophic. Laparoscopic hysterectomy, bilateral salphingo-oophorectomy, pelvic and para-aortic lymphadenectomy were performed. According to Federation International of Gynecology and Obstetrics (FIGO) staging the tumour was classified Ib. The adjuvant therapy was vaginal cuff brachytherapy. After 6 months, she has no evidence of the disease.

Revisión del tratamiento del embarazo ectópico sobre cicatriz de cesárea previa. Una localización poco habitual / Review of the treatment of ectopic pregnancy in a previous cesarean section scar. A unusual location

La gestación implantada sobre cicatriz de cesárea previa es una forma poco habitual de embarazo ectópico, pero cuya incidencia ha aumentado en los últimos años en relación con las técnicas de reproducción asistida. Precisa de un diagnóstico temprano para poder minimizar las posibles complicaciones que pueden ocurrir (metrorragia, hemoperitoneo, rotura uterina,..). Disponemos de diferentes opciones diagnósticas y terapéuticas que revisaremos en este trabajo y que elegiremos en función de las características individuales de cada paciente (AU)

The pregnancy implanted on cesarean scar is a rare form of ectopic pregnancy, but whose incidence has increased in recent years in relation to assisted reproduction techniques. Accurate early diagnosis is needed in order to minimize the possible complications that can occur (metrorrhagia, hemoperitoneum, uterine rupture,..). We have different diagnostic and treatment options that will be reviewed in this paper and we will choose based on the individual characteristics of each patient (AU)

Diagnóstico prenatal no invasivo: presente y futuro de mano de las nuevas tecnologías / Non-invasive prenatal diagnosis: present and future by means of new technologies

Desde que en 1997 se demostrara la presencia de ADN fetal en sangre periférica materna, son numerosos los grupos que se dedican a investigar en este campo para intentar desarrollar e incorporar a la rutina clínica el diagnóstico prenatal no invasivo. De la mano de la constatación de la presencia del ADN fetal en el torrente materno surgió el diagnóstico no invasivo del sexo fetal. Este y el estudio del RhD fetal han sido los únicos análisis incorporados a la rutina clínica. Aunque existen grupos investigando en el campo del diagnóstico de las enfermedades mendelianas, los esfuerzos se han centrado en el diagnóstico de las aneuploidías fetales. En un principio, el alcance de los diagnósticos estuvo limitado por la presencia mayoritaria de ADN materno coexistiendo con el ADN fetal. Sin embargo, el desarrollo reciente de tecnologías mucho más sensibles, está permitiendo un avance vertiginoso de este campo(AU)

Since the presence of foetal DNA in maternal peripheral blood was demonstrated in 1997, several research groups have developed their activity in this field in order to promote non-invasive prenatal diagnosis into clinical routine. By demonstrating the presence of foetal DNA in the maternal bloodstream, the non-invasive assessment of the sex of the foetus was achieved. This test, together with the foetal RhD determination, has been the only ones incorporated into clinical routine. Although there are research groups working on the diagnosis of Mendelian diseases, efforts have focused on the diagnosis of foetal aneuploidies. At first, the diagnostic scope was limited by the higher presence of maternal DNA co-existing with the foetal DNA. However, recent advances in more sensitive technologies is enabling dramatic progress to be made in this field(AU)

Noninvasive prenatal diagnosis of monogenic disorders.

INTRODUCTION: Since the presence of circulating cell-free fetal DNA (ccffDNA) in maternal peripheral blood was demonstrated in 1997, great efforts have been done in order to use this source of fetal material for noninvasive prenatal diagnosis. The advantage that it represents is avoiding the obstetric invasive procedures required for conventional prenatal diagnosis. AREAS COVERED: Efforts are mainly focused on finding the most accurate way to diagnose the most common fetal aneuploidies, paying special attention to trisomy 21. Recent advances in technology offer new diagnostic tools with high degrees of sensitivity thus generating great expectations for this type of diagnosis. However, there are other reasons why pregnant women undergo conventional prenatal diagnosis. Being at risk of transmitting a monogenic disorder is one of them. And although the percentage of those pregnancies may represent a small percentage of the diagnosis performed in the first trimester, these numbers should not be underestimated. EXPERT OPINION: Management of pregnancies at risk of an X-linked Mendelian disorder has changed thanks to the noninvasive fetal sex assessment. As for other Mendelian disorders, until recently, their study was limited to those cases paternally inherited. Nevertheless, the new emerging technologies are also opening the scope to maternally inherited disorders.