Úlceras vulvares: un reto diagnóstico / Vulvar ulcers: A diagnostic challenge

Las úlceras vulvares son una entidad patológica relevante por su repercusión en la calidad de vida de la mujer y suponen un desafío diagnóstico dada la variedad etiológica y de presentación clínica. El diagnóstico se basa en la anamnesis, la exploración física detallada y pruebas complementarias.Presentamos el caso clínico de una paciente de 39 años con diagnóstico de úlceras vulvares graves, recidivantes, que requirió ingreso hospitalario prolongado en tres ocasiones. Se describe el proceso de identificación, los posibles diagnósticos diferenciales y el resultado del tratamiento aplicado.(AU)

Vulvar ulcers are an important pathological condition due to their impact on the quality of life of women. It is a diagnostic challenge given the aetiological variety and clinical presentation. The diagnosis is based on anamnesis, detailed physical examination, and complementary tests.The clinical case is presented of a 39-year-old patient diagnosed with severe, recurrent vulvar ulcers, and who required prolonged hospital admission on three occasions. The diagnostic process, possible differential diagnoses, and the outcome of the applied treatment are described.(AU)

Tratamiento con plasma autólogo rico en plaquetas en una paciente estéril con un endometrio refractario / Treatment with rich platelets autologous plasma in a sterile patient with suspected refractory endometrium

Paciente de 36 años con esterilidad primaria de 2 años. Tras estudio completo se decide donación de ovocitos. En los controles se observa un grosor endometrial adelgazado. Con el diagnóstico de endometrio refractario, se realiza un tratamiento con estrógenos a altas dosis, vitamina E y pentoxifilina durante 3 meses. Como el grosor endometrial no aumenta, asociamos AAS. Finalmente se administra intraútero plasma autólogo rico en plaquetas. A las 96 horas se observa un endometrio de 7,3 mm, transfiriéndose dos embriones vitrificados, resultando en un aborto bioquímico. Discusión: El tratamiento médico del endometrio refractario constituye un reto. Existen numerosas opciones terapéuticas, hormonales y no hormonales. Sin embargo, la mayoría de estas opciones están escasamente evaluadas por lo que se requieren de estudios mejor diseñados y con mayor tamaño muestral (AU)

36 years old patient with primary sterility of 2 years. An oocyte donation was decided after the study. An endometrial thickness slimmed was observed in different visits. With the diagnosis of refractory endometrium, a treatment was performed with high-dose estrogen, vitamin E and pentoxifylline for 3 months. As the endometrial thickness did not increase, we associated AAS. Finally intrauterine platelet-rich autologous plasma was administered. At 96 hours 7.3 mm of endometrium was observed, two vitrified embryos transferred, resulting in a biochemical abortion. Discussion: The medical treatment of refractory endometrium is a challenge. There are many therapies, hormonal and nonhormonal options. However, most of these options are poorly evaluated so they require better designed studies and larger sample size (AU)

Diagnóstico prenatal de peritonitis meconial simple / Prenatal diagnosis of simple meconium peritonitis

Nos encontramos ante un feto que presenta una masa anecoica con una superficie calcificada desde el principio del segundo trimestre que posteriormente se resuelve con la aparición de calcificaciones distribuidas en la cápsula hepática. No presenta ninguna otra calcificación en el parénquima hepático ni patología a nivel intestinal o abdominal. Clínicamente se mantuvo estable. Estos hallazgos conducen al diagnóstico de peritonitis meconial simple. El diagnóstico ecográfico prenatal de la peritonitis meconial juega un papel muy importante y se ha demostrado para mejorar los resultados prenatales significativos. Los resultados son de todo tipo y también dependerán de la gravedad de la perforación y el momento en que se diagnostica

We report the case of a foetus with an anechoic mass with a calcified surface from the beginning of the second trimester, which subsequently resolved with the appearance of calcifications distributed in the liver capsule. No calcification of the liver parenchyma or intestinal or abdominal organ disease was identified and the condition was clinically stable. These findings led to the diagnosis of simple meconium peritonitis. The antenatal ultrasonographic diagnosis of meconium peritonitis plays a very important role and has been shown to significantly improve the antenatal results. The findings are varied and depend on the severity of the perforation and the timing of diagnosis

Do knowledge of uterine artery resistance in the second trimester and targeted surveillance improve maternal and perinatal outcome? UTOPIA study: a randomized controlled trial.

OBJECTIVES: To ascertain whether screening for pre-eclampsia (PE) and intrauterine growth restriction (IUGR) by uterine artery (UtA) Doppler in the second trimester of pregnancy and targeted surveillance improve maternal and perinatal outcomes in an unselected population. METHODS: This was a multicenter randomized open-label controlled trial. At the routine second-trimester anomaly scan, women were assigned randomly to UtA Doppler or non-Doppler groups. Women with abnormal UtA Doppler were offered intensive surveillance at high-risk clinics of the participating centers with visits every 4 weeks that included measurement of maternal blood pressure, dipstick proteinuria, fetal growth and Doppler examination. The primary outcome was a composite score for perinatal complications, defined as the presence of any of the following: PE, IUGR, spontaneous labor < 37 weeks' gestation, placental abruption, stillbirth, gestational hypertension, admission to neonatal intensive care unit and neonatal complications. Secondary outcomes were a composite score for maternal complications (disseminated intravascular coagulation, maternal mortality, postpartum hemorrhage, pulmonary edema, pulmonary embolism, sepsis), and medical interventions (for example, corticosteroid administration and induction of labor) in patients developing placenta-related complications. RESULTS: In total, 11 667 women were included in the study. Overall, PE occurred in 348 (3.0%) cases, early-onset PE in 48 (0.4%), IUGR in 722 (6.2%), early-onset IUGR in 93 (0.8%) and early-onset PE with IUGR in 32 (0.3%). UtA mean pulsatility index > 90(th) percentile was able to detect 59% of early-onset PE and 60% of early-onset IUGR with a false-positive rate of 11.1%. When perinatal and maternal data according to assigned group (UtA Doppler vs non-Doppler) were compared, no differences were found in perinatal or maternal complications. However, screened patients had more medical interventions, such as corticosteroid administration (relative risk (RR), 1.79 (95% CI, 1.4-2.3)) and induction of labor for IUGR (RR, 1.36 (95% CI, 1.07-1.72)). In women developing PE or IUGR, there was a trend towards fewer maternal complications (RR, 0.46 (95% CI, 0.19-1.11)). CONCLUSIONS: Routine second-trimester UtA Doppler ultrasound in an unselected population identifies approximately 60% of women at risk for placental complications; however, application of this screening test failed to improve short-term maternal and neonatal morbidity and mortality. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Influencia de la edad gestacional, el tipo de parto y la reanimación en el riesgo de neumotórax en neonatos mayores de 37 semanas / Influence of gestational age, type of delivery, and resuscitation, on the incidence of pneumothorax in term neonates

INTRODUCCIÓN: La cesárea electiva antes de las 39 semanas de edad gestacional (EG) se ha asociado a un incremento en la incidencia de distrés respiratorio iatrogénico y de neumotórax en el recién nacido a término (RNT), probablemente en relación con una mayor morbilidad respiratoria y necesidad de reanimación. Estos aspectos no han sido evaluados sistemáticamente en nuestro medio. OBJETIVO: Conocer si la EG, el tipo de parto y la intensidad de la reanimación cardiopulmonar (RCP) se asocian con un incremento en la incidencia de neumotórax en el RNT. PACIENTES Y MÉTODOS: Se estudiaron todos los RNT (≥ 37 semanas de EG) nacidos en nuestra maternidad durante el periodo 2006-2010, según el tipo de parto (vaginal, cesárea o fórceps) y su indicación en el caso de las cesáreas. Se consideró RCP avanzada la aplicación de presión positiva con mascarilla, intubación, o necesidad de compresiones torácicas y/o medicación. El diagnóstico de neumotórax fue clínico y radiológico. RESULTADOS: Se incluyeron un total de 32.238 RNT. Tipo de parto: vaginal 76,1%, cesárea 12,4% y fórceps 11,5%. La incidencia de neumotórax fue del 0,316%, siendo significativamente mayor en las cesáreas (0,85%) que en los fórceps (0,59%) o nacimientos vaginales (0,19%) (p < 0,001); en ≥ 40 semanas de EG (0,37%) frente a ≤ 39 semanas de EG (0,24%) (p = 0,033) y en RCP avanzada (4,29%) frente a RCP básica (0,18%) (p < 0,001). CONCLUSIONES: La EG ≥ 40 semanas, el parto mediante cesárea o fórceps y la RCP avanzada se asociaron significativamente a una mayor incidencia de neumotórax en el RNT. En nuestra población no se observó un aumento en la incidencia de neumotórax tras cesárea electiva en menores de 39 semanas de EG

BACKGROUND: Elective caesarean section before 39 weeks gestational age (GA) has been associated with a higher incidence of iatrogenic respiratory distress and pneumothorax in term newborn babies, probably because of a higher respiratory morbidity and the need for resuscitation. These factors have not been systematically evaluated in our patients. OBJECTIVE: To determine whether the gestational age, type of delivery, and intensity of resuscitation, are associated with an increase in the incidence of pneumothorax in term neonates. PATIENTS AND METHODS: Full term neonates (≥37 weeks GA) born in our maternity unit from January 2006 to December 2010 were studied, along with the type of delivery (vaginal, forceps or caesarean section). Advanced cardiopulmonary resuscitation (CPR) was defined as the need of bag and mask intermittent ventilation, intubation, chest compression, and/or administration of medication. The diagnosis of pneumothorax was clinical and radiological in all cases. RESULTS: A total of 32,238 full term newborns were included. Type of delivery: vaginal 76.1%, C-section 12.4%, and forceps 11.5%. The incidence of pneumothorax was 0.316%. It was significantly higher in C-section (0.85%), than in forceps (0.59%), or non-instrumental vaginal deliveries (0.19%) (P < 0.001), and in infants ≥40 weeks GA (0.37%) compared to ≤39 weeks GA (0.24%) (P = 0.033), and in advanced CPR (4.29%) compared to basic CPR (0.18%) (P < 0.001). CONCLUSIONS: A GA≥40 weeks, C-section, or forceps delivery, and advanced CPR immediately after birth were significantly associated with a higher incidence of pneumothorax in full term newborn babies. In our population, we did not observe an increase in pneumothorax among neonates born by elective C-section before 39 weeks of gestation

[Influence of gestational age, type of delivery, and resuscitation, on the incidence of pneumothorax in term neonates]. / Influencia de la edad gestacional, el tipo de parto y la reanimación en el riesgo de neumotórax en neonatos mayores de 37 semanas.

BACKGROUND: Elective caesarean section before 39 weeks gestational age (GA) has been associated with a higher incidence of iatrogenic respiratory distress and pneumothorax in term newborn babies, probably because of a higher respiratory morbidity and the need for resuscitation. These factors have not been systematically evaluated in our patients. OBJECTIVE: To determine whether the gestational age, type of delivery, and intensity of resuscitation, are associated with an increase in the incidence of pneumothorax in term neonates. PATIENTS AND METHODS: Full term neonates (≥ 37 weeks GA) born in our maternity unit from January 2006 to December 2010 were studied, along with the type of delivery (vaginal, forceps or caesarean section). Advanced cardiopulmonary resuscitation (CPR) was defined as the need of bag and mask intermittent ventilation, intubation, chest compression, and/or administration of medication. The diagnosis of pneumothorax was clinical and radiological in all cases. RESULTS: A total of 32,238 full term newborns were included. Type of delivery: vaginal 76.1%, C-section 12.4%, and forceps 11.5%. The incidence of pneumothorax was 0.316%. It was significantly higher in C-section (0.85%), than in forceps (0.59%), or non-instrumental vaginal deliveries (0.19%) (P<.001), and in infants ≥ 40 weeks GA (0.37%) compared to ≤ 39 weeks GA (0.24%) (P=.033), and in advanced CPR (4.29%) compared to basic CPR (0.18%) (P<.001). CONCLUSIONS: A GA ≥ 40 weeks, C-section, or forceps delivery, and advanced CPR immediately after birth were significantly associated with a higher incidence of pneumothorax in full term newborn babies. In our population, we did not observe an increase in pneumothorax among neonates born by elective C-section before 39 weeks of gestation.