Embarazo abdominal a término con recién nacido vivo sin malformaciones. Reporte de caso: revisión de la bibliografía / Abdominal term pregnancy with a live newborn without malformations. Case report: literature review

Resumen ANTECEDENTES: El embarazo abdominal representa el 1% de los embarazos ectópicos, con una mortalidad materna que puede alcanzar, incluso, hasta el 20% y una mortalidad fetal hasta del 90%. CASO CLÍNICO: Paciente de 31 años, en curso de las 39 semanas del segundo embarazo. El primero se atendió, sin complicaciones, en el domicilio cuando tenía 25 años; enseguida se le indicó, como método anticonceptivo, acetato de medroxiprogesterona inyectable trimestral. Acudió al Hospital Regional Docente de Cajamarca debido a un dolor abdominal luego de siete controles prenatales. Se ingresó al servicio de Obstetricia al tercer día con pródromos de labor de parto, feto en transverso y placenta previa. En la cesárea de urgencia el útero se encontró de 18 cm, la placenta adherida al epiplón, intestino, colon sigmoide, recto y pared izquierda del útero. Se obtuvo una recién nacida con Apgar 8-9, sin malformaciones. Se practicaron: extracción de la placenta, histerectomía abdominal subtotal y salpingooforectomía izquierda. El sangrado intraoperatorio fue de 1800 mL por lo que ameritó la transfusión de dos paquetes globulares. La madre y su hija evolucionaron favorablemente por lo que se dieron de alta del hospital, sin complicaciones. CONCLUSIÓN: El embarazo abdominal es un evento raro, sobre todo si llega a término y con un recién nacido vivo saludable. A pesar de los estudios ultrasonográficos, el embarazo abdominal no es de diagnóstico fácil; por eso casi todos se diagnostican durante la cirugía. Si la placenta no afecta estructuras vasculares extensas, ni órganos abdominopélvicos, podrá retirse, con cuidados extremos, para no originar males mayores.

Abstract BACKGROUND: Abdominal pregnancy represents 1% of ectopic pregnancies, with a maternal mortality that can reach up to 20% and a fetal mortality of up to 90%. CLINICAL CASE: 31-year-old female patient, in the course of 39 weeks of her second pregnancy. The first pregnancy was attended, without complications, at home when she was 25 years old; she was immediately prescribed quarterly injectable medroxyprogesterone acetate as a contraceptive method. She went to the Regional Teaching Hospital of Cajamarca due to abdominal pain after seven prenatal check-ups. She was admitted to the obstetrics service on the third day with prodromes of labor, transverse fetus and placenta previa. In the emergency cesarean section the uterus was found to be 18 cm, the placenta adhered to the omentum, intestine, sigmoid colon, rectum and left wall of the uterus. A newborn was obtained with Apgar 8-9, without malformations. Placental extraction, subtotal abdominal hysterectomy and left salpingo-oophorectomy were performed. Intraoperative bleeding was 1800 mL, which required the transfusion of two packs of red blood cells. The mother and daughter evolved favorably and were discharged from the hospital without complications. CONCLUSION: Abdominal pregnancy is a rare event, especially if it is carried to term with a healthy live newborn. Despite ultrasonographic studies, abdominal pregnancy is not easily diagnosed; therefore almost all are diagnosed during surgery. If the placenta does not affect extensive vascular structures or abdominopelvic organs, it can be removed, with extreme care, so as not to cause greater harm.

Resección histeroscópica de embarazo ectópico cervical posterior a fecundación in vitro

El embarazo ectópico cervical es una patología de baja frecuencia, que presenta alto riesgo de hemorragia y pérdida de la fertilidad debido a la necesidad de histerectomía. Presentamos un caso de embarazo ectópico cervical después de fecundación in vitro tratada con éxito con resección histeroscópica.

Cervical ectopic pregnancy is a low frequency pathology, which presents a high risk of hemorrhage and loss of fertility due to the need for hysterectomy. We present a case of cervical ectopic pregnancy after in vitro fertilization successfully treated with hysteroscopic resection.

Comparison of the efficacy of the aromatase inhibitor letrozole and clomiphene citrate as adjuvants to recombinant follicle-stimulating hormone in controlled ovarian hyperstimulation: a prospective, randomized, blinded clinical trial.

OBJECTIVE: To study the efficacy of the aromatase inhibitor letrozole as adjuvant to recombinant FSH (rFSH) in controlled ovarian hyperstimulation (COH). DESIGN: Prospective, randomized, and blinded clinical study. SETTING: Academic tertiary institute. PATIENT(S): Forty-one patients with unexplained infertility undergoing intrauterine insemination (IUI) therapy were randomized to receive either letrozole or clomiphene citrate (CC) as adjuvants to rFSH. INTERVENTION(S): From day 3 to 7 of the cycle 2.5 mg/d letrozole or 100 mg/d CC were administrated. All patients received 75 IU rFSH starting on day 7 of stimulation until the day of hCG administration. Ovulation was triggered with recombinant hCG (250 microg) when the leading follicle(s) reached 18 mm in diameter. A single IUI was performed 36 hours later. The luteal phase was supplemented with micronized progesterone vaginally. MAIN OUTCOME MEASURE(S): Ovarian stimulation response (E(2) levels and number of follicles) was our primary outcome. RESULT(S): There were no differences in demographic characteristics between groups. Although there was a significantly lower peak serum E(2) level in the group receiving letrozole + rFSH compared with CC + rFSH (914 +/- 187 vs. 1,207 +/- 309 pg/mL, respectively; P<.007), there were no differences in the number of mature (>16 mm) preovulatory follicles. A significantly higher endometrial thickness was observed at the time of hCG administration in patients that received letrozole (9.5 +/- 1.5 mm vs. 7.3 +/- 1.1 mm; P=.0001). The clinical pregnancy rate was similar between groups (23.8% vs. 20%, respectively). CONCLUSION(S): The aromatase inhibitor letrozole appears to constitute a good alternative to CC in patients with unexplained infertility undergoing gonadotropin-stimulated COH cycles combined with IUI therapy.

[Changes in a semen analysis related to spontaneous pregnancy in patients with infertility history]. / Cambios seminales relacionados con embarazo espontáneo en pacientes con antecedente de infertilidad.

OBJECTIVE: To describe changes in a semen analysis before getting a spontaneous pregnancy. MATERIAL AND METHODS: In an observational, descriptive, longitudinal and retrospective study a semen analysis of the first evaluation of 96 patients was compared with the exam accomplished before getting a spontaneous pregnancy. A descriptive analysis of the semen exam was performed and the results of both exams were compared by means of at Student test with statistical significance for p < 0.05. RESULTS: In the first analysis, the volume, density, mobility, normal morphology, total number of mobile cells and total number of mobile cells with normal morphology (TNMCNM) were 2.45 +/- 1.39 mL, 79 +/- 43 million/mL, 40 +/- 21%, 27 +/- 14%, 84 +/- 84 million and 23 +/- 29 million, respectively, and in the final analysis were 2.6 +/- 1.26 mL, 79 +/- 42 million/mL, 43 +/- 21%, 28 +/- 14%, 97 +/- 98 million and 28 +/- 33 million, respectively. None of them were different. In four patients with low testosterone and a LH/FS > or = 1 ratio, volume increased from 1 +/- 0.31 to 1.65 +/- 0.17 mL and normal morphology from 22 +/- 7 to 31 +/- 5. Both variables were different. In six patients with high prolactine and low testosterone or low FSH, density increased from 56 +/- 21 to 114 +/- 18 million/mL and TNMCNM from 14 +/- 12 to 46 +/- 32 million. Both variables were different. CONCLUSION: Only those patients with low testosterone and a LH/FSH > or = 1 rate had an increase of semen volume and normal morphology. Those with high prolactine-low testosterone or high prolactine-low FSH had an increase of the total mobile cells and the total mobile cells with normal morphology. There were not changes in any semen variable of the other patients.

[Prognostic factors of pregnancy in intrauterine insemination]. / Factores pronóstico de embarazo en inseminación intrauterina.

BACKGROUND: The artificial insemination is the introduction of spermatozoa in the feminine genital tract without carrying out sexual contact and with the purpose of obtaining the pregnancy. The insemination intrauterine has improved its rate of success thanks to the technological advances and the best knowledge of human reproductive physiology. OBJECTIVES: To evaluate the prognostic factors for the pregnancy success and calculate the cumulative rate per cycle in IUI (intrauterine insemination). PATIENTS AND METHODS: This study was descriptive, retrospective, analytic, and longitudinal. The cycles of IUI were analyzed from January 1st 2003 to December 31st 2005. Couples 24-41 years old with primary and secondary infertility were included. The following variables were studied: age of participant, type of infertility, length of infertility, aetiology, postcapacitation sperm density and motility, number of follicles, endometrial thickness, and the cycle number in which the IUI was performed. Patients carried out a protocol of ovarian stimulation and follicular follow up. The results were analyzed with 11.0 SPSS, continuous variables were analyzed and reported as means +/- SD with univariate logistic regression to determine statistic significance. Categoric variables were reported in frequencies and percentages. ROC curves were calculated to determine optimal cutting points. RESULTS: 668 cycles were analyzed in 391 couples. The pregnancy rate per cycle and couple was of 13.0 and 21.7% respectively. Means +/- SD patient age was 33.5 +/- 3.4 years old. The three variables with p < 0.05 were: the infertility duration, sperm motility and the cycle number in which IUI was performed. No statistical significance was found in the remaining variables. CONCLUSIONS: The greatest success in IUI will be achieved with infertility of 4 years or less, with sperm motility of 77.6% and in the first two cycles of treatment.