Cervix assessment for the management of labor induction: reliability of cervical length and Bishop score determined by residents.

AIM: To evaluate the reliability of two techniques of cervical ripeness assessment at the beginning of labor induction, as assessed by inexperienced observers. METHODS: A total of 120 women were prospectively studied at admission for labor induction. Two independent physicians examined consenting women successively but separately. One experienced consultant and one of the six first-year obstetrics residents composed the pairs of observers. The trainees had very limited prior experience with cervical ultrasound scan or evaluating Bishop score. Cervical length and Bishop score were evaluated according to standard methodology. Reliability was described by intraclass correlation coefficients (ICC) and coefficients of variation (COV). Ultrasound cervical length was plotted according to the Bland-Altman method. RESULTS: The median Bishop score and mean cervical length were similar for all observers. Ultrasound cervical length and Bishop score were highly reliable when evaluated by first-year residents. Ultrasound cervical length showed the highest interobserver agreement, with ICC values over 0.9 and COV values of approximately 10% or less for all trainees. The Bishop score was also reliable, but with lower ICC and higher COV values. CONCLUSION: Bishop score and ultrasound cervical length examination for the management of labor induction are accurate and easy to learn by inexperienced first-year residents. However, cervical length showed higher reliability than the Bishop score.

[Conservative management of cervical ectopic pregnancy]. / Tratamiento conservador de la gestación ectópica cervical.

BACKGROUND: Cervical ectopic pregnancy is a rare type of ectopic pregnancy (less than one percent of all ectopic pregnancies). OBJECTIVE: Assess the efficacy of the treatment options available. MATERIAL AND METHODS: Retrospective study of the cervical ectopic pregnancies treated in our hospital from January 2005 to December 2011. RESULTS: Three patients were diagnosed cervical ectopic pregnancy in our hospital during that period, that is, an incidence of 1.7 per 10,000 gestations. The main symptom was a moderate-to-severe genital hemorrhage. In two of the cases a single dose of 50 mg/cm2 methotrexate was administered, and in the third one, curettage and uterine arterial embolization were performed. Histerectomy was not necessary in either of the cases. CONCLUSION: Conservative management of cervical ectopic pregnancy is an effective and safe option.

Predictors of perinatal outcomes and economic costs for late-term induction of labour.

OBJECTIVE: We aimed to predict the perinatal outcomes and costs of health services following labour induction for late-term pregnancies. MATERIALS AND METHODS: We conducted a cohort study of 245 women who underwent labour induction during their 41st week of gestation. The cervical condition was assessed upon admission using the Bishop score and ultrasound cervical length measurements. We estimated the direct costs of labour induction, and a predictive model for perinatal outcomes was constructed using the decision tree analysis algorithm and a logit model. RESULTS: A very unfavourable Bishop score at admission (Bishop score <2) (OR, 3.43 [95% CI, 1.77-6.59]), and a history of previous caesarean section (OR, 7.72 [95% CI, 2.43-24.43]) or previous vaginal delivery (OR, 0.24 [95% CI, 0.09-0.58]) were the only variables with predictive capacity for caesarean section in our model. The mean cost of labour induction was €3465.56 (95% confidence interval [CI], 3339.53-3591.58). Unfavourable Bishop scores upon admission and no history of previous deliveries significantly increased the cost of labour induction. Both of these criteria significantly predicted the likelihood of a caesarean section in the decision tree analysis. CONCLUSION: The cost of labour induction mostly depends on the likelihood of successful trial of labour. Combined use of the Bishop score and previous vaginal or caesarean deliveries improves the ability to predict the likelihood of a caesarean section and the economic costs associated with labour induction for late-term pregnancies. This information is useful for patient counselling.

Amniotic fluid sludge as a marker of intra-amniotic infection and histological chorioamnionitis in cervical insufficiency: a report of four cases and literature review.

Amniotic fluid sludge (AFS) is defined as the presence of particulate matter in the amniotic fluid in close proximity to the cervix. Although its prevalence is known to correlate with the risk of preterm delivery, initial reports describe a strong association between AFS and microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis. However, AFS is also present in uncomplicated pregnancies, and its prevalence appears to increase with gestational age. Recent evidence debates the usefulness of AFS as a marker of early preterm delivery risk. We present four cases with AFS diagnosed by transvaginal ultrasound at admission for cervical insufficiency between 20 and 24 weeks of gestation, with confirmed lower genital tract and intra-amniotic infections by amniocentesis and histological chorioamnionitis and funisitis. Our findings reinforce the presence of AFS as a useful marker of MIAC, chorioamnionitis and funisitis that increase the likelihood of preterm delivery at an extreme gestational age.

Economic implications of labor induction.

OBJECTIVE: To assess health service costs associated with labor induction according to different clinical situations in a tertiary-level hospital. METHODS: In a prospective study, individual patient cost data were assessed for women admitted for induction of labor at a tertiary hospital in Spain between November 1, 2012, and August 31, 2013. The costs of labor induction were estimated according to maternal and neonatal outcomes, method of delivery, cervical condition at admission, and obstetric indication. Direct costs including professional fees, epidural, maternal stay, consumables, and drugs were calculated. RESULTS: Overall, 412 women were included in the final cost analysis. The mean total cost of labor induction was €3589.87 (95% confidence interval [CI] 3475.13-3704.61). Cesarean delivery after labor induction (€4830.45, 95% CI 4623.13-5037.58) was significantly more expensive than spontaneous delivery (€3037.45, 95% CI 2966.91-3179.99) and instrumental vaginal delivery (€3344.31, 95%CI 3151.69-3536.93). The total cost for patients with a very unfavorable cervix (Bishop score <2; €4283.47, 95% CI 4063.06-4503.88) was almost double that for women with a favorable cervix (€2605.09, 95% CI 2327.38-2837.58). Labor induction for hypertensive disorders of pregnancy was the most expensive obstetric indication for induction of labor (€4347.32, 95% CI 3890.45-4804.18). CONCLUSION: Following the induction of labor, a number of patient- and treatment-related factors influence costs associated with delivery.

Schwannoma Con Una Localización Cervical Infrecuente En Un Paciente Pediátrico: Reporte De Caso / Schwannoma With A Non-Frequent Location In Pediatric Patient. Case Report

Resumen Los schwannomas son tumores usualmente benignos, de crecimiento lento y generalmente propios de adultos. Son muy raros en la población pediátrica y su diagnóstico requiere un alto índice de sospecha clínica. Se presenta el caso de un paciente de sexo masculino de 9 años con historia de una masa cervical asintomática, sin otros antecedentes clínicos relevantes. La escisión total de la masa fue posible e histopatología confirmó el diagnóstico de schwannoma. El paciente se recuperó completamente, con excelente pronóstico. Es necesario tener presente a los schwannomas en el diagnóstico diferencial en casos de masas cervicales en pacientes pediátricos.

Abstract Schwannomas are usually benign, slow-growing tumors, usually found in adults. They are very rare in the pediatric population and their diagnosis requires a high index of clinical suspicion. We present the case of a 9-year-old male patient with a history of an asymptomatic cervical mass, with no other relevant clinical history. Total excision of the mass was possible, and histopathology confirmed the diagnosis of schwannoma. The patient recovered completely, with excellent prognosis. It is necessary to keep in mind schwannomas in the differential diagnosis in cases of cervical masses in pediatric patients.

Low-risk pregnancy at 41 weeks: when should we induce labor?

OBJECTIVE: To study the perinatal outcome according to whether labor was induced or not, when a low-risk pregnancy reached 41 weeks of gestation. METHODS: A quasi-experimental study of 11492 low-risk singleton pregnancies was designed. A total of 1,721 patients (15.0%) women met the study criteria, were informed about the risks and benefits and gave their informed consent, of whom 629 (36.5%) were planned for induction soon after the 41 weeks (287-289 days). RESULTS: An intention-to-treat analysis was performed. The proportion of small-for-gestational age babies was lower in the early-induced labor cohort (10.5% versus 15%; p = 0.008). This cohort showed an increased hospital stay (4.54 versus 3.80 days; p < 0.001), and a higher rate of requiring delivery by caesarean section (31.1% versus 19.8%;p < 0.001), including the need for caesarean section for failed induction (21.8% versus 11%;p < 0.001). Three stillbirths occurred in the group followed expectantly, whereas no stillbirths were seen in the early induction group. CONCLUSIONS: Induction of labor for prolonged pregnancy in low-risk patients soon after the 41 weeks, reduces the proportion of small-for-gestational age babies, but increases the mean hospital stay as well as the need for delivery by caesarean section, including that for failed induction.

Estudio observacional, transversal, de una muestra representativa de las mujeres españolas en edad fértil, sobre los cuidados, hábitos y promoción de la salud previamente y durante el embarazo: Estudio GESTMUJER / Cross-sectional study of vitamin and folic acid supplementation in a representative sample of Spanish women of fertile age before and during pregnancy: The GESTMUJER study

Objetivo. Conocer los hábitos de las mujeres españolas en edad fértil, respecto al uso de suplementos vitamínicos y ácido fólico antes y durante el embarazo. Material y método. Encuesta telefónica realizada a una muestra representativa de 1.020 mujeres residentes en España de 15 a 49 años de edad, durante el mes de marzo del 2013. Resultados. Una de cada 4 mujeres españolas planifica su embarazo. Como consecuencia de esta falta de planificación, solo el 28,6% de las mujeres había tomado un suplemento de ácido fólico con anterioridad al momento de quedar embarazada. Conclusiones. Sigue existiendo la necesidad de informar y aconsejar a las mujeres en edad fértil sobre la conveniencia de utilizar ácido fólico previamente a un embarazo. Parecen necesarias campañas institucionales que promuevan tanto la planificación de un futuro embarazo, como el uso de suplementos vitamínicos antes y durante el mismo (AU)

Objective. To identify the use of folic acid and other vitamins in Spanish women of fertile age before and during pregnancy. Material and method. A representative survey of 1020 Spanish women aged 15 to 49 years was carried out in March 2013. Results. Only one quarter of Spanish women planned their pregnancies and,as a result, only 28.6% of women took folic acid before becoming pregnant. Conclusions. There is a lack of information about the role and importance of folic acid to prevent neural tube defects. Institutional campaigns are needed to promote both pregnancy planningand the use of vitamin supplements before and during pregnancy (AU)

Un nuevo escenario asistencial / A new healthcare scenario

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Los procedimientos diagnósticos y los tratamientos excesivos en obstetricia y ginecología / Diagnostic procedures and overtreatment in obstetrics and gynecology

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Mortalidad materna en África / Maternal mortality in Africa

Los autores presentan en este informe la dramática situación de la salud materna en los países de África. De acuerdo con las estimaciones más recientes, en este continente muere anualmente cerca de medio millón de mujeres (1 muerte materna/min); un número importante de ellas (entre 3 y 4 millones) queda con fístulas genitourinarias invalidantes. Al contrario, en los países industrializados sólo se registran anualmente 2.500 muertes maternas (el 0,47% del total mundial) con una tasa de mortalidad materna (TMM) del 20/100.000. La situación es especialmente mala en los países del África subsahariana donde las distintas TMM superan los 1.000/100.000 nacidos vivos, con un riesgo de muerte materna durante toda la vida de 1/14 frente a 1/2.800 de los países desarrollados. El informe analiza las causas de muerte materna en el continente africano, las razones por las que se producen los 3 retrasos que las condicionan (retraso en la solicitud de ayuda, en llegar al hospital y en este último), así como las intervenciones necesarias para disminuir las elevadas TMM. Finalmente se presenta un plan integral, auspiciadopor la World Association of Perinatal Medicine (WAPM) y la International Academy of Perinatal Medicine (IAPM), que tiene por objetivo reducir en tres cuartas partes la TMM en África Central, de acuerdo con el espíritu de la Declaración de los Objetivos del Milenio de la Asamblea General de las Naciones Unidas

In this report, the authors describe the dramatic situation of maternal health in African countries. According to the most recent estimates, almost 1 million African women die each year (one maternal death per minute) and a significant proportion of these (between 3 and 4 million) have incapacitating genitourinary fistulae. In contrast, in industrialized countries, only 2,500 maternal deaths are registered yearly (0.47% of the total worldwide) with a maternal mortality ratio (MMR) of 20 per 100,000 live births. The situation is especially unfavorable in Sub- Saharan Africa, where the distinct MMR are higher than 1,000 per 100,000 live births, with a lifetime risk of maternal death of 1/14 compared with 1/2,800 in developed countries. This report analyzes the causes of maternal death in the African continent, the reasons for the three type of delay that affect these causes (delay in requesting help, delay in arriving at a hospital and delay in receiving medical attention after arrival), as well as the interventions required to reduce the elevated MMR. Finally, an Integral Plan, developed by the World Association of Perinatal Medicine (WAPM) and the International Academy of Perinatal Medicine (IAPM) is presented. This initiative aims to reduce theMMR in Central Africa by two-thirds, in agreement with the spirit of the «Declaration on the Millenium Development Goals» of the United Nations General Assembly

Efecto del ácido levofolínico sobre las concentraciones de homocisteína plasmática en la mujer joven y sana en la consulta preconcepcional / Effects of levofolinic acid on plasma homocysteine concentrations in healthy and young women in preconceptional care

FUNDAMENTO: El aumento de la homocisteína plasmática total (tHcy) es un factor de riesgo para los defectos del tubo neural. Se estudia el efecto de la suplementación con ácido levofolínico (l,5-formil-tetrahidrofólico) sobre los valores de la tHCy plasmática en la mujer en edad reproductiva. PACIENTES Y MÉTODO: Treinta mujeres sanas de 18 a 35 años recibieron 5 mg/día de ácido levofolínico por vía oral durante 30 días. La tHcy y los folatos intraeritrocitarios se determinaron antes de la suplementación (día 0), los días 2, 5, 10 y 30 durante el tratamiento, y 30 (día 60) y 60 días (día 90) después de finalizado. La tHcy plasmática se determinó por inmunoanálisis de polarización de fluorescencia (coeficiente de variación [CV] intraanálisis e interanálisis < 8 por ciento) y el ácido fólico intraeritrocitario, mediante inmunoanálisis quimioluminiscente (CV intraanálisis e interanálisis < 5 por ciento). RESULTADOS: La tHCy plasmática disminuye a partir del segundo día de tratamiento (día 0 frente a 2: media de la diferencia, -1,24 µmol/l; intervalo de confianza [IC] del 95 por ciento, -0,84 a -1,63; p < 0,001). El descenso máximo (32,3 por ciento) se observa a los 30 días (media de la diferencia, -2,72 µmol/l; IC del 95 por ciento, -2,20 a -3,24; p < 0,001). Tras finalizar el tratamiento el efecto hipohomocisteinémico persiste el día 60 (media de la diferencia, -2,67 µmol/l; IC del 95 por ciento, -2,07 a -3,26; p < 0,001) y 90 (media de la diferencia, -1,49 µmol/l; IC del 95 por ciento, -0,94 a -2,03; p < 0,001). La respuesta fue mayor cuando la tHcy plasmática fue de 9 µmol/l o más. CONCLUSIONES: El ácido levofolínico provoca un descenso temprano, intenso y persistente de las concentraciones de tHcy plasmática (AU)