Diagnóstico y tratamiento quirúrgico de una paciente con una neoplasia trofoblástica gestacional / Diagnosis and surgical treatment of a patient with gestational trophoblastic neoplasia

Resumen ANTECEDENTE: La neoplasia trofoblástica gestacional forma parte del grupo de afecciones derivadas de la proliferación anómala del trofoblasto con capacidad para invasión y metástasis. CASO CLÍNICO: Paciente de 42 años, asintomática, con sospecha ecográfica de mola hidatiforme. El legrado uterino y el estudio anatomopatológico confirmaron el diagnóstico de mola hidatiforme completa. Con la cuantificación consecutiva de tres elevaciones de la β-HCG se diagnosticó: neoplasia trofoblástica gestacional. Se estadificó en estadio I, bajo riesgo y ante el deseo genésico satisfecho la paciente aceptó la histerectomía más salpingectomía bilateral. En el seguimiento posterior la paciente se encontró asintomática, con determinaciones seriadas de b-HCG negativa y ecografías vaginales sin hallazgos. CONCLUSIÓN: La histerectomía con salpingectomía bilateral puede ser el tratamiento definitivo en casos seleccionados de neoplasia trofoblástica. La evidencia disponible es escasa, por lo que es necesario seguir investigando en este campo.

Abstract BACKGROUND: Gestational trophoblastic neoplasia is one of a group of conditions resulting from abnormal trophoblast proliferation with capacity for invasion and metastasis. CLINICAL CASE: 42-year-old asymptomatic patient with ultrasound suspicion of hydatidiform mole. Uterine curettage and anatomopathological study confirmed the diagnosis of complete hydatidiform mole. With the consecutive quantification of three elevations of β-HCG a diagnosis of gestational trophoblastic neoplasia was made. It was staged as stage I, low-risk, and the patient agreed to hysterectomy plus bilateral salpingectomy. At subsequent follow-up the patient was found to be asymptomatic, with negative serial determinations of β-HCG and vaginal ultrasound scans without findings. CONCLUSION: Hysterectomy with bilateral salpingectomy may be the definitive treatment in selected cases of trophoblastic neoplasia. The available evidence is scarce and further research is needed in this field.

Applicability, Safety, and Efficiency of Salpingectomy versus Electrocoagulation and Laparoscopic Tubal Section in Ambulatory / Aplicabilidade, segurança e eficiência da salpingectomia versus eletrocoagulação e secção tubar laparoscópica em regime de ambulatório

Abstract Objective Female sterilization is a surgical procedure that aims women to permanently stop the use of conception. The benefits, risks and cost-effectiveness are important issues. The purpose of this study was comparing the applicability, complications and efficacy of salpingectomy versus electrocoagulation and tubal occlusion by laparoscopy in the Ambulatory Surgery Unit. Methods We performed a retrospective and observational study that included women undergoing laparoscopic sterilization procedures at our Ambulatory Surgery Unit, during three years. Statistical analysis was performed using SPSS, applying the Fisher exact test, the Mann-Whitney test, and Linear Regression. Results Two hundred and twenty-one laparoscopic surgical procedures were performed, including 79 (35.7%) bilateral total salpingectomies and 142 (64.3%) electrocoagulation and bilateral tubal occlusion procedures. The majority of the procedures were performed by a resident (n = 162; 73.3%), with 40% (n = 33) of salpingectomies. The surgical time, independently the type of surgeon, was significantly shorter in the tubal occlusion (42.2 vs. 52.7 min, p < 0.001). Safety and efficacy endpoints were not significantly different between the two groups, with a case of pregnancy in tubal occlusion group. Conclusion Salpingectomy is a safe and effective alternative comparing with electrocoagulation and tubal occlusion.

Resumo Objetivo A esterilização feminina é um procedimento cirúrgico que auxilia as mulheres na paragem permanente de utilização de métodos contraceptivos. Os objetivos desde estudo foram comparar a aplicabilidade, complicações e eficácia da salpingectomia vs. eletrocoagulação e secção tubar na esterilização feminina em regime de ambulatório. Métodos Realizou-se um estudo retrospectivo e observacional que incluiu mulheres submetidas a procedimentos de esterilização por laparoscopia no Serviço de Cirurgia de Ambulatório da ULSAM, durante três anos. A análise estatística foi realizada com recurso ao SPSS, aplicando o teste exato de Fisher, o teste de Mann-Whitney e Regressão Linear. Resultados Foram realizados 221 procedimentos cirúrgicos por laparoscopia, incluindo 79 (35,7%) salpingectomias totais bilaterais e 142 (64,3%) procedimentos por eletrocoagulação e secção tubar bilateral. A maioria dos procedimentos foram realizados por um interno de formação específica (n = 162; 73,3%), com 40% (n = 33) de salpingectomias. O tempo operatório foi significativamente inferior no grupo da eletrocoagulação (42,2 vs. 52,7 min, p < 0,001). Em relação à segurança e à eficácia não se observaram diferenças estatisticamente significativas entre os dois grupos, com um caso de gravidez após eletrocoagulação e secção tubar. Conclusão A salpingectomia é uma alternativa segura e com alta taxa de eficácia quando comparada com eletrocoagulação e secção tubar.

Tratamiento quirúrgico conservador del embarazo intersticial, con antecedente de salpingectomía homolateral. Reporte de un caso / Conservative surgical management of interstitial pregnancy, with a history of ipsilateral salpingectomy. Report of a case

Resumen ANTECEDENTES: El procedimiento quirúrgico del embarazo intersticial puede complicarse con hemorragia difícil de controlar; por esto en los últimos años se recurre a las técnicas que permiten el control hemostático, con lo que disminuyen la morbilidad y mortalidad relacionadas con el procedimiento. OBJETIVO: Describir el proceso para establecer el diagnóstico y decidir el tratamiento quirúrgico conservador en una paciente con embarazo intersticial con antecedente de salpingectomía homolateral y deseo de preservación uterina. CASO CLINICO: Paciente de 27 años, con antecedentes de un parto, tres abortos y un embarazo ectópico previo, con salpingectomía izquierda. Acudió a consulta debido a un retraso menstrual de siete semanas y dolor pélvico agudo. Ante la sospecha de embarazo ectópico se integró el protocolo diagnóstico. La cuantificación de la fracción-β de hormona gonadotropina coriónica fue de 8962 mlU/mL, el ultrasonido transvaginal reportó una imagen compatible con saco gestacional hacia la región del cuerno izquierdo y probable hemoperitoneo. En la laparotomía exploradora se encontraron: hemoperitoneo y embarazo intersticial izquierdo. Con el propósito de preservar la fertilidad se hizo una doble ligadura de la arteria uterina izquierda, a nivel de istmo uterino y del ligamento útero-ovárico y resección del saco gestacional intersticial, con cornuostomía. CONCLUSION: El embarazo intersticial es una urgencia obstétrica con alto riesgo de ruptura y hemorragia, por fortuna poco frecuente. La ligadura de las arterias uterinas, previa a la ablación quirúrgica del saco gestacional, es una alternativa individualizada en pacientes con esta complicación.

Abstract BACKGROUND: The surgical procedure of interstitial pregnancy can be complicated by bleeding that is difficult to control; for this reason, in recent years, techniques that allow hemostatic control to have been used, thus reducing morbidity and mortality related to the procedure. OBJECTIVE: To describe the process to establish the diagnosis and decide the conservative surgical treatment in a patient with interstitial pregnancy with a history of homolateral salpingectomy and desire for uterine preservation. CLINICAL CASE: 27-year-old patient, with a history of one childbirth, three miscarriages and a previous ectopic pregnancy, with left salpingectomy. She came for consultation due to a seven-week menstrual delay and acute pelvic pain. In view of the suspicion of ectopic pregnancy, the diagnostic protocol was integrated. The quantification of the β-fraction of chorionic gonadotropin hormone was 8962 mlU/mL, the transvaginal ultrasound reported an image compatible with gestational sac towards the left horn region and probable hemoperitoneum. At exploratory laparotomy, hemoperitoneum and left interstitial pregnancy were found. To preserve fertility, a double ligation of the left uterine artery at the level of the uterine isthmus and the utero-ovarian ligament and resection of the interstitial gestational sac with cornuostomy was performed. CONCLUSION: Interstitial pregnancy is an obstetric emergency with a high risk of rupture and hemorrhage, fortunately rare. Ligation of the uterine arteries, prior to surgical ablation of the gestational sac, is an individualized alternative in patients with this complication.

Salpingectomía oportunista: patrones de práctica en un grupo de ginecólogos colombianos / Opportunistic Salpingectomy: patterns of practice in a group of colombian gynecologists

INTRODUCCIÓN Y OBJETIVOS: El cáncer de ovario es la neoplasia de origen ginecológico más letal y el 90% de los casos son de origen epitelial. Se ha postulado el origen del cáncer epitelial de ovario (CEO) en las fimbrias de las trompas de Falopio, por lo cual, se ha sugerido la realización de la salpingectomía oportunista como método de prevención primaria. La presente investigación tiene como objetivo determinar la frecuencia con que los ginecólogos adscritos a la Federación Colombiana de Ginecología y Obstetricia (FECOLSOG) incluyeron salpingectomías oportunistas en su práctica clínica durante los años 2017-2018. MÉTODOS: Se realizó una encuesta a los ginecólogos adscritos a la FECOLSOG. Las variables analizadas incluyeron características demográficas, práctica profesional, método de prevención primaria de cáncer de ovario en pacientes de bajo riesgo y la realización o no de la salpingectomía oportunista y sus respectivas razones. Las variables cualitativas se analizaron con frecuencias absolutas y relativas, mientras que las cuantitativas con medidas de tendencia central y desviaciones estándar con el software STATA 13. RESULTADOS: De 1765 ginecólogos contactados, 353 contestaron la encuesta (tasa de respuesta del 20%). El 62.5% de estos realizan salpingectomía oportunista en su práctica ginecológica y de estos, el 75.2% lo hizo para prevenir cáncer de ovario. Entre las razones manifestadas por los especialistas para no realizar salpingectomía oportunista, el 12.5% no la consideraba un factor de protección frente al cáncer de ovario y un 14.4% consideraba que incrementaba el riesgo de falla ovárica temprana y morbilidad asociada. CONCLUSIÓN: Aunque existen controversias en su realización, la salpingectomía oportunista muestra ser una conducta adoptada por ginecólogos adscritos a FECOLSOG. Se requieren investigaciones futuras para determinar la efectividad de la salpingectomía e implementar estrategias de prevención del cáncer epitelial de ovario.

INTRODUCTION AND OBJECTIVES: Ovarian cancer is the most lethal gynecological malignancy and 90% of cases are of epithelial origin. Recently, different investigations attribute their origin to the fimbriae of the fallopian tubes, reason why it has been suggested to perform elective salpingectomy for the prevention of high-grade adenocarcinoma, its most frequent histological variant. This research aims to determine the frequency with which gynecologists from the Colombian Federation of Gynecology and Obstetrics (FECOLSOG) included this procedure in their clinical practice during the years 2017-2018. METHODS: A survey was sent electronically to the gynecologists assigned to FECOLSOG on three different occasions with an interval of 15 days between them. The variables analyzed included demographic characteristics, professional practice, primary prevention method of Ovarian Cancer in low-risk patients and the performance or not of elective salpingectomy with their respective reasons. Qualitative variables were analyzed with absolute and relative frequencies, while quantitative variables with measures of central tendency and standard deviations with STATA 13 software. RESULTS: From 1765 gynecologists contacted at least once via email, 353 answered the survey, indicating a response rate of 20%. 62.5% perform elective salpingectomy in their gynecological practice and of these, 75.2% do so to prevent ovarian cancer. Among the reasons for not practicing salpingectomy, 12.5% ​​do not consider it a protective factor for ovarian cancer, and 14.4% believe that it increases the risk of early ovarian failure and morbidity. CONCLUSION: Elective salpingectomy is a promising procedure as a preventive measure against epithelial ovarian cancer. Although there are controversies regarding its performance, salpingectomy seems to be a common practice amongst gynecologists from FECOLSOG, and seems to have higher recurrence within this field. Future research is required to determine the effectiveness of salpingectomy and thus, implement the best strategies for ovarian cancer prevention.

Embarazo ectópico intraligamentario / Ectopic Intraligamentary Pregnancy

Introducción: El embarazo ectópico es la implantación del producto de la concepción fuera de la cavidad endometrial. Objetivo: Reportar un caso de embarazo ectópico intraligamentario por lo infrecuente que es esta localización. Métodos: Presentación de caso de paciente de 25 años, con antecedentes de VIH e infecciones vaginales a repetición. Asiste a emergencias con dolor intenso en bajo vientre e historia de amenorrea de 12 semanas. Se hace el diagnóstico de posible embarazo ectópico abdominal y se decide laparotomía de urgencia. Resultados: Durante el transoperatorio se diagnostica un embarazo ectópico intraligamentario izquierdo, se realiza salpingectomía con resección de todo el ligamento ancho. La paciente evolucionó satisfactoriamente. Conclusiones: El embarazo ectópico continúa siendo una de las principales urgencias dentro de las especialidades quirúrgicas. Sigue elevando la mortalidad materna a nivel mundial y siempre que las condiciones lo permitan se debe pensar en él para hacer un diagnóstico oportuno(AU)

Introduction: Ectopic pregnancy is the implantation of the product of conception outside the endometrial cavity. Objective: To report a case of intraligamentary ectopic pregnancy because of the infrequent nature of this location. Case Report: This is a 25-year-old patient with a history of HIV and repeated vaginal infections. She comes to the emergency room with severe pain in the lower abdomen and history of amenorrhea for 12 weeks. Possible abdominal ectopic pregnancy is diagnosed and the emergency laparotomy is decided. During the transoperative period, a left intraligamentary ectopic pregnancy was diagnosed. Salpingectomy was performed with resection of the entire broad ligament. Result: The patient evolved satisfactorily. Conclusions: Ectopic pregnancy continues to be one of the main emergencies in surgical specialties. Maternal mortality continues raising worldwide and whenever the conditions suggest so, we must think about it to make a timely diagnosis(AU)

Eficacia del retiro quirúrgico de Essure para el alivio del dolor pélvico: serie de casos / Surgical removal of the Essure device as a response to pelvic pain: case series

Resumen OBJETIVO: Evaluar la eficacia del retiro quirúrgico del Essure como medida para aliviar el dolor pélvico ocasionado, presuntamente, por este dispositivo. MATERIALES Y MÉTODOS: Estudio descriptivo y retrospectivo de una serie de casos. Se revisaron las historias clínicas de las pacientes atendidas entre el 1 de enero de 2016 y el 15 de agosto de 2018 en el Complexo Hospitalario Universitario de Ourense para la extracción quirúrgica del dispositivo Essure. Parámetros de estudio: datos demográficos, historial médico, información de la inserción, características del dolor, tipo de intervención, hallazgos durante la intervención y posoperatorios. Los datos se analizaron con el programa SPSS, versión 24 para Windows. RESULTADOS: Se intervinieron 11 pacientes y 7 de ellas tuvieron dolor abdominal después de la colocación del dispositivo, con una tardanza media de aparición de 3.75 años. La técnica quirúrgica más practicada fue la salpingectomía bilateral (7 de 11 pacientes). 7 de las 11 pacientes continuaron con dolor luego de la extracción del dispositivo; de ellas, 2 tenían diagnóstico previo de dolor crónico y 3 antecedente de cirugía abdominal. CONCLUSIONES: En esta muestra de pacientes a quienes se extrajo el Essure, el retiro no resultó eficaz para aliviar el dolor en casi dos tercios de ellas. Esto pone de relieve que la extracción no garantiza la eliminación del dolor. Las investigaciones futuras deberán dirimir porqué en algunos casos la cirugía de extracción no resulta efectiva.

Abstract OBJECTIVE: To evaluate the efficacy of the surgical removal of Essure in the elimination of pelvic pain caused, presumably, by this device. MATERIALS AND METHODS: A descriptive study of case series was conducted retrospectively. A review was performed of the medical histories of all the patients (11 in total) who underwent surgical removal of Essure devices at the University Hospital of Ourense (Spain) in the period between 1 January 2016 and 15 August 2018. The following items were collected: demographic data, medical history, data related to the insertion, characteristics of the pain, type of intervention, findings during the intervention and postoperative findings. The total number of patients intervened during that period was 11. The data was analyzed with the statistical software SPSS version 24 for Windows. RESULTS: Eleven patients were operated and 7 of them had abdominal pain after placement of the device, with an average delay of appearance of 3.75 years. The most practiced surgical technique was bilateral salpingectomy (7 of 11 patients). 7 of the 11 patients continued with pain after removal of the device; of them, 2 had previous diagnosis of chronic pain and 3 antecedents of abdominal surgery. CONCLUSIONS: It is evident that surgical removal of the Essure insert was not effective in almost two-thirds of the patients under study, which highlights that its removal does not guarantee the elimination of pain. Future research should determine why in some cases surgical removal is not effective.

Embarazo ectópico tubárico con feto vivo en una adulta joven / Ectopic tubal pregnancy with alive fetus in a young adult woman

Se describe el caso clínico de una paciente de 21 años de edad quien acudió al Cuerpo de Guardia del Hospital Ginecobstétrico Docente Tamara Bunke Bider de Santiago de Cuba por presentar dolor leve en bajo vientre y sangrado en forma de manchas luego de que le fuera realizado un legrado uterino por aspiración 8 días atrás. Se efectuó una ecografía ginecológica que mostró un embarazo ectópico tubárico de 11 semanas en el lado derecho, con el feto vivo, por lo cual se indicó laparotomía exploratoria de urgencia y salpingectomía parcial en la trompa derecha. La paciente evolucionó de manera satisfactoria

The case report of a 21 years patient who went to the emergency room of Tamara Bunke Bider Teaching Gynecological-Obstetrics Hospital in Santiago de Cuba is described. She presented a slight pain in low stomach and bledding in form of stains after a suction curettage 8 days earlier. A gynecological echography that showed an ectopic tubaric pregnancy of 11 weeks in the right side, with alive fetus was carried out, reason why an exploratory emergency laparotomy and partial salpingectomy in the right tube were indicated. The patient had a satisfactory clinical course

Patrón menstrual y reserva ovárica en pacientes con salpingectomía y oclusión tubárica para esterilización definitiva / Menstrual pattern and ovarian reserve in patients undergoing to salpingectomy and tubal occlusion for definitive sterilization

Resumen Objetivo: Evaluar el patrón menstrual y la reserva ovárica mediante la determinación de FSH y conteo de folículos antrales en pacientes con salpingectomía y oclusión tubárica bilateral como métodos de esterilización definitiva. Material y métodos: Estudio prospectivo, longitudinal, comparativo, experimental, con asignación al azar, ciego simple, al que se incluyeron pacientes con deseos de esterilización definitiva como método anticonceptivo. Las pacientes se asignaron al azar a dos grupos, el primero con oclusión tubárica bilateral y el segundo con salpingectomía. A los seis meses posprocedimiento se evaluaron en forma ciega el patrón menstrual y la determinación sérica de hormona folículo estimulante (FSH) y el recuento de folículos antrales por ultrasonido transvaginal como marcadores de reserva ovárica. El análisis estadístico se llevó a cabo con t de Student para muestras independientes (comparación entre los grupos) y dependientes (comparación intragrupo) para comparación de medias y la prueba x2 para comparación de proporciones. Resultados: Se estudiaron 60 pacientes, 31 con oclusión tubárica bilateral y 29 con salpingectomía. Se registraron aumentos significativos en los días de sangrado menstrual con respecto a la basal después de la oclusión tubaria bilateral (p = .002) y salpingectomía (p = .008). No hubo diferencias entre oclusión tubárica bilateral y salpingectomía con respecto al tiempo quirúrgico para llevar a cabo la técnica de esterilización (p = .83), duración del ciclo menstrual (p = .35), duración de los días de sangrado menstrual (p = .40). Tampoco resultaron diferencias en las concentraciones séricas de FSH (p = 0.75) ni en el recuento de folículos antrales (p = .44) entre los grupos. Conclusiones: El patrón menstrual y la reserva ovárica son muy similares en pacientes con oclusión tubárica bilateral o salpingectomía. Ambas técnicas incrementan la duración del sangrado menstrual posterior al procedimiento. La salpingectomía implica un aumento ligero en el tiempo quirúrgico, sin diferencias en la frecuencia de complicaciones.

Abstract Objective: To evaluate the menstrual pattern and ovarian reserve in patients undergoing salpingectomy and bilateral tubal occlusion as definitive sterilization methods. Material and methods: A prospective, longitudinal, comparative, experimental, randomized, single blind study was carried out in patients with a desire for definitive sterilization as a contraceptive method. Patients were randomly assigned to perform bilateral tubal occlusion or salpingectomy. Six months after the procedure in each patient, the menstrual pattern and the serum determination of follicle stimulating hormone (FSH) and the antral follicle count were evaluated by transvaginal ultrasound as markers of ovarian reserve. The statistical analysis was carried out using the student's t-test for independent samples (comparison between groups) and dependent samples (intra-group comparison) for comparison of means and the x2 test for comparison of proportions. Results: Sixty patients were studied, 31 with bilateral tubal occlusion and 29 with salpingectomy. Significant increases were observed in the days of menstrual bleeding with respect to the baseline after bilateral tubal occlusion (p = .002) and salpingectomy (p = .008). No differences were observed between bilateral tubal occlusion and salpingectomy with respect to the surgical time to carry out the sterilization technique (p = .83), menstrual cycle duration (p = .35), duration of the days of menstrual bleeding (p = .40). No differences were observed in the serum levels of FSH (p = .75) nor in the antral follicle count (p = .44) between the groups. Conclusions: The menstrual pattern and the ovarian reserve are very similar in patients who undergo bilateral tubal occlusion and salpingectomy, although the two techniques increase the duration of menstrual bleeding after the procedure.

Is ovarian cancer prevention currently still a recommendation of our grandparents? / A prevenção do câncer de ovário ainda é uma recomendação de nossos avós?

Abstract Ovarian cancer is the leading cause of death among gynecologic tumors because in most of the cases (75%), the disease is diagnosed in advanced stages. Screening methods are not available since the disease is rare, and the tested methods, such as ultrasound and CA125, were not able to decrease the mortality rate for this type of cancer. This article discusses the main risk factors for ovarian cancer, and the potential clinical and surgical strategies for the prevention of this disease.

Resumo O câncer de ovário é a principal causa de morte entre os tumores ginecológicos, já que na maioria dos casos (75%) o diagnóstico ocorre em estádios avançados. Métodos de rastreamento não estão disponíveis, já que a doença é rara, e osmétodos diagnósticos, como ultrassonografia e CA 125, não são capazes de reduzir a taxa de mortalidade desse câncer. Este artigo discute os principais fatores de risco para o câncer de ovário e as possíveis estratégias clínicas e cirúrgicas para a prevenção dessa doença.

Tuberculosis genital: diagnóstico e implicaciones en fertilidad. A propósito de un caso / Genital tuberculosis infection: diagnosis and fertility impact. A case report

Resumen CASO CLÍNICO: Paciente de 18 años de edad, sin embarazos previos, que acudió a consulta por dolor y distensión abdominal. La exploración física solo mostró signos de ascitis. La ecografía abdominal reportó líquido libre intraabdominal perihepático, periesplénico y, en ambos flancos. La radiografía de tórax mostró infiltrado intersticial bilateral, de predominio en los campos medios; granuloma calcificado en el lóbulo superior izquierdo. La tomografía toraco-abdomino-pélvica evidenció adenopatías axilares, mediastínicas y cardiofrénicas; útero de tamaño normal y estructuras tubulares pélvicas de 1 cm, bilaterales, compatibles con salpingitis. Ante la sospecha clínica de tuberculosis, se realizó la prueba de Mantoux, que resultó positiva. El estudio ginecológico reportó anejos aumentados de tamaño, duros y de consistencia sólida. La ecografía mostró las trompas de Falopio engrosadas, de morfología arrosariada y vascularización aumentada (53 x 23 mm la derecha y 53 x 14 la izquierda). En la biopsia de endometrio se identificó el bacilo ácido-alcohol resistente. Con estos hallazgos se estableció el diagnóstico de tuberculosis diseminada, con afectación pulmonar y peritoneal. Se prescribió tratamiento con isoniacida, rifampicina, pirazinamida y etambutol, con lo que se observó reacción satisfactoria. La paciente fue dada de alta por disminución de los síntomas, con posterior seguimiento en la consulta de Enfermedades Infecciosas y Ginecología. CONCLUSIÓN: La tuberculosis genital es una alteración poco frecuente en España. El diagnóstico se establece con alta sospecha clínica o durante el estudio de otras enfermedades, pues para su confirmación se requieren medios de cultivo específicos. La importancia del diagnóstico radica en las consecuencias de la fertilidad a futuro, ya que la funcionalidad del aparato reproductor se ve afectada.

Abstract CLINICAL CASE: 18-year-old female patient, who came to the hospital for pain and abdominal distension. Physical examination showed only signs of ascites. Abdominal ultrasound reported perihepatic, perisplenic, and intraabdominal free fluid on both flanks. The radiography showed bilateral interstitial infiltrate, predominantly in the middle fields; Calcified granuloma in the left upper lobe. Thoraco-abdomino-pelvic tomography evidenced axillary, mediastinal and cardiophrenic adenopathies; Uterus of normal size and tubular structures of 1 cm, bilateral, compatible with salpingitis. Before the clinical suspicion of tuberculosis, the Mantoux test was performed, which was positive. The gynecological study reported enlarged aids, hard, solid consistency. Ultrasound showed enlarged fallopian tubes with augmented morphology and increased vascularization (53 x 23 mm on the right and 53 x 14 on the left). Endometrium biopsy identified the resistant acid-bacillus bacillus. With these findings the diagnosis of disseminated tuberculosis with pulmonary and peritoneal involvement was established. Treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was prescribed, with which a satisfactory reaction was observed. The patient was discharged due to decreased symptoms, with subsequent follow-up in the Infectious Diseases and Gynecology service. CONCLUSION: Genital tuberculosis is a rare disorder in Spain. The diagnosis is established with high clinical suspicion or during the study of other diseases, because for its confirmation specific culture media are required. The importance of diagnosis lies in the consequences of future fertility, since the functionality of the reproductive system is affected.

Gestación heterotópica: dos casos con gestación intrauterina viable a término / Heterotopic pregnancy: two cases with viable intrauterine pregnancy at term

Se presentan dos casos de gestación heterotópica, el primero de ellos espontáneo y el segundo tras técnicas de fecundación in vitro. En ambos la gestación intrauterina evolucionó de forma favorable, con control gestacional normal y llegando a término, con el nacimiento de recién nacidos sanos. La gestación heterotópica se define como la presencia simultánea de gestación en dos lugares de implantación distintos, lo más frecuente una gestación intrauterina acompañada de otra ectópica. Se trata de una situación poco frecuente, con una incidencia de 1/8000 embarazos espontáneos según la bibliografía más reciente.

We report two cases of heterotopic pregnancy, the first one spontaneous and the second one after in vitro fertilization techniques. In both, the intrauterine gestation evolved favorably, normal pregnancy control and coming to terms with the birth of healthy newborns. Heterotopic pregnancy is defined as the simultaneous presence of gestation at two different locations, most often in utero accompanied by another ectopic pregnancy. This is a rare situation, with an incidence of spontaneous pregnancies 1/8000 according to the most recent literature.

Salpingectomia "oportuna" como profilaxia do câncer de ovário / "Timely" salpingectomy for ovarian cancer prophylaxis

O câncer de ovário é o tumor ginecológico mais letal, alvo de interesse de centenas de estudos publicados anualmente, buscando melhor entendimento fisiopatológico e a possibilidade de métodos de rastreio. Trata-se da quinta causa de morte por câncer em mulheres, sendo, na maioria das vezes, encontrado em estágios avançados. Existem diversas teorias sobre a origem do câncer de ovário, sendo uma delas a de que a neoplasia ovariana teria sua origem nas tubas uterinas. Sendo assim, estudos sugerem que a exérese das tubas uterinas poderia reduzir a incidência da neoplasia maligna ovariana. A proposta do artigo é realizar uma revisão sobre a salpingectomia bilateral durante cirurgias pélvicas eletivas e suas implicações na qualidade de vida da paciente, seu potencial preventivo e possíveis complicações.(AU)

Ovarian cancer is the most lethal gynecological tumor. Hundreds of manuscripts are annually published, aiming better pathophysiological understanding and screening strategies. Ovarian cancer is the fifth of cancer death in women worldwide and, in most times, the diagnosis is performed in advanced stages. There are several theories about the origin of ovarian cancer, one of which is that the ovarian cancer would have their origin in the fallopian tubes. Thus, current research suggests that the removal of the tubes could reduce the incidence of ovarian malignancy. The purpose of the article is to review of the bilateral salpingectomy during elective pelvic surgeries and their implications for the quality of life of the patient, its preventive potential and possible complications.(AU)

Cáncer serosopélvico de alto grado: evidencia sobre su origen en la trompa de Falopio / High-grade serous pelvic cancer: evidence of its origin in the fallopian tube

Cáncer epitelial de ovario es una enfermedad altamente letal. Constituye la quinta causa de muerte por cáncer en mujeres a nivel mundial. El subtipo histológico más frecuente es el carcinoma seroso de alto grado. Este es el responsable de la alta letalidad de la enfermedad. Se presenta evidencia que respalda el origen tubario de este tipo histológico desde lesiones precursoras. A partir de estos datos se ha establecido que el cáncer tradicionalmente conocido como cáncer ovárico seroso de alto grado, el cáncer de trompa de Falopio y el carcinoma peritoneal primario, corresponden a una misma entidad nosológica: cáncer seroso pélvico de alto grado. Se revisa además la evidencia disponible para establecer que la salpingectomía podría constituir una medida de prevención para este tipo de cáncer.

Epithelial ovarian cancer is a highly lethal disease. It is the 5th cause of cancer death in women worldwide. The most common histologic subtype is the high-grade serous carcinoma. This is the responsible for the high lethality of the disease. Evidence supporting the tubal origin of this histological type from precursor lesions is presented. From these data it has been established that cancer traditionally known as serous high-grade ovarian cancer, cancer of the fallopian tube and primary peritoneal carcinoma, correspond to a single disease entity: pelvic serous high-grade cancer. We also check the available evidence to establish that the salpingectomy could be a preventive measure for this type of cancer.

Câncer no ovário ou do ovário? O grande dilema atual / Cancer from de ovary or into the ovary? The current dilemma

O risco de câncer de ovário varia muito de acordo com a população estudada. Apesar de não ser o tumor maligno ginecológico mais comum é o de maior letalidade. Infelizmente, a maioria dos casos de câncer de ovário é diagnosticada em estadios avançados. Isto ocorre pois até o presente momento todos os programas de rastreio falharam. Mais recentemente, foi proposto um modelo dualístico, que agrupa os cânceres epiteliais em duas grandes categorias, designados por Tipo I e Tipo II. Os do tipo II, compostos principalmente pelos carcinomas serosos de alto grau, são agressivos e geralmente diagnosticados em estadios avançados. Apesar de todos os avanços, ainda não se conseguiu detectar uma lesão precursora do câncer de ovário. Novas teorias sobre a origem do câncer do ovário têm sido descritas e investigadas e sugerem que não é no ovário que a patologia se inicia. Essas teorias trazem novas perspectivas para o diagnóstico precoce e a prevenção deste agressivo tumor.(AU)

The risk of ovarian cancer varies according to the population studied. Although ovarian cancer is not the most common gynecological malignancy, it is the most lethal. Unfortunately, most cases of ovarian cancer are diagnosed in advanced stages. It occurs because until now all screening programs have failed. Most recently, it was proposed a dualistic model, which combines several types of epithelial ovarian cancer into two broad categories, known as Type I and Type II. The Type II is mainly composed by high-grade serous carcinomas and it is aggressive, usually diagnosed in advanced stages. Despite these advances, detect a precursor lesion of ovarian cancer is still not possible. New theories about the origin of ovarian cancer have been reported and investigated, and suggest that it is not in the ovary that pathology begins. These theories provide new perspectives for early diagnosis and prevention of this aggressive tumor.(AU)

Embarazo ectópico en el hospital “Manuel Noriega Trigo”: 20 años después / Ectopic pregnancy in the \"Manuel Noriega Trigo\" hospital: 20 years later

Objetivo: Determinar si la incidencia del embarazo ectópico se ha modificado en el Hospital “Manuel Noriega Trigo” de Maracaibo en los últimos 20 años y si la recolección de los datos clínicos ha mejorado. Métodos: Se revisaron las historias clínicas de pacientes que fueron intervenidas quirúrgicamente en el período comprendido entre agosto 2008 hasta diciembre de 2012. Resultados: Se encontraron 93 casos de embarazo ectópico. La tasa anual fue de 5,9 x 1 000 nacidos vivos. El embarazo ectópico representó el 0,59 % del total de partos, lo que significó uno por cada 170 partos o 5,87 embarazos ectópicos por cada 1 000 partos. La edad promedio de las pacientes fue de 28,1 ± 5,6 años de edad. El dolor abdominal fue el síntoma y el signo clínico más frecuente (95,7 % y 94,6 %). Solo 55 pacientes (59,2 %) refirieron amenorrea. La edad gestacional promedio del embarazo ectópico fue 7,17 ± 2,5 semanas. Once pacientes refirieron cirugías en el área pélvica: 7 casos (7,5 % de 93 casos) con salpingectomía parcial bilateral y 4 apendicectomías. La culdocentesis fue positiva en 31 de 46 casos (72,1 %). El ultrasonido se realizó en el 74,2 % de las pacientes. El diagnóstico al ingreso de embarazo ectópico fue realizado en el 92,5 % de las pacientes. Ochenta y siete (93,5 %) fueron de localización tubárica. El embarazo ectópico fue encontrado roto en 67 casos (81 %). Se realizaron 72 salpingectomías. No hubo muertes maternas. Conclusiones: La incidencia del embarazo ectópico se ha duplicado pero la recolección de los datos clínicos a pesar que ha mejorado sigue siendo deficiente.

Objective: To determine if the incidence of ectopic pregnancy has changed at “Manuel Noriega-Trigo” Hospital, Maracaibo, in the last 20 years; also if the recollection of data has improved. Methods: Medical charts from patients who had surgery due to ectopic pregnancy between August 2008 and December 2011 were reviewed. Results: Ninety three cases were reported. Annual rate of ectopic pregnancy was 5.9 x 1 000 live births. Ectopic pregnancy was 0.59 % of total deliveries, meant an ectopic pregnancy for every 170 deliveries or 5.87 ectopic pregnancies for 1 000 deliveries. Abdominal pain was the clinical symptom and sign more common (95.7 % and 94.6 %). Amenorrhea was present in 55 patients (59.2 %). The mean gestational age of ectopic pregnancy was 7.17 ± 2.5 weeks. Eleven patients mentioned that they had pelvic surgery: 7 bilateral salpingectomy (7.5 % de 93 cases) and 4 appendectomies. Culdocentesis was positive in 36 of 46 cases (72.1 %). Ultrasound was performed in 74.2 % of patient. Ectopic pregnancy diagnosis was done in 92.5 % cases. Tubal ectopic pregnancy was found in 87 (93.5 %) patients. Sixty seven of 83 ectopic pregnancy (81 %) were found ruptured. Seventy two salpingectomies were performed. There was no maternal death. Conclusion: The incidence of ectopic pregnancy has increased twofold. The recollection of data has improved but not enough.

Embarazo ectópico intersticial: ¿variedad de incidencia incrementada? / Interstitial ectopic pregnancy: a variety of increased incidence?

Se describen 6 casos clínicos de mujeres con embarazo ectópico intersticial de menor incidencia entre las formas de la variedad tubárica, tratadas en el Hospital Ginecoobstétrico Docente "Tamara Bunke Bider" de Santiago de Cuba. Esta entidad clínica ha mostrado un incremento inusual en la población asistida (7,59 %) que resulta, 2,57 veces mayor que la media (2,95 %) del intervalo notificado en la bibliografía médica (1,9-4 %). Se exponen las historias individuales de las pacientes en forma tabulada y, asimismo, los autores ofrecen sus consideraciones a propósito de estas experiencias.

Six case reports of women with interstitial ectopic pregnancy of lower incidence among the forms of tubaric variety treated in "Tamara Bunke Bider" Teaching Gynecological and Obstetrical Hospital from Santiago de Cuba are described. This clinical entity has shown an unusual increase in the assisted population (7.59%), which is 2.57 times higher than the mean (2.95%) of the interval notified in the medical literature (1.9-4%). Tabulated individual medical records of the patients are exposed and, likewise, the authors offer their considerations concerning these experiences.

Electroanalgesia for the postoperative control pain in dogs / Eletroanalgesia para o controle da dor pós-operatória em cães

PURPOSE: To evaluate the analgesic and neuroendocrine effects of electroanalgesia in dogs undergoing ovariohysterectomy. METHODS: Eighteen dogs were randomly distributed to three groups of six animals each and received either electrical stimuli at acupuncture points (EA), at peri-incisional dermatomes (DER) and at both acupuncture points and peri-incisional dermatomes (EAD). Pre-anesthetic medication was acepromazine (0.05mg kg-1, IV). Anesthesia was induced with propofol (4 to 5mg kg-1, IV) and maintained with isoflurane. Postoperatively pain degree was measured using a numerical rating scale. Dogs were scored at 1, 3, 6, 12 and 24 hours postoperative. If the pain score was ≥6, supplemental morphine (0.5mg kg-1, IM) was administered. Serum cortisol concentration was measured before pre-anesthetic medication (basal), and at 1, 12 and 24 hours postoperative. RESULTS: EA and EAD- treated dogs had lower pain scores than DER treated dogs one hour postoperatively. Fewer EA and EAD-treated dogs required rescue analgesia. Serum cortisol did not differ among treatments. CONCLUSION: Preoperative application of electrical stimuli to acupuncture points isolated or in combination with peri-incisional dermatomes provides a reduced postoperative opioid requirement and promotes an effective analgesia in dogs undergoing ovariohyterectomy.

OBJETIVO: Avaliar os efeitos analgésicos e neuroendócrinos da eletroanalgesia em cadelas encaminhadas para ovariossalpingohisterectomia. MÉTODOS: Foram avaliadas 18 cadelas, distribuídas aleatoriamente em três tratamentos de seis animais cada: aplicação de estímulo elétrico em pontos de acupuntura (EA), em dermátomos periincisionais (DER) e em pontos de acupuntura associados aos dermátomos periincisionais (EAD). Todos os animais foram tranquilizados com acepromazina (0,05mg kg-1, IV), seguindo-se a indução com propofol (4 a 5mg kg-1, IV) e manutenção anestésica com isofluorano. O grau de analgesia foi avaliado 1, 3, 6, 12 e 24 horas após a cirurgia mediante escala descritiva numérica. Animais com escores ≥6 receberam analgesia de resgate com morfina (0,5mg kg-1, IM). A concentração sérica de cortisol foi avaliada antes da tranquilização, 1, 12 e 24 horas após a cirurgia. RESULTADOS: Escores inferiores de dor foram observados nos tratamentos EA e EAD em relação ao DER na primeira hora pós-operatória. A analgesia de resgate foi menos requerida nos animais dos tratamentos EA e EAD. O cortisol não diferiu entre os tratamentos. CONCLUSÃO: A eletroestimulação de acupontos isolados ou associados aos dermátomos periincisionais reduz o requerimento pós-operatório de opioides, bem como confere efetiva analgesia para cadelas submetidas à ovariossalpingohisterectomia.

Embarazo ectópico / Ectopic pregnancy

Introducción: Se define al embarazo ectópico como la implantación del blastocisto en cualquier lugar distinto de la cavidad endometrial. La trompa de Falopio es el lugar más común, siendo responsable del 95% de los embarazos ectópicos. Su frecuencia ha experimentado un incremento en los últimos 20 años y se ha estimado en 14,3 a 16 embarazos ectópicos por cada 1000 embarazos informados. Objetivo: determinar la prevalencia de casos de embarazo ectópico y sus características clínicas. Materiales y método: estudio descriptivo retrospectivo, de corte transversal, basado en las historias clínicas de pacientes que consultaron al Servicio de Ginecología y Obstetricia de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción en el año 2011. Fueron estudiadas la edad, motivo de consulta, edad gestacional al momento del diagnóstico, sitio de implantación del embarazo, tratamiento empleado y días de internación hasta el momento del alta. Resultados: la prevalencia de embarazos ectópicos hallada fue 1,47%. La edad media fue 29±5 años. El motivo más frecuente de consulta fue dolor abdominal. La edad gestacional promedio al momento de la consulta fue 6,5±1,8 semanas. El sitio más frecuente de localización fue el tubárico (84%). El tratamiento de elección fue el quirúrgico recurriendo al tratamiento médico en sólo tres oportunidades. La media del tiempo de internación fue 3,6±3 días. Conclusión: la prevalencia de embarazo ectópico fue 1,47% en el año 2011. La edad media fue 29 años, se presentó en las trompas de Falopio en 87% y requirió un promedio de 3,6 días de internación.

Introduction: Ectopic pregnancy is defined as implantation of the blastocyst in any place other than the endometrial cavity. The fallopian tube is the most common, accounting for 95% of ectopic pregnancies. Its frequency has been increasing in the last 20 years, and has been estimated at 14.3 to 16 per 1000 ectopic pregnancies reported. Objective: To determine the prevalence of ectopic pregnancy and their clinical characteristics. Materials and Methods: A retrospective, cross-sectional study was performed, based on the medical records of patients who consulted at the Department of Gynecology and Obstetrics, Faculty of Medicine, National University of Asunción in 2011. We studied the age, chief complaint, gestational age at diagnosis, site of implantation of pregnancy, treatment used and length of hospitalization until the time of discharge. Results: The prevalence of ectopic pregnancy was 1.47%. Mean age was 29 ± 5 years. The most common chief complaint was abdominal pain. The mean gestational age at the time of the consultation was 6.5 ± 1.8 weeks. The most common anatomical site was the tubal location (84%). The treatment of choice was surgery, recurring to medical treatment in only three chances. The mean length of stay was 3.6 ± 3 days. Conclusion: The prevalence of ectopic pregnancy was 1.47% in 2011. Mean age was 29 years, located in the fallopian tubes in 87% and required an average of 3.6 days hospitalization.

Diez años después de aprobada la ley del derecho a la esterilización en Costa Rica / Ten years after the passage of the law the right to sterilization in Costa Rica

Realizar un balance histórico de los principales hechos que han ocurrido al cabo de diez años de haberse aprobado el Decreto para plantear interrogantes de cara a las nuevas demandas sociales en esta materia. Método: El trabajo está estructurado en tres partes: en la primera se exponen los principales hechos que antecedieron la aprobación del Decreto y que contribuyeron a dar cuenta de los cuestionamientos que se le hacían en aquel entonces a la aprobación del mismo. En la segunda se presenta una descripción de algunas investigaciones que se generaron en el ámbito académico, a la luz de la aprobación del Decreto y finalmente se analizan algunos datos estadísticos del comportamiento que han tenido las esterilizaciones de hombres y mujeres del 2000 al 2008. Resultado: Investigaciones han mostrado los motivos que han llevado a las mujeres a tomar esta decisión, no así para los hombres cuyos motivos están pendientes de investigar. En el periodo 2000-2008, las salpingectomías experimentaron al inicio un incremento que luego ha tendido a disminuir. No obstante persisten desafíos en salud reproductiva tales como alto número de embarazos, abortos, incremento de VIH. Discusión: El Decreto Ejecutivo 27913-S, aprobado en Costa Rica en el año 1999, ha constitutito un importante logro en materia de derechos reproductivos, ya que ha permitido la democratización del acceso a las operaciones de esterilización femeninas y masculinas...

Take stock of the major historical events that have occurred within ten years after the adoption decree to raise questions in the face of new social demands in this area. Methods: The work is structured in three parts: the first presents the main events that preceded the approval of the decree and that contributed to the account of the questions put to him at the time of approval. The second is a description of some investigations that were generated in academia, in the light of the decree and finally discusses some of the behavior statistics that have sterilizations of men and women from 2000 to 2008. Results: The grounds that have led women to make this decision, but less so for men whose motives have yet to be investigated. Conclusions from the analyzed period show that salpingectomy procedures increased at the beginning but then started to decrease, unlike the situation of men. Although clearly important, it is considered that challenges such as high number of pregnancies, abortions, and increasing HIV infections remain in reproductive health. Discussion: Executive Decree 27913-S -adopted in Costa Rica in 1999- has been a major achievement in terms of reproductive rights, as it has broadened the possibilities for men and women access to sterilization...

Prolapso de trompa uterina: reporte de casos y revisión de la literatura / Fallopian tube prolapse: case reports and literature review

Objetivo: el prolapso de la trompa uterina constituye una complicación quirúrgica poco frecuente y habitualmente ocurre de manera secundaria a la histerectomía vaginal. Dicha patología constituye un reto diagnóstico dado el espectro de lesiones benignas y malignas a nivel del cuello uterino. El presente reporte de casos tiene como objetivo revisar la literatura respecto a la etiología, el diagnóstico y el tratamiento de la entidad. Materiales y métodos: se presentan tres casos de prolapso de trompa uterina, así como una revisión de la literatura, a través de una búsqueda electrónica en las bases de datos Medline vía PubMed, Hinari, SciELO y EMBASE, para recopilar información publicada, tanto en inglés como en español, de los últimos 5 años. Conclusión: el prolapso de trompa uterina poshisterectomía, ya sea vaginal o abdominal, es una complicación quirúrgica anómala. El diagnóstico definitivo se realiza por medio del estudio histopatológico, al evidenciar tejido tubárico asociado a un infiltrado inflamatorio. Para su tratamiento, diferentes técnicas quirúrgicas han sido propuestas con el objetivo de resecar, ya sea parcial o totalmente, la trompa prolapsada con reparo de la apertura vaginal.

Objective: fallopian tube prolapsed is a rare surgical complication, usually occurring secondary to vaginal hysterectomy. Such pathology forms a diagnostic challenge, given the spectrum of cervical benign and malign lesions. The present case reports were aimed at revising the literature regarding the pertinent etiology, diagnosis and treatment. Materials and methods: three cases of fallopian tube prolapse are presented, as well as a literature review involving a search of PubMed via Medline, Hinari, SciELO and EMBASE databases to compile relevant information published in both English and Spanish during the last 5 years. Conclusion: post-hysterectomy fallopian tube prolapse, whether vaginal or abdominal, is a rare surgical complication. Definitive diagnosis is made by histopathological study when tubal tissue associated with inflammatory infiltrate has been shown. Different surgical techniques have been proposed for its treatment aimed at partially or totally removing the prolapsed tube and repairing the vaginal opening.