Malformação arteriovenosa uterina: um relato de caso / Uterine arteriovenous malformation: a case report

O presente estudo tem como objetivo relatar o caso de uma paciente com malformação arteriovenosa uterina, efetivamente tratada com embolização seletiva e com fertilidade preservada. A malformação arteriovenosa uterina é uma alteração vascular rara até então pouco descrita na literatura. A paciente do sexo feminino apresentou quadro de sangramento uterino anormal, com início 30 dias após um abortamento, sem realização de curetagem, de uma gestação resultante de fertilização in vitro. Foram, então, realizados exames de imagem, que levaram ao diagnóstico de malformação arteriovenosa uterina. O tratamento de escolha foi a embolização arterial seletiva, com resolução do caso. Após sete meses, nova fertilização in vitro foi realizada, encontrando-se na 36a semana de gestação. São necessários mais estudos sobre essa malformação a fim de que sejam estabelecidos os métodos mais eficazes para o manejo de casos futuros, especialmente quando há desejo de gestar.

The present study aims to report the case of a patient with uterine arteriovenous malformation, effectively treated with selective embolization and with preserved fertility. Uterine arteriovenous malformation is a rare vascular disorder that has so far been rarely described in the literature. Female patient presented with abnormal uterine bleeding, starting 30 days after an abortion without subsequent curettage, of a pregnancy resulting from in vitro fertilization. Imaging tests were then performed that led to the diagnosis of uterine arteriovenous malformation. The treatment of choice was selective arterial embolization, with successful results. After seven months, a new in vitro fertilization was performed, being in the 36th week of pregnancy. Further studies on this pathology are needed in order to establish the most effective methods for the management of future cases, especially when there is a desire to become pregnant.

Comparative study of the levonorgestrel intrauterine system and laparoscopic hysterectomy for the treatment of heavy menstrual bleeding in enlarged uteri

ABSTRACT Objective To evaluate the effectiveness of the levonorgestrel intrauterine system in the treatment of patients with heavy menstrual bleeding and an enlarged uterus and to compare satisfaction and its complications with hysterectomy. Methods This was a comparative cross-sectional observational study of women with heavy menstrual bleeding and an enlarged uterus. Sixty-two women were treated and followed up for four years. Insertion of the levonorgestrel intrauterine system was performed in Group 1, and laparoscopic hysterectomy was performed in Group 2. Results In Group 1 (n=31), 21 patients (67.7%) showed improvement in the bleeding pattern, and 11 patients (35.5%) had amenorrhea. Five patients (16.1%) remained with heavy bleeding and were considered to have experienced treatment failure. There were seven expulsions (22.6%); in five patients, bleeding remained heavy, but in two patients the bleeding returned to that of normal menstruation. No relationship was found between treatment failure and greater hysterometries (p=0.40) or greater uterine volumes (p=0.50), whereas expulsion was greater in uteri with smaller hysterometries (p=0.04). There were 13 (21%) complications, seven (53.8%) in the group that underwent insertion of the levonorgestrel intrauterine system (all were device expulsions), and six (46.2%) in the surgical group, which were the most severe ones (p=0.76). Regarding satisfaction, 12 patients (38.7%) were dissatisfied with the levonorgestrel intrauterine system and one (3.23%) was dissatisfied with the surgical treatment (p=0.00). Conclusion Treatment with the levonorgestrel intrauterine system in patients with heavy menstrual bleeding and an enlarged uterus was effective, and when compared with laparoscopic hysterectomy, it had a lower rate of satisfaction and the same rate of complications, although less severe.

Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil / Mudança de paradigmas do tratamento inicial de gravidez ectópica em um hospital universitário no Brasil

Abstract Objective To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital. Methods Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression. Results In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36). Conclusion there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.

Resumo Objetivo Avaliar as diferentes opções de tratamento para gravidez ectópica e a frequencia de complicações graves em um hospital universitário. Métodos Estudo observacional com mulheres com gravidez ectópica admitidas no Hospital da Mulher da UNICAMP, no Brasill, entre 01/01/2000 e 31/12/2017. As variáveis de desfecho foram o tipo de tratamento (primeira escolha) e a presença de complicações graves. As variáveis independents foram dados clínicos e sociodemográficos. A análise estatística foi realizada pelo teste de Cochran-Armitage, teste de qui-quadrado, teste de Mann-Whitney e Regressão de Cox Múltipla. Resulados No total, 673 mulheres foram incluídas no estudo. A idade médica foi de 29.0 anos (± 6.1) e a idade gestacional media foi de 7.7 (± 2.5). A frequencia de tratamento cirúrgico diminuiu significativamente ao longo dos anos(z = -4.69; p < 0.001). Simultaneamente, houve um aumento da frequencia do tratamento clínico(z = 4.73; p < 0.001). Setenta e uma mulheres (10.5%) desenvolveram algum tipo de complicação grave. No modelo estatístico final, a prevalência de complicações graves foi maior nas mulheres que tiveram diagnóstico de gestação ectópica rota à admissão (PR = 2.97; 95%CI: 1.61-5.46), que não apresentaram sangramento vaginal (PR = 2.45; 95%CI: 1.41-4.25), sem antecedentes de laparotomia/laparoscopia (PR = 6.69; 95%CI: 1.62-27.53), com gravidez ectópica não-tubária (PR = 4.61; 95%CI: 1.98-10.74), e não tabagistas (PR = 2.41; 95%CI: 1.08-5.36). Conclusão Houve uma mudança na escolha do primeiro tratamento indicado nos casos de gravidez ectópica durante o período analisado. Os fatores inerentes a doença relacionados a maior dificuldade de tratamento foram associados a maior frequencia de complicações graves.

Factores asociados a atonía uterina

La hemorragia postparto (HPP) es la patología de mayor transcendencia con respecto a mortalidad materna, siendo esta una de las principales preocupaciones de la salud pública. La atonía uterina es la principal causa de HPP. Objetivo : Determinar los factores asociados al desarrollo de atonía uterina. Métodos : Estudio observacional analítico de casos y controles de 4,148 pacientes puérperas inmediatas atendidas en el servicio de Obstetricia del Hospital Regional Docente de Trujillo, Perú, entre los años 2009 y 2019; 1,037 pacientes presentaron atonía uterina y 3,111 fueron los controles. Resultados : Al realizar el análisis bivariado, las variables que presentaron significancia estadística como factores asociados para el desarrollo de atonía uterina fueron el parto por cesárea [OR 1,98 (IC 95%: 1,71 a 2,29)], proceder de la sierra [OR 1,38 (IC 95%: 1,12 a 1,70)], el embarazo múltiple [OR 4,48 (IC 95%: 3,43 a 5,83)], parto disfuncional [OR 1,82 (IC 95%: 1,44 a 2,31)] y feto macrosómico [OR 1,37 (IC 95%: 1,08 a 1,73)]. Por otro lado, se mostraron como factores no asociados con significancia estadística el haber sido primípara [OR 0,79 (IC 95%: 0.65 a 0,94)] y el ser multípara [OR 0,82 (IC 95%: 0,69 a 0,97)]. Conclusiones : Los factores asociados al desarrollo de atonía uterina fueron la cesárea como vía de culminación del parto, el ser procedente de la sierra, y haber tenido un feto macrosómico, polihidramnios y embarazos múltiples.

Postpartum hemorrhage (PPH) is the most important pathology in terms of maternal mortality, being one of the main public health concerns. Uterine atony is the main cause of PPH. Objective : To determine the factors associated with the development of uterine atony. Methods : Observational analytical case-control study of 4,148 immediate postpartum patients attended at the Obstetrics Department of the Hospital Regional Docente de Trujillo, Peru, between 2009 and 2019; 1,037 patients presented uterine atony and 3,111 were controls. Results : When performing the bivariate analysis, the variables that presented statistical significance as associated factors for the development of uterine atony were cesarean delivery [OR 1.98 (95% CI: 1.71-2.29)], being from the highlands [OR 1.38 (95% CI: 1.12-1.70)], multiple pregnancy [OR 4.48 (95% CI: 3.43-5.83)], dysfunctional delivery [OR 1.82 (95% CI: 1.44-2.31)] and macrosomic fetus [OR 1.37 (95% CI: 1.08-1.73)]. On the other hand, having been primiparous [OR 0.79 (95% CI: 0.65-0.94)] and being multiparous [OR 0.82 (95% CI: 0.69-0.97)] were shown as factors not associated with statistical significance. Conclusions : Factors associated with the development of uterine atony were cesarean section as the route of delivery, being from the highlands, and having had a macrosomic fetus, polyhydramnios and multiple pregnancies.

Clinical features and perinatal outcomes of twin pregnancies with complete placenta previa / 中华围产医学杂志

Objective:To investigate the clinical features and perinatal outcomes of twin pregnancies with complete placenta previa (CPP).Methods:We conducted a retrospective study on 266 women with CPP, including 62 twin pregnancies (twins group) and 204 singleton pregnancies (singleton group), who gave birth in Peking University Third Hospital from January 2012 to December 2020. T-test, nonparametric test and Chi-square test were adopted for univariate analysis. Differences between the two groups regarding clinical features and perinatal outcomes were compared using multivariate logistic regression or multivariate linear regression. Results:The incidence of twin pregnancy with CPP was 2.11% (62/2 937). Placenta accreta spectrum disorders (PAS) accounted for 48.4% (30/62) and 53.9% (110/204) in the twin and singleton group, respectively, but the difference was not statistically significant ( χ 2=0.58, P>0.05). In terms of antepartum hemorrhage, the proportion of women affected, those with first onset <29 weeks, amount of bleeding ≥200 ml, and the number of episodes of bleeding ≥3 were significantly higher in the twin group than those in the singletons [56.5% (35/62) vs 39.7% (81/204); 35.5% (22/62) vs 12.7% (26/204); 17.7% (11/62) vs 4.9% (10/204); and 21.0% (13/62) vs 10.3% (21/204), χ 2=5.42, 16.62, 10.78, and 4.86, respectively, all P<0.05]. Multivariate Logistic regression analysis showed that compared with the singleton group, the twin group was at higher risk of antepartum hemorrhage volume >200 ml, the number of antepartum hemorrhage episodes ≥3, preterm delivery before 34 weeks and 32 weeks, emergency cesarean section, and emergency cesarean section caused by antepartum hemorrhage [a OR(95% CI)=4.36(1.17-16.30), 3.15(1.01-9.79), 17.24(5.36-55.46), 9.85(2.32-41.77), 3.98(1.72-9.20), and 3.10(1.22-7.85), respectively, all P<0.05]. Multivariate linear regression analysis showed that the gestational week at the emergency cesarean section in the twins group was about 2.22 weeks (0.17-4.27 weeks) earlier than that in the singletons. The postpartum hemorrhage amount and the risk of postpartum hemorrhage after cesarean section, infusion of red blood cells, and hysterectomy did not differ significantly between the two groups. Conclusions:Compared with singleton pregnancies, the proportion of preterm delivery, cesarean sections, especially those caused by antepartum hemorrhage, is significantly higher among twin pregnancies combined with CPP. Accordingly, preterm delivery should be actively prevented, and the timing of cesarean section should be individualized according to the condition of the mothers and babies, and early delivery may be considered.

Clinical characteristics of 16 cases of acquired uterine arteriovenous malformation / 中国综合临床

Objective:To analyze the clinical characteristics, diagnosis and treatment of acquired uterine arteriovenous malformation (UAVM).Methods:The clinical data of 16 patients with diagnosis of UAVM from January 2014 to March 2021 in Beijing Friendship Hospital, Capital Medical University were enrolled in this retrospective study. The general data of patients were observed and analyzed: age, pregnancy and childbirth, etc. Auxiliary examinations: human chorionic gonadotropin (hCG), B-ultrasound, CT angiography (CTA), magnetic resonance (MRI), digital subtraction angiography (DSA), lesion diameter, resistance index (RI), peak systolic velocity (PSV), treatment and postoperative pathology.Result:Among the 16 patients, hCG was negative in 10 cases and positive in 6 cases. The first abnormal bleeding time was (43.4±36.4) days and (16.0±9.0) days, respectively. The rehospitalization time was (63.3±54.4) days and (48.3±54.0) days. Six patients with massive bleeding were HCG negative. Ultrasound in 16 cases showed mixed echo light mass with rich blood flow in the uterine cavity, and magnetic resonance examination in 14 cases also showed abnormal signals in the uterine cavity or uterine wall. Mass staining was seen in 6 cases by DSA, vein development in advance, contrast medium overflow was seen in 2 cases, and the conclusion of CTA was consistent with DSA in 5 cases. Uterine artery embolization was performed in 5 cases, including 2 cases of massive bleeding, emergency bilateral uterine artery embolization and 3 cases of preventive embolization. Hysteroscopy was performed in 4 cases after embolization, and balloon compression was performed in 1 case because there was no obvious tissue in the uterine cavity. Hysteroscopy were performed in 10 cases without UAE. Mifepristone combined with misoprostol was used in 1 case. Among the 15 patients treated by surgery, 14 cases showed degenerative trophoblasts or villi. During the follow-up, one patient after uterine artery embolization complained of decreased menstruation, and ultrasound considered the possibility of intrauterine adhesion.Conclusion:After termination of pregnancy, imaging examination should be strengthened to guard against the occurrence of UAVM. Once diagnosed, medical intervention should be started as soon as possible to reduce bleeding. There is no standardized treatment for UAVM related to pregnancy. Comprehensive consideration should be given to the clinical manifestations, bleeding situation, lesion location and fertility requirements of the patients.

Hallazgos histopatológicos en sangrado uterino anormal en pacientes posmenopaúsicas del Hospital de Clínicas

RESUMEN Introducción: El sangrado uterino anormal en la posmenopausia es cualquier sangrado uterino que se presenta después de un año de amenorrea en la mujer en edad postmenopáusica, sin uso de terapia hormonal. Metodología: Es un estudio observacional, descriptivo y temporalmente retrospectivo. El muestreo es no probabilístico de casos consecutivos. La población accesible son pacientes posmenopáusicas con sangrado uterino anormal que fueron sometidas a biopsia de endometrio en la cátedra de Ginecología y Obstetricia del Hospital de Clínicas de la Universidad Nacional de Asunción en el período enero 2019 a diciembre 2020. Resultados: Sobre el hallazgo histopatológico se puede ver que el 30,8 % fue pólipo endometrial, el 24,2 % mucosa endometrial normal, el 11 % adenocarcinoma. Discusión: El sangrado uterino anormal ya sido investigado en el Hospital de Clínicas por Franco-Domínguez quien llega a la conclusión de que la prevalencia de hemorragia uterina anormal de causa orgánica es 16,3 %. El principal motivo de consulta es la hipermenorrea (63,3 %). Los diagnósticos finales fueron mioma uterino (57 %) y las patologías endometriales. La mayoría fue sometida a cirugía (71 %) y 38 % presentó anemia

ABSTRACT Introduction: Abnormal uterine bleeding in postmenopause is any uterine bleeding that occurs after one year of amenorrhea in women of postmenopausal age, without the use of hormonal therapy. Methods: It is an observational, descriptive and temporally retrospective study. The sampling is non-probabilistic of consecutive cases. The accessible population are postmenopausal patients with abnormal uterine bleeding who underwent endometrial biopsy in the Department of Gynecology and Obstetrics of the Hospital de Clínicas of the National University of Asunción in the period January 2019 to December 2020. Results: About the histopathological finding was You can see that 30.8% were endometrial polyp, 24.2% normal endometrial mucosa, 11% adenocarcinoma. Discussion: The abnormal uterine bleeding has already been investigated at the Hospital de Clínicas by Franco-Domínguez who concludes that the prevalence of abnormal uterine bleeding of organic cause is 16.3%. The main reason for consultation is hypermenorrhea (63.3%). The final diagnoses were uterine myoma (57%) and endometrial pathologies. Most underwent surgery (71%) and 38% had anemia.

Prematuridade em um hospital de referência ao parto de alto risco / Prematurity in a hospital of reference to high risk children

Este estudo objetivou investigar a prevalência de partos prematuros em hospital de referência para partos de alto risco e verificar a associação de fatores maternos (demográficos, socioeconômicos, comportamentais e obstétricos) com a prematuridade. Estudo descritivo analítico transversal prospectivo e quantitativo, com amostra populacional de 489 puérperas, conduzido por entrevista, durante seis meses. As análises descritivas utilizaram o Teste de Fisher para associação e regressão logística para análises multivariadas. A prevalência de prematuridade foi de 11,65%, significativamente maior em mães solteiras (40,4%), com menos de nove anos de estudo (40,4%), que pertencem à classe econômica C (47,4%), usuárias de drogas (12,17%), sedentárias (12,93%), hipertensas (16,67%) e que foram internadas (17,82%) ou tiveram sangramento vaginal durante a gestação (25,58%). Uso de drogas (p = 0,001) e sangramento vaginal (p = 0,010) foram considerados preditores maternos para prematuridade.

To investigate the prevalence of premature births in a referral hospital for high-risk births and to verify the association of maternal factors (demographic, socioeconomic, behavioral, and obstetric) with prematurity. Descriptive cross-sectional prospective and quantitative study, with a population sample of 489 mothers, conducted by interview, for six months. The descriptive analyzes used the Fisher Test for association and logistic regression for multivariate analyzes. The prevalence of prematurity was 11.65%, significantly higher in single mothers (40.4%), with less than nine years of study (40.4%), who belong to economic class C (47.4%), drug users (12.17%), sedentary (12.93%), hypertensive (16.67%) and who were hospitalized (17.82%) or had vaginal bleeding during pregnancy (25.58%). Drug use (p = 0.001) and vaginal bleeding (p = 0.010) were considered maternal predictors of prematurity.

Melanoma primario de cuello uterino: Reporte de caso / Primary malignant melanoma of the cervix: Case report

Resumen El melanoma primario de mucosas representa el 1% de todos los cánceres. Su localización en cuello uterino es rara y existen menos de 100 casos reportados en la literatura hasta la fecha. Los datos son limitados en cuanto su estadificación y tratamiento y su pronóstico es malo con tasas de supervivencia del 10% a 5 años. Se presenta el caso clínico de una paciente de 82 años con sangrado vaginal, con evidencia de una lesión melanótica en cuello uterino, la biopsia de la lesión reportó compromiso por tumor maligno pobremente diferenciado, con inmuno perfil que confirma melanoma maligno. Los estudios de extensión no mostraron enfermedad metastásica a distancia, se presentó el caso en junta multidisciplinaria de ginecología oncológica por lo que se indicó tratamiento con radioterapia pélvica externa exclusiva con intención paliativa para control de síntomas, teniendo en cuenta: la edad, las comorbilidades y el estado funcional ECOG (Eastern Cooperative Oncology Group) 3; luego de 10 meses de seguimiento la paciente falleció.

Abstract Primary mucosal melanoma represents 1% of all cancers, the location in the cervix is rare, there are less than 100 cases reported in the literature to date, the data is limited in terms of staging and treatment, its prognosis is poor with survival rates of 10% at 5 years. We present a clinical case of a primary melanoma of the cervix in an 82-year-old patient with vaginal bleeding with evidence of a melanotic lesion in the cervix. The biopsy of the lesion reported poorly differentiated malignant tumor involvement, with an immuno-profile that favors melanoma. Extension studies were performed that did not show distant metastatic disease, the case was presented in a multidisciplinary oncological gynecology meeting, indicating treatment with exclusive external pelvic radiotherapy with palliative intention for symptom control taking into account patient comorbidities and ECOG functional status. (Eastern Cooperative Oncology Group) 3, after 10 months of follow-up the patient died.

Malformación arteriovenosa uterina gigante. Presentación de un caso / Giant uterine arteriovenous malformation. A case report

RESUMEN Se presenta el caso de una paciente que cursó con hemorragia uterina anormal debido a malformación arteriovenosa adquirida diagnosticada por ecografía Doppler y resonancia magnética. Dicha patología es hallada cada vez con mayor frecuencia y consecuencias graves, si no se realiza un manejo adecuado y oportuno.

ABSTRACT The case of a patient who presented with abnormal uterine hemorrhage due to an acquired arteriovenous malformation diagnosed with Doppler ultrasound and magnetic resonance is presented. This pathology is becoming more and more frequent and with serious consequences, if proper and timely management is not given.

Inversión uterina no puerperal: primer caso reportado en el Perú / Non-puerperal uterine inversion: first case reported in Peru

RESUMEN La inversión uterina no puerperal es muy rara. Se comunica un caso asociado con leiomiomatosis. Se trató de una multípara de 45 años que manifestó sangrado vaginal grave, dolor pélvico y sensación de cuerpo extraño vaginal. Se diagnosticó mioma uterino en fase abortiva. Se programó para miomectomía con probable histerectomía abdominal y se encontró inversión uterina completa. Este reporte constituye un caso anecdótico de inversión uterina no puerperal, cuyo tratamiento quirúrgico fue exitoso.

ABSTRACT Non-puerperal uterine inversion is very rare. A case associated with leiomyomatosis is reported. The case of a 45-year-old multiparous woman with severe vaginal bleeding, pelvic pain and vaginal foreign body sensation is presented. Uterine leiomyoma in abortive phase was diagnosed. She was scheduled for myomectomy with probable abdominal hysterectomy and complete uterine inversion was found. This report is an anecdotal case of non-puerperal uterine inversion, whose surgical treatment was successful.

Effect of electroacupuncture on postpartum uterine contraction pain and uterine involution: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the effect of electroacupuncture on postpartum uterine contraction pain and uterine involution.@*METHODS@#A total of 80 patients with postpartum uterine contraction pain were randomly divided into an observation group and a control group, 40 cases in each group. The observation group was treated with electroacupuncture at Dahe (KI 12), Zhongzhu (KI 15), Hegu (LI 4), Xuehai (SP 10), etc. for 30 min, once a day, 3 days were as one course, and 2 courses with 1-day interval were required. The control group was treated with oral @*RESULTS@#Compared before treatment, the VAS scores of 24, 48, 72 h into treatment and after treatment were decreased in both groups (@*CONCLUSION@#Electroacupuncture can effectively relieve postpartum uterine contraction pain, accelerate the discharge of residual uterine hemorrhage in the uterine cavity, and promote uterine involution.

Diagnostic accuracy of a hysteroscopic score for the detection of endometrial cancer in patients with postmenopausal bleeding and endometrial thickening / Exactitud diagnóstica de una escala histeroscópica para la detección de cáncer endometrial en pacientes con sangrado posmenopáusico y engrosamiento endometrial

RESUMEN Objetivo: evaluar la exactitud diagnóstica del sistema de puntaje histeroscópico de cáncer endometrial. Materiales y métodos: estudio de exactitud diagnóstica ensamblado en estudio transversal, que incluyó pacientes con sangrado posmenopáusico y engrosamiento endometrial mayor o igual a 5 mm, a quienes se practicó histeroscopia, cuyo resultado se comparó con la biopsia endometrial como patrón de oro diagnóstico, en dos hospitales de alta complejidad. Se midieron variables sociodemográficas, clínicas, puntaje de evaluación histeroscópica y resultado histopatológico de tejido endometrial. En el análisis se estimó sensibilidad, especificidad, razones de probabilidades y área bajo la curva con sus respectivos intervalos de confianza. Resultados: con una prevalencia del cáncer endometrial del 9 %, el sistema de evaluación por histeroscopia mostró una sensibilidad de 75 % (IC 95 %: 30,1-95,43), especificidad de 95,1 % (IC 95 %: 83,9- 98,7), una razón de probabilidades positiva de 15,38 (IC 95 %: 3,55-66,56), una razón de probabilidades negativa de 0,26 y un área bajo la curva del 85 %. Conclusión: el sistema de evaluación endometrial histeroscópico estandarizado mostró una sensibilidad aceptable para hacer la tamización en pacientes con sangrado posmenopáusico y engrosamiento endometrial (≥ 5 mm). Se requiere la realización de estudios con un mayor tamaño muestral que permitan hacer una estimación más precisa de las características operativas de este sistema de evaluación histeroscópico para la detección de cáncer endometrial.

ABSTRACT Objective: To assess the diagnostic accuracy of hysteroscopic scores in endometrial cancer. Materials and methods: Diagnostic accuracy study assembled within a cross-sectional study that included patients with postmenopausal bleeding and endometrial thickening greater than 5 mm in whom hysteroscopy was performed and then compared with endometrial biopsy as the diagnostic gold standard, in two high complexity hospitals. Clinical, sociodemographic variables, as well as hysteroscopic scores and the results of endometrial tissue histopathology were measured. Sensitivity and specificity, likelihood ratios and area under the curve with their respective confidence intervals were estimated in the analysis. Results: With a 9 % prevalence of endometrial cancer, the hysteroscopic assessment system was shown to have 75 % sensitivity (95 % CI; 30.1- 95.43), 95,1 % specificity (95 % CI; 83.9-98.7), a positive likelihood ratio of 15.38 (95 %; CI 3.55- 66.56), a negative likelihood ratio of 0.26 and area under the curve of 85 %. Conclusion: The standardized hysteroscopic assessment system was found to have an acceptable sensitivity for screening in patients with postmenopausal bleeding and endometrial thickening (≥ 5 mm). Further studies with larger sample sizes are required in order to arrive at a more precise estimation of the operational characteristics of the hysteroscopic assessment system for the detection of endometrial cancer.

Síndrome de OHVIRA, a propósito de un caso / A case of OHVIRA syndrome

Resumen Introducción: El síndrome de obstrucción hemivaginal y anomalía renal ipsilateral (OHVIRA, por sus siglas en inglés) o también llamado síndrome de Herlyn-Werner-Wunderlich es una rara malformación mulleriana que consiste en la presencia de útero didelfo, obstrucción hemivaginal y anomalía renal ipsilateral. La incidencia de malformaciones mullerianas son del 2 al 3%, y la menos común es el síndrome de OHVIRA. Objetivo: Descripción de un caso excepcional de alteraciones mullerianas poco conocido. Presentación del caso: Adolescente de 14 años con historia de dolor pélvico, dismenorrea e infecciones urinarias a repetición. Se estudió con gammagrafía renal que reveló agenesia renal derecha y resonancia magnética pélvica que mostró útero didelfo con hematocolpos derechos. Se confirmaron los hallazgos por laparoscopia diagnóstica. Conclusiones: Este síndrome es poco conocido. Debe sospecharse en casos de agenesia renal, dolor pélvico crónico y alteraciones menstruales en pacientes postpuberes. El abordaje es multidisciplinario.

Abstract Introduction: The obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome, also known as the Herlyn-Werner-Wunderlich syndrome, is a rare müllerian anomaly characterized by didelphic uterus, hemivaginal obstruction, and ipsilateral renal anomaly. The incidence of müllerian malformations is 2% - 3%, OHVIRA being the least common of these cases. Objective: To describe an exceptional case of a müllerian disorder. Case presentation: A 14-year-old adolescent with a history of pelvic pain, dysmenorrhea, and recurrent urinary infections. Renal gammagraphy analysis revealed right renal agenesis, and pelvic magnetic resonance imaging showed a didelphic uterus with right hematocolpos. These findings were confirmed by diagnostic laparoscopy. Conclusions: This syndrome is not well known. Renal anegesis, chronic pelvic pain, and menstrual abnormalities in post-pubertal patients must be presumed as indicators of OHVIRA, whose treatment requires a multidisciplinary approach.

Rare occurrence of uterine arteriovenous malformation clinically mimicking a malignant growth: A critical reminder for pathologists

Arteriovenous malformation (AVM) is a rare lesion in the uterus, which can lead to abnormal uterine bleeding. While AVM has been described in other organs in the literature, there is a paucity of pathology reports of the AVM in uterus. On gross examination, the uterus was markedly enlarged and partly distorted with a pedunculated solid mass, which on the cut surface showed multiple well-circumscribed hemorrhagic cysts ranging from 0.1 to 4.0 cm in size. Microscopically, they were malformed dilated vascular structures containing organized thrombi. We present this case of uterine AVM with gross and microscopic findings, which can serve as a crucial reminder for pathologists to keep in the differential diagnoses as a potential cause of abnormal uterine bleeding.

Sangrado uterino anormal y PALM COEIN / Abnormal uterine bleeding and PALM COEIN

Resumen OBJETIVO: Comunicar la nueva terminología del sangrado uterino anormal y de la clasificación PALM COEIN. MÉTODO: Búsqueda bibliográfica de artículos publicados en inglés o español con la palabra clave PALM COEIN. Desde el primer artículo publicado en 2010 hasta 2018 en las bases de datos MedLine, PubMed, Embase y Ovid. RESULTADOS: Se reunieron 64 artículos, pero solo 18 mencionaban el término, 24 eran repetidos. Se seleccionaron 22 que trataban el tema en estudio y eran referidos con la clasificación actual, de esos trabajos 6 eran de cohorte, 2 de revisión sistemática, 2 boletines y 12 revisiones de tema. CONCLUSIÓN: Esta nueva terminología facilitará el entendimiento y la comunicación, independiente del idioma y la cultura, además del acercamiento más entendible con nuestras pacientes. La clasificación PALM COEIN facilita la investigación epidemiológica, etiológica y el tratamiento de las pacientes con sangrado uterino anormal.

Abstract OBJECTIVE: To update the new terminology of abnormal uterine bleeding and the PALM COEIN classification METHOD: Bibliographic search of articles published in English or Spanish with the keyword PALM COEIN. From the first article published in 2010 to 2018 in the MedLine, PubMed, Embase and Ovid databases. RESULTS: 64 articles were collected, but only 18 mentioned the term, 24 were repeated. 22 were selected that dealt with the subject under study and were referred to with the current classification, of these works 6 were cohort, 2 systematic review, 2 newsletters and 12 theme reviews. CONCLUSION: This new terminology will facilitate understanding and communication, independent of language and culture, in addition to the most understandable approach with our patients. This classification of PALM COEIN facilitates the epidemiological, etiological investigation and treatment of patients with abnormal uterine bleeding.

Tratamiento de pacientes con placenta anormalmente adherida, con hemorragia. Revisión sistemática / Treatment of patients with abnormally attached placenta, with hemorrhage. Systematic review

Resumen OBJETIVO: Reportar la evidencia quirúrgica, disponible en la bibliografía actual, acerca de la conducta médica que debe seguirse en pacientes con placenta anormalmente adherida en embarazos mayores de 20 semanas, según la pérdida hemática que se correlaciona con la morbilidad y mortalidad materna. METODOLOGÍA: Revisión sistemática de la bibliografía asentada en PubMed, Google Scholar, Uptodate y SciELO de artículos publicados en inglés y español, entre 2002 y 2019, con las palabras clave Mesh (Medical Subject Headings): placenta acreta; placenta previa; uterine repair; caesarean hysterectomy; placenta percreta; uterine conservation; uterine compression suture; hemorragia obstétrica; placentación anómala; placenta anormalmente adherida. Criterios de inclusión: artículos de casos y controles, y series de casos que incluyeron pacientes con diagnóstico de placenta anormalmente adherida, con apartados de la técnica quirúrgica utilizada y descripción de su desenlace. RESULTADOS: Se encontraron 40 artículos y se seleccionaron 34 que describían casos con diagnóstico de placenta anormalmente adherida y descripción de la técnica quirúrgica aplicada para disminuir la morbilidad y mortalidad materna. Se compararon las distintas técnicas quirúrgicas; se encontraron 9 artículos con técnicas quirúrgicas distintas para el control de la hemorragia obstétrica, en 2 de ellos no hubo reporte de la pérdida hemática, útil para esta revisión. CONCLUSIONES: Se demuestra que la técnica vascular integral avanzada (VIVA) y de Bautista son las que mejor se relacionan con disminución de la morbilidad y mortalidad materna. La búsqueda de técnicas quirúrgicas y estrategias para abatir la muerte materna, por placenta anormalmente adherida y la aplicación y comprensión de lo aquí expuesto, puede contribuir a disminuir la incidencia de desenlaces fatales.

Abstract OBJECTIVE: Report the surgical evidence available in the current literature about the medical behavior to be followed in patients with abnormally attached placenta in pregnancies older than 20 weeks, according to blood loss that correlates with maternal morbidity and mortality. METHODOLOGY: Systematic review of the literature available on PubMed, Scholar.google.com, Uptodate, SciELO, of articles published in English and Spanish, from 2002 to the present (August 2019), with the following keywords Mesh (Medical Subject Headings ): placenta acreta; previous placenta; uterine repair; Caesarean Hysterectomy; placenta percreta; uterine conservation; uterine compression suture; obstetric hemorrhage; anomalous placentation; abnormally attached placenta. Inclusion criteria: articles of control cases and case series that included pregnant patients with abnormally adhered placental diagnosis and sections of the surgical technique used, the outcome of which is described in the manuscript. RESULTS: 40 articles were found but only 34 studies were described that described cases with abnormally adhered placental diagnosis and description of the surgical technique used to achieve a decrease in maternal morbidity and mortality, so the different surgical techniques were compared, 9 articles were found with techniques different surgical procedures for the control of obstetric hemorrhage, in 2 of them there was no report of blood loss, useful for this review. CONCLUSIONS: It is shown that the advanced integral vascular technique (VIVA) and that of Bautista are the ones that are best related to a decrease in maternal morbidity and mortality. The search for surgical techniques and strategies to reduce maternal death, due to an abnormally attached placenta and the application and understanding of what is stated here, can contribute to reducing the incidence of fatal outcomes.

Factors associated with the complications of hysteroscopic myomectomy / Fatores associados às complicações da miomectomia por histeroscopia

Abstract Objective To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications. Methods A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure. Results We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French),most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38). Conclusions Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

Resumo Objetivo Avaliar os fatores associados a miomectomia por histeroscopia completa em um único procedimento e as suas complicações. Métodos Estudo de corte transversal com mulheres submetidas a histeroscopia para exérese de miomas submucosos. As variáveis dependentes foram a miomectomia completa realizada em um tempo cirúrgico único, e a presença de complicações precoces relacionadas ao procedimento. Resultados Analisamos 338 mulheres que foram submetidas a miomectomia histeroscópica. Em 89,05% dos casos, o mioma a ser tratado era único. Quanto à classificação da Federação Internacional de Ginecologia e Obstetrícia (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, em francês), a maioria era de grau 0 (66,96%), seguidos pelos graus 1 (20,54%) e 2 (12,50%). As miomectomias foram completas em 63,31% das mulheres, sendo que os fatores independentemente associados à miomectomia completa foram o diâmetro do maior mioma (razão de prevalência [RP]: 0,97; intervalo de confiança de 95% [IC95%]: 0,96-0,98) e a classificação FIGO grau 0 (RP: 2,04; IC95%: 1,18-3,52). Foram observadas complicações precoces em 13,01% dos procedimentos (4,44% apresentaram sangramento excessivo durante o procedimento, 4,14%, perfuração uterina, 2,66%, falso pertuito, 1,78%, intoxicação hídrica, 0,59%, laparotomia exploradora, e 0,3%, infecção pósoperatória). O único fator independentemente associado à ocorrência de complicações precoces foi a realização de miomectomia incompleta (RP: 2,77; IC95%: 1,43-5,38). Conclusão Nossos resultados mostram que as complicações da miomectomia por histeroscopia podem ocorrer em até 13% dos procedimentos. A chance de ressecção completa é maior em miomas pequenos e completamente intracavitários; mulheres com miomas maiores e com maior grau de penetração miometrial têm maiores chances de desenvolver complicações.

Clinical effect of Huoxue Qing Gong decoction in the treatment of vaginal bleeding after medical abortion / 中国基层医药

Objective@#To explore the clinical effect of Huoxue Qing Gong decoction in the treatment of vaginal bleeding after medical abortion.@*Methods@#From May 2016 to June 2017, 90 cases of vaginal bleeding after drug abortion in the People's Hospital of Dongping County were divided into the observation group and the control group according to the digital table, with 45 cases in each group.The two groups were all treated with drug abortion to terminate pregnancy, and the control group was treated with metronidazole tablets + carbazochrome tablets after the termination of pregnancy.The observation group was treated with Huoxue Qing Gong decoction on the basis of the control group.The effect of abortion, bleeding time and bleeding volume after drug abortion, the time of menstrual recovery and menstrual duration after treatment in the two groups were observed and compared.@*Results@#The total abortion rate in the observation group was 95.6%, which was significantly higher than that in the control group(84.4%), the difference was statistically significant(χ2=5.620, P<0.05). The proportion of bleeding time≤7d after abortion in the observation group was 37.8%, which was significantly higher than that in the control group(11.1%), the difference was statistically significant(χ2=5.628, P<0.05). The proportion of bleeding time 8~14d of the observation group was 60%, which was significantly lower than that of the control group(73.3%), the difference was statistically significant(χ2=6.571, P<0.05). The proportion of bleeding time more than 15d after drug abortion of the observation group was 2.2%, which was significantly lower than that of the control group(15.6%), the difference was statistically significant(χ2=5.028, P<0.05). The proportion of vaginal bleeding volume<previous menstrual volume after drug abortion of the observation group was 60.0%, which was significantly higher than that of the control group(28.9%), the difference was statistically significant(χ2=6.021, P<0.05). The proportion of amount of vaginal bleeding=previous menstrual volume after drug abortion in the observation group was 22.2%, which was significantly lower than that in the control group(26.7%), the difference was statistically significant (χ2=5.114, P<0.05). The proportion of vaginal bleeding volume>previous menstrual volume after drug abortion of the observation group was 17.8%, which was significantly lower than that of the control group(44.4%), the difference was statistically significant(χ2=6.375, P<0.05). The period of menstrual recovery of the observation group was (29.5±4.2)d, which was significantly shorter than that of the control group[(37.9±4.3)d](t=5.028, P<0.05). The duration of menstruation in the observation group was (5.0±1.1)d, which was significantly shorter than that in the control group[(6.9±1.2)d], the difference was statistically significant(t=3.229, P<0.05).@*Conclusion@#Huoxue Qing Gong decoction in the treatment of vaginal bleeding after drug abortion can significantly shorten the time of vaginal bleeding, reduce the amount of vaginal bleeding, improve the rate of complete abortion, and has no obvious effect on the first menstrual cycle and menstrual period after the drug flow.