Uso de mifepristona en embarazo ectópico intersticial: un reporte de caso / Use of mifepristone in an interstitial ectopic pregnancy: a case report

Introducción: El embarazo ectópico intersticial es una forma de presentación poco frecuente, con una incidencia del 2-4% de los embarazos ectópicos; sin embargo, a pesar de su baja incidencia la mortalidad es cinco veces mayor, impactando en las cifras de mortalidad materna y representando en torno al 10-15% de los casos. Objetivo: Presentar un caso de embarazo ectópico intersticial, cuya ocurrencia es poco frecuente, así como el abordaje satisfactorio del manejo médico con mifepristona y metotrexato. Caso clínico: Mujer de 28 años con antecedente de resección tubárica por quiste paraovárico derecho, quien acudió a urgencias por hallazgo en ecografía obstétrica de sospecha de embarazo intersticial izquierdo y se le administró manejo farmacológico con dosis de metotrexato y mifepristona, con éxito. Conclusiones: El manejo médico con metotrexato y mifepristona para el embarazo ectópico intersticial parece ser una elección eficaz en los casos con estabilidad hemodinámica y deseo de conservación de la fertilidad.

Background: Interstitial ectopic pregnancy represents a rare form of presentation, with an incidence of 2-4% of all ectopic pregnancies. However, despite its low incidence, it is associated with a five-fold increase in mortality, significantly impacting maternal mortality rates, accounting for approximately 10-15% of cases. Objective: To present a case of interstitial ectopic pregnancy, which is a rare occurrence, as well as the successful medical management approach with mifepristone and methotrexate. Case report: A 28-year-old women with a history of right paraovarian cyst tubal resection presented to the emergency department due to suspected left interstitial pregnancy identified on obstetric ultrasound. The patient was successfully managed with pharmacological treatment using doses of methotrexate and mifepristone. Conclusions: Medical management with methotrexate and mifepristone for interstitial ectopic pregnancy appears to be an effective choice in cases with hemodynamic stability and a desire for fertility preservation.

A scary complication: single-center study on management and outcome of cesarean scar pregnancy

Abstract A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases.We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.

Misoprostol on trial: a descriptive study of the criminalization of an essential medicine in Brazil / O misoprostol nos tribunais: um estudo descritivo da criminalização de um medicamento essencial no Brasil / El misoprostol en juicio: un estudio descriptivo de la criminalización de un medicamento esencial en Brasil

Misoprostol is a medicine with a "double" social life recorded in several places, including Brazil. Within formal and authorized health facilities, it is an essential medicine, used for life-saving obstetric procedures. On the streets, or in online informal markets, misoprostol is treated as a dangerous drug used to induce illegal abortions. In the Brazilian case, despite a rich anthropological and public health analysis of the social consequences of misoprostol's double life, there are no studies on the legal implications. This article offers such descriptive analysis, presenting and examining a comprehensive dataset of how Brazilian courts have treated misoprostol in the past three decades. It consists of an encompassing mapping of the "when, where, how, and who" of misoprostol criminalization in Brazil, pointing to the unjust consequences of the use of criminal law for the purpose of protecting public health.

O misoprostol é um medicamento com uma "dupla" vida social registrada em vários lugares, inclusive no Brasil. Nos serviços de saúde formais e autorizados, é considerado um medicamento essencial, utilizado para procedimentos obstétricos que salvam vidas. Nas ruas ou nos mercados informais online, o misoprostol é tratado como um medicamento perigoso, usado para induzir abortos ilegais. No caso brasileiro, apesar de uma rica análise antropológica e de saúde pública das consequências sociais da vida dupla do misoprostol, não há estudos sobre as implicações jurídicas. O artigo oferece essa análise, apresentando e examinando um amplo banco de dados sobre o tratamento dado ao misoprostol pelos tribunais brasileiros nas últimas três décadas. Ele consiste em um mapeamento. Consiste em um mapeamento amplo do "quando, onde, como e por quem" da criminalização do misoprostol no Brasil, apontando as consequências injustas do uso do direito penal em questões de saúde pública.

El misoprostol es una medicina con una "doble" vida social registrada en varios países, incluyendo Brasil. En los centros de salud formales y autorizados, es una medicina esencial, usada en procedimientos obstétricos que salvan vidas. En las calles o en las tiendas en línea informales, el misoprostol está considerado como una peligrosa medicina usada para inducir abortos ilegales. En el caso brasileño, a pesar del rico análisis antropológico y de la salud pública sobre las consecuencias sociales de la doble vida del misoprostol, no existen estudios de sus implicaciones jurídicas. Este artículo ofrece este análisis, presentando y examinando un banco de datos completo de cómo las cortes brasileñas de justicia han tratado el misoprostol en las últimas tres décadas. Consiste en un exhaustivo mapeo del "cuándo, dónde, cómo y quién" respecto a la criminalización del misoprostol en Brasil, señalando las injustas consecuencias del uso del derecho penal en cuestiones de salud pública.

Retrospective evaluation of patients treated for ectopic pregnancy: Experience of a tertiary center

Abstract Objective In recent years, there has been an increase in the incidence of ectopic pregnancies; therefore, it is important for tertiary centers to report their approaches and outcomes to expand and improve treatment modalities. The aim of the present study was to evaluate the general characteristics, treatment and outcomes of cases diagnosed with ectopic pregnancy. Methods In total, 432 patients treated for ectopic pregnancy between February 2016 and June 2019 were retrospectively evaluated. Results Overall, 370 patients had tubal pregnancy, 32 had cesarean scar pregnancy, 18 had pregnancy of unknown location, 6 had cervical pregnancy, and 6 had interstitial pregnancy. The most important risk factors were advanced age (> 35 years; prevalence: 31.2%) and smoking (prevalence: 27.1%). Thirty patients who did not have any symptoms of rupture and whose human chorionic gonadotropin (β-hCG) levels were ≤ 200 mIU/ml were followed-up with expectant management, while 316 patients whose β-hCG levels were between 1,500 mIU/ml and 5,000 mIU/ml did not have an intrauterine gestational sac on the transvaginal or abdominal ultrasound, did not demonstrate findings of rupture, and were treated with a systemic multi-dose methotrexate treatment protocol. In total, 24 patients who did not respond to the medical treatment, 20 patients whose β-hCG levels were > 5,000 mIU/ml, 16 patients who had shown symptoms of rupture at the initial presentation, and 6 patients diagnosed with interstitial pregnancy underwent surgery. Patients with cervical and scar pregnancies underwent ultrasound-guided curettage, and no additional treatment was needed. Conclusion The fertility status of the patients, the clinical and laboratory findings, and the levels of β-hCG are the factors that must be considered in planning the appropriate treatment.

Experiencia y manejo del embarazo ectópico cervical: revisión del tema / Experience and management of cervical ectopic pregnancy: topic review

Introducción y Objetivos: El Embarazo Cervical (EC) corresponde a una patología de muy baja frecuencia y tasa de sospecha. En la literatura actual se han propuestos diferentes tratamientos, pero se recomienda el manejo médico con Metotrexato como primera línea. Los objetivos de este estudio son describir las características relevantes de los casos de EC en el servicio de Ginecología del Hospital Dr. Sótero del Río y realizar una revisión actualizada del tema. Métodos: Estudio Retrospectivo de todas las pacientes hospitalizadas en la unidad de Ginecología entre 2004 y 2020. Análisis descriptivo de las pacientes con diagnóstico de Embarazo Cervical. Resultados: Se revisaron 33740 pacientes. 1910 presentaron diagnóstico de Embarazo ectópico, de las cuales 6 corresponden a embarazo cervical, 5 casos se sospecharon desde el ingreso y sólo 1 caso ingresó con el diagnóstico de aborto en evolución. La mayoría fue manejada con Metrotrexato, con buenos resultados y sin complicaciones. Conclusiones: El Embarazo cervical es una patología poco frecuente. El manejo médico con Metrotrexato es la opción de primera línea en pacientes hemodinámicamente estable posibilitando la fertilidad posterior.

Introduction and Objectives: Cervical Pregnancy is known as a pathology of very low frequency and suspicion rate. Different treatments have been proposed in the current literature, but medical management with Methotrexate is recommended as the first line. The objectives of this study are to describe the relevant characteristics of cervical pregnancy cases in the Gynecology Department of the Dr. Sotero del Rio Hospital and to carry out an updated review of the subject. Methods: Retrospective study of all hospitalized patients in the Gynecology unit between 2004 and 2020. Descriptive analysis of patients diagnosed with Cervical Pregnancy. Results: 33740 patients were reviewed. 1910 presented a diagnosis of ectopic pregnancy, of which 6 correspond to cervical pregnancy, 5 cases were suspected from admission and only 1 case entered with the diagnosis of abortion in progress. Most were managed with Methotrexate, with good results and without complications. Conclusion: Cervical pregnancy is a rare disease. Medical management with Methotrexate is the first line option in hemodynamically stable patients enabling subsequent fertility.

Methotrexate therapy for ectopic pregnancies: A tertiary center experience

Abstract Objective Our aim is to demonstrate the importance of methotrexate (MTX) therapy for the treatment of ectopic pregnancy (EP). Methods This retrospective study consisted of 99 patients (72 tubal EPs, 20 pregnancies of unknown location (PUL), 4 cesarean section (CS) scar EPs and 3 cervical EPs) treated with MTX. Results Methotrexate therapy was successful in 68.5% of EPs. There were statistically significant differences between the MTX success and failure groups based on ultrasonographic findings, patient complaints, gestational week and serum human chorionic gonadotropin (hCG) values. The MTX success rates in PUL and tubal pregnancies were 95% and 61.1%, respectively. The MTX success rates in single-dose, two-dose and multi-dose protocol groups were 86.9%, 28.6% and 40%, respectively. All cervical and CS scar ectopic pregnancies were treated successfully with MTX therapy. Conclusion Methotrexate might be the first-line treatment option for EPs under certain conditions. Physicians must be more cautious in cases with higher hCG values, the presence of abdominal-pelvic pain, the presence of fetal cardiac activity, larger gestational sac (GS) diameters, and more advanced gestational weeks according to the last menstrual period.

Las jóvenes: entre la "marea verde" y la decisión de abortar / Young women: between the "green tide" and the decision to have an abortion

RESUMEN Este trabajo analiza las características, argumentos y condiciones de posibilidad que presentan los activismos de género, desplegados en los últimos años por las mujeres jóvenes en Argentina, con especial atención en la marca generacional que imprimen a las demandas y luchas colectivas por el aborto legal, seguro y gratuito. Se reconstruyen algunas de las circunstancias sociales y personales que están en la base de la motivación o decisión de un conjunto de chicas a abortar con misoprostol, con el propósito de explorar, en concreto, las redes de apoyo y la información que circula entre esas jóvenes con relación a la práctica de aborto medicamentoso, en tiempos en los que el acceso a este derecho no ha podido ser aún consagrado legalmente en el país. Nos interesa poner en diálogo esas realidades con el contexto más amplio del protagonismo juvenil femenino en estos reclamos, condensado en la expresión "marea verde" y en la idea de una "batalla cultural" socialmente ya ganada.

ABSTRACT The work analyzes the characteristics, arguments and conditions of possibility present in the gender activisms carried out in recent years by young women in Argentina, with special attention paid to the generational mark they imprint onto the collective demands and struggles for legal, safe and free abortion. The article reconstructs some of the social and personal circumstances at the base of the motivation or the decision of a group of young women to carry out an abortion with misoprostol, with the purpose of exploring concretely the support networks and the information circulating among these young women in relation to the practice of medical abortion, at a time in which access to this right has not yet been legally instituted in the country. We are interested in putting these realities in dialogue with a broader context of female youth prominence in these demands, condensed in the expression "green tide" and in the idea of a "cultural battle" that has already been won socially.

A experiência do aborto na rede: análise de itinerários abortivos compartilhados em uma comunidade online / Abortion experience in the media: analysis of abortive paths shared in an online community

Resumo O objetivo deste artigo é analisar narrativas sobre as experiências de abortar disponíveis em uma comunidade online, buscando discutir os métodos e estratégias aos quais as mulheres recorrem frente à impossibilidade legal de interrupção voluntária de gravidez e os efeitos da criminalização do aborto induzido. Como método, utilizou-se a etnografia virtual, com observação da plataforma Women on Web, coleta e análise de 18 narrativas, disponíveis publicamente e sem restrições, selecionadas entre novembro de 2016 e janeiro de 2017. As narrativas informam métodos mesclados para a realização de aborto, com prevalência de utilização do medicamento Cytotec. Em alguns casos, hospitais e consultórios médicos são incluídos nos itinerários, seja para realização de exames ou para atendimento de intercorrências. A internet se revela uma ferramenta de informação, negociação e mesmo aquisição de medicamento abortivo bastante comum, além de uma plataforma de troca de experiências. Conclui-se que as narrativas sinalizam as inseguranças, riscos e violências às quais estão submetidas as mulheres no contexto da clandestinidade, indicam a importância do debate sobre a descriminalização do aborto no Brasil, e também reforçam a existência de uma cultura compartilhada do aborto, já apontada em estudos anteriores.

Abstract This paper aims to analyze the narratives about abortion experiences available in an online community to discuss the methods and strategies to which women resort, facing the legal impossibility of voluntarily interrupting a pregnancy and the effects of the criminalization of induced abortion. The methodology used was virtual ethnography, observing the platform Women on Web, collection and analysis of 18 narratives publicly available without restrictions, selected between November 2016 and January 2017. The narratives report mixed methods to perform an abortion, with widespread use of Cytotec. Some cases include hospitals and medical clinics in the paths, whether to conduct examinations or attend to intercurrences. The internet appears as a popular tool to gather information, negotiate and even purchase abortive drugs, as well as a platform to share experiences. We concluded that the narratives point to insecurities, risks, and violence to which women are submitted in clandestine setting; they show the relevance of debate on decriminalizing abortion in Brazil, and also reinforce the existence of a shared abortion culture, as stated in other studies.

Medical Termination of Delayed Miscarriage: Four-Year Experience with an Outpatient Protocol / Terminação médica de gravidez inviável do 1° trimestre: quatro anos de experiência com um protocolo de tratamento em ambulatório

Abstract Purpose To evaluate the efficacy of an outpatient protocol with vaginal misoprostol to treat delayed miscarriage. Methods Retrospective analysis of prospectively collected data on women medically treated for missed abortion with an outpatient protocol. The inclusion criteria were: ultrasound-based diagnosis of missed abortion with less than 10 weeks; no heavy bleeding, infection, inflammatory bowel disease ormisoprostol allergy; nomore than 2 previous spontaneous abortions; the preference of the patient regarding the medical management. The protocol consisted of: 1) a single dose of 800 μg of misoprostol administered intravaginally at the emergency department, after which the patients were discharged home; 2) clinical and ultrasonographic evaluation 48 hours later - if the intrauterine gestational sac was still present, the application of 800 μg of vaginal misoprostol was repeated, and the patients were discharged home; 3) clinical and ultrasonography evaluation 7 days after the initiation of the protocol - if the intrauterine gestational sac was still present, surgical management was proposed. The protocol was introduced in January 2012. Every woman received oral analgesia and written general recommendations. We also gave them a paper form to be presented and filled out at each evaluation. Results Complete miscarriage with misoprostol occurred in 340 women (90.2%). Surgery was performed in 37 (9.8%) patients, representing the global failure rate of the protocol. Miscarriage was completed after the first misoprostol administration in 208 (55.2%) women, with a success rate after the second administration of 78.1% (132/169). The average age of the women with complete resolution using misoprostol was superior to the average age of those who required surgery (33.99 years versus 31.74 years; p = 0.031). Based on the ultrasonographic findings in the first evaluation, the women diagnosed with fetal loss achieved greater success rates compared with those diagnosed with empty sac (p = 0.049). Conclusions We conclude this is an effective and safe option in the majority of delayed miscarriage cases during the first trimester, reducing surgical procedures and their consequences.

Resumo Objetivo Avaliar a eficácia de um protocolo de tratamento médico da gravidez inviável do primeiro trimestre (GI1°T) com misoprostol vaginal em regime de ambulatório. Métodos Análise retrospectiva de dados colhidos prospectivamente de grávidas tratadas com misoprostol vaginal em ambulatório. Os critérios de inclusão foram: diagnóstico de GI1°T com < 10 semanas de gestação; ausência de hemorragia abundante, infeção, doença inflamatória intestinal ou alergia ao misoprostol; 2 abortamentos anteriores; e preferência da paciente por tratamento médico. O protocolo consiste em: dia 0-aplicação demisoprostol intravaginal (800μg) no Serviço de Urgência e alta para o domicílio; dia 2-se persistência de saco gestacional intrauterino, aplicação de segunda dose de misoprostol (800μg) e alta; Dia 7-se persistência de saco gestacional intrauterino, proposto esvaziamento uterino instrumentado. O protocolo foi implementado em janeiro de 2012. Todas as grávidas receberam analgesia oral e informação por escrito com recomendações gerais. Receberam ainda um formulário a ser preenchido em cada vinda à urgência. Resultados Das 377 mulheres incluídas, observou-se abortamento completo em 340 (90,2%). As restantes 37 (9,8%) necessitaram de tratamento cirúrgico - taxa de falência global do protocolo. Em 208 (55,2%), o sucesso foi observado ao fim da 1ª dose, com uma taxa de eficácia da 2ª dose de 78,1% (132/169). A idade média das mulheres com sucesso do tratamento médico foi superior à das mulheres sem sucesso do mesmo (33,99 versus 31,74 anos; p = 0,031). O sucesso do tratamento foi maior quando o diagnóstico ecográfico inicial era de um embrião sem vitalidade comparado com os casos de ovo anembrionado (p = 0.049). Conclusões Conclui-se que esta é uma opção de tratamento eficaz e segura na maioria das situações de GI1°T, evitando a necessidade de internamento e de intervenção cirúrgica.

Induction of Labor using Misoprostol in a Tertiary Hospital in the Southeast of Brazil / Indução de parto utilizando misoprostol em um hospital terciário no sudeste do Brasil

Abstract Purpose To assess cases of labor induction with vaginal 25-μg tablets of misoprostol and maternal outcomes in a tertiary hospital in southeastern Brazil. Methods This was a retrospective cohort study of 412 pregnant women with indication for labor induction. Labor induction was performed with vaginal 25-μg tablets ofmisoprostol in pregnant women with Bishop scores < 6. Stepwise regression analysis was used to identify the factors present at the beginning of induction that could be used as predictors of successful labor induction. Results A total of 69% of the pregnant women who underwent labor induction progressed to vaginal delivery, and 31% of the women progressed to cesarean section. One or two misoprostol tablets were used in 244 patients (59.2%). Of the 412 patients, 197 (47.8%) required oxytocin later on in the labor process, after induction with misoprostol. The stepwise regression analysis showed that only Bishop scores of 4 and 5 and previous vaginal delivery were independent factors with statistical significance in the prediction of successful vaginal labor induction (β = 0.23, p < 0.001, for a Bishop score of 4 and 5, and β = 0.22, p < 0.001, for previous vaginal delivery). Conclusion Higher Bishop scores and previous vaginal delivery were the best predictors of successful labor induction with vaginal 25-μg tablets of misoprostol.

Resumo Objetivo Avaliar os casos de indução do trabalho de parto com misoprostol 25 mcg por via vaginal e seus desfechos maternos em um hospital terciário do Sudeste do Brasil. Métodos Realizou-se um estudo retrospectivo de coorte com 412 gestantes com indicações para indução de trabalho de parto. A indução do trabalho de parto foi realizada com misoprostol 25 mcg vaginal em gestantes com índice de Bishop < 6. Realizou-se análise de regressão stepwise para identificar os fatores presentes ao início da indução que poderiam ser usados como prognosticadores do sucesso da indução do trabalho de parto. Resultados A indução de trabalho de parto determinou 69% de partos normais, sendo que 31% evoluíram para cesárea. Em relação ao número de comprimidos de misoprostol, 1 ou 2 comprimidos foram utilizados em 244 pacientes (59,2%). Das 412 pacientes, 197 (47,8%) necessitaramde ocitocina após a indução commisoprostol para dar continuidade ao trabalho de parto. Na análise de regressão stepwise, apenas a presença de índice de Bishop 4 e 5 e parto vaginal prévio foram fatores independentes com significância estatística na predição do sucesso da indução emobter parto vaginal (β = 0,23, p < 0,001, para índice de Bishop 4 e 5, e β = 0,22, p < 0,001, para parto vaginal prévio). Conclusão Maiores índices de Bishop e parto vaginal prévio são os maiores prognosticadores do sucesso de indução de trabalho de parto com misoprostol 25 mcg vaginal.

Tratamiento médico del embarazo ectópico no complicado; experiencia del hospital regional de Talca / Medical treatment of uncomplicated ectopic pregnancy: regional hospital of Talca experience

El tratamiento médico del embarazo ectópico (EE) no complicado es una alternativa para el manejo de esta patología. Existen distintos criterios para su uso y las tasas de éxito publicadas son variadas. Realizamos una revisión de 34 casos de pacientes con diagnóstico de EE no complicado en el Hospital Regional de Talca, reportándose una tasa de éxito con dosis única de metotrexato de 65%. Un 20,5% de las pacientes requirieron una dosis adicional de metotrexato. La tasa total de éxito con tratamiento médico alcanzó un 73.5%. El manejo médico es una alternativa efectiva a la cirugía en pacientes bien seleccionadas. Se debe evaluar de manera local los criterios de inclusión para el tratamiento médico del EE no complicado.

Medical treatment of non complicated ectopic pregnancy is an alternative for the management of this pathology. There are different criteria for it's use, and published success rates are heterogeneous. We reviewed 34 cases of patients with diagnosis of no complicated ectopic pregnancy in Hospital Regional de Talca, and we reported a success rate of 65% with a single dose of methotrexate. 20,5% of patients needed an additional dose of medication. The global success rate of medical treatment was 73,5%. No surgical management is an effective alternative for well-selected patients. The criteria for medical treatment of no complicated EE must be evaluated locally.

Local management with methotrexate of cesarean scar ectopic pregnancy with live embryo guided by transvaginal ultrasound: A case report / Tratamento local com metotrexato guiado por ultrassonografia transvaginal de gravidez ectópica em cicatriz de cesárea com embrião vivo: relato de caso

Summary Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy with high morbidity and mortality. Use of conservative conducts, including medical management with methotrexate, has avoided mutilating surgeries such as hysterectomy and spared the fertility of women. We report the case of a 30-year old patient with a cesarean scar ectopic pregnancy, with a live embryo, who was treated locally with transvaginal ultrasound-guided injection of methotrexate, complemented with various doses of systemic methotrexate.

Resumo A gravidez ectópica na cicatriz de cesárea é uma forma rara de gestação ectópica com elevada morbimortalidade. O emprego de condutas conservadoras, como o tratamento medicamentoso com metotrexato, tem evitado cirurgias mutiladoras, como a histerectomia, e preservado o futuro reprodutivo da mulher. Relatamos um caso de paciente de 30 anos, com gravidez ectópica em cicatriz de cesárea, com embrião vivo, tratada com injeção local de metotrexato guiada por ultrassonografia transvaginal, complementada com tratamento sistêmico com múltiplas doses de metotrexato.

The biomedicalisation of illegal abortion: the double life of misoprostol in Brazil / A biomedicalização do aborto ilegal: a vida dupla do misoprostol no Brasil

Abstract This paper examines the double life of misoprostol in Brazil, where it is illegally used by women as an abortifacient and legally used in obstetric hospital wards. Based on my doctoral and post-doctoral anthropological research on contraception and abortion in Salvador, Bahia, this paper initially traces the “conversion” of misoprostol from a drug to treat ulcers to a self-administered abortifacient in Latin America, and its later conversion to aneclectic global obstetric tool. It then shows how, while reducing maternal mortality, its use as an illegal abortifacient has reinforced the double reproductive citizenship regime existing in countries with restrictive abortion laws and poor post-abortion care services, where poor women using it illegally are stigmatised, discriminated against and exposed to potentially severe health risks.

Resumo O artigo examina a vida dupla do misoprostol no Brasil, onde ele é usado ilegalmente por mulheres como um facilitador do aborto, e legalmente, em alas de obstetrícia de hospitais. Utilizei minhas pesquisas antropológicas de doutorado e pós-doutorado sobre contracepção e aborto em Salvador, Bahia. Começo retratando a “conversão” do misoprostol, medicamento usado para tratar úlceras, em um facilitador do aborto autoadministrado na América Latina, e sua conversão em uma ferramenta de obstetrícia global. Apesar da redução da mortalidade materna, seu uso como um método abortivo ilegal reforçou a dupla cidadania reprodutiva em países com restrições abortivas e pouca assistência pós-aborto, onde mulheres pobres que usam o método ilegal são estigmatizadas, discriminadas e expostas a potenciais riscos à saúde.

Abdominal alterations in disseminated paracoccidioidomycosis: computed tomography findings / Alterações abdominais da paracoccidioidomicose disseminada: achados por tomografia computadorizada

Objective: To evaluate the incidence and spectrum of abdominal computed tomography imaging findings in patients with paracoccidioidomycosis. Materials and Methods: Retrospective analysis of abdominal computed tomography images of 26 patients with disseminated paracoccidioidomycosis. Results: Abnormal abdominal tomographic findings were observed in 18 patients (69.2%), while no significant finding was observed in the other 8 (30.8%) patients. Conclusion: Computed tomography has demonstrated to play a relevant role in the screening and detection of abdominal abnormalities in patients with disseminated paracoccidioidomycosis. .

Objetivo: Avaliar a frequência e variedade de achados de imagem por exames de tomografia computadorizada de abdome em indivíduos com paracoccidioidomicose disseminada. Materiais e Métodos: Estudo retrospectivo dos exames de tomografia computadorizada de abdome de 26 pacientes com paracoccidioidomicose disseminada. Resultados: Foram encontradas alterações tomográficas abdominais em 18 pacientes (69,2%) dos casos analisados e 8 pacientes (30,8%) apresentaram exames normais. Conclusão: A tomografia computadorizada de abdome mostrou grande importância no rastreamento e identificação de alterações abdominais nos pacientes com paracoccidioidomicose disseminada. .

Interventional radiology and endovascular surgery in the treatment of ectopic pregnancies / Radiologia intervencionista e cirurgia endovascular no tratamento das prenhezes ectópicas

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers.

O advento da radiologia intervencionista tornou possível avanços notáveis no diagnóstico e no tratamento de diversas situações, na área de ginecologia e obstetrícia. No campo da obstetrícia, esses avanços incluem oclusão temporária das artérias hipogástricas para o manejo de placenta acreta e/ou prévia, embolização de fístulas arteriovenosas após curetagem uterina e manejo de prenhezes ectópicas uterinas e extrauterinas. A gravidez ectópica não tubária, seja cervical, abdominal, ovariana ou na cicatriz de cesárea, muitas vezes representa grande desafio terapêutico, principalmente quando há desejo de manutenção da fertilidade. As opções terapêuticas mais utilizadas para o tratamento de prenhez ectópica não tubária, são: terapia sistêmica com metotrexato e ressecção cirúrgica do saco gestacional ectópico; porém a abordagem intervencionista com injeção direta de metotrexato no saco gestacional ou quimiembolização intra-arterial das artérias uterinas, apresentam-se na literatura recente, como modalidades terapêuticas viáveis, seguras, eficazes, com baixa morbidade, menor tempo de internação e rápida recuperação clínica. Devido ao diminuto arsenal de materiais utilizados e à crescente formação de especialistas na área, a intervenção radiológica, como opção de tratamento nas prenhezes ectópicas, é financeiramente viável e apresenta acessibilidade considerável no mundo e na maioria do centros médicos brasileiros.

Induced abortion among Brazilian female sex workers: a qualitative study / Aborto induzido entre prostitutas brasileiras: um estudo qualitativo

Prostitutes are vulnerable to unplanned pregnancies and abortions. In Brazil, abortion is a crime and there is no data about unsafe abortions for this population. The study describes how prostitutes perform illegal abortions and the health consequences thereof. Semi-structured interviews with 39 prostitutes from three cities in Brazil with previous induced abortion experience were conducted. Sixty-six abortions, with between one and eight occurrences per woman, were recorded. The majority of the cases resulted from sexual activity with clients. The inconsistent use of condoms with regular clients and the consumption of alcohol during work were indicated as the main causes of unplanned pregnancies. The main method to perform abortion was the intravaginal and oral use of misoprostol, acquired in pharmacies or on the black market. Invasive measures were less frequently reported, however with more serious health complications. The fear of complaint to the police meant that most women do not inform the health team regarding induced abortion. The majority of prostitutes aborted with the use of illegally-acquired misoprostol, ending abortion in a public hospital with infection and hemorrhagic complications. The data indicate the need for a public policy focusing on the reproductive health of prostitutes.

As prostitutas estão vulneráveis à gravidez não planejada e ao aborto. No Brasil, essa prática é crime e não há dados sobre aborto inseguro entre essa população. O estudo descreve como prostitutas abortam ilegalmente e o impacto à saúde. Foram realizadas entrevistas semiestruturadas com 39 prostitutas de três cidades do Brasil com experiência prévia em aborto induzido. Foram realizados 66 abortos, entre 1 e 8 ocorrências por mulher. A maioria dos casos resultaram de atividades sexuais com os clientes. O uso inconsistente dos condoms e o consumo de álcool na prostituição foram indicadas como as principais causas de gravidez não planejada. O principal método para abortar foi uso intravaginal e oral de misoprostol, adquirido em farmácias ou no mercado clandestino. Métodos invasivos foram menos frequentes, apesar de com mais sérias implicações à saúde. O medo de denúncia à polícia fez com que a maioria das mulheres não informasse à equipe de saúde sobre a indução do aborto. A maioria das prostitutas abortou com uso de misoprostol adquirido ilegalmente, finalizando o aborto em hospital público com quadros de infecção e complicações hemorrágicas. Os dados indicam a necessidade de uma política pública voltada à saúde reprodutiva das prostitutas.

Pronóstico reproductivo posterior a un embarazo ectópico según modalidad de tratamiento / Subsequent reproductive prognosis ectopic pregnancy according to treatment modality

Introducción: Entre un 20 - 60 por ciento de las pacientes que presentan un embarazo ectópico (EE) desarrollarán infertilidad en el futuro. Objetivo: Comparar las tasas de fertilidad posterior a un EE según tipo de tratamiento: médico con Metotrexato o quirúrgico, en un grupo de pacientes sin acceso a técnicas de fertilización asistida. Métodos: Presentamos un estudio de cohorte retrospectivo de pacientes con diagnóstico de EE tratadas en el Servicio de Ginecología del Hospital Padre Hurtado, entre enero de 2002 y diciembre de 2007. Se excluyeron pacientes con EE cervical o cornual, las de manejo expectante, y pacientes esterilizadas. El seguimiento mínimo fue de 4 años posterior al EE. Resultados: Se diagnosticaron 288 EE. Se excluyeron del estudio 69 pacientes. De los 219 casos restantes, se obtuvo seguimiento completo en 193 casos (88,1 por ciento). De los 193 casos analizados, 128 fueron pacientes sometidas a resolución quirúrgica, consistente en una salpingectomía de la tuba comprometida y 65 pacientes se trataron con Metotrexato. En 18 de éstas últimas, fracasó el tratamiento médico, requiriendo de una salpingectomía diferida. Excluyendo a estas 18 pacientes, la tasa de embarazo para el grupo de resolución quirúrgica fue de 83,6 por ciento (107 de 128 pacientes) y para el grupo de manejo médico con Metotrexato fue de 80,9 por ciento (38 de 47 pacientes), sin diferencia estadísticamente significativa entre ambos grupos (p=0,67). Conclusión: En este estudio, las tasas de embarazo para ambos grupos de manejo fueron similares, siendo mayores que las reportadas por la literatura.

Introduction: It is estimated that 20-60 percent of patients with ectopic pregnancy, will develop infertility on the future, but knowledge about this matter is scarce. Aims: To compare fertility rates after ectopic pregnancy, among medical treatment with methotrexate and surgery, in patients without opportunity for assisted reproductive techniques. Methods: Retrospective cohort study of patients diagnosed with ectopic pregnancy, treated in Hospital Padre Hurtado's gynecology service, Santiago - Chile, between January 2002 and December 2007. Patients with cervical or cornual ectopic pregnancy, expectant management, or patients, who didn't want future pregnancies, were excluded from the analysis. Follow up was for at least 4 years. Results: 288 ectopic pregnancies were diagnosed; 69 patients were excluded. From the 219 participants, 193 cases (88.1 percent) with complete follow, were included for analysis. Surgical management, which consisted of salpingectomy of the compromised tube, was done on 128 patients. Medical management was done on 65 patients, but 18 patients required differed salpingectomy for treatment failure. Excluding those 18 patients, the pregnancy rates for the surgical management group was of 83.6 percent (107/128) and 80.9 percent (38/47) for the medical management group, not statistically significant (p=0.67). Conclusion: There are similar pregnancy rates for surgical and medical management for patients with ectopic pregnancy history; although these were higher than those reported in literature.

Efectividad del tratamiento médico con misoprostol según dosis administrada en aborto retenido menor de 12 semanas / Effectiveness of medical treatment with misoprostol as abortion retained dose administered in less than 12 weeks

Antecedentes: El manejo terapéutico del aborto retenido consiste en evacuar la cavidad uterina espontáneamente o utilizando misoprostol previo al legrado quirúrgico. Objetivo: Evaluar la necesidad de dilatación mecánica post maduración cervical con misoprostol y la tasa de perforación uterina post legrado, utilizando diferentes dosis de misoprostol en pacientes con diagnóstico de aborto retenido menor a 12 semanas. Métodos: Se registraron datos demográficos y ginecológicos de una cohorte retrospectiva de pacientes con diagnóstico de aborto retenido menor a 12 semanas, entre enero de 2008 y diciembre de 2010. Se establecieron 3 grupos de trabajo según la dosis de misoprostol administrada vía vaginal, siendo de 100 (n=131), 200 (n=231) y 400 micrones (n=230), y se observaron las complicaciones asociadas al procedimiento. Resultados: La necesidad de dilatación mecánica fue significativamente mayor en el grupo que recibió 100 micrones de misoprostol al compararlo con el de 200 micrones y 400 micrones (p<0,01). No hubo diferencias estadísticamente significativas entre las que recibieron 200 versus 400 micrones de misoprostol. No hubo diferencias significativas respecto a perforación uterina. Conclusión: En el aborto retenido menor a 12 semanas, la necesidad de dilatación mecánica post maduración cervical, es menor si se utiliza 200 o 400 micrones de misoprostol, sin diferencias en la tasa de perforación uterina.

Background: The therapeutic management of missed abortion consists on evacuating the uterine cavity, spontaneously or by administration of misoprostol previous to curettage. Objectives: Evaluate the need of mechanical dilatation after cervical maturation with misoprostol and the rate of uterine perforation before curettage, using different doses of misoprostol in patients with diagnosis of missed abortion before 12 weeks. Methods: Demographic and gynecologic data were registered of a retrospective cohort of patients with the diagnosis of missed abortion before 12 weeks, between January 2008 and December 2010. Three groups were established according to the dose of misoprostol: 100 (n=131), 200 (n=231) and 400 microns (n=230). Complications associated to the procedure were observed. Results: The need of mechanical dilatation was significant higher for the group with 100 microns of misoprostol in comparison with 200 and 400 microns (p<0.001). There was no statistical significance among who received 200 versus 400 microns of misoprostol. No statistical significance was found for uterine perforation. Conclusion: In the missed abortion before 12 week, the need of mechanical dilatation is lower with 200 or 400 microns of misoprostol, without difference in uterine perforation rate.