Manejo das irregularidades menstruais secundárias ao uso de contraceptivos ­ análise das recomendações atuais / Management of menstrual irregularities secondary to contraceptive use ­ analysis of current recommendations

As irregularidades menstruais representam uma série de desordens na quantida- de, duração, frequência ou regularidade do sangramento uterino. Entre suas cau- sas destaca-se o sangramento secundário ao uso de anticoncepcionais, uma razão frequente de descontinuidade dos contraceptivos, podendo aumentar as taxas de gestações não planejadas. Boa parte dos contraceptivos pode levar a mudanças no padrão de sangramento uterino, e a abordagem inicial do sangramentos irregula- res inclui a avaliação de outras possíveis causas, o reforço do uso correto da medi- cação, a tranquilização da paciente quanto à benignidade do quadro e à tendência a melhora com a continuidade do uso. Os anti-inflamatórios podem ser usados como estratégia inicial, e, não havendo resposta satisfatória, há alternativas espe- cíficas para cada método. Este trabalho visa identificar as recomendações atuais sobre o manejo do sangramento anormal decorrente de contraceptivos, por meio de revisão narrativa de estudos publicados sobre o tema nos últimos vinte anos.

Abnormal uterine bleeding represents a series of disorders in the amount, du- ration, frequency and or regularity of uterine bleeding. Among its causes, uterine bleeding secondary to the use of contraceptives stands out as a frequent reason for contraceptive discontinuity, which could lead to unplanned pregnancies. Most contraceptives can cause changes in the pattern of uterine bleeding, and the ini- tial approach of the abnormal bleeding includes assessing other possible cau- ses, reinforcing the correct use of medication, and reassuring the patient about the benignity of the condition and the tendency to improve with the continuity of the treatment. Anti-inflammatory drugs can be used as an initial strategy, and, if there is no satisfactory answer, there are specific alternatives for each contracep- tive method. This work aims to identify them current recommendations on the management of abnormal bleeding resulting from contraceptives use, through a narrative review of studies published on the subject in the last twenty years.

Gestação heterotópica espontânea: relato de caso com diagnóstico e manejo oportunos / Spontaneous heterotopic pregnancy: a case report with appropriate diagnosis and management

Introdução: A gravidez heterotópica é um fenômeno obstétrico muito raro em concepções espontâneas no qual gestações tópica e ectópica coexistem. O diagnóstico é difícil, mas, se realizado precocemente, o prognóstico é favorável. Descrição do caso: Paciente do sexo feminino, de 35 anos de idade, admitida com quadro de dor abdominal e pequeno sangramento vaginal. Diagnosticada precocemente e tratada cirurgicamente por gravidez heterotópica naturalmente concebida. Como resultado, a gravidez tópica seguiu sem intercorrências. Conclusão: Esse caso enfatiza a necessidade de considerar esse diagnóstico diferencial e analisar clínica e ecograficamente as características globais da pelve, mesmo na ausência de fatores de risco em gestações tópicas.(AU)

Introduction: Heterotopic pregnancy (HP) is a rare obstetric phenomenon in spontaneous conceptions in which intrauterine and ectopic pregnancies coexist. The diagnosis is difficult, but, if performed early, the prognosis is favorable. Case description: A 35-year-old woman was admitted with abdominal pain and light vaginal bleeding. She was early diagnosed and surgically treated for a naturally conceived heterotopic pregnancy. As a result, the intrauterine pregnancy went on healthily. Conclusion: This case emphasizes the need to regard HP as a differential diagnosis and analyze the global pelvis characteristics both clinically and in ultrasound scans, even in the absence of risk factors when dealing with intrauterine pregnancies.(AU)

Coronary Angioplasty with Stent in Woman with Active Vaginal Bleeding

Uterine leiomyoma and coronary artery disease are two common diseases in women. However, the association of uterine bleeding caused by leiomyoma with unstable coronary syndrome is not frequent. Here we describe a case of a patient with active vaginal bleeding and unstable angina who underwent a unique approach by performing percutaneous procedures. The report demonstrates that new interventional options can be used to control active bleeding in patients in need of coronary angioplasty

Pseudoaneurisma de la arteria uterina post cesárea / Pseudoaneurysm of the uterine artery after cesarean

El pseudoaneurisma de la arteria uterina es poco habitual pero una grave complicación de la cesárea, puede manifestarse con hemorragia de importancia clínica durante el postoperatorio tardío. La ecografía doppler fue un procedimiento importante para su sospecha diagnóstica del pseudoaneurisma la misma que puede tratarse por medio de la embolización arteriográfica de la arteria uterina. Comunicamos el caso de una paciente con 17 días de hemorragia post cesárea sometida a legrado uterino y 21 días después del legrado se le realiza histerectomía con el diagnóstico de pseudoaneurisma de arteria uterina. (AU)

The pseudoaneurysm of the uterine artery is uncommon but a serious complication of caesarean section may manifest with hemorrhage clinical importance during the late postoperative period. Doppler ultrasound was an important procedure for its diagnostic suspicion of the pseudoaneurysm, which can be treated by arteriographic embolization of the uterine artery. We report the case of a patient with 17 days of post-cesarean haemorrhage submitted to uterine curettage and 21 days after curettage a hysterectomy was performed with the diagnosis of pseudoaneurysm of the uterine artery. (AU)

Características clínico-epidemiológicas y manejo del cáncer endometrial (2010-2013) / Clinical-epidemiological characteristics and management of endometrial cancer (2010-2013)

Introducción: el cáncer de endometrio ha incrementado su incidencia y se asocia a factores de riesgo presentes en muchas mujeres en la perimenopausia. El síntoma más común es el sangramiento y la modalidad de tratamiento más empleada es la cirugía. Objetivo: caracterizar el cáncer endometrial en el Hospital América Arias desde enero de 2010 hasta junio de 2013. Métodos: se realizó un estudio descriptivo en el Hospital América Arias, desde 1ro de enero de 2010 hasta el 30 de junio de 2013. Se incluyó el total las pacientes con sangramiento uterino anormal en la etapa peri y posmenopáusico a partir de 40 años de edad. Las pacientes con diagnóstico histopatológico de cáncer endometrial constituyeron la muestra (n= 49). Resultados: la edad promedio de las pacientes fue de 60,8 ± 9,9 años. Presentaban sobrepeso 30,6 por ciento, y 44,9 por ciento eran obesas. El examen histopatológico posquirúrgico muestra que la lesión estuvo limitada al endometrio en 14,3 por ciento de las pacientes; pero hubo invasión de los dos tercios externos del miometrio en 61,2 por ciento de ellas. La extensión al cuello y a los anejos uterinos fue de 38,8 por ciento y 22,4 por ciento respectivamente. Conclusiones: existe una tendencia a la aparición del adenocarcinoma endometrial en edades cada vez más avanzadas. Se asocia a factores de riesgo como obesidad, infertilidad y el uso de terapia hormonal de remplazo. Además de la cirugía, algunas pacientes requirieron tratamiento oncológico específico(AU)

Introduction: The incidence of endometrial cancer has increased and it is associated with risk factors present in many perimenopausewomen. The most common symptom is bleeding and the most widely used treatment modality is surgery. Objective: Characterize endometrial cancer at America Arias Hospital from January 2010 to June 2013. Methods: A descriptive study was conductedat America Arias Hospital, from 1 January 2010 to 30 June 2013. The total included over 40 year patients with abnormal uterine bleeding in perimenopausal and postmenopausal. Patients with histopathologic diagnosis of endometrial cancer constituted the sample (n= 49). Results: The mean age of patients was 60.8 ± 9.9 years. 30.6 percent were overweight and 44.9 percent were obese. Postoperative histopathologic examination shows that the lesion was limited to the endometrium in 14.3 percent of patients, but there was invasion of the two outer thirds of the myometrium in 61.2 percent. The extension cervix and adnexa was 38.8 percent and 22.4 percent, respectively. Conclusions: There is a tendency to the appearance of endometrial adenocarcinoma at increasingly advanced ages. It is associated with risk factors such as obesity, infertility, and the use of hormone replacement therapy. In addition to surgery, some patients required specific cancer treatment(AU)

Adolescent menorrhagia: causes and evaluation

To find out different causes of adolescent menorrhagia. Cross-sectional descriptive study. This study was conducted in Department of Gynecology and Obstetrics Fauji Foundation Hospital Rawalpindi from 1[st] April 2011 to 31[st] December 2011. Fifty one un-married patients aged 9-19 years with menorrhagia were selected by non probability convenience sampling. All the details of history including blood loss, clinical examination and investigations were recorded in a proforma for analysis. The most common cause of menorrhagia was dysfunctional uterine bleeding [76.5%] followed by thyroid disorders [13.7%] and bleeding disorders [9.8%]. Dysfunctional Uterine bleeding [DUB] was found to be the commonest cause of adolescent menorrhagia. Patients with adolescent menorrhagia should be carefully investigated for different causes as timely intervention can help these young patients

Gravidez ectópica cervical com embrião vivo: o uso do metotrexato é eficiente? / Cervical ectopic pregnancy with alive embryo: the use of methotrexate is effective?

A gravidez ectópica cervical é tida como de localização excepcional, representando menos de 1% das implantações ectópicas. Embora rara, constitui patologia obstétrica de elevada gravidade. Sua letalidade, no passado, atingia índices assustadores. Estabelecido o diagnóstico, a conduta clássica era a histerectomia total, pois o sangramento intravaginal oriundo do canal cervical era frequentemente mortal, diante de tentativas de tratamento conservador por curetagem e/ou sutura local, sobretudo em nulíparas, desejosas de manter a fertilidade. Mais recentemente, tem sido proposto o uso do metotrexato por via local e/ou sistêmica, por vezes associado a técnicas de ligadura e embolização arterial, como forma de evitar a cirurgia mutiladora. Este trabalho teve como objetivo buscar evidências científicas na literatura que possam avaliar a eficácia do tratamento dessas pacientes utilizando o metotrexato.

The cervical ectopic pregnancy is considered of exceptional location, less than 1% of ectopic implantations. Although rare, is extremely serious obstetric pathology. Lethality in the past, reached frightening levels. After the diagnosis, the procedure was the classic radical hysterectomy, because the bleeding originated from intravaginal cervical canal was often fatal before the attempts of conservative treatment by curettage and/or suture, especially in nulliparous women desiring to maintain fertility. More recently, it has been suggested the use of methotrexate by local and/or systemic way, frequently associated with techniques of ligation and arterial embolization, in order to avoid mutilating surgery. This study aimed to look for evidence in the scientific literature to evaluate the effectiveness of treatment of these patients using methotrexate.

Embryonic heart rate correlation with pregnancy outcome in women with first trimester bleeding

To assess the correlation between fetal heart rate and the fate of pregnancy in women with first trimester bleeding. This prospective observational study included 281 consecutive women with first trimester bleeding and Singleton pregnancies. The embryonic heart rate measured at the time of first trans-vaginal scan as per protocol in our university hospital for the evaluation of pregnancy. The heart rate was classified as slow if it was fewer than 110 beats per minute. The primary outcome measure is the occurrence of spontaneous early pregnancy loss prior to 12 weeks. Other outcome measures included the occurrence of late pregnancy loss [prior to 24 weeks], gestational age at birth, and fetal weight at birth. Embryonic heart rate at less than 110 bpm was associated with a high likelihood of pregnancy loss. The sensitivity, specificity, positive and negative predictive value, and accuracy were 43.1%, 86%, 40.7%, 87.2%, and 78.2%, respectively. The OR [95% CI] of first-trimester pregnancy. Embryonic heart rate can be an independent predictor of the outcome of pregnancy in women with intrauterine pregnancy complaining of first trimester bleeding

Análisis de un quinquenio en la histerectomía obstétrica de emergencia / A five-year analysis in the emergence obstetric hysterectomy

La histerectomía obstétrica de emergencia (HOE), realizada en casos de hemorragia obstétrica severa e incontrolable, se relaciona con una significativa morbilidad materna. Se realizó un estudio descriptivo de corte transversal en el hospital general docente "Enrique Cabrera", para caracterizar a las pacientes obstétricas histerectomizadas de urgencia e identificar las indicaciones y morbimortalidad asociadas al proceder. Todas las puérperas histerectomizadas en el quinquenio 2002-2006, constituyeron el universo de trabajo. De las historias clínicas se obtuvieron datos sociodemográficos, obstétricos y aquellos relacionados con la indicación de la histerectomía, técnica y complicaciones. Se utilizaron distribuciones de frecuencias y otras técnicas de estadística descriptiva, mediante el procesador estadístico para Windows, SPSS, versión 13. El 47 % de las HOE ocurrió en mujeres mayores de 30 años, el 44 % de las pacientes fueron primíparas, la atonía uterina fue la indicación en el 48 % de los casos, la morbilidad incluyó la politransfusión (80 %), admisión en unidad de cuidados intensivos (88 %) y coagulación intravascular diseminada (45,4 %). Se concluyó que la edad materna mayor de 30 años predominó entre las pacientes histerectomizadas, que los eventos hemorrágicos fueron la primera indicación para HOE y entre ellos la atonía uterina y que el proceder se asoció a una elevada morbilidad materna

Emergence obstetric hysterectomy (EOH), carried out in cases of severe and uncontrollable obstetric hemorrhage is related to a significant maternal morbidity. A cross-sectional and descriptive study was conducted in "Enrique Cabrera" Teaching General Hospital to characterize the obstetric patients underwent an emergence hysterectomy and to identify the indications and morbidity and mortality associated to procedure. Sample included all the hysterectomy puerperants during 2002-2006. From medical records it was possible to collect the sociodemographic, obstetric data and those related to prescription of hysterectomy, technique and complications. Frequency distribution and other descriptive statistic techniques were used by statistical processor for Windows, SPSS version 13. The 47 percent of EOHs was in women aged over 30, the 44 percent of patients were primipara, uterine atomy was the indication in the 48 percent of cases; morbidity included polytransfusion (80 percent) and disseminated intravascular coagulation (45.4 percent). We conclude that mother aged over 30 predominates among hysterectomy patients, that hemorrhagic events were the first indication for EOH and mainly the uterine atony and that procedure was associated with a high maternal morbidity

[ effects of risk factor of pregnancy period on infant's weight]

Low birth weight [LBW] is one of the most important causes of mortality in newborns, therefore identifying the associated risk factors is of crucial necessity. To investigate the risk factors among women during the pregnancy leading to delivery of a LBW infants. This was a case-control study in which the data from 191 infants characteristic of LBW as cases [chosen out of a total of 203] and 199 normal infants as controls were compared. Controls were intentionally chosen to be the next live birth to the LBW infant. Statistical univariate analyses were performed using t-test and X2 test. Also, Multiple Logistic Regression was employed to identify the risk factors associated with LBW. Univariate analysis showed that LBW was related to gestational age [p<0.001], mother's weight [p=0.004], mother's higth [p=0.001], mother's age [p=0.040], history of chronic desease in mother [p=0.026], bleeding during pregnancy [p=0.007], mother's education level [p =0.003], and birth order [p=0.047]. Logistic Regression [multivariable analysis] revealed that, in presence of all factors, LBW was only associated with gestational age, mother's higth, bleeding durring pregnancy, and the history of chronic desease in mother with odd ratios of 1.77, 1.90, 0.60, 0.66, respectively, Increased gestational age, appropriate management of bleeding durring pregnancy and also of mothers' chronic desease could reduce the chance of LBW

O uso intravenoso de sacarato de hidróxido de ferro III em pacientes com anemia ferropriva / Evaluation of the efficacy of intravenous iron III-hydroxide saccharate for treating adult patients with iron deficiency anemia

OBJETIVO: Avaliar a eficácia do uso intravenoso de sacarato de hidróxido de ferro III no tratamento de pacientes adultos com anemia ferropriva que não obtiveram resposta satisfatória à terapia com ferro oral. MÉTODOS: No período de janeiro de 2003 a janeiro de 2004, estudamos 25 pacientes com anemia ferropriva que apresentaram intolerância e/ou resposta inadequada ao tratamento com ferro por via oral e/ou valor de hemoglobina < 7 g/dl. Os principais exames laboratoriais realizados foram: hemograma completo, contagem de reticulócitos, ferro sérico, capacidade total de ligação de ferro e ferritina sérica. Os pacientes receberam uma dose semanal de 200 mg de sacarato de hidróxido de ferro III diluído em 250 ml de soro fisiológico 0,9 por cento administrado por via intravenosa em 30 minutos. O tratamento foi realizado até a obtenção dos valores de hemoglobina =12 g/dl para mulheres e =13 g/dl para homens, ou até a administração da dose total de ferro parenteral recomendada para cada paciente. RESULTADOS: A idade mediana dos 25 pacientes estudados foi de 45 anos, variando entre 31 e 70 anos; 19 (76 por cento) eram do sexo feminino. A causa mais comum de anemia ferropriva no sexo feminino foi sangramento uterino anormal observado em 13/19 pacientes (68 por cento) e, no sexo masculino, gastrectomia parcial observada em 4/6 (67 por cento). Dezessete (68 por cento) pacientes foram incluídos neste estudo por falta de resposta à terapia com ferro oral, 6/25 (24 por cento) por intolerância ao ferro oral e 2/25 (8 por cento) por hemoglobina < 7 g/dL. Correção da anemia foi obtida em 12/19 (63 por cento) dos pacientes do sexo feminino e em 5/6 (83 por cento) dos pacientes do sexo masculino. Os valores médios da hemoglobina e da ferritina eram de 8,09 g/dl e 4,20 ng/ml (pré-tratamento) e 12,42 g/dl e 87,78 ng/ml (pós-tratamento) (p<0,001), respectivamente. O aumento médio de hemoglobina foi de 3,74 g/dl, variando entre 1,30 g/dl e 7,60 g/dl. Nenhum paciente recebeu transfusão de sangue durante ou após o tratamento com ferro intravenoso. CONCLUSÃO: O uso intravenoso de sacarato de hidróxido de ferro III é uma opção eficaz e segura no tratamento de pacientes adultos com anemia ferropriva que não obtiveram resposta satisfatória com a utilização do ferro oral. Esta opção terapêutica deve ser levada em consideração sobretudo nos pacientes com intensa anemia a fim de se obter rápido aumento dos valores da hemoglobina e se evitar transfusão de sangue.

Outcomes of pregnancies complicated by early vaginal bleeding

The association between early gestational bleeding and suboptimal pregnancy outcome was examined. Postpartum women were interviewed during January-October 1998 at the two main obstetric hospitals in Alexandria, Egypt. Of 1503 singleton deliveries, 10.6% reported bleeding; 63.5% and 36.5% during first and second trimesters respectively. Bleeding was more frequent among women of age >33 years, with history of low-birth-weight babies or previous miscarriage. Suboptimal outcomes occurred more often among women reporting bleeding than among those who never bled and the risk of such outcomes significantly increased with second trimester bleeding. Risk of a low-birth-weight baby, preterm delivery and perinatal death significantly decreased with increasing interpregnancy interval for women with first trimester or second trimester bleeding

Anaesthetic management of a morbidly obese patient.

Morbid Obesity (MO) is associated with various pathophysiological changes which affect the outcome of anaesthesia and surgery. We report here anaesthetic management of a fit morbidly obese patient for transcervical resection of endometrium (TCRE) under spinal subarachnoid block. The preoperative preparation, intraoperative and postoperative management is described and the various problems in morbidly obese patients are discussed.

Uso de analogo do GNRH no tratamento do sangramento uterino anormal: relato de um caso de aplasia medular / GNRH analogue in the treatment of abnormal uterine bleeding: a case report of aplastic anemia

Objetivo: apresentar um caso de aplasia medular severa com sangramento uterino recidivante controlado com goserelin, um analogo do GnRH. Relato do caso: Paciente de 18 anos, raça amarela, nuligesta, com manifestaçäo inicial de moniliase bucal, palidez cutânea progressiva, petequias e equimose pelo corpo, adenopatia generalizada e amenorreia. O hemograma revelou pancitopenia acentuada e o mielograma confirmou o diagnóstico de aplasia medular. Näo houve doador compatível para transplante de medula ossea. Após sucessivas transfusöes sanguineas e plaquetarias, evoluiu com metrorragias recidivantes apesar do emprego de altas doses de hormonios esteróides...

Enfoque hemodinámico y metabólismo en el sangrado genital grave / Hemodynamic and metabolic views in the serious genital bleeding

La hemorragia genital grave en la mujer, casi siempre se presenta durante el estado grávido puerperal, por lo que es importante recordar los cambios hemodinámicos y metabólicos que fisiológicamente se presentan durante la gestación: hipovolemia, hemodilución, taquicardia, modificaciones en los factores de la coagulación sanguínea y en el electrocardiograma. Se expone una clasificación del sangrado genital en 4 clases, de acuerdo a la magnitud de la pérdidad sanguínea, donde las clases III y IV corresponden al estado de choque hipovolémico y ameritan cuidados intensivos. Se enfatiza en la necesidad de contar con todos los recursos materiales necesarios para el manejo de estos casos y con la participación de un equipo humano multidisciplinario. Se recuerda la necesidad de preservar también la vida y la integridad del producto de la concepción en los casos en que sea viable y todavía se encuentre in utero

Unexpected malignancy in perimenopausal versus postmenopausal uterine bleeding

In this study, a total of 600 cases of irregular uterine bleeding in the age group 40-60 years were chosen. Full dilatation and endometrial curettings was done in every patient and the biopsy obtained was subjected to histopathological examination. Out of the 600 patients studied, 515 [85.8%] were perimenopausal and 85 [14.2%] were postmenopausal. The incidence of malignancy was 6.5%. The highest incidence was coporal malignancy with a peak at the age group 55-59 years followed by cervical malignancy with a peak at the age group 40-49 years. The incidence of malignancy in age group 40-44 was 2% and it increased tremendously with age representing 68.4% of cases of uterine bleeding at the age group 55-59 and 87.5% at the age of 60. Premalignant lesions represented 81.5% of cases. Cystic hyperplasia and simple hyperplasia with or without atypia represented 56.7% and affected mostly women of the age group 40-44 years. Disorders of pregnancy represented 7.8% of cases, while atrophic endometritis accounted for 4.2% of causes of uterine bleeding. Thus, the relatively high incidence of malignancy in peri and postmenopausal bleeding justified the employment of dilatation and full curettings as a definite diagnostic method to exclude malignancy

Evaluación del comportamiento de la hemorragia uterina disfuncional en pacientes de dos instituciones de salud de Bogotá

Objetivo: Conocer si el comportamiento del HUD en el ISS guarda la misma relación encontrada en IMI de la ciudad de Bogotá. Material y Métodos: Se analizaron 158 biopsias endometriales del IMI de Bogotá y se compararon con 474 del ISS-Clínica san Pedro Claver de Bogotá. Se clasificaron como Endometrio Funcional al secretor proliferativo y atrófico, como orgánicos:Endometritis, R. Ovulares, Hiperplasia simple o Atípica, Cervicitis, Pólipo. Como prueba estadística se aplicó Chi-cuadrado y diferencia de promedio y proporciones. Resultados: Al clasificar la HUD por grupos de edad, el comportamiento es similar en ambas instituciones tanto para la HUD(IMI 72 por ciento, ISS 70 por ciento) como para HUO (IMI 28 por ciento, ISS 30 por ciento) al examinar los diferentes endometrios en la HUD se encuentra una diferencia significativa del E. secretor según edad(IMI 37 por ciento ISS 47 por ciento) P menor 0.01 y el E. Proliferativo (IMI 58 por ciento ISS 21.9 por ciento) P menor 0.01 Atribuible este hallazgo al mejor estado nutricional de la población estudiada o a la ingesta hormonal exógena. Conclusión: En el diagnóstico clínico de HUD al comparar con la biopsia endometrial el 30 por ciento obedece a origen orgánico y se confirman los hallazgos de la literatura donde a medida que aumenta la edad, el endometrio se hace proliferativo y tiende a la hiperplasia