Espectro do acretismo placentário: recomendações atualizadas da perspectiva do profissional de imagem pré-natal / Placenta accreta spectrum disorders: current recommendations from the perspective of antenatal imaging

O parto cesáreo (PC) é o procedimento cirúrgico mais comumente realizado nos Estados Unidos (mais de 1 milhão de cirurgias por ano) e um dos procedimentos mais realizados em todo o mundo.(1) Embora o PC seja um procedimento potencialmente salvador de vidas, quando corretamente indicado, sua frequência aumentou constantemente nas últimas décadas (atualmente 21,1% globalmente, variando de 5%, na África Subsaariana, a 42,8%, na América Latina e no Caribe). Além disso, estudos demonstram tendência continuada de aumento (projeção para 2030: 28,5% globalmente, variando de 7,1%, na África Subsaariana, a 63,4%, no leste da Ásia).(2) República Dominicana, Brasil, Chipre, Egito e Turquia são os líderes mundiais, com taxas de PC variando de 58,1% a 50,8%, respectivamente, o que aponta para uma tendência preocupante de medicalização do parto e indicação excessiva do PC.(2) Outros procedimentos cirúrgicos como dilatação, curetagem, miomectomia e histeroscopia cirúrgica são menos frequentes que o PC. Ainda assim, devido à tendência de maior idade materna, o número de gestantes previamente submetidas a esses procedimentos também tende a aumentar. Esses dados apontam para um número crescente de gestações em úteros manipulados cirurgicamente Gestantes com cicatrizes uterinas prévias correm risco de aumento da morbimortalidade. Complicações como placenta prévia, rotura uterina espontânea, deiscência uterina (com ou sem intrusão placentária), gestação em cicatriz de cesariana (GCC) e distúrbios do espectro do acretismo placentário (EAP) estão associadas a sangramento uterino potencialmente fatal, lesões extrauterinas e parto pré-termo

Mucinous Cystadenoma Arising in a Uterine Isthmocele: A Case Report / Cistadenoma mucinoso surgindo em istmocele uterina: relato de caso

Abstract Isthmocele is a discontinuation of the myometrium at the uterine scar site in a patient with a previous cesarian section (CS). The cause of isthmocele appears to be multifactorial. Poor surgical technique, low incision location, uterine retroflection, obesity, smoking, inadequate healing of scars, and maternal age are possible related factors. Most patients with this condition are asymptomatic. However, women can present with postmenstrual bleeding, pelvic pain, subfertility, dysmenorrhea, infertility, and scar abscess. Brazil has one of the world s highest cesarean section rates. One of the consequences of the rising rate of CS is the isthmocele, an emerging female health problem. Here we report a case of mucinous cystadenoma arising in a uterine isthmocele, a complication, as far as we could investigate, not yet described in the literature.

Resumo Istmocele é a descontinuidade do miométrio no local da cicatriz uterina em paciente com cesariana anterior. A causa da istmocele parece ser multifatorial. Má técnica cirúrgica, baixa localização da incisão, retroflexão uterina, obesidade, tabagismo, cicatrização inadequada de cicatrizes e idade materna são possíveis fatores relacionados. A maioria dos pacientes com esta condição é assintomática. No entanto, as mulheres podem apresentar sangramento pós-menstrual, dor pélvica, subfertilidade, dismenorreia, infertilidade e abscesso cicatricial. O Brasil tem uma das maiores taxas de cesariana do mundo. Uma das consequências da taxa crescente de cesarianas é a istmocele, um problema emergente de saúde feminina. Aqui relatamos um caso de cistoadenoma mucinoso originado em uma istmocele uterina, uma complicação ainda não descrita, até onde pudemos investigar.

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.

Gunshot wound to the pregnant uterus: case report / Ferimento por tiro em útero gravido: relato de caso

Crime and violence have become a public health problem. Pregnant women have not been the exception and gunshot injuries occupy an important place as a cause of trauma. An important fact is that pregnant women, who suffer trauma, are special patients because pregnancy causes physiological and anatomical changes. Management of these patients should be multidisciplinary, by the general surgeon, the obstetrician and the neonatologist. However, even trauma referral centers could neither have the staff nor the ideal training for these specific cases. In this context we present the following case.

Crime e violência tornaram-se um problema de Saúde Pública. As mulheres grávidas não constituem exceção e ferimentos por arma de fogo ocupam um lugar importante como causa de trauma. Um fato importante é que as mulheres grávidas que sofrem um trauma são pacientes especiais, porque a gravidez provoca modificações fisiológicas e anatômicas importantes. O manejo dessas pacientes deve ser multidisciplinar, realizado pelo cirurgião geral, pelo obstetra e pelo neonatologista. No entanto, até mesmo centros de referência de trauma poderiam nem ter o pessoal nem a formação ideal para esses casos específicos. Neste contexto, apresentamos o seguinte caso.

Extracción de cuerpos extraños intrauterinos / Removal of intrauterine foreing bodies

Evaluar la extracción transcervical de cuerpos extraños de la cavidad endometrial por histeroscopia. Estudio descriptivo y retrospectivo sobre hallazgos inusuales y extracción de cuerpos extraños intrauterinos por histeroscopia entre junio 2000 y junio 2005. Unidad de Endoscopia, Hospital Universitario de Caracas. Se identificaron seis casos con cuerpo extraño en cavidad endometrial, entre ellos: fragmento de madera, dispositivo intrauterino (DIU) fragmentado, algodón, catéter de peridural, metaplasia ósea. La histeroscopia es una herramienta indispensable para la evaluación de la cavidad endometrial, y en especial en los casos en los que se sospecha la presencia de un cuerpo extraño intracavitario. La histeroscopia permite el diagnóstico y tratamiento del problema de una forma rápida y segura.

To evaluate the transcervical removal of foreign bodies from the endometrial cavity for hysteroscopy. Descriptive and retrospective study about unusual findings and extraction of intrauterine foreign bodies for hysteroscopy between June 2000 and June 2005. Endoscope Unit of Gynecology Service, University Hospital of Caracas. Six cases with foreign bodies in endometrial cavity were identified, such as wood sticks, intra uterine device fragmentÆs (IUD), piece of cotton, peridural catheter, bone metaplasy. The hysteroscopy is an indispensable tool for the evaluation of the endometrial cavity, and specially in cases with suspicion of intracavitary foreign bodies. The hysteroscopy permit the diagnostic and treatment of the problem with security and safety.

The location of needle insertion effect on maternal pain in amniocentesis.

OBJECTIVE: The purpose of this study was to determine whether maternal pain in amniocentesis was associated with the location of needle insertion and other identifiable clinical correlates. MATERIAL AND METHOD: This prospective study of mid-trimester amniocentesis was conducted between October 2005 and December 2005. Women were asked to complete a visual analog scale (VAS) after the amniocentesis. The distance from uterine fundus to symphysis pubis and from the location of needle insertion to symphysis pubis were measured and calculated to divide the insertion into two groups: upper third and middle third. The effect of previous amniocentesis, previous abdominal surgery, needle insertion through placenta and operators' experience was determined. The t-test was used for analysis; a probability value of < 0.05 was considered significant. RESULTS: Seventy-two women were participated in the study. The mean VAS was 2.7 +/- 2.1. The perception of pain was significantly less in patients with the upper-third insertion as compared with the middle third insertion (VAS 2.2 vs 3.9, p = 0.002). Previous amniocentesis, previous abdominal surgery, needle insertion through placenta and operators' experience had no impact on pain intensity. CONCLUSION: The pain from amniocentesis was significantly less in the patients with the needle insertion in the upper third of the uterus.

[Uterine synechias treated exclusively hysteroscopically - about 127 cases]

This retrospective study of 127 patients with uterine synechias treated exclusively hysteroscopically included 84 [66.25%] low fertility patients, 36[28.5%] with menstrual disorders and 7 [4%] with no other symptoms. About ninety three patients [73.8%] had a past history of trauma on a gravid uterus. Operative hysteroscopy was performed in all cases, including sections with scissors in 8 cases [13.3%] between 1995 and 1996, and electrosection between 1997 and 2003. A single endoscopic procedure was efficient in 70% of cases and second procedure were required in 6 cases [7.5% of the patients]. No complications due to infection, bleeding or metabolic disorders occurred, but perforations were seen in 2 patients [2.5%] both with complexe synechia. Good anatomic results were achieved after 1 hysteroscopic procedure [70%]. Clinical results were less satisfactory, particularly in cases with low fertility in which another pathology was often associated [31.42%]. We obtained good results in 78.57% of the patients with amenorrhea. However, 49 pregnancies were achieved including 12 normal deliveries

Retardo de crecimiento intrauterino (RCIU) y sus alteraciones bioquímicas / Retard of intra-uterine growth (RCIU)and their biochemical alterations

El estudio del retardo de crecimiento intrauterino (RCIU) continúa siendo importante tanto a nivel obstétrico como pediátrico. El interés se centra en los factores que inciden directamente en las fallas de crecimiento in útero y sobre sus consecuencias postnatales. Además del potencial genético, heredado de los padres, el desarrollo y supervivencia del feto depende directamente del suministro de los sustratos necesarios, como azúcares, ácidos grasos, proteínas, aminoácidos; de esta manera alcanza su peso potencial. Si la disponibilidad de estas fuentes disminuyen en forma persistente, la supervivencia del feto puede verse amenazada. En este artículo se hace una revisión sobre el papel que tienen dichas fuentes y sus alteraciones e implicaciones en los casos de RCIU.

Expressão da ciclo-oxigenase-2 e do Ki67 em lesões precursoras do cancer do colo uterino / Expression of cyclooxygenase-2 and Ki67 in precursor lesions of cervical cancer

Objetivos: Avaliar a expressão da ciclo-oxigenase-2 (COX-2) em lesões escamosas da cérvice uterina e suas relações com a expressão nuclear do Ki67, a detecção do papilomavírus humano (HPV) e com a persistêncialrecorrência de neoplasia intra epitelial cervical (NIC) após conização diatérmica. Sujeitos e métodos: Este foi um estudo de coorte, com análise intermediária em corte transversal, para o qual foram selecionadas mulheres submetidas à conização diatérmica para o tratamento de anormalidades cervicais, entre fevereiro de 2001 e abril 2004. O estudo é apresentado em dois artigos: o primeiro consiste de análise transversal, incluindo os espécimes cirúrgicos de 164 mulheres submetidas à conização. Foram avaliadas a expressão citoplasmática da COX-2 e a expressão nuclear do Ki67, determinadas por imuno-histoquímica, segundo a gravidade da lesão cervical e a detecção do HPV de alto risco oncogênico, realizada através de Captura de Híbridos 11. No segundo artigo, com análise longitudinal, foram incluídas 104 mulheres com NIC, seguidas por até 36 meses após conização diatérmica, para avaliar possíveis relações entre a expressão da COX-2 e Ki67, comprometimento das margens do cone e d_tecção do HPV (durante o seguimento), com a persistêncialrecorrência da NIC. Resultados: No primeiro artigo pode-se observar que não houve diferença na expressão citoplasmática da COX-2 relacionada à gravidade da lesão cervical, à expressão do Ki67 e à detecção do HPV de alto risco. Houve maior expressão de Ki67 nos espécimes com NIC 3. No segundo artigo, 14 casos de recorrência/persistência da NIC foram detectados durante o seguimento. A expressão citoplasmática da COX-2 e a expressão nuclear do Ki67 foram semelhantes nos casos com ou sem...

Objectives: To assess the expression of cyclooxygenase-2 (COX-2) in squamous lesions of the uterine cervix and its possible relations to nuclear expression of Ki67, Human papillomavirus (HPV) detection and to the persistence/recurrence of cervical intraepithelial neoplasia (CIN) after diathermic conization. Subjects and methods: This was a prospective study with intermediate cross-sectional analysis, in which women subjected to diathermic conization due to cervical abnormalities were selected between February 2001 and April 2004. The first article is a cross sectional study, including surgical specimens of 164 women subjected to conization. Cytoplasmic expression of COX-2 and nuclear expression of Ki67, ascertained through immunohistochemistry, was evaluated according to cervicallesion grade and high-risk HPV detection through Hybrid Capture 11. In the second article, 104 women ith CIN were included, followed-up for 36 months after diathermic conization, in order to assess possible relation between COX-2 and Ki67 expression, adjusted by the cone margin status and high-risk HPV detection during follow-up with persistentlrecurrent CIN. Results: Cross-sectional analysis of baseline data disclosed that COX-2 protein expression did not differ in relation to grade of cervical lesion, Ki67 expression and high-risk HPV detection. A higher expression of Ki67 was associated exclusively with CIN 3. In the follow-up series, fourteen cases of recurrentlpersistent CIN were detected after diatherrny conization. Persistence/recurrence of CIN were not related to cytoplasmic COX-2 and nuclear Ki67 expression, but had a positive...

Complicaciones en histeroscopía / Hysteroscopy complications

La histeroscopía, procedimiento con fines diagnósticos y terapéuticos, permite una visión directa de la cavidad uterina. Es relativamente sencilla, pero no exenta de complicaciones, reportándose en la literatura mundial cifras variables entre 0,95 y 25 por ciento. Se realizó un estudio retrospectivo de los procedimientos histeroscópicos ejecutados entre el 1º de mayo de 2000 y el 31 de julio de 2001 en el Departamento de Obstetricia y Ginecología del Hospital Clínico de la Universidad de Chile. Se registró en cada paciente la edad, paridad, patología uterina que justificó el procedimiento, tipo de operación practicada, operador y presencia de complicación. Se realizaron 120 procedimientos histeroscópicos en el período definido, encontrándose tres perforaciones uterinas, siendo ésta la única complicación encontrada, lo que corresponde a un 2,5 por ciento del total, cifra que está acorde a la literatura mundial. Los autores concluyen que la histeroscopía constituye un buen método de diagnóstico y tratamiento para la patología intrauterina, poco invasiva, de alto rendimiento, bajo costo, rápida, pero no exenta de riesgos, lo que amerita un adiestramiento adecuado

Alteraçäo do eco da linha média da cavidade uterina: um sinal ecográfico para diagnóstico diferencial entre lesöes do endométrio e do miométrio submucoso / Alteration in the middle echo of the uterine cavity: an echographic signal in the differential diagnosis of endometrial versus myometrial submucous lesions

O presente trabalho originou-se de uma observação ainda não descrita da alteração do eco da linha média da cavidade uterina através da USTV; o método proposto mostrou-se de grande valor no diagnóstico diferencial entre as lesões do endométrio e do miométrio submucoso

Ferimento transfixante de útero em gestante / Penetrating injury in gravid uterus

In the past 50 years, maternal mortality rates have declined, in contrast, the number of deaths due to injury during pregnancy is on the rise. The authors report a case of 24a week pregnant woman victim of penetrating abdominal trauma by gunshot who sustained a grade III transfixing injury of the uterine fundus. Treatment was conservative regarding the fetus. Hysteroraphia of the injuries was executed with closure of both penetrating orifices. Obstetrical-gynecological evaluation and echogram documented fetal viability in the post-operative period. Post-operative follow-up was performed with periodical echograms up to delivery on the ninth month. Clinical findings, treatment and follow-up will be discussed

Complications attributed to illicit abortions

A four year prospective study was carried out involving 83 cases of induced abortions, 72 were induced illegally and 11 were medically indicated, to determine the incidence and types of complications of illegally induced abortions as well as those of therapeutic ones. The prevalence of illegal abortion was 3.61% and that of therapeutic was 0.55%. In illegally induced group, age of 48 [66.66%] women ranged between 21-35 years, 34 [47.22%] were grand multiparas and 79% were illiterate. In 31 [43.25%] women, illegal abortions were carried out by TBAs and the most commonly used method was instrumentation employed in 46 [63.88%] of cases. The commonest complication detected was haemorrhage occurred in 31 [43.25%] patients, followed by sepsis in 24 [33.33%] and trauma in 13 [18%] cases. Indications of therapeutic abortions included maternal malignant diseases and fetal anomalies. Only one patient developed post abortal endometritis

Relative potentiality of some contragestational agents on trauma induced deciduoma formation in immature rats.

Relative progestational and antiprogestational profile of four contragestational agents, viz. RMI-12,936, RU-38,486, STS-557 and WIN-32,729, known to possess either or both the properties in other test systems, was determined in immature rats using deciduoma induction as marker. The deciduoma was produced by needle traumatization in one of the uterine horn, and the extent of stimulation was analysed, both macro and microscopically, against the control nontraumatized horn. The results indicated that the agents which demonstrated better potentiality(ies) as progestational and/or antiprogestational in this bioassay exhibit contraceptive efficacy at relatively lower doses as compared to those that showed mild to moderate potentiality.

Rupture of the gravid uterus a study of sixty nine cases

A three years study from January 1993 to December 1995 was carried out in the Department of Obstetrics and Gynaecology, Bolan Medical College, Quetta, to study the incidence, risk factors appropriate operative management and fetal outcome in cases of rupture of the gravid uterus. During this period a total of 13072 patients were delivered, out of these 69 had ruptured uterus giving a frequency of 1:189 deliveries. Thirteen patients were having scarred uterus, while uteri of the 56 patients were unscarred. A part from scar common causative factors were obstructed labour due to cephalopeluic disproportion, malpresentation, hydrocephalus, transverse lie and injudicious use of oxytocic drugs in grand multiparas with poor illiterate socioeconomic background. Most of the patients had come from far flung areas of rural Balochistan, where no expert gynaecological help was available. Repair of the uterus with tubal ligation was performed in 39 cases, hysterectomy was performed in 12 cases. Only repair was done in 14 cases keeping in view the parity and site of the tear. Hysterectomy with bladder repair was performed in 4 cases. Maternal mortality was 14.5%. General improvement of overall socioeconomic conditions, availability of improved health services, family planning advice and good supervision during delivery can help in reducing this risk

Ruptura uterina / Uterine rupture

Desde enero de 1986 a junio de 1991 (66 meses) se han estudiado en el Hospital Gineco-obstetrico Dr. Jaime Sanchez, 10.068 nacimientos por partos y cesareas en los cuales se encontraron 17 rupturas uterinas lo que representa el 0.17 por ciento . De estos 17 casos de ruptura 8 (47.05 por ciento ) fueron ruptura traumatica, 5 (29.42 por ciento ) ruptura expontanea, 4 (23.53 por ciento ) dehiscencias.