Manejo farmacológico del sangrado irregular no menstrual asociado al uso de implantes anticonceptivos subdérmicos / Pharmacological management of irregular non-menstrual bleeding associated with the use of subdermal contraceptive implants

El spottingo sangrado irregular no menstrual es uno de los principales efectos secundarios de los implantes anticonceptivos, situación que se recomienda discutir con la usuaria previo a la colocación, para evitar falsas expectativas o temores que lleven a la extracción temprana del dispositivo. A propósito de una paciente sin antecedentes relevantes que consultó al centro de salud por spotting desde la colocación del implante cuatro meses antes, decidimos revisar la evidencia sobre la efectividad de los distintos esquemas farmacológicos disponibles para el manejo de este evento adverso. Luego de realizar una búsqueda bibliográfica concluimos que, si bien existe sustento para indicar algunos de los esquemas farmacológicos, este es aún débil y son necesarios estudios clínicos adicionales que brinden evidencia sólida sobre qué esquema en particular utilizar, evaluando sus riesgos y beneficios. (AU)

Spotting or irregular non-menstrual bleeding is one of the main side effects of contraceptive implants, a situation that health professionals must discuss with the user prior to its placement in order to avoid false expectations or fears that lead to early removal of the implant. Regarding a patient with no relevant history who consulted the health center due to spotting four months after implant placement, we decided to review the evidence onthe effectiveness on different pharmacological schemes available for the management of this adverse event. After performing a literature search, we concluded that, although there is support for indicating some of the pharmacological schemes, this is still weak, and further clinical studies are needed to provide solid evidence on which particular scheme touse, assessing its risks and benefits. (AU)

Síndrome de Klipper-Trenaunay-Weber con compromiso vesical y uterino tratado por vía endoscópica y endovascular / Klippel-Trenaunay-Weber syndrome with vesical and uterine involvement treated by endoscopic and endovascular routes

El síndrome de Klippel-Trenaunay-Weber (SKTW) es una rara malformación venosa que, en general afecta a los miembros inferiores y, más raramente, a los superiores. Se caracteriza por formaciones angiomatosas cutáneas, várices e hipertrofia del miembro afectado. El compromiso genitourinario es sumamente infrecuente. Se presenta el caso de una paciente de 14 años. Ingresó por hematuria macroscópica de 48 h de evolución y metrorragia con grave compromiso hemodinámico. Se encontraba en estudio por presentar un hemangioma en el miembro inferior izquierdo que se extendía hasta la región pelviana. La uretrocistofibroscopía demostró la presencia de múltiples lesiones angiomatosas diseminadas en forma amplia en la vejiga, algunas de ellas con sangrado activo. La angioresonancia mostró una voluminosa formación hipervascularizada en contacto con la pared vesical a la cual desplazaba y fístulas arteriovenosas a nivel pelviano y en el miembro inferior izquierdo confirmando el diagnóstico etiológico. Se realizó una embolización arterial selectiva de los territorios ilíacos interno y externo e inmediatamente después una endocoagulación láser de los focos angiomatosos sangrantes. La hematuria remitió completamente en las 24 h posteriores al procedimiento. La metrorragia asociada al SKTW fue controlada mediante la utilización de análogos LHRH y progestágenos.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

Two Cases of Uterine Tumors Resembling Ovarian Sex-cord Tumors: Rare Case of Uterine Tumor / 이화의대지

Uterine tumors resembling ovarian sex-cord tumors (UTROSCT) are very rare tumors that occur mainly in the uterine fundus of women in reproductive age. These tumors can be classified into group 1 and group 2 by histological results. In group 1, epithelial-like differentiation is partially observed in the tumors. In group 2, sex-cord elements are predominant in uterine mural mass. We experienced UTROSCT group 1 in a 29-year-old woman who complained of severe abdominal pain that started one week after delivery and UTROSCT group 2 case in a 49-year-old woman who complained of dysfunctional uterine bleeding. We report two different types of UTROSCT cases that we experienced.

Caracterización clínica y epidemiológica de pacientes diagnosticadas con embarazo molar durante los años 2012-2019 en el Hospital de Chillán / Clinical and epidemiological characterization of patients diagnosed with molar pregnancy during the years 2012-2019 in Hospital de Chillán

La enfermedad trofoblástica gestacional (ETG) constituye un conjunto heterogéneo de afecciones malignas y benignas derivados de la proliferación anormal del trofoblasto o de las células germinales de ambos sexos. La ETG tiene una incidencia variable a lo largo del mundo. A nivel nacional, no se han realizado estudios de caracterización epidemiológica de esta población y, frecuentemente, los datos manejados están basados en estudios extranjeros. Objetivo: Determinar las características clínicas y epidemiológicas de las pacientes diagnosticadas con embarazo molar en el período transcurrido entre el año 2012 y 2019, en el hospital Clínico Herminda Martin de Chillán. Materiales y métodos: Estudio observacional transversal de serie temporal, se consideró el número total de fichas clínicas del Hospital Clínico Herminda Martin de Chillán durante los años 2012 al 2019, con diagnóstico confirmado de Embarazo Molar. Los datos se registraron en la hoja de recolección de datos elaborada, realizándose los análisis estadísticos pertinentes. Resultados: Se analizaron 44 pacientes, la edad promedio de presentación fue de 30.96 años. Los principales síntomas de consulta fueron metrorragia 52.27% (n=23) y dolor abdominal 20.45% (n=9). El principal tratamiento efectuado fue aspiración y legrado en un 77,27% (n=34). El 4.54% (n=2) presentó recurrencia, presentando un segundo episodio de embarazo molar. Conclusiones: El embarazo molar es una patología poco frecuente, pero es un diagnóstico diferencial a tener en cuenta, sobre todo cuando nos enfrentamos a mujeres en edad fértil que consultan por metrorragia o dolor abdominal.

Gestational trophoblastic disease (GTS) is a heterogeneous group of malignant and benign conditions derived from abnormal proliferation of the trophoblast or germ cells of both sexes. GTS has a variable incidence throughout the world. Nationally, no epidemiological characterization studies have been carried out for this population and, frequently, the data handled is based on foreign studies. Objective: To determine the clinical and epidemiological characteristics of patients diagnosed with molar pregnancy between the period between 2012 and 2019 at the Hospital Clinico Herminda Martin of Chillan. Materials and methods: Retrospective observational descriptive cross-sectional study, considering the pregnancies registered at the Hospital Clinico Herminda Martin of Chillan during the years 2012 to 2019, with a confirmed diagnosis of Molar Pregnancy, as sample of study. The data were recorded on the prepared data collection sheet, performing the relevant statistical analyzes. Results: 44 patients were analyzed, the average age of presentation was 30.96 years. The main symptoms of consultation were metrorrhagia 52.27% (n = 23) and abdominal pain 20.45% (n = 9). The main treatment was aspiration and curettage in 77.27% (n = 34). 4.54% (n = 2) presented recurrence, presenting a second episode of molar pregnancy. Conclusions: Molar pregnancy is a rare pathology, but it is a differential diagnosis to take into account, especially when we are faced with women of childbearing age who consult due to bleeding or abdominal pain.

Isthmocele: an overview of diagnosis and treatment

SUMMARY An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

RESUMO A istmocele ou nicho uterino é representada por uma descontinuidade miometrial ou um defeito anecoico triangular na parede uterina anterior, com a base se comunicando com a cavidade uterina no local de uma cicatriz anterior de cesárea. O defeito pode ser classificado como pequeno ou grande, dependendo da espessura da parede miometrial deficiente. Embora geralmente assintomático, seu principal sintoma é o sangramento uterino anormal ou pós-menstrual; a dor pélvica crônica também pode ocorrer. Infertilidade, placenta acreta ou prévia, deiscência de cicatriz, ruptura uterina e gravidez ectópica em cicatriz de cesárea prévia também podem aparecer como complicações dessa condição. Os fatores de risco para desenvolvimento da istmocele comprovados até o momento incluem útero retroverso e múltiplas cesarianas. No entanto, fatores como localização mais inferior de uma cesárea prévia, fechamento incompleto da histerotomia, aderências precoces na parede uterina e predisposição genética também podem contribuir para o desenvolvimento de um nicho. Como não existem critérios definitivos para o diagnóstico de uma istmocele, vários métodos de imagem podem ser usados para avaliar a integridade da parede uterina e, assim, diagnosticar uma istmocele. Entretanto, ultrassonografia transvaginal e sono-histerografia com infusão salina surgem como métodos específicos, sensíveis e custo-efetivos para o diagnóstico de istmocele. O tratamento inclui manejo clínico ou cirúrgico, dependendo do tamanho do defeito, da presença de sintomas, da presença de infertilidade secundária e de planos de gravidez. O manejo cirúrgico inclui abordagens minimamente invasivas como histeroscopia, laparoscopia ou transvaginal, de acordo com o tamanho do defeito.

Spinal Hydatid Cyst Disease : Challenging Surgery - an Institutional Experience

OBJECTIVE: Hydatid cyst disease is caused by the parasite Echinococcus granulosus. It is rarely seen in the vertebral system, occurring at a rate of 0.2–1%. The aim of this study is to present 12 spinal hydatid cyst cases, and propose a new type of drainage of the cyst.METHODS: Twelve cases of spinal hydatid cysts, surgical operations, multiple operations, chronic recurrences, and spinal hydatic cyst excision methods are discussed in the context of the literature. Patients are operated between 2005 and 2016. All the patients are kept under routine follow up. Patient demographic data and clinicopathologic characteristics are examined.RESULTS: Six male and six female patients with a median age of 38.6 at the time of surgery were included in the study. Spinal cyst hydatid infection sites were one odontoid, one cervical, five thoracic, two lumbar, and three sacral. In all cases, surgery was performed, with the aim of total excision of the cyst, decompression of the spinal cord, and if necessary, stabilization of the spinal column. Mean follow up was 61.3 months (10–156). All the patients were prescribed Albendazole. Three patients had secondary hydatid cyst infection (one lung and two hepatic).CONCLUSION: The two-way drainage catheter placed inside a cyst provides post-operative chlorhexidine washing inside the cavity. Although a spinal hydatid cyst is a benign pathology and seen rarely, it is extremely difficult to achieve a real cure for patients with this disease. Treatment modalities should be aggressive and include total excision of cyst without rupture, decompression of spinal cord, flushing of the area with scolicidal drugs, and ensuring spinal stabilization. After the operation the patients should be kept under routine follow up. Radiological and clinical examinations are useful in spotting a recurrence.

Clinical Characteristics Indicating Uterine Leiomyoma, Adenomyosis, and Uterine Leiomyoma Coexisting with Adenomyosis: Retrospective Study

OBJECTIVE: This study is to compare the baseline characteristics and symptoms between groups with leiomyoma only (group M; myoma group), adenomyosis only (group A; adenomyosis group), and leiomyoma and adenomyosis together (group B; group for both disease). METHODS: Selected patients were who received total abdominal hysterectomy, laparoscopy-assisted vaginal hysterectomy, or total laparoscopic hysterectomy from January 2014 to December 2015, and whose pathology result showed leiomyoma (n=74), adenomyosis (n=27), or both (n=63). Baseline characteristics and symptoms were reviewed from the medical records. Researched characteristics included patients' age, degeneration of leiomyoma, endometrial hyperplasia, endometriosis, weight of the removed uterus, menopause before the surgery, method of the surgery, necessity for blood transfusion before and after the surgery, difference of hemoglobin level before and after the surgery, and number of gravida, para, and abortion. RESULTS: Eleven symptoms were checked. Thirty-eight point four percent of total subject had uterine leiomyoma and adenomyosis at the same time. Number of abortion was higher in the group B. The group B showed a tendency of presenting more menorrhagia, dysfunctional uterine bleeding, acute lower abdominal pain, and urinary frequency. Symptoms related to mass effect seem to be relative to uterine leiomyoma, and symptoms related to menorrhagia seems to be relative to adenomyosis. The group M showed suddenly growing mass symptoms, and was more likely to have massive hemorrhage during the surgery. It is hard to differentiate coexistence of uterine leiomyoma and adenomyosis from each disease. CONCLUSION: Coexistence of two disease exhibits mixed symptoms of each disease, but shows different tendency.

Spinal Hydatid Cyst Disease : Challenging Surgery

OBJECTIVE: Hydatid cyst disease is caused by the parasite Echinococcus granulosus. It is rarely seen in the vertebral system, occurring at a rate of 0.2–1%. The aim of this study is to present 12 spinal hydatid cyst cases, and propose a new type of drainage of the cyst. METHODS: Twelve cases of spinal hydatid cysts, surgical operations, multiple operations, chronic recurrences, and spinal hydatic cyst excision methods are discussed in the context of the literature. Patients are operated between 2005 and 2016. All the patients are kept under routine follow up. Patient demographic data and clinicopathologic characteristics are examined. RESULTS: Six male and six female patients with a median age of 38.6 at the time of surgery were included in the study. Spinal cyst hydatid infection sites were one odontoid, one cervical, five thoracic, two lumbar, and three sacral. In all cases, surgery was performed, with the aim of total excision of the cyst, decompression of the spinal cord, and if necessary, stabilization of the spinal column. Mean follow up was 61.3 months (10–156). All the patients were prescribed Albendazole. Three patients had secondary hydatid cyst infection (one lung and two hepatic). CONCLUSION: The two-way drainage catheter placed inside a cyst provides post-operative chlorhexidine washing inside the cavity. Although a spinal hydatid cyst is a benign pathology and seen rarely, it is extremely difficult to achieve a real cure for patients with this disease. Treatment modalities should be aggressive and include total excision of cyst without rupture, decompression of spinal cord, flushing of the area with scolicidal drugs, and ensuring spinal stabilization. After the operation the patients should be kept under routine follow up. Radiological and clinical examinations are useful in spotting a recurrence.

Schwannoma of the uterine cervix: a rare case report

Schwannomas are neurogenic tumors, which are among the most varied tumors with respect to morphology, clinical associations, and presentations; they occur in a wide variety of sites. The uterine cervix is a rare site of occurrence and only 15 cases of schwannomas of the uterine cervix, including 5 benign and 10 malignant cases, have been reported to date. Thus, schwannomas of the uterine cervix may pose diagnostic difficulty. Here, we report a case of benign schwannoma of the uterine cervix in a 37-year-old female, who presented with vaginal spotting.

Uterine arteriovenous malformation with repeated vaginal bleeding after dilatation and curettage

Uterine arteriovenous vascular malformation (UAVM) is a disease that causes excessive bleeding. The symptoms do not subside without proper treatment and this can lead to life-threatening situations. The correct diagnosis of UAVM can be complicated if the patient's uterus did not completely discharge everything during abortion (in broader terms, retaining remnants of the products of conception). In this case, Doppler ultrasonography and computed tomography angiography with 3-dimensional rendering were used to analyze the cause of bleeding and provide proper treatment of this patient. Then, uterine artery embolization, dilatation, and curettage were performed safely and successfully. The patient no longer had symptoms of vaginal spotting during the planned follow up care. UAVM is uncommon; however, if reproductive-age women show repeated abnormal vaginal bleeding after dilatation and curettage, a diagnosis of UAVM must be considered based on the medical history and examination.

Sangrado y terapia hormonal en la menopausia (THM) / Bleeding during menopause hormone therapy (MHT)

La definición de sangrado ginecológico anormal durante terapia hormonal de la menopausia es aquel sangrado no programado durante el uso de la terapia. Este artículo es un pauteo que describe: 1) cuándo diagnosticar unsangrado anormal, ya que difiere según el tipo de esquema hormonal utilizado; 2) eldiagnóstico diferencial del origen del sangrado anormal; 3) los métodos de evaluación para diagnosticar el origen del sangrado. Se destacan los aspectos principales para el diagnóstico diferencial entre patología orgánica versus disrupción endometrial debida al tratamiento hormonal. Además, se describen los ajustes posibles para resolver el sangrado cuando éste se debe a disrupción del endometrio.

Abnormal bleeding related to menopausal hormone therapy is defined as unscheduled bleeding during the use of the therapy. This article outlines when to diagnose an abnormal bleeding -as this differs according to the type of hormonal scheme used-, the differential diagnosis of the origin of abnormal bleeding, and the methods of evaluation to assess the origin of the bleeding. The main aspects are highlighted on the differentiation of organic pathology versus disruption of the endometrium due to treatment. Also, treatment adjustments to resolve bleeding when it is due to disruption of the endometrium are outlined.

Hiperplasia endometrial y criterios ecográficos: reporte de caso y revisión de la literatura / Endometrial hyperplasia and sonographic criteria: Case report and literature review / Hiperplasia endometrial e critérios ecográficos: relato de caso e revisão da literatura

El objetivo de este artículo es revisar los criterios ecográficos de hiperplasia endometrial y evaluar los puntos de corte para indicar la realización de biopsia endometrial. Se reporta el caso de una mujer de 47 años, con cuadro clínico de 4 años de evolución de sangrado vaginal anormal tipo menorragia, metrorragia e hipermenorrea, en manejo con anticonceptivos orales, sin mejoría, y con ecografía transvaginal con diagnóstico de hiperplasia endometrial. Para el diagnóstico de patología endometrial en las mujeres posmenopáusicas con sangrado vaginal, los autores recomiendan un valor de corte del grosor endometrial por ecografía transvaginal entre 4-5 mm con sensibilidad del 98% y valor predictivo negativo del 99% debido a que valores superiores están altamente relacionados con carcinoma endometrial.

The aim of this article is to review the sonographic criteria of endometrial hyperplasia and define the cutoff value to indicate the completion of the endometrial biopsy due to its relationship with the risk of endometrial carcinoma. We report the case of a woman aged 47 with four years of vaginal bleeding characterized by menorrhagia, metrorrhagia, and hypermenorrhea being treated with oral contraceptives without improvement, and transvaginal ultrasound diagnosis of endometrial hyperplasia. For the diagnosis of endometrial pathology in postmenopausal women with vaginal bleeding, the authors recommend a cutoff value of endometrial thickness by transvaginal ultrasound of 4-5 mm with sensitivity of 98% and negative predictive value of 99% since higher values are closely related to endometrial carcinoma.

O objetivo deste artigo é revisar os critérios ecográficos de hiperplasia endometrial e avaliar os pontos de corte para indicar a realização de biopsia endometrial. Se reporta o caso de uma mulher de 47 anos, com quadro clínico de 4 anos de evolução de sangrado vaginal anormal tipo menorragia, metrorragia e hipermenorreia, em manejo com anticonceptivos orais, sem melhora, com ecografia transvaginal com diagnóstico de hiperplasia endometrial. Para o diagnóstico de patologia endometrial nas mulheres pós-menopáusicas com sangrado vaginal, os autores recomendam um valor de corte do espessura endometrial por ecografia transvaginal entre 4-5 mmcom sensibilidade de 98% e valor preditivo negativo de 99% devido a que valores superiores estão altamente relacionados com carcinoma endometrial.

Effectiveness and safety of sublingual misoprostol in medical treatment of the 1st trimester miscarriage: experience of off-label use in Korea

OBJECTIVE: This study was conducted to determine the effectiveness and safety of medical treatment with sublingual misoprostol (MS) in the 1st trimester miscarriage under the approval by Health Insurance Review and Assessment Service (HIRA) for off-label usage by the single medical center in Korea. METHODS: A retrospective cohort study was performed in one institution between April 2013 and June 2016. Ninety-one patients diagnosed with miscarriage before 14 weeks of gestation and wanted to try medical treatment were included. A detailed ultrasound scan was performed to confirm the diagnosis. Patients took 600 microgram (mcg) of MS sublingually at initial dose, and repeated the same dose 4–6 hours apart. Successful medical abortion was defined as spontaneous expulsion of gestational products (including gestational sac, embryo, fetus, and placenta). If gestational products were not expelled, surgical evacuation was performed at least 24 hours later from the initial dose. Information about side effects was obtained by medical records. RESULTS: About two-thirds of patients had a successful outcome. The median interval time from pill to expulsion was 18 hours in the successful medical treatment group. There was no serious systemic side effect or massive vaginal bleeding. Presence or absence of vaginal spotting before diagnosis of miscarriage, uterine leiomyomas, subchorionic hematoma, or distorted shape of gestational sac on ultrasound scan were not statistically different between the two groups. CONCLUSION: Medical treatment with sublingual MS can be a proper option for the 1st trimester miscarriage, especially for the patient who want to avoid surgical procedure. We can reduce the unnecessary sedation or surgical intervention in the patients with the 1st trimester miscarriage.

Malformation artério - veineuse utérine acquise : à propos de trois cas diagnostiqués à l'Hôpital Militaire d'Antsiranana à Madagascar

Les malformations artério-veineuses utérines acquises sont rarement rapportées dans le mécanisme de métrorragie. Ses caractéristiques cliniques sont non spécifiques et trompeuses. Elles sont potentiellement graves et peuvent mettre en jeu le pronostic vital de la patiente en cas d'aspiration-curetage, du fait d'hémorragies. Nous en rapportons trois cas qui ont été diagnostiqués dans le post abortum. Le premier cas était découvert 2 mois après une fausse couche spontanée, le deuxième 3 mois après une interruption volontaire de grossesse par curetage et le dernier 2 mois après prise de misoprostol. Dans tous les cas, le motif de consultation était des saignements à répétition de quantité variable. Le diagnostic était posé devant un test de grossesse négatif associé à des images hétérogènes intramyométriale bordant la cavité utérine et/ou intracavitaires très vascularisées à l'échographie doppler avec d'importants phénomènes d'aliasing

Nevus Vascularis Mixtus / 대한피부과학회지

The concept of mosaicism has been used to explain different cutaneous patterns, such as the lines of Blaschko, the checkerboard pattern, the phylloid pattern, and a patchy pattern. Many mosaic patterns are caused by loss of heterozygosity, the genetic mechanism by which a heterozygous somatic cell becomes either homozygous or hemizygous. A particular form of loss of heterozygosity is twin spotting, which give rise to two contrary homozygous daughter cells. The concept of twin spotting has been used for some of these human phenotypes, which are characterized by the co-occurrence of two different nevi, including nevus vascularis mixtus. Nevus vascularis mixtus is a rare vascular malformation characterized by the coexistence of a nevus anemicus and a nevus telangiectaticus, and can be associated with extra-cutaneous anomalies, such as cerebral malformations. Herein, we report a 6-year-old girl with paired cutaneous vascular nevi telangiectaticus, anemicus, and nevus vascularis mixtus, that were distributed on the left side of her chest and left arm, without other systemic and neurologic anomalies.

Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding

OBJECTIVE: To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE) before obstetrical procedures with high risk for massive bleeding. MATERIALS AND METHODS: A retrospective review of 29 female patients who underwent prophylactic UAE from June 2009 to February 2014 was performed. Indications for prophylactic UAE were as follows: dilatation and curettage (D&C) associated with ectopic pregnancy (cesarean scar pregnancy, n = 9; cervical pregnancy, n = 6), termination of pregnancy with abnormal placentation (placenta previa, n = 8), D&C for retained placenta with vascularity (n = 5), and D&C for suspected gestational trophoblastic disease (n = 1). Their medical records were reviewed to evaluate the safety and efficacy of UAE. RESULTS: All women received successful bilateral prophylactic UAE followed by D&C with preservation of the uterus. In all patients, UAE followed by obstetrical procedure prevented significant vaginal bleeding on gynecologic examination. There was no major complication related to UAE. Vaginal spotting continued for 3 months in three cases. Although oligomenorrhea continued for six months in one patient, normal menstruation resumed in all patients afterwards. During follow-up, four had subsequent successful natural pregnancies. Spontaneous abortion occurred in one of them during the first trimester. CONCLUSION: Prophylactic UAE before an obstetrical procedure in patients with high risk of bleeding or symptomatic bleeding may be a safe and effective way to manage or prevent serious bleeding, especially for women who wish to preserve their fertility.

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)

Malformación arteriovenosa uterina: a propósito de un caso / Arteriovenous uterine malformation: a case report

Paciente de 37 años que acudió a urgencias por metrorragia, G3P1A2, el último de ellos un aborto tardío en gestación gemelar monocorial biamniótica de 20 semanas hacía dos meses. En la ecografía destaca en zona miometrial un área de marcada vascularización de 67 x 45 mm. Tras descartar proceso residual gestacional y ante la sospecha de malformación arteriovenosa uterina se solicitó resonancia magnética nuclear y angiotac, tras confirmar la malformación vascular se programó para embolización de ambas arterias uterinas con el fin de preservar la fertilidad.

A 37-year-old patient came to the emergency due to metrorrhagia, G3P1A2, the last of them a late abortion in a 20 weeks monochorionic diamniotic twin pregnancy two months ago. Ultrasound revealed an intramiometrial area of 67 x 45 mm with increased vascularization area. A diagnosis of an arteriovenous malformation was considered. In order to confirm the diagnosis pelvic magnetic resonance and angiogram was performed. Once the vascular malformation was confirmed the patient was scheduled for transcatheter arterial embolization in order to preserve fertility.

Coriocarcinoma postgestacional / Post-pregnancy choriocarcinoma

El coriocarcinoma es una patología infrecuente pero potencialmente fatal si no se trata. Se incluye dentro de las neoplasias trofoblásticas gestacionales, un grupo de tumores malignos altamente invasivos, metastáticos y muy vascularizados. Su presentación tras una gestación a término conlleva peor pronóstico que tras un aborto o una mola hidatiforme porque refleja un retraso en el diagnóstico y tratamiento. Describimos el caso de una paciente que acudió al servicio de urgencias, refiriendo metrorragia escasa desde un parto normal hace dos meses y posteriormente presentó un sangrado grave durante su hospitalización. Los elevados niveles de β-hCG, la ecografía-Doppler, las pruebas de imagen y las manifestaciones clínicas fueron suficientes para diagnosticar un coriocarcinoma postparto. El tratamiento precoz con poliquimioterápicos permitió una evolución favorable de la paciente.

Choriocarcinoma is an infrequent disease but potentially fatal if untreated. It is included in trophoblastic gestational neoplasia, a range of malignant tumors highly invasive, metastatic and very vascular. Its presentation after term pregnancies carries a worse prognosis than after a miscarriage or a hydatidiform mole because it reflects a delay in diagnosis and treatment. We report the case of a patient who presented to the emergency department referring little metrorrhagia from a normal delivery two months ago and severe bleeding later during her hospital stay. The high serum β-hCG level, the Doppler ultrasonography, the imaging test and the clinical manifestation were enough to diagnose a non-metastatic postpartum choriocarcinoma. Early treatment with polychemotherapy allowed a favorable evolution of the patient.

Sangramento uterino anormal: proposta de abordagem do Grupo Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice (HELP) / Heavy menstrual bleeding: management proposal of the Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice Group (HELP)

O Sangramento Uterino Anormal (SUA) representa um problema de saúde pública complexo que pode acometer 1/3 das mulheres em todo o mundo. Apresenta um impacto negativo importante na qualidade de vida de mulheres e associa-se a elevados custos econômicos diretos e indiretos. Trata-se de uma condição desafiadora tanto para as mulheres afetadas quanto para os profissionais de saúde. A nomenclatura atribuída ao SUA é confusa e faltam ainda recomendações diagnósticas e terapêuticas padronizadas. Foi criado o grupo Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice (HELP) com proposta abordar os aspectos inconclusivos do SUA. Foram avaliados 134 documentos, incluindo 121 artigos científicos e 14 revisões de medicamentos, para desenvolvimento dos protocolos HELP. Foram elaborados protocolos simplificados referentes ao diagnóstico e tratamento do SUA, visando contribuir de forma mais eficaz com os médicos em seus diferentes cenários de atuação. O roteiro diagnóstico sugerido, compreendendo perguntas chaves e ações específicas, sinaliza para indicação de métodos propedêuticos adicionais. O tratamento proposto visa reduzir a perda do sangue menstrual e melhorar de a qualidade de vida das pacientes.(AU)

Abnormal uterine bleeding (AUB) is a complex public health problem that can affect one third of women worldwide. It has a significant negative impact on quality of life of women and is associated with high direct and indirect economic costs. It is a challenging condition for both the women affected and for the health professionals. The nomenclature assigned to the AUB is confusing and still miss diagnostic and therapeutic recommendations standardized. The Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice Group (HELP) was created with the proposal to address the inconclusive aspects of AUB. The group evaluated 134 documents, including 121 scientific articles and 14 reviews of drugs for the development of protocols HELP. Simplified protocols were drawn up relating to the diagnosis and treatment of AUB, to contribute more effectively with doctors at different scenarios of operation. The script diagnostic suggested, comprising keys questions and specific actions, can indicate additional diagnostic methods. The proposed treatment aims to reduce the loss of menstrual blood and improve the quality of life of patients.(AU)