Abordaje integral de la Interrupción Voluntaria del Embarazo: (segunda entrega) / Comprehensive approach to the voluntary interruption of pregnancy: (second issue)

La legalización de la interrupción voluntaria del embarazo ha transformado la práctica médica con respecto a la atención de las pacientes que desean interrumpir la gestación hasta la semana 14 en Argentina. En la primera entrega, el equipo PROFAM compartió su punto de vista a través de una adaptación de su material educativo destinado, sobre todo, a aclarar los aspectos legales que hacen a la práctica cotidiana. En esta entrega se desarrolla en detalle el procedimiento para realizar un aborto farmacológico con misoprostol y mifepristona, así como las generalidades del aspirado manual endouterino. (AU)

The legalization of voluntary termination of pregnancy has transformed medical practice regarding the care of patients who wish to terminate a pregnancy up to 14 weeks in Argentina. In the first issue, the PROFAM team shared its point of view through an adaptation of its educational material aimed, above all, at clarifying the legal aspects of daily practice. In this issue, the procedure to perform a pharmacological abortion with misoprostol and mifepristone is developed in detail, as well as the generalities of manual uterine aspiration technique. (AU)

Hematometra y hematocervix en paciente postmenopáusica: reporte de caso / Hematometry and hematocervix in postmenopausal patient: case repor

El hematometra es la retención de sangre en el útero y comúnmente se presenta en mujeres jóvenes con anomalías mullerianas pero puede aparecer también en mujeres postmenopausicas por causas secundarias como traumas, tumores, terapia de remplazo hormonal, estenosis cervical, entre otras. En esta presentación de caso interesante se describe una mujer postmenopáusica bajo terapia de remplazo hormonal. Dicha mujer inicia con hemorragia uterina anormal por lo que se le realiza ultrasonido evidenciando hematómetra y hematocervix. Como método diagnóstico y terapéutico de la hemorragia postmenopáusica se le realiza histerectomía abdominal en la cual la patología evidencia leiomiomatosis uterina con endometrio secretor

Hematometra is the retention of blood in the uterus and commonly occurs in young women with Mullerian abnormalities but can also appear in postmenopausal women due to secondary causes such as trauma, tumors, hormone replacement therapy, cervical stenosis, among others. In this presentation an interesting case is described a postmenopausal woman under hormone replacement therapy. She said woman began with abnormal uterine bleeding, so an ultrasound was performed showing hematometer and hematocervix. As a method diagnosis and treatment of postmenopausal hemorrhage, abdominal hysterectomy is performed in which the pathology shows uterine leiomyomatosis with secretory endometrium

Métodos terapêuticos de maturação cervical / Therapeutic methods for cervical ripening

Métodos de maturação cervical são utilizados há décadas, apresentando mecanismos, efetividade e riscos diversos. Para reconhecer os métodos existentes e delimitar quais possuem os menores riscos, melhor efetividade e disponibilidade na prática médica, foi realizada uma revisão crítica, que buscou artigos nas bases Medline/Pubmed, biblioteca Cochrane e LILACS/SciELO, referentes à maturação cervical mecânica ou farmacológica em gestantes com termos e palavras-chave relacionadas à maturidade cervical, misoprostol e parto induzido. Constatou-se que os métodos mais utilizados na prática são a prostaglandina sintética (misoprostol) e a sonda de Foley. Estes se mostraram superiores aos demais métodos encontrados, uma vez que são efetivos, têm baixo custo, são fáceis de armazenar e utilizar, especialmente o misoprostol. Ambos apresentaram uma efetividade similar, mas os métodos mecânicos estão relacionados a um maior risco de infecção.

Cervical ripening methods have been used for decades, showing different mechanisms, risks and effectiveness. To recognize the existing methods and delineate which have the lower risks, best availability and effectiveness in clinical practice, a critical review was conducted, which sought articles in Medline / Pubmed, Cochrane Library, and LILACS/SciELO regarding mechanical or pharmacological cervical ripening in pregnant women, with terms and keywords related to cervical ripening, misoprostol and induced labor. It was found that the most used methods in practice are synthetic prostaglandin (misoprostol) and the Foley catheter. They seem to be superior to other methods because they are effective, inexpensive and easy to store and use, especially misoprostol. Both showed a similar efficacy, but mechanical methods are related to a higher risk of infection.

comparison between sublingual misoprostol and intravenous oxytocin for inducing labor in women with term pregnancy

In this study efficacy of sub lingual Misoprostol was examined in comparison to Oxytocin [I.V.] for inducing of labor in term pregnancy. Seventy patients were allocated by blocked randomization to Groups A [n=35, sub lingual Misoprostol 25 micro g four hourly to maximum of 5 doses] and B [n=35, continuous Oxytocin infusion]. Delivery active phase and total labor phase were shorter with sublingual Misoprostol in comparison to intravenous Oxytocin [p< 0.001] and the rate of cesarean section was lower in Misoprostol group [p<0.04] but delivery latent phase, meconium staining, uterine hypertonisity and apgar score [1 and 5 minute] were similar in two groups. Sublingual Misoprostol is better than intravenous Oxytocin for induction of labor at term

Farmacocinética e farmacodinâmica do misoprostol em Obstetrícia / Pharmacokinetics and pharmacodynamics of misoprostol in Obstetrics

Nos últimos anos a antecipação do parto vem sendo uma prática frequente na Obstetrícia. O misoprostol é um produto sintético, metil análogo da prostaglandina E1 que tem recebido maior atenção, principalmente para a indução do trabalho de parto e do abortamento, além de outras indicações, como controle da hemorragia pós-parto e para promover modificações na cérvice uterina, facilitando a realização de procedimentos como histeroscopia e colocação de dispositivo intrauterino. A administração do misoprostol atualmente é realizada por diferentes vias: oral, vaginal, bucal, sublingual e retal. Assim, é prudente o conhecimento da farmacologia, dos efeitos e mecanismos de ação do misoprostol nas diferentes formas de administração, com base nas evidências científicas e de acordo com os graus de recomendação. O maior pico do nível plasmático de misoprostol, em ordem decrescente, é do grupo sublingual, oral, vaginal com adição de água e vaginal. A biodisponibilidade é também maior na via sublingual. Entretanto, o nível plasmático é mantido por um maior período de tempo quando a via vaginal é utilizada.

Anticipation of delivery has been a frequent practice in Obstetrics nowadays. Misoprostol is a synthetic metyl analogue of prostaglandin E1 that has been used mainly for induction of labor and abortion, as well as for other indications like prevention and control of postpartum hemorrhage. In Gynecology, its use has been introduced to induce cervical modifications for facilitating gynecologic procedures as hysteroscopy and intrauterine device insertion. Misoprostol administration can be done by different routes: oral, vaginal, buccal, sublingual and rectal. Therefore, it is prudent to study pharmacokinetics and pharmacodynamics of this drug and its various routes of administration, according to scientific evidences and grades of recommendation. The highest plasmatic peak of misoprostol, in decreasing order, is sublingual, oral, vaginal and vaginal plus water administration route. Bioavailability is also greater for sublingual route. Notwithstanding, plasmatic levels are maintained for more time when vaginal route is used.

Efficacy and Complication of misoprostal for second tremester pregnancy termination among primigravida versus multigravida

To compare the efficacy and complications of Misoprostol for Second Trimester Pregnancy termination among primigravida and multigravida. It was a prospective study conducted at Department of Obstetrics and Gynaecology, Bahawal Victoria Hospital, Bahawalpur. The study was done in the period from June 2008 to February 2009. One hundred and twenty pregnant women at 14-24 weeks of gestation divided into two groups viz. Group 1: Primigravida and group 2: Multigravida. Patients needing terminations of pregnancy were 10%. The data was collected on a specially designed proforma. It was analyze on SPSS version 13.0.0. Chi-square test was applied to determine the statistical significance. The mean age of primigravida was 22.57 years as compared to that [27.37 years] of multigravida. The mean gestational age was comparable in both groups. The mean induction expulsion interval found in primigravida was 15.59 hours and in multigravida 9.13 hours. The complications like dead fetus, pelvic infection, coagulopathy, rupture, incomplete abortion were less among multigravida as compared to primigravida. Our study concludes that use of Misoprostal for second trimester pregnancy termination is cost effective and easy to administer among primigravida and multigravida. The complications like pelvic infection are less common among the multigravida

Utilización del misoprostol como método preinductivo del trabajo de parto / Use of the misoprostol as a preinductive method of labor

Se realizó un estudio descriptivo, longitudinal y prospectivo en el Hospital Materno Sur Docente Mariana Grajales Coello de Santiago de Cuba durante el 2006, con vista a caracterizar a 332 gestantes en quienes se usó misoprostol como método preinductivo del trabajo de parto, así como a valorar su utilidad en las integrantes de la casuística. Entre los resultados sobresalieron, por citar algunos, que este procedimiento favoreció el logro de una exitosa inducción definitiva del parto y la evolución a fase activa de la mayoría de las grávidas, con un reducido número de dosis del fármaco.

A descriptive, longitudinal and prospective study was carried out in Mariana Grajales Coello Southern Maternity Hospital from Santiago de Cuba during the 2006, aimed at characterizing 332 pregnant women in whom misoprostol was used as preinductive method of labor, as well as at evaluating its usage in the members of the case material. Among the results there were that this procedure favored the achievement of a successful and definitive induction of the childbirth and the clinical course to the active phase of most of the pregnant women, with a reduced dose of the drug.

Defecto del cierre del tubo neural: acrania: a propósito de un caso / Neural tube defect closing: acrania: a purpose of a case

Las malformaciones congénitas son un problema poco frecuente; considerando todas las malformaciones en conjunto, éstas se presentan en menos del 2 por ciento de los recién nacidos. Los defectos del cierre del tubo neural: anencefalia, espina bifida, acrania y meningocele, al igual que la mayoría de las malformaciones congénitas, son un grupo de afecciones de etiología multifactorial, producto de la interacción de factores genéticos y ambientales. Los factores genéticos actúan en un sistema poligenético, en el que se tienen que considerar los riesgos de recurrencia, cálculos de heredabilidad, la frecuencia de consanguineidad y las variaciones raciales, los factores ambientales, las infecciones virales, agentes físicos como la hipertemia (fiebre), deficiencia o alteraciones del metabolismo del ácido fólico, así como la exposición a diversas substancias químicas.

Muerte fetal intrauterina por nudo real: a propósito de un caso clínico / Intrauterine fetal death by royal knot: a purpose of a case clinical

El cordón umbilical tiene una longitud de 50-60 centímetros en una gestación de término y constituye la comunicación entre placenta y feto. Entre las patologías de cordón están los nudos falsos (debidos a asas vasculares recubiertas por la acumulación de la gelatina de Wharton que se forma porque la longitud de los vasos supera a la del cordón) y reales. Este último es el que con más frecuencia lleva a muerte fetal intrauterina por causa funicular. Inexplicable cuando el producto se encuentra dentro del útero y evidenciable al producirse su posterior salida, como ocurrió en el caso presentado a continuación.

Mid-trimester termination of pregnancy-comparison of sublingual with vaginal misoprostol

This paper compares the efficacy, side effects and patient's satisfaction of sublingual with vaginal misoprostol for mid-trimester termination of pregnancy. The study was performed in the department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore. One hundred patients presenting for termination of pregnancy between 13-24 wks of gestation were selected. They were divided into two groups, group I was managed with sublingual and group II with vaginal misoprostol. The dose of misoprostol was 200 pg repeated at intervals of 6 hours up to a maximum of four doses. The primary outcome measure was induction expulsion interval and secondary outcomes were maternal complications, and women's acceptance of the termination procedure. Successful termination was achieved in 96% patients in group I and 94% in group II. The patients in the two groups were comparable regarding their parity, gestational age and indications for termination. As regards the dosage, 76% in each group required a dose of 400 - 600 ug [P value 0.000]. Induction expulsion interval was < 12 hrs in 92% patients in group 1 and 88% in group II, a difference not statistically significant [P value > 0.005]. Pyrexia > 38°C was found in 8% and 6% in each group respectively while 8% in group I and 4% in group II had nausea and vomiting. So, sublingual misoprostol is as effective as vaginal misoprostol but with more nausea and vomiting, which can be managed easily. As a conclusion misoprostol can play a very important role in the practice of obstetrics and gynecology in resource poor countries where cost of other prostaglandins is prohibitively high and temperature maintenance is a problem. In proper dosage the risk of complications is low and most of the patients achieve completion of expulsion in less than 12 hrs by both routes

Inducción del parto en embarazos de alto riesgo obstétrico: misoprostol vaginal versus ocitocina / Labor induction in high risk pregnancy: vaginal misoprostol versus oxytocin

Efectuamos ensayo clínico controlado, con 1000 ug de misoprostol intravaginal para borramiento cervical e inducción de parto, en 175 pacientes con embarazos de alto riesgo obstétrico, con score de Bishop bajo 7. Comparamos resultados con 1999 pacientes de un grupo histórico similar, sometido a inducción ocitócica. Los tiempos de lactancia y de trabajo de parto fueron significativamente menores con misoprostol (p<0,05). La polisistolia fue más frecuente con misoprostol (55 por ciento versus 1 por ciento p<0,05). El síndrome de hiperestimulación fue más frecuente con misoprostol (10,2 por ciento versus 0,05 por ciento, p<0.05) pero no representó mayor compromiso de la unidad fetoplacentaria. La cesárea fue menos frecuente con misoprostol (24,6 por ciento versus 33,6 por ciento, N.S). El éxito en 24 horas fue mayor para misoprostol (66,2 por ciento versus 43,7 por ciento p<0,05). Los resultados neonatales fueron similares. Conclusiones: misoprostol produce borramiento cervical preinducción, es más eficiente como inductor de parto y posee similar seguridad comparado con ocitocina. El análisis de riesgos relativos apoya estas conclusiones. Dosis menores de misoprostol podría ser eficientes y aún más seguras

Comparative study of misoprostol versus dinoprostone in cervical ripening and labour induction

The aim of this study was to compare the safety and efficacy of intravaginal administered misoprostol [cytotec] versus dinoprostone pessary [prostin E2] for cervical ripening and labor induction. Sixty patients requiring induction of labor for different medical or obstetrical indications were included in this study. The misoprostol group had a significant reduction in median induction delivery time compared to dinoprostone group. There was a reduced need for the oxytocin augmentation and there was no significant difference in the mode of delivery. There were no adverse neonatal outcomes associated with the use of misoprostol. It was concluded that 100 mug vaginal misoprostol was a more effective induction agent than 3 mg dinoprostone vaginal pessary

Uso do Misoprostol em ginecologia e obstetrícia / Misoprostol use in ginecology and obstetrics

Revisäo prática e atualizada sobre o uso do misoprostol em ginecologia e obstetrícia.

Uso actual de misoprostol intravaginal para inducción de parto en diferentes patologías / Use of intravaginal misoprostol to labor induction in different pathologies

Se presentan los resultados generales de 542 casos con diversas patologías inducidos con misoprostol 50 ug intravaginal cada 8 horas por dos veces al día durante los años 1997 y 1998 en el Servicio de Obstetricia y Ginecología del Hospital de Talcahuano, 138 de ellos fueron seguidos prospectivamente los últimos 4 meses. Se obtuvo un 96,4 por ciento de éxito, 79 por ciento las primeras 24 horas y 17,4 por ciento al día siguiente. El porcentaje de cesárea fue 7,5 por ciento y 6 por ciento de polisistolia y ningún recién nacido deprimido. De los 5 casos de fracasos (3,6) 3 terminaron en cesárea

Evaluation of the cytoprotective role of misoprostol and omeprazole against tenoxicam induced toxicity

One hundred sixty adult albino rats were deployed into 8 equal groups, each of 20 rats. The first group [I] received tenoxicam daily orally for 14 days at a dose of 20 mg/kg bw. The second group [II] received tenoxicam together with misoprostol in a dose of 16 mg/kg bw daily orally. The third group [I: T1] received tenoxicam as in group I together with omeprazole in a dose of 20 mg/kg bw daily orally for the same period. The fourth group [IV] received tenoxicam together with misoprostol and omeprazole at the previously mentioned doses and duration. There were four control groups, one negative control group and three positive control groups, received gum acacia in distilled water, misoprostol and omeprazole groups in doses equivalent to those given to the test groups. At the end of the study, the rats were sacrificed 24 hours after drug administration. Liver and kidney functions were investigated. Serum pancreatic amylase, blood platelets and hemoglobin were also determined. Histopathological examination of liver, kidney, stomach, duodenum and pancreas were done

Experiencia en el uso de misoprostol vaginal como inductor de trabajo de parto en pacientes en un servicio de alto riesgo obstetrico / Experience in the use of vaginal misoprostol as inductor of labor in patients in an obstetric high risk service

Se presentan 90 pacientes de alto riesgo obstétrico inducidas por Misoprostol intravaginal 50 µg en dosis únicas; con un éxito de 93 por ciento y escasas complicaciones

Experiencia del uso de misoprostol en embarazos de 36 ó más semanas con feto vivo / Experiencia of the use of misoprostol in pregnancy of 36 weeks of gestational age with alive fetus

Se diseñó un estudio prospectivo descriptivo de inducción de partos sobre 36 semanas, con el objetivo de certificar su seguridad y efectividad para obtener resulución vaginal del parto en pacientes con indicación de interrupción, pero con malas condiciones cervicales. A 207 pacientes del Hospital Regional de Puerto Montt, con feto único vivo sobre 36 semanas, en presentación cefálica y sin compromiso de la Unidad Fetoplacentaria (UFP) se les administró 100 mcg de Misoprostol intravaginal, obteniéndose un parto vaginal en el 81 por ciento de los casos, el 90,4 por ciento se produjo antes de las 24 horas. La complicación más frecuente fue la polisistolia y la principal causa de cesárea fue la sospecha clínica de compromiso de UFP, destacando sólo 5 casos con apgar < 7 a los 5 min. Se concluye que el Misoprostol intravaginal es un método eficaz, seguro, económico y de fácil uso en la inducción de parto en éste grupo de pacientes